Exercise: Case Study of Randall
You are a clinical psychologist specializing in the diagnosis and treatment of psychological problems among children. A colleague has sent you information regarding Randall Ellis (see below) in hopes that you will provide a second opinion as to the correct diagnosis for Randall. Read the case study, make a diagnosis, and then answer the following questions in a report to be written to his family. Be careful to fully explain concepts such that someone outside of the area of abnormal child psychology would understand. (DO NOT assume that you are writing this paper to me.)
1. What is the primary diagnosis for Randall (be sure to specify the major diagnosis and type if necessary)? Using the criteria in the DSM-IV-TR specifically describe why Randall’s symptoms fit this particular diagnosis. Give specific examples of the symptoms he manifests. Do not just list the symptoms of the disorder according to the DSM. Instead tell the reader (the parent) how Randall’s characteristics specifically fit the criteria listed in the DSM. It may help to use direct quotes from the case study. You must get the diagnosis EXACTLY correct. There is enough information given so that you can make the exact diagnosis. (3 points will be deducted for the wrong diagnosis, if the given diagnosis is close. 5 points will be deducted for an entirely incorrect diagnosis. The remainder of the paper will be based on the diagnosis you gave, and not the correct diagnosis such that you can still make a B even though you gave an incorrect diagnosis.) In order to help you arrive at the correct diagnosis, try doing this. First list all of the possible diagnosis that you think Randall has, then rule out each diagnosis until you are left with only one. Once you reach this one diagnosis, confirm it with specific examples from the case study. (10 points)
2. With most diagnoses there are differential diagnoses and co-morbid conditions that you need to consider. Discuss differential diagnoses and co-morbid conditions that exist with your primary diagnosis by answering Parts 1, 2, and 3.
a. Part 1: For your primary diagnosis that you gave in question #1, list the common differential diagnoses and co-morbid conditions.
b. Part 2: Next, take one of the differential diagnoses listed in Part 1, and explain how you would make a differential diagnosis between your primary diagnosis and that particular differential diagnosis. Next, apply it to Randall’s case. In other words you are going to explain why Randall has the primary diagnosis that you gave him and not the common differential diagnosis. For example, if you gave Randall the primary diagnosis of schizophrenia (he doesn’t have schizophrenia), you would need to list autism as a common differential diagnosis, and then explain how you would make a differential diagnosis between schizophrenia and autism. What key characteristic do you look for to indicate that Randall has schizophrenia and not autism? If there is additional information that you would like to have to help you make a differential diagnosis, you may discuss this here.
c. Part 3: Take one of the common co-morbid conditions listed in part 1, and discuss whether or not Randall also has this common co-morbid condition in addition to his primary diagnosis. Explain why you think he also has this additional diagnosis by listing the specific symptoms that Randall displays or explain why he does not have this additional diagnosis by discussing what symptoms he does not display. If there is additional information that you would like to have to be able to say that he has another diagnosis, you may discuss this here. (10 points)
3. Based on the known causes of the particular primary diagnosis you gave Randall, speculate about the cause(s) of his diagnosis. You don’t have enough information to definitively know what caused the problem. Consider the most common cause of the disorder. It would be appropriate to address two or three causes; one that applies specifically to Randall’s situation and one based on the most common cause of the disorder. You want to explain these causes from a technical perspective. Use information from the textbook to explain why this causes the disorder that Randall has or provide data that supports that this is a true cause of the disorder. Hint: You absolutely need to cite information from the text or another source in this section. (10 points)
4. Based on the known treatments for Randall’s primary diagnosis, what treatment(s) can you recommend for him and his family? How is this type of treatment conducted? Be very specific about the name of the treatment and what is done in the treatment. Generic statements like, “Randall should seek therapy,” are inappropriate. What type of therapy would you recommend? How is this type of therapy conducted? Be careful not to give a laundry list of all the possible treatments. Pick the best treatment for Randall, and explain this treatment in detail. (10 points)
5. What information can you give Randall and family about his prognosis? Base your answer on known information about the prognosis for his particular disorder, and not just what you hope for Randall and his family. For example, you may discuss what is known about what might make the prognosis better or worse. Avoid generic statements like, “With proper treatment Randall will get better.” This is true for almost all disorders, and is what we hope for all of our clients. Say something more specific like, “Generally speaking the prognosis for Randall’s disorder is positive. 75% recover within one year, and only 15% relapse.” (10 points)
IMPORTANT NOTE: The information supporting the symptoms of the diagnosis, common co-morbid and differential diagnoses, treatment, and prognosis, should be taken from another source like your textbook, the DSM, or another source. However, this information should NOT be copied word-for-word from the source, and should be correctly cited within the text and in a reference listing at the end of the paper. APA format should be used for the in-text citation and reference listing. Information on how to use APA format can be found in a document located on Blackboard in the Assignment area titled, “A Primer on Citation” or at http://owl.english.purdue.edu/owl/resource/560/02/ . Severe penalties could result from failure to follow this requirement.
Also, remember that papers containing more than three direct quotes (sentences and phrases) from sources other than the case study will receive a grade of 0.
The interviewer was first made aware of Randall Ellis while attending a workshop. A school psychologist approached the interviewer and described Randall, aged twelve, who was presently in the sixth grade at a local elementary school. He had been diagnosed with Attention Deficit Hyperactivity Disorder in the second grade and had been taking Ritalin since that time. According to the school psychologist, Randall was on the verge of being suspended from school because of his inappropriate behavior. The school psychologist was hopeful that the interviewer might be willing to assess Randall to determine if Randall has the correct diagnosis or if he has other psychological difficulties. The school psychologist reported being comfortable assessing school-related problems but believed Randall’s problems required more expertise in assessing psychopathology. The interviewer agreed to see Randall if his parents so desired.
The following week the interviewer received a call from Randall’s mother, Mrs. Ellis. Mrs. Ellis expressed her frustration with Randall, and directly asked whether bringing Randall to another therapist was ”…going to do any good?” The interviewer told Mrs. Ellis that all that she could be promised was a complete evaluation. At the end of the evaluation, the interviewer would be able to answer her questions more thoroughly. Mrs. Ellis agreed to the consultation, made an appointment for Randall, and authorized the therapist to observe Randall in school.
On the following morning, the interviewer went to Randall’s school. School records confirmed the school psychologist’s report. Randall had attended the elementary school since kindergarten. His behavior in kindergarten and first grade was characterized by his teachers as extremely immature. Randall was described as being constantly out of his seat, rude to his teachers, and impulsive. Randall did not wait to be called upon but simply shouted out answers. In the music class, he held his hands over his ears and complained that the music was too loud. His interactions with other children were also described as problematic. Randall called other children names, pushed them, and would take their change from their desks.
In second grade, Randall’s physician, at the request of his parents and his teachers, diagnosed Randall as having ADHD, and placed him on Ritalin. Other than during the summer, Randall had been on Ritalin since that time. Teachers had reported that Randall was calmer when he was taking his Ritalin but that he continued to demonstrate inappropriate behaviors such as stealing small things, lying, being disrespectful to the teachers, hitting other children, disrupting the class by passing gas, pounding his head on the desk or wall, and talking loudly.
Randall’s academic performance was also problematic. While standardized test revealed that Randall had an above average level of intelligence (117 on the Cognitive Skills Index, a test frequently used by the local elementary schools to estimate level of intelligence), he typically earned C’s and D’s in his classes. He was always promoted from one year to the next, but teachers expressed concern about the discrepancy between his performance and his level of ability.
The interviewer sat in the back of Randall’s class during the class period before lunch. During lunch and recess, the interviewer observed Randall from a distance while pretending to interact with the lunchroom monitors and the playground monitors. Randall was below average height, but slightly overweight. He was the only child in the room of Asian descent. He was dressed in jeans, a t-shirt, and sneakers in a manner similar to that of the other children in the class.
In the classroom, Randall was off-task for the entire forty-minute period. While the other student were answering questions or listening to the teacher, Randall banged his head on his desk, poked the student in front of him with a pencil, and repeatedly passed gas. The teacher ignored Randall’s misbehavior for the most part. When Randall passed gas, the teacher commented, “Let’s all get our gas masks out.” The child in front of Randall told Randall to stop poking her. When this happened, the teacher told the girl she would receive a discipline card if she did not stop talking in class.
At lunch, Randall continued to behave inappropriately. He made rude comments about the food to the children sitting around him, attempted to put french fries down one girl’s t-shirt, and was eating with his mouth open. When the girl told Randall not to touch her, several other students yelled at Randall. Randall responded to their yells by sitting quietly for several minutes.
Recess showed a continuation of this pattern. Randall chased girls around the playground and pushed one girl to the ground twice. Children who reported Randall’s misbehavior to the teachers or to the playground monitors were told to leave him alone. When Randall’s behavior became enough of an irritant, the other children would yell at him or tell him that they or their parents would beat him up if he did not stop. The children’s approach halted Randall’s behavior for approximately two to five minutes.
On the following day, Randall and his parents came to see the interviewer. Randall waited in a playroom while the interviewer met with his parents. Mrs. Ellis was a small women of Asian descent dressed casually in a denim skirt and blouse. Mr. Ellis was a large man dressed in jeans and a polo shirt. Mr. Ellis was Caucasian.
The Ellis’s reported that Randall was Mrs. Ellis’s child from a previous marriage. She had divorced Randall’s father when Randall was six-months-old. Mr. Ellis had adopted Randall when he was fourteen months after marrying Randall’s mother. Mr. Ellis was the only father Randall had ever known. According to Mrs. Ellis, she and her first husband were both Korean, and had come to the United States with their parents during the Korean War in the 1950s. After the birth of Randall, her husband had returned to Korea to work. She had refused to leave the United States, leading to their divorce. Randall’s biological father refused to have anything to do with his son, claiming that the child wasn’t his because he was too “Americanized.”
The Ellis’s had three additional children, aged nine, seven, and four. No problems were reported with the other three children. Mrs. Ellis reported that she believed in mothers remaining home while their children were small. She hoped to return to college and pursue a degree in sociology once her youngest was in first grade. Mr. Ellis worked with his family on their farm. The farm was a large one, over 1,000 square acres, and was open to the public for picking strawberries, blackberries, apples, peaches, and pumpkins.
The Ellis’s reported that Randall had been an easy baby with no medical or behavioral problems during his first two years. All developmental milestones were achieved within normal limits. They began to notice how “stubborn” Randall was shortly after his second birthday. They attributed this to the “terrible two’s” and tried not to punish him for hitting other children or throwing temper tantrums when he was denied a toy or treat. Randall’s behavior did not improve when he turned three or four. When Randall began kindergarten, his teacher expressed concern about Randall’s behavior and suggested that he stay in kindergarten for two years to “mature.” The Ellis’s were concerned that Randall would be made fun of and sent him to the first grade. The Ellis’s stated that the same type of behavioral problems were reported by Randall’s first-grade teacher, and that Randall continued to disobey at home, often hitting his siblings when Mr. and Mrs. Ellis were not watching. When questioned about his misbehavior, Randall would lie, even though his parents had observed him engaging in the misbehavior.
When questioned, the Ellis’s reported that they spanked Randall once for each lie and twice for each time he hit another child. Mr. Ellis administered all spankings because Randall would laugh and tell his mother that her spankings did not hurt him.
The Ellis’s reported that Randall did not sleep as much as their other children except when he was taken off the Ritalin during the summer. No problems with appetite were noted. No other problems, including developmental, were noted, although Mrs. Ellis reported that Randall was physically awkward, leading to his being unable to perform well in sports. She noted that he still occasionally fell off his bicycle or ran into parked cars or trees.
Randall was seen by the interviewer immediately following completion of the parents’ interview. Although complaint, Randall frequently rolled his eyes when the interviewer asked a question. Randall reported that he knew his parents were upset with him for “being bad,” but that it wasn’t his fault because he had ADHD. He explained that his ADHD caused him all sorts of problems and that he shouldn’t be penalized because he was sick. He reported that hitting the other children, farting, and talking loudly was because of his ADHD, and that his Ritalin just wasn’t strong enough to control all of his illness. He commented that his behavior was much worse when he forgot to take his medicine.
Randall reported that he disliked school and found most of his teachers boring. He stated that teasing girls was “a lot of fun” because they would squeal. He enjoyed getting the other children, especially girls, in trouble and didn’t really mind getting in trouble himself if one of the girls also got in trouble. He reported that the school never really followed their own rules. He explained that they had repeatedly told him that he would be expelled if he caused additional problems, but that they never kicked him out for good.
When questioned, Randall reported that he enjoyed reading about motorcycles and race cars and would like to attend a race someday like the Indianapolis 500. He reported that the only school subject he liked was English. Randall reported that he had several friends in his neighborhood, including two boys with whom he would catch stray cats. When questioned about what he did with these cats, Randall replied, “Nothing.”
Randall was administered the Wechsler Scale of Intelligence for Children, A Wide-Range Achievement Test, and the Bender-Gestalt. His performance on the Bender-Gestalt was normal for his age. The Wide-Range Achievement Test confirmed his teachers’ reports of his poor academic performance; he scored in the 77th percentile for Reading, the 50th percentile for Spelling, and the 45th percentile for Arithmetic. His relatively high Reading score corresponded with Randall’s own comments about liking English and how he enjoyed reading about certain topics.
On the Wechsler scale, Randall scored in the above average range on the Verbal Scale (125), and average on the Performance Scale (108). His Full Scale IQ of 115 placed him in the above average range of intellectual functioning which corresponded well with the school’s estimate of his intellectual functioning.
Adapted from: Morgan, R. K. (1999). Case Studies in Child and Adolescent Psychopathology. Upper Saddle River, New Jersey: Prentice Hall.