The Clinical Assessment Outline
Identifying Data
Name:
Sex: Male
Date if Birth: May 19, 1988
Legal Status:
Grade:
Ethnic Background: Chinese
Citizenship: Canadian
Name D.O.B.
Parents: (Father) October / 1958
(Mother) August / 1965
Siblings: (Brother) December / 1990
Referral Source
Agency Name:
Special Program Leader
Toronto Board of Education
Date of Referral: June 25, 2007
Presenting Problems
Adam has been diagnosed with Autism/PDD and has shown behavioural problems most of his life. and the teachers at Secondary School felt that Adam had shown no real academic progress over the past two years. Also, Adam seems doesn’t get his own way to show anger as form of retaliation, resulting in an outburst or tantrum. He had involved in several fighting incidents with his classmates and two incidents of attacking the staff and teachers in the past 2 months. Every time he tried to deny he was wrong instead he complained he had been picked on.
Informants
History of Current Difficulties
Adam is a 19 years old young man of Asian decent. Adam is development delayed with Autistic tendencies. His verbal skills are equivalent to those of 4-5 years old child. He is tall and slender at 5’10” and weighing 130 lbs. He has black hair and brown eyes.
Adam is talkative, friendly and likeable. He has a good sense of humor and a generally easygoing demeanor. He presents a positive self-esteem and relatively good self-help skills.
He is immature in his social skills and his relationship building efforts require assistance.
Adam is the older of 2 boys in his family, who live in Toronto. Father, and , were born in Hong Kong; with both boys being born in Canada.
is a Family Doctor and is a Registered Nurse.
Adam’s difficulties were identified at a relatively early age. He was diagnosed as mildly retarded at age 2 through an assessment at General Hospital. His behaviour difficulties challenged his parents beyond their capabilities and despite supports and resources available, the family requested he be placed out their home at age 7. Finally, the marriages of his parents failed when he was at age 9.
Adam was cared for within the Metro Toronto Children’s Aid Society foster care program until June 1997, at which time he was placed with the Home Program in the home of Monique and Martin Smith in Barrie, Ontario.
During this placement, Adam’s diagnosis was defined to include Autistic Tendencies, Obsessive Tendencies and Pervasive Development Disorder. Adam, at his age of 12, was identified as functioning between 3 & 5, depending on the area of the assessment.
Throughout his life, Adam has demonstrated an ongoing obsession with balls and round objects. He has exhibited aggressive behaviours requiring close supervision and monitoring as well as the need of frequent reminders to stay on task.
Adam’s behaviours, specifically aggressive outbursts, began to escalate in his mid-teen years. His frequent aggression both verbally and physically towards peers and members of Smith’s family having the negative impact on their relationship. These aggressions includes biting, scratching, hitting, kicking, and spitting. He can be defiant and non-compliant, impulsive.
Also, his violent obsession in watches to the point he had involved in numbers of stealing watches incidents in the department store while he was bringing out for shopping by the Smith’s family. The incidents made his foster parents was so frustrated he had stolen all the watches from his foster parents’ house and buried one by one in different area of the back yard. Subsequently, Adam’s school and home placements began to deteriorate. In 2006, with the approach of this 18th birthday, a long term planning was established to Arthur. A review was undertaken to assess his current situation; including his placement with Smith’s, the increase of negative behaviours, his needs and challenges. Through this progress, it was determined that a placement in a structured semi-independent living program would best suit Adam’s needs.
Credit:ivythesis.typepad.com
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