Clinical Rewrite

2. The minor experienced emotional deregulation and was engaging in aggressive behaviors in the learning center on 11/1/2018. The minor punched and kicked his classroom teacher. In addition to aggressive behavior with his teacher, the minor also walked up to the Skills Trainer and punched her several times in the abdomen. The minor continued aggressive behaviors towards peers and Skills Training Staff. The minor was not responsive to clinical intervention and program called 911 in response to the minor’s emotional deregulation and aggressive behaviors.

3. On November 2nd, 2018 during dismissal time this minor was playing in the classroom. When another minor walked by, this minor grabbed her wrist and twisted it. The Skills Trainer immediately separated the minors and checked the second minor for injury. There was some redness on the second minor’s wrist, but it was not swollen. Skills Trainer brought the second minor to Learning Center supervisors, who spoke with the second minor about the incident and iced her wrist. Another Skills Trainer stayed with this minor in the classroom and spoke with him about the importance of treating our classmates gently and kindly. Both minors were able to reintegrate into classroom activity.

4. On 11/20/2018 at approximately 2:30pm, FP reported a physical altercation happened in the foster home on 11/18/2018 involving three minors, resulting in one of the minors falling and bleeding from his nose. FP reported that the minor had no other injuries and she spoke to the minors about the risks of playing roughly. As per foster parent, reports that this minor stuck his leg out on purpose to trip the minor. The other minor fell and was bleeding from his nose. FP reported that the minors had no other injuries. CL assessed the minor accused of tripping the other minor. The minor reported that he did not trip the other minor. The minor stated that he was playing with another minor who mistakenly tripped the other minor while playing.

5. On 11/21/2018 at , CL assessed minor accused of hitting other minor. The minor stated that he did not hit the other minor. CL asked minor if he remembered possibly bumping into her or hitting her by mistake and the minor stated that he did not remember doing so.

6. On 12/2/2018 at approximately 7:45pm, Foster Parent called on-call clinician to report that a minor pushed another minor in the foster home. As a result, the minor lost his balance, fell and scratched his left cheek against a piece of furniture. The other minor did not respond. There was no bleeding or bruising. Foster Parent reminded both minors of the house rules. Both minors reported feeling safe and comfortable in the home. As per Foster Parent, the minor was playing with a pair of gloves around the Television. Another minor took the gloves away from the minor because in the Foster Home they’re not allowed to play around the Television. The minor responded by pushing the other minor; the minor lost his balance, fell and scratched his left cheek against a piece of furniture. There was no bleeding or bruising. As per minor, he was playing and her fell and scratch his left cheek. Minor denied being in any pain. The minor denies pushing another minor. Foster Parent reminded both minors of the house rules. Minor reported feeling safe and comfortable in the home.

7. At approximately 4:15 PM during dismissal time at the learning center, this minor approached another minor and bit her on her right lower arm. After being separated by a staff member, this minor was asked why he had bitten the other minor. This minor stated “porque no queria darme la galleta de merienda”[ because she didn’t want to give me the biscuit(snack)]. This minor then stuck his tongue out and walked away.

8. During snack time at approximately 9:15 am, this minor punched another minor on his back, after being punched by the other Description of Incident) minor. Learning center staff immediately intervened to separate minors.

· Per behavioral observations and clinical assessment, the minor appears to be functioning below his expected developmental range. Per educational staff report the minor is only able to maintain attention while watching cartoons. The minor presents difficulty with socialization and demonstrates low frustration tolerance and aggressive behaviors with peers and staff. The minor has a warm disposition however has difficulty following re-direction and has been experiencing frequent temper tantrums including laying on the floor and crying. Minor has difficulty communicating and playing with others. This is the ability to handle everyday tasks.

· CM met with UAC, but UAC seemed distracted and he did not want to talk. UAC did not seem cooperative when CM asked him about his trip to U.S.CM stated to UAC that she is on charge of his case.

· CM met with minor to provide the phone call and get know minor better. Minor did not want to speak on the phone with mom. CM will try again. Since minor has been having difficulties adapting to the classroom, CM and CL It was recommended to see minor for every other day until he gets comfortable. CM did the home visit and minor is currently staying at this house. FP home looked clean and safe. Minor seemed to trust FP as evidenced of holding her hand, seeking her and talking to her. FP stated that she is doing her best to make UAC comfortable in the home, learning center and city.

· CM went to see minor to provide with the phone call. Minor seemed hyperactive and run to his classroom. Minor was hanging on the curtains and CM asked minor to please behave and sit on the chair for the phone call.

· CL is still waiting for psychiatric appointment to be confirmed.

· CM and CL coordinate to take minor to medical due to a swelling on the left eyebrow took minor to medical around 2:20pm. Minor was seen by the provider and provider stated that minor’s eye is good. Provider recommended that minor should be given Tylenol or motrin in case of pain and some ice to lower the swelling.

· Minor also was very hyperactive and running around when CM took him to medical and when CM returned him to class.CM called FP to inform her about what the provider recommended.

· CL informed that UAC will see the doctor for psychiatric evaluation on Tuesday, 08/28/18. CL and CM will continue working on what is best for UAC.

· CL explained that a TVPRA home study will take place in order to proceed with the reunification to assess minor’s safety.

· CM received home study report with a negative recommendation. HS worker adviced CM to assess other potential sponsor such as the back up sponsor due to current sponsor not being able to care for the minor due to having mental health issues and also financial. CM will staff case and assess how to proceed with reunification.

· CM asked if there was a police report in COO of alleged sexual abuse towards minor in COO. Sponsor stated there was no report done due to the fact that minor’s grandmother was not sure if the allegation is valid.

· CM informed sponsor that FFS advice CM to proceed with releasing minor to biological parent since sponsorship cannot be denied by law to a biological parent. A safety plan, parenting classes, psychiatric appointment and PRS must be in place prior release.

· CM provided minor a phone call. Minor at first stated that did not want to talk to the sponsor then he agreed. He spoke with his mother for 15 minutes. After the call CM took the minor to his classroom where she tossed a little bag of candy. CM asked why did he tossed the candy. He said he did not know. After 15 minutes of CM leaving the classroom. CM is notified he is having a tantrum. Kicking and punching his teacher. CM went to assist. CM was accompanied by Clinical specialist and a CL. All were assisting as well as the education department to help minor deescalate behavior. Minor continued throwing his shoes to Clinical specialist. Minor also hit her in her legs with shoes. CM also observed minor pulling her hair. He seemed very angry, agitated, and not empathetic. Minor then proceed with stating he did not know what he wanted and kept reaching for the door knob to leave the facility. After an hour minor calmed down and agreed with playing.

· Minor’s TVPRA HS was negative, however as per your guidance we will submit with safety plan, psychiatric appointment and strong back ups in place.

· On the event date, at a later time minor acted out again. The teacher stated he was still hitting other minors and staff members. 911/EMS was called. Minor was sent to ______ for an evaluation since his behavior escalated.

· Minor seemed very distracted and active. Minor did not stay still.

· Case Coordinator sent an email recommending a HS addendum or change in sponsorship. CM replied to stand by for a response.

· CM sent an email to AD of CM in regards what we will be doing with minor’s case. An addendum may be needed.

· Case is staffed with FFS and GDIT. FFS advised for a HS addendum to be conducted prior release. HS worker should assess sponsor’s progress and knowledge of resources.

Minor is 8 years old. He traveled from honduras with a guide to reunite with biological mother  Minor was raised by his grandmother. According to primary caretaker(grandmother) he was molested by his maternal uncle. He also was given marijuana. His mother disclosed that she was prostituted by a pimp  and drank alcohol during pregnancy. After further assessment minor showed defiant behavior. Yelled at staff member, had cognitive delays( didn’t know how to count or days of the weeks). He likes to feel in control and have attention. He was prescribed_____ for ADHD and after sessions and interventions in the ER he also was diagnosed with fetal alcohol syndrome. His face and height influenced the diagnosis and history of mother drinking during pregnancy.