Background Information
Sarah Cisneros is a 7-year-old Hispanic female who has just started the second grade at Hutto Elementary School. She is a friendly and engaging child, although she has had numerous problems at school. Last year, the teacher reported that Sarah had difficulty following directions and staying in her seat and talked incessantly. She often got into disagreements with other children on the playground when she couldn’t seem to follow the rules of a game they were playing. Her teacher also stated that she had difficulty learning the alphabet and writing letters and numbers. Sarah often reversed words, saying “tac” instead of “cat” and “kool” instead of “look.” Although she had a difficult time in first grade, her teacher felt that Sarah was just an active child who would “settle down” when she entered second grade.
At the beginning of second grade, Sarah’s parents separated. Sarah stayed with her mother, Regina, age 27. Regina moved back to Sarah’s grandmother’s home and went to work as an administrative assistant at a law firm in town. Sarah’s father, Don, age 32, moved in with a girlfriend he had been seeing for several months prior to the separation. Don travels extensively in his job as an international computer sales representative. He is often out of the country for 3–4 weeks at a time. Sarah told her grandmother, “My heart won’t hurt anymore when my daddy comes back to live with me.” Regina and Don have told Sarah that they are just living in separate places for a little while. When Regina discovered that Don was seeing another woman, she became very angry and depressed. She began working overtime, sometimes 12 hours a day, as a way of coping with the upheaval in her marriage. Sarah often sees her mother only early in the morning when Sarah is getting ready
When Regina discovered that Don was seeing another woman, she became very angry and depressed. She began working overtime, sometimes 12 hours a day, as a way of coping with the upheaval in her marriage. Sarah often sees her mother only early in the morning when Sarah is getting ready for school. Sarah’s grandmother takes care of her after school. She complains to Regina that Sarah is “headstrong” and “can’t seem to follow directions.” She also tells Regina that if Sarah were given a good spanking she would “straighten up.” Regina just doesn’t feel she has the energy to deal with Sarah’s behavior and told her mother, “I just can’t deal with everything, Mom. You need to help me with the discipline. I can’t be mother and father, hold down a job, and deal with Don. It’s just too much for me right now.”
Regina’s mother told Sarah that if she didn’t follow directions, she would get a spanking. Sarah screamed, “If my Daddy was here, he’d give you a spanking,” and ran to her room, slamming the door. Regina decided to enroll Sarah in Brownie Scouts for one afternoon a week after school. The Brownie Scout leader is a friend of Regina’s who lives down the street and said she’d bring Sarah home after the Scout meeting. Although Sarah was very excited about being a Brownie, she had difficulty getting along with the other girls. She couldn’t sit quietly and work on projects; she often interrupted the leader with silly outbursts; she got bored easily and began running around the room; and she disrupted the meetings with her constant chatter. After several weeks, the Brownie leader called Regina and told her that perhaps Sarah needs another year before she’s mature enough to be in Brownie Scouts. Regina was so frustrated that when she got home from work, she screamed at Sarah, gave her a spanking, and sent her to her room. Sarah slammed her door and began throwing all her toys off the shelves. She screamed for 2 hours until she was so exhausted that she lay down on the floor and went to sleep.
After this incident, Regina, feeling very guilty, sought the advice of the counselor at school. The counselor suggested that Sarah may need an outlet for all her energy—something that involves physical activity. Regina decided to enroll Sarah in a ballet class on Saturday mornings at the local dance company. Once again, Sarah was very excited about being in the ballet class. She went shopping with Regina and bought a pink leotard with matching ballet slippers. Sarah danced around the house all day in her leotard in anticipation of the class. Unfortunately, when Sarah began the dance lessons, the ballet teacher had the same complaints the Brownie leader had about Sarah’s inability to follow directions and pay attention in the class. Regina felt at her wit’s end about what to do next. She called Don and told him the problems she has been having with Sarah, and he told her, “You just let her get away with murder. When I was that age and I didn’t obey my parents, I got a whipping and it never happened again. I’ll take her for a weekend and teach her a lesson or two.” Regina angrily told him, “Don’t bother,” and hung up the phone. Late one night shortly after this altercation with her husband, Regina was sitting by herself in the living room of the dark house watching the news on television. During a public announcement commercial for a Fun Run, she noticed that one of the sponsors was the Family Mental Health Center, a private nonprofit organization. Regina wrote down the phone number, and the next day at work, she made an appointment to go talk to a counselor about Sarah. The intake worker told Regina that the counselor would like to talk to Regina at the first appointment before she brought Sarah to the agency.
Initial Interview with Regina
The counselor introduces herself as Peggy Ross, a clinical social work practitioner who works with children and families. Peggy tells Regina about the agency and what her role as a counselor is. Regina tells Peggy about the problems she has been having with Sarah since her separation from her husband. She states that she just can’t do anything with Sarah anymore and she just doesn’t know what to do. She states that it is difficult living with her mother; however, her mother does provide child care so that Regina can work. Peggy asks Regina whether the behaviors that Sarah has been displaying are new behaviors or ones that were present before the separation. “Come to think of it,” says Regina, “Sarah has had trouble ever since she started school. Even in kindergarten, she didn’t seem to listen to the teacher. She’s not a dumb child. In fact, I think she’s very smart, above average. But when it comes to completing her homework, she’s a mess. She loses things she needs for assignments. She seems completely disorganized; she spreads all her stuff around and then can’t find anything. She’s always excited when she starts projects, but then it’s like pulling teeth to get her to finish.” Peggy asks Regina about her and Don’s childhood experiences. Although Regina doesn’t know why that’s important, she tells Peggy that she had no problems in school and, in fact, excelled in all her classes. “I was a classic good little girl. I knew if I wasn’t, I’d get in big trouble at home,” Regina told the counselor.
Peggy asked about Don’s childhood experiences. Regina stated that Don’s experience was very different. He was constantly getting into trouble and was very active as a little boy. He once told Regina that he was considered the “class clown” all through elementary school. Although he attempted a variety of sports, he was never very good at anything except soccer. He said he could run longer than most kids his age. He was a skinny, high-strung child. Regina tells the counselor that Don recently told her that he got whipped all the time for his bad behavior. She says that she doesn’t really think spanking helps Sarah. She relates the incident of the night she spanked Sarah out of frustration and the tantrum that Sarah threw afterward. After obtaining information about Regina, Don, and Sarah’s present difficulties, Peggy suggests that Regina bring Sarah with her for the next interview. She states that she has some ideas about what is going on with Sarah but would like to talk with her before making any assessment. In the meantime, she gives Regina a form to fill out on Sarah’s behavior as she observes it over the next week. She also asks her to sign a form giving Peggy permission to talk to Sarah’s teacher at school. The following week, Regina brings Sarah to the agency to talk with Peggy.
Interview with Sarah
Peggy meets Sarah in the waiting room of the agency. She readily goes with Peggy to her office. Peggy gives Sarah a few choices of some things they can do together while they talk, including drawing, puppets, and a board game. Sarah has a hard time deciding what to do and after making a choice, she quickly grows bored with drawing a picture and wants to do something else. When Peggy suggests they can do something else once they have finished their pictures, Sarah gets irritable and keeps jumping up from the table and wandering around the room. She says that she has lots of friends at school. She likes recreation time the best because she likes to jump rope. She also tells Peggy that she doesn’t like her teacher, who is always mean to her. When Peggy asks her why she is mean, Sarah states, “She makes me sit in my chair and do my letters over and over again. It’s boring.” While Sarah is easy to engage, she talks constantly and has difficulty focusing her attention on any one task. She wants to play with all the items on Peggy’s desk, and when Peggy says she can’t play with those things, Sarah stomps her feet and says, “If my daddy were here, he’d let me.” Peggy feels very tired after 30 minutes with Sarah. Peggy invites Don to come in for an interview, but Don states that he has to be out of town for a month and thinks that the problem is simply Regina’s problem with lack of discipline with Sarah. Peggy tells Don that she’ll call him when he returns from his trip. After talking to Sarah’s teacher at school and the school counselor, Peggy is ready to make an initial assessment of Sarah. The teacher told Peggy that Sarah often makes careless mistakes, has difficulty finishing her work, is two grade levels below in math and often gets in trouble for irritating other children. Peggy asks herself the following questions. How would you answer them?
1 How would you describe the presenting problem?
2 What resources might be available to help Sarah and her family?
3 Would you refer Sarah to any other professional while she is being seen by you?
4 What diagnosis would you give Sarah?
5 List the psychosocial and cultural factors as V codes that would follow your diagnosis of Sarah.
Q