THEO CASE STUDY 1
THEO’S CASE STUDY ASSIGNMENT
Ashley Hogans
School of Behavioral Sciences, Liberty University
THEO CASE STUDY 2
Client Concerns
Symptoms Behaviors Stressors
Frequent nightmares Wakes up startled and has
difficulty falling back
asleep again.
The family had a near head
on collision accident
6months ago.
Fearful/scared and guilty Says he’s scared he's going
to die. Watches out for the
road keenly. Feels he was
the cause of the accident
Mom was screaming at
him just before the
accident
Academic performance
decline
Struggles with sitting
quietly and reading.
Difficulty completing
spelling worksheets.
Near a head-on collision
accident, he was an honor
roll student.
Withdrawn socially No longer engages in
activities he used to think
were fun, avoids friends,
and video games
Hasn’t visited friends at
their kingdom hall.
Restlessness/ fidgeting He is frequently restless,
fidgeting, and never sitting
still.
Stressed over the accident
Startle response and panic Screams and covers her
head when oncoming cars
Two-lane roads
THEO CASE STUDY 3
approach
Assessment
Theo was involved in a near head-on collision accident 6 months ago, and since then has
been presenting with behavioral and emotional issues that the parents and teachers are now
concerned about. Given the traumatic experience Theo had, and the presented behaviors and
symptoms, evaluating for possible posttraumatic stress disorder (PTSD) is crucial, as before the
accident, he did not have any issues other than overstaying his gadget's time limit. The Child
PTSD Symptom Scale for DSM-5 (CPSS-5) is a self-report tool used to assess symptoms in
children and adolescents. It will help the counselor identify the symptoms Theo is experiencing,
such as nightmares, fear, avoidance, and hypervigilance. The CPSS-5 is a 27-item tool that is
quite useful because it is easy to administer to young children with the support of a counsellor
and is reliable for assessing PTSD in school-aged children (Greenspace, 2023). There are two
parts to the scale, with the first consisting of 20 items that evaluate the frequency and severity of
re-experiencing, hyperarousal, and avoidance symptoms in individuals exposed to distressing or
traumatic experiences. The second part has 7 items that determine whether any of the
posttraumatic symptoms have functionally impaired an individual's life over the past month.
Diagnostic Impression
Theo's presenting problems related to a past accident can be explained by posttraumatic
stress disorder (PTSD), unspecified (F43.10), as he meets the criterion for exposure to trauma.
Since the accident happened, Theo has presented with trauma-related symptoms such as
nightmares, hypervigilance, avoidance of reminders such as playing video games, guilt feelings
that he caused the accident, social withdrawal, fear of dying, sleep disturbance, exaggerated
startle response, and poor concentration in school, causing academic decline (American
THEO CASE STUDY 4
Psychiatric Association, 2021). A possible secondary diagnosis could be other specified anxiety
disorders (F41.8) if Theo is found to have excessive worry and hypervigilance beyond the
traumatic triggers, and this could make a secondary diagnosis possible to capture the anxiety
symptoms. However, Theo’s fears appear to be directly connected to the near head-on collision
that happened 6 months ago.
Signs and Symptoms
DSM-5-TR Diagnostic Criteria:
Posttraumatic Stress Disorder, unspecified
(F43.10)
Client’s Signs/Reported Symptoms:
Criterion A:
Exposure to actual or threatened death,
serious injury, or sexual violence; directly
experiencing, witnessing in person, or
learning that the event occurred to people
close to them.
About 6 months ago, the family was in a near
head-on collision. Since then, Theo fears
getting into an accident and will not play his
games as he feels it was the cause.
Criterion B:
Presence of one or more intrusion symptoms Theo experiences nightmares in which he is in
a car about to crash into another car. He
reports that he was scared he was going to
die. Once he has nightmares, he fears going
back to sleep. Screams and covers his head
when he sees oncoming cars.
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Criterion C:
Persistent avoidance of stimuli associated
with a traumatic event
Theo has become more withdrawn and no
longer enjoys activities he used to think were
fun. Doesn’t play his new video game and
fears something might happen if he plays. Sits
in the middle of the backseat to watch out for
oncoming cars.
Criterion D:
Negative alterations in cognitions and mood,
such as negative beliefs, blame, diminished
interest, and withdrawal
Theo feels guilty and blames himself for
playing video games, as his mother was
yelling at him about playing his game too
much. He is withdrawn and doesn’t want to
visit friends at the Kingdom Hall. Doesn’t
play with the new video game.
Criterion E:
Marked alterations in arousal and reactivity,
such as irritable behavior and angry outbursts,
hypervigilance, exaggerated startle response,
concentration problems, and sleep disturbance
Theo frequently appears restless, fidgeting,
and having difficulties sitting still. He has
trouble completing his work at school and
usually appears distracted. Sits in the middle
backseat to watch out for oncoming cars. Has
difficulty falling back to sleep after a
nightmare. Covers his head with his hands
and screams when he sees oncoming cars
THEO CASE STUDY 6
Criterion F:
The duration of the disturbance is more than a
month
Theo’s family was involved in a car accident
6 months ago. His parents report that his
nightmares, hypervigilance, and withdrawal
have been ongoing for several months
Criterion G:
Clinically significant distress or impairment Theo has difficulties participating in social
activities, has declined in academic
performance, and he frequently avoids car
rides and wakes up his parents when he has
nightmares
(American Psychiatric Association, 2021)
Other DSM-5-TR Conditions Considered
Other symptoms of disorders and diagnoses considered were the generalized anxiety
disorder (GAD, F41.1) because Theo showed excessive worry and vigilance, was restless, had
difficulties sitting still, and struggled with concentration. However, this was not the correct
diagnosis because Theo’s anxiety is specific to reminders of him in the near head-on-collision.
To be diagnosed with GAD, one criterion to observe is excessive worry over various topics and
not limited to one single traumatic stressor. Acute stress disorder (ASD, F43.0) was also
considered since Theo showed trauma reaction symptoms such as nightmares, intrusive
memories, hypervigilance, avoidance, and startled response (American Psychiatric Association,
2021). However, the DSM-5-TR criterion specifies that ASD applies only when symptoms last at
THEO CASE STUDY 7
least 3 days but no longer than 1 month after trauma. Theo has had the symptoms since the
accident from 6months ago, hence ASD does not fit the criteria.
Developmental Theories and/or Systemic Factors
Dunkel & Harbke (2016) posit that children within the range of 3 to 6 years are naturally
curious and eager to take the initiative on some activities and may develop guilt if they are
unsuccessful or when their boundaries have been overstepped. This is the initiative versus guilt
stage as per Erik Erikson’s psychosocial theory. Success at this stage helps them develop
confidence and purpose, but in cases where their initiative leads to negative outcomes or they
assume they have caused them, they tend to develop excessive guilt (Dunkel & Harbke, 2016).
This happened in the case of Theo as his mom was yelling at him at the time of the accident,
which traumatized him and thereby disrupted normal development at this stage. The guilt that he
caused the accident is making him withdraw from fun activities and blame himself for something
that was not his fault. His parents could as well have been traumatized from the near-death
experience as they have adjusted driving routes. His family system or the environment he is in,
due to their sense of safety and trying to adjust for their son’s sake, could be unintentionally
reinforcing his fear, such as they are avoiding the two-lane roads and allowing Theo to sit in the
middle to watch out for cars.
Multicultural and/or Social Justice Considerations
One of the identities to discuss is the religious or spiritual background of Theo’s family
and its influence on their lived experiences. His family identifies as Jehovah's Witnesses, where
they have their weekly meetings at their Kingdom Hall. Although Theo is yet to be baptized, he
THEO CASE STUDY 8
has been exposed to the weekly teachings as well as his parents' beliefs, which shape his
understanding of safety, responsibility, and guilt (Gorski & Goodman, 2016).
Treatment Recommendations
Key Issues for Treatment
Frequent nightmares
Hypervigilance and fear in the car
Avoidance of play
Recommendations for Individual Counseling
Some treatment recommendations for Theo include child-centered play therapy (CCPT),
which is age-appropriate for Theo as it creates a safe and supportive space for him to express his
feelings. CCPT is crucial for him since he has shown aggressive play behaviors with his toy cars,
which is a sign that he is replaying the traumatic experience he experienced 6 months ago. In the
play therapy, the counselor will help him gently process his fear while gradually encouraging
him to reconnect with normal play, such as video games, without him feeling guilty or being
fearful (Dillman Taylor et al., 2021).
Another recommendation would be cognitive behavioral therapy (CBT), which is a form
of treatment that utilizes techniques to help modify negative reactions, thoughts, and behaviors.
CBT will be appropriate for Theo as it will help him talk about his fear of dying, nightmares of
the crash, and stop blaming himself for the accident (Mirzaeian et al., 2023). CBT will help Theo
to manage anxiety, correct his unhelpful thoughts, and involve the parents as well, so they can
support and ensure there is progress even at home.
THEO CASE STUDY 9
Theo does not necessarily need to take medications at this point, as children’s first-line
treatment for trauma-related symptoms is evidence-based psychotherapy. Play therapy combined
with CBT will directly target his nightmares, hypervigilance, avoidance, or withdrawal from
play, and guilt. However, in case his symptoms persist despite the psychotherapy treatment he is
undergoing, referring him to a child psychiatrist would be appropriate for a medical evaluation.
According to the Veterans Department Affairs, a low-dose selective serotonin reuptake inhibitor
(SSRI) may be effective in treating PTSD in children; however, there may be risks, such as poor
sleep, inattentiveness, and irritability, which may occur in the process. Other medications that
could be used include fluoxetine, citalopram, and sertraline (Patricia R. Casey & Strain, 2015).
Specific Considerations
Theo, being a 6-year-old, would benefit from using a trauma-informed treatment
approach, which focuses on creating a safe, supportive, and predictable environment where he
feels understood. It is important through the play therapy and CBT approach that his issues are
well-addressed, as it makes the client feel heard and understood. This would also involve the
parents as active partners and educate them on how trauma affects Theo’s concentration, fears,
sleep, and play, and provide them with ways they can help him feel secure and free from guilt.
Collaboration is essential from both the parents and Theo to ensure the client gets full support
towards his recovery (Gorski & Goodman, 2016). Some potential barriers noted are such as
limited insurance coverage, as they are only covered for six sessions, which could limit their
continuity of care, and Theo’s age, as he may struggle to talk directly about the crash. To
overcome such barriers, the counselor may provide parent coaching where they could extend the
impact at home after the sessions end. For Theo, using techniques such as storytelling, drawing,
and playing around could be helpful for him to process the trauma.
THEO CASE STUDY 10
References
American Psychiatric Association. (2021). Diagnostic and statistical manual of mental
disorders (DSM-5). American Psychiatric Publishing. Arlington, VA.
Dillman Taylor,HD., Purswell,HK., Cornett,HN., & Bratton,HS.HC. (2021). Effects of child-
centered play therapy (CCPT) on disruptive behavior of at-risk preschool children in
head start. International Journal of Play Therapy, 30(2), 86-97.
https://doi.org/10.1037/pla0000125
Dunkel,HC.HS., & Harbke,HC. (2016). A review of measures of Erikson’s stages of
psychosocial development: Evidence for a general factor. Journal of Adult
Development, 24(1), 58-76. https://doi.org/10.1007/s10804-016-9247-4
Gorski,HP.HC., & Goodman,HR.HD. (2016). Introduction: Toward a decolonized multicultural
counseling and psychology. International and Cultural Psychology, 1-10.
https://doi.org/10.1007/978-1-4939-1283-4_1
Greenspace. (2023, January 27). Child PTSD symptoms | CPSS-5. Greenspace (US).
https://greenspacehealth.com/en-us/child-ptsd-symptoms-cpss-5/
Mirzaeian,HN., Mirzaian,HB., & Abbasi,HG. (2023). The effectiveness of trauma-focused
cognitive-behavioral therapy (TF-CBT) on bereavement symptoms in bereaved
children. Applied Family Therapy Journal, 4(3), 182-198.
https://doi.org/10.61838/kman.aftj.4.3.12
Patricia R. Casey,HF., & Strain,HJ.HJ. (2015). Trauma- and stressor-related disorders: A
handbook for clinicians. American Psychiatric Pub.
