SOCW 6090 - Discussion: Applying Differential Diagnosis to Neurodevelopmental Disorders

The Case of Juan

Intake Date: June 2020

Juan is a 10-year-old male in 5th grade who was brought in for services by his adoptive mother. He is very small in stature. Juan was adopted at age 3½ from an orphanage in Guatemala. The orphanage knows little about his early developmental milestones, but the Guatemalan staff noted that Juan’s language was far less developed than that of his peers at the time of his adoption.

Juan’s mother stated that Juan 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 Guatemala was horrible and that Juan 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.

The adoptive parents are upper middle class and have three biological children (ages 9, 7, and 5). Juan is reported to often get jealous of his siblings and has temper tantrums when he thinks his siblings are getting more than he does. His mother stated that Juan has always had issues with jealousy, and when her other children were younger, she had to closely monitor him when he was around them to stop him from fighting with them. He has trouble listening to the rules that his parents set for him. 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.” Juan has difficulty waiting for others to finish their sentences and knowing when to take his turn to speak.

She also reported that Juan 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 seems to pay less attention to teachers and often interrupts class with his own comments.

Initially Juan’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. Juan’s mother shared her frustration with Juan’s father, who “just does not understand how hard it is to get Juan to understand rules and intentions.”

The parents have never sought help before, as Juan managed to largely keep up with his schoolwork even though he had trouble at school. Recently, behaviors at school changed and worsened. His school has complained of his inability to follow the rules and the increase in his disruptive behaviors.

Collateral contact with his teachers confirmed that he struggles with school and has no friends. He seems to bully others into giving him what he wants. One teacher noted that in small group classroom activities, Juan has trouble with restlessness and will stumble over his words, pause excessively, and restart talking fairly rapidly and loudly.

Upon intake Juan appeared oriented to time and place. He was generally cooperative, but he became frustrated easily. The interview passed without incident although it was obvious that he was eager to be “dismissed” from the meeting.