![]() ![]() While behaviorally improved, Jim had intermittent difficulties with motivation, attention, and task completion. At the 6-week follow-up visit, Jim was described as "a lot better, a completely different kid, calm, polite, settled at night, helpful and nsiderate and sharing." Jim's history, symptoms, and mental status were indicative of mood disorder not otherwise specified: juvenile-onset bipolar disorder (BD), oppositional defiant disorder, and reactive attachment disorder.Ī recommendation to discontinue the methylphenidate and to start a trial of lithium was accepted. His judgment and insight were fair to poor. His short- and long-term memory was intact. His intelligence appeared to be within a low average range. He was oriented to person, place, time, and situation. There was no evidence of delusions, hallucinations, or homicidal or suicidal ideation. During the 2-hour evaluation his mood vacillated from anxious to agitated to giggly to irritated to dysphoric to calm. He was easily distracted and evidenced some mood lability and inappropriate affect. He appeared immature, anxious, and had a difficult time expressing the reasons his parents had brought him for help. ![]() ![]() During a mental status examination, Jim presented as a thin, fidgety, hyperactive boy who had trouble staying in his seat. Jim had been treated for attention-deficit/hyperactivity disorder (ADHD) for 3 years with high doses of methylphenidate, with minimal benefit. His birth father had an extensive juvenile criminal history and his familial history included substance abuse, sexual abuse, and domestic violence. Jim's birth mother had a history of physical and sexual abuse. Regardless of his cycles, he had consistent difficulty in falling asleep. His adoptive parents described him as having up-and-down cycles: when up, Jim was easy to please and wanted to please others when down, he was disruptive and intrusive. He was verbally and physically aggressive, exhibited temper outbursts and rage reactions, and was assaultive toward his peers and parents. Jim's symptoms began before he was 2 years old and included acting out he was easily agitated, disruptive, and intrusive. He had been removed from his birth mother at 2 years of age because of pathogenic care. Jim had lived with his adoptive parents for 5 years before that he had been with those same parents in a foster placement for 2 years. 3,4 The effects of disrupted attachment are the converse of a secure attachment.Īt 9 years of age, Jim was referred for a psychiatric evaluation by his psychotherapist of the last year and a half. Pathogenic care is the cause of the disorder. 2Īttachment disorders are the effects of significant disruptions in attachment, especially disturbed social relatedness, mostly because of abuse, neglect, or prolonged maltreatment during early development. Effects of secure attachment include trust, intimacy, affection, development of reciprocal relationships, positive self-esteem, future independence and autonomy, ability to manage impulses and emotions, and resilience in the face of adversity. 1 Attachment experiences are vital for sound social and emotional development. Attachment may be defined as a composite of behaviors in an infant, toddler, or young child that is designed to achieve physical and emotional closeness to a mother or preferred caregiver when the child seeks comfort, support, nurturance, or protection.
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