Psychiatric Evaluation: Adam First, Describe

Psychiatric Evaluation: Adam

First, describe the primary problem. Don't use labels, use descriptions. What stands out for you in the client's behaviors, thinking, and affect (feelings)?

The primary problem for an adolescent like Adam is finding a secure personal and social identity. His difficult relationship with his parents seems to be the root of his defiance. Both of his parents are physically and emotionally incapable of exercising control and setting limits on Adam's behavior and their own behavior in relation to their son. Adam is about to enter adolescence, and to develop as normally as possible it is essential that he be placed in a stable family environment, and receive appropriate treatment for his psychiatric difficulties, whatever their cause.

Sexual development and exploration is normal for adolescents within Adam's age group. Adam's sexual behavior may be a kind of cry for help, given how withdrawn he is at school and how little emotional support he has at home, from parents who are unable to set boundaries or show affection in an appropriate manner. It is unsurprising that a normally developing male would want to establish a friendship or a relationship with a girl his own age. The Internet is a sufficiently 'safe' and distanced format for Adam, as he cannot be rejected by the girl face-to-face, given how far away she lives, and exposing himself online may be the only way he knows to show affection. Although disturbing when viewed in consort with Adam's other social difficulties and behaviors, Adam's behavior with the girl over the Internet should not, in and of itself, be seen as psychiatrically abnormal in a clinical sense, and it is more symptomatic of Adam's difficulties in relating to others in his peer group, as well as with adults. This largely springs from his difficult situation with his parents.

Question

Look at the Axis 1 diagnosis. Does it match your description of what you believe is the problem. Do you agree with the diagnosis?

The diagnosis seems to give insufficient attention to Adam's relationship with his parents. It is true that bipolar disorder runs in Adam's family. However, Adam does not seem to have the symptoms of mania or depression. He does not have hallucinations and has normal sleep and appetite patterns. This is inconsistent with full-blown bipolarity. His inability to concentrate could indicate ADHD, but given the stressors he has at home and at school (justifiably given the rating of 'five') having difficulty focusing might be a result of these factors, rather than the disorder. Conduct disorder is a fairly vague term, and while Adam's poor judgment and defiance of adults, especially with the young woman he interacts with on the Internet, seems to be fairly categorized as such, it is noteworthy that the definition of conduct disorder itself is rather vague. Calling Adam a perpetrator of sexual abuse against a girl his own age, with whom he has tried to establish a relationship with in a fashion that encompasses letter-writing as well as sexual behavior, seems both extreme and unfair.

Question

Look at the medications; look them up online. Do they fit the symptoms?

Concerta is proscribed for individuals with a bipolar diagnosis, and given that so many of Adam's relatives have suffered mood disorders, it is odd that he was given Concerta, even if there is a question as to whether Adam's diagnosis was overly influenced by what the therapists knew about his family history. It seems sound to recommend that Adam stop taking Concerta, because it might aggravate underlying bipolar symptoms.

Strattera not stimulating, but it can have side effects, like prolonged erections, and it is also a fairly new drug. It should be prescribed with caution. It is still uncertain whether Adam's conduct disorders are due to his unstable home environment, and not due to any biological factors. Prescribing Strattera seems like a normal course of therapeutic action, but should not be regarded as a panacea.

Question

If you were the clinician, counselor, or therapist, what would be the primary issue you would want to address?

To be diagnosed with ADHD, the individual should exhibit the symptoms in two environments, and Adam's behavior seems to primarily assert itself in the home. With support, he seems functional in school, and he is substantially less functional at home than at school or with his peers. The first question that should be addressed is what is the most appropriate environment for Adam -- a foster setting, or remaining at home.

Question

Are there any discrepancies, contradictions, or concerns that stand out for you?

In terms of evaluating Adam's personal strengths, to say that "Adam is a very personable young man," seems contradictory, given Adam's manipulative behavior and his sexually inappropriate displays via the young woman he met on the Internet. Also, to say that "Adam's family is supportive and wants him home with them when he leaves Vernia TF" seems strange, given that they claim that Adam has tried to engage in a sexual relationship with his mother, because of their health issues that make it difficult to exercise control over a fourteen-year-old boy, and also their apparent willingness to relinquish control of their child to the state. His mother is also observed to be very physically demonstrative with her child, and says that she loves him frequently. This is not in and of itself unusual were it not for the fact that she says Adam's sexuality makes her uncomfortable and the fact that she characterized it as 'molestation.'