PAA Workshop Case Presentation

IASA Conference 2010

Hélène Hétu, MD

Child & Adolescent Psychiatrist

Montréal, Canada

Objective:

Show how PAA & DMM were used in a psychiatric consultation

To contribute to the formulation of the problem and recommendations.

Case of 2 ½ y.o. adopted girl with single adoptive mother

Plan:

Revise quickly essential theoretical points

Case and PAA presentation

Pairing case & theory for recommendations

Conclusion

Theory: “Attachment” in DMM Our case

Specific relationship

Self-Protective strategy

Information processing

2 ½ girl + single mother

PAA: Compulsive A

Temporal order based(“cognitive”)

Theoretical illustration (with permission from P.M. Crittenden)

Case Presentation: Story

Short hospitalization by paediatrician for infected scratching lesions and difficulty sleeping- M burnt out

Colleague Psychiatrist Consultant sees the girl and asks if attachment evaluation would clarify understanding and recommendations

Services by post adoption worker

Adopted at around 15 months (rupture from foster family)

Connection with adoptive mother was long to establish

PAA:

The dyad and how they relate during low stress episode 2

Child asks a lot of questions about toys “What is this?”

M gives some answers but asks child to find answers, also asks questions

t

h

e

t

o

y

s

a

n

d

a

s

k

s

a

l

o

t

o

f

PAA:

How does the 1st separation go?

Child apparently accepts without problem M’s departure, says “yes”, but watches her depart

PAA:

How Is 1st Reunion

Some inhibition

Looks down, glances at Stranger, and comes back to relation with clear question

Posture: discomfort

Approaches sideways

PAA:

2nd separation

Compare with first one

Gets up at the knock

No look

No word

Takes it in and sits back to door and seems to play

PAA:

How does the child manage the high stress of being alone?

Quiet at first

Gets distressed

Manages it

Goes back to toys

Notice carefulness with toys

PAA:

What if an external factor raises the stress level?

Same thing but greater difficulty because stress increased

Getting it under control

Notice she places the hat right

PAA:

2nd reunion with Mother

Does not go to M

Pulls away a bit when M approaches

Points to the stranger, then

takes care of M by joking

Understanding and hypothesis:

Child came with own history ( separation from foster parents) and strategies

Child took long time to connect to new mother (6 months ago)

Child currently uses with M an A +strategy (mostly A4-(performing) , and 3 (care giving: ‘cheering up’ form)

We think most probable that M also uses A+ strategy : History - AAI: very collaborative, compelled to phone back, surprised to cry in F’s part – typist notes FPA +++, markers of compulsivity

Understanding and hypothesis (cont’d):

From the model we deduct that child processes information based on “cognitive” information, splits positive and negative affect and inhibits the negative

If mother also uses the same type of strategy, she probably has most trouble helping child with negative affect

Intervention has to address supporting mother to identify and validate her child’s negative affect (eventually her own )

Obstacle

Plan and treatment recommendations

Discussion with the post-adoption worker to share understanding and clinical impressions (NB Worker describes anxious mother) and where to focus her intervention & offer collaboration

Discussion with mother about assessment and recommendations which are:

• Series of mother-child interventions focussed on enhancing mother’s sensitivity

• Possibility of individual support to the mother*

Conclusion: ideas to address

Finalize coding of M’s AAI to validate /or modify, add to current hypothesis

Consider the “somatization” development of the DMM ?