Case Study: Teddy Assignment

CASE STUDY ASSIGNMENT INSTRUCTIONS

OVERVIEW

Each Case Study Assignment is an APA-style formatted, 35-page assignment designed to help

you apply the course content, including the DSM-5-TR, to a fictional case example. This will not

require an abstract. You will need a minimum of 7 peer-reviewed scholarly resources; one of

these may be the course textbook. All resources need to be less than 10 years old. The 3-5 pages

exclude the title page and reference page.

In this Case Study Assignment, you will have the opportunity to think through a clinical case,

identify and prioritize key imperative issues involved, consider and clarify relevant diagnostic

concerns, provide at least one assessment to substantiate the diagnosis, and formulate beginning

treatment recommendations. This Case Study Assignment will directly apply to your future

coursework in diagnosis and treatment planning, which is also included in field experience

classes.

Be sure to review the Case Study Grading Rubric and the Case Study Template before

beginning this Case Study Assignment.

Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.

INSTRUCTIONS

For this assignment, you will read the case study and then generate a report that uses the

assignment template.

INTRODUCTION TO THE CASE STUDY (1-2 statements) introducing the case.

Client Concerns

Biological factors Psychological Social/Cultural Spiritual

Physical symptoms, for

example: neurological,

past, present impact

Past and present

Ideas, thoughts,

feelings, beliefs,

values about self,

others, and the

world

Past and present

Family systems

Relationships with

others

Cultural elements

Past, present

Religious and

spiritual aspects of

self/family, Past,

present

Trouble sleeping hopelessness Early parent

relationships avoidant

Attends church weekly

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Headaches Ongoing worry and

ruminating

Loss of colleagues

when retired

Would like to explore

more prayer time and

spiritual connection

Muscle tension Fear of things bad

happening

Divorced Grew up with mother

who used religion

against her

Genetic predisposition

with parent with similar

features reported

Sees the world as

glass half empty

Adheres to strict

animal rights group

ideology

Each section should be separated by the appropriate APA headings (Level 1, Level 2…)

Client Concerns

Using a table as in the example above, complete each column to identify and list the

clients symptoms and any other key issues/concerns noted. (Modify the chart size as needed.)

For example, these include biological, psychological, social, and/or spiritual problems. If

symptoms/behaviors overlap, you only need to list them once.

Assessment

Provide at least one assessment that will be used to substantiate the diagnosis you chose –

a valid assessment that a counselor can use. (Note this means it has high reliability and validity

for the sample population you are hoping to administer it to.) Please be sure to cite support for

the assessment tool you use by using one peer-reviewed journal article to reference your choice

of assessment. Give a short (3-5 sentences) overview of the assessment, what it would help you

learn about the client, and why you chose it over other assessments (for example: Beck

Depression Inventory: identifies clinical depression, strong research base, its internal

consistency – around 0.9 – indicates that the items relate to each other and measure the same

construct. Test-retest reliability ranges from 0.73 to 0.92, suggesting consistent scores over

time. It is also short, easy to administer, and score).

Diagnostic Impression

Provide the primary diagnostic impression based upon the DSM-5-TR. Be sure to use the

full code and full name for each diagnosis. Start with an introduction statement or two as

illustrated in the template. Be sure to consider secondary disorders in addition to the primary

disorder. Is there more than one diagnosis? Provide the following for all diagnoses.

Signs and Symptoms

List the signs (clients report) in the right hand column of the chart and link them directly

to the symptoms (criteria you find in the DSM-5-TR) in the left hand column of the chart

(example below) to make sure you have linked every client symptom to every DSM-5-TR

symptom. This is to substantiate your choice for diagnosis. Be sure to adjust the size of the table

accordingly. If there are client-reported signs that do not fall into the DSM-5-TR diagnosis, make

note that you considered them, but they did not align with the DSM-5-TR.

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DSM-5 Diagnostic Criteria for your TOP

CHOICE of dx you are giving disorder name

and code number. Note: this should align with

your DSM-5

Clients Signs/Reported Symptoms from case

study:

Criterion A:

Criterion B:

Criterion C:

Criterion D:

Criterion E:

Criterion F:

Other DSM-5 Conditions Considered

List other DSM-5 conditions you considered and the process you went through to decide

they were not the correct diagnosis. For example: The client reported three symptoms of Major

Depressive Disorder, but five symptoms are needed for this diagnosis, so the disorder was ruled

out.

Developmental Theories and/or Systemic Factors

Consider a developmental or systemic perspective as you conceptualize your client. For

example: What stage is the client in within Eriksons Stages of Developmental theory? or

What is occurring within the clients family system that may be influencing the clients current

functioning or behavior?

Multicultural Competencies and Considerations

Discuss multicultural considerations that may be relevant to your client. For example,

what would the client say about their symptoms/situation from their cultural point of view? How

might you apply cultural competencies in your understanding of the client? Cite one peer-

reviewed counseling source to support your point.

Treatment Recommendations

Key Issues for Treatment

In bullet point form, identify the top 2-3 symptoms/issues you believe are imperative to

the client in the case study. Be sure to list in order of importance. For example, 1.

Suicidal ideation 2. Extreme anxiety/depression symptoms such as X, Y, Z

3. Interpersonal distress regarding relationships with immediate family

The goal here is to clearly delineate what you believe is most time sensitive to address to

be of support to the client.

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Recommendations for Counseling

Identify two evidence-based treatment recommendations for counseling based on the 2-3

key issues you identified. For example, if you are seeing crisis symptoms, what theory is

identified in the literature as best practices for Crisis Intervention Counseling that you might

choose? If you see anxiety symptoms, what theoretical evidence-based theory and or

interventions might be best suited to support the client?

You will need to cite these recommendations using peer-reviewed journal articles,

focusing on the treatments a counselor would provide. Consider if a medication referral or

medication evaluation is recommended, and if so, support why you believe this to be the case

with a peer-reviewed scholarly citation.

Specific Considerations

For each case study, you will have additional critical thinking points to consider. You

will need to provide one paragraph, with source support, responding to the question assigned to

each case that corresponds with the list below. In your response to these questions, address how

these considerations affected your diagnostic impression and your treatment recommendations.

Amelia Case Study 1:

What additional information would you need about her culture and why? What kinds of value

conflicts might you experience due to the clients culture? How would you manage your personal

values while working with this client?

Shelia Case Study 2:

How does a client in crisis change the focus of your assessment and treatment planning? What

suicide assessment tool would be best to use with her, given the ethical and legal requirements

counselors have?

Jake Case Study 3:

How do multiple diagnoses affect the decision-making process for diagnostic impressions and

treatment planning? How does a substance use disorder affect the process of diagnostic

impressions and the order you make treatment recommendations? What are the unconscious or

conscious biases to consider when you are personally working with Jake?

Teddy – Case Study 4:

How does the clients experience of a triggering event inform your conceptualization process?

How might you collaborate with this client when treatment planning? What are some barriers

you might encounter in the treatment planning process with this client, and how might you

address those barriers?

Vince Case Study 5:

How might the clients age affect diagnosis and treatment recommendations? What kind of

consideration must be made for the family system, and how does it impact your entire

conceptualization of the client?

Case Study Assignment

Student Name

School of Behavioral Sciences, Liberty University

Author Note

“Insert full name here. Include ORCID number in URL format if you have one.”

I have no known conflict of interest to disclose. “<Disclose conflicts, if any>”

Correspondence concerning this article should be addressed to “Insert Student’s Full

Name” . Email: <Insert Your LU Email>

CASE STUDY ASSIGNMENT 2

Case Study Assignment [Case Name]

Write brief introduction to the case here (1-2 sentences)

Client Concerns

Biological factors Psychological Social/cultural Spiritual

Physical symptoms, for

example: neurological,

past present impact

Past and present

Ideas, thoughts

feelings, beliefs,

values about self,

others the world

Past and present

Family systems,

Relationships with

others,

Cultural elements

Past, present

Religious and spiritual

aspects of self/family

Past present

Assessment

Diagnostic Impression

Signs and Symptoms

DSM-5-TR Diagnostic Criteria: disorder name

and code number

Clients Signs/Reported Symptoms from case

study:

Criterion A:

Criterion B:

Criterion C:

Criterion D:

Criterion E:

Criterion F:

CASE STUDY ASSIGNMENT 3

Other DSM-5-TR Conditions Considered

Developmental Theories and/or Systemic Factors

Multicultural Competencies and Considerations

Treatment Recommendations

Key Issues for Treatment

One

Two

Recommendations for Counseling

Specific Considerations

CASE STUDY ASSIGNMENT 4

References

TEDDY CASE STUDY

Teddy is a 6-year-old African American male who is currently in first grade. He is an only child

and lives with his parents in a suburban neighborhood in the Midwest. Teddy was reportedly

referred to the clinic due to “behavioral and emotional difficulties”, noted by his parents and his

teacher. Teddy’s parents expressed concerns about his sudden changes in mood, frequent waking

in the night with nightmares, and difficulty participating in social activities. When asked why he

is at the clinic, Teddy reported, “I was scared I was going to die.” Teddy’s parents reported that

the family experienced a near head-on auto collision about six months ago.

Teddy recalled he was sitting on his booster seat, in the backseat of the family vehicle, playing a

handheld video game, when his father was driving the family home from dinner one night. “It

was very scary, I crashed on my Nintendo game and in real life!” Teddy’s mother reported she

was yelling at Teddy to stop playing his game since he had already reached his daily screen time

limit, and his father was yelling at his mother to stop yelling while he was driving, and they were

reportedly also “running late”. His mother stated they were driving on a two lane, 55-mile-per-

hour road and were approximately five miles from home when she noticed an oncoming vehicle

swerving toward them. Teddy remembered the sound of his mother screaming as the oncoming

car’s headlights crossed over into their lane. Teddy’s father quickly swerved to the right to avoid

hitting the car head-on, and their car veered off into the ditch along the road. When the car hit the

ditch, it flipped over and landed upside down. Teddy reported that all he remembers is that his

video game went flying and hit the shattered windshield. Teddy’s mother reported that all three

of them were wearing their seatbelts. Both front airbags deployed, resulting in Teddy’s mother

receiving a bloody nose. Both mom and dad report feelings of stress and irritability since the

accident, off and on. Initially, the three of them struggled to move from the overturned vehicle,

and Teddy’s mother recalled that some other passersby stopped to help them out of the vehicle.

One of the passersby called 911, and Teddy and his parents were transported to the hospital by

ambulance. Upon assessment at the local hospital, Teddy’s parents were treated for broken ribs

and contusions. The doctors reported it was a miracle that Teddy did not have any physical

injuries, other than some bruising from the seat belt. The family later learned that the driver of

the oncoming car had been under the influence of alcohol, with a blood alcohol content level

twice the legal limit.

Since the accident, Teddy’s parents have noticed several symptoms concerning their son. He

reportedly often experiences nightmares in which he is in a car that is about to crash into another

car. Teddy reported that he always wakes up right before the crash. He stated this makes it

difficult to fall asleep because he is afraid, and when he wakes up due to a nightmare, he has

difficulty falling back asleep again. Teddy’s mother reported that when he has a nightmare, he

will wake her or his father to sit with him until he can fall asleep again. Teddy frequently appears

restless, fidgeting, and having difficulty sitting still. Teddy has also become more withdrawn and

no longer engages in activities that he used to think were “fun.” His mother reported that she

bought him a new video game after his game was destroyed in the accident, but he has not

played with it yet, and often he prefers to play with his live action toys in his room alone. She

stated she is surprised, as she used to have trouble getting him to reduce his screen time, and now

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she almost wishes that she had that problem again. It appears he is afraid that he caused the

accident because his mom was yelling at him about playing his game too much, and now he is

afraid something bad will happen again if he plays the video game. Teddy shared, “I don’t think

that’s a good idea, to play that game, it was bad and made the cars crash!” Now, when they are in

the car, Teddy always sits in the middle of the backseat, “so he can help Mom and Dad watch for

cars coming at them.” Sometimes it is a struggle to get him to go places due to his “worry”.

Teddy’s mother reported she has never seen a child pay that much attention to the road; Teddy

says, “I just want to look out for my parents when they’re driving.” When the family is driving on

a two-lane road and an oncoming vehicle is approaching, Teddy screams and covers his head

with his hands, even when the vehicle is in its own lane. Teddy’s father noticed that Teddy

doesn’t do this when they are driving on the interstate or a divided highway, and so he has tried

to alter their routes in order to avoid driving Teddy on a two-lane road.

Teddy’s parents have received messages from his teachers noting a decline in his academic

performance. Teddy was an honor roll student during the first quarter of first grade. At his most

recent parent-teacher conference (one month ago), Teddy’s teacher reported that Teddy has been

having trouble completing his work at school and usually appears distracted. The teacher noted

that recently he has struggled with sitting quietly and reading during the class reading time. He

has also had difficulty completing spelling worksheets. During recess, instead of playing with the

other students in class, he has begun playing with Matchbox and Hot Wheels cars. His teacher

noticed that Teddy used to be very social and engaged easily with the other children in the

classroom. Now, when he is playing, he is focused on the cars, slamming them together

aggressively and then flipping them over. His teacher saw other kids backing away from him as

if they didn’t want to get hit with a flying car, and she had to reprimand him to not play with the

toys so aggressively.

Teddy’s parents are Jehovah’s Witnesses, and while Teddy attends weekly meetings with them,

he has not yet been baptized, as his parents believe he is too young to make that decision for

himself. Teddy’s mother noted that since the accident, Teddy has not asked to visit with his

friends at their Kingdom Hall. He has also had difficulty sitting throughout the meetings; his

mother reported he often claims he needs to use the restroom, sometimes leaving as often as

three times in an hour.

Teddy’s mother reported that Teddy has no significant health problems or history of surgeries,

has reached all his developmental milestones, and recently had a visit with the family’s

pediatrician. Teddy is not currently prescribed any medications and has never been exposed to

alcohol or other substance use. The pediatrician referred them to the clinic, stating that Teddy

may benefit from counseling. Teddy’s mother stated her husband’s insurance will cover six

sessions of counseling, but she is unsure about continuing treatment after that.

Case Study Grading RubricDownloadCriteriaRatingsPtsClient Concerns

view longer description

20 to >18 pts

Advanced

Client concerns/key issues are noted from the case study. The important symptoms, behaviors, and stressors are identified. Sufficiently identified the client concerns as presented in the case.

18 to >16 pts

Proficient

Identifies most of the client concerns in the case; 1 or 2 concerns (symptoms, behaviors, and/or stressors) may be missing.

16 to >0 pts

Developing

Identifies few of the client concerns in the case; 2 or more concerns (symptoms, behaviors, and/or stressors) are missing.

0 pts

Not Present

/ 20 pts

Assessment

view longer description

5 to >4 pts

Advanced

Assessment is clearly stated. Rationale for assessment includes what information assessment will provide, professional literature support for use of assessment and what made assessment a better choice than others available. One professional citation given.

4 to >3 pts

Proficient

Assessment is stated. Missing 1-2 parts of rationale or rationale is weak. Citation is older than 10 years or from questionable source.

3 to >0 pts

Developing

Assessment is stated. Missing more than 2 part of the rationale and rationale is weak. Missing citation.

0 pts

Not Present

/ 5 pts

Diagnostic Impressions

view longer description

25 to >20 pts

Advanced

The diagnosis and a rationale for the diagnosis are included and appropriate (or only minor errors). Link between symptoms and DSM criteria clearly provided. Differential diagnoses are reviewed and discussed. In addition to the main disorder, additional diagnoses are also considered (that the client may have more than one diagnosis), examined, and discussed. Developmental Theories and/or Systemic Factors and Multicultural Considerations are addressed.

20 to >15 pts

Proficient

The initial diagnosis given is not correct but is in the correct DSM category OR Not all link between symptoms and DSM criteria addressed OR Not all the differential diagnoses are reviewed and discussed. Additional diagnoses were considered. Developmental Theories and/or Systemic Factors are partially addressed. Multicultural Considerations are partially addressed.

15 to >0 pts

Developing

The initial diagnosis is not close to the correct diagnosis, but one is given OR Link between symptoms and DSM criteria vague or missing OR Differential diagnoses were not considered OR Additional diagnoses (secondary) were not considered. Developmental Theories and/or Systemic Factors were minimally or not addressed. Multicultural Considerations were minimally or not addressed.

0 pts

Not Present

/ 25 pts

Treatment Recommendations

view longer description

25 to >20 pts

Advanced

Recommendations for treatment are included in order of importance, appropriate, and supported by the professional literature. The recommendations demonstrate the use of a collaborative approach. The rationale is linked to potential outcomes of treatment for this client. How the order of priority will contribute to a successful outcome for the client is evaluated. The recommendations are, also, relevant to the case, able to be implemented by the client, and have some basis of support from professional literature. Considerations for whether the counselor would refer for medication evaluation are discussed and supported by scholarly literature. Specific Considerations questions are thoroughly addressed.

20 to >15 pts

Proficient

Recommendations for treatment are included but order unclear or not supported. More support from the professional literature is needed. One of the suggestions may not be appropriate or primary case management. Considerations for medication evaluation are somewhat discussed but unclear or not supported. Specific Considerations questions are partially addressed.

15 to >0 pts

Developing

Recommendation order is not appropriate. There is little support from the professional literature. A significant requirement of treatment may have been missed. Recommendations primary… [Content truncated to 3000 words]

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