Biopsychosocial Assessment and Treatment Plan


Question Description

Assignment: Biopsychosocial Assessment


  1. To practice utilizing a client’s personal information to create a concise, yet robust and appropriate, biopsychosocial assessment.

Students will receive a detailed case from the instructor. The students’ assignment is to develop a comprehensive bio-psychosocial assessment for this child’s needs, and on the basis of this assessment, recommend a plausible intervention plan with one overarching goal, two reasonable objectives, and two relevant tasks for each objective.


The paper is expected to have three sections, and be organized in the following sequence:

  1. ASSESSMENT INFORMATION (the “what” or facts that exist or are missing; 2-3 pages) Write this section in a succinct narrative using the following headings.
    1. Identifying Information
      1. Description of the identified client: name, sex, age, grade/occupation
      2. Description of the immediate family and/or others in the household
      3. Description of parent-child interaction with attached ecomap and/or genogram (attached in Appendix A [not part of 2-3 pages]) to understand the child’s environmental context
    2. Presenting Problem
      1. Referral source
      2. History of presenting problem
      3. Precipitating event for the child’s presenting problem
      4. Manifestation of the presenting problem and its developmental and/or behavioral impact on the child’s developmental functioning, and behavior toward others (siblings, peers, parents, teachers, etc.)
      5. Parents’ or caregivers’ understanding or perception of the child’s presenting problem
      6. Teachers’ or school environment’s perception of the child’s presenting problem
      7. Presence of other problems in the child’s environment subject to treatment
    3. Developmental History
      1. Health history
        1. Developmental history
      2. School history
      3. Family (history of caregivers, substance abuse, violence, mental illness)
    4. Current Child Functioning
      1. Present developmental capacity in physical and mental and social functioning for age
      2. Current school and education functioning: Academic achievement, behavioral interaction with peers and adults in school context.
      3. Child’s own awareness and perception of the presenting problem
      4. Child’s strengths and competencies to cope or manage the presenting problem
      5. Presence of family resources, strengths, and capacity for addressing the problem
      6. Presence of any environmental resources or connections
      7. Presence of environmental barriers or challenge
  2. PSYCHOSOCIAL FORMULATION (1 page; of the child ONLY).
  3. TREATMENT PLAN (2-3 pages)
  1. Identify one overarching treatment goal. Discuss the rationale or logic for selecting this goal, and support your choice based on the child’s presenting problem and agency services.
  2. Select two objectives that serve to achieve the overarching goal. Discuss the rationale or logic for selecting each objective and support your discussion based on the information presented in section I of this paper.
  3. For each objective, present at least two tasks. Discuss who is responsible for carrying out each task, the timelines for task completion, how task completion would be measured (including tracking tools if relevant), and why the task is central to problem resolution.

Notes for developing this assignment:

  • Section I is expected to focus on the “facts” in the case without any subjective interpretation.
  • Section II focuses on your interpretation, analysis, or assessment of the situation.
  • Section III develops the treatment plan based on the proposed or recommended data collection and theoretical assessment of the situation.
  • The overall paper is to be 7-11 pages in length. This includes a title page, 5-7 pages of content, a reference page, and your appendix/appendices.
  • The paper should be formatted using APA format, be double spaced, and use font sized 12, Times New Roman.
  • This paper does not need to have an abstract.

Unformatted Attachment Preview

SSS805 Final Assignment Case Study: Isaiah Isaiah Butler, born April 25, 2007, is a 9 year old African American male who currently resides in Washington DC. Isaiah resides in a shelter for homeless families with his mother, MaryAnn, and 6 year old sister, Sasha. Isaiah and his family have been referred to your agency from the social worker at the local school, Court Street Elementary School, where Isaiah and Sasha both currently attend. As per the school social worker, Isaiah presented to school last week with a gun in his backpack. The gun was found after Isaiah shared with a peer that he brought it to school. His peer, feeling afraid, told the classroom teacher, who then looked in the backpack and called school security. When asked about this specific incident, Isaiah presented with flat affect. He explained that the gun was given to him to hold on to by a friend but would not tell any adults who the friend was. He then stated “But of course I’m in trouble, right?” Isaiah was born in Washington DC at Washington Hospital Center. MaryAnn did not know she was pregnant until 10 weeks, but received regular prenatal care after that time. Isaiah was born full term via vaginal birth without complications. He weighed 6 pounds 7 ounces at birth. He reached developmental milestones at respective stages. Aside from 2 days in the hospital due to minor concerns from an infection on his chin last year, Isaiah has never had any health concerns or surgeries. Isaiah has always been able to make friends easily, but has never identified a best friend other than his little sister. As a toddler Isaiah related well to adults, but had a noticeably avoidant attachment to MaryAnn. Isaiah has attended Court Street Elementary School since PreKindergarten, which started when he was 3 years old. He has been very close with one security guard, Mr. Walters, and his 1st grade teacher Mrs. Green, for many years. It is often one of those two adults he seeks out when eloping from his classroom. SSS805 Final Assignment Case Study: Isaiah Isaiah has a history of chronic and severe behavioral difficulties characterized as intense opposition/defiance, disruptive/aggressive behaviors towards peers and school personnel, and resistance in response to adult redirection. Isaiah’s history is remarkable for behavioral concerns, impulsivity, and inattention, which reportedly date as far back as preschool. One month prior to this incident, Isaiah was assessed at the local children’s hospital after threatening to climb out of a window at school and kill himself. He did not make an attempt, but continued to state the threat in order to avoid classwork that was challenging. The school social worker called MaryAnn and stated that she needed to come pick him up from school and take him to the hospital, which she did. During the assessment it was shared that when Isaiah was 4 years old, he tried to slash tires in his neighborhood using a butter knife from the house. MaryAnn described this as “play”, sharing “Isaiah witnessed someone slashing tires on television and was just playing around.” Isaiah was not admitted to the hospital, but an appointment was made with a child psychiatrist so that he could be fully assessed, as the emergency room doctor suspected ADHD and Oppositional Defiant D/O. MaryAnn did not take Isaiah to the appointment, stating that she did not have transportation and that she feared they would put Isaiah on medication. MaryAnn followed through with the appointment at your agency after it was made clear that not following through would lead to a mandatory call to Child and Family Services. The family has been residing at the homeless shelter for 8 months. Prior to that time they were residing temporarily with Isaiah’s aunt, MaryAnn’s sister, Margaret. Isaiah is having difficulty adjusting to the environment of the shelter due to the overcrowded conditions and having to share a space, which he has not had to do in the past. The family resided with Margaret since Isaiah was 2. Isaiah described his relationship with Margaret as positive, until the family moved. Margaret believes Isaiah suspects it is her fault, but neither Margaret nor MaryAnn SSS805 Final Assignment Case Study: Isaiah explained the reason for the move to the children. Prior to the move, Isaiah enjoyed cooking and watching movies with Margaret, and described her as someone who “cared how he was feeling.” Reportedly, Isaiah's biological father "abandoned" the family when MaryAnn was pregnant with Sasha. They had been married and have not since legally divorced, although the father has not made contact with the family since he left. MaryAnn reports that the father had “anger issues” and that she observes similar behaviors in Isaiah. Mother shared that she and the father used to both use drugs, and that she was using when she found out she was pregnant with Isaiah. She was able to stay clean until his birth, and during her pregnancy with Sasha, but has been using “on and off” since. She shared that this is the reason that her sister asked her to leave. MaryAnn describes her relationship with Isaiah as “challenging.” She feels guilty about her addiction and blames that on her not being able to be a “better parent.” She stated “I try my best, but I can’t do everything on my own.” MaryAnn has been offered substance abuse services through the shelter but has not followed through. She does not think that Isaiah knows what drugs are, or that she has an addiction. Isaiah and Sasha were removed from the home for a short period of time when Isaiah was 6 and Sasha was 3, due to MaryAnn’s severe drug use. They were placed in a temporary foster home until MaryAnn agreed to substance abuse therapy. Once MaryAnn enrolled in services the children were returned to her. MaryAnn completed her treatment program, but was clean for only 6 months after. While attending the treatment program, MaryAnn received a diagnosis of Depression. Medication was recommended but MaryAnn declined. During the time Isaiah and Sasha were in foster care, Isaiah became very protective of Sasha and has since referred to her as his “best friend.” They used to play well together, but this has occurred less and less. SSS805 Final Assignment Case Study: Isaiah Isaiah describes the relationship with his mother as “fine.” He does not feel that she cares about him, and sometimes wishes she would ask him about school or ask what he thinks about the move from Margaret’s house. Isaiah tried to ask questions but MaryAnn only shared “We don’t need Aunt Margaret anymore, so don’t ask to see her. She doesn’t love us anymore.” Isaiah has recently been absent from the shelter after school, which MaryAnn says she has no control over. She says that he does not want to be there, but does not know where he goes after school when he does not come home. When the family was living with MaryAnn’s sister, a group of neighborhood boys made attempts to recruit Isaiah into their crew. Since moving to the shelter, Isaiah has been walking to meet the boys after school. Although the crew members have never asked Isaiah his age, Isaiah has told them that he attends middle school. Although rare, when asked where he has been, Isaiah tells MaryAnn he is spending time with friends after school. Isaiah is often tardy for school and has had several absences in the last 2 months. When asked about these instances, MaryAnn plainly explains that “Isaiah is a big boy, so when he doesn’t want to wake up for school I cannot force him until he is ready.” Recent educational testing found Isaiah’s current intellectual functioning is estimated as below average. The school support team has provided weeks of prescriptive interventions for Isaiah, including academic support and one-on-one behavioral supports. Isaiah struggles to engage consistently in the academic and social environment. Peer and adult discord is often and Isaiah easily becomes angered. Isaiah displays verbal and physical aggression that results in his eloping or removal from the classroom environment. A Functional Behavior Assessment (FBA), completed by the school social worker, found that Isaiah is more likely to exhibit outbursts and mood dysregulation when avoiding academic activities. He becomes angered when confronted SSS805 Final Assignment Case Study: Isaiah by others, limits are set or with the removal of an activity or item. When Isaiah is asked to do a task that he does not want to do, he becomes irritable and annoyed. The FBA also found that Isaiah enjoys, and is motivated by, computer time, playing football, and receiving positive affirmations. A teacher interview was conducted with Mr. Blue, the Science and Social Studies teacher. These subjects are scheduled daily in the morning from 9 am until 10:15 am. Mr. Blue reported that the behaviors most concerning for him is when Isaiah “bothers the other students” by pushing, chasing and name calling. The behaviors occur in the classroom during instruction and the duration and frequency varies. The above mentioned behaviors are most likely to occur during structured activities and with any peer. Triggers for the behaviors are unknown and when Mr. Blue attempts to redirect Isaiah, he becomes angry and elopes from the classroom. Mr. Blue thinks the motivating factor for Isaiah’s behavior is avoiding classwork. He reports that Isaiah is a great writer and is on grade level. Isaiah is more likely to participate in class when asked to be a “teacher’s helper”, but Mr. Blue does not feel this “reward” is appropriate if Isaiah has not worked to earn it. The school hopes that MaryAnn follows through with this appointment and that a treatment plan can be created that meets Isaiah’s needs. They also hope that your agency can engage the family to ensure consistency, something that Isaiah is currently lacking. ...
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Biopsychosocial Assessment and Treatment Plan
Student’s Name
Institutional Affiliations




Biopsychosocial Assessment and Treatment Plan
Identifying Information
Name: Isaiah Butler
DOB: April 25, 2007
School: Court Elementary School
Parents: MaryAnn
Residence: Washington DC
Presenting Problem and History
Isaiah Butler was born in 2007 on April 25th and currently lives with his mother Maryanne
and sister Sasha. Isaiah and his family have been referred to my agency from a social worker at
Court Street Elementary School, where Isaiah schools together with his sister. According to the
social worker, Isaiah came to school last week with a gun in his bag, which was discovered upon
his disclosure to a peer about it. His peer talked alerted the class teacher concerning the issue,
resulting in the checking of his bag, after which the security personnel was informed. When asked
to explain the issue, Isaiah said that a friend of his had given it to him to take care of it but was not
ready to disclose further details.
MaryAnn, Isaiah’s mother, realized that she was pregnant with Isaiah, ten weeks into her
pregnancy. She later gave birth at Washington DC in Washington Hospital center. Isaiah's birth
was normal with no complications, and he weighed 6 pounds and 7 ounces at birth. Thus, he was
able to hit developmental milestones at respective ages. Apart from minor complications which he
suffered from a chin infection last year, he has never encountered any health surgeries or concerns.
Isaiah is good at making friends but is unable to find a best friend other than his little sister. As a



child, he interacts well with adults but was intentionally avoiding any form of attachment with
MaryAnn. Isaiah has been attending Court Elementary School from pre-kindergarten, which he
began at three years old. At the school, he has been having a close relationship with Mr. Walters.
One of the security guards, and Mrs. Green, his first-grade teacher. He always ensures that two
never see him when eloping from class.
Developmental History of the family
It has been observed that Isaiah exhibits a progressive pattern of severe and chronic
behavioral attributes such as aggressiveness towards his peers and school staff, defiance, and
resistance to any form of redirection by an adult. His past life is characterized by behavioral
concerns, inattention, and impulsivity, which dates back from preschool. One month before the
incident, Isaiah was assessed at a local children hospital following his threat to commit suicide.
Despite not jumping off the window, he kept threatening to take his life to avoid challenging class
assignments. The social worker, therefore, called Maryann to pick her son and take him to the
hospital. During the assessment, he tried to cut tires in the neighbor's compound with a knife he
had taken from their house.
Before starting the homeless shelter life, the family had been living with Isaiah’s aunt,
Margaret who is the sister to MaryAnn. Isaiah has a big challenge trying to adapt to the new
environment because the new shelter is overcrowded and they have to share space unlike in the
past whereby Margaret’s place had been spacious enough and comfortable since he was two years
old. The relationship between Isaiah and Margaret is described as positive until the family moved
to the new shelter whereby neither Margaret nor MaryAnn explained the reason for the shift.
Before shifting, Isaiah was passionate about watching movies and cooking with Margaret and
described the latter as an understanding and empathetic person. Isaiah's father had left them during



the period when MaryAnn was pregnant with Sasha. They remained in marriage because they did
not initiate any legal divorce process. Since he left, the father did not help or take responsibility
for the child. According to the report by MaryAnn, the father experienced characters, which could
have been passed on to Isaiah. MaryAnn also narrates how they had been using drugs with Isaiah's
father when she realized about her pregnancy with Sasha. She, however, managed to stop the habit
until her delivery time but kept going on and off the drugs, which made her sister chase her away.
When Isaiah was 6 and Sasha was 3, they were evicted from their home for a short period
because of MaryAnn's ultimate indulgence in drug abuse. They were taken to a temporary foster
home until their mother gave in to undergoing substance abuse therapy. She completed the
treatment program and remained sober for about six months. While going through treatment in the
program, she was diagnosed with depression. However, she refused the prescribed medication. In
the period when the two were living in a foster home, they bonded very well and became the best
of friends. However, after some time, the friendship started fading.
Current Child Functioning
Lately, Isaiah has been absent from the shelter after leaving school something MaryAnn
feels she is beyond her control. She says that Isaiah hates being in that place. She does not know
about his whereabouts after school whenever he fails to come home. During his stay with Margaret,
a neighborhood group of boys recruits him in their crew. He has, therefore, been going to meet
them after school, since leaving the foster home. Although the members of the team never
questioned him about his age, he informed them that he was attending a middle school. Whenever
Isaiah is asked about his failure to come home, he tells his mother that he has been with friends at
school. For the last two months, In most cases, he arrives at school late and has been absent on



several occasions. When questioned about these issues, MaryAnn says he cannot force him to
come home because he is already a big boy.
Recent educational testing indicated the intellectual functioning of Isaiah currently to be below
The support team of the school has offered prescriptive interventions for him, which entail
one on one behavioral supports and academic assistance. Isaiah struggles to adapt to the social and
educational environment consistently. Adult and peer discord happens often, and Isaiah is easily
frustrated. He demonstrates a high degree of aggressiveness leading to the teacher sending him
away from class. From a functional behavior assessment done by the social worker, it is clear that
the boy is likely to exhibit mood dysregulation and outbursts when escaping from academic
responsibilities. He quickly gets angry when asked a question by others or is asked to perform a
particular task. The assessment indicated that he gets motivated by computers, football, and
positive remarks.
Summary of Child Assessment Interviews

Educational Assessment- An interview was conducted with Mr. Blue the social studies and
Science teacher, whose subjects are taught every day from to 10.15 am. According to
Mr. Blue, when Isaiah disturbs other students by calling them names, pushing and chasing
is the most concerning thing. The behaviors take place in the classroom during learning,
and the frequency, and duration vary. Mr. Blue says that the possible motivating factor is
avoiding classwork

Functional behavioral Assessment –The social worker conducts a behavioral assessment
on Isaiah and realizes that he is likely to experience dysregulation of moods and outburst



when avoiding classwork. He concludes by saying that the only motivating factor for Isaiah
is playing football, positive compliments, and using a computer.
The outline of Isaiah’s life indicates mental problems, which makes it hard for him to live
with other people. Since his preschool age, he is seen to exhibit signs of severe mental challenges
that lead to being inattentive, impulsive and show other behavioural problems, such as
aggressiveness. It appears that the problem may have emanated from the father who had similar
anger challenges. From the incidence of trying to commit suicide, it is evident that the condition
is affecting his mind negatively and could lead to injuries or his death. MaryAnn also seems to
have other problems as seen by her refusal to take Isaiah for the assessment by a psychiatrist,
claiming that she had no means of transportation and did not want his son to be under medication.
Nevertheless, she seems to have a positive attitude towards the agency, where she follows up on
the matter after being threatened and forced to make a compulsory call or child, and family support
will be halted.
Since Isaiah had adopted to a good life at his aunt’s place, the overcrowding in the shelter
could be affecting his...

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