What would be an appropriate DSM-5TR diagnosis based on the following case study? It can include comorbid disorder and/or Z codes.

Identifying Information.Jessie, who refuses to use her last name because "it reminds me of them" (her foster parents), is an 11-year-old white preteen who has, for the last 3 months, been living at the Storyland Home for Girls. She has displayed increasingly disturbing asocial behavior at this facility, which has led to her spending increasing time alone, "shying away" from staff, and watching other peer residents with what was described as

a "cold aloofness." In appearance, she can be described as a wiry, energetic, and wide-eyed red-haired waif. She has her own room at the facility because of her wary behavior and unwillingness to interact with the other residents.

Presenting Concerns.Jessie was referred for counseling by the disciplinary dean at the Storyland School due to escalating concerns about her highly ambivalent reactions to staff and peers.

Background, Family Information, and Relevant History.Jessie was born in Muskegon, Wisconsin, the youngest and unexpected third child to parents who were both under 20 years old. Jessie's mother and father were both raised in the Wisconsin Foster Care System after being abandoned at birth; her father was in recovery for Alcohol Use Disorder. When Jessie was born, her parents were living in a one-bedroom apartment over a grocery store in downtown Muskegon, were receiving government support, and had recently placed Jessie's older brother up for adoption.

Jessie was born 5 weeks premature and presented a significant challenge to her young parents, who were referred to, but did not take advantage of, pre- and postnatal social services resources. As a result, Jessie

received poor postnatal care and was often left in the company of her parents' friends, where she was also neglected. When Jessie was 1 year old, she was removed from her parents' care and placed with a private foster family who hoped to adopt her; however, when those plans fell through, Jessie was moved into a foster-care facility where she remained until 4 years of age. By that time, Jessie was already showing signs of disrupted

attachment, including resisting the attentions of her foster parents, avoiding her foster parents' soothing touch or comforting remarks, hiding from foster siblings in the home, and carefully watching babysitters before responding. She also began a habit of sometimes leaving the home and telling strangers that she was lost.

Invariably, she would be returned to the foster home. In spite of her troubled history, Jessie was once again adopted at age 6 by an ostensibly loving and older couple who convinced the state that they had ample financial and psychological resources to provide for the girl's needs. However, Jessie was harassed by the biological child of this couple and when she began running away from their care at age 8 she had already displayed a

pattern of seeming to indiscriminately approach strangers on the sidewalk as if she was closely familiar to them.

When one of these "strangers" turned out to be a state care worker, Jessie was immediately removed from this couple's care and placed with a middle-aged couple who had successfully raised their own children and who had been foster parents for 15 years. In that home, Jessie appeared to thrive and slowly began to trust her new parents. Although she tested limits, attempted to run away from home, aggressed toward them, and challenged their patience and experience, the couple's commitment to the 9-year-old seemed to be having a positive effect on her. By the time Jessie was enrolled in Storyland Middle School she, at least outwardly, appeared ready to enter into a new social world. She was placed in a small classroom with a teacher who had been extensively trained in providing for the educational and emotional needs of troubled children, and Jessie seemed to trust this woman, at least as much as she had ever trusted anyone before. She formed very tentative bonds with several classmates, mostly other troubled children, joined the school's Martial Arts Program, and was referred to the school guidance department for possible inclusion in group and individual therapy.

Problem and Counseling History.Jessie was referred by the Storyland facility to Creative Counseling Consultants, where she was seen for three sessions separated by a week in time. She was a very charming and superficially endearing child who was playfully dressed in what appeared to be a cowgirl outfit and indicated that "this reminds me of that movie cartoon character who lost her parents and was looking for a family."

Ironically, much of Jessie's creative play, whether it was art, story-telling, clay modeling, or dollhouse activities, centered on themes of disrupted families, abuse of children, and retaliatory behavior against parents. Jessie's affect during this disturbing play was quite flat as she recounted incidents in several of the foster and adoptive placements that "make me feel so angry and sad." The results were a very highly destructive element to her play in that she would angrily erase, destroy, or negate her various creations, followed by a tantrum and withdrawal to a corner of the room. She resisted supportive and compassionate gestures by the evaluator and

made it quite clear that "I don't like you and I'm only doing this because they made me." At such moments, her body stiffened, her face reddened, and she quickly withdrew and stared off into space for minutes at a time.

Jessie spoke dispassionately about the various families with whom she had lived over the years and noted that "if they really loved me they would have kept me . . . I hate them all so much." She angrily added that "they all thought that if they just sent me to a shrink, that I could be fixed . . . like some sort of broken toy." When asked about her current living situation, she quickly shot back with, "Oh yeah, they're nice enough people, but I don't think they're going to keep me and maybe they're just using me to get money from the state like everybody else." Nevertheless, Jessie acknowledged that they seemed different from previous foster or

adoptive parents but that "I'm going to keep a really close eye on them and if they make one wrong move, that's it." Jessie denied having difficulty with her anger, trusting people, or feeling safe, but reluctantly agreed to return to counseling.