Download PTSD Analogue Report

Smith, Simon
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CONFIDENTIAL
PTSD Analogue Report
Client Name: Simon Smith
Date of Birth: 11/13/95
Age: 9 years, 4 months
Grade: 3rd
Date of Evaluation: 12/01/05 and 12/02/05
Examiner: Your name, & degree (B.A. or B.S.)
Measures:
Children’s PTSD Inventory (CPTSDI)
Structured Clinical Interview for Axis I Disorders –Child Report (SCID)
separation anxiety, social phobia, ADHD, and substance abuse modules
DSM-IV PTSD Clinical Interviews –Child and Parent Respondents
Child Depression Inventory (CDI)
Revised Children’s Manifest Anxiety Scale (RCMAS)
Documents Reviewed
Transcript of Record from Andrew Smith Elementary School dated 01/09/03-12/02/05
Records from Saint Joseph’s Hospital dated 04/25/05-04/26/05
Sergeant Harahan of the South Carolina Sate Highway Patrol report dated 04/25/05
Reason for Referral:
Simon Smith, a 10 year 0-month old boy was referred for testing by his parents because
they said that they were concerned about his academic achievement after a reported
abduction.
Background Information:
According to Simon’s mother, Simon was a “typical active boy” who loved to play
baseball outside prior to the traumatic event. Mr. Smith said that Simon played on a little
league team. Mr. and Mrs. Smith reported that had lots of friends and performed well in
school before the reported abduction.
Academic records from the first and second grades at Andrew Smith Elementary School
indicate that Simon had an 85 average on a 0-100 point grading scale during the first
grade and a 90 average during the second grad. His school records indicate that he was
absent on 2 days during the first grade and 3 days during the third grade. His average for
the semester after the reported abduction was 65 and the records show that he missed 40
days of class that semester.
Simon’s parents said that he had several friends in his neighborhood prior to the
traumatic event. Ms. Chandler, Simon’s second grade teacher at Andrew Smith
Elementary School, observed in an anecdotal note dated 12/06/05 that Simon “interacts
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very well with other students in his class and myself. He likes going to school and has
done very well in my class.”
As police documents signed by Sergeant Harahan of the South Carolina Sate Highway
Patrol indicates that “A public school bus containing 26 children and a driver were forced
off the road by an armed man in a Chevy pick up truck near Columbia, South Carolina on
April 25, 2005.” Officer Harahan’s report indicates “The assailant boarded the bus and
struck the driver with the but of a revolver rendering her unconscious.” Officer Harahan’s
report indicates that the assailant pointed an automatic pistol at the children and told them
to ‘shut up or you’ll wish that you had’.” Officer Harahan’s report further indicates “the
children were driven to a rural area and moved into an old barn where they remained until
some of the older children were able to force a door open and let themselves out.”
Mr. and Mrs. Smith reported that Simon was seen at Saint Joseph’s Hospital emergency
room. Simon’s hospital record indicates that that he was admitted for observation at 9:45
PM on April 25, 2005 and released on April 26, 2005 with a diagnosis of acute stress
disorder. The discharge records from Saint Joseph’s Hospital also indicate that “Although
Simon is in good physical condition, he is scared and anxious.”
His mother reported that Simon remained at home for three days and then went back to
school. Both parents said that he was feeling much better when he left the house. His
mother reported “Simon returned that day in a terrible condition. He told me that a
counselor had taken him out of his gym class and had him join 20 of the children that had
been on the bus, Each child had to tell the others about what he saw, heard, and felt
during the abduction. Simon told us that he became very upset after hearing what his
classmates had to say about their experiences. He said that when he was called to speak,
he told the counselor that he did not want to talk and the counselor told him that he
should as this would help get it all out. “ His mother reported, “Simon told us that he
spoke about what had happened and this really bothered him.”
Mr. and Mrs. Smith reported that Simon started refusing to go to school after that day.
They also reported that his grades dropped to a 60 average. She said “He started to
complain that he was sick to his stomach and I let him stay home a lot.” According to
Mrs. Smith, Simon also lost all interest in baseball and refused to go outside at all unless
he was forced to do so by his parents.
Test Results:
As based on the administration of the Children’s PTSD Inventory (CPTSDI), Simon met
criteria for chronic Posttraumatic Stress Disorder (PTSD).
With reference to trauma exposure, Simon reported on the CPTSDI that he was riding his
school bus when “A man made the bus stop and got on. He knocked Mrs. Jones out and
pointed a gun at us. I was real scared when this happened. The man told us to shut up or
he would make sure that we wished that we had”. Simon reported that the man “drove out
to the country and made us get into a barn”. He reported that the man “shut the door to
the barn and it was very dark” He said that “after a while, the older kids pushed the door
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open and we ran out”. Simon reported feeling very “scared” and afraid that he “was going
to die” during the incident. Simon said that he sometimes feels as if the experience was
happening all over again.
On the reexperincing and reactivity symptoms, Simon said that he has nightmares about
the incident two to three times a week. He said that he has vivid thoughts about what
happened during the day. He said that he gets very nervous when he sees people that
resemble the assailant. With reference to avoidance and numbing, Simon reported that he
is trying to stay away from school because it reminds him of what happened. He also said
“I am afraid to go outside because the man might come back.” He said that he feels
“different from his classmates. He said that he lost his interest in baseball.
With reference to increased arousal, Simon reported that since the traumatic incident he
has become “very watchful and careful” and that he finds it difficult to “pay attention in
class.” He said that he has problems staying asleep. He also said “I am always on the look
out for danger these days.”
With regard to significant impairments, Simon said that his grades are much lower than
they had been before the incident. He reported, “I don’t have a lot of friends like I used
to.” According to Simon, these symptoms have persisted for more than a month.
A DSM-IV based clinical interview also indicated that Simon meets criteria for chronic
PTSD.
He reported, “A man came onto our bus with a gun and knocked out Mrs. Joneses. He
told us to shut up and drove to the country farm. He backed the bus into a barn and told
us that he was going to shoot us if we made any noise. He locked the door and it got real
dark, After a while some of the older boys were able to open a small door and we ran out.
I was real scared at the time.” He reported reexperincing the incident through nightmares
and flashbacks.
With reference to avoidance and numbing, he said that he feels scared when he sees men
that resemble the assailant. Simon said that he is afraid of going to school because it
reminds him of what happened. He also said that he stays away from shopping mauls
because he becomes anxious when he sees men that resemble the assailant that are
walking in his direction. He said that he has lost interest in sports.
As for increased arousal, he reported that he has trouble going to sleep and can not go
back to sleep after a nightmare. He said that he is “always watching out” since the
incident. He said that “my mind wanders and it is hard to listen in class.”
In terms of impairments, he reported that his school grades have appreciably deteriorated
since the incident.
His academic records from the Andrew Smith Elementary School from the first and
second grades at indicate that he had an 85 average on a 0-100 point grading scale during
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the first grade and a 90 average during the second grad. His school records indicate that
he was absent on 2 days during the first grade and 3 days during the third grade. His
average for the semester after the reported abduction was 65 and the records show that he
missed 40 days of class that semester.
Simon did not meet criteria for simple phobia, social phobia, substance abuse, ADHD,
and major depression modules as indicated by clinical DSM-IV diagnostic interviews.
Simon endorsed some of the criteria for separation anxiety disorder (i.e., he evidenced a
reluctance to go to school or elsewhere). On the other hand, this reluctance was not
exclusively due to a fear of parental separation. He did not endorse symptoms such
nightmares with separation themes, excessive worry about the loss of attachment figures,
or fear that an untoward event will befall an attachment figure.
As based on an administration of the Children’s Depression Inventory (CDI), Simon’s
total CDI score fell on the 55th percentile. His Ineffectiveness and Anhedonia scores fell
on the 55th and 60th percentiles respectively. His Negative mood and Negative self-esteem
scores fall on the 60th percentile. Results from the Revised Children’s Manifest Anxiety
Scale (RCMAS) administration indicated that Simon’s total anxiety score falls on the
90th percentile. His Worry and Social Concerns scores fell on the 90th and 85th percentile
respectively. His physiological anxiety scale on the RCMAS fell on the 50th percentile.
His RCMAS lie score was 20th percentile suggesting that he responded in a truthful way.
Summary:
As based on police, hospital, and parent and child reports, Simon Smith was abducted on
April 25, 2004. Based on administrations of the CPTSDI, clinical parent and child
interviews, Simon met the criteria for a diagnosis of chronic PTSD. Clinical interviews
failed to identify simple phobia, social phobia, substance abuse, ADHD, separation
anxiety and major depression modules. His scores on the CDI, while slightly elevated,
were within normal limits. His scores on the RCMAS were significantly above the
average range.
Diagnostic Impressions:
Axis I – 309.81 Posttraumatic Stress Disorder (Chronic)
Axis II – None
Axis III – Deferred
Axis IV –Academic Problems and Peer Social Interaction Deficits
Axis V – GAF=50
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