T.W Case Presentation

T.W Case Presentation

Demographics

T.W is a 12-year-old, African American, female who was referred for services by her mother due to being shot last Easter. She is currently in the 7th grade and is strong academically.  T.W is the youngest of three children. She currently lives in a 5 bedroom house with 9 other family members in the Englewood Community. Client indicated that she does not have a particular religious or spiritual orientation, but reports her family attends a Baptist Church occasionally. Client identifies herself as a heterosexual. She reports that she is not currently sexually active.

Key Findings

T.W presents with symptoms that are in alignment with Post Traumatic Stress Disorder. She reports that she has difficulty concentrating in class due to intermittent traumatic flash backs, problems sleeping, and complains of being easily startled consistently since being a survivor of gun violence. She also reports that she experiences a loss of appetite, which has resulted to weight loss , and a loss of interest in activities she use to enjoy. T.W indicated that she has experienced the majority of these symptoms for the past year. Client reports that her symptoms are triggered when she has to walk home from school. She stated that in order to get home, she must walk near the place where she was shot.  Client reports being afraid that she will be shot again or someone in her family will also become a victim of gang related violence. She also indicated that the police accused her family of being gang affiliates and believed her family to be intended targets. T.W teacher reports that she appears withdrawn from friends, sad, and is often observed crying at her desk.  Client denies suicidal ideation, however according to her 6th grade teacher client was evaluated last May by SASS due to writing a letter to a friend stating that she wanted to kill herself.

Social Workers Clinical impression

Client initially difficult to engage and did not appear interested in receiving services. After the 3rd session, client begin to open up and trust Clinical intern. Client often presents with a flat or labile affect. She often presents with minimal energy, poor eye contact, and demonstrates poor social skills.  Client does not present with any Suicidal/Homicidal ideations or self-harming behaviors. Barriers to treatment consist of lack of insight into trauma, unsafe/unstable living conditions, family gang involvement, limited support, history of physical abuse, and history of family involvement in legal system.

Background

Although client’s mother lives in the home, client reports that she is being raised by her grandmother. She stated that she does not rely on her mother for support because she does not feel that her mother can keep her safe. Client indicated that her mother lacks skills to take care of her. Client reports that he mother was in prison for a few years, and she does not have a strong relationship with her as a result. Client reported that she witnessed domestic violence between her parents. Also, Client stated that she is angry with her mother because her mother did nothing to prevent the domestic violence. In addition, Client reported that her mother allowed her father to physical abuse her a few years ago, which now has caused a strained relationship between her and her father. She states that he has always been inconsistent in her life and she addresses him by his first name. Client reports that her grandmother is her “angel” and she feels safe in her presence. Client reports that she has a good relationship with her siblings and other relatives that reside in the home. However, client indicated that she feels smothered because of how many people live in the residence.  Client reports that she likes being at school because she get a break from her family. Client was shot at the age of 11, and reports that after the shooting she met with the School Social Worker for about a month. She indicated she did not receive any other outside services.