Solution Manual for Mental Health in Social Work: A Casebook on Diagnosis and Strengths Based Assessment, 3rd Edition

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Instructor’s Resource ManualForMental Health in Social Work: ACasebook on Diagnosis and Strengths-Based AssessmentThirdEditionJacqueline Corcoran,University of PennsylvaniaJoseph M. Walsh,Virginia Commonwealth University

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Table of ContentsInstructions for UseivChapter 3: AutismSpectrumDisorder1Chapter 4: AttentionDeficitHyperactivity Disorder10Chapter 5: Schizophrenia19Chapter 6: BipolarDisorder29Chapter 7: MajorDepressiveDisorder35Chapter 8: TheAnxietyDisorders42Chapter 9: Obsessive-Compulsive Disorder49Chapter 10: Post-TraumaticStressDisorder53Chapter 11: Eating Disorders: Anorexia Nervosa,BulimiaNervosa, andBinge Eating Disorder62Chapter 12: OppositionalDefiantDisorder andConductDisorder72Chapter 13: Substance-Related andAddictiveDisorders81Chapter 14: GenderDysphoria95Chapter 15: Alzheimer’s Disease102Chapter 16: Borderline Personality Disorder115

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Instructions for UseDirections Part I, Diagnosis: Given the case information, prepare the following: a diagnosis, therationale for the diagnosis, and additional information you would like to know in order to make amore accurate diagnosis.Directions Part II, Bipsychosocial Risk and Resilience Factors Assessment: Formulate a risk andresilience assessment, both for the onset of the disorder and for the course of the disorder,including the strengths that you see for this individual.Directions Part III, Goal Setting and Treatment Planning: Given your risk and protective factorsassessments of the individual, your knowledge of the disorder, and evidence-based practiceguidelines, formulate goals and a possible treatment plan for this individual.Directions Part IV, Critical Perspective: Formulate a critique of the diagnosis as it relates to thiscase example. Questions to consider include the following: Does this diagnosis represent a validmental disorder from the social work perspective? Is this diagnosis significantly different fromother possible diagnoses? Your critique should be based on the values of the social workprofession (which are incongruent in some ways with the medical model) and the validity of thespecific diagnostic criteria applied to this case.

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Chapter 3Autism Spectrum DisorderCase 1Questions to consider when formulating a diagnosis for Emmanuel1.What are Emmanuel’s significant symptoms with regard to a possible mental disorder?Emmanuel had a hard time separating from his parents at school and was continuouslycrying, trying to run away, and throwing tantrums. He had difficulty with transitions atschool and did not follow directions well. He did not approach other children and did notrespond to their attempts to play or talk. Emmanuel used few of his own wordsbutrepeated what others said. When upset, he made guttural noises or screams. He wassensitive to loud noises and reacted by covering his ears and screaming. Emmanuel hadno interest in his peers. He preferred to play on his own. When Emmanuel got exited heflapped his hands, clapped his thighs and crotch, and tapped his face. He appeared to bein a world of his own. He was content with writing numbers and letters over and over,and he frequently wrote down numbers to sooth himself when upset. He showed somedevelopmental delays in areas of self-help and adaptation. His parents report thatEmmanuel acted impulsively at times.2.For how long have Emmanuel’s problem behaviors been evident?The extentof Emmanuel’s problem behaviors and developmental difficulties were notedimmediately upon his enrollment in school, when he was five years old. While the familymay have minimized their prior suspicions of some of these difficulties, the formalassessmentrevealedthattheyhadbegunhavingconcernsaboutEmmanuel’sdevelopment at 30 months of age, due to his language difficulties. It is possiblethat hisproblems had been emerging before then.3.Has there been any recent stressful event occurring in Emmanuel’s life that might accountfor any of his symptoms?There is no evidence of any recent stressors in Emmanuel’s life, although his beginningkindergarten has placed him in a more structured environment than heexperiencedbefore. Rather than accounting for his symptoms, however, this seems to have made themmore evident.4.To what extents do Emmanuel’s (and his parents’) cultural traditions contribute to hisproblem behaviors?Because of their mixed Spanish and American heritage and lifestyles, the family did notacknowledge Emmanuel’s developmental delays as evidence of any internal problem.Rather, they perceived Emmanuel’s delays as being due to his need to live bi-culturallyand make a gradual transition between his two cultures.5.Given that Emmanuel has a developmental disorder, with what other disorders of childhoodand adolescence (if any) do his symptoms overlap?In addition to the autism spectrum disorders, Emmanuel’s inability to follow directionsand adhere to the demands of the structured environment could be seen as symptoms ofoppositional defiant disorder. His problems with attention and concentration could beseen as symptoms of attention-deficit hyperactivity disorder. His academic limitations,and slightly below-normal measured IQ, might make an observer suspect an intellectualdisability. Still, Emmanuel does not meet the full criteria for any of those disorders.

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DSM DiagnosisF84.0AutismSpectrumDisorder,withoutaccompanyingintellectualimpairment,withaccompanying language impairment,requiring substantial supportRationaleThe diagnosis of Autism Spectrum Disorder was made because Emmanueldisplays significantdeficitsin his social interactions, such as reduced eye contact, lack of social reciprocity, andfailure to develop relationships with others. His communication skills are considerably limited;he does not initiate or sustain conversations with others, and his language development has beendelayed since he was a baby.He also uses unusual forms of language, such as echolalia. For allthese reasons, he was given the additional specifierwith accompanying language impairment.Moreover, Emmanuel is unable to participate in imaginative play.Additionally, he exhibitsrestricted interests, such as writing numbers repeatedly in an artistic, almost calligraphic manner.Emmanuel displays repetitive motor mannerisms, including hand flapping and face tapping.Further support for this diagnosis is evident in his impulsivity and difficulty with sensoryintegration.Emmanuel’s developmental and psychological testing has determined the absence of IntellectualDisability. His IQ is 95. Therefore, the specifierwithout accompanying intellectual impairmentwas added.He was assessed as Level 2, requiring substantial support because of his languagedelays and lack of ability to interact socially.A review of Emmanuel’s medical history indicates that he is a healthy five-year old with noproblematic medical condition. His mother reports that pregnancy and deliverywere normal anduncomplicated.He was toilet trained at age three.Additional Information RequiredEmmanuel’sassessmentwascomprehensive,includinginputfromarangeofhealthprofessionals,andthusthere is no other information required at this time.Risk and Resilience AssessmentIt ismore appropriate to focus onrisk and protective influences for the course of the disorderbecause little is known about its originother than it has a biological basis.The onlysignificantrisk mechanisms are that Emmanuel is male and has limited social skills and interest in peers.Regarding protective factors he experiences significant parental involvement in his care and hasan average IQ, a good support system, and health insurance.What questions could be used to assess for additional strengths in this client?1.What types of social situations seem to bring out Emmanuel’s positive adaptive qualities?How can they be facilitated?2.What are the features of the 1:1 interpersonal situations in which Emmanuel is effectivelyable to interact? What are the personality characteristics of those who “bring out the best”in his interactional qualities?3.How can Emmanuel’s various interests be encouraged, since he can participate inactivities with others so long as the activity interests him?

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4.What are the circumstances in which Emmanuel is most likely to engage in his artisticpursuits, including calligraphy and listening to music?5.What playground conditions does Emmanuel seems to enjoy the most? What are thefeatures of those times when he is most able to attend to his puzzles?6.What are the circumstances that seem to encourage Emmanuel’s use of humor?7.How can Emmanuel’s visits with family members be structured to maximize his positiveengagement with them?Intervention PlanIn the case of autism spectrum disorder, it is necessary to develop and implement an interventionplan as soon as possible, especially in light of Emanuel’s relatively late diagnosis. Emmanuel iseligible for special education within his school district, and his parents and the special educationteam will meet within the next two weeks to develop an IEP (Individualized EducationProgram). As soon as this has been accomplished, Emmanuel will be able to join a classappropriate to his needs. The elementary school he attends offers a class for children with autismspectrum disorder, which is small in size and staffed with two special education specialists. Thisclass focuses on the development of social skills, as well as the reduction of stereotypedbehaviors. Speech therapy will also be necessary to enhancehis pragmatic language skills.In addition to these services it is important to educate Emanuel’s parents about the disorder,relevant parenting practices, and resources in the community. Fortunately, the school district hasa Parent Resource Center, which offers anarray of informational material in Spanish, as well asworkshops and classes on variousdisorders and their treatment. The social worker has providedthe parents with some basic information and has set up a meeting for the parents with Spanish-speaking staff at the Parent Resource Center. Due to the parents’ difficulties with consistentparenting, the social worker has already sharedinformation on discipline and has introducedthem to a behavioral approach to reinforce desired and reduce problematic behaviors. She hasalso suggested strategies to decrease the extent of Emmanuel’s TV watching. The social workerwill check in weekly with the family to review progress and assist when necessary.The diagnosis of autism spectrum disorder came as a shock to the family, who had viewedEmanuel’s behavior as a temporary delay in development. Therefore, they may need togothrough a grieving process.They also might requiresupport for their adjustment.A number oforganizations in the area offer support groups for the Spanish-speaking population. This will givethe parents the opportunity to share their feelings without having to rely on an interpreter.Additionally, disability in the Latino community is often viewed with stigma. In a support groupof their peers, Emmanuel’s parents could receive advice and support from people with a similarcultural background to their own.A sibling support group could also be offered to Emmanuel’sbrother and sister.Critical PerspectiveWhile the primary diagnosis appears to be valid, the DSM-5 criteriaare less clear about how todetermine its severity level, despite including a table for determiningrequiring very substantialsupport(level 3),requiring substantial support(level 2), andrequiring support(level 1).Although the DSM provides some general guidelines on how to assess social communication andrestricted repetitive behaviors along these lines, there ismuchsubjectivity on how these ratings

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are reached. In Emmanuel’s case, his parents had just found out about the disorder and he had,up until that time, limited supports. It may not befair to judge Emmanuel as “requiring verysubstantial support” when he had not yet received intervention.For that reason, hewas not giventhatrating, although it my later become evident that he needs it.Case 2Questions to consider in formulating a diagnosis for Hao:1.What are Hao’s significant symptoms with regard to a possible mental disorder?Hao is unable to relate to other children in class or follow directions, and he frequentlyengages in hand washing.He cannot follow classroom routines and only persists withactivities in which he is interested. He speaks with an inappropriately loud volume inclose proximity to others’ faces, and is unable to retain the teacher’s instructions aboutstanding back and speaking more quietly.Hao looks off into space while the teacherspeaks, and he does not react to comments she makes.At times he has temper tantrums atschool. His mother noticed in preschool that Hao was not connecting with other childrenand only wanted to play alone. Hao is not developing socially. He does not follow therules set forth by his family, and tends to ignore his parents when they try to disciplinehim. Hao tends to laugh inappropriately during activities at the park to a degree that hisfather threatens to take him home.2.For how long have Hao’s problem behaviors been evident?Hao’s problem behaviors have only been evident for one year. They were formallyidentified only when he enrolled in school and demonstrated an inability to functionwithin the structure of that institution. His parents had been concerned about his socialisolation one year before, when he entered preschool, but his teachers at the time did notsee Hao’s withdrawal and preference for playing alone as significant issues.3.Have there been any recent stressful events occurring in Hao’s life that might account forany of his symptoms?The Hao family has experienced much stress at times in their lives, but there is noevidence of significant stress in the past year or so that might help to account for Hao’ssymptoms.4.To what extent do Hao’s (and his parents’) cultural traditions contribute to his problembehaviors?Interestingly,Hao’sbeinginAmericamayhavedelayedtherecognitionofhisdevelopmental problems. According to his mother, in Vietnam Hao’s behavior would beconsidered unacceptable and outside the norm.Her own observations of the patience ofAmerican teachers led her to be less concerned about Hao’s behavior. In Vietnamchildren are warned against bad behavior by being threatened with physical punishment.While it is not clear what interventions Hao would have received in Viet Nam, hisabnormal behavior would have been less tolerated.5.Aside from autism spectrum disorder, what other disorders of childhood and adolescencedo Hao’s symptoms possibly represent?While ASP is distinct from the disruptive behavioral disorders, there is some overlapamong their symptoms. Hao might be considered for a diagnosis of oppositional defiantdisorder in that he seems to ignore instructions from adult authority figures (his parentsand teacher). He also could be considered for attention deficit/hyperactivity disorder in

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that he seems to have difficulty at times with his attention span, concentration ability, andactivity level.DiagnosisF84.0AutismSpectrumDisorder,withoutaccompanyingintellectualimpairment,withoutaccompanying language impairment, requiring supportAllergies (which canresultin eczema, byparent report)RationaleSocial workers do not diagnose neuro-developmental disorderswithoutcontributions fromamulti-disciplinary team.Therefore, Hao shouldparticipate in a physical examination, visual andhearing examinations, and neurological exams, as well as a speech and language assessment,before the diagnosis can be confirmed.Moreover, most of the information in the above reportcomes from Hao’s mother’s perspective, and other perspectives should be sought, includingthose of Hao’s father. Extended observations of Hao,in free play situations and with his parents,might yield additional information. That being said,Hao appears to tentatively meetthe DSMcriteria for Autism Spectrum Disorderas follows:A.Haoexhibitsqualitativeimpairmentsinsocialcommunicationandinteractionasevidenced by a failure to develop peer relationships appropriate to his developmentallevel (as noted in his preschool class and in his interactions with most of his cousins) anda lack of social or emotional reciprocity (as noted by his inability to relate to others at hispreschool, the parochial school kindergarten, and most of his cousins, with the exceptionof Thanh, who will talk about subjects of interest to Hao.)B.Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, asmanifested by an encompassing preoccupation with stereotyped and restricted patterns ofinterest that are abnormal either in intensity or focus (Hao frequently washes his hands)and an inflexible adherence to specific, nonfunctional routines or rituals (Hao displaysfrustration, sometimes culminating in temper tantrums, when he is not allowed to pursuewhat he wants to do at home and in the kindergarten setting).C.There is evidence that the relevant symptoms were present in Hao’s early developmenteven though they were not discovered until he attended school.D.The disturbance causes clinically significant impairment in social (lack of sustained playwith age mates and most family members of his age) and school functioning (Hao wasexpelled from the parochial school due to his behaviors).E.Criteriaarenotmetforanotherspecificpervasivedevelopmentaldisorderorschizophrenia.Hao’s diagnosis includesthe specifierswithout accompanying intellectual impairmentandwithout accompanying language impairmentbecause he isbothintelligent(by testing) and ableto communicate and be social. He is also given the specifierrequiring supportbecause hefunctions rather well in some ways and this is the mildest functional indicator.Additional Information RequiredAs noted earlier, it would be necessary for Hao to undergo a multi-disciplinary assessment tomake a valid diagnosis.Additionally, other reporters, such as his father, should be involved.

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Risk and Resilience AssessmentThere is no reported family history of ASD, althoughHao’s father was 40 when Hao wasconceived, which may present a risk factor, as older age of fathers has been associated with thedisorder. Regarding the course of the disorder, Hao appears to possess a number of resilienceinfluences. Hehas temper tantrumsbuthe doesn’t hurt himself or others. He isintelligent andgifted in music and computers.At the social level, Hao’s family is supportive and financiallysecure. He has a largeextended family available, although at this point they don’t understand thenature of his disorder. In addition to the extended family, Hao is being brought up in a religiousfaith.Hao’s disordercould have been caught earlier (he is being diagnosed at five years of age)but on the positive sidehe will now be receiving services through the public school system.What questions could be used to assess for additional strengths in this client?1.How can Hao’s treatment providers nurture his talents and curiosity?2.Given that Hao is responsive to time-outs, strong verbal communication, and direct eyecontact from his mother, what kind of structured program of reinforcement could beimplemented for him?3.How can sports activities be used to facilitate Hao’s learning and serve as reinforcers foradaptive behavior?4.How can Hao’s family be encouraged to support Hao’s adaptive activity and perhapsincorporate spirituality into his activities of daily living?5.How is it that Hao becomes focused when engaged in his artistic interests? What relatedskills can be put to additional productive use in his treatment?6.HowcanHao’sendearingpersonalityqualities,notedby histeachers,befurtherdeveloped toward his interpersonal skill development?7.Howcantheprofessionals’learningaboutVietnamesecultureprovideabetterunderstanding of how his behaviors are reflective of that culture?Intervention PlanParent InterventionsIt is important that Hao’s parents understand that he is not purposefully acting in a willful anddefiant way, but that his behaviors and style of interactingare a result of his disorder.At thesame time, managing the behaviors and training the child with ASDis challenging for parents,and the Chungs will require much support.Lang and An will be encouraged to attend a localsupport group for parents of special needs children, and an effortwill be made to find a supportgroup conducted in Vietnamese.The Chungs should receive parent training and information andtraining on how to promote Hao’s communication and social skills.Lang should be encouragedto return to part-time haircutting.Further, Lang and An should inform the extended family aboutHao’s disorder to ensure a more supportive network.Child InterventionsHao’s individual interventions will include three strategies: communication and social skilltraining; behavioral therapy;and educational intervention.

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Communication and social skills training:Hao will be taught in an explicit and rotefashion therules of socialization and communication. He will learn how to monitor hisown speechin termsof volume and rhythm, as well as how to interpret the communication of others, such as gestures,eye contact, and tone of voice. Opportunities to role-play communication and social skills will beimportant, as well as practice in social interaction through supervised and structured activities.Initially, it may be helpful for Lang to schedule play dates for Hao with other children withAsperger’sto practice developing skills.Behavior therapy:Thisclass of techniques is targeted at curbing problem behaviors, such asobsessions (frequent hand washing) and tantrums.These behaviors are identified and specificguidelines willbe devised to deal with them.Hao’s parents and his teachers/school staff will betaught to handle the behaviors in the same way, so that clear expectations are setand consistencyis maintained.Behavior therapies also focus on training a child to recognize a troublesomesituation—such as a new place or an event with lots of social demands—and then select aspecific learned strategy to cope with the situation.Educational interventionswill make full use of Hao’s individual's interests and talents in theareas of computers, music, and books.In school, there may be opportunities in the classroom forHao to take on leadership in activities revolving around these interests. Teaching other studentsskills can help Hao’s self-esteem, as well as assist him in learning social skills, such as taking theperspective of others, following conversational and social interaction rules, andengaging in two-wayexchanges.Hao maybe able toparticipateinthe mainstreamclassroomgivenhisintellectual abilities, but may need additional help from a support person.He also may requireindividualized curriculum centered on his deficits.Critical PerspectiveA debate occurred duringthe school system’s Individualized Educational Plan meeting whendiscussinga possible diagnosis for Hao.The psychologist who had administered the IQ testingdetermined that Hao has Autism Spectrum Disorder since his social awkwardness was profound.However,therepresentativefromthecityschooldistrict’sgiftedandtalentedprogrammaintained that Hao’s symptoms were a function of his giftedness.In other words, Hao’s highIQ and intellectual interests made him unable to relate to same-age mates and caused him to bebored and under-stimulated by the classroom routine. These differences of opinion underscorethe care with which any neuro-developmental diagnosis should be made. Despite these differentperspectives, Hao was ultimately diagnosed with Autism Spectrum Disorder because of hissocial deficits,manner of communicating, andrigid, circumscribed interests.Case 3Questions to consider when formulating a diagnosis for DeShon:1.What are DeShon’s symptoms with regard to a possible mental disorder?DeShon is distant from others, even his family members.He is unable to relate to othersin his class and does not play imaginatively.He repeats other people’s words when hespeaks with them.He displays flat affectand fails to make eye contact.Additionally, herocks back and forth and waves his hands in front of his face.According to his mother,DeShon also becomes frustrated when he is asked totransition to a new activity.Finally,

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he shows sensitivity to tactile experiences, particularly with regard to food texture.2.For how long have DeShon’s problem behaviors been evident?DeShon’s problem behaviors and developmental difficulties became evident between 18to 24 months; at that time, his speech development slowed and his already minimal eyecontact decreasedfurther.3.Have there been any recent stressful events occurring in DeShon’s life that might accountfor any of his symptoms?The family seems subject to many financial hardships, contributing to their frequentmoves and temporary homelessness.However, DeShon’s symptoms have been stablesince he was 18 to 24 months old,and he is now five years old.If his problem behaviorswere in reaction to a stressful live event, there would have been some shift in hissymptoms over the years.DiagnosisF84.0AutismSpectrumDisorder,withaccompanyingintellectualimpairment,withaccompanying language impairment, requiring substantial support.RationaleCriterion A: Deficits in social communication and social interaction across multiple contexts asevidenced by:1.Deficits in social and emotional reciprocity, manifested by an inability to sustain eyecontact; a failure to develop peer relationships appropriate to developmental level;impairment in the ability to initiate or sustain conversations; echolalia; and a lack ofsocial or emotional reciprocity.2.Deficits in nonverbal communication as noted by an inability to sustain eye contact, amisunderstandingofgestures,andpoorlyintegratedverbalandnonverbalcommunication.3.Deficitsindevelopingandmaintainingrelationshipsasevidencedbyalackofimaginative play appropriate to his developmental level and a lack of spontaneousseeking to share enjoyment, interests, or achievements with others.Criterion B: Restricted, repetitive and stereotyped patterns of behavior including rocking andwaving his hands back and forth.Criterion C: The abnormal functioning occurred prior to age three.DeShon has a tested IQ of 60 and thus is given the specifierwith accompanying intellectualimpairmentandalso,duetohislimiteduseoflanguage,withaccompanyinglanguageimpairment. He is further specified asrequiring substantial supportbecause he functions poorlyon his own unless involved in an isolated activity of particular personal interest.Additional Information RequiredWe can assume DeShon went through the appropriate testing needed to determine his diagnosis,although not much information is provided in the case study about the results of variousassessments and tests.

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Risk and Resilience AssessmentBiological factors are the major contributors to the development of autism spectrum disorder, butwe knowvery little about how any such factors are affectingDeShon. Regarding his riskinfluences for the course of the disorder, he has serious problems with play deficits andstereotypicalbehaviors,andthefamilyroutinelyexperiencesmaterialhardships.Ontheprotective side, DeShon is not aggressive, has a supportive mother and extended family structure,and is part of a school system that can offer and coordinate a range of interventions.What questions could be used to assess for additional strengths in DeShon?The assessment could focus more carefully through additional interviews with DeShon’s motheronhisstrengths withcoping questions(It sounds like you’ve had a lot of challenges.How haveyou been able to manage with all you’ve been through? How do you go on?What are thequalities you draw on?What would your stepmother say that you do?How about yourboyfriend?) andexceptions(When does DeShon seem more responsive? Who is there?What arethey doing and saying?).Other questions may include “What are thetypes of social situationsthat seem to bring out DeShon’stalentsand positive adaptive qualities?” and “What positivecharacteristicscan be channeled to enhance DeShon’s adaptation to the newly structuredsetting?”Intervention PlanThe social worker should ensure that mother is linked with social services(e. g., Medicaid, foodstamps, Temporary Aid to Needy and Dependent Families) so that DeShon’s basic health,medical, and nutritional needs can beconsistently met.The state Autism Society might havefurther informationon available family resources.DeShon’s mother’s financial situation needs tobe stabilized so that DeShon can remain in the same school system once he begins services.The social worker will present education about autism to DeShon’s mother and a referral to asupport group forparents of children with ASD.Special education services will be provided bycertified professionals at and through the school, including applied behavior analysisthat canteach DeShon skills and knowledge and extinguish hisnegative behaviors (i.e.,tantrums) byconsistent ignoring.DeShon’s mother and her boyfriend willbe taught behavioral techniquessothey can apply the same structure with him in the home.Critical PerspectiveIt seems clear in this case, based on the thoroughness of the examination process, that DeShonhas aneurodevelopmental disorder, and he most clearly fits the criteria for autismspectrumdisorder.However, such a diagnosis implies that the client has less potential to improve withregard to social and interpersonal functioning, so it is important that the social worker continueto look for evidence of strengths when this diagnosis is made, and not assume that the client’schange capacity is modest.

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Chapter 4Attention Deficit Hyperactivity DisorderCase 1:Questions to consider when formulating a diagnosis for Billy:1.Has Billy suffered any recent stressors that could account for his symptoms?Didhissymptom pattern precede or follow the stressful life events?Billy has recently disclosed sexual abuse that went on during a recent six-month period.However, to make the criteria for an adjustment disorder, the behaviors would have hadto start shortly after (within three months) of the stressful life event, and, according toMrs. Bronsky, Billy has been exhibiting the pattern of behaviors (oppositionality, poorschool performance, bedwetting, and encopresis) since he was a young child.2.Dotheoppositionalbehaviorsariseoutoffrustrationduetoinattentionandhyperactivity?According to Mrs. Bronsky, the opposite is the case; she views his inattention symptoms(forgetfulness, inability to concentrate, losing things, inability to complete work) as beingpurposefullyundertakentoannoyothers.Theteacherseestheexistenceofbothinattentive and oppositional symptoms rather than the oppositionality stemming fromADHD.Although Billy’s mother attributes his inattentive symptoms to oppositionality, ingeneral school report is the more validsource of information on ADHD.In addition,Billy’s mother doesnote the inattentive symptoms.One must also remember that ADHDand oppositional defiantdisorder often occur together.3.HasBilly been exposed to trauma?Could his symptom pattern be indicative ofPTSD?The presenting problem fortreatment is the sexual abuse.Although Mrs. Bronksy insiststhat his behaviors started long before the sexual abuse, witnessing family violence can beatraumatic event for children.Billy, like most children his age, may not be able to detailhis internalexperience about the violence.For this reason, parents are an importantsource of information for PTSD symptoms in children, although theymay tend tominimize symptoms.Mrs. Bronksy denied that the sexual abuse or the family violencehas had an impact on her children, although she is willing to seek counseling at therecommendation of the child advocacy workers. In terms ofre-experiencing, both Billyand his mother say he does not have nightmares, but it would be important to hear fromhim what he dreams of and if particular dreams are associated with his bedwetting.Shesayshe does not report flashbacks.In the therapist’s sessions with Billy, it will beimportant to see if re-experiencing of the abuse occurs through drawings, stories, or play.The child’s re-experiencing the event can be facilitated through its re-enactment withdrawings, stories, and play.Thehyperarousalcriterion for PTSD could be manifested by his inattention symptoms(forgetfulness, lack of concentration, inability to sit still) and his bursts of irritability andanger. His incontinence could further be construed as indicative of PTSD, and one couldspeculate that the sexual abuse by his cousin could have resulted from possible decreasedarousal to threat.Avoidancesymptoms could be seen in his tendency to avoid discussionsaboutthe sexualabuse,although othermotivations couldbe responsible,such as

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embarrassment, threats from the abuser, a desire to please adults by not discussingnegative events, and the belief that he is at fault (James, 1989).In a conversation with the therapist, Billy was positive about his father and his girlfriendand didn’t mention the family violence.Again, this could be avoidance due to PTSD, or itcould be embarrassment, pressure from the family, his wanting to preserve a good imageof his father for himself and people outside the family, and possibly other reasons.Numbingcould have been signified by Billy’s refusal to talk or respond to the therapistwhenshefirstmetwithhim,althoughthiscouldalsohavestemmedfromhisoppositionality.4.Is Billy’s enuresis primary (there never was a period that he had a dry bed) or secondary(developed after a period of time when there was a dry bed)?From Mrs. Bronsky’s report, the enuresis is primary, which is considered to relate toeither a physically and/or neurologically immature bladder and/or a deep sleeping patternin which the child is unaware of messages to the brain that the bladder is full (ChildDevelopment Information, 2006).Note further that children with ADHD are at increasedrisk of bedwetting compared to children from the general population.DSM Diagnosis314.01 Attention-Deficit/Hyperactivity Disorder, PredominantlyInattentive Type, Mild313.81 Oppositional Defiant Disorder, Mild307.7 Encopresis, without constipation and overflow incontinence307.6 Enuresis, Nocturnal OnlyV61.21 (995.53) Sexual Abuse of Child, Confirmed (Reason for visit)RationaleBilly has been given the diagnosis of Attention Deficit Hyperactivity Disorder, PredominantlyInattentive Type.He meets the following seven symptoms of inattention for longer than sixmonths (six are required) and for that reasonhe was given a “Mild” severity:1.Does not give close attention to details or makes careless mistakes in schoolwork.2.Has trouble keeping attention on tasks (schoolwork).3.Does not follow instructions and fails to finish schoolwork or chores, or duties.4.Avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a longperiod of time (such as schoolwork or homework).5.Loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books,or tools).6.Is easily distracted (looking out the window instead of completing work)7.Is forgetful in daily activities (forgets to bring homework home, forgets what teacher tellshim)Billy meets only two of the hyperactivity symptoms (fidgeting and squirming,often gets up fromseat when remaining in seat is expected).The impairment (strained relationship with his mother,poor academic performance) is present in two settings as required.Billy was given the Sexual Abuse of a Child V code because his recent abuse was the reasonfor treatment seeking.Oppositional Defiant Disorder was also diagnosed.His mother states thatBilly’s behaviors began before the sexual abuse and as far back as she can remember. The

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diagnosis requires that symptoms started before the age of seven.Billy displays four of the eightcriteria in section A that are required for six months or longer, as follows:1.Refusal to carry out rules or requests by adults (refuses to do schoolwork)2.Blaming others (blaming another student at school for his misbehavior)3.Arguing with adults4.Deliberately doing things to annoy others (banging stick in house)Billy exhibits these behaviors both at home and at school, according to his mother.It is currentlyaffecting his ability to function appropriately in school and is causing strained relationships inthe home.Because he only has four symptoms and that is the minimal requirement, the “mild”specifier is indicated.Another diagnosis is Encopresis without constipation and overflow. Billy passes feces in hispants once a month.Although we need to confirm that it meets the minimal time frame of threemonths, it sounds like the behaviorhas been ongoing for a while.He meets the age requirementfor this diagnosis.Billy also exhibits behaviors that led to the diagnosis of Enuresis, nocturnalonly, because he wets the bed almost every night.It is clinically significant because of itsfrequency and duration.Additional Information RequiredMost of the information for Billy’s diagnoses is from maternal report, supplemented by teacherreport.Other questions for Billy’s mother could involve her pregnancy and delivery of Billy toassess if therewere any early complications.Did she smoke during Billy’s pregnancy?Did hehave exposure to lead? She also might know of any family history of ADHD (particularly aboutBilly’s biological father).An assessment ofmother’s current adjustmentis necessary,asmaternal stress and lack of social support are associated with poor outcome for ODD.Herperspective on Billy’s peer relationships is also important, as is the teacher’s.From the casestudy, it is unknown if Billy has friends and if his oppositional and inattentive symptoms havecaused children to avoid him.Once Billy has built some trust with the therapist, it would be helpful to have more directinformation to rule out Post-Traumatic Stress Disorder. Several measures have been designed toassess PTSD in children (see Corcoran & Walsh, 2006), including the Children’s Impact ofTraumatic Events Scale, which was specifically formulated to assess PTSD symptoms inchildrenwho have been sexually abused.A release to talk to Billy’s doctor about his enuresis and encopresis and a recommendedtreatment plan is also suggested.Additionally, results of IQ and learning tests might indicate thatBilly meets other diagnoses for intellectual or learning disorders and would thus need additionalresources in the school setting.Risk and Resilience AssessmentThe neurodevelopmental risks that may have contributed to the development of ADHD in Billyare unknownat this time, but are assumed.Billy’s gender places him at additional risk forADHD.Other risk andprotective influences may affect the persistence of ADHD over time.Riskinfluences involve Billy’s mother’s inconsistent and ineffective efforts to manage her child’sbehavior. Fortunately, Billy’s mother does not present with ADHD symptoms herself.Anotherprotective influence is that Billy lives in a two-parent home, although the adjustment into astepfamily household might have been stressful for him.The fact that Billy is diagnosed withoppositional defiant disorder increases his overall risk for poorer outcome. Other strengths

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involve father involvement in activities.Billy reports a positive relationship with his biologicalfather and sees him regularly.His stepfather has stable employment, and mother is seekingmental health services for her children.What questions would you ask to elicit further strengths?For Billy’s mother:1.When are she and her husband able to follow through with consequences to Billy? Whatdo they do? How does he respond?How do they support each other?2.What is different about times when Billy had a dry bed at night?3.He is able to control his defecation most of the time.What is he doing to achieve this?For Billy and his teacher:When is Billy able to complete his assignments?What is different about those times?What timeof day is it?Who is he sitting near?What is he doing and saying to make this happen?For Billy:Externalizing techniques might be helpful for Billy; these may involve getting him to give aname to the behaviors that are getting him in trouble, then drawing it (“the volcano,” “the foolingaround,” “the silly stuff,” “the fighting,” and so on), and showing how he is able to exert controlover this “externalized entity.”TreatmentThe sexual abuse is the presenting problem for treatment, although other aspects of his carerequire an immediate approach.The sexual abuse will be addressed using a cognitive-behavioralapproach that has been validated with children who have experienced PTSD, as well as othersymptoms, as a result of sexual abuse (Deblinger & Heflin, 1996).The focus with Billy will beon stress management (progressive muscle relaxation, thought stopping, positive imagery, ordeep breathing) and desensitization procedures, so that he will be progressively able to talk aboutthe traumatic event and its aftermath in a way that diminishes arousal and distressing emotions.This intervention will include Billy’s mother since maternal support is critical to a child’sadjustment for sexual abuse.Billy’s mother has shown her support in a number of ways (i.e., shehas cooperated in the civil and criminal investigations, she has brought Billy for therapy), butthere is also some ambivalence on her part.Her remark about the children not being able to playwith their cousin anymore was of concern, although she was able to respond appropriately onceshe was questioned.She also shows a reluctance, like many parents do, about talking with theirchildren about the abuse.Intervention with mother will help her communicate more effectivelywith her children about the sexual abuse and handle their questions, concerns, and possiblesymptoms.AnothercriticalaspectoftheinterventioninvolvesBilly’shavinganIndividualizedEducation Plan in the school system. The social worker will find out from the State Departmentof Education how Mrs. Bronsky can initiate this process.Specifically, Billy will need to be testedfor his IQand any learning disabilities.It could be that many of his frustrations are due to thework being too difficult for him.

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AnotherimportantcomponenttotheinterventionwillbeMr.andMrs.Bronsky’sparticipation in parent training to manageBilly’s ADHD and ODD symptoms.Further, Mr. andMrs. Bronsky (as well as Billy’s father) needs to be provided information about ADHD.Treatment for bedwetting in children includes behavioral conditioning devices (pad/buzzer)and/ormedications(anti-diuretic hormone nasalsprayand theanti-depressantmedicationimipramine). Eventually the child becomes conditioned to wake up and to go to the bathroomonce he or she experiences the urge to urinate.Although these conditioning devices may takemonths to work, they havehigh success rates long-term.The American Academy of Family Physicians (2003) recommends that the treatment ofencopresis should entail managementof any oppositional behaviors.For both the enuresis andthe encopresis, Mrs. Bronsky should be encouraged to follow her physician’s recommendationsas to treatment approach.As part of a behavioral reinforcement system that Mrs. Bronsky willlearn to implement through parent training, she can set up positive reinforcement for Billyhaving “dry nights,” as well as appropriate use of the toilet for bowel movements.Critical PerspectiveBilly has already experienced many stressful life events, including domestic violence, divorce,and sexual abuse.Some of these events, particularly the domestic violence, might have occurredfrom a very young age.Therefore, this is a case that shows the possible impact of a dysfunctionalenvironmenton a person’s functioning.Although there are biological aspects to ADHD andenuresis, an argument could be made that some of his central diagnoses (sexual abuse of a child,oppositional defiant disorder) are a reaction to a stressful environment, which includes familyviolence, divorce, mother’sre-marriage, and sexual abuse.The diagnosis ofPTSD was considered for Billy.However, some of the difficulties withdiagnosing PTSD in children became apparent, although DSM 5 has taken some pains to createcriteria that is applicable to children under six.First, there is a great deal of symptom overlapbetween ADHD and PTSD (Perrin, 2000). At the time of the assessment, Billy was not able toconvey informationabout his internal experience.Parental report may be biased, and Billy’smother may be minimizing his PTSD symptoms.Case 2:Questions to consider in formulating a diagnosis for Wayne1.Has Wayne suffered any recent stressors that could account for his symptoms? Ifso,didhis symptom pattern precede or follow the stressful life events?Wayne came to the agency because of a specific stressor–the break-up with hisgirlfriend, an event for which he accepts blame. While some his symptoms have certainlybeen exacerbated by that event (especially his low mood and the constant calling of hisgirlfriend), it appears that all of them have been present for many years, and some forperhaps his entire life. Wayne’s difficulties controlling his temper and his absent-mindedness appear to be long-standing aspects of his personality.2.Do Wayne’s angry outbursts arise out of frustration due to inattention and hyperactivity?Wayne’s outbursts are due at times to his symptoms of inattention and hyperactivity, butthose symptoms do not fully account for that behavior. The angry outbursts also seem toarise from his feelings of insecurity and fears of rejection. In fact, Wayne describes many

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of his episodes of forgetfulness rather calmly; as if this is a characteristic to which he hasbecomeaccustomed.Itappearsthatwhenhisinattentionandhyperactivitycauseproblems in his primary relationships (with women), they are more likely to result inangry outbursts.3.Has Wayne been exposed to trauma in his past?Could his symptom pattern beindicativeof PTSD?Wayne has experienced trauma in the past, although the nature and extent of that traumaneeds to be more fully evaluated. Wayne experienced physical abuse by his father, aswell as witnessing the abuse of his mother. These experiences may have provoked fear,helplessness, or horror in Wayne. Further, Wayne and Wendy both describe a variety ofsituationswhereWaynebecomesintenselyangryatnormallifeoccurrences.Hisoutbursts of anger could represent physiological reactivity but whether it is in reaction tocues of trauma is questionable.Wayne spoke primarily of the breakup and only brieflyand vaguely of his past experiences with his father. This could represent his efforts toavoid thoughts, feelings, or conversations associated with the trauma.Wayne did notappear to exhibit signs of numbing.Therefore, without additional information, the socialworker would be unable to consider further a diagnosis of PTSD.4.WasalearningdisorderbehindWayne’sfrustrationandinabilitytocompleteschoolwork?It is possible that Wayne has a learning disorder, but without the corroboration of schoolrecords or new testing this will be difficult to determine. Clearly, some symptoms ofADHD and its outcomes are similar to those involving learning disabilities.DSM Diagnosis309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood.314.01 Attention-Deficit/Hyperactivity Disorder, PredominantlyInattentive Type, Mild995.81 Spouse or Partner Violence, Physical, ConfirmedRationaleAn adjustment disorder provides a least restrictive diagnosis that accommodates the fact thatWayne’s responses could be considered “normal” for someone going through a breakup with asignificantother(aweekprior).Wayne’sanxietymanifeststhrough constantlyrecurringthoughts about Wendy, and his depression can be indicated by insomnia and an irritable mood.Wayne copes with the breakup by staying as busy as possible.The V code Spouse or Partner Violence, Physical, was added because of Wayne admitting tobeing physically violentwith his previous girlfriend.Also of concern was his violence to his ex-girlfriend’s child. When the social worker inquired about this, Wayne was vague, but soundedregretful about hitting the child. The social worker notes that this will be something to explore infurther sessions, as it relates to the experience of Wayne’s own physical abuse and watching thephysical abuse of his mother by his father.Wayne was also diagnosed with Attention-Deficit/Hyperactivity Disorder, PredominantlyInattentive Type. Wayne meets six of the symptoms of inattention:1.Often has difficulty sustaining attention in tasks or play: Wayne admitted to having ahard time concentrating on anything other than watching television.

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2.Difficulty organizing tasks and activities:Wayne said he becameeasily frustrated if hehad to deal with too many things at once, such as a lot of work orders.3.Avoids, dislikes, reluctant to engage in tasks that require sustained mental effort: Theclient typically avoids activities that require him to do a lot of thinking, and typicallyspends his time watching television. Wayne chose his current occupation because he isable to move around a lot, through the apartment units.4.Loses things: Wayne leaves his tools in different apartment units and wastes time at worksearching for them.5.Easily distracted:If Wayne is cleaning the kitchen, he will sometimes leave the tap waterrunning as his attention becomes diverted on something else.6.Forgetful:Wayne will forget instructions that have been givento him at work.Wayne does not seem to meet enough criteria to meet the hyperactivity-impulsivity subtype.He does leave situations in which remaining seated is expected.For instance, during thecounseling session, Wayne jumped out of his seat to go to the water fountain without announcinghis departure.He is also restless and impatient when faced with traffic.Wendy states his mother found him to be an “exhausting” child. He ran around constantly,was easily distracted, and acted on every whim he had. Although he did not receive a diagnosisas a child, we can assume that he met criteria for ADHD before age twelve.Wayne’s symptomscause both social (relationship problems) and occupational impairment (he is unable to hold jobsfor long periods oftime).Additional Information RequiredThe social worker would like to explore Wayne’s background and current symptoms in moredetail to rule out several other possible diagnoses. Specifically, she would like to inquire furtherabout possible PTSD symptoms, including re-experiencing, avoidance, and numbing of generalresponsiveness.Risk and Resilience AssessmentOnsetManyofWayne’srisksforADHDareunknownastheyaretheorizedtoinvolveneuropsychological factors.Very little is also known about his biological father and his historyof mental illness, although he was said to have an alcohol problem and was physically abusive.On the protective side, Wayne’s mother did not smoke or use substances during pregnancy.CourseFrom the information provided, it does not appear that Wayne developed ODD or CD in hisyouth, which bodeswell for the course of ADHD.However, the past physical abuse of his ex-girlfriend and her child is troubling.With the help of his girlfriend, Wayne has some insight intohis behaviors and seems determined to get better, if only to get her back.Wayne suffersfinancially, which puts him at risk; he is in debt, earns little, and does not receive healthinsurance benefits.This means that treatment might be difficult to pay for.What techniques could be used to elicit additional strengths?Wayne has many strengths.It is known, for example, that he is well liked by his co-workers,does well on the job, and has an attractive personality to some women. Further, he always feels

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remorse for his angry outbursts. His strengths could be further assessed by asking Wayne torecount the various successes he has experienced throughout his life, asking him to make a list ofhis personal qualities, asking how he learned to be such a good repairman, and how he has beenable to implement the organizational tasks suggested by his girlfriend.Other techniques couldinclude:1.Exception-findingAttention: When are you able to focus your attention on what you need to get done, evenfor a little while?What are you doing differently?Who is there? What is going on?Frustration and anger: When was a time you started to feel mad but was able to stopyourself from letting it take over? What did you do?2.Future without the problem: When you are able to control your anger and focus yourself,whatwill you be doing differently?How will you be responding to others?What will they be saying towards you?Talkabout times this happens now.When you have the kind of relationship you want towards your girlfriend, how will yoube acting?Howwill she be responding to you?What will you be doing together?TreatmentMedicalGoal:ToreceiveacomprehensiveassessmentforADHDandappropriatebiologicalinterventions for that disorder.Plan: Wayne will receive a medical exam to determine if there is a physical basis to hisirritability and angry outbursts. He will also complete a series of rating scales for furtherassessment of his ADHD. He will be referred for a psychiatric evaluation to determine a need formedication.PsychologicalGoal: To become educated about ADHD and its management.Plan: Wayne will attend a psychoeducational group on ADHD at agency.Goal: To increase quality of social and occupational functioning.Plan:Waynewillreceivecognitive-behavioralinterventionsconcentratingonangermanagement,frustrationtolerance,timemanagement,problem-solvingskills,andcommunication skills. The social worker will continue to support and guide Wayne’s efforts toincrease structure in life, including budget schedules, increased usage of dry erase board andmemos, and files for important documents.Goal: To resolve the nature of romantic current relationship.Plan: Wayne and Wendy will attend couples counseling and problem-solve about the nature oftheir relationship.SocialGoal: To resolve financial concerns.Plan: The social worker will refer Wayne to a legal aid agency to determine whether he has abasis for not being liable for the student loans. He will also be helped to inquire about healthinsurance options through his current place of employment, and possible to inquire about otherplaces of employment that provide such benefits.

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Critical PerspectiveWayne’s case highlights some of the problems in applying the ADHD DSM diagnostic criteriafor adults, although improvements have been made in DSM-5.Wayne suffers from suchsymptoms as overreacting to frustration, poor motivation, and difficulty with time management,although these are not listed in the DSM.As it is, he only met criteria for the “PredominantlyInattentive Type” of ADHD, but many of his symptoms involve impulsivity, and these are notcaptured in the diagnosis.

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Chapter 5SchizophreniaCase 1Questions to consider in formulating a diagnosis for Anna:1.What symptoms of problematic thinking, feeling, and behavior does Anna present?Anna displays a variety of thoughts, feelings, and behaviors that aredetrimental to hersocialfunctioning. She exhibits poor self-care, iswithdrawn from almost all interpersonalinteraction, displays little emotion, maintains a blank affect, does not communicatecoherently, talks to herself, seems preoccupied, and uses poor judgment by agreeing tolive witha relative stranger. She has nightmares and evidently no motivation to make anychanges in her life.2.Are any of the above symptoms clearly psychotic?Many of Anna’s symptoms appear to represent psychotic ideation, including her level ofwithdrawal, talking to herself, absenceof affect, and preoccupation with internal stimuli.Because she does not communicate well verbally, however, it is difficult to understandthe extent of her psychotic ideation.3.Is it possible that Anna has, or has had, a mood or schizoaffective disorder?Anna’s presentation is striking in that she does not exhibit any affective range. There areno symptoms of depression orelation. Schizoaffective disorder canbe ruled out becauseof this absence of a strong and variable mood component to her psychotic symptoms.4.How does Anna’s poor communication complicate the process of her assessment anddiagnosis?Anna is somewhat puzzling diagnostically because she is not verbally engaged with herservice providers, and as such is not a valid self-informant. Without the benefit of therecent testing, physical exams, reports fromher recent hospitalization, andinput from herfather, it would bedifficult toconfidently reach aconclusion about her diagnosis. Still,medical conditions have been ruled out as contributing to her bizarre behavior, and it isknown that she does not use any substances that might be mind-altering.5.Is there evidence of a premorbid personality disorder in this client?Adiagnosis of schizoid personality disorder couldbe made as a premorbid condition.This is based on her father’s history of Anna’s being a quiet, withdrawn girl who alwaysdid what was expected of her, but without evident enthusiasm or conviction, and thenwithdrawing to her room. Since her adolescent years shehasrarely left the confines ofher home, has taken no social initiatives, and seemsmost comfortable when alone. Herpremorbidbehavior was not bizarre enough to warrant a consideration of schizotypalpersonality disorder.6.How would you characterize Anna’s childhood and adolescent functioning, given theinformation presented?Anna’s childhood and adolescent functioning appears to have been characterized byadutiful fulfillment of some family and school responsibilities but alsosocial withdrawal,affective flatness, a lack of desire forsocial contact, and a lack of interest in manyconventional daily living activities. She does not appear to haveeverbeen distressedabout her lifestyle.

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DSM DiagnosisF20.9Schizophrenia, ContinuousF60.1 Schizoid Personality Disorder (Premorbid)RationaleRegarding the diagnosis of schizophrenia, Anna exhibits abnormal patterns of thought andbehavior that have persisted for well more than six months. It is not clear whether she is havingdelusions or hallucinations right now, because she is not sharing much of her thinking. However,it appears that she is distracted by, and preoccupied with, thoughts unrelated to here-and-nowcircumstances, so we mayassume the presence of auditory hallucinations or delusions. Further,her behavior is clearly disorganized, as she is unable to care for herself. She does not bathe orwash her clothes and has no evident sense of the effects these actions have on others (such as thesecretaries who objected to her behavior). Therefore, she meets the criteria for two of the activesymptoms of schizophrenia.What is equally striking about the client is her affective impairment, or her negativesymptoms. Her affect is continuously flat; she is socially isolated, non-communicative, andpassive in her orientation to those around her. She rarely asserts what she wants or how she isfeeling. Finally, Anna’s social functioning ispoor, and seems to have declined from the higherlevel of her early college years. Her functioning is currently so marginal that it does not appearthat she could carry out any of those activities.The specifier “continuous” wasadded, as it appears from the history that Anna’s activepsychotic symptoms are always present and have been for more than six months.Adiagnosis of schizoid personality disorder can bemade as a premorbid condition based onthe symptoms summarized in the first section.At present the client does not experience medical problems. The client’s gross lack ofpersonal hygiene does place her at risk for a variety of physical illnesses, for which the socialworker should stay alert through observation and referrals for physical examinations.Risk and Resilience AssessmentOnsetAnna appears to have a genetic loading for schizophrenia, since her mother also has a psychoticdisorder. The specific biological factors are not known, and cannot be directly investigated, butthey may involve a disorder in her limbic system, enlargement of certain brain ventricles, andabnormal levels of certain neurotransmitters. There is no evidence of early trauma, but it ispossible that Anna’s risk could have been complicated by birth complications or prenatalviralexposure.Regarding psychological factors, it is possible that the household in which Anna grewup was not a nurturing one, given the reports of erratic and unpredictable behavior ofher mother.Thismay have activated Anna’s biological sensitivityto the disorder. There are a variety oftraumatic events along the lines of parental neglect and family tension that could have beenpresent in her household. Finally, Ann’s poor level of social skills indicates that she would havedifficulty making transitions into adulthood. Regarding protective factors, Anna’s environmentwas materially comfortable and there is no evidence that she experiencedphysical trauma thatmay have contributed to constitutional weakness.Regarding the course of her disorder, Anna faces certain risk influences. She experienced agradual onset of schizophrenia, demonstrated marginal premorbid social functioning, does notexperience her psychotic symptoms as strange, and shows prominent negative symptoms. She

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lives in a large urban area and continues to experience high levels of family tension with herfather’s disapproval and her stepmother’s lack of support. She has poor social skills and hasexperienced deterioration in her intellectual capacity. Regarding protective factors, Anna is partof a family systemthat could potentially become more supportive. Further, she has someindependent living skills, to the extent that she has been living in a condominium with her sister.What questions can help to assess for further strengths in Anna:1.DespiteAnna’slimitations,doesshedemonstrateanypersonalqualitiesthatarefunctional or adaptive? Where, when, and with whom does she demonstrate thesequalities?2.Does Anna express any personal goals that might be used to motivate her for change?3.What talents did Anna demonstrate in her childhood and adolescence? Does she everutilize these talents now, or indicate a desire to do so?4.In what kind of environments (both housing and social) does Anna seem to best manageher activities of daily living? What characteristics of those settings seem to be appealingto her?5.When does Anna seem most comfortable with other persons? In what situations is shemost verbal? Is Anna capable of developing relationships in which she seems trusting?Intervention PlanThere are many services from which Anna might benefit with regard to the remission of both thepositive and negative symptoms of schizophrenia, and her acquisition of social and vocationalskills. Still, the social worker needs to be cautious in developing an initial treatment plan. Likemany persons with schizophrenia, Anna is reluctant to participate in an extensive interventionprocess at the outset because she seems to be easily overwhelmed. She may also be reluctant totrust others because she is not comfortable in relationships. It will initially be important toengage Anna ina relationship of trust, and then later she may take the initiative to participate inother interventions. What follows here is a summary of interventions that could be utilized nowand others that might eventually be used with the client.Anna may wellbenefit from taking antipsychotic medications, given the severity of hersymptoms. The social worker can schedule Anna to meet with the physician in the coming weekso that he may at least talk with her about the possible benefits of medication.Family education and support will be importantif the client’s father (and perhaps step-mother) would be obliging. Mr. Yannucci appears to havelittle awareness of schizophrenia andits treatment. He has suffered greatly as he has tried to help his daughter, but he does not knowhow to do so, given her condition. This service may be provided individually or in a groupsetting. Anna’s parents could learnabout her disorder,available interventions,and behaviormanagement strategies;and find support for the burden that they experience.The remaining goals could be provided by a case manager or though an assertive communitytreatment team.Clubhouse involvement would be a helpful way for the client to add structure toher life, improve her activities of daily living skills (budgeting, laundry, home care) and improvehersocial skills. Anna might learn to cook and engage in modest work activities.Vocationalassessment and rehabilitation could assess Anna’s skills and potential for work, and place her inprograms where her skills could be developed.Through referrals for recreational activities theclient might be able to expand her range of daily activities. For example, since she enjoyswalking, she might be helpedto get a membership at ahealth club.Linkages with entitlement

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services could help Anna insure that she was receiving benefits such as social security disabilitymoney and health insurance. Her father has been providing her with such assistance, but hemight like to assume less responsibility for this aspect of his care, if possible.Critical PerspectiveThe DSM’s reliance on behavior observation in making diagnoses presents a problem withAnna’s presentation. She is withdrawn, passive, and marginally communicative, which makes itdifficult to assess with certainty if she is experiencing the active symptoms of schizophrenia(hallucinations and delusions). Her presentation also demonstrates the necessity of relying onhistorical data (from her father and the referring hospital) in diagnosis. If the social worker waslimited to the client’s current presentation, many other diagnoses (including cognitive, medical,and substance abuse) would need to be considered more seriously.Case 2Questions to consider in making a diagnosis:1.What symptoms of psychosis does Donald display andfor how long have theybeenevident?Donald experiencesdelusions. He believes that people are ridiculing him and reading hismind, that the day treatment program is evil, that fathers are perverted,that he ispossessedby the devil and that by not eating he could starve people away.The client alsoexperienceshallucinations.Hefeelsapresencetouchinghimandhearsvoices.Additionally, he shows disorganized behavior, sittingoutside in cold weather with lightclothingand sleepingin the back yard.Moreover, he displays disorganized speechasevidencedbyfrequentderailment.Finally,negativesymptoms,namelyaffectiveflattening, are evident. Donald has experienced these symptoms for three years,well pastthe six months minimum required for the diagnosis of schizophrenia.2.The diagnosis of schizophrenia also requiresfunctionalimpairment.Is impairmentevident in this case?Donald was unable to continue with college orwork, andwas not ableto socialize withothers.3.Are psychotic or mood disorders present among relatives?There is a family historyof mental and mood disorders.Donald’s mother is taking anti-depressants and her brother has bipolar disorder with psychosis during his manic episodesand a substance use disorder. There is also history in Donald’s mother’s family ofattempted suicides and a paternal great uncle having “a breakdown.”4.Does Donald have a history of depression or mood swings that might indicate aschizoaffective, major depressive, or bipolar disorder?Donald has a long historyof depression (since age 13).At the age of 20, he started tohave psychotic symptoms.During periods of psychosis, he continues to have periods ofdepression, which persist for several weeks at time.At these times, he exhibits adepressed mood as indicated by his parents’ and helpers’ reports; a decrease in appetite;hypersomnia; aloss of energy as noted by his parents’ and helpers’ reports; andmorewithdrawal and isolation sometimes than others, which suggestseven less interest orpleasure in activities most of the time.Donald has two-week periods or longer in which

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he continues to display psychotic symptoms but does not have the depressive episodes.He does not demonstratehypomanic or manic episodes.5.Are there any medicalconditions that may be contributingto Donald’s symptomdevelopment?Although there is no specific information in the caseabout a medical evaluation, thepsychiatrist is said to be coordinating Donald’s case with his primary care physician, sowe can assume that medical causes have been ruled out.6.Is the client’s use of substances or medications causing symptoms?Donald has no history of alcohol or drug use.7.Arethere psychosocialstressorsthatmightbecontributingtoDonald’ssymptomdevelopment?Donald has not experienced any recent stressors that might account for his symptoms.The social worker might want to inquire about any stressors that were present at the timeof his first psychotic symptoms.8.What was Donald’s premorbid functioning like?Donald was described as a shy childwho started to become depressed at age 13. Little isknown about Donald’s relationships before theonset of his psychotic symptoms, forexample, whetherhe desiredor enjoyedclose relationships, hadinterests and activitiesthat he enjoyed, was indifferentto the opinions others had of him, or exhibitedemotionalcoldness, detachment, orflattened affectivity even then.These symptoms, if confirmed,mightbe indicative of a premorbid schizoid personality disorder.DSM DiagnosisF25.1Schizoaffective disorder, depressive type, multiple episodes, currently in acute episodeRationaleThe diagnosis of schizoaffective disorder, depressed type was made because Donald’s illnessmeets the criteriafor schizophrenia andmajor depressive episodes. He shows the characteristicsymptoms of schizophrenia in that he experiences the following during a one-month period:Delusions (people are ridiculing him and reading his mind, the day treatment program is “evil,”fathers are “perverted, he is possessed by the devil and by not eating, he could starve themaway),hallucinations (a presence is touching him, voices), disorganized speech (frequentderailment), disorganized behavior (sitting outside in cold weather with light clothing, sleepingin the back yard), and negative symptoms (namely affective flattening).Donald’s social and occupational functioning is disturbed in that he is currently unable towork, continue his college education, or socialize.He has been experiencing symptoms for threeyears.He experiences delusions and hallucinations for periods of at least two weeks in theabsence of mood symptoms, but he also has prolonged depressive episodes during the majorityof his illness.Donald has a history of depression going back to age 13. Episodeslasting several weeks havecontinued since he experienced his first bout of psychosis at age 20. During these periods he willsleep at least 12 to 14 hours and has difficulty waking.He eats less, is more withdrawn andisolative, and is lessactive than at other times.The specifier “multiple episodes, currently inacute episode” was selected to reflect the fact that Donald has fluctuating symptoms of hisdisorder over time, but at the present time his psychotic symptoms are prominent.

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Additional Information NeededThe pattern of Donald’s illness seems to fit schizoaffective disorder without question. However,it would be helpful to know the true pattern of his psychotic and depressive symptoms.It was notclear how long the depressive episodes last, or how long the psychotic symptoms had beenpresent when he had his first depressive episode after the psychosis.It is not certain, however,that this information would change the diagnosis. It would certainly create a clearer picture of thepattern that is typical for Donald’s illness. If the depressive episodes decrease over time, whetherin number or in length of the episode, the diagnosis would have to be reevaluated to determine ifa diagnosis of schizophrenia would be more appropriate.Risk and Resilience AssessmentDonald’sriskfortheonsetoftheschizoaffectivedisordermayincludethebiologicalvulnerability present in his family. Althoughthere is no clear familial history of schizophrenia,there seems to be a history of mental illness.Donald’s age (early 20’s) and gender also presentrisk.In addition, he was born in February, which puts oneat a higher risk for the disorder.Protective mechanisms for the onset of Donald’s illness include the fact that he suffered nomajor traumatic event or brain injury and that he has a relatively high socioeconomic status and astable, functional family. His mother also had anormal pregnancy and delivery.The main risk influence for the course of the disorder includes repeated relapses, with someresidualsymptomsbetweenepisodes.ProtectivemechanismsincludeDonald’sabilitytomaintainsome insight.Therefore, the social worker, doctor, and his family members can talkwith Donald about treatment options when he is most receptive.Other protective influencesinvolve the fact that he receivedthe early interventions of medication and day treatment.He iscurrently compliant with his medication and if that continues, it will be another protective factorfor the course of his illness. One of the most critical protective factors in this case is Donald’sfamily’s supportiveness and their involvement in his care. Finally, he has access to qualitytreatment in the community wherehe lives and his family has the means to pay for it.What questions can help to assess for additional strengths in Donald1.What behaviors does Donald currently demonstrate that are functional or adaptive?Where, when, and with whom does he demonstrate these qualities?2.Donald has attempted to live on his own on several occasions. While he was notsuccessful in this regard, what positive survival skills account for his persistence at thesetimes?3.Does Donald express any realistic personal goals that might be used to motivate him forgoal setting?4.Donald demonstrated some vocational capacities in his adolescence. How might these betapped as a means of developing vocational goals?5.There are times when Donald’s behavior seems more socially appropriate than others,and when his symptoms are less evident. In what situations do these behaviors appear tobe most prominent?6.What personal aspirations or desires for social interaction account for Donald’s severalattempts to “succeed” at the day treatment program?7.Donald cares deeply about children. Even though the behaviors related to his caring havebeen inappropriate, is there a way to tap into his empathy toward a constructive end?

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Intervention PlanSince Donald is opposed to a hospital setting for a revamping of his medications, other optionsneed to be explored.One option is that at his day treatment program, a doctor can observe hisbehaviors daily, monitor his medications,and gradually adjust them as needed.Another option inthe community is a 16-bed short-term residential facility in which clients are closely monitoredand receive transportation to appointments, referrals to necessary agencies, meals, recreationalgroups, individual therapy, group therapy, and medication management. The facility has apsychiatrist and a nurse practitioner. Theseprofessionals can help the client through a medicationtransition in agradual manner.As part of Donald’s intervention, his parents could attend a family psychoeducational groupthat can provide them with support from others, education about schizoaffective disorder,treatment strategies, ways to manage their son’s behavior, andcoping skills for themselves.Participation in such a group may help Donald avoid relapse and also help them gain neededsupport and knowledge about living with a son with the disorder.Critical PerspectiveSchizoaffective disorder is a psychotic disorder although it has some similarities to bipolardisorder with psychotic features, which is a mood disorder. It appears in this case the diagnosiscould be accurately made due to the clarity of symptoms, but social workers must always takecare to differentiate between the two disorders, because their treatments are quite different.Case 3Questions to consider in making a diagnosis:1.What symptoms of psychosis does Emma display?Emma experiencesdelusions. She believes she still owns a house, her son is an imposter,she was shot at work, and she has no siblings. The client also experiences hallucinations.She has been observed responding to internal stimuli in the hospital setting, and shereported that she hears the doctor’s voice telling her she has been released from thehospital. Emma appears to have experienced these psychoticsymptoms for the past 14years.She may have experienced residual periodsas well, although this isnot clear fromthe case study.Finally, Emma displays flat affect and avolition (e.g., she would sit infront of the television with no volume on and was unable to care for herself), which arenegative symptomsof schizophrenia.2.The diagnosis of schizophrenia also requires impairment.Is impairment evident in thiscase?Emma has been unable to hold a job orlive independently, and she is estranged from herson who is “worn out from dealing with her.”3.ArethereanymedicalconditionsthatmaybecontributingtoEmma’ssymptomdevelopment?There is no information in the case presentation about a medical evaluation, so thisshould be completed to rule outthe possible influence ofany medical conditions.4.Is the client’s use of substances or medications causing symptoms?Emma has no current useor history of alcohol or drugs.She takes medication forhypertension,but this is monitored in the hospital settingand there is no reason to believethis medication results in her symptoms.

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5.AretherepsychosocialstressorsthatmightbecontributingtoEmma’ssymptomdevelopment?The divorce in her 40s might have precipitated the psychotic symptoms, but they onlyworsened over time rather than dissipating. She has now hadsymptoms of schizophreniafor 14 years.6.Are psychotic or mood disorders present among relatives?According to Emma’s son, there is no family history of psychotic disorders.7.Does Emma have a history ofdepressionormoodswings that mightindicate aschizoaffective, major depressive, or bipolar disorder?There is no evidence that Emma has suffered from depressive, manic, or hypomanicepisodes.8.What was Emma’s premorbid functioning like (to determine the presence of a possibleschizotypal, schizoid, or paranoid personality disorder)?Little is known about Emma’s personality before the onset of her current symptoms.More information needs to be gathered in order to decide if she had a personality disorderthat preceded the schizophrenia.However, Emma seemed fairly well-functioning fromthe information we do have, in that she was married, employed, and raised a son.DSM DiagnosisF20.9Schizophrenia, ContinuousHypertension, EssentialRationaleEmma meets the first of the basic criteria for the diagnosis of Schizophrenia, in that sheexperiences at least two psychotic symptoms that persist for more than a month. Emma hasauditory hallucinations, although it’s not clear if this symptom is present for a significant portionof a month. Emma also hasbizarre delusions. Emma also has the negative symptoms of flataffect and lack of volition. Emma’s symptoms emerged many years ago and shehas been unableto workor take care of herself due to the illness. Schizophrenia further requires coding of courseof illnessafter one year. Emma’s disorder is specifiedas “continuous” as there has been noremission of “A” symptoms. It is not possible to determine for certain if Emma’s behaviors aredue solely to schizophrenia or if another disorder with some relationship to her behavior ispresent. The fact that she did not develop clear symptoms of a psychotic disorder until midlife isunusual.Risk and Resilience AssessmentEmma’s onset of schizophrenia was unusually late in life. According to her son, there is nofamily history of schizophrenia.There was no information provided on Emma’s prenataldevelopment, or her delivery, so the extent to which any complications might have played intothe developmentof Emma’s illness is unknown.It is also unknown how well Emma’s son knowsher history, but he claimed that there were no traumatic events in her childhood.There werereports of Emma being “whipped,” but whether this was outside the boundaries of what a childin her historical and cultural background experienced is not established.A traumatic event duringadulthood, the end of her marriage, seemed to have acted as a trigger for the disorder. Emmacomesfrom a low socioeconomic background, which alsoconfers risk for the disorder.

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In assessing risk and resilience for the course of the illness, on the positive side, Emma had arelatively late age of onset and a good premorbid adjustment.From what we know, she wasmarried and raised a sonwho went on to go to college.She had an identifiable precipitatingevent for the disorder rather thana gradual onset, whichbodes well for her adjustment. She alsohas an unfortunate number of risk influences thatinclude poor insight about the disorder, livingin a large urban area, delayed treatment, repeated relapses, a history of non-compliance withmedication, andtheabsence of a support system. Her son was involved with her care for a time,but he became “worn out,” and she doesn’t seem to have other supportive people available toher.On a more formal level, Emma receives support from the mental health facility in which sheis housed. Her medication compliance is assured, although evensoshe continues to experienceboth positive (delusions and hallucinations) and negative (flat affect, lack of volition) symptoms.She receives dailysupervision in living tasks,her housing is provided, and she also receivespsychological interventions.Additional information neededBecause it is unusual for schizophrenia to develop in one’s 50s, Emma’s professionals should bealert to any additionalmedical and psychosocial information that becomes available to make surethat shehas been diagnosed accurately.It does not appear that any such information is availableat present.Ways to assess for additional strengths in Emma1.Emma is said to be generally pleasant when interacting with others. How could herpleasant nature be built upon to further develop interpersonal skills?2.Emma did not develop the symptoms of schizophrenia until relatively late in life. Whatsocial and vocational skills did she develop prior to the onset of her illness that might stillbe available to her?3.Emma has generally been non-compliant with medications, but now she takes thembecause the nurses give them to her. Are there times when she has been willing to usemedications? Why was she more willing at those times?4.Are there times when Emma has been aware of her need for medical treatment? Are theretypes of medical treatment with which she seems relatively comfortable?5.What hobbies or interests does Emma have that can be encouraged as part of herrehabilitation?6.Emma seems to enjoy certain aspects of her hospital program (goingon outings,attending groups).What is about these structured activities that she enjoys? How mightthese elements be transferred to other areas of her life?Intervention PlanA major goal for Emma is stabilization of her symptoms, which will hopefully be achieved byfinding an effective antipsychotic medication at an appropriate dose.Nursing staff and the doctoron her team willmonitor her symptoms and the effect of the medication.Another goal is for Emma to participate in psychosocial interventions, whichwill includeeducation about her mental and physical illnesses. At this time, Emma does not believe she haseither a mental illness or hypertension. Greaterawareness and management of her symptomswill

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