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?