Solution Manual for Mental Health in Social Work: A Casebook on Diagnosis and Strengths Based Assessment, 3rd Edition

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Instructor’s Resource Manual
For
Mental Health in Social Work: A
Casebook on Diagnosis and Strengths-
Based Assessment
Third Edition
Jacqueline Corcoran, University of Pennsylvania
Joseph M. Walsh, Virginia Commonwealth University

Table of Contents
Instructions for Use iv
Chapter 3: Autism Spectrum Disorder 1
Chapter 4: Attention Deficit Hyperactivity Disorder 10
Chapter 5: Schizophrenia 19
Chapter 6: Bipolar Disorder 29
Chapter 7: Major Depressive Disorder 35
Chapter 8: The Anxiety Disorders 42
Chapter 9: Obsessive-Compulsive Disorder 49
Chapter 10: Post-Traumatic Stress Disorder 53
Chapter 11: Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, and
Binge Eating Disorder 62
Chapter 12: Oppositional Defiant Disorder and Conduct Disorder 72
Chapter 13: Substance-Related and Addictive Disorders 81
Chapter 14: Gender Dysphoria 95
Chapter 15: Alzheimer’s Disease 102
Chapter 16: Borderline Personality Disorder 115

Instructions for Use
Directions Part I, Diagnosis: Given the case information, prepare the following: a diagnosis, the
rationale for the diagnosis, and additional information you would like to know in order to make a
more accurate diagnosis.
Directions Part II, Bipsychosocial Risk and Resilience Factors Assessment: Formulate a risk and
resilience assessment, both for the onset of the disorder and for the course of the disorder,
including the strengths that you see for this individual.
Directions Part III, Goal Setting and Treatment Planning: Given your risk and protective factors
assessments of the individual, your knowledge of the disorder, and evidence-based practice
guidelines, formulate goals and a possible treatment plan for this individual.
Directions Part IV, Critical Perspective: Formulate a critique of the diagnosis as it relates to this
case example. Questions to consider include the following: Does this diagnosis represent a valid
mental disorder from the social work perspective? Is this diagnosis significantly different from
other possible diagnoses? Your critique should be based on the values of the social work
profession (which are incongruent in some ways with the medical model) and the validity of the
specific diagnostic criteria applied to this case.

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Chapter 3
Autism Spectrum Disorder
Case 1
Questions to consider when formulating a diagnosis for Emmanuel
1. What are Emmanuel’s significant symptoms with regard to a possible mental disorder?
Emmanuel had a hard time separating from his parents at school and was continuously
crying, trying to run away, and throwing tantrums. He had difficulty with transitions at
school and did not follow directions well. He did not approach other children and did not
respond to their attempts to play or talk. Emmanuel used few of his own words but
repeated what others said. When upset, he made guttural noises or screams. He was
sensitive to loud noises and reacted by covering his ears and screaming. Emmanuel had
no interest in his peers. He preferred to play on his own. When Emmanuel got exited he
flapped his hands, clapped his thighs and crotch, and tapped his face. He appeared to be
in a world of his own. He was content with writing numbers and letters over and over,
and he frequently wrote down numbers to sooth himself when upset. He showed some
developmental delays in areas of self-help and adaptation. His parents report that
Emmanuel acted impulsively at times.
2. For how long have Emmanuel’s problem behaviors been evident?
The extent of Emmanuel’s problem behaviors and developmental difficulties were noted
immediately upon his enrollment in school, when he was five years old. While the family
may have minimized their prior suspicions of some of these difficulties, the formal
assessment revealed that they had begun having concerns about Emmanuel’s
development at 30 months of age, due to his language difficulties. It is possible that his
problems had been emerging before then.
3. Has there been any recent stressful event occurring in Emmanuel’s life that might account
for any of his symptoms?
There is no evidence of any recent stressors in Emmanuel’s life, although his beginning
kindergarten has placed him in a more structured environment than he experienced
before. Rather than accounting for his symptoms, however, this seems to have made them
more evident.
4. To what extents do Emmanuel’s (and his parents’) cultural traditions contribute to his
problem behaviors?
Because of their mixed Spanish and American heritage and lifestyles, the family did not
acknowledge Emmanuel’s developmental delays as evidence of any internal problem.
Rather, they perceived Emmanuel’s delays as being due to his need to live bi-culturally
and make a gradual transition between his two cultures.
5. Given that Emmanuel has a developmental disorder, with what other disorders of childhood
and adolescence (if any) do his symptoms overlap?
In addition to the autism spectrum disorders, Emmanuel’s inability to follow directions
and adhere to the demands of the structured environment could be seen as symptoms of
oppositional defiant disorder. His problems with attention and concentration could be
seen as symptoms of attention-deficit hyperactivity disorder. His academic limitations,
and slightly below-normal measured IQ, might make an observer suspect an intellectual
disability. Still, Emmanuel does not meet the full criteria for any of those disorders.

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DSM Diagnosis
F84.0 Autism Spectrum Disorder, without accompanying intellectual impairment, with
accompanying language impairment, requiring substantial support
Rationale
The diagnosis of Autism Spectrum Disorder was made because Emmanuel displays significant
deficits in his social interactions, such as reduced eye contact, lack of social reciprocity, and
failure to develop relationships with others. His communication skills are considerably limited;
he does not initiate or sustain conversations with others, and his language development has been
delayed since he was a baby. He also uses unusual forms of language, such as echolalia. For all
these reasons, he was given the additional specifier with accompanying language impairment.
Moreover, Emmanuel is unable to participate in imaginative play. Additionally, he exhibits
restricted interests, such as writing numbers repeatedly in an artistic, almost calligraphic manner.
Emmanuel displays repetitive motor mannerisms, including hand flapping and face tapping.
Further support for this diagnosis is evident in his impulsivity and difficulty with sensory
integration.
Emmanuel’s developmental and psychological testing has determined the absence of Intellectual
Disability. His IQ is 95. Therefore, the specifier without accompanying intellectual impairment
was added. He was assessed as Level 2, requiring substantial support because of his language
delays and lack of ability to interact socially.
A review of Emmanuel’s medical history indicates that he is a healthy five-year old with no
problematic medical condition. His mother reports that pregnancy and delivery were normal and
uncomplicated. He was toilet trained at age three.
Additional Information Required
Emmanuel’s assessment was comprehensive, including input from a range of health
professionals, and thus there is no other information required at this time.
Risk and Resilience Assessment
It is more appropriate to focus on risk and protective influences for the course of the disorder
because little is known about its origin other than it has a biological basis. The only significant
risk mechanisms are that Emmanuel is male and has limited social skills and interest in peers.
Regarding protective factors he experiences significant parental involvement in his care and has
an average IQ, a good support system, and health insurance.
What questions could be used to assess for additional strengths in this client?
1. What types of social situations seem to bring out Emmanuel’s positive adaptive qualities?
How can they be facilitated?
2. What are the features of the 1:1 interpersonal situations in which Emmanuel is effectively
able to interact? What are the personality characteristics of those who “bring out the best”
in his interactional qualities?
3. How can Emmanuel’s various interests be encouraged, since he can participate in
activities with others so long as the activity interests him?

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4. What are the circumstances in which Emmanuel is most likely to engage in his artistic
pursuits, including calligraphy and listening to music?
5. What playground conditions does Emmanuel seems to enjoy the most? What are the
features of those times when he is most able to attend to his puzzles?
6. What are the circumstances that seem to encourage Emmanuel’s use of humor?
7. How can Emmanuel’s visits with family members be structured to maximize his positive
engagement with them?
Intervention Plan
In the case of autism spectrum disorder, it is necessary to develop and implement an intervention
plan as soon as possible, especially in light of Emanuel’s relatively late diagnosis. Emmanuel is
eligible for special education within his school district, and his parents and the special education
team will meet within the next two weeks to develop an IEP (Individualized Education
Program). As soon as this has been accomplished, Emmanuel will be able to join a class
appropriate to his needs. The elementary school he attends offers a class for children with autism
spectrum disorder, which is small in size and staffed with two special education specialists. This
class focuses on the development of social skills, as well as the reduction of stereotyped
behaviors. Speech therapy will also be necessary to enhance his pragmatic language skills.
In addition to these services it is important to educate Emanuel’s parents about the disorder,
relevant parenting practices, and resources in the community. Fortunately, the school district has
a Parent Resource Center, which offers an array of informational material in Spanish, as well as
workshops and classes on various disorders and their treatment. The social worker has provided
the parents with some basic information and has set up a meeting for the parents with Spanish-
speaking staff at the Parent Resource Center. Due to the parents’ difficulties with consistent
parenting, the social worker has already shared information on discipline and has introduced
them to a behavioral approach to reinforce desired and reduce problematic behaviors. She has
also suggested strategies to decrease the extent of Emmanuel’s TV watching. The social worker
will check in weekly with the family to review progress and assist when necessary.
The diagnosis of autism spectrum disorder came as a shock to the family, who had viewed
Emanuel’s behavior as a temporary delay in development. Therefore, they may need to go
through a grieving process. They also might require support for their adjustment. A number of
organizations in the area offer support groups for the Spanish-speaking population. This will give
the parents the opportunity to share their feelings without having to rely on an interpreter.
Additionally, disability in the Latino community is often viewed with stigma. In a support group
of their peers, Emmanuel’s parents could receive advice and support from people with a similar
cultural background to their own. A sibling support group could also be offered to Emmanuel’s
brother and sister.
Critical Perspective
While the primary diagnosis appears to be valid, the DSM-5 criteria are less clear about how to
determine its severity level, despite including a table for determining requiring very substantial
support (level 3), requiring substantial support (level 2), and requiring support (level 1).
Although the DSM provides some general guidelines on how to assess social communication and
restricted repetitive behaviors along these lines, there is much subjectivity on how these ratings

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are reached. In Emmanuel’s case, his parents had just found out about the disorder and he had,
up until that time, limited supports. It may not be fair to judge Emmanuel as “requiring very
substantial support” when he had not yet received intervention. For that reason, he was not given
that rating, although it my later become evident that he needs it.
Case 2
Questions to consider in formulating a diagnosis for Hao:
1. What are Hao’s significant symptoms with regard to a possible mental disorder?
Hao is unable to relate to other children in class or follow directions, and he frequently
engages in hand washing. He cannot follow classroom routines and only persists with
activities in which he is interested. He speaks with an inappropriately loud volume in
close proximity to others’ faces, and is unable to retain the teacher’s instructions about
standing back and speaking more quietly. Hao looks off into space while the teacher
speaks, and he does not react to comments she makes. At times he has temper tantrums at
school. His mother noticed in preschool that Hao was not connecting with other children
and only wanted to play alone. Hao is not developing socially. He does not follow the
rules set forth by his family, and tends to ignore his parents when they try to discipline
him. Hao tends to laugh inappropriately during activities at the park to a degree that his
father threatens to take him home.
2. For how long have Hao’s problem behaviors been evident?
Hao’s problem behaviors have only been evident for one year. They were formally
identified only when he enrolled in school and demonstrated an inability to function
within the structure of that institution. His parents had been concerned about his social
isolation one year before, when he entered preschool, but his teachers at the time did not
see Hao’s withdrawal and preference for playing alone as significant issues.
3. Have there been any recent stressful events occurring in Hao’s life that might account for
any of his symptoms?
The Hao family has experienced much stress at times in their lives, but there is no
evidence of significant stress in the past year or so that might help to account for Hao’s
symptoms.
4. To what extent do Hao’s (and his parents’) cultural traditions contribute to his problem
behaviors?
Interestingly, Hao’s being in America may have delayed the recognition of his
developmental problems. According to his mother, in Vietnam Hao’s behavior would be
considered unacceptable and outside the norm. Her own observations of the patience of
American teachers led her to be less concerned about Hao’s behavior. In Vietnam
children are warned against bad behavior by being threatened with physical punishment.
While it is not clear what interventions Hao would have received in Viet Nam, his
abnormal behavior would have been less tolerated.
5. Aside from autism spectrum disorder, what other disorders of childhood and adolescence
do Hao’s symptoms possibly represent?
While ASP is distinct from the disruptive behavioral disorders, there is some overlap
among their symptoms. Hao might be considered for a diagnosis of oppositional defiant
disorder in that he seems to ignore instructions from adult authority figures (his parents
and teacher). He also could be considered for attention deficit/hyperactivity disorder in

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that he seems to have difficulty at times with his attention span, concentration ability, and
activity level.
Diagnosis
F84.0 Autism Spectrum Disorder, without accompanying intellectual impairment, without
accompanying language impairment, requiring support
Allergies (which can result in eczema, by parent report)
Rationale
Social workers do not diagnose neuro-developmental disorders without contributions from a
multi-disciplinary team. Therefore, Hao should participate in a physical examination, visual and
hearing examinations, and neurological exams, as well as a speech and language assessment,
before the diagnosis can be confirmed. Moreover, most of the information in the above report
comes from Hao’s mother’s perspective, and other perspectives should be sought, including
those of Hao’s father. Extended observations of Hao, in free play situations and with his parents,
might yield additional information. That being said, Hao appears to tentatively meet the DSM
criteria for Autism Spectrum Disorder as follows:
A. Hao exhibits qualitative impairments in social communication and interaction as
evidenced by a failure to develop peer relationships appropriate to his developmental
level (as noted in his preschool class and in his interactions with most of his cousins) and
a lack of social or emotional reciprocity (as noted by his inability to relate to others at his
preschool, the parochial school kindergarten, and most of his cousins, with the exception
of Thanh, who will talk about subjects of interest to Hao.)
B. Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, as
manifested by an encompassing preoccupation with stereotyped and restricted patterns of
interest that are abnormal either in intensity or focus (Hao frequently washes his hands)
and an inflexible adherence to specific, nonfunctional routines or rituals (Hao displays
frustration, sometimes culminating in temper tantrums, when he is not allowed to pursue
what he wants to do at home and in the kindergarten setting).
C. There is evidence that the relevant symptoms were present in Hao’s early development
even though they were not discovered until he attended school.
D. The disturbance causes clinically significant impairment in social (lack of sustained play
with age mates and most family members of his age) and school functioning (Hao was
expelled from the parochial school due to his behaviors).
E. Criteria are not met for another specific pervasive developmental disorder or
schizophrenia.
Hao’s diagnosis includes the specifiers without accompanying intellectual impairment and
without accompanying language impairment because he is both intelligent (by testing) and able
to communicate and be social. He is also given the specifier requiring support because he
functions rather well in some ways and this is the mildest functional indicator.
Additional Information Required
As noted earlier, it would be necessary for Hao to undergo a multi-disciplinary assessment to
make a valid diagnosis. Additionally, other reporters, such as his father, should be involved.

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Risk and Resilience Assessment
There is no reported family history of ASD, although Hao’s father was 40 when Hao was
conceived, which may present a risk factor, as older age of fathers has been associated with the
disorder. Regarding the course of the disorder, Hao appears to possess a number of resilience
influences. He has temper tantrums but he doesn’t hurt himself or others. He is intelligent and
gifted in music and computers. At the social level, Hao’s family is supportive and financially
secure. He has a large extended family available, although at this point they don’t understand the
nature of his disorder. In addition to the extended family, Hao is being brought up in a religious
faith. Hao’s disorder could have been caught earlier (he is being diagnosed at five years of age)
but on the positive side he will now be receiving services through the public school system.
What questions could be used to assess for additional strengths in this client?
1. How can Hao’s treatment providers nurture his talents and curiosity?
2. Given that Hao is responsive to time-outs, strong verbal communication, and direct eye
contact from his mother, what kind of structured program of reinforcement could be
implemented for him?
3. How can sports activities be used to facilitate Hao’s learning and serve as reinforcers for
adaptive behavior?
4. How can Hao’s family be encouraged to support Hao’s adaptive activity and perhaps
incorporate spirituality into his activities of daily living?
5. How is it that Hao becomes focused when engaged in his artistic interests? What related
skills can be put to additional productive use in his treatment?
6. How can Hao’s endearing personality qualities, noted by his teachers, be further
developed toward his interpersonal skill development?
7. How can the professionals’ learning about Vietnamese culture provide a better
understanding of how his behaviors are reflective of that culture?
Intervention Plan
Parent Interventions
It is important that Hao’s parents understand that he is not purposefully acting in a willful and
defiant way, but that his behaviors and style of interacting are a result of his disorder. At the
same time, managing the behaviors and training the child with ASD is challenging for parents,
and the Chungs will require much support. Lang and An will be encouraged to attend a local
support group for parents of special needs children, and an effort will be made to find a support
group conducted in Vietnamese. The Chungs should receive parent training and information and
training on how to promote Hao’s communication and social skills. Lang should be encouraged
to return to part-time haircutting. Further, Lang and An should inform the extended family about
Hao’s disorder to ensure a more supportive network.
Child Interventions
Hao’s individual interventions will include three strategies: communication and social skill
training; behavioral therapy; and educational intervention.

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Communication and social skills training: Hao will be taught in an explicit and rote fashion the
rules of socialization and communication. He will learn how to monitor his own speech in terms
of volume and rhythm, as well as how to interpret the communication of others, such as gestures,
eye contact, and tone of voice. Opportunities to role-play communication and social skills will be
important, as well as practice in social interaction through supervised and structured activities.
Initially, it may be helpful for Lang to schedule play dates for Hao with other children with
Asperger’s to practice developing skills.
Behavior therapy: This class of techniques is targeted at curbing problem behaviors, such as
obsessions (frequent hand washing) and tantrums. These behaviors are identified and specific
guidelines will be devised to deal with them. Hao’s parents and his teachers/school staff will be
taught to handle the behaviors in the same way, so that clear expectations are set and consistency
is maintained. Behavior therapies also focus on training a child to recognize a troublesome
situation — such as a new place or an event with lots of social demands — and then select a
specific learned strategy to cope with the situation.
Educational interventions will make full use of Hao’s individual's interests and talents in the
areas of computers, music, and books. In school, there may be opportunities in the classroom for
Hao to take on leadership in activities revolving around these interests. Teaching other students
skills can help Hao’s self-esteem, as well as assist him in learning social skills, such as taking the
perspective of others, following conversational and social interaction rules, and engaging in two-
way exchanges. Hao may be able to participate in the mainstream classroom given his
intellectual abilities, but may need additional help from a support person. He also may require
individualized curriculum centered on his deficits.
Critical Perspective
A debate occurred during the school system’s Individualized Educational Plan meeting when
discussing a possible diagnosis for Hao. The psychologist who had administered the IQ testing
determined that Hao has Autism Spectrum Disorder since his social awkwardness was profound.
However, the representative from the city school district’s gifted and talented program
maintained that Hao’s symptoms were a function of his giftedness. In other words, Hao’s high
IQ and intellectual interests made him unable to relate to same-age mates and caused him to be
bored and under-stimulated by the classroom routine. These differences of opinion underscore
the care with which any neuro-developmental diagnosis should be made. Despite these different
perspectives, Hao was ultimately diagnosed with Autism Spectrum Disorder because of his
social deficits, manner of communicating, and rigid, circumscribed interests.
Case 3
Questions to consider when formulating a diagnosis for DeShon:
1. What are DeShon’s symptoms with regard to a possible mental disorder?
DeShon is distant from others, even his family members. He is unable to relate to others
in his class and does not play imaginatively. He repeats other people’s words when he
speaks with them. He displays flat affect and fails to make eye contact. Additionally, he
rocks back and forth and waves his hands in front of his face. According to his mother,
DeShon also becomes frustrated when he is asked to transition to a new activity. Finally,

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he shows sensitivity to tactile experiences, particularly with regard to food texture.
2. For how long have DeShon’s problem behaviors been evident?
DeShon’s problem behaviors and developmental difficulties became evident between 18
to 24 months; at that time, his speech development slowed and his already minimal eye
contact decreased further.
3. Have there been any recent stressful events occurring in DeShon’s life that might account
for any of his symptoms?
The family seems subject to many financial hardships, contributing to their frequent
moves and temporary homelessness. However, DeShon’s symptoms have been stable
since he was 18 to 24 months old, and he is now five years old. If his problem behaviors
were in reaction to a stressful live event, there would have been some shift in his
symptoms over the years.
Diagnosis
F84.0 Autism Spectrum Disorder, with accompanying intellectual impairment, with
accompanying language impairment, requiring substantial support.
Rationale
Criterion A: Deficits in social communication and social interaction across multiple contexts as
evidenced by:
1. Deficits in social and emotional reciprocity, manifested by an inability to sustain eye
contact; a failure to develop peer relationships appropriate to developmental level;
impairment in the ability to initiate or sustain conversations; echolalia; and a lack of
social or emotional reciprocity.
2. Deficits in nonverbal communication as noted by an inability to sustain eye contact, a
misunderstanding of gestures, and poorly integrated verbal and nonverbal
communication.
3. Deficits in developing and maintaining relationships as evidenced by a lack of
imaginative play appropriate to his developmental level and a lack of spontaneous
seeking to share enjoyment, interests, or achievements with others.
Criterion B: Restricted, repetitive and stereotyped patterns of behavior including rocking and
waving his hands back and forth.
Criterion C: The abnormal functioning occurred prior to age three.
DeShon has a tested IQ of 60 and thus is given the specifier with accompanying intellectual
impairment and also, due to his limited use of language, with accompanying language
impairment. He is further specified as requiring substantial support because he functions poorly
on his own unless involved in an isolated activity of particular personal interest.
Additional Information Required
We can assume DeShon went through the appropriate testing needed to determine his diagnosis,
although not much information is provided in the case study about the results of various
assessments and tests.

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Risk and Resilience Assessment
Biological factors are the major contributors to the development of autism spectrum disorder, but
we know very little about how any such factors are affecting DeShon. Regarding his risk
influences for the course of the disorder, he has serious problems with play deficits and
stereotypical behaviors, and the family routinely experiences material hardships. On the
protective side, DeShon is not aggressive, has a supportive mother and extended family structure,
and is part of a school system that can offer and coordinate a range of interventions.
What questions could be used to assess for additional strengths in DeShon?
The assessment could focus more carefully through additional interviews with DeShon’s mother
on his strengths with coping questions (It sounds like you’ve had a lot of challenges. How have
you been able to manage with all you’ve been through? How do you go on? What are the
qualities you draw on? What would your stepmother say that you do? How about your
boyfriend?) and exceptions (When does DeShon seem more responsive? Who is there? What are
they doing and saying?). Other questions may include “What are the types of social situations
that seem to bring out DeShon’s talents and positive adaptive qualities?” and “What positive
characteristics can be channeled to enhance DeShon’s adaptation to the newly structured
setting?”
Intervention Plan
The social worker should ensure that mother is linked with social services (e. g., Medicaid, food
stamps, Temporary Aid to Needy and Dependent Families) so that DeShon’s basic health,
medical, and nutritional needs can be consistently met. The state Autism Society might have
further information on available family resources. DeShon’s mother’s financial situation needs to
be stabilized so that DeShon can remain in the same school system once he begins services.
The social worker will present education about autism to DeShon’s mother and a referral to a
support group for parents of children with ASD. Special education services will be provided by
certified professionals at and through the school, including applied behavior analysis that can
teach DeShon skills and knowledge and extinguish his negative behaviors (i.e., tantrums) by
consistent ignoring. DeShon’s mother and her boyfriend will be taught behavioral techniques so
they can apply the same structure with him in the home.
Critical Perspective
It seems clear in this case, based on the thoroughness of the examination process, that DeShon
has a neurodevelopmental disorder, and he most clearly fits the criteria for autism spectrum
disorder. However, such a diagnosis implies that the client has less potential to improve with
regard to social and interpersonal functioning, so it is important that the social worker continue
to look for evidence of strengths when this diagnosis is made, and not assume that the client’s
change capacity is modest.

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Chapter 4
Attention Deficit Hyperactivity Disorder
Case 1:
Questions to consider when formulating a diagnosis for Billy:
1. Has Billy suffered any recent stressors that could account for his symptoms? Did his
symptom pattern precede or follow the stressful life events?
Billy has recently disclosed sexual abuse that went on during a recent six-month period.
However, to make the criteria for an adjustment disorder, the behaviors would have had
to start shortly after (within three months) of the stressful life event, and, according to
Mrs. Bronsky, Billy has been exhibiting the pattern of behaviors (oppositionality, poor
school performance, bedwetting, and encopresis) since he was a young child.
2. Do the oppositional behaviors arise out of frustration due to inattention and
hyperactivity?
According to Mrs. Bronsky, the opposite is the case; she views his inattention symptoms
(forgetfulness, inability to concentrate, losing things, inability to complete work) as being
purposefully undertaken to annoy others. The teacher sees the existence of both
inattentive and oppositional symptoms rather than the oppositionality stemming from
ADHD. Although Billy’s mother attributes his inattentive symptoms to oppositionality, in
general school report is the more valid source of information on ADHD. In addition,
Billy’s mother does note the inattentive symptoms. One must also remember that ADHD
and oppositional defiant disorder often occur together.
3. Has Billy been exposed to trauma? Could his symptom pattern be indicative of PTSD?
The presenting problem for treatment is the sexual abuse. Although Mrs. Bronksy insists
that his behaviors started long before the sexual abuse, witnessing family violence can be
a traumatic event for children. Billy, like most children his age, may not be able to detail
his internal experience about the violence. For this reason, parents are an important
source of information for PTSD symptoms in children, although they may tend to
minimize symptoms. Mrs. Bronksy denied that the sexual abuse or the family violence
has had an impact on her children, although she is willing to seek counseling at the
recommendation of the child advocacy workers. In terms of re-experiencing, both Billy
and his mother say he does not have nightmares, but it would be important to hear from
him what he dreams of and if particular dreams are associated with his bedwetting. She
says he does not report flashbacks. In the therapist’s sessions with Billy, it will be
important to see if re-experiencing of the abuse occurs through drawings, stories, or play.
The child’s re-experiencing the event can be facilitated through its re-enactment with
drawings, stories, and play.
The hyperarousal criterion for PTSD could be manifested by his inattention symptoms
(forgetfulness, lack of concentration, inability to sit still) and his bursts of irritability and
anger. His incontinence could further be construed as indicative of PTSD, and one could
speculate that the sexual abuse by his cousin could have resulted from possible decreased
arousal to threat. Avoidance symptoms could be seen in his tendency to avoid discussions
about the sexual abuse, although other motivations could be responsible, such as

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embarrassment, threats from the abuser, a desire to please adults by not discussing
negative events, and the belief that he is at fault (James, 1989).
In a conversation with the therapist, Billy was positive about his father and his girlfriend
and didn’t mention the family violence. Again, this could be avoidance due to PTSD, or it
could be embarrassment, pressure from the family, his wanting to preserve a good image
of his father for himself and people outside the family, and possibly other reasons.
Numbing could have been signified by Billy’s refusal to talk or respond to the therapist
when she first met with him, although this could also have stemmed from his
oppositionality.
4. Is Billy’s enuresis primary (there never was a period that he had a dry bed) or secondary
(developed after a period of time when there was a dry bed)?
From Mrs. Bronsky’s report, the enuresis is primary, which is considered to relate to
either a physically and/or neurologically immature bladder and/or a deep sleeping pattern
in which the child is unaware of messages to the brain that the bladder is full (Child
Development Information, 2006). Note further that children with ADHD are at increased
risk of bedwetting compared to children from the general population.
DSM Diagnosis
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly
Inattentive Type, Mild
313.81 Oppositional Defiant Disorder, Mild
307.7 Encopresis, without constipation and overflow incontinence
307.6 Enuresis, Nocturnal Only
V61.21 (995.53) Sexual Abuse of Child, Confirmed (Reason for visit)
Rationale
Billy has been given the diagnosis of Attention Deficit Hyperactivity Disorder, Predominantly
Inattentive Type. He meets the following seven symptoms of inattention for longer than six
months (six are required) and for that reason he was given a “Mild” severity:
1. Does not give close attention to details or makes careless mistakes in schoolwork.
2. Has trouble keeping attention on tasks (schoolwork).
3. Does not follow instructions and fails to finish schoolwork or chores, or duties.
4. Avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long
period of time (such as schoolwork or homework).
5. Loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books,
or tools).
6. Is easily distracted (looking out the window instead of completing work)
7. Is forgetful in daily activities (forgets to bring homework home, forgets what teacher tells
him)
Billy meets only two of the hyperactivity symptoms (fidgeting and squirming, often gets up from
seat when remaining in seat is expected). The impairment (strained relationship with his mother,
poor academic performance) is present in two settings as required.
Billy was given the Sexual Abuse of a Child V code because his recent abuse was the reason
for treatment seeking. Oppositional Defiant Disorder was also diagnosed. His mother states that
Billy’s behaviors began before the sexual abuse and as far back as she can remember. The

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diagnosis requires that symptoms started before the age of seven. Billy displays four of the eight
criteria in section A that are required for six months or longer, as follows:
1. Refusal to carry out rules or requests by adults (refuses to do schoolwork)
2. Blaming others (blaming another student at school for his misbehavior)
3. Arguing with adults
4. Deliberately doing things to annoy others (banging stick in house)
Billy exhibits these behaviors both at home and at school, according to his mother. It is currently
affecting his ability to function appropriately in school and is causing strained relationships in
the home. Because he only has four symptoms and that is the minimal requirement, the “mild”
specifier is indicated.
Another diagnosis is Encopresis without constipation and overflow. Billy passes feces in his
pants once a month. Although we need to confirm that it meets the minimal time frame of three
months, it sounds like the behavior has been ongoing for a while. He meets the age requirement
for this diagnosis. Billy also exhibits behaviors that led to the diagnosis of Enuresis, nocturnal
only, because he wets the bed almost every night. It is clinically significant because of its
frequency and duration.
Additional Information Required
Most of the information for Billy’s diagnoses is from maternal report, supplemented by teacher
report. Other questions for Billy’s mother could involve her pregnancy and delivery of Billy to
assess if there were any early complications. Did she smoke during Billy’s pregnancy? Did he
have exposure to lead? She also might know of any family history of ADHD (particularly about
Billy’s biological father). An assessment of mother’s current adjustment is necessary, as
maternal stress and lack of social support are associated with poor outcome for ODD. Her
perspective on Billy’s peer relationships is also important, as is the teacher’s. From the case
study, it is unknown if Billy has friends and if his oppositional and inattentive symptoms have
caused children to avoid him.
Once Billy has built some trust with the therapist, it would be helpful to have more direct
information to rule out Post-Traumatic Stress Disorder. Several measures have been designed to
assess PTSD in children (see Corcoran & Walsh, 2006), including the Children’s Impact of
Traumatic Events Scale, which was specifically formulated to assess PTSD symptoms in
children who have been sexually abused.
A release to talk to Billy’s doctor about his enuresis and encopresis and a recommended
treatment plan is also suggested. Additionally, results of IQ and learning tests might indicate that
Billy meets other diagnoses for intellectual or learning disorders and would thus need additional
resources in the school setting.
Risk and Resilience Assessment
The neurodevelopmental risks that may have contributed to the development of ADHD in Billy
are unknown at this time, but are assumed. Billy’s gender places him at additional risk for
ADHD. Other risk and protective influences may affect the persistence of ADHD over time. Risk
influences involve Billy’s mother’s inconsistent and ineffective efforts to manage her child’s
behavior. Fortunately, Billy’s mother does not present with ADHD symptoms herself. Another
protective influence is that Billy lives in a two-parent home, although the adjustment into a
stepfamily household might have been stressful for him. The fact that Billy is diagnosed with
oppositional defiant disorder increases his overall risk for poorer outcome. Other strengths

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involve father involvement in activities. Billy reports a positive relationship with his biological
father and sees him regularly. His stepfather has stable employment, and mother is seeking
mental health services for her children.
What questions would you ask to elicit further strengths?
For Billy’s mother:
1. When are she and her husband able to follow through with consequences to Billy? What
do they do? How does he respond? How do they support each other?
2. What is different about times when Billy had a dry bed at night?
3. He is able to control his defecation most of the time. What is he doing to achieve this?
For Billy and his teacher:
When is Billy able to complete his assignments? What is different about those times? What time
of day is it? Who is he sitting near? What is he doing and saying to make this happen?
For Billy:
Externalizing techniques might be helpful for Billy; these may involve getting him to give a
name to the behaviors that are getting him in trouble, then drawing it (“the volcano,” “the fooling
around,” “the silly stuff,” “the fighting,” and so on), and showing how he is able to exert control
over this “externalized entity.”
Treatment
The sexual abuse is the presenting problem for treatment, although other aspects of his care
require an immediate approach. The sexual abuse will be addressed using a cognitive-behavioral
approach that has been validated with children who have experienced PTSD, as well as other
symptoms, as a result of sexual abuse (Deblinger & Heflin, 1996). The focus with Billy will be
on stress management (progressive muscle relaxation, thought stopping, positive imagery, or
deep breathing) and desensitization procedures, so that he will be progressively able to talk about
the traumatic event and its aftermath in a way that diminishes arousal and distressing emotions.
This intervention will include Billy’s mother since maternal support is critical to a child’s
adjustment for sexual abuse. Billy’s mother has shown her support in a number of ways (i.e., she
has cooperated in the civil and criminal investigations, she has brought Billy for therapy), but
there is also some ambivalence on her part. Her remark about the children not being able to play
with their cousin anymore was of concern, although she was able to respond appropriately once
she was questioned. She also shows a reluctance, like many parents do, about talking with their
children about the abuse. Intervention with mother will help her communicate more effectively
with her children about the sexual abuse and handle their questions, concerns, and possible
symptoms.
Another critical aspect of the intervention involves Billy’s having an Individualized
Education Plan in the school system. The social worker will find out from the State Department
of Education how Mrs. Bronsky can initiate this process. Specifically, Billy will need to be tested
for his IQ and any learning disabilities. It could be that many of his frustrations are due to the
work being too difficult for him.

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Another important component to the intervention will be Mr. and Mrs. Bronsky’s
participation in parent training to manage Billy’s ADHD and ODD symptoms. Further, Mr. and
Mrs. Bronsky (as well as Billy’s father) needs to be provided information about ADHD.
Treatment for bedwetting in children includes behavioral conditioning devices (pad/buzzer)
and/or medications (anti-diuretic hormone nasal spray and the anti-depressant medication
imipramine). Eventually the child becomes conditioned to wake up and to go to the bathroom
once he or she experiences the urge to urinate. Although these conditioning devices may take
months to work, they have high success rates long-term.
The American Academy of Family Physicians (2003) recommends that the treatment of
encopresis should entail management of any oppositional behaviors. For both the enuresis and
the encopresis, Mrs. Bronsky should be encouraged to follow her physician’s recommendations
as to treatment approach. As part of a behavioral reinforcement system that Mrs. Bronsky will
learn to implement through parent training, she can set up positive reinforcement for Billy
having “dry nights,” as well as appropriate use of the toilet for bowel movements.
Critical Perspective
Billy has already experienced many stressful life events, including domestic violence, divorce,
and sexual abuse. Some of these events, particularly the domestic violence, might have occurred
from a very young age. Therefore, this is a case that shows the possible impact of a dysfunctional
environment on a person’s functioning. Although there are biological aspects to ADHD and
enuresis, an argument could be made that some of his central diagnoses (sexual abuse of a child,
oppositional defiant disorder) are a reaction to a stressful environment, which includes family
violence, divorce, mother’s re-marriage, and sexual abuse.
The diagnosis of PTSD was considered for Billy. However, some of the difficulties with
diagnosing PTSD in children became apparent, although DSM 5 has taken some pains to create
criteria that is applicable to children under six. First, there is a great deal of symptom overlap
between ADHD and PTSD (Perrin, 2000). At the time of the assessment, Billy was not able to
convey information about his internal experience. Parental report may be biased, and Billy’s
mother may be minimizing his PTSD symptoms.
Case 2:
Questions to consider in formulating a diagnosis for Wayne
1. Has Wayne suffered any recent stressors that could account for his symptoms? If so, did
his symptom pattern precede or follow the stressful life events?
Wayne came to the agency because of a specific stressor – the break-up with his
girlfriend, an event for which he accepts blame. While some his symptoms have certainly
been exacerbated by that event (especially his low mood and the constant calling of his
girlfriend), it appears that all of them have been present for many years, and some for
perhaps his entire life. Wayne’s difficulties controlling his temper and his absent-
mindedness appear to be long-standing aspects of his personality.
2. Do Wayne’s angry outbursts arise out of frustration due to inattention and hyperactivity?
Wayne’s outbursts are due at times to his symptoms of inattention and hyperactivity, but
those symptoms do not fully account for that behavior. The angry outbursts also seem to
arise from his feelings of insecurity and fears of rejection. In fact, Wayne describes many

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of his episodes of forgetfulness rather calmly; as if this is a characteristic to which he has
become accustomed. It appears that when his inattention and hyperactivity cause
problems in his primary relationships (with women), they are more likely to result in
angry outbursts.
3. Has Wayne been exposed to trauma in his past? Could his symptom pattern be indicative
of PTSD?
Wayne has experienced trauma in the past, although the nature and extent of that trauma
needs to be more fully evaluated. Wayne experienced physical abuse by his father, as
well as witnessing the abuse of his mother. These experiences may have provoked fear,
helplessness, or horror in Wayne. Further, Wayne and Wendy both describe a variety of
situations where Wayne becomes intensely angry at normal life occurrences. His
outbursts of anger could represent physiological reactivity but whether it is in reaction to
cues of trauma is questionable. Wayne spoke primarily of the breakup and only briefly
and vaguely of his past experiences with his father. This could represent his efforts to
avoid thoughts, feelings, or conversations associated with the trauma. Wayne did not
appear to exhibit signs of numbing. Therefore, without additional information, the social
worker would be unable to consider further a diagnosis of PTSD.
4. Was a learning disorder behind Wayne’s frustration and inability to complete
schoolwork?
It is possible that Wayne has a learning disorder, but without the corroboration of school
records or new testing this will be difficult to determine. Clearly, some symptoms of
ADHD and its outcomes are similar to those involving learning disabilities.
DSM Diagnosis
309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood.
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type, Mild
995.81 Spouse or Partner Violence, Physical, Confirmed
Rationale
An adjustment disorder provides a least restrictive diagnosis that accommodates the fact that
Wayne’s responses could be considered “normal” for someone going through a breakup with a
significant other (a week prior). Wayne’s anxiety manifests through constantly recurring
thoughts about Wendy, and his depression can be indicated by insomnia and an irritable mood.
Wayne copes with the breakup by staying as busy as possible.
The V code Spouse or Partner Violence, Physical, was added because of Wayne admitting to
being physically violent with his previous girlfriend. Also of concern was his violence to his ex-
girlfriend’s child. When the social worker inquired about this, Wayne was vague, but sounded
regretful about hitting the child. The social worker notes that this will be something to explore in
further sessions, as it relates to the experience of Wayne’s own physical abuse and watching the
physical abuse of his mother by his father.
Wayne was also diagnosed with Attention-Deficit/Hyperactivity Disorder, Predominantly
Inattentive Type. Wayne meets six of the symptoms of inattention:
1. Often has difficulty sustaining attention in tasks or play: Wayne admitted to having a
hard time concentrating on anything other than watching television.

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2. Difficulty organizing tasks and activities: Wayne said he became easily frustrated if he
had to deal with too many things at once, such as a lot of work orders.
3. Avoids, dislikes, reluctant to engage in tasks that require sustained mental effort: The
client typically avoids activities that require him to do a lot of thinking, and typically
spends his time watching television. Wayne chose his current occupation because he is
able to move around a lot, through the apartment units.
4. Loses things: Wayne leaves his tools in different apartment units and wastes time at work
searching for them.
5. Easily distracted: If Wayne is cleaning the kitchen, he will sometimes leave the tap water
running as his attention becomes diverted on something else.
6. Forgetful: Wayne will forget instructions that have been given to him at work.
Wayne does not seem to meet enough criteria to meet the hyperactivity-impulsivity subtype.
He does leave situations in which remaining seated is expected. For instance, during the
counseling session, Wayne jumped out of his seat to go to the water fountain without announcing
his departure. He is also restless and impatient when faced with traffic.
Wendy states his mother found him to be an “exhausting” child. He ran around constantly,
was easily distracted, and acted on every whim he had. Although he did not receive a diagnosis
as a child, we can assume that he met criteria for ADHD before age twelve. Wayne’s symptoms
cause both social (relationship problems) and occupational impairment (he is unable to hold jobs
for long periods of time).
Additional Information Required
The social worker would like to explore Wayne’s background and current symptoms in more
detail to rule out several other possible diagnoses. Specifically, she would like to inquire further
about possible PTSD symptoms, including re-experiencing, avoidance, and numbing of general
responsiveness.
Risk and Resilience Assessment
Onset
Many of Wayne’s risks for ADHD are unknown as they are theorized to involve
neuropsychological factors. Very little is also known about his biological father and his history
of mental illness, although he was said to have an alcohol problem and was physically abusive.
On the protective side, Wayne’s mother did not smoke or use substances during pregnancy.
Course
From the information provided, it does not appear that Wayne developed ODD or CD in his
youth, which bodes well for the course of ADHD. However, the past physical abuse of his ex-
girlfriend and her child is troubling. With the help of his girlfriend, Wayne has some insight into
his behaviors and seems determined to get better, if only to get her back. Wayne suffers
financially, which puts him at risk; he is in debt, earns little, and does not receive health
insurance benefits. This means that treatment might be difficult to pay for.
What techniques could be used to elicit additional strengths?
Wayne has many strengths. It is known, for example, that he is well liked by his co-workers,
does well on the job, and has an attractive personality to some women. Further, he always feels

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remorse for his angry outbursts. His strengths could be further assessed by asking Wayne to
recount the various successes he has experienced throughout his life, asking him to make a list of
his personal qualities, asking how he learned to be such a good repairman, and how he has been
able to implement the organizational tasks suggested by his girlfriend. Other techniques could
include:
1. Exception-finding
Attention: When are you able to focus your attention on what you need to get done, even
for a little while? What are you doing differently? Who is there? What is going on?
Frustration and anger: When was a time you started to feel mad but was able to stop
yourself from letting it take over? What did you do?
2. Future without the problem: When you are able to control your anger and focus yourself,
what will you be doing differently? How will you be responding to others?
What will they be saying towards you? Talk about times this happens now.
When you have the kind of relationship you want towards your girlfriend, how will you
be acting? How will she be responding to you? What will you be doing together?
Treatment
Medical
Goal: To receive a comprehensive assessment for ADHD and appropriate biological
interventions for that disorder.
Plan: Wayne will receive a medical exam to determine if there is a physical basis to his
irritability and angry outbursts. He will also complete a series of rating scales for further
assessment of his ADHD. He will be referred for a psychiatric evaluation to determine a need for
medication.
Psychological
Goal: To become educated about ADHD and its management.
Plan: Wayne will attend a psychoeducational group on ADHD at agency.
Goal: To increase quality of social and occupational functioning.
Plan: Wayne will receive cognitive-behavioral interventions concentrating on anger
management, frustration tolerance, time management, problem-solving skills, and
communication skills. The social worker will continue to support and guide Wayne’s efforts to
increase structure in life, including budget schedules, increased usage of dry erase board and
memos, and files for important documents.
Goal: To resolve the nature of romantic current relationship.
Plan: Wayne and Wendy will attend couples counseling and problem-solve about the nature of
their relationship.
Social
Goal: To resolve financial concerns.
Plan: The social worker will refer Wayne to a legal aid agency to determine whether he has a
basis for not being liable for the student loans. He will also be helped to inquire about health
insurance options through his current place of employment, and possible to inquire about other
places of employment that provide such benefits.

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Critical Perspective
Wayne’s case highlights some of the problems in applying the ADHD DSM diagnostic criteria
for adults, although improvements have been made in DSM-5. Wayne suffers from such
symptoms as overreacting to frustration, poor motivation, and difficulty with time management,
although these are not listed in the DSM. As it is, he only met criteria for the “Predominantly
Inattentive Type” of ADHD, but many of his symptoms involve impulsivity, and these are not
captured in the diagnosis.

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Chapter 5
Schizophrenia
Case 1
Questions to consider in formulating a diagnosis for Anna:
1. What symptoms of problematic thinking, feeling, and behavior does Anna present?
Anna displays a variety of thoughts, feelings, and behaviors that are detrimental to her
social functioning. She exhibits poor self-care, is withdrawn from almost all interpersonal
interaction, displays little emotion, maintains a blank affect, does not communicate
coherently, talks to herself, seems preoccupied, and uses poor judgment by agreeing to
live with a relative stranger. She has nightmares and evidently no motivation to make any
changes in her life.
2. Are any of the above symptoms clearly psychotic?
Many of Anna’s symptoms appear to represent psychotic ideation, including her level of
withdrawal, talking to herself, absence of affect, and preoccupation with internal stimuli.
Because she does not communicate well verbally, however, it is difficult to understand
the extent of her psychotic ideation.
3. Is it possible that Anna has, or has had, a mood or schizoaffective disorder?
Anna’s presentation is striking in that she does not exhibit any affective range. There are
no symptoms of depression or elation. Schizoaffective disorder can be ruled out because
of this absence of a strong and variable mood component to her psychotic symptoms.
4. How does Anna’s poor communication complicate the process of her assessment and
diagnosis?
Anna is somewhat puzzling diagnostically because she is not verbally engaged with her
service providers, and as such is not a valid self-informant. Without the benefit of the
recent testing, physical exams, reports from her recent hospitalization, and input from her
father, it would be difficult to confidently reach a conclusion about her diagnosis. Still,
medical conditions have been ruled out as contributing to her bizarre behavior, and it is
known that she does not use any substances that might be mind-altering.
5. Is there evidence of a premorbid personality disorder in this client?
A diagnosis of schizoid personality disorder could be made as a premorbid condition.
This is based on her father’s history of Anna’s being a quiet, withdrawn girl who always
did what was expected of her, but without evident enthusiasm or conviction, and then
withdrawing to her room. Since her adolescent years she has rarely left the confines of
her home, has taken no social initiatives, and seems most comfortable when alone. Her
premorbid behavior was not bizarre enough to warrant a consideration of schizotypal
personality disorder.
6. How would you characterize Anna’s childhood and adolescent functioning, given the
information presented?
Anna’s childhood and adolescent functioning appears to have been characterized by a
dutiful fulfillment of some family and school responsibilities but also social withdrawal,
affective flatness, a lack of desire for social contact, and a lack of interest in many
conventional daily living activities. She does not appear to have ever been distressed
about her lifestyle.

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DSM Diagnosis
F20.9 Schizophrenia, Continuous
F60.1 Schizoid Personality Disorder (Premorbid)
Rationale
Regarding the diagnosis of schizophrenia, Anna exhibits abnormal patterns of thought and
behavior that have persisted for well more than six months. It is not clear whether she is having
delusions or hallucinations right now, because she is not sharing much of her thinking. However,
it appears that she is distracted by, and preoccupied with, thoughts unrelated to here-and-now
circumstances, so we may assume the presence of auditory hallucinations or delusions. Further,
her behavior is clearly disorganized, as she is unable to care for herself. She does not bathe or
wash her clothes and has no evident sense of the effects these actions have on others (such as the
secretaries who objected to her behavior). Therefore, she meets the criteria for two of the active
symptoms of schizophrenia.
What is equally striking about the client is her affective impairment, or her negative
symptoms. Her affect is continuously flat; she is socially isolated, non-communicative, and
passive in her orientation to those around her. She rarely asserts what she wants or how she is
feeling. Finally, Anna’s social functioning is poor, and seems to have declined from the higher
level of her early college years. Her functioning is currently so marginal that it does not appear
that she could carry out any of those activities.
The specifier “continuous” was added, as it appears from the history that Anna’s active
psychotic symptoms are always present and have been for more than six months.
A diagnosis of schizoid personality disorder can be made as a premorbid condition based on
the symptoms summarized in the first section.
At present the client does not experience medical problems. The client’s gross lack of
personal hygiene does place her at risk for a variety of physical illnesses, for which the social
worker should stay alert through observation and referrals for physical examinations.
Risk and Resilience Assessment
Onset
Anna appears to have a genetic loading for schizophrenia, since her mother also has a psychotic
disorder. The specific biological factors are not known, and cannot be directly investigated, but
they may involve a disorder in her limbic system, enlargement of certain brain ventricles, and
abnormal levels of certain neurotransmitters. There is no evidence of early trauma, but it is
possible that Anna’s risk could have been complicated by birth complications or prenatal viral
exposure. Regarding psychological factors, it is possible that the household in which Anna grew
up was not a nurturing one, given the reports of erratic and unpredictable behavior of her mother.
This may have activated Anna’s biological sensitivity to the disorder. There are a variety of
traumatic events along the lines of parental neglect and family tension that could have been
present in her household. Finally, Ann’s poor level of social skills indicates that she would have
difficulty making transitions into adulthood. Regarding protective factors, Anna’s environment
was materially comfortable and there is no evidence that she experienced physical trauma that
may have contributed to constitutional weakness.
Regarding the course of her disorder, Anna faces certain risk influences. She experienced a
gradual onset of schizophrenia, demonstrated marginal premorbid social functioning, does not
experience her psychotic symptoms as strange, and shows prominent negative symptoms. She

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lives in a large urban area and continues to experience high levels of family tension with her
father’s disapproval and her stepmother’s lack of support. She has poor social skills and has
experienced deterioration in her intellectual capacity. Regarding protective factors, Anna is part
of a family system that could potentially become more supportive. Further, she has some
independent living skills, to the extent that she has been living in a condominium with her sister.
What questions can help to assess for further strengths in Anna:
1. Despite Anna’s limitations, does she demonstrate any personal qualities that are
functional or adaptive? Where, when, and with whom does she demonstrate these
qualities?
2. Does Anna express any personal goals that might be used to motivate her for change?
3. What talents did Anna demonstrate in her childhood and adolescence? Does she ever
utilize these talents now, or indicate a desire to do so?
4. In what kind of environments (both housing and social) does Anna seem to best manage
her activities of daily living? What characteristics of those settings seem to be appealing
to her?
5. When does Anna seem most comfortable with other persons? In what situations is she
most verbal? Is Anna capable of developing relationships in which she seems trusting?
Intervention Plan
There are many services from which Anna might benefit with regard to the remission of both the
positive and negative symptoms of schizophrenia, and her acquisition of social and vocational
skills. Still, the social worker needs to be cautious in developing an initial treatment plan. Like
many persons with schizophrenia, Anna is reluctant to participate in an extensive intervention
process at the outset because she seems to be easily overwhelmed. She may also be reluctant to
trust others because she is not comfortable in relationships. It will initially be important to
engage Anna in a relationship of trust, and then later she may take the initiative to participate in
other interventions. What follows here is a summary of interventions that could be utilized now
and others that might eventually be used with the client.
Anna may well benefit from taking antipsychotic medications, given the severity of her
symptoms. The social worker can schedule Anna to meet with the physician in the coming week
so that he may at least talk with her about the possible benefits of medication.
Family education and support will be important if the client’s father (and perhaps step-
mother) would be obliging. Mr. Yannucci appears to have little awareness of schizophrenia and
its treatment. He has suffered greatly as he has tried to help his daughter, but he does not know
how to do so, given her condition. This service may be provided individually or in a group
setting. Anna’s parents could learn about her disorder, available interventions, and behavior
management strategies; and find support for the burden that they experience.
The remaining goals could be provided by a case manager or though an assertive community
treatment team. Clubhouse involvement would be a helpful way for the client to add structure to
her life, improve her activities of daily living skills (budgeting, laundry, home care) and improve
her social skills. Anna might learn to cook and engage in modest work activities. Vocational
assessment and rehabilitation could assess Anna’s skills and potential for work, and place her in
programs where her skills could be developed. Through referrals for recreational activities the
client might be able to expand her range of daily activities. For example, since she enjoys
walking, she might be helped to get a membership at a health club. Linkages with entitlement

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services could help Anna insure that she was receiving benefits such as social security disability
money and health insurance. Her father has been providing her with such assistance, but he
might like to assume less responsibility for this aspect of his care, if possible.
Critical Perspective
The DSM’s reliance on behavior observation in making diagnoses presents a problem with
Anna’s presentation. She is withdrawn, passive, and marginally communicative, which makes it
difficult to assess with certainty if she is experiencing the active symptoms of schizophrenia
(hallucinations and delusions). Her presentation also demonstrates the necessity of relying on
historical data (from her father and the referring hospital) in diagnosis. If the social worker was
limited to the client’s current presentation, many other diagnoses (including cognitive, medical,
and substance abuse) would need to be considered more seriously.
Case 2
Questions to consider in making a diagnosis:
1. What symptoms of psychosis does Donald display and for how long have they been
evident?
Donald experiences delusions. He believes that people are ridiculing him and reading his
mind, that the day treatment program is evil, that fathers are perverted, that he is
possessed by the devil and that by not eating he could starve people away. The client also
experiences hallucinations. He feels a presence touching him and hears voices.
Additionally, he shows disorganized behavior, sitting outside in cold weather with light
clothing and sleeping in the back yard. Moreover, he displays disorganized speech as
evidenced by frequent derailment. Finally, negative symptoms, namely affective
flattening, are evident. Donald has experienced these symptoms for three years, well past
the six months minimum required for the diagnosis of schizophrenia.
2. The diagnosis of schizophrenia also requires functional impairment. Is impairment
evident in this case?
Donald was unable to continue with college or work, and was not able to socialize with
others.
3. Are psychotic or mood disorders present among relatives?
There is a family history of mental and mood disorders. Donald’s mother is taking anti-
depressants and her brother has bipolar disorder with psychosis during his manic episodes
and a substance use disorder. There is also history in Donald’s mother’s family of
attempted suicides and a paternal great uncle having “a breakdown.”
4. Does Donald have a history of depression or mood swings that might indicate a
schizoaffective, major depressive, or bipolar disorder?
Donald has a long history of depression (since age 13). At the age of 20, he started to
have psychotic symptoms. During periods of psychosis, he continues to have periods of
depression, which persist for several weeks at time. At these times, he exhibits a
depressed mood as indicated by his parents’ and helpers’ reports; a decrease in appetite;
hypersomnia; a loss of energy as noted by his parents’ and helpers’ reports; and more
withdrawal and isolation sometimes than others, which suggests even less interest or
pleasure in activities most of the time. Donald has two-week periods or longer in which

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he continues to display psychotic symptoms but does not have the depressive episodes.
He does not demonstrate hypomanic or manic episodes.
5. Are there any medical conditions that may be contributing to Donald’s symptom
development?
Although there is no specific information in the case about a medical evaluation, the
psychiatrist is said to be coordinating Donald’s case with his primary care physician, so
we can assume that medical causes have been ruled out.
6. Is the client’s use of substances or medications causing symptoms?
Donald has no history of alcohol or drug use.
7. Are there psychosocial stressors that might be contributing to Donald’s symptom
development?
Donald has not experienced any recent stressors that might account for his symptoms.
The social worker might want to inquire about any stressors that were present at the time
of his first psychotic symptoms.
8. What was Donald’s premorbid functioning like?
Donald was described as a shy child who started to become depressed at age 13. Little is
known about Donald’s relationships before the onset of his psychotic symptoms, for
example, whether he desired or enjoyed close relationships, had interests and activities
that he enjoyed, was indifferent to the opinions others had of him, or exhibited emotional
coldness, detachment, or flattened affectivity even then. These symptoms, if confirmed,
might be indicative of a premorbid schizoid personality disorder.
DSM Diagnosis
F25.1 Schizoaffective disorder, depressive type, multiple episodes, currently in acute episode
Rationale
The diagnosis of schizoaffective disorder, depressed type was made because Donald’s illness
meets the criteria for schizophrenia and major depressive episodes. He shows the characteristic
symptoms of schizophrenia in that he experiences the following during a one-month period:
Delusions (people are ridiculing him and reading his mind, the day treatment program is “evil,”
fathers are “perverted, he is possessed by the devil and by not eating, he could starve them
away), hallucinations (a presence is touching him, voices), disorganized speech (frequent
derailment), disorganized behavior (sitting outside in cold weather with light clothing, sleeping
in the back yard), and negative symptoms (namely affective flattening).
Donald’s social and occupational functioning is disturbed in that he is currently unable to
work, continue his college education, or socialize. He has been experiencing symptoms for three
years. He experiences delusions and hallucinations for periods of at least two weeks in the
absence of mood symptoms, but he also has prolonged depressive episodes during the majority
of his illness.
Donald has a history of depression going back to age 13. Episodes lasting several weeks have
continued since he experienced his first bout of psychosis at age 20. During these periods he will
sleep at least 12 to 14 hours and has difficulty waking. He eats less, is more withdrawn and
isolative, and is less active than at other times. The specifier “multiple episodes, currently in
acute episode” was selected to reflect the fact that Donald has fluctuating symptoms of his
disorder over time, but at the present time his psychotic symptoms are prominent.

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Additional Information Needed
The pattern of Donald’s illness seems to fit schizoaffective disorder without question. However,
it would be helpful to know the true pattern of his psychotic and depressive symptoms. It was not
clear how long the depressive episodes last, or how long the psychotic symptoms had been
present when he had his first depressive episode after the psychosis. It is not certain, however,
that this information would change the diagnosis. It would certainly create a clearer picture of the
pattern that is typical for Donald’s illness. If the depressive episodes decrease over time, whether
in number or in length of the episode, the diagnosis would have to be reevaluated to determine if
a diagnosis of schizophrenia would be more appropriate.
Risk and Resilience Assessment
Donald’s risk for the onset of the schizoaffective disorder may include the biological
vulnerability present in his family. Although there is no clear familial history of schizophrenia,
there seems to be a history of mental illness. Donald’s age (early 20’s) and gender also present
risk. In addition, he was born in February, which puts one at a higher risk for the disorder.
Protective mechanisms for the onset of Donald’s illness include the fact that he suffered no
major traumatic event or brain injury and that he has a relatively high socioeconomic status and a
stable, functional family. His mother also had a normal pregnancy and delivery.
The main risk influence for the course of the disorder includes repeated relapses, with some
residual symptoms between episodes. Protective mechanisms include Donald’s ability to
maintain some insight. Therefore, the social worker, doctor, and his family members can talk
with Donald about treatment options when he is most receptive. Other protective influences
involve the fact that he received the early interventions of medication and day treatment. He is
currently compliant with his medication and if that continues, it will be another protective factor
for the course of his illness. One of the most critical protective factors in this case is Donald’s
family’s supportiveness and their involvement in his care. Finally, he has access to quality
treatment in the community where he lives and his family has the means to pay for it.
What questions can help to assess for additional strengths in Donald
1. What behaviors does Donald currently demonstrate that are functional or adaptive?
Where, when, and with whom does he demonstrate these qualities?
2. Donald has attempted to live on his own on several occasions. While he was not
successful in this regard, what positive survival skills account for his persistence at these
times?
3. Does Donald express any realistic personal goals that might be used to motivate him for
goal setting?
4. Donald demonstrated some vocational capacities in his adolescence. How might these be
tapped as a means of developing vocational goals?
5. There are times when Donald’s behavior seems more socially appropriate than others,
and when his symptoms are less evident. In what situations do these behaviors appear to
be most prominent?
6. What personal aspirations or desires for social interaction account for Donald’s several
attempts to “succeed” at the day treatment program?
7. Donald cares deeply about children. Even though the behaviors related to his caring have
been inappropriate, is there a way to tap into his empathy toward a constructive end?

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Intervention Plan
Since Donald is opposed to a hospital setting for a revamping of his medications, other options
need to be explored. One option is that at his day treatment program, a doctor can observe his
behaviors daily, monitor his medications, and gradually adjust them as needed. Another option in
the community is a 16-bed short-term residential facility in which clients are closely monitored
and receive transportation to appointments, referrals to necessary agencies, meals, recreational
groups, individual therapy, group therapy, and medication management. The facility has a
psychiatrist and a nurse practitioner. These professionals can help the client through a medication
transition in a gradual manner.
As part of Donald’s intervention, his parents could attend a family psychoeducational group
that can provide them with support from others, education about schizoaffective disorder,
treatment strategies, ways to manage their son’s behavior, and coping skills for themselves.
Participation in such a group may help Donald avoid relapse and also help them gain needed
support and knowledge about living with a son with the disorder.
Critical Perspective
Schizoaffective disorder is a psychotic disorder although it has some similarities to bipolar
disorder with psychotic features, which is a mood disorder. It appears in this case the diagnosis
could be accurately made due to the clarity of symptoms, but social workers must always take
care to differentiate between the two disorders, because their treatments are quite different.
Case 3
Questions to consider in making a diagnosis:
1. What symptoms of psychosis does Emma display?
Emma experiences delusions. She believes she still owns a house, her son is an imposter,
she was shot at work, and she has no siblings. The client also experiences hallucinations.
She has been observed responding to internal stimuli in the hospital setting, and she
reported that she hears the doctor’s voice telling her she has been released from the
hospital. Emma appears to have experienced these psychotic symptoms for the past 14
years. She may have experienced residual periods as well, although this is not clear from
the case study. Finally, Emma displays flat affect and avolition (e.g., she would sit in
front of the television with no volume on and was unable to care for herself), which are
negative symptoms of schizophrenia.
2. The diagnosis of schizophrenia also requires impairment. Is impairment evident in this
case?
Emma has been unable to hold a job or live independently, and she is estranged from her
son who is “worn out from dealing with her.”
3. Are there any medical conditions that may be contributing to Emma’s symptom
development?
There is no information in the case presentation about a medical evaluation, so this
should be completed to rule out the possible influence of any medical conditions.
4. Is the client’s use of substances or medications causing symptoms?
Emma has no current use or history of alcohol or drugs. She takes medication for
hypertension, but this is monitored in the hospital setting and there is no reason to believe
this medication results in her symptoms.

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5. Are there psychosocial stressors that might be contributing to Emma’s symptom
development?
The divorce in her 40s might have precipitated the psychotic symptoms, but they only
worsened over time rather than dissipating. She has now had symptoms of schizophrenia
for 14 years.
6. Are psychotic or mood disorders present among relatives?
According to Emma’s son, there is no family history of psychotic disorders.
7. Does Emma have a history of depression or mood swings that might indicate a
schizoaffective, major depressive, or bipolar disorder?
There is no evidence that Emma has suffered from depressive, manic, or hypomanic
episodes.
8. What was Emma’s premorbid functioning like (to determine the presence of a possible
schizotypal, schizoid, or paranoid personality disorder)?
Little is known about Emma’s personality before the onset of her current symptoms.
More information needs to be gathered in order to decide if she had a personality disorder
that preceded the schizophrenia. However, Emma seemed fairly well-functioning from
the information we do have, in that she was married, employed, and raised a son.
DSM Diagnosis
F20.9 Schizophrenia, Continuous
Hypertension, Essential
Rationale
Emma meets the first of the basic criteria for the diagnosis of Schizophrenia, in that she
experiences at least two psychotic symptoms that persist for more than a month. Emma has
auditory hallucinations, although it’s not clear if this symptom is present for a significant portion
of a month. Emma also has bizarre delusions. Emma also has the negative symptoms of flat
affect and lack of volition. Emma’s symptoms emerged many years ago and she has been unable
to work or take care of herself due to the illness. Schizophrenia further requires coding of course
of illness after one year. Emma’s disorder is specified as “continuous” as there has been no
remission of “A” symptoms. It is not possible to determine for certain if Emma’s behaviors are
due solely to schizophrenia or if another disorder with some relationship to her behavior is
present. The fact that she did not develop clear symptoms of a psychotic disorder until midlife is
unusual.
Risk and Resilience Assessment
Emma’s onset of schizophrenia was unusually late in life. According to her son, there is no
family history of schizophrenia. There was no information provided on Emma’s prenatal
development, or her delivery, so the extent to which any complications might have played into
the development of Emma’s illness is unknown. It is also unknown how well Emma’s son knows
her history, but he claimed that there were no traumatic events in her childhood. There were
reports of Emma being “whipped,” but whether this was outside the boundaries of what a child
in her historical and cultural background experienced is not established. A traumatic event during
adulthood, the end of her marriage, seemed to have acted as a trigger for the disorder. Emma
comes from a low socioeconomic background, which also confers risk for the disorder.

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In assessing risk and resilience for the course of the illness, on the positive side, Emma had a
relatively late age of onset and a good premorbid adjustment. From what we know, she was
married and raised a son who went on to go to college. She had an identifiable precipitating
event for the disorder rather than a gradual onset, which bodes well for her adjustment. She also
has an unfortunate number of risk influences that include poor insight about the disorder, living
in a large urban area, delayed treatment, repeated relapses, a history of non-compliance with
medication, and the absence of a support system. Her son was involved with her care for a time,
but he became “worn out,” and she doesn’t seem to have other supportive people available to
her.
On a more formal level, Emma receives support from the mental health facility in which she
is housed. Her medication compliance is assured, although even so she continues to experience
both positive (delusions and hallucinations) and negative (flat affect, lack of volition) symptoms.
She receives daily supervision in living tasks, her housing is provided, and she also receives
psychological interventions.
Additional information needed
Because it is unusual for schizophrenia to develop in one’s 50s, Emma’s professionals should be
alert to any additional medical and psychosocial information that becomes available to make sure
that she has been diagnosed accurately. It does not appear that any such information is available
at present.
Ways to assess for additional strengths in Emma
1. Emma is said to be generally pleasant when interacting with others. How could her
pleasant nature be built upon to further develop interpersonal skills?
2. Emma did not develop the symptoms of schizophrenia until relatively late in life. What
social and vocational skills did she develop prior to the onset of her illness that might still
be available to her?
3. Emma has generally been non-compliant with medications, but now she takes them
because the nurses give them to her. Are there times when she has been willing to use
medications? Why was she more willing at those times?
4. Are there times when Emma has been aware of her need for medical treatment? Are there
types of medical treatment with which she seems relatively comfortable?
5. What hobbies or interests does Emma have that can be encouraged as part of her
rehabilitation?
6. Emma seems to enjoy certain aspects of her hospital program (going on outings,
attending groups). What is about these structured activities that she enjoys? How might
these elements be transferred to other areas of her life?
Intervention Plan
A major goal for Emma is stabilization of her symptoms, which will hopefully be achieved by
finding an effective antipsychotic medication at an appropriate dose. Nursing staff and the doctor
on her team will monitor her symptoms and the effect of the medication.
Another goal is for Emma to participate in psychosocial interventions, which will include
education about her mental and physical illnesses. At this time, Emma does not believe she has
either a mental illness or hypertension. Greater awareness and management of her symptoms will

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Solution Manual for Mental Health in Social Work: A Casebook on Diagnosis and Strengths Based Assessment, 3rd Edition

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