Mental Status Examination

Mental Status Examination: This is a 10-year-old Caucasian male who looks age stated,
appearance is neat and clean, and dressed appropriately. He is restless and fidgety during the
interview. He did not answer questions directed toward him but instead would ask the
interviewer about specific cars. Upon response to the client’s question, he then proceeded to list
vehicle designs and comment the interviewer on her voice. Talking about cars, seemed to open
the client up, and his tone became more expressive, and eye contact more engaged. He knew he
did not make friends but was unsure of why. Unable to assess mood accurately due to limited
facial expressions and inability to describe his feelings. He denies SI, HI, hearing or seeing
things, or any kind of hallucinations. Denies sleep or issues with appetite.
Diagnostic Impression:
 Autism Spectrum Disorder (ASD) (F84.0)- To diagnose ASD, all of the five criteria
must be met including social communication deficits, fixated interests, and repetitive
behaviors consisting of four items including stereotyped or repetitive motor movements,
insistence on sameness, highly restricted, fixated interests that are abnormal in intensity
or focus, and hyper or hypo reactivity to sensory input or unusual interests in sensory
aspects of the environment, of which at least two must be met to satisfy this criterion;
symptoms existing in early childhood; symptoms impairing functioning; and impairments
are not better explained by intellectual disability or global developmental delay (APA,
2013). Based on the evidence of his persistent difficulties in social interaction and
communication, as well as the restricted patterns of behavior that have been presenting
from an early age, including his consistent daily routines and inability to change them,
his lack of eye contact and smiling, his non-verbal behaviors, his inability to form
relationships, his fixation on cars, the disturbances cause clinically significant
impairment in social functioning, as evidenced by his pronounced difficulties in social
interaction, absence of friendships, aggression, oppositional behaviors, and inflexibility
and/or rage in response to changes in routines, and the fact that he does not have a history
of clinically significant delay in language development, cognitive development, or
acquisition of other adaptive behaviors, provides enough criteria and makes the diagnosis
of ASD justifiable.
 ADHD Combined (F90.2)- According to the DSM-5, a diagnosis of ADHD is defined as
the presence of six or more specific symptoms occurring for at least six months of either
inattention, hyperactivity, or both (APA, 2013). Specific issues that can be seen with
ADHD include poor performance in school, behavioral problems, difficulty expressing
feelings or building relationships, and the inability to think correctly (Krull, 2019).

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