Hb mj tw_tac_presentation


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Hb mj tw_tac_presentation

  1. 1. TAC Case Study of Jane (a case involving significant trauma history) by Heather C. Blessing Maria Luisa Johnston Tricia Watters 1
  2. 2. Identifying Information • Jane is a 14 year old female • Caucasian • Adopted at 4 years old • Currently in a level 12 group home. • Jane can be pleasant. • She likes math. • She can spell. • She likes school. • She has a good singing voice. • She likes horses and can ride them. • She wants to be home with her adoptive family. • She would like to have more friends she can hang out with. 2
  3. 3. Identified Problems and Issues Related to Adoption • Jane's birth parents were drug addicts and were dealing meth. • She was removed from her birth parents home when she was almost 2 years of age for severe neglect and exposure to their drug abuse • Placed in emergency foster care. • She was soon placed with her paternal grandmother by CPS with visits by her parents on a sporadic basis. • Grandmother died in her sleep while she was in the process of adopting Jane. • Child was asleep with her grandmother when she died. • She then was placed in foster care until adoptive parents, Terry and Barbara, adopted her. 3
  4. 4. Identified Problems and Issues Related to Adoption (cont.) • Terry and Barbara have been trying to get pregnant for several years. • Barbara was adopted as an infant. • They decided to adopt a child. • Jane was the first child they met and promptly decided they will adopt her. • Information about Jane was sketchy. • According to adoptive parents, they were told child was not officially TOX positive when she was born. • There was no documentation saying otherwise. 4
  5. 5. Identified Problems and Issues Related to Adoption (cont.) • Jane was prone to eat out of the trashcan. She was hoarding food in her room under her bed. • She has very dry skin requiring use of lotion on a regular basis to moisten her skin. She is prone to severe itching resulting in scratches and skin lesion all over her body. • She has history of MRSA. • At night, she would take off her nightclothes, take off beddings from her bed, stay awake and roam around the house when everyone is asleep. She has scary dreams and a history of reporting hearing voices and hallucinating. • She was defiant, hyperactive, impulsive, could not stay still, highly distracted, difficulty concentrating, angry, irritable and would have all day tantrums and angry outbursts in the home, school and even out in the community. At school, she was in a SED classroom. • Two years after she was adopted, adoptive mother became pregnant and gave birth to a baby boy. • When she was 7, she was hospitalized and was placed at River Oak Center for children for a thorough diagnostic assessment for 90 days. • She was transferred to a level 14 River Oak group home. She received EMQ Wraparound services while she was in the group home as they prepared child and family for reunification. • She was in placement for 2 years. 5
  6. 6. Identified Problems and Issues Related to Adoption (cont.) • Jane’s adoptive parents attended PCIT with their child for a year. • A psychiatrist supervised her medications and provided psychiatric services. • An EMQ Wrap team provided in home services for 2 1/2 years and was transitioned to EMQ FOCUS, another program providing in home services. • Jane attended a non-public school SED classroom for the next 3 years. • Jane’s behaviors somewhat improved and she made some academic progress. • After 2 years in the non-public school setting, Jane was transferred to a public school SED setting where she thrived academically. • She was able to get 2 grade levels closer to her expected grade level academic performance. • She continued to struggle in her social skills and emotional regulation skills. • With adult guidance and one on one coaching. the frequencies of the tantrums and outbursts were no longer daily and all day. Instead they would occur on the average 3x weekly at home and at school combined. • When she has the outbursts and tantrums at home, they were intense where either parent needed to stay at home with her. • She continued to be easily frustrated and easily overwhelmed. • Parents stopped eating out and resorted to take out food as Jane had tantrums and outbursts while they are dining out. 6
  7. 7. Identified Problems and Issues Related to Adoption (cont.) • Jane became jealous and physically aggressive9pushing, shoving) towards her younger brother. • She would go to his room, take away his toys, and hide them in her bedroom. • She destroyed any stuffed animal or dolls left in her bedroom. • Adoptive parents installed an alarm to warn them if she leaves her room at night. • At school, she is known to go into the school cafeteria trash to obtain food even if she has her own food. • She has difficulty making friends. • She has history of being physically aggressive towards the house pets. 7
  8. 8. Assessment Based on Theoretical Frameworks from TAC Training • We can use the theoretical framework of complex trauma to better understand Jane’s early life experiences and the impact of her adverse traumatic childhood experiences (Cook, et al., 2007). • Complex trauma describes exposure to multiple traumatic events and the devastating consequences. • For Jane, it is possible trauma began in the form of being exposed to illicit substances in utero. • While tests were negative at birth for illicit drugs in her system, both of her birth parents were drug addicts and were involved with selling methamphetamine. • Due to her drug addiction, Jane’s birth mother may not have received prenatal care and may have been engaged in high risk behaviors which negatively affected Jane’s earliest experiences while still in the womb. 8
  9. 9. Assessment Based on Theoretical Frameworks from TAC Training (cont) • Jane was removed from her birth family (close to age two) due to severe neglect and exposure to her birth parents’ drug use, sever neglect and exposure to domestic violence. By the time child welfare intervened, Jane had already suffered maltreatment in that her emotional and physical needs were not being adequately met. • If her parents were often under the influence of illicit substances it is likely they were not attentive her cries of hunger, discomfort, pain, or fear. Her birth parents may not have responded to her at all or were sporadic and unpredictable. She may not have been well fed, bathed, or supervised. • Jane may not have been in a safe environment or may have been over or under stimulated resulting in delays reaching early childhood developmental milestones. • The formation of a secure attachment bond with a dependable caregiver was compromised, shaping her view of the world and her expectations of those around her. Then Jane was removed from the only environment she had known and placed with an emergency foster placement then her maternal grandmother. 9
  10. 10. Assessment Based on Theoretical Frameworks from TAC Training (cont) • Jane experienced another traumatic loss when her grandmother, who was going to adopt her, passed away while sleeping in the bed they were sharing. • Jane identifies this as her greatest loss and continues to grieve for her grandmother and the life that might have been. • Another attachment was been broken resulting in further issues in developing trust and intimacy and there was another change in placement, this time to a foster home. • In the context of complex trauma we see how Jane’s early childhood experiences happened at a time when patterns of attachment are established, the brain is developing at a rapid pace, and infants and toddlers are depending on their caregivers to help them co-regulate. Due to the layers of traumatic experiences from an early age with little opportunity for repair it is understandable that Jane would struggle with self regulation, developing meaningful relationships, and identity. 10
  11. 11. Assessment Based on Theoretical Frameworks from TAC Training (cont) • Terry and Barbara adopted Jane when she was four years old and Jane exhibited a number of problem behaviors which can all be understood through a trauma informed lens. For example, she would eat out of the trash can and hoard food suggesting that her basic need for nourishment was not consistently met while in the care of her birth parents. She likely had to rummage for food to survive and continued to do this not only in the home with her adoptive parents who were providing her with access to healthy meals but also in the school and community settings. • Jane had a very difficult time regulating her emotions and she presented as defiant, impulsive, irritable and angry. Lack of a secure attachment can result in a loss of core capacities for self-regulation and interpersonal relatedness (Cook, et al., 2007). • Jane’s adoptive parents gave birth to their son two years after she was adopted. Jane’s symptoms and behaviors were likely exacerbated by worries and concerns about her place in the family. • She was not well equipped to cope with day to day activities and this added another complicated layer. Jane was unable to function at home, in school, or in the community. 11
  12. 12. Assessment Based on Theoretical Frameworks from TAC Training (cont) • As time progressed Jane’s behaviors and symptoms were persistent and pervasive. • At age seven she experienced a psychiatric hospitalization followed by out of home placements. The lack of an early secure, predictable, nurturing environment with caregivers who are attuned contributed to Jane’s growth and development. Children exposed to complex trauma often experience lifelong problems that place them at risk for additional trauma exposure and other difficulties including psychiatric and addictive disorders, chronic medical illness and legal, vocational, and family problems (Cook, et al., 2007). • At age fourteen Jane remains in a level 14 groups home and continues to struggle with many of the same symptoms and behaviors she has been challenged with for years. Chronic trauma interferes with neurobiological development and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole (Van der Kolk, n.d.). 12
  13. 13. Diagnosis Axis I 313.89 Reactive Attachment Disorder Inhibited Type 314.01 Attention Deficit Hyperactivity Disorder Combined Type R/O 296.90 Mood Disorder NOS 309.81 Post Traumatic Stress Disorder 313.81 Oppositional Defiant Disorder R/O 315.9 Learning Disorder NOS Axis II V71.09 No Diagnosis Axis III Eczema Axis IV Victim of child neglect and physical abuse, previous foster care and group home placements, possible in utero drug exposure Axis V GAF 38 (American Psychiatric Association, 2000) 13
  14. 14. Treatment and Intervention Strategies a. We will employ the following interventions and strategies: b. Grief-Focused Cognitive Behavioral Therapy (Cohen et al., 2006) c. Life Book (Child Welfare Information Gateway, 2013) (Henry, 2005) d. Trauma Focused Cognitive Behavioral Therapy (Cohen et al, 2006) (Burns, 2005) e. DDP - Using DDP, we would work first to connect to Jane using curious questioning and meeting her emotionally where she is. Asking questions such as, "I was wondering if you might be angry that your brother gets to stay at home while you are in a group home?" to get her to start working through her problems and to really understand why she is acting and reacting the way she is. Then slowly using DDP between Jane's parents and Jane to shift from behaviors to being able to communicate feelings. The more Jane's parents are able to actually understand what is behind the behaviors the more they are going to be able to help her work through those issues or not react in a way that makes those issues worse. (Hughes,1997) 14
  15. 15. Treatment and Intervention Strategies (cont) f. Employ various interventions and strategies suggested by Daniel Hughes, Heather Forbes and Beneath the Masks - Using art projects, games, and other methods of communication can help build the family bonds and understanding so Jane will not feel the need to throw temper tantrums to get heard or be understood. These also may let Jane learn more about her parents. Doing some of these activities with her brother in a structured, positive setting may help to reduce the competitiveness and animosity Jane sometimes feels towards her brother. (Hughes,1997) (Riley & Meeks, 2005) (Forbes, 2008). g. Another intervention we would use with the adoptive parents, Jane and her brother is psycho education. It would be important to provide everyone with information about the effects of trauma, grief and loss, and separation from multiple caregivers and offer possible explanations for Jane’s challenging behaviors (Chamberlin, 2009). This would increase the parent’s ability to empathize with Jane’s early childhood experiences as well as help them to understand her behaviors are not aimed at hurting them. Psychoeducation can also help Jane understand her own behaviors, attachment style, and perception of the world in the context of the adverse childhood experiences she has endured. For example, once given information about the impact of trauma on brain development she may blame herself less and be better able to develop coping strategies that are more effective (Cain, 2006). We may also use psychoeducation to identify and prepare for future developmental stages both as an adopted family and for Jane as she enters early adolescents. h. In therapy we may also help Jane develop an ecomap, timeline and genogram. Information cane be added over time to provide a visual picture of her life story. The ecomap can be used to identify strengths, interests and supports which can be very helpful when addressing problems and challenges. A timeline can help Jane and her family visually see the number of disruptions and losses she experienced prior to the age of five as well as other significant events over time. This can be useful when looking at her experiences along with typical social- emotional development and brain growth. It can support Jane in coherently understanding her adoption story. A genogram can help Jane explore biological, genetic and social factors related to her birth family. The ecomap, timeline and genogram can become part of her lifebook. 15
  16. 16. Specific Examples – The utilization of Life Book (Child Welfare Information Gateway, 2013) and masks to help child and adoptive parents (Riley & Meeks, 2005). – A trained therapist who can provide Trauma Focused Cognitive Behavioral Therapy for one specific traumatic experiences at a time identified by child. – A trained DDP therapist to work initially with the parents then with child and parents (Hughes,1997). – Incorporation of child’s genogram, ecomap and timeline in her Life Book. – Regular Child and Family team meetings with the parents, child, school and treatment team to identify strengths, bring resources to help the family meet their needs including respite information and a review of treatment progress (Delaney & Kunstal, 1997) (Karp & Butler, 1996) 16
  17. 17. Challenging Aspects to the Case • Due to the possibility of severe neglect and other adverse childhood experiences of Jane, treatment might be somewhat slow. It is necessary to recognize growth no matter how minute as soon as it is observed and on a periodic basis. • The state of the adoptive parents marital relations will be taken into consideration and respite services and a suggestion for them to get help may be necessary. • When it is time for child to be reunified with parents, reinstatement of the Wraparound services 6 months before discharge from the residential home will be looked at. If necessary, Therapeutic Behavioral Services (TBS) will be requested. 17
  18. 18. Genogram 18
  19. 19. EcoMap 19
  20. 20. Time Line 20
  21. 21. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed, text revision). Washington, DC, American Psychiatric Association. Burns, G. W. (2005). 101 healing stories for kids and teens using metaphors in therapy. Hoboken, N.J.: Wiley. Cain, C. S. (2006). Attachment disorders: treatment strategies for traumatized children. Lanham, Md.: Jason Aronson. Chamberlain, L.B. (2009). The Amazing Teen Brain: What Every Child Advocate Needs to Know. Available at: http://www.americanbar.org/content/dam/aba/administrative/child_law/clp/sampleissue/teenbrain.authcheckdam.pdf Child Welfare Information Gateway. (2013). Resources and tips for creating lifebooks. Retrieved from http//www.adoptionlifebooks.com/adopt_parenting/Lifebooks.cfm Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M. & Sprague, C. (2007). Complex Trauma in Children and Adolescents. Available at: http://www.rtc.pdx.edu/PDF/fpW0702.pdf Delaney, R. J., & Kunstal, F. R. (1997). Troubled transplants: unconventional strategies for helping disturbed foster and adoptive children (2nd ed.). Oklahoma City, OK.: Wood 'N' Barnes Pub.. Forbes, H. T. (2008). Beyond consequences, logic, and control : a love-based approach to helping children with severe behaviors [Volume 1&2]. Orlando, FL: Beyond Consequences Institute. Henry, D. (2005). The 3/5/7 Model: Preparing Children For Permanency. Children and Youth Services Review, 27(2), 197- 212. Hughes, D. A. (1997). Facilitating developmental attachment: the road to emotional recovery and behavioral change in foster and adopted children. Northvale, N.J.: J. Aronson. Karp, C. L., & Butler, T. L. (1996). Treatment strategies for abused children: from victim to survivor. Thousand Oaks: Sage Publications. Riley, D., & Meeks, J. (2005). Beneath the mask: Understanding adopted teens. Silver Spring, MD: C.A.S.E Publications. Van der Kolk, B. (n.d.). Developmental trauma disorder. Available at: http://www.traumacenter.org/products/pdf_files/preprint_dev_trauma_disorder.pdf 21