Rate mother Suzanne in the Caregiver domain.

Laura is an 11-year-old girl who lives with her mother, Suzanne, and her 8-year-old little brother, Jerry. Until six months ago, Laura’s father lived with the family, but now he is incarcerated for domestic violence against Suzanne. Laura and Jerry witnessed his attack on their mother. Suzanne’s injuries included a broken pelvis from being shoved down the stairs, requiring her to be hospitalized for 3 weeks with a subsequent and ongoing convalescence at home. Suzanne’s mother came from California to care for Laura and Jerry for almost 4 months during Suzanne’s convalescence before returning home 2 months ago.

Both children are on the autism spectrum. Jerry’s condition is profoundly evident, but Laura’s symptoms are relatively mild, and often not noticed by people who are not familiar with spectrum disorders. She has a friendly personality and smiles easily. But she has difficulty maintaining eye contact and often fixates on specific topics. Her teachers report that she has no conflicts with other children, but that her literal thinking, mild perseveration, and difficulty understanding humor is a barrier to close friendships, and her standoffishness frequently results in other children excluding her.

Laura’s current educational needs (as indicated by her IEP) are primarily related to anxiety and sensitivity to loud noises or inability to tolerate large crowds. Until recently the school’s accommodations have been sufficient to help her maintain acceptable grades. School officials report, however, that in the two months since her grandmother returned to California, Laura’s anxiety has become much worse. She is seldom able to get through a whole day without her teachers allowing her to leave the classroom to self-isolate in a small time-out room adjacent to the social worker’s office. Additionally, within the last few weeks Laura has begun regularly missing a day or two of school each week due to complaints of feeling unwell although there doesn’t seem to be a medical cause. As a result, her grades have fallen.

The school social worker usually visits at least briefly with Laura during her self-isolation periods and has a good rapport with her. While talking with Laura, she noticed that anxiety episodes no longer seem connected to external surroundings or stressful environments. More often, her anxiety is focused on her brother who Laura says is not receiving the support and attention he needs either at home or at the school he attends for children with autism. The social worker reports that Laura has said many times that “Jerry needs me. Nobody can take care of him like I can.”

The social worker contacted Suzanne to talk about Laura’s behaviors and her more frequent absences at school. Suzanne welcomed the phone call, saying Laura is also obsessed with mothering Jerry at home, and Jerry has come to depend on Laura’s constant attention. Suzanne said that, while she tries to show her love for and commitment to them, the two children have developed a “co-dependent” relationship that she fears is not healthy for either of them, and she doesn’t know what to do about it. If she tries to separate them, even to make them sleep in separate rooms, Jerry will become upset and sometimes bite, slap himself or bang his head. Laura becomes hysterical at these times and begins screaming and has started pulling her own hair; she tends to pull at her own hair when her anxiety overwhelms her, and this is a release for her. It is difficult to calm her down, so Suzanne almost always relents and lets them be together in the same room, at which point they quickly calm down and the household can go back to normal.

Suzanne said that before this terrible incident with her husband, she always managed her children’s behavior well, but now she feels frozen. She believes Jerry likely needs a medication adjustment, but she has avoided making an appointment because of ongoing mobility issues that make it very painful to drive. She said she also feels depressed and sometimes overwhelmed by her own and her children’s needs and doesn’t know how to put this experience behind her and start making her life better. She does get some help from a neighbor, but she has no nearby family, and her husband’s family refuses to talk to her since he was arrested. The social worker asked Suzanne if she would like her to refer Laura to a care management program, and Suzanne responded that she would like that very much.

The social worker made the referral, and recently a care manager visited with Suzanne and Laura. The care manager noted that the house was clean but cluttered, with stacks of mail in various places in the living and dining areas. During the initial interview, Suzanne said she has a great deal of difficulty keeping up with bills, because she doesn’t have money to pay them, and it depresses her to even think about them and what things they may have to temporarily go without.

The case manager visited with Laura, while Jerry watched YouTube on a tablet in the same room. The CM noted that Laura’s affect was cheerful, but she provided only very shallow and rote answers to questions, often consisting of just “yes” or “no” or “I don’t know.” She would only make brief eye contact. The only voluntary comment she made was to ask if the social worker had sent her

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