Social work practice with a Taiwanese family experiencing mental retardation

Mental Retardation

This work examines the case study of a Taiwanese Family in which one of the children, Po-Sheng, 23 years of age, has mild mental retardation. This family is experiencing frustration and angst because Po-Sheng feels that he should be allowed more freedom and independence than his parents allow. This work takes a look at the values and principles in the social worker's practice that are relevant in view of this particular family which is the focus of this case study. "Social work knowledge is based on a range of perspectives and content areas derived from various schools of thought. Hepworth, Looney and Larsen (1997) note that the Council on Social Work Education (CSWE) categorized the knowledge base for social work practice into five content areas: Human Behavior and Social Environment; Social Welfare Policy and Services; Social Work Practices; Research; and Practicum. The National Association of Social Workers further identified 25 knowledge areas needed for effective social work practice. To become culturally competent, social workers must acquire technical and substantive knowledge in social work as well as cultural information" concerning their clients."

Berger, Federico and McBreen, 1991, Cross et al. (1989) Devore and Schlesinger (1996), Green (1995), Leight (1998), Lum (1994), and Wilson (1982) identified over 50 knowledge areas and attributes essential in developing cultural and ethnic competence." The following is a partial list of the knowledge areas:

1. Knowledge about human behavior including individual and family life course consideration of the family and the effect that bio-psycho-social, cultural and spiritual systems have on their behavior;

2. Knowledge about the family sub-culture;

3. Knowledge about the impact of class, ethnicity, dialects and speech communication patterns;

4. Knowledge about the perceived effectiveness of service providers and social services in meeting identifiable needs of their clients; and 5. Knowledge about the ways that professional values, knowledge and skills may clash with those of family members.

The NASW 'Code of Ethics' states that the core values of social work practice are inclusive of: (1) social justice; (2) dignity and worth of the person, (3) the importance of human relationships, (4) integrity; and (5) competence." Additionally stated is: "Within these values are ethical principles that social workers aspire to attain. Cultural Competence and Social Diversity are emphasized in the social work practice. Among these principles are the following values:

1) Value cultural diversity and cultural integrity with a genuine and open appreciation of inter and intra-group differences;

2) Value the social and historical contributions of the client in relation to their culture, community and the broader society.

3) Value the cultural resources and natural support system utilized by the family in problem-solving;

4) Respect the traditional beliefs, folk methods, and spiritual roles of the family members.

5) Value culture and ethnicity as interactive and emergent forces in the life of the client.

6) Validate the experiences (positive and negative) of the family members from a social, cultural, historical, political and spiritual perspective.

In the area of skills there are core skills which are a requirement for social work practice. The work of McMahon (1996) categorizes foundation skills into four key areas:

1) Relationship skills;

2) problem-solving skills;

3) Political skills; and 4) Professional skills subsumed under the overarching person in environment perspective."

This method of practice is inclusive of "micro or direct practice with individuals, families and groups, and macro practice with communities, organizations and policy planning arenas." There are 26 total skills and abilities identified by NASW that are essential in social work practice. Stated is that social work skills "reflect a broad range of interpersonal, technical, therapeutic and organizational skills that are comprehensive, complex and enable social workers to work with diverse populations and settings.

I. Purpose and rationale for the paper

The purpose of this paper is to examine the values and principles as set out by NASW in relation to the relevance of those values and principles to the case study that is the focus of this work.

II. Clear presentation of the client system

The objective of this work is to report a case study on a Taiwanese Family where one of the members has mild mental retardation. The Hsiang family is comprised of the father; Joseph Hsiang, 56 years of age; the mother; Helen Hsaing, 53 years of age, Po-Sheng the son who is 23 years of age and who has mild mental retardation and Andy, the brother who is 19 years of age. This family previously lived in a rented home but were evicted due to the problematic behaviors of Po-Sheng. Po-Sheng has been found trespassing in a neighbor's backyard and the police were called but no charges were filed. The Hsiang family has only recently emigrated from Taiwan two years ago and have not adjusted to the cultural life in the United States. Helen's sister sponsored the family to come to the United States because the family believed that Po-Sheng would received better services for those with mental retardation than in Taiwan. The Hsiangs speak Mandarin Chinese at home and have limited English-speaking ability except for their son Andy who currently attends university. The language barrier has greatly limited the family in assimilating into the American culture. Isolation is one problem experienced by this family. Po-Sheng does not believe that he is limited in any way and craves freedom and independence which is allowed the brother Andy, who is younger. Po-Sheng has been diagnosed with Attention Deficit Hyperactivity Disorder and Impulse Control Disorder due to his exposure to mercury poisoning when his mother was pregnant with him. Helen apparently ate some fish tainted with mercury. The effects of mercury poisoning have led to developmental delays with Po-Sheng and he was tested in the United States and had an IQ of 68 which meant he has mild mental retardation. Po-Sheng fell behind in school and refuses to attend in the U.S. stating the school is too loud. There is constant argument between Po-Sheng and his parents regarding not listening or doing his chores. This results in communications problems within the family and the self-worth and self-esteem of the family is very low. The family has sought help from the community mental retardation agency due to their limited English and lack of knowledge surrounding mental retardation. The Hsaing family is frustrated and confused with the services being provided and are skeptical of the relationship with the social services agency due to the language barrier. The family strengths include a constant love for one another and the family is financially stable having lived prudently due to their cultural background. Both Po-Sheng's mother and father are educated and hold bachelor degrees from Taiwan universities. The family is involved in church and receives a great deal of support from the church members. The cultural beliefs of the Asians people view mental retardation and mental illness as something evil and shameful to the family. (Smith and Ryan, 1987) Because of the language barrier Po-Sheng's parents are not fully informed and there is clearly a lack of language appropriate and culture-appropriate information relating to the nature of mental retardation and the course that intervention should take.

III. Social Policy

It is important that social policy take into account the diversity expressed in and among the many races and ethnicities that social policy is idealistically designed to serve and protect. Melvin Delgado writes that: "Culture represents humankind's master plan; it molds our way of explaining the world and charts the limits of allowable behavior." (2004) Furthermore Delgado writes that "Ethnicity is an equally significant concept in the ecological perspective with multiple definitions and relevance to service providers. In a sense, ethnicity refers to a sense of peoplehood, a psychological and social identity involving commonality and loyalty to race, religion, nationality and ancestry (Cos and Ephross, 1998; Devore and Schlesinger, 1996). It is distinguishable as categorical and transactional ethnicity (Gteen 1995)" (Delgado, 2003) Delgado states that "categorical ethnicity refers to specific predetermined traits or 'content' about a group such as color, food, music, dress and the like, believed to be descriptive and characteristic of a particular group." In contrast, transactional ethnicity focuses more on ethnic boundaries that define a group - the manner in which people behave, communicate and act upon their differences. The former is presumed to stigmatize and perpetuate existing stereotypes and preconceived notions about ethnic groups, while the latter views ethnicity as an emergency positive feature of human development (Green, 1995). (Children are often stigmatized when the have mental retardation even in its mildest form. The work of Jones 2006) states that:."..self-stigmatization - the internalizing of stigma - is one of the most significant barriers keeping people from accessing mental health treatment."

In fact Jones states that "Fifty-four million Americans - nearly one in five - have a mental health disorder and nearly two-thirds of them won't seek treatment because of stigma. That means the playground stereotypes that affect our attitudes have consequences - often fatal consequences."

Even within the American society the stigmatization of mental illness still exists due to lack of understanding. Jones relates that statement of Corrigan: "Our work suggests that the biggest factor changing stigma is contact between people with mental illness and the rest of the population. The public needs to understand that many people with mental illness are functioning, fully contributing members of society." (Jones, 2006) Jones states that "the social cost of stigma associated with mental illness is high because it translates into huge numbers of people with treatable mental illness not getting help." Jones relates the fact that the National Alliance of Mental Illness (NAMI) is a group of advocates that works toward fighting the "inaccurate, hurtful representations of mental illness" that are found in the media. Jang (2002) states that the National Health Law Program has a priority to access of healthcare. In fact, the Executive Order (EO 13166) was focused toward the implementation of guidelines in overcoming the language barriers. Jang states that LEP individuals continue to face significant challenges and problems when healthcare providers use untrained interpreters, particularly family members and/or friends to interpret for patients. The reason for this is that many times friends or family members will misinterpret or self-interpret and in many languages there just are no words to convey the precise meaning that needs to be conveyed to the individual. There are many considerations in the initiative of assisting the independence of clients. Jones (2006) states that: "Social workers need to change some powerful mental models before they can effectively advocate and negotiate appropriate accommodations for their clients with mental illness who are entitled under the ADA."(Jones, 2006) This mental models are filled with misassumptions and myths. They are not 'evidence-based'. The mental models include the following:

Mental model: People get worse when they are forced to go to work.

Reality: "There is absolutely no research evidence to prove that people with mental health conditions will decompensate because they work. There is none. On the contrary, there is significant research evidence that suggests that people improve and recovery is promoted by employment."

Mental model: People don't want to work.

Reality: Seventy percent of people with a severe mental illness want to work.

Mental model: Individuals must have their benefits protected because you can't get back on benefits once you're off them; they will face a long waiting period to get back on benefits.

Reality: "It is not true that once you are working that you can't get back on benefits [SSI (supplemental security income) and SSDI (Social Security Disability Insurance)]. It also is not true that there is a long waiting period to get back on benefits once you are off them. In fact, there is no waiting period at all. Another misconception is that if you are working you will lose your health benefits."

Mental model: People on medications do not have the energy to work.

Reality: Medications can be adjusted to support working people. Morris has found that often medications do have to be adjusted because families have preferred that their family member with a mental health condition is sedated, which makes it easier for them but creates problems in the workplace." (Jones, 2006)

These are only a few of the misconceptions that exist in relation to mental retardation.

1) Develop positively worded expectations

2) Select expectations that all family members agree on and are willing to enforce; and 3) Combine expectations into three or four housewise rules. (Universal Preventative Practice for Use in the Home for Children with Behavioral Problems, 2007)

Effective instruction of this expectations for behavior may be accomplished through the following steps:

1. Review the housewide behavioral expectations with the child and with the family members who will be implementing the universal preventative practices. This review can be done through discussion and examples. For example, Marcel and his father, mother, and sister may sit down and discuss how the housewide rules were created and what they are.

2. Demonstrate how using the housewide rules leads to the behavioral expectation. For example, Marcel's father may use the rule "Respect others" and provide verbal examples of what that may look like during Marcel's after-school routine. "Your after-school routine is doing your homework at the kitchen table, then you can play video games at the kitchen TV until your mother tells you it is time for dinner. When you hear her say, "Marcel, it's dinnertime, please turn the TV off," you can show your respect for her by following her directions and turning off the TV. When you yell at her and refuse to turn the TV off, you are not following the housewide rule of "Respect others."

3. Let the child practice the housewide rule and give feedback based on his or her performance. To demonstrate the rule, the family can create role-playing scenarios in which each family member takes his or her role and each provides feedback on whether the rule and the consequent behavioral expectation was observed. It may also be helpful for the child to take on the role of another family member to see what it is like when the housewide rule is not followed. For example, Marcel may take on his mother's role as she refuses to do what he asks.

4. Praise and reinforce the correct use of the housewide rule and the behavioral expectation. This praise and reinforcement should be provided each time the child displays the desired behavior. It can take many forms: oral ("Awesome!" "Great job!"), physical (hi-five, hug, pat on back, smile), and tangible (a family treat). 5. Review the housewide rules and behavioral expectations specific to the routine being targeted. For example, the child or another Review the housewide behavioral expectations with the child and with the family members who will be implementing the universal preventative practices. (Universal Preventative Practice for Use in the Home for Children with Behavioral Problems, 2007)

Comprehensive Diagnosis

Exposure to lead may have one of many effects on the development of a child and the child's behavior. Inattentiveness is one symptom as well as are hyperactivity and irritability. Children exposed to large levels of lead have more difficulty learning as well as reading and often experience delayed growth and loss in hearing. In addition to this Po-Sheng has been diagnosed as ADHD meaning that Po-Sheng's behavior is characterized by impulsivity and trouble in paying attention during class including his causing problems in the classroom. The child with ADHD is stated to have some of the following symptoms:."..trouble paying attention inattention to details and makes careless mistakes easily distracted loses school supplies, forgets to turn in homework trouble finishing class work and homework trouble listening trouble following multiple adult commands blurts out answers impatience fidgets or squirms leaves seat and runs about or climbs excessively seems "on the go" talks too much and has difficulty playing quietly interrupts or intrudes on others." (Lead Exposure in Children Affects Brain and Behavior (2004) Often the child with ADHD has an accompanying disorder such as:

1) conduct disorder;

2) anxiety disorder;

3) depressive disorder;

4) bipolar disorder. (Lead Exposure in Children Affects Brain and Behavior, 2004)

If the child is not properly treated, as in the case of Po-Sheng, the child may fall behind the class in schoolwork. Treatment variations include "cognitive-behavioral therapy, social skills training, parent education, and modifications to the child's education program. Behavioral therapy is helpful in assisting the child in controlling aggression, modulating social behavior and in becoming more productive. Cognitive therapy is greatly assistive in building the individual's self-esteem, reducing negative thoughts and improving problem-solving skills. It is possible for parents to learn management skills inclusive of giving instructions in steps instead of multiple instructions at once. Medication in the form of stimulants such as methylphenidate ands amphetamine as well as the non-stimulant, atomoxetine are available including medications such as guanfacine, clonidine, and other antidepressants. (Children Who Can't Pay Attention/ADHD. 2004)

The work of Magana'a, Scwartz, Rubert and Szapocanik (2006) states that: "The majority of adults with mental retardation live at home with their mid-life and aging parents (Braddock, 1999; Fujuira, 1998; Seltzer, Greenberg, Floyd, Petee, and Hong, 2001)." The work of Heller, Miller and Factor, 1997; Seltzer and Krauss, 1989; and Smith, 1996 states that there is a growing body of research concerning understanding the experiences of older parents who have adult mentally retarded children living at home under their care. Researcher have just recently acknowledged "ethnic variations in the caregiving process and its consequences for caregivers." (Magana'a, Schwartz, Rubert, and Szapocanik, 2006) it is acknowledged in this work that the investigation of the role of family relationships and the potential for caregiving stressors and family burden are importance for understanding. Stated is that "maladaptive behaviors will have a negative impact on family relationships, which in turn will lead to higher levels of family burden and subsequently higher levels of caregiver psychological distress." (Ibid) This study further found that "higher levels of acculturation are related to lower levels of depression among older adults. The findings of this study state that" the relationship of family burden to caregiver distress highlights the importance of assessing the whole family's needs and problems..." (Ibid) Helping the caregiver and service provider identify each family member's needs may lead to better referrals to family services for caregiving families."

Within the realm of the social worker's direct practice there are both knowledge and skills required in knowing what 'to' and what 'not' to do. Mental retardation is defined as follows:

Mental retardation identifies a subset of persons who have developmental disabilities with below-average general intellectual functioning measured through standardized general aptitude evaluation tools before the age of 18 years of age. Mental retardation accompanies two or more deficits in adaptive behavior used for everyday living (e.g. communication, self-care, home-living, social skills, community use, self-direction, health and safety, functional academics, leisure, work) as determined by a structured evaluation tool such as the Vineland Adaptive Behavior Scales."(Prater, and Zylstra, 2006)

Protection of Clients

Prater and Zylstra (2006) state that it is important to monitor the behavior of someone who has mental retardation as a "change in behavior may be the first indication of a problem. An unrecognized medical disorder or environmental change should be considered before concluding that a new challenging behavior or an exacerbation of a previous behavior is caused by a underlying psychiatric disorder." The following table lists the 'Triggers for challenging behavior in persons with mental retardation':

Triggers for Challenging Behavior in Persons with Mental Retardation

____Type of Stressor

Examples

Transitional phase Change of teacher or residence, adolescence or retirement of patient

Interpersonal loss or reject Loss of parent, job, romantic partner

Environmental Stress at group home or day program

Family, social support problems

Neglect from family, friends, caregivers, abuse

Medical or psychiatric illness Tooth pain, depression

Anger, frustration Being teased; inability to complete tasks.

The following table lists topics that must be addressed in relation to 'relationships, sexuality, and protection from harm in person with mental retardation.

Protection from harm

1. Alcohol and drug use

2. Physical, emotional and sexual abuse

3. Sexually transmitted diseases

Relationship development

1. Respecting the boundaries of other persons

2. Setting boundaries

Sexuality

1. Appropriate and inappropriate behaviors

2. Appropriate and inappropriate dress

3. Appropriate and inappropriate places for behavior

Religion

The work of Surface (2006) published in Social Work Today states that: Today, social workers are being challenged to acknowledge and understand how their own core beliefs enter into their relationship with clients and then manage that in ethical and competent ways." (2006) it is advised in the work of Surface that social workers "consult with religious authorities from their client's tradition to help them interpret how that particular religious community views religious concepts..."(2006) Social workers are cautioned against sharing religious beliefs "at a time when the client is especially psychologically or emotionally vulnerable." (Surface, 2006) the reason given is that: "the client may make decisions involving deeply moral matters, such as divorce and reproductive rights, based on the social worker's beliefs." (Surface, 2006)

Language Barriers

The most common interpreter errors were shown in the study of Dr. Flores to be those of:

Omission (52%), in which the interpreter left out an important piece of information.

False fluency (16%), in which the interpreter used words or phrases that didn't exist in a specific language.

Substitution (13%), in which a word or phrase is replaced with another word or phrase of a different meaning.

Editorialization (10%), in which the interpreter's opinion is added to the interpretation.

Addition (8%), in which a word or phrase is added by the interpreter

Stated in the work entitled: "Language Barriers Lead to Medical Mistakes" is the fact that: "45 million people in the U.S. speak a language other than English in their homes, and of those, 19 million are limited in their proficiency of the English Language." (2007) in sixty percent of the errors during the study there were "potential clinical consequences." Currently only five states include the services of an interpreter in insurance policy coverage which are the states of Hawaii, Maine, Minnesota, Vermont and Washington. The legal costs associated with lawsuits relating to misinterpretation by medical practitioners is astronomical as compared to the relatively small cost of insurance coverage of interpreters for non-English speaking patients.

The work of Duvdevany (2003) states that the study made examination of a social support system and its effects on the "level of stress and the sense of personal well-being of 100 Israeli Arab mothers of young children with special needs." Fifty mothers were stated to be served by the Nazareth area welfare services while another fifty did not receive help regularly. A comparison was done between mothers who were educated and urban and those who were rural and less-educated. The results point to "a relationship between informal support resources, and the marital and economic stress of the mothers: the higher the amount of the informal support resources, the lower the level of stress that was experienced by the mothers. A relationship between the amount of informal support and level of parental stress was not confirmed. A relationship between the amount of support resources and the personal well-being of the mothers was found: the higher the amount of informal support resources, the higher the sense of well-being of the mothers. A relationship between formal support (the welfare services), and level of stress or personal well-being was not found. Education and place of living were not related to level of stress or personal well-being. Educated mothers from urban areas used the formal support (the welfare services) less than less-educated mothers who lived in rural areas." (Duvdevany, 2003)

The work of Floyd, and Gallagher (1997) entitled: "Parental Stress, Care Demands and Use of support Services for School-Age children with Disabilities and Behavioral Problems states that the presence "of significant behavior problems is more important than disability type in determining most forms of parental stress, and predicts mental health services use. Parents of children with intellectual disability worried most about providing ongoing care into adulthood." The study found that single parents did not experience more stress but used more services than did families with two parents.

The work of Hayden and Goldman (1996) states findings the marital status of the caregiver, the level of retardation and the frequency of maladaptive behaviors as well as the health status of the adult family member with mental retardation combined with the number and level of services needed and utilized are all factors in stress experienced by families. In a longitudinal study of older mothers caring for an adult with intellectual disability Greenberg, Seltzer, Krauss, and Kim concluded that: (1) support groups were not beneficial although some groups may provide a forum for social contact and information exchange (2) mothers whose friendship networks were composed largely of close friends who were also coping with a relative with disabilities, reported greater increases in burden than those with more diverse networks; and (3) mothers who were pessimistic about their son's or daughter's future had increasing levels of burden and depressive symptoms over time. Service providers could encourage these parents to make arrangements to help them reduce their fears and pessimism " (1997)

The work of Shearn (1996) entitled: "Time and Person: The Impact of Support Services on the Lives of Parents with Adults with Intellectual Disabilities" published in the Journal of Applied Research in Intellectual Disabilities" states that data from interviews showed: "support services for adult offspring were positively received by parents in the way they interrupted, what would otherwise be, a continuous cycle of care. However, for some parents the nature of the provision was such that support services heightened rather than moderated their sense of living a restricted lifestyle. The authors noted that the challenge for service providers and planners is to find innovative responses to these parents by allowing a greater flexibility of provision.

The paradox is that, greater support could lead to an increased demand for residential provision, as parents sought to emulate their non-carer peers." (Hayden and Goldman, 1996)

In a systematic review of the literature Allen (1999) makes recommendations for the support of caregivers of those with intellectual disability and challenging behavior as follows:

1. Stress management techniques were effective for use both routinely and at times of high arousal

2. Respite care services which genuinely provide respite and are able to offer support both on a planned and crisis basis are valuable

3. Information should be provided (eg regarding the child's disability, challenging behavior, support services and welfare benefits