CASE STUDY 2
Client’s Concerns
Signs/Symptoms Behaviors Stressors
Mood swings sad to angry Speaking disrespectful to
teachers/fighting with peers
Parent’s divorce
Anger outbursts/verbally
aggressive
Excessively argumentative Trouble in school
Hard time concentrating Poor academic performance Trouble with mother
Difficulty falling asleep Excessive crying before bed Father’s new marriage
Loss of interest in friends and
sports
No interest in getting driver’s
licenses
Wanting his family back
together
Hopelessness No interest in socializing with
friends/playing sports
Grades have started to drop
Feeling of guilt Refusal to communicate with
his father
Mother thinks faith is the
center of life
Assessment
The Adjustment Disorder–New Module 20 (ADNM-20) is a highly effective self-report
assessment that thoroughly evaluates the stressors and symptoms associated with adjustment
disorder (AjD) (Lorenz et al., 2016). It is available in two formats: a comprehensive 29-item
version and a streamlined 20-item version. Participants provide insights into their experiences by
rating the frequency of various symptoms over the past two weeks using an intuitive 4-point
Likert scale, where 1 indicates "never" and 4 signifies "often" (Lorenz et al., 2016). I confidently
chose the ADNM-20 for its established validity and reliability in diagnosing AjD, making it an
CASE STUDY 3
indispensable resource. This assessment will not only help Victor clearly identify his stress
triggers but also equip me with crucial insights into the underlying stressors and symptoms that
significantly impact his well-being.
Diagnostic Impression
DSM-5-TR Diagnostic Criteria: Acute
Adjustment disorder & with mixed disturbance
of emotions and conduct (F43.25)
Client’s Signs/Reported Symptoms:
Criterion A: Emotional or behavioral
symptoms can emerge as a direct result of
identifiable stressors, typically within three
months of their onset. Recognizing this
connection is essential for timely support and
intervention.
The client has been navigating feelings of
sadness and anger over the past four months
since his father's remarriage, reflecting a
journey of growth and self-discovery.
Criterion B: These symptoms are clinically
significant if they meet one or both of the
following:
1. Distress that is disproportionate to the
stressor's severity and influenced by context
and cultural factors.
Victor has disrespected his teachers and mother
and has gotten into arguments and fights with
peers.
2. Significant impairment in social,
occupational, or other important areas of
functioning.
He is facing difficulties socially, academically,
and with his behavior.
Criterion C: It is important to recognize that He clearly does not meet the criteria for any
CASE STUDY 4
the stress-related disturbance you are
experiencing does not align with the criteria for
any other mental disorder and is not simply an
intensification of a pre-existing condition.
Your feelings and experiences are valid, and
understanding this distinction can be an
important step in your journey toward healing.
condition.
other mental disorder and has no prior history
of mental illness, establishing a robust case for
his mental well-being.
Criterion D: The symptoms distinctly diverge
from typical bereavement and cannot be
sufficiently accounted for by prolonged grief
disorder.
His sadness aligns with normal bereavement,
but the increased aggression is a concern.
Criterion E Symptoms will typically resolve
within six months after the stressor and its
effects have ended. It is crucial to address these
issues promptly to ensure a smooth recovery
and restore well-being..
Victor reports that his stress and its
consequences have persisted for four months.
Other DSM-5-TR Conditions Considered
Several conditions from the DSM-5 were thoughtfully considered for diagnosis,
including acute stress disorder and oppositional defiant disorder. At first, disruptive mood
dysregulation disorder seemed relevant; however, since it requires symptoms to last 12 months
CASE STUDY 5
or longer and Victor’s symptoms have been present for less than six months, we felt it was best
to rule this out.
While oppositional defiant disorder was initially contemplated due to Victor’s angry
mood and defiant behavior, we ultimately decided it wasn’t the most fitting diagnosis. It seems
that his symptoms are closely tied to the significant changes in his life following his parents'
divorce. This suggests he may be experiencing an adjustment disorder with mixed disturbances
of emotions and conduct. It's important to acknowledge how challenging this situation has been
for him.
Victor does not satisfy the criteria for acute stress disorder, as he exhibits very few
associated symptoms and will require further evaluation. At present, he is experiencing
difficulties in his relationships due to his parents' separation and demonstrates excessive
aggressive behavior toward family members, peers, and staff at school.
Developmental Theories and/or Systemic Factors
Victor is currently grappling with significant family stressors that are impacting his
emotional regulation. His father's divorce and subsequent remarriage have led to feelings of
sadness and frequent anger outbursts, contributing to his diagnosis of adjustment disorder, which
was made within three months of these changes. In Erikson's stage of Identity vs. Role
Confusion, identity is expressed through self-realizing activities that individuals find self-
defining, engaging, energizing, purposeful, and conducive to achieving their life goals
(Ragelienė, 2016).
Victor has been candid about his feelings regarding his parents' separation, which has
resulted in behavioral challenges. He senses a profound difference in his circumstances and
recognizes that the dynamics within his family have shifted, affecting his identity and sense of
CASE STUDY 6
self. These changes have left him feeling uncertain about how to navigate life and interact with
others.
Multicultural and/or Social Justice Considerations
According to the DSM-5-TR, cultural context plays a vital role in understanding how an
adjustment disorder diagnosis affects an individual (APA, 2022). The manual highlights that, in
some cultural contexts, experiencing suffering is often viewed as a normal part of life. During
the assessment, Victor's mother observed that he has always been a sensitive child, skilled at
expressing his emotions rather than repressing them. Nevertheless, she also shared that Victor’s
father encouraged him to conceal his feelings and adopt a more stoic, "macho" demeanor. As a
result, Victor may feel uncertain and confused, as if no one truly understands what he is
experiencing or how to support him during this challenging time.
Victor's family comes from a unique cultural background that shapes their perspectives
on marriage and divorce. Research indicates that various social contexts can help cultivate
resilience in children who are exposed to parental divorce (Van Schalkwyk & Gantz, 2023).
While many studies report that children often face difficulties adjusting after a divorce, it is
estimated that around 50% of all marriages ultimately end in divorce (Van Schalkwyk & Gantz,
2023).
In the diagnostic process, it is crucial to consider multicultural factors. Victor has
expressed that he once enjoyed attending church and has several friends within that community.
However, he is currently grappling with the belief that his faith should carry more significance
for him than it does at present. It is essential that support for Victor extends beyond his
immediate family; connections with extended family members, peers, schools, and the broader
CASE STUDY 7
community can play an important role in facilitating children's adjustment (Van Schalkwyk &
Gantz, 2023).
Treatment Recommendations
Key Issues for Treatment
Anger outbursts/verbally aggressive
Mood swings sad to angry
Hard time concentrating
Recommendations for Individual Counseling
Recommendations for individual counseling should focus on understanding Victor's
cultural background and his perspective on counseling. It is crucial to help him work through the
traumatic experiences related to his parents' divorce. Cognitive Behavioral Therapy (CBT) is an
effective approach, though it remains underutilized among children. CBT is essential for
addressing the observed patterns of maternal and paternal rejection, as well as psychological
control during parent-child interactions (Van der Giessen et al., 2019).
Victor is going through a challenging time with his parents' divorce and his father's
remarriage. Taking the time to understand and express his feelings about these changes could be
beneficial for him. By working on developing more positive thought patterns, he may find not
only relief from his sadness but also an improvement in his academic performance. It's important
for him to know that he can navigate these emotions and come out stronger on the other side.
According to Victor's mother, his father disciplines him differently, aiming to prevent
him from feeling less than a man for expressing emotions. Consequently, Victor tends to cry
when he is alone and has begun exhibiting aggressive behaviors due to his difficulty in
CASE STUDY 8
articulating his feelings. I also recommend providing Victor with strategies to manage his anger
and introducing him to the practice of meditation.
Specific Considerations
Victor, a 15-year-old male, is at a critical stage in his life regarding social interactions.
When working with this specific client, it is essential to consider his age and the appropriate
treatment recommendations. As Victor is a minor, obtaining permission from both of his parents
will be necessary before moving forward.
The treatment approach should be tailored to Victor's unique needs, and in this context,
family therapy could be particularly advantageous. Research shows that parental separation can
adversely affect children's well-being, whereas the extent of intimate disclosure within the
parent-child relationship is vital for addressing behavioral challenges in children (Kleinschlömer
& Krapf, 2023). In our study, we define intimate disclosure as the child's ongoing
communication with the resident parent and their ability to openly express personal feelings and
thoughts (Kleinschlömer & Krapf, 2023).
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental
disorders. https://doi.org/10.1176/appi.books.9780890425787.
https://doi.org/10.1016/j.phrs.2024.107454.
Kleinschlömer, P., & Krapf, S. (2023). Parental separation and children’s well-being: Does the
quality of parent-child relationships moderate the effect?MJournal of Social and Personal
Relationships,M40(12), 4197-4218.Mhttps://doi.org/10.1177/02654075231201564.
CASE STUDY 9
Lorenz L, Bachem RC, Maercker A. (2016). The Adjustment Disorder--new Module 20 as a
screening instrument: Cluster analysis and cut-off values. International Journal
Occupational Environment Medicine. (4):215-20. doi: 10.15171/ijoem.2016.775. PMID:
27651082; PMCID: PMC6817961.
Ragelienė T. (2016). Links of adolescents identity development and relationship with peers: A
systematic literature review. Journal Canadian Academy Child Adolescent Psychiatry.
25(2):97-105. EpubPMID: 27274745; PMCID: PMC4879949.
Van der Giessen, D., Colonnesi, C., & Bögels, S. M. (2019). Changes in rejection and
psychological control during parent–child interactions following CBT for children’s
anxiety disorder.MJournal of Family Psychology,M33(7), 775–787.
https://doi.org/10.1037/fam0000543.
Van Schalkwyk J, Gentz S. (2023). Factors affecting resilience in Namibian children exposed to
parental divorce: a Q-Methodology study. Front Psychology 28;14:1221697. doi:
10.3389/fpsyg.2023.1221697. PMID: 37701873; PMCID: PMC10493287.
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