REASON FOR REFERRAL: This is a (XX)-year-old boy who has a history of aggression, defiance, and oppositional behavior. It is reported that the aggressive and violent behavior has been taught to the patient and his brother and encouraged by adults prior to placement.
HISTORY OF THE PRESENT ILLNESS: The patient and his brother have been in the foster home for the past two months. He is very lovable and affectionate. He is aggressive and can be violent. He can be labile and will attack his brother unprovoked. He is easily frustrated and has temper tantrums. He will throw himself on the floor when frustrated. He sleeps well but moves around a lot while sleeping. Occasionally, he will fall to the edge of the bed. His bed is low to the floor. He eats well, is toilet trained, and is dry at night. Fluids are restricted after dinner. He is unable to dress himself and seems to have difficultly learning his activities of daily living. He needs constant monitoring and redirection. He will push others and throw things. He is difficult to manage when others visit. He returns from visits with his mother agitated, aggressive, and unruly. It takes up to 24 hours for the patient to calm down after visits with his mother. There is no strange or unusual behavior reported.
PAST PSYCHIATRIC TREATMENT HISTORY: The patient sees (XX) for weekly therapy.
PAST MEDICAL HISTORY: The patient has a history of asthma as well as anemia. He was taking iron supplements, which were recently discontinued, and his asthma inhaler, as needed, was also recently discontinued as he has not had symptoms in a long time.
MENTAL STATUS EXAMINATION: The patient was well groomed and appropriately dressed. He was marginally cooperative and engaged with encouragement. He was well related and displayed normal psychomotor activity. Attention span was adequate. Mood was euthymic. Affect was labile. He is easily frustrated, but he is also able to be redirected. Speech displayed normal rate, rhythm, and tone. No significant articulation difficulties noted. His thoughts are goal directed. There is no evidence of auditory or visual hallucinations nor delusional perceptions. There is no evidence of suicidal or homicidal ideation, intent or plans. He is alert and oriented x3. Memory is adequate. Concentration was adequate while playing. He needed constant supervision and redirection throughout the interview. Insight is poor. Judgment and impulse control are both poor.
SUMMARY: The patient is a (XX)-year-old boy who was placed in foster care program on MM/DD/YYYY. He has a history of aggression, defiance, and oppositional behavior. He seems to require constant monitoring and very close supervision due to his unprovoked aggressive outbursts.
DIAGNOSTIC IMPRESSION:
AXIS I:
1. Oppositional Defiant Disorder.
2. Adjustment Disorder with Disturbance of Conduct due to increased aggressive and violent behavior following maternal visits.
AXIS II: Expressive speech delays.
AXIS III: Asthma and anemia, history of both, in remission.
AXIS IV: Moderate, ongoing foster care, significant dysfunction in his nuclear family.
AXIS V: Current Global Assessment of Functioning is 45.
RECOMMENDATIONS:
1. This child should continue weekly psychotherapy.
2. Extensive structure and support is required for this young man. He needs constant redirection and encouragement for appropriate behavior.
3. This child will require special education services in order to develop appropriately and be able to function academically. He should be evaluated as soon as possible for special education placement and services as well as possible speech therapy, physical therapy, and occupational therapy.
4. This child requires speech therapy evaluation.
5. A positive behavior modification plan would be very helpful in order to encourage appropriate behavior.
6. Community-based services are recommended for his health and well being.
7. Medical followup and monitoring for his history of asthma and anemia, in remission.
