Sarah Case Presentation 2
I. Key Clinical Issues
A. Client Demographics
Sarah is a 13-year-old female client, currently lives with her mother who is an
attorney, and her father, whom is an investment banker.
B. Presenting Problem
Sarah has been referred for therapy due to a series of behavioral situations that have
been presented in both school and at home. (1) Aggressive Behavior at School:
Client often threatens classmates with physical violence to get her way. She has been
suspended from school three times in the past three months, including an incident
where she punched a classmate in the stomach and another where she pushed a
classmate into a locker. She has also been caught trying to steal lunch money from
classmates. This also includes her skipping school once every two weeks. (2)
Reckless Behavior: Client engaged in reckless and defiant conduct outside of school,
while she stunk out the house out night to meet up with older males to engage in
vandalism and breaking into community swim clubs. (3) Defiant Behavior at Home:
Client becomes outrange and defiant with her parents when they try to reprimand her
for breaking rules at home.
II. Diagnosis
A. Diagnostic Impressions
1. Disruptive Mood Dysregulation Disorder (DMDD) (DSM-5 code
296.99): According to the Diagnostic and statistical manual, the client must
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Sarah Case Presentation 3
show severe recurrent temper outbursts manifested verbally and/or
behaviorally that are grossly out of proportion in intensity or duration to the
situation or provocation (American Psychiatric Association, 2013). Client shows
severe and recurrent temper outbursts, including physical aggression, which
are out of proportion to the situation.
2. Conduct Disorder (CD) (DSM-5 code 312.89):
Client displays a pattern of aggressive behavior towards others, including
physical violence and theft. Client would take others lunch money, punch
other students in the stomach area to move them out the lunch line.
3. Oppositional Defiant Disorder (ODD) (DSM-5 code 313.81):
Client vindictiveness, aggression, and defiance towards authority figures, as
well as her long history of behavioral problems at home and school, aligns
with the diagnostic criteria such as the patterns of angry/irritable mood,
argumentative/defiant behavior, or vindictiveness lasting at least 6 months
(American Psychiatric Association, 2013).
4. Attention-Deficit/Hyperactivity Disorder (ADHD) (DSM-5 code
314.01):
Although Sarah’s behaviors overlap with symptoms of ADHD, like
impulsivity and difficulty with following rules, the client’s core issue is more
related to aggression and conduct rather than inattention and/or hyperactivity.
5. Post-Traumatic Stress Disorder (PTSD) (DSM-5 code 309.81):
The listed criteria for PTSD in the DSM-5, gives an explanation that the client
is exposed to actual or threatened death, serious injuries, or sexual violence.
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Sarah Case Presentation 4
The information provided states that she has a history of a head injury at the
age of 3 and potential trauma from prenatal complication and delays. Further
assessment may be needed to confirm a thorough diagnosis.
B. Differential Diagnosis:
1. The current diagnostic criteria for DMDD are characterized by persistent
and pervasive irritability, underlying, and punctuated by frequent temper
outbursts (Varghese, Kirpekar, & Loganathan, 2020). Although the client has
frequent temper outbursts both at home and school, DMDD is able to be ruled
out as the client’s age, primary symptoms of aggression and defiance are more
aligned closely to conduct and oppositional defiant disorder., therefore,
Disruptive Mood Dysregulation Disorder can be ruled out.
2. Attention-Deficit/Hyperactivity Disorder refers to inattention and
hyperactive in children (Cabral, Liu, & Soares, 2020). The client is presented
with behaviors that may be impulsive and has difficulty following simple
behavioral instructions, there are no clear indications of any significant
problems with the client paying attention or being hyper. Therefore, ADHD
can be ruled out as a possible diagnosis.
3. Post-traumatic stress disorder includes disorders in which exposure to a
traumatic or stressful event is listed explicitly as a diagnostic criterion
(American Psychiatric Association, 2013). The client was presented with a head
injury during her preliminary stages in life, age 3. Although this may be
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Sarah Case Presentation 5
considered a potential trauma, it does not meet the specific criteria for PTSD.
As a result, PTSD can be ruled out.
C. Full DSM Diagnosis
1. Based on the information provided in the presented study of the client, it is
considerable right to have a final diagnosis of Conduct Disorder (DSM-5
Code 312.89).
(A) The client’s continuous behavior of repeated bullying, threats, and
intimidation towards others such as the punching classmates, pushing
classmates into lockers, deliberately destroying others property, engaging in
deceitfulness or theft, such as stealing items all fall within the criteria of CD.
(B) The client engages in serious violations of rule breaking as she stays out late
nights without parental permission. The client sneaks out to engage in activities
with older males which resulted in her being escort home being local
authorities.
(C) The client’s case file gives a clear explanation of her displayed behavior as
she has aggression towards others, engages in property damage, and violated
rules in school and at home. The client meets all the diagnostic criteria for
Conduct Disorder.
III. Etiology of the Problem/Disorder
A. Biological Theory:
The one biological theory that can be applied to the case given the causation of the
client is neurological abnormalities. This potentially resulted from the brain injury in
her earlier aged years. As presented, she experienced developmental delays referring
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Sarah Case Presentation 6
to delay of speech and not being able to crawl. According to the study by (Maresca, et
al., 2023), those individuals who has suffered a head injury of any sort is likely to
develop a higher risk of aggressive behavior. Neurological abnormalities can
effectively control impulses, emotions, and can also contribute to behavioral issues
within those individuals. Added imagines such as an MRI scan of the client’s brain
would give more support to the biological theory as it will provide more details on
any specific brain abnormalities.
B. Psychosocial Theory:
Lack of parental involvement or parental neglect is one psychosocial theory for the
causes of the client’s behavior. This leads to emotional dysregulation. As presented,
the client’s parents are considered busy with their work which leads to the client
possibly feeling neglected. In the study of (Flaherty & Sadler, 2011), secure attachment
to caregivers during childhood is especially important. Children who do not
experience secure attachment seemingly develop the feeling of being neglected and
possibly develop insecure attachment patterns. The relationship that has been set up
between the client and her parent isn’t presented to be pleasant as they report the
concerns they have for her behavior. Furthermore, more information on the client’s
early childhood attachment experiences and relationships with other family members
would support the psychosocial theory. This would give more detailed information on
any traumatic experiences or disruptions in the client’s early relationships with her
caregivers.
IV. Treatment Recommendations
A. Biological Intervention:
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Sarah Case Presentation 7
Given the data presented in the case, the best treatment for the client would be
pharmacotherapy such as a medication that has lithium. This will address aggression and
impulsivity. The client’s history of head injury and neurological abnormalities suggest
disruptions contributing to her behavioral symptoms. Study by (Felthous, et al., 2021) proves
that pharmacotherapy with mood stabilizers has shown to be effective with the reduction of
aggression in individuals who suffered brain injuries. This treatment is again applicable to
the client after undergoing a comprehensive evaluation and has the guidance and
supervision of a child psychiatrist.
B. Psychosocial Intervention:
In the presented case, the most effective psychosocial intervention is family therapy to
address the attachment issues and support given by the client’s family. Family therapy is
shown to be effective in improving communication and promoting secure attachment
(Diamond, Diamond, & Levy, 2021). Because the client seems to have a strained relationship
with her parents, there is a need for interventions that supports potential attachment issues
that will help improve the families’ dynamics and strengthen the relationship with both the
client and her parents. In order for this to be successful, the client and her parents will need
to regularly participate in family therapy sessions with a licensed provider in-which they
will receive proper guidance that will improve their communication skills and strengthen
their family bond. The family could also receive help from parent-child homework
practices that promote continuous improvement that can be shown at home and at school.
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Sarah Case Presentation 8
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders: DSM-5 (Vol. 5th ed). American Psychiatric Publishing.
Cabral, M. D., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: Diagnostic
criteria, Epidemiology, risk factors and evaluation in Youth. Translational Pediatrics,
8(s1). doi:https://doi.org/10.21037/tp.2019.09.08
Diamond, G., Diamond, G. M., & Levy, S. (2021). Attachment-based family therapy: Theory,
clinical model, outcomes, and process research. Journal of affective disorders, 294, 286-
295. doi:https://doi.org/10.1016/j.jad.2021.07.005
Felthous, A. R., McCoy, B., Nassif, J., Duggirala, R., Kim, E., Carabellese, F., & Stanford, M. S.
(2021). Pharmacotherapy of Primary Impulsive Aggression in Violent Criminal
Offenders. Frontiers in psychology, 12. doi:https://doi.org/10.3389/fpsyg.2021.744061
Flaherty, S. C., & Sadler, L. S. (2011). A review of attachment theory in the context of
adolescent parenting. Journal of pediatric health care : official publication of National
Association of Pediatric Nurse Associates & Practitioners, 25(2), 114-121.
doi:https://doi.org/10.1016/j.pedhc.2010.02.005
Maresca, G. L., Cardile, D., Formica, C., Latella, D., Quartarone, A., & Corallo, F. (2023).
Traumatic Brain Injury and Related Antisocial Behavioral Outcomes . A Systematic
Review. Medicina, 59(8), 1377. doi:https://doi.org/10.3390/medicina59081377
Varghese, M., Kirpekar, V., & Loganathan, S. (2020). Family interventions: Basic principles and
Techniques. Indian Journal of Psychiatry, 62(8), 192. doi:
https://doi.org/10.4103/psychiatry.indianjpsychiatry_770_19
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