Child and Adolescent Disorders

Cases adapted from:
Reid, W. H., & Wise, M. G. (1989).  DSM-III-R training guide.  New York: Brunner.

Case Study 1

        Jeremy, age 9, is brought by his mother to a mental health clinic because he has become increasingly disobedient and difficult to manage at school.  Several events during the past month convinced his mother that she had to do something about his behavior.  Several weeks age he swore at his teacher and was suspended from school for 3 days.  Last week he was reprimanded by the police for riding his bicycle in the street, something his mother had repeatedly cautioned him about.  The next day he failed to use his pedal brakes and rode his bike into a store window, shattering it.  He has not been caught in any more serious offenses, though once before he broke a window when he was riding his bike with a friend.
        Jeremy has been difficult to manage since nursery school.  The problems have slowly escalated.  Whenever he is without close supervision, he gets into trouble.  He has been reprimanded at school for teasing and kicking other children, tripping them, and calling them names.  He is described as bad-tempered and irritable, even though at times he seems to enjoy school.  Often he appears to be deliberately trying to annoy other children, though he claims that others have started the arguments.  He does not become involved in serious fights, but does occasionally exchange few blows with another child.
        Jeremy sometimes refuses to do what his two teachers tell him to do, and this year has been particularly difficult with the one who takes him in the afternoon for arithmetic, art, and science lessons.  He gives many reasons why he should not have to do his work, and argues when told to do it.  Many of the same problems were experienced last year when he had only one teacher.  Despite this, his grades are good, and have been getting better over the course of the year, particularly in arithmetic and art, which are subjects taught by the teacher with whom he has the most difficulty.
        At home Jeremy's behavior is quite variable.  On some days he is defiant and rude to his mother, needing to be told to do everything several times before he will do it, though eventually he usually complies; on other days he is charming and volunteers to help; but his unhelpful days predominate.  "The least little thing upsets him, and then he shouts and screams."  Jeremy is described as spiteful and mean with his younger brother, Rickie; even when he is in a good mood, he is unkind to Rickie.
        Jeremy's concentration is generally good, and he does not leave his work unfinished.  His mother describes him as "on the go all the time", but not restless.  His teachers are concerned about his attitude, not about his restlessness.  His mother also comments that he tells many minor lies, though when pressed, is truthful about important things.

Case Study 2

        Eddie, age 9, was referred to a child psychiatrist at the request of his school, because of the difficulties he creates in class.  He has been suspended for a day twice this school year.  His teacher complains that he is so restless that his classmates are unable to concentrate.  He is hardly ever in his seat, but roams around the class, talking to other children while they are working.  When the teacher is able to get him to stay in his seat, he fidgets with his hands and feet and drops things on the floor.  He never seems to know what he is going to do next, and may suddenly do something quite outrageous.  His most recent suspension was for swinging from the fluorescent light fixture over the blackboard.  Because he was unable to climb down again, the class was in an uproar.
        His mother says that Eddie's behavior has been difficult since he was a toddler, and that as a 3-year-old he was unbearably restless and demanding.  He has always required little sleep and been awake before anyone else.  When he was small, "he got into everything," particularly in the early morning, when he would awaken at 4:30 a.m. or 5:00 a.m. and go downstairs by himself.  His parents would awaken to find the living room or kitchen "demolished."  When he was age 4, he managed to unlock the door of the apartment and wander off into a busy main street, but, fortunately, was rescued from oncoming traffic by a passerby.  He was rejected by a preschool program because of his difficult behavior; eventually, after a very difficult year in kindergarten, he was placed in a special behavioral program for first- and second-graders.  He is now in a regular class for most subjects, but spends a lot of time in a resource room with a special teacher.  When with his own class, he is unable to participate in games because he cannot wait for his turn.
        Psychological testing has shown Eddie to be of average ability, and his achievements are only slightly below expected level.  His attention span is described by the psychologist as "virtually nonexistent."  He has no interest in TV, and dislikes games or toys that require any patience or concentration.  He is not popular with other children, and at home prefers to be outdoors, playing with his dog or riding his bike.  If he does play with toys, his games are messy and destructive, and his mother cannot get him to keep his things in any order.

Case Study 3

        Phillip, age 12, was suspended from a small-town Iowa school and referred for psychiatric treatment by his principal.  The following note came with him:

This child has been a continual problem since coming to our school.  He does not get  along on the playground because he is mean to other children.  He disobeys school rules, teases the patrol children, steals from the other children, and defies all authority.   Phillip keeps getting into fights with other children on the bus.  He has been suspended from cafeteria privileges several times for fighting, pushing, and shoving.  After he misbehaved one day at the cafeteria, the teacher told him to come up to my office to see  me.  He flatly refused, lay on the floor, and threw a temper tantrum, kicking and screaming.  The truth is not in Phillip.  When caught in actual misdeeds, he denies everything, and  takes upon himself an air of injured innocence.  He believes we are picking on him.  His  attitude is sullen when he is refused anything. He pouts and when asked why he does these  things, he points to his head and says, "Because I'm not right up here."
This boy needs help badly.  He does not seem to have friends.  His aggressive behavior  prevents the children from liking him.  Our school psychologist tested Phillip, and the results indicated average intelligence, but his school achievement is only at the third- and  low-fourth grade level.

        The psychiatrist learned from Phillip's grandmother that he was born when his mother was a senior in high school.  Her parents insisted that she keep the baby and help rear him; most of his upbringing has been by his grandparents, however.
Phillip was "3 months premature," and a "blue baby," requiring oxygen for 24 hours.  Shortly after his birth, Phillip's mother ran off with a man, married him, and had a second child.  The marriage broke up, and she left this child with its father.  Phillip has had no contact with his mother since she left him.
        Phillip's toilet training was not successful, and he remained a bedwetter for some years.  At age 5, his maternal grandparents adopted him because they were afraid that his mother might some day claim him.  He showed anxiety at separation from his grandmother when he began school.
        He was then in a serious car accident, in which his grandmother was injured and one person in the other car was killed.  Phillip did not appear to be injured, but seemed to have some transient memory loss, probably a direct, immediate result of the impact.  Subsequently, he had nightmares, fear of the dark, and an exacerbation of his fear of separation from his grandmother.
        Phillip's school progress was not good.  He repeated third grade and then was in a special class for underachievers.  His grandmother recalls that Phillip's teacher complained that he "could never stay in his seat."

Case Study 4

        Tina, a small, sweet-faced, freckled, 10-year-old child, has been referred by a pediatrician who was unsuccessful in treating her for refusing to go to school.  Her difficulties began on the first day of school one year ago when she cried and hid in the basement.  She agreed to go to school only when her mother promised to go with her and stay to have lunch with her at school.  For the next 3 months, on school days, Tina had a variety of somatic complaints, such as headaches and "tummy aches" and each day would go to school only reluctantly, after much cajoling by her parents.  Soon thereafter she could be gotten to school only if her parents lifted her out of bed, dressed and fed her, and drove her to school.  Finally, in the spring, the school social worker consulted Tina's pediatrician, who instituted a behavior-modification program with the help of her parents.  Because this program was of only limited help, the pediatrician had now, at the beginning of the school year, referred Tina to a psychiatrist.
        According to her mother, despite Tina's many absences from school last year, she performed well.  During this time she also happily participated in all other activities, including Girl Scout meetings, sleep overs at friend's houses (usually with her sister), and family outings.  Her mother wonders if taking a part-time bookkeeping job 2 years ago, plus the sudden death of a maternal grandmother to whom Tina was particularly close, might have been responsible for the child's difficulties.
        When Tina was interviewed, she at first minimized any problems about school, insisting that everything was "okay," and that she got good grades and liked all the teachers.  When this subject was pursued, she became angry and gave a lot of "I don't know" responses as to why, then, she often refused to go to school.  Eventually she said that kids teased her about her size, calling her "Shrimp" and "Shorty"; but she gave the impression, as well as actually stated, that she liked school and her teachers.  She finally admitted that what bothered her was leaving home.  She could not specify why, but hinted that she was afraid something would happen, though to whom or to what she did not say; but she confessed that she felt uncomfortable when all of her family members were out of sight.