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Psychological Associates
Ima Doctor, Psy.D. - Licensed Psychologist
Jane Doe, M.A., NCC
Consulting – Evaluations - Therapy
Everytown, PA 12345
PSYCHOLOGICAL EVALUATION
Susie B. Good
March 19, 2010
Identifying Information
Birth Date:
6/6/07
Age:
2 years, 9 months
Gender:
Female
Race: African-American
Address:
1430 First St
Anytown, PA
Phone:
Resides with: Norma Johnson
Parents (Separated):
Mother: Norma Johnson
Father: N/A
Custody:
Birth Date: 06/07/89
Birth Date: N/A
Mother
Siblings:
Mother pregnant due in 3 months
School District: N/A
School: J & D Child Care Center
Birth Date: N/A
Grade: Older Toddler Room
Community Systems Involved:
County Children and Youth: Penny Jones, Caseworker
Primary Physician: Children’s Health Clinic
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Reason for Referral
Susie Good was referred for a Psychological Evaluation by the Case Worker at County,
Penny Jones, due to her reported history of noncompliance with her caregiver’s
directives, tantrum behaviors, poor manners, aggressive behavior toward others, and
safety concerns. The purpose of this evaluation was to determine whether her emotional
and behavioral functioning warrant Behavioral Health Rehabilitation Services, as well as
to make treatment recommendations.
Relevant Information
Background History
Susie Good is a 2-year, 9-month-old African-American female, whose strengths as
reported by her mother include her intelligence, interest in being outside, and enthusiasm
for life. Susie currently resides with her mother. Ms. Johnson is apparently nearly five
months pregnant at this time. It is reported that Susie has had no contact with her
biological father, whose name was not provided, throughout her life, and she considered
her mother’s former boyfriend to be her father. This boyfriend left the home several
months ago reportedly upon learning that Ms. Johnson is pregnant. Regarding family
history, Susie’s maternal grandmother has a history of illicit substance use including
alcohol and crack cocaine. Susie’s mother reportedly was raised in foster care from an
early age. Also, a paternal uncle allegedly was a fire-starter and had unspecified mental
health issues. In addition, her father has a history of incarceration for unspecified
charges. There was no other reported family history. Susie reportedly has not
experienced any physical, sexual, or emotional abuse, although it seems that she has
experienced a good deal of neglect while in the care of her mother. Ms. Johnson has
reportedly failed to follow through on treatment recommendations for Susie while
involved with services in the past.
Developmentally, Susie was reportedly born at 42 weeks gestation via vaginal delivery.
It was apparently a very complicated pregnancy, as Ms. Johnson was anemic. Ms.
Johnson reportedly worked throughout the pregnancy despite the fact that doctors had
ordered her to go on bed rest. She reportedly had recurrent stress tests throughout the
pregnancy, and was prescribed extra vitamins and iron. Susie apparently attained her
developmental milestones within normal limits, although specifics of there were not
available. Medically, Susie apparently has asthma. It was reported that there is a family
history of diabetes, and Ms. Johnson has had a cyst on her ovary. Susie is currently
attending a toddler class at J & D Child Care Center. It was apparent that Susie is
developmentally on target, if not advanced. In the past, she had reportedly attended
another child care facility. She seemingly had severe aggressive behavioral issues in this
setting.
Behaviorally and emotionally, Susie has reportedly evidenced noncompliance with her
caregiver’s directives, tantrum behaviors, poor manners, aggressive behavior toward
others, safety concerns, and difficulty with self-regulation, as well as emotional issues.
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Her temper tantrums have reportedly been triggered by limits being set on her, and she
has reportedly exhibited quick changes in mood, and risk-seeking behaviors. Due to her
emotional and behavioral difficulties, Susie has received several interventions. She has
been receiving case management services through the County Children and Youth
Agency since March of 2008. She was referred psychiatric services through Dr. Krane,
but no progress was achieved, as Ms. Johnson was noncompliant with treatment and did
not follow through with recommendations. Involvement in community activities was
denied, and history of involvement was unknown.
Evaluation Procedures
Clinical Interview
Behavioral Observations
Review of Records
ADHD Rating Scale-IV-Home Version
Behavior Assessment System for Children (BASC) – Parent Rating Scales
Interview/Test Results
Behavioral Observations
Susie was brought to the current evaluation by her mother, Norma Johnson. Susie
presented as a casually dressed youth of possibly below average height and of average
weight for her age. Her hygiene appeared to be good. She readily accompanied this
evaluator to the evaluation room, and was cooperative in participating fully in the
session. She made appropriate eye contact, and was quite active and outgoing, although
she did not evidence any difficulty with self-regulation during this session. Susie
attempted to do a puzzle, even though it was difficult for her as it was advanced for her
age, and she stayed with this activity for some time. She put the puzzle back into the box
with one prompt from Betsy Johnson. She then requested if she could use the dry erase
board, and was provided with markers to do so. She scribbled on the board. She did not
know how to write her name, although when this evaluator showed her she seemed intent
on learning. She seemed to enjoy when this evaluator helped her form her letters,
although she also made an effort to form them without assistance. Susie asked for an
eraser for the board, and was given a paper towel. She spontaneously responded “Thank
you” when handed the towel. She also spontaneously thanked this evaluator when given
the markers. She stuck the ends of the markers together at one point, and twirled them as
a baton. She also moved them along when they were stuck together, and made a train
sound. Susie listened to limits within the first directive, and she was easily able to be
redirected by this evaluator and by her maternal great-grand mother. She saw a carpenter
bee outside the window, and seemed to become a bit anxious with this. She closed the
inside shutters so that the bee could not come in. This evaluator then watched the bees
with her, although it seemed that she was able to withstand this activity for only a short
time before becoming nervous about the bees getting inside again. She discussed
squishing the bee with her foot. At the end of the session, Susie asked this evaluator to
put the markers back up on the board. She spontaneously stated “Thank you for letting
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me play with them” when handing over the markers. In general, Susie did not evidence
any atypical behaviors given her age. Overall, given the information obtained from this
evaluation, as well as the information obtained from a review of her records, it was felt
that the results of this evaluation provided an accurate reflection of her primary issues.
Mental Status Exam
During the evaluation, Susie was alert and oriented to her name. She seemed to become
familiar with the facility quickly. However, she was not questioned regarding the other
two spheres given her young age. Her affect was felt to be unrestricted, and her mood
appeared to be level. Betsy Johnson reported that her mood seems to be generally
positive. Thought processes appeared to be reasonably clear, logical, and goal-directed,
and there was no evidence of loose associations, flight of ideas, or other signs of a formal
thought disorder noted. Susie has not evidenced that she experiences any perceptual
abnormalities, such as auditory or visual hallucinations, and there was no evidence of
delusional thinking. There was no information that she has experienced homicidal
ideation with intent, or suicidal ideation. However, she has a reported history of
aggressive acts toward her caregivers, and peers. Susie’s intelligence seemed to be in the
average, to possible above average range, based on her ability to comprehend language,
verbalize, and understand ideas and activities quickly. Insight was felt to be adequate
relative to her age, and judgment was felt to be somewhat impaired.
Emotional/Behavioral Functioning
A predominant area of difficulty for Susie has involved her disruptive behaviors,
including those of an oppositional, defiant, or aggressive nature. She has reportedly been
aggressive with her caregivers and her peers. Susie reportedly is noncompliant with her
caregivers directives and limits, and tantrums when she does not get her own way in her.
She also has poor manners, according to a report. She has also apparently been
argumentative and disrespectful to her caregivers. Susie has also has exhibited violent
plan, including putting baby dolls, stuffed animals, and clothing, in the toy oven,
pretending to turn the oven on and stating “Now they will all burn up”. In addition, she
has apparently thrown toys, and tried to convince other children to throw themselves
down the steps. She has hid her caregiver’s personal items at home, and has put pencils,
crayons, and other larger objects into the toilet and flushed it. She has broken light
switches from turning them on and off repeatedly. She reportedly refuses to take
responsibility or apologize for her behaviors. At the Interagency Meeting in March 2010,
Susie was reportedly not permitted to have a drink from a glass bottle, and was offered a
plastic cup instead. She reacted to this by throwing the glass bottle against the wall and
hitting and kicking staff. She also reportedly has a history of evidencing temper tantrum
behaviors when limits are placed on her or when others do not comply with Susie’s
demands. Susie has a history of calling names, when given a directive by a caregiver
Susie reportedly responded by calling the caregiver a “mother f—king b—ch”. In
addition, she has been aggressive over toys, and has hit her classmates to get the toys she
wanted. She also has broken toys. Her mother has reports that Susie never behaves in
this manner at home. She did relate in the past that Susie stays awake until 2 am and is
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up at 6 am.
Susie’s mother did report significant symptoms of hyperactivity, impulsivity, and
distractibility in the past. A recent report indicated that she has a history of poor selfregulation involving jumping on the furniture, running around the house, jumping off of
the stairs and off of her bed, and being constantly on the go. She also reportedly has a
history of being unable to focus her attention or maintain concentration to complete tasks,
and going from one activity to the next very rapidly. She also has a reported history of
being impulsive, including blurting out answers and not being able to wait her turn. Ms.
Johnson completed the ADHD Rating Scale-IV-Home Version, according to her
observations. On the ‘hyperactivity/impulsivity’ subscale, her responses indicated that
Susie frequently fidgets with her hands or feet or squirms in her seat, leaves her seat in
the classroom or in other situations in which remaining seated is expected, is “on the go”
or acts as if “driven by a motor”, and has difficulty awaiting her turn. Also, on the
‘inattentiveness subscale, Ms. Johnson’s responses indicated that Susie frequently, fails
to give close attention to details or makes careless mistakes in schoolwork, has difficulty
sustaining attention in tasks or activities, does not seem to listen even when spoken to
directly, has difficulty organizing tasks and activities, avoids tasks that require sustained
mental effort, and is easily distracted. It is of note that many of these symptoms are ageappropriate, given that Susie is only a few months over 2.5 years old. Ms. Johnson
completed the Behavior Assessment System for Children (BASC)-Parent Rating Scales
based on her observations of Susie. The results of this measure indicated to Clinically
Significant areas of concern.
Emotionally, Susie is reportedly not evidencing any issues at this time. However, she
does show some extreme anxiety related to bugs, and she cries and tries to go away from
them. Her caregivers have apparently previously reported that she goes from a happy
mood to an angry mood very quickly with no known trigger.
In discussion of Susie’s issues, it seems important to consider that, given her young age,
she seems to have had a great amount of time to act independently without appropriate
adult supervision while in the care of her mother. It also seems that Susie has been in the
presence of poor modeling by adults, given the fact that she knows curse words and the
appropriate context in which to use them. Susie has also likely been left unsupervised for
some time, as she reportedly has been surprised at time when she sees another person in
the Johnson home when it is relatively quiet, as she has reported during these times that
she “thought no one was here.”
Diagnostic Impressions
Susie Good is a 2-year, 9-month-old African-American female, whose strengths as
reported by her mother include her intelligence, interest in being outside, and enthusiasm
for life. Susie’s behaviors, have reportedly involved aggression, argumentativeness,
noncompliance, and problems related to her own safety and the safety of others, when in
a child care setting. However, she has not evidenced such issues in the home, by report
of her mother. However, it is also evident that she has experienced a great amount of
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time when she is alone and unsupervised in the home of her mother, as children of her
ages are not typically able to behave in such a manner and to become involved in the
reported activities as she reportedly has when they are properly supervised. Also, it
seems that Ms. Johnson was unable to effectively recognize her behaviors when she was
present. Therefore, Susie is currently assigned diagnoses of Disruptive Behavior
Disorder Not Otherwise Specified, By Report, and Parent-Child Relational Problem.
Also, by report, Susie seems to have a history of having difficulty with self-regulation,
involving hyperactivity, impulsivity, and inattentiveness. It is of note that she is currently
not prescribed medication to address these symptoms. In addition, these symptoms
during this session seemed to be age-appropriate. As such, she is assigned a ‘rule-out’
diagnosis of Attention-Deficit/Hyperactivity Disorder at this time. This is assigned on a
‘rule-out’ basis given that her behaviors during session seemed age-appropriate, and
given that she has not been provided with a structured home setting at the time when
these behaviors were reportedly a problem. In general, it appears that Susie has a number
of issues that suggest the need for intensive intervention. Her issues appear to be more
significant than could be treated simply in weekly outpatient therapy. While she does not
appear to require inpatient treatment, it appears that Behavioral Health Rehabilitation
Services are both psychologically and medically necessary. Specific diagnoses and
recommendations follow.
Diagnoses
Axis I
312.9
V61.20
995.52
r/o 314.01
Disruptive Behavior Disorder Not Otherwise Specified
Parent-Child Relational Problem
Neglect of Child, Victim, By Report
Attention-Deficit/Hyperactivity Disorder, Combined Type
Axis II
799. 9
Diagnosis Deferred on Axis II
Axis III
History of anemia and asthma.
Axis IV
Psychosocial Stressors: Problems related to the primary support group
involving, history of conflict with caregivers, history of a lack of
supervision; history of social difficulties due to aggression; eminent
introduction of new sibling.
Axis V
Current GAF:
Highest GAF in Past Year:
50
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Recommendations
1.
Given Susie’s emotional and behavioral difficulties, it is felt
psychologically and medically necessary that she be provided with BHRS Case
Management services, to work in conjunction with the County and Children
Agency in order to coordinate services among all providers involved in her care,
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and for the identification, assessment, development, facilitation, and monitoring
of service needs. Regular communication between family members, treatment
providers, is also recommended.
2.
With regards to specific interventions, it is recommended that Susie
receive Behavioral Health Rehabilitation Services with treatment delineated by a
Behavioral Specialist Consultant (2 hours per week) and caregivers. It is
recommended that the Behavioral Specialist Consultant hours are utilized to
observe and assess Susie across environments to better assess her needs and to
design and implement a behavioral treatment plan, if necessary.
4.
Susie seems to be eager to learn, and she is currently receiving consistent
academic instruction for the first time. It is recommended that her child care
placement be closely monitored and assessed for its appropriateness, and that
Susie be provided with interventions to enable her to perform to her academic
potential in the least restrictive environment possible.
5.
Socially, Susie is able to initiate friendships. However, she seems to have a
tendency to be aggressive in social interactions at times. It will be important to
ensure that she has ample opportunities to socialize with her peers in healthy
activities with supervision, so that she can continue to hone social skills and be
redirected when she behaves inappropriately.
6.
It is recommended that Susie receive another psychological evaluation within four
months to assess her progress and to determine the necessity and nature of
continued services.
Respectfully Submitted,
______________________________
Jane Doe, M.A., N.C.C.
Psychological Assistant
Supervised by, Reviewed by, and Submitted by
______________________________
Bob Jones, Psy.D.
Licensed Psychologist
Lic # PS-02030405
__________________
Date