MENTAL STATUS EXAM
MENTAL STATUS EXAM
The client is an 8-year-old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is neutral. Katie says that she doesn’t hear any ‘voices’ in her head but does admit to having an imaginary friend, ‘Audrey’. No reports of delusional or paranoid thought processes. Attention and concentration are somewhat limited based on Katie’s short answers to your questions.
Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHAT IS YOUR DIAGNOSIS FOR KATIE?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.
299.00 Autism Spectrum Disorder (ASD), mild and co-occurring; 300.23 Social Anxiety Disorder
315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in Mathematics
314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation
ANSWER CHOOSEN: Attention Deficit Hyperactivity Disorder,
predominantly inattentive presentation 314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· You selected Attention deficit hyperactivity disorder, predominantly inattentive presentation. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer
· Decision Point Two
· BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
· 
Wellbutrin 75 mg orally daily
·
· Strattera 25 mg orally daily
·
· Adderall XR 10 mg orally daily
ANSWER CHOOSEN: Adderall XR 10 mg orally daily
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Katie’s parents seem absolutely delighted upon their return stating that Katie is paying more attention in school, but note that there is still room for improvement, particularly in the afternoon
· They report that Katie’s teacher has reported that Katie is able to maintain her attention throughout the morning classes but come afternoon, she “daydreams.”
· Katie’s parents are also concerned about her decrease in appetite since starting the medication.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Katie’s parents that weight loss is common with stimulant medications
medication with family thearpy
a small dose of immediate release Adderall in the early afternoon
ANSWER CHOOSEN: Add a small dose of immediate release Adderall in the
Guidance to Student
Whereas weight loss is common with stimulant medication, this option does not address Katie’s parents’ concerns about the return of symptoms in the afternoon.
Augmentation with family therapy is also a good idea as it can help Katie with her symptoms and further help her parents to understand the unique challenges that Katie experiences, as well as ways that they can help her with symptoms, however, this option does not address the return of inattentive symptoms in the afternoon.
Adding a small dose of immediate relate Adderall in the afternoon can help Katie to maintain attention throughout the afternoon and into the early evening when she must do homework. This would be the best option.
Learning Resources
Required Readings
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
- Chapter 3, “Contributions of the Sociocultural Sciences” (pp. 131–150)
- Chapter 31, “Child Psychiatry” (pp. 1152–1181, 1244–1253)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
- “Neurodevelopmental Disorders”
o “Intellectual Disabilities”
o “Communication Disorders”
- “Disruptive, Impulse-Control, and Conduct Disorders”
Required Media
Optional Resources
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutter’s child and adolescent psychiatry (6th ed.). Hoboken, NJ: Wiley Blackwell.
- Chapter 51, “Autism Spectrum Disorder” (pp. 665–682)
