An early male adolescent with externalizing behaviors, school failure, and a colostomy

Jeff is a 14 1/2 years old ninth grader who presents with his mother, father, and step-father because he is failing in school. Jeff was born with an imperforate anus, and he had several surgical procedures in the first few years of life. He has a colostomy, but it is not clear how well he cares for it independently. Jeff's parents state that there other concern is that to prepare for school each morning or for other activities, they literally remind him of each step. Jeff has been active and disruptive since preschool, but is also described as "charming." School work and peer relations improved following a diagnosis of attention-deficit hyperactivity disorder (ADHD) in the second grade and treatment with a long-acting stimulant medication. An Independent Education Plan (IEP) in second grade included achievement tests that demonstrated above grade level scores. Jeff continued to have problems with written expression, but did quite well in verbal expression. By seventh grade, Jeff complained to his parents that he "wasn't fun to be around," and refused to take medication for ADHD. He increasingly refused to do most of his homework or class work. Grades were approaching failing levels in the eighth grade when he was suspended twice for impulsive behaviors-drawing a picture of a gun pointed at another student, and signing a petition stating that a classmate was gay. After his second suspension, he was sent to a continuation school, where he resisted doing the required work, failed each subject, and socialized with peers. Jeff is failing in ninth grade although his teachers describe him as respectful in the classroom. His parents divorced when Jeff was a preschooler, and they do not agree on how to manage Jeff. Jeff's father has not supported medication for the treatment of ADHD. The parents tried numerous strategies to help Jeff, including improving organizational skills, offering rewards and punishments and counseling; they have participated in parenting classes. The parents acknowledge that Jeff always tries to negotiate with them and they often give in. There is no known substance abuse or illegal behavior, although he has demonstrated destructiveness and stealing at home. Jeff's mother remarried a year ago, and her husband backed her in setting more strict limits for Jeff; at Jeff's request, he is currently living with his father most of the time.