Assessment social history.xls

Assessment / Social History
Identifying Information
Presenting Problem, Onset and History of Problem Information pertaining to this assessment was gathered from the mother, client, and chart. Client is referred to IIH from case management due to demonstrating disrespectful behaviors towards peers and adults. The mother reports that client is exhibiting aggressive behaviors towards siblings, crying easily, anger outburts, screaming, name calling, hitting walls, and not listening. He is diagnosed with ADHD, Bipolar (NOS) and ODD. The mother reports that client was diagnosed with ADHD at age five by his primary care physician. He was diagnosed with ODD and Bipolar NOS within the last year by Dr. Reddy, since starting services with PCS. The mother reports that client seems more depressed with displays of anger outbursts for the last twelve months. Client exhibits poor self-care by not bathing or changig clothes unless prodded. Client is presently taking medication for ADHD and symptoms of Bipolar--Focalin, Depakote, and Seroquil.
Developmental, family of origin & marital hx., children The mother reports that the client was born early after 8 months of pregnancy. He was low birth weight at 5'11" and was juandice. She considers her health "not good" due to her consumption of alcohol, tobacco and drugs during the pregnancy. The client reached his developmental milestones at a normal rate at and appropriate stages. The client is the youngest of five children, born of Hispanic descent, as are his other four siblings. He lives in the house with his mother, her live-in boyfriend, an older brother (16) and a sister(15). Another brother (17) lives with the maternal grandmother. His oldest brother (18) was adopted at a very early age and did not have contact with the family until recently when he reached age 18. The client's siblings Francisco and Sonovia are diagnosed with mental health disorders as well as the mother and the client. Client is on Medicaid, and mother received TANF for him and SSI disability for herself.
Currently attends Laurel Park MS, 7th grade. Good attendance, as the mother states, "I make sure he goes to school." Had has a history of fighting in school--last year, per the mother.
Client reports that he likes to play video games and watch television. He did not identify any coping skills.
Current or previous treatment history: Identify current providers as well as services provided Services / Treatment Provided / Outcomes(including rehab., social services, etc.) Legal History (include past arrests, incarcerations, pending charges & if on P/P) Which court?_________________________________________ Mental Status: Indicate symptoms and describe below: Mother and client report eating more than usual and gaining weight as a result within the last 12 months. Client stays to himself a lot and shows anxiety in eating nails. Does not think of consequences when lashing out at siblings. Reports that concentration is difficult in the school setting.
Has anyone suggested client should cut down? Who suggested? ___________________________________ Has client ever been unable to remember what happened when he/she had used A/D? Has client ever lost time at work or been arrested because of drug or alcohol use? Has anyone in client's family had a drug or alcohol problem? If yes, who? How did it affect the client? Mother has history of drugs and alcohol. Separated from client for eight months (jail) as result of DUI charges. Mother admits to continual use of marijuana when away from the children. No alcohol use for the last six months.
Does client have other habitual problems? Client's insight and prognosis is poor. Lacks insight in decision making in dealing with siblings, peers and adults. Client fights and lashes out at others to solve problems. Exhibits poor insight into how his choices are having a negative impact on him. Additional information & recommendations Augustin is at risk of being removed from the home due to hostile and aggressive behaviors. The states states that she is experiencing difficulty handling the aggressive behaviors. Augustin experiences difficulty in functioning at home and in the school setting. There are major conflict issues between the two siblings and home and the mother. In home services are needed to confirm or rule out diagnosis of bipolar so that treatment can be prescribes. Augustin needs self-esteem building, anger management, stress management, behavior modification, and problem solving. Monitoring Augustin's functioning in the school setting and at home will be a case management goal, as well as continued assessment of needs.


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