case study of children's behavior

Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

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Developmentally Appropriate Behavior: A Case Study

• Children's mental health case studies
• Parenting and caregiving
• Mental health

Explore the experiences of children and families with these interdisciplinary case studies. Designed to help professionals and students explore the strengths and needs of children and their families, each case presents a detailed situation, related research, problem-solving questions and feedback for the user. Use these cases on your own or in classes and training events

Each case study:

• Explores the experiences of a child and family over time.
• Introduces theories, research and practice ideas about children's mental health.
• Shows the needs of a child at specific stages of development.
• Invites users to “try on the hat” of different specific professionals.

By completing a case study participants will:

• Examine the needs of children from an interdisciplinary perspective.
• Recognize the importance of prevention/early intervention in children’s mental health.
• Apply ecological and developmental perspectives to children’s mental health.
• Predict probable outcomes for children based on services they receive.

Case studies prompt users to practice making decisions that are:

• Research-based.
• Practice-based.
• Best to meet a child and family's needs in that moment.

Children’s mental health service delivery systems often face significant challenges.

• Services can be disconnected and hard to access.
• Stigma can prevent people from seeking help.
• Parents, teachers and other direct providers can become overwhelmed with piecing together a system of care that meets the needs of an individual child.
• Professionals can be unaware of the theories and perspectives under which others serving the same family work
• Professionals may face challenges doing interdisciplinary work.
• Limited funding promotes competition between organizations trying to serve families.

These case studies help explore life-like mental health situations and decision-making. Case studies introduce characters with history, relationships and real-life problems. They offer users the opportunity to:

• Examine all these details, as well as pertinent research.
• Make informed decisions about intervention based on the available information.

The case study also allows users to see how preventive decisions can change outcomes later on. At every step, the case content and learning format encourages users to review the research to inform their decisions.

Each case study emphasizes the need to consider a growing child within ecological, developmental, and interdisciplinary frameworks.

• Ecological approaches consider all the levels of influence on a child.
• Developmental approaches recognize that children are constantly growing and developing. They may learn some things before other things.
• Interdisciplinary perspectives recognize that the needs of children will not be met within the perspectives and theories of a single discipline.

There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

• Adolescent depression.
• School mental health.
• Rural mental health services.
• Social/emotional development.

The Brianna and Tanya case study reflects themes of:

• Infant and early childhood mental health.
• Educational disparities.
• Trauma and toxic stress.
• Financial insecurity.
• Intergenerational issues.

The case studies are designed with many audiences in mind:

Practitioners from a variety of fields. This includes social work, education, nursing, public health, mental health, and others.

Professionals in training, including those attending graduate or undergraduate classes.

The broader community.

Each case is based on the research, theories, practices and perspectives of people in all these areas. The case studies emphasize the importance of considering an interdisciplinary framework. Children’s needs cannot be met within the perspective of a single discipline.

The complex problems children face need solutions that integrate many and diverse ways of knowing. The case studies also help everyone better understand the mental health needs of children. We all have a role to play.

These case has been piloted within:

Graduate and undergraduate courses.

Discipline-specific and interdisciplinary settings.

Professional organizations.

Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

Instructors have used the case study effectively by:

• Assigning the entire case at one time as homework. This is followed by in-class discussion or a reflective writing assignment relevant to a course.
• Assigning sections of the case throughout the course. Instructors then require students to prepare for in-class discussion pertinent to that section.
• Creating writing, research or presentation assignments based on specific sections of course content.
• Focusing on a specific theme present in the case that is pertinent to the course. Instructors use this as a launching point for deeper study.
• Constructing other in-class creative experiences with the case.
• Collaborating with other instructors to hold interdisciplinary discussions about the case.

To get started with a particular case, visit the related web page and follow the instructions to register. Once you register as an instructor, you will receive information for your co-instructors, teaching assistants and students. Get more information on the following web pages.

• Brianna and Tanya: A case study about infant and early childhood mental health
• About Steven: A children’s mental health case study about depression

Cari Michaels, Extension educator

Reviewed in 2023

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Assessment Case Studies for Preschool to School-Age Children

• First Online: 31 December 2016

Cite this chapter

• Kimberly Maich 4 ,
• Darren Levine 5 &
• Carmen Hall 6  

178k Accesses

Behavior assessment is the first step in developing behavior support programs. Before attempts at changing behaviors can be made, information about target behaviors must be gathered, analyzed, synthesized, and translated into individualized support programs. This involves gathering information about the behaviors in question, the individuals, the specific environments, and individual histories of reinforcement and punishment in those contexts. More specifically, it is important to begin to gain insight into what the behavior in question looks like and what function it serves for the individual; when and where behaviors occur; why behaviors occur in some contexts, at certain times, and not in other contexts, at other times; and how the individuals and their skills, abilities, strengths, and limitations interact with the environment and his or her history of reinforcement and punishment to produce the observed behavior. The goal of behavior assessment is to develop a hypothesis as to why particular behaviors are occurring—their functions—and determine how the individuals might best be supported to be successful in the environments in which they are currently experiencing difficulties. The desired outcome is not only cessation of target problem behaviors, but also the learning of new skills that will provide access to reinforcement, make the problem behavior unnecessary, and contribute to improved quality of life for the individual involved. In this chapter, entitled “Assessment Case Studies for Preschool to School-age Children,” behavior assessment principles, processes, and practices are explored through five case scenarios involving preschool and school-age children in home, school, clinical, and community settings.

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Maich, K., Levine, D., Hall, C. (2016). Assessment Case Studies for Preschool to School-Age Children. In: Applied Behavior Analysis. Springer, Cham. https://doi.org/10.1007/978-3-319-44794-0_1

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Introduction.

Following are case studies of children with typical developmental behavioral issues that may require a host of referrals and recommendations.

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A descriptive study of behavioral problems in schoolgoing children

Anindya kumar gupta.

Department of Psychiatry, Command Hospital (Air Force), Bengaluru, Karnataka, India

Monica Mongia

1 National Drug Dependence Treatment Centre, AIIMS, Ghaziabad, Uttar Pradesh, India

Ajoy Kumar Garg

2 Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India

Background:

Behavioral problems among schoolgoing children are of significant concern to teachers and parents. These are known to have both immediate and long-term unfavorable consequences. Despite the high prevalence, studies on psychiatric morbidity among school children are lacking in our country.

Materials and Methods:

Five hundred children aged 6–18 years were randomly selected from a government school in Kanpur, Uttar Pradesh, and assessed for cognitive, emotional, or behavioral problems using standardized tools.

About 22.7% of children showed behavioral, cognitive, or emotional problems. Additional screening and evaluation tools pointed toward a higher prevalence of externalizing symptoms among boys than girls.

Conclusion:

The study highlights the importance of regular screening of school children for preventive as well as timely remedial measures.

About 20% of children and adolescents, globally, suffer from impairments due to various mental disorders. Suicide is reportedly the third major reason for death among adolescent population.[ 1 , 2 ] The alarming rise in the number of children and adolescents in low- and middle-income countries leaves this population with inadequate attention from mental health professionals, minimal infrastructure, and limited resources for managing their mental health problems.[ 3 ]

The prevalence rates of behavioral problems across various studies conducted in different states in India vary, thus making it difficult to get a collective understanding of the extent of the problem. A study by Srinath et al ., in 2005, conducted on a community-based sample in Bengaluru, revealed the prevalence rates of behavioral problems to be around 12.5% in children up to 16 years of age.[ 4 ] Another study done on school children in Chandigarh found the rate of behavioral problems among 4–11 years’ old to be 6.3%.[ 5 ] As evident from the available literature, the overall rates of psychiatric illnesses among children and adolescent population across the various states in India and other middle- and low-income countries vary between 5% and 6%. A cursory look at the Western data on the subject indicates that these figures are still on the lower side as prevalence rates of behavioral problems among children and adolescents in Canada, Germany, and the USA have been reported to be 18.1%, 20.7%, and 21%, respectively.[ 6 ]

Further, many problems among this population do not meet the diagnostic criteria and are thus considered “subthreshold.” Nonetheless, the significant distress that children/adolescents and their families go through because of these mental health issues cannot be undermined.[ 7 ] Since research studies on psychiatric problems among children and adolescents in India are relatively few and variable in methodology, the present study was conducted with more robust screening and assessment measures to generate relevant data. This study thus improves our current understanding of the extent and type of behavioral problems among children and adolescents, in our cultural context.

MATERIALS AND METHODS

Ethical approval for the current study was obtained from the hospital ethics committee of the first author. In this descriptive study, 500 boys and girls from a government school in Kanpur in the age group of 6–18 years, without any diagnosed medical/surgical/psychiatric/other illnesses, were included after appropriate randomization. All parents/caregivers provided informed consent for participation in the current study. Brief screening was done using the parent-completed version (pediatric symptom checklist [PSC]; 4–10 years) and the youth self-report (Y-PSC; 11+ years) to assess cognitive, emotional, and behavioral problems.[ 8 ] After initial screening, wherever the score was found to be significant, children were selected for detailed evaluation. Further assessment was carried out using the following:

• Child Behavior Checklist (CBCL): The CBCL developed by Achenbach is a family of self-rated instruments that surveys a broad range of difficulties encountered in children from preschool age through adolescence. It is a multiaxial scale normed by age and gender[ 9 ]
• Wechsler Intelligence Scale for Children (WISC): The WISC is an individually administered intelligence test for children between the ages of 6 and 16 years[ 10 ]
• Childhood Autism Rating Scale (CARS): CARS is a behavior rating scale intended to help diagnose autism[ 11 ]
• Conner's Rating Scale (CRS)-Revised: CRS-revised is an instrument that uses observer ratings and self-report ratings to help assess attention-deficit/hyperactivity disorder (ADHD) and evaluate problem behaviors in children and adolescents from the age of 3 years through 18 years.[ 12 ]

Of 500 children selected, 480 children underwent detailed assessments. Two-hundred and forty children in each age group, i.e., 6–10 years and 11–18 years, were administered PSC/Y-PSC, as applicable. Mean ages of boys, girls, and their scoring pattern in PSC are shown in Table 1 .

Distribution of mean age of children and comparison of scores

About 41 (17.08%) children demonstrated positive scores in PSC and 68 (28. 33%) for Y-PSC. The CBCL was then administered to evaluate behavioral problems. Table 1 shows the distribution of mean age of children along with their mean PSC/Y-PSC scores above cutoff. The difference was not found to be statistically significant across the groups and gender.

Table 2 shows the distribution of mean CBCL scores by gender and age groups where boys had significantly higher scores than girls. However, the relation of CBCL scores (above cutoff) to gender and different age groups was not found to be significant.

Distribution of mean child behavior checklist scores by gender and age groups

The common behavioral problems in school children who scored above cutoff ( n = 52) in CBCL were found to be argumentativeness (55%), followed by lack of concentration, restless, and hyperactive behavior. Gender-wise distribution of common behavioral problems noted lack of remorse, argumentativeness, and restlessness more in boys, compared to preoccupation with cleanliness and neatness, perfectionistic ideas, and argumentativeness among girls, though the difference was not statistically significant either.

All 52 children were administered CARS and none were found to have significant scores above cutoff. An assessment of intelligence noted 7 children of 52 to be below average in intelligence, though none had intellectual disability.

On administering CRS for ADHD on 27 children in the age group of 6–10 years, 14 were found to be above cutoff, and 15 children were above cutoff scores in children in the age group of 11 years and above ( n = 25). There were no statistically significant differences between boys and girls in CRS scores. Overall, the results showed that a brief screening instrument can be useful for using in schools to obtain a cross-sectional view of common behavioral problems in children, which can then be further assessed and intervention can be provided.

A total of 109 children (22.7%) were found to have behavioral problems with initial screening by PSC/Y-PSC. This is slightly higher than another Indian study,[ 4 ] but similar to study by Muzammil et al .[ 13 ] and Malhotra andPatra.[ 14 ] Few western studies have shown higher prevalence rates.[ 15 , 16 , 17 ] The disparate estimate of prevalence and need for national data on epidemiology has been highlighted by Sharan and Sagar.[ 18 ] It emphasizes that although available Indian studies have started to address the unmet need for systematic information tracking of the prevalence and distribution of mental disorders, national data are still not available. The absence of empirical data on the magnitude, course, and treatment patterns of various mental disorders in a nationally representative sample of children and adolescents has largely restricted the efforts essential for establishing mental health policy for this population.

The mean CBCL scores of this study population were higher than most similar studies in India.[ 5 , 19 ] This can be attributed to the type of study population (school based vs. community based) and informant chosen (teachers/parents) among other factors. CBCL was being used in the present study in a population which was already screened for behavioral problems by PSC/Y-PSC, this put together with greater sensitivity of CBCL, growing concern among teachers and parents of behavioral problems or even growing magnitude of behavioral disturbances may have contributed to a higher mean score. The epidemiological issues of different vantage points have been discussed by Wolpert.[ 20 ]

The analysis of CBCL scores showed significant differences between the mean scores of boys and girls who scored above cutoff, as per age groups. This was similar to the findings by Malhotra et al .,[ 21 ] which is a clinic-based study with advantage of long-term data. The age-wise distribution of positive CBCL scores did not show any significant difference between the two groups.

The analysis for a pattern of distribution of behavioral problems in children revealed them to be more of externalizing ones. This goes along with the findings by Chaudhury et al .,[ 22 ] Shetty and Shihabuddeen,[ 23 ] and Shastri et al .[ 24 ] Girls had more internalizing behavioral problems whereas boys had more externalizing problems.

Overall difference was not significant which could be due to the small size of CBCL screened sample ( n = 52) only analyzed for these dimensions. This is similar to the findings by Deb et al .[ 25 ] No cases of autism spectrum disorder were found in this study when CARS was applied to this group of children. This is possibly due to the fact that the average age for diagnosis of children with the above disabilities is 3–4 years and these are not common in general population. This finding is similar to the study by Malhi and Singhi[ 26 ] and Vijay Sagar.[ 27 ]

Majority of children among the screened study population showed intelligence level in average range, and no cases of intellectual disability were noted though few ( n = 7) children were noted to have below average intelligence. This is similar to other school-based studies in India by Eshwar et al .[ 28 ] and Basu.[ 29 ]

Analysis of CRS when applied to these children for ADHD and related disturbances did not show a significant difference between the groups. This is similar to the study by Meyer et al .[ 30 ]

Relation of CRS scores in both genders was analyzed in respect of total number of children who scored positive in CBCL. The difference in boys and girls were not found to be significant. This is similar to the findings by Efron et al .[ 31 ] and Malhotra and Patra.[ 14 ]

All the children who showed positive scores in tests were taken up for remedial treatment or referred for further follow-up as per target symptoms.

About 22.7% of children among the total study population were found to have behavioral problems such as anxiety, hyperactivity, argumentativeness, and perfectionist ideas during initial screening which needed attention. Boys showed more externalizing behavioral problems and girls more internalizing ones. There were no children with intellectual disability or pervasive developmental disorders although ADHD was noted and addressed. This finding is close to the findings of various western studies where up to a quarter of children have various mental health issues, but higher than the available Indian studies quoted – where a different vantage point and methodology may have been responsible.

This study emphasizes the need for periodic screening of children among schools for behavioral problems which may serve as early indicators of future psychopathology. Once a detailed assessment of behavioral problems is over, life skills training modules developed by the World Health Organization for schools may help schools in reducing the number of behavioral problems and development of psychopathology among children.

This study, however, has the following limitations:

• The study is a descriptive study, trying to find out the extent of various behavioral problems in schoolgoing children. Participants may not be truthful or may not behave naturally when they know they are being observed
• Descriptive studies cannot be used to correlate variables or determine cause and effect
• Researcher bias may play a role in selection of the questionnaire and interpretation
• Findings may not be replicable in a different population
• Findings may be open to interpretation.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

National Center for Pyramid Model Innovations

• PBS Process
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Meet Brendan!

Brendan is a very happy, energetic, young boy. Prior to implementing Positive Behavior Support (PBS), Brendan had severe challenging behavior. Brendan and his family were physically, mentally, and emotionally exhausted and in desperate need of help. Brendan’s parents had tried absolutely everything in their “bag of tricks” but nothing seemed to work with their youngest son. They felt like they were failing!

PBS provided Brendan’s family with new hope. PBS was a match with their family routines and values and allowed Brendan’s parents to view their dreams and visions for their son as achievable.

Brendan is an example of a young boy who benefited from the process of Positive Behavior Support. This case study provides specific details of the success that Brendan and his family experienced with PBS. Below you will find products, videos, and materials produced and utilized that illustrate the steps the support team went through to determine the purpose of Brendan’s behavior and how they moved from conducting a Functional Assessment through the steps of the process to finally developing and implementing Brendan’s Behavior Support Plan.

“Positive Behavior Support is a set of tools that has allowed our children to more fully participate and succeed in everyday life .” -John Hornbeck, Brendan’s father

Components of Brendan’s Case Study

Brendan before pbs.

Brendan After PBS

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General resources.

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Sample behavior support plan

Case study child and family description

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Hypotheses for Brendan’s case study

Observation data used in Brendan’s functional assessment

This booklet provides a report on the program-wide implementation of the “Teaching Pyramid” within a Head Start Program. The Southeast Kansas Community Action Program (SEK-CAP) provides information on the implementation of the model and the outcomes for the children, families, teachers, and program.

This website was made possible by Cooperative Agreement #H326B220002 which is funded by the U.S. Department of Education, Office of Special Education Programs. However, those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government. This website is maintained by the  University of South Florida . Contact  webmaster . © University of South Florida

Perspectives

A Case Study of the Early Childhood Mental Health Therapeutic Consultation Protocol within a Specialty Multidisciplinary Pediatric Clinic for Adopted and Foster Care Children

Experiences of maltreatment, caregiver transitions, and other forms of chronic stress in early childhood have been related to an increased likelihood of health and mental health disorders. Despite having a number of well-developed and validated therapeutic options for fostered and adopted children, families are often overwhelmed by their child’s multiple health needs and have a difficult time accessing care. This case report describes a 2-year old female child in foster care who took part in a multidisciplinary program for fostered and adopted children ages 0 to 5 years old. This family’s experience highlights that patients can receive streamlined evaluations, short-term therapeutic interventions, and long-term service recommendations by providing families with a single point of contact in an integrated care setting. This approach decreases the time burden placed on parents, increases the effectiveness in understanding and addressing a child’s needs, and improves family and provider collaboration. Further, models of integrated care reduce the likelihood of misdiagnosis. Many symptoms of early childhood adversity and attachment disorders can present like other common mental (i.e., Autism Spectrum Disorder) and physical disorders (i.e., motor delays). Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. Given the range of general and mental health effects of multiple housing transitions, maltreatment, and/or neglect, this case underscores how a team approach is invaluable for promoting at-risk young children’s wellbeing and development.

Keywords: Foster Care; Adoption; Mental Health; Early Childhood; Integrated Care

Introduction

Over 443,000 children were involved in the foster care system in the United States during 2017 (Child Trends Databank, 2019). Children under the age of five are the largest group within foster care (~41%, N = 183,959; Child Trends Databank, 2019). Almost all children involved in these systems have experienced multiple transitions, maltreatment, and/or neglect. Many have also experienced malnourishment, pre-and post-natal substance exposure, premature birth, and exposure to infectious diseases. Environmental stress, bodily harm, and illness in early childhood can carry consequences for physical and mental health functioning across the lifespan (Cicchetti & Handley, 2019; Malionsky-Rummel & Hansen, 1993; Smith & Thornberry, 1995; Vachon, Krueger, Rogosch, & Cicchetti, 2015; Anda et al., 2006). Given the medical complexity of foster children, multi-disciplinary care models, including medical providers, mental health specialists, public health nurses, social workers, and occupational therapists (OT), are essential.

The purpose of this paper is to highlight the experience of a 2-year old female in foster care with a program that integrates early childhood mental health therapeutic consultation with a unique multidisciplinary medicine program for fostered and adopted children. We will, 1) illuminate the need for new ways for fostered and adoptive children under five to engage with health, mental health and other services, and 2) highlight an early mental health therapeutic consultation protocol within a pediatric setting. Ultimately we aim to motivate the development of this and similar programs across the United States to better serve young children facing threats to their life long trajectories of mental and physical illness due to early experiences of adversity.

Early Childhood Mental Health Evaluation in an Interdisciplinary Pediatric Team

Multiple housing transitions, maltreatment and/or neglect can be related to a range of medical, developmental, and emotional symptoms, with treatments located outside of the sphere of early childhood psychological intervention. Early childhood experiences of abuse and neglect have been linked to cardiovascular concerns, sensory processing disorders, failure to thrive, and chronic infections associate with immune system dysfunction (Anda et al., 2006; Felitti et al., 1998). Malnutrition, often associated with experiences of neglect, can have a detrimental impact on a child’s development trajectory if left unaddressed – including an increased risk for cardiovascular and metabolic disease in adulthood (Campbell et al., 2014), lower IQ scores in early adolescents (Liu et al., 2003), and micronutrient deficiencies that cause irreversible alterations to brain development (Monk et al., 2013).

While physicians in the United States are typically underprepared to address mental health ramifications of early childhood trauma, mental health providers similarly lack the training to fully conceptualize a child’s necessary medical interventions for their physical health needs. Due to this increased medical complexity for children who have faced early adverse experiences, it is invaluable to have a team approach that addresses concerns and efficiently rules out multiple etiologies for symptoms.

Further, many mental health symptoms related to trauma or attachment disorders can present like other common early childhood disorders. This may be difficult for providers without specialized training in early childhood trauma and attachment disorders to accurately determine the appropriate diagnosis. Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. For example, Autism Spectrum Disorder (ASD), trauma-related disorders, and attachment disorders have a similar profile of symptoms in early childhood. This includes delayed speech, delayed social cueing, difficulties with attention, and self-harm behaviors. However, for children with experiences of neglect, clinicians would recommend trauma-informed treatments focused on building attachment relationships and stability. For children with ASD, more behavioral oriented approaches would be recommended to target the growth of specific social skills. An ASD diagnosis for children with a trauma-related or attachment disorder could further disturb the child’s developmental trajectory by delaying appropriate services that focus on bolstering the child’s relational needs.

Access to Care and Therapeutic Consultation

Early childhood interventions that address parent-child attachment for children who have experienced early trauma have shown efficacy in reducing children’s negative behavioral and emotional outcomes (Reyes et al., 2017; Dozier et al., 2017; Cohen et al., 2000). However, a large number of children facing adversity do not ever receive the benefits of early interventions (Hartinger-Saunders et al., 2019). Specialty pediatric care settings that work with early mental health providers and their state’s department of human services have the unique opportunity to dramatically increase the likelihood that children who are at risk are identified and receive evidence-based interventions. However, to our knowledge, there are no standardized protocols, on how to incorporate early mental health and relationship-based evaluations into pediatric specialty care. This paper aims to highlight the benefits of a cross-systems integrated care model for addressing mental health concerns among young children in foster and adoptive care.

In the United States, foster care and adoption legislation is determined by the State. In Minnesota, children in foster care have a case review hearing 90 days after a child’s removal from parental care. After the court reviews the parent’s progress on their case plan, there may be a 6-month extension on the child’s foster care placement. Once a child has been in foster care for 12 months, the court will file a petition to decide on a permanency plan. Children in foster care can be adopted when their birth parents sign a voluntary consent, after which they have a ten-day period to change their mind. Children may also be made available for adoption through a court procedure to end parent rights. Birth parents have 20 days to appeal the court’s order.

The Adoption Medicine Clinic (AMC) at the University of Minnesota has been evaluating internationally adopted children since 1986 and in the past decade has focused on providing more services for children who have been domestically adopted or are in foster care. Funded by a grant from the Minnesota Department of Human Services the clinic has incorporated specialists into pediatrician visits, including psychology, OT, pediatric/public health nurses, and genetic counseling to address the far-reaching effects of early childhood adversity on physical and psychological functioning.

In 2019, approximately 48% (N = 188) of the population seen by AMC were children 5 years old or younger and were noted to have high rates of behavioral and emotional difficulties. Throughout 2019 and the beginning of 2020, the program spent large amounts of time doing community outreach to create partnerships and referral pathways. The program encouraged social workers across the state to refer young children and their foster families to the AMC for integrated care. All data and the case review were collected via chart review and approved by the University of Minnesota Institutional Review Board. At the onset of visits to the AMC, foster parents were provided with consents by check-in staff to choose to include their clinical information in research.

Early Childhood Mental Health Therapeutic Consultation Program Description

The over-arching goal of integrating the Early Childhood Mental Health Evaluation Protocol into AMC was to identify young children who are at high risk for long term mental health difficulties and displacement from their current foster or adoptive home. The mental health portion of the evaluation protocol consists of three components by which children are screened for (1) prenatal and postnatal experiences of trauma, (2) current behavioral, social, cognitive, and emotional concerns, as well as (3) current service access. In addition to the evaluation, the service includes referrals and a tailored psychoeducational intervention.

The first component of the evaluation consists of collecting information on pre and post-natal experiences of adversity. Prenatal risk factors can include the biological parent’s level of stress, access to prenatal care, prenatal substance use, and genetic liability for psychopathology. Postnatal risk factors for this population often include neglect, abuse, chronic mobility, food insecurity, and multiple separations or transitions from primary caregivers. We identify the duration and age of these experiences in order to integrate a developmental framework that considers how the developmental timing and duration of these experiences could affect functioning. The clinician utilizes a standardized traumatic event screening form to identify risk for post-traumatic stress disorder as well as the Disturbances of Attachment Interview (Smyke & Zeenah, 1999) which inquiries about symptoms of Reactive Attachment Disorder and Disinhibited Social Approach Disorder (DC:0-5; Klaehn, 2018).

The second component of the evaluation is collecting information on the child’s mental and behavioral health difficulties. Information is gathered via medical chart review, foster parent interview, and behavioral observations in the clinical setting. Providers review the child’s previous psychological evaluations and diagnoses. Clinicians complete a foster parent interview assessing the child’s developmental trajectory and the formation of their current attachment relationship using the Disturbances of Attachment Interview (Smyke & Zeanahm, 1999).

Mental health providers then observe child behavior in the context of a medical and occupational therapy exam. The observation protocol is designed to help mental health providers identify children’s difficulties in cueing distress elicited by the exam, using foster or adoptive parents for emotion regulation and support, as well as indiscriminate friendliness with unfamiliar medical staff. Mental health providers observe the parent-child relationship (Crowell, 2003; Cooper, Hoffman, Powell, & Marvin, 2011). The observation protocol captures a snapshot of how foster and/or adoptive parents attend to children’s distress and how, they provide structure, guidance and direction to their children. Children lacking a caregiver with these skills are the most likely to experience high levels of maladjustment related to early experiences of risk. Consistent and responsive caregiving has been shown to act as a buffer between young children and their environment, preventing the negative consequences of stress on mental and physical health (Johnson et al., 2018; Measelle & Albow, 2018; Liberman et al., 2004).

At the end of the exam, mental health providers review the foster parent and/or adoptive parents’ concerns and goals for the child’s mental health, and evaluate if there are any risks for these foster/adoptive parents requesting the child be removed from their current placements. Child placement instability has been related to a host of emotional, behavioral and developmental difficulties in children (Fisher et al., 2016). Unfortunately, many states have a high rate of foster care placement instability (U.S. Department of Health and Human Services, 2014). Foster parents who are at risk for requesting that children be moved to a different placement often have young children with high medical, behavioral, and emotional needs. Research suggests that children with more trauma symptoms are at an increased risk for foster care displacement (Clark et al., 2020). During the interview, foster/adoptive parents at risk often highlighted feeling exhausted by the child’s needs, feeling as if they do not have the skill set to help the child, and feeling like they don’t have the resources to identify those skills. Through our work, we have found it to be really important and impactful to have a candid discussion with foster parents about any of these concerns. Many foster parents were very grateful to have a space to talk through these concerns without judgement.

The third component of the evaluation consists of reviewing the child and their foster/adoptive family’s current service utilization and needs. This involves reviewing if full developmental assessments using the DC:0–5™ Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood have been completed as well as what mental health services the families may be using. In evaluating current mental health services, we review families’ satisfaction with those services as well as provide recommendations for evidence-based interventions and providers with whom those interventions can be accessed. Families then receive a brief educational therapeutic consultation, based on our conceptualization of the child’s current functioning and history. Foster/adoptive parents are provided with information on how to best emotionally and behaviorally support children’s development in the context of their early adverse experiences. Most foster/adoptive parents receive educational information based on the Circle of Security (Zanetti et al., 2011) as well as in the moment feedback during the end of the session based on the Attachment Biobehavioral Catch-Up protocol (Dozier et al., 2017). We also discuss ways young children signal distress and ways foster/adoptive can help buffer those responses.

Young children who are identified as high-risk for placement disruption or long-term mental health difficulties are referred for a full mental health evaluation (using the DC:0–5™) and trauma-informed as well as relationship-centered evidence-based treatment. Children that need immediate intervention and care because their current level of dysfunction is a risk for their wellbeing receive rapid access to a one to three session brief intervention while they wait for longer-term therapeutic options to become available.

Rationale for a Case Study

We chose to highlight Anna’s* participation in our program as a case study for multiple reasons. First, there is limited knowledge on the feasibility of integrated care consultation models for young children in foster care. We will highlight how a common point of contact can increase high-risk children’s access to appropriate and timely early intervention services. Relatedly, we hope to use this case to highlight the medical complexity of these young foster care children and hope to support program and policy development. Third, many of these children are at risk for experiencing multiple foster-care placements. Multiple placements have been related to increased maladaptive functioning (Lloyd & Barth, 2011). We hope to use this case to highlight how providing consultations services, short term emergency care, and facilitating the prioritization and referrals to community services, integrated care settings like these may decrease the likelihood of multiple placements.

Case Background

Anna is a 2-year 8-month-old Black female who presented to the AMC. Anna was accompanied by her foster mother Rachel*, who was interested in gaining a better understanding of Anna’s behaviors and wanted to learn additional techniques to help support her development. Rachel described Anna as bold, talkative, active, and loving. Rachel had an initial interest in adopting Anna, but had concerns about her ability to provide long term care due to Anna’s many medical and emotional needs.

Based on a medical record review and foster/adoptive parent interview, Anna was prenatally exposed to marijuana, cocaine, and alcohol. Anna’s biological mother experienced homelessness and engaged in sex work while pregnant. Anna’s biological mother has a history of substance use, an anxiety disorder, and depression. Anna was born at 36 weeks gestation via cesarean section due to maternal preeclampsia. At birth Anna weighed 3 lbs. and spent one week in the neo-natal intensive care unit due to her low birth weight. At birth, she had Δ9-tetrahydrocannabinol (THC) in her system and was potentially exposed to a Sexually Transmitted Disease. As a young infant, Anna was reported to have spent time with various caregivers for extended periods of time while under her biological mother’s care and experienced residential mobility. At 10 months, Anna had a documented emergency room visit after reportedly being dropped by her biological mother. At 11 months, she was removed from her biological mother’s care due to concerns for neglect and placed with her current foster family. At placement, Anna was malnourished – weighing only 11 lbs. – and was diagnosed with failure to thrive. Since being placed with her foster parent, Rachel reported multiple ear infections but otherwise noted that Anna had appeared to be medically healthy. At the time of the AMC visit Anna was living with her two foster parents, her biological sister (1-year-old), and three foster siblings (9, 5, and 2 years old). Anna did not have any contact with her biological mother or father since being in foster care.

At the initial foster care placement, Anna displayed flat affect and was socially uninhibited. At the time of evaluation, Anna displayed extreme difficulties with separating from her foster parents, often refused food, and had no independent self-soothing behaviors. Anna and Rachel had previously engaged with play therapy, but Rachel reported that it seemed to make Anna’s symptoms worse. Rachel noted high levels of intense meltdowns after play therapy sessions as well as regression in her toileting abilities. Due to these symptoms, they ceased services. Over the few months leading up to the appointment, Anna displayed high-intensity distress and anger at home and appeared inconsolable. In order to manage Anna’s emotional and behavior needs, Rachel took 6 months off of work and sent Anna’s 1-year old biological sister and foster siblings to daycare. This was a challenging experience financially and emotionally for Rachel and the other children. Additionally, there were concerns with sensory processing, speech development, and muscle reflex issues. Anna covered her ears during loud noises, displayed freezing behaviors in new or unfamiliar situations, and had a hard time with zippers and putting clothes on.

Implementing the Early Childhood Mental Health Therapeutic Consultation Protocol

Anna and her foster mother spent an hour with our multi-disciplinary team of occupational therapist, nurses, medical doctors and psychologists. All team members were present for the duration of the visit. Results of the medical exam noted generalized muscular weakness, vitamin D insufficiency, iron deficiency, and tonsillar hypertrophy. Anna was prescribed a series of vitamin supplements. The experience of traumatic stress and micro-nutritional deficit prenatally and in early childhood may cause an altered vitamin D metabolism in children (Terock et al., 2020). Further, iron deficiency – also related to micro-nutritional deficits – can worsen for children directly in proportion to the amount of rapid post-placement growth (Fugelstad et al., 2008). Both nutritional issues have been related to numerous long-lasting developmental and cognitive deficits (Doom et al. 2014; Terock et al., 2020).

Due to prenatal exposure to substances, the medical team assessed Anna for the facial features of prenatal alcohol exposure. Her facial feature measurements were not consistent with those seen in children with Fetal Alcohol Spectrum Disorder. The occupational therapy team noted a speech delay and slight sensory processing difficulties on their developmental screening. They recommended a full assessment with a speech language therapist.

In Visit Observations

The mental health team observed Anna’s interactions with her primary caregiver, Rachel, and her emotional reactivity/regulation during novel situations. During the visit, Anna started by cuddling into her foster mother and was not interested in exploring the toys in the room. Throughout the hour Anna became increasingly more interested in the toys and displayed more positive emotions. Anna looked to her foster mother for support when she was unsure of toys or new people. Her mother provided comfort as well as acknowledged and validated her emotional expressions (both positive and negative). Anna appeared to experience her foster mother as an emergent secure attachment figure. However, Anna appears to have a difficult time relying on Rachel to provide support when she became distressed. At those moments Anna would appear to freeze in the middle of the room. Anna appeared to become particularly distressed and cover her ears if she believed something would make a loud noise. Observations of Anna suggested that she was developmentally delayed in her fine motor movements, and speech. Anna also demonstrated potential delays in social-emotional development.

Mental Health Treatment and Therapeutic Outcomes

At the end of the initial visit, the mental health provider engaged in a short educational intervention, using augmented protocols from the circle of security program (Zanetti et al., 2011). We described the impact of children’s trauma on development and highlighted the ways Anna’s trauma was playing out in her relationship with Rachel. Trained Circle of Security providers ( https://www.circleofsecurityinternational.com/trainings/about-trainings/ ) introduced the circle and being with Anna on the circle. The provider and Rachel practiced identifying when Anna was on the top or bottom of the circle over the course of the medical exam. The mental health team referred Anna to receive a full DC-0-5 screening from our team and engaged with two brief emergency intervention sessions to build Rachel’s skills on identifying when Anna was experiencing distress and how to help soothe that distress. The team also assisted Rachel in setting up respite caregiving services. Anna was referred to and subsequently engaged in early childhood day-treatment therapy services. Rachel also engaged with a circle of security group through our partner community clinics. Outside of the mental health and medical interventions described above, Anna received OT services for her speech and sensory concerns. At a follow-up appointment approximately one year later with AMC, Anna was still placed with the same foster family. They reported that many of the interventions helped reduce Anna’s symptoms and that they are hoping to move forward with adoption.

Piloting the Early Childhood Mental Health Evaluation Protocol

In the pilot of the evaluation protocol that Anna took part in at the AMC, there were 105 children like Anna seen by the clinic team in the span of ten months. Children ranged from 0.7 to 71 months of age and were 41.38 months on average. They were 43.3% female and 72% (n = 75) of the children were in foster care. There were thirty-one domestically adopted children and twenty children adopted internationally. Of those adopted internationally, fourteen had experiences of institutional care. On average children experienced 2.35 transitions, but this ranged from one transition to seven. Children were 10.61 months old on average at their first primary caregiver transition, and children were 24.49 months at their most recent transition. All children had experienced some form of neglect or abuse, with the most common experience being parental drug use (n = 49 parental drug use; n = 64 prenatal drug exposure; n = 43 prenatal alcohol exposure). Of the children seen at the clinic, 21 experienced physical abuse, 19 witnessed domestic violence, and 36 experienced neglect.

Approximately 68% (n =71) of primary caregivers noted behavioral, social, or emotional concerns for their children at the onset of the visit. Concerns included failure to thrive, broad developmental delays, sleep difficulties, feeding difficulties, high amounts of emotional distress and difficulty soothing. Clinical observations noted that 24% (n = 25) of children exhibited maladaptive stress behaviors. However, the vast majority of children sought and received comfort from their caregivers effectively (n = 82; 79%). There were five children who exhibited significant levels of indiscriminate friendliness by clinician observation.

Only 32% (n = 23) of these children were accessing psychological services at the time of their visit, and 29% (n = 30) of all children had seen a neuropsychologist. Three of those receiving neuropsychological evaluations were based in DC:0-5 protocols (2016). DC:0-5 evaluations review the development and functioning of young children in the context of their relationship with caretakers and other environmental inputs such as traumatic events. Of the children who had caregiver reported emotional and behavioral concerns or exhibited difficulties in the clinic, six were referred for an immediate consultation or brief therapeutic interventions with the early childhood mental health team.

At the time of this manuscript, four of those referrals have been fulfilled. Of the two whose referral has not been fulfilled, one lived out of state and the other is unknown. Further, twenty-six individuals were referred for a full mental health assessment with our team and eleven of those have been fulfilled. Many families traveled to the clinic from multiple hours away and either preferred to see a provider closer to them and/or we also recommended they could receive services from a member of the community closer to their homes. We recommended that forty-eight children (46.7%) receive a trauma-informed diagnostic assessment and pursue evidence-based therapeutic treatment.

Conclusions and Clinical Recommendations

We found that social, emotional, and behavioral concerns are highly prevalent and a central concern for foster care and adopted children (Measelle & Ablow, 2018; Shonkoff et al., 2012). These concerns often present in addition to the many medical symptoms’ that foster children are experiencing. Working with an interdisciplinary collaborative team can offer the opportunity for an efficient consideration of other etiologies for behavior and intervention programs to address sensory, physical, genetic, or neurodevelopmental issues. In Anna’s case, she was able to benefit from all aspects of these interventions including medical interventions for micronutrient deficiencies, as well as OT services. Collaborative consultation programs lower the amount of time families spend going to appointments as well as the time demands on providers. This is particularly a positive for families who live in rural communities, who have to travel far distances to receive care. It is essential to not only provide recommendations but also explicitly state how families should prioritize these recommendations. Anna needed help to first address her emerging attachment relationship with Rachel in addition to her immediate medical concerns. Following these services, additional pediatric rehabilitation and sensory-based interventions were effectively introduced.

Collaborative environments should create access points to care while also decreasing the strain of accessing care on families who are balancing the many needs of their children. Potential community mental health referrals should be located in a convenient location for families and operate under a developmental and trauma-informed lens and offer evidence-based treatment. Creating referral lines and professional relationships with community clinics that provide this care was an element central to this program’s success.

However, we also found that for cases like Anna’s it is essential to have opportunities for immediate longer therapeutic sessions with a mental health provider. Many families seeking our care are families currently in crisis where children are facing potential long-term harm to their developmental trajectory. This includes highly distressing child symptoms such as self-harm behaviors or those that are highly challenging for caregivers to manage and who are at risk for placement disruption due to these symptoms.

Integrated care settings that specialize in foster and adoptive care experiences in early childhood could greatly reduce the probability that children will sustain long term consequences of early childhood stress. This case study demonstrated the feasibility and need for these services. Future work should evaluate if access to multiple service providers in one meeting decreased the number of appointments for those children and if it increased knowledge, and access to appropriate therapeutic care for families. Further, studies should evaluate if access to therapeutic care reduces the child’s likelihood of foster care displacement.

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Palmer, Alyssa R., Institute of Child Development, University of Minnesota

Dahl, Claire, Department of Pediatrics, University of Minnesota

Eckerle, Judith K., Department of Pediatrics, University of Minnesota

Spencer, MaryJo, Department of Pediatrics, University of Minnesota

Gustafson, Kimara, Department of Pediatrics, University of Minnesota

Kroupina, Maria, Department of Pediatrics, University of Minnesota

Author Note:

Corresponding author is Maria Kroupina, PhD, LP. Department of Pediatrics, University of Minnesota, 717 Delaware St SE, Minneapolis, MN 55414; e-mail: [email protected]

This work was supported by the Minnesota Department of Human Services [1501MNAIPP-75-1516-1536]; The National Institute of Health [T32 MH015755] and the University of Minnesota Interdisciplinary Fellowship to the first author.

We thank the children and families who participated in our services and the work of Amina Qureshi for data processing.

Ethics Statement: The case study and descriptive pilot data provided were approved by the BLINDED Institutional Review Board. All participants provided consent for their data to be included in scientific research and their related products.

*All names presented in this publication have been changed for privacy.

Data Availability: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Pre-School and a Child With Behavioural Issues: A Case Study

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For many children, starting their local pre-school group is the first step towards attending primary school. Pre-schools offer a fun and safe environment for children, where they can start to get used to looking after themselves, gaining independence and learn to socialise.

Table of Contents

Learning Through Play

The emphasis on pre-school education has always been learning through play, and children are encouraged to display positive social behaviour and find ways to interact with one another. The ratio of staff to children is quite high and groups tend to hold small sessions in the morning or afternoon and occasionally all day. There are breaks for drinks, snacks and lunch and many pre-schools will also have a quiet time where children can relax on floor cushions and have a rest.

Once Rachel had the chance to sit down with the pre-school staff and come up with a plan of action, she felt confident that William would eventually be fine. She said: “The staff were great and very supportive. I hated leaving William when he was so upset and sad, but the staff reassured me that this was very normal and that in time he would adjust. They also suggested that William was assessed for special needs, and after some time and lots of meetings we did actually discover that he is on the spectrum of Autism as well. This is obviously a big issue, but again we received massive support from everyone and now he is thriving at primary school. If it hadn’t been for pre-school getting involved, William may well have slipped through the net.”

Coping Strategies

Rachel recognised that William had problems with being left, and this was also evident at friend’s houses, parties and other events and activities. With the support of pre-school, she found a way for William to take part in some activities where she could also be involved. To help William deal with his insecurity, Rachel also volunteered to help out at pre-school a couple of times a week. This way she could keep an eye on him.

Rachel added: “It’s not always the best idea – spending all that time with a child when they are being encouraged to become independent can be a bit negative – but for William it worked really well. In fact, when I was at pre-school he pretty much ignored me, but knowing I was there made a big difference and he was much happier, I think we were keeping an eye on each other!”

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Major Depressive Disorder in Children: A Case Study

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The characteristics of visitor behavior and driving factors in urban mountain parks: a case study of fuzhou, china.

1. Introduction

2. materials and methods, 2.1. research site, 2.2. spatial typology, 2.3. data acquisition, 2.3.1. acquisition of visitor behavior data, 2.3.2. acquisition of behavioral driving factors, 2.4. methodology, 2.4.1. visitor density calculator, 2.4.2. tourist behavioral diversity calculator, 2.4.3. tourist behavioral variability calculator, 2.4.4. geographical detector model (gdm) calculation method, 2.5. data analysis, 3.1. characteristics of visitors’ distribution in the three mountain parks, 3.1.1. characteristics of the overall number of visitors’ behavior, 3.1.2. characteristics of the spatial and temporal distribution of visitors’ behavior, 3.2. characteristics of behavioral diversity, 3.2.1. distribution of behavioral diversity, 3.2.2. differences in behavioral composition between spaces, 3.3. visitor behavior relevance exploration, 3.3.1. environmental factors that influence recreational behavior, 3.3.2. landscape pattern factors that influence recreational behavior, 3.3.3. extraction of major landscape factors, 3.4. driving factor analysis, 3.4.1. analysis of visitors’ behavior drivers, 3.4.2. analysis of behavioral diversity driver, 4. discussion, 4.1. characteristics of visitors’ recreational behavior, 4.2. environmental factors that influence the behavior of tourists, 4.3. limitations and perspectives, 5. conclusions, author contributions, data availability statement, acknowledgments, conflicts of interest.

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Fan, S.; Huang, J.; Gao, C.; Liu, Y.; Zhao, S.; Fang, W.; Ran, C.; Jin, J.; Fu, W. The Characteristics of Visitor Behavior and Driving Factors in Urban Mountain Parks: A Case Study of Fuzhou, China. Forests 2024 , 15 , 1519. https://doi.org/10.3390/f15091519

Fan S, Huang J, Gao C, Liu Y, Zhao S, Fang W, Ran C, Jin J, Fu W. The Characteristics of Visitor Behavior and Driving Factors in Urban Mountain Parks: A Case Study of Fuzhou, China. Forests . 2024; 15(9):1519. https://doi.org/10.3390/f15091519

Fan, Shiyuan, Jingkai Huang, Chengfei Gao, Yuxiang Liu, Shuang Zhao, Wenqiang Fang, Chengyu Ran, Jiali Jin, and Weicong Fu. 2024. "The Characteristics of Visitor Behavior and Driving Factors in Urban Mountain Parks: A Case Study of Fuzhou, China" Forests 15, no. 9: 1519. https://doi.org/10.3390/f15091519

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Fbi is still mishandling child sex crimes even after nassar case, watchdog finds.

The Justice Department’s internal watchdog has found continued shortfalls in the FBI’s handling of tips about child sexual abuse despite a series of changes put in place following the bureau’s bungled handling of the Larry Nassar scandal .

Inspector General Michael Horowitz’s office examined 327 cases between October 2021 and late February 2023. It says it found no evidence that FBI employees complied with mandatory reporting requirements to local or state law enforcement in nearly half the cases.

“It’s critically important that the FBI appropriately handle all allegations of hands-on sex offenses against children,” Horowitz said. “Because failure to do so can result in children continuing to be abused and perpetrators abusing more children.”

In one of the cases examined in the audit, the inspector general’s office found that a registered sex offender allegedly victimized a minor for a 15-month period after the FBI initially became aware of the abuse allegations.

In its response to the audit, the FBI said in a letter to the IG that it takes seriously the “significant compliance issues” outlined in the report, and will “continue to work urgently to correct them.”

The latest inquiry follows the inspector general’s examination of how the FBI handled sexual abuse allegations against Larry Nassar, the longtime USA Gymnastics doctor who sexually abused gymnasts—including members of the U.S. women’s national team-—for years.

FBI had vowed to change

In that case, the FBI took few steps to act on tips that Nassar abused young gymnasts, and also failed to share information with other FBI offices or state and local authorities.

In the wake of the Nassar scandal, FBI Director Christopher Wray said the bureau's failed to protect the victims.

"It never should have happened, and we're doing everything in our power to make sure it never happens again," he told Congress at the time.

At the same time, the FBI began to make changes to how it documents and reviews cases of child sexual abuse, including steps to ensure that complaints are addressed quickly.

But the new report from the inspector general makes clear that the FBI is still falling short in several areas, including in reporting suspected child abuse to other law enforcement agencies, and in sharing of tips with other FBI field offices.

In a statement, the Democratic chairman of the Senate Judiciary Committee, Dick Durbin (Ill.), said “it’s shameful that the FBI is continuing to fail victims.”

“Today’s report shows that new policies implemented by the FBI to address these egregious failures are effectively being ignored, leading to similar abuses as seen in the Nassar investigation," he said.

Also flawed tip system

All FBI personnel are required to report suspected child abuse to state, local and tribal law enforcement and social services. But in 47% of the cases the inspector general reviewed, it found “no evidence” that FBI employees complied with mandatory reporting requirements.

Of the reports that were filed, it said, only 43% were made within 24 hours, as required by FBI policy.

The inspector general found similar shortcomings with the FBI’s compliance with its new tips management system, including a policy that requires verbal contact and a confirmed receipt when transferring abuse complaints or cases between FBI field offices.

The report found that the FBI did not document and process all allegations into its new system, and in 73% of cases or allegations transferred between field offices, there was no evidence of verbal contact or confirmed receipt as required by FBI policy.

Durbin, the Judiciary Committee head, said he would hold a hearing on the matter later this year.

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