Case Study 7

The following case study illustrates a holistic approach to psychosocial intervention for PTSD in a child from a refugee background. The case study provides a question for viewers to consider and reflect on.

Case Study 7: Post-traumatic stress disorder (PTSD) (Somali)

(Adapted from Ministry of Education, 2007).

Mohammed is a ten year old Somali boy from a refugee background who presents with severe outbursts of violent behaviour at school, and extended periods of isolation and withdrawal. Mohammed copes poorly with his anxiety about being away from his mother while at school. He abruptly leaves the classroom and calls his mother who collects him whenever he becomes anxious. Mohammed avoids school whenever possible, missing as many as 20 days a term. While at school, he is unsettled, attention seeking, aggressive with other children and unable to concentrate in the classroom. He is unable to form positive relationships with his peers. He is the only Somali child in his class. Mohammed is referred to the Child and Adolescent Mental Health Service (CAMHS) after a critical incident at the school, which is the latest of an on-going series of issues the school has experienced with this child.

Family history

Mohammed’s mother Zahra is a solo mother. Mohammed has a younger sister Deeqa who is eight years old. The family fled to a refugee camp in Kenya when Zahra’s husband was killed during the civil war. Zahra is using the parenting techniques which are used in Somali culture but these are ineffective in the New Zealand context. The children have no routines or boundaries and the discipline used to control them is ineffective. The family has a range of stressors which are impacting on Mohammed’s behaviour and his mental health including: living a long way from the school with no transport; having inadequate means of support and not enough clothing and bedding. Zahra is suffering from depression and posttraumatic stress disorder related to the family’s traumatic refugee experiences and to social isolation in New Zealand. Mohammed and his sister’s English is developing but their mother speaks very little English.

The Initial Engagement and Assessment

The CAMHS team’s initial process of engagement requires more time than it would usually take to build trust and rapport with the family. This happens with the assistance of a cultural adviser who speaks Somali. Zahra gives informed consent to proceed with an assessment and intervention. Engagement activities include:

• Talking to school staff (including teachers and counsellors).
• Observation of Mohammed at school and at home.
• Interviewing Mohammed, his mother and sister.
• Assessing mental health, trauma and other issues using standardised tests that are culturally appropriate for the context as well as discussions with family members.
• Consultation with CYFs regarding any care and protection issues.
• Multiagency meetings and review meetings to discuss the case.

Analysis and Intervention Planning

In the assessment and analysis phase the following issues are considered for the child and the family:

• Predisposing factors eg past trauma.
• Precipitating factors eg antecedents/ existing stressors.
• Perpetuating factors eg reinforcing consequences.
• Preventative factors eg resilience, strengths, support systems.

Analysis of this information provides a framework for organising interventions. A coordinated, culturally appropriate/intersectoral intervention plan sets achievable goals for Mohammed and his family.

Coordinated intervention plan

• It is evident that Zahra is not coping with the many ongoing stressors she faces. The social worker arranges respite care for her and arranges for the children to be placed with extended family in her community.
• The children are monitored both at school and in their temporary placement during this period.
• The CAMHS therapist works with an educational psychologist who coordinates a ‘managing difficult times’ strategy at Mohammed’s school to respond to his outbursts of violent 
• When Zahra improves she returns home and is provided with further support from the social worker.
• The family applies to Housing New Zealand for the family to be re-housed closer to the school, and accesses warm clothing and bedding for the family.
• An intervention plan to deal with the behavioural and mental health issues is then developed with Zahra and the children, addressing the most pressing issues first.

Clarifying and Responding

• The clinical case worker introduces play therapy as a medium to help identify and reduce Mohammed’s anxiety. The clinical and education case workers collaboratively develop a number of coping interventions for him to deal more effectively with his anxiety in school and home environments. These include curriculum adaptation at school, techniques of positive visualisation and arousal reduction techniques.
• Mohammed is encouraged to delay contact with his mother until school break times rather than leaving the classroom mid-lesson.
• Mohammed has a number of one-to-one counselling sessions to begin working with his past trauma and his overwhelming feelings of anxiety.

Improving parenting skills

• The CAMHS and education case workers establish a behaviour modification programme to be run concurrently by Mohammed’s mother at home and by his teacher at school.
• In this programme, Mohammed is rewarded on a decreasing reinforcement regime to stay at school for an increasing number of days. Rewards include computer time in the classroom and a favourite weekend activity.
• Work with Zahra involves discussions to increase her understanding of her role in colluding with her son in his absences from school.
• Zahra is taught effective ways to manage Mohammed’s bedwetting and how to use more effective parenting methods. As a result of this, the bedwetting stops and bedtime and homework routines are established for both children. Zahra and the children report that they feel more rested and less stressed as a result of the changes.
• Both the education and CAMHS case workers undertake a series of family and one-to-one therapy sessions with the family to help them deal with the trauma they have previously experienced. As a result, Zahra and the children are better equipped to talk to each other about things that bother them. They report that they are starting to have conversations about real issues and are beginning to understand each other’s viewpoint better.

The School Context

• Mohammed’s school provides a school counsellor when he is feeling anxious and unsettled. The education case worker works with the staff to help them understand the issues faced by refugee families and how these might impact on Mohammed’s behaviour at school.
• The education case worker develops, in collaboration with the school, a specific social programme for Mohammed based on his skills and interests, to help his socialisation and to reduce his anxiety.
• As part of the intervention, a sports team is formed in which Mohammed plays a prominent role. This provides opportunities for him to improve his social standing with his peers as well as teaching him about team work, sharing and taking turns.
• The education case worker also works with Mohammed to improve his learning skills through exercises such as mnemonic techniques.

Positive Outcomes Identified

• As a result, the school reports that Mohammed’s absences have dramatically decreased to four days per term and that Mohammed is using the strategies to deal with his anxiety well.
• Mohammed reports that he is feeling less depressed.
• He is using his newly acquired academic techniques to improve his concentration at school and is more engaged with his schoolwork. Although Mohammed’s academic results have not significantly improved, staff comment on how noticeably relaxed he now seems to be and his marked improvement in his command of English.
• As a result of his social programme, he excels at a sport, increases his confidence and develops better social skills. In using those skills, he makes friends at school and reports that he feels less isolated from his peers.
• Incidents where his behaviour is inappropriate decrease and school staff feel more positive about Mohammed.
• Zahra experiences more confidence in approaching the school about any problems. She also reports feeling less stressed and is motivated to attend English language classes for herself. This not only improves her language skills but also provides an opportunity for her to socialise and, as a result, she feels less isolated. She starts thinking about employment options. Her son’s behaviour has improved enough for her to venture out into her own community with the children without feeling embarrassed about their behaviour. She reports that this has made her feel more supported.