Activity: Defining the Concern: Juana

Activity: Defining the Concern: Juana

Girl smiling

Consultants must find ways to describe the child’s behavior, any observations and screening/assessment results, and hypotheses about the cause of the concern in a “dialogue” with families and providers in ways that are meaningful and culturally relevant to the child’s family and care providers. Review the case study of Juana, her family, and her experience and respond to the questions related to Defining the Concern for Juana at the end of the case study.

NOTE: This case study of Juana, her family, and her Head Start experience is referenced for three additional learning activities. Each activity builds on the previous learning activity and your responses. Save or print this case study for easy reference as you continue the tutorial.

Case Study: Juana

The ECMH Consultant:

My name is Dolores Delgado and I am an early childhood mental health consultant to a small Head Start program in a rural town south of Chicago. This Head Start program serves families who are both native to the area as well as resettled migrant workers from Mexico, Guatemala, and El Salvador. Many of the migrant farm families were accustomed to traveling for seasonal work, but with support from a local church and a growing sense of community, some have decided to make this town their permanent home. I myself am a bi-lingual (Spanish and English speaking) Hispanic woman of second generation immigrants from Mexico. I have some knowledge of the immigrant and migrant experience through the stories my parents and grandparents have shared. My own growing up was very different since my parents settled in suburban Chicago before I was born.

Reason for Referral:

Recently, I was contacted by my supervisor and asked to observe Juana, age 3, a child in the Head Start preschool program, who was displaying behaviors that were not typical for her age or her peers. The teachers had requested a consultation after speaking with the family about the child’s behavior, sharing their observations with the parents, and obtaining their written consent for my involvement. To define the concerns for Juana and develop a plan for any further assessment and intervention, I conducted interviews with the teachers, the parents, and an individual classroom observation.

Teachers Interview:

In speaking with the teachers, they described Juana as extremely shy, somewhat withdrawn, non-verbal, and difficult to engage. She also has difficulty keeping up with the classroom routine and seems easily startled, especially by loud noises which cause her to cover her ears with her hands. This is Juana’s first year in the program, and she has been attending regularly for the past 3 months.

Initially, the teachers allowed for some adjustment time to her new environment as well as the fact that Juana speaks only Spanish in a dialect common to western El Salvador. Although the teacher’s aide is Spanish speaking, Juana does not respond to her attempts to engage verbally. Early on, the teachers had to use physical guidance (touching shoulders, leading by hand) and distraction to help Juana be less withdrawn and to transition Juana from her individual activity to participate in the regular classroom routine.

Only recently, Juana has become more able to move from one activity to another without physical guidance and she has begun to seek out the company of one female classmate. Her verbal interaction is still extremely limited; mostly using gestures in communication with her classmate. It has been difficult to complete a formal screening and assessment for Juana because of the language challenges for both Juana and her family, difficulty engaging Juana, and her parents’ seeming acceptance of Juana’s behavior. The parents agreed to the observation because it was recommended by Juana’s teachers, rather than due to their own concerns.


Two observations occurred in the classroom, one in the morning and another in the afternoon. In the first observation, Juana was unaware that I was there to observe her. Other classroom students, the classroom teacher, and the teacher aid were present in the room. I was two feet away from the child, and Juana neither looked at me nor otherwise acknowledged my presence. She appeared calm and focused, working alone at putting a puzzle together. In transition to nap time, Juana was able to put the puzzle away with and move to her cot. She was able to sleep without any apparent difficulty or anxiety.

On the second observation, I interacted with Juana. As I entered the classroom, the children were instructed to wash their hands and sit at their activity table to eat a snack before preparing to leave for the day. She followed instructions with no additional guidance, moving to the table looking slightly downward and no eye contact with the teachers or her classmates.

I sat next to her, and Juana turned around, away from me in her chair, made no eye contact with me, and did not respond to my greeting to her in Spanish. When the teacher offered Juana dessert, she did not make eye contact but nodded yes and held out her hands to receive her plate. She did not speak throughout the snack-time, but darted her eyes toward those children who were talking close by – looking away quickly. When the other children began talking about the stickers they had received that day and showing them to one another, Juana touched the sticker she had on her shirt but did not speak.

As the teacher came round to collect the empty plates, Juana turned to put her plate in the trash-bag, without eye contact. She then accepted crayons and paper to color from the teacher’s aide. I put my paper next to hers and began to color, drawing three items: a happy face, a sad face, and a heart. When I asked her to, Juana was able to point to each item by name and color, but with no verbal interaction or eye contact. When the children were asked to put the colors away, Juana appeared to follow instructions or visual cues from the activity of the other children. She put her colors away and followed the other children to the door to prepare to leave.

Family Interview:

In order to build trust, I chose to include the Family Service Worker already familiar to Juana’s family. Because of the Spanish dialect and language issues, I chose to use an interpreter more familiar with the western Salvadorian dialect for the interview with Juana’s family.

Both Juana’s parents attended the meeting – Marco, her father and Patricia, her mother. As I greeted them, both Marco and Patricia smiled, nodded their heads slightly, and softly repeated my greeting. I introduced myself, explaining my role as well as my interest in Juana, her family, and her participation in Head Start. I explained confidentiality, including the interpreter’s role and the presence of the Family Service Worker. I reminded Marco and Patricia about the meeting with Juana’s teachers and their concerns about Juana’s behavior in the classroom. I expressed appreciation that they had agreed to have me observe Juana in the classroom and to meet with me themselves. I assured them that their perspective was most important as they know Juana best and that together we would help Juana get the most out of her time in Head Start.

When I inquired about their family, Marco spoke first and explained that Juana lives with her parents and two male siblings, Nicolas (age 10) and Rodrigo (age 6). Juana is the youngest of the family and the only child to attend Head Start. The family immigrated to the United States 4 years ago, to have a “better life”, compared to Marco and Patricia’s growing up with political violence and poverty in their own families in El Salvador. After arriving in the states, they moved from town to town for a year and a half following agricultural work opportunities. With the help of the local church here, they decided to stay in this area to give their children a more settled life and good education. Juana was born here. Marco works at a local meat processing plant while Patricia has stayed home and taken care of the children. Since moving here, their middle child, Rodrigo, has been diagnosed with Autism Disorder and their older child, Nicolas, participates in special education classes in the local elementary school. Other than work and church services, both parents state they do not socialize much and tend to stay home and to themselves.

In response to questions about Juana’s birth and early development, at Marco’s nod, Patricia indicated that the pregnancy and birth were uncomplicated and that all milestones were reached at an appropriate time. They report she is cooperative at home and plays with her brothers. Moreover, parents report there is no current concern on their part with Juana’s communication. She interacts with them verbally and non-verbally. They report that while she is often quiet, when she does speak, her speech is clear and accurate for her age. Parents also state that she is able to interact verbally with some members of the family such as young cousins. With other family member’s, though, she does not interact and withdraws, much like she does in school.

Marco and Patricia’s one concern is Juana’s holding her ears when she hears a loud noise. This behavior reminds them of Rodrigo’s behavior around the same age, and a time when he stopped being able to communicate well. They worry if she will have the same “trouble” as him as she gets older. When asked about how they helped Rodrigo, Marco explained that when he was a little younger than Juana, they noticed he was different from other children, including their older son Nicholas. At the time, they spoke to a trusted promotora (health educator) who met with the migrant farm workers near the fields. The promotora encouraged them to take Rodrigo to the Migrant Health Services clinic for evaluation. The doctor there recommended further testing and early intervention services. Marco also consulted their family back in El Salvador about Rodrigo. Marco’s grandfather recommended seeking a curandero to give Rodrigo a cure with herbs. Marco explained that they followed both recommendations and believe that the combination has helped Rodrigo. They think that maybe the curandero could help Juana too – especially in school. Marco added that they already made contact with a curandero after the teachers first spoke to them about Juana’s behavior at school and she has received several herb treatments.

Given the case study scenario of Juana, her family, and her Head Start experience:

  1. How would you define the concern based on information gathered from the teachers, consultant observations, and the family?
  2. What is/are your hypothesis/es of the factors contributing to Juana’s behavior?
  3. What cultural and linguistic considerations and challenges are part of this consultation and co-creating meaning to reach agreement and plan for any intervention?
  4. What, if any, formal diagnosis might be appropriate here?
  1. The concern for Juana could be defined as a failure to speak in specific social situations (such as school) despite speaking in other situations (such as home and with family) and difficulty participating fully in the classroom routines, activities, and social interaction.
  2. Factors contributing to the concern could be: the presence of language differences, Juana's first experience in a school setting, her developmental stage, her strong attachment to her mother and family, limited socialization experiences outside of the home and family, and linguistic and social isolation of the family.
  3. Cultural and linguistic considerations and challenges in co-creating meaning could include: Language differences, the family's home experience that Juana's use of language is appropriate, beliefs about the causality of Juana's behavior, the family's social isolation, the high value for attachment of the child to her mother and family, the family's experience (positive or negative) with getting support and services for their son Rodrigo, the view of what might help – the use of the curandero and herbs
  4. At this time, Juana does not appear to have a Pervasive Developmental Disorder. She appears to have more of a Selective Mutism Disorder as indicated by the Diagnostic and Statistical Manual IV-TR and defined as a failure to speak in specific social situations (such as school) despite speaking in other situations (such as home). Juana is a child learning two languages and is demonstrating some behaviors that are typical of young dual language learners ( isolation, withdrawal, non-verbal interactions).
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This product was developed [in part] under grant number 1H79SM082070-01 from the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The views, policies and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS.