Diagnosing Ricky

I wrote this diagnosis and intervention plan for my problem identification class at the University of Rochester. The professor asked us to review a case study of a fictional boy Ricky and diagnose him and plan an intervention. I have included my diagnosis and intervention below.

Diagnosing Ricky

Discussion of presenting signs and symptoms of the client

 Our client Ricky is showing several signs and symptoms, each disclosed by different sources. I have summarized the signs and symptoms by source and itemized them below.

Ricky (Self-Report)

 Ricky has disclosed that he is having difficulty adjusting to his new school year and specifically to his new school teacher, Mrs. Candler, who appears to be abusing Ricky by yelling at him and instructing him to do things he is unable to do, specifically paying attention in class or following rules, especially when Ricky is bored, sad, tired, and angry in the classroom.

 Ricky also seems to admit to throwing tantrums, crying, stomping his feet, speaking disrespectfully, and defying the teacher as methods of attempting to get his needs met in the classroom.

Ricky says he only has one friend at school due to Mrs. Candler preventing him from making friends due to her putting him in punishment. Ricky seems to be frustrated that other children do not seem to play with him, but he does not understand why.

Mrs. Smith (Ricky's Mother)

 Mrs. Smith considers her son "out of control." Mrs. Smith notes that Ricky acts out to get his needs met, is defiant, and does not follow instructions. Ricky also displays a lot of hyperactive energy, is disorganized, fidgets, and loses a lot of his items. As a result, Ricky only leaves the house infrequently.

Mrs. Candler (Ricky's Teacher)

 Mrs. Candler reports that Ricky only completes assignments when he wants to. He is also inconsistent in his attention and displays hyperactivity, frequently getting out of his seat and desiring personalized attention.

School Psychologist

 Ricky's intelligence test score is normal, yet he received low achievement grades due to his inability to pay attention. Ricky struggles with interpersonal relationships with classmates, but he is doing well in athletics.

Additional Family Factors

 Mrs. Smith reports a separation from her husband around 14 months ago. Mrs. Smith reports continued alcohol use, including when Ricky was in utero, and increasing levels of alcohol use since the separation. Mrs. Smith has a busy work schedule and often is not present to care for Ricky, leaving this task to his sister, Renee.

Summary of Presenting Signs and Symptoms

 Our diagnosis is only as good as the veracity of the information we have received; for these reasons, we should be tentative in assigning signs and symptoms. Although, there seems to be a commonality of:

Difficulty adjusting – to a new school, teacher, and also home situation without a father

Abuse & Neglect – teacher yelling at student and forcing obedience to instructions Ricky cannot follow, potential neglect at home

Inattention – inconsistently pays attention in class or at home.

Depressive symptoms – such as boredom, sadness, fatigue

Hyperactivity – such as throwing tantrums, fidgeting, or running around with excess energy

Disorganization – losing items

Anger – anger at authority figures and friends

Defiance – refusing to follow instructions by teacher or parent

Social anxiety – inability to interact well with friends

Rule out diagnoses with supporting rationale

 Following the process described by Gary Gintner in Chapter 6 of Diagnosis in Clinical Mental Health Counseling (Gintner, 2017), I would first seek to rule out Medical Diagnoses in the form of physical illness. We do not have medical information. However, we can move on to the next level of diagnosis, keeping in mind that we will ask for fuller medical details before we complete the diagnosis. According to Gintner, next is substance use; we have not received any evidence of substance use, although it is something that we should consider due to Ricky's mother's alcohol problem; one may wonder if Ricky has been drinking or taking other substances. For now, we can put a tentative hold on medical and substance use concerns but will come back to them later. We can consider which medication Ricky may be taking; this report provides no information here; this, once again, should be followed up on to check for side effects.

 Next, we shall screen for major mental disorders, schizophrenia, or mood disorders. None of the reports show positive symptoms of delusions, hallucinations, disorganized speech, or catatonia. There also does not seem to be a flattening of affect or poverty of speech. There is a slight loss of pleasure and some social withdrawal. There is also impaired executive functioning and inattention. There are also some symptoms of depression and anxiety, especially in social relations. Because there are no positive symptoms, we can rule out schizophrenia; also, the age of onset is typically adolescence, so Ricky is too young.

 For mood disorders, there is mention of sadness. We have not ascertained the frequency, but from the description, it seems like it is not most of the day for every day, so this may allow us to rule out Major Depressive Disorder and other similar depressive disorders; we may consider Disruptive Mood Dysregulation Disorder though, due to the anger issues Ricky has been facing. Next, we should consider Bipolar and Related Disorders; Ricky is exhibiting impulsivity and irritability, but not a grandiosity or decreased need for sleep seen in mania in Bipolar I in children. Ricky may be exhibiting hyperactivity similar to hypomania in Bipolar II, and he is experiencing sadness, irritability, lack of interest, and withdrawal from activities; it does not seem like he is cycling between episodic experiences of hypomania and depression unless it were Ultra-Rapid or Ultradian cycling Bipolar II or Cyclothymia.

 According to Gintner (2017), we would now look at Anxiety, Neurodevelopmental Disorders, OCD, and Personality Disorders. We do not see the worry typically associated with generalized anxiety disorders, nor do we see panic attacks or specific phobias. However, we do see some frustration and avoidance of interacting with others, especially friends, so we may consider social anxiety. For our neurodevelopmental disorders, we can consider Intellectual Development Disorder (IDD), Communication Disorders (CD), Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Specific Learning Disorder (SLD), and Motor Disorders. The school psychologist has advised us that Ricky's intellectual functioning is normal, so we can rule out IDD and SLD. No symptoms are present for language, speech, or stuttering, nor in using language socially. No motor symptoms, such as tics, are present. For ASD, Ricky is not showing social-emotional deficiency; in fact, he appreciates close attention. He does not show restrictive or repetitive behavior or interests, so I believe we can rule out ASD.

 Ricky is presenting many features of ADHD, including inattention: lacking attention to detail in work, inability to sustain attention, not following instructions when spoken to, being disorganized, losing possessions, forgetfulness, hyperactivity, and impulsivity: fidgeting, leaving the seat. These symptoms are present in two or more settings: school, home, and other places throughout the community. Ricky also matches the typical age of onset and first diagnosis of ADHD, which appears before age 12. Ricky is not presenting with any obsessions, including any persistent intrusive thoughts, nor is he facing any compulsions or repetitive behaviors, so I believe we can rule out OCD. We also do not typically diagnose personality disorders in children as their personalities are still developing.

 I now wish to consider Trauma and Stressor-Related Disorders. Ricky is not presenting symptoms of being emotionally withdrawn from caretakers nor disproportionately familiar interaction with unfamiliar adults. Therefore, we can rule out Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. The report details no evidence of Ricky's exposure to a traumatic or acutely stressful event such as death, serious injury, or sexual violence. However, while the report provides no evidence, we can imagine living in his house with an alcoholic working single mother could be very stressful, so we should screen for PTSD and Acute Stress Disorder. Also, it seems Ricky is adjusting to the separation of his parents and a new school year. Due to this, we may consider Adjustment Disorder (AD). The report did not inform us about the death of any loved ones or grief; therefore, we can rule out Prolonged Grief Disorder.

 Ricky does not present multiple personalities, a lack of memory of autobiographical information, or a feeling of detachment from himself. Due to this, we can rule out Dissociative Disorders. Ricky does not appear preoccupied with serious illness nor describe unexplained medical symptoms that could be of psychological origin. However, we have not received his medical reports, so we are unsure about them. We can rule out Somatic Symptoms and Related Disorders for now until we receive them.

 Ricky is not demonstrating any concerns regarding Feeding or Eating, nor concerns regarding Elimination; we can rule these out. Ricky has mentioned feeling sleepy in class, but he has not elaborated on difficulty falling asleep, maintaining sleep, or waking or falling asleep during the day; we can rule out sleep-wake disorders. Clinicians do not commonly diagnose sexual dysfunction in children; we can rule this out. No one has raised concerns about paraphilic disorders or gender expression; we can rule these out. We can rule out neurocognitive disorders because clinicians do not commonly diagnose them in children, and Ricky's intelligence tests are normal.

 When considering Disruptive, Impulse-Control, and Conduct Disorders, Ricky is not presenting symptoms of pyromania or kleptomania that we know of; we can rule these out for now. Although Ricky is demonstrating features of Oppositional Defiant Disorder (ODD), as seen by reports of his anger and irritability, argumentative nature, and inability to follow rules and requests from authority figures, we see this in two or more settings, which indicates a moderate specifier. We may consider Intermittent Explosive Disorder if we look at Ricky's verbal impulsive outbursts. While Ricky is showing anger, it is not clear that this is directed physically toward people or animals, vandalism or theft, or arson; for these reasons, we can rule out Conduct Disorder (CD).

Rationale for decision-making process for final diagnosis

 Considering the diagnoses ruled out, I believe we can start with the following preliminary diagnoses candidates:

Attention-Deficit/Hyperactivity Disorder (ADHD) - Combined Presentation

 The rationale for this potential diagnosis is that Ricky is showing inattention, including lack of attention to details, inability to sustain attention, not listening, not following instructions, disorganization, avoiding school work, and often losing items. Ricky also shows signs of hyperactivity, including fidgeting, leaving his seat, running around the house, inability to play quietly, being constantly on the go, and difficulty interacting with others. Ricky also meets the age of onset criteria of ADHD and presents these symptoms in multiple locations, including school, home, and public places. These symptoms clearly interfere with Ricky's functioning. Ricky has also been displaying these symptoms for over six months, as evidenced by the report of his mother, and no other mental disorders explain all of these particular symptoms.

Oppositional Defiant Disorder (ODD) – Moderate Severity

 The rationale for this potential diagnosis is that Ricky is often losing his temper, as seen by temper tantrums and outbursts. Ricky is easily annoyed, angry, and resentful. Ricky also often argues with authority figures, especially Mrs. Candler and his mother. Ricky also does not follow requests or instructions from these authority figures. The behavior specified here is causing considerable distress for Ricky and those who interact with him. There is also no clear indication of any other disorder that could be causing this behavior.

Disruptive Mood Dysregulation Disorder (DMDD) - Possible

 The rationale for this potential diagnosis is that Ricky is having severe recurrent temper outbursts that are inconsistent with his developmental level. The report does not tell the frequency of his temper outbursts, although, from the vignette, we may consider that they happen more than three times a week. Ricky's mood, while angry frequently, does have moments of sweetness, such as when an authority figure gives him kind one-on-one attention; this does not fully meet the criteria of DMDD. However, Ricky does meet other criteria for DMDD, such as being under 10 years old and presenting these behaviors for more than 12 months, as evidenced by his mother's reports and occurring in multiple settings, home, school, and in the community.

 Ricky also has not met the criteria of a manic or hypomanic episode, nor does he exhibit symptoms of major depressive disorder. It could be that if Ricky has ADHD and/or ODD, his symptoms are presenting similarly to DMDD. I have listed this as a possible diagnosis, but we need more information to determine if it is correct. It is also worth noting that a client cannot be diagnosed with ODD and DMDD simultaneously. DMDD must take precedence over ODD if it is present, so it will be crucial to discern between the two here by obtaining additional information.

Adjustment Disorder – Possible

 The rationale for this potential diagnosis is that Ricky is experiencing stressors, such as his parent's divorce, his mother's alcoholism, and his new school year. The report describes stressors with clinically significant emotional and behavioral problems that Ricky is facing. If these behaviors began or became significantly worse within 3 months of the onset of particular stressors, we could consider adjustment disorder. ADHD, ODD, or DMDD may also explain the client's symptoms, so gathering further information will be essential. We also should observe the stressors and see if things change for Ricky as the stressors end.

Discussion on what more information you may need

 I want to get a medical workup done for Ricky from his primary care physician as well as catalog any medications he is currently taking. I would ask the physician to consider looking into Ricky's sleep patterns to see if anything medical could explain his daytime sleepiness. I would also like to, as part of this, have Ricky tested for any drug or alcohol use. If possible, I would also like to arrange a home visit to Ricky's house to check that his living conditions are suitable and he is not subject to any environmental abuse or neglect that the report has not described.

 I would then conduct assessments to gather information on potential diagnoses more formally and screen for other areas. These would be:

Attention-Deficit/Hyperactivity Disorder (ADHD) - Conners'Rating Scales (Conners-3) and the Vanderbilt ADHD Diagnostic Rating Scales.

Oppositional Defiant Disorder (ODD) - Child Behavior Checklist (CBCL) and the Eyberg Child Behavior Inventory (ECBI).

Disruptive Mood Dysregulation Disorder (DMDD) - Affective Reactivity Index (ARI) and the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS)

Adjustment Disorder – Adjustment Disorder New Module (ADNM)

Social Anxiety – Social Phobia and Anxiety Inventory for Children (SPAI-C)

Trauma and Stressor-Related Disorders – Additionally, I would use the Acute Stress Disorder Scale (ASDS) and Child PTSD Symptom Scale (CPSS) to screen for any trauma or acute stress that the report may have overlooked.

Substance Use – I would also use the CRAFFT Screening Tool to screen Ricky for substance and alcohol use and I would recommend her mother additional support for her alcohol use.

Comprehensive problem list, prioritizing which problems are most important

 The primary problem we are facing is Ricky's emotional and behavioral outbursts. These are causing active problems for Ricky and for those he interacts with, including his family, school, and community in general.

 The next problem I see is Ricky's family system and home environment, which includes the separation of his parents and his mother's absence and increasing alcohol use. Unless those responsible remedy the neglect that Ricky may be experiencing and address the unstable attachments, he could develop more severe and long-lasting problems such as substance use, mood disorders, or personality disorders in the future.

 The next problem I see is Ricky's inability to pay attention, which includes fidgeting and restlessness. While these do not have as much immediate impact on those around Ricky, they do impact his ability to learn in the classroom and impact his ability to develop relationships with others. This could lead to Ricky's academic performance becoming a problem and lead him to become more isolated, both of which could accelerate problems in the coming years.

 The final problem I identify is Ricky's lack of social skills and isolation from his peers. Positive peer relationships can be prophylactic to other stressors and will become even more essential for Ricky as he enters adolescence. Not having a network of friends could lead to more severe problems in the future.

Short-term goals aligning with the problem list

 For emotional outbursts, we could set goals with Ricky, such as reducing the number of outbursts reported by 50% within one month. We could measure short-term goals for Ricky's family system and home environment by assessing Mrs. Smith's reduction in alcohol use and her development of new parenting strategies within three months. For inattention issues, short-term goals could involve Ricky submitting at least 75% of assignments on time and practicing mindfulness exercises at least once a week. Lastly, we could set goals to address Ricky's social isolation; we could measure this by asking Ricky to try to have positive social interactions at least three times a week.

Long-term goals aligning to diagnosis and problem list

 Over the long term, we can see Ricky developing emotional regulation skills to significantly reduce his outbursts in all settings. This could be measured by no outbursts reported by teachers after 12 months. For Ricky's family system, we can establish long-term goals such that after 12 months, Mrs. Smith reduces her alcohol intake to a healthy level as well; she provides more structured active parenting for Ricky, with new skills she has learned, measured by at least one time a week of positive mother-son engagement and further by establishing a structured and predictable engagement with Ricky's father, such that he also spends at least one time a week in a positive activity with Ricky and there are minimal unexpected absences.

 For Ricky's inattentiveness and academic issues, our goal could be for him to increase his grades by one letter point in a 12-month period and reduce his calls home to parents for poor behavior to zero. Lastly, to address Ricky's social isolation, we can establish a goal that he makes at least two good friends within twelve months and hangs out with them at least once a week.

Proposed interventions to address problems and work toward goals

 I would advise two immediate actions to address the first problem of Ricky's emotional and behavioral outbursts. The first would be to enlist Ricky in weekly counseling sessions using CBT techniques in order to teach him coping strategies to manage his behavioral and emotional outbursts. The second is that I would also refer Ricky to a psychiatrist for a secondary opinion on diagnoses as well as an evaluation for medication. I would advise Ricky's mother that clinicians have used stimulant medication to treat ADHD, yet it comes with noted side effects, and that it will be important to weigh the pros and cons of using medication for treatment.

 To address the family system problems, I would recommend additional sessions of family system counseling with Ricky, his mother, and his sister. This forum could help discuss the experiences related to the divorce and adjustment to the stressors around this issue, how access to Ricky's father is managed, and the home environment in general. I would also recommend Mrs. Smith to a counselor for her own therapy sessions and give her resources for local community support groups for alcohol use.

 To address Ricky's inattention difficulties, especially in the classroom, I would work with the teacher and school psychologist to structure accommodations for Ricky and an individualized learning plan that will allow him more flexibility in reaching his goals. I would also advise training the teacher, Mrs. Candler, and the school on how to work with children who display symptoms such as Ricky's, so no staff yell at children. I would work with Ricky to identify his strong suits, which appear to be in science and physical education and to lean into these. I would work with Ricky on mindfulness practices to help manage his impulsivity and inattentiveness.

 Lastly, to address Ricky's social isolation and lack of connection with peers, I would recommend that he attend a mentoring program where he may get an assigned older buddy to work with him to learn more social skills. I would also give Ricky information on social skills training programs. I would also try to lean into areas where Ricky is showing success, especially in athletics, to see if Ricky could demonstrate social leadership in these areas.

Consideration for ethical and cultural considerations

 First and foremost, from an ethical perspective, we must have informed consent for any exercises we undertake or any therapeutic interventions we deploy. Since Ricky is a minor, this includes Ricky's personal assent and the informed consent of his parent, in this case, likely his mother Mrs. Smith. We must fully inform Ricky's mother of any risks, especially medication-related ones. Assent and informed consent must be obtained through the use of appropriate language, especially in the case of Ricky, describing things in language terms he and his mother may be able to understand, making sure they feel heard and included in the process.

 Culturally, the report tells us Ricky is African American. We do not know his parents' race, nor whether Ricky is mixed race or the other cultures with which Ricky identifies. We should be mindful of cultural considerations; for example, if researchers build assessments based on populations that do not identify as African American, we must interpret Ricky's results cautiously, as they may be biased. Furthermore, there is ongoing debate regarding the over-diagnosis and pathologizing of certain minority cultures and groups, such as African Americans; this is why it is critical not to jump to a diagnosis, especially ones like ADHD or ODD. These may tend to place the blame on Ricky psychologically. We must be mindful that Ricky's actions very well are appropriate responses to biopsychosocial stressors, specifically racism, and poverty, which may play a role here, as well as the divorce and other stressors impacting Ricky. I feel it is very important to screen Ricky for trauma and stressor-related disorders because his environment may be causing his actions, not just his biology or psychology.

 We also need to consider the school system and community to which Ricky belongs. The report does not tell us the teachers' or community members' race or socioeconomic status. Mrs. Candler's actions of singling out Ricky and verbally abusing him may be caused by unconscious racist bias, especially if he is only one of few African American students.

References

 Gintner, G. G. (2017). Diagnosis. In J. S. Young & C. S. Cashwell (Eds.), Clinical mental health counseling: Elements of effective practice. SAGE Publications.