Friday, December 6, 2013

WHY SOME KIDS MAY NOT FOLLOW RULES DUE TO CONDUCT DISORDER (THE CASE OF RAUL & JOSE)


Case History

“Raul is 14 years old. His younger brother, Jose, is 13. They were raised together by their parents. The two boys, along with their younger sister, Maria, age 8, were recently removed from their parents’ custody by Arizona Child Protective Services. 

The two boys have experienced regular physical and verbal abuse by their father, Alberto Lopez. Mr. and Mrs. Lopez are illegal immigrants from Mexico. They are both migrant workers in the Western USA, moving continuously throughout California, Oregon, Arizona, Idaho, and Colorado to follow the availability of seasonal farm work. The children have not attended school regularly due to the family’s mobility, and Raul has often been left in charge of the younger two children when the Lopez’s have been working long days, sometimes seven days a week during picking season.

The family has had two encounters in the past year with INS, but has escaped by fleeing and hiding. They live in fear of deportation and/or arrest. Mr. and Mrs. Lopez do their best to feed and clothe their children while also sending money home to family members in need in Mexico.  Money is very tight, and resources are limited.

Mr. Lopez had bouts of drinking before he and his family slipped over the US border three years ago. But since that time, due to the stresses of migrant life, he has abused alcohol regularly. He will drink whatever he can afford or obtain free of charge. Mr. Lopez often becomes violent when he is drunk. He routinely loses patience with his children, demeans them verbally, blames them for his stresses, and beats them with his hands or belt. 

He also batters his wife when he is drunk. He breaks objects and/or throws them at his family. The children have all suffered bruises, contusions, and occasional broken bones, for which medical care has not been available. When Mr. Lopez is sober, he hates himself for how he is treating his family, and he sees a priest whenever he can to confess his behaviors and start again. The family often attends Catholic Church services in their native language, run by Catholic missionaries. 

The three children came to the attention of CPS because of Raul’s behavior. Raul was caught setting fire to a German Shepherd who was outside in the backyard of family in a nearby town.  The family was away for the day. Raul had smashed a window and entered the house, and stolen jewelry and coca cola. He ran from the police when they arrived at the house. When interviewed, he was defiant and denied any wrongdoing. 

Others in the community report that Raul has been involved in fights with their children, and that he is often seen verbally taunting other kids. The police picked up Raul, along with his younger brother and sister, who were apparently horrified at what Raul had been doing to the dog. Jose and Maria were trying to save the dog.

While left in charge of his younger siblings, Raul has been verbally and physically abusive to them, “to keep the discipline”, he says. He is worried about his younger brother, Jose, because he believes that Jose “acts like a little girl.” Jose appears nervous and shy. He speaks in a barely audible voice. He has problems getting out of bed in the morning, daydreams most of the day, bites his nails continuously, wets the bed at night, cries a lot, does not seem to have any interest in sports or physical activities, and does not connect well with other children. 

When interviewed by CPS, Jose seemed to blame himself for how his father is acting, believing that he is the main cause of the family’s stress. Jose did seem very bonded to his younger sister, Maria, however, and seemed to view himself as her protector” (American Academy of Child and Adolescent Psychiatry. 2004).

Diagnoses For Raul:

After reviewing all details of this case and AXIS I diagnoses which are listed in the DSM-IV-TR, I believe that Raul may be experiencing:

·         Attention-Deficit and Disruptive Behavior Disorders: Conduct Disorder (312.8)

Adjustment Disorders (with): Disturbance of Conduct (309.3)

·         Relational Problems: Parent-Child (V61.20), Sibling (V61.8)
·         Problems Related to Abuse or Neglect: Neglect of Child (V61.21) Physical Abuse of Child (V61.21)
·         Child or Adolescent Antisocial Behavior (V71.02)
·         Phase of Life Problem (V62.89)

According to (Facts for Families. 2004), “conduct disorder refers to a group of behavioral and emotional problems in youngsters. Children and adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable way” (p. 1). Since, these children suffer from certain behavioral disorders that cause lack of control they may also experience several social problems in a normal setting if the disorder is left untreated. Some of these problems can include bullying and intimidating others, initiating physical altercations, forcing sexual activity, and using weapons to harm people and/or animals. 

In a “normal” society, children who suffer from conduct disorder may also be viewed as bad or delinquent instead of being evaluated by a mental health professional. If this lack of adequate support and treatment continues with Raul, then he may also experience oppositional defiant disorder as he gets older. This may be especially true in his case because he might eventually begin to defy the “authoritative” abuse that is occurring at the hands of his father. Therefore, treatment of his suspected diagnoses must be addressed as soon as possible.

Diagnoses For Jose:

After reviewing all details of this case and AXIS 1 diagnoses which are listed in the DSM-IV-TR, I also believe that Jose may be experiencing:

·         Elimination Disorders: Enuresis (307.6)

Adjustment Disorders (with): Mixed Disturbance of Emotions and Conduct (309.4)

·         Relational Problems: Parent-Child (V61.20), Sibling (V61.8)
·         Problems Related to Abuse or Neglect: Neglect of Child (V61.21) Physical Abuse of Child (V61.21)
·         Child or Adolescent Antisocial Behavior (V71.02)
·         Age-Related Cognitive Decline (780.9)
·         Phase of Life Problem (V62.89)

Adjustment disorder with mixed disturbance of emotions and conduct usually occurs due to a stressful life event and may cause negative behavioral changes and a lack of emotional stability. This disorder normally affects children who are under the age of 18 and symptoms may include anxiety, sadness and/or a disruption of normal routine. When this disorder is present, it may be possible to affectively overcome these symptoms with the right support. Therefore, a suitable treatment plan will need to be implemented to address this possible disorder. If this occurs, it is also possible that many of Jose’s other disorders and/or conditions will improve or be reduced over time.

Recommendations For Treatment

After evaluating this case, I also believe that these boys may be experiencing different disorders and/or other conditions for several reasons. However, the main factor could be due to a difference in cognitive processing of incoming environmental stimuli. This is because most individuals have the ability to process symptoms of trauma like fear, anger, helplessness and sadness on different levels. This may also be individually determined based on what coping mechanisms are most needed to successfully support psychological and/or physical survival. Regardless, of varying symptoms, there are several strategies which can be used with both Raul and Jose to address these individual disorders and/or other conditions. These include:

1. Early Intervention – This is a key factor in order to offer the best possible support and treatment before behavior/s get worse.

2. Comprehensive Evaluation – This will help determine whether Raul and Jose may be suffering from other existing disorders like (PTSD) due to years of physical and psychological abuse. If this is the case, then that could also be what initially contributed to the onset of their current disorders and/or other conditions.

3. Treatment Plan – A trained professional can devise an individualized plan for Raul and Jose by gathering information and support from teachers, family members, and any pertinent medical staff that may exist. This plan may also include behavioral therapy and psychotherapy which can help both boys control these maladaptive behaviors and better adjust within their psychological and physical environments. However, in this case, I don’t believe that these treatment plans will be successful unless the parents take an active approach by obtaining suitable treatment for their issues as well.

4. Medication – This can be prescribed to Raul and Jose, because they are exhibiting issues with specific behavior/s that may be directly related to their individual disorders.

References:

American Academy of Child and Adolescent Psychiatry: Facts for Families/Conduct Disorder 2004. Retrieved on September 19 2012 via the World Wide Web at http://www.aacap.org/galleries/FactsForFamilies/33_conduct_disorder.pdf

BehaveNet: APA Diagnostic Classification DSM-IV-TR. Copyright (2000). American Psychiatric Association. Retrieved on December 20 2012 via the World Wide Web at http://behavenet.com/apa-diagnostic-classification-dsm-iv-tr

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