Julieta Hernandez, Ph.D, LCSW Jason Jent, PhDClinical Social Worker Assistant Professor of

Clinical PediatricsUniversity of Miami Miller School of Medicine

My name is Jason Jent. I will be providing a case presentation. I have no relevant financial interests or conflicts of interests. I am employed by the University of Miami. I don’t have other relevant financial interests to disclose. I am the Communications Task Force Chair for Parent-Child Interaction Therapy International. I don’t receive any compensation for that role.

My name is Julieta Hernandez. I will be facilitating a problem-based learning exercise on strategies for promoting positive behavior in children with disabilities. I have no relevant financial interests or conflicts of interests. I am employed by the University of Miami and Florida International University. I don’t have other relevant financial interests to disclose. I am a member of the Leadership in Education for Neurodevelopmental Disabilities and other related disorders (LEND) Family Discipline Network, the Overtown Children and Youth Coalition, and the AUCD/ICI-ADA International Fellowship Program Committee. I don’t receive any compensation for my roles related to these memberships.

Four year old boy, youngest of four siblings Lives with his mother on weekdays and father on

weekends Manny and his siblings are cared for by their

grandmother during the day/afternoons in a two bedroom apartment in a Zika zone

Manny’s grandma exclusively speaks Spanish to the children

Both parents are bilingual, but Mom speaks to Manny in Spanish and Dad speaks to Manny in English

Manny has not been in school to date

Given that Manny lived within a bilingual home, Manny’s pediatrician only recently became concerned that Manny wasn’t speaking enough

The pediatrician referred Manny to FDLRS for an evaluation

The child is administered a Battelle Developmental Inventory and is provided the opportunity to respond to items in English and Spanish

He scores within normal limits for Adaptive, Motor, and Cognitive Domains of functioning

Manny achieved a low average score in the Personal-Social Domain

As it relates to Communication, Manny achieved a borderline score in Expressive Communication and low average score in Receptive Communication

He responded to test items primarily in Spanish, but did respond to some items in English.

All of Manny’s other developmental milestones are within normal limits per parent report.

As a result, the family seeks out home-based Speech and Language Therapy

What do you know? What do you need to know? What hypotheses do you have about Manny and his

family? As a health professional, what would be your best next

steps?

You show up for your initial appointment with Manny at the grandmother’s home.

Manny’s siblings are also at the home. You explain to grandma that you would like to further

assess Manny’s expressive and receptive language. Grandma provides permission for you to proceed. You look around the home for a quiet place to engage

Manny

Manny is currently in the living room watching afternoon cartoons with his three siblings.

The older siblings are quite fidgety and loud while watching the show and Manny seems to be getting frustrated with them.

You notice that there is a kitchen table that is in the breakfast area, but you can still see and hear the television from there.

What is your initial reaction to the set-up of the home for the purposes of your services?

What would you do to create an optimal environment to deliver your services?

You come up with some creative solutions with the grandmother for her to keep the other kids occupied while you attempt to work with Manny.

Manny has a difficult time separating from his grandmother

Also, Manny indicates that he wants to continue to watch television.

You attempt to engage Manny in further assessment of his expressive language to establish a baseline of functioning for services.

You start testing, but Manny keeps running off to another room where the siblings are still watching television.

While Manny maintains a calm composure when naming simple items for the task, the moment that the expressive words become more difficult, Manny quickly becomes frustrated, starts crying, and attempts to rip the pages out of the book.

You attempt to weather through Hurricane Manny during testing, but once he starts trying to destroy your materials, you briefly stop testing.

After reminding Manny it is important for him to keep his hands to himself, you attempt to re-engage Manny in the task.

Now he won’t even look at you and is yelling for help from his grandma.

His siblings run out to check out what is going on.

What do you now know? What do you need to know? What new hypotheses do you have about Manny and

his family? What could you have done differently? As a health professional, what would be your best next

steps?

Manny’s behavior does not seem to match the information that you were provided by the parents

You decide to ask the grandma more about Manny’s behavior.

She plainly states that she works hard to get Manny to use his words to express his needs.

However, his parents just allow him to point to whatever he needs and he throws tantrums whenever he is required to use his words.

Manny’s grandma feels like she has to re-train Manny to use his words whenever at her place

Given the different settings and caregivers, you decide that it is important to gain a better understanding of their perceptions of Manny’s behavior.

You decide to have all three caregivers complete the Strength and Difficulties Questionnaire.

You score them up using the online scoring system and are presented with the following results.

Grandma

Mother

Father

How would you communicate the results to the family?

How could you provide a warm hand-off or linkage to services (if indicated)?

Based on the screening results, the additional information that you have gained about the family environment, and your consideration of antecedents, behaviors, and consequence, you go back to the grandmother’s home to attempt to test Manny again.

This time by using all of your wonderful strategies that you recently learned at a conference you attended, Manny is able to complete the testing within just mild to moderate frustration. However, he is able to complete the entire task.

You arrange for both parents and the grandmother to attend a feedback sessions related to your testing.

You confirm Manny’s expressive language delay and offer the family an initial exercise to immediately begin to help with Manny’s expressive language.

You recommend to the family to give Manny and his siblings two choices for each meal and inform them that Manny has to verbally attempt to say the meal that he prefers.

Upon this recommendation, the grandmother says that she will have no problem doing this for Manny but expresses concern that the parents won’t follow through.

The mother then adds that the father only wants to have fun with Manny and won’t do anything to upset him.

The father states that the mother tries to micromanage his time with the kids.

How would you set it up for all caregivers to work together to effectively implement the skill practice across homes regularly with Manny?

At the start of your next session with Manny at the grandmother’s home, the grandmother gladly informs you that the family came up with a communication system for reporting the skill practice between homes.

The grandmother also notes that Manny is beginning to use his words more often and show less frustration when attempting to express his needs across settings.

The grandmother reported that despite the parents’ disagreements they have agreed to participate in behavioral parent training so that they can approach Manny’s behaviors in a consistent manner.

The grandmother has offered to watch the children during those appointments and learn about the strategies being taught from the parents. She hopes this will allow for consistency across all three homes.