sample psychiatric report for an autistic patient

What is the purpose of this special report on autism?

The purpose of this special report is to summarize the latest understanding of autism’s commonly associated physical and mental health conditions, including how best to identify, treat and in some cases prevent them to improve overall health and quality of life. INTRODUCTION 2

Are there any sample reports of psychiatric-oriented mental status examinations?

The following two fictional reports are samples of psychiatric-oriented MSEs. These sample reports can be helpful if you’re learning to conduct Mental Status Examinations and write MSE reports. They’re excerpted from the text, Clinical Interviewing (6th edition; 2017, John Wiley & Sons).

What are the symptoms of autism in Ralph?

Ralph plays with toys appropriately and in creative ways and does not line them up or arrange them by color or shape. He only occasionally imitates or wants to do the things his parents do, such as pretending to cook or clean. Treatment Plan Ralph is not displaying enough signs and symptoms to be consistent with having an ASD.

Why did the Department of Behavioral Medicine request an autism evaluation?

Consultation Report of the Department of Behavioral Medicine ASD Diagnostic Service Reason for Consultation An evaluation was requested to confirm a previous diagnosis of autism. Consultation History

What is a psychological evaluation for autism?

The ADOS is an assessment used for autism. The ADOS consists of structured and semi-structured subtests that involve different components of social interactions and communication. The assessment has five modules. The module is chosen based on the individual's developmental level.

What should an autism evaluation include?

Because ASD is a developmental disability, the evaluation will usually include tests of language, intelligence, behavior, and adaptive behavior (daily living skills and activities). Some tests are given directly to the child, and others are forms completed by the parent/caregiver.

How do you assess a patient with autism?

A comprehensive autism spectrum evaluation should include a developmental history, observations, direct interaction, a parent interview and an evaluation of functioning in the following areas: social, communication, sensory, emotional, cognitive and adaptive behavior. At times, additional assessments are indicated.

Does a psychological evaluation test for autism?

For children with autism spectrum disorder (ASD) they may participate in a psychological evaluation to determine if they meet criteria for the ASD but also to provide information about their intellectual or academic strengths and weaknesses, speech and language skills, and/or difficulties with behavior and executive ...

What are the 3 main symptoms of autism?

The symptoms to look out for in children for suspected autism are:Delayed milestones.A socially awkward child.The child who has trouble with verbal and nonverbal communication.

What questions are asked at an autism evaluation?

Here are a few questions to start you thinking about what to bring up at your child's autism evaluation:When did your child first speak?Does your child remember the words he or she learns, or seem to forget them easily?Does he or she continue to grow their vocabulary by learning new words?More items...•

What are the 12 symptoms of autism?

Signs of autism in childrennot responding to their name.avoiding eye contact.not smiling when you smile at them.getting very upset if they do not like a certain taste, smell or sound.repetitive movements, such as flapping their hands, flicking their fingers or rocking their body.not talking as much as other children.More items...

Does autism affect mental capacity?

The impact of autism should be considered when assessing under the Mental Capacity Act 2005 or the Mental Health Act 2007. For example, someone with autism may have good theoretical knowledge about an issue and appear to have capacity, but in fact are not able to retain or weigh up the information.

What is a cognitive test for autism?

Research has demonstrated that the Spatial Working Memory (SWM) test is highly sensitive to cognitive dysfunction in autism (including higher functioning autism), highlighting that deficits in this cognitive process are prevalent within individuals with autism.

Is autism a neurological disorder?

Autism spectrum disorder (ASD) is a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave. Although autism can be diagnosed at any age, it is described as a “developmental disorder” because symptoms generally appear in the first two years of life.

What is autism spectrum disorder?

Autism is a spectrum disorder – meaning it has many forms that affect people in a variety of ways and in varying degrees. Each person’s experience with autism presents unique challenges, as well as strengths, which define the type of support needed to lead a fulfilling life.

How many children with autism are overweight?

Of the 5,053 children with autism in the study, nearly a third (32 percent) of 2 to 5 year olds were overweight, compared to less than a quarter (23 percent) of 2- to 5-year-olds in the general population. Sixteen percent of 2- to 5-year-olds with autism were medically obese, compared to 10 percent of 2- to 5-year- olds in the general population. The investigators found that the likelihood of being overweight or obese increased with the number of psychoactive behavioral medicines a child or teen was taking. Some of these children were taking as many as five. (Hill 2015)

What percentage of people with autism have ADHD?

Over the last decade, studies have suggested that between 30 and 61 percent of people with autism also have symptoms of ADHD. (Goldstein 2004, Lee 2006, Gadow 2006, Romero 2016) By contrast, the CDC estimates that ADHD affects 6 to 7 percent of the general population. (Perou 2013)

What percentage of children have depression?

Depression affects an estimated 7 percent of children and 26 percent of adults with autism. (Greenlee 2016, Croen 2015) This compares to 2 percent of children and close to 7 percent of adults in the general U.S. population. (Perou 2013, NIMH 2015) A recent report in the journal Pediatrics found that the rate of depression among children with autism rose dramatically with age, from just under 5 percent in grade-schoolers to just over 20 percent in teenagers. (Greenlee 2016) It likewise rose with intellectual ability (IQ), as well as the presence of one or more of the medical conditions that commonly accompany autism – particularly seizures and gastrointestinal issues.

How many times is autism risk?

As a group, people who have autism are more than twice as likely to die prematurely. For some subgroups, the risk can be up to 10 times that of the general population.

How does anxiety affect autism?

Anxiety can trigger strong internal sensations of tension that include a racing heart, muscle tightness and stomachache. In someone with autism, these feelings can prompt an increase in self- soothing, repetitive behaviors (flapping, rocking, spinning, etc.) and/or destructive or self-harming behaviors (shredding clothing, head banging, etc.). Similarly, anxiety can be the underlying cause of new resistance to what had been an enjoyed activity (a trip to the beach, a birthday party, school, etc.).

What is an EEG for autism?

Suspicion of seizures warrants prompt evaluation by a neurologist, who may order an electroencephalogram (EEG), a noninvasive process that involves placing electrodes on the head to monitor activity in the brain. By analyzing EEG patterns, the neurologist can identify seizures and other altered brain activity of concern. Often patients who have autism need EEG protocols that address their sensory and communication challenges. (Katz 2015)(See resource section for more information on autism-friendly EEG procedures.)

INTRODUCTION

Although autism was once considered rare, it is now estimated that 1% of adults meet current criteria for autism spectrum disorder (ASD) with no difference in prevalence by age.

ASD DIAGNOSIS IN ADULTS

In 2013, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) unified autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and Pervasive Disorder Not Otherwise Specified into one diagnosis called ASD.

REFERRALS FOR ASSISTIVE TECHNOLOGIES AND THERAPIES

Assistive technologies, therapies, and services for autistic adults are not meant to treat or cure autism. They may improve function or quality of life by increasing coping strategies, treating co-occurring conditions, or providing access to accommodations and supports.

ASSOCIATED CONDITIONS

Both genetic and environmental factors play a role in health outcomes. 10 Current evidence suggests autistic adults have high rates of associated chronic medical illness, especially epilepsy, gastrointestinal disorders, feeding and nutritional problems, metabolic syndrome, anxiety, depression, and sleep disturbances.

FACILITATING EFFECTIVE HEALTH CARE INTERACTIONS

People with disabilities face significant disparities in health and health care.

UNDERSTANDING AND ADDRESSING BEHAVIOR CHANGE

In people with nontraditional communication or atypical cognition, common medical problems can present in unusual ways. Illness often presents as a change from baseline behavior or function. For example, pain can present as social withdrawal or self-injurious or agitated behavior.

LEGAL AND ETHICAL CONSIDERATIONS

Issues of autonomy can be particularly significant for autistic individuals, many of whom have been denied opportunities for self-determination. The capacity of autistic people to consent to treatment or participate in shared decision-making is often overlooked.

What is Sally's performance on visual motor coordination?

Sally’s performance on measures of visual-motor coordination indicated that She was not experiencing any serious neurological problems at the time of her examination. Her ability to coordinate her visual perceptions with the movements of her hands was in the average range and appropriate for someone her age. There were no unusual circumstances or disruptions during her testing which might have interfered with Sally giving her best performance. The results of the cognitive and academic sections of this report are held to be a valid measure of Sally’s functioning at the time of her examination. However, it appears that Sally has a tendency to minimize her problems, and in some cases resort to denial, affected the validity of socioemotional measures given. Her self report indicates a possible effort to appear less in need than She actually is. This was especially evident in situations where the questions had obvious intentions to tap feelings of depression and anxiety. Others measures that did not rely on her self-report, or were not obvious in their intent, indicated a higher degree of problems than her self report. Due to the consensus of the information obtained by objective (non-self report) methods, they will make up the bulk of the results presented in these sections.

What is Sally's cognitive development?

Sally’s Cognitive Development was found to be at a level appropriate for her age. While She demonstrated even development across all cognitive areas, two specific areas of weakness were noted. Sally was found to have particular difficulty with visual discrimination and mental construction. This appears to be mitigated with the addition of time and structure to the task.

What is Sally's self-concept?

Sally’s self-concept was found to be moderately impaired with evidence that She estimates herself to be inferior to others and inadequate to the demands of life. Her responses indicate that these beliefs are mainly due to her poor school performance rather than a global sense of inferiority. Sally also appears to be significantly confused about her identity and her potential role as an adult. The results also indicate that She attempts to present herself with an somewhat masculine attitude as a way to compensate for her feelings of vulnerability. Sally is currently experiencing a high level of introspection and appears to be ruminating about the past in a negative and painful way.

What is Sally's intellectual functioning?

Sally’s general intellectual functioning was measured to fall within the Average range with her overall thinking and reasoning abilities exceeding those of approximately 30 percent of her same-age peers. Although She performed slightly better on verbal than on nonverbal reasoning tasks, there was no significant difference between Sally's ability to reason with or without the use of words.

What are Sally's physical characteristics?

Notable physical characteristics included height and weight in the upper percentiles making her look older than her stated age. Sally’s grooming appeared adequate and She wore her hair short. Her activity level during her evaluation was normal and her speech was clear and unremarkable. No unusual mannerisms were noted and her eye contact was within normal limits. No overt indicators of aggression or impulsivity were noted during the examination. Sally’s mood and affect were observed to be normal and congruent. Likewise, there were no undue signs of anxiety, hostility, or irritability. Sally was cooperative throughout the evaluation and appeared to give her best effort to all of the tasks presented. In fact, Sally demonstrated an admirable level of persistence in solving difficult problems. Finally, her reactions to failure and frustration were normal and appropriately modulated.

What is Sally's learning disability?

These processing disabilities have resulted in a Specific Learning Disability in Reading. The Reading and Writing Aptitude profile summarizes her strengths and weaknesses in reading and should be useful to her teachers in planning a remediation program.

Is Sally a poor reader?

Sally’s achievement scores are summarized in the graph that follows. They reveal that Sally is a very poor reader and should be diagnosed as having a Specific Learning Disability in Reading. The finding that her Listening Comprehension score is superior indicates that she does not have a generalized receptive language problem but one specific to reading. Good ability was also found in Expressive Language (oral and written) and Math.

Is ADHD a unitary disorder?

The ADHD PROFILE recognizes that ADHD is not a unitary disorder but rather a collection of symptoms which vary in intensity from person to person. The profile has been designed so that someone reviewing the results of the testing can see at a glance the severity of the core ADHD symptoms.