About Jenni
This is a case study analysis on Jenni, a 10-year old girl who has had a difficult childhood growing up. Some issues that she has been facing are having an inconsistent familial environment, experiencing trauma from the passing of a primary caregiver, being emotionally bullied in school and has a low self-confidence about her appearance.
Concerns
Well-Being and Mental Health
After reading Jenni’s case, her social, emotional, cognitive and brain development, as well as her physical and mental health stands out and would be of concern. It sounds like Jenni has been having depressive symptoms such as social isolation, lethargy, loss of interest in going to school and not doing her homework. Although according to the American Psychiatric Association (2013), these symptoms are not enough to diagnose her as having depression in the DSM-5, however, these are the onset of the disorder and Jenni would easily escalate to having major depressive disorder (MDD) in the future if no action is taken. Through counselling, the session would also aim to find out if there are other possible mental health issues such as post-traumatic stress disorder (PTSD) as she was said to have been experiencing trauma after the unexpected death of her foster carer who she was close to when she was 7 years old. It is required to find out whether the traumatic event is persistently re-experienced, whether there is an avoidance of trauma-related stimuli, whether there were negative thoughts, feelings or trauma-related arousal that began or worsened after the trauma, and how long she has been experiencing these symptoms for, if any (American Psychiatric Association, 2013).
Currently, it appears that Jenni has been experiencing social, emotional and behavioral issues with herself and mainly in school. She has trouble making friends and has mentioned that she was being emotionally bullied. Her schoolmates often said mean things to her, and her teacher has said that Jenni has been eating lunch by herself in the library. This led her to become withdrawn and reluctant to participate in school, including not completing her homework. In one recent study, elevated depressive symptoms were found to significantly predict an increase in friendship instability by the following month among an early adolescent sample (Poulin & Chan, 2010). This could help explain the withdrawals Jenni was experiencing, and gave the girls in her school further reasons to say mean things to her.
Jenni would most probably have formed a combination of an anxious and avoidant attachment style. Because of the inconsistency in environment while growing up, she has formed an anxious attachment. In this attachment, she feels insecure and unsure about the relationship with her primary caregivers. As she was moved from several foster carers, Jenni might not be willing to fully trust her current parents as she may think that there would be a chance of her changing families again. Another type of attachment style she might have is avoidant attachment. Children with avoidant attachment style are typically brought up by caregivers who were emotionally unavailable. They also mature quickly, refuse to accept help and are self-contained. Jenni could have also formed this type of attachment, as she did not have a permanent caregiver for a period, hence becoming isolated and independent compared to her peers at an early age. The children with these type of attachment style often are literally are “out of touch” with their feelings, and often have no language to describe internal states (van der Kolk, 2017). Having an anxious and avoidant attachment style may also pose problems to Jenni in having quality social circles as she might feel doubtful of her friendships and would be unwilling to engage. Cognitively, It was found that children with secure attachment at 36 months had higher school performance than those with anxious ambivalent and disorganized attachment (Sümer & Harma, 2015).
Risk Factors
Some of the past risk factors Jenni might have would be the biomedical risk factors that are associated with depression. This includes a genetic predisposition to depression. Parental depression or a family history of depression increases the risk that adolescents will also develop depression (Naylor, 2018). There were no mention of Jenni’s biological parents so there is a risk factor one or both parents had depression. Also, having a mother younger than 18 years old at the time of their birth also increases the risk factor of getting depression. Further, the hormonal changes during puberty can bring about a depressive episode, and girls are twice as likely to experience depression as boys (Naylor, 2018).
Other past risk factors for Jenni would include the childhood trauma she has experienced when the primary caregiver that she was closed to unexpectedly passed away. This led to her being under several foster cares in her childhood where she had, to some degree, a lack of nuture and emotional bonding. Children exposed to adverse early family environments are more prone to mental health issues as compared to a child who grew up in a non-adversive environment.
The trauma Jenni has experienced would also be carried forward to her current risk factors. She might feel depressive symptoms and down for a long period of time following the trauma. This would lead her to have low activity levels and avoiding social activities such as socialising and sports. As physical activity helps the brain to release chemicals which elevate mood, having low physical activities might be a risk factor for Jenni developing depressive disorders.
Jenni has also been facing issues that negatively impact self-esteem, like having an early onset of puberty and experiencing emotional bullying. She may look mature or different for her age which could enhance the levels of bullying by her schoolmates. Risk status for externalising problems, internalizing problems, and academic difficulties has been shown to be associated with problematic peer relations in childhood and adolescence (Bukowski, Buhrmester & Underwood, 2011).
The would be risk factors for Jenni to be experiencing poor physical health as children who has experienced trauma tend to suffer from distinct alterations in states of consciousness, including amnesia, hypermnesia, nightmares of specific events, school problems, difficulties in attention regulation, disorientation in time and space, and sensorimotor developmental disorders (van der Kolk, 2017). Cognitive factors also influence adolescent depression. Negative thinking and low self-esteem can contribute to risk in children. Depressed individuals see themselves as worthless, and undesirable. They also tend to view all of their experiences in negative ways (Naylor, 2018).
Possible Impact on Future Development
As mentioned above, Jenni has an anxious and avoidant attachment style, signs of depressive symptoms and PTSD, experienced trauma as a child and also has low self-confidence. These issues, if not addressed, could lead to more problems for her social, emotional, physical health, brain and cognitive development.
Social & Emotional
Although Jenni has a permanent family, there is likelihood that she might not be willing to fully open up to her new parents even after a long time. This could possibly be for fear that she gets situated in a different family again, or thinking there would be a possibility that they might unexpectedly pass away like the foster carer she was close to. This would act as a defense mechanism for her to protect herself from hurt. As children and adolescence lack the capacity to see themselves in the perspective of the larger context, they see themselves as the center of the universe. Everything that happens is related directly to their own sensations (van der Kolk, 2017). Hence Jenni might think that what has happened so far were because of her fault and engage in self-blame.
In childhood, mental health problems consist primarily of internalising (anxiety, depression) and externalising (aggression, oppositional defiance) problems (Bayer, Ukoumunne, Mathers, Wake, Abdi & Hiscock, 2012). It is found that externalising problems were more prevalent in all groups except among bullied girls aged 7–16, where internalising problems were more prevalent (Bjereld, Daneback, Gunnarsdóttir, & Petzold, 2015). This applies to Jenni, who is 10 and has been bullied in school. Different indicators of internalizing behavior have been linked to friendship stability, notably depressive symptoms, shyness, withdrawal and peer victimization (Poulin & Chan, 2010). It was also found that there is a highly significant relationship between adverse childhood experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, cigarette smoking, obesity, physical inactivity, and sexually transmitted diseases (American Academy of Pediatrics, 2012).
As Jenni has expressed on many occasions that she does not want to go to school, it was likely that she views her school as an unsafe and unaccepting place. This could be due to the emotional bullying and girls being mean towards her, as well as her self-consciousness regarding her appearance. If it continues, Jenni might form a greater dislike and fear in attending school and eventually drop out when it gets too much. This would lead to her having less opportunities to socialise and also have her academic studies put to a halt. The American Academy of Pediatrics (2012) has written that socialising would allow adolescence to learn how to share, negotiate and resolve conflicts, and to learn self-advocacy skills. It also helps to build bonds. However, if Jenni loses the chance to socialise in school, it might affect her and create problems when she tries to form friendships and close relationships in the future.
Physical Health
As discussed, if not handled properly, Jenni has could potentially develop major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) in the future. This poses serious health issues as individuals with mental health issues typically have symptoms, tendencies and behaviours which are unhealthy. This could significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day, and insomnia or hypersomnia nearly every day (American Psychiatric Association, 2013). There would also be a possibility of self harm, as well as suicide.
According to D’Andrea, Sharma, Zelechoski, and Spinazaola (2011), risk for disease and health issues also increased linearly with exposure to traumatization. It was also found that there would be an increased in physical health problems in children whose relationship with a primary caregiver is compromised by negativity. In addition, the more adverse childhood experiences reported, the more likely a person was to develop heart disease, cancer, stroke, diabetes, skeletal fractures, and liver disease. (van der Kolk, 2017). This is also supported by D’Andrea, Sharma, Zelechoski, and Spinazaola (2011), who also wrote that PTSD is linked with arthritis, insulin-dependent diabetes, and thyroid disease, up to 30 years after the initial trauma exposure.
Trauma has also been linked with chronic pelvic pain, sexual problems, infertility and miscarriage, preterm delivery, and low birth weight of one’s children (D’Andrea, Sharma, Zelechoski, & Spinazaola, 2011). This might pose a problem to Jenni if she has an intimate relationship in the future. Firstly, sexual issues could affect the relationship between her and her partner, with a possibility that her partner might engage in infidelity. Secondly, fertility could be a problem if Jenni tries to conceive. If she manages to, the likelihood of a miscarriage and preterm delivery is high. Lastly, babies with low birth weight have a higher chance of having health issues compared to babies who were born with a normal birth weight. These issues mentioned might amplify her depressive symptoms and stress if they do occur.
Brain & Cognitive Development
Experiencing depressive symptoms, trauma, and high levels of stress could contribute to an unhealthy brain development. A meta-analysis by Simmons et al. (2017) has provided evidence of significantly larger hippocampal volume in children with PTSD compared to controls, with such enlargement further associated with greater externalizing behaviors. This suggests developmental effects in the influence of trauma on the brain. In addition, nervous system changes stemming from traumatic stress and neglect affect brain development (De Bellis & Zisk, 2014; Nemero, 2016; Teicher & Samson, 2016). Late childhood (8 to 10 years), marks the first stages of significant brain growth, development and reorganization. The brain is highly plastic, and potentially more sensitive to environmental influence in comparison to other periods of life. Thus, the effects of the family environment on the brain during late childhood may have significant implications for later functioning. (Simmons et al., 2017). This is the period that Jenni is currrently in, and if there has a lack of interaction with people and her environment, her brain might be underdeveloped. Further, because she has depressive symptoms, she is at risk of developing MDD and other problems as they often comorbid with each other.
With Jenni being withdrawal and having a lack of social skills, her cognitive and brain development would not be as significant compared to children her age. It is found that the most important information for successful development is conveyed by the social rather than the physical environment (van der Kolk, 2017), hence not only does socialising help to create friendships, it also help to expand a child’s creativity and imagination, which aids in developing cognitive functions. Bukowski, Buhrmester & Underwood (2011) show that peer relations are essential to development, as they provide the context for the acquisition of critical skills needed for adequate functioning during adulthood. In addition, play and recess may increase children’s capacity to store new information, as their cognitive capacity is enhanced when they are offered a drastic change in activity (American Academy of Pediatrics, 2012). Hence it is important for Jenni to improve on her self-confidence, be less self-conscious and exercise more social skills so that there would be a decreased risk of having any developmental impacts in the future.
Counselling Approaches & Critical Discussion
Creative Therapy
Based on Jenni’s situation, art therapy is chosen as the type of creative therapy for her sessions, more specifically clay art therapy (CAT). Drama therapy was also considered for its expressive nature, however, it was decided that CAT would be more suitable as it is more versatile and she might feel less comfortable acting out traumatic events in drama therapy.
The primary goal of the session is to allow Jenni to tell her story in a safe environment with the aid of art therapy. It is to help her feel comfortable and relaxed in a social setting, especially when it is difficult to open up to a complete stranger about her deepest and darkest emotions. This is diffciult even for adults, not to mention Jenni, who is only 10 and struggling with self-consciousness. The secondary goals would include improving her social skills and ability to articulate her thoughts and feelings better outside of the counselling sessions. It is also to help her with understanding and learning the body’s survival responses during and after the trauma (Richardson, 2015). The basic idea was to allow Jenni to have a platform for the discharge of pent-up feelings. Creative therapy is also a good form therapy for children as they don’t need much direction or an extensive warm-up in order to play and allow images to emerge. This kind of play activity is much more indigenous to the experience of children (Levine, 2015).
CAT was chosen because firstly, it is a very versaltile medium. There could be a use of either clay or plasticine, for a range of colors as visual stimulation. It could also be used to express difficult emotions such as sadness and anger by contorting the shape of the clay. The child could smoothen, punch, throw, stretch, rip and mould sculptures from it. Secondly, from the sculptures, the counsellor could ask the child to conduct a role play using them by visualising using the figures to act out situations. This helps both the counsellor and the Jenni to pinpoint aspects of her life that she wants to change or was troubling her. Thirdly, clay is also less threatening and it could act as a form of a conversation starter and aid Jenni in communicating better. This is especially so when she has gone through trauma and grief at a young age, and would definitely be difficult for her to deal with when asked about it directly.
According to Elbrecht (2012; 2015), there are a variety of somatosensory qualities of clay, including the prominent experiences of touch and physicality. Because clay is a three-dimensional material, there are also unique perceptual and decision-making responses that involve the self-soothing characteristics of clay may enhance self-regulation through interaction with the medium. This is limited in 2D platforms such as drawing and painting. Malchiodi (2017) has also conducted a study regarding the effectivenes of CAT compared to nondirective visual art (VA) therapy sessions, and In brief, results of this study suggest that CAT sessions were more effective than the nondirective VA sessions in reduction of depression and improvement of daily functioning, general mental health and a sense of well-being. CAT also brought positive outcomes in the treatment of depression, particularly in the area of cognitive functioning and symptom reduction (Malchiodi, 2017)
The room of that the therapy taking place would be slightly different from a typical counselling room. The room would be slightly more spacious with furniture that are easily movable. This is to allow space for Jenni to walk around, feel comfortable in the setting and also create an area covered with plastic sheets to allow her to throw the clay if she wanted to. The room should also be brightly lit and have some amount of sunlight as sunlight has been reported as having positive effects on stress and feelings of anxiety (Dijkstra, Pieterse, & Pruyn, 2008).
While CAT is not a definite cure for depression and trauma it definitely is a technique to help understand Jenni and also a method to improve her emotional and social health through the help of a medium. Among all age groups and “professions”, children would also most probably have the least restrictions for creative therapy since playing is their form of communication (Levine, 2015), hence it is a great therapy for Jenni. Expressing her thoughts and emotions in art therapy also helps her understand her feelings while also learning how to address and resolve her problems on her own which helps improve her self- esteem (Ray & Bratton, 2010)
Other Strategies
I would suggest Jenni’s current family to pay attention to her behaviors and communication at home. I would tell them that it is important to listen carefuly and try not to dismiss her feelings when she opens up. Also, I would remind them to stay calm and try not to let her see that they are worried about her. Instead, use praise and positive feedback to help her with her confidence. However, they should avoid over praising for every single thing that Jenni does as she might end up feeling that they are ingenuine. An important thing to note is also reminding them that they should not do everything for her. Though they could help her out with some things, they should also encourage her how to cope by herself. Another strategy is to tell her parents that they could try requesting to sit in on one of Jenni’s class to observe what the problem is, although this suggestion should only be used with caution as there is a possiblity that Jenni might get teased further because her parent sat in on her class.
In her school setting, I would suggest Jenni to join social activites such as clubs to increase social interaction. By joining a club, she can explore her interests, have a sense of belonging and it is also an opportunity for her to make new friends. I would talk to Jenni’s teacher to know how much they understand about her situation. Hopefully the teacher would be willing to discuss and together we can come up with a action plan to help Jenni with her low self-consciousness and confidence. However, if it seems like the degree of the bullying is extreme, her teacher is unwilling to help and there seem to be no signs of it improving, I would suggest to Jenni’s parents regarding the option of transferring schools.
Further, I would teach Jenni some relaxing and coping techniques during the session, so that when she feels anxious or depressed outside of therapy, she can use these techniques to manage her feelings. I would also ask Jenni if she was open to a group therapy session with other children who have similar problems. By initiating a group therapy, we could attempt to achieve several things. Firstly, in the group, Jenni could make new friends which would help her in her social skills. Secondly, as the children in this group would also have some form of personal difficulty the session would target increasing their confidence. She will learn that there children with similar issues and feel less alone and instead feel motivated to learn and improve. Lastly, this group would hopefully become a safe circle of friends that Jenni feels comfortable enough to express her feelings, and to experiment socialising on, so that she would be self conscious when mixing with her classmates in school. The challenge is to make each child feel competent in a school setting, because the experience of success forms positive associations with school attendance (American Academy of Pediatrics, 2012).
Conclusion
With Jenni having experienced trauma, stress and depressive symptoms at such a young age, as a counsellor I should take extra precautions when handling her case. If her case was not brought to a professional’s attention, Jenni could possibly develop MDD, PTSD and other mental health issues in the future. She would also be at risk of developing social and emotional, physical health, and brain and cognitive problems. With the help of art therapy, namely clay art therapy, hopefully Jenni would be able to express herself better and understand that she does not have to keep all her feelings to herself. However, though art therapy would help, it is not enough. To ensure that Jenni makes good progress in counselling, there should be a mix of other therapies to tackle her problems as well.