Essay: Risk and protective factors (biological, psychological and social) in a patient (case study)

The patient of interest is an 8-year-old boy Shoji who presented for clinical assessment accompanied by his mother, Masako. Masako expressed concern for her son, stating that she is not sure what is wrong with him or how to help him. Masako outlined Shoji’s difficulties in social and developmental contexts and further explained Shoji’s current state as well as her own and Shoji’s father.
There are many risk, and protective factors in Shoji which are classified into biological, psychological and social contexts. Biological risk factors are Shoji’s parents history of mental illness, abuse and addiction. Psychological risk factors are social isolation, poor relationship with mother and parental divorce. Social risk factors are Shoji’s poor relationship with his mother, history of sexual abuse and the social ramifications of Shoji’s parents divorce.
I am tentative in diagnosing Shoji with Autism Spectrum Disorder (ASD) and will require further input from both Masako and Shoji. It would be helpful to hear Shoji’s perspective without Masako. Self-report surveys and a diary of adverse behaviours would also be of use.
There is potential for differential diagnosis of Social Communication Disorder (SCD) and comorbidity of Intellectual Disability (ID.)
One model which may account for Shoji’s behaviours is the biological model. The biological model insists on the importance of physiology in the formation of one’s disorder (Blake, Turner, Smoski, Pozdol & Stone, 2003). That, the nervous system, hormones and brain function affect the makeup of an individual (Blake et al., 2003).
Shoji’s key biological risk factors are his parent’s history of mental illness and abuse, and his father’s issues with addiction, whereas Shoji’s key biological protective factors are sex and ethnic background.
Inheritance and genetics may explain Shoji’s biological factors. Shoji is predisposed to develop a psychological disorder due to his parents history of mental illness. The development of the disorder may be elicited due to a gene and environment interaction. The gene and environment interaction explain that some genes are sensitive to particular environments and experiences (Chaste & Leboyer, 2012). In Shoji, this would comprise of his genetic predisposition interacting with his unstable home environment and history of abuse. Gene-environment interactions can often be classed based on their cause. In Shoji, a passive causal relationship may explain the association between the genotype he inherited from his parents and the environment he inhabits due to his parent’s heritable characteristics (Chaste et al., 2012).
It is possible that a chronobiotic imbalance in melatonin may also explain Shoji’s biological factors. Shoji has difficulty toileting and wetting the bed thus maintains a disturbed sleep cycle. A chronobiotic imbalance may also explain Shoji’s desire for routine, due to his bodies inability to adapt and form a circadian rhythm (Cardinali, 2016).
Piaget’s theory of cognitive development may also explain Shoji’s biological factors. The first stage of Piaget’s theory is sensorimotor intelligence; how individuals are exposed to and learn to respond to sensory stimulation (Piaget, 1976). When the amount of sensory input is too high or low, the child will respond in an atypical manner. Sensory overload may account for Shoji’s adverse behaviours at school. The second stage of Piaget’s theory is preoperational thought, in regards to cognitive development via imitation language and speech production (Piaget, 1976). If Shoji is experiencing a deficit at this level, he may be unable to communicate appropriately or use relevant actions in social situations. This deficit may explain Shoji’s difficulty in assimilating and interacting with others.
Both the gene-environment interaction and Piaget’s theory are robust in accounting for Shoji’s biological factors. The gene-environment interaction succinctly certifies Shoji’s behaviours, in conjunction with his parents although remains dependent on further input. Additionally, Piaget’s model takes into consideration developmental deficits affecting Shoji’s cognitive functioning, however, the theory is based on typical development and assumes normality, thus is limited.
In addition to the biological model is the psychological model. The psychological model explains that disruption and dysfunction faced due to psychological factors may result in the development of a psychological disorder (Happé & Fletcher-Watson, 2005).
Shoji’s key psychological risk factors are his social isolation, poor relationship with his mother and parental divorce. Whereas, Shoji’s key psychological protective factors are Masako’s openness in seeking treatment for Shoji, Masako’s concern for Shoji and Shoji’s limited access to his father. A hierarchy of concern in Shoji’s psychological factors would first address his relationship with Masako and his social isolation.
One concept which could account for Shoji’s psychological factors is the theory of mind (TOM). TOM is the ability to attribute mental states, beliefs and emotions to others and oneself (Baron-Cohen & Frith, 1985). The concept implies an understanding of others, which is usually absent in individuals with ASD.
Shoji’s inability to relate to and interpret others makes it challenging for him to interact socially. Where, Shoji’s physical presentation in the clinical assessment; showing disinterested and avoidant behaviour in a social context arguably reinforces Shoji’s absence of TOM. These inabilities leave Shoji frustrated and cause him to use maladaptive behaviours (biting and kicking.) Resultantly, Shoji is further isolated and disconnected.
Akin to TOM is emotional intelligence (EI). EI is the ability to identify, assess and control the emotions of oneself, others and groups (Brady, Saklofske, Schwean, Montomery, McCrimmon & Thorne, 2014). Individuals with ASD struggle to process and interpret emotions resulting in a lower EI (Brady et al., 2014). Shoji responds disproportionately emotionally, by having temper tantrums when given simple instructions, and becoming aggressive when he feels misunderstood. A 2014 study comparing school-aged children with ASD and typically developing children, found that those with ASD responded lower on emotion-based questions and descriptively used fewer emotional terms (Brady et al., 2014).
Bowlby’s attachment theory may also elucidate Shoji’s psychological factors. The theory explains that children enter the world with a predetermined desire to form attachments to ensure safety and security (Bowlby, 2008). If an individual is unable to form a secure attachment, they will base future social interactions off this negative experience (Bowlby, 2008). Shoji’s inability to interact socially and respond in a contextually appropriate manner may be due to his unstable attachment with Masako and inability to depend on her as a secure base. This may have been further jeopardised by Shoji’s father and the abuse he inflicted. If Shoji were to base his future relationships off of that with his parents, the theory indicates that he may be severely socially impaired (Bowlby, 2008).
The theories applied to Shoji’s psychological factors provide a substantial explanation. TOM is vital in assessing an individuals psychological and social functioning and may clarify Shoji’s deficits. EI comparatively draws on Shoji’s abilities to gauge and reciprocate emotions and the effect this may have on him. Moreover, Bowlby’s theory surmises how child-parent relationships may cause social deficit; however, cannot solely account for a disorder.
The final model which may justify Shoji’s behaviours is the social model. The social model explains that it is not someone’s medical condition that makes them impaired, rather societies attitudes and values in response to their condition (Shakespeare & Watson, 2001.)
Shoji’s key social risk factors are his poor relationship with Masako, the abuse upon both Shoji and Masako, and Shoji’s parent’s divorce and the associated ramifications; stress of divorce, Masako’s new partners and obeying non-parental figures. Shoji’s key social protective factors are Masako’s work, Masako’s pro-activeness in remedying Shoji’s issues and Masako’s efforts to keep Shoji self-sufficient. There is a hierarchy of concern in Shoji’s social factors, where addressing Shoji’s relationship with Masako and his history of abuse are of primary concern.
Shoji’s social factors may be attributed to Masako’s parenting style. Masako’s parenting style is classed as authoritarian, where she has a strong focus on obedience and ensuring Shoji follows the rules set out by her. Masako reinforces this notion when stating that Shoji will stay at home when she tells him to (he will not wander). Furthermore, Masako prefers punishment over discipline, as Masako admits that spanking was unsuccessful in ameliorating Shoji’s behaviours. Moreover, Masako spoke for Shoji in the clinical assessment and explained her judgment of his feelings.
A consequence of authoritarian parenting, is that the child becomes hostile or aggressive towards their parent (Hutchison, Feder, Abar & Winsler, 2016). This is apparent in Shoji’s behaviour towards Masako across contexts, responding with physical aggression. Restultantly, Shoji may struggle to express himself or confide in Masako. Another theory which may explain Shoji’s social factors is Bandura’s social learning theory. The theory condones classical and operant conditioning while determining behaviour as a learned process through observation (Bandura & Walters, 1977). Due to the sexual and physical abuse inflicted by Shoji’s parents, it is possible that Shoji may be modelling aggressive behaviour based on his past experiences (Bandura, 1978).
The theories mentioned earlier provide a sound basis for the interpretation of Shoji’s social factors. Parental styles are controversial in determining the cause for the deficit; however, a disorder cannot be entirely contributed to parenting styles, although impacting severity and prognosis. Social learning theory is a viable explanation given the abuse Shoji has experienced in his life thus far, however, does not account for genetic predisposition or protective factors and is therefore limited.
The combination of the three prior models forms the biopsychosocial model. The model proposes that biological, psychological and social factors contribute to an individuals mental and physical health, where this interaction can explain the majority of clinical disorders (Borrell-Carrió, Suchman & Epstein, 2004).
Biopsychosocial factors identified in Shoji, are sleep problems, school performance and social interaction. The vast majority of children with ASD have sleep problems and issues settling, proving relevant to Shoji with his disrupted sleep cycle. Sleep problems are a biopsychosocial factor due to the genetic inheritability of ASD, the psychological distress associated with toileting issues and the social stigma of toilet training outside of the normative period.
In addition, is school performance, where Shoji’s abilities are three years behind that of his peers. Academic performance is a biopsychosocial factor due to the biological component of ASD and academia which he has potentially inherited, the psychological stressor of an academic lag and the social ramifications of performing below one’s expected ability.
Shoji’s limited capacity for social interaction is trait like/ typical of that of ASD, which also can be explained via biopsychosocial factors. Individuals struggling with social awareness usually have a hypoactive anterior insula, face psychological distress due to their inability to perceive and display contextually relevant emotions, and the resulting social deficit faced.
The biological model arguably best accounts for Shoji’s presenting issues. ASD has an active genetic component and does not occur solely due to stressors or environment (Portnoy & Raine, 2013). However, the interaction of the three models may have lead to a more profound presentation of the disorder or a worsened level of impairment (Lind & Williams, 2011).
It is imperative that there is an additional clinical assessment with both Shoji and Masako. Alike to, a physical examination in order to in rule out any underlying medical conditions. Input from Christine and Shoji’s school would also be of assistance in order to gain a better grasp of Shoji’s current situation. Pending further input, it is challenging to diagnose Shoji with ASD conclusively. Moreover, there is the possibility of differential diagnosis of SCD and comorbidity of ID.