SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST

NAME: Mr Li Harris DOB: 30/11/1996

ADDRESS:  *Redacted Foster Carers Address – By Author*

GP: Dr HJ Roux, The Bethesda Medical Centre, Palm Bay Avenue, Cliftonville,

Margate, Kent CT9 3NR

DATE ADMITTED: 01/05/2012 CONSULTANT: Dr Helen M Garrett

Specialty Dr: Dr Pearl Akobundu

____________________________________________________________

Presenting Circumstances:

Li is a 15 year old looked after child with a history of ADHD referred by Dr Nairac due

to concerns for his safety re self harm and deteriorating mental health.

Li reported 2 year history of self-harm but refused to give further information

regarding this. History was mostly from foster carers. Li reported feeling very happy

on some days but predominantly has low mood.

He is happy to take his prescribed medications as they help him concentrate.

Li’s hobbies include ‘pinging’ on his blackberry phone, computers, internet, website

design. He loves music as it keeps him calm. He has 6 close friends who he only

sees at school. He does not like inviting people home as ‘it’s his space’. Li has

chronic anxiety. He eats his clothes when anxious. He stated his energy levels have

been low for ages; sleep is normal, appetite is good. He reported no rituals/

compulsions.

Collateral History: Carers (John and Carol Thomson)

Li lives with them and 2 other looked after children (siblings – male and female). He

has been under their care for ~ 4 years. (Redacted by author – “The Thing”); refuses to accept it’s from him. He

no medical examination since onset over 3 years ago. Bleeding only occurs at night. Foster mum Carers state they cannot help Li further especially with regards to the bleeding.

Moreover, he has been self harming more – punching walls and now asking other

students to step on his fingers, stamp on them and sit with chair legs over his hand.

His anger outbursts also have become increasingly unmanageable. They have lived

with Li’s self harming for years but the bar appears to have been raised, now

increasing DSH, school now cannot keep him safe and he is now getting people to

hurt him. They reported that Li thinks it’s a ‘game’ and that he needs help. He has

never been a problem to his foster carers but changes as soon as he leaves home.

Blood on his bed last Monday was described as horrific – covered the entire width of

his bed. Bloody footprints were also found in the bathroom. Foster mum is concerned

about the severity of bleeding. (Redacted by author – “The Thing”) The source of bleeding could not be identified.

The Thomsons have been caring for children for 14 years and had never seen any

problem like Li’s. He does not feel pain. They are on their guard with him and never

leave Li alone with the other children.

They can have a good conversation with him but not for very long. Li usually shuts

down with ‘I don’t know’ which signals the end of whatever conversation they were

having with him. They stated that Li had seen so much violence. He does not

remember much of his past / childhood and this frustrates him. Li is physically ahead

of his peers but emotionally behind.’ He probably never developed basic skills;

cannot manage relationships’.

They described him as severe and dysfunctional; school having problems with him.

He is however fantastic at home; his carers respect him. He has never been violent

or aggressive at home. Bullying in school reported; – both ways (on and by Li). He

questions authority; pushes boundaries. He is a very personal boy; never brought

anyone home. He had appeared excited about being sectioned and sent text

messages to his siblings about it.

Li hacks into networks; potentially could hack into the system in the unit. He

previously attempted to shut down the system in his school.

Li cannot manage relationships, verbally aggressive outside the home and pushes

boundaries in school. Only family time with carers is during meals.

According to his carers – “what you see is not what you get with Li”. He appears

painfully shy and timid but is quite the opposite.

Li neglects his personal hygiene (long standing). He would not wash unless

prompted. His carer usually has to run a bath for him as she concerned with the type

of shower they have at home which Li is not able to negotiate due to clumsiness,

thus at risk of falls. They stated that staff would need to ensure he had had a bath as

he will often lie about this.

They have tried him without medications and he was observed to be ‘silly’ – like a big

little boy. He continued playing and never stopped. Without above medications Li ‘is

all over the place’. He becomes fidgety, unable to sit still or sleep, agitated.

Family History:

Li was said to be from a dysfunctional home. His parents are separated and mum

has had many partners; she’s getting married to current partner for 5 months. Li has

2 siblings of same parents – Kera and David. Michael, Lucy and Chloe (twins) are maternal half- siblings; David of different father to the twins. Aiden is

a paternal half-brother. (Redacted by author – “Deeply Personal Information about other relatives that I have no rights to share”)

Li’s father was violent to both him and his mother. He has an on- and – off

relationship with Li’s mum and has been arrested on several occasions. Li went to

live with his father Li and his brother David lived with his father for approximately one year, but both were taken into care as he could not cope with them. Li was in his first placement for 10 months before coming to the Thomson’s. David is currently in supported lodgings. Li loves his mum and now sees her unsupervised. Mum lives with the twins and is reported to be struggling with them. Li is ‘petrified’ of his dad and only contacts him via social media. Li’s father and brother David are bisexual. He loves Michael and the twins (though cannot tolerate the twins for too long).

Personal History

Pregnancy, delivery childhood information was not available. GP summary showed

he was fully immunised though MMR was delayed; he was placed on child protection

register – 08/08/2007; suspected self harm aged 6 years.

In primary school was said to be ‘running all over the place’ and did not spend much

time learning. He is currently attending mainstream school and is Statemented.

Li does not like his teachers and has ‘outrageous’ outbursts in school. He is

disorganised and un-cooperative in school and gets picked on at school due to his

behaviour. He had to be restrained in school when he brandished a stick at others-

he had appeared to enjoy this as it made him the centre of attention. There is no

reported truancy. Li reports poor performance in science subjects, maths, English.

Li feels frustrated – that people do not understand him because of the way he

presents himself. He thinks’ the whole world revolves around him’ as stated by

carers; he has no patience with younger children. Li cannot play a game as he

disrupts it and thinks it’s fun to distress other people.

Li stated he was ‘gay’ and has known this for a long time. He informed his carers of

his sexuality 2 – 3 months ago.

Li has been known to social services for about 5 years and has been in care

approximately same duration. He has been with current foster carers for around four

years.

Past Psychiatric History

Known to CAMHS; on medication for ADHD.

Current meds: Equasym XL 30 mg od; Sertraline 50mg mane;

Risperidone 0.25mg bd; 0.5mg od prn.

Forensic History

Previously cautioned for stealing.

Physical Health:

(Redacted by author – “The Thing”) other systems were essentially

normal. ECG showed normal sinus rhythm with normal range QTc.

Mental State Examination:

Anxious, appropriately dressed, polite, good rapport and had poor eye contact. He

was well oriented in time, place and person. He had no psychomotor agitation.

Speech was non-spontaneous and guarded; hardly talking in complete sentences.

There was no flight of ideas. He had no formal thought disorder, thoughts of self

harm or suicide. Mood was subjectively 6/10 but Li looked somewhat sad; there was

decreased reactivity but congruity of affect. No hallucinations or delusions. He has

partial insight – needs help and wants to get better but refused to talk about his self

harm and the bleeding episodes; doubtful if he understood the medical implication.

He was noticed to smile with a hint of satisfaction when talking about his website

design.

Risk Assessment:

Li is a looked after boy with a history of ADHD. There is risk of DSH (punching walls,

getting other pupils to stamp on his hand); ?self induced injury and bleeding per

(Redacted by author – “The Thing”) His carers reported that he hacks into computer networks and steals compulsively; questions authority and has a tendency to violence / aggression outside the home.

Risk of absconsion is low as he can only get around with his GPS (on mobile phone)

which he does not have unrestricted access to while on the unit.

He was said to have been physically abused by his dad who also abused his mum.

(Redacted by author – “Deeply Personal Information about other relatives that I have no rights to share”) Carers reported longstanding nocturnal enuresis and that Li would not attend to his

personal hygiene if not prompted. He is also said to have chronic anxiety and eats

his clothes when anxious.

Assessment Summary

Li is a 15 year old statemented and looked after boy with a history of ADHD; has

been known to Orchard House since primary school. He has a ‘dysfunctional’ family

history with physical abuse by dad He has been known to social services for about 5 years. He was referred by Dr Nairac for admission due to escalation in his risk to himself. He self-harms by punching walls and recently getting fellow pupils to trample on his hand. He also has

a long history nocturnal enuresis and nocturnal bleeding ? (Redacted by author – “The Thing”) he has been denying and avoiding this issue, refusing all medical assessment and

examination. His Foster parents are concerned about the degree of blood loss and

worsening deliberate self-harm. Li refuses to talk about the possible (Redacted by author – “The Thing”)

He stated he was ‘gay’ and had known for a long time.

Goals of admission would include observation and clarifying diagnosis. He will

require close monitoring re physical health concern of blood loss and prompting by

staff regarding personal hygiene. Access to computer networks will also be

discussed with the team re concerns of hacking, as above.

Current Multi Axial Diagnosis:

Diagnosis under review; requires further assessment.

CGAS Score: Inpatient Admission – Total score: 42

Yours sincerely

Dr Pearl Akobundu Dr Helen M Garrett

Locum Specialty Doctor Consultant Child & Adolescent Psychiatrist