Family Therapy

Greater Surrey Children's Services

Gemma D. Walker, Ph.D., Psy.D. Psychologist UK License PSY17946

Child/Adolescent Intake Information

Date: 10/1/1989

Identifying information:

Name: Potter, Harry Age: 9 yr, 3 mon Sex: M

Parent: Potter, James (deceased) Causasian male Cause of death: traffic accident

Parent: Potter, Lily (deceased) Causasian female Cause of death: traffic accident

Parents' Primary Language: English

Current Caregiver(s): Vernon & Petunia Dursley Rel: Legal Guardians (biol. Aunt)

Current Address: 4 Privet Drive, Little Whinging, Surrey 1LW 3NO

Caregiver(s)' Primary Language: English Interview conducted in: English

Informant: Current LGs, ind (H. Potter) Relationship: Biological Aunt; Uncle

Referred by: Teacher, Little Whinging Primary School.

Reason for Referral/Chief Complaint:

LG s report that ind, their nephew, is "shiftless, useless, lazy, and probably mentally deficient." Ind described as not compliant w/ LGs' directives at home, torments same-age cousin at home, hoards food, lies, steals, "does not show respect or gratitude" for LGs or family members. No problems reported at school, but teacher allegedly "strong-armed" family into seeing therapist.

Ind refused to answer therapist's questions w/ family present.

Duration: According to Uncle: "Ever since we adopted the useless beggar." Adoption at age 18 mos. Duration approximately 7.5 years. Adoption due to abrupt death of parents in car crash, as reported by Aunt, biol sibling of ind's mother.

History of Presenting Problem:

LGs report that ind was problem "from the moment he entered our home." LGs report ind as tantruming throughout infancy/toddler years, sibling rivalry w/ same-age cousin, as expressed by intrusive behaviors w/ cousin, stealing cousin's toys, "lying as soon as he could speak", stealing & hoarding food, physical aggression towards cou, fearfulness w/ same-age peers, inability to make lasting friendships.

LGs perceive cause to be ind's deceased parents who "were never any good to begin with." Attempted solutions: LGs report that they have tried grounding, time-outs, loss of family privileges, w/ no success.

No environmental factors apparent. Loss of pars at age 18 mos., although LGs report that ind ds not remember pars. No apparent physical/sexual abuse. LGs report that ind sleeps too much, approx. 14 hr/day if allowed. LGs report that ind overeats, altho ind's physical presentation ds not suggest this.

Ind is age-appro @ school, no apparent Mental Retardation or Learning Disorder. No developmental d/o apparent or reported. Disruptive bx at home only. No feeding issues, tics, communication, elimination problems apparent or reported. No delusions or hallucinations reported. LGs report that ind "drags around home"; low mood apparent. No reports of nightmares, phobias, anxiety bxs. No known neurological issues.

Related Issues:

LGs report inability to make age-appro friends.

Other History:

No prior Mental Health hx or known treatment. No known substance abuse history. Substance abuse questionnaire filled out by ind, LGs. No known falls, seizures, medications, allergies, surgeries, head injuries. Vaccines current. Wears glasses. Last physical: 6 mos previously. Last dental: 6 mos previously. No braces on teeth.

Developmental History:

Prenatal history unknown. Aunt believes ind was vaginal birth at normal 40 wks. No known history re: bio mom's stressors, use of substance, etc.

Ind met normal developmental milestones when living w/ LGs. Onset of speech, walking, crawling, etc. unknown.

Loss of pars at age 18 months. Inability to sustain positive relationship w/ cousin since placement w/ Aunt. No positive adult or peer relationships sustained. No known hobbies; Uncle reports that ind "lives in his own world." Poor impulse control & low moral development, as reported by aunt.

No relevant school history; ind is a B-level student in grades. No court or legal hx. No hx of child abuse reports or reported domestic violence in home. No Protective Services hx.

Current Setting:

Ind lives w/ biological Aunt & Uncle w/ same-age male cousin. Upper-middle-class SocioEconomic Status. Uncle has university education w/ business degree; Aunt has college education.

No reported hx of mental illness in Aunt's & ind's family, no legal issues in Aunt & ind's family.

Family/Ind Strengths:

Uncle: "We're decent, hard-working folk, not given to any freak stuff. All we want is a quiet home and we're willing to do whatever it takes."

Aunt: "We understand that our nephew would have had a poor upbringing, had his parents lived. We only want to model for him how a decent family behaves."

Ind: Refused to speak, but nodded when asked if he would attend weekly therapy sessions.

Family's Expectations of Treatment:

Family openly skeptical of potential effectiveness of therapy. Uncle states therapy is "for weaklings like my nephew." Ind presents as unwilling to participate in family sessions, but may tolerate individual sessions.

Family contracted verbally w/ therapist to bring ind for weekly meetings. School has set requirement of 20 sessions minimum. Ind's Public Health status confirmed; financial eligibility for sessions confirmed thru Public Services.

Mental Status Exam:

Ind presents as a white male of slightly smaller size than expected for age, unusually slender. Grooming appropriate, although clothing dishevelled, old, seemingly too large. Poor eye contact thruout interview, sagging posture, stared at floor, refused to speak to therapist, despite warnings from Uncle. Sighed often. Low impusivity apparent, no aggressiveness apparent.

When willing to speak, ind speaks in normal tone w/ age-appropriate vocabulary, no pressure or impediment, low volume.

No hallucinations/delusions apparent or reported. No expressed fears or concerns, but avoided contact w/ LGs by eye or speech.

No apparent lapses in attention, concentration. Thought process presents as within normal limits.

Ind oriented to place, name, time, reason for presence at session. No apparent cognitive dysfunction.

Low mood throughout session; LGs report this as "typical". Some irritability apparent in responses to LGs remarks.

No suicidality, intention or hx, reported or apparent. No homicidality, intention or hx, reported or apparent.

Ind presents as resistant to therapy, despite agreement to try. Seemingly poor insight, adaptive capacity, low motivation for treatment, possibly due to overall sense of hopelessness as visibly expressed thruout interview.

Summary & Formulation:

Axis One:

300.4 Dysthymic Disorder:

Ind presents as having low mood present for most of day, more days than not, for at least 1 year, as indicated by LGs. Ind reported to have inappropriate appetite, although ind appears to undereat & LGs claim he overeats. Low self-esteem, low energy. Feelings of hopelessness. Ind does not seem to have ever been without these sxs since age of 18 mos. No Major Depressive Episodes or manic Episodes evident or reported. Sxs cause impairment in home functioning and some distress at school.

313.81: Oppositional Defiant Disorder:

By LGs' report, ind has pattern of negativistic, hostile, and defiant bx, lasting more than 6 months, including frequent loss of temper, frequent arguing w/ LGs, refuses to comply w/ adult requests, deliberately annoys people, often angry & resentful, spiteful, & vindictive. Criteria not met for Conduct Disorder.

Axis Two:

V71.09 No diagnosis.

Axis Three:

No significant health issues reported.

Axis Four:

Bxs cause impairment in the following: social settings, home, school, ability to maintain peer relationships.

Axis 5:

60 out of 100: Moderate sxs.

Progress Note: October 1^st, 1989

Met w/ ind, LGs for first interview and to complete intake summary. See summary for details. LGs present as hostile towards ind, who responds w/ passive disinterest, hopelessness towards therapy & possibility of changes in family. No fam therapy at this time; ind will attend therapy alone. Referred for psychiatric evaluation, will consult w/ local psychiatrist re: antidepressants as appropriate. LGs presented also as v. anxious, easily startled when th's candy jar exploded for no apparent reason on shelf; ind also startled, but not as visibly. Uncle overbearing, many angry glances at ind, angry expressions while using inappropriately coaxing voice to prompt ind. Session terminated early, due to sounds of breaking glass throut building; fam, th evacuated w/ other staff.

Goals for therapy: Reduce ind's depressive sxs by teaching ind to recognize sxs, use appro coping skills to reduce negative feelings. Teach ind to appropriately express negative feelings at least 1x/wk w/ therapist.