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CASE STUDY
Case Study Assessment: Phil
Ashara Morrisbrown
School of Behavioral Sciences, Liberty University
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CASE STUDY
Client Concerns
Symptoms Behaviors Stressors
Sadness Angry outbursts Parents’ divorce
anger Beg his father to come back Father remarriage
hopelessness Did not attend father’s
wedding
His mom is pushing him to
do things
Increased engagement in
verbal arguments
Argumentative 3-5 x’s/wk
with mom & daily with
siblings
Received in-school
suspension
Mood swings Refuse to speak to his father Struggling academically
Hard time falling asleep Verbally aggressive Grades dropping
Not interested in the things he
likes (friends, sports)
Reprimanded weekly Social life negatively affected
by his mood
Depressed symptoms Fighting and being
disrespectful
Feeling shame around being
“the first broken home” in the
family
Concentration issues
Assessment
The assessment used to clarify the diagnosis in this case is the Adjustment Disorder–New
Module 20 (ADNM-20). The ADNM-20 is a self-report measure consisting of two parts: a
stressor list and an item list. According to Lorenz, Bachem, and Maercker (2016) the stressor list
of the ADNM-20 “captures a broad range of acute and chronic life events of the past two years
[and] the item list measures the symptoms in response to the most distressing event(s)” (p. 216).
The ADNM-20 consists of six subscales: preoccupation, failure to adapt, avoidance, depressive
mood, anxiety, and impulse disturbance (Lorenz et. al., 2016). Participants use a 4-point Likert
scale ranging from 1 to 4 to indicate how frequently they experience various symptoms in the
previous two weeks: 1 being never and 4 being often (Lorenz et. al., 2016). This assessment is
easy to administer, score, and studies highlight that the internal consistency of each of the scales
are high ( =>.80).
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CASE STUDY
Diagnostic Impression
Phil presents a pattern of angry and sad mood swings. His mother reported that symptoms
began four months ago, which is when his dad was remarried. More recently, he has been
uninterested in the things he once looked forward to. His mother reported that his social life has
been affected by his mood. His mother also reported that his reaction is far more intense than his
siblings.
Phil meets criteria for the following DSM-5 Diagnoses:
F43.25 Acute Adjustment Disorder with Mixed Disturbance of Emotions and
Conduct
Signs and Symptoms
DSM-5-TR Diagnostic Criteria:
Adjustment Disorder with Mixed disturbance
of emotions and conduct (F43.25)
Client’s Signs/Reported Symptoms:
Criterion A:
The development of emotional or behavioral
symptoms in response to an identifiable
stressor(s) occurring within 3 months of the
onset of the stressor(s) (APA, 2022)
Phil’s mother brought him in for an assessment
because “He been struggling with feelings of
sadness and angry outbursts over the last four
months.”
Phil reported that he was sad when his parents
separated but since the divorce has been finalized
and his father remarried four months ago, he has
been “sad but mainly angry.”
Criterion B:
These symptoms or behaviors are clinically
significant, as evidenced by one of both of the
following:
1. Marked distress that is out of proportion
to the severity or intensity of the stressor,
taking into account the external context
The distress Phil is experiencing is intensified
by his feelings around being the “first broken
home” in the family.
Phil and his mother agreed that his social life
has been negatively affected by his change in
mood
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CASE STUDY
and the cultural factors that might
influence symptom severity and
presentation.
2. Significant impairment in social,
occupational, or other important areas of
functioning (APA, 2022).
Phil’s mother is worried that if Phil’s refusal
to engage continues, he will not have any
friends.
Criterion C:
The stress-related disturbance does not meet the
criteria for another mental disorder and is not
merely an exacerbation of a preexisting mental
disorder (APA, 2022).
Phil reported that he has never been diagnosed
with an illness only takes vitamins and .
Phil has no history of any past mental health
issues.
Criterion D:
The symptoms do not represent normal
bereavement and are not better explained by
prolonged grief disorder (APA, 2022).
No one died
The parents had been separated for 2.5 years
and divorced for a year
Criterion E:
Once the stressor or its consequences have
terminated, the symptoms do not persist for more
than an additional 6 months (APA, 2022).
Acute adjustment disorder.
Has been less than 6 months
Other DSM-5-TR Conditions Considered
Phil presents with a pattern of angry and sad mood swings. His mother reported that he is
more argumentative and verbally aggressive. More recently, he has been getting in trouble in
school for having verbal arguments with friends, teachers, and the principal. Phil reports having
trouble getting to sleep, feeling sad, and uninterested in things he used to love. Phil’s symptoms
were consistent with Oppositional Defiant Disorder. However, Phil and his mother did not report
meeting four of the listed symptoms in criteria A for the ODD diagnosis. Moreover, since ODD
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and Adjustment Disorder can present with similar symptoms, what can distinguish between the
two is observing the symptoms six months following resolution of the stressor (APA, 2022).
More importantly, the ODD diagnosis criteria does not mention a time period for the symptoms
to begin after the individual experiences the stressor and Phil’s mother reported that until Phil’s
father was remarried four months, Phil has never had any behavioral problems, which indicates
that the symptoms began within three months of the stressor.
Developmental Theories and/or Systemic Factors
In the past 2.5 years, Phil’s parents separated, divorced, and his father remarried. Phil’s
father’s remarriage has taken place within the past four months, which is also when Phil began to
misbehave according to his mother. Up until Phil’s father got remarried, Phil reported hoping that
his parents would get back together, even though he knew his father was engaged. Phil reports
feeling like his family will never understand what he is feeling since they are the first “broken
home” in the family. Phil’s idea of what a family system is has been disrupted and that may be
influencing his current functioning and behavior. Phil is currently in what Erikson’s fifth stage of
psychosocial development, identity vs. role confusion (Wong et. al., 2020). It seems as though
part of Phil’s identity is linked to his family staying together and the divorce has him confused
about who he is supposed to be with everything change. This can explain why his mom describes
Phil as seeming like a new person and wondering “...how to get [her] sweet son back”.
Multicultural and/or Social Justice Considerations
The DSM-5-TR notes that understanding the cultural context surrounding is critical,
especially considering that how individuals respond to stressors will vary from one culture to the
next (APA, 2022). Since Phil reports that the divorce causes them to be the first broken home in
the family, it can be concluded that marriage is important in their culture. It is possible that Phil
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CASE STUDY
is feeling shame about his parents’ divorce. The client would probably say that his symptoms
would have gone away if his parents would have gotten back together. From their cultural
perspective he is probably assuming that his family will judge them and not know how to support
them since they do not have a similar experience. It is possible that Phil may feel marginalized
because of his culture, ethnicity, and now because he comes from a self-reported broken home.
Treatment Recommendations
Key Issues for Treatment
Behaviors (aggression, arguments, disruptive behaviors)
Depressive symptoms
Shame about the divorce
Recommendations for Individual Counseling
Treatment recommendations for the above-mentioned key issues include individual CBT
with parental consent, parent management training (PMT), and family therapy. The first
recommendation for Phil individual therapy for Phil to discuss his depressive symptoms, work
on impulse control, anger, and stress management. The second recommendation would be family
therapy to assist in helping him feel supported in the divorce. Family therapy can also help the
family understand Phil and teach them how to operate with the new changes. Lastly, parent
management training (PMT) is recommended to assist the parents in learning how to address the
behaviors (Kazdin et. al., 2018). Also, Phil’s mother reported his father being more of an
aggressive parent and he could learn new ways to help Phil feel supported.
Specific Considerations
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The client’s age affect diagnosis and treatment recommendations. Certain diagnoses are
not prevalent at, or until, a certain age. The type of treatment given depends on the child’s age,
the symptoms, and the stressor. Consideration must be made for the family system. For example,
a parent or guardian must be present or give consent for treatment of the minor. The age of a
client can even impact the techniques used in session, while challenging adults may be
appropriate, it is important to consider a more age appropriate approach when dealing with
children so that do not feel powerless in the therapeutic relationship.
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References
Lorenz, L., Bachem, R. C., & Maercker, A. (2016). The adjustment disorder–new module 20 as a
screening instrument: Cluster Analysis and cut-off values. The International Journal of
Occupational and Environmental Medicine, 7(4), 215–220.
https://doi.org/10.15171/ijoem.2016.775
Kazdin, A. E., Glick, A., Pope, J., Kaptchuk, T. J., Lecza, B., Carrubba, E., McWhinney, E., &
Hamilton, N. (2018). Parent management training for conduct problems in children:
Enhancing treatment to improve therapeutic change. International Journal of Clinical and
Health Psychology, 18(2), 91–101. https://doi.org/10.1016/j.ijchp.2017.12.002
Trauma- and stressor-related disorders. (2022). Diagnostic and Statistical Manual of Mental
Disorders.
https://doi.org/10.1176/appi.books.9780890425787.x07_trauma_and_stressor_related_disorders
Wong, D. W., Hall, K. R., Justice, C. A, Hernandez, L. W. (2020). Counseling individuals
through the lifespan. New York, NY: SAGE
