Child and Adolescent Psychiatry Assessment

Consultation Report,

Liam Vance was seen for an initial psychiatry assessment at the Youth Mental Health Outpatient Clinic, on 14/05/2024, accompanied by his mother, Sarah Vance.

ID: Liam Vance is a 14-year-old male who lives in Toronto with his mother, father, 11-year-old sister, and their dog. Liam Vance is registered in Oakwood Collegiate Institute, Grade 9.

Sources of Information

• Separate and joint interviews with Liam Vance and his mother, Sarah Vance
• Review of Connect care and Netcare
• Case discussion with nurse, David Miller, RN, who contributed collateral information
• Psychometric measures completed and reviewed

Reason for Referral

Referred by Dr. Aris Thorne, MD (Family Physician), for assessment and management of worsening depressive symptoms, anxiety, and school avoidance.

Presenting Complaints

1. Low mood for 6 months: "I just feel empty and tired all the time."
2. Generalized anxiety and school refusal for 4 months: "I can't handle the pressure at high school."
3. Initial insomnia for 4 months: "My brain won't shut off at night."

History of Presenting Complaints

Liam reports a 6-month history of progressively worsening low mood, anhedonia, and fatigue, beginning in November 2023 following his transition to high school. He describes daily sadness, loss of interest in video games and basketball, and feelings of worthlessness regarding his academic performance. Over the past 4 months, he has developed prominent anxiety centered on social evaluation and academic failure, accompanied by somatic symptoms including morning nausea and tension headaches. He experiences initial insomnia, taking 2 to 3 hours to fall asleep, resulting in daytime exhaustion. Appetite is decreased with a 2 kg weight loss over 3 months. He endorses passive suicidal ideation ("Sometimes I wish I could just disappear") but denies active intent, plan, or self-harm behaviours. He explicitly denies a history of hallucinations, psychosis, mania, or OCD symptoms. Functional impairment is significant, with Liam missing 2 to 3 days of school per week over the past 2 months and dropping out of his community basketball league.

Collateral History: Sarah Vance (Mother)

Ms. Vance reports that Liam has become increasingly irritable and isolated at home, spending most of his time in his bedroom. Ms. Vance notes that his grades have dropped from A's and B's in Grade 8 to C's and D's in Grade 9. Ms. Vance confirms that Liam has been adherent to his current trial of fluoxetine for the past 6 weeks with no observed improvement in mood or anxiety, though she notes he experienced mild transient nausea during the first week of initiation.

Past Psychiatric History

No previous formal psychiatric diagnoses or hospitalizations. Liam attended 6 sessions of supportive counselling through his school social worker between January and March 2024, with minimal reported benefit. No Child and Family Services (CFS) involvement.

Developmental History

Term pregnancy, spontaneous vaginal delivery without complications.

No maternal drug, tobacco, or alcohol exposure during pregnancy.

Met all motor, language, and social developmental milestones on time.

Medical History

Mild intermittent asthma.

Tonsillectomy at age 6.

Medication History

• fluoxetine (Prozac®) 10 mg PO daily
• salbutamol (Ventolin®) 100 mcg inhaled PRN

No known drug or environmental allergies (NKDA).

No previous psychotropic medication trials prior to current fluoxetine regimen.

Family History

Maternal history of Major Depressive Disorder and Generalized Anxiety Disorder, successfully treated with sertraline. Paternal uncle with Alcohol Use Disorder. Negative for family history of bipolar disorder, psychosis, or suicide.

Lives in a single-family home with his biological parents and younger sister. Relationships with family members are described as supportive, though recent conflict has arisen regarding school attendance.

Educational History

Grade 9.

Irregular attendance; currently missing 2 to 3 days per week due to anxiety and fatigue.

Struggling with mathematics and science due to missed classes; no formal Individual Education Plan (IEP) currently in place.

No behavioural problems, suspensions, or expulsions.

Social History

Grade 9 student.

Explicitly reports no current or previous use of tobacco, vaping, alcohol, cannabis, or illicit drugs.

None.

Has two close male friends from middle school, though he sees them less frequently now.

Previously played competitive basketball; enjoys digital art. Unsure of post-secondary plans.

None.

Premorbid Personality

Described by mother as previously outgoing, conscientious, and easygoing, though somewhat perfectionistic regarding schoolwork.

Expectations

Parent

Ms. Vance hopes for clarification regarding Liam's diagnosis, optimization of his medication, and documentation to support school accommodations.

Child

Liam states he wants to "feel normal again, sleep better, and not feel sick before school."

Trauma History/ ACEs

• Household mental illness (maternal depression). Denies physical, emotional, or sexual abuse, neglect, or domestic violence.

Mental Status Examination

Liam appeared stated age, dressed casually in a dark hoodie and jeans with adequate grooming and hygiene. He was cooperative but exhibited mild psychomotor retardation and poor eye contact initially, which improved as the interview progressed. Speech was spontaneous with a normal rate, low volume, and normal prosody. His stated mood was "tired and stressed," and his affect was dysthymic, anxious, and constricted, though congruent with thought content. Thought process was linear, logical, and goal-directed. Thought content was notable for themes of academic failure, low self-esteem, and passive suicidal ideation without intent or plan; there were no delusions, obsessions, or phobias. He denied auditory or visual hallucinations, and none were evident during the assessment. He was alert and oriented to time, place, and person, with intact immediate and recent memory, though mild difficulty with sustained concentration was noted during interview tasks. Insight into his depressive and anxious symptoms was fair, and judgment was intact as evidenced by his willingness to engage in treatment and safety planning.

Risk Assessment

• Moderate chronic risk, low acute risk. Endorses passive suicidal ideation without active intent, plan, or preparatory behaviour. No history of suicide attempts or non-suicidal self-injury (NSSI). Denies homicidal ideation. Protective factors include strong family support, treatment engagement, and future-oriented goals regarding returning to sports.

Psychometric Measures

• PHQ-A (Patient Health Questionnaire for Adolescents): Score 16 (Moderately severe depression).
• SCARED (Screen for Child Anxiety Related Emotional Disorders): Score 34 (Clinically significant anxiety, elevated on generalized and social anxiety subscales).
• CADDRA Weiss Functional Impairment Rating Scale - Parent Report (WFIRS-P): Marked impairment in School and Life Skills domains.
• Laboratory values (02/05/2024): CBC, ferritin, vitamin B12, and TSH within normal limits.

Impression

Liam is a 14-year-old male presenting with a 6-month history of major depressive symptoms and generalized/social anxiety resulting in significant school avoidance. Predisposing factors include a family history of mood and anxiety disorders and premorbid perfectionistic traits. Precipitating factors include the academic and social transition to high school. Perpetuating factors include poor sleep hygiene, avoidance behaviours reinforcing school anxiety, and subtherapeutic dosing of current pharmacotherapy. Protective factors include a supportive nuclear family, absence of substance use, and intact insight.

DSM-5 Diagnosis

• Major Depressive Disorder, single episode, moderate, with anxious distress (F32.1)
• Generalized Anxiety Disorder (F41.1)

Treatment Plan

1. Provided psychoeducation about the formulation, diagnoses and available treatment options
   • No further baseline bloodwork required given recent normal TSH and CBC.
   • Increase fluoxetine (Prozac®) from 10 mg PO daily to 20 mg PO daily for 4 weeks, monitoring for activation or emergent suicidality. Discussed melatonin 3 mg PO QHS PRN for initial insomnia alongside sleep hygiene measures.
   • Referred to clinic psychologist for individual Cognitive Behavioural Therapy (CBT) focusing on behavioural activation and graded exposure for school return.
   • Provided letter for Oakwood Collegiate Institute recommending a temporary reduced course load and access to a quiet space during panic/anxiety episodes. Discussed behavioural strategies with mother to reduce accommodation of avoidance at home.
   • Follow-up appointment scheduled in 4 weeks (11/06/2024 at 10:00) to assess medication titration response and school attendance.

Safety Plan: Liam and his mother agreed to remove sharps and lock all medications at home. If passive thoughts progress to active suicidal ideation, Liam will inform his mother immediately, utilize the Kids Help Phone (1-800-668-6868), or present to the nearest Emergency Department.