Case Study: Johnny

Johnny is a 9 year old boy brought to the emergency room where you are employed as a crisis therapist. The patient was transported by a crisis mobile team who was called by the school. The evaluation by the ER physician as well as the urine drug screen is unremarkable: there are no acute or chronic concerns with this patient. In the chart, you note the DSM-5 Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 6–17 form completed by the mother (attached). Admission paperwork identifies that Johnny has had numerous visits to the principal’s office in the past year, all triggered by various disruptive behaviors.

Today’s crisis started when Johnny refused to follow directions regarding an in-class assignment. When the teacher attempted to redirect his behavior things escalated rapidly: Johnny yelled at the teacher, cursed at him using vulgar language, and when the teacher grabbed him by the shoulders to take him to the principal’s office Johnny impulsively stabbed the teacher in the arm with a pencil he was clenching in his hand. Johnny was escorted to the principal’s office who immediately called the police and Johnny’s parents. The police officer was compelled to contact the county crisis hotline who dispatched a crisis mobile team. The crisis clinicians made the determination that Johnny is a danger to others and he must be taken immediately to the nearest emergency room for emergency psychiatric evaluation. Johnny has refused to speak to the ER physician or his nurse.

You gather most of your clinical information from his mother who is at the bedside. Johnny’s mother reports that he has always been a clever, charming, and very playful boy. She informed that for the past year Johnny has been increasingly stubborn, repeatedly challenging his mother’s and his teacher’s authority when compliance with home and/or classroom rules is required. Johnny used to be an A+ student. For the past year, however he has been averaging Bs in most subjects, grades that he earned effortlessly.

His mother repeatedly assures you that his drop in grades is not due to lack of intellectual ability but rather because Johnny prefers playing over any type of work. His mother denies any changes in sleep, appetite, or any mood fluctuations. Furthermore, his mom reports that Johnny is a healthy and happy boy who is interested in sports, the outdoors, videogames, and that he wishes to become a software engineer when he grows up. She reports that the school counselor has mentioned that Johnny may be suffering from ADHD or even bipolar disorder. The thought of these diagnoses appear very disturbing to Johnny’s mom. She quickly assures you that she has not observed Johnny to ever struggle with depression, or distractibility, and reports that he has always been a good sleeper. She reports that Johnny has never made any statements amounting to thoughts or impulses to harm self or others.

Johnny’s mother presents shaken by today’s events and she assures you that she will seek any treatment you recommend. At this time, Johnny looks up at you and with tears in his eyes; he states that he did not mean to stab his teacher explaining that he just got mad when he grabbed him. Johnny’s mother listens then states that while he obeys her most of the times, he has always been obedient to his father, who is a traveling salesman. In fact, Johnny has never challenged his father and, on the weekends when he is around, Johnny manages to catch up with his schoolwork in record time and enjoy spending most of his time with his father.