Genogram Intake Assessment

There are different types of trauma child welfare programs focus on. They typically focus on behavioral and emotional problems and ways to correct the child (Greeson et al. 94). However, it is not as simple as the welfare programs want it to be. One first must look at the trauma history of the child, or the “Trauma History Profile”, also known as THP (Greeson et al. 97). The THP addresses “lifetime exposure to trauma and contains a

Reporter (Charlesetta) stated the following: He has been talking about the abuse and has been going back and forth since October 20th/ He said he was sexually assaulted by a 12 year old girl (unknown). Ms. Katina allowed the girl to come over. No one was responsible for their care. Ms. Katina was not there.

The victim was court ordered to be admitted at the Specialized Treatment Facility by Harrison County Youth Court on 04/27/16; he will be admitted for six months and the expected discharge date is 10/27/16. The reporter stated John was has been diagnosed with bipolar disorder, ADHD, marijuana abuse, mood disorder, severe mood swings, disruptive behavior, border line dyslectual disorder, basic personality disorder, mental incompetance; John is unable to function on his age level and has a very low IQ; John is unable to read, write, and count. Mr. Young stated John will never be able to live on his own and will always need assistance. During a session with John on 04/28/16, he disclosed that his father punched him in the face but that the details

IRTC spoke with CPS, Cari Covahey, who reported that she spoke with the subject child twice and there was no disclosure of sexual abuse. CPS expressed that she only conducted minimal fact finding interviews with the subject child and will inquire more pertaining to the alleged relationship between the subject child and her boyfriend. CPS expressed that the only person the subject child informed this information to was her 7 year old cousin. CPS expressed that the foster parent is unaware of the child having a boyfriend and the source indicated that the child was alleged telling her cousin a “dirty story.” CPS articulated that the subject child was medically assessed at Richmond University and there was no observed trauma to the vagina or the

Other than her mental health issues she has received medical services for a urinary tract infection. The client has pierced her own lip, navel, but denied any self-injurious behaviors on her body at the time of assessment. She also displayed her forearms, which is her primary area of superficial cutting and denied any self-cutting on concealed areas on her body. Her mother reported she has an uncomplicated pregnancy and delivery and that Katie met al of her developmental milestones within typical limits. Katie is also capable to complete all appropriate developmental

According to The Federal Child Abuse Prevention and Treatment Act, child abuse is defined as “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation or an act or failure to act which presents an imminent risk of serious harm,” (www.childwelfare.gov). This could be interpreted as physical, sexual or emotional abuse in childhood for those 18 years of age and younger. Child abuse can cause many risk factors and health issues for those affected which can life in later years.

Furthermore, stays at a friends house while his mother works from 1:00am to 5:00am. Per documentation the patient presents with mannerism of throwing his head back, laughing at inappropriate times, and throws his hands over eyes to talk. The patient presented with these behaviors during the time of assessment. According to collateral the patient reports to "Ms. Mitchell, principal at Tabernacle Elementary School, that he was going to kill himself and others." Collateral reports that patient cut himself with a broken razor from a pencil sharpener. Further, the patient reports that he is useless and that no one likes him nor does he have anyone to play video games with. The patient expresses these thoughts during the assessment. According to collateral the patient has multiple incidents with his behavior since 2013. As noted, "Some of these behaviors including pulling string out around neck from sweatshirt, smashing milk in cafeteria, kicking others students, swinging a waffle bat at another student, inappropriate language and hitting a student on the bus." The mother expresses that the patient does not see a need to go to school and wishes to stay home.

On 1/6/16 at approximately 12:05PM the reporting party (RP) was alone with foster child Michael Martinez as they worked on a puzzle on the floor of the resource room. The RP questioned Michael regarding the prior day after school. Michael answered "stupid, I had to stay in my room until dinner." The RP asked why and Michael responded "I don't behave right at school." The RP asked what else did he do and Michael responded "got spanked, and then spanked myself in my room. I hit the crap out of my butt." The RP asked if he played with toys at which Michael responded "yes after I spanked the crap out of my butt because I'm bad." The RP asked Michael what is a spanking and he responded "we get hit on the butt." When the RP asked who, Michael stated

Pt is a 12 y/o African American female presented at NNBHC with dx of ADHD combine type, ODD, Disruptive Mood Dysregulation D/O, Mood D/O, PTSD and Sexual Abuse (victim/ perpetrator), who have been feeling severely depressed and SI. Pt states that she has had SI with a plan to overdose or cut her wrist. Pt is considered high risk due her unsuccessful attempt to commit suicide on 7/5/2015 by taking a handful (unknown quantity) of Clonidine. She was hospitalized at CHKD until she was medially stable, than transferred to Maryview for mental stabilization. Pt states that she is unable to contract for safety at this time, and unsure of what she may do due to her impulsivity. Pt has also have been currently distributing nude pictures to adult males via cell phone. Virginia Beach Police Department is involved with the solicition of child pornography per report from pt mother. Pt have been using explicit communication of sexual acts via text message with males and females. Since 7/5/15 there have been a change in medication Vyvanse 70mg to 30mg. Pt have a hx of becoming verbally aggressive towards hospital staff when medications change. Pt denies any psychosis or paranoid thinking.

Presenting Problem: He has 2 Kempsville Acute visits, endorses anger and thoughts of suicides. Reported hx of Neurodevelopmental problems most recently as consistent with Autistic Spectrum Symptoms. He reported having intense anger toeards his parents but denies homicidal thoughts, acknowledges suicidal thinking. On May 27, 215 he pulled a knife on his mother, no injury occurred. Mother states he has been increasingly agitated. He has been posturing at his mother yeling clinching his fist at her as well as sneaking out and lying. Mother states he obtained the knife from his room and threatene her life. He states his mother swas chasing him around with a broom which is why he grabbed the kife. He states he is depressed all the time. He a Hx of suspensions for fighting while in school and he was the aggressor.

According to Quanzarius’s statement, he left the house at 6am, on 2-19-16. When he returned to the home from his walk, his mother wanted him to “come here”. She hit him with an extension cord. He tried to take the cord because it hurt. Quanzarius ran in the hallway, and the mother got the mop and him; the mop broke. She grabbed him by the neck and choked him. Quanzarius ran into the kitchen, but the mother was tired and told him to get ready for school. Quanzarius has marks/bruises on his left and right arm, lower back and lower left leg. Physical abuse has occurred before, and it has been reported to DHS. At the time of the incident, Jakevious was in the housing watching it.

The reporting party (RP) stated a home visit was made on 4/8/16 for foster child Ronny Perdomo. During the visit the RP observed multiple bruising to the foster child's lower part of his spine, upper left shoulder, and on his back area. The RP stated she took pictures of the bruises. The foster mother Ana Ramos explanation for the bruising was the child is Anemic. The RP stated on 4/11/16 she consulted with her SCSW who advised her to take the child for a forensic exam. The RP stated on 4/12/16 she took the child to have a medical examination. The RP stated on 4/19/16 at approximately 1:50PM she received a call from a Nurse Practitioner (name not provided) from High Desert Regional Clinic who informed the RP the child's bruising was highly

On 4/27/17 at approximately 1835 Medical was requested to respond to Higbee to do an assessment on offender Smith OID 252929 following an altercation with another offender in Tubman Unit. Offender was assessed and was noted to have a small abrasion on the left arm and scratches on the legs. Vital signs were stable. The dressing was applied on the abrasion on left arm and ffender was informed to contact health service if she has any other medical concerns.

It is very hard to distinguish and recognize actual abuse but as the practitioners we must not be afraid to seek for more information from parents or other specialists. If concerned we should contact to social services to prevent/stop the crime from being committed. It is crucial to keep in head how serious consequences of any kind of abuse are and how disturbing they are on development and future of every child. We must not ignore any symptoms especially if they do not stop with the time. Our one action or referral can change whole life of the child for better.

Tangeman, Keegan R. and Shelby, Janine. (2012) “Intervention Application for Self-Injury Following Childhood Sexual Abuse”. Handbook of Child Sexual Abuse: Identification, Assessment, and Treatment. Online.