Tori J. is a 12-year-old girl who was removed from her family at the age of 8, when she was placed with a foster family. Although her foster mother discussed some episodes of violence and defiance in the home, Tori was not initially violent or defiant in school. However, she frequently failed to complete her assignments, instead spending hours simply looking into space. She also spoke frequently to social workers and school counselors about problems in her foster home including allegations that she was not being fed sufficiently, that they would not purchase school supplies for her, and that there was emotional and physical abuse in their current home. These allegations were reported and determined to be unsubstantiated, but allegations of emotional and physical abuse and neglect in her family home were substantiated. The children were removed because of physical abuse and neglect. Interviews with Tori J.’s older brother reported that she her birthmother, a known prostitute, had allowed clients access to Tori J on repeated occasions. However, Tori J. refuses to confirm or deny these allegations; whenever asked questions about any type of sexual abuse, she puts her head down, closes her eyes, and pretends to nap. As she has gotten older, Tori J. has begun engaging in violent behavior. The behavior is unpredictable; she will not react with violence in situations where it might be anticipated, such as when another child aggresses against her, but will engage in violence in unprovoked situations. She also engages in stealing and is very manipulative.
A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event.
Differential Diagnosis
Tori J. has received a number of different diagnoses over her lifetime, which are complicated by the fact that she has been in the foster care system and has seen a large number of mental health professionals, and none of them for lengthy periods of time. She has never received a definitive diagnosis. Moreover, funding concerns have limited access to the full range of diagnostic tools. The four basic tools for psychological assessment include: norm referenced tests such as the MMPI, interviews, observations, and informal assessment (Framingham, 2012). Tori J. has never taken the MMPI or any similar psychological testing tools. Furthermore, “Psychological assessment should never be performed in a vacuum. A part of a thorough assessment of an individual is that they also undergo a full medical examination, to rule out the possibilities of a medical, disease or organic cause for the individual’s symptoms. It’s often helpful to have this done first, before psychological testing.
There are five axes to the DSM-IV. Axis I look for clinical syndromes, which is what many people consider traditional mental illnesses. Axis II refers to developmental disorders and personality disorders. Axis III looks at a person’s physical condition. Axis IV looks at the severity of psychosocial stressors. Finally, Axis V looks at the person’s highest level of functioning. Taken as a whole, the five axes should give an overall picture of the patient’s functioning and expected functioning under the current circumstances.
Axis I Because Tori J. refuses to discuss the known prior child abuse but engages in seemingly unpredictable violent behavior and appears to exhibit symptoms of depression, one possible diagnosis is Post-Traumatic-Stress Disorder (PTSD). Because Tori J. was an abuse victim, she has the necessary trauma component for PTSD that separates it from generalized anxiety disorder:
Axis II disorders include developmental disorders such as autism or mental retardation and personality disorders. There is substantial evidence that Tori J. may suffer from either antisocial personality disorder or borderline personality disorder. However, for antisocial personality disorder, one of the diagnostic criteria is a pattern of behavior existing after the age of 15, which is not applicable to Tori J. At this time. However, if her behavior continues, it is likely that she will eventually receive this diagnosis, because she engages in unprovoked violence, fails to comply with norms (such as completing schoolwork), is very manipulative, and engages in impulsive behavior:
Axis III refers to the physical condition of the person. Although Tori J.’s early medical history is incomplete, there is no indication of any physical condition that would contribute to a problem. She is in good physical condition for a girl her age. She is in the normal range for height and weight and has no known health or physical problems. She has recently begun menstruating, so that hormones may be impacting her behavior. However, there is significant evidence of maternal drug and alcohol usage and no indication that Tori J.’s birth mother was sober while pregnant. While the substances used, if any, are not known, it is possible that this impacted Tori J.’s biological condition.
Axis IV examines the severity of psychosocial stressors. Tori J. has a history of significant psychosocial stressors: she was abandoned by both parents, sexually abused, neglected, physically abused, and placed in a foster home. Her current foster parents are both loving, but Tori J. reports a significant amount of marital conflict in the home. This conflict has been witnessed by this author. This creates a tremendous amount of stress in the home, which increased Tori J.’s stress.
Axis V examines the person’s highest level of functioning. Tori J. is a school student, so that her functional expectations are, completing schoolwork, turning in schoolwork, interacting with her teachers, interacting with her family, and forming peer relationships. She does not complete the majority of her schoolwork and has failed two prior grades. However, she has not engaged in self-directed violence or in violence with a substantial risk of harm to others. As a result, it seems that her GAF score would probably be in the 31-40 range. A GAF score in the 31-40 range indicates a major impairment in several areas, and Tori J. has major impairment in social and school functioning.
You will be divided into groups. Each group will have three students. One student will play the role of the client, another the provider and the third person the foster mother.
Your role:
- a) In order to understand what Tory is going through, you are to ask a series of therapeutic questions of Tori, her foster mother and doct These questions should flow, and you are to observe the non-verbal communications of yourself and the person in which you are questioning. Document each verbal question in quotes, the answer (quote) as well as
the non-verbal. Look for any defense mechanisms like denial, projection etc. Try to stay within the context of the story
- b) Explain why Tori’s Axis I diagnosis is relevant to her childhood history
- c) Tori was removed from her birth parents, explain how this could have affected her and explain how her foster family been better prepared for some of Tori J.’s behaviors?
- d) What are some of the symptoms that Tori may display and explain your reasons for your selection?
- e) Should Tori be given choices to increase compliance, if so, why?
- f) What should be Tori’s long term/short term treatment plan?
