Nina was age 8 when her guidance counselor at school referred her to the Family Treatment Center in Cleveland because of disruptive, aggressive behavior. Her 11-year-old brother, Don, and her 9-year-old sister, Sara, were also evaluated, together with her mother.
Several months earlier Nina had been admitted to the hospital with vaginal bleeding and a discharge. A diagnosis of vaginal warts (condyloma acuminatum) was made, and the vaginal culture proved to be positive for gonorrhea. When questioned by a social worker whom the pediatrician asked to see the children, Nina revealed that she and Sara had been sexually molested by their father for the past 2 years. According to her, he would come into their bedroom regularly at night and have vaginal intercourse with her and, more rarely, with Sara. The girls noticed that if they were awake, their father often would not bother them. Nevertheless, Nina was so frightened that she would close her eyes and feign sleep during the molestation. Their father threatened them with beatings if they divulged the secret, so they had never told anyone.
Their brother, Don, after witnessing one of the molestations, told their mother. She did not believe him and told her husband, who then proceeded to beat Don. In fact, Don had often been beaten by his father. After Don’s disclosure, Nina and Sara told their mother what had been happening, but she scolded them for “making up stories.”
When the social worker talked with the mother about these events, she admitted that she had suspected that her children were telling the truth, but was afraid of confronting her husband about his sexual abuse because she feared his murderous rage. During their 12-year marriage, he had frequently beaten her, but she never thought of leaving him because her religion forbade divorce.
After the medical confirmation of the sexual abuse, the children were temporarily placed in foster care, the father was jailed, and the family court cited the mother for neglect because she had failed to intervene to protect the children from the father’s sexual abuse. The children were subsequently placed with their maternal grandmother and then returned to their mother after she agreed to a psychiatric evaluation and treatment for herself and her children.
When interviewed at the Family Treatment Center, Nina is a sad, unusually quiet child who rarely smiles. She describes that, since the abuse started 2 years ago, she spends most of her time in her room alone doing little more than watching television. She often has difficulty falling asleep and reports nightmares about her father coming into her room. Nina has talked with the children in school about being molested and now believes that they all dislike her because of it. When she testified in court, she was certain that she would be sent to jail because she had done something wrong. She also fears that her father will return and attack her. At home, she is generally irritable and often fights with Sara and Don, and feels “picked on” by her mother, whom she feels has always favored her siblings.
WHODAS 2.0 score
ANXIETY DISORDER II
Eight-year-old Tim was referred by a pediatrician who asked for an emergency evaluation because of a serious weight loss during the past year for which the pediatrician could find no medical cause. Tim is extremely concerned about his weight and weighs himself daily. He complains that he is too fat, and if he does not lose weight, he cuts back on food. He has lost 10 pounds in the past year and still feels that he is too fat, though it is clear that he is underweight. In desperation, his parents have removed the scales from the house; as a result, Tim is keeping a record of the calories that he eats daily. He spends a lot of time on this, checking and rechecking that he has done it just right.
In addition, Tim is described as being obsessed with cleanliness and neatness. Currently he has no friends because he refuses to visit them, feeling that their houses are “dirty”; he gets upset when another child touches him. He is always checking whether he is doing things the way they “should” be done. He becomes very agitated and anxious about this. He has to get up at least two hours before leaving for school each day in order to give himself time to get ready. Recently, he woke up at 1:30 A.M. to prepare for school.
WHODAS 2.0 score
ANXIETY DISORDER III
Emily is a 7-year-old girl who was brought to an outpatient mental health clinic for children by her mother because of difficulties with peer relationships. A recent telephone call from Emily’s second-grade teacher convinced her mother that it was necessary to seek professional help for Emily. The teacher was becoming increasingly concerned about Emily’s reluctance to interact with the other children in the class. During recess, Emily stands off to the side of the playground with her head down, looking extremely uncomfortable. In the classroom she never initiates conversation with the other children and has great difficulty responding even when approached by another child. It is now 6 months into the school year, and Emily’s extreme discomfort around her peers has not improved at all. Indeed, she does not have a single friend in the classroom.
Emily’s discomfort in interacting with peers dates back to kindergarten. Her teachers in kindergarten and first grade had commented on her report card that she was very withdrawn and nervous with the other children. However, her second-grade teacher was the first to take an active role in trying to get Emily the help she needed.
Emily’s mother had tried repeatedly to get Emily involved with other children in the neighborhood. In fact, she would take Emily by the hand and lead her to neighbors’ homes where there were children of the same age to try and make friends for her child. Unfortunately, when she did this, Emily would start to shake or cry and would not be able to say a word to the neighbor’s child. Emily has never been asked to attend a birthday party for another child.
Her behavior at home is quite different. Emily is warm and outgoing with her family, in marked contrast to the withdrawn and anxious child observed by her teachers and peers.
WHODAS 2.0 score