Presenting Situation Ella is a 5-year-old girl who was brought by her mother, Kate, to an outpatient mental health clinic. Kate came because she is concerned with Ella’s frequent and persistent crying, clinginess, and periodic refusal to go to school. Ms. Xiao is the counselor assigned to Ella’s case. In the initial assessment, Kate reports to Ms. Xiao that she doesn’t know how to deal with Ella’s emotional outbursts. Ella cries easily over minor things and is difficult to soothe. When Ella hits a certain point, she is inconsolable. Her whole body shakes and she gasps for air between sobs. If Kate is not there, she cries out for her. If Kate is present, Ella will clutch onto her and cling to her limbs. These outbursts are especially likely when it is time to take Ella to school or when Kate is stressed herself. Getting Ella into the car for school is such an endeavor that Ella ends up missing school at least once a week. School Functioning and Developmental History Kate says that Ella’s teachers are also exasperated by her attendance issues and tantrums. In conferences, they said that they have difficulty predicting how Ella will behave at any given time. In the classroom, she appears distant and inattentive most of the time. When playing, she stops and stares somewhere for a long time before resuming. She does not play with other children and is quiet a lot of the time. When encouraged to interact and participate, Ella can be bright and creative, but she sometimes becomes easily frustrated and often bursts into tears when she becomes upset. At times, her tantrums are so intense that her teachers have to call Kate to come pick her up; otherwise Ella does not calm down. They say that her crying agitates the other students and they don’t have the resources to deal with her in the classroom. Ella’s attendance problems have become such an issue that the school administration has begun asking for a doctor’s note every time she is absent. Ella only began kindergarten a few months ago, and the school has already threatened to expel Ella because of these attendance issues. This is what brought Kate to the clinic; she doesn’t know what to do. After noting these concerns, Ms. Xiao asks about Ella’s development and medical history. Kate says part of her concern is that Ella was calm as a baby, but there has been such a drastic change in her overall nature in the past year. Ella was the product of an uncomplicated, full-term pregnancy with no post-natal difficulties. She was physiologically healthy and her development was on track—she started crawling at six months, spoke her first words at ten months, and started walking at twelve months. She hardly cried and when she did, she was able to self-soothe and usually put herself to sleep. Kate described her as an “easy” child who was typically compliant and pleasant. The Accident It is only after being asked what could have prompted this drastic change that Kate shares that her husband and Ella’s father, Jeremy, died in a car accident a year ago. Struggling to remain collected, she shares a brief version of what occurred: “He had been out of town and was on his way home when it happened. His small car was hit by a van that ran a red light. A nurse was nearby and tried to help but there was nothing she could do. He was dead by the time he got to the hospital.” With downcast eyes, Kate says that she was not informed until hours after her husband’s death. Ella and Kate had been at the zoo all day and Kate had forgotten her phone at home. When they returned home, they found Kate’s younger brother, Richard, with tears running down his cheeks as he waited for them on the porch. He broke the news even before they could enter the house. Kate remembers little of that night, or even the next week or two. Kate and Ella stayed with Richard and his wife that night. Richard’s wife took care of Ella while Richard helped Kate handle the logistics of the funeral and finances. Ms. Xiao asked Kate about how she and Ella have been adjusting since the loss of her husband. Kate said that she has “tried to keep it together” for Ella, but that it’s been very hard. The lifestyle changes are difficult, but she has kept so busy that she has not been able to pause and think. Financial security has been a major source of stress since the loss of her husband’s income. She had to get a job after her husband died and was forced to sell their family home because the mortgage was too high. The other driver in the accident was uninsured, and Kate’s claim on her husband’s life insurance was rejected over paperwork issues. She has been looking for an attorney to help her appeal her case, but they say it might take a few years to settle. Kate got a job as a bank teller, moved in closer to the city, and found an apartment a couple of miles from her brother’s place. Ella Looks for Daddy Kate says that Ella’s problematic behavior seemed to get worse after the move. Their old house was big and spacious, surrounded by gardens that her husband maintained. Ever since she was a toddler, Ella and her father had gardened together. Kate laughed when she thought of Ella’s gardening attempts, “He used to be so patient with her as she would dig out plants, he had just put in. That was their time together. I’m not a gardener myself. I kill anything I try to plant. The new apartment is nice, but small. The neighborhood is busy; there are lots of parks and lots of other kids. Our apartment complex even has a playground in the center. Ella doesn’t seem too interested in any of it. We have a retired neighbor next door, Mrs. Cole, who watches Ella while I am at work. Mrs. Cole says that she asks Ella every day if she wants to go play at the playground, but Ella just wants to wait for me. She just sits by the window and watches for my car. If I’m running late, she gets nervous and becomes frantic if I don’t call to say I’m on my way.” Ms. Xiao comments that Mrs. Cole seems to be a real help to Kate. She asks about other support systems Kate might have. Kate mentions her brother, Richard, and his family again. However, Richard’s life is busy. He is working full time, married, and raising a toddler and a baby. Nevertheless, he and his family have been trying to help Kate ​‌‍‍‍‌‍‍‍‌‍‍‍‌‌‌‌‌‌‍‍​in any way they can. On Sundays, when she is feeling up to it, Kate and Ella accompany his family to church. Ella gets along with her cousins, really admires her aunt, and seems to enjoy the singing during the service. Before continuing the interview, Kate sends Ella to go play in the corner. “Going to church has been difficult for me lately. I still can’t understand why God let this happen in our lives.” She hesitates but continues, “I had been carrying my second child at the time but miscarried right after I lost Jeremy. He didn’t even know she existed yet. I’m not sure if that makes it better or worse.” Sensing Kate’s discomfort, Ms. Xiao redirects the conversation to Ella again. She asks how Ella responded to hearing about her father’s accident, since children at that age generally do not understand the concept of death. Kate shares that Ella initially asked a lot of questions about her father. She often asked when Jeremy would be returning and was disheartened each time, she learned that daddy won’t be coming home. She talked about him daily and asked questions about dying and what happens to people after they die. After her miscarriage, Kate was in the hospital for a day and spent a lot of time in bed for the next few days. Ella became extremely worried about her mother during that time. Since then, whenever someone becomes ill, she asks if they are going to die. Kate recalls an incident when Ella found a dead bird in the yard. She became concerned with it and insisted that Kate bury the bird. At her brother’s suggestion, Kate and Ella attended a grief counseling session, but Kate found it so upsetting that they didn’t return again. Since that time, Ella refuses to talk about her father or his death and becomes very angry if she’s questioned about him. Kate Attempts to Cope When asked about Ella’s current functioning, Kate says that Ella doesn’t sleep well at night, “She shows up in my bed, crying about a bad dream, but only remembers something about monsters.” Early on, her aunt could calm Ella by telling her that when she missed her dad, he would visit her in her dreams. That worked for a while, but the nightmares have come back. Nowadays, Ella is afraid to be in her room alone at night. She becomes irritable throughout the day and gets angry with her mother and Mrs. Cole easily. She can’t follow directions once she becomes agitated or irritable. Her frustration frequently leads to tantrums and outbursts. Kate assures Ms. Xaio that she’s very invested in her child and wants to be compassionate and supportive but is also becoming tired of her clinginess. She allows Ella to stay home from school if she is “too upset” and often lets her sleep in her bed at night when she is afraid. Kate clearly feels for Ella and acknowledges that she lets her “get away with things” that she would have received consequences for before. Kate admits that she becomes tired by the end of the day and just allows Ella to let “her frustration out”. When asked for an example, Kate says that Ella sometimes becomes rude and defiant, but she lets it go “because Ella has a right to be angry.” The school’s recent threat of expulsion has been very stressful for Kate, who says, “I know I need to get Ella’s behavior under control, but I don’t know what to do”. At the end of the visit, Ms. Xiao assures Kate that they will work together to find the best treatment. She sets up the next appointment and sends Kate and Ella home. Ms. Xiao compiles all of her notes and begins to strategize a therapy plan for Ella. As she reviews her papers, she thinks back to several years ago when her own pregnancy ended in a miscarriage. A memory of feeling a sharp pain and looking down to see blood flashes through her mind. She has not been able to conceive since. Ms. Xiao’s heart starts beating faster, and she starts to feel lightheaded. She closes her eyes, takes a few deep breathes, and pulls out her cell phone. She makes an appointment with the counselor who helped her deal with her own loss. Paper is based on above Case Study and these following reflection questions. Reflection Questions How might these events be interpreted differently if the school utilized a trauma-informed lens? What examples can you identify where Kate’s own distress