702 Discussion 2- Response 702 Discussion 2- Response

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Becca is a 10.2-year-old Caucasian female, referred to specialty mental health by her pediatrician. According to Becca’s foster parent, she is having difficulty falling asleep resulting in problems with daytime fatigue. Becca is the oldest of 3 children and was removed from her biological parents home due to neglect, exposure to substance abuse and domestic violence. Becca shared that she had not had difficulty falling asleep in the past but for the past four weeks in foster care she has. She reports that she feels worried about her biological parent’s health and safety, and she has difficulty “not thinking about it.” Observations by the foster parent include that Becca will go through her bedtime routine in a typical fashion willingly, and she appears physically tired (yawning, wiping eyes). When she lays down, this is when Becca begins having worrying thoughts. She said she occasionally has thoughts that her parents are dead or don’t have a place to stay. She also reports that sometimes she will replay the last fight they had, where her dad said, “I may as well just kill myself.” Although Becca has since had contact with her father, his words and the events were highly stressful to her. On most nights, it takes Becca between 2 to 4 hours before she can fall asleep. She has tried counting sheep, having warm milk, reading a book and snuggling with her teddy bear. The sleep disruptions Becca is experiencing are impacting her ability to concentrate in school. She has been found napping during reading class on several days and doesn’t feel well enough to participate in physical education.

Simon, Duncan and Mentrikoski (2014) report that sleep difficulties and pediatric insomnia have a host of secondary symptoms including reduced ability to concentration and problem solve, increased mood irritability and disruptions, and impoverished motor control (p 566). One of the most obvious ways I would have modified Becca’s course of treatment would if she could have utilized a Behavioral Health Clinician rather than specialty mental health. Due to the nature of her presenting symptoms and context of situational assessment, Becca was diagnosed with an Adjustment Disorder with mixed anxiety and depressed mood. She was referred to 8-12 sessions of play therapy using cognitive behavioral interventions to help her develop self-soothing skills.

While Becca’s course of treatment was relatively brief in the Mental health world, it is this clinician’s belief that a similar amount of improvement could have occurred within a 30-minute behavioral health consultation. Using Collaborative Problem Solving, a Plan B conversation could have provided sufficient emotion regulation, patient-centered buy in and increase her ability to develop problem-solving pathways (Greene & Ablon, 2014). Unfortunately, within the specialty mental health world with encouragement from other systems (child welfare, attorney) the treatment was highly activating and made her problems worse. Becca was viewed as a victim which opened a host of additional difficulties. She started to see her parents as perpetrators making the reunification much more challenging. She began using her ‘victim’ identity as the reason she could not adapt or implement new skills. Becca resented coming to therapy as she was missing school and time with her peers.

During her episode of care in the mental health system, specific, measurable, achievable, realistic/relevant and timed (SMART) goals and objectives were developed as part of her treatment plan (Bovend’Eerdt, Bottell & Wade, 2009). “Becca will learn 3-5 self-soothing skills to help her sleep. She will increase her sleep from 5 hours per night to 7 or more for at least two months in duration.” What I understand more fully now, is the self-soothing skills that were implicitly taught to Becca, did not improve her sleep. Rather the collaborative problem conversation surrounding her primary concern (parents safety) and how she could reduce her anxiety surrounding this (call them, pray for them, write them letters) ultimately improved her medical condition. The Plan B conversation took about 15 minutes, rather. I am very optimistic about the use of behavioral health in an application with youth to prevent situations like Becca’s. Thousands of dollars in health care costs, time of attendance and most importantly the increased symptomology lend to the awareness that our system needs to change.