Problem:
Clinically re-write
Sophia has been doing well in session; she is beginning to open up more and express herself in a positive way. Sophia continues to struggle with peer conflict within the home. We continue to discuss healthy relationships in sessions; Sophia continues to express that she wants to learn how to make and maintain healthy relationships. Sophia has expressed that she is enjoying her time spent with Ms. Robin on her passes she and Ms. Robin reports that the visits are going well. We were able to have a family session in which we discussed boundaries and expectations while visiting her home. Overall session went well; we also discussed a watch that was purchased for Sophia that had a camera. Ms. Robin was advised that there are no cameras devices allowed in the home to protect Sophia as well as other residents in the home. The camera that was confiscated did contain inappropriate pictures of Sophia. We discussed this in session and discussed age-appropriate activities, as well as discussed, the dangers surrounding taking inappropriate pictures. An ongoing discussion in sessions will be age-appropriate activities, interactions and how to build healthy relationships.
A concern that I continue to have with Sophia is her inability to have positive social connections as well as healthy relationships. We can discuss further in our upcoming treatment meeting. It was reported that while on pass with Ms. Robin there were cupcakes that were made to celebrate her three-month anniversary with her "boyfriend". Because Sophia's struggles with knowing the difference between positive and negative relationships the way in which she interacts with this young man really should be monitored. We have a message out to the school to follow-up on the cupcake celebration as it is not common that a school would allow a celebration for an anniversary/timeline in a relationship. I continue to work with Sophia on focusing on herself as she is really not in a space to focus her attention in other areas.
Please note that Sophia was restrained on Monday as a result of getting in an argument with a peer, Sophia was allowed to retreat to her room in an attempt to reset. Staff noticed that Sophia has a metal ended sharp comb in which she verbalized that she wanted to harm herself. Sophia then began to engage in headbanging behaviors in which staff quickly intervened utilizing our Ukeru Intervention. Sophia's behaviors continued to escalate which required a physical intervention. Staff were able to contact me via phone in which Sophia was able to deescalate utilizing some deep breathing and ground techniques.
Education Update
Sophia has been having her ups and downs in school. She's had some days that have gone well in school where she really stayed on task and earned level 4's, which is the highest level to earn. She's also had some days where she struggled to stay on task and not insert herself in other people's issues. She's struggled some days in school with being disrespectful to staff, staff splitting, and pushing boundaries. All in all, Sophia has been able to reset the majority of those days and finish off the school day on a good note. Sophia still does struggle with not inserting herself into other youth's conversations and issues in the home. She has been instigating some issues with the other youth at times, such as bringing up incidents that other youth have done or been involved in, which causes conflict. She did have to be restrained earlier in the week as well. Sophia struggles when staff gives non preferred directives or rules and often becomes disrespectful. She has had some good days where she tries to stay positive and is able to follow staff's instructions. Sophia is continuing to work on focusing on herself to stay out of trouble. Need Assignment Help?