Staying in the clinical ballpark while running the evidence bases.

Leimomi was a 16-year-old female of Asian Pacific Island descent born and raised onOahuwho was referred to the Department of Health’s Child and Adolescent Mental Health Division (CAMHD) by her public school student services coordinator for running away, chronic truancy, aggressiveness, and drug abuse. She had been diagnosed with systemic lupus erythematosus about 1 year before this referral and treated with prednisone 25 mg/day, Plaquenil 400 mg at bedtime, Plendil 2.5 mg twice daily, and Elavil 40 mg at bedtime for sleep. There was no relationship between her behavior, affective state, lupus, or her lupus treatment. At the time of referral she had not been taking her medications, had been on the run for 2 months abusing methamphetamine, and was then living in the state detention home for violating probation. A child and adolescent psychiatrist with extensive experience using structured diagnostic interviews completed her evaluation. She reported a long history of oppositional and defiant behavior, willful disobedience, lying, stealing, fighting, gang involvement, running away from home, truancy, and suspensions and expulsions from school. She was on probation, but only because of truancy. Onset of her conduct and behavior problems was at age 5. The problems were mild in elementary school, and her grades were good at that time. Her behavior worsened at age 9, when a family friend repeatedly sexually abused her. Leimomi experienced subsequent nightmares, flashbacks, autonomic arousal, and avoidance from the abuse. At age 10, she joined a native Hawaiian gang and began using drugs, being truant, and failing in school. At the age of 13, Child Protective Services removed her from the family home because of neglect and abuse by her mother. Her mother and entire family have an extensive history of drug addiction and criminality. Child Protective Services placed Leimomi in a permanent foster placement with a caring older sister. A year before the referral, Leimomi completed a chemical dependency treatment program but quickly relapsed when she recontacted her drug-using peers. At the time of evaluation, she was an overweight female adolescent of Asian/Pacific Island ancestry who met criteria for conduct disorder, amphetamine abuse, systemic lupus erythematosus, and posttraumatic stress disorder, chronic.