Posted: February 28th, 2023
MSW Assessment Case Study Assisgnment
**Below is a brief summary of the assignment. Attached you will find the complete detailed assignment along with supplemental information needed to complete.**
For this final assignment, you will integrate your knowledge, skills, and values from course work and field learning to demonstrate that you have achieved the MSW level competencies set forth in the 2015 Council on Social Work Education’s Education Policy Accreditation Standards.
This integrated case study will be based on a case from your field placement and will be divided into two primary sections:
Section I will provide the foundations of the case, as well as supportive information regarding policy, diversity, theory, ethics, human rights and social justice considerations. This section should include the following information:
A. Overview of the Case
B. Application of Social Welfare Policy to the Case
C. Theoretical Framework and Context for Analyzing Client System’s Situation
1. Theoretical Framework for Understanding the Case
2. Impact of the Urban Environment on the Case
3. Ethical Considerations for the Case
4. Diversity Considerations for the Case
5. Human Rights and Social Justice Considerations for the Case
Section II will provide information on the Engagement, Assessment, Preliminary Diagnosis, Intervention, and Termination of Treatment with Client (individual, family, community, or organization) System for the case. This section must include the following information:
D. Engagement, Assessment, Preliminary Diagnosis, Intervention, and Termination of Treatment with Client (individual, family, community, or organization) System
1. Engagement of Client System
2. Assessment of Client System
3. Intervention Plan for Client System
4. Termination of Intervention with Client System
E. Plan for Evaluating Effectiveness of Practice with Client System.
social workcase studysocial policy
MSW Assessment Case Study Paper
For this final assignment, you will integrate your knowledge, skills, and values from course work and field learning to demonstrate that you have achieved the MSW level competencies set forth in the 2015 Council on Social Work Education’s Education Policy Accreditation Standards.
This integrated case study will be based on a case from your field placement and will be divided into two primary sections:
Section I
will provide the foundations of the case, as well as supportive information regarding policy, diversity, theory, ethics, human rights and social justice considerations. This section should include the following information:
A. Overview of the Case
B. Application of Social Welfare Policy to the Case
C. Theoretical Framework and Context for Analyzing Client System’s Situation
1.
Theoretical Framework for Understanding the Case
2.
Impact of the Urban Environment on the Case
3.
Ethical Considerations for the Case
4.
Diversity Considerations for the Case
5.
Human Rights and Social Justice Considerations for the Case
Section II
will provide information on the Engagement, Assessment, Preliminary Diagnosis, Intervention, and Termination of Treatment with Client (individual, family, community, or organization) System for the case. This section must include the following information:
D. Engagement, Assessment, Preliminary Diagnosis, Intervention, and Termination of Treatment with Client (individual, family, community, or organization) System
1.
Engagement of Client System
2.
Assessment of Client System
3.
Intervention Plan for Client System
4.
Termination of Intervention with Client System
E. Plan for Evaluating Effectiveness of Practice with Client System.
For this paper:
(1) APA style must be used correctly, (2) All required relevant course readings and materials must be used, (3) At least 10 scholarly sources used (beyond course materials), (4) You must include at least 4 social work sources, (5) The paper must be clear, well organized, and should be 12-15 pages
not including
the cover page, abstract, references and any other attachments.
SECTION I (Directions)
Integrative Case Study: Write a case study based on an actual case from your advanced (i.e., 2nd year) field practicum.
The case study must reflect your ability to apply knowledge and skills from all major content areas in the MSW curriculum including Human Behavior and the Social Environment, Social Welfare Policy, Practice, and Research.
Organize the case study using the subheadings below. Include the bulleted information under each section below in a written narrative (i.e., essay in paragraph format). Use American Psychological Association (APA) 7th edition format, including references when citing theorists and other sources.
A. Overview of the Case
A1. Describe the client system, including its composition (i.e., the client may be a child, youth, or family).
A2. Give a succinct but comprehensive statement of the client system(s) presenting problem. This statement should be enough to establish a thorough understanding of the significant factors that are influencing the identified client (i.e., the client may be a child, youth, or family).
B. Application of Social Welfare Policy to the Case
B1. Delineate a (Macro) Policy that could (has) or currently transforms the client system (1 paragraph) – Find a policy that involves child welfare linked to juvenile delinquency
1) What is the policy to be analyzed?
2) What is the nature of the problem targeted by the policy?
a. How is the problem defined?
b. Origin of the problem, challenge, or opportunity and for whom is it a problem?
B2. Historical Analysis (2 paragraphs)
3) What policies and programs were developed in the past to deal with the problem?
4) How did these policies specifically impact African American (Individuals, Families,
Communities, or Organizations)
5) Problem, Challenge, or Opportunity and Solutions
a. Identify the client/organizational problem, challenge or opportunity
b. What people, or groups of people, initiated and/or promoted the policy (ideologies)?
c. What people, or groups of people, opposed the policy (ideologies)?
6) Describe key elements of proposed change (theoretical/model basis of the proposed
change based on literature review)
C. Theoretical Framework and Context for Analyzing Client System’s Situation
C1. Theoretical Framework for Understanding the Case
Select two human behavior theories that can be integrated and applied to understanding the client’s situation and presenting problem
(USE SYSTEMS THEORY AND PSYCHODYNAMIC THEORY)
and discuss their practical application to this case. Students should ensure that the application of the identified theories demonstrates their ability to integrate both frameworks AND a thorough understanding of application (individual, family, communities, organizations) within the case. This can be done through the identification of the basic tenets of theory including the concepts and propositions that each theory is comprised of.
C2. Impact of the Urban Environment on the Case
Discuss how the dynamics of the urban environment impact the client system, including cultural, social justice and economic factors affecting the presenting problem of the client system (e.g., racial/cultural, sexual orientation, physical or mental disability, gender, class, etc.).
C3. Ethical Considerations
Identify ethical principles from the NASW Code of Ethics that are relevant to the case. Identify any ethical dilemmas in this case and describe the steps/actions a social worker might take to respond to the situation; using the Code of Ethics to support the response
C3.1. Professional Boundaries
Students will identify and discuss professional boundaries that should be maintained as students’ progress throughout the case. These should include but not be limited to topics such as timeliness, professional appearance, dual relationships, use of personal electronic devices, professional documentation, etc.
C4. Diversity Considerations for the Case
Identify and discuss the specific aspects of diversity that impact the social work process with the client system selected for this case. This should include diversity outside of race and could include but not be limited to gender, sexual orientation, gender expression, culture, and any other areas of diversity or “otherisms” that have been identified.
C5. Human Rights and Social Justice Considerations for the Case
Identify and discuss the specific human rights or social justice considerations that impact the social work process with the client system and other marginalized groups selected for this case. Students should think broadly on how these issues could or have previously or continue to impact African American individuals, families, groups and organizations.
SECTION II
D1. Engagement, Assessment, Intervention, Termination
(Please see additional attachment: Treatment Planning Strategies for Youth With Disruptive Mood Dysregulation Disorder)
Using evidence-based practice specific to your Urban, Children, Youth and Families ASP, identify a practice framework and explain the processes of engaging, assessing, and intervening with the client system identified for this case. Make certain that you address any ethical and/or cultural considerations that might impact service delivery. Organize your response using the outline provided below.
D2. Assessment of Client.
BIO-PSYCHO-SOCIAL–SPIRITUAL ASSESSMENT OF CLIENT SYSTEM
Complete a Bio-Psycho-Social-Spiritual Assessment of Client System using the template outlined below.
Please follow this template exactly:
DESCRIPTION OF THE CLIENT SYSTEM:
a) Client/Family Identifying Information
b) Reason(s) for services
c) Household Members (to include relationships with one on another, and their patterns of functioning)
d) Household Living Conditions
e) Financial History (to include all insurance information, excessive debt, etc.)
SOCIAL RELATIONSHIPS AND SUPPORTS
Family History: In this section, you will present data on family members (be sure to designate the members living in the household). Names, gender, birth dates (or ages), relationships, marriage dates, education, occupations, deaths (causes), chronic conditions (e.g. alcoholism, mental retardation), significant trauma (e.g. fire, rape, incarceration), anything significant to describing individual. Other data that may be significant: adoptions, miscarriages, pregnancies, separations, current locations, etc.
a)
Community System: Describe relationships between client/family members and the various systems they are affiliated with or connected to. Describe community context and include a description of neighborhood resources.
b)
Assets and Resources: Information about the client’s informal sources of support. Information about the client primary and secondary sources of support. The type (what need does the source meet) and frequency (how often) of support from whom (e.g., friends, extended family members, church, etc.) provides support? Assess if the support provided is reliable.
SOCIAL HISTORY:
a)
Physical Health (past and present, make certain to include any medication schedules, family history of medical conditions
b)
Mental Health: This section will include a brief history of family psychiatric problems. Report whether client has a history of psychiatric disorders; admission into mental health clinic (inpatient or outpatient), dates receiving services, outcome of services, medication, treating therapist (past or present); family history or mental disorders. History of homicidal and suicidal ideation;
c)
Alcohol and Drug Use: Summarize if client used any substance in lifetime (e.g., cigarettes, marijuana, cocaine, etc.). Periods of sobriety and treatment (when, where and with whom); describe outcome of treatment.
d)
Sexual History: Describe sexual activity, sexual orientation, physical, sexual abuse (victim/offender). Explore if relevant to problem situation. It is appropriate to assess if client practices safe sex and receives regular physical check-ups. If client reports being diagnosed with sexual disease, it is appropriate to explore, medication received, primary physician, etc.
e)
Educational: Describe client’s educational background, highest level of degree attained. Difficulties in school (why, where, when); special education needs; suspensions. Include any informal educational skills. If client did not graduate from high school or received a GED, explore what barriers were present.
f)
Employment/Work History: Summarize client’s type of work; attitudes toward work, reasons for leaving or being fired from previous jobs. Also, include any voluntary work (e.g., community, church, etc.). Make sure to include any military experience and informal employment
g)
Recreational: Describe their activities or interest they enjoy, such as hobbies, sports, or leisure pursuits, special talents or skills. Are they involved in any church related activities (e.g., bible school, bible camp)?
h)
Cultural Family Norms: Describe cultural beliefs; rituals, patterns. Do they have family reunions or times when they come together (outside of marriages and funerals?
i)
Religious/Spiritual: Describe if client identifies with a particular religion or faith. Describe how client expresses spirituality. Describe client’s current and past religious and spiritual practices. Describe if client is associated with a place of worship. Describe if their religion or spirituality is helpful to them.
j)
Strengths and Competencies: Describe client/family strengths, capacities, abilities, competencies and resources that may help to address and resolve the issues of concern.
PRESENTING PROBLEM: Provide a concise clinical assessment of the presenting problem(s). You must complete a case formulation with preliminary diagnosis and justification as to why you selected these diagnoses. Justification for the identified diagnoses should be included and identified within the case summary.
D3. Intervention Plan for Client System
Create a master treatment plan to include goals and tasks to be completed.
(Make certain that you include who will do what and when.)
Students should include
at least three long-term goals, and two short-term goals (objectives) for each.
D4. Termination of Intervention with Client System
Describe the process and plan of a successful termination with the client system based on the EVIDENCE-BASED PRACTICE child welfare practice model
(WRAPAROUND – https://www.cebc4cw.org/program/wraparound/) utilized, (i.e., follow-up sessions, rituals, etc.,) Be specific and make certain that you include feelings and reactions that the client might experience and explain how you would address the feelings based on the practice model implemented.
E. Plan for Evaluating Effectiveness of Practice with Client System.
Outline a plan for evaluating the effectiveness of your intervention including the following:
1) Desired outcome(s) of intervention;
2) Measurement of outcomes;
3) Research approach used and rationale (quantitative, qualitative, or mixed method);
4) Research design used and rationale (single system, quasi experimental, etc.);
5) Process for collecting data on outcome measures;
6) Plan for analyzing data; and
7) How you will use the findings to improve your practice with this or similar clients in the future.
APPENDIX – References
Include a reference page in APA 7th edition format citing all sources used (e.g., theorists, authors).
PSYCHIATRIC – CERTIFICATE OF NEED
IDENTIFYING INFORMATION
Dewayne Lowe (DOB: 06/08/2010) is a 12-year-old African American right-handed male
who was admitted to Spring Grove Hospital Center (SGHC) on May 2022. He was
transferred from Charles H. Hickey, Jr. School (CHHJS), where he was admitted on May
2022, to SGHC pursuant to the court order from the Circuit Court for Baltimore County
Sitting as a Juvenile Court in May 2022 for a competency evaluation and in May 2022 for
emergency evaluation including psychiatric evaluation and medication reconciliation. The
court order stated: “The Respondent should return before the Circuit Court for Baltimore
County on June 2022.”
Dewayne has 12 counts of pending charges including Robbery with Dangerous Weapon;
Robbery; Assault-First Degree (x2); Assault-Second Degree (x2); Att-Dangerous Weapon-
Int/Injure; Dangerous Weapon: Conceal; Threat of Mass Violence; Theft: $100 To
Under $1,500; Malicious Destruction Of Property/Value Less Than $1,000; and Animal
Cruel Fail: Provide from an alleged incident that occurred in May 2022.
CHIEF COMPLAINT
“Nothing.”
SOURCES OF INFORMATION
– SGHC records of Dewayne Lowe at SGHC, dated between May 2022 and June 2022.
Reliable.
– Phone interview with Dewayne Lowe’s maternal aunt, Dianna Moore, on multiple
occasions since Dewayne’s admission to SGHC in May 2022. Partially reliable.
– Records from Charles H. Hickey, Jr. School including emails, dated in May 2022.
Reliable.
– Court orders from the Circuit Court for Baltimore County Sitting as a Juvenile Court,
in May 2022. Reliable.
– State of Maryland Department of Health and Mental Hygiene Division of Vital Records,
Certificate of Live Birth, Date issued was in 2010. Reliable.
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– Psychiatric Evaluation from Catholic Charities Baltimore by OMHC Baltimore City
BARDS DSS team, dated in April 2022. Reliable.
– Psychiatric Evaluation completed in November 2017. Reliable.
– Baltimore City Public School records, dated between 2014 and 2019. Reliable.
HISTORY OF PRESENT ILLNESS
Dewayne was upset when he arrived at SGHC. He expressed frustration about the length of
time he spent in a van while transported from CHHJS to SGHC. When he entered SGHC
after completing a COVID-19 rapid test, he continued to express his frustration. He became
upset when he was given a mask to wear. He also did not want to comply with admission
photography and covered his face with his hands. When he was redirected to wear a mask before
entering the unit, Day B, he started cursing at staff members and threw a mask on the floor. It
was picked up by a staff member and when he was offered a mask again, he started becoming
agitated. Dewayne cursed at staff members, clenched his fists and made verbal threats to hurt
staff members. Due to ongoing agitation, more security officers came on the scene.
Dewayne then opted to don a facemask, but he remained upset.
Upon arrival to the unit, Dewayne continued to show agitation, using profanity and making
threats that he would hurt others. Because of ongoing agitation, he was offered as-needed
(PRN) medications (lorazepam-anxiolytic and chlorpromazine-antipsychotic) which he initially
refused but eventually accepted encouragement. Within couple of minutes of taking the
medications, he displayed a change in his behavior. He was more calm and pleasant. In
addition, he stopped using profanity and making threats to others. Instead, he was saying “thank
you” when a security officer brought him some snacks after Dewayne reported feeling
hungry. The admission assessment continued until he started feeling sedated from the
medications and went to nap.
Dewayne reported “I worry about her (mother) a lot” after he heard from her that she
was diagnosed with breast cancer while he was at CHHJS. Later, I found out, his mother
was not diagnosed with breast cancer by his guardian, Dianna Moore, who told me: “He
(Dewayne) is lying.” Ms. Moore reported Dewayne has difficulty telling being truthful. For
example, Dewayne stated his date of birth is June 8, 2008 on his birth certificate, when his actual
birth date is June 8, 2010. Dewayne also said his cousin died two years ago, which Ms. Moore
said was untrue. She clarified that the last time any family member was shot was in 2011
when Dewayne was a year old. Dewayne also reported he was living with his brother, who is
four years younger than him, in the community, but Ms. Moore stated his younger brother
never lived with Dewayne. She described Dewayne’s behavior as “he always lies… real bad
liar and manipulator.” Ms. Moore shared with me in November 2021, Dewayne reported her
boyfriend was trying to kill him with a gun, which she said, “none of that is true.”
Dewayne denied feeling depressed or having issues with sleep or appetite. Ms. Moore, however,
feels he has been showing some signs of sadness after his maternal grandmother, who lived with
Dewayne since age seven months, passed away when Dewayne was three years old. She pointed
out Dewayne has difficulty regulating his mood as he gets quickly angry and acts
aggressively. He previously reported to an evaluator at Catholic Charities Baltimore that he
struggles with anger.
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While Dewayne was at CHHJS, there were four restraints documented. In May 11, 2022,
Dewayne reported he felt “lied [to] and said COVID was over and it wasn’t” and he was
“becoming an imminent threat while in Douglas Hall.” He was subsequently placed in
restraint. On May 14, 2022, Dewayne “took their (staff) keys” and was restrained “due to
becoming an imminent threat to self and or others.” On May 17, 2022, Dewayne was restrained
“due to an imminent threat.” On May 18, 2022, Dewayne made an allegation toward DJS
staff and also was restrained “for becoming an imminent threat to self and/ or [sic] others.”
On May 21, 2022, Dewayne was not restrained but he “broke the Television on Douglas Hall
while youths [sic] were having leisure time.”
Psychiatric evaluation completed April 2022 noted “A certificate of need was provided in Feb
2022; however, DSS was unable to find the recommended placement.” Dewayne
“eloped from a treatment foster care placement as well as from his aunt’s home. There have
been countless incidents where he has been AWOL in the past few months.” When he is out of
home, he tends to engage in risky behavior such as “sexual activity, smoke cannabis, and
has attempted robbery. He has two active charges in Baltimore County for first degree
assault and armed robbery for an incident in which patient went into a grocery store with a
bebe gun with intent to rob them.” It was noted that Dewayne incurred several more theft charges
since the grocery store incident. In March 2022 he ran away from home and was not located until
April 2022 when Dewayne asked his DSS worker to pick him up in Hagerstown. He was placed
back with his aunt but ran away again a few days later. It was noted Dewayne “was placed on
punishment and smashed her car window with bricks. Following this event, he was caught on
camera stealing [a] package off of a friend’s porch.” In April 2022, he injured his shoulder while
he was trying to forcefully enter his aunt’s home by running into a door and self-presented to an
emergency room.
Dewayne’s aunt, Ms. Moore, reported he frequently ran away overnight from home and at times
went missing for days to weeks since age 10. Ms. Moore told me when Dewayne does not have a
place to go, he goes to a hospital emergency room, police station or “any type of
building.” There are about 20 to 30 police reports filed due to him running away from home.
One time, Dewayne went to Johns Hopkins Hospital emergency room and told a staff member
there that his aunt was parking a car and he had back pain. He was given Motrin and got
treated for it. Then, child protective service (CPS) was contacted as his aunt was not showing
up, as she was not there and she did not know about this. Ms. Moore stated Dewayne was
also asking “random people to see if he could stay” with them.
PAST PSYCHIATRIC HISTORY
Previous diagnoses: Dewayne was previously diagnosed with Attention-Deficit/
Hyperactivity disorder, Predominantly inattentive presentation; Unspecified Trauma- and
Stressor-Related Disorder; Oppositional Defiant Disorder.
Previous admission: Available record indicated in March 2022, Dewayne was hospitalized
at Johns Hopkins Hospital Bayview for 10 days after endorsing suicidal ideation. Dewayne’s
aunt stated, “I don’t exactly know what happened.”
Page 4 of 9
Previous suicide attempt: Dewayne never attempted suicide in the past.
Previous non-suicidal self-injurious behavior: Dewayne denied previous self-injurious
behavior and his aunt reported “I never seeing that myself.” Available records indicated in
March 2022, Dewayne was hospitalized at Johns Hopkins Hospital Bayview for 10 days after
endorsing suicidal ideation. Dewayne’s aunt stated, “I don’t exactly know what happened.”
Previous medication trials: Methylphenidate (Ritalin), Methylphenidate extended-release
(Concerta).
Previous outpatient treatment: Dewayne started receiving mental health services from
Baltimore Child & Adolescent Response System (BCARS) then moved to Villa Maria
school-based service. After the COVID-19 pandemic hit, he could no longer get
medications; thus, his pediatrician started prescribing methylphenidate extended-release
(Concerta, stimulant) 36 milligrams in the morning. Available records indicated Dewayne
was in BCARS three times in 2021. He was last admitted to BCARS in February 2022 and
received in-school therapy in fifth grade. When Dewayne was six years old, the school
recommended he see a mental health professional as he did “basically everything that [a]
child with ADHD did.” He was diagnosed with Attention-Deficit/Hyperactivity Disorder
(ADHD) and prescribed methylphenidate (stimulant). He initially had no behavioral issues
at home but at age 10 he started running away from home and “missing for weeks.” Ms. Moore
reported Dewayne never told her where he was staying.
Previous community placement: Dewayne was placed in the home of family members and
an unlocked residential treatment center (RTC). He has a history of eloping from the RTC
and leaving his family’s home without permission.
TRAUMA HISTORY
Previous physical, sexual, emotional abuse or neglect: Dewayne reported he does not like
people. He said his 16-year-old cousin was killed in 2020 after a gang member shot him
when “I was around a corner” from the incident. He noted feeling guilty as he feels “I wish I
was there.” He also noted witnessing a “shoot out” about four years ago when he was on his way
home.
Symptoms of trauma: Dewayne reported feeling hypervigilant and negative alteration of his
mood and cognition along with difficulty controlling his anger.
When I asked his aunt, Ms. Moore, about those incidents, she stated “never heard that before,
more than likely [a] lie.” She told me Dewayne struggles with telling the truth to others.
SUBSTANCE ABUSE HISTORY
Dewayne reported using marijuana and tobacco products since age eight. He reported
marijuana products make him feel “happy.” He also reported drinking hard liquors.
Page 5 of 9
SOMATIC HISTORY
Current medical concerns: None. Available records indicated Dewayne has a history of
eczema, dry skin and increased blood lead level. Dewayne was circumcised at age four.
History of traumatic brain injury: Dewayne does not have a history of traumatic brain
injury according to his legal guardian, Ms. Moore.
History of seizure: none.
ALLERGIES
Medication allergies: none.
Other allergies: none.
Medication or food intolerances: none.
Medications at the time of admission: none.
SOCIAL & DEVELOPMENTAL HISTORY
Birth and early development: Certificate of live birth indicated Dewayne was born with the
full name, Dewayne Allen Lowe Jr., on June 8, 2010 at 11:30pm from Jessica Olivia
Rand (mother) and Dewayne Allen Lowe (father). Mother’s age was 13 and father’s age was 19
when they gave birth to Dewayne.
Family dynamics: Dewayne was born and raised in Baltimore City. His aunt, Dianna
Moore, voiced concern that there is community violence and Dewayne is a follower and he
is easily influenced by others. Ms. Moore works as a manager at McDonald’s and she is
looking into transferring her job to North Carolina as this would be a better environment to raise
Dewayne.
Education: Dewayne was attending Commodore John Rodgers as a sixth grader. He has 504
for “behavior” issues but no individualized education program (IEP). He has been having more
days missing school than attending recently as he has been frequently running away from
home. When he was attending school consistently, he was getting average grades (Bs and Cs).
Records indicated he was suspended “’a lot’ for fighting peers, accidentally hit a teacher once.”
He also was suspended for threatening school staff and telling administrator he wished he
were dead. Dewayne reported he threw a boot at a school staff member’s head and was
suspended.
Social: Dewayne was living with his maternal aunt (mother’s maternal half-sister) in
the community. Dewayne stated he can obtain firearms in the community. Dewayne has two
younger siblings.
FAMILY HISTORY OF SOMATIC AND MENTAL ILLNESS
Page 6 of 9
Dewayne’s mother (bipolar disorder, ADHD, schizophrenia) and maternal
grandmother (depression, substance use) have mental health issues. Ms. Moore informed
that Dewayne’s maternal grandmother had “a lot of mental issues.” Available record indicated
there is a family history of cancer and high blood pressure.
LEGAL HISTORY
Dewayne reported his first legal contact was at age 10 for “credit card fraud, assault, possession
of fire arm.” Available records indicated Dewayne has two active charges in Baltimore
County for first degree assault and armed robbery for an incident in which he went into a grocery
store with a bebe gun with intent to rob them.
Dewayne was admitted to SGHC court ordered with 12 counts of pending charges
including Robbery with Dangerous Weapon; Robbery; Assault-First Degree (x2); Assault-
Second Degree (x2); Att-Dangerous Weapon-Int/Injure; Dangerous Weapon: Conceal; Threat of
Mass Violence; Theft: $100 To Under $1,500; Malicious Destruction Of Property/Value Less
Than $1,000; and Animal Cruel Fail: Provide from an incident that happened on 5/9/2022.
SGHC – HOSPITAL COURSE
Dewayne was admitted to the SGHC Adolescent Unit in May 2022 and he is going through
evaluations from the following disciplines: psychiatry, psychology, somatic medicine, nursing,
social work, recreational therapy, and occupational therapy.
Mental status on admission:
Dewayne was awake and alert during the interview process. He was oriented to place, time,
and person based on his ability to correctly state today’s month, today’s year, the name of
“crazy hospital” and his DOB.
He was wearing detention-issued clothes and shoes. He had fair personal hygiene and grooming.
He appeared younger than his biological age based on his short stature and slim body. His gait
was stable and he did not appear having any abnormal muscle movement (AIMS was
zero). Initially, Dewayne was oppositional by refusing to comply with wearing a mask, using
profanity at security officers and glaring at staff members. However, after receiving as-
needed (PRN) medication for agitation, he started engaging in the interview properly and his
demeanor was calm with intermittent eye contact.
Dewayne’s speech was regular rate and rhythm without any difficulties with articulation.
His thought process was goal directed and linear without any disorganization. He
denied experiencing any thoughts to harm self or others (Suicide Behaviors Questionnaire-
Revised Plus 2, SBQR-2 was 3). He denied paranoia or ideas of reference. However, he
exhibited behavior that would indicate hypervigilance based on him constantly assessing any
threats around him and not liking to have anyone where his back is facing. He did not appear
having any perceptual disturbances and denied experiencing any hallucination.
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Dewayne had an intact ability to register for three objects (penny, table, cat), which indicates
his immediate memory was intact. He exhibited deficient short-term memory based on his ability
to only recall one out of three objects (penny) in five minutes. His long-term memory
appeared intact as he was able to recall the names of a couple of past presidents: “Donald
Trump” and “Barack Obama.” He was able to tell me the name of the current president.
Dewayne’s judgment was poor based on his answer (“I’m gonna pick it up and see if money
in there”) when I asked him “What would you do if you find a stamped, addressed and
sealed envelope on a sidewalk?” His insight appeared poor as he did not seem to understand
reasons for his admission to SGHC.
Dewayne did not answer when I asked him how he feels (just glaring at me). His affect was
angry and upset, but this improved after he was given with PRN medications. He was not
able to perform serial 7s (subtracting 7 from 100 and keeps subtracting 7 from the previous
answer) as his answer was “ninety something” when he subtracted seven from 100. He was
able to spell ‘WORLD’ forward but not backward (he spelled it DLORW). His abstraction
ability was not able to be tested as he started feeling sedated from PRN medications given to
him.
Behavioral:
Upon admission, Dewayne was placed on one-to-one staff observation for COVID-19
admission quarantine and threat to hurt others. The day after he was admitted, SGHC
received an email from his DJS worker that his COVID-19 PCR testing, which was performed
in May 2022, came back positive. Thus, Dewayne was placed on quarantine. Dewayne
struggled wearing a mask properly over his nose and maintaining distance from other peers.
After he completed with COVID-19 admission quarantine, he continued on one-to-one
staff observation for making threats to hurt others.
Dewayne’s behavior was described as “oppositional, defiant, rude and disrespectful to staff for
the most part of the shift. He was rude during rehab group, cursed staff walked back to the unit.”
His interaction with other peers was “negative” as he was “cursing and rude to staff.”
Dewayne gets upset when redirected. He was also making a gun gesture with his hand at a
charge nurse. When he was redirected for such behavior “patient became verbally and
physically aggressive posturing in manner to attack staff.”
Dewayne was restrained six times since his admission to SGHC: May 27, May 28, May 29,
May 31, June 5 and June 8. On May 27, he became very agitated and refused to
follow any redirections along with not complying with mask wearing. On May 28, Dewayne
was agitated and not complying with wearing a mask. On May 29, he was not following
redirections and wanted to stay in the hallway and did not comply with mask wearing (he was
COVID-19 positive) and was close to another peer, cursing at staff members and made a
threat to “fuck them (staff members) up.” On May 31, Dewayne became upset when staff
could not locate a movie. He kicked trash, threw a food tray, broke a pay phone and threatened
to hit staff. On June 8, he was restrained after throwing a plastic chair, posturing at a staff
member and making threats to hurt
Page 8 of 9
staff. He received oral as needed medications including lorazepam 1mg, olanzapine 5mg, and
diphenhydramine 50mg.
Medication history:
Dewayne was not prescribed any medications while at the detention center. Upon admission
to SGHC, he was not prescribed any medication to assess his clinical symptoms. When he was
seen in milieu, he was struggling with ADHD symptoms including inattention,
hyperactivity and impulsivity. Verbal consent was obtained from his guardian and
Methylphenidate 5 milligram was initiated. Dewayne has been verbalizing not wanting to
take his medications stating his mother would not want him on any medications. When I
called his guardian, she told me there was no conversation with Dewayne about his
medication and she would like Dewayne to take his medications as she feels medications do
help him with his behaviors. He was observed once to spit out his medication; thus he was
ordered to have a mouth checks with each medication administration.
DIAGNOSES
PRIMARY PSYCHIATRIC DISORDERS
Disruptive Mood Dysregulation Disorder (DMDD)
Attention-Deficit/Hyperactivity Disorder, combined presentation (ADHD)
Posttraumatic Stress Disorder (PTSD)
Conduct Disorder, Childhood onset
PERSONALITY DISORDERS
None
SUBSTANCE-RELATED DISORDERS
Cannabis Use Disorder
Tobacco Use Disorder
Alcohol Use Disorder
OTHER MEDICAL CONDITIONS
History of elevated blood lead level
History of dry skin
History of Eczema
RECOMMENDATIONS
1.Dewayne has primary psychiatric diagnoses of Disruptive Mood Dysregulation Disorder
(DMDD); Attention-Deficit/Hyperactivity Disorder, combined presentation (ADHD);
Page 9 of 9
Conduct Disorder, Childhood onset; Posttraumatic Stress Disorder (PTSD); Cannabis
Use Disorder; Tobacco Use Disorder; and Alcohol Use Disorder.
2. In light of available aftercare options and in considering the least restrictive clinically-
appropriate option, Dewayne should be released to the care of a residential treatment
center (RTC) where he would receive intensive mental health care services
including medication management. The program should emphasize anger management,
treatment of oppositional behaviors, and have a substance abuse treatment component.
Considering his PTSD diagnosis, individual trauma therapy is recommended. Family
therapy would be appropriate to provide Dewayne’s guardian with resources and
education to provide structure and discipline at home once he is released into the
community.
3. Dewayne should meet with a psychiatrist on a regular basis. He is currently
prescribed methylphenidate 5 milligrams in the morning and methylphenidate 5
milligrams at 1pm.
4. Dewayne should see a primary care provider for regular monitoring of his
physical wellness and prior history of elevated blood lead level, dry skin and
eczema. While Dewayne was at SGHC, he did not require any medications for somatic
conditions.
5. Dewayne should return to his grade appropriate education. Dewayne was
attending Commodore John Rodgers as a sixth grader. He has 504 for “behavior” issues.
6. Dewayne would benefit from male mentor who can guide him to healthier ways to
manage his anger and encourage him to engage in prosocial behaviors.
Catholic Charities
Psychiatric Evaluation
Client Name: Lowe, Allen, Dewayne Client ID: Status: Show
Clinician Name: Service:
Date Of Service: April 2022 Start Time: 3:19 PM
BCARS Psych Eval
End Time: 3:41 PM Duration: 22.00 Minutes
Team:
Location: Specific
Location:
Comment:
OMHC Baltimore City BCARS DSS
HOME BCARS DSS OMHC
Therapist:
D/C Date: May 2022
Mode of Delivery: Face to Face
County: School:
Makeup Date: Makeup Session Duration:
Makeup Type:
General
Chief Complaint:
“We are still trying to get a certificate of need.”
Course of Present Illness:
This session is being provided through home-based telehealth with verbal consent. The location was verified, and the phone
number was confirmed in case of a technical issue. No other parties except the client and/or guardian were present.
Patient presents today accompanied by DSS worker, Mr. Purple, for evaluation for a certificate of need. A certificate of
need was provided by this author in Feb 2022; however, DSS was unable to find the recommended placement. Since last
seen by this author, patient has eloped from a treatment foster care placement as well as from his aunt’s home. There
have been countless incidents where he has been AWOL in the past few months. Mr. Purple reports that patient tends to
engage in risky behaviors when AWOL. He will engage in sexual activity, smoke cannabis, and has attempted robbery. He
has two active charges in Baltimore County for first degree assault and armed robbery for an incident in which patient went
into a grocery store with a bebe gun with intent to rob them. He has incurred several more theft charges since then, the
last of which occurred in March 2022. That same day, patient ran away and was not located until April 2022. He called his
DSS worker from Hagerstown asking to be picked up. He was placed back with his aunt at that time. He did well for a few
days and then left without permission overnight. He got upset when he was placed on punishment and smashed her car
window with bricks. Following this event, he was caught on camera stealing package off of a friend’s porch. Patient’s latest
episode of dangerous behavior occurred yesterday during which he injured his shoulder trying to forcibly enter his aunt’s
home. He self-presented to the ED after this event.
During interview today, patient alleges he injured his shoulder by carelessly running into a door. He reports his mood has
been “good”. Admits to struggle with anger but states “I’m good” when asked for further detail. Denies any suicidal or
homicidal ideation. He has been doing “ok, not ok”. Denies any anxiety symptoms. Reports focusing well. Patient was
irritable and impatient during session. He was guarded and in a rush to complete the appointment as he wanted to go to
lacrosse practice. Provided few details when asked for updates on how he has been doing in the past few months. He has
been off of medication and out of treatment since last seen by this author due to multiple unsuccessful attempts to maintain
him in any one placement in the community. Patient was evaluated in the Johns Hopkins emergency room at Bayview. He
was recommended for residential treatment placement; however, he eloped from the interview from a unlocked RTC facility
in which DSS was hoping to place him.
Client ID: Page 1 of 5
Page 1 Printed on: 04/21/2022Page 1 Printed on: 04/21/2022
History
Past Psychiatric History, Treatment Providers, Past Medications and Hospitalizations:
Inpt: EP in Dec 2021, JHH Bayview ED visit for 10 days for suicidal ideation March 2022 (voiced when police picked
him up for the second time after he eloped from a different aunt’s home) was referred to an RTC, eloped from the
interview at a non-secure residential treatment center
Outpt: BCARS three times in the past, last BCARS admission 2/2022, in-school therapy in 5th grade
Med trials: Ritalin, concerta (max dose 36mg)
Diagnoses: ADHD
Past SI/SIB: denies
Family History:
Mother- bipolar, schizophrenia, ADHD
Maternal grandmother- depression, substance use disorder
History of severe cardiac disease or MI under the age of 40?:
none
Psychosocial History:
Born and raised: Removed from mother’s care at birth (mother was 13). Raised by maternal aunt until Dec 2021 as he
reported aunt’s boyfriend held gun to his head, threatened to harm him, and hit him in the chest. Has been in foster
care since Dec 2021, has had 5 placements (one of which was emergency placement) in the past month. Currently
living with a different maternal aunt who has raised him “off and on” throughout his life, per her report. No contact
with bio parents
Lives with: placed wit aunt most recently but threw brick through her car window when he got into trouble for not
following rules a few days ago, whereabouts since then is unknown as patient ran away
Parent info: mother- 26, education and employment details not known; father- 31, no other information available
Siblings: maternal half- brother- 8, maternal half-sister- 9
Sexual History: partner of 3 months, heterosexual, denies history of sexual activity
Substance Abuse:
Cigarettes/e-cigarettes/juuling: denies
Alcohol: denies
Prescription Medication Abuse: denies
Illicit Substances: DSS worker reports patient has admitted to cannabis use
Trauma history as obtained during Feb 2022 evaluation: “Yeah, but I don’t want to talk about it” august 2021,
endorses flashbacks, avoidance. Denies nightmares, increased startle and hypervigilance. Irritable once per week
when they talk about his family.
Legal: several active charges for assault and theft
CPS/DSS involvement: patient in DSS custody, most recent CPS involvement due to patient reporting sexually
inappropriate behavior by foster father, CPS report made by BCARS 4/2017 for patient alleging aunt’s boyfriend hit
him with a belt, punched him in the leg, and hit him in the head, also reported aunt hit him with a belt
Medical History:
Allergies: none
Medications: none
PCP: saw a doctor Jan 2022 for well-child check, unremarkable exam
Diagnoses: none
History of surgeries?: none
History of Seizures?: none
History of head trauma with loss of consciousness?: none
History of heart murmurs or arrhythmias?: none
History of dyspnea on exertion or unexplained syncope?: none
Developmental History:
Client ID: Page 2 of 5
Page 2 Printed on: 04/21/2022Page 2 Printed on: 04/21/2022
Planned pregnancy?: unknown
Birth weight: 6lb 12oz
Complications with pregnancy: unknown if there were intrauterine exposures, mother had chlamydia while pregnant, no
known complications, unknown if mother received routine prenatal care
Complications with delivery: full-term, vaginal delivery, no complications
NICU: none
Milestones on time: yes
Educational History:
School: Commodore John Rodgers, 6th grader, patient reports he likes school as he likes all of his classes
Current Academic Performance: sporadic attendance due to frequently AWOL, likely failing currently per Mr. Purple,
previously made average grades (Bs and Cs) when attending school consistently
IEP/504: none currently
History of suspensions/expulsions: suspended “a lot” for fighting peers, accidentally hit a teacher once, often suspended
for AWOL, has been suspended for threatening school staff and telling administrator he wished he were dead
History of being held back/skipping a grade: none
Bullying?: none
Medications Reconciled on this Date
Current Medications
Drug Name Instruction Special
Instructions
Start End Refills Prescriber
Self-Reported Medications
Drug Name Instruction Special
Instructions
Start End Refills Prescriber
Discontinued Medications
Drug Name Instruction Special
Instructions
Start End Refills Prescriber
CONCERTA
36mg, TR24, Oral 1.00
each Morning
02/03/2022 0.00
Current Medications
No Medications
Substance Use History
Is substance use
a concern? Yes
Marijuana/CBD smokes cannabis
Family History Of Addiction:
maternal grandmother, per records
Triggers/Cues To Use Substances:
none reported
Current/Past Treatment:
none
Exam
Complete Mental Status Exam
Mental Status Examination:
Appearance: WNL
Client ID: Page 3 of 5
Page 3 Printed on: 04/21/2022Page 3 Printed on: 04/21/2022
Grooming: WNL
Hygiene: WNL
Psychomotor Activity: WNL
Behavior: Guarded, Withdrawn
Affect/Mood: Irritable
Speech: Rate: WNL
Rhythm: Normal prosody
Volume: WNL
Thought Process: Logical, Goal directed intact associations
Thought Content: Appropriate
Orientation and Memory: Alert,Oriented to person place time and situation
Insight and Judgment: Denies problems, Impaired judgment, Poor impulse control, Poor decision making
Cognition: WNL
Knowledge Base: Appropriate to age
Self Harm: No thoughts, plans or intentions
Has the individual reported any changes in risks or protective factors related to suicide? No
Harm to Others: No thoughts, plans or intentions
Harm To Others Comments :
Participant Strengths:
Assessment/Formulation:
11yoM presenting with worsening behaviors that are a significant safety risk to himself and the community. He continues
to struggle with impulsivity and agitation in the setting of untreated ADHD and possible trauma-related disorder (such as
PTSD). Attempts to safely maintain him in the community have been unsuccessful. While patient does not present as an
acute risk warranting inpatient hospitalization at this time, he is currently failing all outpatient services and demonstrating
evidence of decline in functioning (recent psychiatric ED eval, new legal charges, continued AWOL behaviors).
Recommendations and Treatments:
Recommending placement in a diagnostic facility due to escalating dangerous behaviors, inability to engage patient in
consistent treatment due to frequent disappearances, and need for diagnostic clarification. Patient currently presents as a
danger to himself due to persistent behaviors (running away, traveling long distances unattended, speaking to strangers)
that put him as risk in the community. His impulsivity, possibly due to his suboptimally treated ADHD in the setting of poor
medication compliance, has contributed to behaviors such as aggression towards teachers, theft, and property destruction
that put those around him at risk. There is concern that his history of untreated trauma has influenced his behaviors (as
evidenced by reports of patient touching a younger female child inappropriately in a previous placement) and previously
reported symptoms (flashbacks, avoidance). Attempts to manage his symptoms and behaviors at an outpatient level have
been unsuccessful, mostly due to his frequent running away and low treatment compliance. There are no acute safety issues
that warrant inpatient hospitalization at this time. Patient would benefit from 24/7 supervision and assessment in a
diagnostic facility to better understand his symptoms and determine the appropriate treatment. Additionally, he would
benefit from a trauma evaluation along with trauma- focused therapy.
Diagnosis
Client ID: Page 4 of 5
Page 4 Printed on: 04/21/2022Page 4 Printed on: 04/21/2022
Additional Information
Screening Tools Used
Other General Medical Conditions
Level of Functioning Score
Unspecified trauma- and stressor-related disorder
DSM5/ICD10 F43.9 DSMIV/ICD9 309.9 SNOMED 102497008
ICD/ DSM
Description
Unspecified trauma- and stressor-related disorder
Remission Specifier Type Primary
Source Severity Order 1
Rule Out No Billable Yes
Oppositional defiant disorder
DSM5/ICD10 F91.3 DSMIV/ICD9 313.81 SNOMED 18941000
ICD/ DSM
Description
Oppositional defiant disorder
Remission Specifier Type Additional
Source Severity Order 2
Rule Out Yes Billable Yes
Attention-deficit/hyperactivity disorder, Predominantly inattentive presentation
DSM5/ICD10 F90.0 DSMIV/ICD9 314 SNOMED 31177006
ICD/ DSM
Description
Attention-deficit/hyperactivity disorder, Predominantly inattentive
presentation
Remission Specifier Type Additional
Source Severity Medium Order 3
Rule Out No Billable Yes
Psychosocial, Environmental, and Other Factors
Comments
GAF Score
WHODAS Score
CAFAS Score
Clinician: Signature Date: 04/20/2022
Client ID: Page 5 of 5
Page 5 Printed on: 04/21/2022Page 5 Printed on: 04/21/2022
36
The Professional Counselor™
Volume 12, Issue 1, Pages 36–48
http://tpcjournal.nbcc.org
© 2022 NBCC, Inc. and Affiliates
doi: 10.15241/gth.12.1.36Gregory T. Hatchett
Treatment Planning Strategies for Youth With
Disruptive Mood Dysregulation Disorder
The addition of disruptive mood dysregulation disorder (DMDD) to the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) was a controversial decision in 2013 and one that continues
to the present. Researchers have found that DMDD exhibits both poor interrater reliability and discriminant
validity from other common childhood-onset disorders, most notably oppositional defiant disorder (ODD).
Research also indicates that DMDD might be better conceptualized as a component of ODD, and consistent
with such a conceptualization, experts have recommended that effective treatments for ODD be applied to
youth who fit the diagnostic pattern of DMDD. The purpose of this article is to help readers understand the
problematic diagnostic validity associated with DMDD and to present recommended treatment strategies for
working with youth who fit this challenging symptom profile.
Keywords: disruptive mood dysregulation disorder, oppositional defiant disorder, conceptualization,
diagnostic validity, youth
A pattern of emotional and behavioral dysregulation—characterized by severe irritability, temper
outbursts, and aggressive behavior—is one of the most common reasons that children and adolescents
are referred to mental health service providers (Axelson et al., 2012; Brotman et al., 2017; Stringaris et al.,
2018) and a common antecedent to inpatient hospitalization (Chase et al., 2020; Rao, 2014). Despite the
prevalence and severity of these associated symptoms, mental health professionals have often disagreed
as to how children and adolescents who fit this symptom profile should be conceptualized and properly
diagnosed. Over the years, chronic irritability and temper dysregulation have been conceptualized as
associated features of externalizing disorders (Carlson, 1998), developmental variations of early-onset
bipolar disorder (Biederman et al., 2000), and core features of an experimental research phenotype
(Leibenluft et al., 2003; Rich et al., 2005; Stringaris et al., 2010).
In 2013, the American Psychiatric Association (APA) provided a new diagnostic home for youth
with chronic and severe irritability in the depressive disorders chapter in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013). This new disorder—disruptive
mood dysregulation disorder (DMDD)—was specifically added to the DSM-5 to prevent clinicians from
overdiagnosing a bipolar and related disorder in children and adolescents who exhibited non-episodic
irritability and temper outbursts. Beginning in the 1990s, there began an exponential increase in the
number of children and adolescents who were diagnosed with bipolar disorder. As just one example
of this pattern, Moreno et al. (2007) reported a 40-fold increase of the number of outpatient office visits
for children and adolescents treated for bipolar disorder between 1995–1996 and 2002–2003. Not only
was this increase unusual from an epidemiological perspective (Van Meter et al., 2011), but researchers
also began to accumulate evidence that these youth did not match the profile of either youth or adults
with traditional bipolar disorder (Leibenluft, 2011; Towbin et al., 2013). To better characterize children
and adolescents who exhibited chronic irritability and temper outbursts, researchers at the National
Institute of Mental Health (Leibenluft et al., 2003) developed a new diagnostic phenotype, severe
emotional dysregulation (SMD), to differentiate this symptom pattern from traditional bipolar disorder.
SMD subsequently became the foundation for the inclusion of DMDD in the DSM-5 (APA, 2013).
Gregory T. Hatchett, PhD, NCC, LPCC-S, is a professor at Northern Kentucky University. Correspondence may be addressed to Gregory T.
Hatchett, MEP 211, Highland Heights, KY 41099, hatchettg@nku.edu.
mailto:hatchettg@nku.edu
The Professional Counselor | Volume 12, Issue 1
37
Many experts disagree about DMDD as a valid and coherent diagnostic category. However, there
seems to be a strong consensus that many children and adolescents are severely impaired because of
chronic irritability and severe temper dysregulation (Copeland et al., 2014; Rao, 2014). Although early
estimates indicate that only 1%–3% of children and adolescents may meet the full diagnostic criteria for
DMDD (Copeland et al., 2013), many more may present with at least subthreshold symptoms of the
disorder (Baweja, Mayes, et al., 2016; Freeman et al., 2016). Thus, counselors, especially those working
in clinical settings, will likely find themselves working with many children and adolescents who
exhibit symptoms of DMDD, symptoms which need to be carefully evaluated as part of any differential
diagnostic process. To provide the best possible services for this population, counselors need to be
familiar with the current literature on both the diagnosis and treatment of DMDD. Consequently, this
article summarizes these current DMDD topics and presents treatment recommendations for working
with youth diagnosed with DMDD. Because it is important for counselors to understand the questionable
diagnostic validity of DMDD and how these diagnostic limitations should inform the treatment planning
process, this topic will be preceded by criticisms of DMDD as a valid mental disorder. Also discussed are
the challenges of diagnosing youth who present with chronic emotional and behavioral dysregulation.
The Diagnosis of DMDD
The diagnostic criteria and decisional rules for DMDD in the DSM-5 (APA, 2013) are rather detailed,
so only a summary will be provided here. (Readers should consult pages 156–160 in the DSM-5 for
more detailed information.) The core diagnostic features for DMDD include recurrent (3 or more times
a week) temper outbursts that are developmentally inappropriate, severe, and disproportionate to
any identifiable stressor along with the persistence of a chronically irritable or angry mood between
these temper outbursts—a disruption in mood that is noticeable by others. These symptoms must have
begun before the age of 10, persist for a minimum of a year (with no more than 3 consecutive months
of symptom-free periods), and be present in at least two out of three settings (i.e., home, school, peer
relationships). According to the DSM-5, this diagnosis should not be made if these symptoms occur
exclusively during a major depressive episode or if the symptoms are better explained by another
mental disorder, such as autism spectrum disorder. Also, a diagnosis of DMDD cannot be given
concurrently with oppositional defiant disorder (ODD), bipolar disorder, or intermittent explosive
disorder. If a child meets the diagnostic criteria for both DMDD and ODD, only DMDD should be
given. As mentioned previously, DMDD was specifically added to the DSM-5 to prevent clinicians
from overdiagnosing bipolar and related disorder in children and adolescents who exhibit non-
episodic irritability and temper outbursts. However, at first glance, a youth who meets the diagnostic
criteria for DMDD may be suspected of having a bipolar and related disorder. Thus, it is important for
counselors to recognize the fundamental differences between the two disorder classifications.
As explained above, in DMDD, a child or adolescent experiences non-episodic irritability that is
punctuated by severe and disproportionate temper outbursts. This symptom presentation must
occur for at least 365 days, and during the year, have no more than a 3-month period in which the
child or adolescent does not experience the core features of the disorder. In contrast, youth who meet
the diagnostic criteria for bipolar disorder experience distinctive episodes of mania (at least 7 days),
hypomania (at least 4 days), or depression (at least 14 days). Although irritability and temper outbursts
can certainly occur in the context of a manic or hypomanic episode, there are additional symptoms that
must also be present. Specifically, the irritability or temper outbursts should be episodic, accompanied
by an increase in goal-directed activity/energy, and include additional symptoms, such as grandiosity,
decreased need for sleep, pressured speech, racing thoughts, or reckless impulsivity (APA, 2013). More
information on the differential diagnosis of bipolar disorder from DMDD and other conditions can be
found in Hatchett and Motley (2016).
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The Professional Counselor | Volume 12, Issue 1
Diagnostic Validity of DMDD
Many have argued that adding DMDD to the DSM-5 traded one problem—overdiagnosis of bipolar
disorder—for another: a poorly conceptualized diagnostic construct lacking any evidence-based
treatments (e.g., S. C. Evans et al., 2017; Freeman et al., 2016; Parker & Tavella, 2018). As Malhi and Bell
(2019) recently observed, “more than half a decade later, the ‘creation’ of this new diagnostic entity
[DMDD] has not provided any novel insights or greater understanding and is yet to demonstrate any
tangible benefits” (p. 706).
Though DMDD has been criticized for its poor interrater reliability (Regier et al., 2013) and low
temporal stability across time (e.g., Axelson et al., 2012), the strongest criticism of DMDD has been
directed toward its standing as an independent and coherent diagnostic construct, a concern that
was not only present at the time of its introduction in the DSM-5, but one that has been bolstered by
subsequent research since the publication of the DSM-5 in 2013. Ironically, the evidentiary basis for
including DMDD in the DSM-5 was not based on studies of children and adolescents who actually
matched the specific diagnostic criteria for DMDD. Instead, the research support for DMDD was
inferred from research conducted on SMD (Baweja, Mayes, et al., 2016; Bruno et al., 2019; Rao, 2014;
Towbin et al., 2013). As mentioned previously, the phenotype of SMD was developed by researchers
at the National Institute of Mental Health (Leibenluft et al., 2003) to provide an alternative
conceptualization to bipolar disorder for youth who exhibited chronic and severe irritability, temper
dysregulation, and hyperarousal. However, there are important differences between the diagnostic
criteria for SMD and DMDD. Compared to the diagnostic criteria for DMDD, SMD includes different
age parameters, the presence of an abnormal mood characterized by anger or sadness, different
exclusion criteria, and most importantly, the presence of hyperarousal (e.g., insomnia, agitation,
distractibility; Leibenluft, 2011). As S. C. Evans et al. (2017) pointed out, “Given the differences
between the operationalization of SMD in the literature and the definition of DMDD, virtually no
evidence regarding DMDD existed at the time of its inclusion in DSM-5” (p. 33).
Consistent with these differences, researchers have found low levels of correspondence between
the two syndromes. For example, Copeland et al. (2013) reported that only 38.9% of those who met
the criteria for SMD also met the diagnostic criteria for DMDD. These differences have important
implications for the treatment planning process. Specifically, it is unclear whether any of the
interventions that have been found to be helpful for youth with SMD (e.g., Towbin et al., 2020) will
generalize to youth who match the different diagnostic profile for DMDD (Benarous et al., 2017).
Furthermore, since the publication of the DSM-5 in 2013, researchers have increasingly challenged
the validity of DMDD as a stand-alone diagnostic construct (Freeman et al., 2016). For one, there
is very little evidence to suggest that DMDD can be reliably differentiated from other common
childhood-onset disorders (S. C. Evans et al., 2017; Malhi & Bell, 2019). Several of the core symptoms of
DMDD—chronic irritability and recurrent temper outbursts—are not exclusive to DMDD, but rather
represent transdiagnostic symptoms often present in many other disorders, such as ODD, generalized
anxiety disorder, depression, autism spectrum disorder, bipolar disorder, and post-traumatic stress
disorder (e.g., Stringaris et al., 2018). As Parker and Tavella (2018) pointed out, “Those who meet
the criteria for DMDD may in fact have a conduct disorder, ODD, attention deficit hyperactivity
disorder (ADHD), or any of myriad other behavioral disorders” (p. 815). However, on the one hand,
the diagnostic criteria for DMDD in the DSM-5 is very extensive and detailed, especially compared to
what is commonly delineated for many other disorders in the DSM-5. Clinicians who carefully follow
these detailed criteria and decisional rules should, in theory, arrive at valid and reliable diagnoses of
The Professional Counselor | Volume 12, Issue 1
39
DMDD. Yet, in real practice, the diagnostic process is often plagued by careless errors and clinician
biases (Garb, 1998; Lacasse, 2014). Consequently, the issue becomes how well clinicians can apply
these criteria in often complex clinical situations.
More research is needed on how well counselors and other clinicians can reliably diagnose DMDD
and differentiate it from other conditions in ordinary practice settings. Concerns about the diagnostic
validity of DMDD have been most pronounced in the differentiation of DMDD from ODD. In the
DSM-5 (APA, 2013), a diagnosis of DMDD automatically supersedes a diagnosis of ODD; thus,
these two diagnoses cannot be given concurrently. However, when researchers have removed this
exclusionary rule, they have found that nearly all the children and adolescents who met the diagnostic
criteria for DMDD also met the diagnostic criteria for ODD (Axelson et al., 2012; Freeman et al.,
2016; Mayes et al., 2016). As just one example, Mayes, Waxmonsky, et al. (2015) reported that 91%
of the children who met the criteria for DMDD in their study also qualified for a diagnosis of ODD.
However, the reverse is not true. Researchers have found that diagnoses of ODD commonly occur
in the absence of DMDD. Approximately one-third of children and adolescents who meet diagnostic
criteria for ODD do not have significant symptoms of DMDD (Mayes et al., 2016).
According to the hierarchy or parsimony principle in the DSM-5 (APA, 2013), a clinician should
diagnose the most severe disorder that best captures the multitude of symptoms that a client is
experiencing instead of adding on several more minor diagnoses to the diagnostic record. For
example, children and adolescents who meet the diagnostic criteria for autism spectrum disorder
simultaneously meet the diagnostic criteria for social communication disorder. Therefore, an
additional diagnosis of social communication disorder is unnecessary. Likewise, in the DSM-5, a
diagnosis of DMDD is higher on the diagnostic hierarchy than ODD, and thus many of the symptoms
of ODD are subsumed under a diagnosis of DMDD. For clinicians who carefully follow the diagnostic
rules of the DSM-5, both negative affectivity and oppositional behavior can be recognized and targeted
as part of a treatment plan for a youth with DMDD.
For an alternative point of view, some researchers have expressed the concern that a single,
overruling diagnosis of DMDD will fail to adequately acknowledge the behavioral problems
associated with ODD, resulting in suboptimal treatment planning decisions (S. C. Evans et al., 2017;
Mayes et al., 2016). Mayes et al. (2016) pointed out that a diagnosis of DMDD fails to acknowledge
many of the disruptive behavioral components of ODD that are nearly always present in children and
adolescents who meet the diagnostic criteria for DMDD. Likewise, S. C. Evans et al. (2017) argued that
treating DMDD as a Depressive Disorder—and withholding a diagnosis of ODD,
per DSM-5 hierarchical rules—may lead clinicians to conceptualize these youth as
having a mood disorder rather than a behavior disorder. For primary care providers
and pediatricians, treating DMDD as a mood disorder and removing the ODD label
may both decrease referrals for behavioral interventions that are well established
(e.g., parent management training) and increase the administration of psychotropic
medications such as antidepressants, antipsychotics, and mood stabilizers, for which
evidence is limited. (p. 39)
However, the concerns just mentioned may reveal more about problems in the correct use and
application of the DSM-5 by clinicians rather than problems inherent in diagnostic rules prescribed
by the DSM-5.
40
The Professional Counselor | Volume 12, Issue 1
Because of the transdiagnostic nature of DMDD symptoms (e.g., Parker & Tavella, 2018), several
experts have recommended that DMDD be recognized as either a subtype or specifier under other
DSM-5 diagnoses (Mayes, Mathiowetz, et al., 2015), most often as a subtype or specifier under ODD
(S. C. Evans et al., 2017; Malhi & Bell, 2019; Mayes et al., 2016; Mayes, Waxmonsky, et al., 2015). This
was the approach recently taken by the World Health Organization (2019) in the 11th edition of the
International Statistical Classification of Diseases and Related Health Problems (ICD-11). In the ICD-11,
clinicians have the option to diagnose a youth with oppositional defiant disorder with or without
chronic irritability-anger. Thus, this diagnostic code allows clinicians to concurrently recognize both
symptoms of emotional dysregulation and symptoms of argumentative, oppositional, and vindictive
behavior. However, at the time of this writing, the ICD-11 has not been adopted in the United States,
so counselors in the United States are still using the DSM-5 (APA, 2013) and the ICD-10 (World
Health Organization, 2016).
On the other hand, some have cautioned against the use of DMDD as only a subtype or specifier
under ODD (e.g., Benarous et al., 2017; Stringaris et al., 2018). Brotman et al. (2017) expressed the concern
that many clinicians do not record available specifiers in diagnostic records, and consequently, children
and adolescents who are diagnosed with ODD under the DSM-5 might not receive targeted interventions
for symptoms of severe irritability and temper outbursts. At the very least, perhaps clinicians should be
allowed to diagnose DMDD and ODD concurrently.
Another concern in the differential diagnosis of DMDD is potential racial/ethnic bias. As a depressive
disorder in the DSM-5 (APA, 2013), DMDD is conceptualized as an internalizing disorder, whereas ODD
is conceptualized as an externalizing or disruptive behavior disorder. Researchers have found that African
American youth are more likely to be diagnosed with externalizing disorders, whereas European
American youth are more likely to be diagnosed with internalizing disorders (e.g., Fadus et al., 2020;
Minsky et al., 2006). Though this research has not yet been replicated specifically in the diagnosis of
DMDD, prior research indicates that African American youth may be less likely to be identified as having
DMDD and may not receive adequate treatment for potential depressive symptoms. Furthermore,
researchers have found that African Americans and other minority groups who experience higher
rates of racial/ethnic discrimination also experience more mental health and psychosocial functioning
difficulties compared to those with lower experienced rates of racial/ethnic discrimination (Tobler et
al., 2013). Consequently, counselors should evaluate the extent to which irritability and aggression
among minority youth are associated with experiences of discrimination as opposed to internal
psychopathology implicit in the DSM framework (e.g., Carter et al., 2019; Mouzon et al., 2017).
Treatment Planning Strategies
Diagnostic Considerations
Certainly, the main source of information for the proper diagnosis of DMDD is the explicit
diagnostic criteria and decision rules in the DSM-5 (APA, 2013). To document these diagnostic
criteria, counselors might consider using one or more of the cross-cutting measures included in
Section III of the DSM-5 (pp. 733–741). Outside the DSM-5, there are currently few diagnostic
tools for counselors to use in confirming a diagnosis of DMDD (Baweja, Mayes, et al., 2016). The
assessment tools most often used in the research literature measure general irritability, such as the
Affective Reactivity Index (Stringaris et al., 2012) or the Clinician Affective Reactivity Index (Haller
et al., 2020). Specific to the diagnosis of DMDD, Wiggins et al. (2016) developed a DMDD module
that was used in conjunction with the Kiddie Schedule for Affective Disorders and Schizophrenia for
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School-Age Children–Present and Lifetime Version (K-SADS-PL; Kaufman et al., 1997). However, this
is a new module that has not undergone extensive psychometric evaluation.
In addition to confirming a diagnosis of DMDD, counselors should also assess for common
comorbid mental disorders (Mayes et al., 2016). Youth who meet the diagnostic criteria for DMDD
almost always have comorbid disorders, most often attention-deficit/hyperactivity disorder (ADHD),
conduct disorder, and specific learning disorders (Althoff et al., 2016; Bruno et al., 2019). Though one
cannot technically diagnose DMDD and ODD concurrently under DSM-5 rules, counselors should
also carefully assess and document symptoms of ODD, which will likely be appropriate targets in the
treatment planning process (e.g., S. C. Evans et al., 2017).
Though there are currently not any clearly validated inventories for directly assessing DMDD,
there are several inventories available for assessing the comorbid conditions that often accompany the
DMDD symptom profile. In addition to the previously mentioned cross-cutting measures in Section III
of the DSM-5 (APA, 2013), there are several commercially available inventories for assessing symptoms
of ODD, such as the Achenbach Series (Achenbach & Rescorla, 2006) or the Child and Adolescent
Disruptive Behavior Inventory (Cianchetti et al., 2013). Again, though a diagnosis of DMDD technically
overrides a diagnosis of ODD, symptoms of ODD will likely be present and a major target area of a
counseling plan. Administration of a validated measure of ODD will not only help counselors identify
symptom severity at the beginning of the counseling process, but can also be repeatedly administered
throughout the counseling process to evaluate areas of improvement and areas that need additional
attention. This same assessment process could also be used for other conditions comorbid with
DMDD. Counselors might use the Conner’s Rating Scales (Conners, 1999) to assess for ADHD and
other associated symptoms, such as aggression and learning problems. Symptoms of depression can
be evaluated through administering the Children’s Depression Inventory (Sitarenios & Kovacs, 1999)
or the Beck Depression Inventory with older adolescents (Beck et al., 1996). As is often the case, an
assessment and treatment protocol that targets specific symptoms may be more effective than one that
tries to remediate global diagnostic constructs, such as DMDD (e.g., Weisz & Kazdin, 2017).
Evidence-Based Treatments for DMDD
This next section will review the currently available research on both the use of pharmacotherapy and
psychosocial interventions in working with youth who meet the diagnostic criteria for DMDD. This will
be followed by a review of evidence-based treatments for related clinical conditions and will end with a
summary of general treatment recommendations for working with youth diagnosed with DMDD.
Psychopharmacology
Researchers have conducted only a few studies on the effectiveness of pharmacotherapy in reducing
symptoms of DMDD. For youth diagnosed with both DMDD and ADHD, researchers have found some
evidence for the effectiveness of psychostimulant monotherapy (Baweja, Belin, et al., 2016; Winters et al.,
2018) as well as the combination of methylphenidate with aripiprazole (Pan et al., 2018); however, in a
small (n = 12) retrospective study, Ozyurt et al. (2017) found that methylphenidate resulted in increased
irritability in children diagnosed with both DMDD and ADHD. Most recently, Rice et al. (2019) found
some effectiveness for the use of amantadine with a 12-year-old diagnosed with DMDD who was
admitted to a psychiatric hospital. Consistent with this limited research base, there are currently not
any medications that have received Food and Drug Administration approval for treating children and
adolescents specifically diagnosed with DMDD.
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Psychosocial Interventions
Parallel to the research on pharmacological interventions, very little research has been published
on the use of psychosocial interventions with youth who meet the diagnostic criteria for DMDD.
Perepletchikova et al. (2017) reported that a modified version of dialectical behavior therapy,
which also included a parent training module, was more effective than treatment as usual (TAU)
in improving irritability, temper outbursts, and overall functioning among youth diagnosed with
DMDD. In a subsequent study, Miller et al. (2018) reported that a modified version of interpersonal
psychotherapy—interpersonal psychotherapy for mood and behavior dysregulation (IPT-MBD)—
was more effective than TAU in reducing irritability and angry outbursts. However, both treatment
groups had equivalent scores on measures of depression and anxiety by the end of treatment. There
have also been a couple of case studies published in the literature. Tudor et al. (2016) reported that
cognitive behavioral therapy was effective in reducing irritability and aggression in a 9-year-old girl
diagnosed with DMDD and ADHD. In another case study report, Linke et al. (2020) reported that an
exposure-based, cognitive behavioral model was effective in treating an 11-year-old boy diagnosed
with both DMDD and ADHD.
Interventions for Comorbid Disorders
In the absence of evidence-based treatments for DMDD, many experts have recommended that
clinicians select evidence-based treatments for disorders that are often comorbid with DMDD, most
commonly ODD (Baweja, Mayes, et al., 2016). As Freeman et al. (2016) recommended, “Until a better
evidence base exists, clinicians should be cautious when diagnosing youth with DMDD, and treatment
often might best start with using evidence-based practices for ODD” (p. 129). This recommendation is
also consistent with the ICD-11, in which the core features of DMDD are conceptualized as a potential
subtype of ODD. There are several evidence-based interventions for oppositional behavior in general
and ODD in particular, such as cognitive therapy (Greene et al., 2004), parent management training
(Costin & Chambers, 2007), and multisystemic therapy (Asscher et al., 2013). There are also several
established treatments for ADHD, a condition that is also often comorbid with DMDD. Effective
interventions include the use of psychostimulants (Castells et al., 2020) as well as several variations of
behavior therapy (S. W. Evans et al., 2014).
Treatments for General Irritability
Another source of information for selecting potentially effective treatments for youth with DMDD
may be found in research programs that have targeted transdiagnostic symptoms of irritability and
aggressive behavior (Roy et al., 2014). Some evidence suggests that cognitive behavior therapy may
be effective in reducing general symptoms of irritability in youth (Derella et al., 2020; S. C. Evans et
al., 2020; Sukhodolsky et al., 2016). Along this line, Sukhodolsky and Scahill (2012) have published a
treatment manual for working with youth and their families who struggle with anger and aggression.
The competencies covered in this manual include, but are not limited to, relaxation training, emotional
regulation, problem solving, and social skills training. With regard to pharmacotherapy, Tourian et
al. (2015) conducted a literature review on the use of pharmacological agents in reducing symptoms
of chronic irritability, aggression, and temper outbursts in children and adolescents. Based on their
review, they found that methylphenidate, risperidone, and divalproex may offer some measure of
effectiveness in reducing irritability and aggressive behavior.
General Treatment Recommendations
As mentioned earlier, one of the criticisms of adding DMDD to the DSM-5 was that DMDD
provided clinicians with a new diagnostic label in the absence of any evidence-based treatments (e.g.,
Parker & Tavella, 2018). As evidenced by this review, this criticism continues to be valid. Based on
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43
the limited treatment literature for DMDD and the larger literature for disruptive behavior disorders,
only a few general guidelines seem suitable at this time. For one, experts generally recommend that
treatment commence with the use of cognitive behavior therapy combined with parent management
training (Brotman et al., 2017; Bruno et al., 2019; Roy et al., 2014; Stringaris et al., 2018). As previously
mentioned, recent research indicates that dialectical behavior therapy (Perepletchikova et al., 2017)
and interpersonal therapy (Miller et al., 2018) may also be promising. Second, if there is comorbid
ADHD, it is recommended that pharmacotherapy begin with the use of a psychostimulant (Blader
et al., 2016; Roy et al., 2014). Mood stabilizers and atypical antipsychotics may also be considered if
psychostimulants prove ineffective or in cases where there is a need for a quick reduction in severe
irritability or aggressive behavior (e.g., Baweja, Mayes, et al., 2016; Roy et al., 2014). Stringaris et al.
(2018) recommended that these medications should be used very cautiously:
Our recommendation is that antipsychotic prescriptions be reserved for those
young people who have not responded to a series of other treatments and that the
prescription be for a short period of time during which health indicators such as
weight are tightly monitored. (p. 733)
Third, as mentioned previously, counselors should also consider the use of evidence-based
interventions for ODD, a disorder that substantially overlaps with DMDD (e.g., Freeman et al., 2016).
Concluding Comments
The addition of DMDD to the fifth edition of the DSM was a controversial decision, a dispute that
continues to the present. At the time of its inclusion in the DSM-5, there was no solid evidentiary
foundation for including DMDD as a new diagnostic category (S. C. Evans et al., 2017). Evidence for
the validity of DMDD was inferred from the research on SMD, a distinct phenotype (Bruno et al.,
2019). Subsequent research since the publication of the DSM-5 in 2013 on the nature of DMDD has
demonstrated that DMDD lacks discriminant validity from other common disorders, most notably
ODD (Parker & Tavella, 2018).
As this literature has revealed, there continues to be a paucity of evidence-based treatments for
children and adolescents who fit the common symptom profile of DMDD. Although evidence-based
treatments for comorbid disorders offer promise, it is important that clinicians and researchers develop
and validate psychosocial and pharmacological treatments that directly target the core symptoms
of DMDD (Baweja, Mayes, et al., 2016). Yet, in addition to more effective remediation strategies
(i.e., tertiary prevention), there is also a clear need for prevention processes that can identify and
effectively help those children and adolescents who exhibit severe and chronic irritability (Stringaris
& Goodman, 2009). Though research is still emerging, a diagnosis of DMDD seems to be a precursor
for a lifetime of impairment. Youth with DMDD are at high risk for developing numerous mental
health problems in adulthood, including major depressive disorder, persistent depressive disorder
(dysthymia), and generalized anxiety disorder (Copeland et al., 2014; Stringaris et al., 2009; Stringaris
& Goodman, 2009). The development and evaluation of such prevention processes should be taken up
by professional counselors in both school and community settings, a responsibility that is part of our
professional identity (Albee & Ryan-Finn, 1993).
44
The Professional Counselor | Volume 12, Issue 1
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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