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Kristian Heløe, age 4


Department of Child Psychiatry
Nils Lie and Marit S. Indredavik, 2003

Part 1
Imagine you have just started as a general practitioner in a rural district in
Norway. The health visitor is worried about 4-year-old Kristian, who has arrived at
kindgergarten several times lately with bruises on his face.

Kristian doesn't play with other children, and he easily becomes aggressive if
disturbed while playing by himself. His interest in adults is very variable. His
vocabulary only consists of a few words, even though he has special language
lessons at kindergarten. He often has fits of screaming during which he may
knock himself in the head or bang his head against the wall.

1.1 Clarify the problem.

1.2 What child psychiatric disorders are possible diagnoses?

1.3 What should you do now?

Part 2
Family anamnesis
Kristian's mother is from a large family with poor social and intellectual abilities.
Like Kristian, she was included in a special-needs programme at school. She was
only 15 years old when she got pregnant. During the pregnancy she moved in
with Kristian's father, a man 10 years her senior, whom she later married.

Pregnancy, delivery and neonatal period:


Kristian's mother had a slight pre-eclampsia. Kristian was born prematurely. Birth
weight 1500 g. Birth length 42 cm. He was put in an incubator, suffered transient

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hypoglycaemia and hyperbilinirubinemia, but was thriving steadily from age 3


months.

Development during the first year


Kristian was discharged home when he was one month old. At the time, his
mother was depressed and took very little notice of him. The health visitor visited
their home on a regular basis to give advice and make sure that the mother was
taught how to feed, care for and stimulate Kristian. Together with the child welfare
authorities she arranged for a home consultant to visit Kristian twice a week. In
spite of this, Kristian turned out to be a passive child. He didn't undergo a period
of separation anxiety, which normally occurs at about 7--8 months. When he was
1.5 years old, his mother had a second baby, a little girl, with whom she spent
most of her time and developed a more normal relationship. The health visitor
reported that 2-year-old Kristian seemed understimulated and was often left by
himself. His father was described as being intellectually normal, and a skilled
worker, but he was often away from home due to his job.He was also known to
have a bad temper, and to abuse alcohol when off duty.

2.1 What are the risk factors within this family for the development of
complications during pregnancy and/or psychosocial disorders in the child?

2.2 What are the usual signs of healthy social/interrelational development during
the first three years of life?

2.3 What might have interfered with the attachment process between Kristian and
his mother?

Part 3
Investigating Kristian at age 4
You perform a physical examination in which you try to assess these problems:
bruises, lack of normal play, isolation, aggressiveness, poor contact abilities,
limited language skills. Your findings are: Kristian is small for his age, with a
weight in the 2.5th percentile. He has a bluish bump on his forehead and serious
bilateral otitis, otherwise a normal somatic status. Kristian is clumsy when tested
for both gross and fine co-ordination, and there is a lot of superfluous movement
associated with his motor skills.

At the start of the examination Kristian seems apprehensive or fearful, but he


calms down when you explain what you are doing and prepare him for the next
steps. He refuses to look at you, and when you actively try to catch his eye, he
turns away. Nevertheless, you get a sense that he is interested in you and
observes you surreptitiously. You talk to Kristian throughout the examination
process, even though he doesn't answer your questions. His mother is always in
the room, but Kristian doesn't turn to her for comfort when he is anxious, and she
neither supports nor encourages him. On the other hand he uses her as a
"means" when he puts his clothes on. During the examination you observe that

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Kristian says short two- or three-word sentences, some of them incorrectly


pronounced.

You decide to refer him for further investigation:

• Blood status (bleeding disorder?)


• ENT specialist (serious otitis)
• EEG: normal
• Cerebral CT: normal
• Mental test: score located in the lower normal area for his age, but this test
result may be influenced by poor intellectual stimulation. His intellectual
profile is uniform without any specific difficulties.

3.1 What child psychiatric disorders are possible now? Which seems most likely?

3.2 What steps can be taken to address Kristian's problems?

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