PAA Workshop Case Presentation IASA Conference 2010 PAA Workshop(1)… · PAA Workshop Case...
Transcript of PAA Workshop Case Presentation IASA Conference 2010 PAA Workshop(1)… · PAA Workshop Case...
PAA Workshop Case Presentation
IASA Conference 2010
Hélène Hétu, MD
Child & Adolescent Psychiatrist
Montréal, Canada
Objective:
Show how PAA & DMM were used in a psychiatric consultation
To contribute to the formulation of the problem and recommendations.
Case of 2 ½ y.o. adopted girl with single adoptive mother
Plan:
Revise quickly essential theoretical points
Case and PAA presentation
Pairing case & theory for recommendations
Conclusion
Theory: “Attachment” in DMM Our case
Specific relationship
Self-Protective strategy
Information processing
2 ½ girl + single mother
PAA: Compulsive A
Temporal order based(“cognitive”)
Theoretical illustration (with permission from P.M. Crittenden)
Case Presentation: Story
Short hospitalization by paediatrician for infected scratching lesions and difficulty sleeping- M burnt out
Colleague Psychiatrist Consultant sees the girl and asks if attachment evaluation would clarify understanding and recommendations
Services by post adoption worker
Adopted at around 15 months (rupture from foster family)
Connection with adoptive mother was long to establish
PAA:
The dyad and how they relate during low stress episode 2
Child asks a lot of questions about toys “What is this?”
M gives some answers but asks child to find answers, also asks questions
t
h
e
t
o
y
s
a
n
d
a
s
k
s
a
l
o
t
o
f
PAA:
How does the 1st separation go?
Child apparently accepts without problem M’s departure, says “yes”, but watches her depart
PAA:
How Is 1st Reunion
Some inhibition
Looks down, glances at Stranger, and comes back to relation with clear question
Posture: discomfort
Approaches sideways
PAA:
2nd separation
Compare with first one
Gets up at the knock
No look
No word
Takes it in and sits back to door and seems to play
PAA:
How does the child manage the high stress of being alone?
Quiet at first
Gets distressed
Manages it
Goes back to toys
Notice carefulness with toys
PAA:
What if an external factor raises the stress level?
Same thing but greater difficulty because stress increased
Getting it under control
Notice she places the hat right
PAA:
2nd reunion with Mother
Does not go to M
Pulls away a bit when M approaches
Points to the stranger, then
takes care of M by joking
Understanding and hypothesis:
Child came with own history ( separation from foster parents) and strategies
Child took long time to connect to new mother (6 months ago)
Child currently uses with M an A +strategy (mostly A4-(performing) , and 3 (care giving: ‘cheering up’ form)
We think most probable that M also uses A+ strategy : History - AAI: very collaborative, compelled to phone back, surprised to cry in F’s part – typist notes FPA +++, markers of compulsivity
Understanding and hypothesis (cont’d):
From the model we deduct that child processes information based on “cognitive” information, splits positive and negative affect and inhibits the negative
If mother also uses the same type of strategy, she probably has most trouble helping child with negative affect
Intervention has to address supporting mother to identify and validate her child’s negative affect (eventually her own )
Obstacle
Plan and treatment recommendations
Discussion with the post-adoption worker to share understanding and clinical impressions (NB Worker describes anxious mother) and where to focus her intervention & offer collaboration
Discussion with mother about assessment and recommendations which are:
• Series of mother-child interventions focussed on enhancing mother’s sensitivity
• Possibility of individual support to the mother*
Conclusion: ideas to address
Finalize coding of M’s AAI to validate /or modify, add to current hypothesis
Consider the “somatization” development of the DMM ?