This assignment is to provide a 500-word paper on Evaluation using ev

Since first entering school, Johnathan has experienced difficulties with school work completion, inattentiveness and distractibility, disorganization, impulsivity, and mood fluctuations. Johnathan's teachers describe him as a hard-working, cooperative student, but they indicate that homework responsibilities have been an issue since Johnathan losses his notes and does not remember what was assigned. They also note that he is a very reluctant reader, and has consistently scored lower than average on reading comprehension and vocabulary tests. Psychoeducational testing indicated average cognitive abilities.

Johnathan indicates that he often becomes anxious when he is asked to speak in public, or to spend time with people he does not know. Johnathan experiences ongoing sleep difficulties, primarily with settling into routines at night. Johnathan reports feeling nervous when going to school because of presentations and homework since it takes a lot of effort to prepare the presentations. Everyone will be watching him and know he is anxious. He describes hating school and experiencing difficulties completing his work on time because "he can never focus."

PAST PSYCHIATRIC HISTORY: Johnathan reports no involvement with mental health facilities prior to this appointment.

SUBSTANCE USE HISTORY: Johnathan denies any drug or alcohol use.

PAST MEDICAL HISTORY: Johnathan has had all the childhood vaccinations. There were no reported major illnesses.

CURRENT FAMILY ISSUES AND DYNAMICS: Maria works 2 jobs and has difficulty making ends meet. She knows that she hasn’t been providing the best parenting but is very tired when she gets home from work. Johnathan reports that some kids are bullying him because he wears glasses and doesn’t have the most fashionable clothes to wear. Johnathan states that he struggles to meet expectations at home and at school, complete academic work, and communicate effectively with others who do not share his interests. Maria notes that Johnathan has difficulties making new friends and taking risks – he reports

increased anxiety around school participation this year.

MENTAL STATUS EXAM: Johnathan presents as a casually dressed teenager who appears his stated age of 14. He is a bit anxious during the interview. His affect is appropriate but worries about disappointing his mom. Motor activity is appropriate. Speech is clear. At times during the interview, he lost his train of thought and had to be redirected to the subject. There is no evidence of delusions or hallucinations. Johnathan’s intelligence appears average. He is oriented to time, place, and person. Johnathan denies any thoughts about homicide or suicide.

Diagnosis:

F90.0 ADHD – Predominantly Inattentive Presentation

Z55.9 – Academic or Educational Problem

F41.1 – Generalized Anxiety Disorder

Z55.3 – Underachievement in school

Z55.8 – Other problems related to education and literacy

Description:

F90.0 ADHD – Predominantly Inattentive Presentation

Sever

Criterion A1 (Inattentive)