Challenging Case: Health Care Professionals as Cultural Brokers for a Boy From Central America With Attention-Deficit Hyperactivity Disorder and Trauma and Stressor-related Disorder.

case"Javier" is an 8-year-old boy with a complex psychosocial history presenting for a developmental-behavioral pediatrics consultation because of concerns regarding hyperactivity (affecting safety) and developmental delays, including "lack of independence." He is not yet toilet trained and in his mother's words, "he has the mindset of a child that is much younger than his actual age." Javier's family emigrated to the United States from Central America a year ago to seek asylum. During his family's journey to the United States, Javier and his mother were kidnapped and sexually assaulted. On settling into the United States, Javier was evaluated by his local school district and qualified for specialized services. His mother is not aware of what support he receives at school and is concerned that he is not making sufficient progress. He has not previously received developmental therapies or psychosocial interventions.Javier has demonstrated developmental delays, including reduced reciprocal social communication skills, since birth. His mother shared that he was not able to attend school in Central America as "no schools had the resources to educate him." He began speaking around age 5 years and currently communicates using phrased speech. There have been long-standing safety concerns related to his impulsivity, including wandering, which first emerged in his early toddler years. His hyperactivity predates his history of trauma and sexual abuse. Currently, he demonstrates intermittent physical aggression toward family members. He is interested in fire and has set objects on fire in the home. He is also drawn to placing items in electrical outlets, which has resulted in multiple self-electrocutions.Javier does not have medical insurance but receives limited health coverage through a program for uninsured residents with low income. He was evaluated by a psychiatrist and prescribed 2 medications, although his mother does not know the names of the medications prescribed. Review of psychiatry records indicated that he was prescribed guanfacine extended-release and amphetamine and dextroamphetamine salts extended release. These medications led to improvements in his behavior regulation, although he was not able to take these medications consistently because of cost.Javier's developmental evaluation included assessment of his cognitive, adaptive, and social communication skills in his native language. His diagnostic evaluation yielded provisional diagnoses of autism spectrum disorder with accompanying speech and intellectual impairment. Psychiatric diagnostic impressions included complex attention-deficit/hyperactivity disorder in the context of his significant trauma history. His mother did not have prior conceptualization of developmental or psychiatric diagnoses, and psychoeducation through a cultural lens was provided. What are your next steps in partnering with Javier's family as they navigate medical and educational systems following their recent arrival to the United States?* "Javier" is a pseudonym.