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O​‌‍‍‍‌‍‌‍‍‍‌‌‌‍‌‌‌‌‌‌​verview: Part 1 (50%): Diagnosis and Formulation 1. De

Part 1 (50%): Diagnosis and Formulation
1. Describe
a. key diagnoses that you would be considering, based on the information presented (explaining why) using the DSM-5 Criterion. You must use the DSM-5 Criteria for why Andrea may have the diagnosis.
b. Consider and delve into other other/comorbid diagnosis that might well need exploration base on the case information
i. Consider complex trauma – Complex trauma describes both children’s exposure to multiple traumatic events – often of an invasive, interpersonal nature – and the wide-ranging, long-term effects of this
– Please consider diagnostic considerations: DSM-5 Trauma and Stressor Related Disorders
o Reactive Attachment Disorder
o Disinhibited Social Engagement Disorder
o Acute Stress Disorder
o Posttraumatic Stress Disorder
o Adjustment Disorders
o Other specified Trauma and Stressor-related Disorders
o Unspecified Trauma- and Stressor-related Disorders
2. Present a case formulation where you summarise:
a. Presenting Problems
i. The current problem, including symptoms and the context in which they occur, distress, and impact on functioning
b. Describe hypothesised
i. Predisposing(vulnerability)
1. What may have made the person vulnerable to developing the problem(s) in the first place?
2. Factors which contributed to the individuals’ vulnerability to developing the presenting problem.
3. Biological factors, genetics, social-cultural factors
4. Thinking about factors such as family history of mental health, child temperament, and the in utero environment (eg thinking about stress).
ii. Precipitating(triggers)
1. What might have triggered the onset of the problem(s) at this time? (or triggered the current referral).
2. Factors which triggered the presenting problem, or directly preceded it
3. Trauma, life changes, stress, family problems
iii. Perpetuating(maintaining)
1. What may be keeping the problem(s) going?
2. Factors which are maintaining the presenting problems
3. Ongoing trauma, abuse, ongoing stress, ongoing family problems
4. Parenting behaviours/practices and how these might be inadvertently perpetuating the behaviour.
iv. Protective factors(strengths)
1. What are some factors within the child/the system that might help to overcome the problem(s)?
2. Factors which protect the individual against the presenting problem worsening
3. What strengths you see as existing for Andrea.
– If there is key information/further assessment that you think would be important, to clarify your diagnosis and/or your aetiological formulation, please briefly describe what this would be (and why).
– Please do not use global, confusing, and judgmental-sounding statements
– Please use relevant literature to support the formulation

Part 2 (50%): Intervention Plan
1. Present an intervention plan, to address the presenting concerns, that is evidence-informed, and that takes into account your individualised case formulation. Cite references where possible, to support your formulation and your treatment plan.
a. What would be the targets of your intervention?
b. What specific intervention strategies would you be using for each of these targets?
c. How might you sequence your various intervention components?
– Consider assessment considerations such as:
o Asking about trauma exposure as part of routine assessment
o Consider wide range of possible outcomes
o Multi-method; multi informants (NB poor parent-child concordance)
o Assess for trauma within family (and other systems)
o The child/family may not conceptualise the events as traumatic
o Hallmark avoidance – assessment is ongoing
o Developmental considerations in how difficulties will manifest
– Consider standardised assessment tools for trauma
o The Child and Adolescent Trauma Screen (CATS)
o The ULCA PTSD Reaction Index
o The Child PTSD Symptom Scale (CPSS-5)
o Clinician-Administered PTSD Scale for DSM-5: Child and Adolescent Version (CAPS-CA)
– Consider intervention(s):
o Trauma-Focused Cognitive-Behavioural Therapy (TF-CBT): the ‘treatment of choice’
? Phase 1: Stabilisation Skills – Psychoeducation and parenting, relaxation, affect expression and modulation, cognitive coping
? Phase 2: Trauma Narration and Processing – trauma narrative development and processing
? Phase 3: Consolidation/integration – in vivo mastery of trauma reminders, conjoint parent-child sessions, enha​‌‍‍‍‌‍‌‍‍‍‌‌‌‍‌‌‌‌‌‌​ncing future safety
Case Study Situation:
Andrea is a 14-year-old female who was referred to you via a recommendation from her school counsellor following reports of declining academic performance and withdrawn behaviour in recent months. Eight months ago, Andrea was physically assaulted by 2 intoxicated men; one was carrying a knife. The incident occurred on a dark and quiet platform at a train station at night. Andrea sustained lacerations and bruises to various parts of her body in the attack, and still has a small scar on one cheek.

Andrea lives with her mother and her two 2 half-brothers (8y.o.; 10y.o.). She no longer has contact with her father nor her stepfather. There is a history of family violence in the household: both Andrea’s father and stepfather were violent towards her mother. Andrea’s mother Jenny has been diagnosed with depression and PTSD. Andrea attended Child and Adolescent Mental Health Services (CAMHS) when she was in primary school for assistance with the management of “suspected ADHD” and school refusal.

Currently, Andrea is having flashbacks and intrusive memories and thoughts about her assault, reporting that she is spending a great deal of energy “trying to push them away”. Andrea describes her sleep as “terrible”. She often wakes through the night. She has nightmares 3 or 4 nights a week about “people hurting me or coming to get my little brothers”. Because of her nightmares, Andrea is very reluctant to go to bed and to go to sleep; she ‘mucks around’ every night on her phone until she falls asleep – this often takes several hours. She often wakes up in the middle of the night with the light still on and the phone still in her bed.

Andrea describes her mood as “stressed out”. She feels as though she is constantly “jumping out of my skin”, especially when she hears an unexpected noise. Andrea describes being “on guard all the time”, because she believes that it’s “never safe to relax”, because “nowhere is safe” and “men can’t be trusted”. With some assistance, Andrea is able to identify a variety of people/situations that trigger what she describes as feelings of “panic”; she has strong associated physical reactions (heart racing, tight chest, shortness of breath, ‘butterflies’ in the stomach). These situations include: seeing groups of men, seeing people wearing hoodies, teachers raising their voices, people coming close to her, intoxicated people, and “when people are acting crazily”.

Andrea is struggling to concentrate, and feels “unmotivated to study”. She is spending a lot of time at home, is seeing very little of her friends, and has stopped going out at all at night-time. She was formerly a keen runner, but is no longer doing this. Andrea is avoiding catching public transport, and when walking during the daytime, is going out of her way to walk only down main roads, and to steer clear of deserted streets.

Andrea described having become “obsessed with charging my phone and checking it’s with me”. Several times a day she “checks in” with her mother and siblings about their plans and their whereabouts. She has been arguing with her brothers more than usual. Andrea is showering 3 or 4 times some days, and also noted (with a wry sense of humour) that “I’ve become obsessed with tidying my room”.

Andrea says that she “constantly” feels anxious when she’s out and about. She feels “embarrassed” about the attack – because, she says, “I should have seen it coming” and “shouldn’t have let my guard down”. Andrea has started to feel quite “down” over the past few weeks, and is feeling somewhat hopeless about the future, sharing with you her view that “I’ll never be the same again” and “this has damaged me forever”. Last week, for the first time, Andrea has started to cut her thighs, superficially, with a razor blade. She has been thinking a lot about death – e.g., “wondering whether I will live a long life” and “thinking about what the afterlife might look like”.

Jenny is concerned about her daughter’s wellbeing, but is also unsure how best to help her. She is reluctant to bring up the topic of the assault with Andrea “because I don’t want to re-traumatise her”. She feels guilty that this happened to her daughter, and blames herself for “not ​‌‍‍‍‌‍‌‍‍‍‌‌‌‍‌‌‌‌‌‌​protecting her”. Jenny has started driving Andrea to activities when possible, “so that she stays safe and doesn’t have to worry about being attacked again”.

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