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Jamal Miller (13), an 8th grader with ADHD diagnosed in 2021, is the index client. Since 2023 he has lived in Loretta's kinship home, a temporary placement with his grandmother, Loretta Jackson (60), a certified nursing assistant with diabetes since 2015. With them live his sisters, Aaliyah Miller (16), an 11th grader with anxiety since 2024, and Zoe Miller (9), a 4th grader with asthma since 2019; Zoe's fraternal twin, Zion Miller (9), a 4th grader; and their half-sister, Nevaeh Delgado (2), a toddler, who has had neonatal abstinence syndrome from birth and was placed with Loretta straight from the hospital. Since 2024 Loretta has been the legal guardian of Jamal, Aaliyah, Zoe, Zion and Nevaeh.

Presenting problem: fights at school and a shoplifting charge in 2026. Loretta says Jamal is "just like his father". A date convergence: Jamal was charged at 13, the age his father was at his first arrest, in 1998.

Recent changes: the children's mother, Tasha Miller (née Jackson, 39), unemployed, has had polysubstance use since 2006 and is still using; she lost custody in 2023 after an arrest for possession and misses most visits. She married DeShawn Miller (41), a barber, in 2009, and they separated in 2020. DeShawn has been in state prison since 2022 for drug distribution, with earliest release in 2029. Since 2019 he has had an affair with Keisha Brown (36), a retail manager; their son, Darius Brown (6), a kindergartner, is half-brother to Tasha's children, and Keisha takes him to visit DeShawn in prison. Since 2023 Tasha has lived with her partner, Ray Delgado (43), a day laborer with drug misuse and Nevaeh's father.

Extended family: Loretta married Curtis Jackson (1963–2018), a forklift operator, in 1986. He had alcohol misuse from 1985, drank through his children's childhoods, beat Terrence and died of a heart attack in 2018, leaving her widowed. Tasha's brother, Terrence Jackson (36), a peer recovery coach, had polysubstance use from 2008 and has been in remission since 2021; he attends NA. He married Alicia Jackson (née Reed, 35), an elementary school teacher, in 2018, and in 2022 they adopted Elijah Jackson (11), a 5th grader, from foster care; the three make up the Jackson–Reed household. Loretta's parents are Willie Johnson (1941–1999), a sanitation worker who died of lung cancer, and Hattie Johnson (80), a retired domestic worker; they married in 1964, Hattie was widowed in 1999, and she takes the grandchildren to church every Sunday. DeShawn's parents, Darnell Miller (1961–2004), a bus mechanic, and Bernice Miller (63), a school custodian, married in 1984; Darnell died of a gunshot wound in 2004, when DeShawn was 19, leaving Bernice widowed. Bernice petitioned for custody in 2023 and takes the children to visit their father monthly.

Patterns: Aaliyah is Zoe's caretaker; she parented her while their mother was using. Loretta, Tasha and Jamal form a triangle: Loretta and Tasha are close but hostile, Loretta is focused negatively on Jamal, and Tasha is distant from him. Jamal is close to his father and speaks to him every Sunday. Tasha and Keisha are hostile. Curtis was physically abusive to Terrence, who cut Tasha off in 2024 to protect his sobriety. The two grandmothers, Bernice and Loretta, are hostile, and Hattie is close to Loretta.

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Rohan Patel (26), born in 2000, is the index patient, a software developer. A workplace health check at 25 found an HbA1c of 44 mmol/mol and a BMI of 29, in the prediabetes range, and he has been referred to the diabetes prevention programme. The Patels are a Gujarati family.
His father, Arjun Patel (55), born 1971, is an IT project manager. He was diagnosed with type 2 diabetes at 46 after an HbA1c of 58 mmol/mol and with hypertension at 49, and takes metformin and a statin. Rohan is close to his dad. His mother, Meera Patel (née Shah, 52), born 1974, is an accountant; she had gestational diabetes in her first pregnancy, at 26, which resolved after delivery and is in remission, and her yearly HbA1c has been normal since. Arjun and Meera married in 1998.
They have three children: Rohan; Anika Patel (23), born 2003, a university student with irregular cycles and raised androgens, in whom polycystic ovary syndrome has been suspected since 21 and a pelvic ultrasound is pending; and Dev Patel (17), born 2009, a school student with a normal fasting glucose at a school sports medical and no conditions. Arjun, Meera, Anika and Dev share a household; Rohan lives elsewhere.

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Desmond Campbell (65), born 1961, a train driver, is the index patient, referred to the cardiometabolic clinic. He has had type 2 diabetes since 47, with an HbA1c of 71 mmol/mol on metformin and empagliflozin, and had a myocardial infarction at 58, stented in 2019.
Desmond's parents came from Jamaica. His father, Winston Campbell (1934–1999), a bus driver, arrived in 1958; he had hypertension from 40, poorly controlled for years, and died of a haemorrhagic stroke at 65. His mother, Gloria Campbell (née Brown, 88), born 1938, a retired nurse, followed in 1960. Winston and Gloria married in 1957, and she was widowed in 1999. Gloria has had hypertension since 50, type 2 diabetes since 52 and chronic kidney disease since 80, and has been on haemodialysis since 2024. In 2003 she married Clive Thompson (1935–2021), a retired carpenter; they were close until he died at 86 of heart failure, which he had had since 80, and she was widowed again in 2021.
Desmond's first marriage, to Paulette Grant (63), born 1963, a school administrator, lasted from 1988 until their divorce in 1996, and the two are still hostile. Paulette had gestational diabetes at 27, when pregnant with their daughter, and depression at 33, around the divorce; both are in remission. That daughter, Kezia Campbell (36), born 1990, a radiographer, is close to her mother and distant from her father. Kezia has lived with Jerome Baptiste (38), born 1988, a sound engineer with no cardiometabolic history, since 2019. They had a miscarriage in 2021. When expecting their daughter, Naomi Baptiste (3), born at term in 2023, Kezia had gestational diabetes at 33; it resolved after the birth, so it is in remission, and yearly HbA1c checks have been advised.
In 1998 Desmond married Fiona Campbell (née Ross, 62), born 1964, a Scottish practice nurse; they are close and live together, while Fiona and Paulette keep their distance from each other. Fiona started smoking at 16 and stopped in 2008, so it is in remission. She had been widowed in 1994: her first husband, Rory Douglas (1958–1994), a Scottish joiner whom she married in 1990, collapsed while playing football and died of sudden cardiac death at 36, and hypertrophic cardiomyopathy was found at post-mortem. Their son, Jamie Douglas (34), born 1992, a software tester, is Desmond's stepson, and the two have a hostile relationship. A screening echocardiogram at 30 showed a septal thickness of 14 mm, so hypertrophic cardiomyopathy is suspected and genetic testing is pending; Fiona is anxious and focused on his results. Desmond and Fiona's son, Callum Campbell (27), born 1999, the year his grandfather Winston died, is a delivery driver with prediabetes since 25 (HbA1c 45 mmol/mol); he is close to his half-brother Jamie.
Desmond's sister, Marcia Adebayo (née Campbell, 60), born 1966, a head teacher, has had type 2 diabetes since 45; it has been in remission since bariatric surgery in 2018. She is her mother's caretaker and drives her to dialysis. In 1991 Marcia married Tunde Adebayo (64), born 1962, a civil servant who emigrated from Nigeria in 1985 and has had hypertension since 50. Their daughter, Bisi Adebayo (33), born 1993, a junior doctor, had a normal blood pressure and HbA1c at her last check. Their son, Kunle Adebayo (30), born 1996, an electrician, has been smoking ten a day since 17 and has been offered stop-smoking support. Since 2023 Marcia and Tunde have fostered Jayden Cole (15), born 2011, a school student who has had obesity since 12 and attends a healthy-weight clinic; Marcia is close to him, and the three live together as a foster placement. Kunle married Priya Nair (29), born 1997, a dentist with no cardiometabolic history, in 2020; they live with their daughter, Zara Adebayo (5), born 2021, whose development checks are normal.

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Rachel Ortiz (née Reyes), born in 1987, is the client. She is a part-time dental hygienist with depression diagnosed in 2023, the year her divorce was finalised. She married Daniel Ortiz (born 1985), a software engineer, in 2012, and they divorced in 2023; their relationship is still hostile. Their son Leo Ortiz, born in 2015, is an elementary school student, and Rachel and Leo are close. Daniel pays child support: he gives Leo financial support every month.

Rachel's parents are Manuel Reyes (born 1957), a retired accountant with diabetes since 2012, and Carmen Reyes (born 1959), a real estate agent; they married in 1984. Since 2023 Manuel has given Rachel monthly financial support that covers her rent and Leo's after-school care. Carmen and Manuel have a close-hostile relationship: they are close, but they argue about the money and whether it keeps Rachel from standing on her own.

Rachel's younger brother, Andrés Reyes (born 1990), is a firefighter. In 2023 he signed Rachel's apartment lease with her; the co-signed lease makes Andrés liable if she misses a payment. Rachel wants to stop depending on her father within two years without losing the apartment.

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Jayden Webb (born 2014), an elementary school student with ADHD, is the index child. He and his sister Aaliyah Webb (born 2011), a middle school student with anxiety, were removed from their mother's care in 2024 and placed in kinship care with their maternal aunt and uncle. Keisha Morgan (née Carter, born 1984), a transit dispatcher, and her husband Darnell Morgan (born 1982), a postal carrier, married in 2008; the four of them have formed a temporary household since 2024.

The children's mother, Tanya Carter (born 1990), is unemployed and has drug misuse that began in 2019. Their father, Marcus Webb (born 1988), a former line cook, lived with Tanya from 2010 until they separated in 2022, when he was incarcerated; he is distant from Jayden and writes to him only now and then. Tanya has court-ordered visitation with Aaliyah and with Jayden twice a month at the agency office. Keisha and Tanya are sisters, and Keisha has cut off contact with Tanya since the removal.

The sisters' parents are Raymond Carter (1958–2015), a bus mechanic who died of heart disease, and Gloria Carter (born 1961), a home health aide with diabetes; they married in 1981 and Gloria was widowed in 2015. Gloria is close to Keisha and does the school pickups. Elena Ruiz (born 1979) is the county child welfare case manager; she has case manager contact with Jayden every month and reports to the court on the placement.

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This is a multi-agency child-welfare case with four generations. The index child is Jada Mendes.

Jada Mendes and her fraternal twin brother, Jalen Mendes, were born in 2012 to Ashley Dawson (born 1991) and Luis Mendes (born 1988). Both twins are 8th grade students. Jada has suspected anxiety, first noticed in 2024, and has long been Jalen's caretaker; Jalen has ADHD, diagnosed in 2019. Luis, a line cook, is an immigrant from Recife, Brazil. He and Ashley lived together from 2011 until they separated in 2017, and their relationship is hostile.

Ashley is unemployed. She has drug misuse that began in 2016 and depression since 2019. From 2018 she lived with Tyler Briggs (born 1990), a roofer with suspected drug misuse; they separated in 2022. Ashley and Tyler had a miscarriage in 2019, and their daughter Lily Briggs was born in 2020, making Lily the twins' half-sister. Lily is a preschool pupil with a speech delay identified in 2023. Tyler is distant from Lily. Ashley is now in residential treatment at Riverside Recovery Center.

The children were removed in 2024. The twins were placed in a temporary kinship household with their maternal aunt, Brenda Kowalski (née Dawson, born 1986), a medical receptionist, and her husband, Mike Kowalski (born 1984), an HVAC technician; they married in 2010. Mike is focused negatively on Jalen and blames him for the strain on the household. Lily was placed in foster care in 2024 with Martin Pruitt (born 1974), a civil engineer, and Gail Pruitt (born 1976), a foster carer and former teacher, who married in 2001. Their son Caleb Pruitt (born 2006) is a college student, and their daughter Hope Pruitt (born 2014), a 6th grade student, joined the family by adoption in 2016. Lily is close to Gail.

Brenda and Ashley's parents are Ray Dawson (born 1958), a long-haul trucker with alcohol misuse that began in 1978 and is now in recovery, and Linda Fisher (née Walsh, born 1960), a school bus driver with diabetes since 2015. Ray and Linda married in 1984 and divorced in 1995, and they are still hostile. In 1998 Linda married Gary Fisher (born 1956), a retired electrician, who is Ashley's stepfather; Linda and Gary live together. Linda and Gary are close, Gary and Ashley are hostile, and Linda and Ashley are close-hostile, so Linda is caught in a triangle between her husband and her daughter. Linda gives Brenda monthly financial support towards the twins' costs.

Linda's parents were Frank Walsh (1932–1998), a steelworker who died of heart disease diagnosed in 1990, and Irene Walsh (née Byrne, 1935–2019), a homemaker with dementia from 2013. They married in 1954, and Irene was widowed in 1998. Irene and Linda were close.

The agencies and the court. Since 2025 Ashley has had supervised contact with Jada, with Jalen and with Lily every other Sunday at Riverside, supervised by agency staff. Since 2024 Luis has had court-ordered visitation with Jada and with Jalen on alternate weekends. Renee Adler (born 1982), the county child welfare case manager, has had case manager contact with Brenda every month since 2024. Marcus Bell (born 1979), the middle school counsellor, is a support for Jada and sees her every week.

Date convergence: Irene died in the spring of 2019, Ashley's miscarriage followed weeks later, and both Ashley's depression and Jalen's ADHD diagnosis date from that same year.

The team must decide whether Ashley's progress supports reunification with all three children, and whether Lily can be placed with her half-siblings.