Child Therapy First-Visit Assessment Note

Client Information

• Client Name: Leo Vance
• Provider Name: Dr. Sarah Jenkins, MD
• Date of Service: 24/10/2023
• Session Duration: 60 mins (14:00 - 15:00 CST)

Brief Summary of Session

Initial psychiatric evaluation and therapy intake with 9yo male and mother. Reviewed presenting separation anxiety, school refusal, and somatic complaints. Completed MSE, biopsychosocial hx, and initial tx planning. Pt shy initially, warmed up using drawing materials. Formulated initial CBT goals.

Consent

• Informed Consent: Reviewed limits of confidentiality (mandated reporting, harm to self/others), clinic policies, and pt rights with mother and assent with pt. Mother signed consent forms electronically.
• Quote (Consent): "I understand that everything stays here unless Leo is in danger of hurting himself or someone else, or if someone is hurting him."

Presenting Problem

• Chief Complaint: Referred by PCP (Dr. Ross) for escalating anxiety regarding separation from mother, resulting in frequent school tardiness and somatic sx (morning abdominal pain, nausea).
• Quote (Chief Complaint): "He cries every single morning before the bus comes and begs me not to make him go because he thinks something bad will happen to me."
• Impairments and Challenges: Academic decline due to missed morning instruction (tardy 3-4x/wk); frequent nurse visits at school; inability to attend sleepovers or playdates without mother present; disrupted family sleep schedule.
• Quote (Impairments and Challenges): "I can't even go to the grocery store alone without him calling me five times in an hour."

Psychological Factors

• Family Mental Health History: Mother has hx of GAD (treated with SSRI). Maternal grandmother with MDD. Paternal hx unremarkable.
• Previous Mental Health Treatments: None. Seen by school counselor 3x this semester for check-ins.
• Symptom Description: Sx onset 2 mos ago at start of 4th grade. Daily morning distress (intensity 8/10), crying, clinging, GI upset. Nightmares 2x/wk about family separation. Sx remit on weekends when home with parents.
• Quotes (Symptoms): "My tummy hurts really bad when I have to get in the car, and I worry mom will get in a crash while I'm at school."

Biological Factors

• Medications: melatonin 1 mg PO QHS PRN insomnia.
• Allergies: NKDA.
• Medical Conditions: Mild intermittent asthma (uses salbutamol (albuterol, ProAir HFA®) 90 mcg/actuation MDI 2 puffs INH Q4H PRN SOB). GI workup by PCP negative for organic cause of abdominal pain.
• Sleep: Difficulty falling asleep alone; requires mother to lie in bed with him for 45 mins. Sleeps ~8.5 hrs/night once asleep.
• Nutrition: Decreased appetite on school mornings; normal intake at dinner and on weekends. Normal BMI.
• Physical Activity: Plays recreational soccer 2x/wk, though frequently checks sidelines to ensure mother is watching.

Social Factors

• School: 4th grade, mainstream classes. Strong academic ability (A/B student), but missing morning math block due to tardiness.
• Relationships: Lives with intact nuclear family (mother, father, 6yo sister). Close bond with mother. Has 2 close friends at school, though avoids out-of-school hangouts.
• Recreation: Enjoys Lego building, Minecraft, and drawing comic books.
• Recent Changes or Stressors: Transition to a new, larger elementary school building this academic year; mother returned to in-office work 3 days/wk (previously WFH full-time).
• Traumatic Experiences: Denies physical, sexual, or emotional abuse. Witnessed minor fender-bender with mother 6 mos ago (no injuries, minimal car damage).

Clinical Assessment

• Clinical Conceptualization: 9yo male with genetic predisposition to anxiety (maternal GAD), triggered by environmental transitions (mother returning to office, new school building) and a minor MVA stressor. Maladaptive coping via avoidance/reassurance-seeking is negatively reinforced by parental accommodation (staying in bed, allowing late arrivals).
• Diagnosis: F93.0 Separation Anxiety Disorder of Childhood
  • Reasoning: Meets DSM-5 criteria: developmentally inappropriate, excessive fear concerning separation from attachment figure lasting > 4 wks, evidenced by recurrent distress upon separation, persistent worry about losing mother to an accident, reluctance to go to school, refusal to sleep alone, and physical complaints (stomachaches) on school days.
  • Assessment Tool: SCARED (Screen for Child Anxiety Related Emotional Disorders) - Parent Version: Total score 34 (clinical cutoff ≥ 25); Separation Anxiety subscale score 11 (cutoff ≥ 5).
• Status: Intake complete. Initiating outpatient therapy; deferring pharmacotherapy trial at this time per parental preference for CBT first.

Mental Status Exam

• Mood and Affect: Mood "a little nervous"; affect anxious initially, brightening to euthymic when discussing Legos.
• Speech and Language: Soft-spoken initially, normal rate, rhythm, and volume once comfortable. Age-appropriate vocabulary.
• Thought Process and Content: Linear, logical, goal-directed. Preoccupied with worries about mother's safety. No delusions, hallucinations, or OCD sx.
• Orientation: Oriented x4 (person, place, time, situation).
• Cognition: Attention intact (focused on drawing task for 20 mins); recent and remote memory grossly intact; average intelligence estimated.
• Insight: Fair for age; recognizes his worries are "bigger than other kids'" and cause his stomachaches.

Risk Assessment

• Safety Concerns: Denies SI/HI, NSSI, or aggressive behaviors. Low acute risk.
• Quotes (Risk): "No, I would never try to hurt myself."
• Safety Plan: Standard outpatient monitoring. Provided mother with 24/7 crisis line numbers and reviewed ER protocols as routine precaution.

Strengths and Resources

• Internal Strengths: High verbal intelligence, creative, cooperative, motivated to feel better and attend soccer without worry.
• External Resources: Supportive, involved parents; stable housing/finances; accommodating school staff.
• Quote (Resources): "I really want to be able to go to my friend Sam's birthday sleepover next month."

Interventions

• Therapeutic Approach: Cognitive Behavioral Therapy (CBT) with parent management training.
• Specific Interventions: Psychoeducation on the cognitive triangle (thoughts-feelings-behaviors) and the physiology of anxiety ("false alarm" in the brain causing tummy aches). Externalized anxiety by naming it the "Worry Bully."
• Rationale: CBT is first-line, evidence-based tx for pediatric anxiety disorders; externalizing helps reduce shame and increases child's sense of agency over sx.

Progress and Response

• Client Engagement: Receptive; actively drew his "Worry Bully" and identified where he feels anxiety in his body.
• Specific Examples: Successfully separated from mother for the final 10 mins of session while she waited in the lobby.
• Quote (Progress): "So my brain is just pulling the fire alarm when there's no real fire."
• Challenges: High parental accommodation; mother feels guilty when pt cries and tends to give in to reassurance requests.

Goals

1. Goal:
   • Description: Increase independent school attendance and reduce morning separation distress.
   • Metrics: Arrive at school on time 5/5 days per wk with ≤ 1 nurse visit per wk.
   • Timeframe: 8 weeks.
   • Quote (Goal): "I want to walk into school with my friends instead of crying in the car."
2. Goal:
   • Description: Increase bedtime independence.
   • Metrics: Fall asleep in own bed without parent lying down with him 6/7 nights per wk.
   • Timeframe: 12 weeks.
   • Quote (Goal): "It would be nice to have my evenings back so I can get housework done after he goes to bed."

Follow-Up Plan

• Homework: Pt to track daily "Worry Bully" appearances using a 1-5 thermometer worksheet. Mother to limit reassurance answers to one brief statement ("I am safe, and you are safe") rather than repeated explanations.
• Next Session Plan: Develop a gradual exposure hierarchy ("bravery ladder") for morning drop-offs and bedtime separation; introduce diaphragmatic breathing.
• Coordination of Care: Obtain signed ROI to collaborate with school counselor (Ms. Davis) regarding morning drop-off transition plan. Send intake summary to PCP (Dr. Ross).
• Long-Term Plan: Weekly 50-min individual/family CBT sessions for 12-16 wks, reassessing need for SSRI if minimal response at 8-wk mark.