Comprehensive Client Family Assessment

Comprehensive Client Family Assessment

Presenting problem

Mother reports that she and J.S’s father separated in October of 2015. She reports J.S wishes for her and his father to reunite and get back together. She believes that he could benefit from additional support with understanding the separation of his parents. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room). Mother reports J.S talks to her, but is uncertain if he has any suppressed thoughts or feelings. She shared that J.S’s father was recently on the phone with a women while he was visiting. Mother reports since this J.S has been having a lot of questions about whether his parents will be together again and whether they have other significant relationships. She shared that she wants J.S to understand the concept of his parents being apart.

 

History or present illness

Mother reports onset of Jayden’s behavior occurred in 2015 when her and Jayden’s father separated.

 

Past psychiatric history

Mother reports none

 

Medical history

Mother reports none.

 

Substance use history

Mother reports none.

 

Developmental history

Mother reports no delays.

 

Family psychiatric history

Mother reports anxiety and depression on both J. S’s paternal and maternal side of family. Father is struggling with addiction.

 

Psychosocial history

J.S reports having a lot of friends. He reports getting along with his friends.

 

History of abuse/trauma

Mother reports none.

 

Review of systems

 

Gen:  Denies weakness, fatigue, fever, chills, night sweats, heat intolerance.

Head: normocephalic; denies migraine headaches.

ENT: Denies visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty

Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes. Cardiopulmonary: Denies cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, hypertension.

GI: Negative for decreased appetite. Neg for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.

GU: No dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.

MS: Denies backache, joint pain, stiffness. Gait is normal and steady.

Heme/Skin: Denies bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.

Neuro: Denies seizures, paralysis, muscle weakness, parasthesia, sensation changes.

Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.

 

 

 

Physical assessment

Vital Signs:

47 Height: inches

Weight: 115lbs

Temp: 37 C.

RR: 16

BP: 110/62

Pulse: 82 BPM

Appearance: Slender bi-racial male, slightly tan, appearing younger than stated age in   distress, no acute distress, neatly dressed and groomed.

 

Mental status exam

 

J.S presents to the appointment with his mother. He alert and oriented x4. Neurologically intact. J.S. is neatly dressed. Polite mannerism and very social. Mood and affect is euthymic and appropriate. J.S. is comfortable interviewing with therapist while mother steps out. He seems to like talking to therapist and asks many questions about games, books, etc. that are present in the room. J.S. denies any SI/HI or A/V/H. Speech is coherent and clear. J.S. fidgets with his hands during interview and processed better after therapist offered Play-Dough to figet with instead.

 

 

Differential diagnosis

Z63.5 Disruption of family by separation and divorce

Diagnosis

 

Seperation and Anxiety Disorder

 

Case formulation

 

Mother reports that her and J.S’s father separated in October of 2015. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room).

 

J.S attended session with his mother. He completed a Basic Emotion Assessment indicating mixed emotions (sad, angry, happy, excited). J.S rated sadness as a 4 on a scale from 0-5 with 5 indicating very sad. Jayden explained, “I am sad that my dad does not live with me anymore.” He reported that he is happy and excited because he will be going to his grandmother’s home for the summer.

 

According to the American Psychological Association (2013), diagnosis assigned to individuals who have an unusually strong fear or anxiety to separating from people they feel a strong attachment to. The diagnosis is given only when the distress associated with the separation is unusual for an individual developmental level, is prolonged and severe. In accordance with J.S.’s intake assessment and individual therapy session, he fits the criteria for this diagnosis.

 

Treatment plan

 

Treatment Goals

J.S will acknowledge and accept the separation of his parents. He will begin a healthy grieving process and manage reactions experienced due to disruption of family by separation.

Estimated Completion: 3 Months

Objective #1

J.S will bring awareness to thoughts and feelings related to his parents’ separation as evidenced by (a) identifying and listing emotions surrounding two parents and two homes, (b) clarifying his relationship patterns with his custodial (mother) and noncustodial (father) parent, and (c) participating in expressive art activities or psychotherapy exercises to help express thoughts and feelings about parents’ separation. Progress will be measured per J.S’s report, parent report, and Therapist direct observation.

 

Treatment Strategy / Interventions: Supportive psychotherapy, integrating psychodynamic, cognitive-behavioral, and interpersonal conceptual models and techniques will be used to address and respond to J.S’s thoughts and feelings related to his parents’ separation.

Therapist will educate J.S on how relationships may begin and end. Therapist will elicit J.S’s exploration, description, and ventilation surrounding the disruption of family by separation. Therapist will assist him in developing vocabulary to express emotions. Psychoeducation, Psychotherapy Homework, Psychotherapy Worksheet, Expressive Arts Therapy will be used to help him identify, list, and bring awareness to his emotions and thoughts. Therapist will help Jayden learn how to rate his emotions using basic emotion assessments each session. Supportive Reflection, Interactive Feedback, Symptom Management, Relaxation/Deep Breathing will be used to foster a therapeutic environment and alliance where J.S is comfortable in sharing.

Estimated Completion: 3 Months

Objective #2

J.S will accept parents’ separation with consequent understanding and control of feelings and behavior as evidenced by (a) practicing emotion regulation skills (e.g., opposite actions, checking the facts, focusing on positive events, etc.), (b) developing and using relaxation techniques (e.g., deep breathing, mindfulness, drawing, coloring, etc.), and (c) learning and verbalizing the stages of loss and grief for children whose parents have separated. Progress will be measured per J.S’s report, parent report, and Therapist direct observation.

 

Treatment Strategy / Interventions: Therapist will gently explore, confront, and address J.S’s reactions to his parent’s separation. Using DBT and CBT approaches, J.S will be educated, taught, and modeled skills he can use to cope with strong negative emotions. Therapist will help J.S understand the stages of loss and grief experienced by children. Therapist will determine what stage of loss and grief he is in and help him move towards acceptance. J.S will be asked to identify and list the advantages and disadvantages of his parent’s separation. He will be encouraged to focus on positive experiences he has had since his parents’ separation to help him accept and embrace changes. Role-Play/Behavioral Rehearsal, Psycho-Education, Psychotherapy Worksheet, Supportive Reflection, Symptom Management, Interactive Feedback, Exploration of Coping Patterns, Exploration of Coping Patterns, Exploration of Emotions will be used.