This paper is based on the case study of a 14 years old girl Frances. She suffers from mild development disability and neurofibromatosis, which is a genetic disorder. Frances have conflicts with her parents and also suffers from depression. Frances often feels lonely at the school and because of the genetic disease she suffers from, other children also tease her. The referral for Frances was made by the school counselor, when Frances informed them about deliberately cutting herself. Her parents also informed that she refuse to complete her homework, and often become aggressive with her parents, whenever she is challenged. Frances suffers from mental as well as physical problem, due to which she is not able to live a quality life. Her condition has also made her aggressive and unstable. According to the given case study, she has lack of family support and social support, due to which her condition is becoming worse. Thus, the aim of this paper is to prepare an assessment plan, formulation and a treatment plan for Frances. Paper will also discuss the challenges that may arise during the course of treatment.
Frances suffer from mild developmental or intellectual disability. The children, who suffer from mild intellectual disability, are generally two or three years back in academics, language, socially and in different cognitive areas, when they are compared to children of same age. The development of such children is slow, but they are able to learn academic skills, activities of daily life and can also perform other household chores. Frances also have mild developmental disability and her development in all the areas has been slow. However, she has been able to learn all the practical skills; she has not been able to blend socially. She has the ability to function in the daily life, but she suffers from aggression and depression.
She suffers from two genetic problems since birth; first is mild development disability and second is neurofibromatosis. The later is the genetic disorder, which is characterized by neuroectodermal abnormality. There is a progressive involvement in the disease, which mainly impacts the skin, nervous system, bones, eyes and possibly other organs as well. The disease can be manifested in various ways and these manifestations may vary from person to person (Vranceanu, Merker, Park, & Plotkin, 2015). In the last six month this disease has gain much progress in the case of Frances and due to her physical appearance, she is been teased at school. This disease is associated with the family history.
Quality of life and social development of the adolescents suffering with NF are adversely affected. NF1 is the most common disorder, which appears since birth. This disorder is very challenging for the children and adolescence like Frances. Childhood and adolescence is the period, which is itself very challenging for the individuals, where most of their focus is on developing a sense of self, forming relationships, mastering in academic and social integration. For the individual suffering with NF, the change in physical appearance becomes very difficult (Vranceanu, Merker, Park, & Plotkin, 2015).
Frances suffer from neurocognitive and physical symptoms of NF. The children with this disorder have to face the myriads of social, emotional and physical problems. According to Martin et al (2012), “children with NF1 experience more problems with social skills, anxiety, depression, and aggressive behavior compared to normative means and unaffected siblings”. Frances is also different from her 16 years old sister. Her sister is academically bright. Frances suffer from learning and thinking difficulties due to the genetic disorder NH and mild development disability. The children suffering with neurofibromatosis are at the higher risk of being present with behavioural and emotional problems (Riccio, Sullivan, & Cohen, 2010). The children with NF suffer from varying degree of cognitive impairments and are at the risk of behavioral and emotional dysfunction.
The study carried out by Noll et al (2007), evaluates the psychological difficulties that children with NF1. Such children are more socially isolated and display less leadership skills. Such children also displayed low social functioning and are less linked to their peers. Frances also suffers from mild development disability, which has also increased her learning and thinking disabilities. The assessment for the Frances will include skin assessment for understanding the progression of the disease. Assessment of the growth and development will also be done to evaluate developmental problem in her. Assessment will also include evaluation of physical abnormalities and cognitive disabilities.
She requires a wide array of interventions and care actions. The neurological assessment will include behavioral and cognitive checklist, preliminary language screening and special education for learning disabilities. The assessment of Frances will include the details about the medical history including the onset of the behavior disorders, environmental stressors, and family history of psychiatric problems, functional impairments, and impact of behavioral problems on family members.
Development of the Frances problems is associated with her genetic disorders. Frances suffer from Neurofibromatosis 1 (NF1), which is a condition associated with an autosomal dominant patter of inheritance. Diverse complications are associated with the problem and manifestations may differ from individual to individual. The most common clinical manifestation in NF1 “include caf?-au-lait macules, skin-fold freckling, cutaneous and plexiform neurofibromas, scoliosis, and optic gliomas” (Martin et al, 2012).There are no effective treatments found for this genetic disorder other then surgical removal of the tumors. The surgical procedure is also complicated, as it can damage the nerve tissues and tumors can also re-grow (Tonsgard, 2006).
The studies have also found the involvement of the central nervous system in this disease, due to which the children may also suffer from cognitive disabilities or impairments. Some of the areas of deficits are problems with functioning, planning memory, visual problems and other issues like socio-cultural problems. The physical and neurocognitive symptoms associated with NF1 and mild development disability, Frances suffer from various social, emotional and physical problems. Development and maintenance of her disease is associated with lack of family and peers support. According to Child Behaviour Checklist (CBCL), the parents and teachers of the children suffering with NF1 have rated them worse than their unaffected siblings.
The psychological well-being of Frances has been affected due to various reasons. These reasons include the severe progression of the disease, un-acceptance from the peer and daily conflicts that child and family face. According to the study of Martin et al, (2012), “cognitive functioning, disease severity, and environmental stressors may contribute to social–emotional wellbeing in children with NF1”. Frances is also going through various stressors, such as conflicts with her parents, rejection from classmates, and sudden progression of her disease, which is also affecting her physical image. All these problems are contributing in increasing her loneliness and depression. The study of Noll et al (2007), states that children suffering with NF1 have very few friends and they are less liked by their peers. Such children are also found to be socially isolated. Same is found in the case of Frances, she feels socially isolated because she is teased at the school due to the physical symptoms of the disease (Ferner et al, 2007).
Mild development disability does not have any kind of physical symptoms, but they contribute in cognitive and emotional impairments. Due to depression she has started hurting herself. Her emotional well-being is affected and she also has behavior problems. The involvement of the central nervous system has contributed to the psychological problems. The study of Vranceanu et al (2015) found that involvement of the nervous system increases the risk of psychological problems and other problems associated with social acceptance, friendship and also emotional functioning (i.e. depression). Due to the emotional troubles, the children suffering with NF1 also suffer from anxiety and depression. Frances also suffer from depression, which is turning her towards aggression. The study conducted by Coutinho et al (2016) concluded that children suffering with NF1 face neuropsychological disabilities, which also includes behavioral problems and learning difficulties. Due to all these problems, Frances is not able to cope with her condition and her behavioral problems have lead to aggression.
The qualitative study carried out by Barke, Coad, & Harcourt (2016) informs that children with NF1 and their parents have problem in managing the uncertainty of the disease. They are also affected by the altered appearance of their children and have less understanding of disease management. Due to such problems, parents are not able to significantly help their children with development disabilities. The study also found that providing effective information about the disorder and related symptoms have been beneficial for the parents. Parent understanding and awareness towards the disease, has helped them to support their children. Frances’s parents also lack understanding and awareness of the development disability and neuropsychological problems she is going through.
The study of Ageranioti-B?langer et al (2012) informs that children suffering with intellectual disability also suffer from behavior disorders. Such disorders can create problems in everyday life of children and also results in psychiatric illness. The behavior problems in such individuals significantly impacts the family members and also affects the “individual’s level of functioning including cognitive, adaptive, social-functioning, levels of receptive understanding and expressive language” (Ageranioti-B?langer et al, 2012). Family history can significantly affect the condition of the Frances. Family history of depression can also result in her depressive and aggressive condition. The psychiatric problems are found to be very high in individuals suffering with development or intellectual disabilities. Thus, Frances may also suffer from such problems due to psychiatric illness.
Treatment Plan for Frances
There is no specific treatment for the NF1, but the treatment of Frances will mainly focus on the behavioral problems, functional and cognitive disabilities.
Involvement of the Parents and Family members: The first intervention for the treatment of Frances will include the involvement of the caregivers. The first care givers for Frances are the family member. Involvement of the family members and parents in care of the individual helps in providing positive environment (Ageranioti-B?langer et al, 2012). Frances lack the support and care of family. Involvement of her parents in the care plan can help her to build bonding with her parents. Engaging families in the treatment of the children provides great benefit. The great degree of parental involvement helps children to gain confidence, feels supported, and also helps in providing valuable insight to their condition (Ferrel, 2012). Frances is going through depression and isolation. Involvement of her family members will help her to come out of isolation and to participate in social activities.
Challenging Behavior: Challenging behavior is seen in Frances, which impacts the daily life of her and her parents as well. Challenging behavior includes problem of self injury, aggression, non-compliance and destroying objects (Ke, & Liu, 2012). These problems can be overwhelming for the family and may also seek medical help. Such individuals are often not able to cope with their condition. Behavior assessment and treatment is very important for Frances, because it will help in correcting her behavior and will increase the quality of her life. “Challenging behaviour, such as aggression towards others, self-injury or non-compliance, is often concerning reason for a behaviour assessment” (Virtanen, 2016). Frances will be observed for environmental stressor that triggers the challenging behavior. Her daily routine requires to be observed for possible environmental factors for her challenging behavior. Interview of Frances with psychiatrist will help in finding stressors.
Medication: Medication is an effective treatment that can be used in the case of Frances to control her behavior and depression. Medication can be provided according to the prescription of the healthcare professional. Medication helps in controlling behavioral challenges (Ke, & Liu, 2012). There are many medications like antidepressants, antipsychotics and mood stabilizers that can be used in treatment of Frances.
Ineffective Coping: The treatment for ineffective coping is very important in the case of individuals, who are suffering from beahvioural, cognitive and functionin problems. Frances suffer from mild development disability as well as NF1, which resulted in hel altered behavior and social isolation. She is also found involved in self-injury. To encourage patient for forming coping skills it is important to establish therapeutic relationship with her. Frances will be provided with supportive and caring atmosphere, where she can discuss freely about her problem, fears and feelings (Townsend, 2010). Altered body image may be the main reason of problem, thus she will b supported to accept her physical image and to feel comfortable with it. She must also be encourage to identify her own strengths and capabilities to deal with her problems.
Barriers or Challenges
The three major challenges or barriers that may arise while treating Frances are
- Resilience could be the challenge that can hamper treatment. Development of resilience in Frances is important for improving treatment outcomes, so she will be encouraged to stay positive, develop hope and ability to cope with stress. She will be encouraged for self regulation over feelings and thoughts (Stuntzner, & Hartley, 2014).
- Non-Adherence could be another barrier in case of Frances. Due to beahvioural problems, she may not adhere to treatment plan. Non compliance or non adherence to the treatment can result in increasing severity of the disorder. The main goal would be to make therapeutic relations with Frances and her parents will be involved for supporting her.
- Depression is also barrier in the case of Frances. She may not be able to accept the treatment or to understand the importance of treatment. Medication will be used to overcome this barrier.
This paper is based on the case study of 14 years old girl Frances. She suffers from mild development disability and neurofibromatosis (NF1). The paper discussed assessment plan for Frances followed by a formulation and treatment plan. Paper also discussed the three major barriers that may arise while treating Frances.
Ageranioti-B?langer, S., Brunet, S., D’Anjou, G., Tellier, G., Boivin, J., & Gauthier, M. (2012).
Behaviour disorders in children with an intellectual disability. Paediatrics & child health, 17(2), 84.
Barke, J., Coad, J., & Harcourt, D. (2016). Parents’ experiences of caring for a young person with neurofibromatosis type 1 (NF1): a qualitative study. Journal of community genetics, 7(1), 33-39.
Coutinho, V., Kemlin, I., Dorison, N., de Villemeur, T. B., Rodriguez, D., & Dellatolas, G. (2016). Neuropsychological evaluation and parental assessment of behavioral and motor difficulties in children with neurofibromatosis type 1. Research in developmental disabilities, 48, 220-230.
Ferner, R. E., Huson, S. M., Thomas, N., Moss, C., Willshaw, H., Evans, D. G., ... & Kirby, A.
(2007). Guidelines for the diagnosis and management of individuals with neurofibromatosis 1. Journal of medical genetics, 44(2), 81-88.
Ferrel, J. (2012). Family engagement and children with disabilities: A resource guide for educators and parents. Family Involvement Network of Educators (FINE).
Ke, X., & Liu, J. (2012). Intellectual disability. Retrieved From:
Levine, T. M., Materek, A., Abel, J., O’Donnell, M., & Cutting, L. E. (2006, March). Cognitive profile of neurofibromatosis type 1. In Seminars in pediatric neurology (Vol. 13, No. 1, pp. 8-20). WB Saunders.
Lewis, A. K., Porter, M. A., Williams, T. A., North, K. N., & Payne, J. M. (2016). Social Competence in Children with Neurofibromatosis Type 1: Relationships with Psychopathology and Cognitive Ability. Journal of Childhood & Developmental Disorders.
Martin, S., Wolters, P., Baldwin, A., Gillespie, A., Dombi, E., Walker, K., & Widemann, B.
(2012). Social–emotional functioning of children and adolescents with neurofibromatosis type 1 and plexiform neurofibromas: relationships with cognitive, disease, and environmental variables. Journal of pediatric psychology, jsr124.
Noll, R. B., Reiter?Purtill, J., Moore, B. D., Schorry, E. K., Lovell, A. M., Vannatta, K., & Gerhardt, C. A. (2007). Social, emotional, and behavioral functioning of children with NF1. American Journal of Medical Genetics Part A, 143(19), 2261-2273.
Riccio, C. A., Sullivan, J. R., & Cohen, M. J. (2010). Neuropsychological assessment and intervention for childhood and adolescent disorders. John Wiley & Sons.
Sangster, J., Shores, E. A., Watt, S., & North, K. N. (2010). The cognitive profile of preschool- aged children with neurofibromatosis type 1. Child Neuropsychology, 17(1), 1-16.
Stuntzner, S., & Hartley, M. T. (2014). Resilience, Coping, & Disability: The Development of a Resilience Intervention.
Tonsgard, J. H. (2006, March). Clinical manifestations and management of neurofibromatosis type 1. In Seminars in pediatric neurology (Vol. 13, No. 1, pp. 2-7). WB Saunders.
Townsend, M. C. (2010). Nursing diagnoses in psychiatric nursing: care plans and psychotropic medications. FA Davis.
Virtanen, M. (2016). Nursing interventions in the management of challenging behaviour in adults with learning disabilities.
Vranceanu, A. M., Merker, V. L., Park, E. R., & Plotkin, S. R. (2015). Quality of life among children and adolescents with neurofibromatosis 1: a systematic review of the literature. Journal of neuro-oncology, 122(2), 219-228.