The School - Aged Child
Case 4.8 Disruptive Behavior
124 The School-Aged Child
Family h istory: Jack ’ s mother has history of Hashimoto thyroiditis and depression and is medicated for both of these conditions. She is fairly adherent to her medication regime. She was an average student, graduated from high school, and works as a cashier. His 33 - year - old father has a history of substance abuse, depression, and hypertension. He was incarcerated briefl y for selling drugs and now declines all medications. He did not complete high school, has a history of delinquency and attention problems, and currently works intermittently in construction. The maternal grandparents both have well - controlled hypertension and hypercholesterolemia. The paternal grandparents ’ histo- ries are unknown to the father since he has not had contact with them in 15 years. Jack ’ s sister is healthy and doing average school work.
Social h istory: Jack ’ s mom is single and lives on the second fl oor of a 1940s 2 - family house with the maternal grandparents on the fi rst fl oor. The household consists of his mother, an 8 - year - old sister, 2 dogs, and several cats. His mother and the children have frequent contact with the father, but he is not a regular part of the household. Both parents smoke while with the children. Jack attended daycare full - time until school entry but now returns home to the care of his grandparents after school.
Toward the end of his time in daycare, his mom reports that she had received a few calls about Jack ’ s behavior, specifi cally some diffi culties participating in group activities and following directions.
Medications: Takes no medications.
OBJECTIVE
General: Alert, active, responsive to most requests with good articulation, some fi dgeting with instruments.
Vital s igns: Height: 46 inches (115 cm); weight: 45 lbs (20.9 kg); heart rate: 92; respiratory rate: 18;
blood pressure: 98/62.
HEENT : Normocephalic; PERRL full EOMs, normal convergence, normal discs; gray TMs with good light refl exes and landmarks. Nose is normal, midline septum, boggy turbinates. Throat reveals large tonsils, no erythema, and uvula midline.
Neck: Supple; FROM; thyroid not palpable; no LAD.
Cardiac: RRR; S1/S2; no murmur; pulses full and equal.
Respiratory: Clear breath sounds throughout.
Abdomen: Soft, no mass, no HSM.
Genitourinary: Normal male, circumcised, testes descended × 2.
Musculoskeletal: FROM all extremities; symmetric movement.
Neurologic: Normal tone, strength, coordination, refl exes and cranial nerves II - XII grossly intact.
Skin: Clear, dry patches on elbows and knees.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___CBC
___Thyroid studies ___Lead screening ___Vision screening
Disruptive Behavior 125
___Hearing screening
___Vanderbilt ADHD screening for school and parent ___Learning disability evaluation
___Pediatric Symptom Checklist
What is the most likely differential diagnosis and why?
___Normal active behavior of early childhood ___Hearing impairment
___ Attention defi cit hyperactive disorder ( ADHD ) ___Learning disability
___Oppositional defi ant disorder ___Conduct disorder
___Depression
What is the plan of treatment?
What is the plan for follow - up care?
Are there any demographic factors that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: Selected lab evaluations help to convince parents that the child is physically healthy and that other conditions may be important to consider. A CBC and lead screening assures that there is no anemia, infection, or elevated lead level. Hyperactive thyroid would be very unlikely to present this constellation of symptoms and need not be obtained unless the mother is very concerned because of her own thyroid disorder. Vision and hearing screening are essential to assure that Jack has intact sensory systems so he is able to respond appropriately to directions and facial cues.
Jack ’ s hearing screen was normal. Vanderbilt ADHD screening indicated no concerns with inat- tentiveness or combined type ADHD. Information gathered from the school suggested that Jack started the year as a capable student who has begun to lag behind his peers, especially in reading and social skills. Jack ’ s mother completed The Pediatric Symptom Checklist. Scoring revealed that Jack has trouble obeying his teacher, is often irritable and angry, fi ghts with other children, does not listen to rules, does not understand other people ’ s feelings, blames others for his troubles, teases others, and refuses to share.
What is the most likely differential diagnosis and why?
Oppositional defi ant disorder:
To arrive at a working diagnosis, much more information needs to be gathered from Jack ’ s teacher and from standardized screening tools and possibly school assessments of learning issues. Based on the test results and further history from his mother and teacher, it appears that Jack meets the DSM - IV diagnostic criteria for Oppositional Defi ant Disorder ( ODD ). This diagnosis is more likely than depression. Jack ’ s behavior is more extreme than his peers, and it interferes with his social and aca- demic development. Jack also has numerous risk factors for this disorder including fi nancial problems in the family, family instability, a parent with a substance abuse disorder, parents with a history of ADHD, lack of positive parental involvement, and inconsistent discipline.
What is the plan of treatment?
Discuss the diagnosis with his mother and father. Reinforce that this is a manageable condition and that primary care will provide support to the family in their efforts to make change. Discuss that early intervention is critical and has the greatest possibility of preventing ODD from progressing to conduct disorder. Address parental concerns and assure them that effective, consistent discipline can make signifi cant improvements.
126 The School-Aged Child
• Recommend parent - focused discipline literature such as 1 - 2 - 3 Magic by Thomas Phelan.
• Refer for parent - management training such as Russell Barkley ’ s Parent Management Training or Ross Greene ’ s Collaborative Problem - Solving.
• Refer to Conduct Clinic, if available in community or university setting.
• Refer for family therapy or individual play therapy for Jack.
• Consider social skills training if peer relationships deteriorate.
• Encourage close communication with his teacher to assure consistent approaches to behavior changes.
• If comorbid ADHD develops at a later time, stimulant medications may be helpful.
What is the plan for follow up care?
Follow up in the primary care setting to reinforce strategies learned in therapy and to offer continued support for family efforts. Encourage the grandparents ’ participation in visits so they will utilize the same approaches as the parents are learning,
Are there any demographic factors that might affect this case?
This condition can occur in any socioeconomic or racial group. Risk factors are noted above.
Are there any standardized guidelines that you should use to assess or treat this case?
American Psychiatric Association (2000). See reference below.
REFERENCES AND RESOURCES
American Psychiatric Association ( 2000 ). Diagnostic and statistical manual of mental disorders , 4th text revision DSM IV - IV TR, 4th edition, APA, Washington, DC.
Barkley , R. A. ( 1997 ). Defi ant children . New York, NY : The Guilford Pres .
Greene , R. W. , Ablon , J. S. , & Goring , J. C. ( 2003 ). A transactional model of oppositional behavior: Underpinnings of the Collaborative Problem Solving approach . Journal of Psychosomatic Research , 55 , 67 – 75 .
Jellinek , M. S. , Murphy , J. M. , Little , M. , et al. ( 1999 ). Use of the Pediatric Symptom Checklist (PSC) to screen for psychosocial problems in pediatric primary care: A national feasibility study . Archives of Pediatrics & Adolescent Medicine , 153 ( 3 ), 254 – 260 .