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Hernandez Family Assessment

Hernandez Family Assessment

Hernandez Family Assessment

The purpose of this paper is to complete a comprehensive assessment of the Hernandez family by addressing all information possible from the videos presented in this week’s module.

Part 1: Comprehensive Client Family Assessment

Demographic information

Juan Hernandez Senior, a 27-year-old Latino man, married to Elena Hernandez, a 25-year-old Latino woman, and have two sons, Juan Jr., 8-years-old and Alberto 6-years-old.

Presenting problem

The Administration for Children Services (ACS) referred the family for allegations of child abuse.

History of present illness

Mr. and Mrs. Hernandez are questioning why they are here. They are “punishing the children the way we were when we were their age”. Mr. Hernandez discusses how his father would make him hold encyclopedias for “hours” when he did not obey his father. They both express they are good parents, and everything they do is to better the children’s lives.

Past psychiatric

The style of punishment has been passed down from Mr. and Mrs. Hernandez parents. Both describe punishment by their parents as “misery”.

Needs to be added to

Medical history

Needs to be added to

Substance use history

Needs to be added to

Development history

There appear to be no developmental delays in any member of the family at this time

Needs to be added to

Family psychiatric history

Mr. and Mrs. Hernandez appear to be very concerned about the reason for the referral. They seem to care genuinely for their children. In discussing their upbringing, there doesn’t seem to be a family history of mental illness.

Psychosocial history

Mr. Hernandez appears to be the primary source of income, per the discussion of overtime and the inconvenience of having to attend meetings.

History of abuse/trauma

Juan Jr has reported no other form of abuse except for the type of punishment of holding encyclopedias.

Review of Systems:

Needs to be added to

Physical assessment

All members of the family appear to be in good health.

Needs to be added to

Mental status exam

All members of the family are appropriately dressed and well groomed. The sons are playing together appropriately. Mr. and Mrs. Hernandez’s speech is clear and appropriate. Mr. Hernandez is visibly upset about the ACS claims. Mr. and Mrs. Hernandez appears at this time to be mentally stable with no abnormal thought processes, insight, or judgment.

Differential diagnosis

V62.4 – Target of (Perceived) adverse discrimination or persecution (APA, 2013)

The therapist expresses concerns that there may be evidence of discrimination committed by the ACS worker using the term “Mexicans” when discussing the case. The Hernandez case could be a valid concern and should be discussed further between supervisors.

Diagnosis

V61.20 – Parent-Child Relational Problem (APA, 2013)

Juan Sr admitting to disciplining Juan Jr. in maybe an inappropriate manner supports the diagnosis. Although there is no physical abuse, the mental consequences of using book holding as a punishment could lead to Juan Jr. avoiding books in school. This avoidance could lead to poor performance in school later on.

Case formation

ACS has referred this family for investigation of abuse by the father (Mr. Hernandez) for possible inappropriate punishment of son (Juan Jr.). Both parents appear to be very concerned about this accusation and express their concerns and frustrations appropriately. Both sons are present and appear to be interacting appropriately without aggression. Mr. Hernandez discusses attending parenting class as an inconvenience by having to miss overtime, which is essential to provide for his family. Mrs. Hernandez expresses concerns about keeping the family together. Both agree to ACS recommendations of attending parenting classes.

Treatment Goals

Goals: 

Teach safe and effective discipline skills

Teach age appropriate behavior

Teach managing of frustrations

Treatment strategy/interventions: 

Positive Parenting Program and family therapy can assist with attaining set goals for this family.

Estimated completion: 12 weeks

Part 2: Family Genogram

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

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Address in a comprehensive client assessment of the Hernandez family the following:

  • Demographic information
  • Presenting problem
  • History or present illness
  • Past psychiatric history
  • Medical history
  • Substance use history
  • Developmental history
  • Family psychiatric history
  • Psychosocial history
  • History of abuse and/or trauma
  • Review of systems
  • Physical assessment
  • Mental status exam
  • Differential diagnosis
  • Case formulation
  • Treatment plan

What is the purpose of family assessment?
What happens in a family assessment?
What is a family assessment in nursing?
What are professionals looking for when assessing a child and their family?

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