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Use the Case Study Template media piece in the Course Resources to complete an i

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Use the Case Study Template media piece in the Course Resources to complete an individual assessment, including:
Description of the individual’s mental health history. (C6.SP.B, C7.SP.B, C7.SP.D, C8.SP.B, C9.SP.B)
Identifying Information.
Referral Source.
Presenting Problem.
History of Problem.
Previous Counseling Experience.
Description of the individual’s family history. (C6.SP.B, C7.SP.B, C7.SP.D, C8.SP.B, C9.SP.B)
Description of the individual’s personal history. (C6.SP.B, C7.SP.B, C8.SP.B, C9.SP.B)
Medical History.
Educational History.
Social Class.
Cultural History.
Spirituality.
Mental Status or Current Functional Exam. (C7.SP.D)
References.
As you complete the Case Study Template media piece based on one of the provided case studies, use your text and the DSM-5 as guides as well as one of the assessment tools from this unit’s studies:
The guidelines for the mental status exam on pages 50–51 of Clinical Social Work Practice. Use questions 1–14 for the interview.
One of the tools provided in the American Psychiatric Association’s Online Assessment Measures (link in the Resources) for diagnostic assessment tools and resources.
When you have completed the template, follow the instructions to generate a document. Be sure to check it for accuracy before turning it in for your instructor to review.
Additional Requirements
The assignment you submit is expected to meet the following requirements:
Written communication: Written communication is free of errors that detract from the overall message.
APA formatting: Resources and citations are formatted according to the current APA style and formatting standards.
Use the Case Study Template provided in the Resources.
Note: Your instructor may also use the Writing Feedback Tool to provide feedback on your writing. In the tool, click the linked resources for helpful writing information.
Resources
Case History Scoring Guide.
Social Work Masters Library Research Guide.
APA Style and Format.
Capella Writing Center.
Writing Feedback Tool.
Case Studies.
Case Study Template.
Online Assessment Measures.
Case- Sam is a 15 year old Native American male who was referred for a mental health assessment by his CPS case worker. Sam has been living with his foster family for 6 months and his foster mother Diana has brought him into the center for the assessment.
Sam currently lives in a foster home with Diana, her husband Steve and there older daughter Rebecca who is 17. Rebecca and Sam attend the same high school in Wellington, Colorado.
Sam presents himself as quiet, anxious, and shy. He looks down at the ground, and his hair is covering his eyes. Sam is very soft spoken and it is hard to hear him as he speaks. Diana shared that she suggested to Sam’s caseworker that Sam needed someone to talk to and an assessment as she is worried about him, that he has been having a difficult time going to school, that he wants to spend all of his time in his room, and he has only one friend that she knows of at his school.
While reviewing the file it shares that Sam was born on the Hopi reservation in Arizona where he was living with his mother. His mother was killed in a car accident when he was 12 years old. He was an only child with no siblings. His mom worked as a para-professional in the local school district and according to the file was a supportive and loving mother with no significant history or reports on file. There is no indication that Sam’s father has been present in his life as he went to life with his grandmother in Colorado when his mother passed away. Nine months ago Sam’s grandmother fell and broke her hip and moved into a skilled nursing facility and was unable to care for Sam any longer. Sam lived with his one friend briefly during that time but his friend’s family did not have enough room in their home and he was then placed with Diana and her family.
Throughout the interview Sam would not obtain eye contact and it was difficult to hear what he was saying due to his soft voice. He shared that he likes Diana and Steve that they are very nice to him. He also reports that he likes Rebecca and that she makes him laugh and helps him with his school work. Sam stated “they are nice, but I just like being by myself.” Diana shared that the only time Sam comes out of his room is during dinner or if they directly ask him to, but she feels bad about forcing him. Sam reports that he has one friend that lived next to his Grandmother but he only sees him at school.
When asked what Sam likes to do for fun, he stated playing on my computer and listening to music. Sam stated “I like that I have my own room, I am used to sleeping on my grandmother’s and friend’s couch.” He also shared that he really likes that he has a computer, that “my mom could never buy us nice things.” Sam reports that he does not go to church, he shared that he used to go to a big church on the reservation with his mom, but he can’t remember what kind it was, but that it was fun. Diana shared that her family does not attend church but would bring Sam if he would like, Sam looked down and shrugged his shoulders.
When asked how he likes school Sam again shrugged his shoulders. Diana shared “he becomes very anxious about going to school, he acts like he is afraid to leave the house sometimes.” Diana continued, “in fact I think that is what is making him sick, he gets so worked up over going to school that he will often throw up before school, it is as if he is having a panic attack.” When asked Sam if he was afraid to leave the house he again shrugged his shoulders and then became tearful. Sam then shared “I am fearful that if I leave something will happen and then I won’t have a place to go again.” When asked to explain Sam continued to share that when his mother was killed it was because he was down the street playing and he should have been home waiting for his mother. He then shared that he felt it was his fault that his grandmother fell. Sam shared “If I hadn’t gone to school, she would be fine.”
Sam continued to share that when Diana asks his to go to school he feels like “my chest is going to explode and like I can’t breathe,” Diana shared that he becomes sweaty and also complains that he is going to be sick to his stomach and will often vomit because “he gets so worked up over it.” Sam shared that it was the same at his grandmother’s, that he has just felt nervous and scared all the time since his mother “left.”
Sam’s medical history includes a broken arm when he was four from falling off of a trampoline, he is of average weight with acne typical of a teenager. He is on no medication and has no history of illness. https://media.capella.edu/coursemedia/swk5013element17658/wrapper.asp Temple
The Mental Status Exam
The mental status exam is a way of organizing and recording information about the mental state of the client, according to guidelines established by medical schools in the United States (Jordan & Franklin, 1995; Othmer & Othmer, 2002; Paniagua, 2001; Robinson, 2001; Sommers-Flanagan & Sommers-Flanagan, 2009; Taylor, 1981). A mental status exam helps the social worker assess the quality and range of perception, thought, feelings, and psychomotor activity of a client so as to better understand how the client’s behavior may be symptomatic of a mental disorder. It leads to establishing a diagnosis according to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), a classification system that divides mental disorders into categories with defining features. The following are the broad categories that are considered in the mental status exam:
1. Appearance. Is the client well groomed or disheveled? Is his manner of dress appropriate for the occasion of the interview? Is he flamboyant or bizarre?
2. Attitude. Is the client cooperative? Guarded? Suspicious? Aggressive or belligerent?
3. Motor Activity. Is the client calm or agitated? Does he have tremors, tics, or muscle spasms? Is he hyperactive?
4. Affect. Is the client’s tone appropriate to the conversation? Is he, for example, talking about a sad event and smiling? Is his affect flat or blunted, apathetic, or labile—rapidly switching up and down. Is he expansive or constricted? A flat affect is a term used to describe clients who seem unable to relate emotionally to other people. Blunted affect describes a client who has a restricted, minimal emotional response (Sommers-Flanagan & Sommers-Flanagan, 2009, p. 221).
5. Mood. What does the client report? How does the client seem? Is the client depressed or anxious? Is there variability in his mood? Mood tends to be longer than affect and changes less spontaneously than affect.
6. Speech. Is the client’s tone of voice loud or soft, whiny or high pitched? Are there any unusual characteristics or affectations (such as an accent or a halting manner)? Is the speech rapid or pressured? Does he stutter?
7. Thought Processes. Do the client’s thoughts flow logically? Are the thoughts organized or disorganized? Is the client coherent? Are there perseverations (repetitions of thoughts as if the client were stuck)? Does the client experience thought blocking (thought stopping or interfering thoughts) or loose associations (not following logically from one thought to another)?
8. Thought Content. Are hallucinations or delusions present? Does the client speak of being controlled by external sources? Is the content of his thoughts grandiose or bizarre? Is suicidal ideation present? Is the content circumstantial (the client demonstrates the loss of capacity for goal-directed thinking) or tangential (the client loses the main idea of the conversation and is unable to return to it)?
9. Perception. Is the client’s view of reality correct, or are there distortions in his thinking? Is there evidence of depersonalization or derealization?
10. Orientation. Is the client oriented to time, place, and person? How is his memory for present as well as past events? (Does he forget what he ate for breakfast but recall childhood events?) How are his concentration level and attention span? Is anxiety, a mood disturbance, or a learning disability responsible for the difficulty in focusing?
11. Cognitive Function. What is the client’s general fund of knowledge? Is it intact? (This function can be tested by asking the client to count backward serially by sevens.) It is important to consider the client’s intellectual level when assessing cognitive function, as his IQ may impact his ability to perform this as well as other cognitive functions, including the ability to be abstract or problem solve.
12. Abstraction. Is the client an abstract or concrete thinker? (To help you assess this function, ask him to interpret a proverb.)
13. Judgment. Are there any disturbances in judgment? Does the client understand the consequences of his behaviors, and to what degree?
14. Insight. Does the client have insight into his difficulties, or are there impairments (minimal, moderate, or severe) that lead him to deny them? Is the insight intellectual or does he have an awareness of motives and feelings on an emotional level?

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