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Clinical Case ConceptualizationJessica P. StewartState University of New York at BuffaloFebruary 24, 2013IntroductionMatthew Davis was referred to the Gateway-Longview Behavioral Health Clinic (BHC) by the social worker at his pediatrician’s office. His aggressive behavior at school and home had been a continuous problem and the recent development of encopresis raised the level of concern with his grandmother and doctor. During intake Matthew’s Grandmother Margaret reported that Matthew has anger issues, he can’t calm himself down, he is violent, often throwing things and hitting others. Matthew is not focusing in school and is defiant to authority figures. It was also reported that Matthew feels that nobody loves him.Due to the constant chaos in his life, Matthew is struggling to find his place in his family and doesn’t feel any stability. He is a very passionate child who is often laughing, playing and is full of life in session.Nature of InteractionsMatthew began attending the BHC on May 11, 2012 and was admitted after three intake sessions on June 5, 2012. He has since attended 21 sessions and missed or cancelled five sessions. He is scheduled for individual and family sessions on a bi-weekly basis.Background InformationDemographicsMatthew is an eight year old African American male. He attends a local charter school and is in third grade. Family HistoryMatthew lives with his grandmother, his sister (13) and brother (6). He was placed in his grandmother’s care at birth because of his mother’s inability to care for him due to her alcohol and drug usage. Matthew’s mother has open visitation, but only sees him a few times a year. While he is with his mother, he is exposed to her drug usage and domestic violence between her and her boyfriend. Margaret reports that Matthew often acts out upon return from these visits. Matthew does not know his father.Matthew’s Sister Bernice also attends the BHC and has several emotional problems. She is a regular source of stress at home and gets a lot of attention for her negative behavior. Bernice has gotten into trouble with the law on multiple occasions. The attention that Bernice’s behavior draws is often at the expense of Matthew and his brother. Bernice was removed from the home and was placed with kinship for a short while during the time that Matthew has been in counseling.Matthew and his siblings often fight with each other well beyond normal sibling conflict. They often hit and punch each other when they are arguing. Most nights at home are chaotic and Margaret has little control over the children, the police have even been called when fighting has gotten out of control.Medical HistoryMatthew’s mother’s pregnancy, labor and delivery were uneventful, though Matthew was born with drugs in his system. As an infant he had heart problems which he outgrew. Matthew reached all of his developmental milestones appropriately with the exception of toilet training which was a problem until he was five years old. Matthew gets migraine headaches on a regular basis. Matthew’s mother has been diagnosed with bi-polar disorder and is receiving treatment for this.Substance Use/Abuse HistoryMatthew reports that he has not used alcohol or other substances and shows no signs of using such substances. Matthew’s mother is an alcoholic and drug addict, and Matthew has been exposed to her drug use while visiting with her.Treatment HistoryMatthew has no prior treatment history.Current AssessmentDiagnosesAxis I:313.81 Oppositional Defiant Disorder314.01 Attention Deficit Hyperactivity Disorder – Combined Type787.6 EncopresisAxis III:Migraine HeadachesAxis IV:Problems with primary support group: Unable to live with mother due to substance abuse issues, does not know father.Problems related to social environment: Fights with peers when they upset him.Educational problems: Trouble concentrating at school.Other psychological and environmental problems: Makes threats to hurt others, has made past suicidal comments.Current GAF: 45MedicationsUpon admission Matthew was taking Miralax daily at his doctor’s advice to help with the encopresis. After seeing the child psychiatrist at the BHC on August 30th, Matthew was prescribed Adderall XR to help with his ADHD symptoms. Because of Matthew’s history of heart problems, he needed clearance from his cardiologist prior to taking the Adderall. Margaret reports that the Adderall has been helpful and his teachers report an improvement in Matthew’s school performance. TreatmentMatthew and Margaret meet with a counselor at the BHC on a bi-weekly basis. The goals and objectives that were set in Matthew’s original Individualized Action Plan (IAP) dated June 29, 2012 were:Goal 1: Matthew will decrease the frequency and intensity of his aggression towards others.Goal 1 Objective A: Matthew will decrease his verbal and physical aggression towards others as evidenced by fewer reports of fighting from his grandmother.Matthew will process triggers for his aggression and will identify self-calming statements that he can use to de-escalate.Matthew will identify appropriate outlets that he can use to express his anger in a healthy manner.Matthew will identify how his cognitions tie into his aggression and will learn to replace negative thinking and positive, healthier cognitions.Goal 1 Objective B: Matthew will replace his defiance toward authority figures with increased respect and compliance.Margaret will utilize a system that encourages positive behavior while deterring negative outbursts.Matthew will recognize the benefits of treating authority figures in a respectful manner.Goal 2: Matthew will improve his sense of self and feel better about the person that he is.Goal 2 Objective A: Matthew will identify actions that can be taken to help him improve his self-image.Matthew will identify things that he does which he can use to affirm a more positive sense of self.Matthew will focus on his positive qualities and share them with others.Matthew will learn how his own thoughts contribute to his feelings and will work on being able to replace these with healthier schemas.Matthew will recognize negative consequences that arise from his encopretic behaviors and will focus on changing these behaviors so as to gain a sense of mastery over this.Goal 2 Objective B: Matthew will recognize and express feelings of abandonment in a healthy way so as to move past them.Matthew will process his feelings about his mother during sessions and discuss how her actions have made him feel about himself.Matthew will identify healthy reactions to his feelings and will also note any cognitive distortions which may ne influencing his feelings of abandonment.Matthew’s goals have remained the same throughout his treatment. He has made some progress in that the frequency of his aggression has decreased, but not to a healthy level. Sessions include cognitive behavioral techniques to help Matthew learn coping skills and to help Margaret develop an effective parenting strategy. The Davis family is in a constant state of chaos and often come into session with a current crisis to address which has been a detriment to Matthew’s progress. A great deal of time and energy has been spent on Bernice’s negative behavior which has also taken away from Matthew’s treatment. Throughout treatment it has been stressed that Margaret implement a reward based system that will track Matthew and his Brother Aaron’s behavior. Multiple tracking sheets have been created in therapy for Margaret to utilize at home. Margaret agrees that the system seems fair and effective and that she can implement it at home. In spite of this agreement she has been inconsistent in her attempts to track the boys’ behavior. While Margaret is a loving caregiver, she is overwhelmed with the responsibility of parenting her grandchildren and is often not able to be consistent with her disciplining and rewarding of the children.Through role playing and story-telling Matthew has started to learn that he has control over his behaviors and that there are many people in his life who support him in his goal of learning to control his anger. Margaret has also been able to show Matthew how to control his anger by modeling appropriate responses for him.As stated in the goals for Matthew’s treatment, he has a negative view of himself. When questioned about a situation that was observed in the waiting room, Matthew reported that he responded inappropriately when he in fact handled himself well. This situation where Matthew viewed himself incorrectly was used to show both Matthew and Margaret how skewed and negative Matthew’s self-image was. Time in therapy has been spent focusing on Matthew’s positive traits and how he is a valued part of the family. It was suggested that Margaret write down the positive things that Matthew do each day and spend a few minutes each night going over them. Margaret wrote down a few comments sporadically, but again was inconsistent with this technique. Prognosis Matthew has made some progress towards his goals, but still has a long way to go. Unless Margaret is willing to really implement a consistent routine at home it is not likely that Matthew’s behavior will reach its potential. Functional AssessmentStrengths: Matthew is intelligent and creative. He is very creative and enjoys many activities including football, singing, dancing and drawing. Matthew has a good relationship with his grandmother who consistently brings him in for counseling. Matthew has proven that when he sets his mind to it he can succeed in reaching his goals. He takes great pride in being a good helper at home and is often praised for this.Limitations: Matthew doesn’t have a strong support system. While his grandmother is well-meaning, she is not being consistent in her efforts with Matthew. He has few good role models in his life. Matthew’s low self-esteem causes him to doubt his ability to succeed. Matthew’s home environment is very chaotic and there is little parental control. His sister’s out-of-control behavior tends to dominate things at home.Preferences: Matthew tends to react impulsively. He has very few coping skills to handle the inevitable stresses of his life and so he responds in the only way he know how: with physical aggression. It is clear in session that he tries to gain attention through negative or inappropriate responses which is his approach at home as well. Resources: Matthew and his family attend sessions at the BHC where they are provided with support through the counseling relationship. They are also involved in their church and report their faith and church family being a resource for them. Margaret is able to provide food and shelter for the family. They are able to use public transit to get to appointments and run errands. In addition to their basic needs the family has access to some toys and share an ipad for entertainment. Psychological test results: Matthew’s grandmother completed the Strengths and Difficulties Questionnaire (SDQ) and he scored in the abnormal range for all areas: emotional symptoms, hyperactivity symptoms, peer problems and prosocial behaviors. He was also administered the SNAP-IV which measures ADHD symptoms. Matthew scored above the cutoffs for each area on the test: hyperactivity/impulsivity, inattention and ODD.Recommendations and ConclusionsMatthew will continue to benefit from therapy sessions. In order for any parenting strategy to work, consistency is needed, so this will continue to be stressed with Margaret. It would be beneficial if a few sessions can be spent solely with Margaret to help her develop more parenting skills and to gain confidence in implementing a good system at home. Matthew has grown through therapy and has the ability to reach his goals with the proper support. ................
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