Ben was a 12-year-old boy who reluctantly agreed to admission to a psychiatric unit after getting arrested for breaking into a grocery store. His mother said she was “exhausted,” adding that it was hard to raise a boy who “doesn’t know the rules.”
Beginning as a young child, Ben was unusually aggressive, bullying other children and taking their things. When confronted by his mother, stepfather, or a teacher, he had long tended to curse, punch, and show no concern for possible punishment. Disruptive, impulsive, and ‘fidgety,” Ben was diagnosed with attention-deficit/hyperactivity disorder (ADHD) and placed in a special education program by second grade. He began to see a psychiatrist in fourth grade for weekly psychotherapy and medications (quetiapine and dexmethylphenidate). He was adherent only sporadically with both the medication and the therapy. When asked, he said his psychiatrist was “stupid.”
During the year prior to the admission, he had been caught stealing from school lockers (a cell phone, a jacket, a laptop computer), disciplined after “mugging” a classmate for his wallet, and suspended after multiple physical fights with classmates. He had been arrested twice for these behaviors. His mother and teachers agreed that although he could be charming to strangers, people quickly caught on to the fact that he was a “con artist.” Ben was consistently unremorseful, externalizing of blame, and uninterested in the feelings of others. He was disorganized, was inattentive and uninterested in instructions, and constantly lost his possessions. He generally did not do his homework, and when he did, his performance was erratic. When confronted about his poor performance, he tended to say, “And what are you going to do, shoot me?” Ben, his mother, and his teachers agreed that he was a loner and not well liked by his peers.
Ben lived with his mother, stepfather, and two younger half-siblings. His stepfather was unemployed, and his mother worked part-time as a cashier in a grocery store. His biological father was in prison for drug possession. Both biological grandfathers had a history of alcohol dependence.
Ben’s early history was normal. The pregnancy was uneventful, and he reached all of his milestones on time. There was no history of sexual or physical abuse. Ben had no known medical problems, alcohol or substance abuse, or participation in gang activities. He had not been caught with weapons, had not set fires, and had not been seen as particularly cruel to other children or animals. He had been regularly truant from school but had neither run away nor stayed away from home until late at night.
When interviewed on the psychiatric unit, Ben was casually groomed and appeared his stated age of 12. He was fidgety and made sporadic eye contact with the interviewer. He said he was °mad” and insisted he would rather be in jail than on a psychiatric unit. His speech was loud but coherent, goal directed, and of normal rate. His affect was irritable and angry. He denied suicidal or homicidal ideation. He denied psychotic symptoms. He denied feeling depressed. He had no obvious cognitive deficits but declined more formal testing. His insight was limited, and his judgment was poor by history.
Provide a thoughtful evaluation, discussion, initial diagnostic impression(s), and differential diagnoses for the above case.