CASE STUDY ASSIGNMENT INSTRUCTIONS
OVERVIEW
Each Case Study Assignment is an APA-style formatted, 35-page assignment designed to help
you apply the course content, including the DSM-5-TR, to a fictional case example. This will not
require an abstract. You will need a minimum of 7 peer-reviewed scholarly resources; one of
these may be the course textbook. All resources need to be less than 10 years old. The 3-5 pages
exclude the title page and reference page.
In this Case Study Assignment, you will have the opportunity to think through a clinical case,
identify and prioritize key imperative issues involved, consider and clarify relevant diagnostic
concerns, provide at least one assessment to substantiate the diagnosis, and formulate beginning
treatment recommendations. This Case Study Assignment will directly apply to your future
coursework in diagnosis and treatment planning, which is also included in field experience
classes.
Be sure to review the Case Study Grading Rubric and the Case Study Template before
beginning this Case Study Assignment.
Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.
INSTRUCTIONS
For this assignment, you will read the case study and then generate a report that uses the
assignment template.
INTRODUCTION TO THE CASE STUDY (1-2 statements) introducing the case.
Client Concerns
Biological factors Psychological Social/Cultural Spiritual
Physical symptoms, for
example: neurological,
past, present impact
Past and present
Ideas, thoughts,
feelings, beliefs,
values about self,
others, and the
world
Past and present
Family systems
Relationships with
others
Cultural elements
Past, present
Religious and
spiritual aspects of
self/family, Past,
present
Trouble sleeping hopelessness Early parent
relationships avoidant
Attends church weekly
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Headaches Ongoing worry and
ruminating
Loss of colleagues
when retired
Would like to explore
more prayer time and
spiritual connection
Muscle tension Fear of things bad
happening
Divorced Grew up with mother
who used religion
against her
Genetic predisposition
with parent with similar
features reported
Sees the world as
glass half empty
Adheres to strict
animal rights group
ideology
Each section should be separated by the appropriate APA headings (Level 1, Level 2…)
Client Concerns
Using a table as in the example above, complete each column to identify and list the
clients symptoms and any other key issues/concerns noted. (Modify the chart size as needed.)
For example, these include biological, psychological, social, and/or spiritual problems. If
symptoms/behaviors overlap, you only need to list them once.
Assessment
Provide at least one assessment that will be used to substantiate the diagnosis you chose –
a valid assessment that a counselor can use. (Note this means it has high reliability and validity
for the sample population you are hoping to administer it to.) Please be sure to cite support for
the assessment tool you use by using one peer-reviewed journal article to reference your choice
of assessment. Give a short (3-5 sentences) overview of the assessment, what it would help you
learn about the client, and why you chose it over other assessments (for example: Beck
Depression Inventory: identifies clinical depression, strong research base, its internal
consistency – around 0.9 – indicates that the items relate to each other and measure the same
construct. Test-retest reliability ranges from 0.73 to 0.92, suggesting consistent scores over
time. It is also short, easy to administer, and score).
Diagnostic Impression
Provide the primary diagnostic impression based upon the DSM-5-TR. Be sure to use the
full code and full name for each diagnosis. Start with an introduction statement or two as
illustrated in the template. Be sure to consider secondary disorders in addition to the primary
disorder. Is there more than one diagnosis? Provide the following for all diagnoses.
Signs and Symptoms
List the signs (clients report) in the right hand column of the chart and link them directly
to the symptoms (criteria you find in the DSM-5-TR) in the left hand column of the chart
(example below) to make sure you have linked every client symptom to every DSM-5-TR
symptom. This is to substantiate your choice for diagnosis. Be sure to adjust the size of the table
accordingly. If there are client-reported signs that do not fall into the DSM-5-TR diagnosis, make
note that you considered them, but they did not align with the DSM-5-TR.
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DSM-5 Diagnostic Criteria for your TOP
CHOICE of dx you are giving disorder name
and code number. Note: this should align with
your DSM-5
Clients Signs/Reported Symptoms from case
study:
Criterion A:
Criterion B:
Criterion C:
Criterion D:
Criterion E:
Criterion F:
Other DSM-5 Conditions Considered
List other DSM-5 conditions you considered and the process you went through to decide
they were not the correct diagnosis. For example: The client reported three symptoms of Major
Depressive Disorder, but five symptoms are needed for this diagnosis, so the disorder was ruled
out.
Developmental Theories and/or Systemic Factors
Consider a developmental or systemic perspective as you conceptualize your client. For
example: What stage is the client in within Eriksons Stages of Developmental theory? or
What is occurring within the clients family system that may be influencing the clients current
functioning or behavior?
Multicultural Competencies and Considerations
Discuss multicultural considerations that may be relevant to your client. For example,
what would the client say about their symptoms/situation from their cultural point of view? How
might you apply cultural competencies in your understanding of the client? Cite one peer-
reviewed counseling source to support your point.
Treatment Recommendations
Key Issues for Treatment
In bullet point form, identify the top 2-3 symptoms/issues you believe are imperative to
the client in the case study. Be sure to list in order of importance. For example, 1.
Suicidal ideation 2. Extreme anxiety/depression symptoms such as X, Y, Z
3. Interpersonal distress regarding relationships with immediate family
The goal here is to clearly delineate what you believe is most time sensitive to address to
be of support to the client.
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Recommendations for Counseling
Identify two evidence-based treatment recommendations for counseling based on the 2-3
key issues you identified. For example, if you are seeing crisis symptoms, what theory is
identified in the literature as best practices for Crisis Intervention Counseling that you might
choose? If you see anxiety symptoms, what theoretical evidence-based theory and or
interventions might be best suited to support the client?
You will need to cite these recommendations using peer-reviewed journal articles,
focusing on the treatments a counselor would provide. Consider if a medication referral or
medication evaluation is recommended, and if so, support why you believe this to be the case
with a peer-reviewed scholarly citation.
Specific Considerations
For each case study, you will have additional critical thinking points to consider. You
will need to provide one paragraph, with source support, responding to the question assigned to
each case that corresponds with the list below. In your response to these questions, address how
these considerations affected your diagnostic impression and your treatment recommendations.
Amelia Case Study 1:
What additional information would you need about her culture and why? What kinds of value
conflicts might you experience due to the clients culture? How would you manage your personal
values while working with this client?
Shelia Case Study 2:
How does a client in crisis change the focus of your assessment and treatment planning? What
suicide assessment tool would be best to use with her, given the ethical and legal requirements
counselors have?
Jake Case Study 3:
How do multiple diagnoses affect the decision-making process for diagnostic impressions and
treatment planning? How does a substance use disorder affect the process of diagnostic
impressions and the order you make treatment recommendations? What are the unconscious or
conscious biases to consider when you are personally working with Jake?
Teddy – Case Study 4:
How does the clients experience of a triggering event inform your conceptualization process?
How might you collaborate with this client when treatment planning? What are some barriers
you might encounter in the treatment planning process with this client, and how might you
address those barriers?
Vince Case Study 5:
How might the clients age affect diagnosis and treatment recommendations? What kind of
consideration must be made for the family system, and how does it impact your entire
conceptualization of the client?
Case Study Assignment
Student Name
School of Behavioral Sciences, Liberty University
Author Note
“Insert full name here. Include ORCID number in URL format if you have one.”
I have no known conflict of interest to disclose. “<Disclose conflicts, if any>”
Correspondence concerning this article should be addressed to “Insert Student’s Full
Name” . Email: <Insert Your LU Email>
CASE STUDY ASSIGNMENT 2
Case Study Assignment [Case Name]
Write brief introduction to the case here (1-2 sentences)
Client Concerns
Biological factors Psychological Social/cultural Spiritual
Physical symptoms, for
example: neurological,
past present impact
Past and present
Ideas, thoughts
feelings, beliefs,
values about self,
others the world
Past and present
Family systems,
Relationships with
others,
Cultural elements
Past, present
Religious and spiritual
aspects of self/family
Past present
Assessment
Diagnostic Impression
Signs and Symptoms
DSM-5-TR Diagnostic Criteria: disorder name
and code number
Clients Signs/Reported Symptoms from case
study:
Criterion A:
Criterion B:
Criterion C:
Criterion D:
Criterion E:
Criterion F:
CASE STUDY ASSIGNMENT 3
Other DSM-5-TR Conditions Considered
Developmental Theories and/or Systemic Factors
Multicultural Competencies and Considerations
Treatment Recommendations
Key Issues for Treatment
One
Two
Recommendations for Counseling
Specific Considerations
CASE STUDY ASSIGNMENT 4
References
TEDDY CASE STUDY
Teddy is a 6-year-old African American male who is currently in first grade. He is an only child
and lives with his parents in a suburban neighborhood in the Midwest. Teddy was reportedly
referred to the clinic due to “behavioral and emotional difficulties”, noted by his parents and his
teacher. Teddy’s parents expressed concerns about his sudden changes in mood, frequent waking
in the night with nightmares, and difficulty participating in social activities. When asked why he
is at the clinic, Teddy reported, “I was scared I was going to die.” Teddy’s parents reported that
the family experienced a near head-on auto collision about six months ago.
Teddy recalled he was sitting on his booster seat, in the backseat of the family vehicle, playing a
handheld video game, when his father was driving the family home from dinner one night. “It
was very scary, I crashed on my Nintendo game and in real life!” Teddy’s mother reported she
was yelling at Teddy to stop playing his game since he had already reached his daily screen time
limit, and his father was yelling at his mother to stop yelling while he was driving, and they were
reportedly also “running late”. His mother stated they were driving on a two lane, 55-mile-per-
hour road and were approximately five miles from home when she noticed an oncoming vehicle
swerving toward them. Teddy remembered the sound of his mother screaming as the oncoming
car’s headlights crossed over into their lane. Teddy’s father quickly swerved to the right to avoid
hitting the car head-on, and their car veered off into the ditch along the road. When the car hit the
ditch, it flipped over and landed upside down. Teddy reported that all he remembers is that his
video game went flying and hit the shattered windshield. Teddy’s mother reported that all three
of them were wearing their seatbelts. Both front airbags deployed, resulting in Teddy’s mother
receiving a bloody nose. Both mom and dad report feelings of stress and irritability since the
accident, off and on. Initially, the three of them struggled to move from the overturned vehicle,
and Teddy’s mother recalled that some other passersby stopped to help them out of the vehicle.
One of the passersby called 911, and Teddy and his parents were transported to the hospital by
ambulance. Upon assessment at the local hospital, Teddy’s parents were treated for broken ribs
and contusions. The doctors reported it was a miracle that Teddy did not have any physical
injuries, other than some bruising from the seat belt. The family later learned that the driver of
the oncoming car had been under the influence of alcohol, with a blood alcohol content level
twice the legal limit.
Since the accident, Teddy’s parents have noticed several symptoms concerning their son. He
reportedly often experiences nightmares in which he is in a car that is about to crash into another
car. Teddy reported that he always wakes up right before the crash. He stated this makes it
difficult to fall asleep because he is afraid, and when he wakes up due to a nightmare, he has
difficulty falling back asleep again. Teddy’s mother reported that when he has a nightmare, he
will wake her or his father to sit with him until he can fall asleep again. Teddy frequently appears
restless, fidgeting, and having difficulty sitting still. Teddy has also become more withdrawn and
no longer engages in activities that he used to think were “fun.” His mother reported that she
bought him a new video game after his game was destroyed in the accident, but he has not
played with it yet, and often he prefers to play with his live action toys in his room alone. She
stated she is surprised, as she used to have trouble getting him to reduce his screen time, and now
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she almost wishes that she had that problem again. It appears he is afraid that he caused the
accident because his mom was yelling at him about playing his game too much, and now he is
afraid something bad will happen again if he plays the video game. Teddy shared, “I don’t think
that’s a good idea, to play that game, it was bad and made the cars crash!” Now, when they are in
the car, Teddy always sits in the middle of the backseat, “so he can help Mom and Dad watch for
cars coming at them.” Sometimes it is a struggle to get him to go places due to his “worry”.
Teddy’s mother reported she has never seen a child pay that much attention to the road; Teddy
says, “I just want to look out for my parents when they’re driving.” When the family is driving on
a two-lane road and an oncoming vehicle is approaching, Teddy screams and covers his head
with his hands, even when the vehicle is in its own lane. Teddy’s father noticed that Teddy
doesn’t do this when they are driving on the interstate or a divided highway, and so he has tried
to alter their routes in order to avoid driving Teddy on a two-lane road.
Teddy’s parents have received messages from his teachers noting a decline in his academic
performance. Teddy was an honor roll student during the first quarter of first grade. At his most
recent parent-teacher conference (one month ago), Teddy’s teacher reported that Teddy has been
having trouble completing his work at school and usually appears distracted. The teacher noted
that recently he has struggled with sitting quietly and reading during the class reading time. He
has also had difficulty completing spelling worksheets. During recess, instead of playing with the
other students in class, he has begun playing with Matchbox and Hot Wheels cars. His teacher
noticed that Teddy used to be very social and engaged easily with the other children in the
classroom. Now, when he is playing, he is focused on the cars, slamming them together
aggressively and then flipping them over. His teacher saw other kids backing away from him as
if they didn’t want to get hit with a flying car, and she had to reprimand him to not play with the
toys so aggressively.
Teddy’s parents are Jehovah’s Witnesses, and while Teddy attends weekly meetings with them,
he has not yet been baptized, as his parents believe he is too young to make that decision for
himself. Teddy’s mother noted that since the accident, Teddy has not asked to visit with his
friends at their Kingdom Hall. He has also had difficulty sitting throughout the meetings; his
mother reported he often claims he needs to use the restroom, sometimes leaving as often as
three times in an hour.
Teddy’s mother reported that Teddy has no significant health problems or history of surgeries,
has reached all his developmental milestones, and recently had a visit with the family’s
pediatrician. Teddy is not currently prescribed any medications and has never been exposed to
alcohol or other substance use. The pediatrician referred them to the clinic, stating that Teddy
may benefit from counseling. Teddy’s mother stated her husband’s insurance will cover six
sessions of counseling, but she is unsure about continuing treatment after that.
Case Study Grading RubricDownloadCriteriaRatingsPtsClient Concerns
view longer description
20 to >18 pts
Advanced
Client concerns/key issues are noted from the case study. The important symptoms, behaviors, and stressors are identified. Sufficiently identified the client concerns as presented in the case.
18 to >16 pts
Proficient
Identifies most of the client concerns in the case; 1 or 2 concerns (symptoms, behaviors, and/or stressors) may be missing.
16 to >0 pts
Developing
Identifies few of the client concerns in the case; 2 or more concerns (symptoms, behaviors, and/or stressors) are missing.
0 pts
Not Present
/ 20 pts
Assessment
view longer description
5 to >4 pts
Advanced
Assessment is clearly stated. Rationale for assessment includes what information assessment will provide, professional literature support for use of assessment and what made assessment a better choice than others available. One professional citation given.
4 to >3 pts
Proficient
Assessment is stated. Missing 1-2 parts of rationale or rationale is weak. Citation is older than 10 years or from questionable source.
3 to >0 pts
Developing
Assessment is stated. Missing more than 2 part of the rationale and rationale is weak. Missing citation.
0 pts
Not Present
/ 5 pts
Diagnostic Impressions
view longer description
25 to >20 pts
Advanced
The diagnosis and a rationale for the diagnosis are included and appropriate (or only minor errors). Link between symptoms and DSM criteria clearly provided. Differential diagnoses are reviewed and discussed. In addition to the main disorder, additional diagnoses are also considered (that the client may have more than one diagnosis), examined, and discussed. Developmental Theories and/or Systemic Factors and Multicultural Considerations are addressed.
20 to >15 pts
Proficient
The initial diagnosis given is not correct but is in the correct DSM category OR Not all link between symptoms and DSM criteria addressed OR Not all the differential diagnoses are reviewed and discussed. Additional diagnoses were considered. Developmental Theories and/or Systemic Factors are partially addressed. Multicultural Considerations are partially addressed.
15 to >0 pts
Developing
The initial diagnosis is not close to the correct diagnosis, but one is given OR Link between symptoms and DSM criteria vague or missing OR Differential diagnoses were not considered OR Additional diagnoses (secondary) were not considered. Developmental Theories and/or Systemic Factors were minimally or not addressed. Multicultural Considerations were minimally or not addressed.
0 pts
Not Present
/ 25 pts
Treatment Recommendations
view longer description
25 to >20 pts
Advanced
Recommendations for treatment are included in order of importance, appropriate, and supported by the professional literature. The recommendations demonstrate the use of a collaborative approach. The rationale is linked to potential outcomes of treatment for this client. How the order of priority will contribute to a successful outcome for the client is evaluated. The recommendations are, also, relevant to the case, able to be implemented by the client, and have some basis of support from professional literature. Considerations for whether the counselor would refer for medication evaluation are discussed and supported by scholarly literature. Specific Considerations questions are thoroughly addressed.
20 to >15 pts
Proficient
Recommendations for treatment are included but order unclear or not supported. More support from the professional literature is needed. One of the suggestions may not be appropriate or primary case management. Considerations for medication evaluation are somewhat discussed but unclear or not supported. Specific Considerations questions are partially addressed.
15 to >0 pts
Developing
Recommendation order is not appropriate. There is little support from the professional literature. A significant requirement of treatment may have been missed. Recommendations primary… [Content truncated to 3000 words]