SOAP Note and treatment plan based on the information provided

SOAP Note and treatment plan based on the information provided

Subjective Data, objective data, assessment, plan, and professional application.

Case Vignette—Joshua

Presenting Situation

Joshua is a 12-year-old boy who attends Middle School as a 6th grader. Joshua has been in placement with his grandmother for several months. His behavior has been on the decline since his middle sibling was recently placed in the home with him. He was strongly reactive to any signs that his sister was receiving more attention than he was. He becomes easily angered, his moods shift from constricted to volatile, with frequent angry outbursts, that carryover to and interfere with school. Joshua shows multiple signs of arousal (e.g., difficulty sleeping, impaired concentration, edginess, and irritability). He was recently diagnosed with oppositional defiant disorder and ADHD although he doesn’t yet have an IEP. In school, he is taking the following classes: Remedial Reading, Math, 6th grade Science, Art, Social Studies, and P.E. His favorite class is Art, and the Remedial Reading class is his least favorite. He is at least two years behind in reading. When he is in a happy mood, Joshua is talkative and social with his peers.

Joshua’s grandmother, who has her own history of childhood trauma, has become more depressed and overwhelmed by his emotional outbursts and she has had difficulty providing consistent caretaking to either of the children, including sending them to school. She is reluctant to contact the school as it just adds one more overwhelming responsibility to her life.

Trauma History

Joshua has been in the care of his grandmother since he was 18 months old at which time Child Protective Services removed him from his parents’ care due to neglect, physical abuse and parental substance abuse. When initially interviewed by CPS the mother acknowledged that she was under tremendous stress due to an often-violent relationship with her husband. She admitted that caring for Joshua was difficult because he was often irritable and rejecting of her attempts to console him. At other times, he was very restless and clingy toward the mother, especially when the father was present. She also said Joshua was “slow to develop.” The mother admitted that she and her husband had a history of drug and alcohol abuse.

At age 5, an attempt to reunify Joshua with his parents failed when he was once again removed from their care due to a report made by his Kindergarten of seeing bruises on Joshua’s legs and arms. He was placed back in care with his grandmother and has been with her since. His parents have separated, and he only sees his mother at family events and holidays. He has had no contact with his father since the second set of allegations was substantiated when he was 5.

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