10 pg. Social Work Biopsychosocial Assginment Due 12/4

Rhiane Jones

11/16/2021

Biopsychosocial Assessment

*All names were changed to protect the identity of the client

Agency:

Child Protective Services

Referral Date:

October 2021

Referral Source:

Ms. Roberta Brown, School Nurse at Montview Academy

Family Data:

Father: David Smith, age 30

Mother: Yolanda Smith, age 27

Child(ren): Mark Smith, age 7

Presenting Problem

In October 2021, Child Protective Services (CPS) received a phone call from Ms. Roberta Brown, the School Nurse at Montview Academy. She called with a concern for 2nd grader, Mark Smith. He is unkempt every time he comes to school and his clothing usually is not weather appropriate. He continuously gets into physical altercations with other students. This behavior concerned the principal and he called home numerous times, but his phone calls have not been returned. He is also falling asleep in class often and has a hard time paying attention.

When CPS was called, they arranged a meeting to meet with the family. The father, David Smith, was late to the meeting. Before he came home, the case worker was able to receive important information from the mother, Yolanda Smith. She claims to be overwhelmed and overworked. She said she no longer feels like herself and is just floating through life. She informed the case worker that she takes care of the household by herself. She is currently working two jobs. David has a hard time holding onto a job and seems to have given up about three months ago. He is a veteran that suffers from PTSD and copes by drinking. He watched his best friend die about three years ago when they were deployed in the Middle East. Does not like to talk about it.

Family Background

Yolanda comes from parents who are financially well off. Her parents decided to cut her off after she decided to marry David. They had picked out a rich man for her, but she did not like him. She fell in love with David and made the decision to walk away from her family’s financial security. David comes from a middle-class home. His father was physically abusive to his mother and was an alcoholic. One thing David is able to say about his father is that he always had a job. His mother worked to take care of the home. He always thought his mother was weak and resented her for staying in that situation. Once he turned 18 years old, he joined the army. When he left, he vowed to himself that his family would not resemble the one he was raised in. The only difference he was able to spot is he does not beat his wife and is currently unemployed.

Mental Health/Medical History

Yolanda describes her mother as suffering from depression. Yolanda was often in charge of preparing dinner or cleaning when her mother wasn’t up to it. David’s father suffered from alcoholism. David had his first drink from his father when he was 11 years old. Mark is having difficulties focusing during class. His teacher is concerned and recommended the family see a specialist. The specialist diagnosed Mark with ADDD. He was prescribed some medication as well as the use of fidget toys in class.

Mark Smith is currently taking medication for his ADD (Attention Deficit Disorder). David is suffering with his PTSD. Yolanda experienced a miscarriage. About a year after, Yolanda had a psychotic break and was checked into a Psychiatric Hospital. They said she was extremely exhausted and overwhelmed. She was working three jobs at the time. She was able to get some much-needed rest and decided to quit one of her jobs. David was advised to help her out more because she needs to rest. It lasted for about 3-4 months until he drifted back to his old ways. David’s father suffers from Liver Disease but continues to drink occasionally.

Substance Abuse History

David has developed a drinking problem like his father. It is triggered by his PTSD. He does not know what triggers his episodes. Yolanda seldom has a few drinks. She is scarred from her husband and his family, as well as her mother. Her mother used to drink heavily as she got older.

Legal History

David and Yolanda became legally married when their son was one years old. She has never been arrested. David did almost receive a DUI one day, but he knew the police officer. Instead of arresting him, the officer made David sign up for an intensive outpatient program. David was sober for three months following this program, but the anniversary of his friend John’s death triggered his relapse. He no longer drinks and drive but tends to stay home. David was released from the military about two months after John’s death. He continued to come to work intoxicated and was not willing to receive any help.