Informal Assessment, Case Study Example

Background Information: The client, Shana, is a 31-year-old woman, a working mother of three. Her son Jason is 15, her daughter Maria is 13, and her son Adam is 11. The father is unnamed, but she mentioned he has custody. The father has remarried, and his second wife has a 7-year-old from a previous relationship; the two have recently had a baby together. Shana and the children live with Shana’s mother, a retiree and veteran. As presented, the case is about financial responsibility: Shana needs her ex-husband to contribute financially so that the three children can stay with her and her mother. However, there also appear to be behavioral and/or emotional concerns: Adam is receiving medication for ADD, and all three children are on Prozac. The family will need initial screening before therapy strategies can be identified and agreed upon.

Case History: Shana appears to be under severe strain due to her current financial predicament: she is working, but she is not receiving financial assistance from the children’s father. According to Shana, the father has custody because of her own past drinking problem. However, in Shana’s words, the father and his new wife “don’t think they can handle teens any more.” The eldest, Jason, has expressed the desire to quit school in order to work and support the family, indicating both the severity of the situation and the young man’s own considerable maturity. Shana has also mentioned a number of behavioral and/or emotional concerns: she has put all three of the children on Prozac to help them deal with the stress of their circumstances, and to combat the depression evinced by the youngest, Adam. Adam is often absent, possibly at the mall, and Shana fears he may be using marijuana. Maria spends most of her free time with her boyfriend, an indication of the adolescent desire for increasing independence, and possibly a sign of her desire to escape a stressful situation. Although all three of the children will need therapy, Shana has correctly identified the need to involve their father as well.

Problem Areas: The first problem area concerns the father: he has custody, but he is apparently unwilling to either take care of the children himself, or financially assist Shana in doing so. This is a severe dysfunction, so it will be essential to involve the father in order to get his side of the story, both with regard to the divorce and the custody situation, and the current situation. Jason’s willingness to drop out of school to work and support the family attests to admirable strength of character, but it is also a concern: he would be jeopardizing his own future by dropping out. Shana’s mother is another concern: by Shana’s own admission, she drinks, and may be using marijuana. Maria’s absences may simply be normal adolescent desires for independence and time with her boyfriend, but they may also indicate a desire to escape a dysfunctional and stressful environment. Perhaps most worrisome is the youngest, Adam: he has depression and ADD, is on two medications, is often absent and may be using marijuana.

Ethical Concerns: The first ethical concern is privacy: legally and ethically, clients have a right “to choose who has access to information about them” (Sori & Hecker, 2006, p. 160). Since all of Shana’s children are minors, the responsibility for making these decisions falls to her and their father (p. 160). This responsibility includes the right to sign forms giving consent to treatment, forms pertaining to releases of information, and forms pertaining to the children’s records (p. 160). However, this raises a very important, related point: who should sign, Shana or the children’s father, who has custody? Under the law and ethically speaking, the father should sign the consent forms to allow treatment for the children (pp. 169-170). Because he has custody, his consent is an essential prerequisite for treatment (pp. 169-170). Moreover, state laws vary with regard to the rights of the non-custodial parent, Shana in this case (pp. 169-170). It would be essential for me to have access to the final divorce decree, in order to ensure that I accurately understood the situation with regard to custody of the children (p. 170). Since tensions and emotions often run high in post-divorce families, the involvement of the custodial parent is all the more essential (p. 170).

Confidentiality is another important ethical issue, one that applies to all minor clients: as with adult clients, minor clients’ information must be protected and not shared with unauthorized parties (Welfel, 2013, pp. 141-142). In fact, the seminal distinction between the privacy rights of adult clients and minor clients is that the latter’s information may be shared with a parent or guardian (p. 142). Ethically, then, in this situation I could not keep any of the children’s information from their father or from Shana (p. 142). However, there is something of a gray area here, in that a number of ethics scholars have argued that older, more mature minors can be granted a greater measure of confidentiality (Welfel, 2013, p. 143). Jason, for example, could probably be granted a larger measure of confidentiality, certainly more than Maria and especially Adam. As Welfel explained, between the ages of 11 and 14 children differ greatly in their ability to understand counseling, because of their particular cognitive development: minors who can engage in formal operations thinking will be able to participate effectively in counseling (p. 143). In this situation, therefore, it would be very important for me to assess the level of cognitive maturation of each of the three children (p. 143). And in this vein, client privilege is another important issue, a legal right with ethical ramifications: privilege protects the information of clients from being used in any judicial proceedings (Sori & Hecker, 2006, p. 160). State laws vary: minors as young as 16 can claim privilege for certain issues (p. 160). As none of the children are sixteen yet, privilege falls to their father and, depending on state laws, to Shana as well (p. 160).

The fact that Shana has all three children on Prozac is another ethical concern, as well as a medical one. The drug is FDA-approved for use with children from eight years of age and older, in order to treat major depression (Preston, O’Neal, & Talaga, 2010, p. 21). However, Turkington and Kaplan (2001) cautioned that there is insufficient evidence about the effects of Prozac and other selective serotonin reuptake inhibitors (SSRIs) on children (p. 79). According to these authors, studies of the use of Luvox to treat obsessive-compulsive disorder (OCD) in children found that younger children experienced side effects that were not observed in adults: “abnormal thinking, muscle twitching, or bloody or stuffy nose” (p. 79).

Breggin (2001) also argued that Prozac has not been found to be useful in children, and researchers are beginning to have second thoughts about the ethics of using antidepressants on children (p. 276). There are also concerns about the potential of antidepressants to cause or exacerbate suicidal ideation and even attempts at suicide (Kottler & Shepard, 2011, p. 372). However, it is difficult to ascertain whether a depressed individual, including a child or teen, committed suicide because of their medication: in any given case, it may have ‘simply’ been the effects of the depression (p. 372). Nonetheless, the ethical issue here is not difficult to discern: if the medication is actually dangerous to children, or at the very least may be, then any helping professional should carefully and critically examine any case in which it has been prescribed to a minor client.

Assessment and Discussion: In this case, I would contact the doctor as per Shana’s request, though of course I would need her to sign the information releases. If at all possible, I would try to arrange to see the doctor in person, in order to speak with him face-to-face about the Prozac prescription for all three children, and of course the anti-anxiety medication for Adam. I would raise my concerns, and ask specific questions about the reasons for the prescriptions, and any observed differences in the children’s behavior before and after the medications. I would discuss with the doctor the prudence and wisdom of continuing the prescription. Afterwards, I would speak with both of the parents and with the children, in order to ascertain the best course of action for all concerned.

Testing and assessment is an important part of the counselor’s work. However, informal assessment is important as well. A good example is observation: counselors can use observation to gather information about clients’ personality and behaviors (Whiston, 2009, p. 242). In this scenario, I would want to use observation to gain a better understanding of Shana, all three children, and the father. Interviewing is another good informal assessment technique, wherein counselors ask clients questions in order to elicit information about their personalities (p. 243). Again, I would want to do this with all three children, as well as Shana and the children’s father: it would be essential to get the father’s story and understand his actions and motivations. Rating scales are another important way of gathering information about clients (Whiston, 2009, p. 247). Likert scales, for example, can be used to assess individuals’ preferences, opinions, and beliefs (p. 25). I would also use behavior checklists and feeling word checklists, such as the Child Behavior Checklist/6-18 (CBCL/6-18), which is filled out by the parents; the Teacher Report Form/6-18 for the teachers, and the Youth Self-Report/11-18 (YSR) for the children themselves (p. 129). I would also talk to the children’s teachers, their grandmother, their father and their step-mother in order to get an idea of their home and school environments.

Having done all of that, I would then move on to the more formal assessments. A key distinction here is between objective tests, wherein clients’ responses yield quantitative data, and projective tests, wherein clients’ responses yield qualitative and far more subjective information about their own personalities (Altmaier & Hansen, 2012, p. 225). The substance abuse subtle screening instrument (SASSI) is an example of an objective instrument that I would definitely want to use for Shana, specifically the adult version, SASSI-3. According to the SASSI Institute (n.d.) the instrument has an overall accuracy of 94% in distinguishing between individuals who abuse substances or are dependent on them from those without (p. 1). Moreover, the accuracy of the instrument is not affected significantly by demographic characteristics, including gender (p. 1). As a questionnaire, it is relatively easy to administer and score; ergo, I would administer it to Shana myself. The adolescent version of the test, the SASSI-A2, is for minors from the ages of 12-18 (SASSI Institute, 2001, p. 1). It is just as accurate for adolescents as the SASSI-3 is for adults (p. 1). And as with the SASSI-3, because the SASSI-A2 is a questionnaire, it would be quite easy for me to administer to the children, both Jason and Maria, and score myself. Unfortunately, Adam is too young for this instrument.

I would also assess Maria and Jason with the Beck Depression Inventory-II (BDI-II), which is applicable to minors from the age of thirteen to seniors of the age of 80 (Goldfinger & Pomerantz, 2010, p. 69). The BDI-II consists of a mere 21 items, and should take no more than about 5 minutes for either of the children to complete (p. 69). For each item, the respondent chooses “one of four statements that best describes his or her experience of a particular symptom” (p. 69). Although it is brief, it is very potent, and yields good data about respondents’ state of mind (p. 69). In fact, it is very sensitive to treatment change, and there is a quite large empirical database to provide comparison with any results (Hersen, 2004, p. 57). I would also assess Adam’s ADD with a specific instrument, the Vanderbilt ADHD Parent Rating Scale (VADPRS) (Shen, Hales, & Shahrokh, 2010, p. 136). This scale is free online, as is the teacher-report version (p. 137). I would also assess all of the children’s self-esteem by means of the Culture-Free Self-Esteem Inventory (SEI), which is a self-report test (Braaten & Felopulos, 2004, p. 228). Along with the BDI-II, the SEI is an important instrument for the analysis, precisely because it would give me information from the point of view of each of the three children, and help me to understand their respective states of mind.

So much for the objective testing. Projective testing would be important as well, in order to better ascertain the character of each child’s personality, and identify any possible disorders or other problematic thought patterns. The Rorschach test is a good example of a projective test, one which would be helpful to the analysis (Braaten & Felopulos, 2004, p. 228). The Children’s Apperception Test (CAT) is another example of a projective test with high value for such cases (p. 228). What both tests offer the therapist is a singular opportunity to understand more of the child’s mind, and these insights can help the therapist to understand the source of any depression or other psychological problems (p. 228).

Recommendations and Conclusion: All three of the children need counseling. It is essential to understand how this situation is affecting them, and what their wishes are. Jason is clearly attempting to be ‘the man of the house’, indicating a maturity beyond his years. However, for him to leave school would be to jeopardize his own future career prospects. Maria is frequently absent: it is important to understand why, and to identify ways in which the home could be made a more welcoming environment. Adam seems to have the most psychological problems, with his ADD and depression; there are also the concerns of his absences and possible marijuana use. For him, therapy should focus on addressing the roots of these problems.

The home environment and the father’s lack of support are major systemic concerns. The father and Shana should undertake family therapy in order to reconcile their differences. The father must take an active role in supporting their children, and if he is unable or unwilling to do so in his own home, then he must assist Shana financially. These relationship issues, if resolved, could make the home a more welcoming and secure place for all of the children.

References

Altmaier, E. M., & Hansen, J.-I. (Eds.). (2012). The Oxford handbook of counseling psychology. New York: Oxford University Press.

Braaten, E., & Felopulos, G. (2004). Straight talk about psychological testing for kids. New York: The Guilford Press.

Breggin, P. R. (2001). Talking back to Ritalin: What doctors aren’t telling you about stimulants and ADHD. Cambridge, MA: Perseus Books Group.

Goldfinger, K., & Pomerantz, A. (2010). Psychological assessment and report writing. Thousand Oaks, CA: SAGE Publications, Inc.

Hersen, M. (Ed.). (2004). Comprehensive handbook of psychological assessment: Vol. 2—personality assessment (Vols. 1-2). Hoboken, NJ: John Wiley & Sons, Inc.

Kottler, J. A., & Shepard, D. S. (2011). Introduction to counseling: Voices from the field (3^rd ed.). Belmont, CA: Brooks/Cole.

Preston, J., O’Neal, J. H., & Talaga, M. C. (2010). Child and adolescent clinical psychopharmacology made simple (2^nd ed.). Oakland, CA: New Harbinger Publications, Inc.

SASSI Institute. (n.d.). Estimates of the reliability and criterion validity of the adult SASSI-3. SASSI Institute, pp. 1-4. Retrieved from http://www.sassi.com/

—. (2001). Estimates of the reliability and criterion validity of the adolescent SASSI-A2. SASSI Institute, pp. 1-8. Retrieved from http://www.sassi.com/

Shen, H., Hales, R. E., & Shahrokh, N. C. (2010). Study guide to child and adolescent psychiatry: A companion to Dulcan’s textbook of child and adolescent psychiatry. Arlington, VA: American Psychiatric Publishing, Inc.

Sori, C. F., & Hecker, L. L. (2006). Ethical and legal considerations when counseling children and families. In C. F. Sori (Ed.), Engaging children in family therapy: Creative approaches to integrating theory and research in clinical practice (pp. 159-176). New York: Routledge.

Turkington, C., & Kaplan, E. F. (2001). Making the antidepressant decision: How to choose the right treatment option for you or your loved one. New York: McGraw-Hill.

Welfel, E. R. (2013). Ethics in counseling & psychotherapy (5^th ed.). Belmont, CA: Brooks/Cole.

Whiston, S. C. (2009). Principles and applications of assessment in counseling (3^rd ed.). Belmont, CA: Brooks/Cole.