Psychological Examination Ms.

A Smith Psychological Evaluation Confidential

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Name: irthdate: Age: (ender: Education: *e+ort ,riter: -ate of re+ort: /nstruments Administered: Clinical intervie0

Case Number !ctober "#$ "%&' "# years$ ' months )emale %th grade November .$ .''5

*eason )or *eferral Ms. A. Smith is a "#1year1old African1American female 0ho 0as referred for a +sychological evaluation as +art of a -iagnostic Assessment Class at Clar2 Atlanta 3niversity$ Atlanta$ (a. She +resented as a 0ell1nourished female of average height and 0eight. 4er hygiene and grooming seemed ade5uate. No unusual behaviors 0ere observed and she did not demonstrate any difficulty moving about the evaluation site. 6he Ms. A. Smith +rovided the follo0ing information. Ms. Smith 0as born in Connecticut and is an only child. 4er +arents never married and +rimarily her mother$ Ms. Smith$ reared Ms. Smith. She re+orted that she did not 2no0 much about his biological father. Ms. Smith 0as the +roduct of a full term uncom+licated birth. No history of head trauma 0as re+orted. Ms. Smith7s mother re+orted that sexual abuse 0as sus+ected 0hen Ms. Smith 0as in daycare$ 8it 0as investigated but never +roven.8 No history of health +roblems 0as re+orted. No medications are currently +rescribed. Educational 4istory Ms. Smith began school at the ex+ected time. 4er mother re+orted that she demonstrated behavioral +roblem beginning in daycare$ 8she had +roblems 0ith authority even then.8 She re+eated 2indergarten because 8her teachers thought that she 0as not mature enough to be +romoted to the first grade.8 Ms. Smith mother re+orted that her daughter 8 has al0ays had +roblems 0ith teachers and being told 0hat to do.8 Ms. Smith7s mother re+orted that at "" years of age$ Ms. Smith began staying out late and 8hanging out 0ith undesirables.8 ,hen she 0as "" she 0as arrested 0hen the +olice raided a house for drugs. 4er mother stated that Ms. Smith 0as almost ra+ed once$ but this 0as never confirmed. After the arrest Ms. Smith 0as +laced in a residential facility. She 0as there for one and one1half years. 6he family moved from Connecticut to California9 they

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0ere there only nine months. 8She did !: 0hile 0e 0ere in California.8 Ms. Smith and her mother moved to (eorgia in "%%5. Ms. Smith7s mother is currently unem+loyed. Since moving to (eorgia Ms. Smith 0as +laced in classes for the learning disabled. /n the ninth grade$ Ms. Smith 0as +laced in classes for the behavioral disordered. Currently$ Ms. Smith is a ninth grade student at a high school in -e:alb County$ (eorgia. 4ealth 4istory Ms. Smith denied having a history of health +roblems. No history of being diagnosed as having an attention deficit disorder 0as re+orted. Substance Abuse 4istory Ms. Smith re+orted that she began ex+erimenting 0ith alcohol at the age of ".. She re+orted that her alcoholic use 0as s+oradic. She denied having a history of intoxication due to alcohol use. She began using mari;uana at the age of "<. She admitted smo2ing mari;uana about once a month and she has been intoxicated five to six times smo2ing mari;uana. No current mari;uana usage 0as re+orted because of her being incarcerated. Ms. Smith re+orted that she smo2es less than a +ac2 of cigarettes a day. No other drug use 0as re+orted. =egal 4istory 4er initial contact 0ith the >uvenile Court 0as in A+ril "%%5$ 0hen she 0as charged 0ith ma2ing 6errorist 6hreats. 6hat charge 0as dismissed. /n May "%%5$ Ms. Smith 0as charged 0ith *un A0ay and ungovernable behavior. 4er mother refused to allo0 Ms. Smith to return home and a de+rivation charge 0as filed. Ms. Smith 0as +laced on ". months +robation and tem+orary custody 0as granted to the -e+artment of )amily and Children Services for "& months. ,hile on +robation she 0as charged again 0ith *unning A0ay on August "%%5. /n >anuary "%%#$ Ms. Smith 0as charged 0ith ?iolation of Probation and 0as ordered to +artici+ate in intensive .< months +robation. ,hile involved in intensive +robation$ Ms. Smith 0as charged 0ith ?iolation of Probation. /n A+ril "%%# Ms. Smith 0as ordered to serve <5 to #' days in a youth develo+ment center for using fighting$ vulgar language$ and harassing +hone calls. Ms. Smith 0as again charged 0ith ?iolation of Probation again on >uly ".$ "%%#$ and on >uly .<$ "%%#. Since being at this facility her mother re+orted$ 8Ms. Smith has been good 0hile at this facility.8 4er mother also re+orted that she is in counseling and this has hel+ed their relationshi+. ,hen as2ed about her behavior Ms. Smith re+orted 8/ have a tem+er that / need to control. / have outbursts. ,hen / get angry / cuss a lot. / have been having these outbursts since / 0as "<. My attitude has changed since being her$ but / don7t 2no0 0hy.8

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Mental Status Examination Ms. Smith +resented as a 0ell1nourished female of average height @57A8B and 0eight @""5 +oundsB body build. She a++eared her stated age. She 0as casually dressed and her hygiene seemed ade5uate. 4er gait and +osture 0ere normal. No unusual behavior 0as observed. *a++ort 0as easily established and maintained. ,hen as2ed about her mood Ms. Smith re+orted that she felt ha++y and +layful most of the time. Ms. Smith re+orted that she has a tem+er and admits that anger is a +roblem for her. Ms. Smith7s s+eech 0as relatively clear9 at times she mumbled 0hen she s+o2e 0hich made her res+onses difficult to understand at times. 4er thoughts 0ere organiCed and coherent. She denied having +ast or +resent thoughts of harming herself or others. No histories of auditory or visual hallucinations 0ere re+orted. Ms. Smith denied having any s+ecific +hobias$ obsessions$ or com+ulsions. She denied having feelings that others can read her mind or that she can broadcast her thoughts to others. 4er attention and concentration 0ere age1a++ro+riate and her immediate$ recent$ and remote memory seemed intact. She denied having +roblems concentrating. She demonstrated limited insight into her +roblems and her ;udgment seemed ade5uate. Ms. Smith a++ears to be functioning in the Average range of intellectual abilities. !verall$ she did not +resent as having a thought disorder nor did she +resent as being a danger to herself or others. ehavior !bservations Ms. Smith a++roached the testing session in a coo+erative and friendly manner. Neither disru+tiveness nor difficulty in coo+eration and com+liance 0ere noted during the evaluation. 4er a++earance and grooming 0ere ade5uate and a++ro+riate. She had a deliberate style of ans0ering and 0or2ing on most +roblems. Attention and effort 0ere age a++ro+riate. Most 0or2 0as com+leted 0ith an orderly +lan and self1correction. *es+onses 0ere usually made in a reflective$ thoughtful manner. Signs of im+ulsivity or carelessness 0ere not observed. 4er activity level 0as observed to be 0ithin normal limits for age range. )idgeting or difficulties remaining seated 0ere not noted. Ms. Smith did not engage readily in s+ontaneous verbal ex+ression$ and had to be +rom+ted or urged to elaborate on brief res+onses. /nstructions 0ere follo0ed carefully and understood 0ithout a++arent difficulty. *e+etition and em+hasis 0ere not needed. ,hen ne0 tas2s or ne0 instructions 0ere +resented$ there 0as no difficulty ad;usting or res+onding a++ro+riately$ and no signs of emotional reactions or unex+ected errors on early items. She made an ade5uate effort on most tas2s$ and reacted to failure 0ithout clear frustration or rene0ed effort. Motivation to succeed and +erform 0ell a++eared to be ade5uate. /n general$ the obtained results are considered a valid and reliable sam+le of her +ercent level of functioning.

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Summary Ms. Smith is a "#1year1old African American female 0ho is currently housed at Another Chance Children7s Center. 6he -e+artment of Children and Douth Services for violation of +robation +laced Ms. Smith at this facility. Ms. Smith has a history of involvement 0ith the ;uvenile ;ustice system as 0ell as the ;uvenile ;ustice system in her birth state$ Connecticut. 4er most recent arrest 0as for sho+lifting$ running a0ay from home$ and violation of +robation. -iagnostic /m+ressions 1 -SM1/? Axis /:A"..& Conduct -isorder$ Adolescent onset ty+e$ moderate. A'5.#' Cannabis Abuse A"..A' /m+ulse Control -isorder$ Not !ther0ise S+ecified. ?#"..' Parent1Child *elational Problem Axis //: ?E".'% No -iagnosis on Axis // Axis ///: None Axis /?: None Axis ?: E'. *ecommendations ". Ms. Smith 0ill re5uire a 0ell1su+ervised residential +rogram. A +rogram that re5uires and fosters interde+endence and coo+erative 0or2 is +referred. Com+liance to social standards and +robation ex+ectations must be em+hasiCed firmly and consistently. Periods of detainment may be needed to reinforce com+liance and a++ro+riate behavior. .. /ndividual thera+y$ in addition to grou+ thera+y$ 0ill be needed to hel+ Ms. Smith and develo+ more a++ro+riate and functional inter+ersonal +roblem1solving s2ills. Ms. Smith may benefit from involvement in a substance abuse +sycho educational grou+. Additionally$ she may be a good candidate for a ?ocational *ehabilitation assessment. 4e seems motivated to 0or2$ but her vocational choices are vague. )amily thera+y 0ill be needed to hel+ Ms. Smith7s mother develo+ more a++ro+riate strategies to manage her behavior in the community$ if and 0hen a return to home is considered

A.

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*es+ectfully submitted$ FFFFFFFFFFFFFFFFFFFFFFFFFFFF *e+ort ,riter

Psychological Examination Ms. A Smith

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