HECTOR, JASMINE, and JESSICA

DESCRIPTION at INTAKE

Hector Vega, a seven-year-old boy of Puerto Rican and Dominican descent, was brought to the outpatient clinic by his foster parents, Mr. and Mrs. Armstrong, because of their concerns about Hector’s difficulty functioning at home and in his special education school.  In a recent incident, Hector was suspended from school for trying to stab a classmate with a pencil after the classmate accidentally knocked into him while passing by.

Hector and his two sisters, Jasmine (11) and Jessica (5), have lived with the Armstrongs since being removed from their biological mother’s care four years ago.  A preschool teacher had called child protective services after she noticed bruises on Hector’s buttocks when she was helping him get dressed after using the bathroom.  After child protective service workers interviewed the children and visited the home, they determined that Hector and Jasmine had been repeatedly physically abused by Ms. Vega and her boyfriend.  When the two older children misbehaved, they were beaten with an extension cord, had hot sauce put on their genitals, or were made to kneel on uncooked rice.  Jasmine told the Armstrongs that she didn’t remember when their mother had started hitting her when she was “bad,” but that Hector’s abuse had started when he was about eighteen months old.  All three children had witnessed many violent episodes between their mother and her boyfriend.  Jasmine said that the two often hit, kicked, and threw things at each other when they were angry, and that she had seen blood all over their faces and clothes after some of their fights.  Jasmine said she would take her younger siblings into the bedroom closet during these incidents.

The Armstrongs know little about the siblings’ early developmental history, but they reported that all three children were underweight, quiet, and fearful when they were first placed with them.  Hector was still in diapers and using a pacifier.  His language seemed significantly delayed, and he wasn’t yet speaking in full sentences.  As Hector got older, his behavior became increasingly difficult to manage.  His foster parents reported that he often becomes angry and aggressive with very little provocation.  He seems to crave danger, and once climbed out the window to walk on the railings of their fourth-story fire escape.  He also has difficulty falling asleep, and sometimes gets no more than one or two hours of sleep a night.  When he does fall asleep, he often has nightmares about monsters and vampires.  His foster mother also reported that he has always hidden food in his room.  On several occasions, she has found week-old sandwiches and glasses of milk under his bed.

The Armstrongs have concerns about Hector’s sisters, too.  When Jasmine was placed with the Armstrongs she was seven years old.  Mrs. Armstrong said that Jasmine acted just like her siblings’ mother, and insisted on feeding and diapering Hector and Jessica.  They don’t have confirmation of this, but they assumed that much of the responsibility for taking care of her brother and sister was left to her.  The Armstrongs also reported that Jasmine has always seemed sad and anxious, and is very hard on herself when she doesn’t do well in school or when she makes even a small mistake.  Mrs. Armstrong reported that Jasmine recently dropped a glass of milk on the floor.  Mrs. Armstrong said that she didn’t have the heart to yell at her because Jasmine called herself stupid and hit herself in the head with her fists three or four times.

Mr. and Mrs. Armstrong report that they worry about five-year-old Jessica’s activity level and difficulty concentrating.  They described Jessica has always being on the go and not being able to stay with any one activity for very long.  She also has a very strong startle response and jumps and gets upset when she hears loud voices.

QUESTIONS FOR DISCUSSION

1. What kinds of trauma have Hector and his sisters been exposed to?
2. If you didn’t know the children’s trauma history, what diagnoses might you consider for them?
3. How does knowing about the siblings’ trauma history impact the diagnoses they might receive?
4. What are your hypotheses about how the siblings’ traumatic experiences have impacted their functioning?
5. Assess the degree of emotional regulation for Hector using Saxe’s framework.
6. Assess the stability of the social environment, using Saxe’s framework.
7. What does your assessment suggest for treatment plans?
8. How would you prioritize treatment plans?

INTAKE SESSION WITH FOSTER PARENTS

During their intake appointment at the clinic, the Armstrongs reported that the children seem to have both good and bad days.  They describe Hector as being a loving and sensitive child who can nevertheless suddenly become enraged if he perceives another child as becoming threatening or if he’s criticized by a teacher.  The stabbing incident that brought Hector to the clinic is only the last in a long line of instances of aggressive behavior at school.  When asked, Hector said that the kids in his class are mean to him and hit him all of the time.  He said that he has no choice but to defend himself and hit them back.  In the last year, Hector had two previous suspensions for hitting and kicking one of his male teachers.  When asked about this teacher, Hector said that the teacher yells at him a lot and always blames everything that goes wrong in the class on him.

Although Hector attends a special school for emotionally disturbed children, he learns very little because he is rarely able to sit through a full class period.  Hector appears to be extremely hyperactive and is unable to sit for more than a few minutes at a time.  He has great difficulty attending to his classwork and has very poor frustration tolerance.  He often appears angry and sullen, but he can quickly become expansive and almost hysterical.  Hector was initially put on a trial of Ritalin.  While on the medication, Hector was better able to attend to his work and stay in his seat for longer periods of time.  The medication, however, did not help Hector’s poor frustration tolerance, his aggressive behavior, or his emotional lability.

The Armstrongs report that Jasmine tends to hurt herself when she becomes disappointed in herself for making mistakes of any kind and not doing well in school.  She often hits herself in the head and on several occasions has cut her forearm with the edge of a paper clip.  Five-year-old Jessica seems to have the most difficulty when she’s required to sit quietly in school.  She tells them that she “sees bad things” at those times and she “feels better” when she’s running around.  She also has an extremely strong startle response and jumps whenever she hears loud voices in the street, in other classrooms, or from other apartments in her building.

The Armstrongs report that all the children seem anxious before and after the scheduled monthly visits with their biological mother, Ms. Vega, but that Hector’s behavior at school becomes particularly problematic.  Two of his suspensions from school have closely followed visits with Ms. Vega.  The Armstrongs report that Ms. Vega is inconsistent with her visits, and that she comes to the foster agency for only about half of her scheduled visits with her children.  When she does come for her visits, she seems to feel that the children don’t show her enough affection.  She either cries or becomes angry and yells at the children.  The Armstrongs have spoken to the children’s case manager many times about how upset the children become around the times of the visits, but she says that she can’t do anything to change the schedule because the judge has ordered the visits.

QUESTIONS FOR DISCUSSION

1. Use the concept of survival circuits (Saxe et.al.)  to describe the presentation by the Armstrongs of Hector having “good and bad days”.

1. What factors secondary to the siblings’ exposure to chronic trauma may be influencing their functioning?

1. What are some explanations for Ms. Vega’s (biological mother) inconsistent and inappropriate behavior at the scheduled visits with her children?

1. What are the major symptoms Hector is having?  List potential reasons why a 7 year old might have these symptoms

1. Discuss how Hector’s developmental level and age influence his symptoms.

1. Are these symptoms likely to be transient or chronic?

1. List the symptoms of Hector’s sisters, and how they differ from his. Discuss why there might be these differences.

1. What do you want to do next?

INTERVIEW

Upon interviewing the Armstrongs, the intake therapist learned that the Armstrongs received special training so that their home could be certified as a therapeutic foster home.  The Armstrongs appear to be highly skilled, patient, and loving.  In addition, they report having close relationships with their two biological children, who are both employed and have families of their own.

The Armstrongs both grew up in Jamaica and report that an authoritarian style of parenting and using physical punishment is the norm there.  They report that their parents used harsh methods of punishment and they were both “flogged” with switches as children.  The Armstrongs said that they used less harsh methods with their own children, but they describe themselves as being strict and reported that they sometimes spanked their children when they were young.  They’ve found, though, that the same methods of discipline are less effective with their foster children.  Their experience has been that Jasmine becomes overly fearful and Hector and Jessica become disturbingly agitated when they raise their voices.  They reported that, although the training they received from the foster agency was extremely helpful, they would welcome some education about how to parent children like Hector, Jasmine, and Jessica.

Mr. and Mrs. Armstrong are committed to caring for the three children.  They make sure to spend some individual time with each child engaging in an activity that each child loves. For example, Hector is a very good athlete and loves to play soccer.  He and Mr. Armstrong go to a nearby park to play soccer at least once a week.  Hector has formed a very good relationship with his foster parents and calls them Mommy and Daddy.  He appears to especially admire and respect his foster father.

QUESTIONS FOR DISCUSSION

1. Why do you think the Armstrong’s decided to become therapeutic foster parents?
2. What cultural factors may be influencing the Armstrongs’ parenting practices?
3. What are Hector’s strengths?  What are the protective factors in Hector’s environment?
4. What do you need to look up?  What do you want to do next?

ASSESSMENT

Hector’s new therapist completed a full assessment and determined that her first task was help Hector achieve a sense of psychological safety.  Hector called his incidents of affective dysregulation “going crazy,” and said that they scared him sometimes.  The therapist decided to work on improving Hector’s ability to manage his emotions.  Hector had severe difficulties in the following areas:

1. Range and intensity of emotions. Hector was expressing his emotions so intensely and inappropriately that they were interfering with his social and academic functioning.
2. Ability to label emotions or use feelings language. Hector was not able to talk about or accurately label his feelings.   He could say only that he “goes crazy” a lot.
3. Ability to connect emotions to trigger events. Hector was not aware of the connection between his emotional reactions and the situations or thoughts and beliefs that caused them.  When his therapist walked him through a “moment by moment” assessment of the stabbing incident that led to his last suspension from school, Hector said that all of a sudden and for no reason a kid in his class pushed him hard.  Hector said that he wasn’t thinking of anything and that his mind was blank when he “went crazy” and stabbed the kid who pushed him with a pencil.
4. Use of coping strategies. Hector had few strategies for coping with overwhelming emotions, and most of these were maladaptive. While the therapist was observing him play a frustrating game, she noticed that Hector didn’t use coping self-statements before approaching a difficult task or ask for help. And when she asked him about his biological mother, he seemed overwhelmed and began to take objects off her desk and throw them in the garbage.

QUESTIONS FOR DISCUSSION

1. What neurobiological consequences of trauma do you see in Hector?
2. How might these symptoms relate to his trauma history?
3. How might you intervene with these neurobiological consequences?
4. What do you think “psychological safety” means? Why do you think the therapist decided to start with helping Hector achieve a sense of psychological safety?
5. How does your body react when you are feeling anxious (sad, angry, excited)
6. What coping skills do you regularly use when you experience strong emotions?
7. What strategies might you use with Hector to help him cope better?
8. What do you want to do next?

TREATMENT

Hector’s therapist initially began working on helping Hector become aware of and label his feelings.  She worked on this in two ways.  First, she made sure to label any feelings that came up in the course of pretend play.  Hector particularly liked to play with superhero figures, so the therapist labeled the feelings of the figures during play.  For example, when two superheroes were engaged in a battle, the therapist labeled the figures as being angry, frightened, ashamed, or sad, as dictated by the play situation, and connected the situation to the feeling it evoked.  She also helped Hector understand that emotions often have physical manifestations.  When she worked with Hector, they often played frustrating games such as Operation or Sorry because Hector has particular difficulty managing frustration and disappointment.  The therapist helped Hector discover that his stomach hurts and that he clenches his fists and jaw when he feels frustrated.

Next, the therapist worked on helping Hector identify the thoughts and situations that trigger difficult behavior……