Clinical Case Studies, Ahead of Print.
This case study demonstrates the use of a modified evidence-based treatment protocol for “Maya,” a 13-year-old girl who presented with a fear of sleeping alone, Autism Spectrum Disorder (ASD), and separation anxiety disorder (SAD). The treatment, which spanned across 36 sessions, consisted of skills acquisition and exposure, with modifications made to address Maya’s ASD symptoms and cognitive limitations. Modifications for treating comorbid anxiety and ASD are described, including the use of: forced-choice list for emotions and somatic cues of anxiety, concrete props for teaching skills, and a higher level of parent involvement than typical for adolescent clients being treated for anxiety. Based on in-office observations and parental reports of at-home behavior, Maya’s avoidance of sleeping alone decreased over time, and she was able to sleep alone by the end of treatment. This case demonstrates successful treatment of fear of sleeping alone in a child with co-occurring anxiety and ASD.
Category Archives: Clinical Case Studies
Applying the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in a Case of Ultra-High Risk for Psychosis With Emotional Comorbidity
Clinical Case Studies, Ahead of Print.
This case study aims to describe the application of the Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders in the case of a 30-year-old patient with a diagnosis of Ultra-high Risk for Psychosis (UHR) and comorbid anxiety and depression. UP is a psychological intervention that uses cognitive-behavioral techniques whose objective is to reduce emotional dysregulation, which is one of the transdiagnostic mechanisms of emotional disorders. UP has demonstrated its efficacy in samples of patients with emotional disorders. Frank was a 30-year-old man diagnosed with UHR and other emotional disorders (major depressive disorder, bulimia nervosa, generalized anxiety disorder, and social anxiety disorder) who underwent the UP intervention in 15 group and online sessions, lasting 2 hours each, over the course of 4 months. At the 6-month follow-up evaluation, Frank presented significant improvement in all emotional and functioning variables: anxious and depressive symptoms, negative and positive affect, neuroticism and extraversion, emotional dysregulation, maladjustment, and quality of life. There was also a reduction in subthreshold psychotic symptoms. Frank no longer met the criteria for any emotional disorder. We also found an improvement trend, although not significant, in other variables such as insight and cognitive biases measured with specific questionnaires for psychosis. Frank attended all treatment and follow-up sessions and rated the program very positively. UP may be a clinically useful treatment for young people with comorbid UHR and emotional disorders in the early stages of mental health illnesses that could improve clinical and functional outcomes.
This case study aims to describe the application of the Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders in the case of a 30-year-old patient with a diagnosis of Ultra-high Risk for Psychosis (UHR) and comorbid anxiety and depression. UP is a psychological intervention that uses cognitive-behavioral techniques whose objective is to reduce emotional dysregulation, which is one of the transdiagnostic mechanisms of emotional disorders. UP has demonstrated its efficacy in samples of patients with emotional disorders. Frank was a 30-year-old man diagnosed with UHR and other emotional disorders (major depressive disorder, bulimia nervosa, generalized anxiety disorder, and social anxiety disorder) who underwent the UP intervention in 15 group and online sessions, lasting 2 hours each, over the course of 4 months. At the 6-month follow-up evaluation, Frank presented significant improvement in all emotional and functioning variables: anxious and depressive symptoms, negative and positive affect, neuroticism and extraversion, emotional dysregulation, maladjustment, and quality of life. There was also a reduction in subthreshold psychotic symptoms. Frank no longer met the criteria for any emotional disorder. We also found an improvement trend, although not significant, in other variables such as insight and cognitive biases measured with specific questionnaires for psychosis. Frank attended all treatment and follow-up sessions and rated the program very positively. UP may be a clinically useful treatment for young people with comorbid UHR and emotional disorders in the early stages of mental health illnesses that could improve clinical and functional outcomes.
Combined ACT-Based Contingency Contracting Intervention for Aggressive Behavior and Psychologically Flexibility in an Adolescent With Comorbid Autism, Bipolar Disorder, and Schizophrenia
Clinical Case Studies, Ahead of Print.
Comorbid diagnoses including autism spectrum disorder, bipolar disorder, schizophrenia, and intellectual disability can present a variety of personal barriers and challenges to interventions that promote safety and autonomy. The current case study provides an overview of a 10-week intervention that included elements of Acceptance and Commitment Therapy and contingency contracting to target psychological flexibility and aggressive behavior in a 17-year-old presenting with these comorbid diagnoses. The treatment was fully individualized to include the client’s interests in Star Wars and focused on supporting the client’s self-identified valued outcomes associated with independent living. Prior to intervention, baseline data showed high levels of aggressive behavior in both frequency and duration, and low levels of psychological flexibility and adaptive behaviors were reported. Following implementation of the combined intervention, aggressive behavior reduced significantly below baseline levels, psychological flexibility improved, and the client engaged in a greater frequency of adaptive behaviors relative to baseline. Positive outcomes were also maintained 1-month and 1-year following the intervention. Implications of this case for clinicians and staff are discussed.
Comorbid diagnoses including autism spectrum disorder, bipolar disorder, schizophrenia, and intellectual disability can present a variety of personal barriers and challenges to interventions that promote safety and autonomy. The current case study provides an overview of a 10-week intervention that included elements of Acceptance and Commitment Therapy and contingency contracting to target psychological flexibility and aggressive behavior in a 17-year-old presenting with these comorbid diagnoses. The treatment was fully individualized to include the client’s interests in Star Wars and focused on supporting the client’s self-identified valued outcomes associated with independent living. Prior to intervention, baseline data showed high levels of aggressive behavior in both frequency and duration, and low levels of psychological flexibility and adaptive behaviors were reported. Following implementation of the combined intervention, aggressive behavior reduced significantly below baseline levels, psychological flexibility improved, and the client engaged in a greater frequency of adaptive behaviors relative to baseline. Positive outcomes were also maintained 1-month and 1-year following the intervention. Implications of this case for clinicians and staff are discussed.
An Intervention Program for Families of Adults on the Autism Spectrum: A Case Study
Clinical Case Studies, Ahead of Print.
Caregivers of adults on the autism spectrum report having limited access to resources that aid in supporting their child and helping them lead more independent lives. There is a need for interventions designed to teach caregivers strategies that address challenging behaviors, as well as promote independence. Using a case study design, we evaluated the preliminary feasibility and acceptability of Research Units in Behavioral Intervention (RUBI) with caregivers of three adults on the autism spectrum. Outcomes support preliminary feasibility and acceptability, as indicated by low attrition (0%) and high adherence to the RUBI manual (mean adherence = 91%). Following intervention, all adults on the autism spectrum demonstrated decreased levels of challenging behaviors and increased independence. The results of this study provide insight on next steps for investigation, including avenues for RUBI adaptation when delivered to adults on the autism spectrum and their families.
Caregivers of adults on the autism spectrum report having limited access to resources that aid in supporting their child and helping them lead more independent lives. There is a need for interventions designed to teach caregivers strategies that address challenging behaviors, as well as promote independence. Using a case study design, we evaluated the preliminary feasibility and acceptability of Research Units in Behavioral Intervention (RUBI) with caregivers of three adults on the autism spectrum. Outcomes support preliminary feasibility and acceptability, as indicated by low attrition (0%) and high adherence to the RUBI manual (mean adherence = 91%). Following intervention, all adults on the autism spectrum demonstrated decreased levels of challenging behaviors and increased independence. The results of this study provide insight on next steps for investigation, including avenues for RUBI adaptation when delivered to adults on the autism spectrum and their families.
A Clinical Case Study of Solution-Focused Brief Therapy for Young Adult Cancer Patients’ Psychological Distress: Focusing on Positive Emotions
Clinical Case Studies, Ahead of Print.
Psychological distress is highly prevalent among adolescent and young adult (AYA) cancer patients, an age-defined population (15–39) disproportionately impacted by their cancer diagnosis. Solution-focused brief therapy (SFBT) is a strength-based and evidence-supported approach for youth with medical conditions. The use of SFBT in young cancer patients, however, has been rarely described. Building on the broaden-and-build theory of positive emotions, this study describes how SFBT clinicians intentionally foster positive emotions, especially hope, in an AYA cancer patient to foster therapeutic change. We found improvements in the patient’s psychological distress as well as growth in levels of hope both in the immediate post-intervention assessment and in the 2-week follow-up. The findings of the study suggested that SFBT is a promising approach to the unique challenges confronting AYAs with cancer. It was not feasible for this case study to match the sex and racial identities for a therapist with the client’s preference, which is considered a main limitation of this study.
Psychological distress is highly prevalent among adolescent and young adult (AYA) cancer patients, an age-defined population (15–39) disproportionately impacted by their cancer diagnosis. Solution-focused brief therapy (SFBT) is a strength-based and evidence-supported approach for youth with medical conditions. The use of SFBT in young cancer patients, however, has been rarely described. Building on the broaden-and-build theory of positive emotions, this study describes how SFBT clinicians intentionally foster positive emotions, especially hope, in an AYA cancer patient to foster therapeutic change. We found improvements in the patient’s psychological distress as well as growth in levels of hope both in the immediate post-intervention assessment and in the 2-week follow-up. The findings of the study suggested that SFBT is a promising approach to the unique challenges confronting AYAs with cancer. It was not feasible for this case study to match the sex and racial identities for a therapist with the client’s preference, which is considered a main limitation of this study.
Grandparent-Implemented Interventions to Reduce Challenging Behavior of an Adult With Autism: A Pilot Telehealth Case Study
Clinical Case Studies, Ahead of Print.
Adults with autism spectrum disorder (ASD) often engage in challenging behavior that requires individualized intervention to remediate. However, access to high-quality services is limited for adults, leaving this population without necessary behavioral healthcare. This study addressed the needs of a 22-year-old man with ASD and intellectual disability (ID) who lived with his grandmother and engaged in tangibly maintained challenging behavior. The interventionist coached his grandmother via telehealth in the implementation of two behavior analytic interventions: signaled multiple schedule arrangement and a modified contingency contract. The effects of the interventions were evaluated using an alternating treatments design with baseline. While both interventions were effective at decreasing challenging behavior when compared to baseline, the signaled multiple schedule arrangement resulted in zero instances of challenging behavior. Both the participant and the grandparent completed post-intervention social validity assessments and reported overall positive satisfaction with the interventions. Practice recommendations are presented.
Adults with autism spectrum disorder (ASD) often engage in challenging behavior that requires individualized intervention to remediate. However, access to high-quality services is limited for adults, leaving this population without necessary behavioral healthcare. This study addressed the needs of a 22-year-old man with ASD and intellectual disability (ID) who lived with his grandmother and engaged in tangibly maintained challenging behavior. The interventionist coached his grandmother via telehealth in the implementation of two behavior analytic interventions: signaled multiple schedule arrangement and a modified contingency contract. The effects of the interventions were evaluated using an alternating treatments design with baseline. While both interventions were effective at decreasing challenging behavior when compared to baseline, the signaled multiple schedule arrangement resulted in zero instances of challenging behavior. Both the participant and the grandparent completed post-intervention social validity assessments and reported overall positive satisfaction with the interventions. Practice recommendations are presented.
Therapist-Assisted Internet-Delivered Cognitive Behavioral Therapy for Insomnia: A Case Report
Clinical Case Studies, Volume 22, Issue 4, Page 383-402, August 2023.
Despite its well-documented efficacy, few clinicians are trained to deliver Cognitive Behavioral Therapy for Insomnia (CBT-I), and it remains an inaccessible treatment. Therapist-Assisted Internet-Delivered Cognitive Behavioral Therapy for Insomnia (TAI-CBT-I) holds promise for overcoming barriers to accessing this evidence-based treatment. However, to date, there have been no case reports published that describe how to deliver TAI-CBT-I. This case report fills in this gap by illustrating the application and utility of such a treatment on an asynchronous platform. We report on a course of TAI-CBT-I for a 34-year-old Caribbean Canadian male who presented with chronic insomnia characterized by difficulty falling and staying asleep, night awakenings, and reduced helpfulness from medication. Self-report measures of sleep, depression, functioning and ability, and therapist satisfaction were administered throughout treatment, post-discharge, and at follow-up. Improvement was noted across all measures. This case report demonstrates that TAI-CBT-I can be an effective treatment for chronic insomnia and showcases how to deliver it.
Despite its well-documented efficacy, few clinicians are trained to deliver Cognitive Behavioral Therapy for Insomnia (CBT-I), and it remains an inaccessible treatment. Therapist-Assisted Internet-Delivered Cognitive Behavioral Therapy for Insomnia (TAI-CBT-I) holds promise for overcoming barriers to accessing this evidence-based treatment. However, to date, there have been no case reports published that describe how to deliver TAI-CBT-I. This case report fills in this gap by illustrating the application and utility of such a treatment on an asynchronous platform. We report on a course of TAI-CBT-I for a 34-year-old Caribbean Canadian male who presented with chronic insomnia characterized by difficulty falling and staying asleep, night awakenings, and reduced helpfulness from medication. Self-report measures of sleep, depression, functioning and ability, and therapist satisfaction were administered throughout treatment, post-discharge, and at follow-up. Improvement was noted across all measures. This case report demonstrates that TAI-CBT-I can be an effective treatment for chronic insomnia and showcases how to deliver it.
Skills Training in Affective and Interpersonal Regulation Narrative Therapy Delivered via Synchronous Telehealth: A Case Study of a Rural Woman Veteran With Complex Posttraumatic Stress Disorder
Clinical Case Studies, Volume 22, Issue 4, Page 420-435, August 2023.
The International Classification of Diseases–11th Revision (ICD-11) includes the diagnosis of complex posttraumatic stress disorder (CPTSD). Clinical practice guidelines support the use of phased care for individuals with CPTSD. This case study illustrates the use of synchronous telehealth to deliver phased treatment to a rural woman veteran with CPTSD. Mrs. A experienced sexual, physical, and emotional abuse throughout her life, perpetrated by family members, intimate partners, and military authority figures. She sought treatment for posttraumatic nightmares and body image issues; she also had pain related to fibromyalgia and chronic migraine headaches. Mrs. A participated in 19 sessions of Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative therapy via synchronous telehealth. Trauma and eating disorder symptoms were assessed before and after treatment and the patient demonstrated clinically significant improvement on measures of these disorders. Patient-provider working alliance and quality of life were assessed post-treatment. Synchronous telehealth use drastically increased with the onset of COVID-19; however, little information on treating CPTSD via synchronous video teleconferencing is available. This case study illustrates an evidence-based, phased therapy for CPTSD while highlighting the feasibility and value of in-home delivery of psychotherapy for CPTSD via synchronous telehealth.
The International Classification of Diseases–11th Revision (ICD-11) includes the diagnosis of complex posttraumatic stress disorder (CPTSD). Clinical practice guidelines support the use of phased care for individuals with CPTSD. This case study illustrates the use of synchronous telehealth to deliver phased treatment to a rural woman veteran with CPTSD. Mrs. A experienced sexual, physical, and emotional abuse throughout her life, perpetrated by family members, intimate partners, and military authority figures. She sought treatment for posttraumatic nightmares and body image issues; she also had pain related to fibromyalgia and chronic migraine headaches. Mrs. A participated in 19 sessions of Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative therapy via synchronous telehealth. Trauma and eating disorder symptoms were assessed before and after treatment and the patient demonstrated clinically significant improvement on measures of these disorders. Patient-provider working alliance and quality of life were assessed post-treatment. Synchronous telehealth use drastically increased with the onset of COVID-19; however, little information on treating CPTSD via synchronous video teleconferencing is available. This case study illustrates an evidence-based, phased therapy for CPTSD while highlighting the feasibility and value of in-home delivery of psychotherapy for CPTSD via synchronous telehealth.
Increasing Food Consumption With an Antecedent and Reinforcement-Based Treatment Generalized Via Telehealth
Clinical Case Studies, Volume 22, Issue 4, Page 403-419, August 2023.
We report a case with a 7-year-old girl with autism spectrum disorder and anxiety disorder who had severe restrictive eating leading to various medical concerns raised by her pediatrician. Following medical consultation and a descriptive functional assessment, a therapist implemented behavioral intervention consisting of a visual cue, choice, and differential reinforcement of alternative behaviors. The intervention was focused on both in-home meals and telehealth consultation during mealtimes, as the COVID-19 pandemic necessitated moving to remote consultation for continued treatment. The success of this study has long-standing implications for the benefits of positive feeding interventions and telehealth as well as parental training strategies.
We report a case with a 7-year-old girl with autism spectrum disorder and anxiety disorder who had severe restrictive eating leading to various medical concerns raised by her pediatrician. Following medical consultation and a descriptive functional assessment, a therapist implemented behavioral intervention consisting of a visual cue, choice, and differential reinforcement of alternative behaviors. The intervention was focused on both in-home meals and telehealth consultation during mealtimes, as the COVID-19 pandemic necessitated moving to remote consultation for continued treatment. The success of this study has long-standing implications for the benefits of positive feeding interventions and telehealth as well as parental training strategies.
The Impact of Maternal Depression on Internet-Parent–Child Interaction Therapy for Child Attention-Deficit/Hyperactivity Disorder: A Case Study
Clinical Case Studies, Volume 22, Issue 4, Page 363-382, August 2023.
Conduct disorders and attention-deficit/hyperactivity disorder (ADHD) are highly comorbid, with an estimated prevalence rate of 51.5% for children between 2–17 years of age (Centers for Disease Control and Prevention, 2020). Parent–Child Interaction Therapy (PCIT) is an empirically supported behavioral parent training program for children with disruptive behavior. PCIT research consistently demonstrates decreases in disruptive behaviors and increases in positive parenting strategies among families of young children with ADHD; however, PCIT has yet to become widely recognized as a treatment for ADHD. This case study presents the treatment of a 6-year-old boy with ADHD and severe behavior problems. The case was further impacted by the single mother’s depressive symptoms and internet delivery of PCIT during the COVID-19 pandemic. Findings from this case report documented an improvement in disruptive child behaviors and emotion regulation and increased positivity during parent–child interactions, despite worsening maternal depressive symptoms. This case study highlights the utility of PCIT to improve child disruptive behaviors and ADHD symptoms in the midst of several complicating factors.
Conduct disorders and attention-deficit/hyperactivity disorder (ADHD) are highly comorbid, with an estimated prevalence rate of 51.5% for children between 2–17 years of age (Centers for Disease Control and Prevention, 2020). Parent–Child Interaction Therapy (PCIT) is an empirically supported behavioral parent training program for children with disruptive behavior. PCIT research consistently demonstrates decreases in disruptive behaviors and increases in positive parenting strategies among families of young children with ADHD; however, PCIT has yet to become widely recognized as a treatment for ADHD. This case study presents the treatment of a 6-year-old boy with ADHD and severe behavior problems. The case was further impacted by the single mother’s depressive symptoms and internet delivery of PCIT during the COVID-19 pandemic. Findings from this case report documented an improvement in disruptive child behaviors and emotion regulation and increased positivity during parent–child interactions, despite worsening maternal depressive symptoms. This case study highlights the utility of PCIT to improve child disruptive behaviors and ADHD symptoms in the midst of several complicating factors.