Bio-psycho-social-spiritual history

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Oct 30, 2023

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1 Bio-Psycho-Social-Spiritual History Presentation NAME Bio-Psycho-Social-Spiritual-History Presentation University of Mississippi

2 Bio-Psycho-Social-Spiritual History Presentation Social Worker: NAME Date of Assessment: April 15, 2020 Client Name: Pearl Date of Birth: Unknown Source of Information: Referral from DHS Bio-Psycho-Social-Spiritual History PRESENTING PROBLEM Not much information about Pearl is known. As of now, we are unaware of her age, race, religion and date of birth. We know that she is a female with a nine-month old son, Robert. She is unmarried and has no contact with Robert’s father. We are unaware of her employment status and sexual preference, although she has a child. Pearl is here because she is ordered by DHS. She is at risk of losing her son, Robert. Pearl will not answer the door when agency staff arrives for visits. There have been many occurrences during visits where there has been little baby food for Robert. It is noted that Robert is considered to be a very irritable and fussy. There are obvious delays with Robert’s development, such has not able to sit up or babbling. There are many safety hazards surrounding Pearl and Robert’s living situation, although these hazards are not specified. It is noted that Pearl acts as if she doesn’t want the help of the programs. All other attempts at helping Pearl and her skills of caregiving for Robert have failed. BACKGROUND There are many unknown facts surrounding Pearl’s background. Pearl has stated that she grew up in a rural community. She dropped out of grade school in the third grade. As a teenager, Pearl began getting pregnant, although she was unable to take any of them home until she had Robert. She was unable to keep her children because some had thought her developmental delays

3 Bio-Psycho-Social-Spiritual History Presentation were too severe to take care of a child. Pearl also mentioned that nobody in her family was ever able to attend school at a preschool/head start age. QUESTIONS FOR PEARL 1. What was your family life like growing up? 2. Are you an only child? 3. Were your parents married? 4. What led you to dropping out in the third grade? FAMILY BACKGROUND The only thing about Pearl’s family background that we are aware of is that Pearl has two children, Robert who is almost two years old and Maria who is an infant. We know that Pearl is single and is not in contact with the father of her children. Pearl became pregnant with Maria when Robert was around twelve months old. It was suggested that Pearl’s extended family are “questionably alcoholics” and “have a history of mental illnesses.” QUESTIONS FOR PEARL 1. Does your family have a history of any mental illnesses? 2. If yes, what illnesses are they? 3. Are your parents married/together? 4. Who did you live with growing up? SOCIAL LIFE In the beginning, Pearl had little social interaction. She would not speak and conversate with the other parents. She would not make any eye contact and would rarely smile/grin. She would often keep her head down towards the floor. She did not talk much with her son, Robert, but she would hold him close to her and stroke. She watched everything that staff members did

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4 Bio-Psycho-Social-Spiritual History Presentation with Robert. If questions were asked, they were very short, but she did seem to be very concerned with Robert’s delays in sitting and eating. After around a month of continuously coming, she began conversating with a few of the other parents. She began telling us she liked getting to meet the other families and began telling us goals that she had for Robert. She told her caseworker that it was difficult for her to understand conversations. After having an evaluation of her hearing, it was discovered that she had mild to severe hearing loss of the right ear and declining, normal hearing of the left ear. This is believed to be the reason that she would never answer the door for the agency staff, she could not hear them. QUESTIONS FOR PEARL 1. What are some hobbies or activities that you enjoy doing? 2. Do you have any friends that you like to spend time with? 3. Are there any social interaction goals that you would like to work on? 4. If yes, what are they? ACADEMIC OR INTELLECTUAL HISTORY Pearl does not have an education past the third-grade level because she dropped out. She possibly had hearing impairments during this time, unaware when the hearing-loss began. It is stated that she is unable to read and comprehend. She does have a goal of learning to read. There is an adult literacy program down the road from her new home that she is pushing herself to be involved in. QUESTIONS FOR PEARL 1. Have you ever considered earning your GED? 2. What subject interested you most in school? 3. What did you struggle with most in school?

5 Bio-Psycho-Social-Spiritual History Presentation 4. Are the appropriate adjustments that have been made helping you? MEDICAL HISTORY The biggest medical concern that we are aware of his Pearl’s hearing loss. She is currently waiting to receive hearing aids. A psychologist has evaluated Pearl and stated that she is capable of making important and informed decisions as long as they are thoroughly explained to her. A gynecologist had refused to tie her tubes because he said that she was unable to comprehend and make her own decisions. She conquered her fears of an MRI machine so that they could further resolve her hearing loss. She has still not received her hearing aids or tubal ligation. QUESTIONS FOR PEARL 1. Have you found a new gynecologist to perform the tubal ligation? 2. Are there any illnesses that run in your family? 3. What significant allergies do you have? 4. What medications are you currently on? PSYCHIATRIC HISTORY We are unaware of any previous psychiatric treatments or problems that Pearl may have had in the past. Our suggested psychologist said that Pearl is capable of making informed decisions as long as they are clearly explained to her. QUESTIONS FOR PEARL 1. Are you currently on any medications prescribed by a psychiatrist? 2. If yes, what are they? 3. Have you ever received psychiatric treatment?

6 Bio-Psycho-Social-Spiritual History Presentation 4. If you are aware of any psychiatric issues in your family history, what are they? PSYCHOSOCIAL/ENVIORNMENTAL PROBLEMS Pearl was struggling with finding a home that met the safety standards for her to keep Robert, but she is now in a new home that meets requirements set by DHS. Her hearing and lack of comprehension skills does still affect her. She thought that Robert was not making any progress in his therapy, but it was because the therapist was unaware of her setbacks and was able to explain them to her in person and to her understanding after being told about them. She is now able to balance both children’s appointments/school along with her own. She has learned how to utilize the bus to help her get to places that she needs to be at. She is receiving assistance from multiple programs. QUESTIONS FOR PEARL 1. Do you feel that the programs are adequately meeting all of your needs? 2. Where do you feel that you could improve your environment? 3. Do you feel that you are functioning fairly in your environment? 4. What concerns do you have about functioning in the environment you’re in? STRENGTHS I believe that Pearl has gained many strengths during this time. Pearl may not have known how to express this in the beginning, but she is very concerned for her children’s development and well-being. She is also willing to conquer her fears in order to help herself and her children. She got past her fear of the MRI machine without any sedative because she wanted to be able to take Maria home immediately after. After gaining Pearl’s trust, she is willing to get help. She went to hear caseworker explain she had problems following conversations, which led

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7 Bio-Psycho-Social-Spiritual History Presentation to her receiving the hearing tests. She wants her kids to succeed. She wanted to pull Robert out of therapy because she thought he wasn’t making any improvements. She also was excited for him to be enrolled in Head Start. She made significant growth in her communication skills. She can now communicate with her caseworker, doctors, other parents, etc. She’s willing to learn how to read for her children. She is now taking pride in her appearances along with her children’s. She has become more confident and independent. CASE FORMULATION Pearl is a single mother who is at risk her losing her child due to living conditions. Her biggest limitation is her hearing impairment, although her does not let it stop her. She dropped out of school in the third grade, so she has a hard time comprehending and following conversation, which is helped when explained things clearly. Her desired goals include learning to read, change her children’s appointments to fit the schedule of the family, and to make toys for her children so that they can live a better life. SERVICE PLAN 1) Pearl will change her children’s pediatric appointments so that they fit into the schedule of the family. 2) Pearl will learn to read so that she can keep up with the appointments of her children, Robert and Maria. 3) Pearl will make homemade toys for Robert and Maria because she wants them to “have a better life”