Case Formulation Case Study

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Psychotherapeutic Case Formulation

Salomon has clearly evidenced educational and emotional problems at least since the 6th grade; however, this 9th grader has apparently neither been thoroughly physically and psychiatrically evaluated, nor received an Individual Education Plan, evincing a stunning level of neglect by his educators, the school psychologist and his Nurse-mother, all of whom theoretically know better. The system for identification, triage, referral and management of care will be followed. His case formulation will be approached from the "Underlying Factors Orientation" and from the "Observable Factors Orientation."

Initial Problem Identification

There is not enough available information to understand the problem. Therefore, Salomon will be referred for several sources of additional data. First, Salomon should be referred for a complete physical examination to determine if there are any physical factors contributing to his educational and emotional problems. He should also be referred for assessments by a neurologist and a psychiatrist. Assessments by the mother and school psychologist will be considered but not heavily relied upon due to the possibilities of inaccuracy due to "distorted samples of child behavior influenced by their own adult agendas" as well as the fact that they are "apt to reflect beliefs, values, practices, and social ideals of [their] cultural groups"(Weisz, 2004, p. 9). Salomon should also receive Neuro-psychiatric testing to define and specifying subtle abnormalities in "calculation, memory, language function, abstraction, visual-motor ability, and specific aspects of intelligence," as well as the Minnesota Multiphasic Personality Inventory (UBM Medica, LLC, 2010). Salomon should also receive a complete psychiatric evaluation, including the Psychiatrist's report on: Salomon's problems and descriptions; physical and psychiatric health, illness and treatment, including any current psychotropic medications; health and psychiatric histories of Salomon and his family; information about the school and his friends; information about his familial relationships; the psychiatrist's interview with Salomon; the psychiatrist's interview with Salomon's mother (and father, though unlikely); laboratory results of blood tests, x-rays and special assessments of his psychological, educational, speech and language evaluation(s) (American Academy of Child Adolescent Psychiatry, 2010).

3. Screening/Assessment

After receipt and review of results from his physical examination, neuro-psychiatric testing, and psychiatric evaluation, Salomon's case should be formulated per the format presented by Yeung and Chang (Yeung & Chang, 2002), though placing "diagnostic formulation" before "course and outcome," simply because it flows logically:

a. CLINICAL HISTORY

1) Patient Identification

Salomon is a 15-year-old 9th grade student at a public high school in San Francisco. His primary language is Spanish but he is also fluent in English. Salomon was accompanied by his mother, who is a Nurse. He presents as shy with coherent and thoughtful speech. Salomon was referred by his high school psychologist.

2) History of Present Illness

His teachers describe him as highly imaginative, kind, and often insightful, yet also extremely shy, unmotivated and hopelessly disorganized with a pervasively defeatist attitude in regard to academic tasks he finds challenging, especially mathematics. His homework binders and backpack are stuffed haphazardly with reams of crumpled paper in no discernible organizational pattern. Although he lives only a few blocks from school, he is frequently tardy. He rarely delivers homework assignments on time, claiming that he forgot, despite daily email reminders from his teachers to his mother. While his spoken English is coherent and thoughtful, his handwriting is a virtually indecipherable scrawl, and even when given the opportunity to complete assignments on computer his typing is so slow he generally abandons assignments in the middle of the first page. When directed to answer questions orally in class, he often appears panic-stricken, and unable to speak. His reading comprehension has remained at the sixth grade level since sixth grade. His mathematical ability has similarly stalled at the sixth grade level.

Salomon lives with his mother, who is employed as a nurse. Approximately three years ago, his mother and father divorced following the revelation that his father had been involved for several months in an extramarital affair. Salomon's father often travels out of state on business, and often cancels meetings with Salomon with minimal advance warning. Salomon's school psychologist noted symptoms of moderate depression, possible deficits in attention, and possible impairments in visual and/or auditory processing. In the evaluation, the psychologist cites a fragment of a short story written by Salomon in the previous month in his English class about a boy abducted by federal agents on arbitrary and unwarranted suspicion of terrorism. In the story, the agents replace the boy with a doppelganger, who purports to be the boy, yet whose behavior eventually alerts his mother to the fact of the abduction.

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The story follows the mother's attempts to retrieve her real son. Salomon's mother's principal concern is that because Salomon appears chronically sad, unmotivated, and unable to sustain attention on challenging academic tasks, his prospects of successfully graduating from high school appear to be diminishing by the day. She understands that the lack of a consistent father figure in Salomon's life has been a significant stressor for him. At the same time, she says she has exhausted all potential means of convincing her ex-husband to maintain his paternal role more consistently. She would like a therapist to help Salomon move forward with his life.

3) Psychiatric History and Previous Treatment

None.

4) Social and Development History

Salomon was born on January 1, 1997 in San Francisco. He is the only child of John, a businessman, and Mary, a nurse. Salomon is Hispanic and his first language is Spanish, though he also speaks English fluently. Salomon appeared to perform satisfactorily in school until his parents divorced, approximately 3 years ago, allegedly due to his father's extramarital affair. Since that time, Salomon has lived with his mother at 1 Main Street, San Francisco, CA. His father lives nearby; however, Salomon's father often travels out of state on business, and often cancels meetings with Salomon with minimal advance warning.

5) Family History

There is no family history of mental disorder.

b. CULTURAL FORMULATION

1) Cultural Identity

i. Cultural reference group

Salomon is second generation Hispanic, born and raised in San Francisco, CA.

ii. Language Salomon's first language is Spanish, though he also speaks English fluently.

iii. Cultural factors in development

The immigration story of Salomon's parents dovetails with the popular trend of voluntary migration from Mexico to the United States for educational and occupational opportunities. Having relatives in the San Francisco area, Salomon's parents settled there and assimilated the culture without much difficulty. Salomon was raised as an American and is culturally similar to his American peers.

iv. Involvement with culture of origin

Salomon reports no specific involvement with his Hispanic Culture.

v. Involvement with host culture

Salomon is essentially an American teenager. When he socializes at all, it is with American peers.

2) Cultural Explanation of the Illness

Per self-reports by Salomon, an interview of his mother (Duncan & Arntson, 2004, p. 60), plus review of results from physical, neurological and psychiatric testing, there is no culturally-related explanation for Salomon's illness (Lewis-Fernandez & Diaz, Winter 2002, p. 275).

c. DIAGNOSTIC FORMULATION

In formulating a diagnosis, Weisz's assertion is valuable. A high number of referrals for young people stem from four clusters: "Anxiety Disorders (Social Phobia, Separation Anxiety Disorder, Generalized Anxiety Disorder, and others); Depressive Disorders (i.e., Dysthymic Disorder, Major Depressive Disorder); Attention Deficit Hyperactivity Disorder (ADHD); Conduct Related Disorders (Oppositional Defiant Disorder, Conduct Disorder) (Weisz, 2004, p. 8).

In addition, the diagram to examine primary and secondary instigating factors, originally set forth by H.S. Adelman and L. Taylor (1993), should be used. Learning problems and learning disabilities. Pacific Grove. Brooks/Cole, and later espoused by the Center for Mental Health in Schools at UCLA (Center for Mental Health in Schools at UCLA, 2010, p. 9). The therapist should also check for stressors (Center for Mental Health in Schools at UCLA, 2010, p. 10). Finally, the therapist should check common behavioral responses to environmental situations and potentially stressful events (Center for Mental Health in Schools at UCLA, 2010).

1) The resulting diagnosis would be:

Axis I: 309.21 Separation Anxiety Disorder

309.28 Adjustment Disorder, With Mixed Anxiety and Depressed Mood

315.00 Reading Disorder

315.2 Disorder of Written Expression

315.9 Learning Disorder NOS

Axis II: 301.82 Avoidant Personality Disorder

Axis III: None

Axis IV: V61.9 Parent-Child Relational Problem

V62.3 Academic Problem

Axis V: Current GAF = 40 (presentation at clinic)

2) Differential Diagnosis

None.

4. Treatment

a. Goals

Goals for Salomon's treatment would be: effective treatment of his anxiety, adjustment and learning disorders; effective treatment of his home environment by working with both Salomon and his mother; remedial education significantly improving his reading skills; a transitional program preparing Salomon for life in school and beyond.

i. Underlying Factors Orientation

The "underlying factors orientation" (Center for Mental Health in Schools at UCLA, 2010, p. 24) is used, seeking "motivational and development differences and disabilities that disrupt desired functioning" (Center for Mental Health in Schools at UCLA, 2010, p. 25). An attempt was made to find motivational and development problems through.....

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