Child And Adolescent Mental Health Assessment

Other Person/Sources of Information

Mother (Sarah Evans) attended the assessment and provided collateral history. Referral letter from GP (Dr A. Patel, dated 02/10/2023) and SENCO report from Oakwood High School reviewed.

Services Involved

• GP: Dr A. Patel, High Street Surgery
• School Pastoral Team / SENCO (Oakwood High School)
• School Counsellor (6 sessions completed in July 2023)

Protected Characteristics

Diagnosed with mild dyslexia (2020); requires extra time and coloured overlays for reading and examinations.

Child Safeguarding

Resides full-time with biological parents, Sarah and David Evans, who both hold parental responsibility. No current or historical social care involvement.

Household Composition

• Sarah Evans (Mother, 42, primary school teacher)
• David Evans (Father, 44, IT consultant)
• Toby Evans (Younger brother, 11)
• Barnaby (Family dog, cocker spaniel)

History of Presenting Complaints

Chloe (15, DOB: 14/05/2008, NHS: 485 772 9104) was referred urgently by her GP following an escalation in low mood, severe anxiety, and superficial self-harm over the past 6 months. Symptoms began insidiously at the end of Year 10 (April 2023) and worsened significantly at the start of Year 11 in September 2023. She experiences daily pervasive sadness, tearfulness, anhedonia, and overwhelming worry regarding academic performance and peer acceptance.

Everyday functioning is markedly impaired. Chloe reports initial insomnia (taking 2–3 hours to fall asleep) and frequent nocturnal awakenings, averaging 5 hours of sleep per night. Appetite is reduced, with an estimated 3 kg weight loss over 2 months. Personal hygiene is maintained when attending school, though she neglects self-care on weekends. School attendance has dropped to 65% over the last month due to morning panic attacks. At home, she isolates in her bedroom and avoids family meals. She has withdrawn from her peer group and ceased attending dance classes.

Associated symptoms include episodic panic attacks (3–4 times weekly) characterised by tachycardia, SOB, dizziness, and paraesthesia, lasting 20 minutes. Triggers include school mornings, Mock GCSE discussions, and social media use. To manage distress, she uses distraction (listening to music) or engages in superficial cutting to her left forearm.

Precipitating Factors

• Breakdown of primary friendship group in April 2023, accompanied by indirect cyberbullying via group chats.
• Transition into Year 11 and commencement of GCSE mock examination preparations.
• Death of maternal grandmother in March 2023, to whom Chloe was very close.

Perpetuating Factors

Symptom maintenance is driven by school avoidance, which temporarily relieves anxiety but increases academic backlog and guilt. Maladaptive coping via emotional suppression and self-harm prevents processing of distress. High self-imposed perfectionistic standards and fear of disappointing parents further perpetuate anxiety.

Social History

Lives in a stable, owner-occupied 4-bedroom house with no reported financial stressors. Attends Oakwood High School (Year 11); currently on a reduced timetable. Spends recreational time in her room watching streaming services or scrolling social media; previously active in contemporary dance.

Significant life events include maternal grandmother's bereavement (March 2023). Reports a happy early childhood. Historically had a close group of four friends, now isolated following a dispute. Maintains one supportive online friendship.

Independent in all basic ADLs (washing, dressing, dental hygiene), though requires maternal prompting on weekends. Eats small portions; drinks adequate water but consumes 2 cans of caffeinated energy drinks daily to combat fatigue. Does not participate in household chores currently due to low energy.

Past Medical & Psychiatric History

• No previous formal psychiatric diagnoses or CAMHS admissions. Attended 6 sessions of school counselling (June–July 2023) with limited benefit.

• Mild asthma (diagnosed age 7)

• Iron deficiency anaemia (diagnosed August 2023)

Child Development

Born at term (39 weeks) via normal vaginal delivery, birth weight 3.4 kg. No antenatal substance exposure or neonatal complications. Met all motor, speech, and social developmental milestones within normal limits. No neurodevelopmental concerns raised in early childhood, aside from literacy difficulties identified in Year 5 (dyslexia).

Forensic/Offending History

No forensic or offending history was reported.

Premorbid Personality

Described by mother as a conscientious, sensitive, and perfectionistic child who was previously outgoing and enthusiastic about dance. Tended to internalise stress and avoided conflict to please others.

Medications

• Salbutamol 100 mcg/dose inhaler PRN
• Ferrous fumarate 210 mg PO BID

Family History

• Mother: Postnatal depression (2012), treated successfully with sertraline and CBT.
• Maternal Aunt: Generalised Anxiety Disorder.

Mental Status Examination

Appearance: Slim Caucasian female, looks stated age. Dressed casually in an oversized hoodie and jeans. Clean and kempt. Noted healed linear scars on left volar forearm (seen briefly when sleeve rode up).

Behaviour: Guarded initially, fidgeting with sleeves, poor eye contact. Warmed up gradually during individual interview. Cooperative and polite. No psychomotor retardation or agitation.

Speech: Quiet volume, normal rate and rhythm, coherent, spontaneous when discussing interests.

Mood: "Exhausted and stressed out."

Affect: Constricted, predominantly anxious and dysphoric, congruent with reported mood. Tearful when discussing grandmother and friendship loss.

Thoughts: Linear and logical form. Content preoccupied with academic failure, peer rejection, and feeling like a "burden." Passive suicidal ideation ("wish I could just sleep and not wake up"), no active plans or intent. No delusions or obsessions.

Perceptions: No hallucinations or perceptual disturbances elicited.

Cognition: Alert, oriented to time, place, and person. Attention and concentration mildly impaired during conversation (required questions to be repeated twice). Gross memory intact.

Insight: Good; recognises that anxiety and low mood are impacting her functioning and expresses desire for help, though struggles to stop self-harming.

Judgment: Intact regarding general safety, though impaired during acute distress leading to impulsive superficial self-harm.

Risk Assessment

Risks to self: Reports frequent passive suicidal ideation over the past 4 weeks, occurring 2–3 times weekly when overwhelmed by schoolwork at night. Denies active suicidal intent, planning, or preparatory acts. Risk increases during late evenings and following peer conflict on social media.

Self-harm: Engages in superficial cutting to left forearm using a pencil sharpener blade, approximately once or twice weekly since August 2023. Describes this as a tension-release mechanism, not an attempt to end life. Wounds are superficial, kept clean, and have not required medical attention. Mother has now removed sharps from the bedroom.

Risks to others: No risks to others were reported.

Substance use: No substance-use concerns were reported. Denies alcohol, tobacco, vaping, or illicit drug use. Consumes 2 energy drinks daily.

Risks from others: No current safeguarding or abuse concerns. Previous cyberbullying (April–June 2023) has ceased since blocking peers.

Protective factors: Strong, supportive relationship with parents and younger brother; attachment to family dog; future orientation (wants to attend sixth form college to study photography); good insight and willingness to engage with CAMHS.

Service User Views and Goals

Chloe wants to feel less panicked in the mornings, return to full-time schooling without crying, stop cutting herself, and improve her sleep pattern.

SMART Goal 1

To reduce morning anxiety and increase school attendance from 65% to 80% over the next 6 weeks by utilising a graded exposure return-to-school plan and morning grounding techniques.

SMART Goal 2

To replace self-harm with alternative distress tolerance strategies (e.g., TIPP skills, using the Calm Harm app) so that there are zero episodes of cutting over a consecutive 4-week period.

Initial Formulation/Impression

Chloe is a 15-year-old girl presenting with a moderate depressive episode and comorbid social and generalised anxiety, precipitated by bereavement, peer rejection, and GCSE academic pressures. She is predisposed by a family history of affective disorders and a perfectionistic, internalising premorbid temperament. Symptoms are maintained by school avoidance, sleep deprivation (exacerbated by caffeine use), and maladaptive coping via superficial self-harm. Risk to self is currently assessed as low-to-moderate: whilst she experiences passive suicidal ideation and engages in regular non-suicidal self-injury, she has strong family support, future goals, and no active suicidal intent. She is motivated for psychological therapy and suitable for outpatient CAMHS intervention.

Recommendations / Agreed Action Plan

Check routine baseline bloods via GP (FBC, ferritin, U&Es, LFTs, TFTs, Vitamin D) to ensure anaemia is resolving and exclude organic contributors to fatigue.

Place on waiting list for individual Cognitive Behavioural Therapy (CBT) targeting depression and anxiety (estimated 12–16 sessions), incorporating DBT-informed distress tolerance skills for self-harm.

Liaise with Oakwood High School SENCO to formalise a temporary reduced timetable, quiet room pass, and exam access arrangements. Parents provided with psychoeducation regarding safe storage of sharps and medications at home. Advised gradual reduction and cessation of caffeinated energy drinks, alongside sleep hygiene guidance.

Allocated to CAMHS Care Coordinator (Community Psychiatric Nurse) for fortnightly risk monitoring and brief emotional support while awaiting CBT. Psychiatric review in 8 weeks to consider SSRI (fluoxetine) if no improvement with psychosocial interventions.

Risk Assessment Formulation

Predisposing factors: Family history of depression/anxiety; perfectionistic personality traits; dyslexia contributing to academic vulnerability.

Precipitating factors: Bereavement (maternal grandmother); breakdown of peer group and cyberbullying; onset of Year 11 GCSE mock exam pressures; acute sleep deprivation.

Perpetuating factors: Ongoing academic pressure; social isolation; high caffeine intake disrupting sleep architecture; reliance on avoidance and self-harm for emotion regulation.

Protective factors: Vigilant, supportive parents willing to implement home safety measures; absence of substance misuse; engagement with safety planning; clear future educational aspirations.

My Staying Well Plan

My safety and wellbeing: I feel most unsafe late at night when I am alone in my room thinking about school tests, or around the anniversary of my Nan's birthday (12th November). Looking at old group chats on my phone also triggers me.

Signs I need additional support: I start staying in bed all weekend, stop walking Barnaby, snap at my little brother, or wear long sleeves all the time even when it is warm.

How I cope: Listening to indie playlists on my headphones, cuddling Barnaby, holding ice cubes in my hand, or using the Calm Harm app. If those do not work, I can text my mum from my room (using a red heart emoji so she knows I am struggling without me having to explain) or call Childline (0800 1111) or the CAMHS Crisis Line.

Giving support: If I am struggling, I want my parents to sit with me and watch a movie without asking loads of questions about school. Please do not shout or panic if I say I have urges to self-harm.

Staying well: Walking Barnaby in the woods, practicing photography, getting into college next year, and spending time with my family.

Mental Wellbeing Intervention Plans

Identified needs:

• Management of depressive symptoms and pervasive academic/social anxiety.
• Reduction of non-suicidal self-injury and development of safe emotion regulation skills.
• Restoration of normal sleep architecture and nutritional intake.
• Educational reintegration and reasonable adjustments for dyslexia and anxiety.

Interventions: Provided initial psychoeducation on the CBT cycle of avoidance and anxiety, sleep hygiene, and caffeine reduction. Co-produced a Staying Well Plan and agreed on home environment restriction of sharps/medications with mother. Care Coordinator to review fortnightly.

Consent to Care

Explained the role of CAMHS, multidisciplinary team working, and confidentiality limits (specifically that information is kept within the team unless there is a significant risk of harm to self or others).

Discussed the proposed care plan, including CBT, school liaison, and potential future pharmacological options (SSRIs) if therapy alone is insufficient. Outlined the benefits of engaging (improved mood, coping skills, exam support) and risks of non-engagement (worsening isolation, academic decline, escalating self-harm). Both Chloe (deemed Gillick competent) and her mother provided informed verbal consent to the care plan and information sharing with GP and school.

About Me

My Story: I came to CAMHS because everything got too much at the end of Year 10 after my Nan died and my friends fell out with me. I started feeling really down and panicky about school, and I started hurting myself to cope with the stress. Before this, I loved dancing and taking photos, and I am usually a hard worker.

My health and wellbeing, and how I want my life to change: Right now I feel tired and stressed all the time. I want to be able to go to school without feeling sick every morning, get my GCSEs, and go to sixth form college to do photography.

What is important to me?: My family, my dog Barnaby, and my photography are really important to me. Pressure about grades and people talking behind my back makes my mood much worse. I prefer talking 1-to-1 with someone calm rather than group therapy.

My individual needs: I have dyslexia, so I need information printed on cream or yellow paper and extra time to read things through. When I am anxious, I need people to speak slowly and give me time to answer.

My strengths: I am creative, caring towards animals, good at photography, and I have a really supportive mum and dad who listen to me.

The views of my family, friends and people who are in my life: My mum and dad are really worried about my cutting and how much weight I have lost, and they just want me to be happy and safe again rather than worrying about getting top grades.

Talking to Family and Friends about my health and wellbeing: I am happy for the CAMHS team to talk to my mum and dad about my care and safety plan, and to share necessary support information with the SENCO at my school.