Tori J. Is a 12-Year-Old Girl Who

¶ … Tori J. is a 12-year-old girl who was removed from her family at the age of 8, when she was placed with a foster family. Although her foster mother discussed some episodes of violence and defiance in the home, Tori was not initially violent or defiant in school. However, she frequently failed to complete her assignments, instead spending hours simply looking into space. She also spoke frequently to social workers and school counselors about problems in her foster home including allegations that she was not being fed sufficiently, that they would not purchase school supplies for her, and that there was emotional and physical abuse in their current home. These allegations were reported and determined to be unsubstantiated, but allegations of emotional and physical abuse and neglect in her family home were substantiated. The children were removed because of physical abuse and neglect. Interviews with Tori J.'s older brother reported that she her birthmother, a known prostitute, had allowed clients access to Tori J. On repeated occasions. However, Tori J. refuses to confirm or deny these allegations; whenever asked questions about any type of sexual abuse, she puts her head down, closes her eyes, and pretends to nap. As she has gotten older, Tori J. has begun engaging in violent behavior. The behavior is unpredictable; she will not react with violence in situations where it might be anticipated, such as when another child aggresses against her, but will engage in violence in unprovoked situations. She also engages in stealing and is very manipulative.

Differential Diagnosis

Tori J. has received a number of different diagnoses over her lifetime, which are complicated by the fact that she has been in the foster care system and has seen a large number of mental health professionals, and none of them for lengthy periods of time. She has never received a definitive diagnosis. Moreover, funding concerns have limited access to the full range of diagnostic tools. The four basic tools for psychological assessment include: norm referenced tests such as the MMPI, interviews, observations, and informal assessment (Framingham, 2012). Tori J. has never taken the MMPI or any similar psychological testing tools. Furthermore, "Psychological assessment should never be performed in a vacuum. A part of a thorough assessment of an individual is that they also undergo a full medical examination, to rule out the possibilities of a medical, disease or organic cause for the individual's symptoms. It's often helpful to have this done first, before psychological testing (as it may make psychological testing moot)" (Framingham, 2012). Therefore, it is important to keep in mind that the informal diagnosis discussed for Tori J. is informal.

There are five axes to the DSM-IV. Axis I looks for clinical syndromes, which is what many people consider traditional mental illnesses (AllPsych, 2011, DSM-IV). Axis II refers to developmental disorders and personality disorders (AllPsych, 2011, DSM-IV). Axis III looks at a person's physical condition (AllPsych, 2011, DSM-IV). Axis IV looks at the severity of psychosocial stressors (AllPsych, 2011, DSM-IV). ). Finally, Axis V looks at the person's highest level of functioning (AllPsych, 2011, DSM-IV). Taken as a whole, the five axes should give an overall picture of the patient's functioning and expected functioning under the current circumstances.

Axis I

Because Tori J. refuses to discuss the known prior child abuse, but engages in seemingly unpredictable violent behavior and appears to exhibit symptoms of depression, one possible diagnosis is Post-Traumatic-Stress Disorder (PTSD). Because Tori J. was an abuse victim, she has the necessary trauma component for PTSD that separates it from generalized anxiety disorder:

Symptoms include re-experiencing the trauma through nightmares, obsessive thoughts, and flashbacks (feeling as if you are actually in the traumatic situation again). There is an avoidance component as well, where the individual avoids situations, people, and/or objects which remind him or her about the traumatic event (e.g., a person experiencing PTSD after a serious car accident might avoid driving or being a passenger in a car). Finally, there is increased anxiety in general, possibly with a heightened startle response (e.g., very jumpy, startle easy by noises) (AllPsych, 2011, PTSD).

Axis II

Axis II disorders include developmental disorders such as autism or mental retardation and personality disorders. There is substantial evidence that Tori J. may suffer from either antisocial personality disorder or borderline personality disorder. However, for antisocial personality disorder, one of the diagnostic criteria is a pattern of behavior existing after the age of 15, which is not applicable to Tori J. At this time. However, if her behavior continues, it is likely that she will eventually receive this diagnosis, because she engages in unprovoked violence, fails to comply with norms (such as completing school work), is very manipulative, and engages in impulsive behavior:

The symptoms of antisocial personality disorder include a longstanding pattern (after the age of 15) of disregard for the rights of others. There is a failure to conform to society's norms and expectations that often results in numerous arrests or legal involvement as well as a history of deceitfulness where the individual attempts to con people or use trickery for personal profit. Impulsiveness is often present, including angry outbursts, failure to consider consequences of behaviors, irritability, and/or physical assaults.

Some argue that a major component of this disorder is the reduced ability to feel empathy for other people. This inability to see the hurts, concerns, and other feelings of people often results in a disregard for these aspects of human interaction. Finally, irresponsible behavior often accompanies this disorder as well as a lack of remorse for wrongdoings (AllPsych, 2011, Antisocial).

However, while antisocial personality disorder is a possibility, there is also a strong likelihood that she is suffering from borderline personality disorder. Not only do many of her symptoms align with this diagnosis, but so does her history. Females are more likely than males to receive a diagnosis of borderline personality disorder, and childhood sexual abuse and neglect are both linked to the diagnosis (AllPsych, 2011, Borderline). Tori J.'s erratic behavior has contributed to instability in her relationships, which makes this diagnosis seem possible:

The major symptoms of this disorder revolve around unstable relationships, poor or negative sense of self, inconsistent moods, and significant impulsivity. There is an intense fear of abandonment with this disorder that interferes with many aspects if the individual's life. This fear often acts as a self-fulfilling prophecy as they cling to others, are very needy, feel helpless, and become overly involved and immediately attached. When the fear of abandonment becomes overwhelming, they will often push others out of their life as if trying to avoid getting rejected. The cycle most often continues as the individual will then try everything to get people back in his or her life and once again becomes clingy, needy, and helpless (AllPsych, 2011, Borderline).

Axis III

Axis III refers to the physical condition of the person. Although Tori J.'s early medical history is incomplete, there is no indication of any physical condition that would contribute to a problem. She is in good physical condition for a girl her age. She is in the normal range for height and weight and has no known health or physical problems. She has recently begun menstruating, so that hormones may be impacting her behavior. However, there is significant evidence of maternal drug and alcohol usage and no indication that Tori J.'s birth mother was sober while pregnant. While the substances used, if any, are not known, it is possible that this impacted Tori J.'s biological condition.

Axis IV

Axis IV examines the severity of psychosocial stressors. Tori J. has a history of significant psychosocial stressors: she was abandoned by both parents, sexually abused, neglected, physically abused, and placed in a foster home. Her current foster parents are both loving, but Tori J. reports a significant amount of marital conflict in the home. This conflict has been witnessed by this author. This creates a tremendous amount of stress in the home, which increased Tori J.'s stress.

Axis V

Axis V examines the person's highest level of functioning. Tori J. is a school student, so that her functional expectations are: completing school work, turning in school work, interacting with her teachers, interacting with her family, and forming peer relationships. She does not complete the majority of her school work and has failed two prior grades. However, she has not engaged in self-directed violence or in violence with a substantial risk of harm to others. As a result, it seems that her GAF score would probably be in the 31-40 range. A GAF score in the 31-40 range indicates a major impairment in several areas, and Tori J. has major impairment in social and school functioning.

Macro Analysis

Tori J. is connected to a loving foster/foster family, which consists, not only of her parents, but also of a network of aunts, uncles, and cousins. She is a white, protestant female in a community that is white and protestant. Her outward appearances make her indistinguishable from the surrounding community. However, the seeming support of her community is somewhat misleading. Her foster family is involved in a moderately fundamental church community that believes in the Bible as the word of God. Given the numerous biblical passages that suggest that rape is not an offense against the victim but against her father or husband, this religiosity could actually reinforce Tori J.'s feelings that she somehow deserved any sexual abuse she received. As a result, I think this is a macro weakness. However, the state is not prohibited to discriminate on the basis of religion, so there may not be a realistic solution to this macro weakness. Moreover, the middle-class suburban atmosphere in which she currently lives is sufficiently different from the impoverished community that Tori J. experienced as a child that she may not feel as if she can discuss any of the circumstances of her childhood. However, the educational and social opportunities linked to the increase in financial status are, overall, a macro strength.

Intervention that went well

Although very well intentioned, Tori J.'s foster family, particularly her mother, engage in a high-control style that results in Tori J. not being able to exercise a lot of control in her life. One of the interventions that Tori J.'s school counselor suggested was for Tori J. To always be given a choice of at least two alternative behaviors. For example, rather than instructing Tori J. To brush her teeth, her foster mother was told to give her the option of "brushing her teeth first and then taking her shower or taking her shower first and then brushing her teeth." Every instruction was to be given as a choice between two alternatives. Tori J.'s teachers have also, to the extent possible, changed their approach to her so that they would be giving her choices as well.

Although presenting Tori J. with choices does not always result in complete compliance with expectations and norms, it does result in a higher compliance rate than when she is simply told to do something. This makes sense in light of the known history of physical abuse and the strongly suspected history of sexual abuse. "Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning" (Herman, 1997, p.33). This seems to be especially true for sexual assault victims, who lose the right to control their own bodily autonomy during the assault.

Intervention that went less well

In many ways, I would suggest that Tori J.'s removal to a foster home, which hopes to eventually become an adoptive home, is an intervention. In terms of her physical safety, this intervention has gone very well; she is not in any physical danger in her new foster home. However, from an adjustment and psychosocial perspective, I believe that this intervention, on its own, has not done very well. Tori J.'s foster mother is the biological mother of two other children and the foster mother for three children (Tori J. And two of her biological siblings). By all reports, she is a loving, non-violent woman with a long history of positive community involvement. However, Tori J.'s behavior has been aimed at transforming their relationship into an antagonistic one. She repeatedly provokes her foster mother, going so far as to use physical violence and threats against her. This has resulted in the foster mother feeling many negative emotions, including fear and resentment, towards Tori J. The foster mother has also imposed an increasingly controlling regime, in an effort to stem the negative behaviors by Tori J., which only increased Tori J.'s negative behaviors towards her foster mother.

This result is not actually a surprise. On the contrary, this pattern could and should have been anticipated by mental health professionals. "The youngster who has internalized the abusive object relationship will provoke peers and authority figures into the same abusive relationship as the original abusive object. They often will reject and abuse good external objects who offer support, empathy, or nurturance" (Seinfeld, 1989, pp.42-43). However, Tori J.'s foster mother was not warned of this probable reaction. Although told to expect some problems, I do not feel as if they were adequately prepared to deal with the extent of the problems presented by Tori J. Moreover, although the state has continued to provide supportive care, it has not provided on-going training for the foster family to enable it to deal with the developments in Tori J.'s personality as she ages.

While this intervention has not gone as well as it could have been if Tori J.'s foster mother had been given better preparation to parent her, it has not been an absolute failure. Tori J.'s foster mother may be strict with her, but has formed a loving relationship with her, despite the negative emotions that she also feels. It is actually the presence of this loving relationship that led to the elimination of a possible reactive attachment disorder (RAD) diagnosis, which is common in children whose circumstances are sufficiently abusive to necessitate removal . "If a child has RAD, the lack of connection and attachment goes both ways…As a result, these children are difficult to work with because their lack of interest in other people and their inability to empathize makes them hard to like. Interacting with them feels empathy, not engaging" (Perry & Szalavitz, 2008, pp.206-207.) However, Tori J.'s foster family feels highly engaged in their relationship with her and like her. Although this affection has not been sufficient to fix Tori J.'s behavior, it has helped guide her diagnosis and point the way to different interventions.

It is difficult to suggest a better intervention in this scenario, because removal from the birth parent home was necessary. Tori J. was in immediate danger of continued physical and sexual abuse, so that her removal from the home was necessary. Furthermore, placement in a foster home environment meant that she could stay with her male siblings and be placed in a family environment. However, better training and preparation for potential foster parents would help foster parents know how to deal with a child who attempts to elicit the same abusive relationship from foster parents that existed in a traumatic home. Had her foster family been better prepared for some of Tori J.'s behaviors, they may have sought formal intervention at an earlier point in time and not reacted as they would have with a child who had not experienced trauma.