Week 10: Training Title 48 – Comprehensive Psychiatric Evaluation

Week 10: Training Title 48 – Comprehensive Psychiatric Evaluation

Subjective

CC (chief complaint): “Sometimes I lose the list.”

HPI: Sarah is an elementary-aged girl brought in by her mother because of persistent issues with hyperactivity, focus, attention, and memory. Since kindergarten, these symptoms have persisted and are affecting both everyday life and performance in school. She frequently loses personal items, forgets instructions, becomes easily distracted, and struggles to sit still unless deeply engaged. Symptoms are described as persistent and disruptive both at school and at home.

Past Psychiatric History

• General Statement: No previous formal mental health diagnosis were mentioned, although longstanding behavioral concerns have been noted.
• Caregivers (if applicable): Her parents are not together but plan to reunite; she resides with her mother.
• Hospitalizations: None reported.
• Medication trials: None reported.
• Psychotherapy or Previous Psychiatric Diagnosis: No formal mental diagnosis or history of psychotherapy.

Substance Current Use and History

There is no indication of current or past substance use, which is expected given Sarah’s young age. Her mother did not report any concerns regarding exposure to tobacco, alcohol, or illicit substances in the home environment. There is also no documentation or disclosure of prenatal exposure to substances during pregnancy, including alcohol or drugs. Sarah appears to reside in a stable, substance-free household. Her behavioral issues are therefore unlikely to be substance-related in origin.

Family Psychiatric/Substance Use History

Sarah’s family psychiatric and substance use history appears unremarkable based on the caregiver’s report. No family members were identified as having been formally diagnosed with mental illness or substance use disorders. Her mother is attentive, responsive, and appears to have a healthy psychological baseline. Although the biological father was not present during the interview, no psychiatric conditions were attributed to him by the mother. Overall, there are no generational psychiatric or addiction-related risk factors currently disclosed.

Psychosocial History

Sarah currently lives with her mother following a separation of her parents, which may contribute to her emotional vulnerability and distractibility. Despite this disruption, she demonstrates affection toward her pet dog and finds comfort in creative interests such as art and museums. Her mother described her as polite in structured, individual interactions but noted that Sarah tends to struggle more in group settings. Peer relationships and school social dynamics may be contributing to her academic challenges. These environmental factors could be exacerbating her symptoms of inattention and emotional reactivity.

Medical History

No chronic illnesses or neurological conditions have been reported for Sarah. Her mother recounted incidents from early childhood involving impulsive and risky behavior, such as jumping into a swimming pool before learning to swim and attempting to reach into zoo enclosures. These episodes suggest a longstanding pattern of poor risk awareness and impulsivity. At present, no medical conditions or developmental delays are observed. Sarah is otherwise physically healthy and is not receiving treatment for any somatic complaints.

• Current Medications: None
• Allergies: No known drug or food allergies reported
• Reproductive Hx: Not applicable due to age. Sarah is a prepubescent child and has not reached menarche.

ROS

• GENERAL: Active, polite but easily distracted; history of impulsivity
• HEENT: No concerns reported
• SKIN: No rashes, lesions, or noticeable skin changes
• CARDIOVASCULAR: Denies experiencing palpitations, lower extremity swelling, or chest pain.
• RESPIRATORY: No reports of wheezing, dyspnea, or coughing.
• GASTROINTESTINAL: No complaints; appetite may be inconsistent.
• GENITOURINARY: No incontinence or genitourinary concerns.
• NEUROLOGICAL: Easily distracted, forgetful; history of impulsivity.
• MUSCULOSKELETAL: No pain or movement limitation noted.
• HEMATOLOGIC: No bleeding or bruising tendencies noted.
• LYMPHATICS: No lymphadenopathy.
• ENDOCRINOLOGIC: There were no reports of endocrine dysfunction.

Objective

Physical Exam

Not conducted in the session.

Diagnostic Results

The primary data source was observational and interview-based. Sarah demonstrated inattentiveness during the interview, frequent forgetfulness, distractibility, and impulsive responses. Her mother’s and teacher’s reports support consistent patterns of inattention and hyperactivity dating back to early childhood. These symptoms have negatively affected academic and social functioning. While polite and cooperative during the session, Sarah displayed rapid shifts in attention and an inability to retain interview content.

Assessment

Mental Status Examination

Sarah is a well-groomed child, alert and oriented to person and place. She appears age-appropriate in speech and language but exhibits delayed processing and difficulty with sustained attention. Affect is congruent, though shallow; mood is cooperative yet distractible. The thought process is goal-directed but frequently interrupted by external stimuli. She denies hallucinations or delusions. Insight and judgment are limited due to age and condition. Memory and concentration are notably impaired.

Differential Diagnoses

Attention-Deficit/Hyperactivity Disorder, Combined Presentation (F90.2)

Sarah meets the DSM-5-TR criteria for Attention-Deficit/Hyperactivity Disorder with a history of persistent symptoms of inattention, such as forgetting assignments, losing items, distractibility, and hyperactivity, such as fidgeting and trouble sitting still (Magnus et al., 2023). The onset occurred in early childhood, symptoms are present in multiple settings, and they interfere with her daily life. This is the most supported diagnosis based on clinical observations and collateral data from caregivers and teachers.

Specific Learning Disorder, with Impairment in Reading (F81.0)

Specific Learning Disorder may account for some of Sarah’s difficulties in retaining reading material and completing assignments, especially when distracted (Chieffo et al., 2023). However, there is insufficient evidence of consistent academic underperformance or formal educational testing to support this diagnosis. Her issues seem broader and more pervasive than a single domain learning disorder, causing it to be disregarded as the primary diagnosis.

Autism Spectrum Disorder, Level 1 (F84.0)

Although Sarah exhibits some social difficulties and intense focus on preferred activities such as art and video games, she demonstrates appropriate emotional responses, makes eye contact, and engages with others. The absence of restricted, repetitive patterns of behavior and social communication deficits per DSM-5-TR criteria argues against Autism Spectrum Disorder in this case (Hodges et al., 2020).

Reflections

If I were to conduct this session once again, I would include structured Attention-Deficit/Hyperactivity Disorder-specific assessment tools such as the Vanderbilt or Conners Rating Scales and gather more extensive teacher feedback (Anderson et al., 2022). I would also allocate more time to exploring any potential trauma-related impacts from parental separation, which may contribute to Sarah’s inattention and emotional dysregulation. A multidisciplinary approach involving school counseling and psychoeducation for the parent would be initiated earlier.

From a legal and ethical perspective, it is vital to consider Sarah’s right to educational accommodations under the Individuals with Disabilities Education Act (IDEA) and Section 504 (Office of Communications and Outreach (OCO), 2025). Moreover, the parental separation and inconsistent caregiving could necessitate child advocacy services or referrals. Given Sarah’s age, cultural background, and possible economic limitations, it is essential to promote health equity by integrating supportive school-based interventions, early behavioral therapy, and parenting education, all of which are key to improving long-term outcomes.

References

Anderson, N. P., Feldman, J. A., Kolko, D. J., Pilkonis, P. A., & Lindhiem, O. (2022). National norms for the vanderbilt ADHD diagnostic parent rating scale in children. Journal of Pediatric Psychology, 47(6), 652–661. https://doi.org/10.1093/jpepsy/jsab132

Chieffo, D. P. R., Arcangeli, V., Moriconi, F., Marfoli, A., Lino, F., Vannuccini, S., Marconi, E., Turrini, I., Brogna, C., Veredice, C., Antonietti, A., Sani, G., & Mercuri, E. M. (2023). Specific learning disorders (SLD) and behavior impairment: Comorbidity or specific profile? Children, 10(8), 1356. https://doi.org/10.3390/children10081356

Hodges, H., Fealko, C., & Soares, N. (2020). Autism spectrum disorder: Definition, epidemiology, causes, and clinical evaluation. Translational Pediatrics, 9(1), 55–65. https://doi.org/10.21037/tp.2019.09.09

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2023). Attention deficit hyperactivity disorder (ADHD). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441838/

Office of Communications and Outreach (OCO). (2025, July 8). Section 504. U.S. Department of Education. https://www.ed.gov/laws-and-policy/individuals-disabilities/section-504

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Week 10: Training Title 48 – Comprehensive Psychiatric Evaluation

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Symptom Media. (Producer). (2017). Training title 48Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-48