TRANSITIONS

Case Report TDESTIA 20.10.15

Dr Abigail Steenstra CT3

Dr Shazia Zahid –ST5

Aims

Recent referral from CAMHSClinical case presentationDiagnostic considerationsManagementService provision

Referral

TD 18 year old male. Referral from CAMHS Neurodevelopmental

serviceProblems:

Cognitive: memory problems and executive dysfunction

Very poor sleep Intermittent “rage attacks” Mood “difficulties”

Presenting Complaint

INITIAL ASSESSMENT: Being forgetful:

forgets to eat, forgets to turn off appliances Poor sleep

2-3 hours per night Mood swings Irritability and anger Burning items in bedroom Hoarding food

Known to CAMHS since 2010

Past Psychiatric History I

Referred to CAMHS in September 2004 age 7 Suicidal thoughts, talk of throwing self off building,

tried to open door of a moving train Morbid thoughts about deceased grandfather Bedwetting School refusal Bullying Secretive and withdrawn

Past Psychiatric History II

Referred to CAMHS June 2010 Recurrent sudden emotional and behavioural

outbursts Erratic and impulsive behaviour Poor concentration and memory Distractible and disorganised Socially naive and immature Close to being excluded form school

Medical History

At 2 weeks old admitted to Lewisham hospital with alcohol withdrawal, scabies, impetigo, ringworm and cigarette burns over body

Broke his arm age 9 after climbing onto a lift shaft – feels relatively little pain from injury

No medication at time of 2010 referral

Family History

Has 7 half siblings most of whom are adopted and he is not permitted to see

Adopted by maternal grandparents age 7 months. Grandmother has depression.

Some contact with biological father few times year

No contact biological mother –history of addiction. Met once 2013

2 nephews with ADHD and OCD

Developmental History

In utero – mother misused cannabis and drank excessive alcohol

First two weeks of life, notes report that she fed him cider

Emergency foster care then age 7 months, grandparents got residential order then adopted

Crawled at 10 monthsWalked 18 monhtsTalked 24 months but age 3-4 SALT to aid

pronunciation

CAMHS

Cognitive assessmentConnors questionnairesReferral to Neurodevelopmental team

Cognitive assessment age 13-14

Full scale IQ 85 does NOT have a learning disability

More specific deficits Block design 6 (problem solving and appraisal) Matrix reasoning 6 (visual and motor organisation) Digit span 6 (working memory)

Difficulties with reading and spelling, indicate a specific learning difficulty

Social History

ADLs – needs help cooking, prompting for dressing and all other self care

Cannot manage moneyCan only travel well known routes aloneAttends college – carpentry no formal

qualifications never worked. Drug/alcohol – nilSmokes cigarettesForensic – one episode shop lifting, no chargeRelationships – will say he has friends, and

girlfriends but mother reported this is not the case

Metal State Examination

A+B: TD is a young looking 18 year old white British man, he was well kempt and dressed appropriately. He is reasonably tall and very slim. He engaged well and reasonable rapport was established. He made good eye contact and demonstrated reciprocal interactions. S: His speech was of normal rate, volume and tone. T: He denied any particular thoughts or worries. There was no evidence of delusional beliefs or formal thought disorder. TD denied any thoughts of deliberately harming himself or others. He reported not being able to think through the possible consequences of his behaviour. M: He reported that his mood was unpredictable and that he would feel suddenly very upset or angry and completely unable to control this or manage the impulse to act in a destructive way. TD often responded to questions reporting he was “fine”. Objectively he appeared euthymic with reactive affect. He was visibly irritated and angry towards grandmother.P: no abnormality notedC: Orientated I: He said he wanted help to change his behaviour as he knew it upset his (grand) parents and wishes that things could be easier for them. He denied the need for any psychological intervention but stated that he would “let us know” if that changed.

Formulation

TD was able to sit without fidgeting throughout the entire assessment lasting 1hour 30 minutes. He engaged well in the assessment and maintained good eye contact with both of us. TD seems to have good attachment bonds with his grandparents. However, it is likely that TD has unresolved anger as a result of neglect, abandonment and being severely mistreated by his mother who reportedly fed him alcohol as an infant. It is likely that TD’s learning difficulty is a source of frustration and he may not fully comprehend his special needs. This sense of confusion can result in behavioural difficulties, hasty and impulsive acts resulting in angry outbursts. It appears that mainstream schooling and large groups in classes enhanced his academic difficulties resulting in social isolation and perhaps augmenting his inattentiveness. Perhaps a sense of not belonging to a peer group contributes to his sense of isolation and loneliness.

Diagnosis

FASD/FAEADHDLearning difficulty? Mood disorderHow much of this explained by FAE and how

would this best be managed?

Clinical Summary

18 year old man IQ 85 but worse than expected results in problem solving,

visual and motor organisation and working memory Poor adaptive functioning, not currently capable of

independent living Very poor impulse control Aggression and destructive behaviour Inability to consider consequences Risks – fire setting Very poor sleep Socially vulnerable and isolated Unusual food behaviours and hoarding of food Poor insight to limited function

Medications - CAMHS

Oct 2011 Clonidine 25 -50 micrograms

Sept 2012 Concerta XL 18-27mg OM Clonidine 75micrograms

Nov 2013 Melatonin MR (Circadin) 4mg ON Clonidine 100 micrograms

Feb 2014 Stop melatonin start risperidone 25 micrograms (later increased to 1 mg)

October 2014 stop risperidone Start fluoxetine 20mg OM

Services available

Where and how can we best provide appropriate care? LD services General Adult services ADHD services Neuropsychiatry services