CASE STUDY #4
CASE STUDY ASSIGNMENT INSTRUCTIONS
Client Concerns
Symptoms Behaviors Stressors
Nightmares about accident Restlessness—fidgeting
and unable to sit still (also
symptom)
Was in significant car
accident
Difficulty sleeping (also a
symptom)
Feels he caused accident
Will not play video game
that he was playing at time
of accident
Hyper-vigilance when
driving (sits in middle seat
to watch for cars)
Not completing work at
school
Distracted (also symptom)
Lack of socialness at
school and church
Aggressively uses
matchbox cars to recreate
accidents
Assessment
The assessment used will be The Child PTSD Symptom Scale for DSM-V (CPSS-V SR).
This assessment is tailor-made for children, and communicates in child-friendly language.
Additionally, it gives five severity ranges, which is a helpful piece of information to have.
Hukkelberg et al. (2014) stated that while the specificity was moderately low, the sensitivity for
this assessment was high.
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Diagnostic Impression
The diagnostic impression is posttraumatic stress disorder (F43.10). As Theo is 6 years of
age, the criteria for children 6 years and younger is used.
Signs and Symptoms
Note: Criteria below used from The:Diagnostic and Statistical Manual of Mental Disorders(5th
ed.; DSM–5; American Psychiatric Association, 2013)
DSM-5-TR Diagnostic Criteria: Posttraumatic Stress
Disorder in Children 6 Years and Younger (F43.10)
Client’s Signs/Reported
Symptoms:
A. In children 6 years and younger, exposure to actual
or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it
occurred to others, especially primary
caregivers.
3. Learning that the traumatic event(s) occurred
to a parent or caregiving figure.
Was involved in significant car
accident with his parents
B. Presence of one (or more) of the following intrusion
symptoms associated with the traumatic event(s),
beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive
distressing memories of the traumatic
event(s).
Note::Spontaneous and intrusive
memories may not necessarily appear
distressing and may be expressed as
play reenactment.
2. Recurrent distressing dreams in which the
content and/or affect of the dream are related
to the traumatic event(s).
Note::It may not be possible to
ascertain that the frightening content
is related to the traumatic event.
3. Dissociative reactions (e.g., flashbacks) in
which the child feels or acts as if the
traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with
the most extreme expression being a
complete loss of awareness of present
A. Has distressing dreams
(nightmares) about having
an accident. Wakes up
right before the crash
B. Recreates car accidents in
play
C. Psychological distress
(screaming and covering
up head) when on two-lane
road (type that accident
occurred on).
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surroundings.) Such trauma-specific
reenactment may occur in play.
4. Intense or prolonged psychological distress
at exposure to internal or external cues that
symbolize or resemble an aspect of the
traumatic event(s).
5. Marked physiological reactions to reminders
of the traumatic event(s).
C. One (or more) of the following symptoms,
representing either persistent avoidance of stimuli
associated with the traumatic event(s) or negative
alterations in cognitions and mood associated with
the traumatic event(s), must be present, beginning
after the event(s) or worsening after the event(s):
Persistent Avoidance of Stimuli
1. Avoidance of or efforts to avoid activities,
places, or physical reminders that arouse
recollections of the traumatic event(s).
2. Avoidance of or efforts to avoid people,
conversations, or interpersonal situations that
arouse recollections of the traumatic
event(s).
3. Negative Alterations in Cognitions
3. Substantially increased frequency of
negative emotional states (e.g., fear, guilt,
sadness, shame, confusion).
4. Markedly diminished interest or participation
in significant activities, including
constriction of play.
5. Socially withdrawn behavior.
6. Persistent reduction in expression of positive
emotions.
A. Refuses to play video
game that he was playing
at the time of accident
B. Feels his video game
caused the accident (guilt,
shame)
C. Does not want to
participate in activities he
once considered “fun”
D. Withdrawn from
classmates and church
peers
D. Alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after
the traumatic event(s) occurred, as evidenced by two
(or more) of the following:
1. Irritable behavior and angry outbursts (with
little or no provocation) typically expressed
as verbal or physical aggression toward
people or objects (including extreme temper
tantrums).
2. Hypervigilance.
3. Exaggerated startle response.
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling or
staying asleep or restless sleep).
A. Shows aggressive behavior
towards matchbox toys,
and peers feel need to keep
distance if they want to be
safe
B. Sits in middle seat while
driving to help parents
look out for cars
C. Screams and covers head
if driving on two-lane road
D. Struggles to concentrate in
school as well as church
E. Has nightmares, which
makes it difficult to fall
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CASE STUDY #4
asleep, and difficult to go
back to sleep.
E. The duration of the disturbance is more than 1
month.
Duration has lasted greater than
one month
F. The disturbance causes clinically significant distress
or impairment in relationships with parents, siblings,
peers, or other caregivers or with school behavior.
Particularly with peers, Theo has
withdrawn from his classmates,
and has showed disregard for his
peers’ safety while playing with
his toys
G. The disturbance is not attributable to the
physiological effects of a substance (e.g., medication
or alcohol) or another medical condition.
Family denies medication
use/exposure to substances
Other DSM-5-TR Conditions Considered
Acute stress disorder would have been the diagnosis if Theo’s symptoms were the same
as they currently present, but Theo was being assessed between 3 days and 1 month after the
event. The fact that it has been greater than one month since the event rules out acute stress
disorder. Generalized anxiety disorder is also considered, but criteria F states that the anxious
feelings must not be better explained by a different disorder. PTSD is a better explanation for
Theo’s anxious feelings, ruling out GAD.
Developmental Theories and/or Systematic Factors
Theo is at the transition point between Erikson’s play age stage and school age stage, the
two core virtues in those stages being purpose and competence, respectively. Theo should be
beginning to hit his stride, academically. Optimally, he would be doing his assignments,
learning, setting the groundwork for the next decade of his schooling. But this traumatic event
has limited Theo’s ability to focus, to perform academically, and to build relationships with his
peers. Metsäpelto et al. (2020) found that high grades positively predicted good self-esteem. . If
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not quickly addressed, Theo could find himself significantly behind his peers, academically and
emotionally.
Multicultural and/or Social Justice Considerations
Theo’s family are Jehovah’s Witnesses. Friedson (2015) states that the religious believes
of Jehovah’s Witnesses may pose significant obstacles to counseling. While Theo’s family seems
proactive in getting Theo counseling, there may be pushback along the way. Friedson cites a
statement from the Jehovah’s Witnesses official publication that says “It is only when we have a
strong friendship with Jehovah that we can really be happy and safe. Only Jehovah can help us
with all our problems”. Perspectives like this may lead members of the church to feel like Theo’s
family is relying on the world rather than on God to heal him.
Treatment Recommendations
Key Issues for Treatment
Treating sleep hinderances
Decreasing negative response to activating stimuli
Recommendations for Individual Counseling
Trauma focused cognitive behavior therapy (TF-CBT) is a subsection of cognitive
behavior therapy that implements trauma treatment, and has been validated as one of the superior
forms of treatment (Cohen & Mannarino, 2015). There are a handful of requirements to use this
treatment method, all of which Theo meets. The trauma must be remembered, and there must be
prominent symptoms of PTSD, though no formal diagnosis is required. As Theo seems to still
have a solid relationship with his parents following the accident, TF-CBT will work well as the
parent participates in the child’s treatment, giving the clinician someone in the room who the
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child trusts. This method can be utilized in as few as 12 sessions, making it accessible to Theo’s
family whose insurance provides limited long-term therapy.
Another treatment method that may be a fit for Theo is eye movement desensitization and
reprocessing (EMDR). A metanalysis by Lewey et al. (2018) found that TF-CBT is marginally
more effective than EMDR in treating childhood trauma, but if for whatever reason Theo did not
respond to TF-CBT, or the clinician is not trained in TF-CBT, EMDR is an appropriate and
efficacious option.
Specific Considerations
Being that Theo is only six years old, a clinician might feel the need to lead Theo to a
significant degree. But Theo is an autonomous human who perhaps feels that some autonomy
has been lost due to the psychological/physiological responses from his accident. The last thing a
clinician would want is to continue to take that autonomy and re-traumatize him, to whatever
degree. Thus, it is incredibly important to collaborate with Theo on his treatment. That being
said, it might be difficult to do so. Theo, being six, may not fully understand the scope of what is
going on. He may withdraw from therapy as a soothing measure, not understanding that the
discomfort he may feel in therapy is actually meant to help him in the long run. A clinician may
feel like they must walk on eggshells as to not trigger the child, who is possibly less able to
articulate distress before they become particularly aware of it, but Berliner & Kolko (2015)
found that screening for PTSD was not distressing to children, the implication being that children
are adequately able to articulate when they are and are not distressed.
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References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders
(5th ed., text rev.). American Psychiatric Press, Inc.
Berliner, L., & Kolko, D. J. (2016). Trauma informed care: a commentary and critique. Child
Maltreatment, 21(2), 168-172. https://doi.org/10.1177/1077559516643785
Cohen, J. A., & Mannarino, A. P. (2015). Trauma-focused cognitive behavior therapy for
traumatized children and families. Child and adolescent psychiatric clinics of North
America, 24(3), 557–570. https://doi.org/10.1016/j.chc.2015.02.005
Friedson, M.L. Psychotherapy and the fundamentalist Client: the aims and challenges of treating
Jehovah’s Witnesses. Journal of Religious Health 54, 693–712 (2015).
https://doi.org/10.1007/s10943-014-9946-8
Hukkelberg, S., Ormhaug, S. M., Holt, T., Wentzel-Larsen, T., & Jensen, T. K. (2014).
Diagnostic utility of CPSS vs. CAPS-CA for assessing posttraumatic stress symptoms in
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children and adolescents. Journal of Anxiety Disorders, 28(1), 51-56.
https://doi.org/10.1016/j.janxdis.2013.11.001
Lewey, J. H., Smith, C. L., Burcham, B., Saunders, N. L., Elfallal, D., & O’Toole, S. K. (2018).
Comparing the effectiveness of EMDR and TF-CBT for children and adolescents: A
meta-analysis. Journal of Child & Adolescent Trauma, 11, 457–472.
https://doi.org/10.1007/s40653-018-0212-1
Metsäpelto, R.-L., Zimmermann, F., Pakarinen, E., Poikkeus, A.-M., & Lerkkanen, M.-K.
(2020). School grades as predictors of self-esteem and changes in internalizing problems:
A longitudinal study from fourth through seventh grade. Learning and Individual
Differences, 77, 101807. https://doi.org/10.1016/j.lindif.2019.101807
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