CASE of ALIM

Intake Date: August 2020

IDENTIFYING/DEMOGRAPHIC DATA: Alim is a 12-year-old male in 7th

grade who lives with his mother, father and brought in for services by

his adoptive mother. The adoptive parents are upper middle class and have three

biological children (ages 9, 7, and 5).

CHIEF COMPLAINT/PRESENTING PROBLEM: The mother reported that

Alim often hides food in his room and gorges himself when he eats. She said she

does not understand this behavior because he always has enough food, and she

never restricts his eating. In fact, because of his small size and weight, she often

encourages him to eat more. Alim sometimes reacts when his lunch is packed

differently within his lunch box for school. He also seems to pay less attention to

teachers and often interrupts class with his own comments.

HISTORY OF PRESENT ILLNESS: Alim acts younger than his 12

years, carrying around toy cars in his pockets, which he proudly displays and talks

about in detail. Aim’s mom reports that Alim hates any type of transition and will

get upset and have temper tantrums if she does not prepare him for any changes in

plans. He is reported to kick and hit both parents, and they have had to restrain him

at times to stop him from hurting himself and others.

The parents have never sought help before, as Alim managed to largely keep up

with his schoolwork. His mother said that he has always taken things literally, but

up until 6th grade, he had attended school without major problems. They had not

been concerned about his grades or lack of friends. His mother said that he has

always been “very shy” and never had a “best friend.” He has always

shown interest in cars, trains, and trucks. Recently, behaviors at school changed

and worsened. His school has complained of his inability to focus and the increase

in his disruptive behaviors.

Collateral contact with his teachers confirmed that he struggles with school, has

no friends, and often has “meltdowns” when he does not get his way. One teacher

noted that in small group classroom activities, Alim has trouble with restlessness

and will stumble over his words, pause excessively, and restart talking fairly

rapidly and loudly. In 6th grade his teachers were concerned about occasional

facial “tics” that occurred at times. His teachers commented that Alim talks more

about World War II topics than any other topic.

PAST PSYCHIATRIC HISTORY: Alim had never had any testing for special

education, nor had he ever received any counseling services.

SUBSTANCE USE HISTORY: No substance use is reported.

PAST MEDICAL HISTORY: Alim is very small in stature, appearing to be only

8 years old. His parents report that Alim was given all the vaccines required to

attend school.

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Alim

was adopted at age 3½ from an orphanage in Haiti. The orphanage knows little

about his early developmental milestones, but Haitian staff noted that Alim’s

language was far less developed than that of his peers at the time of his adoption.

The mother stated that Alim came to the United States not knowing any English.

She knows very little about his family of origin other than that he lived with

his biological parents until age 2 and then lived in the orphanage until he was

adopted. She reported that the plane ride from Haiti was horrible and that

Alim cried the entire flight and refused to sleep for the first 2 days they had him.

They tried holding him, but he would not quiet down.

CURRENT FAMILY ISSUES AND DYNAMICS: Alim is reported to often get

upset with his siblings and hit or kick them. His mother stated that Alim has

always had issues with jealousy, and when her other children were younger, she

had to closely monitor him when he was around them. She reported several

occasions when she found Alim attempting to suffocate each of his younger

siblings when they were babies. Alim’s mother explained this as part of his

“always being immature” and not good at explaining himself. Besides this, his

mother reported that he is not a “mean” child but tends to function according to his

own rules. He often needed reminders to use his “indoor voice” and to “wait his

turn to speak.”

Initially Alim’s parents were unsure what to do about their son’s behaviors. His

mother is the primary caretaker and his father thought she should handle any

therapy or problems related to school. His mother reported that she was now “at

the end of her rope” and was ready to give her son up to foster care. Both parents

are exhausted. Alim’s mother shared her frustration with Alim’s father, who “just

does not understand how hard it is to care for him.”

MENTAL STATUS EXAM: During this intake, the school social worker met

briefly with Alim alone. During this time, he was clearly restless, appeared

anxious, and avoided her in the room. He was very slow to engage with her

and was distracted by his pocket toys, which he fingered. He had pressured speech

and some facial tics and was unable to keep his legs still during the

interview. When he did engage, he chose to play a board game during his time in

the session and he talked in detail about World War II and each of the boats in the

game. His hand was in his pocket fingering toys at some moments. When asked

how he knew so much about all the warships, he stated that he often watched

television documentaries on the subject. Once on this topic he took less time to

respond and spoke at length. Alim appeared oriented to time and place. His voice

in this interview was somewhat monotonic and repetitive of his interests. He was

generally cooperative, and the interview passed without incident although it was

obvious that he was eager to be “dismissed” from the meeting.