The patient was born at full term from non-consanguineous parents with a birth weight of 3750 g. He was treated with phototherapy for jaundice and had no further neonatal complications. He was not breast fed, was a quiet baby and in the first 3 months of his life his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He uttered his first words at 12 months of age, he spoke his first sentence at 2, 5 years of age and at 3, 5 years of age he was fully conversational. The patient's first three years of life were spent under maternal care until he attended day-care starting at the age of 3.5 years. There, he presented with separation anxiety. Also, he did not spontaneously approach other children, he was very active and he would only take part in activities that interested him. Currently, he attends primary school. He is more sociable, but still he approaches his schoolmates on his own terms. He has severe learning disabilities (especially in reading and writing) and requires extra teaching help. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. He suffers from primary nocturnal enuresis and occasional fecal soiling by day. The patient has two female siblings, an 18 year-old one, currently a university student and recently diagnosed with bipolar disorder, and a 10 year-old one, currently in primary school. His father is 44 years of age and describes having had a difficult childhood; he is characterized by the family as indifferent to the children's problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for the patient's difficulties and makes excuses for his violent outbursts. The maternal grandmother suffers from depression and has a history of attempted suicide. She is currently using antidepressant medication. There are also thyroid problems in the two female siblings, the mother and her two sisters; heart problems in four of mother's siblings and the maternal grandmother; cervical/ovarian cancer in the paternal grandmother; and lung cancer of paternal grandfather. One of the maternal sisters has a history of cervical cancer, heart problems, diabetes mellitus, and psychiatric problems (probably depression; she is currently using medication). Some of the patient's relatives are also obese or overweight: his mother, his younger sister, maternal grandmother and two of maternal sisters.
The patient was an overweight pre-adolescent of tall stature (height: 167 cm, weight: 73 kg*, BMI: 26.25), as are his older sister, mother, and maternal grandparents. There are no apparent dysmorphias present in the patient, nor in his siblings and parents. He was likeable with elements of oddness during the clinical contact, as well as in the way he walked and moved in the clinic. His medical history includes coloboma of the iris with almost total vision loss of the left eye and myopia and astigmatism of the right eye. He was interviewed by using the semi-structured psychiatric interview K-SADS-PL, and received the diagnosis of both Conduct and Attention Deficit Hyperactivity Disorders. On Children's Global Assessment Scale (CGAS), he scored 41-50 (moderate effect on functionality). On the Child Behavior Checklist (CBCL), he scored in the clinical range on externalizing (oppositionality, aggression, rule violation, and conduct problems), internalizing (anxiety, depression), and social and attention problems. On the Youth Self-Report (YSR), he scored in the clinical range, as he did on the CBCL. On the ADHD Rating Scale-5 for children and adolescents, the ratings of both parents and teachers were indicative of a combined type ADHD symptoms (inattention and hyperactivity/impulsiveness). The Autism Diagnostic Interview-Revised (ADI-R) was also performed and he scored above the cut-off on restricted, repetitive and stereotype behaviors and interests. In all other ADI-R subscales, the ratings were below the cut-offs for ASD. The psychiatric diagnosis, according to DSM-IV-TR was conduct disorder (childhood onset, 312.81) and ADHD (combined type, 314.01). On axis IV, there were problems with the primary care taking group (lack of support by family, family quarrels), academic problems/difficulties, and conflicts with peers and teachers. The routine laboratory chemistry tests and the structural brain-MRI were normal.
His overall IQ score, as measured by WISC-III-R, was 75, but his profile was considered discordant: his performance IQ was 22 units superior to his verbal IQ, with heterogeneous performance. He had severe difficulties in abstract thinking, verbal conceptualization, and executive functioning while he scored better in visual construct and visual spatial reasoning. The projective tests (H.T.P., C.A.T.) depicted limited emotional intelligence, difficulty in processing things that bothered him, loneliness and rage which he was trying to repress. He needs relationships but doesn't know how to associate with people and has many projections around aggression and loss.
On the Behavior Observation Guide (BOSS), he had deficits in communication, management of money, educational activities, play, social participation and motor activities (bilateral body coordination, balance, static control and fine activity). On the Occupational Therapy Practice Framework Domain and Process, he demonstrated difficulties in sustaining attention, organizing tasks, remaining seated, and impulsive behaviors; his main difficulty was in visual motor coordination and skills. As a result, on the ABC-2-Movement Assessment Battery for children-2, he scored on the 9th percentile. On the Developmental Test of Visual Perception-2, he performed in most scales below average to normal with the exception of visual motor completion with scores showing significant pathology. The difficulties described above may well have contributed to his reading and writing difficulties. On the Vineland Adaptive Behavior Scales, he performed poor on written and verbal, as well as on community and domestic everyday activities. In general, he presents with mild difficulties in adaptive behavior and moderate maladaptive behaviors.
During his stay (for 21/2 months) in the inpatient unit, the patient underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit's psycho-educational activities and was started on risperidone, 2 mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. He was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow up, continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement in general has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.