Diagnosis and Treatment Planning
Robbyn Wallace
Theories of Psychotherapy
June 14, 2015
Diagnosis and Treatment Planning
Jeremy Collins, a 14-year old African-American male of lower socioeconomic status (SES) in urban Chicago, was referred by school authorities, per school counselor, for presentation of conduct disorder. In addition to the school referral, he presents with post-traumatic stress symptoms from chronic childhood trauma due to domestic violence and physical abuse as reported by his adult sister who brought him in. His symptomology bears great concern for his safety as well as those around him and are causing significant maladaptive and potentially criminal behaviors, dysphoric mood states and negative cognitions. The complex childhood trauma is thought to be a causal factor in his presentation of conduct disorder and personality disorder presentations. Treatment will include individual, family, and school, while considering sociocultural systems.
Assessment Methods
The Diagnostic Interview for Children and Adolescents (DICA) was used to “review medical, developmental, psychological, and social history” (Foltz, Dang, Daniels, Doyle, McFee, & Quisenberry, 2013). Furthermore, it assessed emotional and behavioral functioning skills across various settings using checklists that was completed by Jeremy, his sister and her husband, and teachers. Case management conducted direct observation in Jeremy’s classroom(s) and home settings. In addition to interviews, assessment tools was also used to further understand Jeremy’s symptom constellation and to identify hidden determinants of his behavior, both weaknesses and strengths. Piers-Harris Children’s Self-Concept Scale, 2nd Edition (Piers-Harris 2; Piers, Harris, & Herzberg, 2015) was used to provide an overall view of Jeremy’s self-perception, aimed at identifying specific problem areas, coping and defense mechanisms. Clinician Administered PTSD Scale for Children and Adolescents will be used to assess the frequency and intensity of the 17 symptoms of PTSD. This assessment tool also “evaluate[d] the impact of the symptoms on the child’s social, occupational, and developmental functioning; subjective distress; global severity; and validity of the interview” (Nader, Newman, Weathers, Kaloupek, Kriegler, & Blake, 2004). Strengths and Difficulties Questionnaire-Child Report (Goodman, 1997) was used as a brief behavioral screening instrument assessing child positive and negative attributes across five scales; (1) emotional symptoms, (2) conduct problems, (3) hyperactivity-inattention, (4) peer problems, and (5) prosocial behavior. It assessed the following domains: anxiety/mood (internalizing symptoms), externalizing symptoms, relationships and attachment, psychosocial functioning, and cognition and development.
Caregiver assessment (Family Caregiver Alliance, 2006) was used on Jeremy’s sister and brother-in-law to assess strengths and weaknesses in the family dynamic and level of functioning. The results confirm a need for parenting classes and family therapy. Therefore, the proposed plan of action is for his sister and brother-in-law to begin parenting classes at the community center. In addition, family narrative therapy will parallel Jeremy’s individual therapy to provide them an opportunity to build a narrative that will encourage positive growth while setting fundamental boundaries.
Diagnosis
“In a DSM-IV Field Trial sample of 528 adolescents and adults, Van der Kolk and colleagues (2005) report that particularly for interpersonal trauma, the younger the age of onset and the longer the duration, the more likely one is to develop both PTSD and the cluster of Disorders of Extreme Stress Not Otherwise Specified (DESNOS) symptoms (i.e., difficulties with regulation of affect and impulses, memory and attention, including dissociative symptoms, self-perception, interpersonal relations, somatization, and systems of meaning)” (Kohl, 2010). The formal diagnosis concluded from the assessment phase was post-traumatic stress disorder (PTSD; 309.81 (F43.10); APA, 2013) with dissociative symptoms, moderate conduct disorder with adolescent-onset type (CD; 312.82 (F91.2); APA, 2013), unspecified personality disorder (301.9 (F60.9); APA, 2013), parent-child relational problem (V61.20 (Z62.82); APA, 2013), upbringing away from parents (V61.8 (Z62.29); APA, 2013), and academic or educational problem (V62.3 (Z55.9); APA, 2013). The Diagnostic Interview for Children and Adolescents (DICA) was used to review medical, developmental, psychological and social history, which indicated Jeremy has developmental impairment—specifically mild comprehension deficit or learning disability, psychological impairment across various domains, contributing factors from his social history, but no relevant medical history. The Piers-Harris 2 revealed impairment in his self-perception. More specifically, it identified a low self-concept score overall and in each domain, indicating problems in the following areas; behavior adjustment domain, intellectual and school status domain, physical appearance and attributes domain, freedom from anxiety domain, popularity domain, and happiness and satisfaction domain. This is indicative of a poor self-concept and very few active coping skills. More specifically, it indicated dysregulation of (a) self-perception, (b) relations with others, (c) affect and impulses, (d) consciousness or attention, (e) systems of meaning, (f) perception of his father, and (g) somatization (Swart & Apsche, 2014). Clinician Administered PTSD Scale for Children and Adolescents revealed posttraumatic stress impairment in social and developmental functioning, subjective distress through externalized expression, and validated the DICA results.
The Strengths and Difficulties Questionnaire-Child Report (Goodman, 1997) indicates difficulties with emotional symptoms, conduct problems, inattention, and peer problems, but it also indicates that he has few prosocial behaviors that could be encouraged as coping mechanisms. Jeremy developed maladaptive schemas (Swart & Apsche, 2014) related to childhood trauma, which are likely underlying his emotions, ability to direct emotions appropriately, and the dysfunctional expression—specifically the externalized expression. The assessment phase indicates that his schema mode (Swart & Apsche, 2014) may be persistent, which signifies a need to address the schema mode, which may be more effective than addressing the schemas which underlie them (p. 23).
Gathering of Information from Treatment Plan
The information gathered during the interview and assessments is used to inform diagnosis and write the treatment plan, which includes goals and strategies for the treatment process. This information is based on Jeremy’s symptoms and how those symptoms align with diagnostic criteria. “It requires clinical training to recognize when the combination of predisposing, precipitating, perpetuating, and protective factors has resulted in a psychopathological condition in which physical signs and symptoms exceed normal ranges” (APA, 2013, p. 19). The complex nature of Jeremy’s case demands an in-depth analyses of the combination of the interview and assessment data to fully understand his symptom constellation and to formulate diagnoses as well as what treatment strategies or approaches will be most effective.
Elements of the Treatment Plan
A treatment plan “informs the provider and others about the goals, type of services, service intensity and progress indicators that are designed for the child’s problems, needs and preferences” (dhs.state.mn.us). The elements of a treatment plan: (1) treatment goals and objectives; (2) specific strategies and methods for treating needs identified through the assessment phase; (3) scheduling time-frame for accomplishing the goals and objectives; (4) responsibility for providing each treatment component; and, (4) mental health status and progress, including changes in functioning (dhs.state.mn.us). “The objectives must be achievable, measurable steps toward improved mental health” (dhs.state.mn.us). Treatment plans should be frequently reviewed to remain adaptable to client symptoms and goals.
Focus of Therapy
The focus of therapy will be to address Jeremy’s belief system, specifically schema mode deactivation, reducing reactivity and aggressive behaviors, and encouraging productive behavior change. Jeremy will be participating in an integrated approach in his individual treatment—using MDT and TF-CBT, while paralleling Cognitive Behavioral Intervention for Trauma in Schools (CBITS; Leenarts, Diehle, Doreleijers, Jansma, & Lindauer, 2013) in his school setting. This parallel treatments are focused on cognitive, emotional, and behavioral change across settings. In addition, family therapy will be focused on improving the level of functioning for the family dynamics.
Goals for the Client
Jeremy will successfully complete problem-solving training (PSST). Actively participate in the therapeutic process. Identify and practice specific coping skills. Identify core belief. Reduce aggressive behavior. Reduce conduct problems. Keep all mental health appointments. Complete homework assignments. Maintain school attendance. Stay away from drugs and alcohol. Follow rules and regulations.
Goals to Address the Relational Problems
No bullying. Reduce aggressive behavior. More tolerant toward others’ perceptions. Reduce relational reactivity. Follow sister’s house rules. Respecting boundaries. Learn to manage impulsive behaviors. Identify social and community support. Report to youth program once a week.
Specific Interventions for Individual Goals and Relational Problems
Mode Deactivation Therapy (MDT) has been shown to be an effective evidence-based treatment (Kohl, 2010; Swart & Apsche, 2014) for African-American adolescent males, with PTSD and CD stemming from complex childhood trauma, from lower socioeconomic status (SES) in urban communities. MDT seeks improve client conditions, such as internalized problems, dysfunctional beliefs, aggressive behavior and fears, by restructuring the experiential (conscious) components of the individual’s schema, as well as “a corresponding cognitive restructuring of the structural [unconscious] components” (Apsche & Siv, 2005, p. 131) in effort to alter or deactivate Jeremy’s schema mode—i.e. reactivity. The goal is to address Jeremy’s underlying perceptions “that may be applicable to setting in motion the mode related charge of aberrant schemas” (p. 131), this may begin with “radical acceptance and examining the “truth” in each [of Jeremy’s] perceptions” (p. 131).
In addition, trauma-focused cognitive-behavioral therapy (TF-CBT) has shown high efficacy in treating “children following childhood maltreatment” (Leenarts, et al., 2013, p. 269). TF-CBT will involve “exposure to the traumatic event; exposure can be implemented by applying techniques such as direct discussion, imagining or visualization of the traumatic event, and may be carried out in an explicit graduated manner or by discussing specific aspects of the trauma in various sessions” (p. 227), while focusing on “teaching positive alternatives to aggressive or violent based interpersonal behavior” (p. 227).
Problem-solving training (PSST; Eyberg, Nelson, & Boggs, 2008) is an evidence-based (EB) behavioral treatment; with a hopeful outcome of modified behavior pattern. This program will teach Jeremy problem-solving strategies, in context of real life problems, such as; (a) identifying the problem, (b) generating solutions, (c) weighing pros and cons of each possible solution, (d) making a decision, and (e) evaluating the outcome. This strategy can be used collaboratively between the therapist and school counselor so to monitor behavior change throughout the program (Eyberg, Nelson, & Boggs, 2008).
Cognitive Behavioral Intervention for Trauma in Schools (CBITS; Leenarts, et al., 2013) will be recommended to the school counselor as the parallel treatment in the school setting, so that all components of Jeremy’s treatment are aligned. Family-based interventions, such as parent training, family narrative therapy or multi-systemic therapy (Carr, 2014), will be used to include Jeremy, his sister and brother-in-law aimed at constructing a stable home environment as well as setting healthy boundaries and establishing a family narrative.
Environments and Social Systems
There is a reciprocal influence between “individual, family, sociocultural systems, and overall cultural ideologies” (Okun & Kantrowitz, 2008, p. 2). Jeremy, an African-American adolescent male—representing cultural ideologies—lives with his sister and brother-in-law—representing family—in urban Chicago where he attends high school—representing community. Jeremy coming from an abusive home and dysfunctional family had a major effect on his psychological development, but other factors, such as lower SES, urban versus rural communities, residing with other than parental caregivers among others, also influence the construction of his schemas. The collaboration of Jeremy’s individual therapy, family narrative therapy, community youth program, and school therapy is essential to the treatment plan. It is beneficial to elicit multi-systemic treatment when dealing with clients’ who have complex pathology.
Conclusion
Jeremy presents complex pathology as a result of chronic and complex childhood trauma. There is urgency to stabilize Jeremy so that he can find permanent placement with his sister and brother-in-law and not be expelled from school. Using a multi-systemic framework, treatment will work collaboratively to stabilize Jeremy and improve his level of functioning. The goal is to take consistent steps toward short- and long-term goals in an organized fashion with active participation. The plan may have to be somewhat flexible in consideration of participation and temperament, but should set clear boundaries and requirements.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Bronner, M. B., Beer, R., Jozine van Zelm van Eldik, M., Grootenhuis, M. A., & Last, B. F. (2009). Reducing acute stress in a 16-year old using trauma-focused cognitive behaviour therapy and eye movement desensitization and reprocessing. Developmental Neurorehabilitation, 12(3), 170-174. doi:10.1080/17518420902858975.
Carr, A. (2014). The evidence base for family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, 36(2), 107-157. doi:10.1111/1467-6427.12032.
Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37(1), 215-237. doi:10.1080/15374410701820117.
Family Caregiver Alliance (2006). Caregivers count too! A toolkit to help practitioners assess the needs of family caregivers. San Francisco: Author.
Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A Research Note. Journal of Child Psychology and Psychiatry, 38(5), 581-586. Retrieved from http://www.nctsn.org/content/strengths-and-difficulties-questionnaire-child-report
Kohl, K. (2010). Trauma, dissociation, and traumatic stress at a trauma center serving low-income children and adolescents. Dissertations. Paper91. http://ecommons.luc.edu/luc_diss/91
Leenarts, L., Diehle, J., Doreleijers, T., Jansma, E., & Lindauer, R. (2013). Evidence-based treatments for children with trauma-related psychopathology as a result of childhood maltreatment: a systematic review. European Child & Adolescent Psychiatry, 22(5), 269-283. doi:10.1007/s00787-012-0367-5.
Minnesota Department of Human Services Online. Retrieved June, 14, 2015, from http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_168991
Nader, K.O., Newman, E., Weathers, F.W., Kaloupek, D.G., Kriegler, J.A., & Blake, D.D. (2004). National Center for PTSD Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) Interview Booklet. Los Angeles: Western Psychological Services. Retrieved from http://www.nctsn.org/content/clinician-administered-ptsd-scale-children-and-adolescents
Okun, B. F., & Kantrowitz, R. E. (2008). Effective helping: Interviewing and counseling techniques (7th ed.). Belmont, CA: Brooks/Cole.
Piers, E. V., Harris, D. B., & Herzberg, D. S. (2015). Piers-Harris 2: Piers-Harris Children’s Self-Concept Scale, 2nd Edition. Retrieved June 12, 2015 from http://www.mhs.com/product.aspx?gr=edu&prod=piersharris2&id=overview
Swart, J., & Apsche, J. (2014). A comparative treatment efficacy study of conventional therapy and mode deactivation therapy (MDT) for adolescents with conduct disorders, mixed personality disorders, and experiences of childhood trauma. International Journal of Behavioral Consultation & Therapy, 9(1), 23-29.
Appendix A
Jeremy was referred by school authorities, per school counselor, presenting with conduct disorder symptoms to include: bullying, physical fights, carrying a knife on school grounds, taking things from other students, vandalized school lockers and vending machines with physical aggression—sometimes with an object, and skipping school excessively. The school reports that his behavior has been a concern for at least two years, but about a year ago the behaviors began to escalate and become increasingly more severe leading to more serious concerns for his, and the people around him, safety. Therefore, he was mandated to mental health in order to avoid being expelled—already have been suspended multiple times—from school due to aggressive and destructive behaviors as well as his relentless violation of school rules.
His oldest sister, who is 26-years old, reports that Jeremy does not abide by any of the house rules, stays out all hours of the night, experiences nightmares—as witnessed by her able to hear him struggle in his sleep and complain about them, snaps out in fits of rage or anger outburst and not be able to remember much about the occurrence later, notices that he profusely sweats when reminded of his dad, avoids any topic relating to their parents, refuses any contact with his dad, self-destructive, always on alert like something might happen, freaks out when surprises, and seems emotionally numb.
