Comprehensive Psychiatric Evaluation Template Essay

Comprehensive Psychiatric Evaluation Template Essay

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CC (chief complaint): The chief complaint is the increasingly defiant behavior at home and in school, accompanied by temper tantrums in a six-year-old boy.

HPI: The patient, a bright six-year-old boy, is displaying disruptive behavior at home and school. The behavior seems to be exacerbated after the recent birth of a younger sibling, leading to feelings of loneliness and aggression towards the younger sibling. Arguments, particularly with the mother, often escalate to temper tantrums, including destructive behavior. Symptoms of perfectionism are noted, possibly related to the recent stresses in the family dynamic. Comprehensive Psychiatric Evaluation Template Essay


Past Psychiatric History:

  • General Statement: No history of mental illness reported in the extended family, including grandparents, parents, and siblings.
  • Caregivers: The mother is the primary caregiver who brought the child to the hospital.
  • Hospitalizations: No information was provided regarding past psychiatric hospitalizations.
  • Medication trials: No information was provided regarding past psychiatric medications.
  • Psychotherapy or Previous Psychiatric Diagnosis: No information was provided about previous psychotherapy or psychiatric diagnoses.

Substance Current Use and History: No information was provided about the child’s substance use or exposure. Comprehensive Psychiatric Evaluation Template Essay

Family Psychiatric/Substance Use History: No reported history of mental illness or substance use in the extended family.

Psychosocial History: Recent stressors include the birth of a younger sibling, which has led to the child feeling neglected and displaying aggressive behavior. Loneliness and a need for attention appear to be significant factors.

Medical History:

  • Current Medications: No information was provided regarding the child’s current medications.
  • Allergies: No information provided regarding allergies
  • Reproductive Hx: Not applicable to the case study.


Diagnostic results: No specific diagnostic results are mentioned in the case study.


The assessment involves a diagnosis of Oppositional Defiant Disorder (ODD) based on signs and symptoms, as there are no specific tests available for ODD.Comprehensive Psychiatric Evaluation Template Essay

Mental Status Examination:

In the case of the six-year-old boy with oppositional defiant disorder symptoms, conducting a child-specific MSE can provide valuable insights into his psychological well-being. The reported behaviors include increasingly defiant behavior, temper tantrums, and symptoms of perfectionism. The child’s aggressive acts, particularly towards the younger sibling, suggest difficulties in managing emotions and adjusting to the birth of a sibling. Temper tantrums imply possible difficulties in communication and expression of emotions. Affect refers to the observable expression of emotion. In the case study, symptoms like perfectionism, defiance, and aggression suggest a potentially labile or intense effect. Symptoms of perfectionism may imply a focus on high standards and the need for control. The child’s behaviors appear more related to emotional and behavioral regulation rather than distortions in perception. Information about the child’s cognitive functioning, such as attention, concentration, memory, and problem-solving skills, is not explicitly provided. The initiation of therapy sessions suggests a recognition of the need for intervention. The reported symptoms, including aggression and temper tantrums, suggest impaired judgment in managing emotions and responding appropriately to stressors.

Primary Diagnosis

Oppositional Defiant Disorder (ODD)

Oppositional Defiant Disorder (ODD) is a childhood behavioral disorder characterized by a persistent pattern of defiant, disobedient, and hostile behavior toward authority figures (Arias et al., 2021). Individuals with ODD often display negative and oppositional behaviors that go beyond typical childhood defiance. The child in the case study exhibits defiance and disobedience at home and school. This is evident in the increasing frequency of temper tantrums, destructive behavior during arguments, and aggression towards the younger sibling. Comprehensive Psychiatric Evaluation Template Essay

Differential Diagnoses


Adjustment Disorders


Adjustment Disorders (AD) involve the development of emotional or behavioral symptoms in response to identifiable stressors occurring within three months of the stressor’s onset (O’Donnell et al., 2019). In the case study, the six-year-old boy presents with disruptive behavior, aggression, temper tantrums, and symptoms of perfectionism following the recent birth of a younger sibling.


Mood Disorders


While the case study primarily focuses on Oppositional Defiant Disorder (ODD), mood-related aspects are indirectly mentioned, especially concerning the child’s emotional regulation and the disruptive behaviors he exhibits. Mood disorders involve disturbances in mood and emotional regulation, which may manifest as depressive or manic symptoms (Rainville & Hodes, 2019). In this case, the child’s emotional well-being appears affected, particularly in response to the recent changes in the family dynamic. Comprehensive Psychiatric Evaluation Template Essay


Disruptive Behavior Disorders


Disruptive Behavior Disorders are a group of psychiatric conditions characterized by persistent patterns of disruptive, defiant, and aggressive behaviors (Johnston & Burke, 2020). In this case, Oppositional Defiant Disorder seems to be a relevant consideration, given the child’s defiant behavior, temper tantrums, and aggression, especially in response to perceived neglect after the birth of a younger sibling.


The case emphasizes the importance of addressing the psychosocial factors contributing to the child’s behavior, particularly the recent birth of a sibling. Using therapeutic interventions, including cognitive-behavioral therapy, behavior modification, motivational therapy, psychodrama, and reinforcement, highlights a multidimensional approach to address the child’s difficulties. The positive outcome and absence of relapse over a year suggest the therapeutic strategies’ effectiveness. Ongoing support for the child and the family is essential to maintain the observed positive progress. Comprehensive Psychiatric Evaluation Template Essay

Case Formulation and Treatment Plan:

The six-year-old boy’s primary concern is his increasingly defiant behavior at home and school, along with temper tantrums. The recent birth of a younger sibling has triggered feelings of loneliness and aggression towards the new family member. The child is exceptionally bright academically. Belongs to an extended family without a history of mental illness. The disruptive behavior started after the birth of the younger sibling. The treatment plan includes regularly assessing the child’s progress, family dynamics, and the effectiveness of interventions. It can also be adjusted as needed based on ongoing evaluation and feedback from the child and the parents. Collaborating with other professionals, such as teachers and school staff, to ensure a holistic and coordinated approach to the child’s well-being. Regular follow-ups will ensure the sustainability of these positive changes from the treatment plan.

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning. Comprehensive Psychiatric Evaluation Template Essay


Arias, V. B., Aguayo, V., & Navas, P. (2021). Validity of DSM-5 oppositional defiant disorder symptoms in children with intellectual disability. International Journal of Environmental Research and Public Health18(4), 1977.

Johnston, O. G., & Burke, J. D. (2020). Parental problem recognition and help-seeking for disruptive behavior disorders. The Journal of Behavioral Health Services & Research47, 146-163.

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International journal of environmental research and public health16(14), 2537.

Rainville, J. R., & Hodes, G. E. (2019). Inflaming sex differences in mood disorders. Neuropsychopharmacology44(1), 184-199. Comprehensive Psychiatric Evaluation Template Essay






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