Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA.
J Dev Behav Pediatr. 2010 Jan;31(1):72-4. doi: 10.1097/DBP.0b013e3181c8cc94.
Adam's mother was concerned about her 3-year-old son's hyperactivity, violence, and activity level. Adam and his mom had recently moved into a shelter for pregnant women. The rest of the residents are primarily in their early 20s, whereas Adam's mom is 42. She had found about 3 months ago that she was pregnant. This was her fourth pregnancy, second with this father, and he had recently left her when she refused an abortion. Her other children are 22 and 24 and live out of state. She has a history of opioid addiction. She had been on methadone during Adam's gestation and had recently started on buprenorphine to treat her addiction during this pregnancy as well. Adam is here today for his 3-year-old checkup and you had not seen him for a year. Mom states that he has been healthy but has become progressively active over the last year. He is very angry about his dad leaving, and according to Adam's mother "blames her" for sending him away. They are living in 1 room at the shelter, and mom is finding it increasingly difficult to keep him busy all day. When she goes out looking for a job, he is very challenging at the shelter, and she constantly receives complaints that he is "too loud" in the common rooms. She feels like she is at the end of her rope with him, he is constantly climbing, bolting from her, and taking risks.When you examine Adam, you find a robust, healthy young boy. His eye contact is good, and he is socially related but does actively explore your office. When he begins taking the instruments off your wall, his mother sits passively watching him. When he begins playing with the faucet, she half heartedly tells him to "stop" but he looks at her and continues splashing. He then begins flicking the light switch on and off in the room with no response from mom. When you ask about discipline, mom states "nothing works." When you ask about supports, she states "I have nobody except Adam and the new baby now."Adam was born after an uneventful full-term pregnancy with his mother on 100 mg methadone daily. She denies cigarette smoking, drugs, alcohol, or other medications. Urine testing throughout was positive only for opioids. Motor milestones were achieved at the appropriate time. Language milestones at the 2-year-old visit consisted of 10 single words. Now, he has a 50 single-word vocabulary but no 2-word combinations. He primarily takes whatever he wants and has a tantrum if mom cannot figure out what he desires. Adam's medical history is unremarkable. Family history is significant for drug abuse by her father and mother; mental illness in the father's family consisting of bipolar disorder in several uncles. Where do you go from here?
亚当的妈妈对她 3 岁儿子的多动、暴力和活动水平感到担忧。亚当和他的妈妈最近搬进了一个为孕妇提供的庇护所。其余的居民主要是 20 出头，而亚当的妈妈是 42 岁。她大约在 3 个月前发现自己怀孕了。这是她的第四次怀孕，第二胎和这个父亲，最近当她拒绝堕胎时他离开了她。她的其他孩子分别是 22 岁和 24 岁，都住在州外。她有阿片类药物成瘾史。在亚当的孕期她一直在服用美沙酮，最近她开始服用丁丙诺啡来治疗她在怀孕期间的成瘾。今天是亚当 3 岁的体检日，你已经有一年没见过他了。妈妈说他一直很健康，但在过去的一年里他变得越来越活跃。他对爸爸的离开非常生气，据亚当的妈妈说，“他责怪她”把他送走了。他们住在庇护所的一个房间里，妈妈发现让他整天都忙起来越来越困难。当她出去找工作时，他在庇护所里非常具有挑战性，她经常收到投诉说他在公共休息室里“太吵了”。她觉得自己已经受够了他，他一直在攀爬，从她身边狂奔，冒险。当你给亚当做检查时，你会发现他是一个健壮、健康的小男孩。他的眼神交流很好，与社会有联系，但积极地探索你的办公室。当他开始从墙上取下仪器时，他的妈妈只是被动地看着他。当他开始玩水龙头时，她只是半心半意地告诉他“停下来”，但他看着她继续泼水。然后他开始在房间里不停地开关灯，妈妈没有反应。当你询问纪律问题时，妈妈说“什么都不管用”。当你询问支持时，她说“除了亚当和新生儿，我现在没有人了。”亚当是在母亲每天服用 100 毫克美沙酮的足月孕期后出生的。她否认吸烟、吸毒、酗酒或其他药物。尿液检测结果仅呈阿片类药物阳性。运动里程碑在适当的时间达到。2 岁时的语言里程碑包括 10 个单词。现在，他的词汇量达到了 50 个，但没有两个词的组合。他主要是想要什么就拿什么，如果妈妈不知道他想要什么，他就会发脾气。亚当的病史无明显异常。家族史表明，他的父母都有药物滥用史；他的父亲家族中有精神病史，包括几位患有躁郁症的叔叔。你从哪里开始呢？
