Childhood Depression Case Study

By Jennie Shafer / a couple of years ago
This isn’t an article about how to treat childhood depression as an occupational therapist, but is instead a case study of how I figured out I COULDN’T treat a child.
As occupational therapists, we live by the motto “we will find a way or make one”. We are also known for ‘blending science, arts and compassion’ all into a one hour treatment. Obviously, we don’t back down easily and are willing to try anything to help a client. Since I work with children, I feel especially called to FIGURE IT OUT. To understand why a child is acting (or reacting) in a certain way, but some psychological issues, depression, anxiety, OCD, can be more difficult to eek out.

Case Study

First Glimpse

I had a 9 year old boy scheduled for an evaluation with ‘skin sensitivities’ listed on his referral, which I took to mean ‘sensory issues’. (Not all doctors are familiar with OT lingo!)  I went through his paperwork before he came in and found he had no other diagnoses. This is odd because:

  1. At 9 years old, someone isn’t likely to develop sensory processing issues out of the blue.
  2.  While you can certainly have a stand alone diagnosis of sensory processing disorder, it’s unusual. Normally there are other diagnoses that have been tacked on, possibly erroneously, throughout the years.

I go to gather the family and mom is in scrubs and the child is sitting calmly in his chair reading an age appropriate book. I say this because both of these things are highly unusual in my work place. Normally the mother looks exhausted and the child is running around like a mad-man, screaming and playing.

As a therapist, I can generally get a feel for how the evaluation will go, how the child will perform, etc, just by how the family is behaving in the waiting room.

Evaluation Time

Once we start the fine motor evaluation (BOT-2), it is clear as day this child does not have any fine motor difficulties. He had appropriate pencil grasp, was able to understand and complete the tasks, wasn’t showing any sign of behavioral issues, etc. Everything’s coming up aces here…

While the kiddo is working through the BOT, I am conducting a parental interview. Mom reports the child becomes upset when the seams on his socks are wrong, or the sleeves of his shirt don’t fit just right. She also mentioned that he’s been in speech therapy and play therapy for most of his life. I asked about the play therapy and she said he used to struggle with aggression towards his siblings and needed help with his self-esteem. Yet, he’s not on any medication…

If you’re following at home, there are several things here that are standing out as weird. 1. His age and referral status 2. His behavior and fine motor abilities, 3. Play therapy for aggression, yet the kiddo is very calm, cognizant and capable.

As far as social skills go, the child was able to interact typically in conversation, had good eye contact, and was overall behaving like a very calm 9 year old boy. Mom said he does have friends at school, but doesn’t have a desire to be with them outside of school, eg: doesn’t want to go to their birthday parties, have play dates. She also reported he get’s very agitated at large social events like weddings.

After about 10 minutes of discussion with the mom, I terminated the FM evaluation because it was clear this wasn’t the child’s issue. I even told mom that this child wouldn’t qualify for services because his FM skills were appropriate and that even if he does have sensory processing difficulties, that his insurance will not cover treatment on that alone.

I Don’t Understand…

At this point, I was pretty honest with mom and told her I didn’t understand what the problem was. I even asked the boy, ‘what’s the deal with your socks?’. He said “if they are too small, my feet feel squished and if they are too big, you can see them over my shoes.” I replied, ‘well, then why don’t you change your socks?’ and he shrugged. The same thing happened when I asked him about getting a haircut, he easily identified what annoyed him about the process, but basically chose to get annoyed and act out about it.

This to me indicates the child is aware of what annoys him and is cognizant enough to identify it. The sensory issue became a behavioral issue.

We completed the Sensory Processing Measure (SPM), which I like, but unfortunately, nearly all sensory profiles and tests are parent report, which clearly skews the information you get as a therapist. He definitely had reported dysfunction in the tactile input section (skin sensitivities, if you will).  But it just wasn’t making sense to me.

I explained to mom that while, yes, he did appear to have tactile sensitivities, he didn’t necessarily need OT to address his sensory system. He was making a choice to get upset about the activities. (ooohhh I know, I said it).

At this point the mother is getting frustrated and so am I. I’m starting to wonder if this is a munchausen mom (a person who wants something to be wrong with their kid.) I start reviewing the information I’ve gathered and recall her briefly mentioning the child had a ‘strangulation issue’ and had a few resultant headaches from the incident, but that no brain damage had occurred. Naturally I went back to this for more information.

The Real Story

Long story short, the child attempted to hang himself about 7 months ago. (BIG STINKIN’ HUGE RED FLAG). She said he made a rope swing with a loop to place his foot in, then ‘he said he doesn’t know why’ but he put his head in the hole. He was unconscious for several minutes by the time his aunt/cousin/whomever, was able to actually get the noose off him. 

I asked mom if she thought it was attempted suicide and she said she didn’t know.

Hello. It all starts to fall into place. This is not about sensory processing at all- he’s clearly dealing with depression or anxiety or some other type of psychological issue. 

I have a strong feeling mom did not want to believe there could be something psychologically ‘wrong’ with her child and that’s why she’d been running all over kingdom come to find therapies for the kid.

Now we can start getting answers. I was very open with mom that I thought his struggles needed to be addressed by a psychologist. As an occupational therapist, I would not be able to truly help the child. I wanted to speak to my supervisor about this before she left because I didn’t want to send her off with nothing. Thankfully, I was able to get a few local resources for her to follow up with, even though this is certainly not my area of expertise or even experience.

Wrap Up

I presented mom with the resources I had obtained and did my best to empower her. I told her she needed to go with her gut and address her child’s issues head on, because this type of activity is likely to progress if not treated and puberty can exacerbate the problem. The mother was thankful for the resources, but clearly intimidated by what all of this meant. I gave her my number and encouraged her to call me if she hit a wall with obtaining appropriate services for the kiddo.

Conclusion

Obviously this was a difficult situation that mom wasn’t entirely ready to handle. As a therapist, even though the child demonstrated sensory processing issues, I had to be able to identify that they were not sensory driven, but instead part of a larger, complex psychological issue. In fact, the sensory issues should have been the last of moms worries when it came to her son’s behavior.

So many things stand out to me now about this, from his glib answers, to his mom’s reports of anxiety when he was out in public. While I am not a psychologist or a diagnostician, it sounded like the kid was dealing with depression/anxiety. Even when mom said he was doing play therapy to address his self-esteem issues, it should have clicked in my brain.

I could have said, ‘yes, he has sensory issues, here’s a home exercise plan’ or ‘no, he doesn’t have FM issues, so he doesn’t qualify’- goodbye! I’m glad I was able to steer the family in what I hope was the right direction and it was a great reminder to me that as an occupational therapist, we have to look at the WHOLE child and the WHOLE situation for a holistic approach.

Resources

  1. Sundance Behavioral Health

Phone: 817-222-9191

Address: 2707 Airport FWY, Fort Worth, TX 76111

 

  1. Millwood Hospital

Phone: 817-261- 3121

Address: 1011 North Cooper St, Arlington, TX 76011

 

  1. The Excel Center

Phone: 817-335- 6429 or 817-261-3121

Address: 1220 W. Presidio St, Fort Worth, TX 76102

About the author

Jennie Shafer

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