INTRODUCTION

Annalisse is a 6-year-old Caucasian female who lives with her foster parents and foster brother in a single-family home in a small town. Annalisse is related to her foster mother and her father is her foster mother’s nephew. Annalisse is in kindergarten and is in a regular education classroom but has an Individualized Educational Plan (IEP) due to issues with attention. Her foster mother reports that “Annalisse does well at school when she is paying attention.” She attends school regularly and reports that she likes people. However, her foster mother reports that Annalisse is “so high energy that friends eventually ask her to leave.”

Annalisse was removed from the care of her biological parents due to neglect. During an incident between her parents, the police were called to her residence. On arrival, the police found Annalisse strapped naked in her car seat in the corner. The police reported to children’s services that they had found a neglected 6-month-old child. In actuality, Annalisse was 2 years old at that time. Annalisse was so malnourished that she gave the perception of being only 6 months old. When the police tried to remove her from the car seat, they found that she was congealed in her seat. She had not been removed from the seat for some time and had been urinating and defecating on herself. When Annalisse was examined at the hospital, they found that her vaginal walls were sealed together. They had to separate her vagina during her hospitalization.

FAMILY HISTORY

Annalisse’s parents struggle with mental health and drug and alcohol issues. Her father is reported by her foster mother to have a severe temper. Annalisse’s foster mother believes that her nephew is a batterer and that is why none of his relationships work out. Annalisse has many half-siblings, although she has not seen any of them. They are all in the care of children’s services or live with their individual biological mothers.

Annalisse’s father may have some cognitive delays or disabilities. After Annalisse was born, he read on the internet that cherry juice works just as well as formula for an infant. Her father began giving Annalisse cherry juice instead of formula. He also had given her a taste of strawberry frosting and Annalisse appeared to really like it. From then on, he fed her strawberry frosting only. This is thought to be the reason that she was so malnourished when she was found. This also caused all of her teeth to rot out. When her foster mother received custody of Annalisse, one of the first procedures Annalisse had to endure was to have every tooth in her mouth removed.

Annalisse’s foster brother Keith has suffered some of the same neglect that Annalisse did as a child. Keith is 23 years old now and he and Annalisse do not get along well due to Keith being very “hard” on her. Keith talks about how he does not want her to make the same mistakes that he made. He was also raised by parents who have mental health, alcohol and drug, and battering issues. Keith calls Annalisse names and constantly yells at her when she makes mistakes. He does not admit to hitting Annalisse, but she is often left in his care and Keith reports punishing her “when she is bad.” Annalisse appears to be afraid of Keith and sad in his presence.

Annalisse’s foster parents have been married for 30 years. They were never able to have children of their own. They adopted Keith and his brother Kevin when they were 8 and 9 years old. They are now 23 and 22. Kevin is away in the Navy. Annalisse’s foster parents also have had numerous foreign exchange students every year for at least 20 years. Currently, there is a student from Paris named Pierre living with them during his school year.

CURRENT FUNCTIONING

Annalisse is overly friendly and has no fear of strangers. She is very anxious every day and fears that her foster parents will die. Annalisse has asthma and allergies and takes medication for both. Annalisse does not listen. She does not follow through on directions and does not pay attention or sustain attention. She consistently overlooks important details. Annalisse is impulsive all of the time. She is easily distracted and forgetful. Annalisse has mood swings, which are mostly happy to sad. She is hyper every day, squirms, runs, and uses things without permission. Annalisse does not like to be quiet, seated, or noninteractive. She has a hard time getting to sleep every night, so she takes melatonin.

Annalisse cannot handle being away from her foster parents. When her foster father told her that he was going to go out to the waiting room, Annalisse began decompensating and held onto to him. She began hyperventilating and crying excessively. These behaviors are increased when Annalisse is forced to have visitation with her biological parents. The visits are supervised by her foster parents, but each visit leaves her more and more concerned that she would have to go back to living with her biological parents. Annalisse’s biological mother tells Annalisse that her foster mother is not her real mother.

Annalisse is a very sweet and kind child. Her foster father tends to favor her due to what she has experienced in her life. He admits that he has a soft spot in his heart for her. Annalisse’s foster parents have always wanted a girl, but it was never meant to be, until now. Annalisse’s foster mother tends to be more of the disciplinarian in an appropriate and authoritative manner.

DIAGNOSTIC IMPRESSIONS

Annalisse continues to feel the effects of her early childhood trauma. She is a sweet and kind child, however, she suffers from severe anxiety due to fear that she will be sent back in her biological family’s care or lack thereof. Annalisse’s foster family has no intention of allowing this to happen and they have filed for her permanent custody.

Annalisse has a lot of energy and is “busy” all the time. She makes friends easily but can be “too much” for most friends. Annalisse has a hard time listening, following directions, paying attention, being impulsive and forgetful, and does things without permission. Annalisse has a hard time sleeping at night and needs melatonin to get to sleep and stay asleep.

Annalisse lacks insight into her issues. She needs to have individual treatment, community psychiatric supports and treatment, and a referral for medication. She will need to process her trauma and be taught coping skills to deal effectively with her past and future self. She has an IEP to manage her many symptoms that appear to be attention deficit hyperactivity disorder (ADHD) and that should be assessed, especially if she begins medication.

DIAGNOSTIC CONCLUSIONS

SUGGESTED THERAPEUTIC INTERVENTIONS

Annalisse could benefit from Trauma Focused Cognitive Behavioral Therapy (TF-CBT). TF-CBT could be utilized to process the trauma that Annalisse has endured. This treatment modality can also provide coping skills such as relaxation and breathing techniques. At the end of the treatment process, a trauma narrative is facilitated with the client. The client is able to pick a piece of the trauma to analyze. This could be the first time, the worst time, or the last time that the trauma occurred. With Annalisse being so young, she may be processing trauma that is not as viable as someone older. A clinician can process her feelings and the trauma associated with the visitation.

Annalisse also needs skills to manage her ADHD. Aside from medication, a clinician can help Annalisse and her family to provide pieces to give Annalisse the best environment for growth. (a) Structure and routine need to be maintained at all times. (b) The rules and expectations need to be clear. (c) Children with ADHD need to be moving and exerting physical energy. They can be involved in play, sports, dance, and so on. (d) Nutrition can be a great adjunct to treatment. Some children can have allergies that increase their symptomatologyDr. Sudhi Singh: . (e) Self-care for the entire family is paramount. Mental health concerns can be taxing and overwhelming. Family members can manage stress by doing things that they enjoy together and apart.

FOR YOUR CONSIDERATION

INTRODUCTION

Jacob is a 9-year-old male who lives with his mother, father, and two sisters aged 15 and 17 years. Jacob’s mother presented for the initial intake session without Jacob to discuss concerns she had regarding Jacob and to determine whether counseling would be beneficial. Jacob is in the third grade at a public elementary school in a suburban setting. Jacob’s mother, Patricia, reported that Jacob struggles in the home setting as well as in school—both academically and with peers.

Patricia reported that from the time he was a toddler, Jacob has been “different from the other kids.” Although Jacob started speaking around the age of 2 years, Patricia also reported that he used his words mainly to get what he wanted, and he did not seem to be interested in talking for any other reason. He did not use his words to express thoughts or feelings like her other children. He would often get upset (tantruming) over minor things—not having a particular cup or changing brands of common items. Jacob never asked “why” questions or appeared interested in engaging with others unless he needed or wanted something. Patricia noted that Jacob was often the child who played alone at birthday parties or family get-togethers. Jacob often resisted interacting with the other kids or failed to notice their attempts at engagement. As he got older, Jacob appeared to become more interested in peers; however, peer interactions rarely ended well. Jacob had difficulty initiating interactions with others, often “bossing the other kids around.” Jacob was intolerant with games that the other kids “made up” and imaginary play, frequently getting into arguments with peers and insisting that they were not playing “the right way.” From an early age, Jacob had a fascination with trains, and he would talk about trains incessantly. Trains have become a topic of irritation for Jacob’s family because he does not seem to recognize that others are not following or interested in the topic. Jacob will have one-sided conversations about trains and does not seem to understand that others have different interests. Jacob has not expanded his interests and seemingly resists all attempts to engage him in other topics.

Jacob’s mom reports that at home, the family feels as though they are walking on eggshells all the time. Jacob is demanding and bossy, frequently throwing “fits” when things do not go the way he wants. His mom reports that Jacob will scream, cry, and throw objects at the slightest provocation. She also reports that Jacob’s need for consistency and routine has caused significant turmoil within the family. Problematic situations can include things like moving the furniture to accommodate the Christmas tree; changing brands of food, laundry detergent, or personal products; or even the changes in the route taken to school. Patricia admits that she frequently gets frustrated with his sister’s refusal to adhere to some of Jacob’s specifications, which has caused animosity and discord within the family unit.

Recently, Jacob has been having difficulty in school, particularly with his peers. Jacob has begun expressing dissatisfaction with his peers’ behavior during class as well as a lack of friends. Patricia reports that Jacob seems to be unhappy and is concerned that his “selfishness” has affected his ability to make and keep friends. Per teacher report, Jacob has difficulty with peers who do not adhere to the rules of the classroom. Jacob will tell on his peers, even his “friends,” if they talk when they are not supposed to be talking or for any other slight infractions. His teacher refers to him as a “rule follower.” Jacob’s teacher reports that he is often alone during recess despite his awkward attempts to initiate interactions with others. His attempts to engage with his peers are often disruptive and off-putting to others. When she approached the topic with Jacob, he did not seem to understand why his peers may be upset with him for telling on them when he was “just telling the truth.” Jacob struggles with group work because he is inflexible with ideas and often tries to dictate how and what the group will do. Jacob’s teacher reports spending inordinate amounts of time helping his groups resolve conflicts for which he is responsible. When the students are given the opportunity to choose their own groups, Jacob is frequently left out. Jacob blames the children for being “mean” and purposefully excluding him. He frequently yells at his peers, accusing them of “bullying,” and demanding to be in their group and threatening to report them to the antibullying task force.

In addition to difficulties with peers in the school setting, Jacob’s teacher reports that his grades are suffering. Jacob frequently argues with his teacher about the accuracy of tests, papers, and work materials. Jacob struggles to complete creative writing assignments, refusing to “make things up,” and insisting on providing “real” and “right” information. For example, Jacob’s teacher reported that when given the writing prompt: “If you could have a superpower what would it be and why?” Jacob argued the plausibility of such a thing and refused to complete the assignment. Jacob also argued with peers about their assignments, telling them that it is not real and that it could not happen. Despite his difficulties in the academic realm, both his teacher and his mother report that Jacob’s ability far exceeds his current level of functioning.

Jacob presented with his mom for the second session. Jacob greeted the counselor by stating that he did not know why he had to come and that he is not the one with the “problems.” When asked why he thought that his mom brought him, he stated that he “didn’t know.” Jacob did not make eye contact and moved about the room picking up and touching objects. When asked to describe the “problems” that others have with him, he reported that the kids in his class are mean and stupid. Jacob reported that he wants to have friends but that there are not many good ones in his school. Jacob reported that they do not talk to him and that no one plays with him. During the session, Jacob was given the opportunity to play with various toys and games. Jacob took control of the play tasks, telling his mom and the counselor how to play by using statements such as “that’s not right,” “this is what you’re supposed to do,” and “stop it.” When Jacob encountered something that he did not agree with or something that was not “right,” he criticized the counselor by using statements such as “don’t you know anything?” and “aren’t you supposed to be smart?” When asked to speculate how others may feel when he uses such statements, Jacob responded that he did not know. When asked how he would feel, Jacob stated that it never happened, so he does not know. When asked to guess, Jacob became frustrated and irritated and told the counselor, “This is stupid. I’m not talking about this anymore.”

DIAGNOSTIC IMPRESSIONS

Jacob demonstrates deficits in social communication and social interaction across multiple contexts including: deficits in social–emotional reciprocity by history and continuing in the present, demonstrated by abnormal, often intrusive and disruptive, social approach, failure of normal back-and-forth conversation, failure to respond to social interactions, and reduced sharing of interests and emotions; deficits in nonverbal communicative behaviors for social interaction—abnormalities in eye contact; and deficits in developing, maintaining, and understanding relationships demonstrated by difficulties with adjusting behaviors to suit various social contexts, difficulties with imaginative play, and difficulties making friends. Jacob also demonstrates restrictive, repetitive patterns of behavior, interests, and activities demonstrated by insistence on sameness and inflexible adherence to routine reflected in his “rule-following” and bossy behavior with peers and his history of strong preference for specific objects (cup) or brands. In addition, Jacob’s intense interest in trains is a highly restricted, fixated interest that is abnormal in intensity and focus. Jacob’s symptoms presented in the early developmental period and have created a clinically significant impairment in social and academic functioning in multiple settings.

DIAGNOSTIC CONCLUSION

SUGGESTED THERAPEUTIC INTERVENTIONS

Family/Individual Therapy—Individual sessions with parents to educate the parent’s about the symptoms, causes, and treatments of ASD. Assist the family in developing realistic expectations based on Jacob’s abilities. Individual sessions with parents will also be used to teach behavior management skills to increase prosocial behaviors and decrease disruptive behaviors. Family sessions should be utilized, with all members present, to share and work through their feelings related to the impact that ASD has on the family.

Individual Therapy—Research demonstrates that the use of cognitive behavioral therapy (CBT) for children with ASDs is effective in reducing the symptoms of anxiety and also has an impact on issues with social cognition (Kincade & McBride, 2009). Individual therapy with Jacob should focus on emotion identification and expression, perspective taking, and to develop prosocial coping skills.

School Collaboration—Therapist should assist the parents in collaborating with the school to develop a behavioral management system in the classroom to reinforce appropriate behavior and to improve school performance. In order to increase communication between the school and home, a communication system should be established (i.e., daily behavior reports). In addition, Jacob should participate in a school-based social group (e.g., a lunch bunch) to facilitate appropriate peer interaction.

Social/Peer Relationship Building—Involvement in a child-based social skills group program that focuses on peer relationships will assist Jacob in developing and maintaining appropriate friendships. The program should not occur without simultaneous parent behavior management training and ongoing collaboration with the program instructors.

FOR YOUR CONSIDERATION

REFERENCE

INTRODUCTION

Julia is an 8-year-old female who lives with her mother, father, and a 5-year-old brother. Julia presented with her mother and brother for her initial visit due to concerns that had become more pronounced as her school career progressed. Julia’s father travels frequently for work and was not able to attend counseling sessions. Julia is in the second grade at a public elementary school in a suburban neighborhood.

Julia presented in a pleasant and talkative mood. Julia was very animated, exploring the room, touching, picking up objects, and often interrupting her mom by putting the objects in her face. Julia did not sit down for the duration of the initial session and moved from task to task without engaging in any one activity for more than a few minutes. Julia had to be reminded multiple times not to climb on the couch. She frequently intruded on her brother’s play by grabbing objects from him and whined to her mom when he did not cooperate with her intrusion by saying that he would not “share.” At times, Julia would intrude on her brother’s play by giving him directions on what to do and how to play.

During the initial session, her mom reported that Julia has always demonstrated difficulty following directions and completing various tasks at home. Her mom specifically reported that cleaning her room has become a constant battle because Julia will remain in her room for hours, often “playing” when she should be cleaning. Her mom reports that she is often frustrated because Julia does not listen to her even when she is speaking directly to her. Her mom admits that Julia knows how to clean her room and can do so with constant supervision and specific instructions—what to do when—but states that they (parents) refuse to “overfunction” for their daughter who is “old enough” to complete independent chores. Her mom states that if Julia was more organized, she would not have such a big mess to tackle in her room. Her mom also states that Julia often becomes overly emotional with “things that really aren’t a big deal.” For example, she can become tearful when she is not going to a place she likes to eat or when her brother plays with something that is hers and she is afraid that he will break it. Her mom described a situation in which Julia was upset because she could not wear a shirt that she had outgrown, and it took her 20 minutes to calm down and stop crying.

Her mom reports that Julia has been constantly “on the go” since she could walk. Julia rarely sits still and constantly has something to say. Her mom explained that they stopped going out to restaurants when Julia was a toddler because she could not sit still and would disrupt the entire restaurant. Her mom reports constantly having to tell Julia to “sit like a lady” and that she gave up on dresses long ago because Julia is constantly climbing on objects or sprawling around on the floor. Julia’s mom explains having difficulty getting anything done when Julia was little because her daughter would not remain engaged in any activity long enough.

Her mom reports that there have been additional problems as Julia has gotten older and the demands of school have increased. Based on teacher reports, Julia has difficulty remaining in her seat and following the directions of the classroom as well as specific directions from her teachers. Julia has difficulty completing her seatwork, often playing with items in her desk and attempting to engage other students or simply staring off into space. Her mom reports that getting Julia to complete her homework is a nightly struggle that takes hours to finish. Despite finishing her homework, Julia often loses homework points because she frequently fails to follow her morning routine at school and forgets to turn it in. Julia’s teacher reports that she has to constantly remind Julia to raise her hand if she wants to answer a question or needs to get the teacher’s attention. Another area of concern for the school is Julia’s difficulty with walking and/or waiting in line—she often gets out of line to talk to peers and has difficulty keeping her hands to herself. Julia also displays some intrusive behaviors with peers, often interrupting games and taking others’ belongings without asking. Her mom believes that these intrusive and impulsive behaviors have made it difficult for Julia to make and maintain friendships. Her mom reports that Julia has the habit of being too honest by saying whatever comes to her mind without considering others’ feelings. Despite the various concerns in the school setting, Julia’s teachers report that when she pays attention, she avoids careless mistakes and generally knows the material. All parties involved agree that Julia is a bright girl.

Julia reports that her parents are always yelling at her and that she is always getting in trouble. Julia maintains that she wants to do well in school but reports that the teachers hate her and make her work more difficult on purpose. Julia expressed sadness and frustration at not having any close friends and reported that she tries to play with the girls at recess but that they always run away from her.

DIAGNOSTIC IMPRESSIONS

According to her mother’s report, Julia has demonstrated a persistent pattern of inattention, hyperactivity, and impulsivity since she was a toddler. Julia’s symptoms include making careless mistakes in schoolwork, difficulty sustaining attention/focus during tasks, does not seem to listen when spoken to directly, often does not follow through on instructions, fails to finish schoolwork and chores, demonstrates difficulty organizing tasks and activities, is easily distracted by extraneous stimuli, is often forgetful in daily activities, often squirms in her seat, leaves her seat when expected to remain, runs and climbs in situations where it is inappropriate, is unable to play or engage in leisure activities quietly, is often “on the go,” talks excessively, blurts out answers, has difficulty awaiting her turn, and often interrupts or intrudes on others. The difficulties that Julia is experiencing have demonstrated a greater impact as academic expectations and the expectation of independence have increased. Julia’s symptoms have persisted for at least 6 months, have had a direct negative impact on social and academic functioning, and are present in two or more settings (home and school).

DIAGNOSTIC CONCLUSION

SUGGESTED THERAPEUTIC INTERVENTIONS

Pharmacotherapy—Julia’s mother should schedule an evaluation with a psychiatrist to assess the appropriateness of ADHD medication to reduce her symptoms.

Family/Individual Therapy—Individual sessions with parents to educate them about the symptoms, causes, and treatments of ADHD. Individual sessions will also be used to teach behavior management skills to increase prosocial behaviors and decrease disruptive behaviors coupled with family sessions (with Julia) to model and reinforce positive parent–child interactions.

School Collaboration—Therapist should assist the parents in collaboration with the school to develop a behavioral management system in the classroom to reinforce appropriate behavior and to improve school performance. In order to increase communication between the school and home, a communication system should be established (i.e., daily behavior reports).

Social/Peer Relationship Building—Involvement in a child-based group program that focuses on peer relationships will assist Julia in developing and maintaining appropriate friendships. The program should not occur without simultaneous parent behavior management training and ongoing collaboration with the program instructors.

FOR YOUR CONSIDERATION