Associate Name: Jane C. Probst, MSW, LCSW
Age/Gender of Client: 13 y.o. female
Background:
Sarah was referred to Clinician in October 2013 by her Pediatrician, who was concerned about exposure to trauma/domestic violence and possible learning disabilities, in addition to ADD/ADHD Vanderbilt criteria being met. Sarah cycled unsuccessfully, through multiple ADD/ADHD medications and mood stabilizers, at the time of intake with her Mother, Maternal Grandmother and newborn brother for her initial session. English is not spoken in the home, as Step Father is a non-English speaker. Mother is a native English speaker, however, Maternal Grandmother, Step Father, and Biological Father are not. At intake, Mother reported that Sarah was struggling socially and academically, and witnessed domestic violence between her parents before they divorced. Sarah’s biological father is an alcoholic.
After several weeks of weekly Out Patient Therapy (OPT), using SMART (Sensory Motor Arousal Regulation Therapy) and play therapy, Clinician referred Sarah back to her primary care physician for further evaluation orders for Developmental Pediatric Evaluation, Central Auditory Processing (CAP), and Sensory Integration (SI) Evaluations. Sarah responded with non sequitur answers to simple questions. When asked to draw a picture of her family, Sarah handed Clinician a toy, clearly unable to respond accordingly.
Expressive/receptive language deficits (undiagnosed at the time) resulted in Sarah referring to “things” and “people” interchangeably, with little definitions beyond minimal descriptions. Emotional language was absent other than basics: happy, sad, angry. Her charming smile was a disarming coping skill as she would smile sweetly and say, “yes” to almost anything. This was a significant risk factor for Sarah’s safety even though the family found her compliant. It was when “yes” didn’t mean “yes”, it meant “pass”, that family meltdowns happened, leaving family members stunned at the outcomes of tantrums.
Given the family’s limited resources, it took over 2 years for all of the evaluations to be completed, in large part due to a lack of local rural resources, as well as limited providers who accept Medicaid. Cultural misunderstandings also were a barrier to seeking treatment. Sarah met criteria for PTSD-Chronic, Dissociative Subtype within a short time in OPT, in addition to the myriad of sensory deficits Clinician observed on a weekly basis, prompting referrals.
It must be noted that at the time of this Case Study submission, January 2019, Sarah no longer meets criteria for PTSD. She continues to struggle with mood swings; however they are manageable as she is better equipped to know how to care for herself with positive self-regard, bilateral physical activity, and diaphragmatic breathing, which is greatly improved with her choice of musical instruments.
June 2015 – Central Auditory Processing Evaluation completed and deficits identified. “Results indicate normal hearing sensitivity and auditory processing delay/disorder in the area of tolerance/fading memory.”
December 2015 – Neurological evaluation endorsed confirmation with Audiologist of Central Auditory Processing Disorder. Neurological exam with EEG all within normal ranges and no concerns about founded fading memory, in spite of school reports and Central Auditory Processing evaluation findings. Sleep study completed w/o findings. No services were recommended per report. PCP and Clinician alike, confounded by findings but no services recommended.
January 2016 – Intensive In Home Services implemented as Sarah began making suicidal gestures and threats to run away at age 11 yo. Case Management supporting parents to get services at school with 504 as IEP was denied despite medical documentation.
February 2016 – Developmental Pediatric evaluation with University of Virginia – identified Speech/Language problems (referred out for S/L evals), Sensory Integration deficits in proprioceptive and vestibular, and PT for right side weakness. Medications for ADHD and insomnia with multiple failures in sustained level of functioning (LOF). Clinician reported to PCP that since ADHD/ADD meds aren’t working, maybe it’s SI problems instead, given Sarah’s diagnosis of PTSD Dissociative Subtype.
May 2016, Sarah is evaluated by Occupational Sensory Integration clinic with Speech/Language eval, and multiple issues were finally pinpointed and treatment began. 504 in school finally led to IEP.
The following assessment tools were administered:
- Bruininks-Oseretsky Motor Proficiency BOT-2
- Manual Dexterity deficits
- Upper limb coordination deficits
- Adaptive Behavioral Assessment System ABAS -2
- 8 of 9 domains either below average or low
- Sensory Processing Measure – SPM Home and Report Deficits
- Hearing
- Tactile/touch
- Balance & Motion
The following issues were identified and a weekly OPT treatment plan developed.
- Reading comprehension.
- Right side weakness.
- Fading memory (reading comprehension)
- Proprioceptive and vestibular deficits.
- Expressive and receptive language deficits.
- Reading comprehension improved when Sarah read while sitting on a stationary bike. This activity was prompted by Clinician as Sarah’s LOF improved with bilateral movements when engaged in weekly OPT using SMART. OT/SI providers complied and Sarah made further gains.
Sarah began making progress with SI/PT interventions. Grades improved, as did social relationships. The rocky relationship with her biological father became intolerable and Sarah was able to create a boundary of contact without significant meltdowns, as she no longer accepted her father’s drinking. Relationship with Mother and Step Father improved, suicidality evaporated, grades improved, and Sarah began playing the flute.
Intervention:
July 2017 – Sarah completes her first 5 consecutive days of Safe and Sound Protocol in clinician’s office. She tolerated the treatment well initially, but then found it boring and she had difficulty paying attention to the music. Within a couple of weeks, the family noticed improved reciprocity. Sarah’s flute playing improved as her ability to read music took a developmental leap.
September 2017 – Sarah begins a new school with improved reading comprehension, muscle tone, and memory. She successfully completed OT/SI treatment. Sarah asks to do the Safe and Sound (what she now calls the “headphones”) again. Treatment begins immediately with Days 1-4 completed in the office, and Day 5 at home under Mother’s supervision.
December 2017 – Sarah is doing remarkably well and is stable in home and school. She reports some mild sadness from time to time, and has tools and supports she readily accesses because now she knows how to ask for help, and let others know what type of help she needs. Sarah’s sense of personal agency is greatly improved and Sarah asks to scale back to monthly OPT sessions, with the caveat to return for every 2 weeks if needed.
August 2018 – Sarah’s sessions become increasingly less frequent until she experiences anxiety returning to school for 8th grade. Sarah and her Mother agree to do another round of Safe and Sound as school begins. At the end of the 5 days, Sarah reported her famous – “You laugh at me because I’m different. I laugh at all of you because you’re all the same” line, looking her bullies straight in the eyes, and then walks away, unphased.
October 2018 – Sarah makes A/B Honor roll for the first time since 4th grade. Auditory processing is greatly improved, as is her memory, and overall LOF. She’s in the school’s marching band and joined after-school activities such as recycling, girl’s basketball, and other educationally fun programs. School and family members report significant improvements in LOF and Sarah reports that she is able to keep lists in her head and follow directions. Eye contact is greatly improved.
November 2018 to Current – Sarah accesses OPT on an as-needed basis. Her Mother sends periodic reports that she is doing well and active in after-school activities and marching band.
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