Standard Diagnostic Assessment

Transcription

1 Standard Diagnostic Assessment Name: Ana Lucia Fernandez Date of Birth: June 30, 1995 Client Identification Number: Date of Assessment Interviews: July 12, 2010 and July 19, 2010 Contributions to the Assessment: Two diagnostic interview sessions were conducted; one with both parent and child conducted in a mixture of English and Spanish without an interpreter and one which was separated between individual time with each party. Releases of information were sought for medical providers, school and father (who is not legally recognized as the second parent). All were granted except for the release to the father. Phone conversations were had with the primary care physician, primary nurse for the Endocrinologist and school counselor. Current Life Situation: Ana Lucia Fernandez is a 15 year old Mexican American female who lives with her family on the East Side of St. Paul. In her home, she lives with her mother, step-father and his 2 children from a previous relationship. Ana Lucia reports that her older half brother lives in Mexico with her grandmother and may be moving to St. Paul soon. The family owns their own home; her mother, Sra. Maria Lopez, owns and operates her own small cleaning business. There has been an unsubstantiated report, made by Ana Lucia, stating that her step-father has been sexually inappropriate with her. Ana Lucia s father lives nearby with his wife and their daughter. She reports not being able to see him often because her parents don t get along. Whether or not she is allowed to visit her father depends on if she did her chores sufficiently and if she behaves appropriately. Ana Lucia has voiced interest in moving in with her father and his family. Her mother does not approve of that idea and doesn t allow her to have overnight visits. The family has MNCare for the children but the parents currently do not have any health insurance. Ana Lucia is in high school at Como High School and is the 10 th grade. Her mother reports that she has been a good student until this past year. Ana Lucia used to get A s and at the last report card indicated that Ana Lucia was getting mostly B- s with a C- in English. Ana Lucia has no employment outside of the home, but she is expected to babysit her younger step-brothers (who are 10 and 9) often but does not receive fiscal compensation for the task. Ana Lucia reports that she is quite socially isolated as her April 11,

2 mother does not let her spend time with friends and expects her to take care of her step-brothers while her parents are working after school. She states that she has many friends in school and has begged her father to give her a cell phone so that she can communicate with them. Ana Lucia says that she would be able to do more things if she lived at her father s house with her friends; but as it is, she feels trapped at home. Ana Lucia spends most of her day (when not at school or taking care of her brothers) upstairs in her room by herself texting her friends. Her mother has threatened to take away the phone and is quite upset that her father bought it for her. Ana Lucia s mother is from Mexico and her father is from El Salvador. Ana Lucia says that she doesn t know much about El Salvador because she s never been there and hasn t had a chance to get to know much about food and culture because of her distance from her father (he only recently moved to St. Paul after living in Boston for many years). Ana Lucia says that while she speaks Spanish she prefers to talk in English and doesn t feel like she can communicate very well in Spanish; she thinks in English. She says that she friends with all sorts of kids at school Hmong, African American, Latino and a few European American kids. Ana Lucia was born in Boston and is a US citizen. She reports to feeling a bit nervous about her brother coming to live in the states because she doesn t know how he ll find a job. She identifies as Mexican American and says that she d like to know more about Salvadoran culture. Sra. Lopez reports that the family goes to mass almost every Saturday evening at St. Stephen s Catholic Church; she is worried though, that Ana Lucia seems less interested in mass and refuses to talk to the priest about her troubles. Ana Lucia was diagnosed with Type I Diabetes 3 years ago. Her mother reports that she is very bad at remembering to check her sugar level and take her medication. They have been in many power struggles over this and her mother is very concerned about her health. Ana Lucia is supposed to take Novolog and Lantus but infrequently takes them, even with prompting, alarms and many lectures. Her mother is also concerned about her diet as she needs to regulate the amount of carbohydrates she consumes; during the interview, Ana Lucia started eating candy that she had picked up in the lobby. Presenting Problems & Reason for Referral: Sra. Lopez states that she brought in Ana Lucia today because she found a note indicating that she was thinking about running away and had cut herself on the wrists. Ana Lucia sat stoically as her mother described how she had run away from school the previous week and had been picked up by the police and brought to Arlington House Shelter because she had stated that she was being taken advantage of by her step-father. This had started a child protection investigation which had been transitioned to the Family Assessment Case Management unit in Ramsey County after Ana Lucia had recanted her allegation of abuse. She now states that she had only been saying that so that she could move in with her father s family. Other than being in the shelter for running away, Ana Lucia has had no April 11,

3 involvement in the legal system and this is the first time that the family has been involved in Child Protection Services or any social service program except for health insurance. Ana Lucia states that for at least 3 years she has been feeling hopeless and sad. She can t remember when she was happy and had a good time doing something since before she got sick with diabetes and was in the hospital. She thinks that the maybe the last time she was happy was before she got sick with diabetes. She said that she thinks maybe she deserves diabetes because she was a bad kid and didn t do what she was supposed to do. Her mother thinks that she became sad when she found out her father had another daughter (this happened around the same time that she was diagnosed with diabetes) and that his secrets have made her sad. She doesn t remember feeling like this for any stretch of time before she got sick with diabetes. She says that she used to like herself before she got sick and now just hates how much everyone has to alter their lives to accommodate her (like food, etc) and she doesn t think she s worth it. She also says that she hasn t really wanted to eat all that much since her favorite things have been taken away from her and when she eats them she feels guilty. Ana Lucia isolates at home, her mother reports her as being irritable, she thinks about death as a means of escaping, and is lately having trouble concentrating on anything especially school work. Her lack of concentration has made it difficult to focus in class and has resulted in her poor grades, inability to turn in homework and pass tests. She has never been assessed for IEP services and has not been in the English Language Learner program since Kindergarten. Ana Lucia used to attend school faithfully but had her mother call her in sick frequently at the end of the year because she doesn t feel well and has headaches and stomach aches. Her mother is worried that this is related to her diabetes and will discuss it at the next medical appointment. Ana Lucia also says that for the past 4 months she hasn t cared about playing basketball and dropped out of the track team this spring; she used to love being on a team as she got most of her friends from there and it was a way for her to be out of the house. Ana Lucia reports that she would love to sleep all day and all night and usually goes to sleep at 8pm each night. When asked what she thinks her life will be like when she s 25, Ana Lucia reports that she used to want to go to college and become a lawyer and now she doesn t really think about her future. Sra. Lopez called for an intake appointment 3 months ago to a local counseling agency and never heard back from them. After the first call she gave up until her Family Assessment worker urged her to make this appointment. The Endocrinologist that treats Ana Lucia s diabetes has suggested anti-depressants, which the family has declined (her mother thinks Ana Lucia has trouble taking medication as is for diabetes why add another pill). Sra. Lopez reports that she doesn t remember any concerns about Ana Lucia s development. She doesn t remember being worried if she walked on time, etc. She does remember that in kindergarten, April 11,

4 Ana Lucia started preferring to speak in English and stopped answering her questions in Spanish and that has caused problems in their relationship. Ana Lucia reports that she tried beer once at a family barbeque and didn t like it. Sra. Lopez is not concerned about her using drugs or alcohol. Sra. Lopez does not know if anyone else in her family history has diabetes or any other medical condition (she s from a rural area in Mexico and her family didn t have access to regular medical care). She does not know about Ana Lucia s father s family. Sra. Lopez stated that depression and emotional problems do run in her family. She spent time in a hospital in Boston for depression after her second child died; she has gotten counseling on and off over the years and currently talks to her priest. It was after her serious bout with depression that she met Ana Lucia s father in Boston. He helped her start to feel better. She has never taken any medication. She is unsure if anyone else in the family history has had problems with depression. Throughout the interview, Ana Lucia conveys that she does not feel comfortable speaking Spanish and prefers English even when her mother is in the room. Ana Lucia states that she identifies as Mexican American but wants to know more about being Salvadoran and wonders what her father s family has for dinner most nights and would like to know how to make pupusas. She indicates that she feels shame about her mother s inability to speak in English and reports that she feels more comfortable being outside of her house in a more English world. Ana Lucia reports that she has trouble taking her medication at consistent times because she forgets to look at a clock and doesn t want to be bothered with remembering that she s sick. Often, when asked a question that she doesn t feel comfortable with, Ana Lucia just stares at the wall not answering this happened frequently when her mother was in the room. She voices that she does not feel in control of her life and that it is determined by the adults around her (including her doctors). While her mother was vocal about the family s spiritual beliefs, Ana Lucia remained quiet during the interview on the topic. Ana Lucia does not want to talk to her priest about her depression or diabetes but she also does not consistently follow her medical team s treatment regime. Mental Health Status Exam: Ana Lucia was well groomed and properly dressed for the July weather in Minnesota. She is of average build. She was quiet and shy while her mother was in the room and more open and cooperative when her mother was not in the room. She had no eye contact when her mother was present and had intermittent eye contact when she was not. Her level of activity in the session was appropriate for an office appointment. Her speech was clear; she preferred to speak in English even when spoken to in Spanish. She indicated no thoughts of delusions or hallucinations. She expressed no symptoms of depersonalization or derealization. Ana Lucia voiced thoughts of death but no active plan on immediate harm to herself; however, her lack of taking care of her diabetes is impacting her health. April 11,

5 She has no issues of harm to others or property. She was oriented to person, place and time. She expresses no issues with memory loss. She states that she has difficulty with sustained concentration and tends to zone out when things get complicated for her. She indicated a fairly normal level of insight for a 15 year old female. Her thought process seemed logical and coherent with a little fantastical thinking that her problems would be magically solved if she switched residences. Her mood was depressed and irritable towards her mother. She had flat affect. Her behavior was cooperative towards the interviewer and withdrawn towards her mother. She seemed to be of above average intelligence. Screenings: Ana Lucia completed the GAIN-SS and indicated no further need for a chemical health evaluation. April 11,

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7 Assessment Methods and Standardized Assessment Tools: Needs Assessments: Based on Ana Lucia s current level of care determination, outpatient psychotherapy would be the best fit for her psychological needs. Ana Lucia has an appropriate level of insight for this form of therapy and would benefit from Cognitive Behavioral Therapy. Her medication compliance for managing her diabetes also needs to be monitored and further conversation and treatment planning with her medical team is warranted. While she currently states that she is safe in her living environment and April 11,

8 this has been investigated by child protective services, further monitoring of her home environment, safety and feelings of security should occur with the Family Assessment Case Manager. Clinical Summary and Recommendations: Ana Lucia currently meets criteria for Major Depressive Disorder, Single episode and Dysthymic Disorder with early onset. Ana Lucia reports to feeling sad more days than not for the past 3 years, with poor appetite and feelings of low self-esteem that she feels have come out of her struggle to manage her diabetes. For the past 4 months, her Dysthymic Disorder has become a Major Depressive Disorder, Single Episode with the increase of her symptoms to include diminished interest in things that she used to enjoy, her poor self-esteem has turned to feelings of worthlessness and guilt, hypersomnia nearly every day, diminished ability to concentrate and recurrent thoughts of death. All of the symptoms have caused her clinically significant level of distress as they impact her relationships with friends, school grades and attendance, and her commitment to maintain her physical health. While her Diabetes has not caused her depression symptoms, her physical illness certainly contributes to her lack of consistent good nutrition, the vacillation of her insulin levels which leads to irritability and sadness as well as a passive means of trying to hurt herself. Ana Lucia s sadness also stems from her family conflict, inability to relate consistently with both parents, and her desire to learn more about her father and his family. As Ana Lucia has recently recanted statements of sexual abuse, it is important to continue to build rapport to further investigate her safety and abuse history within her home as well as assess for trauma symptoms. If her depression continues to be untreated, she will continue to struggle with thoughts of death and hopelessness which have led her to cutting behaviors and serious isolation from her family. She is currently negatively impacting her health by not taking care of her diabetes through not taking her medication and consciously eating foods which she knows are bad for her. Research demonstrates that the best mechanism of treatment for clients with diabetes and depression is a combination of medical management of the diabetes and cognitive behavioral therapy for the depression. Ana Lucia is a bright and engaging youth who voices interest in wanting to feel better to stop the cycle of sadness in her life. She is willing to engage in alternative strategies for self-care but is currently hesitant towards working with her mother on their relationship and ability to communicate with each other. Recommendations for further services that are medically necessary to treat her depressive disorders and alleviate current symptoms to prevent hospitalization, partial hospitalization and rehabilitative services include: April 11,

9 Outpatient psychotherapy focusing on depression psycho-education for herself and her family, cognitive behavioral therapy surrounding negative thoughts, activity planning, problem solving, and self-monitoring Medical case management to help monitor her diabetes symptoms and medication compliance A psychiatrist evaluation to determine if psychotropic medication would be beneficial to her treatment for depression at this time Group psychotherapy/psycho-education surrounding Teens with Type I Diabetes 5 Axis Diagnosis: Axis I: Major Depressive Disorder, Single Episode, Moderate in Severity Dysthymic Disorder, early onset Axis II: none Axis III: Type I Diabetes Axis IV: School issues, Parental fighting, family involvement in child protection Axis V: GAF: 55 Martha J. Aby, MSW, LICSW 7/21/2010 Martha J. Aby, MSW LICSW, July 21, 2010 April 11,