STUDENT’S NAME: Leticia I. Cordero
NAME OF FICTIONAL CHARACTER: Hilda Acevedo
MARITAL STATUS: Single
OCCUPATION: Employee Part time
RESIDENCE/LIVING CIRCUMSTANCES: Lives with maternal grandparents
REFERRAL SOURCE: Administration For Children Services
REASON FOR REFERRAL
The case was referred program through the Field Office on 10/26/19, with allegations of substance use against client related to her child. Client tested positive for marijuana at the birth of baby. baby was born on 2019 at hospital. She tested negative for all substances
HISTORY OF CHIEF COMPLAINT
Client reports that she began smoking cannabis at the age of 18 and steadily increased to smoking three times a day. She states that she stopped when she was four months pregnant, prior to that she was unaware of the pregnancy. She reports that she then stopped smoking for the duration of the pregnancy with the exception of one month before delivery when she was upset about the uncertainty of the baby’s paternity. She indicates that her main triggers for use were negative emotions (e.g., anger, sadness).
SIGNIFICANT MEDICAL HISTORY
There are no known medical concerns.
BORN & RAISED
Client is a domiciled twenty-year-old woman who was born, raised and currently resides in the New York.
PARENTS: Age/living-deceased, client’s age and reaction to death and consequences
Personality characteristics of Mother (discipline, involvements, characteristics)
Personality characteristics of Father (discipline, involvements, characteristics)
General physical and mental health during client’s childhood
Parental history of substance abuse, physical, emotional, sexual abuse, or traumas
MARITAL: Single never being married. 1 sister. client currently lives with her maternal grandparents. Family has lived there for over 20 years
CHILDREN (NATURAL & ADOPTED)
Pregnancies: 1 unplanned; accepted.
Complete 11 grade in high school.
Client reports a history of trauma, including early separation from her mother due to her mother’s incarceration and subsequent deportation to country of birth, attempted sexual assault by a stranger last year and physical altercations in the community. Nevertheless, client denies any current symptoms of Posttraumatic Stress Disorder.
SUBSTANCE ABUSE HISTORY (Past/Present)
DRUGS: In terms of substance use, her reports on the ASSIST (Score = 19/Cannabis) and UNCOPE (Score = 2) are consistent with her clinical interview. She reports that she smoked one blunt one month prior to giving birth. However, prior to discovering she was pregnant, when she was 4 months along, she would smoke 3 “blunts” a day. She acknowledges that smoking cannabis helps her “forget” about the stressful aspects of her life. Client reports that she began smoking cannabis at the age of 18 and steadily increased to smoking three times a day. She states that she stopped when she was four months pregnant, prior to that she was unaware of the pregnancy. She reports that she then stopped smoking for the duration of the pregnancy with the exception of one month before delivery when she was upset about the uncertainty of the baby’s paternity. She indicates that her main triggers for use were negative emotions (e.g., anger, sadness).
SEXUAL: Attempted sexual assault by a stranger last year.
PHYSICAL: Client denies at this time
Client reported a significant loss when her mother was incarcerated then subsequently deported to country of birth. Client denies any negative feelings towards her mother and reports that her maternal aunt is to blame because she introduced her mother to criminal activities. Client reported that as an adolescent she initially used cannabis socially but then began using it more frequently. She often used cannabis to numb her emotions and no longer have to think about the stress that was going on in her life at any given moment. Client may be struggling with her identity as a mother given the history of her unexpected separation from her own mother. It is likely that she has attempted to fill that emotional void via substance use and poor relationships. Nevertheless, she appears motivated to engage in services that will support her and assist her in fulfilling her role as a new mother.
Client denies at this time
During the interview, Client was generally forthcoming and pleasant. She denied feeling overwhelmed by the involvement of ACS and she reported feeling grateful that baby was not removed from her care. Throughout the interview, Client presented with blunted affect and therefore at times it was difficult to ascertain her feelings or level of understanding on particular topics, especially related to the ACS process. Given Client’s history, it is a possibility that she lacks a sense of agency and therefore does not provide much input into decision making processes.
SLEEP PATTERNS: N/A
ACTIVITIES OF DAILY LIVING: N/A
ANXIETY/AGITATION/PANIC ATTACKS: N/A
BEHAVIORAL CHANGES: N/A
RACING THOUGHTS: N/A
SHORT & LONG TERM MEMORY
MENTAL STATUS EXAM:
Familiar objects (hold up hand, pencil, watch…)
Other people (family members, doctor…)
THOUGHT PROCESSES & CONTENT
The client denies any current suicidal ideation, any past suicide attempts or any current non-suicidal self-injury. She reports a history of passive suicidal ideation as a teenager but did not have any plan, intent or previous attempts. She also reports a history of one event in which she engaged in non-suicidal self-injury in which she scratched herself superficially with her nails. She denies any current or past homicidal ideations.
• Client is willing to engage in MH services and substance abuse treatment.
• Client has identified sources of support in her community and family
• She exhibits a sense of self-awareness and the function of substances in her life.
• Client has been observed to exhibit warm and appropriate interactions with her child
• baby was observed to be well cared for during the evaluation and during home visits.
Father, maternal grandmother, sister and mother.
CONCERNS: Client’s marijuana use and Client history of poor impulse control/lack of coping skills.
GOALS: Consistent engagement in MH services and substance abuse treatment.
Generalized Anxiety Disorder 300.02 (F41.1)
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least
6 months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least
some symptoms having been present for more days than not for the past 6 months):
Note: Only one item required in children.
1. Restlessness, feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse,
a medication) or another medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about
having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia],
contamination or other obsessions in obsessive-compulsive disorder, separation from attachment
figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder,
gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived
appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder,
or the content of delusional beliefs in schizophrenia or delusional disorder).
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington, DC: