Page 1

The Middle The Heck Family Assessment California State University San Marcos Nursing 480 ISSUU Visual Report

Introduction: “Meet the Hecks” Description of condition: Autism Spectrum Disorder (ASD) as described by Perry, Hockenberry, Lowdermilk and Wilson (2014) is a complex neurodevelopmental disorder of unknown origin manifested in decreased social skills, verbal impairment with repetitive, restricted and stereotype behavioral patterns. ASD is a spectrum from mild to severe and is noticed usually in early childhood, generally between 18 to 36 months. It occurs in one in 100 to 150 children in the United States; and is four times more common in boys than in girls. Brick Heck - 9-years-old is socially awkward, has a hard time making friends, eidetic memory. Bricks has ticks that include whooping and whispering words to himself. These unusual speech patterns and his obsessions of reading and fonts and the fact that he gets tired easily trigger his school teachers to give him the Waterman-Ginsberg test. This is a fictitious test that showed Brick is very smart, but has trouble making friends and that his parent’s Francis and Mike should be concerned but not overly concerned. And that they should do just a little bit more than the usual to help him socialize and hope for the best (Heisler et al. 2009). The show does not officially diagnose Brick however, his social impairments, obsessive rituals like reading and showering while seated, and staring into the mirror because he thinks his reflection moves most closely match ASD. Duvall developmental stage: The Hecks are a married nuclear family with one school-age child and two adolescents Hisley and Ward (2016). Duvall’s family development theory states school age children form friendships and launch socially outside of the family and the family system must adjust. Duvall says that during adolescence the child moves towards launching and independence and the parents start to refocus on their marriage (Hisley et al., (2016) pp 766).

Family Structure Family structure: The Hecks are a traditional nuclear family, meaning the Mother and Father of all the children are married and the whole family depends on one another for emotional, physical, and financial support according to Kaakinen, Coehlo, Steele, Tabacco and Harmon Hanson (2015).

Family Dynamic and Functions Denham, Eggenberger, Young and Krumwiede (2016) describe family interactions as dynamic but also become patterned after time. Family interactions set the tone for, build, and continue relationships that help meet the goals of the family. Kaakinen et al. (2105) explain family function as the family’s way to reproduce offspring, raise young, cooperate to meet financial needs and relate to the larger society. The goal of the Heck family is to maintain their middle class lifestyle and raise their children into financially independent adults that can go and raise families of their own. Francis/Frankie functions as Mother/Wife, 43-years-old, sells cars, and her contribution to the family dynamic is a pattern of acting overwhelmed by caring for her family and Brick’s special needs as well as working full time. Season 1, episode 1 shows her using a test drive with a potential customer to pick up her son Brick from school after her husband forgets Hisley et al. (2009). Mike functions as Father/Husband, 46-years-old, manages a stone quarry, his contribution to the family dynamic is to also act overwhelmed at caring for his family along with Brick’s special needs. Season 1, episode 1, Pilot shows Francis in the middle of a car sale and the overhead speaker comes on suddenly from Brick’s school. Mike forgot to read the post it note on his coffee mug that it’s his turn to pick up Brick from school Hisley et al (2009). Axl functions as oldest son/older brother, 14-years-old, football team, his contribution to the family dynamic is as a sarcastic teenager who wakes up in the morning and wanders into the kitchen in only his boxer shorts, drinks milk out of the container and only speaks to complain that there are no chips Hisley et al. (2009). Axl has a distant relationship with all members of his family. Sue functions as older sister/middle child, 12-years-old, her contribution to the family dynamic is her pattern of not making any school teams or clubs, but always staying optimistic. In the first episode she gets so excited to be accepted on show choir, she doesn’t even care that it’s show choir crew and not the actual choir Hisley et al. (2009). Brick functions as youngest brother, 9-years-old, his contribution to the family dynamic is to be mostly oblivious to others around him, but is a happy second grader in a general education class that has just been identified as having social issues at school. Brick is placed in a social skills class to help him make friends.

Culture and Religious Traditions Culture and Religious Traditions: The Hecks are Christian, and only go to church as a family unit on Christmas and Easter. Frankie sings in the church choir and is there every Sunday, her daughter Sue is active in the youth group. The family all holds Christian values and beliefs even if their attendance is splintered. During season one Brick grapples with the tradition of Christmas and starts thinking about how he had a Santa pez dispenser one day and then it was gone, and one day they will all be gone and it makes him sad. So he lays under the Christmas tree looking at all the lights for hours Hisley et al. (2009). Strengths: ● The family loves each other and even if they don’t eat at the table they eat dinner together every night in front of the television ● Frankie and Mike will actively parent, like taking Brick to join a basketball team to help his social skills ● Frankie is only as happy as her least happy child ● School placed Brick in a social skills class ● Axl and Sue have distant, but tolerable relationships with their siblings and parents. ● Frankie gets creative when she tries to help Brick learn kickball. She brings candy to help him, “kick for candy”

Challenges: ● Both parents work full time and have financial problems ● No medical diagnosis for Brick ● No therapy for Brick ● All siblings fight a lot and have distant relationships ● Frankie and Mike yell ● Mike is overly blunt with his family similar to Brick. ● Mike and Frankie often compete with their kids over who is the better parent. ● Both Mike and Frankie are embarrassed by Brick being what they call “special”

Communication Practices The Hecks (all except for Brick) communicate verbally and nonverbally in a neurotypical manner. Brick’s ASD put the family into hot water when on trash morning his Mom tossed a beer bottle toward the trash can and it accidently scratched Brick on the arm. Frankie told Brick, “don’t tell anybody I hit you with a beer bottle, that sounds terrible.” Brick asked to use the first aid kit and ended up using all the supplies to cover a very small scratch. Naturally, a school hall monitor noticed and when he asked Brick what happened to his arm, he became alarmed when Brick said he’s not supposed to tell. The hall monitored continued to ask and Brick said his Mom hit him in the arm with a beer bottle this morning. Soon the principal was alerted and the police and social services were called and Brick’s parents were called in to explain themselves. Brick’s nonverbal communication of using all the supplies in the first aid kit to cover a small scratch combined with his lack of ability to see viewpoints from an outside perspective made his verbal communication of what happened to his arm sound so terrible. Weill, Zavodny, and Souders, (2018) describe conversation challenges of children with ASD, ASD kids have trouble with a four-point volley, where each person adds information, allowing the next person to continue. Often these kids will stick to scripted phrases that they heard on a favorite cartoon program or will restrict their language to preferred topics. ACitVu1AkKynZoj_XlMT5O1dYJd8zCok7wrpe88IFC pg

Bioecological Family Theory Family Bioecological theory looks at the interactions on the family from systems at different levels of engagement. The Family bioecological theory can help nurses locate missing resources and support for families dealing with ASD. 1.





Microsystem: interaction between individual/family a. Brick’s interaction with his parents and siblings is mostly distant Hisley et al. (2009). Mesosystem: interaction between microsystem/school, church, peers a. Brick’s interaction with his school, social skills group, font club and library is also distant, but improving with the skills he is learning at social skills group Hisley et al. (2009). Exosystem: interaction between mesosystem/external environments like jobs/healthcare a. Brick’s interaction with his school psychologist and placing him into the social skill group. Frankie hiding Brick in a car at his Mom’s work because she couldn’t miss work and stay home when he was sick. He literally walked into the break room during a meeting and took a donut behind Frankie’s boss while he was yelling at his staff for not meeting their sales quotas Hisley et al. (2009). Macrosystem: interaction between exosystem/broad cultural attitudes like Judeo-Christian ethic, democracy a. Brick’s interaction with the idea Christmas (he is so concrete in his thinking he just can’t understand how Santa is possible and can’t enjoy the holiday) Hisley et al. (2009) Chronosystem: interaction between time related context on all other four levels a. Progression of Brick’s interaction over a period of time can be seen as Brick improves and experiences setbacks. His main tick is whispering, then whooping as the show progresses Hisley et al. (2009) (Kaakinen et al. (2015) pp 84)

Problems, Interventions, Outcomes Problem One: Mike and Frankie have never taken Brick to a developmental pediatrician, psychologist, psychiatrist to get a diagnosis and education and resources. Nursing diagnosis: Deficient knowledge related to no medical diagnosis secondary to social challenges. Intervention: Brick’s parents need to get Brick into his primary care provider and show him his Waterman-Ginsberg results from the school and have Brick evaluated for Autism. Rationale: early identification of ASD is critical to ensuring that children with ASD are able to access evidence-based interventions that mitigate their levels of disability Elder, Kreider, Brasher and Ansell (2017). Outcome: Brick’s parents need to make an appointment with their primary care provider. An autism diagnosis will open the door to therapy like applied behavior analysis and respite care for his parents. These services would improve Brick’s life and reduce family stress related to living with his autism behaviors.

Problem Two: Brick is isolated socially and when his Father Mike tries to get him to play basketball; Brick becomes so stressed he copes with fixating on unimportant details in the environment and his Father is left disappointed and frustrated because he can’t help his son socialize. Nursing diagnosis: Impaired socialization related to social challenges secondary to likely autism diagnosis. Intervention: Social skills group for Brick, parental support group for Mike and Frankie. Rationale: ASD causes alterations in verbal and nonverbal communication that necessitate extensive learning of social skills, in the form of social skills training Guivarch, Murdymootoo, Elissalde, Salle-Collemiche, Tardieu, Jouve, and Poinso (2017). At support groups for parents of children with ASD facilitates the exchange of information and can lead to a variety of benefits including enhanced knowledge, relationship quality, and team performance Brown, Tang, and Hollman (2014).

Problem Three: Brick’s older brother and sister have distant relationships they will even watch the same thing on three separate television sets because they can’t agree on the volume. Intervention: Brick and his older siblings Axl and Sue need to spend more shared supervised by their parents in organized activities. Rationale: A study of siblings showed that more time spent by the siblings in the company of parents was linked to better sibling relationships McHale, Updegraff, and Feinberg, (2016). Outcome: Mike and Frankie will start having family dinners around the table instead of in front of the television. They can give their daily highs and lows (Hilsey et al. (2009).

Outcome: Brick is placed in a social skills group at school and this helps give him skills to decrease his parents stress and worry about his future. Brick’s parents will contact the Autism Society of Indiana to help them locate a local support group (

References Ackley, B. J.,Ladwig, G. B., Makic, M. B. F. (2017). Nursing Diagnosis Handbook: An Evidence-based guide to planning care. St. Louis, MO: Elsevier. Autism Society of Indiana (2018) Support Groups. Retrieved from: Brown, L. D., Tang, X., & Hollman, R. L. (2014). The Structure of Social Exchange in Self-Help Support Groups: Development of a Measure. American Journal of Community Psychology, 53(0), 83–95. Denham, S., Eggenberger, S., Young, P., Krumwiede, N. (2016) Family-Focused Nursing Care. Philadelphia, PA: F.A. Davis Company Elder, J. H., Kreider, C. M., Brasher, S. N., & Ansell, M. (2017). Clinical impact of early diagnosis of autism on the prognosis and parent–child relationships. Psychology Research and Behavior Management, 10, 283–292. Heisler, E., Heline, D., Hunter, J., Hunter, M., Hobert, T., Dahm, R., Wernick, I., Shorr, R., Saltzman, M., (Writers), & Lee Shallat Chemel (Director). (2009).Season 1 Episode 1, 5, 7 [Television Series Episode]. Heisler, E., Heline, D., (Executive Producers), Hollywood, CA: Blackie & Blondie Productions & Warner Bros. Television Hisley, S., Ward, S. (2016) Maternal-Child Nursing Care: Optimizing Outcomes for Mothers, Children and Families (2nd ed). Philadelphia, PA: F.A. Davis Company

Guivarch, J., Murdymootoo, V., Elissalde, S.-N., Salle-Collemiche, X., Tardieu, S., Jouve, E., & Poinso, F. (2017). Impact of an implicit social skills training group in children with autism spectrum disorder without intellectual disability: A before-and-after study. PLoS ONE, 12(7), e0181159. Hisley, S., Ward, S. (2016) Maternal-Child Nursing Care: Optimizing Outcomes for Mothers, Children and Families (2nd ed). Philadelphia, PA: F.A. Davis Company Kaakinen, J. R., Coehlo, D. P., Steele, R., Tabacco, A., Harmon Hanson, S., M. (2015) Family Health Care Nursing: Theory, Practice and Research. Philadelphia, P.A: F.A. Davis Company McHale, S. M., Updegraff, K. A., & Feinberg, M. E. (2016). Siblings of Youth with Autism Spectrum Disorders: Theoretical Perspectives on Sibling Relationships and Individual Adjustment. Journal of Autism and Developmental Disorders, 46(2), 589–602. Perry, S, E., Hockenberry, M, J., Lowdermilk, D, L, Wilson, D. (2014) Maternal Child Nursing Care (5th ed). St. Louis, MO: Elsevier. Weill, V., Zavodny, S., Souders, M., C. (2018) The Nurse Practitioner. Autism Spectrum Disorder in Primary Care.43(2), 21–28. doi: 10.1097/01.NPR.0000529670.62188.1a .