Case Study #1

Post-natal psychological adjustment

Amy Mullens, University of Southern Queensland

This case study explores a range of bio-psycho-social factors contributing to distress and related functional impacts experienced post-childbirth.

‘Debbie’ is a 35-year-old female, who is currently on 12 months maternity leave from senior role at a law firm. She recently had a baby girl who is now 8 weeks old and Debbie is continuing to recover from birth complications resulting in significant recovery (3rd degree tears). Debbie’s parents live across the country, and both sets of in-laws are alternating staying with them to provide support. There is conflict with the parents because both sets of grandparents have varied views of parenting and raising babies and both are vocal in their views; Debbie’s mother also desires to be ‘highly involved’. Debbie has no siblings. Debbie lives with her husband in a small two-bedroom apartment in inner-city Brisbane.

Debbie reports limited social and practical support, as she feels she does not ‘fit in’ with the mother’s groups she has attended. She has a strong desire to return to running, but has difficulty doing this due to physical symptoms (e.g., lethargy, difficulty concentrating) and poor sleep. Debbie’s baby has difficulties with colic, which has further impacts on her sleep and daily functioning. She is breastfeeding the baby.

Debbie’s husband is working long hours with some interstate travel, in a stressful job. There is increased conflict with her partner due to the long hours he is working and feeling that he does not understand, ‘how much I’ve given up’. There has also been no sexual contact with her husband since the baby was born which is creating marital tension, as well as financial adjustments due to Debbie’s time off from paid work.

Although Debbie is enjoying her time away from work, she continues to ‘feel involved’ in her professional role because business partners meet her for coffees and seek her opinion regarding work politics-which she also finds stressful. Debbie is feeling increasingly ‘worn down’ and feels she is a ‘bad mother’ and ‘can’t cope’ reportedly due to the baby’s continued colic and she reports she is feeling ‘overwhelmed’ due to the significant changes in her roles.

Discussion questions

• How would you start to build rapport with Debbie?
• How would you work with Debbie to identify strengths and increase protective factors?
• How could you conceptualise her current challenges from a bio-psycho-social model?
• What are some ways you would work to prioritise possible targets for intervention (therapy, counselling) in collaboration with Debbie?

 

Case Study #9

Autism spectrum disorder with dual diagnosis

Dianne Perrett-Abrahams, Forensic & Health Psychologist, Victorian Occupational Support Service

Autism and Down syndrome are life-long conditions and health practitioners involved in such care are increasingly of the view that effective intervention and therapies are the most vital factors to improve the life quality of these individuals and their families. This case study explores the associated health conditions and social challenges of a man with dual diagnosis of Autism spectrum disorder (ASD) and Down syndrome.

Mr H is one of four adopted children and is now 32 years and adopted at four months of age in Victoria, Australia, as a special needs adoption, having been diagnosed at birth with Down syndrome and later diagnosed with ASD by a health psychologist who has treated him for 20 years.

It was evident to his psychologist, when he was approximately 10 years of age, that Mr H sustained more than the stated Down syndrome and a diagnosis of ASD was indicated. A moderate/severe autism (score 43) was established. He has been later diagnosed with ADHD and dyspraxia and prescribed stimulant medication to assist with self- regulation.

The patient’s Down syndrome has caused a range of associated health conditions, which have affected his heart, resulting in surgery and bowel dysfunction, including chronic constipation and bowel leakage. He suffers with associated muscle weakness which has affected his hands in particular, preventing or making it difficult to perform tasks, i.e., writing, typing, drawing, dressing himself. His ASD has resulted in mutism. He suffers with severe dyspraxia which impacts upon his fine and gross motor skills disrupting his ability to communicate using a Fusion machine with an automated voice; his preferred method of communication. He is facilitated by an Aide who supports his wrist to maintain stability to use the keyboard. Dyspraxia causes distress by his unintended banging on walls, furniture and sometimes people near him, particularly when he is anxious. His ADHD causes agitation and wakefulness. He requires trained carer/aids 12 hours a day, who are trained in facilitated speech and Applied Behavioural Analysis (ABA) to manage his behaviour and assist him in with independent living skills acquisition. Mr H, with such support, cooks, manages his own washing, dresses and showers himself. He now shares a flat with his brother.

Initially Mr H spent his school life with Intellectual Disability Services after being assessed with psychometric tests reliant on speech and fine motor skills, i.e., drawing. With both functions unable to be met by the patient, a diagnosis of severe intellectually disability was made, in two separate diagnostic assessments. Due to interventions implemented by his health psychologist, who instigated IQ psychometric tests in the form of the Slosson Intelligence Test, 1985 edition, on 27 May 1997, test results indicated an above-average IQ. Accordingly, he was integrated into a public primary school with his brother. He loved this school and learning. He became interested in other children.

Behaviourally, Mr H was a passive child. He spent hours looking at books when he was smaller. He then became passionate about watching videos and would watch and listen to these repeatedly. Mr H related well to his carers, his siblings and he was well bonded with his mother.

He relocated to another local primary school when the family moved house. In this school, Mr H was noted to be behaviourally difficult and highly sexualised behaviour was observed. With his health psychologist’s assistance, he disclosed extensive details of alleged sexual abuse to him by his male school aide. This matter was reported to police and investigated.

Mr H was never settled appropriately in school thereafter, though, several were trialled. In all he attended 8 schools, including secondary school education. He attended a Technical and Further Education College for his Victorian Certificate of Education, required to commence tertiary education; he has completed a Diploma in Community Development and he is now studying a degree in management and entrepreneurship at university; he has excelled in his studies.

Psychological treatment includes a Person-Centred Planning formulation, which places the patient at the centre of the therapy process, to achieve his personal goals in life. With this treatment modality, ABA is utilised to facilitate self-regulation of behaviour. Additionally, a modified form of CBT is utilised to facilitate social acceptance, to build self-esteem and to reduce anxiety and enhance mood self-regulation. He is co-treated with methylphenidate to reduce ADHD and dyspraxia symptoms.

Discussion questions

• Autism is a spectrum disorder: it may be mild or severe. How do we define a spectrum disorder?
• Autism a life-long condition, as is Down syndrome, how important is appropriate diagnosis and ongoing psychological intervention in improving the lives of those with these conditions?
• How is ASD different from Down syndrome?
• Is it important for professionals to consider the possibility of a dual-diagnosis (e.g., Down syndrome with a psychiatric condition such as ASD)?