PSYCHOLOGICAL REPORT BY ADJUSTMENT AREAS

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The following report contains relevant information about the consultant, obtained in a process of
psychological assessment is presented by areas of personal adjustment, relevant for the
Establishment of a psychological intervention plan according to the individual needs of the
patient.

EVALUATED DATA:
Nombre
Document:
Place of Birth:
Date of Birth:
Age:
Sex
Address:
Degree of Study:
Evaluation date:

EVALUATOR DATA:
Viviana Carolina Pérez Andrade
(ID) 1026579622 from Bogotá
Profession: Psychologist
Professional Card: 179502 of the Colombian College of Psychologists

I. REASON FOR CONSULTATION:

The patient's maternal figure requests a psychological evaluation process.

II. PSYCHOLOGICAL CHARACTERISTICS:

Throughout the psychological evaluation process, the 23-year-old user shows physical appearance.
You, your clothing is clean and appropriate for your life cycle. You enter the consultation in a lucid and alert state.
The allopsychic and autopsychic orientations are preserved. At the motor level, he is agile and does not
no apparent abnormalities or difficulties are found, their gait is fast and steady.
Emotionally, the user reports fluctuations between a euthymic state and sadness. It is even
It is possible that the user has a presumed alexithymic trait (inability to express emotions)
emotions) a trait that prevents him from expressing his emotions fluently. These characteristics being
psychological aspects consistent with their current cognitive psychopathology.
He responds to questions simply compared to his chronological age. He is in
the ability to describe facts, places, situations, and objects from their daily life in a
simple. At the same time, difficulties are identified around executive functions in the different
associated processes; such as anticipation of behaviors, planning, time estimation
ability to estimate the passage of time and the duration of an event or
activity); In
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 PSYCHOLOGICAL REPORT BY ADJUSTMENT AREAS

relationship to the recognition and awareness of everyday situations that involve a moral judgment,
a slight failure in self-recognition is identified in the recreation of the
future consequences of their actions.

III. PERSONAL AREA:

In relation to self-schemas, the consultant finds it difficult to arrive at associations of themselves that
involve the use of metacognitive processes, such as short, medium, and long-term projections
deadline. When it comes to self-recognition, it is difficult for them to arrive at answers quickly. It is defined
as respectful, collaborative, and shy. At the same time, self-care guidelines are identified.
preserved, evidencing basic daily living activities such as, 'bathing, brushing one's teeth'
teeth, to dress, to eat.
The consultant self-references as a person who has a limitation, stating 'I have'
difficulties in my way of thinking, especially when it comes to numbers
the consultant addresses this topic verbally expressing that they have a cognitive disability, acknowledges
general aspects of the diagnosis and describes them simply, highlighting their difficulties.
time to do mental arithmetic, money management (the consultant has managed a
maximum amount of $20,000), hold conversations with their peers especially figures
feminine.
Regarding the sense of self-efficacy, a poor processing of it is identified since
the consultant verbalizes that "they cannot do many things", due to their way of thinking,
therefore he states that he would like to feel "more useful," it is evident that, despite having the
training and knowledge in computer equipment repair, has never attempted to repair
some equipment or work in the environment, as it states that, "it can damage some equipment," he expresses not
to feel secure even in the ability to apply what has been learned in the vocational training that
received. The feeling of insecurity transfers from different areas of your daily life, such as the
interpersonal, intrapersonal, academic and work-related.

IV. FAMILY AREA – FAMILY SYSTEM GENOGRAM.

 PSYCHOLOGICAL REPORT BY ADJUSTMENT AREAS

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The subject index is part of a nuclear family consisting of four members where he
occupies the last place in chronological order in the fraternal filial system, it is evident that it is a
nuclear family structure, with children aged between 28 and 23 years.
Regarding the subject's relationship with their parental figures, it reports a very
close to her adoptive mother figure, who is the person in the family system with whom she is most
shares time with his adoptive father figure reports a good and close relationship, he
evidence of the consulting person's parental figures as a support network in the face of situations
daily. On the other hand, the consultant reports that the relationship with his stepbrother is conflictive,
since it is reported that 'sometimes he doesn't treat him well,' due to his cognitive condition, making
hurtful comments related to their mental processing of situations. In turn, the
The consultant indicates that the relationship with their nephews has always been good and close.
they state that they spend their free time playing, in the same way they verbalize that before
present the allegations of touching his nephews, his sister-in-law (despite knowing his
(cognitive condition), she was tasked with picking up the children from school and taking them home.
The family history shows that the index subject was adopted on the day of birth, the mother
current adoptive, verbalizes that the biological mother of the consultant 'gave him away' and never returned
to know about the biological parents of the index subject, therefore, from there the members of the system.
They welcomed him and raised him like a son alongside his older stepbrother.

V. SOCIAL AREA

Social skills such as greeting, introducing oneself, listening, expressing gratitude, saying goodbye,
"follow instructions, apologize" are preserved.
Deficiencies are identified in the acquisition and use of other social skills such as
hold and initiate conversations, participate, give their opinion, give instructions, ask questions,
making a compliment, refers that the difficulty is greater when it comes to female figures
contemporaries, he recognizes that when it comes to contemporary male figures, he does not find it so difficult.
because it is easier for him to find topics of conversation with men.
Due to this, he finds it difficult to establish lasting social relationships, he states that throughout his cycle
Vital has only had one friend, he states that they became friends because both he and his...
friends were excluded from the group. Throughout his life he has been excluded from social groups to the
which it belongs.

VI. ACADEMIC AREA

In relation to his academic history, despite his cognitive psychopathology, he has been educated.
in public regular education schools, therefore, the support for their cognitive condition
has been what has been offered to him in the educational centers. Throughout his evolutionary cycle, he has been
difficulty in processing mathematical reasoning and arithmetic areas, resolution of
problems that require the use of these skills, shows difficulties in handling the
money, since it is a skill that despite his chronological age he has not acquired. The
The consultant reads without commissions or omissions; despite their psychopathology, they manage to read fluently.
He completed secondary education without major difficulties compared to his
cognitive condition.
He received vocational training in systems, stating that the difficulty in processing
numerical and arithmetic remains the same, however, he managed to finish and later
 PSYCHOLOGICAL REPORT BY ADJUSTMENT AREAS

to graduate from this training cycle. Currently, the admission process is underway.
at SENA, to study the technical labor program in Network Management, however, is

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waiting for the interview with the psychology department there, as it requires a
curricular flexibilization process according to their cognitive needs.
VII. AFFECTIVE AREA
In relation to recognizing their emotions and feelings, the user has difficulties.
because he is unable to explicitly narrate his own emotional processes. When he
explores the emotional area, the client recognizes basic emotions such as anger,
sadness, happiness, surprise, and fear, however, when it comes to consolidating emotional stimuli in
cognitive associations, he/she is unable to evoke them in accordance with his/her chronological age, reaches to
simple analysis of their emotional state, revealing deficiencies in the recognition of the
auto-schemas, especially self-concept and self-esteem, which trigger predominance
of feelings of sadness and rejection, reported by the consultant repeatedly. Due to
the difficulties of social adaptation that have been present throughout their life cycle,
the consultant has not managed to establish emotional bonds with their peers.
VIII. SEXUAL AREA
Regarding the recognition of sexuality, the consultant simply expresses some
general aspects, such as sexual orientation, as they verbalize 'I like women'
It also states that guidelines for care should be followed when being sexually active with another person.
person, expressing the importance of using condoms to prevent diseases of
sexual transmission, however, it is difficult for them to infer that the condom prevents pregnancies, just as
There is difficulty in mentioning sexually transmitted diseases, stating that they do not know.
the names of them and the consequences.
On the other hand, the consultant mentions the parts of the female and male reproductive system,
however, when investigating the functionality of each part, the consultant does not succeed
to respond.
The consultant reports not having started a sexual life, he has no knowledge about what it is.
erection, ejaculation, an orgasm or similar concepts of sexuality, which are consistent with
subjects with their chronological age. However, it has started the stage of exploring their
genitals reaching masturbation.

IX. BIOLOGICAL AREA

The consultant has the diagnosis of: (Other developmental disorders of skills
schoolchildren), in the latest application of the Wechsler Intelligence Scale for Children WISC-R obtained
a total IQ score of 71, which is consistent with a diagnosis of
borderline intellectual capacity. Currently, there is no pharmacological management or comorbidities.

X. WORK AREA:
The consultant states that the only job he has had is as a construction helper, his duties
were related to assistance in the activities of the work, specifically moving
heavy objects from the work, such as bricks, bundles, and tools.
Despite having a vocational training in systems, the consultant has never worked in.
the repair of computer equipment, the consulting person states that they do not feel confident to start
private repair.
The consultant does not have a consolidation of their resume, they have never received guidance on it.
area, as well as having never had a job interview, in accordance with the skills
 PSYCHOLOGICAL REPORT BY AREAS OF ADJUSTMENT

lacking social skills, it is identified that currently the abilities must be enhanced
speech for the interview. He has never been employed in a formal company.

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XI. DIAGNOSIS

The consultant attends the psychological assessment, with a medical history of management by psychiatry.
currently not medicated, also attends with the results of the battery of
Wechsler Intelligence Scale for Children-Revised obtained a total IQ score of 71.
And, assist with the following diagnoses.

a) (F818) Other disorders of the development of school skills

b) Borderline intellectual ability –(IQ: 71)

XII. RELEVANT FINDINGS

a) The applicant is not in a position to see himself as a person of his age.

chronological (23 years), due to the difficulties she has in recognizing and analyzing the
moral judgments and the future consequences of their actions may be presented as vulnerable
in front of the different contexts.
b) The consultant does not have all the processes of autonomy and independence developed.
expected for their chronological age, such as money management and activities that
they involve cognitive associations of planning, execution, anticipation, for example,
taking a bus alone, buying something at the supermarket or everyday activities
that are acquired in early adulthood.
The consultant has mild difficulties in the use of executive functions.
especially anticipation of behaviors, planning, time estimation
(ability to calculate approximately the passage of time and the duration of a
event or activity)
d) Shortcomings are identified in the acquisition and use of social skills such as
hold and start conversations, participate, give your opinion, give instructions, formulate
questions, give a compliment, refers that the difficulty is greater when it comes to figures
contemporary females, showing deficiencies in social adaptation with their peers.
e) Regarding the establishment of emotional bonds, the consultant has not at this date
established lasting emotional ties, nor social relationships with people other than
the members of your family system, this deficiency being consistent with the one stated
previously.
f) The consultant has poor knowledge of the themes of sexuality according to
expected for his chronological age (23 years).
g) The consultant has never formally worked in a company, as of the date he does not have
resume, nor does he know the basic aspects for a job interview. An aspect that
considerably impacts their sense of self-efficacy, due to the time
he uses it while at home.

SUGGESTIONS
 PSYCHOLOGICAL REPORT BY ADJUSTMENT AREAS

The consultant must have interdisciplinary professional and family support.

permanent to increase their levels of functionality since having poor judgment
of everyday moral dilemmas, as well as having shortcomings in the processes of
basic autonomy may be subject to contextual and social conditions, without being
aware of

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his actions. A neuropsychological support should be provided to strengthen the

executive functions that present deficiencies.

2. Psychotherapeutic support is necessary for the strengthening of the following aspects:

Emotional and affective area: Prevention of the onset of any mood disorder
mood, specifically depression or similar.
Social area, personal: Training in the acquisition of basic social skills and
advanced, strengthening the discourse for academic and work contexts.
Strengthening individual processes, such as self-concept, self-esteem, self-efficacy,
self-assessment, self-respect among others. Work must be done on the development of the processes of
independence and personal autonomy for the performance of basic activities, such as
moving from one place to another alone, managing money and other associated activities.
Sexual area: Psychoeducation about the axes of sexuality (physical, emotional, and cognitive)
Work Area: Psychoeducation in immersion into the labor world, writing of resumes,
management of virtual job portals, development in a job interview.
Academic area: A special education assessment is necessary, as well as to make
contact with the professionals in charge of SENA, in order to identify if it is done
necessary a curricular flexibility according to their cognitive abilities. Likewise, it would be
it is relevant to reapply the Wechsler intelligence scale for
adults-IV (WAIS-IV), in order to identify the current status of the competencies it evaluates
the test, since the results available are over 5 years old.

Report Prepared by:

Viviana Carolina Pérez Andrade

Psychologist UCC.
TP. 179502