Joshua is a 13-year-old Caucasian boy referred to the child day treatment unit of a children’s
community mental health centre. Joshua’s parents, Mrs. and Mr. Jackson, referred Joshua
amidst growing concerns about Joshua’s attitudes and behaviours. Most recently, Joshua’s
parents’ concerns were ignited by reports from his school that he recently missed a few
afternoon classes, and their discovery that some vodka had gone missing from their alcohol
cabinet. When confronted with the situations Joshua swore he knew nothing of the alcohol, and
blamed his apparent absences on a “stupid” attendance system, that marks you as absent if you
are more than 3 minutes late. He assured his parents that while he was in fact late coming back
from lunch, he had not been skipping classes. Mrs. and Mr. Jackson, aren’t sure what to believe.
They would like to trust Joshua but he frequently blames others for his mistakes and doesn’t
follow rules at home, so they are not surprised by the thought that he might be breaking rules at
The Clinical Psychologist, the Social Worker, and the Psychiatrist at the child day treatment
centre conducted a comprehensive psychosocial assessment. Mrs. Wilson, the team
social worker, met with Joshua and his parents. Mrs. Wilson’s interviews provided the following
information about Joshua, his family’s history, and current family relationships:
Joshua currently lives with his two biological parents, and his younger brother, age 9 years. They
live in a middle class neighborhood, relying on both parents’ income to meet their financial
• The Jacksons moved from a supported housing program for low-income families to their
current home when Joshua was 4. Mr. and Mrs. Jackson indicated that they both went through
the school system in their old neighborhood and worked hard to move to a “better”
neighborhood before their sons began their schooling. Mr. Jackson had learning difficulties,
never managing to finish high school, and felt that if he would have had access to better
schooling he might have completed high school – he did not want the same situation to befall
• Mr. and Mrs. Jackson indicated that Joshua had a difficult temperament as a child; he didn’t
sleep through the night, and he was a fussy eater. However, at the time they had attributed
Joshua’s behavior to the lack of stability in their household. Up until their move both Mr. & Mrs.
Jackson had to sacrifice some of the time that they would have liked to spend with Joshua, and
eventually his brother, as they each worked two jobs in order to save for the down payment on
a house that eventually allowed them to move into a middle class neighborhood, and gain
access to a more reputable school system.
• Mr. and Mrs. Jackson reported that Joshua began preschool at the age of three years. They
expected that the stability of going to school everyday would help to mitigate Joshua’s difficult
temperament. However, Joshua’s teachers reported that he was stubborn, impulsive, and
• Mr. and Mrs. Jackson expected that Joshua would “grow out” of his stubborn and disinhibited
ways. However, in elementary school Joshua’s teachers continued to complain that he
“wouldn’t stay in his seat” and that they couldn’t hold his attention for more than a few
minutes, especially if Joshua decided that he wasn’t interested in something. 2
In grade three, Joshua’s academic performance began to be impacted by his behaviours and one
of his teachers suggested that Joshua might have Attention Deficit Hyperactivity Disorder, and
that treatment might help him get back on track.
Mr. and Mrs. Jackson indicated that they did not have health care benefits, so they took
Joshua to a walk in clinic to see a physician. The physician completed a brief assessment
including a questionnaire and an interview with the parents, indicated that Joshua met clinical
cut offs for ADHD, and prescribed a course of stimulant medications to help him focus in
• Presently, Mr. and Mrs. Jackson, both have stable employment. Mrs. Jackson works as a
teacher’s aide and Mr. Jackson is a truck driver. Mr. Jackson remarked that his job keeps him
away from his family for longer than he would like, but the income is good, and he has
continued to work extra hours to pay the mortgage on their house.
•Mr. and Mrs. Jackson indicated that following the stimulant prescription Joshua’s grades
stopped slipping, however he continued to experience “academic difficulties”, obtaining mostly
C’s and D’s throughout his schooling. Mr. and Mrs. Jackson said that Joshua’s school has been
quite supportive. He attends a relatively small school (20 students per grade) and the school
has consulted closely with Mr. and Mrs. Jackson to prevent Joshua from falling behind a grade.
• Mr. and Mrs. Jackson described Joshua as “difficult.” They said that he frequently “looses his
cool,” and “lashes out” at those around him, by going on aggressive verbal rants. They said that
Joshua has no respect for his elders. He challenges them and argues with anyone and everyone
that gets in the way of whatever it is he happens to want to do. They said that he refuses to
follow their rules. They can’t get him to complete any chores at home (e.g., take the garbage
out, clear the dishes, etc.). When they try to impose consequences for his behavior, Joshua gets
resentful and angrier. He often deliberately picks on his younger brother, pocking him, or taking
things from his room. Mr. and Mrs. Jackson say that when they try to confront him about
bullying his younger brother, Joshua makes up a story in order to put the blame on his brother.
Recently, they have become increasingly worried about Joshua’s behaviours because of the
truancy reports from his school and the alcohol they found missing in the cabinet.
• In addition, Mr. & Mrs. Jackson are worried that Joshua’s behaviours are starting to “rub off”
on his younger brother, as now he has also begun to refuse their rules and requests.
• Joshua would not talk to Mrs. Wilson, simply stating that none of this is “his problem.” He says
that he isn’t failing in school, and he has lots of friends, so he is not sure what the problem is.
Dr. Ozonoff, the team psychiatrist, supplemented this information with the following:
• Overall, Joshua appears to be in good health. His symptoms do not appear attributable to an
underlying medical condition.
•Joshua continues to take stimulant medication on school days and indicated that he finds that
it helps him to focus in the morning, but by the time the afternoon comes around the
medication seems to have “worn off.”
• According to Mrs. Jackson, Joshua met all developmental milestones. She noted that, as
indicated to Mrs. Wilson, Joshua had a difficult temperament as a child. He had difficulty
sleeping through the night and he was a fussy eater. He had particular difficulty with transitional
times (e.g., going from one place to another, when one of his parents would go to work). He
would become visibly upset and was very difficult to calm.
• Joshua stated that he “didn’t understand what all the fuss was about”. He said that he was
“fine” and that he felt that all of these conversations were “wasting his time.” He stated that he
doesn’t understand why he is always being “punished” because his parents are “crazy.”
Dr. Soodie, the clinical psychologist also met with Joshua, his parents, and Joshua’s
• Joshua’s parents completed the Parent Informant Report form of the Child Behaviour Checklist
(CBCL). Reports from Joshua’s parents were largely consistent. They placed Joshua in the clinical
range in terms of the withdrawn/depression subscale, attention problems, rule breaking
behavior, and aggressive behavior.
• Joshua’s homeroom teacher, Ms. Doiron, completed the Teacher Report Form of the CBCL.
Joshua’s scores were in the clinical range in terms of attention problems and rule breaking
• Joshua’s teacher noted that Joshua likes to “challenge her authority” in the classroom. She
said that he appeared to break rules “on purpose” to get a rise out of her, and to impress his
classmates. She said that while Joshua has missed two classes in the past month, most of the
time when he is marked at absent it is because he “deliberately” comes to class three to ten
minutes late after lunch “to show that he can.” She noted that this behavior disrupts her
classroom. Ms. Doiron, also noted that Joshua has little motivation to do well in school. She said
that while she was aware that he has always had difficulties in school, his previous teachers
indicated to her that up until the age of 11 he used to “try his best.” Ms. Doiron, stated that
Joshua is not “motivated” by schoolwork, rather he spends his time in class “testing her
•When asked about Joshua’s social relationships, Ms. Doiron said that Joshua appears to have
several close friends. She indicated that, while on occasion Joshua’s behavior irritates her
“keen” students, the majority of the class don’t seem to bothered when Josh disrupts
the classroom. In fact, she said that many of them seem interested to “see what will happen
next.” She indicated that Joshua has been in the school for a long time, and he has had the same
classmates since early elementary school. She feels that they just see Joshua as Joshua, and
they take the good with the bad. She noted that the exception to this is that when she assigns
group work the students don’t want Joshua in their group because they don’t think he will “pull
his weight” and they are worried that he will “make things more difficult than they need to be.”
•Ms. Doiron indicated that Joshua doesn’t seem to be phased by it, as he is aware of his
academic underperformance, and jokes “I wouldn’t want me in a group either.”
• Given his difficulties in the classroom Dr. Soodie conducted a psychoeducational assessment
including a memory test, an achievement test, and an IQ test. Results from the IQ test indicated
that Joshua’s IQ was on the low end of the average range. His verbal abilities were slightly below
the normal range, but his performance abilities were well within the average range. Joshua’s
performance on the achievement and memory tests also fell on the low end of the average
range. There was no indication of a Learning Disability. Joshua’s school grades (C’s & D’s) seem
reasonable given his verbal IQ.
• When asked about when Joshua’s aggression and defiance started, his parents restated that
he has been difficult since he was a child, but he became really difficult to manage around the
age of 10 years.
• When asked about how they react when Joshua lashes out, his parents indicate that they try
to be strict with him and instill punishments. For example, they remove privileges, like computer
use and television time. They noted that Joshua doesn’t seem to be bothered by punishment; he
just threatens other bad behaviours. They noted that sometimes Joshua seems to like
punishment, in so much as he likes getting a rise out of them.
• The clinical psychologist spoke to Joshua about school and his social circles. Joshua indicated
that he has a bunch of friends at school. He indicated that he likes going to school to see his
buddies, but doesn’t really care about schoolwork. He said he knows he is “no good” at school 4
and he will probably just become a truck driver like his dad, or something. He said that as long as
he passes so that he can stay with his classmates, he doesn’t care. When confronted about how
his classmates react to his behavior in the classroom he said that they think he is “funny”.
A 1-page case report will be due two weeks after the case is presented. Each
student will need to determine the best diagnosis and treatment plan given the
information provided. Potential predisposing, precipitating, perpetuating factors
(defined in class) should be identified, as should protective factors and strengths
(also defined in class). Implications of not providing treatment should be
discussed, consistent with a lifespan approach to psychopathology
30 pts. total
Brief biographical description of Joshua: 4pts
Instructions/notes: This is where you would list demographic and identifying information that
you believe to be most relevant (e.g., age, sex/gender, culture/ethnicity, living situation, family
composition). Include one sentence that summarizes the main presenting concern or referral
question (note: this may or may not be consistent with what you arrive at for your diagnosis).
Primary diagnosis: 2pts
Instructions/notes: This is where you would provide your main hypothesis about the diagnosis
that best summarizes and explains Joshua’s presenting concerns. This could include “no
diagnosis”- but only do this if you think that diagnostic criteria have not been met for any
disorder. Do not select “no diagnosis” because you disagree with diagnosis on philosophical
grounds. The diagnosis will be for a disorder we have covered in class- an anxiety disorder, a
mood disorder, Attention-Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, or
Justification: 4pts (link symptoms to criteria for diagnosis)
Instructions/notes: This is where you would demonstrate your knowledge of the diagnostic
criteria for the disorder you selected and list the symptoms described in the case study that fit
these criteria. E.g., Joshua meets all diagnostic criteria for disorder x. For example, the first
criteria for disorder x is having at least # symptoms of y. Joshua has more than # symptoms of y.
He reports (symptom 1), (symptom 2), (symptom 3)… Use the DSM 5 for this.
Consideration of other possible diagnoses: 2pts
Instructions/notes: This is where you would list any other disorder(s) you think Joshua might
have or that you considered but did not choose as a primary diagnosis.
Justification: 4pts (why considered, criteria met/not met)
Instructions/notes: As above, demonstrate your knowledge of the other disorders we’ve covered
in class. There are symptoms in the case that could be relevant to other disorders. Your response
should demonstrate an awareness of possible comorbid disorders and whether or not full criteria 5
for these disorders are met. Your response could also highlight areas where you’d want more
information in order to make a diagnosis.
Possible predisposing factors: 2pts
Instructions/notes: Predisposing factors are risk factors that increase the likelihood of developing
a disorder (e.g., family history, early child experiences, genetic and environmental factors). List
at least two factors in the case study that might have predisposed Joshua to develop the disorder
you diagnosed. You might look through the relevant chapters and the theories and causes
sections to help guide you.
Possible precipitating factors: 2pts
Instructions/notes: Precipitating factors can be thought of as events and situations that lead to
the presenting concerns (i.e., pushed an individual predisposed to developing a disorder to the
point of developing the disorder). Describe at least two factors that you think may have
precipitated the presenting concerns and current disorder.
Possible perpetuating factors: 2pts
Instructions/notes: Perpetuating factors are factors that maintain the disorder. These may be
within the individual (e.g., certain thoughts and behaviours, ways of dealing with the symptoms
that aren’t effective in the long term) or in their environment (e.g., patterns of relationships,
consequences that reinforce maladaptive behaviours). List at least two perpetuating factors.
Possible protective factors and strengths: 2pts
Instructions/notes: Protective factors are “personal or situational variables that reduce the
chances of a child developing a disorder”. List at least two strengths or protective factors that
are relevant to Joshua. Strengths could include strengths within the child, family, or community.
Treatment recommendation: 1pt
Instructions/notes: Identify a treatment for the disorder you identified. In the absence of a
diagnosis, identify a treatment that might help the presenting problems from becoming severe
enough to merit diagnosis in the future.
Rationale for treatment recommendation: 2pt
Instructions/notes: Why did you select the treatment you did (e.g., evidence-base, treatment
matches some characteristic(s) of Joshua and his situation or strengths)?
Prognosis if no treatment: 1pt
Instructions/notes: Based on the literature described in the textbook, outline in one or two
sentences what might happen if Joshua did not receive treatment (e.g., comorbid problems,
Description of treatment: 2pt
Instructions/notes: Describe what the treatment you recommended would look like so that a
parent might understand. For example, if you selected CBT, what happens in CBT? What does
CBT address? How does CBT work? What would Joshua (and possibly his parents) be expected to
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