Child, Adolescent,
and Family Treatment
Case Studies in
Child, Adolescent,
and Family Treatment
e d i t o r s
Second
Edition
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Library of Congress Cataloging-in-Publication Data:
LeCroy, Craig W.
Case studies in child, adolescent, and family treatment / Craig Winston LeCroy, Elizabeth K. Anthony.—
Second edition.
1 online resource.
ISBN 978-1-118-12835-0 (pbk) ISBN 978-1-118-41897-0 (epdf ) ISBN 978-1-118-41644-0 (epub) 1. Child psychotherapy—Case studies. 2. Adolescent psychotherapy—Case studies. 3. Family psychotherapy—Case studies. I. Anthony, Elizabeth K. II. Title.
RJ504.L43 2015 618.92′8914—dc23
2014017654 Printed in the United States of America
10 9 8 7 6 5 4 3 2 1
v
EPAS standards ix
Matrix for chapter content xiii Preface xvii
1 Case Studies in Individual Treatment and Assessment 1 Case Study 1‐1 From Childhood to Young Adulthood with
ADHD 5
Susan Bogas
Case Study 1‐2 Solution‐Focused Th erapy with Child
Behavior Problems 29
Jacqueline Corcoran
Case Study 1‐3 Crisis Intervention with a Depressed
African American Adolescent 45
Jewelle Taylor Gibbs
Case Study 1‐4 What a Few CBT Sessions Can Do:
Th e Case of a Motivated Young Adult 64 Kathy Crowley
Case Study 1‐5 Th e Case of Aundria: Treating Substance Abuse During Adolescence Using CBT and
Motivational Interviewing 72 Paul Sacco
Charlotte Lyn Bright Janai Springer
Case Study 1‐6 A Developmental Approach to
Working with Sexually Abusive Youth 86 George Stuart Leibowitz
Susan L. Robinson
Case Study 1‐7 Eff ective Interventions for Adolescent
Conduct Disorder in Residential Treatment 110 Jamie L. Glick
2 Case Studies in Group Treatment 130 Case Study 2‐1 A Social Skills Group for Children 133
Craig Winston LeCroy
Case Study 2‐2 A Culturally Grounded Empowerment
Group for Mexican American Girls 145 Lori K. Holleran Steiker
Eden Hernandez Robles
Case Study 2‐3 Developmental Play Groups with
Kindergartners in a School Social Work Setting 162 Timothy A. Musty
Case Study 2‐4 Gay Youth and Safe Spaces 174 Nora Gustavsson
Ann MacEachron
3 Case Studies in Family Treatment and
Parent Training 182 Case Study 3‐1 HOMEBUILDERS®: Helping Families
Stay Together 184 Nancy Wells Gladow
Peter J. Pecora Charlotte Booth
Case Study 3‐2 Evidence‐Based Approach to
Parent Training 203 Randy Magen
Case Study 3‐3 Promoting Positive Parenting:
Infant Mental Health Intervention with
High‐Risk Families 219 Brenda Jones Harden
Elena Aguilar Cindy Cruz
Elizabeth Aparicio
4 Case Studies in Child Welfare and Adoption 236 Case Study 4‐1 A Case Study of the Application of
NTU Psychotherapy for Treatment Foster Care and
Emotional Trauma 239
Frederick B. Phillips Peter Fitts
Case Study 4‐2 Helping Families with Reunifi cation:
Returning a Child to a Less‐Th an‐Perfect Family 263 Lindsay Bicknell-Hentges
John Lynch
Case Study 4‐3 Nothing Left to Lose:
Growing Up in Foster Care 277
Debbie Hunt
Case Study 4‐4 Deciding What Is Best for Savannah:
Th e Grief and Joy in a Successful Adoption 289 Melissa Evans
5 Case Studies in School and Community Settings 296 Case Study 5‐1 Zai: A Hmong Adolescent Creates
His Own Way 299
Harriet Cobb A. Renee Staton Krystal Studivant
Case Study 5‐2 Understanding Bullying and Peer Victimization: Th e Important Roles of Peers, Parents,
and School Personnel in Prevention and Intervention 312 Anne Williford
Case Study 5‐3 Finding a Voice and Making It Heard:
A Case Study of Low‐Income Urban Youth 328 Nicole Nicotera
Case Study 5‐4 Living in Survival Mode:
A Young Woman’s Experience of Homelessness 346 Richard Geasland
Rachelle Wayne Author Index 363 Subject Index 371
ix
Th e Council on Social Work Education’s Educational Policy and Accreditation Standards for 2015 has set forth recommendations for students of social work to master nine competencies. Within each competency are practice behaviors that further defi ne the core competencies. Case Studies in Child, Adolescent, and Family Treatment, 2nd Edition addresses the nine competencies within the vari- ous case studies presented in the book. Th e following table lists the EPAS com- petencies and the case studies that most directly refl ect the competency. Th is may be helpful to both instructors and students as they relate the educational material in the book to the core competencies for eff ective social work practice.
Competency 1 Ethical and Professional Behavior
1-4 Providing brief treatment when indicated 1-3; 1-5; 5-4 Professional self-awareness
1-5; 3-3 Balancing various professional roles
1-6 Staying current on developments in a rapidly changing fi eld 4-4 Staying objective in a complex intervention environment 5-1 Recognizing the need for more information to ethically
treat a client system Competency 2 Diversity and Diff erence
1-3 Engaging with the client’s culture in treatment 2-2 Culturally grounded empowerment
2-4 Engaging peer support with sexual minority youth
3-1 Treatment with single father and son 4-1 Infusing cultural intelligence into treatment 4-2 Recognizing and respecting diff erent parenting
5-1 Addressing the cross-cultural nature of the therapeutic relationship
5-4 Understanding the culture of street-dependent youth homelessness
Competency 3 Social Justice and Human Rights
2-4 Advocating for equal rights for LGBT youth 4-1 Changing systems
5-2 Prevention of victimization by bullying and other forms of aggression
5-3 Youth advocacy for low-income neighborhood reform Competency 4 Practice-Informed Research and Research-Informed Practice
2-3 Using research in practice
3-2 Consulting empirically tested models in the design of a parent program; using client feedback to inform treatment 3-3 Integrating infant mental health principles into an ex-
isting primary prevention program
5-1 Applying evidence-based, culturally sensitive treatment modalities
Competency 5 Policy Practice
2-4 Narrow and discriminatory policies 4-1 Working within system constraints 5-2 School-level bullying policy
5-3 Challenging negative beliefs about low-income youth 5-4 Limited services for homeless youth
Competency 6 Engagement
1-2 Parent and child together in session 1-5 Court-mandated treatment
1-7 Diffi cult to engage client 4-3 Engaging client systems
1-3; 5-1 Th erapeutic alliance, evaluating suicidality
Competency 7 Assessment
1-1 Changing therapeutic strategy as the needs of the indi- vidual client system change
1-7 Prioritizing treatment strategies based on client process and professional judgment
2-3 Using knowledge of child development to design treat- ment
3-2 Stages of group process
4-2 Sequencing goals in family treatment Competency 8 Intervention
2-1 Social skills group with children; treatment in the natu- ral environment
2-4 Facilitating group work 3-1 Using theory-based treatments
3-3 Treatment focused on the caregiver–infant dyad
4-1 Developmentally appropriate treatment for adolescents 5-2 School-level intervention/prevention
5-3 Neighborhood-level intervention 1-1; 1-2; 1-4; 2-2; 3-3; 5-3 Strengths approach Competency 9 Evaluation
1-5 Use of standardized assessment measures 2-3 Pre-test/post-test design in treatment
4-3 Self-refl ection; understanding role within other systems of professionals
xiii
Topic Area: Advanced Treatment Methods
1-1; 3-3 Eff ective use of a treatment team 1-2; 5-1 Solution-focused therapy
1-3 Crisis intervention
1-4; 1-5; 1-6; 1-7; 5-1 Cognitive-behavioral therapy 1-5, 1-7 Motivational Interviewing
1-6 Multiple modalities; trauma-informed therapy; psycho- sexual assessment
1-7, 4-2 Counseling within residential programming 2-3 Th eraplay
3-1 Intensive, home-based family preservation 3-1 Rational-emotive therapy
3-3 Attachment and Biobehavioral Catch-Up (ABC) 4-1 NTU Psychotherapy
5-1 Integrative psychotherapy Topic Area: Advocacy
2-2 Cultural connection and support for marginalized pop- ulations
2-4 Environmental manipulation and support for gay youth 4-1 Advocating for child in legal guardianship transitions 5-2 Preventing victimization
5-3 Community organizing with low-income youth 5-4 Positive youth development with homeless youth Topic Area:Mental Health Disorders
1-1 ADHD 1-3 Depression 1-5; 4-1 Substance abuse
1-6 Co-occurring PTSD and ADHD 1-7 Conduct disorder
Topic Area:Child Welfare Involvement 1-6 Group home
3-2 At risk for child maltreatment
4-1 Th erapeutic foster care/specialized foster care 4-2 Reunifi cation
4-3 Foster care
3-1; 3-3; 4-4 Preventing possible child welfare involvement Topic Area:Juvenile Justice Involvement
1-5 Marijuana charges
1-6 Sexual off ending, animal cruelty, destruction of prop- erty, stealing, fi re-setting, aggression
4-1 Shoplifting
4-3 Dually adjudicated (dependent and delinquent) Topic Area:Families
1-1 Family involvement in treatment 1-2 Parent involvement in youth treatment 1-5 Multigenerational substance use 3-1 Family preservation
3-2; 3-3 Parent training and education
3-3 Intimate partner violence and family processes 4-1 Working with sibling group as the family unit 4-2 Challenging family dynamics in family therapy Topic Area:Diversity
2-2 Mexican American girls’ empowerment group
2-4 Group work with gay youth 3-3 Immigrant Latino family
4-1 Afrocentric approach to treatment
5-1 Understanding the culture of a Hmong adolescent 5-3 Working with low-income youth living in public housing Topic Area: Ecological Model/Generalist Practice
2-1;2-3 Promoting competence in children
2-3 Preventive group counseling in school setting 2-4 Treatment of systems
4-3 Systems of care; wraparound services 5-2 Prevention
5-3 Capacity building for prevention 5-3; 5-4 Positive youth development
xvii
Th is book relies on a successful formula for teaching students about clinical practice—the case study method. Th is method provides a diff erent format to learn about social work practice than is currently available in traditional social work textbooks. Our intent was to provide an educational experience that emerges from reading and thinking about case studies. Th e case study method became well known because of its use as a primary teaching method in schools of business, in particular, its use in the Harvard Business School.
In social work, case studies can be used as action-oriented educational tools that essentially help students “participate” in the process of doing social work. Th is book builds on an earlier eff ort, Case Studies in Social Work Prac- tice , which focused on social work generally. We thought it would be equally e valuable to create a case study book that was focused on child, adolescent, and family practice.
Th is book can be used as a primary or secondary textbook for direct practice courses in social work. Because the case study method builds on the theory of social work practice presented in most textbooks, this book can be used in foundation and advanced courses. In particular, the book would be a good fi t for courses on social work practice with children, adolescents, and families. Also, many instructors have used this book to complement fi eld seminars where there is more focus on the practical aspects of doing social work. Lastly, because the book includes a diverse range of case studies, this book can be used to present an overview of practice content with children, adolescents, and families. For example, this book has been used
as a supplement to a Human Behavior and Social Environment course to integrate the more theoretical content of that class with the practical applica- tion of social work principles across the fi rst part of the life course. Because the case study method can be used in many creative ways, we hope this book fi nds broad application in the social work and human services curriculum.
TO THE INSTRUCTOR (AND STUDENT)
Th e purpose of this book is to help students learn clinical practice by study- ing how practitioners have applied clinical principles to particular real-world case situations. In order to facilitate learning, each case study begins with a set of questions. Th ese questions are designed to help students engage with the material, to stimulate critical thinking, and to promote classroom discussion.
As students read these case studies, they can be encouraged to think about the cases as if they were practitioners. How would you feel if confronted with this case? What stands out as important in this case to you and why? Do you agree with the approach taken by the practitioner? What alternative methods would you consider with this case? Classroom discussions can investigate the judgments made by the clinicians and discuss what is considered good or bad about the approach taken in each case. Other suggestions about how the case studies can be used in a course include the following:
◆ Have students think about what they might have done diff erently and why.
◆ Have students write out a treatment plan based on the case.
◆ Have students describe and analyze policies, organizational factors, and ethical issues inherent in the case studies.
◆ Conduct role-plays in which students act out the roles of the practitio- ners and clients in each case.
Our hope is that students and instructors can use these case studies to stimulate critical, analytical, and objective thinking about clinical practice.
As a case is discussed, several perspectives are likely to emerge. Within this context, underlying assumptions about human behavior and clinical practice can be brought out in a discussion. Most importantly, the interaction and exchange of ideas can promote an atmosphere of critical discussion. Clinical
case presentations are frequently accepted without critique and analysis, limiting the learning that can occur. We hope that as students and instruc- tors move from case to case, they will begin to develop an accumulation of experience in thinking and reasoning as applied to the diff erent case material presented, resulting in more eff ective clinical practice.
THE SECOND EDITION
It is very exciting to have a second edition of the Case Studies in Child, Ado- lescent, and Family Treatment ! Thtt e overall organization of the text remains similar to the fi rst edition. Th e major changes include updating the case material and adding new cases. In particular, new material has been added that refl ects newer changes in the fi eld. For example, case studies have been added in areas such as CBT for youth, adolescent substance abuse, treatment for conduct disorder in a residential setting, developmental play groups, facilitating a successful adoption, and prevention and intervention for bully- ing and peer victimization.
Th is edition includes case study material in fi ve separate sections that include case studies in individual treatment and assessment group treatment, family treatment and parent training, child welfare and adoption, and school and community settings. Also included are an EPAS crosswalk, which shows how the material meets the Council on Social Work Education (CSWE) competency standards, and a matrix for chapter content that shows the dif- ferent concepts covered by the cases. Th is information will be particularly useful for instructors who want to use only specifi c case studies to cover their course content. For example, an instructor teaching foundations of social work practice might want to use the case studies that present an ecological framework.
ACKNOWLEDGMENTS
Th is book would not exist without the many authors who graciously agreed to contribute a case study. We appreciate their eff orts and their patience throughout the process. Although many individuals contribute to the suc- cessful publication of a book, we would like to particularly thank Rachel Livsey, senior editor, and Amanda Orenstein, editorial assistant—this team provided valuable support throughout the process.
xxi
CRAIG WINSTON LECROY is a professor in the School of Social Work Y at Arizona State University. He also holds appointments at the University of Arizona in the John & Doris Norton School of Family and Consumer Sciences, Family Studies and Human Development division, and at the University of Arizona College of Medicine, Department of Pediatrics. He has been a visiting professor at the University of Canterbury, New Zealand; the Zellerbach Visiting Professor at the University of California at Berkeley; and a senior Fulbright specialist.
Professor LeCroy has published 10 books previously, including Parenting Mentally Ill Children: Faith, Hope, Support, and Surviving the System; First Person Accounts of Mental Illness and Recovery; Handbook of Evidence-Based Treatment Manuals for Children and Adolescents; Handbook of Prevention and Intervention Program for Adolescent Girls; Th e Call to Social Work: Life Stories, Case Studies in Social Work Practice; Empowering Adolescent Girls: Examining the Present and Building Skills for the Future with the “Go Grrrls” Program; Go Grrrls Workbook; Human Behavior and the Social Environment; and Social Skills Training for Children and Adolescents.
Professor LeCroy has published more than 100 articles and book chapters on a wide range of topics, including mental health, the social work profes- sion, home visitation, and research methodology. He is the recipient of numerous grants, including (as principal investigator or co-principal inves- tigator) interventions for risk reduction and avoidance in youth (NIH), Go Grrrls Teen Pregnancy Prevention Program, evaluation of Healthy Families
(a child abuse prevention program), a mental health training grant for im- proving service delivery to severely emotionally disturbed children and ado- lescents (NIMH), and Youth Plus: Positive Socialization for Youth (CSAP).
ELIZABETH K. ANTHONY is an associate professor in the School of Y Social Work at Arizona State University, where she teaches advanced clinical practice with children and adolescents and practice-oriented research. She is also a Faculty Affi liate of the Southwest Interdisciplinary Research Center.
Her scholarship focuses on resilience among children and youth living in urban poverty and the prevention of risk behaviors and mental health condi- tions among ethnically and culturally diverse adolescents. She has published more than 30 peer-reviewed articles, books, and book chapters on these top- ics. Dr. Anthony’s current study in multiple public housing neighborhoods supports the design of contextual-developmental interventions to increase positive adaptation among adolescents who are exposed to considerable risk and stress. Dr. Anthony is also an author of Risk, Resilience, and Positive Youth Development: Developing Eff ective Community Programs for At-Risk Youth. Lessons from the Denver Bridge Project.
xxiii
Elizabeth Aparicio, PhD School of Social Work University of Hawaii Hilo, HI
Lindsay Bicknell-Hentges, PhD Professor of Psychology and Counseling Chicago State University
Chicago, IL Susan Bogas, PhD
Psychologist, Private Practice Princeton, NJ
Charlotte Booth, MSW Executive Director
Institute for Family Development Federal Way, WA
Charlotte Bright, PhD Associate Professor School of Social Work University of Maryland Baltimore, MD
Harriet Cobb, EdD Professor
Department of Graduate Psychology James Madison University
Harrisonburg, VA
Jacqueline Corcoran, PhD Professor
School of Social Work
Virginia Commonwealth University Richmond, VA
Kathy Crowley, LCSW Lecturer
School of Social Work Arizona State University Phoenix, AZ
Cindy Cruz, MSW School of Social Work University of Maryland Baltimore, MD
Melissa Evans, LCSW Social Worker
Foster Care and Adoption, Agape of Central Alabama, Inc.
Birmingham, AL Peter Fitts, LCSW-C
Maryland Regional Director for Foster Care and Independent Living Progressive Life Center, Inc.
Landover, MD
Richard Geasland, LCSW Former Executive Director
Tumbleweed Center for Youth Development Phoenix, AZ
Jewelle Taylor Gibbs, PhD Clinical Psychologist and
Zellerbach Family Fund Professor Emerita School of Social Welfare
University of California, Berkeley Berkeley, CA
Nancy Wells Gladow, MA Social Worker
King County Department of Public Health Seattle, WA
Jamie Glick, LCSW Clinical Director
Ridge View Youth Services Watkins, CO
Nora Gustavsson, PhD Associate Professor School of Social Work Arizona State University Phoenix, AZ
Brenda Jones Harden, PhD Associate Professor
Institute for Child Study University of Maryland College Park, MD Debbie Hunt, LCSW Retired Former Supervisor Child Welfare Training Unit Arizona State University Tucson, AZ
John Lynch, PsyD Associate Professor
Department of Psychology Chicago State University Chicago, IL
George Stuart Leibowitz, PhD, LICSW Associate Professor
Department of Social Work University of Vermont Burlington, VT
Ann MacEachron, PhD Professor
School of Social Work Arizona State University Phoenix, AZ
Randy Magen, PhD, ACSW Professor
School of Social Work University of Alaska Anchorage, AK
Timothy A. Musty, MSSW, LCSW Private Practice
Retired School Social Worker Tucson Unifi ed School District and
Retired Clinical Lecturer of Psychiatry College of Medicine
University of Arizona Tucson, AZ
Nicole Nicotera, PhD Associate Professor
Graduate School of Social Work
University of Denver Denver, CO
Peter Pecora, PhD
Managing Director of Research Services at Casey Family Programs
and Professor
School of Social Work University of Washington Seattle, WA
Frederick B. Phillips, PsyD, MSW Founder/Senior Advisor
Progressive Life Center Washington, DC
Susan L. Robinson, MSW, LICSW Vermont Counseling and Trauma Services Williston, VT
Paul Sacco, PhD, LCSW Assistant Professor School of Social Work University of Maryland Baltimore, MD
Eden Hernandez Robles, MSW, PhD Candidate Th e University of Texas, Austin
School of Social Work Austin, TX
Janai Springer, MSW School of Social Work University of Maryland Baltimore, MD
A. Renee Staton, PhD, LPC Professor
Department of Graduate Psychology James Madison University
Harrisonburg, VA
Lori Holleran Steiker, PhD Associate Professor
School of Social Work
Th e University of Texas, Austin Austin, TX
Krystal Studivant, EdM Doctoral Candidate
Combined-Integrated Clinical and School Psychology James Madison University
Harrisonburg, VA Rachelle Wayne
Lead Youth Care Worker Phoenix Youth Resource Center
Tumbleweed Center for Youth Development Phoenix, AZ
Anne Williford, PhD Assistant Professor School of Social Welfare University of Kansas Lawrence, KS
Elena Wright-Aguilar, BA School of Social Work University of Maryland Baltimore, MD
1
1
Case Studies in Individual Treatment and Assessment
W
hen adults contemplate childhood, they often imagine anW W
idyllic time of innocence and exploration. Unfortunately, for many children, life is fraught with stress. Biological and environmental factors contribute to the development of mental disorders in children, and many young people must struggle to achieve the developmental tasks that lead to a healthy life. It is crucial for mental health professionals from all disciplines to consider the common disorders aff ecting children.
According to the New Freedom Commission on Mental Health ( 2003 ), one in fi ve children has a diagnosable mental disorder, and 1 in 10 young people experiences suffi cient problems related to mental health that impact home, school, or community functioning. Th e National Institute of Men- tal Health ( 2013 ) notes that anxiety is among the most common mental health disorders in children and adolescents, with approximately 8 percent of young people aff ected. Attention‐defi cit hyperactivity disorder (ADHD) is another one of the most common reasons that children are referred for mental health services, and it is estimated by parent report that 10 percent of
children have received a diagnosis of ADHD (Centers for Disease Control and Prevention, 2010 ). Depression becomes more of an issue as children grow into adolescents. According to the New Freedom Commission on Mental Health ( 2003 ), depression aff ects as many as 1 in every 33 children and one in eight adolescents. Eating disorders, while not as prevalent, aff ect an inordinate percentage of teenage girls. An estimated 2.7 percent of female adolescents have an eating disorder (National Institute of Mental Health, 2010 ), but approximately 50 percent of teen girls express negative emotions about body image (Littleton & Ollendick, 2003 ). Roughly the same percent- age of early‐adolescent girls are dieting at any given time (Neumark‐Sztainer
& Hannan, 2000 ).
Th e statistics clearly indicate that children in our society are not living the carefree existence that we would like to imagine. And yet few texts con- centrate on treatment of children’s mental disorders. When we treat children for physical ailments such as fever, we often use smaller amounts of the same medicine administered to adults. In children’s mental health, however, there is no downsizing of doses. Instead, practitioners must approach treatment with a very diff erent perspective. A child’s unique physical, developmental, gender, social, and environmental factors must be considered carefully prior to and throughout the treatment process. It seems clear that all practitioners, whether they specialize in work with youth or with the broader population, must become acquainted with the common disorders of childhood and methods of helping young clients and their families.
Th e seven case studies in this chapter focus on individual assessment and treatment of common disorders in childhood and adolescence. Clearly, family plays a major role in childhood treatment, but this section primarily focuses on the child or adolescent developmental aspects of assessment and treatment as they overlap with family issues. Family‐specifi c therapies are described in Section III.
In the fi rst case study, Bogas relates the tale of a young boy with ADHD.
Th e author describes the important processes of establishing rapport with the child, engaging and maintaining parental involvement in treatment, and working as part of a treatment team. Because of the practitioner’s ex- tended treatment relationship with the family, we are privileged to follow the boy and his family’s progression in dealing with ADHD from childhood to young adulthood. In the second case study, Corcoran guides the family of a boy with behavioral problems through solution‐focused therapy. She
clearly describes and demonstrates techniques such as identifying resources through the use of exceptions, using the miracle question, and employing scaling questions. Th e next case study paints a picture of a depressed African American adolescent girl. Gibbs describes the importance of considering the client’s developmental stage, environmental issues, and sociocultural issues from the very beginning of the case and shares her insights about exploring the client as a person rather than as a problem.
Th e next four case studies focus on developmental issues in individual treatment in a variety of treatment settings. Crowley describes the treat- ment of a young man dealing with developmental life changes through a brief cognitive‐behavioral therapy model. She discusses the role of the clini- cian in working from a strengths perspective and allowing the client’s assets and needs to guide the treatment. Next, Sacco, Bright, and Springer provide an encounter with a young woman’s beginning involvement with the juve- nile justice system as a result of her marijuana use. Th ey describe a staggered treatment approach using motivational interviewing and then cognitive‐
behavioral therapy to address her stage of awareness about her substance use. Next, Leibowitz and Robinson capture the complexity of working with a sexually abusive youth through a developmental understanding of his treatment needs. By conducting a thorough and ongoing developmental assessment of risk and protective factors, the therapists are better equipped to make empirically supported treatment decisions. Finally, Glick describes the use of motivational interviewing and cognitive‐behavioral therapy in the treatment of a young man living in residential treatment. He de- scribes the challenges of mandatory treatment and strategies that can engage a young person, in addition to those that will be more likely to push him or her away.
Each of these cases provides a window into the world of the practitio- ner and demonstrates the unique manifestations of common disorders of childhood, and subsequent assessment and treatment considerations. Th e emphasis on treating the individual child and the techniques that the prac- titioners employ to gain the trust and cooperation of their young clients merit special attention. Th ese stories ring true because they are true (or composite) pictures of children’s and adolescent’s lives. Students and prac- ticing professionals alike may profi t from the glimpse into the treatment of these clients who experience some common disorders of childhood and adolescence.
REFERENCES
Centers for Disease Control and Prevention . ( 2010 ). Increasing preva- lence of parent‐reported attention‐defi cit/hyperactivity disorder among children—United States, 2003 and 2007. Retrieved from http://www.cdc .gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w Littleton , H. L. , & Ollendick , T. ( 2003 ). Negative body image and disor-
dered eating behavior in children and adolescents: What places youth at risk and how can these problems be prevented ? Clinical Child and Family Psychology Review, w 6 ( 1 ), 51 – 66 .66
National Institute on Mental Health . ( 2010 ). Eating disorders among chil- dren. Retrieved from http://www.nimh.nih.gov/statistics/1eat_child .shtml
National Institute on Mental Health . ( 2013 ). Anxiety disorders in children and adolescents. Retrieved from http://www.nimh.nih.gov/health/publications/
anxiety‐disorders‐in‐children‐and‐adolescents/index.shtml
Neumark‐Sztainer , D. , & Hannan , P. J. ( 2000 ). Weight‐related behaviors among adolescent girls and boys: Results from a national survey . Archives of Pediatric and Adolescent Medicine, e 154 ( 6 ), 569 – 577 . doi: 10.1001/
archpedi.154.6.569
New Freedom Commission on Mental Health . ( 2003 ). Achieving the promise:
Transforming mental health care in America. Final report (DHHS Pub. No. a SMA‐03‐3832). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.
CASE STUDY 1-1 FROM CHILDHOOD TO YOUNG ADULTHOOD WITH ADHD
Susan Bogas
Working with a child diagnosed with ADHD involves treatment in the context of the family, with all the challenges and strengths that exist in a family system. Th is case highlights the developmental trajectory of ADHD and the fl exibility required by the therapist in a unique portrayal of assessment and treatment progression from Nate’s childhood to young adulthood using a combination of structural family therapy and parent- ing techniques.
Questions for Discussion
1. How does the practitioner establish rapport with the youth with ADHD during the fi rst session? Why does she delay gathering back- ground information during the fi rst session?
2. Why is it important for the parents to provide tight external controls for the client in this case study?
3. What is the length of the therapeutic relationship in this case study?
Why? Could or should it be any diff erent?
4. Why does the practitioner explore each parent’s childhood with them?
How does that knowledge contribute to the treatment?
5. What is the important factor in fi nding a treatment team to work with a child with ADHD?
6. What was important about Nate’s parents coming to view art as
“elemental to who Nate was”?
7. What was diff erent about Nate’s experience of ADHD in childhood versus adulthood?
Nate, age 7, could not fi nd his favorite army men. Ellen, his mother, told him to look in his closet. Like a wild creature springing from nowhere and without taking a step toward the closet, Nate burst into a frenzied campaign.
He stomped around the room, kicking the furniture and toys in his path, and screaming as loudly as he could.
Nate’s sudden escalation from calm to rage, without warning and seem- ingly unprovoked, was all too familiar to Ron and Ellen, Nate’s parents.
Th ey did not know what made him react to an ordinary situation with such fury, and they could not predict when, and over what, an explosion would occur. Th ey had learned, however, that there would be another incident and that there was no reasoning with Nate during such incidents. “When Nate is angry,” Ellen explained, “it’s as if he were possessed. His emotions come out very fast. He ‘spews’ . . . and has to go to his room to calm down, to regain control. He then comes down and feels remorseful.”
Th is was a typical event in the Barclay household at the time when Nate’s parents brought him to therapy. Th ey were baffl ed by their third child’s total inability to tolerate frustration, to be patient, and to cope with the routines and challenges of daily life. Th e point had come when they knew they needed help.
I had known this family, which included three boys (John, 18; Peter, 15;
and Nate, 7), for more than fi ve years. I treated their oldest son for procras- tination (which turned out to be ADHD), their next son for adolescent social issues, and the couple for marital issues. Ron, a tall, thin businessman, combines a curious, incisive mind with a fi erce task‐oriented mentality.
Ellen, a stay‐at‐home mom, is bright, outgoing, and energetic. She has a gift for words and great warmth and humor.
Ellen read widely about attention problems in relation to her fi rst son and began to be concerned about Nate when he was in kindergarten. Nate was always in motion. He asked to listen to storytime from under his desk. In fi rst grade, he was in trouble a lot. At the end of fi rst grade, the Barclays took Nate to a specially trained pediatrician, who administered a “neurodevelopmental”
evaluation (developed by Mel Levine, M.D., an expert in attention and learning problems). Th e pediatrician diagnosed Nate with attention‐defi cit hyperactivity disorder (ADHD), but found no signifi cant learning defi cits, such as problems with memory, language, higher‐order thinking, motor skills, or social ability.
FIRST SESSION
Th ere was no hint of negativity or defi ance in Nate at the fi rst therapy session in my offi ce. I didn’t even detect fi dgetiness. Nate was tall, blond, and cute.
He looked a bit wide‐eyed and serious, as if he anticipated hearing a lot about how bad he was. As I chatted with him, asking about his friends and what they liked to do, he relaxed and told me that he loved playing with boys in his
neighborhood, especially on his trampoline. Once I sensed he was comfort- able, I off ered Nate the option of drawing at a table in a corner of my offi ce.
It was time to hear his parents’ concerns. I wanted to allow Nate to listen and to participate in the discussion, but also to have some distance from us. He made a beeline for the table, took a chair facing the wall, and began to draw.
Ron and Ellen talked about two key problems with which they struggled daily. First, Nate refused to sleep in his own room. Afraid to be alone, he slept downstairs where his parents were early in the evening and, later, beside their bed. Th ey had no time for themselves. Second, he was extremely un- cooperative. He opposed absolutely everything, refused to perform his rou- tines and responsibilities, and defi ed directions and suggestions. His answer to everything was an emphatic and instant “No!”
Ellen, who handled Nate’s daily behavior, was at her “wits’ end.” Her stress was palpable. I decided to delay gathering background information or going over the evaluation they brought with them—steps I might have taken if the immediate situation was not so pressing. Th e priority was to deal in a practical way with the problems at hand. We turned to problem solving, leav- ing for later discussion the more theoretical questions about Nate’s ADHD, its etiology, and his particular nature. For the fi rst session, my goal was to develop a map, or a structured plan, for each of the two presenting problems to be carried out by the family at home.
Nate had said earlier that he feared sleeping alone in his own room be- cause someone could come in the window and “something bad will happen.”
I asked Nate, who was busy drawing monster and animal‐like fi gures with big teeth, what he thought about this. He said he was embarrassed about it.
His two friends slept in their own rooms, although with brothers, and he would really like to sleep in his room. I was impressed by his candor and glad to hear he was motivated to change. I suggested an interim plan. Instead of Nate falling asleep in the same room as his parents, he would fall asleep in the next room. Nate would be in the dining room, with his parents in the kitchen. Each night that he complied, he would receive a small daily reward.
If this was successful, then Nate would gradually move to falling asleep in his own room. Ron proposed moving Nate’s bed away from the window and closer to the door to allay his fears of someone coming in the window. He also proposed the ultimate “carrot”: When Nate was able to sleep most nights in his own room, he would be given an allowance, something he wanted very much because he associated it with his older brothers.
On the second issue, Ellen gave an example of Nate’s opposition to almost anything she asked him. “If I ask, ‘What do you want for breakfast?
Pancakes?’ Nate’s typical response is ‘No.’ I try again. ‘Cereal?’ ‘No!’ ‘Waffl e?’
‘No!’ Finally, Nate will announce: ‘I want pancakes! Pancakes!’” Such interac- tions went on all the time and left Ellen worn out and exasperated.
Explaining further, Ellen astutely observed that her own disciplinary style was that of a negotiator. She operated with a win/win approach to situations.
She knew that it did not come naturally to her to be fi rm, to draw the line, or to lay down the directives in black‐and‐white terms. Ron, by contrast, noted that he was fi rm and tough. However, he acknowledged that he became an- gry quickly and exploded when Nate did not comply.
To me, it was clear that the family’s authority system needed to be or- ganized and tightened in order for Nate to develop better internal controls.
Ellen and Ron had to learn to operate from a policy rather than reacting to their son’s behavior, either with appeasement or anger. I introduced them to the basics of setting limits and delivering consequences. My intervention, a combination of structural family therapy developed by Salvador Minuchin, Braulio Montalvo, and Jay Haley and the theories found in 1‐2‐3 Magic, a c book by Th omas Phelan ( 1996 ), went like this:
Th e child has two choices—comply with the request or take the consequence. Lack of cooperation (refusing to make a choice) leads to a consequence. Devise ready‐to‐use short‐ and long‐term lists of consequences.
Do not engage in conversation when setting limits (actions—
such as losing a play date, going to his room, or suff ering an
“electrical black‐out”—speak louder than words). Noncompli- ance with the direction or the consequences results in a time‐out.
As I laid out the principles, Ellen recognized the diff erence between her approach to Nate’s behavior and what I was advocating. Her approach amounted to appeasement, and she needed to be an authority fi gure. Ellen said she thought that if she negotiated so that Nate got something he wanted and she got the behavior she wanted from him, then he would be motivated to cooperate. I explained to Ellen and Ron that the reason Nate needed an authority fi gure was that because of his ADHD with impulsivity and hyper- activity, he lacked the inner controls to contain his own behavior. He needed
Ellen, as his primary caretaker, and Ron to provide tight external controls so that he could (a) learn to function responsibly and (b) gradually develop stronger inner controls himself.
Th e other issue I stressed was that parents must become a team. Together they must learn the skills of confl ict resolution; that is, how to compromise and come to an agreement about their policy toward Nate. I emphasized the following: Expectations and consequences for Nate must be clear and precise, and the presentation of these expectations is to be in a visual mode (prefer- ably a chart, with pictures).
From our previous work together, I knew that this couple had a strong commitment to each other and to their children. I also knew there were some diffi culties and disagreements between Ron and Ellen that would emerge and have to be dealt with if they were to make headway. I closed our fi rst session with a warning intended to focus them on whether they, as parents, were presenting Nate with one message or two diff erent messages. “If you two are not absolutely clear, meaning that you deliver one airtight message, and then absolutely consistent in setting expectations and carrying through on consequences, there will be no change.”
TWO MONTHS LATER: ELLEN AT THE BREAKING POINT Th e next session excluded Nate in order to allow Ellen and Ron to speak candidly and at length about their concerns. Nate had responded somewhat to the structures related to sleep. He was beginning to sleep in his own room and to earn an allowance. However, he did backslide sometimes, and the issue was by no means solved. Nevertheless, the Barclays were pleased and relieved because following the step‐by‐step plan showed them that Nate could make progress if they provided him with appropriate structure. Nate was proud to join his brothers in earning an allowance, and the Barclays now had some time for themselves in the evening.
Ellen, however, continued to be extremely upset over Nate’s opposition to anything she asked him to do and the verbal attacks that followed. Tears over- came her as she described the ongoing obstacles that Nate presented to her every statement, request, or direction: “I hate you!” “You’re mean!” “You’re stupid!”
“I wish you weren’t my mother!” “I hate this family!” “I hate my life!” Th ese were just some of the things he had said to her. With a mixture of desperation and sadness, Ellen said, “He doesn’t like me. He doesn’t want to be around me.
Nothing I do works.” I felt the gravity of the situation. It was time to gain some perspective by gathering background information on Nate and on Ellen.
In Nate’s early history, there were extreme patterns. As an infant and even as a newborn, he did not tolerate being in a car seat. He had diffi culty sleeping. At about nine months old, he started banging his head on the crib rail, the wall, and the fl oor when he was frustrated. Ellen actually had put a helmet on him to keep him from hurting himself. As a young child, Nate developed a pattern of hitting himself when he was angry, as well as hitting, kicking, and throwing objects. In short, Nate “acted in” as well as “acted out.”
Hearing about those early and consistent patterns of very low frustration tolerance and of angry outbursts directed either inward or outward led me to suspect that these behaviors were hardwired in Nate—that is, biologically based and not the result of environmental factors such as quality of mother- ing or family dynamics. (It is, of course, impossible to completely sort out these nature versus nurture issues.)
Much to Ellen’s sadness, Nate never cuddled and, unlike his brothers, he did not climb into his parent’s bed in the morning. He did not like to be hugged and kissed. “Sometimes Nate has a shocking lack of empathy. He is often mean to the cat, which he loves,” she said. Yet each parent corrobo- rated that Nate was an extremely social kid, choosing interaction over doing anything else. “Nate must have a play date. He’s insatiable about play dates,”
Ellen said. Ron chuckled as he described how he would say to Nate: “C’mon, Nate, let’s go take out the garbage!” and Nate would enthusiastically accom- pany him. Nate indeed embodied an interesting mix of traits.
I explored Ellen’s history in a pointed way. I was searching for themes of confl ict in her early life that related to what she was struggling with now. Th is is not to suggest that I doubted the reality of Nate’s outrageous behavior or how in- credibly diffi cult the behavior was for Ellen to address. I intuited, however, that something else was operating here and that its roots were in Ellen’s past. I sought to identify times in Ellen’s experience when she felt inadequate to address a chal- lenge and to determine whether Nate was evoking those same feelings in her.
ELLEN
Ellen was the third of three children. Bright, kind, and cheerful, she was viewed by her parents as the easy one, and she felt loved and cherished by both. Her brother, Rob, was eight years her senior and had learning
disabilities. Her sister, Carol, was fi ve years older and had a diffi cult character—moody, angry, and demanding. Ellen, ever optimistic, constantly tried to win the aff ection of her big sister, but Carol was either mean to Ellen or dismissive of her. When Carol was unhappy, she often blamed Ellen.
Ellen’s failure to get through to her sister left her with underlying feelings of loneliness and guilt.
When Ellen was 15, the sudden death of her father left her sad and aware of the precariousness of life. From this information, Ellen and I derived two key themes in her behavior. First, Ellen believed in the goodness of people.
Second, she believed that she could get through to anyone if she just tried hard enough. Th e relationship with her sister reinforced in Ellen, as an adult, the tendency to assume the entire responsibility (and blame) for how a rela- tionship was working and whether the other individual—her husband, son, or someone else—was pleased or displeased. She was left very vulnerable to feelings of blame, rejection, and abandonment.
Turning to the situation at hand, I asked Ellen to describe in detail how she was handling Nate and what methods she was using to get through a day with him. Her description revealed the enormous eff ort she was making to ensure that things worked for him. She was his coach, short‐order cook, tutor, and cheerleader all wrapped in one. She prepared him for challenging situations, praised any product or sign of eff ort he made, structured tasks to be followed by fun activities, and, in general, made the things Nate found diffi cult or boring as palatable as possible. In one sense, this was excellent mothering—committed, creative, fl exible, and loving—but it clearly was not eff ective. Nate’s anger was not contained. Ellen felt hurt, rejected, and burned out. Ron was deeply concerned about Nate’s continuously outra- geous behavior and about Ellen’s growing despair, especially because he was frequently away on business.
Due to time constraints, I cut to the chase, focusing on Ellen’s immediate need for help. It was apparent that Ellen was failing to draw a line that Nate could not cross. She was allowing Nate to control the situation. I told her she needed to move in and set a limit at the moment his negativity began.
I pointed out to her that, contrary to the situation with her sister, in which she had been little and could not take charge, here she was the adult, and she could take charge. I emphasized that she must learn to hold her ground and d become a strong authority fi gure, fi rm and non‐negotiating on the things Nate was required to do. As long as Nate perceived any possibility of getting
his way, he would not have to muster the internal controls necessary to com- ply with her expectations. If he sensed that she was trying to accommodate him, he would act out of his base instincts rather than exercise control. I went over the how‐tos of setting limits and consequences, which I had laid out in the previous sessions.
A YEAR LATER
When I next met with Nate, Ron, and Ellen, Nate was 8 years old and repeating second grade because his parents felt he would profi t emotion- ally and academically from the extra year. We began by discussing his academic progress. Ellen praised Nate’s teacher, Mrs. Turner, who com- bined fi rmness and structure with a real understanding of what Nate was struggling with. To discharge his excess energy, she allowed him to stand up during “quiet time,” when singing, and to deliver messages to the offi ce.
Academically, Nate was having some diffi culty with reading and could not grasp mathematical concepts such as telling time or counting money.
He basically did not “get” games. As the semester progressed, Mrs. Turner suggested that Nate needed more help, so the Barclays returned to the pediatrician who had fi rst evaluated him. Based on the earlier diagnosis of ADHD, Nate was placed on a trial of Ritalin, a stimulant medication commonly used for ADHD. His parents and teacher immediately saw “a diff erent child”—one who was calm, able to sustain his focus, and able to do his work. He stopped calling out and fooling around in the classroom and was able to control himself in the library. Mrs. Turner said that, for the fi rst time, she saw Nate as able to be a “member of the team rather than captain.” Nate had previously demonstrated a pattern of being bossy with children his age.
Next we addressed Nate’s at‐home behavior. “He’s negative, mean, and utterly insatiable, and he says ‘no’ to everything!” Ellen reported. She went on to say that she had become more structured and fi rm in setting limits and was not appeasing him as she had been. She was careful to make sure that pleasurable activities and rewards followed—but did not precede—
Nate’s carrying through on responsibilities. Despite these eff orts, the level of Nate’s hostility and opposition was still so intense that things felt very out of control to Ellen. However, she had found one method to stop Nate in his tracks. She called this her “drill sergeant” mode. Uncharacteristically,
she would speak to him in a loud and menacing tone of voice and say something mean, such as “your brother never did that,” which would upset Nate greatly. Although she said it went against her nature to be so mean, at present it was absolutely the only thing that made Nate stop being opposi- tional. While I did not view this method as functional for the long term, I did not intervene here because I saw Ellen as “in process” toward becoming a stronger authority fi gure. At this stage, she was fi nding, perhaps for the fi rst time in her life, her own aggression, which she needed to access in order to stand up to her son’s aggression.
Nate was quite talkative when he joined us. After he told me that school was going well, I inquired about home life. “I worry that I shout too much.
I’m going to grow up like pop,” Nate said, referring to Ron’s father, who was not well liked. Nate also admitted to being mean to his friends. I was again impressed by Nate’s candor and his ability to observe and show concern re- garding his own behavior. He was maturing and developing self‐awareness, and he was not identifi ed with his angry behavior, which is to say he had not taken on the identity of an angry boy. I viewed this as a positive sign of emotional growth.
Our discussion for the remainder of the hour centered on several diffi cult topics and was open, honest, and nonjudgmental, although it was clear that Ron and Ellen were concerned about their son. Ellen brought up her discom- fort with Nate’s play, which involved “never‐ending death and destruction:
traps, weapons, killing, spikes, war ships, and knives.” Ron, however, won- dered whether Nate’s aggressive drawings and play might be helping him to deal with his own aggression. Ellen added that while Nate was well liked by his peers, he had a close buddy in school with whom he got into trouble for things such as laughing at a child who gave a wrong answer, keeping children out of a game, and other mean behaviors. I ended the session by having Ron and Ellen discuss (in front of Nate) the message that they wanted to give him about his mean behavior in school. Th en, I asked them to discuss the subject with Nate. Th ey took a clear stand: “Mean behavior toward kids in school is not appropriate, and we will not tolerate it! If and when it occurs, you will be given a very stiff consequence.”
Nate’s explosiveness continued over the next year, despite Ellen and Ron’s serious eff orts to tighten their at‐home structures. He exploded when he was asked to do things, when he was told he must go somewhere, and even with friends when he did not get his own way. Persistence of the problem led
Ellen, Ron, and me to develop even more airtight strategies, which included the following:
◆ Minimizing spontaneous requests to Nate (anticipate what is ahead for e him, and schedule all responsibilities into the routine)
◆ Scheduling his after‐school obligations in detaill(viola 30 minutes, read- ing 30 minutes, homework 20 to 30 minutes; then, if everything is complete, he can play with friends)
◆ No spontaneous buying (in order to buy anything over $15, Nate mustg wait two weeks [with the request written and dated]; state “no buying”
whenever leaving the house; and no spontaneous trips to McDonald’s) Structure, structure, and more structure was the operating principle.
As the year progressed (Nate was now 9 years old), Ellen was being clear, straightforward, fi rm, and sometimes “furious” in her approach to Nate. She had learned to allow no deviation from the plans, schedules, and routines. “I sometimes grab him and make him look me in the eye. Th en I tell him what I expect him to do.” She was, in short, giving Nate less space to act out his anger, and he was responding with somewhat better control, but there was still a long way to go.
RON
For a long time after Nate was diagnosed with ADHD, Ron did not ac- cept the diagnosis. Th us, his approach to the situation was ambivalent.
On the one hand, he learned about ADHD, especially through attending workshops with Ellen. In therapy, he worked with Ellen on strategies and limit setting. On the other hand, when Nate attempted to negotiate every direction or had a meltdown over something small, Ron became impatient and angry. He often exploded. Underlying Ron’s inappropriate reactions to Nate’s behavior was the belief that Nate could do it (if he really wanted to).
Ron judged Nate as average “compared to what a child should be able to do in our household,” and he conveyed that to Ellen. He was disappointed in Nate for traits such as having to be fi rst, refusing to share, showing limited curiosity, and making everything a struggle. What in Ron’s history contrib- uted to his resistance to accepting Nate’s diagnosis and his rigid, judgmental approach to Nate?
“You are as good as your performance!” was the paradigm that Ron learned at an early age from his father. With a hint of sarcasm, he reported that he was a model son: “the best boy, the best scout, the best student.”
Nevertheless, he felt absolutely no support for his accomplishments, nor acknowledgment from either parent that he had done well. His face reg- istered pain when he admitted that he did not feel his parents took pride in him. He remembered, with sadness, his father pointing out things he admired in other people.
Ron was able to link his parents’ emotional coldness with certain aspects of himself. He noted, “I did not learn to give myself credit. I had no well‐
developed sense of self‐respect and not much empathy.” Th e lack of support he experienced left him with signifi cant feelings of inferiority. Th e result of these parental messages was an interesting mix of behaviors: Ron was a very hard worker, task oriented, and focused on accomplishment. He could also be a ruthless taskmaster who was devoid of empathy and compassion. His attitude in relation to his sons, all of them, was: “If I could do it (be a hard worker, oriented to tasks and accomplishment), then so can they.”
NATE AS A PREADOLESCENT
Beginning in mid‐winter, when Nate was 10 1/2, the Barclays had a series of sessions spread over a year. Tremendous growth took place that year. In general, Ron and Ellen described Nate as developing better inner controls.
He accepted the structures of the household and his own routines, although he did not do his after‐school work without prompting. When he got angry, Nate would often comply with Ron or Ellen’s direction to take the industrial‐
strength bat and go hit the tree in the backyard or to jump on the trampo- line. Nate was beginning to participate actively in his own recovery from anger. Instead of relentless arguing, begging, and manipulating to change the rules as he used to do, Nate was also learning to negotiate in an appropriate way. For example, “Rob is available to play. Can I practice 20 minutes instead of 30? I’m negotiating, mom.”
Nate continued to have serious episodes of opposition and rage, although they occurred less frequently. On one snow day, he was impossible all day.
He refused to do two tasks that Ellen asked of him—read for 20 minutes and practice viola for 30 minutes. At the end of the day, Ellen broke down, sob- bing. Th en Nate calmed down and stopped being hostile. On another day,
Ron repeatedly told Nate to get ready for church: over and over Nate refused.
Ron “bellowed.” Nate was shaken and complied. Ron cried.
During this period, when Nate was 11, something very signifi cant hap- pened. Ron stopped traveling and began to work from home. Having been away fi ve days a week, now he was home all the time. Th is change in the family routine was central to what followed. Ron was happy to be at home and de- lighted to have the opportunity to improve his relationship with Nate. He had a growing awareness that his older sons viewed him as critical more than sup- portive. He was very unhappy about this and wanted a chance to “do it right this time.” Specifi cally, he wanted to move from taskmaster to a warmer, more supportive father‐son relationship with Nate. However, he did not know how to reconcile this desire with his deeply internalized performance expectations.
As Ron spent time at home, his annoyance and impatience with Nate grew. He frequently exploded. Ellen and Ron argued about managing Nate.
Gradually, it became clear that Ron resented Nate. He was mad at Nate. For what? For being fl awed. For not being as right as his brothers. In Ron’s eyes, Nate was an underachiever (previously, Ron had the same belief about each of his other sons).
Being task oriented and a “doer,” Ron took the initiative to have Nate tested again. Ron wanted to be satisfi ed that he and Ellen had done everything possible to help Nate. He was also motivated by a desire not to do “mental combat” with Nate on homework for the rest of Nate’s time at home. Th is time Nate would be evaluated by a school psychologist for IQ (“to see what was under the hood”) and to clarify his learning weaknesses. Th e results indi- cated that Nate scored in the “high average” range. He achieved a “superior”
score in verbal functioning and a “high average” score in perceptual motor skills. Th e evaluator found that because of Nate’s “attentional ineffi ciency” and impulsivity, he performed best in a highly structured situation. Th is validated the work Ron and Ellen were doing with him. Ron was pleased with the re- sults; Ellen was not surprised. A turning point had been reached.
Ron’s view of Nate began to shift. He started to perceive Nate as capable rather than incapable. He struggled not to get so mad at Nate when he worked with him. He became Nate’s advocate rather than his critic. He spent time with Nate on both homework and fun activities. He was fi nally a true partner with Ellen in providing Nate with a solid foundation of support, along with tight structures and fi rm limits. Ron was fully on board regarding the parenting of Nate.
MEDICATION
Since Nate was 7 years old, when his second‐grade teacher discretely suggested that medication might be helpful, he has been on one of the three most com- monly used stimulant medications: Ritalin, Adderol, or Dexedrine. Early on, he only took medication for school. Later, Ellen learned that Nate dealt much better with his after‐school responsibilities if he had a small dose at that time as well.
One might think that with the intensity and persistence of Nate’s anger and explosiveness, the family would have pressed for more treatment through medication. Actually, Ron attributes the fact that Nate was minimally medi- cated to Ellen’s tireless work with him. I agree and add that Ellen and Ron each confronted a core personality issue and, through doing so, expanded their capabilities to deal with Nate and with each other in constructive ways.
Th e work that each one did had a powerful and very positive eff ect on Nate and his ability to make progress.
WHERE IS NATE AT AGE 13?
Perhaps the most compelling statement of where Nate was at age 13 was made by his father in my offi ce in October 2001:
I continue to be impressed, astonished, at how, with patience and structure, modeling, explaining, trying not to get mad, he has been able to improve his own behaviors, which include re- sponsibilities around the house, and his academics and music.
He is at a point where he accepts his responsibilities. He is able to submit himself to the applied disciplines. An example of how far he has come is refl ected in something he said to me recently:
“Dad, would you help me get up early tomorrow because I didn’t get my reading done?” And he does it!
Does Nate take “no” for an answer these days? Ellen says he is still resistant and pushes back. She stated that they still must draw the line and be somewhat harsh at times, but “nothing like the old days.” And as for meltdowns, Ellen re- ported that what Nate has is an “instant fl ash” or “anger surge” that appears to be physical, lasts two or three seconds, and may involve “a door banging and a shoe (going) across the room.” Ellen feels that, even while it is going on, Nate knows that he should not be doing it. She even suspects that it’s not all right with him.
