December 15, 2013
Dr. Stephanie Sencil-White
Clara is a four year old adopted child who is exhibiting lack of eye contact, inconsolable temper tantrums, and an aversion to school; these behaviors have her parents concerned.
During the interview with Clara’s family I would begin by asking if there were any recent changes in the household, such as, a new baby or pregnancy, or the loss of a loved one. I would inquire if these behaviors were sudden or a gradual progression. I would ask if the temper tantrums preceded or followed a specific incident or if they appeared for no apparent reason. I would also ask if a specific incident happened at school or if there was an area of concern that the teacher had mentioned that may be causing the lack of desire to attend. I would inquire ...view middle of the document...
I would also have Clara do a Kinetic Family Drawing as it is geared more towards children in a clinical environment. Lastly, I would ask Clara’s parents to agree to some neurological testing to rule out any brain abnormalities that may affect behavior (Comer, 2011).
Before treatment options can be explored for Clara, some factors I would consider would be the physical and mental health of the biological parents in case there were possible genetic disorders that could be linked to Clara, I would also explore the possibility of there being environmental factors that could be contributing to the behaviors that Clare is exhibiting. I would suggest family sessions so that I could monitor the interaction between the family while gathering further information necessary to formulate a treatment plan for Clara.
The information I would enter into each Axis would be as follows:
* Axis I: Frequent, inconsolable temper tantrums.
* Axis II: Quiet and exhibiting lack of eye contact.
* Axis III: Poor sleep and poor appetite.
* Axis IV: Phobia of school.
* Axis V: GAF of 61-70, mild symptoms in one area or difficulty in one of the following: social, occupational, or school functioning. But, the person is generally functioning pretty well and has some meaningful interpersonal relationships (APA, 2000).
I think that a diagnosis for Clara would be premature at this point in time and that more thorough testing needs to be done in order to get to the cause of her behavior. A premature diagnosis can have lasting consequences that can follow a person throughout adulthood due to the stigma that can be attached to someone who is considered to have a mental disorder (Comer, 2011). A premature diagnosis could also cause Clara to exhibit additional behavior if she feels that it is expected of her because she is labeled (Comer, 2011).