Child and Adolescent Psychiatry Assessment (custom)

CONSULTATION REPORT, Sarah Jones was seen for an initial psychiatry assessment at the Children's Mental Health Clinic, on 1 November 2024, accompanied by her mother, Mrs. Jones. ID: Sarah Jones is a 14-year-old female who lives in Toronto with her mother and her dog, Max. Sarah is registered in Grade 9 at Maplewood High School. Sources of Information: • Separate and joint interviews with Sarah Jones and Mrs. Jones • Review of Connect care and Netcare • Case discussion with nurse, Emily Carter, who assisted with collateral information • Psychometric measures completed and reviewed **Reason for referral:** Referred by Dr. Smith due to concerns about Sarah's persistent low mood and social withdrawal. **Presenting Complaints:** 1. Low mood for the past 6 months, "I just don't feel happy anymore." 2. Social withdrawal, avoiding friends and activities she used to enjoy. 3. Difficulty sleeping, experiencing insomnia most nights. **History of Presenting Complaints:** Sarah reports feeling sad and down most days for the past six months. She states that she has lost interest in activities she used to enjoy, such as playing soccer and spending time with friends. She has withdrawn from social activities and spends most of her time in her room. She reports difficulty falling asleep and staying asleep, often feeling tired during the day. She denies any history of hallucinations, psychosis, or mania. Collateral History: (Mrs. Jones, Mother) Mrs. Jones reports that Sarah's mood has been declining gradually over the past six months. She has noticed a significant change in Sarah's behaviour, including social withdrawal, decreased appetite, and difficulty sleeping. Mrs. Jones is concerned about Sarah's well-being and is seeking help to address these issues. She reports that Sarah has no previous mental health concerns and is compliant with all medical appointments. **Past psychiatric history:** None reported. Developmental History: No issues reported. Medical History: No chronic medical conditions reported. Medication History: No current medications. No known allergies. **Family History:** Mother reports a history of depression in her maternal grandmother. No history of suicide in the family. Living arrangements: Sarah lives with her mother. The relationship is generally supportive, although there have been some recent conflicts related to Sarah's mood and behaviour. Educational History: Sarah is in Grade 9 at Maplewood High School. Her attendance has been regular, but her grades have declined recently. She is not currently receiving any academic supports. She has not had any behavioral problems at school. **Social History:** Sarah is a student. She denies any substance use. She has a few close friends, but she has been avoiding them recently. She enjoys playing soccer, but has stopped playing. She has no vocational goals at this time. Premorbid Personality: Sarah was previously described as a happy, outgoing, and well-adjusted teenager. Expectations: Parent: Mrs. Jones hopes that Sarah will feel better and be able to return to her normal activities. Child: Sarah wishes to feel happy again and to be able to enjoy her life. Trauma History/ ACEs: No adverse childhood experiences identified. Mental Status Examination: - Appearance: Sarah is dressed in casual clothing and appears her stated age. Her hygiene is appropriate. - Behaviour: Sarah is withdrawn and appears sad. She makes limited eye contact. - Speech: Speech is normal in rate and volume. Speech is coherent. - Mood: Sarah reports feeling sad. - Affect: Affect is congruent with mood, appearing sad and constricted. - Thoughts: No evidence of thought disorder. No suicidal ideation reported. - Perceptions: No hallucinations reported. - Cognition: Oriented to time, place, and person. Memory intact. - Insight: Sarah acknowledges that she is experiencing difficulties and is seeking help. - Judgment: Judgment appears intact. **Risk Assessment:** - No current suicidal or homicidal ideation reported. Psychometric measures: PHQ-9 score of 18, indicating moderate depression. **Impression:** Sarah Jones, a 14-year-old female, presents with a six-month history of low mood, social withdrawal, and sleep difficulties. Biopsychosocial formulation reveals predisposing factors including a family history of depression, precipitating factors including a recent decline in academic performance, perpetuating factors including social isolation, and protective factors including a supportive family environment. **DSM-5 Diagnosis:** Major Depressive Disorder, single episode. Treatment Plan: 1. Provided psychoeducation in relation to above formulation/ diagnoses and treatment options - Medications: Discussed the use of antidepressant medication and referred to a paediatrician for further assessment. - Psychotherapy: Referred to individual therapy with a focus on cognitive-behavioral therapy (CBT). - Follow-up appointments and referrals: Scheduled a follow-up appointment in 4 weeks.