The Adult Psychotherapy Progress Notes Planner. David J. Berghuis
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reflects significant concerns related to ADHD, and this was communicated to the client.The psychosocial assessment reflects minimal concerns related to ADHD, and this was reflected to the client.
4 Conduct/Refer for Psychological Testing (4)The client was administered psychological testing in order to establish or rule out the presence of an ADHD problem.Psychological testing has established the presence of an ADHD problem.The psychological testing failed to confirm the presence of ADHD.The psychological testing results were processed with the client to assist him/her/them in understanding his/her/their condition and to answer any questions that he/she/they might have.The client understood the explanation of the psychological testing and has accepted the presence of an ADHD problem.The client has denied the presence of ADHD and refused to accept the confirming results of the psychological testing; he/she/they were urged to be more open about this diagnosis.
5 Refer for Physician Assessment Regarding Etiology (5)The client was referred to a physician to rule out nonpsychiatric medical etiologies for his/her/their ADHD.The client was referred to a physician to rule out substance-induced etiologies for his/her/their level of ADHD.The client has complied with the referral to a physician and the results of this evaluation were reviewed.The client has not complied with the referral for a medical evaluation and was redirected to do so.
6 Process Medical and Psychological Evaluation (6)Results and recommendations of the medical evaluation were processed with the client and all questions were answered.The results and recommendations of the psychological evaluation were processed with the client and all questions were answered.As a result of the physician's evaluation, the client was prescribed medication to assist in the control of ADHD symptomatology.As a result of the psychological evaluation, the client was provided with several different techniques to assist in the control of ADHD symptomatology.
7 Hold a Conjoint Session to Give Evaluation Feedback (7)A conjoint session was held with the client and his/her/their significant others in order to present the results of the psychological and medical evaluations.All questions regarding the evaluation results were processed.The client's family members were solicited for support regarding his/her/their compliance with treatment for his/her/their ADHD symptoms.The client's family members were verbally reinforced as they gave strong support to the client regarding medical and psychological treatment for his/her/their ADHD symptoms.
8 Refer for Medication Evaluation (8)The client was referred to a prescribing clinician to evaluate him/her/them for psychotropic medication to reduce symptoms of ADHD.The client has completed an evaluation by the prescribing clinician and has begun taking ADHD medications.The client has resisted the referral to a prescribing clinician and does not want to take any medication to reduce ADHD levels; his/her/their concerns were processed.
9 Monitor Medication Adherence (9)The client has begun taking medications for ADHD symptoms and the side effects and effectiveness were processed.The client has struggled to adhere to regularly taking medication for ADHD symptoms and his/her/their concerns were processed.The client has not begun taking medications for ADHD symptoms and was redirected to do so.
10 Arrange Substance Abuse Evaluation (10)The client's use of alcohol and other mood-altering substances was assessed.The client was assessed to have a pattern of mild substance use.The client was assessed to have a pattern of moderate substance use.The client was assessed to have a pattern of severe substance use.The client was referred for a substance use treatment.The client was found to not have any substance use concerns.
11 Assess Level of Insight (11)The client's level of insight toward the presenting problems was assessed.The client was assessed in regard to the syntonic versus dystonic nature of his/her/their insight about the presenting problems.The client was noted to demonstrate good insight into the problematic nature of the behavior and symptoms.The client was noted to be in agreement with others' concerns and is motivated to work on change.The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.The client was noted to be resistant regarding acknowledgment of the problem areas, is not concerned about them, and has no motivation to make changes.
12 Assess for Correlated Disorders (12)The client was assessed for evidence of research-based correlated disorders.The client was assessed in regard to his/her/their level of vulnerability to suicide.The client was identified as having a comorbid disorder, and treatment was adjusted to account for these concerns.The client has been assessed for any correlated disorders, but none were found.
13 Assess for Culturally Based Confounding Issues (13)The client was assessed for age-related issues that could help to better understand his/her/their clinical presentation.The client was assessed for gender-related issues that could help to better understand his/her/their clinical presentation.The client was assessed for cultural syndromes, cultural idioms of distress, or culturally based perceived causes that could help to better understand his/her/their clinical presentation.Alternative factors have been identified as contributing to the client's currently defined “problem behavior,” and these were taken into account in regard to his/her/their treatment.Culturally based factors that could help to account for the client's currently defined “problem behavior” were investigated, but no significant factors were identified.
14 Assess Severity of Impairment (14)The severity of the client's impairment was assessed to determine the appropriate level of care.The client was assessed in regard to his/her/their impairment in social, relational, vocational, and occupational endeavors.It was reflected to the client that his/her/their impairment appears to create mild to moderate effects on the client's functioning.It was reflected to the client that his/her/their impairment appears to create severe to very severe effects on the client's functioning.The client was continuously assessed for the severity of impairment, as well as the efficacy and appropriateness of treatment.
15 Identify Difficult ADHD Behaviors (15)The client was assisted in identifying the specific ADHD behaviors that have caused him/her/them the most difficulty.The client was supported as he/she/they listed such things as distractibility, lack of concentration, impulsivity, restlessness, and disorganization as the most difficult for him/her/them.The client was assisted in identifying specific behaviors that will be treatment targets.The client was resistive to becoming specific about identifying ADHD behaviors that cause him/her/them the most difficulty; he/she/they were encouraged to do this as he/she/they feel capable.
16 Review Evaluation Results (16)The results of the psychological testing and physician's evaluation were reviewed again with the client in order to assist him/her/them in the choice of his/her/their most difficult, problematic behaviors to address in counseling.The client was assisted in selecting those behaviors that are most difficult as focal points for treatment.The client was supported as he/she/they agreed to concentrate his/her/their efforts to change on these most difficult behavior areas.
17 Direct Family to Rank Client's Behaviors (17)The client was asked to request family members to complete a ranking of the three behaviors that they perceive as those that interfere the most with the client's daily functioning.Family members have ranked the client's behavior and have identified those three behaviors that they perceive to be the most problematic for the client; these were processed with the client.It was noted that the client's family has refused to cooperate with ranking his/her/their behaviors and would not provide such a list for him/her/them.The client has failed to ask for the family's participation in his/her/their treatment and has not asked them to rank his/her/their problematic behaviors; he/she/they were asked to get this feedback.
18 List Negative ADHD Consequences (18)The client was asked to make a list of the negative consequences that result from his/her/their problematic ADHD behaviors.The client was assigned “Impulsive Behavior Journal” in the Adult Psychotherapy Homework Planner (Jongsma).The list of the negative consequences that result from ADHD behaviors was processed to increase the client's awareness of the impact of his/her/their behavior on self and others.Coping strategies were reviewed that could be implemented as alternatives to the problematic ADHD behaviors that produce negative consequences.The client was guarded about making a list of the negative consequences that result from his/her/their problematic ADHD behaviors and was gently offered examples in this area.
19 Engage Significant Other (19)The client was directed to invite a significant other to participate in the therapy.The significant other was trained to help