Midterm – Psychosocial Assessment of Jessica

Identifying Data

Jessica is a 9-year-old white female and now lives with her mother, sister and grandparents in a community about four hours away from the home she lived in prior to her parent’s divorce. At this time, Jessica’s mother has full custody of Jessica and her sister. Jessica has no contact with her father at this time.

Presenting Concerns

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Jessica was referred to an outpatient medical health clinic for children because her grandmother is concerned about her change in mood and behavior. Jessica has started acting out in school and has become more defiant and argumentative at home. Jessica’s grandparents also reported her as appearing anxious, having nightmares, and behaving uneasy and restless the majority of the time. Her grandparents believe she has become more withdrawn, as she is no longer engaging in activities that she previously enjoyed.

Background Information

Jessica is the youngest of 3 children that grew up in a lower-middle-class urban area until her biological mother and father divorced two years ago as a result of interpersonal violence experienced by Jessica’s mother. Jessica’s father had been physically abusive to her mother and the home environment was filled with fighting and yelling between the adults. Jessica’s mother left the home with Jessica and her sister to live with Jessica’s maternal grandparents who are helping raise Jessica and her sister and babysit often. Jessica’s brother is still living with their father. Jessica adjusted well to her new elementary school and made friends easily. Her mother has started to date again and has been reported as spending more time with one boyfriend in particular.

Assessment BPSCR

Biological

Jessica is a 9-year-old white female. Her grandparents have reported that she has been anxious, experiencing nightmares, and appears uneasy and restless most of the time.

Psychological

Jessica’s grandparents reported her as becoming more defiant and argumentative at home and are worried about her change in mood and behavior.

Social

Upon first moving, Jessica adjusted well to her new elementary school and made friends easily. However, she has started acting out in school and begun talking about moving in with her father and brother. Her grandparents believe she has become more withdrawn, as she is no longer engaging in activities that she previously enjoyed. During my initial assessment, I noticed Jessica makes minimal eye contact. She also proceeded to gently pick up and then aggressively throw toys on the ground while saying, “bad kids”. Upon ending the session, Jessica began to scream, “don’t make me go.” as I got up to walk her out of the room.

Cultural/Spiritual

Jessica is 9-year-old white female and the youngest of 3 children now living with her mother, sister, and grandparents after her parents divorced as a result of her father committing interpersonal violence against her mother. Prior to the divorce, Jessica grew up in a lower-middle-class urban area. No data on spirituality or other cultural considerations were provided.

Risks

Jessica was exposed to interpersonal violence while her mother and father were married and living together. She has been reported as anxious, experiencing nightmares, and appears uneasy and restless most of the time. Jessica’s grandparents reported her changes in mood and behavior as she has become more defiant, argumentative, and withdrawn. No reports on suicidal thoughts/tendencies, homicidal thoughts/tendencies or child abuse have been reported thus far.

Assessment Tools

Assessment tools that will be used to assist in a possible diagnosis for Jessica include the Revised Children’s Anxiety and Depression Scale (RCADS) (Chorpita, 2000), the Child and Adolescent Disruptive Behavior Inventory (CADBI) Screener (Burns, 2001a), the Adjustment Disorder – New Module questionnaire (ADNM) (Lorenz, 2016) and The Attachment Child Questionnaire (AQC) (Muris, 2001). The Revised Children’s Anxiety and Depression Scale (RCADS) will be used to assess Jessica’s experience of anxiety, it’s duration and severity, while simultaneously assessing for symptoms of depression. The Child and Adolescent Disruptive Behavior Inventory (CADBI) Screener will be used to identify symptoms of a possible diagnosis of Oppositional Defiant Disorder (ODD) and Attention Deficit Hyperactity Disorder (ADHD) as noted by Jessica’s defiant behavior and restlessness. The Adjustment Disorder – New Module questionnaire (ADMN) will be used to assess any stressful life events that may be burdening – such as transitioning into a new family dynamic and home environment. The ADMN may also assist with identifying a possible diagnosis of Adjustment Disorder. The Attachment Child Questionnaire (AQC) will be used as a 1-item self-report measure of Jessica’s attachment style with her primary caregiver(s). Jessica will be given three explanations of feelings and viewpoints on her relationships with other children and will be asked to choose which explanation best fits with herself. The measure will assign Jessica with either a Secure, Avoidant, or Ambivalent attachment style.

Summary of Clinical Statement

Considering Jessica’s background information and family history may assist in a better understanding of why Jessica’s changes in mood and behavioral patterns have occurred. It is possible that Jessica was raised in a family that lacked safety and security within the family system and the home environment. As a result, Jessica may be experiencing defiance, anxiety, social withdrawal, restlessness, and a loss of interest in previously enjoyable activities as she is expected to adjust into a new school setting, home, and family dynamic with her grandparents, mother and sister – and without her father and brother. As a witness of interpersonal violence between her parents, Jessica may also be replicating aggressive behavior as a result of trauma as seen during the initial assessment where she was throwing toys and saying, “bad kids”. Jessica may also have an ambivalent attachment style as she screamed, “don’t make me go” while I attempted to walk her out of the room.

Based off of my clinical observations of Jessica’s presenting concerns and background information, it appears that previous exposure to stress or trauma may be the cause of a wide range of symptoms. I would also take Jessica’s developmental stage, genetics, temperament, and environmental factors into consideration (Reichenberg & Seligman, 2016). Other Specificied Trauma- and Stressor-Related Disorder is a possible diagnosis for Jessica at this time due to the presence of delayed onset of emotional and behavioral symptoms that occured more than 3 months after the stressor was experienced as in accordance of the DSM-V (American Psychiatric Association, 2013).

Overall Treatment Strategy

Jessica’s treatment plan will consist of 2 stages of Parent Child Interaction Therapy (PCIT) to address the presenting concerns and current treatment plan goals. The first stage will address (1) Jessica’s lack of security, safety, and attachment to her primary caregiver(s); either mother and or grandparents to build a stronger bond that will help address all other listed treatment goals moving forward. This stage will also focus on (2) reducing anxiety and (3) increasing self-esteem, as her primary caregiver(s) utilize the importance of embracing Jessica with a sense of warmth and well-being when interacting with one another.

The second phase will address (4) Jessica’s defiant behavior that has been noticed as a contributor to Jessica’s change in mood and behavior as well as her argumentative characteristics at home. Immediate needs include decreasing the severity of defiant behavior, anxiety and social withdrawal while increasing Jessica’s secure attachment between herself and her caregiver(s). Long term needs include an increase in compliance with adult requests and an increase in Jessica’s self-esteem.

Intervention

Parent Child Interaction Therapy (PCIT) is conducted through “coaching” sessions during which the child and their caregiver(s) are in a playroom while the therapist is in an observation room interacting with the child through a one-way mirror or live video feed. The parent wears an 'in-ear' device that the therapist communicates through to offer instant training in skills the caregiver(s) is learning to manage in their child's behavior. PCIT is performed in two stages of treatment. The first stage of treatment highlights the establishment of warmth between the caregiver(s) and their child through learning and utilizing skills to help their child feel at ease, secure in their relationships with their caregiver(s), and positive about themselves (Stevens, 2019).

The second stage of treatment will enable the caregiver(s) to manage their child’s behavior as challenging as possible while staying calm, safe, and consistent when they attempt to discipline their child. At this stage, the caregiver(s) utilize methods to help their child accept boundaries, respect guidelines, abide by rules within the home, and display appropriate behavior while the child is in public. With ongoing homework completion and follow-ups, PCIT takes place from 12-20 session and treatment is not time-sensitive. Treatment will be recognized as finished when the caregiver(s) has mastered a set of abilities and assess their child's behavior on a behavioral rating scale within the average limits (Zisser, 2010).

Resources

Resources that will be provided to the family include caregiver support and psychoeducation. Caregiver support includes community resources for health care access, childcare services, child caregiver support groups, domestic violence resources, child mental health resources, and community Head Start Program resources. Psychoeducation will include information on the diagnosis of the child, the typical norms for children at Jessica’s developmental stage, and the effects of domestic violence on the family system as a whole (Early Childhood Learning & Knowledge Center, 2019).

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
2. Burns, GL., Taylor, TK., & Rusby, J. C. (2001a) Child and Adolescent Disruptive Behavior Inventory 2.3: Parent Version. Pullman: Washington State University, Department of Psychology
3. Chorpita, B. F., Yim, L. M., Moffitt, C. E., Umemoto L. A., & Francis, S. E. (2000). Assessment of symptoms of DSM-IV anxiety and depression in children: A Revised Child Anxiety and Depression Scale. Behaviour Research and Therapy, 38, 835-855.
4. Early Childhood Learning & Knowledge Center. (2019, December 30) Preventing and Responding to Domestic Violence. Retrieved from https://eclkc.ohs.acf.hhs.gov/family-support-well-being/article/preventing-responding-domestic-violence
5. Lorenz, L., Bachem, R., & Maercker, A. (2016). The Adjustment Disorder–New Module 20 as a Screening Instrument: Cluster Analysis and Cut-off Values. The International Journal of Occupational and Environmental Medicine, 7(4), 215–220. doi: 10.15171/ijoem.2016.775
6. Muris, P., Meesters, C., van Melick, M., Zwambag, L. (2001). Selfreported attachment style, attachment quality, and symptoms of anxiety and depression in young adolescents. Personality and Individual Differences, 30, 809-818.
7. Reichenberg, L. W., & Seligman, L. (2016). Selecting effective treatments: a comprehensive systematic guide to treating mental disorders. Hoboken, NJ: John Wiley & Sons, Inc.
8. Stevens, & N’z, (2019). Parent-child interaction therapy. In C. H . Zeanah Jr. (Ed.), Handbook of infant mental health (4th ed., pp. 543-552)
9. Zisser, A., & Eyberg, S. M. (2010). Parent-child interaction therapy and the treatment of disruptive behavior disorders. In J.R. Weisz & A.E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 179-193) New York, N: Guilford Press.

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