Child Assesment and Clinical History of Couseling

Clinical Assessments in Counseling

Luis Ramos Delgado

University of Phoenix

CNSL/526

February,9 2013

Dra. Nadja I Crespo Llado

 1
CHILD CLINICAL HISTORY OF COUNSELING

Demographic Information:

Name: Jose Luis Rivera Davila

Date of birth: December 15, 2005

Age: 7 years

Gender: Male

Social Class: Lower middle class

Clinical History:

Jose Luis Rivera Davila, minor of 7 years, son of Elizabeth Davila mother of 22 years
and father Lorenzo Rivera aged 41years . It is first child of above transcribed couple's
which recently is in the process of divorce, after the birth of Jose , born three years after
the younger brother Joel Rivera. José is receiving services from the special education
program at the School José de Diego, rural elementary school in the town of Humacao,
is in third grade. Jose Rivera has a diagnosis of autism with mental retardation made
recently by a psychiatrist Dr. Jose Lopez. Mother points that the birth of Jose Luis was
complicated, as the doctors explained that the child was born she could suffocate
doctors indicates that this will affect the brain development through development
through life. Mother tells that the child was born after observation, he was tubing for
more than four months. He said that after they left the hospital with the child always
noticed that physical appearance was different because it was much smaller and
moving the arms, hands, legs and head uncontrollably. Mother weeping account that
doctors had told him that the child would not live more than three years, he was not
going to be able to walk or talk. Panorama than the current seven years to your walks,
says a few words but not phrases, mom, dad and baby. Given that you cannot get an
interview with lower notes of observations there.

Jose Luis Rivera The minor is neat and clean clothes, looking alert though distant look.
It is seen less smiling, but avoids looking face to face with the observer. It is seen
playing with a smaller vessel and using the floor as a drum. It seems like music or
sound patterns somewhat musical. No hyper-vigilant notes or no aggressively. He is
very active and playful with he’s toy and quiet and interacts even with little physical
 2
CHILD CLINICAL HISTORY OF COUNSELING

contact with their caregiver. Although not expressed in words can do so through
nonverbal language. Displays capacity for independence, says mother to Look for him
and he wants the community rides alone and sometimes in the night stands to eat
something in the kitchen. Caregiver says his fear is that the younger brother who does
not suffer from any diagnosis copied his brother's behavior. Notes that is concerned
sometimes as caregivers not to have control or discipline to know less about having
autism. Also mother want one day see Jose as self-sufficient as possible in their care.
The young Jose Luis no marks or signs of abuse, at the time of the interview is nurtured
and cared for.

Mother indicated that the child was operated Jose Luis Rivera to a two years old had
kidney failure since. Mother identifies source of support to her parents, her former
partner, the church, school and a lady who helps care for the child when she has to go
to college.

Mental Status

Appearance

Adequate hygiene

Clothing: clean, appropriate

Makeup: none

Eye Contact: casual

Proper posture: no

Tone of voice: no

State of mind / mood:

Euthymic (normal)

Affection:Variable

Content of thought: No

Oriented in three spheres (person, place and time): N / A

suicidal / homicidal: N / A

Sample Basic language comprehension and leisurely way

 3
CHILD CLINICAL HISTORY OF COUNSELING

Obsession / bizarre / grandiosity: N / A

Ideas disabilities / hopelessness: N / A

Content of thought:

Delusions: N / A

Psychomotor Activity: Active

Judgement and Introvision: N / A

Cognitive Processes: N / A

speech disorganization

Perception:

Hallucinations: No

Assessments Tools

DSMIV TR

AXIS I: 299.00 Autistic Disorder

AXIS II: 318.1 Severe Mental Retardation

AXIS III: Renal failure, unspecified

AXIS IV: Problems with primary support group - disruption of family by separation and
divorce.

AXIS V: 20-11

Theoretical Framework

Autism itself is a condition that affects the social behavior through, it is read or
interpreted in the person with autism as a stranger, afraid, asocial. There are a number
of theory that attempts to explain the existence of autism through the bio-physiological
perspective. However, as we have already noted is in the capacity of interaction with the
environment and the affected person. The autistic family member needs to understand
 4
CHILD CLINICAL HISTORY OF COUNSELING

what is happening, and to get all members to provide a specialized interaction given
your situation. So familiar is the prospect of learning intervention for the purpose of
implementing and facilitating skills development through positive conditioning to self-
sufficiency of Joseph and the ability to interact at least at home and systems close to
him. Operant conditioning theory states that individuals have the ability to respond to
stimuli, and that as these stimuli are immediately This experience reward or punishment
such conduct could be extinguished or continuous.

Treatment Plan:

Strengths and Weaknesses

Among the strengths that we mention in José Luis Rivera Davila, learning ability is not
closed completely to the family system, exceeding the early medical prognosis indicates
that there is still hope and still learning capacity provided. José has its own form of
functional communication. There are desires of capacity in the interest of context.
Joseph's family that despite the divorce has been maintained in cooperation as a team
for the best interests of the child.

Weaknesses

The presence of a clearly established diagnosis behaviors expected, therefore much of

this diagnosis are labels that may influence in some services.

The condition of autism affects interaction and behavior management that is a

weakness that could exist.

The family needs more guidance and skills for handling special situations.

Lack of specialized services for people with the condition.

Short-and long-term

Short Term

Coordinate supplemental education services such as occupational therapy and animal-

assisted therapy company.

Provide tools to conduct effective and healthy family with people who have the condition
of autism.

In cooperation with family and loved ones create a behavior modification plan centered
on the life paths of self-sufficiency of Joseph.

Coordinate a speech therapist evaluation.

 5
CHILD CLINICAL HISTORY OF COUNSELING

In coordination with a neurologist to establish what is the current status of the child's
condition and recommendations across studies may be recorded.

Long Term

Joseph to direct functional life and self-sufficiency. Strengthen family ties will be
significant over the life of Joseph. Changing behaviors that are culturally defined as
foreign.
 6
CHILD CLINICAL HISTORY OF COUNSELING

Bibliography

Guidelines for writing a treatment plan. In University of Phoenix Retrieved from

https://portal.phoenix.edu/classroom/coursematerials/cnsl_526/20130119/
OSIRIS:42116768

Fong, M. (1993). Teaching assessment and diagnosis within a DSM-III-R® framework.

Counselor Education and Supervision, 32, pp. 276-286.