Case of Arthur
Intake Date: January xxxx
F84.0 Autism Spectrum Disorder, Level I “requiring support”
F95.1 Persistent Motor or Vocal Tic Disorder, with motor tics
only Z55.9 Academic or Educational Problem
Z65.8 Other Problem Related to Psychosocial Circumstances
Z72.810 Child or Adolescent Antisocial Behavior
IDENTIFYING/DEMOGRAPHIC DATA: Arthur is a 12-year-old male in 5th
grade who was brought in for services by his adoptive mother. He is very small
in stature, appearing to be only 8 years old. He also acts younger than his 12
years, carrying around toy cars in his pockets, which he proudly displays and talks
about in detail. Arthur was adopted at age 2 by distant cousins. His mother was a
single mom that had become involved with drugs. She knew she was unable to
care for Arthur and decided to give him a better home. The adoptive parents are
upper middle class and have three biological children (ages 9, 7, and 5).
CHIEF COMPLAINT/PRESENTING PROBLEM: Arthur 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. He
sometimes reacted when his lunch was packed differently within his lunch box for
school. He also seemed to pay less attention to teachers and often interrupted class
with his own comments.
HISTORY OF PRESENT ILLNESS: Initially Arthur’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. Arthur’s mother shared
her frustration with Arthur’s father, who “just does not understand how hard it is
to care for him.” Arthur’s language and developmental skills were far less
developed than his age at the time of his adoption. When the adoption was
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