Case Presentation First Client S_Mobley

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May 17, 2024

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CASE PRESENTATION FIRST CLIENT 1 Case Presentation First Client Shawn Mobley School of Behavioral Sciences, Liberty University Author Note Student Name https://orcid.org/0000-0002-1222-9908. I have no conflicts of interests to disclose. Correspondence concerning this paper should be addressed to Shawn Mobley, 1971 University Blvd., Lynchburg, VA 24515. Email: smmobley1@liberty.edu

CASE PRESENTATION FIRST CLIENT 2 Case Presentation First Client Identifying Data Date of Initial Assessment: 02/02/2024 PSEUDO Name: “Patrick” Age: 8 Gender: M Sexual Orientation: Race/Ethnicity: Native American Marital/Relationship Status: S Employment Status/Grade Level: 3 rd Part I – Intake Information Presenting Problem The principal problem is adjustment disorder with mixed anxiety and depressed mood, which has been present for more than six months. Associated symptoms are low mood, anxiety, jitteriness, headaches, and irritability during the past six months. Traumatic memories have resurfaced after a forensic interview regarding physical abuse. High expressed emotion level during shopping trip to Target where he dropped a small toy and they eye popped out. Frozen and in panic state for several minutes. Confidentiality My supervisor and I, as this was my first time, went over the limits of confidentiality with “Patrick” and the foster family at the Kids Crossing Pueblo Office. Confidentiality forms for Kids Crossing and Liberty University were signed by foster parents for “Patrick” and copies were provided to the foster family, the caseworker for department of human services, and the original kept in the client file. The video informed consent was also provided, which was signed by me, and the clinical director and a copy provided to the foster parents. Source of Information

CASE PRESENTATION FIRST CLIENT 3 Information was gathered from the El Paso County referral form and the client himself during the initial intake. This came in the form of an assessment covering bio-psycho-social aspects and a mini mental status examination. Some of the assessments I may give an adult client, were not age appropriate in Patrick’s case, such as the ADNM-20, BDI-II, BAI, and PANAS. Prior to and at the time of the initial intake, I was unable to contact the caseworker for Patrick for any additional information. Part II: Client Assessment Information Observational Data/Mental Status Exam Patrick is an eight-year-old boy approximately 4 feet, three inches tall and 55 pounds of average stature and thin build. He is right-handed, well-groomed, and dressed well in jeans and a polo shirt. He has short cut hair and wears glasses. He showed some anxiousness and restlessness during the initial interview. Patrick is an intelligent person and has a polite demeanor. He was attentive during the intake interview process and cooperative and thoughtful in his responses, though he resorted to “I don’t know” or remember for some of the questions about past trauma. He is able to communicate clearly, form strategies, and problem solve. He has demonstrated, according to foster parents, that he and his sister tell “little lies” such as saying they have eaten, when they obviously had not, which is the only concerning behavior noted. When asked some questions that related to or seemed to bring memories of trauma, he became guarded and quiet. He does have a stutter. Biological Assessment Information Demographic

CASE PRESENTATION FIRST CLIENT 4 Date of intake interview was February 2, 2024. Patrick is an 8-year-old male of Native American descent and belonging to the Patrick and his older sister are currently placed with a foster family and assigned guardian ad litem. Sleep Patrick reports no sleep disturbances and sleeps regularly, approximately 8 hours per day. He has his own bedroom in his current living arrangement, where he used to share a room with his sister and one of his other brothers. Diet Patrick reports having a healthy appetite and trying new foods. On a typical day he eats three full meals per day and may have one or two snacks between meals or before bedtime. Exercise Patrick is very physically active, playing at recess in school, plays soccer on the weekends, and has swimming practice and gym twice per week at the local YMCA. When at home he likes to play outdoor sports with neighborhood boys. Medical History Unknown medical history. Last known inquiry was 11/20/23 for records. Up to date on medical and dental appointments. Patrick appears to be in good physical health. Mother says the children are current on immunizations and I noted that he wears glasses. Medication No known history of use of medication and is not currently taking any medications. History of Developmental Milestones

CASE PRESENTATION FIRST CLIENT 5 There are no records or reports specific to this, however based on assessment and interview with Patrick and the foster family, it appears that all of the developmental milestones up to age eight have been met. Psychological Assessment Information Historical Assessment Patrick reports having never participated in any type of counselling. Trauma History Patrick and sister Haven were referred to Kids Crossing by a DHS, caseworker. Their agency became involved due to complaints about physical and substance abuse. After a forensic interview regarding physical abuse, some traumatic memories have surfaced. The caseworker requested individual therapy to help them process their trauma. DHS was involved on 08/13/2023 on an allegation of mother using meth amphetamine and was confronted by the oldest sibling, and then their stepfather strangled the oldest sibling around the throat holding his nose, and then throwing him around, causing injury requiring medical attention. The two oldest siblings were placed in foster care in Colorado Springs, and Patrick and his sister were placed in Pueblo West. Patrick was present for at least part of this incident. Addiction Screening None Risk Assessment I asked Patrick if he had ever had any thoughts of hurting himself or anyone else and he told me that he never had. Based on his response and my conversation with him I do not believe him to be suicidal or homicidal. Family Psychiatric History

CASE PRESENTATION FIRST CLIENT 6 No known psychiatric history for family members were available. Social Assessment Information Cultural Factors All siblings and their mother are members of the Standing Rock Sioux Tribe of North Dakota. Patrick feels a connection to nature and animals. English is Patrick’s primary language. Family of Origin Patrick has grown up with his three siblings, living with his mother and stepfather, who works for the Air Force. Mother was referred to Aspen Pointe for substance abuse evaluation and an earlier referral for Insight Services for substance use evaluation, and no record of completion or compliance with UAs. She did participate in a Family Engagement Meeting in November. The stepfather is facing a criminal case pertaining to an incident involving Patrick’s older brother. Completed Domestic Violence evaluation with Vivus Counseling, Family Engagement Meeting, and visiting children at New Horizons, aside from oldest brother, who has no contact with him. The birth father of Patrick was not involved with Patrick or siblings. Uncle has had phone conversations with children. Patrick’s mother refused to provide additional information on her mother or other relatives. Romantic Partner Dynamic None Current Living Arrangements Patrick and his sister both live in a foster home in Pueblo West. Patrick has weekly visits with mother at New Horizons family services in Colorado Springs for 2 hours. Patrick says he enjoys the visits and would like more time. He also receives weekly supervised phone calls and also has sibling visits on Fridays and occasional sleepovers with them.

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