Questions and answers
Question 1.
Considering the fact of the adoption, I would ask about the circumstances of the adoption. I think that it would be important to learn the time that Clara was placed up for adoption, was it at birth. Clara could have been taken from her family for neglect, abuse, parental deaths, or financial reasons as a toddler. If so Clara could be, reliving painful memories that she is unable to convey effectively to her family and they are manifesting as abnormal behaviors. The timeline for the adoption is also important especially if she has only recently been placed with her new adoptive family permanently. If Clara's adoptive parents have access to her family history I would like to know if there are any genetic reasons in past generations that would help to explain her recent behavioral changes.
I would also ask if there were any changes in Clara's daily life or the family unit's life at or before the onset of these behaviors- visitors, economic status, a new sibling on the way, the loss of a friend, family member or pet (death or a sudden move). If there have been recent changes to Clara's daily life as noted by the parents I would also like to ask Clara about her feelings on those changes and how she sees that they have affected her life.
I think that learning how Clara's day normally progresses at home and day care is also an important part of her life, and Clara's personal perception is important here as well as things noted by the parents and/or day care workers. If Clara is being harassed at preschool by either a student or teacher, perhaps for the cloths that she wears, her ethnicity, speech, toileting habits, or even "Teddy" her security bear, could offer some insight into the abnormal behaviors that she is experiencing throughout her life. I would also like to know if any of the other children at the preschool are demonstrating these same behaviors.
Concerns for Clara's current and recent health might also shed light into her behavioral issues, perhaps there are biological issues that are affecting the way that she feels or hearing and vision. Some sever childhood diseases leave lasting neurological problems that may go undetected for a considerable amount of time. Has her diet or level of exercise changed suddenly?
I would like to know if there are stressors that Clara comes in contact with that elevate her behavioral issues consistently or if they were random incidences. What were the first signs of the behavioral problems, did they happen in a sequence or random? I think that I would try to discover each person's perception- the parents, day care workers, and Clara's own understanding of her actions and reactions.
I think that I would also ask Clara if she understands that her parents love her and are concerned about how she is acting. I would also like to know how Clara feels about her life in general, if she is happy, if so why, if not why-what makes her happy and unhappy, angry, sad, or empty. After that I would also like to know how she feels during a tantrum, what she thinks about when she cannot sleep, and why she does not want to eat, and what she gets out of these times emotionally.
question 2.
I think that for children of Clara's age I would encourage her to draw, play, neurological and neuropsychological tests.
Young children are often able to express themselves better through drawings then they are with words, if they have a personal drawing in front of them they are able to answer questions about that drawing and their feelings concerning the drawing. I would encourage Clara to draw different things, places, and people in her life and that would open up the line of dialogue concerning these different drawings. Also the level of intensity for each drawing tells a story in itself- light to dark marks, scribbles, letters and words, the colors used, and the overall effect of the picture, happy, sad, or angry. Children love to play, to invent new realities, or just change the present/past. By encouraging Clara to play as though she were another person, mother, sister, the day care worker, or the kid next door that babysits on the weekend with Clara, she is able to tell us what really happens when no one else is around even regardless of the behavior- it's just playing. Children tell the most amazing stories when they feel safe to do so.
I think that considering Clara's age, I would also like to be able to evaluate her in her natural surroundings, naturalistic observation. Realizing that everyone's behavior will be affected by a personal observation by a therapist, there are limited benefits to this but there is another alternative, finding a reliable observe that is a part of Clara's daily environment at home and preschool such as a parent or teacher. Including another person that wants the best for Clara, adds a certain amount of accountability to their average day. They would be looking for changes in her behavior and watching her surroundings for things that may have provoked or prevented the behavior. A detailed list of events in Clara's life allows me to be able to objectively evaluate her environment, however if the chosen observe holds any bias or does not closely observe Clara throughout her day the integrity of the information is limited.
Considering that, the onset of Clara's abnormal behaviors started so suddenly I would also like to run several neurological and neuropsychological tests to analyze her brain structure and brain activity. A comprehensive neural exam with a functional MRI would allow clinicians to evaluate the developmental stages of brain development as well as neurotransmitter activity. Some behavioral problems stem from neurological problems such as autism, cerebral palsy, or a recent fall off the bed resulting in brain disorders. These tests have a high factor or reliability and are accurate in the information that they share with us concerning our patients.
question 3.
The first and possibly the most important factor in deciding on a treatment for Clara would be her age. At four years old, Clara is limited with pharmacological interventions as well as cognitive levels of understanding. Therapy also needs to align itself with the cultural beliefs of the client and in this case her family for it to be lasting. Other issues to consider is the measured effectiveness of a given treatment within those parameters. Time may also be a factor for this family as issues of money come into play for some clients because some means of therapy are long drawn out processes that last for years. This all goes back to the initial interview and idiographic information received from Clara and her adoptive parents concerning Clara's past and present life. most therapist also have a personal orientation to the type of treatment that they rely on and continue to fall back on time after time, whether it be focusing on a psychoanalytical, humanistic, cognitive, cognitive behaviorist, or any of the other means of treatment in practice at the current time. Psychology is an ever changing and advancing practice with new treatment being tested frequently, some have positive results in limited cases while others have strong results across a broader range of disorders. The latest and greatest treatment may not be the most effective methods of treatment for Clara at the present or for her future. I personally would prefer to stay with treatment options for all of my clients that are empirically supported or evidence based from reliable sources. In Clara's case I would not just be treating Clara for her abnormal behaviors, I would also be counseling her parents on how to redirect her behaviors for more positive ones. As Clara ages her parents may be the most effective part of her treatment since they will be with her most of the time and have the opportunity to influence her treatments success or failure through their actions and behaviors as well.
question 4.
DSM axis I-anxiety disorders, clients may have a general feeling of overall anxiety and worry concerning everyday life (general anxiety disorder), anxiety concerning specific experiences in life (phobias), periods of panic (panic disorder)repetitive thoughts and behaviors (obsessive-compulsive disorder), memories of trauma (acute stress disorder or post traumatic stress disorder)
Clara may be experiencing any one of these symptoms/disorders considering her loss of appetite, insomnia, and sudden dislike for her preschool.
DSM axis II- mood disorders, suffers with a sad or elated mood for extended periods of time major depressive disorder or bipolar disorders-mood swings from manic to depression) Considering Clara's flat affect she could easily be suffering with depression or bipolar disorder-the recent onset of the changed behaviors. DSM axis III- general medical disorders, physical or mental disorder that are not accounted for in either axis I or II Clara could also have something wrong with her neurologically that is affecting her behaviors. Depending upon what the results are from the functional MRI a neurological disorder or neurological trauma may be the cause of Clara's recent behavioral issues. DSM axis IV- psychosocial and environmental issues, perhaps a life trauma that had previously been repressed, feelings of social inadequacies, family stressors Clara's new environment could be the cause of her new behavioral issues, or perhaps as she is growing older her memories are becoming more vivid and active in her life, but she is unable or fearful of talking about them in a constructive way that promotes healing instead of abnormal behaviors. DSM axis V- global assessment of functioning, assesses a patients overall ability to thrive (to lead a productive life independently) Clara's apathy concerning life in relation to her environment (people, preschool, restful sleep, and food) may mean that she has an overall indifference to life in general making it difficult for her to develop her mental and emotional status that will sustain her throughout the rest of her adult life.question 5
I personally think that labeling a child Clara's age with a mental disorder will limit her future abilities. Personal perceptions of mental health disorders have evolved within the past fifty years and the stigma is no longer one of shame, however we have not evolved to a point where suffering from bipolar and schizophrenia disorders are totally overlooked. I also think that tagging a child with mild to moderate learning disabilities only limits them in their true potential, both personally and from a societal viewpoint. Why should we allow a child a "crutch" to lean on when we are not sure how far they can go. People automatically believe that when a child suffers from mental retardation that cannot do for themselves, yet people are proving that belief wrong every day as people with MR thrive in a working and personal environments living independently supporting themselves with only minimal adaptations from the rest of the world. People that are told tagged with an illness begin to demonstrate signs of that illness and give into it without trying to overcome it. If Clara is diagnosed with a depressive disorder then she carries the feelings that her life is less than what it should be and therefore is predisposed to that thought process. She may give in to those feelings of inadequacies and accept defeat before ever applying her true abilities. Labeling a child before they have ever applied themselves and been pushed and encouraged by the people that love them is a personal defeat and an excuse for everyone that may come in contact and be touched by a person unachieved gifts. Later in life once a person has developed mentally and physically diagnoses are needed to support those that need assistance, monitoring, and continued counseling. Many of the neurological disorders that affect people can be managed with proper care, medications, and close monitoring and without a history and clinical diagnoses then these issues are uncontrolled. Some neurological disorders can be harmful to the person or to society without these clinical interventions. I think that the best practice would be to evaluate the circumstances on an individual basis and to not make snap decisions that have life-long ramifications for our clients.
