20 Feb Focused SOAP Note Patient: 11‑year‑old male
Child (Age 11) Adjustment Disorder and Impulse-Control Disorder A 11-year-old boy showed increased irritability and aggression following parental separation. Introduced emotional regulation skills and caregiver training in behavioral management strategies.
Focused SOAP Note
Patient: 11‑year‑old male Presenting Problems: Irritability and aggression following parental separation Diagnosis: Adjustment Disorder with disturbance of conduct; Impulse‑Control Disorder
Subjective
Chief Complaint: “I get angry quickly and sometimes hit or yell when things don’t go my way.”
History of Present Illness:
Increased irritability and aggressive behaviors noted since parental separation several months ago.
Episodes include yelling, throwing objects, and occasional physical aggression toward peers.
Reports feeling sad and frustrated about family changes.
Psychiatric History: No prior psychiatric hospitalizations; no prior therapy.
Family/Social History: Lives with mother; limited contact with father. School performance declining due to behavioral issues.
Patient’s Perspective: States he “can’t control” his anger but wants to “be better.”
Objective
Appearance: Alert, casually dressed, cooperative but restless.
Mood/Affect: Irritable mood; affect congruent.
Speech: Normal rate and tone; occasionally loud when discussing frustrations.
Thought Process: Logical, goal‑directed.
Thought Content: Preoccupation with parental separation; no psychotic features.
Behavior: Fidgety, impulsive responses during interview; difficulty waiting his turn.
Cognition: Age‑appropriate; concentration mildly impaired.
Physical Exam (limited): No acute medical concerns noted.
Assessment
Primary Diagnoses:
Adjustment Disorder with disturbance of conduct (related to parental separation).
Impulse‑Control Disorder (manifested by aggression and poor emotional regulation).
Clinical Impression:
Child exhibits irritability and aggression linked to psychosocial stressor (parental separation).
Impulse‑control difficulties exacerbate behavioral problems at home and school.
Protective factors include caregiver involvement and willingness to engage in therapy.
Plan
Psychotherapy:
Initiate emotional regulation skills training (deep breathing, coping strategies, problem‑solving).
Begin CBT‑based interventions tailored for children.
Incorporate play therapy elements to facilitate emotional expression.
Family/Caregiver Interventions:
Provide caregiver training in behavioral management strategies (positive reinforcement, consistent boundaries).
Encourage family sessions to address adjustment to parental separation.
School Collaboration:
Communicate with teachers and school counselor to support behavioral strategies in the classroom.
Develop individualized behavior plan.
Monitoring:
Track frequency and severity of aggressive episodes.
Monitor mood changes and adjustment over time.
Safety:
Assess risk of harm to self or others regularly.
Provide crisis plan for caregiver if aggression escalates.
Follow‑Up:
Weekly therapy sessions for child.
Biweekly caregiver training sessions.
Reassess in 6–8 weeks for progress and need for further intervention.
Signature/Provider: ___________________________ Date: ___________________________
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