CASE PRESENTATION 2
Case Presentation Assessment & Diagnosis (C-PAD)
Basic Case Summary
Identifying Information
Date of initial assessment – 07/04/2023
Client’s name – Gretel Gerstenhagen
Employment status – unemployed
School status – 4th grade at Gingerbread
Learning Academy
Age – 10
Gender –female
Presenting Concern
Gretel was referred by her school principle for escalating concerning behaviors as well as
a recent diagnosis of juvenile diabetes Additionally, her father recently remarried. Gretel has
stated to her teacher that “maybe I’ll just kill myself” following the discipline of her and her
brother for running away. Additionally, Gretel reports that her stepmother is a “witch”.
Background, Family Information, and Relevant History
Gretel is 10 year old female from Austria who is in the 4th grade at Gingerbread Learning
Academy. Gretel lives with her twin brother, Hansel, her father, and step- mother. They moved
from Austria to the United States. Her father, a skilled carpenter, recently married her step-
mother and went back to working all the time, just as he previously had reported Gretel. This
followed the death of Gretel’s mother. She reports not being close to her step-mother at all and in
fact thinking that she is a witch. Gretel is very close with her brother Hansel, they have been in
trouble together during most of the conflicts that have occurred. Prior to her stepmother, Gretel
had an au pair who often ignored and forgot to feed her and her brother.
Gretel was referred by the school principle due to ongoing behavioral issues. Gretel has
stolen other children’s lunch boxes on multiple occasions as well as ignoring teachers requests
when the behavior is being addressed. Additionally, her father reported that Gretel often gets
CASE PRESENTATION 3
loud and angry when she perceives insults. Gretel often argues with others and blames her
brother for things that she has done. Gretel has on occasion stolen from the local grocer.
Gretel was recently diagnosed with Juvenile Diabetes. Her father reported that when she
steal from the grocer and home it is cookies and candies that she is stealing to eat.
Problem and Counseling History
Following the death of Gretel’s mother, whom she was only able to spend limited time
with due to illness, there have been ongoing signs of defiance. Gretel does not follow directions
in school or at home. Additionally she blames others when she is caught breaking the rules.
Gretel had a neglectful au pair and currently reports having a neglectful step mother. Her father
works out of the home majority of the time, leaving Gretel and her brother to fend for themselves
at times. Gretel was recently diagnosed with Juvenile Diabetes. Additionally, Gretel was moved
from her home country of Austria to the United States shortly after her mother died. Although
she found a good school and home, the culture was much different than she was used to. Gretel
and her brother will be undergoing psychological evaluations during counseling.
Diagnostic Impression
F91.3 Oppositional defiant disorder (moderate)
Z62.812 Personal history (past history) of neglect in childhood
Z69.020 encounter for mental health services for victim of nonparental child neglect
Z69.010 encounter for mental health services for victim of child neglect by parent
Discussion of Diagnostic Impression
Gretel has been diagnosed with oppositional defiant disorder (moderate). She has met the
DSM-5 criterion for persistence of more than six months (American Psychiatric Association,
CASE PRESENTATION 4
2014). Gretel meets six of the specifiers for this diagnosis. Gretel often loses her temper at
school with her teacher, and at home with her step mother (criterion A.1). Additionally her father
reports that Gretel has a “short fuse” becoming extremely irritable if anyone comments on her
behavior (Criterion A. 2). Gretel demonstrates criterion A.4 often arguing with teachers when
they correct her and with her father and step mother about rules and consequences. Gretel
additionally meets criterion A.5 defying her teacher when asked to return other students property
after taking it. Gretel reported that she wears her German costume because it annoys her step
mother, which demonstrates criterion A.6. Lastly, Gretel has often blames her brother for actions
that lead to her being punished (Criterion A.7).
Z62.812 Personal history (past history) of neglect in childhood was assigned to Gretel
because of the neglect she faced from her caretakers in the past and currently by her step mother.
Z69.020 encounter for mental health services for victim of nonparental child neglect was
assigned for the neglect Gretel faced from her au pair who brought different men around, did not
pay attention to the kids, and handled them roughly which was reported by a neighbor.
Additionally it was reported that she did not feed them at times. Currently, she Is facing neglect
by her step mother who does not properly take care of Gretel and her brother. Gretel even reports
that her step mother is a “witch”. Z69.010 encounter for mental health services for victim of
child neglect by parent was assigned because of the neglect from Gretel’s father while he is
working all the time and leaving them with various care givers.
