Social Involvement of the Patient with ADHD - Case Study Example

Biological Information Client’s BC 22/06/11 Gender: Male Age: 16 Birth: 27/12/1993 Place of Birth: Australia Family Placementin the family: youngest Father and Mother not married, living in the house with 2nd sister. Father – age unknown – has leukaemia Mother – age unknown – has had multiple Cerebral Vascular Accident (CVA) 1st Brother – aged 25 years – farm worker, living away from family 2nd Sister – aged 18 years – living with family 3rd Sister – died when 2 years of age BC left home when he was three years old. He lived on the street before, lived with Foster Care and was hit by his carer. He is now living in residential care by Berry Street. Medical Information: Intellectual disability, Attention Deficit Hyperactivity Disorder (ADHD) 2. Referral information and presenting Problems A. Referral Source Workers in the residential care took BC to Dr. W to have him examined for his problem. Later on, the client was referred by Dr. W using the Mental Health Care Plan. B. Reason for Referral The main reason for BC’s referral was to deal with his anxiety and behavioural problems. Workers from residential care have reported that sometimes it was hard to get BC to stay still and to follow orders. BC was at times very difficult to engage and he often found it hard to concentrate especially if he was distracted by something in the room. The observations carried pertaining to his behaviour including two sessions at YJ office showed that BC had problems to concentrate when he is engaged in a discussion. He is quickly distracted by other objects especially inside a building as these drew his attention away from the discussion being carried out. (i) BC is a reluctant client who has a lot of social and psychological problems. During the sessions, it was observed that BC cannot be easily engaged given that he was fidgety. BC’s attention problems can be attributed to a diagnosis of attention deficit hyperactivity disorder (ADHD). However, in a couple of sessions, he engaged well and he discussed in detail issues related to his family as well as sexuality. The client stated that he preferred gay relationships, street work and sexual encounters with an alleged pedophile. However, there is need for proper management of his anxiety and behavioural problems since he can become aggressive at times. C. Expectations The workers at the residential care expect that the services BC will get from us will enable him to learn different social skills such as engaging with others in a proper way. The workers expressed that they expect BC to explore his relationship with his carers as well as peers such that he can fit well in the society. The carers also expected that the counseling sessions BC would receive would play a significant role in helping him to manage his anger which is seen as a threat given that it can be uncontrollable at times. They also expected him to learn to practice self control so that he does not pose a threat to the other people. On the other hand, the client expects to transform his behaviour so that he can fit well in the society. 3. Background Information BC had an unfortunate childhood which forced him to leave home when he was three years old. He had a bad relationship with his family especially his father. He used derogatory words such as ‘not good, violent as well as arsehole’ to describe his father. BC presents a wide range of social and psychological problems which affected his childhood. It has been observed that issues of attachment, abuse and trauma have affected his brain development as it can be seen that he desperately needs to belong to a family unit and being accepted as a human being. His dire situation has been compounded by the absence of a family which he can identify with given that he idealized the view of the family. BC has been described by his carers at the residential care as an aggressive young man. This can be attributed to the challenges he experienced during his childhood especially growing up at that tender age outside the family. However, BC stated that his mother was good and he would sleep besides her and he would also touch the workers which showed that he longed to love and be loved by someone who was caring. In June 2010, he left home to go and live under foster care though he would occasionally visit his family. He was hit by the carer and he left for the streets. The environment he grew up in his family was not conducive for normal upbringing of a child and it significantly contributed to the problematic behaviour related to attention deficit which he is currently experiencing. BC lacks social skills and he is obsessed with the desire for material things such as money to buy cigarettes and other goodies. Usually, obsessive symptoms and rituals often occur in individuals with a developmental disability anxiety. For instance from 22 June 2010, he started sleeping on the streets and would sometimes steal in order to have money he so much desired. He would also be involved in man for sex since he said that he would earn anything around $400. On 29 June he said that he was scared of his father so could not go home and at times he would engage in fights as a result of the harsh conditions he was exposed to in his life. BC felt rejected and at times he contemplated to kill himself since he was desperately in need of belonging to a family. However, he stopped going back home on 15 July 2010 when he stole $500. He stated that he needed money to buy food as well as cigarettes (see appendix 1). He would sleep for a long time when there was no day activity and he became anxious when he ran out of cigarettes. He would become very angry and his sexual behavior worsened. He would also fight with other friends and he disliked sessions. He could not find anything interesting to him and his situation worsened when he was no longer allowed to call his mother. Nothing good happened to him during this period and his anger also increased. However, he felt bad for throwing a stone at the neighbor’s window. Assessment Instruments/Procedures Informal assessment: This involved the use of observation to establish the behaviour of BC. As noted, he was often distracted from concentrating especially inside a building. This method involved a twofold process where BC’s behaviour was observed inside the office as well as outside in a bid to establish if his attention was affected. The student counselor would engage BC in a conversation inside the office and he would carefully observe the way he responded. The same process was repeated outside in an open space where there were no objects and the counselor asked him certain questions to see if he responded differently from the behaviour he would have exhibited inside the office. The observation method is valid and reliable given that it involves close contact with the subject (Haffer & Kipp, 2007). The other advantage of this assessment method is that there is no formal arrangement where the behaviour of the client can be observed at any time which is likely to be reflective of his usual behaviour. If the observation was planned, it was thought that BC would display a wrong impression which is not characteristic of his usual behaviour. Under normal circumstances, attention is found to be displayed when one is engaged in a conversation and this can be easily observed in an informal setting. Formal assessment: The changes explored technique was used in order to establish if there were some changes in the behaviour of BC since he is affected by the problem of attention deficit. A diary was used to record the score of his responses to certain questions in two different environments, inside the office as well as outside the building to see if there was a negative or positive change in behaviour with regards to his attention. The counselor would engage BC in a conversation at different intervals which were not planned in order to establish if there were positive changes in his behaviour. This particular method is valid given that if an action is repeated over time, there are likely chances that it will show some change in behaviour (Fivush & Hamond, 1989). The environmental context is also very important with regards to monitoring the behaviour of the client if he pays particular attention to certain events. 4. Assessment Outcome Observations: The client showed that his attention if often interrupted especially by charts displayed on the wall as well as other objects such as furniture. At times, BC is seen wandering as if he is looking for something special to the extent that he forgets that he is talking to someone. He is fidgety when sitting on a chair while talking to him. If he does not like the subject, he becomes furious. However, there was positive change when the client was taken to an empty room since he somehow attempted to concentrate on the conversation and would respond well. When taken to an open environment, it was observed that the client was less distracted and would respond quite well. If the client sees that you are saying something, then he would respond. In an open space, the client is less fidgety given that he would be standing. However, of notable concern is the fact the customer would display the same behaviour in both situations if he is caught unaware that he is being asked something. The counselor had to ask the same question twice if the customer was caught unaware. He was slow to respond in such a situation but if he is aware, he would positively respond. The element of just wandering is still present though there are some positive changes that have been observed. The environment has a bearing on the behaviour of the client and he has to be aware of the situation in order to respond in a timely manner. In the changes explored technique, it was also observed that the client scored higher in both situations if he is aware that someone is talking to him. He would pay attention and try to give meaningful responses in both situations. However, if the client is caught unaware, he does not fully pay attention the counselor had to ask him the same question twice. The problem noted is that the client needs to be engaged in a conversation when he is in good mood. It showed that when he is not interested in talking, he does not pay attention like he does when he is in good spirits. He was no longer fidgety especially when engaged in a conversation in the open. 5. Practitioner’s Conceptualization of the Presenting Problem The client presented some inconsistencies in behaviour particularly on paying attention to a particular situation. The client presents problems in trying to concentrate since he is found to be wandering aimlessly at times. This behaviour is aggravated by anger if the client is being forced to engage in a conversation if he is not interested at that particular time. The environment matters in this particular case where the client displayed different behaviours in varying environments. If the client is in a safe environment, he does not get furious quickly. The above mentioned problems can be attributed to lack of experience and education given that the client was brought up in a hostile environment. This negatively impacted on his mind such that it did not develop in a normal way. The problem displayed by the client represents more of an adaptational problem rather than a disorder given that BC is active though he forgets to concentrate. From this perspective, it can be noted that the client’s activeness does not mesh with focused attention that is required when people engage in a meaningful conversation or dialogue. This can be attributed to one’s social and emotional development. In this case, the client showed that he was brought up under harsh conditions. The situation he experience bore heavily on his mind such that he at times loses concentration or fail to focus on something. 6. Intervention Plan or Recommendations Goals and strategies: BC has ADHD/intellectual disability and the goal is to continue developing skills to be able to deal with different life situations. Motivational interviewing to assist with engagement and problem solving skills that increase emotional self-control is the intervention strategy used for the client given that it was discovered to be more effective for this particular kind of problem before insight strategies such as CBT. This strategy is ideal for people with emotionally disturbed life histories. 1. The intervention plan was to increase self control and personal power within the client. 2. The other aim of this intervention plan was to develop BC’s interpersonal tools other than aggression and to improve conflict resolution through problem solving skills. These social skills are seen to play a pivotal role in dealing with aspects related to aggression since they will inculcate a sense of understanding the feeling for others in the affected person. Demonstrated efficacy: There is a good deal of evidence on the development of the brain and the impact of trauma and neglect. The intervention strategy involving motivational interviewing to assist with engagement and problem solving skills that increase emotional self-control is seen as effective in dealing with aspects related to intellectual disability. Fivush & Hamon (1989) suggests that people who experienced hostile environments during their childhood are likely to suffer from intellectual disability and they can be rehabilitated through developing their social skills so that they can manage to cope with different situations on their own. Research has shown that the neural system needs to be activated by outside sensory input to get the base of the brain activated and this can be done through engaging the person socially. Shaffer & Kipp (2007) suggest that social engagement of the effected person help in developing social skills such as problem solving as well as emotional self control in order to recover from the effects of ADHD. BC is also a sexual offender hence this strategy will significantly help in addressing his behavioural problem. This method is very effective given that there is personal involvement of the teacher and the client hence the reaction period in behavior change is likely to be speeded. Practicality: The sessions were held at periodic intervals where the counselor would be in close contact with the client. The client would be engaged in different sessions since this was seen as an opportunity to inculcate a sense of personal development in him. Carrying out this assessment is feasible given that there are no formalities involved since the counselor and the client would be meeting on a social background so that he can develop positive feelings towards the help he would be getting. Engaging someone on a personal basis is effective given that there are likely chances of mutual understanding between the two parties involved which can lead to positive behaviour change in the client. The client and the counselor met at certain agreed times and this worked well for both parties. Social and Ethical ability: The Australian Counseling Association’ code of conduct was observed in this given case involving BC. This is intended to provide a code of conduct that would guide the operations of the members involved in counseling services. For instance, clause 2.1 which deals with the issues of responsibility was observed where the counselor sought to establish a good relationship with the client. Clause 2.3 which deals with the aspect of confidentiality was also observed in this particular case. Confidentiality is a means of providing the client with safety and privacy. As such, it can be observed that privacy and confidentiality were always upheld given that BC was still a young person hence information about his ongoing sessions and treatment could not be divulged to any third party. 7. Intervention Procedures There were three sessions involved in the motivational interviewing technique in order to assist BC with development of problem solving skills that increased emotional self control. These sessions were carried between 22 June 2010 and 25 July 2010. Session 1 This session was specifically concerned with identifying the client’s background behaviour. This included information like family, age as well as he relations with other siblings. This session was conducted in the office. Session 2 This session particularly dealt with identification of factors that lead to aggression as well as lack of concentration by BC. The counselor asked different questions with the aim of getting to the bottom of the matter with regards to the mental state of BC’s mind and behaviour. BC could not easily concentrate if there were other distractions in the room. He also displayed actions of anger if he felt that he was not in the mood to respond to the questions asked. Session 3 This session involved reviewing of the previous sessions as well as developing his social skills in an engaging way. Compared to the previous sessions, it was observed that BC was responding positively in this session and it could also be seen that he was gaining stability. 8. Evaluation of Intervention Outcomes Data related to BC’s behaviour change was gathered through observation of his behaviour at different intervals as well as different environments. During the first days, it could be noted that the rate of BC’s aggressiveness was higher compared to the last days of undergoing some counseling sessions. The behaviour changes during his last days were positive and commendable as it could be observed that he was slowly gaining stability and some degree of self control. The client’s sexual behaviour has not changed much. 9. Overview ad Further Recommendations Over and above, it can be observed that the main reason for BC’ referral for BC’s referral was to address the problem of anxiety and behavioural problems given that the workers at the residential care reported that it was difficult to engage BC and at times he was very aggressive. The observation method was used to gather more information about different aspects surrounding the behaviour of this client. The intervention method used was motivational interviewing to assist with engagement as well as social skills development. The observations carried pertaining to his behaviour including two sessions at YJ office showed that BC had problems to concentrate when he is engaged in a discussion. He is quickly distracted by other objects especially inside a building as these drew his attention away from the discussion being carried out. However, the last session of his counseling showed that there was a steady improvement in his general behaviour though sexual behaviour has not significantly changed which is the reason why it is recommended that his blood must be checked for other disease which can contribute to this particular state of the mind. It is also recommended that BC’s behaviour must be closely monitored and efforts to reintegrate him with his family should be made given that he always displayed the desire for belonging to a family. Ethical considerations were upheld during the counseling sessions with this particular client. Aspects such as privacy and confidentiality were given priority since all the information related to the client was not divulged to any third party. I can safely say that my approach to management of BC’s condition was professional given that my interactions with him were objective since they were directed towards the attainment of the desired outcome. However, I still need to improve in the area of establishing a good communication network with my clients in the future. References Australian Counseling Association, (12 June 2008). Code of conduct: The Association for Counselors in Australia. http://www.theaca.net.au/documents/code_conduct.pdf Accessed 11 November, 2011. Brewer, S. (2001). A child’s world: A unique insight into how children think. London. Headline Book Publishing. Camp, A. & Russell, J. (2003). Comparative Psychology. London. Hodder & Stoughton. Eder, R.A. (1990). Uncovering young children’s psychological selves: Individual and developmental differences. Child development, 61, 849-863. Fivush, R., & Hamond, N.R. (1989). Time and again: Effects of repetition and retention interval event recall. Journal of Experimental Child Psychology, 47, 259-273. Kenrick, D.T. (1994). ‘Evolutionary social psychology: From sexual selection to social cognition. Advances in Experimental Social Psychology. 26, 75 121. Shaffer, D & Kipp, K. (2007). Developmental psychology: Childhood and adolescence. 7th Edition. Belmont. Thomson Wadsworth. Vasta, R., Marshal, M., & Scott, M.A. (1999). Child Psychology: The modern science. 3rd Edition. Brisbane: John Wiley & Sons. Appendices BC is a reluctant client, hard to engage and have quite a lot of social and psychological problems During sessions, observed BC being fidgety Hard to get him engage 22/6/10 B attended with Farrow reported left home 3 YO – Fa ‘not good’, Mo – OK, parents live with sister (18) Occationally sees parents lived Foster Care ? 5 Yr – carers hit him ? now with new carers he will travel on trains all day has some ‘friends’ – catch up D’nong was in secure he sleeping on streets theft to sell to have money involved with men for sex – can get $400 10 helping police nerd paedophile to I observed he continually pitched sore face was open (s/what) about paedophile Follow up 1. ACC 2. Social skills 3. Explore r’ships – carers/friends 29/6/10 Scared of dad stressed because did not get to go out fights with G/F – said she is scared - usually b/c B does not take him out discussed emotions – relate to Myrial understand feeling others B more confident other wa identified strengths in family (cards) ? units/co-operation 15/7/10 B reflective re family – engaged well busy organising access been begging on streets budget need – food, cigarette $30 go back to parents well stop Fa yells at Mo Fa does not like B coming around because stole $500 Daniel coming home to live B loves his Mo ? sleeps beside Mo parents move out soon not allowed to sit on couch Think about killing self ? under train ? never do it sad – feels rejected – desperate to belong to family – ‘hates’ Fa Identify (reflection) belonging/acceptances ? sleeps with Mo issues – idealised family – drifter, trust 10/9/10 Living with Berry St. Unit no day activity sleep lot anxious when don’t have smokes ? leads to anger today angry get $15 weekly curfew 29/9/10 Cath discussed with resi. Worker, brought up problems - sexual behaviour and comments - lying appeared not interested in sessions stated that not doing much on own time fist has wound – gas burn caused by other kids can’t find things that interested him get anxious when no cigarettes Plan: - flash cards - offending cycle 5/11/10 Feels shit – not allowed to call Mo ? workers busy feels happy when see parents ? would like more contact worker’s comment: - sense of entitlement - attention seeking - can escalate when contact with mum Plan: peer association – dealing with group pressure 12/11/10 Came in session with worker – Lisa B has been to Mo’s since last week - went by himself - happy to be with Mo - Mo has been in bed whole time – has had few minor heart attacks police came last weekend ? threatened Lisa with stick – used stick hit around unit – wall B stated because worker hung up phone when talking to Mo taught B Thinking errors and gave him practice sheets Plan: social skills (understanding feeling of others, make complains) follow up mindfulness exercise 26/11/10 The past week – ‘shit’ - not getting money he usually gets – only $18 - not doing what he should e.g. pack up room taking ritaline – cant motivate himself ‘can’t do anything’ appears to be flat, bored, unwilling to attend * - having shower, not going into office, not tapping on window, cleaning room, not swear B’s incentive list – swear Wednesday (24/11/10) – court – property damage 15/12/10 – court – DVD player 10/12/10 No good things happened came in looking a bit blue, dull last see Mo Tuesday sometimes upset ? want to stay over with Mo ‘Home’s pretty good’ ? like everyone in house felt bad about throwing stones on neighbour’s window chroming friend commented B as paranoid taught him to think of choices and consequences - stop and think before do - think of Mo Read More