Assessing Client Progress

September 21, 2020

Assessing Clients

Demographic Information

The client is a 7 year old Caucasian male who comes to the clinic accompanied by his father and mother who are 32 years and 28 years respectively. The client has been referred to the clinic by his teacher who believes that the child is developing oppositional defiant disorder. The teacher stated that the client screamed at her shouting that the school sucks and that the she could not tell him what to do. According to the client, the teacher constantly nags him and he even states that the teacher is stupid. The client’s academic performance is deteriorating. According to the client’s parents, the client’s behavior began when his grandmother passed away. It is reported that the client was so close to his grandmother. The client’s parents are social and they usually take their children out during the weekends to visit their grandparents, parents to the client’s mother. Both of the client’s parents are employed.

Presenting Problem

The client has had violent outbursts, he gets easily annoyed, and aggressive. His behavioral changed has had a negative impact on his academic work and performance.

History or Present Illness

The change in the client’s behavior started immediately after the death of his grandmother with whom he was very close with. The client confronted his teacher furiously accusing her of nagging him. He even called his teacher stupid during the confrontation. The client’s academic performance is deteriorating and when he is asked about his grades, the client claims that he fails because the teacher is stupid. At home, the client is aggressive and gets easily annoyed by his siblings and he even uses obscene language towards them. The client’s parents believe that his behavior has been triggered by the recent death of his grandmother.

Past Psychiatric History

No psychiatric history

Medical History

No medical history

Substance Use History

No substance use history

Developmental History

The client has no known developmental issues.

History of Abuse or Trauma

The client has no history of abuse. The only history of trauma is the death of his grandmother who he was really close with.

Review of Systems

The client has a depressed mood. HEENT shows no signs of seizures or dizziness. The client has no signs of nausea or vomiting, no history of mental issues, and no dysuria.

Physical Assessment

The following are the client’s vital signs, Height 59, weight 53lbs, RR 18, BP 1060, T 99. The client looks well developed for his age, the skin is clear and healthy, has no signs of edema. His overall physical health is good.

Mental Status

The patient is an oriented person and is very alert. The client is well developed for his age and he is well dressed according to the weather of the time of the assessment. According to the client, during the interview, everything is in school is okay. When asked about his poor grades, the client blames this on his teacher and friend claiming that they are both stupid. The client denies any suicidal thoughts or ideation.

Differential Diagnosis

According to the symptoms displayed by the client, there is a possibility that he might be suffering from Post-Traumatic Stress Disorder due to the recent loss of a loved one, his grandmother (American Nurses Association, 2014). The client might also be suffering from Attention Deficit Hyperactive Disorder which affects his academic work and performance negatively.

Case Formulation

The client is a 7 year old Caucasian male who comes to the clinic accompanied by his parents. The client has been referred to the clinic by his teacher with the teacher describing that he might be suffering from oppositional defiant disorder. The client has a history of violent outbursts, getting easily annoyed and engaging in disruptive behavior both at home and school. The client’s condition began immediately after his grandmother, whom he was closely attached to, passed away.

Treatment Plan

The recommended treatment for the client is parent management training therapy. The client is expected to attend eight therapeutic sessions that are to happen for 45 minutes, once a week. The objective of the treatment plan is to manage the client’s current behavior to help him reduce aggressiveness and defiance towards his teacher, siblings and friend. The parent management training therapy focuses on teaching the client’s parents on the most effective methods to handle their child (Kelsberg & Anna, 2016). The parent management training therapy will ensure that the client’s behavior causes less disturbance both in school and at home. The treatment plan helps to make the client’s parents understand the benefits of empathy which is the best solution when dealing with children suffering from oppositional defiant disorder.

Family Genogram

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