Psychological Examination Ms.

A Smith Psychological Evaluation Confidential

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Name: Birthdate: Age: Gender: Education: Report Writer: Date of report: Instruments Administered: Clinical interview

Case Number October 16, 1980 16 years, 0 months Female 9th grade November 2, 2005

Reason For Referral Ms. A. Smith is a 16-year-old African-American female who was referred for a psychological evaluation as part of a Diagnostic Assessment Class at Clark Atlanta University, Atlanta, Ga. She presented as a well-nourished female of average height and weight. Her hygiene and grooming seemed adequate. No unusual behaviors were observed and she did not demonstrate any difficulty moving about the evaluation site. The Ms. A. Smith provided the following information. Ms. Smith was born in Connecticut and is an only child. Her parents never married and primarily her mother, Ms. Smith, reared Ms. Smith. She reported that she did not know much about his biological father. Ms. Smith was the product of a full term uncomplicated birth. No history of head trauma was reported. Ms. Smith's mother reported that sexual abuse was suspected when Ms. Smith was in daycare, "it was investigated but never proven." No history of health problems was reported. No medications are currently prescribed. Educational History Ms. Smith began school at the expected time. Her mother reported that she demonstrated behavioral problem beginning in daycare, "she had problems with authority even then." She repeated kindergarten because "her teachers thought that she was not mature enough to be promoted to the first grade." Ms. Smith mother reported that her daughter " has always had problems with teachers and being told what to do." Ms. Smith's mother reported that at 11 years of age, Ms. Smith began staying out late and "hanging out with undesirables." When she was 11 she was arrested when the police raided a house for drugs. Her mother stated that Ms. Smith was almost raped once, but this was never confirmed. After the arrest Ms. Smith was placed in a residential facility. She was there for one and one-half years. The family moved from Connecticut to California; they

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were there only nine months. "She did OK while we were in California." Ms. Smith and her mother moved to Georgia in 1995. Ms. Smith's mother is currently unemployed. Since moving to Georgia Ms. Smith was placed in classes for the learning disabled. In the ninth grade, Ms. Smith was placed in classes for the behavioral disordered. Currently, Ms. Smith is a ninth grade student at a high school in DeKalb County, Georgia. Health History Ms. Smith denied having a history of health problems. No history of being diagnosed as having an attention deficit disorder was reported. Substance Abuse History Ms. Smith reported that she began experimenting with alcohol at the age of 12. She reported that her alcoholic use was sporadic. She denied having a history of intoxication due to alcohol use. She began using marijuana at the age of 14. She admitted smoking marijuana about once a month and she has been intoxicated five to six times smoking marijuana. No current marijuana usage was reported because of her being incarcerated. Ms. Smith reported that she smokes less than a pack of cigarettes a day. No other drug use was reported. Legal History Her initial contact with the Juvenile Court was in April 1995, when she was charged with making Terrorist Threats. That charge was dismissed. In May 1995, Ms. Smith was charged with Run Away and ungovernable behavior. Her mother refused to allow Ms. Smith to return home and a deprivation charge was filed. Ms. Smith was placed on 12 months probation and temporary custody was granted to the Department of Family and Children Services for 18 months. While on probation she was charged again with Running Away on August 1995. In January 1996, Ms. Smith was charged with Violation of Probation and was ordered to participate in intensive 24 months probation. While involved in intensive probation, Ms. Smith was charged with Violation of Probation. In April 1996 Ms. Smith was ordered to serve 45 to 60 days in a youth development center for using fighting, vulgar language, and harassing phone calls. Ms. Smith was again charged with Violation of Probation again on July 12, 1996, and on July 24, 1996. Since being at this facility her mother reported, "Ms. Smith has been good while at this facility." Her mother also reported that she is in counseling and this has helped their relationship. When asked about her behavior Ms. Smith reported "I have a temper that I need to control. I have outbursts. When I get angry I cuss a lot. I have been having these outbursts since I was 14. My attitude has changed since being her, but I don't know why."

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Mental Status Examination Ms. Smith presented as a well-nourished female of average height (5'3") and weight (115 pounds) body build. She appeared her stated age. She was casually dressed and her hygiene seemed adequate. Her gait and posture were normal. No unusual behavior was observed. Rapport was easily established and maintained. When asked about her mood Ms. Smith reported that she felt happy and playful most of the time. Ms. Smith reported that she has a temper and admits that anger is a problem for her. Ms. Smith's speech was relatively clear; at times she mumbled when she spoke which made her responses difficult to understand at times. Her thoughts were organized and coherent. She denied having past or present thoughts of harming herself or others. No histories of auditory or visual hallucinations were reported. Ms. Smith denied having any specific phobias, obsessions, or compulsions. She denied having feelings that others can read her mind or that she can broadcast her thoughts to others. Her attention and concentration were age-appropriate and her immediate, recent, and remote memory seemed intact. She denied having problems concentrating. She demonstrated limited insight into her problems and her judgment seemed adequate. Ms. Smith appears to be functioning in the Average range of intellectual abilities. Overall, she did not present as having a thought disorder nor did she present as being a danger to herself or others. Behavior Observations Ms. Smith approached the testing session in a cooperative and friendly manner. Neither disruptiveness nor difficulty in cooperation and compliance were noted during the evaluation. Her appearance and grooming were adequate and appropriate. She had a deliberate style of answering and working on most problems. Attention and effort were age appropriate. Most work was completed with an orderly plan and self-correction. Responses were usually made in a reflective, thoughtful manner. Signs of impulsivity or carelessness were not observed. Her activity level was observed to be within normal limits for age range. Fidgeting or difficulties remaining seated were not noted. Ms. Smith did not engage readily in spontaneous verbal expression, and had to be prompted or urged to elaborate on brief responses. Instructions were followed carefully and understood without apparent difficulty. Repetition and emphasis were not needed. When new tasks or new instructions were presented, there was no difficulty adjusting or responding appropriately, and no signs of emotional reactions or unexpected errors on early items. She made an adequate effort on most tasks, and reacted to failure without clear frustration or renewed effort. Motivation to succeed and perform well appeared to be adequate. In general, the obtained results are considered a valid and reliable sample of her percent level of functioning.

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Summary Ms. Smith is a 16-year-old African American female who is currently housed at Another Chance Children's Center. The Department of Children and Youth Services for violation of probation placed Ms. Smith at this facility. Ms. Smith has a history of involvement with the juvenile justice system as well as the juvenile justice system in her birth state, Connecticut. Her most recent arrest was for shoplifting, running away from home, and violation of probation. Diagnostic Impressions - DSM-IV Axis I:312.8 Conduct Disorder, Adolescent onset type, moderate. 305.60 Cannabis Abuse 312.30 Impulse Control Disorder, Not Otherwise Specified. V61.20 Parent-Child Relational Problem Axis II: V71.09 No Diagnosis on Axis II Axis III: None Axis IV: None Axis V: 70. Recommendations 1. Ms. Smith will require a well-supervised residential program. A program that requires and fosters interdependence and cooperative work is preferred. Compliance to social standards and probation expectations must be emphasized firmly and consistently. Periods of detainment may be needed to reinforce compliance and appropriate behavior. 2. Individual therapy, in addition to group therapy, will be needed to help Ms. Smith and develop more appropriate and functional interpersonal problem-solving skills. Ms. Smith may benefit from involvement in a substance abuse psycho educational group. Additionally, she may be a good candidate for a Vocational Rehabilitation assessment. He seems motivated to work, but her vocational choices are vague. Family therapy will be needed to help Ms. Smith's mother develop more appropriate strategies to manage her behavior in the community, if and when a return to home is considered

3.

4.

Respectfully submitted, ____________________________ Report Writer

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