Ruth Martin DOB: 02/19/1998

Western Regional Counseling Center

PSYCHOSOCIAL ASSESSMENT

NAME: RUTH MARTIN

DATE OF BIRTH: 02/19/1998
DATE OF INITIAL EVALUATION: 04/24/2015
CLINICIAN: Larry S. Dickson, MA, NCC, LPC, CRS, Fellow,
PTSD-C, DAPA, BCPC, IC/RC-CCJP, IC/RC-
CCDP Diplomate, DCC

SOURCE AND REASON FOR REFERRAL: Ruth was referred for psychological services by
CART Services of Crawford County, due to difficulties associated with an alleged assault by a
foster brother in her home.

EVALUATIVE PROCEDURES: Clinical interview, Review of available records, Behavioral

observation

PRESENTING PROBLEM: Ruth is a 17-year-2-month old Caucasian female who is currently

living on the family farm with her biological parents, Sarah and Michael (Mike) Martin; Bruce
Vance, a 22-year-old past foster brother that has been living with the family for 12 years; three
foster sisters ages 16, 15, and 13 that have been in the home for less than 6 months. Ruth’s
biological brother Mike Jr. currently attend Edinboro University of Pennsylvania and is home
on the weekends and holidays. She is left handed. Ruth reports experiencing difficulties with
an alleged sexual assault from former foster brother, John age 17, who was living in the family
home at the time of the assault (John lived with the family for 7 years). Ruth became aware of
the assault when the former foster brother confessed to touching her breasts on approximately 7
different occasions, while Ruth was sleeping. This was reportedly confirmed through a
polygraph test conducted at CART Services of Crawford County. John was removed from the
home and is currently in placement and requesting a return to the family home. Ruth also
reports problems with anger towards her parents related to their response to the alleged assault
and continued contact and support for John. Ruth reports property destruction, aggression, and
elopement behaviors as a result of this incident and her parents’ response to the incident. Ruth
reports symptoms of increased anxiety, appetite changes (increased eating), difficulties with
concentration, difficulty sleeping (reported as difficulty falling asleep, remaining asleep, and
associated with not feeling safe), sensory flashback including touch, auditory, and olfactory
recall, feelings of guilt (related to the 7 years relationship with the foster brother who allegedly
assaulted her), impulsivity, irritability/anger outbursts, and suicidal thoughts (approximately one
month age; without plan or intent). Ruth denied any additional past or present suicidal or
homicidal ideation, plan, or intent.

Ruth attended the assessment appointment accompanied by with her mother but insisted that her
mother remain in the lobby. They arrived on time for the appointment and mother completed the
initial information packet. Ruth was casually dressed and neatly groomed for a female
adolescent. Ruth appeared her stated age. She is of average height 5’ 5’, moderate body type,

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Ruth Martin DOB: 02/19/1998

slightly overweight at a reported weight of 189 pounds, and has dyed black shoulder length hair.
Ruth reported that following the confirmation of the assault she cut her previously long blonde
hair and died it jet black. Posture and gait were normal. Motor activity was normal with no
abnormal movements observed for walking, standing, and sitting. There were no unusual or
stereotypic behaviors noted. Ruth appeared alert throughout the session. Ruth was in no
apparent distress. She was friendly, polite, sociable, and cooperative throughout the interview
process. Rapport was easily established as Ruth is known to this clinician. Appropriate eye
contact was maintained throughout the interview process. Behavior was pleasant with good
participation in the discussion and questioning. Ruth presented her personal history in a
spontaneous fashion, organized in a chronological sequence, and with sufficient detail. Speech
was within normal limits for rate, rhythm, and volume; articulation was clear and
communication was fluid and unrestricted. Mood was reported as “angry”. Affect was reactive,
periods of tearfulness, anger, and varied appropriately related to setting and content. Thought
processes were coherent, logical, relevant, and organized. Ruth was alert and well-oriented x3.
Memory was intact for recent and remote. Attentional processes were good with no signs of
distractibility, undue digression, or tangentiality. Ruth appears to be of average intelligence, her
reasoning and judgment abilities appear to be good at this point, and impulse control is reported
as poor. Ruth appears to have intellectual insight but limited emotional regulation and
behavioral control at this time.

Ruth identified her strengths as playing basketball, talking with people, and riding horses. Ruth
identified long term goals of taking a road trip with her best friend and getting through this
abuse issues with her family. She identified short term goals of being able to talk with her
mother and father without feeling rage. Ruth reported that her support system is usually her
parents, but right now it is her best friend, Cindy.

MENTAL HEALTH HISTORY: Ruth reported previous mental health treatment as

participating in family therapy with one of the past foster children in the home. She denied any
other mental health history of Psychiatrist, Psychologist, or Inpatient treatment.

MEDICAL HISTORY: Ruth reported limited information or knowledge regarding her birth
and early childhood. Ruth stated that developmental milestones were achieved at expected ages
with no outstanding departures from normal development. Ruth reported medical issues
throughout childhood and adolescence as two broken ankles, a broken elbow, two broken
wrists, and a significant knee injury (basketball injury). Ruth reported no current medical
conditions. Ruth identified family medical history as cancer, diabetes, multiple sclerosis, and
high cholesterol. Ruth identified family psychological history of mother and three maternal
aunts being sexually abused during childhood and adolescence by a non-biological uncle, father
being physically and emotionally abused as a child by his father, depression, and panic
disorders.

Ruth stated that her primary care physician is Dr. Spock. Ruth reported current medications as
birth control pills.

SOCIAL HISTORY: Ruth reported that she has always had a great relationship with her
mother, Sarah Martin. Ruth stated that they argue a lot of the time but can usually work things

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Ruth Martin DOB: 02/19/1998

out. Ruth said that she and her father are close but not the “hugging” type of relationship. She
reported that her father, Mike Martin, is a redneck farmer and that they tease each other and
each of them tries to have the last word. Ruth stated that following the report of alleged sexual
abuse by a foster brother, the relationship with her parents has been strained. Ruth stated that
she cannot talk with them about this issue and often reverted to punching the wall, a door, or
have a tantrum.

Ruth has two biological siblings: Rachel, who is married, and lives locally and Mike who is
currently away at college and only home for holidays and breaks.

Ruth stated that there have been many foster siblings in and out of the home since Ruth was
very young. She reported that these have been children with significant behavioral needs and
have caused stress on her and the family at times.

Ruth reported alleged sexual abuse by an adolescent foster brother. Ruth does not remember the
abuse, but it was reported by the foster brother during a polygraph test. The alleged abuse was
the foster brother touching Ruth’s breasts on 6 or 7 occasions while she was sleeping. This was
reported to Childline and has been verbally reported as an indicated report. The district
attorney’s office has reportedly stated that they are pressing charges for the assault. Ruth was
required to make a recorded statement about the abuse.

Ruth is in the 11th grade at Cochranton High School. She reports that she is in regular classes
and that her grades were A’s & B’s but have recently fallen to low B’s & C’s and below.

Ruth is a member of several school and community related organization. She stated that she
currently holds offices in two of these organizations. She stated that she works at a local store
about 10 to 12 hours per week.

Ruth denied any past or current legal involvement. Ruth reported that she began drinking
alcohol at age 14, drinks only on occasions, and has been tipsy approximately 5 times in her
life. She stated that she only got drunk once, became sick, was hungover, and will never do that
again. She reported that she has been drinking almost daily since the incident was discovered.
She denied other substance use or abuse. Ruth denied nicotine use and reported limited caffeine
intake.

DIAGNOSTIC IMPRESSION:
DSM-5:
F43.25 Adjustment Disorder with disturbance of emotions and conduct
F43.0 Acute Stress Disorder
T76.22 XA Child sexual abuse, Suspected, Initial encounter
Z62.820 Parent -Child relational problem
Z65.4 Victim of crime

RULE OUT: F 32.9 Unspecified Depressive Disorder

F 43.10 Post-Traumatic Stress Disorder

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Ruth Martin DOB: 02/19/1998

SUMMARY AND RECOMMENDATIONS: Moderate to severe psychosocial stressors

include: symptoms of anxiety, symptoms of depression, family stressors, inadequate social
support, problems related to social environment and reported sexual abuse. Additional concerns
identified during the interview include problems with current parent child conflicts, aggression,
and suicidal ideations without plan or intent.

The following recommendations are offered:

1. It is recommended that Ruth participate in outpatient individual therapy to address issues

related to managing depression symptoms, managing anxiety symptoms, processing
abuse response, developing appropriate coping strategies, increasing functioning level,
stress management, anger management, addressing relationship issues with her parents,
and monitoring for issues of safety.

2. It is recommended that Ruth and her family participate in outpatient family therapy to
address issues related to addressing relationship issues with her parents, and monitoring for
issues of safety.

3. It is recommended that Ruth continue with her primary care physician, Dr. Spock for
continued general medical management.

4. It is recommended that Ruth complete a formal safety plan.

Thank you for referring Ruth for psychotherapy services at the Western Regional Counseling
Center. If you have any further questions for me, please feel free to contact me at the Center at
555-9876. Thank you for your time and attention.

_____________________________________
Larry S. Dickson, MA, NCC, LPC
License # PC004060

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