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Clinical Assessment

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Clinical Assessment
Kat Grimaldi
PSY/270
3 October 2013
Michelle Bailey

Clinical Assessment Scenario for this clinical assessment includes: A four year old daughter, named Clara, adopted by Mr. and Mrs. Lawson. Mr. and Mrs. Lawson took Clara to see a psychiatrist, named Dr. Mason. As Clara was entering the room, she was polite and greeted Dr. Mason, but did not smile and kept her gaze down as she took a seat. Clara’s adoptive parents took a seat next to her and began explaining, to the doctor, about their concerns. They described Clara as a quiet child who has recently begun throwing temper tantrums, during which she is inconsolable. Clara’s sleep and eating patterns have changed, and she no longer wants to go to preschool. Based on the limited information provided in this scenario, there are other questions that I would like to see answered. The very first step I would take, before asking for more information from the adoptive parents, is to remove Clara from the room and place her in an atmosphere that better suites her, like a play room located in the office building. After Clara is removed from the office, I would start of by asking if the adoption was an open adoption, and the age when Clara was adopted. If the adoption was not an open adoption, the true parents of Clara could be trying to make contact with her while she away from her adoptive parents. This can cause confusion in Clara, and possibly be a reason why her behavior has all of a sudden changed. I would also ask how long they had Clara, and if they had any information on Clara’s biological parents. If they did have background information on the biological parents, I would want to find out if there was a history of any psychological disorders or mental illnesses that could include; depression, anxiety, or any learning disabilities. I would ask if anything changed in their household since they noticed changes in Clara’s behavior. Some changes could include, moving, changing work hours, or changing preschools. I would ask how the marriage is between Mr. and Mrs. Lawson. Do they fight or argue when Clara is present? I would ask how the teachers, and kids are in the preschool Clara is attending. I want to know how the teachers and kids are because there could be something occurring at the preschool involving another child or some of the other kids, and/or teachers. I would also want to know when Clara throws her temper tantrums. Is it when she is told no, or is it when she does not get her way? I would also ask when Clara’s last physical exam was. I want to know if the medical doctor said she was in tip top shape, or if the doctor noticed that something was wrong. For example, if the doctor had a concern about her hearing or eyesight. After I asked all of the above questions, I would bring Clara in to interview her. I would want to see how she interacts with me. After interviewing the adoptive parents, I would bring Clara in for her interview. I want to interview Clara so that I could see, for myself, how she reacts to me. Even though I asked her adoptive parents all of the questions that came to mind in order to get to know Clara and her situation better, I know that the adoptive parents could be keeping some things to themselves because they are automatically going to have a guard up to protect themselves and Clara. I would try and interact with Clara as much as I could. I would ask Clara what she thinks about preschool, and her adoptive parents. I would ask Clara the kind of activities she does in preschool. At four years old, Clara should be able to communicate with me fairly well. After talking to Clara, and seeing how she reacts to me, I would use some clinical assessment tools so that I could gain more insight on what is exactly going on with this four year old. Using clinical assessment tools will help me evaluate the current state of the patient. The first clinical assessment test that I would consider giving Clara, would be a drawing test. Drawing tests are put in place to assess the functioning of children. Kinetic family drawing test is a popular test to give to children. The child draws their family performing some kind of activity, then the child explains what the people in the drawing are doing (Comer, 2011). I would also consider some neurological testing. Neurological testing are tests that directly measures brain structure or activity. I would highly consider a neuroimaging test. These are tests that provide images of brain structure or activity, such as CT scans, PET scans, and MRIs (Comer, 2011). By performing neuroimaging tests, I would be able to determine if there are any abnormalities in the brain that is causing Clara’s extreme behavior. I would also consider an intelligence test. An intelligence test is a test designed to measure a person’s intellectual ability (Comer, 2011). Clara is a four year old. Four year olds should know how to dress themselves, speak in a fairly complex sentence, know names, addresses, and phone numbers, if taught, names 6-8 colors and 3 shapes, and they should be able to understand and remember their own accomplishments (National Network for Child Care, 2002). After considering the above clinical tests, I would like to observe Clara in her natural environment. People often act a different way if they put in a position where they are not comfortable. An office setting in a psychiatrist’s office may make this family uncomfortable therefore; they may be hiding their true feelings, and concerns.
If I was preparing to diagnose Clara, I would use the DSM-IV classification system to evaluate her condition. I would have to consider whether or not Clara is displaying one or more disorder. Axis I is an extensive list of clinical syndromes that typically cause significant impairment. Axis I may involve anxiety and major depressive disorder. Axis II would include; dependent personality disorder or mental retardation. Axis III could include; brain cancer or any other medical conditions the patient is suffering from. Axis IV could include; social problems. Axis IV is about special psychosocial or environmental problems the person is facing, such as school or housing problems, and Axis V would rate the person’s psychological, social, and occupational functioning overall (Comer, 2011). I think diagnosing Clara, at her present age, would be beneficial to her. Being diagnosed at such a young age helps the person cope and learn how to control their disorder. She has her whole life ahead of her. For example, if Clara was diagnosed with having a learning disability, Clara would receive treatment at the age she is now, and be able to learn how to live a productive life while learning how to handle and control her disability. Her adoptive parents would also benefit because they would have the tools needed to help Clara with her disability. Another example would be anxiety and depression. If it was found that Clara was suffering from anxiety and depression at such a young age, she could be put on anti-depressants or anti-anxiety medication to help her deal with her disorder. Her parents would better understand what she is going through, and they would have more insight on how to help her control her disorder. At such a young age, Clara would have the time to find out what works for her, when addressing her disorder, and she would be able to do better in her overall life as she grows and gets older.

References

National Network for Child Care. (2002). Retrieved from http://www.nncc.org/child.dev/ages.stages.4y.html
Comer, R. J. (2011). Fundamentals of abnormal psychology (6th ed.). New York, NY: Worth.

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