Post-traumatic stress disorder in a sexually abused foster child

QUESTION 1

1. Case #1 – Jenna

Jenna is a six-year-old Caucasian female who currently resides with her foster parents, her older biological sister, and two foster brothers. Jenna and her siblings were taken from her biological parents because of suspected sexual abuse and neglect. It is reported that Jenna lived in a home without food, water, and utilities. Jenna’s foster parents report that her biological mother “may have some disabilities and has never had the financial means to take care of her children.” Jenna’s biological brother is in a separate foster home. He is suspected of sexually abusing both Jenna and her older sister. It has been reported that he sexually abused Jenna, while her sister was helplessly told to watch. Jenna has expressed this trauma with agitated behavior. The traumatic event is re-experienced by repetitive play where she stimulates herself on furniture. Jenna avoids the stimuli associated with the trauma by avoiding conversations associated with sexual abuse. Jenna avoids activities, places, and people associated with the trauma except for her sister who was also a victim. Jenna also has a sense of a foreshortened future. She frequently brings up death with her foster parents. Jenna has persistent symptoms of increased arousal that were not present before the trauma as indicated by irritability and outbursts of anger nearly every day with her biological sister and her foster father. Jenna is also hyper vigilant and does not want her foster father around. The disturbances have lasted for over a month and have caused clinically significant social impairment to the point she is unable to attend a full day of school due to emotional breakdowns.
1) What intake information should be obtained and assessed to formulate a provisional DSM-5 diagnosis? Select AS MANY as you consider essential. History of learning disabilities. Length of time problematic behaviors have persisted. Changes in sleeping patterns. Substance use. Attention problems. Details of sexual trauma. g. Hypervigilance or increased arousal.
In order for us to establish a provisional diagnosis we need to understand the duration that the client has been having or showing the symptoms, details regarding their sexual trauma, the attention problems mentioned in the case, and hyper vigilance. This information will assist us in making an initial diagnosis of the client's mental disorder, which might be revised when we have more information.

2 points   

QUESTION 2

1. What assessment tools might offer meaningful information on this client? Select the ONE most appropriate option. (Refer to Case #1)

a. Beck Anxiety Inventory

b. Attachment Questionnaire for Children (AQC)

c. Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA)

d. Child and Adolescent Needs and Strengths (CANS)
The Child and Adolescent Needs and Strengths (CANS) tool is the most appropriate tool to use in order to get meaningful information regarding the client. The tool is aimed at offering support for care planning and this can only be possible once one has all the information necessary regarding the client. With this tool it is possible for one to uncover information about the client since the tool is administered from a communication perspective. The toll focuses on the child and not on the service that is offered to the child.

2 points   

QUESTION 3

1. Based on the available information, what would appear to be the most appropriate provisional DSM-5 diagnosis? Select the ONE most appropriate primary diagnosis. (Refer to Case #1)

a. Disruptive Mood Dysregulation Disorder (296.99)

b. Posttraumatic Stress Disorder (309.81)

c. Acute Stress Disorder (308.3)

d. Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (309.4)

Acute Stress Disorder is the initial diagnosis for the client and this is based on the symptoms that have been presented in the case. The client has avoidance symptoms that they use to avoid the stimuli for the traumatic event (American Psychiatric Association, 2013). She constantly avoids talking about the trauma. During play the client does demonstrate arousal symptoms where the client stimulates herself on furniture.

2 points   

QUESTION 4

1. Based on the provisional diagnosis, what interventions might work best as you begin to work with this client? Select AS MANY as you consider indicated. (Refer to Case #1)

a. Group Therapy

b. Behavioral Rehearsal

c. Grounding Techniques

d. Play Therapy

e. Flooding Techniques

f. Medical Referral for Anxiety Medication

g. Assertiveness Training
Behavioral rehearsal is aimed at practicing and imagining behaviors, responses, and social skills for the client (James & Gilliland, 2013). This way the client can be prepared for when they might need to use them in reality. Grounding techniques allow the client to remain in the present and to not focus on what happened in the past. This will assist in reorienting the client to the here and now. Since the client has overwhelming anxiety this technique will be helpful in enabling them to manage these feelings. Play therapy assists children aged between 3 and 12 years to freely express their repressed emotions and thoughts via play. This will enable the client to express herself and allow the therapist to observe the client's decisions, choices, and style of play. The main goal is to help the client to learn how to express herself in a healthier way, be more respectful and empathetic, and discover positive ways for solving problems.

2 points   

QUESTION 5

1. In developing a collaborative treatment plan with the client, identify immediate goals to be addressed. Select AS MANY as you consider correct and necessary. (Refer to Case #1)

a. Reunification with Biological Family

b. Addressing Sexualized Behaviors

c. Increasing Emotional Regulation

d. Preventing Revictimization

e. Reenactment of Traumatic Events
The immediate goals for the client would be to ensure that the client symptoms do not progress for too long. It is for this reason that we have selected the immediate goals to be addressing sexualized behavior, increasing emotional regulation and preventing revictimization. By addressing sexualized behavior, we will be able to deal with the client trauma and allow her to heal. Emotional regulation will enable the client to better deal with her emotions and to learn how to express herself in a healthy manner. Preventing revictimization will ensure that the client does not suffer from the same trauma again.

2 points   

QUESTION 6

1. Case #2 – Morgan

Morgan is staying at a local shelter after she experienced a natural disaster that destroyed her home three days ago. She is a 25-year-old lesbian female who was living with her partner. She has a flat affect and makes no eye contact as she talks about having to vacate her home in the middle of the night as the waters were filling her condo. Her partner did not make it out and drowned in the storm. She has not made contact with any of her other relatives who she says she has been distant from for “many years.” She mentions that before the storm she was taking “some meds to help with my moods” but is not sure of the medication name. Since she arrived at the shelter, she has laid in her cot, not taken any showers, eaten very little food, and avoided any contact with shelter workers or other families. She has a significant startle response when approached and has difficulty remembering basic information. She cries herself to sleep and has moments where she screams out at night after having “nightmares about drowning.”
What intake information should be obtained and assessed to formulate a provisional DSM-5 diagnosis? Select AS MANY as you consider important.

a. Substance abuse history

b. Medical history

c. Educational history

d. Military history

e. Quality of family relationships

f. Psychiatric history

g. Employment history

h. Threat to self or others
The intake information will allow the therapist to determine what could be ailing the client. Information regarding substance abuse, client's medical history, quality of family relationships, and psychiatric history are vital in order to understand the client. This information will assist in establishing a diagnosis for the client and to uncover information that is vital for making a conclusive diagnosis.

2 points   

QUESTION 7

1. What assessment tools might offer meaningful information on this client? Select the ONE most appropriate option for your work while she is at the shelter. (Refer to Case #2)

a. Beck Depression Inventory

b. Inventory of Complicated Grief

c. Triage Assessment Form

d. The Behavioral Assessment Rating Scales
Since the client is having nightmare this is the best tool for diagnosing the client's symptoms. The tool assesses indicators for pathological grief. The client is suffering from bereavement-related depression and the best way to assess this would be by using this tool.

2 points   

QUESTION 8

1. Based on the available information, what is the most appropriate provisional DSM-5 diagnosis? Select the ONE most appropriate primary diagnosis. (Refer to Case #2)

a. Major Depressive Disorder, Single episode, Mild (296.21)

b. Posttraumatic Stress Disorder (309.81)

c. Generalized Anxiety Disorder (300.02)

d. Acute Stress Disorder (308.3)

e. Adjustment Disorder with Depressed Mood (309.3)
Acute stress disorder is the appropriate provisional diagnosis for the client. The client is experiencing psychological distress that is caused by the loss of their partner (American Psychiatric Association, 2013). ASD is a temporary condition that normally persists for up to do days after the traumatic event. The client is having intrusion symptoms where they keep revisiting the traumatic event through dreams. She also has negative mood.

2 points   

QUESTION 9

1. Based on the intake data, identify immediate potential issues to be addressed as a crisis counselor while the client is in the shelter. Select AS MANY as are correct and necessary. (Refer to Case #2)

a. Hygiene

b. Impulse Control

c. Family Relationships

d. Housing

e. Suicidality

f. Medication compliance

g. Employment issues

h. Stress management
According to James and Gilliland (2013) it is vital that the client is able to handle and deal with the trauma that took place. The client also needs to maintain proper hygiene and having not showered since she came to the shelter could result in her developing diseases that are caused by lack of proper hygiene. Having lost her house it is vital that the client gets shelter where she has the necessary support systems in place. Therefore, talking to her about family relationships will assist the client to reconnect with her family and get the support that she needs.

2 points   

QUESTION 10

1. Based on the provisional diagnosis, what theories or models will likely work best for the client? Select AS MANY as you consider correct and appropriate in working with the client while she is at the shelter. (Refer to Case #2)

a. Group Therapy

b. Psychological First Aid

c. Existential Therapy

d. Grief Therapy

e. Maslow’s Hierarchy of Needs
Grief therapy aims at helping the client to cope with the emotional, physical, social cognitive, and spiritual responses to loss. Having experienced the loss of her partner, the client does need grief therapy to help her cope (James & Gilliland, 2013). Psychological First Aid (PFA) is a modular approach for helping individuals immediately after a disaster. PFA aims at reducing the initial distress that is caused by a traumatic event and to promote short and long-term adaptive coping and functioning. Existential therapy will help the client to focus on their free will, search for meaning, and self-determination. Emphasizing the client's capacity to make rational choices and developing their maximum potential. This therapy also aims at assisting the client to build relationships, which is what our client needs the most.

2 points   

QUESTION 11

1. Case #3 - Bob

Bob is a 45 year old African American man. He was recently medically discharged from the US Navy due to extensive injuries he sustained during his last time in combat. He is separated from his wife and has two teenage children. He has a prescription for an opioid pain medication and discloses that he has been engaging in daily marijuana use and drinks about 5-6 beers a day “to cope.” He has an extensive history of childhood physical and emotional trauma. His mother was alcoholic and his father was physically abusive to him and his siblings. He says that he is struggling over the past few months with "what could have been" if he was not so "damaged." He sounds very agitated, stating that the pain is unbearable and he “can’t stand it anymore.” He mentions that he might be better off dead.
Based on the available information, what would appear to be the most appropriate provisional DSM-5 diagnosis? Select the ONE most appropriate.

a. Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (309.4)

b. Substance-Induced Anxiety Disorder (292.89)

c. Posttraumatic Stress Disorder (309.81)

d. Acute Stress Disorder (308.3)

e. Generalized Anxiety Disorder (300.02)
The most appropriate provisional diagnosis would be Posttraumatic Stress Disorder. This is because the client has lived with the trauma he suffered when he was a child and the symptoms are beginning to manifest themselves when he is all grown up (American Psychiatric Association, 2013). The client has recollections of the traumatic event that was experienced when he was a child and this is triggering him to feel like he is damaged. He takes marijuana and alcohol as a way of coping with his trauma. The client is also having suicidal thoughts and he feels that he is better dead than alive.

2 points   

QUESTION 12

1. To better determine the client’s current level of functioning and behavioral problems, what additional data may be helpful? Select AS MANY as are necessary. (Refer to Case #3)

a. Collateral contact with the medical provider.

b. Collateral contact with his spouse and children.

c. Military record review.

d. Substance abuse screening.

e. Legal history review.
Contact with his spouse and children will provide vital information regarding the client's ability to function and their behavior (James & Gilliland, 2013). Having lived with them for a long period is good since they can attest to his behavioral problems. Military record will uncover the client's behavior when dealing with others and how he handled difficult situations. This information if vital since it shows the client's endurance to stress and might also uncover any other traumatic event that the client could have suffered when he was in the Navy. While the client clear states that he does take marijuana, it is vital to establish if there is any other substance that he uses and has opted to not disclose.

2 points   

QUESTION 13

1. Which of the following risk factors are present in the case description? Select AS MANY as you consider indicated. (Refer to Case #3)

a. History of previous attempts.

b. Specific plan.

c. History of drug and/or alcohol use.

d. Cut off from others.

e. Lack of belongingness.

f. Feelings of helplessness.

g. Financial loss.

h. Access to firearms.

i. Radical shifts in behaviors and mood.
The client has indicated that he is separated from his wife and children meaning that he lives alone. This brings about a lack of belongingness. He has a history of drug and alcohol use as clearly pointed out in the case. The suffering that he is enduring is too much and he feels helpless and this is why he is having suicidal thoughts.

2 points   

QUESTION 14

1. Indicate the responses that would be most appropriate for addressing potential suicidal ideation. Select AS MANY as you consider correct. (Refer to Case#3)

a. You say you are suicidal, but what’s really bothering you?

b. You can tell me. I’m a professional and have been trained to be objective about these things.

c. It seems like you’ve been suffering so much that hurting yourself seems like the only way you can make the pain go away.

d. You have so much to live for, think about your wife and children.

e. Tell me more about your suicidal feelings.

f. You seem to be somewhat upset.
When dealing with a client who is suicidal one needs to ensure that they do not agitate the client further. Instead, one should seek for the client to open up to them. It is for this reason that we have selected these responses. They are all aimed at giving the client an opportunity to speak up and disclose what could bothering them in a safe environment. Prompting the client to rethink their thoughts and to speak about them will enable the client to have a different view and this might be beneficial in altering their suicidal desires.

2 points   

QUESTION 15

1. Based on the provisional diagnosis, what interventions and referrals might work best for the client? Select AS MANY as you consider indicated. (Refer to Case #3)

a. Suicide Safety Plan

b. Create a No Harm Contract

c. Family Counseling

d. Medication Review

e. Cognitive Reframing

f. Vocational / Job Training
With suicidal thoughts it is vital that we mitigate against these thoughts and this is why we would recommend a suicide safety plan. The separation from the wife and children should be mitigated against and this can only be possible through family counseling. With family counseling, the client and his wife can both attend counseling sessions in order to uncover the underlying issues enabling them to work them through. Medication review is necessary to eliminate the change the client's opioid medication. Opioid medications have been shown to result in addiction and it is vital that the client's pain medication is changed to a medication that will not result in addiction.

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). Washington, DC: American Psychiatric Pub.

James, R. K., & Gilliland, B. E. (2013). Crisis intervention strategies (8 ed.). Boston, MA: Cengage Learning.