Jenny Davis Case Study

Progress Review- Cheyenne Davis
Please list outcomes of any/all drug screens. Please include the date, type, results, and substance (if applicable)
Not applicable
Progress in treatment: (please choose either moderate-significant-slight improvement, or moderate-significant-slight deterioration, or no change) ISSUE PROGRESS
Anger Outburst Regression. Client continues to have behaviors in her school setting which resulted in her hours being increased.
Night Terrors Slight Deterioration- Client had an incident in which she was climb into the bed with her mother and start to display inappropriate sexual behaviors towards her mother.

Please include any/all changes or updates in diagnosis:
Current diagnosis:

AXIS I:
296.90 Mood Disorder
307.46 Sleep Terror Disorder

AXIS II: Deferred

AXIS III: None

AXIS IV:
Limited peer interactions, inconsistent parenting and multiple family members providing care/discipline

GAF:
N/A

Please list any/all medications: (please include dose amount, frequency, prescribing physician, and target symptom)
Current meds include: Methylphenidate 36mg extended release 1 x morning Abilify 2mg tab 1 x evening

Have other medications been tried and discontinued since last review? If yes, please list medications and response to them.
No.
Is the client in danger to himself or herself or someone else due to mental illness or substance abuse? If yes, how?
Client’s anger outburst does not put her and others at risk, but she recently displayed inappropriate sexual behaviors which has alerted a concern of client and others.
Describe the safety plan developed for the child:
Separate CT from targeted peers/people
Designated area for CT to calm down
Help CT replace negative thoughts with positive thoughts
If appropriate:
Number of unscheduled medication (PRN) for agitation/aggression since last review? None
Number of seclusions/restraints since last review? None
Number of incident reports completed since last review? None

Number of family sessions since last review? 3 Family sessions
How many scheduled? 3 Family session schedule.
How many attended? 3
Where were sessions held? (community, home, office, over the phone?) Client’s home, school and psychiatrist office.
Describe steps taken to address any family related impediments to step-down.
None at this time. Client is exhibiting inappropriate sexual behaviors at her home which needs to be address in order to provide family with therapeutic strategies to improve family situation. In addition, the client has been having outburst in here classroom setting. The Outpatient Therapist is providing the family with IEP/504 support in the school setting to ensure clients receive the accurate classroom setting.
Number of individual sessions since last review?
How many scheduled? 7 How many attended? 7
Where were sessions held? (community, home, office, over the phone?)
Session were held in the community, home and school.
Number of group sessions since last review?
How many scheduled? 7 How many attended? 7
Number of med checks since last review?
How many scheduled? 1 How many attended? 1
Number of internal aids/CI sessions since last review?
How many scheduled? 9 How many attended? 9
Describe how the client functions in his/her neighborhood and the community?
Client is continuing to work on social skills in addition to express herself when reflecting on negative interaction with others in school.
Describe how community resources/community support, including extended family, is being utilized by client. Note steps taken to address any impediments to step-down:
Client has a strong support system.
Current school? Towne Point Elemen Grade? 2
Any behavioral problems in school? If yes, please explain:
Client continues to display behaviors in her classroom setting. The school has requested her parents pick her up on multiple occasions as she is being removed from the classroom due to her outburst. Client’s hours have been increased as the school wants some support in the classroom by observing the client’s behaviors. There was a school meeting which suggested they will evaluate the client for special educational services as she requires a small classroom environment.
Are there any changes or updates necessary in classification, IEP, or class placement? If yes, what steps are being taken to ensure these changes are made?
Client is being evaluated for an IEP/504
Describe programs contact with home school, if applicable: Not applicable
Are there any significant changes in the client’s physical health since last review?
If yes, what steps are being taken to treat this problem? There are no changes in client’s health.
Please explain why this client cannot be treated at a less restrictive level of care including barriers to step-down.
Client hours were increased from 6 to 10 due to her erratic outburst behaviors in her classroom setting. The client works better in a smaller environment where she is able to receive down-time and attention when she has an outburst. Therefore, the client is in need of an IEP/504 plan with a Behavioral Intervention Plan to provide supported intervention in the classroom setting. This will also allow the Therapeutic for Support worker to help client improve her social skills ability in the community.
Describe the current discharge plan: None
Please include a brief summary of the client’s progress in treatment, including any barriers to treatment and/or
recommendations…
Client has been active in the IOP program for 9 months and will continue services in the Outpatient program of New Behavioral Network. Client has recently disclosed a sexual incident which involves a former Doctor and a report was made which lead to an open investigation. The client has also display inappropriate sexual behaviors which has become a concern and will possible receive services at another agency to target her inappropriate sexual behaviors while continuing to work with New Behavior Network on aggression and family support. Sarina Wilson, OPT