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Running head: AN ECOLOGICAL CASE STUDY
An Ecological Case Study
Sarah Cross
Northcentral University
The Department of Marriage and Family Science
MFT 8211: Systemic Treatment of Neurodevelopmental Disorders in Children and Adolescents
Dr. Melissa Arias Shah
May 9, 2021
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AN ECOLOGICAL CASE STUDY
An Ecological Case Study
Case Study
History Jaime is an eight-year-old, white male who resides with his biological parents, Bryan and Kate, and his three-year-old sister, Megan. Bryan and Kate have been married for ten years and are both professionals. Bryan works full-time supervising the IT department in a large corporation. Kate is a
family law attorney, though she reduced her hours to part-time after Jamie’s birth to be home with her children. The family does not report financial stressors and are adequately supported by their external family; however, Kate’s parents do not live close. Kate feels isolated from friends and family. Bryan and Kate report that their marriage had been strong but recently they have noticed that they are arguing more, specifically, Kate feels that she is often the one who deals with Jamie’s challenging behaviors, even if Bryan is home. She states she feels resentful when Bryan and Megan go out together to do something fun and she is left to manage Jamie. She is feeling as though
she doesn’t get enough time with Megan and it often seems as though Megan prefers Bryan to her. Bryan states that Kate is critical of how he deals with Jamie and he has felt that it is more helpful to just get out of the way and remove himself and Megan from the situation when Kate is dealing with Jamie’s more challenging behaviors.
Jamie was diagnosed with ASD with a severity requiring substantial support at age four by his pediatrician. He is in the third grade and has seen
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AN ECOLOGICAL CASE STUDY
an occupational therapist through his public school system for the past two years as mandated by his Individualized Education Plan (IEP). Though Jamie has an above average IQ and is academically proficient, he has difficulty maintaining social interactions and engaging in age-appropriate play with his peers and sibling.
His developmental pediatrician has recently diagnosed Jamie with a co-
morbid diagnosis of ADHD and has prescribed methylphenidate (Ritalin) 10mg. Jamie does not have any other providers.
Reason for referral/Presenting Issues Bryan and Kate have expressed that Jamie is having difficulty with his morning routine, causing behavioral issues such as irritability, aggression, hyperactivity, and self-injury when he bites himself. Aggression often is targeted at mom, as he will hit her or bite her when he is upset. He will also sometimes bite his sister if she interrupts his play. When Jamie has these issues, his entire day is thrown off, resulting in trouble concentrating on schoolwork and increasing difficulties interacting with his peers throughout the day and an increase in anxiety, noncompliance and disruptive behaviors such as crying and yelling. Other symptoms reported included sometimes screaming when he is awakened by noises in the house such as the blender, his alarm clock, or his sister crying. Jamie has a difficult time waking, getting ready for school, interacting with peers, and completing coursework during these days. He has trouble sleeping through the night and he frequently appears fatigued but is unable to nap during the day. Family therapist observed Jamie flopping on the floor, and demonstrating poor motor
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AN ECOLOGICAL CASE STUDY
coordination. He was unable to engage in interactive play with his three-
year-old sister, and when his parents asked him to share toys with her, he ignored the request. Therapist also observed Jamie in play with toys and noted that he was preoccupied with a single spinning toy, engrossed in ritualistic, repetitive play with the object. Jamie also became engrossed in turning the lights on and off repetitively in the therapy office for several minutes before transitioning to a different activity when redirected by Kate. Bryan and Kate would like additional support to allow him to function better and to reduce the stress he is experiencing and the stress the family is experiencing. Intervention Plan Outline
1.
PROBLEM:
F84.0 Autism Spectrum Disorder
PROBLEM DEFINITION:
Jamie demonstrates a pervasive lack of interest in other people, including his sister and parents. He also demonstrates overreaction to minor changes in routines or environments.
According to parents, he often becomes aggressive towards others, specifically mom, and
self-injurious when expected to change routine or transition environments and tasks.
GOALS:
1.
Reduce challenges associated with Jamie’s ASD, such as stabilizing mood and tolerating changes in his environment and eliminate his aggressive behaviors towards self and others.
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AN ECOLOGICAL CASE STUDY
2.
Alleviate family distress
3.
Increase the quality of family life and functioning
INTERVENTIONS:
•
Help parents promote and set reasonable expectations for themselves and their children i.e., schedules, routines, structure
•
Support family’s efforts to create a therapeutic, safe, and positive home environment:
o
coordinate with OT to identify beneficial therapeutic equipment; o
Teach parents to apply behavior management techniques such as prompting behavior and reinforcement of positive behaviors through a token economy or other reward system to decrease anger outbursts, aggression, and self-injury.
•
Parents will work with therapist to evaluate the need for additional therapeutic, medical, and educational support:
o
Provide parents psychoeducation regarding additional treatment options such as intensive in-home behavioral therapist;
o
Maintain ongoing communication with Jamie’s primary care physician, SPED
case manager, and occupational therapist, as well as any additional providers to join the care team.
•
Increase the frequency of positive interactions with parents and sibling:
o
Encourage family members to include Jamie in structured work or play activities daily
o
Encourage parents to sing songs with Jamie, such as nursery rhymes, lullabies,
popular hits, or any songs related to his interests to help establish a closer parent-child bond and increase verbalizations at home.
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AN ECOLOGICAL CASE STUDY
o
Encourage Bryan to increase his involvement in Jamie’s daily life, leisure activities, or schoolwork.
o
Facilitate a closer parent-child bond and sibling-sibling bond using Theraplay approaches to increase the parents’ awareness of the client’s thoughts, feelings, and needs.
•
Kate and Bryan will attend “couple meetings” to support their marriage and reduce the risk of disconnection and blame
•
Identify strategies for self-care that work for each family member 2.
PROBLEM:
Family Relational Problems:
•
Z62.820 Parent-Child Relational Problem
•
Z62.891 Sibling Relational Problem
•
Marital issues
PROBLEM DEFINITION:
Kate and Bryan describe engaging in verbal fights multiple times per week and the children find these fights very distressing, possibly contributing to both children acting both at home and school, which causes further conflict between the parents. Kate is the primary care taker of both children who need constant attention, contributing to increased
irritability and greater friction between Kate and Bryan. Bryan struggles to control his emotional reactions when the children act out and Kate feels that she has exhausted ideas to manage Jamie’s behavior which frequently leads him to becoming aggressive with self
and others, including his little sister. GOALS:
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AN ECOLOGICAL CASE STUDY
1.
Explore the interactional dynamics of the family and how Jamie’s ASD impacts the dynamics between family members.
2.
Mobilize the family's internal strength and functional resources
INTERVENTIONS:
•
Through the therapeutic process, family members will witness each other’s journey thereby cultivating deep acceptance for the unique differences between each family member
•
Provide therapeutic space to address the coexistence of multiple stories and transcend the question of why to create resilience and connection to one another
o
Create compassionate and empathetic environment where family members feel comfortable enough to express their authentic feelings;
o
Utilize narrative techniques such as ‘Telling One’s Story’ and adjust to meet the developmental capabilities of the children i.e., through play, art, and puppets;
o
Elicit the role each parent takes in the parental team and their perspective on parenting and assist Bryan and Kate in identifying the areas that need strengthening in their parental team thereby creating a narrative of their shared
meaning in parenting their children. 3.
PROBLEM:
Poor communication; detachment; diminished connectiveness
PROBLEM DEFINITION:
Bryan and Kate describe feelings less connected to one another and their children. They
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AN ECOLOGICAL CASE STUDY
have expressed feeling frustrated and resentful of the other, inadequate in their parenting of their children, and feeling that there are little to no positive experiences with their children and as a family. GOALS:
1.
Restructure the maladaptive interactional family styles, such as improving communication.
2.
Strengthen the family's problem-solving behaviors.
INTERVENTIONS:
•
Work on transforming dichotomies •
Engage Bryan and Kate in complex discussion of acceptance and change
•
Process the contention between acceptance and fight
•
Facilitate dialogue to explore the emotions each parent has and construct a narrative about what certain things mean to each parent – from this place of collaboration Bryan and Kate can create an action plan that feels ‘good enough’
•
Utilize Emotionally-Focused Therapy (EFT) strategies such as empathy-based techniques, relational techniques, experiencing techniques, reprocessing tasks, and action tasks to:
o
create awareness through accessing emotional experiences and linking them to
patterns.
o
de-escalating using “parts language” and an attachment perspective such as identifying conflicting attachment strategies such as anxiety and avoidance.
Family therapist will direct the enactment and dialogue between family members, explore the underlying needs/wants, and support a new experience
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AN ECOLOGICAL CASE STUDY
of safety and empowerment. The goal is of this strategy is to integrate previous emotions, soften critical parts, and consolidate that integration or bond.
o
consolidation of the newly developed models of self-and/or other allowing for
internal and external positive interaction cycles. Positive narratives are contrasted with old ways of coping, thinking, and feeling. The goal of this strategy is increased security within the familial relationships.
References
Ackerman, C. E. (2021, April 15). 19 Narrative
techniques, interventions + worksheets.
PositivePsychology. https://positivepsychology.com/narrative-therapy/
Hock, R., & Ahmedani, B. K. (2012). Parent perceptions of autism severity: Exploring the social ecological context.
Disability and Health Journal
,
5
(4), 298-304. http://dx.doi.org/10.1016/j.dhjo.2012.06.002
Johnson, S. (2008). Hold Me Tight: Seven Conversations for a Lifetime of Love. Little, Brown Spark.
Neely, J., Amatea, E., Echevarria-Doan, S., & Tannen, T. (2012). Working with families living with autism: Potential contributions of marriage and family therapists. Journal of marital and family therapy, 38
(1), 211-26. DOI: 10.1111/j.1752-0606.2011.00265.x.
Nichols, W. C. (2001). Integrative family therapy. Journal of Psychotherapy Integration, 11
(3), 289-312. DOI: 10.1023/A:1016650132579
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AN ECOLOGICAL CASE STUDY
Spain, D., Sin, J., Paliokosta, E., Furuta, M., Prunty, J. E., Chalder, T., Murphy, D. G., & Happé, F. G. (2017). Family therapy for autism spectrum disorders.
The Cochrane database of systematic reviews
,
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(5), CD011894. https://doi.org/10.1002/14651858.CD011894.pub2
Varghese, M., Kirpekar, V., & Loganathan, S. (2020). Family Interventions: Basic Principles and
Techniques.
Indian journal of psychiatry
,
62
(Suppl 2), S192–S200. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_770_19
Wagner, D. V., Borduin, C. M., Kanne, S. M., Mazurek, M. O., Farmer, J. E., & Brown, R. M. A. (2014). Multisystemic therapy for disruptive behavior problems in youths with autism spectrum disorders: A progress report. Journal of Marital and Family Therapy, 40(3), 319–331. DOI: 10.1111/jmft.12012