Psychological Disorders of Childhood and Adolescence

Assignment 10
Read the following case summary and assign a diagnosis to Camilla. This case is completely fictional; any resemblance to a real person is purely coincidental.

Introduction: Camilla is a 12-year-old female Latina client presenting to the clinic with her mother with symptoms of feeling anxious, irritable, upset, and falling behind in school.
Developmental History: Camilla was born in Honduras in a hospital in June 2009 with no complications. She was born full-term at 8lbs 2 oz. During her pregnancy, Camilla’s mother reported high levels of stress due to family conflicts and financial strain. She reported no alcohol or drug use, but she reported that she smoked approximately one cigarette every day during the pregnancy.
Camilla’s mother reports that she was a fussy baby that cried often. Whenever she was left alone, Camilla would cry a lot, and she was inconsolable even after her mother returned. Camilla met all of her motor milestones on time, but she did have some mild delays in language development. Camilla spoke two-word sentences for longer than peers her age and also had difficulty with a few speech sounds from ages 3-4. Currently, she has no difficulty with language or speech and is at the same level as her peers with language production. She also met her social milestones on time and does not seem to have impaired social skills. The family mostly speaks Spanish in the home, and Camilla was also taught English from a young age.
Trauma History: At age 5, Camilla experienced a trauma in which her uncle was killed. At age 6, Camilla experienced the trauma of separation from her parents and brother in the process of immigrating from Honduras to the US. She was separated from her family for a total of 4 months. Camilla’s mother states that when Camilla was reunited with her family at age 6, she experienced high levels of separation anxiety, bed wetting, and trouble sleeping, but those symptoms resolved at age 7.
Family History: Camilla’s mother’s side of the family has a history of major depressive disorder, PTSD, and anxiety. Camilla’s father’s side of the family has a history of ADHD and major depressive disorder. Camilla’s older brother has ADHD-combined type.
Camilla’s mother reports that overall, she and her daughter have a good relationship. Camilla’s father is away most of the time due to working two jobs, but when she can see him, they have positive interactions. However, during the past year they have noticed that Camilla seems to be irritable most of the day. When she is asked to do chores, she argues with them and completely forgets to do them. She has also been getting into fights with her brother over things like what to watch on the TV and who gets the last serving at dinner, but their fights are out of proportion compared to the small conflict, often ending in tears, screaming, and hitting. There have been four times when Camilla “got back” at her brother for hurting her feelings; for instance, two weeks ago, she destroyed his baseball uniform and broke his trophy with his baseball bat after he made fun of her art project.
Social History: Camilla’s mother described her as a shy but lovable child that often seemed to be “in her own world”. She reports that she met all of her social milestones, including making eye contact, engaging in imaginative play, and reading non-verbal cues. She also does not have any restrictive or repetitive behaviors. In 2017-2019, Camilla played on a soccer team with her friends, and she had two best friends that she would spend a lot of time with. However, because of the COVID-19 pandemic, her soccer team was disbanded and school transitioned to online. As a result, Camilla lost touch with her two best friends and now rarely spends time with peers her age outside of her brother and cousins. Camilla’s mother reports that Camilla does not seem to be motivated or interested in doing much of anything. School is back in person and the soccer team has been restarted, but Camilla is resistant to going back. When her mother tried to take her to try outs, she had a tantrum in the car and refused to get out for 30 minutes, so they went home. In addition, teachers report that although she has some acquaintances, she does not have close friends at school. She sometimes gets into fights with other students and is very sensitive to criticism. There was one instance where two girls teased Camilla, so she cut their hair off and was suspended.
Educational history: Camilla’s mother has 12 years of formal education, and her father has a GED and a certification. Camilla started preschool in Honduras but because of immigrating to the US, she missed kindergarten. She ended up going straight into first grade. Because Spanish is her first language and she missed a year of school, she was behind in 1st grade. By the end of 2nd grade, she was performing at a similar level as her peers, but her teachers report that she doesn’t seem to be paying attention during class. Overall, Camilla does well on her assignments, but she has to be given instructions for assignments multiple times and often misses deadlines. It takes Camilla twice as long to do assignments compared to her peers. These symptoms persist throughout her education. Camilla is currently in 6th grade. When school transitioned online, she seemed down for a majority of the day and did not feel motivated to complete schoolwork. She started to do poorly on tests and assignments even though she was doing fine before. She seems to give up more easily when doing difficult tasks and gets visibly frustrated. She has negative self-talk during homework assignments and gets very upset when she gets questions wrong. She almost had to repeat the 5th grade instead of continuing onto the 6th grade. Camilla’s mother reports that she expected Camilla to go back to normal now that school is back in person, but Camilla is still doing poorly and still resists going to school. She gets angry, sad, and upset every morning when she is getting ready to leave and makes up excuses to stay home. She often pretends to have a cough or fever, and there have been times where she actually throws up from being so anxious about going to school. At school, she defies the teacher’s requests and breaks rules. When she gets home from school, she is very “moody”, doesn’t want to talk to her family members, and isolates herself. She also still takes a long time to do assignments in school and does not complete them in time. According to the neuropsychological assessments completed, she does not appear to have any specific deficit in reading, math, or writing.
Medical history: Camilla does not have any medical diagnoses, but her mother reports that Camilla often pretends to have a cough or fever to avoid going to school. Camilla is coordinated and athletic, and she was very good at soccer when she was on the team. It takes Camilla around 3 hours to fall asleep every night and sleeps about 7.5 hours per day, which is below average for her age. She does not experience any nightmares and does not seem to wake up during the night. Camilla is the appropriate weight for her age and has not experienced any recent weight gain or loss.
Camilla’s Interview: Camilla reports that thinking about going to school makes her feel sick. Her heart beats really fast, her chest feels tight, and she feels like she is going to throw up. She reports that she also feels the same way when thinking about going to soccer practice, doing her homework, taking a test, talking to kids at school, getting sick with COVID-19, her parents’ finances, and just being in unfamiliar situations. She forgets things a lot and has anxiety about that too. She worries that things will go badly, something unexpected will happen, she will disappoint her family, or that she will embarrass herself. She also says that she often stays up late worrying. She feels like she can’t stop worrying even if she tries to distract herself. She feels like activities that she liked to do in the past that used to bring her joy, like playing soccer, drawing, and playing games with her brother, don’t feel like they are fun anymore. She also says that she hates school; she made lots of mistakes on her work and struggled to keep up when she was trying her hardest, so she stopped putting in so much effort. She reports that she also gets angry a lot of the time and feel like she is “on edge”. She says she doesn’t want to get angry and hurt her parents’ feelings, but she feels like she can’t control her anger. Thinking about her anger outbursts makes her feel guilt and shame. She says that she gets angry at herself for other reasons too; she reports that she loses things a lot, she makes a lot of mistakes in school, she feels like she is stupid, and she feels like she can’t do anything right. Camilla reports suicidal ideation: she says that she feels overwhelmed, she wishes “everything could just stop”, and she often thinks about wanting to be dead. Camilla does not report any plan or intent for suicide. Camilla does not have any hallucinations, delusions, nightmares, or flashbacks. She does not have any vocal or motor tics. During the interview, Camilla is visibly tearful and upset, and we had difficulty de-escalating these feelings after the interview was over.

Camilla’s mother reports that she is very concerned about these symptoms. Camilla has been experiencing these symptoms for about a year and a half, but they have been getting much worse over the past 5 months. Because of these symptoms, Camilla is falling behind in school, becoming socially isolated, and feeling upset most of the day nearly every day.
Question:
1. What is Camilla’s current diagnosis? (8 points)
• Use the DSM-5 criteria to explain why Camilla meets criteria for that disorder and therefore would be diagnosed with that disorder. You can find them on the PowerPoint slides.
• You must refer to ALL the DSM-5 criteria for that diagnosis to get full credit- see below example
• You do not need to assign a severity level or include subtypes. (except if you choose ADHD- you must define the subtype- inattentive, hyperactive, or combined)
• Please note that Camilla meets criteria for more than one disorder, so there can be multiple correct answers. You just need to choose one and explain it.
2. EXTRA CREDIT: Create a treatment plan for Camilla. See below example response. It must include:
• Choose two of her risk factors and explain how they can be improved. (be specific- 1.5 points extra credit)
• What is one intervention that you could use for Camilla for the diagnosis you gave her, and how would it help? (ex. which medication, what type of therapy- must be specific) (1.5 points extra credit)
Example response:
1. Harry Potter meets the DSM-5 criteria for PTSD and therefore would be diagnosed with PTSD.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
• Harry Potter experienced a life-threatening event when Voldemort attempted to kill him in a graveyard.
2. Witnessing, in person, the event(s) as it occurred to others.
• Harry Potter witnessed the death of Cedric Diggory during the event where Voldemort attempted to kill him in the graveyard.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
• Not applicable
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
• Not applicable
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
• Harry Potter reports that he remembers the traumatic event often, three times per day or more. Remembering this event causes feelings of depression and anger. When he has these intrusive memories, he has difficulty focusing on his schoolwork or anything else.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.
• Harry Potter reports that he has distressing dreams four times per week where he relives the traumatic event that occurred in the graveyard. He reports high levels of anxiety (increased heart rate, sweating, fast breathing, tightness in chest) upon waking from these dreams.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
• Not applicable- Harry Potter does not experience flashbacks
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
• Harry Potter experiences feelings of depression, anger, and anxiety when memories of the traumatic event are triggered by internal and external cues.
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
• Harry Potter experiences increased heart rate, sweating, hyperventilating, and nausea when thinking about the traumatic event, when experiencing dreams about the traumatic event, or when exposed to media coverage of the trauma.
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
• Harry Potter avoids talking about the traumatic event as much as possible, and he refuses to speak to anyone but his closest friends about anything related to the event. He fears falling asleep to avoid distressing dreams.
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
• Not applicable- Harry Potter does not avoid people who remind him of the event, like Cho Chang, and he does not avoid graveyards (where the event occurred).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, and not to other factors such as head injury, alcohol, or drugs).
• Not applicable- Harry Potter remembers all aspects of the event
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
• Harry Potter has persistent thoughts that he is bad or evil, and he feels that the whole world is against him.
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
• Not applicable- Harry Potter does not blame himself or irrationally blame others for the traumatic event.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
• Harry Potter has anger and depression that is present at school, when engaging in extracurricular sports, and when spending time with friends.
5. Markedly diminished interest or participation in significant activities.
• Not applicable- Harry Potter demonstrates the same level of interest in his favorite activities as he did prior to the event.
6. Feelings of detachment or estrangement from others.
• Harry Potter reports feeling isolated and alone and like nobody understands him despite the efforts of teachers and friends to connect with him.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
• Not applicable
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
• Harry Potter’s teachers and friends have reported multiple events where he shows verbal aggression toward others with little or no provocation.
2. Reckless or self-destructive behavior.
• Harry Potter shows high levels of rash decision-making, and he engages in activities that could result in danger or harm to himself.
3. Hypervigilance.
• Not applicable- Harry Potter does not have higher levels of alertness or vigilance.
4. Exaggerated startle response.
• Not applicable- Harry Potter does not report an exaggerated startle.
5. Problems with concentration.
• Harry Potter reports that he has difficulty focusing during class and extracurricular activities.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
• Harry Potter reports difficulty falling asleep and has restless sleep almost every night.
F. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.
• Harry Potter has been experiencing all of the symptoms described since June when the event occurred, and they have persisted for 5 months up to today.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Because of his symptoms, it takes Harry Potter longer to complete his homework. His behavioral problems have resulted in multiple detentions. His social relationships are hurting due to his outbursts of anger and thoughts that everyone is against him. He has difficulty completing his extracurricular activities due to the symptoms.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
• Harry Potter does not consume alcohol or drugs, he does not take any medications, and he does not have any medical conditions.
In conclusion, Harry Potter meets the required criteria for PTSD. He meets 3 criteria for Part A, 4 criteria for Part B, 1 criterion for Part C, three criteria for Part D, and four criteria for Part E. Finally, he meets the criteria F, G, and H.
2. EXTRA CREDIT: sample response:
• Harry Potter has multiple risk factors, including social isolation and being a victim of bullying from Draco and Professor Umbridge. To improve his social isolation, we could encourage him to send more letters to his friends, get him involved in more extracurricular activities such as the defense against the arts club, and encourage him to visit Hagrid once a week. To decrease the negative effects of being a victim of bullying, we can help him reach out to a trusted adult when bullying occurs, teach him social problem-solving skills to learn how to respond to bullies, and we can collaborate with his teachers to improve the classroom environment.
• Because Harry Potter is diagnosed with PTSD, he would benefit from trauma-focused cognitive-behavioral therapy (TF-CBT). In TF-CBT, Harry will learn about the reasons behind his symptoms, and he will learn how to use relaxation skills, impulse control, and emotion regulation skills. Also, in TF-CBT, the therapist will help Harry process his trauma and become desensitized to his traumatic memories by completing a trauma narrative.