Child and Adolescent Psychopathology A Casebook

Child and Adolescent Psychopathology
Fourth Edition
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Child and Adolescent Psychopathology
A Casebook
Fourth Edition
Linda A. Wilmshurst
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Library of Congress Cataloging-in-Publication Data
Names: Wilmshurst, Linda, author.
Title: Child and adolescent psychopathology : a casebook / Linda A. Wilmshurst, Elon University.
Description: Fourth edition. | Thousand Oaks : SAGE, [2018] | Includes bibliographical references and index.
Identifiers: LCCN 2017027063 | ISBN 9781506349350 (pbk. : alk. paper)
Subjects: LCSH: Child psychopathology—Case studies. | Adolescent psychopathology—Case studies.
Classification: LCC RJ499 .W46 2018 | DDC 616.8900835—dc23 LC record available at https://lccn.loc.gov/2017027063
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Cover Image: Rachel Wilmshurst (www.rachelwilmshurst.com)
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Contents
Preface
Acknowledgments
About the Author
1 Introduction: Understanding the Complexities of Child and Adolescent Psychopathology
1 Terry Hogan: The Avoidance Trap (10 years old) Developing a Case Formulation
2 Jeremy Jones: Mommy and Me and Grandma Makes Three (6 years old) Developing an
Intervention Plan
3 Neesha Wilson: Phoenix Rising (10 years old) Risks, Protective Factors, and Psychological
Well-Being
2 Introduction to Neurodevelopmental Disorders
Part A: Problems of Attention and Specific Learning Disorders
4 Colby Tyler: Attention Problems or Distracted by Life? (14 years old) ADHD; Gifted; Divorce
5 Thomas McLearn: Read Me a Story (10 years old) Dyslexia
6 Sandy Smith: Marching to the Tune of a Different Drummer (8 years old) Nonverbal Learning
Disability
Part B: Autism Spectrum Disorders (ASD) and Intellectual Disabilities (6 years old) Mild Variant of
ASD
7 Dylan Bach: The World According to Dylan (6 years old) Mild Variant of ASD
8 Arthur Watson: Won’t or Can’t: a Case of Mistaken Identity (15 years old) Intellectual
Disability; Parent Denial; Academic and Behavior Problems
9 Brian Williams: My Name Is Williams, Too (10 years old) Williams Syndrome
10 Bradley Hunter: Not Yet Diagnosed (5 years old) Neurodevelopmental Symptoms
3 Introduction to Disruptive Behavior Disorders
11 Scott Michaels: Boys Will Be Boys? (9 years old) Oppositional Defiant Disorder; ADHD
12 Tyrone Wilson: The Gang’s All Here (15 years old) Neesha’s Brother; Multifinality; Learning
and Behavior Problems; Gang Activity, Forensic Assessments; Fetal Alcohol Spectrum Disorders
4 Introduction to Anxiety and Compulsive Disorders
13 Winnie Kent: Silence Is Not Golden (5 years old) Separation Anxiety Disorder; Selective
Mutism
14 Shirley Yong: Worried to Perfection (11 years old) General Anxiety Disorder; Depression;
Relational Aggression; Cultural Conflict; Trichotillomania
15 Jordan Neeson: Let Me Count the Ways (9 years old) Obsessive-Compulsive Disorder
16 Sandra Silver: Shy or Social Anxiety Disorder (Social Phobia) (15 years old) Social Anxiety
Disorder
5 Introduction to Problems of Mood: Depression and Bipolar Disorders
17 David Steele: Hopelessness and Despair (17 years old) Adolescent Depression; Suicidal
Ideation
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18 Matthew Morgan: Out of Control and In Control (9 years old) Child-Onset Bipolar
Disorder/Mood Dysregulation Disorder
19 Jenny Sloan: The All-American Girl (16 years old) Bipolar Disorder; Suicide Attempt
6 Introduction to Disorders of Emotion and Behavior Dysregulation
20 Alex Bishop: The Slippery Slope (15 years old) Substance Use; Multidimensional Family
Therapy (MDFT)
21 Sarah Burke: Food for Thought (16 years old) Disordered Eating and Eating Disorders
22 Tori Benson: Skin Deep: Cutting Through the Pain (16 years old) Self-Mutilation; Borderline
Personality Disorder
7 Introduction to Traumatic and Stress-Related Disorders
23 Juan Hernendez: The Crash (16 years old) Posttraumatic Stress Disorder; Survivor Guilt
24 Jason Coleman: Disconnected Connections (16 years old) Conduct Disorder; Reactive
Attachment Disorder; Traumatic Childhood
25 Ericka White: Not Yet Diagnosed (10 years old)
APPENDIX A: Supplemental Case Information
APPENDIX B: Systems of Classification
APPENDIX C: Guidelines to the Interpretation of Test Scores and Assessment Information
Index
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Preface
Tell me and I’ll forget. Show me, and I may not remember. Involve me, and I’ll understand.
—Native American Proverb
The major goal of this casebook is to provide the reader with an opportunity to gain deeper insight into the
complexities of child and adolescent psychopathology and to apply this knowledge within the context of the
diagnostic framework of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013).
A case study approach is used to involve the reader in the simulated practice of child psychopathology. As
problems unfold, a dynamic illustration of a given child’s problems can be observed during several different
stages of development and from the perspective of different theoretical viewpoints. Within a developmental
context, complex problems of child and adolescent adjustment become grounded in the realities of family and
school experiences. Case studies presented in this text are especially relevant to the study of child and
adolescent psychopathology, because all cases are based on actual clinical cases. Although the cases have been
altered to maintain confidentiality, they continue to represent actual living files, and as such, provide a unique
opportunity to capture the dynamics of child and adolescent psychopathology in virtual presentations of life as
the children develop and their stories unfold before the reader’s eyes.
Cases have been selected to include a breadth of childhood and adolescent psychopathology and are
representative of the high rates of comorbidity demonstrated in this population. Each case presents an
opportunity to practice and develop clinical skills in the assessment, diagnosis, and treatment of childhood
disorders from a number of theoretical perspectives and at various levels of interest and expertise. The text is
suitable for upper level undergraduate students in its rich presentation of case materials that demonstrate
applications of many of the core concepts in child psychopathology (e.g., how therapists from differing
theoretical backgrounds would approach a given case). The text is suitable for graduate students in providing
opportunities to practice and hone clinical skills across a breadth of clinical cases with opportunities for in-
depth discussion and application in specialty areas of concentration: assessment, diagnosis, and treatment. The
text can be a valuable resource for courses in child psychopathology, abnormal child psychology,
developmental psychopathology, school psychology, behavior problems of childhood, child psychotherapy,
child assessment, and case formulation in child psychopathology.
Case studies provide diagnostic information at two levels. Case studies are presented to illustrate the
dual nature of diagnosis in its emphasis on diagnosis as case formulation (an ongoing process of
information gathering, problem solving, and hypothesis testing) and diagnosis as the formulation of an
outcomes statement (the classification or conclusion).
Case studies provide comprehensive assessment information. Case information is available from a
variety of sources (case history, observations, psychometric assessment, raw data, and clinical interviews)
and developmental contexts (individual child, family, school, and peers) to encourage students to
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develop skills in integrating information from diverse sources.
Case studies provide opportunities to develop and practice skills in case formulation. A semistructured
flexible format for case formulation is presented and demonstrated to emphasize how case formulation
can apply to a wide variety of theoretical perspectives and developmental contexts.
Each case provides an opportunity to develop case formulations that address developmental issues relative to
the case and to evaluate outcomes relative to expectations.
Case studies provide information on current research findings and conceptual issues. Questions posed at
the end of each case will challenge the reader to integrate information concerning conceptual issues or
research findings with material presented in each case.
Case studies provide information concerning evidence-based treatments. Each case is accompanied by a
discussion of current issues in treatment.
However, advanced students can also have the challenging opportunity of forging new directions in
integrating information from effectiveness studies in the development of individual intervention plans and a
“case-based” pragmatic approach to treatment (Fishman, 2000).
Case studies provide opportunities to discuss issues in classification from a variety of conceptual
frameworks and different systems of service delivery.
Case studies demonstrate unique issues in the classification of childhood disorders.
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The DSM-5 and Child and Adolescent Psychopathology
In the past, there has been considerable controversy regarding the suitability of DSM diagnostic criteria for
child and adolescent disorders. The main issues concerned whether the categorical approach used by the DSM
was suitable for conceptualizing disorders from a developmental perspective that favored a continuum of
severity (dimensional approach) and one that recognized that symptoms of disorders would manifest in
different ways throughout development. In addition, theories of developmental psychopathology often looked
to family and environmental factors that placed children at increased risk for psychopathology, such as
insecure attachment, family dysfunction, or social skills deficits. However, it is important to note that the
newly revised DSM-5 (APA, 2013) does represent significant improvement in its conceptualization and
applicability of disorders within a developmental perspective in several important ways, with increased
recognition and emphasis on the following:
Developmental and lifespan considerations. The DSM-5 has been reorganized around a lifespan
orientation, progressing from disorders that have early onset (neurodevelopmental disorders), to those
most common in adolescence and young adulthood (bipolar, depressive, and anxiety disorders), and
ultimately focusing on disorders most often associated with adulthood and later life (neurocognitive
disorders).
Comorbidity and clustering of disorders along internalizing and externalizing dimensions. The DSM-5
represents a movement away from more traditional emphasis on categorical classification towards
increased emphasis on dimensional aspects of diagnosis based on shared features, including “neural
substrates, family traits, genetic risk factors, specific environmental risk factors, biomarkers,
temperamental antecedents, abnormalities of emotional or cognitive processing, symptom similarity,
course of illness, high comorbidity and shared treatment response,” (APA, 2013, p. 12). Within this
context, the DSM-5 framework is consistent with research supporting clustering of disorders along
dimensions of internalizing (anxiety, depressive, and somatic symptoms) and externalizing factors
(impulsive, disruptive, and substance use symptoms), based on similarities in environmental and genetic
risk factors for these two dimensions.
Supporting diagnosis using dimensional cross-cutting symptoms measures. In addition to the traditional
diagnostic criteria available from the use of the categorical symptom criteria, the DSM-5 also encourages
the use of a questionnaire targeting more general symptoms common to a number of psychological
disorders and difficulties (13 domains for adults, 12 domains for children and adolescents). The adult
form consists of 23 questions in a self-report measure indicating the extent to which problems are
evident, for the 13 domains, ranging from not at all (0) to severe (4). The Parent/Guardian symptom
measure is used for children ages 6 through 17 years.
Reconceptualization of childhood disorders and unique diagnostic criteria for some disorders with onset
in early childhood. The previous category of Disorders Usually First Diagnosed in Infancy, Childhood, or
Adolescence originally housed disorders of mental retardation, learning disorders, motor skills disorder,
communication disorders, pervasive developmental disorders, attention-deficit and disruptive behavior
disorders, feeding and eating disorders of infancy or early childhood, tic disorders, elimination disorders,
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and other disorders of infancy childhood or adolescence (separation anxiety disorder, selective mutism,
reactive attachment disorder, stereotypic movement disorder). This category has been removed and a
new category, Neurodevelopmental Disorder, has been added, which includes intellectual disabilities,
communication disorders, autism spectrum disorder, attention-deficit/hyperactivity disorder, specific
learning disorder, motor disorders, and other neurodevelopmental disorders.
Separation anxiety disorder and selective mutism are now both part of the category of anxiety disorders,
while reactive attachment disorder can currently be found in the category of Trauma- and Stressor-
Related Disorders, which also contains disorders of posttraumatic and acute stress disorders, as well as the
adjustment disorders. Obsessive compulsive disorder has been moved from the anxiety disorders to a
new category of Obsessive-Compulsive and Related Disorders, which also includes such disorders as body
dysmorphic disorder, hoarding, and trichotillomania. In addition to these reorganizational features, the
DSM-5 now includes unique diagnostic criteria for posttraumatic stress disorder (PTSD) for children 6
years of age and younger, and a new diagnostic category, Disruptive Mood Dysregulation Disorder, which
has been developed as a potential alternative diagnostic category for symptoms of pediatric bipolar
disorder featuring severe recurrent (three or more times, weekly) temper outbursts (verbally or
behaviorally). Within the category of Feeding and Eating Disorders, a new diagnostic category of
“avoidant/restrictive food intake disorder” has been added, with onset most likely in early childhood.
This new disorder replaces the previous category of Feeding Disorder of Infancy or Early Childhood.
Conduct disorder and oppositional defiant disorder can be found in the category of Disruptive, Impulse-
Control, and Conduct Disorders, which also includes intermittent explosive disorder.
Risk and Prognostic Factors: In addition to providing information concerning prevalence, development,
and course, the DSM also includes specific sections on comorbidity and any available information
regarding temperamental, environmental, and genetic/physiological factors.
Clinical Case Formulation: The DSM emphasizes that “it is not sufficient to simply check off the
symptoms in the diagnostic criteria” and that developing a clinical case formulation requires the ability
to recognize the constellation of “predisposing, precipitating, perpetuating and protective factors” that
have contributed to the development of psychopathology and utilizing this information for effective
treatment planning (p. 19).
This casebook can provide the materials necessary to develop and enhance clinical skills in all the areas listed
previously; however, the reader should not lose sight of the fact that, ultimately, each case study in this text is
a story about a lost child. In these “living files,” the children have lost the path to normal development. Based
on clues provided in the story, the reader’s goals are to determine a child’s current path relative to normal
adjustment and redirect the child’s course in the right direction. With these goals in mind, read their stories
and develop your expertise so that you can be better prepared to help the next child who may find you.
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Overview of the Casebook
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Chapters 1–7: Cases of Child and Adolescent Psychopathology
Children and youth depicted in the 25 case studies in these chapters manifest symptoms of several comorbid
disorders, as is often seen in real life. The case studies provide an in-depth look at the multiple pathways that
can lead to maladaptive behaviors and how children can be buffered from harm or become increasingly more
vulnerable based on individual and environmental factors. Cases are presented as they appear in the newly
revised DSM-5 and are clustered into chapters that allow for extensive discussion of how the case studies
represent similar but different disorders within a given category. Each chapter begins with an introduction to
the types of disorders discussed within that chapter. The introduction will also provide information regarding
any changes to the DSM criteria that may have altered symptom criteria or how the disorder is to be
conceptualized in the future. Each case study is presented in the same format and includes the following
information:
Overview
Introduction
Developmental History/Family Background
Reason for Referral
Assessment Results
Issues, Trends, and Treatment Alternatives
Post-Case Questions
References
At the end of each case study, there is a discussion of relevant issues or trends and a review of the latest
empirical findings regarding developmentally appropriate treatment programs. Finally, a number of post-case
questions challenge the reader to apply theory and research to case-based practice. The following is a brief
summary of the content and cases discussed in each of the seven chapters.
Chapter 1: Introduction to Understanding the Complexities of Child and

Adolescent Psychopathology
The opening chapter poses 10 important questions that clinicians ask to guide their determination of whether
a behavior is typical or atypical based on their understanding of normal development. Initial discussions will
evolve around developing a case formulation and the three stages that are involved in the process (problem
identification, problem explanation, and treatment planning). Case formulations can be influenced and guided
by assumptions that are derived from a variety of theoretical frameworks. There are a number of theoretical
approaches available to assist our understanding of the nature of child and adolescent psychopathology (how
disorders develop and why they persist) and inform us as to potential treatment alternatives. The decision-
making process is strengthened by drawing on information from five theoretical models (biological,
behavioral, cognitive, psychodynamic/attachment, and parenting/family systems), which can assist in
understanding maladaptive behaviors from a developmental perspective. Ultimately, these perspectives can be
integrated into an overarching transactional bio-psycho-social framework that considers the influences of
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child characteristics (genetics, temperament) and environmental factors (immediate and distal contexts, such
as family, teachers, peers, extended family, and culture) in the etiology and maintenance of maladaptive
behaviors. Using the different models as a guide, learners will be given an opportunity to develop case
formulations and intervention plans for three cases presenting with a variety of comorbid issues. Finally the
chapter will conclude with a discussion of the risks and protective factors associated with the different levels of
influence in Bronfenbrenner’s ecological bio-psychosocial model, including child characteristics (genetic and
temperament factors), and the immediate (family, school, peers, neighborhood) and more distal influences
(exosystem and macrosystem).
In the first chapter, readers are introduced to three cases that have been specifically selected to provide
opportunities for readers to develop and apply important skill sets, including developing a case formulation
from a variety of theoretical perspectives, developing a specific behavioral intervention plan, and developing an
increased awareness of risks and protective factors that can influence child outcomes.
The first case, Terry Hogan (Case #1), presents a complex set of mental health issues that prompt the reader
to investigate case formulations along a number of theoretical perspectives. For the second case, Jeremy Jones
(Case #2), readers are introduced to a young boy who is raised by his mother and maternal grandmother. The
case affords further opportunities to examine case formulations from a number of different angles and
provides the added bonus of involving the reader in the process of conducting a functional behavioral
assessment with the goal of developing a behavioral intervention plan for Jeremy that can be used in the home
by his mother and grandmother. Finally, the third introductory case, Neesha Wilson (Case #3), serves as the
spokesperson for resilience as her case presentation highlights the importance of considering risks and
protective factors that influence the trajectory of child development. However, although Neesha’s path is one
of resilience, outcomes for her brother Tyrone (Case # 12) provide a powerful lesson in the concept of
multifinality illustrating that despite sharing similarities in their environments, the two siblings’ experiences
result in very different outcomes.
Case 1: Terry Hogan developing a case formulation

Case 2: Jeremy Jones developing a behavioral intervention plan
Case 3: Neesha Wilson focus on risks and protective factors
Chapter 2: Introduction to Neurodevelopmental Disorders

Neurodevelopmental disorders are disabilities that are associated primarily with dysfunction of the
neurological system and brain. There are many disorders that can be classified within this category, including
ADHD, the learning disorders, autism spectrum disorder, disorders of intellectual disability (formerly known
as mental retardation), communication disorders, and motor disorders. The introduction to this chapter will
provide updated versions of diagnostic criteria for the cases to be discussed, as outlined in the DSM-5.
Children with neurodevelopmental disorders can often experience difficulties with speech and language,
motor skills, learning and memory, or other functions related to neurological dysfunction. Children who
experience neurodevelopmental disorders can demonstrate problems in processing information about their
social and academic world that have far reaching implications for the trajectory of their future development.
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Although individuals who meet criteria for neurodevelopmental disorders share many comorbid features, the
cases in this chapter will be clustered around two themes: cases involving problems of attention and specific
learning disorders, and cases addressing issues of intellectual disability and autism spectrum disorder.
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Problems of Attention and Specific Learning Disorders
This part of the chapter will provide an overview of the nature of diagnostic criteria, etiology, and course of
disorders that can influence a wide range of academic and social concerns: attention-deficit/hyperactivity
disorder (ADHD), and the learning disorders. This section will address how these disorders can impact
learning through difficulties with executive functions (ADHD) and information processing (specific learning
disorders). The discussion will also include any conceptual changes or modifications to the criteria for these
disorders in the DSM-5. Three cases will be introduced that address difficulties in the diagnosis and treatment
of these disorders, as well as the importance of recognizing other comorbid disorders that often co-exist with
these problems.
From a developmental perspective, children with ADHD and learning disorders often can go undiagnosed,
and not recognized as having problems, until the academic difficulties become more obvious, around the third
or fourth grade. Colby Tyler (Case #4) is a young adolescent who is gifted and living in a home situation that
has just been shattered by his parents’ divorce. All this would have been difficult to contend with for any teen,
however Colby also has ADHD and his unsettled conditions have taken their toll on his academic progress.
Thomas McLearn (Case #5) is an eight-year-old boy who is talented athletically and a natural go getter.
Everything seemed to be going his way, until his parents discover the secret that Matthew had been keeping
for years. Matthew has learned to cope with his inability to read by memorizing his favorite books. Despite all
his natural talent and innate intelligence, Thomas has dyslexia and he cannot read. Finally, Sandy Smith
(Case #6) presents with a different set of problems. Although she is able to read very well, she has other subtle
problems that seem to go unnoticed, until she is asked some very basic questions about money or time. She
also seems to take everything literally and as a result can be the brunt of jokes and peer ridicule. Sandy is very
awkward and socially has very few friends. Sandy has a rare form of specific learning disorder known as a
nonverbal learning disability.
Case 4: Colby Tyler attention-deficit/hyperactivity disorder (ADHD) and gifted

Case 5: Thomas McLearn dyslexia
Case 6: Sandy Smith nonverbal learning disability
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Autism Spectrum Disorder and Intellectual Disability
Children like Dylan Bach (Case #7) and Bradley Hunter (Case #10) represent extremes in symptom
presentations manifesting symptoms that at times can result in poor ability to engage in social reciprocity, yet
at other times, may exhibit islands of insight that are well beyond their years. Although some children with
intellectual disabilities (general patterns of cognitive deficits) are readily diagnosed due to more obvious delays,
others like Arthur Watson (Case #8) may manage to escape detection due to behavioral problems that
overshadow their disability, resulting in caregivers setting expectations far beyond the level that the child is
able to master, resulting in frustration and escalation of behavioral issues. Other children with intellectual
disabilities, like Brian Williams (Case #9), who has Williams syndrome, may demonstrate special talents, like
musical ability, or heightened motivations to engage in social situations, although they may be significantly
limited in areas of cognitive functioning.
Case 7: Dylan Bach autism spectrum disorder (ASD; mild variant)

Case 8: Arthur Watson intellectual disability
Case 9: Brian Williams intellectual disability (Williams syndrome)
Case 10: Bradley Hunter not yet diagnosed; possible neurodevelopmental disorder
Chapter 3: Introduction to Behavioral Disorders

Children who exhibit symptoms of externalizing disorders, such as oppositional defiant disorder (ODD) or
conduct disorder (CD) can be a very disruptive force in their surroundings through their behaviors, which may
be highly visible, intrusive, and unsettling. Children with ODD or CD may demonstrate poor ability to
regulate behaviors and emotions, resulting in responses to emotionally charged situations that escalate out of
control, regardless of whether these events are positive or negative (Rydell, Berlin & Bohlin, 2003). While
children with ODD can present as willfully disobedient and defiant of authority, adolescents with CD often
violate the rights of others in behaviors that are either overt (bullies, initiates fights, cruelty) or covert (break
and enter, cons others, theft) in nature. Family characteristics can be an important underlying dynamic in
developing a case formulation for children and adolescents with disruptive behavior disorders, such as Scott
Michaels (Case #11), while peer influences can be an important contributing factor for adolescents with these
tendencies, such as Tyrone Wilson (Case #12).
Case 11: Scott Michaels oppositional defiant disorder (ODD)

Case 12: Tyrone Wilson conduct disorder (CD)
Chapter 4: Introduction to Anxiety and Compulsive Disorders

Children who experience anxiety disorders can exhibit internalizing problems in a number of different ways,
including withdrawal from social contact, agitation, physical tension and physical complaints, and a plethora
of fears and worries causing excessive distress. Unlike the externalizing behaviors, the anxiety disorders can be
more subtle and difficult to detect. Developmentally, very young children often can present with a mixture of
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anxiety and depression, known as negative affectivity, which presents as an undifferentiated form of shared
characteristics of anxious/depressed features (Achenbach & Rescorla, 2001). Case studies provide a glimpse of
the nature of anxiety and compulsive disorders from several perspectives, including separation anxiety disorder
(SAD; Winnie Kent, Case #13); generalized anxiety disorder (GAD; Shirley Yong, Case #14); obsessive
compulsive disorder (OCD, Jordan Neeson, Case #15); and social anxiety disorder (Sandra Silver Case #16).
Discussions will include the DSM-5 rationale for moving the category of OCD from the anxiety disorders to
the section on Obsessive Compulsive and Related Disorders.
Case 13: Winnie Kent separation anxiety disorder (SAD); selective mutism
Case 14: Shirley Yong generalized anxiety disorder (GAD)
Case 15: Jordan Neeson obsessive compulsive disorder (OCD)
Case 16: Sandra Silver social anxiety disorder
Chapter 5: Introduction to Problems of Mood: Depression and Bipolar

Disorders
Research in the area of mood problems in children and adolescence has increased rapidly in the past 20 years,
changing the way that these disorders are conceptualized in children. Although it is widely recognized today
that children and adolescents can experience the entire array of depressive symptoms, from depressed mood to
depressive disorder, there is less agreement on how these symptoms may appear developmentally, in very
young children, school age-children, or adolescents. Nowhere is this controversy more prevalent than in the
diagnosis of pediatric bipolar disorder (PBD). In fact, in one study of psychiatric discharge rates, prevalence
rates of PBD escalated from 1992 to 2004 by 53.2% in children and 58.5% in adolescents (Brotman, et al.,
2006). This chapter will include a discussion of the rationale behind the DSM-5 decision to separate the
categories of bipolar disorders from depressive disorders and the new category of Disruptive Mood
Dysregulation Disorder, which has been recently added to the depressive disorders of the DSM-5 to classify
recurrent behavior patterns of temper outbursts, depression, and anger. For comparative purposes, the case
studies present two very different perspectives on bipolar disorder, demonstrating how the disorder can
manifest in childhood (Matthew Morgan, Case #18) relative to adolescent onset (Jenny Stone, Case #19).
The chapter also probes whether Matthew should be diagnosed with disruptive mood dysregulation or
pediatric bipolar disorder. The case of David Steele (Case #17) provides an in-depth look at suicidal ideation
in an adolescent with comorbid substance use issues.
Case 17: David Steele depression and suicidal ideation

Case 18: Matthew Morgan pediatric bipolar disorder
Case 19: Jenny Sloan bipolar disorder, adolescent onset
Chapter 6: Introduction to Disorders of Emotion and Behavior

Dysregulation
Case studies presented in this section all share underlying facets of emotion dysregulation (inability to regulate
emotions in stressful situations), resulting in behavior dysregulation (binge eating, excessive substance use,
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non-suicidal self-injury). The rationale for including these three behaviors in the same chapter is that
although no study could be found that links disordered eating to substance use and nonsuicidal self-injury
(NSSI), several studies have reported associations between substance use disorders (SUDs) and disordered
eating, while some studies have also linked eating disorders to NSSI (Arbuthnott, Lewis, & Bailey, 2015;
Muehlenkamp, Peat, Claes, & Smits, 2012) or NSSI to substance use (Gratz & Tull, 2010). Although the
majority of youth will navigate this period of development without incurring long-term negative
consequences, for some, the road taken can lead to involvement in greater risk-taking behaviors resulting in a
trajectory that includes increased risk for negative outcomes. Increased risk for body dissatisfaction has been
associated with early maturing girls (Swarr & Richards, 1996), while initial experimentation with cigarettes,
alcohol, and marijuana can take a turn for the worse under the tutelage of deviant peer practices.
Disorders in this category have later onset, usually in late childhood or adolescence and include disturbances
in body dissatisfaction that may result in eating disorders and substance use. Since this period of development
is marked by significant changes in biological, psychological, and social systems (Cicchetti & Rogosh, 2002),
youth face a number of challenges that can result in shifts in mood, risk taking, and conflicts with authority
figures (Arnett, 1999).
Alex Bishop (Case #20) is a youth who demonstrates many signs that should warn his caregiver that he is at
increased risk of substance use. His case is an important lesson in the importance of recognizing the early
warning signs and the need to involve his caregiver in the intervention process. Alex’s case provides a good
example of multidimensional family therapy (MDFT) and how this intervention program can be an effective
method for working with troubled teens and their family. Family conflict is also an area of concern for Sarah
Burke (Case #21), an adolescent who is openly defiant and aggressive with her mother. Sarah is experiencing
social and academic difficulties and secretly engages in binge and purge episodes when her mother and sister
are at work. Discussion will include difficulties of implementing and sustaining treatment interventions for
adolescents with eating disorders. Although little is known about Tori Benson’s (Case #22) past, her current
self-abusive behavior suggests that her physical scars mimic the emotional pain she feels within.
Case 20: Alex Bishop substance use; multidimensional family therapy

Case 21: Sarah Burke eating disorder (bulimia nervosa)
Case 22: Tori Benson self-injurious behavior
Chapter 7: Introduction to Traumatic and Stress-Related Disorders

Stress can trigger an attempt to adjust to an isolated event or result in the on-going depletion of resources
resulting from living in chronically stressful conditions. Over time, stress can result in erosion of the immune
system, placing individuals at risk for negative consequences to physical and mental health and emotional
well-being. Children can experience trauma resulting from a significant traumatic event (natural disaster,
actual or threatened harm to self or others), or from repeated exposure to sexual or physical abuse (type II
trauma). Juan Hernendez (Case #23) feels a deep sense of survivor guilt having lived through the fatal
accident that claimed the life of his best friend, while Ericka White (Case #25) and Jason Coleman (Case
#24) have past abusive experiences that have placed them on a developmental trajectory that can have far-
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reaching negative outcomes for their future development. This chapter will discuss the shift in classification of
the stress disorders (posttraumatic stress disorder, acute stress disorder), adjustment disorders, and reactive
attachment disorder to the newly formed category of Trauma and Stressor-Related Disorders, and proposed
future criteria for nonsuicidal self-injury, as well as criteria for PTSD established for children under 6 years of
age.
Case 23: Juan Hernendez posttraumatic stress disorder (PTSD)

Case 24: Jason Coleman reactive attachment disorder (RAD)
Case 25: Ericka White not yet diagnosed
Overview of Case Presentations

The cases are a rich source of information on a number of developmental themes and diagnostic
considerations. Since children and youth can often present with a number of comorbid disorders and features,
an overview of the cases is presented in Table P1, which can serve as a guide to the nature of the types of
problems and developmental considerations discussed in each of the 24 cases.
Table P1 Summary of Important Developmental Themes and Diagnostic Considerations
Case # Developmental Themes Diagnostic Considerations
case formulation from different
#1 Terry theoretical frameworks symptoms of depression
Hogan
avoidant patterns symptoms of anxiety
10 years old
attachment and emotion somatic complaints
regulation
biological perspective: genetic

inheritance
#2 Jeremy attention-deficit/hyperactivity disorder (ADHD)
family environment
Jones
problem behaviors (noncompliance)
attachment and emotion
6 years old
regulation possible specific learning disability
maternal depression
multifinality (sibling to Tyrone

Wilson)
cultural diversity
#3 Neesha somatic complaints
Wilson risks and protective factors,
22
10 years old resilience internalizing and externalizing symptoms
maternal depression
school problems
#4 Colby
parent divorce gifted
Tyler
risks and protective factors attention-deficit/hyperactivity disorder (ADHD)
14 years old
#5 Thomas
McLearn biological: left hemisphere
specific learning disability (dyslexia)
dysfunction
10 years old
#6 Sandy biological; right hemisphere

nonverbal learning disability
Smith dysfunction
symptoms of worry
8 years old social and academic problems
#7 Dylan
Bach similarities to nonverbal learning autism spectrum disorder (ASD) (mild variant;
disorder high intellectual functioning)
6 years old
#8 Arthur
intellectual developmental disability
Watson family dynamics
adaptive behavior
15 years old
#9 Brian Williams syndrome

biological factors
Williams
intellectual developmental disability
hypersociality
10 years old
adaptive behavior
#10 Bradley
Comparison to higher functioning
Hunter autism spectrum disorder (ASD)? (lower
medical complications functioning)

5 years old
oppositional defiant disorder

#11 Scott
Michaels learning disorder
family dynamics
23
ADHD
biological factors: fetal alcohol

syndrome
forensic assessments
#12 Tyrone juvenile justice

intellectual functioning
Wilson
multifinality (sibling to Neesha
Wilson) conduct disorder
15 years old
cultural diversity
family dynamics
deviant peer groups

selective mutism
#13 Winnie factors
Kent separation anxiety disorder
family dynamics
5 years old adjustment reactions
environmental factors
family dynamics
#14 Shirley generalized anxiety disorder
cultural diversity
Yong
symptoms of depression
maternal depression
11 years old
trichotillomania
relational aggression
#15 Jordan
obsessive compulsive disorder
Neeson family dynamics
specific learning disorder
9 years old
#16 Sandra genetic factors

Silver social anxiety disorder
developmental presentations of
15 years symptoms
#17 David depression

Steele
risks and protective factors suicide ideation
17 years old
24
17 years old alcohol abuse

inheritance
#18 Matthew
Morgan medical management pediatric bipolar disorder or mood dysregulation
disorder?
9 years old aggression
ADHD and bipolar disorder
biological and environmental

#19 Jenny factors
Sloan bipolar disorder
suicide risk
16 years old
medical management
biological and environmental

#20 Alex factors multiple substance use
Bishop
academic issues symptoms of depression
16 years old
multidimensional family therapy
family dynamics
#21 Sarah environmental factors disordered eating or eating disorder
Burke
social relations anorexia nervosa
16 years old
risks and protective factors bulimia nervosa
emotion regulation
family dynamics
risks and protective factors self-injurious behavior

#22 Tori
Benson emotion regulation and impulse symptoms of depression
control
16 years old
borderline personality disorder
ethical issues working with
adolescents
#23 Juan
cultural diversity
25
Hernendez cultural diversity posttraumatic stress disorder
16 years old survivor guilt
#24 Jason
conduct disorder
Coleman history of child abuse
reactive attachment disorder
16 years old
not yet diagnosed

#25 Ericka
history of child abuse intellectual functioning
White
academic and social problems externalizing and internalizing problems
10 years old
mood swings
26
Appendices, Additional Information, and Resources
The Appendices contribute a wealth of additional information for advanced areas of study.
Appendix A: Supplemental Case Information

This appendix will be especially helpful for readers interested in increasing their understanding of the
assessment process. Actual raw data are provided for four cases (Colby Tyler, Scott Michaels, Arthur Watson,
and Shirley Yong), and readers are encouraged to use this information in practicing skills in developing case
formulations and generating a written report. A sample psychological report and an exercise in differential
diagnoses are provided for the case of Colby Tyler.
Appendix B: Systems of Classification

Appendix B provides an in-depth discussion of the educational classification system as it relates to four
primary childhood disorders: specific learning disabilities, intellectual disabilities (previously, mental
retardation), ADHD, and emotional disturbance. This information is a must for advising parents and for
integrating assessment results within a school-based setting. The section includes recent updates of the
Individuals with Disabilities Education Improvement Act (IDEA, 2004) and the Americans with Disabilities
Act Amendments Act of 2008 (ADAAA), which impacts Section 504 of the Rehabilitation Act of 1973. This
section will also address the discrepancy criterion and response to intervention (RTI) as they relate to criteria for
determining whether a child meets criteria for designation as learning disabled.
Appendix C: Guidelines to the Interpretation of Test Scores and Assessment

Information
In this section, readers will find a guide to interpreting standard scores and T scores, as well as descriptions of
the specific assessment instruments used in the text.
27
References
Achenbach, T. M. & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms and profiles.
Burlington: University of Vermont, Research Center for Children, Youth and Families.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders-5.
Washington, DC: Author.
Arbuthnott, A. E., Lewis, S. P., & Bailey, H. N. (2015). Rumination and emotions in nonsuicidal self-injury
and eating disorder behaviors: A preliminary test of the emotional cascade model. Journal of Clinical
Psychology, 71(1), 62–71.
Arnett, J. J. (1999). Adolescent storm and stress, reconsidered. American Psychologist, 54(5), 317.
Brotman, M. A., Schmajuk, M., Rich, B. A., Dickstein, D., Guyer, A. E., & Costello, E. (2006). Prevalence,
clinical correlates and longitudinal course of severe mood dysregulation in children. Biological Psychiatry,
60, 991–997.
Cicchetti, D., & Rogosch, F. A. (2002). A developmental psychopathology perspective on adolescence.

Journal of Consulting and Clinical Psychology, 70(1), 6.
Fishman, D. (2000). The case for pragmatic psychology. New York, NY: New York University Press.
Gratz, K. L., & Tull, M. T. (2010). The relationship between emotion dysregulation and deliberate self-harm
among inpatients with substance use disorders. Cognitive Therapy and Research, 34(6), 544–553.
Muehlenkamp, J. J., Peat, C. M., Claes, L., & Smits, D. (2012). Self-injury and disordered eating: Expressing
emotion dysregulation through the body. Suicide and Life-Threatening Behavior, 42(4), 416–425.
Swarr, A. E., & Richards, M. H. (1996). Longitudinal effects of adolescent girls’ pubertal development,
perceptions of pubertal timing, and parental relations on eating problems. Developmental Psychology,
32(4), 636.
28
29
Acknowledgments
SAGE wishes to acknowledge the valuable contributions of the following reviewers.
Beth Gibbons, Gallaudet University

Elizabeth J. Kiel, Miami University
Isabelle Chang, Ph.D., Temple University
Melissa A. Barnett, University of Arizona
Rachael Lapidis, University of California, San Diego
Dr. Eraina Schauss, University of Memphis
Gregory Canillas, Ph.D., The Chicago School of Professional Psychology (Los Angeles campus)
Jeffrey M. Smith, Creighton University
Lisa Clark Keith, Psy.D., Fresno Pacific University
Martha Mendez-Baldwin, Ph.D., Manhattan College
Tracey M. Duncan, Ed.S., Ph.D., LPC, ACS, New Jersey City University
Wendy K. Killam, Stephen F. Austin State University
30
About the Author
Linda A. Wilmshurst, Ph.D.,

ABPP, received her BA and MA in psychology from the University of Windsor and her Ph.D. from the
University of Toronto. Linda, a diplomate in clinical psychology (ABPP) and a registered psychologist
and school psychologist in Florida, has previously held licenses in Ontario, Canada, Texas, and North
Carolina. For the past 10 years, prior to coming to the Center for Psychology in Florida, Dr.
Wilmshurst was a professor in the Psychology Department at Elon University, in Elon, North Carolina,
where she taught courses in child and adult psychopathology. She was also involved in the supervision of
student internships and mentoring undergraduate research, primarily in areas related to resiliency, self-
perceptions, and well-being in college students with attention-deficit/hyperactivity disorder. Dr.
Wilmshurst has authored a number of textbooks, including Clinical and Educational Child Psychology: An
Ecological-Transactional Approach to Understanding Child Problems and Interventions (Wiley-Blackwell,
2013), Abnormal Child Psychology: A Developmental Perspective (2nd ed.; Routledge, 2017), and Essentials
of Child Psychopathology (2nd ed.; Wiley, 2014). In addition, Linda has co-authored three books with
Alan W. Brue: Essentials of Intellectual Disability, Assessment and Identification (Wiley, 2016); A Parent’s
Guide to Special Education (AMACOM, 2005), and The Complete Guide to Special Education (Jossey-
Bass, 2010; currently under revision with Routledge Taylor Francis).
Linda has worked in public school systems and mental health facilities, internationally. She has
published articles in scholarly journals concerning programs for children and youth with severe behavior
problems and university students struggling with ADHD. She currently works as a psychologist for the
Center for Psychology in Fort Myers, Florida, and she also continues to teach graduate student
psychology courses online for Capella University.
31
Chapter 1 Introduction Understanding the Complexities of Child
and Adolescent Psychopathology
Afundamental challenge inherent in the study of child and adolescent psychopathology is distinguishing
normal from atypical behavior. There are several reasons why this decision-making process is so complex and
why the task is so difficult.
Determining “normal” from “abnormal” behavior requires an evaluation of the frequency of the behavior (e.g.,
does the behavior occur on a daily, hourly basis), the duration (is this a recent or ongoing problem), and
whether the behavior is pervasive across all situations (or situation specific). With these factors in mind, we
can now begin to probe whether the behavior is atypical within a developmental context. Ten of the most
important questions that will need to be addressed are the following:
1. Is the behavior atypical, given the child’s developmental stage? An understanding of normal developmental
milestones provides the foundation for decisions regarding whether a behavior is atypical. For example, Grace
is concerned because her 2-year-old is aggressive. Yesterday, he shoved another child off the swing because he
wanted the swing. We know that aggression typically peaks around 2 years of age and then progressively
declines, as children develop increased skills in self-control and emotion management. Furthermore,
instrumental aggression (pushing the child to obtain an object, e.g., the swing) is a typical form of early
aggression, which is less serious than hostile aggression, which is an intent to injure someone. As a result, we
would be able to tell Grace with some measure of confidence that the aggressive behavior is not atypical and
will likely decline from this point onward.
2. Is the behavior typical at one stage and not at another? Some behaviors are more typical or atypical at various
developmental stages. For example, toddlers often engage in oppositional behaviors (the “terrible twos”) as
they flex their newfound sense of independence. However, when introduced to the cases of Jeremy Jones, who
is 6 years old (Chapter 1; Case #2), and Scott Michaels, who is 9 years old (Chapter 3; Case #11), we see
“oppositional behavior” that is atypical for both of these boys, given their ages. Both boys are defiant and
refuse to comply with the most reasonable of requests. Unchecked, these behaviors can continue to escalate in
severity, perhaps even developing into conduct disorder (CD), a more serious variant of the disruptive
behavior disorders, which we see in the case of Jason Coleman (Chapter 7; Case #24).
3. Is it possible for the same disorders to have different symptom presentations at different developmental stages?
Matthew Morgan (Chapter 5; Case #18) and Jenny Sloan (Chapter 5; Case #19) are case studies of bipolar
disorder (BPD); however, while Matthew potentially has child-onset BPD, Jenny has adolescent-onset BPD.
Matthew’s symptoms evidence high levels of aggression and rapid mood swings, typical of child-onset BPD,
while Jenny’s symptoms are closer to the adult version of the disorder, manifested in pressured speech,
grandiosity, the need for little sleep, and eventually crashing into a depression and suicide attempt.
4. Do symptoms of disorders appear the same in children and adults? Many times, symptom presentations in
children are different from adult versions of the disorders. The question is an important one because on the
32
surface, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychological
Association [APA], 2013) actually lists even fewer disorders that specifically refer to children (disorders with
onset in infancy, childhood, and adolescence) than the previous version of the DSM (DSM-IV, TR; APA,
2000). This continues to be an area of concern, since symptoms for the majority of disorders (including
anxiety and depression) have historically been based on field trials with adults. The DSM has attempted to
address this concern by adding increased descriptions of child and adolescent criteria to the disorders, as well
as associated developmental features. For example the “depressed/sad” features of adult depression may appear
as “irritable mood” in a child. Child and adolescent symptoms for posttraumatic stress disorder (PTSD) differ
from adults and across different developmental levels. While younger children, like Ericka White (Chapter 7;
Case #25), will often reenact traumatic experiences through repetitive play, adolescents like Jason Coleman
(Chapter 7; Case #24) and Juan Hernendez (Chapter 7; Case #23) may respond by engaging in high-risk
behaviors (e.g., theft, fast driving, moving in with a girlfriend and leaving home). In preschool children, these
symptoms can reveal even more deviations from how symptoms present in older children and adults, as was
evident in Ericka’s clinical history. Compared to adults, children experience far higher rates of comorbidity
(more than one disorder occurring at the same time). As a result, it is important to recognize that there are
different patterns of comorbidity and that some disorders have a greater tendency to occur together than
others. The next three questions (5, 6, and 7) address issues of comorbidity.
5. What are internalizing behaviors, and do they have a tendency to be comorbid? Internalizing behaviors, or
overcontrolled behaviors, refer to syndromes that signify “problems within the self, such as anxiety, depression
and somatic complaints that are without known medical cause and result in withdrawal from social contact”
(Achenbach & Rescorla, 2001, p. 93). Comorbidity among internalizing disorders is frequent, since they share
many common symptoms. Prior to adolescence, anxiety and depression may often appear somewhat
undifferentiated as negative affectivity (Achenbach & Rescorla, 2001; Kronenberger & Meyer, 2001).
6. What are externalizing behaviors and are they comorbid as well? Externalizing, or undercontrolled behaviors, are
referred to in the DSM-5 as the disruptive behavior disorders: oppositional defiant disorder (ODD) and
conduct disorder (CD). The hyperactive/impulsive and combined types of attention-deficit/hyperactivity
disorder (ADHD) often are comorbid with ODD and CD. Scott Michaels (Chapter 3) and Jeremy Jones
(Chapter 1) are case studies that exemplify comorbid ODD and ADHD (hyperactive-impulsive type).
7. Can internalizing and externalizing disorders ever exist in the same child? Children can have a number of
different disorders at the same time (e.g., specific learning disorder, ODD, and ADHD). Having a multitude
of comorbid disorders can result in symptoms of depression, due to the cumulative effect of these disorders on
adjustment. The case of Jason Coleman (Chapter 7) provides an illustration of how many of the internalizing
and externalizing disorders can occur together in the same child.
Developmental trajectories are the outcome of interactions between child characteristics (intelligence, social
competence, heritability, temperament, etc.) and environmental characteristics (family, school, teachers, peers,
neighborhood, etc.). An investigation of situational or contextual variables can uncover the underlying
dynamics that precipitate and maintain problem behaviors. Question 8 is related to environmental influences.
33
What are some of the influences in the environment that can contribute to problem behaviors? Problems may be
more evident in one environment (home) than another (school) or pervasive across situations. The case study
of Jeremy Jones (Chapter 1) reveals how a “well meaning” mom and grandma exacerbate his behavior problems
through reinforcement (at times thinking his behaviors are “cute” and at other times giving in to his demands
out of exhaustion). Jeremy is more controlled at school, due to the structure in the classroom. The case of
Colby Tyler (Chapter 2) illustrates how conflict in the home can tip the scales. Even though he is trying to
keep his world together, academically and emotionally, with his parents going through a difficult divorce,
Colby’s resources have been stretched to the limit.
Some factors can place children at increased risk for negative outcomes, while other factors can provide a
protective buffer against harm. Risks and protective factors are addressed in Question 9.
What are some important risk and protective factors? There has been increased effort to uncover protective factors
that can contribute to resilience despite hardship. Knowledge of risk factors can alert practitioners to warning
signs, while knowledge of protective factors can provide the foundation for the development of preventive
measures. A number of risk and protective factors will be discussed at the end of this chapter.
It is important to know that there are several possible pathways (developmental trajectories) that may produce
the same outcome—equifinality—and that children who experience similar risks may have very different
outcomes—multifinality (Cicchetti & Rogosch, 1996). The final question addresses these issues.
10. What are equifinality and multifinality? In the case studies to follow, you will meet Neesha Wilson (Chapter
1) and her brother, Tyrone Wilson (Chapter 3), two African American siblings who have very different
outcomes, despite living in the same home and being exposed to the some of the same risk factors. Neesha is
10 years of age and Tyrone is 15 years of age. However, while Neesha’s story is one of resilience, her brother
follows the path of least resistance, developing a substance-use problem and joining a street gang to support
his habit. Neesha and Tyrone illustrate the concept of multifinality. Although they were exposed to similar
circumstances growing up, Neesha is successful despite the odds. When you read these two cases, ask yourself
what factors could have contributed to the very different outcomes for these two siblings.
Whereas adults often self-refer, children are most likely to be referred based on adult concerns. However,
behaviors that may be concerning to parents (nightmares, aggression, overactivity) are often frequently
reported in “normal” children. In addition, there may be wide variations in parent responsiveness to a child’s
given problems, based on extraneous circumstances at the time, such as tolerance level, and stressors like
financial difficulties or family conflict.
With an understanding of the complexities inherent in child and adolescent psychopathology, we can now
turn our focus to a number of theoretical perspectives that have been developed to explain how problem
behaviors develop and provide direction for treatment and intervention.
34
35
Case Formulation
Kronenberger and Meyer (2001) present a framework for diagnosis, assessment, and treatment based on three
essential questions that must be answered by the child clinician. The authors suggest that regardless of the
presenting problem or the theoretical background of the therapist, the child clinician is usually faced with
providing answers to three primary questions:
1. What are the primary characteristics of the child’s problem?

2. How does the clinician conduct an in-depth evaluation of the problem?
3. How does the clinician decide which interventions are important?
The authors suggest that each of the questions addresses a specific issue or aspect of child psychopathology.
Clinicians respond to the first question when they classify a child’s problem relative to a diagnostic category or
provide a provisional diagnosis or a case formulation based on the presenting symptoms and characteristics. The
second question involves the in-depth evaluation. Here, the assessment process requires knowledge of
appropriate interview and observational techniques, as well as broad assessment strategies (e.g., cognitive,
behavioral, and emotional functioning) and syndrome-specific tests (e.g., instruments to detect anxiety,
depression). These assessment instruments can assist in confirming or ruling out potential diagnoses. The
final question requires knowledge of developmentally appropriate evidence-based treatment methods that can
be applied to modify the problem (Kronenberger & Meyer, 2001, pp. 1–2).
Although the questions can be answered by the majority of theoretical viewpoints, Held (1996) emphasizes
the need for therapists to spend more time reconsidering the nature and composition of the theoretical system
that guides their decision-making process, in what she calls the three predetermined components of therapy:
1. What constitutes problems or impediments to solutions?

2. What causes those problems or impediments to occur?
3. What methods can help clients to solve their problems, overcome their impediments, and obtain their
goals? (p. 37)
Weerasekera (1996) defines case formulation as a process conducted to provide a “hypothesis of how an
individual comes to present with a certain disorder or circumstance at a particular point in time” (p. 5). Case
formulations have been explored from a number of theoretical approaches, including psychodynamic (Eells,
1997; McWilliams, 1999; Shirk & Russell, 1996), behavioral (Mash & Terdal, 1997; Cipani & Golden,
2007), cognitive–behavioral (Bruch & Bond, 1999; Esbjørn et al., 2015), and family systems perspectives
(Berman, 1997). Within the realm of child psychopathology, research linking child outcomes to parenting
styles (Baumrind, 1991) and attachment patterns (Ainsworth, Blehar, Waters, & Wall, 1978) suggests that
these areas could also provide rich materials for weaving into the fabric of case formulations. Case formulation
can provide a framework for assessing and organizing information in a way that informs treatment planning,
by going beyond symptom presentation to deriving hypotheses regarding how the behavior developed and
why it is being maintained. Although the concept of case formulation has its origins in the psychodynamic
36
approach, the approach is readily adaptable to a variety of theoretical perspectives and is gaining increased
recognition across a wide variety of theoretical models regarding adult as well as child populations (Hersen &
Porzelius, 2002; Shirk & Russell, 1996).
The case formulation approach is particularly well-suited to clinical/developmental child concerns because the
approach
1. supports an understanding of underlying processes (cognitive, behavioral, and emotional);

2. readily allows for consideration of the impact of personal and environmental factors on past and present
functioning at several levels: individual, immediate, social and economic, and culture;
3. provides an opportunity to address how risks and protective factors can impede or assist treatment;
4. provides a unique opportunity to place therapeutic interventions within an ecologically valid context;
5. can accommodate behavioral (Weisz, Weiss, Han, Granger, & Morton, 1995) and cognitive–behavioral
training programs that have been demonstrated to reduce anxiety (Esbjørn, et al., 2015; Kendall et al.,
1992) and depression (Stark, Swearer, Kurkowski, Sommer, & Bowen, 1996), disruptive behavior
disorders (Cipani & Golden, 2007; Spaccarelli, Cotler, & Penman, 1992) and, combined with
pharmacology, symptoms of ADHD (Barkley, 1997);
6. is best utilized when a therapist is not confined to a single model or approach and is best viewed as “part
of a holistic approach, encompassing the biological, psychological and social, cultural” perspectives (Sim,
Gwee, & Bateman, 2005, p. 291).
37
Three Stages in Case Formulation: A Conceptual Model
As a construct, case formulation seeks to address the essential questions posed by Kronenberger and Meyer
(2001) and Held (1996). When a diagnosis is made, a wealth of clinical knowledge about the disorder is
readily available. The case formulation is a hypothesis about potential underlying influences that precipitate
(cause) and maintain the behavior, including child factors (biological, genetic, and neurobiological) and
environmental factors (family, school, peers, and community). To this end, the case formulation provides a
better understanding of
Problem identification (What is the problem?)

Precipitating and maintaining factors (Why does the problem exist? Why is the problem persisting?)
Intervention (How can the problem be alleviated?)
The case formulation presents a three-stage model that provides an organizational framework for discussing
diagnosis, assessment, and treatment or intervention. The three stages of the case formulation are
Stage 1: Problem identification (clarification and classification)

Stage 2: Problem interpretation/understanding (precipitating and maintaining factors)
Stage 3: Treatment formulation (intervention strategies).
Stage 1: Problem identification.
Knowledge of normative expectations, awareness of the etiology of disorders, and familiarity with empirical
research all add to our understanding of specific disorders. At this stage, a wide variety of assessment methods
allow us to access information from multiple sources (parents, teachers, child). In some multiple-problem
cases, there may be a need to prioritize among problem areas based on urgency or severity of problems.
Sometimes, what was originally thought to be “the main problem” is actually secondary to a different concern.
In these cases, hypotheses are reformulated.
Stage 2: Problem interpretation/understanding.
Developmental and family history can provide important information regarding potential genetic (family
pathology, biological implications) or event-based causes (family or school history, traumatic events, etc.).
Knowledge of risks and protective factors can also assist in better understanding conditions that might
exacerbate or moderate the problem. At this stage, theoretical assumptions can influence how the problem is
conceptualized; however, the ability to integrate information from diverse theoretical perspectives can increase
our understanding of the dynamics involved.
Stage 3: Treatment formulation.
Knowledge of evidence-based treatments that best apply to the unique aspects of the case will increase
opportunities for success. Monitoring and evaluating treatment effectiveness are also important in order to
validate the effectiveness of the treatment or intervention.
38
Box 1.1 Thinking Out Loud
Sections titled “Thinking Out Loud” will provide opportunities to consolidate information, identify areas for further exploration, and
assist in working through the process of case formulation.
Although case formulation involves three stages, it is a dynamic and ongoing process that has a built-in capacity for flexible thinking
and revision at all stages. In this way, case formulation can become case reformulation, allowing for ongoing refinement and
evaluation of problem areas and treatment plans.
39
Case Formulation from Five Different Perspectives
The following section is devoted to case formulations developed from five different theoretical frameworks:
biological, behavioral, cognitive (social cognitive), psychodynamic/attachment, and parenting style/family
systems.
40
Case Formulation Based on the Biological Perspective
The biological perspective looks to genetics, physiological factors, and brain anatomy (function and
biochemical activity) to assist in understanding the etiology of human behavior and possible treatment
alternatives. Developmentally, rapid growth in brain development in the first 2 years of life results in pruning
of less useful connections while increasing the efficiency of neural transmissions due to a process of
myelination, which improves conductivity. Neurotransmitters, chemicals released into the synapse between
neurons, can have a profound influence on moods and behaviors, such as depressive moods that can result
from low levels of serotonin or norepinephrine, or increases in anxiety resulting from malfunction of GABA
(gamma-amniobutryic acid), which is not performing adequately to inhibit anxious responses. In addition,
secretion of hormones into the bloodstream, such as the release of cortisol in response to stressful
circumstances, can cause the hypothalamus-pituitary-adrenal system (HPA) to go on high alert by activation
of the sympathetic nervous system, in individuals with PTSD or those vulnerable to other anxiety provoking
situations. In addition to these responses, certain parts of the brain have also been implicated in the etiology of
specific disorders, such as low levels of activity in the frontal cortex of individuals with ADHD or irregular
patterns of amygdale functioning in individuals with autism spectrum disorders.
When considering the biological perspective, it is important to consider the principle of epigenesis, a concept that had its origins in
biology but has been adapted by psychology to explain how interactions between organisms and their environment can transform
both entities in the process. There are two variations on the theme of epigenesis: deterministic epigenesis and probabilistic epigenesis.
Deterministic epigenesis was a concept that was originally supported by such theorists as Freud and Erikson, who believed strongly
that developmental stages were predetermined and that there was a direct link between biology (genes) and structure (behavior) such
that biology was destiny. However, more contemporary theorists, such as Gottlieb (2007), support a probabilistic epigenesis
approach, which speaks to the theory that “there are bidirectional influences” (p. 1), such that biology is not destiny because one can
reduce the impact of a genetic inheritance (e.g., heart problems) by intervening in the process (e.g., taking medications to reduce
cholesterol, and changing exercise and diet). Within the probabilistic epigenetic framework, biology is not necessarily destiny
(Greenberg & Partridge, 2003).
The influence of genetics in placing individuals at risk for specific disorders, such as depression, anxiety, and
schizophrenia, has been well documented in research, while specific types of child temperament have also
been implicated in regulating individual responses to positive or negative environmental stimuli (Kagan,
1992). Temperament involves individual differences in reactivity evident in responses related to motor,
affective, autonomic, and endocrine functions, and self-regulation resulting from processes and behaviors that
serve to moderate reactivity, such as approach, withdrawal, attention, attack, inhibition, and self-soothing
(Kagan, 2003, p. 8).
Therapeutic Implications: Many biologically based treatments rely on medical management to regulate chemical
imbalances due to faulty neurotransmitter production. Medications for depression often seek to correct for low
levels of serotonin by either blocking the reuptake of serotonin (SSRIs medications), or by blocking the
reuptake of serotonin and norepinephrine (SNRIs medications).
41
Biological correlates of isolation: Results of a neuroimaging study have found that the anterior cingulate cortex (ACC), which is
activated during physical pain, is also activated in response to distress caused by social exclusion and rejection (Eisenberger,
Lieberman, & Williams, 2003). The researchers suggest that these neural connections may be part of the social attachment survival
system to promote the goal of social connectedness. In addition, studies of attachment patterns have implicated neural pathways in
the cognitive–affective processes that generalize internal working models (IWM) from interactions with caregivers to other social
situations. White and colleagues (2012) suggest that in situations of social interactions or stimuli, there are differences in the
activation of reward and approach-related circuitry (e.g., left frontal activity) in the brains of those with secure attachment patterns
relative to those with insecure attachment patterns. White et al. (2012) theorize that “Securely attached individuals learn to anticipate
(and elicit) support from others owing to similar past experiences with caregivers. Conversely, insecure children, whose parents are
thought to be on average less sensitive and responsive to bids for comfort, . . . may develop corresponding beliefs of others as less
supportive during distress and themselves as essentially unwantable” (p. 691).
42
Case Formulation Based on the Behavioral Perspective
According to Mash and Terdal (1997), the behavioral systems assessment (BSA) is a “functional/utilitarian
approach” to the assessment of children and families that closely adheres to the broader meaning of diagnosis
as “an analytic information-gathering process directed at understanding the nature of a problem, and its possible
causes, treatment options and outcomes” (pp.11–12). In direct contrast to psychodynamic theories, “BSA is more
often concerned with behaviors, cognitions and affects as direct samples of the domains of interest” rather than
attempting to speculate about “some underlying or remote causes” (pp. 11–12; emphasis added). There has been
increased focus on the use of BSA practices and strategies in the decision-making process (Cipani & Schock,
2007; La Greca & Lemanek, 1996). For example, functional behavioral assessments (FBA) are routinely
conducted in the schools (Plotts & Lasser, 2013) with the goal of developing behavioral intervention plans
(BIP) that often focus on increasing “on-task behaviors” (as in the case of children with ADHD) or increasing
“compliance” (as in cases of children with oppositional defiant disorder). It has been debated by some that
FBA is a better approach to intervention planning than classification of disorders by either the dimensional or
categorical systems (Cone, 1997; Haynes & O’Brien, 1990). An example of the FBA approach can be found
in this chapter, in the case of Jeremy Jones, where issues of noncompliance are addressed in a program
designed to increase compliance. Proponents of BSA/FBA argue that the problem-solving strategy inherent
in this approach provides a flexible system of hypothesis testing that includes diagnosis, prognosis, treatment
design, and treatment efficacy/evaluation (Cipani & Golden, 2007; Mash & Terdal, 1997). The continuity
between conducting the BSA/FBA and developing the BIP are emphasized by proponents of the system
(Mash & Terdal, 1997; Wielkiewicz, 1995). The behavioral framework consists, at its basis, of a four-stage
process to identify the problem, analyze the problem, implement a plan, and evaluate the plan.
From the behavioral perspective, behavior is learned in one of three primary ways: classical conditioning,
operant conditioning, or modeling (observational learning). Classical conditioning occurs when a normally
neutral stimulus takes on a positive or negative connotation due to association with another stimulus that has
the power to trigger a reflexive response. Classical conditioning is not voluntary and occurs, often beyond our
control. Phobias are a very good example of irrational fears that have been classically conditioned. For
example, fear of flying can result from an experience of flying under turbulent conditions. In this case, the
airplane is initially a neutral stimulus (NS) that evokes a neutral response (NR): for example, I see the plane as
a means of transportation. However, on one particularly turbulent flight, I am extremely fearful that the plane
is going to crash, and when I finally land, I get off the plane, vowing never to fly again. Now, the plane has
been changed from a neutral stimulus to one of which I am afraid. In this situation, the plane has been
associated with “bad plane” because it caused me to be very “fearful.” In the moment of flight, bad plane (US:
unconditioned/automatic stimulus) was linked to bad flight (UR: unconditioned/automatic response). Now
the next time I look at a plane, I don’t think of a means of transportation, as I initially did; I now think of
crashing and dying. So the plane has now become a conditioned stimulus (CS), which elicits the conditioned
response (CR) of fear. In this case, it is also likely that if offered a ride in a hot air balloon, I would also turn
that down, since my fear would generalize to all airborne systems of transportation. This conditioning
paradigm is actually used to explain and de-condition phobias in an exposure therapy called systematic
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desensitization, where a fear hierarchy is developed and relaxation techniques are paired at each step in the
hierarchy until the phobia is extinguished.
Rather than a reflex response, operant conditioning serves to increase our tendencies to produce or inhibit
behaviors based on our experiences with rewards and punishments. If I produce a behavior and it is reinforced
(rewarded), then my chances of repeating that response increase accordingly. If I produce a response and I am
punished, then the chances of me repeating that response decrease accordingly. In operant conditioning,
reinforcement can occur in two ways: (1) I can be rewarded positively by the addition of some positive
consequence—for example, money or candy; or (2) I can be rewarded by the removal of something negative—
for instance, if I do a good job on my school work, I do not have to serve a detention after school to finish my
school work (this is referred to as negative reinforcement, because it involves the removal of a negative
consequence). Punishment, which always serves to reduce a response, can also be applied in two ways: (1) I can
apply a direct adverse consequence for bad behavior (hitting, shocking, slapping); or (2) I can be punished by
the withdrawal of something I value, such as removal of privileges.
According to Cipani and Golden (2007), “In a functional behavioral treatment, the function of the presenting problem needs to be
disabled, while an alternate function (that is more acceptable) needs to be enabled. To determine how such consequences should be
altered, a behavioral case formulation, relying heavily on ascertaining the social and environmental function of the presenting
problems, is needed” (p. 539). In their case presentation, Cipani and Golden discuss a case of avoidant behaviors (academic tasks)
manifesting in aggressive responses. The case concerns a severely disruptive boy, in the third grade, who was placed on home
instruction due to violent outbursts in the classroom. The child had a history of abuse resulting in lack of attachment, poor emotion
regulation, and an inability to perform academically. In this case, it was crucial to reduce the academic load (difficulty level) and
reward success with stars that were later traded for time volunteering in the first-grade class (a teacher with whom he had a very
good rapport), which served as a positive reinforcement. This combination proved successful and after 3 months, the child was
attending school on a regular half-day basis.
Understanding how reinforcement and punishment can be effective consequences on behavioral outcomes can
provide powerful tools to institute behavioral change. For example, schedules of reinforcement and objective
observation techniques can be very helpful in developing behavior intervention plans that can be monitored,
and modified if needed.
Although Mash and Terdal (1997) argue against narrowly contrasting BSA with more traditional assessment approaches, they do
suggest some fundamental conceptual differences between the two approaches. The BSA approach tends to focus on state (situation-
specific patterns of behavior) versus trait (underlying personality dynamic) characteristics, and ideographic versus nomothetic
comparisons, and places emphasis on stability and discontinuity over time versus consistency and stability of underlying causes.
Finally, modeling behavior refers to learning a behavior from observing the behavior in others. Bandura’s
classic experiment of the “bobo doll” is an example of this type of learning. Children who watched an adult hit
a doll were more likely to imitate the same behaviors when they were placed in a room alone with the doll,
demonstrating the power of observational learning.
Therapeutic Implications: Although many practitioners use a cognitive–behavioral approach to therapy (CBT;
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combined therapy based on both cognitive and behavioral perspectives), there are situations that are very
conducive to the use of a primarily behavioral focus. For example, school psychologists will often conduct a
functional behavioral assessment (FBA) to determine the antecedents and consequences of specific behaviors
(ABCs). Case formulations derived using the FBA approach provide information concerning the precipitating
and maintaining factors inherent in a given behavioral pattern with the goal of developing an appropriate
behavioral intervention plan (BIP) to reduce negative and enhance positive behaviors (Plotts & Lasser, 2013).
Children who experience various anxieties, fears, and phobias can benefit from the use of exposure techniques
such as systematic desensitization and exposure and response prevention based on behavioral methods that
gradually expose the child to the fearful situation or object while the child executes relaxation responses (e.g.,
deep breathing, mediation) that counteract fearful responses.
In conducting a functional behavior assessment, Sattler (2014) emphasizes the need to determine what is
maintaining the behavior (predisposes the individual to repeat the same behavior) by examining events in the
environment that occur prior to the behavior (antecedent events) and those that occur as a result of the
behavior (consequences). There are a wide variety of possible antecedent events, such as social acts (a student
may feel rejected by others) or activities (teacher has instructed the student to read a passage out loud in front
of the class) that can serve as a trigger to a given behavior (child acts out and is removed from class). The key
is to identify the functions of behavior, for example, “what works for an individual in a given context” (p. 415).
Sattler (2014) provides a seven-step guideline for conducting a functional behavioral assessment: define the
problem behavior, perform the assessment, evaluate the assessment results, develop hypotheses, formulate a behavioral
intervention, implement the intervention, and evaluate the effectiveness (pp. 416–417). The crucial step in this
framework is the fourth step, “formulating a hypothesis to account for the problem behavior” (p. 419). Sattler
suggests an extensive 16-point plan to assist practitioners in achieving their goal, noting the following: the type
of behavior; where the problem occurs; when the problem occurs; characteristics of the antecedent events or conditions
and setting; consequences; relevant student background factors; relevant environmental background factors; functions
and goals (escape, attention, control, self-regulation); student’s reactions; others’ reactions; level of teachers’ or parents’
understanding of the nature of the problem behavior; student’s attitude about the learning environment; student
attitude about his or her parents; student’s cognitive and motivational resources for coping; and student, family, school,
and community strengths and resources (pp. 419–420).
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Case Formulation Based on the Cognitive Perspective
Negative appraisals can be part of the maladaptive thought processes inherent in a bias to interpret situations
and behaviors in a negative way (Beck, 1997, 2002). These negative attitudes produce errors in thinking, such
as minimizing the positive and accentuating the negative, which can be automatic and reflexive. For Beck, the
“cognitive triad” refers to thought processes involving feelings of helplessness, hopelessness, and worthlessness.
One potential outcome of this type of thinking bias is the development of learned helplessness, a behavior
pattern based on tendencies to give up in the face of adversity (Seligman, 1975). Cognitive theorists today
believe that learned helplessness is caused by a range of negative attributions that can be global or specific,
blame internal or external causes, and are seen as stable or unstable (Abramson et al., 2002). Attributions that
are global (“Nobody loves me”), internal (“Nobody loves me because I am worthless”), and stable (“No one will
ever love me”) are the most likely combination to result in learned helplessness. Beck suggests that
maladaptive and negative thought patterns often begin in childhood based on responses to negative treatment
and evaluations within the context of their family. For example, research has demonstrated that compared to
mothers who are not depressed, depressed mothers tend to be more inconsistent in their parenting, engage in
less activity with their children, and exhibit more frustration (irritability, control, and impatience) in dealing
with child problems (Malphurs, Field, Larraine, Pickens, & Pelaez-Nogueras, 1996).
Beauchaine, Strassberg, Kees, and Drabick (2002) questioned whether parents using ineffective and harsh methods of discipline fail
to generate alternative solutions due to (a) an availability deficit (limited repertoire) or (b) an accessibility deficit (processing deficit
during times of stress). In order to enhance treatment efficacy, the authors stress the need to address both negative attributions and
affect regulation in parent training programs. They suggest that negative parent attributions may undermine successful use of the
skills taught.
By the end of the preschool period, children have developed consistent expectations about their social worlds
and act accordingly (Main, 1995; Main & Hesse, 1990). Studies have demonstrated that children’s faulty
reasoning about their social relationships can influence inappropriate behavior (Hartup & Laursen, 1993) and
can be reinforced by adult responses to child-behavior patterns. Research suggests that adults respond with
less-than-positive reactions to children who present as “difficult” to manage (Bugental, Blue, & Lewis, 1990),
and that these adult responses can set the stage for a further extension of the child’s belief system. Beauchaine,
Strassberg, Kees, and Drabick (2002) found that parents of children with poor relationship skills were
especially deficient in providing solutions to issues of noncompliance, especially when required to do so under
pressured conditions. The authors recommend the need for treatment plans to target the underlying processes
of negative attribution bias and affect regulation, which they suggest are the pivotal factors that drive coercive
parenting patterns.
Therapeutic Implications: Therapists who use cognitive techniques target maladaptive thinking patterns in
order to increase an individual’s ability to recognize and “reframe” or “restructure” negative thoughts into more
positive and healthy alternatives. Some common maladaptive patterns are overgeneralization, minimization (of
positives), magnification (of negatives), and all-or-nothing thinking. For example, if Sally cancels our movie date,
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I might think to myself, “This always happens to me,” “No one wants to be with me,” or on a more positive note, I
might think, “I guess something came up and Sally had to cancel.” Cognitive programs often include homework
assignments that target day-to-day experiences of negative-thought-inducing situations and exercises on how
to restructure negative thoughts into more positive interpretations. Social skills programs that target problems
in social information processing are also helpful in direct instruction of social information processing
techniques such as encoding social cues, clarifying social goals, appropriate response selection, and monitoring
of the consequences of social actions and reactions (Dodge, 2000).
Cognitive Behavioral Therapy

Although it is possible to provide therapeutic interventions based on cognitive or behavioral perspectives,
practitioners often combine methods in an approach that focuses on the behaviors and thoughts that drive the
behaviors, simultaneously. Cognitive–behavioral therapy (CBT) seeks to facilitate positive integration of
thoughts and behaviors. In their recent meta-analyses, Weisz, Doss, and Hawley (2005, 2006) found that the
most common treatment approaches included some form of behavior or learning approach, and that among
these, CBT was the most frequent treatment for depression. In an earlier study, Weisz, Weiss, Han, Granger,
and Morton (1995) found that an eight-session school-based group CBT program was effective in reducing
symptoms of depression, relative to a wait-list control group. The program focused on activity scheduling and
increasing the likelihood of positive reinforcement. A comprehensive CBT program developed by Stark,
Swearer, Kurkowski, Sommer, and Bowen (1996) emphasized ways to promote positive mood and decrease
negative thought patterns using individual and group formats. Individual sessions provided an opportunity for
children to discuss topics that may be too embarrassing to bring up in the group, while group sessions allowed
for practice in developing social skills within a safe social context.
More recently, Esbjørn and colleagues (2015) evaluated the use of case formulation for cognitive–behavioral
therapy in children (7–12 years of age) with anxiety disorders, under conditions of having parents either as co-
facilitators or co-clients. Comparing the success rates to children’s success rates reported for those who
received therapy by manualized treatment programs, they found the case formulation approach to be as
successful. They found no difference in whether parents were enrolled as co-facilitators or co-clients.
Social Learning Theory

Social learning theory is another theoretical framework that combines cognitive learning theory (learning is
influenced by psychological factors) and behavioral learning theory (learning is based on responses to
environmental stimuli). Bandura, who was most interested in observational learning or modeling, integrated
these two theories, suggesting four pivotal requirements for learning in the social learning model: observation
(environmental), retention (cognitive), reproduction (cognitive), and motivation (both).
Coercion theory came out of the larger behavioral perspective of social learning theory, which at its core has the belief that social
relationships are maintained through rewards and positive reinforcement. However, in nonrewarding or aversive social situations, the
outcome can be negative, resulting in conflict. While reciprocity and positive social exchange are the outcomes of positive
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reinforcement, negative exchanges can give way to coercive and aversive reactions that attempt to exercise control over the behavior
of the other. Patterson (1982) felt that parents were often responsible for unknowingly reinforcing coercive behavior patterns in their
children through such acts as repetitive yelling, and nagging when a child continues to be noncompliant, until the parent reaches the
point of exhaustion, at which point, the parent gives in to the child and the child’s aversive responses are reinforced through negative
reinforcement. Children soon learn that if they misbehave long enough, they will eventually be able to control their parents and get
their way.
Dumas, LaFreniere, and Serketich (1995) observed interactive control exchanges in dyads involving mothers
and children (2.5 to 6.5 years of age) who were socially competent, aggressive, or anxious. The exchanges
between competent children and their mothers were positive and reciprocal with firm limit setting regarding
coercive attempts. Although aggressive children and their mothers engaged in relatively positive exchanges,
there were frequent attempts by the children to gain coercive control and poor ability of the mothers
(inconsistent and indiscriminant attempts) to effectively manage more extreme forms of coercive behaviors.
Exchanges between anxious children and their mothers were predominantly aversive, with mothers using
coercive methods and being unresponsive, and children responding by being resistant and coercive. The study
demonstrated that behavior patterns were influenced by both members of the dyads.
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Case Formulation Based on Psychodynamic and Attachment Perspectives
From a psychodynamic perspective, individuals must come to terms with three components of their
personality: the id (primitive impulses of the libido); the superego (conscience); and the ego, which evolves over
time (reality principle). Freud believed that individuals were only aware of a very small portion of their
motives and beliefs, because the vast majority was hidden from awareness in the subconscious recesses of their
minds. Unconscious conflicts would result in individuals developing fixations or regressions to earlier
psychosexual stages (oral, anal, phallic, latency, genital) based on earlier unresolved issues, while the ego was
often protected through the use of defense mechanisms, such as denial, regression, and repression. Erikson
expanded Freud’s theory to include psychosocial stages defined by tasks that were to be mastered by certain
developmental levels across the lifespan. The development of individual identity requires that the individual
separate from and develop a sense of self unique to the caregiver. Mahler, Pine, and Bergman (1975) describe
this process of separate-individuation as a crucial developmental milestone in the first 3 years of life,
culminating in the rapprochement phase, in which the toddler resolves the dilemma of independence without
vulnerability by developing a sense of object constancy (the caregiver is a secure source of comfort).
Erikson’s first stage (trust versus mistrust) and Mahler’s sense of object constancy provide pivotal points in
development of secure attachment relationships, which was later expanded by Bowlby and Ainsworth in their
theories evolving around issues of attachment. Ainsworth, Blehar, Waters, and Wall (1978) conducted a series
of experiments involving separation and reunion between mothers and infants, called the Strange Situation
experiments. As a result of these studies, two broad categories of responses defined the areas of secure versus
insecure attachment. In the secure attachment situation, although infants protested their mother’s leaving,
they were able to be soothed by the mother upon her return. Infants who were insecurely attached responded
to mother’s leaving and reunion in two different ways. Infants who were “anxiously attached” or
“anxious/resistant types” were distressed upon mom’s leaving but were unable to be soothed upon her return,
often responding with continued distress evident in arching their backs, or crying and squirming. Others,
labeled “avoidant attachment,” responded to mom’s leaving and return by ignoring both events. Later, Main
and Weston (1981) added a fourth category, “disorganized/disoriented attachment,” which they discovered in
their work with abused children. These children displayed atypical patterns of inconsistent and contradictory
(approach and avoidance) behaviors and volatile emotions. Studies of the outcomes of attachment styles have
reasoned that these early patterns may result in embedded templates for future relationships (internal working
models [IWM]), since studies have found that children who are securely attached are more independent and
better problem solvers than their insecure peers (Sroufe, 2002), who are at risk for self-representations that see
the self as “unlovable and unworthy” (Cicchetti & Toth, 1998).
Bowlby’s interest in the evolutionary importance of infant–caretaker relationships initially envisioned

“survival” as the goal to maintaining proximity to the caregiver. He later combined psychoanalytic and
ethological insights into a theory of socioemotional development, which envisioned early experiences with
attachment figures becoming later canalized as emotional responses to others through reference to resulting
cognitive representations (internal working models: IWM) of attachment relationships acquired during this
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early period (Cox, 2013).
However, in the early 1970s, debate began regarding whether insecure attachment was the result of impaired
attachment due to insensitive early caregiving or the result of differences in child temperament. Kagan and
Snidman (2004) found that motor activity at 4 months of age (low or high reactive) predicted social
engagement that remained stable at 2 years of age. Children who were highly reactive to stimuli were socially
inhibited, while those who demonstrated low levels of reactivity were socially engaged. However, even in these
longitudinal studies the extremes of behavior noted at an early age modified over time, suggesting the
importance of environment as a moderating condition.
Greenberg (1999) has embedded attachment theory in an ecological-developmental framework to explain

psychopathology resulting from the interplay of factors evident in the child, parent, and environmental
context. Drawing on principles of equifinality (different pathways may lead to the same disorder) and
multifinality (similar disorders may produce multiple outcomes), Greenberg builds his model drawing on four
underlying processes found in theoretical models of attachment: internal working models, neurophysiology of
emotion regulation, observed behaviors, and functional-motivational processes. The degree of security or
insecurity inherent in primary attachment relationships provides internal working models or templates for all
future relationships (Ainsworth et al., 1978; Belsky, 1988; Bowlby, 1982). While secure attachments can be a
protective factor, insecure attachments may place the child at increased risk for developing problems.
According to Greenberg, neurological findings (neurophysiology of emotion regulation) suggest that humans
require positive experiences of resolving fearful situations to allow for a build-up of brain structures that help
to regulate responses to anxiety and fear-producing situations (Siegel, 1999). In dysfunctional attachment
relationships, caregivers are not a source of assistance in the regulation of emotion and can become a source of
threat. Deficits in the acquisition of mechanisms to regulate emotions result in an inability to self-soothe
when upset, thereby reducing the ability to cope in stressful situations. As far as observed behaviors are
concerned, Greenberg suggests that avoidance behaviors may serve an instrumental role in the attachment
process by acting to control and regulate caregiver proximity and attentiveness. Ultimately, maladaptive
attachment patterns can help explain the functional-motivational processes that can negatively influence social
orientation and subsequent prosocial competencies, including poor social adaptation and withdrawal from
social contact. Secure attachments can lead to better understanding rather than avoidance of negative
emotions (Laible & Thompson, 1998).
More recently, studies have investigated whether differences in attachment strategies may represent
differences in how the brain processes sensory information (Strathearn, 2006). Longitudinal studies have
demonstrated that adult attachment patterns, such as those measured by the Adult Attachment Interview
(AAI; George, Kaplan, & Main, 1996), can reliably predict maternal caregiving patterns, which in turn can
predict subsequent social⁄emotional development (Sroufe, Egeland, Carlson, & Collin, 2005) and attachment
(Shah, Fonagy, & Strathearn, 2010; van IJzendoorn, 1995) in the offspring.
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The Adult Attachment Interview (AAI) classifies attachment into categories of secure attachment and insecure attachment. Insecure
attachment is further classified as either dismissing or preoccupied. Studies have linked the dismissing type of attachment with
difficulties in adolescence in areas of seeking support (overly self-reliant), tendencies to withdraw, lack of trust in others, and weaker
social skills (Allen et al., 2002; Larose & Bernier, 2001), while adolescents with the preoccupied type of attachment evidence
externalizing traits associated with delinquent activities such as the use of violence and aggression toward the self or others
(Bakermans-Kranenburg & van IJzendoorn, 2009).
Strathearn (2011) provides an overview of maternal care-giving behavior that draws on neurobiological
sources to help explain maternal neglect. He specifically addresses how “the oxytocinergic and dopaminergic
systems” interact to inform the mother how to interpret cues from the infant and how to subsequently respond
to those cues. It is his suggestion that oxytocin may be responsive for activating the dopaminergic reward
pathways in response to social cues. Strathearn supports his theory with research evidence that mothers who
have insecure or dismissing attachment patterns (which have been associated with emotional neglect) evidence
“reduced activation of the mesocorticolimbic dopamine reward system in response to infant face cues, as well
as decreased peripheral oxytocin response to mother–infant contact” (p. 1054). Furthermore, Strathearn
hypothesizes from an epigenetic perspective that “attachment” patterns may be transmitted
intergenerationally, mediated by maternal responses to infant cues that are determined at a neuroendocrine
level. The fact that levels of oxytocin and dopamine can be inherited also sets the stage for future patterns of
similar types of insecure attachment, future responses to situations that are stressful, or those that rely on
social engagement. According to Strathearn (2011), “from the emerging field of epigenetics, we are beginning
to understand how the caregiving environment may influence the development of biological systems and
behavioural phenotypes, via stable changes in the regulation of gene expression” (p. 1057).
Therapeutic implications.
Therapeutic attempts to improve the attachment relationship have remained largely rooted in a
psychodynamic approach and have focused primarily on infant–parent psychotherapy (see Lieberman &
Zeanah, 1999, for review). Many of the programs are lengthy due to the emphasis on building a therapeutic
working alliance with the therapist and the need for extensive ongoing assessments of child–parent or child–
caregiver (foster care) interactions and family circumstances. Observations and discussions of joint play
provide opportunities for insight-oriented dialogue designed to assist parents in acquiring more appropriate
perceptions of their child and developing interactional patterns that have greater empathic attunement with
the child’s needs. Based on the belief that obstacles to attachment can occur on several levels (infant, parent,
environment), therapeutic goals in these programs are to determine the nature of the obstacles blocking
attachment (individual differences) and to design treatment to address these specific areas (Zeanah et al.,
1997).
The Seattle Program, developed by Speltz and colleagues (Greenberg & Speltz, 1988; Speltz, 1990), is a
parent training program to assist families of children with insecure attachment that melds attachment theory
with a cognitive–behavioral approach. The program focuses on communication breakdown in the parent–
child dyad and emphasizes the need for better “negotiation skills.” The four-phase intervention program
includes components of parent education, reframing of the child’s behaviors within a developmental
framework, limit setting and problem prioritizing, and communication and negotiation skills.
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Although the realm of the unconscious renders many of the psychodynamic therapies without empirical
support, the application of psychodynamic principles to play therapy has revealed success of a program,
psychodynamic developmental theory of children (PDTC), for children with behavioral issues (Fonagy & Target,
1996). The program has been successful in increasing skills in areas of self-regulation of impulses, capacity to
play effectively, and awareness of others.
The foundations of psychodynamic theory are rooted in uncovering the internal and often unconscious processes that drive an
individual’s behaviors and the internal working models responsible for a weakened sense of ego development. As such, the
psychodynamic approach is not an easy fit with empirical research. While Messer (2000) has called for the development of databases
for case-based research to remedy this problem, Fonagy, Target, Cottrell, Phillips, and Kurtz (2002) have provided empirical support
for the PDTC approach, which has an 85% success rate for internalizing disorders.
Thinking Outside the Box.
Strathearn (2011) compared secure and insecure mothers’ responses to facial pictures of their infant and
reunion with their infant after separation and found that mothers with an insecure⁄dismissing pattern of
attachment may have impaired peripheral and central oxytocin production, which may help to account for the
reduced activation of reward processing regions in the brain when presented with facial cues or opportunities
for reunion with the infant. Based on results from rigorous experimental studies of the use of intranasal
oxytocin in enhancing social responsiveness in areas such as social memory eye gaze and sense of trust,
Strathearn is in the process of conducting randomized trials to investigate the potential benefits of intranasal
oxytocin in enhancing maternal brain and behavioural responses in mothers with dismissing forms of
attachment.
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Case Formulation Based on Parenting Style and Family Systems
Perspectives
Baumrind (1991) investigated parenting styles, or the prevailing attitude and climate evident in the amount of
structure and warmth parents provided in the process of parenting, and the outcomes that the different styles
had on children’s development. In 1966, Baumrind suggested three primary parenting styles that captured
clusters of parenting behaviors and childrearing goals: authoritative parenting, authoritarian parenting, and
permissive (indulgent) parenting. Later, Maccoby and Martin (1983) added a fourth style, neglectful
parenting. These parenting styles are characterized by emphasis on various combinations of warmth,
demandingness or control, and autonomy granting, although the majority of research has focused on two of
the dimensions: warmth and demandingness or control. The combinations evident in each of the styles are as
follows: authoritative (high warmth, high control), authoritarian (low warmth, high control), permissive (high
warmth, low control), and neglectful (low warmth, low control).
Most recently, Baumrind, Larzelere, & Owens (2010) emphasized the distinction between the different types
of demandingness or control exercised by parents using authoritative versus authoritarian parenting styles.
Although both parenting styles are “demanding, forceful, and power-assertive,” the two styles differ in how
they exert “power.” “Although both authoritative and authoritarian parents use confrontive discipline, which is
firm, direct, forceful, and consistent, authoritarian parents differ from authoritative parents in that they also
use coercive discipline, which is peremptory, domineering, arbitrary, and concerned with retaining hierarchical
family relationships” (p. 158).
While authoritarian parents are concerned with maintaining status as power, authoritative parents exercise
control that is “reasoned, negotiable, outcome-oriented, and concerned with regulating behaviors.” In their
study of the longitudinal effects of parenting practices, Baumrind et al. (2010) isolated five different types of
coercive practices: (1) unqualified power assertion, (2) arbitrary discipline, (3) psychological control, (4) severe
physical punishment, and (5) hostile verbal criticism. The study compared the emotional health (low level of
behavioral problems) and competency (social and academic achievement) of adolescents whose parents
employed different types of parenting styles during the preschool period. Results revealed that adolescents
reared by authoritarian power-assertive practices evidenced low communal competence, high internalizing
problems, and low self-esteem, compared to adolescents reared by authoritative and directive parents who
were prosocial and well-adjusted.
In most situations, the authoritative parenting approach (high structure and high warmth) is the desired
practice and yields the best child outcomes. The authoritarian parenting style, although high on structure, is
very low on warmth, and children raised in this type of household may become aggressive and uncooperative.
Parents who are uninvolved provide little structure or warmth, and children are prone to develop a number of
negative traits, including truancy. Permissive parenting provides warmth but minimal structure. Based on an
avoidant attachment pattern and authoritarian parenting practices, parent–child dyads can be thrust into a
hostile-helpless pattern, with one member of the dyad being the hostile aggressor and the other member
becoming the passive, helpless, and overwhelmed recipient (Lyons-Ruth, Bronfman, & Atwood, 1999).
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Is the authoritative parenting style the best style for all children, regardless of environment or culture? Research suggests that the
authoritarian parenting style may actually be more suited to raising children who live in neighborhoods that are at increased risk for
youth engaging in violent behaviors (Bradley, 1998). Studies have also demonstrated that regardless of culture, stress may be the key
variable in moderating parenting style, with increased stress associated with increases in adopting an authoritarian parenting style
(Sue & Hynie, 2011).
Parenting style can also interact with other environmental conditions such as socioeconomic status (SES),
with lower SES predictive of increased risk for negative child outcomes in areas of academics, behavior, and
social difficulties (Dodge, Pettit, & Bates, 1994). However, studies that have included data on maternal
education suggest that higher maternal education is associated with better child outcomes regardless of SES
(Callahan & Eyeberg, 2010).
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The Eye of the Tiger: What is Tiger Parenting?
The term tiger parenting made its way to North America when Amy Chua (2011), a Yale law professor, published Battle Hymn of the
Tiger Mother. The term “tiger mother” originated in China and is well known in Asia. Chua chronicles how her Chinese heritage
prepared her to raise her daughters with strict policies that were driven by the goal to succeed academically (be a straight-A student).
The girls were not allowed to watch TV, play games on the computer, or participate in sleepovers. As a result, Chua reasons they
were highly successful academically and accomplished musicians. Although there are similarities between tiger parenting and
authoritarian parenting, in the focus on adherence to strict rules and routines, tiger parenting also includes the positive element of
“support” (Kim, 2013).
In addition to parenting style, family systems theory has also influenced how we conceptualize the family unit
as the focus of assessment and intervention. The family unit is composed of many subsystems: parent–child,
marriage partners, siblings, extended family, and so on. Within families, behaviors are often directed toward
maintaining or changing boundaries, alignment, and power. Often, a family’s degree of dysfunction can be
defined by boundaries that are poorly or inconsistently defined, or those that are too extreme (too loose or too
rigid). Minuchin (1985), a proponent of structural family therapy, described several family patterns that can
contribute to dysfunction. In enmeshed families, boundaries between family members are often vague, resulting
in family members being overly involved in each other’s lives. According to Minuchin, enmeshed families
(lacking in boundaries) may see a child’s need to individuate as a threat to the family unit. Triangular
relationships are alignments between family members that serve to shift the balance of power and can include
the parent–child coalition, triangulation (e.g., mother and sibling, versus father), and detouring (maintaining the
child as the focus of the problem to avoid acknowledging other family problems, such as marital conflict).
Research with a focus on the family systems model has been instrumental in developing treatment programs
for children (Fosco & Grych, 2013) and adolescents (Grych, Raynor, & Fosco 2004). Research has focused on
such issues in children as the influence of family on emotion regulation and the role of parent conflict on
children’s conflict appraisal (DeBoard-Lucas, Fosco, Raynor, & Grych, 2010; Fosco, & Grych, 2013). Studies
with adolescents have covered such topics as the impact of intraparental conflict on adolescents, family
cohesion, and subjective well-being (Fosco, Caruthers, & Dishion, 2012; Grych et al., 2004).
Treatment implications.
Therapists can work with parents to better understand their parenting style and to understand the benefits of
adopting a consistent parenting approach that more closely resembles the authoritative parenting style. Within
the family systems approach, the family therapist would create an alliance by joining the family and observing
family interactional patterns from the inside out. Once the problem has been formulated, the therapist works
with the family to restructure the family interactions toward positive growth and change, such as repositioning
the balance of power and improving problem solving and communication.
Several treatment programs have been developed that use family systems theory and principles in conjunction
with other therapeutic models and techniques. The following is a discussion of just two of the main bodies of
research in this area.
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Parent–child interaction therapy (PCIT) is a parent management training (PMT) program that was developed
for use with individual families to assist in addressing behavioral problems (oppositional defiant and other
behavior disorders) in children 2 to 7 years of age (Eyberg, Nelson, & Boggs, 2008). The program focuses on
two significant components: child-directed interaction (CDI) with a goal of enhancing the parent–child
relationship; and a parent-directed interaction (PDI) component that focuses on increasing child management
strategies. PCIT is an evidence-based treatment model that integrates aspects of play therapy, behavior
therapy, as well as social learning and family systems theories (Neary & Eyberg, 2002). The program typically
involves 12 to 20 weeks of commitment. The program has been demonstrated to be effective in the treatment
of a variety of behavioral problems and there is increasing evidence that the program is as effective when
delivered in a group or individual format (Niec, Barnett, Prewett, & Chatham, 2016).
The Oregon Model of family behavioral therapy had its beginnings 4 decades ago (Patterson, Chamberlain, &
Reid, 1982) and over the course of time has seen the development of a number of intervention strategies that
have been effective in alleviating behavior problems in children and adolescents. Currently, there are three
models that have been developed to target needs in specific areas: the Family Check-Up Model; Parent
Management Training–Oregon model; and Treatment Foster Care–Oregon Model (Dishion, Forgatch,
Chamberlain, & Pelham, 2016). The Oregon group was one of four research initiatives using family behavior
management strategies that spearheaded parent training programs based on core principles that emphasized
the role of parents—as training agents, observers, recorders of data, and managers of contingency programs.
The research filled an important niche regarding how to assist parents in managing child behaviors in a way
that would halt the development of problem behaviors into more serious forms of delinquency and antisocial
behaviors. Observations that child outcomes were worse for children whose parenting practices were at either
end of the discipline spectrum (overly lax or overly harsh) lead Patterson (1982) to develop the coercion model
based on coercion theory. Later research demonstrated that coercive cycles emerge slowly from repetitive
patterns and cumulative interactions between infants who are very demanding and mothers who are
unresponsive and detached. Over time, these demanding infant and disruptive toddler behaviors predict
disruptive behaviors in childhood (Keenan and Shaw, 1995).
The Parent Management Training Oregon Model (PMTO) contains the underlying interventions and
techniques that are used in all of the Oregon models, with a goal to reduce coercive parenting practices and to
replace these with positive parenting, through the use of positive reinforcement, setting appropriate limits,
and discipline; monitoring and supervision; interpersonal problem solving; and emotion identification and
regulation (Dishion et al., 2016). Significant benefits of the PMTO have been documented empirically for
youth, in such areas as reduced noncompliance, reduced incidences of aggression on the playground, and
police arrests, and for parents in areas of decreased incidences of coercive parenting and increased use of
positive parenting techniques (Forgatch & Patterson, 2010).
The Family Check-Up (FCU) was designed as an initial stage (intake) to assist families in distress and provides
families with feedback concerning the family assessment conducted at that time. Involvement in FCU has
been related to increased parental motivation and engagement in the parent training program and reduced
coercive conflict as well as antisocial behavior (Stormshak et al., 2011; Van Ryzin & Dishion, 2012).
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The Treatment Foster Care–Oregon Model (TFCO) was developed as an alternative to group homes or
residential placements that have not been successful for a number of reasons (Wilmshurst, 2002), including
possible iatrogenic effects of aggregating youth with similar problems increasing the opportunities for
deviancy training (Poulin, Dishion, & Burraston, 2001). The program was developed for youth who can no
longer be managed at home and involves the placement of these youth in special foster care homes under the
supervision of foster parents who have been specifically trained in behavioral methods and the consistent
application of supervision, modeling, and discipline. The youth are placed in the setting for 6 to 9 months
until ready to be reunited with their family or other longer term placement. Foster parents are provided with
daily and on-going support. Therapists also work closely with family members to provide parenting skills to
enhance opportunities for success upon reunification.
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Integrating Theoretical Perspectives: A Transactional Ecological Bio-
Psycho-Social Framework
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Bronfenbrenner and the Contexts of Influence
Bronfenbrenner’s (1979, 1989, 2005) ecological systems theory was developed to explain the importance of
contextual influences on human development and provides an excellent framework for the integration of
numerous theoretical perspectives. Bronfenbrenner depicts the child at the center of a series of concentric
circles, each circle representing a level of influence. Interactions between the child and the environment are
ongoing and transactional, such that changes at one level can influence changes at other levels. The direction
of influence is bidirectional in that a child’s behavior can influence a parent, and a parent’s behavior can
influence the child. For example, in the interaction between the child and his or her parent, responses have a
reciprocal influence and both can be altered in the process. Bronfenbrenner and Morris (1998) have suggested
that the model might more appropriately be referred to as a bioecological model to emphasize biological
characteristics in the dynamic and ongoing interplay between the child’s characteristics (biological and genetic)
and the environmental characteristics (proximal and distal factors).
In discussing the dynamic interchange between the child’s characteristics and environmental characteristics, it is important to revisit
theories of epigenesis and the recent contributions to our knowledge from the field of neuroscience. Within the probabilistic
epigenesis framework, individuals with the same genotype can have different neural and behavioral outcomes based on the
dissimilarity or uniqueness of their relevant life experiences (Gottlieb, 2007).
The ecological-transactional model (Bronfenbrenner, 1979; Cicchetti & Lynch, 1993) can provide an
overarching framework for discussing ecological contexts “consisting of a number of nested levels with varying
degrees of proximity to the individual” (Lynch & Cicchetti, 1998, p. 235). Initially, Bronfenbrenner proposed
three levels of environmental influence: the microsystem, the exosystem, and the macrosystem. The microsystem
represents the immediate environment and includes influences of family (caregivers and siblings), teachers,
peers, the neighborhood, and school settings. Next is the exosystem, which incorporates influences from more
distal factors, such as parents’ employment and socioeconomic status. The macrosystem is the outer rim that
represents influences resulting from cultural beliefs and societal laws. Bronfenbrenner refers to the
communication among factors within the microsystem as the mesosystem, which can be a very potent influence
in the child’s ongoing success. Ultimately, a fourth dimension was added, called the chronosystem, which refers
to the cumulative effect of one’s experiences over the course of a lifetime and includes environmental events
and important life transitions (such as graduation, change of schools, divorce, birth of a sibling).
Bronfenbrenner’s (2005) ecological system evolved into what he referred to as the Process-Person-Context-
Time (PPCT) Model comprised of four interrelated components: developmental process (dynamic
interactions/relationship between the individual and the context), person (the individual’s biological, cognitive,
emotional, and behavioral characteristics), context of human development (the system of nested influences), and
time (temporal aspects that moderate change over the course of development/chronosystem, such as
ontogenetic time, family time, and historical time).
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Mesosystem Effects. If parents and teachers communicate regularly and share the same goals for the child, the potential for academic
success will increase significantly. Conversely, poor communication between home and school has been associated with increased risk
for academic difficulties. Similarly, if both parents share the same goals in their communications with the child, the child will benefit
from the consistency in the message. Bronfenbrenner referred to the system of communication between influences in the child’s
microsystem as mesosystem effects.
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A Transactional Ecological Bio-Psycho-Social Framework: Risks and
Protective Factors
Bronfenbrenner’s model also provides an excellent framework for a discussion of risks and protective factors
that can influence development on a number of different levels.
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Individual Person
Bronfenbrenner (2005) considered the person to be at the core of the series of concentric circles. Each
individual brings unique contributions to the developmental process in terms of their biological, cognitive,
emotional, and behavioral characteristics. Research has demonstrated that from a very early age, as young as 4
months of age, temperament (reactivity and self-regulation) can predict social engagement at 2 years of age.
Infants who demonstrated high-reactive traits were more likely to evidence shy, timid, and fearful responses to
unfamiliar events in their second year (Kagan, 2003). Evidence of such in-born wiring has led Kagan to
believe that different temperamental types are inherited by a distinct neurochemistry that affects the
excitability of the amygdale, and brain activation, with low-reactive children showing more activation on the
left compared to right frontal activation, whereas the reverse was true for high-reactive children who later
demonstrated behavioral inhibition (BI). Kagan also suggests that the inability to moderate stress may signal
impairment in the GABA system, which inhibits neural activation in stressful situations and allows
individuals to regroup. The hypothesis about GABA malfunction is interesting since impairment in GABA is
implicated in many anxiety disorders, and although behavioral inhibition (BI) is a temperamental factor, it
shares many similarities with social anxiety disorder (e.g., wariness, avoidance, and fear). Caouette and Guyer
(2014) hypothesize that during childhood, atypical functioning in a number of areas of the brain (i.e.,
amygdala, basal ganglia, and prefrontal cortex) influences the tendency to develop a cautious approach to
unfamiliar situations for individuals with inhibited temperaments. They reason that when children with BI
enter adolescence, they are at increased risk for developing social anxiety disorder (SAD) resulting from a
conflict between “increased desire for social reward and extreme fear of humiliation or embarrassment . . . a
vulnerability moderated in part by a history of inhibited temperament” (p. 67).
Whereas Kagan believes that behavioral inhibition is directly related to temperament, Cassidy (1994) suggests
that emotion regulation strategies (i.e., responses to events and circumstances meant to regulate emotions,
through suppression or heightened expression of emotions) are related to an individual’s attachment style.
Subsequent longitudinal studies (Schmidt, Nachtigall, Wuethrich-Martone, & Strauss, 2002; Seiffge-Krenke,
2006) conducted regarding insecure attachment patterns (e.g., avoidant/dismissing patterns, or
ambivalent/preoccupied patterns) have found that individuals with the dismissing pattern tend to consistently
use strategies to minimize emotional connectiveness while increasing aggressive responses, compared to those
with preoccupied patterns who tend to be more emotionally dependent and used more negative, ineffective
emotional coping strategies.
Within the area of attachment, Strathearn (2011) has suggested that the transmission of attachment patterns
across generations may be mediated by the mother’s neuroendocrine responses to infant cues, which may in
turn set the stage for infant development of similar patterns either genetically or through a social learning
process that continues to influence the intergenerational transfer within an epigenetic framework. Strathearn
discusses the strong link between social and parenting behaviors and biological mechanisms such as the
oxytocinergic and dopaminergic neuroendocrine systems, which is supported by evidence that women who
report childhood emotional neglect show significantly reduced levels of oxycontin in their system. Support for
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the role of oxytocin in social information processing was recently demonstrated in a study of individuals with
Asperger’s syndrome (AS). Individuals with AS process information about faces in the same region of the
brain that others process information about objects. Domes, Kumbier, Heinrichs, and Herpertz (2014) found
that a dose of oxytocin applied through a nasal spray enhanced facial emotion recognition and amygdala
reactivity in adults with AS. Strathearn (2011) is currently investigating whether a similar procedure used on
mothers who have low oxytocin levels might increase their positive social responsiveness to their infant’s cues.
Other characteristics that can increase the risk for negative outcomes include male gender (Rutter, 1979),
physical handicaps (Werner & Smith, 1992), and having a difficult temperament (Bates, Pettit, Dodge, &
Ridge, 1998). Protective factors at this level include good intelligence, a positive self-concept, effective
emotional and self-regulation, an outgoing style of social engagement, and easy temperament (Alvord &
Grados, 2005; Kitano & Lewis, 2005; Masten & Coatsworth, 1998; Passer & Smith, 2004).
Microsystem
The microsystem encompasses the most proximal influences, including the child’s family, school, peers, and
neighborhood. It is at this level of influence that we see how the process of development unfolds, for better or
worse. In an environment of positive and supportive influences, the child learns to trust, develop a secure
attachment to the caregiver, and construct an internal working model (IWM) that will serve as a blueprint for
social relations with other individuals inside the family (siblings, extended family) and outside the family
context (teachers, peers, coaches, and mentors). However, inadequate, inconsistent, or inappropriate parenting
styles; poor monitoring of child behavior; peer rejection; or other adverse experiences can have a profound
effect on development.
Whereas children who experience risks in their immediate environment (microsystem) are prone to
developing externalizing problems, disturbances at the exosystem level—for example, family hardship—can
increase the risk for internalizing problems (Atzaba-Poria, Pike, & Deater-Deckard, 2004). We also know
that the number of risks experienced can add significantly to the overall risk. For example, the combined effect
of social maladjustment and poor academic achievement can result in a multiplier effect that can have a fourfold
increase in the risk for long-term adjustment problems relative to the presence of only one risk factor
(Burchinal, Vernon-Feagans, & Cox, 2008; Sameroff & Fiese, 2000). Egeland and Sroufe (1981) found that
within the immediate environment (microsystem), having an anxious and insecure attachment pattern can
place a child at risk for maltreatment (anxious attachment), while an avoidant attachment pattern can increase
the risk of physical abuse or having a parent who is emotionally unavailable.
The interaction between biological and environmental factors has also been suggested as a possible mechanism
for exacerbating the outcomes of having a temperament high in behavioral inhibition (BI) evident in extreme
tendencies to avoid social situations. Williams and colleagues (2009) investigated the role of BI and parenting
styles on externalizing and internalizing behaviors in children 4, 7, and 15 years of age. The researchers found
that at 4 years of age, children with BI had the most internalizing problems if they were also exposed to a
permissive parenting style, whereas being exposed to an authoritative parenting style reduced internalizing
problems over time.
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Remember from a biopsychological and probabilistic epigenesis perspective, it has been proposed that attachment can also be
influenced intergenerationally and that “attachment” or “lack of attachment” messages may be sent to infants by mothers based on
neuroendocrine responses (oxytocinergic and dopaminergic neuroendocrine systems) to infant cues that shape caregiving behavior.
This dynamic, in addition to any genetic variation, may also influence the infant’s neuroendocrine development and set the stage for
infant behavioral response patterns (Strathearn, 2011).
Risk and protective factors can be conceptualized along a continuum where a factor can be considered a risk if
it is at one end of the spectrum, and a protective factor at the opposite end (Masten & Powell, 2003). For
example, while having a positive self-concept can serve as a protective factor and buffer a child from harm,
having a poor self-concept can increase the risk for negative outcomes.
While social difficulties can increase the risk for negative outcomes, such as school dropout and delinquency (Blum et al., 2000),
gender can make a difference in the nature of these risks. Girls who feel isolated and are without friends are twice as likely to engage
in suicidal ideation as girls who belong to a social circle. While girls are protected from suicide by a supportive and cohesive network,
for males, sharing activities with friends was a protective factor (Bearman & Moody, 2004).
Family dynamics and family context can influence development on a number of levels, including a child’s
ability to regulate emotions. Fosco and Grych (2013) found that whereas maternal warmth and sensitivity and
having a positive family climate were predictors of the development of positive skills in areas of emotion
regulation, interparental conflict was associated with weaker development of emotion regulation in children.
Grych, Raynor, & Fosco (2004) found that for adolescents, a close relationship with their fathers acted as a
protective factor and was related to reduced symptoms of maladjustment. DeBoard-Lucas, Fosco, Raynor, &
Grych (2010) investigated the relationship between interparental conflict and child self-blame in 150 8- to
12-year-olds and found that a mother’s coercive or controlling and emotionally unsupportive parenting
significantly increased the association between conflict and child self-blame, while emotionally supportive
parenting practices and secure attachment with fathers reduced tendencies for child self-blame regarding
interparental conflict. DeBoard-Lucas et al. concluded that “supportive responsive parenting can buffer the
effects of interparental conflict on children by reducing self-blaming attributions for parental discord” (p.
163).
Parenting style has also been implicated in influencing child behaviors for better or worse. Baumrind’s (1991)
work on parenting styles has inspired several studies that have provided support for the notion that
authoritative parenting (emphasizing high degree of warmth and democracy and negotiation, with a focus on
encouraging autonomy by combining high warmth with high control) has been associated with positive child
outcomes in areas of self-esteem and academic achievement. In their study of over 350 mothers of fourth
graders, Fletcher, Walls, Cook, Madison, and Bridges (2008) found that authoritative and authoritarian
mothers were less likely to yield to coercive tactics than indifferent or indulgent mothers. In addition, within
authoritarian families, tendencies to yield to coercive patterns of behavior resulted in increased problems in
areas of internalizing and externalizing, as well as social skills. Within indulgent parenting styles, greater use
of punitive discipline was associated with more externalizing problems, while within the authoritarian group
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more internalizing problems were evident.
Adverse child experiences (ACEs) can include exposure to such negative circumstances as neglect, abuse,
domestic violence, and maternal depression and can place children at increased risk for developing a number
of negative outcomes. Clarkson Freeman (2014) examined the prevalence of ACEs and the emotional and
behavioral outcomes among children (birth to 6 years of age) in a large national sample using data from the
2014 National Survey of Child and Adolescent Well-Being (NSCAW). Results revealed that 70% of the
sample had experienced at least three ACEs, and that exposure to three or more ACEs increased the risk of
internalizing problems more than 4 times, while increased risk for externalizing problems was almost 4 times
greater. As a result, Clarkson Freeman advocates for increased screening and early intervention.
Using data from the Adverse Childhood Experiences Study (ACE, 1998), a retrospective investigation of
adult reports of early adverse experiences, Anda et al. (2006) report on a number of changes in stress-
responsive neurobiological systems as well as brain structure and function resulting from exposure to ACEs.
Results support other investigations of impaired memory of childhood experiences. The researchers found that
as the ACE score increased, impairment in memory increased, suggesting dysfunction in the hippocampus, as
well as, impairments in other neurological areas, including “the amygdale, medial prefrontal cortex, and other
limbic structures associated with anxiety and mood dysregulation following early abuse” (p. 181).
Exposure to violence (ETV) is highest among ethnic minorities, lower SES youth, and those living in inner
cities (Buka, Stichick, Birdthistle, & Earls, 2001) and has been associated with increased risk for engaging in
violent behaviors (Richters, 1993). As many as 27% of African American youth who have experienced
repeated ETV have symptoms of posttraumatic stress disorder (Fitzpatrick & Boldizar, 1993). However, risk
factors seem to be highest for street children (children socialized into their street role at an early age)
compared to non-street children (parents take a more supportive role and monitor their activities) who are
better equipped to survive in a conventional world (Jarrett, 1998). Case studies in Chapter 7 discuss some of
the outcomes of different adverse child experiences.
Maxfield and Widom (1996) found that 49% of children who were victims of abuse or neglect were arrested for any nontraffic
offense, compared to controls (38%) or committing a violent crime (18% vs. 14%). Almost half of the victims of abuse and neglect
were arrested for nontraffic offenses by the time they were 32 years of age.
Protective factors in the family that can assist in buffering a child in adverse circumstances include secure
attachment; at least one parent or caregiver who is nurturing and emotionally supportive, who provides firm
limits and boundaries; authoritative parenting style; parental monitoring; and structured family routines (Bee
& Boyd, 1999; Alvord & Grados, 2005; Kerr & Stattin, 2000; Luthar, 2006; Masten, Cutulti, Herbers, &
Reed, 2009; Rak & Patterson, 1996).
Other protective factors at this level that can influence positive development include role models outside the
family that act as potential buffers, friendships with prosocial peers, a positive school environment, and
involvement in after school and extracurricular activities (Alvord & Gados, 2005; Masten, 2007; Rak &
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Patterson, 1996).
Box 1.17 Adverse Child Experiences and the Brain
Alvord and McEwen (2013) discuss why early adverse experiences can alter brain activity due to what they refer to as “biological
embedding” resulting from gene–environment interplay that in a sense programs the individual to respond to stressors both internal
or external, in a certain way. However, they also suggest that it is possible that “adaptive calibration” (e.g., extreme conditions early
in life can alter neural and physiological patterns) may have a protective effect in preparing an individual to function better in the
expected extreme environment (e.g., an individual living in high-risk and chaotic conditions may become more vigilant and anxious
and better able to adapt to a high-risk situation than an individual living in a secure environment who is thrown into adverse
conditions).
Exosystem
The exosystem involves the influences of the community and social institutions (such as government and
health care) and prevailing economic conditions (such as employment conditions, inflation rates, and poverty).
According to a recent report by the Children’s Defense Fund (CDF; 2014), 21.1% of children were living in
poverty (defined as a family of four earning less than $2,019 a month, $466 a week, or $66 a day), while
11.4% were living in extreme poverty (living below half the poverty level). Black and Hispanic children are
among those living in the highest rates of poverty, with approximately 2 in 5 Black children and 3 in 10
Hispanic children living in poverty in 2014, compared to 1 in 8 White children.
Protective factors that have been found to exist at this level include availability of economic support for
families and good public health care (Alvord, 2005; Wright & Masten, 2005).
Children living in poverty are at increased risk for abuse or neglect (22 times more likely), poor health (5 times more likely), and
have absences from school in excess of 1½ times compared to those not living in poverty (Maxfield & Widom, 1996).
Macrosystem
The macrosystem is the level of influence that relates to cultural factors or changes in policy that may impact
large institutions, such as schools and businesses on a grand scale. Research concerning the effect of culture on
parenting practices has received increased emphasis in the past decade. A large body of research has been
accumulated on outcomes associated with the parenting styles, as originally proposed by Baumrind (1966).
The authoritative parenting style was initially thought to be the best style of parenting for all parents. More
recently, inclusion of cultural influences in dynamics of parenting have suggested that, although this form of
parenting can serve as a protective factor for a wide variety of children, its influence is most strongly felt in
European American families from middle-class backgrounds. Within this population, positive outcomes have
been noted in a number of areas, including self-esteem, social skills, and academic achievement. An
authoritative parenting style that includes parental monitoring and supervision can enhance an adolescent’s
exposure to positive activities and reduce an individual’s chances of engaging in delinquent or high-risk
behaviors (Wargo, 2007). A warm but firm approach to parenting allows teens to be independent within the
boundaries of developmentally appropriate parental limits. On the other hand, use of the authoritarian
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parenting style has been associated with increased behavior problems and reduced academic success
(Thompson, Hollis, & Richards, 2003).
Although the authoritative parenting style appears to be the gold standard among White families, the
authoritarian style of parenting appears to be more common among ethnic minority families than among
White families. Researchers suggest that these differences in styles may be related to the influence of culture
on parental belief systems and subsequent parenting practices. Although authoritative parenting is less
common in ethnic minority families, this parenting style has been linked to adolescent competence across a
wide range of families (Steinberg & Silk, 2002), with adolescents in minority families benefiting as much
from authoritative parenting as their nonminority peers.
However, within the context of the influences associated with the macrosystem, Chaudhuri, Easterbrooks,
and Davis (2009) suggest that “conceptualization of parenting in minority groups provides a broad definition
of what cultural context can be: a representation of ethnicity, income, immigration experience, and culture” (p.
294). Since different cultural groups support different goals for socialization, it is not surprising to find that
childrearing practices vary among these diverse groups (Chao, 2000; Hughes, 2001; Polaha, Larzelere,
Shapiro, & Pettit, 2004).
In their study of African American mothers, Cain and Combs-Orme (2005) found that 67% of their mothers
(regardless of marital status and family structure) used very strict methods of discipline in authoritarian
parenting styles (high control, low warmth) that featured such discipline practices as hitting, intimidation, and
belittlement (p. 36). There is some support for the use of strict methods of discipline, especially in
environments where parents are using these methods in an attempt to deter the development of high-risk
behaviors in dangerous neighborhoods (Bradley, 1998). In another study, focusing on African American
adolescent girls living in impoverished communities, Pittman and Chase-Lansdale (2001) found that
adolescent girls experienced the most negative outcomes if their mothers were disengaged (low on supervision
and monitoring and parental warmth). However, focusing on a population of predominantly working and
middle-class African Americans, Bluestone and Tamis-LeMonda (1999) found that the majority of mothers
in that study used an authoritative parenting style, which suggests that different situations and economic
conditions are also important considerations when discussion parenting style and ethnicity.
Given the premise that ethnic minorities’ parenting practices may differ from those in families who do not
experience some of the hardships associated with minority status, such as poor financial resources, lower
educational attainment, and feelings of marginalization due to minority and or ethnic status. Domenech
Rodriguez, Donovick, and Crowley (2009) found the more traditional parenting styles (e.g., authoritative)
were not as relevant to ethnic minority families. Some of the differences that researchers have found in studies
investigating ethnic minority parents are the use of culturally specific methods of parental discipline and
control, lower levels of parental sensitivity, and higher levels of protectiveness (Chao, 1994; Mesman, van
IJzendoorn, & Bakermans-Kranenburg, 2012; Domenech Rodriguez et al., 2009).
Domenech Rodriguiez et al. (2009) studied a sample of first-generation, low-income, Latino parents (88%
Mexican origin) and their children (4 to 9 years of age). The researchers found that the four traditional
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parenting styles used in most studies were not a good fit with Latino families, and that expectations for
parenting styles differed depending on whether the parent was the mother or father. Using the three
dimensions of warmth (support), demandingness (expectations and behavioral control), and autonomy
granting (independence, individuation), Domenech and colleagues found that Latino parents in their sample
were high on warmth and demandingness, but lower on autonomy granting. Furthermore there were gender
differences in parenting practices with parents granting less autonomy to girls than boys and higher
demandingness toward daughters than sons. The majority of parents in this sample (61%) met criteria for
“protective parents” (high on warmth and demandingness, low on autonomy granting).
Domenech Rodriguez et al. (2009) suggest that different gender effects in their study might be explained by parents’ perceptions of
girls maturing earlier than boys and having higher expectations for them as a result. They wondered if the expectations might change
as the boys aged.
Although hierarchical parenting (denoting clear guidelines of parental authority) has been associated with
externalizing behaviors in European American and families of mixed ethnic origin, for Hispanic American
families, inconsistent parenting has been associated with increases in problem behavior in boys (Lindahl &
Malik, 1999). Holtrop, McNeil Smith, and Scott (2015) suggest that in Latino families hierarchical parenting
is expected because it embodies the cultural value of respeto, or respect, which might suggest that the
authoritarian parenting style would be more compatible with this value. This has not been supported by the
research however, since application of the authoritarian style in the name of respeto has produced negative
outcomes of increased externalizing and internalizing behaviors (Calzada, Huang, Anicama, Fernandez, &
Brotman, 2012). Based on the inconsistencies in results with Latino families, Holtrop et al. (2015) suggest
that our current knowledge of the relationship between parenting styles and child outcomes in Latino families
remains unclear. They also suggest that findings may also emphasize the need to identify culturally relevant
practices when designing and implementing parenting interventions, especially the concept of familism (i.e.,
emphasis on the family unit).
In a longitudinal study of 444 Chinese American families, Kim, Wang, Orozco-Lapray, Shen, and Murtuza
(2013) identified four parenting profiles: supportive, tiger, easygoing, and harsh. Rather than evaluate
parenting style along the typical two dimensions (control and warmth), Kim et al. (2013) used a multifaceted
approach, which considered both positive (parental monitoring and democratic parenting) and negative
(psychological control and punitive control) aspects of parent control and two forms of parent emotional
responsiveness (warmth and hostility). In this model, warmth and hostility are not considered as extremes of
the same concept but two different dimensions. Within this context, tiger parenting was associated with (high
warmth, high hostility), compared with easygoing parenting (low warmth, low hostility), supportive parenting
(high warmth, low hostility) or harsh parenting (low warmth, high hostility). As for forms of parental control,
researchers compared confrontative control with coercive control (which could be either punitive or
psychological). Finally, they added the dimension of “shaming,” which they found to be highly important in
the Chinese culture. Results of their study revealed that “supportive parenting, which is most beneficial for
adolescent adjustment, includes higher extent of shaming than easygoing parenting, although not as high as
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the level of shaming in tiger or harsh parenting” (p. 15). Results indicated that the supportive parenting
profile was the most common parenting style, followed by easygoing parenting, tiger parenting and harsh
parenting (in that order). Supportive parenting, the most common form of parenting, had the best
developmental outcomes, followed by easygoing parenting, tiger parenting, and harsh parenting. Contrary to
popular belief, Kim et al. (2013) found that tiger parenting was not the most typical parenting profile among
Chinese American families, nor did it produce the best outcomes for adjustment in Chinese American
adolescents. Compared to adolescents reared under a supportive parenting style, adolescents whose parents
had a tiger parenting profile reported less of a sense of family obligation and obtained lower educational
outcomes, including GPA. The concept of the tiger mother will be revisited in Chapter 4, in the case study of
Shirley Yong (Case 14).
Box 1.20 Outcomes of Tiger Parenting
In the study by Kim et al. (2013), adolescents who were raised by tiger parenting reported more academic pressure, greater sense of
alienation (lack of belongingness), and more depressive symptoms.
According to Baumrind (2012), research on culture and parenting styles has identified “culturally syntonic
practices that would be described as confrontational, but not coercive,” including the following: the “training
practices of Chinese American parents,” “the emphasis on prompt compliance by African American parents,”
the emphasis on “respect by Latin American parents,” and emphasis on “deference by conservative European
American parents” (p. 186). Although these processes of directive parenting may look authoritarian on the
surface (forceful and confrontational), they are not, because they are not coercive and are responsive and child
oriented. As such, Baumrind suggests that the directive style may be the universal parenting style that will be
associated with increased levels of competence linking a family’s situational and cultural factors with parent
authority and child autonomy. The emphasis in future research should be, according to Baumrind, on
identifying the “indigenous family patterns specific to a variety of cultural contexts” (p. 186).
Durlak (1998) conducted a meta-analysis of over 1,000 prevention outcome studies and reported the findings
regarding the following breakdown of risks and protective factors within the context of Bronfenbrenner’s
ecological model. In a more recent review, Eriksson, Cater, Andershed, and Andershed (2010) conducted an
extensive review of the reviews on literature (30 different meta-analyses) regarding protective factors that can
buffer children and adolescents from externalizing and internalizing problems. The risk and protective factors
from both studies are summarized in Table 1.1.
Table 1.1 Summary of Risks and Protective Factors
Environmental Context Risk Factor Protective Factor
Child Characteristics Early onset problems Social competence
Difficult temperament Self-efficacy
Behavioral inhibition High intelligence
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Microsystem Family: Family:
Harsh or punitive discipline

Positive parent–child relationship
Marital problems
Maternal sensitivity
Family psychopathology
School: School:
Poor-quality schools Good-quality schools
Peers: Peers:
Negative peer influence Positive peer influence
Negative role models Positive role models
Neighborhood: Neighborhood:
Poor resources Adequate resources
Violence Safe
Exosystem Poverty Lack of financial hardship
Poorly administered schools Effective school policies

Macrosystem
Cultural conflict Cultural acceptance
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Resilience
A discussion of risks and protective factors naturally leads to a discussion of the concept of resilience.
Resilience has been defined as “the capacity for adapting successfully in the context of adversity, typically
inferred from evidence of successful adaptation following significant challenges or system disturbances”
(Masten & Monn, 2015, p. 6). As a result, studies of resilience have studied children in high risk conditions
(adversity) who manage to adapt successfully and have tried to uncover what protective factors can support
this trajectory of positive growth.
Although the topic of resilience has attracted research attention for quite some time, the concept remains
elusive in some respects because of diverse approaches to defining, operationalizing, and measuring it. As a
result, it has been difficult to collate data across different studies (Masten & Gerwitz, 2006). Researchers
studying risk factors that can contribute to adversity have measured diverse sources of potential stressors,
including such aspects as low socioeconomic status (SES), low birth weight, number of adverse life events, and
parent divorce. Yet despite, the diversity of measures used, results point to a number of common outcomes
(Luthar, Cicchetti, & Becker, 2000).
Masten (2001) summarizes results of studies on resilience that have focused on two different methodologies:
variable-focused studies and person-focused studies (comparing groups of children living in the same adverse
conditions who are resilient versus those who are not resilient). Some of the outcome measures used for
variable-focused studies have included academic achievement, measures of prosocial behavior (peer
acceptance), and psychopathology (deviant behavior, internalizing behaviors). Information from these studies
has isolated a number of protective factors that have been associated with resilience. Whereas effective
parenting practices (e.g., authoritative parenting, monitoring, support) have been associated with the best
social and behavioral outcomes, intellectual functioning has been associated with both academic success and
behavioral control. However, since intelligence includes a wide variety of skills and skill subsets (such as
executive functions) that may also influence self-regulatory process, Masten (2001) suggests the need to
further investigate the underlying processes.
In her review of results from person-focused studies (resilient group vs. non-resilient group) Masten (2001)
states that at an early age, individuals in the resilient groups shared better parenting skills and had an easy
temperament. As they progressed in school, they demonstrated more academic success and had better self-
perceptions and social adjustment than their nonresilient peers.
Box 1.21 Protective Factors and Resilience
Some common elements in resilience research have isolated several factors that seem to contribute to the development of resilience
despite living in adverse conditions, including positive, supportive caregivers; positive views of self; motivation to succeed; and
cognitive and self-regulatory skills (Masten, 2001).
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72
Resilience and Neurobiology
Alvord and McEwen (2013) discuss resilience within a neurobiological framework, and within this context
they define resilience as the “ability of an organism to withstand environmental challenges to normal function,
and as such, successful allostatic responses can directly contribute to resilience by providing stability in a
changing environment” (p. 338). They describe “allostasis” as the mediators that the brain activates in order to
regain homeostasis when stressors are detected. Although the process when working should result in a smooth
transition to a steady state, being bombarded by a constant influx of stress can cause a system to “allostatic
overload” resulting in overuse of the system and dysregulation (wearing down the system).
Box 1.22 Resilience and the Brain
In addition to the important role of hormones in communicating between body and brain, Alvord and McEwen (2013) identify key
areas of the brain associated with regulation of the stress response: hippocampus (central role in learning, memory, and mood);
prefrontal cortex (PFC; regulation of executive function, inhibitory control, and cognitive flexibility); and the amygdale (AMY;
regulation of emotions, aggression, and affect related to learning and memory, as in fear conditioning).
Alvord and McEwen (2013) discuss how the interaction between genetics and early environmental
experiences plays an important role in setting the stage for how an individual will respond to stressors later in
life, based on previous areas of the brain activated in areas of emotionality and cognition, especially the
prefrontal cortex (PFC), amygdale (AMY), and the hippocampus.
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Resilience and Maternal Depression
Numerous studies have reported negative outcomes for children and youth who are raised by depressed
mothers. Risks that have been reported include social withdrawal (Yan & Dix, 2014), the acquisition of
inappropriate social skills (Carter, Garrity-Rokous, Chazan-Cohen, Little, & Briggs-Gowan, 2001),
increased risk for psychopathology (Gotlib, Joormann, & Foland-Ross, 2014), as well as evidence of
dysfunctional physiological systems associated with the ability to manage stress, and engagement in social
relationships such as cortisol response (Waters et al., 2013), and oxytocin production (Apter-Levy, Feldman,
Vakart, Ebstein, & Feldman, 2013). For example, Lupien, King, Meaney, and McEwen (2000) demonstrated
that children’s levels of cortisol are correlated with their mother’s socioeconomic status and depressive
symptoms.
Individual characteristics that have emerged as protective factors that can buffer a child from the impact of
having a depressed mother are having an easy temperament (as opposed to difficult temperament) and having
a higher IQ (Compas, Langrock, Keller, Merchant, & Copeland, 2002; Dix & Yan, 2014). At the family or
environmental level, depressed mothers who demonstrate warmth, caring and support, and a minimum of
negativity reduce the impact of their child’s risk for adverse outcomes (Wang & Dix, 2013).
Alvord and McEwen (2013) discuss evidence of hyper or hypo cortisol reactivity in children of depressed
mothers, using a model of “allostatic load.” Apter-Levi et al. (2016) also use the same model to address
malfunctions in the children’s HPA system, in their study of chronically depressed mothers and their children.
Collecting data over a period of 6 years, Apter-Levi et al. found that hyper or hypo levels of cortisol and HPA
malfunctions were related to the mother’s lack of sensitive caregiving, which did not provide opportunities for
children to develop a sense of security or appropriate social responsiveness. In addition, these malfunctions
were also directly related to negative parenting practices (anger, negative affect, hostility, anxiety, depressed
mood) and unpredictable mood swings (parent vacillating between displaying incidents of negative mood or
anger and incidents of withdrawal). Due to these negative practices and unpredictable mood swings, children
would be forced to be in a state of constant vigilance in order to adapt to erratic changes in the mother’s mood
and behavior. As a result, Apter-Levi et al. (2016) suggest that “It is thus possible that children with a
biological propensity for social withdrawal and behavior inhibition who are reared by more negative mothers
are less able to develop flexible HPA system functioning which may lead to a socially-withdrawn style that
places these children at a greater risk for later psychopathology” (p. 54).
Yan (2016) investigated the role of three agentic processes (autonomy/self-assertion, effortful control, and
motivation mastery) on children’s resilience (academic, social behavioral) in a longitudinal study (infancy to
first grade) in a large national sample of children of depressed mothers. Results revealed that effortful control
was the single most reliable predictor of resilience across all areas assessed (social, emotional, behavioral, and
academic). Yan suggests that high levels of effortful control allow individuals to regulate their emotions
(emotion-focused coping, especially in stressful interactions with the mother) and regulate and plan behaviors
allowing them to engage in socially appropriate ways. Children high on self-assertion were resilient in three
areas: social competence, internalizing behaviors, and externalizing behaviors. Yan believes that children high
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on autonomy are more self-assertive and interact with their mother in ways that promote negotiation and self-
assertive communications. Motivation mastery related to only one area of resilience, which was academic
competence.
Yan (2016) investigated patterns and interrelationships between the three agentic processes and resilience and
suggests the following important factors that contribute to resilience in children with depressed mothers: high
intelligence, child temperament, maternal sensitivity, and quality of child care. High intelligence in early
childhood was predictive of greater self-assertion, effortful control, and mastery motivation throughout the
study, which in turn predicted resilience in all areas measured (academic, social, behavioral). Children with
less difficult temperaments were also higher on effortful control and self-assertion, which were predictive of
resilience in all areas of competence. Sensitive parenting was also significantly related to self-assertion,
effortful control, and mastery motivation, which in turn predicted resilience. Finally, the opportunity to attend
high-quality child care facilities was related to effortful control, which was a strong predictor of resilience.
This is an important finding for treatment interventions and prevention, because it suggests that extrafamilial
environments may assist in developing child qualities, such as effortful control, which can foster resilience at a
time when the mother is experiencing challenges due to chronic depression.
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Resilience: Intervention and Prevention
Research regarding promoting resilience in children has focused on two important factors: individual
characteristics, and influences from family and parenting practices. At the level of individual characteristics,
several important factors have been identified. The study by Yan (2016) provides important information
regarding potential avenues for promoting resilience in children who are faced with living in adverse
conditions. Interventions that are focused on enhancing the key processes that are linked to resilience, such as
effortful control and self-assertion, could lead to increased positive, active engagement and adaptive
functioning. In addition, these qualities can be targeted both in enhancing parenting practices and
extrafamilial contexts (good day care and school programs). Prilleltensky, Nelson, and Peirson (2001) suggest
that children’s sense of “personal control, empowerment, and self-determination” are important aspects to
target in programs aimed at increasing psychological well-being and positive mental health. The researchers
suggest that these qualities can be enhanced by providing opportunities for children in three important areas:
(1) material resources (nutrition, housing, stimulation) and psychological resources (secure attachments,
empathy, and exercising problem-solving abilities) necessary to satisfy basic needs, (2) chances to engage in
meaningful decision making to enhance self-determination, and (3) targeting growth in areas of increased
competence and self-efficacy.
The “FRIENDS for life” program (Barrett, 2004a, 2004b) was initially developed as a group treatment
program for children with anxiety disorders and was later adapted into a school-based universal prevention
program. The goal of the program is to build emotional resilience in children by teaching them skills to cope
effectively with feelings of anxiety and depression. The program is based on cognitive–behavioral methods and
has been used extensively throughout the world. Studies have been conducted in Australia (Iizuka, Barrett,
Gillies, Cook, & Miller, 2014; Stallard, Simpson, Anderson, Hibbert, & Osborn, 2007), the Netherlands
(Kösters, et al., 2012), the United States (Briesch, Sanetti, & Briesch, 2010), Ireland (O’Brien et al., 2007),
South Africa (Mostert, 2007), and the United Kingdom (Rodgers & Dunsmuir, 2015).
The FRIENDS acronym stands for Feelings; Remember to relax; I can do it; Explore solutions and coping
step plans; Now reward yourself; Don’t forget to practice; and Stay calm for life. The program has 10 weekly
sessions and two booster sessions that are conducted 1 and 2 months after the program is completed. There
are also two parent sessions during the 10-week program. Coping techniques used include psychoeducation,
relaxation exercises, exposure, social support training, problem-solving skills training, and cognitive
restructuring exercises.
Studies have demonstrated that the FRIENDS program can be successful in enhancing self-concept (Stallard
et al., 2005; Stallard et al., 2007), coping skills (Stopa, Barrett, & Golingi, 2010), social skills (Liddle &
Macmillan, 2010), reduction in symptoms of anxiety and depression (Stallard et al., 2005), as well as
improvements in behavioral inhibition and socioemotional strength (Pahl & Barrett, 2010).
Having a positive, supportive caregiver can enhance opportunities for resilience in the face of adversity.
Studies that have focused on improved caregiving have used several parent training programs to assist parents
76
in developing better skills in areas of emotional communication and appropriate uses of positive
reinforcements. According to Bai and Repetti (2010), engaging in warm, responsive, and supportive family
interactions may cultivate resilience in children through exposure to positive emotional and physiological
stress response systems.
Parent–Child Interaction Therapy (PCIT) is a widely used, evidence-based treatment for parents of children
who have disruptive behavior disorders (Funderburk & Eyberg, 2011). PCIT involves 15 weekly sessions and
is divided into two phases. The first phase, child-directed interaction (CDI), focuses on improving the quality
of the parent–child relationships by strengthening the parent’s ability to actively attend to and reinforce
positive child behaviors, while ignoring negative behaviors. The acronym PRIDE is used to relate to skills in
five different areas: Praise, Reflection, Imitation, Description, and Enthusiasm. Parents practice these skills while
learning to follow their child’s lead in dyadic play sessions. In the second phase, parent-directed interaction
(PDI), parents take over the lead in play and real-life situations that focus on the importance of their child
obeying their instructions and requests. Compliance is rewarded with praise, while the consequence for
noncompliance is a time-out. Sessions involve direct coaching of parent–child interactions. Skills are
introduced in a parent-only session and then skills are practiced in the parent–child dyad the following
session. Coaching takes place using a wireless earphone and one-way mirror.
The Triple P Positive Parenting Program is another widely used and empirically supported parent training
program that can be administered on a variety of prevention levels from Level 1, universal prevention (media-
based information for parents), to Level 5, intensive individually tailored family programs for children with
major behavioral issues within the context of family dysfunction. This behavioral family intervention program
is based on principles of social learning (Patterson, 1982) and has been adapted to serve five different
developmental stages (infants, toddlers, preschoolers, school-age children, adolescents). Parents at Level 4
(parents of children with more severe behavior problems who want intensive parent training) have the
opportunity to take part in one of four different types of programs: Standard Triple P (individual parents may
be involved in face-to-face or phone consultations, home visits, or be self-directed), Group Triple P (groups
of 10–12 parents), Group Teen Triple P, or Self-Directed Triple P (parenting workbooks are provided for a
10-week self-help program). Core parenting skills taught in the programs include observation skills, managing
misbehavior, preventing problems in high-risk situations, self-regulation skills, and mood management and
coping skills (Sanders, Markie-Dadds, & Turner, 2003).
Thomas and Zimmer-Gembeck (2007) conducted a meta-analysis of 24 studies from the United States and
Australia to evaluate and compare the outcomes of PCIT and Triple P-Positive Parenting programs. The
studies consistently found positive outcomes for both programs, although the outcomes varied depending on
the length of intervention, components used, and the sources of outcome data. Both programs were successful
in reducing child behavior problems and parenting problems. Parent reports found large effect sizes for PCIT
and majority of Triple P-Positive Parenting programs. An abbreviated version of the PCIT had moderate
effect sizes in one study, while Level 1 intervention for the Triple P (Media Triple P) had small effects.
77
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Case 1 Terry Hogan The Avoidance Trap: Developing a Case
Formulation
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The Avoidance Trap
Terry’s fourth-grade teacher is concerned due to progressively declining grades. Terry was in a bike accident in the third grade and was
thrown from the bicycle, causing a separation of the cartilage from the rib cage. This very painful condition resulted in Terry missing
several weeks of school and ultimately repeating the Grade 3 program. Terry was assessed 4 months ago and the psychological assessment
revealed intellectual functioning to be in the average range (range 87–100), with academic functioning at a mid–Grade 3 level in all areas
(standard score range 85–87). Terry did not qualify for special education assistance since the school district used the discrepancy criterion
of 2.5 standard deviations difference between intellectual level and academic standard scores, which would require academic standard
scores to be well below current levels. However, academic concerns have continued to escalate, and Terry is becoming more and more
vocal about disliking school. There are frequent complaints of stomachaches, and there is often a refusal to eat lunch. In the past 5
months, Terry has been absent for 17 days and tardy on 16 occasions. The school is requesting further assessment to clarify the nature of
the problems. During the follow-up assessment, Terry completed a number of self-report scales (depression, anxiety, personality), and
scores indicate clinically significant elevations for all internalizing scales, including depression, anxiety, and somatization.
After reading the case of Terry Hogan, ask yourself the following question: Does Terry suffer from a
significant mental illness? According to Shaffer and colleagues (1996), chances are approximately 1in 5 that
Terry does. However, unlike children who have disruptive behavior disorders, Terry’s symptoms are not
readily apparent. How can the clinician determine the nature and severity of Terry’s problems? What are the
essential questions that need to be addressed?
Since a clinician’s theoretical perspective can influence decisions, it is very important that clinicians are aware
of their own theoretical biases in forming their opinions. Looking at a case through a set of theoretically
colored lenses can affect all aspects of information processing, from hypothesis testing to treatment. The
influence of theory on practice will become increasingly clear as case formulations are constructed from various
theoretical viewpoints and applied to the case of Terry Hogan. The following exercise will provide a step-by-
step look at how a case formulation would be developed and applied to this case.
Stage 1: Problem Identification: A Question of “What.”
At this stage, the clinician must ask the question, What is Terry’s problem? However, this is often more
complicated than it looks. For example, although Terry’s poor academic progress was the initial concern, a
very different set of problems eventually unfold that provided increased insight into the high rates of
absenteeism and an increasingly negative attitude toward school.
Stage 2: Problem Interpretation/Understanding: A Question of “Why.”
At this stage of the process, the clinician draws on information from Terry’s developmental and family history
to provide a snapshot of Terry’s history that can provide vital information regarding potential genetic factors
that may suggest a vulnerability to some manifestations of behaviors (family pathology) or circumstances
(family or school history), which might add to understanding how the problem evolved and what is
maintaining the problematic behavior. At this point, it is also important to address any risks or protective
factors that might help explain conditions that could exacerbate or moderate the problem. An understanding
of the different theoretical perspectives can add to the depth and breadth of the analysis and hypothesis, and
the ability to integrate information from these sources can contribute to our overall understanding and success
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in developing interventions based on the underlying dynamics involved.
Stage 3: Treatment Formulation: A Question of “How.”
Ultimately, our understanding of Terry’s problem will help to inform treatment efforts regarding how to best
address the problem based on our knowledge of evidence-based treatments that are most successful in dealing
with problems of this nature. It will also be very important to integrate plans for monitoring and evaluating
the effectiveness of the treatment plan in order to make any necessary changes.
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Case Formulation: Applications to the Case of Terry Hogan
With the first goal of case formulation in mind, return to the initial description of Terry Hogan and reread
the scenario with the following questions in mind:
1. What are Terry’s main problems?

2. What is Terry’s primary problem? Why has the problem developed (precipitating factors) and what is
causing the problem to persist (maintaining factors)?
3. What other information is needed to respond to the above questions? Is Terry a boy or girl? Read the
scenario again to see if you can find the answer. Risk factors for males and females can be different, so
Terry’s gender may also be a factor in determining targets for intervention.
Box C1.1 Thinking Out Loud
Although Terry is struggling academically, the initial assessment suggested that lack of academic progress was not due to lack of
ability (intelligence was in the average range), but some other factor that was contributing to her lack of performance (production).
Terry said that she disliked school. Could lack of performance be attributed to lack of motivation, interest, and effort?
Based on the information to date, pinpointing the problem is not an easy task. In order to understand the
problem, it is necessary to delve into the information and focus on behavior patterns that are most likely to
yield relevant insights into Terry’s difficulties. Based on the latest assessment results, the psychologist records
the following impressions:
During the follow-up assessment session, Terry seemed even more agitated than she had been
previously. She appeared pale and had dark circles under her eyes. When asked about school, she
said that things were worse than before (referring to 4 months ago). Her younger sister, Lilly, is
now in the same grade and even though they are in different classrooms, her younger sister is a
constant reminder of her failure. Terry said the family was living with her grandparents until last
week. She said her grandfather gets “too angry” at her and yells a lot. Just before they moved out,
her grandfather had taken the belt out to hit her and she ran out the front door and down the street.
She said she didn’t care if she was hit by a car, it was better than being hit by him. When asked
about her absenteeism, Terry said that she felt sick a lot. She also mentioned that her back hurt,
because she had been sleeping on a sofa bed that has a bar across the middle that digs into her back
at night, and wakes her up, so she cannot sleep very well.
Her mother is a waitress who works long hours some nights. Since they are no longer living with
her grandparents, Terry and her sister now go to the restaurant to eat their dinner and then walk
home with their mother when she is finished with work. She said that the restaurant can be noisy,
so it is hard to do her homework. Terry’s father is a truck driver and is often away. When asked
about friends, Terry said she used to have some friends, but when she repeated the third grade, they
wouldn’t play with her anymore because she was only a third grader. Terry’s favorite pastime is
watching TV. She said that she liked to watch Disney movies because “they always have a happy
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ending, not like most things.”
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Reason for Referral
Although the original reason for referral was academic concerns, it is becoming increasingly apparent that
academic problems are more a symptom than a cause of Terry’s difficulties. Further investigation is necessary
in order to probe different hypotheses and provide an opportunity to develop case formulations from different
theoretical perspectives. Information on family history, which would usually be obtained at the beginning of
the case, is still lacking, since Terry’s mother has not yet met with the school psychologist.
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Assessment Results
Terry’s responses to the Revised Children’s Manifest Anxiety Scale (RCMAS-2) indicated significant levels of
Social Anxiety (feelings of isolation from peers and feelings of inadequacy compared to other girls her age).
On the Child Depression Index (CDI-2), scores for Total Depression, Negative Mood, Ineffectiveness, and
Anhedonia were all in the clinically significant range. There were indications of suicidal ideation, although
Terry stated that she “would not do it.” Although responses to the Personality Inventory for Youth (PIY)
revealed a valid profile (nondefensive), there were also indications of a potentially exaggerated response
profile. Responses indicated little pleasure derived from academics and school-based activities, high scores for
distractibility and concentration problems, and tendencies to be irritable and impatient. Terry admitted to
having problems with compliance issues and following the rules. She endorsed many somatic complaints often
associated with anxiety and depression (frequent headaches, stomachaches, dizziness, fatigue), placing her
score on the somatic scale in the clinically significant range. Terry’s profile suggested that when
psychologically distressed, she tended to show physical responses, such as feeling ill, loss of appetite, and sleep
disturbance. Responses to the family dysfunction scale revealed that she was unlikely to view her home as a
source of satisfaction and instead saw home as conflicted and fragmented. Responses suggested a troubled
relationship with her parents, who she describes as argumentative, frequently absent, and in disagreement
with each other. Responses indicated that one or both of her parents might drink to excess or demonstrate
other signs of less than stable emotional adjustment.
Terry’s teacher completed the Behavioral Assessment System for Children (BASC-2), a rating scale of
behavioral and emotional problems in children. Unfortunately, the parent version of the scale had not been
returned to the school, despite several calls. Similar to Terry’s responses, her teacher also confirmed clinically
significant concerns on all internalizing scales, including Total Internalizing Problems, Depression, Anxiety,
Somatization, Learning Problems, and Withdrawal (tendency to evade others and avoid social contact).
Based on the assessment results, the psychologist had a growing concern that Terry was experiencing many
symptoms of depression, anxiety, and somatization. However, why these problems were occurring and
seemingly escalating could only be speculated until there was contact with Terry’s family. The school
psychologist made several attempts to contact Mrs. Hogan.
Several weeks later, Mrs. Hogan agreed to meet with the school psychologist to discuss the assessment results.
She provided a brief family history and answered most of the questions asked, although she was guarded in
her responses. She explained that they had been living with her father for the past little while to ease financial
burdens. She said he could be stubborn at times and blamed it on the Irish heritage. Her great-great-
grandparents had emigrated from Northern Ireland at the time of the potato famine (mid-1800s) and worked
as cheap labor in the United States, as did many who settled in America. She said that she’d kept the name
Hogan, not taking her husband’s name, because the name means “warrior” and she was a fighter. After these
comments, she added, “I don’t know why Terry does not live up to her name. She’s a whiner and complainer;
she’s no warrior.”
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Shortly into the interview, Mrs. Hogan announced that the family was relocating to Tennessee at the end of
the week to live with her sister’s family, which would place them closer to her husband’s new truck route.
When the assessment results were discussed, Mrs. Hogan became very defensive and stated that Terry was
pretty good at pulling the wool over people’s eyes, implying that Terry had the psychologist “fooled.” She said
that living with Terry had been difficult since the day she was born. Terry was an irritable baby who never
slept well and was always a fussy eater. She was a clingy baby who cried every time her mother left her, so it
was hard to find sitters who would look after her. She said that Terry was a selfish child who only thought
about herself. She wished that Terry could be more like her sister, Lilly, who was easy to get along with and
had many friends. On the other hand, Terry was moody, irritable, and difficult to please; she often walked
around with a “chip on her shoulder.” Mrs. Hogan said that unfortunately, Terry took after her father, who
was the same way, especially when he was drinking. When asked about family history for depression, Mrs.
Hogan said she suspected that her husband might be “down in the dumps” sometimes, especially when he
would start drinking. However, with the truck driving job, drinking was no longer an option. Mrs. Hogan
admitted to having financial problems and blamed Terry’s willful and disobedient attitude for getting them
“booted out” of Terry’s grandfather’s place. She explained that her father (Terry’s grandfather) had always had
problems controlling his temper and that Terry would “mouth off” and cause him to lose his temper. She
described Terry as a complainer who often said that she was not feeling well to get out of doing chores or
helping around the house. As a result, her sister often had to carry twice the load.
The psychologist emphasized her concerns about Terry’s emotional well-being and her symptoms of
depression and recommended that Mrs. Hogan find a counselor for Terry when they arrived in Tennessee.
However, Mrs. Hogan felt that would just encourage Terry to feel sorry for herself and make it worse. The
psychologist requested permission to send the reports to Terry’s new school, and Mrs. Hogan reluctantly
agreed.
Applying Theory to Case Formulations: The psychologist has now amassed information from several sources and can begin building
hypotheses regarding Terry’s internalizing problems (depression, anxiety, and somatization). The following case formulations will
provide an increased understanding of how the problem can be conceptualized from a variety of theoretical perspectives.
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Case Formulation: Five Different Perspectives
The following section is devoted to case formulations developed from five different theoretical frameworks:
biological, behavioral, cognitive (social cognitive), psychodynamic/attachment, and parenting/family systems.
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Case Formulation Based on the Biological Perspective
Terry’s family history may be positive for depression (father) and if so, then she would have an increased risk
(20% to 45%) for developing depressive symptoms (Rutter, Silberg, O’Connor, & Simonoff, 1999).
Imbalanced levels of serotonin, norepinephrine, and possibly dopamine and acetycholine have been associated
with depression in adults (Thase, Jindal, & Howland, 2002). Abnormalities in the gene responsible for
transporting the neurotransmitter serotonin (5-HTT gene) have been linked to increased risk for depressive
disorder (Caspi et al., 2003; Hecimovic & Gilliam, 2006). Caspi and colleagues (2003) found that children
who inherited the short allele of the serotonin transporter (5-HTT) were more likely to respond to stressful
events with symptoms of depression and suicidal ideation than peers who did not inherit the short allele.
Cortisol is a hormone that is released by the hypothalamic-pituitary-adrenal system (HPA) in times of stress.
High cortisol levels can result in heightened sensitivity to threat that have been linked to increased risk for
depression (Pliszka, 2002).
Studies of the neurophysiology of emotion regulation are based on the need for positive resolution of fearful
experiences to allow for the development of self-soothing behaviors in response to fear and anxiety (Siegel,
1999). Results of a recent neuroimaging study have found that the anterior cingulate cortex (ACC), which is
activated during physical pain, is also activated in response to distress caused by social exclusion and rejection
(Eisenberger, Lieberman, & Williams, 2003). The researchers suggest that these neural connections may be
part of the social attachment survival system to promote the goal of social connectedness. These results help
explain Terry’s feelings of physical pain in response to her emotional loss and rejection.
Therapeutic Implications.
Although medical management is common in the treatment of depression in adults, approximately 30% to
40% of children with depression do not respond to medical treatment (Emslie et al., 1997). Fluoxetine
(Prozac) is the only medication that has been approved by the FDA for use with children 8 years of age and
older. Results of a 6-year-long investigation with adolescents found that combined treatment using
antidepressants and cognitive–behavioral therapy was superior to cognitive–behavioral therapy alone (Apter,
Kronenberg, & Brent, 2005). However, in 2006, the FDA issued a black box warning (the highest level of
caution) for antidepression medications potentially increasing depression and suicidal behaviors in youth and
young adults up to 25 years of age.
Does the benefit outweigh the risk? Based on results of their exhaustive review of clinical pediatric trials between 1988 and 2006, Bridge
and colleagues (2007) conclude that not taking prescription medication for depression places children at greater risk than taking the
medications.
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Case Formulation Based on the Behavioral Perspective
From a behavioral perspective, principles of operant conditioning can be very helpful in understanding how
Terry’s symptoms of depression, often manifested in claims of “not feeling well,” have become ingrained in a
repetitive pattern of avoidance behaviors. When Terry initially stated that she was “not feeling well,” it is
likely that responses included increased attention from those around her (positive reinforcement) and an
opportunity to escape from doing chores (negative reinforcement). Either way, feeling sick was reinforced with
a positive outcome, thereby increasing the likelihood for the behavior to be repeated in the future. Positive
reinforcement involves the addition of a reward (e.g., when you feel sick, I will comfort you and nourish you),
while negative reinforcement involves the removal of a negative situation. Negative reinforcement, not to be
confused with punishment, is rewarding because it involves the removal of a negative (e.g., if you are sick, you
do not have to do chores or go to school). Negative reinforcement has sometimes been called escape because it
allows one to escape a negative consequence.
In the Introduction, coercion theory (Patterson, Capaldi, & Bank, 1991) was discussed as it relates to a social
learning theory (a spin-off from the behavioral perspective). Coercion theory can help explain how Terry and
her mother have established a negative cycle of interaction patterns. Parents who eventually yield to a child’s
escalating and demanding behaviors serve to positively reinforce the child’s misbehavior. In this case, Terry’s
feeling sick has resulted in numerous absences from school, which allows her to escape from a situation she
wants to avoid (negative reinforcement). In addition, as far as the communication pattern is concerned, when
Terry is allowed to play the “sick role,” the behavior is reinforcing for Terry (escapes going to school) and her
mother (Terry stops whining and complaining). Therefore, the parent learns that giving in will stop the
demands and whining (negative reinforcement), while the child learns that increased demands result in parent
compliance (positive reinforcement). Since positive and negative reinforcement serve to strengthen behaviors,
parent and child become locked in to an escalating and never-ending battle.
Based on behavioral analysis, the payoff for Terry feeling ill has been an ability to escape negative situations,
such as doing chores around the house or having to attend school, where she is failing academically and
socially. In developing a behavioral program, goals would be to increase her sense of academic and social
competency at school in an attempt to reduce her need to escape from a negative situation. At home,
reintroduction of chores should be done in a way that requires a sense of responsibility but is also inherently
rewarding, for example, preparing dessert for the family. Terry and her sister should have a chore list that is
negotiated between them in the presence of their parents, with a list of rewards (e.g., allowance, privileges)
that can be earned and traded at the end of each week as compensation for completion of required tasks.
Through the use of behavioral tools such as knowledge of schedules of reinforcement and objective
observation techniques, behavior intervention plans can be developed, monitored, and modified to assist with
behavioral change. Rewarding obedience with attention and praise; issuing demands that are clear and age
appropriate; and providing consistent follow-through would strengthen Terry’s compliant behaviors while
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increasing her self-confidence and breaking the cycle of avoidance behaviors. Building on earlier successes has
proven to be a source of motivation in increasing compliance with more difficult tasks later on (Ducharme &
Popynick, 1993).
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Case Formulation Based on the Cognitive Perspective
Terry’s cognitive framework for social interaction places her at risk for social rejection (Dodge, Bates, &
Pettit, 1990). If Terry is overly sensitive to rejection, then she is likely to misinterpret ambivalent social
situations as hostile and rejecting, or what has come to be known as the hostile attribution bias. Recently,
Beauchaine, Strassberg, Kees, and Drabick (2002) found that parents of children with poor relationship skills
were especially deficient in providing solutions to issues of noncompliance, especially when required to do so
under pressured conditions. The authors recommend the need for treatment plans to target the underlying
processes of negative attribution bias and affect regulation, which they suggest are the pivotal factors that drive
coercive parenting patterns. Mrs. Hogan’s communication pattern with Terry is high on expressed emotion, a
negative, critical, and disapproving interactive style. Such communication styles have been found to increase
the risk for psychopathology in vulnerable family members (Nomura et al., 2005).
Cognitive–behavioral therapy (CBT) seeks to facilitate positive integration of thoughts and behaviors. For
Terry, CBT would focus on how Terry’s faulty belief system contributes to feelings of negative self-worth and
avoidant behaviors. Social cognitive treatment might involve role-play in areas of social cue awareness and the
underlying processes that contribute to the development of prosocial behavior, such as secure attachment,
social perspective taking, empathy, and self-control. Parent training using CBT methods would focus on
negative attributions, emotion regulation, and, ultimately, on increasing effective strategies for more positive
communication. One possible program to enhance communication between Terry and her mother is the
Seattle Program, which was developed by Speltz and colleagues (Greenberg & Speltz, 1988; Speltz, 1990).
This parent training program uses cognitive–behavioral methods to assist families of children with insecure
attachment which is discussed next. The program focuses on communication breakdown in the parent-child
dyad and emphasizes the need for better “negotiation skills.” The four-phase intervention program includes
components of parent education, reframing of the child’s behaviors within a developmental framework, limit
setting and problem prioritizing, and communication/negotiation skills.
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Case Formulation Based on Psychodynamic and Attachment Perspectives
On a psychodynamic level, Terry’s internalizing problems would be represented as the internal manifestations
of unconscious conflicts stemming from an imbalance in the underlying personality structure. In Terry’s case,
her mother’s rejection could represent a symbolic loss resulting in feelings of depression and feelings of guilt
and self-blame for driving her mother away. Freud would interpret the loss within the context of unmet needs
(lack of parental nourishing) during the oral stage. This pervasive sense of loss can result in feelings of
emptiness and withdrawal from social contact, which can increase symptoms of depression. Individuals may
remain overly dependent on others, feel unworthy of love, and have low self-esteem (Busch, Rudden, &
Shapiro, 2004). In addition, Terry’s somatic complaints may be interpreted as tendencies to translate psychic
pain into physical pain.
Ego psychologists might suggest that Terry’s insecurities result from a lack of resolution of the rapprochement
phase in the separation individuation process. In this phase, the toddler is faced with awareness of separation,
separation anxiety, and conflicting desires to stay close to the mother. Normally, the process of gaining greater
independence and self-identity is facilitated by the parent, who performs the dual role of remaining
emotionally available while gently encouraging the push toward greater independence (Settlage, 1977).
However, as Terry’s mother was not emotionally available for her, theory would predict that conflicts between
autonomy and dependence would be repeated throughout development, especially in vulnerable times (Kramer
& Akhtar, 1989). Successful resolution of the conflict at this stage is achieved through the development of an
internal representation or model of the parent–child relationship that can sustain separation due to the
securely developed ego. To ego theorists, the focus is on consolidation of the ego, while for attachment
theorists, the focus is on the relationship (Fonagy, 1999).
From an attachment perspective, the degree of security/insecurity inherent in primary attachment

relationships provides internal working models (IWM) or templates for all future relationships (Ainsworth et
al., 1978; Belsky, 1988; Bowlby, 1982). While secure attachments can be a protective factor, insecure
attachments may place the child at increased risk for developing problems. Terry’s avoidant behaviors may be
the result of internal working models (IWMs) based on an early avoidant attachment pattern. It is likely that
Terry’s mother was, at times, withdrawn and emotionally unavailable, and at other times harsh, emotionally
charged, and highly punitive (negative and highly critical). Within this context, Terry’s avoidance behaviors
may serve to manipulate and regulate caregiver proximity and attentiveness. Through the use of avoidant
techniques, Terry can shield her sensitivity to her mother’s harsh and rejecting responses. It has been
suggested that these maladaptive behaviors may fit with the overall schema of family dysfunction (Marvin &
Stewart, 1990). Terry’s IWM is likely to evolve around avoidance and withdrawal to shield her from fears of
rejection. Within this framework, parent–child dyads can be thrust into a hostile/helpless pattern, with one
member of the dyad being the hostile aggressor and the other member becoming the passive, helpless, and
overwhelmed recipient (Lyons-Ruth, Bronfman, & Atwood, 1999).
Insecure attachments can develop for a variety of reasons, including child characteristics (e.g., difficult
temperament) and characteristics in the immediate environment, such as parenting style (Belsky, 1999). In
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Terry’s case, there is strong evidence to suggest that both factors are highly interrelated. Greenberg, Speltz,
DeKlyen, and Endriga (1993) incorporate four factors in their risk model for behavioral disorders, all of which
are evident in the case study of Terry: insecure attachment, atypical child characteristics, ineffective parenting, and
family environment. Although quality of attachment can be seen as a risk or protective factor in its own right,
living in an environment that contains multiple risk factors (low SES, family stress, parent maladjustment,
etc.) also increases the likelihood of developing an insecure attachment (Belsky, 1997).
Socially, maladaptive attachment patterns can also undermine social orientation and subsequent prosocial
competencies. Terry’s lack of social reciprocity and withdrawal from social contact preclude strong social
motivation at this point in her life. For Terry, the social world is a hostile territory that she would rather
escape from than attempt to cope with. On the other hand, there is evidence that children with early secure
attachments are more socially oriented and compliant and have better developed abilities to regulate their
emotions (Ainsworth et al., 1978; Greenberg, 1999).
Depending on the therapist’s psychodynamic orientation, the therapeutic process might focus on the
individual child (working through internal conflicts in play therapy), the parent (helping a parent resolve his
or her own childhood conflicts and traumas), or the parent–child dyad (conjoint play therapy). In Terry’s case,
all three approaches would be appropriate—initially engaging Terry and her mother in individual therapy
sessions and ultimately bringing them together in conjoint play therapy sessions. Psychodynamic
developmental therapy for children (PDTC) is a relatively recent advancement in psychodynamic therapy
developed by Fonagy and Target (1996). Although the approach is psychodynamic in origin, principles of
social information processing (social cognition) are used to assist children in linking thoughts to feelings and
behaviors (reflective processes). A PDTC therapist might provide corrective experiences through play therapy and
the use of metaphor to assist Terry in replacing self-damaging feelings with increased positive views.
Secure attachments can lead to better understanding rather than avoidance of negative emotions (Laible & Thompson, 1998). Terry
demonstrates very few coping skills to effectively deal with negative emotions or negative information. Thompson (1999) suggests
that “lessons learned” in attachment relationships may be instrumental in defining expectations in such areas as how others react
when the child is experiencing difficulties coping with stress, anxiety, or fears.
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Case Formulation Based on Parenting Style and Family Systems
Perspectives
The authoritarian parenting style is a controlling and harsh style of interacting that is lacking in warmth and
often predictive of avoidant attachment patterns (Rubin, Hymel, Mills, & Rose-Krasnor, 1991). Baumrind
(1991) found four different parenting styles, based on the amount of structure and warmth parents provided.
The authoritative parenting approach (high structure and high warmth) has been associated with the best child
outcomes. Children raised in a household that uses authoritarian parenting practices may demonstrate
aggressive and uncooperative characteristics, while those whose parents are uninvolved or permissive may
respond with more negative traits due to the lack of structure. Based on an avoidant attachment pattern and
authoritarian parenting practices, Terry may have developed her tendency to feel overwhelmed by any
emotional demands placed on her, or feel unable to cope with challenges in her environment, and respond by
withdrawing and avoiding uncomfortable situations.
Family systems theory represents a variety of approaches that are unique to the traditional psychological focus
on individual differences. Family systems theory, instead, looks at the family unit at the primary source for
assessment and intervention. Within Terry’s family constellation, we see that Terry’s mother has aligned with
Lilly (the good daughter) and has used this system of triangulation to shift the balance of power toward her
and against Terry. The family also tends to have a combination of very loose boundaries (mother shares too
many intimate details with Terry) but rigid boundaries regarding how much Terry can share with the family.
Terry has also been flagged as the “problem child,” a stereotype that allows Terry’s mother to detour her focus
(Terry is the problem, rather than to acknowledge other problematic issues in the family, such as marital
conflict, father absenteeism, and financial concerns).
Treatment Implications.
Beauchaine, Strassberg, Kees, and Drabick (2002) found that parents who used ineffective and harsh methods
of discipline associated with the authoritarian parenting style often had children who demonstrated poor
relationship skills and did not have a good ability to generate alternative solutions to problems. Parents and
children were especially deficient in providing solutions to issues of noncompliance, especially when required
to resolve these issues under pressured conditions. Beauchaine and colleagues (2002) suggest the need for
treatment plans to target the underlying processes of negative attribution bias and poor affect regulation,
pivotal factors that drive coercive parenting patterns.
Within the family systems approach, the therapist would attempt to observe family interactional patterns as
they emerge in the family situation. The goal would be to restructure the family interactions toward more
positive growth and change. In Terry’s case, the therapist would likely focus on repositioning the balance of
power and on improved problem solving and communication between family members. As far as
communication style, the main style of communication in this household best fits a description of expressed
emotion (EE), a communication style that is hostile, critical, and prone to emotional overinvolvement (EOI).
Families with communication styles high in EE attributes tend to be more rigid, have more intense and
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negative verbal exchanges that are often conflicted and oppositional in tone, and have been associated with
relapse of psychiatric symptoms in individuals who are vulnerable to stress. As such, communication styles
that are high in EE attributes are often considered within a diathesis-stress model, as an environmental stressor
that can exacerbate or precipitate mental distress in individuals with a given genetic vulnerability (Hahlweg et
al., 1989; Hooley & Hiller, 2000; Wuerker, Haas, & Bellack, 2001).
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Integrating Theoretical Perspectives: A Transactional Ecological Bio-
Psycho-Social Framework
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The Case of Terry Hogan: A Brief Summation
Our case formulations for Terry Hogan have provided increased awareness of how different theoretical
perspectives can contribute to an overall understanding of the nature and seriousness of her depressive
symptoms. For Terry, risk factors evident on several levels of Bronfenbrenner’s model (Bronfenbrenner &
Morris, 1998) have added to the severity of her problems. At the individual level, Terry’s difficult
temperament was a poor fit for her mother’s impatient, inherently negative, and hostile approach to parenting
(authoritarian parenting style). At a biological level, it is possible that Terry inherited a genetic vulnerability to
depression. Terry’s poor relationship with her mother and isolation from her peers have added to her feelings
of being ineffectual, culminating in a sense of learned helplessness. Her tendencies to use withdrawal and
avoidance, likely patterned after an avoidant attachment relationship, have successfully allowed her to escape
from situations of discomfort (school and chores) by claiming to be feeling ill, which has resulted in these
patterns being negatively reinforced, thereby increasing and strengthening this avoidant behavior pattern.
Risks in the immediate environment, microsystem (home and school), exosystem (financial stress), and the
overall cumulative effect of her experiences, chronosystem, suggest that Terry is in serious need of intervention.
Her mother has focused on Terry as the “problem child,” allowing her to ignore major problems in the marital
relationship. In addition to these underlying dynamics, Terry is at increased risk for major depression and
possibly a suicide attempt because of the presence of a multitude of risk factors. It is unknown whether her
recent move to Tennessee will provide a more stable environment with increased support from her aunt’s
family or begin a spiral that leads to increased symptoms of depression and increased risk for suicide.
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Post-Case Questions
At the end of every case, you will find a series of post-case questions that are intended to assist you in consolidating the information from
the case with information provided in the Introduction to Chapter 1, Appendices, and any outside readings that may be suggested.
1. Terry’s family seems to have a history of depression. From a biological perspective, what are the potential dynamics that might be
involved in inheriting the risk for depressive symptoms? What are some of the positive and negative issues and implications
regarding medical management of depression symptoms for Terry, based on the research findings regarding children her age, and
given the family dynamics?
2. Terry’s lack of compliance may be explained from a behavioral perspective by using the ABC paradigm (antecedent, behavior,
consequence). How would coercion theory explain the dynamic of escalating aversive responses between Terry and her mother?
Develop a behavioral intervention plan to assist Terry and her mother with her noncompliant behaviors.
3. Terry and her mother often engage in communication that is high in “expressed emotion.” From a cognitive perspective, this
communication style has been associated with a number of negative outcomes. Explain how this dynamic works and apply this to
exchanges between Terry and her mother. What suggestions would you have for improving the interactions?
4. Explain how Terry’s attachment history and attachment pattern can be used to better understand the underlying dynamics in this
case. Be sure to include information on attachment from the Introduction to Chapter 1, regarding the ecological-developmental
framework (Greenberg, 1999) and Strathearn’s (2011) work on neurobiological factors influencing maternal responsiveness.
5. The authoritarian parenting style can often result in an avoidant attachment pattern. Explain how this applies to Terry’s case.
Beauchaine and colleagues (2002) suggest the need for treatment plans to target the underlying processes of negative attribution
bias and poor affect regulation that may develop from harsh parenting styles. How would you address these issues therapeutically
in Terry’s case and what do you see as your biggest challenges to being successful?
6. Using Brofenbrenner’s ecological transactional model as a framework, discuss the risks and protective factors that exist for Terry
given the dynamics in her case.
7. Suggested Individual or Group Presentation Activity: The principal has called a parent–school meeting to discuss concerns about
Terry’s progress and her future. Assign roles to individuals who will role play important individuals in Terry’s life and how they
would interact in this situation. Develop important questions for each of the players who can add information to the case. Some of
the casting members might be Terry, Terry’s mother, Terry’s father, Terry’s grandfather, Terry’s teacher, the psychologist, and any
other individual that you feel might contribute to an understanding of the case and assist with developing an overall case
formulation and treatment plan.
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Case 2 Jeremy Jones Mommy and Me and Grandma Makes
Three: Developing an Intervention Plan
Jeremy is a 6-year-old Caucasian boy who came to the clinic accompanied by his mother, Debbie, and his
maternal grandmother, Blanche. Jeremy was referred for assessment by his pediatrician. Despite trials of
numerous medications and doses, Jeremy has continued to demonstrate problem behaviors that are
hyperactive, impulsive, and noncompliant. Jeremy currently takes Adderall twice daily (morning and noon)
and risperidone (Risperdal) three times daily (morning, noon, and evening). Jeremy has been taking Adderall
for 2 years and risperidone for the past year. Although Jeremy appears to be a very bright boy, he is currently
repeating the kindergarten program, since he was considered “too immature” to progress to Grade 1.
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Jeremy’s mother provided the following background information. Jeremy weighed 7 pounds 6 ounces at birth.
Although the pregnancy, labor, and delivery were all normal, Jeremy was severely jaundiced at birth. As a
result, he remained hospitalized for 5 days while he was placed under special lights called bili lights to alleviate
the jaundice. Neonatal jaundice was the result of G6PD deficiency (an inherited human enzyme deficiency), a
condition that causes an allergic reaction to fava beans, which can induce a severe anemic response. A similar
response could develop if Jeremy developed viral hepatitis or pneumonia. He is monitored by his pediatrician,
and all medication trials have been closely supervised. Jeremy has had no adverse reactions to the Adderall or
the risperidone.
Jeremy’s milestones were advanced: walking at 8 months and speaking in simple phrases at 7 months.
However, Jeremy continues to exhibit articulation problems, which his mother attributes to constant bouts of
recurring ear infections. Mother and grandmother reported that by 2½ years of age, Jeremy was using words
such as humiliation and victimization in his conversation and would have long conversations about
experiments he was conducting in his “laboratory.” Currently, Jeremy is receiving assistance for articulation
from the speech pathologist at the school.
Shortly after his second birthday, Jeremy began to say “No” to everything, and power struggles have been
ongoing ever since. According to grandmother, “Jeremy is as stubborn as a mule!” However, as much as
Jeremy will say “No” or “I amn’t gonna’ do it,” he will not take no for an answer. Jeremy coined the word
amn’t as a short version of “am not” when he was about 2 years of age, and his mother and grandmother
continue to find it very amusing and repeatedly taunt him with it, saying they “amn’t gonna’ do it either.”
Apparently, Jeremy will argue about anything and everything and will “throw a fit” if he does not get his way.
Although he likes to be challenged by doing difficult tasks (multipiece puzzles), he is very quickly frustrated
and easily upset when he can’t solve something. His mother believes Jeremy’s stubbornness and strong desire
to be first have caused problems at school, since Jeremy will push others out of the way in order to be first, and
many of the other children avoid him. Reportedly, Jeremy loves to go to school, but adjusting to formal school
routines and expectations has been difficult for him. His impulsive and willful behaviors get him into trouble,
and his tendencies to carry boisterous and loud activities from the schoolyard into the classroom are
disruptive. Jeremy was retained in kindergarten due to issues of immaturity, problems relating to peers, and
lack of productivity regarding academic schoolwork. His teacher was unable to estimate Jeremy’s current levels
of functioning due to issues of noncompliance and failure to complete assigned work.
Jeremy was described as a very active and curious toddler. He was generally a good sleeper (mother said that
he just wore himself out) and had a good appetite. When asked about any health issues, mother stated that
Jeremy has been in good health. He has not had an ear infection in the past 2 years. He is vulnerable to skin
rashes and seasonal allergies. They believe that Jeremy inherited both of these conditions from his
grandmother, who has significant bouts of psoriasis and allergies to pollens and grasses. During the interviews,
Grandma’s psoriasis was very noticeable, as patches covered her exposed arms.
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According to his mother, Jeremy has always had his “good days and bad days.” He can be fun and playful, but
then again, he can be very difficult and demanding. There were some difficulties with potty training and once
again, his caregivers suggested this might be due to Jeremy’s stubborn nature. Grandmother was quite proud
of the fact that her potty training methods made the difference in Jeremy finally becoming trained.
Grandmother said that eventually he was trained by 3 years of age; however, she attributes successful training
to monetary rewards. At one point, grandmother was rewarding successful potty episodes at $5.00 each.
There is a history of mental instability in the maternal family. Jeremy’s mother and grandmother are currently
on medication for depression (Prozac), and Jeremy’s mother, Debbie, said that she has suffered from episodes
of depression “on and off” for years. She did not do well in school and also wonders whether she has a learning
disability or attentional problems. Mother is 25 years of age, is unemployed, and is currently taking one course
at the local college. Grandmother is 55 years of age and is on a small disability pension. Grandmother reports
that she is a highly anxious individual, as well as depressed, and “worries” about most things. Blanche said that
most people in the family have “some mental problem or another” and added that her sister (Jeremy’s great
aunt) will not leave the house (agoraphobic?) and has panic attacks. Apparently, the maternal grandfather is
an alcoholic and is also subject to violent outbursts and depression (bipolar?); his inability to tolerate
medication made him “impossible to live with.” Shortly after Jeremy’s birth, Blanche moved in with her
daughter and Jeremy to help with child rearing, since Debbie suffered an episode of postpartum depression
lasting about 3 months. During this period, Debbie spent much of her time in bed sleeping, while Blanche
cared for Jeremy. She said that she was “very anxious,” since she had not cared for a baby in 20 years and was
fearful that she might do something wrong. Debbie reported that Jeremy’s birth father told her he was
“clinically classified as insane” and that he often engaged in reckless, dangerous behaviors and had been in
trouble with the law. Jeremy has had no contact with his birth father or grandfather since his birth.
Debbie was in a car wreck 9 months ago, when her car was sideswiped by a truck. Although she was not
hospitalized, she did sustain major bruising and continues to receive chiropractic treatment twice a week.
Apparently, a teacher at Jeremy’s school showed Jeremy a picture of the car, which had appeared in the
newspaper, and Jeremy was so upset that he did not want to separate from his mother to go to school for the
next 6 weeks. This has been a very difficult time for the family because of the stress of the accident and
Jeremy’s behaviors. School attendance has been sporadic, since some days, Blanche doesn’t have the energy to
“drag” Jeremy to school while Debbie is recuperating from her injuries.
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Reason for Referral
When asked the primary reason for having Jeremy assessed, the caregivers’ immediate response was that the
pediatrician had recommended it. When pressed further, both stated that they were very interested in
knowing what Jeremy’s IQ was. There was no mention of possibly finding a solution to managing his behavior
problems.
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Assessment Results
Descriptions of the test instruments used in this assessment and guidelines for interpretation of standard
scores and T scores are available in Appendix C.
Jeremy literally exploded into the clinician’s office, abruptly letting go of his mother’s hand and immediately
trying to pry open the test kit on the table. The psychologist was able to halt further efforts to dismantle the
test kit with a firm, “Not yet, Jeremy,” while providing drawing paper and markers for his immediate
attention. Despite his whirlwind arrival, his mother confirmed that Jeremy had taken his medication prior to
coming. Mother left immediately after introducing Jeremy to the psychologist, and Jeremy evidenced no
noticeable reaction to being left with a stranger or to his mother’s departure. Although the psychologist
attempted to engage Jeremy in conversation, his poor articulation skills made conversation difficult.
Jeremy was far more interested in getting to the test materials, which were undoubtedly the “good stuff” of the
assessment for him. Test behaviors and learning style revealed a youngster who was highly active and very
fidgety and restless throughout the assessment sessions. Although he was responsive, he did have some
difficulty staying on task when required and in complying with specific requests. Jeremy had trouble
remaining seated and took turns sitting, standing, kneeling, rocking, and walking around the room. Attention
span and compliance with task demands varied considerably across tasks. Tasks requiring manipulation of
materials and hands-on activity were met with far more enthusiasm and focus than verbal tasks. He responded
poorly, if at all, to questions that required oral responses and provided minimal visual input. During the
vocabulary test, rather than provide oral answers in response to word definitions, Jeremy delighted in giving
clues to the psychologist in visual form in a game-playing type of format. When asked to spell the word cat on
the test protocol, Jeremy jumped out of his chair and drew a large picture of a cat on the blackboard. When
asked to describe what a “clock” was, Jeremy made an arrow on the blackboard in the room pointing to the
clock above it. When asked for a definition for the word hat, Jeremy again ran to the blackboard and added a
hat to his drawing of the cat.
On tasks that were maximally engaging (blocks, puzzles, working with pictures), it was often necessary to curb
Jeremy’s enthusiasm. On these tasks, Jeremy often attempted to grab test materials before they were
introduced and ignored instructions to wait until materials were presented. Jeremy was very intent on pursuing
his own agenda, and there were frequent compliance issues. Redirection to task was frequently required
throughout the assessment. There were two 35-minute assessment sessions, one week apart. At the
completion of the first session, Jeremy heard the elevator and immediately ran out of the room and down the
hall toward the top of a long staircase. The psychologist was concerned about safety since Jeremy could easily
have fallen down the stairs. Mother and grandmother took the opportunity to scold Jeremy for his behavior
and, as punishment, canceled plans to stop at a restaurant on the way home.
When engaged in a task he enjoyed doing, Jeremy was able to attend to the stimulus materials adequately and
problem solve without impulsive responding. He did evidence frustration on occasion, when he was unable to
obtain an adequate solution, and appeared fatigued after working unsuccessfully on a block design for 1½
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minutes. However, he was able to regroup and was more successful on the next two designs attempted. His
speech evidenced many sound substitution errors (“wabbit” for “rabbit” and “ewebwoddy” for “everybody”) and
cluttering of words resulting in indistinct utterances. However, Jeremy readily repeated phrases when asked
for clarification.
Responses to the Wechsler Intelligence Test for Children (WISC-V) revealed that Jeremy’s Verbal
Comprehension Index (VCI) was within the average to high average range at approximately the 66th
percentile (VCI range 99–112). Jeremy’s scores for Visual Spatial Index (VSI) and Fluid Reasoning Index
(FRI) were both within the Very High Range (VSI range 121–137; FRI range 118–135). His overall score for
nonverbal learning (Nonverbal Learning Index, NVI, range 123–135) was significantly higher than his VCI.
Given the significant discrepancy between scores in the verbal and visual areas, the full scale IQ was not
calculated, since it would merely represent the numerical average of three very discrepant scores (Kaufman &
Lichtenberger, 2000). Caution should be used in interpretation of the VCI score as a valid indicator of
Jeremy’s verbal skills, since his motivation and cooperation were questionable during the administration of the
verbal items. Given Jeremy’s attention span and interest level, it was not possible to administer tasks for the
Working Memory Index (WMI), including digit recall and number–letter sequence. He did, however,
complete the coding and symbol search tasks of the Processing Speed Index (PSI) well above average (scale
score of 16 for the coding test and scale score of 13 for symbol search). Scores for visual reasoning were more
consistent and revealed very strong performance overall. Relative strengths were noted in figure weights, visual
puzzles, matrix reasoning, and block designs, all of which were at the 98th percentile. Academically, Jeremy’s
responses to the Wechsler Individual Achievement Test (WIAT-III) revealed inconclusive information, since
Jeremy completed only those questions he wanted to try. When asked to draw a boy, Jeremy stated that he
would draw a man instead. The drawing was very immature in areas of line juncture and body proportion.
Jeremy participated in providing responses to the Joseph Pre-School and Primary Self-Concept Screening
Test. Jeremy’s responses indicated that his Global Self-Esteem was within the high positive range.
During the clinical intake interview, Jeremy’s mother completed several checklists derived from criteria
outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013). Mother endorsed
the following items from the ADHD scale as occurring often or always: fidgets with hands or feet (squirmy); has
problems awaiting his turn; problems playing quietly; problems sustaining attention in tasks; does not listen; problems
organizing tasks; problems remaining seated; easily distracted; forgetful; loses necessary items; runs about and climbs
incessantly; often on the go, driven; blurts out answers before questions are asked; and avoids tasks that require
sustained mental effort. On informal scales for problem behaviors, Jeremy’s mother noted that he was very often
“noncompliant” and “defiant” and that he could, at times, be very difficult to deal with. Particular behaviors
that occurred frequently included loss of temper; blames others for his mistakes; argues with adults; touchy, easily
annoyed; and actively defies or refuses to comply with adult requests.
In addition to informal diagnostic scales, Jeremy’s mother also completed the Conners Parent Rating Scale
(Conners 3) and the Child Behavior Checklist (CBCL). According to ratings on the Conners and CBCL,
Jeremy demonstrated clinically significant symptoms of attention-deficit/hyperactivity disorder,
predominantly the impulsive/hyperactive presentation. In addition, oppositional defiant behaviors and
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perfectionistic tendencies were also in the clinical range. There were indications that Jeremy complains of
physical symptoms more than the average child and that he can be prone to anxiety. Symptoms of
distractibility and tendencies to perseverate on ideas were evident on the CBCL. As part of the intake
information, mother also completed the Parenting Stress Index (PSI; Abidin, 1995) where she rated Jeremy at
or above the 99th percentile for distractibility/hyperactivity, inability to adjust to changes in environment, and
demandingness. Elevations on these scales are typical for parents of children with ADHD, with
demandingness often the peak scale (Abidin, 1995). With respect to family stresses, mother endorsed only
concerns about her health as a significant stressor. Grandmother declined to complete any forms, saying that
“Debbie is the mother.”
Jeremy’s teacher completed the Conners 3 Teacher Rating Scale and the Teacher Report Form (TRF:
Achenbach). Although the teacher ratings were less elevated than Jeremy’s mother’s ratings in all areas, his
teacher also noted some concerns regarding perfectionistic tendencies. According to the TRF, hyperactive-
impulsive behaviors were at the 95th percentile, indicating significant difficulties in this area. In addition,
thought problems were also noted.
Based on assessment results, intake information, and clinical observations, the psychologist produced the
following preliminary summary and diagnostic impression:
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Summary of Jeremy’s Formal Assessment
Jeremy is a 6-year-old boy who is currently repeating kindergarten at J. J. B. Elementary School. Jeremy is a
bright and engaging child; however, he is experiencing difficulties at home and at school as a result of
hyperactive and impulsive behaviors and tendencies to be noncompliant in situations when he is not in control
and when he is expected to follow directions that may or may not be to his liking.
Although Jeremy scored in the superior range on tasks of visual reasoning, his scores on verbal reasoning tasks
were less impressive due to several factors, including Jeremy’s lack of interest and motivation to respond to
verbal tasks. It is suspected that his weaker performance on verbal tasks reflects his lack of task engagement
rather than his learning potential. Despite his excellent reasoning ability, Jeremy may continue to experience
difficulties due to poor ability to regulate activity levels relative to task demands; Jeremy was either
understimulated (task was not interesting to him), or overstimulated (task was very exciting). In the former case,
Jeremy revealed poor attention span and distractibility, whereas in the latter case, he showed poor restraint
and impulsivity. Problems with compliance were also noted throughout, suggesting that Jeremy has developed
a strong repertoire of manipulative strategies that may be more resistant to correction than if he were not so
high functioning. Another way in which his superior intelligence may be a risk factor is that Jeremy’s lack of
success academically may be even more frustrating for him. The significant discrepancy between VCI and
NVI may also indicate a specific learning disability, which might complicate academic progress. Certainly at
this point, Jeremy’s academic skill levels are virtually nonexistent. Whether academic difficulties result from a
specific learning disability or an inability to apply himself to the task at hand remains to be seen.
Mother and grandmother jointly completed the Home Situations Questionnaire (Barkley, 1997) to provide
increased understanding of the nature of Jeremy’s noncompliant behaviors and how they were being managed
within the home. The Home Situations Questionnaire classifies compliance problems in three areas within
the home: instructions, commands, and rules. Results revealed four primary problematic situations: when
adults are talking on the telephone, when adults are watching television, when Jeremy is asked to do chores
(cleaning the room), and when Jeremy is asked to do homework. Problem areas were discussed at length, and
the caregivers engaged in role-play to demonstrate how each would interact with Jeremy under problem
conditions. Based on the dialogue and role-play, two areas of compliance difficulty were targeted for further
investigation. The caregivers selected problems with chores (specifically, when Jeremy is asked to clean up his
room or pick up his toys) and talking on the telephone (Jeremy’s intrusiveness when mother or grandmother is
occupied) as the two problem areas of most concern.
1. Compliance with requests to clean his room: Mom and grandmother agreed that when asked to clean
his room, Jeremy typically engages in argumentative behaviors (why he shouldn’t have to do it), delay
tactics (says he will do it later), manipulations (asks for help), or refusals (says he can’t or won’t do it).
There was also agreement about the methods used by each parent, saying that each had figured out the
“good cop, bad cop” routine wasn’t working, nor was mother’s response to count to three. Jeremy had
pretty well figured out that most times there wasn’t going to be anything happening after the three
count, so this was not very effective. Mom’s response to Jeremy not cleaning his room usually involved
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yelling and screaming. She proudly described a recent situation in which Jeremy yelled back at her “as
loud as possible,” but mother retaliated even more loudly, just to show him that she could out-scream
him. He tried but he couldn’t do it; as a result, mother said he had learned the lesson that she screams
the loudest. While mother screams, grandmother basically gives in and cleans the room for him to avoid
any further problems. A functional behavioral assessment and behavioral intervention plan to increase
compliant behaviors will be discussed as a treatment alternative later in the chapter.
2. Interruptions while trying to talk on the telephone: Specifically, “Jeremy will stand in your face and talk
at you, so you can’t hear the person on the telephone; he won’t wait until the call is finished.” Mother’s
typical response is to take the phone outside (if the weather is nice) or to yell at Jeremy. Grandmother
reports getting very upset with him and hanging up the phone as a result.
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Developing a Case Formulation from Several Perspectives
Biological Perspective
Jeremy has a long history of family psychopathology (Cicchetti & Toth, 1998), including attention problems
(mother and possibly father); mood disorders (mother, maternal grandmother, possibly maternal grandfather);
anxiety disorders (grandmother, potentially maternal aunt); substance abuse (maternal grandfather); and
antisocial personality disorder (father). Studies reveal that 50% of parents with ADHD have a child who is
also ADHD (Biederman et al., 1995). Genetic transmission for depression is estimated to be between 20%
and 45% (Rutter, Silberg, O’Connor, & Simonoff, 1999), with almost half developing bipolar disorder; odds
for bipolar increase if there is a family history for the disorder (Geller et al., 2002). General anxiety disorder,
panic attacks, or obsessive thoughts and behaviors result from malfunctions of GABA (gamma-aminobutyric
acid), which normally inhibits arousal, resulting in heightened levels of stimulation (Lloyd, Fletcher, &
Minuchin, 1992). Heritability of GABA malfunction can be as high as 30% to 40% (Eley, 1999). If antisocial
personality disorder is present in the immediate family, there is an increased risk for aggressive and disruptive
behavior disorders (DSM-IV-TR; APA, 2000). Studies have found that individuals with disorders of impulse
control, such as antisocial personality disorder, react to stressful circumstances in a dysregulated and
destructive manner, often directing their destructive actions toward violation of the rights of others. In these
cases, individuals who inherit the short allele (5HTT) of the serotonin neurotransmitter react with heightened
activation of the amygdale and cortical systems (Barr et al., 2003; Hariri et al., 2002). During these stressful
episodes, aggressive behaviors (destructive impulses toward others) become more probable (Stanley, Molcho,
& Stanley, 2000). Lyons-Ruth and colleagues (2007) found that the short form of the 5HTT was linked to an
increased risk for antisocial symptoms; individuals who had inherited the short form of the serotonin
transporter allele were twice as likely to express impulse disorder symptoms, whereas those who inherited two
of the short alleles were at four times the risk of developing impulse disorders.
Child temperament can be another biological marker influencing a child’s response to his or her environment.
Rydell, Berlin, and Bohlin (2001) studied children who were high on emotionality (intensity of emotional
arousal) and low on social adaptation (respond to emotionally charged situations in either a flight [withdrawal
and avoidance] or fight [anger and aggression] pattern). They found that children with this combination were
poorly equipped to manage their emotional responses to environmental demands. Although previous research
has demonstrated that maladaptive responses occur under highly negative conditions (e.g., internalizing
children would withdraw and avoid social contact, while externalizing children would aggress and break rules),
Rydell, Berlin, and Bohlin (2001) found that children with externalizing problems escalated out of control in
highly positively charged situations as well (e.g., the child cannot manage negative or positive emotions).
Although above-average intelligence is usually thought of as a protective factor (Luthar & Zigler, 1992), in
Jeremy’s case, superior intelligence may place him at greater risk for maladaptive behaviors, if he uses his
intellectual capacity to “outwit and outsmart” his caregivers by developing manipulative strategies and
engaging them in power struggles.
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Environmental factors can interact with biological traits and vulnerabilities in a way that exacerbates existing
conditions. Barkley (1997) suggests a four-factor model to explain factors that can maintain and increase
noncompliant behavior. According to this model, predisposing characteristics are
1. The temperament of the child (temperamental, high emotional reactivity, impulsive, active, inattentive)
2. The temperament of the parents (immature, temperamental, impulsive)
3. Child management patterns (inconsistent, harsh, indiscriminate, and coercive parenting, poor
monitoring of child activities)
4. Distressed family environment (financial, health, and personal stressors)
The model is well-suited as a framework for developing case formulations that can integrate information
across theoretical models.
Disruptive behaviors can be enduring, with patterns of persistent oppositional and aggressive behaviors
beginning in the preschool years and persisting across development (Owens & Shaw, 2003). Jeremy has
several risk factors for the development of disruptive behavior patterns. Historically, Jeremy’s temperament
has been problematic in areas of adaptation to change and emotional reactivity, resulting in difficulties with
emotion regulation (Bridges & Grolnick, 1995). When we place this temperament pattern within the context
of the underlying dynamics inherent in this mother–grandmother-parented family that often seems to shift
roles as to who is the parent and who is the child, the problems increase in intensity. Other environmental risk
factors for disruptive behavior disorders include insecure attachment (Rutter, 1995; Sroufe, 1997), cycles of
maternal depression and rejection (postpartum depression), child aggression and impulsivity (Owens & Shaw,
2003), poor school adjustment, and lack of positive peer relationships (Blum et al., 2000). Maternal
depression with features of irritability, criticism, and lack of positive affect can also increase the risk of
disruptive behaviors in children (Aguilar, Sroufe, Egeland, & Carlson, 2000).
Parenting, Attachment, and Family Systems Perspective

Insecure attachment may pave the way for Jeremy to develop separation anxiety in response to his mother’s
recent car accident, resulting in excessive need for proximity and heightened fears of possible loss. When
placed in fearful situations, being soothed by the parent can assist the infant in building brain structures that
can help regulate responses to fearful situations in the future. However, in dysfunctional attachment
relationships, caregivers do not provide assistance in the regulation of emotions, such as fear, and actually can
become a fear-provoking agent. In these circumstances, infants do not learn how to self-soothe in stress-
producing situations. Lyons-Ruth and colleagues (2007) found that early child care problems resulted in
negative outcomes several years later. As a result, Lyons-Ruth (2008) suggests that “disruptions in early
mother–infant communication are clearly important to long-term prediction of some forms of
psychopathology” (p. 209). Since early attachment patterns provide the schema for later relationships, Lyons-
Ruth goes on to suggest that contradictory cues may disable an individual’s ability to develop an appropriate
working model for relationships. Pertinent to Jeremy’s case, research has also found transgenerational effects
that explain how the controlling pattern of hostile, punitive, or rejecting behaviors of mothers with insecurely
attached boys with oppositional defiant disorder mimic their own backgrounds of insecure attachment
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patterns (DeKlyen, Speltz, & Greenberg, 1996). Disruptive behaviors may play an instrumental role in the
attachment process by acting to control and regulate caregiver proximity and attentiveness. Through the use of
negative attention-seeking behaviors, such as noncompliance, the child can “lock in” attachment figures based
on the use of negative attachment behaviors. It has been suggested that these maladaptive behaviors may fit
with the overall schema of family dysfunction (Marvin & Stewart, 1990).
Family systems theory would recognize several problems inherent in this family triad that has few limits and
very loosely defined boundaries. Mother, grandmother, and Jeremy seem to be enmeshed in each other’s lives
(Minuchin, 1985) and, as a result, Jeremy is often privy to information that is well beyond his years. It is also
likely that triangulation can occur, with the balance of power and status shifting among the family members,
depending on which two members are aligned together.
Today, many grandparents fill the role of surrogate parent for their grandchildren (Edwards, 2003). Within the
past 20 years, the number of grandparents who assume an active role in caring for their grandchildren has
increased dramatically (Cox, 2000; Goodman & Silverstein, 2005). Currently, approximately 4.5 million
children are living in grandparent-headed households (American Association of Retired Persons, 2007), with
the average age of grandparents in this situation between 55 and 64 (Smith & Dannison, 2002).
Within this situation, family members are often placed in a non-normative relational context that can place
grandparents in a conflicted relationship (Cox, 2000), and many grandparents have revealed feelings of being
“torn” between tending to their grandchildren’s needs and the needs of their own adult children (Musil,
Schrader, & Mutikani, 2000). According to Cox (2000), this ambiguous role often leaves grandparents
confused regarding how to define their position in the family, while at the same time feeling “responsible for
shaping and giving meaning to this new identity, defining it according to their own personalities, resources,
and values” (p. 6). In their research, Williamson, Softas-Nall, and Miller (2003) identified a number of
positive feelings that grandparents associated with their surrogate role, including the emotional feeling of
grandmothering and being able to contribute; however, a number of negative experiences were also revealed,
including depression, financial worries, abuse and neglect of grandchildren, and problems with disciplining
the children.
Erbert and Alemán (2008) investigated the dialectical tensions inherent in the grandparenting experience and
identified three contradictory processes that occurred in their sample: connection versus separation (a feeling of
greater connectedness with their family is offset by the loss of their own retirement activities and fears about
their inabilities to care for grandchildren), stability versus change (becoming reinvolved in the raising of
children at a time when the intergenerational gap has widened, e.g., an inability to relate to their social world
in the face of fears of increasing gang violence), and protection versus expression (fears of being unable to protect
the children from threats that are so different from when they raised their children, e.g., gangs, kidnapping,
molestation).
Grandparents raising children are twice as likely to be diagnosed with depression than their peers who are not
in a caregiver role (Fuller-Thompson, Minkler, & Driver, 2000) and experience lower levels of psychological
well-being (Baker & Silverstein, 2008). Grandparent-headed households reveal a significantly higher rate for
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poverty level than parent-headed households, while children in these families are twice as likely to receive
public assistance (Fuller-Thompson et al., 2000).
Social Cognitive Perspective

Parents of aggressive children may be unsuccessful in de-escalating conflict due to a negative attribution bias
regarding their aggressive children, blaming the defiant behavior on the child’s personality trait (e.g.,
stubbornness), which is beyond the parent’s control (Dix & Lochman, 1990; Strassberg, 1995). Especially in
ambivalent situations, or when compliance is not immediate, some parents may anticipate more defiance and
resistance and act accordingly (Bargh, Lombardi, & Higgins, 1988). The coercion model describes the
processes involved in the parent–child exchange that serve to precipitate and maintain aggressive and defiant
behaviors (Campbell, Pierce, Moore, Marakovitz, & Newby, 1996; Patterson, Capaldi, & Bank, 1991;
Snyder, Schrepferman, & St. Peter, 1997). Within this paradigm, parents’ negative schema drive coercive
parenting practices that escalate and maintain aggressive child responses, in a pattern of increasing arousal that
becomes negatively reinforced (Snyder, Edwards, McGraw, Kilgore, & Holton, 1994). Observational studies
of parent–child attempts at conflict resolution have determined that while mothers of nonaggressive boys are
successful in decreasing conflict, mothers of aggressive boys tend to escalate conflict (Snyder et al., 1994).
Parents of aggressive children generate fewer cognitive strategies for noncompliance (Azar, Robinson,
Hekimian, & Twentyman, 1984). Parent strategies are weakest when required to perform under pressured
conditions and tend to dissipate over the course of several trials (Beauchaine, Strassberg, Kees, & Drabick,
2002). The authors recommend the need for treatment plans to target the underlying processes of negative
attribution bias and affect regulation, which they suggest are the pivotal factors that drive coercive parenting
patterns.
Behavioral Perspective
Mash and Terdal (1997) suggest that behavioral assessments provide a form of data collection that naturally
lends itself to an increased understanding of the nature of a problem, the precipitating causes, treatment
options, and potential outcomes. By maintaining a focus on the “observable,” the behavioral approach to case
formulation distinguishes itself from other theoretical approaches that target underlying process.
Based on results of the Home Situations Questionnaire, behavioral analysis revealed two situations that were
especially problematic for Jeremy and his parents:
1. Problems with chores (noncompliance when asked to clean up his room)

2. Interruptions while trying to talk on the telephone (Jeremy’s demands for attention when parents are
otherwise engaged, e.g., talking on the telephone)
In the next section (treatment alternatives), a functional behavioral assessment is conducted and, based on the
prevailing assessment information, a behavior management program developed for implementation in the
home. The exercise demonstrates how behavioral assessment can be applied to this and future case studies.
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138
Treatment Alternatives and Developing an Intervention Plan
Cognitive–Behavioral Treatment
The cognitive–behavioral approach seeks to understand the link between thinking and behaving. Therefore,
the cognitive–behavioral therapist would focus on how Jeremy’s faulty belief system might contribute to
aggressive behavior. Social cognitive treatment might involve role-play in such areas as social perspective
taking, empathy, and self-control. Parent training using cognitive–behavioral methods would focus on
negative attributions, emotion regulation, and, ultimately, increasing effective strategies for behavior
management.
In their investigation of maternal responses to child noncompliance, Beauchaine and colleagues (2002)
investigated whether parents using ineffective and harsh methods of discipline fail to generate alternative
solutions due to an availability deficit (limited repertoire) or an accessibility deficit (processing deficit during
times of stress). The authors contend that research support for the accessibility bias has important
implications for parent training programs devoted to teaching parents alternate methods of child
management, since parent attributions may undermine successful use of the skills taught. The authors
emphasize the need to address negative attributions and adding an affect-regulation component to parent
training programs in order to enhance treatment effectiveness.
Jeremy’s Functional Behavioral Assessment and the Behavioral Intervention

Plan
Functional Behavioral Assessment.
The behavioral framework consists of a four-stage process designed to
identify the problem,

analyze the problem,
implement a plan, and
evaluate the plan.
Jeremy’s noncompliant behavior can be identified as a behavioral deficit (low levels of obedience) or a
behavioral excess (high levels of noncompliance). Placing Jeremy’s behaviors within a functional behavior
assessment paradigm (see Table C2.1), the goal is to identify the problem as it relates to precipitating
conditions, consequences, and results.
One of his parents’ presenting complaints is Jeremy’s lack of compliance when asked to clean his room. In this
case, the precipitating conditions would represent the requests initiated by the parents that would begin the
behavioral sequence of events. When faced with these requests, Jeremy demonstrates the following repertoire
of behaviors (argues, delays, manipulates, refuses). When faced with these behaviors, parents respond with a
number of reactions or consequences ranging from doing the task themselves (in whole or part) to escalating
139
battles that may end in either abandoning the request or in harsh punishment.
Table C2.1 Behavior Assessment Paradigm
Precipitating Conditions Behaviors Consequences Results (Rewards)
Behavioral Intervention Plan.
In developing a behavioral plan, it is preferable to concentrate on increasing a deficit behavior rather than on
reducing an excessive behavior. In this case, it is preferable to increase obedient behavior rather than to
attempt to reduce noncompliant behavior, since increasing a positive behavior can be inherently rewarding in
itself. At this time, the positive reinforcement that Jeremy is receiving due to his noncompliance far outweighs
the occasional and inconsistent punishment he may receive. The behavior plan would be to shift the positive
reinforcement to obedience rather than reduce noncompliance.
Principles of operant conditioning predict that there are two options available for increasing or maintaining
obedient behavior: positive reinforcement or negative reinforcement. Reinforcements are acts that have a positive
outcome and, as such, will be rewarding, thereby increasing the likelihood that a behavior will be repeated.
Positive reinforcement involves the addition of a reward (e.g., clean your room and you will get a sticker book).
Positive reinforcement, however, is not always what it appears to be, and in Jeremy’s case his parents
unknowingly reinforce many of his negative behaviors in various ways: humor (suggesting acceptance),
boasting (suggesting pride), and providing increased attention. In this case, Jeremy is rewarded by negative
attention, which to Jeremy might be better than no attention at all. Negative reinforcement, not to be confused
with punishment, is also rewarding because it involves the removal of a negative (e.g., if you clean your room,
you will not have to take out the trash). Negative reinforcement has sometimes been called escape because it
allows one to escape a negative consequence. Jeremy’s argumentativeness and noncompliance are often
negatively reinforcing because they allow him to escape having to do a task. Principles of learning also provide
a set of assumptions for reducing or eliminating behavior: punishment that involves adding a negative
consequence or penalty, removing a positive. Complete withholding of any reinforcement will eventually result
in elimination of the behavior, or what the behaviorists refer to as extinction.
Although coercion theory from a cognitive framework attends to the underlying processes of negative
attribution and emotion regulation, a behaviorist might use the theory to describe the antecedents and
consequences of noncompliance. Parents who eventually yield to a child’s escalating and demanding behaviors
serve to positively reinforce the child’s misbehavior (child eventually gets what child wants) and at the same time
give negative reinforcement for their own compliance (cessation of whining and complaining). Therefore, the
parent learns that giving in will stop the demands, while the child learns that increased demands result in
parent compliance. Since positive and negative reinforcement serve to strengthen behaviors, parent and child
become locked in to an escalating and never-ending battle.
The importance of developing early treatment interventions to reduce noncompliant behaviors is evident in
the repeated associations of defiant behavior and later maladjustment in adolescence and adulthood. In their
140
meta-analysis of psychosocial treatments for children and youth with oppositional defiant disorder and
conduct disorder, Brestan and Eyberg (1998) revealed behavioral parent training programs to be a successful
method for reducing deviant behavior in young children.
Home-based, parent-delivered interventions often are the result of programs directed toward parent
management training (PMT), and research has demonstrated that between one third and two thirds of
children show clinically significant improvement (Barkley, 1997, 2006; Kazdin, 1996, 2013). The rationale for
PMT is based on the premise that coercive parent–child interchanges and environmental contingencies are
predisposing factors in the development and maintenance of oppositional, defiant, and noncompliant
behaviors. Given the dynamics involved in this family and the issues of compliance, the goal was to develop a
home-based behavioral intervention plan. Barkley (2006) suggests a number of components that are helpful in
organizing a behavior intervention plan, including assessment and establishment of a baseline,
operationalizing treatment goals, psychoeducation for parents concerning issues of behavior management,
monitoring, contingency management, generalization to other settings, maintenance and relapse prevention,
and follow-up.
A behavioral intervention program was developed for Jeremy for use in the home, based on behaviors targeted
by mother and grandmother on the Home Situations Questionnaire. A written copy of “Jeremy’s Star Chart
Program” was provided, outlining agreed-upon consequences for rule infractions, such as loss of stars, as well
as other possible strategies (time out, logical consequences, loss of privilege). A general description of possible
rewards was discussed; however, it was urged that Jeremy also be involved in selecting some of the rewards to
increase incentive and participation in the program. Goals of the behavior program were to assist with
increasing compliant behaviors and applying a consistent approach to consequencing Jeremy for
noncompliance. The program involved posting of house rules on the fridge and dealing with rule infractions
through the use of (a) time-out, (b) logical consequences, and (c) a Response Cost Coupon Program. The
Response Cost Coupon Program, called Jeremy’s Star Chart, was illustrated in a booklet with rules outlined for
loss of stars, regaining of lost stars, and adding up of star gains to trade for rewards on the Star Chart menu.
The program was monitored by weekly telephone contact. An example of the Star Chart is shown in Table
C2.2.
Another powerful source of learning is observation. Bandura’s (1977) understanding of the social aspects of
learning has been instrumental in increasing our awareness of the possible implications of observing the
behavior of others. Children’s observation and subsequent modeling of adult behavior can have positive
(nurturing and empathic caring behaviors) or negative (aggressive responses, e.g., witness of domestic
violence) consequences. These responses can be immediately observable or can be evident in a delayed
response.
Table C2.2 Jeremy’s Daily Star Chart
Morning Afternoon Evening Bedtime Total Stars
★★★★ ★★★★ ★★★★ ★★★★
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All-Star Rules:
1. Rule-breaking or misbehavior = 1 lost star
2. At the end of each day, stars are added up
3. Jeremy can trade his stars for the following rewards:
5 ★ = _____________________ 10 ★ = ___________________
15 ★ = _____________________ 20 ★ = ___________________
25 ★ = _____________________ 30 ★ = ___________________
Research has repeatedly demonstrated that the nature of parent–child interactions is a strong predictor of
childhood noncompliant, defiant, and aggressive behavior patterns. Poor management practices due to
ineffective, inconsistent, and indiscriminate parental controls often result in overly harsh but inconsistent
discipline and inadequate monitoring of activities. As a result, child noncompliance becomes an effective
means of avoidance or escape from doing undesirable tasks such as picking up toys or cleaning a bedroom.
Mother and grandmother are often at odds over setting limits and often present Jeremy with contradictory
messages. Grandmother is particularly reinforcing of Jeremy’s manipulations and often gives in, allowing his
successful escape or avoidance of unpleasant tasks. Jeremy’s mother often responds with escalating and
coercive responses (screaming as loud as possible), likely due to their occasional success (“he couldn’t scream as
loud, even though he tried, so I won that time”). In this context, Jeremy has learned how to successfully avoid
unpleasant tasks on the one hand and learned to model negative behaviors on the other.
142
Post-Case Questions
1. Jeremy presents with symptoms of ADHD and ODD. Using the DSM-5 (APA, 2013) as a guide describe how Jeremy’s
symptoms match criteria as outlined in the DSM-5. Based on what you have found, would Jeremy meet criteria for either disorder,
and if so, which disorder(s) and why?
2. Jeremy’s parents indicated two areas on the Home Situations Questionnaire that were in need of behavior management. One
problem, compliance with chores, was selected to demonstrate how a functional behavioral assessment and behavior intervention
plan were developed to assist in increasing compliant behaviors. What was the second problem that his parents identified?
Conduct a functional behavioral assessment and develop a behavioral intervention plan to assist his parents with the second
problem.
3. According to Bronfenbrenner (1989), the mesosystem predicts the degree to which a system remains healthy, functional, and in
balance. Given the information you know about Jeremy’s family and the school system, describe what you believe the current
status to be and how you would attempt to maximize the mesosystem between these two environmental contexts.
4. Using coercion theory as the overarching dimension, describe power struggles in the family from the viewpoint of cognitive,
behavioral, and family systems theories.
5. From an attachment theory perspective, using information from the case study, the Introduction, and any related outside sources,
describe the potential transgenerational effects that are underlying problems with the parent–child interaction. How does having
the grandmother living in the home contribute or moderate the effects of attachment issues?
6. Child temperament can be another biological marker influencing a child’s response to his or her environment. Using information
from the case study, the Introduction, and any related outside sources, discuss the role of temperament in influencing Jeremy’s
response to situations and other individuals. Explain how this can be better understood within the context of epigenesis.
7. Suggested Individual or Group Presentation Activity: The teacher has asked Jeremy’s mother and grandmother to attend a
meeting at the school to address Jeremy’s increasing non-compliance and difficulties with emotion regulation, especially during
less structured activities. Jeremy’s mother has requested that the psychologist come to the meeting to share the results of the
assessment and assist with planning a behavior program for Jeremy. At a minimum, the meeting will include the teacher, Jeremy’s
mother and grandmother, and the psychologist. Prepare a script for role-playing each of the player’s parts in the meeting and how
they could potentially contribute information to assist with developing a case formulation, functional assessment, and behavioral
intervention plan. Who else would you want to invite to the meeting and why?
143
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Case 3 Neesha Wilson Phoenix Rising Risks, Protective Factors,
and Psychological Well-Being
Neesha Wilson, a 10-year-old African American girl, was referred for assessment to the school psychologist as
a result of a child study team meeting held at the school in May. Presenting problems included poor school
progress and escalating behavioral concerns. It was the school’s impression that Neesha might qualify for
special education assistance as a child with an emotional disorder. Currently, Neesha has an older brother,
Tyrone, who is attending an alternate school program for children and youth with severe emotional
disturbance.
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The school social worker completed Neesha’s initial work-up just prior to the end of the academic term;
intake information is summarized as follows:
Neesha lives with her 15-year-old brother, Tyrone, and her mother in a two-bedroom apartment. The social
worker described the apartment as tiny but very well kept. Neesha has her own bedroom, and Tyrone sleeps
on the couch, which folds out into a bed. The social worker noted that it was difficult to book an appointment
with Mrs. Wilson, who was reportedly working two jobs: cleaning offices and working as a hairstylist. Mrs.
Wilson graduated from hairstylist classes last year. Although her career as a hairstylist has a lot of potential,
she is only beginning to develop clientele. She also works part time cleaning offices. Despite the lack of
financial resources, the children were clean, well dressed, and did not miss any meals. The children were on
the free-lunch program at the schools. According to Mrs. Wilson, Neesha’s early history was unremarkable
and motor and language milestones developed on schedule.
An immediate concern of the social worker’s centered on who cared for the children when their mother,
Tanya, had to work evenings cleaning offices. Tanya stated that it was not a problem for her because she
would either send the children to her sister’s apartment a few blocks away, or have a cousin who lived in the
building check in on the kids. Also, Tyrone was 15, so he was capable of watching his sister, although she
preferred to have an adult nearby, given Tyrone’s behavior problems.
Neesha’s mother described her as an easy baby and said that she never really had any problems with her. She
added that it was Tyrone who was giving her all the problems, not Neesha. The family had struggled since her
husband, Walt, left the family about 3 years ago, when Neesha was in Grade 1. In the past two years, Walt
has had virtually no contact with the children. He moved in with his girlfriend and their one-year-old baby
and recently moved to another state. Neesha was very upset with the marriage breakdown and misses her
father very much. Neesha visited with her dad and his new family, initially, but was very disappointed that the
visits were neither consistent nor more frequent. Neesha did not like Walt’s girlfriend and felt that her father
was more interested in the new baby than her. According to Tanya, Neesha often talks about wanting to visit
her father and continues to set herself up for disappointment. Tanya blames Walt’s lack of involvement with
the children for Tyrone’s problems, which became more severe after Walt left.
When Walt moved out, Tanya could no longer afford to live in the apartment they were living in. Tanya
described the previous 2 years as very difficult for her and the kids. As Tanya spoke, the social worker noted in
the file that the mother’s affect was very flat. She also seemed preoccupied with her financial situation and
said that at times she just wasn’t sure how she would make the rent. They have struggled to survive financially,
and Tanya often gets depressed and—if she isn’t working the evening—either goes to bed early or cries herself
to sleep. On these occasions, Neesha is very quiet and tries to comfort her mother. Tanya said that when she
woke up the other morning, Neesha had placed a handmade card on her pillow. The card was decorated with
hearts and bows and huge letters: “I love you, Mom. Neesha.” Tanya said she didn’t understand why Neesha
was doing so poorly in school because she seemed to love to “play school” on the weekends and in the evening.
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When asked whether Neesha has demonstrated any behavior problems at home, Tanya said she is more like a
little mother than a kid and has no behavior problems at all. Her brother is the problem; Neesha is more like a
little adult. She described Neesha as a sweet and loving child who always tries to please.
The social worker expressed her concern to Tanya about her own symptoms of depression and fatigue and
wondered if Tanya might see her physician for a referral to talk to a counselor. The social worker stated that
she was concerned because Tanya seemed overwhelmed by all the financial stresses the family faced that
seemed to be taking their toll on her emotionally. However, Tanya was quick to say that the extended family
was very supportive and that her two sisters were always there for her to talk to when she needed it. She also
said that her church was a continued source of comfort and support for herself and the children. In addition to
information obtained from the clinical interview, the social worker also had Tanya complete the Behavioral
Assessment System for Children (BASC-2).
In August, at the beginning of the new term, the school psychologist completed a review of Neesha’s
cumulative school record and obtained teacher ratings (BASC-2) from her previous years’ teachers, which
were on file in the guidance office. Neesha’s school record contained the following additional information.
Neesha began her formal schooling at Franklin Elementary School but transferred schools midway through
the Grade 1 program. She completed Grade 1 and Grade 2 at Vista Springs Elementary. She has been
attending Heartfield Elementary since her enrollment in the Grade 3 program. Neesha is currently repeating
the fourth grade. Neesha’s records reveal that her Grade 3 teacher was concerned because Neesha was
repeatedly falling asleep in class. Because Neesha seemed overly fatigued, her mother took her to the family
physician to check out any possible physical causes; however, no medical reason was evident to explain her
fatigue. Last year, Neesha was absent 15 days. On the days she attended school, Neesha was late more than
one third of the time (51 days). The school counselor had written a summary report based on her observations
of Neesha in the classroom, toward the end of the Grade 4 program, when the paperwork was being collected
for her assessment in the fall. The notes indicated that Neesha was off task (daydreaming, looking out the
window, staring out into space) for the majority of time that she was observed. The observation supported
teacher comments that Neesha often failed to complete her seatwork and handed in assignments unfinished.
During another observation session, the counselor recorded that during a 25-minute seatwork session, Neesha
completed only 2 out of 8 comprehension questions for a story read aloud in class. Her teacher also reported
that, at times, Neesha’s lack of attention to task could also result in class-disturbing behaviors such as
humming, playing with articles on her desk, and socializing.
As part of the referral process, in addition to notes on classroom observations, the teacher also was asked to
record what interventions were attempted and to comment on the success of these attempts. Interventions
included sending a daily agenda regarding Neesha’s behavior for home signature, providing extra time for task
completion, and seating her closer to the teacher’s desk. However, the daily agenda often was returned
unsigned, since her mother was sleeping, and providing extra time did not increase her productivity. In all, the
interventions generally were not successful. Ultimately, the decision was made to have Neesha repeat the
Grade 4 program, since she had not completed any assigned tasks during her Grade 4 year, and to place her
on high priority for a comprehensive assessment early in the fall term.
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The school psychologist saw Neesha for an initial assessment session, early in the fall term. Neesha was very
well groomed, with matching accessories and her hair stylishly braided in a way that must have taken hours to
complete. When asked about her hair, Neesha was very proud to say that her mother had done it for her, and
that her mother was a very good hairdresser. Neesha was very polite and cooperative. Neesha’s responses and
demeanor suggested a precocious maturity for her 10 years. The psychologist felt that Neesha tried her best on
all tasks presented but questioned the validity of overall intellectual scores.
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Reason for Referral
The school requested assessment due to Neesha’s escalating academic difficulties and increased behavioral
problems (irritability, moodiness, and beginning to strike out at other children). There were concerns that
Neesha might warrant placement in a program for children with emotional problems.
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Assessment Results
Information concerning specific assessment instruments and the interpretation of standard scores and T scores
can be found in Appendix C.
Responses to the Wechsler Intelligence Scale for Children (WISC-V) revealed Neesha’s overall intellectual
score of 92, which was within the average range (IQ range 87–98). However, there were several indicators to
suggest that this score was likely an underestimate of her “true potential.” Neesha’s mature conversational
tone, insight, and academic levels obtained on standardized testing suggested intellectual functioning more
appropriately suited to the upper average to high average range. Based on her overall obtained score, Neesha
performed in the average range of ability at the 30th percentile when compared with children her age. There
was minimal difference in her scores for the Verbal Comprehension Index (VCI, standard score of 90), the
Visual Spatial Index (VSI, standard score of 95), and the Fluid Reasoning Index (FRI, standard score of 93).
Based on these scores, it would be anticipated that Neesha should be performing approximately at grade level
academically. An analysis of the individual pattern of test results indicated that Neesha had relative strengths
in the areas of the Working Memory Index (WMI = 100), which involves the manipulation of mental
information and short-term working memory, and Processing Speed Index (PSI = 103), which measures
speed of copying and scanning information. An analysis of the individual pattern of subtest scores indicated
that Neesha had relative strengths in the area of visual analysis and reasoning (picture concepts) and recall for
letter and number sequences. Weaknesses were noted in vocabulary development, social judgment, and part-
to-whole visual organization (block design).
Academically, according to the Woodcock Johnson Test of Achievement, Neesha’s current functioning levels
were far in excess of her current grade placement and also exceeded predicted levels according to the WISC-V
(which was considered as an underestimate of her intellectual potential). Overall, Neesha was performing at a
Grade 7.2 level in Broad Reading (age score of 12.7), Grade 5.8 level in Broad Math (age score 11.4), and
Grade 7.9 level in Broad Written Expression (age score 13.2). Overall, Neesha was achieving in the high
average range when scores were compared with those of other children her age who would be enrolled in a
regular Grade 5 program. When compared with other children enrolled in a regular Grade 4 program (which
Neesha was currently repeating), her scores represented functioning in the superior range.
Neesha was cooperative during the clinical interview and provided thoughtful and conscientious responses to
the interviewer’s questions. When asked what types of things or situations made her feel happy, sad, angry, or
frightened, Neesha provided the following information. Neesha stated that “compliments, surprises, and visits
with her Dad” were all things that could make her “happy.” She said she felt “sad” when kids threaten her or
people say bad things about her or her family. She also stated that she gets very sad when her mother cries
because she doesn’t know how to make it better.
Neesha looked sad as she spoke about her mother, and her voice trailed off as she swallowed hard. Neesha
admitted to feeling angry and upset when her older brother (15 years of age) hits her, and she is “frightened”
when she visits her aunt’s neighborhood, because the kids are loud and scary. In response to what worries her
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presently, Neesha said that she is worried that she won’t be able to advance to the fifth grade this year. She
said that she asked her mother to talk to the principal because she is working very hard and wants to go to
Grade 5. She said she did not want to be in Grade 4 again, and she is very afraid that the kids will start being
mean again and call her names like they did last year. She said she did not want to get into trouble this year
like she did last year.
When asked why she was falling asleep in class, Neesha said that in the past she had lots of problems falling
asleep but added that was 2 years ago and things were different then. She said that at that time she would
come home from school very tired and fall asleep after dinner. Then she would wake up at night and not be
able to go to sleep again. She said that she has stopped taking naps in the afternoon and now she doesn’t wake
up at night anymore. Neesha volunteered that she also worried a lot about things and that sometimes when
she worries she has a hard time falling asleep. Not so much now, but it was bad then because she missed her
dad and wanted him to come home. She said that last year she got in trouble for being late so many times, but
it was hard to wake up. Neesha said that she was tired and had trouble getting herself ready for school. Her
mom was sleeping late because she was working more nights cleaning the offices. Neesha said it was a very
hard year. She was tired and cranky and just couldn’t seem to concentrate on her work. She said she would
read a page and then not remember what she read. Neesha said she got so far behind that she just gave up.
She was also having problems with the other girls in the class, who were starting to tease her about sleeping in
class and not doing her work. She said they called her names like “Sleepy” and “Dummy.” She said that at first
it made her very sad, and then it made her very mad. That’s when she started to hit them to make them stop.
When I asked what made the difference this year, Neesha said, for one, she now has an alarm clock. She sets
the clock and lets her mom sleep in. The school bus picks the kids up on the corner, so she just goes and waits
with the other kids who live in the apartment building. When asked about schoolwork, Neesha stated that she
was very proud of her reading ability and said that she is now concentrating on finishing her work and that
keeps her going.
Neesha completed several self-report inventories. Overall response to the Revised Children’s Manifest
Anxiety Scale (RCMAS-2) revealed total anxiety to be within normal limits. However, there was a significant
elevation on the Physiological Indicator scale, and Neesha endorsed several items indicating a generalized
heightened state of arousal often associated with stressful conditions, such as trouble getting her breath,
feeling sick to her stomach, and hands feeling sweaty. She also admitted to worrying a lot of the time and
having problems falling asleep. An elevated validity scale (the Lie scale on the RCMAS) was suggestive of
Neesha’s tendency to try to project a good image and suggesting that perhaps her anxiety was more of an issue
than Neesha was letting on.
Neesha’s responses to the Children’s Depression Inventory (CDI-2) revealed overall depression level to be
within the norm when compared to girls of a similar age. However, the elevation on the Negative Mood scale
was significant, indicating problems with sleeping, fatigue, and worry about aches and pains. Neesha also
completed the Personality Inventory for Youth (PIY), a 270-item questionnaire that assesses emotional and
behavioral adjustment and family characteristics and interactions, as well as school adjustment. The
instrument also includes validity scales that identify a respondent’s level of consistency and defensiveness.
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Neesha’s scores on the validity scales suggested that her profile was an honest attempt to reflect her current
emotional and behavioral concerns. Scores indicated normal concerns typical of girls her age in most areas.
However, consistent with the RCMAS, Neesha endorsed a significant number of items indicating somatic
concern (T = 73). Scores in this range suggest a large and varied number of somatic symptoms and health
concerns, such as fatigue, headache, stomachache, back pain, dizzy spells, trouble breathing, and the like.
Results of this kind are often seen in children who worry about and are preoccupied with illness and may
become emotionally upset when they are sick. Often these symptoms represent the physical aspects of anxiety
and tension. Neesha’s particular pattern of endorsement suggests that symptoms are likely connected to
feelings of psychological distress within the home.
Projective assessment was also conducted using the Robert’s Apperception Test, a series of pictures that are
used as prompts for children’s stories. The characters in Neesha’s stories revealed difficulties in the following
areas: conflicts with siblings, fear of being punished for doing something wrong, fear of being ill, and concerns
regarding school performance. Family matters included a mother having a new baby and a young girl being a
bridesmaid for her parents’ wedding. Neesha’s drawings for the House–Tree–Person indicated a positive
openness to communication and were generally free of suggested pathology.
Two of Neesha’s teachers from the fourth grade last year, her current teacher, and her mother completed the
Behavioral Assessment System for Children (BASC-2). It should be noted that although the BASC-2
suggests that rating be conducted by individuals who have known the child for at least 6 months, the desire to
have a current behavioral rating for comparison violated this suggestion since her current teacher has known
Neesha only since the beginning of August (less than 2 months). Therefore, results should be interpreted with
caution. The BASC-2 is a comprehensive measurement of common behavioral and emotional problems in
children. Ratings of children are interpreted to indicate behavioral concerns that are normal, at risk, or
clinical. Behaviors falling within the at-risk range represent an emerging problem area that needs attention
but does not warrant a formal diagnosis, while behaviors within the clinical range are problems that warrant
attention and intervention.
Ratings are based on the observations of informants in different situations, and it is not unusual for children
to behave differently in various situations. Therefore, inconsistencies between informants are not unusual.
According to Neesha’s teachers last year, there was agreement in several areas on the BASC-2 ratings. The
two teachers rated her behaviors as clinically significant in the following areas: Aggression (physical and
verbal), Conduct Problems (rule-breaking behaviors), and overall Externalizing Problems. They also agreed
that the following behaviors were at risk: Attention Problems, Leadership, Social Skills, and Study Skills. At-
risk or clinically significant elevations were also noted for Composite Adaptive Skills (Adaptability, Social
Skills, Leadership, Study Skills). Neesha’s current teacher and Neesha’s mother have indicated all behaviors
currently to be within the normal range.
In the final assessment session, Neesha appeared very positive about her school successes this year and said
that she was working very hard to go to the next grade level. When asked if she would like to meet with the
school psychologist once in a while, just to talk about her worries, Neesha said that she would like that very
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much. As she left the office, she turned and thanked the psychologist for working with her, and added, “You
know, sometimes, it’s hard being a kid.” When Neesha’s mother came to talk to the school psychologist about
the test results, the psychologist mirrored the social worker’s earlier concerns about the mother being
depressed and preoccupied. Affect was very flat despite the excellent news she was receiving regarding her
daughter’s academic skills and behavioral turnaround. Her mother reported that what Neesha had
accomplished, she had done on her own. She stated that Neesha had received no help from her. Mother
appeared preoccupied with the interview making her late for work and asked if she could please leave quickly.
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Postscript
Three weeks later, at 10:00 a.m., the school principal received a call from Neesha’s mother, who asked that
her daughter not be sent home from school because she was going to kill herself. As she spoke on the
telephone, she explained that she was holding a loaded gun to her head and that she had to do it, because she
was not going to make this month’s rent. She could not take it any longer, but she did not want Neesha to
come home and find her dead.
While the guidance counselor continued to keep the mother talking, the school principal contacted the police,
who apprehended mom while she was talking on her cell phone from her car in the driveway of the apartment
building. The loaded gun was on her lap. Mother was Baker Acted (taken into custody due to fears regarding
danger to self) and taken to the local psychiatric facility. Currently, mother is on medication for depression.
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Considering Neesha’s case within the framework of developmental contexts and environmental influences,
there are several risk factors that are affecting her development that are not within Neesha’s immediate
control, including poverty, her mother’s mental illness (depression), and living with a sibling who has severe
emotional disturbance.
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Case Formulation
Unlike the other two cases presented in this introductory section, developing a case formulation for Neesha
requires thinking outside the box. Neesha does not present with enough symptoms of depression or anxiety to
meet criteria for any specific anxiety or depressive disorder. However, she does meet diagnostic criteria for an
adjustment disorder with mixed anxiety and depressed mood. Adjustment disorders are evident as emotional
or behavioral symptoms that develop in response to an identifiable stressor and occur within 3 months of the
onset of the stressor. Although this stress-related disorder is considered to be a “temporary” condition that
“lasts no longer than 6 months after the stressor or its consequences have ceased” (APA,2013, p. 287), in
Neesha’s case, she is experiencing ongoing stress related to environmental influences that continue to be
present. The DSM does specify that “if the stressor or its consequences persist, the adjustment disorder may
continue to be present and become the persistent form.”
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Risks, Protective Factors, and Resilience
Several researchers have focused on the role of protective factors in buffering some children living in high-risk
environments. Emphasis has shifted from focusing on risks to determining environmental resources and
adaptive strengths in children who do not show early signs of deviance (Richters & Weintraub, 1990). Rutter
(1987) noted several years ago that instead of searching for broadly defined protective factors, emphasis needs
to be placed on better understanding “why and how some individuals manage to maintain high self-esteem
and self-efficacy in spite of facing the same adversities that lead other people to give up and lose hope” (p.
317). Further, Rutter (1990) suggests that we go beyond listing risk factors to looking at the underlying
processes or mechanisms that are instrumental in producing the buffering effect. Rutter defines these
processes as reducing risk impact, reducing negative chain reactions, increasing factors that promote self-
esteem, and opening opportunities. The role of timing (life events) in changing the trajectory away from
vulnerability is also discussed. In their discussion of risk and resilience, Werner and Smith (2001) concluded
that certain environmental factors, such as positive emotional support from caregivers and mentors, could
provide protection from negative outcomes, despite living in adverse conditions. Although resilience was once
thought of as a trait, currently, resilience is thought of as “a process or phenomenon reflecting positive child
adjustment despite conditions of risk” (Luthar & Zelazo, 2003, p. 510).
Durlak (1998) reviewed 1,200 outcome studies concerning prevention programs for children and identified
several common risk and protective factors across seven major outcome areas: behavior problems, school
failure, poor physical health, physical injury, pregnancy, drug use, and AIDS. Analysis of risk and protective
factors linked each factor with the appropriate developmental context, including individual, immediate
(family, school, peers), and community. Durlak found multiple factors playing a protective role for more than
one outcome. For example, attending a “high quality school” protected against behavior problems, school
failure, early pregnancy, drug use, and AIDS, and having “positive peer models” also protected across the same
five areas. Having a good parent–child relationship and good personal and social skills protected across all
seven major outcomes. High-risk factors included living in an impoverished neighborhood, low family SES,
parental psychopathology, marital discord, and punitive parenting. Stress was considered to be a risk factor
that crossed all levels of development, while social support was a protective factor that crossed all
developmental levels.
When discussing risk and protective factors, the risks of being in an ethnic minority have rarely been
addressed. Gibbs and Huang (2001) emphasize that when ethnic identity is combined with membership in a
minority race, children are faced with a dual challenge. The authors also note that ethnic minority status has
often been associated with restricted range of opportunities, and children growing up in minority families may
be exposed to circumstances and experiences very different from the majority of the community. In addition,
there is often an interaction among factors of ethnicity, race, and social class (SES), with higher status
typically perceived for White, Anglo-Saxon, middle-class families, and lower status associated with non-
White, ethnic minority, and lower class families (Hacker, 1992). In their study of child poverty rates,
Lichtner, Quian, and Crowley (2005) found that whereas 9% of White children were living below the poverty
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line, one third of all Black children and 27% of Hispanic children were living at this level. According to the
2014 census, approximately 38% of African American youth under 18 years of age live below the poverty line,
compared with 30% Hispanic, 9.6% Asian and 10.7% Whites (DeNavas-Walt & Proctor, 2014). Within this
context, the role of the family has assumed a position of strength and resilience. One central value that is
cultivated by African American families is the importance of being “independent” and the value of
independence. In this manner, the family unit is sustained by members who are self-reliant. Other strong
family values often include obedience, respect for elders, and emphasis on obtaining a good education.
However, culture clash may be evident in the way in which family members or children whose sense of time is
fluid and event oriented interact with largely White establishments where time is determined by the clock,
calendar, or school agenda (Lynch & Hanson, 1998).
A growing body of research has revealed that maternal depression and depressive symptoms place children and
adolescents at increased risk for negative social and emotional outcomes (Goodman & Gotlib, 2002). Recent
studies have found that by adolescence, children and youth exposed to maternal depression demonstrate
higher levels of internalizing and externalizing problems relative to peers whose mothers are not depressed
(Foster, Garber, & Durlak, 2008; Nelson, Hammen, Brennan, & Ullman, 2003). Campbell, Morgan-Lopez,
Cox, and McLoyd (2009) found that adolescents whose mothers reported chronic depressed symptoms across
their childhood evidenced more symptoms of depression, dysphoria, and loneliness compared to peers whose
mothers were without a history of depression. It has also been found that children living in stressful conditions
surrounding maternal depression (parent–child conflict, less parental monitoring and supervision) are likely to
engage in more risk taking and externalizing behaviors (Wiesner & Kim, 2006). Research has also
demonstrated that boys and girls may respond differently to maternal distress, with boys being more inclined
to react with externalizing problems, while with increasing age, girls are more likely to develop internalizing
problems (Angold, Erklani, Silberg, Eaves, & Costello, 2002). In addition to trajectories that might be
predicted by gender, the principles of equifinality and mulifinality provide different mechanisms to assist our
understanding of the nature of different outcomes (Cicchetti & Rogosch, 1996). The principle of equifinality
is used to explain how similar symptoms (depression) can result from different sources (e.g., two children may
both suffer from depression; however, one child may be reacting to a parental divorce, and another child may
be depressed because of peer rejection). The second principle of mulifinality is important in understanding
how individuals who experience similar circumstances may be on different paths that will predict very
different outcomes. For example, although Neesha shows many signs of distress due to her stressful living
conditions, she also demonstrates qualities that suggest resilience in the face of adversity. However, her
brother Tyrone, whom we will meet in greater depth in the case study of Tyrone Wilson, has moved further
and further along a path of self-destructive behaviors, leading to his recent entry into the juvenile justice
system. Therefore, despite living in the same stressful conditions, their outcomes are very different. Children
who grow up in less-than-ideal conditions may accept these conditions as part of the “normalcy” of their life
and learn to cope with what they have. Others may develop a sense of positive self-esteem and independence
that may serve to buffer them from more negative outcomes (Cicchetti & Rogosch, 1997). Yet others, like
Tyrone, will follow a path of aggression and retaliation and join others who are on a similar self-destructive
trajectory.
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Post-Case Questions
1. In discussing the plight of resilient children, Luthar (1993) contrasts earlier concepts of the invulnerable child with present
concepts of the resilient child. Luthar observed that children who survived difficult circumstances without developing maladaptive
outcomes often presented with more subtle internalizing problems. In Luthar’s study, 85% of the resilient children had clinically
significant symptoms of anxiety and depression. Similarly, longitudinal data from studies by Werner and Smith (1992) also noted
that resilient children in adulthood were plagued with somatic complaints (headaches, backaches) and feelings of dissatisfaction.
In the Introduction to this chapter, the topic of resilience and neurobiology was discussed. According to Karatoreos and McEwen
(2013), initially an individual can withstand environmental challenges (stressful circumstances) by successful allostatic responses
that can contribute to resilience, however, over the course of time, continued stressful circumstances can cause a system to go into
“allostatic overload” resulting in overuse of the system and dysregulation (wearing down the system). Discuss Neesha’s current
clinical profile in light of the information provided by these studies on resilience.
2. In a study of developmental response patterns to maternal depression, Solantaus-Simula (2002) found four response patterns:
active empathy, emotional overinvolvement, indifference, and avoidance. Of the four types, children in the emotional
overinvolvement and avoidance groups demonstrated the most internalizing and externalizing symptoms, independent of mother’s
level of depression. Furthermore, children in the active empathy group fared best. They did not feel guilty about their parent’s
depression and were able to discriminate their experiences from those of the depressed parent, supporting Beardslee’s theory
(1989) of the protective function of self-understanding. The most common response to maternal depression in the active group
was to make some effort to cheer up the parent. Discuss these findings in relation to Neesha’s case.
3. The way in which a child responds to distress can be strongly influenced by the cultural context in which the circumstance is
embedded. Discuss this comment with respect to Neesha’s case.
4. Studies on resilience and maternal depression discussed in the Introduction to this chapter report a number of negative outcomes
that can occur for children and youth who are raised by depressed mothers. Some of the reported risks include social withdrawal,
inappropriate social skills, increased risk for psychopathology, and dysfunctional physiological systems associated with managing
stress and regulating social engagement (e.g., cortisol responses and oxytocin production). Karatoreos and McEwen (2013) discuss
how hyper or hypo cortisol reactivity in children of depressed mothers can influence a child’s tendency to withdraw socially or
demonstrate behavioral inhibition. Describe how Neesha’s mother’s parenting behaviors may have influenced the development of
these behaviors in Neesha.
5. Research regarding promoting resilience in children has focused on two important factors, individual characteristics and influences
from family and parenting practices. Discuss possible interventions that would enhance Neesha’s opportunities for developing and
sustaining resilience.
6. Suggested Individual or Group Presentation Activity: The guidance counselor has asked Neesha’s mother to attend a meeting at
the school to address Neesha’s academic skills and social engagement. The school psychologist and social worker will be invited to
attend the meeting, as well as Neesha’s teacher. Prepare a script for role-playing each of the player’s parts in the meeting and how
they could potentially contribute information to assist with developing a case formulation and intervention plan. Who else would
you want to invite to the meeting and why?
7. After reading the case of Neesha’s brother, Tyrone Wilson, discuss the concepts of mulitfinality and equifinality as they are related
to the two case studies.
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Beardslee, W. R. (1989). The role of self-understanding in resilient individuals: The development of a

perspective. American Journal of Orthopsychiatry, 59, 266–278.
Campbell, S. D., Morgan-Lopez, A. A., Cox, M. J., & McLoyd, V. C. (2009). A latent class analysis of
maternal depression symptoms over 12 years and offspring adjustment in adolescence. Journal of Abnormal
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psychopathology. Development and Psychopathology, 8, 597–600.
Cicchetti, D., & Rogosch, F. A. (1997). The role of self-organization in the promotion of resilience in
maltreated children. Development and Psychopathology, 9, 797–815.
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Journal of Orthopsychiatry, 68, 512–520.
Foster, C. J. E., Garber, J., & Durlak, J. (2008). Current and past maternal depression, maternal interaction
behaviors, and children’s externalizing and internalizing symptoms. Journal of Abnormal Child Psychology,
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Luthar, S. S., & Zelazo, L. B. (2003). Research on resilience: An integrative review. In S. S. Luthar (Ed.),
Resilience and vulnerability: Adaptation in the context of childhood adversities (pp. 511–549). Cambridge,
England: Cambridge University Press.
Lynch, E. W., & Hanson, M. J. (1998). Developing cross-cultural competence (2nd ed.). Baltimore, MD:
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Chapter 2 Introduction to Neurodevelopmental Disorders
Disorders that are classified under the category of neurodevelopmental disorders include those conditions with
early onset (likely prior to formal school entry) that are characterized by “developmental deficits that produce
impairments of personal, social, academic, or occupational functioning” (Diagnostic and Statistical Manual of
Mental Disorders [DSM-5]; APA, 2013, p. 31). The recent revision process of the DSM included lengthy
discussions regarding how to best to recategorize childhood disorders that were previously housed in the
category of Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. Although the category of
Neurodevelopmental Disorders was an obvious choice for a classification category, there was considerable debate
as to the validity of including or excluding specific disorders from this category. A meta-analysis was
conducted and several possible candidates were considered for inclusion under this umbrella, including
conduct disorder (CD), separation anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), mental
retardation (intellectual disability), pervasive developmental disorders (autism spectrum disorder), motor
disorders, communication disorders, and learning disorders (Andrews, Pine, Hobbs, Anderson, & Sutherland,
2009). However, while some disorders were a more natural fit, meeting the majority of validating criteria
(such as intellectual disability and autism spectrum disorder), other disorder subtypes, such as the
externalizing features of conduct disorder and the hyperactive-impulsive or combined subtypes of ADHD
seemed to share features not common to other disorders. Based on shared features, such as etiology, symptom
similarity, early onset, and course persistence, Andrews, Pine, Hobbs, Anderson, and Sutherland (2009)
suggested five potential disorders for inclusion under the category of neurodevelopmental disorders:
intellectual disability, autism spectrum disorders, motor disorders, communication disorders, and learning
disorders.
On final publication, the Diagnostic and Statistical Manual of Mental Disorders-5 (APA, 2013) included six
disorders under the category of neurodevelopmental disorders: intellectual disability, communication
disorders, autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), specific
learning disorder, and motor disorders.
The rationale for including the above six disorders within this category include the following:
a. The disorders are often comorbid (children with ASD also often evidence intellectual disabilities;
children with ADHD often experience specific learning disorders).
b. The disorders represent a wide range of neurodevelopmental functioning and impairments from global
delays to specific deficits in executive functions.
This chapter contains seven cases that provide a broad look at the types of disorders that area clustered within
the category of neurodevelopmental disorders: Colby Tyler (Case #4), a gifted teenager who also has been
diagnosed with ADHD; Thomas McLearn (Case #5), a young boy with a specific reading disorder (dyslexia);
Sandy Smith (Case #6), a young girl who has a very unique type of learning disorder, a nonverbal learning
disability; Dylan Bach (Case #7), a child with higher functioning autism who is exceptionally gifted in specific
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areas; Bradley Hunter (Case #10), a case that presents a more traditional picture of a child with more severe
autistic features; and Brian Williams (Case #9), a child who has an intellectual disability but a very specific
variant, known as Williams syndrome. Since children with Williams syndrome are often hypersocial,
comparing Brian’s profile to Dylan’s can make for a very interesting discussion, as would reviewing both these
cases in the light of comments made earlier about Sandy Smith (nonverbal learning disability). Arthur Watson
(Case #8) is an example of a case that is frequently seen in clinical settings: a child who can be a puzzle to
those who attempt to address whether lack of performance is a matter of “won’t or can’t.”
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Disorders of Attention and Learning
Attention-deficit/hyperactivity disorder: Individuals who meet criteria for attention–deficit/hyperactivity
disorder (ADHD) display a persistent pattern of inattention, overactivity, or impulsivity. Based on the
symptom configuration, specifiers for ADHD will indicate whether the disorder represents a predominantly
inattentive, hyperactive-impulsive, or combined presentation. Diagnostic criteria for ADHD in the DSM-5
remain consistent with previous criteria (DSM-IV-TR; APA, 2000), with the following exceptions: the
symptoms now must be evident prior to 12 years (rather than 7 as noted previously); only five symptoms,
instead of six, are required for inattention or hyperactive-impulsive presentations if individuals are 17 years of
age or older; the symptom descriptions include more examples of how the disorder may appear in adults; and
indicators of the degree of severity (mild, moderate, or severe) are also included. The most recent prevalence
rates suggest that the disorder is present in about 5% of children and 2.5% of adults, and the disorder
commonly is comorbid with a specific learning disorder (APA, 2013).
Specific learning disorder: Specific learning disorders (formerly learning disorders) are biological in origin and
influence an individual’s ability to effectively process visual or verbal information necessary for the acquisition
of academic skills in areas of reading (accuracy, fluency, comprehension), written expression (spelling,
grammar, organization), or mathematics (number sense, math facts, calculation, or reasoning) (APA, 2013, p.
67). Although the DSM no longer requires a significant discrepancy between intellectual functioning and
academic performance (previously a significant discrepancy between intellectual functioning and achievement
was suggested to be two standard deviations), the DSM-5 requires that academic skills be significantly below
age expectations (as measured by a standardized assessment), are persistent (originating in the school years),
and “are not better accounted for by intellectual disabilities,” in addition to other neurological problems or
lack of instruction (p. 67). Severity can range from mild to severe.
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Intellectual and Developmental Disabilities
Intellectual disability: The criteria for intellectual disability (formerly mental retardation), also known as
intellectual developmental disorder, remain consistent with previous diagnostic requirements of significant
deficits in intellectual (IQ 65−75; 70 ± 5) and adaptive functioning. However, there is a significant change in
how the ranges are now conceptualized. Specifiers for mild, moderate, severe, and profound levels of
intellectual disability are no longer related to levels of intellectual functioning but are now linked to levels of
adaptive functioning and the supports required across three domains of adaptive functioning: conceptual
(academics, problem solving), social (social judgment, communication, relationships), and practical (life skills)
domains. The rationale for this change was the lower validity of IQ measures in the low ranges. In addition,
the change is more in keeping with the concept of intensity of support services (ISS) recognized by the
American Association of Intellectual Developmental Disabilities (AAIDD).
Global developmental delay: The DSM-5 has added this category for children under 5 years of age who may
demonstrate lags in achieving milestones; however, given their age or conditions (e.g., physical impairments,
problem behaviors), valid measures of functioning may not be obtainable. This category is considered to be
temporary and is to be removed following a formal assessment.
Autism spectrum disorder (ASD): Disorders that are included in this category were previously known as the
pervasive developmental disorders (PDD) which contained five different but symptom-related disorders:
autism, Asperger’s disorder, Rhett’s disorder, childhood disintegrative disorder, and PDD not otherwise
specified (PDDNOS). Disorders within ASD meet criteria for two broad symptom categories, indicating
persistent
a. deficits in social communication and social interaction in three areas (social-emotional reciprocity,
nonverbal communication, developing/maintaining relationships); and
b. restricted, repetitive patterns of behaviors, interests, or activities in 2 out of 4 possible areas (motor
movements, rituals, fixated interests, hyper/hypo response to sensory information).
Specifiers can be used to indicate whether ASD is accompanied (1) with or without intellectual or language
impairment, or (2) by the severity of supports required for problems in areas of social communication or
restricted repetitive behaviors (APA, 2013, pp. 50–51). According to the DSM-5, the diagnosis of autism
spectrum disorder should replace previous diagnoses for autistic disorder, Asperger’s disorder, or PDDNOS.
The prevalence rates suggest that ASD can be evident in up to 1% of the population, and the DSM-5 states
that it is unclear whether escalating rates reflect inclusion of “subthreshold cases, increased awareness,
differences in study methodology, or true increases in the frequency of ASD” (APA, 2013, p. 55).
171
References
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Arlington, VA: Author.
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VA: Author.
Andrews, G., Pine, D. S., Hobbs, M. J., Anderson, T. M., & Sunderland, M. (2009). Neurodevelopmental
disorders: Cluster 2 of the proposed metastructure for DSMV and ICD11. Psychological Medicine, 39,
2013–2023. doi:10.1017/S0033291709990274
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Part A Problems of Attention and Specific Learning Disorders
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Contents
Case 4: Colby Tyler: Attention Problems or Distracted by Life?
Case 5: Thomas McLearn: Read Me a Story
Case 6: Sandy Smith: Marching to the Tune of a Different Drummer
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Case 4 Colby Tyler Attention Problems or Distracted by Life?
ADHD; Gifted; Divorce
Colby, a 14-year-old teenager in the ninth grade, came to the clinic accompanied by his mother, Tina. The
appointment had finally been booked after Tina found Colby’s midterm report card crumpled in the garbage
can.
Not only was he failing one course, he was performing miserably across all subjects. When confronted, Colby
lashed out at her, saying it was her fault, and ran out of the house. Tina admitted to running down the street
after him, yelling like a “maniac.” It was at this point that she realized that things had gotten out of control
and that she needed help with Colby. His academic performance and temper outbursts were getting worse
and worse. Tina explained that she also felt less able to cope with circumstances lately, due to her recent
separation from her husband, Josh. Colby and his 7-year-old sister, Susy, continued to visit with their father
every Wednesday and every second weekend.
Colby’s parents both have university degrees. Tina works as an advertising account executive and Josh is an
entrepreneur.
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Despite a normal and full-term pregnancy, Tina stated that the labor was lengthy (12 hours) and ended with a
forceps delivery. Tina reported that she was under a lot of stress during her pregnancy due to marital conflicts,
and she admitted to smoking and having an occasional drink during the pregnancy. Colby weighed 6 pounds
2 ounces, and although somewhat underweight, he seemed to be in good health at birth. The first 3 months
were very difficult for Tina and Colby due to Colby’s sensitive digestive system. After eating, Colby would
often have bouts of projectile vomiting, diarrhea, and colicky behavior. Although Tina tried to nurse Colby,
he was constantly hungry (feeding every 2 hours), and after 6 weeks, the doctor felt that Colby and mom
would both be better off if he went on formula. Eventually, Colby settled into a better routine, although
digestive problems and poor sleep patterns continue to be areas of difficulty for him, especially when under
stress. On occasion, Colby will complain of stomachaches and ask to stay home from school. He also has
difficulty both falling asleep and staying asleep. On many nights, Colby is still awake when Tina goes to bed,
which is around midnight.
Developmental milestones were achieved within normative expectations, with the exception that Colby started
to read spontaneously at 2 years of age. His first sight word was Sears; he pointed to the catalog after seeing a
commercial on TV. After that, he started recognizing labels and logos on billboards and on the television. He
was able to read printed words on paper by about 2½ years of age. Language skills also developed rapidly, and
Colby’s conversational skills were very well advanced by the time he entered nursery school.
Although Colby’s health has been generally good, he had a severe outbreak of hives at 5 years of age (source
never detected) and was placed on an elimination diet for 1 month during which time his food was restricted
to rice and lamb broth. Colby has never been hospitalized, although he does have a tendency to be accident
prone and has experienced cuts, scrapes, and bruises from falls and bike accidents. Colby’s hearing and vision
have both been assessed. Hearing is within normal limits, and glasses have been prescribed for distance vision.
When asked about family history, Tina noted that Colby’s maternal grandmother has always been an anxious
woman who has many fears and who has been on medication for depression. Colby’s maternal grandfather
was a heavy drinker and often became aggressive and physically abusive to his wife and eldest son. Colby’s
maternal grandfather also had Parkinson’s disease and eventually died after a lengthy battle with Alzheimer’s.
Tina feels that her mother also likely suffers from posttraumatic stress disorder, due to the violence in the
home. Although Tina’s parents lived some distance away, Colby has maintained contact with his grandmother
through her biyearly visits. Tina is herself an anxious woman who was a witness to domestic violence. Colby’s
paternal grandmother and grandfather are deceased and, according to Tina, there was no known pathology.
There is a paternal uncle who has problems with alcohol and is also believed to have some psychotic features
(hallucinations and delusions). He is unable to support himself, is currently on assistance, and is basically
estranged from Tina’s husband.
Tina described her marriage of 15 years as very turbulent. There was a previous marital separation due to
Josh’s infidelities, about 8 years earlier; however, Tina discovered that she was pregnant with Susy and they
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reconciled the marriage. Tina was never able to reestablish a sense of trust in Josh, and their relationship
continued to slide. During the past year, the children had been exposed to many arguments and verbal
accusations that centered on Josh’s denial of any infidelities. Although Tina and her husband Josh had been
living in the same house for the past year, they slept in separate rooms. Six months ago the house finally sold,
and they moved into separate quarters. Tina has been seeing a counselor for the past year.
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Reason for Referral
Colby presented as an articulate and well-mannered adolescent. According to Colby, his mother got very
upset and angry when she found his report card. He wasn’t eager to share it with her because she got very
angry at him after the parent–teacher conference in January. He described the parent–teacher conference as
embarrassing and frustrating. First of all, both his mom and dad were present and were throwing cold stares at
each other across the room. All his teachers were in the room at the same time, and he felt like he was on trial.
Only one teacher, his English teacher, Mr. Brighton, had anything good to say about him. The other teachers
made him angry by saying that he wasn’t trying, wasn’t motivated, and didn’t care about his schoolwork. Mrs.
Fischer said that most times Colby wasn’t prepared for class and didn’t even bring his text with him. All
accused him of wasting his potential. After all, Colby had been identified as a “gifted” student as part of the
Grade 4 screening for the Gifted Program.
Colby’s IQ was 147. However, despite all this intelligence, Colby had never really been a shining academic. In
elementary school, Colby managed to get by with the little amount of effort he put in. However, Colby began
to really slide academically when he entered Grade 9. Currently, Colby’s grades are well below what would be
expected, and he may not pass chemistry at all.
Colby is up most nights until very late, and he can’t get up in the morning. He has been late many times, and
the school counselor has called Tina often to complain about Colby’s tardiness.
Historically, Colby has always had problems sleeping. As a consequence, getting ready for school in the
mornings had been problematic, with one exception. One day a week, when Colby attended the gifted
program, he would have no difficulty getting up or being on time. The gifted program was Colby’s favorite
day of the week, and Colby was noticeably distressed upon learning that the gifted program would not extend
into the secondary school level.
The level of Colby’s intelligence was evident in his articulate conversational style and the depth of his
knowledge in areas of interest, like computers. He was an engaging youth who was very captivating. However,
as the conversation turned toward academics, Colby’s entire demeanor changed, and he became very quiet.
Tina addressed the issue of homework, which was a constant source of frustration for both of them. Colby
seemed to have tremendous difficulty staying on task; everything was a potential distraction. Little things, like
the telephone ringing or a noise outside, would be enough to break Colby’s concentration, and once off task it
was very difficult to get him back on track. However, when Colby was playing computer games, he was
riveted to the screen, and it would become very difficult to disengage Colby from the task. Tina could not
understand how Colby could be so intensely focused when interested in something and so distractible when
interest level was low. Like Colby’s teachers, Tina thought it was a question of motivation. Tina described
how Colby would begin each academic year all motivated and excited about school: new binders, pencils, and
so on. Within a matter of weeks, however, old patterns would return and Colby would begin sleeping in,
assignments would remain incomplete, and pencils would be lost or misplaced. According to Tina, Colby was
the master of good intentions. Although Colby would often start projects with great enthusiasm, he had
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considerable difficulty sustaining this effort over the long haul. The gifted program was the only place where
Colby really seemed to do well.
When asked what was so special about the gifted program, Colby said the teacher was fantastic, most of the
kids were great, and they did a lot of computer work and mind-bender logic games. Tina interjected that she
had talked at length with the teacher of the gifted program, who described Colby as a great kid and a
wonderfully creative and divergent thinker. The teacher of the gifted program thought that one of Colby’s
difficulties might be that he had so many ideas that it was very hard for him to put things down on paper. He
had, as she described it, “an explosive mind for brainstorming.” Colby said that outside of the gifted program,
it was difficult to concentrate and focus. When asked what helped to clear his head and give him a better
ability to stick with something, he immediately said, “walking or riding my bike in the park.” Colby explained
that sometimes he had the clearest thoughts just walking by himself on the golf course. He wished he could
bring that kind of focus into the classroom.
When asked about temper outbursts, Tina said that at times Colby seems incredibly patient, and she saw this
behavior at its best when he was tutoring younger children in a reading program and giving golf lessons.
However, at other times, Colby could be highly reactive and respond with a short fuse. At these times, Colby
would be more prone to take things personally, be less responsive to logical reasoning, and be in a highly
aroused state. When in this aroused state it is not possible to reason logically with Colby until he settles down,
which can take a while.
According to Colby’s mother, behavioral outbursts had increased since the marital breakup. Tina stated that
Colby has never adapted well to change and that the emotional split and physical move have likely added to
the intensity of Colby’s reactions. Having to shift between two households was not easy for Colby, especially
in light of his problems with losing things and misplacing his notes. Colby now seemed even more
disorganized than before. Tina also wondered whether Colby at some level somehow blames himself for the
split.
When asked about the separation, Colby said very little. He said that his little sister was upset because he got
to choose where he wanted to live and she didn’t. He said she doesn’t understand. It’s awful to have to choose.
Colby said his dad asked him why he chose to be with his mom and he said “because she is closer to school.”
Colby said that his dad called him “shallow.” According to Tina, Colby has a tense relationship with his father
because Josh tries to compete with Colby instead of supporting him. Tina said she is afraid that unless there
are some answers to what is going on with Colby at this stage, Colby may end up having real problems. As it
is, he can get very angry and flare up in a second, and this is really beginning to worry her. In response to that
comment, Colby just looked at his mother and said, “I have been living in a house that is like the movie The
War of the Roses . . . and you wonder why I get angry.”
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Assessment Results
Guidelines for the interpretation of standard scores and T scores are available in Appendix C, as are
descriptions of the assessment instruments used in the current assessment, as well as other resources. Colby’s
case serves as the prototypical case for this book, and with this goal in mind, actual test scores for each
assessment measure and anecdotal examiner comments are available in Appendix A, along with scores for the
assessments of three other children (Scott Michaels, Shirley Yong, and Arthur Watson). In addition, there is
an in-depth discussion in Appendix A concerning how the clinician arrived at the case formulation for Colby
based on differential diagnosis: evidence in support of a diagnosis of ADHD primarily inattentive
presentation, and the rationale for ruling out other comorbid or competing diagnoses. There is also a written
report wherein the clinical psychologist reports and shares her clinical and diagnostic impressions of Colby
based on the assessment results. Since there is significant supplemental information for this particular case in
Appendix A, the summary of assessment results in this chapter will be relatively brief.
Responses to the Wechsler Intelligence Scale for Children (WISC-V) confirmed overall intellectual
functioning to be within the Extremely High Range (General Ability Index 142; range 138–149), with all
Index Scores in the Extremely High Range with the exception of Processing Speed (PSI 103; range 94–112),
which was in the Average Range. Colby’s overall IQ score places him within the top 1% of the population
(99.9th percentile). However, his scores were not evenly distributed among the different aspects of the IQ
profile. Colby’s score of 130 on the Working Memory Index (WMI; range 120–135) was an area of relative
weakness, compared to his Index Scores for Verbal Comprehension (VCI 142; range 131–146), Visual Spatial
analysis (VSI 135; range 124–140), and Fluid Reasoning (FRI 137; range 127–142). As was noted above, his
PRI scores were severely impaired, relative to all his intellectual scores. Slow speed of psychomotor responses
noted on paper-and-pencil tasks was accompanied by fatigue, awkward writing style, and ease of distraction.
Despite adequate core academic skills (reading, spelling, math calculations), Colby had significant problems
organizing his ideas when asked to write a short paragraph. Colby had difficulty getting started on the task,
changed his topic many times, and after approximately 10 minutes, ultimately produced a very short but well-
written passage of two lines.
Colby’s mother completed the Conners Parent Rating Scale and the Achenbach Child Behavior Checklist
(CBCL). Significant elevations were noted on scales of Somatic Complaints, Anxious-Depressed Mood, and
Attention Problems. Teacher responses on the Teacher Report Form (TRF) also noted significant Somatic
Complaints, and significant problems with Inattention and low frustration tolerance (Emotional Lability)
were noted on the teacher’s Conners Scale. Colby’s self-ratings on the Youth Self-Report (YSF), Conners-
Wells Adolescent Self-Report Scale (CASS:L), and Beck Youth Inventories (BYI-2) revealed significant
elevations for Internalizing, Inattentive Behaviors, and Low Self-Concept, and significant elevation of
Depressed and Anxious Moods. Further assessment with the Children’s Depression Inventory (CDI-2) ruled
out significant depression or suicidal ideation.
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Issues, Trends, and Alternative Treatment Methods
Attention-deficit/hyperactivity disorder (ADHD) is a commonly diagnosed neurodevelopmental disorder
with between 3% and 5% of school-age children meeting criteria for the disorder (APA, 2013; Barkley, 1998).
Although once thought of as a childhood disorder, it is now estimated that between one third and two thirds
of children with ADHD will continue to exhibit symptoms of the disorder throughout their lifetime
(Wender, Wolf, & Wasserstein, 2001). Prevalence rates in adulthood are estimated to be around 2.5% (APA,
2013). Although hyperactivity and impulsivity decline with age, inattention and distractibility are likely to
persist (Larsson, Lichtenstein, & Larsson, 2006), at a time when the educational setting is becoming more
demanding (increased workload and expectations) and complex (multiple teachers) and requires more self-
discipline and organization (Barkley, 1998).
Adolescents with ADHD are at increased risk for academic problems, difficult interpersonal relationships,
low self-esteem, and car accidents; and they have a higher incidence of psychiatric disorders, substance-use
disorders, and antisocial behavior (Grenwald-Mayes, 2002; Thompson, Molina, Pelham, & Gnagy, 2007).
Mannuzza and Klein (2000) found that children who demonstrate deficits in social skills and self-esteem
continue to experience difficulties in these areas throughout adolescence and adulthood. Although there has
been significant research and theoretical emphasis devoted to the primarily hyperactive-impulsive presentation
of ADHD (Barkley, 1997), less is known about the predominantly inattentive presentation of ADHD, which
has only been recognized as a separate type of disorder since the DSM-III (APA, 1980). The DSM-5 (APA,
2013) has included increased descriptions of how symptoms may manifest in adulthood (e.g., work is
inaccurate; has poor time management; fails to meet deadlines; problems reviewing lengthy papers; misplaces/loses
important items, such as keys, mobile telephones). The number of symptoms required for a diagnosis in late
adolescence (17 years or older) and adulthood has been reduced to five symptoms (six are required for
children) from a list of nine possible symptoms in the inattentive or hyperactive/impulsive symptom categories
(APA, 2013, pp. 59–60).
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Medication as a Treatment
From a neurobiological perspective, ADHD has been associated with low levels of the catecholamines
(dopamine, norepinephrine, epinephrine), which are neurotransmitters that impact attention and motor
activity. Dopamine is especially important since pathways usually rich in dopamine, such as the prefrontal
cortex, are underactive in brains of individuals with ADHD (Barkley, 1998). The most widely researched
treatment for ADHD is the use of stimulant medication. The most commonly prescribed medications for
ADHD are methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and pemoline (Cylert), which act to
increase the number of catecholamines in the brain. Each of these medications has been demonstrated to be
effective in reducing the symptoms of ADHD in numerous clinically controlled trials (Greenhill, 1998;
Spencer et al., 1995). Recently, a nonstimulant medication, atomoxetine (Strattera), a selective norepinephrine
reuptake inhibitor, has met with FDA approval for ADHD.
Although some parents are concerned that giving their child medication for ADHD can result in a gateway
phenomenon, leading to abuse of other types of substances later on, most research supports the opposite
conclusion. Adults with ADHD who were not treated are more likely to abuse substances later in life
compared to those whose ADHD was managed medically in their youth (Biederman, Wilens, Mick, Spencer,
& Faraone, 1999). Wilens (2001) found youth with ADHD who took medication had lower rates of
substance use (marijuana, cocaine, alcohol) compared with controls. However, Molina and Pelham (2003)
conducted an 8-year follow-up of children and youth with ADHD and found higher levels of substance use
across all substances (alcohol, tobacco, illicit drugs) compared to peers without ADHD. Surprisingly, the
greatest substance use was related to the severity of attention problems, not impulsivity-hyperactivity, as had
been noted previously (Barkley, DuPaul, & McMurray, 1990). However, in their longitudinal study of drug
use outcomes for youth, August and colleagues (2006) found that youth with ADHD who also demonstrated
externalizing problems had significantly worse drug outcomes (frequency of use and substance disorders) than
those with ADHD-only or community controls, suggesting that ADHD without externalizing problems is
not an increased risk for drug problems.
Although medication has been proven effective in reducing symptoms of inattention, impulsivity, and
hyperactivity, effects have not consistently been demonstrated to carry over to other areas such as social
relationships or academic achievement (Pelham, Wheeler, & Chronis, 1998). There has been significant
controversy regarding the overuse of stimulant medication for children with ADHD (Diller, 1996). Although
research has supported the use of methylphenidate (Ritalin) as a performance enhancer for children and adults
with ADHD, it has been estimated that the use of stimulant medication has increased as much as 300% since
1990 (Hancock, 1996; Robison, Sclar, Skaer, & Galin, 1999). Although a recent study conducted in
Tennessee found that prevalence rates for primarily inattentive (4.7%), primarily hyperactive (3.4%), and
combined subtypes (4.4%) of ADHD to be below 5% (Wolraich, Hannah, Pinnock, Baumgaerrel, & Brown,
1996), according to Leutwyler (1996) as many as 10% to 12% of all boys in the United States are currently
taking Ritalin for ADHD.
In part, the tendencies to overprescribe medication may result from the fact that the core symptoms of
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inattention, restlessness, and impulsivity found in ADHD also occur in other disorders, such as anxiety, learning
disorders, childhood depression, bipolar disorder, and posttraumatic stress disorder. There is also evidence
that only one third to one half of children diagnosed with ADHD by their pediatrician have had any type of
psychological or educational assessment to support the diagnosis (Leutwyler, 1996). More recently, Reich,
Huang, and Todd (2006) studied treatment patterns for a large sample (1,555) of twins diagnosed with
ADHD and found that 60% of boys and 45% of girls who met full diagnosis for ADHD were on stimulant
medication, while 35% of the sample was receiving stimulant medication but did not meet DSM criteria for
ADHD.
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Multimodal and Alternative Treatment Methods
Some children may be unable to tolerate the side effects of medications for ADHD, or some parents may opt
for alternative methods to treat the disorder. For these reasons, and the wide range of possible negative
outcomes for children and youth with ADHD, the management of ADHD will often require a multimodal
approach, combining psychosocial approaches in lieu of or conjoint with medical interventions. Other forms
of treatment that have been used to treat children and youth with ADHD include behavior modification and
contingency management in the classroom, cognitive–behavior modification (CBM), parent training, and a
variety of coaching techniques (Goldstein, 2005; Hallowell, 1995; Pelham et al., 1998).
There are many examples in the research literature of attempts to justify the use of CBM for children with
ADHD, in programs designed to increase verbal self-instruction, problem-solving strategies, cognitive
modeling, and self-monitoring. The underlying premise in these approaches is that training in problem
solving will assist children with ADHD to manage behavioral self-control better (Hinshaw & Erhardt, 1991).
However, while initial results of CBM were encouraging, more recent evidence suggests that CBM in
isolation does not enhance outcomes for children with ADHD (Pelham et al., 1998).
In collaboration with the National Institute of Mental Health (NIMH), the MTA (multimodal treatment
study of ADHD) investigated treatment alternatives for ADHD in six independent research centers. The
investigators compared medical management alone (MEDMGT), behavioral modification (BEH), combined
treatment (COMB), and a community comparison (CC). The BEH and CC groups did not receive
medication. At the completion of the study, only the MEDMGT and COMB groups demonstrated symptom
reductions (Swanson et al., 2001). However, follow-up at 14 months revealed that the effect size was reduced
by 50%, while follow-up at 24 months revealed further deterioration. Within-group analysis revealed the
greatest deterioration was for those who took medication as part of the study but discontinued after the study
was completed, while the greatest long-term reduction in symptoms was for those children who were not
medicated during the study, but who began taking medication once the study was completed (MTA
Cooperative Group, 2004). One important side effect for the group who took medication the longest
(throughout the study and remained on medication throughout the follow-up periods) was after the first 2
years, they demonstrated a 20% reduction in stimulant-related height gain (approximately 2 cm.) compared to
peers who never took the medication. Although a rebound was expected in the third year, it never occurred,
although no further reduction was evident; researchers continue to monitor the effects over 10- and 12-year
periods for height and weight concerns and other long-term functional and symptomatic outcomes (Swanson
et al., 2008).
Psychiatrist Ned Hallowell (1995) introduced the concept of “coaching” as a therapeutic measure for assisting
adults with ADHD to manage life’s challenges and expressed his frustration at being unable to provide such
support on a daily basis. In practice, the technique, which seems to make clinical sense, has gained
momentum; however, there has been very little effort to empirically measure the effectiveness of this
intervention (Goldstein, 2005). Although Jaksa and Ratey (1999) attempt to define coaching as a set of goal-
driven and practical strategies that are developed by a coach and client to facilitate meeting the challenges of
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everyday life, they do not address how the strategies are developed, which strategies are most successful, and
how success should be objectively measured and monitored. Recently, the Edge Foundation funded a national
study, involving eight universities and two community colleges. The goal of the study was to document the
effectiveness of coaching for college students with ADHD, and the study examined the effects of coaching on
127 students randomly assigned to treatment or control conditions. In this study executive functioning and
related skills were measured using the Learning and Study Strategies Inventory (LASSI; Weinstein & Palmer,
2002). Results revealed a significant difference in total gain on the LASSI for those enrolled in the coaching
group relative to controls on all three cluster scores: self-regulation, skill, and will. Follow-up focus groups
revealed increased positive feelings of well-being, empowerment, and reduced feelings of stress in those who
participated in the coaching groups (Field, Parker, Sawilowsky, & Rolands, 2010). Similarly, Kubik (2010)
found that ADHD coaching for adults with ADHD showed a positive effect on pre- to post-coaching scores
for cognitive, behavioral, and emotional outcomes.
When Colby mentioned that he could think more clearly after riding his bike or walking in the park or on the
golf course, he had intuitively discovered a method of increasing his focus and attention in a way that has only
recently been investigated empirically. Taylor and Kuo (2009) studied the attention and concentration abilities
of 17 children diagnosed with ADHD (7 to 12 years of age) after taking a 20-minute walk in three different
environments: downtown, in a neighborhood, or in the park. Children in the study concentrated significantly
better after the walk in the park, relative to walks in the other two environments. The researchers suggest that
“doses of nature” might be a “new tool in the tool kit for managing ADHD symptoms” (p. 402).
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Post-Case Questions
1. According to Russell Barkley (1997), sustained attention comes in two different forms: contingency-shaped attention and goal-
directed persistence.
Factors that can be instrumental in increasing or decreasing contingent attention include task novelty, intrinsic interest,
reinforcing properties inherent in the task, fatigue state of the participant, and presence or absence of adult supervision. According
to Barkley, this form of sustained attention is often not problematic for ADHD children. However, goal-directed persistence
requires sustained persistence of attention and effort in the absence of highly reinforcing task properties, which is extremely
problematic for children with ADHD.
a. Based on Barkley’s descriptions of the two forms of sustained attention, prepare a response for Colby’s mother that would
address her questions regarding why Colby can stay focused for long periods of time playing video games but is extremely
distracted while attempting his homework assignments.
b. Given your understanding of sustained attention, how might Colby’s “gifted” intelligence serve to further exacerbate his
problems?
2. Based on the information presented in the case study, would Colby’s symptoms match criteria in the DSM for attention-
deficit/hyperactivity disorder (ADHD)? If so, which type of ADHD does Colby exhibit?
3. Develop a case formulation for Colby from two different perspectives (e.g., cognitive–behavioral, family systems, biological). How
would these different models influence the nature and development of an intervention program for Colby?
4. Colby was identified as “gifted” when he was in the fourth grade. Do you believe that Colby’s gifted label was ultimately a positive
factor or a negative factor in his development? Explain.
5. Recently, there has been increasing research in the area of resilience. For example, Wilmshurst, Peele, and Wilmshurst (2011)
found that college students with ADHD might be a particularly resilient group. Individual characteristics that have emerged as
protective factors that can buffer a child from the impact of having a depressed mother are having an easy temperament (as
opposed to difficult temperament) and having a higher IQ. Some common elements in resilience research include the following:
positive, supportive caregivers; positive self-views; motivation to succeed; and cognitive and self-regulatory skills. Given these
findings, and the discussion of resilience in the Introduction to Chapter 1, discuss the strengths and limitations that Colby faces
that will challenge his ability to be resilient. How might his chances for increasing resilience be increased?
6. Suggested Individual or Group Presentation Activity:
a. As part of your intervention plan, you have asked that Tina and Josh attend a session together in the clinic to address how
to best manage Colby’s attention problems and his issues with emotion regulation. You want Colby to be part of the
session as well. How would you prepare Colby for the session and what questions would you want answered by Tina and
Josh? Who else might you want to invite to the meeting at the clinic? Prepare a script for role-playing each of the player’s
parts in the session and how they could potentially contribute information to assist with developing an intervention plan
that would best meet Colby’s needs.
b. Tina has asked that you attend a meeting at the school to provide feedback regarding your assessment and to assist in the
development of a 504 plan for Colby. Who do you think should be involved in the meeting? Prepare a script for role-
playing each of the player’s parts in the school meeting and how they could potentially contribute information to assist
with developing a 504 plan that would best meet Colby’s needs.
187
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Case 5 Thomas McLearn Read Me a Story Dyslexia
Thomas was referred to the clinic by his parents to evaluate his learning potential, academic profile, and to
investigate any possible areas of social/emotional concern. His parents were puzzled. Thomas, a bright, chatty,
and active child, was falling behind in the second grade. What made this situation even more difficult to
comprehend was that Thomas had already repeated the first grade to allow for consolidation of foundation
skills. Parents were convinced that if they held Thomas back a year, his increased maturity would guarantee
his academic success. Although he seemed to enter second grade much better prepared than he would have a
year ago, his first progress report indicated that he was well below his peers in the language arts areas.
Thomas presented as a typical 8-year-old and immediately was drawn to the picture of the solar system on the
psychologist’s office wall and engaged in a lively conversation about the planets and the fact that Mars has at
least three moons that we know of. Thomas chatted at length about his love of the television science program
Bill Nye the Science Guy, and how he loved the show on gravity, called “Attraction Action.”
Thomas has an older sister, Elaine, who is currently at the top of her class, in the fifth grade.
Although Elaine is very protective of Thomas, he is finding it increasingly difficult to accept her successes,
given his academic failures. His parents are now feeling uncomfortable praising her accomplishments in front
of Thomas and are becoming increasingly concerned because their once confident son who can be a leader on
the athletic field was becoming increasingly turned off by school and frustrated by homework assignments that
he could not complete on his own.
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Nancy McLearn was very prompt in completing and returning the intake surveys and called the clinic to
inquire whether there was any additional information that she might provide. The birth history was relatively
uneventful, except for the fact that the delivery was very long and labor was intense. Eventually, they had to
use forceps to complete the delivery. Thomas achieved all developmental milestones as expected and walked
just a few days after his first birthday. Once he began talking, he was very chatty and loved to talk to his sister
who treated him as if he were a real live doll. Because they lived in a rural area, there were few other children
around and Thomas and Elaine became very close “buddies” early on. Nancy did not send Thomas to
preschool, since she was a stay-at-home mom and loved the time together, as she was home-schooling Elaine
at the time. Eventually, the family moved closer to town, across from the community park, and at that point,
Thomas and Elaine seemed to find their own set of friends.
The family took advantage of the community athletic complex, which had a very strong program for children
in the summer and during the school year. Thomas loved sports and was a natural at T-ball. Soon he was
playing soccer, softball, and joining his friends skateboarding at the park. He was a natural athlete and the
young boys on his team looked up to him as their leader.
In the fall, Thomas and Elaine were enrolled at Garden City Elementary School, which was a short walk from
their home. Thomas entered the first grade, while his sister began the third grade. Nancy also found a part-
time job working for a real estate company, while her husband, Arnold continued to gain promotion after
promotion in the sales department of a major corporation, 20 minutes from their new home. Everything
seemed to be going according to plan, until Thomas got his first mid-term report. Even with his natural
curiosity and love of science, his teacher was concerned because he was not progressing as she expected in the
language arts program. Despite his love of science books, he was having problems learning the weekly word
lists. His teacher also described him as having problems remaining focused on the task at hand and taking
forever to get to work. Thomas clearly preferred socializing to working on academic tasks. Strengths were
noted in his gross motor skills (well-coordinated), his ability to produce very detailed drawings for projects,
and his facility with numbers. Nancy and Arnold met with Thomas’s teacher to find out how they could
support her efforts and enhance Thomas’s success in the language arts program. The teacher recommended
that Nancy continue to read to Thomas every night (Thomas loved this, especially science books) and help
him review his word lists daily. Despite these efforts, Thomas was clearly not ready to progress to the second
grade at the end of the school year, and the consensus was to repeat the first grade to allow for consolidation
of key academic skills.
Although his parents were reluctant to have Thomas repeat the grade, they rationalized that since he had an
early birthdate anyway, that this additional year would allow for Thomas to catch up and the increased
maturity would benefit his skill acquisition and his ability to remain focused in class. Mid-way through the
second year in the Grade 1 program, it looked as if the decision was a good one. Thomas was feeling more
confident academically, although they did catch him telling his teammates that he was in the second grade,
because he was embarrassed to let them know he had to repeat the first grade. The following year, it seemed
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that Thomas has started out on a better level; however, the mid-term report was very discouraging. Thomas
was not progressing at the same rate as his peers, and despite his ability to tell beautiful stories orally, he was
becoming increasingly embarrassed during oral reading and was not very successful on his spelling tests. In
order to avoid his embarrassment, Thomas would have his mother read the passages to him at home every
night and then memorize them so he could “appear” to be reading them during oral reading, the next day.
This worked for a while, until the teacher introduced a new set of reading materials to the class. When it was
Thomas’s turn to read, it was as if the words were in a foreign language; he could not recognize any of the
words he had previously “read.”
His teacher expressed a number of additional concerns about Thomas’s classroom performance, including ease
of distractibility, poor ability to concentrate, daydreaming, losing or misplacing items necessary for tasks,
making careless mistakes, being very disorganized, and forgetfulness. The teacher recommended smaller
group instruction led by some of the older children (the reading buddies program) and suggested parents talk
to the school psychologist about potential attention problems. Nancy and Arnold agreed to have the school
psychologist observe Thomas in the classroom and then meet with them to discuss her impressions.
The school psychologist observed Thomas for one morning, during a class lesson, followed by a 15-minute
period of independent seat work. During this time, Thomas was noted to be engaged in on-task behaviors for
approximately 15% of the time and engaged in off-task behaviors for the vast majority of the observation
period. The school psychologist asked the parents to complete the Conners Rating Scales and also obtained
permission to have his teacher complete the scales as well. Thomas’s parents and teacher both rated Thomas
in the clinical range for inattentive problems (failing to finish tasks, problems in sustaining attention), the
ADHD Index, and the DSM Inattentive and Total Scales. Based on the findings, the family agreed to seek
further counsel regarding potential treatment for ADHD from the family pediatrician. Thomas was
diagnosed with ADHD, primarily inattentive type, and was placed on a trial of Ritalin.
Although Thomas seemed to improve his on-task performance initially, and seemed to be better able to focus
while on Ritalin, the quality of his work continued to reflect his continued struggle with reading and written
expression. Despite considerable effort at home, Thomas was not able to bring these skills to new tasks with
new reading or writing assignments.
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Reason for Referral
Nancy and Arnold were becoming increasingly concerned about Thomas’s psychological well-being. He could
often be heard calling himself “stupid” when he was trying to complete his homework and was becoming more
temperamental, breaking into tears or throwing his books on the floor in fits of frustration. He would be
entering the third grade in the fall and was still struggling to learn even the most basic reading vocabulary. His
strong analytical skills were often evident in class discussions, especially on science topics, yet written work
would be far inferior to what he could express verbally. Often his poor spelling would result in Thomas using
only words that he had memorized by sight, resulting in a very basic response to most writing assignments.
Nancy and Arnold decided to take Thomas to the clinic for a complete assessment over the summer so that
they could be better prepared to help Thomas tackle the Grade 3 program.
During the intake interview, the McLearns answered many questions about their family history, Thomas’s
developmental milestones, and his school history. There were a number of relatives on both sides of the family
who did not go far in school, not because they were not intelligent (most were highly successful
entrepreneurs), but because formal schooling was not a good fit for them. Nancy excelled academically, and if
her financial resources had been better, she would have loved to go on to university and study architecture.
Arnold was a different story. He admitted that he did not like school because he found it “boring.” He would
much rather “experience” life than read about it. In fact, he really disliked reading and throughout English
classes, he would always seek out the “movie version” rather than have to labor through the written word. He
stated that his high energy profile is an excellent fit with sales, and he could never be a “book worm.” He also
wondered if maybe Thomas was just more like him than Nancy.
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Assessment Results
Guidelines to the interpretation of standard scores and T scores, as well as information regarding specific
assessment instruments used in the case, can be found in Appendix C.
When Thomas entered the assessment room, he seemed innately curious about what was going to take place
and asked some very good questions about the nature of the assessment process. He also asked if he had to do
“school type work.” When the response was “a bit,” he immediately confessed that he was not good at reading
or spelling, and he said that if the work was too hard he wouldn’t be able to read it. He asked if we were going
to do any “fun stuff.” The interviewer continued to try and establish rapport, since it was clear that Thomas
was getting apprehensive about having to read or spell. When ask what he liked to do best, he responded that
he loved to build things, do science experiments, and draw robots. Thomas was given a sheet of paper and
asked to draw one of his favorite robots. There was no delay in responding, and Thomas immediately set
pencil to paper producing a very sophisticated picture of a robot with transformer-like capabilities. He went
on to add detailed drawings of different features that could be activated to transform into different functions.
He was very animated and engaged as he described the features in the robot he had created.
Thomas’s overall IQ score on the WISC-V of 110 places him in the high average range overall. Usually
students who score within this level do not encounter problems academically; however, his intellectual scores
did not produce an even profile. Thomas scored at the 16th percentile (Standard Score of 85) for the Verbal
Comprehension Index (VCI); however, this was significantly below his scores on the Fluid Reasoning Index
(FRI) of 120 (91st percentile). Working memory was higher than might be anticipated given his attention
problems (Standard Score of 105), but still well below his FRI score. Processing speed was within the average
range (50th percentile). Given these scores, the immediate impression is that Thomas has a significant
strength in areas of visual-perceptual reasoning and a relative weakness in the area of verbal comprehension.
Academically, Thomas managed to struggle through the academic tests and was much more confident in his
approach to the mathematical portions of the test than when asked to read, spell, or write. On the Wechsler
Individual Achievement Tests (WIAT-III) Thomas scored in the high average range for mathematics
(Standard Score 115) and in the borderline range for reading (Standard Score of 72) and written expression
(Standard Score 70). Clearly, Thomas’s ability in the language arts areas was significantly below his
intellectual level, especially his superior skills in fluid reasoning.
Further assessment was conducted using the Woodcock Johnson Cognitive Assessment and revealed
additional support for a diagnosis of a specific learning disorder. There was significant variation between skill
levels for perceptually based versus auditory-based functioning. Significant strengths ranged from standard
scores of 120 (visual spatial thinking), short-term memory (115), and processing speed (115) compared to
significant weaknesses in standard scores ranging from 80 (long-term memory), 75 (cognitive fluency,
auditory processing), and 70 (phoneme awareness). Results suggest that Thomas is experiencing problems
primarily with auditory processing, which likely translates into difficulties making fine discriminations
between letter sounds. Students with this type of difficulty may mishear sounds (like b, p, t, v). There are also
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difficulties with fluency, which would make oral reading more difficult and require additional time to respond
to questions. Reading would likely be slow and labored and due to problems with longer term memory would
be difficult to retrieve out of long-term storage because information is poorly organized and labeled. When
asked a question, there would be anticipated delays, due to retrieval problems. These processing problems are
severe and when standard scores in these weak areas (70–80) are compared to his IQ (110) there is a
discrepancy of over 1½ standard deviations (30–40 points) between these two areas of functioning.
Thomas’s parents and teacher completed the Achenbach System of Empirically Based Assessment (ASEBA)
Scales with parents noting clinical elevations on scales for anxious/depressed behaviors and attention
problems, while his teacher noted elevations on the attention problems scale. On the Beck Youth Inventories,
Thomas’s score for self-concept was at the 40th percentile.
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A specific learning disorder (SLD) or specific learning disability is evident when an individual encounters
significant problems in the acquisition of specific academic skills during the school-age period and are noted
in skills that are significantly below age expectations (American Psychiatric Association [APA], 2013). There
has been considerable controversy regarding how SLD is defined and identified, and differences exist in
recommendations proposed by the DSM-5, Individuals with Disabilities Education Act (IDEA; 2004), and
organizations such as the Learning Disabilities Association of America (LDA) and the National Joint
Committee on Learning Disabilities (NJCLD). Please see Appendix B for a detailed discussion on issues in
the definition and classification of SLD.
The DSM-5 recognizes learning disorders in three broad areas, including impairments in reading (dyslexia),
written expression, and mathematics (dyscalculia). In order to meet criteria for an SLD, the impairments must
indicate skill levels that are significantly below age expectations (as measured by standardized assessments);
manifest when demands for the skill exceed limitations; and are not better accounted for by intellectual
disabilities, organic causes (hearing, vision), other neurodevelopmental disorders, or adversity (lack of
teaching/learning opportunity) (APA, 2013, p. 67). The most recent criteria do not emphasize the
discrepancy between IQ and achievement that was part of the previous description of the disorder, stating
simply that the disorder appears in those who otherwise demonstrate normal levels of intellectual functioning,
which the DSM defines as “generally estimated by an IQ score of greater than about 70,” and that the SLD is
an “unexpected academic achievement” that is not part of a more global learning problem such is evident in
intellectual disability or global developmental delay (APA, 2013, p. 69).
Several different types of SLD have been identified in the research, including dyslexia (reading disability),
dysgraphia (disability in written expression), dyscalculia (disability in mathematics), nonverbal learning
disability (disability in visuospatial areas), and dyspraxia (developmental coordination disorder, DCD). Most
researchers consider dyslexia to be the most common type of SLD, accounting for up to 80% of all cases, with
prevalence rates ranging between 5% to 17% depending on the nature of the population sampled (Ferrer et al.,
2010). However, others contend that as many as 92% of those with SLD cite written expression as the major
problem (Mayes & Calhoun, 2007). Younger children with dyslexia may go undiagnosed, especially if good
memory skills allow the “appearance” of reading. However, by the third grade, children with dyslexia are often
painfully aware of their reading problems and may try to avoid reading in public to escape embarrassment.
Individuals with dyslexia evidence problems in accuracy of decoding, especially in the primary grades;
however, with increasing age, fluency problems (reading that is slow and labored) pose increased barriers to
academic success, especially during “high stakes standardized tests” such as the SAT and GMAT (Ferrer et
al., 2010; Shaywitz & Shaywitz, 2008).
Heritability is associated with etiology for at least half of all cases (Olson & Byrne, 2005), with between 23%
and 65% of individuals with dyslexia having a parent with the disorder, and 40% having a sibling with the
disorder (Pennington & Gilger, 1996). The association between ADHD and dyslexia runs high with between
38% to 45% of those with ADHD or SLD being diagnosed with both disorders.
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Weaknesses in working memory, executive function, and receptive and expressive language have all been
associated with dyslexia (Johnson et al., 2010). Neurological studies using functional magnetic resonance
imaging (fMRI) have charted the path of reading in poor readers compared to normal readers and have found
that whereas those with dyslexia access both the left and right anterior systems, good readers focus primarily
on the left hemispheres for phoneme recognition (anterior system), sound symbol association (posterior
system), and storage of sight vocabulary (posterior system). Developmentally, normal reading progresses from
the right to left hemisphere and from the posterior to frontal regions (Shaywitz & Shaywitz, 2008).
Far less information is known about disorders of written expression (dysgraphia) even though dysgraphia
often accompanies dyslexia (Hooper et al., 2002). Dysgraphia can manifest in a number of different ways,
including errors of grammar, punctuation, spelling, organizational presentation, and initiating written
assignments.
Intervention: Although Response to Intervention (RTI) is an approach that is frequently used to identify early
reading problems and provide supportive remedial interventions, results of at least one metacognitive study
suggest that for those with SLD who have IQ scores in the higher ranges, this method may not be ideal. Tran
and colleagues (2011) found that children with significant reading problems who had IQ scores in the higher
ranges were less responsive and that reading problems were resistant to this form of intervention. On a more
positive note, Shaywitz and Shaywitz (2008) found that individual tutoring and direct instruction (50 minutes
daily) on phonemes, and sound symbol association resulted in the development of reading patterns detected by
fMRI that resembled those of normal readers.
Programs that target problems in written expression have met with success through the use of direct
instruction in techniques of planning, the use of prompts, and guided feedback (Vaughn, Gersten, & Chard,
2000). For students with severe writing problems, dictating passages orally may be the only way that they can
be successful in maximizing their potential (Graham, Harris, & Larsen, 2001).
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Post-Case Questions
1. Using information from the case study and the supplemental information in Appendix B, state how Thomas’s SLD might be
identified and described by proponents of the different classification systems: DSM-5, IDEA (2004), Joint National Joint
Committee on Learning Disabilities (NJCLD).
2. Develop a case formulation for Thomas from two theoretical perspectives. How would these formulations affect different
treatment outcomes?
3. At one point, Thomas’s parents had a significant disagreement about whether or not Thomas should continue to be involved in
extracurricular activities such as being a member of the soccer team, given his poor academic performance. If you were the school
psychologist, how would you advise his parents regarding this issue? What are the benefits and what are the disadvantages for
Thomas of being involved in extracurricular activities?
4. There has been a major controversy regarding whether identification of SLD should involve the discrepancy criteria (See
Appendix B). Having read the different arguments, what identification procedure would you support and why? Please use citations
to support your arguments.
5. There are several theories on student “retention and promotion.” Visit the NASP website and read the article that is posted
regarding “Grade Retention and Promotion: Information for Parents.” After reading the article, what advice would you have given
Thomas’s parents if they consulted with you regarding having Thomas repeat the first grade?
6. Thomas’s mother has invited you to attend a meeting at the school to provide feedback regarding your assessment. In the meeting,
it will be decided whether or not Thomas meets criteria for special education and related services. If it is determined that he is
eligible for services, what goals and objectives would you want to see as part of his IEP?
7. Would you recommend he receive “related services” and if so, what should the nature of those services be?
8. Prepare a script for role-playing each of the player’s parts in the school meeting. Who do you think should be attending the
meeting? How could each participant potentially contribute information to assist with developing an intervention plan that would
best meet Thomas’s needs?
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References
Ferrer, E., Bennett, A., Shaywitz, J. M., Holahan, J. M., Marchione, K., & Shaywitz, S. E. (2010).
Uncoupling of reading and IQ over time: Empirical evidence for a definition of dyslexia. Psychological
Science, 21(93), 93–101.
Graham, S., Harris, K. R., & Larsen, L. (2001). Prevention and intervention of writing difficulties for
students with learning disabilities. Learning Disabilities Research and Practice, 16, 74–84.
Hooper, S. R., Swartz, C. W., Wakely, M. B., de Kruif, R. E., & Montgomery, J. W. (2002). Executive
functions in elementary school children with and without problems in written expression. Journal of
Learning Disabilities, 35(1), 57–68.
Johnson, E. E., Humphrey, M., Mellard, D. F., Woods, K., & Swanson, H. L. (2010). Cognitive processing
deficits and students with specific learning disabilities: A selective meta-analysis of the literature. Learning
Disability Quarterly, 33, 3–18.
Mayes, S. D., & Calhoun, S. L. (2007). Challenging the assumptions about the frequency and coexistence of
learning disability types. School Psychology International, 28(4), 437–448.
Olson, R., & Byrne, B. (2005). Genetic and environmental influences on reading and language ability and
disability. In H. Catts & A. Kamhi (Eds.), The connections between language and reading disability (pp.
173–200). Hillsdale, NJ: Erlbaum.
Pennington, G., & Gilgern, J. (1996). How is dyslexia transmitted? Baltimore, MD: York.
Shaywitz, S. E., & Shaywitz, B. A. (2008). Paying attention to reading: The neurobiology of reading and
dyslexia. Development and Psychopathology, 20, 1329–1349.
Tran, L., Sanchez, T., Arellano, B., & Swanson, H. L. (2011). A meta-analysis of the RTI literature for
children at risk for reading disabilities. Journal of Learning Disabilities, 44(3), 283–295.
Vaughn, S., Gersten, R., & Chard, D. J. (2000) The underlying message in LD intervention research:
Findings from research syntheses. Exceptional Children, 6, 99–114.
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Case 6 Sandy Smith Marching to the Tune of a Different
Drummer Nonverbal Learning Disability
When Eileen opened the clinic door, it was as if she were facing her worst fears head on. Sandy’s pleas and
verbal exchanges could be heard by the office staff all the way from the elevator at the other end of the
building. Although Sandy was physically petite for her 8 years, her stiff posture almost anchored her mother’s
arm to the ground. Eileen was embarrassed by Sandy’s behavior, but Sandy’s reaction only served to confirm
her resolve to finally seek professional help. As Eileen approached the receptionist’s desk, Sandy bumped into
the desk and slid onto the couch awkwardly beside her mother, with her legs entwined around each other like
a pretzel. In the waiting room, Eileen tried to collect her thoughts about her daughter’s development in
anticipation of the many interview questions that might be asked.
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Eileen had hoped for a daughter her entire pregnancy, even though Tom’s family lineage had produced
predominantly males. Against the odds, Eileen’s hopes were answered and miraculously Sandy was born 8
years ago. The pregnancy and delivery were uneventful. Sandy was a beautiful baby, and Tom was proud to be
the father of a baby girl. Sandy was also adored by her two older brothers, Jason, 6 years, and Sean, 4 years of
age. Everything seemed to be going well. There were some minor stresses initially when Eileen had to give up
attempts to nurse Sandy. Eileen had no problem nursing her other two infants, but due to Sandy’s erratic sleep
habits and irritability, her doctor recommended switching to the bottle. This switch proved difficult; Sandy’s
poor coordination meant that propping the bottle wouldn’t work, since she often lost the bottle if her mother
was not holding it. Sandy was a very active baby and she seemed to require little sleep. Eileen reasoned that
perhaps the fact that the baby needed less sleep was a sign of curiosity and intelligence. Eileen placed a
brightly colored mobile over the bed and added the crib activity center that her infant sons had enjoyed so
much. However, Sandy had no interest in the mobile or in exploring the activity center. Sandy actually
became very agitated with the crib additions, and Eileen responded by removing everything from the crib,
which seemed to calm Sandy down. Through trial and error, Eileen eventually found that the sound of a
wind-up merry-go-round on the dresser could be helpful in soothing Sandy. To this day, Sandy listens to
music to help calm her down when she is anxious.
Despite her difficulties adjusting to any changes in her environment or schedule, Sandy did demonstrate one
extremely advanced area of development. She was a very early talker and had amassed an amazing vocabulary
by the time she was 2. At 2½ years of age, Sandy was sounding more like a miniature adult than a child and
would repeat her grandmother’s phrases “verbatim.” Sandy would surprise onlookers in the grocery store with
her pseudo-adult comments on the quality of the fruits and vegetables. By 3 years of age, Sandy could repeat
stories from taped texts, word for word, and Sandy often recited these stories riding in the car, during dinner,
or when playing by herself.
Sandy’s strong verbal skills were in sharp contrast to her slower developing motor skills. Sandy was a highly
verbal but very awkward toddler. Initially, Eileen worried about her muscle coordination, since Sandy was
slow to sit and would fall over if not securely propped with a pillow. When Sandy began to walk, she looked as
though she was drunk, swaying to the left and with an off-balance gait. Sandy’s legs were black and blue from
falling down and bumping into things. At first, Eileen thought that Sandy was so preoccupied with talking
that she wasn’t looking where she was going. She eventually had Sandy’s vision checked, but results came back
negative. Sandy’s poor coordination also seemed to influence her choices of play activities. Unlike the boys,
Sandy had little interest in Legos, blocks, or puzzles. Sandy was definitely much more interested in chatting
than doing. Eileen tried to enroll Sandy in a preschool gymnastics program to improve her coordination.
However, this strategy backfired, since Sandy was extremely frustrated and unable to reproduce many of the
tumbling movements; she could not touch her toes to her head and repeatedly fell off the balance beam. The
other children were soon making fun of Sandy, imitating her awkward movements, and Eileen removed her
from the program. Eileen was becoming concerned about Sandy’s fears of going anywhere new and her
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increasingly clingy behavior. Sandy was soon going to be kindergarten age, and Eileen worried about the
transition. She enrolled Sandy in a morning preschool program 2 days a week. Each day was torture, getting
Sandy into the car and over to the day care center. Sandy did not want to go and would scream, hide, and run
away (often running into something) in a frenzied panic. Eileen was determined to persist, however, knowing
that it would only be worse if she were to give in.
Sandy’s preschool experience was not very successful. As long as she could sit and read by herself or play on
the flannel board, spelling words with preformed letters, Sandy was quite content. However, other children
did not seem to want to play with Sandy and during free playtime, Sandy was often left alone. On the few
occasions that Sandy tried to enter a group activity, her awkward sense of timing and poor social skills usually
resulted in a negative experience, and Sandy would withdraw once again. She did not seem to profit from
experiences either. The following day, Sandy would approach the same child in the same way, setting herself
up for another rejection and subsequent retreat. When Sandy was enrolled in the kindergarten program, her
social struggles continued on a regular basis.
Social skills were very immature and Sandy did not seem to take nonverbal communication (facial expressions,
conversational tone) into consideration at any time. Her sense of social-personal space was also poor, and
Sandy would often stand too close and encroach on other children’s sense comfort zone. Eventually, Sandy
preferred to shadow the teacher instead of interacting with the other children. She gained her rewards when
she could read aloud to the class and write words on the board in big letters. However, a lot of kindergarten
activities were very difficult for Sandy: cutting and pasting, tracing, drawing, painting, and the big shoe with
the lace to be tied and untied. Sandy often cried at home, asking if she could please stay home from school.
Sandy continued to experience problems with coordination. At 8 years of age, Sandy had yet to learn how to
ride a two-wheeler. She never made the transition from training wheels, and even with the training wheels on,
Sandy continued to lose her balance and fall over. Had it not been for the bicycle helmet, Eileen was sure that
Sandy might have also had a head injury to deal with. Luckily, to Eileen’s knowledge, Sandy never injured her
head in any of the falls, although she did sustain many bruises on her arms and legs. Recently, Sandy’s teacher
had contacted Eileen concerning Sandy’s reluctance to participate in the gym class and the many excuses that
she gave to avoid engaging in the ongoing activities. Sandy had begged her mother to write a note to the
teacher to get her out of gym class, but Eileen refused. Sandy’s lack of coordination and clumsiness also
seemed to permeate her total appearance. Despite her mother’s extensive efforts at home to coordinate and
organize Sandy’s outfits for the next day, Sandy always looked somewhat disheveled and thrown together:
buttons would not match the right button holes; shoelaces were dangling from her feet. Eileen eventually
refurbished Sandy’s wardrobe, removing button-up shirts and replacing lace-up shoes with Velcro-strap shoes.
Sandy’s lack of organization and messiness were pervasive. If Sandy wanted to remove an object from her
dresser drawer, half the drawer often spilled over onto the floor. It was the same with her desk at school,
which was jammed with papers crumpled and rolled into little balls.
Although Sandy’s messiness and disorganization were annoying, they were not the reasons that brought
Eileen to the clinic. Eileen was frustrated and confused. Sandy was a real puzzle to her and Eileen was now
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very motivated to find out what could possibly explain how her daughter’s abilities could be so extreme:
seemingly so very bright in some areas, yet totally lost in others. Sandy had an excellent vocabulary and
wonderful memory for words. As a result, she could read beautifully and spell most words she had seen,
without error. However, despite Sandy’s excellent vocabulary, spelling, and reading skills, she was having
increasing problems with reading comprehension. Sandy could recall a passage verbatim, but she seemed to
have real problems answering any questions that required an inference going beyond information presented in
the passage. Eileen recalled last night’s homework assignment involving a reading passage that described a
family eating breakfast together. Sandy had to answer a number of comprehension questions about the story.
Sandy had no idea how to answer one question, which asked, “What time of day is it?” Even with Eileen’s
help and questions directed at passage clues, Sandy was unable to answer the question, saying: “I read it over
and over. It doesn’t tell you the time of day!” Eileen wondered if Sandy’s problems telling time could
somehow be related to her difficulties with comprehension. Sandy was still unable to tell time on an analog
clock. Even if she could tell you the time on a digital clock, she seemed oblivious to how time related to
activities. Eileen recalled an incident where Sandy wanted to have some ice cream for breakfast. When Eileen
told Sandy, “You don’t have ice cream for breakfast,” Sandy’s response was: “Fine. Then I’ll have dinner,
now!” Initially, she thought Sandy was joking, but she was completely serious. There were other situations as
well, where Sandy’s odd thinking caught Eileen completely off guard. Sandy seemed to take things very
literally, all the time. Sandy could be very gullible, and Eileen had to monitor her brothers carefully so they
would stop playing tricks on Sandy. Eileen remembered one time that Sean told Sandy if she ate her ice cream
cone from the bottom of the cone, she would get more ice cream. Eileen came in to find Sandy trying to eat
the ice cream cone upside down with it melting all over the place. Eileen recalled another incident when they
were watching a TV movie about an odd character and Tom mentioned that “He certainly marches to the
tune of a different drummer.” Sandy looked up and said, “Where’s the parade?” Tom tried to explain the
expression, but Sandy just didn’t get it and continued to ask about the drummer in the parade. She was very
upset that she missed the parade. She eventually went to bed that evening upset, talking about the parade and
how drummers march. At school, Sandy’s literal interpretations often were not appreciated by her teacher,
who thought that Sandy was just being smart.
Mathematics was another area of real difficulty for Sandy. It was as if mathematics involved a foreign
language. Homework was an endless struggle involving hours and hours of explanations and discussions.
Sandy didn’t seem to be able to perform the same task twice in a row without having it all explained over and
over again. The next day, it was as if she had never heard the explanation. Academic problems were
compounded by Sandy’s poor handwriting. Numbers as well as letters were often scrawled across the page
without attention to writing between the lines, spacing, or direction. Often, her writing was impossible to
decipher. As a result of her problems with math, comprehension, and writing, Sandy was falling farther and
farther behind. At a recent school conference, Eileen was informed that the school was recommending that
Sandy repeat the third grade.
Socially, Sandy seemed to have few friends at school. At the parent–teacher conference, Eileen asked Sandy’s
teacher what was keeping Sandy from forming more friendships with the other children. According to Sandy’s
teacher, it was Sandy’s poor sense of timing that often turned the other kids off. Sandy often made comments
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at inappropriate times or out of context, and the other girls seemed to respond by ignoring and excluding her.
Sandy also talked nonstop and didn’t give the other girls a chance to get a word in. Eileen was very
disappointed last week by the poor showing of classmates at Sandy’s birthday party. After Sandy struggled for
hours making invitations to her birthday party (cutting, coloring, and pasting were never Sandy’s strengths),
only one child showed up. Ann, a 5-year-old who lives next door, was the only one who attended the party.
Although initially upset, Sandy soon became absorbed in playing a new audiotape she received as a gift and
totally ignored Ann for the rest of the party. When Ann finally left, Sandy seemed to have no idea as to where
she went or why she might have left.
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Reason for Referral
Eileen had talked to Sandy’s pediatrician, hoping to gain insight into Sandy’s “odd” ways of thinking and
marginal school progress. Eileen had always thought that Sandy would outgrow her awkward ways, but she
was now beginning to fear that her daughter’s difficulties were more permanent. Her concerns were also
escalating because of the lack of social contacts in her daughter’s life and how this might impact negatively on
her social development later on. Finally, Eileen decided that “knowing” was better than “not knowing,” and
she brought Sandy to the clinic with the hope that she could find some answers to her questions.
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Assessment Results
Information regarding specific assessment instruments and guidance in the interpretation of standard scores
and T scores can be found in Appendix C.
The psychologist administered the Wechsler Intelligence Scale for Children (WISC-V) and noted the
following test behaviors. Sandy was very verbal throughout the assessment, and comments often resulted in
digressions away from the target task. Sandy often had to be redirected to the task at hand. When verbal
responses were required, such as on the Vocabulary and the Similarities subtests, Sandy tended to
overelaborate, giving verbose responses far in excess of what was required. When nonverbal tasks were
presented, Sandy used self-talk to work her way through the task. Sandy frequently requested feedback
regarding her performance and seemed to become somewhat agitated when informed by the examiner that he
was unable to tell her how she was doing. Sandy seemed to be somewhat comforted, however, when the
examiner expressed comments of encouragement and praised her effort in general.
Visual tasks were very difficult for Sandy. She was able to reproduce the initial block designs by placing the
blocks on top of the designs in the model booklet itself. However, as the designs increased in complexity and
external cues were reduced, Sandy became visibly upset. She wanted to know where the lines went in the sixth
design: “There are supposed to be lines to tell you where the blocks go!” She also reproduced two of the
designs correctly, but in a rotated manner, not recognizing the need to match the orientation as well as the
colors of the blocks. Although able to complete the initial items on the Picture Concepts task, when a third
row of pictures was added, which increased the complexity and demands for abstract reasoning, Sandy began
to respond in a random manner. Sandy was extremely frustrated by the Matrix Reasoning task, which requires
the child to select the correct solution to complete a pattern from five possible alternatives.
Responses to the WISC-V revealed a significant discrepancy between her Verbal Comprehension Index (VCI
= 112; range 103–119), which was in the high average range, and her scores on the more visually oriented
tasks, such as those clustered in the Fluid Reasoning Index (FRI = 83; range 80–98), and Visual-Spatial Index
(VSI = 82; range 79–95), which were in the low average range. Less than 1% of the population would have
had a discrepancy of this extent between these components. Scores for the Working Memory Index (WMI =
94; range 87–102) and the Processing Speed Index (PSI = 88; range 80–98) were in the upper low average to
average range. On the VCI, Sandy revealed a significant strength in Vocabulary (SS = 14), while scores on the
PRI were very weak overall: Block Design (SS = 7), Picture Concepts (SS = 7), and Matrix Reasoning (SS =
6). Sandy’s full scale IQ was 89 (range 83–101), which placed her functioning in the upper limits of the low
average range.
Academically, Sandy’s scores for language arts subjects on the Wechsler Individual Achievement Test
(WIAT-III) revealed average to low average scores for Reading Comprehension and Fluency (SS = 102; 55th
percentile) and Written Expression (SS = 86; 18th percentile). Scores for Numerical Operations (SS = 75; 5th
percentile) and Math Problem Solving (SS = 73; 4th percentile) were significantly below what would be
anticipated given her overall intellectual ability and represent a discrepancy of more than one standard
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deviation (e.g., greater than 15 points) between her full scale IQ of 89 and her overall score for Mathematics
(SS = 74; 4th percentile). Math was at an early Grade 2 level with difficulties noted in computation, word
problems, and math reasoning. Sandy demonstrated some letter and number reversals on the spelling test.
Handwriting was very poor.
Sandy’s response to the Bender Gestalt test revealed a visual motor perception score to be equivalent to a child
of 5 years 5 months, two standard deviations below her expected age level. Sandy’s drawings were extremely
immature, despite taking excessive time to complete the task (in excess of 15 minutes). Although Sandy
counted and recounted dots, and often traced designs with her finger before execution, the resulting
reproductions were poor due to problems with rotations, design integration, substitution of circles for dots,
and tendencies to run designs into each other. When asked to “draw a person,” Sandy seemed to take forever
to produce the finished product, and after many erasures, the resulting image was very immature. Somewhat
embarrassed by the lack of results, and partially as an evasive tactic, Sandy eventually produced a stick figure.
She compensated for her poor motor skills, however, by creating an elaborate story about what the stick figure
was doing and how he came from the “land of stick people.” Parent responses to the Achenbach Child
Behavior Checklist (CBCL) revealed significant elevations on scales for Withdrawn/Depressed Symptoms,
Social Problems, Thought Problems, and Attention Problems, while Conners Scale responses noted
elevations for Cognitive Problems/Inattention, Anxious/Shy, and DSM Inattentive scale. Teacher responses
to the Achenbach Teacher Report Form (TRF) revealed significant concerns in areas of Social Problems,
Thought Problems, and Attention, while responses to the Conners Scale revealed significant elevations on
scales measuring Oppositional Behaviors, Cognitive Problems/Inattention, and Social Problems.
Sandy’s responses to the Revised Child Manifest Anxiety Scales (RCMAS-2) revealed significant elevations
in areas of Worry/Oversensitivity and Attention/Social Concerns. There were no significant elevations on the
Child Depression Index (CDI-2).
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Children who experience specific learning disorders (SLD) differ from children with general learning
problems or intellectual disabilities (ID) in that those with ID will demonstrate generalized problems across a
wide variety of adaptive areas commensurate with impaired intellectual functioning (e.g., cognitive ability,
functional academics, life skills, communication), while those with SLD will experience difficulties in a
specific domain (such as reading, written expression, or mathematics) despite having average intelligence. It
has been estimated that between 5% and 15% of school-age children will be diagnosed with SLD (DSM-5,
APA, 2013). The most prevalent type of SLD (80%) is dyslexia, a reading disability often evident in poor oral
reading, fluency problems, and faulty reading comprehension. Disorders of written expression are often
detected in errors of punctuation, grammar, organization, spelling, and poor handwriting. Mathematics
disorders are relatively rare and seen in approximately 1% of the population. Many children who experience
SLD in reading and/or written expression will be significantly stronger on tasks of visual/perceptual reasoning
(PRI) than those that measure verbal reasoning (VCI).
The criteria for identifying children with SLD differ depending on the classification system used. While the
DSM-5 (APA, 2013) refers to learning disorders (reading disorder, mathematics disorder, disorders of written
expression), and provides criteria for diagnosis, the educational system (IDEA, 2004) refers to specific learning
disabilities (SLD) and provides guidelines for determining whether children meet criteria for special education
services based on the extent and nature of their learning disability. An in-depth discussion of the criteria used
by the different systems of classification and additional insight into current issues in the identification process
can be found in Appendix B. Children who suffer from reading disorders (dyslexia) experience problems
decoding words due to basic phonological processing deficits; however, they are usually able to perform
adequately in math. However, children with nonverbal learning disability (NLD) experience just the opposite
pattern: They are able to fluently decode words but encounter significant problems with mathematics
(Rourke, 1999; Rourke, Hayman-Abello, & Collins, 2003). Although not all children with NLD will
experience math problems (Pennington, 1991; Semrud-Clikeman & Hynd, 1990), based on extensive
research, Rourke (2000) found that 72% of children with NLD also experience deficits in math reasoning, and
in some cases, math skills may be limited to achievement levels equivalent to the fifth grade (Rourke, 1995).
The syndrome of NLD, which has also been referred to as nonverbal learning disorder, or developmental right
hemisphere syndrome (DRHS), has been described in a number of sources over the past 10 to 15 years
(Gross-Tsur, Shalev, Manor, & Amir, 1995; Harnadek & Rourke, 1994; Palombo, 2006; Rourke, 1989;
Strang & Casey, 1994). Individuals with this syndrome experience problems in information processing and
motor impairments in three broad areas: motor skills (coordination), analysis and synthesis of visual
information (visuospatial integration), and social/pragmatic awareness and development.
The core symptom presentation includes social problems due to interpersonal skill deficits, motor slowness,
weak visual-perceptual organization, difficulties with nonverbal problem solving, and especially weak
arithmetic ability. Soft neurological signs can also be evident on the left side of the body (Gross-Tsur et al.,
1995). Often symptoms of ADHD are comorbid with the disorder. Results of a recent investigation by
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Garcia-Sanchez, Estevez-Gonzalez, Suarez-Romero, and Junque (1997) suggest that visuospatial deficits
associated with right hemisphere dysfunction are more pronounced in those youth who had attention-deficit
disorder without hyperactivity, compared to youth with ADHD hyperactive-impulsive type. Recent studies
have increased our understanding of the role of visuospatial processing problems in children with NLD to the
extent that Cornoldi, Venneri, Marconato, Molin, and Montinari (2003) suggest calling the disorder a
visuospatial learning disability. In one study, Liddell and Rasmussen (2005) found that despite average ability
to recall verbal information, children with NLD demonstrated significant deficits in the recall of visual
information. Of special note was the very poor performance of these children on a task of immediate recall for
faces, even though their scores improved on the delayed facial recall task. The researchers suggest that right
hemisphere processing deficits (right temporal lobe) may contribute to the problem, while the need for
additional time to consolidate information may explain the better performance on the delayed task. Rourke
and colleagues (2002) have also addressed deficits in the right cerebral hemisphere of individuals with NLD,
suggesting potential damage to white matter (myelinated fibers) evident in mild abnormalities to the right
hemisphere in brain scans of those with NLD (Rourke, 1995).
In a recent investigation of the clinical characteristics associated with NLD or DRHS, Gross-Tsur and
colleagues (1995) found the following characteristics that were shared by children in their sample: 65%
demonstrated left-sided soft neurological signs; the mean Verbal IQ was approximately 20 scale score points
higher than the mean Performance IQ of 85; the lowest Verbal scale score was Arithmetic, followed by
Comprehension; the lowest Performance scale score was for Coding; 94% had at least one specific learning
disability; and 67% had dyscalculia (math disability). In this particular sample, 90% demonstrated
graphomotor impairment evidenced by weak performance on Coding and the Bender Visual Motor Gestalt
Test, and 80% were referred for slow cognitive and motor performance.
Descriptions of slow cognitive and motor output were noted in an inability to complete schoolwork, sluggish
response to activity, and slowness to initiate and complete routine tasks. All children demonstrated poor social
skills, often evident in inadequate or inappropriate facial expression, eye contact, weak pragmatic language,
and poor comprehension of social rules. Children with NLD display considerable difficulties in nonverbal
problem solving. According to Harnadek and Rourke (1994), deficits in concept formation and hypothesis
testing result in poor ability to profit from environmental reinforcers that normally shape our behavior. These
children do not readily establish a cause-and-effect relationship, which brings structure and contextual
meaning to our experiences. They fare poorly in complex or novel situations and can appear scripted and
inappropriate in their responses.
Rourke and colleagues (2002) compared the syndrome of NLD to other pediatric neurological disorders and
ranked the disorders from high to low on the basis of symptom overlap. They found the closest sharing of
similar features was for Asperger’s syndrome (impairment in motor skills, social pragmatics, and pragmatic
communication, and visuospatial deficits). Individuals with Williams syndrome shared similar features of
deficits in visuospatial processing and the pragmatics of communication, although obvious differences were
also evident in overall cognitive ability and hypersociability.
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Interventions and Treatment
Empirically supported interventions for NLD continue to remain a high-need area for research. Despite the
lack of empirically supported programs for NLD, a number of recommendations have been suggested as
clinically effective in remediating neuropsychological deficits (visual-perceptual organization, psychomotor
and concept-formation skills) responsible for problems in areas of social skills, mathematical abilities, and
responses to novel problem-solving situations (Rourke, 1993). Treatment suggestions involve direct
instruction and guided practice. The following list summarizes some of the suggested directions for treatment
(Foss, 1991; Rourke, 1995):
Teach the child in a predictable, step-by-step, rote manner.

Ensure that language concepts are clarified.
Enhance verbal reasoning.
Encourage the application of problem-solving strategies and their transfer to new situations.
Teach a problem-solving format, or template, that the child can use to structure the situation (e.g.,
STOP: Stop and see what is happening; Think about what I am going to do now; Observe how others
are responding to me; Practice and improve).
Enhance social cognition through the use of direct instruction to teach appropriate verbal social
responses and how to read verbal cues.
Provide many opportunities for practicing these new skills and applying them to new situations until the
responses become more fluid and automatic.
Teach the child to link visual information (facial expression, body posture) with auditory information—
not only what is said, but how (tone, inflection) it is said.
Teach visual-organizational skills.
Teach comprehension directly.
Enhance self-esteem and feelings of self-efficacy.
As is evident in these guidelines, direct instruction is crucial to assisting children with NLD to make
connections that they may miss due to subtleties in the language, interpreting information literally, or not
attending to nonverbal communication (facial expressions and body language). Since children and youth with
NLD often take things literally, one of the major difficulties with problem solving is generalizing from one
situation to another or interpreting statements in a more generic manner (Marti, 2004). As a result, directions
need to be as specific as possible, for example, the statement “I want you to clean up your room” could lead to
an array of probable uncertainties (Does cleaning mean washing my room? How do I do that? What part of the
room do I clean? How long do I have to do that for? When do I know I am done? and so on) that could be
circumvented through proper elaboration.
Despite increasing awareness of NLD, Thompson (1997) suggests that many school districts have not
recognized NLD because the syndrome does not conform to the more traditional concept of a language-based
learning disability. In these cases, students may not receive appropriate CAMS (compensations,
accommodations, modifications, and strategies). Furthermore, if students with NLD fall into the minority of
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those with the disability who do not have significant problems in math, they will likely not qualify for special
education assistance, despite encountering many problems in the regular classroom (Semrud-Clikeman &
Glass, 2008). The dangers and risks of not detecting or providing early intervention can be found in
retrospective studies of adults with NLD. These retrospective studies (Ellison & Semrud-Clikeman, 2007;
Rourke, Young, & Leenaars, 1989; Rourke, Young, Strang, & Russell, 1986) suggest that undetected children
with NLD demonstrate a greater degree of developing internalizing disorders, such as depression; are at
greater risk for suicidal behaviors; and report a greater incidence of loneliness and social isolation as adults.
Palombo (2006) suggests a wide variety of therapeutic approaches that might be applied to strengthen
functioning in two important areas: enhanced self-efficacy and increased awareness of the nature of their
problems and how to navigate stressful and challenging situations, academically and socially.
In a case study investigation, Brodeur (2006) demonstrated that direct instruction techniques were highly
beneficial for a 15-year-old female with NLD who participated in a class to increase awareness of social
pragmatics. After attending the classes, the student demonstrated significant gains on all measures of adaptive,
social, and leadership skills (self-ratings, teacher ratings, and parent ratings). Recommendations for future
research included a focus on forming and maintaining friendships for older students, and instruction focusing
on maintaining eye contact and turn taking for younger children with NLD.
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Post-Case Questions
1. Children who demonstrate a nonverbal learning disability (NLD) may pose a particular problem for diagnosis and intervention
since their symptoms do not conform to the traditional concept of a language-based learning disability.
2. Discuss some of the difficulties of diagnosis of NLD with respect to how learning disabilities are defined by (a) the DSM-5 (APA,
2013), (b) education (IDEA, 2004), and (c) National Joint Committee on Learning Disabilities (NJCLD; see Appendix B).
3. Discuss the similarities and differences between a nonverbal learning disability (NLD) and a variant of higher functioning autism
spectrum disorder (Dylan’s case) or Williams syndrome (Williams’ case).
4. Discuss case formulations from the following theoretical frameworks: biomedical, psychodynamic, behavioral, cognitive, family
systems, and attachment/parenting style. How would these different theoretical frameworks influence the development of
intervention strategies?
5. Social skills are often an area of weakness for children with NLD. Using a social information processing model, develop a case
formulation for Sandy’s social skills deficits and explain how you would target specific areas for treatment.
6. Compare and contrast differences between strengths and weaknesses in the two cases of specific learning disorders that have been
discussed so far—for example, Thomas (who has dyslexia) and Sandy (who has a nonverbal learning disability). In your discussion
be sure to include information on the different parts of the brain that are influenced by each of these disorders, especially left
versus right hemisphere dysfunction.
7. Suggested Individual or Group Presentation Activity: You have been invited to provide feedback to the school regarding Sandy’s
assessment, at a meeting where they will decide whether Sandy meets criteria for Special Education and Related Services. If it is
determined that she is eligible for services, what goals and objectives would you want to see as part of her IEP? Would you
recommend she receive related services, and if so, what would the nature of those services be?
8. Prepare a script for role-playing each of the player’s parts in the school meeting mentioned above. Who do you think should be
attending the meeting? How could each participant potentially contribute information to assist with developing an intervention
plan that would best meet Sandy’s needs?
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References
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study. Dissertation Abstracts International: B. The Sciences and Engineering, 67, 531.
Cornoldi, C., Venneri, A., Marconato, R., Molin, A., & Montinari, C. (2003). A rapid screening measure for
the identification of visuospatial learning disability in schools. Journal of Learning Disabilities, 36,
299–306.
Ellison, P. A., & Semrud-Clikeman, M. (2007). Child neuropsychology. New York, NY: Springer.
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128–140.
Garcia-Sanchez, C., Estevez-Gonzalez, A., Suarez-Romero, E., & Junque, C. (1997). Right hemisphere
dysfunction in subjects with attention-deficit disorder with and without hyperactivity. Journal of Child
Neurology, 12, 107–115.
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learning disabilities in children. Journal of Learning Disabilities, 27, 144–153.
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Disabilities Research & Practice, 20, 137–141.
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nonverbal learning disability. Journal of Child Neurology, 19, 830–836.
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nonverbal learning disabilities: Neurodevelopmental manifestations. New York, NY: Guilford Press.
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New York, NY: Lippincott Williams, & Wilkins.
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disabilities, reading disabilities, and without learning disabilities. Annual of Dyslexia, 58, 163–180.
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http://www.nldline.com/nld.htm
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Part B Autism Spectrum Disorders (ASD) and Intellectual
Disabilities
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Contents
Case 7: Dylan Bach: The World According to Dylan
Case 8: Arthur Watson: Won’t or Can’t; a Case of Mistaken Identity
Case 9: Brian Williams: My Name Is Williams, Too
Case 10: Bradley Hunter: Not Yet Diagnosed
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Case 7 Dylan Bach The World According to Dylan Mild Variant
of ASD
Dylan’s behavior was discussed at a school intervention meeting shortly after Dylan enrolled in the
kindergarten program at Cyprus Springs Elementary School. His teacher was concerned because Dylan
displayed very “odd” behaviors and despite being very verbal seemed to be in “his own world.” Dylan’s speech
was indistinct, and although he seemed to chatter a lot, it was very difficult to comprehend what he was
saying. Often he would talk to himself, in a singsong refrain, reciting entire monologues. Dylan was a
spontaneous reader, and he would take great pleasure in reading everything from book titles to footnotes. He
could also spell his name. However, Dylan preferred solitary activities and it was very difficult to engage
Dylan in the normal classroom routines and group activities. Dylan could be very resistant. Not only did the
teacher have problems engaging Dylan in regular classroom activities, it was equally difficult trying to
disengage Dylan from an activity that he was involved in. When asked to participate in activities not to his
liking, Dylan had thrown a number of temper tantrums. On these occasions, he would scream a very loud and
persistent “No!!!!”
Dylan is awkward and poorly coordinated and often walks into things. He seems to be in constant motion and
is very fidgety. During quiet times, like story or circle time, Dylan’s constant motion (rocking, squirming,
fidgeting) is often disturbing to the other children. This, coupled with Dylan’s poor coordination, often results
in his falling into other children or tripping over things in the classroom.
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The school social worker met with Dylan’s mother, Celeste Bach, to discuss the school’s concerns and to
obtain a social history. Celeste and her husband Arnold were both 23 years old when Dylan was born. They
had been married for 2 years. The Bachs owned an art studio and made their living through the sale of their
own creative art pieces. Celeste was an oil painter and Arnold was a sculptor. They supplemented their
income by giving art lessons and selling art supplies. Celeste described a difficult and unpleasant pregnancy.
She was nauseated through most of the pregnancy and also developed toxemia midway through the
pregnancy. Dylan was born 2 weeks ahead of schedule after a very long labor (40 hours) and weighed almost 9
pounds (8 lbs. 10 oz.). The delivery was uneventful.
Celeste described Dylan as cheerful, affectionate, and sociable during his first year. He had a good appetite
but was difficult to put on a schedule. He experienced many colicky bouts, and sleep was often disrupted.
When he awoke, it was difficult to get him back to sleep. Milestones were achieved within the norm, and
Dylan was walking and saying his first words by 1 year of age. Mrs. Bach admitted to difficulties with toilet
training, and at almost 5 years of age, Dylan continued to exhibit occasional bed-wetting incidents. Accidental
soiling stopped about a year ago. Health was described as good, with the exception of vulnerability to ear
infections and food allergies (dairy products). Dylan is rarely ill; however, when he does get ill, he tends to
develop a fever and requires monitoring.
Family history notes a paternal uncle with cerebral palsy and intellectual disability. There is a history of
bipolar disorder with obsessive-compulsive disorder in the family (maternal grandmother), as well as anxiety
(paternal aunt). Celeste reported that Dylan’s pediatrician thought he might be autistic; however, no further
assessment was conducted. She added that Dylan can be stubborn at home but that he will comply when
necessary. Dylan gets along well with their adult neighbors, who have all been very impressed with his reading
and writing abilities. Celeste added that they currently live in a neighborhood with no other children Dylan’s
age and that he’s had very little practice socializing with peers.
Toward the end of the kindergarten program (Dylan was 5 years 6 months of age), the school psychologist
conducted a brief assessment of Dylan’s cognitive functioning. The Differential Ability Scales (DAS) were
administered and revealed a Verbal Cluster standard score of 56, and a Nonverbal Cluster score of 86. The
school psychologist noted that rapport was very difficult to establish and questioned the validity of the
assessment results due to Dylan’s immaturity, lack of compliance, low frustration tolerance, and insistence on
doing things his own way.
The school convened a staffing meeting to determine eligibility for special education programming and
decided on the following course of action. Due to difficulties establishing whether the results of the
assessment were valid, based on Dylan’s test behavior, Dylan was given a temporary designation as
developmentally delayed, which would lapse on his sixth birthday, the age established by the Local
Educational Authority (LEA) for discontinuation of services under the category of developmental delay. (See
Appendix B for an explanation of the classification of developmental delay under IDEA, 2004; and the DSM-
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5 Category of Global Developmental Delay). The decision allowed for an additional 6-month period in which
a more valid and in-depth evaluation of Dylan’s ability levels could be conducted. Dylan would be provided
with services from occupational therapy, speech and language therapy, and the special-programs teacher, while
awaiting his reevaluation.
Unfortunately, Dylan’s parents moved over the summer holidays, and Dylan began attending Lawton
Elementary School for the next academic year. Meetings were convened prior to the start of school to
determine how to best accommodate Dylan’s special needs within the new school environment. At this time,
the decision was made to have Dylan attend the kindergarten program for a half day and receive specialized
services in a class for children with varying exceptionalities (VE Program) for the remainder of the day.
Speech therapy was provided on a daily basis by the school speech pathologist, and occupational therapy was
programmed for on a once-weekly visit. Dylan had always experienced problems with adjusting to new
routines, and it was not surprising that the move to a new school was very difficult for Dylan. The first
struggle began when he did not want to get on the bus and threw himself on the ground kicking and
screaming. However, his parents were persistent and eventually his resistance mellowed. After about 3 weeks,
Dylan began to settle into his new routines. Recently, he has begun to reexperience difficulties, and his
resistance to riding on the school bus has resurfaced. Just prior to his formal reassessment, Dylan was observed
throwing himself to the ground and refusing to get on the school bus. School officials are currently
investigating potential reasons for the resurgence of Dylan’s refusals to board the school bus.
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Reason for Referral
A referral for reevaluation was initiated by Dylan’s new school to remove his temporary designation as
developmentally delayed. A full assessment was requested to update intellectual estimates of Dylan’s abilities
and to determine how to best meet Dylan’s academic, social, and emotional needs within the current school
system.
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Assessment
Knowing the difficulties that the previous school psychologist had encountered in attempting to conduct a
comprehensive assessment, the school psychologist took several precautions to obtain a valid assessment of
Dylan’s functioning on several levels. Several observations of Dylan’s behaviors were obtained by classroom
observations of Dylan’s behaviors in different classroom environments, and more formal psychometric tasks
were administered in environments that were within Dylan’s comfort zone and within his tolerance for
removal from normal classroom routines.
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Classroom Observations
The school psychologist began a series of observations of Dylan in the two classroom settings. Observation of
Dylan in the kindergarten program revealed a number of interesting behaviors. On one occasion, Dylan was
observed while his teacher read a story to the class. The children were sitting on the floor, gathered around the
teacher’s chair. Although Dylan seemed attentive initially, he soon began a series of excessive movements
(fidgeting, rocking, sprawling on the floor, hanging upside down) that were distracting to the other children.
He spontaneously got up and walked to the back of the classroom in search of paper and crayons. For the next
15 minutes, the teacher would verbally redirect Dylan back to the circle and Dylan would comply
momentarily, then get up and return to the back of the classroom. At one point he was very insistent on
leaving the circle, saying, “I want to do my work!” The teacher responded by saying, “You will sit and listen to
the story!” Dylan responded, “I won’t sit and listen to the story!” At this point, the teacher reminded him of
good and bad choices and the consequence of losing a star for bad choices. If he did not do as he was told, he
would lose a star. (The star chart was a classroom behavior merit program. Children earned stars for good
behavior and lost stars for poor behavior. Stars could be traded in for activities and small prizes at the end of
the day.) Dylan immediately complied and remained on the floor. However, his constant motion eventually
resulted in his kicking another child (by accident), and the child broke into tears. Dylan seemed oblivious to
his role in the event and clearly did not understand the teacher’s request to apologize to the other child for the
infraction. Within the kindergarten program, the teacher’s goals and expectations for Dylan were the same as
for all children in her classroom. Within this environment, Dylan struggled with the lack of flexibility and did
not understand the need to be involved in activities that held little interest for him.
For Dylan, the Varying Exceptionalities (VE) Program had several advantages: fewer children, older children
(7–9 years of age), and a teacher trained in special education. In this environment, Dylan seemed to enjoy the
freedom of being allowed to work on a task at his own pace. Dylan worked very quickly and seemed to
thoroughly enjoy coloring in pictures, drawing animated cartoons, and writing captions beside the drawings.
He was highly productive and was not distracted by the grouped activities that were going on around him.
Since the children were of varying levels of ability (slow learners, learning disabled), the children were often
grouped for instructional purposes. Due to Dylan’s uniqueness, his teacher provided instruction on a 1:1 basis
and then provided opportunities for independent learning (computer access) or individual seatwork. While he
worked, Dylan was observed to be singing to himself, mimicking lyrics from various audio computer programs
(e.g., “Rock and Roll,” “ABCs”). Dylan often repeated refrains over and over in a singsong fashion while he
worked. Although reluctant to disengage from a task when requested to do so, he did comply and brought his
work to the teacher for her remarks. He followed routines relatively well and enjoyed his times when called on
to read to the teacher, which he did flawlessly. He was rewarded for following routines and completing
seatwork with individual computer time. During individual computer time, Dylan quickly became totally
absorbed in the computer programs, repeating the monologue as if he were narrating the program himself.
Comments on Classroom Observations.
The school psychologist noted that many behaviors demonstrated by Dylan fit descriptions in the literature on
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autism spectrum disorders, especially the higher functioning variation of this disorder, including: idiosyncratic
areas of interest, odd and peculiar behaviors, intense interest in specific areas, poor coordination, and lack of
social reciprocity. Having the opportunity to watch Dylan’s behavior in the two different classroom settings
provided considerable insight. While Dylan constantly resisted attempts to engage him in group-oriented
activities in the regular kindergarten program, he welcomed an opportunity provided by the special education
setting to work within the confines of his own little world, without attempts to draw him into any group
activities.
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Individual Assessment Sessions
In addition to observational assessments, Dylan was seen for three individual assessment sessions. The
psychologist decided to conduct Dylan’s assessment in a small resource room off the VE classroom. Dylan was
familiar with the room because he received his language and occupational therapy in the same room; also, he
could readily see his teacher through the glass windows. By this time, Dylan was also familiar with the school
psychologist and willingly accompanied her into the room. Since Dylan seemed to enjoy artwork, as an
introductory task, Dylan was asked to draw a person. Dylan responded by saying that he would draw a pig,
which he did. The pig had a big sign on its neck: “Babe.” Apparently, Dylan had been watching the movie
Babe (a story about a pig) over and over and was very interested in pigs at this time. He did comply with a
request to copy Bender Designs and completed the Bender design drawings in a short period of time. Dylan
used a whole-hand pencil grip for all drawing and printing.
Throughout the assessment sessions, Dylan’s enthusiasm waxed and waned, and his compliance shifted
relative to his interest in the task at hand. Dylan was very excited about doing the Picture Concepts subtest of
the WISC-V (a supplementary test that was included due to the suspected level of interest that the task would
have for Dylan). He loved to find out “What goes together?” and repeated the phrase “What goes together!”
over and over again. He wanted to draw an arrow connecting the pictures that went together in the stimulus
book, and the examiner had to confiscate writing materials to ensure this did not happen. Dylan’s enthusiasm
for visual materials far outweighed his interest in responding to verbal questions, and assessment results reflect
this disparity. Despite a predominance of fidgety and tense behaviors, Dylan became very focused, deliberate,
and methodical working with block designs. He carefully moved each block with precision, checking and
rechecking with the stimulus card to ensure accuracy. Dylan also made humorous comments, and when the
11th block design was revealed, he said, “Scary!” and laughed. Then he added, “You will have to help me on
this one.” Throughout the assessment, when one subtest was completed, Dylan repeatedly asked if he could
play the “What goes together” game again. Eventually, the examiner had to remove the stimulus book from
the room, since Dylan kept trying to find it, to play the find the “What goes together” pictures game.
Williams (1995) discusses the impact of sensory overload on children with Asperger’s disorder (a type of
pervasive developmental disorder that was recognized by the DSM-IV-TR (APA, 2000), prior to the DSM-5
(APA, 2013), which excluded Asperger’s disorders as a specific diagnosis, and clustering it among the other
autism spectrum disorders). According to Williams these children can be overwhelmed by very little change
and sensory overload can throw these children off balance. During the course of this first session, Dylan fell
off his chair three times. A combination of poor coordination and becoming overly stimulated served to throw
him off balance, literally and figuratively.
Currently, the DSM-5 includes the symptom of “hyper-or hypo-reactivity to sensory input” as one of possible
symptoms of restricted/repetitive response patterns evident in ASD.
When the examiner arrived in the classroom for the second session, Dylan jumped up from his seat (almost
falling into the desk) and greeted her with an enthusiastic and announced, “You’re back! You’re back!” He
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spontaneously took her hand and led her to the assessment room. The Woodcock Johnson Test of
Achievement was introduced and Dylan completed the Letter Word Identification subtest with ease. The
Passage Comprehension subtest was next, and it was anticipated that this would be another area of high
interest for Dylan. However, what transpired was not expected. The Passage Comprehension subtest requires
that the students read a passage and then orally fill in the blank to complete the sentence in the stimulus book.
For example, a statement that “Children often like to play on swings in the park” is followed by a statement to
test comprehension, such as: “Children like to play on ____ in the park.” When this task was introduced,
Dylan was insistent on filling in the blanks by writing the answer in the stimulus book. Although the school
psychologist made several attempts to explain why Dylan could not write in the book, it was not possible to
console him. He became visibly upset and started to shake, was on the verge of tears, and repeatedly stated,
“You must fill in the blank with the missing word! . . . You must fill in the blank with the missing word!”
Dylan was extremely distraught. At this point, the examiner removed the book from the room and brought in
sheets of paper and crayons, allowing Dylan to draw and color his favorite cartoons. Drawing seemed to be an
activity that served to soothe Dylan in times of stress; this discovery could play an important role in the
development of a treatment plan.
After Dylan calmed down, the examiner accompanied Dylan to the kindergarten room, where he was
supposed to go after lunch. However, when they arrived, the other students had already left for physical
education (PE) and the examiner began to walk Dylan over to the playground to join his class. Given Dylan’s
poor coordination and reluctance to engage in group activities, it is not surprising that PE is his least favorite
subject. He became very upset about going to PE and began clinging to the examiner’s arm, refusing to let go.
The examiner talked to him about all the good choices he had made that day and added that he might earn a
star for joining his class, because this was a very good choice indeed. Reluctantly, he separated and joined his
class in session. The psychologist then talked to his teacher to ensure that he did receive a star for compliance,
to provide support for his difficult choice.
In order to complete the academic assessment the following day, the examiner photocopied the Passage
Comprehension and Applied Problems subtests of the Woodcock Johnson. The plan was to provide Dylan
with worksheets that would allow him to fill in the blanks on the actual pages rather than respond orally.
Although this technique was not part of the standardized procedure, the psychologist wanted to avoid unduly
upsetting Dylan, who was “locked into” a “filling in the blanks” mode of operation. The psychologist
considered the deviation in protocol a minimal concession, and it avoided the risk of another emotional upset
for Dylan. In addition, the task actually became more difficult, since Dylan now had to spell the words to
complete the sentences, rather than just provide the answers orally. When presented with the sheets, Dylan
proceeded to fill in a large number of blanks correctly, and also spelled the words appropriately. He was
rewarded by being allowed to color in the pictures and then draw another series of cartoon animals. As he was
drawing, Dylan recited, verbatim, an entire dialogue from a computer program that he had previously heard:
“This CD program is a Random House Production. As a special bonus feature, be sure to try our newsletter and
programs for kids. . . . Each issue is packed with behind-the-scenes action and fun-filled games for kids. Your first issue
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Dylan’s drawings were quite remarkable and very well done. He titled his drawing of animated characters as
the “Walkabe Rabbit Collection.” Dylan also drew another picture, this time of the Windows 2000 logo,
complete with copyright. Ultimately, Dylan completed the academic assessment, although it required
considerable redirection to task. Dylan fell out of his chair again during this assessment session.
Dylan was able to engage with the examiner socially, albeit within a restricted range. Although eye contact
was established, at times he would actually open his eyes wide with a penetrating stare, but at other times
visual distance and lack of eye contact were far more comforting. Dylan displayed a sense of humor and could
be very engaging; however, laughter would often escalate quickly out of control. Dylan preferred to engage the
examiner on his own terms and could become totally absorbed in paper-and-pencil tasks or verbal monologues
that effectively excluded social contact. Dylan was able to request help when needed for a cognitive problem-
solving task (puzzles, blocks); however, he experienced difficulty eliciting assistance when emotionally upset,
due to a very high level of anxiety and distress. On these occasions, Dylan seemed to respond either by
clinging or by attempting to escape (tantrums).
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Assessment Results
Dylan’s responses to the Wechsler Intelligence Scale for Children—Fifth Edition (WISC-V) revealed a
Verbal Comprehension Index (VCI = 92; range 86–99) in the average range. Scores for the Visual Spatial
Index (VSI = 117; range 108–123) and the Fluid Reasoning Index (FRI = 115; range 106–122), which rely on
visual tasks and visual information processing, were in the high average range. Both scores were considered to
be an underestimate of global cognitive reasoning, yet likely an adequate picture of day-to-day functioning.
Verbal tasks were responded to poorly, and despite an excellent base vocabulary, Dylan’s responses to verbal
tasks were lower than anticipated, but in the predicted direction for higher functioning ASD. A relative
strength was noted in Vocabulary (12), while weaknesses were noted in Comprehension (4) and Similarities
(5). On tasks measuring VSI a significant strength was evident on Block Design (16), while the VSI and
Picture Concepts (14) was also an area of strength. Dylan’s WISC-V profile of superior visual to verbal ability
was not in the predicted direction (Klin, Sparrow, Volkmar, Cicchetti, & Rourke, 2001); however, Dylan was
also more compliant on visual tasks, which may have served to alter overall scores. Despite this fact, subtest
scatter actually did conform to suggested patterns in the literature on Asperger’s disorder: Vocabulary was
much higher than Comprehension (Klin, Volkmar, Sparrow, Cicchetti, & Rourke, 1995). Dylan received an
error score of 9 for his reproductions of Bender Designs, which was within the expected range for his age. His
substitution of lines for dots in designs 2, 3, and 5 is often associated with brain dysfunction.
Standard scores for academic performance on the Woodcock Johnson Achievement Test revealed a score for
Broad Reading equivalent to a standard score of 150, which is in the highly gifted range. The Broad Reading
score is a composite based on performance from three reading tasks: Letter Word Identification (SS = 135),
Reading Fluency (SS = 119), and Passage Comprehension (SS = 128). Scores for written expression revealed
Spelling (SS = 148) and Writing Samples (SS = 140) to also be within the gifted range. Scores for Math
Calculation (SS = 94) and Applied Problems (SS = 84) were Dylan’s weakest areas of performance.
Dylan’s mother completed the Vineland Adaptive Behavior Scale, the Gilliam Autism Rating Scale (GARS),
and the Asperger Syndrome Diagnostic Scale (ASDS). Mrs. Bach’s ratings placed Dylan within the normal
range of behaviors on the GARS (SS = 87), which would suggest below average indicators for autism. Ratings
on the ASDS indicated an overall Asperger’s Syndrome Quotient of 105, suggesting that Dylan met criteria
for a likely diagnosis of Asperger’s disorder. A significant elevation was noted for the Social Behavior scale on
the ASDS. According to Dylan’s mother, overall adaptive behavior on the Vineland was within the expected
range for his age level.
Dylan’s teachers also completed the GARS and the ASDS. Since Dylan was observed to behave very
differently in the two classroom settings, it was not surprising that the kindergarten teacher and the special
programs teacher (VE teacher) rated Dylan’s behaviors quite differently. On the GARS, the kindergarten
teacher rated Dylan as having an average probability of autism (SS = 91), with only Communication slightly
232
elevated. The VE teacher rated Dylan much higher on the Autism scale (SS = 126), suggesting a “high”
probability of autism with significant elevations on the Communication scale (scale score = 14) and Social
Interaction scale (SS = 19). Teachers reported better agreement on the ASDS, with his kindergarten teacher
suggesting a likely (SS = 97) probability of Asperger’s syndrome and his VE teacher ratings indicating a very
likely (SS = 111) probability of Asperger’s syndrome. According to the ASDS, the kindergarten teacher noted
significant escalation on the Cognitive scale (SS = 13), while the VE teacher noted significant elevations on
the Social (SS = 13) and Sensorimotor scales (SS = 13).
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Prior to the fourth edition of the DSM (APA, 1994), Asperger’s disorder was not a recognized Axis I
disorder. The DSM-IV listed Asperger’s disorder as one of the five disorders under the category of pervasive
developmental disorders (PDDs), which were characterized by severe and lifelong impairments in a number of
areas. Currently, the DSM-5 (APA, 2013) has replaced the category of PDD with a new category of autism
spectrum disorder (ASD) to include disorders that share two common features: pervasive and consistent
deficits in social communication and interaction (evident in three areas); and restricted, repetitive patterns of
behavior, interests, or activities (in two areas). The DSM-5 states that children previously diagnosed with
Asperger’s disorder, autistic disorder, or PDD should now be reclassified as meeting criteria for autism
spectrum disorder (ASD). Based on the symptom criteria, Dylan meets criteria for ASD based on social
communication and interaction deficits in the three areas of: social-emotional reciprocity, verbal and
nonverbal communication, and social relatedness; and restrictive, repetitive behavior patterns, evident in
insistence on sameness (inflexibility), restricted/fixated interests, and hyperactive response to sensory input. In
Dylan’s case, the specifier “without accompanying intellectual impairment” would be identified due to his
elevated scores evident in the intelligence testing.
Some children with ASD can become preoccupied with numbers or letters and demonstrate an ability to
decode almost anything (hyperlexic) at a very early age. Some higher functioning children are able to form
attachments to family members; however, their ability to relate to others is often not evident outside the
family circle, and the skills do not transfer to peers. Attempts to carry on a meaningful reciprocal conversation
with children who have high functioning ASD is often derailed by their tendencies to produce pedantic
monologues on topics of interest to them and their lack of understanding of the give and take necessary in
areas of social pragmatics (Attwood, 1998).
The ability to form and maintain social relationships and friendships are often at the core of normal emotional
development and can provide children with feelings of belongingness, emotional security, and self-worth
(Rubin et al., 2004). In normally developing adolescents, friendships provide the basis for gaining increased
social-cognitive awareness through disclosures evident in intimate relationships, such as sharing information
with close friends (Allen, Porter, McFarland, Marsh, & McElhaney, 2005). Although it was once thought
that children with higher functioning ASD preferred to be alone, more recent investigations have found that
although adolescents with the disorder demonstrate less participation in social activities (Orsmond, Krauss, &
Seltzer, 2004), lack of social relationships may not be related to lack of desire, but to difficulties they
encounter with social understanding due to such deficits as theory of mind (Kaland et al., 2002). As a result,
higher functioning adolescents with ASD disorder can become very lonely and isolated at a time when they
want to join peer groups (Klin & Volkmar, 1997; Whitehouse, Durkin, Jaquet, & Ziatas, 2009) and may be at
increased risk for depression and anxiety disorders, relative to the population at large (Sofronoff, Attwood, &
Hinton, 2005). Whitehouse and colleagues (2009) investigated the relationship between depression and
quality of friendship in youth with high functioning ASD (HFASD) and found that relative to their peers,
youth with (HFASD) demonstrated less intrinsic motivation to engage in friendships and experienced poorer
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quality of friendships and elevated levels of loneliness and depression. The researchers suggest that
intervention to improve social competence in adolescents with HFASD (possibly through the use of story
modeling techniques; Carrington, Papinczak, & Templeton, 2003) might have significant implications for
enhanced mental health.
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Higher Functioning ASD (HFASD)
HFASD is an informal subcategory of ASD and applies to approximately 25% of children with ASD who
score above the mentally retarded range (who have an IQ greater than 70). Individuals with HFASD may be
far more likely to attempt conversations with others than those with lower functioning ASD (LFASD), whose
conversations are usually one-sided in nature. Ghaziuddin (2008) suggests that in social interactions,
individuals with HFASD may tend to be more aloof and passive or may appear more active, but odd.
Individuals with HFASD score higher on IQ tests than those with LFASD, either due to strengths in areas of
perceptual reasoning, or better verbal skills (Ehlers et al., 1997). Sahyoun, Soulieres, Belliveau, Mottron, and
Mody (2009) found that while some individuals with HFASD used visuospatial processing during a pictorial
reasoning task, others with HFASD used linguistic mediation to solve the same tasks.
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HFASD and Nonverbal Learning Disabilities (NLD)
The distinction between children with HFASD and children with an NLD (NLD: See Case of Sandy for a
comparison) can be a difficult differential diagnosis since both share similar features of a social disability due
to poor understanding of the pragmatics of social communication, inability to read social cues, and poor
understanding of nonverbal social indicators. Klin and colleagues (1995) suggest that it is most likely that
these disorders represent different perspectives on a heterogeneous set of disorders that share some
overlapping features.
Rourke and colleagues (2002) found that youth with HFASD and youth with NLD shared strengths in
processing left-hemisphere functions (e.g., verbal ability) and deficits in right-hemisphere processing
(weaknesses in social interaction, complex reasoning, and nonverbal communication). Although they note that
little research has been published regarding interventions for HFASD, Klin and colleagues (1995) suggest
that interventions developed to address NLDs might also be helpful for this population.
237
Communication and Social-Pragmatic Speech
Woodbury-Smith, Klin, and Volkmar (2002) suggest it is important to recognize that individuals with
HFASD process deficits in social information and communication that are demonstrated in a different way
from those with LFASD. Although both disorders share impairments in social relationships, the social
disability is unique to each disorder with their own unique patterns of behaviors and communication deficits.
Individuals with HFASD do have communication abnormalities (pragmatic communication impairments)
that “interfere with the ability to initiate and sustain a conversation,” even though deficits are “fundamentally
different from the type of language and communication impairments described in autism in which the
language is delayed, ecolalic idiosyncratic and repetitive” (p. 238). A new addition to the DSM-5 (2012) is the
category of social (pragmatic) communication disorder (SCD), which is clustered among the section on
language disorders in the chapter on neurodevelopmental disorders. Children with SCD have difficulties in
verbal and nonverbal skills related to social communication, in such areas as responding to others
appropriately, staying on topic, talking about emotions or feelings, engaging in two way communication
(reciprocity), taking turns when talking or playing, using gestures, interpretating of nonverbal information
(body language, facial expressions), understanding the subtle nuances language (e.g., jokes, idioms), and
regulating speech to fit the context (location, e.g., classroom, playground; recipient, e.g., teacher, friend). The
DSM-5 (APA, 2013) states that a differential diagnosis between ASD and SCD is made based on the degree
to which an individual also demonstrates the additional criterion for ASD of engaging in restricted or
repetitive behaviors. Individuals with SCD are most likely to receive therapy from speech-language
pathologists.
238
Treatment/Intervention
Far more research evidence is available for the treatment of individuals with more severe forms of autism than
for those with HFASD. Given the wide variations in intellectual functioning between these two populations,
severity of problems exhibited, and the range of areas targeted for improvement, it becomes difficult to
generalize results from these studies of LFASD to a population of HFASD.
Since the typical age for diagnosis of HFASD can be delayed compared to the identification of LFASD
(Howlin & Asgharian, 1999), early treatment and intervention can be challenging. Approaches most often
used for children with LFASD include applied behavioral analysis and approaches that draw on a variety of
behavioral, developmental, and social-pragmatic resources (Tsatsanis, Foley, & Donehower, 2004). For the
most part, treatment has focused on increasing social and emotional awareness and improving social exchange.
Techniques that have been developed to assist social competence include direct instruction in role playing,
social skills groups, practicing of skills with peers, and the use of social stories.
Social stories can provide a framework for teaching lessons about appropriate social behavior, the sequencing
of social events, and the interpretation of social cues. Scripts can provide a template for social exchange and
increase the child’s understanding of what is likely to happen and how to respond. Since the story can include
different characters, the child with HFASD can also learn how to take the perspective of another person, a
skill that is often difficult for individuals with HFASD (Attwood, 2000). Sansosti and Powell-Smith (2006)
introduced children with HFASD to emotions within themselves and others through the use of social stories.
Despite a small sample and lack of long-term effects, the procedure is a promising avenue for further
investigation, especially if stories are infused with highly visual supports (Kana, Keller, Cherkassky, Minshew,
& Just, 2006).
Results from neurological research have revealed that when children with ASD are presented with tasks that
involve decoding facial expressions and vocal tone, their brains are activated in areas used to identify objects in
normal populations (Schultz et al., 2000). Lindner and Rosen (2006) suggest that children with HFASD
focus too heavily on the verbal message and ignore relevant signals in facial cues and tone. LaCava, Golan,
Baron-Cohen, and Myles (2007) used a computer-generated program to teach children with HFASD to
recognize emotional expressions and complex emotional voice patterns.
Marriage, Gordon, and Brand (1995) developed a social skills intervention program for children with
HFASD, targeting skill deficiencies peculiar to that population. The program of eight weekly 2-hour sessions
was followed by six weekly 1-hour reinforcement sessions. Multimodal techniques (role-play, videotaping,
games, show and tell) were practiced during the sessions, and homework was assigned to provide carry-over
into the home. To assist skill generalization, sessions were varied across a number of different settings within
the clinic. Parents met for an informal discussion group while the children attended the sessions. Although
results did not reveal significant positive outcomes, the authors suggest that lack of positive outcomes may
have been an artifact of the measurement process, since anecdotal comments and observation pointed to
overall social gains. The authors’ recommended future studies include increased generalization of the program
239
within an actual school setting.
On a more practical note, Williams (1995) suggests several guidelines for teachers of students with HFASD.
A number of school-based programming suggestions are provided that target seven defining characteristics of
HFASD: insistence on sameness, impairment in social interaction, restricted range of interests, poor
concentration, poor motor coordination, academic difficulties, and emotional vulnerability. Describing
children with HFASD as “easily stressed, and emotionally vulnerable” (p. 9), Williams states that although
there are no precise recipes for success due to the diverse nature of the disorder, broad strategies can be
adapted to meet the needs of the individual child. For example, insistence on sameness can be counteracted by
giving the student sufficient warning or pretraining regarding pending changes, incorporating consistent
routines, minimizing transitions, and providing a safe and predictable environment. Issues of emotional
vulnerability can be addressed by skill-building exercises to reduce stressful responding. The introduction of
step-by-step problem-solving exercises can be very helpful in providing a structured plan to adopt in times of
stress.
240
Post-Case Questions
1. Initially, Dylan was diagnosed with developmental delay because testing was inconclusive due to his noncompliance during the
testing session. Discuss how “developmental delay” is recognized by the DSM-5 and IDEA, 2004. What are the similarities and
what are the differences? The category is controversial because some favor delaying a diagnosis to avoid a misdiagnosis, while
others feel that the delay only delays the inevitable and may result in fewer immediate services. What side of this debate would you
support and why (provide support for your comments from the research and documents).
2. In terms of differential diagnosis, how do Dylan’s behaviors fit with a profile of HFASD relative to that of LFASD or nonverbal
learning disability? Use illustrations from Sandy’s case (Case of Sandy Smith) and Dylan’s case presentation to compare and
contrast the most salient features.
3. Provide some possible explanations for the wide discrepancies in ratings between the three raters (two teachers and parent).
Discuss these potential differences relative to various levels of influence, or developmental contexts, suggested by Bronfenbrenner’s
model. Design an intervention program drawing on the strengths of both classroom programs.
4. With the newly introduced category of social (pragmatic) communication disorder (SCD), and changes in the DSM-5 that now
allow comorbid diagnoses of ADHD and ASD, develop a differential diagnosis for Dylan that considers ruling out or ruling in
ASD, SCD, and ADHD. Support your comments with citations from the case and the DSM-5.
5. The “theory of mind” refers to the ability to understand and attribute mental states (beliefs, attitudes, interests, prior knowledge)
to oneself (self-perception) and to other individuals (perception of others). Fundamental to this theory is the ability to understand
that others may have different beliefs, attitudes, and knowledge, based on their own unique experiences. An example of an
experiment involving theory of mind is as follows. John watches as the teacher places chalk in a crayon box. The teacher tells John
that she wants to store the chalk in the crayon box because the chalk box is broken. Stuart is out of the classroom when this
happens and enters shortly after the teacher is finished. The teacher asks John: “What do you think Stuart will say is in the crayon
box?”
If John is capable of understanding theory of mind, he will respond “crayons”; if not, he will respond “chalk.” Find a research
article on autism and theory of mind. Construct a theory of mind experiment for Dylan, and predict (based on the article and your
reading of this case study) what Dylan’s responses would be. Support your comments with symptoms from his diagnosis and the
research.
Suggested Individual or Group Presentation Activity:

6. You have been invited to provide feedback to the school regarding Dylan’s assessment, at a meeting where they will decide
whether Dylan continues to meet criteria for special education and related services. If it is determined that he is eligible for
services, what goals and objectives would you want to see as part of his IEP? Would you recommend he receive related services,
and if so, what would the nature of those services be?
7. Prepare a script for role-playing each of the player’s parts in the school meeting, mentioned above. Who do you think should be
plan that would best meet Dylan’s needs?
241
References
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adolescents’ success with peers: Adolescent popularity, social adaptation, and deviant behavior. Child
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Attwood, T. (1998). Asperger’s syndrome: A guide for parents and professionals. London, England: Jessica
Kingsley.
Attwood, T. (2000). Strategies for improving the social integration of children with Asperger syndrome.
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Carrington, S., Papinczak, T., & Templeton, E. (2003). A phenomenological study: The social world of five
adolescents who have Asperger’s syndrome. Australian Journal of Learning Disabilities, 8, 15–21.
Ehlers, S., Nyden, A., Gillberg, C., Dahlgren, S. A., Dahlgren, S. O., Hjelmquist, E., & Odén, A. (1997).
Asperger syndrome, autism and attention disorders: A comparative study of the cognitive profiles of 120
children. Journal of Child Psychology and Psychiatry, 38, 207–217.
Ghaziuddin, M. (2008). Defining the behavioral phenotype of Asperger syndrome. Journal of Autism and
Developmental Disorders, 38, 138–142.
Howlin, P., & Asgharian, A. (1999). The diagnosis of autism and Asperger syndrome: Findings from a survey
of 770 families. Development and Medical Child Neurology, 41, 834–839.
Kaland, N., Moller-Nielsen, A., Callesen, K., Mortensen, E. L., Gottlieb, D., & Smith, L. (2002). A new
‘‘advanced’’ test of theory of mind: Evidence from children and adolescents with Asperger syndrome.
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Kana, R., Keller, T., Cherkassky, V., Minshew, N., & Just, M. (2006). Sentence comprehension in autism:
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autism and pervasive developmental disorders (2nd ed., pp. 94–122). New York, NY: Wiley.
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emotion recognition to students with Asperger syndrome: A pilot study. Remedial and Special Education,
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Lindner, J. L., & Rosen, L. A. (2006). Decoding of emotion through facial expression, prosody and verbal
content in children and adolescents with Asperger’s syndrome. Journal of Autism and Developmental
Disorders, 36, 769–777.
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pictorial reasoning between high-functioning autism and Asperger’s syndrome. Journal of Autism and
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Schultz, R. T., Gauthier, I., Klin, A., Fulbright, R. K., Anderson, A.W., & Volkmar, F. (2000). Abnormal
ventral temporal cortical activity during face discrimination among individuals with autism and Asperger
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Case 8 Arthur Watson Won’t or Can’t: a Case of Mistaken
Identity Intellectual Disability; Parent Denial; Academic and
Behavior Problems
Arthur, who was 15 years and 5 months of age, came to the interview accompanied by his mother and father.
Mr. and Mrs. Watson were requesting a psychological assessment of their son Arthur to determine whether
Arthur might have a learning disability. The parents were concerned that weak academic progress and lack of
behavior controls might be the result of frustration resulting from learning problems.
245
Arthur was delivered by cesarean section, 2 weeks post due date, weighing 8 pounds 3 ounces. The pregnancy
was reportedly normal with the exception of fluid retention, which was monitored over the course of five
ultrasound assessments as well as pelvic X-rays. Arthur was jaundiced at birth; however, this was treated and
he was released from the hospital within the normal time frame.
Developmental motor milestones were delayed: sitting at 8 to 9 months, walking at 16 months. Language
skills were also reported as delayed, and although he did say his first word at about 1 year, he reportedly did
not speak much in his initial years. Descriptions of infant behaviors revealed that Arthur was not
temperamental, nor was he overly active or colicky. Arthur experienced febrile convulsions, and he had a
history of earaches, ear infections, and impacted ears due to wax build-up. There were difficulties with bed-
wetting until Arthur was 11 years of age.
Family history reveals that Arthur is the oldest child in a family of three, having a younger sister (11 years)
and brother (8 years). Arthur’s siblings appear to be well adjusted both emotionally and academically. There is
no known history of psychopathology in the families of either parent. Arthur’s parents, Celia and Paul
Watson, met in college and have been in a stable marital relationship for almost 20 years. Celia works as a
counselor in a women’s shelter, and Paul works as a financial consultant for the government.
246
Previous Assessment Results/School History
Arthur has had an extensive history of previous assessments, and his initial investigation was conducted by a
developmental pediatrician when he was 3 years 8 months of age. At that time, Arthur presented with
articulation problems and developmental delays. An EEG was conducted and results were normal. The
recommendation was for enrollment in a nursery school program, and Arthur began attending a Montessori
program the next year. However, progress continued to be difficult and problems with aggression, overactivity,
and difficulty following directions made the transition to kindergarten problematic. Arthur’s behaviors
continued to be a concern with a high level of overactivity, aggressive responding, and poor ability to follow
directions. Arthur was reassessed by the developmental pediatrician at 5½ years of age. On this occasion,
Arthur presented with “silly” behaviors and appeared distractible and agitated, although he was able to score
in the lower average range on a picture vocabulary test. The recommendation was for a classroom with
reduced pupil–teacher ratio and a trial of stimulant medication. However, the placement broke down and
Arthur’s parents were asked to remove Arthur from the kindergarten program midway through the academic
year. Apparently, Arthur’s behavior could not be maintained within the kindergarten program and
administrative staff felt that Arthur required more supervision than could be provided in the regular program.
Mr. and Mrs. Watson were becoming increasingly frustrated with the public education system and took
Arthur to a private psychologist for an assessment when he was 5 years 9 months old. Results of the Wechsler
Preschool and Primary Intelligence Test (WPPSI-R) revealed verbal functioning to be within the lower limits
of the lower average range, while performance skills were within the borderline range. Results from the picture
vocabulary test were identical to those obtained 6 months earlier by the developmental pediatrician, indicating
receptive vocabulary to be within the lower average range. The recommendations were in support of a trial
medication period, future assessment of central auditory processing, and the need for a structured behavioral
management program. History repeated itself, however, and Arthur’s continued behavioral outbursts resulted
in his eventual removal from the regular class program in the public school. As a result, the school board
recommendation was for future placement in a behavioral program. Parents appealed the decision, stating that
Arthur had attention-deficit/hyperactivity disorder (ADHD) and that his needs would be better served in a
program that addressed his learning needs. However, Arthur’s parents were unable to produce a clear
diagnostic statement to confirm that Arthur had ADHD, and Arthur had not responded favorably to
stimulant medication. Ultimately, the school board decision to place Arthur in a special program was upheld;
however, the designation of exceptionality was changed from “Emotionally and Behaviorally Disordered”
(EBD) to “Learning Disabled” (LD).
Over the course of the next 4 years, Arthur attended programs in several schools with limited success. At 7
years of age, he enrolled in a day treatment program affiliated with a local children’s mental health center.
While at the center, assessment of intellectual level was attempted; it was only partially completed, however,
due to lack of compliance on Arthur’s part. Although results of that intellectual assessment were inconclusive,
it was reported that subtest scores ranged from average (general information, block design) to very delayed
(oral math, visual sequencing). Arthur scored at the 8th percentile on a re-administration of the picture
247
vocabulary test, which was well below previous scores. It was suggested that Arthur’s outbursts might be
attempts to avoid academic difficulties and were likely developmental in nature. The following year, Arthur
was discharged from day treatment and placed in a primary learning disability program in a community
school. However, Arthur’s transition to the program was not successful and parents ultimately removed
Arthur from school; he was homeschooled the following year.
Parents enrolled Arthur in a local private school when he was 9 years of age; progress was minimal and the
school was forced to shut down due to financial reasons. For the next 2 years, Arthur returned to the public
school system and was placed in a Junior Special Learning Class. Despite continued problems with attention
and concentration, Arthur demonstrated improved work habits, and aggressive acting out was replaced with a
newly developed sense of humor. Arthur seemed to relate to his teacher in a very positive manner. However,
the following year, when Arthur was moved to a Senior Special Learning Class, previous difficulties with
aggression resurfaced and Arthur was removed once again and homeschooled. Parents hired a tutor to assist
Arthur during this period, and assessments conducted by the tutor revealed core academics to be at the first
percentile (kindergarten/Grade 1 level). Reassessment on the picture vocabulary test revealed receptive
language to be below the first percentile, and at 14 years of age, Arthur had a vocabulary that was
approximately equivalent to a child half his age (7 years 9 months).
Arthur was now becoming a teenager, and aggressive outbursts were becoming more threatening to his
parents and younger siblings. Out of desperation, parents sent Arthur to a private boarding school in upstate
New York. They were hopeful that the school would be able to provide the structure and behavior
management that Arthur required and that he would return from the school with many positive changes. A
review of reports suggests, however, that the facility was more of a prep school than one geared to special
needs and was highly inappropriate for Arthur. Parents have had little understanding of what transpired over
the year, since Arthur has refused to share any information about his school experience with his parents.
When Arthur returned home after 1 year in the program, he was more angry and resentful than ever.
Behaviors continued to escalate, and Arthur was beginning to use threatening gestures toward his parents and
physically and verbally abusive behaviors toward his siblings (kicking, swearing, hitting, pushing).
As a result of a recent violent outburst (Arthur chased his sister around the house with an electrical cord,
saying he was going to get her), parents sought temporary placement for Arthur in a residential facility for
youth with emotional and behavioral problems. At the time of the current interview, Arthur was being slowly
integrated back into his home on weekends.
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Reason for Referral
Arthur’s parents were desperate for any information that would help them with Arthur. They were requesting
a formal assessment to clarify the nature of cognitive functioning, academic levels, and any other information
that might assist in better understanding Arthur’s social-emotional and behavioral difficulties. According to
Mr. and Mrs. Watson, despite a number of previous attempts to assess Arthur’s functioning, to their
knowledge Arthur had not had a complete formal psychological assessment in the past.
During the interview, Arthur appeared highly agitated. He shifted his position in the chair continuously,
slouching down with his long legs dangling across the floor. At approximately 5 feet 10 inches tall, Arthur
towered over his parents when he stood up. Throughout the interview, Arthur would make grimacing faces,
mimic his parents’ comments, interrupt often, and correct his parents, especially his mother, in a loud and
mocking voice. When asked about the private school he had attended in New York, Arthur said that he hated
the school and he hated the kids at the school. In response to specific questions, Arthur was difficult to
understand, partially due to poor articulation and sound substitutions (“s” for “t”), but mostly because he
tended to be very tangential in his responses. Cluttered speech, a tendency to trail off at the ends of sentences,
and a propensity to make “silly voices” also rendered communication difficult to understand.
When asked if he knew why he was at the clinic, Arthur said that he was “too violent” sometimes and added
that lately he was “more bad than good.” He did seem remorseful, however, and said that he wanted to be
better. When asked if he might agree to take medication to help control his behavior and do better at school,
Arthur responded that he was prepared to try, if it would work. He added that things were very difficult now,
and he was getting into trouble a lot because of his temper. He said that he was also having trouble sleeping
and falling asleep. In response to a question about what concerned him most, Arthur said that sometimes he
did stuff that he wished he hadn’t but then it was too late. He spontaneously added that he did not have any
friends and that he hated his “zits” and wanted them to go away so he could get a girlfriend. He worried that
he would not be able to get rich and find a wife when he got older.
Arthur was seen for three assessment sessions. Behavior varied across sessions, with Arthur becoming more
vocal and volunteering more personal information as time progressed. However, Arthur was quite agitated
when he arrived for the third session and muttered an obscenity as his father dropped him off at the office.
When asked if he wanted to talk, he said that he just wanted to do his work with the psychologist for the day,
but then spontaneously began to discuss what had occurred. Arthur was of the impression that he would not
be able to go back to school because it cost too much money and that he would have to stay home and do jobs
all day. When he was reassured that parents and psychologist were working together to find out which school
he would be happiest at, he seemed to be very relieved and was eager to get back to the assessment. A fourth
assessment session was scheduled; however, further assessment was preempted when Arthur’s behavior again
escalated at home, resulting in admission to the crisis unit at the regional children’s hospital. On that
occasion, Arthur had threatened harm to his parents, sister, and eventually himself and was admitted to the
hospital for 1 month to allow for medication trials, observation, and behavioral stabilization.
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While in the hospital, Arthur responded well to a combination of sertraline and thioridazine, his behavior
stabilized, and he was discharged back to his home at the end of the month. A discharge planning meeting
was held prior to Arthur’s release from the hospital, and parents again voiced their frustrations with the
“system,” complaining that they had been given very little direction regarding future placements for Arthur.
Parents returned to the clinic to complete Arthur’s assessment and for assistance regarding future planning.
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Assessment Results
Arthur’s scores for all the assessment instruments that he completed and the scales completed by his parents
are available in Appendix A. The following is a summary of those findings. Information regarding specific
assessment instruments and guidelines for the interpretation of standard scores and T scores are available in
Appendix C.
The Wechsler Intelligence Scale for Children (WISC-V) was administered over three sessions to allow for
sufficient rapport building and to accommodate Arthur’s tangential response style. Spontaneous digressions
were frequent throughout the assessment session. Arthur’s effort was considered optimum, and although
anxiety and low frustration tolerance were evident, results were considered to be a valid index of functioning
levels. Although Arthur’s overall scores on the visually oriented tasks, Visual Spatial Reasoning (VSI = 69;
range 65–76) and Fluid Reasoning (FRI = 65; range 59–72), were superior to his score of 55 for the Verbal
Comprehension Index (VCI; range 51–62), the discrepancy was not significant. Therefore, Arthur’s full scale
IQ of 57 (range 53–64) is considered to be a good index of composite intellectual functioning. Scores for the
Processing Speed Index (PSI) of 54 (range 49–61) and Working Memory Index (WMI) of 55 (range 51–62)
were similar to scores for VCI. Overall intelligence was below the 1st percentile. Arthur is cognitively
challenged and his abilities range within the range of mild intellectual disability. Developmentally, cognitive
skills are similar to a child several years his junior, at approximately 8 to 8½ years of age. Results suggest a
global and pervasive cognitive deficit rather than any specific learning disorder. Arthur is a concrete thinker,
and transferring information between different environments is challenging for him. Verbal expression is weak
and vocabulary knowledge is limited. Arthur often uses words inappropriately, familiar with the word but not
completely grasping the meaning. His comprehension improves if visual aids (pictures) are added.
Academically, according to the Wechsler Individual Achievement Test (WIAT-III), Arthur’s academic
performance was commensurate with his intellectual functioning, and Arthur scored consistently at the Grade
1 level across the core academic areas. He demonstrated a relative weakness in numerical operations and a
relative strength in spelling.
Parents completed the Adaptive Behavior Scale (ABS-S:2) and Vineland Adaptive Inventory. According to
the ABS-S:2, Arthur was rated at age level in all areas of Personal and Personal-Social Responsibility.
Similarly, parents also rated Trustworthiness and Social Engagement within the norm. Language
Development, Hyperactive Behaviors, and Disturbing Interpersonal Behaviors were rated as minor problems.
Ratings on the Vineland Interview were consistent with the ABS-S:2 and placed Daily Living Skills and
Socialization within the normal range for his age and Communication Skills at a low average level. Caution
was advised in interpreting overall adaptive functioning using the scores from the parental assessments, which
evaluated his behavior in an environment of high familiarity (home, high predictability, highly structured) and
offered situations with few external distracters. It was suggested that adaptive functioning would deteriorate
considerably when he was in situations that were novel and unexpected offered many distracters, were
unstructured, and offered a wide variety of academic and social pressures.
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According to parent ratings on the Conners Scales and Achenbach (CBCL), Arthur demonstrated significant
problems in areas of Conduct (T = 96), Learning (T = 71), Impulsivity (T = 68), and Anxiety (T = 68).
Further Assessment: Psychiatric Consult.
A psychiatric referral was initiated to assist in the monitoring of Arthur’s medication following his release
from the hospital. Resulting from the psychiatric consult, the possibility of Tourette’s disorder was also raised
due to evidence of some complex motor and vocal tics with associated mimicry. During his interview with the
psychiatrist, Arthur admitted that although he sometimes would engage in swearing, facial grimaces, silly
voices, and mimicry on his own accord, at other times, he had difficulty controlling these behaviors. As a
result, the psychiatrist suggested that Tourette’s disorder might also be a possibility.
Although recent evidence of depression with aggressive behavior patterns had responded to a combination of
sertraline and thioridazine, the psychiatrist recommended that the family slowly wean Arthur off the
thioridazine, which was causing excessive sedation. The psychiatrist indicated that future pharmacological
treatment might include an SSRI (sertraline or Prozac) in combination with stimulant medication. Other
areas to be addressed would include possible risperidone for the motor tic disorder and/or lithium to reduce
aggressive behavior.
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The concept of intellectual disability (formerly known as mental retardation) has evolved over the course of
history. Seguin, the founding father of the American Association on Mental Retardation (AAMR),
established the association in 1876 to advocate for the rights of individuals who had mental deficiencies
resulting from arrested development. By the late 1950s, there was growing discontent with the practice of
determining an intellectual disability on the sole basis of intelligence testing (IQ below 85; one standard
deviation below the mean), and criteria were expanded to include the need to establish accompanying deficits
in adaptive functioning, in addition to onset in childhood (initially before age 16). Twenty years later, criteria
were further narrowed to include an IQ level that was two standard deviations below the mean (IQ 70), and in
1992 the AAMR increased the age of onset to include onset prior to age 18 (American Association on Mental
Retardation [AAMR], 1992), which was also the age of onset in the DSM-IV-TR (APA, 2000).
In January 2007, the AAMR changed its name to the American Association on Intellectual and
Developmental Disabilities (AAIDD) to address concerns with the use of the label mental retardation for
individuals with intellectual disabilities (AAMR 2006). The switch from mental retardation to intellectual and
developmental disability was instituted to better conform to terminology used in Canada and Europe and to
focus on the mission of AAIDD, which is to assist and advocate for those with developmental disabilities,
such as autism, which often coexist with intellectual disabilities. The newly revised DSM-5 (APA, 2013) has
also changed the name of the disorder to one of intellectual disability (intellectual developmental disorder).
The DSM–5 criteria for intellectual disability remain unchanged from the previous version of the DSM, with
onset during the developmental period and including significant deficits in intellectual (IQ score of 65–75)
and adaptive functioning. However, the DSM-5 no longer classifies the severity of intellectual disability by
range of intellectual functioning (mild, moderate, severe, profound), as was the previous methodology;
instead, specifiers of mild, moderate, severe, or profound can be used to identify levels of support needed for
adaptive functioning in three domains: conceptual (academic functioning), social, and pragmatic (life skills).
At least one of the three domains must be sufficiently impaired (requiring support to adequate functioning) to
meet criteria for diagnosis of intellectual disability.
There are currently three different systems that can be used to classify intellectual disabilities in North
America: the DSM-5 (APA, 2013), AAIDD (2009), and the educational system (IDEA, 2004). A more
detailed discussion of the similarities and differences among these systems regarding the classification of
intellectual disabilities is available in Appendix B. In addition to revealing impairment in intellectual
functioning, deficits in adaptive functioning have also been a critical component of a determination of
intellectual disabilities for both systems, although the systems vary in how they define adaptive behaviors.
Regarding the case of Arthur, in addition to deficits in mental capacity and adaptive behavior problems, there
was also concern that Arthur might demonstrate symptoms of Tourette’s disorder. According to the DSM-5
(APA, 2013), Tourette’s disorder is a tic disorder classified under neurodevelopmental disorders that is
characterized by uncontrollable tics (rapid, nonrhythmic movements or vocalizations) that are evident in
multiple motor and at least one vocal tic. The course of the disorder is unpredictable, with many youth
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outgrowing the disorder in adulthood.
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Behavioral Interventions and Treatments
Treatments and interventions for children and adolescents with mental impairments often focus on two broad
areas:
1. intellectual-adaptive deficits, and

2. associated behavioral-emotional problems (Kronenberger & Meyer, 2001).
Evidence-based treatment for associated behavioral difficulties will be discussed first, followed by a discussion
of the efficacy of educational treatments.
The Behavior Management of Behavioral and Emotional Problems

The prevalence of challenging behaviors among children and youth with intellectual disabilities has been
estimated at approximately 7% (Kiernan & Qureshi, 1993), although rates for children attending special
schools have been reported to be as high as 22% (Kiernan & Kiernan, 1994). Negative outcomes for youth
with impaired cognitive functioning and challenging behaviors include physical risk to the youth or peers and
increased risk of isolation, abuse, and other forms of inappropriate interactions with peers (Emerson, 2001),
which increases the long-term risk of developing serious psychological difficulties (Deater-Deckard, 2001;
LaFontana & Cillessen, 2002). Furthermore, in their study of child and adolescent impressions of those with
challenging behaviors, Byrne and Hennessy (2009) found that similar to their average-functioning peers,
children and adolescents with intellectual disabilities are less willing to engage in shared activities with peers
who display challenging behaviors.
Treatment programs developed to assist with behavioral and emotional problems in populations with
intellectual disabilities have largely used methods of functional analysis based on applied behavior analysis
(ABA). ABA has been defined as “the extension of experimental methods to applied settings” (Kazdin, 1994,
p. 25). Behavior management programs can be simplistic (using praise to increase or ignoring to decrease
behaviors) or very complex (contingency-based programs). Behavior management techniques are based on
sound empirical support that has been documented in countless studies (for review, see Lipsey & Wilson,
1993) and journals devoted specifically to behavioral research: Behavior Modification, Journal of Applied
Behavior Analysis, Behavior Therapy, and others. However, successful behavior management programs require
more than a knowledge of the mechanisms of behavioral change. They also require an understanding of how
the child’s different situational contexts contribute to the problem behaviors (Phares, Compas, & Howell,
1989).
Behavioral treatment programs can be developed to either increase deficit behaviors or decrease behavioral
excess. Although it is always preferable to increase deficit behaviors, such as targeting increased compliance
through the use of positive reinforcement or negative reinforcement, there are times when it is necessary to
focus on reducing a behavioral excess (e.g., highly aggressive behavior) through the use of punishment or
extinction. Behavioral principles of schedules of reinforcement, shaping behavior and behavior chaining,
secondary rewards, and token economies have all been demonstrated as effective methods for managing
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behavioral change. Empirical studies have emphasized the need to assess baseline behavior rates and to
monitor the effectiveness of programs (Jensen, 1988) and time-out techniques (Solnick, Rincover, &
Peterson, 1977).
Behavioral programs can benefit from the use of an empirical approach to select target behaviors (Weist,
Ollendick, & Finney, 1991). For example, research has investigated how to create a reinforcer hierarchy
(Christian, 1983); the selection of reinforcers for specific populations, such as adolescent populations
(Reynolds, Salend, & Beahan, 1989, 1992); and techniques to promote generalization of outcomes across
situations (Rutherford & Nelson, 1988; Stokes & Baer, 1977). The efficacy of using contingency management
systems or token economies to improve behavior in children and adolescents has been demonstrated across
many settings (Wielkiewicz, 1995). Children can be motivated to increase desirable behaviors by earning
tokens or coupons to be traded in for concrete reinforcers. Contingency programs to increase deficit behaviors
can be used in the regular classroom (Brantley & Webster, 1993), special classroom (Kratochwill, Elliott, &
Rotto, 1990), and home (Clark, 1985). Contingency programs can also be developed to reduce excess
behaviors. Programs that target reducing behaviors function on a response cost basis, where children lose
tokens, coupons, and the like when they demonstrate the undesirable behavior.
Response cost programs can also be effectively introduced in the regular class (Rapport, Murphy, & Bailey,
1982), the special class (Proctor & Morgan, 1991), and the home (Little & Kelley, 1989). Other approaches
to improving behavior in populations with intellectual disabilities have included the use of relaxation training
(Cautela & Groden, 1978; McPhail & Chamove, 1989) and functional equivalence training or teaching of
replacement behaviors (Horner & Day, 1991), while behavior reduction can involve techniques such as
performing restitution or undoing/overcorrection (Azrin & Besalel, 1980). Behavior programs for training in
adaptive skills and social behaviors have also demonstrated successful positive change (Embregts, 2000).
Parent training programs have also been demonstrated to be an effective component for treatment of children
with intellectual and other disabilities (Handen, 1998), and inclusion of parent treatment components can be
superior to treatments conducted in clinics alone (Koegel, Schreibman, Britten, Burke, & O’Neill, 1982).
Parent training programs have been proven effective whether administered in groups (Harris, 1983) or
individually (Clark & Baker, 1983). Parent training programs can also be helpful in increasing compliant
behaviors in the home (Forehand & McMahon, 1981).
Positive behavior support (PBS) is a theoretical framework for understanding problem behaviors that was
primarily derived from ABA. The PBS approach emerged in the mid-1980s amid increasing concerns
regarding the use of aversive techniques to control behavior (Will, 1999) with the goal of extending programs
from the laboratory and clinics into the broader community at large (Horner et al., 1990).
Currently, PBS interventions encompass social, behavioral, educational, and biomedical science drawing on
evidence-based practices conducted in naturalistic settings (Clarke & Dunlap, 2008; Gable, Hendrickson, &
Van Acker, 2001; Scott et al., 2005) to improve quality of life and reduce problem behaviors (Carr et al.,
2002). PBS has attempted to integrate the ABA framework of instrumental/operant learning (evident in
principles of reinforcement, contingency management, stimulus control, shaping, fading, prompting,
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functional equivalence, generalization, and maintenance) with information available from other disciplines
(Cooper, Heron, & Heward, 2007). As a result, PBS creates a cross discipline view of behavior that
encompasses pharmacological, genetic, neurodevelopmental, and psychological approaches that can assist in
the development of a more comprehensive view of the range of factors that can influence the development of
challenging behaviors and the interventions that can help alleviate them (Carr & Owen-DeSchryver, 2007;
Eisenberg et al., 2005).
PBS has moved away from the tendency to emphasize immediate environmental contingencies in favor of a
broader look at systems-level factors that may be influencing behaviors and potential outcomes (e.g., the
classroom, the family). There has also been increased focus on strategies for prevention, intervention, and the
importance of developing positive replacement behaviors to accompany the reduction of problem behaviors
(Dunlap, Carr, Horner, Zarcone, & Schwartz, 2008). In a recent meta-analysis of interventions for
challenging behaviors, Harvey, Boer, Meyer, and Evans (2009) found that behavioral interventions, especially
when developed through functional behavioral analysis, significantly reduced challenging behaviors, and that
teaching replacement skills for problem behaviors was highly effective.
Educational Programs: Academic Achievement and Intellectual-Adaptive

Deficits
Fundamental to IDEA (Individuals with Disabilities Education Act, 2004) is the assurance that all children
with disabilities in the United States receive a free and appropriate public education (FAPE) in the least
restrictive environment. The IDEA also outlines procedures that should be followed by special education
personnel, including obtaining informed written consent of the parents prior to assessment and the need to
develop an individualized education program (IEP) for each disabled child. The IEP serves as the child’s
educational plan and outlines needs for meeting the child’s educational goals through assessment,
intervention, and monitoring of progress during annual reviews (see Appendix B for a more detailed
discussion of IDEA, 2004). Controversy concerning the validity of special education placements evolves
around two important questions:
1. Does placement in special education programs benefit students with special needs?
2. Should placements be categorical (separate placements for different disabilities) or noncategorical, for
example, all children with special needs can benefit from the same resources?
With regard to issues of placement, IDEA (2004) focuses on providing education for children with disabilities
in the least restrictive environment such that special education programs are complemented by mainstreaming
(the integration of disabled children into the regular class program) for as much time as possible. Students
who qualify for special education also are provided with related services (speech language, occupational therapy,
etc.) if these are needed. Most recently, the Regular Education Initiative has taken the position that full
inclusion, rather than mainstreaming, would be the best solution and that the needs of children with
disabilities would be best served by full-time placement in the regular or general education program.
Proponents of mainstreaming and inclusion frequently cite results from the Carlberg and Kavale (1980) meta-
analysis comparing general with special education. Results of this analysis suggested that students with mild
257
intellectual disabilities (MID) generally obtained better outcomes in regular programs. It has further been
argued that placing students with MID in contained special classrooms can actually place them at a
disadvantage, isolating them from normative role models (Ysseldyke, Thurlow, Christenson, & Muyskens,
1991).
More recently, Hocutt (1996) reviewed more than 100 studies conducted over the last 25 years and suggests
that claims of the efficacy of special education placement versus regular placement are difficult to substantiate,
since much of the research is flawed methodologically or outdated with respect to today’s classification
systems. On a more positive note, Hocutt suggests that it is the intervention program (intensive individualized
instruction and monitoring of progress) rather than the placement that predicts success for students with
MID. The question remains, however, whether adequate monitoring and intervention are more likely to occur
in a class with smaller enrollment.
In response to the second question, regarding whether different disabilities warrant separate types of special
education programming, early reports by Hallahan and Kauffman (1977) suggested that research did not
support separate special education services for the major high-incidence disabilities: specific learning
disabilities (SLD), mild intellectual disabilities (MID), or emotional and behavioral disabilities (E/BD).
Further support for noncategorical special education was indicated by later research (Reschly, Tilly, &
Grimes, 1999; Ysseldyke & Marston, 1999) published at a time when the need for cost-saving endeavors was
increasing. More recently, Sabornie, Cullinan, Osborne, and Brock (2005) conducted a meta-analysis of 58
studies to determine whether separation of students into high-incidence categories (SLD, MID, E/BD) was
meaningful based on research examining three dependent variables that are necessary for eligibility for special
education placements, including intelligence (IQ), academic achievement, and behavior. Results of their study
support the retention of different disability categories, especially for students with MID, based on significant
differences between students with MID and the other two groups in areas of IQ; academic achievement; and
the need for specific emphasis on functional and life skills, personal care skills, communication ability, social
skills, and transition-oriented planning in their educational programming (p. 55).
Mortweet (1997) studied the effect of classwide peer tutoring of MID students within the regular program;
results revealed positive gains academically and socially, although social interaction did not generalize to other
settings outside the programmed instruction. However, Gottlieb, Alter, and Gottlieb (1991) found that
mainstreaming did not have a positive impact on the academic achievement of children with MID, while
Taylor (1986) cautioned that mainstreaming students with MID without attention to direct training in areas
such as social skills can have detrimental effects. A comparison of 34 mainstreamed EMR students with a
sample of 34 nonimpaired peers, matched for sex, race, and grade level (Grades 3 through 6), revealed that
children with MID reported feeling more lonely and dissatisfied with their social relationships in school than
their non-MID peers. Lack of social awareness and inappropriate social behaviors may result in students with
disabilities not only having fewer friends but being actively rejected by peers (Farmer & Rodkin, 1996;
Nabasoku & Smith, 1993). Furthermore, there is some evidence that students with MID who are
mainstreamed may be stigmatized, avoided, and marginalized in that setting (Dovidio, Major, & Crocker,
2000), while students in segregated settings may be protected from being stigmatized (Todd, 2000). However,
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the potential negative impact of living within such a protective environment might be that they have more
limited awareness of their potential, since their only comparables are other students with intellectual
disabilities (Finlay & Lyons, 2000; Todd, 2000). In summary, comparing oneself to similar peers may be
protective of self-esteem, while comparing oneself to nondisabled peers may lower one’s self-esteem (Crabtree
& Rutland, 2001).
Cooney, Jahoda, Gumley, and Knott (2006) studied 28 students attending mainstream schools and 32 who
attended a segregated school (mean age 15.6 years; mean IQ = 62). While both groups of students reported
similar levels of stigmatization beyond school (in the community), the students who were mainstreamed also
reported stigmatization at school by their nondisabled peers and perceived problems with support from
teachers and staff who they felt were not sympathetic to their learning needs. There was no difference
between the two groups with respect to future goals and the likelihood of meeting these goals.
Although there has been attention paid to the possible positive and negative social implications of integration
within the regular class program, there has been less attention paid to the longer term and vocational
implications of educational preparation for youth with MID. Polloway, Patten, Smith, and Roderique (1991)
contend that the educational curriculum for the population with MID should focus on community
integration, starting as early as elementary school. The Hawaii Transition Project (Patton, Beirne-Smith, &
Payne, 1990) provides an example of such a program geared to providing a bridge from school to community
functioning. The National Longitudinal Transition Study-2 (Wagner, Newman, Cameto, Garza, & Levine,
2005) revealed that students with MID demonstrate persistent underemployment, with only 52% of
postgraduates with MID engaged in postgraduate activities, such as employment, training, or further
schooling (Wagner, Newman, Cameto, Levine, & Garza, 2006). Hartman (2009) outlines a step-by-step
approach to creating a community-based treatment program for students with intellectual disabilities that is
focused on the integration of resources in schools, business partnerships, and training in self-determination
and advocacy issues.
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Post-Case Questions
1. Would Arthur’s profile warrant a diagnosis of intellectual disability? Discuss this question from the perspective of each of the
following classification systems: DSM-5 (APA, 2000), AAIDD (American Association on Intellectual and Developmental
Disability), and the educational system (IDEA, 2004). Information available in the case study and Appendix B will provide the
framework for answering this question.
2. Lalli, Kates, and Casey (1999) investigated the rates of problem behavior relative to academic demands in two boys with mild
intellectual disability (MID). Results revealed that aggression was highest during spelling instruction and that problem behavior
was driven by negative reinforcement. Changes in instructional format produced a reduction in negative behaviors.
a. Explain how these findings might be relevant to Arthur’s case. How might a functional behavioral assessment of Arthur’s
behaviors have helped with programming? Based on information in the case presentation, develop a likely functional
behavioral assessment for Arthur’s disruptive classroom behaviors outlining possible behaviors (suggest possible examples of
disruptive behaviors), precipitating conditions (situations that trigger the behavior), consequences of behavior (situations/events
that follow the behavior), and functions of behavior (underlying processes/motivations that sustain the behavior).
b. Show how you would conduct a similar assessment to determine the extent to which behaviors were also occurring in other
contexts: playground, after-school program, home.
3. The psychiatrist felt that Arthur may also have Tourette’s syndrome. How common is it for individuals with intellectual
disabilities to have Tourette’s syndrome and how might this impact his overall functioning, socially, behaviorally, and
academically? Would Arthur also meet criteria or ADHD, given the information provided in the case and in the extended results
section in Appendix A?
4. Given the research on benefits versus negative outcomes of children with MID receiving instruction in special education versus
regular education classes, what would you recommend for Arthur based on his profile and past history? Support your comments
with citations from the case and the research.
5. Patricia McGill Smith (2010) published an article that is particularly relevant to Arthur’s case because it explores the many feelings that
parents experience when they have been told that their child has a disability. The article, which was originally published on the
NICHY website, can still be found at the following link: https://www.eastersealswaiver.com/study_guides/not_alone.pdf. In the
article, Smith describes feelings of shock, denial, fear, grief, guilt, confusion, powerlessness, disappointment and rejection (of either the
diagnosis or the child). Read the article and map the feelings on to the responses of Arthur’s parents to a history of information received from
assessments and failed interventions. Reflect on whether the system did not provide enough support and, if so, how the parents could have
been better informed and their expectations managed throughout. What would you do to assist these parents and Arthur at this time?
Suggested Individual or Group Presentation Activity:

6. You have been invited to provide feedback to the school district regarding Arthur’s assessment, at an administrative meeting called
to decide placement options for Arthur within the public school system. Given his test results, you suggest he have a specialized
placement where he can receive sufficient attention to his learning, behavioral, and emotional needs. In addition to an IEP, you
are also recommending a functional behavioral assessment be conducted by school personnel so that they can develop a behavioral
intervention plan for use in the school. What goals and objectives would you want to see as part of his IEP? Would you
recommend other related services, and if so, what would the nature of those services be?
plan that would best meet Arthur’s needs?
260
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Case 9 Brian Williams My Name Is Williams, Too Williams
Syndrome
Brian came to the clinic accompanied by his grandmother. At 9 years 7 months of age, Brian was a walking
paradox. On the one hand, he was a highly sociable youngster and showed a maturity in caring and empathy
for others. His welcoming and friendly demeanor should have set the stage for a host of social relationships.
However, he experienced extreme problems with social functioning. Despite a keen love of people and a
strong desire to have friends, Brian could also appear anxious, experience numerous peer difficulties, and then
withdraw socially. Brian’s original assessment results from testing conducted when he was 4 years old and
again when he was 6½ have revealed wide variations in patterns of strengths and weaknesses for intellectual
and adaptive functioning. An update was requested to evaluate interim gains and to reexamine his profile of
strengths and weaknesses, especially in the social arena, and to provide intervention strategies to assist with
social functioning. Academically, Brian continues to struggle, especially with very basic math concepts, while
language-based functions are an area of relative strength. A reevaluation was requested to better identify the
nature of his difficulties to assist with recommendations for interventions in the future.
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Brian’s paternal grandmother accompanied him to the clinic and provided the information for the family
background and developmental history for this African American family. Brian’s mother gave birth to Brian
when she was only 17. The delivery was by cesarean section due to fetal distress. Brian was a full-term baby,
born at approximately 41 weeks gestation, and weighing 7 pounds 11 ounces. The Apgar score was 9 for
entries recorded at 1 and 5 minutes. Brian’s biological father was 20 years old at the time of his birth. Brian
currently lives with his father and paternal grandparents and has visitation with his mother two or three times
monthly. Currently, his father works as a machine operator and his mother is a cashier.
Motor milestones were achieved on schedule and he was able to roll over at 3 months, sit at 6 months, and
walk at 11 months. Despite achieving these gross motor milestones, fine motor skills have always been
problematic, and he has experienced problems with writing, buttoning his clothes, and tying his shoes.
Although speech was initially delayed, not saying his first word until his first birthday, once he began to
combine words and produce two-word utterances, his language skills seemed to improve dramatically.
Currently, language is an area of strength for Brian, while fine motor skills continue to be an area of
significant weakness.
When discussing his general health and outlook, his grandmother said that Brian started out as a very fussy
and colicky baby who had a lot of problems swallowing and keeping his food down, and falling asleep and
staying asleep. However, when he outgrew that stage, he developed into a very agreeable and happy youngster.
In fact, he was so overly social that she was afraid he would go away with anyone. He seemed to be totally
focused on people, their faces, and their voices, from the time he could walk, and teaching him about
“stranger danger” continues to be a worry. However, even though he is drawn to people, he is also anxious
enough that she believes he would not really go away with anyone. He has many fears and often can be clingy.
He can also worry about the strangest things. Grandmother recalled that after hearing a story about sink holes
on the news, Brian was worried that he would be swallowed up if a sink hole happened in his yard or the
school yard. Once he starts worrying about something, she said, it takes considerable patience to have him
stop dwelling on it. There are times, she admitted, when he can be oppositional at home, but his teachers
really do not see that behavior at school. For the most part, his teachers describe him as a pleasant child who
tries to be accommodating. However, grandmother and teachers have been puzzled about why there is such a
disconnect between his social desires and the outcomes of his relationships, and to this point, no one seems to
be able to shed any light on the subject. His health has been good; however, he was diagnosed with a heart
murmur last fall, which is being monitored. In view of this, the pediatrician has recommended that he lose
weight, although his grandmother does not think he needs to. He was prescribed glasses this spring for
strabismus and unlike most kids who balk at wearing glasses, he was delighted because the preacher wears
glasses.
When asked about his personality and strengths he might have, his grandmother responded with a huge smile
and said, “That boy is gonna be a preacher some day!” She said church is one of his favorite activities and he
loves to sing the hymns, which he has committed to memory. He is also able to recite the sermon when they
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get home and often she finds Brian standing in front of the mirror preaching the sermon that they have just
heard and using the exact emphasis on the words, sounding just like the preacher. The choir master has said
that Brian has “absolute pitch,” a rare gift, especially in one so young, without any formal training. She was
very proud of Brian’s performance in church last Sunday when he sang a duet in front of the congregation that
was flawless, and he had absolutely no sense of stage fright. Grandmother also mentioned that despite his gift
and love for music, he has very sensitive hearing and will sometimes overreact to sounds (especially high-
frequency sounds) by covering up his ears. Brian did have a middle-ear infection (otitis media) a few years ago,
but it has not happened since. She had mentioned this overreactivity to sound on the last visit to the
pediatrician, who has scheduled an appointment with a hearing specialist. Grandmother wondered why Brian
has such a short attention span for school subjects (he is very distractible at school) but he can listen to music
for a long time and doesn’t miss a musical note.
She said that she has tried to get him to slow down on the sermons, but he seems to be obsessed and often
just goes on whether she likes it or not. Although he has tried to bring this behavior into the classroom, it was
quickly discouraged, as disruptive, and he has complied with his teachers’ requests.
Brian has been assessed twice in the past, and results have been inconclusive, with little explanation of why his
profile is so extreme or to help explain his problems in the social area. The following is a summary of those
findings.
Brian was seen by the child development center prior to his entrance into the kindergarten program, just
before his fifth birthday. At that time, scores on the Differential Abilities Scale (DAS) revealed the following
standard scores: Verbal Cluster of 70 (range 70–87) and Nonverbal Cluster of 67 (range 61–72). General
Conceptual Ability was a standard score of 65. The Spatial Cluster was not reported. Scores on the Bracken
Basic Concept Scale (BBCS-R) revealed significant delays in conceptual development, with an overall
standard score of 63 (1st percentile), equivalent to an age score of 2 years 6 months at a chronological age of 4
years 10 months. The evaluator noted, however, that there was significant variability in his conceptual skills,
with significant weaknesses noted for conceptual skills in areas of Direction/Position and significant strengths
noted in concepts related to Self/Social Awareness. Grandmother completed the Vineland Adaptive Behavior
Scales, which resulted in an overall Adaptive Behavior Concept of 69 (3 years 4 months). Strengths were
noted in areas of Socialization (SS = 76; 3 years 0 months), Communication (SS = 76; 3 years 3 months), and
Daily Living (SS = 86; 4 years 1 month). A significant weakness was evident in Motor Skill Development (SS
= 61; 3 years 1 month).
Brian was seen in the child development clinic, again when he was 6 years 6 months of age. At that time, the
Stanford Binet 5 was administered. His overall full-scale score was 67 (range 60–75), with a standard score for
Verbal Reasoning of 72 and Nonverbal Reasoning of 66. Overall Visual Spatial Reasoning was a significant
weakness (SS = 59), while Working Memory for auditory information was a relative strength (SS = 12).
Academically, according to the Woodcock Johnson Test of Achievement (WJIII), he was functioning at the
following levels: Broad Reading (SS = 86), Broad Math (SS = 69), and Broad Written Expression (SS = 85).
As a result of his assessment, it was recommended that physical therapy be added to his services for “awkward
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gait” and fine motor problems. Brian was already receiving occupational therapy.
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Reason for Referral
When asked what one thing she would like to find out about Brian from the current assessment, his
grandmother said, “To finish the puzzle.” She explained that although he had been assessed twice before, no
one could provide any “name” for his condition or explain why he behaves the way he does and how to help
him. She said that he is becoming increasingly frustrated socially, and she is afraid that he will begin to
withdraw into his fantasy world about being a preacher. She just wanted him to have fun with friends and
wanted to know how to help.
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Assessment Results
When Brian entered the room, he presented as a child who looked much younger than his 9½ years. He had a
short stature, and his facial features were distinct with pronounced eyes, puffiness around the eyes, a short
nose with a broad tip, and large ear lobes. His cheeks were full and filled with a wide smile. Yet his features
seemed almost top heavy, with a broad forehead and a jaw that was very narrow and slight. Although Brian
was very interested in meeting the psychologist, he was somewhat apprehensive and anxious, so his
grandmother sat with them for the first 5 minutes and then Brian was fine. Although he was cooperative
initially, he was very easily distracted and had a hard time remaining seated. He preferred to stand during
parts of the assessment and often shifted his weight from side to side. When asked about his likes and dislikes,
Brian said music and “preaching” were his favorite things. As for dislikes, Brian said that he hated broccoli,
because it tasted like “sand and rocks,” and he also didn’t like surprises because they were scary. When asked
what else was “scary,” Brian said loud noises, especially fire alarms, and that it was scary when another teacher
was in his class because his teacher was sick.
Responses to the Differential Abilities Scale (DAS:2) revealed an overall General Conceptual Ability Level
(GCA) of 70 (range 66–77), placing his functioning at the 2nd percentile. However, as had been found on
previous assessments, there was a significant discrepancy between ability levels in different areas. Whereas he
scored within the low average range for Verbal Reasoning (SS = 84), he scored within the extremely low range
for Spatial Reasoning (SS = 64). Nonverbal Reasoning was approximately midway between these two ranges
(SS = 72). Brian encountered extreme difficulty with both spatial tasks: recall of designs and pattern
construction. He encountered significant problems with design recall because of his very poor fine motor skills
and his inability to recall how the design parts fit together or their orientation in space. He could reproduce
some parts, but there was no relationship between them. Brian did not seem to be frustrated by the pattern
construction task; he just placed his blocks down on the desk and would then look at the psychologist to
indicate that he was done. He did not seem to understand that the blocks had to be turned to match the
direction of the picture or that there was a pattern that was to be constructed. This behavior pattern was in
sharp contrast to his skills on the verbal reasoning tasks, where he was able to provide very good definitions
for words and made good attempts at the verbal similarities; however, this task was more difficult for him due
to the abstract nature of the task.
Academically, scores on the Wechsler Individual Achievement Test (WIAT-III) revealed the following
standard scores and grade-level equivalents: Oral Reading Fluency (SS = 76; grade equivalent of 2.2), Reading
Comprehension (SS = 60; grade equivalent of 1.7), Math Problem Solving (SS = 54; grade equivalent of K.8);
Numerical Operations (SS = 60, grade equivalent of 1.0), and Spelling (SS = 63; grade equivalent of 1.5).
Given these results, Brian is achieving above the level expected, given his GCA (70) in Oral Reading Fluency,
however, all other scores are below the expected level. Math Problem Solving was significantly (16 points)
below his anticipated level of functioning.
Brian’s teacher and grandmother completed the Adaptive Behavior Assessment System (ABAS III), and the
discrepancy between scores obtained on this adaptive measure for the various areas were even more extreme
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than had been obtained in early administrations. Despite having an ability level for cognitive functioning that
places his reasoning ability around the 2nd percentile (GCA 70), ratings for Total Social Adaptation were
well in excess of this level and in the average range, as rated by his teacher (SS = 95) and grandmother (SS =
107). Also, in terms of the Practical Adaptive score (measuring community use, home/school living, health
and safety, and self-care), Brian scored in the average range (SS = 101) according to his grandmother, and just
below the average range (SS = 89) according to his teacher. However, in the area of Total Concepts (including
communication, functional academics, and self-direction), Brian was well below the range expected, given his
GCA. On this area, his grandmother rated him in the extremely low range with a standard score of 55, and
his teacher rated him with a standard score of 61. As can be seen, although his Overall General Adaptive
Composite for grandmother’s rating (SS = 80) and teacher’s rating (SS = 84) is a score that reflects overall
functioning in lower average range, it is based on a profile of abilities that are widely spaced apart.
Finally, Brian’s grandmother and teacher completed the Conners parent and teacher rating scales. Although
his teacher rated him as clinically significant in the area of inattention and in the at-risk range for
hyperactivity, his grandmother did not rate his behaviors on this scale as significant and did not report
significant concerns regarding the possibility of Brian having symptoms of ADHD.
Grandmother and teacher completed the Devereux Scales of Mental Disorders (DSMD), which revealed
significant attention problems, only on the teacher rating scales. However, grandmother and teacher ratings
did agree on the existence of significant symptoms of anxiety, especially endorsing fearfulness in many areas,
and endorsed several items relating to social intrusiveness (annoys others, talks too much, interacts with
strangers inappropriately, etc.).
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Summary of the Psychologist’s Findings/Impressions
Brian is a 9½-year-old boy who demonstrates a wide discrepancy between and within his intellectual and
adaptive functioning skills. Intellectually, although his overall functioning is low (2nd percentile), this
represents a composite score of three very different ability levels: a significant strength in Verbal Reasoning
(low average), a significant weakness in Spatial Analysis (extremely low), and a Nonverbal Reasoning Ability
(low) that is midway between these two levels. From an adaptive perspective, while he has obvious strengths
in social adaptation and a desire to make friends, he is currently not successful in maintaining any long-term
friendships. He has some obvious and possible “savant skills” in the areas of musical ability (pitch, tone, and
recall for lyrics and melodies) and can sustain attention for musical activities over a long period of time. On
the other hand, academically, his attention span is short and he is highly distractible and fidgety when
required to focus on academics in the classroom (or in the assessment situation). During the assessment
session, he was very restless and moved about constantly. He has acquired a good ability to decode and read;
however, this is likely due to his good memory for phonetic information. His reading comprehension and
written expression lag behind, likely due to cognitive deficits in dealing with more abstract applications of
language functions. Mathematical skills that can benefit from visual-spatial abilities are an obvious area of
weakness for Brian.
Brian’s physical features, including his short stature, distinctive facial features (broad forehead; wide eyes with
puffiness around the eyes; a short nose with a broad tip; full lips; wide smile; full cheeks; and small, receding
chin), his intellectual and adaptive profile, his musical ability, and his intense interest and desire for social
connectivity all suggest the possibility of a diagnosis of Williams syndrome (WS). Individuals with WS often
present as a paradox because they are drawn to social contact, and on the surface, due to strengths in verbal
skills, seem that they should be among the most popular children. However, deficits in processing cognitive
information may result in their inability to interpret the subtle nuances of social situations or to understand
the more complex social dynamics evident in visual-spatial processing (e.g., appreciating social space), and
they are likely to be rejected by peers as a result. Because of their empathy and sensitivity, however, this may
result in their becoming more apprehensive and anxious in social situations, and they may withdraw from
social contact. Since they are drawn to social contact, though, they may place themselves in this situation in a
repetitive basis, which may result in increased anxiety and depression in adulthood. Since the majority of
individuals with WS have cardiovascular problems, and especially in light of a heart murmur being recently
diagnosed, it is recommended that Brian receive a complete cardiology work-up. Also, since individuals with
Williams share many symptoms of ADHD, and given his behavior in the classroom and assessment setting,
further consultation with the family physician is recommended. Brian also has many fears and anxieties that
can be overwhelming for him at times, especially loud unexpected noises, like fire alarms. He also has a
tendency to dwell on things that cause him to be fearful, and it takes much convincing to calm him down.
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In the introduction to their book about Williams syndrome (WS), Semel and Rosner (2003) pose the
question, “How is it possible to conceptualize a group of children who test as though retarded, speak as
though gifted, behave sometimes as though emotionally disturbed, and function like the learning disabled?”
(p. 1). In essence, this summarizes some of the puzzling aspects of individuals with WS, a genetic
neurodevelopmental disorder occurring in approximately 1 in 7,500 births. While the disorder is most
commonly referred to as Williams syndrome in the United States, in Europe the disorder is often referred to
as Williams-Beuren syndrome (Morris, 2006a). There is a deletion on chromosome 7 (part of the
chromosome is missing), and although it occurs as a random genetic mutation, individuals with WS have a
50% chance of passing the gene on to their children (Bellugi et al., 2007). The deletion involves the elastin
gene (ELN), which is a major component of connective tissues, such as ligaments, lungs, heart valves, and
arteries, allowing them to expand and contract (Gosline et al., 2002). Approximately 80% of those with WS
will have some cardiovascular anomaly, while 95% will have developmental delay (Morris, 2006b). Individuals
with WS often exhibit early cardiovascular problems that may result in premature death (average life span of
50 years). Some of the more common cardiovascular difficulties include narrowing of the arteries,
hypertension, and strokes (Kaplan, 2006). In one study of individuals with WS, 75% were diagnosed with a
heart murmur at some point in their lives (Jones & Smith, 1975). Problems with ears and hearing include
middle-ear infections (otitis media experienced by 60% of children with WS) and ear pain or hyperacusis
(Klein, Armstrong, Greer, & Brown, 1990), often associated with heightened sensitivities to certain sounds,
often high-frequency sounds (Dykens, 2003; Einfeld, Tonge, & Florio, 1997; Van Borsel, Curfs, & Fryns,
1997). By late childhood, some children with WS will develop sensorineural hearing loss for high-frequency
sounds in one ear (Johnson, Comeau, & Clarke, 2001). There are also vision problems associated with WS,
such as hypopia, which occurs in 68% of those with WS (Winter, Pankau, Amm, Gosch, & Wessel, 1996),
and strabismus, which is likely in between 27% and 78% of the population (Olitsky, Sadler, & Reynolds,
1997). Infants with WS are often described as fussy and colicky, although the majority outgrow this in the
first year and become much more content and happy as toddlers (Levine & Wharton, 2000). However, many
children with WS have difficulty falling asleep and maintaining sleep (Einfeld et al., 1997), and they are more
likely to experience “restless leg syndrome,” periodic limb movements during sleep, than peers without the
disorder (Arens et al., 1998).
While many with WS will exhibit developmental delays, there is a wide range of IQ scores possible within the
WS population, from low average intelligence to severe intellectual disabilities. Mean IQ scores have been
reported in the 55 to 60 range (Mervis, Morris, Bertrand, & Robinson, 1999; Udwin, Davies, & Howlin,
1996). There are excellent strengths in verbal short-term memory (Udwin & Yule, 1991), and linguistic skills
are far superior to those with Down syndrome (Bellugi, Lichtenberger, Jones, Lai, & St. George, 2000);
however, Singer Harris, Bellugi, Bates, Jones, and Rossen (1997) found that the superiority of skills in those
with WS did not surface until after the initial accumulation of approximately 50 words. As children and
adults, despite overall limitations, intellectually they demonstrate remarkable skills in expressive vocabulary,
syntax, and semantics (Bellugi, Wang, & Jernigan, 1994; Udwin & Yule 1990). However, in individuals with
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WS, there are significant deficits in the visuospatial area, including tasks of visual motor integration evident in
difficulty with fine motor tasks such as handwriting and copying (Mervis, Robinson, & Pani, 1999).
According to Rourke and colleagues (2002), individuals with WS evidence processing deficits similar to those
of individuals with nonverbal learning disabilities (NLD). This is especially true for strengths in verbal skills
(yet obvious weaknesses in the subtle nuances of social pragmatics) and deficits in visual-spatial and visual
motor integration. Often there is evidence of remarkable musical ability both in the ability to produce absolute
and relative pitch (Lenhoff, 2006) and in memory for tone and lyrics, which may be related to their strong
phonological memory skills (Peretz & Coltheart, 2003).
In their study of social competence in individuals with WS, Rosner, Hodapp, Fidler, Sagun, and Dykens
(2004) found that compared to peers diagnosed with Down syndrome or Prader Willi syndrome, in a
situation of free choice activities, those with WS tended to gravitate toward activities that included musical
instruments, while they tended to avoid activities like puzzles that required visual-spatial skills. Occupational
problems that have been associated with adolescents and adults with WS include job interference due to
distractibility, social disinhibition and overfriendliness, and anxiety (Davies, Howlin, & Udwin, 1997). In
addition, deficits in visual motor skills required in many chores, such as bed making, and entry-level jobs, such
as assembly-line work, have also been identified as barriers to success (Dykens, Hodapp, & Finucane, 2000).
Individuals with WS are characteristically overly friendly and often can be socially inappropriate and
somewhat intrusive due to their trait of “social disinhibition” (Wang, 2006). Bellugi and colleagues (2007)
describe those with WS as demonstrating a “hypersociability, including overfriendliness and heightened
approachability toward others, combined with anxiety relating to new situations and objects and a difficulty
forming and maintaining friendships with peers” (p. 99). The researchers suggest that although they do not
see social situations as threatening, per se, their overly anxious nature may undermine their ability to
successfully connect their social perceptions with their social expression, resulting in an inability to successfully
engage in social encounters. Also, they seem to lack social pragmatics, such as the recognition of social group
membership, which can place them at a serious disadvantage and even risk, since they enthusiastically will
approach strangers and family members in the same manner. They are also prone to repetitive greetings,
unaware of social conventions, and may engage in incessant greeting behavior or use forms of address that are
overly familiar when greeting virtual strangers (Semel & Rosner, 2003).
Although children with WS can be anxious by nature, they do not respond to threatening faces like other
children do, as a result of unusually low activation levels in the amygdala, which is responsible for regulating
the fear response (Meyer-Lindenberg et al., 2005). Fifty percent of individuals with WS are diagnosed with
ADHD and generalized anxiety, while about 50% have specific phobias, especially fear of loud noises (Doyle,
Bellugi, Korenberg, & Graham, 2004; Klein-Tasman & Mervis, 2003).
Semel and Rosner (2003) identify six types of behavior problems that commonly occur in individuals with
WS: “fears and anxieties, distractibility and attentional problems, impulsivity, poor adaptability, low
frustration tolerance, and atypical activity” (p. 295), evident in such behavior patterns as restlessness, fidgeting
and stereotyped movements (squirmy or engaging in repetitive motor routines), wandering, overactivity, and
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hyperactivity. Individuals with WS also experience problems in regulating their emotions, which can result in
heightened responses and inflated emotional reactions to unexpected sights, sounds, or tactile stimulation.
Semel and Rosner (2003) suggest that inherent to their behavior problems are tendencies toward high
reactivity in the presence of low self-regulation.
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Intervention Programs
Medical management is an important component of planning and programming for children with WS.
Kaplan (2006) suggests that “optimal medical, educational and community support can help the child with
WS lead a fulfilling life” (p. 83). Physicians can consult the guidelines for managing WS produced by the
American Academy of Pediatrics (2001), while parents can also consult specialists in multidisciplinary clinics
that have been established throughout the United States for the treatment of WS. The multidisciplinary team
servicing the WS clinic would have personnel with expertise in such areas as cardiology, genetics,
developmental pediatrics, behavioral pediatrics, psychiatry, pediatric psychology, and neurology, as well as
access to physical, occupational, and speech therapies. According to Kaplan (2006), children should be
reevaluated in the clinic every 3 years.
Special education and related services would be an important aspect of the child’s programming on a day-to-
day basis. Because most of the children will require assistance with academics, special education programming
would be required, especially in areas that are more dependent on visual-spatial analysis such as mathematics,
and for assistance in understanding subject material that requires higher order processing, such as reading
comprehension, solving word problems, and written expression.
Related Services.
Physical and occupational therapy should be provided, if needed, for possible areas of support such as
awkward gait, handwriting, and fine motor skills.
Social skills training programs may be helpful to increase the ability to integrate social perceptions and social
expression, and to provide an opportunity to practice skills in an environment that minimizes anxiety.
A successful cognitive–behavioral intervention for reducing anxiety in children is the Coping Cat Program
(Kendall, 1994). The program is suited to children 7 to 16 years of age and has been used to treat several
forms of anxiety, including separation anxiety disorder, generalized anxiety disorder, and social anxiety
disorder. The program can be administered individually or in group settings (Flannery-Schroeder & Kendall,
2000) and focuses on the development of coping skills (first eight to nine lessons) and then on practicing
those skills in either imagined or in vivo (actual) conditions (last eight to nine sessions). An acronym
developed for the program acts as a memory aid for highlighting the four key steps in the process:
Feel frightened (recognition of physical symptoms that accompany anxiety)?

Expect the worse (recognition of negative self-talk)?
Attitude/Actions that can help (replace negative self-talk with positive coping comments)
Results and Rewards (self-monitoring, evaluation, and self-reward)
For adolescents and young adults with WS, concerns about completing chores and doing many entry-level
jobs such as assembly-line work that rely on visual-spatial skills can be assisted with the ongoing support of
job coaches (Dykens et al., 2000).
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Semel and Rosner (2003) suggest a number of interventions that can assist the behavioral problems of those
with WS. They suggest that techniques that draw on strengths of individuals with WS (e.g., verbal mediation,
stress reduction, environmental control) would all potentially benefit those with WS. The following is a
summary of some of the techniques that have been addressed by Semel and Rosner.
Fears and Anxieties.
In addition to methods already suggested (e.g., Kendall’s Coping Cat Program), Semel and Rosner (2003)
suggest teaching verbal mediation strategies and providing reassurance, role-play, explanations, and self-
instruction (self-statements to calm in times of stress) can all assist in reducing fears and anxieties. In addition,
providing a structured and predictable environment and minimizing alterations to schedules can also assist in
reducing anxiety. Teaching relaxation techniques for use in the presence of behavioral methods such as
systematic desensitization and imagined or in vivo practice to overcome feared situations in a step-by-step
manner can also be beneficial.
Learning and Distractibility.
Using direct instruction to focus on the task at hand and ensuring that instructions are repeated to check for
errors can assist with day-to-day performance in a number of areas, academically and socially.
Classroom Seating.
Seating close to the board and where the child can have eye contact with the teacher will assist focused
performance and reduce distractibility. Seating away from major traffic routes in the classroom can also
improve chances of success.
Medication.
To date, few studies have investigated psychopharmacology alternatives for individuals with WS for such
problems as anxiety, depression, and ADHD.
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Post-Case Questions
1. Individuals with Williams syndrome (WS) often meet criteria for intellectual disability. Given Brian’s assessment results and
symptoms as presented in the case study, would Brian meet criteria for an intellectual disability according to the DSM-5 (APA,
2013)? Would he qualify under IDEA (2004) for special education and related services? Support your answer with specific
references to the criteria (Appendix B may be helpful) and Brian’s assessment results.
2. There are several similarities and differences between individuals with WS and individuals with nonverbal learning disabilities.
Compare information from Brian’s case with that of Sandy Smith. What are the similarities and what are the differences in these
two cases?
3. Children with WS are often seen as the opposite of those with autism spectrum disorders. What are the similarities and
differences between the case studies of Brian and Dylan Bach?
4. As Brian’s therapist, how would you help him deal with his fear of loud noises? Develop a program that can be used in the home
and in the school.
5. Using Brian’s strengths, develop a program to help him feel more successful socially.
6. Suggested Individual or Group Presentation Activities:
You have been invited to provide feedback to the school regarding Brian’s assessment at a meeting where they will decide whether
Brian should receive Special Education and Related Services. If it is determined that he is eligible for services, what goals and
objectives would you want to see as part of his IEP? Would you recommend he receive related services, and if so, what would the
nature of those services be?
Prepare a script for role-playing each of the player’s parts in the school meeting mentioned above. Who do you think should be
plan that would best meet Brian’s needs?
281
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Case 10 Bradley Hunter Not Yet Diagnosed Neurodevelopmental
Symptoms
Bradley is an African American male who is 5 years 5 months of age and enrolled in the kindergarten program
at John Williams Elementary School. He is currently receiving services from the special education resource
teacher under the category of developmental delay. He also receives speech and language, as well as
occupational therapy, as related services. Reevaluation was requested to determine the extent of his delays
currently and the nature of his learning problems.
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Bradley is at risk for neurodevelopmental difficulties due to a history of prematurity and its complications.
Bradley’s mother provided the following information regarding his developmental history. Mother was 22
when she was pregnant with Bradley and reported that she did not smoke or drink during the pregnancy. She
was, however, involved in a car accident when she was 25 weeks pregnant and was admitted to emergency due
to vaginal bleeding. Throughout the remainder of the pregnancy, there were several incidents of vaginal
discharge. Bradley weighed 3 pounds at birth and was born at 28 weeks gestation. Apgar was 6 at 1 minute
and 7 at 5 minutes. Bradley was placed on a ventilator for 2½ weeks after birth because he suffered from
respiratory distress syndrome.
A tracheotomy was performed due to upper airway obstruction as Bradley was not getting enough oxygen. He
remained in the hospital until he was discharged, 120 days after his birth. While hospitalized, he developed
pneumonia several times. Two years ago, he returned to the hospital, where he had a laryngoscopy and
adenoidectomy in preparation for having the tracheotomy tube removed 2 months later.
Bradley’s motor and speech and language milestones have all been delayed, and Bradley did not begin walking
until he was 19 months of age. When he was 26 months old, he was seen at the Infant Care Clinic for
physical therapy and speech and language assessments. At that time, his expressive and receptive language
score was 18 months, while global language was 16 months. Physical therapy evaluation at that time revealed
that motor skills ranged from 14 months for stationary skills to 17 months for locomotion to 19 months for
object manipulation.
Due to the severity of his problems and pervasive delays, Bradley was seen in the Child Developmental Clinic
when he was 34 months of age. At that time, the Bayley Infant Scales (Bayley-2) were administered and
Bradley scored an age equivalent of 22 months, with a Mental Development Index (MDI) of 54. Mother was
interviewed and the Vineland Adaptive Behavior Scales were administered. Bradley scored in the following
ranges: Communication SS = 64 (16 months), Daily Living SS = 67 (19 months), Socialization Skills SS = 83
(24 months), Motor Skills SS = 70 (23 months), and the Adaptive Behavior Composite SS = 65 (21 months).
At 34 months of age, Bradley was in the process of being toilet trained; however, nocturnal enuresis was
occurring on a nightly basis. The examiner noted that although Bradley was almost 3 years old, his mother
reported that he was not yet able to drink from a cup or use a fork. He was, however, able to use a spoon and
drink from a sippy cup. During the interview with the psychologist at the clinic, Bradley’s mother described
him as being a highly active youngster who was impulsive and easily distracted. She also noted that he can be
very stubborn and aggressive, especially with his brother, whom he often fights with. He is difficult to manage
and is prone to throw temper tantrums when he cannot have his way.
Mother is now 27 and father is 30, and they both have some community college education. Mother said that
neither she nor Bradley’s father had any learning problems in school. Bradley has an older brother who is 8
years old who has significant developmental delays and receives special education services. Mother and father
are no longer living together, and Bradley lives with his mother, the maternal grandmother, an uncle, and his
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older brother. Bradley has not had any contact with his biological father since his birth. Several paternal
cousins have behavior problems and ADHD. A paternal aunt has an intellectual disability.
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Reason for Referral
It has been approximately 2 years since Bradley has had an assessment of intellectual and adaptive functioning.
Having the benefit of scores from his previous assessments will be helpful in understanding how Bradley’s
skills have developed since that time. There was a question as to whether Bradley might have symptoms of a
neurodevelopmental disorder, such as autism spectrum disorder (ASD), so a comprehensive assessment was
conducted to provide as much information as possible to assist with future planning.
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Assessment Results
Bradley was initially observed in the regular kindergarten classroom for a 30-minute observation period. At
the time, the class was engaged in determining the sequential pattern of a series of interlocking colored blocks
(independent seatwork), followed by a small-group interactive activity about community helpers.
During the first part of this observation period, Bradley dropped a block and he bent down to pick it up until
the teacher came over to see why he was not working. He then told the teacher that he could not work
because the block fell on the floor. The teacher instructed him to pick up the block and continue with the
sequencing task. This delay set him behind his classmates in completing the task. While he worked, he talked
out loud to himself in order to guide his selections (e.g., “blue, blue, black . . .) but then shortened the scheme
(“blue/black . . . blue/black), which resulted in completing the task incorrectly. He seemed excited about
completing the task (“I did it!”) and was not discouraged when the teacher noted that it was incorrect and he
set out to fix it.
Bradley seemed to be very aware of the class routines and followed the other children as they participated in
snack time and tidying up. Although he did not interact with the other children, he did seem to be observing
them and then would follow along and imitate what they were doing. After snack time, Bradley went to the
play mat and was joined by a couple of other children. He then made some strange guttural noises and faces,
which the other two boys repeated, until the teacher told the boys to stop imitating him. The final activity was
matching community uniforms to community/employment roles. Bradley was the only one in the group to
recognize the word “astronaut” and was very pleased to be able to dress the cut-out appropriately in the correct
uniform. Although Bradley demonstrated an ability to follow predictable routines, he also revealed an inability
to adapt if something unpredictable happened, such as dropping the block. Adaptive behavior deficits seemed
to be most pronounced in areas of social and pragmatic concerns.
The psychologist administered the Differential Ability Scales (DAS-2) and Bradley obtained the following
standard scores, placing his ability in the low average range: Nonverbal Reasoning Ability, SS = 87; Verbal
Ability, SS = 85; and Spatial Ability, SS = 83. Overall, General Conceptual Ability was a standard score of 81,
at the 10th percentile. Academically, his scores on the Young Children’s Achievement Test (Y-CAT)
revealed standard scores above his ability level in all areas except Spoken Language (SS = 79). Other academic
scores included General Information, SS = 90; Reading, SS = 100; Mathematics, SS = 91; and Writing, SS =
109. Compared to his previous assessment results, Bradley had made excellent gains in his ability and
academic skills.
Bradley’s mother and teacher completed the rating scales for the Adaptive Behavior Assessment System
(ABAS III). There was a significant difference between scores obtained on the mother’s ratings when
compared to the teacher’s ratings. Scaled scores can range between 1 (very inferior) to 19 (very superior).
While his mother rated him extremely low (all scores were scaled scores of 1 or 2), the teacher’s ratings were
significantly higher. However, both mother and teacher rated Bradley a scale score of 1 for communication.
According to his teacher, his functional academics were within the average range (scale score of 11), which is
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consistent with Bradley’s scores on the YCAT. However, even though his teacher rated him significantly
higher than his mother, his adaptive scores were much lower than would be predicted, given his scores on the
DAS-2. According to the teacher, his adaptive scores for Social were SS = 70, and Practical SS = 75, with an
Overall General Adaptive Composite of SS = 70. According to his mother, these scores were significantly
lower: Social, SS = 54, Practical, SS = 40, and Overall General Adaptive Composite, SS = 41.
The parent and teacher completed an informal screening questionnaire concerning symptoms often associated
with ASD. The following list of descriptions was endorsed as occurring sometimes or frequently, both at
home and at school:
Social Interaction:
Requires specific instructions to begin task

Lacks subtlety in expression of emotion
Has difficulty cooperating in a group
Has difficulty playing with other children
Does certain things repetitively or ritualistically
Has difficulty understanding when being teased
Fails to predict consequences in social events
Communication:
Repeats or echoes words or phrases

Speaks with flat affect
Fails to initiate conversations
Inappropriately answers questions
Uses pronouns inappropriately
Stereotypical Behavior:
Flaps hands or fingers

Eats specific foods, a fussy eater
Rocks back and forth while seated or standing
Flaps hand or fingers in front of his face
Demonstrates eccentric forms of behaviors
Has abnormal focus, preoccupied with specific objects
Requires extensive direction from others
Is clumsy or uncoordinated
Cognitive Patterns:
Talks about single subjects excessively

Displays superior knowledge or skill in a specific area
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Has difficulty understanding jokes, humor, sarcasm
Shows excellent memory
Pragmatic Skills:
Has difficulty understanding slang

Has difficulty understanding when being teased
Has difficulty understanding when ridiculed or made fun of
Has difficulty understanding what causes others to dislike him
Fails to predict probable consequences to social events
Mother and teacher agreed that Bradley has a love of reciting the alphabet and that he has the same two
books that he wants to read on a daily basis. At home, when Bradley wants something, he repeats it over and
over again, if the answer is no.
Mother and teacher also completed the Devereux Scales of Mental Disorders (DSMD). Results revealed a
number of areas of concern. There is a consistent agreement between raters regarding externalizing problems,
especially in areas of conduct problems. Although attentional problems are very evident at school, in the home
situation, these are less pronounced. Teacher and parent agreed that the following attention problems occur at
school and in the home, at least occasionally, in the form of the following behaviors: He fidgets or acts
restless, becomes easily distracted, and fails to pay attention. During classroom activities, Bradley is easily
distracted, preoccupied, has trouble concentrating, and fails to follow through on assignments.
Other areas that have some overlap between the home and school environments include behaviors that are
atypical (e.g., autism). According to parent and teacher ratings, there was a consensus that Bradley frequently
or very frequently makes odd movements, facial grimaces, and noises that can be disruptive in the classroom.
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Post-Case Questions
1. Based on the referral information and the assessment results, what are your impressions of Bradley? Does he meet criteria for any
of the diagnoses in the category of neurodevelopmental disorders? If so, which diagnoses?
2. If you were assessing Bradley, what other information might be valuable in developing a case formulation? What other
assessments could you conduct, or what other interview information might be relevant?
3. How would you account for the significant difference between the mother’s ratings for Bradley and the teachers ratings on the
Adaptive Behavior Assessment System?
4. Suggested Individual or Group Presentation Activities:
The principal has called a parent–school meeting to discuss concerns about Bradley’s progress and his future. Assign roles to
individuals who will role-play important individuals in Bradley’s life and how they would interact in this situation. Develop
important questions for each of the players who can add information to the case. Some of the casting members might be Bradley’s
mother, maternal grandmother, teacher, the psychologist, and any other individual that you feel might contribute to an
understanding of the case and assist with developing an overall case formulation and treatment plan.
You have been invited to provide feedback to the school regarding Bradley’s assessment, at a meeting where they will decide
whether he meets criteria for Special Education and Related Services. If it is determined that he is eligible for services, what goals
and objectives would you want to see as part of his IEP? Would you recommend he receive related services, and if so, what would
the nature of those services be?
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Chapter 3 Introduction to Disruptive Behavior Disorders
In the previous version of the DSM, oppositional defiant disorder (ODD) and conduct disorder (CD) were
classified under the category of “Attention-Deficit and Disruptive Behavior Disorders,” which was a
subcategory of disorders under the main classification of Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence. Currently, ODD and CD are found under the category of Disruptive, Impulsive-
Control, and Conduct Disorders (DSM-5; APA, 2013). Other disorders in this category include intermittent
explosive disorder, antisocial personality disorder (cross-referenced and also appearing under the category of
personality disorders), pyromania, and kleptomania. Disorders in this category share “problems in self-control
of emotions and behaviors.” The DSM-5 (APA, 2013) states that although other disorders may also
demonstrate problems in areas of emotion regulation, the disorders in this category are unique in the
manifestation of “behaviors that violate the rights of others (e.g., aggression, destruction of property) and/or
that bring the individual into significant conflict with societal norms or authority figures” (p. 461).
Conceptually, the DSM-5 further subdivides problems of self-control into two major areas: emotional control
and behavioral control. At one extreme, disorders of conduct evidence a significant lack of behavioral controls
in a number of areas, which often can result from a lack of emotional control (anger), while disorders of
impulse control primarily are associated with a lack of emotional control and emotional responses that are well
in excess of what would be attributed to the event or exchange that provoked the response. Oppositional
defiant disorder (ODD) is seen midway between these two extremes with equal tendencies to exhibit
problems in areas of emotional control (irritability) and behavioral control (defiance).
Developmentally, ODD has earlier onset than CD and may appear as early as the preschool years, with the
average onset around 4 and 8 years of age. Although there was once considerable debate as to whether ODD
and CD were unique disorders or represent a continuum of the same disorder, with ODD being the milder
version of CD, research supports the retention of two separate disorders, since age of onset for ODD is
considerably earlier than CD, and the fact that the majority of children with ODD (as many as 75%) never to
go on to develop CD although 90% of those with CD do meet criteria for initially having ODD (Rey, 1993).
Although it was once thought that ODD was specific to childhood, more recent research has suggested that
the disorder may have more longevity than previously thought with evidence of symptoms persisting into
young adulthood, evident as late as 25 years of age (Biederman et al., 2008; Harpold et al., 2007).
Comorbidity rates for ODD and ADHD have been reported to be as high as 65% (Biederman et al., 1996;
Petty et al., 2009) with 30% of those with this combination persisting into adulthood (Harpold et al., 2007).
In addition to evidence of a pervasive pattern of “angry/irritable mood, argumentative/defiant or

vindictiveness” lasting for at least 6 months, the DSM-5 (APA, 2013) criteria for ODD requires four
additional symptoms evident in one of three symptoms clusters: angry/irritable mood (temper, touchy,
angry/resentful); argumentative/defiant behavior (arguments with authority figures, compliance refusals,
annoys, blames); and vindictiveness (spiteful, vindictive at least twice in last 6 months). The DSM-5 suggests
that the extent to which symptoms are clustered around “angry-irritable mood” or “defiant and vindictive
traits” might predict whether a child is at risk for developing internalizing disorders (former cluster) or
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conduct disorder (the latter presentation). The DSM-5 provides guidelines for decision making regarding the
frequency of behaviors relative to normal development for children younger than 5 years of age (most days in
past 6 months) or older than 5 years of age (weekly occurrence, past 6 months). In addition, specifiers are
available to indicate the severity of the disorder from mild (one setting), moderate (two settings), or severe
indicators (three or more settings).
Conduct disorder (CD) is also recognized as a persistent pattern of behavior, but one that focuses on the
violation of the rights of others or societal norms. Three symptoms are required from a list of 15 possible
symptoms clustered into four themes: aggression to people or animals (bullies, physical fights, weapon use,
physical cruelty to humans, physical cruelty to animals, theft while confronting, forced sexual activity);
destruction of property (fire setting, vandalism); deceitfulness or theft (break and enter, lies or cons,
shoplifting/forgery); and serious violations of rules (out all night prior to 13 years, run away, truant prior to 13
years) (APA, 2013, pp. 469–470).
Specifiers are available for CD to provide additional information in three different areas (onset, limitation in
prosocial emotions, and severity): Onset: One of three onset categories can be specified (childhood onset, one
symptom prior to 10 years; adolescent-onset, no symptoms prior to 10 years; unspecified onset, unknown).
With limited prosocial emotions: This specifier was added to reflect recent research in the area of callous and
unemotional characteristics (CU) that are evident in some youth with CD. Studies have demonstrated that
individuals with CU traits do not recognize emotions in others; exhibit less physiological response to
emotional cues; and are more likely to demonstrate proactive aggressive patterns and have a family history of
antisocial personality disorder (Hubbard, Smithmyer, & Ramsden, 2002). This specifier is used if youth
demonstrate persistent characteristics in two of the following areas for the past 12 months:
lack of remorse/guilt
callous/lack of empathy
lack of concern about performance
shallow/lack of affect (APA, 2013, pp. 470–471)
Severity: Mild, moderate, and severe specifiers are used to denote the degree to which symptoms are present.
Children who demonstrate earlier onset have the poorer prognosis; they are more likely to be male and tend to
display more aggression and have an increased risk for developing CD. Many individuals with CD also exhibit
comorbid disorders of impulse control, ADHD, and ODD. Other disorders that may be comorbid with a
diagnosis of CD include specific learning disorder, anxiety disorders, depression and bipolar disorders, and
substance use disorders (APA, 2013).
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References
VA: Author.
Biederman, J., Petty, C. R., Dolan, C., Hughes, S., Mick, E., Monuteaux, M.C., & Faraone, S. V. (2008).
The long-term longitudinal course of oppositional defiant disorder and conduct disorder in ADHD boys:
Findings from a controlled 10-year prospective longitudinal follow-up study. Psychological Medicine 38,
1027–1036.
Biederman, J., Faraone, S.V., Milberger, S., Garcia Jetton, J., Chen, J., Mick, E., . . . & Russell, R. L. (1996).
Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder? Findings from a
four-year follow-up study of children with ADHD. Journal of the American Academy of Child and
Harpold, T., Biederman J., Gignac, M., Hammerness, P., Surman, C., Potter, A., & Mick, E. (2007). Is
oppositional defiant disorder a meaningful diagnosis in adults? Results from a large sample of adults with
ADHD. Journal of Nervous and Mental Disease 195, 601–605.
Hubbard, J. A., Smithmyer, C. M., Ramsden, S. R., Parker, E. H., Flanagan, K. D., Dearing, K. F., . . . &
Simons, R. F. (2002). Observational, physiological and self-report measures of children’s anger: relations to
reactive versus proactive aggression. Child Development, 73, 1101–1118.
Petty, C. R., Monuteaux, M., Mick, E., Hughes, S., Small, J., & Faraone, S. V. (2009). Parsing the
familiality of oppositional defiant disorder from that of conduct disorder: A familial risk analysis. Journal of
Psychiatric Research, 43, 345–352.
Rey, J. M. (1993). Opposition defiant disorder. American Journal of Psychiatry, 150, 1769–1777.
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Case 11 Scott Michaels Boys Will Be Boys? Oppositional Defiant
Disorder; ADHD
Scott came to the intake interview accompanied by his mother, Ruth. Scott is 9 years old and is currently in
Grade 4 at Second Street School, which he has attended since his earliest enrollment in kindergarten.
According to Ruth, the presenting concerns are twofold: academic problems at school and behavior problems
at home.
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Ruth described the birth history as uneventful. Scott was born 2 days early and weighed 8 pounds 4 ounces.
Developmental milestones were mildly delayed, and Scott walked at 15 months. Scott was slow to speak and
did not use simple phrases at 3 years. Speech problems continued, and Scott received assistance for problems
with articulation and speech production in prekindergarten and kindergarten.
Scott was described as an active infant who was not content to take long naps. Sleeping was not a problem,
however, since he seemed to need his rest after all the activity. There was a problem with bed-wetting until
Scott was 6 years old. The problem was resolved when they stopped allowing Scott to have apple juice before
bedtime. As a toddler, Scott seemed to be more demanding than all of Ruth’s other children put together.
Scott was not content to stay in the playpen like his other siblings. He would often scream and have tantrums
until Ruth took him out of the playpen. However, when he was out of the playpen, he seemed to be into
everything. Scott was very easily frustrated and difficult to calm down, especially if he couldn’t have his way.
At first, Ruth said she could distract him by offering something else, but that usually didn’t last very long.
Ruth added that for Scott the “terrible twos” never went away but just got worse with each passing year.
Ruth recalled one incident that occurred shortly after Scott’s sixth birthday. On this occasion, Ruth had asked
Scott to help her pick up some toys that his brother Brian (age 4) and sister Tia (age 2) had scattered. All of a
sudden, Scott started grabbing toys out of their hands and throwing them at Tia and Brian. Then he went
over to his toy box and dumped the entire toy box all over the floor. The event made such a lasting impression
on Ruth that since that time she has not asked Scott to help her with cleaning up.
Scott’s academic difficulties became evident early in his schooling, and Ruth was contacted by the teacher
diagnostician, who recommended that Scott have his vision and hearing tested to rule out any physical reasons
for Scott’s learning problems. Although Scott’s vision was normal, testing of central auditory processing
(CAP) revealed a selective attention deficit in the left ear, problems tuning in to auditory information, and
likely difficulties with visual tracking. Recommendations from the CAP assessment were to present
information to the dominant right ear, cue prior to presenting information, and provide assistance in copying
information from the board. Ruth stated that she had asked her family physician for a referral to have Scott
tested for learning problems; however, when she took Scott to the appointment (about a year ago), she was
told that testing was not necessary because Scott did not have any “developmental” problems. Ruth could not
elaborate further on the nature of the therapist’s expertise.
Ruth outlined the following family history during the course of the intake interview. There is a history of
depression (maternal grandmother) and alcohol abuse (maternal grandfather) in Ruth’s family. Ruth’s father
was incarcerated several times for assault resulting from fights in local bars. Ruth’s only brother, Jacob, was
bright but did poorly in school. Jacob seemed to fall in with the wrong crowd and dropped out in Grade 9. He
spent some time in juvenile detention for breaking and entering but eventually got back on track when he
joined the armed forces, where he received training as a mechanic.
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Ruth’s husband Eric knows very little about his own family history, since he was adopted as an infant. Eric’s
adoptive parents were killed in a car accident shortly after Ruth and Eric were married. Eric has no known
siblings. Ruth liked school and graduated from high school prior to getting married to Eric. Eric did not do
well in school, and he did not complete high school. He currently works at a local box-making factory. Ruth
worked as a grocery clerk at the local supermarket after graduation, until the birth of her daughter when she
was 20. Ruth has not returned to work since that time. Ruth admitted that they have had financial problems
recently, since the money from her husband’s inheritance has been exhausted.
Although she was never diagnosed with depression, Ruth does admit to feeling overwhelmed and exhausted
much of the time, especially since the birth of Tia. Ruth is considering returning to work now that Tia is in
school, but she is afraid of what the consequences will be for Scott’s behavior. Ruth recalled recently going to
a shower for a neighborhood friend and returning home to find the kitchen an absolute mess. Apparently,
Scott had deliberately messed up the kitchen in her absence because he was upset that she was not there to
make his lunch. When asked why he had messed up the kitchen, Scott said that it was his mother’s fault. If
she had been home, it wouldn’t have happened. When asked how he would feel about his mom returning to
work, Scott said that it would be unfair, and that moms should be home for their kids.
Ruth described Scott’s relationship with his siblings in the following way. Scott gets along with his youngest
sister, Tia (5 years), the best, while his relationship with his older sister, Christine (11 years), is the most
problematic. She added that Scott often responds to Christine in the same way he responds to his mother.
When asked to clarify what she meant, Ruth replied that whenever Christine wants Scott to help her with
dinner or the dishes, he starts a huge argument. It always ends the same way, with Scott saying that “it’s
unfair” and that he has to do all the work, or it’s not his turn. Finally, Christine ends up just doing it herself,
rather than argue with Scott. His relationship with his younger brother Brian (7 years) is less predictable.
When Scott wants to play with Brian and Brian goes along with him, they have a great time. However, when
Brian does not want to follow Scott’s lead, Scott loses his temper very quickly.
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Reason for Referral
When asked what brought her and Scott to the clinic at this time, Ruth stated that Scott had become
progressively more difficult to manage. He walks around with a “chip on his shoulder” and responds to even
the smallest requests with an inflated emotional response. The outbursts have increased in frequency and
intensity. Ruth admitted that she is beginning to “lose it” more frequently. According to Scott, his mother is
always picking on him and asking him to do things, like chores, that his brother and sisters should be doing.
He added that he only gets mad when his mother is “not fair.” Scott’s school reports have noted increasing
difficulties, especially in reading comprehension. Scott struggles with retaining the sequential order of
information and has problems recalling information he has read. He is slow to copy information from the
board and his notes are not only messy but often incomplete.
Scott is receiving approximately 30 minutes daily of resource help to focus on reading, spelling, and written
work. His teacher is very supportive of an assessment for Scott to provide specific information to assist with
programming. The teacher noted that although behavioral problems are not significant at school, Scott does
have some difficulty accepting criticism and waiting his turn. The teacher has also noted, on more than one
occasion, that Scott will complain that the teacher has not been fair. Homework assignments are often
incomplete or not returned, despite attempts to set up a home–school communication system. Socially, he is
not well liked by peers because he tends to want to be in control and often interrupts or intrudes on others.
Problems waiting his turn are also evident on the playground, and Scott has to constantly be reminded to give
others a chance to talk.
Scott was asked to comment on his feelings about school. Scott said that the kids were all right, but that some
of the teachers were not so great. When asked what he liked best about school, Scott rolled his eyes back and
said “Recess.” Scott became defensive when questioned about academics and said that he could do better if the
teacher didn’t pick on him. He also said that the teacher is always busy with other students and doesn’t have
the time to answer his questions. He says he has to sit and wait until the teacher finally gets around to his
question and that’s why he doesn’t get his work done. According to Scott, the resource room teacher is also
too busy with other kids to help him. Scott added that if the teacher would explain schoolwork better, he
would be able to understand it better. He described his teacher as unfair in the amount of work she expected
students to do. Outside of school, Scott said he really likes playing hockey and that he probably would drive
race cars, like NASCAR, when he was older. He said he wouldn’t go to school if he didn’t have to.
Ruth began to describe the current home situation by saying that Scott is a good-natured boy when things are
going his way. However, he can be very difficult to manage when asked to comply with any requests that
interfere with his own agenda. Ruth has tried various incentive programs (such as using the purchase of a new
bike as a reward for completing his homework for a week); however, after receiving his incentive, Scott loses
all motivation and things go right back to where they began. She described it as a tug of war to get him to do
anything. Attempts to set up a communication system with the school have been undermined by Scott’s
forgetfulness to bring messages home. At times, when asked to do something, Scott will be very touchy, talk
back to her, and begin yelling and complaining that it is unfair and comparing himself to his sister who he
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says has no responsibilities around the house. At the worst of times, tantrums will escalate into a shouting
match that involves throwing things and yelling. During these times, Ruth admits to “losing it” and producing
numerous threats and ultimatums. More often than not, these scenarios end with Ruth completing the tasks
herself, just to stop the battle. At the best of times, Scott will not be confrontational, though he will still avoid
doing tasks by either passively ignoring the requests or trying to buy time, saying he will do it later (when a
TV program is finished or when he finishes what he is working on, etc.). Ruth stated that sometimes it just
seems easier to do it herself than to nag and hound Scott. Scott seems to be in constant motion, and he has a
hard time even sitting down for dinner. He becomes very restless and squirmy when he is asked to remain
seated, and often his leg is in motion while he is sitting down.
Scott’s relationship with his older sister is very poor, since Scott is often jealous and resentful of any attention
that she receives. Yesterday, when Christine asked him to turn down the volume on the television because she
was on the telephone, Scott deliberately turned the volume up to the absolutely loudest notch. Ruth seemed
notably depressed in her admission that it is getting to the point that everyone at home is afraid to ask Scott to
do anything for fear of retaliation.
When asked about her husband Eric’s role in the management of Scott’s behaviors, Ruth stated that her
husband often works the 4:00 to 11:00 p.m. shift and is not home when Scott has his behavioral outbursts.
Although Eric tries to be supportive of her, he has said that he thinks Ruth is making too much out of Scott’s
behavior. He says that he was like Scott when he was a kid. After all, he says, “Boys will be boys.” When Eric
and Scott do things together, like fishing, there are rarely any outbursts.
Ruth is very hopeful that the assessment will not only provide help for her to manage Scott’s behavior at home
but perhaps also help convince her husband that Scott is in need of some kind of management program. Right
now, Eric is of the opinion that Scott will just grow out of it.
At the completion of the intake interview, Ruth admitted in confidence to the psychologist that she was
feeling increasingly overwhelmed, distraught, and alone. Her husband seemed to be withdrawing from the
family and was coming home from work later and later, often stopping in at the local sports bar before
returning home. There were many arguments about money and Ruth’s desire to return to work because her
husband was not in favor of her working. Ruth was feeling less and less capable of managing Scott’s escalating
problems. At Ruth’s request, a referral was provided to a therapist for her to obtain supportive therapy.
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Assessment Results
The actual raw scores for Scott’s assessment are available in Appendix A. The following is a summary of those
findings. Guidelines to the interpretation of standard scores and T scores, as well as information regarding
specific assessment instruments used in this text and other assessment resources, can be found in Appendix C.
Examiner comments noted frequent requests for repetition throughout the assessment, word-finding
problems, and tendencies toward word substitutions (e.g., using found instead of lost). Overall intellectual
functioning on the Wechsler Intelligence Scale for Children (WISC-V) was within the low average to average
range (IQ = 88; range 83–93), with no significant discrepancy between scores among the various Indexes. The
Working Memory Index (WMI) was an area of relative weakness (WMI = 80; range 74–89), and Scott
experienced significant difficulties understanding the instructions to sequencing tasks, especially for picture
span, which asked that he remember the pictures “in order” of presentation. On the VCI, Scott’s responses to
the comprehension subtest revealed that as the questions became more complex, Scott asked for several
repetitions of the questions and asked for further explanations, which are not permitted, according to the
manual.
Academically, according to the Wechsler Individual Achievement Test (WIAT-III), Scott was functioning
commensurate with his intellectual level in most areas assessed (standard scores ranged from highs of 100 for
math computation and 95 in Reading Fluency to lows of 80 for reading comprehension). Although the two
lowest scores were below his full scale IQ of 88, the discrepancy of 9 points (88–79) was not significant. In
Scott’s school district, a discrepancy between IQ and achievement must be in excess of one and a half standard
deviations, which requires a discrepancy of at least 22 points. (For further information on applications of the
discrepancy criteria, please see Appendix B: Specific Learning Disorders and the Discrepancy Model.)
Analysis of cognitive processing revealed that academic difficulties are largely due to problems in cognitive
fluency (SS = 67). Scott required more than the anticipated time to label common objects and to perform
tasks that required him to recall names for “as many”______ (friends, foods, etc.) that he could name in one
minute. In this task, after naming two or three objects or names, Scott would either go blank or repeat names
he had already given.
Response to parent ratings scales (ASEBA) revealed borderline clinical elevations on Withdrawn/Depressed
and Total Internalizing Behaviors, and significant clinical elevations on Attention Problems, Aggressive
Behavior, Total Externalizing, and Total Problems. Teacher ratings noted clinical elevations for Social
Problems and Attention Problems. While his mother’s comments pertained to aggressive behaviors in the
home (e.g., argues, brags, is mean, is stubborn, disobeys, etc.), his teacher noted many problems in the
classroom (e.g., acts young, fails to finish, poor schoolwork, doesn’t listen, etc.) and with classmates (doesn’t
get along, is not well liked, prefers younger kids). On the Conners scales, Scott’s mother rated Scott’s
Hyperactivity/Impulsivity (DSM scales) as in the borderline clinical range. Oppositional behaviors and the
emotional lability scale of the Global Index were both within the clinically significant range. Scott’s teacher
rated him as borderline clinical for Social Problems, and in the clinically significant range for Cognitive
Problems/Inattention, Inattentive scale (DSM), Hyperactive-Impulsive scale (DSM), and the DSM Total
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scale.
Scott endorsed items at the borderline clinical level on the Beck Youth Inventory (BYI-2) for Disruptive
Behaviors (SS = 68; 94th percentile) and in the highly significant clinical range for the Anger Inventory (SS =
86; 99th percentile).
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Current Issues, Trends, and Treatment Alternatives
Oppositional defiant disorder (ODD) is one of the most stable disorders of childhood; the prognosis is
therefore often poor (Rey, 1993). The transition from normal behavior demonstrated in what has been called
the “terrible twos” to ODD behavior is evident in the frequency and intensity of noncompliant behaviors that
continue to persist well beyond the toddler period (Gabel, 1997). Results of a recent longitudinal investigation
suggest that by 25 years of age, ODD was persistent in 16.6% of the ODD group (Biederman et al., 2008),
although Harpold and colleagues (2007) found that of referred adults with ADHD who had ODD in
childhood, 30% continued to demonstrate symptoms of ODD into adulthood. Risk factors that have been
associated with ODD include attachment problems noted in insecure attachment (DeKlyen, 1996) and
anxious avoidant attachment patterns (Erickson, Sroufe, & Egeland, 1985); difficult temperament (Rey,
1993); and parenting style and level of parental involvement (Frick et al., 1993; Griest, Wells, & McMahon,
1980). One of the difficulties with isolating risk factors specific to ODD is that many studies have examined
“behavior disorders” or “disruptive behavior disorders,” which combine populations of children and youth with
oppositional defiant disorder (ODD) and conduct disorder (CD). As a result, far less is known about the
specific risks for children with ODD or long-term prognosis for children who demonstrate both ODD and
ADHD, despite comorbid rates as high as 65% for youth exhibiting both disorders (Biederman et al., 1996;
Kadesjo & Gillberg, 2001; Petty et al., 2009). A more recent investigation has suggested that comorbid
ADHD and ODD may represent a distinct familial subtype, and, furthermore, that antisocial, mood, anxiety,
and addictive disorders found in relatives were related to risk for CD and not ODD when the two groups are
separated out. Based on these findings, Petty and colleagues (2009) suggest further support for considering
ODD and CD as separate and distinct entities (Biederman et al., 1996; Greene et al., 2002), which they hope
will deter “lumping” CD and ODD together in future clinical studies.
Biederman and colleagues (2008) investigated the long-term outcomes for children who are diagnosed with
comorbid ODD and ADHD. Their results suggest that youth with comorbid ADHD and ODD
demonstrated higher scores on the CBCL Aggressive Behavior scale compared to those with ADHD alone.
Youth with ODD at 10-year follow-up were at increased risk for major depressive disorder compared to
controls. Longitudinally, the majority of youth with comorbid ODD and ADHD demonstrate a decline in
ODD symptoms with age (Biederman et al., 2008; Whittinger, Langley, Fowler, Thomas, & Thapar, 2007).
Although some youth with ODD will later progress to CD (Rowe, Maughan, Pickles, Costello, & Angold,
2002; Whittinger et al., 2007), results suggest that the majority of subjects with ADHD and comorbid ODD
will not develop CD (Biederman et al., 1996, 2008).
One of the difficulties in locating evidence-based treatments specifically for ODD is that despite evidence of
the existence of ODD and conduct disorder (CD) as two distinct disorders (Biederman et al., 2008; Frick et
al., 1993), treatments are often discussed relative to the broader category of “disruptive behavior disorders,”
which include both ODD and CD. Brestan and Eyberg (1998) reviewed psychosocial treatments for
disruptive behavior disorders (ODD or CD) in 82 studies involving more than 5,000 youths. The authors
then evaluated the treatment programs relative to criteria suggested by the APA Task Force. Results revealed
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two models of intervention, both involving parent training, that met with the more stringent criteria
established for “well established psychosocial interventions”:
1. A parent training program involving videotaped modeling (Webster-Stratton, 1984) has been successful
in reducing deviant behaviors in children and increasing parent competencies in the management of
behavior problems (Spaccarelli, Colter, & Penman, 1992; Webster-Stratton, 1984, 1994). In this model
of intervention, parents receive training in therapist-led groups.
2. Behavioral parent training programs (Alexander & Parsons, 1973; Bernal, Klinnert, & Shultz, 1980;
Firestone, Kelly, & Fike, 1980) based on a manual called Living With Children, developed by Patterson
and Gullion (1968), have also demonstrated success across several controlled studies. Lessons obtained
from the manual Living With Children have been successfully incorporated into behavioral treatment
programs designed to teach parents how to implement behavioral change by targeting problem
behaviors, rewarding incompatible behaviors, and ignoring or punishing undesirable behaviors.
Other treatments for school-age children that are cited as “probably efficacious treatments” (Brestan &
Eyberg, 1998) include problem-solving skills training (Kazdin, Esveldt-Dawson, French, & Unis, 1987;
Kazdin, Siegel, & Bass, 1992) and anger control therapy (Lochman, Burch, Curry, & Lampron, 1984;
Lochman, Lampron, Gemmer, & Harris, 1989).
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Problem-Solving Skills Training (PSST; Kazdin, 1996)
A typical problem-solving intervention would teach children how to approach a problem in a logical and
predictable fashion, using a six-step procedure (Kazdin et al., 1987; Kendall, 1988).
1. Define the problem.

2. Identify the goal.
3. Generate options.
4. Evaluate options.
5. Choose the best option.
6. Evaluate the outcome.
Children are taught how to apply this approach to social problems in a number of ways, including role-
playing, social reinforcement, and therapeutic games. The PSST procedure is administered individually over
20 sessions, each lasting approximately 45 minutes.
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Coping Power (Larson & Lochman, 2002)
This anger-control program has evolved from an original 12-session school-based program called Anger
Coping (Lochman, Lampron, Gemmer, & Harris, 1987), to a 33-session program called Coping Power
(Lochman & Wells, 1996), with sessions for a parent group recently added. Children develop skills in anger
management through in vivo practice sessions (weekly groups of six children) using problem-solving
techniques to address specific goals and objectives in social situations. Children are also taught to be aware of
feelings and physiological states associated with anger arousal.
In their research review, Brestan and Eyberg (1998) found that the majority of interventions involved direct
contact with the child and/or the child’s parent (usually mother) and usually were based on cognitive–
behavioral techniques. In their summation, the authors conclude that age may be the overarching variable that
determines the effectiveness of the outcome of treatment: Parent training programs would be more effective
for younger children, while cognitive–behavioral methods may be more applicable for older, school-age
populations. There is evidence to suggest, however, that for some groups (Kazdin et al., 1992), combining
PSST and parent training may be more effective than either treatment alone.
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Collaborative Problem Solving (Greene et al., 2001, 2003, 2004)
Since many children with ODD also experience ADHD, Greene (2001) and colleagues (Greene, Ablon, &
Goring, 2003; Greene, Ablon, Goring, Fazio, & Morse, 2004) have developed a program that focuses on
deficits in cognitive skills involved in “executive functions” such as working memory, self-regulation (emotion
regulation, frustration tolerance, and regulation of arousal to engage in goal-directed activity), shifting of
cognitive set (flexibility and transfer of rules and expectations from one situation to another), and problem
solving (organization of information and generating a plan of action). The program, Collaborative Problem
Solving (CPS; Greene, 2001; Greene et al., 2004), focuses on parent education (underlying parent–child
dynamics) and interventions aimed at deficits in executive functions.
Many children diagnosed with mood disorders (Geller & Luby, 1997) and anxiety disorders (Greene et al.,
2002) also have comorbid ODD. In one study, 70% of youth with major depressive disorder (MDD), 85% of
those with bipolar disorder, and 45% of those with an anxiety disorder had comorbid ODD (Greene et al.,
2002). In addition, language processing problems are also prevalent, with over 20% of youth diagnosed with
ODD also demonstrating processing problems that can compromise problem solving in academic as well as
social situations. Previous research by Dodge and colleagues (Dodge & Coie, 1987; Dodge, Price,
Bachorowski, & Newman, 1990) demonstrated that some children act aggressively when they misread social
cues based on cognitive distortions such as the hostile attribution bias (e.g., child interprets an ambivalent facial
expression or provocation as hostile and responds aggressively as a result). In order to address these processing
issues, Green and colleagues incorporate tasks of social cognitive processing in their program to assist children
in developing increased ability to analyze social situations, develop alternative responses, and monitor
outcomes. The program also focuses on parent–child compatibility by helping parents understand the
processing difficulties, the need for providing consistent patterns of discipline, and the need for increased
monitoring and feedback. The program has been very successful.
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Academic Interventions
An empirical review of specific programming remediation for difficulties in reading and written expression
reveals the following information. The importance of developing phonological awareness for reading
acquisition and spelling has been demonstrated by several researchers (see Rathvon, 1999, for a review).
Therefore, strategies that focus on improving phonics (e.g., Fernald Keller approach) can be helpful in
assisting Scott in developing greater phonetic awareness. Given Scott’s learning profile, the following specific
strategies may be helpful. A repeated readings approach (O’Shea & O’Shea, 1988) is suggested to target
difficulties in decoding (sight word vocabulary, fluency) and comprehension, and to enhance Scott’s attention
to task as well as independent work habits. Cognitive approaches to spelling, such as the 12 plus 1 strategies
for remediation of misspellings (Montgomery, 1990), would also be very helpful in emphasizing the phonetic
as well as rule-based aspects of spelling.
The focus is on improving homework submission and reducing home conflict regarding homework
completion. A homework management program would be helpful to increase productivity (percentage of
homework completed) and accuracy (percentage completed correctly) of homework, using a combination of
home-note, self-monitoring, and group-contingency approaches based on the Good Behavior Game Plus Merit
approach developed by Darveaux (1984).
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Post-Case Questions
1. Using situational and contextual factors, explain why Scott’s behaviors were described as more oppositional at home than at
school. Is this a common finding?
2. Barkley (1997a) has developed a theoretical model for ADHD that places “behavioral inhibition” as the focal point of the model.
According to this model, the ability to delay or inhibit a given response allows for the necessary time required for executive
information processing to occur. Included within these executive processes are abilities to manipulate information mentally
(working memory), self-regulation (emotional control, motivation/drive), self-reflection (inner speech, problem solving), and
reconstitution (analysis and synthesis). Furthermore, the ability to maintain the delay is also required to block possible interference
factors (see Barkley, 1997b, for a complete description of this model of hyperactivity and impulsivity). How might the concept of
“behavioral inhibition” be used to help explain Scott’s behaviors?
3. At a minimum, Scott demonstrates at least two comorbid disorders. What are the two disorders? How often do they occur
together in clinical populations? Using Barkley’s model of behavioral inhibition, explain the underlying dynamics in these two
comorbid disorders.
4. The role of parenting practices in the maintenance and management of disruptive behavior disorders has been well documented
(Barkley, 1997a; Chamberlain & Reid, 1991, 1998; Patterson, Reid, & Dishion, 1992). Various theoretical perspectives have
focused on different aspects of parent–child interactions in maintaining maladaptive behaviors—for example, coercion theory
(Patterson et al., 1992) and conflicting goals of connectivity versus individuation (Mahler, Pine, & Bergman, 1975). Refer to the
section on coercion theory in Chapter 1: Introduction, to refresh your memory about the importance of coercion theory. Develop
case formulations to explain how Scott’s interactions with his family members serve to sustain his disruptive behavior from the
following perspectives: behavioral, cognitive, family systems, and parenting style/attachment.
5. Although most children who have ODD do not progress to CD, some are more at risk than others. Taking into consideration
what research suggests are risk factors for ODD developing into CD, and looking at Scott’s individual assessment results
(Appendix A), do you think that Scott is at risk for developing CD? If so, why? If not, why not? Also, the DSM-5 suggests that
the extent to which symptoms cluster around two predominant themes (angry/irritable versus argumentative/defiant) may predict
whether a child is at greater risk for internalizing versus externalizing disorders. Based on Scott’s symptom profile, do you think he
is more at risk for internalizing or externalizing problems in the future? Why?
6. Using information from the case study itself and the supplementary assessment data found in Appendix A, identify as many
symptoms as you can find of ODD and ADHD that meet the DSM criteria. Remember to specify the predominant type of
ADHD that Scott’s symptoms match.
7. Scott’s parents do not agree about the extent and nature of his behavioral problems. As his therapist, how would you approach this
situation, and what suggestions do you have for bringing his parents in closer alignment regarding his difficulties?
The principal has called a parent–school meeting to discuss concerns about Scott’s progress and attitude at school. Assign roles to
individuals who will role-play important individuals in Scott’s life and how they would interact in this situation. Develop
important questions for each of the players who can add information to the case. Some of the casting members might be Scott, his
mother and father, his teacher, the school psychologist, and any other individual that you feel might contribute to an
understanding of the case and assist with developing an overall case formulation and treatment plan.
You have been asked to attend a meeting at the school to share your assessment results with the student support team. What
would be the main emphasis in your presentation? Who would you want to be present at the meeting? What would your
recommendations be for accommodations or modifications to his program based on the test results?
310
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Case 12 Tyrone Wilson The Gang’s All Here Neesha’s Brother;
Multifinality; Learning and Behavior Problems; Gang Activity;
Forensic Assessments; Fetal Alcohol Spectrum Disorders
Tyrone Wilson, 15 years of age, is an African American youth who is the older brother of Neesha Wilson (see
Case of Neesha Wilson). Although the two siblings were brought up under somewhat similar circumstances,
there was a significant difference in the outcomes for the two children. While Neesha’s story is one of
resilience, Tyrone suffered through significant challenges that have escalated out of control since his father left
the family 3 years ago.
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Tyrone lives with his 10-year-old sister, Neesha, and their mother in a two-bedroom apartment. The
apartment is small but very well kept. Tyrone sleeps on the couch, which folds out into a bed. Tyrone’s
mother is currently working two jobs: cleaning offices and working as a hairstylist. Mrs. Wilson graduated
from hairstylist classes last year. Although her career as a hairstylist has a lot of potential, she is only
beginning to develop clientele. She also works part time cleaning offices. Despite the lack of financial
resources, the children are clean and adequately fed. Mother admits to drinking more than she should have
when she was pregnant with Tyrone. She said,
You know you read about it a lot now, but when I was growing up, I mean I was 19 when I got
pregnant with Tyrone, I just became legal drinking age, and it was time to party. I was done with
high school and I was taking some community college courses and working part time at the deli.
Their dad was a mechanic and he worked hard and long hours. When we were done with working,
like we just were ready to let loose.
When asked how much she drank during her pregnancy, Mrs. Wilson said there wasn’t a night that she didn’t
drink probably one or two beers, plus a couple of glasses of wine. She stated that she did not do any drugs
whatsoever during her pregnancy. When she conceived Neesha, she was more mature and had heard more
about drinking and pregnancy, so she did not drink while pregnant with Neesha. Tanya stated that although
there are some nights that she is not home because she may be working, she is not too concerned about the
children since she has family nearby. She can send the children to her sister’s place a few blocks away, or if
they do not want to go, they can stay home, since she also has a cousin who lives in the apartment complex,
who can drop by if the children need something. Also, Tyrone is old enough to babysit his sister; however,
given his behavior problems, she prefers to have an adult nearby.
When asked about Tyrone’s developmental milestones, Tanya said that he seemed to start out on the wrong
foot. She said that she and her husband were not great parents because they were so young and immature and
Tyrone was a difficult child to manage. Tanya said that Tyrone was an agitated infant and did not eat or sleep
well. He was a late talker but was walking by 14 months. He was a difficult child to potty train because it
seemed to take forever for him to make the connection. He was also an impulsive child, and still is, which can
get him into trouble since he often acts without thinking. He also does not seem to learn from past mistakes
and will do the same thing over again, even if he was punished for it previously.
He managed to have some academic success when enrolled in special education, but he continually would get
into trouble for disobeying the rules. His mother feels that part of his disability is that he cannot understand
rules, but the school did not agree. Tanya felt that punishments at school for rule violations (in-school
suspensions, after-school detentions, being kept in at recess, etc.) resulted in Tyrone becoming more resentful
and anxious about school. Social skills were also poor, and Tyrone experienced problems being accepted by
the other children and was often isolated as a result. She said that she began to feel guilty because Tyrone was
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having so many problems, so after trying a few different schools, she decided to try homeschooling, which
would also allow her to stay home with Neesha, who was then 4 years of age, and she would not have to pay
for day care. But eventually, Neesha was ready for school and Tanya felt it was unfair to Neesha to hold her
back from a normal school experience, so they enrolled Tyrone back into the school system. At this time,
Tyrone was almost 11 years of age and the school recommended an updated assessment, since Tyrone had not
had an evaluation since he was 6 years of age. Results of the assessment at that time revealed intellectual
functioning in the below average range (full scale IQ was 84, range 80–89), with scores for the Fluid
Reasoning and Visual Spatial Reasoning in the average range (FRI = 93, range 87–100; VSI = 95, range 88–
102) and much higher than Verbal Comprehension (VCI = 80, range 74–89). The Similarities subtest, which
measures abstract reasoning, was very challenging for Tyrone. A severe problem was noted in speed of
processing, likely due to poor eye–hand coordination and deficits in short-term visual memory. Academically,
Tyrone was functioning at approximately a mid–Grade 4 level in reading and written expression
(approximately 1½ years below the expected level) and almost 2½ years below the expected level in
mathematics. Problem solving was especially weak, and Tyrone did not know which numbers were relevant to
the questions and which numbers were not needed to solve the problem. Based on his assessment results, it
was recommended that Tyrone receive special education assistance to assist in meeting his educational goals.
Initially, Tyrone seemed to improve his academic skills with the resource room help. However, after his father
left, Tyrone became very unsettled and started to experience more problems socially and academically. He was
suspended for fighting, and when the suspension was lifted, he immediately got into another fight and was
placed in an alternative school program for students with severe behavioral problems.
At home, Tyrone was getting more and more difficult to control. When his mother worked nights, he would
stay out until 3:00 or 4:00 a.m. and leave his sister Neesha alone. On these occasions, he would threaten to
make Neesha’s life miserable if she told her mom that he was not home. On the nights that Tanya was not
working, she would often go to bed early. She said that she was fatigued and just needed to sleep a lot. This
also gave Tyrone more freedom to come and go at all hours of the night. One night, when Tyrone eventually
arrived home, he was very badly beaten. He would not tell his mother, but this was the night he was “beaten
down” as part of his initiation into the gang. That was the night that he was “jumped in,” the rite of passage
for a new male gang member who gains entry into the gang by being beaten up by the brothers. It wasn’t so
bad, Tyrone thought, since afterward, all the gang members hugged him. This was his new family. For
Tyrone, joining the gang would give him protection on the streets and the respect he was looking for.
However, it also opened the door to drugs and crime. Tyrone started hanging out on the streets and getting
involved in petty theft (stealing bikes for parts), and by 14 he was regularly smoking marijuana and drinking
beer on a daily basis.
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Reason for Referral
Currently, Tyrone is in detention following his recent arrest for robbery and assault with a weapon. He and
two of his gang members were arrested as they confronted and threatened two youth with knives, as they were
waiting for a bus. Tyrone was especially belligerent and aggressive during the incident, wielding his knife in
the air and shouting lyrics from “gangsta” rap music.
The detention center is a short-term, secure facility, sometimes called a youth jail, where a youth may be held
“during the processing and disposition of the youth’s legal case for the purposes of evaluation or placement if a
secure environment is deemed necessary” (American Academy of Child and Adolescent Psychiatry
[AACAP], 2004, p. 2). The judge had ordered an assessment to determine the nature of Tyrone’s difficulties
and to assist in determining an appropriate placement (e.g., juvenile correctional facility, community-based or
other residential treatment program).
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Assessment Results
320
Forensic Assessments Versus More Traditional Psychological Assessments
Forensic assessments differ from the more conventional psychological assessments that have been discussed in
this casebook in several ways. Traditional psychological assessments are conducted for a variety of reasons
(e.g., to evaluate educational or occupational aptitudes or investigate mental health concerns) and may include
assessments of intelligence (learning capacity), achievement (academic performance), cognitive or
neuropsychological functioning (information processing, brain-based functioning, executive functions),
personality assessment (traits and personal style), and emotional or behavioral status (mood disorders, anxiety,
etc.). However, forensic assessments are more likely to be conducted to address questions of competency on two
levels:
1. Is the individual competent to stand trial? (Is the individual competent at the time of the trial?)
2. Was the individual competent at the time of the crime (which addresses issues of criminal responsibility)?
In the former situation, three areas of competency are considered to determine whether the individual is
mentally competent to stand trial: Does the defendant understand the charges, does the defendant understand
the seriousness of the potential outcomes of the trial, and is the defendant capable of assisting in his or her
own defense? Regarding whether the individual was competent at the time of the crime, experts would be
called in to provide opinions as to whether the defendant was suffering from diminished capacity because of a
mental or emotional disorder that interfered with the ability to distinguish right from wrong.
Forensic assessments may also investigate whether an individual is malingering, or pretending to be more
incapacitated (competency or mental illness), in order to obtain a lesser penalty. Other questions that forensic
assessments may address include determining the risk of recidivism (repeat offending), or providing
information about the psychological factors that may be contributing to the maladaptive and criminal
behavior.
In addition to differences in the types of assessment instruments that may be used and the general goals of the
assessment, forensic assessment also differs in the nature of the psychologist–(mental health practitioner)
client relationship. While most children and adolescents are referred for assessment by concerned parents and
teachers, forensic assessments are conducted to answer forensic questions and, as a result, clients are often
mandated to participate in the process by the authorities. Therefore, rather than developing a therapeutic
relationship, the psychologist is required to remain neutral.
The American Psychiatric Association (APA; 2013) has issued a “cautionary statement for the forensic use of
the DSM-5,” stating that when the DSM-5 “categories, criteria, and textual descriptions” are used for forensic
purposes “there is a risk that diagnostic information will be misused or misinterpreted.” Furthermore, APA
clarifies that the clinical diagnosis of a mental disorder, such as intellectual disability, does not suggest that an
individual with that diagnosis meets “legal criteria” such as legal standards for “competence, criminal
responsibility or disability” (p. 25).
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Assessment Findings
The forensic psychologist reviewed Tyrone’s file and noted his developmental history, especially the
information regarding his mother’s drinking habits during the pregnancy. The psychologist also reviewed the
intellectual assessment information noting intellectual delays in language functions, relative to average scores
for visual reasoning. The need for special education assistance was also noted, especially for significant
difficulties with mathematics. There were indications that behavior problems have been ongoing, with poor
ability to profit from prior experiences, and weak social skills, making him vulnerable to gang recruitment and
involvement in crime and drug usage.
In order to answer a number of forensic questions, the psychologist administered a battery of tests, including
the Structured Assessment of Violence Risk in Youth (SAVRY), the Jesness Inventory Revised (JI-R), the
Vineland Adaptive Behavior Scales, and the Behavior Rating Inventory of Executive Function (BRIEF). A
summary of historical risk factors from the SAVRY included history of nonviolent offending and poor school
achievement. Social contextual risk factors were significant with many items endorsed, including peer
delinquency, peer rejection, stress and poor coping, poor parental management, lack of personal/social
support, and community disorganization. Individual risk factors on this instrument were highly significant, as
Tyrone matched many of the high-risk items, including negative attitudes, risk taking/impulsivity, substance-
use difficulties, anger-management problems, low empathy/remorse, attention-deficit/hyperactivity
difficulties, and poor compliance/commitment to school. Unfortunately, significant problems indicated by
personal risk factors were not offset by any protective factors that could buffer the harmful effects posed by the
risk factors.
On the JI-R, the DSM subscales of Conduct Disorder and Oppositional Defiant Disorder were both clinically
significant. In addition, Tyrone had high clinical loadings on the Personality scales for social maladjustment,
immaturity, alienation, asocial index, manifest aggression, and withdrawal. He also endorsed significant items
on scales measuring depression, social anxiety, and denial. On the subtype scales, Tyrone’s responses placed
him in the clinical range for the following subscales: aggressive/undersocialized and conformist/immature.
The Vineland Adaptive Behavior Scales were completed by Tyrone’s mother, and according to her responses,
Tyrone obtained the following standard scores: Communication Skills, 80; Daily Living Skills, 80; and
Socialization Skills, 75. Therefore, adaptive behavior was below the norm for all areas assessed and especially
poor in the area of social competence.
On the BRIEF, the subscales of the Metacognitive Index (MI) were significant for deficits in areas of working
memory, self-monitoring, and organization/planning ability. On the Behavioral Regulation Index (BRI),
significant problems were evident in his ability to inhibit responses, in his ability to shift attention between
tasks, and in the area of emotional control.
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The psychologist noted that although Tyrone did not have any of the physical features often associated with
fetal alcohol syndrome (FAS), such as dysmorphic facial features or microcephaly, he did exhibit a number of
abnormalities often associated with fetal alcohol effects (FAE), including small stature, delays in motor and
speech performance, poor coordination, and impulsive/hyperactive behaviors. Also, his poor social skills and
inability to consider the consequences of his behaviors are characteristics that often can make youth with FAE
vulnerable to gang recruitment and eventual problems with the law.
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Fetal Alcohol Spectrum Disorders (FASD)
There are several issues that have been raised concerning how to best define and diagnose FAS and other
variations that exist among those with fetal alcohol spectrum disorders (FASD). Currently, the term FASD is
used to refer to “the spectrum of structural anomalies and behavioral and neurocognitive disabilities” evident
in individuals who have been exposed to alcohol prenatally (Hoyme et al., 2005, p. 39). Individuals with FAS
present with cardinal diagnostic features, in various degrees of severity: facial anomalies, central nervous
system damage or dysfunction, and exposure to alcohol in utero (Hoyme et al., 2005). Although individuals
who have the more severe and physically recognizable form of FAS may be more readily diagnosed, many
cases of FAS often are undetected and undiagnosed (Little, Snell, Rosenfeld, Gilstrap, & Gant, 1990), while
those with more subtle forms of FASD are at even higher risk for going undetected (Astley & Clarren, 2000).
Controversy has also surrounded the term fetal alcohol effects (FAE), since the term has been used to refer to
such a wide variety of symptoms that it is often of little diagnostic value (Anase, Jones, & Clarren, 1995). In
1996, a study group of the Institute of Medicine (IOM) developed five diagnostic categories under the label of
FASD:
1. FAS with confirmed maternal alcohol exposure

2. FAS without any confirmed maternal alcohol exposure
3. Partial FAS with confirmed maternal alcohol exposure
4. ARND: alcohol-related neurodevelopmental disorder
5. ARBD: alcohol-related birth defects (Stratton, Howe, & Battaglia, 1996)
Children and youth with ARBD and ARND have normal faces, growth, and development, but those with
ARBD have specific structural malformations, while those with ARND demonstrate characteristics and
behavioral patterns typically associated with fetal alcohol exposure (Hoyme et al., 2005). One of the
characteristic problems facing children and youth with ARND is marked impairment in executive functioning
(EF) associated with poor judgment and failure to consider the consequences of their behaviors. EF is used to
describe cognitive abilities that are required to adequately perform complex tasks, including cognitive
flexibility, planning, organization, sequencing, response inhibition, and self-regulatory behaviors (Eslinger,
1996). Connor, Sampson, Bookstein, Barr, and Streissguth (2000) studied EF in individuals diagnosed with
FAS or FAE and controls. Results revealed that the mean IQ scores were higher for those with FAE (SS
mean = 90) than those with FAS (SS mean = 79) and that subjects with FAS and FAE performed poorer on
tasks of executive functions than would have been predicted by IQ alone. The researchers noted deficits in EF
related to “shifting or changing strategies, especially when there is uncertainty about which rules to employ”
and problems in interpersonal relationships due to an inability to detect subtle cues resulting in feeling isolated
or from being “prone to inappropriate behaviors that could get them into trouble both socially and legally”
(Conner et al., 2000, p. 351). Hoyme and colleagues (2005) list a number of characteristics commonly found
in the behavioral profile of children with FASD, including
problems with communication and speech (talking too fast or interrupting others), difficulties in
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personal manner (clumsiness, disorganization, and losing or misplacing things), emotional lability
(rapid mood swings, overreacting), motor dysfunction (difficulty playing sports), poor academic
performance (poor attention span and completing tasks), deficient social interactions (lack of
awareness of the consequences of behavior and poor judgment) and unusual physiologic responses
(hyperactivity and sleep disturbances). (p. 45)
In their study of 415 patients with FAS and FAE, Streissguth and colleagues (2004) found that 42% reported
placement in special education, 66% had received resource room assistance, and 65% had received remedial
help for reading and arithmetic. Adaptive scores from the Vineland Adaptive Behavior Scales and
performance on arithmetic were two of the greatest areas of deficit for both groups. Adverse life outcomes
were evaluated for five different areas: inappropriate sexual behaviors (ISB), disrupted school experiences
(DSE), trouble with the law (TWL), confinement (CNF), and alcohol and drug problems (ADP). Of the
study sample, 53% of adolescents had been suspended from school, 29% had been expelled, and 25% had
dropped out. The most common areas of school difficulty included problems with attention, incomplete work,
problems getting along with peers, and being disruptive in class. Sixty percent of adolescents and adults
reported TWL, with crimes against persons (45%), shoplifting/theft (36%), and assault (17%), the three most
common areas of criminal activity. Sixty-seven percent of adolescents had been charged, arrested, or
convicted, while 35% were actually incarcerated for a crime. Twenty-nine percent of adolescents admitted to
ADP. The authors found that one of the strongest correlates for adverse outcomes was age of diagnosis, with
the odds increasing from twice to four times the risk, if age of diagnosis was after 12 years of age. A
significant finding from the study was that patients with FAE had higher rates of adverse outcomes in all five
areas than those with FAS, and double the odds of TWL and ADP than those with FAS. Streissguth and
colleagues (2004) suggest that those with FAE, who do not have the physical features associated with FAS,
nevertheless are significantly impaired in academic and adaptive behavior.
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Gang Involvement
The number of youth who are members of gangs has increased over the past number of years, with estimates
of more than 650,000 youth who are gang members in the United States (Howell, 1998). Joining a gang can
increase the risk of participating in antisocial activities, which can result in incarceration, injury, and even
death (Hammond & Yung, 1993). There are two primary theories that have been developed to explain why
some youth join gangs: selection theory, which suggests that aggressive youth are drawn to gang activity (Staub,
1996); or socialization theory, which suggests that youth who join gangs become aggressive as they model gang
behaviors (Winfree, Backstrom, & Mays, 1994). In their longitudinal study of predictors for gang
membership, Lahey, Gordon, Loeber, Stouthamer-Loeber, and Farrington (1999) found some support for
selection theory, as youth who were already on an aggressive pathway were more likely to become gang
members. In their study, increased risk for gang membership was also predicted by having friends who
engaged in delinquent behaviors, and less parental supervision in early adolescence. In their study, 23.8% of
African American boys joined antisocial gangs prior to 19 years of age, compared to 3.9% of non-Hispanic
white males.
Race is a strong predictor of poverty and the problematic behaviors that may result, such as delinquency,
violence, and substance use (Dryfoos, 1990; McLoyd, 1998). However, individual differences exist in that not
all African American male youth experience the problematic behaviors associated with poverty and race
(Mincy, 1994). Taylor and colleagues (2003) examined characteristics of African American adolescent males
who were involved in gangs (GI) participating in criminal behaviors (drug use, violence) relative to African
American adolescent males who were involved in community groups (CG). Researchers found very different
attitudes and attributes among the two groups. Youth in CG were more likely to describe their parents as
supportive, as having rules, and as settling disagreements peacefully. As for drugs, while the CG sample
reported having as many friends who got high as did not, the GI youth were significantly more likely to
associate with friends who get high. Attitudes toward school were also highly discrepant, with the GI sample
attending school to socialize or to meet parent demands, while those from the CG sample attended school to
get a better job or go to college. With respect to role models, youth in the GI group were more likely to have a
“rapper” as a role model, and those in the CG sample were more likely to seek advice from a role model.
Brown (1998) interviewed African American gang members and their caregivers and concluded that there was
a pervasive sense of loss of hope and feelings that youth have no chance of making it outside of the gang.
Campbell (1992) found that many of the African American youth who joined gangs shared similar
backgrounds, such as living in poverty-stricken areas and coming from single-parent households, and often
joined a gang based on peer pressure, inability to find a job, and the need to belong. In his research on the
parents of gang members, Knox (1994) suggests that youth who have a low level of self-esteem is not nurtured
by parents may be able to recover if the self-esteem is nurtured by some other agency of socialization, such as
school or faith-based organizations. However, if this does not happen, then the youth will be socialized by the
gang. According to Vigil (2002), minority youth are subjected to multiple marginality, “living and working in
marginal situations and conditions,” where there is a breakdown of social control, and are socialized by the
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street and assume the street or “gang” identity (p. 8), as the gang replaces the family and becomes the family.
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Treatment/Prevention
FASD.
Of course, the best prevention for FASD is to increase awareness of the dangers of females drinking during
pregnancy. As there has been no safe amount of alcohol determined, abstinence is the best method.
Prevention programs can be launched on several levels, including primary/universal prevention (targeting all
pregnant females), secondary/selective prevention (targeting pregnant women who are at risk for drinking),
and tertiary/indicated prevention (targeting women who drink who become pregnant).
There is an increased risk for individuals with FASD to become involved in the juvenile justice system
(Streissguth et al., 2004; Streissguth & Kanter, 1997), due to problems in the areas of intellectual disabilities,
learning disabilities, hyperactivity, attention deficits, and poor social skills, which can increase their chances of
breaking the law. In their fact sheet on FASD and the juvenile justice system, the Substance Abuse and
Mental Health Services Administration (SAMHSA, 2007) suggests that youth with FASD can be impulsive
and not consider the consequences of their actions. Furthermore, their poor sense of personal boundaries,
susceptibility to peer pressure, and tendency to be easily led can all contribute to their vulnerability for
criminal and gang-related behaviors. Substance Abuse and Mental Health Services Administration
(SAMHSA; 2007) emphasizes many ways that youth with FASD pose a “challenge” to the judicial system,
including their inability to understand the process and communication problems. As a result, it is
recommended that youth should be screened for FASD at all entry points into the juvenile justice system to
ensure that if the condition exists, it can be detected. The resource also encourages attorneys to become aware
of FASD and the consequences that this can have in order to appropriately advocate for their client, in areas
of
competency (understand the charges and participate in their defense);

diminished capacity (ability to distinguish right from wrong);
decisions to decline/remand/waive (juvenile rather than adult facility);
sentencing (FASD as a mitigating factor); and
treatment (appropriate court-ordered interventions).
The SAMHSA (2007) report also cautions that incarceration may increase the risk of reoffending, due to the
iatrogenic effects of deviancy training from other youth in detention. It is also recommended that probation or
aftercare include a supervised and structured living situation, where life skills can be monitored and supported.
Given their cognitive limitations, it is unlikely that insight-oriented therapy would be beneficial; however,
training in ways to improve executive functions can assist in developing better skills to enable individuals to be
more successful in their relationships with others and in following through on task demands. Involvement in
community groups can also foster increased socialization with more normative peers and counteract gang
involvement.
Gang Involvement.
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Most gang members showcase their involvement by a form of dress, behaviors, hand signals, and tattoos
(Gaustad, 1990). Potential gang members are typically recruited when they reach the teen years, when
developmentally, adolescents are seeking a sense of belonging to a group and identity formation. The gang can
provide both (Reiboldt, 2001). While Latino members join gangs for a sense of “macho,” African American
youth join gangs to be “cool” (Hunt & Laider, 2001). In their study of gang member characteristics,
Esbensen, Winfree, He, and Taylor (2001) found these youth to be more impetuous and violent, engage in
more high-risk behaviors, and report less feelings of guilt.
There are a number of prevention programs that have been launched to reduce the successful recruitment of
new gang members. Vigil (2002) suggests that unless the policymakers understand why gangs formed from a
cultural and economic perspective, then intervention and prevention will not be possible. Further, he states
that a proactive approach is necessary and must begin in early childhood, in low-income areas, with secondary
prevention programs aimed at those children most at risk. Interventions must also focus on the critical preteen
years (9–12), when youth are at the optimum age for gang recruitment. Finally, tertiary intervention should
focus on those youth who have already joined a gang to recruit them back into society, not through punitive
means (incarceration), but by offering mentoring, tutoring, and counseling for them, as well as their families.
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Post-Case Questions
1. The concepts of equifinality (several possible pathways can lead to the same outcome) and multifinality (being raised in similar
circumstances can result in different outcomes) have been suggested to assist our understanding of the nature of different
developmental trajectories (Cicchetti & Rogosch, 1996). Although Neesha and Tyrone were siblings who were raised in the same
household, Neesha’s story is one of resilience, while Tyrone’s path has led to gang membership and the juvenile justice system.
What are some of the factors that have contributed to the negative outcomes that Tyrone has experienced?
2. There are many issues and different definitions for the fetal alcohol spectrum disorders (FASD). Which type of FASD is most
likely to apply to Tyrone, and what characteristics are most common in this form of FASD?
3. What are some reasons that gang membership was so attractive to Tyrone, and how is this complicated by FASD?
4. Name several ways in which a forensic assessment differs from a more conventional psychological assessment.
5. Why are so many individuals with FASD involved with the juvenile justice system, and what are the challenges that the juvenile
justice system must face in dealing with these cases?
6. In the Introduction to Chapter 1, several reasons were discussed for why children and youth raised by depressed mothers have
reported a number of negative outcomes, including social withdrawal, the acquisition of inappropriate social skills, increased risk
for psychopathology, as well as evidence of dysfunctional physiological systems associated with the ability to manage stress and
engage in social relationships such as cortisol response. Individual characteristics that have emerged as protective factors that can
buffer a child from the impact of having a depressed mother are having an easy temperament (as opposed to difficult
temperament) and having a higher IQ. Given Tyrone’s history and biological and psychological profile, what are the risks and
protective factors for him regarding the potential for positive or negative outcomes?
7. Suggested Individual or Group Presentation Activity: You have been invited to provide feedback to the court regarding Tyrone’s
assessment. What would be the focus of your presentation, and what would your recommendations be. How would you prepare
for your presentation (who would you interview and what additional data would you want to collect), and who would you want to
be in attendance at that session, for potential questioning. How could each participant potentially contribute information to assist
with developing an intervention plan that would best meet Tyrone’s needs?
332
References
American Academy of Child and Adolescent Psychiatry. (2004). Practice parameter for the assessment and
treatment of youth in juvenile detention and correction facilities. Retrieved from http://www.aacap.org
Anase, J. M., Jones, K. L., & Clarren, S. K. (1995). Do we need the term “FAE”? Pediatrics, 95, 428–430.
Astley, S. J., & Clarren, S. K. (2000). Diagnosing the full spectrum of fetal alcohol exposed individuals:
Introducing the 4-digit diagnostic code. Alcohol, 35, 400–410.
Brown, W. B. (1998). The fight for survival: African-American gang members and their families in a
segregated society. Juvenile and Family Court Journal, 49, 1–14.
Campbell, A. (1992). Black single female headed households and their children’s involvement in gangs. In M.
Carlie, (2002), Into the abyss: A personal journey into the world of street gangs. Retrieved from
http://faculty.missouristate.edu/m/MichaelCarlie/Preface/preface.htm
Cicchetti, D., & Rogosh, F. A. (1996). Editorial: Equifinality and multifinality in developmental
psychopathology. Development and Psychopathology, 8, 597–600.
Connor, P. D., Sampson, P. D., Bookstein, F. L., Barr, H. M., & Streissguth, A. P. (2000). Direct and
indirect effects of prenatal alcohol damage on executive function. Developmental Neuropsychology, 18,
331–354.
Dryfoos, J. G. (1990). Adolescents at risk: Prevalence and prevention. New York, NY: Oxford University
Press.
Esbensen, F., Winfree, L., He, N., & Taylor, T. (2001). Youth gangs and definitional issues: When is a gang
a gang, and why does it matter? Crime & Delinquency, 47, 105–130.
Eslinger, P. J. (1996). Conceptualizing, describing and measuring components of executive function: A

summary. In G. T. Lyon & N. A. Krasnegor (Eds.), Attention, memory and executive function (pp.
367–395). Baltimore, MD: Paul H. Brookes.
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Gaustad, J. (2000). Gangs (ED321419). Retrieved from http://files.eric.ed.gov/fulltext/ED321419.pdf
Hammond, R. W., & Yung, B. (1993). Psychology’s role in the public health response to assaultive violence
among young African American men. American Psychologist, 48, 142–154.
Howell, J. C. (1998). Youth gangs in the United States: An overview. Washington, DC: Office of Juvenile
Justice and Delinquency Prevention.
Hoyme, H. E., May, P. A., Kalberg, W. O., Kodituwakku, P., Gossage, P., Trujillo, P., . . . & Robinson, L.
K. (2005). A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: Clarification of the
1996 Institute of Medicine criteria. Pediatrics, 115, 39–47.
Hunt, G., & Laider, K. (2001). Alcohol and violence in the lives of gang members. Alcohol, Research and
Health, 25, 66–71.
Knox, G. W. (1994). An introduction to gangs. Bristol, IN: Wyndham Hall Press.
Lahey, B. B., Gordon, R. A., Loeber, R., Stouthamer-Loeber, M., & Farrington, D. P. (1999). Boys who
join gangs: A prospective study of predictors of first gang entry. Journal of Abnormal Child Psychology, 27,
261–276.
Little, B. B., Snell, L. M., Rosenfeld, C. R., Gilstrap, L. C., & Gant, N. F. (1990). Failure to recognize fetal
alcohol syndrome in newborn infants. American Journal of Disabilities in Children, 144, 1142–1146.
McLoyd, V. C. (1998). Children in poverty: Development, public policy, and practice. In W. Damon (Ed.),
I. E. Sigel, & K. A. Renninger (Vol. Eds.), Handbook of psychology: Vol. 4. Child psychology in practice
(5th ed., pp. 135–208). New York, NY: Wiley.
Mincy, R. B. (1994). Conclusions and implications. In R. B. Mincy (Ed.), Nurturing young black males:
Challenges to agencies, programs, and social policy (pp. 187–203). Washington, DC: Urban Institute
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Reiboldt, W. (2001). Adolescent interactions with gangs, family and neighborhoods: An ethnographic
investigation. Journal of Family Issues, 22, 211–242.
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epidemiology, prevention, and treatment. Washington, DC: National Academy Press.
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factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Developmental and
Behavioral Pediatrics, 25, 226–238.
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secondary disabilities. Seattle: University of Washington Press.
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juvenile justice: How professionals can make a difference. Retrieved from
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Taylor, C. S., Lerner, R. M., von Eye, A., Bobek, D., Balsano, A. B., Dowling, E., & Anderson, P. M.
(2003). Positive individual and social behavior among gang and nongang African American male
adolescents. Journal of Adolescent Research, 18, 496–522.
Vigil, J. D. (2002). A rainbow of gangs. Austin: University of Texas Press.
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and youth gangs: A new twist on a general theory of crime and delinquency. Youth and Society, 26,
147–177.
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Chapter 4 Introduction to Anxiety and Compulsive Disorders
Compared to the behavioral disorders, which are externalizing disorders that are often highly visible,
disruptive, and disturbing to others, the anxiety disorders can often go undiagnosed because they are behaviors
that are more subtle and internalized within the self. Other disorders that share similar overcontrolled features
include depression and somatic complaints, which can often be comorbid with anxiety disorders.
Over time, the DSM has changed the way that anxiety disorders in children have been conceptualized. While,
the DSM-III (APA, 1980) recognized three anxiety disorders of childhood (separation anxiety disorder,
avoidance disorder, and overanxious disorder), the DSM-IV-TR (APA, 2000) included only separation
anxiety disorder (SAD) in the category of Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence,
although the symptom criteria for all other anxiety disorders were expanded to include descriptions of child-
oriented symptoms in the text revision. In keeping with the move toward a more developmentally oriented
perspective, the DSM-5 (APA, 2013) lists all anxiety disorders in the section on Anxiety Disorders.
Although the actual symptom criteria for the anxiety disorders remain consistent with the previous version of
the DSM-IV-TR (APA, 2000), in addition to medically or substance-induced disorders, the chapter on
anxiety disorders is arranged developmentally (based on age of typical onset) and now includes discussions of
separation anxiety disorder (SAD), selective mutism, specific phobia, social anxiety disorder (social phobia),
panic disorder, panic attack specifier, agoraphobia, and generalized anxiety disorder (GAD). Selective mutism
is new to this category and was previously included as one of the Other Disorders of Infancy, Childhood or
Adolescence along with separation anxiety disorder, reactive attachment disorder, and stereotypic movement
disorder. Missing from the category of anxiety disorders are the stress disorders (posttraumatic stress disorder
[PTSD], acute stress disorder), which are now found in the section on Trauma and Stressor-Related Disorders,
and obsessive compulsive disorder (OCD), which has been relocated to a new section, Obsessive-Compulsive
and Related Disorders. In this chapter, we will discuss cases that include symptoms of SAD, selective mutism,
GAD, OCD, and social anxiety. Cases related to trauma (reactive attachment disorder, nonsuicidal self-
injury) and stress-related disorders (PTSD) are presented in Chapter 7.
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Anxiety and Anxiety-Related Disorders
Anxiety disorders share common traits of excessive fear and worry that go beyond what is developmentally
appropriate and persist longer than what would be expected given a normal adjustment period (lasting longer
than 6 months). Although the anxiety disorders share reactions of excessive fear and avoidance, the nature of
the situation or event that induces the response will determine the type of anxiety disorder that is present. For
example, persistent fear of harm to a caregiver would suggest symptoms of SAD, while a sense of free-floating
anxiety and worry across a variety of situations or events may signal GAD. Individuals with specific phobias
have an excessive fear and avoidance of an anxiety provoking situation or event or object (e.g., fear of heights
or animals), while those with social anxiety disorder are fearful of being humiliated or embarrassed while in
the company of others unfamiliar to them. The DSM emphasizes that panic attacks can accompany a variety
of different mental disorders; however, the attack itself is not a mental disorder, whereas panic disorder is
diagnosed when individuals fear having panic attacks to the extent that it interferes with normal functioning.
Agoraphobia is diagnosed if an individual avoids two or more situations because of excessive fear of having a
panic attack, including public transportation, open spaces, enclosed spaces, crowds, or being outside the home.
The following summaries provide an outline of DSM criteria for anxiety disorders discussed in this chapter:
Separation anxiety disorder (SAD): Individuals with SAD have an excessive fear of being separated from their
caregiver, lasting for at least 4 weeks, evident in at least three symptoms, including persistent and recurrent
distress or worry, resulting from
separation or the expectation of separation from the caregiver,

fears of harm to the caregiver,
fear of an event that will result in separation (accident, illness),
refusal or reluctance to leave home or caregiver,
refusal to sleep away from home,
nightmares about separation, or
anticipation or fear of separation results in physical complaints or symptoms.
The distress is not accounted for by refusal to change or adherence to rituals as noted in autism spectrum
disorder (APA, 2013, p. 191).
Selective mutism.
Children diagnosed with selective mutism refuse to speak in certain social situations (e.g., school) despite
being able to speak in other situations (e.g., home). Their reluctance to speak in these specific situations is not
related to any sense of discomfort in speaking, lack of language fluency, or any communication disorder. The
condition must persist for at least 1 month, excluding the first month of school (APA, 2013, p. 195).
Generalized anxiety disorder (GAD).
Individuals diagnosed with GAD will present with symptoms of excessive and pervasive anxiety and worry
337
regarding events or activities related to day-to-day functioning and performance (school or work), lasting for
at least 6 months. While adults with GAD must present with three of more symptoms from a list of six
possible symptoms, only one symptom is required for a diagnosis in children: restlessness, ease of fatigue,
problems concentrating, irritability, muscle tension, and sleep disturbance (APA, 2013). The nature of worries
tends to vary developmentally with children and adolescents exhibiting concerns related to performance at
school or in sports, while adult worries tend to focus on family well-being or health-related concerns.
Social anxiety disorder.
Social anxiety disorder occurs when an individual has a marked fear or anxiety associated with social situations
where the individual is exposed to possible evaluation or judgment by others and fears embarrassment or
humiliation as a result. The social activities may include such situations as having a conversation with
someone, meeting unfamiliar people, or eating, drinking, or performing in the presence of others. For
children, the fear or anxiety must occur in the presence of peers, not just adults. Often the situations are
avoided because they are so anxiety provoking.
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Obsessive Compulsive and Related Disorders
Although the diagnostic criteria for obsessive compulsive disorder (OCD) have not changed from the previous
edition of DSM-IV-TR (APA, 2000), the disorder has been relocated to a newly created chapter, Obsessive
Compulsive and Related Disorders, which includes such disorders as OCD, body dysmorphic disorder, hoarding
disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder. Disorders in this
chapter share features of preoccupations and repetitive behaviors that are excessive and beyond what would be
expected given an individual’s developmental level or insight.
Obsessive compulsive disorder (OCD).
Individuals with OCD experience intrusive obsessions (recurrent and persistent thoughts, urges, images) that
they attempt to neutralize or suppress through some action (e.g., compulsion), or compulsions (repetitive
behaviors or mental acts) performed in order to reduce anxiety associated with a situation or event, or they
experience both obsessions and compulsions. These obsessions or compulsions are pervasive, consuming more
than 1 hour daily. Individuals with OCD can demonstrate various levels of awareness, from good/fair insight,
to poor insight, or with absent insight and delusional beliefs (APA, 2013, p. 238). Common forms of OCD
include contamination (cleaning or hand-washing compulsions), symmetry (ordering, arranging), and safety
(checking).
Trichotillomania (Hair-Pulling Disorder).
Trichotillomania is a repetitive behavior that involves hair pulling often resulting in hair loss in a specific area
(eyelids, scalp, eyebrows, etc.). The act of hair pulling causes significant distress (embarrassment, feeling of
loss of control), as does repeated attempts to not engage in the activity. Females are significantly more likely
to engage in trichotillomania than males (ratio of 10:1), although among children there is a minimal gender
difference (APA, 2013).
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References
340
Case 13 Winnie Kent Silence Is Not Golden Separation Anxiety
Disorder; Selective Mutism
Winnie, a 5½-year-old girl, was referred for assessment by her pediatrician. Winnie was accompanied by her
mother, Isabel. Despite being a seemingly normal and talkative youngster at home, Winnie had always been
rather shy and reticent in larger group settings. Although her mother had anticipated some early reservations
on Winnie’s part regarding her initial school placement, Isabel was totally unequipped to deal with the current
situation, which had developed over the past 6 months of enrollment in the kindergarten program.
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Isabel Kent and her husband Frank were both in their early 40s. They met and married while attending
graduate school. Frank is an engineer, and Isabel is currently a stay-at-home mom. Prior to Winnie’s birth,
Isabel was a research assistant for a pharmaceutical company. Isabel stated that there was no serious mental
illness on either side of the family, although she described herself as “high-strung” and a bit of a loner. She felt
that her husband was a workaholic because he spent the majority of his time either working or thinking about
working. She described their marriage “as successful as most enduring marriages.”
Isabel stated that although Winnie is an only child, it was not by choice. The pregnancy was planned and it
was decided that when the baby was born, Isabel would quit her job and devote her time to child rearing.
Although the plan was to have two or three children, Isabel suffered a miscarriage when Winnie was about 14
months old, and then a second miscarriage about 5 months later. Isabel described herself as depressed during
this period with frequent bouts of crying and fatigue. Her physician suggested a trial of Prozac; however,
Isabel developed headaches and nervousness and agitation as side effects. A trial of Paxil produced fewer side
effects and eventually, with the help of Paxil, Isabel was coping much better. Because of the risk of
complications in pregnancy, given Isabel’s age, and fear of the depression returning if she had another
miscarriage, the Kents decided to abandon any further attempts to conceive a child.
Winnie weighed 5 pounds 6 ounces at birth, and although pregnancy and delivery were normal, complications
developed later on. Immediately after the birth, an attempt to intubate a blocked nasal passage resulted in
swelling. Winnie was fed intravenously and required an artificial airway until the swelling subsided and
surgery could finally be performed to remove the membrane that was blocking the nasal passage. During this
time, Winnie experienced what her mother described as “blue spells,” a term she used to describe the color of
Winnie’s face and body resulting from lack of oxygen. Isabel said that this was a very emotionally draining
time for her. Isabel was very fearful and anxious concerning Winnie’s health, even though the medical staff
assured her that Winnie would be fine. Winnie remained in the neonatal intensive care unit for 3 weeks
before Isabel could take her home from the hospital.
As an infant, Winnie had bouts of being fretful and colicky, and she had some difficulties keeping her food
down. Mrs. Kent recalled that at least twice a week, if not more, Winnie would lose almost half her intake in
rather severe episodes of projectile vomiting. Mrs. Kent was concerned and asked the pediatrician about it, but
his response was that it was likely due to a sensitive and immature digestive system. He suggested they change
the baby formula; that helped somewhat, but the matter never really resolved itself until Winnie was totally on
solid food. Mrs. Kent stated that even today, Winnie is a picky eater, and if she is upset, she tends to eat very
little because her stomach is easily upset.
Motor milestones were slightly advanced developmentally, and Winnie was sitting independently at 4 months,
standing at 7 to 8 months, and walking at 10 months of age. Language development lagged behind motor
skills. Winnie did not say her first word until about 15 months, and simple sentences weren’t produced until
about 2½ years of age. Winnie had some articulation problems and substituted a few sounds, the most
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prominent of which were “w” for “r” (wabbit for rabbit) and “1” for “y” (lellow for yellow). The articulation
errors stopped about a year ago. Currently, Isabel believes that Winnie’s speech is normal for her age, based on
conversations between Winnie and her best friend Kate’s daughter, Molly, who is almost the same age as
Winnie. At home, she described Winnie as very chatty and quite the conversationalist, with speech far more
adult-like than childlike.
Isabel described herself as somewhat aloof and not one to initiate a lot of social contact. She was fortunate
that Kate lived across the street, since Winnie and Molly were about the same age and played very well
together. Kate was more outgoing than Isabel and was often responsible for organizing activities for the
foursome, such as outings to the park, or attending movies or concerts. Isabel and her husband Frank rarely
went out in the evenings, due to Frank’s long work hours; but when they did, Winnie would just go over and
spend the night at Kate’s house with Molly. Similarly, Molly would spend the night with them whenever Kate
and Brian went out for an evening. People often mistook Winnie and Molly for twins, since they were about
the same age and looked somewhat alike. Unfortunately, about 9 months ago, Brian was suddenly transferred
and the family moved out of state. Isabel said that until the separation, she never really realized how much
time the four of them had spent together. Isabel said that she really misses Kate’s company and she is sure that
Winnie must really miss Molly, too, although she doesn’t talk about Molly very much. Isabel wondered if she
were grieving in silence or just didn’t feel as strongly as an adult might.
About 2 months after Kate and Molly left, Isabel decided to enroll in a Tuesday morning art class at the local
gallery and enroll Winnie in a once-weekly preschool program for that morning. Isabel thought that this
would be good for both herself and Winnie. However, when she tried to drop Winnie off at the preschool
center, Winnie had a severe temper tantrum, attached herself to her mother’s leg, and began sobbing
uncontrollably. Isabel was in shock since she had never seen such behavior from Winnie before. Isabel stayed
with Winnie for the next half hour hoping that Winnie would calm down. Eventually, sobs dissipated into
heaving sighs and Isabel decided to make another attempt to leave. On cue, Winnie’s sobs began again, this
time even more violently and accompanied by screaming and begging her mother not to go. The preschool
staff encouraged Isabel not to give in to Winnie at this point, since it would only make matters worse. Isabel
left, without looking back, afraid if she saw Winnie, she would not be able to carry on. When Isabel returned
3 hours later, Winnie looked as though she was totally drained. She was engaged in subdued solitary play in
the corner, rocking her doll. Her eyes were red and swollen from crying. The preschool staff said that she
continued with her sobbing for quite some time after Isabel had left. That night, Winnie was like Velcro and
refused to sleep alone. The whole ordeal was far more than Isabel had bargained for. The next night, had it
not been for Frank’s insistence that Winnie sleep in her own bed, the nightly ritual probably would have
continued. As it was, Winnie started calling out at night, and often Isabel would have to go into Winnie’s
bedroom to comfort her. Isabel ended up sleeping in Winnie’s room the next night because Winnie had a
nightmare that her mom had gone away. Isabel started leaving the light on in Winnie’s bedroom so she would
not be afraid of the dark.
The following Tuesday, Winnie started crying when Isabel began to prepare to leave. Winnie started to
complain that her stomach was hurting and held on tightly to her stomach saying, “It hurts, it hurts.”
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Although Isabel could not be definite, she was pretty sure that Winnie was saying she was sick and wanted to
stay home. Rather than give in, she picked Winnie up and carried her to the car, with Winnie sobbing and
complaining about her aching stomach. The tears, the sobbing, the protests, and the aches and pains
continued every Tuesday for the next 3 months. Eventually, Winnie would comply but began to sit beside the
preschool window waiting and watching for signs of her mother’s return. When they were home, Winnie was
constantly in need of reassurance that her mother was all right and that everything was okay.
Despite the difficulties, Isabel persisted in taking Winnie to preschool because kindergarten would be starting
shortly, and Isabel knew Winnie had to become more prepared. Winnie was having considerable difficulty
adjusting to preschool, which was only one day a week. How would she cope with kindergarten on a daily
basis? She also needed more practice socially. She seemed so withdrawn at the preschool and didn’t seem to
interact with the other children. Her teachers said that she was very cooperative, but she didn’t seem
comfortable talking to anyone.
Isabel was thrilled when a new family moved in a few doors down the road because they had a daughter
Winnie’s age. Isabel really pushed herself to be more social and extended an invitation to the new mother and
daughter to come over for afternoon tea. Winnie seemed to get along well with her new friend and soon they
were playing together, much like she and Molly had. After a few months, Winnie was invited to a sleepover at
Becky’s. Although the girls had planned the event for some time, Winnie began to get anxious just before it
was time to leave. She asked an endless series of questions about what her mother would be doing in her
absence. Isabel continued to reassure her that she was just going to take a bath and watch television. Winnie
immediately became concerned that her mother might slip in the bathtub and if nobody else was home, she
could drown. Isabel continued to attempt to calm Winnie’s fears. Finally, Becky and her mother came to pick
up Winnie for the sleepover. Winnie’s goodbye hug was more like a desperate attempt to carry her mother
along with her. Two hours later, Winnie was standing at the door, sleeping bag in tow, complaining that she
had to come home because she didn’t feel well.
Kindergarten finally started and after much struggle and distress, Isabel finally got Winnie to walk to school
with her friend Becky. Winnie would walk beside Becky with her head bent down, constantly looking
sideways to see if her mother was still watching from the outside steps. The school was only a block away, and
Winnie told herself that if she looked really hard, she could probably see her house between the trees. At
school, Winnie just seemed to go through the motions until it was home time. On the playground, she was
always peering through the fence, trying to see her house. Her teachers were very patient and encouraging,
and Winnie was cooperative, but she would not participate verbally in any activities that were going on. For
the first month, her teachers thought it was just a case of reluctance to talk in the new environment. After all,
Winnie did appear to be very shy, and her mother had cautioned the kindergarten teachers that Winnie was
slow to warm up. They anticipated that it might take a while for her to feel comfortable talking to the teachers
and the other children. However, 4 months had gone by and Winnie had not said a word. When asked a
question, Winnie would nod her head in the affirmative or shake her head to signal “no,” but no words
accompanied the gestures. Winnie would talk only to Becky at school, and then only in whispers, until they
got far enough away from the schoolyard that no one could hear. Then she would talk to Becky as if they were
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at home.
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Reason for Referral
Isabel finally brought Winnie to the pediatrician for help, not understanding why her daughter was giving the
school situation the silent treatment. The pediatrician suggested that Isabel take Winnie to see a child
psychologist, who could evaluate the causes of Winnie’s silent behaviors and suggest ways to best deal with
this behavior in the school.
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Assessment Results
When Isabel contacted the psychologist at the clinic, prior to seeing Winnie in the clinic, the psychologist
requested permission to observe Winnie in the classroom. Isabel was very much in agreement. After observing
Winnie for a morning and interviewing her teachers, the psychologist sat beside Winnie and asked her to
draw a picture for her. Winnie drew a picture of a little girl skipping. The psychologist found it interesting
that the skipping rope surrounded the little girl’s head, as if her head were in a space capsule. The drawing was
sophisticated enough, however, to suggest that Winnie was likely, at least, of average intelligence. The
psychologist contacted Isabel and suggested she bring Winnie to the clinic for a comprehensive assessment.
Isabel brought Winnie to the clinic the following week. Winnie would not go into the assessment room unless
her mother came with her. Throughout the assessment, Winnie would not speak directly to the psychologist
or answer any questions verbally. On occasion, Winnie would bend over toward her mother and whisper
something into her mother’s ear. But even on these occasions, she would cup her hand around her mouth,
blocking the psychologist from any entry into her verbal world.
Winnie’s drawing of a person (Draw-a-Person) and Bender Visual Motor Gestalt designs were all within the
average range. Scores on the Peabody Picture Vocabulary Test (PPVT-IV) also revealed an understanding of
vocabulary that was above the expected level for her age (SS = 110). The psychologist asked Winnie’s teacher
and mother to complete the Behavioral Assessment System for Children (BASC2) Preschool Scales. Based on
Winnie’s responses to the school setting, Mrs. Kent rated Winnie in the clinical range for Adaptability;
however, all other ratings were within the norm. Winnie’s teacher rated clinical elevations for Anxiety,
Atypicality, Adaptability, and Social Skills.
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348
Separation Anxiety Disorder
Anxiety disorders can result from a combination of genetic factors (heredity, inhibited temperament) and
environmental factors, such as cumulative risks, exposure to traumatic events or repeated exposure to negative
outcomes, and overprotective parenting practices (Ollendick, Vasey, & King, 2001; Vasey & Dadds, 2001).
Although most infants go through normal anxieties related to separation from caregivers, which usually
decline after 2 years of age, for some children, separation anxiety may intensify and persist well into early
childhood (Kearney, Sims, Pursell, & Tillotson, 2003). Separation anxiety disorder (SAD) is an intense
emotional response resulting from excessive worry surrounding the possibility of separation from the caregiver.
The DSM-5 (APA, 2013) lists a number of possible symptoms of the disorder resulting from excessive
distress, fears of harm coming to the caregiver, and fears of being alone (see Appendix D for the complete list
of criteria). Because it is so painful for the child to separate from the caregiver, young children will often
refuse to participate in activities that remove them from their caregiver. As a result, approximately 75% of
children with SAD will demonstrate school refusal when it is time to begin school, or refuse to return to
school following an absence due to illness or a school move (Black & Uhde, 1995; Kearney & Albano, 2004).
While some research has linked SAD to problematic or chaotic home environments (Egger, Costello, &
Angold, 2003; Kearney et al., 2003), other findings have suggested that children are at increased risk for SAD
if their mothers were diagnosed with an anxiety or major depressive disorder (Biederman et al., 2001). Deiner
and Kim (2004) found that mothers who reported feelings of separation anxiety, themselves, were significantly
more likely to have children who evidenced social withdrawal and problems with self-regulation. In their
study, Dallaire and Weinraub (2005) reported that children who were classified as insecurely attached at 15
months of age demonstrated significantly higher levels of separation anxiety at 6 years of age compared to
securely attached peers.
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Selective Mutism
Although selective mutism was initially thought to be a rare disorder (e.g., ranging between .03 and 1%),
according to the DSM-5 (APA, 2013), some studies have found as many as 7 children in every 1,000 in
kindergarten through second grade meet criteria for the disorder (Bergman, Piacentini, & McCracken, 2002),
with prevalence rates ranging between .7 and 2% of early elementary school children (Kopp & Gillberg, 1997;
Kumpulainen, Rasanen, Raaska, & Somppi, 1998). Prevalence rates have been reported as disproportionately
higher among female populations (Cunningham, McHolm, Boyle, & Patel, 2004; Kumpulainen et al., 1998).
There has been controversy about how the disorder should be conceptualized relative to other childhood or
anxiety-related disorders. Although the DSM-IV-TR (APA, 2000), placed selective mutism among one of the
five disorders listed under the category of Other Disorders of Infancy, Childhood or Adolescence (separation
anxiety disorder, reactive attachment disorder, stereotypic movement disorder, and disorder of infancy,
childhood, or adolescence NOS), the DSM-5 (APA, 2013) has located the disorder within the chapter on
anxiety disorders. Since a number of studies have found that children with selective mutism also meet
diagnostic criteria for social phobia (social anxiety disorder), some researchers have suggested that selective
mutism be considered as a subtype of social phobia (Black & Uhde, 1995; Kristensen, 2000) while
Cunningham, McHolm and Boyle (2006) provide some evidence in favor of considering two subtypes of
selective mutism (generalized versus specific mutism), similar to subtypes of social phobia, although their
study suggests that both types share significant socially phobic behaviors and deficits in social skills.
Black and Uhde (1992) have suggested that since the onset of the disorder often coincides with initial school
entrance for the majority of children, an underlying feature of the disorder may be school refusal. However,
the DSM attempts to control for this issue by criteria that state that the disorder must be present for at least 1
month “not limited to the first month of school” (APA, 2013, p. 195). Issues regarding how the disorder
should be conceptualized have affected research, diagnosis, assessment, and treatment. There has been
significant debate regarding whether selective mutism should best be conceptualized as an early precursor to
social phobia (Krysanski, 2003). However, while selective mutism has onset most likely in the 4- to 7-year
range, social phobia is most likely to have onset in adolescence, which makes this line of reasoning difficult to
support.
There have been a number of suggestions regarding how to best classify variants of the disorder. Although
initially called elective mutism (DSM-III; APA, 1980), current emphasis is on the “selective” nature of those to
whom the child will speak. As noted earlier, Cunningham et al. (2006) suggested classifying groups with
selective mutism along criteria used for social phobia: generalized (for those whose symptoms are
demonstrated across a variety of situations) and specific (for those whose symptoms are restricted to speaking
in classrooms at school). Cunningham and colleagues (2006) found that children with the generalized variant
of selective mutism experienced more symptoms of obsessive thinking, somatic complaints, and depression
and were less proficient socially than controls, leading the authors to suggest that the generalized variant was
the more severe form of selective mutism, although as previously mentioned, both groups shared similar
significant results when compared to controls. Another form of categorizing for the disorder has suggested
350
division along the dimension of passive, shy, fearful, and insecure behaviors versus noncompliant and resistant
types of responders (Lesser-Katz, 1988). However, more recent research suggests that the vast majority (90%)
of children with selective mutism will conform to the anxious-compliant type (Black & Uhde, 1995; Drummit
et al., 1997). Finally, Beidel and colleagues (Beidel, Turner, & Morris, 1999) outline several areas of social
anxiety in children that might be seen to overlap with selective mutism, such as fears of reading aloud in class,
joining in on conversations, speaking to adults, and starting conversations.
351
Treatment for Separation Anxiety Disorder and Selective Mutism
Separation Anxiety Disorder.
Treatments that have been successful for children’s phobic disorders have also been successful for treating
separation anxiety disorder (Werry & Wollersheim, 1991). In their extensive review of treatments for
childhood phobic disorders, Ollendick and King (1998) found one well-established method (contingency
management) and a number of probably efficacious treatments (systematic desensitization, modeling,
cognitive–behavioral). Contingency management relies on principles of operant conditioning and differs
fundamentally from the other approaches discussed. Conceptually, while systematic desensitization, modeling,
and cognitive–behavioral methods share a belief that reducing the fear is a necessary precursor to increasing
the desired behaviors, contingency management focuses directly on increasing the desired behavior through
rewarded practice. Using contingency management methodology, a child afraid of the dark would be rewarded
for spending time in the dark, resulting in increased dark tolerance (Leitenberg & Callahan, 1973). Applying
these methods to separation anxiety disorder (SAD), children would be rewarded for spending time away
from their caregiver and for developing greater tolerance for separation. Using cognitive–behavioral methods
to reduce fear of the dark might involve modeling and verbal rehearsal to assist children to generate positive
self-statements. Graziano and Mooney (1980, 1982) combined parent reward for “brave statements” with
“brave” self-statement training, relaxation training, and imagined positive scenes to successfully reduce fear of
the dark in young children. Ollendick and King (1998) reviewed several modeling techniques and concluded
that although modeling is generally successful, participant modeling (actual engagement with the feared
object, in conjunction with observation of the model) is the superior method.
Systematic desensitization (Wolpe, 1958) was a procedure designed to incorporate two inherent assumptions:
(1) fears are conditioned responses (learned behaviors) and can be deconditioned (unlearned), and (2) fear or
anxiety and relaxation are two competing and incompatible responses. Although there are variations on the
method, at its basis, systematic desensitization involves the following steps:
a. lessons in deep muscle relaxation,

b. creation of a fear hierarchy (least to most fearful), and
c. graduated pairings of the feared thought with deep muscle relaxation.
Feared thoughts can involve actual behaviors (“in vivo”) or “mental images.” An interesting variation that has
been used successfully with children is emotive imagery (Cornwall, Spence, & Schotte, 1997; Lazarus &
Abramowitz, 1962). In this variation, emphasis is placed on conquering the fear, rather than on pairing the
feared responses with relaxation, and “child mastery” becomes the antidote to fear. Children participate in
creating exciting stories, and as their heroes defeat the elements of the fear hierarchy, a new sense of control
and mastery develops to replace the anxiety and fear.
In a recent study of cognitive–behavioral therapy (CBT) for youth (7 to 14 years of age) with a principal
diagnosis of separation anxiety disorder (47), generalized anxiety disorder (88), or social phobia (63), Suveg
and colleagues (2009) found comparable results for individual child-focused CBT and child-focused family
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CBT in decreasing symptoms and improving adaptive functioning. Furthermore, a family-based education
support and attention approach (a 16-session treatment featuring education about youth anxiety and providing
attention and support, but not including any training in how to manage anxious responses or exposure tasks)
also proved to be equally effective.
Selective Mutism.
Graduated behavioral exposure treatments (systematic desensitization) can also be very helpful in the
treatment of selective mutism (McHolm, Cunningham, & Vanier, 2005; Stone, Kratochwill, Sladeczek, &
Serlin, 2002).
Currently, given the research findings, selective mutism is considered by most to be a form of anxiety disorder
(Anstending, 1999). It is not surprising, then, that CBT, which has been so successful in treating childhood
anxiety disorders (Kendall, 1994), is under current investigation regarding its potential role in the treatment of
selective mutism. Given the high rates of comorbidity with social phobia, behavior therapies often used in the
treatment of phobias have also been adapted for use in treating selective mutism. A third avenue of treatment
for the disorder is a pharmacological approach.
Various theories about selective mutism have been advanced, including psychodynamic (fixation at the anal
stage), family systems (enmeshment and overprotection), behavioral (avoidance), and cognitive (maladaptive
thinking). Success has been minimal for the psychodynamically oriented therapies, such as play therapy or
family therapy (Dow, Sonies, Scheib, Moss, & Leonard, 1995).
Behaviorally based treatments that combine multimodal techniques have been the most successful (Sluckin,
Foreman, & Herbert, 1991). Kehle, Hintze, and DuPaul (1997) outline several behavioral interventions that
have been successfully integrated into treatment programs, including contingency management (rewarding
speech and ignoring silence); shaping and fading (e.g., reward speech in school in the presence of mother;
gradually remove mother’s presence); minimizing escape and avoidance, by ignoring attempts to escape or
avoid and rewarding any efforts to approach or engage; and self-modeling of videotaped presentations of
desired behaviors (Kehle et al., 1997). Blum and colleagues (1998) investigated the potential use of audiotape
recordings as a self-modeling technique. Results were very encouraging, suggesting that this easy-to-use and
brief technique can provide a successful intervention approach for use in school settings. Fung (2002) recently
adapted a CBT program for children (Coping Bear Workbook; Mendlowitz et al., 1999) into a web-based
Internet program for selective mutism and reports success in alleviating symptoms of selective mutism in a 7-
year-old child. In cases where behavioral interventions are not successful, selective serotonin reuptake
inhibitors (SSRIs) have met with success, especially if anxiety is a comorbid feature (Black & Uhde, 1994;
Dow et al., 1995).
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Post-Case Questions
1. Does Winnie meet the DSM-5 criteria for separation anxiety disorder (SAD) and selective mutism? If so what symptoms are
evident? If not, why not?
2. There are several models that can be advanced to explain the sequential development of internalizing disorders, such as anxiety
disorders and the factors that might be responsible for variable outcomes. From the perspective of the diathesis-stress model, an
inherited genetic vulnerability to anxiety may remain dormant until environmental conditions are adverse (e.g., peer rejection,
family conflict, parent psychopathology, depression), causing the disorder to become overt (Kazdin & Weisz, 1998). In addition,
temperamental factors such as behavioral inhibition may also account for why one child may be more vulnerable to stressful or
unfamiliar surroundings than another child (Kagan & Snidman, 1991). Discuss how Winnie’s separation anxiety might be
explained using the diathesis-stress model.
3. There are a number of possible theories that can be suggested to account for the etiology or development and onset of separation
anxiety disorder (SAD). There is some support to suggest that children with SAD come from families that share a greater
prevalence for anxiety and mood disorders (Black & Uhde, 1995). Attachment theory might predict that an anxiously attached
infant might be more prone to develop SAD than a securely attached or resistant infant. Discuss the onset and development of
Winnie’s SAD as a psychologist from each of the following perspectives: behavioral, cognitive, and psychodynamic. Suggest
possible treatment alternatives that might be developed for each of these perspectives relative to probable cause.
4. Discuss how selective mutism might be influenced by the various contexts of development, using Bronfenbrenner’s model:
individual characteristics, immediate environment, social and economic factors, and cultural factors.
5. Develop a case formulation for Winnie, based on factors discussed in Chapter 1, “Introduction: Understanding the Complexities
of Child and Adolescent Psychopathology,” from the perspectives of the family systems and attachment theories. What
therapeutic interventions would you recommend that are consistent with these frameworks?
6. Suggested Individual or Group Presentation Activity: The principal has called a parent–school meeting to discuss concerns about
Winnie’s poor social interaction skills and her lack of verbalization. Assign roles to individuals who will role-play important
supports in Winnie’s life and how they would interact in this situation. Develop important questions for each of the players who
can add information to the case. Some of the casting members might be Winnie’s parents, teacher, psychologist who observed
Winnie in the classroom, and any other individual that you feel might contribute to an understanding of the case and assist with
developing an overall case formulation and treatment plan.
354
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Case 14 Shirley Yong Worried to Perfection General Anxiety
Disorder; Depression; Relational Aggression; Cultural
Conflict; Trichotillomania
Shirley was referred to the clinic by her family physician, Dr. Long, to evaluate her emotional status. For the
past 6 months, Shirley has been suffering from alopecia (hair loss), which has resulted in a prominent bald
spot on the side of her head. Shirley was wearing a hat when she came to the interview accompanied by her
mother, Lilly. Shirley presented as a serious young girl who looked more mature than her age of 11 years.
Shirley was currently attending Heartfield Middle School in the regular Grade 6 program. Shirley has one
younger sibling, a brother, David, who is 4 years of age. Lilly Yong is a nurse and her husband, David, is a
computer programmer. The Yongs came to the United States from China when David was offered a position
as a senior computer programmer with an American-based firm. The move occurred approximately 4 years
prior to Shirley’s birth. Lilly began working soon after their arrival in the United States. With a background in
nursing, Lilly was able to obtain a position very quickly, due to a nursing shortage.
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Shirley weighed 7 pounds 5.5 ounces at birth. Shirley’s mother described the pregnancy as difficult and the
labor as lengthy (12 hours). Although the delivery was normal, there were minor complications due to
meconium aspiration, and Shirley stayed overnight in the pediatric critical care unit. Lilly said that to her
knowledge, Shirley was relatively easy to manage as an infant, and for the most part slept well and had a good
appetite. Mrs. Yong admitted, however, that Shirley’s early years were spent primarily under the care of her
mother, Shirley’s grandmother.
Shortly after Shirley was born, Lilly’s widowed mother came from China to live with the Yong family. This
situation provided Lilly with a full-time caregiver for Shirley and, as a result, Lilly was able to return to work
at the hospital almost immediately. The situation was also helpful for Lilly’s mother, who was grieving the
loss of her husband. When asked about other extended family, Lilly was not eager to discuss the extended
family, saying that she had lost contact with most of her relatives. Lilly stated that to her knowledge there
were no known mental or physical difficulties for any of the extended family members. With the exception of
her mother, all other extended family continued to reside in China.
Although Lilly could not recall much information about Shirley’s early development, she did believe that
developmental milestones were generally achieved within the norm. There were some difficulties with speech,
however, and Shirley did not say her first word until 18 months of age. Lilly remembered this vividly, since a
colleague at work had an infant boy who was already saying words at 13 months, and Lilly felt that Shirley
should have been talking by then as well. She had read that, generally, girls begin to speak earlier than boys
and felt that the delay was unusual. The concern actually resulted in a fight between Lilly and her own
mother, since Lilly began to blame her mother for Shirley’s speech delay. Lilly was worried that Shirley’s
language delay may have resulted from the use of both Chinese and English in the home. Despite Lilly’s
protests, her mother continued to speak to Shirley exclusively in Chinese, while Lilly communicated with
Shirley only in English.
Although Shirley was described as a relatively timid and passive toddler, Lilly admitted that there were times
when Shirley could become quite irritable or fussy. On these occasions, Shirley would experience problems
falling or staying asleep. Lilly recalled these incidents because they were very annoying and disruptive to her
schedule. Being a nurse, Lilly needed her sleep to survive the lengthy shifts at the hospital. When Shirley had
those fretful and irritable nights, it was impossible to get any sleep or to soothe Shirley.
Shirley remained very close to her grandmother, who was her primary caregiver, until the grandmother’s death
7 years ago. Shirley’s grandmother passed away in her sleep of natural causes when Shirley was 4 years of age.
When asked how Shirley responded to her grandmother’s death, Lilly said that the whole family was very
distraught. Not only had they suffered a great personal loss, but now they had to face child care problems as
well. Shirley could not adjust to the new babysitters and would cry endlessly when her mother left for work,
only to refuse to be comforted upon her return. Fretfulness, eating difficulties, and sleeping problems were
prominent during this period. After an endless parade of babysitters, Lilly eventually had to quit work and
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stay home to care for Shirley. Lilly readily admitted that this was not an easy time for both of them. Shirley’s
demands for consoling were exhausting and frustrating, and Lilly longed for the days when she could return to
work at the hospital.
Lilly enrolled Shirley in a half-day Montessori program, and was very adamant that Shirley do well in the
program. However, she was unhappy with the multiage grouping principle and did not like the fact that
Shirley’s classmates ranged from 2 to 6 years of age. After one month, she removed Shirley from the program
and placed her in a “private learning center,” which was designed to escalate academic skills in children and
prepare them for entrance into the traditional school environment. When Shirley would come home from the
program, her mother would insist she do homework at the kitchen table. Shirley was only allowed to watch
television on Saturdays. Lilly welcomed Shirley’s sixth birthday, since this signaled mandatory schooling and
some relief from parenting demands. Shirley was able to find work as a nurse in a physician’s office, which
meant that she did not have to contend with shift work in the evenings. For the next year, Lilly did not
tolerate Shirley’s complaints about her school, the teacher, and her classmates. Lilly constantly reminded
Shirley that when she was a child in China, no one was allowed to complain; you just did your work and did
what was expected of you. Lilly often felt a sense of relief after she dropped Shirley off at school and went to
work. However, after a year of working, Lilly found out that she was pregnant, and 7 months later, Lilly was
again homebound with her new son, David Jr.
Shirley was now 7 years old and did not adjust well to having a baby brother who was able to stay home with
her mother while she was forced to go to school. Mornings were often disruptive and chaotic. Shirley would
compete with David’s cries for food with her own complaints of stomachaches or headaches and asking to stay
home from school. Lilly reminded Shirley constantly that complaining was not allowed and that she needed to
keep those types of concerns to herself because she was not really sick. Lilly refused to give in to Shirley’s
demands and instead demanded that she be more successful in school. Shortly after the birth of David Jr.,
Lilly was diagnosed with postpartum depression, which manifested in fatigue, loss of pleasure in activities,
overwhelming bouts of sadness, and self-blame. During this time, Lilly was increasingly demanding of Shirley
and when she came home from school, after her homework time, she was expected to also help out with the
baby and to assist with household chores. Because her mother was so demanding, Shirley tried to keep
everything spotless and would immediately pick up David’s toys, sometimes, almost before they hit the floor.
Lilly says that all the cleaning Shirley did as a child may have backfired somewhat, because Shirley can now be
“a real neat freak” to the extent that others find it annoying. Shirley will often become very upset at David Jr.
for playing with toys in an area that she has cleaned. She is always at him to clean up and put his toys away
before he has even had a chance to play with them. Shirley’s own bedroom is arranged to perfection, with a
place for everything and everything in its place. Shirley has asked for a lock for her door to make sure David
Jr. does not go into her room or touch her things.
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Reason for Referral
Shirley was reticent throughout the initial part of the interview and did not volunteer any information
spontaneously. Lilly said that she was concerned most recently because Shirley was demonstrating more
tension and mood swings than she had seen before. The hair loss was particularly upsetting for both mother
and daughter, and Lilly mentioned that it was embarrassing for her to be seen with a daughter who was
partially bald. She described her daughter as being more moody and short-tempered in the past few months.
She also thought that her daughter was starting to be more secretive and not sharing information about what
she was doing at school. Shirley would often come straight home after school and go right up to her room,
where she locked the door. A call from Shirley’s teacher last week revealed that Shirley was not handing in her
assignments and that she was falling behind the class, especially in her journal writing. Of course, Lilly was
extremely upset that Shirley was not being successful at school, after all the effort she had put into getting
Shirley ready for school, and the high expectations she had created.
When Lilly confronted Shirley about the missing assignments, Shirley stomped into her room and slammed
the door. Lilly said that this was totally unacceptable behavior from her daughter. She also complained that
Shirley was spending more and more time in her room and less time with the family. When asked what she
was doing in her room, Shirley would say that she was working on her homework. Lilly said that she did not
believe her because the teacher said the assignments were not being completed.
When asked about stress in her life, Shirley looked at her mother and then responded to the interviewer in a
disgruntled manner. Attempts to engage Shirley in a conversation about her school life also met with minimal
response. However, when asked how she was feeling, physically, Shirley said that she was not feeling very well
and complained of headaches, stomachaches, and feeling very tired. Lilly interjected that Shirley was very
quick to complain and that complaining was not allowed in her culture. More recently, Shirley’s mother had
found her getting up in the middle of the night making herself a snack at midnight. Lilly said that this seemed
to be becoming a nightly ritual. (Although it was not addressed in the interview due to Shirley’s guarded
nature, Lilly had mentioned when making the appointment that Shirley was putting on much weight recently
and had gained about 10 pounds in the past 2 months.) Shirley was obviously upset by her mother’s comments
and responded defensively, saying, “Well, I was hungry because I didn’t like the tofu stuff you made for
dinner. It was awful . . . like eating chalk.” When asked if she could change one thing in her life, Shirley’s eyes
filled with tears and she said, “Everything.”
With encouragement and patience, Shirley began to outline some of her worries about herself and her school
situation. Shirley said that reading had become harder and harder because she couldn’t concentrate. She would
read a page and then not remember what she had read. She wanted to make her work very neat, and so she
would print out all her assignments. Often she would work long hours making sure that the printing was
perfect. Many times, she would have erased so many words that she would have to start all over again from the
beginning on a fresh piece of paper. It took so long to print her work that she had problems finishing the
assignments. Shirley said that she received only a C on the last assignment she handed in because it was
incomplete. Shirley said she didn’t tell her mother about the paper because she was embarrassed about her
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grade and felt guilty that her mother would be ashamed of her.
When asked about social life at school, Shirley admitted that she was miserable socially. Shirley said that she
had no friends and the girls at school teased her. They were calling her names and laughing at her bald spot,
saying that she was going to be a “bald old fat man.” She had also found a note hidden in her desk from
someone, with a drawing of a fat, bald person with the label “Shirley” written across the top. One girl had
started a rumor that Shirley was contagious and that if you touched her, your hair would fall out too. Now no
one would even stand beside her in line. Shirley was so upset the other day that she just hid in the restroom
during recess so she wouldn’t have to go outside. When asked if she knew why her hair had fallen out, Shirley
denied that she had anything to do with it. Her mother seemed incredulous that the interviewer would ask
Shirley if she had been pulling out her own hair.
When asked if she was a worrier, Shirley looked concerned and said that she couldn’t stop worrying and
added, “I worry about doing poorly at school; I worry about being late for school; and I worry about making
mistakes in my work. I worry so much that I keep waking up because I think I forgot to do something, or I
am afraid I might sleep in and be late for school. I can’t sleep so I straighten and clean my room or go to the
kitchen and eat something. But then I can’t remember if I have cleaned the kitchen, so I go back and check on
it. Sometimes, I have to keep checking because I don’t remember seeing it clean enough.” In response to
Shirley’s list of concerns, Lilly shook her head and said, “Kids today, what can you do about them.” She then
looked at Shirley and in an attempt to minimize her difficulties, stated that Shirley was exaggerating her
problems. “In China,” she said, “we did what we were told and worked hard at our schoolwork. That was our
job. We didn’t have time to complain about all these things. In our culture, we value emotional restraint, not
self-indulgence.”
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Assessment Results
The actual raw scores for Shirley’s assessment can be found in Appendix A. The following is a summary of
those findings. Information regarding specific assessment instruments and the interpretation of standard
scores and T scores is available in Appendix C.
Shirley’s responses to the WISC-V were notable. The examiner reported that Shirley lost bonus points due to
slow task completion resulting from tendencies to waste time lining up edges to meet perfectly on the block
designs. Multiple responses to verbal items were also observed, as if Shirley were unsure when to stop giving
information. Requests for feedback were also frequent.
Shirley’s full-scale IQ was in the lower average range (IQ = 85; range 81–91) with a significant strength in
Verbal Comprehension (VCI) with an index score of 100 (range 93–107), which was in the average range.
Generally, weaknesses were evident in tasks measuring the Visual Spatial Index (VSI) with an index score of
84 (range 79–93); Fluid Reasoning Index score of 86 (range 82–95); Working Memory Index with a score of
83 (range 77–92), and Processing Speed (PSI) with an index score of 83 (range 76–94). Academically, Shirley
was functioning at grade level in language arts (Grade 5 level on both decoding and comprehension), but she
was approximately 1 year behind grade placement in math computation. Shirley’s mother’s response to CBCL
noted significant elevations on all Internalizing scales: Withdrawn/Depressed (T score = 68; borderline
clinical range and Anxious/Depressed (T = 73) and Somatic Complaints (T = 74) were all in the clinical
range. In addition, Thought Problems (T = 73) were in the clinical range due to many obsessions and
repetition of acts, while Attention Problems (T = 70) were also in the clinical range, evident in problems of
concentration and frequent confusion. On the Conners scales, Mrs. Yong also endorsed clinical levels for
Inattention, Anxious-Shy, Perfectionism, Social Problems, and Psychosomatic concerns. Shirley’s teacher
responded to the TRF with clinical elevations on scales for Anxious-Depressed Mood (T = 72) and Thought
Problems (T = 70) noted in obsessions and repetitive behaviors. On the Conners scales, Shirley’s teacher
indicated significant concerns in areas of Inattention, Anxious-Shy, Perfectionism, and Social Problems.
According to the YSR, Shirley self-reported significant concerns for all Internalizing scales:
Withdrawn/Depressed, Somatic Complaints, and Anxious/Depressed symptoms, as well as Social Problems
and Thought Problems. Other problems noted by Shirley included many fears, nightmares, nail biting, sleep
problems, and concerns regarding being overweight.
On the Beck Youth Inventories of Social and Emotional Impairment, Shirley endorsed significantly low levels
for Self-Concept (below the 4th percentile) and significantly high levels of anxiety (98th percentile) and
Depression (95th percentile). Clinical levels of depression were also noted on the Child Depression Inventory
(CDI; Kovacs, 1992), with significant concern in areas of Ineffectiveness, Anhedonia, and Negative Self-
Esteem. On the CDI, Shirley admitted that she thinks about killing herself, but would not do it. Shirley scored
just below the threshold for high hopelessness on the Hopelessness scale (Kazdin, Rodgers, & Colbus, 1986).
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Anxiety disorders represent one of the highest prevalence rates for disorders occurring in childhood and
adolescence, with a rate of up to 13% for 1-year prevalence (Costello et al., 1996). According to the DSM-5
(APA, 2013), when considering a diagnosis of general anxiety disorder (GAD) in children, “a thorough
evaluation for the presence of other childhood anxiety disorders should be done to determine whether the
worries may be better explained by . . . separation anxiety disorder, social phobia and obsessive compulsive
disorder” (p. 224), since these disorders may present with symptoms that can “appear” to be symptoms of
GAD. There is also a likelihood that GAD symptoms of “restlessness” and “concentration problems” may be
mistaken as symptoms of ADHD. In addition to the various forms of anxiety disorders, diagnosis in
childhood is further complicated by some disorders appearing early and others manifesting at later
developmental stages. One study reported an increase in prevalence rate for anxiety disorders from 7% at 11
years of age to almost 20% in early adulthood (Kovacs & Devlin, 1998). In addition, high rates of comorbidity
are evident within the anxiety disorders, and studies report between 65% and 95% of the population
demonstrating more than one anxiety or affective disorder (Last, Perrin, Jersen, & Kazdin, 1992). Many
adults with anxiety and depressive disorders report that these problems had their onset in childhood,
indicating that anxiety disorders can represent a stable construct across the life span (Ollendick & King,
1994). For children and adolescents with GAD, concerns and worries often focus on their performance
academically or athletically even if competence in these areas is not under the evaluation and scrutiny of others
(APA, 2013).
Perfectionism can be conceptualized as an individual’s tendency to set goals or expectations that are overly
rigid, excessively high, and subject to self-criticism when the exceptionally high standards are not met (Frost,
Marten, Lehart, & Rosenblate, 1990). Pushed to the extreme, perfectionistic tendencies can place individuals
at increased risk for a number of mental health issues, including depression (Enns & Cox, 2005; Rice &
Aldea, 2006) and worry (Change et al., 2007; Santanello & Gardner, 2007). Perfectionist tendencies may be
evident in such areas as worry about punctuality, overdoing or redoing tasks in order to improve the quality of
the product, and the need to seek constant reassurance about their performance (APA, 2013).
In childhood, rates for comorbidity of anxiety and depression have been reported to be as high as 60% to 70%
(Kovacs & Devlin, 1998), which has led some theorists to speculate that in childhood “negative affectivity”
may be a more accurate reflection of variations of the same syndrome (Laurent et al., 1999), rather than two
unique disorders. There is support for this line of reasoning, based on high rates of comorbidity in childhood
and the fact that developmentally, the onset of anxiety is earlier than the onset for depression (Kovacs &
Devlin, 1998). In the past decade, research has focused on investigating the role of temperamental influences
on increasing the risk for both disorders in children (Compas, Connor-Smith, & Jaser, 2004). Studies have
demonstrated that children with high levels of negative affectivity (NA) are at increased risk for the
development of anxiety and depression (Lonigan, Vasey, Phillips, & Hazen, 2004). With respect to anxiety, it
has been demonstrated that an attentional bias toward threat can be an important factor in precipitating and
maintaining anxiety problems (Dandeneau, Baldwin, Baccus, Sakellaropoulo, & Pruessner, 2007). Muris and
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Ollendick (2005) suggest that children who have a high tendency to react emotionally (high reactivity) and
poor effortful control (EC) suffer from an inability to defer their attention from the bias to threat, resulting in
increased fear (negative affectivity) and social withdrawal (internalizing problems). Other children who are
also highly reactive, emotionally, but who have poor behavioral control may react aggressively (externalizing
problems). Furthermore, Lonigan and Vasey (2008) suggest that while high NA is a necessary condition for
anxiety, it is not a sufficient condition, and that low effortful control (EC) is also a required ingredient.
Studies have found that these patterns (high NA, low EC) predicted internalizing problems in children
(Muris, Meesters, & Blijlevens, 2007), and that fearfulness at age 10 predicted the development of
internalizing symptoms 2 to 3 years later.
Longitudinal studies have demonstrated that children who experience the combined effect of anxiety and
depression have more severe and persistent problems, as well as present with a more serious history of risk
factors (Moffit et al., 2007). In addition to temperamental factors, such as NA and EC, contextual influences
have also been related to the development of anxiety and depression in children. Some of the pathways that
have been linked to anxiety and depression include family adversities and maternal distress (Essex et al., 2006;
Rutter, Moffit, & Caspi, 2006), which can be moderated by the availability or lack of social support (Leech,
Larkby, Day, & Day, 2006). In a recent study of the potential pathways and predictors of anxiety and
depression, Karevold, Roysamb, Ystrom, and Mathiesen (2009) identified two main pathways: temperament
(emotionality), and early family adversity in support of the concept of “equifinality” (Cicchetti & Toth, 1998),
namely, that different pathways might lead to the same outcome. Leve, Kim, and Pears (2005) found that the
combination of child shyness at 5 years of age and maternal distress predicted an increased trajectory for
internalizing problems for girls in early, middle, and late childhood, through adolescence, while Essex, Klein,
Cho, and Kraemer (2003) found that exposure to maternal depression, family conflict, or divorce from the
preschool years forward increased the risk for internalizing problems in girls. Furthermore, Eaves, Silberg, and
Erkanli (2003) found that genes specific to depression can lead to an increased sensitivity to the impact of
adverse life events, increasing the risk through genetic vulnerability in children of distressed mothers. Other
factors in the family environment that have been associated with increased anxiety in children include
overprotective or overly controlling parents, overinvolvement, encouragement of avoidant or anxious
responses, parental rejection, parental criticism, and lack of parental warmth (Hudson & Rapee, 2002; Micco
& Ehrenreich, 2008).
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Trichotillomania (TTM)
In addition to symptoms of anxiety and depression, Shirley also suffers from symptoms of TTM, which
manifests in persistent and excessive pulling out of one’s own hair, resulting in noticeable hair loss or alopecia.
The most common areas affected include the scalp, eyebrows, and eyelashes. Since the dermatologist had
already ruled out any medical cause for the hair loss, it was believed that Shirley was responsible for pulling
out her own hair, although she and her mother adamantly denied this possibility.
Within the DSM-5 (APA, 2013), TTM can be found in the chapter on obsessive compulsive and impulse-
related disorders, which includes other impulse-control disorders, such as excoriation (skin picking),
pyromania, kleptomania, and pathologic gambling. The impulse control disorders all share an increase in
tension, prior to the impulse, in this case hair pulling, and a sense of pleasure or relief once the act (hair
pulling) is completed. It has been suggested that individuals with the disorder often deny their hair-pulling
behavior and try to conceal the results. Children may not meet criteria for the disorder because they may not
be aware of the tension/release cycle. Nail biting is often also evident, as are symptoms of other disorders, such
as the mood and anxiety disorders (especially obsessive compulsive disorder) and eating disorders. Prior to the
publication of the DSM-5, it was suggested (Kaplan, 1992) that TTM might better be included among the
anxiety disorders, especially because of its association with obsessive-compulsive features. However, the
relocation of obsessive-compulsive disorder to this chapter, including TTM, accomplishes this goal. Onset is
typically between 9 and 13 years, and children typically pull their hair when alone and in a relaxed situation:
on the phone, watching television, reading, or falling asleep (Tay, Levy, & Metry, 2004).
TTM may not be readily detected since hair pulling often takes place outside the presence of others and can
be substituted by pulling hair from pets, dolls, or other hair-like fibrous materials, such as sweaters (APA,
2013). TTM can be triggered by a number of situations, including separation from an attachment figure,
problems with school performance, birth of a young sibling, or sibling rivalry (Tay et al., 2004). Children with
TTM also have more perfectionistic tendencies and low feelings of self-worth (Soriano et al., 1996). The
disorder onset may be associated with the onset of puberty, and symptoms in females may be exacerbated by
hormonal fluctuations (APA, 2013).
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Treatments of Anxiety Disorders in Children
Cognitive-Behavioral Methods.
In their review of empirically supported treatments for children with phobic and anxiety disorders, Ollendick
and King (1998) found several treatments to be effective in reducing fears and phobias. However, with respect
to anxiety disorders, the authors found only one treatment method, cognitive–behavioral procedures, with or
without family inclusion, that met criteria for the probably efficacious treatment category.
Despite the high rate of prevalence for anxiety disorders, until recently there have been relatively few studies
regarding the treatment of childhood anxiety disorders. Cognitive–behavioral treatment (CBT) for childhood
anxiety disorders has received increasing empirical support, with Ollendick and King (1998) citing several
studies conducted by separate research teams in the United States and Australia. Kendall and colleagues
(1992) have developed several treatment strategies, based on CBT methods, including a treatment manual
called Coping Cat, for children with generalized anxiety disorder, which has been demonstrated effective in
several studies. The CBT program focuses on four components: (1) training children to recognize feelings and
physiological responses associated with anxiety, (2) helping them become aware of self-defeating negative
attributions and expectations, (3) reframing negative thoughts into positive constructive thoughts, and (4)
evaluating successful coping. Children are taught behavioral strategies over 16 sessions and increase their
ability to manage anxious responses through the use of role-play, modeling, in vivo exposure, and relaxation
training (Kane & Kendall, 1989; Kendall et al., 1992; Kendall & Treadwell, 1996). In Australia, researchers
investigated the combined effect of CBT for children and a family component (FAM). The FAM included a
parallel 12-week program for parents to learn skills in areas such as supportive praise for courageous behavior
and planned ignoring for excessive anxious responses. Results revealed that the Australian children treated
with a 12-week CBT + FAM performed significantly better than children treated by CBT alone (Bartlett,
Dadds, & Rapee, 1996). More recently, Wood, Piacentini, Southam-Gerow, Chu, and Sigman (2006)
demonstrated that children who received CBT treatment for anxiety disorders with their families (family-
focused CBT) had better outcomes than children who received child-focused CBT, with minimal parent
involvement.
Medical Management of Anxiety Disorders.
The selective serotonin reuptake inhibitors (SSRIs) have been found to successfully alleviate symptoms of
obsessive-compulsive disorder (OCD) in adolescents and children (Riddle, Subramaniam, & Walkup, 1998).
Other treatments that are currently under increased investigation include exposure with response prevention
and cognitive–behavioral therapy. Exposure procedures such as desensitization or flooding can bring the child
into increased contact with the anxiety-provoking stimulus either in reality (in vivo) or through guided
imagery or pictures. The child is taught a form of muscle relaxation that is incompatible with heightened
anxiety in an attempt to link the object or situation that evokes anxiety with a lower level of arousal (relaxed
state).
Neziroglu, Yaryura-Tobias, Walz, and McKay (2000) found that combining an SSRI (fluvoxamine) with
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behavior therapy of exposure and response prevention was superior to medication alone and that children and
adolescents in the study continued to show improvement 2 years later. March and Mulle (1998) have
developed a cognitive–behavioral treatment manual for children and adolescents with OCD that provides a
session-by-session guide for clinicians through the four stages of treatment: psychoeducational, cognitive
training, mapping OCD, and graded exposure and response prevention. Initial studies of the effectiveness of
the manualized program with adolescents are encouraging (Thieneman, Martin, Creggar, Thompson, &
Dyer-Friedman, 2001).
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Treatment of Trichotillomania (TTM) in Childhood
Treatment for TTM in children and youth can be challenging, since they often deny that they are pulling out
their own hair. Nonpharmacologic treatments such as cognitive and cognitive–behavioral therapy should be
considered initially, especially if the psychosocial trigger(s) can be identified (e.g., sibling rivalry, birth of a
new sibling). Golomb and Vavrichek (2000) have developed a workbook for children and adolescents (10 to
16 years of age) to assist them in developing the means for “How to solve the trichotillomania puzzle” by
developing strategies to help manage their behavior. Parents can adapt the workbook for use with younger
children. Other behavioral methods that can be used with children include
habit reversal (methods to increase awareness, develop competing replacement behaviors, practice
stress/anxiety reduction, and increase parental support and encouragement),
self-monitoring (charting behavior and responses), and
teaching replacement behaviors (this can be used alone to develop socially appropriate behaviors that can
be used as alternatives to hair pulling; Ellis & Roberts, 2006).
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Post-Case Questions
1. The co-occurrence of depression and anxiety in childhood is not unusual.
In younger children, this co-occurrence is frequently associated with a depressive-anxious syndrome (see CBCL: Achenbach). The
features of this syndrome have also been referred to as negative affectivity. Research has demonstrated that while children in the
sixth grade can demonstrate the separate syndromes for all three presentations of these disorders (anxiety, depression, and negative
affectivity), children in the third grade are better represented by the combined syndrome of negative affectivity alone (Cole,
Truglio, & Peeke, 1997). It has been suggested that developmentally, negative affectivity represents a less differentiated form of a
syndrome primarily dominated by negative emotions. Developmentally, differentiation into anxious responses (physiological
arousal) and depressed mood (deflated mood) would occur at a later date.
Given the information in the previous paragraph, describe how Shirley’s anxious and depressed symptoms can be conceptualized
with respect to negative affectivity.
2. According to the DSM-5 (APA, 2013), Shirley might meet criteria for one of the anxiety disorders. Given the symptoms noted in
the case and your understanding of the different anxiety disorders, which anxiety disorder does Shirley most likely exhibit? What
are the symptoms that meet the DSM-5 criteria?
3. Gibbs and Huang (2001) outline three broad ways in which ethnicity can influence mental health in children and adolescents.
First, ethnicity can shape beliefs about what constitutes mental illness at a general and specific level. Next, cultures may also
influence the manifestation of the symptoms (internalizing, through physical somatic symptoms, externalizing), as well as reactive
patterns and defensive styles. Ultimately, ethnicity can also be highly influential in determining whether it is acceptable to seek
assistance for mental health issues outside of the family, and who should be consulted for assistance (family elder, priest, minister,
herbalist, etc.). Some high-risk factors related to cultural context include high risk for suicide in native populations and dropout
rates for ethnic minorities.
Huang and Ying (2001) discuss a number of potential stressors and conflicts that may face the bicultural child who is attempting
to incorporate values from both the Chinese and the American cultures. While expression of feelings is often encouraged in
Western cultures, the Chinese culture values emotional restraint, especially for negative emotions. The authors also suggest that
although many children develop somatic complaints in response to stress, this particular form of symptom expression is often
accompanied by sleep and appetite disturbances, followed by declines in academic performance in children of traditional Chinese
American families. A major barrier to effective treatment for these children is that mental health service is highly underutilized by
the Chinese American population. For those few families who seek treatment, drop out after the initial sessions is highly probable.
Discuss the potential impact of cultural contexts on Shirley’s emotional status.

4. In the Introduction to Chapter 1, Kim and colleagues discuss four parenting profiles: supportive, tiger parenting, easygoing, and
harsh parenting. Rather than evaluate parenting style along the typical two dimensions (control and warmth), Kim et al. (2013)
used a multifaceted approach, which considered both positive (parental monitoring and democratic parenting) and negative
(psychological control and punitive control) aspects of parent control, and two forms of parent emotional responsiveness (warmth
and hostility). Discuss whether Lilly employs a “tiger parenting” approach. Within this context, compare tiger parenting, easy going
parenting, and supportive parenting.
5. Children of depressed mothers are twice as likely to become depressed themselves (Peterson, Compas, Brooks-Gunn, Ey, &
Grant, 1993). Possible suggestions for this linkage include lack of adequate models for emotion regulation; excessive use of
controlling, irritable, and impatient parenting (Cicchetti & Toth, 1998); and lack of emotional availability (Malphurs et al., 1996).
Girls seem to be at much higher levels of risk for transmission of depression than boys (Hops, 1992). Based on this information,
discuss Shirley’s depressive features relative to her mother’s.
6. While boys are more likely to use bullying tactics, which rely on physical aggression, girls have been found to engage in forms of
relational aggression, such as causing hurt to others through the propagation of rumors, ridicule, exclusion from a peer group, or
withdrawal of friendship and support (Crick & Grotpeter, 1995). Research has demonstrated that girls are more relationally
aggressive than males and that relational aggression is associated with peer rejection and feelings of loneliness and isolation (Crick,
Casas, & Mosher, 1997; Crick & Grotpeter, 1995).
Explain how relational aggression had an impact on Shirley’s socialization. What could be done at a school level to counteract this
behavior in peers?
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7. In an Australian study, Bartlett, Dadds, and Rapee (1996) found that children who were involved in the combined effect of CBT
and a family component (FAM) performed significantly better than children treated by CBT alone. What challenges do you see in
involving Shirley’s family in the therapeutic process?
8. Develop a therapeutic plan to assist Shirley in reducing tendencies to hair pull.
You have been invited to provide feedback to the school regarding Shirley’s assessment at a meeting where they will decide
whether Shirley meets criteria for Special Education and Related Services. If it is determined that she is eligible for services, under
what category would you expect that she would meet criteria, and what goals and objectives would you want to see as part of her
IEP? Would you recommend she receive related services, and if so, what would the nature of those services be?
Prepare a script for role-playing each of the player’s parts in the school meeting mentioned above. Who do you think should be
plan that would best meet Shirley’s needs?
374
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380
Case 15 Jordan Neeson Let Me Count the Ways Obsessive-
Compulsive Disorder
Jordan appeared agitated and upset as he walked into the clinic accompanied by his mother, Sally Neeson.
The last thing Jordan wanted to do this morning was get dressed and go to a clinic. After all, he was on his
summer vacation. Mrs. Neeson brought Jordan to the clinic because the school had recommended he be
retained in the Grade 3 program due to academic difficulties and problems with attention and concentration.
Work was rarely handed in or completed, and Jordan was beginning to really hate school.
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Sally Neeson completed the intake survey and was available for a telephone intake conversation prior to
bringing Jordan in for his assessment session. In recalling Jordan’s birth history, Sally stated that the
pregnancy was very hard on her. She had considerable nausea in the first 3 months and was very fatigued
throughout the majority of her pregnancy. The delivery was also difficult, and Jordan had a lowered Apgar
score because of birth complications. During the delivery, there were knots in the umbilical cord that cut off
or reduced the oxygen supply. It seemed to take forever, but he was finally breathing on his own. Jordan
seemed to rebound, and Sally was able to bring Jordan home with her when she left the hospital. Sally
reported that appetite and sleep habits were normal for the first year.
At one point in the rather lengthy telephone conversation, Sally seemed particularly agitated and wanted to
know why the interviewer was asking her personal questions about her marriage and relatives. After all, she
just wanted to have Jordan tested for school; there was absolutely nothing wrong with his behavior and he
didn’t have any “mental” problems. Sally described Jordan as a sensitive boy who was very aware of his
academic difficulties. Sally was definitive in stating that Jordan did not have any behavior problems. Sally also
was very sure that there was no mental illness in either her family or her husband’s. However, Sally did recall
an aunt, Bertha, who wouldn’t leave her house. She remembered family members talking about Bertha at
family functions, because she would never attend. They said she was afraid to go outside and that she even had
to have groceries delivered to her door. Sally could not recall any more about Bertha, who died about 10 years
ago. Sally described herself as a bit of a worrier and said that her husband, Ralph, was pretty easygoing and
just liked to watch sports on TV when he finished work at the office. Ralph sold insurance and Sally was a
full-time homemaker. Jordan has a sister, Susy, who is 2 years older than Jordan, but she is very mature for her
age. Sally said that Susy is 11 years old, going on 20, while Jordan is 9 years old, going on 5. When asked how
they get along, Sally said that there are times when Susy, who really is a very patient person, just loses it when
Jordan goes into what she calls his “weirdness.” Sally explained that Jordan can be very fussy about particular
things, such as having his food all separate on the plate with nothing touching (peas separate from potatoes
and chicken). If the foods touch each other, then he does not want to eat it. Susy also is very annoyed when
she has to take Jordan to school, since he takes forever to get ready in the morning, and bathroom rituals, such
as hand washing or teeth brushing, seem to take a very long time. In the evening, Sally said that these
bathroom routines are a normal part of his getting ready for bed, and she is fine with it because, unlike some
kids, Jordan really likes being clean, and she never has to remind him to wash up or brush his teeth at
bedtime.
Sally stated that Jordan’s milestones were achieved on time and he walked at about 14 months and talked a bit
later. Sally admitted that she was not a very good historian about dates and times. Jordan had some ear
infections and had tubes inserted for drainage when he was about 3 years old. Sally described Jordan as a bit of
a “mama’s boy.” She said that they were like “two peas in a pod,” and when Jordan was a toddler, Sally took
him everywhere with her. Jordan never went to preschool and Sally chose to homeschool him rather than send
him to kindergarten. Jordan was not eager to go to first grade. Most mornings, his sister Susy had to hold his
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hand all the way to school so that he would not try to run the other way. Jordan was finally starting to settle
into Grade 1 by December, when the family had an opportunity to purchase a home in a better neighborhood
across town. As a result, Jordan had to change schools in January. Jordan started to resist going to school all
over again, and Susy was once again forced to drag him with her. One good thing about the relocation was
that the house was within eyesight of the school. Jordan’s mother told him that if he missed her, he could just
look across the street and know that she was thinking about him. This seemed to comfort Jordan somewhat.
One day shortly after the move, Jordan’s mother had an appendicitis attack and had to be rushed to the
hospital. Unfortunately, shortly after the ambulance arrived, Jordan’s class was let outside for recess. Jordan
was terrified when he saw the ambulance in his driveway, and he ran across the street just as the ambulance
pulled away. Jordan ran down the street, yelling and crying, until he was retrieved by the school principal. For
the next 5 months, Jordan was very fearful of leaving the house. He was afraid that something might happen
to his mother if he left. Often he would ask to stay home, saying that he wasn’t feeling very well. Sally said
that she felt she was to blame because she had scared him with her appendicitis attack. Often she felt sorry for
him and would let him stay home. By the end of first grade, Jordan’s teachers were becoming concerned. He
had missed quite a bit of school (21 days) and did not have a firm grasp of the fundamentals. His handwriting
was very poor and most of his letters and numbers were reversed or upside down.
The following year, Sally tried to keep Jordan’s absences in check by making promises that they would do
things together after class. Jordan went to school, but his midyear report was very poor. Jordan was falling
further and further behind. Sally tried reading with him at home, but Jordan seemed to have a very poor
memory for the words, and each day it was like he had not seen the word before. Recently, the school
recommended that Jordan repeat Grade 3. Sally finally decided to have him assessed.
Sally noted that Jordan’s health had been good except for frequent complaints of headaches and stomachaches.
Vision and hearing had been recently tested and were within the normal range. Although the intake
supervisor sent behavior rating scales to Mrs. Neeson (Behavior Assessment Scale for Children [BASC2]) and
the Conners Parent Rating Scale to be completed prior to his first assessment session, Sally forgot to complete
them ahead of time and brought them with her to the first assessment session. As a result, it was not possible
to score these results until after Jordan’s first assessment session. In hindsight, having this information
beforehand would have provided significant insight into Jordan’s emotional profile. On a positive note, Sally
was able to locate Jordan’s Grade 3 teacher, who volunteered to complete the teacher forms during her
summer break.
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Reason for Referral
Sally brought Jordan to the clinic because she wanted to know why he was having academic problems and
whether Jordan had this “attention deficit” problem his teacher had mentioned. It was important to Mrs.
Neeson that an assessment be completed before the new school year because she was very concerned about his
success in the Grade 4 program and Jordan’s growing reluctance to continue attending school.
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Assessment Results
Information regarding the specific assessment instruments used in this assessment and guidance in the
interpretation of standard scores and T scores can be found in Appendix C.
The examiner found Jordan to be a very cautious participant in the assessment process. Jordan took a long
time to respond to open-ended questions, and it was often difficult to determine whether he was formulating
a response to a question, not comprehending the question, or lost in his own thoughts. During the first
assessment session, Jordan participated in a semistructured clinical interview and completed the WISC-V and
Bender Gestalt.
Jordan obtained a full scale IQ within the average range (IQ = 91; range 85–98), with minimal discrepancy
between his Verbal Comprehension Index, Visual Spatial Index, and Fluid Reasoning Index. Jordan’s profile
indicated a number of strengths and weakness. Strengths were noted in vocabulary knowledge, picture
concepts, and matrix reasoning (SS in the 11–13 range), while relative weaknesses were evident in
comprehension (SS = 7), block design (SS = 8), digit span (SS = 6), and coding (SS = 6). The Working
Memory Index (WMI) was at the 8th percentile (WMI = 79; range 73–88).
Jordan became very anxious when the stopwatch was introduced for the timed tests (block design, visual
puzzles, figure weights, coding, and symbol search) and was visibly upset. He said he was afraid that he would
not be able to do his work on time. At this point, the examiner explained that he would have plenty of time to
compete the tasks and encouraged Jordan to continue, which he did. Throughout the assessment, Jordan was
hesitant and tentatively approached each task in an approach-retreat style. Requests for question repetition
were frequent, and Jordan also evidenced word-finding problems throughout. On a supplementary task of
mental arithmetic, Jordan was observed tapping on his leg with his index finger, three times, before he would
verbalize a response. When he saw that the examiner had noticed this, he pulled himself farther under the
desk to conceal his legs from view. Other mannerisms were noted, such as touching his shoe before lifting his
pencil and touching his ear before writing. However, Jordan was very subtle and secretive in performing these
touching and counting compulsions, and it is likely that these rituals had escaped detection in most situations.
In addition to these behaviors, Jordan also demonstrated perfectionist tendencies on many tasks. For example,
he spent considerable time and effort carefully aligning his blocks to ensure that the edges were straight, a
procedure that resulted in the loss of any possible bonus points he may have earned on the task. Similarly,
repeated erasures to make the symbols “just so” resulted in reducing his score on the coding subtest. At
Jordan’s age level, it is considered to be significant if the Bender Gestalt designs are not completed within 7
minutes. Jordan required 20 minutes to complete the task. Jordan requested a ruler prior to starting the
Bender Gestalt so that his lines could be straight and the paper could be partitioned. However, he was told
that this was a task to see how well he could reproduce the designs himself, without a ruler. At this point,
Jordan folded the paper to make eight sections and proceeded to draw each design in one of the folded
squares. Despite all the attempts to structure his responses, the designs were very poorly executed due to his
weak visual motor integration skills. He spent a great deal of time checking and rechecking the number of
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dots on the cards, rather than actually executing the designs. Jordan would count the dots and start to draw,
then recount to make sure that he had remembered the number correctly. On one design, Jordan recounted
the dots 15 times before he completed the drawing. His responses were delayed even further by a ritualistic
tendency to punctuate each drawing by the touching and tapping compulsions noted previously. Furthermore,
although Jordan achieved above average scores on the untimed tasks of picture concepts and matrix reasoning
(WISC-V), he required excessive time to complete these tasks (twice the amount of time that normally would
be required).
Jordan’s response to the Wechsler Individual Test of Achievement (WIAT-III) was also enlightening. It took
almost an hour and a half to complete this instrument, which usually takes about 40 minutes. Prior to starting
tasks, Jordan had a series of questions he asked to make sure that he understood what was required. On the
spelling dictation test, Jordan spent several minutes erasing and rewriting words to improve the quality of his
writing. Each mathematical calculation had a pizza drawn beside it (he called them “pizza faces”), with
pepperoni slices indicating the number. For example, in order to perform the calculation 5 + 6, Jordan drew
two pizzas: one with five slices of pepperoni and one with six slices of pepperoni. He then added up the
pepperoni slices to obtain the final answer. Reading was also performed very hesitantly, with much doubting
as to the correct pronunciation. Jordan continually requested feedback about his performance. Only the
Reading Fluency is timed on the WIAT-III, and his score for reading fluency was significantly below his age
level (standard score of 72, at the 3rd percentile). On the remaining tasks, which are not timed, Jordan
demonstrated functioning about 2 years behind his grade level in all areas. Jordan continued to demonstrate
the touching and tapping rituals noted during his previous assessment session.
After Jordan’s first assessment session, it became evident from clinical observations that Jordan was
experiencing many symptoms of obsessive-compulsive disorder (OCD), and that these ritualistic compulsions
were likely causing significant problems at school and at home. Subsequent assessment sessions and behavioral
reports would confirm the extent to which Jordan’s secret world would be revealed.
Mrs. Neeson completed three behavioral rating scales: the Achenbach CBCL, BASC-2, and Conners scales.
Clinical elevations were noted on the Thought Problems and Anxious/Depressed scales of the Child Behavior
Checklist (CBCL); the Atypicality scale (BASC-2); and the Perfectionistic scale (Conners). Teacher reports
noted elevations on the Attention and Thought Problems scales (Achenbach TRF); and on Atypicality,
Adaptability, Learning Problems, Social Problems, and Attention Problems (BASC-2; Conners).
Further clinical interviews with Mrs. Neeson confirmed several other OCD behaviors and possible family
history for the disorder. Mrs. Neeson said that Jordan could be superstitious, much like her mother, who
seemed to have a superstitious saying for everything. Her mother was also what she called a “clean freak” and
“checking perfectionist.” Often they would make several attempts to get out of the driveway because her
mother would constantly get out of the car and return to the house to make sure that the stove and coffee
maker were turned off or the door was locked securely. Although Sally did not consider these behaviors to be
mental health problems, she did say it was very annoying to try to do anything with her mother. During the
course of the conversation, Sally began to discover several likenesses between Jordan and his grandmother.
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Sally was aware that Jordan did have some superstitions, like counting or touching rituals; however, she did
not know the extent to which Jordan engaged in these behaviors. Sally became aware of these rituals when she
caught him on occasion and questioned his repetitive behaviors. Jordan explained that it was about “threes.”
Apparently, he had some system worked out that if he repeated an action three times or tapped three times,
then it would prevent something from happening. Sometimes, he had to do more than one count of “threes,”
for example, count to 3 two or three times in a row before he was satisfied. Further conversation revealed that
Jordan also hoarded useless items under his bed and had other peculiar habits involving arranging and
placement of certain items in very specific places. At the dinner table, the family had just accepted the fact
that Jordan’s fork and knife had to be perfectly aligned on the stripe of the place mat before he would begin
eating. They were also accustomed to his odd mannerism of eating his food starting at the outside of the plate
and working toward the center. Sally had just accepted these behaviors as “Jordanisms” and reasoned to herself
that he would eventually outgrow the habits, or they would later develop into other orderly and beneficial
ways of organizing his world.
Although Jordan’s bathroom routines in the morning could be a source of annoyance when trying to get
Jordan to school, Mrs. Neeson never thought that these behaviors would signal any cause for concern. Sally
said that personal cleanliness was a strength of Jordan’s, and she surely did not want to discourage his excellent
hygiene.
Jordan completed the BASC-2 but had considerable difficulty with the yes/no response format. He had
trouble making up his mind and was very uncomfortable not being able to use “sort of” as a response. On the
Personality Inventory for Youth (PIY), the Feelings of Alienation scale was somewhat elevated due to Jordan’s
endorsement of items referring to repetitive and distressing thoughts and behaviors. Jordan did not endorse
significant symptoms on the Child Depression Inventory (CDI-2), which was in the normal range for his age.
Jordan did, however, admit to having a significant number of symptoms that were indicative of
Worry/Attentional Concerns and Physiological Indicators on the Revised Child Manifest Anxiety Scale
(RCMAS-2).
Based on clinical interviews, observations, and assessment results, increasing confirmation and support were
obtained to suggest that Jordan suffered from an OCD. Jordan evidenced a number of compulsions: repeating,
touching, counting, arranging, cleaning, and hoarding. Obsessive thoughts that seemed to drive these
compulsions included concerns regarding doubts, lack of symmetry, contamination, and danger. Upon
completion of the Children’s Yale Brown Obsessive-Compulsive Scale (CY-BOCS), the examiner felt that
Jordan’s compulsions were time-consuming (likely involving more than 1 hour a day) and were interfering
significantly with his schoolwork and social relationships. Furthermore, Jordan seemed to have very little
control over his obsessions nor was he able to resist performing the compulsive acts.
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Although initially thought to be uncommon among children, current prevalence rates (between .5% and 2%)
for OCD are similar for children and adults (Heyman et al., 2003); however, OCD in children often goes
undiagnosed (Valleni-Basile et al., 1994). Because the disorder involves distressing and often unpleasant
thoughts (obsessions) that drive unwanted acts or behaviors (compulsions) that can often appear embarrassing
to children, OCD may be hidden by young children and adolescents, who secretly suffer in silence. OCD is
characterized by obsessive thoughts that cause individuals to feel anxious and distressed, unless they engage in
compulsive behaviors that serve to reduce the anxious state. Though OCD was once thought to have a
primarily psychological basis, many who suffer from it show evidence of a biological basis for the disorder.
Two areas of research have investigated biological explanations for the disorder: one explanation involves
relating OCD behaviors to low levels of the neurotransmitter serotonin; the other explanation looks to
malfunctioning in a key area of the brain.
Support for the serotonin theory has come from clinical trials that have established SSRIs such as fluoxetine
(which serve to increase serotonin levels) as a successful treatment approach for OCD in adults and children
and adolescents (Riddle et al., 1992; Rosenberg, Russell, & Fougere, 2005). Other biological theorists suggest
that regions of the brain that convert sensory information into thoughts and actions (orbital region of the
frontal cortex and caudate nuclei) may be overactive in people with OCD. Because the system malfunctions,
impulses that should be filtered pass on to the thalamus and the person becomes driven to perform the acts
(Peterson et al., 1998; Saxena & Rauch, 2000). Although the DSM-IV-TR (American Psychiatric Association
[APA], 2000) considered OCD as one of several anxiety disorders, results from several recent investigations
led researchers to question whether OCD should be conceptualized apart from the other anxiety disorders, as
a distinct disorder based on unique physiological and neurological dysfunctional patterns (Bartz & Hollander,
2006; MacMaster et al., 2006). As it is, the DSM-5 (APA, 2013) has removed OCD from the section on
anxiety disorders and has created a new chapter in the DSM, Obsessive Compulsive and Related Disorders that
clusters OCD with body dysmorphic disorder, hoarding disorder, trichotillomania (hair pulling), and
excoriation (skin picking). Disorders in this chapter all share features of obsessive thoughts or compulsive
behaviors related to cycles of tension production and tension release.
Implications of the basal ganglia in OCD have also been suggested due to the high rates of comorbidity
between OCD and Tourette’s syndrome (King, Leonard, & March, 1998). Recently, research has amassed
increasing support for some children who develop acute OCD symptoms resulting after a strep infection.
These children, who demonstrate OCD symptoms from an autoimmune response to streptococcal infection
(PANDAS), may require a very different method of treatment. Murphy and Pichichero (2002) monitored 12
cases of OCD with new-onset PANDAS and found that antibiotic treatment was effective in alleviating
symptoms of OCD in all the children on first trial, and for the 7 children who suffered a future relapse, once
mediation was reintroduced resulting in symptom remission. The PANDAS-related OCD symptoms
included hand-washing behaviors and preoccupation with germs and are thought to result from an
inflammation of specific regions of the brain.
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According to Leonard, Swedo, and Rapoport (1991), some indicators that OCD behaviors may be occurring
in children and adolescents include hoarding of useless objects, repeated touching of objects, taking an
inordinate amount of time to complete tasks, and constant erasures or reworking of homework assignments.
The long-term consequences of OCD have long been established, and the disorder is also often associated
with other comorbid disorders (Bolton, Luckie, & Steinberg, 1995). Research evidence supports the
importance of early intervention in childhood and adolescence in reducing the long-term severity of OCD
(Leonard et al., 1993). Some of the most frequently occurring compulsions in child and adolescent
populations include hand washing, checking, counting, touching, rearranging, and hoarding. The following
obsessions have also been identified as occurring most frequently in child and adolescent populations: doubts,
danger, contamination, aggression, and sexual impulses (King et al., 1998; Leonard et al., 1991).
Piacentini, Bergman, Keller, and McCracken (2003) studied functional impairment in 151 children and youth
with OCD and report that almost 50% indicated OCD-related problems were evident in all three major
domains: home, school, and social relationships. At school, concentration and homework surfaced as the two
most critical areas of difficulty. Within the home, 60% of families of children with OCD report detrimental
effects of the OCD behaviors on siblings and marital discord due to increased distress and feelings of
manipulation (children attempting to engage family members in the OCD behavioral rituals; Cooper, 1996).
Perfectionistic tendencies have also been significantly associated with OCD, and many cognitive theorists see
perfectionism and responsibility (self-blame) as two of the core features of cognitive models of OCD
(Obsessive Compulsive Cognitions Working Group [OCCWG], 2001, 2005). In their study of perfectionism
and OCD, Wu and Cortesi (2009) found that perfectionism was most strongly associated with checking
rituals related to ordering, arranging, symmetry, and grooming, and more weakly associated with
contamination obsessions and washing compulsions, a finding that supported results of an earlier study by
Julien, O’Connor, Aardema, and Todorov (2006). Wu and Cortesi (2009) suggest that this finding provides
an important contribution for targeting cognitive restructuring in those with checking rituals.
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Treatment for OCD
Historically, theoretical explanations for OCD have focused on the maintenance of fear and anxiety due to
negative reinforcement—for example, performing the compulsion serves to reduce the anxiety caused by the
obsession (behavioral theories); and the faulty appraisals (excessive self-doubt and self-blame, and feeling
overly responsible for the obsessive thoughts), which tend to lock individuals into the obsessive and
compulsive rituals (cognitive theoretical perspective). As a result, the majority of treatments have focused on
behavioral techniques, such as exposure and response prevention (ERP) and cognitive–behavioral therapy
techniques (CBT) for reframing maladaptive thinking (e.g., self-blame, self-doubt) into more positive thought
patterns. From a neurobiological perspective, unlike anxiety disorders that respond to a wide range of
medications (benzodiazepines and norepinephrine reuptake inhibitors), antidepressant medication (serotonin
reuptake inhibitors: SRI, such as fluoxetine) has been the only category of medication that has been successful
in alleviating symptoms of OCD in adults and assisting some children in reducing symptoms of OCD (Geller
et al., 2001; Riddle et al., 1992).
Barrett, Farrell, Pina, Peris, and Piacentini (2009) conducted a meta-analysis of evidence-based treatments for
children and youth with OCD, based on 21 studies conducted since 1994 that adhered to Type 1, 2, or 3
criteria as set out by Nathan and Gorman (2002). The two treatments that maintained the highest quality of
empirical rigor (Type 1: randomized, controlled studies) were studies conducted by Barrett, Healy-Farrell, and
March (2004) and the Pediatric OCD Treatment Study Team (POTS Team; 2004). Barrett and colleagues
(2004) compared family-focused individual therapy (ICBT) and family-focused group therapy (GCBT) using
a manualized family component, “Freedom From Obsessions and Compulsions Using Cognitive-Behavioral
Strategies” (FOCUS; Barrett, 2007), which was adapted from an earlier version of the individual treatment
program established by March and Mulle (1998). The FOCUS program included sessions devoted to
education, cognitive training, exposure and response prevention, and parent sessions. Follow-up 12 and 18
months after the completion of the program revealed that 70% of those in the ICBT program and 84% from
the GCBT program remained symptom free (Barrett, Farrell, Dadds, & Boulter, 2005). The POTS study
(POTS Team, 2004) compared treatment groups of youth with OCD (7–17 years of age) who were randomly
assigned to one of four conditions: ICBT alone, sertraline (SRI medication) alone, combined ICBT and
sertraline, or placebo pill. The CBT protocol was based on the program developed by March and Mulle
(1998) and included 14 sessions over a 12-week period. Results revealed that all three treatments were
superior to placebo but that combined CBT and sertraline was superior to either treatment alone, although
both of the CBT conditions (with and without sertraline) were superior to the sertraline alone condition,
suggesting that CBT alone or in conjunction with SRI is an effective treatment for OCD in children and
youth. Another study, conducted by Asbahr and colleagues (2005) and also using the GCBT format
prescribed by March and Mulle (1998), found that youth who received CBT in the group condition
demonstrated significantly lower rates of symptoms compared to youth who were treated with sertraline.
In another recent research program designed to compare the effects of combined treatments, Neziroglu,
Yaryura-Tobias, Walz, and McKay (2000) found that children who received a combination of fluvoxamine
390
and exposure and response prevention demonstrated more immediate improvement and continued
improvement 2 years later than those receiving either treatment in isolation. However, Sabine (2001) argues
that CBT may be at least as effective and a less stressful alternative than ERP for children and adolescents
with OCD. Techniques commonly used in CBT programs include cognitive restructuring, psychoeducation
(to dispel irrational fears of contamination, etc.), distraction, and relaxation.
391
Post-Case Questions
1. It is possible to explain obsessive-compulsive disorder (OCD) from a number of theoretical positions. Develop a case formulation
to explain the development of obsessions and compulsions based on the following theoretical perspectives, in light of Jordan’s
history: biomedical, behavioral, cognitive, and family systems. Provide the specific treatment implications for Jordan’s OCD based
on each of the case formulations derived.
2. Behavioral interventions for OCD often include exposure techniques designed to elicit the anxiety (either gradually or completely)
by either direct exposure (in vivo) or in an imagined state. Graduated levels of anxiety can be predetermined by the construction of
an anxiety hierarchy (from least to most stressful situation). Anxiety can be reduced by pairing increasing levels of anxiety-
provoking situations with a relaxation response (muscle relaxation exercises).
Another intervention for OCD involves exposure followed by response prevention. In this technique, the child would be limited in
performing the compulsion (e.g., checking, counting) when he or she has an obsessive thought. The child would agree to limit the
response and would be rewarded for following through.
Design a behavioral intervention plan for Jordan’s use in the classroom, using exposure and response prevention.
3. Discuss the relationship between separation anxiety and OCD in Jordan’s developmental history.
4. Based on the DSM-5 (APA, 2013) criteria for OCD, what symptoms of OCD does Jordan demonstrate, and does he qualify for a
diagnosis of OCD according to the DSM?
5. ln the Introductory Chapter, the section on case formulation based on a psychodynamic and attachment perspective discusses
Greenberg’s theory of the neurophysiology of emotion regulation. According to Greenberg humans require positive experiences of
resolving fearful situations to allow for a build-up of brain structures that help to regulate responses to anxiety and fear-producing
situations. In dysfunctional attachment relationships, caregivers are not a source of assistance in the regulation of emotion, and
children do not develop the ability to self-soothe when upset. Explain whether Greenberg’s theory applies to Jordan, and if so,
how and why this situation has developed.
You have been invited to provide feedback to the school regarding Jordan’s assessment, at a meeting where they will decide
whether Jordan meets criteria for Special Education and Related Services. If it is determined that he is eligible for services, under
what exceptionality would you suggest he meets criteria for services? What goals and objectives would you want to see as part of
his IEP? Would you recommend he receive related services, and if so, what would the nature of those services be?
plan that would best meet Jordan’s needs?
392
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Case 16 Sandra Silver Shy or Social Anxiety Disorder (Social
Phobia) Social Anxiety Disorder
When they arrived at the clinic, it was clear that Sandra was not pleased to be here. Sandra tried to distance
herself from her mother and sat in a chair on the other side of the waiting room. She slumped in the chair as
if she wanted the chair to swallow her up. Her mother, Georgia, on the other hand, was a very gregarious
woman who immediately tried to engage the woman sitting next to her in a conversation. After what seemed
to Sandra to be an eternity, the psychologist finally came into the waiting room and asked them to accompany
her to her office. Sandra’s mother had finally decided to get some help for Sandra because she was very shy
and fearful, especially in social situations. Initially she thought that this was just part of being an adolescent
but now that she was in the tenth grade, she was still experiencing problems socially, at a time when others
her age were becoming even more social.
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Sandra was visibly uncomfortable when she sat down on the couch in the psychologist’s office. Her mother
immediately sat beside her and started to provide some history, almost before the introductions were finished.
The psychologist was immediately very aware of the contrast between these two individuals. Georgia stated
that there was no biological history available for Sandra, who was adopted from an orphanage in China at 2
years and 8 months of age. Georgia is a single mother, who was never married. She retired from teaching 2
years ago when Sandra graduated from middle school. Gloria was able to be close to her daughter during her
early schooling since she taught at the elementary school that Sandra attended and when Sandra transferred to
middle school, Georgia was able to obtain a job at the local middle school. Georgia was quite proud of the fact
that Sandra was able to have her mother teaching at the same school she attended until she moved on to high
school.
When it came time to start school, Sandra was fearful of being in a class with so many children but with her
mother nearby, the situation was not as bad as it could have been. However, by the third grade, her teacher
noticed that Sandra had problems focusing on her work and was very easily distracted by everything around
her. She had problems sitting still and was very inattentive, and as a result, she started to fall behind
academically. With increased pressures evident in the third grade (when state testing would determine
whether the student remained in the third grade or passed on to the fourth grade), the teacher talked to
Gloria about the possibility of having her tested for ADHD. Gloria did not want to have Sandra tested and
instead took Sandra to her pediatrician who asked Sandra’s mother and teacher to complete the Vanderbilt
Rating Scales (NICHQ). The teacher rated Sandra as demonstrating many symptoms associated with
ADHD-Predominantly Inattentive Type, such as fails to give attention to details or makes careless errors,
difficulty sustaining attention during tasks, does not seem to listen when spoken to, does not follow through on
instructions, has difficulty organizing tasks and activities, and avoids or dislikes, or is reluctant to engage in tasks that
require sustained mental effort. Although Sandra’s mother also rated the same symptoms, the teacher’s ratings
were significantly more elevated than Gloria’s ratings. The teacher also endorsed other symptoms not related
to ADHD, including is fearful, anxious, or worried; is self-conscious or easily embarrassed; and is afraid to try new
things for fear of making mistakes. These symptoms were not endorsed by Sandra’s mother. Based on these
ratings, the pediatrician diagnosed Sandra with ADHD and prescribed Concerta (methylphenidate), a central
nervous system stimulant medication for ADHD.
Georgia stated that shortly after the medication was prescribed, Sandra started to get better grades and her
teacher noted that her attention and concentration had improved significantly. However, her mother noticed
that as she entered puberty, she started to become more irritable, especially when she took her medication for
school (Gloria had her taking the medication on school days only). Although never a social child, toward the
end of middle school and in the transition to high school, Gloria stated that Sandra was becoming more
reclusive. Although she had a few close friends, these friends were not what Gloria would have liked to see as
Sandra’s “friends” because they came from very dysfunctional home situations.
The psychologist asked Gloria to take a seat in the waiting room while she asked Sandra some questions
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privately. Both Gloria and Sandra agreed that this would be appropriate at this time. When asked what her
biggest problem was, Sandra said she was very angry that her mother does not understand her. She said she is
very uncomfortable in social situations and that her mother makes this worse by approaching strangers and
talking to them, or saying things to her in public that other people might overhear. She said her mother is
loud and talks about personal things that are private to her, and she is devastated when her mother does this
in public. She felt her mother was very judgmental and critical of her. She said her mother has made
comments about her to other people that are embarrassing (saying she is 4 feet, 11½ inches tall; one foot is
bigger than the other). She ended up saying that her mother just doesn’t get her. Sandra agreed to come for
therapy sessions, where the psychologist said she would help her to learn how to cope with her fears and
feelings of discomfort socially and also work to help her mother to understand her better. Sandra said she was
looking forward to coming to sessions with the psychologist.
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Reason for Referral
Gloria brought Sandra to the clinic because she was concerned about her poor social skills and her increased
tendencies to avoid being out in public and socializing with her peers. She was becoming increasingly self-
conscious and reclusive. She was fearful of going places that were not familiar and even when going to familiar
places, would try to be as inconspicuous as possible, and often ask to leave soon after they got there. She
wanted Sandra to be more outgoing like she was.
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Assessment Results
Information regarding the specific assessment instruments used in this assessment and guidance in the
interpretation of standard scores and T scores can be found in Appendix C.
During the intake, the psychologist had Gloria complete the Child Behavior Checklist (C BCL) while Sandra
completed a number of self-report scales (Child Depression Inventory- [CDI-2]; Revised Child Manifest
Anxiety Scale- [RCMAS-2]; and the Youth Self Report– [YSR]). Sandra and her mother were in agreement
that she demonstrated a number of Anxious/Depressed symptoms, although the degree of elevation was
significantly higher on Sandra’s rating (T score of 93) compared to her mother’s rating (T score of 67). Sandra
and her mother agreed that she demonstrated symptoms, including feeling she must be perfect, feeling worthless,
nervous, self-conscious, and worries; however, Sandra also noted that she cries a lot, has many fears, is fearful of
going to school, fears she will do something bad, feels guilty, and has had thoughts of suicide. None of the other scales
on Gloria’s CBCL were elevated, and all ratings were within the normal range (T score 40 to 60). Sandra
endorsed several scales in the elevated ranges with clinical ratings on scales for Withdrawn/Depressed
symptoms (T score 70), Social Problems (T score 77), Thought Problems (T score 77), and Attention
Problems (T score 74). Withdrawn/Depressed symptoms were evident in enjoys little, would rather be alone,
won’t talk, secretive, shy/timid, and withdrawn. Sandra indicated Social Problems in behaviors such as lonely,
doesn’t get along with others, jealous, feels others are out to get her, gets teased, and not liked by others.
On the RCMAS-2, Sandra’s overall score for Anxiety was a T score of 67, which is in the At-risk Range,
with elevations on individual scales for Physiological Anxiety (T score of 63) and Social Concerns (T score of
67). Items endorsed on the Social Concerns scale included others seem to do things easier than I can; I feel that
others do not like the way I do things; I feel alone even when there are people with me; Other people are happier than I;
I feel someone will tell me I do things the wrong way; and A lot of people are against me. On the CDI-2, her overall
depression score was a T score of 73; however, all individual scales were only marginally elevated, with the
exception of the scale for Interpersonal Problems, which was a T score of 84. Items endorsed on this scale
included I get into fights many times with other people; I do not have any friends; and I do not want to be with
people at all.
Based on the results of the interview and behavioral rating scales, the psychologist diagnosed Sandra with
social anxiety disorder (social phobia) and developed several goals for Sandra’s treatment plan, which included
cognitive–behavioral therapy (CBT) to work on assisting Sandra to recognize how her negative thoughts are
contributing to her anxious feelings and work on trying to get her to reframe her thinking into more positive
terms (use of Situation, Feelings, and Thoughts worksheets); psychoeducation for Sandra’s mother regarding
the nature of social anxiety disorder and how she can assist Sandra to develop her coping skills; and having
Gloria and Sandra talk to the pediatrician regarding the potential to switch medications from Concerta, which
may be contributing to feelings of anxiety, to something like Strattera (atomoxetine), a selective
norepinephrine reuptake inhibitor (SNRI), which may target both ADHD and anxiety.
401
402
Anxiety disorders for females in middle and late adolescence have been reported to be as high as 17% to 24%
(Verhulst, van der Ende, Ferdinand, & Kasius, 1997). Although this pattern seems to be consistent across all
age groups for most anxiety disorders (Roza, Hofstra, van der Ende, & Verhulst, 2003), certain anxiety
disorders, like social anxiety disorder, are more prevalent in females during adolescence (Weems & Costa,
2005). Social anxiety disorder is among the most common mental disorders in children and adolescents.
Studies suggest that 6% of children (Chavira, Stein, Bailey, & Stein, 2004) and 12.1% of adolescents meet
criteria for a diagnosis of social anxiety disorder (Merikangas, 2011).
However, despite high rates of prevalence of the disorder, Colognori and colleagues (2012) found that few
students are actually treated for the disorder. Colognori and colleagues surveyed a sample of over 1,500 high
school students and found that 17.2% of the sample met criteria for social anxiety disorder (clinical cut off
score on the Manifest Anxiety Scale), however only 14% of those who met criteria were receiving any sort of
services for the disorder. Of those receiving services, 68% saw a therapist outside of school, 22% saw a school
counselor, and 6.5% were being treated medically.
According to the DSM-5 (APA, 2013), 75% of individuals who have social anxiety disorder have onset of the
disorder between 8 and 15 years of age, with the median age of onset being 13 years of age. Temperamental
traits such as fear of negative evaluation and behavioral inhibition (which is predominantly an inherited trait)
can predispose an individual to social anxiety disorder. The DSM-5 (APA, 2013) notes that shyness should be
distinguished from social anxiety disorder when social reticence impacts social, occupational, or other
important areas of functioning. According to the DSM-5, “only a minority (12%) of self-identified shy
individuals in the United States have symptoms that meet criteria of social anxiety disorder” (p. 206).
Caouette and Guyer (2014) suggest that social anxiety disorder is prevalent in adolescence because there is
significant pressure to engage in social activities during this time period when those who have an inhibited
temperament (mediated by arousal of the amygdale, basal ganglia, and prefrontal cortex) are motivated to
develop a cautious approach that has been rooted in childhood. The conflict now is evident between the
pressure to engage in social activities and the extreme fear of humiliation and embarrassment that might result
from social engagement.
It has also been suggested that adolescence also brings with it a pronounced change in perspective and
preoccupation with peers and romantic interests. Compared to adults, adolescents are far more apprehensive
regarding peer feedback and react more negatively to peer exclusion (Reijntjes et al., 2006; Westenberg et al.,
2004). Although there is significant improvement in self-regulation in adolescence compared to earlier stages
of development, studies using fMRI techniques have found that the integration of the prefrontal cortex with
other brain areas is not as effective as it is in the adult brain. Adolescents still lag behind adults in the ability
to inhibit responses, planning ability and future orientation (Steinberg et al., 2009). The immaturity of the
prefrontal network in conjunction with heightened neural activity and excitation during adolescence results in
adolescents responding to situations with inflated reactions, whether this involves responding to a distressing
(stressful) or pleasurable experience. In addition, the sex hormones are also responsible for heightened
403
responsiveness in the prefrontal cortex and amygdale, which are instrumental in our recall for emotional events
and our interpretation of nonverbal emotional expressions (Steinberg et al., 2008). Increases in sensitivity and
heightened activation of the emotional centers and increases in hormone levels can result in instabilities in
adolescent moods. It has been determined that adolescents report more dissatisfaction with their mood states,
which has been attributed to an increase in stressful life experiences during this period, such as problems at
home and school, relationship problems, and family conflict (Larson & Ham, 1993).
In addition, adolescents tend to be more self-consciousness and increasingly use social comparison as a means
of self-evaluation compared to preadolescent children (Elkind, 1967, 1985). The preschool child views the
world through an egocentric perspective because of an inability to take the perspective of another. In
adolescence, the ability to think about thinking (metacognition) and consider abstract and hypothetical
situations can result in a self-conscious framework for analysis. Adolescents are also highly sensitive to
emotional information due to heightened brain activity in the subcortical regions relative to immaturity in the
prefrontal cortex. Within this context, adolescent egocentrism can result from excessive self-reflection and a
preoccupation that they are the focus of everyone’s attention.
Two important concepts that are fundamental to adolescent egocentrism are the concepts of the imaginary
audience and personal fable (Elkind, 1967; Elkind & Bowen, 1979). The imaginary audience reflects the
adolescent’s concern that everyone is looking at them, which may cause them to retreat into their own private
world or perform for the audience (talking loudly, wearing dramatic clothing, etc.). The personal fable typically
reflects an exaggerated sense of uniqueness (“You couldn’t possibly understand what I am going through!”), which
may also place the adolescent at risk for danger, since they do not generalize that mishaps of others could ever
happen to him or her (e.g., teen pregnancy, reckless driving). Eventually, sharing experiences with peers often
enhances the understanding that others share similar feelings and concerns. However, adolescents who are
isolated from peers may continue to harbor fears of being scrutinized and criticized by others, as well as
increased feelings of being misunderstood, which can increase the risk for developing social anxiety disorder.
Studies using behavioral paradigms have found that adolescents reveal a growing understanding of another’s
mental state, a tendency to “mentalize” in terms of visual perspective taking, feelings and motivations
(Dumontheil et al., 2010; Vetter et al., 2013), and a more differentiated sense of prosocial behavior (Guroglu
et al., 2014).
The DSM-5 (APA, 2013) considers social anxiety disorder (social phobia) as an excessive anxiety regarding a
social situation, or multiple social situations where the individual is fearful of scrutiny by others. Examples of
situations that might be associated with social anxiety disorder include social interactions (communicating
with individuals; meeting new individuals), being observed (e.g., eating), or performing in front of others (e.g.,
talking in front of the class, giving a speech). For children, the anxiety must also be evident in peer
interactions, not just during interactions with adults. The anxiety results from the fear that the individual will
be judged by others in a negative way, leading to humiliation, embarrassment, and rejection. Because of these
intense feelings, social situations are avoided if possible, and if situations cannot be avoided, they are
experienced with intense fear and anxiety, which may result in a panic attack. The DSM-5 uses the specifier
performance only to refer to a form of social anxiety disorder that is restricted to situations where the individual
404
is fearful of performing or speaking in public. Velting and Albano (2001) found evidence of two adult
subtypes of the disorder: generalized form of social phobia (pervasive across most social situations), and specific
social phobia (evident in particular situations, e.g., public speaking). Hoffman and colleagues (1999) found that
almost half of the adolescents in their study had the generalized subtype of the disorder, which is the more
severe form associated with higher levels of psychopathology. Wittchen, Stein, and Kessler (1999) revealed
that compared to those with specific social anxiety disorder, adolescents and young adults with the generalized
form of social anxiety disorder developed the disorder at earlier ages and were more likely to have a history of
behavioral inhibition, as well as exposure to a greater number of early childhood risk factors.
A typical profile of someone with social anxiety disorder would often include having fewer friends, avoidance
of social situations, and experiencing difficulties participating in activities that involve others, such as
classroom discussions, answering or asking questions, working in groups, and avoiding social situations and
interactions, such as joining clubs or groups (Connolly et al., 2007). Social anxiety disorder has been
associated with feelings of loneliness, depression (Beidel et al., 2007), and impairment in functioning that can
impact a number of areas, including transitions, employment, suicidal ideation, and increased risk for
substance use and abuse (Kessler, 2003; Stein & Stein, 2008).
405
Treatment for Social Anxiety Disorder
Individuals with social anxiety disorder are very self-conscious and anticipate and believe that they will not do
well in social interactions and social events, which ultimately becomes a self-fulfilling prophecy because they
become so nervous and anxious in anticipation of the event that they are unable to perform adequately.
Treatment often can involve psychoeducation to better understand the nature of negative thought patterns
and the use of cognitive and behavioral methods to decrease anxiety and to reframe negative thought patterns.
Cognitive–behavioral charts can be very helpful to have individuals better understand the nature of their
negative thought patterns.
Participant modeling and reinforced practice are two treatment alternatives that have been successfully used to
treat phobias in children and adolescents (Ollendick & King, 1998). Techniques rely on modeling and
observational learning to demonstrate positive responses to feared social situations. The models can be live or
seen on videotaped segments, although live models (known as in vivo participation) have been shown to have
more successful outcomes than those viewed on tapes or imagining oneself in a fearful situation (covert or
imaginal participation). Reinforced practice using these methods can positively reduce anxiety (Ollendick &
King, 1998), especially if used in conjunction with systematic desensitization programs based on methods
initially developed by Wolpe (1958). Systematic desensitization involves initial training in methods of deep
relaxation (deep breathing, or muscle relaxation exercises); developing a fear hierarchy (from the least feared
situation to the most feared situation); and gradually progressing up the list pairing the feared situation with
deep relaxation, until the situation no longer evokes an anxious response. At each step in the hierarchy, the
individual is exposed to a higher level of approximation to their feared situation while pairing each step with a
relaxation response.
Increased emphasis has been placed on the advantages of providing services in schools for children and
adolescents with mental health issues, especially internalizing disorders, such as anxiety disorders (Masia-
Warner, Nangle, & Hansen, 2006). School-based mental health interventions can become one of a number of
services that have been integrated into the school culture and in many cases may be the venue that students
prefer. A recent study by Husky, Sheridan, McGuire, and Olfson (2011) revealed that 80% of youth who were
identified “at-risk” for mental health problems would likely access treatment from school-based services
compared to only 42% who indicated that they would access community-based treatment. Given these
advantages, school-based services have been increasingly recognized as a critical avenue for helping address the
unmet mental health needs of youth with anxiety disorders. However, Herzig-Anderson, Colognori, Fox,
Stewart, and Warner (2012) recommend that additional research be conducted to determine the best methods
for training school personnel to implement evidence-based treatments.
Recognizing the need for an empirically supported program that could be provided in the schools, Masia-
Warner and colleagues (1999) developed a school-based program, Skills for Social and Academic Success (SASS),
based on techniques developed by Beidel, Turner, and Morris (1998) in their program called Social
Effectiveness Therapy for Children (SET-C). The program involves 12 individual sessions of behavioral
exposures, 12 social skills training sessions in group format, and unstructured peer generalization exercises
406
where children who are socially anxious can practice social skills with children who are not socially anxious.
The emphasis on peer mediated learning was especially conducive to use within a school setting. Adolescents
enrolled in the SASS program demonstrated significant reduction in social anxiety compared to the wait list
control group (Fisher, Masia-Warner, & Klein, 2004).
The SASS program typically runs over the course of 3 months and involves twelve 40-minute weekly in-
school group sessions. The groups are comprised of three to six students and are facilitated by one or two
group leaders. Group sessions are devoted to four main topics: (1) psychoeducation, (2) realistic thinking, (3)
social skills training, and (4) exposure. The two final group sessions are concerned with relapse prevention. In
addition to the group sessions, there are two 20-minute individual sessions.
In addition to the above, the program also involves four weekend social events lasting approximately 1½ hours
where children in the SASS program can mingle with peers (called peer assistants) who do not have social
anxiety issues and participate with them practicing their social skills in activities such as bowling or
rollerblading. Parents are encouraged to attend two group sessions (45 minutes each) that focus on
psychoeducation regarding social anxiety issues and techniques that can be used to assist the child at home.
Teachers can also be invited to attend similar sessions for their information.
The following is a very brief description of what each of five main topics focus on and the overall goals of each
of the session topics. The first sessions evolve around psychoeducation and realistic thinking where participants
are given an overview of what social anxiety disorder is all about and the relationship between thoughts,
feelings, and behaviors. Emphasis is placed on increased awareness that thoughts drive feelings, and it is the
anticipation of negative outcomes that drives the anxiety. The goal is for students to identify the negative
thoughts and to practice developing the necessary skills to replace these negative thoughts with more positive
“realistic” ways of thinking.
Social Skills sessions focus on developing skills in four key areas: (1) initiating conversations, (2) maintaining
conversations and establishing friendships, (3) listening and remembering, and (4) assertiveness. Concepts are
introduced and students are given opportunities to practice each skill within the group session. The first
session involves topics to initiate conversations with others and the importance of attending to nonverbal
communication. Throughout the training sessions, students are given feedback regarding their performance
and also provide feedback for their peers.
There are five Exposure sessions referred to as “Facing your Fears.” During these sessions, participants are
introduced to the role that avoidance plays in maintaining anxiety and presented with information regarding
an exposure technique to assist in reducing the anxiety. Students are assisted in the development of a personal
fear hierarchy by rank ordering 10 anxiety-provoking situations using a scale called the subjective units of
distress scale (SUDS) assigning ratings from 1 to 100 (1 = very calm to 100 = extreme distress) for each
situation on the hierarchy ladder. Individual sessions involve practicing these exposure trials and mastering
their fear hierarchy. The object is to reduce the fear by at least 50% after each exposure. A final group session
focuses on Relapse and Prevention.
407
408
Post-Case Questions
1. It is possible to explain social anxiety disorder from a number of theoretical positions and case formulations. Develop a case
formulation to explain the development of social anxiety disorder from a cognitive and behavioral perspective.
2. Sandra’s therapist is using CBT charts as homework assignments to assist Sandra in better identifying the negative feelings that
are causing her anxious responses to social situations, and to help her identify “realistic” thoughts that could apply in this situation.
Table C16.1 shows an example of the CBT chart and Sandra’s responses.
Table C16.1 CBT Chart and Sandra’s Responses
Negative Emotion
Situation That Triggered
(How Strong, 0– Automatic Thought Realistic Thought
the Negative Emotion
100)
School cafeteria buying People are looking at me because I They could have been looking
Anxious (60)
lunch am fat. out the window behind me.
Home 11:30 p.m. Just Depressed/Lonely No one is responding to my texts; no Everyone could be sleeping or
finished my homework (80) one cares or wants to talk to me. busy doing their homework.
Develop your goal and treatment plan for the session with Sandra based on what she has given you as her homework assignment.
3. Individuals who experience various anxieties, fears, and phobias can benefit from the use of exposure techniques such as systematic
desensitization and exposure and response prevention based on behavioral methods that gradually expose the individual to the
fearful situation or object while the individual executes relaxation responses (e.g., deep breathing, mediation) that counteract
fearful responses. David is 15 years old and he is experiencing serious problems resulting from a social anxiety disorder. He is
fearful of approaching other students at school and his parents are very concerned because he is making excuses to avoid social
situations. Assist David to develop a fear hierarchy to increase his ability to start conversations and engage with other students in
his school.
4. In Chapter 1, the Introduction, case formulation from a biological perspective discusses several implications for malfunction of
GABA and cortisol production in the etiology of anxiety disorders. Provide a case formulation for Sandra’s social anxiety disorder
based on a biological perspective, including theories of behavioral inhibition. In addition, provide a case formulation for Sandra
from an attachment perspective.
5. Sandra and her mother are two very different personality types. Develop a case formulation from a parenting perspective that
would discuss how dynamics between these two distinct personality types might have a positive and/or negative impact on
Sandra’s disorder.
6. Based on information from theory and research regarding biological, social, emotional, and cognitive development, explain why
adolescence is a particularly vulnerable time for the development of social anxiety disorder.
7. Studies have noted that as high as 30% to 40% of those with ADHD have a comorbid anxiety disorder (Jarrett, 2013). However,
stimulant medication, which is the most common medication used for ADHD, has been found to be less effective in children who
also have an anxiety disorder (Blouin, Maddeaux, Firestone, & Van Stralen, 2010), while not reducing and potentially increasing
the anxiety. Geller et al. (2007) found that atomoxetine (Strattera) did effectively reduce both anxiety and ADHD symptoms in
children with comorbid ADHD and anxiety. Conduct a research investigation and provide a statement supported by research
regarding the impact of stimulant medication on preexisting anxiety disorders in children with ADHD.
You have been invited to provide feedback to the school regarding Sandra’s assessment. Prepare a script for role-playing each of
the player’s parts in the school meeting, mentioned above. Who do you think should be attending the meeting? How could each
participant potentially contribute information to assist with developing an intervention plan that would best meet Sandra’s needs?
409
410
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Chapter 5 Introduction to Problems of Mood Depression and
Bipolar Disorders
415
Bipolar Disorders
The DSM-5 (American Psychiatric Association [APA], 2013) has made a major change regarding how
bipolar disorders are to be conceptualized relative to depressive disorders. With its focus on presenting a
continuum of mental illness based on developmental onset and severity, the DSM states that the rationale for
the placement of bipolar disorders as separate from depressive disorders and between chapters on
schizophrenia spectrum and psychotic disorders and depressive disorders was based on the need to recognize
bipolar disorders “as a bridge between the two diagnostic classes in terms of symptomatology, family history
and genetics” (APA, 2013, p. 123). As such, the DSM-5 emphasizes family history as “one of the strongest
and most consistent risk factors for bipolar disorders” with a “ten-fold increased risk” for the disorder among
adult relatives with bipolar I or bipolar II (p. 130). Although historically, bipolar I has been considered to be
the more serious variant of the disorder, the DSM questions this assumption based on the increased
recognition of the amount of time that individuals with bipolar II are in a depressive state and the high degree
of impairments the disorder causes to their functioning on the job or in social relationships resulting from
instability in mood.
Bipolar disorder has been considered by many to be a more severe disorder than major depression based on
reports of lifelong recurrence and higher rates of comorbidity with other disorders, such as anxiety and
substance use disorders (Angst, 2007). Bipolar disorder I is diagnosed when an individual meets criteria for
experiencing a manic episode that has been “preceded or may be followed by a hypomanic or major depressive
episode” (p. 123), while bipolar II is diagnosed if a hypomanic episode follows or precedes a major depressive
episode, and there has never been a manic episode (pp. 132–133). In order to improve the diagnostic
reliability in the criteria, the DSM-5 has expanded Criterion A for manic and hypomanic episodes so that in
addition to a distinct period of “abnormally and persistently elevated, expansive or irritable mood,” the episode
also includes “persistently increased goal directed activity or energy,” lasting for at least 1 week (manic
episode) or 4 consecutive days (hypomanic episode) (p. 124). Other criteria remain unchanged from the
previous DSM, and include three or more symptoms (four if the mood is only irritable), from Criterion B,
including grandiosity (inflated self-esteem), decreased sleep, pressured speech, flight of ideas, distractibility,
increased goal-directed activity, and excessive engagement in high-risk activities. While mania is associated
with severe impairment, hypomania does not cause marked impairment.
Developmentally, bipolar disorder is difficult to diagnose in children and adolescents since many of the above
symptoms overlap with symptoms for other disorders, such as attention-deficit/hyperactivity disorder
(ADHD), including distractibility, racing thoughts, pressured speech, and less need for sleep. Since children
and adolescents also often manifest symptoms of depression as irritability, the DSM warns that a diagnosis of
bipolar should only be given in cases where there is an identifiable “time-based” episode of irritability marking
the onset of Criterion B symptoms. In addition, there are high rates of comorbidity with anxiety disorders
(75% of those with bipolar disorder also have anxiety disorders), ADHD, and the disruptive behavior
disorders adding to the complexity of this diagnosis (APA, 2013, p. 132).
In addition to the increased emphasis on increased energy (activity) as well as mood for Criterion A
416
symptoms, the DSM has also added a number of specifiers that can assist in clarifying the nature of the
bipolar disorder, such as those accompanied by symptoms of anxious distress (restless, keyed up), rapid cycling
(4 mood episodes within 12 months), or melancholic features (loss of pressure and emotional reactivity, guilt,
weight loss, depression).
Because symptoms of bipolar disorders can manifest in conditions that do not meet all criteria for bipolar I, II,
or cyclothymic disorder, or mimic bipolar disorder, especially in children, the DSM has a number of possible
alternatives for diagnosis, including disruptive mood dysregulation disorder (see depressive disorders below for
an explanation) and other specified bipolar and related disorders, which include depressive episodes with
short-duration hypomania included in Section III, Conditions for Further Study. The DSM-5 (APA, 2013)
suggests that future study be conducted to determine whether this new category should be established for
individuals who experience at least one major depressive disorder and at least two episodes of hypomania,
lasting 2 to 3 days. These hypomanic episodes would meet all criteria for a hypomanic episode but would be
shorter than the required 4-day duration (p. 787).
417
Depressive Disorders
The chapter on depressive disorders (previously called mood disorders) has incorporated a number of changes in
addition to removing the bipolar disorders from the chapter and establishing a unique section for these
disorders separate from what would be considered as “unipolar” versus bipolar disorders. Included within this
chapter are the original disorders from the previous edition, including major depressive disorder, persistent
depressive disorder (previously known as dysthymia), and depressive disorders that are medication or
substance induced, and those related to medical conditions. New to the chapter are premenstrual dysphoric
disorder, which has been moved from Appendix B (Criteria Sets and Axes Provided for Further Study of the
DSM-IV), and a new category of depressive disorders, disruptive mood dysregulation disorder, which was
created to address concerns of overdiagnosis of bipolar disorder in children up to 18 years of age. After a
discussion of the criteria for a major depressive episode, criteria for disruptive mood dysregulation disorder
will be addressed.
Major depressive disorder (MDD): Individuals are diagnosed with MDD if they experience a major depressive
episode, which requires five or more symptoms evident during the same 2-week period, with at least one
symptom meeting criteria for (1) depressed mood (which may appear as irritability in children and
adolescents), or (2) loss of interest or pleasure. The other 6 symptoms of major depressive episode are
significant weight loss or gain (failure to meet expected weight for children); nightly insomnia or
hypersomnia; psychomotor agitation or retardation; feelings of worthlessness, guilt; problems in concentration
and decision making; and recurrent suicidal ideation (APA, 2013, p. 161). Although the previous version of
the DSM excluded bereavement (of 2 months or less) from the criteria for MDD, the DSM-5 omits this
exclusion, due to the recognition that bereavement can last up to 2 years and the degree to which bereavement
can act as a significant psychosocial stressor. Although depression can occur at any age, the prevalence rates
increase significantly in adolescence with the onset of puberty.
Persistent depressive disorder (previously known as dysthymia): The category of persistent depressive disorder
replaces the disorder of dysthymia and chronic major depressive disorder in the DSM-IV. Criteria for
persistent depressive disorder differ from criteria for MDD in two important ways: the duration of the
disorder and the number of symptoms required. For a diagnosis of persistent depressive disorder, depressed
mood (irritability in children and adolescence) must be evident for most days (with no lapse from depressive
symptoms for longer than 2 months) over the course of 2 years for adults (1 year for children and adolescents),
with evidence of an additional two symptoms from a list of six possible symptoms: problems of appetite (over-
or undereating); insomnia or hypersomnia; fatigue; low self-esteem; poor concentration or decision making;
and feelings of hopelessness.
The DSM-5 notes that if symptoms meet criteria for MDD over the course of 2 years (either during or
preceding persistent depressive disorder), then a diagnosis of persistent depressive disorder as well as major
depressive disorder should be applied. The DSM-5 also includes specifiers for MDD and persistent depressive
disorder, including the addition of symptoms of anxious distress, and melancholic features.
418
Disruptive mood dysregulation disorder: There has been increased concern regarding the suitability of criteria for
bipolar disorder for children and youth, especially in view of the rapidly increasing rates of diagnosis of the
disorder in children. In their study of prevalence rates for bipolar disorder among children, youth, and adults
in 1996 compared with rates in 2004, Brotman and colleagues (2006) found alarmingly high increases in
prevalence rates between these two time periods for children (53.2% increase), and teens (58.5% increase),
relative to adults (3.5% increase). Since symptoms of pediatric bipolar disorder often are accompanied by
patterns of volatile behaviors and low frustration tolerance, also seen in disruptive behavior disorders, such as
oppositional defiant disorder and ADHD (combined inattentive/hyperactive-impulsive types), some
researchers have suggested that the use of “irritability” as a marker for bipolar has been confused with bouts of
“episodic irritability” associated with depression and more “chronic” forms of irritability associated with
oppositional defiant disorder (ODD), attention-deficit/hyperactivity disorder (ADHD), and some variants of
autism spectrum disorders (Geller, et al., 2000; Leibenluft, Charney, Towbin, Bhangoo, & Pine, 2003). In
order to address these concerns and the resulting overdiagnosis of bipolar disorder in children and youth,
researchers have suggested the use of the term severe mood dysregulation syndrome to identify children who
exhibit these severe forms of irritability. In the DSM-5, disruptive mood dysregulation disorder was included
in this chapter to address the above issues and concerns and to assist in distinguishing children who
demonstrate severe and persistent irritability “relative to children who present with classic (e.g., episodic)
bipolar disorder” (APA, 2013, p. 157).
Criteria for disruptive mood dysregulation disorder require that the disorder be present for at least 1 year,
occur in more than one setting, and include two major criteria, involving Criterion A, severe temper outbursts
(verbal or physical) that are significantly beyond what would be expected (intensity/duration) given the
situation, and Criterion D, a predominant mood of severe irritability and or anger that is evident between
tantrums. Tantrums must be inconsistent with developmental level (Criterion B) and occur three or more
times weekly (Criterion C). The diagnosis is reserved for children and youth from 6 to 18 years of age, with
onset before 10 years of age. It is important to consider children in this category, if and only if the severe
irritable or angry mood is present “most of the day, nearly every day.” The diagnosis cannot accompany a
diagnosis of ODD, intermittent explosive disorder, or bipolar disorder but can be comorbid with major
depressive disorder, ADHD, conduct disorder, and substance-use disorders. Individuals who meet criteria for
ODD and disruptive mood dysregulation disorder are given a diagnosis of disruptive mood dysregulation
disorder (APA, 2013, p. 156).
419
Differential Diagnosis
Because of the nature of disruptive mood dysregulation disorder (DMDR), it is important to be able to
distinguish this disorder from others that will present with similar features, including bipolar disorder,
oppositional defiant disorder (ODD), and ADHD, MDD, the anxiety disorders, and autism spectrum
disorder.
In their study of bipolar disorder in preschoolers and young school-age children, Wilens and colleagues (2003)
described manic episodes as those that demonstrated abnormally high levels of “giddy, goofy, drunk-like” or
severely irritable mood and temper outbursts (p. 497), in the presence of at least three other symptoms, from
the following list: grandiosity, insomnia, pressured speech, flight of ideas, distractibility, extreme goal-directed
behavior, and excessive pleasurable activities (e.g., masturbation) (p. 497). In making a differential diagnosis
between DMDR and bipolar disorder, Youngstrom, Findling, Youngstrom, and Calabrese (2005) emphasize
that it is important to not define bipolar disorder by symptoms such as “distractibility, impulsivity,
concentration problems and motor agitation” that overlap with other disorders but to focus on those
symptoms that can assist in making a differential diagnosis associated with bipolar disorder, namely,
grandiosity, hypersexuality, pressured speech, and racing thoughts characteristic of mania. Furthermore,
bipolar disorder should be considered as an episodic disorder and as such, irritable mood states should be
identifiable as episodes distinct from day to day functioning, and in the company of other bipolar symptoms
(such as grandiosity and elevated/expansive mood), as opposed to DMDR where irritability or anger is
persistent over many months (at least 1 year). When considering DMDR and ODD, Wozniak and colleagues
(2005) suggest that irritability associated with ODD can best be described as the type of irritability associated
with being easily annoyed, which can result in loss of temper. Although children who meet criteria for
DMDR will also exhibit symptoms of ODD, only approximately 15% of those with ODD would meet
criteria for ODD (APA, 2013). Irritability associated with MDD can best be associated with the type of
irritability that one relates to a mad or cranky mood that would be evident most of the day (Wozniak et al.,
2005). These descriptors can assist in distinguishing episodic or milder forms of irritability from the severe
form of pervasive irritability and angry outbursts associated with DMDR.
420
References
Angst, J. (2007). The bipolar spectrum. British Journal of Psychiatry, 190, 189–191.
Brotman, M.A., Schmajuk, M., Rich, B. A., Dickstein, D., Guyer, A. E., & Costello, E. J. (2006).
Prevalence, clinical correlates and longitudinal course of severe mood dysregulation in children. Biological
Geller, B., Zimerman, B., Williams, M., Bolhofner, K., Craney, J. L., & Delbello, M. P., (2000). Diagnostic
characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender,
puberty and comorbid attention deficit hyperactivity disorder. Journal of Child and Adolescent
Leibenluft, E., Charney, D. S., Towbin, K. E., Bhangoo, R. K., & Pine, D. S. (2003). Defining clinical
phenotypes of juvenile mania. American Journal of Psychiatry, 160, 430–437.
Wilens, T., Biederman, J., Forkner, P., Ditterline, J., Morris, M., & Moore, H. (2003). Patterns of
comorbidity and dysfunction in clinically referred preschool and school-age children with bipolar disorder.
Journal of Child and Adolescent Psychopharmacology, 13, 495–505.
Wozniak, J., Biederman, J., Kwon, A., Mick, E., Faraone, S. V., & Orlovsky, K. (2005). How cardinal are
cardinal symptoms in pediatric bipolar disorder? An examination of clinical correlates. Biological
Youngstrom, E. A., Findling, R., Youngstrom, J. K., & Calabrese, J. R. (2005). Toward an evidence-based
assessment of pediatric bipolar disorder. Journal of Clinical Child and Adolescent Psychology, 34, 433–448.
421
Case 17 David Steele Hopelessness and Despair Adolescent
Depression; Suicidal Ideation
David sat at his desk staring off into space. When he glanced back down at the paper in front of him, he
realized that he had been drawing boxes for the last half hour. Each box connected to the next. Just like his
life. There was no way out and there was no way in. He was boxed into a corner. There was no escape.
David hated school and he hated the kids. They were all a bunch of phonies. No one understood anything
that mattered. He could hear them at their lockers, talking and laughing. They were all so ridiculous, so
shallow. They were all full of themselves. They didn’t see life like he did. They never would. He was sick and
tired of the whole damn thing. He had done his thing. He had tried it their way. But they always wanted
something from him. There was always a catch. Either they needed to borrow money or they needed a ride
somewhere. They always wanted something. He was sick of being used. He hated them anyway. Better this
way.
His mother’s voice talked at him from the other side of the closed door. She said something about going out
for the evening, something about making sure his homework was done, and then he heard the front door close
behind her. Good, she was gone. He didn’t need her interruptions either. She was always going out
somewhere. No wonder his father left. She was never home. Life was just one big party. She was as shallow as
the rest of them. She didn’t understand him either. She said he was just a moody teenager. Laughed at him.
Called him “James Dean, tortured teen.” The funny thing was, that didn’t even upset him anymore. He was
beyond upset. Upset needed feelings. He felt nothing. He looked back down at the drawings of the boxes;
they were all empty, too. Just sides. Nothing inside. Empty boxes.
It was very quiet now. Just four walls with emptiness inside. Dead air. Death. He thought about death a lot.
They put dead people in boxes. Was he dead already? There was no noise. There was no feeling. Ah . . . the
betrayal. Thoughts. Dead people don’t think. Dead people don’t have to listen to the same damned thoughts
echoing in their heads over and over and over. What was the noise in his head? Was that a voice talking to
him from the grave? A dead person calling to claim him? Or was it just the sound of his own voice, caught in
his head and bouncing back and forth in the emptiness? . . . Dead people are better off. If he were dead,
would anyone care? Would anyone notice that he wasn’t in class? He thought about the philosophical
argument about the tree falling in the forest. How did it go? If a tree falls in the forest and no one is there to
hear it . . . did it make a noise? If he killed himself, and no one cared . . . did he even exist? David started to
write a suicide note but gave up because he couldn’t think of anyone who would be interested in his thoughts.
He berated himself because he couldn’t even make his mind up about this. He was pathetic. He would wait
for another day. He didn’t even have the energy to figure out how to do it. Maybe just walk into the traffic.
But then, what if you screw up with that, too, and only get run over and lose a leg or something. That would
be worse. He walked into the living room and poured himself another shot of whiskey. At least he knew one
thing, the whiskey would stop the thinking soon, and he would pass out. Passing out worked. You stopped
thinking, at least for a while. . . .
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David’s case is typical of many adolescents who live in a private world of despair. The majority never end up in
a psychologist’s office or a clinic. Some suffer in silence. Others end their suffering.
423
Youth with unipolar depression do not experience the highs and lows of bipolar disorder; instead, they
experience a pervasive sense of sadness, irritability, or loss of pleasure in their lives. While some of the
negative feelings may result from situational factors (loss of a friend, break-up of a romance, problems at
home or school), emotional pain can also result from biological causes, such as low levels of the
neurotransmitter serotonin. Depression can occur as a result of the complex interplay between biopsychosocial
and environmental factors (Harrington, Rutter, & Fombonne, 1996), which can add to problems with the
regulation of affect in children and youth (Cicchetti & Toth, 1995). Depression can be conceptualized as
depressed mood, depressive syndrome, or depressive disorder, depending on the nature and severity of the mood
(Angold, 1988).
Children and youth experience depressed mood when temporary symptoms of depression and irritability are due
to negative outcomes from some situation (e.g., getting a bad grade on a test, getting into a fight with a
friend). A depressed syndrome is a cluster of symptoms of depression that occur together and share similar
features. The Achenbach behavioral scales (Achenbach & Resorla, 2001) include two depressive syndromes:
anxious/depressed syndrome (symptoms of depression that are accompanied by anxiety) and the
depressed/withdrawn syndrome (symptoms of depression that share common features of low positive affect).
The DSM-5 (American Psychiatric Association [APA], 2013) recognizes a number of categories of depressive
disorders, based on symptom severity and duration: adjustment disorder with depressed mood (which is discussed
in the chapter on trauma and stress-related disorders), disruptive mood dysregulation disorder (DMDD), major
depressive disorder, persistent depressive disorder (previously known as dysthymia), premenstrual dysphoric disorder,
substance medication-induced depressive disorder, and other specified or unspecified depressive disorders. Adjustment
disorder with depressed mood is a temporary response to a known stressor that occurs within 3 months of an
event and lasts no longer than 6 months (e.g., a child who reacts with irritability and sadness to a relocation
because the child has moved away from friends and school). Major depressive disorder (MDD) is a pervasive
feeling of sadness, irritability, or loss of interest/pleasure that lasts for at least 2 weeks and is accompanied by
at least five symptoms from the following areas: emotional (worthlessness/guilt), behavioral
(insomnia/hypersomnia), cognitive (recurrent thoughts of suicide/death; diminished concentration), and
physical (psychomotor retardation/agitation; fatigue; loss of appetite/increased appetite). Persistent depressive
disorder is a low-grade depression involving fewer symptoms (two instead of five) over a longer duration (2
years for adults; 1 year for children). Children and adolescents may have symptoms similar to adults; however,
depressed mood can often appear as “irritable mood,” and symptom presentations will vary given different
developmental levels. It is possible for MDD to precede persistent depressive disorder, or occur during the
course of persistent depressive disorder. Individuals can receive a diagnosis of MDD and persistent depressive
disorder.
In this revision of the DSM (APA, 2013), there are several changes to the manner in which depressive
disorders are conceptualized, including the addition of two new variants (DMDD and premenstrual dysphoric
disorder) and the addition of a number of specifiers that can be added to enhance diagnostic clarity, including
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depression with anxious distress, mixed features, or melancholic features. Degree of severity can also be
identified from mild and moderate to severe variations of the disorders. The category of other specified
depressive disorder is reserved for those cases where symptoms cause significant distress and dysfunction but do
not meet criteria for a specific depressive disorder. Subtypes of depression within this category include
recurrent brief depression, short-duration depressive episode (less than 2 weeks), or depressive episode with
insufficient symptoms (pp. 183). See Appendix D for the DSM-5 diagnostic guidelines for DMDD, MDD,
and persistent depressive disorder.
There has been growing concern about the onset of mood disorders in children and youth and the lifelong
impact that this can have (Costello et al., 2002). It is estimated that 20% of all adolescents will experience at
least one episode of depression by age 18, and 65% will report less severe, transient symptoms (Lewinsohn,
Hops, & Roberts, 1993). Prevalence rates vary according to type of depression (major depression vs. persistent
depression) and whether the population sampled is normative or clinical. According to Kovacs, Devlin, and
colleagues (1997), major depression in children and adolescents usually lasts from 7 to 9 months, while the
average duration for persistent depression is 4 years. There is increasing evidence that episodes of pediatric
depression can be highly recurrent. Emslie, Rush, and Weinberg (1997) found that 72% of their sample had a
relapse within 5 years, while Park and Goodyer (2000, p. 148) report that “short-term relapse is common,
occurring in 40–60% of children and adolescents within two months of remission” (reduction of symptoms
during a specified period of time).
Recently, using a modified DSM-IV diagnostic profile (four instead of five symptoms required and
eliminating the need for a stable mood state over 2 weeks), researchers at the Washington University School
of Medicine (Luby et al., 2002, 2004, 2006) found that preschoolers evidenced episodes of hedonic depression
(a reactive form of depression) and anhedonic depression (melancholy and loss of pleasure). Characteristics that
accompanied depression in preschoolers included delayed milestones (walking, talking), regression in
previously acquired milestones, and night terrors or nightmares.
In school-age children, depression can manifest in acting-out behaviors (anger), withdrawal, and low
frustration tolerance, which can negatively affect academic achievement and social relationships (Yorbik,
Birmaher, Axelson, Williamson, & Ryan, 2004). Depression at this stage of development is most likely
related to situational events rather than due to genetic heritability. Children who live in stressful environments
and are exposed to more stressful events (family conflict, parenting style, peer rejection) are at increased risk
for developing depression (Eley, Deater-Deckard, Fombonne, & Fulker, 1998). Although children may
experience symptoms that are similar to adult symptoms (loss of interest, apathy, sadness, self-doubt, feelings
of worthlessness, guilt, and despair), young children may also experience associated feelings of separation
anxiety and exhibit a wide variety of physical complaints (Mitchell, McCauley, & Burke, 1988; Ryan, Puig-
Antich, & Ambrosini, 1987). Childhood symptoms of depression often include symptoms of irritability,
somatic complaints, and social withdrawal. Behavior disorders, ADHD, and anxiety disorders are often
comorbid with depression (APA, 2013).
Rates of depression increase dramatically with age, rising from 2% in childhood to between 4% and 7% in
425
adolescence (Costello et al., 2002). In adolescent populations, depression may appear as irritability mixed with
features of anxiety or anger (Compass, Connor, & Hinden, 1998), and there is a higher rate of the
melancholic (anhedonic) subtype of depression. Depression in children and adolescents may go undiagnosed
due to a failure to recognize irritability, anxiety, and physical complaints (headaches, body pains, and
stomachaches) as signs of depression. In addition, adolescent “mood swings” may be considered as normal
teenage angst by some parents. While there are equal numbers of boys and girls who will experience
depression in childhood, by 16 years of age, girls are twice as likely to be depressed as boys (Hankin &
Abramson, 2001). Findings from studies that have followed adolescents with MDD suggest that the disorder
is continuous, specific (Lewinsohn, Rohde, Klein, & Seeley, 1999), and linked to increased risk for mortality
from suicide, parasuicidal behaviors, substance use, negative life events, and poor levels of academic and social
functioning (Weissman et al., 1999).
In their sample of youth with depressive disorders, Escher, Romme, Buiks, Delespaul, and van Os (2002)
found that hallucinations tended to persist if they were severe and frequent and associated with anxiety and/or
depression. In their review of studies conducted concerning auditory hallucinations in nonpsychotic children,
Best and Mertin (2007) conclude that auditory hallucinations seem to be a consistent feature in cases where
youth demonstrate high levels of anxiety and/or depression.
Between 40% and 60% (Angold & Costello, 1993; Rohde, Lewinsohn, & Seeley, 1994) of depressed children
and youth have at least one other comorbid disorder, the most common of which are anxiety, substance abuse,
and disruptive behavior disorders. Twenty percent of youth that experience a depressive episode will develop
bipolar disorder. Depression in children and adolescents has been linked to multiple causes, including family
history (Kovacs, Obrosky et al., 1997), biological factors (low levels of serotonin, high levels of cortisol), and
cognitive factors (negative and maladaptive thought processes). Factors that can increase the risk of depression
in children include stress (Lewinsohn, Rogdem, & Seeley, 1998); loss of a parent or loved one (Wells, Deykin,
& Kierman, 1985); romantic break-up (Monroe, Rohde, & Seeley, 1999); school problems (Gould, Fisher,
Parides, Flory, & Shaffer, 1996); and family problems, including family poverty, conflict with parents
(Hammen, 2006), and the stress and challenges of living with a single parent (Garrison, Addy, Jackson,
McKeon, & Waller, 1992). Personality factors linked to increased risk for MDD and suicide include high
levels of neuroticism, novelty seeking, and low self-esteem (Fergusson, Beautrais, & Horwood, 2003).
Protective factors that can buffer youth from depression include family cohesion and connectedness
(Borowsky, Ireland, & Resnick, 2001) and positive team-sport involvement (Boone & Leadbeater, 2006).
Although having friendships is a protective factor for both boys and girls, the nature of the friendship varies
by gender. While girls benefit from having a cohesive and interconnected set of friends who are not at odds
with each other, a protective factor for boys involves a network of friends who participate in common activities
(Bearman & Moody, 2004).
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Treatment Alternatives for Depression
The nature of the treatment method used can reflect the therapist’s theoretical perspectives: cognitive
behavioral, family and parenting, or biological basis of behavior. Kaslow and Thompson (1998) reviewed
interventions for depression targeting children and adolescents, the majority of which involved cognitive–
behavioral therapy (CBT). Although a number of the programs demonstrated success in alleviating depressive
symptoms, none of the studies met with the stringent criteria for well-established treatments. Furthermore,
the authors noted that most of the interventions had been adapted from adult treatments and neglected to
include modifications related to the child’s or adolescent’s developmental stage. They found only two child
studies and two adolescent studies that met criteria for probably efficacious interventions set forth by the APA
Task force (APA Task Force on Psychological Intervention Guidelines, 1995).
The child studies that met the standard were two studies conducted by Stark and colleagues (Stark, Reynolds,
& Kaslow, 1987; Stark, Rouse, & Livingston, 1991) demonstrating the benefits of CBT self-control therapy.
Adolescent studies meeting the standard included studies by Lewinsohn and colleagues (Lewinsohn, Clarke,
Hops, & Andrews, 1990; Lewinsohn, Clarke, Rhode, Hops, & Seeley, 1996). In the first study (Lewinsohn et
al., 1990), adolescents who received a 14-week CBT program or adolescents whose parents conjointly received
a 7-week CBT program reduced more symptoms of depression than the wait-list control group. Replication
of the study (Lewinsohn et al., 1996) with some modifications revealed similar results with maintenance of
reduced depressive symptoms at follow-up, 2 years later. Kaslow and Thompson (1998) concluded their
review by emphasizing the need for future studies to recognize developmental differences and incorporate
cultural perspectives.
Weisz, Doss, and Hawley (2005) conducted a meta-analysis of empirically supported youth treatment
approaches for anxiety, depression, ADHD, and conduct problems. For adolescents, youth-based programs
were more common for all disorders compared to family-focused treatments. The most common youth-based
treatment program for depression was based on behavioral- and learning-based perspectives (78%), with CBT
being the most common component in this category (67%). Programs for depression were most often
delivered in group (89%), compared to individual (11%) format, with an average of 12 group sessions per
program.
In their review of programs aimed at the prevention of depression in children and adolescents, Gladstone and
Beardslee (2009) found that several programs have developed their prevention strategies based on cognitive–
behavioral or interpersonal approaches building on the success of these programs in the treatment of
depressive disorders in youth (Kaslow & Thompson, 1998). Gladstone and Beardslee suggest that common
features among these approaches include “clearly identified, well-specified targets for preventive interventions
that are manual-based, delivered with fidelity, and involve cognitive and social-relationship dimensions”
(2009, p. 213). Results of the review (see Gladstone & Beardslee, 2009) produced several promising programs,
such as the Penn Resiliency Program (Gillham, Brunwasser, & Freres, 2008), the Interpersonal
Psychotherapy Prevention Program for High-Risk Teens (Young, Mufson, & Davis, 2006), and Problem
Solving for Life (Spence, Sheffield, & Donovan, 2005).
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Medical Management of Depressive Disorders in Children and Youth
Between 30% and 40% of children fail to show a positive response to medication for depression (Emslie,
Rush, & Weinberg, 1997). Difficulties with prescribing medications for mood disorders in childhood can be
related to the fact that there are very few pediatric trials and, as a result, the majority of medications are
prescribed “off label,” since they contain no information about pediatric use. Some studies have shown that
selective serotonin reuptake inhibitors (SSRIs) have limited success for pediatric populations (March et al.,
2004).
Although initial studies concerning medical treatments for adolescent depression revealed contradictory
results, these studies involved trials of tricyclic antidepressants. Recently, trials of SSRIs point to more
persuasive evidence for the benefits of fluoxetine (Prozac) and paroxetine (Paxil). In controlled studies,
fluoxetine was proven effective for children and adolescents (Emslie et al., 1997), while paroxetine has proven
successful with adolescents (Keller, Ryan, & Strober, 2001). However, the FDA has recommended that
paroxetine not be used with children or adolescents. Currently, fluoxetine is the only FDA-approved
medication for use with children 8 years of age or older.
Based on a review of outcomes regarding the use of medications with children and youth, the FDA found
statistical evidence for increased suicidal ideation and behaviors among youth taking the antidepressant
medications (Newman, 2004). Although one of the most common symptoms of depression is lethargy and
loss of energy, antidepressant medications serve to increase the energy level. However, often the energy
returns before the mood improves, resulting in an increased risk for suicide (the youth is now mobilized to act
on the depression and engage in suicidal impulses). As a result, the FDA issued a black box warning (the most
serious warning level available) regarding the use of antidepressant medication (SSRIs) for child and
adolescent depression. The FDA also cautioned that antidepressants could trigger a manic episode in patients
with bipolar disorder.
There is significant controversy regarding the use of medications for children and youth with depressive
disorders. Some researchers (Emslie et al., 1997) have found success with fluoxetine; however, potentially
serious side effects from the use of the drug also exist. At least one adolescent male (Webb & Cranswick,
2003) was reported to have developed auditory hallucinations telling him to kill his family and himself shortly
after taking fluoxetine for the first time. As a result, controversy has resulted as to whether the risks outweigh
the benefits; however, there is also evidence to suggest that the use of medications can increase treatment
success. The Treatment for Adolescents With Depression Study (TADS) revealed that using CBT with
antidepressants was significantly more effective than CBT alone (Apter et al., 2005; March et al., 2004), while
other studies have found that the use of antidepressants act to reduce the risk of suicidal behavior (Olfson,
Shaffer, Marcus, & Greenburg, 2003; Valuck, Libby, Sills, Giese, & Allen, 2004). Bridge and colleagues
(2007) conducted a comprehensive review of all pediatric medication trials in the past 18 years (1988–2006)
and concluded that based on the results, the benefits of using antidepressant medications far outweighed any
risks.
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Suicide Risk, Treatment, and Prevention
431
Suicide Risk
Although rare in childhood, current suicide rates for children are 8 times higher than noted in the 1950s
(Goldman & Beardslee, 1999), and suicide is now the third leading cause of death among 10- to 19-year-olds
(Borowsky et al., 2001). Twice as many females attempt suicide, but males are four times more likely to
succeed, due to the more lethal methods used by males. In September 2007, the Centers for Disease Control
and Prevention (CDC) released a report concerning the largest annual increase in suicide rate for youth in the
10- to 14-year bracket, with 94 suicides during 2003–2004 compared to 56 suicides the previous year.
Increases were also noted in the 15- to 19-year span for that year as well. Methods also reported a change
from using firearms in 1990 to hanging/suffocation in 2004, which accounted for 71% of the deaths reported
for females in the 10- to 14-year category, and 49% of deaths among the older girls (15–19). Males continued
to use firearms as the most frequent method (Centers for Disease Control and Prevention [CDC], 2007).
The CDC suicide factsheet (CDC, 2009) reports that in 2007, 14.5% of U.S. high school students surveyed
(18.7% of females, 10.3% of males) stated that they had seriously considered attempting suicide in the
previous 12 months, while 6.9% (9.3% of females, 4.6% of males) reported that they had actually made a
suicide attempt in the previous 12 months. Among the 15- to 21-year-old group, suicide is responsible for
12% of all deaths annually.
According to the CDC report on youth suicide, the top three methods used by youth to commit suicide are
firearms (46%), suffocation (39%), and poisoning (8%). However, more youth survive than complete suicides,
and approximately 149,000 youth ages 10 to 19 were seen in emergency departments across the United States
to receive medical support for self-inflicted injuries. The following behaviors were noted as risks for potential
suicide in the CDC report:
History of previous suicide attempts

Family history of suicide
History of depression or other mental illness
Alcohol or drug abuse
Stressful life event or loss
Easy access to lethal methods
Exposure to the suicidal behavior of others
Incarceration (CDC, 2007)
Although major depression seems to be the most prominent risk factor for suicide in girls (Shaffer et al.,
1996), somatic symptoms, peer suicide attempt, and illicit drug use were all found to increase the risk of
suicide in females regardless of ethnicity (Borowsky et al., 2001). Having made a previous suicide attempt is
the most lethal risk factor for males (Shaffer et al., 1996), along with weapon carrying at school and same-sex
romantic attraction (Borowsky et al., 2001). Other risk factors that cut across gender and ethnicity include
violence victimization, violence perpetration, alcohol use, marijuana use, and school problems. In their
examination of adolescent profiles for more than 13,000 students between 1995 and 1997 (Grades 7–12),
432
Borowsky and colleagues (2001) found that having three protective factors reduced suicide attempts by
between 70% and 85%. Protective factors were identified as parent and family connectivity, emotional well-
being (girls), and high grade-point average (boys). Although acting on suicidal impulse has been linked to
serotonin malfunction in adults, this association has not been confirmed in children and adolescents. Children
and adolescents who contemplate suicide feel intense emotional distress and choose death as a means of
ending severe psychological pain. Kaminski and Fang (2009) found that victimization of youth by peers
significantly increased the risk of suicidal ideation. Youth who were victimized by peers (threatened or
injured) were more than twice as likely (2.4) to report suicidal thoughts and more than three times as likely
(3.3) to report suicidal behavior than peers who were not victimized.
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Suicide Treatment Program
A major stumbling block in the treatment of youth with suicidal thoughts is the fact that youth who are
experiencing these negative feelings are among the least likely to reach out for help (Carlton & Deane, 2000).
Intervention should restrict suicidal youth to a very structured environment where they can be placed on a
suicide watch and where a “no harm” contract is employed. Hospitalization in a psychiatric unit may be
required in some cases, and monitoring with reevaluation of potential future hospitalizations is crucial at this
stage (Rudd & Joiner, 1998). Cognitive therapy can be helpful in reframing thoughts of hopelessness and
improving problem-solving skills for increased adaptive functioning. It is important that the therapist ask and
establish whether the individual (a) has thought about suicide, (b) has a plan to carry out the suicide intent, (c)
has any previous suicide attempts, and (d) has other related clinical issues (Jobes et al., 2005, p. 405).
Multisystem therapy (MST) has been successful in the treatment of youth with a wide variety of serious
emotional difficulties (Henggeler, Clingempeel, Brondino, & Pickrel, 2002). MST is an ecologically based
and manualized program that incorporates a youth’s family and community resources (peers and school
system) in the therapeutic process. Huey and colleagues (2004) found that for youth with severe psychiatric
illness who were at risk for suicidal behavior, MST proved more effective in reducing future suicide attempts
than hospitalization.
The American Association for Child and Adolescent Psychiatry (AACAP) Practice Parameters for
Assessment and Treatment of Children with Suicidal Behavior (2001) suggests the following therapeutic
approaches for the treatment of suicidal behavior in children and adolescents: cognitive–behavioral therapy
(CBT), interpersonal psychotherapy for adolescents (IPT-A), dialectical behavioral therapy (DBT), and
psychodynamic and family therapy. Interpersonal therapy for adolescents is a program that consists of weekly
meetings (for 12 weeks) with the goal of increasing problem-solving skills. Results suggest that the program
successfully reduced depressed symptoms in adolescent participants (Mufson, Weissman, Moreau, &
Garfinkel, 1999).
Dialectical behavioral therapy (DBT; Linehan, 1993) has been successful in treating some of the most
challenging behaviors, including self-harm, in patients with borderline personality disorder (BPD). DBT is a
therapeutic approach that is designed to treat individuals who experience emotional dysregulation, which is an
inability to manage emotions, especially negative emotions, due to heightened levels of arousal. The program
integrates methods from the cognitive, behavioral, and psychodynamic schools of thought. Goals of the
program are to increase the ability to tolerate stress, increase social skills, and provide lessons and
opportunities to learn how to respond more effectively to challenging life situations. The therapist’s role is to
empathize with the clients and validate their needs. Individual therapy is supported by enrollment in skill-
building practice sessions (group therapy) to develop the needed skills to relate more effectively to others in a
safe environment. The program evolves around three stages:
1. Increase skills in managing behavior, while decreasing behaviors that are suicidal, interfere with therapy,
and reduce the quality of life.
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2. Increase awareness of stress-related trauma and reduce the distress.
3. Focus on long-range goals such as increased self-esteem and interpersonal success.
The efficacy of DBT has been reviewed extensively (Koerner & Dimeff, 2000; Robins & Chapman, 2004),
and although some critics have found fault with methodology in some of the studies, the success of the
program in reducing harmful behaviors such as suicide attempts and other acts of self-harm in patients with
BPD has resulted in recent applications of the approach to treat adolescents with suicidal ideation (Rathus &
Miller, 2002). Preliminary results have been promising.
In their chapter on adolescent suicidality, Jobes, Berman, and Martin (2005) discuss the application of a crisis
intervention model in working with adolescents who are at risk for suicide. The seven-stage model developed
by Roberts (1991) focuses on assessing the extent and nature of the risk and developing an appropriate
treatment plan. The plan involves the following seven stages:
Stage 1: Assess lethality or risk.

Stage 2: Establish rapport and communication.
Stage 3: Identify major problems.
Stage 4: Provide support.
Stage 5: Explore alternatives.
Stage 6: Develop an action plan.
Stage 7: Provide follow-up.
In the first stage, if the psychologist determines that the individual is at high risk (suicide is an imminent
risk), then legally, the psychologist must inform the parents of the suicide ideation (unless abuse by a parent is
a suspected cause, in which case, child protective services must be notified), and arrange for emergency
psychiatric treatment.
If the risk is not imminent, then it becomes imperative to provide counseling services to assist the adolescent
to deal with the distressing situation and emotional outcomes. During the counseling sessions (Stage 2), it is
important to develop rapport and trust to provide the individual with a source of support he or she can feel
confident in and trust. Once the sense of trust is established, then the focus turns to clinical assessment of the
history, extent, and nature of the problems the individual is facing (Stage 3). In Stage 3, the psychologist may
use self-report affective or behavioral rating scales, or parent and teacher rating scales or interviews to obtain
additional information to inform treatment planning, provide support (Stage 4), and determine the most
appropriate treatment alternatives.
435
Suicide Prevention Programs
Prevention programs can focus on one of three audiences: widely based, or universal, health promotion
programs targeting all children; selective, or secondary prevention, programs that target those at risk for suicide
(Hayden & Laurer, 2000); and indicated, or tertiary, prevention programs for those youth who are having
suicidal thoughts or who have attempted suicide previously.
Unfortunately, mass approaches to suicide prevention, such as suicide hot lines (Shaffer, Garland, & Bacon,
1989) and in-school awareness programs (Shaffer, Garland, Vieland, Underwood, & Busner, 1991), have, for
the most part, not been successful in preventing suicide, while some programs have actually increased the risk
of suicidal ideation in vulnerable youth (iatrogenic effects). However, the majority of these programs have
adopted a “stress” model that attributes suicidal behavior to induced stress in healthy people, as opposed to a
mental illness model, which views suicide as the outcome of mental illness (Connecticut Center for Effective
Practice [CCEP], 2006). At a global level, however, it is possible that routine screens can serve to identify at-
risk students for more intensive services (Shaffer & Craft, 1999). Borowsky and colleagues (2001) suggest that
targeting protective factors is an important key to developing successful suicide prevention programs.
Targeting risk factors such as substance abuse, stress, and lack of social support, and protective factors such as
family cohesiveness, academic success, and emotional well-being, may well be important ingredients in future
prevention programs for these children of despair.
Increasing rates of suicide in North America have focused attention on urgent need for the development and
evaluation of suicide prevention programs. Given the vulnerable nature of the target population, concerns have
been voiced about the need to protect against possible iatrogenic effects that might be imbedded in the
program (Gould et al., 2005; Shaffer et al., 1991). Schools are an obvious venue for service delivery, since
children and youth spend the majority of their time within the school environment. As a result, in the United
States, the majority of suicide prevention programs are school based (Kalafat & Elias, 1995). Within this
context, programs have been delivered in a number of different formats, including curriculum-based prevention
programs, staff in-service programs, and schoolwide student screening programs (Eckert, Miller, DuPaul, & Riley-
Tillman, 2003).
Curriculum-based programs are usually brief (a few hours) and provide psychoeducational information about
symptoms associated with suicidal ideation and offer information about community resources. Although there
has been some reported success in the reduction of suicidal ideation, there has been a lack of empirical support
(Mazza, 1997) and evidence that the programs may actually have a negative impact on those who are most in
need (Shaffer et al., 1991). In one study, participants actually reported an increase in feelings of hopelessness
and despair after involvement in the program (Overholser, Hemstreet, Spirito, & Vyse, 1989). Based on their
comprehensive review of curriculum-based suicide prevention programs, Gould and Kramer (2001) have
advised caution in launching future programs.
Faculty and staff awareness programs have been widely used despite the fact that there is very little empirical
support to attest to the value of this approach, although at least one study has suggested that staff in-service
436
was a successful component in a school-based program (Zenere & Lazarus, 1997). Kalafat and Elias (1995)
have suggested that another barrier to the success of school-based programs was reluctance of personnel to
participate in the programs based on the incorrect assumption that discussing suicide could actually lead to
suicidal behavior.
One of the most successful universal prevention programs that has been launched is the Signs of Suicide (SOS)
Prevention Program. The SOS Program (Aseltine, 2003; Aseltine & DeMartino, 2004) is unique relative to
previous programs in its dual emphasis on suicidal ideation as a mental illness (rather than stress induced) and
the detrimental effect of alcohol on those who suffer from mental illness. The program has been empirically
proven to reduce suicidal behavior and reduce suicide attempts by 40%. SAMHSA’s National Registry of
Effective Programs has recognized the SOS program, which was adopted by 675 schools as of the 2004–2005
academic year. A randomized clinical trial has also ruled out any possibility of iatrogenic effects resulting from
participation in the program.
The focus of SOS is on training adolescents as first responders to recognize the warning signs of suicide in
peers and teaching them to understand the importance of treating suicidal ideation as a medical emergency in
need of an immediate response. The program uses the acronym ACT (acknowledge, care, and tell):
ACKNOWLEDGE the signs of suicide that others display and take them seriously.
Let the person know you CARE about him or her, and that you want to tell.
Then TELL a responsible adult.
Descriptions of the SOS Program are available from several sources, including Aseltine, 2003; Aseltine,
James, Schilling, and Glanovsky, 2007; and Aseltine and DeMartino, 2004. The program includes an
educational component with a curriculum designed to increase student awareness of suicidal ideation,
including a film, Friends for Life, with an accompanying discussion guide to assist in developing appropriate
ways to act and respond to someone who is depressed or suicidal. The program also includes a self-screening
component (Brief Screen for Adolescent Depression [BSAD]; Lucas et al., 2001): a self-administered
instrument to determine risk based on suicidal ideation and problem drinking. Students are advised to seek
help if they score above a given level on the screening survey. The program’s emphasis is on suicidal ideation
as a product of mental illness, not a normal response to stress or disappointment and, as such, it requires an
emergency response, similar to any serious medical illness. A 2-year investigation of the program operating in
nine schools with socially, economically, and geographically diverse high school students revealed that the
program was effective in reducing the number of suicide attempts and in increasing awareness, as well as
adaptive attitudes, about suicide and depression in youth (Aseltine et al., 2007).
437
Post-Case Questions
1. Given David’s depression and suicidal ideation, what risk factors should have alerted family and school personnel to David’s
condition?
2. If you were a school counselor and David was a participant in the SOS program in your school, what results would you anticipate
from his self-report survey and why?
3. If you were aware of David’s suicidal ideation, what recommendations would you make to his parents? How should the
intervention begin?
4. Suppose that David’s mother had become aware of his depressed mood, and the physician was recommending placing David on
antidepressant medication. What advice would you give her?
5. What symptoms of depression does David exhibit, and would they meet criteria for a diagnosis of major depressive disorder or
persistent depressive disorder? Justify your response.
6. David’s creative writing teacher has become increasingly concerned about his journal entries, which she describes as “very dark.”
She was especially concerned about what he wrote yesterday.
“I am contemplating the philosophical argument about the tree falling in the forest. If a tree falls in the forest and no one is there to hear it, . . . did it
make a noise? If someone kills themselves, and no one cares, . . . does that mean that the individual never existed? Just like the tree in the forest?
What does dead air sound like?”
As the school psychologist, she has shared some of these entries with you. Based on the crisis intervention model described by Jobes et al.
(2005), how would you conduct your interview with David and what would the seven stages of the intervention model look like given your
knowledge of the information in the case study?
438
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Case 18 Matthew Morgan Out of Control and In Control Child-
Onset Bipolar Disorder/Mood Dysregulation Disorder
Since Matthew’s mother left, when he was only 1 year old, Tom has struggled continually to meet his son’s
escalating needs. Being a single father was a very difficult task, especially with all of Matthew’s problems. In
fact, Tom couldn’t believe that Matthew would be celebrating his ninth birthday soon. For Tom, Matthew’s
childhood was just a blur, like watching a roller coaster speed down the track at 100 miles an hour. The highs
and the lows were beginning to run into each other more and more. There were days when Matthew seemed
to be able to handle things, and then he would just fall apart, crying and saying he hated himself.
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Matthew had always been difficult, even as a baby. As an infant, he seemed to spit up more food than went
down and then he would wake up crying in the middle of the night because he was hungry. Then he would
overeat and cry again, his little stomach distended with gas. Matthew’s mother would have had problems
handling the best of babies; with Matthew, she didn’t have a chance. Tom worked nights and would often
arrive early in the morning after the night shift to hear Matthew screaming in the crib and his wife sleeping
through it on the couch.
Eventually, she left, saying that she just wasn’t cut out for motherhood. In the first 3 years, Tom struggled
with Matthew’s mother going in and out of his life. Matthew would wait patiently for her visits, and then she
would either not show up or come over in one of her “moods.” Her erratic behavior and mood swings were
what caused the marriage break-up in the first place. Ultimately, she stopped coming for visits altogether, and
it had now been 4 years since Matthew had seen his mother. In the beginning, Matthew talked about his
mother incessantly, asking why she would not see him. Often he would cry himself to sleep at night.
Although Matthew finally seemed to accept the fact that his mother would not return, Tom felt that Matthew
never really understood why.
Matthew did not get along with his stepsister, Emily. Emily was 14 years old and Tom’s daughter from his
first marriage. Matthew and Emily were like night and day. While Matthew was extremely temperamental
and hard to get along with, Emily was sweet, soft-spoken, and eager to please. Emily did well in school and
had many friends. Often Matthew would deliberately set out to annoy Emily, as if he were angry that she
seemed so happy. When Tom started dating again, Matthew went ballistic. One night when Emily was
babysitting, Matthew went totally out of control. He started smashing things in Tom’s room. Emily called her
father on his cell phone and he came home immediately, but not before Matthew had made a complete mess
of his room. Drawers were dumped on the floor and the lamp was smashed against the wall. Tom tried to
restrain Matthew, who was flailing his arms and behaving like a human tornado. After this frenzied burst of
activity, Matthew collapsed on the floor and began sobbing. He told his father he was sorry and felt very bad
about the damage he had done. The pattern repeated itself again and again. Angry outbursts would be
followed by remorse and guilt. Matthew seemed to have little control over his emotions in either direction.
On days when he was having a good time, his exuberance would also spiral out of control. Tom remembered
the day Matthew got his new bike. He went right out into the traffic and was almost hit by a truck. Matthew
also had few friends because he always seemed to overreact and either get in fights with other kids or blame
them if things were not going well. His behavior was often unpredictable and bossy. He would often come
home from the playground in tears.
Although Matthew’s behaviors made it difficult for Tom to have a social life, Tom eventually met Eileen, and
despite Matthew’s efforts to come between them, Eileen moved in. The next 2 years were horrible for
everyone in the house. Matthew was very easily upset and seemed to have a continual chip on his shoulder.
Eileen initially thought that Matthew would warm up to her in time; however, any time she attempted to get
close to him, Matthew would do something to draw the line. Matthew’s irritable disposition also made it
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difficult for anyone to get close to him. Discipline was very problematic because Matthew was unable to
handle criticism at any level. Any time Eileen would reprimand Matthew, he would break into tears, yelling at
her that she was not his mother and had no right to act as if she were. In time, Matthew’s behavior became
the focal point for arguments between Tom and Eileen. Matthew was also spending an inordinate amount of
time in the garage working on his go-cart. On several nights in succession, Eileen found Matthew in the
garage painting and putting decals on the cart well after bedtime. He was getting up at all hours of the night,
seemingly obsessed with these late-night activities as well as seemingly not needing to sleep. Eileen and Tom
incessantly argued about how to deal with the problem and could not agree on a resolution, so nothing was
done. Homework assignments were not handed in and homework became another battleground for Matthew
and Eileen. Finally, Eileen refused to get involved with Matthew’s schoolwork and the job fell to Tom, who
was often very tired after working a long day at the trucking firm. Matthew began to complain of headaches
and stomachaches and wanted to stay home from school. While doing his homework, Matthew would make
self-deprecating comments, calling himself stupid and a dummy. He complained frequently of feeling ill, and
he was not eating or sleeping very well.
Eileen eventually left, saying that she could no longer tolerate the family situation. She said that Matthew was
spoiled and that Tom did nothing to control his behavior. Their constant fights about Matthew had finally
taken their toll. Matthew said that he was happy the “witch” was gone. Tom wondered, however, if Matthew
felt that he had just lost another mother, or worse yet, that he had caused another mother to leave.
Matthew was also beginning to get into more trouble at school. His teacher had called Tom twice in the past
week, and Tom was asked to come in for a parent–teacher conference. At the school’s suggestion, Tom agreed
to have the school psychologist observe Matthew in the classroom and conduct a full assessment to determine
if Matthew might also be having learning problems that were adding to his difficulties.
When the school psychologist observed Matthew in the classroom, it was readily apparent which child she
was there to observe. Matthew was sitting at his desk, slouched down with his arms folded around himself in
one enormous pout. Apparently, his teacher had reprimanded Matthew on the way back from lunch because
he was running in the hall. Matthew continued to glare at the teacher with his eyes bearing down on her and
his lips pursed tightly. The teacher asked the class to break into small groups of six for the next activity, which
was a math game. Matthew quickly got out of the chair and gleefully joined his group, hopping and bouncing
up and down.
In the groups, children rotated the leadership role by selecting the next child to take the math lead. For a brief
time, Matthew seemed to be doing well and getting along with the others in his group, until it was his time to
pick another child to be the group leader. Instead of picking another child, Matthew began teasing the others
in the group, pretending to pick someone and then changing his mind, pointing at them with his chalk and
then retracting it. Finally, Matthew’s group began to ignore him and selected another leader. At this point,
Matthew threw the chalk on the floor, sulked, stomped his feet, and returned to his chair and resumed his
position of master pouter. Matthew’s teacher intervened, once again, and directed Matthew back to his group.
At this point, Matthew returned to the group but threw himself down on the floor in the middle of the group,
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which was ignoring him. He managed to get the chalk away from the leader and would not give it back. At
this point, the group was becoming very upset with Matthew and asked the teacher to intervene. This time,
the teacher walked Matthew back to his seat, and Matthew sat quietly while the other children returned to
their seats as well. When the teacher asked for volunteers to write their group’s response on the board,
Matthew’s hand shot up and he started yelling, “Me, pick me!!” When he was not picked, Matthew threw his
book on the floor and resumed the pout position.
Prior to the outburst that landed Matthew in the alternate school placement, Matthew started repeatedly
asking if he could see his mother again. He was very disturbed that no one seemed to know where she was.
Matthew was obsessed with finding her and would spend long hours at night searching for her on the
Internet. At school, Matthew was getting into trouble on a regular basis. He was not sleeping well and was
now irritable most of the time. He was having problems concentrating on schoolwork, and he seemed unable
to cope with other children or school demands. Matthew would frequently burst into tears and had to be
removed from the classroom on several occasions.
Socially, other children would either tease him or ignore him. Matthew’s responses were very unpredictable:
volatile and aggressive at one moment; at another time, crying and saying that he wished he were dead. Tom
attended another school conference, and the school psychologist shared concerns regarding her observations of
Matthew in class and around the school on her regular visits. After discussing Matthew’s family history, the
psychologist asked if Matthew’s mother had ever had a psychiatric assessment, or if anyone in the family had a
psychiatric disorder. Tom mentioned that his ex-wife had been diagnosed with bipolar disorder but would not
take the prescribed medication, saying it made her feel lousy. He added that her extreme mood swings made
their marriage very difficult. The school psychologist said she wondered if Matthew might also have bipolar
disorder. Tom scheduled a psychiatric appointment for Matthew; however, the earliest date he could get was
in 2 months’ time. In the interim, Tom agreed to take Matthew to his family physician for his medical
opinion.
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Reason for Referral
On Friday morning, Tom took Matthew to his family physician. Tom did not tell the physician that the
school psychologist mentioned the possibility of bipolar disorder, since he wanted the doctor to have an
unbiased opinion. The physician said that given Matthew’s problems with concentration, attention, and
hyperactivity/impulsivity, Matthew was likely demonstrating symptoms of attention-deficit/hyperactivity
disorder (ADHD), which could explain why he tended to be so impulsive and demonstrate such poor
behavioral controls. The physician prescribed a trial of Ritalin and asked Tom to have the teacher rate his
behavior on the rating scale when he dropped Matthew off at school and then again on Monday when the
Ritalin would be started. The physician was hopeful that the Ritalin would reduce Matthew’s impulsivity and
attention problems. Two days after he began taking the Ritalin, when a peer started teasing him, Matthew ran
out in front of the school bus and narrowly avoided being struck by the bus. When the teachers retrieved him
and tried to get him back into the classroom, he began kicking and screaming. Matthew grabbed a chair and
threw it at one of the teachers. Matthew was removed from the school and placed in an alternative school
placement for the next 45 days. While in the alternative setting, the Ritalin was discontinued, since there were
major concerns that the medication might have escalated his behaviors. While in the alternate setting, his
behavior was charted on an hourly basis to see what, if any, patterns might be evident in his moods, and also
to determine if certain triggers were likely to set him off. Tom was also asked to keep a similar record of
Matthew’s behaviors in the home. A pattern began to emerge, which seemed to repeat every 24 hours.
Results of the observations revealed mixed hypomania evident in ultradian cycling (brief manic episodes,
lasting from minutes to hours, occurring on a daily basis) that became evident in the late afternoon and
progressed onward until about 2:00 to 3:00 in the morning. Matthew would come to school in a very irritable
mood, tired, sleepy, and very grumpy, since he had been up until very late the night before. This irritable
mood, in which he was very “touchy,” distractible, easily upset, and difficult to communicate with, began to
wear off in the late afternoon, gradually being replaced by increased physical movement, agitation, and
excessive need to talk about anything and everything. At home, shortly after dinner, around 7 o’clock in the
evening, Matthew’s behaviors would begin to escalate in a more rapid and consuming fashion; this was
evident in giddy and silly behaviors (laughing, dancing, singing), with increased energy and insomnia until the
early hours of the morning (around 2:00 to 3:00 a.m.), when he would literally crash into a deep sleep. It was
nearly impossible to get him up for school in the morning, and Matthew would begin each day irritable,
grumpy, and half asleep. The consulting psychiatrist diagnosed Matthew with pediatric bipolar disorder
(bipolar II, mixed), and a trial of Risperdal (Risperidone) proved relatively successful in reducing the
depressive episodes and emotional volatility.
Matthew was referred for assessment to determine intellectual potential, academic progress, and emotional
status.
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Assessment Results
Guidelines to the interpretation of standard scores and T scores, as well as information regarding specific
assessment instruments used in this case can be found in Appendix C.
While in the alternate school placement, Matthew was assessed by the psychologist, who found that
Matthew’s intelligence on the Wechsler Intelligence Scale for Children (WISC-IV) was in the high average
range overall, at the 79th percentile (IQ = 112, range 106–117). There was minimal discrepancy between the
Index scores and no indication of problems with Working Memory or Processing Speed, which were within
the average range. Academically, although reading and math were at grade level, written expression was about
a year behind and in need of remediation. Matthew demonstrated problems with grammar and organizing his
ideas.
During his clinical interview, Matthew talked at length about his real mother and said that he was having
problems because she left. He said that he was sure he would be better if she would return. On the Achenbach
System of Empirically Based Assessment (ASEBA; Achenbach & Rescorla, 2001), Matthew’s father’s ratings
on the Child Behavior Checklist (CBCL) placed Matthew in the clinical range for Anxious/Depressed (T =
72), Attention Problems (T = 78), and Aggression (T = 74). His father endorsed the following items as very
true (occurring often) for the three significant scales: Anxious/Depressed scale (worries, talks of suicide, nervous,
feels worthless, feels unloved, cries a lot), Attention Problems scale (acts young, problems sitting still, impulsive, poor
schoolwork), and Aggression scale (argues a lot, mean, demands attention, destroys own things, destroys others’
things, disobedient at home, screams a lot, mood changes, sulks, temper, threatens others). Other items that were
endorsed significantly included brags, shows off, talks too much.
Matthew’s teacher did not endorse significant problems for the Anxious/Depressed scale (T = 64); however,
she did see significant difficulties with Attention (T = 78) and Aggression (T = 72). Social Problems were in
the high-risk range (T = 66). Similar to his father, items endorsed by his teacher for the Attention Problems
scale suggested high rates of hyperactivity and impulsivity (acts young, noisy, brags, fidgets, disturbs, impulsive,
talks out, disrupts discussions, irresponsible, shows off, talks too much). Aggressive behaviors that were significant
included argues, is mean, demands attention, destroys own things, attacks, screams, explosive, sulks, temper.
On the Beck Youth Inventories (BYI-2), Matthew rated himself as significantly depressed (T = 70),
aggressive (T = 82), and with low self-concept (T = 40). His score for anxiety was in the at-risk range (T =
66). During the course of the assessment sessions, Matthew’s moods vacillated abruptly. He could be very
cooperative and engaging, but in the next moment he could become difficult to engage and irritable. During
one of his more expansive moods, Matthew stated that he hated the school he was attending and that he
could teach better than the teachers in “this dump.” He also said he believed that he was going to be very
successful when he grew up and was intending to be a rock star or a movie star. When asked if he played an
instrument or was ever involved in a school play, he immediately changed the subject.
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455
The DSM-5 (APA, 2013) considers bipolar and related disorders (bipolar I and II, cyclothymia) as separate
from the depressive disorders, which represents a conceptual shift from how these disorders were presented in
previous versions of the DSM (bipolar disorders were previously classified with depressive disorders under the
category of “mood disorders”). The rationale behind the reclassification is that the current DSM considers
bipolar disorders as more severe than depressive disorders and as a “bridge” between the
schizophrenic/psychotic disorders and depressive disorders “in terms of symptomatology, family history, and
genetics” (p. 123). In this case of Matthew Morgan and the next case of Jenny Sloan, bipolar disorder (BP)
will be discussed as it relates to the manic part of the episode and will provide an opportunity for readers to
compare how these manic and hypomanic states can appear in childhood and adolescence.
The DSM-5 (APA, 2013) lists criteria for several types of BP, based on the nature and duration of the manic
episodes, including bipolar I, bipolar II, cyclothymic disorder, and other specified or unspecified bipolar and
related disorders. The DSM-5 criteria for bipolar disorders can be found in Appendix D. Individuals who are
diagnosed with BP will meet criteria of having three out of a possible seven symptoms of a manic episode, the
nature and duration of which will determine whether it is a full manic episode (lasting for at least 1 week), or
hypomanic episode (less severe than full mania; lasting for at least 4 days). Cyclothymic disorder involves
chronic hypomanic episodes for at least 2 years (at least 1 year in children and adolescents) that do not meet
criteria for a hypomanic episode, interspersed with numerous depressive episodes that do not meet criteria for
major depressive episode. During this time frame (1–2 years), there has been evidence of hypomanic and
depressive symptoms for at least half the time, remitting for no longer than 2 months at a time. Bipolar
disorders can be accompanied by a number of different specifiers, including anxious distress (two symptoms
from the following: tension, restlessness, concentration problems, fearfulness, worries about loss of control),
mixed features (full criteria not met for mania or hypomania and three symptoms from the following: depressed
mood, loss of interest, psychomotor retardation, fatigue, worthlessness/guilt, suicidal ideation), rapid cycling
(at least four mood episodes in past 12 months meeting criteria for manic, hypomanic or major depressive
episode), or melancholic features (loss of pleasure or reactivity to pleasant stimuli, and three symptoms from the
following: depressed mood, morning depression, early waking, psychomotor agitation or retardation,
significant weight loss, or excess guilt). Cyclothymia can be accompanied by symptoms of anxious distress.
In addition rapid cycling, Geller and colleagues (2000) have identified two other cycling patterns that can
occur in young children with BP:
ultrarapid cycling: manic episodes that are brief and recurrent (hours to days) but do not meet criteria for
hypomania, since they do not last for 4 days; and
ultradian cycling: manic episodes that are brief (minutes to hours), occurring on a daily basis.
Although later-adolescent-onset BP will more closely resemble the adult version (see the case of Jenny Sloan),
in younger children, symptoms are atypical and do not often resemble the adult version of the disorder.
Although BP was once thought to be rare in children (Carlson, 2005), prevalence rates have shown dramatic
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increases. In their recent study of discharge rates for children with BP, Blader and Carlson (2007) found that
the primary diagnosis of BP had increased from 10% in 1996 to 34% in 2004. Until the late 1990s, there was
considerable debate as to whether bipolar disorder existed in children, or if the symptoms represented a more
severe variant of ADHD. More recently, the emphasis has shifted from debates on whether the disorder exists
to more productive discussions of how to best identify and treat the disorder in children (Wozniak, 2003).
Dilsaver, Benazzi, and Akiskal (2005) found that 82% of their sample of youth with depression evidenced
mixed states, while in a later sample, Dilsaver and Akiskal (2009) found that 85% of their sample with
depression had mixed moods states. Based on their findings, Dilsaver and colleagues (2005, 2009) suggest that
“mixed hypomania” may be a common syndrome of those with juvenile bipolar disorder, who vacillate from
depression early in the day to spikes of hypomania in the evening, with transitions between the two mood
states occurring in the mid- to late afternoon. Furthermore, youth who demonstrate “mixed hypomania”
(bipolar II, mixed) demonstrate a 24-hour cycle that begins with “depressed mood, quietness, lethargy and
cognitive slowing” in the morning, with “rising afternoon and early evening mood” with evidence of pressured
speech, racing thoughts, flight of ideas, and psychomotor agitation (increased goal directedness, energy, and
lack of need for sleep), which often peaks between 11:00 p.m. and 3:00 a.m. (Dilsaver & Akiskal, 2009, p.
15).
Early diagnosis of BP in childhood is important for several reasons. It has been suggested that a prior episode
of mania or depression can sensitize the child and increase the risk for more frequent episodes in the future, a
theory that Post (2004) refers to as the “kindling hypothesis.” Furthermore, research has documented the
disruptive effect that BP can have on early childhood development by negatively affecting the child’s
relationships with parents and peers and undermining school success (Birmaher & Axelson, 2006; Pavuluri,
O’Connor, Harral, Moss, & Sweeney, 2006; Schenkel, West, Harral, Patel, & Pavuluri, 2008). Furthermore,
delays in diagnosis and identification can not only result in delayed treatment, but more important, can
potentially result in “iatrogenic and exacerbatory effects of pharmacotherapy applied without consideration of
an underlying bipolar diagnosis, e.g., psychostimulants or antidepressants [that are] not paired with a mood
stabilizer” (Fields & Fristad, 2009, p. 167).
In younger children, symptoms can present with rapid fluctuations in mood and behavior that is often
associated with comorbid ADHD and the disruptive behavior disorders, which can increase the complexity of
diagnosing the disorder (American Academy of Child and Adolescent Psychiatry [AACAP], 2007). Manic
states in very young children (preschoolers) can appear as “giddy, goofy, drunk-like” or severely irritable
moods with temper outbursts (Wilens et al., 2003, p. 497), emotional states that vary widely from the
euphoric states evident in adult versions of the disorder. Biederman and colleagues (2004) found that children
with BP often can present with mixed episodes that are primarily evident as irritability and explosiveness,
while Wozniak and colleagues (2004) have found that when both anger and dysphoria are evident, children
are more likely to also have comorbid problems of conduct and anxiety, compared to those who demonstrate
unipolar depression only.
Symptoms of BP in children often differ considerably from the cyclical patterns of depression and mania
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found in adults. Children’s symptoms are atypical relative to adult symptoms and commonly are evident in
mood lability (volatility), reckless behavior, irritability, and aggression, while the duration of mood shifts can
involve hours or days, rather than the more stable and enduring pattern found in adults (Geller et al., 2000,
2004). Using the criteria of grandiosity and elation as symptoms of a manic phase in children, Geller and
colleagues (2000, 2002, 2004) found that 10% of their sample met criteria for ultrarapid cycling, while 77%
met criteria for ultradian cycling. Average age of onset for BP in their study was approximately 7 years of age,
while the average number of cycles per day was approximately 3.7 cycles (Geller et al., 2004).
There is significant controversy about the appropriateness of the DSM criteria for the diagnosis of BP in
children. The National Institute of Mental Health (NIMH) Roundtable on Prepubertal Bipolar Disorder
(2001) made a recommendation that one of two classifications be applied to children who manifest symptoms
of juvenile bipolar disorder: a “narrow” phenotype for those who meet the DSM criteria for adult BP, including
euphoria, grandiosity, and other classic manic symptoms (Geller, Tillman, Badner, & Cook, 2005; Leibenluft,
Charney, Towbin, Bhangoo, & Pine, 2003); and a “broad” phenotype for those who do not meet adult criteria
but evidence prominent symptoms of irritability and labile mood shifts (Wozniak et al., 2005). It has been
argued by some that children with pediatric BP are basically nosologic orphans, since symptoms of the disorder
in young children do not match the current DSM criteria (Carlson, Pine, Nottelmann, & Leibenluft, 2004).
Others have suggested using a non-DSM alternative, namely the Child Behavior Checklist Juvenile Bipolar
Disorder Phenotype as an alternative (Biederman et al., 1995; Giles, DelBello, Stanford, & Strakowski,
2007). Based on their meta-analysis of seven studies, Mick and colleagues (2003) found a distinct CBCL
profile associated with BP in children and youth, namely elevations on the subscales for attention problems,
aggression, and anxious/depressed behaviors. These are the same three scales that Faraone, Althoff, Hudziak,
Monuteaux, and Biederman (2005) identified as the CBCL Pediatric Bipolar profile (CBCL-PBD) in their
study of BP in children. However, more recently, researchers have suggested that this profile may be a better
indicator of functional impairment, severity of psychopathology, and comorbidity in general, rather than an
identifier of bipolar disorder in particular (Meyer et al., 2009; Volk & Todd, 2007). Research has been
consistent in associating elevations on these three scales (attention problems, aggression, anxiety/depression)
with increased suicidal behaviors; greater impairment (Volk & Todd, 2007); and placing children at increased
risk for developing bipolar disorder, anxiety, ADHD, or cluster-B personality disorders later on (Meyer et al.,
2009).
The American Academy of Child and Adolescent Psychiatry (AACAP, 2007) Practice Parameters for the
assessment and treatment of BP in children and adolescents have suggested several guidelines and cautions
regarding the diagnosis of BP in very young children. The AACAP recognizes that the disorder can vary
widely from adult forms of BP and include changes in “mood, energy levels, and behavior” marked by “labile
and erratic” mood shifts rather than persistent moods, where “irritability, belligerence, and mixed manic-
depressive features” are far more common than euphoria (p. 111). However, the AACAP cautions that
irritable mania may be difficult to distinguish from common anger problems in young children and that
“hallmark manic symptoms of grandiosity, psychomotor agitation and reckless behavior must be differentiated
from . . . more common childhood disorders such as hyperactivity, irritability, dangerous play, and
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inappropriate sexualized activity, as well as from normal childhood phenomena of boasting imaginary play,
overactivity and youthful indiscretions” (p. 113). Increased prevalence rates for BP in very young children have
been reported in research. For example, Wilens and colleagues (2003) state that 26% of preschool children
with ADHD have comorbid BP, while a survey conducted by the Child and Adolescent Bipolar Foundation
(Hellander, 2002) reports that 24% of those diagnosed in the survey were from the ages of 1 to 8 years of age.
As a result, the AACAP (2007) recommends adhering to DSM criteria and advises extreme caution when
considering a diagnosis of BP before the age of 6. The AACAP emphasizes that the validity of a diagnosis of
BP in preschool children has not yet been established and cautions against the aggressive use of
pharmacotherapy in the prescription of mood stabilizers and atypical antipsychotics to children in this age
group (Biederman, McDonnell et al., 2005; Tumuluru, Weller, Fristad, & Weller, 2003). The AACAP
(2007) endorses the use of the DSM criteria (symptoms and duration) for diagnosis of mania and hypomania
in children, with the proviso that those who do not meet the criteria for duration (less than 4 days) be
classified as unspecified bipolar disorder. The AACAP document concludes with a list of several
recommendations for the assessment and treatment of BP in children.
In their evaluation of current assessment practices for BP in children, Youngstrom, Findling, Youngstrom,
and Calabrese (2005) suggest that although the child will often be referred for assessment due to explosive
rages, resulting from aggressive and irritable behaviors, these behaviors in and of themselves do not constitute
a diagnosis of BP. They recommend that in addition to a comprehensive clinical work-up, including family
history, assessment should also include handle symptoms (symptoms that can assist the clinician to get a better
“handle” on what the primary issue is), a history and evidence of the nature of cycling patterns and distinct
changes in mood functioning, and multisession interviews to obtain sufficient information. The authors agree
with Geller (2001) that an important part of the diagnosis should focus on differentiating BP from other
disorders by emphasizing those symptoms that are most often associated with mania, such as elevated mood,
grandiosity, hypersexuality, pressured speech, and racing thoughts.
In their study of the earliest symptoms that distinguished BP from non-BP children, Fergus and colleagues
(2003) found that an “irritability/dyscontrol” factor including poor frustration tolerance, increased aggression,
and temper tantrums could distinguish the two groups at ages 1 through 6. Further investigation focused on a
bipolar cohort with onset prior to 9 years of age, which they labeled juvenile onset bipolar disorder (JO-BP).
In this study, Luckenbaugh, Findling, Leverich, Pizzarello, and Post (2009) compared children with a
diagnosis of ADHD (n = 22) to groups of JO-BP with or without comorbid ADHD (n = 27) and a control
group (n = 26; no diagnosis). The researchers were able to demonstrate that brief and extended periods of
elevated mood were present in the bipolar group as early as 3 years of age with the difference in magnitude
increasing with age over the 10-year rating period. Three symptoms that distinguished the JO-BP group from
those with ADHD (non-JO-BP) at the earlier ages were more severe irritability, decreased need for sleep, and
inappropriate sexual behavior, while more periods of sadness, change in appetite, and suicidal ideation became
significant discriminators after 7 years of age. Children in the JO-BP group also reported significantly more
night terrors and bedwetting than those in the ADHD group. Classic symptoms of ADHD (hyperactivity,
impulsivity, and decreased attention span) did not distinguish between groups, likely because the symptoms
are similar for JO-BP, and the fact that 79% of those with JO-BP in the study had comorbid ADHD.
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Disruptive Mood Dysregulation Disorder (DMDD)
Most recently, significant increases in the diagnosis of bipolar disorder in children and adolescents have led
researchers to an increased emphasis on distinguishing between fluctuations in mood evident in bipolar
disorder and those that might more appropriately be classified as a mood dysregulation disorder in children
and youth. Because the DSM does not specifically address developmental concerns in the criteria for bipolar
disorder (e.g., manic episode descriptors for high risk activities include buying sprees, sexual indiscretions, or
foolish business investments) or address how mood fluctuations may be developmentally appropriate or
inappropriate, there has been much concern about children being overdiagnosed due to a lack of guidance
regarding how to best interpret child behaviors as atypical for a given child, based on a child’s own behavioral
patterns, developmental level, or the particular setting the behavior occurs in. Furthermore, as already
addressed, the nature of “irritability” (episodic versus nonepisodic) and duration of episodes (an episode may
last for 4 days in an adult and for 4 hours in children) have added to the complexity of clarity in diagnosis of
BP in children and youth. In order to address these concerns, the DSM-5 (APA, 2013) has added a disorder,
disruptive mood dysregulation disorder, which can be found in the chapter on depressive disorders and was
specifically developed to address the growing number of children diagnosed with BD. This disorder is to be
diagnosed when severe irritability is non-episodic in nature, in order to distinguish between this diagnosis and a
diagnosis of bipolar disorder. Criteria for disruptive mood dysregulation disorder (DMDD) includes severe
recurrent temper outbursts, evident for 12 or more months, occurring three or more times a week, in at least
two settings (home, school, with peers). The temper outbursts are in the presence of a pervasive irritable or
angry mood and are significantly out of proportion to the precipitating cause and inconsistent with
developmental level (p. 156). In order to be diagnosed with DMDD, the clinician must rule out diagnoses of
oppositional defiant disorder (ODD), intermittent explosive disorder, or bipolar disorder, and if a child meets
criteria for both DMDD and ODD, the diagnoses should be given as DDMD. A diagnosis of DMDD can
be comorbid with disorders of depression, ADHD, or conduct disorder.
Recently, Copeland, Angold, Costello, and Egger (2013) conducted a study to determine the prevalence,
comorbidity, and correlates of DMDD and found that prevalence rates ranged between .8% and 3.3% of the
population with the highest rates occurring among preschoolers. Within their community sample, the highest
rates for comorbidity occurred with depressive disorder and oppositional defiant disorder.
Towbin, Axelson, Leibenluft, and Birmaher (2013) conducted an extensive literature review to determine
whether bipolar disorder and severe mood dysregulation represent two distinct phenotypes with unique
clinical presentations and longitudinal course. In their study, children were diagnosed with severe mood
dysregulation, if for the past 12 months, in more than one setting, they met with the following criteria:
abnormal mood (anger or sadness) for at least half the day for most days; hyperarousal (three or more
symptoms of insomnia, agitation, distractibility, racing thoughts/flight of ideas, pressured speech,
intrusiveness); and negative emotional/behavioral response to frustration at least three times weekly (temper
tantrums, verbal rages, aggression). Children were excluded if they demonstrated any of the following
symptoms: elevated mood, grandiosity, or episodic decreased need for sleep (p. 469). It is important to note
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that these symptom criteria are very similar to criteria that have been adopted by the DSM-5 (APA, 2013) as
criteria for disruptive mood dysregulation disorder. The authors suggest that the study emphasizes the
importance in recognizing that “children who present with chronic irritability (but no distinct manic episodes)
should be differentiated from those with BD” (Towbin et al., 2013, p. 469). Results of the study suggest that
while up to 45% of children diagnosed with BD-NOS (not otherwise specified) met criteria for BD 5 years
later, only 1.2% of those with mood dysregulation met criteria for BD after 29 months of follow-up while
adolescents with chronic irritability were at higher risk for depression and unipolar depression, but not bipolar
disorder. Also rates of family history for BD were significantly higher for children with BD (25% had a first
degree relative with BD) than those with mood dysregulation (3% had a parent with BD, which is
commensurate with prevalence rates in the general population).
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Treatment Approaches
The AACAP (2007) recommends a multimodal treatment plan combining medications and
psychotherapeutic interventions that includes
psychoeducational therapy (informing parents and family about BP, its nature and course, and available
treatment alternatives),
relapse prevention (advising parents and family of the importance of compliance with medication
regimes, and the need to monitor sleep patterns and outside stressors),
individual psychotherapy (skill building in younger children),
social and family functioning (enhance family and social relationships through improved communication
and problem-solving skills),
academic skills and occupational functioning (the need to monitor educational progress, special programs,
and individual educational plans and any related services), and
community consultations (treatment plans should include communication with any community agencies
that may also be involved, e.g., social welfare, juvenile justice).
Because young children with BP experience difficulties with behavioral and emotional control, many
behavioral programs can also be applied to assist parents in managing the child’s behaviors. Functional
behavioral analysis (FBA) can be helpful in isolating environmental triggers in the home and school that can
exacerbate emotional reactivity and outbursts. Increased structure and predictability of routines can also serve
to reduce stress and provide a framework for increased self-control.
Collaboration with school personnel is also an essential component of the treatment process for school-age
children (Kronenberger & Meyer, 2001). In The Bipolar Child, Papolos and Papolos (2000) present a mock-up
IEP (individual education plan) for a hypothetical bipolar student, Elan. The plan is a practical example of
how interventions can address children’s needs across developmental contexts, such as the school environment.
Elan’s IEP is developed to incorporate six goals in his school programming aimed at learning and applying
strategies to divert inappropriate thoughts, reduce anxiety, increase on-task behaviors, increase
communication skills, increase academic competence, and reduce explosive outbursts. The plan is written in
behavioral terms that allow Elan to earn points for meeting goals on a daily basis.
Medication and Medication Management.
It is very important to monitor medications of children who have BP. If a child with BP is given an
antidepressant without a mood stabilizer, the antidepressant can trigger a manic episode. Furthermore, if a
child with BP is given stimulant medication (for ADHD-related symptoms), this can also exacerbate manic
symptoms (Fields & Fristad, 2009). Atypical antipsychotics, such as risperidone and olanzapine, have also
been effective in the treatment of severe mania in children as young as 6 years of age (Biederman, Mick et al.,
2005). In August 2007, the FDA approved Risperdal (an antipsychotic medication) for the treatment of BP in
children and adolescents from 10 to 17 years of age.
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Treatment and Mood Dysregulation Disorder.
Towbin and colleagues (2013) report that only one study in their literature review reported inclusion of
children with severe mood dysregulation in their sample (Dickstein et al., as cited in Towbin et al., 2013), and
this study demonstrated no significant differences in responses to lithium and a placebo. Because children
with severe mood dysregulation often present with other comorbid disorders, Towbin et al. (2013) emphasize
the importance in identifying other DSM diagnoses in these children (ADHD, anxiety, depression) to
determine what form of therapy might be indicated (e.g., medical management, cognitive–behavioral
therapy). The need to determine whether a child meets criteria for BD or severe mood dysregulation can be
extremely important in decisions regarding the use of stimulant medication for ADHD, which is
contraindicated in children with BD but has been shown to be effective in reducing severe irritability and
aggression in treatment of youth with ADHD, without comorbid BD (Connor, Glatt, Lopez, Jackson &
Melloni, 2002; Isper & Stein, 2007).
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Post-Case Questions
1. Using the framework for a functional behavioral assessment (FBA; Box C1.2a), develop a case formulation outlining the
precipitating and maintaining variables regarding Matthew’s behavior. Working from this assessment information, develop a
behavioral intervention plan for use in Matthew’s school to assist in monitoring his behaviors.
2. Develop a case formulation from the perspective of an attachment theorist. What treatment plan would best accommodate
Matthew’s needs using this approach?
3. Develop a case formulation from the perspective of a family systems therapist. How would you attempt to restore the balance of
power in this family?
4. Develop a case formulation for Matthew, relating his behaviors to developmental theory and contexts (Bronfenbrenner’s model),
using the framework of risks and protective factors.
5. The IDEA definition of emotional disturbance is highly controversial (see Appendix B: Systems of Classification). Based on the
IDEA, would Matthew qualify for an exceptional designation as an emotionally disturbed or seriously emotionally disturbed
child? If not, why not?
6. Matthew presents with significant symptoms of irritability, which can be challenging in making a differential diagnosis in
children. Based on the DSM criteria for bipolar disorders (bipolar I, II, cyclothymia) and disruptive mood dysregulation disorder,
address how you would conduct a differential diagnosis and what your likely conclusion would be as to the nature of Matthew’s
primary diagnosis.
You have been invited to provide feedback to the school regarding Matthew’s assessment, at a meeting where officials will decide
whether Matthew meets criteria for Special Education and Related Services. If it is determined that he is eligible for services, what
goals and objectives would you want to see as part of his IEP? Would you recommend he receive related services, and if so, what
would the nature of those services be?
plan that would best meet Matthew’s needs?
464
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Case 19 Jenny Sloan The All-American Girl Bipolar Disorder;
Suicide Attempt
Jenny, a strikingly attractive 16-year-old, arrived at the clinic with her mother, Stella. Jenny was recently
released from the hospital after an unsuccessful suicide attempt. Jenny’s mother had found her on the
bathroom floor, unconscious, amid empty bottles of nonprescription drugs: Advil, Tylenol, Sudafed.
Fortunately, the ambulance arrived in time. What scared Stella the most was that there were no warning signs
of depression and suicide. Or were there?
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Jenny was a beautiful baby—bright, alert, and very easy to manage. Stella and Carl, both in their mid-thirties,
were very proud of their baby girl and were especially thankful that they were able to conceive a child after so
many years of trying. Although Carl was a successful banker, he kept his priorities in check and was often
more interested in family life than corporate life. Stella did a lot of volunteer work in the community and the
local school. They had a strong marriage and were well suited to each other. Stella, who was an avid reader,
had purchased several books on child rearing and charted Jenny’s milestones diligently in her daughter’s
journal. Jenny developed perfectly in tune with what the books would say. She began walking on her first
birthday and actually was saying words before she was walking.
As a preschooler, Jenny was very social and loved attending school and playing with the other children. It
seemed that the other children were drawn to Jenny by her infectious laughter, something that would continue
throughout her school years. Jenny was very well coordinated, and Stella enrolled her in kinder-gym, dance,
and swimming. Jenny embraced each new activity with vigor and enthusiasm and was an excellent gymnast,
dancer, and swimmer.
In elementary school, Jenny won awards for track and field and was voted most popular girl in her Grade 5
class. She continued dance lessons and gymnastics and competed in several regional meets with relative
success. Jenny seemed to be a born leader, and her popularity with the other children was readily apparent. It
seemed as though there was no stopping her.
When Stella thought back, there may have been early warning signs that all was not well. Middle school
seemed to launch Jenny into early adolescence and her responses to change or adjustments in her life started to
trigger more intense and extreme reactions. Stella recalled when Jenny’s class schedule was changed by the
guidance counselor, Jenny came home extremely irritated and agitated, complaining that the counselor had no
right to do this to her. She demanded that her parents go to the school and have the schedule changed. Stella
and Carl tried to reason with Jenny after they talked to the guidance counselor on the telephone. However,
Jenny said they were all in on the conspiracy against her. She was up most of the night on the telephone with
classmates, trying to organize a protest. The next day, she was very agitated and angry at her friends for not
supporting her in the protest. Were it not for the fact that Jenny was so popular, Stella was sure that these
behaviors would have cut off all her social contacts. However, Jenny continued to be very popular with her
peers. She was a formidable leader, beautiful, full of life, and assertive. Many of her classmates may have
cowered in her wake, but they secretly desired to be just like her.
Stella and Carl were concerned about Jenny’s escalating behaviors; however, Stella had read several books on
adolescence and convinced Carl that Jenny was probably just being a difficult adolescent and flexing her
increased independence. When it came to parent–teacher conferences, some of Jenny’s teachers were not
pleased with her confrontational nature, but others seemed to admire her perseverance. Jenny’s grades were
good, and she excelled in extracurricular activities. She was beautiful, bright, and motivated. These were
qualities to be admired. She was the “all-American girl.” These comments left Stella and Carl uncertain about
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how to deal with Jenny’s behaviors, and they wondered if they were overreacting or maybe doing something
wrong at home. They discussed whether they should take Jenny to a child psychiatrist or psychologist, but
other parents convinced them that Jenny was just being a teenager, and that many parents would readily
change places with them. How great it must be to have a teenager as motivated as Jenny.
Jenny seemed to embrace the transition to high school at a time when others were thrown off balance by the
increased number of students and having so many different teachers. Jenny signed up for a number of school
clubs, such as the Girls Athletic Club and the Glee Club, and although few would have had the courage to
attempt it, she even tried out for the Junior Cheerleading Squad. She did not make the team, which was
devastating for her, but she vowed that the following year she would come back with a vengeance. During her
freshman year, Jenny continued to be actively involved in sports and school clubs and told herself that she
would rather play on the girls’ volleyball team than be a cheerleader anyway, since they got to travel to
conferences. Jenny and her parents continued to have disagreements throughout the year, with Jenny wanting
to stay out later and go on dates of which her parents did not approve. That summer, Jenny got a job as a
camp counselor and spent the summer at camp away from her parents. When she returned in the fall, it was as
if the break had restored all harmony, and her parents felt as if they had finally gotten their daughter back.
In the fall, Jenny tried out again for the Junior Cheerleading Squad, and this time she made it. Jenny was
elated about being selected for the team and was eager to show off her new cheers and routines for her parents
at home. However, shortly thereafter, things began to go noticeably out of control. Socially, Jenny began
pushing the limits with her parents and dressing very provocatively despite their protests. Jenny’s behavior
became more erratic. One day, Jenny decided that the cheerleading uniforms needed to be revamped: the
skirts were too long and the design on the front of the sweater was outdated. For the next week, Jenny was
relentless. She became obsessed with getting the uniforms changed. She rarely slept and instead was
consumed with ideas on how to improve the cheerleading outfits. She talked nonstop about cheerleading
outfits, to the point that her parents asked her to please stop. Jenny would run home from school each day and
search the Internet for costume designs. She spoke on the phone most of the night. Jenny’s mother picked up
the extension by mistake one time and couldn’t believe Jenny’s rambling on about buying material and sewing
patterns, pantsuits, designs, European fashion trends, and megaphones. Much of what Jenny was rambling on
about seemed to make no sense. Of course, when her mother questioned her about the conversation, Jenny
was furious at her mother for picking up the extension and eavesdropping on her. Eventually, Jenny’s friends
stopped calling. Jenny was now spending more and more time on the Internet at night when she was supposed
to be doing her homework. She told her parents that she was doing “research”; what she didn’t reveal was that
her research was focused on trying to locate a uniform designer that the school could hire to redesign the
uniforms. Ultimately, she began drawing her own designs and spending hours at night cutting out patterns
and trying new designs. She was convinced that she had the talent to become a world-famous uniform
designer and ran up expensive phone bills trying to contact clothing manufacturers across the United States
who might support her line of uniforms: Jeunesse by Jenny. She got the name from the French word for
“youth.” She felt totally empowered; it was as if she were wearing magical senses: Colors were more intense,
sounds were more reverberating, and touch was more penetrating. No one could possibly understand how
euphoric her life had become.
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During that week, Jenny amassed hundreds of dollars in international phone calls. Her parents were furious
and Jenny was upset, saying that they didn’t support her. Maybe they would believe her when she became
famous. The problem intensified the night her mother found yards and yards of new fabric stuffed in a box in
the basement, along with dozens of pictures of cheerleading uniforms. Some of the cloth had been cut into
patches and sewn together to make patterns. That’s when her mother found out that Jenny had also run up a
sizable bill on her mother’s account at the department store where she purchased all the fabric and patterns.
No one seemed to understand how intense Jenny could be. Her parents were the only windows on her all-
night vigils, extensive phone bills and fabric bills, and constant diatribes at home. Yet her parents somehow
felt powerless to intervene because they were constantly being reminded by parents of other teenagers that
Jenny was “the all-American girl” and that they were fortunate to have such a talented and motivated
daughter. Finally, after all the glitter and sparkle, came the crash . . . the awful crash. The mood swing was
devastating.
In the hospital, Jenny admitted to her parents that she was beginning to feel out of control about a week
before the suicide attempt. Jenny had been on the phone for hours frenetically attempting to organize a party
that would be the biggest and best party ever, where she was going to launch her new “Jeunesse” line of
cheerleading uniforms, but by the time the party was to begin, her mood had spiraled into a deep depression.
It was as if someone had pulled the floor out from under her. Jenny felt riveted to the bed, immobile, as if her
feet were stuck in buckets of poured concrete, and she was being sucked into the horrible pain of a black hole.
It was as if someone had vacuumed out her very soul. The emptiness and the pain were unbearable. She felt as
if she were worthless and would never amount to anything. On that night, the pain hurt so much, she woke
up in a panic, ran to the bathroom, and devoured bottles of painkillers—anything she could find to end the
pain once and for all.
A review of the intake information showed a history of bipolar disorder in Jenny’s paternal grandmother and
alcohol abuse in the maternal grandfather. There were also several cousins with a history of depression and
suicidal behavior.
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Reason for Referral
When Jenny was in the hospital, a comprehensive clinical assessment was conducted to determine her
functioning on several levels, including intellectual, academic, and social-emotional status.
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Assessment Results
Information regarding specific assessment instruments and guidelines to the interpretation of standard scores
When Jenny arrived at the clinic, she brought with her the results of the assessment conducted in the hospital.
Results of the WISC-V revealed average intellectual ability, although scores may have been somewhat
depressed, given her mood state at the time. Low scores were noted on the Working Memory Index, and it
was noted that Jenny complained of having problems concentrating, likely resulting from her depressed state.
Academically, Jenny scored at grade level, with the exception of mathematics, which was approximately 2
years below grade level. Her mother’s responses to the CBCL revealed clinical elevations for Attention,
Anxious/Depressed, and Thought Problems. Scores for Delinquent Behaviors and Aggression were elevated
but not significant. Jenny completed the Revised Child Manifest Anxiety Scale (RCMAS-2), the Youth Self
Report (YSR), and the Beck Inventories for Youth (BYI-2). Jenny’s responses indicated extreme elevations on
the Physiological Indicators of Anxiety scale on the RCMAS-2, clinically significant elevations on the
Anxiety/Depression and Thought Disorder scales (YSR), and significant problems with Self Concept and
Depression (BYI-2). The semistructured diagnostic interview (K-SADS) revealed positive endorsement of
manic and depressive symptoms.
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In this case and the case of Matthew Morgan, bipolar disorder will be discussed as it relates to the manic part
of the episode and will provide an opportunity for readers to compare how these manic and hypomanic states
can appear in childhood and adolescence. For an in-depth discussion of a major depressive episode, readers are
directed to the case of David Steele.
Compared to unipolar depression, which is a pervasive sad or irritable mood state accompanied by a loss of
pleasure, disorders within the bipolar spectrum evidence mood states that vacillate between the lows of
depression and euphoric, expansive, or irritable manic states that can be accompanied by inflated self-esteem,
or grandiosity; pressured speech; reduced need for sleep; flight of ideas, or racing thoughts; distractibility;
increase in goal-directed activities (psychomotor agitation); and engaging in activities that are at high risk for
negative outcomes, such as spending sprees, fast driving, and sexual promiscuity (DSM-5; American
Psychiatric Association [APA], 2013). Although historically there had been a tendency to not identify BP in
children (Scott & Meyer, 2007), more recently, children are increasingly being diagnosed with BP
(Youngstrom, Meyers, Youngstrom, Calabrese, & Findling, 2006), and as a result, there has been a growing
body of research investigating how BP manifests in cases of childhood and adolescent onset (Biffin et al.,
2009; Goldstein & Levitt, 2006; Goldstein et al., 2009). For a discussion of issues, trends, and treatment
connected to childhood-onset BP, readers are referred to the case of Matthew Morgan. Matthew experienced
very early onset BP, and although symptoms share some similarities to those experienced by adolescents, a
comparison of the two cases will reveal significant differences in how BP can be experienced at the different
stages of development, and how to distinguish early signs of BP from symptoms of disruptive mood
dysregulation disorder. The following discussion focuses primarily on symptoms and risks associated with
adolescent-onset BP.
There are different subtypes of BP based on the nature of the manic and depressive episodes. Bipolar I
disorder involves either full manic or mixed manic episodes (lasting for at least 7 days) alternating with
episodes of major depressive disorder. Bipolar II was once considered a less severe form of the disorder with
mood swings vacillating between hypomanic episodes (lasting at least 4 days) and episodes of major depressive
disorder. However, current views on bipolar II suggest that this form of the disorder can be as debilitating as
bipolar I. Bipolar disorder unspecified is a category reserved for cases that meet some but not all criteria for
BP I or BP II. Cyclothymia relates to mood shifts between hypomania and depression, although in this case
depression does not meet criteria for a major depressive disorder. Individuals are considered to be in a state of
rapid cycling if there is evidence of four episodes within a given year. Diagnostic criteria from the DSM-5
(APA, 2013) for the various subtypes of BP can be found in Appendix D.
Responses to the national epidemiologic survey on alcohol and related conditions from over 1,400 respondents
with a diagnosis of BP revealed that 24% reported onset of the disorder in adolescence, compared to 8% who
reported onset in adulthood (Goldstein & Levitt, 2006). Studies have shown that individuals with adolescent
onset are most likely to show depression as the initial affective episode (Biffin et al., 2009; Bowden, 2001;
Lish, Dime-Meenan, Whybrow, Price, & Hirschfeld, 1994). However, adolescents who experience mania
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may also frequently experience psychotic symptoms, labile moods, and mixed manic and depressive
characteristics (Pavuluri et al., 2004, 2005). Compared to younger children, those with later-adolescent-onset
BP tend to have a cyclical course that is more similar to that found in adults (McClellan, McCurry, Snell, &
DuBose, 1999) and manifest more classic BP symptoms of “mania” such as euphoria or grandiosity and
depression (Egeland, 2000). Steiner and colleagues (Steiner, 2000; Steiner, Saxena, & Chang, 2003) discuss
displays of affective, reactive, and defensive aggression in adolescents with BP. Aggression can also be seen as
escalating or intermittent, with adolescents tending to demonstrate more of the escalating types of aggression
than younger children with the disorder. In older children, differential diagnosis between BP and conduct
disorder may be difficult in the case of a youth who impulsively shoplifts, is sexually promiscuous, and engages
in risky behavior. However, differential diagnosis would recognize that in the bipolar adolescent, these
behaviors represent high-risk and stimulation-seeking behaviors devoid of the vindictive and antisocial
elements noted in conduct disorder (Bowring & Kovacs, 1992). Similarly, delusions of grandeur, paranoia,
irritability, and flight of ideas might be difficult to distinguish from schizophrenia. Geller and colleagues
(1995) studied 26 children (13 were from 7 to 13 years of age; 13 were adolescents) with BP. Results revealed
that 80% of the sample had rapid cycling patterns (100% of the younger group and 70% of the adolescent
group). The authors also found a prevalence of hallucinations in the older group (hearing voices), delusions
(grandeur, persecutory, somatic), and ideas of reference that may lead to misdiagnosis of this group as
schizophrenic. Whether these patterns that resemble BP II are an age-specific and developmental antecedent
to BP I in adulthood remains to be seen (Geller, Fox, & Clark, 1994).
One of the core symptoms of BP is sleep disturbance, which can relate to a reduced need for sleep during a
manic or hypermanic episode, or insomnia or hypersomnia during a depressive episode (DSM-5; APA, 2013).
Sleep disturbance has also been reported as a common feature of BP in youth, and a number of studies have
reported high rates of insomnia or parasomnias (disorders causing arousal during REM or partial arousal from
non-REM sleep, such as nightmares, night terrors, sleepwalking, etc.). Studies have found that youth with BP
report reduced REM sleep, lower sleep efficiency, and longer slow-wave sleep, relative to youth without BP
(Faedda & Teicher, 2005; Mehl et al., 2006). Sleep disturbances have consistently been reported by half of
parents of youth who later go on to develop BP, suggesting that sleep disturbances may be one of the earliest
symptoms (Duffy, Alda, Crawford, Milin, & Grof, 2007; Faedda, Baldessarini, Glovinsky, & Austin, 2004).
In their study of prodromes of episodes (early symptoms or warning signs), Jackson, Cavanagh, and Scott
(2003) found that sleep disturbance was the most common prodrome reported by those with BP and the sixth
most common prodrome reported by those with depression. In their review of studies concerning sleep
disturbance and BP, Harvey, Talbot, and Gershon (2009) suggest that sleep disturbance can have far-reaching
consequences on affect regulation, cognitive functioning, risk for substance use, impulsivity, and risk taking.
Swann, Steinberg, Lijffijt, and Moeller (2008) found that different aspects of impulsivity coincided with
different phases of bipolar illness: Attentional impulsivity (lack of cognitive persistence) was most likely to be
associated with depression and mania, motor impulsivity was associated with mania, and nonplanning
impulsivity was associated with depression. Given the impact of sleep disturbance on emotion regulation, it is
possible that sleep deprivation may be instrumental in triggering a manic episode.
Onset in adolescence may also result in a significant deterioration in academic functioning, especially in
477
mathematics and interpersonal relationships. Of those with the disorder in adolescence, 42% will not graduate
from high school on schedule (Kutcher, 2005). Increased stress in family or relationships can cause increased
mood deterioration in youth who develop BP in adolescence (Kim, Miklowitz, Biukians, & Mullen, 2007). In
studies comparing psychosocial functioning among bipolar youth of various ages, greater functional
impairment was found in adolescence, regardless of the age of onset of BP (Biederman et al., 2005; Goldstein
et al., 2009). It has been suggested that adolescents are more severely impaired relative to younger children
because of the increased psychosocial demands occurring at a time when their illness prevents them from
meeting these challenges (Goldstein et al., 2009). The authors suggest that increased impairment in
adolescence may also result from increased social stresses, leading to further deterioration (Hammen’s [1991]
stress generation model), or increased vulnerability for future episodes based on past episodes (Post’s [1994]
kindling theory).
In one study of adolescents with BP, DelBello, Hanseman, Adler, Fleck, and Strakowski (2007) found that
only 39% of adolescents who were hospitalized for an initial manic or mixed episode managed to achieve
functional recovery one year later, despite demonstrating a reduction in severity and symptoms. Furthermore,
Rademacher, DelBello, Adler, Stanford, and Strakowski (2007) reported that adolescents with BP scored
below the national averages for the majority of domains measuring quality of life, with only marginal increases
in functioning noted when they were reassessed after treatment. On a more positive note, results from at least
two studies suggest that while impairment may exist in many domains, leisure activities and recreation (e.g.,
computer games) remain relatively unaffected domains even for BP youth who are in-episode (Goldstein et
al., 2009; Rademacher et al., 2007).
Onset of BP in later adolescence was predictive of the disorder continuing at 24 years of age (Lewinsohn,
Klein, & Seeley, 2000); however, although those who were diagnosed with BP-NOS were at greater risk for
psychopathology and negative outcomes as adults, the NOS (not otherwise specified) category did not predict
BP in adulthood. Goldstein and colleagues (2009) found that impaired functioning levels did not differ
between subtypes of BP (e.g., BP I, BP II, BP-NOS) in their sample, which supports results reported for
adults with BP who demonstrated similar levels of risk for impairment across the BP spectrum (Judd, Akiskal,
Schettler, & Endicott, 2007). However, similar to findings with BP adults, youth with BP show more
significant impairments in functioning during depressive episodes compared to manic or mixed cycling
episodes (Goldstein et al., 2009). Adolescents who have BP are at increased risk of suicide attempts (Strober,
1992; Strober, Morrell, Lampert, & Burrough, 1990). Substance-use/abuse rates are also high in adolescents
with BP (Findling et al., 2001; Wilens et al., 2004).
Bipolar is a highly heritable disorder with estimates in the range of 20% to 40% (Green et al., 2005; Rutter,
Silberg, O’Connor, & Simonoff, 1999). Studies of potential abnormalities in brain structure and function
have found that while adults with BP evidence both increased and decreased volume of the amygdala
(Altshuler et al., 2000), there have been consistent reports of amygdala volume deficits in the brains of
adolescents with BP (Blumberg et al., 2003; Chang et al., 2005; Dickstein et al., 2005). As a result, it is
possible that adolescent BP may represent a separate phenotype of the disorder, or that amygdala volume
development is compromised by the episodes themselves (Blumberg, 2007).
478
479
Treatment Alternatives
Medication Management.
Adult treatment for BP typically includes lithium, valproate, and atypical antipsychotic medications such as
risperidone and olanzapine. While mood stabilizers and antipsychotic medications have been proven effective
for some adolescents with BP, stimulant medications and antidepressants are not effective (Biederman et al.,
1999). However, youth with BP who have comorbid behavior disorders or ADHD seem to be less responsive
to the medical management of BP (Masi et al., 2004; State et al., 2004). Lithium is a mood stabilizer that is
well tolerated by youth with BP (Tueth, Murphy, & Evans, 1998), and it has been approved for the treatment
of acute mania in youth with BP from age 12 and up. The main problem with lithium is that unpleasant side
effects can occur (stomach upset, nausea, weight gain, tremors, enuresis, and acne), and frequent monitoring
of blood levels is required, which may result in issues of compliance, especially in adolescents. Strober,
Lampert, and Burrough (1990) studied adolescents with BP over an 18-month period and found that 12 out
of the 13 cases who were noncompliant relapsed (greater than 90%), while approximately one third (37.5%) of
those who were compliant relapsed as well. Based on the results of recent medication trials, it has been
suggested that maintenance therapy should take place over a 12- to 24-month period to decrease the risk of
relapse (Findling et al., 2001; Strober et al., 1990), whereas for some more severe cases, therapy maintenance
may be required over the course of their lifetime. Frazier and colleagues (1999) noted that the atypical
antipsychotic medication risperidone (Risperdal) was effective in 82% of the 28 adolescent cases surveyed in a
retrospective chart review. Kowatch and colleagues (2000) investigated the effectiveness of three different
mood stabilizers for the treatment of BP in children and adolescents: lithium, valproic acid, and
carbamazepine. Results revealed positive responses (34% to 50%) with no statistical difference between the
different medications.
Therapy.
The practice parameters for the assessment and treatment of children and adolescents with BP (American
Academy of Child and Adolescent Psychiatry [AACAP], 2007) outline a number of suggestions for
therapeutic interventions, which are available in the discussion of treatment alternatives for the case of
Matthew Morgan.
In their review of psychosocial interventions as an adjunct to pharmacological interventions, Lam, Burbeck,

Wright, and Pilling (2009) found that therapy specifically designed for BP patients (e.g., cognitive-behavioral
therapy [CBT], psychoeducation, focused family therapy [FFT]) can reduce the risk of or delay a possible
relapse. Although the majority of studies reviewed included adult populations, the range of therapeutic
options they explored provides an overview of the types of therapeutic approaches available for individuals
who have BP. Disorder-specific therapies were found to include such components as “use of diathesis-stress
model, psychoeducation, promoting medication adherence, self-monitoring and moderating behavior,
promoting routine and structure, problem solving and active relapse prevention measures” (Lam et al., 2009,
p. 474).
480
In the treatment of adults with BP, Miklowitz, George, Richards, Simoneau, and Suddath (2003) report that
a family-focused intervention program targeting family members (spouses, parents, and siblings) was
successful in reducing relapse rates, reducing symptomology, and increasing compliance with medication
regimes. The program focused on providing psychoeducational information to family members about the
disorder and assistance in improving communication and problem-solving skills. The researchers have since
expanded the program to include adolescents with BP (Miklowitz et al., 2009). In their investigation, they
compared family-focused therapy for adolescents (FFT-A) to a brief psychoeducational treatment (enhanced
care [EC]). The FFT-A program included assessment and interventions for “expressed emotion” (EE) in
parents, a parenting communication style that is characterized by criticism, hostility, or emotional
overinvolvement. The 58 adolescents (13–17 years of age) with BP and their parents were randomly assigned
to the FFT-A condition (21 sessions over the course of 9 months involving problem solving, communication
training, and psychoeducation) or the EC condition, which involved 3 psychoeducation sessions. Evaluators,
who were blind to the subject’s group affiliation, recorded depressive and manic symptoms every 3 months
over the course of 2 years. Results revealed that parents who were rated high on EE reported less family
cohesion and adaptability than parents who were low in EE. Adolescents who were from families that were
high in EE showed more improvement in symptom reduction (depressive and manic) when enrolled in the
FFT-A program compared to the EC program. However, those adolescents whose parents were low in EE
did not demonstrate any differences between participation in the two programs. The researchers suggest that
parental EE moderated the success of the family intervention program on the reduction of adolescent
symptoms of BP and recommend future programs include a screening of parental EE to determine which
patients might be benefitted most by the more intense program (FFT-A).
A number of psychosocial treatments also include guidelines for managing sleep disturbance, such as
interpersonal therapy (Frank, Swartz, & Kupfer, 2000), family therapy (Milkowitz et al., 2009), and
individual (Lam et al., 2003) or group (Patelis-Siotis et al., 2001) CBT. However, to date, there is a lack of
empirical support for specific treatments directed toward reducing sleep disturbance, especially in youth with
BP. Harvey (2009) suggests a number of areas that future research initiatives should target to assist in
developing treatment interventions for sleep disturbance in youth, including functional analysis of the nature
and duration of sleep disturbance, antecedents and consequences, and possible motivations for delay of sleep
onset (e.g., text and/or Internet messaging of peers), psychoeducation regarding sleep deprivation and
potential causes, regulation of the sleep–wake schedule, problem solving to reduce hypersomnia (extended
periods of sleep, such as daytime sleepiness), education regarding the need for transitions between waking and
sleeping states, and reduction of sleep-onset difficulties due to bedtime worry and rumination.
481
Post-Case Questions
1. Given the DSM-5 diagnostic criteria, would Jenny’s symptoms meet criteria for bipolar disorder (BP), and if so, what symptoms
does she exhibit and with what type of BP is Jenny most likely to be diagnosed?
2. Given her age and symptoms, based on current research findings, what other disorders might Jenny be at risk for developing?
3. Compare and contrast symptoms and disorder presentation for BP using the cases of Matthew Morgan and Jenny Sloan.
4. Suggest a treatment plan for Jenny based on current research findings. What are the main components that your treatment
program will need to address?
5. Develop case formulations for Jenny from a biological and family systems/parenting perspective.
6. Imagine that you are a psychologist assigned to the hospital where Jenny was transported after her suicide attempt. Using the
seven-stage model of adolescent suicide and crisis intervention introduced in Case 17, discuss how you would apply that model to
Jenny’s case and how you would develop your treatment plan.
You have been invited to provide feedback to the school regarding Jenny’s assessment, at a meeting where they will decide whether
Jenny meets criteria for Special Education and Related Services. If it is determined that she is eligible for services, what goals and
objectives would you want to see as part of her IEP? Would you recommend she receive related services, and if so, what would the
nature of those services be? If not a candidate for special education, would you recommend the school develop a 504 plan for
Jenny? Provide the rationale for your comments. If the response was yes, what would the nature of assistance be for her within the
school system?
plan that would best meet Jenny’s needs?
482
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Chapter 6 Introduction to Disorders of Emotion and Behavior
Dysregulation
This section includes case studies involving disorders that all share underlying facets of emotion dysregulation
(inability to regulate emotions in stressful situations), resulting in behavior dysregulation (binge eating,
excessive substance use, non-suicidal self-injury). The rationale for including these three behaviors in the same
chapter is that although no study could be found that links disordered eating to substance use and non-
suicidal self-injury (NSSI), several studies have reported associations between substance use disorders (SUDs)
and disordered eating, while some studies have also linked eating disorders to NSSI (Arbuthnott, Lewis, &
Bailey, 2015; Muehlenkamp, Peat, Claes, & Smits,2012); or NSSI to substance use (Gratz, & Tull, 2010).
Using information from the Youth Risk Behavior Surveillance System (YRBSS) derived from a nationally
representative high school sample, Pisetsky, May Chao, Dierker, May, and Striegel-Moore (2008) examined
the relationship between disordered eating (fasting, diet product use, and vomiting or laxative use) and
substance use (cigarettes, alcohol, marijuana, cocaine, inhalants, heroin, ecstasy, steroids, methamphetamines,
and hallucinogens) and found that disordered eating was significantly related to substance use for all
substances.
Using a clinical sample of 95 adolescent patients (ages 12–17) who met criteria for anorexia nervosa, bulimia
nervosa, and ED not otherwise specified, Castro-Fornieles et al. (2009) found that 34.7% also met criteria for
regular or risky substance use (RRSU) and/or substance use disorder (SUD) of any substance except tobacco.
Adolescents with comorbid ED and RRSU or SUD also were less successful academically (failed more
subjects, repeated more school years) and reported more problems at school, at home, and socially.
However, substance use seems to differ across the different types of EDs, due to the nature of the traits
associated with the disorder (e.g., anorexia nervosa [AN] is often linked to obsessive-compulsive traits while
bulimia nervosa [BN] is associated more with loss of control and increased emotional and behavioral
dysregulation). It has been suggested that the loss of control in the presence of increased emotional and
behavioral dysregulation serves as the underlying mechanism in driving binge episodes and increased risk of
substance use (Bulik, Sullivan, Carter, & Joyce, 1997).
Mann et al. (2014) investigated the difference in ED type on associated risk for substance use in a sample of
290 adolescents (12–18 years old) who met criteria for ED in their Eating Disorders Program. Results
supported evidence from previous research that adolescents with BN had greater regular alcohol consumption.
Frequency of binge–purge episodes was related to more frequent use of alcohol, cannabis, and tobacco.
Although emotion dysregulation has been discussed in studies investigating substance use and NSSI, only one
study could be found that investigated the link between substance use and NSSI. Gratz and Tull (2010) found
heightened emotion dysregulation among patients with SUD who also had comorbid NSSI versus those
without a history of NSSI. The researchers argue that there is a unique association between emotion
dysregulation and NSSI, even after controlling for such factors as borderline personality disorder,
489
posttraumatic stress disorder, childhood abuse, and severity of substance use. In addition to identifying this
shared association, Gratz and Tull (2010) identify three dimensions inherent in the process of emotion
dysregulation common to both NSSI and SUD: (1) limited access to effective emotion regulation strategies,
(2) difficulties engaging in goal-directed behaviors when distressed, and (3) emotional nonacceptance.
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Eating Disorders
The DSM-5 (American Psychiatric Association [APA], 2013) chapter on eating disorders provides a
developmental perspective on eating and feeding disorders that begins with a discussion of feeding disorders
of infancy and childhood, such as pica (eating nonnutritive substances) and rumination disorder (repeated
regurgitation of food).
Avoidant/restrictive Food Intake Disorder.
Following the discussion of feeding disorders, the chapter introduces a new disorder avoidant/restrictive food
intake disorder, which replaces and extends the previous known “feeding disorder of infancy or early
childhood.” Although avoidant/restrictive food intake disorder often has onset in infancy or early childhood,
the disorder may continue into adulthood and can be conceptualized as a bridge between feeding and eating
disorders. The disorder is characterized as an “eating or feeding disturbance” that is manifested in one or more
of the following: significant weight loss, nutritional deficiency, dependence on supplementary feeding (e.g.,
tube feeding) or oral supplements, or marked interference with psychosocial functioning (p. 334). Individuals
with this disorder demonstrate a lack of interest in food, which may be related to the texture, color, smell, or
taste of the food, or associate eating with some aversive experience, such as choking on food. The disorder
does not occur during anorexia or bulimia nervosa and is not related to any specific medical condition.
Feeding difficulties seem to be most prominent in infants who are irritable, have a difficult temperament, and
may also experience developmental impairments. Family situations may be adversely affected due to the
increased stress during mealtimes. Children who are diagnosed with attention-deficit/hyperactivity disorder,
obsessive-compulsive disorder, anxiety disorders, and autism spectrum disorders are at increased risk for
avoidant/restrictive food intake disorder.
Anorexia Nervosa.
There are three main criteria for a diagnosis of anorexia nervosa: significantly low body weight resulting from
restricted intake, intense fear of weight gain, and disturbance in body perception relative to self-evaluation. In
individuals with anorexia nervosa, self-concept is equated to self-perceptions of their body image that are
distorted and unrealistic. There are two main types of anorexia nervosa: restricting type (low weight is
maintained through dieting, fasting, excessive exercise) and binge-eating/purging type (low weight is
maintained through purging after eating [e.g., vomiting, laxatives]). The DSM-5 (APA, 2013) also provides
ratings for severity level using a body mass index (BMI) formula, ranging from mild (BMI 17 kg/m2) to
extreme (BMI < 15 kg/m2) levels of severity of the disorder (p. 339). For children and adolescents, a criterion
of failure to maintain an expected growth trajectory may be used. Individuals with anorexia nervosa often also
display symptoms of depression and exhibit obsessive-compulsive tendencies that may or may be not related to
food; and when these obsessions and compulsions are not related to food or body weight or shape, then a
diagnosis of obsessive-compulsive disorder may also be warranted.
Bulimia Nervosa.
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Similar to anorexia nervosa, bulimia nervosa also is characterized by three cardinal markers: recurrent binge
episodes (extensive amounts of food are consumed within a given period of time, e.g., 2-hour period; on-
average weekly for 3 months; and binging is accompanied by feelings of lack of control), recurrent
compensatory behaviors (vomiting, laxatives, fasting, excessive exercise), and self-evaluation is related to body
shape or weight. Severity is set by the number of binge/purge episodes per week, from mild (one to three
episodes weekly) to extreme (14 or more episodes a week). Individuals with bulimia nervosa are at increased
risk for a number of comorbid disorders, including depression, bipolar, and anxiety disorders (APA, 2013).
Binge-eating Disorder.
Although individuals with binge-eating disorder experience recurrent binge episodes, and feelings of loss of
control, similar to those with bulimia nervosa, there are no compensatory behaviors that accompany the binge
episode. Instead, episodes are accompanied by three or more of the following responses: rapid eating, eating
until feeling uncomfortable, eating massive amounts when not hungry, eating alone due to embarrassment, or
feeling self-disgust and guilt. The episodes occur weekly for at least 3 months and cause marked distress for
the individual (APA, 2013, p. 350).
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Substance Use Disorders
There has been a significant change in the way the DSM-5 discusses substance use disorders compared with
previous editions. Instead of distinguishing between substance dependence and substance abuse, the current
edition provides criteria for substance use disorder, and the appropriate criteria for intoxication, withdrawal,
substance-induced disorders (where needed) associated with each substance. There are 10 categories of
substances included in the chapter: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives,
stimulants, tobacco, and other. The diagnostic criteria are common to all 10 classes of substances and involve
identification of behavior patterns that are problematic causing clinically significant impairment resulting from
substance use, involving at least two of the following:
increased amounts, or usage extending longer than intended;

unsuccessful efforts to cut down;
excess time spent in procuring or using;
cravings, strong urges to use;
use results in failure to fulfill major role;
continued use despite adverse consequences (social, interpersonal);
reduced opportunities (social, work) due to substance use;
recurrent use in hazardous situations;
persistent use despite knowledge of negative consequences;
tolerance (increased amounts are needed to achieve the desired effect; lessened effect of same amount
used); and
withdrawal (symptoms of withdrawal; substance taken to relieve withdrawal).
Severity is determined based on the number of symptoms evident, ranging from mild (two to three symptoms)
to severe (six or more symptoms).
Intoxication symptoms differ depending on the substance used. For example, alcohol intoxication is related to
problem behaviors (physical or psychological changes) that might manifest in aggressive behavior, mood
swings, or impaired judgment. One or more of the following indicators of alcohol use may be evident,
including slurred speech, lack of coordination, unsteady gait, nystagmus, impaired attention or memory, and
stupor or coma. Cannabis intoxication can cause a wide variety of symptoms ranging from impaired motor
coordination, euphoria, anxiety, and social withdrawal. Two or more of the following often accompany
cannabis intoxication: headache, increased appetite, dry mouth, and tachycardia.
Prevalence rates for substance use vary depending on the nature of the substance. For example, alcohol use is
common among youth and adults in the United States with a 4.6% prevalence rate among 12- to 17-year-olds
and 8.5% rate among adults. Cannabis use is prevalent among approximately 3.4% of youth 12 to 17 years of
age and around 1.5% of adults. Among substance users, genetic influences contribute to the development of
substance use accounting for 40% to 60% of the variance in risk for alcohol use and 30% to 80% of the
variance in risk of cannabis use (APA, 2013).
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Non-suicidal Self-Injury (NSSI)
Criteria for non-suicidal self-injury (NSSI) are included in Section III under “Conditions for Further Study.”
NSSI includes three major criteria, including the nature of NSSI, expectations of engaging in the behavior,
and associated or precipitating conditions. Individuals who engage in NSSI do not intend to commit suicide
but have engaged in NSSI at least five or more times in the past year and use methods that are not usually
lethal, including cutting, burning, stabbing, hitting (Criterion A). Those who engage in NSSI usually seek
one of the following: relief from negative feelings or thoughts, resolution of interpersonal conflicts, or
inducing a positive feeling. There are several factors that can precipitate NSSI, such as interpersonal problems,
a period of preoccupation with self-injurious behavior, or intrusive thoughts about self-injury (APA, 2013, p.
803). According to the DSM, the most prominent theoretical explanation for NSSI can be found in theories
of functional behavioral analysis, relating NSSI to positive and negative reinforcement paradigms.
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References
American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders-5.
Arbuthnott, A. E., Lewis, S. P., & Bailey, H. N. (2015). Rumination and emotions in nonsuicidal self-injury
and eating disorder behaviors: A preliminary test of the emotional cascade model. Journal of Clinical
Psychology, 71(1), 62–71.
Bulik, C. M., Sullivan, P. F., Carter, F. A., & Joyce, P. R. (1997). Lifetime comorbidity of alcohol
dependence in women with bulimia nervosa. Addictive Behaviors, 22(4), 437–446.
Castro-Fornieles, J., Díaz, R., Goti, J., Calvo, R., Gonzalez, L., Serrano, L., & Gual, A. (2009). Prevalence
and factors related to substance use among adolescents with eating disorders. European Addiction
Research, 16(2), 61–68.
Gratz, K. L., & Tull, M. T. (2010). The relationship between emotion dysregulation and deliberate self-harm
among inpatients with substance use disorders. Cognitive Therapy and Research, 34(6), 544–553.
Mann, A. P., Accurso, E. C., Stiles-Shields, C., Capra, L., Labuschagne, Z., Karnik, N. S., & Le Grange, D.
(2014). Factors associated with substance use in adolescents with eating disorders. Journal of Adolescent
Health, 55(2), 182–187.
Muehlenkamp, J. J., Peat, C. M., Claes, L., & Smits, D. (2012). Self-injury and disordered eating: Expressing
emotion dysregulation through the body. Suicide and Life-Threatening Behavior, 42(4), 416–425.
Pisetsky, E. M., May Chao, Y., Dierker, L. C., May, A. M., & Striegel-Moore, R. H. (2008). Disordered
eating and substance use in high-school students: Results from the Youth Risk Behavior Surveillance
System. International Journal of Eating Disorders, 41(5), 464–470.
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Case 20 Alex Bishop The Slippery Slope Substance Use;
Multidimensional Family Therapy (MDFT)
Alex is the 15-year-old son of Wanda Bishop. Alex reluctantly accompanied his mother to the clinic, although
his body language was clear in announcing that he would rather be anywhere but in this place. The tension
between mother and son was evident in their demeanor and lack of communication, as they sat staring at the
door, waiting for the counselor to enter the room. Wanda mentioned to the counselor that her husband was
on his way from work and would be arriving shortly.
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Alex is the only child of Wanda and Jason Bishop. Wanda grew up in a small immigrant family consisting of
her mother, father, and younger sister, Natasha. Wanda’s father, Bill, came to the United States from Poland
when he was just 14 years of age. He was sent here to live with an uncle, for the promise of a better life, but
his uncle was having many financial problems of his own and Bill was soon put to work at the local box
factory. What little he made was used to pay his uncle for his room and board. Eventually, Bill and his uncle
had a falling out and Bill moved out on his own. Soon he met Martha who was a waitress at the local
restaurant. They fell in love, married, and Wanda was born a year later, followed by Natasha who was born
when Wanda was 3 years old. Her mother had always been a homemaker and her father continued to work at
the box factory, although he was promoted to foreman. Bill never lost his traditional roots, and although
Martha wanted to return to work when the children were in school, Bill was against it. Wanda could see her
parents grow apart as her father would spend more time in his den, drinking the night away, while his mother
occupied herself with sewing in her sewing room. On occasion, Bill would come out of his “office” and
demand something to eat or drink, but for the most part, the house was cold and silent.
Wanda dreamt of going to college and becoming a teacher, but her father would have none of it. A woman’s
job was to be a wife and mother. When Wanda was finishing high school, many of her friends were excited
about going away to college, but for Wanda all she could do was look for a job so that she could earn enough
money to get out of the house and find her own apartment. Finally, she got a job at the grocery store as a
cashier, packed her bags, and moved across town into a two-room flat she shared in a house with three other
girls. For Wanda, this was her road to independence. In the beginning, she thought about correspondence
school and how she could earn a degree, but eventually she gave up because there was no one to support her
emotionally or financially. She was on her own. She began to wonder if that was all there was to life, and in
the evenings she too began to take on her father’s habits. Initially, just a drink to fall asleep, then a few to pass
the time and eventually, her drinking became a nightly ritual. Although she drank most nights, it never
interfered with her job or her ability to get her work done. She told herself that it was just good medicine.
One night, she stopped into the local bar after work and met Jason, who had just started working as a reporter
for the local newspaper. They quickly became drinking buddies, and after a few months of dating they decided
to move in together to save rent money. When her father learned of her living arrangements, he disowned her
and forbid his wife to ever talk to her again. Three months later, Wanda found out that she was pregnant.
Jason was upset and offered to pay for an abortion, but Wanda refused to end her pregnancy. They split up
and Wanda was left to raise Alex on her own.
The pregnancy was normal, and Wanda didn’t drink during the entire time because she was afraid that this
might harm the baby. Jason quit his job at the newspaper and moved out of state shortly after Wanda decided
to keep the baby. She continued to work as a cashier and saved as much money as she could because she knew
that there would be many bills to pay soon. Alex arrived on schedule and was a beautiful healthy baby boy who
weighed 7½ pounds. Juggling work and a new baby was very hard, but her landlady was great and watched
Alex during the day while Wanda was at work. Her father would not allow her mother or sister to visit,
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although Natasha came anyway. Her mother was heartbroken not being able to see her only grandson and
Alex never got to know his grandmother before she died.
Alex was a very bright little boy who loved to go to school. He was popular with the other children and the
teachers loved him. Wanda and Alex were making ends meet and even though times were difficult financially,
they managed to get along well. Alex had just turned 12 years of age when Wanda met Logan, at the
company picnic. Logan was a sales distributor who worked for one of the beer companies. Logan was on the
road a lot but spent most of his time in town. He was previously married but was now divorced and had a 17-
year-old daughter who lived in another city with his ex-wife. Wanda was cautious about developing her
relationship with Logan, since she hadn’t really dated anyone seriously for a very long time, but Logan was
eager to build a new family and could see Wanda and Alex in his future. Initially, Alex was a bit jealous of the
attention that Logan was receiving from his mom, since he had been the sole beneficiary of her attention for
so long. That summer, Alex was invited to attend a sports camp for three weeks and he was very excited about
having the chance to do it. With Alex away, Logan saw a great opportunity to move his relationship with
Wanda forward and surprised her with tickets for a boat cruise for the following week. During the cruise, food
and drinks were plentiful and Wanda was literally swept away by the turquoise blue waters of the Caribbean.
On the fourth night of the cruise, Wanda and Logan were married by the ship’s captain.
When Alex arrived home, he found his mother and Logan waiting for him with some “exciting” news . . . they
were married! Alex threw his backpack on the floor, ran up to his room, and slammed the door. He wouldn’t
come out for the rest of the evening. The next day, he didn’t speak to his mother or Logan at breakfast and
went next door to play with a friend. Wanda was so caught up in her own happiness, she did not foresee the
potential effects this move might have on Alex. Logan tried to be supportive, saying “he’ll get over it,” but
Wanda was becoming increasingly worried that Alex may be resentful of Logan and his presence in the home.
Wanda still recalls the look on Alex’s face when she and Logan broke the news. It was a look of “betrayal” that
she will never forget.
For the next year, Logan and Wanda were caught up in their newfound “love” and spent significant time
together, at the local pub and restaurants. Although they always asked Alex to join them for food, he always
seemed to have some excuse, like homework or practice and couldn’t go with them. Finally, they stopped
asking and he stopped making excuses. One night, Alex came home very late and when he stumbled into the
house he woke his mother and Logan up. Logan saw that Alex was drunk and told him to get to his room and
sober up. Logan never shared this with Wanda because he felt that Alex was just blowing off steam. However,
Alex’s behavior began to escalate out of control, and Alex began to experiment with other drugs. By now, in
addition to alcohol, which he was consuming on a daily basis, he had also been frequently using marijuana and
had tried ecstasy and cocaine. His mother had been summoned to the school because of Alex’s increasing
absenteeism and dropping grades. Last week, he was suspended for coming to school intoxicated. This was
the final straw. It was time to get help.
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Reason for Referral
Alex was showing signs of increasing problems with substance use that were beginning to take a heavy toll on
his future in terms of his social, emotional, and academic well-being. Assessment was recommended to
provide a profile of Alex’s current psychological status and to assist in providing directions for future
interventions.
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Assessment Results
Anecdotal comments made by the examiner suggest that Alex’s level of cooperation might have compromised
his performance in some parts of the assessment. Alex appeared to be somewhat despondent and
nonresponsive to the examiner in general. Overall intellectual functioning on the Wechsler Intelligence Scale
for Children (WISC-V) was just within the average to average range (IQ = 90; range 85–99), with no
significant discrepancy between scores for the Verbal Comprehension Index (VCI), low average range (index
score = 85; range 79–91), Perceptual Reasoning Index (PRI), average range (PSI = 93; range 85–100), or
Fluid Reasoning Index (FRI = 90; range 82–97). The Working Memory Index (WMI) was an area of
difficulty for Alex (WMI = 80; range 74–89), who had problems understanding the nature of the instructions
to the letter number sequence task.
Academically, according to the Wechsler Individual Achievement Test (WIAT-111), Alex was functioning
well below his intellectual level in all areas assessed (standard scores ranged from highs of 83 for math
computation and 80 in spelling to lows of 79 for reading comprehension and 80 for sentence composition).
Analysis of cognitive processing (Woodcock Johnson, Cognitive) revealed that academic difficulties are largely
due to problems in cognitive fluency (SS = 67). Alex required more than the anticipated time to label common
objects and to perform tasks that required him to recall names for “as many” _____ (friends, foods, etc.) that
he could name in one minute. In this task, after naming two or three objects, or names, Alex would either go
blank or repeat names he had already given. This type of profile suggests that Alex requires more time to
process information than would be expected and that he would need more time to respond to questions than
normal.
Response to parent ratings scales (ASEBA) revealed borderline clinical elevations on Withdrawn/Depressed,
Attention Problems, Social Problems, and Total Internalizing Behaviors, and significant clinical elevations on
Attention Problems, Total Externalizing, and Total Problems. Teacher ratings noted clinical elevations for
Social Problems and Attention Problems. Both his mother and his teacher noted many problems in the
classroom (e.g., acts young, fails to finish, poor schoolwork, doesn’t listen) and with classmates (doesn’t get
along, is not well liked). On the Conners scales, Alex’s mother rated Hyperactivity/Impulsivity (DSM scales)
as in the borderline clinical range. Oppositional behaviors and the emotional lability scale of the Global Index
were both within the clinically significant range. Alex’s teacher rated him as borderline clinical for Peer
Problems, and in the clinically significant range for the Inattentive scale (DSM), Hyperactive-Impulsive scale
(DSM), and the DSM Total scale.
Alex endorsed items at the borderline clinical level on the Beck Youth Inventory (BYI-2) for Disruptive
Behaviors (SS = 68; 94th percentile), in the highly significant clinical range for the Anger Inventory (SS = 86;
99th percentile), and clinically low range for Self-Concept (SS = 30; 5th percentile).
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Substance use is considered harmful when there are recurrent and adverse consequences of substance use,
leading to at least two of the following conditions: increased consumption, unsuccessful attempts to quit,
excess time devoted to procuring or using, cravings, failure to fulfill roles, loss of opportunities (work, socially),
recurrent use in hazardous situations, persistence despite consequences, tolerance, or withdrawal (APA, 2013).
The DSM-5 lists 10 different substances, the most common of which in youth are alcohol and cannabis.
Recent studies conducted in the United States and Europe have suggested that the most prevalent substances
(lifetime prevalence rates) used in the United States by youth are alcohol (61.7%), tobacco (34.6%), cannabis
(31%), and inhalants (13.6%), whereas the rates in Europe show the following prevalence rates for the same
substances: alcohol (66%), tobacco (58%), cannabis (19%), and inhalants (9%) (Hibell et al., 2009; Johnson,
O’Malley, Bachman, & Schulenberg, 2008). There have been widespread concerns regarding the
appropriateness of classifications for substance use in youth based on criteria established for adults. Harrison,
Fulkerson, and Beebe (1998) take issue with the use of terms like tolerance and impaired control when
describing substance use in adolescents because “many adolescents initiate substance use with out of control
use” and “withdrawal symptoms” may in effect take years to develop. Since adolescence is a time of
experimentation and substance use may be part of this process, it may be very difficult to determine the
severity of substance use at this stage of development (Burrow-Sanchez, 2006). As such, it has been
recommended that the use of a continuum might be more beneficial to determining the severity of substance
use, based on the following hierarchy: abstinence, experimental use, early abuse, abuse, dependence, and
recovery (Winters, 2001).
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Etiology of Substance Use Disorders
Children of alcoholics are at higher risk for alcohol use than peers who are not related to alcoholics (Cadoret,
Yates, Troughton, Woodworth, & Stewart, 1995). The neurotransmitter dopamine has been associated with
the reward center of the brain and researchers have found abnormal dopamine receptors (D2) in those with
alcoholism, as well as those addicted to cocaine (Lawford et al., 1997). From a sociocultural perspective,
studies have also shown that having close friends who use alcohol, tobacco, or cannabis increases the risk of
substance use (Maxwell, 2002). Substances that are used earlier, developmentally, such as cannabis, alcohol,
caffeine, and nicotine, have been linked to dependency on other substances. This finding has led to the
question of whether cannabis can be considered a gateway drug for the use of other substances (Hall &
Lynskey, 2005).
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Treatments, Interventions, and Prevention Programs
In a review of best practices in prevention programs for youth, Montoya, Atkinson, and McFaden (2003)
suggest three steps in the development of prevention programs: isolating relevant risk factors, identification of
characteristics to overcome risks, and determining the optimum environment for the program (home, school
community). Montoya and colleagues also isolate six factors that are key to successful prevention programs,
including
good parenting practices (family bonds, and parental involvement in program),

skill development (resistance skills, social skills),
counteracting peer influence,
retention of participants in the program,
anti-drug media campaigns, and
support of laws and policies for a drug-free environment.
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Multidimensional Family Therapy (MDFT)
Multidimensional family therapy (MDFT) is a highly successful and comprehensive family-based treatment
program that focuses on behavioral and emotional difficulties resulting from substance use in youth.
According to Liddle, Rowe, Dakof, Henderson, and Greenbaum (2009), MDFT can be applied in a multiple
of settings (“office-based, in-home, brief, intensive outpatient, day treatment, residential treatment,” p. 15)
and can be delivered from one to three times weekly, over the course of 3 to 6 months of treatment,
depending on the severity of the problem and the level of family functioning. Therapists in the program
function on four “interdependent” levels:
adolescent domain (focus on engagement in the therapeutic process, communication with parents and
adults, social competence, and alternate strategies to drug use)
parent domain (focus on engagement in therapeutic process, social-emotional involvement with the
adolescent, increase limit setting and monitoring)
family interactional domain (focus on decreasing conflict, increasing attachment, and effective
communication)
extrafamilial domain (focus on collaborative involvement with necessary social systems, e.g., schools,
juvenile justice, recreation).
Therapists will meet with the adolescent and family individually and together depending on the issue to be
addressed (p. 15).
There are ten assumptions underlying the treatment of substance use, using the MDFT method:
Adolescent drug abuse is a multidimensional problem.

Family functioning is instrumental in the development of an adaptive lifestyle.
Problem situations inform the direction for intervention.
Change is a multifaceted, multidetermined, and stage oriented process.
Motivation is malleable but is not assumed.
Multiple alliances are required.
Interventions that are individualized foster competencies.
Treatment occurs in stages; continuity is stressed.
Therapist responsibility is emphasized.
Therapist attitude is fundamental to success (Liddle, 2009, 417–418).
Discussing MDFT brings to mind the concept of case formulation, since at its basis, the approach emphasizes
the need to gather information about the basics (adolescent, parents, family, extrafamilial domains), attend to
the deficits and hidden areas of strengths, and to develop a clinical picture of the system. Within these
parameters,
A contextualized portrait includes a multisystems formulation of how the current situation and
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behaviors are understandable, given the youth’s and family’s developmental history and current risk
and resilience profile. (Liddle, 2009, p. 419)
The following description of the MDFT approach has been adapted from Liddle’s chapter on using MDFT
for adolescent substance use (2009). Treatment usually begins with a home-based or clinic-based session,
which is usually the follow up to previous contact by telephone. Within the first two or three sessions, each
member of the family and adolescent are also given an individual session, as needed. These sessions provide a
view of the different perspectives on the problem and how each member is influenced by what has transpired.
In their session, adolescents are often asked to provide their “life story” (involvement with drugs, family
history, peer influences) and an eco-map outlining their current “life space.” Throughout therapy, the
importance of using drug screens is addressed and the rationale discussed. The parent session also involves
similar questions about parenting practices, monitoring, family history, and getting an appreciation for how
much the parent is aware of the adolescent’s activities. As part of the extrafamilial domain, therapists often
will visit schools to inquire about academic issues and may even observe the youth in a classroom setting, if
advised.
Adolescent Focus: Therapy is viewed as a collaborative process, where the therapist works with the
teen to form an alliance that is unique but related to the parent and family alliance. Therapeutic
goals are identified and the therapist engages the youth in problem solving to determine alternates
to drug use. Within individual sessions, the alliance works on how to motivate, coach, and rehearse
presentations for joint sessions.
Parent Focus: The therapist works with the parents to enhance feelings of love and emotional
connectivity, developing a stronger commitment to assisting their adolescent to achieve his or her
goals. The importance of establishing and increasing parental involvement with their adolescent is
crucial to the process and can be evident in such practices as showing an interest and initiating
conversations.
Parent–Adolescent Interaction Focus: Family systems theory uses the term enactment to refer to the
introduction of important themes into frank discussions about family relationship difficulties.
Behavioral alternatives are discussed in sensitive ways that are nonthreatening and introduced
without blame.
Extrafamilial System Focus: Therapists assist families to interact with systems that are critical to
sustaining future goals and directions.
MDFT has been empirically supported to reduce substance use between 41% to 66% and improve school
functioning and greater increases in grades, and it has shown greater psychiatric symptom reduction (30%–
85%) than other treatment programs (Little et al., 2009).
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Post-Case Questions
1. Many studies have found that heredity plays a large role in substance use. However, there is also support for sociocultural,
cognitive, and behavioral influences in substance use. Discuss how Alex was at risk for substance use based on his family history
and sociocultural factors.
2. Based on the information presented in the case study, would Alex’s symptoms match criteria in the DSM for substance use
disorder? What are some of the problems with the criteria when it comes to applying them to someone of Alex’s age?
3. MDFT is a family-based comprehensive treatment program that is focused on substance use problems in youth. The program is
outlined in the treatment section, and in terms of developing a case formulation MDFT uses assessment information from all
sources to provide a systems formulation for why the youth engages in substance use from the perspective of the youth, the
parents, the family, and the extrafamilial factors. Develop a case formulation that would help to understand how and why Alex
developed his substance use problem and suggest some of the best ways of improving his current situation. In your answer, provide
guidelines for how you would conduct sessions related to adolescent focus, parent focus, interaction focus, and extrafamilial focus.
List some specific goals for each of the sessions.
4. There have been many arguments about whether cannabis is a gateway drug. Discuss the pros and cons of this statement and be
sure to provide resources to back up your comments.
5. Theories of probabilistic and deterministic epigenesis were discussed in the Introduction to Chapter 1, regarding whether biology
is or is not destiny. Compare and contrast the two theoretical approaches with respect to Alex’s case.
6. Suggested Individual or Group Presentation Activity: Alex’s mother wants him to be involved in individual therapy because his
substance use is escalating out of control. She calls a child psychologist to set up an appointment for individual therapy for Alex.
After providing some brief information and obtaining initial assessment results, the psychologist asks Wanda to bring Alex and
her husband to the treatment planning session. Assign roles to the individual players (Alex, Wanda, Logan, and psychologist) who
will participate in the session. Develop important questions and potential responses for your role in the interview, including test
results, responses to the results, a likely method of treatment that would be recommended, and individual reactions and responses
to the treatment recommendation.
510
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Montoya, I. D., Atkinson, J., & McFaden, W. C. (2003). Best characteristics of adolescent gateway drug
prevention programs. Journal of Addictions Nursing, 14, 75–83.
Winters, K. C. (2001). Assessing adolescent substance use problems and other areas of functioning: State of
the art. In P. M. Monti, S. M. Colby, & T. A. O’Leary (Eds.), Adolescents, alcohol, and substance abuse:
Reaching teens through brief interventions (pp. 80–108). New York, NY: Guilford Press.
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Case 21 Sarah Burke Food for Thought Disordered Eating and
Eating Disorders
Sarah, a 16-year-old teenager, came to the clinic accompanied by her mother, Ann. Sarah presented as a
typical teenager of average height and weight. There was a tension between mother and daughter that was
readily recognizable to the clinic staff from the outset. Shouting had accompanied the car ride all the way to
the clinic and both Sarah and her mom looked like they had been through an emotional war. Ann was biting
her lip as they walked through the door, while Sarah gave a sideways glance that could have knocked her
mother over.
Sarah’s behavior was escalating out of control.
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During the telephone intake interview, Ann reported the following background information. Sarah’s birth was
natural and unremarkable. Developmental milestones were all within the normal range with the exception of
speech/language acquisition, which was delayed. Sarah was a quiet baby with a good appetite, and she had no
serious health problems. There was a history of tonsillitis and severe throat infections about twice a year, but
surgery has never been done to correct this due to Sarah’s reluctance to have the procedure. There is no history
of mental illness in the family, although Sarah’s father did abuse alcohol and drugs, which Ann believes
contributed to his eventual heart disease and untimely death when Sarah was 12 years of age.
Sarah was relatively easy to manage as a toddler and she has always been soothed by music. Ann added that as
late as 3 years of age, Sarah’s speech was largely still unintelligible due to articulation difficulties. As a result,
Sarah tended to be very unwilling to speak, especially if strangers were within hearing range. Ann wondered if
some of Sarah’s speech delay might have been attributed to the fact that Sarah’s father was a boisterous, loud,
and verbally abusive man. The marriage was rocky for some time, and when Sarah was 4 years of age, the
marriage finally crumbled. The tension in the home was horrible because they all had to continue living under
the same roof until her father found other accommodations. During this time, Ann tried to avoid any
interaction with Sarah’s father because every incident turned into another eruption.
Ann feels that Sarah might have been fearful and reticent to speak around her father and this made her
nervous about speaking, period. Ann still feels that Sarah continues to have very conflicted feelings about her
dad. Arguments in the household were common, and the children seemed to shrink from their father at times.
Sarah’s older sister, Cindy, coped by literally living at a neighbor’s house with her friend, Tammy. Eventually,
Sarah’s dad moved out. Once her dad left, it seemed that Sarah’s behavior took a turn for the worse.
After that time, Sarah began to have temper tantrums when she did not get her own way. She would scream
so loud that Ann was sure the neighbors thought she was killing her. These incidents were often precipitated
by Ann’s denying something Sarah wanted, but sometimes there seemed to be no apparent reason for the
outburst. During these times, Ann would plead, make deals, cajole, or threaten punishment if Sarah would
not desist. These methods usually failed, and she would eventually give in to Sarah’s demands. Sometimes
Sarah would stop the tantrum on her own, without any intervention. Given Sarah’s difficult behaviors,
delayed speech, and late birthday, Ann was very tempted to delay Grade 1 school entrance for a year to allow
Sarah more time to mature. Since Ann is a teacher, she even thought about homeschooling but decided
against it. Ann wonders if she did the right thing, since Sarah has always lagged somewhat behind her peers
academically and socially.
Sarah and her older sister, Cindy, who is 18 years of age, have never really gotten along. Cindy has always
been a very good student and one who has not had to apply herself too arduously in order to make good
grades. Ann feels that Sarah resents her sister for this, and Sarah feels that her older sister sometimes makes
fun of her and her struggles with academics. The parent adds that Sarah and her older sister, a senior in high
school, argue very frequently, and their arguments sometimes become physical. During one episode, Sarah
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slammed a door on her sister’s hand, causing her sister considerable pain.
Although Sarah is a cheerleader and drill team member at school and appears to be popular enough to be
voted into these activities, Ann feels that she can be very domineering with her friends. Ann has heard Sarah
engage in very intense disagreements with friends on the phone. She has overheard Sarah cursing and
shouting at people on the phone, and Sarah sometimes speaks of “fronting” someone, meaning that she
confronts them angrily or in a hostile way. Ann also stated that she believes Sarah sometimes feigns illness,
giving some vague physical complaint, either in order to get sympathy or to stay home from school.
Sarah is currently enrolled in the 11th grade at Truman High School. Her grades are passing, but presently
she has particular problems with math and chemistry. Sarah has always struggled with math, and Ann is
concerned that this will negatively affect Sarah’s college prospects. Sarah has also verbalized some insecurity
about her academic abilities, and she worries about her future in college. However, when Ann tries to help
Sarah with her homework, Sarah reacts very belligerently, resulting in arguments and accusations about Ann
interfering in her life. On the one hand, Sarah wants her mother out of her life. On the other hand, Sarah can
be a very demanding child whose needs have to be met immediately. On these occasions, Sarah expects her
mother to “be on call” when Sarah needs something. Ann stated that she is constantly “running here and
there” on errands for Sarah, and she wishes that Sarah could take more responsibility for herself.
Ann also revealed several factors that have caused her to be increasingly concerned about Sarah’s welfare and
motivated her to make contact with the clinic. Recently, many fights between Sarah and her mother have
centered on Sarah’s boyfriend. When Ann tries to broach the subject of the boyfriend, Sarah can become very
defensive and verbally aggressive. She has thrown things and cursed her mother. Sarah accuses her mother of
meddling in her affairs and of being unfair and domineering. Ann states that she has legitimate concerns
because she knows some of the boyfriend’s history, which includes involvement with drugs and rumors of
possibly having fathered an illegitimate child. The boyfriend can also be quite thoughtless and mean. He has
made comments on more than one occasion about Sarah putting on weight, which has reduced Sarah to tears.
As a result, Sarah will go off food for days, until she is literally starving, and then break down and clean out
the fridge. Ann has begun to worry about Sarah’s eating habits, since she found a bottle of diet pills hidden in
Sarah’s room. Ann has not confronted Sarah about this, since Sarah would certainly “throw a fit” about her
mother sneaking into her room and invading her privacy. Ann is also concerned that Sarah is having sexual
relations with the boyfriend, given his past history.
When Sarah’s father died of complications due to heart disease, she was 12 years old. Upon the death of her
father, Sarah was inconsolable for a time and seemed to withdraw into herself. She was often irritable and
moody during this time and had difficulty sleeping. Her weight fluctuated from weight loss to weight gain.
Due to the history of divorce and the subsequent death of the father, Ann believes she may have overindulged
Sarah’s behaviors and minimized some difficulties in order to avoid confrontation with her. Ann wonders why
Sarah is not more like her sister; she feels frustrated and unappreciated when Sarah accuses her of meddling.
Ann summed up the telephone interview, outlining her present concerns by saying that she wished Sarah
could behave more tactfully with friends in resolving problems and she wished Sarah could understand that
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what seems like meddling is genuine motherly concern. Ann added that Sarah’s academic difficulties worry
her as well as Sarah, and this seems to add to the tension between them. While she does not approve of
Sarah’s present boyfriend, she does not forbid Sarah’s seeing him. On the other hand, the mother does not
hide her disdain for him either. She can see the negative influence the boy has on Sarah and how he negatively
affects her self-image and confidence. In her final comments, Ann added that she is tired of everyone having
to “tiptoe around Sarah” in order to avoid a confrontation with her. Ann added, “I would like to go through
just one normal week with Sarah.”
Sarah was well dressed for the interview and immediately stated that she was pleased that her mother had to
wait outside and wasn’t going to be part of the interview. Sarah’s speech still reflects some slight articulation
difficulties, but her speech is intelligible. Sarah tends to speak rather rapidly, and the examiner had to ask her
to repeat herself on occasion. Sarah seemed at ease during the interview and was forthcoming with
information. She was somewhat animated but generally appropriate. Sarah admitted to having difficulties
with peer relations and said when she gets into fights, she confronts people and then writes them off: “I just
pretend they don’t exist! I will sometimes even tell them, ‘You’re dead to me.’” Sarah was very vocal about her
resentment regarding her mother’s involvement in her personal matters.
Sarah also seemed to be sensitive about her academic abilities and added that she never did well in math and
that she “hated it.” When describing her social contacts, Sarah said that she most admired Ashley, a peer in
school, because she was smart, pretty, tanned, and thin. She also wished she could live in Ashley’s house
because her parents were rich and they had a pool. She spoke at length about her boyfriend, saying that her
mother doesn’t understand him at all. She added that she thinks her mother is jealous because her mother
doesn’t have a boyfriend and she does. Sarah admits to being sad sometimes, and she wishes her dad were still
alive. She wishes her mom would just “chill” and stay out of her business. When asked about the one thing she
would change about herself, Sarah said her appearance. She said she wished she were taller and thinner, like
Ashley. She admitted to going on diets to lose weight and said that she has tried just about every diet in the
teen magazines and some of her mother’s diets as well. She described her mother as “anorexic” and obsessed
with weight, saying she eats a piece of cheese for lunch. Sarah was asked how she felt after she ate a big meal.
She said, “I feel disgusting, like a blimp. I get really mad at myself for being so grotesque.” She said she makes
a bargain with herself that if she doesn’t eat any more that week, she will be able to binge again the next
weekend. When asked if she ever took pills or vomited to get rid of the food, Sarah flatly denied doing either,
then retracted, saying she had tried vomiting once, but didn’t like it. The examiner was not convinced that
Sarah was being completely honest, especially since her mother had discovered the diet pills. The therapist’s
instincts were correct. Sarah was taking diet pills on a regular basis and vomiting had become a ritual on the
weekends while her mother and sister were at work. Sarah would consume volumes of food over the course of
a few hours and would feel horrible afterward. Vomiting made her feel better because that way she could get
rid of the food, and it was like it never happened in the first place.
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Reason for Referral
Ann had finally acted on her instincts to get help for Sarah, since Sarah was becoming very verbally abusive to
her mother, somewhat reminiscent of the abuse Ann had sustained from her husband during the course of
their failed marriage. Were it not for the abusive situation, Ann might have missed the other cues that
suggested Sarah was having many more difficulties than were apparent on the surface. However, it was Ann’s
feelings of helplessness and fears of confronting Sarah that finally resulted in the referral to the clinic.
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Assessment Results
Information regarding specific instruments and the interpretation of standard scores and T scores can be
found in Appendix C.
The examiner noted that Sarah’s test behaviors revealed a tendency toward impulsive responding and poor
check-back skills (misreading math calculation signs). Frustration tolerance was also low, and Sarah tended to
give up easily. These behaviors, however, were considered to be consistent with Sarah’s everyday approach to
challenging tasks, and results were considered to be a valid index of her current functioning levels.
Sarah’s overall score on the Wechsler Intelligence Scale for Children (WISC-V) revealed a Verbal
Comprehension Index (VCI) of 89 (range 83–96) and a Fluid Reasoning Index (FRI) of 83 (range 76–93).
Verbal weaknesses were noted in Comprehension and Similarities. On the FRI, Sarah had significant
problems with the Matrix Reasoning task and Figure Weights. Given this profile, it would be anticipated that
Sarah would encounter academic difficulties, especially in math. Academically, according to the Wechsler
Individual Achievement Tests (WIAT-III) Sarah was approximately 1 year behind her present grade
placement in Reading Comprehension and Fluency, as well as Spelling and Sentence Composition (Written
Expression); however, she was almost 3 years behind across all math areas (Numerical Operations and Math
Problem Solving).
Sarah completed the Eating Disorder Inventory-2 (EDI-2), and her profile revealed significant elevations on
the Desire for Thinness and the Body Dissatisfaction scales. An elevated Bulimia scale also supported
suspicions regarding Binge Eating/Purging Behaviors, and scores for Impulse Regulation were also elevated.
In response to interview questions and in her responses to the Child Depression Inventory (CDI-2), Sarah did
not endorse symptoms of depression to any significant degree; however, scores for Ineffectiveness and
Interpersonal Problems were in the at-risk level. On the Revised Child Manifest Anxiety Scale (RCMAS-2),
scores for Worry/Oversensitivity and Social Concerns were also within the at-risk range. Responses to the
Beck Youth Scales noted concerns in areas of an elevated Anger Expression score and lowered scores for Self-
Esteem.
Sarah’s mother completed the Conners Parent Rating Scale (Conners-3), which yielded several subscales
elevated to the clinically significant level: Oppositional Behavior (T = 74) and Emotional Lability (T = 77).
Sarah’s mother’s responses suggest that difficulties are evident in having few friends, feelings of being socially
detached, and lack of self-confidence. In view of suspected bulimic activity, there is a cautionary note
regarding the significant number of physical complaints endorsed. Overall, the parent’s rating of Sarah
represents an elevated general profile that might represent global problematic behavior or comorbid
functioning.
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Contemporary preoccupation with thinness and the “thin ideal” has resulted in many young women
developing a sense of body dissatisfaction, which can result in an obsession with weight loss and dieting.
Disordered eating patterns can place adolescent females at increased risk for developing eating disorders.
Eating disorders have become the third leading cause of chronic illness among young women 15 to 19 years of
age (Rosen, 2003). Currently, in addition to feeding disorders, the DSM-5 (American Psychiatric Association
[APA], 2013) recognizes four main categories of eating disorders: avoidant/restrictive food intake disorder
(replaced and expanded the previous category of feeding disorder of infancy or early childhood), anorexia
nervosa (AN), bulimia nervosa (BN), and binge-eating disorder. The DSM-5 diagnostic guidelines for eating
disorders are available in Appendix D.
Approximately half of those diagnosed with AN will demonstrate symptoms of the restricting subtype, who
practice restraint and self-starvation to achieve their goal of maintaining their weight of less than 85% of what
would be expected given their height (based on the Metropolitan Life Insurance tables or pediatric growth
charts available for projected height–weight ratios). Those with the binge-eating/purging subtype of AN may
engage in excessive exercise or other means (laxatives, diuretics) to reduce the caloric content of foods
ingested. Studies have revealed that those who have the binge-purge subtype of AN report less overall life
satisfaction and lower global functioning than their counterparts who have the restricting subtype (Herzog et
al., 1999). The restricting subtype can become trapped in an anorexic cycle involving repetitive thoughts of fear
of obesity and distorted body image, causing anxiety, which drives dieting and starvation, leading to
obsessions with food that start the cycle over again. Low body weight often results in the cessation of the
menstrual cycle (amenorrhea), which was one of the criteria for the diagnosis of AN (DSM-IV-TR; APA;
2000); however, this is no longer a specific criteria for the disorder. Individuals with AN can suffer from
serious medical complications that can place them at increased risk for physical collapse and subsequent
hospitalization due to severe dehydration and electrolyte imbalance. Although primarily associated with onset
in adolescent girls and young women, it is also possible to diagnose AN in adolescent boys, young men,
individuals in later childhood, and older women. The lifetime prevalence rate for AN is approximately 1% of
the population, although until recently, the disorder was primarily seen in Western and developed,
industrialized societies. One out of 10 with AN who are hospitalized will die, either from physical
complications or suicide (DSM-5; APA, 2013). Unfortunately, only 10% with the disorder will achieve a
complete recovery, while approximately 50% will experience partial recovery (Herzog et al., 1999).
Individuals who suffer from BN have many of the same symptoms of eating disturbance as those with AN;
however, they do not present with the same degree of medical problems since they are not successful in
maintaining their weight loss and tend to fluctuate between being overweight and being underweight.
Individuals with BN can engage in a number of different patterns of compensatory behaviors, including
vomiting, enemas, diuretics, or engaging in excessive exercise or fasting. Individuals with BN who engage in
binge-and-purge episodes risk negative physical side effects such as erosion of teeth enamel and deterioration
of the esophagus due to damage from stomach acids resulting from repetitive vomiting. In clinical samples,
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more than 90% of those with BN report self-induced vomiting as the most common form of purging (Reba et
al., 2005), while using several types of purging methods (multiple purging) has been associated with greater
disorder severity, frequency of bingeing, comorbid depression, impulsivity, anxiety, and personality disorder
(Edler, Haedt, & Keel, 2007). In their study of adolescents and young women with eating disorders, Dalle
Grave, Calugi, and Marchesini (2009) found that individuals who engaged in vomiting (as opposed to the use
of laxatives or diuretics) scored higher on novelty seeking, a temperament trait associated with impulsivity,
dramatization, and thrill seeking (Cloninger, Svrakic, Przybeck, & Wetzel, 1994). Dalle Grave and colleagues
suggest that the use of vomiting by those with these characteristics might represent the preferred method of
purging due to the immediacy of the effect.
Anorexics and bulimics are both subject to faulty cognitions; however, the bulimic’s thought processes serve to
perpetuate a self-destructive binge-purge cycle of anger and guilt. Pre-binge thought patterns of anger, guilt,
and loss of control are followed by binge eating. Binge eating serves to increase the sense of anger, guilt, and
loss of control. Post-binge feelings of depression, disgust, and self-deprecation follow, which can be alleviated
only by getting rid of the excess food. Once compensatory measures are taken and the food is expelled, the
bulimic once again feels a sense of calm and self-control. The cycle perpetuates behaviors that are inherently
self-rewarding and compulsive. Tendencies for bulimics to also exhibit comorbid disorders of depression and
anxiety are well documented (Herzog, Keller, Sacks, Yeh, & Lavori, 1992; Johnson, Cohen, Kasen, & Brook,
2002). Stice, Burton, and Shaw (2004) found that substance abuse and depression were related in a
bidirectional way for those with BN, such that either disorder increased the risk of also succumbing to the
other disorder. Among adolescents with BN, substance use also is related to engaging in other high-risk
behaviors, such as suicide attempts, sexual activity, and theft (Conason & Sher, 2006). It has been suggested
that illicit drug use among this population, especially stimulants, amphetamines, or cocaine, may be related to
the drugs’ tendencies to also suppress the appetite. Lifetime prevalence for BN has been reported to be
between 1% and 5% and is significantly higher in females than males: a ratio of 10 to 1 (DSM-IV-TR, APA,
2000; Lewinsohn, Striegel-Moore, & Seeley, 2000). Onset is typically in late adolescence or early adulthood;
however, many individuals with BN can go undiagnosed, and less than half of those who suffer from BN seek
treatment (Hudson, Hiripi, Pope, & Kessler, 2007).
Individuals with AN or BN share common and excessive fears about weight gain, preoccupation with food
and thinness, and a distorted sense of body shape linked to tendencies to evaluate their self-worth relative to
their body image. Often the eating disorder can surface after a period of intense dieting. Individuals with
eating disorders often experience feelings of depression, anxiety, and a desire to be perfect (Thompson-
Brenner & Westen, 2005). Having an eating disorder places an individual at increased risk for self-harm,
suicide attempts, and substance abuse that can often start with excessive use of diet pills (Levitt, Sansone, &
Cohn, 2004; Ruuska, Kaltiala-Heino, Rantanen, & Koivisto, 2005). Personality dynamics of those with the
binge-purge subtype type of AN and the purge subtype of BN relative to the other subtypes evidence poorer
impulsive control, have greater risk for substance abuse, experience more emotional distress (DaCosta &
Halmi, 1992; Garner, Garner, & Rosen, 1993), have elevated rates of suicide attempts (Milos, Spindler,
Hepp, & Schnyder, 2004), and exhibit more symptoms of posttraumatic stress disorder (Blinder, Cumella, &
Sanathara, 2006). Geist, Davis, and Heinman (1998) found high comorbidity rates (15%) for oppositional
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defiant disorder in adolescent girls with binge-purge features in their eating-disorder population.
However, despite the similarities, there are also significant differences between AN and BN, especially
between the restricting subtype of AN and the binge-purge subtype of BN. For example, the onset for AN
can be earlier (range 14–19 years) than the onset for BN (range 15–21 years). There are several other
differences between these two disorders, such as the dynamics inherent in personality and family systems and
the fact that anorexics maintain a body weight less than 85% of the normative weight, while bulimics are more
likely to be of average weight or slightly overweight. Differences in family dynamics are evident between those
with AN and BN. Traditionally, whereas families of those with AN tend to be enmeshed, overprotective,
overly rigid, and in denial of conflict (Kog & Vandereycken, 1989), families of those with BN are more likely
to have a history of psychopathology, open hostility and confrontation, expressed emotion, parent–child
conflict, and relational aggression (Johnson & Connors, 1987). The role of family dynamics in eating
disorders has also been investigated in research. In analyzing the responses of mother–father–daughter triads
in response to the Structural Analysis of Social Behavior, Humphrey (1989) found that parents communicated
very different messages to anorexics and bulimics. Families of anorexics tended to be controlling and allowed
little room for their daughters’ self-expression. They communicated a mixed message of nurturance but no
tolerance for expression of feelings. Families of bulimics, on the other hand, demonstrated more overt signs of
emotional conflict and often blamed and berated their daughters.
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Etiology of Eating Disorders
Studies of the onset and etiology of eating disorders have found that eating disorders can often begin with
patterns of disordered eating that eventually can progress to dysfunction and distress. It has been estimated
that between 9% and 11% of youth demonstrate symptoms of AN or BN (Stice, Killen, Hayward, & Taylor,
1998). Eating disorders can result from interactions among many bio-psycho-social variables.
From a biological perspective, etiology of eating disorders can be linked to genetic factors. Research
concerning familial linkages to eating disorders has revealed that relatives of anorexics and bulimics have a 7-
to 12-times greater risk of having an eating disorder than nonrelatives. In addition, this population also has
greater prevalence of other comorbid disorders, such as major depression, obsessive-compulsive disorder, and
anxiety disorders (Lilenfeld, Kay, & Greenco, 1998; Strober, Freeman, Lampert, Diamond, & Kaye, 2000). If
an identical twin has BN, there is a 23% chance that the other twin will also develop the disorder (Walters &
Kendler, 1995). Also, developmentally, at a time when young girls are beginning to be more conscious of their
weight, they actually begin to accumulate fat (adiposity) in their arms, legs, and trunk to prepare their bodies
for puberty (Brandao, Lombardi, Nishida, Hauache, & Vieira, 2003). The increase in physical body mass is
highly correlated with reports of increased body dissatisfaction among girls at this time (Stice & Whitenton,
2002) and elevated levels of distress due to a lack of success in attempts at dieting (Nowak, 1998). On the
other hand, males tend to develop more muscle mass at this time, which is looked on more positively.
In addition to family links to eating disorders from a genetic basis, there are also connections to eating
disorders from a psychosocial perspective. Family dynamics have also been associated with different types of
eating disorders. In their classic studies of anorexic families, Minuchin, Rosman, and Baker (1978) found
these families to be highly overprotective and enmeshed (intrusive parent), with rigid boundaries, and in
denial of any underlying conflict. From a family systems perspective, Minuchin and colleagues (1978) suggest
that the dynamics in the family environment set the stage for the adolescent to simultaneously act on her
independence by refusing to eat, while at the same time triggering the delay or cessation of menstruation that
ensures her continued dependence on the need for increased parental intervention and control. By contrast,
individuals with BN are often impulsive and confrontational and engage in high-risk behaviors within the
context of their family environments that exhibit a lack of control, open conflict, and hostility (Fairburn
Welch, Doll, Davies, & O’Conner, 1997).
In their article “The Mass Marketing of Disordered Eating and Eating Disorders,” Hesse-Biber, Leavy,
Quinn, and Zoino (2006) blame media messages from television, the Internet, movies, and magazines for the
“cult of thinness” and for increased body dissatisfaction that has evolved. Although initially thought to be a
“white woman’s problem” (Botta, 2000), concerns have now crossed ethnic (Goodman, 2002; Walcott, Pratt,
& Patel, 2003) and gender boundaries (Walcott, Pratt, & Patel, 2003). However, while females are driven to
thinness, males are more inclined to “bulk up” and, as a result, anabolic steroid abuse has become a growing
public health concern in the United States, as well as Europe and Australia (Kanayama, Pope, Cohane, &
Hudson, 2003; Kindlundh, Isacson, Berglund, & Nyberg, 1999). From a sociocultural perspective, there has
been an increased tendency to evaluate the influences of peers, family, and the media (tripartite model;
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Thompson et al., 1995) on body dissatisfaction in youth, which is occurring at younger and younger ages.
Mellin, Irwin, and Scully (1992) found that as many as 80% of 9- and 10-year-old girls reported feeling fat
and had engaged in binge-eating and dieting episodes. A 2005 survey of adolescent attitudes and behaviors
regarding body dissatisfaction (Youth Risk Behavior Surveillance; CDC, 2005) reported that females engaged
in significantly more unhealthy weight-loss methods than males and that the percentage of females trying to
lose weight increased with grade level, from 60% in Grade 9 to 64% in Grade 12. Unhealthy weight-loss
methods also varied by grade level, with the following most popular method by grade: fasting in Grade 9
(18.4%), vomiting or taking laxatives in Grade 10 (7.2%), and pills or powders in Grade 12.
Pressure from family or peers and lack of a support system can serve to reduce self-concept and increase body
dissatisfaction among youth (Wichstrom, 1999), while teasing about weight from peers can increase the risk
for engaging in bulimic behaviors (Thompson, Coovert, Richards, Johnson, & Cattarin, 1995). Weight-
related teasing from family members, especially fathers, places young females at risk for lower levels of self-
esteem; internalization of the thin ideal; and increased rates of social comparison, depression, and engaging in
restrictive or bulimic behaviors (Keery, Boutelle, van den Berg, & Thompson, 2005). Gross and Nelson
(2000) found that “any” messages related to food or body image risk being “perceived” as negative by
vulnerable girls. Criticism from mothers served to reduce self-esteem (Sherwood & Neumark-Sztainer, 2001)
and increase disordered eating behaviors (Gross & Nelson, 2000). One study even found that maternal
comments that supported their daughter’s comments about food or weight also backfired and were interpreted
negatively by the sensitive girls (Hanna & Bond, 2006). Although Rodin, Striegel-Moore, and Silberstein
(1990) called for increased research concerning protective factors to guard against eating disorders, there
continues to be very little information available to this end. However, recent research in the area of dissonance
intervention, which will be discussed shortly, is very promising (Seidel, Presnell, & Rosenfield, 2009; Stice,
Marti, Spoor, Presnell, & Shaw, 2008).
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Treatments, Interventions, and Prevention Programs
Treatment for AN.
Treatment for AN often occurs in response to a medical crisis resulting from significant weight loss (Comerci
& Greydanus, 1997; Mehler & Andersen, 1999) and can be extremely challenging, since patients have likely
been placed into treatment against their will (Patel, Pratt, & Greydanus, 2003). The goal will be to deliver
service in the least restrictive environment (Pyle, 1999); the nature of the medical intervention required
(feeding tubes, restoring electrolyte balance) will determine where the treatment is delivered.
The initial focus of the treatment is to restore the patient’s health and return the nutritional and metabolic
state back to normal. Once stable, individual, group, and family psychotherapy; nutritional counseling; and
exercise management can be introduced. During this phase of treatment, appropriate behavioral interventions,
such as behavior modification, contingency management, and activity management (offering increased access
to privileges or tangible rewards, such as access to telephone and television) can be instrumental in supporting
a return to normalization and stabilization (Patel et al., 2003). The overall focus of treatment will be on long-
term gains and recovery in the absence of relapse (Comerci & Greydanus, 1997).
Distortions in body perception and obsessions with food constitute part of the maladaptive thinking patterns
(perfectionism, negative thinking) in those with AN (King, 2001). Cognitive–behavioral treatment (CBT)
programs focus on reframing disordered thought patterns about eating and body image into more positive and
realistic appraisals (Robin, Siegel, & Moye, 1995). Robin, Bedway, Diegel, and Gilroy (1996) combined CBT
(reframing need for independence and alternative ways of achieving control) with family therapy (including
psychoeducational awareness and communication effectiveness) and achieved a 64% success rate (teens
reached ideal body weight) after 16 months of treatment, which was maintained by 82% of the participants 1
year later.
Treatment for BN.
Compared to those with AN, hospitalization will be required in less than 5% of cases with BN (Phillips,
Greydanus, Pratt, & Patel, 2003). Although hospitalization will be rare, the use of medications and the need
for medication management are on the increase, as prescriptions for antidepressants become more common in
the treatment of BN (Caruso & Klein, 1998; Freeman, 1998). In seeking treatments for bulimia, investigation
of potential biological factors has led researchers to suggest a link between eating disorders and low levels of
serotonin (Carrasco, Diaz-Marsa, Hollander, Cesar, & Saiz-Ruiz, 2000) or chemicals such as GLP-1 that
serve as a natural appetite suppressant (Turton et al., 1996). In support of genetic and biological theories,
studies of monozygotic twins with eating disorders have revealed concordance rates as high as 23%, compared
with only 9% for fraternal twins (Walters & Kendler, 1995). Antidepressants (SSRIs, such as fluoxetine and
Prozac) can assist 25% to 40% of those diagnosed with BN (Mitchell et al., 2002).
CBT is the most widely researched treatment for BN, and long-term success has been reported (Agras &
Apple, 1997; Lewandowski, Gebing, Anthony, & O’Brien, 1997; Wilson & Fairburn, 1993). In their review
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of more than 30 controlled studies, Agras and Apple (1997) found approximately 50% of clients using CBT
eliminate bingeing and purging after treatment, and although some of the participants in these studies report
a periodic relapse of bingeing and purging, follow-up studies (some as long as 5 years) indicate the success
remains stable over time for the majority of participants. Recent efforts to incorporate dissonance-based
intervention in CBT programs have demonstrated even more success in the treatment of individuals with BN.
Based on theories of cognitive dissonance, dissonance intervention engages females who have a highly
internalized sense of the thin ideal to challenge the ideal and create an alternative set of beliefs, ultimately
resulting in feelings of discomfort about the thin ideal. Results have revealed long-term effects (2- and 3-year
follow-up) for significant reduction of body dissatisfaction, negative affect, and bulimic symptoms (Stice et al.,
2008).
Other therapeutic programs for BN have included interpersonal psychotherapy (IPT), which rather than
focusing on the eating disorder, targets the client’s interpersonal relationships and focuses on ways to make
these more satisfactory (Agras & Apple, 1997; Fairburn et al., 1997). Although family-focused therapy is
another potential alternative, well-controlled studies of family intervention for BN are lacking and more
research is needed in this area. Given the family dynamics, perhaps training in communication style (e.g.,
focus on reducing expressed emotion) should be explored.
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Prevention Programs
To date, for the most part, programs targeting the prevention of disordered eating habits among young
females (early to late adolescence) have met with limited success (Striegel-Moore, Jacobson, & Rees, 1997).
While primary or universal prevention programs have targeted reducing the risks and increasing the protective
factors for developing eating disorders in the population at large, secondary prevention programs have focused
on the early identification of symptoms of eating disorders (e.g., body dissatisfaction) with the intent of
reducing the risk.
Primary prevention programs have basically focused on one of two goals: psychoeducational awareness
(healthy weight management, adverse effects of dieting) or enhancing assertiveness skills (resistance to societal
pressures). Although the programs have been successful in enhancing the participants’ awareness levels, they
have not been successful in changing attitudes toward dieting (Carter, Stewart, Dunn, & Fairburn, 1997;
Piran, 1997). Carter and colleagues (1997) also note that although initial results can be encouraging, longer
term results may actually indicate potential harmful effects, which in their study revealed a rebound effect with
an increase in dieting behavior (higher than recorded preintervention) 6 months postintervention. Pratt and
Woolfenden (2006) reviewed 12 prevention programs matched for strict inclusion criteria (randomization,
control group). Similar to other prevention programs targeting youth, the majority of programs (9 out of 12)
were school based. Their review yielded only one procedure that was successful in reducing the risk of eating
disorders, namely, discussions and critical evaluations of media messages regarding body image (Kusel, 1999;
Neumark-Sztainer, Sherwood, Coller, & Hannon, 2000). On a more encouraging note, Stice, Shaw, and
Marti (2007) found 9 of 51 prevention programs that not only reduced risk factors but maintained reduced
eating disorder symptoms on follow-up. As noted earlier, dissonance-based intervention holds considerable
promise as a component in future prevention programs (Seidel et al., 2009; Stice, Martin, & Shaw, 2007).
527
Post-Case Questions
1. Within family systems theories, four characteristics have been observed in “anorexic families”: enmeshment, overprotectiveness,
rigidity, and denial of family conflict (Minuchin et al., 1978). “Bulimic families,” on the other hand, tend to have greater
tendencies toward predisorder conflict with parents; greater incidence of family pathology, especially substance abuse or
depression; and more perceived intense family conflict (Neuman & Halvorson, 1983).
Discuss how Sarah’s family characteristics support or contrast with this theory.
2. Discuss some reasons why Sarah’s sister, Cindy, did not develop an eating disorder, while Sarah did. Support your discussion from
the viewpoint of a theorist from each of the following models: biomedical, psychodynamic, behavioral, cognitive, family systems,
and attachment/parenting style. How might developmental contexts interact to create greater risk or protective factors for the two
sisters?
3. Regarding the above question, address how the principles of multifinality and equifinality can also assist in explaining the two
different outcomes for the two sisters. In discussing, the principles, support your discussion with Greenberg’s model drawing on
four underlying processes found in theories of attachment (see Introduction to Chapter 1 for a discussion).
4. Do Sarah’s symptoms meet criteria for an eating disorder according to the DSM-5? Justify your response.
5. Bruch (1991) has developed a theory linking parenting style to eating disorders that combines facets of psychodynamic and
cognitive theories. Bruch argues that severe and frequent mother–daughter conflicts result in lack of adequate ego development in
the child (poor sense of independence and control) and cognitive distortion regarding eating habits. Developing this line of
thought, Bruch suggests that effective parents correctly identify their child’s internal state and match comfort needs with
appropriate responses. If a child is hungry, food is provided; if a child is emotionally upset, emotional comfort is provided; and if a
child is cold, the parent provides a warm blanket or clothing.
However, ineffective parents do not attend appropriately to the child’s internal cues and provide inappropriate responses, such as
trying to comfort an anxious child with food. Children who grow up in these environments do not learn to recognize their own
internal signals and confuse feelings of anxiety, anger, or distress with feelings of hunger. Feeling helpless and out of control,
adolescent girls may respond by taking excessive measures to assert their control over their own bodies. Research has provided
some support for Bruch’s theory. Studies have shown that bulimics often equate anxiety with hunger (Rebert, Stanton, &
Schwarz, 1991). Bulimics’ desire to please often results in their reliance on others’ opinions and views, consequently feeling less
sense of control in their own lives (Walters & Kendler, 1995). Describe how Bruch’s theory might be used to explain Sarah’s
eating disorder.
6. Suggested Individual or Group Presentation Activity: The school psychologist is planning on having a girls’ group for your teens
in the high school who show signs of having eating issues. Letters are sent home to the parents asking if their child is suspected of
having eating problems and if they would be interested in attending the group. Sarah’s mother receives one of the letters and she
calls the school to make an appointment with the school psychologist. Assign roles to individuals who will role play important
characters in Sarah’s life and how they would interact in this situation. Develop important questions for each of the players who
can add information to the case. Some of the casting members might be the school psychologist, Sarah, Sarah’s mother, Cindy,
etc. What do you think the likely outcome of this meeting will be?
528
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Case 22 Tori Benson Skin Deep: Cutting Through the Pain Self-
Mutilation; Borderline Personality Disorder
Tori was dropped off for her first appointment by her father, who appeared very uncomfortable and as though
he was not sure whether he should stay or go. Tori, who just turned 16 years of age 2 weeks ago, had quit
school on her birthday. She seemed sullen and had a look of disgust on her face. Her father wanted assurance
from her that she would not bolt, once he had left, and she gave him a sideways glance, saying, “Yeah,
whatever.” He made arrangements to pick her up in an hour and then left. That was the first time the
psychologist had met Tori, although she initially interviewed the parents about their concerns a week earlier.
Parents were at a loss as to how to manage Tori, whose behaviors had clearly escalated out of control. Tori
agreed to accompany the psychologist to her office, saying, “Yeah, Shrink, let’s go to your shrink room.”
When Tori had quit school on her birthday, 2 weeks ago, she had also left town and took a Greyhound bus to
visit an older friend who was living on her own in another city. Tori had just been reunited with her parents a
few days ago. Before she returned home, the parents, realizing that their daughter would land on their
doorstep within the next few days and feeling totally unable to relate to her, had contacted the psychologist to
ask for help for Tori when she returned.
537
When George and Andrea Benson contacted the psychologist, they had just been informed that their
wayward daughter had been found in a city several miles away. They had been frantic for days, not knowing
what had happened to her; they were hoping for the best, yet fearing the worst. Although they contacted the
police immediately, there was a delay of several hours between when Tori boarded the bus and when her
parents actually knew that she was missing. It had been a typical morning, with Tori leaving for school at the
same time that her parents left for work. It wasn’t until her mother checked for messages later that day that
she realized her daughter did not attend school at all that day. Andrea’s first reaction was one of anger,
thinking that Tori had lied to them and skipped school again. Andrea called George, who told her to calm
down, saying that Tori was probably using her birthday as an excuse to treat herself with time off and a
shopping trip with her friends. When the phone was not answered at home, they just thought that Tori was
avoiding a confrontation. They had confiscated her cell phone, so they did not have another way to contact
her. Not that she would have answered her cell phone, if she were avoiding her parents. Andrea was even
more upset because it was Tori’s birthday and she and George had planned a quiet meal at her favorite
restaurant for the three of them to celebrate her “sweet sixteen.”
Tori lives with her parents, Andrea and George Benson, who are 38 and 40 years of age. There is another
child, a sister, Cindy, who is 10 years old. Tori and Cindy do not get along and can be quite competitive with
each other for their parents’ attention. When asked about Tori’s milestones, parents seemed to have little
recollection of when important events occurred and actually provided more information about Cindy’s
development than Tori’s. Andrea explained that although the pregnancy and birth were uneventful, she was
quite depressed after Tori was born and, as a result, she really does not have very good recollection of Tori’s
early life at all. This was a dark time in their lives, when George had an alcohol problem that often resulted in
blackouts, when he could not remember what he had done for an entire day. Andrea was seriously depressed,
but medication did not agree with her, so she also indulged in alcohol to help her forget and sleep. There were
financial problems, and Andrea said that she does not know how they all came through that time without any
serious problems. As for Tori, she spent most of her time in day care during the day, and with a neighborhood
boy who was several years older, who took Tori under his wing. Even though he was 12 and Tori was 4, he
was like a big brother to her and they spent a lot of time together, which was a good thing for Andrea,
because at least she felt that Tori was safe and had a companion. This relationship with the boy lasted until
Tori was 6 years old, when the boy and his parents left town unexpectedly. As a result, Tori was crushed,
having lost her “big brother,” and was very lonely and sad, not having developed any friendships with children
her own age. In addition, at that time, Andrea also realized she was pregnant again, and Tori became very
jealous that there would be another child in the house.
When asked about any family history of mental illness, the Bensons were quite reluctant to offer any
information initially; however, they eventually reported problems on both sides of the family. There is a family
history of alcoholism, on the father’s side, with George’s father reportedly an alcoholic. George’s nephew, who
is about 3 years older than Tori, has been arrested several times for possession of drugs and is currently serving
538
a sentence in the correctional facility. George’s mother was a very eccentric woman who claimed to be the
descendent of Danish royalty and forever complained about her lot in life. According to George, she was a
very dramatic woman who would have done well as an actress on the stage. Andrea’s family members were less
flamboyant by description; however, the difficulties that were reported shared a common theme relating to
problems with impulse control. Andrea’s brother is currently incarcerated for theft, DUI, and an incident of
road rage, while her sister has been arrested repeatedly for shoplifting, which has been attributed to
kleptomania.
Tori was just beginning to make friends at school when her father was transferred to another city about 200
miles from where they had been living. At this time, Tori was 8 years of age and in Grade 3. Her parents
recalled that Tori was very upset about the move and had a very difficult time adjusting to her new school and
classmates. Often, during this period, Tori would beg to stay home from school, and cry, complaining of
stomachaches and pains. She became increasingly resentful of her little sister, who was 2 years of age and
could stay home with her mother, while Tori had to go to school. Her parents tried to arrange visits with her
previous friends by inviting them to come over, or arranging for Tori to visit them, but these were not as
frequent as Tori would have liked. They did say, however, that a few years ago, Tori met a girl on one of her
bus trips to the other city and that Tori developed an immediate friendship with and really looked up to the
girl. The girl, Josie, was older (they guessed about 19–20 years of age) and had been on her own for some
time. When Tori ran away on her birthday, she went to visit Josie, who took her in for the week. Andrea and
George were very concerned because they knew very little about Josie and were fearful that she might be a bad
influence on Tori. To this date, they have very little information about Josie or what she does for a living.
Tori has disliked attending school since the third grade when the family moved to another city and school.
Academically, although she has never been assessed for special education services, she has had mediocre
grades, barely passing each year. When Tori is unhappy with her school, parents have responded by
transferring her to another school. As a result, Tori has attended six schools in the past 8 years. Last year, she
was successful in obtaining only one credit in the Grade 10 program.
539
Reason for Referral
When Tori’s parents initially approached the psychologist, they were looking for an immediate solution to
their problems with Tori. However, given Tori’s age and the surrounding circumstances, in the initial part of
the interview with the parents, the psychologist focused on enlightening them about the ethical problems and
difficulties inherent in working with adolescents. The psychologist’s first step was to engage the parents in
allowing her to work with Tori in an environment that encouraged disclosure, without Tori fearing that
everything she told the psychologist would be relayed back to her parents. It was explained that unless the
adolescent is assured that disclosures will be treated confidentially, nothing will be disclosed. Furthermore, it
was emphasized that the long-term goal would be to encourage Tori to discuss these issues with her parents,
through the help of the psychologist at her side as a mediator. The psychologist also discussed that Tori would
be informed in the first session that there are three conditions under which the psychologist would have a duty
to report information to the authorities: information regarding (1) any intent to self-harm, (2) any intent to
harm others, or (3) reporting being the victim of prior abuse (sexual, physical). Once parental support was
obtained, the psychologist agreed to meet with Tori, given that Tori was agreeable. The psychologist also
mentioned that if Tori was not in agreement (they were not able to convince her to seek help) and they were
concerned about her welfare, they should, with the agreement of a mental health professional, seek an
involuntary commitment order to ensure her safety.
Tori, a tall, thin, adolescent, presented with numerous complaints during the psychologist’s initial contact
with her. Tori made it clear during the first meeting that the counseling sessions were her parents’ idea to fix
up how they had “f——up her life.” When asked how her life had been derailed by her parents, Tori
recounted her school history in a lifeless list of facts devoid of emotion. When asked to recall a time when she
was happy at school, Tori stated that she could not remember anything positive about school. Instead, she
seemed to hang on to bitter memories of every situation that went wrong for her. She said that she never
rebounded after her parents moved when she was in Grade 3. She said that the kids in this town are horrible
and that she was unable to fit in because they were snobs. Although Tori talked about “fitting in,” the way she
dressed and her outward flamboyance suggested that fitting in was the last thing on her mind. For the first
meeting, she was dressed in a pair of distressed jeans, which were more “holes” than denim, barely hanging
together by a thread. She wore a dangling earring made out of a fishing lure and carried a purse that was
covered in feathers that were glued to the bag. She was also wearing dark black lipstick that matched her nail
polish.
During the first session, several attempts were made to elicit from Tori what her plans were for the future, in
terms of possibly returning to school, and what plans she might have if the situation at home deteriorated
again. Tori mentioned a number of alternatives, which revealed that she had given it some thought, although
it was questionable how much thought had gone into the process. Tori rattled off a number of possible living
arrangements, including moving in with her boyfriend, doing telemarketing and living off student welfare,
finding accommodations in a group home, or turning herself in to the psychiatric hospital. Each alternative
was delivered in a matter-of-fact tone, with very little accompanying emotion. When asked if she was
540
depressed or had been depressed in the past, Tori said that she had been on Prozac and Paxil previously, but
that her mother made her get off the Paxil because she thought that it was related to Tori doing other “drugs.”
Tori agreed, maybe the Paxil did have something to do with other drugs she was doing at the time. When
asked about a future career, Tori said that maybe she would be a fashion designer. At that point, attention was
drawn to her unique way of dress, and Tori seemed quite proud of her look, which she said could start a
fashion trend.
When Tori arrived for her next session, it was readily apparent that she had spent a great deal of time getting
ready for the session in her selection of clothing, accessories, and grooming. However, Tori also was bare
sleeved and sported a number of very obvious cuts to her arm. When questioned about the cuts, Tori admitted
to cutting herself with a razor when she is distressed. She was very open about the cutting, saying that she had
a big fight with her boyfriend and that often she feels most like cutting when she is emotionally distressed or
depressed. She was interested in learning about ways to curb the tendencies to cut (e.g., worry beads, playing
the guitar). There were no additional cuts in the following two sessions.
During the next session, Tori began to open up a bit more and talked about family matters, focusing on her
sister, Cindy, and the fights that Tori and Cindy had been having. Tori recalled a recent incident where
Cindy embarrassed her at a family gathering, in front of her grandmother and aunt. She asked if the
psychologist would call her parents and explain to them that she was trying, but that Cindy was making it
difficult for her to improve. She complained of problems sleeping, and said she did not feel like eating. She
announced that she had been wearing a heart monitor the past week, and that she is now down to 87 pounds.
Her thoughts seemed to run into each other and made it difficult at times for the psychologist to separate
what was reality from fantasy, or bids for increased attention. The weight was discussed, and Tori was told
that if her eating did not improve, the psychologist would be obligated to transfer her case to someone who
specialized in eating disorders. Tori missed her next appointment, and when this was followed up, her father
reported that Tori was visiting friends for the week in the city.
When Tori arrived at her next appointment, she appeared very nervous. Her hair was blue in color, and she
was now wearing a nose ring and lip ring. When asked why she seemed edgy, Tori said, “It’s been a while,”
and then seemed to settle down a bit. At that point, she revealed several fresh cuts to her arms, wrist, and
ankle that she had done the night before. She admitted to feeling very depressed and said at times that she just
wanted to leave this place and go back to the city. She was especially distraught about her boyfriend, who she
said was a “skinhead.” She said that he could be very mean to her and she didn’t want to see him anymore.
She said that when she cut, she felt nothing; there was no pain. She said she wanted to know if she still could
feel anything. All she felt was emptiness. She also added that she had gained weight and was now 103 pounds.
When asked what she thought about that made her sad, she said that most kids were going back to school
now and that she didn’t want to do that, but she didn’t have any other plans either. When asked if she would
complete some questionnaires to help the psychologist better understand her, Tori agreed.
541
542
Assessment Results
Tori completed the Child Depression Index (CDI-2) and Revised Child Manifest Anxiety Scale (RCMAS-
2). Both scales have a limited number of items and can usually be completed within about 15 to 20 minutes.
However, Tori required almost 45 minutes to answer the questionnaires. She seemed to have significant
problems making up her mind as to which answer was appropriate and seemed to need to read the items
several times before responding. Given her test behavior, it is possible that she is having significant problems
concentrating due to depression or anxiety or that she may have an underlying learning disability that is
interfering with her ability to be a fluid reader. In either case, it was a glimpse concerning why she might have
been experiencing such academic difficulties all these years. Due to time constraints, Tori was given the Youth
Self Report (YSR) to be completed at home and brought back with her to the next session.
Responses to the CDI-2 and RCMAS-2 revealed the following information. Tori’s responses to the CDI-2
placed overall depression at a T score of 87, which is three standard deviations above the norm for her age.
She scored in the clinically significant range in areas of negative mood due to feelings of “ineffectiveness.”
Other areas of difficulty were noted in interpersonal problems, emotional functioning, and negative self-
esteem. Anxiety ratings overall were just below the level of clinical significance, although significant elevations
were found on scales indicating worry/sensitivity and anxiety resulting from social expectations (social
anxiety). Tori also completed the Youth Self Report scale (YSR), and results indicated significant clinical
elevations on several scales, including withdrawn, anxious/depressed, thought problems, delinquent behavior,
internalizing behavior, and the total problem scale.
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Psychologist’s Summary and Impressions
Tori is a 16-year-old high-risk adolescent who presents with numerous symptoms of depression and social
anxiety and significant problems with impulse control and emotion regulation (cutting). Throughout the
sessions, Tori often presented with a confused sense of time and orientation, making it difficult to chart the
course of her history and particular events in her life. Toward the end of the sessions, it was becoming
increasingly apparent that Tori was without a sense of direction at a time when most adolescents are planning
a return to school. Her feelings of depression and sense of ineffectiveness may have a direct bearing on her
sense of being lost and without a future. Given her short-sighted sense of perspective, Tori has ruled out most
of her school options based on social acquaintances who attend the schools and with whom Tori does not get
along. However, it is also important to understand that her only reason for attending school at this point
would be to maintain social contacts, rather than accomplish any educational goals. In our sessions, there has
been a push/pull dynamic based on Tori’s need for increased attention and nurturing and her persistent fears
of abandonment and rejection. There are many gaps in her history that are unaccounted for, and it is
unknown whether there may have been an early history of sexual abuse (childhood friend who was an older
male), although mother did disclose an early history of maternal depression, being emotionally unavailable for
Tori, and a lack of monitoring and supervision were evident in Tori’s early life between the ages of birth and 6
years of age.
In her last counseling session, Tori requested a referral to a female adolescent group home where she had been
placed on a temporary basis a year ago. She recalled a female counselor there who she said made her feel
“safe.” Tori was accepted at the group home and, at last contact, was doing relatively well, saying she wanted
to go back to school and become a counselor for kids in trouble.
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Nonsuicidal self-injury (NSSI) has been described as “deliberate, repetitive self-harming actions like cutting,
burning, poisoning, strangulation, etc.” (Ohmann et al., 2008, p. 226) and has increasingly been identified in
female adolescent psychiatric populations (De Leo & Heller, 2004; Wood, Trainor, Rothwell, Moore, &
Harrington, 2001). Onset of NSSI has often been associated with family or peer problems, disciplinary
problems, crises, or bouts of low self-esteem (Beautrais, Joyce, & Mulder, 1997; Hawton, Cole, O’Grady, &
Osborn, 1982; Ystgaard, Reinholdt, Husby, & Mehlum, 2003). Childhood trauma (Yates, 2004; Ystgaard et
al., 2003), depression (Kumar, Pepe, & Steer, 2004), anxiety (Burgess, Hawton, & Loveday, 1998),
personality disorders (Clery, 2000), eating disorders (Favaro & Santonastaso, 1998), and posttraumatic stress
disorder (Kisiel & Lyons, 2001) have all been found to increase the likelihood of NSSI.
From a neurobiological perspective, self-regulatory behaviors have been associated with the frontal cortex and
the limbic system, including the anterior cingulate, hippocampus, and amygdala (Davidson, Pizzagalli,
Nitschke, & Putnam, 2002). More specifically, the right side of the prefrontal cortex is responsible for
behavioral inhibition (Ohmann et al., 2008). Deficits in executive functions have been related to problems
with behavior and emotion regulation in individuals with a wide variety of emotional and behavioral problems,
including posttraumatic stress disorder (PTSD), borderline personality disorder (BPD), depression, ADHD,
obsessive-compulsive disorder (OCD), and the disruptive behavior disorders (Barkley, Edwards, Laneri,
Fletcher, & Metevia, 2001; Coolidge, Segal, Stewart, & Ellett, 2000). In their samples of adolescent females,
feelings of low self-esteem in the face of inadequate coping strategies were significantly related to deliberate
NSSI (Ohmann et al., 2008; Ystgaard et al., 2003). In their study of almost 100 female adolescent patients
with NSSI, and controls (77 patients), Ohmann and colleagues (2008) found that the patients with NSSI
most often had diagnoses of BPD and PTSD compared to controls, and that child trauma and depression
were most predictive of NSSI. The most common form of NSSI in their sample was cutting. The researchers
suggest that their findings provide support for theories of NSSI as a “learned” behavior independent of
underlying neuropsychological problems. According to this model, “traumatic experiences and parental
pathology predispose to NSSI and depression” (p. 230). In this context, NSSI is initially used as a means to
reduce psychic pain, and then later becomes a learned response, based on the self-rewarding mechanism of
NSSI as a pain reliever.
Studies have found that individuals who demonstrate symptoms of disorders of impulse control, such as BPD
or antisocial personality disorder, share a common predisposition to react to stressful circumstances in a
dysregulated and destructive manner. While vulnerable males tend to develop antisocial personality disorder,
females are more prone to develop BPD and to direct damaging behaviors inwardly in ways that are self-
destructive. Heightened activation of the amygdala and cortical systems (Barr et al., 2003; Hairiri, 2002) can
render individuals with BPD vulnerable to suicide attempts or other self-destructive behaviors during stressful
times (Stanley, Molcho, & Stanley, 2000). Individuals who inherit the short form of the 5HTT (serotonin
transporter allele) are at twice the risk of developing borderline or antisocial symptoms, while those who
inherit two of the short alleles are four times more likely to develop impulse disorders. These odds occurred
545
independent of early rearing conditions or depressed symptoms (Lyons-Ruth et al., 2007).
Crawford, Cohen, Chen, Anglin, and Ehrensaft (2009) studied the impact of extended maternal separations,
prior to age 5, on the potential risk for developing BPD and found that early separations predicted increased
symptoms of BPD from early adolescence to middle adulthood. Although these separations were documented
as “physical,” it is also possible that mothers who are not emotionally available may have a similar impact on
their children, since childhood history of neglect, abuse, and insecure attachment have all been associated with
increased risk for BPD (Zanarini et al., 2002).
There has been a reluctance to diagnose personality disorders in adolescents due to the widely held belief
among mental health practitioners that identity formation is not complete until early adulthood. This belief is
supported by the DSM-5 (APA, 2013), which states that personality disorders may apply to children or
adolescents, but in “these relatively unusual instances,” the characteristics must be “pervasive, persistent and
unlikely to be limited to a particular developmental stage” (APA, 2013, p. 647). Furthermore, the DSM adds
that diagnoses in someone under 18 years of age would require that symptoms be exhibited for at least a year,
with the exception being antisocial personality disorder, which, by definition, requires that the individual be at
least 18 years of age. However, in their chapter concerning bipolar disorder in adolescents, Miller, Neft, and
Golombeck (2008) state that in their clinical experience, “many multi-problem adolescents meet criteria for a
personality disorder but are diagnosed and treated only for Axis I disorders.” Furthermore, the authors
emphasize that “when Axis II criteria are ignored, many adolescents may not receive specific treatment for
their dysfunctional behaviors, or worse, receive inappropriate treatments” (p. 87). As a result of inappropriate
or no treatment, these adolescents could experience more serious outcomes, such as delinquency, social
isolation, suicidal ideation, substance abuse, and academic failure (Kernberg, Weiner, & Bardenstein, 2000).
Although it is possible to diagnose BPD in adolescence, if symptoms are of a long-standing nature (1 year),
the DSM does not provide guidelines as to how symptoms of the disorder may present differently in
adolescents and adults.
In adults, BPD can include symptoms of dissociative or paranoid thoughts, an unstable sense of self, mood
swings that can be extreme and uncontrollable, lack of impulse control, a tendency toward self-harm, and fears
of abandonment that often result in highly turbulent relationships (DSM-5, APA, 2013). Pervasive and high
levels of psychic pain and desperation often accompany suicide attempts or other self-injurious behavior (SIB;
Westen, Shedler, Durrett, Glass, & Martens, 2003). Al-Alem and Omar (2008) suggest that since the DSM
diagnosis of BPD is based on the presence of five out of a possible nine symptoms, the classification leads to a
vast heterogeneity of diagnosis, whether in adolescents or adults that can mimic symptoms of other disorders
(e.g., anxiety disorders, bipolar disorder), which may result in BPD remaining undiagnosed (p. 401).
In their study of “Children in the Community,” Bernstein and colleagues (1993) reported that early adolescent
BPD was predictive of a number of negative outcomes, including grade retention, school dropout, and social
problems. Adolescent females who demonstrated symptoms of BPD reported more break-ups in intimate
relationships, abuse, and stress during the high school years (Daley, Burge, & Hammen, 2000). In their
longitudinal study of adolescents with BPD, Winograd, Cohen, and Chen (2008) found that for individuals
546
who demonstrated higher levels of borderline symptoms in early adolescence, negative outcomes continued
even into their 20s and 30s, suggesting that borderline symptoms during adolescence represent a lifelong
concern, rather than a temporary developmental phase (Bradley, Conklin, & Westen, 2005). Results from
Winograd and colleagues (2008) support earlier findings of Paris (2005) that BPD symptoms in adolescence
are associated with worse prognosis in adulthood, and that the DSM criteria can be used to effectively
diagnose the disorder in adolescence.
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Treatment
Miller and colleagues (2008) outline several challenges that clinicians must face working with adolescents who
have symptoms of BPD, including controversies regarding diagnosis, fears of abandonment, complex
relationship issues at home and at school, and suicidal or self-harm behaviors. The disorder often results in
impaired relationships, resulting in feelings of emptiness and despair, which adversely impact cognitive
functioning and academic performance. Parents and teachers often criticize the teens for “not caring,” which
causes increased emotional dysregulation and continuation of the negative cycle, leading to increased
incidences of self-harm, dysfunction, and emotion dysregulation. According to Miller and colleagues (2008),
treatment problems exist because “teenagers diagnosed with BPD who often have numerous coexisting
problems, including suicidal and self-injurious behaviors, and whose families are also crisis driven, are
particularly difficult to engage and sustain in treatment” (p. 93). Due to the impulsivity inherent in this
population, approximately two thirds of those with BPD will drop out of treatment within a few months
(Linehan, 1993a). Dropouts among adolescent populations range from 33% to 77% (Armbruster & Fallon,
1994; Dierker, Nargiso, Wiseman, & Hoff, 2001).
Another challenge to therapy for adolescents with BPD is that they often come from families where
emotional problems are common. Growing up in an unstable family environment that is low in warmth and
has a history of parental psychopathology, as well as potentially abusive conditions, increases the likelihood of
BPD in adolescents (Bradley, Jenei, & Westen, 2005). In such family constellations, therapists often are faced
with dilemmas involving treating the adolescent, and other family members who themselves are in need of
treatment, as well as addressing invalidating communication styles that often can undermine therapeutic
progress (Miller et al., 2008).
Although the “best” method of treatment is still being investigated, one of the most promising treatments
with adults is dialectical behavioral therapy (DBT). Recently, researchers have found that cognitive analytic
therapy (CAT) can also be effective in reducing psychopathology in adolescents with BPD and serve as an
early intervention program. The following description will review both therapeutic treatments.
Dialectical Behavioral Therapy (DBT).
DBT was developed by Marsha Linehan (1993a) to address the underlying emotional dysregulation that
results in a reduced capacity for individuals to deal with negative emotions, such as anxiety, depression, and
anger. DBT is a cognitive–behavioral therapy that targets affective instability and impulsivity. There are four
stages to the treatment. In the first stage, the therapist strives to address issues of suicidal and self-injurious
behaviors, reduce self-destructive behaviors, and increase coping skills. In the second stage, the therapist
would help the client to experience emotions without shutting down, avoiding, or dissociating from them, and
to work through past issues of trauma or abuse and symptoms of PTSD. In the third stage, the focus is on
self-sustaining and long-term goals, such as increased independence and self-worth, and the development and
monitoring of goals for self-improvement, whether these involve career, education, or interpersonal
relationships. In the fourth and final stage (which was added later by Linehan), individuals with BPD face
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their feelings of “emptiness” and attempt to reconnect with those in their environment. The DBT model
combines psychotherapy and cognitive–behavioral skills training and is focused on acceptance and change.
Linehan’s DBT model was developed to address the underlying dynamics of BPD, which develop in a
childhood environment that chronically invalidates an individual’s feelings and selfhood. As a result,
individuals with BPD seek out proof of or validation for their feelings in other people in their environment
(Skodol et al., 2002). Patients who attend DBT agree to a contract for 1 year of attending weekly group
sessions for 2½ hours and individual sessions for 1 hour. The contract can be renewed if progress is evident
(Al-Alem & Omar, 2008).
In individual sessions, the therapist provides an environment that validates the individual’s attempts at
balancing self-acceptance and developing improved skills for coping with emotional situations. A trusting
relationship between the therapist and individual with BPD is essential to provide assurance that borderline
symptoms will not be punished while at the same time providing guidance regarding the harmful effects of
self-destructive behaviors, such as drug abuse, promiscuity, or other behaviors (Linehan, 1993a). Behavioral
groups provide an opportunity to develop and practice behavioral skills in a safe environment.
Miller and colleagues (2008) suggest that for adolescents with BPD, enlisting the family in treatment is
important in improving compliance and effectiveness of the treatment. In this case, family therapy sessions
will serve to mobilize support for all family members and provide an opportunity to increase the “range of
behavioral skills, and solve family problems,” while at the same time providing the adolescent with the
necessary skills and training (p. 93). Miller, Rathus, and Linehan (2007) have outlined the areas of
dysfunction in BPD that correspond to BPD symptoms (DSM-5; APA, 2013) that have been realigned to
correspond to skill modules in the DBT program:
Problem Areas Skills Modules
1. Self-dysregulation Core mindfulness skills
2. Interpersonal dysregulation Interpersonal effectiveness skills
3. Behavioral and cognitive dysregulation Distress tolerance skills
4. Emotional dysregulation Emotion-regulation skills
5. Adolescent–family dilemmas Walking the middle path
While the first four skill sets are parts of the original program (Linehan, 1993b), the fifth module, “walking
the middle path,” addresses the lack of balance between thoughts and behaviors within the family
environment. According to Miller and colleagues (2007), families and adolescents with BPD need to achieve a
balance and stop vacillating between polarized responses in three important areas:
1. parenting practices that go from leniency to authoritarian control,
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2. conceptualizing normal behaviors as pathological and pathological behaviors as normal, and
3. fostering dependency versus independence and autonomy. (p. 94)
Early Intervention.
Chanen and colleagues (2008) investigated the potential success of early intervention for BPD using cognitive
analytic therapy (CAT) versus individuals with BPD who were provided with good clinical care (GCC). This
was a randomized controlled study of 86 adolescent patients, 78 of which were available for follow-up data
collection. Study inclusion required evidence of at least two symptoms of BPD and one other comorbid
disorder. CAT is described as a “time-limited, integrative psychotherapy.” It combines “elements of
psychoanalytic object relations theory and cognitive psychology” (Chanen et al., 2008, p. 479). The program,
which was developed by Ryle and Kerr (2002), has been used increasingly in Europe to treat BPD (Ryle,
1997, 2004). Results revealed that early intervention individuals in both groups showed significant positive
outcomes, although CAT achieved clinical goals more rapidly than GCC. The researchers state that the study
is the first published randomized controlled study to demonstrate that early intervention for BPD can be a
successful endeavor without incurring risks of possible iatrogenic effects of early diagnosis and treatment.
550
Post-Case Questions
1. If Tori refused to meet with the psychologist, what recourse would her parents have, given her age?
2. The diagnosis of borderline personality disorder (BPD) in adolescents is controversial. What are some of the arguments for and
against diagnosis of BPD in adolescents?
3. Does Tori meet the DSM-5 (APA, 2013) criteria for BPD? If so, how? If not, why not? What suggestions do you have for how
symptom criteria might be altered for individuals in adolescence, or should they be altered?
4. Individuals with BPD often have other comorbid disorders. Does Tori meet criteria for any of the other DSM-5 diagnoses? If so,
which diagnoses are possible?
5. Based on your knowledge of BPD, what family characteristics are evident that may have increased her risk for developing BPD?
6. Discuss Tori’s symptoms from the following theoretical perspectives: biological, psychodynamic, cognitive–behavioral, and
attachment/parenting.
7. There are many gaps in her history that are unaccounted for, and one such assumption in her case is the potential that she was
sexually abused at an early age by a boy in the neighborhood. Discuss the potential relevance of adverse child experience’s (ACE’s)
on Tori’s symptoms and her risks for negative outcomes. What are the contributing risk and protective factors if Tori has been
exposed to ACE? (See Introduction to Chapter 1 for a discussion of ACE).
551
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Chapter 7 Introduction to Traumatic and Stress-Related
Disorders
The DSM-5 introduced a new chapter on trauma- and stressor-related disorders that clusters together a
number of disorders that were previously housed in several different chapters. All disorders in this chapter
have a traumatic or stressful event as the precipitating cause. Although the DSM recognizes that responses to
traumatic and stressful events can be widely variable and can include anxiety and fear, it emphasizes that
responses can also include symptoms of depression, aggression, anger, externalizing behaviors, and dissociative
characteristics. There are a number of disorders discussed in this chapter, including reactive attachment
disorder, disinhibited social engagement disorder, acute and posttraumatic stress disorders (PTSD), and the
adjustment disorders.
Reactive Attachment Disorder: In the DSM-IV-TR (APA, 2000), there was one attachment disorder, reactive
attachment disorder (RAD), which could be manifested in one of two subtypes: the inhibited type or the
disinhibited type. Currently, the DSM-5 (APA, 2013) considers the two variations to represent two different
disorders. Children who develop RAD have been exposed to extreme lack of caregiving, involving at least one
of the following conditions (Criterion C):
Social neglect or deprivation

Recurrent changes in primary caregivers
Being reared in severely limited settings (p. 268)
Children who are exposed to social neglect are deprived of their basic needs of emotional comfort,
stimulation, and affection that should be provided by caregivers. They may have a multitude of primary
caregivers, which does not allow for the formation of attachment or emotional bonding with the caregiver.
Some infants raised in institutions may not have had the benefit of opportunities to form attachments with
specific caregivers, especially if the ratio of caregivers to infants is too high.
As a result of their emotional and social deprivation and lack of secure attachment formation, (Criterion C),
infants may meet criteria for RAD if they exhibit a pattern of inhibited and socially withdrawn behaviors,
evident in the children rarely seeking or responding to comfort when distressed (Criterion A), and displaying
social and emotional disturbance, evident in two of the following: minimal social/emotional responsiveness to
others; limited positive affect; and irritable, sad, and fearful moods without apparent cause (Criterion B, p.
265). Children who display these characteristics between the ages of 9 months and 5 years meet the criteria,
unless they have been diagnosed with autism spectrum disorder. The disorder is considered to be persistent if it
has been enduring for at least 12 months and severe if the child meets all of the criteria. Children who are
diagnosed with reactive attachment disorder often exhibit significant developmental delays due to the lack of
stimulation.
Disinhibited Social Engagement Disorder.
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Children diagnosed with disinhibited social engagement disorder (DSED) are exposed to conditions lacking
in sufficient care (meeting the same conditions as outlined in Criterion C, above, for RAD); however, instead
of responding with social withdrawal, these children respond with indiscriminate and inappropriate attempts
to engage unfamiliar adults. Children with DSED display at least two of the following characteristics from
Criterion A: (1) lack of reticence; (2) engage in overly familiar verbal or physical exchanges; (3) do not check
back with a caregiver after leaving, even in unfamiliar areas; or (4) have minimal or no hesitation leaving with
an unfamiliar adult. In making a diagnosis of DSED, it is important to rule out that impulsivity is not
associated with attention-deficit/hyperactivity disorder (ADHD). Conditions regarding the age of onset (9
months to 5 years), duration (12 months), and application of specifiers (persistent and severe) are the same as
for RAD, above.
Posttraumatic Stress Disorder.
New to the DSM-5 are criteria for posttraumatic stress disorder (PTSD) that differ according to age of the
individual who has experienced the traumatic event. There are now two sets of criteria: one set of criteria
apply to adults, adolescents, and children over 6 years of age (which will be referred to here as standard
criteria), and a second set of criteria for children under 6 years (which will be designated here as criteria for
preschool children). The standard criteria have changed from the previous edition of the DSM, in that the
traumatic event no longer must instill a sense of horror and helplessness; however, the symptoms must still
endure for more than a month. Criterion A requires that individuals must be exposed to a traumatic event
involving actual or threatened death or serious injury, or sexual violence that is characterized by one of the
following: (1) direct experiencing of the event; (2) witnessing the event occurring to others; (3) learning of a
traumatic event involving a close family member or friend; (4) or having repeated exposure or extreme
exposure to the details of a traumatic event, other than through electronic media exposure (e.g., first
responders). There are four categories of symptoms that can result from exposure to a traumatic event, which
are labeled as criteria B through E.
Criterion B refers to symptoms of intrusion and one symptom is required from a list of possible symptoms,
including recurrent distressing memories (repetitive play in children), recurrent distressing dreams
(frightening dreams in children), flashbacks (trauma reenactment play in children), or exposure to cues of the
trauma causing intense psychological distress.
Criterion C refers to symptoms of avoidance, which may manifest in avoidance of internal thoughts, memories
feelings, or avoidance of external reminders. Criterion D describes negative mood states and two symptoms
are required, including inability to recall important trauma-related information, negative beliefs, distorted
perceptions/self-blame, persistent negative emotional state (feelings of helplessness, horror), diminished
interest in activities, feelings of detachment, and inability to experience positive emotions (p. 272). Two or
more characteristics from Criterion E are required, which describe increased arousal and reactivity, such as
irritability and possible aggression without provocation, recklessness or self-destructiveness, hypervigilance,
exaggerated startle response, concentration problems, or sleep disturbance (p. 272).
In children 6 years of age and younger, the criteria for PTSD have been modified so that the symptoms are
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more appropriate, developmentally. There are four criteria for PTDS in preschool children (Criteria A
through D), with additional qualifiers noted for duration (more than 1 month), intensity (causing significant
distress or impairment), and ruling out medically induced responses. The criteria surrounding the nature of
the event (exposure to actual or threatened death, serious injury, or sexual violence) and manner of experience
of the trauma (directly, witnessing or learning about the traumatic event) are the same as in the standard
version with the exception that the criteria of repeated exposure to aversive details (relating to first responders)
is removed. Criterion B in the preschool version requires one or more symptoms of intrusion from Criterion B
in the standard PTSD criteria, listed above. Criterion C is a combination of Criterion C and D from the
standard PTSD criteria and requires one or more symptoms of persistent avoidance or negative cognitions
regarding the traumatic event. Persistent avoidance may be manifest in symptoms of avoidance of activities or
places or avoidance of people or conversations of the traumatic event. Examples of negative alterations in
cognitions include increases in negative emotions, such as fear, guilt, sadness; diminished interest in activities;
social withdrawal; or reduction of positive emotions. Arousal and reactivity (Criteria D) require at least two
symptoms and are evident in irritable/angry outbursts, hypervigilance, exaggerated startle response,
concentration problems, or sleep disturbances. If the onset is delayed by 6 months, the specifier “with delayed
expression” can be applied (APA, 2013, p. 273).
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References
VA: Author.
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Case 23 Juan Hernendez The Crash Posttraumatic Stress
Disorder; Survivor Guilt
Juan is a Hispanic adolescent who recently turned 16 years of age. Juan had returned to school a month ago
after a fatal car crash. Juan had been off school for a week due to minor physical injuries sustained in the
accident; however, he asked to be discharged early from the hospital to attend the funeral of his best friend,
Rico. He agreed to see the school psychologist at the urging of the school guidance counselor. The counselor
had been approached by several of Juan’s teachers, who were concerned about his slipping grades and
uncharacteristic flat demeanor.
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Background Information: An Interview With the School Psychologist
When the school psychologist met Juan for the first time, she was impressed with his manners and soft-
spoken demeanor. Often, when she met adolescent males for the first time, their discomfort in seeing the
“school psychologist” was evident in a defensive and guarded façade that required considerable effort to break
through. But Juan was different; he seemed “approachable.” The following is a sample summary of some of
the most important excerpts from two interviews that occurred over the following 2 weeks (one session per
week):
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Session One
Psychologist: Juan, it is very nice to meet you, and I want to thank you for agreeing to see me.
Juan: Yes, Ma’am.
Psychologist: Juan, please have a seat. It is always important for me to know why you think you have been asked
to see me. I want to know what you have been told about this meeting and what you believe it’s all about.
Juan: Well, Ma’am, I think my teachers are concerned because I am not doing so well in classes and I think
that they think that I have problems learning. You know, like special ed. kids need help. Well, because they’re
not as smart or maybe something like that.
Psychologist: Okay. You are having problems keeping up with your work and your grades are slipping. Is that
correct?
Juan: Well, I guess. Yes, sort of. Yes.
Psychologist: And you think that your grades are not good because you might not be so smart?
Juan: Well, yes . . . no. I mean, I don’t know. Like why would I be having no problems in school before and
now I’m having problems. I mean I don’t get it. I’m confused. I feel bad, because my teachers are good but I
don’t know why it’s not working. I just can’t concentrate. I sit in class and “space out.” I don’t know what has
happened when I tune back in. I don’t know what is going on.
Psychologist: Okay. Let’s just go back a bit and try to think of when your problems concentrating started.
Juan: I don’t know . . . I’m confused. Since, well since I came back, it’s like different.
Psychologist: Back from what . . . like back from the accident?
Juan: Yeah . . . I guess, sort of. Yeah, from then.
Psychologist: Juan, when did the accident happen?
Juan: At night.
Psychologist: How long ago was the accident?
Juan: I’m not sure, like maybe 6 weeks.
Psychologist: Do you want to tell me about it?
Juan: Can we talk about something else? I don’t want to talk about it right now.
Psychologist: Sure, what would you like to talk about?
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Juan: I don’t know.
Psychologist: Let’s talk about the courses you are taking now, and which ones are causing you the most
problems. Is that okay?
Juan: Sure. Social studies. I was doing well in that class because the teacher is really cool and the stuff is pretty
interesting. But when I was away, they talked about important stuff that she keeps referring to and I have no
idea what she is talking about. And the textbook is hard to read. I mean, I start reading a page and by the time
I get to the end of the page, I don’t know what I read. It’s like the words don’t mean anything.
Psychologist: Sounds like you are having problems concentrating on what you are reading.
Juan: Yes, I guess so. I guess my mind is somewhere else. It’s not on the book.
Psychologist: Okay, I have a few suggestions. First of all, I suggest you talk to the social studies teacher and ask
if you can meet with her so that she can fill you in on what you missed while you were away. That way, when
she refers to stuff that you weren’t there for, you will have a better chance of understanding what she is talking
about. Does that sound right to you?
Juan: Yes, that sounds like a good idea. I will do that today.
Psychologist: When you are reading the text, after you read one paragraph, stop and ask yourself what you just
read. Does you textbook have questions on the sidebars, or headings for each section?
Juan: There are no questions, but there are headings.
Psychologist: Okay. When you go to read a section, turn the heading into a question. Do you have your social
studies book with you? Great. See here where the heading says, “The Lewis and Clark Expedition.” Change
that heading into a question before you read the paragraph. For example, using the heading, ask yourself,
“Why is the Lewis and Clark Expedition important?” Then read the paragraph to find the answer. That way
you will be thinking about the question while you read and it will help you concentrate better, looking for the
answer. Does that make sense?
Juan: Yes, great. That is very helpful.
Psychologist: Okay. One more thing I would like you to do for me today. I have some questionnaires that I
would like you to fill out. They are not hard. The questionnaires are about your thoughts and feelings about a
number of different things, and they will help me understand how I can be most helpful to you.
Juan: Sure, no problem.
Psychologist: Great. Would you like to meet with me again next week?
Juan: Okay. Yes, that’s fine.
Psychologist: All right, then, is this time still good for you?
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Juan: Yes, I have a spare period, so I won’t be missing class.
Psychologist: Okay. Let’s meet here again next week and we can go over your responses to the questionnaires.
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Session Two
Psychologist: Hello, Juan. How did your week go?
Juan: All right, I guess.
Psychologist: Were you able to meet with your social studies teacher? And how did that go?
Juan: Yes, she was very good about it and filled me in on what I missed and explained why it is important to
what we are studying now. So it helped out.
Psychologist: Did you try my suggestion for reading the text, by turning headings into questions?
Juan: I did and it worked a bit, but I am still having problems reading parts where there are no headings,
because I forget what the question was.
Psychologist: Are you having problems concentrating in classes, as well?
Juan: Yes. My mind just keeps wandering and then I go blank and I don’t know what has gone on or where I
have been. Sometimes it’s a little scary. It’s like I am losing whole blocks of time.
Psychologist: Okay, Juan, let’s talk about the questionnaires you filled out for me. I am going to explain the
results by showing you this graph. See, here is where most people’s scores would fall, if they were not
experiencing difficulties. See, at this level, you have scores for things like being aggressive or breaking rules.
Which shows that you don’t have any problems with controlling your anger, or obeying rules, because you
scored in the average range in those areas. As the scores increase, it means that you answered more questions
in that area, suggesting that you are experiencing more problems. Okay, let’s look at how you answered
questions about depression. There were a number of questions about depression on a number of the different
questionnaires you filled out. And all the depression scales were high. According to what you have answered,
it seems like you have a lot of feelings of sadness, not liking yourself, feeling guilty, and feeling bad like things
are always happening to you. You say that you have thought about killing yourself, but you would not do it. Is
that how you really feel?
Juan: Yeah, it’s pretty bad. I wouldn’t kill myself because that would be very bad for my parents and I wouldn’t
do that to them. This was bad enough.
Psychologist: You also say that you don’t have any friends. I thought you were part of a group?
Juan: That was before the accident; now they all blame me. No one talks to me anymore and they all say it was
me who killed Rico. I walk in a room and they all stop talking and just stare at me. It’s like I am not even
there. Like a ghost. You know, a couple of nights ago, I had this dream and Rico was in it and he was in my
house drinking milk out of the milk carton in the fridge. He would always do that and it would make my
mom so mad, but this time we were all laughing about it. He looks so real it was like he was still alive. I miss
him so much; we were like brothers; we went everywhere together. I spent more time at his house than I did
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at my own. And now his family won’t speak to me either, because they say I killed their son. My parents and
Rico’s parents used to be good friends and now no one is talking to no one. I can hear the crash in my head. I
can see Rico’s face just before the truck hit us. I tried to swerve but the road was wet and we skidded right into
the truck. I turned the wheel. That’s why Rico is dead. If I didn’t turn the wheel, he would be alive. It should
have been me who was killed.
Psychologist: Juan, it was not your fault; it was an accident.
Juan: Yeah, tell that to the police. The police are still going over the evidence, but they say I was speeding,
which caused the car to go out of control. I still might get arrested for manslaughter and maybe have to go to
jail.
Psychologist: Juan, do you have a lawyer?
Juan: I don’t know; my dad was going to see what he can do. We don’t have much money.
Psychologist: Juan, would you like me to speak to the school social worker for you? She does a lot of work with
the Juvenile Detention Center. Maybe she could find out some information for you.
Juan: Yes, that would be great because it’s like I have no future. I can’t plan for a future because I don’t know
if I will be here or in jail.
Psychologist: I will contact her as soon as we are done today. Were you hurt in the accident?
Juan: I just had a cracked rib. I left the hospital early because I wanted to go to the funeral. It was so horrible;
they were all crying. He was so dead, and I was not. And I didn’t even look like I was hurt.
Psychologist: Tell me what you do when you go home from school. Do you have problems sleeping? Are you
involved in any activities?
Juan: No, I don’t sleep well. I feel tired but I’m all edgy too, and so if I fall asleep, I wake up a lot. I don’t
know what I do. I go home and turn on the TV, but I don’t even know what I am watching half the time. I
don’t go out with friends because they just remind me of Rico and so I just stay here. Sometimes I feel like a
zombie, you know, like I am going through the motions but nobody is home. It’s like nothing is real, it is all a
dream. Like I am going away in my mind, but I am still here. It doesn’t make sense to me. It’s like my mind
has gone blank.
Psychologist: Juan, what you are describing are a lot of symptoms of posttraumatic stress disorder (PTSD) and
a dissociative state that sometimes accompanies it. That is the sense of feeling that things are “surreal,” or a
kind of emotional numbing that often takes place. I am going to recommend a number of things for you,
including a visit to your family physician to discuss your problems sleeping. With your permission and that of
your parents, I would also like to write a report summarizing our talks and the results of your responses to the
questionnaires and send a copy to your physician to see if he can arrange a referral for you to get counseling
for issues related to grief and PTSD, since we are going into summer break and my services will not be
566
available over the summer. How do you feel about that?
Juan: Yes, that would be good.
Psychologist: And I will get in touch with the social worker now and ask her to find out what the status is of
the police report on the accident, and if she can meet with us next week, if she is available. How does that
sound?
Juan: Thank you; that would be very good.
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Assessment Results
Information regarding specific assessment instruments and guidelines for the interpretation of T scores are
available in Appendix C.
Juan responded to several rating scales provided by the school psychologist, including Youth Self Report
(YSR), the Child Depression Inventory (CDI-2), the Revised Children’s Manifest Anxiety Scale (RCMAS-
2), and the Trauma Symptom Checklist for Children (TSCC-A). Responses indicated significant elevation
on scales for depression on the CDI, including Overall Depression (T = 80), Negative Mood (T = 78),
Ineffectiveness (T = 80), Anhedonia (T = 72), and Negative Self-Esteem (T = 70). On RCMAS-2, Juan had
significant elevations on the scales for Physiological Anxiety (T = 85) and Worry (T = 70). Scores on the YSR
were clinically significant for anxious/depressed (T= 74), withdrawn/depressed (T = 72), thought problems (T
= 68), and attention problems (T = 68). In addition to elevated scores for anxiety and depression on the
TSCC-A, Juan also revealed clinically significant ratings for posttraumatic stress (PTS) and dissociation
(DIS). On the PTS scale, Juan endorsed such items as having “bad dreams or nightmares” and “remembering
scary things,” whereas on the DIS scale, he responded that he experienced “feeling like I am not in my body,”
“feeling dizzy,” “feeling like things aren’t real,” “going away in my mind,” “forgetting things,” “my mind going
blank,” and “daydreaming,” all occurring on a frequent basis.
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PTSD was initially introduced as a formal diagnosis in the DSM-III (APA, 1980). In the following revision
(DSM-III-R; APA, 1987), the diagnosis of PTSD was extended to apply to children and youth. There is
controversy in the field regarding how the disorder should be diagnosed in children and youth, since the DSM
has largely adhered to adult criteria. The DSM-III-R included only two minor alterations to account for child
patterns: adding “repetitive play” as a possible cluster-B criterion of reexperiencing, and “loss of acquired
developmental skills” as a symptom under cluster-C avoidance and numbing. Since that time, “loss of acquired
developmental skills” has been removed as a criterion, and the DSM-IV added one additional child criterion
for cluster A, suggesting that responses to the trauma of intense fear, horror, and helplessness that occurs in
adults may appear as “disorganized or agitated behavior” in children and youth, and added two criteria to
cluster B (re-experiencing) to include “frightening dreams” and “trauma-specific reenactment” in children.
The current version, the DSM-5 (APA, 2013), has expanded the criteria to include a special set of criteria for
the diagnosis of PTSD in children under 6 years of age and has added an additional symptom cluster,
Criterion D, to denote negative mood states (negative cognitive alterations, such as negative beliefs, distorted
perceptions about the trauma, memory loss, and detachment). Currently in addition to meeting criteria for the
traumatic event (one of four possible conditions), a diagnosis of PTSD requires six symptoms: one from
Criterion B (intrusive) and C (avoidance), and two from Criterion D (negative cognitions and mood); and
Criterion E (increased arousal/reactivity). In addition to meeting criteria for a traumatic event, the preschool
criteria require four symptoms: one from Criterion B (intrusive) and C (avoidance or negative
cognitions/mood) and two from Criterion D (increased arousal/reactivity). All diagnoses of PTSD require
that symptoms must be evident in excess of 1 month; however, if the criteria are not met within 7 months of
the event, a specifier of “with delayed expression” may be added.
The DSM-5 modification of symptoms from six to four for preschool children (in addition to the experience
of a traumatic event) is a response to controversy regarding the previous criteria, which many clinicians felt
was excessive, especially since many of the symptoms required verbal descriptions, which were beyond a very
young child’s capacity. Scheeringa, Zeanah, Drell, and Larrieu (1995) suggested inclusion of symptoms for
preschool children including new aggression, new separation anxiety, fear of toilet training alone, fear of the
dark, and any new fears of events or things not directly related to the trauma. The new criteria of “negative
alterations in cognitions” do provide the opportunity to include such negative responses (fear, guilt, sadness).
It was the suggestion of Scheeringa and colleagues (1995) that only four symptoms would be required, in
addition to trauma, for preschool children, which has been adopted by the current DSM-5. Perrin, Smith, and
Yule, 2004 suggested that the International Classification of Diseases (ICD-10; World Health Organization
[WHO], 1992) might provide a better clinical description of PTSD for children and youth with its emphasis
on characteristic symptoms of “repetitive and intrusive memories” and “conspicuous emotional detachment,
numbing of feeling, and avoidance of stimuli that might arouse recollections of the trauma are often present
but are not essential for the diagnosis” (WHO, 1992, p. 148). The DSM-5 includes these intrusive symptoms
(Criterion B) as part of the criteria for preschool children as well as the standard PTSD criteria for adults.
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There has been debate about whether unique criteria should be established for children and youth to reflect
developmental differences in how reactions to traumatic events or posttraumatic stress symptoms (PSS) may
be perceived, interpreted, recalled, and expressed (Scheeringa, Zeanah, Myers, & Putman, 2003). Although a
number of PSS might be generic across the life span, such as general reactions to distress, nightmares, and
fears (Silverman & La Greca, 2002), there are PSS that have been found to be more typical for children and
youth, such as repetitive trauma play, dreams of monsters or rescue, regressive behavior, separation anxiety,
somatic problems (headaches and stomachaches), and declines in academic performance (American Academy
of Child and Adolescent Psychiatry [AACAP], 2010; Drake, Bush, & van Gorp, 2001). In addition,
following Terr’s (1991) model, there is still debate on how to assess the relative exposure to trauma in children
who have been exposed to a single traumatic event (Type I), versus exposure to a series of traumatic events or
a stressor that is ongoing over a long period of time (Type II). In addition, little is known about how PTSD
might be expressed by youth from different ethnic backgrounds, since different cultures have different ways of
responding to emotionally charged events and expressing emotions (Cooley & Boyce, 2004). Although there
have been increasing attempts to develop measures for assessing PTSD and PSS in children and youth, there
is less consensus on how these measures either increase our understanding of the disorder in children or how
they can inform treatment (Lonigan, Phillips, & Richey, 2003). Although most evaluations of children
involve a test battery composed of a variety of assessments and involving multiple informants, in cases of
PTSD there is evidence of low agreement between parent and child reports of PSS (Jensen et al., 1999), and
that child self-reports may actually be more accurate (Korol, Green, & Gleser, 1999) and provide more
reliable information regarding their emotional and physiological arousal levels (internal states) than other
informants who rely on their observations of the child (Vogel & Vernberg, 1993). Hawkins and Radcliffe
(2006) reviewed 65 articles to identify current methods of identifying PTSD and PSS in children and youth.
They reported finding seven measures, including clinician-administered interviews and self-report
questionnaires, which they were able to further categorize into eight trauma domains. However, Hawkins and
Radcliffe (2006) found little consensus regarding the measures used within each trauma domain.
Estimates of prevalence rates vary due to the wide variety of different measures used to evaluate the nature of
youth reactions to possible traumatic stressors and depending on whether populations sampled are clinical or
community samples. Studies have established that youth can develop PTSD symptoms to a wide variety of
traumatic stressors (Brown, Madan-Swain, & Lambert, 2003), with severity of symptoms related to the
intensity of exposure (Cooley-Quille, Boyd, Frantz, & Walsh, 2001); physical proximity to the event (Pynoos,
1994); or vicarious exposure (Horowitz, Weine, & Jekel, 1995), such as observing traumatic events on
television (Huesmann, Moise-Titus, & Podolski, 2003) or living in a war zone (Laor, Wolmer, & Cohen,
2001). In addition to location and type, the number of exposures can also influence the severity of PTSD
(Allwood, Bell-Dolan, & Husain, 2002). Elklit (2002) reports a lifetime prevalence of PTSD in nonclinical
samples of youth to be between 5% and 10%, with girls reporting more episodes of traumatic events than
boys, and with between 25% and 87% of all youth reporting exposure to at least one traumatic event prior to
20 years of age.
Posttraumatic stress disorder (PTSD) can occur with mild to severe symptoms of dissociation. In their study
of children with PTSD due to sexual abuse, Kaplow, Hall, Koenen, Dodge, and Amaya-Jackson (2008) found
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that children who were sexually abused earlier in life had higher levels of PTSD symptoms when the abuse
was disclosed. However, they also found that symptoms of dissociation were predictive of later attention
problems in this population. It is possible that the strong links between attention problems and PTSD that
have been found in adults (e.g., Bremner, Krystal, Southwick, & Charney, 1995) and children (Merry &
Andrews, 1994; Saigh, Mroueh, & Bremner, 1997) may be mediated by dissociative symptoms. Dissociation
has been found to interfere directly with children’s perception of their environment and their integration and
processing of incoming information, resulting in problems with attention and concentration (Putnam, 1997).
The main center for connectivity between the two hemispheres of the brain is located in the corpus callosum,
which is responsible for facilitating and integrating information between the two hemispheres (Ramaekers &
Njiokiktjien, 1991). Individuals who experience dissociative symptoms reveal lower levels of “connectivity” in
the corpus callosum (De Bellis, 2001), which may result in fragmented information processing and increased
attention problems. As a result of their findings, Kaplow and colleagues (2008) suggest that as far as PTSD
and attention problems are concerned, it may be the accompanying dissociative symptoms, which are so often
comorbid with PTSD, that actually are responsible for this relationship. The DSM-5 now includes a specifier
for acknowledging the presence of dissociative symptoms in all individuals diagnosed with PTSD. Those who
present “with dissociative symptoms” can be further classified as demonstrating recurrent symptoms of (1)
depersonalization (detachment and sense of being an outside observer); or (2) derealization (experiences seem
unreal, dreamlike, or distorted).
Studies have found that increased levels of distress post trauma are associated with increased severity of later
PTSD (Di Gallo, Barton, & Parry-Jones, 1997). Increased risk for more severe PTSD has also been
associated with symptoms of mental confusion, negative self-appraisal of symptoms, avoidance, and
dissociation (Ehlers, Mayou, & Bryant, 2003). Having a parent who has a tendency toward avoidant behaviors
has been associated with increased PTSD reactions in children involved in motor vehicle accidents (Ehlers et
al., 2001).
Developmentally, PTSD symptoms may result in a restricted sense of involvement such as reluctance to
engage in new activities or exploratory play in young children or withdrawal from normal adolescent activities
such as dating, driving, or planning for the future. While some adolescents may develop feelings of
detachment from their social circle, others may engage in high-risk and reckless behaviors. Children and
adolescents might appear irritable, on edge, or aggressive (APA, 2013).
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The cognitive–behavioral explanation of PTSD considers that the thoughts and behaviors that result from
exposure to the traumatic event are normal responses to catastrophic and life-threatening circumstances;
however, the persistence of these responses after the fact and their generalization to nonthreatening events
become maladaptive. Theoretically, within the context of a classical conditioning paradigm, the unconditional
responses to the trauma (unconditional stimuli), such as increased autonomic arousal (fight-or-flight
responses), startle response, fear, and numbing, begin to be elicited by previously neutral stimuli in the
environment that have been conditioned by association to the traumatic event. As a result, numerous stimuli
in the environment now can act as triggers to memories and feelings associated with the trauma
(reexperiencing and increased arousal). Attempts to avoid exposure to the conditioned stimuli result in
avoidance and escape responses, which become negatively reinforced because they remove the individual from
the stressor (numbing and avoidance).
Empirical support for the effectiveness of cognitive–behavioral therapy (CBT) with adults has been well
documented (Olasov-Rothbaum, Meadows, Resick, & Foy, 2000). Studies of CBT with sexually abused
children have found group CBT to be superior to traditional group therapy (Deblinger, Steer, & Lippman,
1999) while Cohen and Mannarino (1997) found that CBT was superior to nondirective therapy.
Goenjian and colleagues (1997) found treatment with CBT to be superior to no treatment for children
exposed to an earthquake in Armenia, while March, Amaya-Jackson, Murray, and Schulte (1998) found an
18-week group-administered CBT program to be effective for the majority of children and youth treated for a
single-incident trauma. Feeny, Foa, Treadwell, and March (2004) conducted a meta-analysis concerning
treatment programs for children and youth with PTSD and PSS and found a number of programs that
employed cognitive–behavioral methods (CBT) using a variety of different techniques, including exposure
treatments, eye-movement desensitization and reprocessing (EMDR), anxiety-management training (AMT),
and group treatments.
The American Academy of Child and Adolescent Psychiatry (AACAP; 2010) has reviewed best practices for
the treatment of PTSD in children with comprehensive plans involving consultation and collaboration with
primary care physicians, school personnel, and families. Trauma-focused treatment has proven to be superior
to more nondirective approaches because a fundamental issue in treatment is addressing attempts to avoid
talking about the trauma (Cohen, Deblinger, Mannarino, & Steer, 2004). In its review of treatment options
for PTSD in children, the AACAP (2010) recommends the use of trauma-focused cognitive–behavioral
treatment (TF-CBT) and psychodynamic trauma-focused therapy. Cohen, Mannarino, and Deblinger (2009)
outline a number of responses that children can experience resulting from exposure to a traumatic event,
including “dysregulation in affective, behavioral, cognitive and physiological” functioning. Some may develop
“depressive, anxiety or behavioral or physical disorders . . . still others may have changed cognitions about
themselves or others and the world (e.g., shame, self-blame, poor self-esteem, diminished sense of safety or
trust)” (p. 295). Cohen and colleagues (2009) suggest that their program of TF-CBT targets children who
suffer from specific PTSD-type symptoms (avoidance, shame, sadness, fear), rather than those who have
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externalizing behaviors from previous abusive situations, who are more likely to benefit from an evidence-
based treatment (EBT) more specific to their problem, such as parent management training for conduct
problems. The TF-CBT program is described as a “hybrid model” that incorporates elements of CBT,
attachment, family, humanistic, and psychodynamic approaches. The program is based on 8 components
summarized by the acronym PRACTICE:
Psychoeducation
Parenting skills
Relaxation skills
Affective expression and modulation skills
Cognitive coping skills
Trauma narration and cognitive processing of traumatic experiences
In vivo mastery of trauma reminders
Conjoint child-parent sessions
Enhancing safety and future developmental trajectory. (Cohen et al., 2009, p. 298)
The program is offered in eight to 20 sessions (depending on the severity) that run parallel for parents and
child, along with conjoint sessions that include the parent and child. Each of the components focuses on key
skill sets, and the program can be adapted to meet the needs of children from ages 3 to 18. The skills usually
unfold in the PRACTICE sequence, with the initial components (PRAC) focusing on skill acquisition, and
the latter components (TICE) targeting more trauma-specific elements. The program has been researched
extensively in a number of randomized controlled trials. The program has been shown to be effective in
reducing symptoms of PTSD and more effective than child-centered therapy (CCT), especially for children
with multiple-trauma history and elevated symptoms of depression (Cohen at al., 2009).
Exposure Treatments.
Applying exposure treatment programs to fears that accompany PTSD can be a very successful method of
alleviating fears and anxiety in adults (Olasov-Rothbaum et al., 2000). Perrin and colleagues (2004) describe
several methods for adapting exposure techniques for children and youth. Each of the programs evolves
around a three-step program of systematic desensitization. The following example will illustrate how systematic
desensitization could be used to treat a fear of dogs, after a child was bitten on the hand by the neighbor’s pet:
1. The creation of a fear hierarchy (rating the level of anxiety associated with the fear, in this case the dog)
and training in the use of the SUDS scale (subjective units of distress), which involves levels of anxiety or
distress (from calm to very nervous and scared, e.g., scale of 1 to 10)
2. Training in relaxation techniques
3. Pairing of relaxation with fear response at each step in the fear hierarchy
Applying systematic desensitization to a fear of dogs would involve establishing a fear hierarchy. With the
help of the SUDs scale, the therapist and child construct a fear hierarchy involving a number of steps. For
example, if seven steps are selected, and the therapist and child identify “petting a dog” as the SUD that causes
573
an absolute 10 on a scale of 1 to 10, then the therapist will place “petting a dog” as the highest step in the
hierarchy and work down from there. Based on a number of dog-related items reviewed with the child, the
therapist comes up with the following fear hierarchy:
1. Story about a dog

2. Stuffed toy dog
3. Picture of a dog
4. Film of a dog
5. Proximity to dog in a cage
6. Proximity to dog in the room
7. Petting the dog
As the therapist proceeds through each level on the hierarchy, the child is asked to describe the SUDs level
and apply the relaxation techniques until the SUD is close to zero. At that point, the therapist can go to the
next step, repeating the process until eventually the child reaches the final level and is no longer fearful or
anxious about petting a dog.
The procedure as outlined can occur in two different ways: imaginal exposure or in vivo exposure.
Imaginal procedures are those that are indirect, with the child imagining the situation without actually going
through it in real life. In vivo exposure would be going through each step as it actually occurs in real life.
Although some situations lend themselves better to imaginal procedures, in vivo exposure techniques are more
effective.
Eye-Movement Desensitization and Reprocessing (EMDR).
Because this technique is similar to flooding and exposure techniques, it can also be grouped under CBT types
of interventions. The technique (Shapiro, 1995) is controversial and involves engaging the client in rapid eye
movements (tracking a back-and-forth target, e.g., the therapist’s hand or fingers moving rapidly back and
forth) while thinking about a traumatic memory. Although empirical support is limited, at least one study has
demonstrated success for children exposed to a hurricane (Chemtob, Nakashima, & Carlson, 2002).
Anxiety-Management Training (AMT).
AMT (Meichenbaum, 2007) is a program that uses reframing or cognitive restructuring (CR) to replace
negative thought patterns with more positive alternatives. Farrell, Hains, and Davies (1997) found AMT was
a successful component in their program for sexually abused children, while Perrin and colleagues (2004)
suggest that CR can be an effective technique for dealing with responsibility (the accident was my fault), guilt
(especially survivor guilt), and shame resulting from exposure to traumatic events. Perrin and colleagues also
suggest that CR can assist in addressing magical thinking or omen formation (I just knew it would happen) and
heightened sense of arousal and danger associated with the event (fear of going into a car after a crash).
574
575
Post-Case Questions
1. Would Juan qualify for a diagnosis of PTSD according to the DSM-5? If so, what symptoms does he have that would meet the
DSM criteria? What symptoms does he not exhibit that you would expect to see? How might you explain the lack of symptoms?
2. Culturally, do you think that Juan’s Hispanic background makes his situation better or worse than if he were from a different
culture? What does the research say about culture and emotional expression?
3. Based on Juan’s symptoms, develop a CBT program using TF-CBT to assist him in reducing his feelings of self-blame and
survivor guilt.
4. If Juan were fearful of getting behind the wheel and driving again, develop a systematic desensitization program that would help
him regain his confidence about driving again.
5. Develop a case formulation from a biological perspective to assist in better understanding how his symptoms developed, and are
maintained and suggestions for treatment alternatives.
6. Given his situation, discuss his potential for positive outcomes in the future based on an analysis of risks and protective factors.
576
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Case 24 Jason Coleman Disconnected Connections Conduct
Disorder; Reactive Attachment Disorder; Traumatic
Childhood
Jason was almost 16 years of age when he was brought to the clinic by his social worker, accompanied by his
foster mother, Mrs. Belcour.
582
Little is known of Jason’s early history, but according to reports, Jason’s parents died when he was 4½ years of
age. There were reported stories of a murder-suicide, as both parents were found in a submerged car that had
crashed through a bridge. As had happened on other occasions, Jason was not in the car, since he had been
left with an aunt while his parents frequented the local bar. Jason’s mother was barely a teenager when he was
born and had a troubled history of substance abuse and running away from an abusive home situation. Jason’s
father was also a runaway who had his own history of substance abuse and reckless behavior. Although they
never married, they lived together and fought often. There were concerns that Jason’s father was abusive
physically when he was drinking, which was often, and after his death, it was learned that he was also a
registered sex offender.
After his parents’ tragic death, Jason was initially cared for by a maternal aunt; apparently the aunt was also
physically abusive, and Jason moved in with his maternal grandparents 2 years later. At 6½ years of age,
Jason’s behavior was becoming more and more difficult to control. Despite his impulsive behaviors, which
were often reckless and dangerous, Jason also demonstrated intense fears, such as a fear of the dark and fear of
water. He would scream hysterically if the grandparents turned the lights out in his room or even tried to pull
his shirt over his face to get dressed or undressed. Often he would wake up in the middle of the night,
screaming in terror. Because of his fears of water, he was afraid to go in the bathtub and cleanliness became an
ongoing issue.
His grandparents were also at a loss as to how to console Jason when he was upset. He never would seek them
out when he was distressed or seem to respond to any affection or attention they tried to provide. Jason did
not seem to have many happy times, and for the most part appeared irritable, angry, or sad. At school,
children would call him names and Jason would retaliate by hitting, punching, and kicking. Temper tantrums
were frequent at home, and intense. Jason would often throw himself on the floor, arching his back, kicking
and screaming. He would also bang his head on the floor or walls or anything he could find. His grandparents
were increasingly concerned about safety issues. At one point, Jason was hospitalized for 3 days due to injuries
and an apparent concussion sustained when a tantrum resulted in a fall down a flight of stairs. When upset,
Jason could not be comforted. Mood shifts were frequent, and at times Jason seemed to be out of reach and
“in a world of his own.” On these occasions, he would “zone out” and seem to lose contact with everyone
around him. The grandparents eventually went to child protection services to seek help in managing Jason’s
behavior and to obtain weekend relief. Ultimately, they gave him up altogether when he set a fire in their
bedroom.
Jason went through a series of foster placements like a revolving door, breaking down each placement in
succession. It was as if he would destroy the placement before the placement could reject him. His life became
a self-fulfilling prophecy. During this time, Jason was seen for psychotherapy at a regional treatment center.
His behavior was described as “chronically hostile,” and play sessions were directed toward assisting Jason to
understand his behavior and to relate more positively to those around him. Jason’s themes in play therapy were
full of violence and destruction. He would smash toy cars together, bury toy dolls in the sand, and put ropes
583
around the stuffed animals and dangle them from clothes hooks. While Jason was receiving treatment, his
social worker continued to search for a stable therapeutic foster placement and eventually found such a
placement in a city 90 miles away. In order to assist with his transition, Jason was assessed at the center.
Intellectual assessment revealed that despite average intelligence, Jason did evidence significant difficulties
with short-term memory, attention, concentration, and visual motor functioning. Academically, Jason was
below the expected level in the core academic areas. The psychologist who did the assessment also noted that
Jason was emotionally distraught, depressed, and fearful about his move so far away. Ritalin was prescribed to
assist Jason with attention and concentration in his new school placement.
Jason joined the Belcour family just prior to his 10th birthday. He would be the only child in the home, since
the Belcours agreed not to take in any additional foster children at that time. Throughout his history with the
Belcour family, behavioral difficulties would be evident whenever Jason felt threatened or insecure. During the
initial stages of his placement, the foster parents were trained to recognize that Jason would test his new
placement in ways that would test the limits of their patience and endurance. Jason had developed a highly
predictable pattern of self-defeating behaviors that were designed to break down the foster placement.
However, these behaviors were motivated by his highly anxious fears of abandonment and constant need for
reassurance.
Eventually, the behaviors lessened and Jason looked as if he was beginning to settle into the family. Although
Jason’s behaviors continued to challenge the Belcours, these behaviors began to escalate about 18 months ago.
Jason began staying out late and had been truant from school. When confined to his bedroom, Jason sneaked
out the bedroom window and was found wandering the streets with a friend. Despite coming home smelling
of cigarettes, Jason denied that he was smoking. Mrs. Belcour sought the assistance of the social worker, and
Jason began to take part in weekly counseling sessions in an attempt to get his behavior in check. Ritalin
dosage was also increased at that time.
Recently, Jason’s behaviors were escalating out of control. He managed to obtain Mrs. Belcour’s security code
(looking over her shoulder while she withdrew money from her account), removed her ATM card from her
purse, and withdrew $500 from her bank account. The Belcours recently agreed to foster another child, Walt,
who they thought might be a stabilizing influence on Jason, since Jason could assume the role of the “older
brother.” However, Walt was a child who was of limited intellectual ability and Jason took advantage of his
new position of power and Walt’s limitations by manipulating Walt. He convinced Walt to assist him in
breaking into the house across the street, saying that the boy who lived there had stolen his CD collection.
Eventually, it was also learned that alcohol was missing from the Belcours’ liquor cabinet, although the bottles
were cleverly filled with soda pop to avoid immediate detection. Jason had also recently earned a 3-day
suspension from school for being rude to one of his teachers.
Jason, a tall and lean adolescent, 15 years 6 months of age, presented well and was cooperative and congenial
throughout the assessment. He offered to carry the testing materials from the car and assisted the psychologist
in clearing excess paper from her desk to get ready for the assessment. He was not overly spontaneous in
response to open-ended conversation; he responded better to direct questions and then proceeded to elaborate
584
and embellish his responses. In response to questions directed toward areas of interest in school, Jason cited
welding, auto work, and woodworking. When asked what he would like to do when he finished school, Jason
stated that he would like to become a “pyrotechnician.” Jason then asked the psychologist if she knew what a
“pyrotechnician” was. The psychologist asked Jason what type of schooling would be required for such a
position. Jason stated that this was a job that required a 4-year university degree and that it involved staging
“blow-ups” for television and the movies. If this was not a possible career, he said, his next choices were to be
a trucker or a race car driver. At this point in the interview, Jason began asking the psychologist about
becoming a “shrink” and wondered how long it takes to get such a degree. He said that he figured that this
was a profession that probably made lots of money. Conversation then was directed to where a psychologist
might live in the city. When this was not responded to directly, Jason said that he lived in a section of town
where people lived who had less money than psychologists.
Throughout the assessment, Jason attempted to become more familiar with the examiner and often asked
questions that pushed the boundaries of the relationship, but he never quite went beyond the bounds of
decorum. When asked about his recent episode of being caught for a “break and enter,” Jason denied any
direct involvement and stated that he was only waiting outside for his friend. He was upset that the police
would not believe him.
585
Reason for Referral
Given Jason’s escalating behaviors, there were concerns that Jason might act out to the extent that he would
have to leave the Belcour home and be placed with juvenile justice. A comprehensive assessment was
requested to determine what was causing Jason’s recent behaviors and how best to intervene on his behalf.
586
Assessment Results
Information regarding specific assessment instruments and guidelines to the interpretation of standard scores
Although Jason’s responses to the WISC-V revealed an overall level of intellectual functioning within the
average range (full scale IQ range 99–107), this global picture did little to represent the wide range of scatter
on his profile. There was a 25-to-27 point discrepancy between his Verbal Comprehension Index IQ (VCI =
95) and his scores for Visual Spatial and Fluid Reasoning (VSI = 120; FRI = 122); a discrepancy of that
magnitude is rare and seen in less than 1% of the population. The Working Memory Index (WMI) was a
significant area of weakness (SS = 75), as was his speed of symbol copying (SS = 7), which resulted in a score
that placed the Processing Speed Index (PSI = 86) in the low average range. On the Bender Gestalt test of
visual motor integration, Jason’s time to complete the symbols was in excess of 15 minutes: a task that should
take an average 7-year-old about 7 minutes to complete. Jason’s lack of planning ability was evident as he did
not leave enough room to place all the designs on one page, and as a result drawings often collided with one
another. He had significant problems executing angled designs and substituted lines for dots, all signs that
have been associated with some form of brain damage.
Jason demonstrated some surprising strengths, given several years of interrupted schooling and lack of
consistent exposure to formal education. Scores in areas of general knowledge, abstract reasoning, vocabulary
development, and practical reasoning were all within the average range for his age. What was so remarkable
was Jason’s superior ability that surfaced in areas of visual reasoning, evident in excellent attention to visual
details (perceptive/observation skills), his ability to quickly obtain solutions to problems involving visual
reasoning, and the analysis and synthesis of visual information.
When the academic portion of the assessment was introduced, Jason attempted to delay the task at hand by
engaging in a lengthy conversation about who developed the tests and how much money test-makers earn. He
asked whether they got paid every time a test was given, like royalties that songwriters make. It was apparent
that Jason was feeling uncomfortable about his weak academic skills, so only a brief academic assessment was
conducted in order to focus more on isolating strengths and weaknesses in information processing and the
assessment of emotional status. Although Jason was currently enrolled in Grade 10, he was functioning at the
following levels according to the Wechsler Individual Achievement Test (WIAT-III): Decoding, Grade 8;
Spelling, Grade 4; and Math Calculations, at a Grade 6 level. Reading comprehension and speed of reading
were at a mid–Grade 6 range.
Jason was intrigued with the memory assessment and was very cooperative during the administration of the
Wide Range Assessment of Memory and Learning (WRAML-2). Results were enlightening and
demonstrated that despite excellent visual problem-solving skills (WISC-V), Jason had a very weak memory
for visual sequence (1st percentile), which often is associated with poor spelling. Considering the memory
weakness in conjunction with poor copying speed, it became readily apparent why Jason became highly
frustrated and resistant when asked to produce written work. Jason also demonstrated weaknesses in
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attention/concentration on the WRAML-2.
Jason’s former teacher and foster mother completed parallel forms of The Behavior Rating Inventory of
Executive Functioning (BRIEF). Jason’s foster mother and teacher both rated Jason within the clinical range
for the Behavioral Regulation Index (executive functions that regulate emotions and behaviors) with
significant T scores for problems in areas of Inhibit (ability to stop an action or not react to an impulse), Shift
(ability to move from one task or situation to another), and Emotional Control (ability to regulate emotional
responses). Significant difficulties were also evident across the academic and home environments in all areas
rated, including initiating goal-directed activity, working memory, planning, organization of task materials,
and self-monitoring of responses.
Jason and his foster mother completed the Jesness Behavior Checklist. Although Jason presented as a candid
and cooperative respondent, there were wide and significant discrepancies between his self-rating scales and
ratings completed by his foster mother. The profiles presented a mirror image: According to Jason, all
behaviors were within the average to high average positive range; according to his foster mother, the majority
of behaviors were well below average, in the very negative range. Mrs. Belcour endorsed the following
behaviors below the second percentile: ability to take responsibility for his actions, ability to avoid engaging
others in negative interactions, lack of depression/withdrawal, lack of stealing, lack of adherence to rules, weak
frustration tolerance/resistance to teasing, and more. According to Mrs. Belcour, only two areas of behavior
were within the normative range: independence and sociability.
However, on the Jesness Inventory Revised (JI-R), Jason’s scores revealed significant elevations on the Asocial
Index (T score = 64), indicating a predisposition to resolve problems in ways that showed a disregard for social
customs and rules, and the Social Maladjustment scale (SM; T score = 62), often associated with a negative
self-concept and high sensitivity to criticism. Individuals who score high on the SM scale often feel that they
are misunderstood, are unhappy, and can be hostile. Jason also scored in the clinically significant range on the
DSM scale for Conduct Disorder (CD; T = 62). Individuals who score high on the CD scale show persistent
patterns of behavior that can be aggressive, destructive, and deceitful, often entailing violations of rules.
Overall, his performance fit the profile for the Pragmatist/Manipulator (MP) subtype on the Jesness
Inventory.
In addition to weak agreement between Jason’s ratings and his foster mother’s ratings on the Jesness Behavior
Checklist, ratings on the Depression and Anxiety Scales for Youth (DAYS) revealed self-ratings for
depression (16th percentile) and anxiety (50th percentile) to be within normative expectations, compared to
his foster mother’s clinically significant ratings for depression (98th percentile) and anxiety (91st percentile).
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While children with oppositional defiant disorder (ODD) demonstrate a persistent pattern of behavior toward
authority figures that is negativistic, defiant, disobedient, and hostile, youth with conduct disorder (CD)
evidence more serious disruptive behaviors that cause harm to others either by violation of their rights, or by
breaching major societal norms or rules (DSM-5; APA, 2013). Although it was once thought that ODD
represented an early and milder precursor to CD along a continuum of disruptive behavior disorders, research
supports the existence of two separate disorders. Although 90% of youth with CD also had ODD, only 25%
of all children with ODD go on to develop CD (Rey, 1993). Furthermore, a meta-factor analytic study by
Frick and his colleagues (1993) produced behavior clusters that support two unique disorders: ODD-type
behaviors of aggression and opposition that represent more overt and nondestructive forms of behavior; and
property and status violations, or covert and destructive behaviors more typical of CD behaviors. The CD
category of disruptive behavior disorders includes behaviors such as aggression to people and animals,
destruction of property, deceitfulness or theft, and serious rule violations.
In adolescence, the pituitary gland works overtime as puberty is initiated. This can result in increased release
of the hormone cortisol by the adrenal glands, causing the hypothalamus-pituitary-adrenal (HPA) system to
activate “fight or flight” signals, especially in those who are vulnerable to increased stress. When faced with
stressful events, arousal causes physiological reactivity that eventually decreases in a post-stress state of recovery
(Linden, Earle, Gerin, & Christenfeld, 1997). Within the autonomic nervous system, the sympathetic
nervous system is responsible for the activation phase, while the parasympathetic nervous system is responsible
for recovery (Porges, 2003). Developmentally, individuals become increasingly more able to regulate affect as
they refine their ability to self-regulate in conditions that impose increasing challenges. However, for some
individuals, having an overly active sympathetic system and a relatively weak parasympathetic system can
result in inflated emotional reactions of anger and avoidance. This can be especially true for youth who
demonstrate mental health and behavioral difficulties, such as externalizing problems, internalizing problems,
and issues of attention or overactivity (Beauchaine, Gatzke-Kopp, & Mead, 2007).
There are a number of risk factors that can contribute to poor ability to regulate emotions, impulsivity, lack of
planning ability, and poor social problem solving that can result in disruptive behavior disorders. During the
first years of development, a secure attachment relationship can provide the necessary foundation for the
growth of an “autonomous self, the acquisition of effective peer relations and successful adaptation to school . .
. and the legacy of early attachment relationships may include the enhanced, flexible and positive (or
restricted, inflexible and/or maladaptive) social skills that are acquired in the first relationship” (Thompson,
1999, pp. 269–270).
Main and Solomon (1990) found a “disorganized/disoriented” pattern of attachment in infants who displayed
fear and anxiety upon reuniting with the parent. This disorganized/disoriented pattern has been associated
with family correlates of child maltreatment or parent psychopathology (Lyons-Ruth & Jacobvitz, 1999) and
has been linked to aggression toward peers and externalizing behaviors emerging in preschool (Troy & Sroufe,
1987) and persisting throughout elementary (Renken, Egeland, Marvinney, Mangelsdorf, & Sroufe, 1989).
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Reactive attachment disorder (RAD) was initially included in the DSM-III (APA, 1980) and has undergone
substantial revision since that time. Terms such as “failure to thrive, nonorganic failure to thrive, psychosocial
dwarfism, maternal deprivation, anaclitic depression, hospitalism, and reactive attachment disorder” have been used
over time to refer to the disorder (Richters & Volkmar, 1994, p. 328). The DSM-IV-TR (APA, 2000)
described the disorder as a persistent pattern of disturbed and developmentally inappropriate behavior in social
relatedness with onset within the first 5 years, and resulting from “pathogenic care.” In that version of the
DSM, reactive attachment disorder (RAD) was conceptualized as a single disorder that could manifest in one
of two possible subtypes (inhibited type and disinhibited type). Currently, the DSM-5 considers the two
variants as two separate disorders: reactive attachment disorder (RAD) and disinhibited social engagement
disorder (DSED). Within this context, as a result of being exposed to extreme lack of appropriate care; not
having their basic needs met for comfort, socialization, or affection; being exposed to repeated changes in
caregivers; or being reared in highly limited environments (institutions), infants and very young children do
not develop normal attachment patterns or developmentally appropriate responses to social interactions.
While children who meet criteria for RAD demonstrate excessively inhibited behaviors (hypervigilance, or
highly ambivalent and contradictory responses, including resistance to being comforted), those who meet
criteria for DSED exhibit diffuse attachments and indiscriminate sociability with unfamiliar adults marked
with an inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers
or lack of discrimination in their approach to attachment figures).
Despite prolific research initiatives in the area of the attachment process, there are relatively few studies of
severe attachment disorders although findings suggest that this can represent a fairly substantial subset of
adoptees. Boris, Zeanah, Larrieu, Scheeringa, and Heller (1998) found that 42% of their adopted population
met criteria for an attachment disorder. Follow-up studies of children adopted from institutions in Romania
have found evidence of both types of attachment disorders, although DSED was the most common form of
disorder for those who were adopted out (O’Connor, 2002; Zeanah, 2000), while RAD (emotionally
withdrawn behavior) was most prevalent in children who continued to live in the Romanian institutions
(Smyke, Dumitrescu, & Zeanah, 2002). Investigators have also found that the children who exhibited DSED
behaviors persisted for years, regardless of whether the children had developed secure attachments to their
adoptive caregivers (Chisholm, 1998; O’Conner et al., 2003). On the other hand, Zeanah and colleagues
(2004) found that 17% of their sample met criteria for both types of attachment disorders, simultaneously.
Currently, the DSM-5 does not provide any suggestions for how to categorize children who may exhibit
symptoms of both disorders, or possibly meet criteria for both types of attachment disorder. Although a
diagnosis of RAD or DSED is usually made in early childhood, it is not surprising to see symptoms carried
over into adolescence. Children may become disruptive and disorganized with poor affect control and low
frustration tolerance, as well as inattention, impulsivity, and hyperactivity. By the time they reach mid-
adolescence, it is not uncommon to find numerous comorbid diagnoses (ADHD, PTSD, ODD, mood
disorder, or CD), while a diagnosis of an attachment disorder may have been missed altogether (Kemph &
Voeller, 2008).
Longitudinal studies have found that the impact of early deprivation can be found to increase the risk for
cognitive and physical delays, as well as later psychopathology (O’Connor & Rutter, 2000).
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Neuropsychological research has suggested that early deprivation of maternal care can alter neural pathways,
causing dysfunction of the HPA system manifested in elevated cortisol levels (Heim et al., 2002), influencing
levels of the neurotransmitters dopamine (Insel, 2003) and serotonin (Battaglia et al., 2005).
Given the significant potential for abuse or neglect in the history of children and youth with attachment
disorders, it is not surprising to find that these children and youth may meet criteria for both an attachment
disorder and posttraumatic stress disorder (PTSD; Hinshaw-Fuselier, Boris, & Zeanah, 1999). Although
relatively recent, since the early 1990s research has increasingly focused on how symptoms of PTSD might be
presented at different developmental levels, and the potential biological, psychological, and social outcomes
that might result from exposure to extreme psychic trauma and stress in childhood and youth (Pynoos, 1990,
1994). Although PTSD was originally classified as an anxiety disorder by the DSM-IV-TR (APA, 2000), it
differs from the other anxiety disorders in one significant way: Whereas other anxiety disorders result from
“perceptions of threat” that cause distress although most recognize that the fears are unreasonable, individuals
who suffer from PTSD do so because they have been exposed to a catastrophic and traumatic event that
results in feelings of “horror or helplessness,” which can be displayed as disorganized and agitated behaviors in
children and adolescence (DSM-IV-TR, APA, 2000, p. 467). As a result, the DSM-5 has removed PTSD
from the anxiety disorders and more appropriately listed the disorder in the chapter on trauma- and stressor-
related disorders. Individuals who suffer from PTSD exhibit symptom clusters that represent reexperiencing of
the event, avoidance of stimuli associated with the event, altered negative cognitions and mood states, and
persistent levels of increased arousal. Symptoms differ across the developmental stages, with increased risk of
engaging in risky behaviors in adolescence. In children and youth, a common symptom of PTSD is emotional
numbing (Carrion, Weems, Ray, & Reiss, 2002), which can result from emotional exhaustion due to
experiencing high levels of arousal over a prolonged period of time (Weems, Saltzman, Reiss, & Carrion,
2003). The onset of PTSD prior to age 14 has been associated with increased interpersonal problems, while
later onset has been linked to increased academic problems (Amaya-Jackson & March, 1995). Children and
youth are also more likely to suffer from Type II trauma related to repeated exposure to trauma, such as abuse
over time, compared to Type I trauma, which relates to a one-time occurrence (Terr, 1991). As a result, many
children and adolescents who suffer from PTSD may have been exposed to prior abuse (physical, sexual,
emotional abuse or neglect). In addition to being exposed to repeated incidences of the same type of abuse
(Type II trauma), studies have also investigated exposure to multiple types of abuse, or poly-victimization. In
their review of research on child maltreatment, Herrenkohl and Herrenkohl (2009) found that children are
often exposed to more than one form of abuse. Lau and colleagues (2005) reported that 94% of children who
are sexually abused and 78.7% of those who were physically abused experience another form of maltreatment.
Executive functions represent the control system or central processes responsible for managing, organizing,
and planning goal-directed activity within our cognitive and emotional world. This neuropsychological system
of “regulatory control” plays an enormous role “in the child’s cognitive, behavioral and social-emotional
development” to the extent that whether the neuropsychological system is “intact or impaired, has substantial
implications for everyday social and academic function” (Gioia & Isquith, 2004, p. 136.). Executive functions
evolve around four major tasks: defining the problem (representation), developing a plan, following through
and executing the plan, and evaluating the outcome. In order to accomplish the four major tasks, children and
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youth must learn to develop skills in decision making, planning, cognitive flexibility, the ability to inhibit or
ignore competing responses, and monitoring and evaluating the outcomes. Although the structural bases of
executive function are only starting to be understood, executive functions have been increasingly associated
with brain systems involving the frontal and anterior temporal lobes (Levin et al., 1993). Children who exhibit
executive functioning deficits often have damage to the prefrontal regions, which causes dysfunction in such
areas as planning and cognitive flexibility (Ylvisaker, Szekeres, & Hartwick, 1992), organization, memory, and
behavioral inhibition (Scheibel & Levin, 1997). There are many different patterns of executive dysfunction
that may be related to different disorder profiles (Gioia, Isquith, Kenworthy, & Barton, 2002), and several
potential causes of deficits in executive functioning, including in utero exposure to toxins, low birth weight,
birth trauma, traumatic brain injury (TBI), or genetics (Gioia, 2005).
Finally, the last issue in the case of Jason Coleman is the pending termination of foster care. The majority of
youth on the brink of termination from foster care face significant challenges. For the majority, termination
means disconnecting from supportive adults, services, and socioeconomic supports that could significantly
increase their opportunities for becoming successful and self-sustaining adults (Metzger, 2006). In their
review of the recent research concerning aging out of foster care, Avery and Freundlich (2009) discuss the
repercussions of terminating youth from services at 18 years of age, at a time when they are entering a period
of “emerging adulthood,” which represents “a developmental transition period between adolescence and
adulthood” (p. 248). The authors suggest that at this stage, “independent living” should be reconceptualized as
“interdependent living” with the proviso of assigning an adult to act as a committed overseer of the process
prior to termination.
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While parent training programs can be an effective way of treating children with ODD (see the case study of
Scott Michaels), several concerns have been raised regarding optimum treatments for youth with more serious
forms of CD. In the past, few treatments have demonstrated effectiveness with this difficult-to-serve
population; furthermore, there is a risk of potential iatrogenic effects when troubled youth are aggregated for
treatment (Dishion, McCord, & Poulin, 1999). A continuum of service delivery is available for youth with
serious emotional and behavioral disorders, ranging from the least intrusive (outpatient resources) to the most
intrusive (residential treatment centers) environments, based on the severity and nature of the problems.
Although initial empirical investigations were limited to analogue-type studies (Weisz, Weiss, Han, Granger,
& Morton, 1995), more recent investigations of community-based alternatives, such as multisystem therapy
(MST), have produced promising results.
Frick (2001) suggests that based on our current understanding of the complexity of CD, in order for
treatment to be effective, it must attempt to address the vast range of factors within the child (genetic and
environmental history) and within the child’s developmental contexts (family, school, societal and economic,
cultural) that serve to precipitate and maintain the symptoms. In addition, Frick emphasizes the need to tailor
the treatment to the various developmental pathways that may be involved. Programs designed to meet
individual needs, such as the FAST Track Program (Stormshak, Bierman, McMahon, Lengua, & Conduct
Problems Prevention Research Group [CPPRG], 2000) and MST (Borduin, Mann, Cone, & Henggeler,
1995; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) have met with increased success.
Increasing emphasis on community-based interventions has generated research initiatives comparing

residential treatment with community-based treatment alternatives. Chamberlain and Reid (1991, 1998)
found that juveniles assigned to specialized foster care programs were more successful than peers assigned to
residential treatment centers or family or relatives’ homes. Using a multidimensional treatment focus founded
on social learning theory, multidimensional treatment foster care (MTFC) targets coercive family practices. In
this model, youth remain in the community and the foster family setting becomes the training ground for
learning adaptive replacement behaviors, while parents also are schooled in parenting techniques to replace
coercive methods (Smith & Chamberlain, 2009). Wilmshurst (2002) found significantly better outcomes for
youth with severe emotional and behavioral problems when the youth received interventions provided by
family preservation workers in the home (using cognitive–behavioral methods), compared to youth who were
removed to a 5-day residential program for treatment (using brief solution-focused therapy). Furthermore, the
Wilmshurst study found that whereas children and youth in the community-based program demonstrated
significant improvement in all areas 1 year posttreatment, youth who had attended the residential program
revealed poorer outcomes and significant increases in internalizing symptoms (e.g., depression)
postintervention. MST is a community treatment alternative that has been proven to be more effective than
hospitalization in serving the needs of juvenile offenders (Henggeler & Borduin, 1990; Schoenwald, Brown,
& Henggeler, 2000). The success of the MST program has been attributed to the use of cognitive–behavioral
methods within an ecologically valid context (Henggeler & Schaeffer, 2009; Schoenwald, Borduin, &
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Henggeler, 1998).
Recently, several theorists have turned to attachment theory to assist in understanding the disturbed
interpersonal relations of youth with CD, attachment disorders, and PTSD. There is an emerging body of
literature addressing the relationship of attachment theory to early deprivation of maternal care (see Cassidy &
Mohr, 2001, for review), suggesting negative outcomes that may result from perinatal exposure to toxins, poor
parenting, and a lack of “goodness of fit” between parent and child temperament (Kemph & Voeller, 2008).
Research from a biomedical perspective has suggested that some children may possess a particular genotype
(5-HTT short allele of the serotonin transporter polymorphism associated with increased reactivity and
arousal of the amygdala and cortisol systems) that may make them more vulnerable to the effects of poor
parent–child relationships (Barr et al., 2003; Hariri, 2002), while other researchers have focused on the
potential impact of early maternal deprivation on altering the nature and course of brain development in the
child (overactivity of the hypothalamic-pituitary-adrenal [HPA] system results in elevated cortisol levels in
response to stress). It has been found that infants who are traumatized evidence elevated levels of cortisol
when reunited with their caregivers (Spangler & Grossmann, 1999), compared to those who are securely
attached, and are comforted by reuniting with the caregiver, resulting in a reduction in cortisol levels
(Nachmias, Gunnar, Mangelsdorf, Parritz, & Buss, 1996). Given the complex interrelationships between
genotype and neurotransmitter mechanisms that are operating in severe cases of CD, attachment disorder,
and PTSD, pharmacological intervention may be a necessary corollary to cognitive and behavioral
interventions, especially medications that target increasing serotonin or decreasing dopamine levels.
In addition to underlying neuropsychological dynamics, infants who are exposed to deprivation in care often
experience disruptions in the development of normal mother-infant communication, which should pave the
way for engaging in shared relationships with others in the future. Lyons-Ruth (2008) has reasoned that
infants who experience a lack of reciprocity in affective communication, such as joint attention and social
referencing, which typically promotes “affective sharing” in normal infants, fail to develop a sense of self-
awareness and other awareness based on shared feelings. As a result, when they are capable of understanding
intention (usually around 18 months of age), these young children may respond by a “shunning of sharing”
with an unstable caregiver, recognizing that the caregiver is the cause of their distress. Theories such as this
could pave the way for interventions directed toward helping young children restructure and rebuild
connective networks to enable increased relatedness in the future.
Based on work with children in the foster care system, Steinhauer (1998) suggests that precursors of neglect,
abuse, multiple moves, or multiple caregivers set the stage for a reactive attachment disorder resulting in
attachment-resistant children. According to Steinhauer, it is imperative that treatment for conduct-disordered
youth recognize the underlying dynamics of disturbed attachment responsible for creating a self-defeating
working model focused on self-concept as worthless or unacceptable, perception of others as unavailable or
abusive, and an inability to self-soothe or turn to others for comfort. Although there is minimal empirical
support regarding interventions for youth with CD that is based on attachment theory, a program developed
by Holland, Moretti, Verlaan, and Peterson (1993) has produced some encouraging results. Kemph and
Voeller (2008) note that although changes in cognitive functioning and language and motor development may
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be successful for children and adolescents with RAD, improving social relatedness, especially in adolescence,
may be a more challenging task. The authors reiterate what was stated earlier by Steinhauer (1998), namely
that treatment of RAD “requires many repetitions of appropriate thoughts and behaviors over a prolonged
period of time to foster the changes necessary to form new neuronal patterns which may enable the adolescent
to develop socially acceptable relationships with other people” (Kemph & Voeller, 2008, p. 174).
The American Academy of Child and Adolescent Psychiatry (AACAP; 2005) practice parameters for the
assessment and treatment of children and adolescents with RAD suggests a number of possible treatment
alternatives, including enlisting the caregiver (if emotionally available) as a cotherapist, encouraging the
development of sensitive responsiveness (Hart & Thomas, 2000), or conducting conjoint therapy with the
child and primary caregiver together (Lieberman & Zeanah, 1999). The AACAP suggests two established
models for dyadic interactive therapy, including infant–parent psychotherapy (Lieberman, Silverman, & Pawl,
2000) or interaction guidance (McDonough, 2000). The former therapy focuses on emotional communication
and affective sharing in the dyad, while the latter, with the help of videotaped excerpts, strives to increase
awareness of behavioral patterns of interaction with the intent of shaping caregiver responses in a more
positive direction. The next stage in the treatment process is to include other family members in the process,
while a third stage involves individual therapy with the child. The AACAP (2005) also notes that treatments
for aggressive behaviors, such as parent psychoeducation (Brestan & Eyberg, 1998; Webster-Stratton, 1998)
or MST (Henggeler et al., 1998), are also appropriate for aggressive responses in children with RAD.
Regarding potential medical intervention for RAD, the AACAP recommends caution, especially in
prescribing medications for preschoolers who are in the formative stages of brain development (Greenhill et
al., 2003; Jensen et al., 1999), and suggests perhaps pharmacological intervention for comorbid disorders—
such as PTSD, anxiety disorders, disruptive behavior disorders, or mood disorders—may be indicated.
Although the AACAP (2005) report acknowledges the need for firm limits and recognizes that physical
restraint may be necessary for protective purposes in some cases of extreme aggression, the report does not
recommend the use of intrusive treatments, such as forced eye contact, soothing or “holding” of children, or
physical restraints, against the child’s will that have no empirical support and are likely to trigger responses of
fear and humiliation rather than “connection” and “reattachment.” The report cites, as examples, the case of a
10-year-old girl who died while undergoing “rebirthing” therapy (Crowder, 2000) and the death of a 4-year-
old resulting from an “attachment-based” treatment where the child was restrained while being forced to drink
excessive amounts of water (Adams, 2002).
In his discussion of interventions for deficits in executive function, Gioia (2005) emphasizes the need to
pinpoint specific domains where deficits exist relative to task demands. Once developmentally appropriate
expectations for executive functions can be established, the focus then is to teach children the process of goal-
directed problem solving as it applies to everyday functioning and meaningful routines (Goal-Plan-Do-
Review). Within such a context, children will begin to internalize the process and become better able to
monitor what worked and what didn’t work and why (Ylvisaker, Szekeres, & Feeney, 1998).
595
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Post-Case Questions
1. Jason demonstrates symptoms of several possible comorbid disorders. Using the DSM-5 (APA, 2013) as a guide, what disorders
would Jason meet criteria for and what symptoms does he demonstrate that match these criteria?
2. The following is an excerpt from the psychologist’s written report concerning Jason:
Jason’s responses to the Jesness Inventory suggest that he may utilize his strong visual perceptive skills in ways that may be highly
effective in a manipulative and controlling manner. Jason’s profile suggests a tendency to perceive the world in terms of power and
control, both in very subtle ways and in ways that may be more directive in their controlling influence. At the extreme,
manipulation may be used to satisfy his own needs and may, in this manner, become satisfying in and of itself. To this end,
misbehavior may be evident in “conning,” or deception, which is often a means of self-gratification in its ability to “outsmart”
others. Unfortunately, given Jason’s intellectual capacity, his strong skills may be misdirected toward influencing others who may
not be his intellectual equal. Jason’s Jesness Profile also suggests strong tendencies toward denial of responsibility for
actions/consequences of his behaviors.
Discuss the above with reference to how the following models would interpret Jason’s underlying processes: biomedical,
psychodynamic/theories of attachment, cognitive, behavioral, and theories of parenting/family systems. In your response, include
references to how these processes would interact with various developmental contexts: individual, family and school, social and
economic, and cultural.
3. The psychologist felt that history would predict that in times of perceived change or uncertainty, Jason would act out in a
misdemeanor roughly equivalent in intensity to the amount of anxiety he was feeling. Furthermore, since thefts involved large
amounts of money taken from the foster household, it was important to look at what changes or perceived changes were
happening in that environment: the introduction of a new foster child, a pending move farther out into the country, the impact of
turning 16 as a potential threat to loss of his foster placement. Discuss how these factors might be explained in driving Jason’s self-
defeating behaviors.
4. Develop case formulations for Jason from cognitive behavioral and attachment perspectives. How might you integrate community
resources in your treatment planning for Jason?
5. In the Introductory Chapter (Chapter 1), the impact of Adverse Child Experiences (ACE) was discussed, in relation to increasing
the risk for developing a number of negative outcomes. Research discussed in the introduction (such as Anda et al., 2006) suggest
a number of stress-responsive neurobiological systems as well as brain structure and function resulting from exposure to ACEs.
Discuss how the information from these research studies help to explain Jason’s current emotional status.
597
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Case 25 Ericka White Not Yet Diagnosed
Ericka came to the Children’s Center accompanied by her grandmother, who is the legal guardian. Although
Ericka turned 10 years old 2 months ago, her appearance and her behavior suggest a child several years
younger. Ericka has a history of severe emotional and behavioral problems that have interfered with her ability
to be successful at school and with peers. She has two siblings who are also encountering some difficulties but
not to the extent that Ericka is. Her grandmother has decided to bring her to the Children’s Center to obtain
any guidance and direction that she can get about trying to manage Ericka’s behaviors. As Ericka is getting
older, the behaviors are becoming more and more difficult to control.
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Ericka was placed with her grandmother by the Department of Social Services (DSS) when she was 5½ years
old. Her two sisters, Cindy (7 years) and Debbie (2 years), were also placed at the same time. The
grandmother was not sure of her milestones, but said that she was not totally bowel or bladder trained until
she was 5 years old. Although there were no medical problems that the grandmother was aware of, she did not
start talking clearly until she was 3 years old. Ericka has been described as tactile defensive, and she can create
a huge fuss if she can feel the labels or seams of her clothing. She is noted to have an unusual gait (with a
shuffle) and can resort to regressive behaviors (rocking, thumb sucking, tantrums) when she is stressed. Prior
to her placement at her grandmother’s home, there was a history of neglect and suspicions of sexual abuse by
individuals who provided day care in their home. However, the suspicions were never substantiated and papers
were never filed. Initially, Ericka was having unsupervised visits with her mother and monthly visits with her
father; however, visits were then changed to supervised, since Ericka was soiling herself when she visited her
mother. Currently, Ericka has not seen her father for the past 2 years, and maternal visits occur two or three
times a year.
When Ericka was initially placed, there was an attempt to conduct an intellectual evaluation; however, Ericka
was noncompliant and it was not possible to obtain a valid score. Ericka responded to the vocabulary subtest
in very concrete answers with much pointing to objects in the room, rather than providing a definition. She
also rarely responded to the initial request, and it would take several repetitions for her to engage in the tasks
at hand. Ericka’s drawing of a person and house were more typical of scribbles that would be produced by a 2-
or 3-year-old, representing a person as a bodyless head that looked more like a “smiley” face.
The psychologist noted that Ericka’s speech was difficult to understand and that her interaction was similar to
that of a 3- or 4-year-old. Although she seemed to be friendly, there were a lot of giddy and hyperactive
behaviors that suggested underlying anxiety. Moods and behaviors vacillated during the assessment, including
regressive behaviors (withdrawing, becoming absorbed into play activity to the exclusion of others, rocking,
climbing under the testing table); hyperactive, impulsive, and restless behaviors when she became somewhat
more comfortable; and noncompliant behaviors when she felt challenged. At times, Ericka would deliberately
give an incorrect response and then laugh. The psychologist also noted that Ericka had an inappropriate sense
of boundaries, at times wanting to hold hands, and at other times crossing her arms, pouting, and calling the
psychologist a “retard.” The psychologist also described her as a “hypervigilant child” who may be readily
overwhelmed and overstimulated by her environment, since she tends to hyperfocus on details. Often, this
intense focus on details results in her losing the overall concept of what is happening. Based on the interview
information, the psychologist also believed that Ericka would need to stick to her routines in order to feel
some sense of control in her environment that had been so chaotic. Currently, her only means of obtaining
attention is to act out, test the limits, and provoke a response to her behavior.
Ericka is currently registered as a special education student at Forest Hills Elementary School, as a student
with behavioral and emotional problems. Two years ago, Ericka was reassessed by the school psychologist. At
that time, her full scale IQ score on the WISC-IV was 77 (range 73–83). Scores ranged from a strength on
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the Working Memory Index of 86, to a weakness on the Verbal Comprehension Index of 77. Academically,
Ericka was functioning about at a mid–Grade 1 level. The school psychologist noted that results were of
questionable validity due to issues of noncompliance during the assessment.
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Reason for Referral
Ericka’s grandmother continues to experience extreme difficulties managing Ericka’s behavior at home, and
teachers are having similar problems at school. The problems have been increasing over the past year. Her
grandmother has heard of children with autism who exhibit bizarre behaviors and wonders if Ericka might be
autistic. A comprehensive assessment was recommended by the school to address grandmother’s concerns and
to obtain any additional information that might assist the home and school in better managing Ericka’s
behaviors. Currently, Ericka is often refusing to attend school, or if she gets to school, then she refuses to
cooperate with teachers in the regular class or to complete any work that she is assigned. Behaviors have
escalated to the point that she has threatened to kill students, her teacher, and anyone who gets in her way.
She has also begun to tell the other students that God will punish them because they are bad.
When behaviors are not threatening, they are aimed at gaining attention (burping out loud, or yelling out
inappropriate comments during class: “I am getting a training bra!”). Her teacher notes that Ericka is
becoming increasingly preoccupied with boys and has made many in the class uncomfortable by asking to kiss
them. She also tends to dwell on things that have upset her and will relive the experience over and over,
becoming increasingly upset even if the situation happened days ago. At times, she can be very affectionate
and offers to help the teacher or tries to make others like her by giving them her possessions (pencils, books,
stickers). According to her grandmother, the major complaints are Ericka’s oppositional behaviors and her
tendencies to obsess over things to an extreme (she says she is in love with her female teacher from last year).
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Assessment Results
Ericka was seen over the course of two assessment sessions. During the initial assessment period, the
Wechsler Intelligence Scale for Children (WISC-V) was administered. The Wechsler Individual
Achievement Test (WIAT-III) was administered during the second assessment session. Ericka was
moderately cooperative; however, despite her attempts to comply, she often quickly tired of the task and
wanted to discontinue, especially if the task was difficult. The Block Design task was very low (scale score of
3) because Ericka did not understand the nature of the task. Effort was inconsistent throughout, with better
attention and effort on “liked” versus “nonliked” tasks. Problems with attention span were notable, especially
when asked to perform complex tasks, such as remembering the order of items presented in a series (picture
span). Her desire to socialize also interfered with task completion. This was especially notable during the
second session, when she was asked to perform some academic tasks. As a result, the academic evaluation took
considerable time, since work periods were interspersed with chats, coloring, and other more “fun” activities.
Due to the wide range of effort expended among individual tasks and problems remaining focused on the task
at hand, validity is suspect and caution is recommended in the interpretation of test scores.
Although the full scale score on the WISC-V was 75 (range 72–81), there was wide variation between
different scores based on the nature of the process or skill evaluated. Her score on the Visual Spatial Index
(VSI) was very low due to very poor performance on the block design task (FSI index 68), while her score for
Fluid Reasoning (FRI) was somewhat better (FRI score of 78). Her Verbal Comprehension Index (VCI)
score of 83 (range 77–91) was an area of relative strength. Scores for Processing Speed of 75 (range 69–87)
and Working Memory (WMI of 75) were both in the same range.
Academically, although Ericka demonstrated good basic reading skills (Reading Fluency and Comprehension
standard score = 95; grade equivalent 3.7), she experienced significant difficulties with math reasoning
(standard score = 66; grade equivalent 1.4). Written expression (standard score = 70; grade equivalent 2.0) was
also an area of significant weakness.
A number of different scales were administered to provide a better understanding of emotional and behavioral
concerns at school and at home. Her grandmother and teacher both completed the Behavioral Assessment of
Children (BASC-2), Devereux Scales of Mental Disorders (DSMD), and an informal Autism Evaluation
Form.
According to the BASC-2, grandparent and teacher agreement for clinical significance was noted on all
composite scales, including Externalizing Problems, Internalizing Problems, the Behavioral Symptoms Index,
and Adaptive Functioning. Individual scales that were significant for both raters (T score above 67) included
aggression, depression, somatization, atypicality, attention problems, adaptability, social skills, and leadership.
On the DSMD, both grandmother and teacher endorsed significant concerns (T scores in excess of 67) for all
composite scales, including Eternalizing, Internalizing, and Critical Pathology.
Problem areas noted by the teacher that included 100% endorsement of all items on the scale included
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moodiness/sullenness (becomes easily upset, refuses to speak, holds a grudge, appears angry, irritable), obsessions
and compulsions (insists on doing things one way, obsessed or preoccupied, insistence on same routine, shows no
interest in more than one activity), emotional lability (temper tantrums, sudden mood swings, unpredictable, can’t
control anger, easily upset, irritable, angry when frustrated, overexcited, overreacts to change, reactive to mistakes),
somatic complaints (problems sleeping, tired, complains of physical problems), and inattention (problems following
rules, jumps from one thing to another, preoccupied, easily distracted, fails to pay attention, trouble concentrating, fails
to complete assignments). Problem areas noted by the grandmother that included 100% endorsement of all items
on the scale included verbal aggression (tells lies, swears or curses, argues with adults).
In addition to these areas, other areas were also endorsed as showing 80% agreement and included
hyperactivity, fearfulness (distressed when separated from parent, unreasonable fear of strangers, easily startled or
acts jumpy), noncompliance (refuses to go to school, refuses to eat, argues with adults, problems following rules,
appears angry, refuses to speak), social isolation (avoids physical contact, withdraws, fails to participate), and anger
dyscontrol (picks fights, tantrums, easily upset).
The Autism Evaluation was also completed by Ericka’s teacher and grandmother. According to her teacher,
communication problems seen frequently included inappropriate responses to simple commands, and
stereotypical behaviors were making high-pitched noises and preoccupations with objects and people. Her
teacher saw her primarily as having a significant number of difficulties in the domain of social interactions,
such as problems cooperating in a group, problems playing with others, inappropriate laughs or giggles,
tantrums, repetition of certain acts, needs excessive amounts of reassurance, lacks subtle emotions, won’t
initiate tasks, and lack of understanding as to why she is not liked. According to her grandmother,
communication problems were evident in avoiding eye contact, repeating phrases, and responding to questions
inappropriately. Stereotypical behaviors were noted in walks on tiptoes; slaps, hits, or bites self; requires
extensive redirection; and shows obsessive interests. Difficulties with social interactions noted by the
grandmother included avoids eye contact; problems with groups; laughs, giggles inappropriately; repetitive
acts; and needs excessive reassurance.
In addition to test behaviors already described, the psychologist noted that Ericka was capable of many mood
swings within a short period of time. When the psychologist was first introduced to Ericka, she seemed very
startled and agitated and did not want to make eye contact. She seemed to be very fearful and defensive and
required considerable reassurance that she had not done anything wrong and that they were just going to do
some work together to see how she was doing in school. It took a while for rapport to be established, but
Ericka seemed to like to draw and color, so extra materials were gathered and she sat for the first time while
trying to draw a picture of a butterfly, like the one on the book cover that was on the desk. Eventually, after
several erasures, she decided to trace the picture by placing her paper on top of the book. She was pleased with
the result of her efforts.
Once she seemed more comfortable, the psychologist attempted to bring out some of the WISC-V materials,
beginning with the block design; however, since this was a very difficult task for Ericka to understand, she
quickly became frustrated and started banging the blocks together to make a noise and then singing loudly.
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The psychologist suggested they do a different task (Picture Concepts), which met with a more cooperative
response, since she was able to understand the task demands “find pictures that go together.” As Ericka
became more familiar, she began to get more hyperactive and restless, squirming in her chair, and asking if
they could go outside and play. The psychologist said she could take a break and that she could do a few
exercises by the desk to stretch. Again, Ericka began to push the boundaries, jumping up and down and
wiggling her hips, singing, and asking if there was a radio to play music that she could dance to. When the
psychologist said there wasn’t, she immediately sat down in the chair, folded her arms, and pouted. These
mood variations were ongoing throughout the majority of the assessment session.
When she arrived for the second session, she was overly familiar and wanted to hold the psychologist’s hand
as they walked down the hall from the classroom to the office. But soon she was swinging the psychologist’s
arm and became very hyper and asked if they could go out to play. When this was declined, she again became
sullen and withdrew her hand and said that she didn’t want to work today. She then asked the psychologist if
she would come to her house after school to play. These types of inappropriate interactions were ongoing and
occurred throughout the second session, with her demanding attention at one point and then withdrawing
from contact when she did not get the response she wanted. As was noted many years ago in her initial
assessment, Ericka continues to test limits with adults and pushes boundaries. She is very needy of attention,
but she has little ability to control her emotional responses or understand why she is not more successful
socially. She seems to be challenged by significant problems that had their onset very early in her young life
and which she continues to struggle with years later.
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Post-Case Questions
1. Ericka has many difficulties and a number of emotional and behavioral problems. Does Ericka qualify for any DSM diagnosis
based on the information that is available from her history, the interviews, assessments, and her behaviors during the assessment?
If so, what symptoms does she exhibit that meet criteria for a DSM diagnosis or diagnoses?
2. Ericka’s grandmother wondered if she had autism. Based on the assessment results, is there any support for her concerns? Are
there any symptoms that might fall within the autism spectrum, and if so, which ones?
3. What types of treatment would you recommend for Ericka given her intellectual challenges?
4. Research on adverse child experiences (ACEs) have suggested that exposure to such negative circumstances as neglect, abuse,
domestic violence, and maternal depression can cause increased risk for developing a number of negative outcomes. Discuss
Ericka’s history and how this might increase her risks and in what areas the risks are most likely to manifest.
5. Develop a case formulation from the perspectives of the biological and attachment/psychodynamic perspectives.
You have been invited to provide feedback to the school regarding Ericka’s assessment, at a meeting where they will decide
whether Ericka meets criteria for Special Education and Related Services. If it is determined that she is eligible for services, what
goals and objectives would you want to see as part of her IEP? Would you recommend she receive related services, and if so, what
would the nature of those services be?
plan that would best meet Ericka’s needs?
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Reference
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
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Appendix A Supplemental Case Information
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Case of Colby Tyler: Results From Psychological Testing
Results of the multimodal assessment battery are presented in the following pages in the form of standard
scores, T scores, and/or percentiles. Interns will be expected to evaluate, interpret, and integrate findings to
formulate a more refined diagnostic impression. Anecdotal comments from the clinic psychologist (e.g.,
comments on test behaviors,) are presented whenever these comments might aid in interpretation of the
findings. In addition, a list of endorsed items is provided for any scales (checklists and rating scales) elevated
to clinical levels to facilitate interpretation of behavioral patterns within and across sources of information.
Results are presented in their entirety rather than in summarized form to provide the intern with maximum
opportunity to develop independent skills in the analysis and synthesis of information from multiple sources.
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General Cognitive (WISC-V) and Academic (WIAT-III) Results
Administrator Comments: Excellent speed and dexterity on block design; intuitive holistic learner. Excellent
effort and good sense of humor. Very articulate. Frustration evident on lower scored tasks.
Results of the Wechsler Intelligence Scale for Children (WISC-V) and Wechsler Individual Achievement
Test (WIAT-III) are summarized in the tables below.
WISC-V Primary (Composite Scores) and Subscale Score Summary
PRIMARY INDEX Scales and Composite Confidence Interval Percentile

Range
Subtest Scores* Score (95%) Rank
Extremely
Verbal Comprehension 142 131–146 99.7
High
Similarities* (17)
Vocabulary* (18)
Information (19)
Extremely
Visual Spatial 135 124–140 99
High
Block Design* (17)
Visual Puzzles (15)
Extremely
Fluid Reasoning 137 127–142 99
High
Matrix Reasoning* (19)
Figure Weights* (14)
Picture Concepts (12)
Extremely
Working Memory 130 120–135 98
High
Digit Span* (18)
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Picture Span (13)
Processing Speed 103 94–112 58 Average
Coding* (9)
Symbol Search (12)
Cancellation (7)
Extremely
Full Scale IQ (FSIQ) 142 135–146 99.7
High
Ancillary Indexes
Extremely
General Ability Index (GAI) 145 138–149 99.9
High
Extremely
Nonverbal Ability Index (NVI) 132 124–137 98
High
Cognitive Proficiency Index (CPI) 120 111–126 91 Very High
* Subtest scores in bold are those used to derive the Full Scale IQ Score
Wechsler Individual Achievement Test (WIAT-111)
Composite and Subtest Score Areas Standard Scores Percentile Rank Range
Reading Comprehension and Fluency 111 77 (103–119)
Oral Reading Fluency 100 50 (93–107)
Reading Comprehension 118 88 (107–129)
Mathematics 122 93 (116–128)
Numerical Operations 112 79 (106–118)
Math Problem Solving 128 89 (119–137)
Written Expression* 135 99
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Sentence Composition 134 99 (122–146)
* Score for Written Expression derived from the simple aggregate.
Administrator Comments: Excellent comprehension but relatively slow speed of reading. Handwriting very
difficult to read; awkward pencil grip. Math questions required extra paper to compute; used unusual
strategies but got the correct answers. Took excessive time to compose sentences.
619
Checklists and Rating Scales
Assessment results are presented for Colby’s responses to three assessment instruments that measure social,
emotional, and behavioral functioning: Achenbach System of Empirically Based Assessment (ASEBA;
Achenbach & Rescorla, 2000), the Conners Rating Scales, Revised (Conners, 1997), Conners-Wells Self-
Report Scale for Adolescents (Conners & Wells, 1997), and the Beck Youth Inventories of Emotional and
Social Impairment, 2nd ed. (Beck, Beck, & Jolly, 2005).
ASEBA
The following scores are from the multi-informant assessment using the Child Behavior Checklist (CBCL;
completed by Colby’s mother), the Teacher Report Form (TRF; completed by Colby’s teacher), and the
Youth Self Report (YSR; completed by Colby).
If the previous scores were plotted on a profile, it would be possible to compare scores between raters,
graphically. Figure AA.1 provides an example of what Colby’s ASEBA profile would look like based on
parent and teacher ratings.
Conners Rating Scales

The Conners Rating Scales allow for multiple informants to provide information concerning common
attention problems and symptoms of attention-deficit/hyperactivity based on DSM criteria. There are long
and short versions of the rating scales available. In this case, the long versions were completed by Colby’s
mother, teacher, and himself.
Achenbach System of Empirically Based Assessment (ASEBA) Scales
TRF (T YSR (T
SYNDROMES CBCL (T Score)
Score) Score)
INTERNALIZNG PROBLEMS
Anxious/Depressed 70* 62 63
Need to be perfect, Fearful others out to get him,

Worthless, Self-conscious, Worries
Withdrawn/Depressed 65* 62 64
Somatic Complaints 72* 59 72*
Dizzy, Tired, Aches, Headaches, Nausea, Eye, Skin,
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Stomach
Total Internalizing 73* 63 68*
Other Problems
Social Problems 50 54 50
Thought Problems 67* 58 61
Mind wanders off, Repeats things, Stares
Attention Problems 70* 63 59
Problems with concentration, Restless, Confused,

Daydreams, Poor schoolwork, Stares
EXTERNALIZING PROBLEMS
Rule Breaking 50 53 50
Aggressive Behavior 65* 62 61
Total Externalizing 60 60 56
TOTAL
61 63 63
PROBLEMS
Other Problems: Accident prone, Sleeps less than most, Stores stuff, Trouble sleeping.
Anecdotal Comments (Teacher): Additional effort is needed; achievement below ability, weak study
skills, inconsistent effort, assignments not completed, frequently late in the morning. Good natured,
well liked.
Note: Numbers with asterisk
* indicate scales in the significant range (93rd percentile and above). Individual items endorsed by the
respondent are listed for each of the significant scales.
Teacher and Colby agreed on the same six items of inattention:
Makes careless errors, misses details

Avoids sustained mental effort
Has difficulty organizing
Loses necessary items
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Demonstrates poor follow-through
Becomes easily distracted
Figure AA.1 A Comparison of Parent and Teacher Ratings for Colby on the ASEBA
Behaviors Rating Scales
Parent Youth
Teacher (CTRS-R:L)
(CPRS-R:L) (CASS:L)
(T Scores)
(T Scores) (T Scores)
Oppositional 58 57
72*
Cognitive
62 60
Problems/Inattention Avoids/reluctant to engage in tasks of sustained
mental effort; Fails to finish
622
Hyperactivity 54 57 52
Anxious/Shy 44 67*
Perfectionism 48 46
Social Problems 45 48
72*
Psychosomatic
Stomachaches,
pains
Conners ADHD
57 68* 63
Index
Conners Global Index
Restless/Impulsive 65* 64
79*
Emotional Lability 67*
Easily frustrated, Mood swings, Temper
Global Index Total 67* 68*
DSM Scales
DSM-IV: Inattentive 60 70* 72*
DSM-IV:
54 59 47
Hyp/Impulsive
DSM-IV: Total 58 67* 61
CASS Scale Only:
Family Problems 52
Emotional Problems 58
Conduct Problems 50
Anger Control
61
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Problems 61
Note: Shaded areas for items not on the rater’s scale.

Note: Numbers in bold with asterisk* indicate scales in the significant range (93rd percentile and above).
Beck Youth Inventories of Emotional and Social Impairment (2nd Edition)

This self-report scale has 20 questions for each area assessed. Youth respond to a Likert-type response format
to indicate the degree to which an item is like or unlike them: Never = 0, Sometimes = 1, Often = 2, Always =
3.
Beck Youth Inventories
T
Area Assessed Percentile
Score
Self-Concept Inventory
Items endorsed for negative self-concept (0, 1)

44 35
Feel strong; Like myself; Do things well; Happy to be me; Proud of myself; Good at
remembering
Depression Inventory for Youth
Items rated as 2 or 3:
63 93
Think life is bad; Trouble sleeping (3); Feel sorry for myself; Feel like crying; Feel
sad
Anxiety Inventory for Youth
67* 95
Worry about school, Get nervous, Worry I will get bad grades (3), Worry about the
future (3), Worry others will get mad, Worry I might lose control (3), I always
worry (3), Problems sleeping (3), My heart pounds (3), Fear I might get sick (3)
Anger Inventory for Youth 50 62
Disruptive Behavior Inventory for Youth 44 31

Note: Numbers in bold with asterisk* indicate scales in the significant range (93rd percentile and above).
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625
Colby: Case Formulation and Discussion
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Assessment Report for Colby Tyler
Reason for Referral.
Colby was referred for assessment due to presenting complaints of “poor school outcomes” and “temper
outbursts.”
Assessment Instruments
Wechsler Intelligence Scale for Children (WISC-V)
Wechsler Individual Achievement Test (WIAT-III)
Woodcock Johnson Cognitive Tests (Cognitive Fluency)
Conners Continuous Performance Tests (CPT-3, CATA)
Child Behavior Checklist (CBCL)
Teacher Report Form (TRF)
Youth Self-Report (YSR)
Conners Parent Rating Scale
Conners Teacher Rating Scale
Conners-Wells Self-Report Scale
Beck Youth Inventories (BYI-2)
Child Depression Inventory (CDI-2)
Background Information.
Colby was a full-term baby who weighed 6 lb. 2 oz. Labor was lengthy (12 hours) and forceps were used for
delivery. Mother stated that she was under much stress during pregnancy due to marital conflict and admitted
to smoking as well as having an occasional drink.
Colby was difficult to manage as an infant due to eating problems (often hungry, sensitive stomach, vomiting)
and sleeping problems (difficulties falling asleep and staying asleep). However, he was a good-natured and
inquisitive toddler. Developmental milestones were within the norm, with the exception that Colby
spontaneously began to read words at 2 years of age, a skill that continued to develop and progress at a rapid
rate. Colby’s health has been good, with the exception of a severe outbreak of hives at 5 years of age shortly
after he entered kindergarten. The cause remained undiagnosed and there has not been a recurrence. Hearing
and vision have been assessed, and results indicate that hearing is normal. Colby wears glasses for distance
vision. There is a family history of mood disorders, anxiety disorders (maternal grandmother), family violence,
and aggressive impulses, likely related to alcohol abuse (maternal grandfather).
Colby’s parents have recently separated (6 months ago); however, marital conflict has been ongoing
throughout the 15-year marriage. There was a previous brief separation 7 years ago. Colby and his sister Susy
(7 years of age) are living with their mother and visit their father every Wednesday and every second weekend.
Colby gets along well with his mother, but the relationship with his father is often strained and conflicted.
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Colby has stated that his father is often critical of what he does and will often make sarcastic remarks about
him in front of his friends. Colby feels that he cannot please his father. Colby often appears very agitated on
Wednesday evenings and after returning from weekend visits with his father. Colby’s young sister, Susy, is
also having transition problems.
Colby gained entrance to the gifted program in the fourth grade as a result of a districtwide screening
program. Colby scored in the very superior range (full scale IQ 151) on the intellectual assessment conducted
at that time. The gifted program was offered for students from Grades 4–8, one day a week at a regional
school that served the needs of gifted students from all district schools. Colby was very successful in the
program, which offered extensive computer access and various activities emphasizing higher order functioning
(e.g., mind-bender logic games). However, school reports concerning regular school programming were very
disappointing, noting problems in areas of inconsistent effort, incomplete assignments, tardiness, not bringing
required materials to class, and poor work habits. Colby’s most recent report card for his first high school term
was extremely disappointing with one A, four Cs, and one D (chemistry). Colby has also been late many times
for classes, since he is having difficulty getting up in the mornings due to staying up very late in the evenings.
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Present Assessment Results and Interpretation
Colby was seen for two assessment sessions. Rapport was readily established and effort was good throughout.
Therefore, results are considered to be a valid estimate of current functioning levels. Test behavior was notable
in the following ways. Colby was able to complete puzzles and block designs very quickly with an intuitive
holistic learning style. Some frustration was noted on paper-and-pencil tasks, and on these exercises Colby
was much slower to respond and used an awkward pencil grasp. Colby seemed to fatigue when required to
complete a series of three rating scales. Colby stopped halfway through the exercise to start a spontaneous
conversation, unrelated to the forms he was completing. Colby was also easily distracted by extraneous noises
in the room, which was relatively quiet by normal standards. When he would return his attention to the
questionnaires, he had some difficulty with reorienting to task and finding his place in the booklet.
629
Wechsler Intelligence Scale (WISC-V)
The WISC-V is the latest revision of the Wechsler Intelligence Scale for Children and can be administered in
two formats, a paper-and-pencil test (similar to all previous versions of the instrument) or a digital version,
which is the version that was used for this administration.
Colby put forth his best effort and results are considered to be a valid estimate of current functioning levels.
The Full Scale IQ and Composite Scale Scores are expressed as standard scores with a mean of 100 and a
standard deviation of 15. Scores between 85 and 115 are considered to be in the broad Average Range, with
68% of the population scoring within this range. Composite Scores are derived from subtest scale scores that
range from 1–19 with average scores falling in the 8–12 range. Subtest scores are presented in brackets, for
example, Similarities (17).
The WISC-V derives a Full Scale IQ Score based on the scores obtained on 7 of 13 subtests administered.
Overall, Colby’s Full Scale IQ Score on the WISC-V was 142 (131–146), which places him at the 99.7th
percentile relative to similar aged peers. This is considered to be in the Extremely High Range, which is above
the 2nd percentile and is the cut off used for most Gifted Programs. Results of the Wechsler Intelligence
Scale for Children (WISC-V) are summarized in the table below.
WISC-V Primary (Composite Scores) and Subscale Score Summary
PRIMARY INDEX Scales and Composite Confidence Interval Percentile

Range
Subtest Scores* Score (95%) Rank
Extremely
Verbal Comprehension 142 131–146 99.7
High
Similarities* (17)
Vocabulary* (18)
Information (19)
Extremely
Visual Spatial 135 124–140 99
High
Block Design* (17)
Visual Puzzles (15)
Extremely
Fluid Reasoning 137 127–142 99
High
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Figure Weights* (14)
Extremely
Working Memory 130 120–135 98
High
Digit Span* (18)
Picture Span (13)
Processing Speed 103 94–112 58 Average
Coding* (9)
Symbol Search (12)
Cancellation (7)
Extremely
Full Scale IQ (FSIQ) 142 135–146 99.7
High
Ancillary Index Scores
Extremely
Nonverbal Index NVI 132 124–137 98
High
Extremely
General Ability Index GAI 145 138–149 99.9
High
Cognitive Proficiency CPI 120 111–126 91 Very High
* Subtest scores in bold are those used to derive the Full Scale IQ Score
Colby demonstrated a relative strength in the area of Verbal Comprehension (standard score of 142, at the
99.7th percentile). The Verbal Comprehension Index (VCI) is a measure of crystallized intelligence. It measures
the individual’s ability to access and apply acquired word knowledge (Vocabulary, scaled score 18), involving
verbal concept formation, reasoning, and expression, and the ability to categorize and classify information
based on abstract thinking (Similarities, scaled score 18) and knowledge of General Information (scale score
19). The tests involved in this area measure such tasks as word knowledge, ability to retrieve information,
problem-solving using verbal information, and verbal communication.
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A significant weakness was evident in the area of Processing Speed (standard score of 103, at the 58th
percentile). The Processing Speed Index (PSI) measures the individual’s speed and accuracy of visual
identification, decision making, and decision implementation. Colby’s overall score for the Processing Speed
Index (PSI) was in the Average Range and 39 points lower than his overall intellectual ability score. Processing
speed involves the need to quickly and correctly scan or discriminate between simple visual information. There
are three tasks in this area: Symbol Search (scaled score of 12), which measures an individual’s ability to visually
scan items for similarities or differences; Coding (scaled score of 9), which measures the ability to rapidly and
accurately copy a series of random symbols; and Cancellation (scale score of 7), which measures the ability to
focus attention and quickly scan and discriminate between objects. Skills involved in these tasks include short-
term visual memory, concentration, visual-motor coordination, visual discrimination, visual scanning, and
cognitive flexibility.
The Visual Spatial Reasoning Index (VSI) (standard score of 135) measures the child’s ability to evaluate visual
details and to understand visual spatial relationships to construct geometric designs from a model. The tests in
this area involve reconstructing block designs (scale score of 17) and analyzing visual puzzles (scale score of 15)
to identify composite pieces from an array of alternatives. The tests measure such skills as integration and
synthesis of part/whole relationships, attentiveness to visual details, and visual-motor integration.
The Fluid Reasoning Index (FRI) (standard score of 137) measures the child’s ability to detect the underlying
conceptual relationship among visual objects and to use reasoning to identify and apply rules. Tasks involve
Matrix Reasoning (scale score of 19), where the child must determine which comes next in a series of patterns
and Picture Concepts (scale score of 12) or Figure Weights (scale score of 14), which measures abstract
reasoning with visual information. These tasks evaluate skills in such areas as inductive and quantitative
reasoning, broad visual intelligence, simultaneous processing, and abstract thinking.
The Working Memory Index (WMI) (standard score of 130) measures the ability to register, maintain, and
manipulate visual and auditory information in conscious awareness. The tasks involved recalling the order of
digits recited (Digit Span, scaled score of 18) and pictures flashed on a screen (Picture Span, scaled score of
13). Registration requires attention, auditory and visual discrimination, and concentration. Maintenance is the
process by which information is kept active in conscious awareness using auditory or visual rehearsal.
Manipulation is mental resequencing of information based on the application of a specific rule. Skills required
include attention, concentration, and mental control.
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Ancillary Index Scales
In addition to the Primary Index Composites described above, it is also possible to conduct further assessment
in Ancillary Areas to assist in adding additional information. To this end, it is possible to consider Colby’s
overall Nonverbal Reasoning Index (based on scores from six subtests that do not include verbal responses)
using the following six subtests: Block Design, Visual Puzzles, Matrix Reasoning, Figure Weights, Picture
Span, and Coding. Colby’s Nonverbal Reasoning Index (NVI) was an Index score of 132 (124–137), which is
at the 98th percentile, in the Extremely High Range. His score for Verbal Comprehension (standard score of
142) was 10 points higher than his Nonverbal Reasoning Index (132), which indicates a relative weakness in
visual versus verbal reasoning, although both were in the Extremely High Range.
The General Ability Index (GAI) is derived from five different subtests (Similarities, Vocabulary, Block
Design, Matrix Reasoning, and Figure Weights). The GAI is preferable to the Full Scale IQ in cases where
the overall Full Scale IQ would be negatively influenced by lower scores in areas of Working Memory or
Processing Speed. However, in Colby’s case the difference between his GAI (standard score of 145) and his
Full Scale IQ (standard score of 142) was not significant (critical value = 3.05).
The third Ancillary Index that was calculated was the Cognitive Proficiency Index (CPI), which measures an
individual’s efficiency in learning and problem solving and is the composite score derived from four subtests
from the PSI and WMI (Digit Span, Picture Span, Coding, and Symbol Search). Colby’s score for the CPI
(Standard Score of 120, Range 111–126) was significantly lower than his GAI (145). The difference of 25
points met the criteria for significance surpassing the critical value of 9.29. Low scores on the CPI suggest
that his ability to process information (scanning, retrieving information, and executing written responses) is
well below his overall ability level.
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Woodcock Johnson Cognitive Test
The WJ-Cognitive is a test that measures psychological processing across a number of cognitive areas. Similar
to other measures used in this assessment, the WJ-Cognitive also provides scores as standard scores with an
average of 100 and standard deviation of 15. Scores on the Cognitive Fluency cluster and subtests are
presented in the table below.
Woodcock Johnson Cognitive Tests
CLUSTERS/Subtests Standard Score Percentile
COGNITIVE FLUENCY 97 43
Rapid Picture Naming 89 23
Retrieval Fluency 106 65
Decision Speed 108 71
EXECUTIVE FUNCTION
Pair Cancellation 87 20
Relative to his strong problem solving skills, Colby demonstrated a significant weakness in the area of
Cognitive Fluency, which measures the ability to rapidly retrieve information from memory in an accurate and
efficient manner. The tasks are relatively straight forward (naming a series of pictures, naming as many foods
as possible in one minute, searching and locating objects that go together in each of a series of rows).
However, all tasks have a common element in that they are very short and provide only a restricted time frame
for retrieval. Colby’s slow speed of response resulted in his lower scores, relative to similar-age peers. This
would suggest that Colby would require more time to complete tasks than would normally be anticipated
since he generates information at a slower pace. The pair cancellation task was also administered to evaluate
whether speed of scanning visual information contributes to his slow speed of response, and this also was an
area of significant weakness.
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Scores on the Wechsler Individual Achievement Test (WIAT-111) are also presented as standard scores,
which allows for a direct comparison of performance on achievement and ability tests. The mean standard
score is 100 and the standard deviation is 15. Academic scores are available in the table below.
Wechsler Individual Achievement Test (WIAT-111)
Composite and Subtest Score Areas Standard Scores Percentile Rank Range
Reading Comprehension and Fluency 111 77 (103–119)
Oral Reading Fluency 100 50 (93–107)
Reading Comprehension 118 88 (107–129)
Mathematics 122 93 (116–128)
Numerical Operations 112 79 (106–118)
Math Problem Solving 128 89 (119–137)
Spelling 137 99 (131–143)
Sentence Composition 134 99 (122–146)
* Score for Written Expression derived from the simple aggregate.
Colby’s academic skill levels suggest that reading level is lower than would be expected given his strength in
Verbal Comprehension noted on the WISC-V; however, this score was reduced due to his score for oral
reading fluency (rate of oral reading). Colby performed much higher on the task of reading comprehension.
He demonstrated very strong math problem-solving skills and the quality of his written expression was also at
a high level. Although tasks are not timed, it was noted that he required significantly more time than
anticipated to complete these tasks. Colby used an awkward pencil grasp for paper-and-pencil tasks, and
handwriting was difficult to decipher due to poor number and letter formations. Colby scored at the high
average range for numerical operations, which is below what would be anticipated given his ability level.
Colby used unusual strategies to assist in recalling multiplication tables (e.g., for 7 × 8, Colby added eight 7s
together to get 56); however, he was able to obtain correct answers using these methods.
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636
Ability/Achievement Discrepancy
Analysis of the discrepancy between ability and academic achievement is summarized in the discrepancy table
below. A discrepancy is considered significant if the achievement score is at or greater than one standard
deviation (15 points) below the ability score. Based on the scores below, at this time, Colby is scoring
significantly below his ability level in the area of Reading and Mathematics. Written expression was
commensurate with his ability. His ability to combine simple sentences into a compound sentence (standard
score of 133) was better than his performance on a task of sentence building, which required that he develop a
sentence to incorporate a target word. Colby required considerably more time on this less structured task
suggesting that he experiences problems organizing information and initiating tasks that are not organized for
him. Colby’s scores are presented in the discrepancy table, below.
Discrepancy Table
Achievement Cluster WIAT Achievement Score Ability WISC-V FS IQ Discrepancy
Reading 111 142 −31
Mathematics 122 142 −20
Written Expression 135 142 −7
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Conners Continuous Performance Tests
The CPT3 is a computer-generated assessment that measures an individual’s visual attention, vigilance,
impulsivity, and sustained attention when instructed to hit the space bar for every letter presented on the
computer screen, with the exception of the letter x. Colby’s responses indicated a valid profile with three
atypical T-scores. Colby’s profile suggests strong indications of inattentiveness and problems with sustained
vigilance.
The CATA measures an individual’s auditory attention during a computer-generated task that presents high-
tone sounds that are either preceded by a low-tone warning sound or played alone. Respondents are required
to respond only to presentations that feature a high tone preceded by a low tone. Colby’s results on this task
revealed two atypical scores suggesting some problems with inattentiveness and sustained attention. Responses
did not indicate an advantage to listening with either ear.
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Behavioral Rating Scales
The Achenbach System of Empirically Based Assessment (ASEBA)

The Achenbach System of Empirically Based Assessment (ASEBA) is a multi-informant and parallel
assessment system that allows for multiple raters to assess children and youth along a number of behavioral
and emotional indicators. The rating scales were completed by Colby (YSR), his mother (CBCL), and his
teacher (TRF). Scores are considered to be in the clinical range when they are at or above a T score of 70 (at
the 98th percentile); scores are considered to be in the At-Risk clinical range between 65 and 69; and scores
are considered to be Elevated when they are between 61 and 64. Scores are considered to be in the Normal
range when they are between 40 and 60.
Colby’s mother rated Total Internalizing within the clinically significant range (T = 73), while Colby’s self-
rating placed Total Internalizing within the borderline clinical range (T = 68). Colby (T = 72) and his mother
(T = 72) both endorsed significant levels of Somatic Complaints, while Colby’s mother also noted clinically
significant levels for Anxious/Depressed (T = 70) behaviors (feeling worthless, self-conscious, fearful, worried),
and Attention Problems (T = 70), noted in problems with concentration, restlessness, daydreaming, poor school
progress, and weak impulse control. Although Colby’s teacher did not indicate any syndromes to be within the
clinical or borderline clinical ranges, further analysis revealed that Inattention on the Attention Problems
subscale was at the 95th percentile, indicating problems with concentration, failure to finish tasks, daydreaming,
lack of motivation, underachievement, and poor schoolwork. Anecdotal comments from the teacher revealed that
Colby was late for classes 18 times in the first term and that effort was very inconsistent. Although his teacher
also noted overall Adaptive Functioning was within the borderline clinical range (T = 39), this was mainly due
to low scores for effort and performance. Colby and his mother also noted adaptive strengths in areas of
behavior, social competence, and participation in nonacademic activities (sports, hobbies, part-time job).

The Conners Rating Scales are multi-informant scales that collect information from multiple raters to assess
children and youth regarding symptoms of attention-deficit/hyperactivity disorder (ADHD) and commonly
associated behavioral and/or emotional concerns. The rating scales were completed by Colby, his mother, and
his teacher. Similar to the ASEBA, scores are considered to be in the clinical range when they are at or above
a T score of 70 (at the 98th percentile); scores are considered to be in the At-Risk clinical range between 65
and 69; and scores are considered to be Elevated when they are between 61 and 64. Scores are considered to
be in the Normal range when they are between 40 and 60.
Colby’s mother’s ratings revealed a significant elevation on the Psychosomatic Subscale (T = 72), noting
problems with stomachaches, aches and pains, and frequent before-school complaints. Therefore, parent
responses were consistent in endorsing somatic or psychosomatic complaints across both the CBCL and the
Conners Scales. Colby’s mother also noted significant problems in emotional responsiveness on the
Emotional Lability subscale (T = 67), evident in temper outbursts and abrupt mood changes. In addition, his
639
mother also noted a parent responses to the Conners Global Index Total (T = 67) endorsed the following
behaviors occurring much of the time: excitable and impulsive, failure to finish tasks, inattentive, easily
distracted, temper outbursts, fidgeting, easily frustrated, and abrupt mood swings.
Teacher ratings on the Conners scales noted significant elevations for Cognitive Problems/Inattention (T =
72), noted in behaviors of avoidance/reluctance to engage in tasks requiring sustained mental effort, failure to
finish tasks, and lacks interest in schoolwork. Teacher ratings for the DSM Inattentive Scale (T = 70) were
also indicative of significant problems: careless errors/misses details, avoids sustained mental effort, difficulty
organizing information, loses necessary items, poor follow-through, and ease of distractibility.
Emotional Lability (quick temper, ease of frustration, quick mood swings) was also noted to be within the
clinically significant range (T = 79) by Colby’s teacher. Colby also rated himself as having significant problems
on the DSM Inattentive scale (T = 72) of the CASS and endorsed “forgetful in daily activities” in addition to
all items that his teacher had indicated for the same scale.
Colby’s responses to the Beck Youth Inventories revealed that Anxiety (T = 67) and Depression (T = 63) were
moderately elevated, while Self-Concept (T = 44) was lower than average, at the 25th percentile. Colby
admitted to having many worries about school, getting bad grades, and his future.
He also endorsed fears of becoming ill and admitted to having fears about losing control. Trouble falling
asleep and staying asleep were also noted as problematic, often resulting in being late for school in the
mornings. Although there were no indications of suicidal ideation, the Child Depression Inventory (CDI-2)
was also administered to obtain additional information concerning possible depressive features. Colby’s overall
level of Depression on the CDI-2 (T = 47) was within normal limits with no significant findings for any of
the subscales. The most elevated scale on the CDI-2 was predictably on the Ineffectiveness scale (T = 59),
although this was not out of the normal range.
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Summary and Diagnostic Impressions
Colby is a 14-year-old teenager who was referred for assessment by his mother due to concerns regarding poor
school outcomes and temper outbursts. Colby is currently enrolled in the Grade 9 program, and reports
received at the end of his first term suggest that he is underachieving significantly based on his intellectual
ability, which is within the very superior range. In the past 6 months, in addition to a transition to high school
from elementary school, Colby has also had to deal with the recent split-up of his parents. These stressors
have likely caused preexisting problems to escalate, evident in increased levels of anxiety, depression, and
emotional reactivity (frustration, temper tantrums).
Although it is possible that Colby’s current reactions might be interpreted as an adjustment reaction to current
life stressors (transition to high school, parents’ separation), given the current assessment findings, family
history, and chronic nature of Colby’s academic difficulties, a diagnosis of attention-deficit/hyperactivity
disorder—predominantly inattentive presentation—is suggested. According to DSM-5 (APA, 2013) criteria,
Colby presents with at least six of the behaviors required to warrant such a diagnosis, noted in behaviors of
inattention, distractibility, problems with completing assignments, poor organizational skills, avoidance of
activities requiring sustained mental effort, and forgetfulness in daily activities. These behaviors have appeared
at home and at school and have been evident since Colby enrolled in formal education. Lack of diagnosis to
date, however, can likely be attributed to Colby’s extremely high level of intelligence, which has allowed him
to cope in the earlier grades and served to mask the severity of his problem. However, with increased emphasis
on written and independent work, Colby’s inability to engage in planned, meaningful, and goal-directed
behavior, and his reluctance to sustain effort in tasks that are long, arduous, and often group oriented, has
resulted in increasingly poor school performance.
Given the disparity between Colby’s intellectual ability and his poor performance, and in view of continued
family conflict, it is not surprising that Colby would also present with symptoms of anxiety, depression, and
lowered self-concept. Assessment results also reveal that Colby has a high level of emotional reactivity to
stressors that is primarily internalized and likely to find expression in somatic complaints (sleep problems,
digestive complaints, headaches). However, when frustration tolerance is especially low, Colby may also be
prone to externalize feelings of frustration in outbursts of anger. When Colby expresses his feelings in an
angry outburst, however, venting of feelings is often only temporary and often results in negative feelings of
loss of control and erosion of his self-concept.
Based on the diagnostic impressions, the following recommendations are suggested:
The importance of considering stimulant medication to assist with enhancing school performance was
thoroughly discussed with Colby and his mother.
It is essential that Colby’s father also attend a session to receive feedback concerning this assessment to
ensure understanding of Colby’s difficulties.
Colby should receive supportive psychotherapy to provide an outside venue to express his feelings
regarding his ADHD and family problems and to receive relaxation training to assist in reducing anxiety
641
levels and difficulties falling asleep.
The family should be engaged as a whole (father, mother, and son) or as two dyads (father–son,
mother–son) in a training program to develop problem-solving skills to address key areas of conflict,
such as responsibilities, boundaries (rights), and curfews. A program similar to that developed by Robin
and Foster (Robin, 1990) is suggested to develop consistent problem-solving approaches that will focus
on using behavioral techniques to reduce the potential for engaging in emotionally reactive patterns.
Results of the assessment should also be discussed with school officials to provide greater understanding
of how the school might address Colby’s needs for support in several areas. Organizational aids (e.g.,
day planner or agenda, school mentor) should be provided to help Colby remain on task and to provide
guidelines for breaking tasks down into smaller segments to assist with sustaining goal-directed behavior
and to assist Colby in monitoring his performance. Greater use of home and school communication
would also be helpful. Colby would also benefit from being given additional time to complete tests, due
to slow writing and processing skills.
Remediation in handwriting skills or keyboarding skills would assist in improved speed of written
expression. If obtaining one is possible, the use of a laptop would likely greatly enhance performance.
Provide extra time during test-taking activities.
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Case Discussion and Differential Diagnosis
Evidence in support of a diagnosis of ADHD, predominantly inattentive presentation:
1. Symptom Criteria
Colby demonstrated at least six of the required diagnostic criteria of the DSM-5 (APA, 2013) for
attention-deficit/hyperactivity disorder—predominantly inattentive presentation, evident prior to 12
years of age and across at least two settings (home, school): difficulty sustaining attention, fails to finish,
difficulty organizing tasks, avoids tasks with sustained mental attention, loses necessary items, easily distracted,
and often forgetful.
2. Associated Features Often Linked With ADHD
These features noted in the DSM as associated with ADHD were also evident: low frustration
tolerance, temper outbursts, mood lability, poor self-esteem, and dysphoria.
Negative parent–child interactions (especially with the father) and academic deficits and school
problems often associated with ADHD-inattentive were also noted in the presenting problems.
Poor handwriting and slow speed of writing.
More than half of children with ADHD will also exhibit dysgraphia (Mayes, Calhoun, Chase, Mink, &
Stagg, 2009). Dysgraphia is a specific type of learning disorder of written expression that may manifest
in spelling errors, accuracy of grammar and punctuation and organization of written information (DSM-
5; APA, 2013, p. 67). In their study of youth with ADHD and controls, Adi-Japha and colleagues
(2007) found that relative to controls, children with ADHD exhibited poor quality of handwriting and
spent more time writing long (but not short) words. In addition to dysgraphia, there is also a condition
referred to as dypraxia, which is also known as developmental coordination disorder (DCD). This
particular disorder is marked by coordination of motor skills that presents well below age expectations,
such as is evident in clumsiness or “inaccuracy of performance of motor skills,” such as handwriting,
using scissors, or participating in sports, and deficits significantly interfere with daily functioning, in
such areas as self-care, and academic/school productivity (APA, 2013, p. 74). Children with DCD often
demonstrate a “marked slowness in execution,” and “handwriting competence is frequently affected . . .
affecting legibility and/or speed of written output.” In their study, Adi-Japha and colleagues (2007)
found that children with DCD produced letters and words that were inconsistent and disproportionate
in size, resulting in inefficient and illegible written production, and an inability to stay within limits for
writing and copying in the schoolroom. Results indicated that for children with ADHD who had
normal reading skills, handwriting problems were related to impaired motor processes. The DSM-5
notes that DCD is distinguished from specific learning disorder “by the emphasis on the motoric
component of written output skills” (APA, 2013, p. 75). The DSM-5 does not consider DCD as a
learning disorder, but as a motor skills disorder; however, motor skills disorders are classified under the
category of neurodevelopmental disorders.
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In order to gain better control when writing, Schoemaker, Ketelaars, Van Zonneveld, Minderaa, and
Mulder (2005) found that children with ADHD increased the mean pen pressure. Although the
resulting product is still disproportionate, and this does not impact fluency, it may explain why many
children and youth with ADHD complain that their hands are stiff and that writing is a tiresome task.
3. Other Behavioral Risks Linked to ADHD
a. sleep difficulties, such as falling asleep, frequent waking, tiredness due to sleep–wake schedule
(Barkley, 1991), difficulty getting up in the morning (Barkley, 1998), and initial and middle
insomnia (Chervin et al., 2002); and
b. increased rates of academic failure and depression reported at adolescence due to demands for greater
independent work in light of the ADHD, and failure to complete assignments based on poor
organization skills and work habits (Barkley, 1998; Cantwell, 1996).
4. Cognitive Associations Linked to ADHD
Colby’s scores on the WISC-IV were extremely high overall (very superior range); however, his weakest
scores were on the Coding and Symbol Search subtests, which compose the Processing Speed Index (PSI),
which in this case was significantly lower than all other indices. The next lowest subtest was the Digit
Span, with the Working Memory Index (WMI) significantly lower than Verbal Comprehension Index.
Processing Speed Index (PSI). The PSI comprises the Coding and Symbol Search subtests. Both tests
have a 2-minute time limit and are scored for speed and accuracy. While Coding requires psychomotor
speed (copy symbols to match with the correct numbers), Symbol Search is a visual scanning task that
requires the child to determine if the target symbol is represented in a given group of symbols. The PSI
is a measure of psychomotor speed and coordination, short-term visual memory, attention, and cognitive
flexibility (Sattler & Dumont, 2004).
Studies have shown that children with neurological disorders (ADHD, high-functioning autism,
learning disability) perform less well on the PSI and the Working Memory Index (WMI) than children
without these disorders (Calhoun & Mayes, 2005; Sattler & Dumont, 2004). In their study of subtypes
of ADHD (ADHD-combined [ADHD-C] and ADHD-inattentive [ADHD-I]), Mayes, Calhoun,
Bixler, and colleagues (2009) found that children in the ADHD-I groups (ADHD with anxious-
depressed symptoms and ADHD alone) were significantly slower on the PSI than the ADHD-C
groups.
Results from studies by Calhoun and Mayes (2005) and Mayes, Calhoun, Chase, and colleagues (2009)
provide support for significant processing speed differences in subtypes of ADHD, with the inattentive
type showing the greatest deficit in processing speed, due not only to attention difficulties, but to
“sluggish cognitive tempo, under-arousal, low energy and lethargy (hypoactivity)” that can be associated
with the predominantly inattentive type (Calhoun & Mayes, 2005). Colby’s scores on the PSI (103)
were significantly lower than all other indexes and similar to most with ADHD-inattentive type; coding
was the lowest scale score of all (10).
Working Memory Index (WMI) or Freedom From Distractibility Index (FDI). The WMI (WISC-IV)
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consists of a digit-repetition task (forward and backward) and a letter–number sequence task (mixed
presentations of numbers and letters are recalled with the numbers first in numerical order, followed by
the letters in alphabetical order). Previously, the WISC-III contained a Freedom From Distractibility
Index (FDI) composed of the digit span task and a mental arithmetic task. The current WMI removes
the possibility of performance being compromised by weak math skills. The WMI and the previous FDI
both measure attention and working memory (Sattler & Dumont, 2004). There is much conflicting
evidence as to whether the WMI/FDI can successfully discriminate between children with ADHD and
other populations (learning disabled, normal). While there is consensus that the WMI/FDI should not
be used as an exclusive marker for ADHD (Kaufman, 1994; Kaufman & Lichtenberger, 2000),
Schwean and Saklofske (1998) found that the WMI/FDI was the lowest index score for children with
ADHD across three separate studies (Anastopoulos, Spisto, & Maher, 1994; Prifitera & Dersh, 1993;
Schwean, Saklofske, Yackulic, & Quinn, 1993). Calhoun and Mayes (2005) found that 87% of children
with ADHD-inattentive type and 82% of children with ADHD-combined type experienced
significantly lower scores on WMI/FDI relative to their Verbal Comprehension Index (VCI) and
Perceptual Reasoning Index (PRI). Colby’s score on the WMI (129) was significantly below scores for
VCI (155) and PRI (149).
5. Risks Factors from the Developmental History
Prenatal influences/birth history
Difficult delivery by forceps
Early eating and sleeping difficulties
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Differential Diagnoses
Rationale in Ruling Out Other Comorbid or Competing Diagnoses

1. ADHD-Combined Presentation. ADHD-combined type was ruled out, since Colby did not present with
sufficient symptoms (six) of impulsivity and hyperactivity.
2. ADHD + Mood (major depressive disorder, persistent depressive disorder, bipolar disorder). Since depressed
patients also note diminished concentration and sleep difficulties, and bipolar patients can elicit
irritability, poor control, physical hyperactivity, distractibility, and excessive talking when in a manic
state, there is a need to rule out the possibility of comorbid mood disorders.
Mood disorders and ADHD co-occur in approximately 20% to 30% of the population. Since ADHD
without hyperactivity is associated with higher levels of internalizing symptoms, including depression
(Schmidt, Stark, Carlson, & Anthony, 1998), investigating the possibility of a mood disorder is essential
in the current evaluation. In this case, major depressive disorder, persistent depressive disorder, and bipolar
disorder were ruled out because symptoms of sleep problems, concentration problems, and low self-
esteem were better accounted for by associated features of ADHD and related to lack of academic
progress or positive feedback regarding academics. Test results support this assumption.
3. ADHD-Anxiety disorders; obsessive compulsive and related disorders: ADHD and anxiety have been found
to overlap or co-occur in 25% to 40% of the population. Anxiety is thought to positively moderate for
more impulsive behaviors through mechanisms of behavioral inhibition (Wenar & Kerig, 2000).
Anxiety in childhood can take the form of separation anxiety (SAD), selective mutism, phobias, panic
attacks, or general anxiety disorder (GAD). In this case, although Colby did not present with symptoms of
any of the anxiety disorders, he shared many of the symptoms suggestive of GAD (restless, fatigued,
irritable, difficulty concentrating, sleep disturbance). However, GAD was ruled out because the focus of
the anxiety was confined to performance anxiety associated with ADHD.
Given Colby’s tendencies to internalize, however, there is a possibility that Colby might develop more
pronounced symptoms of anxiety and/or depression or a somatoform disorder in the future, if the
ADHD cannot be managed more successfully.
4. ADHD-Specific learning disorders (disorder of written expression): Colby presents with significant
underachievement relative to his intellectual potential. It is the current belief that Colby’s difficulties
with written expression are primarily due to problems with organizing information due to ADHD.
However, it is important to monitor progress in this area very closely, to pinpoint whether there are
other major problems contributing to organizing information for the purposes of written expression.
5. Developmental Coordination Disorder (CDC). Although handwriting was poor, due to poor pencil grip,
Colby was well coordinated in all other activities, was good in sports, and achieved developmental
milestones within the norm. However, handwriting is immature, and he takes excessive time to
complete written material. If keyboarding skills were applied, it would be likely that Colby would be
able to produce increased amounts of written information. It is the current proposition that a diagnosis
646
of CDC be placed on hold at this time until keyboarding is introduced and writing skills are reevaluated.
647
Case of Scott Michaels: Results from Psychological Testing
Results of the multimodal assessment battery are presented in the form of standard scores, T scores, and/or
percentiles. Anecdotal comments from the clinic psychologist (e.g., comments on test behaviors) are presented
whenever these comments might aid in interpretation of the findings. In addition, a list of endorsed items is
provided for any scales (checklists and rating scales) elevated to clinical levels to facilitate interpretation of
behavioral patterns within and across sources of information.
648
General Cognitive (WISC-V, WJ Cog) and Academic (WIAT-III) Results
Wechsler Intelligence Scale for Children, Fourth Edition (WISC-V)
Index and Scales Standard Score (Range 95% confidence level) Percentile
Verbal Comprehension Index 83 (Range 77–91) Borderline to Average Range 13
Similarities* (7)
Vocabulary* (8)
Comprehension (6)
Visual Spatial Index 93 (Range 85–100) Low Average to Average Range 30
Block Design* (9)
Visual Puzzles (10)
Fluid Reasoning Index 93 (Range 82–96) Low Average to Average Range 30
Figure Weights (7)
Working Memory Index 80 (Range 74–89) Borderline to Low Average 9
Digit Span* (7)
Picture Span (6)
Processing Speed Index 90 (Range 82–100) Low Average to Average Range 26
Symbol Search* (10)
Coding (7)
Full Scale IQ 88 (Range 83–93) 21

Note: Scores in bold with an asterisk were used to calculate the Full Scale IQ.
649
Administrator Comments:
Requested many repetitions of more complex verbal information, such as comprehension questions. Extreme
difficulty with digit span and picture span, and was not focusing on the picture span task. Could not
remember the instructions from trial to trial; word-finding problems on similarities task. Vocabulary limited.
As comprehension questions became more involved, he got more confused and required prompting to expand
verbal responses. Often off-target or peripheral in responses; missed the main point. Responded to “lost” as if
responding to “found” in comprehension question and exchanged meanings for interrogatives (e.g., responded
to a what question with a when response). Slow to respond to visual tasks. Scott did not earn any bonus points
on block design. He did better on visual nontimed tasks. Poor attention to details: missed a symbol on
Coding, which made five incorrect symbols in a row and had to go back and erase and restart, which cost him
time.
Subject Standard Score Percentile Grade Level
Reading Fluency and Comprehension 86 18
Reading Fluency 95 37 3.5
Reading Comprehension 80 10 2.0
Mathematics 88 20
Numerical Operations 100 50 4.0
Math Problem Solving 82 11 2.4
Spelling 86 18 2.3
Visual whole-word speller; poor phonetic speller and sound substitutions (correct = qurecht; circle = curcal).
Reading comprehension revealed poor sequencing of information, which altered the meaning.
Sequencing and processing problems lowered scores in math problem solving (word problems), reading
comprehension (could not retain sequence of information to assist with comprehension).
Seemed to have considerable difficulty with retrieving words when asked (name as many animals as you can,
etc.), and also took significantly longer than expected to label pictures of common objects. Became very
650
frustrated on retrieval tasks and said that it wasn’t fair because he wasn’t given enough time.
Woodcock Johnson Cognitive Test (WJ Cog)
Cluster/Area Standard Score Percentile
Overall Comprehension/Knowledge 86 (82–90) 17
Verbal Comprehension 83 (78–88) 13
General Information 89 (89–94) 23
Overall Processing Speed 76 (74–79) 6
Visual Matching 75 (72–79) 5
Decision Speed 83 (79–87) 13
Overall Cognitive Fluency 67 (65–69) 1
Retrieval Fluency 74 (67–82) 4
Rapid Picture Naming 70 (68–71) 2
651
Assessment results are presented for Scott’s responses to three assessment instruments that measure social,
Achenbach & Rescorla, 2000); the Conners Rating Scales-Revised (Conners, 1997); and the Beck Youth
Inventories of Emotional and Social Impairment, 2nd ed. (Beck, Beck, & Jolly, 2005).
ASEBA
The scores below are from the multi-informant assessment using the Child Behavior Checklist (CBCL;
completed by Scott’s mother) and the Teacher Report Form (TRF; completed by Scott’s teacher).
Anecdotal Comments (Teacher): Starting to get more argumentative. Can be bossy at times,
especially with younger children. Academics are starting to slide. Good sense of humor but can also
be sarcastic. Good when he is doing what he wants to do. Can be stubborn and immature.
SYNDROMES CBCL (T Score) TRF (T Score)
INTERNALIZING PROBLEMS
Anxious/Depressed 65* 61
Withdrawn/Depressed 67* 64
Somatic Complaints 56 57
Total Internalizing 68* 62
Other Problems
70*
Social Problems 65*

Doesn’t get along, Jealous, Not
liked, Prefers younger kids
Thought Problems 65* 58
70
70*
Acts young, Fails to finish,
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Attention Problems Acts young, Fails to finish, Can’t sit still, Daydreams, Impulsive, Problems
Stares, Confused with directions, Poor schoolwork,
Messy, Inattentive, Doesn’t listen
Rule Breaking 65* 56
73*
Argues, Brags, Mean, Demands attention,

Aggressive Behavior 63
Destroys own stuff, Disobeys, Jealous, Fights,
Attacks, Screams, Shows off, Stubborn, Mood
changes, Temper, Loud play
Total Externalizing 71* 62
TOTAL
65* 67*
PROBLEMS
Teacher Attention Hyperactive/Impulsive 95th

Inattention 95th Percentile
Problems Subscale Percentile
Note: Numbers with asterisk indicate scales in the significant range (above 93rd percentile). Individual items endorsed by the respondent
are listed for each of the significant scales.

The Conners rating scales allow for multiple informants to provide information concerning common attention
problems and symptoms of attention-deficit/hyperactivity based on DSM criteria. There are long and short
versions of the rating scales available. In this case, long versions were completed by Scott’s mother and
teacher.
Conners Revised Scales
Parent (CPRS-R:L) (T
Teacher (CTRS-R:L)(T Scores)
Scores)
71*
Argues, Loses temper,

Irritable, Defies,
Oppositional 65*
653
Touchy/annoyed,
Blames others,
Annoys others
70*
Cognitive Forgets what he has learned, Careless mistakes,

60
Problems/Inattention Avoids tasks of sustained effort, Doesn’t listen,
Problems with organization, Loses things, Poor
follow-through
70*
66*
Hyperactivity Excitable impulsive, Restless/overactive, Difficulty

Problems with quiet
waiting his turn, Fidgeting, Difficulty with quiet
play, Restless
play, Blurts out answers, Interrupts others
Anxious/Shy 50 60
Perfectionism 52 49
68*
Social Problems 53 Poor social skills, Does not know how to make
friends, Unaccepted by group, One of last to be
picked for games
Psychosomatic 42 Not on the Teacher’s Scale
Conners ADHD
60 68*
Index
54
67*
Restless/Impulsive
72*
65*
Emotional Lability
Cries often and easily,
66*
Rapid mood shifts
Global Index Total 62
DSM Scales
654
72*
Forgets what already learned, Poor attention to

DSM: Inattentive 59 details, Avoids tasks of sustained attention, Does
not seem to listen, Difficulty organizing, Loses
things necessary for tasks, Fails to follow-through
68*
70*
DSM: Fidgets, Squirms,

On the go, Leaves seat, Problems waiting turn,
Hyp/Impulsive Problems with quiet
Problems remaining seated, Fidgets, Interrupts,
play, Problems
Incessant talking, Always on the go
remaining seated
DSM: Total 66* 70*

to indicate the degree to which an item is like or unlike them: Never = 0, Sometimes = 1, Often = 2, Always =
3.
Beck Youth Inventories
T
Score
Feel strong; Like myself; Just as good as others; Normal; Good person; Do things
57 75
well; Happy to be me; Proud of self
Depression Inventory for Youth
Feel like bad things happen to me; I want to be alone 39 11
655
My dreams scare me, I’m afraid I might get hurt, Afraid something bad might
happen to me 40 15
Anger Inventory for Youth
People try to cheat me; I feel like screaming; People are unfair; People try to hurt
me; Life is unfair; People bully me; People make me mad, bother me, try to control
86* 99
me, put me down, are against me; I get angry; When I get mad, I stay mad and have
trouble getting over it
Disruptive Behavior Inventory for Youth
Others get me into trouble, I fight with others, I like getting people mad, I hate
listening to others, I argue with adults, I like it when others are scared of me, I like 68* 94
to trick people, I break things when angry, I swear at adults
Note: Scores in bold with an asterisk are at or above the 93rd percentile.
656
Case of Arthur Watson: Results from Psychological Testing
percentiles. Interns will be expected to evaluate, interpret, and integrate findings to formulate a more refined
diagnostic impression. Anecdotal comments from the clinic psychologist (e.g., comments on test behaviors)
are presented whenever these comments might aid in interpretation of the findings. In addition, a list of
endorsed items is provided for any scales (checklists and rating scales) elevated to clinical levels to facilitate
interpretation of behavioral patterns within and across sources of information.
657
Arthur is left-handed. He asked for numerous repetitions of comprehension questions. He experienced

problems understanding verbal instructions without any visual aids. Better able to process visual information.
Enjoyed picture concepts, until it became more complex and then got frustrated, and engaged in random
responding. Block design was an all-or-nothing approach (he either got it right or did not get it at all).
Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V)
Verbal Comprehension (VCI) 55 (Range 51–62) 0.1
Similarities* (1) Extremely Low Range
Vocabulary* (1)
Comprehension (3)
Visual Spatial Reasoning (VSI) 69 (Range 65–76) 2
Block Design* (4) Extremely Low Range
Visual Puzzles (7)
Fluid Reasoning (FRI) 65 (Range 59–62) 1
Matrix Reasoning* (4) Extremely Low Range
Picture Concepts* (6)
Figure Weights (1)
Working Memory 55 (Range 51–62) 0.1
Digit Span* (2) Extremely Low Range
Picture Span (2)
Processing Speed 54 (Range 49–61) 0.1
658
Symbol Search (2) Extremely Low Range
Coding* (2)
Full Scale IQ 57 (Range 53–64) 0.2
Extremely Low Range

Note: Scores in bold with an asterisk were used to calculate the Full Scale IQ.
Very frustrated. Said he knew it but forgot because it is summer. Upset with math computations, used his
fingers for counting, and said the test was not fair because he didn’t take that type of math yet. Number and
letter formations were very large and immature. Responded well to a calm approach and confirmation that he
did his best and that was most important.
Results of the academic assessment revealed significant deficits in all areas of functioning. Math Problem
Solving was discontinued because Arthur did not understand the questions and stated that he had not taken
that kind of math yet.
Wechsler Individual Achievement Test (WIAT)
Reading Comprehension 52 0.1 1.5
Reading Fluency 50 0.1 1.3
Reading Composite 50 0.1 1.3
Spelling 57 0.2 1.5
Math Computation Below 45 >0.1 1.5
ASEBA
completed by Arthur’s parents). The Teacher Report Form (TRF) was not available, since Arthur is currently
not attending school, and it was not possible to obtain the Youth Self Report (YSR) due to
comprehension/attention problems.
Anecdotal Comments:
Interview revealed that parents believe that attention problems are a result of ADHD and do not consider that
these symptoms may be an indication that Arthur is frustrated; is unable to attend, finish tasks, and achieve in
659
school; and is confused due to his inability to comprehend tasks.
SYNDROMES CBCL (T Score)
INTERNALIZING PROBLEMS
70* Clinical Range

Anxious/Depressed
Lonely, Feels others are out to get him, Worthless, Nervous, Sad, Worries
Withdrawn/Depressed 65* Borderline
68* Borderline
Somatic Complaints
Complains of headaches, Tired, Aches
Total Internalizing 71* Clinical Range
Other Problems
70* Clinical Range

Social Problems
Acts young, Not get along, Not liked, Clumsy
Thought Problems 65*
85* Clinical Range
Attention Problems
Acts young, Fails to finish, Can’t concentrate, Problems sitting still,
Confused, Impulsive, Poor schoolwork, Inattentive, Stares
Rule Breaking 55
75* Clinical Range
Aggressive Behavior
Demanding attention, Attacking others, Temper outbursts, Teasing,
Threatening, Argues, Jealous, Mood changes, Loud
Total Externalizing 68* Borderline
TOTAL 72* Clinical Range
660
PROBLEMS 72* Clinical Range
Other Problems: Speech Problems, Sleep problems, Bites nails

Note: Numbers with asterisks indicate scales in the significant range (at or above the 93rd percentile). Individual items endorsed by the
661
Measures of Adaptive Functioning
Vineland Adaptive Behavior Scales

These scales were completed by the caregiver and provide an index of adaptive functioning in three areas:
Communication, Daily Living, and Socialization.
Vineland Adaptive Behavior Scales
Domains Raw Score Standard Score Age Equivalent
Communication Domain
Receptive, Expressive and Written Communication
Total Communication 125 83 12 years 6 months
Daily Living Skills Domain
Personal, Domestic, and Community
Total Daily Living Skills 161 99 15 years 3 months
Socialization Domain
Interpersonal Skills, Play and Leisure Skills, Coping Skills
Total Socialization Skills 117 96 14 years 9 months
Anecdotal Comments:
Arthur’s chronological age is 15 years 5 months. Parent believes that Arthur is functioning at his appropriate
age level in the majority of areas. Communication is in the low average range.
Anecdotal Comments:
Consistent with ratings on the Vineland scales, Arthur’s mother rates his functioning on Part I domains
(adaptive functioning) to be above his age level in all areas, except Language Development. Ratings for Part II
domains (social and emotional maturity) reveal problems in disturbing interpersonal behaviors and stereotyped
and hyperactive behaviors.
American Association of Mental Retardation (AAMR) Adaptive Behavior Scale:

ABS-S:2
662
PART I: Domain Scores Standard Score (0 to 20) Percentile Age Score
Independent Functioning 17 99 16+
Physical Development 10 50 16+
Economic Activity 11 63 16+
Language Development 7 16 8 years 6 months
Numbers and Time 11 63 16+
Prevocational/Vocational 10 50 16+
Self-direction 20 37 16+
Responsibility 11 63 16+
Socialization 9 37 16+
American Association of Mental Retardation (AAMR) Adaptive

Behavior Scale: ABS-S:2 (higher standard scores indicate higher
adjustment)
PART II: Domain Scores Standard Score (0 to 20) Percentile
Social Behavior 9 37
Conformity 10 50
Trustworthiness 14 91
Stereotyped and Hyperactive 8 25
Self-Abusive Behavior 63 11
Social Engagement 10 50
Disturbing Interpersonal Behavior 7 16
663
Case of Shirley Yong: Results From Psychological Testing
percentiles. Interns will be expected to evaluate, interpret, and integrate findings to formulate a more refined
diagnostic impression. Anecdotal comments from the clinic psychologist (e.g., comments on test behaviors)
are presented whenever these comments might aid in interpretation of the findings. In addition, a list of
endorsed items is provided for any scales (checklists and rating scales) elevated to clinical levels to facilitate
interpretation of behavioral patterns within and across sources of information.
664
Methodical approach to completing the block design task, and she did not earn any bonus points due to the
time taken. Very perfectionistic, lining up edges on blocks so they matched perfectly. Although picture
concepts and matrix reasoning are not timed, Shirley spent excessive time agonizing over her selections, and
changed her responses often, throughout. Multiple responses to verbal questions, as if unsure of her responses,
and elaborated extensively, often resulting in responses digressing from the original point. Frequent requests
for feedback regarding her responses, for example, “Is that right?” Processing speed suffered from excessive
check back to insure responses were correct.
Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V)
Verbal Comprehension Index 100 (Range 93–107) Average Range 50
Similarities* (9)
Vocabulary* (11)
Comprehension (11)
Visual Spatial Index 84 (Range 79–93) Low Average Range 14
Block Design* (7)
Visual Puzzles (8)
Fluid Reasoning Index 86 (Range 82–95) Low Average Range 17
Picture Concepts* (8)
Figure Weights (7)
Working Memory Index 83 (Range 77–92) Low Average Range 13
Digit Span* (8)
Letter–Number Sequence (6)
665
Processing Speed Index 83 (Range76–94) Low Average Range 13
Symbol Search* (8)
Coding (6)
Full Scale IQ 86 (Range 81–91) Low Average Range 18

Note: Scores in bold with an asterisk were used to calculate the Full Scale IQ Score.
Word decoding was not fluid. Often stopped to check for feedback. Read very deliberately. Math questions
noted several erasures and changed answers. Used tally marks in the margins to check on accuracy of
multiplication tables. Shirley counted on her fingers to check addition. Did not attempt many math items,
and left them blank. Spelling also took additional time due to perfectionistic tendencies and careful attention
to letter formations. Did not use cursive writing because she said that printing was neater.
Reading Fluency and Comprehension 92 30
Reading Fluency 95 37 Grade 5.5
Reading Comprehension 93 32 Grade 5.3
Mathematics 88 21
Numerical Operations 86 18 Grade 4.2
Math Problem Solving 89 22 Grade 4.4
Spelling 106 66 Grade 6.0
Sentence Composition 95 37 Grade 6.1

Note: Score for Written Expression derived from the simple aggregate.

Assessment results are presented for Shirley’s responses to five assessment instruments that measure social,
Achenbach & Rescorla, 2000), the Conners Rating Scales-Revised (Conners, 1997), the Beck Youth
666
Inventories of Emotional and Social Impairment, 2nd ed. (Beck, Beck, & Jolly, 2005), the Child Depression
Inventory (CDI; Kovacs, 1992), and the Revised Children’s Manifest Anxiety Scale (RCMAS-2; Reynolds &
Richmond, 2008).
ASEBA
completed by Shirley’s mother), the Teacher Report Form (TRF; completed by Shirley’s teacher), and the
Youth Self Report (YSR; completed by Shirley).
Anecdotal Comments:
On the Anxious/Depressed scale, all three raters endorsed perfectionistic, nervous, worries.
TRF (T
SYNDROMES CBCL (T Score) YSR (T Score)
Score)
INTERNALZING PROBLEMS
72*
73*
Fear of 72*
Anxious/Depressed
Fearful, Self- mistakes,
Cries, Feels guilty, Self-conscious
conscious Very
conforming
68*
69*
Withdrawn/Depressed 66*
Secretive,
Secretive, Shy, Underactive, Withdrawn
Underactive
74* 69*
Somatic Complaints 66*

Tired, Aches, Tired, Aches, Headaches, Stomach
Nausea Problems
75* Clinical 72* Clinical

Total Internalizing 77* Clinical Range
Range Range
Other Problems
70*
667
Social Problems 57 63 Not get along, Teased, Not liked,
Withdrawn
70*
73* 70*
Thought Problems Obsessions,

Obsessions, Obsessions, Repeats acts, Collects stuff,
Repeats
Repeats acts Strange behavior
acts
70*
67*
Attention Problems Concentration, 60

Concentration, Confused, Daydreams,
Confused,
Nervous, Poor schoolwork
Nervous
Rule Breaking 50 50 50
Aggressive Behavior 50 50 50
Total Externalizing 44 42 27
TOTAL PROBLEMS 58 58 52
Fears, Nail Fears, Fears school, Gets hurt a lot, Bites

biting, nails, Nightmares, Eats too much,
Other Problems
Nightmares, Overweight, Sleeps less, Sleep problems
Sleeps less (wakes up in middle of night)
Note: Numbers in bold with an asterisk indicate scales in the significant range (at or above the 93rd percentile). Individual items endorsed by the

The Conners rating scales allow for multiple informants to provide information concerning common attention
problems and symptoms of attention-deficit/hyperactivity based on DSM criteria. There are long and short
versions of the rating scales available. In this case, the long versions were completed by Shirley’s mother and
teacher.
Revised Conners Rating Scales
668
Parent (CPRS-R:L) (T Scores) Teacher (CTRS-R:L) (T Scores)
Oppositional 62 46
70*
69*
Cognitive Difficulty with homework, Sustained

Forgets what learned, Fails to
Problems/Inattention mental effort, Fails to complete work,
finish, Not reading as expected,
Trouble concentrating, Needs
Poor in math
supervision
Hyperactivity 44 46
85* 78*
Anxious/Shy Timid, Afraid of people, Afraid of new Feelings easily hurt, Timid, Easily
situations, Lots of fears, frightened, Sensitive to criticism,
Shy/withdrawn, Clings to adults Shy/withdrawn
85*
88*
Perfectionistic, Everything must
Everything must be just so, Keeps
be just so, Keeps checking and
Perfectionism checking and rechecking, Fusses about
rechecking, Overfocused on
cleanliness, Must be done same way,
details, Likes neat and clean,
Rigid, Has rituals, Sets high goals for
Things done same way every time,
self, Upset if things are rearranged
Rigid
90*
84*
Unaccepted by group, Last to be
Social Problems Loses friends quickly, Doesn’t know
picked, No friends, Doesn’t know
how to make friends, Feels inferior to
how to make friends, Poor social
others
skills
90*
Psychosomatic Stomachaches, Aches and pains, Aches Not on Teacher Scale

before school, Complaints without
cause, Headaches, Tired/fatigued
67*
Conners ADHD
669
Conners ADHD Problems with sustained mental effort, 62
Index Concentration problems, Fails to
finish, Inattentive
Restless/Impulsive 62 46
Emotional Lability 60 58
Global Index Total 62 54
DSM Scales
DSM: Inattentive 62 66*
DSM:
43 45
Hyperactive/Impulsive
DSM: Total 54 58
Note: All scores in bold with an asterisk represent scores that are at or above the 93rd percentile.

that indicates the degree to which an item is like or unlike them: Never = 0, Sometimes = 1, Often = 2,
Always = 3.
Anecdotal comments:
For the Anxiety inventory, Shirley responded with a rating of often or always for 80% of the items on the scale
(16 out of 20 items).
T
Score
28 4.5
Just as good as other kids, Good at jokes, People think I am good at things, Like my
body
670
Trouble sleeping, Feel no one loves me, Stomach hurts, Feel bad things will happen, 70* 95
Feel stupid, Do things badly, Feel bad about what I do, Feel like crying, Feel sad
Worry might be hurt at home, Scary dreams, Worry at school, Think of scary
things, Worry about being teased, Afraid of making mistakes, Get nervous, Afraid 79* 98.5
of being hurt, Worry people might get mad at me, I worry a lot, Problems sleeping,
Heart pounds, Afraid bad things will happen to me, Afraid might get sick
Anger Inventory for Youth
57 82
Think people are unfair, Think others try to hurt me, Life is unfair, People bully
me, People try to put me down
Disruptive Behavior Inventory for Youth
(No ratings 2 or higher) 47 47

671
Further Assessment of Anxiety and Depression
Revised Children’s Manifest Anxiety Scale, 2nd ed. (RCMAS-2)

The RCMAS-2 is a children’s self-report scale used to assess anxiety levels in children and youth. This
recently revised scale can be used with children 6 to 19 years of age and contains five scales, including a scale
that provides a measure of validity of the child’s responses (consistency index).
Anecdotal Comments:
Physiological symptoms included feel sick to my stomach, hands feel sweaty, and have trouble getting my
breath. Endorsed majority of items for worry and feeling anxious around other people (social anxiety).
RCMAS-2
Scale T Score Percentile
Physiological Anxiety 68* 96
Defensiveness 50 51
Worry 73* 99
Social Anxiety 70* 98
Inconsistent Responding Index 45 30

Child Depression Inventory: CDI

This self-report instrument has 27 items that are arranged in a hierarchy from little to moderate and severe
problems (e.g., I can do most work; I can do some work. I can’t do any work). Children select which response from
the three alternatives is most like them.
Child Depression Inventory (CDI-2)
T
Scale Percentile
Score
Total CDI Score 74* 99
Negative Mood
Sad many times, Worry bad things will happen to me, Things bother me many 64 92
672
times
Interpersonal Problems
67* 94
Do not like being with people many times, Get into fights with others often
Ineffectiveness
Do many things wrong, Have to push myself to do schoolwork, Schoolwork is not 70* 98
as good as before, Can never be as good as other kids
Anhedonia
I have trouble sleeping every night, Tired all the time, Many days I do not feel like 69* 97
eating, Worry about aches and pains, Feel alone many times
Negative Self-Esteem
Not sure if things will work out for me, Do not like myself, Think about killing 73* 99
myself, but would not do it, Look ugly, Not sure if anybody loves me
Hopeless Scale: Kazdin (1986)

True-and-false scale to assess degree of hopelessness. Endorsed the following items as FALSE: Want to grow
up because . . . things will get better; Can imagine my life 10 years from now; I will get more good things in
life than most other kids. Endorsed the following items as TRUE: Things just don’t work out the way I want
them to; Tomorrow seems unclear and confusing to me. Total Score = 5, which is just below the threshold for
High Hopelessness.
673
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676
Appendix B Systems of Classification
Given the complexity of issues involved in child and adolescent psychopathology, it is not surprising that
clinicians may reveal wide variations in how they conceptualize maladjustment in childhood. In the
introduction, the case of Terry Hogan provided a living example of the myriad explanations that could be
presented to explain the emotional and behavioral concerns that were evident, based on the assumptions
inherent in different theoretical perspectives. This disparity is evident in how terms are defined, how processes
are conceptualized, and the relative weight certain factors are assigned in the overall design.
Although most clinicians would agree that a major goal of child assessment is to determine where the child’s
presenting behavior fits within the realm of adaptive and maladaptive behaviors, there are several issues
regarding how to categorize or classify the behavior within the broad scheme of other mental disorders or
maladaptive behaviors.
There are at least three major clinical approaches to organizing and classifying information concerning child
and adolescent disorders or problem behaviors: categorical classification (DSM), empirical or dimensional
classification (e.g., behavioral rating scales: ASEBA: Achenbach & Rescorla, 2001; BASC-2: Reynolds &
Kamphus, 2004), and comparing behaviors to normative expectations or developmental psychopathology. It is
assumed that information regarding these classification systems will be well documented in any number of
other clinically relevant courses, and it is not the intention of this text to provide additional coverage in these
areas.
However, a major intent of the text is to provide the student with information that will assist in understanding
the complexity of the child’s environment and to assist in the application of that understanding to contextually
relevant materials.
To this end, presentation of information on educational classification is considered to be highly relevant to

practice in the real world and an area that is likely to have minimal coverage in other clinical courses.
Questions at the end of each case study will reinforce the presentation by addressing some of the variations
between the clinical and educational systems of classification regarding the classification of four primary
disorders: mental retardation/intellectual and developmental disabilities, learning disabilities, serious
emotional disturbance, and attention-deficit/hyperactivity disorder.
677
A Clinician’s Guide to Educational Classification
678
Historical Background and Theoretical Information
Education and the Law

Given the nature and impact of the child’s environment on issues of assessment and treatment, the
importance of having a working knowledge of legislation affecting the rights of the disabled child within the
educational system cannot be understated. Three laws are of particular importance in this regard: the
Americans with Disabilities Act Amendments Act of 2008 (ADAAA), which was passed by Congress in
December 2008; Section 504 of the Rehabilitation Act of 1973; and Individuals with Disabilities Education
Improvement Act (IDEA, 2004), which was signed into law December 2004 and became effective as of July
1, 2005. From a perspective of governance, the U.S. Department of Education (DOE) is responsible for
overseeing public school compliance with laws pertaining to issues of civil liberties (ADAAA, Section 504)
and educational rights (IDEA, 2004).
ADAAA and Section 504

Very briefly, the ADAAA and Section 504 are civil rights laws that prohibit discrimination against individuals
with disabilities. The ADAAA prohibits discrimination on the basis of disability in employment, public
services, and accommodation to perform major life activities, such as caring for oneself, performing manual
tasks, seeing, hearing, speaking, breathing, learning, and working. In the new version, ADAAA has added
eating, sleeping, walking, standing, lifting, bending, reading, concentrating, thinking, and communicating to
“major life activities” for which reasonable accommodations are required for individuals with disabilities to
enable them to perform essential job functions. Some examples of reasonable accommodations include
removing transportation barriers, redesigning equipment, assigning aides, and providing communication in
various formats. ADAAA also covers accommodations to students who may be involved in community job
placements.
Section 504 is a federal law that protects the rights of individuals with disabilities enrolled in programs and
activities that are federally funded and receiving financial assistance from the U.S. Department of Education.
Under Section 504, school districts are required to provide a “free appropriate public education” (FAPE) to
each qualified student with a disability in the school district’s jurisdiction, regardless of the nature or severity
of the disability. Services may be provided in regular or special education programs; however, they must be
designed to meet the student’s individual educational needs as adequately as the needs of nondisabled students
are met. Under Section 504, if a physical or mental impairment substantially restricts one or more major life
activities, then individuals are eligible for services. Children who do not meet criteria for special services under
IDEA may obtain accommodations to support their learning, behavioral, or emotional needs under Section
504. Often, children with attention-deficit/hyperactivity disorder (ADHD) who do not require more
specialized programming, such as is available under IDEA, or who do not qualify under IDEA, can receive
accommodations under Section 504. It is important to note that any student who qualifies for special
education services would also be eligible under Section 504, but the reverse is not necessarily true (i.e., a
student eligible under Section 504 is not necessarily eligible under IDEA).
679
Safeguards for parents and guardians under Section 504 include prerequisite permission for assessments and
informed notice of any significant placement changes. The local education agencies (e.g., school districts) are
required to provide due process hearings if parents disagree with the identification, evaluation, or placement
decisions.
Critique.
Both civil rights laws provide vague descriptions of who may qualify as disabled. Under each law, any
individual with a disability who (a) has a physical or mental impairment that substantially limits one or more
life activities (b) has a record of such impairment, or (c) is regarded as having such an impairment qualifies.
The federal government does not provide direct funding to implement either of the civil rights laws. There are
limited tax credits available to remove architectural barriers, and federal agencies provide grants to public and
private institutions supporting training and technical assistance. Section 504 is also the fiscal responsibility of
the state. Funds from IDEA may not be used to service children who are eligible solely under Section 504,
although, as of 2005, in the spirit of “early intervention” for school-age children, IDEA has determined that
districts can use up to 15% of the funding available for students enrolled in regular education for students who
are at risk of needing special education services in the future. These funds can be used to provide direct
services or teacher training.
IDEA 2004
The Individuals with Disabilities Education Improvement Act (IDEA, 2004) is a revision of IDEA that was
reauthorized in 1997. The IDEA is an education act that provides federal funding assistance to state and local
education agencies to guarantee that special education services (individualized educational programs [IEPs])
and related services (e.g., speech and language pathology, physical and occupational therapy) are available for
children up to 21 years of age who are deemed disabled. Under IDEA, there are 13 possible categories of
eligibility for disabilities: autism; deaf-blindness; deafness; emotional disturbance; hearing impairment; mental
retardation; multiple disabilities; orthopedic impairment; other health impairment; specific learning disability;
speech or language impairment; traumatic brain injury; and visual impairment, including blindness. Several
changes were included in IDEA 2004, including increased state and school district accountability, educational
accountability, educational requirements (accommodations, and alternate assessments for children with
disabilities), efficiency (paperwork reduction, meetings), student conduct (alternative setting placements
changed from 45 calendar to 45 school days, and positive behavioral interventions), and provision of
discretionary funds for early intervention. One of the major changes in the law concerns criteria surrounding
specific learning disabilities, which will be discussed shortly.
Critique.
There have been several criticisms regarding IDEA that have been directed toward (a) problems of definition
or classification of disabilities and (b) issues of inconsistencies in interpretation or compliance with federal
guidelines at the state and local levels. Three of the 13 categories of disabilities eligible for funding under
IDEA have been especially problematic and have generated significant research and controversy: mental
680
retardation (educable mentally retarded [EMR]) or mild mental retardation [MMR]/intellectual disabilities),
learning disabilities, and emotional and behavioral disturbance/serious emotional disturbance (EBD/SED).
MacMillan and Reschly (1998) have referred to these three categories as the “judgmental categories” because
classification reliability for these three categorical groups is considerably less than that for the more
biologically based and well-defined disabilities (e.g., disabilities of physical or sensory impairment). Issues in
the classification/identification of ADHD will be addressed shortly.
681
Applications, Limitations, and Special Topics in Classification
682
Intellectual Disabilities (ID)
As has been noted previously, the term mental retardation has recently been changed to intellectual and
developmental disabilities (IDD) by the American Association on Intellectual and Developmental Disabilities
(AAIID, 2007), which has replaced the American Association on Mental Retardation (AAMR). With the
development of intelligence tests in the early 1900s, increasing emphasis was placed on using IQ scores as the
single defining feature for intellectual disability (ID). By the mid-1900s, this practice was receiving increasing
criticism for two important reasons: (a) concentration on IQ scores placed minimal emphasis on the role of
social adaptation in defining ID populations, and (b) the growing belief that IQ scores were biased with
respect to psychosocial and cultural influences. Proponents of including social adaptive factors in the
definition of ID cited cases of the “6-hour retardates” who might encounter significant cognitive problems
during their 6-hour school day, but whose social adaptive skills allowed them to function successfully outside
the school system. In 1959, the AAMR officially stated that determination of mental retardation should
include consideration of deficits in adaptive behavior as well as subnormal intellectual functioning. Despite
AAMR’s attempts to lobby in favor of deemphasizing IQ scores as the sole determinants of mental
retardation, the practice continued for several years.
During the 1960s and 1970s, disproportionate numbers of minority students in special education programs
increased concerns regarding the efficacy of IQ tests for minority populations, resulting in several lawsuits
during this period. One such class action suit, Larry P. v. Riles, resulted in significant restrictions on the use of
intellectual assessments for placing African American children in special education programs in California. In
1975, the passing of PL 94–142 (the Education for All Handicapped Children Act) provided the necessary
support for the rights of the disabled and reaffirmed the need to incorporate both adaptive and intellectual
features in the definition of mental retardation.
Today, there are still concerns regarding the identification of disproportionate numbers of ethnic minorities
who are placed in special education. Using data from 4,902 school districts sampled in the 1992 School Civil
Right Compliance Report survey, Oswald, Coutinho, Best, and Nguyen (2001) found that African American
students were nearly 2½ times as likely to be identified as having MMR and about 1½ times as likely to be
identified as seriously emotionally disturbed (SED) compared to their non–African American peers. The
study also revealed that poverty had a significant relation to this skewed representation; however, the direction
of effects differed by condition for African American children. While African American children living in
poverty were more likely to be identified as MMR, African American children in more affluent areas were
more likely to be identified as SED.
Currently there are three systems of classification regarding intellectual disabilities: DSM-5 (APA, 2013);
AAIDD, 2007; and IDEA, 2004.
DSM-5: (APA, 2030).
There are three criteria necessary for a diagnosis of an intellectual disability according to the DSM-5:
significantly subaverage intellectual functioning (below an IQ of approximately 70, approximately two
683
standard deviations below the mean, including a margin of + or — 5 points for measurement error, e.g., 65–
75), concurrent deficits or limitations in adaptive functioning (conceptual, social, practical domains) limiting
functioning in one or more life activities (e.g., communication, independent living), and onset before the age
of 18 years. Although the DSM-IV-TR further subdivided degrees of severity relative to levels of intellectual
functioning, the DSM-5 has revised this practice. Currently, specifiers for mild, moderate, severe, and
profound are based on adaptive functioning levels that are used to inform clinicians of the level of supports
required to enhance functioning to the best ability possible. The current diagnostic criteria are more in line
with criteria supported by AAIDD, which are outlined below.
The DSM-5 also recognizes global developmental delay, which is a diagnosis that is only given to children
under the age of five years, and is used to indicate that a child is not meeting developmental expectations in
some areas of intellectual development. This category is subject to change when a valid and reliable
reassessment of functioning can be conducted.
AAIDD. AAIDD has been lobbying to raise the IQ cutoff from 70 to 75 for quite some time. The
classification system of the AAIDD includes the same three criteria as the DSM with respect to IQ cutoff,
adaptive functioning, and age of onset. The most recent classification of the AAIDD (2009a) profiles types of
ID based on the degree of support services required: intermittent, limited, extensive, or pervasive (AAMR,
2002). The AAIDD system is based on the belief that proper supports will effectively enhance the functioning
and quality of life for individuals with ID.
While intellectual functioning, adaptive behavior, and age of onset remain the criteria for evaluating
intellectual disability, supports remain the cornerstone of the AAIDD Definition System. AAIDD
believes that once a diagnosis of intellectual disability is made, planning and providing supports is
the key to reduce the mismatch between a person’s capabilities and the skills, and what is required to
successfully participate in all aspects of daily life. (AAIDD, 2009b).
Education. Although the educational system also recognizes the need to include social and adaptive features of
ID, most state education codes allocate funds for special education to children with disabilities, such as ID
and the learning disabled (LD), based on IQ score cutoffs to determine eligibility for services. Initially,
children who had an IQ between 55 and 80 were classified as educable mentally retarded (EMR), sometimes
also referred to as educable mentally handicapped (EMH), whereas children who had an IQ between 25 and
55 were considered trainable mentally retarded (TMR), or trainable mentally handicapped (TMH).
Currently, there is variation across states, with most states accepting an IQ cutoff between 70 and 75 to
designate ID, although some states, like Iowa, have retained higher cutoff levels (IQ 85; MacMillan &
Forness, 1998). Within education, there has been continued controversy regarding how students are to be
identified as ID; how these students are best serviced, once identified; and more recently, in the wave of
AAIDD (2007), how these students should best be labeled.
Investigation of classification procedures or how students are identified has revealed both inconsistencies in
the application of classification procedures and concerns regarding the impact of minority status and poverty
684
levels on the decision-making process. Regarding classification, MacMillan and Forness (1998) found that of
the 150 students (Grades 2, 3, and 4) referred to the student study teams (SST) from five school districts in
California, only 6 of the 43 children who scored below 75 on the WISC-III (and met diagnostic criteria for
MR) were classified or identified as MMR, while 19 were classified as LD—despite the fact that the mean
academic levels were approximately 2½ standard deviations (SDs) below the mean. The authors suggest that
comorbid externalizing problems in the six children identified as MR likely influenced placement decisions.
Using this same subject sample of 150 students, MacMillan, Gresham, and Bocian (1998) also investigated
outcomes for borderline students (IQ 71–85) and found that almost half (48%) of children referred to the SST
were within the borderline range. Of this number, 27, or 41%, were ultimately categorized as LD. Of the 19
students who were within an acceptable limit for MR designation (71–75), only 1 was identified as MR.
Results from these and other studies have led MacMillan and colleagues to question the direction of special
education, which has become increasingly insistent on assigning children to specific categories to meet
compliance issues. With the recent changes to IDEA 2004, it is likely that increased use of response to
intervention will result in either reducing the need for specific categories, or resulting in increased need to
classify. Time will tell.
IDEA requires that student eligibility for special education be linked to only one disability category. As a
consequence, children are assigned to only one category of disability, despite the fact that high rates of
comorbidity exist between categories. Problems are most pronounced in what MacMillan and Reschly (1998)
have called the “judgmental categories”—mild mental retardation (MMR), learning disabilities (LD), and
emotionally and behaviorally disordered (EBD).
Under Part C of IDEA 2004 (Sec. 631), financial assistance is provided to the state for infants and toddlers
with disabilities (birth to 2 years). Within this section is the provision to meet the needs of infants and
toddlers with developmental delays or at risk for developmental delays. Within this context, developmental
delay refers to a delay of 35% or more in one of five developmental areas (cognitive, motor, speech and
language, social/emotional, or adaptive functioning) or 25% or more in two or more of the developmental
areas. Part B of IDEA 2004 discusses services for students ages 3 to 21 years. Within this context, IDEA
states that children 3 to 9 years of age may receive service education and related services, if services are needed
because of the developmental delays (in one of the five areas noted above). However, it is important to note
that services are not mandated and are at the discretion of the state.
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Specific Learning Disabilities
The definition of specific learning disabilities (SLD), or specific learning disorders (DSM-5), has remained a
highly controversial area of debate. Currently there are conflicting sources available for purposes of
classification:
DSM-5: specific learning disorders, and developmental coordination disorder. The DSM-5 discusses specific
learning disorders (SLD) and developmental coordination disorder (DCD) within the chapter on
Neurodevelopmental Disorders. The DSM recognizes that SLDs can be evident in three primary areas:
reading disorder, mathematics disorder, and disorders of written expression. The DSM-IV-TR (APA, 2000)
used the discrepancy criterion as a guideline to the diagnosis of SLD comparing measures of achievement
(standard scores from standardized assessments) to standard scores for intellectual functioning. A significant
discrepancy of more than two standard deviations between achievement and IQ would be a marker for SLD.
However, the DSM-5 has moved away from use of the discrepancy criterion in favor of age-related criteria;
for example, “academic skills are substantially and quantifiably below those expected for the individual’s
chronological age” (APA, 2013, p. 67). The DSM-5 differentiates between specific learning disorders and
learning problems of a more generalized nature, such as those experienced by individuals with intellectual
disabilities or global developmental delays.
In keeping with other diagnostic features of the DSM, level of impairment is a key determining factor in
defining learning disorders, and the impairment must significantly interfere with academic achievement or
with functions of daily living. The definition is also exclusionary in that if sensory deficits are present, they
must be ruled out as the primary cause of the learning difficulties. According to the DSM, it is expected that
between 5% and 15% of school-age children might be identified as having a specific learning disorder.
Although disorders of reading and mathematics are somewhat self-explanatory, it is important to note that
disorders of spelling or of handwriting alone are excluded from a diagnosis of disorders of written expression.
The DSM-5 does not consider DCD as a specific learning disorder, but instead classifies it as a type of motor
disorder that includes the tic disorders. Although similar to disorders of written expression, which are a
specific type of SLD, children who are diagnosed with DCD often can appear as clumsy and have motor skills
that are well below developmental milestones and interfere with daily living and academic performance.
Although many children with DCD show impaired gross motor skills (coordination, athletics, involving large
muscle movements), others have deficits in fine motor skills such as handwriting. The DSM makes the
distinction between SLD (disorder of written expression) and DCD based on writing skills deficits to due
organization of information (SLD) as opposed to deficits in motor skills production (DCD).
Education: Specific Learning Disabilities (SLD). The federal definition of a learning disability appears in the
Individuals with Disabilities Education Improvement Act (IDEA, 2004). (The document is available online
at http://idea.ed.gov.)
686
687
IDEA 2004: Specific Learning Disability (SLD) Definition and Criteria
Definition
IDEA (2004) did not change the definition for SLD from the 1997 version. IDEA defines an SLD by the
following criteria:
Specific learning disability
i. means a disorder in one or more of the basic psychological processes involved in understanding or in
using language, spoken or written, that may manifest itself in the imperfect ability to listen, think,
speak, read, write, spell or to do mathematical calculations, including conditions such as perceptual
disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia.
ii. Disorders not included: Specific learning disability does not include learning problems that are primarily
the result of visual, hearing or motor disabilities, of mental retardation, of emotional disturbance, or of
environmental, cultural, or economic disadvantage. (Federal Register, 2006: 300.8 (10), p. 46757)
Concerns exist with the wording of the definition, which was not changed despite several issues, including the
use of vague terms such as basic psychological processes and imperfect ability.
Identification Procedures and Criteria

Despite maintaining the same definition, IDEA 2004 did make significant changes regarding identification
procedures and criteria surrounding the use of the discrepancy criteria.
According to IDEA 2004, policy and procedures to determine whether a child has an SLD are now at the
discretion of the state, and
1. Must not require the use of a severe discrepancy between intellectual ability and achievement for
determining whether a child has a specific learning disability;
2. Must permit the use of a process based on the child’s response to scientific, research-based intervention;
3. May permit the use of other alternative research-based procedures for determining whether a child has a
specific learning disability. (Federal Register, 300.307 (a), p. 46786)
This determination is made by the child’s educational team, which includes a child’s parents, a team of
qualified professionals (child’s teacher or teacher qualified to teach students of the child’s age), and at least one
professional who is qualified to conduct diagnostic examinations (school psychologist, speech pathologist,
remedial reading teacher). Furthermore, the team must rule out that lack of achievement is not primarily due
to a disability (visual, motor, hearing), mental retardation, emotional disturbance, cultural factors, economic
disadvantage, limited English proficiency, or inappropriate instruction.
To ensure that underachievement is not due to inadequate teaching, documentation (data) of appropriate
instruction (observations, and repeated assessments) and monitoring of progress during instruction are
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required. Ultimately, children who do not make adequate progress and continue to demonstrate a need for
special education and related services will require parental permission for further (comprehensive) evaluation.
IDEA considers evidence of SLD in eight possible areas of performance:
1. Oral expression
2. Listening comprehension
3. Written expression
4. Basic reading skill
5. Reading fluency skill
6. Reading comprehension
7. Mathematics calculation
8. Mathematics problem solving
Procedures acceptable, under IDEA, to determine SLD:
1. Response to Intervention (RTI): Evidence that the child does not improve in the identified academic areas
when using a process (a series of interventions) based on the child’s response to scientific, research-based
intervention; or
2. Pattern of Strengths and Weaknesses: The child exhibits a pattern of strengths and weaknesses in
performance, achievement, or both relative to age (using grade level standards or intellectual
information). This profile analysis (intra-individual differences in standard achievement scores or
intellectual functioning [IQ]) often results in a comparison of response profiles within and between
assessment instruments (academic achievement). This procedure has typically been used to determine a
discrepancy between IQ and achievement in the past and could still be used in this capacity.
National Joint Committee on Learning Disabilities (NJCLD).
The NJCLD defines learning disabilities (LD) as a general term referring to heterogeneous groups of disorders
manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing,
reasoning, or mathematical abilities.
These disorders are intrinsic to the individual, presumed to be due to central nervous dysfunction, and may
occur across the life span. Problems in self-regulatory behaviors, social perception, and social interaction may
co-occur but themselves do not constitute an LD. Although LD may occur with other handicapping
conditions (e.g., sensory deficits, emotional disturbance, mental retardation, or cultural differences), they are
not the result of those conditions or influences (NJCLD, 1987).
Learning Disabilities Generically and Specifically Defined. Byron Rourke has conducted numerous studies
concerning subtypes of LD based on discrepancy response patterns evident on intelligence tests. As a result of
his work, Rourke suggests a generic definition of LD is most appropriate. Although this “generic” definition
supports the NJCLD definition in general, a major point of difference is evident in Rourke’s view that “the
term LD is also appropriately applied to instances where persons exhibit significant difficulties in mastering
social and other adaptive skills and abilities” (Rourke, 1989, p. 215). Furthermore, according to Rourke, it is
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possible that emotional disturbances and other adaptive deficiencies may arise from the same patterns of
central processing assets and deficits that generate the manifestations of academic and social LD (Rourke,
2000).
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Issues in the Definition and Classification of Children and Adolescents With
Learning Disabilities
Definitions of learning disabilities have been criticized on several fronts. The DSM-IV-TR definition was
faulted for being too narrow and considering only disorders of reading, mathematics, and written expression
(excluding spelling) as true academic disorders. The definition was also criticized theoretically in defining LD
by exclusion (ruling out other disorders), thereby implying that coexisting disorders cannot occur. The
NJCLD definition improved on the DSM-IV-TR by ruling in the possibility of co-occurring disorders and by
introducing the heterogeneity of learning disorders; however, it fails to provide any operable guidelines for
how to measure “significant difficulties in the acquisition” of academic skills. Although Rourke’s generic
definition also remains vague with respect to measurement of “significant difficulties in mastery” of academic
skills, his definition improves on other definitions in the recognition of the existence of LD in areas of social
and adaptive functioning. The federal definition (IDEA) has also been criticized for usage of vague terms
such as basic psychological process and lack of guidance regarding measurement of the “manifestation of an
imperfect ability.” In addition, definition by exclusion also implies that disorders cannot coexist with LD.
Unfortunately, the DSM-IV-TR was the only definition that provided an objective measurement to define a
significant discrepancy between IQ and achievement (suggesting a 2 standard deviation [SDs] rule be applied
as a general guideline). However, the DSM-5 no longer supports the discrepancy criteria in this manner.
Instead, the DSM suggests that academic scores on standardized tests should be below a standard deviation of
1.5 for the population mean, which translates to a standard score of approximately 78. However, academic
scores are only related to intellectual ability in the very generalist of ways, in that individuals with “an IQ score
of greater than about 70” (pp. 67–69) should be considered for this diagnostic criteria, to rule out those with
an intellectual disability rather than a SLD.
Considering the differences evident in the four definitions presented, it is not difficult to understand why the
concept of learning disabilities has met with such controversy. According to Kavale (2005), “The present SLD
definition is too broad to be wrong and too vague to be complete” (Kavale, 2005). Furthermore, Kavale
contends that “changes to the operational definition (RTI) without changes to the formal definition” are
“indefensible” and result in a “disconnect between the formal definition and the operational definition” (p.
553). In support of this argument, Mather and Gregg (2006) agree for the need to achieve consensus on both
the conceptual definition for SLD and the operational diagnostic criteria that will be used for the
identification of SLD.
Some clinicians define the discrepancy between achievement and age expectations by comparing current grade
level to current functioning level. A 2-year rule has been used in several instances; for example, a child in
Grade 4 is functioning at least 2 years behind his or her current grade placement. However, using a fixed
criterion may penalize students in the early grades while being too lenient for students in the later grades.
Sattler (2002) states that some definitions attempt to address this issue by using a gradient of discrepancy
based on grade level: 1 year for Grades 1 and 2, 1.5 years for Grades 3 and 4, 2 years for Grades 5 through 8,
and 3 years for secondary school performance levels.
691
However, Sattler cautions against comparing achievement grade scores with actual grade scores since the
practice is not sound statistically and is likely to lead to invalid conclusions.
Another method of defining discrepancy is to compare standard scores obtained on IQ tests with standard
scores available from achievement tests. A common criterion applied to this method is to use discrepancies
between 15 and 22 points (1.5 to 2 SDs) as significant. However, this method has also been criticized at the
upper and lower levels. Comparisons at the upper levels may note a significant discrepancy, yet it is arguable
whether this discrepancy would define a disability (e.g., IQ 145; achievement 125). At lower IQ levels,
students who tend to score lower on IQ tests (low SES) may not reveal significant discrepancy in the other
direction (e.g., IQ 85; achievement 75).
Furthermore, according to Sattler (2002), processing difficulties that affect achievement (e.g., vocabulary,
comprehension, factual information) may also serve to reduce scores for intellectual functioning that requires
the same processing abilities. Another difficulty arises when a significant discrepancy exists between IQ
components, for example, Verbal IQ (IQ = 85) and Performance IQ (IQ = 115). Under these conditions, the
full scale IQ is rendered meaningless, since it represents only a numeric average of discrepant scores (Kaufman
& Lichtenberger, 2000). Some clinicians would select the higher of the two IQs (in this case, Performance
IQ), arguing that this score is the most representative of the child’s true ability; others might select the Verbal
IQ, stating Verbal IQ correlates better with academic performance. Despite these limitations and other
statistical problems inherent in making comparisons between different test instruments (Sattler, 2002),
Sattler’s conclusion is in agreement with that suggested by Kavale, Forness, and MacMillan (1998), which
supports the need to retain a discrepancy model as a necessary determining eligibility for LD. However, more
research is needed to determine how best to employ this model (Sattler, 2002). Kavale, Holdnack, Mostert,
and Schmied (2003) voice concern about throwing the baby out with the bathwater, and argue for more
rigorous methods in implementing the discrepancy approach rather than adopting a new model.
Despite criticisms of the discrepancy model, many have failed to embrace the RTI approach as an alternative
since the model is vague, especially concerning the potential role of teachers and diagnosticians; and how SLD
will be differentiated from other disabilities: “if RTI cannot discriminate, how can it classify” (Mastropieri &
Scruggs, 2005, p. 528).
Yet others prefer to take the middle ground and suggest a combination of the two approaches. Kavale et al.
(2003) suggest using RTI as an initial step, or a “pre-referral writ large” that could enhance quality control in
the regular classroom, but that is, in isolation, insufficient as an identification system for SLD. Similarly,
Semrud-Clikeman (2005) suggests that RTI needs to integrate neuropsychology into the process; screenings
could then focus on predictor variables (e.g., working memory, attention, and executive functions) that would not
only allow for monitoring of progress in these crucial areas, but also provide access to those students who are
at higher risk in these areas.
The Learning Disabilities Association of America (LDA) responded to the changes in educational legislation
with a White Paper (LDA, 2010) that was prepared by a panel of experts in the field (56 professionals
recognized as experts in the field by their peers). The paper confronts identification procedures that bypass
692
consideration of the cognitive nature of SLD and determination of lack of achievement based on age or grade-
based criteria, instead of ability. The report calls for strengthening identification procedures, including the use
of cognitive and neuropsychological assessments to provide a profile of strengths and weaknesses for the
purposes of developing interventions.
693
Emotional Disturbance
Educational: IDEA.
Although the IDEA provides guidelines and definitions for categories of disabilities, there continues to be
wide variation at the state level concerning how categories are defined. In addition, many of the disabilities
that fall under IDEA are defined in educational terms, which can be at odds with more clinical definitions of
childhood disorders. One such area is the category of emotional disturbance (previously called seriously
emotionally disturbed). Children who are classified in this category will have a wide variety of emotional
problems, behavioral concerns, or both. Within IDEA, children who are considered to be emotionally or
behaviorally disturbed are defined as having a long-lasting condition causing significant educational
impairment that manifests in one of the following five areas:
1. Learning difficulties not explained by intellectual, sensory, or health factors

2. Difficulties developing or maintaining satisfactory interpersonal relationships with peers and teachers
3. Age-inappropriate behaviors or feelings in response to normal circumstances
4. Pervasive mood of unhappiness or depression
5. Tendencies to develop physical symptoms in response to personal problems or problems at school
Although the category of emotional disturbance includes schizophrenia, children who are socially maladjusted
are excluded from this category, unless it can be determined that they have an emotional disturbance.
Center for Mental Health Services (CMHS).
The CMHS is a federal agency that provides mental health services for children less than 18 years of age.
According to CMHS, service is provided to children and youth who present with a diagnosable mental,
behavioral, or emotional disorder meeting criteria set out in the DSM. The disorder must also meet criteria of
duration and functional impairment as defined in the DSM.
Social Security Administration (SSA).
The federal guidelines of the SSA define a mental condition as one that can be medically proven and that
results in marked and severe functional limitations of substantial duration.
DSM-5.
Given descriptions in the IDEA, it is possible that children who qualify under the category of emotional
disturbance may be found in the DSM disorders represented by internalizing disorders, such as depressive
disorders, bipolar disorders, anxiety disorders, obsessive compulsive disorders, or somatic disorders; or by
externalizing disorders, such as oppositional defiant disorder or conduct disorder. Although schizophrenia is a
category recognized by the DSM, it is very rare in children.
Council for Exceptional Children.
The Council for Exceptional Children has lobbied for a new and improved definition that changes the label
694
from emotional disturbance to emotional or behavioral disorder (EBD) and defines the disorder as a condition
in which behavioral or emotional response is so different from the generally accepted, age-appropriate, ethnic,
or cultural norms as to adversely affect self-care, social relationships, personal adjustments, academic progress,
classroom behavior, or work adjustment. Despite strong support, the definition has not been incorporated into
the latest revisions of IDEA.
National Mental Health and Special Education Coalition.
The coalition has also actively lobbied for changes in the federal definition of emotional disturbance. The
National Association of School Psychologists (NASP) has adopted and endorsed the definition put forth by
this group (National Association of School Psychologists, 2005). This definition adopts the label of emotional
or behavioral disorder (EBD) for responses that are so different from expectations (age, cultural, or ethnic
norms) that they adversely compromise educational performance. The responses are demonstrated in more
than one setting (at least one of which is school related) and are unresponsive to direct intervention in a
general educational setting. EBD can coexist with other disabilities. The category may include schizophrenia,
affective disorders, anxiety disorders, or other sustained disturbances of conduct or adjustment.
695
Issues in the Definition and Classification of Children and Adolescents With
Emotional Disturbance
The IDEA definition of emotional disturbance is highly controversial and is problematic for several reasons.
First, although the category of emotional disturbance would apply to children who have evidence of
internalizing disorders, such as anxiety, depression, or withdrawal (sometimes referred to as a behavior
deficit), the definition also applies to an extent to those children who experience externalizing disorders (such
as problems of aggression, defiance, and conduct, sometimes referred to as a behavioral excess).
However, because IDEA does not consider children who exhibit socially maladaptive behaviors as part of this
category, this definition has led some states to exclude children with conduct disorder from identification
within this category, since they interpret behaviors directed toward the violation of the rights of others to be
an example of socially maladaptive behavior, while other states consider these behaviors as part of the category
(Gonzalez, 1991). The problem is intensified by the fact that children with conduct disorder represent one of
the largest diagnostic groups. Wide variations in rates of reporting children within the category of emotional
disturbance or serious emotional disturbance (Connecticut reported 2.06% with SED in 1996, and Arkansas
reported 0.09%) suggest different qualification criteria as well as the severity of children included (MacMillan,
1998).
Second, terms used to define duration (long period of time) and intensity (marked degree) are not
operationally defined and provide no guidelines for measurement. Third, although states must designate
criteria that do not conflict with the federal guidelines of IDEA, there is wide interpretive leeway in how
emotional disturbance is defined by various states (McInerney, Kane, & Pelavin, 1992). In addition, some
states have adopted labels other than emotional disturbance for this category, and labels of behavior disordered
(BD) or emotionally and behaviorally disordered (EBD) have been frequently substituted.
Fourth, studies have demonstrated that children with labels of serious emotional disturbance (SED) are not a
homogenous population (Rosenblatt & Furlong, 1998; Walrath, Nickerson, Crowel, & Leaf, 1998), and
investigators have questioned the usefulness of labels such as SED and EBD with respect to defining
treatments (Kershaw & Sonuga-Barke, 1998). One study by Duncan, Forness, and Harsough (1995) suggests
that the LD label may be the preferred starting point for intervention and often the first label of choice
regardless of the nature of the problem. In their investigation, they found that the majority of children labeled
as SED were initially classified as LD, until the requirement for more intensive service resulted in
reclassification.
696
Attention-Deficit/Hyperactivity Disorder
Educational Definition of ADHD.
The most recent revision of IDEA has added “attention deficit disorder” and “attention deficit hyperactivity
disorder (ADHD)” to the list of disabilities. Prior to this change in regulations, children with ADHD were
able to receive special education assistance under Section 504 of the Rehabilitation Act of 1973, a broader
piece of antidiscrimination legislation. Children with ADHD can now be deemed disabled under the category
of Other Health Impairments, which are defined as “having limited strength, vitality or alertness, including a
heightened alertness to environment stimuli, that results in limited alertness with respect to the educational
environment” (IDEA, 2004). Other disabilities in the same category include acute health problems such as
asthma, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, and rheumatic fever. A
diagnosis of ADHD alone does not guarantee services under IDEA. The ADHD must adversely affect
education to warrant special education.
Issues in the Definition and Classification of Children and Adolescents With ADHD.
Children with ADHD often have comorbid features of emotional or behavioral disturbance and learning
disabilities. Children with ADHD may also qualify under other IDEA categories, such as LD or EBD. At
early developmental levels, ADHD features may overlap and share symptom features of developmental delay,
a noncategorical option of IDEA available for children 3 to 9 years of age. Problems exist concerning how to
assess children with ADHD and high rates of overlap in symptoms between ADHD and other disorders and
conditions (anxiety, abuse, posttraumatic stress disorder, etc.).
697
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Burlington, VT: ASEBA.
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specificity or reconsideration of the variables examined. Journal of Special Education, 19, 239–253.
MacMillan, R. C. (1998). A longitudinal study of the cost effectiveness of educating students with emotional
or behavioral disorders in a public school setting. Behavioral Disorders, 25, 65–75.
Mastropieri, M. A., & Scruggs, T. E. (2005). Feasibility and consequences of response to intervention:
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learning disabilities. Journal of Learning Disabilities, 38, 525–531.
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Appendix C Guidelines to the Interpretation of Test Scores and
Assessment Information
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Interpreting Standard Scores
Scores for most intelligence tests, like the Wechsler Intelligence Scale for Children (WISC-IV) and the
Differential Abilities Scale (DAS-2); standardized academic assessments, such as the Woodcock Johnston
Academic Assessment (WJACIII) and Wide Range Achievement Test (WRAT-IV); and measures of
adaptive functioning (Vineland Adaptive Behavior Scales) are based on standard scores derived from the
standard normal distribution. The standard normal distribution has an average score of 100 and a standard
deviation of 15. On these assessment instruments, approximately 68% of the population will score within one
standard deviation of the mean (scores ranging between 85 and 115). The normal curve is a bell-shaped
distribution with the most intense concentration of individuals in the middle of the curve, and progressively
less population represented under the curve toward the end points. The normal curve, standard deviations,
and standard scores are presented in Figure AC.1.
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Intelligence and Standard Scores
The average IQ score is 100, and approximately 68% of the population will obtain an IQ score between 85
and 115. Scores that range from 80 to 89 are considered to be within the “low average” of intelligence, while
scores above 115 but below 125 are considered to be in the “high average” range.
As we progress to the left of center, individuals who score two standard deviations below the mean would
obtain an IQ of 70, which is the cutoff point for a diagnosis of mental retardation. Individuals who score at
this level are in the bottom 2% of the population. Approximately 2% of the population will obtain an IQ
between 55 and 70, which would be considered in the mild range of mental retardation, intellectually.
Individuals who score below an IQ of 55 (less than .13%) would be at the threshold of more severe levels of
mental retardation (moderate retardation IQ 35–40 to 50–55; severe retardation 20–25 to 35–40; and
profound mental retardation, below IQ of 20–25). In order to be diagnosed with mental retardation, the
DSM-IV-TR (APA, 2000) requires an IQ of approximately 70 (+ or — 5, for standard error of measure),
impairments in at least two areas of adaptive functioning (e.g., work, leisure, communication skills, self-care,
health and safety), and onset before the age of 18.
Figure AC.1 Standard Normal Distribution IQ Scores and T Scores
As we progress to the right of center, individuals who score two standard deviations above the mean would
obtain an IQ score of 130, which is usually the cut point for “gifted” status for most gifted programs and is at
the 98th percentile. Mensa, a society for gifted individuals, has been in existence since 1946. The word mensa
comes from the Latin word for table and was chosen to stand for a round-table society whose only criteria for
acceptance was to achieve a score at or above the 98th percentile on a standard test of intelligence (retrieved
from http://www.mensa.org/index0.php?page=10). Individuals who score at an IQ of 140 are at the top .13%
of the population.
703
704
Assessments of Adaptive Functioning and Standard Scores
According to the DSM-IV-TR (APA, 2000), adaptive functioning “refers to how effectively individuals cope
with common life demands and how well they meet the standards of personal independence expected of
someone in their particular age group, sociocultural background and community setting” (p. 42). For a
diagnosis of mental retardation, in addition to deficits in IQ noted previously, the child must also demonstrate
impaired adaptive functioning in at least two of the following areas: communication, self-care, home living,
social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure,
and health and safety. Adaptive scales, such as the Vineland Adaptive Behavior Scales and the AAMR
Adaptive Behavior Scale-School (ABS-S:2), provide standard scores for adaptive behaviors in a number of
different domains, such as communication, daily living, and socialization. As well as standard scores, the scales
also provide scale scores ranging from 0 to 18, with the average scores being 10, which is at the 50th
percentile. The assessment results for Arthur in Appendix B provide examples of test scores for adaptive
functioning.
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Academic Assessments and Standard Scores
There are several methods of assessing academic functioning, including curriculum-based assessments (CBA)
(comparing a student’s current level of functioning relative to where they should be, given curricula for their
current grade placement), and standardized academic assessments (comparing student performance relative to
norms established for other students of the same age group based on national samples). Similar to intelligence
scores, the vast majority of the population (68%) would be expected to score within one standard deviation of
the norm (100), which would be represented by a range of standard scores from 85 to 115.
Through the use of standard scores, it is possible to compare intelligence scores (IQ) to academic scores based
on the same standard unit of measure (standard scores). In this way, it can be determined whether students are
achieving academically at the same levels that would be predicted given their IQ score. For example, if a
student achieved an IQ score of 100, then it would be anticipated that academic scores should be within the
range of 85 to 115 (within one standard deviation of the norm). If, on the other hand, a student with an IQ of
125 produces an academic score in a given subject area (e.g., reading, written expression, or mathematics) well
below this level (e.g., reading standard score is 85), then we know there is a significant difference between
these two scores.
Discrepancy Criterion:
In the discussion of learning disorders, the DSM-IV-TR (APA, 2000) suggests that a discrepancy between IQ and
achievement scores is considered to be significant if it is “substantially below” and it “is usually defined as a discrepancy
of more than 2 standard deviations between achievement and IQ” (p. 49). In our previous example, if an individual
obtained an IQ of 125, then a significant discrepancy would exist if achievement scores were below 95 (125–
130). The discrepancy criterion has been used historically to determine if children qualified for assistance as
learning disabled; however, the latest revision of the Individuals with Disabilities Education Improvement Act
(IDEA, 2005) has made it possible for an alternative criteria, known as Response to Intervention (RTI), to be
used by school districts to identify children with learning disabilities.
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Interpreting T Scores
Scores for most behavioral rating scales (Achenbach ASEBA Scales, BASC-2, Conners Scales), response
inventories (Beck Inventory, Childhood Depression Scale), and personality inventories are based on T scores
derived from the T score normal distribution. The T score distribution has an average score of 50 and a
standard deviation of 10. On these assessment instruments, the majority of the population will score within
one standard deviation of the mean (scores ranging between 40 and 60). Scores at or above a T score of 65
represent functioning at the 95th percentile and these individuals are often seen to be at risk of developing
more serious difficulties and in need of monitoring. Individuals scoring at or above a T score of 70 are
considered to be in the clinically significant range and in need of immediate intervention. The T score
distribution is also available in Figure AC.1.
707
Description of Individual Assessment Instruments and Resources
Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the Achenbach System of Empirically Based Assessment:
ASEBA school-age forms and profiles. Burlington, VT: ASEBA.
Comment: Revised and renormed in 2001, this scale has parent, teacher, and youth self-report versions (for
youth 11 years and older). The ASEBA rating scales measure behaviors on eight syndrome scales:
Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems,
Attention Problems, Rule-Breaking Behavior, and Aggressive Behavior. Composite scores are also available
for Total Internalizing, Total Externalizing, and Total Problems. The revised version also contains six DSM–
oriented scales, including Affective Problems, Anxiety Problems, Somatic Complaints, Attention-
Deficit/Hyperactivity Problems, Oppositional Defiant Problems, and Conduct Problems.
Barkley, R. A. (1987). Defiant children: Parent-teacher assignments. New York, NY: Guilford Press.
Barkley, R. A. (1997). Defiant children: A clinician’s manual for assessment and parent training (2nd ed.). New
Comment: Contains many excellent resources and handouts for parents, as well as scales and parent and
teacher questionnaires.
Beck, A., Beck, J., & Jolly, J. (2005). The Beck Youth Inventories of Emotional and Social Impairment– (2nd ed.).
San Antonio, TX: Psychological Corporation.
Comment: Five brief (20-item) self-report scales measuring Self-Concept, Depression, Anxiety, Anger, and
Disruptive Behavior, in children and youth, from 7 years of age.
Borum, R., Bartel, P., & Forth, A. E. (2002). Manual for the Structured Assessment of Violence Risk in Youth:
SAVRY. Consultation version. Tampa: University of South Florida, Florida Mental Health Institute.
Comment: The SAVRY is intended for youth 12 to 18 years of age and comprises 24 items representing three
risk domains (Historical Risk Factors, Social/Contextual Risk Factors, and Individual/Clinical Factors). Each
risk item has a three-level rating structure with specific rating guidelines (low, moderate, or high). In addition
to the 24 risk factors, the SAVRY also includes six Protective Factor items that are rated as either present or
absent.
Conners, C. K. (1998). Conners Rating Scales—revised technical manual. North Tonawanda, NY: Multi-Health
Systems.
Comment: Contains long and short versions of parent and teacher rating forms for attentional and behavioral
problems. Manual also provides information about the Conners-Wells Self Report Scale for Adolescents
(Conners & Wells, 1997). Scales provide T score ratings for the type of ADHD (Inattentive, Hyperactive-
Impulsive), as well as many behaviors often associated with the disorder, including oppositional, cognitive,
708
anxious-shy, perfectionistic, emotional lability, and social problems.
Conners, C. K. (2008). Conners (3rd ed.; Conners 3). North Tonawanda, NY: Multi-Health Systems.
Comment: This updated version has added new items and scales to the parent, teacher, and child self-report
forms, including empirical scales for executive functioning, learning problems, aggression, peer relations, and
family relations. Items for oppositional defiant disorder (ODD) and conduct disorder (CD) have been added
to the DSM-IV-TR symptom scales, in addition to a number of validity scales.
Dunn, L. M., & Dunn, L. M. (1997). Peabody Picture Vocabulary Test (3rd ed.). Circle Pines, MN: American
Guidance Service.
Elliott, C. D. (2007). Differential Ability Scales 2nd ed.; (DAS II). San Antonio, TX: Psychological
Corporation.
Comment: Two versions of the scale are available: preschool-age level (2 years 6 months to 5 years 11 months)
and school-age level (6 years to 17 years 11 months). Scores are provided for Verbal Ability, Nonverbal
Ability, Spatial Ability, and General Conceptual Ability (GCA). The Early Years Form allows for the
tabulation of a Special Nonverbal Composite for children whose verbal skills would significantly lower their
overall conceptual score.
Gardner, D. M. (1991). The Eating Disorder Inventory-2. Odessa, FL: Psychological Assessment Resources.
Comment: A 91-item self-report scale measuring traits associated with eating disorders; it yields eight scales,
such as Body Dissatisfaction, Drive for Thinness, and Perfectionism.
Gilliam, J. E. (1995). Gilliam Autism Rating Scale: GARS. Austin, TX: Pro-Ed.
Comment: Autism quotient derived from ratings on four scales: Stereotyped Behaviors, Communication,
Social Interaction, and Developmental.
Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy, L. (2000). The Behavior Rating Inventory of Executive
Function: BRIEF professional manual. Odessa, FL: Psychological Assessment Resources.
Comment: The BRIEF is a rating scale completed by parents and teachers that provides information about
executive functions in two broad areas: Behavior Rating Index (impulse control, shifting between tasks, and
modulation of emotional responses), and Metacognitive Index (task initiation, working memory,
planning/organization, organizing materials, and self-monitoring). A Global Executive Composite can be
derived from scores obtained on the two broad scales. In addition to the clinical scales, there are also scales to
calculate inconsistency and negativity.
Goodman, W., Rasmussen, S., & Price, L. (1988). The Children’s Yale Brown Obsessive Compulsive Scale (CY-
BOCS). New Haven: Connecticut Mental Health Center, Clinical Neuroscience Research Unit.
Guy, S. C., Isquith, P. K., & Gioia, G. A. (2004). BRIEF self-report professional manual: Brief-SRl. Odessa,
709
FL: Psychological Assessment Resources.
Comment: This self-report scale comprises 80 items that measure behaviors and cognitive functioning in areas
similar to those measured by the BRIEF. It is suitable for individuals from 11 to 18 years of age.
Jesness, C. F. (1988). JBC: Jesness Behavior Checklist. North Tonawanda, NY: Multi-Health Systems.
Comment: A multiple rating scale for youth (13 to 20 years) at risk for antisocial behavior. Self-Report and
Observer Rating Scale measures behavior across 14 scales, including Social Control, Anger Control, and
Conformity.
Jesness, C. F. (2003). Jesness Inventory—Revised (JI-R). North Tonawanda, NY: Multi-Health Systems.
Comment: Self-report scale for youth measuring 11 personality traits (e.g., social maladjustment, immaturity,
alienation, withdrawal-depression, denial) and 9 subtype scales (e.g., undersocialized aggressive,
conformist/immature, pragmatist/manipulator, introspective/neurotic). In addition, there are two DSM-IV
scales providing ratings for conduct disorder (CD) and oppositional defiant disorder (ODD).
Kazdin, A. E., Rodgers, A., & Colbus, D. (1986). The Hopelessness Scale for Children: Psychometric
characteristics and concurrent validity. Journal of Consulting and Clinical Psychology, 54, 241–245.
Comment: A 17-item true/false questionnaire measuring hopelessness based on future expectations. Research
supports hopelessness as a correlate of depression and suicide.
Kovacs, M. (1992). Child Depression Inventory. North Tonawanda, NY: Multi-Health Systems.
Comment: Self-report measure for children and youth 7 to 17 years of age. In addition to a Total Depression
score, the scale rates depressive symptoms in five areas: Negative Mood, Interpersonal Problems,
Ineffectiveness, Anhedonia, and Negative Self-Esteem.
Lachar, D., & Gruber, C. P. (1995). Personality Inventory for Youth (PIY) manual. Los Angeles, CA: Western
Psychological Services.
Comment: Objective, multidimensional, self-report measure for children and youth 9 to 18 years of age.
Assesses emotional and behavioral adjustment, family and school impressions, and academic adjustment.
Includes validity and consistency scales.
Lambert, N., Nihira, K., & Leland, H. (1993). ABS-S:2: The Adaptive Behavior Scale–School (2nd ed.). Austin,
TX: Pro-Ed.
Comment: Rating scale to assess adaptive functioning and maladaptive behaviors in children and youth.
Myles, B. S., Bock, S. J., & Simpson, R. L. (2001). ASDS: Asperger Syndrome Diagnostic Scale examiner’s
manual. Austin, TX: Pro-Ed.
Comment: Asperger’s quotient derived from ratings on five scales: Language, Social, Maladaptive, Cognitive,
710
and Sensorimotor.
Naglieri, J. A., LeBuffe, P. A., & Pfeiffer, S. I. (1994). The Devereux Scales of Mental Disorders: DSMD
manual. San Antonio, TX: The Psychological Corporation.
Comment: The DSMD measures functioning in six areas, which represent three composite scales:
Externalizing (conduct, attention), Internalizing (anxiety, depression), and Critical Pathology (autism, acute
problems). In addition, there is a Total DSMD score for total functioning.
Newcomer, P. L., Barenbaum, E. M., & Bryant, B. R. (1994). DAYS: Depression and Anxiety in Youth Scale.
Austin, TX: Pro-Ed.
Comment: Parent, teacher, and child self-report scale with 22 items (true/false format) suitable for children
and youth 6 to 19 years old.
Reich, W., Welner, Z., Herjanic, B., & MHS Staff. (1997). Diagnostic Interview for Children and Adolescents
computer program (DICA-IV). North Tonawanda, NY: Multi-Health System.
Reynolds, C. R., & Kamphaus, R. W. (2004). Behavior Assessment System for Children: BASC-2 manual. Circle
Pines, MN: American Guidance Service.
Comment: Multiple informant (parent, teacher, child) rating scales for adaptive and maladaptive behaviors,
from 2 years to adolescence. Includes validity indexes to screen for excessive positive or negative response
profiles. Composite scales include Adaptive Skills, Behavioral Symptoms Index, Externalizing, Internalizing,
and School Problems. The composite scores are calculated from numerous Primary (depression, learning,
withdrawal, anxiety) and Content scales (anger control, resiliency, etc.).
Reynolds, C. R., & Richmond, B. O. (2008). Revised Child Manifest Anxiety Scale-2. Los Angeles, CA:
Western Psychological Services.
Comment: This 49-item scale can be administered to children 6 to 19 years of age and measures anxiety in four
different areas: Physiological Anxiety, Worry, Social Anxiety, and Defensiveness. The scale also includes an
inconsistent responding index.
Sattler, J. M. (2008). Assessment of children: Cognitive applications (5th ed.). La Mesa, CA: Author.
Sattler, J. M. (2014). Assessment of children: Behavioral and clinical applications (6th ed.). La Mesa, CA: Author.
Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). Vineland Adaptive Behavior Scales. Circle Pines, MN:
American Guidance Service.
Comment: Interview format. Measures adaptive behavior in four areas: Communication, daily living skills,
socialization, and motor skills.
Wechsler, D. (2014). Manual for the Wechsler Intelligence Scale for Children—WISC-V. San Antonio, TX:
711
Psychological Corporation.
Comment: The WISC-V has five major scales: Verbal Comprehension, Perceptual Reasoning, Fluid
Reasoning, Working Memory, and Processing Speed. The Verbal Comprehension score reflects one’s ability
to think in the abstract, vocabulary development, and social judgment. Perceptual Reasoning requires visual
conceptual skills, the analysis and synthesis of visual information (block designs), and reasoning with abstract
visual designs. Fluid Reasoning measures the child’s ability to detect the underlying conceptual relationship
among visual objects and to use reasoning to identify and apply rules. Working Memory measures the ability
to concentrate without distraction while mentally manipulating information. Processing Speed predicts how
quickly one can complete paper-and-pencil tasks.
Wilkinson, G. S., & Robertson, G. J. (2006). The Wide Range Achievement Test: WRAT 4, administration
manual. Wilmington, DE: Wide Range.
Comment: This test provides standard scores, percentiles, and grade levels for academic performance in areas
of word reading, sentence comprehension, reading composite, spelling, and math computation.
Woodcock, R. W., McGrew, K. S., & Mather, N. (2001). Woodcock-Johnson III, Tests of Achievement. New
York, NY: Riverside.
Comment: The WJIII Ach provides scores for academic performance in 22 different areas, from letter–word
identification, to punctuation and capitalization. Scores can be calculated in a variety of ways to provide
composite academic information. For example, Broad Reading is calculated based on scores for letter–word
identification, reading fluency, and passage comprehension; Broad Math includes scores for calculation, math
fluency, and applied problems.
Woodcock, R. W., McGrew, K. S., & Mather, N. (2001). Woodcock-Johnson III, Tests of Cognitive Function.
New York, NY: Riverside.
Comment: The WJIII Cog consists of 20 tests that measure processing in areas of verbal comprehension,
visual/auditory learning, and auditory working memory.
712
Index
Aardema, F., 221, 261

Ability/achievement discrepancy, 373–374
Ablon, J. S., 173
Abuse and neglect
deprivation of care, 344–345
outcomes of, 24 (box)
poverty, effects of, 25 (box)
See also Traumatic- and stress-related disorders
Academic skills
educational programs, 138–140
fetal alcohol spectrum disorders and, 184
homework management programs, 174
individualized education plan (IEP), 138
intellectual levels and, 90–92, 132–133, 135
oppositional defiant disorders and, 174
special education placement, 138–139
specific learning disorders and, 99–104
See also Learning disability
Accurso, E. C., 281
Achenbach Child Behavior Checklist, 92, 111, 135, 218, 240, 258
Achenbach System of Empirically Based Assessment (ASEBA), 102, 363, 364–365, 374–375
Achenbach Teacher Report Form, 111
Adaptive Behavior Assessment System, 148, 159
Adaptive Behavior Scale, 135
Adi-Japha, E., 377
Adjustment disorders, 78–80
Adler, C., 274
Adolescent egocentrism, 228–229
Adult Attachment Interview, 14, 14 (box)
Adverse child experiences, 23–24
See also Abuse and neglect; Violence
Affect, 2
Aggression
antisocial personality disorder and, 61–62
bipolar disorders, 262, 273
forms of, 1
gang activity and, 185
713
parenting practices and, 65
social cues and, 173
substance use and, 284
traumatic- and stress-related disorders and, 332, 343, 348
See also Behavior disorders
Agoraphobia, 190
Ahmad, S., 113, 150
Ainsworth, M. D. S., 13
Akiskal, H. D., 260
Al-Alem, L., 315
Albano, A. M., 229
Alcohol. See Fetal alcohol spectrum disorders; Substance use disorders
Alemán, M. W., 65
Alter, M., 139
Alvord, I. N., 24 (box), 29
Amaya-Jackson, L., 332
American Academy of Child and Adolescent Psychiatry, 261, 264, 332, 348
American Academy of Pediatrics, 151
American Association for Child and Adolescent Psychiatry, 245
American Association on Intellectual and Developmental Disabilities, 136
American Association on Mental Retardation, 135, 402, 403
American Psychiatric Association, 182
American with Disabilities Act Amendments Act of 2008, 400
Amir, N., 113
Andershed, A., 28
Andershed, H., 28
Anderson, P. M., 185
Anderson, T. M., 83
Andrews, G., 83
Anger-control programs, 173
Anger Coping program, 173
Anglin, D. M., 314
Angold, A., 263
Anorexia nervosa, 282–283, 299–304
See also Eating disorders
Antidepressant medication, 47
Antisocial personality disorders, effects on family, 63
Anxiety and anxiety disorders
assessment strategies, 226–227, 391–398
generalized, 62–63, 189, 203–208, 207–208
714
phobias, 189–190, 197
prevalence of, 207, 227
selective mutism, 189, 197–199
separation anxiety, 189, 190, 196–199
social, 191, 225–231
treatment strategies, 197–199, 209–210, 229–231
trichotillomania and, 208–209
Anxiety-management training, 334
Anxiety reduction, 152
Applied behavior analysis, 137
Arellano, B., 104
Asperger’s syndrome, 21, 124, 125–126
Asperger Syndrome Diagnostic Scale, 125
Assessment instruments
for academic skills, 75–76
for ADHD, 92
for anxiety and depression, 45, 196, 206–207, 227
for autism spectrum disorders, 124–125
for behavioral issues, 46, 66, 77–78, 170–171
for bipolar disorders, 259, 272
case study examples of, 361–367
for eating disorders, 298
forensic, 182–183
for intelligence, 60, 75–76
interpretation of test scores, 413–420
for obsessive-compulsive disorders, 218–219
for personality, 45
for posttraumatic stress disorder, 329
for social, emotional, behavioral functioning, 363–367
for specific learning disorders, 101–102, 103
for verbal skills, 60
Assessment results and interpretation samples, 361–375
Assessment strategies
for ADHD, 60–61, 92–93
for anxiety disorders, 196, 206–208, 226–227
for behavioral issues, 60–61, 65–66
for bipolar disorders, 258–259, 271–272
components of, 4
715
for fetal alcohol spectrum disorders, 181–183
forensic, 181–183
for intellectual disability, 133–135
for learning disabilities, 101–102, 110–112
for neurodevelopmental disorders, 92, 110–111, 121–125, 133–135, 147–148, 158–160
for oppositional defiant disorders, 170–171
for school psychologists, 75
for teachers, 61
for traumatic- and stress-related disorders, 341–342
for Williams syndrome, 147–148
Atkinson, J., 290
Attachment patterns
in adulthood, 14, 14 (box)
avoidant, 50
case formulation based on, 14, 50–51
disorganized/disoriented, 13, 343–344
functional-motivational processes, 14
in infants, 13
insecure, 21, 50, 64
intergenerational, 22 (box)
oppositional defiant disorders and, 171
reactive attachment disorder, 343–345
secure, 51 (box)
in young children, 13–14
Attachment theory, 347
Attention, 95–96
Attentional impulsivity, 274
Attention deficit/hyperactivity disorders (ADHD)
assessment strategies, 60–61, 92–93, 367–380
biological perspective, 62–63
bipolar disorders and, 236, 262
brain anatomy and, 6–7
case formulation study, 57–69, 89–95, 367–380
classification system and, 410–411
comorbidity, 379–380
diagnosis of, 377–379
differential diagnosis and, 377–379
DSM-5 criteria, 84
juvenile onset bipolar disorders and, 262
716
oppositional defiant disorders, 171–172, 173
risks and, 93
specific learning disorders and, 103
symptoms of, 93, 377–379
treatment options, 93–95
Attributions, types of, 10
Auditory attention, 374
August, G. J., 94
Authoritarian parenting, 16–17, 17 (box), 23, 51
Authoritative parenting, 23, 51
Autism spectrum disorders
Asperger’s syndrome, 21, 124, 125–126
assessment strategies, 120–124
brain anatomy and, 6–7
common features, 125–126
communication and, 125–128
DSM-5 criteria, 85, 125
higher functioning, 125–127
lower functioning, 127
treatment/intervention strategies, 127–128
Avery, R. J., 345
Axelsen, D., 263, 264
Badner, J., 261

Bai, S., 32
Baker, L., 301
Balsano, A. B., 185
Bandura, A., 9, 12, 68
Barbe, R. P., 48, 244
Barkley, R. A., 63, 68, 95
Barlow, D. H., 229
Baron-Cohen, S., 128
Barr, H. M., 184
Barrett, P. M., 221
Bates, E., 150
Battle Hymn of the Tiger Mother (Chua), 17 (box)
Baumrind, D., 16, 23, 27, 28, 51
Bayley Infant Scales, 157–158
Beardslee, W. R., 243
Beauchaine, T. P., 11, 49, 51, 66
717
Beck, A. T., 10
Beck Youth Inventories (BYI-2), 92, 171, 207, 259, 272, 363, 367
Bedway, M., 302
Beebe, T. J., 290
Behavioral assessments, 65–66
Behavioral Assessment System for Children (BASC-2), 46, 77, 196, 218
Behavioral inhibition, 21, 22
Behavioral intervention plans
for aggressive behavior, 66–69, 67 (table), 69 (table)
development of, 8
Behavioral perspectives
case formulation based on, 8–10, 9 (boxes), 48–49
conditioning, types of, 8–9
operant conditioning, 8, 48
Behavioral systems assessment (BSA), 8–10
Behavior disorders, 332, 343, 348
ADHD and, 62–69, 171–172
assessment strategies, 46, 60–61, 65–66, 77–78, 170–171
conduct disorders, 1, 2–3, 163
DSM-5 classifications of, 163–164
dysregulation, 281
intellectual disabilities and, 132–134, 135
oppositional defiant disorders, 2–3, 163, 167–174
treatment strategies, 171–174
See also Conduct disorders; Oppositional behavior
Behavior Rating Inventory of Executive Function (BRIEF), 182, 183, 342
Behavior Regulation Index, 342
Behaviors
adaptive, 136
aggressive, 62–63, 65, 173, 185, 262, 273, 332, 343, 348
atypical vs. typical, 1–3
behavioral inhibition, 21, 22
criminal, 181–183
disruptive, 63
environmental influences on, 3, 63
gang involvement, 184–185
high-risk, 2
internalizing, 2
neurochemistry and, 20–21
718
oppositional, 1
parenting styles, effects of, 23
reinforcement of, 3, 48
self-control of, 163
self-regulation, 314
Williams syndrome and, 151
See also Aggression; Behavior disorders
Beidel, D. C., 198, 230
Belliveau, J. W., 126
Bellugi, U., 150, 151
Benazzi, F., 260
Bender Visual Motor Gestalt, 196, 218
Bergman, A., 13
Bergman, R. L., 220
Beringer, L., 261
Berlin, L., 63
Berman, A. L., 246
Bernstein, D. P., 315
Best, A. M., 402
Best, N. T., 242
Biederman, J., 171, 238, 261, 262, 275
Binge-eating disorder, 283
Biological perspective
on ADHD, 62–63
case formulation based on, 6–7, 7 (boxes)
on depressive symptoms, 47, 62
on eating disorders, 301
epigenesis, 7 (box)
on self-regulation behaviors, 314
The Bipolar Child (Papolos & Papolos), 264
Bipolar disorders
ADHD and, 236, 262
assessment strategies, 258–259, 262, 271–272
bipolar I, 235, 272
bipolar II, 235, 272–273
case study, 255–259, 269–272
diagnosis of, 236–238, 260–262
DSM-5 classification and criteria, 235–236, 259, 272–273
family history and, 235, 262, 274
juvenile onset, 262
719
suicide and, 271
symptoms, 259–262, 273
treatment strategies, 264–265, 275–276
Birmaher, B., 48, 244, 263, 264
Black, B., 197
Black box warning, 243
Blader, J. C., 260
Blehar, M. C., 13
Blum, N. J., 199
Bobek, D., 185
Boer, D., 138
Bohlin, G., 63
Bolhofner, K., 260, 261
Bookstein, F. L., 184
Borderline personality disorder
case study, 309–313
comorbidity, 314
suicide and, 245–246
symptoms of, 314–315, 317
Borelli, J. L., 7
Boris, N. W., 344
Borowsky, I. W., 245, 247
Botzet, A., 94
Boulter, N., 221
Bowen, B., 11
Bowlby, J., 13
Boyle, M. H., 198
Bradley-Klug, K. L., 199
Brain function
adverse child experiences, effects of, 24 (box)
behavioral inhibition and, 314
biochemical activity and, 6–7
bipolar disorders, 274
borderline personality disorders, 314
emotion regulation and, 14
resilience and, 29–30
stress and, 21
Williams syndrome, 151
Brand, L., 128
720
Breinholst, S., 12
Brent, D. A., 48, 244
Brestan, E. V., 68, 172, 173
Bridge, J. A., 48, 244
Bridges, T. H., 23
Brief Screen for Adolescent Depression, 248
Brock, L. B., 139
Brodeur, C., 114
Bronfenbrenner, U., 19, 20, 52
Brotman, M. A., 237
Brown, W. B., 185
Bucci, J., 275
Buiks, A., 242
Bulimia nervosa, 283, 299–304
See also Eating disorders
Burbeck, R., 275
Burrough, J., 275
Burton, E. M., 300
Byrne, A., 137
Calabrese, J. R., 238, 262

Calhoun, S. L., 378, 379
Calugi, S., 299, 300
Calvo, R., 281
Campbell, A., 185
Campbell, S. D., 80
Caouette, J. D., 21, 228
Capra, L., 281
Carlberg, C., 139
Carlson, G. A., 260
Carmody, T. J., 275
Carter, J., 304
Case formulation
behavioral perspective, 8–10, 9 (boxes), 48–49
benefits of, 4–5
biological perspective, 6–7, 7 (boxes)
case study example, 355–358, 367–368
cognitive perspectives in, 10–12, 11 (box), 12 (box), 49
definition of, 4–5, ix
diagnostic impressions in, 376–377
721
family systems theory and, 17–18, 51–52
integration of theoretical perspectives, 19–20
parenting styles and, 16–19, 51–52
psychodynamic perspectives and, 12–16, 49–51
stages of, 5–6, 44
theoretical approaches to, 4
Case studies
anxiety disorders, 193–196, 203–207, 225–227
bipolar disorders, 255–259, 269–272
borderline personality disorder, 309–313
case formulation and, 43–52, 355–358, 361–380, ix–x
eating disorders, 295–298
fetal alcohol spectrum disorders, 179–181
high functioning autism spectrum disorders, 119–124
intellectual disability and behavior problems, 131–135
intervention plans, 57–69
nonverbal learning disability, 107–114
obsessive-compulsive disorders, 215–219
oppositional defiant disorders, 167–171
as outcomes evaluation, ix–x
posttraumatic stress disorder, 325–329
risks and protective factors, 73–80
self-mutilation, 309–313
social anxiety disorders, 225–227
specific learning disorders, 99–104
substance use disorders, 287–290
suicide, 239–240, 269–272
traumatic childhood experiences, 339–341
Williams syndrome, 145–149
Caspi, A., 47
Cassidy, J., 21
Castro-Fornieles, J., 281
Cater, Å., 28
Cavanagh, J., 273
Center for Mental Health Services, 409
Centers for Disease Control and Prevention, 244
Chamberlain, P., 346
Chanen, A. M., 317
Chase, G. A., 378
Chen, H., 314, 315
722
Child abuse. See Abuse and neglect
Child and Adolescent Bipolar Foundation, 262
Child Behavior Checklist, 218, 227, 261
Child Behavior Checklist Juvenile Bipolar Disorder Phenotype, 261
Child Behavior Checklist Pediatric Bipolar profile, 261
Child care, 31, 64
Child Depression Index (CDI-2), 45, 111, 207, 219, 312, 329
Child development, psychodynamic theories of, 12–14
“Children in the Community” (Bernstein, et al.), 315
Children’s Defense Fund, 24
Children’s Depression Inventory (CDI-2), 77, 92
Children’s Yale Brown Obsessive-Compulsive Scale, 219
Cho, E., 208
Chorpita, B. F., 229
Christ, M. A., 343
Chu, B., 210
Chua, Amy, 17 (box)
Cicchetti, D. V., 126, 127
Cipani, E., 9 (box)
Clarkson Freeman, P. A., 23
Classical conditioning, 8
Classification systems
ADHD, 410–411
educational, 400–401
emotional disturbance, 409–410
intellectual and developmental disabilities, 401–404
learning disabilities, 404–409
Coercion theory, 12 (box), 48, 65, 68
Cognitive-behavior modification, 94
Cognitive-behavior theory, 11–12
Cognitive-behavior therapy
for aggressive behaviors, 66
for anxiety disorders, 199, 209–210
for depressive disorders, 47, 49, 242–243
for eating disorders, 302–303
for emotion regulation, 49
for obsessive-compulsive disorders, 221
for PTSD, 332–333
Cognitive distortions, 173
Cognitive fluency, 372
723
Cognitive perspectives
on aggressive behaviors, 65
case formulation based on, 10–12, 11 (box), 12 (box), 49
learned helplessness, 10
problem solving, 171–173
Cognitive Proficiency Index, 371
Cognitive skills, 7, 163, 173
Cohen, J. A., 332, 333
Cohen, P., 315
Collaborative problem solving, 173
Collins, D. W., 113, 150
Colognori, D., 230
Communication styles
in autism spectrum disorders, 125–126
family and, 52
fetal alcohol spectrum disorders and, 184
social-pragmatic speech, 127
Comorbidity of internalizing and externalizing disorders, 2–3
See also individual disorders
Compulsions, 191
Conditioning, types of, 8, 48
Conduct disorders
childhood trauma and, 343
DSM-5 classification, 163
externalizing behaviors and, 2–3
oppositional behavior and, 1, 172
Conners 3 Teacher Rating Scale, 61
Conners Continuous Performance Tests, 374
Conners Parent Rating Scale, 60–61, 92, 101, 135, 298
Conners Rating Scales, 363–367, 375
Conners-Wells Adolescent Self-Reporting Scale, 92
Connor, P. D., 184
Cook, E. C., 23, 261
Cooney, G., 140
Copeland, W. E., 263
Coping Cat Program, 152
Coping Power program, 173
Cornoldi, C., 112
Cortesi, G. G., 221
Costello, E. J., 237, 263
724
Cottrell, D., 15 (box)
Council for Exceptional Children, 409
Coutinho, M. J., 402
Cox, C. B., 64
Cox, M. J., 80
Craig, I., 47
Craney, J. L., 260, 261
Crawford, T. N., 314
Criminal behaviors, 181–183
Crowley, M. J., 7, 79
Cullinan, D., 139
Cunningham, C. E., 198
Dadds, M., 221

Dakof, G., 291
Dallaire, D. H., 197
Dalle Grave, R., 299, 300
Darveaux, D. X., 174
David, D. H., 7
Davies, M., 43
Davies, W., 334
Davis, R., 300
Deblinger, E., 333
DeBoard-Lucas, R. L., 23
Defense mechanisms, 13
Degnan, K. A., 22
Deiner, M., 197
DeKlyen, M., 50
DelBello, M. P., 260, 261, 274
Delespaul, P., 242
Delinquency, 22 (box)
Depression and Anxiety Scales for Youth, 343
Depressive disorders
biological perspectives on, 47
case study formulation and, 73–80
cognitive–behavioral therapy and, 47
DSM-5 classifications and criteria, 236–237, 240–241
major depressive disorders, 236–237
maternal, 30–31, 80, 197
medical management of, 47, 243–244
725
prevention programs, 243
social anxiety and, 309–313
suicide, 239–240, 244–248
symptoms, 241
unipolar depression, 240
Deterministic epigenesis, 7 (box)
Developmental delay, DSM-5 criteria, 85
Development levels across lifespan
attachment perspectives, 13–14
psychodynamic perspectives of, 13–14
resilience, 28–32
risks and protective factors, 20–29, 29 (table), 52, 79, 242
Devereux Scales of Mental Disorders, 148, 160
Devlin, B., 241
Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA)
anxiety disorders, 189, 228
attention-deficit/hyperactivity disorders, 60, 84
autism spectrum disorders, 85, 125–126
behavior disorders, 163–164
bipolar disorders, 235–236, 259, 272–273
depressive disorders, 236–237, 240–241
developmental and lifespan strategies, 2, x–xii
disruptive mood dysregulation disorders, 263
eating disorders, 299
on eating disorders, 282–283
emotional disturbance, 409
forensic assessment and, 182
global developmental delay, 85
intellectual disability, 84–85, 136, 402–403
learning disabilities, 404–407
neurodevelopmental disorders, categories of, 83–84
obsessive compulsive disorders, 191, 220
posttraumatic stress disorder, 330
selective mutism criteria, 197
social communication disorders, 127
specific learning disorders, 84, 103, 112
on substance use disorders, 283–284, 290
traumatic- and stress-related disorders, 321–323, 344–345
Diagnostic process, components of, 4
Dialectical behavioral therapy, 245–246, 316–317
726
Diathesis-stress model, 52
Diaz, R., 281
Dickstein, D., 237
Diegel, P. T., 302
Dierker, L. C., 281
Differential Ability Scales, 120, 147, 159
Differential diagnosis, 238, 377–379
Dilsaver, S. C., 260
Disinhibited social engagement disorder, 322, 344
Disruptive behavior disorders. See Conduct disorders; Oppositional defiant disorders
Disruptive mood dysregulation disorders
assessment and treatment of, 262–264
diagnosis of, 237
differential diagnosis, 238
Ditterline, J., 238, 262
Dodge, K. A., 332
Dolan, C., 171
Domes, G., 21
Doss, A. J., 11, 243
Dowling, E., 185
Dowrick, P. W., 199
Doyle, T., 151
Drabick, D. A. G., 11, 49, 51
Drell, M. J., 330
Dudgeon, P., 317
Dulcan, M. K., 43
Dumas, J. E., 12
Duncan, B. B., 410
Dunn, V., 304
DuPaul, G. J., 199
Durkin, K., 126
Durlak, J., 28, 79
Dykens, E. M., 150
Dysgraphia, 103
Dyslexia, 99–104
Eating Disorder Inventory-2, 298

Eating disorders
anorexia nervosa, 282–283
assessment of, 298
727
binge-eating, 283
bulimia nervosa, 283
comorbidity, 300
comorbidity of, 281–282, 301
DSM-5 classifications, 282–283, 299
etiology of, 301–302
family dynamics, 300–301
medical interventions, 303
personality dynamics and, 300
types of, 281
Eaves, L., 208
Ecological-developmental framework, 13–14
Ecological systems theory, 19
Ecological-transactional model
contexts of influence, 19–20
Process-Person-Context-Time Model, 20
risks and protective factors, 20–28, 29 (table)
Educational classifications, 400–401
Educational assessments. See Academic skills
Egeland, B., 22
Egger, H., 263
Ego, 13
Ehrensaft, M., 314
Elias, M. J., 247
Emotional disorders
adjustment disorders, 78–80
depression (case study), 73–80
dysregulation, 281–282
See also Anxiety and anxiety disorders; Depressive disorders; Emotions
Emotionality, 63
Emotions
PTSD and, 345
regulation strategies, 21, 49, 151
resilience and, 30–32
self-blame, 23
self-control and, 163
Emslie, G. J., 241
Endriga, M. C., 50
728
Environmental influences
on anxiety disorders, 196–197
on behaviors, 3, 63
ecological-transactional model, 20
Epigenesis, types of, 7 (box), 19 (box)
Equifinality, 80, 187
Erbert, L. A., 65
Erikson, E., 7 (box), 13
Eriksson, I., 28
Erkanli, A., 208
Esbjørn, B. H., 12
Escher, S., 242
Essex, M. J., 208
Estevez-Gonzalez, A., 112
Evaluation process. essential strategies in, 3–4
Evans, I. M., 138
Exosystem, 24–25
Exposure treatment, 333–334
Externalizing behaviors, 2–3
Eyberg, S. M., 172, 173
Eye-movement desensitization and reprocessing, 334
Fahnhorst, T., 94
Fairbanks, L. A., 332
Fairburn, C., 304
Family Check-Up model, 19
Family relations
communication styles, 52
eating disorders and, 300–301
emotion regulation and, 23
family history assessments, 46
grandparents, 64–65
mother–infant, 14–15, 30–31, 80, 197
resilience, effects on, 30–31
See also Parenting styles
Family systems theory
case formulation and, 17–18, 51–52, 64–65
models of, 18–19
See also Parenting styles
Family therapy
729
multidimensional, 291–292
parent–child interaction therapy, 18, 32
Fang, X., 245
Faraone, S. V., 171, 238, 261
Farrell, L. J., 221
Farrell, S., 334
Farrington, D. P., 185
Fazio, V., 173
Fergus, E. L., 262
Fetal alcohol spectrum disorders
diagnosis and prognosis, 183–185
prevention of, 185
treatment strategies, 186
Fidler, D. J., 150
Fiksenbaum, L., 199
Findling, R., 238, 262
Fisher, P., 43
Fleck, D., 274
Fletcher, A. C., 23
Fluid Reasoning Index, 371
FOCUS (Freedom From Obsessions and Compulsions Using Cognitive-Behavioral Strategies) method,
221
Fonagy, P., 15 (box), 51
Forensic assessments, 181–183
Forkner, P., 238, 262
Forness, S. R., 403, 408, 410
Fosco, G. M., 23
Foster care, 19, 340–341, 346, 347–348
Fox, J. K., 230
Fox, N. A., 22
Frazier, J., 261, 273, 275
Frenkel, L., 377
Freud, S., 7 (box), 13
Freundlich, M., 345
Frick, P. J., 343, 346
Friends for Life (film), 248
FRIENDS for life program, 31–32
Fulkerson, J. A., 290
730
Functional behavioral assessments (FBA), 8–10, 66–67, 264
Fung, D. S., 199
Gang involvement, 179–181, 184–185

Garcia-Sanchez, C., 112
Geist, R., 300
Geller, B., 260, 261, 262, 273
Gender
anxiety disorders and, 227
eating disorders and, 300, 301–302
friendships and, 242
reactions to maternal distress, 80
risk factors and, 21, 22 (box)
General Ability Index, 371
Generalized anxiety disorders, 190–191, 203–208
See also Anxiety and anxiety disorders
Genetics, 6–7, 63
George, E. L., 275
Gibbs, J. T., 79
Gignac, M., 171
Gilliam Autism Rating Scale, 125
Gilroy, M., 302
Gioia, G. A., 348
Gladstone, T. R. G., 243
Goenjian, A. K., 332
Golan, O., 128
Golden, J. A., 9 (box)
Golomb, R. G., 210
Golombeck, N., 315, 316
Gonzalez, L., 281
Good behavior Game Plus Merit approach, 174
Goodyer, I. M., 241
Gordon, R. A., 185
Gordon, V., 128
Goring, J. C., 173
Gorman, J. M., 221
Gossage, P., 184
Goti, J., 281
Gottlieb, B. W., 139
Gottlieb, G., 7 (box)
731
Gottlieb, J., 139
Gould, M. S., 247
Grandparents, roles of, 64–65
Granger, D. A., 11
Gratz, K. L., 282
Graziano, A. M., 198
Greenbaum, P., 291
Greenberg, M. T., 13, 15, 50
Greene, R. W., 173
Gregg, N., 407
Gross, R. M., 302
Gross-Tsur, V., 113, 377
Grych, J. H., 23
Gual, A., 281
Gullion, M. E., 172
Gumley, A., 140
Guyer, A. E., 21, 228, 237
Hains, A., 334

Hair-pulling disorders, 191, 208–209
Hall, E., 332
Hallahan, D. P., 139
Hallowell, Ned, 95
Hammerness, P., 171
Han, S. S., 11
Hanseman, D., 274
Hansen, D. J., 230
Hanson, K., 343
Harnadek, M. C. S., 113–114
Harpold, T., 171
Harrington, H., 47
Harrison, P. A., 290
Hartman, M. A., 140
Hartsough, C., 410
Harvey, A. G., 276
Harvey, S. T., 138
Hawaii Transition Project, 140
Hawkins, S. S., 331
Hawley, K. M., 11, 243
Hayman-Abello, B. A., 113
732
Hayman-Abello, S., 113, 150
Healy-Farrell, L. J., 221
Heimberg, R. G., 229
Heinman, M., 300
Heinrichs, M., 21
Held, B., 4, 5
Held’s 3 components of therapy, 4
Heller, S. S., 344
Henderson, C. E., 291
Henderson, H. A., 22
Hennessy, E., 137
Herpertz, S. C., 21
Herzig-Anderson, K., 230
Hesse-Biber, S., 301
Hintze, J. M., 199
Hobbs, M. J., 83
Hocutt, A. M., 139
Hodapp, R. M., 150
Hofmann, S. G., 229
Holdnack, J., 408
Holland, R., 347
Holmes, B., 64
Home Situations Questionnaire, 61, 66
Hopeless scale, 398
Hostile aggression, 1
Hostile attribution bias, 173
Hoyme, H. E., 184
Huang, H., 94
Huang, L. N., 79
Hughes, S., 171
Humphrey, L. L., 301
Husky, M. M., 230
Id, 12–13
Identity, 13
Impulsivity, 273–274
Individual education plan (IEP), 138
Individuals with Disabilities Education Act, 138–139, 401, 404, 405–406, 409–410
Influences on development
exosystem, 24–25
733
individual differences, 20–21
microsystem, 21–24
Institute of Medicine, 183
Instrumental aggression, 1
Intellectual disability
assessments of, 134–135, 386–390
behavioral interventions and treatments, 136–138
behavior patterns and, 132–134, 135
classification systems, 401–404
DSM-5 criteria, 84–85, 136
intelligence testing and, 135
verbal communication and, 133, 134
Intelligence, 31, 90–92
Internalizing behaviors, 2–3
International Classification of Diseases (ICD-10), 330
Interpersonal Psychotherapy Prevention Program for High-Risk Teens, 243
Interview techniques, 4
Ireland, M., 245, 247
Iyengar, S., 48, 244
Jackson, A., 273

Jackson, H. I., 317
Jahoda, A., 140
Jaquet, E., 126
Jarvinen-Pasley, A., 151
Jaska, P., 95
Jayman-Abello, B., 150
Jesness Behavior Checklist, 343
Jesness Inventory Revised, 182–183
Jobes, D. A., 246
Jones, W., 150
Jovev, M., 317
Julien, D., 221
Jume, J. H., 275
Junque, C., 112
Kagan, J., 13, 20, 21

Kalafat, J., 247
Kalberg, W. O., 184
Kaminski, J. W., 245
Kaplan, P., 151
734
Kaplow, J. B., 332
Karayan, I., 332
Karevold, E., 208
Karnik, N. S., 281
Kaslow, N. J., 242, 243
Kauffman, J. M., 139
Kavale, K., 139, 408
Kees, M. R., 11, 49, 51
Kehle, T., 199
Kell, R. S., 199
Keller, M., 220
Kemph, J. P., 347
Kenny, A., 199
Kerr, I. B., 317
Kessler, R. C., 229
Ketelaars, C. E., 378
Kim, D., 197
Kim, H. K., 208
Kim, S. Y., 27 (box)
Kim-Cohen, J., 7
King, N. J., 198
Klein, M. H., 208
Klein, R. G., 93
Klin, A., 126, 127
Knott, F., 140
Knox, G. W., 185
Kodituwakku, P., 184
Koenen, K. C., 332
Korenberg, J., 151
Kovacs, M., 241
Kowatch, R. A., 275
Kraemer, J. C., 208
Kramer, R. A., 247
Kromelis, M., 275
Kronenberger, W. G., 3, 5
Kubik, J., 95
Kumbier, E., 21
Kuo, F. E., 95
Kurkowski, C., 11
Kurtz, Z., 15 (box)
735
Kwon, A., 238, 261
Labuschagne, Z., 281

LaCava, P. G., 128
LaFreniere, P. J., 12
Lahey, B. B., 185, 343
Lam, D. H., 275
Lampert, C., 275
Landau, Y. E., 377
Language processing skills, 173, 174
Larrieu, J. A., 330, 344
Larry P. v. Riles, 402
Larzelere, R. E., 16
Learned helplessness, 10
Learning and Study Strategies Inventory (LASSI), 95
Learning Disabilities Association of America, 408
Learning disability
assessments of, 61
classification systems, 404–409
nonverbal, 126–127
special education and, 138–139
See also Specific learning disorders
Leavy, P., 301
Lee, S., 94
Le Grange, D., 281
Leibenluft, E., 263, 264
Lender, W. L., 199
Leonard, H. L., 220
Lerner, R. M., 185
Leth, I., 12
Leutwyler, K., 94
Leve, L. D., 208
Leverich, G. S., 262
Lichtner, D., 79
Liddell, G., 112
Liddle, H. A., 291, 292
Lifespan development. See Development levels across lifespan
Lijffijt, M., 273
Lindner, J. L., 128
Linehan, Marsha, 316, 317
736
Living With Children (Patterson & Gullion), 172
Loeber, R., 185, 343
Lonigan, C. J., 208
Luby, J., 273
Luckenbaugh, D. A., 262
Lyons-Ruth, K., 64, 347
Maccoby, E. E., 16
MacMillan, D. L., 401, 403, 408
Macrosystem, 25–28
Madison, K. J., 23
Mahler, M. S., 13
Main, M., 13, 343
Major depressive disorders, diagnosis of, 236
See also Depressive disorders
Manassis, K., 199
Manic state. See Bipolar disorders
Mann, A. P., 281
Mannarino, A. P., 332, 333
Mannuzza, S., 93
Manor, O., 113
March, J. S., 210, 221, 332
Marchesini, G., 299, 300
Marconato, R., 112
Marriage, K. J., 128
Marti, C. N., 304
Martin, C. E., 246
Martin, J. A., 16
Mash, E. J., 8, 9 (box), 65
Masia-Warner, C., 230
“The Mass Marketing of Disordered Eating and Eating Disorders” (Hesse-Biber, et al.), 301
Masten, A. S., 29
Maternal depression, 30–31, 80, 197
Mather, N., 407
Mathiesen, K. S., 208
Maxfield, M. G., 24 (box)
May, A. M., 281
May, P. A., 184
May Chao, Y., 281
Mayes, S. D., 378, 379
737
McCracken, J., 220
McCutcheon, L. K., 317
McEwen, B. S., 24 (box), 29
McFaden, W. C., 290
Mcgorry, P. D., 317
McGuire, L., 230
McHolm, A. E., 198
McKay, D., 210, 222
McLoyd, V. C., 80
Mecosystem, 20 (box)
Medical interventions
for ADHD, 93–94
for anxiety disorders, 210
for bipolar disorders, 264, 275
black box warnings, 243
for depressive disorders, 243–244, 264
Williams syndrome and, 151–152
Memory
childhood experiences, 23
short-term, 102, 340
substance use and, 284
traumatic, 334
Williams syndrome and, 145–147, 149–150
working, 60, 75, 103, 173
Mertin, P., 242
Messer, S., 15 (box)
Meyer, L. H., 138
Meyer, M. C., 275
Meyer, R. G., 3, 5
Mick, E., 171, 238, 261
Microsystem influences, 21–24
Miklowitz, D. J., 275
Miller, A. L., 315, 316, 317
Miller, J., 64
Miller, R. B., 262
Minassian, D., 332
Minderaa, R. B., 378
Mink, D. M., 378
Minuchin, P., 17
738
Minuchin, S., 301
Modeling, 8, 230
Mody, M., 126
Moeller, F. G., 273
Moffit, T. E., 47
Molin, A., 112
Molina, B., 93
Montinari, C., 112
Montoya, I. D., 290
Monuteaux, M. C., 171
Mood disorders. See Depressive disorders
Mooney, K. C., 198
Moore, H., 238, 262
Moretti, M. M., 347
Morgan-Lopez, A. A., 80
Morris, M., 238, 262
Morris, P. A., 19
Morris, T. L., 198, 230
Morse, L. R., 173
Morton, E., 11
Mortweet, S., 139
Mostert, M. P., 408
Motor skills, 131, 145–146, 148
Motton, L., 126
Mukerji, P., 241
Mulder, T., 378
Mulle, K., 210, 221
Multidimensional family therapy, 291–292
Multifinality, 80, 187
Multisystem therapy, 245, 346–347
Muris, P., 208
Murphy, M. L., 220
Murray, M. C., 332
Murtuza, M., 27 (box)
Myles, B. S., 128
Najarian, L. M., 332

Nangle, D. W., 230
Nathan, P. E., 221
National Association of School Psychologists, 409
739
National Institute of Mental Health, 94, 261
National Joint Committee on Learning Disabilities, 406
National Longitudinal Transition Study-2, 140
National Mental Health and Special Education Coalition, 409
National Registry of Effective Programs, 248
National Survey of Child and Adolescent Well-Being, 23
Neft, D., 315, 316
Negative affectivity, 2
Negative attribution bias, 65
Nelson, E. S., 302
Nelson, G., 31
Nemoda, Z., 64
Neurodevelopmental disorders, DSM-5 categories, 83–84
See also Attention deficit/hyperactivity disorders (ADHD); Autism spectrum disorders;
Intellectual disability; Learning disability; Williams syndrome
Neziroglu, F., 210, 222
Nguyen, N., 402
Nielsen, S. K., 12
NIMH Roundtable on Prepubertal Bipolar Disorder, 261
Nonsuicidal self-injury, 281, 284
comorbidity, 313–314
Nonverbal learning disorders
autism spectrum disorders and, 126–127
description of, 108–110
Nonverbal Reasoning Index, 371
Object constancy, 13
Observation, classroom, 121–122, 158–159, 196
Observational learning, 8, 68, 230
Observational techniques as assessment, 4
Obsessions, 191
Obsessive-compulsive disorders
case study on, 215–219
diagnosis and prognosis, 219–220
DSM-5 classification and criteria, 191, 220
perfectionism, 221
740
prevalence of, 219
trichotillomania, 191, 208–209
O’Connor, K. P., 221
Olfson, M., 230
Ollendick, T. H., 198, 208
O’Malley, K., 184
Omar, H. A., 315
Operant conditioning, 8–9, 48, 67
Oppositional behavior
attachment issues, 171
case study of, 167–171
family history strategies, 168
treatment programs, 172–174
typical v. atypical, 1
Oppositional defiant disorders
ADHD and, 171–172, 173
assessment of, 381–386
conduct disorders compared to, 171–172
differential diagnosis of, 238
DSM-V classification, 163
externalizing behaviors and, 2–3
problem-solving skills, 172–174
prognosis, 171–172
traumatic childhood experiences and, 343
Oregon Model of family behavioral therapy, 18
Orlovsky, K., 238, 261
Orozco-Lapray, D., 27 (box)
Osborne, M. L., 199
Osborne, S. S., 139
Oswald, D. P., 402
Outcome evaluations, 3, 80, 137, 184
Owens, E. B., 16
Oxytocin, 21
Palombo, J., 114

Pan Yuen, H., 317
Papolos, D., 264
Papolos, J., 264
Parent–child interaction therapy, 18, 32
741
Parenting Stress Index, 61
Parenting styles
authoritarian, 16–17, 17 (box), 23, 51
authoritative, 23, 51
case formulation based on, 16–19, 51–52
child behavior and, 23
coercion theory and, 12 (box), 65
discipline methods, 11 (box)
foster parents, 340–341, 346
permissive, 51
PRIDE skills, 32
tiger, 17 (box), 27 (box)
training programs, 32, 138
uninvolved, 51
See also Family relations; Family systems theory
Parent Management Training Oregon Model, 18–19
Parent training, 18, 68, 172, 346
Paris, J., 315
Park, R. J., 241
Patten, J. R., 140
Patterson, G. R., 12, 18, 172
Pauls, D., 64
Pears, K. C., 208
Pediatric OCD Treatment Study Team, 221
Peer tutoring, 139
Peirson, L., 31
Pelham, W. E., 93
Penn Resiliency Program, 243
Perez-Edgar, K. E., 22
Perrin, S., 334
Persistent depressive disorders, DSM-5 classification of, 237
Personality
eating disorders and, 300
ego, 13
id, 12–13
social disinhibition, 151
superego, 12–13
Personality Inventory for Youth, 45, 77, 219
Peterson, S., 347
Petty, C. R., 171
742
Phillips, J., 15 (box)
Phobias. See Anxiety and anxiety disorders; Social anxiety disorders
Phonological awareness, 174
Physical features, 149, 183
Physiological Indicators of Anxiety scale, 272
Piacentini, J., 43, 210, 220
Pichichero, M. E., 220
Pilling, S., 275
Pincus, H. A., 48, 244
Pine, D. S., 22, 83
Pine, F., 13
Pisetsky, E. M., 281
Play therapy, 15, 51
Pollock, M., 241
Polloway, E. A., 140
Positive behavior support, 138
Post, R. M., 262
Posttraumatic stress disorder (PTSD)
abuse and neglect and, 344–345
assessment of, 329
brain anatomy and, 6
DSM-5 criteria, 189, 322, 330
exposure to violence, 23–24
prevalence rates, 331
symptoms, 330–332
Potter, A., 171
Poverty. See Socioeconomic status (SES)
Powell-Smith, K. A., 128
Practice Parameters for Assessment and Treatment of Children with Suicidal Behavior (AACAP), 245
Pratt, B. M., 304
Prilleltensky, I., 31
Probabilistic epigenesis, 7 (box)
Problem identification, 5–6
Problem interpretation/understanding, 5–6
Problem Solving for Life, 243
Problem-solving skills training, 172–173
Processing Speed Index, 370–371
Process-Person-Context-Time (PPCT) Model, 20
743
Psychodynamic developmental therapy for children, 50–51
Psychodynamic theory, case formulation based on, 12–16, 15 (box), 49–51
Psychosocial stages, 13
PTSD. See Posttraumatic stress disorder (PTSD)
Punishment, 9, 67–68
Pynoos, R. S., 332
Quian, Z., 79
Quinn, C. E., 301
Race and ethnicity

parenting styles and, 27
risks and protective factors, 79–80
youth gangs and, 185
Radcliffe, J., 331
Rademacher, J., 274
Rapoport, J. L., 220
Rapprochement phase of separate-individuation, 13
Rasmussen, C., 112
Ratey, N., 95
Rathus, J. H., 316, 317
Raynor, S. R., 23
Reactive attachment disorder, 321, 343–345
Reactivity, 7
Reading skills, 174
Realmuto, G. M., 94
Regular Education Initiative, 139
Reich, W., 94
Reid, J., 346
Reilly, J., 151
Reinforcement, 9, 48, 67–68
Reinholdt-Dunne, M. L., 12
Reiss, A., 151
Relationship skills, 11, 13, 126
Repetti, R. L., 32
Reschly, D. J., 401
Resilience
definition of, 28–29
intervention and prevention, 31–32
neurobiology and, 29–30
744
as process, 79
Resnick, M. D., 245, 247
Response to Intervention (RTI), 104
Revised Children’s Manifest Anxiety Scale (RCMAS-2), 45, 77, 111, 227, 272, 298, 312, 329
Rich, B. A., 237
Richards, C., 241
Richards, J. A., 275
Risk and protective factors. See Development levels across lifespan
Roberts, A. R., 246
Robert’s Apperception Test, 77
Robin, A. L., 302
Robinson, L. K., 184
Roderique, T. W., 140
Rodin, J., 302
Role models, 24
Romme, M., 242
Ronai, Z., 64
Rosen, L. A., 128
Rosman, B. L., 301
Rosner, B. A., 150
Rosner, S. R., 149, 151, 152
Rossen, M., 150
Rourke, B. P., 112, 113, 126, 127, 150
Rowe, C. L., 291
Roysamb, E., 208
Rubin, K. H., 22
Rush, A. J., 241
Rutherford, H. J., 7
Rutter, M., 79
Rydell, A., 63
Ryle, A., 317
Sabine, W., 222

Sabornie, E. J., 139
Sagun, J. N., 150
Sahyoun, C. P., 126
Salary, C. B., 48, 244
Sampson, P. D., 184
Sanchez, T., 104
Sansosti, F. J., 128
745
Sasvari-Szekely, M., 64
Sattler, J. M., 10, 407, 408
Scheeringa, M. S., 330, 344
Schmajuk, M., 237
Schmied, C. M., 408
Schoemaker, M. M., 378
Schulte, A., 332
Schwab-Stone, M. E., 43, 315
Scott, J., 273
Seattle Program, 15
Seguin, E., 135
Selection theory, 185
Selective mutism, 189, 190, 197–199
Self-control, 163
Self-mutilation, case study, 309–313
Self-regulation, 7, 314
Semel, E., 149, 151, 152
Semrud-Clikeman, M., 408
Separation anxiety, 64
Separation anxiety disorders
assessment of, 196
DSM classification of, 189
symptoms, 190
systematic desensitization method, 198–199
treatment strategies, 196–197, 198
Serketich, W. J., 12
Serrano, L., 281
Shaffer, D., 43
Shalev, R. S., 113, 377
Shaw, H., 300, 304
Shaywitz, B. A., 104
Shaywitz, S. E., 104
Shen, Y., 27 (box)
Sheridan, M., 230
Shinsato, L., 315
Siever, L. J., 315
Sigman, M., 210
Signs of Suicide (SOS) Prevention Program, 247–248
Silberg, J., 208
746
Silberstein, L. R., 302
Simoneau, T. L., 275
Singer Harris, N. G., 150
Skills for Social and Academic Success program, 230–231
Sleep disturbances, 273
Smith, A. C., 12
Smith, J. D., 140
Smith, P., 334
Smith, R. S., 79
Snidman, N., 13
Social adaptation, 63
Social anxiety disorders
adolescent egocentrism and, 228–229
behavioral inhibition and, 21
case study on, 225–227
depression and, 309–313
diagnosis of, 228–229
DSM-5 criteria, 228
prevalence, 227
symptoms of, 191
Social attachment, 7 (box)
Social cognitive perspective, 65
Social (pragmatic) communication disorders, 127
Social cues, 173
Social development and resilience, 30–33
Social disinhibition, 151
Social Effectiveness Therapy for Children program, 230
Socialization theory, 185
Social learning theory, 12
Social phobia. See Social anxiety disorders
Social-pragmatic speech, 127
Social Security Administration, 409
Social stories, 127–128
Socioeconomic status (SES)
parenting styles and, 17
poverty, risk factors and, 25 (box)
Softas-Nall, B., 64
Solomon, J., 343
Sommer, D., 11
747
Soulieres, I., 126
Sound sensitivity, 146
Southam-Gerow, M., 210
Soutullo, C. A., 260, 261
Sparrow, S. S., 126, 127
Special education placement, 138–139
Specific learning disorders
and ADHD, 103
DSM-5 criteria, 84, 103
dyslexia, 99–104
types of, 103
See also Nonverbal learning disorders
Speech. See Communication styles
Speer, M. A., 262
Spelling skills, 174
Speltz, M. L., 15, 50
Spencer, T.J., 275
Sroufe, L. A., 22
Stagg, R. E., 378
Stanford, K., 274
Stanford Binet 5, 147
Stark, K. D., 11
Starr, H. L., 199
Stein, M. B., 229
Steinberg, A. M., 332
Steinberg, J. L., 273
Steinhauer, P. D., 347, 348
Stewart, C. E., 230
Stewart, D., 304
Stice, E., 300, 304
Stiles-Shields, C., 281
Stouthamer-Loeber, M., 185
Strakowski, S., 274
Strange Situation experiments, 13
Strassberg, Z., 11, 49, 51
Strathearn, L., 14, 15, 21
Streissguth, A. P., 184
748
Stress
family and, 61
GABA system and, 21
Striegel-Moore, R. H., 281, 302
Strober, M., 275
Structured Assessment of Violence Risk in Youth, 182
Suarez-Romero, E., 112
Substance Abuse and Mental Health Services Administration, 186
Substance use disorders
comorbidity of, 281
DSM-5 criteria, 283–284, 290
family history and, 290
prevalence rates of, 284
Suddath, R. L., 275
Sugden, K., 47
Suicide
case study, 239–240, 269–272
crisis intervention model and, 246
eating disorders and, 300
prevention programs, 247–248
rates of, 244
risk factors for, 244–245
treatment programs, 245–248
Sun, K., 273
Sunderland, M., 83
Superego, 12–13
Suppes, T., 275
Surman, C., 171
Swann, A. C., 273
Swanson, H. L., 104
Swearer, S., 11
Swedo, S. E., 220
Syndrome-specific tests, 4
Systematic desensitization, 198–199
Tannenbaum, L., 343

Target, M., 15 (box), 51
749
Taylor, A., 47, 139
Taylor, A. F., 95
Taylor, C. S., 185
Teicher, M., 377
Temperament, 7, 20–21, 63
Terdal, L. G., 8, 9 (box), 65
Terr, L., 331
Thomas, R., 33
Thompson, M. P., 242, 243
Thompson, R. A., 51 (box)
Thompson, S., 114
Thought patterns of learned helplessness, 10
Tiger parenting, 17 (box), 27 (box)
Tillman, R., 261
Todd, R. D., 94
Todorov, C., 221
Tourette’s disorders, 135, 136
Towbin, K., 263, 264
Tracey, S., 229
Tran, L., 104
Trauma Symptom Checklist for Children, 329
Traumatic- and stress-related disorders
disinhibited social engagement disorder, 322, 344
DSM-5 classification and criteria, 321–323
PTSD, 6, 23–24, 189, 322, 325–334
reactive attachment disorder, 344–345
risk factors, 343
symptoms, 343–346
traumatic childhood experiences, 339–341, 344–345
See also Posttraumatic stress disorder (PTSD)
Treatment for Adolescents With Depression Study, 244
Treatment formulation, 5–6
Treatment Foster Care–Oregon Model, 19
Treatment strategies
for ADHD, 93–95
for anxiety disorders, 198–199, 209–210, 229–231
750
for bipolar disorders, 264, 275–276
for borderline personality disorder, 315–317
for eating disorders, 302–304
for fetal alcohol spectrum disorders, 186
for nonverbal learning disability, 113–114
for oppositional defiant disorders, 172–174
for PTSD, 332–334
for separation anxiety disorders, 198
for social anxiety disorders, 229–231
for substance use disorders, 290–292
for suicide prevention, 245–248
for traumatic- and stress-related disorders, 346–348
Trichotillomania, 191, 208–209
Triple P Positive Parenting Program, 32
Trujillo, P., 184
Tull, M. T., 282
Turner, S. M., 198, 230
12 plus 1 strategies for spelling, 174
Uhde, T. W., 197

Ultradian cycling, 260
Ultrarapid cycling, 260
Unipolar depression, 240, 272
U.S. Department of Education, 400
van Grondelle, A., 261

Van Horn, Y., 343
van Os, J., 242
Van Zonneveld, M., 378
Vasey, M. W., 208
Vavrichek, S. M., 210
Velez, C. N., 315
Velting, O. N., 229
Venneri, A., 112
Verbal skills, 60, 61
Verlaan, V., 347
Victimization, 245
Vigil, J. D., 185
Vineland Adaptive Behavior Scale, 125, 135, 182, 183, 184
751
Violence
exposure to, 23–24
peer victimization, 245
Visual reasoning, 61
Visual Spatial Index, 60
Visual Spatial Reasoning Index, 371
Voeller, K. K. S., 347
Volkmar, F. R., 126, 127
von Eye, A., 185
Wall, S., 13
Walls, J. K., 23
Walz, J., 210, 222
Wang, Y., 27 (box)
Warner, C. M., 230
Warriner, E. M., 113, 150
Waters, E., 13
Wechsler Individual Achievement Test (WIAT-III), 60, 102, 111, 135, 148, 170, 218, 289, 362–363,
372–373
Wechsler Intelligence Test for Children (WISC-V), 60, 75, 92, 102, 110, 124, 134, 258, 298, 361–362,
369–371, 369–372
Wechsler Preschool and Primary Intelligence Test (WPPSI-R), 132
Weerasekera, P., 4
Weinberg, W. A., 241
Weinraub, M., 197
Weiss, B. B., 11
Weisz, J. R., 11, 243
Werner, E. E., 79
Weston, D. R., 13
White, L. O., 7
Whitehouse, A. J., 126
Wide Range Assessment of Memory and Learning, 342
Widom, C. S., 24 (box)
Wilens, T. E., 93, 238, 262, 275
Williams, K., 128
Williams, L. R., 22
Williams, M., 260, 261, 273
Williamson, J., 64
Williams syndrome
behavior problems, 151
752
medical issues with, 150
memory skills, 150
personality characteristics, 151
treatment and intervention strategies, 151–152
Wilmshurst, L., 346
Winograd, G., 315
Winters, K., 94
Wittchen, H. U., 229
Wolpe, J., 230
Wood, J. J., 210
Woodbury-Smith, M., 127
Woodcock Johnson Cognitive Assessment, 102, 125, 372
Woodcock Johnson Test of Achievement, 76
Woolfenden, S. R., 304
Working Memory Index, 371, 378–379
Wozniak, J., 238, 261, 262, 275
Wright, K., 275
Wu, J., 7
Wu, K. D., 221
Yan, N., 31
Yaryura-Tobias, J. A., 210, 222
Young, J. K., 184
Young Children’s Achievement Test, 159
Youngstrom, E. A., 238, 262
Youngstrom, J. K., 238, 262
Youth gangs, 179–181, 184–185
Youth Risk Behavior Surveillance System, 281
Youth Self-Report, 92, 227, 272, 329
Ystrom, E., 208
Yule, W., 334
Zeanah, C. H., 330, 344

Ziatas, K., 126
Zimerman, B., 260, 261, 273
Zimmer-Gembeck, M. J., 33
Zoino, J., 301
753
754

Child and Adolescent Psychopathology A Casebook

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Child and Adolescent Psychopathology

SAGE Publications, Inc.

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Library of Congress Cataloging-in-Publication Data

Names: Wilmshurst, Linda, author.

Identifiers: LCCN 2017027063 | ISBN 9781506349350 (pbk. : alk. paper)

Subjects: LCSH: Child psychopathology—Case studies. | Adolescent psychopathology—Case studies.

This book is printed on acid-free paper.

Acquisitions Editor: Abbie Rickard

Editorial Assistant: Jennifer Cline

Production Editors: Libby Larson and Veronica Stapleton Hooper

Copy Editor: Diane DiMura

Typesetter: C&M Digitals (P) Ltd.

Proofreader: Lawrence W. Baker

Indexer: Karen Wiley

Cover Designer: Candice Harman

Marketing Manager: Jenna Retana

—Native American Proverb

Chapter 1: Introduction to Understanding the Complexities of Child and

Case 1: Terry Hogan developing a case formulation

Chapter 2: Introduction to Neurodevelopmental Disorders

Case 4: Colby Tyler attention-deficit/hyperactivity disorder (ADHD) and gifted

Case 7: Dylan Bach autism spectrum disorder (ASD; mild variant)

Chapter 3: Introduction to Behavioral Disorders

Case 11: Scott Michaels oppositional defiant disorder (ODD)

Chapter 4: Introduction to Anxiety and Compulsive Disorders

Chapter 5: Introduction to Problems of Mood: Depression and Bipolar

Case 17: David Steele depression and suicidal ideation

Chapter 6: Introduction to Disorders of Emotion and Behavior

Case 20: Alex Bishop substance use; multidimensional family therapy

Chapter 7: Introduction to Traumatic and Stress-Related Disorders

Case 23: Juan Hernendez posttraumatic stress disorder (PTSD)

Overview of Case Presentations

Table P1 Summary of Important Developmental Themes and Diagnostic Considerations

Case # Developmental Themes Diagnostic Considerations

case formulation from different

#1 Terry theoretical frameworks symptoms of depression

biological perspective: genetic

multifinality (sibling to Tyrone

#6 Sandy biological; right hemisphere

#9 Brian Williams syndrome

medical complications functioning)

oppositional defiant disorder

biological factors: fetal alcohol

#12 Tyrone juvenile justice

deviant peer groups

biological perspective: genetic

#16 Sandra genetic factors

#17 David depression

biological perspective: genetic