Case Study

SEI 513, Spring 2014

Kara St.Hilaire
University of Maine

















Background Information
Carter* (*name changed to protect identity) is a 5 year, 5 month year old boy.
For the first four years of Carters life, he grew up living solely with his father in
Gardiner, Maine. In June of 2013, Carter witnessed his father pass away, and was put
into custody with his biological mother. Currently, Carter resides in Gardiner, Maine
with his biological mother, 12-year-old sister, and 2-year-old brother. Carter also
has another sibling, age 10, who was removed from the home six months ago for
sexually perpetrating Carter and his sister, and threatening to kill his other siblings
and mother. On April 28, 2014, Carters mother officially gave up her parental rights
to her 10-year-old son.
Carter currently receives section 65 services, 27 hours a week, based on his
diagnosis of Post Traumatic Stress Disorder, in the Busy Bees classroom at the
Childrens Center Augusta. The Busy Bees classroom is a small, specialized program
for children identified with emotional disorders or challenging behavior. A clinician
who oversees the classroom is in charge of Carters individual treatment plan, and
provides him with individual therapy sessions once a week.
Carters family receives case management services through the Childrens
Center Augusta to assist in making connections to needed services, help develop
parenting skills, and provide on-going emotional support to family members. Their
case manager has recently recommended section 65 home and community
treatment services (HTC); however at this time, Carters mom has declined. Current
priorities and challenges for his family include daily living necessities such as having
enough food, beds to sleep on, medication, and transportation.
Child Functioning
When regulated, Carter is an outgoing boy who enjoys coming to school and
being around his friends and teachers. He is very sympathetic towards his peers,
even helping them problem solve when there is conflict. He has a deep imagination,
which he is not afraid to use during play, and excellent receptive and expressive
communication skills. I witness Carter to possess the most genuine happiness when
he is outside; he has excellent gross motor skills, which are evident in his interests
outdoors: baseball, soccer, climbing, jumping, and riding bikes. When un-regulated,
providers describe Carter as explosive, manic, and unpredictable with behaviors
ranging from growing, screaming, refusing to follow directions, talking about killing
various types of people, raising up fists, or toys as if he was going to hit others, and
making a gun out of his fingers to point at others. When Carter is in this frame of mind,
he is often removed from the group, spending anywhere from fifteen minutes to an hour
to calm his body.
Carter was recently seen at Edmund Ervin pediatric center for an up-to-date
psychological evaluation on April 4, 2014; we are currently waiting to receive the
results.

Family concerns/needs/resources
All of Carters siblings have been exposed to some form of or trauma or
neglect. Carters oldest sister has been diagnosed with an emotional disorder, and
his youngest brother who is two, has yet to reach crucial developmental milestones
such as talking, or making eye contact. Their single, and currently un-employed
mother, who struggles with severe anxiety, does the best she can given her
emotional barriers. Currently, the families case manager is the only individual
Carters mother will have contact with at the Childrens Center, which is who
provides classroom staff members with updates on the family.

Goals for intervention
Carters current goals written on his section 65 treatment plan state that he
will:
Express a wide range of negative emotions in ways that avoid leading to
antisocial behavior.
Express a wide range of negative emotions in ways that avoid leading to
verbal or physical aggression.
Accurately label verbal and non-verbal emotional cues.
Increase awareness of verbal raging.
These goals are directly correlated with Carters independent social and emotional
functioning; while he does need to learn self regulation skills in order to meet other
goals, there are certainly long term objectives that Carter can be working towards
attaining, such as: following one step directions, sharing and turn taking with peers,
sharing space with peers, interactive play, and attending to adult directed tasks.

Intervention process
During the week of March 25, I observed Carter in his classroom
environment in order to create a positive support plan. I broke down the positive
support strategies into two groups as listed below:
Preventative strategies: Throughout my week of observing, I found using
preventative strategies to be most effective in managing Carters behaviors.
Since he has excellent receptive and expressive communication, finding times
when he is regulated to discuss expected behavior throughout the course of
the day is important. Reading books and social stories on feelings and how to
handle emotions such as anger, fear, sadness, and frustration when he is in a
regulated state is also a positive preventative method. Showing him visuals at
the beginning of the session of choices he can make when he starts to feel
angry i.e. squeeze stress ball, take a walk, read a book, etc. is another
preventative tool that may not only fizzle in-the-moment problems, but help
him gain coping strategies for the future. Another strategy to use when he is
in a genuinely happy state of mind is to identify and point out what it is that
is making him happy: Carter, you were smiling a lot while you were dancing
today! Dancing must make you feel happy. Using Carters interests as a
preventative strategy will also help to keep him regulated throughout his
day. Cars, painting, music, and any gross motor movement activities are all
motivating activities. Finding ways to incorporate them into his day, or
having him work for them using a visual reward chart would be beneficial.
Overall, providers should constantly be working on building a positive
relationship with Carter through back and forth interactions, following his
lead, and the use of affect to make him feel safe and accepted in his school
environment.
Strategies for addressing explosive/volatile behaviors: Carter has great
ability to expressively communicate his feelings, but not always
appropriately. Because of this, teachers should practice talking Carter
through angry episodes before sending him away from the group, causing an
immediate overreaction. Modeling effective problem solving techniques with
him will help alleviate the outbursts he tends to have on his peers. When he
does effectively problem solve, it should be positively noted. Any opportunity
that Carter does, or does not problem solve a visual of what occurred may
help him to see what the problem was, and work it out. It may look like this:
Teacher: First, I asked you to line up behind Joey (draw kids in line) then,
you slammed the bathroom door (draw door.) What could you have done
instead? By seeing the visual of the situation laid out in front of him, it may
help him process what occurred, and what he could have done alternatively.
Since Carter is motivated by music, singing a song to get him through one-
step directions, transitions, or confrontations with peers may also help.

I came up with these strategies in order to avoid impulsive punishment techniques
such as being removed from the group and sitting at the table, leading to long,
drawn out overreactions. The week of April 1, I saw providers using much more
preventative strategies to avoid negative behaviors, and within that week I noticed
shorter overreactions, and less time spent away from the group.




Recommendations for addressing future needs

Carter is a young boy who has already faced many challenges in his five years
on earth. In order for him to make progression, I recommend his providers and
caregivers use the same strategies and techniques for addressing his behaviors,
preferably through the use of positive supports, as it has already shown to be
somewhat effective with Carter in the first week. In order for Carters primary
caregiver, his mother, to be involved with his progress I recommend continued case
management services in order for her to have a positive support system, as well as
advice and access to services.