Module Five

Activity three – Taking a Case History

As part of this module, you will be doing a case study of a youngster. It is always easier to do a real child rather than trying to contrive the experience. To make the experience and use of time most practical, try this on a student in your current class. Even if you do not have access to a youngster, you can choose someone you know and go through the experience. Here is a good example of a social history. Review the material and decide which questions you will use to do your case study.

Directions:

1. Make a list of the questions you will pose. Send that list in the response box. It should be fairly thorough, and developed so it can flow with the person, as suggested in the previous reading about taking a medical history.
2. Now get the permissions you decided upon in your ethics assignment, based on FERPA and best ethical practice. Remember to send a copy of the release you will be using. You can keep the actual release for your files.
3. Time to actually conduct that social history.
4. Finally, you will write that social history into a document. It could end up being as long as 6-10 pages. For the purposes of this assignment, it can be a second draft – generally clean and well written. You will want to use initials or a pseudonym for the people so their privacy is maintained, even from your instructor.

Remember:

You are doing this because you want to know more about a youngster so you can gain second person perspective --- really care about him or her, really understand and gain insights about the family that will add to your level of compassion.

Sample Social History

I. Descriptive data

Client identifying information (name, address, phone, age, ethnicity/race, etc.)

II. Referral information

A. Source of referral

B. Reason for contact

1. Challenges faced

2. Previous attempts to resolve

Personal Professional

3. Other professionals currently involved

III. Bio-psycho-social-spiritual assessment

A. Individual Functioning

1. Developmental phase

2. Current capabilities

a. Physical

b. Emotional

c. Psychological and philosophical

d. Social and interpersonal

e. Intellectual or cognitive

3. Areas of need

B. Cultural functioning **

1. Race/ethnicity

2. Primary language/other languages spoken

3. Elaboration of cultural identity

4. Cultural strengths

5. Experience of discrimination or oppression

C. Family information (names, ages, involvement with client)

1 - Spouse/partner

2. Parents

3. Siblings

4. Children

5. Extended family members

D. Family interaction

1. Extent of support

2. Family perspective on client

3. Client perspective on family

4. Family rituals

5. Important "family stories"

6. Relevant family issues

E. Natural support network

1. Significant relationships

2. Nature of involvement

F. Physical environment

1. Housing situation

2. Financial stability

3. Transportation resources

4. Neighborhood

G. Nodal events (situation and client's response)

1 - Deaths of significant others

2. Serious losses or traumas (violence, abuse, oppression, suicidal attempts, etc.

3. Significant life achievements

4. Recent ecological transitions

H. Education

1. Current level of functioning

2. Issues and needs

3. Significance of education to child and family

• Areas of greatest concern
• Behavioral issues
• Time on task
• Interactions with others

Adults

Teacher in charge

Friends

General student population

I. Family Employment

1. Current job both parents - type of work, length of employment (may include field placement)

2. Previous experience, including military

3. Skills, special training

4. Significance of work to family and how it impacts the child

J. Medical History of the child

1. Birth information

2. Illnesses/accidents/ surgery

3. Medications used

4. Family medical issues

5. Physical limitations

6. Diet

7. Alcohol and drug use (including periods of abstinence)

K. Spiritual

1. Religious involvement, including childhood religious training and practice

2. Family view of spirituality

 L. Social activities

1. Interests

2. Clubs/organizations

3. Preferred recreation

4. Travels

IV. Initial Assessment

A. Family's perspective on current situation

B. Student's perspective on current situation (patterns of behavior,

connections between historical information and present situation,

relationship between child and environments)

C. Strengths of family system - personal, familial, social, spiritual, community, cultural

D. Motivation

E. Resources

1. Available resources

2. Resources needing development (include skills needing to develop, as well as external resources)

   Adapted from Miley & O'Melia

  Three response boxes will be needed here: