Clinical description

Tamika is an 11 year old African American female in regular education. Her mother sought treatment for her increased anger, aggression, being “hyper,” having trouble sleeping, lying, talking to herself, and stealing. At home, she was often cranky and refused to share things with her two siblings and younger cousin, who were all living in the same house. When she had tantrums, she screamed, threw things, broke a plate and some toys, and escalated to the point that the mother worried she might injure someone. Tamika is starting to have problems at school, including lower grades and disruptive classroom behaviors such as talking out of turn, getting easily distracted, and frequently arguing with peers and some teachers.

Checklist scores

Tamika, her mother, and her teacher all completed the Achenbach System of Empirically Based Assessment (ASEBA) checklists. Here are the results, reported as T scores (M = 50, standard deviation (SD) = 10, compared to other women between 11 and 18 years of age).

Diagnostic interview findings

Diagnoses are based on a LEAD (Longitudinal expert evaluation of all data) consensus meeting following a Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) interview, using DSM-IV criteria. The same interviewer met with Tamika, and then her mother, then discussed any differences of opinion with them as needed to use clinical judgment. KSADS results were reviewed with a licensed clinical psychologist to arrive at a final decision.

• PTSD (100% confidence post interview)
• ADHD (65% confidence post interview)
• ODD (70% confidence post interview)
• Rule out: reactive attachment disorder (49% confidence post interview)    
• Rule out: mood NOS (33% confidence post interview)

Cognitive and achievement testing

(Not done as part of the evaluation; may be able to match up information later)

Shortlist of probable hypotheses

Based on Tamika's age and the common clinical issues, here are the possible issues:

• Oppositional defiant disorder is a leading hypothesis, based on her high externalizing scores across different reporting groups, and especially from her mother. It also is common.
• Conduct problems would be a second possible diagnosis.
• Attention problems are worth evaluating based on prevalence, though her prior academic performance does not suggest any additional reason for concern.
• Post traumatic stress disorder would be worth considering based on prevalence; nothing immediately suggests it in the presenting problem, but it could explain a similar set of symptoms.
• Parent-child conflict or an adolescent acting out in a somewhat chaotic home environment also should be a contending hypothesis.

Risk and protective factors and moderators

Tamika's gender and age make her on the bubble between oppositional defiant disorder and conduct disorder, for which she is on the younger side of the range.

Updating probability of diagnoses

Below is a worksheet with the DLRs left blank to be filled in. Answers are below.

Click below for filled out chart.

Cross-informant perspectives

Mention that these have DLRs. Also unpack the implications of agreement and disagreement for the client (and add a section about treatment implications of disagreement on the Conceptual Model Pages)

Mental status and clinical observations

(add content)

Genogram and family functioning

Here is a genogram of Tamika's family:

Mom is effectively a single parent raising Tamika and three brothers and a sister. The kids have three different fathers; none of them are currently in the home or contributing directly to child support. On the other hand, there is not any significant conflict with Tamika's father, and she sees him intermittently.

The plot twist hinges around the "uncle" who is shown as being both in and out of the house. Skip to the diagnostic interview section if you want the details.

Treatment selection

The diagnostic interview suggests a combination of a major depressive episode and a prior dysthymia, sometimes referred to as a "double depression." This suggests that Arlene's stress and mood problems have persisted for a long time, and may be more difficult to treat. The mood disorders clearly are associated with impairment and should be a major focus of treatment.

Moderating factors

The double depression is a moderating factor suggesting worse prognosis, along with potential demoralization and early drop out from treatment.

Client preferences

Arlene was originally leaning towards an antidepressant medication, thinking that she could take it without telling her parents. After discussing the pros and cons of medication (including the effect size in youths, the potential side effects, and the fact that her parents would find out as part of the consent process), as well as the pros and cons of different evidence based therapies, she elected to try IPT. She wanted to revisit the possibility of a stimulant helping with her inattention, but she opted to wait and see if that improved along with her mood if the IPT helped.

Clinically significant change

Minimum important difference (MID)

Note that this section is a dangler -- not originally called out in the 12 steps. Medium d as a rule of thumb from Streiner, Norman, & Cairney (2015). Could work from AUC to d to raw units as a way of estimating, since psychology hasn't done research on this yet. Might be able to back into it with studies that had CSQ and outcome data.

Client goals & tracking

These would be personal goals and idiographic measurement -- YTOPS, etc.

Process measures

This would be traces such as coming to sessions, doing homework assignments. (Not sure of other specifics involved in current IPT protocols?)

Progress measures

YTOPS again and goal setting.

Termination planning and maintenance

Revisit Jacobson benchmarks. Is there much chance of relapse? What things would the client need to pay attention to if they were going to nip that in the bud?

References

1. 1 2 Rettew, David C.; Lynch, Alicia Doyle; Achenbach, Thomas M.; Dumenci, Levent; Ivanova, Masha Y. (2009-09-01). "Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews". International Journal of Methods in Psychiatric Research 18 (3): 169–184. doi:10.1002/mpr.289. ISSN 1557-0657. PMID 19701924. https://www.ncbi.nlm.nih.gov/pubmed/19701924.