Presently, researchers on health services, advocates of healthy mental states and the authorities of public health have a growing concern regarding the number of youths suffering from mental illnesses while changing from adolescence to adulthood (Hower et al., 2013). Psychology scholars further note that legal emancipation and growing interdependence among the adolescent population has brought about an increase in diagnosis and treatment rejection, further, exacerbating mental health disorders. Consequently, since the chance of obtaining incident mental illnesses is high, and the reality in which proper education, clinical, and legal outcomes for TAY populations are not taken seriously, it has resulted in adverse effects not only for this population but public health as well. As such, this paper discusses a psychological case pertaining to a TAY client in terms of the problem overview, the client’s psychological assessment, working with the client, and the strategies employed beyond therapy.
Overview of Problem Areas of the Client
Many adolescents often suffer from depression and anxiety, predominantly those within the foster care system. Over time, studies have been conducted delineating the mental states of transition-age youths. One such study focusing on a large sample of more than 300 youths showed that more than 30 percent of them had difficulties of a psychiatric diagnosis in the past one year (Salazar, 2010). Within the study also, females emerged as more likely to suffer from mental degradation compared to males.
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Moreover, follow-up studies showed that at an average age of 19, foster youth were more likely to have had recent diagnoses on mental health. McLeod et al. (2012) note that sociologists agree on the relationship between mental health and social distribution, in that, psychological distress, as well as other psychiatric disorders, have their roots on socioeconomic status among other parameters such as race, ethnicity, and gender. As such, since TAY populations have lower social standings, the prevalence of anxiety and depression leads to problems that are behavioral, social, and cognitive. Present policies often focus on mental health as a prevalent issue among TAY populations and prevent it through early intervention ("Mental Health Promotion, Prevention, and Early Intervention," 2018).
The Client
The client is Sebastian, a 16 years two months old, Black, adolescent male, referred for psychological evaluation due to problems in cognition and the emotional state as a result of poor performance, depression, and anxiety. While Sebastian has demonstrated an immense interest in learning, his academic performance has not been steady for quite some time leading to continuous poor performance. This has been so despite one-on-one tutoring sessions as well as various accommodations from the school. Sebastian’s enthusiasm in obtaining knowledge is apparent. However, contributing factors to his condition manifest in the form of inconsistent attendance, concentration problems, and complex social dynamics including his relationship with his biological family. Primarily, information concerning Sebastian’s psychological background came from his social worker and reports on his educational, psychological, and medical analysis. Such information as those obtained from ratings, developmental histories, and interviews was decidedly significant throughout this assessment.
Chronological events reveal long struggles with proper social behavior and academic performance. To begin with, he does not have a functional relationship with his biological family, predominantly, his father. Moreover, the relationship between his foster caregivers is tense and wanting. Thus, Sebastian finds it hard to motivate himself while doing schoolwork and has started using illegal substances such as alcohol and marijuana. At birth, there were no reported issues during the process of delivery and Sebastian was born a healthy boy with a normal weight. However, through earlier assessments, it became clear that his biological mother was abusing drugs while pregnant. The drug of choice for Sebastian’s mother at that time was heroin, which can have detrimental effects on the life of a child later in life. Ornoy et al. (2010) note that prenatal exposure or consistent use of heroin leads to long-term effects on early and middle childhood development that can even persist throughout adulthood. In addition, researchers have concluded that the persistence of social, cognitive, and emotional effects brought about by prenatal exposure to heroin is directly proportional to exposure amounts during the pregnancy period. Therefore, in Sebastian’s case, prenatal exposure plays a crucial role in his psychological, mental state.
Regarding Sebastian’s developmental history, he went through difficulties as an infant, sleeping for 2 to 3 hours at a time. Such sleep mishaps disrupted his brain development, likely resulting in cognitive problems throughout his developmental period. Moreover, as a child, Sebastian had poor eating habits. In regards to developmental milestones, his language acumen and general motor development were normal, in that, he recognized and returned speech at a normal age and was able to socially interact with other children at a normal age as well. Nonetheless, when it comes to writing, Sebastian has poor coordination of fine motor skills. Medically, the client has had usual childhood illnesses such as strep throat, chickenpox, and ear infections together with frequent broken bones from playing aggressive sports such as soccer and skateboarding. In addition, it is imperative to note that Sebastian developed bladder and bowel control late compared to other children of his age at the time, an indication of psychological issues.
Sebastian’s family and social history is a long and precarious one. As mentioned above, his biological mother was an addict who favored narcotics and used to indulge in them even while pregnant with Sebastian. Presently, his biological mother is a homeless person living on welfare. Regarding his father, Sebastian has not met him for a while as he is incarcerated. While young, Sebastian used to see his father visit his mother on occasions and the father would be violent to the mother in front of Sebastian. In light of such conditions, Sebastian went through difficult times while young and grew up with immense fear, dislike, and disrespect towards his father. Presently, Sebastian’s social setup entails his foster parents and siblings, friends, and the school administration. Inasmuch as he talks with his mother occasionally, Sebastian does not value their relationship as meaningful.
The history of evaluations regarding Sebastian’s case regarding learning and behavior issues has been long. Prior to subsequent psychological tests, an earlier neuropsychological assessment revealed that he had an acute dominance of using both his hands and a left dominance for feet and eyes. In the review, his intellectual capacity measured at the low average percentile with higher verbal and lower performance skills. In addition, low performance suggested further tests, which revealed problems that affected his visual motor, processing speed, and visual sequencing. The evaluation also noted other challenges linked to learning and information assimilation by wanting adequate problem-solving skills.
Moreover, due to severe anxiety impacts, his attention/concentration capability was found to deteriorate significantly. In Sebastian’s case, verbal memory was highly developed compared to visual/spatial memory. However, in these earlier tests, it became clear that he also had problems with spelling and handwriting, demonstrating insufficiencies in the identification of proper tactile stimuli.
In light of previous tests, most psychological indicators showed the possibility of anxiety disorders. Within the context of continued family therapy, earlier tests indicated structured, consistent, and predictable patterns to regulate his academic performance. However, subsequent psychological evaluations indicated further treatment with possible concerns for the development of depressive disorders since results indicated increased levels of this score. Achievement testing using WIAT showed an average intelligence range with higher capacities in excelling in verbal tasks as compared to non-verbal ones. Such scores indicate Sebastian’s prowess in languages and reading as opposed to abstract challenges such as math. For the client, numerical operations and spelling were quite problematic.
My Work with the Client
Ultimately, throughout his testing, Sebastian has displayed due readiness in establishing an easy rapport with psychologists as well as other school counselors. Prior to my evaluation, Sebastian had worked with other assessors over a period of close to five years. During this time, various aspects of his psychological welfare were evaluated, predominantly, concerning his academic performance and its relation to his behavioral tendencies. I assessed him over a period of two days in which he displayed high senses of motivation to complete tasks.
Moreover, throughout the testing periods, Sebastian showed no signs of hyperactivity, resistance, or distractibility. On the other hand, he displayed a rather slow speed of processing information, particularly, information that necessitated proper visual motor responses. On these occasions, Sebastian would become openly frustrated and tended to drum fingers while working through monotonous and tedious tasks. When tasks tended to challenge him, he became more alert and engaged.
The client’s behavior at home is that of an ordinary teenage student albeit it displays certain extremes detrimental to his developmental progress. Primarily, Sebastian enjoys listening to music and riding his skateboard. His PSI ratings indicate difficulty in spatial thinking, hand fidgeting, gradual friendship initialization, excessive feelings of guilt, anger, temper tantrums, inability to listen carefully, and being distracted and frustrated easily. While this is the case, he also displays his desire to learn new concepts and concern for perfection. At school, former teachers indicate his lack of proper motivation for academic achievement with various difficulties in classroom and reading behavior. While Sebastian understands language, he appears nervous and fearful with repetitive habits christened by restlessness and mood swings. Teachers further note his poor planning approaches, ignorance to mistakes, disorganization, and inability to follow through on plans and agendas. Imperative to note is his frustrations and depression when failing to tackle schoolwork problems. Over time, however, his social interactions have augmented resulting in proper self-esteem. Commensurately, he responds to boundaries and structures well, thereby, proper natural leadership and compassion to improve his social skills.
Transference and Counter-Transference Phenomena
To analyze the learning disability in Sebastian, proper tests, which ascertain levels of intelligence, the learning process, emotional/psychological development and academic achievement, were in order. These tests included the Weschler Adult Intelligence Scale-Third Edition; the Cognitive Assessment System; the Gordon Systems Continuous Performance Test; the Trial Marking Test A and B; the Stroop Color Word Interference Test; the Coding and Trials test; and the Rey Osterrich Complex Figure Drawing among others. Other informational assessment techniques included the inventory of primary sources, behavior observations, review of medical reports, and assessments through interviews. Using information from these sources, various domains regarding Sebastian’s condition emerged.
Cognitive-Intellectual-Executive Functioning. Measuring Sebastian’s intellectual prowess and methodologies of cognition entailed the use of the Cognitive Assessment System and the Weschler Adult Intelligence Scale-Third Edition. Both these instruments test adult intelligence from those over 16 years of age. Within its structure, 14 subsets cumulatively test an individual’s IQ measured through attributes such as working memory, the understanding of verbal cues, perception, and the processing speed. Within the CAS testing system, characteristics such as successive and simultaneous processes within cognition, the planning process, and attention are tested. Ultimately, the planning process within the testing of cognitive-intellectual-executive functioning assures cognitive control, the desire to achieve desired goals and the utilization of knowledge and processes. Attention is responsible for selective and attuned cognitive processes over time. On the other hand, while simultaneous processing determines stimuli integration as a whole, successive processing refers to stimuli integration through specific sequences to generate progression chains.
As such, Sebastian’s intellectual capability evaluation shows average functioning after the combination of all subsets. Nonetheless, average functioning indicates poor cognition in numerous pertinent areas. Primarily, throughout the test, various markers indicated earlier diagnosis such as significant differences between verbal comprehension and performance organization. Moreover, depressed scores occurred frequently throughout the test period due to an inability of comprehension, information comparison and interpretation of problems. These markers indicated issues in active working memory. Contrariwise, questions on auditory, visual, verbal and non-verbal information were his strengths. Moreover, he demonstrated great performance in long-term memory, the identification of missing information, and complicated visual problems akin to pattern solving. Based on data from the tests, Sebastian displays divergent capabilities in tasks that require proper working memory; as such, he experiences problems in various aspects of executive functioning.
Attention-Concentration. A primary concern for the learning and behavior patterns of Sebastian is the possibility of having a disorder when it comes to attention. Presently, disorders of attention often have the view of being biochemical and involving neurotransmitters that ferry the dopamine and norepinephrine hormones. Within the brain, these messengers are instrumental in keeping it alert or in arousing it. As such, this disorder affects the parietal and frontal areas of the brain. Such areas have numerous complex connections responsible for these brain states. While attention deficit is considered genetic, various co-morbid conditions aggravate it. Various theories abound regarding the nature and origin of attention deficit disorder. However, two types are common: attention deficit disorder with hyperactivity (ADHD), which involves the frontal lobe and the occurrence of conduct disorders and hyperactivity; and attention deficit disorder (ADD), which does not affect executive functioning. While there are certainly no quantifiable tests of determining the attention span of individuals, observation tools and objective measures, which measure components of attention abound. Ultimately, the attention-concentration aspect of mental health has been a prime concern among the TAY population.
In Sebastian’s case, the Coding and Trials test indicated poor performance on coding. Nonetheless, he performed sequential tasks showing prime ability in delineating differences within Picture Completion Subsets. Sebastian performed well on the sustained element as determined by his continuous performance tests. On vigilance and distractibility, he performed well with less than three errors of commission on each; further, indicating impulsivity since his mind drifted while not working on complex problems. Ultimately, in attention-concentration, the capability of information manipulation after encoding, often described to as the working memory remains highly decisive. Ultimately, although Sebastian demonstrates various aspects of the attention deficit disorder, insufficient evidence absolves a definitive diagnosis in his case. Traditionally, the observation of attention disorders typically follows a continuum that interferes with functioning. Therefore, his condition stems from co-morbid conditions factored in with depression and anxiety.
Memory. Here, tests indicated that Sebastian had challenges with visual memory because he inadequately encodes information relating to visual perception. This phenomenon became apparent through his difficulties in replicating complex figure drawings. In light of this, Sebastian cannot seem to have the ability to recreate mental design models and fails to note important details. In addition, in the interpretation of spatial memory, he fails in constructing proper relationships between parts of a whole. Such difficulties in encoding show he perceives and interprets less visual information and has additional challenges in visual memory strategies of performance enhancement. Moreover, rote memorization of predominantly auditory and verbal information was markedly below average. Such determent in memory emanates from his problems in cognition and attention-concentration. Finally, there is an aggravation of memory problems through co-morbid conditions
Academic Achievement. The Wechsler Individual Achievement Test indicated Sebastian’s basic academic skills. This assessment revealed good basic reading, basic math, reasoning, and comprehension skills. However, notable problems included areas requiring written responses and spelling. Similarly, problems dealing with working memory, visual motor responses, and encoding brought about insurmountable challenges to Sebastian. Contrariwise, the client displays proper word decoding. Nonetheless, he lacks the capability of sustaining proper concentration and the engagement of his mental faculties to answer queries sufficiently. Academics require fast interpretation of visual-motor queues together with strong working memory. These attributes, coupled with proper concentration, ultimately gives rise to proper performance. However, in Sebastian’s case, his motivation and performance are impacted greatly within the classroom setting. It is apparent that he requires external intervention to keep up with academic work and is quite clear that he displays deficits in written production and working memory.
Treatments and Services
To begin with, Sebastian requires various treatment angles targeted for intervention rather than a smooth transition. The prime focus of his treatment should be on the management of his anxiety and depression. Scholars indicate a rising prevalence of anxiety and depression among transition-age youths primarily stemming from socioeconomic adversities and impairment in learning (Saperstein et al., 2014). Therefore, a strong focus on depression and anxiety treatments should continue throughout his recovery period. Since the client is using new assertive ways of communication; his expressive need should not be diminished predominantly while initiating conversations. This way, the formation of therapeutic bonds shall occur consequently resulting in successive cognitive behavioral therapy strategies. Moreover, to manage depression episodes, Sebastian can employ the use of medical treatment.
Aside from clinical treatments and behavioral therapies, Sebastian also requires imperative actions such as the establishment of structures and boundaries both at school and at his foster home. The foster parent should ensure that he follows through on his schoolwork and has consistency in his performance. Doing this enables the client to perceive and exercise internal controls allowing effective monitoring of behavior. Moreover, such roles and boundaries develop Sebastian’s sense of self and may be integrated into his schooling to ensure a more rounded and interactive character development.
Sebastian presently follows a multistep progressive program that increases his independence through the cultivation of responsibility. This program is outward bound, meaning, it challenges his resilience and confidence in catering for his own needs. Although he requires continual support, predominantly through continual monitoring during sensitive times, the program assures part of the success. Such programs include SNS Guidelines Programme as stipulated in the book titled Clinical Practice Guideline on the Management of Depression in Adults (Clinical Practice Guidelines in the Spanish NHS, 2014). Ultimately, to secure proper treatment for Sebastian, proper environmental consistency is imperative since it solidifies his progress and assures predictability and security. Similarly, all plans associated with the client’s schooling should be monitored closely to effect full re-evaluation within three months. Such re-evaluations are quite decisive in the determination of progress and ultimately, the overall treatment and recovery of the client.
The Client in Context
Strength and Limitations of My Work with the Client
The determination of contributing factors to depression, anxiety, and poor academic performance, as well as the extent to which it affects the patient in question is complex. My work with Sebastian entailed going through his past psychiatric records and other germane reports to establish a baseline on which to work with. After this determination, I interviewed the client to establish transference phenomena, which came in handy during the test performances that were done to the best of the client’s ability. Essentially, this three-pronged strategy ensured maximum feedback from the client. Moreover, using standardized tests to determine key factors contributing to poor academic performance ensured integral results, particularly while diagnosing depression and anxiety patterns. As such, the strength of this work was in its results validity and the amount of valid information generated through these tests.
Beyond Therapy
Besides psychotherapeutic treatments, depression entails other treatments under the canopy of two fundamental care models: the stepped-care model and collaborative care. While stepped-care treatment provides limited or less intensive interventions depending on patient development and socioeconomic status, collaborative care has its basis on chronic care models and improves the management of care as well as clinical outcomes. As such, collaborative care augments the responses of care managers whose major work is the improvement of life quality among depressed individuals. As such, to ensure wholesome recovery, both the combination of these two care models is imperative, particularly while tackling depression from an angle of medication use
Primarily, the use of antidepressants usually suppresses symptoms associated with depression. However, differences relating to the chemical structures and mechanisms of action often differentiate between primarily classic depressants and new generational depressants. Among them, classic depressants include non-selective MAOI such as tranylcypromine; heterocyclics such as imipramine and clomipramine; and MAO-A selective MAOI such as moclobemide. New generation drugs include trazodone, mirtazapine, and reboxetine (Clinical Practice Guidelines in the Spanish NHS, 2014). Aside from the use of drugs, other treatments include exercise, which is known to improve mood and a sense of well-being. Studies within the developed world indicate that exercise aids in mood alleviation and positive feedback mechanisms that increase the self-esteem.
Impact on My Practice with TAY
As mentioned earlier, the population of transitional-age youths is highly vulnerable to mental disorders stemming from childhood, developmental, and environmental issues. Consequently, since the chance of obtaining mental illnesses is high, and the reality in which proper education, clinical, and legal outcomes for TAY populations are not taken seriously, this has resulted in adverse effects not only for this population but public health as well. My case with Sebastian has opened my perception of cognitive-behavioral challenges stemming from anxiety and depression among TAY populations. The cornerstone program, a theoretical guided intervention shows that transitional-age youths have elevated mental disorder problems that require immediate intervention. As such, this organization offers services such as trauma-focused cognitive behavioral therapy, peer support, mentoring, practical skill development, and addresses stigmatized individuals (Munson et al., 2016)
Therefore, in my time with Sebastian, I have come to realize the need for more intervention programs for TAY populations. Aside from a negative upbringing, the client faces negative socioeconomic consequences of being in planned care. As such, these victims usually face various challenges in all forms, thereby, necessitating the use of varied strategies to effect lasting change. Most times, a combination of medical treatment and psychotherapy is usually the best route of administering proper care. In addition, a combination of collaborative care models and the stepped-care model assures proper interactions for possible solutions as well as an understanding of the self, which leads to independence and later interdependence. Fundamentally, more needs to be done on dealing with TAY populations to curb the soaring numbers of mental health problems.
References
Clinical Practice Guidelines in the Spanish NHS. (2014). Clinical Practice Guideline on the Management of Depression in Adults . Ministry of Health, Social Services And Equality.
Hower, H., Case, B., Hoeppner, B., Yen, S., Goldstein, T., & Goldstein, B. et al. (2013). Use of Mental Health Services in Transition Age Youth with Bipolar Disorder. Journal of Psychiatric Practice , 19 (6), 464-476. doi: 10.1097/01.pra.0000438185.81983.8b
McLeod, J., Uemura, R., & Rohrman, S. (2012). Adolescent Mental Health, Behavior Problems, and Academic Achievement. Journal of Health And Social Behavior , 53 (4), 482-497. doi: 10.1177/0022146512462888
Mental health promotion, prevention, and early intervention. (2018). Retrieved from http://eenet.ca/resource/mental-health-promotion-prevention-and-early-intervention-through-campus-interventions-and
Munson, M., Cole, A., Stanhope, V., Marcus, S., McKay, M., Jaccard, J., & Ben-David, S. (2016). Cornerstone program for transition-age youth with serious mental illness: study protocol for a randomized controlled trial. Trials , 17 (1). doi: 10.1186/s13063-016-1654-0
Ornoy, A., Daka, L., Goldzweig, G., Gil, Y., Mjen, L., & Levit, S. et al. (2010). Neurodevelopmental and psychological assessment of adolescents born to drug-addicted parents: Effects of SES and adoption. Child Abuse & Neglect , 34 (5), 354-368. doi: 10.1016/j.chiabu.2009.09.012
Salazar, A. (2010). Transition-Aged Youth, Mental Health Challenges, and Survival Self-Reliance. Focal Point: Youth, Young Adults, & Mental Health. Transitions To Adulthood , 24 (1), 14-16.
Saperstein, A., Lee, S., Ronan, E., Seeman, R., & Medalia, A. (2014). Cognitive Deficit and Mental Health in Homeless Transition-Age Youth. PEDIATRICS , 134 (1), e138-e145. doi: 10.1542/peds.2013-4302
