David is a 13 year old boy who has recently been admitted to a juvenile detentio

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David is a 13 year old boy who has recently been admitted to a juvenile detention facility in San Luis Obispo, California. Police reports indicate that he and another boy were arrested for breaking and entering into a private residence. He has also been charged with assaulting police officers at the time of the arrest. David grew up in an upper middle class section of San Luis Obispo. David's father, Oliver, is a professor at a small college, and his mother, Sharon, is a dentist who works for a large health care group. David has an older sister, Sarah, who is 15 years old. Their family has had no prior contact with law enforcement agencies. Even as a small child, David seemed unable to restrain himself. He would bound around the house, crashing into walls and objects, frequently breaking items or destroying house plants. These activities became more pronounced just after meals and when he was angry or disappointed. David seemed to require very little sleep, and he would quickly become bored with most activities. However, he would spend long hours playing computer games, and also enjoyed playing with the family dog, Jessie. David entered a period of low mood at the age of 11 when Jessie died. David's parents say that David has always been an insecure child. David was slow to complete toilet training, and his parents admit that they gently teased him about his frequent "accidents" which continued until he was 8 or 9 years old. David seems unable to compete with his precocious older sister, who has been very successful both socially and academically. Although Sarah takes David's side in front of her parents, David reports that she teases him when they are alone. Sharon took a leave of absence for the first three years of David's life. She then returned to work on a part-time basis and enrolled David in a high quality day care center. David seemed to thrive in this environment and would look forward to his twice weekly visits. Just before his fourth birthday, however, David grew ill and had to be withdrawn from the school for more than a month. Afterward, David seemed highly anxious about returning to the center. Indeed, each time he did go to the center, he was highly agitated; at the school's request, his parents withdrew him from the program. For the next year until he began school, Sharon and Oliver arranged their schedule so that one or the other of them was available to take care of him. At the age of 6 years, David's parents enrolled him in a private Montessori school, and with the help of the school psychologist, David made a fairly smooth transition. David developed few friends at school; most children seemed put off by his high level of energy and incessant talking. In spite of his social isolation, however, David seemed to enjoy learning very much, and did well in school through the fourth grade. Testing indicated an IQ score of 126. He scores particularly high on verbal abilities, though much lower on mathematics. Unfortunately, David did not get along with his fifth grade teacher, who was fairly inflexible in his approach. David's grades dropped dramatically, and since then, he has steadfastly refused to put forth an effort at school. About this time, David began stealing small amounts of money from his mother's purse. When his mother confronted him about it, he denied it. But afterward, he continued stealing the money and made little effort to conceal his actions. David entered puberty at the age of 11, and at that time, his mischievous behaviors became more destructive. He frequently got in fights with classmates, and would verbally assault teachers. He was suspended from school for defacing the school walls with obscenities. David explained himself by telling his parents that he was unable to control his actions. In turn, his parents disciplined him by preventing him from playing with his computer games for a month. Separately, each parent admits to allowing David to occasionally play with the games during this punishment period. In middle school, David began associating with the older boys in school. His parents suspect that he may have tried smoking cigarettes and may have experimented with sniffing glue. He was suspended from school for fighting in the lunch room and repeatedly threatening smaller children. He is frequently truant from school, and his parents have caught him sneaking out of the house late at night. After his arrest for breaking and entering, David began to cry and told his parents that he felt badly for what he had done. He added that he was unable to control himself. David is reluctantly undergoing psychiatric evaluation at the juvenile detention facility.

What disorder do you think this patient could have?

What symptoms led you to this diagnosis? Name 3 that might be relevant.

Think of 2 questions you might ask the patient to narrow down the disorder. For each, say what evidence this provides towards or against your diagnosis.

Explanation / Answer

1. David seems to be showing basic symptoms of conduct disorder. It is considered as a precursor to psychopathy. But since he is a minor, it will be taken as Conduct Disorder. Basic symptoms include:

2. David broke into someone's house, he assaulted police, as a child he showed aggressive behavior, he started stealing, by age of 11 he started getting into fights, defacing school walls, verbal abuses, bullying, truant from school, etc. These all point to conduct disorder. So here he is showing all the symptoms of conduct disorder, namely:

3. 2 questions (included with sub questions) that can be asked are:

Do you know the difference between right and wrong? What things are right and what are wrong (ask with examples)?

Why do you engage in such behaviors? Do you always feel guilty afterwards and feel like changing this behavior?

Depending upon the answers he will give diagnosis can be confirmed. If he is unable to judge right from wrong, he will be judged as having a severe form on Conduct disorder with impaired judgement. Otherwise, he is just acting out of insecurity and complex, and he is having problems adjusting. If he feels like he needs help changing his behavior, he has insight about himself and he can be helped. Otherwise, his insight will also be declared a being impaired. These 2 questions will help us see if he possesses judgement and insight which might be detrimental in diagnosing him as having severe to moderate or mild conduct disorder.

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