Mental Health Disorder: Case Conceptualization

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Table of Contents

Case Conceptualization
Treatment Plan
Interventions
References

Sofia is an 8-year-old Hispanic female who was born prematurely. Sofia is in the second grade and speaks English well. Due to her developmental delays, she held back in kindergarten and is currently at risk of being held back again, and her attendance record is very poor. Sofia states that she hates to see her mom and dad fight. She gets very scared, has trouble sleeping, and hides in her closet. She does not have a lot of friends due to her being bullied and named calling. Sofia has mentioned that another male child occupant of the house where they live enter her room at night to “comfort her by giving her lots of hugs and squeezes.” Her mother has stated that she has caught Sofia “rubbing her private parts” on the couch arm and that she tries to kiss all the other little male children in the house. There are no medical documents available nor any inclination that either Sofia’s mother or father have had her examined for possible sexual abuse, so the history of alleged sexual abuse is unknown. There is also no documentation of any diagnosis, medical problems, or mental health problems that would assist with Sofia’s case.

Diagnosis:

Physical developmental delays due to premature birth;
Fear and anxiety from both parents due to them constantly fighting;
Social and psychological development issues because of bullying at school;
Passive exposure to smoke and drugs;
Lack of care;
Sleep disturbances;
Potential issues associated with sexual abuse.

Case Conceptualization

One source of the client’s psychological strengths appears to be her parents. Despite the two always fighting with one another, neither of them was mentioned to treat the girl poorly or attempt to use physical violence on her. Therefore, their comfort and goodwill have a positive influence on the girl. Bajeux et al. (2018) state that parents have an important supporting influence on a child’s development between ages 4-11.

At the same time, the presence of parents and their relationship with one another is also a source of psychological distress and weakness. They are directly responsible for the child’s phobia of them fighting as well as sleep disturbances. In addition, they are indirectly to blame for Sofia being bullied at school – their lack of care contributes to a disheveled appearance, poor grades, and bullying.

The girl appears to not be suffering from social isolation. It makes her vulnerable to being manipulated by others. The lack of friends and a supportive environment allows for potential predators to gain her trust just by treating her nicely. Sofia lacks the positive influence from her peers, which contributes to feelings of psychological isolation. Adkins (2021) states that isolated children are particularly vulnerable to people trying to get advantage of them.

Separation fear is the result of these significant psychological detriments (Everstine & Everstine, 2019). It is obvious that Sofia is attached to her parents despite them neglecting her needs. She is also trying to make up for a lack of connection at home and at school by making friends with other boys in the condo. Overall, it appears as though the girl has very few psychological strengths helping her while facing a plethora of detrimental issues common in disaster and trauma response.

Treatment Plan

Problem, Issue, Challenge, Obstacle, Symptom: Parental Neglect
Treatment Goal 1: Reduce the consequences of parental neglect on physical and mental health of the patient.
Objective: Reduce or completely resolve the child’s sleeping problems caused by the parents fighting when she is around;
Objective: Completely resolve the issues with Sofia’s physical neglect, such as poor hygiene, malnourishment, etc.
Problem, Issue, Challenge, Obstacle, Symptom: Sexual victimization
Treatment Goal 2: Completely eliminate the chances of Sofia becoming a victim for a sexual predator and generate long-term strategies for resiliency and autonomy of the patient.
Objective: Remove Sofia from the environment in which she is in contact with potential sexual predators;
Objective: Provide the necessary education for the child to be able to identify when someone is trying to molest her, as well as what needs to be done in these situations;
Objective: Provide therapy to increase resilience against such acts and solve any behavioral abnormalities resulting from potential abuse so far.

Interventions

The primary intervention that would work towards both treatment plan goals involve the removal of Sofia from her parents and the household she lives in. The issues that the child experiences are largely out of her control and are related to other people, such as her parents and the male friend who was visiting her at night. The problems parents have with one another are deep and require much work, meaning that until they are resolved it is dangerous for the girl to remain in their presence (Everstine & Everstine, 2019). Likewise, living in a condo with a potential sexual predator would only cause more problems.

While the isolation would remove an important part of her supportive structure, that structure is currently incapable of facilitating its intended function. Until parents resolve their issues together and are made capable of taking care of their child, Sofia should not be exposed to the fighting and violence currently happening at home. Professional caregivers would be able to address hygiene and malnourishment issues, and a peaceful environment would promote sleep recuperation (Everstine & Everstine, 2019).

The second intervention involves resilience and autonomy therapy. This can be done with a single professional, who would teach Sofia about sexual predators, their methods, and what to do if someone is acting inappropriately. Trauma-focused cognitive-behavioral therapy has shown to be effective in overcoming the aftermath of sexual molestation in children (Orengo-Aguayo et al., 2020).

Additional interventions would have to aim at the child’s social isolation, development issues, and studying discrepancies. These could be accomplished by group therapy, exposure to friendly individuals and positive environments (Everstine & Everstine, 2019). The acquiring of skills for basic maintenance and hygiene would enable Sofia to take care of herself, should her parents neglect their duties.

References

Adkins, I. (2021). Mental health and the impact of friendship. WRIT: Journal of First-Year Writing, 4(1), 4-13.

Bajeux, E., Klemanski, D. H., Husky, M., Leray, E., Chee, C. C., Shojaei, T.,… & Kovess-Masfety, V. (2018). Factors associated with parent–child discrepancies in reports of mental health disorders in young children. Child Psychiatry & Human Development, 49(6), 1003-1010.

Everstine, D. S., & Everstine, L. (2019). Sexual trauma in children and adolescents: Dynamics & treatment. Routledge.

Orengo-Aguayo, R., Stewart, R. W., Villalobos, B. T., Hernandez Rodriguez, J., Dueweke, A. R., de Arellano, M. A., & Young, J. (2020). Listen, don’t tell: Partnership and adaptation to implement trauma-focused cognitive behavioral therapy in low-resourced settings. American Psychologist, 75(8), 1158.

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Mental Health Disorder: Case Conceptualization

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