Reference no: EM133272338

Chief Complaint: His dad, a single father, brings Zach to the clinic expressing frustration and discouragement in Zach's school performance and behavior at home. "He's just so hard to control."

Demographics: 10-year-old white male in the fourth grade.

Interview with Dad

"I have a lot of trouble controlling Zach," his father tells you privately, while Zach goes to the clinic's playroom for a few minutes. "He doesn't bounce off the walls, exactly, but I just have trouble teaching him any manners. I guess it's harder for guys to get that across to their kids or something. All I know is when we're at my folks' house on weekends, Zach is the only cousin who won't take turns when playing a game or waiting his turn to ride with Grandpa on the tractor. And he's ten. He should know better. I think he does know better. And then when I try to calm him down (after everybody's mad at him), he can't listen. He interrupts me constantly when I try to tell him why they're all mad at him again. He also climbs all over his favorite cousin Jonah, who's thirteen and while Jonah tries to be patient, you can see he doesn't like it."

"Last time we were there Jonah said, 'Hey Zach, how about we play this game?' Zach, who'd been waiting all day for Jonah to pay attention to him, couldn't sit still and finish even a simple game, even though I know he understands how to play it."

"And now, worse still, his fourth-grade teacher tells me that Zach is easily distracted, can't keep track of his books and pencils, and has trouble making, or keeping, friends, out on the playground.

"I'm just so frustrated," he says, head in his hands. "I am either really angry with Zach or at a complete loss. Sometimes I want to yell at him, and then I feel bad for being mad at him."

Evaluation of Zach: 1st visit

Zach is initially withdrawn and answers most questions with either a yes or no response. He tells you that he came today because "my dad says I have a problem." In response to probing about what he thinks is going on, he states, "I don't know...I just feel bad in my head sometimes." He does tell you that he sleeps "okay" and doesn't really mind going to bed most nights. He would like more friends at school and feels "sad" because other kids don't like him very much. He is frigidity throughout the interview and often has to be redirected back to the conversation

Evaluation of Zach: 2nd visit

Zach is less withdrawn and calmer than at the previous visit. His effect is variable. At times he appears sad and at other times he is irritable and anxious. He tells you that his thoughts are really "fast in his head" and his teacher gets mad at him because he doesn't pay attention in class. He acknowledges that he gets really mad sometimes and just wants to "break stuff." He thinks he does a "really awesome job" of doing his homework and thinks he is smarter than his classmates. He recounts a story in which he told other kids at school that he had super powers and could make all of them disappear if he really wanted to.

Current Medications

None

H&P

Unremarkable. Healthy. Weight= 34.8 kg, b/p= 99/56, P=72

Family history

Biological mom has bipolar I disorder

Question 1. What differential diagnoses are you considering? Provide supportive data and rationale.

Question 2. What are the most likely diagnoses? Include specifiers and diagnostic code.

Question 3. What number (1-5) will you assign to indicate how closely your client fits the ideal diagnosis? (see Morrison, p.3)

Question 4. What evidence-based tools would you recommend to increase the accuracy of your diagnosis?

Question 5. What is your initial treatment plan? Be sure to include pharmacological and nonpharmacological recommendations. Provide a rationale.