Case Study

COUN 525 Example of Final Paper

This is one example of the final paper about the case we discussed in the first of our live class sessions. At the time, this assignment was similar, but not identical to yours, but it can give you a pretty good idea of what is expected.

Case of Marcus X

SEQ CHAPTER \h \r 1Background of Referral

Marcus X, an 8 year old, second grade, African American male, was referred to this mental health agency by his school counselor for symptoms related to behavioral and emotional dysregulation. Marcus has a reputation for “behavior problems” at school and requires excessive attention and redirection from his teachers. He disrupts the classroom, argues with peers and talks out of turn. Marcus is in danger of failing the second grade.

While Marcus’ mother, Mrs. X, did not initiate the referral, she, too, seems to recognize similar symptoms at home. Mrs. X describes her son as a “handful”, requiring constant supervision in order to prevent injuries from consequences related to his impulsive actions. Since the death of his father, Mrs. X also notes that Marcus exhibits mood lability, angry outbursts, nightmares and social isolation. Approximately eight months ago, Marcus witnessed the shooting of his biological father. Since that time, his mother has noticed an exacerbation of symptoms and the presence of social withdrawal, mood lability, nightmares and defiance.

Child

Marcus’ mother relates an unremarkable developmental history with healthy pregnancy and delivery. No information is provided about developmental milestones, so it is assumed that Marcus met milestones within normal limits. However, Marcus does have a history positive for numerous injuries related to high levels of activity and risk-taking. No other information is available related to Marcus’ medical history and/or the presence of allergies. No information is available regarding Marcus’ cognitive development and risk factors.

Marcus presents as a pleasant and friendly young man. He asked to play with Legos in the office, but became frustrated when he was unable to build a particular structure. Marcus seems to have a low threshold for frustration and struggles to complete tasks. He readily interacted with the examiner and immediately shared information related to his father’s death. This disclosure of information may suggest the presence of an indiscriminate attachment, a sign of unhealthy forms of establishing relationships with others, stemming from insecurity or anxiety. It could also be that he cannot contain talking about the trauma of witnessing his father’s murder.

Marcus seems to struggle with interpersonal relationships. He argues with peers and has few healthy friendships. His lack of interpersonal relationships may stem from a transactional style of rejecting others by engaging in negative and socially inappropriate behavior. Peers avoid Marcus, thus further isolating him from social contact. In this sense, Marcus has created a situation that, if continued, could result in failure to establish healthy relationships. Such a style may provide Marcus protection from becoming too “close” to others and possibly experiencing loss or rejection. By rejecting people first, Marcus remains in control of the relationship, unlike the sudden loss of the relationship with his father. Another explanation for Marcus’ pattern of peer relationships could be ADHD. His impulsivity and distractibility may interfere with the “give and take” of healthy peer relationships, which in turn may make peers dislike him. A pattern of interactions may be set up in which others always anticipate negative behavior from him; a prediction that he then fulfills.

Family

Marcus resides with his mother, older sister (age 10 years), and his younger brother (age 6 years). Marcus’ father was present in the home until his death 8 months ago. Marcus witnessed the drive-by shooting of his father while he was playing in the street.

Marcus’ parents were still in high school when Marcus was born. Marcus’ mother eventually dropped out of school, but Marcus’ father was able to graduate. Marcus and his family resided with Mrs. X’s parents for the first two years of their marriage.

It is fairly safe to assume that Mr. and Mrs. X had little parenting experience when Marcus was born, given their young age at the time of Marcus’ birth. It also appears that Mrs. X has been the main disciplinarian in the family. Mrs. X described dealing with her late husband as “like having another kid”. Mr. X reportedly changed jobs often, had many ambitions, but failed to follow through with tasks that would promote him up the employment ladder. Given these characteristics, it is plausible that Mr. X may have been struggling with a psychiatric condition such as a behavior disorder, such as ADHD.

When examining the dynamics of Marcus’ family, several features are salient. First, there are concerns about Marcus’ overall “fit” within the family. Marcus’ mother works long hours and it is questioned whether she is able to devote time to Marcus and his siblings. Marcus has many special needs which seem to require an exorbitant amount of time and attention. It is also questioned whether Marcus is able to appropriately express grief within the family, especially since his mother hasn’t had the time to cope with her own grief. Finally, there are concerns about sister’s role in the family and whether she is becoming a “parentified” child, taking on additional tasks and responsibilities.

Little information is available about the multigenerational family history. It is assumed that Marcus’ grandparents have been involved and responsive. The family resided with the maternal grandparents for the first 2 years of Marcus’ life. In addition, Marcus spent 6 months living with his maternal grandmother in NYC at the age of 4.

Marcus can be considered at significant risk for developing comorbid disorders given the presence of a number of familial, psychological, biological and environmental stressors. Marcus and his family live in a poor community with a high rate of crime and violence. While violence per se is not viewed as heritable, there is literature that indicates that aggression is learned through observation or social learning (Mash & Barkley, 2003). As mentioned earlier, Marcus’ father may have been struggling to manage some type of psychiatric condition, further predisposing Marcus for the inheritance of emotional and behavioral problems. The chance of Marcus experiencing a psychiatric condition is increased with the presence of family members experiencing that condition. In addition, teenage pregnancy and the cycle and feminization of poverty further exacerbates Marcus’ level of risk. These risk factors, coupled with Marcus’ current expression of emotional and behavioral disruption clearly place him at high risk for developing additional psychiatric and psycho social problems.

Larger Systems

The school has initiated support services for Marcus by referring him to a youth mental health agency due to teacher and counselor concerns for disruptive and attention seeking behavior. Information does not indicate that Marcus’ family has been uncooperative in the evaluation process so it is assumed that there exists a relationship between the school and the family. It is unclear, however, how much contact the family has had with the school as details to interventions tried prior to the referral are not provided.

Information regarding involvement in religious, social or community groups is not provided, however Marcus states that he does not have anyone with whom he can play basketball. It may be assumed that he does not belong to any after school community program. Mom has had to start working to support her family and due to the fact that information did not indicate otherwise, it appears that she may have secured the job on her own.

Human service agencies do not appear to be involved with Marcus’ family save for the connection with the agency currently evaluating the student. There is no further mention of home health aides or family support workers.

Local police caught Marcus throwing eggs at passing cars last year. Information provided in the report does not indicate further involvement of authorities or protective services.

Mother’s apparent stress, depression, lack of grieving, and responsibilities of family and work appear to have kept her from taking advantage of any resources that may be available in the community.

Diagnosis

As stated in the above narrative, there are many diagnostic issues to resolve as the evaluation is far from complete, but given the information presented, I would consider:

ADHD-hyperactive-impulsive or combined presentation.

Marcus seems to meet the criteria for the Hyperactivity/ Impulsivity part of the ADHD diagnosis. Marcus endorses a number of symptoms related to hyperactivity and impulsivity. He is disruptive in the classroom, argues with peers, talks excessively and requires a great deal of attention and redirection. His mother states that he has always been very active and he was unable to complete building LEGOs structure in the therapist’s office. However, there is not enough information in the vignette to ascertain whether or not he meets the criteria for Inattention. We would need to gather more information in order to make the diagnosis. But, it is a likely diagnosis. It seems like his father may have had ADHD, and it is is a highly genetic disorder. These behaviors seem to have preceded his father’s death.

Oppositional Defiant Disorder

Marcus does not seem to follow rules at home or at school and ODD is frequently comorbid with ADHD, however there is not enough information to support his meeting ODD diagnostic criteria. Also, these behaviors could be secondary to his irritability due to depression.

Major Depression

Marcus seems to meet the criteria for MDD. Sadness and irritability; talk of father’s death, less interest in previously enjoyed activities, insomnia, psychomotor agitation,diminished ability to concentrate, recurrent thoughts of death. But, his symptoms seem to be better explained by PTSD. Need to rule out whether both diagnoses are indicated.

Post traumatic Stress Disorder

Marcus meets the diagnostic criteria for PTSD A. Witnessed his father’s murder; B. intrusion symptoms: seems to have intrusive memories of the event; trouble sleeping (nightmares); C. Persistent avoidance: avoids playing outside for fear of being shot; D. Negative alterations in cognitions and mood: fears that something could happen to his mother; .E. Marked alterations in arousal and reactivity: irritability; sleep disturbance; problems with concentration.

The most likely diagnoses are: Post traumatic stress disorder and

ADHD, combined presentation.

It would be important to conduct the Cultural Formulation Interview in the DSM 5 to see how cultural factors may affect the diagnoses and presentation and to guide treatment more appropriately.

Treatment Planning

Considering that resources are readily available for Marcus and his family, a myriad of interventions ought to be proposed:

Trauma-focused CBT would seem to be the most evidence-based treatment for his PTSD. A support group for child witnesses to homicide may also be beneficial for Marcus and his siblings. A similar support group for Marcus’ mother would also be beneficial.

In addition, consultation with a child psychiatrist to consider medication for ADHD as medication has been found to be the most effective treatment for ADHD. Also, CBT strategies to treat ADHD would be helpful.

Seek alternatives to the current child-care situation after school programs for both Marcus and his siblings. Perhaps a setting where Marcus could continue to play basketball, since that is an area of strength and enjoyment for him.

Collaboration with extended family may be necessary in order for the family to access the most amount of support. Perhaps moving closer to the grandparents may provide support to the family.

Intensive intervention at the school level is also a priority. Provide consultation to Marcus’s teachers regarding working with children experiencing trauma as well as an individualized education plan with strategies to address his ADHD.

No information is available regarding Marcus’ cognitive development and risk factors. A neuropsychiatric evaluation, educational and intelligence testing would provide these necessary pieces of information.