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Case Management
by Deborah Hage

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(My book Therapeutic Parenting and When Love Is Not Enough by Nancy Thomas provide the background and context for these specific techniques. It is not advisable to use these techniques without reading the books as these suggestions could easily be misunderstood and misapplied if not used in the context of a whole therapeutic philosophy and regimen.)

For most agencies the central duties for the case manager assigned to the family are somewhat mechanical. The primary goal of case management with a child and family affected by attachment disorders, mood disorders, thought disorders and oppositional defiant disorder is more extensive. The very specific goal is to provide those services that will enable the family to remain a unit. Determining what those elements are and helping the family obtain them is critical. Since it is the parents who are living with the child and the parents who are the experts on the child, they are the final determiners of what services are needed. The parents decide if therapy is effective. The parents help write the IEP so it is useful to them. The parents decide if medications are effective or not. The parents are pivotal members of the team and final arbiters of what is and what is not helpful to them in parenting the child in their care. The task of the case manager is to create a "circle of support" (Nancy Thomas coined the phrase) for the parents. This circle of support includes the respite providers, schools, therapist and psychiatrist.

When asked, the case manager can provide crucial support and information when the foster family must deal with others who work with the child. When not asked, it is often because the family believes (often correctly) that the case manager does not have the skills to help appropriately, does not have an understanding of the special needs which the child presents and thus interferes with, rather than contributes to, the provision of services.

In order for the team model to work the parents must have every opportunity for training in ways to gain control of the family environment and effectively discipline (train) child in the reciprocal tasks necessary for a healthy life. They must learn to do this while taking good care of themselves. The child must be able to come when called, stay where he/she is put, do what is expected, follow rules and regulations and go where he is told in order to be able to live independently as an adult. (That is, go to school, maintain a job, drive a car and stay out of jail.) Parent training must consist of appropriate and effective, yet nurturing, interventions, to teach parents how to have backbones of steel and marshmallow hearts. Training in Proactive, Reactive and Intrusive techniques; getting a child to cooperate in chores and engage in reciprocal activities; and when to engage in control battles and when and how to disengage are all essential.

In order to be able to offer appropriate support and advice, the case manager must know as much as the parents about parenting interventions effective with severely behaviorally disturbed children. Attending trainings with the parents, reading, listening to audiocassettes, and being willing to be trained by the parents who, as front line providers, often have more expertise than the worker, are all important.

As members of the circle of support the respite providers' goal is to support parents by giving them a break while enforcing their discipline. They must provide a safe, yet emotionally distant, environment. The goal is not to compete with the child for the parent's affection. The case manager's task is to identify people to provide respite, train them, help them identify and avoid efforts of the child to triangulate and manipulate the adults against each other and to listen to and address the parent's concerns regarding respite. (See Respite Training outline.) The case manager must make sure there is appropriate respite available for the parents as any time the child is in control of the home he will not get well. When the child takes control then the child needs to go to respite until he demonstrates he is willing to allow parents to give him appropriate directives.

The school staff enter the circle of support by teaching the child life skills while not imposing that task on parents already overwhelmed with living with and managing a child whose behavior is extremely challenging. The IEP must be written in such a way that homework is assigned to the child with no expectation of parental involvement. The child's behaviors must be dealt with effectively at school with parental support and advice, but without expecting parents to consequence for behaviors that occur at school. The case manager provides critical support to the parents at staff meetings to ensure the staff understands the pressures which the parents are facing at home and by not allowing the school to assign them unrealistic and inappropriate education related tasks.

The therapist becomes part of the circle of support by providing appropriate and effective therapy that is supportive of primary therapists - the parents. The goal is not to have the child bond with the therapist and thus compete with the parental bond. In order to avoid the child's attempts at triangulation and manipulation it is imperative the parents are present in the room at all therapy sessions. They must be physically present in order to call the child on all lies and misrepresentations of their behavior. Sessions are most useful to the parents when they begin by asking the parents what positive and negative behaviors the child has been exhibiting during the week. Another critical element of the session is brainstorming parenting interventions that address a specific behavior and have the potential to be more effective than what the parents are doing. The paradoxical techniques, that is, telling the child to do what the child is already doing, have great potential to be effective. After spending time with the parents becoming familiar with the current situation, the therapist brings the child in, praises the positive and confronts the negative. While useful, it is not essential that the therapist be trained in holding techniques. Appropriate interventions are experiential, rather than insight or talk based, such as Theraplay, EMDR, Art therapy, Psychodrama, Brain gym, Sensory Integration and other techniques where the therapist is in control. It is often helpful to have the child redo the behaviors exhibited at home. For example, if the child is calling the mom names, then the child comes to therapy and must say the same thing in the same tone of voice at the same volume to the therapist that he/she said to the mom at home. If the child had a tantrum at home then he/she must re-create the tantrum in the therapist's office on the therapist's terms. The point is that often the first step in stopping a behavior is to take control of it away from the child. If the child refuses to cooperate in therapy then the respite provider must step in and keep the child until the child is ready to do what is required for the therapist.

The case manager has many tasks relative to therapy:

  • Ensure the therapist is not withholding information from the parents and keeping them out of the therapy session.
  • Ensure the therapist is supporting the parents, listening and addressing their pain and giving them effective ideas for parenting techniques.
  • Ensure the therapist is not allowing the child to triangulate and manipulate the adults involved.

  • Ensure the therapist is working on the issues the parents find the most useful, that is addressing the behaviors at home, as well as addressing the underlying issues which drive the behaviors, that is the abuse and neglect and subsequent feelings.

  • Ask the hard question - Is the child getting better in this therapist's care or worse? What do the
    parents believe and why do they believe it?

  • Monitor the parenting advice and direction the therapist is providing, learn from it and question it when necessary
  • Leave no stone unturned - Shiatsu, acupressure, chiropractic, aroma therapy, Bach flower essences, music, exercise, etc.

Many of the behaviors and emotions associated with attachment disorder are not alleviated by medication. However, mood, thought, and oppositional defiant disorders have a huge potential to be minimized by the appropriate use of medication. Finding a knowledgeable psychiatrist with experience in the above diagnoses is an important part of the case manager's job in creating a circle of support. The psychiatrist must not be discounting of the parent's experiences with the child's behavior and be able to ask probing questions regarding the child's behavior while listening carefully to the parent's responses. The goal is accurate diagnosis and provision of appropriate medication in effective doses. (Generally, Ritalin is not only ineffective but has the side effect of heightened physical outbursts! Stimulants in children with ODD, RAD and Bipolar is generally counterproductive)

The case manager is crucial in providing the circle of support the parents’ need in order to be successful in maintaining the child's placement in the home. How the case manager develops personal expertise and puts together and trains the treatment team to be supportive of the parents and effective in dealing with the child is key to the child's success and maintenance in the family.

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Deborah Hage, MSW

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