The Ignored Voice: A Case Study

Volume 13 Issues 11 November, 2023

1. Department of Psychiatry Social Work, Central Institute of Psychiatry, Ranchi, Jharkhand.
2. Professor, Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand.

ABSTRACT: Childhood is the era of growth and development.  A child’s development is mediated by social interactions, shaped by fulfilling love and belongingness needs. Due to some unforeseeable circumstances, family members sometimes create distressing experiences for children leading their mental health and well-being at stake. This case study aims to portray the psychosocial circumstances contributing to internalising disorder in children. It was studied in the inpatient department of the Central Institute of Psychiatry, Ranchi. Psychosocial assessment reveals the main contributory factor lies in family dynamics that act as stressors in the lives of children and adolescents and may cause psychiatric illness.

Key Words: Psychosocial, mental health & wellbeing, case study

INTRODUCTION

Childhood is marked by growth and development. It is the period when individuals start forming the concept of self. A child’s cognitive development and learning ability can be guided and mediated by their social interactions as per social development theory of Vygotsky ^[1]. The psychosocial factors contribute a great deal to internalizing disorders. Reddy et al., observed that 41.82% Indian population with internalizing disorders like dissociative disorder has family disharmony ^[2]. Dissociative disorders are mental health conditions that involve experiencing a partial or complete loss of the normal integration between memories of the past, awareness of the identity and immediate sensations, and control of bodily movements ^[3]. Malhi & Singhi, shared that significant and multiple psychosocial stresses contribute to dissociative disorder in children ^[4].

METHODOLOGY

This is a case study conducted in the inpatient department of the Erna Hoch Centre for Child and Adolescent Psychiatry, Central Institute of Psychiatry, Ranchi, from October 2023 to November 2023. The Case Record File was reviewed. Psychosocial assessment and management were done with the selected case.

CASE HISTORY

Master X, 6 years, Hindu, unmarried male, hailing from middle socio-economic status of urban Jharkhand, studying in UKG, brought to outpatient department (OPD), followed by inpatient department (IPD) with the chief complaints of episodes of fits with loss of consciousness and irritability and stubbornness for past two months from the date of visiting OPD. Chief complaints were insidious in onset, continuous in course and deteriorating in progress. Exploration of the history of present illness revealed that, the predisposing factor was the mother leaving separately from the child one and half years back due to her work from the date of visiting OPD. Precipitating factor was being scolded and punished by father regularly for not doing homework assigned by school or fighting with his elder sister. Index child was maintaining well two months ago from the date of visiting OPD, lived with his father, elder sister and maternal grandmother. His mother shifted to another state one and a half years back due to work. The mother would come home for two to three days in every month. The child used to spend all the day with his mother but he never showed much reaction of emotions when she used to leave, instead he used to console his elder sister when she used to cry every time the mother left home to go to her workplace. The last time the mother came home in July 2023, the child had fever and was taken to the hospital. That time mother took leave for a week from school and stayed longer with the child. After one month the child again had fever. The child had typhoid and the mother took long leave and stayed with the child. After few days the child got better and the mother returned to her workplace. After one week of this the child had a fit like episode at school. Gradually he started having frequent episodes of fits along with irritability and stubbornness. His parents took him to multiple doctors. He went through MRI, CT scan of the brain, EEG brain and various blood tests and took multiple medications. Still, he used to have presenting chief complaints. After this, his parents took him to a faith healer, but nothing worked. Gradually, he started having headaches, and his fit-like episodes turned into three different types of episodes. There was nil significant family history of psychiatric illness. The IPD mental status examination revealed that the child was maintaining personal hygiene; he was oriented to time, place, and person; his attention was aroused and sustained; his affect was anxious, infectious, reactive, and full range throughout the interview. The child was diagnosed with mixed dissociative disorder. In personal history, the child was born out of a full-term normal vaginal delivery with immediate birth cry. No sleep disturbance, nail-biting, thumb-sucking, tic, or stammering was reported during early childhood.  No delay was reported in the attainment of developmental milestones. Index child has an easy-going premorbid temperament.

PSYCHOSOCIAL INTERVENTION & OUTCOME

Psychosocial assessment findings show that the family is extended in nature and composed of five members. The internal boundary of the family is open and the external boundary of the family is diffused. Father shares everything with the paternal grandmother. Mother and paternal grandmother do not have cordial relationship. Relatives and neighbours interfere in the matters of the family and family members also accommodate them. The family is comprised of four subsystems, all the subsystems are found to be formed but functioning inadequately. Interpersonal relationships between family members are found to be inadequate. The family is in the fourth developmental stage.^[5] The parents of the index child had arranged marriage. The child is the second born child in birth order and a planned conception and wanted child. The maternal grandmother is the nominal head of the family, and the father is the functional head of the family. Parents usually make big decisions democratically; small decisions are made on laissez-faire basis. Grandmother does all the household chores, and father does work outside the home. The family follows a switchboard communication pattern due to the mother’s physical absence. The family has an uncongenial home atmosphere and a high noise level due to verbal altercations between the maternal grandmother, elder sister, and father. The father follows strict rules to teach discipline to the child. The child mostly identified with his mother. Inconsistent parenting was observed as his primary caretaker mother has been absent from his life for the past one and a half years. Primary and tertiary social support systems are found to be adequate, and secondary support system is found to be inadequate.

DISCUSSION

Psychosocial management was done with both the child and the family.  The Psychiatric Social Work Trainee was able to build a positive professional relationship with the child and his parents which allowed her to talk about the family and the child’s relationship with each family member freely. Skills and principles of social work were followed while dealing with the child and family. Structured activity schedule and communication improvement through social stories were followed with the child. Rationale behind these activities was explained to him. Psychoeducation, contingency management and structural family therapy were followed with the family.

After interventions are over the child reported significant improvement in his illness. His understanding about the illness enhanced. His social interactions had improved. He reported significant improvement in the behaviour of father and Mother’s engagement was also increased. Mother planned to take a job near the house so that she could spend quality time with the child. The communication pattern among the family members was improved. Improvement in the reinforcement pattern was also noticed. Family’s belief in faith healing was decreased.

CONCLUSION

Psychosocial assessment reveals the main contributory factor lies in the family dynamics. It was also found that parenting style contributes significantly in child’s life. Psychosocial factors like not following authoritative parenting, lack of acceptance, lack of reinforcement, neglecting the child’s needs, not following open and transparent communication, not connecting with children emotionally, criticising and punishing them contributes greatly in developing internalizing disorder in children. Physical absence and disengagement of parents also significantly affects child’s life. All these factors act as stressors in the lives of children and adolescents and may lead to traumatic life events and can be a cause of the development of mental illness in children.

Disclaimer: Informed written consent has been taken. All efforts have been made to conceal the patient’s
identity, but complete anonymity cannot be ensured. There is no conflict of interest.

REFERENCES

1. Vygotsky LS. Mind in society: The development of higher psychological processes. Harvard university press; 1978.
2. Reddy LS, Patil NM, Nayak RB, Chate SS, Ansari S. Psychological dissection of patients having dissociative disorder: A cross-sectional study. Indian journal of psychological medicine. 2018 Jan;40(1):41-6.
3. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. World Health Organization; 1992.
4. Malhi P, Singhi P. Clinical characteristics and outcome of children and adolescents with conversion disorder. Indian paediatrics. 2002;39(8):747-51.
5. Duvall EM. Evelyn Duvall’s life. Marriage & family review. 2002 May 8;32(1-2):7-23.

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