Jack and Jill--and Sam?

     "This is Barbara Wheeler over at Jack and Jill Child Care Center. Look, we have a new kid in our program this summer. His name is Sam, and he's absolutely impossible! We know he got special services during the school year because his mother told us, but he's making things really hard here. We just can't have him in our program unless he gets better. Somebody said you might be able to help us with him. I certainly hope so because, if you can't, I'm afraid he'll have to leave. It's just not fair to the staff or the other children to have to deal with him every day."

     This telephone call from Barbara Wheeler marked the beginning of a 15-month consulting relationship between our program and the Jack and Jill Child Care Center. Our program is designed to help community early childhood programs include young children with disabilities, but the call from Jack and Jill posed a very different kind of challenge from those we had been facing in our other consulting work. Our staff had been working with community child care and preschool programs for a year, hammering out the details, training, and making plans before actually including children with disabilities. We had prepared programs for integration by carefully facilitating dialogue among all of the critical "stakeholders" in the process-parents, school district special education personnel, community early childhood directors, and other community leaders. In short, we had worked in the relative luxury of having time and resources available to support planning and preparation in what were already outstanding childhood programs.

     The Jack and Jill Child Care Center was another story. This was a program with which we had never planned. Suddenly, it was confronted with a child who had special needs, and the staff felt entirely unequipped to respond to this child. In addition, the program had done little, if any, general staff training, much less any staff training specifically related to inclusion. Moreover, the Jack and Jill child Care Center had numerous difficulties with many of the typically developing children they served. Finally, the program director was clearly on the verge of excluding Sam. Her patience and resources were already wearing thin.

     Sam had been enrolled during the regular school year in a local special education preschool. We later learned from Sam's teachers that his mother was desperate to find summer child care that she could afford and that would accept a child with special needs. Sam's mother had pursued all of the obvious center-based options as well. Her efforts, however, had been unsuccessful. The Jack and Jill Child Center seemed to be the only remaining choice in this small rural area.

     It was clear that many things about this center would make inclusion particularly difficult. The class sizes were very large, and many of the staff members were inexperienced college students who usually worked 2-hour shifts 2 or 3 days a week. Fortunately, during the summer, the staff consisted of fewer students who worked longer shifts. Even so, there were still about 18 staff members working in Sam's classroom throughout the week. Barbara, the director, made it very clear that managing the center was difficult enough without the extra hassle of dealing with Sam.

     Although we were not legally bound to provide consultation to the Jack and Jill Child Care Center, we felt an ethical obligation to do what we could to support the inclusion of this child. But where should we start? This was definitely a more difficult situation than we had encountered in our work with other child care centers. In addition to class size and staff scheduling problems, other issues included the long distance to the outdoor play space, the use of an outdated curriculum, and the lack of qualified teachers. To further complicate our work, the staff had already developed negative attitudes about Sam's inclusion. Among ourselves, we discussed the possibilities of an alternative placement for Sam, but we came to the same conclusion his mother had-Jack and Jill Child Care Center was the only choice.

     We knew it was not possible to "fix" the center's problems. We had neither the resources nor the power to make extensive changes in the program. We had to somehow give the center's staff a sense of their own power to solve the difficulties of including Sam, so that they might begin to feel more competent and less overwhelmed by their difficulties with him. One of our staff members, Monica, was elected to take on this challenge. She began with a telephone call to Barbara Wheeler in the hopes of gaining a clearer understanding of the problem.
 

An Impossible Kid

     Barbara  answered the telephone when Monica called. Monica introduced herself and summarized what she had been told about the situation with Sam before asking Barbara for more details.

     "Can you tell me more about what Sam is like when he's at your center?" asked Monica.

     "All I can say is that he's really awful!" began Barbara. She seemed to be a woman who spoke what was on her mind. "He acts like a particularly obnoxious 2-year-old with lots of 'no's' and temper tantrums, but he's actually 4 years old." She took a deep breath and continued, "I don't care what other people say about him, that kid's a lot smarter than people think he is. He knows exactly what he's doing. He'll get what he wants one way or the other."

     "It sounds like it's been pretty rough working with him," Monica sympathized. Then she tried once again to get more detailed information. "Perhaps you could tell me about the specific things he does in the classroom that pose problems. What does he do during morning circle, free play, lunch, or other times of the day?"

     "Well, during circle he's impossible. He won't sit down. He wanders around the room. We can't get him to sit in the circle, so sometimes we let him just wander. When we do make him sit in the circle, he screams and disrupts everything. We don't know if we should expect him to sit or not. Whenever an adults asks him to do something, he starts kicking, scratching, and butting his head into the teacher who's with him."

     "How frustrating that must be for everyone," replied Monica, "Is there anything else?"

     "Are you kidding!" exclaimed Barbara. "He causes giant hassles around going to the bathroom. Mostly he just west in his pants. What's frustrating is that staff will take Sam and some of the other beginners to the bathroom at their regular scheduled times, and Sam starts yelling and kicking and screaming, 'No, no, no!' He'll refuse to even pull down his pants, but not 5 minutes later he wets in his pants."

     Barbara stopped her ranting and there was an uncomfortable moment of silence. Monica didn't know whether Barbara was catching her breath, or if the silence indicated it was Monica's turn to talk. Even worse, Monica wasn't sure how to respond to what Barbara just said. It sounded as through Sam had passed the point of new return as far as Barbara was concerned. Monica was still contemplating a response when Barbara resumed talking.

     "Well, actually it was a lot worse the first week he was here," said Barbara. Her voice was softer and less frantic than it had been a moment before. "Now he'll go to the bathroom without quite as much fussing, but he still won't urinate in the toilet. He just stand there without doing anything, and 5 minutes later he has wet pants."

     For the first time, Monica was encouraged. "It sounds like that first week was a nightmare," she said, "but you seem to have made some real progress with him in a short amount of time. I'm impressed! Whatever you and your staff have decided to do seems to be working. At least it sounds as though he's become a bit more cooperative."

     "Well I guess so, but mostly I'm very frustrated," said Barbara. "Some of my teachers say they don't like him-that he's impossible and shouldn't be in a regular child care center. They don't have the special skills to take are of him, and he's taking their time away from other children." It sounded as if Barbara wasn't the only one was exasperated by Sam's behavior.

     "What really infuriates me," continued Barbara, "is that his mother didn't tell us how bad he was. If things don't get better soon we're going to have to tell her we can't have him in our program. Really, you should see how it is in the classroom! It's not fair to the staff or to the other children."

     "I can appreciate how frustrating this must be for you and your staff," replied Monica. "He sounds like a real handful, but it also sounds as though you've had some success in dealing with him. I'm glad you called us because we'd certainly like to support you in trying to make this work."

     "We have fewer children here in the summer, so we are willing to give it another try. But the fall is another story," cautioned Barbara. "He'll have to improve a lot if he's going to stay in our program then."

     "I see," said Monica. "Well, perhaps I could visit the classroom and then recommend how we might work together. Could I come and watch him in the classroom and then meet with you afterward?"

     "That sounds good," answered Barbara. "Could you come tomorrow?"

     It seemed important to be responsive at this point, so Monica rescheduled the meeting she was supposed to have with her supervisor the next morning. She would go to the center to observe Sam and take notes.

     Although not quite the terror that was described over the telephone the day before, Monica could see that Sam was indeed a difficult child to manage. As she suspected, Monica noted that the staff were inconsistent in how they dealt with Sam and having different staff members in charge throughout the morning only aggravated the problem. Sam seemed to try out each new person who entered the room only to get a different response from each of them. The only consistent management of Sam was during toileting. Although the staff had taken a rather strong-armed approach with him in the matter of going to the bathroom, it was consistent.

     Soon after lunch, the children went outside to play, and Monica met briefly with Barbara Wheeler and one of the lead teachers, Rita. Monica went over the notes she had taken and summarized her observations in terms of the inconsistencies in staff responses to Sam's behavior. Barbara and Rita acknowledged the inconsistencies that Monica described and agreed that it probably contributed to their difficulties in managing Sam's behavior. They talked further about how difficult it would be to ensure that everyone responded to Sam in the same way because there were so many staff members involved and their schedules were so varied. Nevertheless, Barbara made it clear that the number of staff members and their schedules were aspects of the program that could not be changed to accommodate Sam.

     Barbara and Rita discussed ways they had tried to communicate with the large staff on other issues and described their frustration with their previous methods. Even so, Monica asked if they could think of any ideas for improving communication among the staff in deciding on and implementing methods for handling Sam. After much discussion about the difficulties of getting the whole group together, Barbara and Rita decided they would try to assemble the entire staff for a meeting. This had never been done before. Their hope was to come to an agreement on a plan and carry it out consistently. When Barbara asked, Monica agreed to facilitate the meeting.

     Before leaving the center that day, the three women worked out a plan for the meeting so Barbara could better explain to the staff why she was asking them to get together. First, everyone would discuss the problems in handling Sam and decide what needed to be attended to first. They would also share the various methods everyone had tried with Sam and how well they had worked in controlling his behavior The group would then decide on strategies for everyone to follow in responding to Sam's specific problem behaviors. Finally, the group would decide how to monitor its progress and maintain consistency in responding to Sam.

     Monica suggested that Sam's mother might be included in the meeting, but this idea was met with resistance. Barbara and Rita agreed that consistency between home and child care was important, but they said that Sam's mother was not very cooperative. Furthermore, they thought the staff would be uncomfortable with her presence at the meeting. Monica was not pleased with their attitude toward Sam's mother, but kept her feelings to herself. If the staff could experience some success in changing Sam's behavior at the center, they might feel more confident and consequently be more willing to involve Sam's mother in the future.

     In discussing who else should be included in the meeting, Barbara and Rita mentioned that it would be helpful if they knew how Sam's previous teacher had handled him in the classroom. Barbara talked about where he had been enrolled and Monica realized that his previous teacher must have been a woman named Rhonda, whom she had met on several occasions through her work on an interagency committee. Although Rhonda would be on summer vacation now, Monica offered to try to call her at home and see  if she would be willing to come to a meeting about Sam.
 

What is the Problem?

     The meeting was held on a Tuesday evening after the center closed and, of the 20 people invited to the meeting, 15 attended. Monica had succeeded in contacting Rhonda, and she was among those who attended. Following a brief introduction by Barbara, Monica opened the meeting. She began by saying how impressed she was with the group's dedication, as demonstrated by their willingness to get together in the evening to talk about Sam. She also talked about the positive things she had seen during her recent observation in the child care center, emphasizing their successful beginning in overcoming Sam's resistance to toileting. Then Monica outlined the purpose of the meeting and opened the floor to a general discussion of the problems they were experiencing with Sam and strategies for dealing with his misbehavior. For an hour and a half, the group engaged in animated storytelling of their experiences with Sam and lively discusssion about what needed to be done.

     "Well, the hardest thing for me to handle is Sam's yelling, flailing his arms around, and hitting me when I ask him to do something," said one of the child care workers. "It's so frustrating! It's gotten to the point where I try to avoid asking him to do anything-but sometimes I just have to."

     "I think those spells are the hardest thing for a lot of us," agreed Rita. "They seem so out of proportion to what he's been asked to do. It's especially bad when it's time to go to the bathroom or to the kitchen to eat."

     "Yeah," someone else chimed in, "I hate it when he has a fit about going to the bathroom."

     "Well, how about when he's in the bathroom?" interjected a male college student. "It takes him forever, so he's usually late going to lunch. Then he's late finishing lunch and."

     "That's a problem," said another student, "because the confusion of other kids finishing and putting their dishes away distracts Sam, and he ends up barely eating anything."

     "And I'm irritated that with the problems at lunch time you can almost count on him wetting his pants even though you've just taken him to the bathroom," Rita added, rolling her eyes in exasperation.

     "I just hate it when he starts yelling," said a small voice from the back of the room. The woman, a student, couldn't have been more than 17 or 18 years old. "He yells when I take him to the bathroom, he yells at lunch, and he yells when it's time to go outside. He had a real tantrum one day when I told him it was time to go to circle." She paused a moment and scanned the room for indications of agreement. "Now I just let him do what he wants during circle. Sometimes he comes on his own and sometimes he doesn't."

     "And if he comes to circle," said someone else, "he usually only stays a minute or two. Then he goes wandering off. Of course, then the other kids want to wander, too."

     "I'm not sure what to do with circle either," added another student. "I tend to just let him do what he wants, too.Believe me, I regret it if I don't!"

     At this point, Monica felt that enough time had been devoted to descriptions of Sam's misbehavior and staff members had had adequate opportunity to vent their frustration. She wanted to help them clarify and focus the problem. She asked whether others had found that Sam became upset when he was asked to move to a new activity. Everyone agreed that he seemed to be set off by transitions.

     "Are there any other kinds of concerns you have about these situations?" asked Monica.

     "Well, one of the things I find to be difficult," began one of the workers, "is that whenever there is a transition, but particularly with the big transition, he doesn't do the appropriate thing. For instance, he might go into the pantry instead of the free play area after snack."

     Another worker nodded her head and said, "I've seen that a lot. For instance, on his first day here, when we were walking to the playground, he started wandering upstairs."

     "Yeah," agreed a student, "it doesn't seem like he's deliberately trying to disobey the plan-he just wanders off."

     "I've seen that too," said another, "and it makes me worry that he could easily get himself into a dangerous situation. It makes it more difficult to have him in the group because I have to to pay attention to him every second. Sometimes it seems like it isn't fair to the other kids."

     Rhonda, who had not said a word up to this point, finally spoke, "We see that same wandering off in our preschool," she said. "We take turns being the one responsible for keeping close tabs on what he's doing. We list whose turn it is on the daily schedule and we try to make sure he knows the routine."

     "That's a good idea," said someone.

     "That does sound like a good way to relieve the pressure," said Monica. "Have any of the rest of you seen this behavior of wandering off during transitions?" Her question was met with vigorous head nodding and murmurs of affirmation among the group. This did, indeed, seem to be one of the major difficulties in working with Sam. Monica thought she would check out other issues. "Are there any other concerns?" she asked.

     The young woman in the back of the room spoke again. "I just feel uncertain with Sam. Sometimes I expect the same things I do of the other children and he does well. Other times I expect the same and it's totally unrealistic for him."

     Two other group members agreed. They didn't know what was fair to expect of Sam either.

     "Well, we've been working with him for a year now," said Rhonda. "Maybe we could share some of our experiences and testing results."

     "That would be very helpful," said Rita.

     "Yes, that would be helpful," said Monica. "Let's talk about those strategies as soon as we finish identifying what we think the major issues are, okay? Are the rest of you also uncertain of what is reasonable to expect of Sam?" Again, there was vigorous nodding from the group. Another major issue had been identified. "Are there any other concerns?" asked Monica.

     Barbara, who had been looking at her watch with increasing frequency during the past 20 minutes, spoke up. "I think we have other problems," she said, "but some of them are related to the ones we've already talked about. I think we should figure out some strategies to deal with these first and deal with the others later."

     Following Barbara's lead, Monica summarized the concerns the staff had identified: 1) Sam often yells, screams, scratches, and hits when he's asked to change activities, particularly at major transition times; 2) Sam often wanders into an inappropriate activity during transition times, particularly when going to and from meals and the bathroom; and 3) staff are uncertain about the level of behavior they should expect of Sam. The group agreed that these were the major concerns, and Monica turned the discussion in the direction of developing a plan of action.
 

A Plan of Action

     Monica began by having the group discuss strategies they had tried and had seemed to hold some promise for the future. The group members discussed some of their successes in working with Sam. Individuals often identified things that few in the group had tried or known about. Approaches that had helped for two or more care providers included:

• When Sam was informed ahead of time about transitions and had some direct assistance, he seemed to have somewhat fewer outbreaks of screaming.
• If Sam was taken to a quiet place when he was screaming, kicking, and flailing, he often calmed down and could do the proposed activity with assistance.
• When Sam sat near an adult during circle time, he seemed to attend somewhat longer in circle.
• Sometimes Sam responded to a direct contingency statement such as, "You can go to the water table after you eat one bite."
• When Sam's behavior was dealt with in the same way across days and among all staff members, he seemed to eventually catch on to the rules.
• When Sam was chosen to be one of the first children to do an activity, he did better than when he had to wait.

     Everyone agreed that it was important to establish a plan and be consistent in following through with it. Each of the major problems that had been identified were listed on a small chalkboard and ideas were generated for dealing with each. Although Monica facilitated the discussion and helped the group to clarify its decisions, only ideas developed by the staff were included in the plan of action. At the close of the meeting, Monica agreed to write up the plan of action that they had developed.
 

A Measure of Success

     Barbara Wheeler and her staff left the meeting feeling good about the plan they had developed. Several staff members commented that it felt good just to talk about the things with which they had been struggling. Others said that it felt good to know how they would respond to Sam, even if their strategies proved unsuccessful.

     Sam remained enrolled in the center for the next 15 months. The initial plan of action was not completely successful, but Sam did show clear progress in several areas. His screaming almost entirely disappeared, and the cues staff used at transition times greatly reduced his wandering. Monica monitored Sam's progress and took care to reflect his gains back to the staff. The staff began to take real pride in what they had accomplished with Sam.

     During the next few months, Monica facilitated three more meetings, and Barbara and her staff began to view getting together to clarify problems, share ideas, and plan a common "approach" as a strategy they could use to address other problems at the center. As they began to say things like, "maybe we need to get together to deal with this," Monica knew her major goal had been attained.

     All of the problems at the Jack and Jill Child Care Center were not resolved. Barbara faced a continuing dilemma about the time and expense of calling staff meetings, and therefore meetings were often delayed until problems reached crisis proportions. Several of the behavior problems staff saw with Sam were never completely resolved. For example, he never did sit very well during circle time. Nevertheless, Barbara Wheeler and the staff became more aware of their own capacity to sole problems related to including children with special needs in their program-and Sam's mother maintained the child care she so badly needed.
 

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PLAN OF ACTION FOR SAM

Transition to Circle Time

Expectations: Sam will come to circle, sit down, and initially stay for 3 - 4 minutes. Depending on his progress, each week he will stay for a longer period of time, up to the full time of circle (10 -15 minutes). If the circle time is more lengthy, he will be permitted to move to free play as the younger children are.

Approaches

• The head teacher will alert Sam once, prior to the start of circle, that circle is about to begin. She will assist Sam in cleaning up or finishing his activity. She will tell him personally when it is time to come to circle, take his hand, and walk him to circle.
   
• A designated adult will sit near Sam and remind him of the rule: "We all stay in circle until it's time for _________."
   
• If Sam begins to scream, kick, or otherwise act out, the designated adult will take him to the book corner on the other side of the room and explain that he cannot return to the group until he has quieted. The adult will then turn away from Sam, but stay nearby.

Transition to Bathroom

Expectation: Sam will wash his hands and urinate at the times that the group does, and he will leave the bathroom at the appropriate times.

Approaches

• The first adult leaving circle with a group going to the bathroom will ask Sam to join his or her group and take his hand to walk with him.
   
• This adult will be very matter-of-fact. If Sam doesn't do the expected actions once in the bathroom, the adult will give him cues about appropriate behavior such as, "Sam, what do you do first?", "Remember, you need to wash your hands next, Sam," and so forth.
   
• If Sam urinates in his pants, the adult will encourage him to try to urinate again in the toilet before assisting him in changing his clothes.
   
• When Sam is finished using the bathroom, the same adult will ask him, "Where do you go next, Sam?" He or she will monitor Sam as he leaves the bathroom, will assist him in finding a seat at the snack table, and will sit at his table and ensure that he begins eating, in the same way he or she handled the bathroom routine.

Reasonable Level of Behavior to Expect of Sam

Expectation: The staff will be more aware of Sam's capabilities and what is reasonable to expect of him in daily routines.

Approaches:

• Sam's special education teacher, Rhonda, will come to a staff meeting next week and describe what she believes are reasonable expectations of Sam based on her testing and experience with him.
   
• Rhonda will also bring a written sheet she has developed for her staff, listing what Sam can do, and what he's working to accomplish.

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Follow-Up Plan

• Monica will observe Sam and the staff three times weekly for 20 minutes during the next 3 weeks. She will focus her observations on the expectations and approaches identified by the group.
   
• Staff members will report directly to Barbara to inform her of any difficulties they may be having in following through with the plan of action, and whether they are seeing any changes in Sam's behavior.
   
• Monica will meet with Barbara and Rita once a week to report her observations and to discuss the staff's experiences and Sam's progress. If necessary, this group will suggest possible modifications of the plan.
   
• Monica will meet with the entire staff in 1 month to discuss progress and make modifications in the plan.

This case story originally appeared in McWilliam, P.J., & Bailey, D., (Eds.). Working Together with Children & Families, Case Studies in Early Intervention. (1993). Baltimore: Paul H. Brookes Publishing Co.

Jack and Jill--and Sam?
Discussion Questions