The client’s mother reported that her son was not doing well in school and that his grades are falling.



POST # 2 CARLA

SOAP Note 

Subjective

The client’s mother reported that her son was not doing well in school and that his grades are falling. While the client stated that he has not failed any courses, he also feels somewhat sad because his mother will not sign a paper allowing him to play varsity sports despite interest from coaches. However, the client admitted to barely passing his freshman year because he forgot about his homework. He also suggested a lack of interest in studying and not paying attention in class. When asked whether his classes were too easy or too hard, the client stated that things were not working out for him. Although the client likes woodshop and gym classes, his mother is more concerned about her son learning history, math, and other general classes (UMass Nursing 690M, 2016). Interestingly, the client mentioned some interest in his science classes. The client feels like he is struggling in school when teachers and other students say that he does not pay enough attention or makes careless mistakes. Yet, the client wants to perform better in his classes but feels uncertain of which strategies or interventions would produce the best outcomes.

Objective

The client is a sophomore in high school, seems extraverted, and enjoys playing sports like basketball and baseball but does not have an after-school job. Academically, the client is not an exceptional student yet achieves mostly satisfactory outcomes. Math is also not the client’s strongest subject. The client also struggles to concentrate in class as indicated by doodling, texting, or talking to classmates. Fidgetiness and forgetfulness are other behaviors exhibited by the client. Time management issues are also present when distractions at home prevent the client from completing homework. Relationship issues between the client and his mother present other concerns that could impact treatment outcomes. The client successfully recalled a series of words and spelled one word backward. No experience was counseling was indicated in the client’s record.

Assessment

At this point, the client presents symptoms of attention-deficit hyperactivity disorder (ADHD) will need to participate in regular counseling interventions. No symptoms of other behavioral or mental health disorders were present. The client reported having no thoughts of harming himself or others and did not report auditory or visual hallucinations.

Plan

The client will need to attend a follow-up appointment two weeks after the intake session. Extra testing is necessary to gain a more objective view of the client’s condition. Testing results will indicate what types of treatment will help the client. Because the client is a minor, the intake therapist will need to discuss possible treatment options with his mother. While pharmacological interventions are effective in treating ADHD symptoms, psychosocial interventions grounded in behavioral theory can involve a therapist addressing the causes of functional impairments (DuPaul et al., 2020). The therapist may recommend that the client receive individualized education when traditional classroom settings are not conducive to improving academic achievement outcomes (Becker et al., 2020). Involving the client’s mother in discussions of treatment interventions could facilitate the necessary improvements when the client regularly feels distracted and unable to concentrate in school. However, the client’s mother could also benefit from parent training in behavior management when feelings of disappointment interfere with academic progress (DuPaul et al., 2020). Integrating behavior management into the treatment plan may help the client and his mother clarifies expectations while setting manageable goals on which both parties may agree.                         References Becker, S. P., Breaux, R., Cusick, C., Dvorsky, M. R., Marsh, M. P., Sciberras, E., & Langberg,  J. M. (2020). Remote learning during COVID-19: Examining school practices, service continuation, and difficulties for adolescents with and without attention-deficit/hyperactivity disorder. Journal of Adolescent Health, 67(280), 769-777. https://doi.org/10.1186/s13063-018-2665-9 DuPaul., G. J., Evans, S. W., Mautone, J. A., Owens, J. S., & Power, T. J. (2020). Future  directions for psychosocial interventions for children and adolescents with ADHD. Journal of Clinical Child & Adolescent Psychology, 49(1), 134-145. https://doi.org/10.1080/15374416.2019.1689825 UMass Nursing 690M [Username]. (2016, March 6). Psychiatric interview and mental status  exam: Georgianna Shea, case study #2 [Video]. YouTube. https://www.youtube.com/watch?v=pF12xCtHWwc


Scroll to Top