Clinician Name
Jessica Roberts
Patient Age
5
Patient Height
45 inches
Patient Weight
43
Patient Sex
Male
Race/Ethnicity
White
Patient's main medical and/or
Parents are very concerned about child's social skills and poor behavior. For most of child's life
psychiatric problem/s and past
he has had poor communication skills by having tantrums instead of expressing himself.
history.
Whenever he can't figure something out or doesn't get what he wants parents say he throws a fit,
refuses eye contact or redirects his interest to something else. Parents discipline him with time
outs, slapping his wrist, spanking his bottom, or removing him from the situation/thing he wants
to do. When they warn him he completely ignores them.
Mother observed child in school this week and noted that he was hitting others (including
teacher), threw a chair and crayons, wouldn't focus on the teacher but would scribble or talk to
others, get up and walk around, etc. Principal has already called home several times in the first
week of school.
Occasionally when child is angry he says "I don't love you." or "Mommy and Daddy are
stupid."
Child speaks in full sentences and can play well with others, but occasionally he stutters and
parents report having his hearing screened when 1 year old due to speech delay. He will do
simple chores at home, but can only do them if told one thing at a time. His younger siblings
seem to do a better job at socializing appropriately.
Parents report Zach can't sit still and has a disregard for rules. He doesn't wait his turn and
interrupts. However, he is a good problem solver. He sleeps well at night- no insomnia. Parents
report a family history of hyperthyroidism and that child is "always hungry but never gains
weight."
I have now started him on Adderall 5mg daily (for ADHD) before school which showed no
effect on his school performance or behavior, so at the next eval I increased it to 10mg daily
and told parents they may go up to 15mg QAM on schooldays in two weeks if no change is
noticed.
I have counseled the parents multiple times that I think they need to couple his medical therapy
with behavioral counseling and tried to address some discipline issues such as being consistent
over what to reprimand, picking battles carefully, and searching for ways to praise child. Only
at the last visit did dad even take my list of suggestions for people who do counseling that he
could follow up with. (There is a very limited selection in my remote area.)
Clinical questions that you'd like to
What are some behavioral counseling methods I can discuss/teach if the parents still don't feel
discuss related to this patient case
comfortable going to seek out a specialist far away?
Clinical Question 2
So that I might better inform the family, what should I tell them to expect if they see a child
psychiatrist or psychologist?
Clinical Question 3
I have ruled out autism b/c child seems developmentally appropriate; and b/c he maintains good
eye contact with me and has other friends at school I have not considered Asperger's. Are there
any other mental/developmental concerns I should rule out as a co-morbidity? He currently has
ADHD and ODD as diagnoses.
Clinical Question 4
How can one encourage parents to participate in local "parenting classes" without it coming
across to them as an insult?
Lab results from recent exams
CBC and thyroid studies came back nl as seen below with reference range listed to right:
include
WBC 4.9 10\S\3/uL 4.5-13.5
RBC 4.95 10\S\6/uL 4.0-5.3
HGB 14.3 g/dL 11.5-14.5
HCT 41.8 % 33-43
MCV 84.5 fL 82.0-97.0
MCH 28.8 pg 27.0-34.0
MCHC 34.1 g/dL 32.0-36.0
RDW 12.2 % 11.8-15.2
PLATELETS 174 10\S\3/uL 150-400
MPV 9.2 fL 5.2-11.1
NEUTROPHILS % 24 Low % 45-75
LYMPHOCYTES % 63 High % 15-50
MONOCYTES % 11 High % 0-10
EOSINOPHILS 1 % 0-5
BASOPHILS 1 % 0-5
TOTAL T4 8.1 ug/dL 7.3-15.0
T3 UPTAKE 26.5 % 22.0-35.0
T7 (FTI) (Calc.) 2.1 Index 1.0-4.4
TSH (3rd gener.) 1.188 mIU/mL 0.340-5.600
Substance abuse history?
No
Tobacco use history?
No
Depression Screening?
No
Anxiety screening?
No
Other screenings? Please indicate
No Cardiac risk factors, h/o murmur or family cardiac dz
type and results.
Does patient have any allergies or
No
allergies to medications?
Is there social history about this
patient that is important to know
when discussing the case?
Yes
If Yes
Father drinks at home, but won't specify how much, and is former military. He typically cusses
in front of son. He seems to care about his son and thinks he is a strict disciplinarian. He wasn't
involved much in his son's life until recently after he got out of military. Parents are married,
but I can tell there were some marital strains in the past when they talked about how much they
had to be apart while dad was away on deployments.
Dad has mentioned he's seen psychologists/psychiatrists in the past and I suspect a h/o
depression and possible substance abuse that he dealt with while in military. This makes him
very resistant to further psychiatric help for his son b/c he thinks it is pointless.
Additional comments
Sorry this is so long! Plz feel free to cut it down.