Young Person’s Biopsychosocial Mental Health Assessment

Date: 14/05/2026 Attendees: Liam O'Connor (client), Sarah O'Connor (mother, initial 15 mins only), Dr. Elena Rostova (Clinical Psychologist) Confidentiality explained and client questions answered: Limits of confidentiality explained (harm to self/others, child protection, subpoena). Liam asked if school would be notified; reassured no info shared without written consent unless acute safety risk. Informed consent obtained.

Mode of Referral and Relevant Background Regarding Referral GP referral (Dr. A. Patel) under Better Access Mental Health Treatment Plan (MHTP). Referred for 6 months of escalating school refusal, social withdrawal, and somatic complaints (morning nausea, headaches) following transition to Year 10.

Demographics

15 yo cisgender male (DOB: 22/08/2010), Anglo-Australian. Currently enrolled in Year 10 at local public high school; not employed. Lives in stable rental accommodation in western Sydney with mother (Sarah, 42, admin officer) and younger sister (Chloe, 12). Parents separated 3 years ago; minimal contact with father. Medicare number: 2948 58201 3.

Presenting Problem

Liam presents with persistent daily worry regarding academic performance and peer evaluation, accompanied by physiological hyperarousal (tachycardia, GI distress, tremor) on school mornings. Symptoms have resulted in 40% school absenteeism over Term 1. Reports pervasive low mood secondary to isolation, initial insomnia (1–2 hr latency), and loss of interest in soccer.

Presenting Factors

• Morning panic symptoms and GI distress: Directly driving school avoidance behaviour via negative reinforcement.
• Fear of negative evaluation by peers: Contributes to social withdrawal in classroom and refusal to give oral presentations.
• Secondary depressive symptoms (anhedonia, fatigue): Lowering motivation to re-engage with extracurriculars and academic catch-up.

Case Conceptualisation or Formulation

Liam is a 15-year-old male presenting with symptoms consistent with Social Anxiety Disorder and secondary mild-to-moderate depressive features. He carries a genetic predisposition to anxiety (maternal history of GAD) and an inhibited temperament, compounded by the developmental stressor of parental separation at age 12. The current presentation was precipitated by the transition to Year 10, which involved streaming into new classes away from his primary peer group and increased academic expectations. His distress is perpetuated by behavioural avoidance (staying home from school, gaming during school hours), which provides short-term relief from anxiety but reinforces his belief that he cannot cope, while simultaneously increasing academic backlog and peer disconnection. Maternal accommodation (allowing him to stay home when nauseous) inadvertently maintains the avoidance cycle. Protective factors include strong maternal support, average-to-high cognitive ability, insight into his avoidance cycle, and a remaining connection with one close friend.

The Other 4 P’s

Predisposing Factors

• Maternal history of Generalised Anxiety Disorder: Confers biological/genetic vulnerability and potential modelling of anxious coping.
• Inhibited childhood temperament: History of separation anxiety in early primary school indicates longstanding vulnerability to novel social environments.
• Parental separation (3 years ago) and paternal estrangement: Disrupted attachment security and sensitivity to rejection.

Precipitating Factors

• Transition to Year 10 and class restructuring: Separated from his two safe peers, triggering acute social vulnerability.
• Panic attack during an English presentation in Week 3 of Term 1: Created a conditioned fear response to classroom settings.

Perpetuating Factors

• School refusal and avoidance of social situations: Prevents disconfirmation of catastrophic social beliefs and increases workload arrears.
• Maternal accommodation of symptoms: Mother calling him in sick when he reports morning nausea reinforces somatic focus and avoidance.
• Reversed sleep-wake cycle on days off: Late-night online gaming impairs morning alertness and exacerbates lethargy.

Protective Factors

• Supportive relationship with mother: High maternal warmth and willingness to engage in family-supported interventions.
• Intact relationship with best friend (Noah): Maintains daily contact via online gaming, preventing complete peer isolation.
• Help-seeking attitude: Expressed willingness to attend therapy and desire to return to weekend soccer.

Physical Health and Biological Functioning

Positive family history of anxiety (mother) and depression (paternal uncle). Neurodevelopmentally normal; no history of TBI or seizures. Denies alcohol, tobacco, vaping, or illicit substance use. Mild childhood asthma, currently asymptomatic. Medications: salbutamol (Ventolin®) 100 mcg INH PRN; melatonin 2 mg PO nocte initiated by GP 2 weeks ago with mild benefit. Recent bloods (FBC, iron studies, TFTs, Vit D, B12) ordered by GP were NAD. Physical activity ceased 2 months ago (previously played club soccer 2x/week). Sleep characterised by delayed phase (bed at 23:30, asleep by 01:00, waking 08:30 on non-school days). Appetite reduced in mornings; adequate intake in evenings.

Psychological Functioning

No history of Criterion A trauma; reports ongoing distress regarding father's lack of contact since separation. Temperamentally shy, perfectionistic, and sensitive to criticism. Coping repertoire relies heavily on distraction (gaming) and avoidance. Previous mental health history includes 4 sessions with primary school counsellor at age 8 for separation anxiety (resolved).

Mental State Examination (MSE)

Appearance: Slender adolescent male, casually groomed in oversized hoodie and jeans, Appeared stated age. Behaviour: Guarded initially, fidgeting with hoodie strings, intermittent eye contact; warmed up and became cooperative once mother left the room. Speech: Soft volume, normal rate and rhythm, brief responses initially becoming more spontaneous. Mood: "Stressed and tired." Affect: Anxious and restricted, congruent with mood and content. Thought Process: Linear, logical, and goal-directed. Thought Content: Preoccupied with falling behind in schoolwork and peers judging his absences. Passive wish to "disappear when stressed," but no active suicidal ideation, intent, or plan. No delusions or obsessions. Perception: No hallucinations, depersonalisation, or derealisation reported or observed. Cognition: Alert and oriented to time, place, and person. Attention and concentration intact during clinical interview. Insight: Good; recognises that staying home makes returning to school harder. Judgment: Intact; engaging appropriately in safety planning and treatment discussion.

Social Functioning

Currently attending Year 10 approximately 3 days per week (mostly half-days). Grades have dropped from B-average to ungraded due to missed assessments. Strong, supportive relationship with mother and amicable relationship with younger sister; estranged from father (no contact for 14 months). Single, no romantic history. One close friend (Noah) from primary school; broader peer network has diminished over the past 3 months. Family experiences mild financial strain on a single income, though basic needs are consistently met.

Formulation Statement

Clinical Impression, Preliminary Presentation, Diagnosis (if stated), and Differential Presentations

Clinical presentation meets DSM-5-TR criteria for Social Anxiety Disorder (F40.10), Moderate, with secondary Major Depressive Disorder, single episode, mild (F32.0). Differential considerations include Panic Disorder (ruled out as panic attacks are strictly cued by social/evaluative school situations), Generalized Anxiety Disorder (worry is predominantly focused on social evaluation and academic embarrassment rather than diffuse domains), and Undiagnosed Autism Spectrum Disorder (ruled out given intact social reciprocity, non-verbal communication, and absence of restricted/repetitive behaviours in developmental history).

Global Assessment of Functioning (GAF)

55 – Moderate symptoms (frequent situational panic attacks, flat affect) and moderate difficulty in social and school functioning (40% school absenteeism, dropping out of soccer).

Outcome Measures

• K10: 29 (High psychological distress)
• K10+: 31 (Days totally unable to work/study in past 4 weeks: 6; days cut down: 10)
• My Life Tracker: 42/100
• SOFAS: 58
• Willingness to Attend: 8/10
• Clinical Staging: Stage 1b – Attenuated syndrome with mixed anxious and depressive symptoms causing moderate functional impact on schooling.

Personal Safety Risk Assessment

Assessed using Columbia-Suicide Severity Rating Scale (C-SSRS) Screener. Endorsed Question 1 (wish to be dead/go to sleep and not wake up when overwhelmed by school stress in the past month). Denied Questions 2–6 (no active suicidal thoughts, methods, intent, plan, or lifetime suicidal behaviour). Denied non-suicidal self-injury (NSSI). Denied risk of harm to others or vulnerability to exploitation. Overall acute suicide risk assessed as LOW, with chronic risk elevated slightly by social isolation if school refusal remains unaddressed.

Agreed Goals

• Client’s stated treatment goals: "Go through a full week of school without feeling like I'm going to throw up, and start going back to soccer training."
• Therapy treatment goals: Reduce physiological arousal via somatic regulation skills; build a graded exposure hierarchy for school attendance and classroom participation; restructure socially catastrophic cognitions; re-establish sleep hygiene and behavioural activation.
• Timeframes for achieving goals: Initial review after 6 sessions (approx. 8 weeks) per MHTP requirements; target 80% school attendance within 10 weeks.

Proposed Treatment Plan and Therapeutic Approach

10-session Cognitive Behavioural Therapy (CBT) intervention for adolescent social anxiety and school refusal:

• Sessions 1–2: Psychoeducation on the anxiety/avoidance cycle, sleep hygiene, and somatic management (paced respiration, PMR). Parent session (15 mins) to reduce maternal accommodation.
• Sessions 3–5: Cognitive restructuring targeting mind-reading and catastrophic predictions; development of graded exposure hierarchy in collaboration with school Year Advisor.
• Sessions 6–8: In-vivo and interoceptive exposures, behavioural activation (re-joining soccer training), assertive communication skills.
• Sessions 9–10: Relapse prevention, maintenance planning, and GP review.

Single Session Thinking

Not suitable for SST. Presentation involves entrenched avoidance behaviours (40% absenteeism over a full school term) and systemic factors (school liaison and parental accommodation) requiring structured, multi-session graded exposure and stakeholder coordination.

Other Approaches to Consider

Acceptance and Commitment Therapy (ACT) defusion techniques if cognitive restructuring results in over-engagement/rumination with anxious thoughts.

Additional Referrals to Consider

Referral to School Psychologist / Year 10 Coordinator (with client/parent consent) to establish a modified return-to-school timetable and temporary exemption from cold-calling in class during initial exposure phase.

Clinical Responsibilities

No mandatory reporting (Child Protection / ROSH) triggers identified; home environment is safe and supportive. Clinician to provide MHTP feedback letter to referring GP (Dr. A. Patel) following Session 1 and Session 6.

Coping Plan

Healthy Coping

• Texting or playing cooperative online games with Noah after school hours
• Listening to playlists on headphones during morning commute
• Walking the family dog for 20 minutes in the afternoon
• Using 4-7-8 breathing technique when morning nausea starts

Unhealthy Coping

• Staying in bed and scrolling on phone when feeling nauseous in the morning
• Gaming past midnight on school nights
• Avoiding eye contact and sitting at the back of the classroom to hide

Crisis and Safety Plan

• Warning Signs: Feeling trapped, severe knot in stomach on Sunday nights, thoughts of "wanting to disappear," shutting bedroom door and refusing dinner.
• Internal Coping Strategies: Put on noise-cancelling headphones, listen to comfort playlist, splash cold water on face, play with family dog (Buster).
• Social Distractions / Safe People: Hang out in the living room with Mum and Chloe; message Noah to play FIFA.
• Trusted Adults to Contact for Help: Mother (Sarah O'Connor: 0412 345 678); Aunt (Rebecca: 0498 765 432).
• Professional & Crisis Contacts: Kids Helpline (1800 55 1800); Headspace (1800 650 890); Lifeline (13 11 14); Local CAMHS Crisis Team (1800 011 511); Emergency Services (000).
• Environment Safety: Medications at home (paracetamol, ibuprofen) kept in mother's bedroom cupboard.

Safe Engagement

Appointments scheduled at 15:30 to avoid clashing with school hours and prevent therapy from reinforcing school absenteeism. SMS reminders sent to both Liam and his mother 24 hours prior. Agreed that if Liam is too anxious to attend in person, session will pivot to Telehealth rather than cancelling.

Comprehensive Assessment Summary

Liam is a 15-year-old male presenting with moderate Social Anxiety Disorder and secondary mild depressive symptoms manifesting primarily as school refusal. Treatment will utilise an evidence-based CBT framework incorporating graded exposure, cognitive restructuring, parent-led reduction of accommodation, and school liaison. The treatment plan is flexible and will be paced according to weekly K10/MLT tracking and school attendance data; should anxiety remain refractory to CBT by Session 6, a psychiatric or GP review for SSRI pharmacotherapy will be discussed with Liam and his mother.

Dr. Elena Rostova, Clinical Psychologist (PSY000184920)