Clinical Assessment Using DSM-IV Classifications

Mr. and Mrs. Lawson brought their 4-year-old adopted daughter, Clara, to see Dr. Mason, a psychiatrist. Clara was polite in greeting Dr. Mason, but did not smile and kept her gaze down as she took a seat. Mr. and Mrs. Lawson sat next to Clara and began explaining their concerns. They described Clara as a quiet child who has recently begun throwing temper tantrums, during which she is inconsolable. Her sleep and eating patterns have changed, and she no longer wants to go to preschool.

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What other information would you like to learn during the interview with the family? What questions would you ask?

According to Freud’s psychosexual cycle Clara, at the age of 4, would have been in with the anal stage of development (Nevid & Rathus, 2005). During this stage, a child learns to control bladder and bowel movements. This is the child’s first implementation of control over themselves and therefore is very pivotal in the child’s development. Likewise, if Clara’s parents were too lenient during potty-training the child might have developed an anal-expulsive personality, which could lead to this type of rebellion. If I were the clinician conducting the interview I would ask the parents about Clara’s childhood development and slowly move to the subject of potty-training. I would ask questions centered around their disciplinary action towards Clara when she did not control her bowel movements properly. Second, according to the behaviorist tradition, I would try to ascertain what positive reinforcement might be prompting Clara’s actions. Specifically, I would ask if Clara gets what she wants when she does misbehave. If so, that positive reinforcement might work against the resolution of the situation. Lastly, I would ask if the child is allergic to any medicines or had been diagnosed with any diseases or maladies. In line with the biological perspective, I would look for any apparent biological explanation for the temper tantrums.

In addition to the clinical interview, what other clinical assessment tools should you consider? Why?

I thought that neurological tests and maybe the Sentence-Completion Test might be helpful clinical tests to administer to Clara. Before trying to find a psychological explanation for Clara’s tantrums it might be prudent to rule out any physiological problems that might exist. A computerized axial tomography (CAT) scan might be the easiest to implement because the child would only be required to put her head in the scanner, rather than the more involved magnetic resonance imaging (MRI) scan. Second, the Sentence-Completion Test might give some insight into Clara’s self-concept and ideal self. This information might be pivotal in understanding the child’s comprehension of herself and her place in the world. Furthermore, it might be sensible to perform some type of clinical observation, maybe naturalistic observation. I would choose the naturalistic approach because I think the results of the observation might be tainted if the observation occurred in an artificial environment. For instance, Clara’s behavior might be associated with rooms, objects, or situations that only occur inside her home. To that end, it would be beneficial to observe Clara in her everyday environment. In this way all associated factors can be brought to bear on the situation, offering a highly contextualized understanding rather than a situation-specific viewpoint.

Although you need more information to begin treatment, what factors might you take into consideration in designing an effective intervention for this family?

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I do not think that any type of pharmacological approach would be appropriate because of the age of the patient. In fact, I think that most of the therapy should center on the parents rather than the child. At the age of 4, a child is little more than a product of their upbringing. Furthermore, other authoritative figures in Clara’s life should be encouraged to sit in on counseling sessions in order to maintain consistency across all possible environments. Grandparents that Clara might stay with and maybe even daycare workers or babysitters should be included in the discussion so that they are up to date on any changes that are decided upon. Clara’s diet should also be a consideration when dealing with these tantrums. If she has a high sugar diet, then this might cause over-activity that can eventually lead to tantrums. It might be appropriate to limit her sugar intake during treatment. Moreover, the grandparents of Clara on both sides should be a major topic of conversation during the counseling sessions with the parents. The way that Clara’s parents were raised could offer great insight into how and why the parents of Clara discipline her. There should also be included in the sessions some discussion of authoritative/permissive/authoritarian attachment styles and how they affect the child’s development.

If you were preparing to diagnose Clara, you would refer to the DSM-IV classification system to evaluate her condition on five separate axes. What type of information would go into each axis? Note: You are not asked to enter a diagnosis, only describe the kind of information that would be entered in each axis.)

The DSM-IV classification system is broke up into 5 different axes, which aim to put forth a complete picture of a person’s psychological, physiological, and behavioral condition. Axis I covers different diagnosable syndromes and disorders which the patient might be suffering from. Examples of an Axis I classification could be anxiety disorders, mood disorders, and depressive disorders. The second type of classification in the DSM-IV is Axis II which covers mental retardation and personality disorders. Furthermore, Axis III is concerned with significant medical conditions which might contribute to the diagnosis. The next classification, Axis IV, centers around situation data related to environmental problems that the patient might be facing. Lastly, Axis V is a global assessment of functioning (GAF) which seeks to ascertain the patient’s overall social, occupational, and psychological operation. Specifically, any information obtained from Clara’s aforementioned CAT scans would fall under Axis III. Likewise, any information gleaned from the Sentence-Completion Test could be used in the Axis I and Axis II classifications. Behavioral information gathered from the naturalistic observation could be useful in many of the categories. Psychotherapy could then be used to determine the likelihood of any type of syndrome or disorder being present in young Clara. It would probably also be beneficial to complete a DSM-IV classification on Clara’s parents as well.

Do you think that diagnosing Clara would be beneficial or harmful? Explain why.

I do think that diagnosing Clara with be harmful to both her and her parents. For Clara, I think that it might legitimize her actions. At that age, all she will understand is that there is a name for the problems she is having. It might be wiser to simply explain to Clara that her actions are wrong and that they need to be fixed. That way she understands that there is a problem and that she is part of the problem, without giving it a name to legitimize the problem. Consequently, I do not think it would be beneficial at all to explain a diagnosis to the parents. They also need to understand that they have played a part in their daughter’s problems. By giving Clara’s problems a name her parents might shift blame from themselves to the 4-year old. In the case of the parents, it would be important to emphasize their part in her tantrums. That way the parents know that action is required on their part to address the situation. Also, the diagnosis of a psychological disorder at that age might forever impair Clara’s future development. In all, I think that even if a diagnosis is obtained through testing and observation it should be withheld from the involved parties for their own interest.


Nevid, J.S., & Rathus, S.A. (2005). Psychology and the challenges of life: Adjustment in the new millennium (9th ed.). Hoboken, NJ: John Wiley & Sons.


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