SOAP NOTE

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SOAP Note:

Subjective: CC (Chief Complaint): Joshua’s behavior has been on the decline since his middle sibling was placed in the home with him. He becomes easily angered, has frequent angry outbursts, and shows signs of arousal such as difficulty sleeping, impaired concentration, edginess, and irritability.

Name: Joshua
DOB: unknown- (school- aged)
Minor: 12 years old male, 6th grade Middle School
Accompanied by: guardian.

HPI (History of Present Illness): Joshua is a 12-year-old boy attending Middle School as a 6th grader. He lives with his grandmother and has no contact with his father. His mother is only present during family events and holidays.  Joshua has been in placement with his grandmother for several months. He was recently diagnosed with oppositional defiant disorder (ODD) and attention-deficit/hyperactivity disorder (ADHD). He is behind in reading and shows difficulty in school, with his favorite class being Art and his least favorite being Remedial Reading. His grandmother, who has her own history of childhood trauma, is struggling to provide consistent care for Joshua and his sibling.

Joshua has a history of neglect, physical abuse, and parental substance abuse. He has been in the care of his grandmother since he was 18 months old. Reunification attempts with his parents failed, and he has had no contact with his father since the substantiated allegations when he was 5 years old.

PMH (Past Medical History): No significant medical history.

Mental health treatment history:
History of outpatient treatment for the management of ODD and ADHD.
Previous psychiatric hospitalizations: not reported.
Prior substance abuse treatment: not reported.

Suicidal Ideations/ Homicidal Ideations: Denies history.

Allergy Identification: No known allergies.

Medication Reconciliation: None mentioned in the case study.

Social History: Joshua is a 12-year-old boy attending Middle School as a 6th grader. He lives with his grandmother and has no contact with his father. His mother is only present during family events and holidays. Joshua’s grandmother is struggling with depression and overwhelmed by his emotional outbursts, making it challenging for her to provide consistent care.

Family History: Joshua’s parents have a history of drug and alcohol abuse.

Joshua’s grandmother is struggling with depression & PTSD.

Therapy History: none reported.
Trauma History: Joshua was removed from the home at 18 months and placed with grandmother; history of neglect, physical abuse, parental drug abuse, abandonment, and possible sexual abuse.
Substance Use: no reported.

Military: N/A

Legal: N/A

Religion: Unknown

Hobbies/Leisure: Unknown

Health Promotion: No specific information provided in the case study.

ROS (Review of Systems):

  • General: No weight loss, fevers, or fatigue.
  • Neurological: Difficulty sleeping, impaired concentration.
  • Psychiatric: Anger outbursts, mood shifts, irritability.
  • Musculoskeletal: No joint pain or stiffness.
  • Respiratory: No cough, shortness of breath, or wheezing.
  • Cardiovascular: No chest pain or palpitations.
  • Gastrointestinal: No abdominal pain, nausea, or vomiting.
  • Genitourinary: No urinary symptoms.
  • Integumentary: No rashes or skin lesions.
  • Endocrine: No excessive thirst or excessive urination.

Objective: Observations: Joshua’s mood shifts from constricted to volatile, with frequent angry outbursts. He shows signs of arousal, including difficulty sleeping, impaired concentration, edginess, and irritability. He is at least two years behind in reading.

Diagnostic Screening Tool: Conduct the ADHD Rating Scale-5 (ADHD-RS-5) to assess for symptoms of ADHD.

Vital Signs: Taken or deferred.

Labs: N/A, Pending, deferred.

Mental Status Examination: Appearance: Joshua appears his stated age, appropriately groomed. Behavior: Restless, fidgety during the assessment. Speech: Clear, coherent, and relevant. Mood: Constricted at times, volatile at other times. Affect: Anger, irritability. Thought Process: No evidence of formal thought disorder. Thought Content: No evidence of delusions or hallucinations. Perception: No perceptual disturbances noted. Cognition: Age-appropriate orientation, intact memory and concentration.

Suicidal Ideations/ Homicidal Ideations: Denied

Assessment: Based on the available information and the diagnostic screening tool, the following clinical impressions are made:

  1. Oppositional Defiant Disorder (ODD) – ICD-10 code: F91.3 Clinical Reasoning: Joshua displays symptoms of frequent angry outbursts, irritability, and defiance, which are consistent with the diagnostic criteria for ODD. These symptoms have been present since the recent placement of his middle sibling in the home.
  2. Attention-Deficit/Hyperactivity Disorder (ADHD) – ICD-10 code: F90.9 Clinical Reasoning: Joshua demonstrates symptoms of difficulty sleeping, impaired concentration, and restlessness, which are indicative of ADHD. His significant academic challenges and the presence of symptoms across different settings further support this diagnosis.

Differential Diagnosis:

  1. Disruptive Mood Dysregulation Disorder (DMDD) Clinical Reasoning: DMDD involves severe and recurrent temper outbursts, which may be considered as a differential diagnosis given Joshua’s frequent angry outbursts. However, the duration and intensity of his symptoms align more closely with ODD.
  2. Conduct Disorder (CD) Clinical Reasoning: CD is characterized by a repetitive and persistent pattern of behavior that violates the basic rights of others. Although Joshua exhibits oppositional and defiant behaviors, the absence of serious violations and aggression towards others makes CD less likely.

Treatment Options:

  1. Individual therapy: Joshua could benefit from trauma-focused therapy to address his history of neglect, abuse, and the emotional impact it has had on his behavior and functioning.
    • Evidence-based practice article 1: Smith, P., & Elliott, C. (2017). Trauma-focused therapy for children in foster care. Journal of Child & Adolescent Trauma, 10(3), 295-307.
    • Evidence-based practice article 2: Cohen, J. A., Mannarino, A. P., &Deblinger, E. (2017). Trauma-focused CBT for children and adolescents: Treatment applications. Guilford Press.
  2. Behavioral interventions/ CBT: Implementing behavior management strategies and parenting techniques to address oppositional and defiant behaviors.
    • Evidence-based practice article 3: Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37(1), 215-237.
  3. School interventions: Collaboration with the school to develop an Individualized Education Program (IEP) to address Joshua’s learning difficulties and behavioral challenges, providing academic support and accommodations.
    • Evidence-based practice article 4: DuPaul, G. J., & Stoner, G. (2014). ADHD in schools: Assessment and intervention strategies. Guilford Press.

Assessment Summary: Joshua’s assessment indicates a clinical diagnosis of Oppositional Defiant Disorder (ODD) and Attention-Deficit/Hyperactivity Disorder (ADHD). His treatment plan includes individual therapy, behavioral interventions, and school interventions to address his emotional and behavioral difficulties. Regular follow-up appointments will be scheduled to monitor his progress and make adjustments to the treatment plan as needed.

Informed Consent: The assessment findings, treatment options, and potential referrals will be thoroughly discussed with Joshua’s grandmother. The risks, benefits, and alternatives will be explained, ensuring her understanding and agreement to proceed. Consent forms provided and signed accordingly.

References:

  1. Smith, P., & Elliott, C. (2017). Trauma-focused therapy for children in foster care. Journal of Child & Adolescent Trauma, 10(3), 295-307.
  2. Cohen, J. A., Mannarino, A. P., &Deblinger, E. (2017). Trauma-focused CBT for children and adolescents: Treatment applications. Guilford Press.
  3. Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37(1), 215-237.
  4. DuPaul, G. J., & Stoner, G. (2014). ADHD in schools: Assessment and intervention strategies. Guilford Press.