Georgia result Georgia took on the primary caring

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Georgia is a
12-year-old girl, currently in her second year of high school.  She lives with her Father and 3
siblings.  Georgia’s mother experienced
problems with drugs and alcohol when the children were younger and was rarely
home and her Father works a lot.  As a
result Georgia took on the primary caring role for her siblings which was
compounded when her mother unexpectedly left the family home when Georgia was
8.  Georgia has not had contact with her
mother since.


Georgia has been
referred for counselling due to school refusal, social isolation and angry
outbursts.  The referral states that the
onset symptoms coincided with Georgia’s move to secondary school.



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Based on the
information provided I hypothesis that Georgia meets the Diagnostic and
Statistical Manual of Mental Health, fifth edition (DSM-V, 2013) criteria for a
co-morbid presentation of Major Depressive Disorder (MDD) and Generalised
Anxiety Disorder (GAD).


The DSM-V stipulates
that in order for a diagnosis of MDD to be made 5 of 9 listed symptoms must
have been present for at least 2 weeks and represent a change in functioning,
accompanied by either “(1) a depressed mood or (2) loss of interest or

Georgia appears to
have a depressed mood for most of the day, nearly every day (symptom 1),
evidenced by the report from school that she will often detach from a
situation, either by physically leaving class or withdrawing into her own
world, and her Father report that she frequently returns home from school tearful
and has outbursts of anger at her Father. 
In addition, Georgia has little interest or pleasure in most daily
activities, she will sit alone at lunch times, does not have friendships and
there is no evidence that she takes part in any extracurricular activities
(symptom 2).  Georgia’s Father reports
that she often refuses to attend school, preferring to stay in bed, suggesting
there is a loss of energy or fatigue (symptom 6) and teachers state that she
finds it difficult to concentrate and focus in class (symptom 8).  Finally, the case notes suggest that Georgia
would have feelings of worthlessness nearly every day as she struggles to build
friendships with her peers, reports being bullied, a claim that is dismissed by
her Father, and is often left to care for herself and her siblings, rather than
this care being provided through a reliable adult (symptom 7).   

Section B of the MDD
diagnosis criteria stipulates that the symptoms must cause “clinically
significant distress or impairment in social, occupational, or other important
areas of functioning.”  Georgia’s
symptoms cause significant distress in many of her usual day to day activities,
she is unable for form friendships and interact with her peers, resulting in
severe isolation.  She often detaches
from a situation that is overwhelming and does not want to talk about her
difficulties.  She is refusing to attend
school and prefers to stay in bed. 


The referral notes
that the physical symptoms Georgia reports cannot be attributed to a medical
condition (section c), nor does it suggest that symptoms can be better
explained by another disorder such as schizophrenia (section d).  There is also no evidence of Georgia ever
having a manic or hypomanic episode (section e).


In addition to
symptoms indicating the presence of MDD, Georgia’s symptomologies suggest a
diagnosis of GAD would also be appropriate. Symptoms such as school refusal,
frequent reports of stomach aches, headaches and nausea, a lack of
concentration and irritability, which have been present for at least 12 months,
meet the criteria for section A and C of the DSM-V diagnostic criteria.  Georgia’s teachers report that she will often
leave the classroom or detach into her own world when she becomes nervous
suggests that these feelings are too overwhelming for her to manager, meeting
criteria b.

Georgia finds it
difficult to engage in school activities such as reading aloud and
participating in group work.  She is
isolated from her peers and is unable to form friendships, as a result she is
often alone at break times.  Consequently
I would suggest that her symptoms cause clinically significant distress and
impair her social and occupational functioning, meeting criteria.

In order to assess
the severity of Georgia’s symptoms I would use the PHQ9 and GAD7, a moderate
score would suggest that continued therapeutic work is appropriate.  These assessments can then be used for ongoing
assessment to determine any escalating presentations potentially resulting in
referral to CAMHS for further assessment and intervention.


Criticism of the diagnosis

The symptoms set out
in the referral appear to be consistent with a co-morbid diagnosis of MDD and
GAD, however; such diagnoses fail to fully take into account any attachment
difficulties that may have developed due to Georgia’s lack of a secure base and
any trauma that may have occurred earlier in childhood related to her mother’s
drug use.  The DSM-V provides diagnostic
criteria for Reactive Attachment Disorder (RAD) and it is possible that
Georgia’s symptoms would satisfy these. 
She regularly displays “inhibited, emotionally withdrawn behaviour
towards adult caregivers” and rarely seeks or responds to comfort from them
when experiencing distress (criteria A). 
Georgia’s difficulty in building relationships with adults and peers
demonstrates minimal social and emotional responsiveness to others, and she often directs sudden outbursts of anger at her father (meeting
criteria B).  Georgia’s experience of
being parented indicated a pattern of extreme insufficient care, evidenced by a
persistent lack of comfort, stimulation and affection from both parents (criteria
C).  Georgia’s difficulties could be
attributed to neglectful parenting, later exacerbated by her Mother leaving and
subsequent transition to high school, especially if her primary school provided
her with the secure base that was absent at home. (criteria D).  Georgia’s referral does not include
information that would suggest she meets the criteria for Autism Spectrum
Disorder (criteria E) and her developmental age is above 9 months (criteria G). 

difficulty with providing the evidence required for a diagnosis of RAD will
come from criteria F which stipulates that the disturbance must be evident
before the age of 5.  The information
currently available is not sufficient to assess this point, therefore, further
assessment of Georgia’s early childhood and her attachment patterns would be
necessary. However; research has concluded that children who have been raised
in neglectful caregiving environments are at an increased risk of developing
RAD than those who have not (Smyke et al, 2002), and that “signs of this type
of RAD (inhibited) were associated with depressive symptoms” (Gleason et al,
2011), similar to those exhibited by Georgia. 
Consequently, the case formulation for Georgia should be reflected on
regularly as new evidence and information becomes available, as it is possible
that a diagnosis of RAD would be appropriate.

the theoretical diagnosis does not give specific attention to Georgia’s vacant
episodes that could indicate dissociation. 
Alayarian (2001, pg 150) states that whilst dissociation does not
eradicate the effects of trauma from the unconscious, it makes it “possible to
cut off the thoughts, feelings, and memories of particular trauma.”  Ongoing assessment and further information
from Georgia’s Father and teacher could be sought to explore this possibility

Four P’s



information provided in the referral evidences several factors which could
have contributed to Georgia’s vulnerability.  Georgia is likely to have experienced trauma
and a lack of stabilisation from witnessing her mother in a state of
dysregulation due to her use of drugs and alcohol.  (Wlodarczyk 2017) noted that “children of
parents with drug and alcohol use disorders often grow up under severe stress
and are at greater risk of developing psychological and social problems.” this
stress would have been exacerbated by the worry she may have felt when her
Mother was vacant and unavailable, and further compounded by the
traumatic loss she would have experienced when her mother left the family home

Georgia’s experience of
being parented could undoubtedly be described as neglectful, such a traumatic
experience in early childhood has been showed to have a significantly
detrimental impact on children’s development and the likelihood of them meeting
milestones for cognitive, emotional and behavioural development, which in turn
can lead to difficulties in social interaction and academic ability. ((Hildyard
& Wolfe, 2002).  These difficulties could
then exacerbate Georgia’s negative experience of school and evoke challenging
behaviours, such as school refusal and withdrawal thus compounding poor
progress and confirming Georgia’s perception of school being frightening.

There has been much
research examining the impact of trauma on children’s development

The caring
role that Georgia took on for her siblings could have served to strengthen her
relationships within the family (Aldridge, ), however;
Gopfert (    )
stresses that this role has to be proportionate to the child’s development and
that long term, disproportionate care can have adverse effects on the child’s
experience.  As Georgia is likely to have
taken on the primary care role due to her mother’s drug misuse (East, P.
L., Weisner, T. S., & Slonim, A. 2009) it unlikely that such a role could
be deemed proportionate, especially as this resulted in her missing a lot of
school, something that could be seen as a protective factor, indeed, Kearney
(2001) states that poor school attendance can pose a serious threat to a young
person’s academic and social-emotional development.

Georgia’s caring
responsibilities, as a result of neither parent being consistently available,
either physically or emotionally, resulted in Georgia being more vulnerable, as
Bowlby describes, “when an individual is confident that an attachment figure
will be available to him whenever he desires it, that person will be much less
prone to either intense or chronic fear than will an individual who for any
reason has no such confidence” (Bowlby 1973, p.



Georgia’s transition to
high school appears to have triggered the difficulties described within the
referral.  Martinez, Aricak, Graves, Peters-Myszak
& Nellis (2011) state that this is a period of “significant change and
potential turmoil and difficulty,” during which they have to adapt to new
boundaries and expectations.  Most
children manage this successfully due to other protective factors, such as
having a secure attachment (Duchesne, Ratelle, Poitras & Drouin, 2009),
however; children already suffering with anxious symptoms often experience peer
victimisation (bullying) and find it harder to develop new friendships, as a
result they are more likely to develop low self-esteem, depressive symptoms and
anti-social behaviour (West et al, 2010). 
Further, the working model of high school, whereby students interact
with several teachers during the school day, represents a significant shift
from the nurturing environment fostered by one teacher as seen in a primary
school setting.  Consequently, Georgia
will not have one teacher with whom she can develop a secure attachment, and
who can support with stabilisation, thus the new high school environment can
evoke fear and anxiety.

Georgia’s disclosures of being bullied, whether being used
as a school avoidance tactic, as suggested by her Father, or not, represent a
call for help and by not acting on this Georgia’s Father is confirming her
schema that adults are not reliable or dependable.  It is the absence of a stable relationship
that could have resulted in the physical symptoms Georgia reports which have no
medical explanation, as Benner (2011) states that a stable relationship at home
is vital to building a child’s capacity to relate to others, and engage in
school, and without this foundation children will often experience emotional
and physical distress.  


The information contained within the referral indicates
that there are several factors maintaining the problems reported.  Firstly, it is acknowledged that Georgia’s
Father continues to work a lot, it is therefore plausible to assume that she
continues to take on a significant caring role for her siblings, meaning this
responsibility has been present long-term, something Gopfert
warns about when considering whether the role of a young carer can have
adverse consequences.  Whilst this role
may provide Georgia with a sense of purpose and meaning, her transition to high
school, with potentially different hours, could cause her to feel a lack of
need, alternatively she may feel responsible for her siblings but unable to
care for them whilst she is at school, thus prompting her absenteeism due to
fears that they would otherwise not receive the care they require as no one
else appears to be able to fulfil this role.

Georgia’s internalisaing
behaviour, evidenced by her detaching into her own world or leaving the
classroom put her at greater risk of being bullied and her disclosures of being
victim to this type of behaviour needs to be explored further.  Failing to do this will only serve to
compound her schemas adding to her social isolation and stalling the likelihood
of her developing high quality friendships, something that Bollmer et al (2005) found to be a protective factor
in their research into bullying.


Georgia’s avoidant
behaviours perpetuate her difficulties as it prevents her from discovering
whether the fears she holds about speaking aloud, participating in group work
or building friendships are as frightening as she believes them to be (Johnstnd and Dallos, 2006).


Protective factors

The concerns raised by both Georgia’s Father and the
school should be seen as a protective factor, as provide evidence of a
willingness to implement support.  This
could be utilised within the treatment plan and provide valuable resource for
Georgia outside of any therapeutic sessions, reflecting thoughts that “schools
have a key role to play” in delivering emotional wellbeing and mental health
support as they have access to vulnerable groups and can address “interrelated
academic, emotional, behavioural and developmental needs.” (

Georgia’s role as carer could serve as a protective as
well as perpetuating factor.  Caring for
siblings could give meaning and worth to Georgia.  If her relationships with her siblings are
positive this can be used to highlight purpose and meaning in life.

Georgia’s relationship with the family dog appears to
provide her with the comfort and companionship that is missing from close
relationships and friendships, indeed Zilcha and Mikulincer (2007) have
demonstrated that this type of relationship with an animal can fulfil some of
the needs normally met by a human attachment figure. 


Case formulation

Case formulation provides the development of a theory to
explain a client’s presenting problem and inform the resulting treatment
plan.  Traditionally, CBT formulation has
focused on the individual client, however, the need to incorporate systemic
factors, such as family, friends and agencies has become increasingly acknowledged
as a vital element to the process.  Accordingly,
I have chosen to use Dummett’s model for systemic cognitive-behavioural
formulation (2006).

During early childhood Georgia was forced to take on the
primary care role for her sibling due to her mother’s drug use and both parents
persistent absence from the family home. 
As a result of living in a neglectful environment Georgia would not have
developed the skills or confidence necessary to build positive relationships
with others, consequently she has developed schemas of others as rejecting and
unreliable, herself as unlovable and unworthy and the world as unpredictable
and scary.

These schemas, activated by Georgia’s recent
transition to high school and episodes of being bullied, have intensified her avoidant
behaviours and outbursts of anger.  As a
result she has become hyper-vigilant to situations where she has to
interact with others and in such situations Georgia experiences cognitive
(people will make fun of me), physical (headaches, stomach ache, nausea) and
behavioural (withdrawing either physically or psychologically) symptoms of
anxiety.  Georgia copes with her anxiety)
 by avoiding interaction and relationships
with others, these mechanisms appear to have been activated when she
transitioned to high school, and as a result Georgia is isolated from her
peers, has not formed friendships and is not believed when she discloses
bullying as it is seen as a further attempt to avoid school.  These coping mechanisms
prevent Georgia from building peer relationships which in turn provides Georgia
with the evidence that she is rejected by others and is unlovable, thus she is
caught in a vicious cycle which only serves to compound Georgia’s difficulties
and lead to low mood and depressive symptomologies.


The use of CBT for a wide range of child and adolescent
mental health problems has gained much support, especially for the treatment of
depression (March 2004)
and generalised anxiety (Barrett 2001),
therefore my suggested treatment plan will focus on this with the aim of
stabilising and regulating Georgia.

Sessions to be held in school during the first lesson of
the day, this should help regulate Georgia and enable her to join lessons
afterwards.  Sessions should be play
based and not just a discussion as Georgia’s avoidant behaviours indicate a
purely talking therapy would not be appropriate.  Sessions would make use of:

PuppetsBooksWorksheetsSand trayCreative interventions

should include ongoing elements of psycho-education to provide Georgia with an
understanding of how her thoughts, feelings and behaviours interlink.  Fuggel et al (2013) suggest that the purpose
of psycho-education is three fold; firstly, it will support Georgia to understand
her mental state and how this relates to her actions and behaviours; secondly,
as Georgia becomes more able to describe her difficulties in relation to her
thoughts, feelings and behaviours she will become more able to break the
viscious cycle that she is caught in; thirdly, by exploring this triad of
influencing factors the therapist is better able to produce an evidence-based

training will be integrated within the treatment plan to help Georgia manage
anxious symptoms and aid sleep. 
Techniques such as progressive muscle relaxation (Ollendick and Cerny, 1981) and mindfulness can support exposure to
anxiety provoking situations, such as reading aloud, providing Georgia with the
opportunity to experience the activity positively, thus breaking the vicious
cycle she had developed.

I propose
that Georgia’s Father should be involved in some session as facilitator of the treatment
programme, this will provide him with the skills necessary to support Georgia
to practice some of the skills learnt in sessions.  However, consideration must be given to the
apparent lack of care provided to Georgia by her Father, if it is unlikely he
will be able to commit to this role it should be avoided or there is a risk it
will confirm Georgia’s schema that adults are unreliable and she is unworthy.

assessment will need to be completed throughout the intervention to monitor
progress and allow for informed changes to be made to the plan if appropriate,
I plan to use the following assessment tools.

and adolescent core assessment – beginning and endCYP
IAPT – child outcome rating scale to be used weekly at the beginning of each
session.  This will allow me to gauge how
Georgia is prior to any other work being started and amend the session plan if
to be completed by teacher and parentPHQ9
and GAD7 to be completed every 6 weeks to re-evaluate levels of anxiety and
depression and ensure and monitor progressOngoing
observation and updates from Georgia’s Father and teacher


Criticism of
treatment plan

The referral is missing critical information regarding
Georgia’s presentation prior to starting high school.  It is therefore possible that the symptoms
described have been ongoing since early childhood, especially as we are aware
of her Mother’s drug use and disproportionate caring responsibility.  This information should be explored with
Georgia and her Father prior to treatment commencing to try and ascertain
whether an attachment and trauma based approach to intervention should be
adopted.  The possibility of trauma will
also need to be considered throughout treatment should CBT commence before any
such information is disclosed and the treatment plan changed accordingly. 

Research has highlighted a link between insecure
attachment and greater symptoms of depression, particularly in females (Allen,
2007), consequently alternative treatment could consist of attachment based
family therapy (ABFT), taking into consideration Father’s commitment to
engagement and the history of neglect, this approach would reflect calls for a
greater use of family based interventions when treating adolescent depression
(Restifo and Bögels, 2009).  

“ABFT is an empirically supported treatment designed to
capitalize on the innate, biological desire for meaningful and secure relationships”
(Diamond, G., Russon, J., & Levy, S. (2016).  The therapy is grounded in attachment theory focuses
on the role of attachment and its link to trauma and depression in adolescents,
aiming to address the parental risk factors that are present, many of which are
relevant to Georgia, such as; ineffective parenting, parental stress, parental
criticism and parent-adolescent conflict and support.  This type of therapy would provide Georgia
with the opportunity to openly discuss experiences from her earlier childhood,
such as caring and abandonment, within a safe environment. 











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