This case study presents a DSM-IV multiaxial assessment of a 12-year-old girl in foster care with a documented history of physical abuse, neglect, and suspected sexual abuse. The paper works through all five diagnostic axes — from clinical syndromes including PTSD to potential personality disorder trajectories, physical health considerations, psychosocial stressors, and global functioning — before examining macro-level environmental factors. It then evaluates two interventions: a choice-based behavioral strategy that produced measurable gains in compliance, and the foster placement itself, which yielded mixed results. The paper concludes with a discussion of transference and countertransference dynamics and a recommended treatment plan emphasizing autonomy, educational restructuring, and ongoing trauma-informed care.
The paper exemplifies differential diagnosis reasoning: rather than settling on a single label, it considers multiple competing diagnoses (PTSD, borderline personality disorder, antisocial personality disorder, reactive attachment disorder), explains why each is or is not applicable, and uses both behavioral evidence and demographic/historical risk factors to narrow the field. This mirrors the reasoning expected in graduate-level clinical social work and psychology programs.
The paper opens with a detailed case narrative, then moves into formal diagnostic analysis organized by DSM-IV axis. A macro-level environmental analysis follows, succeeded by a comparative evaluation of two interventions. The paper closes with personal reflection on transference dynamics and a concrete treatment recommendation. This progression — from assessment to analysis to reflection to planning — mirrors standard clinical case report structure.
The student at the center of this case study is a 12-year-old girl who was removed from her family at age 8 and placed with a foster family. Although her foster mother reported some episodes of violence and defiance in the home, the student was not initially violent or defiant at school. However, she frequently failed to complete her assignments, instead spending long periods simply staring into space. She also spoke regularly to social workers and school counselors about problems in her foster home, including allegations that she was not being fed sufficiently, that her foster family would not purchase school supplies for her, and that there was emotional and physical abuse in the home. These allegations were reported and determined to be unsubstantiated; however, allegations of emotional abuse, physical abuse, and neglect in her biological family home were substantiated, and the children were removed on those grounds.
Interviews with the student's older brother revealed that her birth mother — a known prostitute — had allowed clients access to the student on repeated occasions. The student herself refuses to confirm or deny these allegations. Whenever she is asked questions about any type of sexual abuse, she puts her head down, closes her eyes, and pretends to sleep. As she has gotten older, she has begun engaging in violent behavior. The behavior is unpredictable: she does 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 displays highly manipulative behavior.
The student has received a number of different diagnoses over her lifetime, a situation complicated by the fact that she has been in the foster care system and has seen a large number of mental health professionals, none of them for lengthy periods of time. She has never received a definitive diagnosis. Funding concerns have further limited access to the full range of diagnostic tools. The four basic tools for psychological assessment include norm-referenced tests such as the MMPI, clinical interviews, behavioral observations, and informal assessment (Framingham, 2012). The student has never taken the MMPI or any similar psychological testing instrument. As Framingham (2012) notes, "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 is therefore important to keep in mind that the diagnosis discussed here is informal.
The DSM-IV organizes diagnosis across five axes. Axis I addresses clinical syndromes — what many people consider traditional mental illnesses. Axis II covers developmental and personality disorders. Axis III examines the person's physical condition. Axis IV assesses the severity of psychosocial stressors. Axis V evaluates the person's highest level of adaptive functioning. Taken together, the five axes are intended to provide a comprehensive picture of the patient's current functioning and expected functioning under present circumstances (AllPsych, 2011, DSM-IV).
Because the student refuses to discuss the documented prior abuse, yet engages in seemingly unpredictable violent behavior and appears to exhibit symptoms of depression, one possible diagnosis is Post-Traumatic Stress Disorder (PTSD). Because she was an abuse victim, she meets the necessary trauma criterion that distinguishes PTSD from generalized anxiety disorder. According to AllPsych (2011), PTSD symptoms include re-experiencing the trauma through nightmares, obsessive thoughts, and flashbacks — a sensation of actually being in the traumatic situation again. There is also an avoidance component, in which the individual avoids situations, people, or objects that serve as reminders of the traumatic event. Finally, there is generally heightened anxiety, possibly accompanied by an exaggerated startle response (AllPsych, 2011, PTSD). All of these features are consistent with the student's observed behavior, particularly her refusal to engage with questions about sexual abuse.
Axis II disorders include developmental disorders such as autism spectrum disorder or intellectual disability, as well as personality disorders. There is substantial evidence that the student may suffer from either antisocial personality disorder or borderline personality disorder. Regarding antisocial personality disorder, one of the diagnostic criteria is a pattern of behavior that must exist after the age of 15 — a criterion that is not yet applicable to the student. However, if her behavior continues, it is likely that she will eventually receive this diagnosis, given that she engages in unprovoked violence, fails to conform to behavioral norms such as completing schoolwork, displays marked manipulativeness, and acts impulsively.
The DSM-IV criteria for antisocial personality disorder describe a longstanding pattern — present after age 15 — of disregard for the rights of others, failure to conform to social norms, a history of deceitfulness, impulsiveness, irritability, and physical assaultiveness. A major component of the disorder is a reduced capacity for empathy, which often produces a disregard for others' feelings and concerns. Irresponsible behavior and a lack of remorse for wrongdoing also typically accompany the diagnosis (AllPsych, 2011, Antisocial).
However, there is also a strong likelihood that the student is suffering from borderline personality disorder. Not only do many of her symptoms align with this diagnosis, but so does her personal 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 condition (AllPsych, 2011, Borderline). The student's erratic behavior has contributed to instability in her relationships, which makes this diagnosis particularly plausible. The major symptoms of borderline personality disorder revolve around unstable relationships, a poor or negative sense of self, inconsistent moods, and significant impulsivity. There is an intense fear of abandonment that interferes with many aspects of daily life — a fear that often acts as a self-fulfilling prophecy, as individuals cling to others, feel helpless, and become immediately and overly attached. When the fear of abandonment becomes overwhelming, they will often push others away as if trying to avoid rejection, only to then do everything possible to bring those people back (AllPsych, 2011, Borderline).
Although the student's early medical history is incomplete, there is no current indication of any physical condition that would contribute to her psychological symptoms. She is in good physical health for a girl her age, falls within the normal range for height and weight, and has no known health problems. She has recently begun menstruating, so hormonal changes may be influencing her behavior to some degree. However, there is significant evidence of maternal drug and alcohol use during pregnancy, and no indication that the birth mother was sober while pregnant. The specific substances used, if any, are unknown, but prenatal exposure remains a possible biological factor affecting the student's development.
Axis IV examines the severity of psychosocial stressors. The student has a history of significant stressors: she was abandoned by both parents, sexually abused, neglected, physically abused, and placed in foster care. Her current foster parents are both loving, but the student reports a significant amount of marital conflict in the home — conflict that has been directly witnessed by this author. This ongoing tension creates a substantial source of stress that compounds the student's existing difficulties.
Axis V examines the person's highest level of adaptive functioning. As a school student, the functional expectations for the student include: completing and submitting schoolwork, interacting appropriately with teachers, functioning within her family, and forming peer relationships. She fails to complete the majority of her schoolwork and has been held back two grades. However, she has not engaged in self-directed violence or in violence carrying a substantial risk of serious harm to others. Based on these factors, her Global Assessment of Functioning (GAF) score would likely fall in the 31–40 range, which indicates major impairment in several areas. The student demonstrates major impairment in both social and academic functioning.
AllPsych. (2011). Antisocial personality disorder. Retrieved July 2, 2013, from
AllPsych. (2013). Borderline personality disorder. Retrieved July 2, 2013, from
AllPsych. (2011). Diagnostic and statistical manual of mental disorders, fourth edition. Retrieved July 2, 2013, from
AllPsych. (2011). Post-traumatic stress disorder (PTSD). Retrieved July 2, 2013, from
Chu, J. (1988). Ten traps for therapists in the treatment of trauma survivors. Dissociation, 1(4), 24–32.
Framingham, J. (2012). What is psychological assessment? Retrieved July 2, 2013, from PsychCentral website:
Herman, J. (1997). Trauma and recovery: The aftermath of violence. New York: Penguin Books.
Perry, B., & Szalavitz, M. (2008). The boy who was raised as a dog and other stories from a child psychiatrist's notebook. New York: Basic Books.
Seinfeld, J. (1989). Therapy with a severely abused child: An object relations perspective. Clinical Social Work Journal, 17(1), 40–49.
Van Dernoot Lipsky, L., & Burk, C. (2009). Trauma stewardship: An everyday guide to caring for self while caring for others. San Francisco: Berrett-Koehler Publishers.
Waska, R. (1999). Projective identification, countertransference, and the struggle for understanding over acting out. Journal of Psychotherapy Practice and Research, 8(2), 155–161.
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