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Physical Health and Impact on Behavioral Health Case Study

  • Presenting Provider Name: Susan Hancock, Behavioral Health Service Manager
  • Presentation Date: 11/14/2019
  • Patient Biological Gender:  Male
  • Patient Age: 17
  • Race: White/Caucasian
  • Ethnicity: Not Hispanic/Latino

Topics to discuss/areas of concern:

  • This member has had 32 hospital admissions to date, six of which have been for BH needs. 
  • This member has been removed from his guardians (paternal grandparents) and placed into DCF custody.  Additionally he has been referred to Foster Care Behavioral Health Service Management that same month.
  • Per this member’s medical file, he has been admitted multiple times to for DKA.  His medical services are set up through his local pediatric endocrinology, social work, therapy and psychiatric departments.  The hospital of choice has been serving this child for several years prior to him being in foster care.
  • There appear to be conflicts between the hospital and the foster care provider, and on at least one occasion, the placement provider.  It has been reported the foster care agency and hospital staff have ongoing struggles communicating effectively.  The foster care agency lacks medical knowledge and their expectations of medical care/needs differed. 
  • This member moves often.  He has had many one-night, emergency foster home placements for several weeks.  The lack of a stable living environment has caused his behaviors to regress and impact his health significantly.  His moving has also resulted in uneducated foster parents and his blood sugars not being monitored or tracked sufficiently.  Often the member does not attend school and therefore his meals often consisted of pizza and junk food snacks.  He has an insulin pump, but most do not know how it works, and those who supervise him change so frequently it is difficult to “train” about his needs.
  • This member has spent several years of his life focused on diabetic education and demonstrating to professionals that he knows how to properly manage his diabetes and supplies. However, he continues to increase the number of his medical admissions back to back and several behavioral health admissions for suicidal ideation and self-harming behaviors, ie. cutting self. 

Pertinent Medical History:

Diagnosis: Type 1 DM W/Ketoacidosis W/O Coma; Type 1 DM Without Complications; Type 1 DM W/Hyperglycemia

Past Dx: Type I Diabetes Mellitus; Oth Spec Diab Ketoacidosis No Coma; Oth Sped Diab Ketoacidosis With No Coma; Type 1 DM W/Uns Complications; Other Specified DM W/Ketoacidosis; Pleurodynia; Dehydration; Urethral Fistula;

Psychiatric History:

Diagnosis: Major Depressive Disorder, recurrent, moderate; ADHD, combined type

Past Dx: Oppositional Defiant Disorder; Brief Psychotic Disorder; Disruptive Mood Dysregulation Disorder; Major Depressive Disorder, recurrent, severe, w/o psychosis; Adjustment Disorder, unspecified; Conduct Disorder, unspecified; Major Depressive Disorder, unspecified; Anxiety Disorder, unspecified; Other Persistent Mood Affective Disorder; ADD Child W/O Mention Hyperactivity; Conduct Disorder, child onset type; Unspecified Episodic Mood Disorder

Details:

This member has received inconsistent mental health services from several providers since 2008. 

Six in-patient stays for BH needs; cutting, verbal and physical aggression, property destruction, threatening to put himself in dka, despite being able to demonstrate to professionals that he knows how to properly manage his diabetes. There are severe concerns for his mental health and that he has voiced suicidal ideations to some professionals. There are also concerns that he may be attempting to kill himself by not managing his diabetes; ie taking pump off, turning it off, don’t dosing properly, refusing to eat or intentional eating to increase blood sugar levels - aware of outcomes.

Additional Information:

Via social media: member has sent and received sexually explicit material on his phone including nude photos of self and others. Member has scheduled contacts with strangers to engage in dominatrics type of sexual activity without using protection –  confusion about sexuality, identified interest in both genders, he desires to engage is BDSM-type sexual activity, engage in pain and torture during sex and not use protection with strangers same age or older - verbal and physical aggression – poor self-care: urinated on mattress (cut hole in mattress cover and directly urinated into mattress), urinated on himself and hid soiled clothing around foster home

Past Dx:  Diabetes W/Ketoacidosis; Hyperglycemia, unspecified; Type I Diabetes Mellitus W/Ketoacidosis W/O Coma; Diabetes Uncomplicated, juvenile; Disruptive Mood Dysregulation Disorder; Major Depressive Disorder, recurrent, moderate; Adjustment Disorder, unspecified; Conduct Disorder, unspecified; Major Depressive Disorder, unspecified; Anxiety Disorder, unspecified; Other Persistent Mood Affective Disorder; ADD Child w/o Mention Hyperactivity; Conduct Disorder, child onset type; Unspecified Episodic Mood Disorder

Medication summary:  ADMELOG SOLOSTAR 100 UNIT/ML – member dc’ed psychotropic meds

Trauma History: (Age of significant traumas and brief summary)

Details:

Physical abuse; emotional neglect and physical neglect from biological parents; witness to parental drug use and domestic violence; parental separation; guardian/sibling separation; self-reported death of two friends in 2017-2018 by suicide and car accident multiple hospital and foster care placements

Social History: (Current living situation, employment status, pertinent legal history, level of education, relationship status, children, support system, etc.)

Details:

  • Biological mother has hx of alcohol and substance abuse; incarceration – hx of attempted suicide multiple times
  • Biological father has hx of alcohol and substance abuse; MH dx of Bipolar Disorder
  • Maternal grandmother and paternal grandmother has hx of suicide attempts
  • Maternal grandmother deceased/ committed suicide
  • This member has one younger sibling; sister. All children were removed from the bio parents home by DCF in 2005, and following termination of parental rights when he was 3 yrs old, custody of this member and sibling were given to paternal grandparents.
  • This member was removed from grandparent’s home in October 2017, due to medical neglect (noncompliance with diabetic care, unstable glucose levels, multiple hospitalizations), their inability to manage his behaviors (defiance, elopement, criminal activity), and for their own safety (this member physically assaulted grandfather).
  • This member has periods of continued contact with biological mother – Bio mother has resided with paternal grandparents in past. 

Trauma: While in bio parents care, member and siblings experienced homelessness, lack of food and appropriate care, witnessed parental drug use and domestic violence between parents, including their father’s attempts to kill mother. This member reports death of two friends in 2017/-2018; one by suicide, other by car accident

Legal: 2015 shoplifting, destruct of property – 2016 failed diversion – 2017 assault on grandfather, battery on peers – 2018 battery on peer

School: 2016-2018 multiple OSS, expelled for truancy, non-compliance (refusing to do work, sleeping in class, on social media), and physical and verbal aggression towards staff and peers

Pertinent Lab Work:  N/A

Summary of recent Urine Toxicology (if applicable):  N/A

Substance Use History, if applicable:

  • Member reported from 2015-2018 occasional marijuana and cigarette use “I use to relax when I am stressed.”
  • No consistent or problematic drug use reported