Pediatric Primary Care Case Studies (50 page)

   
How is Ms. Jenkins doing financially (does she have a job, does she receive child support from the father) and is she having difficult financial times?
“We get along OK with my job, which just covers the bills. I get an occasional token check from the kids’ deadbeat dad. Roy is good and has been giving me some money to help with the kids.”

   
When did she first meet Roy, what is their relationship, is he living in the home, and if so when did he move in and what is his relationship with the children?
She replies, “I met Roy in a bar about 3 months ago. He’s new to town.” She does admit upon further discussion that Roy stays overnight with her, but says, “We’re always discrete.” She tells you that Roy took care of the kids a couple of times when she went out with her girlfriends to celebrate birthdays. He last babysat about 1 week ago.

   
How is Tommy doing in school and have there been any changes in his grades, performance at school (can’t concentrate or is easily distracted), or other behaviors? Has his teacher noted any changes?
“Tommy has been having some problems in kindergarten and the teacher wants me to talk with her. Tommy’s been hitting kids lately.”

The healthcare provider should seek out information from the parent as to whether there has been a change in the child’s general attitude, demeanor, or
behaviors at home or with his friends or family members and whether this change was associated with a particular event. In this case, did Ms. Jenkins notice any changes in Tommy or Lucy since Roy entered their lives and home situation?

In addition, the provider should seek information about the presence of behavioral signs that are associated with the various types of child maltreatment, not just sexual abuse, because multiple types of maltreatment may be being inflicted upon the child (Brady & Dunn, 2009). Key questions to ask include:

   
Has Tommy become overly fearful, clingy, shown indiscriminate attachment, or compliance?
Ms. Jenkins replies “No, that has never been a problem for Tommy.”

   
Have you noticed extremes or drastic changes in his behavior such as extreme passiveness or aggression lately?
She says, “I’ve had to give him more time outs the last 2 weeks because he is fighting more with his sister.”

   
Does Tommy appear wary of physical contact with adults or frightened of anyone?
In this instance, ask Ms. Jenkins how he relates to Roy. She states, “He isn’t frightened of anyone I know. He doesn’t seem to like to be around Roy. Tommy is just jealous of Roy now that Tommy doesn’t have all of my attention.”

   
Has he exhibited signs of being depressed, hypervigilant, withdrawn, or apathetic?
“That’s not my Tommy.”

   
Have there been any changes in Tommy’s bowel or bladder patterns (loss of control such as bed wetting or stool soiling), sleep issues (e.g., nightmares or inability to sleep alone) or eating disorders?
Ms. Jenkins seems to hesitate and says, “He wet the bed last week while I was out with my girlfriends.” Upon further questioning, she tells you that Roy was babysitting the kids and she didn’t get home until 2 a.m. She noted that Tommy was awake in his bedroom when she went in to check on him. He was crying and said that he was sorry that he wet his bed. This was the first time he had wet his bed at night in the last 12 months.

   
Has Tommy talked about suicide plans or thoughts or made any suicide attempts?
(Suicide and running away are more frequently seen in adolescents. This question is more relevant for the older school age and adolescent age group. Therefore, you focus on issues of depression and sadness). She replies, “No, Tommy’s not a sad kid.”

   
Does he have any unusual fears, phobias, or compulsive behaviors or has there been a recent negative change in peer relationships?
Ms. Jenkins again ponders for a short time and says, “He got into a fist fight with his best friend at school the other day but wouldn’t tell me what it was about.” (Ms. Jenkins also said earlier that the teacher wants to talk with her about Tommy’s behavior at school.)