Adjustment Disorder with Disturbance of Conduct Case Study

Identifying the Problem

Bobby is 12-year-old boy. He was referred to counseling due to his recent onset of disruptive behaviors. Bobby’s parents recently divorced and currently he lives with his mother and a 1-year-old sister. During the last five minutes of the sixth session, he confessed that he hated his baby sister and he thought of killing and harming her. He reported that about a month ago, he made his sister sick by giving her a chocolate laxative. He also reported that he did not inform his mother about what he had done to his sister. His mother thought that his baby sister had a stomach virus. He stated that what he did was wrong. Bobby felt that his baby sister changed his life to the worse. He wants her to go away. He added that he did not want to hurt her today. Bobby’s parents has divorced recently which is a substantial change in his family life. There is no enough information or description about his disruptive behaviors except that they were severe enough to bring him to therapy. Additionally, he has homicidal ideation of killing his baby sister and violated her rights by giving her laxative which was luckily not life threatening.

Bobby was diagnosed with Adjustment Disorder with Disturbance of Conduct. People including children develop this disorder due to a reaction of major stress. The intensity of this disorder depends on the child’s disposition, susceptibility, previous experiences and coping skills.

Adjustment disorder lasts for six months. The symptoms may continue dependent on the stressor and its consequences. The divorce of his parents is unquestionably will have a long lasting effect on Bobby and his baby sister. Bobby has some of the feature of oppositional defiant disorder such as disobedience and opposition to authority figures; it does not include some of more severe behaviors such as violating the basic right of others or age appropriate social norms. When the behaviors meet both disorders’ symptoms, the conduct disorder take precedence and ODD is not diagnosed.

I would schedule a same day session with Bobby and his parents to discuss the seriousness of the problem. I would explore all the concerns I have regarding the baby’s safety and depends on the outcome of that meeting, I will determine to call CPS. My responsibility as a therapist is to take each case seriously regardless whether Bobby is going to carry out his homicidal ideation toward his baby sister. Nevertheless, Bobby is having real feeling of hate toward his sister for a whole year. He is not getting used to having her in his life. During this meeting, I will learn from the parents regarding any recent changes in his health, and include his treating physician.

In regards to the parents I would be cautious regarding their quality of care toward their children. I need to know whether there is a possibility of neglect and carelessness or that the parents, especially the mother, is suspecting any intention of Bobby to hurt his sister. They must be given the benefit of the doubt. Within that same vein of thinking, as a therapist, I must be cautious of accusing the parents of neglect due to the serious and could alter the parents’ life.

Ethical Decision Making Model

The author elected to employee the 7 step Kitchner Ethical Decision Making Model (1984) to apply to the aforementioned vignette.

1. Problem or dilemma: be aware of the different perspectives that may be used identify the problem.

It is the duty of the therapist to take Bobby’s intension in homicidal ideation toward his baby sister seriously, while may not be serious about his homicidal ideations, it is important to ensure that baby sister is safe. It is important that this therapist ensure that Bobby’s feeling is not malicious. Sibling abuse can be physical, is the physical, emotional or sexual. It can vary from mild aggression such as shoving or severe such as using weapons or deliberately try to hurt their siblings (Frazier & Hayes, 1994). Parents usually are not aware of the problem because either they are working outside the home or they assume that it is a sibling rivalry, which they conceive as normal (Strauss, & Gelles, 1994). The difference between sibling abuse and sibling rivalry is that sibling may argue or call each other names but the main difference is that it become and abusive relationship when one child is always the victim and the other is always the aggressor. The result of sibling abuse is long lasting that may last to adulthood. Although Bobby’s sister is a baby and does not know what was going on, and that Bobby said that he did not want to kill her today, his anger may trigger this urge and think of killing her again. This therapist does not feel that the baby sister is safe without informing the parents and authority to prevent the next blow (Schneider, Ross, Graham, & Zielinski, 2005).

As a court mandated reporter it is my duty to report suspected child abuse within 24 hours.

However, I have mixed feeling regarding this dilemma. Bobby is my client and by obeying the law, I am preaching the confidentiality and the trust that we built together through the last six sessions. Reporting this information may result in taking the baby out of the home. Would working with parents to ensure the baby’s safety be enough to resolve the issue? After all, the parents are divorced and Bobby may become angrier and more determined to hurt his baby sister. This family went through rough time, as is; however, having a mental disorder, being a teenager, I feel that he present an immediate danger to his sister. Bobby says that he is not thinking about killing her “today” is not guaranteed and the baby’s safety is in jeopardy.

Thus, CPS should be contacted and conferred with in accordance to the APA code of Ethics: As Ethical Standard 5.02 states: “Psychologists have a primary obligation and take reasonable precautions to respect the confidentiality rights of those with whom they work (2010).” At times, the value of confidentiality will conflict with other important values. Such a conflict may arise when a psychologist receives information concerning child abuse–information that may be helpful or necessary to stop the abuse and protect the child. It is also important to schedule separate emergency sessions with the parents and their children to provided support and offer psychoeducation regarding the process.

According to, the California Child Abuse and Neglect Reporting ACT (CANRA), located in California Penal Code Sections 11164 – 11174.3., states that mandated reporters should be knowledgeable of their duty to report. The law states that “when the victim is a child (a person under the age of 18) and the perpetrator is any person (including a child), the following types of abuse must be reported by all legally mandated reporters: Physical abuse (PC 11165.6) is defined as physical injury inflicted by other than accidental means on a child, or intentionally injuring a child.”. Additionally, child abuse must be reported if ““…has knowledge of or observes a child in his or her professional capacity, or within the scope of his or her employment whom he or she knows or reasonably suspects has been the victim of child abuse or neglect…” (PC 11166[a]). “Reasonable suspicion” occurs when “it is objectively reasonable for a person to entertain such a suspicion based upon facts that could cause a reasonable person in a like position, drawing when appropriate on his or her training and experience, to suspect child abuse” (PC 11166[a][1]).

2. Identify the potential issues involved

Consider: autonomy/beneficence/Nonmaleficence/justice.

The first moral principle that applies to this situation is autonomy. In order for Bobby to grow, he needs to be able to make his own decisions and not rely on his therapist to make decisions for him. Corey, Corey and Callanan (2003) stated, “respect for autonomy entails acknowledging the right of another to choose and act in accordance with his or her wishes…” (p.16). If I report the homicidal ideation and possible physical abuse then I am not acting in accordance with Bobby and his family’s wishes and therefore I am not promoting autonomy. I feel very strongly about fostering independent relationships, which causes me to question which decision is best for Bobby. The very real issue of the therapist needing to break Bobby’s confidentiality and thus his autonomy is unfortunate but necessary.

The different issues involved include Bobby homicidal ideation toward his baby sister and the real possibility that he could attempt to kill her. There is a possibility that Bobby is planning to kill his sister, if that the case, then something has to be done to protect the sister from him. Another issue include the possibility of Bobby having a more serious mental illness; his parents do not have to cope with that alone. It would be beneficent to help them through providing the right treatment, which involve therapy, training and medication if necessary to help build positive environment and deal with the disorder early in Bobby’s life.

There is also the possibility that Bobby does not mean what he was saying, if this is the case, Bobby could suffer egregiously and emotionally and so are his parents. Furthermore, the therapist could lose Bobby as a client as a result of the unjust accusation and the subsequent mandated reporting of the claim. However, such a loss, while undesirable is acceptable as the therapist followed the proper code of conduct regarding mandated reporting and nonmalfecience. The therapist will on the same day schedule an individual session with Bobby and assess the client for homicidal ideation and then notify the proper authorities.

Nonmaleficence can support either reporting the abuse or not reporting the abuse. In order to prevent physical harm to the baby, the therapist would have to report the abuse. On the other hand, if the therapist does not report the abuse Bobby, his sister may suffer and may be killed. What if Bobby’s actions of giving his sister harmful substance were a one-time action that will never happen again? Reporting may cause Bobby suffers harm that could have been avoided.

The principle of beneficence can also support both courses of action. On one hand, if I report the abuse I am promoting the safety of the baby. On the other hand, if I do not report the abuse I am promoting Bobby’s best interests and ensuring that he will not be separated from his mother.

Fidelity would support not reporting the abuse because it would require the therapist to break the trust of my client. She has a responsibility to her client and breaking Bobby’s trust would mean that the therapist honoring her responsibility as a professional. On the other hand, veracity would support reporting the abuse because the therapist was truthful from the start with the client when she provided him with informed consent. In the informed consent, the therapist explained that there were limits to confidentiality.

There is an obvious conflict in the moral principles in this ethical dilemma. While some of the principle support reporting the abuse, others support not reporting the abuse. To raise even more conflict some of the principles can support both decisions. The therapist sees clear contradictions between fidelity and veracity, nonmaleficence and beneficence and autonomy and beneficence. Fidelity says not to break the trust of the client, while veracity says that she can because she outlined the limits in my informed consent. Just as nonmaleficence could support not reporting the abuse to avoid harm to Bobby’s emotional state, but beneficence would say that the therapist not promoting the baby’s physical well-being. Beneficence can also contradict with autonomy because if I promote the baby’s physical safety by reporting the abuse then I am not honoring the client Bobby’s wishes, which is not supporting his autonomy.

3. Review the relevant ethical guidelines. Is there one or should there be one?

The client is an adolescent who has notified the therapist that he hated his baby sister and that he had homicidal ideation toward her. He gave her laxative and made her ill a month ago but he said he did not want to kill her today. In deference to section 11165.3 of the California Penal Code: “any mandated reporter who has knowledge of or who reasonably suspects that mental suffering has been inflicted upon the child or that his or her emotional well-being is endangered in any other way may report the known or suspected instance of child abuse or neglect to an agency” (2013). Since the therapist has an indication, that homicidal ideation could be occurring in the home, the therapist is mandated to report that information. In addition, the APA code of Ethics (2010) stipulates in section 5.02: “Psychologists have a primary obligation and take reasonable precautions to respect the confidentiality rights of those with whom they work. At times, the value of confidentiality will conflict with other important values. Such a conflict may arise when a psychologist receives information concerning child abuse.” Reporting the information to proper authorities will likely be helpful or necessary to stop the abuse and protect the child. In deference to the nineteen seventy-four Tarasoff case ruling, the mother should also be notified of possible danger.

4. Obtain consultation.

Prior to reporting the therapist would seek consultation from fellow therapists, CPS and the APA to seek ethical and legal perspectives. In addition, she would refer to an ethical decision making model to assist in the decision process. Whether or not there is any indication on knowledge of the brother is abusing his sister and considering as just sibling rivalry. The therapist concern is that the boy is having enough time with the baby alone without any adult supervision to give her the laxative. Additionally, does the mother know that her son is cruel to his sister but she is afraid of revealing it for the fear that he may be taken away from her?

5. Consider possible and probable courses of action.

Probable courses of action include: Emergency individual sessions with each family member will be scheduled within 24 hours of learning about the homicidal ideation. During the emergency session, the therapist would immediately assess Bobby and the respective family members. In addition, the therapist would assess Bobby’s cognition and remind him that he signed an informed consent form, which highlighted the exceptions to confidentiality. If it appears that the client intends to harm his sister the therapist while in session will call the clients treating physician and confer about the next course of action. If there is no time and the client is definitely going to hurt his sister, then separation and removing Bobby temporarily is appropriate. In addition, a mutually agreed upon plan between the therapist and Bobby needs to be in place to ensure that Bobby may refer to it whenever he feels the need to hurt his sister.

As there has been a possibility of homicidal ideation by Bobby, child protective services (CPS) must be called within 24 hours. As mentioned previously, the mother according to the Tarasoff ruling should also be notified that there is a possible threat to her baby daughter and should be provided with the support they need to cope with the issue. Follow up sessions with the therapist should also be scheduled

6. Enumerate the consequences of various decisions

The therapist could ignore what Bobby said, which could cause further harm to the baby sister. If Bobby decided to physically abuse his sister or gave her laxative or more potent substances then baby would have to continue to suffer from his actions. One of the consequences of reporting Bobby that should be considered is that Bobby may hate his sister even more and would carry out his ideation and actually kill her. On the other hand, if Bobby’s homicidal ideation is just an empty threats, Bobby could be affected emotionally and mentally to such an accusation. In addition, Bobby may refuse to come to therapy and not trust this therapist or any other therapists. Nevertheless, telling the therapist about his feeling toward his sister and wanting to kill her should be considered a “cry for help” and should be treated with respect.

The question of protecting Bobby’s confidentiality arises due to his confession, however: according to the APA code of Ethics: As Ethical Standard 5.02 states, “Psychologists have a primary obligation and take reasonable precautions to respect the confidentiality rights of those with whom they work. At times, the value of confidentiality will conflict with other important values. Such a conflict may arise when a psychologist receives information concerning child abuse–information that may be helpful or necessary to stop the abuse and protect the child (2010). ” In addition, if he were able to comprehend the information I would go over the informed consent form with Bobby, which highlighted the necessity of contacting proper authorities regarding the homicidal ideation. Breaking Bobby’s confidentiality could prove to cause him to react emotionally and his trust in the therapist could be broken. It could be very difficult to reclaim or develop trust in Bobby which could hinder the therapeutic process, however if the therapist believes that abuse is occurring she has the law and the code of ethics on her side.

7. Decide what appears to be the best course of action

After the therapist had conducted the emergency sessions and discussed the concern with Bobby, the therapist would review the issue(s) with her peers, refer to the APA ethical guidelines and consult with the APA attorneys and CPS, she would then likely call the proper authorities. If Bobby claims that, he was exaggerating and that he did not mean it literally. The therapist has to be cautious and ensure the safety of the baby and reassess Bobby to see whether the initial diagnosis is still appropriate.

My initial response is to report this information immediately.

“Failure to Report an abuse result in a misdemeanor punishable by up to six months in county jail and/or up to a $1000 fine (P.C. 11166[c]). He or she may also be found civilly liable for damages, especially if the child-victim or another child is further victimized because of the failure to report (Landeros vs. Flood (1976) 17C.3d399). Furthermore PC 11166.01[b] states that “any mandated reporter who willfully fails to report abuse or neglect, or any person who impedes or inhibits a report of abuse or neglect… where that abuse or neglect results in death or great bodily injury, shall be punished by not more than one year in a county jail, by a fine of not more than five thousand dollars ($5,000), or by both that fine and imprisonment.”

What I understood from this lengthy definition is that if I had any suspicion that the baby was not safe that I should report (CANRA, 1980).

Finally, if I did not report his homicidal ideation I would be sending a wrong message to Bobby and may think that is acceptable to have those feeling about his sister. As a therapist, I am dealing with the dilemma of fulfilling my legal duty to report and protect the baby sister rather than attempting to work with Bobby and doing what is in the best interest for his well being.

Reference

The Child Abuse and Neglect Reporting Act (CANRA), 1980. www.leginfo.ca.gov/calaw.html