Bio psychosocial assessments

SOCW 6200 Final Project: Bio-Psycho-Social Assessment

Submit by Day 7 a 6- to 9-page paper that focuses on an adolescent from one of the case studies presented in this course. For this assignment, complete a bio-psycho-social assessment and provide an analysis of the assessment. This assignment is divided into two parts (Part A & Part B):

Part A: Bio-Psycho-Social Assessment: The assessment should be written in professional language and include sections on each of the following:

· Presenting issue (including referral source)

· Demographic information

· Current living situation

· Birth and developmental history

· School and social relationships

· Family members and relationships

· Health and medical issues (including psychological and psychiatric functioning, substance abuse)

· Spiritual development

· Social, community, and recreational activities

· Client strengths, capacities, and resources

Part B: Analysis of Assessment. Address each of the following:

· Explain the challenges faced by the client(s)—for example, drug addiction, lack of basic needs, victim of abuse, new school environment, etc.

· Analyze how the social environment affects the client.

· Identify which human behavior or social theories may guide your practice with this individual and explain how these theories inform your assessment.

· Explain how you would use this assessment to develop mutually agreed-upon goals to be met in order to address the presenting issue and challenges face by the client.

· Explain how you would use the identified strengths of the client(s) in a treatment plan.

· Explain how you would use evidence-based practice when working with this client and recommend specific intervention strategies (skills, knowledge, etc.) to address the presenting issue.

· Analyze the ethical issues present in the case. Explain how will you address them.

· Describe the issues will you need to address around cultural competence.

BioPsychosocial History

[Template for Part A]

Name: Dalia

Date:

Agency:

DEMOGRAPHIC INFORMATION

Age: 14 years old

Ethnicity: Biracial African American and Irish American

Marital Status: Single

Date of Birth: N/A

PRESENTING ISSUE(S)

Client Self-Assessment of Problem(s)/Reason(s) for Seeking Treatment/Motivation Onset/Duration/Intensity/Frequency Precipitating Stressors/Stressful Events Symptoms (in Client’s/Informant’s Own Words)

Dalia and her mother both appeared agitated with each other and became argumentative when going through the intake information. Dalia quickly told me that she was not planning to talk about anything because this meeting was her parents’ idea. She stated, “I don’t have any problems, my parents do.” Soon into this first visit, Dalia blurted out that her mother was upset with her because she had just shown her a tattoo she had had done recently, purchased by using a fake ID. I acknowledged her news and asked if this was the way that she usually shared important information with her mother. Dalia shrugged and stated, “I don’t know. I figure I better her tell her now before she gets too busy.”

REFERRAL SOURCE

Who referred this individual for treatment? Was the informant a reliable historian? The client’s parents referred Dalia for treatment. They are a reliable informant.

Was information gleaned from previous treatment records, court documents, etc.? No

CURRENT LIVING SITUATION

Living Situation- Dalia currently lives with her mother and father in a suburban area.

Dependents/Care for Dependents Employment/Disability/Seeking Disability Income/Source of Income- N/A

Insurance Transportation Daily Living Skills- N/A

Social/Leisure Activities

Available Social Support- Dalia has her mother and her father as a source of social support. She also expressed that she and her brother have a good relationship and can be used as a source for social support as well.

BIRTH AND DEVELOPMENTAL HISTORY

A. PRENATAL/BIRTH/DEVELOPMENT

Dalia was born with sickle cell anemia. There is no indication that Dalia did not accomplish all of her milestones.

B. EARLY CHILDHOOD

Family of Origin—Dalia lives with both her mother and her father. She also has an older sister and brother.

Geographic/Cultural/Spiritual Factors/as Relevant- Dalia’s mother is African American female, she does not express any cultural or spiritual preference. Dalia’s father is Irish American male, he does not express any cultural or spiritual preference.

Abuse/Trauma History- None mentioned

Physical/Emotional/Sexual Abuse History- None mentioned

SCHOOL AND SOCIAL RELATIONSHIPS

This section should include information about social supports and the nature of those relationships; include current friendships, school/peer group experience, and military history, if applicable.

A. SOCIAL DEVELOPMENT

Cultural/Peer Group/Environment School

Adolescence

B. EDUCATIONAL HISTORY

Public or Private School(s) Where Attended- Dalia attends public school, there was no mention of private school.

Performance- Dalia’s performance in school has decreased since entering middle school. She has been experiencing poor concentration in class, irritable mood, verbal combativeness when confronted, and truancy.

Educational Level- Dalia is currently in middle school

Extracurricular Activities- Dalia mentioned that she enjoyed singing and participating in activities with her peers, but did not go into details as to what those exact activities are.

C. MILITARY HISTORY What Branch- N/A

Duty Assignment (when/where) Rank/Discharge- N/A

FAMILY MEMBERS AND RELATIONSHIPS

A. SIGNIFICANT FAMILY RELATIONSHIPS

Family member and relationship- Dalia expressed that she is close to her brother. Dalia’s older brother lives in another state and described him as “cool.” Dalia has and other sister, that is a sophomore in college, Dalia describes her as “not cool.”

Relationship dynamics- Dalia describes her family relationships as tense, stating, “My dad lets me do what I want” and “My mother is always trying to control me.”

B. INTERPERSONAL/MARITAL HISTORY

Age of Involvement in Relationships

Sexual Orientation- Heterosexual

Length of Relationships- No relationships were mentioned

Relationship Patterns/Problems

Partner’s Age/Occupation- N/A

HEALTH AND MEDICAL ISSUES

A. MEDICAL HISTORY/HEALTH STATUS

History of Traumatic Injuries/Illnesses/Chronic Health Problems- Dalia was diagnosed with sickle cell anemia in early childhood and was hospitalized multiple times.

Describe Current Illness- At the present, Dalia’s health is stable with the last serious episode occurring two years ago.

Is Client in Good General Health? Yes

Is Client Allergic to Any Medications? Who Is Client’s Primary Care Physician? Not discussed

Is the Client Being Treated by Any Other Physician(s)? Was not discussed

What Are the Client’s Current Psychiatric and Nonpsychiatric Medications? Was not discussed

Describe Client’s Health Habits: Appetite, Sleep, Exercise, Nicotine, Alcohol, Illicit Drugs, and Vitamins/Herbal Supplements? Dalia expressed that she has drank alcohol with her friends, but denied any problems with drugs or alcohol.

Sexual Functioning: Preference/Problems- N/A

Pregnancy/Birth Control- N/A

Risk Behaviors for STDs- N/A

B. MENTAL STATUS

Attitude/Appearance/Behavior Affect/Mood/Psychomotor Activity

Orientation/Memory/Cognition Thought Process/Content Speech

Insight/Judgment Homicidal/Suicidal Ideation Hallucination(s)/Delusion(s)- N/A

C. HISTORY OF PSYCHIATRIC ILLNESS AND PREVIOUS TREATMENT

Previous Diagnoses/Medications/Inpatient and Outpatient Treatment History of Suicidal Ideation/Suicide Attempts/Self-Mutilation/Homicidal Ideation/Aggression- N/A

E. SUBSTANCE ABUSE HISTORY

Type/Onset/Duration/Amount Frequency/Pattern of Use Involvement in Treatment- N/A

SPIRITUAL DEVELOPMENT

Religion/spirituality- N/A

SOCIAL, COMMUNITY, AND RECREATIONAL ACTIVITIES

Dalia agreed to more structure in her schedule and accepted a position as a camp counselor in a local day camp for the summer.

CLIENT STRENGTHS, CAPACITIES AND RESOURCES

Cultural/ethnic factors- N/A

Personal strengths- Dalia has shown great personal strength with expressing how her feelings to her parents. She is resilent and was able to navigate the world by herself with her parent’s busy schedule. Dalia has shown bravery in being able to express her feelings to her mother, even though she is aware of the backlash.

Family/social resources- Working with the family, the realities of being a biracial family and raising mixed-race children were also addressed. We discussed how the parents navigated race issues during their own courtship and looked at the role of acculturation and assimilation with their children in their social environments as well as respective families of origin. Educating both parents around race and social class privilege seemed fruitful in understanding distinctions between what they and their children may have faced.

OTHER SIGNIFICANT FACTORS

SUMMARY

PART B

Part B: Analysis of Assessment. Address each of the following:

Explain the challenges faced by the client(s)—for example, drug addiction, lack of basic needs, victim of abuse, new school environment, etc.

Dalia was referred to a social worker because of her behavior in school. Dalia’s parents and teachers expressed concerns over certain behaviors that were not favorable. Dalia’s parents felt that before middle school Dalia was easy going and a good-natured girl. Dalia’s issues consist of being argumentized with people in the position of authority, engaging in physical fights with member her age, displaying lack of concentration while in class, truancy, and using a fake ID to get a tattoo. Dalia denied any use of drugs but did mention that she has drank alcohol with her friends.

Analyze how the social environment affects the client.

Dalia’s social environment plays a huge factor in her development and behavior. Dalia’s parents work odd and long hours. Dalia’ father works overnight and tends to sleep most of the day, where Dalia’s mother works long hours. This leaves Dalia’ being the only child still in the home a lot of time alone. “Other teens develop identities that are in opposition to their parents but align with a peer group. This is common as peer relationships become a central focus in adolescents’ lives” (Pelz). During this time Dalia is learning most of her behavior from her peers instead of her parents because they do not spend enough time with her.

Identify which human behavior or social theories may guide your practice with this individual and explain how these theories inform your assessment.

Using the social learning theory and task centered practice, these will allow the social worker to address Dalia’s issues. “As children become adolescents, they usually begin spending more time with their peers and less time with their families, and these peer interactions are increasingly unsupervised by adults” (Pelz). The social learning theory essentially describes human behavior in terms of complex systems. Once we focus on Dalia’s individual needs and expectations the social worker can then begin to address Dalia’s issues. Working within this theory Dalia and her family will work directly with the social worker to resolve the problems at hand. The task-centered practice approach will be used as a short-term addition. This will help the social worker and Dalia to work together to establish specific and measurable goals.

Explain how you would use this assessment to develop mutually agreed-upon goals to be met in order to address the presenting issue and challenges face by the client.

“Peers can serve both positive and negative functions during adolescence. Negative peer pressure can lead adolescents to make riskier decisions or engage in more problematic behavior than they would alone or in the presence of their family” (Pelz). Dalia will need to make better decision when it come to her friends. Dalia has expressed that she has drank alcohol with her friends and went to get a tattoo using a fake ID. This assessment has allowed the social worker to list all of the important information in the case of Dalia. It will allow the social worker to clearly define behavior patterns and address these concerns with Dalia. With all the information listed Dalia and the social worker can begin working on mutually agreed-upon goals.

Explain how you would use the identified strengths of the client(s) in a treatment plan.

Dalia has demonstrated that she is resilient and brave throughout this entire process. Using Dalia’s strength in the treatment plan would consist of challenging Dalia to be honest with her feelings and emotions. Dalia’s behavior alludes that she might have a bit of resentment to her older sister. Dalia feels that she is consistently compared to her sister in school and at home. Having Dalia use her bravery will help her unlock some of her hidden feelings toward her sister. This could open communication between Dalia and her mother in regards to how that makes her feel.

Analyze the ethical issues present in the case. Explain how will you address them.

There are no ethical issues in this case that needs to be addressed.

Describe the issues will you need to address around cultural competence.

Cultural competence deals with the ability to understand and communicate effectively with people across all cultures. In the case of Dalia, the social worker will need to work on biracial relationships, as Dalia is of mixed race. The social worker would have to work with Dalia’s parents to ensure that they are fully aware of any burdens that Dalia might face being of mixed race.

Reference

Pelz, B. (n.d.). Developmental Psychology. Retrieved from https://courses.lumenlearning.com/suny-hccc-ss-152-1/chapter/social-development/