Case Study of AP

Counseling 621

November 19, 2011

Client Description

AP 19-year-old white male University of Mississippi Student Sophomore Year; Civil Engineering Major Academic Problems Diagnosed with ADHD

Purpose of Assessments

Student Needs Assessment– To get better understanding of problem (why in

EDHE, other factors involved)– To get a sense of AP’s stage of change

Mini Mental Status Exam (MMSE)– To check AP’s current mental status

Mood/Behavior during sessions Talks about sleeping a lot

Assessment Procedures & Protocol

Student Needs Assessment– First Meeting– Series of Questions– Apparent stage of change

MMSE– Second Session– Series of questions/directions related to five

categories

Medical/Developmental History

AP reported that he was diagnosed with ADHD when he was young– He took Adderall from age 5-13; he still takes

Adderall at times– Mentioned that wants to get retested for ADHD so

he can be prescribed Adderall AP reports sleeping a lot

– He contributes this to going to bed late and says he has not been tested for a sleeping disorder

Familial Psychiatric History

AP did not report a history of psychiatric issues within his family

School/Academic History

AP did well in high school and did not have to study much

AP finds it hard to focus in class and when studying now that he’s in college

EDHE Student– AP missed the first 3 weeks of EDHE– During the session AP is unable to sit still and talk

with me; he’s constantly fidgeting and doesn’t talk much unless I prompt him

Home Behavior/Social

Family of Origin– Parents divorced when he was 2 years old and they live in

different states– He has an older sister by his mom and dad– His dad is remarried and his stepmother has a son who is

older than him– He moved to live with his dad and stepmother when he was

13 Fraternity

– He is active in his fraternity Relationship Status

– He says he strays away from having a girlfriend right now

Assessments Used & Appropriate Interpretations

Student Needs Assessment– Understand what caused AP’s academic failure

and how I may be able to help him– Also assess where AP stands in regards to his

stage of change MMSE

– Assess AP’s cognitive state because of his behavior/mood during our meetings

– High Test-Retest Reliability

Summary of Findings

Student Needs Assessment– Lack of motivation– Rush; Drinking and Partying– Trouble focusing in class and when studying– Dad seems to be his support– Contemplation/Preparation stage of change

MMSE– 28/30– AP’s scored high on the MMSE so his overall cognitive

functioning is good

DSM Diagnosis

Axis I– 314.01 ADHD inattention and hyperactive impulsive

Axis II– V71.09 (No Diagnosis)

Axis III– None

Axis IV– None

Axis V– GAF 61-70

Treatment Plan & Recommendations

Help AP establish goals and follow up with him on his progress with them

Refer AP to a doctor who can assess him and see if he still has ADHD; I may also want to encourage him to see a doctor about his excessive sleeping

Continue to monitor AP’s progress in his classes and help him find ways to focus

My recommendation is to discuss AP’s options regarding school and do some motivational interviewing to help with his lack of motivation