Identifying Information
Chiron is a school age male child observed both at school, home, and in his neighborhood.
History of Presenting Illness
The patient is a school-aged male child with symptoms of inattention, isolation from peers, flat affect, and lack of emotional response to interactions with caregiver both in the school and home environments. These symptoms have been present for several years and vary in severity.
The patient does not engage with his peers, and is often bullied and picked on by classmates. He is isolated from groups, being chased after school and leaving group sports games without speaking to anyone. When asked direct questions by both peers and adults, he looks down and gives minimal eye contact without answering or gives short, often one-word responses. When interacting with his mother, the patient is flat in affect and does not display any signs of comfort from being embraced by his mother.
Family Involvement:
The patient lives with his mother in a low-income housing development who is often not present (physically and emotionally) due to her struggle with substance abuse. We have not observed any interactions of patient with father, which suggests that he is not involved at all. Patient does an adult male in his life to provide some guidance and a safe space although patient is still appears apprehensive in his interactions with this male adult.
Personal and Family History of Emotional, Behavioral or Developmental Disorders:
We do not have any information on whether or not the patient has been evaluated or diagnosed with any emotional, behavioral, or development disorders in the past. We need to try and obtain any past medical and/or psychiatric health records.
The patient’s mother suffers from substance abuse and addiction. We have no additional information on other her history of other disorders or information on patient’s father medical and psychiatric history. We need to try and obtain this information if available.
Medical History:
The patient appears small for his in both height and weight. We need to obtain actual numbers and assess BMI. At this time we do not have medical records for the patient but would like to obtain if available.
Relevant Labs/Assessments
Risk assessment for lead poisoning and screening lab work
Risk assessment for TB and PPD test
Risk assessment for anemia and screening lab work
Vision and Hearing screen
BP check and height, weight, and BMI screen
Scoliosis screen
Vaccination status assessment and catch up as needed
SCARED assessment for Anxiety
Developmental screen for School Age child and Autism Disorder Screen
Depression screen for School Age child
Mental Status Examination
Patient is a school aged male child who is small for his age. He is dressed in clean but well-worn clothing appropriate for the season. He sits still with slouched posture but makes little eye contact and has a blank facial expression. When walking his gate is slightly off balance but no other tics or abnormal movements observed. When watching his interactions, he appears to have a flat affect when engaging with others and he typically responds to questions with silence or very few words that are spoken slowly and softly. He appears to have some logical thought process and ability for abstract thought when speaking to the adult male in his life.
In summary, patient is a school age child with symptoms of inattention, isolation from peers, flat affect, and lack of emotional response to interactions with caregiver that are impacting his ability to function socially and emotionally.
Differential Diagnosis:
With the current information the primary diagnosis for this patient is reactive attachment disorder with a differential diagnosis of disinhibited social engagement disorder, post-traumatic stress disorder, adjustment disorder, autism spectrum disorder, and attention deficit disorder. Reactive attachment disorder is likely are patient is experiencing neglect from his caregiver, does not seek out his caregiver for support or help when dealing with being bullied, has a flat affect, and has difficulty engaging in with his peer group. At this time we are unable to completely rule out autism spectrum disorder or attention deficit disorder without completing an autism disorder screen and the Vanderbilt Assessment for attention deficit disorder. Disinhibited social engagement disorder is less likely as children tend to be overly friendly and less fearful of strangers and they don’t check back in with caregivers to see if these interactions are ok. Our patient is apprehensive when meeting new people and not likely to walk up and engage with strangers. Adjustment disorder is less likely as it is an excessive reaction to an identifiable stressor that impairs social, occupational, or academic functioning and symptoms do not last longer than six months. Post-traumatic stress disorder is difficult to rule out as we need to ask the patient if he has been reliving a traumatic event, have trouble sleeping or feeling tense, or having negative thoughts about self or feeling guilt or blame.
Primary Diagnosis
The primary diagnosis for this patient (with the current known information) is reactive attachment disorder. Attachment disorders are the result of social neglect or the absence of adequate social and emotional caregiving during childhood that results in disruption of normal bond between caregivers and children. For a diagnosis of reactive attachment disorder, there must be a history of gross neglect, lack of contingent responses, and little or no attention, interaction, or affection. The DSM-5 diagnostic criteria for reactive attachment disorder are:
• A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers
• A persistent social and emotional disturbance
• A pattern of extremes of insufficient care
• The care described in the third criterion is presumed to be responsible for the disturbed behavior described in the first criterion
• The criteria for autism spectrum disorder are not met
• The disturbance is evident before age 5 years
• The child has a developmental age of at least 9 months
Symptoms of reactive attachment disorder include a child who rarely or minimally seeks comfort when distressed or responds to comfort when distressed. They have minimal social and emotional responses to others or have episodes of unexplained irritability, sadness, or tearfulness. They have limited expressions of positive affect or joy and there is evidence of inadequate basic emotional and social caretaking. Other symptoms that may be present include failure to thrive, poor hygiene, underdeveloped motor coordination, and a bewildered, unfocused, or understimulated appearance. The patient may be unable to recognize or respond to body language cues or facial expressions and may avoid eye contact and protest people coming too close or touching them. Associated signs may include signs of physical abuse, malnutrition, and excessive appetite and/or food hoarding in children. Complications related to attachment disorders may include defiant behaviors, pervasive anger and resentment, cognitive delays, language delays, conduct disorders, and difficulties in social settings and/or school.
Principles of treating reactive attachment disorder include modifying the behavior of the primary caregivers in their everyday interactions with child. A referral to a mental health professional that is well versed in attachment disorders and the need to recreate a sense of security in the child may be necessary. Therapeutic components that aid in promoting attachment when demonstrated by the caregiver include security, stability, and sensitivity. There are not pharmacologic treatments for attachment disorders themselves but using medication to treat comorbid disorders such as depression or anxiety may be helpful.