Psychiatric evaluation and treatment planning for Sam Harris

¶ … Harris

D.O.B.: 03/29/1999

Gender: Male

Ethnicity: Not Given

Date of Evaluation:

REASON FOR REFERRAL:

Sam Harris is a 15-year-old male who was referred by the *(information not available regarding exact referral source, please insert) court for assessment and the development of a treatment program.

Developmental History

According to Sam's mother, Tammy Harris, Sam was born at Howard University Hospital in Washington DC. His reported birth weight is in the low normal range (6 pounds, 5 ounces). According to Ms. Harris there were no complications during the pregnancy and during the delivery. All of the available evidence indicates that Sam met his development milestones on time and there were no significant issues.

Educational History

Sam was held back in the first grade. He has an IEP, Emotional Disturbed Classification. He is currently suspended from school and is reportedly failing all of his classes.

Medical History

Reported medical history appears unremarkable.

Sexual History

None reported.

Social History

Sam reported that he gets in fights constantly and has been involved in over 50 fights. There is no information regarding his social contacts outside of his family.

Substance Abuse History

None reported at this time.

Psychiatric/Psychological History

Sam was admitted to the Psychiatric Institute of Washington for an evaluation regarding potential mania. He received a diagnosis of Bipolar I disorder. He is classified with an Emotional Disturbed category in the educational system.

Legal History

There is an open case of neglect against Sam's mother.

BEHAVIORAL OBSERVATIONS & MENTAL STATUS

Sam has been reported to be very derogatory regarding his mother and family and has been negative towards staff when he does not get his own way. He does respond to redirection.

DSM-5 DIAGNSOTIC IMPRESSIONS

Rule out 296.99 Disruptive Mood Disorder versus 296.40 Bipolar I Disorder

995.51 Child Psychological Abuse

995.54 Child Physical Abuse

V61.29 Child Affected By Parental Relationship Distress

TREATMENT PLAN/PROGNOSIS:

There is just not enough information in the case history to differentiate a diagnosis of disruptive mood disorder or bipolar disorder in this client. In addition, there is a significant amount of abuse both psychological and physical in this case and family issues that contribute greatly to Sam's presentation (American Psychiatric Association, 2013). Sam will require a much longer period of assessment in order to ascertain whether or not he is simply reacting to his environment or he has a true bipolar disorder that contributes to these complications.

Sam will need intensive psychotherapy/counseling. This would include intensive family counseling and further assessment regarding the fitness of Sam's mother to be his primary caregiver and supervisor. At this time it appears as if the level of psychological and physical abuse directed at Sam by his mother and her partner may be significant enough to have Sam placed in foster care. Moreover, Sam will need intensive psychiatric evaluation to determine if medical management of his issues can be of assistance. Currently Sam's prognosis is guarded at best due to very complicated family dynamics and the need for his parents to be involved in this treatment.