Samuel, an 8-year-old black male, lives in an adopted white family consisting of the father, incarcerated for domestic violence charges, the mother, the primary caretaker and the only home provider, and the older sibling. Samuel lives in a rural white area with limited resources, poor transportation, and insufficient childcare. He witnessed the father’s substance abuse, including physical assaults, and heard verbal threats. His childhood traumas result in aggressive and impulsive behaviors, sleeping and academic problems, and low social interactions with peers.
Problem Presentation and History
The major problem of the patient is his uncontrolled behavior. Several observations allow clarifying that Samuel’s impulsivity predetermines his action. The boy prefers to run into roads, hit people unreasonably, and neglect the consequences of his decisions. His verbal and physical aggression is triggered by insignificant factors like battery problems, game loss, or the inability to find something. The boy cannot forget about his father, and he is constantly afraid of the man to return home. This fear explains why Samuel does not sleep well, only 4-5 hours per night.
Patient’s Strengths and Characteristics
Samuel does not demonstrate specific personal strengths that might contribute to his future treatment or behavioral improvements. His mother and older sibling can play an important role in his recovery as a support group. The boy’s family is white and lives in a predominately white community, but no racial conflicts or abuse have been reported during the assessment. These observations might prove the possibility of communicating and cooperating, which becomes a solid coping skill for a future treatment process.
Social/Peer Relationships and Educational Attainment
Samuel is a 1st-grade student, and he attends a special education problem. Still, his impulsivity and aggression affect his relationships with peers because the boy prefers isolation in the classroom. He has few social interactions with other students and avoids friendship obligations. In this case, not much information about his academic attainment is given. What is known is that Samuel likes detouring not to complete a full day at school or even not attending school, which would hardly result in positive educational outcomes.
Family Relationships
His relationships with his parents contribute to his mental health disorder. Samuel observed his father’s aggression towards his mother: physical assaults, verbal threats to kill the boy, attempts to burn her eyes with a cigarette, and other humiliating conditions. The mother has to go to work, earn a living, and deal with the increased stress because of Samuel’s behaviors. The boy is triggered by his mother’s absence, lashes out, and uses verbal and physical assaults.
Assessment of the Client
Mental Status Exam
The Mental Status Exam (MSE) has several categories according to which the patient should be assessed. Samuel is an 8-year-old black male whose general appearance (dressing, grooming, and posture) is normal, but his behavior is abnormal as the boy avoids eye contact, shows aggression and hostility, and demonstrates increased vigilance and startle response. His affect and mood are characterized by the absence of positive emotions, anger, and apprehension. His speech, motor activities, and cognitive abilities are within limits: Samuel understands all the questions, gives answers, and reads as per his age. The evaluation of his perception and thought processes reveals that the boy remembers his father’s abusive behavior, leading to distorted thoughts of himself, his mother, and the causes of aggression. No hallucinations or delusional thinking are observed; his judgments are clear with rather pessimistic insights.
Assessment for Risk and Protective Factors
Samuel’s major traumatic event is his father’s assaultive behavior in his family. This trauma leads to the development of such symptoms as school refusal, irritability, aggression, and uncontrolled thoughts about safety (Seligman & Reichenberg, 2016). The risks include sleep problems, poor socialization, and the inability to talk about the trauma and his feelings. If symptoms occur longer than one month, psychiatrists should pay close attention to the patient’s relationships with family members/peers and identify if there is school distress (Seligman & Reichenberg, 2016). Protective factors may include social support, the development of optimistic attitudes, social competence, and improved family support.
Cultural Formulation
In this case, there are two cultural factors: the patient’s adoption and race. According to Chobhthaigh and Duffy (2019), adopted children are at higher risk of experiencing negative emotions and behavioral challenges than their non-adopted siblings and peers. Besides, racial discrimination may contribute to increased traumatic experiences in African Americans, including poor mental health and decreased life quality (Holliday et al., 2020). As a black adopted child in a white family whose parents do not use professional care, Samuel is predisposed to certain mental health problems.
DMS-5 Diagnosis
Samuel is diagnosed with post-traumatic stress disorder (PTSD), resulting from his exposure to threatened injury. Following the Diagnostic and Statistical Manual (DSM-5) criteria, the patient is exposed to actual or threatened sexual violence (he witnessed in person the events as they occurred to his mother and experienced repeated exposure) (American Psychiatric Association, 2012). Intrusion symptoms include recurrent distressing memories and dreams, persistent negative emotions (anger and fear), diminished interest in social activities, inabilities to experience positive emotions, irritable behavior, angry outbursts, and sleep disturbance (American Psychiatric Association, 2012). The duration of such symptoms and behavior is longer than one month, which requires immediate interventions and professional help.
Differential Diagnosis
Acute stress disorder is one of the possible differential diagnoses because it is characterized by similar symptoms and behavioral changes. The rationale not to use it is its restricted duration from three days to one month, which contradicts the case (American Psychiatric Association, 2012). Depression may explain poor socialization, academic distress, and poor family relationships. However, the presence of recurrent negative memories is not inherent to major depressive disorder (American Psychiatric Association, 2012). Generalized anxiety disorder can be the reason for sleep disturbance, restlessness, and difficulty concentrating (school distress) during the last six months. Still, behavioral changes in the patient are related to a certain traumatic event, which is not inherent to anxiety.
Diagnostic Bias
In Samuel’s case, diagnostic biases will be based on missed evaluation (retrospective distortion), personal judgments (confirmation), or insufficient information (outcomes). For example, PTSD is more prevalent in females for a longer duration (American Psychiatric Association, 2012). This retrospective bias should be removed to explain the possibility of PTSD in a male patient. The confirmation bias emerges when a medical decision is influenced by healthcare professionals and individuals not involved in the medical field. The opinions of relatives and other stakeholders do not define the diagnosis but are used as sufficient background. The outcome bias that domestic violence initiated by the father is the only reason for Samuel’s behaviors must be recognized. The boy may be affected by other external and internal factors that are not reported at the moment of assessment.
Theoretical Orientation
Trauma-focused cognitive-behavioral therapy (CBT) is the proposed treatment intervention for Samuel. This approach includes emotional processing of a trauma (feelings and coping skills) and prolonged exposure (activation of fear memory and its management) (Seligman & Reichenberg, 2016). The American Psychiatric Association (2012) recommends imagined interventions in the form of play or storytelling to improve their thoughts’ expression. This theory aims to stabilize the patient’s condition, narrate the trauma, and integrate recommendations with family members.
Outcomes
All treatment interventions should be under the control of an expert. CBT is associated with decreased interpersonal problems and positive emotional outcomes during a post-treatment period (Han et al., 2021). The first-line treatment for children with PTSD informs assessment to create a safe environment, intervention to train interpersonal regulations, and supportive counseling, which is not as effective as skill training (Seligman & Reichenberg, 2016). Other psychosocial and medication treatment plans are not recommended due to the patient’s young age (Smith et al., 2019). Family involvement is beneficial if all members are ready to recognize a problem and ask for professional help to find a solution.
Treatment Planning
Samuel’s treatment is based on three major goals to stabilize his mental health in terms of his memories, behaviors, and emotions related to the experienced trauma. First, improved control over his traumatic memories must be achieved (Seligman & Reichenberg, 2016). Second, the patient’s aggressive and impulsive behavior must be managed by appropriate coping skills. The third goal is to promote healthy emotional expressions and socialization.
Treatment Objectives
The first goal should include three critical objectives: correcting inaccurate thoughts about traumatic memories, generating alternative attitudes, and cooperating with family members. The second goal may be achieved by learning the skills for assessing safety, applying knowledge through gradual exposure, and using skills to identify triggers properly. The final goal is associated with the following objectives: open discussions with healthcare providers, communication with family members and friends, and implementing feeling ratings.
Protective Factors and Risk to Pathology
The risk of PTSD pathology can be interrupted by several protective factors. For example, Samuel develops optimistic attitudes toward his interactions with family members and avoids negative memories. Participating in social support groups will allow him to talk about his traumatic experiences and learn how to cope with them (American Psychiatric Association, 2012). Appropriate coping strategies will encourage social competence and helps Samuel recognize real and imaginary threats.
Recommendations
Samuel should strengthen his relationships with the mother and the older sibling. Thus, family group counseling is the major recommendation to improve cooperation and enhance trustful communication (Seligman & Reichenberg, 2016). Drawing activities as a part of creative arts in psychotherapy is a way for the patient to reduce his avoidance and irritability symptoms (Van Westrhenen et al., 2019). The task is to communicate with Samuel, reveal his interests and hobbies, and offer activities that minimize emotional outbursts.
Client Engagement
To avoid secondary traumatization, therapists need to ensure the patient is engaged in the offered activities. Seligman and Reichenberg (2016) offer restoration to previous levels of functioning. Samuel likes games, and his habit of hitting people without thinking of the consequences proves the need for cooperation. Sports activities, planning, and cooperation with people at different levels may be engaging for the patient. Alternative ideas to be implemented with his family like traveling, watching kind movies, or picnics can also be offered.
Expected Outcomes
PTSD treatment prognosis depends on personal resilience, outside stressors, and support level. Outcomes may not be good for those with late-onset or co-occurring disorders (Seligman & Reichenberg, 2016). Regarding Samuel’s condition and resources, the main expectations are developing strong coping skills, improved family support, and emotional control by addressing new alternatives. The patient will learn how to deal with his trauma and choose appropriate behaviors at home and school.
References
American Psychiatric Association. (2012). DSM-V: Diagnostic and statistical manual (5th ed.). American Psychiatric Association.
Chobhthaigh, S. N., & Duffy, F. (2019). The effectiveness of psychological interventions with adoptive parents on adopted children and adolescents’ outcomes: A systematic review.Clinical Child Psychology and Psychiatry, 24(1), 69-94. Web.
Han, H. R., Miller, H. N., Nkimbeng, M., Budhathoki, C., Mikhael, T., Rivers, E., Gray, J., Trimble, K., Chow, S., & Wilson, P. (2021). Trauma informed interventions: A systematic review.PLoS One, 16(6). Web.
Holliday, S. B., Dubowitz, T., Haas, A., Ghosh-Dastidar, B., DeSantis, A., & Troxel, W. M. (2020). The association between discrimination and PTSD in African Americans: Exploring the role of gender.Ethnicity & Health, 25(5), 717-731. Web.
Seligman, L., & Reichenberg, L.W. (2016). Selecting effective treatments: A comprehensive, systematic guide to treating mental disorders (5th ed). Wiley & Sons.
Smith, P., Dalgleish, T., & Meiser‐Stedman, R. (2019). Practitioner review: Posttraumatic stress disorder and its treatment in children and adolescents. Journal of Child Psychology and Psychiatry, 60(5), 500-515. Web.
Van Westrhenen, N., Fritz, E., Vermeer, A., Boelen, P., & Kleber, R. (2019). Creative arts in psychotherapy for traumatized children in South Africa: An evaluation study.PloS One, 14(2). Web.