Catholic Charities

Psychiatric Evaluation

Client Name: Lowe, Allen, Dewayne Client ID: Status: Show

Clinician Name: Service:

Date Of Service: April 2022 Start Time: 3:19 PM

BCARS Psych Eval

End Time: 3:41 PM Duration: 22.00 Minutes

Team:

Location: Specific Location:

Comment:

OMHC Baltimore City BCARS DSS

HOME BCARS DSS OMHC

Therapist: D/C Date: May 2022

Mode of Delivery: Face to Face

County: School:

Makeup Date: Makeup Session Duration:

Makeup Type:

General

Chief Complaint:

"We are still trying to get a certificate of need."

Course of Present Illness:

This session is being provided through home-based telehealth with verbal consent. The location was verified, and the phone number was confirmed in case of a technical issue. No other parties except the client and/or guardian were present.

Patient presents today accompanied by DSS worker, Mr. Purple, for evaluation for a certificate of need. A certificate of need was provided by this author in Feb 2022; however, DSS was unable to find the recommended placement. Since last seen by this author, patient has eloped from a treatment foster care placement as well as from his aunt's home. There have been countless incidents where he has been AWOL in the past few months. Mr. Purple reports that patient tends to engage in risky behaviors when AWOL. He will engage in sexual activity, smoke cannabis, and has attempted robbery. He has two active charges in Baltimore County for first degree assault and armed robbery for an incident in which patient went into a grocery store with a bebe gun with intent to rob them. He has incurred several more theft charges since then, the last of which occurred in March 2022. That same day, patient ran away and was not located until April 2022. He called his DSS worker from Hagerstown asking to be picked up. He was placed back with his aunt at that time. He did well for a few days and then left without permission overnight. He got upset when he was placed on punishment and smashed her car window with bricks. Following this event, he was caught on camera stealing package off of a friend's porch. Patient's latest episode of dangerous behavior occurred yesterday during which he injured his shoulder trying to forcibly enter his aunt's home. He self-presented to the ED after this event.

During interview today, patient alleges he injured his shoulder by carelessly running into a door. He reports his mood has been "good". Admits to struggle with anger but states "I'm good" when asked for further detail. Denies any suicidal or homicidal ideation. He has been doing "ok, not ok". Denies any anxiety symptoms. Reports focusing well. Patient was irritable and impatient during session. He was guarded and in a rush to complete the appointment as he wanted to go to lacrosse practice. Provided few details when asked for updates on how he has been doing in the past few months. He has been off of medication and out of treatment since last seen by this author due to multiple unsuccessful attempts to maintain him in any one placement in the community. Patient was evaluated in the Johns Hopkins emergency room at Bayview. He was recommended for residential treatment placement; however, he eloped from the interview from a unlocked RTC facility in which DSS was hoping to place him.

Client ID: Page 1 of 5

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History

Past Psychiatric History, Treatment Providers, Past Medications and Hospitalizations:

Inpt: EP in Dec 2021, JHH Bayview ED visit for 10 days for suicidal ideation March 2022 (voiced when police picked him up for the second time after he eloped from a different aunt's home) was referred to an RTC, eloped from the interview at a non-secure residential treatment centerOutpt: BCARS three times in the past, last BCARS admission 2/2022, in-school therapy in 5th gradeMed trials: Ritalin, concerta (max dose 36mg)Diagnoses: ADHDPast SI/SIB: denies

Family History:

Mother- bipolar, schizophrenia, ADHDMaternal grandmother- depression, substance use disorder

History of severe cardiac disease or MI under the age of 40?: none

Psychosocial History:

Born and raised: Removed from mother’s care at birth (mother was 13). Raised by maternal aunt until Dec 2021 as he reported aunt’s boyfriend held gun to his head, threatened to harm him, and hit him in the chest. Has been in foster care since Dec 2021, has had 5 placements (one of which was emergency placement) in the past month. Currently living with a different maternal aunt who has raised him “off and on” throughout his life, per her report. No contact with bio parentsLives with: placed wit aunt most recently but threw brick through her car window when he got into trouble for not following rules a few days ago, whereabouts since then is unknown as patient ran awayParent info: mother- 26, education and employment details not known; father- 31, no other information available Siblings: maternal half- brother- 8, maternal half-sister- 9

Sexual History: partner of 3 months, heterosexual, denies history of sexual activity

Substance Abuse:Cigarettes/e-cigarettes/juuling: deniesAlcohol: deniesPrescription Medication Abuse: deniesIllicit Substances: DSS worker reports patient has admitted to cannabis use

Trauma history as obtained during Feb 2022 evaluation: “Yeah, but I don’t want to talk about it” august 2021, endorses flashbacks, avoidance. Denies nightmares, increased startle and hypervigilance. Irritable once per week when they talk about his family.

Legal: several active charges for assault and theft

CPS/DSS involvement: patient in DSS custody, most recent CPS involvement due to patient reporting sexually inappropriate behavior by foster father, CPS report made by BCARS 4/2017 for patient alleging aunt’s boyfriend hit him with a belt, punched him in the leg, and hit him in the head, also reported aunt hit him with a belt

Medical History:

Allergies: noneMedications: nonePCP: saw a doctor Jan 2022 for well-child check, unremarkable examDiagnoses: noneHistory of surgeries?: noneHistory of Seizures?: noneHistory of head trauma with loss of consciousness?: noneHistory of heart murmurs or arrhythmias?: noneHistory of dyspnea on exertion or unexplained syncope?: none

Developmental History:

Client ID: Page 2 of 5

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Planned pregnancy?: unknownBirth weight: 6lb 12ozComplications with pregnancy: unknown if there were intrauterine exposures, mother had chlamydia while pregnant, no known complications, unknown if mother received routine prenatal careComplications with delivery: full-term, vaginal delivery, no complicationsNICU: noneMilestones on time: yes

Educational History:

School: Commodore John Rodgers, 6th grader, patient reports he likes school as he likes all of his classesCurrent Academic Performance: sporadic attendance due to frequently AWOL, likely failing currently per Mr. Purple, previously made average grades (Bs and Cs) when attending school consistentlyIEP/504: none currentlyHistory of suspensions/expulsions: suspended “a lot” for fighting peers, accidentally hit a teacher once, often suspended for AWOL, has been suspended for threatening school staff and telling administrator he wished he were deadHistory of being held back/skipping a grade: noneBullying?: none

Medications Reconciled on this Date

Current Medications

Drug Name Instruction Special Instructions

Start End Refills Prescriber

Self-Reported MedicationsDrug Name Instruction Special

InstructionsStart End Refills Prescriber

Discontinued MedicationsDrug Name Instruction Special

InstructionsStart End Refills Prescriber

CONCERTA36mg, TR24, Oral 1.00 each Morning

02/03/2022 0.00

Current Medications

No Medications

Substance Use History

Is substance use a concern? Yes

Marijuana/CBD smokes cannabis

Family History Of Addiction:

maternal grandmother, per records

Triggers/Cues To Use Substances:

none reported

Current/Past Treatment:

none

Exam

Complete Mental Status Exam

Mental Status Examination:

Appearance: WNL

Client ID: Page 3 of 5

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Grooming: WNL

Hygiene: WNL

Psychomotor Activity: WNL

Behavior: Guarded, Withdrawn

Affect/Mood: Irritable

Speech: Rate: WNL

Rhythm: Normal prosody

Volume: WNL

Thought Process: Logical, Goal directed intact associations

Thought Content: Appropriate

Orientation and Memory: Alert,Oriented to person place time and situation

Insight and Judgment: Denies problems, Impaired judgment, Poor impulse control, Poor decision making

Cognition: WNL

Knowledge Base: Appropriate to age

Self Harm: No thoughts, plans or intentions

Has the individual reported any changes in risks or protective factors related to suicide? No

Harm to Others: No thoughts, plans or intentions

Harm To Others Comments :

Participant Strengths:

Assessment/Formulation:

11yoM presenting with worsening behaviors that are a significant safety risk to himself and the community. He continues to struggle with impulsivity and agitation in the setting of untreated ADHD and possible trauma-related disorder (such as PTSD). Attempts to safely maintain him in the community have been unsuccessful. While patient does not present as an acute risk warranting inpatient hospitalization at this time, he is currently failing all outpatient services and demonstrating evidence of decline in functioning (recent psychiatric ED eval, new legal charges, continued AWOL behaviors).

Recommendations and Treatments:

Recommending placement in a diagnostic facility due to escalating dangerous behaviors, inability to engage patient in consistent treatment due to frequent disappearances, and need for diagnostic clarification. Patient currently presents as a danger to himself due to persistent behaviors (running away, traveling long distances unattended, speaking to strangers) that put him as risk in the community. His impulsivity, possibly due to his suboptimally treated ADHD in the setting of poor medication compliance, has contributed to behaviors such as aggression towards teachers, theft, and property destruction that put those around him at risk. There is concern that his history of untreated trauma has influenced his behaviors (as evidenced by reports of patient touching a younger female child inappropriately in a previous placement) and previously reported symptoms (flashbacks, avoidance). Attempts to manage his symptoms and behaviors at an outpatient level have been unsuccessful, mostly due to his frequent running away and low treatment compliance. There are no acute safety issues that warrant inpatient hospitalization at this time. Patient would benefit from 24/7 supervision and assessment in a diagnostic facility to better understand his symptoms and determine the appropriate treatment. Additionally, he would benefit from a trauma evaluation along with trauma- focused therapy.

Diagnosis

Client ID: Page 4 of 5

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Additional Information

Screening Tools Used

Other General Medical Conditions

Level of Functioning Score

Unspecified trauma- and stressor-related disorder

DSM5/ICD10 F43.9 DSMIV/ICD9 309.9 SNOMED 102497008

ICD/ DSM Description

Unspecified trauma- and stressor-related disorder

Remission Specifier Type Primary

Source Severity Order 1

Rule Out No Billable Yes

Oppositional defiant disorder

DSM5/ICD10 F91.3 DSMIV/ICD9 313.81 SNOMED 18941000

ICD/ DSM Description

Oppositional defiant disorder

Remission Specifier Type Additional

Source Severity Order 2

Rule Out Yes Billable Yes

Attention-deficit/hyperactivity disorder, Predominantly inattentive presentation

DSM5/ICD10 F90.0 DSMIV/ICD9 314 SNOMED 31177006

ICD/ DSM Description

Attention-deficit/hyperactivity disorder, Predominantly inattentive presentation

Remission Specifier Type Additional

Source Severity Medium Order 3

Rule Out No Billable Yes

Psychosocial, Environmental, and Other Factors

Comments

GAF Score

WHODAS Score

CAFAS Score

Clinician: Signature Date: 04/20/2022

Client ID: Page 5 of 5

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