PRESENTING ISSUE Four-year-old black male presents in the office with his mother. Mother noticed a "big change" in the patient towards the end of February (this is now July). He started to be "aggressive and hyperactive." Mother believes that his former babysitter may have been "mildly verbally abusive. We had a lot of differences over time." Patient has a new babysitter and his behavior continues to be "aggressive, mean, hitting and biting." The hitting and biting is mostly directed towards his two-year-old brother.
NOTES
Mother is a nurse and father is a mechanic. Patient attends a Catholic preschool that has high expectations for behavior. Patient states, "I like school. I have lots of friends there." Patient enjoys watching television and playing outside in the pool. Mother has concerns about his social behavior, "He usually restricts his friends to one person at a time, he doesn't like to be in groups of kids." Mother relays that the teachers don't notice behavior problems outside of one instance where he bit a friend one time during recess. Mother mentions that she wants "to feel more emotionally connected" to her son.
Mother notes that she was hyperemetic during her pregnancy but otherwise there were no birthing complications. She believes he is developmentally on target. She states he gets "adequate sleep but refuses to sleep in his own room." She notes no nutrition problems and has a healthy appetite. The patient was hospitalized for several days a year prior for high fever and dehydration. Additionally, he was hospitalized for one day in January for Kawasaki Disease. He doesn't take any medication.
MENTAL STATUS EXAMINATION Affect: Bright
Appearance: Neat and clean, age appropriate
Mood: Euthymic Activity: Has difficulty sitting still, explores the office, asks many questions about items in office No apparent psychotic phenomena No noticeable body odor Denies suicidal/homicidal ideation and intent Appears to be of average intelligence Judgement and insight appears to be adequate Speech: Fluid, no idiosyncratic features noted Sleep: Adequate but won't sleep in his own room
INITIAL DIAGNOSES 309.3 Adjustment disorder with disturbance of conduct R/O: Attention Deficit Hyperactivity Disorder
TREATMENT PLAN
Free Play with patient
Structured Play with mother, patient, and little brother
Improve relationship with little brother
Understand relationship with prior babysitter
Bibliotherapy on parenting for mother
COURSE OF TREATMENT (approx 10 sessions)
Free play noted age appropriate activity, cooperation and attention span
Structured play noted sibling rivalry, modeled appropriate response for same, mother quickly picked up on concepts
Aggressive behavior towards little brother decreased to more appropriate levels
Was able to sleep in his own room
No noted abusive behavior by prior babysitter became apparent
Mother picked up on Adlerian parenting concepts easily
DISCHARGE DIAGNOSES Z03.89 No Diagnosis
POSTSCRIPT
This is a classic case of the Adlerian concept of dethronement. The patient was the only child and did not appreciate the attention that his little brother received from his mother. Of note, mother did not want Father involved in treatment. She briefed him on her own and noted that the Father was readily involved in the life of the family. I saw no indication to tell me otherwise. Mother seemed to be a credible historian, easily picked up on concepts, and implemented treatment goals.
In this instance, structured play involved the use of the Talking, Feeling, Doing Game
The bedtime formula is a customized, written plan, implemented by the patient (actually the parent) to help the patient become responsible for his own bedtime. It also increases connection with the parent who is helping the patient follow through with the written plan. At 4-years-old, a child can prepare himself for bed, set alarms, set out his own clothes, get himself up on his own, etc. This article gives some guidelines in helping establish same: https://www.positivediscipline.com/articles/overcoming-bedtime-hassles