Preview
FILED: NEW YORK COUNTY CLERK 12/12/2022 02:38 PM INDEX NO. 154880/2018
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 12/12/2022
PsychiatricEvaluation
JCCA-Edenwald
Name: Frank Rosa
DOB: 5/29/2004
DOAssessment: 7/30/2020
Reason for Referral:To provide Psychiatric Assessment for this16 year old male who was recently
admitted to the JCCA Edenwald Center RTC Program.
Source of Information: Interview with Frank , review of historicalinformation provided upon admission.
Frank was receivingoutpatient behavioral health treatment through the JCCA inthe Bronx since 2012
(afterbeing placed in FosterCare) and had been under the Psychiatriccare of Dustin Von Holten, PNP
for atleast the past year.Collaborative information from Cottage Staffin regards to clinical/behavioral
statusduring the initial
portion of hisEdenwald admission.
History of Present Illness:Frank began becoming physically aggressive during early childhood
(approximately 6 y/o).He also began to engage inself-harm. He had been referred for evaluation
severaltimes at the Bellevue Hospital ER but was not admitted. He was admitted to Mount Sinai
Hospital (9/19/2012 to 10/9/2012) after he threatened to kill
his biologicalmother, and caretaker at
that time, Ms. Janet Vega. A case was called into ACS against Miss Vega by staffafter Frank reported
excessive corporal punishment. He was noted to have bruises, welts and lacerationson his body, and
was reportedly not receiving regular medical care.Miss Vega signed a voluntary placement agreement
on 10/9/2012 due toher inabilityto control Frank's behaviors. He was placed in Foster Care at that time
and began receiving outpatient treatment through the JCCA. He was trialdischarged back to Ms. Vega
on 8/28/2014 but thisfailed, and he returned to Foster Care. A second trialdischarge was attempted on
4/25/2016 but this also failed.
He was transferred to St.Christopher RTC (SCO).
Ottillie Frank was
reportedly sexually molested 3 timeswhile there (sodomy) which led to him returning to Foster Care. A
3d
failedtrialdischarge to Miss Vega occurred on 6/5/2019, after which he returned to treatment
through the JCCA.
Frank was referred for residentialtreatment due to escalation of emotional/behavioral compromises
within the fostercare settingover the past year.He has extremely poor frustration tolerance, is highly
anxious, triggerseasily,becomes aggressive and violent.This has been hisemotional/behavioral pattern
throughout hishistory, but due toescalation itwas determined that referralto thisresidential setting
was indicated.
There is noreported history of psychosis, delusional content.
JCCA 2971
FILED: NEW YORK COUNTY CLERK 12/12/2022 02:38 PM INDEX NO. 154880/2018
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 12/12/2022
Frank has been subjected to physical/sexual traumas inthe past, as noted above. He does endorse
sxs/signs of PTSD inrelationto people touching him, as wellas the NYPD. In relationto the latterwhen
he has become dysregulated in the past the NYPD were often called and on at leastone occasion itwas
required that they physically restrain him. He reports sxs within re-living,hyperarousal, avoidance in
relationto anything having to do with them and that seeing that uniform "sets him off",
Psychiatric History: Frank had been diagnosed with Autism Spectrum Disorder at age 5.He has been
evaluated by multiple Providers across the spectrum of behavioral health settings.Diagnoses include
ASD, ADHS, Social Communication Disorder.
Multiple Psychiatric Hospital admissions since 2012.
" Mount SinaiHospital (9/19/2012 to due to agitated behaviors, threats to
10/9/2012) making
stab/killhis mother, aggression towards school staff.Case against mother called by ACS and he
was discharged to Foster Care
" Metropolitan Hospital (9/2014) due tohomicidal ideation
" Metropolitan Hospital due tohomicidal ideation
(10/2014)
" Four Winds Hospital (9/9/2015 to 10/2/2015) due to self-injuriousbehaviors, such as head
banging, aggression, threats. Discharged prescribed Seroquel, Clonidine
" Metropolitan Hospital 2X (7/2016 to 8/2016) for aggression, threats
" He has been hospitalized in 2019/20 but specificsof such were not available to thisMD at the
time of this report.
Medication trialsinclude Seroquel, Clonidine, Risperdal,Abilify,as well as current medication regimen.
Medical History:
" Eye surgery 2013 to correctstrabismus inhis lefteye
" Congential pes planus with leg length disparity,treated with orthotics/lifts
" Asthma
" Scoliosis
" Born premature at 7 months and was in incubator for 2 weeks
Social/Family History:
" Father deceased secondary to lung cancer
" Mother (Ms. Vega) has a history of depression, anxiety.
Cognitive History:
JCCA 2972
FILED: NEW YORK COUNTY CLERK 12/12/2022 02:38 PM INDEX NO. 154880/2018
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 12/12/2022
" Has received speech-language therapy, occupational therapy, individualcounseling inschool
through an IEP
" Completed a Psychological eExam through JCCA on 11/6/2012 and 2/2/2013 and was assessed
to have a FSIQ of 65.
" Completed a second Psychological Exam through JCCA on 6/2/2016 which was c/w the firstand
assessed a FSlQ of 64.
Mental Status Exam:
Frank presents as a well-developed, well-nourished adolescent who appears hisstated age and is
dressed appropriately for setting/season. Mild limp.Good ADLs, good hygiene. No evidence of a
movement disorder. A/O x 2(name, place). He presented as mildly anxious and hyperkinetic and as
interview progressed these would elevate when asked to discuss hishistoricalpast. Attimes became
overwhelmed, rocking in hisseat,pulling at hishair,yelling,and expressing sensation that he was "going
crazy". Did respond over 2-3 minutes as thisMD moved the discussion to a lesstriggering topic and
allowed him to re-integrate. He expressed clear post-traumatic triggersand experiences within the re-
living,avoidance, hyperarousal realms. Superficiallyrelated, fairand inconsistenteye contact. No sign of
internal preoccupation. Distractibility
noted, with fairabilityto be redirected. Fund ofknowledge does
not meet age/educational expectations. Spoke ina well-modulated voice when calm. Speech is
spontaneous. Speech is fluent,
with fluctuating rate, rhythm, volume depending on level of
distress/anxiety. Mood fluctuated from euthymic to anxious. Affectfluctuated from constricted to labile
but was mood congruent. Thought process is concrete. Denies AVH, Sl/HI and contracts for safety.
Judgment and insight are poor by history. Impulse control is poor.Immediate memory 3/3, after5
minutes 1/3. His wishes are to "get out of thisplace and go home".
Current Medications:
" Zoloft75 mg po QD for anxiety
" Klonopin 1.5 mg po BlD for anxiety
" Guanfacine ER 2 mg po BlD for ADHD sxs (impulsivity,hyperkinesis, inattentiveness)
" Depakote 250 mg po TID foremotional/behavioral dyscontrol, aggression
" Thorazine 25 mg po TlD for aggression
Diagnostic Formulation: Frank Rosa is a 16yearold male diagnosed with Autism, ADHD, Social
Communication Disorder. He has a history of subjection to physical/sexual abuses thatclearly have
promoted post-traumatic sequelae and meets criteriafor Post-Traumatic Stress Disorder. As is common
with those diagnosed with ASD he exhibits emotional/behavioral dysregulation, inabilityto cope with
perceived stressors. In relationto Frank these characteristics are on the severe end ofthe behavioral
spectrum, whereby he has engaged inaggressive/violent/threatening/self-injurious behaviors. Response
to meds has been variable. He is hyperkinetic/impulsive/distractible even when ina calm state and
meets criteriafor ADHD, combined presentation. At present this MD is not able tovalidate past
diagnosis of Social Communication Disorder but itwill be included in Diagnostic profile as itis evaluated
JCCA 2973
FILED: NEW YORK COUNTY CLERK 12/12/2022 02:38 PM INDEX NO. 154880/2018
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 12/12/2022
further. Diagnosis of IntellectualDisabilityis includeddue toIQ and significantadaptive functioning
deficits.
Diagnostic Impression:
" Autism Spectrum Disorder (F84.0)
" Intellectual mild
Disability, (F70.0)
" Post-Traumatic Stress chronic
Disorder, (F43.10)
" Social (Pragmatic) Communication Disorder (F80.89)
" Unspecified Anxiety Disorder (F41.9)
Recommendations:
" Medication management: Continue admission meds and monitor for efficacy,adverse effects.
Changes willadhere to prescribing guidelines and indication
clinical
" Medical: Assessment and management of medical needs and indicatedfindings
" Academic: Enrollment and participationinacademic program that meets Anthony's abilitiesand
needs
" Therapeutic: Engagement inindicudual psychotherapy
Richard Zodda, MD
RICHARD ZODDA MD
JCCA Edenwald Child/Adolescent Psychiatrist
NYS LICENSE # 234352
DEA # BZ9127754
NPI # 1871612788
JCCA 2974
Preview
FILED: NEW YORK COUNTY CLERK 12/12/2022 02:38 PM INDEX NO. 154880/2018 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 12/12/2022 PsychiatricEvaluation JCCA-Edenwald Name: Frank Rosa DOB: 5/29/2004 DOAssessment: 7/30/2020 Reason for Referral:To provide Psychiatric Assessment for this16 year old male who was recently admitted to the JCCA Edenwald Center RTC Program. Source of Information: Interview with Frank , review of historicalinformation provided upon admission. Frank was receivingoutpatient behavioral health treatment through the JCCA inthe Bronx since 2012 (afterbeing placed in FosterCare) and had been under the Psychiatriccare of Dustin Von Holten, PNP for atleast the past year.Collaborative information from Cottage Staffin regards to clinical/behavioral statusduring the initial portion of hisEdenwald admission. History of Present Illness:Frank began becoming physically aggressive during early childhood (approximately 6 y/o).He also began to engage inself-harm. He had been referred for evaluation severaltimes at the Bellevue Hospital ER but was not admitted. He was admitted to Mount Sinai Hospital (9/19/2012 to 10/9/2012) after he threatened to kill his biologicalmother, and caretaker at that time, Ms. Janet Vega. A case was called into ACS against Miss Vega by staffafter Frank reported excessive corporal punishment. He was noted to have bruises, welts and lacerationson his body, and was reportedly not receiving regular medical care.Miss Vega signed a voluntary placement agreement on 10/9/2012 due toher inabilityto control Frank's behaviors. He was placed in Foster Care at that time and began receiving outpatient treatment through the JCCA. He was trialdischarged back to Ms. Vega on 8/28/2014 but thisfailed, and he returned to Foster Care. A second trialdischarge was attempted on 4/25/2016 but this also failed. He was transferred to St.Christopher RTC (SCO). Ottillie Frank was reportedly sexually molested 3 timeswhile there (sodomy) which led to him returning to Foster Care. A 3d failedtrialdischarge to Miss Vega occurred on 6/5/2019, after which he returned to treatment through the JCCA. Frank was referred for residentialtreatment due to escalation of emotional/behavioral compromises within the fostercare settingover the past year.He has extremely poor frustration tolerance, is highly anxious, triggerseasily,becomes aggressive and violent.This has been hisemotional/behavioral pattern throughout hishistory, but due toescalation itwas determined that referralto thisresidential setting was indicated. There is noreported history of psychosis, delusional content. JCCA 2971 FILED: NEW YORK COUNTY CLERK 12/12/2022 02:38 PM INDEX NO. 154880/2018 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 12/12/2022 Frank has been subjected to physical/sexual traumas inthe past, as noted above. He does endorse sxs/signs of PTSD inrelationto people touching him, as wellas the NYPD. In relationto the latterwhen he has become dysregulated in the past the NYPD were often called and on at leastone occasion itwas required that they physically restrain him. He reports sxs within re-living,hyperarousal, avoidance in relationto anything having to do with them and that seeing that uniform "sets him off", Psychiatric History: Frank had been diagnosed with Autism Spectrum Disorder at age 5.He has been evaluated by multiple Providers across the spectrum of behavioral health settings.Diagnoses include ASD, ADHS, Social Communication Disorder. Multiple Psychiatric Hospital admissions since 2012. " Mount SinaiHospital (9/19/2012 to due to agitated behaviors, threats to 10/9/2012) making stab/killhis mother, aggression towards school staff.Case against mother called by ACS and he was discharged to Foster Care " Metropolitan Hospital (9/2014) due tohomicidal ideation " Metropolitan Hospital due tohomicidal ideation (10/2014) " Four Winds Hospital (9/9/2015 to 10/2/2015) due to self-injuriousbehaviors, such as head banging, aggression, threats. Discharged prescribed Seroquel, Clonidine " Metropolitan Hospital 2X (7/2016 to 8/2016) for aggression, threats " He has been hospitalized in 2019/20 but specificsof such were not available to thisMD at the time of this report. Medication trialsinclude Seroquel, Clonidine, Risperdal,Abilify,as well as current medication regimen. Medical History: " Eye surgery 2013 to correctstrabismus inhis lefteye " Congential pes planus with leg length disparity,treated with orthotics/lifts " Asthma " Scoliosis " Born premature at 7 months and was in incubator for 2 weeks Social/Family History: " Father deceased secondary to lung cancer " Mother (Ms. Vega) has a history of depression, anxiety. Cognitive History: JCCA 2972 FILED: NEW YORK COUNTY CLERK 12/12/2022 02:38 PM INDEX NO. 154880/2018 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 12/12/2022 " Has received speech-language therapy, occupational therapy, individualcounseling inschool through an IEP " Completed a Psychological eExam through JCCA on 11/6/2012 and 2/2/2013 and was assessed to have a FSIQ of 65. " Completed a second Psychological Exam through JCCA on 6/2/2016 which was c/w the firstand assessed a FSlQ of 64. Mental Status Exam: Frank presents as a well-developed, well-nourished adolescent who appears hisstated age and is dressed appropriately for setting/season. Mild limp.Good ADLs, good hygiene. No evidence of a movement disorder. A/O x 2(name, place). He presented as mildly anxious and hyperkinetic and as interview progressed these would elevate when asked to discuss hishistoricalpast. Attimes became overwhelmed, rocking in hisseat,pulling at hishair,yelling,and expressing sensation that he was "going crazy". Did respond over 2-3 minutes as thisMD moved the discussion to a lesstriggering topic and allowed him to re-integrate. He expressed clear post-traumatic triggersand experiences within the re- living,avoidance, hyperarousal realms. Superficiallyrelated, fairand inconsistenteye contact. No sign of internal preoccupation. Distractibility noted, with fairabilityto be redirected. Fund ofknowledge does not meet age/educational expectations. Spoke ina well-modulated voice when calm. Speech is spontaneous. Speech is fluent, with fluctuating rate, rhythm, volume depending on level of distress/anxiety. Mood fluctuated from euthymic to anxious. Affectfluctuated from constricted to labile but was mood congruent. Thought process is concrete. Denies AVH, Sl/HI and contracts for safety. Judgment and insight are poor by history. Impulse control is poor.Immediate memory 3/3, after5 minutes 1/3. His wishes are to "get out of thisplace and go home". Current Medications: " Zoloft75 mg po QD for anxiety " Klonopin 1.5 mg po BlD for anxiety " Guanfacine ER 2 mg po BlD for ADHD sxs (impulsivity,hyperkinesis, inattentiveness) " Depakote 250 mg po TID foremotional/behavioral dyscontrol, aggression " Thorazine 25 mg po TlD for aggression Diagnostic Formulation: Frank Rosa is a 16yearold male diagnosed with Autism, ADHD, Social Communication Disorder. He has a history of subjection to physical/sexual abuses thatclearly have promoted post-traumatic sequelae and meets criteriafor Post-Traumatic Stress Disorder. As is common with those diagnosed with ASD he exhibits emotional/behavioral dysregulation, inabilityto cope with perceived stressors. In relationto Frank these characteristics are on the severe end ofthe behavioral spectrum, whereby he has engaged inaggressive/violent/threatening/self-injurious behaviors. Response to meds has been variable. He is hyperkinetic/impulsive/distractible even when ina calm state and meets criteriafor ADHD, combined presentation. At present this MD is not able tovalidate past diagnosis of Social Communication Disorder but itwill be included in Diagnostic profile as itis evaluated JCCA 2973 FILED: NEW YORK COUNTY CLERK 12/12/2022 02:38 PM INDEX NO. 154880/2018 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 12/12/2022 further. Diagnosis of IntellectualDisabilityis includeddue toIQ and significantadaptive functioning deficits. Diagnostic Impression: " Autism Spectrum Disorder (F84.0) " Intellectual mild Disability, (F70.0) " Post-Traumatic Stress chronic Disorder, (F43.10) " Social (Pragmatic) Communication Disorder (F80.89) " Unspecified Anxiety Disorder (F41.9) Recommendations: " Medication management: Continue admission meds and monitor for efficacy,adverse effects. Changes willadhere to prescribing guidelines and indication clinical " Medical: Assessment and management of medical needs and indicatedfindings " Academic: Enrollment and participationinacademic program that meets Anthony's abilitiesand needs " Therapeutic: Engagement inindicudual psychotherapy Richard Zodda, MD RICHARD ZODDA MD JCCA Edenwald Child/Adolescent Psychiatrist NYS LICENSE # 234352 DEA # BZ9127754 NPI # 1871612788 JCCA 2974