2769-CM571ExampleTemplateIntegratedInterpretiveReport (1)

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Example Template Integrated Interpretive Report NAME: SITE OF ASSESSMENT: The Chicago School of Professional Psychology DATE OF ASSESSMENT: DATE OF REPORT: Assessment Instruments Clinical Interview Childhood ADHD Symptom Checklist Screen for Child Anxiety Related Disorders (SCARED): CHILD Version Behavior Assessment System For Children, Third Edition (BASC 3) The Big 5 PCL-5 ACE THQ C-SSRS Part I Referral Statement ANONYMOUS was referred for a mobile diagnostic evaluation for diagnostic analysis. The purpose of this evaluation is to assess diagnostic and educational functioning in order to aid in the formulation of appropriate treatment planning and medication needs. The following assessment results are primarily diagnostic in nature and, therefore, tend to focus upon problems, deficits, and pathology and may de-emphasize strengths and assets. These results should not be used for purposes other than the clinical screening, diagnosis, and medication needs. Interview and Background (Most of this will come from your clinical interview) ANONYMOUS is an 11-year-old Gender. They were appropriately dressed in clean clothing. ANONYMOUS exhibited adequate grooming and hygiene and their appearance was appropriate with their chronological age. They were alert, attentive, and cooperative during the assessment process. ANONYMOUS sustained intermittent eye contact during the assessments. They stated that they do not currently have any suicidal ideation. It seems as if their cognitive functioning is appropriate to age though they had difficulty focusing because of ongoing thoughts and rumination. They seemed to be fearful, intuitive, and cautious when answering questions. ANONYMOUS was oriented to person, place, time, and situation. There was no behavioral evidence of hallucinations or delusions, and they gave no overt signs of a thought disorder. Clinical Interview Family (clinical interview)

Integrated Interpretive Report ANONYMOUS Page -2- ANONYMOUS reports that they are aware that they have family members who might take medication to help with mental distress. They were secure that their family is a safe zone and They feels comfortable at home. ANONYMOUS did provide information about their increased concerns and anxiety when they are in their room at night. The description of fears seems to be a manifestation of responses related to anxiety. Peers (Clinical Interview) ANONYMOUS reports having difficulty maintaining friends. They stated that They know that they are “different than everyone else.” After further inquiry, they explained that they have difficulty during before and after care because of their continuous concerns about their parents being kidnapped or killed. They can no longer return to normal activities. Their anxiety begins to increase when their friends’ parents are late, and they have to find their brother to see if he is concerned. They seem to have learned to use their brother as a way to monitor their level of anxiety and determine if they are overly anxious in their after-school setting. Their realization of thought differences causes them to feel inferior and “different” from the other children. They report not feeling secure enough to talk to the after-care adults about their anxiety and reports that they cry from fear and worry. Health History (Clinical Interview) ANONYMOUS reports that they have not had any past medications of diagnosis. They report that their father suffers from anxiety and is prescribed medication to help alleviate symptoms. Somatic symptoms like stomach aches and stomach pains were reported. These pains seem to be a physical a manifestation of the increased anxiety. Diagnostic report and Education History (Clinical Interview and diagnostic assessment) ANONYMOUS has had difficulty in school with fear of tests and performance, by report. ANONYMOUS reports mild difficulty staying on task and paying attention because of anxious thoughts that they are a disappointment to their parents. ANONYMOUS did not report low quality of learning due to disorganized thoughts, difficulty turning in homework, or difficulty locating daily instruments. ANONYMOUS has difficulty changing from one topic to another and does have difficulty remaining focused during reading assignments. ANONYMOUS is an experiential and hands on learner that enjoys crafts and art projects. ANONYMOUS tends to have difficulty remaining on topic during conversations if they are working on a structured task. ANONYMOUS reports avoiding tasks that take significant thought or focus. ANONYMOUS claims that they are easily anxious in daily situations that require waiting and patience because of their ongoing thoughts about their parents kidnapping, murder, and their inability to please people around them. An example of this behavior is becoming easily anxious when expected to remain on task or being asked to adjust quickly from completing an art project. ANONYMOUS seems to have high motivation to change thought patterns and behaviors but lacks the organizational thought to do so. During the assessment process ANONYMOUS had difficulty remaining cognitively present as evidenced by intermittent eye contact, becoming so anxious that they cannot speak without crying, and using deflection to avoid anxiety provoking thoughts and conversations. Part 2: The BIG 5

Integrated Interpretive Report ANONYMOUS Page -3- Summarize the assessment and the results in this section of the integrated interpretive report. This will help with recommendations for treatment and possible diagnosis. Please write your summary of findings here using the clinical interview language used above as a reference to how you will write it. Summaries should be concise and identify major themes that present from the results. Part 3: Co-occurring Issues Screening (no more than 3 paragraphs for each assessment. Consolidate the information in a clear and concise way) Choose 2 assessments: one substance abuse assessment and one for a possible co-occurring diagnosis such as depression, self-harm (non-suicidal injurious behavior), anxiety, trauma assessment, eating disorder assessment, dissociation etc. or other diagnostics that may correlate with substance abuse listed in the Mental Measurements Yearbook (MMY). Students will practice these two assessments with their partner. You will then present the summary information about the assessment and why the assessments were chosen for this client. Make sure to summarize psychometric properties, interpret findings, consider cultural implications and biases, consider trauma history and survival mechanisms as part of the interpretation. Scores and statistical interpretation as practiced in Khan will be used as part of learning how to score and interpret for this section. Reflect on what the scores indicate and how they fall on the bell curve. How might we interpret this to our clients without providing numerical data but instead explain by using mild, moderate, severe, above average, below average, average or other terminology to help simplify understanding. Part 4: Trauma & Suicide Screening This week you will work with your partner to complete the PCL-5, the ACE, the THQ, and the C-SSRS. Remember that these assessment questions can be triggering and invasive so please use your own discretion to decide if you will participate as yourself or as your alias. For this section, you will complete the assessments and summarize your client’s results in APA. You can combine the information you learned from all of these assessments and interpret them concisely in this section. You do not have to explain each one individually. Scores and statistical interpretation as practiced in Khan will be used as part of learning how to score and interpret for this section. Cultural implications and biases, trauma history and survival mechanisms should be considered as part of the interpretation. This will help inform recommendations for treatment & diagnosis. Part 5: Summary & Recommendations You will create recommendations for treatment, diagnosis if this applies, and a reflection of your work with your client. Make sure that you are using the template provided and have a resource page that is completed in APA. Your assessments and any other resources used should be cited. ANONYMOUS did not score for ADHD symptoms. According to diagnostic criteria ANONYMOUS scores for moderate generalized anxiety disorder that manifests as sleeplessness and depressive symptoms. There is clear evidence of symptoms that interfere with or reduce the quality of academic functioning and proper sleep hygiene. Because of an increased level of continuous worry or thoughts about family member’s mortality,

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Integrated Interpretive Report ANONYMOUS Page -4- academic, and competitive performance, Generalized Anxiety Disorder can be diagnosed as moderate and maintained by proper counseling intervention. ANONYMOUS has the capability of decreasing their own anxiety by learning prevention techniques and insight of physiological reactions that manifest as inability to maintain relationships, inability to focus on after school tasks, and inability to sleep consistently. ANONYMOUS’s account of past events along with review of test data reveals a history of difficulty with relationship maintenance, ability to remain on task, mood stability, listening, mild depressive symptoms, and uncontrollable fears that manifest as moderate situational anxiety. Their manifestation of somatic stomach pain is also reported as a result of extensive anxiety. Many factors are likely to be contributing to these difficulties and should be targets for intervention: pattern of anxiety; attention problems during after school care; deficiencies in skills for coping, problem solving, and mood stabilization. Therapeutic interventions could provide relief of symptoms and the ability to cope with daily tasks. Medication such as Celexa (Citalopram), natural remedies like lavender, lemon balm, and chamomile could be helpful for increased sleep. Calms Forte can be purchased at a local whole foods store that could help decrease anxiety symptoms for sleep. ANONYMOUS has the capability of decreasing their own anxiety by learning behavioral prevention techniques and insight of physiological reactions that manifest as inability to maintain relationships, inability to focus on after school tasks, and inability to sleep consistently. Avoiding anxious thoughts and anxiety can increase symptoms. Learning to cope with ruminating thoughts and fears would help decrease interference in her everyday life. Diagnostic Impression 300.02 Generalized Anxiety Disorder, by report, Moderate ___________________________________ Name/signature of reviewer

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