Case Study: The Knoll Family.

This case study offers an example of a family that experienced trauma, and the impact of individual trauma and family trauma on all family members. The events that occurred within this family illustrate the complexities of prolonged stress, pileup of stressors, risk factors, and resiliency characteristics touching the individual, family, community, and nation.
Family Members
Mother: Emma (age 45)
Father: Peter (age 46)
Oldest daughter: Ignes (deceased at age 11 years)
Oldest son: Jason (age 14)
Youngest son: Bradley (age 12)
See Figure 11-5 for the Knoll family genogram.

The Knoll family has experienced a number of losses and traumas over the past 5 years. This family lives in a low-income trailer within a trailer park. The neighborhood is run-down but considered safe. The parents are currently divorced, and the father visits once a week for 2 to 3 hours. The family is white and non-Hispanic, and the religion is Seventh-day Adventist. Because of the family’s low income, family members have state-provided health care insurance, limiting access to mental health care to 30 minutes per week. Although county mental health care services are available in the community, the waiting list is over 6 months, and experts on family trauma are not currently available. Because of this, the family has sought mental health care and medication management for family members at a private family care clinic specializing in trauma.

The mother, Emma, has a history of learning disabilities and anxiety. Although she denies any stress in her childhood, and describes her parents as stable and loving, she experienced a series of traumas starting 5 years ago. The first trauma was the diagnosis of a severe anemia (Diamond Blackfan anemia) in her 11-year-old daughter. Although the doctors felt her daughter’s prognosis was good, she died from complications following a bone marrow transplant. Because of the intense and traumatic nature of this event, the father left the hospital before his daughter died and did not return to the family for 2 years. He stated he could not handle his grief at her death and just wanted to “run away” and not think about it. His abandonment led to the family losing their home to foreclosure, because the mother had never held a job outside of the home, and she was left with severe grief and the responsibility of caring for her two other children. Her two sons both had the diagnosis of autism, moderate mental retardation, and severe mood disorder. She felt immediately overwhelmed, and felt she had to find a partner to help her.

She met a man at her church. Unfortunately, he raped her during their third date. Her symptoms of PTSD started after this sexual assault, including flashbacks, severe anxiety, hyperarousal, and avoidance of friends and family members. Three months after the rape, she started dating a second man, whom she met online. This relationship was unstable, with episodes of verbal abuse, and frequent abandonment from weeks to months. In spite of this instability, the mother married this man. She divorced him 9 months later due to his abandonment back to the East Coast. She then met a third man online and started dating him. The relationship went well for several months, leading to her decision that she would allow this new man to move into her home. He was initially very helpful with her sons. Soon, however, he revealed that he had been diagnosed with bipolar disorder, and could not afford his medications. He had a manic episode, which included domestic violence and “rage attacks” toward the mother and her two sons. She kicked him out, and has now remained single for several months.

The oldest son (14) is developmentally at the first grade (6-year) level in all areas except art, at which he excels. He struggles with dysregulation of moods, inattention, poor short-term memory, impulsivity, and intermittent rage attacks resulting in aggression toward his mother and destruction of property. These rages occurred up to three times per day without medication but less than once per month on medication. He is currently taking Abilify 15 mg, Straterra 25 mg, and Zoloft 75 mg. He also takes Hydroxyzine up to 50 mg as needed for severe agitation and anxiety. He currently receives special education services through the school district and is in the Life Skills Program. He can read simple books, write three- to four-word sentences, and participate in age-level choir and art classes. He currently states that he has no friends at school or in his neighborhood. He spends his free time drawing, watching television, or playing video games.
The younger son (12) is developmentally at the fifth grade (10-year) level in all areas. He struggles with dysregulation of moods, inattention, poor short-term memory, impulsivity, and intermittent rage attacks resulting in aggression toward his mother and brother, and has in the past threatened his mother and brother with a knife. These rages occurred up to three times per day without medication but less than once per month on medication. He is currently taking Abilify 15 mg, Topamax 50 mg twice daily, Straterra 18 mg, and Zoloft 50 mg. He also takes Hydroxyzine up to 50 mg as needed for severe agitation and anxiety. He currently receives special education services through the school district and is placed in the Life Skills Program. He can read chapter books, write three to four paragraph stories, and participate in age-level choir and music classes. He currently states that he has no friends at school or in his neighborhood. He spends his free time reading, watching television, or playing video games.

The father currently works full-time at a grocery store as a clerk. He has been diagnosed with bipolar disorder and anxiety. He does not take any medication, resulting in manic episodes an average of once every 2 years, evidenced by increased interest in pornography, insomnia, and running from his current situation. In between these manic attacks, he is functional and well regarded at work and at church. He currently has a girlfriend who lives 200 miles away. He visits her every weekend. He pays $350 per month for child support.
Emma assumes the role of primary caregiver of her two children. Her mother, an 83-year-old woman in good health, however, provides daily support, including caring for the two boys and helping with housecleaning. The grandparents also provide regular financial assistance, because child support payments are sporadic. Emma makes all decisions regarding finances, parenting, and leisure activities. Peter has very few roles within the family, because he inconsistently assists with finances and participates in parenting only 3 hours per week. He allows Emma to make all decisions. The two boys are expected to participate in school, and to help with chores within the home. Both boys neglect their chores, and the mother also dislikes housework, leading to the home being messy and disorganized. Child Welfare Services have been called due to the disarray of the house, which led to some community support, including assistance with painting, fixing the bathroom, and cleaning and replacing the carpet.

Communication within the family started out as distant and emotionally abusive. Through intensive counseling and parent coaching within the clinic and through home visits, the family now participates in healthier communication patterns, nonviolent problem-solving, and shared positive experiences. Each family member, however, continues to show signs of chronic PTSD, due to repeated and severe traumas within the family. When asked about adverse events, the mother summarized the events to include:
The diagnosis of autism in her oldest son
The diagnosis of autism in her youngest son
The diagnosis of Diamond Blackfan anemia in her daughter, with resulting death of her daughter
The loss of her husband and divorce
The loss of her home, and the dependence on her parents for financial support
The sexual assault during a date (i.e., “date rape”)
The difficulty finding adequate health care for herself and her children
The difficulty finding adequate educational services for her sons
The abandonment by her second husband
The domestic violence by her domestic partner

Emma was asked about resiliency skills of both herself and her sons. She felt she had positive support through her parents, a strong religious affiliation including daily prayer, the absence of any substance abuse, and the ability to adapt to the many changes and traumatic events occurring in the past 5 years. She noted that her sons were her support as well as her burden. She stated that they both were very adaptable at times to big changes but could not tolerate small changes, such as changes in the schedule. Resiliency areas where this family lacked included optimism, self-efficacy, high cognitive function for all family members except the grandmother, ability to participate in healthy self-care (i.e., the family had poor nutrition, never exercised, and had limited social support), and lack of trust of helping professionals due to negative involvement of Child Welfare Services.
The purpose of this scenario is for you to learn about the needs of families dealing with Trauma and how to best to meet their need;s to identify priorities of care and supports and to plan interventions and follow-up actions.

Based on this week’s family assignment case study answer the following case study discussion questions:
Looking at the ecomap for Knolls Family (Fig 11-5), what do you see as the family’s strengths, competencies, deficiencies, and resources (both existing and potential)?
What are 3 priority family nursing interventions for the Knolls Family? Give your rationale for your answer.