Solution Manual for Mental Health in Social Work: A Casebook on Diagnosis and Strengths-Based Assessment, 3rd Edition

Chapter 3 Autism Spectrum Disorder Case 1 Questions to consider when formulating a diagnosis for Emmanuel 1. What are Emmanuel’s significant symptoms with regard to a possible mental disorder? Emmanuel had a hard time separating from his parents at school and was continuously crying, trying to run away, and throwing tantrums. He had difficulty with transitions at school and did not follow directions well. He did not approach other children and did not respond to their attempts to play or talk. Emmanuel used few of his own words but repeated what others said. When upset, he made guttural noises or screams. He was sensitive to loud noises and reacted by covering his ears and screaming. Emmanuel had no interest in his peers. He preferred to play on his own. When Emmanuel got exited he flapped his hands, clapped his thighs and crotch, and tapped his face. He appeared to be in a world of his own. He was content with writing numbers and letters over and over, and he frequently wrote down numbers to sooth himself when upset. He showed some developmental delays in areas of self-help and adaptation. His parents report that Emmanuel acted impulsively at times. 2. For how long have Emmanuel’s problem behaviors been evident? The extent of Emmanuel’s problem behaviors and developmental difficulties were noted immediately upon his enrollment in school, when he was five years old. While the family may have minimized their prior suspicions of some of these difficulties, the formal assessment revealed that they had begun having concerns about Emmanuel’s development at 30 months of age, due to his language difficulties. It is possible that his problems had been emerging before then. 3. Has there been any recent stressful event occurring in Emmanuel’s life that might account for any of his symptoms? There is no evidence of any recent stressors in Emmanuel’s life, although his beginning kindergarten has placed him in a more structured environment than he experienced before. Rather than accounting for his symptoms, however, this seems to have made them more evident. 4. To what extents do Emmanuel’s (and his parents’) cultural traditions contribute to his problem behaviors? Because of their mixed Spanish and American heritage and lifestyles, the family did not acknowledge Emmanuel’s developmental delays as evidence of any internal problem. Rather, they perceived Emmanuel’s delays as being due to his need to live biculturally and make a gradual transition between his two cultures. 5. Given that Emmanuel has a developmental disorder, with what other disorders of childhood and adolescence (if any) do his symptoms overlap? In addition to the autism spectrum disorders, Emmanuel’s inability to follow directions and adhere to the demands of the structured environment could be seen as symptoms of oppositional defiant disorder. His problems with attention and concentration could be seen as symptoms of attention-deficit hyperactivity disorder. His academic limitations, and slightly below-normal measured IQ, might make an observer suspect an intellectual disability. Still, Emmanuel does not meet the full criteria for any of those disorders. DSM Diagnosis F84.0 Autism Spectrum Disorder, without accompanying intellectual impairment, with accompanying language impairment, requiring substantial support Rationale The diagnosis of Autism Spectrum Disorder was made because Emmanuel displays significant deficits in his social interactions, such as reduced eye contact, lack of social reciprocity, and failure to develop relationships with others. His communication skills are considerably limited; he does not initiate or sustain conversations with others, and his language development has been delayed since he was a baby. He also uses unusual forms of language, such as echolalia. For all these reasons, he was given the additional specifier with accompanying language impairment. Moreover, Emmanuel is unable to participate in imaginative play. Additionally, he exhibits restricted interests, such as writing numbers repeatedly in an artistic, almost calligraphic manner. Emmanuel displays repetitive motor mannerisms, including hand flapping and face tapping. Further support for this diagnosis is evident in his impulsivity and difficulty with sensory integration. Emmanuel’s developmental and psychological testing has determined the absence of Intellectual Disability. His IQ is 95. Therefore, the specifier without accompanying intellectual impairment was added. He was assessed as Level 2, requiring substantial support because of his language delays and lack of ability to interact socially. A review of Emmanuel’s medical history indicates that he is a healthy five-year old with no problematic medical condition. His mother reports that pregnancy and delivery were normal and uncomplicated. He was toilet trained at age three. Additional Information Required Emmanuel’s assessment was comprehensive, including input from a range of health professionals, and thus there is no other information required at this time. Risk and Resilience Assessment It is more appropriate to focus on risk and protective influences for the course of the disorder because little is known about its origin other than it has a biological basis. The only significant risk mechanisms are that Emmanuel is male and has limited social skills and interest in peers. Regarding protective factors he experiences significant parental involvement in his care and has an average IQ, a good support system, and health insurance. What questions could be used to assess for additional strengths in this client? 1. What types of social situations seem to bring out Emmanuel’s positive adaptive qualities? How can they be facilitated? 2. What are the features of the 1:1 interpersonal situations in which Emmanuel is effectively able to interact? What are the personality characteristics of those who “bring out the best” in his interactional qualities? 3. How can Emmanuel’s various interests be encouraged, since he can participate in activities with others so long as the activity interests him? 4. What are the circumstances in which Emmanuel is most likely to engage in his artistic pursuits, including calligraphy and listening to music? 5. What playground conditions does Emmanuel seems to enjoy the most? What are the features of those times when he is most able to attend to his puzzles? 6. What are the circumstances that seem to encourage Emmanuel’s use of humor? 7. How can Emmanuel’s visits with family members be structured to maximize his positive engagement with them? Intervention Plan In the case of autism spectrum disorder, it is necessary to develop and implement an intervention plan as soon as possible, especially in light of Emanuel’s relatively late diagnosis. Emmanuel is eligible for special education within his school district, and his parents and the special education team will meet within the next two weeks to develop an IEP (Individualized Education Program). As soon as this has been accomplished, Emmanuel will be able to join a class appropriate to his needs. The elementary school he attends offers a class for children with autism spectrum disorder, which is small in size and staffed with two special education specialists. This class focuses on the development of social skills, as well as the reduction of stereotyped behaviors. Speech therapy will also be necessary to enhance his pragmatic language skills. In addition to these services it is important to educate Emanuel’s parents about the disorder, relevant parenting practices, and resources in the community. Fortunately, the school district has a Parent Resource Center, which offers an array of informational material in Spanish, as well as workshops and classes on various disorders and their treatment. The social worker has provided the parents with some basic information and has set up a meeting for the parents with Spanish-speaking staff at the Parent Resource Center. Due to the parents’ difficulties with consistent parenting, the social worker has already shared information on discipline and has introduced them to a behavioral approach to reinforce desired and reduce problematic behaviors. She has also suggested strategies to decrease the extent of Emmanuel’s TV watching. The social worker will check in weekly with the family to review progress and assist when necessary. The diagnosis of autism spectrum disorder came as a shock to the family, who had viewed Emanuel’s behavior as a temporary delay in development. Therefore, they may need to go through a grieving process. They also might require support for their adjustment. A number of organizations in the area offer support groups for the Spanish-speaking population. This will give the parents the opportunity to share their feelings without having to rely on an interpreter. Additionally, disability in the Latino community is often viewed with stigma. In a support group of their peers, Emmanuel’s parents could receive advice and support from people with a similar cultural background to their own. A sibling support group could also be offered to Emmanuel’s brother and sister. Critical Perspective While the primary diagnosis appears to be valid, the DSM-5 criteria are less clear about how to determine its severity level, despite including a table for determining requiring very substantial support (level 3), requiring substantial support (level 2), and requiring support (level 1). Although the DSM provides some general guidelines on how to assess social communication and restricted repetitive behaviors along these lines, there is much subjectivity on how these ratings are reached. In Emmanuel’s case, his parents had just found out about the disorder and he had, up until that time, limited supports. It may not be fair to judge Emmanuel as “requiring very substantial support” when he had not yet received intervention. For that reason, he was not given that rating, although it my later become evident that he needs it. Case 2 Questions to consider in formulating a diagnosis for Hao: 1. What are Hao’s significant symptoms with regard to a possible mental disorder? 2. 3. 4. 5. Hao is unable to relate to other children in class or follow directions, and he frequently engages in hand washing. He cannot follow classroom routines and only persists with activities in which he is interested. He speaks with an inappropriately loud volume in close proximity to others’ faces, and is unable to retain the teacher’s instructions about standing back and speaking more quietly. Hao looks off into space while the teacher speaks, and he does not react to comments she makes. At times he has temper tantrums at school. His mother noticed in preschool that Hao was not connecting with other children and only wanted to play alone. Hao is not developing socially. He does not follow the rules set forth by his family, and tends to ignore his parents when they try to discipline him. Hao tends to laugh inappropriately during activities at the park to a degree that his father threatens to take him home. For how long have Hao’s problem behaviors been evident? Hao’s problem behaviors have only been evident for one year. They were formally identified only when he enrolled in school and demonstrated an inability to function within the structure of that institution. His parents had been concerned about his social isolation one year before, when he entered preschool, but his teachers at the time did not see Hao’s withdrawal and preference for playing alone as significant issues. Have there been any recent stressful events occurring in Hao’s life that might account for any of his symptoms? The Hao family has experienced much stress at times in their lives, but there is no evidence of significant stress in the past year or so that might help to account for Hao’s symptoms. To what extent do Hao’s (and his parents’) cultural traditions contribute to his problem behaviors? Interestingly, Hao’s being in America may have delayed the recognition of his developmental problems. According to his mother, in Vietnam Hao’s behavior would be considered unacceptable and outside the norm. Her own observations of the patience of American teachers led her to be less concerned about Hao’s behavior. In Vietnam children are warned against bad behavior by being threatened with physical punishment. While it is not clear what interventions Hao would have received in Viet Nam, his abnormal behavior would have been less tolerated. Aside from autism spectrum disorder, what other disorders of childhood and adolescence do Hao’s symptoms possibly represent? While ASP is distinct from the disruptive behavioral disorders, there is some overlap among their symptoms. Hao might be considered for a diagnosis of oppositional defiant disorder in that he seems to ignore instructions from adult authority figures (his parents and teacher). He also could be considered for attention deficit/hyperactivity disorder in that he seems to have difficulty at times with his attention span, concentration ability, and activity level. Diagnosis F84.0 Autism Spectrum Disorder, without accompanying intellectual impairment, without accompanying language impairment, requiring support Allergies (which can result in eczema, by parent report) Rationale Social workers do not diagnose neuro-developmental disorders without contributions from a multi-disciplinary team. Therefore, Hao should participate in a physical examination, visual and hearing examinations, and neurological exams, as well as a speech and language assessment, before the diagnosis can be confirmed. Moreover, most of the information in the above report comes from Hao’s mother’s perspective, and other perspectives should be sought, including those of Hao’s father. Extended observations of Hao, in free play situations and with his parents, might yield additional information. That being said, Hao appears to tentatively meet the DSM criteria for Autism Spectrum Disorder as follows: A. Hao exhibits qualitative impairments in social communication and interaction as evidenced by a failure to develop peer relationships appropriate to his developmental level (as noted in his preschool class and in his interactions with most of his cousins) and a lack of social or emotional reciprocity (as noted by his inability to relate to others at his preschool, the parochial school kindergarten, and most of his cousins, with the exception of Thanh, who will talk about subjects of interest to Hao.) B. Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, as manifested by an encompassing preoccupation with stereotyped and restricted patterns of interest that are abnormal either in intensity or focus (Hao frequently washes his hands) and an inflexible adherence to specific, nonfunctional routines or rituals (Hao displays frustration, sometimes culminating in temper tantrums, when he is not allowed to pursue what he wants to do at home and in the kindergarten setting). C. There is evidence that the relevant symptoms were present in Hao’s early development even though they were not discovered until he attended school. D. The disturbance causes clinically significant impairment in social (lack of sustained play with age mates and most family members of his age) and school functioning (Hao was expelled from the parochial school due to his behaviors). E. Criteria are not met for another specific pervasive developmental disorder or schizophrenia. Hao’s diagnosis includes the specifiers without accompanying intellectual impairment and without accompanying language impairment because he is both intelligent (by testing) and able to communicate and be social. He is also given the specifier requiring support because he functions rather well in some ways and this is the mildest functional indicator. Additional Information Required As noted earlier, it would be necessary for Hao to undergo a multi-disciplinary assessment to make a valid diagnosis. Additionally, other reporters, such as his father, should be involved. Risk and Resilience Assessment There is no reported family history of ASD, although Hao’s father was 40 when Hao was conceived, which may present a risk factor, as older age of fathers has been associated with the disorder. Regarding the course of the disorder, Hao appears to possess a number of resilience influences. He has temper tantrums but he doesn’t hurt himself or others. He is intelligent and gifted in music and computers. At the social level, Hao’s family is supportive and financially secure. He has a large extended family available, although at this point they don’t understand the nature of his disorder. In addition to the extended family, Hao is being brought up in a religious faith. Hao’s disorder could have been caught earlier (he is being diagnosed at five years of age) but on the positive side he will now be receiving services through the public school system. What questions could be used to assess for additional strengths in this client? 1. How can Hao’s treatment providers nurture his talents and curiosity? 2. Given that Hao is responsive to time-outs, strong verbal communication, and direct eye contact from his mother, what kind of structured program of reinforcement could be implemented for him? 3. How can sports activities be used to facilitate Hao’s learning and serve as reinforcers for adaptive behavior? 4. How can Hao’s family be encouraged to support Hao’s adaptive activity and perhaps incorporate spirituality into his activities of daily living? 5. How is it that Hao becomes focused when engaged in his artistic interests? What related skills can be put to additional productive use in his treatment? 6. How can Hao’s endearing personality qualities, noted by his teachers, be further developed toward his interpersonal skill development? 7. How can the professionals’ learning about Vietnamese culture provide a better understanding of how his behaviors are reflective of that culture? Intervention Plan Parent Interventions It is important that Hao’s parents understand that he is not purposefully acting in a willful and defiant way, but that his behaviors and style of interacting are a result of his disorder. At the same time, managing the behaviors and training the child with ASD is challenging for parents, and the Chungs will require much support. Lang and An will be encouraged to attend a local support group for parents of special needs children, and an effort will be made to find a support group conducted in Vietnamese. The Chungs should receive parent training and information and training on how to promote Hao’s communication and social skills. Lang should be encouraged to return to part-time haircutting. Further, Lang and An should inform the extended family about Hao’s disorder to ensure a more supportive network. Child Interventions Hao’s individual interventions will include three strategies: communication and social skill training; behavioral therapy; and educational intervention. Communication and social skills training: Hao will be taught in an explicit and rote fashion the rules of socialization and communication. He will learn how to monitor his own speech in terms of volume and rhythm, as well as how to interpret the communication of others, such as gestures, eye contact, and tone of voice. Opportunities to role-play communication and social skills will be important, as well as practice in social interaction through supervised and structured activities. Initially, it may be helpful for Lang to schedule play dates for Hao with other children with Asperger’s to practice developing skills. Behavior therapy: This class of techniques is targeted at curbing problem behaviors, such as obsessions (frequent hand washing) and tantrums. These behaviors are identified and specific guidelines will be devised to deal with them. Hao’s parents and his teachers/school staff will be taught to handle the behaviors in the same way, so that clear expectations are set and consistency is maintained. Behavior therapies also focus on training a child to recognize a troublesome situation — such as a new place or an event with lots of social demands — and then select a specific learned strategy to cope with the situation. Educational interventions will make full use of Hao’s individual’s interests and talents in the areas of computers, music, and books. In school, there may be opportunities in the classroom for Hao to take on leadership in activities revolving around these interests. Teaching other students skills can help Hao’s self-esteem, as well as assist him in learning social skills, such as taking the perspective of others, following conversational and social interaction rules, and engaging in two-way exchanges. Hao may be able to participate in the mainstream classroom given his intellectual abilities, but may need additional help from a support person. He also may require individualized curriculum centered on his deficits. Critical Perspective A debate occurred during the school system’s Individualized Educational Plan meeting when discussing a possible diagnosis for Hao. The psychologist who had administered the IQ testing determined that Hao has Autism Spectrum Disorder since his social awkwardness was profound. However, the representative from the city school district’s gifted and talented program maintained that Hao’s symptoms were a function of his giftedness. In other words, Hao’s high IQ and intellectual interests made him unable to relate to same-age mates and caused him to be bored and under-stimulated by the classroom routine. These differences of opinion underscore the care with which any neuro-developmental diagnosis should be made. Despite these different perspectives, Hao was ultimately diagnosed with Autism Spectrum Disorder because of his social deficits, manner of communicating, and rigid, circumscribed interests. Case 3 Questions to consider when formulating a diagnosis for DeShon: 1. What are DeShon’s symptoms with regard to a possible mental disorder? DeShon is distant from others, even his family members. He is unable to relate to others in his class and does not play imaginatively. He repeats other people’s words when he speaks with them. He displays flat affect and fails to make eye contact. Additionally, he rocks back and forth and waves his hands in front of his face. According to his mother, DeShon also becomes frustrated when he is asked to transition to a new activity. Finally, he shows sensitivity to tactile experiences, particularly with regard to food texture. 2. For how long have DeShon’s problem behaviors been evident? DeShon’s problem behaviors and developmental difficulties became evident between 18 to 24 months; at that time, his speech development slowed and his already minimal eye contact decreased further. 3. Have there been any recent stressful events occurring in DeShon’s life that might account for any of his symptoms? The family seems subject to many financial hardships, contributing to their frequent moves and temporary homelessness. However, DeShon’s symptoms have been stable since he was 18 to 24 months old, and he is now five years old. If his problem behaviors were in reaction to a stressful live event, there would have been some shift in his symptoms over the years. Diagnosis F84.0 Autism Spectrum Disorder, with accompanying intellectual impairment, with accompanying language impairment, requiring substantial support. Rationale Criterion A: Deficits in social communication and social interaction across multiple contexts as evidenced by: 1. Deficits in social and emotional reciprocity, manifested by an inability to sustain eye contact; a failure to develop peer relationships appropriate to developmental level; impairment in the ability to initiate or sustain conversations; echolalia; and a lack of social or emotional reciprocity. 2. Deficits in nonverbal communication as noted by an inability to sustain eye contact, a misunderstanding of gestures, and poorly integrated verbal and nonverbal communication. 3. Deficits in developing and maintaining relationships as evidenced by a lack of imaginative play appropriate to his developmental level and a lack of spontaneous seeking to share enjoyment, interests, or achievements with others. Criterion B: Restricted, repetitive and stereotyped patterns of behavior including rocking and waving his hands back and forth. Criterion C: The abnormal functioning occurred prior to age three. DeShon has a tested IQ of 60 and thus is given the specifier with accompanying intellectual impairment and also, due to his limited use of language, with accompanying language impairment. He is further specified as requiring substantial support because he functions poorly on his own unless involved in an isolated activity of particular personal interest. Additional Information Required We can assume DeShon went through the appropriate testing needed to determine his diagnosis, although not much information is provided in the case study about the results of various assessments and tests. Risk and Resilience Assessment Biological factors are the major contributors to the development of autism spectrum disorder, but we know very little about how any such factors are affecting DeShon. Regarding his risk influences for the course of the disorder, he has serious problems with play deficits and stereotypical behaviors, and the family routinely experiences material hardships. On the protective side, DeShon is not aggressive, has a supportive mother and extended family structure, and is part of a school system that can offer and coordinate a range of interventions. What questions could be used to assess for additional strengths in DeShon? The assessment could focus more carefully through additional interviews with DeShon’s mother on his strengths with coping questions (It sounds like you’ve had a lot of challenges. How have you been able to manage with all you’ve been through? How do you go on? What are the qualities you draw on? What would your stepmother say that you do? How about your boyfriend?) and exceptions (When does DeShon seem more responsive? Who is there? What are they doing and saying?). Other questions may include “What are the types of social situations that seem to bring out DeShon’s talents and positive adaptive qualities?” and “What positive characteristics can be channeled to enhance DeShon’s adaptation to the newly structured setting?” Intervention Plan The social worker should ensure that mother is linked with social services (e. g., Medicaid, food stamps, Temporary Aid to Needy and Dependent Families) so that DeShon’s basic health, medical, and nutritional needs can be consistently met. The state Autism Society might have further information on available family resources. DeShon’s mother’s financial situation needs to be stabilized so that DeShon can remain in the same school system once he begins services. The social worker will present education about autism to DeShon’s mother and a referral to a support group for parents of children with ASD. Special education services will be provided by certified professionals at and through the school, including applied behavior analysis that can teach DeShon skills and knowledge and extinguish his negative behaviors (i.e., tantrums) by consistent ignoring. DeShon’s mother and her boyfriend will be taught behavioral techniques so they can apply the same structure with him in the home. Critical Perspective It seems clear in this case, based on the thoroughness of the examination process, that DeShon has a neurodevelopmental disorder, and he most clearly fits the criteria for autism spectrum disorder. However, such a diagnosis implies that the client has less potential to improve with regard to social and interpersonal functioning, so it is important that the social worker continue to look for evidence of strengths when this diagnosis is made, and not assume that the client’s change capacity is modest.