Clinical Assessment

I would being by asking Mr. and Mrs. Lawson basic questions concerning the family’s history regarding any similar symptoms that other family members may have displayed. I would also ask if there were any changes in the family setting, such as relocating or if other family members have recently relocated. I would also ask Mr. and Mrs. Lawson specific details about the symptoms regarding Clara’s eating patterns, and sleeping patterns, and how long this has been occurring.

I would also engage Clara into conversation, so that her direct responses could be included in the conversation, so that I would have a better understanding on the lack of eye contact when talking. During the clinical assessment, I would engage in “play” activities with Clara, so that a better understanding on how she interacts could be established. Children often place themselves in role positions when playing, which in Clara’s case, would give an indication if she displays a lack of self-esteem. This would also give a better understanding concerning the issue of Clara’s not wishing to return to preschool.

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I would encourage the family to engage in more playful activities that would include Clara, with the emphasis on allowing her to win. I would recommend that praise be given to her when she did well, and for the most part, to overlook the events in which she did not do well. Instead of focusing on correcting negative responses, I would recommend that focus be directed to encouraging the positive responses. Children often hear words such as “don’t” or “no” too often, so I would recommend to Clara’s parents that they use re-direction by telling Clara what they want her to do, rather than what they wished her not to do.

Children also respond well, at times, to reward systems. Giving Clara praise when things are done well, and to reward her once the task is completed. In planning to give Clara an official diagnosis, the information that would go it each axis would include; Axis 1 –This would be the primary diagnosis, in which a general understanding of what the displayed symptoms indicates. Axis 2 – This axis includes personality disorders, which involves an enduring pattern of behavior that deviates markedly from the expectations of the individual’s culture, has onset in adolescence or early adulthood, is stable over time and leads to distress or impairment.

Issues of mental retardation are also included with this axis, which is when a significantly sub-average general intellectual functioning that is accompanied by significant limitations in adaptive functioning. Axis 3 – This is where general medical conditions are taken into consideration. Conditions that are potentially relevant to the understanding or management of a person’s mental disorder. Axis 4 – This axis includes information regarding any psychosocial and environmental problems or stressors that would interfere with usual daily activities.

Problems with friends in school, bullying, or a death in the family would be issues regarding this axis. Axis 5 – This would incorporate all of the information given so that a global assessment of functioning could be established. Giving Clara a diagnosis at this time would be beneficial. It would give a better understanding as to what symptoms to look for, and if other possible symptoms develop. It would also give an indication as to what treatments would work, and if symptoms continued, which medication could help to eliminate the symptoms.

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