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Feb 20, 2024

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Your Name: Jessica Morris Client Information: Name: Emily Johnson Age: 14 Sex: Female Race/Ethnicity: Caucasian Grade: 9th grade School: Oakwood High School Emily is a 14-year-old Caucasian female currently in 9th grade at Oakwood High School. She lives with her parents and younger brother in the suburbs. Emily enjoys playing soccer and participating in drama club activities at school. She is an avid reader and enjoys spending time with her friends on weekends. Emily is known for her outgoing and friendly personality, but recently her teachers have noticed a decline in her academic performance and increased social withdrawal. Referral Reason: Emily Johnson is being referred for evaluation and potential intervention/treatment due to concerns raised by her teachers and parents regarding recent changes in her behavior and academic performance. Referring Sources: 1. Teachers: Emily's teachers have observed a noticeable decline in her academic performance over the past few months. She used to be an active participant in class discussions and consistently turned in high-quality assignments. However, her recent assignments have been incomplete, and she seems disengaged during class activities. Teachers have also noticed that Emily appears more withdrawn and less willing to interact with her peers during group activities. 2. Parents: Emily's parents have also noticed changes in her behavior at home. They report that she has become more irritable and spends most of her time alone in her room. Emily used to enjoy family outings and spending time with her younger brother, but lately, she has been avoiding family activities and preferring to isolate herself. Additionally, Emily's parents are concerned about her overall mood and well-being, as she seems more anxious and less enthusiastic about activities she once enjoyed. Given the concerns raised by both her teachers and parents, it is essential to conduct a comprehensive evaluation to better understand the underlying factors contributing to Emily's recent

changes in behavior and academic performance. This evaluation will help determine appropriate interventions and support strategies to address Emily's needs effectively. F AMILY H ISTORY Emily Johnson is the elder child in her family, with a younger brother who is two years her junior. She shares a close bond with her parents and brother, and historically, family dynamics have been supportive and nurturing. Within the family context, there haven't been any significant reports of atypical behavior or emotional disturbances. Emily's parents have always strived to create a warm and supportive environment for both her and her brother, fostering open communication and encouraging their individual interests and pursuits. The subsystems within the family include the parent-child subsystems (Emily with each of her parents individually, as well as both parents together), the sibling subsystem (Emily with her younger brother), and the entire family unit as a whole. Historically, these subsystems have functioned cohesively, with each member contributing to the overall well-being of the family unit. There is no known family history of developmental disorders or hereditary traits that could directly contribute to Emily's recent changes in behavior and academic performance. However, it's essential to explore any underlying familial stressors or dynamics that may be influencing Emily's current presentation, as family context can play a significant role in shaping a child's emotional and behavioral development. A CADEMIC & I NTERPERSONAL H ISTORY Emily Johnson's academic and interpersonal history provides valuable insights into her functioning within various microsystemic influences, as per the bioecological systems theory. At school, Emily has traditionally been an engaged and active student. She has been involved in extracurricular activities such as drama club and soccer, which have allowed her to form friendships and develop social skills outside of the classroom. In the past, Emily has maintained positive relationships with both peers and teachers, often participating in group activities and class discussions. However, recent observations suggest a shift in Emily's behavior and emotions at school. Teachers have noticed a decline in her academic performance, with incomplete assignments and decreased participation in class activities. Emily appears more withdrawn and less willing to engage with her peers during group projects or

social events. She seems to prefer spending time alone and may exhibit signs of anxiety or distress in certain social situations. The changes in Emily's behavior and emotions at school may be indicative of underlying stressors or challenges she is facing within this microsystem. It's essential to explore potential factors contributing to her decreased engagement and social withdrawal, including academic pressures, peer relationships, or changes in her personal life. Furthermore, understanding how Emily perceives her experiences at school and the emotions she associates with these experiences can provide valuable insights into her overall well-being. By addressing both academic and interpersonal factors impacting Emily within the school environment, interventions can be tailored to support her academic success and social-emotional development. P RIMARY S YMPTOMS & D ISORDER Symptoms: 1. Academic Decline: Emily has experienced a noticeable decline in her academic performance, as evidenced by incomplete assignments and decreased participation in class activities. This decline is inconsistent with her previous engagement and achievement in school. 2. Social Withdrawal: Emily has become increasingly withdrawn in social settings, preferring solitude over interactions with peers during group projects or social events. She appears less willing to engage with others and may exhibit signs of anxiety or distress in certain social situations. 3. Emotional Distress: Emily's recent behavior suggests underlying emotional distress, characterized by increased irritability and moodiness at home and school. She exhibits signs of anxiety and seems less enthusiastic about activities she once enjoyed, indicating a shift in her emotional well- being. 4. Disinterest in Extracurricular Activities: Emily's participation in extracurricular activities, such as drama club and soccer, has declined. She shows less enthusiasm for these activities, further reflecting her decreased engagement and interest in previously enjoyable pursuits.

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These primary symptoms, including academic decline, social withdrawal, emotional distress, and disinterest in extracurricular activities, are age-appropriate and consistent with the information provided about Emily's recent changes in behavior and emotional state. Understanding and addressing these symptoms are essential for developing a comprehensive intervention plan to support Emily's overall well-being and academic success. Disorder: Based on the presented symptoms of academic decline, social withdrawal, emotional distress, and disinterest in previously enjoyed activities, Emily Johnson's presentation is consistent with Major Depressive Disorder (MDD).

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