case study coun621 ciara walker
TRANSCRIPT
Case Study of AP
Counseling 621
November 19, 2011
Client Description
AP 19-year-old white male University of Mississippi Student Sophomore Year; Civil Engineering Major Academic Problems Diagnosed with ADHD
Purpose of Assessments
Student Needs Assessment– To get better understanding of problem (why in
EDHE, other factors involved)– To get a sense of AP’s stage of change
Mini Mental Status Exam (MMSE)– To check AP’s current mental status
Mood/Behavior during sessions Talks about sleeping a lot
Assessment Procedures & Protocol
Student Needs Assessment– First Meeting– Series of Questions– Apparent stage of change
MMSE– Second Session– Series of questions/directions related to five
categories
Medical/Developmental History
AP reported that he was diagnosed with ADHD when he was young– He took Adderall from age 5-13; he still takes
Adderall at times– Mentioned that wants to get retested for ADHD so
he can be prescribed Adderall AP reports sleeping a lot
– He contributes this to going to bed late and says he has not been tested for a sleeping disorder
Familial Psychiatric History
AP did not report a history of psychiatric issues within his family
School/Academic History
AP did well in high school and did not have to study much
AP finds it hard to focus in class and when studying now that he’s in college
EDHE Student– AP missed the first 3 weeks of EDHE– During the session AP is unable to sit still and talk
with me; he’s constantly fidgeting and doesn’t talk much unless I prompt him
Home Behavior/Social
Family of Origin– Parents divorced when he was 2 years old and they live in
different states– He has an older sister by his mom and dad– His dad is remarried and his stepmother has a son who is
older than him– He moved to live with his dad and stepmother when he was
13 Fraternity
– He is active in his fraternity Relationship Status
– He says he strays away from having a girlfriend right now
Assessments Used & Appropriate Interpretations
Student Needs Assessment– Understand what caused AP’s academic failure
and how I may be able to help him– Also assess where AP stands in regards to his
stage of change MMSE
– Assess AP’s cognitive state because of his behavior/mood during our meetings
– High Test-Retest Reliability
Summary of Findings
Student Needs Assessment– Lack of motivation– Rush; Drinking and Partying– Trouble focusing in class and when studying– Dad seems to be his support– Contemplation/Preparation stage of change
MMSE– 28/30– AP’s scored high on the MMSE so his overall cognitive
functioning is good
DSM Diagnosis
Axis I– 314.01 ADHD inattention and hyperactive impulsive
Axis II– V71.09 (No Diagnosis)
Axis III– None
Axis IV– None
Axis V– GAF 61-70
Treatment Plan & Recommendations
Help AP establish goals and follow up with him on his progress with them
Refer AP to a doctor who can assess him and see if he still has ADHD; I may also want to encourage him to see a doctor about his excessive sleeping
Continue to monitor AP’s progress in his classes and help him find ways to focus
My recommendation is to discuss AP’s options regarding school and do some motivational interviewing to help with his lack of motivation