Clinical Case Presentation: Shifting the negative mindset of a fatigued caregiver

Clinical Case Presentation:

Shifting the negative mindset of a fatigued caregiver

April 7, 2014

Clinical Question or Learning Outcome

In sharing this case, I’m hoping my classmates will be able to share techniques or best practices to combat the projection and fatigue currently being experienced by a grandmother who is the guardian of her five-year-old granddaughter. Additionally, I’m looking for recommendations about how this child’s therapist and I can work together to help shift the very negative mindset this grandmother has about her granddaughter.

Brief Case Description

Our five-year-old client was removed from the care of her biological mother due to a history of neglect and concerns of physical abuse. She was placed in the care of her maternal grandmother.

Grandmother brought client in for behavioral challenges that include mischievous behavior (e.g., stealing others’ belongings, cutting up sheets, etc.), sleeping disturbances (does not sleep through the night), food hoarding, and symptoms of ADHD. Grandmother treats her son, who is seven, and granddaughter very differently and believes that the granddaughter is incapable of showing affection, lacks remorse, and that demonstrations of remorse are insincere and learned from television. She rejects any improvements in client’s behavior by saying they’re temporary and believes she’ll quickly return to misbehavior.

Summary of Clinical Formulation or Impressions

·      Current diagnosis is ADHD

·      Clinical “hunches”

o   Grandmother may be projecting unresolved issues with her daughter (client’s mother) onto granddaughter

o   The client and grandmother have very different personalities and they are clashing. The client is competitive, headstrong, independent, etc. The Grandmother is controlling, rigid and gives the impression that she wants to be needed

o   The grandmother may have grown used to parenting in a very particular way with her seven year old son and is having difficulty modifying the way she parents with her granddaughter

o   Client’s behavior exacerbated by lack of attention/positive attention from her grandmother

o   Grandmother is fatigued due to lack of sleep and there are concerns about drinking as self-soothing behavior

Interventions used/treatment plan goals

·      Play therapy

·      Psychoeducation (though I think this really needs to be increased)

o   Discuss reasons for behavior

o   Get grandmother to understand that client’s behavior isn’t necessarily directed at her

·      Affective expression and modulation training

·      Treatment Plan Goals

o   Help grandmother/client establish a secure caregiver attachment

o   Increase positive interaction between grandmother and client

o   Increase client’s ability to better self-regulate

Recommendations from Classmates

·      Parents sometimes come to the conclusion because the behavior sometimes seems deliberate so all they see is the negative

o   The Spirited Child (book) is a good resource to help combat this

·      Self-Control Pyramid (google this for more info)

o   Emotions the parent may feel

o   Skills that need to be learned by kids and trying to explain that bc her brain is still young/developing, she’s at the prime age for learning behavior

·      Sometimes you just need time. Continue to build rapport and invest them in your knowledge and clinicians

·      Constant affirmations…this will even model for the caregiver how to engage with client

·      Ask grandmother to try going with client’s expressions of remorse even if she believes them to be insincere.  

·      Special Time (parent/child interaction therapy)

o   Will help grandma loosen the reins even if for just a short amount of time each day

·      Challenging grandma’s cognitions: so what of she learned expressions of remorse from television? Why not still reinforce the behavior from a social skills standpoint

·      Leverage the fact that she evidently wants help bc she’s there

·      Go deeper with grandmother to explore feelings of projection, resentment, etc. Challenge her cognitions

o   Is she treating client like the person her adult daughter is right now?

·      Recognize that grandma has had some emotional stuff too and be sensitive to that

·      Motivational Interviewing   

o   Framework already set given the child’s interaction with grandma’s BF and in the office with me/therapist