case study in guidance and counselling

Writing a Counselling Case Study

As a counselling student, you may feel daunted when faced with writing your first counselling case study. Most training courses that qualify you as a counsellor or psychotherapist require you to complete case studies.

Before You Start Writing a Case Study

However good your case study, you won’t pass if you don’t meet the criteria set by your awarding body. So before you start writing, always check this, making sure that you have understood what is required.

For example, the ABC Level 4 Diploma in Therapeutic Counselling requires you to write two case studies as part of your external portfolio, to meet the following criteria:

• 4.2 Analyse the application of your own theoretical approach to your work with one client over a minimum of six sessions.
• 4.3 Evaluate the application of your own theoretical approach to your work with this client over a minimum of six sessions.
• 5.1 Analyse the learning gained from a minimum of two supervision sessions in relation to your work with one client.
• 5.2 Evaluate how this learning informed your work with this client over a minimum of two counselling sessions.

If you don’t meet these criteria exactly – for example, if you didn’t choose a client who you’d seen for enough sessions, if you described only one (rather than two) supervision sessions, or if you used the same client for both case studies – then you would get referred.

Check whether any more information is available on what your awarding body is looking for – e.g. ABC publishes regular ‘counselling exam summaries’ on its website; these provide valuable information on where recent students have gone wrong.

Selecting the Client

When you reflect on all the clients you have seen during training, you will no doubt realise that some clients are better suited to specific case studies than others. For example, you might have a client to whom you could easily apply your theoretical approach, and another where you gained real breakthroughs following your learning in supervision. These are good ones to choose.

Opening the Case Study

It’s usual to start your case study with a ‘pen portrait’ of the client – e.g. giving their age, gender and presenting issue. You might also like to describe how they seemed (in terms of both what they said and their body language) as they first entered the counselling room and during contracting.

If your agency uses assessment tools (e.g. CORE-10, WEMWBS, GAD-7, PHQ-9 etc.), you could say what your client scored at the start of therapy.

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Writing a Case Study: 5 Tips

Describing the Client’s Counselling Journey

This is the part of the case study that varies greatly depending on what is required by the awarding body. Two common types of case study look at application of theory, and application of learning from supervision. Other possible types might examine ethics or self-awareness.

Theory-Based Case Studies

If you were doing the ABC Diploma mentioned above, then 4.1 would require you to break down the key concepts of the theoretical approach and examine each part in detail as it relates to practice. For example, in the case of congruence, you would need to explain why and how you used it with the client, and the result of this.

Meanwhile, 4.2 – the second part of this theory-based case study – would require you to assess the value and effectiveness of all the key concepts as you applied them to the same client, substantiating this with specific reasons. For example, you would continue with how effective and important congruence was in terms of the theoretical approach in practice, supporting this with reasoning.

In both, it would be important to structure the case study chronologically – that is, showing the flow of the counselling through at least six sessions rather than using the key concepts as headings.

Supervision-Based Case Studies

When writing supervision-based case studies (as required by ABC in their criteria 5.1 and 5.2, for example), it can be useful to use David Kolb’s learning cycle, which breaks down learning into four elements: concrete experience, reflective observation, abstract conceptualisation and active experimentation.

Rory Lees-Oakes has written a detailed guide on writing supervision case studies – entitled How to Analyse Supervision Case Studies. This is available to members of the Counselling Study Resource (CSR).

Closing Your Case Study

In conclusion, you could explain how the course of sessions ended, giving the client’s closing score (if applicable). You could also reflect on your own learning, and how you might approach things differently in future.

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Comprehensive Case Studies in Guidance: A Path to Holistic Understanding

Table of Contents

Have you ever wondered how counselors and educators form a deep, nuanced understanding of an individual’s needs? The answer often lies in the meticulous and revealing process of case studies . Case studies are a powerful tool in the world of guidance and counselling , allowing professionals to collect a comprehensive set of information about an individual. The gathered data is not only rich in detail but also spans various dimensions of an individual’s life, including social attributes, physiological factors, and environmental influences. Let’s delve into how these intricate portraits are painted and the profound impact they can have on educational and vocational guidance.

The anatomy of a case study

At its core, a case study is an in-depth examination of an individual or group. In the realm of guidance and counselling, it’s akin to a detective gathering clues to solve a mystery. But instead of a crime, the ‘case’ is an individual’s life journey.

A well-constructed case study weaves together different threads of a person’s life story. It includes:

• Biographical details: Basic information such as age, education, and family background.
• Medical history: Any relevant health issues that may affect the individual’s wellbeing or capabilities.
• Educational and vocational records: Past academic performance and employment experiences.
• Psychological evaluations: Personality tests, intelligence assessments, and mental health screenings.
• Environmental factors: The individual’s living conditions, cultural context, and support systems.

Gathering the puzzle pieces

Collecting the data for a case study isn’t a one-step process. It involves multiple methods and sources to ensure a full, unbiased picture. Interviews with the individual, their family, teachers, and peers are instrumental. Observations of behavior in different settings, psychological testing, and reviewing past records all contribute to the depth and accuracy of the study. The process is exhaustive but essential for a holistic understanding.

Interviews and observations

Direct interaction with the individual provides invaluable insights into their character, behavior, and circumstances. Observing them in their natural environments, like home or school, offers a glimpse into how they navigate their world.

Psychological assessments

Standardized tests and assessments gauge cognitive abilities, personality traits, and emotional wellbeing. These tools help to identify strengths and challenges that may not be immediately apparent.

Review of records

Past academic records, employment history, and medical files can reveal patterns and pivotal events that have shaped the individual’s journey.

Painting the full picture

Once the data is collected, the real work begins. Counsellors and educators must analyze and synthesize the information to form a narrative. This narrative doesn’t just list facts; it tells the story of an individual’s life, with a focus on identifying their unique strengths and weaknesses. It also illuminates potential paths for development and growth.

Identifying patterns and themes

Patterns in behavior, academic performance, and social interactions can offer clues to underlying issues or untapped potential. Recognizing these patterns is the first step in formulating strategies for guidance.

Understanding the individual’s context

Every person exists within a complex web of environmental and social factors. A case study places the individual within this context, considering how external factors like family dynamics and cultural expectations influence them.

Formulating a guidance plan

With a comprehensive understanding of the individual, counsellors can develop a tailored guidance plan. This plan may address educational choices, career paths, or personal development goals, depending on the individual’s needs and aspirations.

The transformative power of case studies

Case studies are more than just academic exercises; they have the power to transform lives. By providing a deep understanding of an individual’s strengths and challenges, they enable targeted, effective guidance. This can lead to better educational and vocational adjustments, improved mental health outcomes , and more fulfilled lives.

Empowering individuals

A case study can be a source of empowerment, helping individuals understand themselves better and take control of their destinies. It’s a roadmap that points to where they’ve been and where they could go.

Informing educational and vocational decisions

For educators and employers, case studies offer detailed insights that can inform teaching approaches, curriculum design , and job placements, ensuring that opportunities align with individual abilities and interests.

Facilitating growth and development

Perhaps most importantly, case studies can set individuals on a path to personal growth and self\-improvement . They highlight areas for development and serve as a catalyst for change and progress.

Case studies stand as a testament to the unique complexity of each individual. By embracing this complexity, guidance and counselling professionals can provide nuanced support that respects each person’s singular journey. Through the prism of case studies, a one-size-fits-all approach is replaced with a bespoke strategy that acknowledges the richness of human experience.

What do you think? How might an in-depth understanding of an individual’s background influence their future opportunities? Can you think of a situation where a case study approach could have made a difference in someone’s life?

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Guidance & Counselling

1 Understanding Guidance and Counselling

• Guidance: An Introduction
• Need for Guidance
• Purpose of Guidance
• Principles of Guidance
• Types of Guidance

2 Guidance in the School

• Guidance and Curriculum
• Guidance and Learning
• Guidance and Discipline
• Guidance and other Curricular Areas
• Guidance and the Virtual World

3 Personnel in the Guidance Programme

• Need for Guidance Programme and Guidance Personnel
• Counsellors Career Masters and Teachers as Guidance Personnel
• Role of Guidance Personnel
• Need Based Minimum Guidance Programme in Schools and the Role of Personnel

4 Counselling in Schools

• Individual Counselling
• Group Counselling
• Peer Counselling
• Multicultural Counselling
• Crisis Counselling

5 Techniques of Guidance

• The Questionnaire
• Observation
• Autobiography
• Rating Scales
• Anecdotal Record
• Cumulative Record
• Aptitude Tests
• Achievement Tests
• Interest Inventory
• Personality Tests

6 Guidance Programme

• Orientation Service
• Pupil Inventory Service
• Occupational Information Service
• Counselling Service
• Placement Service
• Follow-up Service

7 Group Guidance

• Group Guidance: Concept Need and Significance
• Principles of Group Guidance
• Group Guidance Activities
• Aids to Guidance in Group Situations
• Limitations of Group Activities
• Problems in Organizing Group Guidance Activities

8 Techniques of Counselling

• Counselling Skills
• Behavioural Interventions
• Cognitive Interventions
• Transactional Analysis

9 Nature of Work and Career Development

• Motivation to Work
• Work Affects Way of Life
• Concept of Career Development
• Super’s Theory of Career Development
• Roe’s Theory of Personality Development and Career Choice
• Holland’s Theory of Vocational Personalities and Work Environment
• Ginzberg’s Theory
• Social Learning Theory of Career Development
• Social Cognitive Theory of Career Development

10 Occupational Information

• Collecting Occupational Information
• Classification and Filing
• Updating Occupational Information
• Dissemination of Occupational Information
• Evaluation of Occupational Information Material
• Mobilising Resources for Setting Up Occupational Information Service Programme

11 Career Patterns

• Understanding Career Patterns
• The Relationship of Career Patterns with Life Stages
• Types of Career Patterns
• Determinants of Career Patterns
• Career Maturity
• Vocational Success
• Teacher’s Role in Career Planning
• Role of Parents

12 Career Development of Girls in India

• Career Development of Girls: Salient Features
• Theories of Career Development of Women
• Career Patterns of Women
• Career Problems of Girls
• Role of Teachers

13 Guiding Students with Disabilities

• What Do We Mean by Special Needs?
• Types of Disability
• Provision of Facilities
• Counselling Students with Single or Multiple Disabilities
• Seating Arrangements and Special Attention

14 Socio-Emotional Problems of Students with Disability

• Socio-Emotional Needs
• Importance of the Socio-Emotional Needs
• Emergence of Socio-Emotional Problems
• Stigmatization and Withdrawal
• Emotional Problems
• Problems in Interpersonal Relations and Social Adjustment
• Communication Problems
• Negative Self-concept
• Behavioural Problems
• Problems in Employment

15 Behavioural Problems of Students

• Nature of Behaviour Problems
• Problems of Children
• Problems of Adolescents
• Types of Behaviour Problem
• Causes of Behaviour Problems
• Suggestions for Dealing with Behavioural Problems
• Remedial Measures

16 Mental Health and Stress Management

• Understanding Mental Health
• Mental Healthcare Act 2017
• Impact of Mental Illness
• Characteristics of Mental Health
• Promotion of Mental Health
• Understanding Stress
• Effects of Stress
• Coping Strategies

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Guidance and counseling relations to high school students’ positive development and psychopathology: A non-recursive modeling study

• Published: 06 May 2021
• Volume 42 , pages 4609–4619, ( 2023 )

Cite this article

• Qing Xiong 1 , 2 , 3 ,
• Xiaoyi Fang 1 , 2 ,
• Yang Wu 3 ,
• Haide Chen 4 ,
• Wei Hu 5 &
• Yuchi Zhang 6  

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School guidance and counseling services are important for adolescent development. This study focused on the predictive role of three main delivery strategies (guidance curriculum, group counseling, and individual counseling) on students’ positive development (academic, personal-social, career) and psychopathology (anxiety, depression, problem behaviors) in the high school context. Cross-sectional data were obtained from 59 high schools and 8556 students from mainland China. The results showed that the relationships between the number of times students attended guidance and counseling services and the domains of positive development were significantly higher than the relationship of the services with psychopathology. Furthermore, non-recursive model analyses showed that the latent variable of positive development mediated the influence of the services on psychopathology. In addition, psychopathology mediated the influence of counseling on positive development. The present findings confirm that school guidance and counseling services are effective for student development in China and provide partial support for the classification of guidance and counseling delivery strategies in terms of actual service effects. While paying attention to the differences in delivery strategies, school administrators are advised to consider the indirect effects of guidance and counseling on student development, which benefits the development and integration of comprehensive guidance services.

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Data Availability

The datasets generated during and/or analysed during the current study are not publicly available due ethical considerations but are available from the corresponding author on reasonable request.

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Xiong, Q., Fang, X., Wu, Y. et al. Guidance and counseling relations to high school students’ positive development and psychopathology: A non-recursive modeling study. Curr Psychol 42 , 4609–4619 (2023). https://doi.org/10.1007/s12144-021-01722-7

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Psychology Discussion

Guidance and counselling: tools and techniques | psychology.

ADVERTISEMENTS:

Guidance is the scientific procedure for assisting an individual. Various types of tools and techniques are used for measuring the potentialities of the individual the guidance purpose.

The following are the main tools and techniques which are employed in guidance services:

1. Observation Technique:

The observation technique is not frequently used in guidance and counselling. This is a subjective technique even it is indispensable techniques. For the children no other tool and technique can be used except the observation schedule.

Advantages of Observation:

Observation has certain advantages over the personality test as an approach to understanding children from the practical standpoint. Even hit-or-miss incidental observation gives one a ‘feeling’ for the child’s personality that the test score or even an analysis of the responses to the individual items cannot give. Observation is a relatively ‘free’ situation-one in which the pupils feel the absence of adult pressure-may reveal important aspect of the personality.

This possibility vanished, however, when the pupil knows he is under observation. Then too, observing does not interfere with the usual school activities as testing does. Finally, one can usually see how the child responds in social situations, and note how he reacts to frustrating situations.

Limitations of Observation:

Unfortunately there are many difficulties inherent in the process of observation. In addition to the fact that observation is a highly skilled technique, it is almost impossible for most teachers to spend enough time in observing to enable them to get a well-rounded picture of the child’s personality-in-action.

Errors of properly, or if the observer has no other knowledge of the child, misinterpretation of the meaning of his behaviour is frequent. Bias, of course, on the part of the observer will vitiate the result. In many situations, too, the child, particularly the older child or adolescent, will ‘cover up’ so as to conceal his true feelings. Finally, the same behaviour at different times may not have the same meaning.

Methods of Improving Observation:

Observation may be improved by keeping careful records of the behaviour, preferable writing the observation dawn at the time or, if that cannot be done, as soon afterwards as possible. It is important to pay particular attention to the setting and, if that is vague or equivocal, to forbear from recording the observation.

It is also helpful to record separately the direct observation and the inference drawn from it; this makes possible check by another person on the validity of the interpretation. Simultaneous observation with another capable person and comparison of records afterward is a good method of improving the quality and accuracy of one’s own work.

If the unit of observation are too short, will be highly reliable, but often unimportant observations are likely to be the result. One individual should be observed for measuring one variable at one time. The anecdotal record or check lists prepared in advance may be used.

The Diary Record Method:

Detailed observation of one child is usually for the purpose of comparison with other data already at hand, and to determine the kinds of situations in which he has difficulty. For this purpose a running diary account of the pupil’s behaviour is usually the most length of time and in a variety of situations.

The elementary child may be watched in class, on the playground, in the halls of the child, on the way home, and if possible in the home; the secondary pupil, in the home-room, in various classes, during examinations, in the study hall or library, at a club meeting, or in a child dance, in the child criteria, and in games or sports with his peers.

2. Interview Technique:

Another important technique is the interview technique which is used for collecting information’s about the individual by interview his parents and pears or other family members. It has also some limitations to have the reliable data.

Value of Information from Parents:

From the standpoint of diagnosis, there are two immediate reasons why parents should be seen by the elementary child teacher—to gather sufficient knowledge about a child to provide him with the most suitable educational experiences, and to obtain additional insight into the causes of the behaviour of the child who already has difficulties in adjustment.

The same two reasons apply to the secondary child teacher as well, although the problem of contacts with the parents of the adolescent is complicated by the implied reflection on his feeling of personal worth.

Information for the first of these purposes may sometime be obtained through a questionnaire plus short contacts after child affairs or parents teacher meeting. Although home visits are usually desirable, in most communities teachers do not have time to visit the homes of many of their pupils.

Suggestions for Conducting Interviews:

When the child has shown difficulties in adjustment, it is usually advisable for interviews to be held with at least one of the parents and preferably both. This is frequently difficult to arrange, in view of the many duties of the teacher and the parents, but it usually can be effected by some sacrifice on the part of both. The conference will be facilitated or hindered by the general attitude on the part of the parents toward the child, and by the community’s conception of the role of the teacher.

If the parents have a negative attitude toward the child, and if there is common belief that the teacher’s functions is that of drilling on the three R’s the teacher’s first job will be to establish a friendly attitude before further progress can be made. The teacher should also be alert to differences in cultural background between himself and the parents, to speak in laymen’s language and yet avoid ‘talking down.’

He must appreciate that many parents resent an inquiry into their personal affairs, and in dealing with the parents of problem children he should expect to find many who will be quick to interpret innocuous comments as placing blame on them.

In talking with the parents of young children he should be sensitive to a possible feeling of rivalry on the mother’s part, for the teacher is often the first adult outside the family circle to have an appreciable influence on the child.

Often, too, the parents feel that the child situation is the sole cause of the problem behaviour and that they themselves have no responsibility in the matter. It is particularly important for the teacher to convince the parents that confidence will be scrupulously respected.

3. The Cumulative Record:

The cumulative record means of keeping readily available permanent data about a child. These data in themselves are likely to aid the teacher in appraising the child’s assets and liabilities. The record can also serve as a source of new knowledge if an analysis of the meaningful relationships among the different items is made.

An especially complete record card includes spaces for the following:

i. Tests:  

Intelligence and standardized achievement;

Elementary and high school;

Occupation and nationality of parents, names and ages of siblings, languages spoken;

iv. Health:

Medical examination, physical development, defects, and treatment;

v. Prolonged absences, with causes;

vi. personality-short description by teacher;

vii. vocation-educational aim, vocational aim, special interests,

viii. Vocation-educational aim, vocational aim, special interests, outside employment, school activities;

ix. Records of conferences with pupil-important attitudes, remarks, and decisions.

One can easily see how such a record would provide a valuable basis for guidance of the student in selecting courses, curricula, advanced educational, and a vocational career. It is useful in understanding the maladjusted pupil chiefly as a source of clues for further inquiry. Obviously such a brief compilation of more or less objective data cannot include the type of information needed to understand the sources, and dynamic factors in, most pupil maladjustments.

4. Adjustment Inventory or Schedule:

Adjustment schedules are frequently called self-report blanks, adjustments questionnaires, or inventories. It is impossible to differentiate them clearly from ‘tests’ designed to measure such personality traits as introversion, self-confidence, etc., since most, if not all, aspects of personality are related to adjustment. The purpose of adjustment schedules is to estimate an individual’s degree of adjustment or maladjustment.

In their preparation, as series of questions designed to reveal attitudes, feelings and behaviour indicative of maladjustment is gathered, attempts are made to validate them and they are administered to a representative group, norms are established. Thus, when the inventory is subsequently administered to an individual, the degree of maladjustment indicated by these responses can be compared with those of the original group.

Uses of Adjustment Inventory:

Adjustment inventories cannot yield conclusive assessment due to the following reasons:

i. It is difficult to formulate diagnostic questions which are understood by all and have the same meaning for all.

ii. It is not possible by the use of the inventories which limits to true or false; it is an inventory to expose the extent of adjustment.

iii. An adjustment inventory can be validated.

iv. It is not the reliable. It cannot differentiates.

v. It depends on frankness of the subject in responding.

The adjustment inventories are useful in school situations may be summarized as follows:

i. For identifying some of the pupils needing special aid in adjustment. Those who need help but cannot bring themselves to answer the questions frankly will, of courses, have been located through some other means.

ii. For uncovering unsuspected personal problems through noting an pupil’s answers to the specific questions. The existence of such problems must then be verified through other techniques.

iii. For discovering clues to the basis of the adjustment difficulty by means of a thorough analysis of the answers.

iv. For confirming a suspected maladjustment of a pupils when other evidence yields inconclusive data. (A low score, however, would leave the issue undecided).

Types of Adjustment Inventories:

The adjustment inventories are related to different areas—Home, Health, Social, emotional and School.

These inventories are of the following types:

(i) For elementary child pupils.

(ii) For high child students, and

(iii) For college students or adults.

5. The Case Study:

The case study is the most comprehensive of all methods of special inquiry for use with maladjusted children or with those who exhibit unusual but undeveloped abilities. Such a study is often made by a specialist, though teachers are finding an increasing need to use this device in the course of their professional work.

The case study is employed in a variety of situations. It is an attempt to synthesize and interpret the material gathered by the other techniques for the purpose of making an inclusive picture of the individual and of the background factors affecting his life.

Items of Include in a Case Study:

The amount and kin of information in any one are varies greatly in accordance with its relevance to the particular individual studied, the adequate case study will, with certain exceptions, include information in the nine areas listed below. In accordance with its relevance to the particular individual studied, the adequate case study will, with certain exceptions, include information in the nine area listed below.

In accordance with Allport’s suggestion that “successful case studies seem naturally to fall into three sections – (a) A description to the present status, (b) An account of past influences and successive stages of development, and (c) An indication of future trends,” the topic have been arranged in that fashion.

Allport’s Nine Areas of Case Study :

Suggestions for specific items in the areas must of necessity be tentative. So many variable affect the nature of the information gathered—age, sex, type of problem, to mention but a few-that inevitably some irrelevant items are included and many relevant items are omitted. An attempt has been made to be inclusive rather than brief because many case studies made by teachers and other workers in child have come to erroneous or unsure conclusion owing to the commission of items crucial to understanding the case.

Steps in Conducting a Case Study:

Case studies usually begin with certain identifying data. These include the child’s name, address, age, sex, grade, nationality, colour and religion.

Frequently, too, a very brief description of his physical appearance and a thumbnail sketch of his personality are included. The purpose is to orient the reader or to recall that particular child to the writer of many case studies.

The next topic covered should be the problem, but after that the order of topics depends upon the specific case investigation.

The following information’s are to be collected:

a. Problem at present,

b. Education at present,

c. Intelligence,

d. Health and physical conditions,

e. Development at present,

f. Personality make up,

g. Social adjustment,

h. Educational status if any, and

i. Family conditions-economic and cultural level.

This material should enable one to judge whether the problem originated in the home, the child, or both. In this area one is especially likely to find background material that goes a long way to explain the child’s behaviour.

The Case Study Materials:

In child the best procedure in starting a case study is to assemble the information already collected on the child. The cumulative record, if available, should be consulted first. Usually it is necessary to arrange for tests as the ones on file are not likely to be recent enough. If there is the slightest indication of a physical basis for the problem, a thorough medical examination should be made.

The usual medical examination by the child physician is almost certain to be too superficial to be of much use. Interviews should usually he held with the parents, and the child should be observed in as many situations as can be arranged. Interviews with the child are essential, as only through this means can one establish the type of relationship necessary for understanding the problem and aiding readjustment.

A Diagnosis:

After the material considered pertinent is gathered, there must be an attempt to synthesize; it by comparing the information in the different sections and interrelating it. The purpose is to make a diagnosis, which may be defined as a description of the maladjustment together with the causative factors in both the past and present.

The process is exceedingly difficult; it frequently happens that even when the expert draws on all the psychological and social knowledge at his command he still finds that the case remains unexplained. Certainly the teacher in attempting a diagnosis must use the knowledge of his own motivation and his experiences with other, taking what precautions he can against his own bias.

Remedial Measures:

All the methods of approach to understand the child, constitute at the same time an opening for the prevention of maladjustment. It is through such methods that the teacher can acquire the knowledge of the child’s particular assets and liabilities and of the factors at the basis of his difficulty which are indispensable to the proper use of corrective procedure assets and liabilities and of the factors at the basis of his difficulty which are indispensable to the proper use of corrective procedures.

General prescriptions for handling children’s problems must be of limited value; only the person who understands the specific child can judge whether or not the suggested method of handling is wise or unwise.

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• Understanding Surgical CPT...

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Numerous Current Procedural Terminology (CPT)* coding questions raised during ACS coding courses and received via the ACS Coding Hotline underscore the need to explain key coding concepts in order to ensure accurate coding.

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Laparoscopic Liver Biopsy 

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Concept: It would not be appropriate to report 49321, Laparoscopy, surgical; with biopsy (single or multiple) if the biopsy is the only laparoscopic procedure performed as this code is in the Abdomen, Peritoneum, and Omentum subsection of CPT and not the Liver subsection. For this clinical scenario, code 47379 should be reported and code 49321 should be used as a “proxy” for charges. This information supersedes guidance that was provided in the October 2018 ACS Bulletin column “CPT Coding for Hepatobiliary Surgery.”

Laparoscopic Appendectomy for Perforation

Case: A patient undergoes a laparoscopic appendectomy for perforated appendicitis requiring significantly more work than a typical laparoscopic appendectomy. The reportable code is 44970, Laparoscopy, surgical, appendectomy.

Concept: Although there are separate codes to differentiate an open appendectomy without rupture (44950) and with rupture (44960), there is only one code for a laparoscopic appendectomy (44970), and it is used to report a laparoscopic appendectomy for either scenario; with rupture or without rupture. It would not be correct to report 44979, Unlisted laparoscopy procedure, appendix for a laparoscopic appendectomy for perforation with abscess and peritonitis and use the open code 44960, Appendectomy; for ruptured appendix with abscess or generalized peritonitis as a “proxy” for charges. However, depending on the amount of extra time and/or work effort required when compared to a laparoscopic appendectomy without rupture, it may be appropriate to append modifier 22, Increased procedural services. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).  

Adjacent Tissue Transfer after Breast Surgery

Case: Immediately following a lumpectomy, the surgeon performs reconstructive tissue rearrangement including dissection through the breast parenchyma in order to create a pedicled flap of breast tissue that is then transposed into the defect to improve the contour of the breast. Reportable codes include the following: 19301, Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy) and code(s) for adjacent tissue transfer as appropriate (14000-14041, 14301-14302).

Concept: Reporting adjacent tissue transfer for immediate, partial breast reconstruction following lumpectomy is possible, although it requires the specific criteria for reporting adjacent tissue transfer. In addition to a description of the defect, it requires full documentation of the incisions required to create the pedicled flap of breast tissue, preservation of vascularity, the dimensions of the tissue mobilized, and the technique for transfer of the tissue into the defect. Undermining of the breast tissue off the pectoralis major muscle alone or undermining tissue within the breast parenchyma to advance tissue for primary repair is not considered adjacent tissue transfer and is bundled with the partial mastectomy code and not separately reportable.

Endocrine Surgery

Ca se: A patient underwent a right thyroid lobectomy years ago. It is now necessary to go back and remove the rest of the right lobe and also remove the left lobe (previously untouched). Reportable codes include the following: 60260-RT, Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid, and 60220-LT-59, Total thyroid lobectomy, unilateral; with or without isthmusectomy.  

Concept: This reporting is based on the fact that 60260 is considered a bilateral procedure and since the left lobe was previously untouched, it would be incorrect to report a code for removal of remaining tissue when a total lobectomy is performed.

Case: A patient had a left lobectomy on March 1. On March 14, the patient is taken back to surgery by the same surgeon for a right thyroid lobectomy after pathology showed a malignancy in the right thyroid lobe. Reportable code for the first operation: 60220-LT, Total thyroid lobectomy, unilateral; with or without isthmusectomy. Reportable code for the subsequent operation: 60220-RT-58.  

Concept: Modifier 58 is appended to the second operation because it was a “staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period.”

The ACS collaborates with KZA, Inc. on courses that provide the tools necessary to increase revenue and decrease compliance risk. These courses are an opportunity to sharpen your coding skills. You also will be provided online access to the KZA alumni website, where you will find additional resources and other FAQs about correct coding. Information about the courses can be accessed on the KZA website .

In addition, as part of the College’s ongoing efforts to help members and their practices submit clean claims and receive proper reimbursement, a coding consultation service—the ACS Coding Hotline—has been established for coding and billing questions. ACS members are offered five free consultation units (CUs) per calendar year. One CU is a period of up to 10 minutes of coding services time. Access the ACS Coding Hotline website today .

Dr. Megan McNally is a surgical oncologist at Saint Luke’s Health System in Kansas City, Missouri, and assistant clinical professor in the Department of Surgery at the University of Missouri-Kansas City School of Medicine. She also is a member of the ACS General Surgery Coding and Reimbursement Committee and an ACS advisor to the AMA CPT Editorial Panel.

*All specific references to CPT codes and descriptions are ©2023 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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