case conceptualization of allie doe -...

Running Head: CASE CONCEPTUALIZATION OF ALLIE DOE 1

Case Conceptualization of Allie Doe

Alyssa Heggen

Ball State Universtiy

CASE CONCEPTUALIZATION OF ALLIE DOE2

Identifying Information

Allie Doe is a 7-year old Caucasian girl in the first grade. She has blonde hair and blue

eyes. Compared to other students in her class, Allie seems to be of average height and weight for

her age. Allie dress attire is almost always clean and appropriate. Sometimes Allie’s shirts seem

to be tight, or a bit too small for her body.

Chief Complaint

Allie was referred to counseling at Longfellow Elementary School by her biological

mother. Her mother stated on the referral form that Allie suffers from “separation anxiety.” The

mother further explained that Allie becomes overwhelmed in large crowds, causing her heart to

race and have difficulty in breathing. Because of this, she often wants to leave the room

immediately. The school counselor also reported that Allie would have tantrums before school

started because she would not want to leave her mom to go to class. Specifically, Allie would

cry, kick, and scream. When asked, the teacher reported that Allie would always be calmed down

by the time class began. A couple of times, Allie would ask to go to the nurse when she became

overwhelmed in class. Allie has admitted and confirmed the behavior described above. However,

Allie believes she has improved a lot since last year, where she had tantrums every day before

school for the first few months.

Presenting Problem

Allie has expressed that she wishes she could spend more time with her mom because she

misses her a lot when she’s not with her. Allie lives alone with her biological mother who works

full time. Because her mother works so much, Allie often stays at both her paternal and maternal

grandparents’ house after school. Allie described this routine with a great amount of detail. She

explained that on certain days, she would go to her Grandma Mary’s, whereas other days she


would go to her Grandma Doe’s, unless one of them was sick. Further, if there was a two hour

delay or a school cancellation, she would go to her Grandma Mary’s house. Allie has reported

that even though she likes her grandparents, she doesn’t like spending all her time there because

she only gets four hours a night with her mom. When asked what her and her mom do when they

are together, Allie said they sometimes watch television together and on the weekends they will

go shopping. Here, it seems that not only does Allie not get very many hours with her mom, but

the hours she does get are not quality time spent with her mother. In addition to this, Allie has

also reported that she sleeps in her mom’s bed every night. It seems that all of the factors

mentioned above contribute to the feelings and fits Allie is expressing in the mornings when she

leaves her mom. In addition to separation anxiety, Allie has also reported that she doesn’t have

very many friends besides her cousins. Although Allie has reported having a “boyfriend” in class

that she likes to play with. Allie has further explained that she is a new student this year and is

shy, so she often plays alone at recess.

Behavior Observations

Allie was very quick to build rapport with me during counseling, as evident by her

offering me a toy ring to keep with me from the very first session. Allie is always smiling when I

pick her up from counseling, which allows me to assume she looks forward to counseling. When

Allie walks around in the classroom and hallways at school, she often has her head down, not

looking at anyone in the eye. Similarly, in our counseling sessions, Allie will often prefer to

draw or play with play-dough during our discussions.

In terms of expressing herself, Allie has a large “feeling” vocabulary for her age. When

we reviewed a worksheet with a number of different emotions, such as frustrated, sad, lonely,

excited, etc., Allie was able to describe that emotion and give an example of when she’s


experienced that emotion. Further, Allie’s mother has reported that Allie writes down how she is

feelings on a calendar every day. This behavior and ability to express herself demonstrates that

Allie is very self-aware of her feelings and emotions.

Allie is also very aware of why she is in counseling. In the early stages of our counseling,

Allie expressed that her mom wanted her to work on her feelings about missing her. Because of

these instructions, Allie often likes to take home activities or drawings we do during our sessions

in order to show her mom her progress.

Background Information

Allie is an only child and lives with her biological mother, who was never married to her

biological father. Allie reports that her father makes tee shirts and that she will see him once a

year during the summer. Allie and her mother seem to have a close relationship with the

maternal and paternal grandparents, who often help take care of Allie while the mother is

working. The mother works a 9:00 AM to 5:00 PM job, so she drops Allie off at school in the

morning. Allie will then take the bus home from school to the designated grandparent home for

that day.

In Kindergarten, Allie attended Royerton Elementary School. For about three months of

her Kindergarten year, Allie would throw tantrums in the morning. She would not want to leave

her mom to go to school, so she would cry, kick, and scream. Because of this, Allie’s mother

referred Allie to counseling at Muncie community clinic. Allie reported that she saw a counselor

there for about five months. Allie expressed not enjoying her counseling sessions, but her mom

would make her go because she has anxiety. Allie’s kindergarten round-up scores demonstrate

that she is intelligent, receiving above average scores in all subjects.


In the summertime, Allie spends full days with both sets of grandparents because her

mother is working. Allie describes doing a lot of different activities with her grandparents in the

summertime such as golfing, drawing, and going on vacation to King’s Island.

Since her kindergarten year in school, Allie has moved and is now attending the first

grade at Longfellow Elementary School. Allie’s teacher describes Allie as “very” intelligent.

Allie is in advanced reading level and in the first grade math level. Allie’s teacher has reported

that although Allie has never had a tantrum in class, she will ask to go to the nurse’s office if she

is feeling overwhelmed. The first three weeks of school, Allie would throw tantrums very similar

to the ones she had last year where she would cry, kick, and scream. However, both Allie and the

school counselor were proud to admit that after three weeks, Allie had settled and she was doing

much better. In fact, in the month of October, Allie was awarded Student of the Month.

In terms of health, Allie suffers from seasonal allergies and asthma. In the month of

October, when her mom was replacing the carpet on their house, Allie experienced an asthma

attack that caused her to stay at her grandmother’s and away from school for two days. Allie also

has had several colds since beginning counseling this academic year.

Intervention Plan

Assessment

According to The Child Psychotherapy Treatment Planner (2006), Allie meets the

behavior definition of Separation Anxiety. Allie has demonstrated excessive emotional distress

when leaving her mom before school. According to Allie’s mom and teacher, she has had

repeated complaints and worry, such as having difficulty breathing and asking to go to the nurse,

once separated from her mom. In addition, at age 6, Allie continues to sleep with her mom every

night, which suggests that Allie is unwilling to separate from her mom even in her home. Finally,


Allie has reported playing alone at recess and having few friends besides her cousins,

demonstrating a lack of self-confidence that might be contributing to her fear of being away from

her mom.

Intervention Goals

After consulting and acquiring information from Allie, Allie’s mother, teacher, and

school counselor, I made a clinical decision based on the information from the different

stakeholders that the ultimate goal of counseling for Allie would be to tolerate separation from

her mother without having tantrums and emotional distress. Ultimately, I wanted Allie to

understand and accept her time away with her mother. In addition, I wanted to increase Allie’s

relationships with peers in her class through more play and interaction during free time and

recess. I made this decision based on The Child Psychotherapy Treatment Planner (2006), which

suggested that children who suffer from separation anxiety tend to have difficulties in their peer

relationships due to constant worry and fear when away from the parental figure. In order to

accomplish this, there were several short-term goals that I implemented to help Allie get to a

point where she no longer became upset when she didn’t get to see her mom. First, I wanted

Allie to be able to identify and express the number of feelings she was having when she wasn’t

with her mom. I wanted to help her gain an understanding of the feelings she was experiencing.

With this goal, Gracie will then have a better understand of what she is experiencing, and why

she experiencing, and thus will hopefully be able to handle such emotions appropriately. Once

Allie understood these feelings, our next goal was to develop coping skills or activities that Allie

could do herself when she began feeling separation anxiety. I wanted this to be an empowering

experience for Allie so that she may understand her emotions and better control her actions, and

thus, gain a sense of self-confidence when dealing with situations she may not like. Finally, I


wanted Allie to practice and participate in more peer interactions. This included identifying

friends she can play with and practice asking them to play a game. Again, this short-term goal

was to not only build relationships with her peers, but also to build her self-confidence.

Literature Search

Separation Anxiety Disorder (SAD) is the most commonly diagnosed anxiety disorder in

children, with a prevalence of about 3-5% (Fiese, Winter, Anbar, & Walmboldt, 2010) (Mendez,

Espada, Orgiles, Hidalgo, & Garcia-Fernandez, 2008). Separation anxiety can be

developmentally appropriate during stages such as infancy. However, it can become problematic

for young children when fears and worries about separating from primary caregivers become

excessive and create conflict such as missing school and refusing to sleep in their own bed

(Dallaire, & Weinraub, 2005). It is suggested that SAD has two onsets; juvenile and adulthood.

Those who experience juvenile separation anxiety may eventually recover or evolve into adult

separation anxiety (Kearney, Sima, Pursell, & Tillotson, 2003). Generally, SAD has been found

to not be a very stable disorder, as most children will eventually demonstrate fewer symptoms as

they get older (Kearney et al., 2003). However, studies have also found that children with more

severe SAD also have a greater number of comorbid disorders, especially anxiety-related

disorders such as specific phobias and depression. (Kearney et al., 2003) (Mendez et al., 2008).

In addition, children with more severe SAD have also been found to have greater somatic

complaints and internalizing-behavior problems (Mendez et al., 2008). However, why some

children recover and some do not is a complicated question to answer because of the multitude of

factors that have been found to contribute to children experiencing separation anxiety.

An interesting way of understanding separation anxiety is through John Bowlby’s Theory

of attachment (Dallaire et al., 2005). According to Bowbly’s theory, infants who are securely


attached to their primary caregivers have the confidence and understanding that the caregiver

will be obtainable if needed. On the other hand, insecure infants lack this confidence, become

fearful, and demonstrate coping mechanisms to ensure that their caregiver is near them at all

times. Upon entering elementary school, children who are securely attached seem to be more

outgoing with their peers and less anxious than children who lack such secure attachment.

Research applying this theory has found that responsive parents, emotional support, positive

attitude and stimulation all impact the acquisition of separation anxiety in children (Dallaire et

al., 2005).

An additional study has found that children who suffer from asthma demonstrate higher

rates of separation anxiety than children without asthma (Fiese et al, 2010). It seems that the

experience of an asthma attack, which consists of shortness of breath, wheezing, and coughing

can also be interpreted as symptoms of panic and worry. Such an interpretation can create a

desire to stay close to caregivers. Eventually, the physiological symptoms linked to asthma may

turn into a psychological experience of anxiety. Because of this, Fiese and her colleagues (2010),

emphasize the important of family routines and interactions that allow the child to understand

and feel safe when asthma issues arise. This is an interesting implication considering that Allie

also suffers from asthma, and in fact, has missed school multiple days because of her asthma

attacks.

Other research has found that cognitive-behavioral therapy techniques to be particularly

useful when working with children to suffer from anxiety disorders, including separation anxiety

disorder. Further, family treatment and/or education have found to compliment cognitive-

behavioral techniques well to provide a well-rounded treatment for that child that includes

parental support (Becker et al., 2010). Some interventions that have been included in such


therapy that have been found to be effective include developmentally appropriate skills for

coping with anxiety and exposure exercises that are in the form of games. Parents are also asked

to become involved with the child’s treatment through modeling and reinforcing the coping skills

the child has learned. If needed, parental anxiety management strategies and parent skills training

are also included (Becker et al., 2010). Here, it’s important that the entire family is involved to

reduce feelings of fear and worry in the child.

Case Formulation

Reading the literature about separation anxiety has allowed me to better understand

Allie’s behavior, as well as what has helped and hindered her development of such worry. To

begin, Allie’s situation is quite unique in that she isn’t fearful of leaving her mom because she is

afraid of what might happen when she’s gone, like the typical child who experience separation

anxiety. Instead, Allie expresses strong emotions about leaving her mom because she doesn’t

think she spends enough time with her and doesn’t want that time to end when they are together.

Allie has repeatedly stated she only gets to see her mom for four hours every evening and that

she wishes that time was longer. Allie’s behavior and experiences seem to align with the research

in that there are various factors that influence her anxious behavior. What makes this consistent

is the fact that Allie sleeps with her mom every night, which might create dependency. Sleeping

in her mother’s bed every night does not allow Allie to realize that it is OK for her to be away

from her mom for long period of time. Further, Allie has suggested not interacting well with her

peers. She was expressed being the only child, so there is no one to play with at home; this might

lead to a lack of social skills. Further, Allie has stated that at recess, she often plays alone. It

seems that the lack of social skills has only hindered Allie’s self-confidence. Based on my

observations, I decided it would be most important to help Allie understand her emotions and


feelings when away from her mom so that she may appropriately cope during those situations. It

was also going to be crucial that I help Allie build self- confidence so that she may improve her

interactions with her peers and truly accept being away from her mom.

Intervention and Rationale

One of the first things I wanted to work on with Allie learning and understanding

emotions, particularly in terms of feeling upset and anxious when she leaves her mom. In order

to do this, I brought in a sheet with pictures of 30 faces with various emotions. I reviewed each

of these emotions with Allie and asked her to describe each emotion, or give an example of when

she’s experienced each emotion. Allie did a great job at this task and was able to give personal

examples of many of the emotions. Next, I asked Allie a series of questions about herself and

asked Allie to identify an emotion for each question. Some examples of questions I asked

include, “What feelings do you have when you miss your mom?” “How do you feel when you’re

at school?” and “How would you like to feel instead?” Doing this exercise allowed Allie to

identify how she currently feels and what she would like to feel instead. This exercise took a

couple of sessions. Since then, we often refer back to the emotions sheet to check how she is

currently feeling and what she would like to feel. Since doing other interventions, Allie has

demonstrated progress in counseling while using this emotions sheet by expressing more positive

feelings in regards to schools and spending time with her mom. Specifically, Allie’s mother has

reported marked improvements in Allie’s behavior during her regular morning routine and in the

evenings when Allie’s mother gets home from work. Allie’s mother has also reported that Allie

decided to use a calendar at home to write down how she is feeling every day, thus

demonstrating increased knowledge in expression and awareness of feelings.


Another intervention I did was based on solution-focused therapy. I asked Allie a miracle

question asking, “If you could wake up tomorrow and everything would be perfect, what would

that look like?” This question allowed Allie to envision her life with all her problems solved, and

thus no longer missing her mom. It also helped Allie identify aspects of her life that she would

like to improve. Once Allie thoroughly answered this question, we brainstormed things Allie

could do herself whenever she missed her mom. Allowing Allie to think of things by herself

became an empowering experience for her because she realized she could do things to change

the way she feels. Some of the coping skills Allie came up with included bringing a picture of

her mom to her grandma’s to look at whenever she missed her, and carrying a trinket in her

pocket that reminded her of her mom to school. She also has begun bring her mom’s pillow with

her when she spends the night at her grandma or cousin’s house. Allie said that having these

items has made her feel better. Further, I purchased a small journal for Allie to carry around to

write in whenever she missed her mom to write her thoughts and feelings. We also wrote down

Allie’s coping skills in the journal so she could remember them.

In order to improve Allie’s peer interactions, I implemented role playing in to counseling.

Here, I had Allie practice asking kids in her class to play during recess. We also thought of

several activities she could do that would include playing with others. Role playing during our

counseling sessions gave Allie a safe place to practice social skills that she wasn’t comfortable

with. By allowing Allie to practice and then providing positive feedback gave Allie the

confidence to implement such skills at a later time in the classroom. Once we practiced a skill

enough to where Allie felt comfortable, we made it a goal for Allie to try the skill on a student in

the class at least once before our next session. Allie would then report back the next week and

process how it went. Allie was great at remembering our goals and making an effort to interact


with students more at recess. Although Allie still reports being shy, I see her saying hi to friends

in the hallway and play with friends more during recess.

Case Summary and Evaluation

Since beginning counseling, Allie has made a lot of progress in terms of understanding

her feelings when she misses her mom. Allie is able to effectively communicate when she has

had good weeks or bad weeks and then explain why. Some weeks are better than others, but she

is learning to accept not spending so much time with her mom. This does not mean, however,

that Allie doesn’t wish to spend more time with her mom. Allie still brings up the fact that she

only spends four hours every evening with her mom. Despite this, she seems to be enjoying her

time at school and at her grandparents more.

Allie had a tough time during the winter months because we were not able to meet as

often. She expressed feeling sad because we would not see each other for another three weeks.

She also said she doesn’t enjoy winter break because she spends all day, every day at her

grandmothers’ house. Allie and I talked about this and came up with ways to cope when she is

lonely, bored, or missing her mom. I was at this point that I gave Allie a small journal to write in.

When we met again after winter break, Allie had all positive things to say. She said she got to

see her mom more than she thought she would and she enjoyed playing with her grandmas and

cousins.

Soon after winter break, Allie began reporting playing with friends during school more

and inviting friends to play at her grandparents. When sharing these experiences, Allie is very

energetic and enthusiastic which suggests to me that her self-efficacy has improved. Every

session, I continue to bring up her coping skills and ask whether she has felt the need to use

them. Allie consistently reports positive things, saying she has used them but doesn’t feel she


needs to all the time. This demonstrates to me that Allie has begun to find comfort in her daily

routines at school, her grandmas, and at home.

In the recent month, I have begun to notice that Allie is more and more energetic during

our sessions. At times, it is almost difficult for her to focus on the discussions or activities we do

in counseling. Further, Allie has reported feeling like she has been in counseling for a very long

time, specifically since she was five-years old. I have asked Allie is she feels she needs

counseling. She simply states, “Yes because my mom says I’m anxious.” Since then, I have

began focusing each session on emphasizing all the improvements Allie has been since the

beginning of the school year. Allie will agree that she no longer has fits, she doesn’t miss her

mom as much, and that she is happier. Because of this, I have suggested to Allie terminating our

counseling. I assumed this would be a sensitive topic for Allie because she has past issues with

separation. Because of this, I asked Allie to decide herself how often she feels she needs

counseling. At first, Allie said she wants to see me every day. When Allie said this, I emphasized

the idea of needing counseling, not wanting. Eventually, it was decided between Allie and I that

we would begin the termination process by only having counseling sessions every two weeks.

Since implementing this plan, Allie has done a great job both in and out of counseling and has

reported nothing but good things. Currently, I feel confident that Allie and I will end our

counseling together soon and she will continue to cope appropriately with her separation and

grow in her self-confidence.


References

Dallaire, D., & Weinraub, M. (2005). Predicting children's separation anxiety at age 6: The

contributions of infant-mother attachment security, maternal sensitivity, and maternal

separation anxiety. Attachment & Human Development, 7, 393-408.

doi:10.1080/14616730500365894

Fiese, B. H., Winter, M. A., Wamboldt, F. S., Anbar, R. D., & Wamboldt, M. Z. (2010). Do

family mealtime interactions mediate the association between asthma symptoms and

separation anxiety?.Journal of Child Psychology and Psychiatry, 51, 144-151.

doi:10.1111/j.1469-7610.2009.02138

Hirshfeld-Becker, D. R., Masek, B., Henin, A., Blakely, L., Pollock-Wurman, R. A., McQuade,

J., & ... Biederman, J. (2010). Cognitive behavioral therapy for 4- to 7-year-old children

with anxiety disorders: A randomized clinical trial. Journal of Consulting and Clinical

Psychology, 78, 498-510. doi:10.1037/a0019055

Jongsma, A. E., Peterson, M. L., & McInnis, W. P., (2006). The child psychotherapy treatment

planner (4th ed.). Bruce, T. J. (ed.). Hoboken, NJ: John Wiley & Sons, Inc.

Kearney, C. A., Sims, K. E., Pursell, C. R., & Tillotson, C. A. (2003). Separation anxiety

disorder in young children: A longitudinal and family analysis. Journal of Clinical Child

and Adolescent Psychology, 32, 593-598. doi:10.1207/S15374424JCCP3204_12

Méndez, X., Espada, J. P., Orgilés, M., Hidalgo, M. D., & García-Fernández, J. M. (2008).

Psychometric properties and diagnostic ability of the Separation Anxiety Scale for

Children (SASC). European Child & Adolescent Psychiatry, 17, 365-372.

doi:10.1007/s00787-008-0678-8

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