Case children will feel to their parents and the

Case Formulation

The Children’s Aid
Society of Toronto strives to protect, maintain, and enhance the quality of
children’s lives by responding to and addressing child protection concerns.
Since Tommy and Josh were removed from their home and the allegations of
physical and emotional neglect were verified, they were placed into the foster
care system. As discussed throughout the assessment, Tommy displays significant
developmental delays. It was hypothesized that Tommy’s developmental delay was
reinforced by his inadequate stimulation and lack of access to medical
professionals. It was determined that Tommy should have been referred for
further assessments, and received the appropriate diagnosis and supports. When
Josh and Tommy were apprehended, they were placed in a foster home with two
elderly caregivers. Considering Tommy’s complex needs these parents were
physically unable to care for the children. They were once again transferred to
a new foster home. Tommy and Josh moved between four foster homes in a period
of two weeks due to poor caregiving conditions, geographical issues, and
Tommy’s significantly complex needs. This was extremely unsettling for the
children as well as their biological parents. Rightfully, Laurie and Scott
believed that if their children could not live with them, the least the
Children’s Aid Society could do was find them a stable home. Tommy’s mother
Laurie has since been released from jail and is able to attend access visits.
The transition from access visits with their father Scott to access visits with
both parents was an adjustment, but the family has been able to manage this
well. During the visits, Scott generally helps Josh with his schoolwork, while
Laurie interacts and plays with Tommy. Once the children settled into their
most recent foster home, Tommy and Josh were enrolled in a nearby school. Tommy
received an assessment and was diagnosed with Autism Spectrum Disorder and
Generalized Anxiety Disorder. This diagnosis has prompted the initiation of the
process of more specialized interventions within the classroom. Furthermore,
the foster parents have been counselled on specific management techniques in
terms of managing his behaviours and encouraging more social interaction.
Within the school environment he has been provided with frequent individualized
support in order to promote and support intellectual functioning and
self-regulation. However, there are some concerns I hold regarding future
development. The end goal is for Tommy and Josh to return to their home with
Laurie and Scott. Due to Tommy’s anxious/resistant attachment I believe that it
would be beneficial to have access visits with his biological parents more than
once per week. Nesmith (2013) states that “The more frequent and consistent the
visits, the more connected the children will feel to their parents and the less
anxiety they may experience while waiting to return home” (p. 239). However,
due to agency and government restraints, the court decides the amount of time
that will be allocated each week to access visits. I feel a strong need to
advocate for more time allocated to access visits. This will allow Tommy to
develop a secure attachment with his biological parents in preparation for his
eventual return home. In addition, it will also allow his biological parents to
understand Tommy’s complex needs and help them develop management strategies in
preparation for his ultimate return home. 

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Transference
and Countertransference

            There
are certain aspects of transference and countertransference that I have
identified throughout my relationship with Tommy. The concept of transference
refers to feelings that a client projects onto their therapist resulting from
behaviours or actions that may activate a client’s memories from the past (Shaeffer, 2014, p. 15). Whilst interacting with Tommy I have
identified transference as he has begun to view me as a parental figure. This
may be his association of me being the secure and consistent figure throughout
his recent transitions and unsettling movements from home to home. I could be
perceived as the stable figure providing Tommy with a sense of security and
familiarity. Heineman (2001) states “These parentless
children explicitly and implicitly announce that they need a family, not a
therapist. In response, the therapist, particularly the young and inexperienced
clinician, may devalue the therapeutic relationship and unconsciously move into
a parental role” (p. 5). This may explain Tommy’s reasoning for viewing me as a
parental figure seeking a replacement for the missing parental role in his
life. This was evident as he cried and ran after me as I left the foster home.
I was forced to maintain my professionalism and hand him back to the care of
the foster parents.

I have also identified
countertransference when working with Tommy. Countertransference can be viewed
as a therapist’s emotional reaction to the client based on his or her
unconscious needs and conflicts as identified by conscious responses to the
clients behaviour (Osofsky, 2009, p. 331). As most workers would react to a
child that has experienced such trauma, I have experienced feelings of anger,
sadness, fear, confusion, helplessness and hopelessness. Despite these
feelings, I have also experienced satisfaction in helping provide Tommy with a
stable and safe home environment and created a plan to ultimately receive the
appropriate care and interventions necessary.

Implementing a Treatment Plan

As the investigation of
this case was complete after the forty-five day time limit, the case needed to
be transferred to ongoing family services since the children are in care.
Therefore, the parents were assigned a family service worker, and the children were
assigned a children’s service worker. The purpose of the Children’s Aid at the
ongoing level is to provide support to families’ long term. The role of a
family service worker entails monthly home visits, plan of care meetings, and
referring caregivers and children to the appropriate supports necessary. A plan
of care meeting is a written plan for the child’s care. This family service
worker is the main source of contact for the biological parents. Tommy and Josh
were assigned a children’s service worker who ensures that their rights and
best interests are protected, monitored, and supported. The children’s service
worker ensures that all social, emotional and service needs of the child are
met which is performed through collaboration with other professionals and care
providers. When completing the investigation, a vital part of the job is
referring families to services that may be beneficial in helping their
situation. Therefore, my treatment plan will incorporate referring Tommy to the
appropriate supports necessary to address his complex needs. 

            As a children’s service worker at the Children’s Aid
Society, I believe that an individual treatment modality will be the most appropriate
for Tommy. I am referring Tommy to a Cognitive Behavioural Therapist considering
his diagnosis of Generalized Anxiety Disorder and Autism Spectrum Disorder.
Cognitive behavioural therapy (CBT) is a collaborative and problem focused
therapy intended to reduce symptoms and improve an individual’s quality of life
(Joki?-Begi?,
2010, p. 236). CBT is considered an empirically supported treatment that is
useful for a variety of emotional disorders, such as generalized anxiety
disorder (Joki?-Begi?,
2010, p. 236).

            I believe that CBT
will be the most beneficial treatment in helping Tommy regulate his behaviours,
emotions, and anxieties while adjusting to a new life at home and at school.
Considering Tommy’s diagnosis of Autism Spectrum Disorder, this effective
treatment program will allow Tommy to be taught tasks in simple steps, engage
Tommy’s attention in highly structured activities, include him in a typical
social environment, and provide him with regular reinforcement of positive
behaviours (Autism Speaks, 2012). CBT has been primarily used to help children
with Autism Spectrum Disorder to regulate their emotions, improve impulse
control, and as a result regulate their behaviour. In addition, CBT has been
beneficial in minimizing anxious and depressed feelings and behaviours by
changing thoughts and perceptions of situations through a change in cognition
(Autism Speaks, 2012). However, Tommy’s limited verbal skills potentially are a
significant barrier. Traditional CBT generally requires strong linguistic and
abstract thinking abilities, which may be a challenge considering Tommy’s age
and limited verbal abilities. Therefore, when referring Tommy to a CBT therapist
I need to be mindful of the techniques that the therapist may use. I will refer
Tommy to a CBT therapist that uses modifications of CBT that render it more
ASD-friendly. This includes making is more visual, concrete, and repetitive
(Anderson, 2012). An example of a modified CBT model would be instead of asking
Tommy to rate his anxiety on a scale from one to ten, there may be a visual
thermometer displaying anxiety from low to high. In this case, Tommy would be
able to point to the thermometer to illustrate how high his anxiety may be
during a certain situation. Another modification may entail focusing on Tommy’s
interests and talents, helping him remain engaged and motivated. In addition,
engaging in regular movement breaks and sensory activities are necessary since
he has issues with attention and sensory over reactivity (Anderson, 2012).

            Children with Autism
benefit from and thrive in a consistent and stable environment (Autism Speaks,
2012). The importance of consistency between Tommy’s home and outside life is
crucial thus providing him with a more structured and predictable environment. Therefore,
it is essential that foster parents work closely with service professionals,
schools, and birth parents to ensure consistency and structure which will
provide Tommy with predictability and a sense of greater security in all
environments. I believe that the effectiveness of a treatment program is
dependent on parent involvement. This collaboration fosters the promotion of
self-esteem, helps build on the children’s interests, and offers a predictable
schedule which children with autism potentially thrive and benefit from (Autism
Speaks, 2012). Therefore, it is beneficial to include Laurie and Scott in
Tommy’s treatment plan. This will be advantageous when facilitating the
transition back into the home. We are fortunate that Laurie and Scott are willing
to work with us and are committed to being a part of their child’s treatment
plan.

Relationship Building and the Therapeutic
Alliance

            As a children’s service worker at the Children’s
Aid Society of Toronto, the responsibility is to ensure that Tommy’s social,
emotional and service needs are met. The worker will be responsible for the
coordination between the society, services, and the foster home. Therefore,
building a strong relationship with Tommy is vital in developing and
maintaining trust, enabling him to feel secure. Considering Tommy’s diagnosis
of Autism Spectrum Disorder and Generalized Anxiety Disorder, it is important
to ensure that Tommy is placed in an environment that is stable and
predictable, thus providing him with a sense of security necessary to build a
relationship with potential service providers. It will be in the worker’s best
interest to coordinate with the school and the foster home ensuring adequate
communication between them. 

Engagement and the Therapeutic Alliance

            Engagement will be a key aspect when
working with Tommy due to his inability to focus as well as his developmental
delay. It is important that Tommy develops a strong relationship with the CBT therapist
in order to maximize the effectiveness of his therapy process. While it is
often a challenge to engage children in therapy, children with Autism Spectrum
Disorder present more challenges with regards to engagement and cooperation. It
will be essential to provide Tommy with a youth friendly space during therapy,
which may include multiple toys and a bright room. In addition, a
person-centered approach will be necessary, and the therapist should begin
where Tommy is at, developmentally as well as physically. The therapist should
be flexible in sessions and go with what works best for Tommy, consistently
assessing his engagement and motivation. It may be necessary to reduce a
session time to thirty or forty-five minutes rather than the typical hour
session to accommodate Tommy’s
short attention span. Due to his limited exposure to appropriate stimuli, and
challenges with motor and language skills, it is important to monitor his
engagement and adjust the session accordingly. Providing
Tommy with a safe space will allow him to feel comfortable over time which will
assist in working towards addressing goals. Furthermore, it is imperative to therapeutic success
that Tommy develops a strong and trustworthy therapeutic alliance with his
counsellor. It is essential that the therapist displays warmth and empathy
whilst maintaining boundaries in order to establish this trustful and engaging
relationship. Whilst Tommy will be attending
sessions alone, it is
very important to consider therapeutic boundaries when working with children in
foster care. One should be aware they are a part of a wider system, and
consideration should be made to the interests of the Children’s Aid Society,
the foster parents, as well as his biological parents.

            Children often find it difficult to
find words to describe and express their distress, and the use of play may
provide a child with a non-verbal form of expression. In fact, “Play is a medium for symbolic
communication with the child which can relieve emotional distress” (King,
2017). The use of play may encourage Tommy to play and reenact some of his
traumatic experiences. This will allow the therapist to gain greater insight
into his traumas, and allow the therapist to provide him with some symptom
relief. Play therapy treatment goals should be outlined with a clear purpose
and direction for Tommy’s treatment plan.

            Based
on existing barriers, I believe that engagement will be a huge factor in the
success of Tommy’s treatment plan. By remaining flexible, Tommy’s social and
emotional needs will be addressed. I am hopeful that the outcome of this
treatment plan will help regulate Tommy’s complex behaviours, as well as mitigate
his anxious thoughts and tendencies.