1. What observations from the vignette inform each domain of the MSE (e.g., appearance, mood, thought process)?

• Appearance

  • Walked slowly 

  • Shoulders hunched 

  • Gaze fixed on the floor 

  • Appropriately dressed for Winter (oversized hoodie, jeans) 

  • Baggy clothing, dirty jeans 

  • Hair unbrushed, faint odor of urine 

  • Arms crossed in chair 

  • rocking in chair 

  • avoiding eye contact 

  • Disengaged posture  

  • Fidgeting 

  • Physically responsive 

• Mood

  • Face expressionless 

  • Flat affect (no reactions) 

  • Sitting quietly and remained in the room 

  • Did not smile, frown, or show any visible emotional reaction 

  • Flat tone of voice and lacked inflection 

  • Did not report feelings of sadness, changes in sleep or appetite, or loss of interest in activities 

  • Emotionally flat, socially withdrawn 

• Thought Process 

  • Did not verbally confirm awareness of the time, place, or people present 

  • No apparent signs of confusion or disorientation 

  • Did not volunteer any thoughts or ideas during session 

  • Avoided answering and looked away when asked about recent events 

  • Speech slow and hesitant 

  • Mother reports him feeling embarrassed 

  • Aware of surroundings

2. How do you distinguish between objective observations and subjective impressions in your write-up?

• Objective observations

  • Facts, based on what is seen, heard, or measured such as an assessment score.

    • Appearance

• Subjective Impressions

  • Quotes from the client

  • Phrases like “appeared,” “clinician noted,” or “therapist observed.”

  • Mood and thought process

3. What findings in the MSE support or challenge your diagnostic impression?

• Support

  • Client is distracted and lacks focus

  • Rocking in the chair and fidgeting

  • Avoiding eye contact

  • Shame present

  • Odor of urine

• Challenge

  • Client did not report feelings of sadness, changes in sleep or appetite, or loss of interest in actives

4. How might cultural norms or trauma history influence the client’s presentation in the MSE?

• Affect and emotional expression

• Avoidance of eye contact

• Appearance (dress and hygiene)

• Behavior

• Thought process

• Insight and judgement

• Client has reported sexual abuse (trauma history)

  
  

  5. How would you write a concise but clinically rich MSE summary for inclusion in a diagnostic assessment?

• The client, an 8-year-old male, presented as appropriately dressed for the Winter season as indicated by wearing a sweatshirt and jeans; however, the client appeared disheveled as evidenced by his unbrushed hair, baggy clothing, dirty and stained jeans, and a presence of urine odor emitting from the client. The client was cooperative as evidenced by entering the room, visibly acknowledging the therapist, sitting in the chair, and remaining in the room throughout the entire session. The client was observed by the therapist to be disengaged, distracted, and reluctant to respond to prompts as demonstrated by his fidgetiness, avoidance of eye contact, rocking in the chair, and lack of responses. The client had a flat affect as indicated by the lack of facial expressions and physical or verbal reactions. The client did not report any changes in sleep or appetite, feelings of sadness, or loss of interest in activities. The client did not verbally confirm awareness of time, place, or people present, but as mentioned above, the client did acknowledge the therapist by glancing at them periodically. In response to questions from the therapist, the client had slow, hesitant speech with long pauses and no apparent signs of confusion or disorientation. Client was avoidant when discussing traumatic experiences (i.e., the client’s sexual abuse history). There is no indication of suicidal or homicidal ideation. Client’s mother and teacher have not reported any concerning statements or behaviors as it relates to suicidal ideation or homicidal ideation. 

1. What observations from the vignette inform each domain of the MSE (e.g., appearance, mood, thought process)? – it could also include behavior, speech, thought content, perception, and cognition. The client is an 8-year-old boy. There is no information regarding his physical appearance. The client reports a feeling of embarrassment regarding bed wetting incidents. Based on vignette, client refuses to follow instructions, therefore feelings related to frustration, irritability, and resistance may be present. However, the client appears to be easily distracted, have poor attention span, and difficulty concentrating. The client constantly blames other for their actions and struggles with accountability and behavioral impact. Therefore, his academic performance and sense of impulsivity are affected in a negative manner.

2. How do you distinguish between objective observations and subjective impressions in your write-up? Objective: Based on the vignette, the client avoids answering questions or engagement with therapist during first session alone. According to teachers, the client argues with teachers and is constantly fidgeting with an item or out of his seat. Client’s mother reports constant bed wetting incidents and occasional incidents of soiling himself.

Subjective: According to client’s mother, the client is “difficult” and behaviors are “purposeful”. The therapist’s perception is the client is guarded and avoidant. The client’s teacher refers to client as a “classic ADHD” and reports client has no sense accountability.

3. What findings in the MSE support or challenge your diagnostic impression? Support ADHD/ODD: Client struggles with distractibility, fidgeting, constantly leaving seat when expected to be in seat, and has poor academic performance. Per ODD, Client also shows argumentative and defiant behavior across a variety a setting. Additionally, client refuses to take responsibility for his mistakes and misbehaviors.

Challenge ADHD/ODD: Client has a history of trauma related to sexual abuse, domestic violence exposure, and inconsistent parental figures. This could also influence the behaviors related to being guarded, avoidant, irritable, and defiant.

4. How might cultural norms or trauma history influence the client’s presentation in the MSE?

The client's history of trauma may influence his presentation during the MSE. The client has struggled to stay on task and concentrate during class which may impact his response to the memory aspect of the MSE. The client has also presented as guarded, quiet, and embarrassed which may impact his presentation during the MSE, leading him to struggle to readily answer questions.

5. How would you write a concise but clinically rich MSE summary for inclusion in a diagnostic assessment?

Client is an 8-year old boy. He is dressed appropriately for the weather but is not well groomed (e.g. smell of urine, hoodie and jeans, unbrushed hair). Client did not verbally participate in the assessment, but showed an awareness of his surroundings by responding to environmental cues (e.g. acknowledging the therapist with glances). This suggests Client was alert AEB with eyes open, sitting and responding to directives. His speech appeared slow and hesitant, with long pauses. His tone was flat and lacked inflection. Client did not disclose anything that led to a concern of suicidality or homicidality. He did not present any symptoms of psychosis. Client presented with a flat affect, not changing his expression throughout the session. Client avoided eye contact throughout session, making infrequent glances, suggesting a guarded nature. Overall, client presented as distracted (e.g. easily distracted by environment) and guarded.

Appearance - entered slowly, eyes downcast; wore oversized hoodie with wrinkled/stained jeans, unbrushed hair, urine odor present; sat with arms crossed, avoiding eye contact; facial expression expressionless

Mood - closed body language, flat, uncooperative, did not show visible emotion, appeared alert

Thought - no signs of confusion or disorientation; Billy appeared oriented to circumstance, did verbally confirm awareness of time, place, or people present, did not volunteer any thought or ideas during session

How do you distinguish between objective observations and subjective impressions in your write-up?

Objective observations are direct, observations. Subjective impressions are the ideas/opinions inferred from the assessment, which would be paired with evidence. 

What findings in the MSE support or challenge your diagnostic impression?

Supporting - fidgeting throughout the session with hoodie drawstring, shifted attention frequently (distracted by noises outside); Billy’s mother reports that he struggles to follow rules and instructions

Challenge - reports from school was opposite of his behavior displayed during the session; he spoke shortly throughout the session, but is reported as talkative and disruptive during school

How might cultural norms or trauma history influence the client’s presentation in the MSE?

Mom mentioned trauma had not been discussed, which may be considered a cultural norm for their family. Billy’s embarrassment from bedwetting may have caused his mood and disengagement. Additionally, the abuse from the older cousin may have led to Billy being disengaged and expressionless due to his embarrassment and distrust to outside individuals of their family. 

How would you write a concise but clinically rich MSE summary for inclusion in a diagnostic assessment?

BESTPICK

Billy is an 8 year old white male who presented with closed-body posturing and avoidant eye contact. Billy’s appearance was dishelveled with wrinkled clothing, ungroomed hair, and the presence of urine odor, despite attire consistent with prevailing weather conditions. 

 Billy did not display visible emotions; appeared flat, uncooperative, and mood seemed agitated despite no verbal confirmation, as evidenced by fidgeting, minimal verbal response, and avoiding eye contact. 

Speech was slow and hesitant with long pauses. 

Billy was conscious of circumstance, but did not engage. He did not volunteer confirmation of orientation to person, place, and/or time. Billy did not communicate any thoughts of SI/HI. 

Billy did not report any indication of audiovisual hallucinations.

Billy was easily distracted by external factors. 

Billy was conscious of surroundings, but did not engage in conversation unless directly spoken to.

His mother reported he does not recognize the impact of his behavior on others.

Appearance: Dressed appropriately for the season, dishelved appearance, poor hygiene, closed off posture, frequent glances at familiar people in room and door but poor eye contact with clinician

Mood: Fit affect and emotionally withdrawn

Thought process: Mute, Flat tone of speech

• How do you distinguish between objective observations and subjective impressions in your write-up?

Objective observations are things that are direct observations that are factual and not up for debate, for example, the fact that Billy smelled of urine. Subjective impressions are based on objective observations and may be assumptive.

• What findings in the MSE support or challenge your diagnostic impression?

Support: distracted by noises outside or things inside the room, smelled of urine, fidgeting with a sweatshirt

Challenge: Lack of communication in session but talkative at school, remained seated and quiet during the session, no visible emotional reactions,

• How might cultural norms or trauma history influence the client’s presentation in the MSE?

Given Billy’s history of trauma and his reluctance to speak about it or in general, it makes it difficult to make a viable assessment using the MSE. There may also be some influence from his Mother due to her desire to move on and not speak about Billy’s sexual assault.

• How would you write a concise but clinically rich MSE summary for inclusion in a diagnostic assessment?

The client is an 8-year-old male. Client presented to the assessment dressed appropriately for the season but appeared unkempt, as evidenced by his unbrushed hair and odor. He was uncooperative, as evidenced by his refusal to respond to or elaborate on prompts. His speech was limited as he avoided verbalized responses and was silent for the majority of the assessment. When he did speak, it was slow and labored with long pauses. The client’s affect was flat, which was congruent with his flat and emotionless tone of speech. The client would not confirm orientation to time, place, or people present. He appears to have poor insight, as evidenced by his inability to recognize the impact of his behavior on others. Similarly, he showcased poor judgment as evidenced by his decisions frequently leading to conflict or punishment. Client denied any thoughts of wanting to harm himself or others.

2) Objective observations would be considered Billy’s lack of response within the session. Subjective observations include Billy’s mother’s perception of his behaviors.

3) Billy was observed as being fidgety, restless, and inattentive and these items support the ADHD diagnosis. Billy also came off as defiant, uncooperative, and closed. This supports his ODD diagnosis.

4) The previous exposure to family violence may contribute to guarded affect and difficulty trusting adults. The mother’s minimization of abuse, as evidenced by “she would prefer they just all forget about it” may leave Billy feeling unsupported emotionally and prolong his dysregulation. Billy may experience heightened stress response as evidenced by his stepfather yelling. Trauma may also further impact or worsen enuresis/encopresis.

5) Billy presented as a school-age child. He was appropriately dressed but not well-groomed. (i.e clothes smelling of urine). Billy was guarded and minimally verbal during the individual session, with downcast gaze and limited eye contact. His affect appeared flat and irritable at times as evidenced by: crossed arms and lack of participation. Attention and concentration were impaired, evidenced by distractibility and difficulty remaining seated. Thought process was logical but oppositional, characterized by blaming others for misbehavior and refusal to follow directions. No perceptual disturbances or suicidal ideation were reported. Insight and judgment appeared limited, as he denied personal responsibility for academic and behavioral concerns. He denied having bad dreams, even though his mother reported that he was. Findings are consistent with attentional and behavioral dysregulation, with consideration for ADHD (combined type) and Oppositional Defiant Disorder. Trauma history and ongoing family stressors should be considered as contributing factors.

1.     Appearance – unbrushed hair, overside hoodie, faint odor of urine

a.     Mood – disengaged (hunched shoulders), expressionless, unresponsive

b.     Thought process – unawareness of impact of behaviors

c.     Objective observations are related statements of fact based on Billy’s present body language (e.g. fidgeting with hoodie, hunched shoulders), speech patterns (slow, hesitant, with long pauses). Subjective impressions could be concluded based on the therapist’s perception that Billy was anxious and withdrawn.

2.     Easily distracted by noises and fidgeted during session. The therapist had no visual evidence of hyperactivity or defiant behavior as stated by teachers and parents to accompany an ADHD diagnosis.

3.     History of sexual abuse and mother’s minimization of abuse. Billy’s understanding of what occurred and feelings of shame and embarrassment. Billy is accustomed to others speaking or performing on his behalf.

The client, an 8-year-old white male, presents with complaints (from parents) of sexual abuse and challenging behaviors with authority. Billy has been described by caregivers and teachers as being difficult (i.e., argues with authority, refusing to do chores and homework, and argues). During the initial assessment, Billy provided no verbal responses, and his gaze was primarily focused downward. Billy was observed in a disheveled state as evidenced by wearing an oversized hoodie, wrinkled jeans with stains and emitted a scent of urine. The client did not verbally confirm his awareness of time, place, or people present. The client’s actions indicated that he appeared to understand the context of the visit evidenced by no apparent signs of confusion or disorientation. During questioning Billy avoided eye contact, sat with hunched shoulders and avoided eye contact. Billy seemed to be withdrawn observed by rocking and fidgeting during questioning.