Case Study: Jake

An 11-year-old boy, Jake, was referred to an inpatient unit of the Children’s Hospital for further diagnostic evaluation and treatment by the pediatric liaison team on call. He was socially isolated at school and in the rural community where he lived. He had behavioral difficulties at home and difficulties in adhering to the boundaries set by the parents. His mother labeled him as a “troublemaker” and he was oppositional at school with inappropriate behavior. He was frequently interfering with teaching in the classroom. Although he wanted to socialize with other children, he was clumsy and aggressive in his attempts to initiate contact. Teachers and other children’s parent’s complaints objectified the presence of behavioral problems. His behavior was described as aggressive and violent. His play and his reactions were often inappropriate and fear-provoking to others—i.e., he performed animal amputations, made and collected poisons, destroyed objects, and set fires.

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts.^[1]

Treatment

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

A 15-year-old girl, Kelli, is referred to a neurologist due to unexplained symptoms of involuntary, uncontrollable behavior that includes eye-blinking, shoulder shrugging, frequent throat clearing, and randomly moving her arm around in circles. These symptoms have been present since she was in preschool and have increased in intensity. She told the doctor that she had difficulty reading because she was constantly blinking and had to re-read sentences over and over. She tried to control the behaviors at school because kids in her class called her “weird” and “freakshow,” but by the time she got home she was exhausted, experienced more involuntary movement, and had difficulty completing homework. When asked how she felt about her symptoms and experience, she began crying and asked if there was medication to “just make everything stop” so she could be “normal.”

Treatment

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.