Final Week

To say the least, Kendra's life did not turn out the way she had hoped. She was scarcely able to muster the capacity to reflect on herself and her situation and did her best not to think about it too much. Over the last few years, she had almost withered away, appearing as a shadow of her former self. Her face was sunken, and the dark circles under her eyes had become permanent. In rare moments of lucidity, Kendra brought to mind her mother and father who she hadn't seen for years. One part of her whispered to them how sorry she was, and another part of her raged at them for setting her life on the course they had. On one level, she knew that they both did the best they could with what they had, but on another level, she could never forgive them.

Thankfully such moments were rare for Kendra as they were quickly overtaken by more of the drug, more of the buzz. She got to the point where she continued to need more of it to dull the pain.

It must have been this desire that pushed her over the edge. She injected once and then again --- and then there was a blinding light followed by nothing but darkness.

Police found her body outside on a very cold December night. There was no one there for her, no one to claim her as their own.

1) What are the provisions made for deaths for which there is no next of kin or family? Who provides burial services, and who pays for these services?

2) How many people die each day in the U.S. who have no living relatives?

Week Ten

At age 50, Kendra looks like someone much older. She has been in and out of any number of treatment facilities and counseling centers, and none have succeeded in helping her kick her drug habit. Now, she lives in a small, two room house and spends her time shooting up while wondering where the next dollar will come from for food and more heroin. She permanently lost parental rights to her son when he was just 6 years old, and she really doesn't know where he is. Underneath all of her drug use is this incredible pain that she has lived with all these years.

Kendra shares the house with a man who shares her habit. He does little except help her to get more drugs, and the two spend most of their days high in front of the TV. On occasion, she has even taken to prostituting herself in order to get money to buy more drugs. Her life is one big spiral of despair.

1) Assuming that Kendra has been identified as having a disability, how much assistance (in dollars per month) is she likely to receive in the way of SSI? How about food stamps?

2) What is the prognosis for Kendra given that she is addicted to heroin? How likely is it that she will be able to "get clean?"

3) In thinking about Kendra, consider her life up to this point. Whose "fault" is it that she is in the state she is in? Is there an individual to "blame," or are the causal factors more complex?

Week Nine

Kendra has continually struggled with making interpersonal relationships with her life as her regular outbreaks usually scare away other students.  Also since Kendra started using drugs she tends to steal from the people closest to her in order to get the money to get the drugs and get high.  No matter how many times the police or her mom has caught her, she continues to buy weed.  She says that the weed calms her down and allows her to function in her broken home. 

Kendra’s mom is looking for her to enter a rehabilitation center since she thinks Kendra is addicted to pot.  Kendra’s mom is very fearful that her daughter’s drug use will escalate into more harmful drugs that will put Kendra’s life in danger along with other people’s lives in danger by the decisions that Kendra makes while she is high.  But Kendra wants none of the help that her mother is giving her since she feels that Esther just wants to get rid of her so she decided to move back with her father and drop out of school with only a year left.

A few years have passed by and Kendra is now 21 facing financial problems as she cannot hold a job for longer than 2 months at a time.  This leaves her without any health benefits and little money since she only received minimum wage at the jobs she has worked.  She cannot rely on her father because he has problems with alcohol and he only feeds constantly into her drug problem and has started drinking herself.  Her mom used to send her money every week to help Kendra get by but Esther has stopped that seeing that money was not being put to good use.  Kendra is going to apply for welfare in order for her to be able to buy food for herself and some clothes when she needs them. 

Kendra’s 25^th birthday is coming up and she realizes that she has only a couple of friends to surround her to celebrate in which they just use her to get to drugs easier but this only bothers her for a little while before she starts going back to her old ways.

Kendra is now thirty-two years of age. She has been through a lot in her twenties. After spending more and more time with her “new” group of friends Kendra got into a little too much trouble with the police and spent seven years in prison. Prison was hard, very hard for Kendra. She got into many fights and confrontations with inmates.

After serving her time she was released on probation. Kendra was very severely underweight as she did not eat the prison food and the drug use has eaten up her body.  Sadly, Kendra did not learn any lessons from jail time and quickly got back into doing drugs just about 6 months after she was released. In addition to being high and under the influence almost daily, Kendra got pregnant. She currently has a three-year-old son. She currently does not have custody of her little boy due to her lack of being able to provide for him.  Child services have put him into a foster home for the time being.

Kendra has had many ups and downs since high school and has tried to straighten up. However, she always finds herself in trouble.  She fears that she will never see her son again and wants to get help as the years keep passing by.  She hopes that she can regain strength for her family to accept her back and raise her child in the Jewish faith as she was.  Kendra feels that she has lost herself between her episodes and drug use.

1) What are typical milestones of a woman with Bipolar disorder in early adulthood?

2) What are the steps that Kendra has to do to get her son back?

3) What is the likely hood that Kendra’s child will have a mental disability or disorder? Provide evidence of how genetics play a role in mental health disorders.

4) Explain the effects that drug use has on the body in an average person and the effects it has on someone living with a mental disorder.

5) What are a few short term goals that will help Kendra stop using drugs? What are some long term goals that she could keep in mind?

Week Eight

Kendra's life continued to fluctuate between somewhat stable and incredibly chaotic. At age 17, Kendra was looking at the inside of a detention cell. She thought back to how she got here, and a lot of it seemed to be a blur. There was the theft of a pair of shoes that got her community service and lots of therapy with that annoying woman that she tried to play - but the therapist was on to Kendra's games and didn't let her get away with her usual tricks. Annoying, but maybe a little helpful even if help was the last thing Kendra would admit to experiencing.

Then there was the fight at school - even thought Kendra was in classes for students with emotional/behavioral disorders, there were plenty of opportunities for her to get into trouble. When she was 15, somebody looked at her the wrong way, and she jumped on the student and started punching the student in the head. Luckily, two PE teachers were rounding the corner and were able to break up the fight. This, however, led to a manifestation determination hearing and, subsequently, placement at a "special" day school.

Kendra did OK at the school, but she was running the streets at night as her mother lost any degree of management and relationship that she might have had with Kendra at one point. It was just after her 17th birthday that she found her way into a heap of trouble with a group of so-called friends who provided the opportunity for her to get high. She was caught bringing drugs to school, and the local police were called.

1) What is a manifestation determination hearing? When is it used?

2) What do you think is the nature of Kendra's disability?

3) What are typical developmental milestones for a 17 year old young woman?

4) What are the outcomes for children involved in the juvenile justice system in Virginia? Provide statistical data.

Week Seven

Now at age 12, Kendra had been through quite a bit. When she was 9 years of age, she couldn't take all of the chaos and fighting and uncertainty. Kendra tried to reach out, but, at age 9, no one really listened to her or took her seriously. Kendra cut herself terribly in an attempt at suicide.

Kendra was taken to the hospital and, after the initial injuries healed, placed at a children's residential facility for ongoing mental health treatment. Here she stayed for 9 months. Her mother participated in some "family" sessions over the phone and occasionally in person.

When Kendra was released, she returned to Philadelphia to live with her mother. The next two years were a mix of outpatient therapy, in-home therapy, "alternative" therapies, all to little avail. Now at age 12, Kendra was as unhappy as ever. She thought about going to live with her dad, but she knew that his drinking had only gotten worse since the divorce.  

Kendra had few friends in Philadelphia, although there happened to be a girl who she met at the residential placement whose family lived nearby. She occasionally got together with this person, one of her only friends. They sometimes didn't seem to have much to say, and other times they couldn't stop talking the whole time they were together.


1) What residential facilities are typically available for children, and who pays for a child to attend? What kind of mental health treatment was Kendra likely to have received?

2) What kinds of follow-up treatment are typical when a child has been in a residential facility?

3) Assuming that Kendra was treated for depression and possibly other kinds of mood difficulties, describe the outcomes associated with residential treatment for children given the diagnosis of depression. How much improvement typically occurs? On what factors does this depend? What is the rate of return to residential facilities? On what factors does that depend?

4) What are the typical developmental milestones for a 12 year old girl? In what ways is Kendra atypical as far as you can tell?

Week Five/Six

Esther has finally moved out. She got the job at the museum, but only for part –time employment. Esther took Kendra and Marsha to Philadelphia to l live with her sister.  Esther and the kids have only been there two weeks and they are over-taking Esther’s sister’s house. There is barely enough room for all of them to eat at the same time. The sister has made it very clear that Esther can only stay three months until she finds a full-time job and support herself and the kids alone.

Art on the other hand is furious! He knows exactly where Esther and the kids have gone but he has decided to wait to act legally until his large contract is finished. He never calls or emails Esther and the kids. The kids even believe that Art doesn’t love them at all.

In addition, Art’s company has just gotten sued and is on the verge of shutting down only causing more financial problems and stress for the family.

Since Kendra moved to Philadelphia, things have only gone downhill.  Often she hears her mom and dad fighting on the phone when they do talk and her parents plan on getting divorced.  Now this means a long custody battle that she is going have to go through.  Kendra seems depressed by withdrawing from activities in school and at home.  But the simplest things still agitate her, where she kicks, bites, and screams when she is angry or anxious all the time.  She hasn’t received much therapy because of the changes going on and feels neglected.

Her doctor and psychiatrist don’t want to directly diagnose her with bipolar disorder just yet as she is still young where she would have to take medications.  They have told her mother that she has child attachment disorder which likely stemmed from the fighting that occurred at home between her mother and father all the time.  She also displayed symptoms like not smiling and rejects any attention her mother tries to give her to calm her down.  Esther thinks that her job at the museum is taking away even more valuable time from caring for Kendra but it’s her only option right now to be able to support the family as the moved down the street into a small apartment from her sister.

Her lack of interest in school doesn’t have too much effect on her as she does average for her grade level but her mother thinks that the school can do more for her as Esther believes school is the best option for Kendra to get help.   She has progressed normally to each grade as she is currently in 3^rd grade now but has only 1 friend and teachers often don’t want her in class because she is very disruptive.  Third grade has proven to be very difficult for her as her social and emotional problems have taken over her life and her mother fears that she won’t pass the 3^rd grade.

11)    Is it too late for the school to develop an IEP for Kendra? Develop some goals and objectives that would most likely be on her IEP.

22)    What help should Kendra be receiving for child attachment disorder? If she were to receive the correct help what would be the outcome of it?

33)    What are common problems that usually result from divorce and custody battles?  How will this affect Kendra?

44)    Would it be beneficial for Kendra to be put in special education classes? Why or why not?

Week Four

Art and Esther live in Washington, DC. They have been married for 12 years having met through a mutual friend when Esther was finishing her Master’s degree in Fine Art. Art is now 45 years of age, and Esther is 41. Art had owned his own construction company for several years, and his marriage to Esther was his second. He did not have any children with his first wife. Recently, Art’s business has barely been scraping by, and their middle to upper-middle class lifestyle has been threatened. Art and Esther consider themselves Caucasian, and both were raised in the Jewish tradition. At this point, their religious life is not of the utmost importance for them, much to the disappointment of Art’s parents. Esther’s parents were killed in an auto accident when she was 19, and she has been on her own ever since. Esther has a sister in Philadelphia and a brother in prison. Art was an only child, and his parents live in California; they meet up about once a year.

Now as a four-year old, Kendra’s behavior and temper hasn’t gotten any better. Esther has been quietly laying the groundwork to move out; she is planning to go to her sister’s house in Philadelphia where she thinks she has secured a job at a museum. She is not yet sure but hopes to be able to take both of the kids and leave.

For his part, Art’s company got a large contract for a new shopping center, so he, thankfully, hasn’t been around that much in the last year and a half. When he has been at home, he has mostly been exhausted or has been on the phone with subcontractors.

Kendra is, at times, inconsolable. She kicks, scratches, and bites Esther for no apparent reason, and Esther thinks there is really something seriously wrong with her. She can’t explain it any other way. She has heard that some kids get bipolar disorder, and she really thinks that is what is happening with Kendra. She has talked with her pediatrician and is planning to take Kendra to see a child psychiatrist. 

1) Research the diagnosis of pediatric bipolar disorder. Be certain to include the views of the psychiatric establishment as well as the views of those who would critique such a diagnosis for children. Compare the symptoms of pediatric bipolar to those of avoidant and/or resistant attachment. Based on what you know of Kendra’s family, is an organic, biochemical imbalance more likely or is an attachment difficulty more likely?

2) Of all of the mental health providers available, why do you think Esther would take Kendra to a child psychiatrist? What are the potential risks and benefits to such a choice? Are there other options that Esther might consider?

3) Given the family’s limited disposable income, if Esther had wanted some kind of intervention for Kendra starting at age two, what would her options have been for both outpatient and (perhaps) in-home services? Remember that the Kleinman’s live in a big city (we are using DC as our big city).

4) Describe typical developmental milestones for a four year old. How unusual is Kendra’s behavior?

DECISION POINT ::: Does Esther take Kendra to a child psychiatrist? If so, what is the outcome of the visit? 

Week Three

Kendra is 2 years old. Esther and Art have managed to stay together, but it has been, to say the least, difficult. Esther keeps saying that if “it” happens again, she’s going to leave - Art’s temper has only gotten worse, and he sometimes hits Marsha. Kendra’s behavior seems erratic and confusing to Esther in particular, and Art to some extent: Kendra throws temper tantrums for no apparent reason, and Esther doesn’t know what to do to soothe her. The tension in the house is unbearable.

Art and Esther have been going to see a couples therapist since Kendra was about a year old. At the beginning of the work, things seemed to improve slightly, but Esther noticed that Art was able to “put on a good show” in therapy and, while the worst aspects of his behavior ceased for a time, the real issues present in their relationship did not come to the fore. Art started refusing to return, saying that the therapy “wasn’t much help at all.” About 3 months after they stopped going, Art started to escalate in his demands and controlling behavior once again, saying that if Esther leaves he will “find a way” to get back at her, making veiled threats about her safety. At other times, he said he would kill himself if the two split up. All of this was complicated further by the fact that Art had started drinking.

Esther was worried about her own state of mind, and she was worried about Kendra. She didn’t know how the fighting would affect her, and she had a nagging sense that there was some relationship between Kendra’s tantrums and the overall stress level in the home. There were wonderful times of joy and delight with Kendra, and Esther loved her with all that she could. She also had Kendra’s older brother to care for who, at age 4, was also having significant challenges behaviorally. Esther was glad he would start school soon.    

1) What are the major developmental milestones for a 2 year old? What should Kendra be doing physically, cognitively, and emotionally at this point?

2) What is the impact of domestic violence on the family? On attachment patterns? Objectively, what options does Esther have (in other words, what could she do if Art hits her again)? In Esther’s mind, what options does she have?

3) What services (if any) would you recommend for the family at this point?

4) How might you explain Kendra’s behavior in light of the violence in the home?

5) What else is important for you to know about Kendra’s family at this point? (Hint: Think about all that you don’t currently know about the family that could be helpful for you with regard to demographic information.)

Week Two

Kendra is now 6 months old. The last year has been incredibly stressful for Art and Esther, and they have barely been able to make the payments on their home. The new baby has only added to their already tense daily lives. The stress has taken a toll on their relationship, and they get into verbal shouting matches frequently. Art’s anger scares Esther and makes her think back to her own upbringing when her mother and father got into shouting and shoving matches.

Kendra seems to be a particularly difficult child to console, and she hasn’t come close to sleeping through the night. Esther is at her wits end and is feeling more and more alone – she often has a hard time getting out of bed in the morning, and she hasn’t had much of an appetite in spite of the fact that she has been breastfeeding. Things with Art continue to deteriorate, and she is not sure whether to be worried or relieved.    

1) Write a developmentally appropriate dialogue that the Kleinmans might have with their son to introduce him to his new sister.  

2) What should Kendra be doing physically, cognitively, and emotionally at 6 months of age? Are there aspects of her development at this point that we might legitimately expect to be “culture bound?”

3) What is the likely effect of the ongoing verbal arguments on Kendra’s development?

4) If Esther is suffering from depression, what might be helpful for her? If she were to go on medication, would this be safe for the baby? What are the risks associated with post-partum depression? What effect might such a condition have on the attachment relationship between mother and child?

5) Describe typical practices in the three major Western religions with regard to the newborn baby. If the Kleinmans practice Judaism, are there specific practices or actions they would have undertaken when Kendra was born or shortly thereafter?

DECISION POINT

* Do the Kleinmans stay together? If not, what happens to Kendra and her brother?

Week One

They had planned for this, but they couldn’t believe it was actually true – they were having a girl! Their 2 ½ year old son would have a sister.  They busily made preparations and made sure to keep all of the “baby” things they had used with their son. The Kleinmans were concerned because Art had just lost his job, and Esther didn’t work. They had made a decision that one of them would stay home, and Esther was the one. Now it looked like they would both be home — for a while. Art and Esther were unsure how they would keep their home, and they both started to look for work.

How much money does it take per year to raise a family of four in Virginia? (Hint: there was a study out of UVA about a year ago that had this data) 

What is the average annual salary and the median salary in Virginia? In Harrisonburg/Rockingham? In Northern Virginia/DC? Which measure (mean or median) is more useful?

What is the cost of having a child in a hospital? What if a C-section is necessary – what is the cost for that?