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Posted: April 25th, 2023

Patient is a 7-year-old Caucasian female who is present

Write FOCUSED Soap Note Week 9
CHILD CASE
2. Patient is a 7-year-old Caucasian female who is present for a follow-up visit. The client is accompanied by her mother. Her general appearance is neat and well-groomed in casual clothing. She is mildly intrusive initially but cooperates more appropriately as the session progresses. The client is A&OX3. Her mood is irritable; Affect is congruent with mood. Her diagnosis includes oppositional defiant disorder. No psychopharmacologic treatment is indicated currently. The client’s mother reports that the client has begun to see some adults, teachers, and even parents as possible allies as she has decreased her hostile attitude. She identified that the client often has temper tantrums and defiance of direction from adult caregivers. There has been a noticeably marked decrease in the client’s lying and she has started taking responsibility for her behavior. Family therapy was used during the session. The client’s mother was coached in setting limits and the skills necessary to maintain an authoritative approach with their child. Information regarding positive parenting and child development was provided to the mother, including the importance of boundaries and structure to promote children’s sense safety and security. The client was taught new ways to conceptualize and manage anger. Her family therapy will continue every two weeks for three months.

Subjective:

Patient is a 7-year-old Caucasian female who is present for a follow-up visit. The client is accompanied by her mother. Her general appearance is neat and well-groomed in casual clothing. She is mildly intrusive initially but cooperates more appropriately as the session progresses. The client is A&OX3. Her mood is irritable; Affect is congruent with mood. Her diagnosis includes oppositional defiant disorder. No psychopharmacologic treatment is indicated currently. The client’s mother reports that the client has begun to see some adults, teachers, and even parents as possible allies as she has decreased her hostile attitude. She identified that the client often has temper tantrums and defiance of direction from adult caregivers. There has been a noticeably marked decrease in the client’s lying and she has started taking responsibility for her behavior.

Assessment:

The patient is a 7-year-old female diagnosed with oppositional defiant disorder. The client’s mood is irritable, and she presents with mild intrusive behavior. The client’s mother reports improvements in the client’s behavior, with a decrease in lying and an increase in accepting responsibility for her actions. Family therapy was used during the session to coach the mother in setting limits and maintaining an authoritative approach with their child. The client was taught new ways to conceptualize and manage anger.

Plan:

The client’s family therapy will continue every two weeks for three months. Information regarding positive parenting and child development was provided to the mother, including the importance of boundaries and structure to promote children’s sense safety and security. No psychopharmacologic treatment is indicated currently.

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