Session Summary: Eliza Petrova
Introduction
Full Name of Client: Eliza Petrova
Session Attendance: The session was attended by Eliza Petrova (client), Elena Petrova (mother), and Ivan Petrov (father).
Session Conducted Via: The session was conducted via telehealth, utilizing a secure online platform.
Client Location During Session: The family's address is listed as 456 Pine Ridge Ave, Apt 2B, Lakeview, IL 60000, per the Kickoff Session form. However, the client's specific physical location during this telehealth session was not specified in the provided information.
Confidentiality & Mandated Reporting: Yes, the principles of confidentiality and its limits, including my role as a mandated reporter for safety concerns, were discussed with both the parents and the child.
Key Demographics: Eliza Petrova is an 8 years old.-year-old. Sex assigned at birth: Female. Preferred pronouns: She/her. Gender identity: The client's listed pronouns are she/her. Her gender identity was not explicitly discussed or stated during this session..
Review of Initial Screening Measures: Review of initial screening measures, based on data from pre-assessment forms, indicated the following: MFQ Parent Short Form score was 4/26. The Spence Parent Report yielded a total score of 64/114, indicating an *Elevated Risk*. Subscales also indicating Elevated Risk included: Separation Anxiety (8), Social Phobia (10), Obsessive Compulsive (9), Panic/Agoraphobia (12), Physical Injury Fears (12), and Generalized Anxiety (13).
Session structure followed standard initial assessment flow: introductions, agenda setting, confidentiality review, goal elicitation, exploration of presenting problem (child & parent perspectives), strengths, context/stressors, collateral review, safety screen, summary, formulation/psychoeducation, plan proposal, and logistics, as detailed in the session transcript.
Dimension I: Clinical Presentation
Primary presenting concerns
The primary presenting concern is severe emetophobia (fear of vomiting), reportedly triggered by a gastrointestinal illness approximately one year ago. The child described symptoms including an intense fear of herself or others vomiting; associated physical anxiety symptoms such as a tight or 'bubbly' stomach, throat tightness, rapid heart rate, and feeling hot; and feared cognitions including the unpleasantness of the sensation, fear of judgment, loss of control, and choking. Avoidance behaviors are prominent, encompassing specific foods, restaurants, the school cafeteria, parties, and travel. Safety behaviors include seeking reassurance about food, frequent handwashing related to germ concerns, and checking expiration dates. The client was previously diagnosed with Generalized Anxiety Disorder (GAD) by her Primary Care Physician (PCP). Rapport was established, and goals were elicited from the family during the session.
Impact of child's symptoms on child and on whole family functioning
The child's symptoms result in significant impairment across multiple domains. Regarding eating, she exhibits restrictive eating patterns and significant distress surrounding meals, leading to parental concerns about her nutrition. In the school setting, she avoids the cafeteria, frequently visits the nurse for nausea, requests to go home, is described as quiet and reserved in class, and avoids group activities. Socially, she avoids parties, sleepovers, and has limited playdates, primarily engaging with one friend (Maya) at home. Her sleep is impacted by difficulty falling asleep due to worry about nocturnal nausea. Emotionally, she reports hating to feel worried and describes significant distress. The phobia significantly influences family routines, meals, activities, and travel plans, contributing to high reported family stress, described as 'overwhelming' and 'exhausting.' There is notable tension and disagreement between parents regarding the management of the phobia, specifically concerning accommodation versus encouraging the child to face her fears. Contextual stressors include cultural adjustment, financial pressures, and a lack of extended family support, which contribute to a sense of isolation.
Patient Presentation (Observed)
Eliza initially presented as somewhat shy but became articulate when discussing her fears and engaged positively about her strengths. During the session, she denied suicidal or self-harm ideation.
- Speech: The client's speech appeared fluent and articulate for her age. She was able to describe her internal experiences, such as feelings and thoughts, with some prompting. Her speech volume was appropriate, and her rate of speech was normal. No notable speech-related issues were observed.
- Mood: The client's predominant mood was reported and observed as anxious and worried, particularly when discussing her fears. She self-reported being 'worried all the time,' and her parents described her as 'scared all the time.' Pre-assessment forms also indicated that she sometimes feels sad, unhappy, or miserable. She demonstrated interest and engagement when discussing her strengths.
- Behavior: The client exhibits significant avoidance behaviors related to her phobia, including avoidance of certain foods, places, and social events. Reassurance-seeking and safety behaviors, such as handwashing and checking, are prominent. She is described as quiet and reserved in class and reluctant to participate in group activities. Perfectionistic tendencies were also noted. During the session, she was cooperative and engaged.
- Affect: The client's affect appeared congruent with her reported mood and the content of the discussion. An anxious affect was noted when discussing fears, based on content and tone, with a possibly brighter affect observed when discussing her strengths. Her affective range seemed somewhat constricted by anxiety but was otherwise appropriate. A full assessment of affect was limited by the virtual format and the absence of non-verbal cues in the provided information.
- Impulse Control: The client's impulse control appears adequate. No impulsivity was noted during the session, nor was it reported as a major concern (denied on the FMHC).
- Attention: The client appeared able to focus and attend during the session, answering questions relevantly. Reports suggest potential distractibility due to internal worries or physical sensations (as indicated on the FMHC), and her teacher noted that perfectionism can slow her work completion. Good focus was observed during preferred activities, such as map drawing.
- Motor Activity: The client's motor activity was not described, as non-verbal descriptions were omitted from the available information. Pre-assessment forms suggest she may sometimes appear fidgety or shaky when anxious.
- Insight: The client appears to possess age-appropriate insight. She recognizes her worry as unpleasant, stating, 'I don't like feeling worried all the time,' and is able to connect her specific fears and behaviors to triggers.
- Judgment: The client's judgment appears generally intact. However, it is significantly impaired by her anxiety, which leads to avoidance of situations she perceives as highly risky (e.g., parties, the school cafeteria). Her decision-making processes seem to be overly influenced by fear.
- Thought Content: The client's thought content is characterized by a preoccupation with emetophobic fears, including the possibility of herself or others vomiting, concerns about contamination and germs, and worries about food safety. Specific feared outcomes include experiencing an unpleasant physical sensation, being judged or laughed at, losing control, and choking. She reports intrusive and unpleasant images of vomiting, describing it as 'seeing it happen.' There was no evidence of psychosis.
- Orientation: The client appears oriented to person, place, and situation.
- Hallucinations: Hallucinations were denied by the client and not observed during the session. The client did report experiencing unwanted intrusive *images* related to her fear, which she distinguished from hallucinations.
Parent Presentation (Observed)
Both parents (Elena, mother; Ivan, father) were engaged and open throughout the session. Elena presented as highly concerned, motivated for treatment, and stressed, acknowledging her own anxiety. Ivan presented as frustrated by the phobia's impact, seeking practical solutions, and was open about disagreements on management style. Both parents agreed to the proposed treatment plan and the importance of their involvement.
Past and present attempts to address child's presenting concerns and barriers to progress
Previous attempts to address the concerns include brief school counseling (3-4 sessions at age 7) for cafeteria refusal, which the family deemed 'not very helpful' as it reportedly focused on basic coping skills without addressing the intensity of the emetophobia, leading Eliza to feel unheard. Identified barriers to progress include the severity and intensity of the phobia; a lack of prior specialized treatment such as Exposure and Response Prevention (ERP); parental disagreement on management approaches (i.e., protection/reassurance versus encouraging confrontation of fear), which causes conflict; the mother's own anxiety, which may contribute to accommodation of the child's fears; and the child's anticipation that facing her fears will be 'scary'.
Reporters denied the presence of the following concerns:
Based on pre-assessment forms, reporters denied the following: On the MFQ, endorsements related to feeling no good, hating oneself, being bad, feeling unloved, not feeling as good as others, or doing everything wrong were denied. On the Spence Children's Anxiety Scale, fears of the dark, dogs, heights, and insects/spiders were denied. On the FMHC, concerns related to bullying, fighting, impulsivity, lying, overactivity, or stealing were denied. Regarding medical history, adoption, birth complications, hospitalizations/surgeries, various specific medical conditions (including asthma, allergies, hearing/vision issues), ADHD, Depression, Disruptive Behavior Disorders, Tics, and Learning/Speech disorders were denied. Concerning family history, known genetic disorders, Intellectual Disability (ID), Autism Spectrum Disorder (ASD), Depression, Bipolar Disorder, Schizophrenia, Trauma-related disorders, body image-related Eating Disorders, and suicide were denied. During direct questioning in the session, Eliza denied thoughts of not wanting to be alive or thoughts of hurting herself. Her parents also denied any concerns regarding suicidality or self-harm.
Family and client strengths
Client strengths include being highly intelligent (as reported by her teacher), articulate (as observed during the session), observant (according to her mother), creative (e.g., draws detailed imaginary maps), and curious (e.g., enjoys history and learning). She also enjoys reading historical fiction, plays the piano (when not experiencing significant worry), and demonstrated bravery in sharing difficult feelings during this assessment. Academically, she reportedly excels in reading and writing. Family strengths include a two-parent household structure, parental motivation for specialized treatment, and their presence and engagement during the session. The family is fluent in English and immigrated together from Bulgaria.Dimension II: Relationships and Social Interactions
Family relationships
With whom does the client reside: The child resides with her mother, Elena Petrova, and her father, Ivan Petrov.
Other important adults in child's life: Other important adults in the child's life include her teacher, Ms. Garcia, and her pediatrician, Dr. Susan Chang. She has one close friend, Maya. Her extended family resides in Bulgaria, and no local family support network was reported.
Describe important family members for child: Mother (Elena Petrova), Father (Ivan Petrov).
Relationship dynamics between family members: The parents are married and reside together. Significant tension within the parental relationship was reported, stemming from disagreements on how to manage Eliza's anxiety. The father expressed concern that accommodation may reinforce her fear and stated a desire for a 'middle ground' approach. The mother described a protective instinct driven by Eliza's distress and her own anxiety. Both parents acknowledged this conflict while also expressing love and concern for Eliza. The lack of external support may be increasing pressure on their marital relationship. Eliza is reported to be attached to her mother and frequently seeks reassurance from her, as indicated on pre-assessment forms and consistent with observations during the session.
Social relationships
The client has one close friend, Maya, whom she sees at home. She is described as shy and reserved. Due to her phobia, she avoids group activities, parties, and sleepovers. Her teacher noted that she mostly keeps to herself or plays only with Maya during recess. The client's social functioning is significantly limited by anxiety, and her FMHC peer score indicates a clinical level of concern in this area.
School functioning
While reportedly academically strong, excelling in reading and writing according to her teacher, the child's school functioning is significantly impaired by her anxiety and phobia. She avoids the school cafeteria and is reluctant to participate in group activities, particularly those involving food. She is described as quiet and reserved in class and does not volunteer frequently. She makes frequent visits to the school nurse complaining of nausea and sometimes asks to return home. Perfectionistic tendencies have been noted, which can slow her completion of schoolwork. Her teacher, Ms. Garcia, is reportedly aware of these challenges and is understanding.
School Supports: The child attended 3-4 school counseling sessions, lasting approximately two months, at age 7 due to cafeteria refusal. Her mother reported that this intervention was 'not very helpful' as it did not address the intensity of the specific phobia.
Dimension III: Medical History
Past mental health treatment and diagnoses
Past mental health treatment includes school counseling (3-4 sessions at age 7). Past diagnoses include Generalized Anxiety Disorder, diagnosed by her pediatrician, Dr. Susan Chang. A Specific Phobia, Emetophobia subtype, is suspected based on her presentation.
Current mental health treatment and diagnoses
Current mental health treatment involves initiating therapy at Little Otter. Current diagnoses include Generalized Anxiety Disorder (GAD), as per her PCP. A Specific Phobia, Situational Type (Emetophobia), is strongly indicated by her symptoms.
Current and past psychotropic medications
No current or past psychotropic medications were reported.
Family psychiatric history
Regarding maternal family psychiatric history, the mother reports a personal history of significant anxiety, specifically health anxiety, and acknowledges that her anxiety is triggered by Eliza's symptoms. A maternal aunt has a diagnosis of Panic Disorder. On the paternal side, the father denies a personal history of psychiatric conditions but reports that his mother was a 'worrier.' The paternal grandfather reportedly had issues with alcohol.
Child's physical health history
Current and prior medical diagnoses: Current medical concerns include frequent somatic complaints, such as stomach aches and nausea, which her PCP, Dr. Susan Chang, has linked to anxiety after ruling out underlying medical causes. Prior medical history includes an episode of gastroenteritis approximately 13-14 months ago, which has been identified as the trigger for the onset of her phobia.
History of medical hospitalizations & surgeries: No history of medical hospitalizations or surgeries was reported.
Current healthcare providers for child: The child's current healthcare providers include Dr. Susan Chang of River City Pediatrics (Pediatrician).
Eating and sleeping
Eating challenges: The client experiences significant eating challenges, characterized by food avoidance and restriction due to her emetophobia. She expresses worries about food safety, contamination, and expiration dates. She avoids school lunches, party food, and eating out. Frequent complaints of nausea are reported, and her mother expressed concerns about her nutrition. These eating challenges are understood to be phobia-driven and not related to body image concerns.
Sleeping challenges: The client experiences sleeping challenges, including difficulty falling asleep due to worry about waking up feeling sick or having bad dreams about vomiting. She also reportedly wakes up worrying about feeling sick and avoids sleepovers. The mother also reported experiencing poor sleep due to her worry about Eliza.
Additional details on sleep: The client's nighttime worries primarily center on the possibility of waking up feeling nauseous or experiencing nightmares related to vomiting.
Dimension IV: Psychosocial Stressors
Psychosocial Stressors
For the child, the primary stressor is her severe emetophobia and the associated anxiety, which significantly impacts her daily life across multiple domains. For the family, the child's emetophobia is identified as the main stressor, described by them as having 'completely taken over' and being 'exhausting.' Other significant family stressors include financial pressure related to long work hours and establishing their life in the U.S.; cultural adjustment and acculturation stress following their immigration from Bulgaria five years ago; a lack of a local extended family support network, leading to feelings of isolation; and disagreements and tension between the parents regarding how to manage Eliza's anxiety.
Trauma history
Trauma history for client: No specific trauma history, such as abuse, neglect, or violence, was reported for the client. The episode of gastroenteritis approximately one year ago, which triggered the phobia, could be considered a medically-related event that precipitated her current condition. The family's immigration five years ago is noted as a significant life event and stressor but was not framed as a traumatic experience by the family.
Trauma history in any member of the immediate family: No specific trauma history was explicitly reported for the parents beyond the stress associated with immigration and the current family situation. The family history form indicates no known trauma-related disorders among family members.
Social determinants of health
The family is reportedly experiencing financial stress, cultural adjustment/acculturation stress, and a lack of local family and community support.
Dimension V: Developmental History
Pregnancy, birth, and early development
Concerns during pregnancy or birth: No concerns during pregnancy or birth were reported.
Developmental milestone achievement
Regarding developmental milestones, walking and toilet training were reportedly achieved on time, and talking was achieved early. This information is per pre-assessment forms and was not discussed in detail during the session.
Dimension VI: Risk & Safety
Client and parents denied any current or past suicidal ideation, intent, plans, or self-harm behaviors during the assessment. Client denied lifetime suicidal ideation. Client denied lifetime self-harm thoughts/behaviors. Other relevant risk factors: During direct questioning, both the client and her parents explicitly denied any current or past suicidal ideation, intent, plans, or self-harm behaviors or thoughts. No aggression was reported or observed. Primary risk factors identified relate to the severity of the phobia symptoms, the significant functional impairment (particularly concerning eating habits and potential nutritional impact, which requires monitoring), high levels of distress, and the potential for increased family conflict stemming from parental disagreement on management approaches. A family history of anxiety/panic (maternal line) and substance use (paternal grandfather) is also noted as a relevant factor.
Dimension VII: Cultural Assessment
Important aspects of the family's cultural identity:
The family identifies as White/Bulgarian and immigrated from Bulgaria five years ago. While the primary language spoken at home is Bulgarian, the family is fluent in English. They are reportedly experiencing cultural adjustment and acculturation stress, as well as a lack of nearby extended family support, which contributes to feelings of isolation.
Influence of cultural identity on presenting problem:
Cultural adjustment stress and the lack of a local support network are identified as significant contextual factors that appear to exacerbate family stress and potentially limit their coping resources. It is possible that cultural perspectives on mental health, the expression of illness, or parenting styles may influence parental responses and contribute to disagreements;
Clinical Global Impressions Severity of Symptoms (CGI-S)
Score & Rationale: 6 - Severely Ill. The client's symptoms are pervasive, causing significant distress and major impairment across multiple domains including eating, school attendance and participation, social activities, and family life. This level of impairment far exceeds typical developmental variations for her age.
Clinical Formulation
Clinical formulation
Eliza is an 8-year-old female who presents with a severe Specific Phobia, Emetophobia subtype, and features consistent with Generalized Anxiety Disorder (GAD), as previously diagnosed by her PCP. Her symptoms reportedly emerged and significantly escalated following a gastrointestinal illness approximately one year ago. The core fear involves vomiting (either herself or others), with associated fears related to the physical sensation, potential judgment from others, loss of control, and choking. These fears manifest as intense anxiety (with described physical symptoms), intrusive thoughts and images, significant avoidance behaviors (related to food, the school cafeteria, parties, and travel), concerns about contamination, and safety behaviors (such as reassurance seeking, handwashing, and checking). The impairment resulting from these symptoms is severe across eating, school, social, and family domains. The family context is characterized by significant stress related to managing the phobia, conflict between parents regarding their approach (i.e., protection/reassurance versus encouraging exposure), immigration and acculturation stress, and a lack of local support. The mother has a reported history of anxiety. Client strengths include intelligence, creativity, articulateness, and the family's motivation for treatment. The proposed treatment plan involves Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP), integrated with parent coaching.Recommendations and Plan
Proposed plan for care
The proposed plan for care includes individual therapy for the child, focusing on Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP) specifically tailored to emetophobia. The initial phase of treatment will concentrate on psychoeducation regarding the anxiety and phobia cycle and the development of a coping skills toolbox. This will be followed by the implementation of a gradual, collaborative exposure hierarchy. Integrated parenting support and coaching sessions will be provided to offer psychoeducation, teach supportive response strategies (such as reducing accommodation and reinforcing brave behaviors), foster parental alignment, and assist in managing family stress. Therapy will initially consist of weekly 45-minute sessions. Ongoing monitoring of symptoms and functioning, including eating habits and nutrition, will be essential. Consideration will be given to administering the CY-BOCS checklist to assess for features of OCD.Inviting Collaborators:
With parental consent, consideration will be given to inviting the client's PCP, Dr. Susan Chang, and her teacher, Ms. Garcia, to collaborate for collateral information and coordinated support.
Targets for Parenting Specialty services:
Parent coaching and support integrated into CBT/ERP to offer psychoeducation, teach supportive response strategies, foster parental alignment, and assist in managing family stress.
Disposition:
The disposition is to initiate regular weekly therapy sessions, incorporating CBT/ERP for the child and parent support, as scheduled.