Client History Report Draft: Psychological Assessment

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Identifying Information

Timothy Childers is 15 years old; he is a male of Caucasian ethnicity, although he describes himself as ‘mixed-race’. Timothy is right-handed, cisgender, and heterosexual. Timothy was born and raised in Minnesota, the youngest of 3 children – he has a sister and a brother. Timothy has a good relationship with his siblings, as he mentions admiring his sister and going out to sports games to support his brother. Timothy lives in a full family; his parents have been married for his whole life. His father is an account manager, and his mother is an engineer. Timothy claims to have a good relationship with his parents. Timothy has a 7-year-old golden retriever whom he loves very much.

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Timothy says that his religious affiliation is ‘seeking’, although his mother states that he is Baptist. Timothy goes to High school; he is currently in the 10th grade. Timothy is not interested in sport; he likes playing drums and dancing. Besides, he is interested in auto racing and claims he would want to become a NASCAR racer in the future. Another possible career choice for Timothy is being a drummer in a rock band.

Timothy has several friends with whom he likes hanging out. When his parents allow him, Timothy goes out to games, to the mall, or the cinema with friends. There are girls that Timothy finds attractive – he says that they talk, and the girls consider him ‘cute’ as well. Timothy denies having any interest in smoking, drinking alcohol, or taking drugs.

Reason for Referral

Timothy was cooperative and pleasant to work with, and there were no behaviors that suggested a reason to doubt the validity of the test results. Nevertheless, the contradictive results from Harris-Lingoes subscales suggest possible underlying issues that did not come up during Timothy’s interview. Ms. Childers, Timothy’s mother, brought him to the appointment based on the possibility of a learning disability and/or Attention-Deficit/ Hyperactivity Disorder (Kennedy & Harper, 2014).

Timothy has a history of varying grades and academic difficulties stemming from first grade. He has had issues with his mathematics teacher about his accomplishments. He has been accused of cheating because he does not always show his work that leads up to the result. Timothy himself values the correctness of the result but believes that he does not have to show his process of thinking if the answer he has gotten is right.

Lucangeli and Cabrele’s statement that students with ADHD / ADD may “fail in a variety of cognitive tasks because of their inability to focus on the most relevant information” was contradicted by observations of mathematically gifted students (qt. in Singer, 2016, p. 216). Krutetskii claims that the traits of mathematical giftedness include the ability to handle information that is more towards the complicated level and therefore skip steps, which allows them to abbreviate problem-solving (qt. in Singer, 2016, p. 313).

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Based on the Behavior Rating Inventory of Executive Function, Timothy’s mother sees him as someone who has difficulty resisting the urge to act on impulse or as someone who has problems inhibiting his behavior appropriately. He has also been flagged, through the Metacognition Index’s scales related to planning and organization, as someone who has difficulty organizing his work and plays spaces and having difficulty planning out and sequencing the steps needed to achieve a goal.

Although Timothy’s mother reports no problems with emotional control, from the examination of his underlying personality factors with the PSY-5 scales, results show that he tends to look at the world in a negative manner proven by his moderate score on the Negative Emotionality/Neuroticism scale (Butcher & Williams, 2014). However, Timothy himself believes that there is nothing wrong with him, that the problems lie with the teachers and his parents (Kennedy & Harper, 2014). His learning difficulties in his eyes are a result of the teacher’s inability to follow the textbook, which may lead to an assumption that skipping steps during classes leads to him not grasping the full concept, something that is known to be a problem for students with ADHD (Singer, 2016).

The reason for the referral is to realize what Timothy may or may not need help with. It is getting his abilities and traits assessed so there could be a clear picture of whether or not his daily life is interrupted by the characteristics connected to Attention-Deficit / Hyperactivity Disorder.

Current Symptoms / Presenting Concerns

Symptoms present, and concerns with Timothy come under an umbrella term of behavioral problems such as direction following, disruptiveness and loudness, and issues with authority. Sometimes he may come off as rebellious, impulsive (from the subscale “Adolescent Anger” on Content Component Scales), and argumentative. An additional cause for trouble maybe his poor judgment, from the subscale ‘Interpersonal Suspiciousness’. It can be interpreted that he is suspicious of positive, and once that arises, he may show little remorse for his wrong actions.

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This comes as a bit counter-intuitive, given that his mother sees no such traits in him, and sees his psychological and social development on the normal scales. Tests of interpersonal relations show that although he seems likable and may leave a good impression on others, his relationships are troubled because of his self-centeredness, self-critical nature, and amorality on the higher scale close to the T score that allows it to be interpreted. There are also substantial results on the scale for Social Alienation and Self – Depreciation (Butcher & Williams, 2014).

The Pd elevation does suggest that behavior problems should be considered for further definitive diagnosis to be made. Given his answers and elaborations on his relationship with his siblings, he speaks fondly of them and their intrapersonal relationship. He shared that he admires his sister for standing up to their parents but did not elaborate further. It can correlate with his fear of conflict or contact with authoritative figures and his lack of elaboration as a mask for the underlying issue.

Amber Childers, Timothy’s mother, stated in her interview that her first notices of Timothy’s difficulties in school were in his first grade when his grades would fluctuate from B’s to D’s. She says that he has issues with multistep tasks, grammar, and vocabulary, and being able to organize his homework assignments. It can be noted on ‘Verbal Comprehension’, ‘Vocabulary’, and ‘Comprehension’, which are based on low average and average.

Psychosocial History

Educational history: Timothy is a pupil in the tenth grade; his studies have been continuous. He is an average student, varies from B’s to D’s, and has difficulties following his teacher’s teaching methods when he skips through the material and does not focus on the structure in the book. His education is not being followed by anxiety during tests, but his main issue is not showing the following steps that got him to the result. Timothy’s teacher wants to value and see the step-by-step process as well as the final answer.

Occupational history: There is currently no precise occupational history, given the fact that Timothy is still attending high school and does not have a job. He is dependent on his parents, as most children are at the age of 15. However, there is information on what Timothy aspires to be, which is a NASCAR race driver or a drummer in a rock band. Timothy has no interest in sports such as basketball or football – sports that his siblings take part in – but he does play in the school band, and he takes dance classes after school. However, he did not give the same answers to his religious views or his ethnicity, as his mother did.

That is where the responses from Timothy and Ms. Childers differentiate. Besides, Timothy stated that he would like to be a NASCAR racer or a drummer in a band, but his mother says that she would prefer him to go to college and become a writer. These may be some of the reasons for his impulsiveness or abruptness, argumentativeness, and issue with authority since he may feel like his feelings and wants are disregarded. Nevertheless, it is what happens in almost every child-parent relationship during the teenage years.

Medical history (including substance use/abuse): Timothy has a noted asthma condition and seasonal allergies. There has not been a history report of psychiatric or substance abuse, no notable family history of learning disability / ADHD in either his parents or siblings nor is Timothy taking any other additional medication. Timothy denied having an interest in trying alcohol or any substances, as well as using them.

Psychiatric history: It is unclear whether there have been any previously reported assessments done by a psychiatrist or any other specialist. However, someone has referred Timothy and his mother for further neuropsychological evaluation for possible disability and/or Attention Deficit Hyperactivity Disorder (ADHD).

Social history: Timothy’s mother describes Timothy as a child who has a good circle of friends and that she has no concerns about his social development. The important people from Timothy’s point of view seem to be his siblings, given that he speaks very fondly of his brother and sister. His perspective on his social circle is that he likes to go out with his friends to games and that he does go to support his older brother. He considers his 7-year-old golden retriever, Lucky, a very close companion. His opinion on romance is that he talks to girls that he deems attractive. Besides, he stated that he is liked amongst girls and that they think he is ‘cute. His social circles and outings are still controlled by his parents, given from his statement that he goes out when he is allowed, to the mall, games, and the movies. He denies the use of alcohol, tobacco, or other drugs, and has stated disdain for them by taking his uncle as an example and him not wanting to be seen as ‘crazy’ like him.

References

Butcher, J. N. & Williams, C. L. (2014). Contemporary Use of the MMPI-2 in Forensic Assessment. Web.

Kennedy, N. & Harper, Y. (2014). ABS 300 Week Five Final Paper Adolescent Male Case Study Timothy Childers. Web.

Singer, F. M. (Ed.). (2016). Mathematical creativity and mathematical giftedness: Enhancing creative capacities in mathematically promising students. Hamburg, Germany: Springer.

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PsychologyWriting. (2022) 'Client History Report Draft: Psychological Assessment'. 29 January.

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PsychologyWriting. 2022. "Client History Report Draft: Psychological Assessment." January 29, 2022. https://psychologywriting.com/client-history-report-draft-psychological-assessment/.

1. PsychologyWriting. "Client History Report Draft: Psychological Assessment." January 29, 2022. https://psychologywriting.com/client-history-report-draft-psychological-assessment/.


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PsychologyWriting. "Client History Report Draft: Psychological Assessment." January 29, 2022. https://psychologywriting.com/client-history-report-draft-psychological-assessment/.