Forming a Differential Diagnosis
Counselors of children and adolescents typically receive informal information about their client before the first meeting. Someone has become concerned enough about the young person to suggest counseling. Counselors use this background information to develop questions for themselves that they try to answer in their first interview with a child. The answers lead the counselor through a process called differential diagnosis, whereby various plausible alternatives are ruled out to form an initial diagnosis. The initial diagnosis is the basis for the initial treatment plan. The initial diagnosis and treatment plan may be changed later as more facts come to light, but they are very important because they offer a counselor a place to start. Your task for this assignment is to develop a differential diagnosis.
Choose either the case of Luis, the child, or the case of Crystal, the teen. Decide upon your diagnosis by working through these six specific steps, as described in the DSM-5 Handbook of Differential Diagnosis, linked in Resources (see pages 1–16).
1. Rule out malingering and factitious disorder. (Are the symptoms genuine?)
2. Rule out substance etiology. (Are the symptoms a result of the consumption of drugs or alcohol?)
3. Rule out an etiological medical condition. (Is there a medical condition that explains the symptoms?)
4. Determine the specific primary disorder(s). (What appears to be the most accurate initial diagnosis?)
5. Differentiate Adjustment Disorder from the residual Other Specified or Unspecified Disorders. (Have the symptoms developed into a sufficiently maladaptive response meriting a primary disorder, or are they better described with one of these other diagnoses?)
6. Establish the boundary with “no mental disorder.” (Is a primary diagnosis merited due to “clinically significant” symptoms, or are the concerns better described as “Other Conditions that May Be a Focus of Clinical Attention“? Not all counseling involves treating a mental disorder.)
The Case of Luis
Luis is in the fourth grade. His mother is concerned that he may need counseling because he has not grown out of a fear he has had since he was young that is now interfering with developing peer friendships. Luis is afraid of vomiting in a public place. As you speak with him, you learn that when he was in kindergarten, he once got upset and cried so much that he vomited. His teacher was not particularly sympathetic and his parents could not be reached for a while, so he spent several hours with soiled clothes, feeling very ashamed and embarrassed. Subsequently, he became fearful that he might vomit again, with no reason or warning. His behaviors have become more restricted over the years, and now he will not eat if his family goes out to dinner because he fears the food might make him sick. He eats very little at school—just a few foods that he has decided are safe—and his peers have begun to tease him. If he eats something and starts worrying about vomiting, he soon begins to feel sick and often does vomit. So he has begun avoiding more and more social occasions; he declines invitations to birthday parties and sleepovers because he doesn’t want to refuse to eat (and risk being teased) but he is afraid that he will vomit if he does eat. His mother says she has always had trouble with a sensitive stomach so she is very sympathetic toward Luis’s fears. However, Luis’s pediatrician says he can find no medical problem with Luis.
Note: It is important to follow your protocol in exactly the order it is presented below.
Develop a differential diagnosis for Luis by reviewing the following DSM-5 Handbook for Differential Diagnosis Decision Trees and Tables:
o 2.13 Decision Tree for Anxiety.
o 2.15 Decision Tree for Avoidance Behavior.
o 2.17 Decision Tree for Somatic Complaints or Illness/Appearance Anxiety.
o 2.18 Decision Tree for Appetite Changes or Unusual Eating Behavior.
o 3.5.3 Specific Phobia.
o 3.5.4 Social Anxiety Disorder (social phobia).
o 3.10.1 Avoidant/Restrictive Food Intake Disorder.
The Case of Crystal
Crystal is a 14-year-old girl in the tenth grade. Crystal’s school counselor has contacted you in order to refer her due to concerns about recent changes in her behavior. Last year, when Crystal was in ninth grade, her grandmother had a fatal stroke. Crystal was very attached to her grandmother, as she had lived with her intermittently during childhood. Crystal’s teachers reported that she seemed extraordinarily sad about this loss; she lost interest in her studies and seemed very withdrawn, spending entire class periods with her head on her desk. This year, however, Crystal has been very irritable toward her teachers and has been caught fighting with other girls on several occasions over minor provocations. She has been suspended twice for this behavior. She was recently referred to a community health center, where no physical problems were found. When you talk with Crystal, she confirms all this but also tells you that she witnessed her grandmother’s death, and that her father blames her, saying Crystal “stressed her out.” Crystal says she hates her current family situation because her father plays favorites with her siblings and step-siblings, and admits to occasionally sneaking whiskey from her father’s stash when she feels very upset. She says she finds it difficult to concentrate in school. She feels very guilty about her grandmother, and says she sometimes wishes she could join her “on the other side.”
Develop a differential diagnosis for Crystal by reviewing the following DSM-5 Handbook for Differential Diagnosis Decision Trees and Tables:
o 2.1 Decision Tree for Poor School Performance.
o 2.15 Decision Tree for Behavioral Problems in a Child or Adolescent.
o 2.9 Decision Tree for Irritable Mood.
o 2.9 Decision Tree for Depressed Mood.
o 2.16 Decision Tree for Trauma or Psychosocial Stressors Involved in the Etiology.
o 3.4.1 Depressive Disorders.
o 3.4.4 Disruptive Mood Disorder.
o 3.14.1 Oppositional Defiant Disorder.
o 3.7.1 Trauma- and Stressor-Related Disorder.
o 3.15.1 Substance Use Disorders.
The differential diagnosis for your chosen case will be used in this unit’s discussion.
Diagnosing Children and Adolescents
In your Discussion post, use the differential diagnosis you developed for your chosen case in this unit’s third study:
o Note your thoughts for each of the six steps, including your rationale for your initial diagnosis.
o What other diagnoses did you consider, but tentatively rule out?
o List three questions you could pursue in future sessions to be even surer of your diagnosis (by ruling out other potential diagnoses).
- Discussion Participation Scoring Guide.
- APA Style and Format.
- DSM-5 Handbook of Differential Diagnosis.
Practice Child Counseling Skills
For this discussion, you are to create a two-page transcript of a hypothetical counseling interaction, including the skills of reflection, paraphrase, and summarization, in order to practice adapting skills and techniques for use with children.
Imagine that you are a counselor creating a transcript from a recent session. When creating your transcript, adhere to the following:
o Choose either a child or an adolescent. You may wish to use the client you created for your background sketch in Unit 1.
o Begin by writing a one- or two-sentence narrative indicating the issue being discussed, such as concerns about schoolwork, sadness about a lost pet, or anger about getting grounded.
o Complete a counseling transcript, using the instructions below.
§ Each comment or question by a counselor must have the skill and counselor purpose or counselor intention clearly identified.
§ Use a range of skills from the list of Universal Counseling Skills, on pages 84–85, in Counseling Children.
Take a few minutes to carefully examine the example of a transcript and transcription instructions below and in the Counseling Transcript Template, linked in Resources. Then, develop your own transcript. Be sure to follow the instructions. Upload your completed transcript to the discussion.
1. Counseling Transcripts should have three columns.
1. The left-most column designates who was speaking—the client or the counselor.
2. The center column depicts what was said.
3. The third column labels the skill that the counselor used and the counselor’s intentions [in brackets].
4. The skill should come from the list of Universal Counseling Skills in Counseling Children, pages 84–85.
5. The intention should apply one of the Purposes listed in the text’s table to the interaction with the client.
2. Each talk turn should be on its own row.
3. You may use the template linked in Resources after deleting the instructions, or create your own form that meets Specifications 1 and 2. Add more rows if necessary.
4. Your transcript should be no more than 2 pages long.
5. Please be sure to cite two sources in this discussion. You may cite them in the third column to indicate what sources you used to identify the universal skills you used.
[purpose and counselor intentions]
I’m glad you could come talk to me. Jess and Harry told me they are worried about you.
Providing information [to give Sari the facts about why she was sent to talk to me].
[says nothing but sits on her hands and looks at her shoes; sighs]
(Gently) Sari, you look like you feel a little sad.
Reflection of feeling [to show awareness of her emotion and her body language].
(Looking up) I guess so.
How long have you been feeling sad?
Closed question [to get more information].
Since my last report card. I think Mr. Gomez hates me.
Oh, so you’re worried that Mr. Gomez doesn’t like you because he gave you a bad grade.
Paraphrase [to give back he message and make sure I got it right].
Yep. (Wiping away a tear.)
Sounds like this caught you by surprise…and it really hurt.
Empathy [to let her know I can “read between the lines” and imagine what is like to be her].
Mmm Hmm. (Looking up.) Now I’m afraid my grades won’t be good enough so I can go out for track.
Sounds like you want me to help out with that.
Defining the problem [I’m guessing what she wants help with].