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HoNOS-LD case study written vignette - Raymond

Raymond is an 18-year-old male with a diagnosis of moderate intellectual disability mental retardation and bipolar disorder. He is one of 10 siblings but was only briefly under his mother’s care as she was unable to cope due to severe alcohol and drug abuse issues. Raymond has had 14 foster home placements since he was 2 years old, and he is currently having inpatient treatment. He was admitted three weeks ago due to concerns re escalating mood swings, deteriorating daily functioning and violent behaviours, including an assault on his foster mother.

Raymond has good verbal skills but has limited cognitive abilities to understand consequences. He has poor impulse control and appears to have no remorse for past anti-social behaviours. He is generally well presented with a tidy appearance, and his foster mother reports he usually takes care with his personal appearance and likes to wear ‘designer gear’. He doesn’t smoke, use alcohol or drugs and keeps good physical health apart from the occasional cold.

Raymond has been attending the local special needs school and it is reported he was doing well. Raymond attempted to bus to school. However, following two incidents where he did not get off the bus at the school stop his foster mother travelled on the bus with him in the morning, while a support worker from the school drove him home in the afternoon. Raymond reported he walked to the local shops and visited the library on his own, on a weekly basis, but says that over the last few weeks he has not enjoyed this as much as usual.

He enjoys and is particularly interested in working on the computer and he can sustain attention with this task for up to two hours at a time. Six days prior to admission a female student at the school accused him of stealing her play station game. Raymond denied this, a subsequent investigation by the school found this accusation to be unfounded. The event has had an adverse effect and Raymond’s behaviours and his mood has rapidly deteriorated, both at school and his foster home. He has become disengaged from tutors and other students, has had difficulty concentrating on tasks previously enjoyed, and subsequently threatened others. He attempted to stab a teacher at school with a pen and has been excluded for an indefinite period.

He went on to assault his foster mother; this has resulted in her sustaining a fractured arm, requiring surgical repair, and hospital treatment. Police took Raymond to Psychiatric Emergency Services after the assault at home, where the decision was made to admit him to the inpatient unit at the local hospital for assessment.

Raymond has an extensive history of violence including assault and threatening behaviours, stealing, cruelty to animals and frequent absconding. He has a court appearance scheduled in three weeks.

At interview Raymond appears to have lost interest in most activities previously enjoyed, including working on the computer. His usual tidy presentation is now dishevelled and he requires prompting and supervision with his self-care. Raymond previously cooked and completed other household chores but in the week prior to his admission refused to contribute. Raymond said that he didn’t enjoy this work as it was too difficult, and his foster Mum should do it.

Despite the assault on his foster mother, his foster parents are still committed to maintaining contact with him. They are aware that the incident at the school triggered the current adverse behaviours. His foster mother believes that if they can provide Raymond with a stable living environment his behaviour will improve and that is what they are striving to accomplish in the foster home. They are aware that it will probably be sometime before Raymond comes back to live with them due to the charges and likelihood of a prolonged stay in the inpatient unit. His foster parents visit him regularly in the IPU. Visits from his birth family are also important to Raymond. Due to transport difficulties since his admission these visits are infrequent and add to Raymond’s current instability.

Staff at the unit reported a ‘honeymoon’ period for the first two weeks of Raymond’s admission. He appeared settled, even animated at times especially when he found out there was a computer available for client use. However, seven days ago, a new admission arrived. Raymond has had negative contact with this person in the past and there has been a noticeable deterioration in his behaviour. There have been several incidents in the dining room of attempted assault on the new service user. This has resulted in Raymond being restrained to keep him and the other person safe. Raymond has trashed his room on two occasions, causing distress for two other service users occupying rooms either side of him.

Initially Raymond was reported to be eating and sleeping well, but since the other service user was admitted his sleeping pattern has become disrupted. Raymond wakes frequently through the night, rises early in the morning, and is reported to be drowsy through the day. On admission Raymond weighed a healthy 80kgs, he is now 77kgs and continues to display a poor appetite and general loss of interest in food.

Current medication is Quetiapine, Lorazepam, and Sodium Valproate. There are no plans to trial behaviour modification at this stage of the admission while his mood level remains low and he is less likely to engage in treatment.