Case Conceptualization
Assignment Content
- Review The Assessment and Treatment of Long-Standing Disruptive Behavior Problems in a 10-Year-Old Boy article, located on this week’s Electronic Reserve Readings page.
Write a 175- to 350-word brief case conceptualization of the client in the article.
Complete the College of Social Sciences Treatment Plan, located on the College of Social Sciences Resources webpage. Your response should be a minimum of 350 words.
Write a 175- to 350-word justification for the treatment plan you created.
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Format your assignment consistent with appropriate course-level APA guidelines.
Submit your case conceptualization, treatment plan, and justification.
ResourcesThe Assessment and Treatment of Long-Standing Disruptive Behavior Problems in a 10-Year-Old Boy
Julian A. Rote, Debra A. Dunstan
First Published May 24, 2011 Research Article
https://doi.org/10.1177/1534650111410228
Article information A 10-year-old boy was referred for ongoing behavioral problems. These problems were reported as having occurred at home since preschool years and had become increasingly problematic outside of the home in latter years, resulting in frequent suspensions from school. A range of diagnoses had been made in the years prior to referral, including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder, and pervasive developmental disorder–not otherwise specified (PDD-NOS). The central intervention since age 6 had been pharmacotherapy, with intermittent support at school in the form of school counseling and teachers’ aids. However, the situation appeared to only be worsening, and the need for a more integrated, multimodal approach was recognized. In addition to individual therapy for the client and his mother, the intervention also included engagement of the father, collaboration with other educational and professional service providers, and the development of an integrated plan with shared objectives and strategies. The case explores limitations inherent in taking a medical model diagnostic approach to child behavioral problems and highlights the need to utilize an idiographic approach taking a range of individual psychosocial circumstances into account, rather than taking a more nomothetic treatment approach based mainly on diagnostic assessment.
Keywords disruptive behavior disorders, collaborative multimodal approach, nomothetic, idiographic
1 Theoretical and Research Basis for Treatment
Disruptive behavior disorders (DBD) is an umbrella term covering a range of conditions involving negativistic, rule-breaking, and noncomplaint behavior. The category subsumes conduct disorder (CD)—characterized by behavior violating social norms and rules, and infringing on the rights of others—and oppositional defiant disorder (ODD), featuring negativistic, hostile, and defiant behavior. Attention-deficit/hyperactivity disorder (ADHD) is also included in this general category (American Psychiatric Association, 2000).
Although the etiology of these disorders is not fully understood, twin and adoption studies suggest that biological (including genetic) and a range of environmental factors are involved (Hendren & Mullen, 2006). Those potentially relevant in this case included comorbid ADHD, fearlessness and stimulation-seeking behavior (Raine, Reynolds, Venables, Mednick, & Farrington, 1998), early maternal rejection and inadequate caregiving (Marks, Miller, Schultz, Newcom, & Halperin, 2007; Raine, Brennan, & Mednick, 1997), and neglect, abuse, or violence (Loeber & Stouthamer-Loeber, 1986). Specifically taken into account were findings of a recent study indicating that moderators of childhood conduct problems include marital adjustment, maternal depression, paternal substance use, and child comorbid anxiety or depression, whereas critical, harsh, and ineffective parenting were found to both predict and mediate outcomes (Beauchaine, Webster-Stratton, & Reid, 2005).
A range of mechanisms has been suggested as being of influence in child behavioral disorders. A social-cognitive approach to mechanisms sees behaviors such as reactive aggression as influenced by a hostile attribution bias—in which interpretation of the action of others is biased in the direction of assumed hostility, resulting in retaliatory anger and aggression (Dodge, 1993). Behaviorally disordered children may also be deficient in the cognitive problem-solving skills of generating alternative solutions to presenting problems (Richard & Dodge, 1982). Emotional dysregulation and high levels of temperamental activity from a young age are also seen as factors involved in the development of ODD (Stringaris, Maughan, & Goodman, 2010).
As the above risk factors and mechanisms would indicate, each individual case of disruptive behavior is best conceptualized in terms of factors operating within the child, factors operating outside of the child, and the interaction between the two (Kazdin, 2002). Thus, targets of intervention should include not only the behavior-disordered individual but also family members, peers, teachers, and other community members (Cowling et al., 2005).
Individual-focused interventions generally involve components of cognitive–behavioral therapy (CBT), including social skills training, problem solving, cognitive restructuring, coping, and anger control (Domitrovich, Cortes, & Greenberg, 2007; Henggeler & Sheidow, 2003; Kazdin, 2002; Kazdin, Siegel, & Bass, 1992). The importance of adding parental training to individual-focused approaches, especially for preadolescent children, has been demonstrated (e.g., Kazdin et al., 1992; Kazdin & Whitley, 2003) and integrated into empirically validated programs such as Incredible Years (Webster-Stratton & Reid, 2003) and the Positive Parenting Program (“Triple P”; Sanders, Markie-Dadds, & Turner, 2003). Furthermore, multisystemic (home, school, clinic) interventions have shown promise for producing more durable outcomes (Cowling et al., 2005) and the prevention of relapse (Baker & Scarth, 2002; Brestan & Eyberg, 1998). School-based interventions usually involve a behavioral approach, although more recently there has been a shift toward using humanistic strategies, building on the child’s strengths and involving the child in planning and decision making, to build value and self-worth (Chaplain, 2003).
Although a range of treatment programs has been devised and demonstrated to be efficacious, it is not always possible for a full intervention program to be implemented or that any one manualized program will accurately address needs of an individual case (Chorpita, Daleiden, & Weisz, 2005). There is increasing recognition of the need to “distill” common elements of the range of efficacious treatment programs, and implement these elements in a flexible and idiographically tailored manner (Garland, Hawley, Brookman-Frazee, & Hurlburt, 2008). Such core elements involve both youth skills training and parent-mediated interventions, and include factors such as application of positive reinforcement, delivery of effective limit-setting, parent/child relationship building, problem-solving skills, anger management and affect education, psychoeducation and didactics, modeling, role-playing and behavioral rehearsal, reviewing goals and progress, and assigning and reviewing homework (Garland et al., 2008).
A range of pharmacological treatments has been utilized in the treatment of behavioral problems in children, including psychostimulants, antipsychotics, antidepressants, mood stabilizers, and antiepileptic and adrenergic drugs (Tcheremissine & Lieving, 2006). However, research into the efficacy of pharmacological treatment has been carried out mainly on inpatient, rather than outpatient, populations (Tcheremissine & Lieving, 2006). Pharmacological treatment alone has shown, in general, only limited efficacy in the treatment of childhood behavioral problems (Kazdin, 2002; McMahon, Wells, & Kotler, 2006) and no drugs have been demonstrated to be consistently effective in treating CD (U.S. Department of Health and Human Services, 1999). It has been suggested that the utilization of pharmacotherapy is most strongly indicated in cases involving extreme or explosive aggression (Campbell, Gonzalez, & Silva, 1992) and also that pharmacological treatments are only successful when a comorbid condition, such as ADHD or depression, is present (Waddel, Lipman, & Offord, 1999). This efficacy of pharmacological treatments for behavioral problems tends to be associated with, or perhaps rely on, their integration into multifactorial treatment approaches (Tcheremissine & Lieving, 2006).
The issue of child behavioral problems, then, is one that is not easily addressed by conceptualizing the problems within a straightforward medical-model framework, where a diagnosis may be seen as “explaining” or being the main driver of the behaviors. Viewing behavioral problems in this way tends to lead to nomothetic-type “interventions to match the diagnosis”—such as an emphasis on pharmacological treatment—which are unlikely to adequately address the broader influences on the child’s behavior. Rather, interventions for childhood behavioral problems have been found to be most effective when a multimodal approach has been used and coordinated across a variety of settings (Baker & Scarth, 2002). Such an approach is fundamentally idiographic in nature, taking into account the range of pertinent factors specific to an individual child’s life circumstances. Indeed, diagnostic issues are just one of a range of variables to be taken into account in selecting intervention strategies for any one client (Chorpita et al., 2005).
The client, “Sam,” was a relatively small, slightly built 10-year-old boy whose presentation was somewhat unkempt, with tousled hair and worn and/or ill-fitting clothing. He had a naturally shy demeanor, but a ready and charming smile when in good spirits.
The first appointment was attended by all members of the family; Sam, his mother and father (who were separated), and his (18-month-older) sister. Sam’s mother did most of the talking and indicated that she felt unable to cope with Sam’s ongoing behavioral problems. She displayed a rather harsh, angry, and bitter demeanor—although she also displayed a sense of humor on occasion. Sam’s father reported less difficulty with Sam’s behavior than did his mother, and was reserved and appeared to be somewhat dominated by his ex-wife. At this session, Sam was sullen at times, but at other times he was open and talkative.
Sam’s documented history indicated that while there had been many assessments and consultations, there had been an absence of substantial individual therapy for Sam, minimal therapy or support for his mother, inadequate attempts to involve Sam’s father in a more constructive role, and inadequate communication and coordination between relevant medical, educational, and other support services. A range of assessments had been carried out and recommendations made; however, intervention had been largely limited to help from teachers’ aides and school counselors, and advice to Sam’s mother. The reported worsening of Sam’s behavior in recent years indicated that these previous interventions had not met with any notable success. The file review also indicated that diagnostic issues remained somewhat unclear (see below).
An outline of Sam’s difficulties was obtained from his parents, school representatives, and Sam himself. The difficulties were clustered in the areas of behavioral, emotional, social, and academic problems. Sam’s mother described verbally and physically aggressive behavior by Sam toward her and Sam’s sister on most days, breakage of household items, persistent defiance and disobedience, frequent school refusal, and poor sleeping and eating habits. She indicated that Sam’s behaviors had resulted in extreme negative feelings on her behalf toward Sam and that she felt depressed and “at my wit’s end.” Sam’s behavior had reportedly resulted in other families not wanting their children to play with Sam. Conversely, Sam’s father identified no major problems in the times that he was with Sam and described Sam as “just like any other kid.”
Representatives from Sam’s school identified persistent disobedience, swearing, occasional physical aggression, repeated transgressions of school boundaries, failure to complete schoolwork, and disruption of classes. A range of disciplinary actions had been undertaken, including regular suspensions and repeated transfers to a School Suspension Center. Sam was reported as lagging approximately 1 year behind in academic achievement.
Sam spoke of being taunted and teased by other children, and a perception that teachers were mean to him and did not listen to his side of the story. He described feelings of ostracism and loneliness (especially at school), embarrassment about being behind academically, and sadness at his lack of friends.
Information about Sam’s history was gathered from an extensive file review, a clinical interview with all family members, and the gathering of information from past and present school staff and the local pediatrician.
Social history
Up to age 6, Sam lived with his mother, father, and sister in a major metropolitan city. His parents then separated, and Sam, his mother, and sister relocated to a rural town. Sam’s father also moved to the same town 2 years later and lived alone, having regular contact with his children but little involvement in school or day-to-day issues. Ongoing parental discord was described, and financial hardship was reported; Sam’s mother had part-time employment and his father was unemployed.
Long-term conflict between Sam and his mother, and also increasing conflict with his sister, were described. At school, lack of manners and aggressive tendencies had reportedly resulted in ongoing relational difficulties with teachers and peers. Sam was reported to have lost most of his friends over the years due to his problematic behaviors.
Sam’s hobbies included skateboarding, riding bikes, art, swimming, rugby league, soccer, X-box, and caring for his pet cats. Despite his ongoing behavioral problems, Sam was also described as having “a good heart,” a good sense of humor, able to be loving toward other family members, “tender” with animals and younger children, “enthusiastic,” and “responsible” (generally came home on time following after-school skateboarding, locking the house at night, looking after pets).
Developmental history
Sam’s mother reported frequent illness during with her pregnancy with Sam and delivery via emergency caesarean section. However, his birth weight was in the average range. He was bottle-fed but did not tolerate formula well. Major developmental milestones were achieved as expected. At age 7, an occupational therapy report stated that Sam demonstrated no psychomotor problems. Sam’s cognitive ability was shown to be in average range in testing carried out at age 3 with the Wechsler Preschool and Primary Scale of Intelligence–Revised (WPPSI-R; Wechsler, 1989) and at age 7 with the Wechsler Intelligence Scale for Children–Third Edition (WISC-III; Wechsler, 1991)—with no attentional problems evident. However, Sam gradually began to lag behind in his schoolwork—by approximately 1 year by age 9—due mainly to behavioral problems. There were no reports of exposure to any major traumatic life events (beyond the psychosocial stressors already outlined).
Medical history
No history of major illness or physical trauma was reported. At age 5, Sam’s head circumference was noted as “just on the 2nd percentile,” but with no other significant findings. No impairment of sight, hearing, speech, or motor functioning was evident.
Family history
Sam’s mother reported a personal history of a deprived childhood and chronic depression. She described her father as violent and dominating, and stated that she had two brothers one of whom was psychotic and the other alcoholic. Sam’s mother expressed the opinion that “all the males in the family had mental health problems” and that Sam was following in this path. Sam’s father reported a happy and stable childhood, and no family mental health problems, but a personal history of drug and alcohol abuse.
Previous treatment
Although contact had been made over the years with a range of service providers, the main focus appeared to have been on assessment and diagnostic issues. Some direct psychological and educational support for Sam had been provided by school counselors and teachers’ aids but limited success was apparent. Attempts at family intervention, comprised mainly of psychoeducation for Sam’s mother regarding behavioral management, also had met with little success, with no substantial treatment planning evident. The central and ongoing treatment had been the prescription of psychotropic medications for Sam.
History of medications
Sam had been prescribed Dexamphetamine from age 5 to 6; Ritalin at age 7, and then also Risperdal and Catapres; Risperdal increased at age 8 but ceased after deleterious effects and Strattera commenced; “on and off” Strattera at age 9, and Ritalin recommenced; Strattera increased to maximum dose at age 10 and Ritalin ceased—but then Strattera ceased after sudden worsening of behavior and Risperdal was represcribed. At the time of assessment, Sam reported that Risperdal made him “tired and happy” whereas some other medications (e.g., Strattera) had made him “angry.”
Assessment involved an extensive file review, a clinical interview with all family members, and the gathering of information from past and present school staff. At age 3 years 10 months Sam was assessed, both by an early intervention team and a psychiatrist, for “behavioral problems” at home; however, no diagnosis resulted. At age 6, Sam was seen by a pediatrician who had his mother and grandmother fill out brief ADHD checklists—which indicated possible hyperactivity but not inattention. The pediatrician then described Sam as “a boy who has ADHD with some severe socialization difficulties . . . there may be an element of ODD/parenting.” The pediatrician also raised the possibility of pervasive developmental disorder (PDD), seemingly based on the responses by Sam’s mother on the Gilliam Asperger’s Disorder Scale (GADS).
At age 7, Sam was administered the WISC-III, administered by a school counselor, who wrote that he “was a delight to work with and was easily refocused after short breaks when necessary.” An occupational therapy report the same year also indicated no problems with attention or stamina. However, problematic behaviors at home continued, and two incidents of verbal aggression toward a teacher were reported. Sam was seen by a child psychiatrist who wrote that his “developmental history and previous standardized testing is not suggestive of a longitudinal history consistent with ADHD”; however, the diagnostic description was given as “DBD with ADHD and Conduct Problems.” The psychiatrist also wrote of “social difficulties and some mild symptoms possibly suggestive of PDD-NOS.” Letters by the pediatrician subsequently referred to Sam having “known PDD.”
At age 8, a (teacher report) Achenbach checklist showed aggressive behavior in the clinical range, whereas other subcategories including anxious/depressed, social problems, thought problems, and attentional problems were shown to be in the normal range.
At age 9, Behavioral Assessment System for Children (BASC) reports from Sam, his mother, and his teacher again indicated that attentional and hyperactivity problems were not in the clinical range. However, the results led to the conclusion that “Sam presently meets criteria for ODD,” and “his difficulties persist despite medication.” The diagnosis of CD was also used in some communications by the pediatrician at this time. Sam’s case manager at Child and Adolescent Mental Health Services (CAMHS) communicated Sam’s diagnosis to the school at this time as “(a) DBD with ADHD and conduct problems and (b) social difficulties and possible symptoms of PDD-NOS.” However, it is notable that after communication with the school, this diagnostic picture was changed several days later to “(a) PDD-NOS, (b) ADHD, (c) ODD”—apparently to enable school funding for support services, an increasingly recognized problem (Hansen, 2010).
Following referral to our Clinic, an Achenbach System of Empirically Based Measurement (ASEBA) Teacher’s Report (Achenbach, 1981) indicated that social problems, attentional problems, rule-breaking behavior, and aggressive behavior were all in the clinical range, whereas internalizing problems and thought problems were in the borderline clinical range. The Adaptive Functioning Profile indicated that “academic performance,” “working hard,” “behaving appropriately,” “learning,” and “happiness” were all in the clinical range. An ASEBA Parent Report sent to the father was not returned. Sam and his mother were not asked to complete forms, as part of the overall aim of shifting their focus from assessment to treatment.
Given the diagnostic history, it appeared that the broad diagnostic category of “DBD” was justified, and perhaps ODD. The diagnostic picture was complicated and confused, however, by the PDD-NOS and ADHD diagnoses, which appeared to be initially based on brief questionnaires answered by Sam’s mother when Sam was seven. Minimal evidence of PDD or ADHD was suggested by formal testing or social/developmental history up until that time (little evidence of any impairment in verbal or nonverbal communication skills; no stereotyped behavior, interests, or activities; no significant developmental delays; little evidence of attentional or hyperactivity problems). It is also notable that according to the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV), ADHD should not be diagnosed in the presence of a PDD (American Psychiatric Association, 2000).
Although possibility of attentional problems playing a current role was raised by the clinical range result on the latest teacher report ASEBA, the lack of any evidence of attentional problems during ongoing therapy sessions—combined with the lack of evidence of attentional problems evident in Sam’s documented history—indicated that ADHD was unlikely to be accurate as a diagnosis. Overall, the category DBD was considered the most appropriate term for describing Sam’s ongoing behavioral problems and possibly the most useful for informing multifocal, idiographic treatment.
It was obvious that social isolation, falling behind in schoolwork, and difficulty in getting along with others caused Sam emotional distress. However, he was not apparently suffering from a depressive disorder, as he did not exhibit significant guilt, hopelessness, worthlessness, anhedonia, low energy, or suicidal ideation. Sam also showed no significant indication of suffering from an anxiety or other disorder.
Although a range of diagnostic possibilities had been suggested for Sam, it seemed that perhaps lack of clarity regarding diagnosis may have contributed to the lack of consistent therapeutic support beyond pharmacotherapy. As Dr. Jon Juredeini, of the Adelaide Women’s and Children’s Hospital, has succinctly stated,
The approach to kids who present with behavior problems seems to be, “What’s wrong with this kid? What is their medical diagnosis?” I think it’s the wrong question to be asking. The question we should be asking is “What is bugging this kid? What is not right in this kid’s life?” (Juredeini, 4th time quoted, in Cleary, 2005).
In Sam’s case, it was evident that some of the things “not right” in his life included social, environmental, emotional, and learning issues. The past inability of Sam’s family, support services, and school to successfully deal with his behavior had led to what appeared to be an ongoing cycle of punishment, suspension, and ostracism, followed by increased feelings of social isolation, inadequacy, and negativity. These negative emotions appeared to have underpinned much of Sam’s propensity toward angry outbursts, lack of academic motivation and achievement, and continuing interpersonal and behavioral problems. We proposed that any successful intervention would thus need to address emotional issues and improve social capacities. Findings that emotional outbursts and temperamental actions tend to be associated with ODD (and hyperactive-type ADHD; Stringaris et al., 2010) underscored the need to address emotional triggers and regulation.
CBT was the main approach utilized in individual therapy for Sam. A behavioral approach, aimed at understanding the function of particular behaviors in relation to the antecedents and consequences, was utilized in the school and at home. Elements of a humanistic approach were applied to all settings to address Sam’s negative self-view and feelings of low self-worth. For Sam to become engaged in therapy, we considered it vital that he feel accepted, valued, and capable of change (Chaplain, 2003). Thus, a central theme in helping Sam to alter his negative views of school and of other people was to help him to value himself as a worthwhile person.
Although the possibility of a manualized treatment for ODD was considered, it was felt that a more tailored idiographic approach, utilizing the recognized key elements of the range of treatment programs available, would be likely to optimize engagement and outcomes (see Chorpita et al., 2005; Garland et al., 2008).
Treatment Plan
The overarching goal of treatment was to return Sam to healthy ways of interacting at school, home, and with peers. Factors taken into account in developing the treatment plan included Sam’s apparent problems with emotional regulation and lack of problem-solving skills; Sam’s mother’s negative feelings toward Sam in the context of her own emotional difficulties, resulting in critical and harsh maternal parenting; paternal substance abuse issues and the minimal involvement of Sam’s father in day-to-day issues; and the punishing and ostracizing cycle that had developed in the educational system’s handling of Sam. The aims and objectives of the plan were as follows:
· Aim 1: To facilitate development of a healthier sense of acceptance, inclusion, and emotional connection, at home, school, and with peers. Objectives: (a) improve feelings of self-efficacy and control, (b) facilitate improved social skills, and (c) facilitate better emotional connection with others.
· Aim 2: To empower Sam to be able to control his own behavior. Objectives: (a) reduce angry and violent reactions, (b) build self-efficacy, and (c) increase Sam’s capacity for communication.
· Aim 3: To facilitate successful reengagement with school environment. Objectives: (a) reduce negative factors at school, (b) improve Sam’s capacity to communicate his needs/desires/frustrations at school, and (c) build on positive aspects of school.
· Aim 4: To improve communication and family dynamics at home. Objectives: (a) strengthen the ratio of positive to negative interactions at home, (b) support the emotional well-being of Sam’s mother, (c) engender greater positivity from Sam’s mother, (d) facilitate greater involvement by Sam’s father, and (e) engender greater stability and certainty at home.
· Aim 5: To remediate academic problems. Objectives: (a) facilitate improved understanding by Sam of the relevance of academic matters to him and (b) increase academic work being done at home.
To bring about meaningful change in these areas, it was evident that a goal-focused, collaborative, multimodal treatment plan was required. As well as engaging Sam and his parents in treatment, work was also undertaken to facilitate communication and collaboration between all involved parties (educational and other health professionals), and to enable a common framework and goals within a shared treatment plan.
7 Course of Treatment and Assessment of Progress
Summary of Contact With Relevant Parties
Following the initial interview, the first author (J.R.) provided 3 therapeutic sessions with Sam’s mother alone, 2 joint sessions with Sam and his mother, 10 sessions with Sam alone, 2 sessions with Sam’s father alone, and 2 joint sessions with the father and Sam. As Sam’s mother was obviously struggling with her own emotional issues and expressed exasperation at being “told what she should be doing at home” over the years, she was offered a supportive individual intervention—provided in the form of 6 therapy sessions by the second author (D.D.). Four meetings with staff from Sam’s school and three meetings with staff from the School Suspension Center, were held. Two child-protection-service-convened meetings of all relevant parties and one psychiatric review were also attended. The period of individual treatment was limited to 5 months because of the vagaries of the timetable of the movement of interns through the Clinic, and the number of individual sessions for Sam was further limited because of his reluctance to attend during school holidays and several missed appointments.
Psychological Therapy for Sam
The initial therapy session focused on rapport-building and resulted in Sam engaging well. The relationship between moods and behaviors was discussed in Session 2, and Sam identified “respect” as an important theme in communication—in that he felt he wanted to be treated with respect and recognized how others might similarly dislike not being treated with respect. Breathing and relaxation exercises were also introduced and practiced.
In Sessions 3 to 5, the focus was on the relationship between thoughts and feelings. The concept of the “anger (thermo) meter” was introduced, illustrating anger as graduated, not simply “on or off.” Sam demonstrated good capacity to recognize and manage unhelpful thoughts, and thus become more the boss (a term that appealed to him) of his own reactions, and thus be more able to orchestrate desirable (“green”) outcomes rather than negative, unwanted (“red”) outcomes. These themes were explored using real-life examples and also through the use of puppets.
In Session 6, the “Magic Macaroni Jar” (Irvine, 2000) was introduced. In this activity, positive messages about the child are written on small pieces of paper by various people in the child’s social environment, then rolled up and placed inside tubes of penne pasta, and collected over time in a large jar. This activity engenders a focus on the positive and provides a physical (and readable) reminder of positivity and competence. Sam clearly enjoyed the initial activity of writing positive messages about himself and saving them in the jar—and the activity was subsequently continued over coming weeks by his parents, sister, and school staff.
In Session 7, the distinctions between “Cool, Weak, and Aggro” responses to various situations were introduced (“Stop Think Do” behavioral program; Adderley, Petersen, & Gannoni, 1997). These distinctions tied in with the “red” and “green” alternative response choices from Session 5. Sam identified strongly with wanting to remain “cool” in his responses, and a coping statement of “Stay Cool” was formulated.
Sam’s father attended the next session with Sam. Material covered so far was reviewed and a hand-drawn summary, similar to Figure 1, was formulated. Sam took pride in describing his learning and achievements to his father. Also introduced in this session was a discussion about change and growth, and how the past did not have to dictate, or reduce hope in, possibilities for the future.
Figure 1. Overall “framework” in which the various strategies and skills were conceptualized
In the ninth session, Sam was able to express much-improved positivity regarding his own positive attributes and capabilities. However, he expressed concern about his ability to cope when returning to school (from the Suspension Center), which was discussed in the light of the strengths he had identified and the possibility of growth and change.
In the last session (after return to school), Sam indicated that he was feeling much better about himself and expressed pride in his achievements. Gains and changes were reviewed, and Sam expressed sadness that the therapeutic relationship was ending. We discussed the need for ongoing practice, learning, and growth in the years ahead.
Intervention for Sam’s Mother
The three initial sessions with Sam’s mother addressed parenting skills, whereas the six sessions of psychotherapy by D.D. that followed focused on validation and acceptance, self-awareness, personal goal-setting, and behavioral activation. Sam’s mother later indicated improved mood, smoother interactions at home and with her ex-husband, and increased positivity about Sam.
Counseling for Sam’s Father
J.R. provided two individual sessions with Sam’s father, supplemented by several telephone discussions. The value and importance of his role in his children’s lives was reinforced, and relevant information regarding fathering provided. This translated to a reported increase in enthusiasm and willingness to be more involved with his children. An offer of ongoing support to address alcohol abuse problems was declined.
Collaboration With Department of Education and Other Professionals
In addition to the seven meetings held with Education Department staff, numerous telephone contacts were also made with teachers and support staff. Communication was entered into with the pediatrician and psychiatrist, and culminated in a joint meeting, plus a follow-up meeting, of all concerned parties to facilitate an ongoing coordinated approach. A coordinated treatment plan for Sam’s further management was collaboratively formulated and distributed to all relevant parties, and other relevant documents and materials regarding behavioral management provided.
Sam’s Perceptions of Outcomes
By the end of treatment, Sam demonstrated positive feelings about himself and no longer showed the sullen moods that had been evident in some early sessions. He was able to more readily articulate positive self-attributes and expressed pride in his achievements, including being more socially accepted. He said that his friends at school were “communicating more” with him, and he named a list of people who thought he was “more cool now” (including friends, family, and school staff). Sam also expressed significantly increased enthusiasm about school and schoolwork, and reported positive interactions with teachers. Conflict at home was reported as having reduced in intensity and frequency, from almost-daily to approximately once every week or two.
Changes at School
Some strategic changes were implemented regarding the management of Sam’s behavioral problems at school (e.g., self-initiated “time-out”). Sam was invited to contribute to formulation of strategies to address his issues at school, which he found empowering. School staff, Sam’s parents, and Sam himself reported that he was demonstrating minimal disruptive behavior, increased prosocial behavior, a more positive mood and attitude, and improved enthusiasm for schoolwork. On his return to school near the end of treatment, the deputy principal emailed J.R. to say that Sam “seems relieved to be back at school and was very positive about doing quality work (ran across the playground to show me his morning’s efforts!)”
Changes at Home
Sam’s mother expressed pleasure in the positive changes that had taken place. She reported minimal arguing and fighting at home, appeared more relaxed, and was more positive about Sam and his behaviors. Sam’s father had become more involved in Sam’s school activities and homework, and was caring for him for some hours each day.
Overall, all parties agreed that Sam’s behavior and emotional state had improved but that, given the recency of changes in the context of long-term problems, ongoing work and consolidation was necessary.
A complicating factor was the lack of clarity regarding Sam’s past diagnostic picture. It seemed that the unclear and often-changing past diagnoses had contributed to a sense that Sam was more “complicated” than was actually the case, and resulted a degree of pessimism regarding his treatment. It also appeared to maintain the “ongoing search for the correct diagnosis” at the cost, it seemed, of directly addressing relevant issues.
The tendency of relevant parties to continue conceptualizing Sam’s problems in medical model terms also reinforced the perception by Sam’s mother that the problem was sourced “inside Sam.” This supported her view that she was relatively powerless to alter the situation and that behavioral management strategies were doomed to fail.
The continuation of conceptualization within a biomedical framework was evident in a decision by the pediatrician to reinstate prescription of Risperdal for Sam toward the end of treatment at our Clinic—even though he had been making substantial gains while undertaking psychological therapy, without medications, for some months. This decision reinforced ongoing perceptions of Sam’s problems as having a biological substrate, and blurred the picture regarding what factors had been effective in achieving the positive changes noted.
The difficulties that can occur in attempting to engender a collaborative and unified approach were also illustrated by defensiveness and resistance by Suspension Center staff to changing their conceptualization that Sam’s problems basically emanated only from Sam himself. This resulted in a lack of engagement by Suspension Center staff in the collaborative plan and a subsequent decision by Sam’s school to withdraw Sam from the Suspension Center service.
It appeared that the range of diagnoses proposed for Sam, prior to referral to our Clinic, was influenced by the need for specific diagnoses to obtain school funding (see Hansen, 2010). Utilization of the diagnosis of PDD-NOS, while it may have achieved access to services such as teachers aids, appeared to do little in terms of leading to treatment options pertinent to Sam’s behavioral problems.
A major complicating factor was the restricted time frame (5 months) available. To be effective, treatment for child behavior disorders must be multimodal, address multiple foci, and continue over extensive periods of time (Steiner & Dunne, 1997). Although we attempted to address multiple foci in a multimodal fashion, and in this way appeared to facilitate substantial gains over a relatively short period, we were unable to offer treatment over an extensive period of time—and thus had to rely on other services to continue the work after our contact with Sam and his family had ended.
Due to the ending of J.R.’s placement, and the closure of our Clinic for some months, we were unable to provide longer term follow-up. Sam was referred—with substantial information regarding treatment that had been undertaken and the collaborative plan—to a private psychologist (with funding from a child support agency) for a further 12 sessions of individual therapy. Sam’s parents were referred to a family support service for counseling on shared parenting and communication. Sam’s school and the child protection agency stated their intention to continue working with the collaborative treatment plan and had a case conference of all relevant parties organized for a date some months following the end of treatment by our clinic. Unfortunately, follow-up data were also unable to be collected.
10 Treatment Implications of the Case
The case demonstrates the need, in the case of child behavioral problems, to take a broad, idiographic approach incorporating all relevant influences on behavior. The way in which we assess and diagnose largely determines the type of interventions that are chosen—and ultimately the outcomes that might be achieved. The current dominance of the biomedical model-based classificatory diagnostic approach, which encourages clinicians to conceptualize problematic behavior through the lens of a diagnosis, may at times sway our thinking toward “seeing the problem in the person,” rather than as the end result of a range of influences occurring within and outside of the person. The World Psychiatric Association International Guidelines for Diagnostic Assessment Workgroup (WPA; 2003) has called for standardized diagnostic formulation to be supplemented by an idiographic diagnostic formulation—involving the contextualization of clinical problems and “the elucidation of pertinent mechanisms and contributory factors, from biological, psychological, social, and cultural perspectives” (WPA, 2003, p. s55). Thus, there is recognition that the nomothetic diagnostic approach needs to be balanced by a more idiographic approach—in order that clients be offered treatment options pertinent to their individual circumstances, and not necessarily dictated by diagnosis. This interplay of idiographic and nomethetic approaches is an area of ongoing debate (e.g., Thornton, 2010).
In Sam’s case, it was necessary for diagnostic factors to be understood in relation to relevant contextual factors and for treatment to occur within a broadly focused, idiographically tailored plan. It seemed that had this been possible from earlier in Sam’s life, the deterioration of his behavior and academic functioning may not have occurred to such a significant degree.
11 Recommendations to Clinicians and Students
This case demonstrates the need for children to be understood in the social context in which they are embedded and, in complex or chronic cases, that working with both the child and the adults in the child’s social environment is imperative to achieving positive outcomes. A large part of a necessary intervention should involve broadening the view of people in the child’s social world, away from a focus purely on “faults” or problems, toward an understanding of the emotional underpinnings and environmental influences on undesirable behaviors. It is also important that clinicians are aware of theoretical frameworks and approaches that influence case conceptualization and intervention design. The pervasive influence of the currently dominant classificatory diagnostic paradigm needs to be recognized for both its utility and limitations. To again quote Dr. Jon Juredeini (6th time quoted, in Cleary, 2005),
If you just assume that this is a condition that needs treatment with medicine and you don’t try and understand what is going on, you can miss very important things, very dangerous things that might be happening in the child’s life.
Clinicians need to take the best that both nomothetic and idiographic approaches have to offer and combine them in the most effective way for any individual case to optimize outcomes for each client.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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