peek

My female owner has her own version of weekly therapy sessions. She meets with her clinical supervisor at 1400hr every Wed (yes, right in the middle of the week!) to discuss her cases and get clinical guidance. The supervisor plays many roles - therapist, teacher, mentor, role model, critique. And after each session, my female owner writes up a supervision record, detailing what was discussed (parallels her client session notes).

I managed to get a peek into the latest one (today's). It's pretty boring.. unless you are a parent.. Here's a portion of what she wrote (hope she doesn't use what she learns on us):

Intake interviews

• It is very important to get specific examples of problem behaviours. This includes what happened before, during and after the event: sequence of behaviour, what did the parents do/ respond? Is this a typical occurrence, how often does it happen, how long does it last etc?
• Check for level of severity: e.g. no of times/ day. For compliance, ask “out of 10 instructions, how many will she obey?” Need to ascertain baseline/ percentage. Also, note whether instructions tend to be repeated.
• From the information gathered, we will know more about parenting styles, perpetuating factors (e.g. accidental rewards through screaming, being yelled at by parents as a form of getting attention, modelling parents’ behaviours), precipitating factors etc. Only then can we do an accurate formulation. We cannot base our formulation on speculation.
• When giving feedback/ discussing about problem behaviours, use behavioural descriptors such as “yell”, “scream” and not labels like “temper tantrums”, “emotional outburst”, “rude”. Make sure that you state things as they are. Be objective.
• Do a reality-check on parents’ perceptions. Sometimes they may exaggerate, sometimes they under-estimate. Never take anything at face-value. Use the information given to identify the underlying mechanisms that perpetuates the problem behaviours (e.g. inconsistent discipline resulting in accidental rewards? Escalation traps?).
• When parents use labels, clarify: e.g. “what does being ‘rude’ look like?” What was said? How was it said (tone/ volume of voice)? What happened after that?
• Get parents to talk through how they use rewards and punishments with the child. The strategies have been shown to work. If they don’t, it usually means that something has not been done correctly. So need to identify those areas with the parents.

School observations

• Need to be done before seeing the child in the clinic
• Consider what information you need and whether you can obtain it from other means (e.g. parents or teachers – usually a very good and reliable source of information).
• Sometimes you may not get to observe what you intend to observe (e.g. interaction with peers)

Parent-child observations

• Main consideration: setting up a social interaction that is able to answer the questions that you want.
• Younger children: play and clean up. Check for things like no of instructions given, no of instructions repeated, praise, delay in responding to misbehaviour
• Older children: problem solving/ discussion. Get parents to come up with a list of problems to discuss while you interview the child to get his perspective on things. At the end of the time with the child, help him to generate 2-3 problems that he would like to discuss with his parents. Put the family together in the room and observe them from the point where they decide what to discuss (one from child and one from parents). Max 15mins of observation.
• Use the questionnaires to decide what you want to focus/ keep track on.

Interviewing children

• For children less than 7, the process of interviewing is more important than the content of what they say (because they may not be able to articulate their responses in a manner that you will want them to). They may provide trivial answers to your question (e.g. if you have a magic wand and can change anything about your family, what would it be?).
• For younger children, you may be able to get the answers you want from their care-givers. So you may not need to interview them. Interviews will be about 10mins. For older children, it would be about 20mins.
• Observe the way they interact with you: eye contact, posture, ability to follow instructions etc. Especially if you are looking out for symptoms of autism or ADHD.
• Can get the child to draw his family: observe the way he holds the pen, how he starts on the drawing.
• Externalising children would not see their behaviours as a problem, because they get what they want. Their parents would see their behaviours as problematic.
• Internalising children may have more insight, as they do not get what they want. Hence, their answers may provide more information to what they are feeling.

Sharing of assessment findings

• Use information from: Intake interview with the parents, interview with the child, questionnaires, parent-child observations, school reports, information/ reports from other mental health professionals.
• Look out for consistencies in data (e.g. laxness vis-à-vis intake interview) and discrepancies.

Report writing

• Need to be comprehensive in the report by including the background of the child’s problem behaviour. Otherwise, it may create confusion when other people try to interpret the report later on. Numbers, without any context, don’t mean anything.

Case formulation

• Check if problem behaviour occurs across different contexts (school, family, outdoors) or only in the home à what is the underlying issue?
• Consistency of problem behaviours across different contexts suggest a disorder (e.g. biological causes)
• If it’s happening only in the home, then environmental factors may be more important (medication may lose its effectiveness over time)
• Need specific examples in order to formulate