Download Part 2- Treatment Plan

Audrey Fairchild
CPSY 214
November 24, 2013
FINAL PAPER:
Identifying Information:
Proposed Treatment Plan for Distorder
Johnny is a seven year old boy who attends the second grade at
Guadalupe Elementary School. He lives with his mother and two younger brothers four days
of each week, and with his father for each Friday, Saturday, and Sunday. Johnny was
diagnosed with a NVLD (non-verbal learning disorder) and anxiety disorder this school year..
CPS has been called to the home repeatedly over the past three years, due to domestic
violence incidents, and Johnny and his sibling were removed from the home until the parents
separated, recently,. At that time, the children were split up, Johnny was sent to foster care,
and Johnny’s maternal grandmother took in the younger siblings, 1 yr. and 3 yrs. until now.
Presenting Problem:
Johnny responds negatively and emotionally in his classroom when
he does not do well on assignments, including crying, withdrawing (head down on desk),
shouting back at teacher, or running from the room. In the past, there were concerns by his
kindergarten teacher about Johnny’s need for constant approval. He seems disinterested in
his classmates, and does not initiate play with his peers. When grouped in dyads or triads,
Johnny remains mute in the group, and sometimes wanders off to seek out the teacher, asking
“what do we do next?” On the playground at recess, Johnny typically swings by himself.
History of the Problem:
There have been several behavioral problems reported from
school in the last three school years. Historically, Johnny has “melt-downs” at school when
he feels he has done poorly at a task, and then becomes sullen or emotionally overwrought
and non-communicative or hostile toward teachers/counselors.
Johnny has been referred by
the school district for individual counseling to address his anxiety and self-regulation issues.
Audrey Fairchild
CPSY 214
November 24, 2013
BACKGROUND INFORMATION:
Developmental history:
Johnny walked and talked at 16 months, and development seemed
uninterrupted and consistent. Most of Johnny’s developmental milestones were met within
expected limits. He does have a Fine Motor Skills delay and has a current IEP at school for
occupational therapy, to deal with pencil grip FMS and related penmanship issues.
Academic History:
According to test results, Johnny has significant difficulties
understanding multi-step math problems, social skills, and executive functioning, which
compromises his completing assignments. He is easily distracted and pulled off task.
During the testing, he repeatedly asked, “what will happen if I flunk this?” and “do these get
mailed home?” He asked to have questions repeated on 8 of the 20 questions read to him.
Family History:
Johnny was born on 4/11/2006, in California, to Hispanic parents, both
aged 23, and newly married. The mother is the custodial caregiver at this time. His father
was granted shared custody in a recent marital separation, culminating after three years of
domestic violence allegations, in which Child Protective Services acted to remove the three
siblings (7, 3, and 1) earlier this year, due to allegations of verbal and physical child abuse by
both parents, none requiring hospitalization.
While the mother continues to care full-time for
the children, Johnny alone visits his father each weekend, for Friday, Saturday, and Sunday
sleepovers. Neither parent has a history of mental health issues or congenital disease.
Medical history: Johnny’s medical history is unremarkable. Records are intermittent, but
contain necessary inoculations; height and weight goals are within normal range for his age.
Audrey Fairchild
CPSY 214
November 24, 2013
Assessment: (Anecdotal)
Johnny, age 7, entered slowly, shyly, and stood facing away from
therapist for initial four minutes. Hesitant to sit down, client was encouraged twice to look
around the room. Held hand to mouth, then placed hands in pockets , very limited conversation.
Shrugged underneath hoodie, appearing to want to hide. During our two intake appointments,
Johnny played with two small dragon figurines in a sand tray, Johnny repeatedly watched the
door. When the books on the shelf slid, knocking one to the floor, Johnny exhibited an
exaggerated startle response, and called out profanity to the books for sliding. He advised me to
“get rid of those kind of books”. Johnny kept his hands in his hoodie pockets unless he was
moving dragons about. When spoken to, Johnny maintained only minimal eye contact.
Assessment: (Formal) Johnny was given the “Anxiety Disorders Interview Schedule for
Children” (ADIS-C IV, Silverman and Albano, 1996), a series of semi-structured interviews, on
which he scored an adequate number of symptoms required as “present” to meet the DSM-V
criteria. His mother was given the parent version (ADIS-P) of the same instrument When asked
if these symptoms were interfering with the child’s life, parent and child were asked to indicate on
a 9-point scale called the “Feelings Thermometer” and both indicated the impairment rating was
above 4, required for a final diagnosis of Anxiety Disorder.
Assessment: (Parent and grandmother interview): Johnny’s mother confirmed the
episodes in his intake history that there was violence in the home from both parents, and
Johnny, being the oldest child of three, tended to have the most visible reactions, leading the
younger siblings but that since the break up, Johnny seemed fine, ‘like nothing ever
happened”. She added that “he hasn’t been beat in like, months, so he’s good now.”
Audrey Fairchild
CPSY 214
November 24, 2013
Johnny’s maternal grandmother, conversely, reported that Johnny had trouble sleeping
through the night, and often crept into bed with his 2 younger siblings, asleep on her rollout
couch, rather than remaining on the cot in his grandmother’s bedroom. She noted Johnny
wept at night, and told her of disturbing dreams where Johnny was repeatedly “burnt by the
dragon’s breath until his skin turned red”. When asked about the dream, Johnny grew further
agitated and distressed and buried his head in his pillow or sat “like a robot that just shut
down”. He often told his grandmother he was “so so sad”. On one occasion, he defended
the dragon, saying that “if he fed the dragon, the dragon wouldn’t have to burn anybody”.
Some symptomatic depression is evident, particularly in the demeanor he presents with
in the therapy room, withdrawn, quiet, repressed affect, aloof and disengaged.
Treatment Plan:
Based on Johnny’s diagnosis of Generalized Anxiety Disorder, his
problematic behavior at school and at home, consider the following treatment
recommendations:
-
To address Johnny’s anxiety, social reactivity and withdrawal, individual psychotherapy
is recommended. Given Johnny’s frustration intolerance, an integrated set of interventions
formed by CBT and play therapy is recommended, such as TR-CBT (trauma-related
Cognitive Behavioral Therapy) Please see the following page for TR-CBT Treatment Plan.
-
To assist Johnny’s mother and father with providing consistent support at home,
collateral work with his psychotherapist, school counselor, teacher and parents is
recommended, including monthly collateral parent meetings.
Court mandated parenting
classes should continue, as scheduled by the court, including Conjoint parent-child therapy.
Audrey Fairchild
CPSY 214
November 24, 2013
-
To address Johnny’s depression, a medical blood panel should be requested by the
pediatrician, and any chemical imbalances should be reviewed by a pediatric psychiatrist for
possible nutritional / medication supplementation.
-
To address Johnny’s academic skills development and OT issues (pencil grip,
penmanship, attention issues), special education accommodations should continue, as
prescribed by Johnny’s Individual Education Plan (IEP) in place.
Cognitive Behavior Tx for Hyperarousal, Avoidance, and Trauma Stress Disorder:
A range of treatments, services, and preventive interventions have been identified as meeting
scientific criteria and being efficacious with children who exhibit symptoms of traumatic
experience.
However, the highest standard of Evidence-based practice currently proposes
Trauma-Focused Cognitive Behavior Therapy (TF-CBT) for children experiencing the
symptoms of PTSD.
CBT is an exposure-based cognitive behavioral intervention that is
used for both adults and children experiencing PTSD.
TF-CBT draws upon the strength of
cognitive behavior therapy to assess, triage, and treat children who have experienced at least
one traumatic event, which has produced symptoms of hyper-arousal, re-experiencing, or
avoidance.
Results of TF-CBT reflect a significant reduction in conduct disorder, child’s
personal safety skills, general anxiety, and problems in social relations. Specifically dealing
with treatment for children with Trauma-Attachment Disorders including child sexual abuse,
(CSA), TR-CBT shows significant impact on the child’s severity of internalizing,
externalizing, depressive, and anxiety symptoms, along with their levels of sexualized
behaviors, fear, shame, and body safety skills.
Audrey Fairchild
CPSY 214
November 24, 2013
TF-CBT is a treatment approach that incorporates separate individual sessions for the child and the
non-offending parent (foster parent, step parent, adoptive parent, or caregiver), along with conjoint
parent-child sessions. TF-CPT includes components that spell out the acronym PRACTICE.
Psycho-education and parenting; Relaxation; Affective modulation, Cognitive coping, In-vivo
exposure, Conjoint parent-child sessions, and Enhancing safety and future development.
Some protocols of TF-CBT also include a Trauma-Narrative (TN), which the child vocalizes to
the practitioner, who then records the detailed narration and exploration of the traumatic event
for the child, over several sessions, and processes with the child as well as the caregiver. The
recommendation for Johnny is sixteen sessions, with two sessions per week for 8 consecutive
weeks, for 90 minutes: 45 minutes with Johnny individually (play therapy, psycho-education,
exposure, relaxation, and journal recording), and 45 minutes with Johnny and his mother in
treatment together, playing a series of trust-building and social skill-building games, as well as
psycho-education about the process of healing trauma and ameliorating the stress response.
During therapy, they will receive the six parts of the CBT acronym “P.R.A.C.T.I.C.E. (Psychoeducation and parenting; Relaxation; Affective modulation, Cognitive coping, In-vivo
exposure, Conjoint parent-child sessions, and Enhancing safety and future development.
Long Term Goals for Treatment:
1.) Recall the traumatic events of child abuse and parental separation without becoming
overwhelmed with negative emotions, and instead to use self-advocacy skills;
2.) Interact normally with schoolmates and teachers, without irrational fears or intrusive
thoughts that control behavior and cause impulsive outbursts
3.) Return to pre-trauma level of functioning without avoiding people, thoughts or feelings
associated with the abuse, or parental separation;
4.) Display a full range of emotion without experiencing a loss of control
5.) Develop and implement effective coping skills that allow for carrying out normal play,
sibling interactions, school work and school play, interactions with teachers, and a
relationship with both parents founded on self-advocacy, safety and security
Audrey Fairchild
CPSY 214
November 24, 2013
INDIVIDUAL SESSION PLAN: (twice weekly, 45 minute sessions)
Sessions 1-2:
(Week 1)
Establish rapport with Johnny through play with sand tray.
Assess Johnny’s frequency, intensity, duration, and history of PTSD
symptoms and impact on functioning at school, with peers and family.
Complete additional psychological tests to assess PTSD nature , severity
PTSD Scale – Child and Adolescent Version (CAPS-C) to compare this
baseline value to post-treatment values in Week 16, at termination.
Sessions 3:
(Week 2)
Gently explore Johnny’s recollection of scary nights and his emotional
reactions at the time. Psycho-education about the difference between
a feeling (tightness in tummy, shallow breathing) and the thoughts about it
(I’m going to die” “I need to get out of here” “I need to hide”) Use of
puppets or sand tray toys may be included.
Session 4-6
(Week 2-3)
Discuss the model of PTSD and how it results from exposure to scary
things (intrusive thoughts, shame, anger, guilt) as normal responses.
Read a therapeutic book called “It Happened to Me” by Carter, modeling
that bad things can happen, and the protagonist can make a choice to
keep themselves safe in similar, future situations with calming strategies
Discuss how coping skills, cognitive restructuring, and exposure help
build confidence, desensitize and overcome fears, and see one’s self,
others, and the world in a less fearful and depressing way.
Learn and implement calming and coping strategies to manage
challenging situations related to trauma: relaxation, breathing control,
covert modeling (imagining the successful use of the strategies) and role
playing with therapist for managing fears until sense of mastery is evident
Session 7-9
Parent contract written by child and parent, and facilitated by therapist
to build in predictable consequences, expectations of behavior,
appropriate discipline, and self managing strategies that both child and
parents will abide by, and consequences\Plan-B for lapses in either
child or parent(s) behavior. All parties sign the agreement and are given
copies to post in both homes, and a copy mailed to school and teacher.
Learn and implement anger management techniques: teach the child and
parents anger management techniques such as taking time out, engaging
in physical exercise, and relaxation, and expressing feelings assertively.
Identify, challenge and replace fearful self-talk with reality based positive
self talk. Explore clients schema and self talk that mediate trauma fears
Identify and challenge biases, assist him in generating appraisals that
correct for biases and build self confidence.
Audrey Fairchild
CPSY 214
November 24, 2013
Session 10-12
Exposure and desensitization with role play with therapist, using puppets,
sand play, and ultimately, role play with parent(s) while therapist guides
relaxation and self management of emotions.
Read aloud to the client about cognitive restructuring in books on anxiety
Assign the client homework exercises in which he identifies fearful selftalk, in which he creates reality-based alternatives; review and reinforce
success; provide corrective feedback for failure.
Direct the client to construct a detailed narrative description of the
trauma(s) for imaginal exposure; construct a fear and avoidance hierarchy
of feared and avoided trauma-related stimuli for in vivo exposure (yelling,
angry voices, falling furniture)
Session 13-15
Have the client undergo imaginal exposure to trauma at increasing but
client-chosen level of detail, repeating until associated anxiety reduces
and stabilizes; record the session, having C listen to it between sessions.
Teach the client thought-stopping in which he internally voices the word
“stop” and/or imagines a stop sign immediately upon noticing the
unwanted thoughts.
Relapse prevention and maintenance, What do I do if the feelings come
back? Rehearse with the client the management of future situations or
circumstances in which lapses could occur. Instruct the client to routinely
use strategies learned in therapy while building social interactions.
Reassessment on same instrument …CAPS-C to compare to baseline.
Session 16:
Termination: Closure ritual and celebration that Johnny has completed
an entire program and learned some new strategies for handling big
feelings, and staying calm at school and at home, even when triggered.
(“Taking something with you (memento) and leaving something behind”)
(Follow with ceremony of cessation of conjoint parent-child sessions also)
Reinforce the client’s positive, reality-based messages that enhance
self confidence and increase adaptive action.
Schedule a follow therapy session in 3-6 months, depending on teacher
reports and parent and grandparent outreach to therapist. Share
reports as needed with CPS, court system, school district, parents.
Audrey Fairchild
CPSY 214
November 24, 2013
REFERENCES
Arvidson, Joshua; Kinniburgh, Kristine; Howard, Kristin et al, “Treatment of Complex
Trauma in Young Children: Developmental and Cultural Considerations in Application
of the ARC Intervention Model”, Journal of Child and Adolescent Trauma , 4:14-51,
Taylor & Francis Group, LLC Publishers, 2011
Becker-Weidman, Arthur, “Treatment for Children with Trauma-Attachment
Disorders: Dyadic Development Psychotherapy”, Child and Adolescent Social Work
Journal, Vol 23, No 2, April 2006, Springer Science-Business Media, Publishers, 2006
Conradi, Lisa; Kletzka, Nicole Taylor; and Oliver, Tonya: “A Clinician’s Perspective
on the Trauma Assessment Pathway (TAP) Model: A Case Study of One Clinician’s Use
of the TAP Model”, Journal of Child and Adolescent Trauma, 3: 40-57, Taylor and
Francis Group, LLC Publishers, 2010
Copping, Valerie, E, Warling, Diane, Benner, David, and Woodside, Donald, A Child
Trauma Treatment Pilot Study, Journal of Child and Family Studies, Dec. 2001, Volume
10, Issue 4, pg 467-475,
Deblinger, Esther; Mannarino, Anthony, et all “Trauma-Focused Cognitive Behavioral
Therapy for Children: Impact of the Trauma Narrative and Treatment Length”
Depression and Anxiety Journal, Vol. 28, pg 67-75, John Wiley & Sons Publishers, 2011
Hoagwood, Kimberly Eaton, and Felton, Chip, et al, New York State Office of Mental
Health: “Implementing CBT for Traumatized Children and Adolescents After September
11: Lessons Learned from the Child and Adolescent Trauma Treatments and Services
(CATS) Project” Journal of Clinical Child and Adolescent Psychology, Vol. 36, No. 4,
pg 581-592, Lawrence Erlbaum Associates, Inc., Publishers, 2007
Nader, Kathleen, “Trauma in Children and Adolescents: Issues Related to Age and
Complex Trauma Reactions”:, Journal of Child and Adolescent Trauma, 4: 161-180,
Taylor & Francis, LLC Publishers, 2011
Prather, Walter and Golden, Jeannie A. “A Behavioral Perspective of Childhood
Trauma and Attachment Issues: Toward Alternative Treatment Approaches for Children
with a History of Abuse”, International Journal of Behavioral Consultation and Therapy,
Vol. 5, No. 2, pg 222-241, 2001
Yule, William, “A Comparative Study of Different Developmentally Grounded and
Culturally Sensitive Mental Health Approaches towards the Treatment of Trauma in
Children and Adolescents” , Development Strategies to Deal with Trauma in Children,
pg 65-74, 2005
Audrey Fairchild
CPSY 214
November 24, 2013
ADDITIONAL RESOURCES
United States Department of Veterans Affairs website: National Center for PTSD:
DSM-5 Criteria for PTSD
http://www.ptsd.va.gov/professional/pages/dsm5_criteria-ptsd.asp
American Psychiatric Publishing:
Post Traumatic Stress Disorder website DSM5.org
Griffin, Gene, “Addressing the Impact of Trauma Before Diagnosing Mental Illness in
Child Welfare”, Child Welfare, Vol. 90, No. 6, pg 9-89, 2011
Grohol, John, Ph.D. PsychCentral: Final DSM 5 Approved by American Psychiatric
Association website:
http://psychcentral.com/blog/archives/2012/12/02/final-dsm-5-approved=by-americanpsychiatric-association