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Assessment Report According 1

Running Head: ASSESSMENT REPORT ACCORDING TO A CASE STUDY

Assessment Report According to a Case Study

Catherine J. Fajardo

PS 410-04

Kaplan University

Bridget Rivera

September 28, 2010


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Assessment Report According to a Case Study

Screening and assessment is a major part of psychology. To help individuals understand the

process of creating an assessment report, a case study will be provided that will amplify the steps

to consider such as the reasons of selecting interviewees and documents that should be on file.

Ethical considerations will be identified prior to assessing the client and other family members as

well as how these considerations influence therapy. The case study will explain issues in which

assessments must be performed to certain members of the family to diagnose potential disorders

and other issues while providing reasons for choosing these analyses. Furthermore, other

screening methods will be considered as well as referrals that must be given to the family

members.

The following case scenario will help illustrate how a family therapist can find clues to the

assessments that should be conducted and to whom they should be administered. Marceline is a

19 year-old female who has a 26-month-old male child named Michael Jr. (Junior). While the

child is with Marceline’s best friend, she tells me that she is very frustrated with her situation.

First of all her child is very disruptive and can hardly keep quiet while he is being cared for by

Marceline’s friend. Marceline states that her child is often very hyperactive. She stated that she

has a boyfriend named Leon who needs to be more patient with Junior and more attentive with

her like he used to be. Marceline complained that Leon has began drinking more because of his

job loss at the grocery store she works at, and that he has shown threatening behavior when he

gets upset; though she has not specified yet what the behavior is. Marceline admits that she also

drinks with Leon usually at night to calm her nerves due to her son’s behavior as well as her

financial situation, on account of her hours at the grocery store getting cut. Marceline explained

that they all live in a one-room studio apartment that is no adequate to live in because the paint in
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the walls is peeling, the toilet has water running constantly, and the heater is not working at all;

meanwhile her landlord is not complying with any of her complaints. Marceline stated that Leon

and she often pay the rent late, but that the landlord does not complain as long as they pay within

that month and the late fees as well. In addition, they had to change their phone number because

bill collectors were often calling them.

Marceline stated that she is still married to her high-school sweetheart, Michael, and their

marriage was in Las Vegas after she found out she was pregnant with Junior. She explained this

was her first romantic involvement and that everything was fine for the first year. The problems

came about after Michael left them to be with another woman, but Michael has recently

resurfaced to try to get his family back. She confides in me that she has been intimate with

Michael, but only communicates sparingly with him when she takes Junior to her mother-in-

law’s daycare at 9:00 a.m. Marceline said that she is confused and does not know what to do

because she is still hurt that Michael left them to be with another woman. Marceline stated that

Grace (mother-in-law) runs a small daycare to pay her house that she inherited; she takes care of

three children. Marceline states that Grace’s house is in good condition except for some

plumbing problems and the need for a refrigerator. She admits that she regrets having Junior and

that Leon and she are ready to give up custody of Junior to Michael and his mother Grace, who

would love to have him since she already has him the majority of time anyway. She says that her

feelings are due to Junior being often avoidant with people, crying constantly, throwing

tantrums, and will not try to communicate when he does not get his way. She says that is hard to

love Junior and that the only thing she can do is to stare at him- she thinks Junior hates her.

Marceline said that she is depressed and has had suicidal thoughts. She also has been

drinking more often than usual to calm her nerves. Typically after 5:00 p.m. she drinks with
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Leon, then after she picks up Junior from daycare and starts making dinner. After a while

Marceline admits that she wants to end the relationship with Leon and move in with Grace. After

a few days, Grace called me to let me know that she can provide some information to help me

assist Marceline and Junior, and that she hopes to see Michael and Marceline together again.

Michael is also a willing participant and is in fact in another phone extension to talk to me. They

let me know that they also want to help Junior. Subsequent to this family’s ordeal the next phase

is to screen and asses the family members.

The succeeding issues that have to be dealt with by the family therapists, after detailing the

family’s condition consist of the selection of interviewees, the paperwork that should be on file,

and the ethical guidelines to consider. The first task for me as a family therapist is to choose the

family members that I want to interview. In this case this will be Marceline, Junior, Grace, and

Michael. The first person is Marceline because she was the first person to seek help for her

family’s problem, also because she can describe the issues that she is having with her son Junior,

and she is a crucial part of her son’s success with treatment as well as her own. The next person

is Junior because he is one of this family’s priorities and he is in crucial need of finding a

treatment for his behavior, which can have a negative result not only with his family and others

but with his academic education. Subsequently, I want to interview Grace because she is caring

for Junior the majority of time and she can provide insight to Junior’s problems and behavior.

The last person that I would like to interview would be Michael; this is because I want to know

first-hand what his family expectations are, how serious he is in integrating back to his family,

and how far he is willing to help his wife and son. I opted not to interview Leon because

Marceline has decided to end the relationship and according to her explanation is my opinion

that he is a negative influence on this family. I might also want to interview her friend just in
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case she can provide me with important information about important events concerning

Marceline and Junior that Marceline may be hesitant to share with me such as sexual, physical

and/or psychological abuse that Leon could have executed on them. The important

documentation that should be on file is quite a few. I would need biographical inventories, these

include: demographics, presenting problem, family of origin, current family, educational history,

vocational background, financial history, counseling and mental illness history, medical history,

and substance abuse and abuse history (Fawcett & Neukrug, 2010). Other important

documentations are: cumulative records, which are a collection of documents from the employer,

school, or mental health agency; anecdotal information, which is subjective notes or comments

in the client’s records relating to his or her typical or atypical conduct; and journals or diaries,

which can make the client remember an important time in his or her life that would be helpful in

therapy or provide insight to the unconscious (Fawcett & Neukrug, 2010). In therapy a

Genogram, or map of the client’s relevant history and family relationships (Fawcett & Neukrug,

2010) can also be a useful document to have on file because it serves as a visual aid with quick

access to information.

The ethical guidelines that should be considered for this case study are based on the

screening and assessment of the participants that will be counseled. The first ethical guideline to

consider is to obtain a written consent from the client to gather the important medical

information mentioned previously as well as to authorize the therapist to communicate with other

family members, friends, and medical professionals about the issues that will be dealt with in

therapy. Another type of consent is informed consent. This is the permission given by the client

or whoever is being evaluated to begin the assessment process; the examiner must have

explained in layman’s terms what each assessment consists of an how it will be performed,
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although there are some exceptions in research such as with double-blind-research (Fawcett &

Neukrug, 2010). Confidentiality is also a very important guideline because it ensures the

protection of the client’s information (Fawcett & Neukrug, 2010); the client being any person

that will be screened and assessed. Invasion of privacy must also be thoroughly explained to the

client so that he or she has the ability to refuse being tested (parental consent when the client is

underage) as well as understanding the confidentiality limits (Fawcett & Neukrug, 2010). The

next ethical considerations are: cross-cultural difference, which in this case study can include

race, gender, age, and social status; choosing the appropriate assessment instrument, which will

vary like in Junior’s case in which his assessment must be administered according to his age and

his needs; competence in the use of assessments, meaning that the examiner must be qualified to

perform the evaluation; and test administration, which will have to follow the standardized and

established methods (Fawcett & Neukrug, 2010).

Thereafter, the other ethical guidelines to follow are: test security, proper diagnosis, test

scoring and interpretation, and release of test data in which the client must give consent prior to

sharing the results with other professionals (Fawcett & Neukrug, 2010). In ethics there are three

categories: consequential (judges an action’s righteousness or wrongness based on its

consequences), non-consequential (judges an action’s righteousness or wrongness based on the

fundamental properties) (Queensborough Community College, 2006), and virtue (dedication and

excellence to the common good) (Santa Clara University, 2010). As a therapist the ethical

considerations mentioned previously can belong to any of these three categories of ethics. For

example, a court’s ruling can supersede a client’s choice of refusing psychological treatment; this

can be classified under consequential because the consequences of not being treated could cause

harm to the client or others. A non-consequential example would be for a therapist to treat every
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client the same even though some individuals can have a disrespectful demeanor toward the

therapist. In virtue, an example in psychology would be to serve any client regardless of socio-

economic problems like in the case of Marceline. Regardless of the client being screened and

assessed, it is essential that the therapist follows the ethical consideration to ensure the best

possible outcome.

After interviewing the client and other possible family members, the next step is to select the

appropriate assessments that will be performed on the subjects; furthermore, other possible

screening methods will be mentioned according to the individual that will need to be evaluated

as well as referrals. As a family therapist, the first person I would evaluate would be Marceline.

The case study detailed that she is depressed, has had suicidal thoughts, and is drinking often due

to nerves (being anxious). The assessments that can be used are: the Minnesota Multiphasic

Personality Inventory (MMPI-2), the Million Clinical Multiaxial Inventory- III Scales (MCMI),

Personality Assessment Inventory (PAI), the Beck Depression Inventory- II (BDI-II), and the

Substance Abuse Subtle Screening Inventory-3 (SASSI-3) (Fawcett & Neukrug, 2010). MMPI-2

can assist in identifying depression, which can include suicidal thoughts. The same can be said

for MCMI, but this assessment is more thorough because it also can evaluate Marceline for

anxiety, alcohol addiction, dependency (e.g. having a hard time ending the relationship with

Leon), and post-traumatic stress (probably after giving birth to Junior); in addition, it has been

favored by most psychologists (Fawcett & Neukrug, 2010). PAI can also be very useful because

it can help me evaluate Marceline’s anxiety, depression, alcohol dependency, and suicidal

ideation; moreover, besides assisting with diagnoses it also creates a treatment for the client

(Fawcett & Neukrug, 2010). BDI-II can be a very helpful assessment because it focuses on the

level of depression that Marceline may be suffering from, which depending on the severity she
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may have to resort to prescribed medication in addition to the therapy. SASSI- 3 can also be

important to use if I wanted to know whether or not Marceline’s alcohol consumption is the

result of dependency or a substance abuse disorder (Fawcett & Neukrug, 2010). Besides these

clinical assessments, I would like for Marceline to take some career and occupational

assessments such as the Strong Interest Inventory (SII), which assesses general occupational

themes, occupational scales, basic interest scales, personal style scales, and provides a response

summary (Fawcett & Neukrug, 2010). This will help Marceline obtain an idea of what career she

may choose or a vocational skill she may want to pursue so that her financial situation can

improve, and it can serve as self-fulfillment; thus, improving her emotional state.

In Junior’s case it can be hard to evaluate him because of his young age, but I could try to

evaluate his emotions through drawing tests, but the best method is to use event and time

sampling to make important observations about the child (Fawcett & Neukrug, 2010). Even

though clinical assessments cannot be performed on Junior because of his age, I can evaluate him

through cognitive assessments such as with the Wechsler Scale- III (WPPSI-III), which evaluates

children 6 months to 7 years (Fawcett & Neukrug, 2010). This test helps to distinguish mental

retardation, high intelligence, general cognitive functioning, and possible learning problems

(Fawcett & Neukrug, 2010), which are likely due to Junior’s inability to communicate with

family members and others as well as hyperactivity and lack of concentration. Another

assessment for Junior is the Kaufman Assessment Battery for Children (KABC-II) (Fawcett &

Neukrug, 2010). This test evaluates children from the age of 3 to 18 (Fawcett & Neukrug, 2010),

but I think that Junior could probably take this assessment because he is close to the minimal age

required for testing. Its purpose is to measure fluid reasoning, visual processing, and short-term

memory as well as long-term memory (Fawcett & Neukrug, 2010). The last assessment that can
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be administered to Junior is the Standford-Binet (SB5), which measures nonverbal and verbal

intelligence by testing knowledge, fluid reasoning, visual-spatial processing, quantitative

reasoning, and working memory (Fawcett & Neukrug, 2010). Until further screening process is

established, the other family members will need to wait before being assessed.

Additional screening must take place for the remaining family members and the friend;

furthermore, there is also a need to refer all the family members to specific services. To

accomplish the additional screening process of Grace and Michael as well as Marceline’s friend,

I would need to conduct a semi-structured interview to each one of them. This is a combination

of structured and unstructured questions; structured referring to pre-established questions, and

unstructured referring to questions based on the response of the client (Fawcett & Neukrug,

2010). Thereafter, a clinical interview can take place because it offers the ability to gather

reliable information from each client (Fawcett & Neukrug, 2010); in this case it would be Grace,

Michael, and Marceline’s friend. This interview is important because it helps to set the type of

information that will be covered in the assessment process, helps the client to become

desensitized to information that is personal and very intimate, allows the therapist to view facial

expressions and behaviors (especially when talking about sensitive information), helps the

examiner to learn about the client’s problem areas and put them in perspective, and helps the

examiner and client see each other’s character to ensure that they can work successfully (Fawcett

& Neukrug, 2010). Some referrals that are needed for Marceline and Junior are to a physician

and possibly a psychiatrist if medication is needed, an outpatient rehab facility for Marceline,

and probably a specialized instructor/therapist for Junior (due to a probable learning or cognitive

disorder). Once the vocational assessment has been completed by Marceline, I can refer her to

the appropriate agency that can help her achieve her career goals to improve her financial
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situation. I would refer Grace and Michael to a support group that deals with family members

with alcohol problems and another support group for family members dealing with children with

a learning and/or cognitive disorder. Assessing each family member is crucial for the success of

therapy, but other factors to consider involve additional screening and referrals that will enhance

the diagnosis and treatment of each client.

One of the first tasks that therapists will have to accomplish with a client is to begin the

interview process. After the interview is complete, the therapist must gather the important

paperwork that must be on file while following the ethical guidelines set in psychology. Ethical

considerations are essential to the success of the diagnosis and treatment of the client. Therapists

must also follow these ethical guidelines when assessing the client so that the result can be clear

of errors or prejudice results. Other screening methods can assist in interviewing the client’s

family members and friend to supplement the information that has been gathered by the

therapist; in addition, referrals are important because it is a vital step in the treatment or recovery

process.
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References

Neukrug, E. S., & Fawcett, R. C. (2010). Essentials of testing an assessment. California:

Cengage Learning.

Psyweb. (2010). DSM-IV Diagnoses and codes. Retrieved September 28, 2010, from

http://psyweb.com/Mdisord/DSM_IV/jsp/dsmnu.jsp

Queensborough Community College. (2006). Ethical theory. Retrieved September 28, 2010,

from http://www2.sunysuffolk.edu/pecorip/SCCCWEB

Santa Clara University. (2010). Ethics and virtue. Retrieved September 28, 2010, from

http://www.scu.edu/ethics/practicing/decision/ethicsandvirtue.html
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ASSESSMENT REPORT

DEMOGRAPHIC INFORMATION

Name: Michael Junior Smith D.O.B.: 02/15/2008


Address: 4564 E. Meadow St.
Age: 26 months
Fountain Hills, AZ
Phone: (480) 236-9646 Sex: Male
E-mail: marcelinesmith@yahoo.com
Ethnicity: White
(mother’s e-mail)
Name of Interview: Smith, M.J. 9/2010 Date of Interview: 9/28/2010

PRESENTING PROBLEM OR REASON FOR REFERRAL

This 26-month old male (Junior) was referred by his mother (Marceline Smith)
due to high levels of hyperactivity and lack of communication and focus. Because
of the lack of communication the child is unable to communicate with me
according to his age. I will try to assess his issues through drawing assessments as
well as cognitive assessments.

FAMILY BACKGROUND

Junior was born in Fountain Hills, Arizona. His parents are from the same city
and state and they are both white. His mother (Marceline) is apparently suffering
from depression, suicidal thoughts, and alcohol abuse. The only known
information about his father (Michael) is that he has been absent the second year
of Junior’s life due to an affair. His father has resurfaced and wants his family
back. Marceline currently has a relationship with her boyfriend (Leon) who also
abuses alcohol and has shown threatening behavior as well as impatience with
Junior. Marceline has mentioned that she is thinking about ending the relationship
to live with Junior’s grandmother (Grace) who is taking care of Junior while
Marceline is at work. Junior does not have any other siblings, though it is
unknown if Michael has other children.

SIGNIFICANT MEDICAL/COUNSELING HISTORY

Marceline reports that she had to take Junior to the E.R. about a year ago because
he felt and cut his knee while having one of his hyperactive outbursts. She said
that he had to get four stitches in his knee. She said that Junior has not had any
counseling for his issues, nor he has been seen by a pediatrician to evaluate
physical impairments that could be causing his lack of communication, focus, and
hyperactivity. She has stated that she is very frustrated with Junior’s behavior and
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lack of communication, and that is the reason that she has currently sought
psychological help for him. She has stated that she will also be counseled for her
own issues. Marceline also mentioned that she had a stressful labor and that there
were complications with him getting oxygen at birth. This is very important
information because stressful labor and lack of oxygen at birth can cause
cognitive problems and there are studies that have linked this to learning disorders
and probably behavior disorders.

SUBSTANCE USE AND ABUSE

There is no possibility of substance use or abuse by Junior, but his mother has
mentioned that in the last stages of pregnancy she did drink alcoholic beverages;
approximately 2 to 3 drinks per week, after she found out that Michael had an
affair and abandoned them to be with this woman. Because there has been
correlation with alcohol use during pregnancy and children with cognitive
problems it is important to assess neurological impairments.

EDUCATIONAL AND VOCATIONAL HISTORY

The only education that Junior has had so far is at daycare. His grandmother
(Grace) is the one that has tried to teach him curriculum according to his age.
Although she has mentioned to Marceline that he gets very distracted and
“rowdy” with the other children, and because of his lack of focus Grace has a hard
time seating him down to teach him pre-school curriculum.

OTHER PERTINENT INFORMATION

So far Junior has not displayed any concerning behavior relating to sexual
orientation, preference, or other dysfunctions in this area. Marceline has no legal
problems at this time. Marceline’s concern is her financial situation at the moment
because her hours were cut short at the grocery store she works at and she has no
additional income at the moment. The studio where they live is in bad condition
and there is not enough room for three people (Marceline, Junior, and Leon), but
this could change because Marceline is thinking about ending the relationship
with Leon and moving in with Grace.
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MENTAL STATUS

Junior seemed to be well groomed, although his clothing seemed a little bit tight.
When I tried to talk to him he would not answer back, instead he would become
distracted with objects around the office and would run around and constantly
jump. I had to try several times before I got his attention. After I built some trust I
decided to talk with him by myself, while his mother watched from a two-way
mirror in another room. I asked Junior to point to some objects and stuffed toys
around the office; he was able to follow my directions. This shows that he is
capable of cognitive responses. Thereafter, I decided to have him paint and color.
According to his age, it seems that he has fine motor skills.

ASSESMENT RESULTS

Tests used: drawing assessments, Wechsler Scale- III (WPPSI-III), Kaufman


Assessment Battery for Children (KABC-II), and Standford-Binet (SB5).
Because Junior still is very young I was not able to administer any specific
drawing assessments, but I did have him draw whatever he felt like drawing. This
gave me a chance to view his perception and what he was thinking about. I was
not able to find any significant information relating to his emotional state, but I
was able to check for his cognitive and motor skills after asking him to draw
specific items that were easy to sketch according to his age. This process took
time to accomplish due to Junior’s lack of focus, getting easily distracted, and
hyperactivity.
After measuring Junior’s IQ with the aid of the WPPSI-III, it was found that
his IQ ranked in the 70th percentile. Even though, this can be concerning because
this rank demonstrate mild retardation, Junior has to be evaluated further because
his IQ results could have been influenced by other factors such as a learning or
behavior disorder; thus, the disorder could probable have intervened with his
ability to learn, not his intelligence according to his age.
The next assessment administered to Junior was KABC-II. Even though he
will not turn three years of age until 10 months, which is the minimal age for
testing, I decided to use it. This test took 25 minutes to administer and he ranked
in the 77th percentile, which shows that he has some difficulty with fluid or inborn
intelligence as well as his crystallized or learned intelligence that is affected by
cross-cultural differences and the environment. Other problems he has are in the
areas of visual processing, and short and long-time memory
The last assessment that was administered to Junior was the SB5 and it took 45
minutes to administer. According to the results, Junior’s nonverbal score was 36
while his verbal score was 18. The nonverbal and verbal subsets included: fluid
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reasoning, knowledge, and visual-spatial processing, and working memory


(Fawcett & Neukrug, 2010). His inability to stay focus could have determined a
low score in these areas as well as his incapacity to stay still. Due to his low score
in verbal communication is imperative that he is referred to a physician to check
for the possibility of physical disabilities such as visual and/or hearing loss that
could impede his learning and understanding. If he does not have any physical
impairments, then the likely result of his lack of communication could be
psychological and/or the result of lack of appropriate education.

DIAGNOSIS

Axis I: 307.9 Communication Disorder,


315.9 Learning Disorder,
309.3 Adjustment Disorder with Disturbance of Conduct
Axis II: 317 Mild Retardation
Axis III: No diagnosis
Axis IV: Mother’s financial situation, father absent for all of the
child’s life, and mother’s current boyfriend has shown
threatening behavior toward mother and probably the
child.
Axis V: GAF = 40 (Over the past year)

(DSM-IV Diagnoses and Codes provided by: http://psyweb.com/Mdisord/DSM_IV/jsp/dsmnu.jsp)

SUMMARY AND CONCLUSIONS

Junior was referred by his mother (Marceline) because according to her and other
family members he is hyperactive, is unable to communicate according to his age,
and cannot concentrate. Both of his parents were born in Fountain Hills, Arizona
just like him. Junior’s father (Michael) has been absent for the second year of his
life because of an affair he had while Marceline was pregnant. Michael has
resurfaced and wants his family back. Marceline has chosen to move with
Junior’s grandmother (Grace) and end the relationship with her current boyfriend
(Leon).
Junior has not attended preschool, yet his grandmother has tried to teach him
preschool curriculum according to his age. Grace has had a hard time teaching
him due to his hyperactivity and lack of focus, even though she takes care of him
for most of the day. Grace has stated that he can be disruptive with other children
and he is easily distracted.
Besides the visit to the E.R. (knew gash), Junior has not been evaluated by a
physician or a psychologist prior to this visit. I have noticed that Junior cannot
stay still, cannot focus, and cannot communicate according to his age. Through
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the assessments’ results it is likely that Junior may have Attention-


Deficit/Hyperactivity Disorder (ADHD), though he will need to be re-tested
around the age of 5 because his symptoms and lack of attention span could be due
to his age. In addition, his IQ evaluation has shown that he has mild retardation,
but this diagnosis cannot be final until a physician has assessed him for physical
impairments and he has been treated for ADHD. Once the results of the physical
are finished and treatment has been put into effect, then another IQ test can be
given to check for changes in his score; most likely given around the age of 5
when children are able to reason more suitably. If the score is within the same
range, then further cognitive assessments must be given to investigate possible
developmental delays.
Possible environmental factors that could be the result of Junior’s behavior can
be attributed to the mother’s financial strain and her emotional state, his father’s
absence, and conflicts between his mother’s current relationships. Probable
mistreatment (e.g. emotional and physical abuse) is possible by his mother’s
boyfriend as she mentioned he has displayed “threatening behavior”. No sexual
abuse has been noted at this time. Mother’s frustration with Junior could have
produced negative conduct toward her child (e.g. yelling, spanking, ignoring, lack
of love and support, etc.); although this has not been declared by any family
member or friend at this time. Consequently all these negative reactions from
individuals close to Junior (especially his mother) could have unconsciously or
consciously resulted in Junior’s lack of communication and disobedience.

RECOMMENDATIONS

1. Child therapy, 1 hour a week to work with cognitive and speech problems
as well as disobedience issues.
2. Family Therapy, 2 hours a week to work on relationships with Junior,
Marceline, Michael, and sometimes Grace.
3. Referral to a physician to check for physical impairments.
4. Possible referral to a psychiatrist due to the possibility of having ADHD;
although because of his age future assessments are needed to determine
for a fact that he has this learning disorder.
5. Further assessments needed at the age of 5 to check his IQ and possible
developmental delays as well as communication problems.
6. Possible referral to speech therapist if by the age of 5 his communication
has not improved.
7. Refer parents to support groups for children with ADD and ADHD.
8. Refer mother to services that can improve her financial situation.
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9. Future course of action needed when Junior starts elementary to have his
teachers help him learn his curriculum in accordance with his probable
learning disorder and make adequate arrangements such as with an
Individualized Education Program (IEP).

Catherine J. Fajardo, MD
Catherine J. Fajardo