The Team Meeting

     "I suppose they're all too good to make the coffee too," Marilyn mumbled as she put the empty pot back on the warming pad. She turned towards the Coca-Cola machine and fiddled through her pockets for change.

     "They really got to you, didn't they?"

     Marilyn startled at the sound of the voice behind her. It was Juanita. Marilyn hoped she hadn't been there long enough to hear her grumbling at the coffeepot. "Yeah, I suppose they did a bit," Marilyn replied. "I don't know why I even bother sometimes. They just seem to do as they please. It makes you wonder if they ever really listen to what the rest of us say." She popped the top on her can as Juanita's coins jangled through the machine.

      "It's stuffy in here. Do you want to step outside?" asked Juanita.

      "Sure," said Marilyn. "Maybe that will help me get through the rest of the meeting."

     The two women stood just outside the side entrance to the building. Marilyn sighed and leaned against the brick wall. Juanita chose a spot of sunlight on the sidewalk nearby. "I don't understand how they can get away with choosing who they will or won't work with," Marilyn began. "So what if Adam has mental retardation? Doesn't he have the same rights to physical therapy and speech-language therapy as any other child in this program? The only kids they want to work with are the smart, little kids with cerebral palsy who have braces on their legs and Coke bottle-bottom glasses. That way they can perform their miracles and get their egos stroked. Well, there isn't much applause for working with the Adams in this world, but that doesn't mean he doesn't have the right to everything the other kids get." She sighed and took a drink from her can before continuing, "To tell you the truth, I think that kids like Adam may need therapy even more. Those other kids will probably make it no matter what. But what chance has Adam got without being pushed along?"

     "I know what you mean," agreed Juanita, "but being smart and cute isn't their only criterion for working with a kid. They also have a strong aversion to roaches and trailers. They get the lower class kids off their caseloads just as fast as they can. They always give a good reason, but isn't it funny how they seem to keep the cute kids with middle-class parents on their caseloads forever?"

     "Yeah, real funny," replied Marilyn looking down at her watch. "I suppose we better get back. After all, we wouldn't want to waste any of their precious time," she said sarcastically. "It's so much more valuable than ours."
 

Family Concerns

     Stan Goodman, age 27, and his wife, Tracy, age 25, have been married for 3 years. Stan has worked as a police officer for a local department for the past 5 years and has earned several promotions. Tracy is a clerical worker in a large lumber yard on the outskirts of town. She handles requisitions and does some work on the company's accounts. The Goodmans have a 26-month-old son, Adam, who has developmental delays. The family lives in an apartment complex in the suburbs of a metropolitan area.

     Adam's problems were not detected at birth. It was a normal pregnancy and delivery, and Adam seemed to be a typical baby-- for a while. Adam was an extremely irritable newborn. He rarely slept for more than an hour at a time and had long crying bouts. "Colic," the pediatrician said. Tracy noticed early on that Adam was not as alert as most babies nor was he very responsive to his parents' attempts to play with him. For a while, it was easy to blame it on the colic.

    When Adam was 7 months old, he was still not sitting up by himself and made few attempts to play with toys or people. The pediatrician then confirmed Tracy's and Stan's suspicions of their son's delays and suggested that they look into the early intervention program in their area. It took the Goodmans a while to adjust to the idea, but they called the program and began receiving home-based services when Adam was 10 months old. Marilyn, the special educator on the team, became the primary service provider for the family and has visited the family once a week for nearly a year and a half.

     Adam has made slow but steady progress since his entry into the program, but still has considerably delays in his development. Although he is 26 months old, his skills are more similar to those of a 9- or 10- month-old child. Adam is also quite small for his age and is underweight. Recently, Stan and Tracy were told that Adam has microcephaly (i.e., small head-circumfrence); however, the size of his head is proportional to his small stature and frame. Overall, Tracy and Stan seem to be adjusting to their son's diagnoses remarkably well. They are, however, having a difficult time handling the situation that has developed since Adam began trying to walk on his own about a month ago.

     Adam's walking is a marvel to behold. He never learned to crawl.  Instead, he scoots on his bottom to any vertical surface and pulls himself to a stand. Then he starts to walk, moving his little feet as fast as he can with his upper body lunging forward. Gravity eventually wins out and Adam goes crashing to the floor. His stiff-legged, wide gait looks awkward and he doesn't appear to have any protective reactions as he is falling. Consequently, he is covered with bumps and bruises. Both Stan and Tracy are concerned that he will be seriously hurt one day.

     Stan refers to Adam as the "kamikaze pilot" in light of his unique style of walking, and Tracy calls him her "little tornado" because of the chaos in their home since he has begun to pull to a stand and walk. Adam can clear the coffee table, or any other horizontal surface, in 2 seconds. He will pull, push, or otherwise tumble any object that he comes across. Although his actions are quite destructive, Adam hardly seems aware of what he is doing. He just moves along calmly to the next thing in the room. Tracy, however, is totally exasperated. She has "Adam-proofed" the apartment as much as possible, but he still requires constant supervision. It's next to impossible to clean, cook, or even go to the bathroom when she has him on her own. Unfortunately, Stan works long hours and often works evenings and weekends.

     On the advice of the team psychologist, the Goodmans have tried a "time-out" procedure to control Adam's destructive behavior. This involved saying "No" very firmly whenever he toppled or threw an object and placing him immediately in the playpen for 3 minutes. They tried it for about a week and a half but, according to Tracy, he never seemed to catch on to why they were putting him in the playpen. "I guess the wiring just isn't there," said Tracy on one visit as she gently patted Adam's head. In addition to the chaos Adam has been creating at home, the director of the day care center that Adam attends has spoken to Tracy several times about his behavior. The center is the only classroom program in their community for children with special needs, and Tracy is afraid that they might kick him out of the program.

     The Goodmans are also concerned that Adam does not talk and has poor eating habits. Adam rarely makes any attempt to communicate verbally. Sometimes he makes a grunting noise when he wants something that is out of reach, such as a favorite food sitting on the counter top. He may or may not accompany this grunting with a hand raised in the direction of the desired object. Adam also has a high-pitched squeal he makes when he is stopped from doing something or when something is taken away from him, but he makes this sound at other times as well. For the most part, Adam is silent. Tracy has recently asked Marilyn about the possibility of obtaining speech-language therapy through the early intervention program.

     Adam is an extremely picky eater. There are only a few foods that he will eat. Among these are vanilla yogurt, bananas, cheese, crackers, and peanut butter sandwiches--smooth not crunchy. He also loves milk and apple juice. Although Adam is constantly offered new foods, he quickly rejects them. The parents have thought about withholding these favorite foods until he tries something new, but they have rejected this idea because Adam is underweight. It's hard to get enough food into Adam to maintain his weight, let alone increase it.

A Difference of Opinion

     The early intervention team consists of six core members: a special educator (Marilyn), a social worker (Juanita), a psychologist (Brenda), a physical therapist (Carol), a speech-language pathologist (Scott), and a pediatrician (Jim). Other services and consultations are available through several community agencies that collaborate with the program. All team members provide both assessment and intervention services to children and their families.

     Once a week the team meets to handle routine administrative matters, plan and discuss upcoming assessments, and review one or two ongoing cases. During these case reviews, the primary service provider updates the rest of the team with the progress that the child or family is making toward established goals and objectives, notes any new or proposed changes in the intervention program, and enlists the assistance of other team members in problemsolving or service delivery. Today it was Marilyn's turn to review Adam Goodman.

     Marilyn went through the standard review of the Goodmans' goals and objectives and quickly updated her colleagues on their progress. She wanted to get to the heart of the matter.

     "Tracy and Stan are really under a lot of stress right now," she told the team. "They're tickled pink about Adam learning to walk but they are scared to death that he'll really injure himself in the process. Maybe Carol could get more involved in the case and visit the family."

     "I really don't see what good that would do," Carol said. "Adam isn't a good candidate for physical therapy right now. He's too out of control. I'd just be putting him through the motions and he'd be screaming. Besides, his motor skills are about on par for his overall developmental level. It's just that he doesn't have the protective reflexes. Protection may be about the best that can be done for him right now. I could order a lightweight helmet if you think the parents would go for it."

    "Well, I don't know," replied Marilyn. "I'll think about it. There are a few other issues I wanted to mention. Adam's speech-language development is one of them." Marilyn went on to explain the parents' concerns and described the types of sounds Adam was making as well as his nonverbal communication. "The parents have asked about getting speech-language therapy for Adam," she said in closing.

     "My caseload is full," said Scott quickly. "Besides, I think that it would be better to help the Goodmans understand that Adam's delayed speech is probably a direct function of his cognitive delays. You know what I mean. Adam can't talk about something he doesn't understand. Of course Adam could use some communication training, but he doesn't need my services. Marilyn, you can work with Adam on basic communication skills."

     "Maybe it would help if you explained that to the family," replied Marilyn bitterly.

     "Maybe," said Scott, "but you've had a long relationship with them, and I can't help thinking that they'd rather have it come from you."

     Perhaps sensing the tension building, Jim interrupted the discussion, "Why don't we stop here and take a 10-minute break. Marilyn, we'll continue with the Goodman family when we get back, okay?" Marilyn left her papers spread out on the table and headed down the hall toward the coffee maker--only to find the pot empty.

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.

The Team Meeting Discussion Questions