Running head: CASE STUDY 1

CASE STUDY
9-year-old Diagnosed With Mood Disorder NOS and ADHD

Katherine Koplow
University Neuropsychiatric Institute
Recreational Therapist intern
Summer 2014

















Running head: CASE STUDY 2
Patient Description
Patient is a 9-year-old, Caucasian female, presenting to the psychiatric hospital outpatient
childrens program after being discharged from inpatient treatment and spending 10 days at home. Patient
shows aggression and behavioral problems at home and at school. Examples include: damaging property,
threatening others, being aggressive to family and peers, kicking walls and doors violently and throwing
objects. Patient self reported that she had been hospitalized for aggressive behaviors and doesnt know
why she is so angry. Patient stated that she couldnt control herself when angry.

Past Psychiatric History
Patients first UNI admission was from January 22 until February 7, 2013. After discharge,
patient met with psychiatrist monthly to review her medications and document the outcomes. This lasted
from March 2013- April 2014. During that time, records indicate that the patient experienced signs of
anxiety, anger, and sleep deprivation. She also had weight gain and loss, which was believed to be due to
medications. Behaviorally, the patient had tantrums and aggression. Her mood instability was evidenced
by unpredictable reactive outbursts, which had minimal correlation with medication side effects.
In July of 2013, parents stated the issues were worsening. Psychiatrist noted that he didnt think it
was solely a medication issue. In September of 2013, patient experienced an increase in behavioral
problems at school. On April 23, 2014, patient was readmitted to CIP. Upon discharge on May 2, 2014
patient spent some time at home and then was admitted to the Kidstar program on May 28
th
and stayed in
the program until discharge on June 30
th,
, 2014.

Substance Use
Denies

Abuse History
Patient previously was sexually abused by her 12-year-old uncle.

Sexual History
Running head: CASE STUDY 3
Denies

Legal History
Denies

Relevant Social Information
Patient is currently in 3
rd
grade but has fallen behind academically. Patient refuses to participate
or do homework. Reading is a trigger for her. Patient has threatened peers and teachers at school
numerous times.
Patient lives with dad, step-mom and five siblings permanently. She is allowed to have
unsupervised visits with bio mom (Wednesdays and every other weekend). After visits it has been
reported that the patient has an increase in acting out and engaging in negative behaviors.

Cognition
Patients mood often inhibits her problem solving skills. Patient struggles in school due to lack of
desire to do the schoolwork and being oppositional when told what to do. Patient is capable of doing
schoolwork but lacks the motivation.

Summary of RT Assessment
What are patients strengths and interests? (What do they enjoy doing or are they good at?)
Pt stated that she likes to color and do science experiments. Pt stated that she feels
she is good at listening.

Are there specific people they enjoy doing these things with? (Do they consider these people part
of their support system?)
Pt stated that she likes to spend time with her real mommy and real daddy. Pt
stated that she feels supported by the 13 year old in the house, Alexis, because
the grown ups dont care.

What do they do to deal with their upset, stress, or worries? What does patient used to cope?
Pt stated that when upset she freaks out, screams and cries. Pt stated that she
yells that she misses her mom and dad. Pt stated she doesnt hurt herself, but that
she threatens others. Pt stated that talking to any of her parents helps.

What gets in the way of using these positive coping strategies?
Pt stated that she couldnt use positive coping when, real dad smacks me.

Running head: CASE STUDY 4
Other (Does patient have an allergy to pets? Has the patient ever harmed an animal? Also can be
used for other note worthy things ET might like to know about the patient that come out)
Pt stated no pet allergies, no harm to animals and is a little nervous around cats as
she was recently bitten.

Treatment goal
Increase emotional regulation through developing positive coping skills, support
emotional regulation

Risk Assessment
Risk of harm towards others

Initial Diagnosis
Axis I- Mood Disorder NOS, ADHD
o Mood Disorder NOS- Includes disorders with mood symptoms that do no meet the
criteria for any specific Mood Disorder and in which it is difficult to choose between
Depressive Disorder Not Otherwise Specified and Bipolar Disorder Not Otherwise
Specified. (DSM-IV-TR)
o ADHD- Inattention or hyperactivity-impulsivity that has persisted for at least 6 months to
a degree that is maladaptive and inconsistent with developmental level. Some
hyperactive-impulsive or inattentive symptoms that caused impairment were present
before age 7 years. Some impairment from the symptoms is presented in two or more
settings (school, work, at home). There must be clear evidence of clinically significant
impairment in social, academic, or occupational functioning. The symptoms do not occur
exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or
other Psychotic Disorder and are not better accounted for by another mental disorder
(Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder).
(DSM-IV-TR)
Axis II- N/A
Axis IV- primary support, social environment, educational
Axis V- GAF- 35 (31 40 Some impairment in reality testing OR impairment in speech and
communication OR serious impairment in several of the following: occupational or school
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functioning, interpersonal relationships, judgment, thinking, or mood.)

Treatment Goals/Plan
Active Problem: Mood Instability
Problem Details: Increased mood lability and physical aggression. Patient is having 2-3 episodes of
physical aggression and/or property destruction per week. Patient kicks holes in the walls and breaks her
toys. Patient is also physically aggressive towards her family members.
STG
o Patient will report self-harm thoughts to staff and use alternate distress tolerance skills,
as suggested by staff to tolerate thoughts and feelings without engaging in in self-harm
o Identify 3 positive self-statements. Identify 3 positive coping skills

LTG - Prior to discharge, patient and her families will identify a safety plan, to include 1-3
effective coping skills to manage distress, and 3 people/crisis numbers to use as contact when in
crisis

Goal Intervention-

o Monitor implementation and consistency of behavioral interventions

o Social Skills Training

o Contact patient's school to gather collateral information and to coordinate
recommendations for school per family request

In order to try and meet these goals the patient worked with the following disciplines: Interdisciplinary,
Physician, Nurse, Social Work, Psychology, Expressive Therapy, Nutrition, Education Specialist

Selected Interventions
Patient participated in expressive therapy groups while receiving outpatient services. The goals of
the recreational therapy group interventions were to learn and practice Dialectical Behavioral Therapy
skills: support emotional regulation, build resources for distress tolerance, build mindfulness skills and
promote interpersonal effectiveness skills.




Running head: CASE STUDY 6
Response to interventions

5/28 FIRST DAY in Kidstar. She seemed excited about the group and has lots of questions. Had a hard
time accepting limits and following rules. When the group got started she worked for a few minutes to try
and accomplish the task but when she felt like she ran out of ideas to build a structure to the top she gave
up and started to add random parts to the structure. When another pt tried to get her engaged in the
purpose of the activity she said she just wanted to be creative. Later when the group took a time out to
refocus and direct the attention she became upset and started to say mean words, break the toys and cry.
She needed help to remove herself from the room. Later returned to help continue to build the structure
and finished group. Became very upset when she learned that she lost -200 points and had to leave the
room because she was so sad.
5/29 Pt seemed excited for group and was able to interact with peers and staff better today. She had good
behavior and wanted to work on the group goal with everyone. She tried to continue to get others to
interact with her and combine the different Legos. When peers where not listening she grew upset. Staff
prompted her and she said she didnt like that no one would listen to her so she was going to stop. She
was upset and wouldnt interact with others until a staff work offered their Lego creation and she was able
to overcome her frustration and engage with group. Later Pt was seen being carried into the timeout room
by 3 staff and heard yelling and hitting the walls.
BH- level green, struggled in school but complied, upset and took a break during music group,
did well during lunch and rec., during relaxation became upset, removed self and did school work, ripped
up her school papers, broke pencil, threatened to throw and break things, and hit people, refused to make
positive choices, refused. Escorted to timeout and didnt stay, door was locked, spitting and screaming
during timeout. Complied eventually and step mom picked her up.
5/30 Pt was first seen when doing an assessment. Had a fixation on getting a snake and would interrupt
RT to talk about it. Had a hard time staying calm and was impatient when she didnt her way. She was
calm when talking about things she could earn and get. Gave RT hug after assessment. Seen prior to RT
group ripping, yelling and very agitated stating she wanted to call her mom. Was late to RT group. Didnt
want to work as a team and talk about ways to connect the Legos. During initiative she grew upset when
she wanted to build her own creation and not work as a team. Doesnt like directions, being told what to
do or working with others. Threw Legos and broke her car and left the room. Wasnt able to calm down
and return. Seen in the hall doing a behavior chain with step-mom still unable to focus.
BH- level red, struggled taking responsibility for behavior and hard time remembering what she
did. Grew upset when she didnt like the activity. Calm during school. Upset at lunch when she got a
behavior chain to fill out. Jointed RT group late spoke in rude tone and left when smashed her Legos. Had
option to return to group but couldnt ad screamed in hall until step-mom came and tried to help her finish
the assignment. Cried and couldnt remember why she had to leave group.
6/2 Pt finished all their schoolwork, asked for help, and was able to remain in control when frustrated.
BH- Level yellow. Generally compliant throughout the day. Cried and whined when she didnt
like the activity. Calmed down quicker than she has in the past. Pt brought a clam down bag and used it
throughout the day. Complained frequently during activities and directions but remained calm rather than
throw a fit. Had appropriate social interactions with peers. Maintained safety.
ET ART- participated in-group on self-expression and frustration tolerance with clay. Engaged
and expressed ideas in art making. During clean up stated she wanted to make something else. Reminded
it was time to clean up and she had completed her work. Became upset and threw clay, destroying it and
cried. Asked to calm down and couldnt. Didnt return to group.
6/3 School- worked quietly and independently, needed some prompts to refrain from neg. personal
hygiene. Accepted directions. Became upset, argumentative and disrespectful. Worked with staff to use
coping skills and stay calm. Eventually calmed down and earned computer time.
Psychology- Meet with step-mom and said that pt had good weekend because bio-mom doesnt
make her do things and grandma is fun. Problems with her picking nose. During a meeting with pt she
stated she wanted to die from a staph infection because she hates this life and if she cant live with her
bio-mom she wants to die. She stated that she thinks about dying whether she is happy or sad, or mad.
ET RT- Pt was active in RT group and participated in emotional regulation. Identify coping skills
as pos. self talk
6/4 On level red. Able to accept her level drop calmly. Refused to follow directions during lunch.
Running head: CASE STUDY 7
ET- stuff animals were identified as a coping skill to help her calm down.
Tx plan- slow progress in the milieu. Having a hard time accepting limits and is very
oppositional. Frustrated during groups and minor issues are causing her to be disruptive. Destroying her
projects/ property and physically aggressive. Verbally threatens her family. Intended to be in Tx 2-3
weeks more.
School- bright and cooperative but when she started assignment she whimpered and said she
didnt want to do reading. Staff ignored and she got louder. Was asked to leave and refused to leave room.
Continued to scream and directed to time out room. Keep walked out of time out room and had door
locked and shut on her. Processed with staff and sat out of next group.
Psychiatry- Angry in morning and spent time in seclusion. Happens frequently when she has to
do something she doesnt want to. Questions about autism. Wants to keep her thoughts the way they are.
* Review of Tx plan: insignificant progress during the week. Her pattern is become reactive, forcing real
crying, throwing things, needed to be escorted from the room. Other times she can manage emotions and
behavior through self-break, stuff animals, problem solving.
6/6 On level yellow today. Said it was due to new medication. Calm and compliant mostly. Upset during
school. During free time said she was bored and declined suggestions from staff, pouted before picking an
activity. Attended groups with good participation, positive interactions with peers and was safe.
ET- Able to identify beep breaths as a coping skill and playing basketball. Engaged in initiative
but struggled to demonstrate insight on own needs.
6/9 Pt had a good weekend. Unsure about the patterns in her bx., sometimes she had appropriate bx and
sometime she acts out.
ET- pt had the opportunity to lead an activity for other pts. She was able to create the game and
explain it to the group. After she stated she didnt want to do the group anymore. One prompt and was
able to be redirected and continue to participate. Engaged and social during art making time. Seemed
restless with energy and tried to control it.
School- got amped up at school but was able to control herself and problem solve to complete the
assigned work.
BX- arrived late but was happy because she had a good weekend. FD1X and made an effort to
use positive coping skills when upset or distressed. Tried to show positive friendship towards staff and
peers.
6/10 On level green, called disrespectful names towards staff.
Struggles during school refusing to do her work and having a melt down. Using staff as resources. Low
frustration tolerance and cant manage bx when upset.
ET- discouraged when peers speak over her. Manages with deep breathing. Hit upper thighs with
fists
Psychology progress- continues issues of oppositional behavior.
6/11 Tx plan review behaving better on milieu. 2-3 more weeks in tx to ensure stability
Struggled to keep good hygiene
Bx- struggled to accept limits and needed prompts to keep a calm voice and problem solve.
6/16 Pt refused to accept help. Needed self breaks during school. Maintained safety throughout the day.
ET- Used coping skills to refocus herself. Needed multiple prompts for calm body Worked well
with peers.
6/20 Talk of preparing for discharge.
ET- needed several breaks for the level of difficulty of the activity.
6/24 Home note stated that pt was found at a friends house without telling parents. Troubles apologizing.
Seems cognitively rigid. Finished all her schoolwork. Whining and negative comments about self stated
towards staff.
ET- engaged in-group, open to sharing with peers. Later, frustrated and didnt want to continue
group. Was given an option and left room with assistance. Returned but was upset and sent to time out
room.
6/26 Struggled to ignore negative bx and stay on task. Oppositional at times. Frustrated with limits set on
her. Had to be escorted to time out. Was able to rejoin group at the end of day.
ET- asked to leave group due to inappropriate bx.
6/30 LAST DAY- stated she wants to be happy because it was her last day but she wasnt able to and
didnt know why. Brainstormed with staff but wasnt able to practice any of the ideas.
Running head: CASE STUDY 8
Checked in as very happy. Had negative interactions with peers. Became angry. Removed self
from group. Refused to share her work. Realized the importance of using her calm down bag but still
frustrated with the group.

Discharge Summary
During Kidstar outpatient treatment, patient attended expressive therapy groups to learn and
practice DBT skills. Patient lacked the ability to regulate her emotions and behaviors. Patient was
unpredictable with no clear precipitant when acting out. Patient often wanted things her own way and
became aggressive when she didnt get what she wanted. These factors significantly impacted patients
ability to succeed. Patient would benefit from continued therapy to work on emotional regulation and
frustration tolerance.

Discharge Diagnosis
Axis I: 1) Mood disorder, NOS
2) ADHD
Axis II: None
Axis III: None
Axis IV: Severe family and school problems
Axis V: Global Assessment of Functioning at discharge 55

Condition on Discharge
Upon discharge, patient had slightly improved. She learned coping skills to help her calm down
when upset and was educated on how to use power talk to express her feelings and needs. She had very
little predictability and lacked the ability to be in control of her behavior and emotions.

Disposition
Patient will return home to her biological fathers house. Patient will continue to see an outpatient
therapist once a week. Patient will start school again in September. Patient will continue to take her
medications.