ADOLESCENT

TREATMENT PLAN
 
INTRODUCTION TO CLINICAL ASSESSMENT AND DIAGNOSIS
LUIS RAMOS DELGADO
M A R I A N E L A T AVA R E Z
UNIVERSITY OF PHOENIX
CNSL/526 VERSION 4
JANUARY 7, 2012
NADJA CRESPO-LLADO
 ADOLESCENCE

• is commonly used to describe the transition stage between

childhood and adulthood. Adolescence is also equated to both
the terms “teenage years” and “puberty.” Puberty refers to the
hormonal changes that occur in early youth; and the period of
adolescence can extend well beyond the teenage years. In fact,
there is no one scientific definition of adolescence or set age
boundary. There are key development changes that nearly all
adolescents experience during their transition from childhood
to adulthood.
• Kaplan, P. S. (2004). Adolescence. Boston: Houghton Mifflin Company

CLINICAL HISTORY
• Mariela Lopez Ramos, age 14
years, daughter of William Lopez
(52 years) and Diana Ramos (41
years). It's only daughter family
female, third in order of birth of
four brothers, Joselito Roman,
23, Daniel Roman 18 and
younger brother Emiliano Lopez
7 years. Mariela is school student
of Rosa Costa Valdivieso,
Intermediate school in the
municipality of Yabucoa, is in
eight grade when she
Marianela
demonstrates academic
excellence, according to grades
and notes from teachers.
Currently the minor MLR and
younger brother ELR live with
his maternal grandparents Ana
Rivera (60 years) and Alejo
Ramos (63 years), 3 years ago,
through a temporary custody
decided by the Department of
Family by gross negligence.
 Luis
CLINICAL HISTORY (CONT)

• Through the intake and interview with mother and grandmother

unusual situation is not identified in the process of pre-and
postnatal development of Mariela, indicates that conducted
prenatal care and assistance as were indicated.
• Previous history indicates that after years of parental divorce,
Ms. Diana Ramos mother began to show behavioral and verbal
thinking erratic and disorder in relation to interpersonal
relationships. Behaviors such as delusions of persecution,
grandeur delusion, aggression episode and others. After that the
children were removed because of a manifestation of aggression
against one of his sons, shifting all children home for safety.
 Marianela
CLINICAL HISTORY (CONT)

• The client MLR continues interacting with his mother who

comes home to grandparents without any restrictions, under
the supervision of the grandparents, they say indicates and not
dangerous. Father of MLR visit on weekends and maintains a
healthy emotional relationship. Collateral’s Grandparent
indicated needs further help and assistance in the effective
care of health and hygiene of the children.
 CLINICAL HISTORY (CONT)
• During the interview process with
client MLR was identified that
expressed anxiety about recent events
on their condition, said to have good
relationships with all members of the
family. Although would like to talk
more with her mom. Indicates that she
loves play and share with neighbors,
friends and brothers of the Adventist
Church which visit their grandparents.
Meet and know about the process of
personal care and hygiene, as school
health teacher showed it in several
classes. Indicates that sometimes helps
at home with homework and can do
Luis
some “pasteles” because his
grandmother sells its. We explored the
methods of discipline , who teaches and
as he said that grandma is the one who
taught discipline through punishment,
remove access to play for the afternoon
and rarely has hit in the legs with the
hand without causing damage. Notes
that grandma loves indicating aware of
why he lives with her, "Mom is sick."
Expresses that is afraid to fall and lose
control of your body and can gross. No
presentation of suicidal ideation.
 Luis
SIGNIFICANT INFORMATION

• DX: 345.40 = partial epilepsy seizures with impairment of

consciousness
• Tx: 100 mg Tegretol (Carbamazepine may cause side effects. Tell your
physician if symptoms are any of These severe or do not go away:
• Drowsiness, dizziness, unsteadiness, nausea, vomiting,
headache, anxiety, memory, problems, diarrhea, constipation,
heartburn, Dry Mouth, back pain.Some side effects can be
serious. Confusion, loss of contact With Reality, chest pain,
yellowing of the skin or eyes, Vision problems.
• Carbamazepine may cause other side effects. Call your Doctor
if You have any unusual problems while taking this
medication.
 Luis y Marianela
SIGNIFICANT INFORMATION

• The adolescent deals with the fear "of what can happen at any time," the
process of misunderstanding about their age condition has overloaded
agenda caregiver care of your grandmother.

• The mother has created signs of faults in fault grandparents because of the
onset of the condition, said that "she hits her on the head and because of that
the girl has epilepsy. The child has indicated that she is been treated
differently by their classmates and family, through processe of self-concept of
the child is disabled.

• One of Marcela's brothers, Daniel, was involuntarily hospitalized several times

because of the lack of control by the Act 408, but the lack of background
issues for the continuation of treatment, has not been officially diagnosed or
received psychiatric treatment to stabilize.
 Marianela

THEORETICAL FRAMEWORK

• In light of the existential and humanistic approach Mariela is seen as a person

in Search for meaning in life. But first it is important to bring to our attention
what will tells us the specific developmental theories of aging. Mariela is see
through Piaget she is in the stage of formal operations, which means that
Mariela is able to solve abstract problems logically. Her thinking is more
scientific and thorough. You can develop interest in social issues, identity.
• Mariela from the social psychological approach should encounter in Erikson
psychosocial stage of identity versus role confusion, meaning that the growing
human being is becoming more independent, and begin to look to the future in
terms of career, relationships, families, housing, etc.. During this period, they
explore possibilities and begin to form their own identity based on the result of
his explorations. This sense of who they are can be hindered, which leads to a
sense of confusion about themselves and their role in the world.
• This gaves us a kind of cognitive map from which to depart.

THEORETICAL FRAMEWORK (CONT)
• The origins of a neurological condition
such as epilepsy can be one or multiple • The Mariela’s condition is called mal
reasons unknown.
• Historically epilepsy has been
misunderstood by ignorance and
religious interpretations is surrounded
by many myths, which label people
become possessed and other forms of
feedback.
Luis
petite crises, which is characterized by
intermittent episodes of not
unexpectedly. However, minor
problems confronting academics and
learning.
• There is a psychosocial issues with
which to work while as crisis, the fear
of the unknown, anxiety for the future,
strengths and support, the biological
will be supervised and evaluated by a
professional neurologist.
 Luis y Marianela

THEORETICAL FRAMEWORK (CONT)

• The Mariela’s situation is a circumstantial crisis, for

unexpected events of a health condition.
• According to the theory of crisis, a crisis can be an opportunity
or trauma, if the person receives the support and tools through
their situations. This complies with the theory which is
centered on the person who uses a constructionist linked
approach, which reconstructs the person interpreting the world
through the process of therapy.
 Marianela
DSM IV TR
• AXIS I: 300.02 Generalized Anxiety Disorder
• AXIS II: 799.9 Deferred (At this point, no personality disorder is
evident.)
• AXIS III: 345.00 = petit mal seizures
• A petit mal seizure is the term commonly given to a staring spell, most
commonly called an "absence seizure." It is a brief (usually less than 15
seconds) disturbance of brain function due to abnormal electrical activity in the
brain.
• AXIS IV:
health problems in family; disruption of family by separation, divorce, or
estrangement; removal from the home.
• AXIS V: 59
 Luis
INTERVENTION - TREATMENT PLAN

Treatment Plan or Crisis Intervention:

• Let expression ventilation for the child and parents and grandparents
• Time to think: Orientation, Backlight compensation what is happening.
• Time to share the experience and expression of the immediate client systems.
• Resource assessment moment.
• To explore the level of lethality, take steps to extinguish or minimize it through
coordinating medical services to the customer immediately.
• Develop a plan and orientation guide for teachers, parents and peers.
• After the session:
• Empower the customer, knowing itself to unexpected situations.
• Teach self-relaxation exercises.
• Work some family situations that affect the customer.
 STRENGTHS AND WEAKNESSES OF THE
MODEL OF THERAPY Luis y
Marienela

Strengths
• Is aimed at long-term recovery and future tools to make
circumstantial and unexpected crises.
Weaknesses
• The Plan works some situations in the context of the client
immediately but does not create a solution to the situations
that already are affecting you as a mother figure in
uncontrolled mental condition.
  
SHORT-AND LONG-TERM
Marienela

Short-term
• Create family and teachers immediate support, face what is
happening with the solution-focused tools. (Statement by a
doctor immediately.) And conscience regains control of what
is happening.
• Strengthen self-esteem and make the tag to customer.

Long Term
• Empower a human to unforeseen situations and toward self-
realization.
• The end …. Question?

• Thank you for you attention!!!