INTAKE DATE: May xxxx
Diagnosis:
F91,1 Conduct Disorder, Childhood-onset type
F90.0 Attention Deficit Hyperactivity Disorder, Predominantly
hyperactive/Impulsive presentation, moderate
Z55,9 Other Problems Related to Education and Literacy
Z65.3 Problems Related to Other Legal Circumstances
IDENTIFYING/DEMOGRAPHIC DATA: Omari is a 10 year old male in the
third grade. He lives in Houston, Texas with his parents. He is the only child of
parents whom have completed post-graduate education. The family is from St.
Lucia and relocated to the United States when Omari was 6 months old for job
opportunities. Omari is an intelligent young boy who presents with significant
potential to excel academically.
CHIEF COMPLAINT/PRESENTING PROBLEM: Omari was referred for an
evaluation because his parents and teacher indicate that Omari is restless and often
requires reminders to help him stay on task. Omari has difficulty focusing and
sitting still in class. He is described as "constantly running around" and presented
with difficulties listening and following instructions. His teacher notes that he
sometimes acts 'socially immature', and that he often demonstrates attention-
seeking behavior.
HISTORY OF PRESENT ILLNESS: Omari enjoys spending time with his
friends. Most recently Omari was found in a neighbor’s house that he broke into.
The friend group recently were found starting fires in the woods and neighbors
called the police. While Omari interacts well with peers his own age, his parents
believe he is easily led and influenced by others. Omari does get upset when he
does not receive what he wants and acts out, forcing others to give things to him.
He physically and verbally fights with his peers when this happens but then he gets
back hanging around with his friends.
Omari is able to 'hyper focus' on some activities of interest however he often has
difficulty sustaining his attention at school. Omari has been known to blurt out
answers and interrupts other students in the classroom. His parents describe
emotional reactivity as well as confrontational behaviors demonstrated both at