Provisional Diagnosis Case Study

Provisional Diagnosis

Client, Devon, is a 10 years old male who has been referred to this clinician for a clinical assessment due to his ongoing disruptive behaviors in the home of each parent and in the school.

Per report from Devon’s mother, these behaviors have been ongoing since the beginning of the summer. It is noteworthy to state that Devon’s parents have separated the summer before the last school year started. It was also reported that since he could walk, he has been strong-willed and it took major redirection for him to comply. This assessment is being conducted in the late month of March. The following diagnosis was obtained by a one time, in-person assessment with collaborative reports from teacher and parents and school reports.

The provisional diagnosis for Devon is:
Oppositional Defiant Disorder, Severe
Academic Stressor i.e. Reading Comprehension, Family Stressors i.e. Parent Separation, Living stability
Clinical Reasoning
The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) (American Psychiatric Association, 2013), define Oppositional Defiant Disorder (ODD) as “ a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness last at least six months as evidenced by at least four symptoms… and exhibited during interaction with at least one individual who is not a sibling.” In this case, Devon is presenting as all of the aforementioned types based on his symptoms of deliberately annoy his brother, arguing with his teachers and parent, defying rules or request from his parents and teacher, and his vindictive behavior toward people he feels have done him wrong, appearing to be frequently angry and irritable, and throwing numerous tantrums.
Peer Reviewed Articles Supporting Provisional Diagnosis
Steiner and Remsting (2007), inform practice in that they discuss the importance of noticing the child’s behavior when in an assessment.

Steiner and Remsting (2007) suggest that usually children are not in agreement with their parents and lack insight into their behavioral issues. Devon was willing to meet with the clinician but ended the assessment early due to him become irritable with the line of questioning and thinking the interview was “stupid”. This behavior is expected with children who have ODD. The American Academy of Child and Adolescent Psychiatry (2009) also support the provisional diagnosis as they advise that children with ODD often are going through a transition, under stress, or in the midst of a crisis. This clinician believes that a pressing factor of Devon’s behavioral issues may have come from the separation of his parents and the new living arrangements. Devon may have not handled the stressor correctly and may be reacting to it, which was a deciding factor in the diagnosis of ODD. Lastly, this clinician was concerned about the parenting style continuity between both homes of each parent. Although no exclusive parenting style was reported, the father stated that they never spanked Devon and if they had maybe there would not be any behavioral issues arising. That statement was key to this clinician because Portes, Dunham, and Williams (2007), allude to the fact that some children become oppositional when parents have excessive or unrealistic demands and may be overly punitive or overly passive. The fact that there may be overly punitive demands at dads home and overly passive demands at moms home may suggest a confusion of what is expected of Devon, which in turn could be causing him to exhibit oppositional defiant

behaviors.
Alternative Diagnosis
Oppositional Defiant Disorder has several differential diagnoses. However, there are three that could have applied to this case specifically. First, a differential diagnosis of an Adjustment Disorder could have been explored prior to diagnosing Devon with ODD. However, the symptoms that surfaced seemed to be out of the time frame specified in the DSM-5 to diagnose one with such disorder. According to Casey (2009), the criteria for an adjustment disorder are a response to a stressful event with an onset of symptoms within three months of exposure to stressor. Devon started to exhibit these rebellious behaviors since the beginning of the summer, per report, and there has not been a stressor since the last summer separation of his parents. Sadock and Ruiz (2015), state that if the behaviors that occur from a temporary reaction to a stressor (i.e. Devon’s parents separating) then the client should be diagnosed with an adjustment disorder, however, the time limitation for Devon to have a symptomatic response to the stressor has passed.
Secondly, there could have also been a diagnosis of a Specific Learning Disorder due to concerns with his reading comprehension. Conversely, there has been not been a standardized test that has been given to Devon that can measure his ability to read and show that it is less than what would be expected from his age, intelligence, and education. The fact that he is receiving tutoring does not justify a specific learning disorder.
Lastly, there is significant evidence that suggest children who exhibit oppositional defiant behaviors usually struggle with attention deficit/hyperactivity disorder (ADHD). Yet, Devon does not present as predominantly inattentive, or predominantly hyperactive or impulsive. He displays impulsive behaviors, however, it is not interfering with his academic performance. School reports confirm that he is a solid ‘B’ student and obtains ‘A’ grades in math. A comorbid diagnosis of ADHD would be a misdiagnosis.