Katheryn Case Study Clinical vignette

Caucasian girl, Katheryn, aged 10, was referred on account of her increasingly aggressive behavior towards her 8-year-old brother, Carl. Mrs. Smith, their maternal grandma, has been raising the two children. Carl was a baby when she had taken him under her wing. In fact, she was responsible for their upbringing since their infancy; the two kids were taken away from Mrs. Smith's daughter (the children's mother) because of her alcoholism and substance/cocaine abuse behaviors. Katheryn and Carl are the two youngest of eleven children; none of them have been brought up by the mother and each of them struggles in one or other way. In fact, it has been reported that two older siblings of Katheryn had cleft palates at birth, and one sister hadn't spoken till she turned five. Further, many siblings have been diagnosed with attention deficit hyperactivity disorder (ADHD); they are all on medication therapy. Katheryn's problems are not confined to home life; at school, she is enrolled in an SDC (special day class), in which she is found to struggle with staying focused. Although Katheryn is quite responsive to her adults and is engaged easily, she sometimes needs to be redirected, as she gets overly excited. On the social level, Katheryn appears to feel slightly awkward, and reports that she is at the receiving end of her peers' teasing, at times. While there have been no reports of her engaging in fights at school, Katheryn has, on occasion, been taken to the principal's office, on account of wrongdoings such as stealing pencils at school, nicking candy and chips from the local store, and yelling at fellow students. Katheryn's teacher reports that she can sometimes be clumsy (for instance, breaking articles by accident) as well as forgetful (Katheryn has to wear glasses, and on several occasions, she forgets about wearing them, or loses them). According to Mrs. Smith, Katheryn is not a good influence at all on Carl, as she lies, steals, and destroys articles at home. At the office, however, Katheryn appears to be curious, quite engaged, and really taken with her therapist. Clearly, she has attended therapy sessions somewhere before, as she speaks about stress, remarks that she really feels bugged by Carl, and worries about her grandmother who, in her opinion, needs therapy as well, as she suffers from stress too.

Strengths-Based Treatment Plan

Treatment Plan: Individual/Behavioral

Goal 1: The patient (Katheryn) will increasingly comprehend the aggressiveness cycle and its effect on relationships in her life (particularly with her brother); this will be evidenced by her ability of discussing the aggression cycle and how her relationships reflect the cycle. Katheryn will be able to report a feasible and well-defined safety or self-care strategy.

Treatment Recommendations: One-on-one therapy sessions once every week.

Timeline: Between 3 and 6 months

Goal 2: Katheryn will exhibit decreased isolation from peers. This will be evidenced by the development and implementation of a strategy to increase social support as well as self-report frequency of weekly contacts with children belonging to her age group.

Treatment Recommendations: One-on-one therapy sessions once every week.

Timeline: Between 3 and 6 months

Goal 3: Dysthymic symptoms in the child (Katheryn) will reduce. This will be evidenced by decreased sleep disturbance, increased energy, and decreased self-reports of feeling helpless and miserable.

Treatment Recommendations: One-on-one therapy sessions once every week; potential medication evaluation referral, if Katheryn's condition worsens or doesn't change in three months' time.

Timeline: Between 3 and 6 months

Goal 4: Katheryn's self-esteem will increase. This will be evidenced by decreased negative statements regarding self and more positive self-statements.

Treatment Recommendations: One-on-one therapy sessions once every week

Timeline: Between 3 and 6 months

Treatment Plan: Individual/Cognitive

Goal 1: The patient (Katheryn) will increasingly comprehend the violence cycle and its effect on relationships in her life; this will be evidenced by her ability of discussing the violence cycle and how her relationships reflect the cycle. Katheryn will be able to report a feasible and well-defined safety or self-care strategy. She will also become capable of identifying her faulty perceptions with regard to her relationship with her brother and peers, as well as her role in these family/social relationships. Katheryn will also start demonstrating more reality-based thinking.

Treatment Recommendations: One-on-one therapy sessions once every week

Timeline: Between 3 and 6 months

Goal 2: Katheryn's social isolation will decrease. This will be evidenced by her reports of increased understanding of how her relationship dynamics promote her isolation. She will also start to make a conscious decision to reach out to her brother and interact more with other children of her age.

Treatment Recommendations: One-on-one therapy sessions once every week

Timeline: Between 3 and 6 months

Goal 3: Dysthymic symptoms in the child (Katheryn) will reduce. This will be evidenced by her reports of a better understanding of erroneous assumptions and attitudes regarding herself and her relationships with others, and will reflect more reality-based opinions of herself and her worth.

Treatment Recommendations: One-on-one therapy sessions once every week; potential medication evaluation referral, if Katheryn's condition worsens or doesn't change in three months' time.

This will be evidenced by decreased negative statements regarding self and more positive self-statements, in addition to reports of comprehension of the role of her existing relationship dynamics in self-perception. She will be able to perform reality checks with her brother and peers when she experiences negative feelings regarding herself.
Treatment Recommendation: One-on-one therapy sessions once every week; possible bibliotherapy.

Treatment Timeline: Between 3 and 6 months.

DSM Multi-axial Diagnosis DSM-IV

The following diagnosis was made in case of Katheryn;

Axis I: Clinical Disorders

This covers:

• Disorders typically diagnosed among infants, children or adolescents (ADHD)

• Anxiety disorders

• Mental disorders on account of any general medical ailment

• Mood disorders (like depression)

• Adjustment disorders

• Impulse-control disorders (Kleptomania, Intermittent Explosive Disorder)

Axis II: Personality Disorders and Mental Retardation

• Antisocial personality disorder

Axis IV: Psychosocial and Environmental Problems

• Issues with one's primary support group (family, brother, and grandmother)

• Social environment-related issues (friendships problems, loneliness)

• Educational problems (academic issues, conflicts with educators)

Axis V: Global Assessment of Functioning

This number between 1 and 100 reflects judgment of caregiver, with regard to overt functioning level. In my opinion, Katheryn's score must be 60: she exhibits moderate symptoms/difficulty in functioning at school and in society (American Psychiatric Association, 2000).

Clinical Conceptualization of Working with This Client

The clinical case preparation concept supports collaboration with patients for identifying idiosyncratic facets of presentation, and selecting interventions based on this. Hence, it is a two-way street. Therapist and client need to establish a bond where impacts of both may be felt. Effects of therapist refer to the quantity of variance attributable to the therapist rather than the therapeutic model employed (Duncan, 2010).

The Clinical conceptualization of working with Katheryn;

Background Information

Caucasian girl, Katheryn, aged 10, has an 8-year-old brother, Carl. Mrs. Smith, their maternal grandma, has been raising the two children. Katheryn is, at present, enrolled in SDCs.

Reasons for Referral

Referred on account of her increasingly aggressive behavior towards Carl

Presenting Problem

Aggressive behavior at home

Attends SDC

Sometimes yells at peers

Lies, steals, and destroys objects at home

Is forgetful and clumsy

Level of Functioning

The DSM Multi-axial Diagnosis' result places Katheryn's functioning level at 60.

Stressors -- Present/Past

1. Katheryn's mother is an alcoholic, and a substance (cocaine) abuser.

1. Several siblings of Katheryn's suffer from ADHD and receive medication therapy

1. Katheryn claims she's stressed out and notes that her little brother really irritates her; Ingram (2006) states that extreme emotional responses to moderate and mild stressors indicates the presence of vulnerabilities whose roots are in the individuals' experiences of early childhood. In Katheryn's case, such an experience may be connected with her mother's drug issues.

Treatments Received (Current/Past)

Katheryn has received therapy earlier.

Summary of Risk and Protective Factors

In brief, Katheryn has relational issues. Key elements of concern in her case include domestic violence, dysthymia, poor self-esteem, and social isolation.

Outcomes -- Goal-attainment Scaling (GAS)

Goodheart (2011) claims that outcome measurement is included in the push towards healthcare quality and accountability; review of treatment outcomes is a means of ensuring proper resource allocation (Goodheart, 2011). Hence, outcomes of every training stage govern overall plan execution. If goal 1 isn't achieved and the succeeding goal is dependent on it, therapists won't proceed till it is met. But outcome assessment alone is not sufficient; the information has to be translated into a sustainable evidence-based practice model, which can extend, further, to employing innovative methodologies for assessing recovery rates, monitoring patient progress, intervening when response is poor, and contributing to benchmarking risk-adjusted patient outcomes. GAS needs to include information feedback for refining patient-clinician interactions. A novel focus on individual outcomes, taking into consideration risk variables and clinical characteristics, will facilitate improved patient care delivery (Elizabeth A. Newnham & Page, 2010).

Barriers

For effecting the above behavioral changes, some obstacles must be anticipated as well as dealt with, including; Individual obstacles like level of neurological and psychological impairment, and absence of a motivation to effect change. The latter obstacle may be addressed through motivational interviewing, whose effectiveness is enhanced when it supplements other active therapeutic approaches (Miller & Rose, 2009). Societal barriers include growing up in an atmosphere characterized by HI EE (High Expressed Emotion), obstacles of criticism and dependence…