The template outline should include the following 7 areas described below. Examples and descriptions have been added to this template.
Case Study: (400-600 words)
Differential Diagnosis: (150-200 words)
Differential Diagnosis – Medical: (35-70 words)
Diagnosis: (35-70 words)
Treatment plan: (400-600 words)
Medications: (100-200 words)
References and/or Resources:
Case Study: (400-600 words)
Johnny Smith is an 11-year-old boy who is in the 6th grade. He is of average height and weight in relationship to his male peers. However, his mother reported that at the age of three he was described as low toned with awkward motor skills, inconsistent imitation skills, and little to no interest interacting with others. He is dressed well with clean clothes on every day. At home he lives with his parents and younger sister, who is 6 years of age. Family dynamics and interaction with his sister can be very awkward and disruptive at times.
Johnny communicates very little with no eye contact unless addressed by the person speaking to him which he would then look at you and then turn away. When he speaks his enunciation is poor except when he is agitated at which time the words would become clear. His grammar and sentence structure is poor, which makes it hard for some people to understand what he is referring to when speaking and writing. There are times when he will use a different word in place of the word that he is talking about which makes it difficult to understand by many people.
Johnny’s social and emotional needs are not as severe as his communication needs. Socially Johnny will interact with others with little disruptive behavior. Johnny will need to learn to express his emotions with symbols and to share his intentions for joint attention by commenting on objects, actions, events, or requesting information from others. He needs to seek emotional regulation from others, respond to assistance, and respond by using language strategies across environments. Johnny is good with responding to familiar persons when he trusts when recovering from extreme dysregulation with the use of behavior strategies, such as a fidget source or a specific environment to help refocus and calm himself.
Johnny is currently attending his first year of middle school where he has had good attendance so far this year. He is currently in all regular education classes along with his enrichment resource class. So far this year, his regular education teacher and special education teacher have noticed improvements in his language skills, responsiveness, memory, and his level of understanding with little disruptive behavior. However, he needs a lot of coaching to be an active member during group work. The teachers are having to really express to him the importance of communicating with his peers. His language skills and vocabulary continued to improve, along with his social skills.
Differential Diagnosis: (150-200 words)
Explain the reasons as to why the differential diagnosis was considered yet ruled out (lack of symptoms, incorrect timeline, criteria not met, etc.). In other words, why it’s NOT these different diagnosis.
Rett Syndrome was ruled out because the disruption of social interaction may be observed during the regressive phase of Rett syndrome (typically between 1-4 years of age) but improve after this phase.
Selective mutism was ruled out because there were early developmental delays of low toned with awkward motor skills, inconsistent imitation skills, and little to no interest interacting with others at the age of 3. Social reciprocity can be impaired, additionally.
Language disorders and social (pragmatic) communication disorder was ruled out because it’s not associated with abnormal, nonverbal communication, nor with the presence of restricted, repetitive patterns of behaviors, interests, or activities.
Attention-deficit/hyperactivity disorder was ruled out because it isn’t observed to exceed that of typically comparable mental age individuals.
Schizophrenia was ruled out because hallucinations and delusions aren’t present which can’t be explained with a concrete reasoning.
Differential Diagnosis Medical: (35-70 words)
Diagnosis, symptoms medical conditions, syndromes, etc. NOT found in the DSM5 but could be considered for a differential diagnosis.
Diagnosis: (35-70 words)
Explain your clinical reasoning supporting the main DSM5 diagnosis. In other words, Why IT IS this diagnosis.
Autism Spectrum Disorder
Treatment plan: (400-600 words)
Short term Goals:
- Increase communications skills
- Creating a journal for commenting on object, actions, events, or interaction with peers.
- Creating a preferred healthy stress relief outlet. (Exercise, breathing, etc…)
Long term Goals:
- Demonstrate communication and social skills
- Long-term educational support and social skills
Treatment: (Six weeks, one visit per week) Goals will be divided by session.
- Introduce Solution-Focused Brief Therapy (SFBT)- with regards to relationship building between the counselor and the clients as well as Encouragement skills and the importance of the client’s changed behavior and attitude from problem/failures to solution/success.
- Introduce Reality Therapy- the ability for the client to have a choice in their decisions through role play
Session 1: Goal setting with Johnny discuss what his goals are for the next six session. Get to know the client through detailed history discussion.
Session 2: Follow up questions and concerns. Introduce SFBT on attitudes and behavior – Work on developing some good communication skills that will enhance his ability to work with adults and peers
Session 3: Follow up questions and concerns. We will work on developing healthy relationships by talking about past and present relationships and the affects that it had on him personally and what they could have changed in the situation.
Session 4: Follow up questions and concerns. Introduce RT- Work on verbal and nonverbal socials skills through Role play.
Session 5: Follow up questions and concerns. Talk about different types of situations that he can face throughout the day and have him journal about how he would respond.
Session 6: Follow up questions and concerns. Assessing progress made, Discuss future goals.
Medications: (100-200 words)
List and explain the typical medications that might be used to treat the diagnosis.
References and/or Resources:
Watts, R. E., & Pietrzak, D. (2000). Adlerian “Encouragement” and the Therapeutic Process of Solution-Focused Brief Therapy. Journal Of Counseling & Development, 78(4), 442-47.
Passaro, P. D., Moon, M., Wiest, D. J., & Wong, E. H. (2004). A Model for School Psychology Practice: Addressing the Needs of Students with Emotional and Behavioral Challenges through the Use oan In-School Support Room and Reality Therapy. Adolescence San Diego, 39(155), 503
