Case Study: Posttraumatic Stress Disorder in a 6-Year-Old Boy, Assignments of Psychology

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Page 1 of Case Study Assignment: Toby School of Behavioral Sciences, Liberty University

Page 2 of

CASE STUDY ASSIGNMENT INSTRUCTIONS

Client Concerns Symptoms Behaviors Stressors Nightmares about accident Restlessness—fidgeting and unable to sit still (also symptom) Was in significant car accident Difficulty sleeping (also a symptom) Feels he caused accident Will not play video game that he was playing at time of accident Hyper-vigilance when driving (sits in middle seat to watch for cars) Not completing work at school Distracted (also symptom) Lack of socialness at school and church Aggressively uses matchbox cars to recreate accidents Assessment The assessment used will be The Child PTSD Symptom Scale for DSM-V (CPSS-V SR). This assessment is tailor-made for children, and communicates in child-friendly language. Additionally, it gives five severity ranges, which is a helpful piece of information to have. Hukkelberg et al. (2014) stated that while the specificity was moderately low, the sensitivity for this assessment was high.

Page 4 of surroundings.) Such trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to reminders of the traumatic event(s). C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s): Persistent Avoidance of Stimuli
6. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).
7. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).
8. Negative Alterations in Cognitions
9. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).
10. Markedly diminished interest or participation in significant activities, including constriction of play.
11. Socially withdrawn behavior.
12. Persistent reduction in expression of positive emotions. A. Refuses to play video game that he was playing at the time of accident B. Feels his video game caused the accident (guilt, shame) C. Does not want to participate in activities he once considered “fun” D. Withdrawn from classmates and church peers D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
13. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums).
14. Hypervigilance.
15. Exaggerated startle response.
16. Problems with concentration.
17. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). A. Shows aggressive behavior towards matchbox toys, and peers feel need to keep distance if they want to be safe B. Sits in middle seat while driving to help parents look out for cars C. Screams and covers head if driving on two-lane road D. Struggles to concentrate in school as well as church

Page 5 of E. Has nightmares, which makes it difficult to fall

Page 7 of not quickly addressed, Theo could find himself significantly behind his peers, academically and emotionally. Multicultural and/or Social Justice Considerations Theo’s family are Jehovah’s Witnesses. Friedson (2015) states that the religious believes of Jehovah’s Witnesses may pose significant obstacles to counseling. While Theo’s family seems proactive in getting Theo counseling, there may be pushback along the way. Friedson cites a statement from the Jehovah’s Witnesses official publication that says “It is only when we have a strong friendship with Jehovah that we can really be happy and safe. Only Jehovah can help us with all our problems”. Perspectives like this may lead members of the church to feel like Theo’s family is relying on the world rather than on God to heal him. Treatment Recommendations Key Issues for Treatment

• Treating sleep hinderances
• Decreasing negative response to activating stimuli Recommendations for Individual Counseling Trauma focused cognitive behavior therapy (TF-CBT) is a subsection of cognitive behavior therapy that implements trauma treatment, and has been validated as one of the superior forms of treatment (Cohen & Mannarino, 2015). There are a handful of requirements to use this treatment method, all of which Theo meets. The trauma must be remembered, and there must be prominent symptoms of PTSD, though no formal diagnosis is required. As Theo seems to still have a solid relationship with his parents following the accident, TF-CBT will work well as the parent participates in the child’s treatment, giving the clinician someone in the room who the

Page 8 of child trusts. This method can be utilized in as few as 12 sessions, making it accessible to Theo’s family whose insurance provides limited long-term therapy. Another treatment method that may be a fit for Theo is eye movement desensitization and reprocessing (EMDR). A metanalysis by Lewey et al. (2018) found that TF-CBT is marginally more effective than EMDR in treating childhood trauma, but if for whatever reason Theo did not respond to TF-CBT, or the clinician is not trained in TF-CBT, EMDR is an appropriate and efficacious option. Specific Considerations Being that Theo is only six years old, a clinician might feel the need to lead Theo to a significant degree. But Theo is an autonomous human who perhaps feels that some autonomy has been lost due to the psychological/physiological responses from his accident. The last thing a clinician would want is to continue to take that autonomy and re-traumatize him, to whatever degree. Thus, it is incredibly important to collaborate with Theo on his treatment. That being said, it might be difficult to do so. Theo, being six, may not fully understand the scope of what is going on. He may withdraw from therapy as a soothing measure, not understanding that the discomfort he may feel in therapy is actually meant to help him in the long run. A clinician may feel like they must walk on eggshells as to not trigger the child, who is possibly less able to articulate distress before they become particularly aware of it, but Berliner & Kolko (2015) found that screening for PTSD was not distressing to children, the implication being that children are adequately able to articulate when they are and are not distressed.

Page 10 of children and adolescents. Journal of Anxiety Disorders , 28(1), 51-56. https://doi.org/10.1016/j.janxdis.2013.11. Lewey, J. H., Smith, C. L., Burcham, B., Saunders, N. L., Elfallal, D., & O’Toole, S. K. (2018). Comparing the effectiveness of EMDR and TF-CBT for children and adolescents: A meta-analysis. Journal of Child & Adolescent Trauma , 11, 457–472. https://doi.org/10.1007/s40653-018-0212- Metsäpelto, R.-L., Zimmermann, F., Pakarinen, E., Poikkeus, A.-M., & Lerkkanen, M.-K. (2020). School grades as predictors of self-esteem and changes in internalizing problems: A longitudinal study from fourth through seventh grade. Learning and Individual Differences , 77, 101807. https://doi.org/10.1016/j.lindif.2019.