Psychological Evaluation Report

Client Name: Kurt Andrei B. Cantos

Client Address: Banga 1st, Plaridel, Bulacan

Chief Complaint: (Inattention) Attention-Deficit/Hyperactivity Disorder

History of Present Illness: The client is a 9 year-old male with a history of neglect and care

from his parent. He is often taken cared by his relatives while his parents are busy with their

work. His grandmother reported that he would always forget the tasks that were given to him.

Whenever he plays, he makes peculiar sounds and often plays alone. He has difficulty in

constructing language which makes him hard to understand. His mind seems somewhere

whenever you try to have a conversation.

Current Symptoms:

1. Inattentive or hyperactive-impulse

2. Often does not follow through on instructions and fails to finish schoolwork, chores, or

duties

3. Easily distracted by extraneous stimuli

Relevant History: The client had been in therapies but it was stopped last year due to financial

incapability. To the best of knowledge of the client’s family, the client was often been left with

phones to play while his parent work. The client wasn’t properly trained to social/occupational

situations. The client has been transferring from place to another that developed anxiety. The

client also witnessed how his parents separated. The client doesn’t drink adequate amount of
water, he opted to drink juices, iced teas or soda. The client’s parent didn’t even bother to

recognize such problem.

Social/Developmental/Educational

The client is currently a grade 3 school student of St. Francis de Assisi Montessori School. The

client had been in preparatory and nursery classes. He was bullied when he transferred from Sto.

Nino Academy to his current school. The client felt anger and resentment but opted to express it

through playing with his gadgets. It came to a point where he can smash his computer just

because of the emotions he felt or break the phones LCD because of what he felt toward the

games he play. He opted to be alone but he can still be friendly.

Mental Status Examination

Appearance: Well-groomed/Neat/Casual/Unkempt/Other:______________
Weight: Average/Overweight/Slim Posture: Normal/Stooped/Stiff/Bizarre
Mood: Euthymic/Depressed/Dysphoric/Angry/Elated/Other:__Neutral____
Affect: Appropriate/Anxious/Apathetic/Sad/Tearful/Fearful/Confused/Angry
Speech: Normal/Slow/Blocking/Non-spontaneous/Loose Associations/Flight of Ideas/
Incoherent/Circumlocution/Short answers/Pressured
Thought Process: Normal Associations/Loose/Circumstantial/Tangential/Other:_______
Thought Content: Hallucinations (auditory__________/visual___________)
Delusions/Paranoid/Grandiose/Not Psychotic/OCD/Other:________
Intelligence: Average/Above Average/Below Average/Other:_______________
Memory: Intact/Abnormal/Developmental
Insight: None/Partial/Full
Judgement: Good/Average/Fair/Impaired/Questionable
Test Administered
1. Bender Visual Motor Gestalt Exam
2. House-Tree-Person Test
3. Draw a Person Test

Interpretations of Test Results

1. Bender Visual Motor Gestalt Exam
Figure A
Error: position of first drawing – center
Figure 5
of page
Error: retrogression
Interpretation: The client has the
Interpretation: The client has the tendency to have
tendency to have narcissism,
defense against trauma, anxiety and poor defenses.
egocentrism, and passive
oppositionalism.
Figure 6
Figure 1 Error: curvature difficulty, collision
Error: retrogression Interpretation: The client has the tendency to have
Interpretation: The client has the emotional disturbances, increased emotionality, and
tendency to have defense against decreased repression of emotions and can indicate
trauma, anxiety and poor defenses. depression, loss of control, poor anticipatory planning
and impulsivity.
Figure 7
Figure 2 Error: change in angulations, crossing difficulty,
Error: retrogression redrawing of total figure
Interpretation: The client has the Interpretation: The client has the tendency to have
tendency to have defense against problems with emotional control, psychological
trauma, anxiety and poor defenses. blocking, indecisiveness, compulsive doubting, and
phobias.
Figure 3
Error: perceptual rotation Figure 8
Interpretation: The client has the Error: no error
tendency to have severe disturbances in Interpretation: The client has no tendency to have
ego functioning, psychotic tendencies problems.
and oppositional tendencies.
Figure 4
Error: curvature difficulty
Interpretation: The client has the
tendency to have emotional
disturbances, increased emotionality,
and decreased repression of emotions
and can indicate depression.
2. House-Tree-Person Test

House
• Overly large roof, overhanging & dwarfing the rest of the house
• Schizophrenic patients or schizoid p.d.

Walls

• The outline of the walls of the house drawn with a faint and inadequate line quality

Accessories

• Some patients directly reveal their feelings of insecurity by having to surround and
buttress their house with many bushes, trees, and other details unrelated to the
instruction.

Tree

• Pregnant women often offer fruit trees and depressed patients, shows a propensity for
weeping willows.

• Young children will frequently draw apple trees; 35% of kindergarten children; 9% at
the age of 10; and close to none by 14 years old.

Person/Size

• May also mean manic or expansive tendencies, anxiety/conflict.

• Unusually small.

3. Draw a Person Test

• Large head- fantasy is primary source of satisfaction.

• Tiny eyes- strong visual curiosity
• Tiny mouth- denial or oral dependent needs.
• Stick figure-possible depression.
Behavioral Observations/ MMSE
It was noticed that the client would walk around the room while the interview was on
going. He appeared to be inattentive, uncooperative and not composed but follows commands
rarely. He appears disoriented. There was some difficulty in communicating since he was pre-
occupied by his own "world" and questions need to be repeated numerous times in order to be
answered. He seems to be small and thin than the average of his age. He seems to have no idea
when asked where his father is and appears to answer favourably when asked about his mother.
His reaction time is sometimes delayed. His thoughts are scattered and is a word salad when
answering the questions mid-way of the interview. Memory seems to have a problem and might
need further observation.

Cognitive Functioning
The client’s general intellectual functioning was measured to fall within the Below
Average range with his overall thinking and reasoning abilities. He performed slightly better on
nonverbal than on verbal tasks, there was no significant difference. The client’s performance on
the verbal subtests contributing to this overall index, indicating that his verbal cognitive abilities
are not properly developed. The client’s nonverbal/perceptual reasoning abilities were also
measured to be in average. He performed similarly on the perceptual reasoning subtests
contributing to this overall measure of nonverbal reasoning, indicating that his visual-spatial
reasoning and perceptual-organizational skills are not quite developed. The client’s overall
ability to regulate her responses and respond appropriately (Inhibition of Impulses) was
measured to be seriously impaired. The largest impairment in this area was with regulating his
responses to auditory stimuli. The ability to regulate his responses to visual inputs was also
impaired but much less so. His overall ability to make accurate responses, stay focused, and
sustain his attention was found to fall in the below average range. The client’s ability to reliably
respond accurately and quickly under low demand conditions as well as sustain his attention and
be flexible under high demand conditions was weaker with auditory input than with visual
inputs. His auditory performance in this area was found to be in the below average range.
However, the client’s visual performance in this area was in the average range. Overall, it
appears that the client is best able to attend to visual information when time is not a factor and
when he is able to do so in a distraction-free environment.
Affective Functioning
The client’s ability to regulate his emotional responses is likewise impaired and
experiences of frustration can overwhelm his efforts to constrain their overt expression. Task
initiation appears to be a significant problem for him. The client’s ability to shift from one mode
of solution seeking to another also appears to be less developed than most persons of his age. His
level of flexibility in problem solving is significantly limited and leads to him engaging in
unproductive efforts until he gives up rather than systematically trying different approaches. The
client’s capacity for sustained attention is compromised as he is easily distracted by external
stimuli. The results indicate a significant level of distractibility especially to sounds. When on an
effective goal directed path, he effectively sticks with an activity. The client’s ability to hold
items in memory while performing another operation is another area of significant impairment
for him. His working memory is not as developed as most of his age group. He appears to have
problems keeping more complicated information in memory. This might be more of a measure of
his inattentiveness than of a memory problem in that he knows what to do, but does not do it in
the moment something more desirable is present.

Interpersonal Functioning
The client’s profile indicates that her interpersonal functioning is somewhat impaired due
mostly to his unusual antics and behavior. While he is capable of a normal level of openness and
tends to be friendly at times. The client’s intimate relationships, once established, are prone to
show a clingy quality of relatedness as his needs met. The results indicate that he tends to see
others as a player in a game.

Diagnostic Impression:
The client has ADHD-Inattentive type features. There is a serious deficit of emotional
support to handle psychological functioning. His psychological controls and functioning can be
underdeveloped. He presents with mother for trouble doing homework and other simple chores.
Problem was first noticed 2 years ago but started getting worse lately. He is not able to focus,
concentrate, very easily distracted and gets angry, agitated and anxious under conditions of
stress. He is having trouble with being bullied at school and is being shunned by peers. He fits
into the criteria of ADHD but other conditions like generalized anxiety disorder, general medical
conditions, conduct and oppositional defiant disorders, age appropriate behavior, response to
environmental problems, mental retardation, autism and mood disorders are to be ruled out. His
precipitating issues are school work and any type of stress. His perpetuating issues are the
unaddressed problems.

OR

Axis I: working diagnosis of ADHD. Need to rule out generalized anxiety disorder, general
medical condition, conduct disorder and oppositional defiant disorder.

Axis II: possible dependent personality on mother

Axis III: myopia/ Need to rule out general medical conditions

Axis IV: mild to moderate social issues

Axis V: GAF 55
 BULACAN STATE UNIVERSITY
City of Malolos, Bulacan
College of Social Sciences and Philosophy

Psychological Evaluation Report

Prepared by:

Deogrades, Charlotte
Due, Jasthene Marie T.
Estanislao, Nuena Y.

BS Psychology 3A

Dr. Raymundo Faustino, RP

Instructor, Clinical Psychology

May 2017