Case Study

Case # 1 Imoan

Imoan is an 11 year old girl whose mother, Ms. A, brought her into the clinic seeking a second

opinion regarding her diagnosis. Ioman has been in psychotherapy for 4 years, with Ms. T, a

clinical social worker in private practice.

Around the time of her parents divorce 4 years ago, Ioman began to show behaviors that worried

her mother. At first, Ms. A thought these behaviors were in reaction to her and her ex-husband’s

separation, but the behaviors have continued or worsened. Her therapist has diagnosed her with

ADHD and depression. She has had academic difficulties in school, such as lack of attention

(she seems to “space out” at times and does not seem to be paying attention in the classroom)

which led to the diagnosis of ADHD. According to Ms. A, at times Ioman has an unusual way of

relating to others; she can be friendly and upbeat and suddenly, for no apparent reason, become

angry and sulky. She can behave in a seemingly mature manner sometimes, while at other times

she can show immature behaviors such as clinging and sucking her thumb. Her mother describes

her affect as flat sometimes, “as if she were daydreaming or far away; not quite there”.

Something Ms. A remarked on was that, at times, Ioman calls one of her friends’ mother “Mom”,

even in Ms. A’s presence. This began from the time that she first met this woman. At this time,

Ms. A is considering trying medication for Ioman, which has been previously recommended,

because Ioman’s behaviors have recently escalated. She has angry outbursts on a daily basis

during which can become physically aggressive. She has been abusive towards the family’s cat.

Recently she has also begun to act in a highly sexualized manner. She is very interested in

female singers and entertainers who are considered “sexy”, and imitates them in her clothing and

mannerisms. Recently, while dancing at home with some friends, she took her clothes off. Ioman

has several friends from school that she visits, and who visit her. She also takes dancing lessons.

Ms. A describes her pregnancy with Ioman as well as her birth and infancy as uneventful. Ioman

has been healthy aside from fairly common conditions such as ear infections, colds, etc. Ms. A

describes Ioman’s teachers as very supportive and understanding but feeling frustrated by the

fact that they have not been successful in figuring out how to best help Ioman. In a note they

sent with Ms. A they said that “The behavior management strategies that we have put in place

seem to work some times, but not others. At times, Ioman cannot sit still; and at other times

seems tired and distracted. She often seems to be ‘on edge’, irritable, impatient, uncooperative,

having to always get her way. Other days she can be funny, and lead her classmates in games at

recess. We do not know which Ioman is going to come from day to day. She is a friendly, smart

girl but it is difficult to consistently get her to do her work in the classroom. We have tried to

give her more individualized attention. Sometimes she enjoys it and other times she is bothered

by it. Rewarding her for on-target behavior seems to work sometimes, but other times, it doesn’t

matter what we do; she seems to have a mind of her own and no one can change it. We would

appreciate any suggestions you may have for us to help Ioman.”

Assessment information:

Results on the WISC-III revealed average to high average intellectual ability, with verbal scores

slightly higher than performance scores. Low scores were noted on the Freedom from

Distractibility Index. Her mother’s responses on the CBCL revealed clinical elevations for

Attention, Anxious-Depressed, and Thought Problems. Scores for Delinquent Behaviors and

Aggression were elevated but not significant. Ioman completed the Revised Child Manifest

Anxiety Scale (RCMAS) and the Youth Self- Report (YRS). Her responses indicated extreme

elevations on the Physiological Indicators Scale on the RCMAS and clinical elevations on the

Anxiety-Depression and Thought Disorder Scales of the YSR. The semi-structured diagnostic

interview (K-SADS) revealed positive endorsement of manic and depressive symptoms.

Family background:

Ioman’s parents, both of Irish descent, divorced five years ago. Currently, they have a friendly

relationship and share custody of Ioman and her sister. Ioman lives with her mother (37), her

sister (14), half-brother (2) and her step-father (55) four days a week. Three days a week she and

her older sister live with her father and step-mother.

Ms. A worked as a secretary in a medical practice until she became pregnant with her son two

years ago. She married Ioman’s father at age 22 after becoming pregnant with their oldest

daughter. Ms. A reports that she and her ex-husband are recovering alcoholics, who were

drinking heavily during Ioman and her older sister’s early years. When Ioman was 5, she and her

ex-husband went into treatment and have been sober ever since. Ms. A reports that her father

was an alcoholic. She used to attend AA meetings, and has been in therapy for many years. Ms.

A says she feels very guilty about neglecting the care of her daughters in their early years and

leaving them in the care of extended family and friends a lot of the time while she and her ex-

husband were drinking. She says she initiated their divorce because, “I couldn’t continue to live

with a man who was depressed and angry all the time and who didn’t want to get help after

achieving sobriety”. Currently, they share custody of their daughters and have a friendly

relationship with each other and with each other’s spouses.

Ms. A met her current husband, Mr. A, three years ago, and became pregnant shortly thereafter.

She decided to marry Mr. A, who is 16 years older than her. She and her daughters moved to Mr.

A’s house, which was extensively renovated to accommodate the new family. Ms. A describes

her husband as an intelligent and interesting man with whom she shares many interests and

values. He didn’t have any previous experience with children. Thanks to having won the lottery

when he was 21, Mr. A has never had to work to support himself. He spends his time in

activities such as reading, gardening, and collecting exotic fish which he keeps in specialized

aquariums. The adjustment to the step-family has been very challenging. Mr. A and Ms. A’s

daughters have never liked each other or gotten along. Both sides are very open in their dislike

of one another and can get into pretty hostile verbal exchanges. Ms. A has felt very much in the

middle and reports feeling very anxious trying to mediate the relationships. She and Mr. A have

been in marital therapy since she became pregnant with their son. She has decided that she

cannot continue to live or have her daughters live in this situation and is planning to separate

from her husband and move out of the house in a few months. Mr. A refused to attend the

session at the clinic.

Ioman’s father, Mr. C is 38 years old and works as a case aide in a program for developmentally

disabled adults. He remarried about 4 years ago. Ioman and her sister like their step-mother

very much and get along very well with her. Mr. C has a good relationship with his daughters,

but seems to leave major decisions about them to Ms. A. Mr. C’s relatives live about 1 hour

away. He has a good relationship with them and the extended family gets together for holiday

celebrations.

Because of her experience as a secretary in a medical practice, Ms. A is knowledgeable about

services and resources in the community. She and her children have been in psychotherapy since

she started her substance abuse treatment.

Interview with Ioman

Ioman is an attractive 11 year old girl who came to the office meticulously dressed and groomed

with very stylish clothing and matching shoes, purse and hair accessories. While physically she

appears her age, her manner is more like that of a teenage girl. At the beginning of the interview,

she was very friendly towards the clinician and seemed to feel very comfortable in this setting

(perhaps because of her previous years in therapy). She seemed to enjoy the attention she was

getting. She was comfortable describing her family life. She was oriented X3.

Her description of the various family relationships was congruent with the way in which her

mother described them. About her siblings, she says that her oldest sister doesn’t want to spend

anytime with her because “she thinks she’s a grown-up and calls me a “little girl”. She described

some arguments between them, but nothing out of the ordinary. She says she likes taking care of

her baby brother, but is annoyed by all the attention that is paid to the baby, particularly by her

stepfather. She said she likes how it feels to be at her Dad’s house, but misses her Mom when

she is there. She became most animated when asked about her stepfather. As she talked about

him, she became very angry and loud. Her dislike of this man was very evident; she referred to

him as “a weirdo”. She said she didn’t understand why her mother married him. About her

mother she said that she’s ok, but that she didn’t like it when she put her stepfather and half-

brother ahead of her and her sister. When asked about her early years when her parents were

drinking, she said she doesn’t remember much, that her parents were ill with alcoholism, so they

didn’t know what they were doing. She recalls spending a lot of time with just her sister or at

friends’ homes when her parents were drunk. She said she’s tired of talking about that time, but

that her mom can’t stop talking about it. She said she finds school boring, but likes going

because she gets to spend time with her friends. She didn’t talk much about her school

difficulties, and when asked why she thought she was having them, she replied “I don’t know”.

She said she gets very upset and angry when teachers discipline her. There was no indication of

suicidal ideation.

When asked about what she liked to do, she immediately said she loves to dance and stood up

and sang and demonstrated a dance routine. When asked why she thought she had been brought

to the clinic, she replied in a sing-songy voice, “To see if you can figure out what’s going on in

my head; nobody else has!” When asked what she thought might be going on, somewhat

flippantly, she said, “Who knows? Maybe I’m crazy! After that, she said: “Are you going to ask

me the same things as Ms. T (her therapist)? I hope not; she thinks she’s so smart, but she knows

nothing!”, and then, changed the subject and complimented the clinician’s necklace. Her three

wishes were: 1) that her mother would divorce her stepfather, 2) to grow up to be one of the

“Pussycat Dolls”, and 3) to be 18, because then I can move out on my own, and do whatever I

want.”