Question

NSG 350 Extra Assignment: Impulse Control Case Study

(Please Provide Answers with Rationales)

Mr. and Mrs. Lahud have come to the clinic to initiate family therapy. The whole family is under stress because their youngest daughter, 10-year-old Elia, loses her temper “almost constantly,” the parents say.

“In fact, she seems to be always seething under the surface, even when she’s laughing and seeming to have a good time, just waiting to explode. She argues about the simplest things—you can try to give her choices, like, instead of saying, ‘time to get dressed for school,’ you might say, ‘Elia, do you want your green sweater or your yellow one today?’ She just starts screaming and says, ‘You can’t tell me to get dressed!’ And she’s ten.”

Jaival, their new therapist, asks, “Can you tell me how often, on average, you’d say Elia loses her temper? Can you make an average guess at, say, how many times a week?”

Elia’s mother says, “It would be easier to estimate how many times per day.”

Mr. Lahud nods, “Yes, I’d say about 18 times a day, at least once for every hour that she’s awake.”

“And that’s on a daily basis?” says Jaival.

Both parents nod without hesitation.

“How long has it been like this?”

“Well,” Mrs. Lahud tilts her head. “She was always kind of a fussy baby. She’s never slept much and has just kind of always thrown tantrums and never stopped.”

Jaival takes some notes and then asks, “Is there anything else about her behavior that fits a pattern that’s fairly longstanding?”

Mr. Lahud sighs. “It just feels like she wants a big fight, then blames everyone else for something that she started—even when it’s clear no one else is even participating in the fight. It’s getting to be really hard on the other two kids because she just never lets up from the time she wakes up until late into the night; she tries to annoy us and them pretty equally, and now they’re having trouble with her at school too. She’s not getting along with other kids there either.”

“We’ve tried positive reinforcement, like a sticker chart for good behavior—”

“—but after a while,” Mrs. Lahud adds, “we just took it down. The other two kids would have rows of stickers, but she defies even the simplest of rules, so she’d have maybe 1 or 2 stars to their 8 or 10. It started to feel like the sticker chart was just making her feel worse about herself. Her teachers say the same thing.”

Mrs. Lahud’s eyes fill with tears. “We don’t know what to do any more. I feel sorry for her. We can’t help feel that this is not the ‘real’ her, if you know what I mean.”

She looks at her husband, who nods and squeezes her hand.

“She does some pretty mean, spiteful things to ‘get even with everyone.’” Mrs. Lahud continues, “but then the other night, she was quiet and thoughtful when I cuddled with her at bedtime, and while we were alone, she whispered, ‘Mom, why does it have to be so hard to be good? It’s really hard.’”

She breaks down and cries, and her husband hugs her.

1. Jaival meets with Elia subsequently, and though she is very charming and intelligent at first, she does make an effort to annoy him, but he doesn’t take the bait. The next day, with her parents’ permission, the school counselor also calls Jaival, asking if she can share some concerns of her own, which confirm for Jaival that Elia’s parents have pretty accurately described her behavior. Subsequent testing does not reveal a psychotic or mood disorder, and Jaival initially makes a tentative diagnosis of “oppositional defiant disorder.” Do you agree or disagree? What criteria would you cite to support your opinion?

2. What can cause oppositional defiant disorder?

3. Do you think a young patient like Elia, in our case study, could be at risk for suicide?

4. How would you assess a child for suicide risk?

5. Why is self-assessment so crucial when working with this population?

Answer 1

1)

Yes, I agree with the tentative diagnosis of "Oppositional defiant disorder".

I agree on the basis of the following criterias :-

• The patient often loses temper.
• She is often angry and resentful.
• She defies or refuses to comply with requests from others or with rules.
• She deliberately annoys others.
• She often argues with others.
• She is often touchy and easily annoyed.
• She often blames others for her mistakes and misbehaviour.

2)

Oppositional defiant disorder is caused by the following factors :-

• Genetic factors : Oppositional defiant disorder can be hereditary and can be inherited from the parents.
• Birth related problems.
• Neurobiological factors : Deficits and injuries to certain areas of brain.
• Environmental factors : Negative parenting, parent - child conflict, insecure parent - child relationship, family instability and stress, low socioeconomic status, etc.
• Socio - cognitive factors.

​​​​​​​3)

Yes, I think this young patient in our case study could be at risk for suicide.

4)

The child can be assessed for suicide risk. The different steps of assessment for suicide risk are :-

• Identification of risk factors for committing suicide that can be modified to reduce risk.
• Identification of protective factors that can be enhanced to prevent suicide.
• ​​​​​​Clinical interview of the patient should be conducted to know the suicidal thoughts, plans, intent and behaviour of the patient.
• Use of some scales like Suicidal affect - Behavior - Cognition scale, Columbia - Suicide - Severity Rating Scale, etc to measure the level of suicidal risk.

​​​​​​​5)

Self-assessment is so crucial when working with the population with the suicidal risk because this can save the life of a person with suicidal risk. This could help to reduce the risk factors and enhance the protective factors to prevent the suicide.

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