Phillip, age 12, was suspended from a small town lowa school and referred for psychiatric treatment by his principal. The following note came with him: This child has been a continual problem since coming to our school. He does not get along on the playground because he is mean to other children. He disobeys school rules, sasses the patrol children, steals from the other children, and defies all authority. Phillip keeps getting into fights with other children on the bus. He has been suspended from cafeteria privileges several times for fighting, pushing, and shoving. After he misbehaved one day at the cafeteria, the teacher told him to come up to my office to see me. He flatly refused, lay on the floor, and threw a temper tantrum, kicking and screaming. The truth is not in Phillip. When caught in actual misdeeds, he denies everything, and takes upon himself an air of injured innocence. He believes we are picking on him. His attitude is sullen when he is refused anything. He pouts and sasses. When asked why he does these things, he points to his head and says, "Because I'm not right up here." This boy needs help badly. He does not seem to have friends. His aggressive behavior prevents the children from liking him. Our school psychologist tested Phillip and the results indicate average intelligence, but his school achievement is only at the third and low fourth grade level. The psychiatrist learned from Phillip's grandmother that he was an illegitimate child, born when his mother was a senior in high school. Her parents insisted that she keep the baby and help rear him; most of his upbringing has been by his grandparents, however. Phillip was "three months premature," and a "blue baby," requiring oxygen for 24 hours. Shortly after birth, Phillip's mother ran off with a man, married him, and had a second child. The marriage broke up, and she left this child with its father. Phillip has had no contact with his mother since she left him. Phillip's toilet training was not successful, and he remained a bed-wetter for some years. At the age of five years, his maternal grandparents adopted him because they were afraid that his mother might someday claim him. He showed anxiety at separation from his grandmother when he began school. He was in a serious car accident, in which his grandmother was injured and one person in the other car was killed. Phillip did not appear to be injured, but seemed to have some transient memory loss, probably a direct, immediate result of the impact. Subsequently, he suffered from nightmares, fear of the dark, and an exacerbation of his fear of separation from his grandmother. Phillip's school progress was not good. He repeated third grade and then was in a special class for underachievers. His grandmother recalls that Phillip's teacher complained that he "could never stay in his seat." A few months before the consultation, Phillip was seen in a mental health clinic and placed on some mild tranquilizers. A three-month return appointment was arranged, but the school suspended him before that date. Notable Stressors Notable Deviance Notable Dysfunction Notable Distress Notable Dangerousness