Descriptive Information of the case
Jessica is a ten-year-old white female from Philadelphia, PA. She currently resides with her biological mother and step-father. Jessica is an only child and has no contact with her biological father; her mother had his rights terminated for reasons unknown by school personnel. Jessica is a new student this year in the fourth grade at Shawmont Elementary School in Philadelphia, PA. She began receiving services through the special education department this March. Jessica appears to be of average height and weight for her age. She arrives well-dressed and on time to school every day. She looks healthy and there seems to be no evidence of sleeplessness or malnutrition.
Presenting Problem
Jessica was referred by her homeroom teacher to meet with the School Counselor and School Counselor Intern in January. Jessica’s teacher expressed concerns with her ability to get along with her classmates and with her teachers. Jessica presents with poor social skills, difficulty interacting with her peers, and low self-esteem. She struggles with understanding social cues, as well as lacking a filter for what is socially acceptable among her peers. Jessica shows flat affect talking in a monotone voice, and she shows very little, if any, facial expressions. In addition, Jessica presents with poor self-regulation skills, and has difficulty with self-awareness.
Relevant psychosocial information
Jessica is a new student a Shawmont School this year and has had issues adjusting to the new environment. The family moved to the area after the paternal rights were terminated, however it is unknown why they were. Overall her attendance has been good, only missing four days unexcused due to a family trip.
Jessica’s cognitive skills are below grade level expectations, and she is reading at a first-grade level. A formal diagnosis has not been disclosed to the school or is known to the school. Her former school district did not share classroom struggles or behavior incidents when her information was sent over. She has not received any therapy or counseling, until beginning sessions with the school counselor and school counselor intern this March.
Jessica tends to spend most of her time alone and reports her dislike for school. She is always seen by herself at recess not participating in normal age-related activities. She reports having a strong relationship with her mother and step-father, and a good home life. The mother and step-father are largely involved in Jessica’s life and are a source of support for her and the school. Jessica will receive weekly group counseling sessions, as well as individual counseling sessions with periodic check-ins with the school counselor and school counselor intern.
Assessment and differential diagnosis
Since Jessica’s presenting problems began to result in functional limitations in her academic achievement, Jessica was referred to the school psychologist to begin the IEP process in February by the school counselor. Upon assessment in March, Jessica was diagnosed with Autism Spectrum Disorder 299.00 (F84.0). She is not currently on medication, and no other diagnosis is suspected. Jessica has never been to counseling before meeting with the school counselor and school counselor intern this year. An IEP meeting was set for early April to create a plan for Jessica. During this time, a Functional Behavior Assessment was conducted and added into Jessica’s plan. In relation to the IEP, Jessica will be attending weekly counseling sessions with the school counselor and school counselor intern, to address issues surrounding social skills and peer relationships.
Case Dynamics
Individual Counseling Dynamics
Jessica arrives on-time to the counseling office when her sessions are planned. She has difficulty reading other people’s social cues such as facial expressions body language, and tone of voice. Typically, Jessica talks in a monotone. She exhibits very little emotion in her voice. Only one time when she had an altercation with another student was she visibly distraught and sobbing. She has only recently begun to show a change in tone when she mimics other students, or when angry/frustrated. During session she discusses her struggles with her peers but is unable to come up with solutions on her own. Jessica and the school counseling intern have begun to create a good rapport and she appears to be open and honest about her concerns.
Ecological Dynamics
Jessica has a strong relationship with her mother and step-father. They are her primary sources of support and are extremely attentive to her needs. However, this causes her mother to sometimes be a stressor in that she gets into power struggles with Jessica and does not allow Jessica to invite friends over to her house. In addition, her teacher is new, and has never had a student with Autism Spectrum Disorder, therefore is having a difficult time dealing with Jessica. When students pick on Jessica, her teacher will do nothing to correct the situation, and often the teacher will side with the other students. The teacher also will openly show her frustration to the whole class. She will sometimes yell at Jessica in front of the whole class. However, the school counselor/intern has planned to meet with the teacher to assist with interventions and techniques.
Case Conceptualization
Jessica is a ten-year-old female student, who is diagnosed with Autism Spectrum Disorder. Due to her diagnosis, Jessica presents with lack of appropriate social skills. Jessica desperately seeks the approval of her peers and adults. She reports her feelings of low self-esteem. Jessica is unable to read facial expressions, body language, or interpret basic social cue from her peers. Jessica understands the concept of positive friendship behaviors and negative friendship behaviors, yet she cannot make the transition to her everyday interactions with her peers. She cannot make the leap from thoughts to actions. She wants to be a friend and to have friends, yet she sends mixed messages to her peers, and often does not have the social skills to relate to them. She is often bossy on the playground; she will push and hit her peers; then she will give them try and give them a hug moment after. She struggles with wanting the approval of others, and not understanding why she does not receive it. Her irrational belief is that “I must have friends”, yet she is unable to process about how to go about making and keeping friends. This is confusing to the other students and they often ignore her or mistreat her. Her distorted thoughts and actions about these situations often result in her feelings of being overwhelmed and tend to leave her in a state of anger.
In treatment with Jessica, two theoretical approaches will be utilized: Cognitive Behavioral Therapy (CBT), and Rational Emotive Behavior Therapy (REBT). Working with Jessica from a CBT approach will help to address these distorted thought patterns. By focusing on changing the unhealthy thought patterns with positive healthy ones, this will help Jessica to begin to be able to work on reframing her thoughts, and in turn hopefully to take control of her actions and behaviors. In relation to these thought patterns, Jessica has a difficult time controlling herself when she gets angry or upset. She will scream and yell; one time she ran out of the classroom. To address this behavior, help her to gain self-control through offering calm down techniques. Jessica will be given a choice of 3 different methods that will be on a small sheet of paper that she can carry with her for when she is experiencing these periods. From an REBT approach, I would teach Jessica how to recognize her own body cues when she gets anxious, frustrated, or angry. I would ask her to identify how her head feels, how her stomach feels, what she does with her hands during these times of frustration. By knowing what her body is doing, she can recognize these moments and use the calm down technique to address them appropriately.
In addressing Jessica’s social skills and peer relations, I would have her describe her present behaviors, and then help her evaluate what is going on in her life and how she is helping herself to make and keep friends. After we would work on possible alternatives for getting what she wants (friends). I would then have Jessica choose one alternative to do to help her reach her goal of having and maintaining friendships. In order to improve these peer interactions, I would implement role playing into our sessions counseling. Here, I will have Jessica practice asking kids in her class to play during recess. In addition, we will brainstorm several activities she could do that would include playing with others. Role playing during our counseling sessions gave Jessica a safe place to practice social skills that she isn’t comfortable with. By allowing her to practice, and then provide positive feedback, it will give Jessica the confidence to implement such skills at a later time. In addition, Jessica will participate in a social skills group to assist her in implementing these skills with her peers. During the social skills group sessions, corrective feedback and positive reinforcements will be implemented in order to supplement the skills built during individual sessions.
Treatment Plan & Intervention Strategies
Jessica will meet with the School Counselor and School Counselor Intern in an individual and group setting to work on her short-term and long-term goals. Developing Jessica’s social skills and self-control, are among her short-term goals. This can be understood as developing self-awareness and self-regulation and learning how to communicate without giving mixed messages. Through her individually meetings with the school counselor intern, Jessica will be able to work on her social and communication skills. She will be able to appropriately use her calm down techniques more than half of the time and will be able to access “quiet spaces” when needed for her to do so.
Ultimately, Jessica will focus on the long-term goal of developing healthier peer relationships and taking control of her actions and behaviors. In doing so, we will focus on Jessica identifying her present behaviors and how this is helping her progress in creating and maintaining peer relationships. She will be a part of an on-going social skills group, in order to encourage peer relations, and for her to practice her communication skills. The skill she receives from her individual and group sessions are intended to develop these long-term goals. Collaboration between the special education department and the school counseling department will remain on-going to address issues/concerns in relation to the IEP.
Challenges & Accomplishments
The Client
The school counselor/intern has just begun sessions with Jessica, but in a short time the rapport built has been a major accomplishment. Jessica has been able to accurately address where she is feeling her emotions to the school counselor/intern and has successfully used the calm down techniques twice. However, there has been little progress with working towards adapting her social skills. She has been unable to attend group sessions, due to PSSA testing, and has had negative peer relationships in the last few weeks. I can see this being a challenge working with Jessica as our sessions continue.
You and your work
Personally, I see working with Jessica as an amazing opportunity to broaden my skills and knowledge. I have not been able to work with a student with a diagnosis of Autism Spectrum Disorder, and find this to be a challenging, yet rewarding experience. Working with a student outside my professional comfort zone has given me the opportunity to explore new techniques and examine my capabilities as a future counselor. However, I do find this case challenging because of the termination period at my site. I am not able to directly work with Jessica since I will be leaving in a few weeks.
Plans for next steps
In continuation with Jessica’s IEP, the school counselor and school counselor intern will continue to meet with Jessica twice a week for individual and group counseling. The development of her social skills will be assessed by the school counselor and from teacher observations. Communication with the special education department will remain, and progress reports will be shared as well. Moving forward, I will begin to discuss termination at the end of our sessions, in order to prepare her for my departure from the site.
Specific Questions for attendees
1. Would you use any other specific interventions with her diagnose in mind?
2. How would you handle termination with this client?
3. Would you have taken a different approach in developing her goals? If so, what?