CONFIDENTIAL PSYCHOLOGICAL EVALUATION
Patient Name: Roy Yuan Wang
Age: 18
Gender: Male
Date of Evaluation: [Insert date]
Referred by: Jackson Wang (Legal Guardian and Older Brother)
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Presenting Concerns:
Roy was referred by his older brother and legal guardian, Jackson Wang, after exhibiting persistent regressive behaviors, emotional detachment, and hypersensitivity to sensory input. Jackson reports a history of severe emotional neglect and physical abuse from Roy’s former caregivers, resulting in significant psychological and developmental regression.
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Developmental & Medical History:
• Early signs of classic autism noted before age 3: limited eye contact, delayed speech, repetitive movements, aversion to touch
• No formal diagnosis or early intervention services received due to familial neglect
• Raised in an unstable environment marked by prolonged emotional deprivation and possible physical harm
• Significant periods of social isolation; lacked consistent caregiving or nurturing relationships
• Recently placed under the full guardianship of Jackson Wang, who removed Roy from the abusive environment
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Observed Behaviors During Evaluation:
• Communicates minimally; frequently uses third-person language and childlike phrases (“Roy scared,” “No yell”)
• Exhibits trauma-linked regression: clings to soft items (stuffed animal, blanket), thumb-sucking, and rocking
• Becomes nonverbal and withdrawn during moments of stress or sensory overload
• Avoids direct physical contact unless initiated by a trusted figure (e.g., Jackson)
• Hyper-reactive to sound and touch; wears noise-canceling headphones when overstimulated
• Displays signs of emotional distress when separated from Jackson or placed in unfamiliar environments
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Cognitive and Emotional Functioning:
• Current emotional and relational functioning estimated at a 3–5-year-old developmental level
• Intact receptive language abilities, though expressive skills are limited by anxiety and regression
• Signs of dissociation when discussing or encountering triggering stimuli
• Severely impaired ability to form new social bonds, though shows trust and attachment toward Jackson Wang
• Demonstrates internal conflict between chronological age and regressed emotional state
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Diagnostic Impressions (Provisional):
1. Autism Spectrum Disorder, Level 2 (requiring substantial support)
• With high sensory sensitivity and communication challenges
2. Complex Post-Traumatic Stress Disorder (C-PTSD)
• Due to prolonged emotional neglect and physical abuse
• With dissociative features and emotional dysregulation
3. Trauma-Induced Developmental Regression
• Regressive behaviors used as coping mechanisms
• Emotional age inconsistent with chronological development
4. Rule Out: Reactive Attachment Disorder (Inhibited Type)
• Pending further evaluation of bonding patterns outside of primary guardian
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Recommendations:
• Continue guardianship and stable, trauma-informed caregiving under Jackson Wang
• Establish a predictable daily routine with limited sensory exposure and emotional safety cues
• Initiate trauma-informed therapy, including somatic work and attachment-based approaches
• Begin speech-language and occupational therapy to support regulated communication and sensory processing
• Provide alternative communication tools (visual aids, AAC device) when verbal communication is challenging
• Encourage supervised, slow social exposure to build trust beyond Jackson, if and when Roy is ready
• Reassessment recommended in 6–12 months to monitor therapeutic response and adaptive functioning
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Evaluator Name: Dr. Min Seo-jin, PhD
Title: Pediatric Clinical Psychologist
License #: [Fictional Number]
Signature: _________________________
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