Case Conceptualization/Integration Project

Case Conceptualization/Integration Project
The Presenting Problem & Diagnosis
Angela Laird
Baker College of Owosso
PSY 4110
Professor Chung

The Presenting Problem & Diagnosis
Client Name: Cody Nicholls
Date of Assessment: 9/23/2017
DOB: 08/12/2011
Age: 6 years old
Interviewer Name and Credentials: Angela Laird, LSW
Presenting Problem/ History:
Tonna Nicholls and her six-year-old son Cody came into counseling because of Cody’s behavioral and repetitive issues. Mrs. Nicholls states that Cody enjoys watching movies repeatedly. Rocking back and forth is an issue. Mrs. Nicholls states no one can be around Cody’s territory nor can he be touched. At the dinner table, Cody cannot sit and eat. Instead, he runs around the table in circles. Cody
Taylor performed a MSE when Mrs. Nicholls took him to the doctor for annual shots. At this visit, Mrs. Nicholls expressed her concerns of Cody’s behavior. Therefore, Dr. Taylor decided to perform more invasive tests. Cody Nicholls, a six-year-old Caucasian boy came into the clinic today. He was dressed in a black t-shirt, gray pants, and red shoes. During the exam, Dr. Taylor noticed symptoms which appeared to be related to Asperger’s. These included Cody being agitated, fidgety, anxious, hyperactive, frequently standing up and pacing around the room. He had poor eye contact and delayed cognition skills. Cody said single words but could not make a sentence and was repetitive (Reynolds, 2011). Dr. Taylor asked patient if he likes school and if he has made friends at school. Patient replied, “I only like school a little and I don’t have any friends”. He seemed to lack interest in most subjects. After the MSE the physician recommended further tests be performed. Dr. Taylor was concerned about Cody’s mental status and
This code states that some of the symptoms include lack of communication, social interaction, isolation, and repetitive behaviors. Poor eye contact and lack of interest are also symptoms. The DSM states that one with Asperger’s would have a challenging time expressing emotions and feelings. These symptoms can range from abnormal, severely abnormal to normal levels (American Psychiatric Association, 2017). The symptoms explained were the same as Cody’s symptoms when seen at the specialist. When Dr. Walley told Mrs. Nicholls the diagnoses, she sat on the floor in the waiting room and cried not knowing how to respond. Mrs. Nicholls is going through a tough time but is elated to finally have the troubling behavior properly diagnosed. She is concerned regarding what to do next. Mrs. Nicholls is inquiring to help her son live a satisfying