Child and Adolescent Psychiatry Intake Evaluation

Chief Complaint

"Everything feels overwhelming right now, and I can't focus on my schoolwork anymore."

HPI

Patient is a 15-year-old female presenting with her mother for worsening depressive symptoms, anxiety, and academic decline over the past 6 months. She states, "I just feel empty most days and have no energy to see my friends." Symptoms began at the start of the current academic year following a transition to a more competitive high school. Functional impairment includes dropping grades (from A's to C's and D's), quitting the JV soccer team due to anhedonia and fatigue, and missing 6 days of school over the past month due to somatic complaints (headaches, stomachaches) and morning dread. Mother notes increased irritability at home and isolation in her bedroom.

Psychiatric Review of Systems

• Depressive, Neurovegetative Symptoms: Endorses depressed mood, anhedonia, fatigue, poor concentration, feelings of worthlessness, and passive suicidal ideation ("I wish I could just go to sleep and not wake up"). Appetite is decreased with a 2.5 kg weight loss over 2 months.
• Manic Symptoms: Denies decreased need for sleep, grandiosity, flight of ideas, or hyperactivity.
• Anxiety Symptoms: Endorses excessive worry regarding academic performance and social judgment, accompanied by muscle tension, restlessness, and GI distress prior to school. Denies discrete panic attacks.
• Trauma Symptoms: Denies history of trauma, flashbacks, or nightmares.
• OCD Spectrum Symptoms: Denies obsessions, compulsions, hoarding, or body dysmorphia.
• Tics, Tourette's Symptoms: Denies motor or vocal tics.
• Psychotic Symptoms: Denies auditory or visual hallucinations, paranoia, or delusions.
• Eating Disorder Symptoms: Denies intentional restriction, body image distortion, bingeing, or purging; attributes weight loss strictly to poor appetite when anxious or sad.
• Sleep Symptoms: Endorses initial insomnia (takes 2 hours to fall asleep due to racing worried thoughts) and non-restorative sleep; sleeps 6 hours on school nights and 11 hours on weekends.
• ADHD Symptoms: Endorses recent difficulty sustaining attention and completing homework, which began concurrently with mood decline; no childhood history of inattention or hyperactivity.
• Autism Spectrum Symptoms: Denies deficits in social-emotional reciprocity, nonverbal communication, or restricted interests.
• Learning Differences: Denies history of learning disabilities or IEP/504 accommodations.
• ODD, Conduct, Antisocial Symptoms: Denies defiance, aggression, property destruction, or rule violations.
• Borderline Personality Traits: Endorses mild sensitivity to peer rejection and history of superficial self-harm; denies frantic efforts to avoid abandonment or chronic unstable relationships.
• Other Personality Disorder Symptoms: Denies perfectionism outside of recent school stress or pervasive suspiciousness.

Past Psychiatric History

• Previous Psychiatric Diagnoses: Generalized Anxiety Disorder diagnosed by pediatrician at age 13.
• Previous Psychiatric Medication Trials: Sertraline (Zoloft®) 25 mg PO daily for 3 weeks at age 14, discontinued due to GI upset and transient restlessness.
• Previous and Current Therapy: Saw a school counselor briefly in 8th grade; currently seeing Ms. Sarah Jenkins, LCSW, weekly for CBT for the past 4 weeks.
• Previous Psychiatric Hospitalizations: None.
• Higher Levels of Care (e.g., residential, day programs): None.
• Prior TMS, Ketamine, ECT, Spravato: None.
• Prior Self-harm: History of superficial cutting on left volar forearm with a paperclip twice at age 14; last episode was 4 months ago.
• Prior Suicidal Ideation and Attempts: Intermittent passive suicidal ideation over the past 2 months; denies active ideation, intent, plan, or prior suicide attempts.
• Prior Violence Toward Others: None.

Substance Use History

Patient explicitly endorses no current or past use of alcohol, nicotine/vaping, cannabis, or illicit substances.

Past Medical and Surgical History

Moderate persistent asthma diagnosed at age 7. Tonsillectomy and adenoidectomy in 06/2016 (age 6). Menarche at age 12; menses are regular without premenstrual mood exacerbation.

Social and Family History

Social History

Sophomore at Lincoln High School; previously an honor roll student. Lives at home in Chicago, IL with married biological parents and a 12-year-old brother. Has one pet golden retriever, Max, who is a major source of comfort. Parents explicitly report that no firearms are present in the home.

Family History

Father (age 45) has hypertension. Mother (age 43) has hypothyroidism. Younger brother (age 12) is healthy.

Family History of Mental Illness

Mother has a history of Major Depressive Disorder and Generalized Anxiety Disorder, successfully treated with escitalopram (Lexapro®). Maternal aunt has Bipolar I Disorder. Paternal grandfather had Alcohol Use Disorder.

Current Medications and Allergies

• Current Medications: Fluticasone propionate (Flovent HFA®) 110 mcg 2 puffs inhaled BID; salbutamol (albuterol, ProAir HFA®) 90 mcg 2 puffs inhaled q4h PRN SOB; melatonin 3 mg PO QHS PRN insomnia.
• Allergies: Amoxicillin (maculopapular rash).

Mental Status Exam

• General Appearance and Behavior: Well groomed and cooperative, dressed in an oversized sweatshirt, appearing stated age; good rapport established easily.
• Motor Abnormalities: Mild psychomotor retardation noted; no abnormal involuntary motor movements.
• Speech: Normal rate, rhythm and prosody, though slightly soft in volume.
• Eye Contact: Fair; intermittently downcast when discussing school failure and passive SI.
• Affect: Dysthymic, anxious, and constricted; congruent with thought content.
• Mood: "Tired and stressed."
• Thought Content: Preoccupied with academic failure and peer perception; future-oriented regarding wanting to feel better by summer; passive SI present without plan or intent.
• Thought Process: Linear and goal directed.
• Cognition: Grossly intact attention and memory during interview.
• Orientation: Alert and oriented to person, place, time, and situation.
• SI, HI, Violent Ideation: Endorses passive SI ("wish I could disappear" when overwhelmed by homework); denies active SI, intent, plan, HI, or violent ideation.
• Insight and Judgment: Good insight into the need for treatment; judgment is intact.

Rating Scales, Labs and Studies

• PHQ-A (Adolescent): Score 16, indicating moderately severe depression.
• GAD-7: Score 14, indicating moderate anxiety.
• Labs (drawn 02/03/2026 via pediatrician): TSH 1.8 mIU/L (normal), Free T4 1.1 ng/dL (normal), CBC w/ diff WNL, Ferritin 18 ng/mL (borderline low), 25-OH Vitamin D 22 ng/mL (insufficient).

Clinical Global Impressions

CGI-S (Severity)

4=Moderately ill. The patient exhibits clear depressive and anxious symptoms resulting in noticeable functional impairment in academics and social withdrawal, though she remains safe for outpatient management.

CGI-I (Improvement)

4=No change. This is an initial intake evaluation establishing baseline status prior to starting pharmacological intervention.

Assessment

15-year-old female presenting with Major Depressive Disorder, single episode, moderate, and Generalized Anxiety Disorder, complicated by academic stressors and vitamin D insufficiency. Biopsychosocial formulation: Biologically predisposed to mood and anxiety disorders via strong maternal family history and borderline low ferritin/Vitamin D levels; psychologically perfectionistic with maladaptive internalization of stress and reliance on avoidance; socially precipitated by transition to a high-pressure academic environment and loss of peer support after quitting soccer, though buffered by a supportive nuclear family. A new treatment was started today, and ongoing psychotherapy was continued without change.

Risk Assessment

Risk to Self or Others

Low acute risk, moderate chronic risk. Patient endorses passive SI without intent or plan, and has a remote history of superficial non-suicidal self-injury (NSSI) 4 months ago. No risk of harm to others.

Protective Factors

Strong support from parents, positive therapeutic alliance with outpatient therapist, attachment to family dog, future orientation, and willingness to engage in treatment.

Risk Factors

Depressed mood (modifiable), severe academic stress and insomnia (modifiable), prior history of NSSI (static), and family history of mood disorders (static).

Risk Management and Level of Care

Patient is appropriate for outpatient level of care given absence of active suicidal intent/plan and responsive family supervision. Parents agreed to secure all sharp objects and over-the-counter medications in a locked cabinet at home. Emergency room evaluation was discussed and deemed unnecessary today, with clear criteria provided for when to seek emergency care.

Medication and Somatic Interventions

• Initiate escitalopram (Lexapro®) 5 mg PO daily for 7 days, then increase to 10 mg PO daily for MDD and GAD. Chosen due to positive maternal response and better GI tolerability profile compared to prior sertraline trial. Reviewed FDA black box warning regarding emergent suicidality in adolescents/young adults, as well as potential side effects (GI upset, headache, activation/bipolar switch given family history).
• Initiate colecalciferol (Vitamin D3) 2,000 IU PO daily for vitamin D insufficiency.
• Continue melatonin 3 mg PO QHS PRN for initial insomnia.

Psychotherapeutic Interventions

Provided supportive psychotherapy and cognitive reframing regarding academic expectations during the 60-minute intake (09:00 to 10:00). Reinforced behavioural activation strategies and sleep hygiene (removing phone from bedroom 1 hour before sleep).

Plan

• Major Depressive Disorder / Generalized Anxiety Disorder:
  • Start escitalopram titration as above.
  • Treatment goals discussed: Reduce PHQ-A and GAD-7 scores by 50%, restore sleep duration to 8 hours nightly, eliminate passive SI, and improve school attendance.
  • Future options discussed: If partial response to escitalopram 10 mg after 4–6 weeks, will consider titration to 20 mg daily or augmentation with aripiprazole if mood lability emerges.
  • Provided letter for school counselor requesting temporary 504 accommodations (extended time on assignments and access to a quiet testing environment).
• Follow-up: Return to clinic in 2 weeks (02/04/2026 at 14:00) for medication check and safety reassessment.

Collaboration Plan

• Current Treaters:
  • Ms. Sarah Jenkins, LCSW (Outpatient Therapist): Patient sees her weekly for CBT. Obtained ROI; will call Ms. Jenkins this week to coordinate behavioral activation goals and safety monitoring.
  • Dr. David Chen, MD (Pediatrician): Will send intake summary and coordinate repeat ferritin and Vitamin D levels in 3 months.
• Family Collaboration: Met extensively with mother and patient together. Provided psychoeducation to mother and patient regarding the neurobiology of depression/anxiety, SSRI timeline for efficacy (4–6 weeks), and monitoring for behavioral activation or worsening SI.

Safety Plan

Patient understands how to contact me, the covering clinician, and treatment-team members during an emergency by cell phone, and understands that email is intended only for non-urgent logistical matters such as scheduling. Patient also understands that overnight text messages may not be heard; if a text receives no response and the situation is urgent, calling is the most dependable way to make contact. Advised to call 911 or go to the nearest emergency department if an acute safety concern develops while awaiting a return call. Patient is also aware of the 988 Crisis Line for additional support. Additionally, patient identified listening to music, walking her dog Max, and talking to her mother as primary internal and external coping strategies if passive thoughts worsen.

Time Spent Same Day on Case

75 minutes (60 minutes face-to-face evaluation with patient and mother from 09:00 to 10:00; 15 minutes reviewing pediatrician records, scoring rating scales, and documentation).