The sole objective of a physician while receiving the case of a child is to understand his individualistic expressions at the holistic level. As described in my article about child centric case witnessing, to understand children at the holistic level, there are five components that are important and helpful:
Child’s centre obtained through case witnessing process
Physician’s observations about the child
Physician’s examination findings of the child (especially in children of young age who cannot express)
Mother’s history during pregnancy
Parents’ observations about the child
The individualistic expression which comes up in all the five areas or at least in more than two areas surely helps us to find the similimum for a child, as per the unique individuality of the child.
Through the following case of Miss M. S., I will illustrate the importance and use of the above mentioned components for child-centric case witnessing.
Miss M. S., 8 year old female came to me with her mother in November 2010. As per the mother’s history about the chief complaint of the child, the child was detected with a solitary granuloma in the right parasagittal frontal cortex which according to the MRI could be granulo nodular cysticercosis or alternatively old tuberculoma. The child was also very hyperactive.
History of chief complaint:
In august 2010, the child fell in school. Post injury she had numbness in the left leg. She was limping for around 20 days and the numbness went on increasing. Hence an MRI was done (Copy of the scanned report is below). For 15 days the child was on steroids and was better, after which the limping and numbness started again. For 2 months the child was on same modern medicine treatment. Limping and numbness was better, however the lesion detected on MRI was the same. After-effects of steroids like weight gain, irritation, and hyperactivity was also noticed in the child, by the mother
Investigation report MRI:
When the child was brought to me, at that time I understood her completely through the case witnessing process.
(NOTE: The case has been edited for brevity. Peculiar sentences are highlighted in italics and/or bold. My explanations and thought process during the case are in plain brackets ( ) and in green. D, P stands for Doctor and Patient respectively. Follow ups have been summarized at the end of the case.)
PASSIVE CASE WITNESSING PROCESS:
D: Tell me a little bit about you.
P: (Pause for 3 – 4 minutes)
I like to play. Can I call my mother in?
D: Tell me about you. I will call your mother later
(Area: playing games)
I like to play…badminton…we have a…in the building…we have a ground…big ground. We play there. We play hide and seek…And then there is an intercom. I’ve one, small sister…cousin. She also plays with us. I’ve many friends in my building. We all come and play but some more times my friend’s mother calling 1-2mins…that’s why we have to go home and we watch TV and we do other some other…other…in computer also there are many games, then we play. My cousin sister’s father has a laptop. There is a cake game so we play that. And we have a TV, there are some little games in that, we play and just again….in all the rooms the intercom is connected, all the friends go home, change their clothes and we go to sleep.
(I did not understand the context of what the patient was saying. However in the passive process, we passively listen to whatever the patient says.)
D: What else?
P: (Area: school)
When we go to the school, our teacher always tells us that complete the books and give us. We always do and give her. In 2nd standard, miss always gave us star, when we complete our books. Then in 1 hour she gave us and but we cannot…not all children can complete the book but from one and the other we complete the book and give to the teacher. Then there were 4 miss (teachers). 1st miss left because in the school she had 1 problem. The other miss also left. Our Hindi miss…P. miss, came to our class then. She also went from our class. She wants to join in our school, another class that’s why she went. One other miss came…S. miss…she teaches us and she also went from school. She told that I’ll just handle these children 2 weeks, and then I’ll also go. Then our principal…principal told all our class that our miss is going. Then we come at home, told our parents also but next time parents came to the school and asked that why you’re changing one and the other teachers; they told we are not changing, they are going from the school. Then we told, no…the miss is here, they’re changing the classes. Then next time, they didn’t change. But sometime they change. Now I’m in 3rd std. The principal is changing the teacher now.
(The child starts talking about her school. She begins with completing books in school, to the number of teachers in the school and then how the teachers are changing class etc., etc. In this area she does not give any significant details about her own self. Hence I ask her, “What else about you?” I am yet passive as I am not directing her to any particular area, however I am subtly telling her to talk about herself. I also note that the child’s voice is hoarse throughout while conversing with me.).
D: What else about you?
P: (Area: building where the patient resides)
I like to play in my building only. In other building… we play, the watchman always shouts and the building people also shout, that’s why we play only in our building. But sometimes…in our building there are mango trees, they’re always there. But children come and pluck the mangoes… then other…then the meeting was there in our building, then we all children went to the manager and told, that in our building there were three mango trees, in all the trees there are many mangoes. But the children are coming and plucking them, please tell them…tell them otherwise tell the watchman to take care of the mangoes.
(Area changes from building to playing to mangoes to watchman to …..In short span of time patient changes many areas)
Then the manager tells to the watchman, but watchman are only plucking the mangoes and taking it to their home. Always night…the morning duty watchman takes some mangoes and gives it to our building; he was very good. The night duty one, he used to take all 3 mangoes, 3 mango trees, there was there. One mango tree, morning watching didn’t pluck it, because they are green. Then the night duty one take the…all the mangoes from trees and we didn’t get. We found everywhere, then in our building only watchman sit and watchman room back it is…then the manager went there and saw that one full box…night duty watchman has taken…The manager shout at him very much but again he…now didn’t do and the manager told that don’t come to our building.
(The child still continuous to talk a lot, changes from one topic to another topic and the talk does not give any significant detail about her. However I remain passive and listen to the child.)
D: What else do you do?
P: (Area: playing)
We just play down sometime…we go at the…there is one garden just down they’ve made it, we go there. It is a nice garden. We play there. There is a…one park…in that only park we…they can do jogging, yoga and all that is there. We children play there, our parents take a round there…
D: Ok, very good. Tell something more about you…
P: (Area garden)
Last time, we went there in the new garden, we saw it, it was very good, but there were many flies and all that. We sat together. We had lunch box. We went at 6’o clock and we came at 7’o clock but our parents didn’t allow it. I told my grandmother…my grandmother told my mother that we can go there and play. There is one…in that only garden…green place is there…green grass…we sit together. We play there also. We take a round, there it is very big… but some other time we went to the mall with friends because a party was there…We went but…they didn’t allow us, then we called my sister that they are not allowing us to go in the mall. Then she came and take us to the…because they…because the… we that birthday card…we forgot at our house. We had to take that.
P: Then my sister told that you had brought the birthday card. Then I told no, we forgot that. Then she said no problem. I’ve many cards you take that and give to watchman, they’ll allow us. Then we went. The party was very nice. There were many games like…it was very…we played hide and seek. They tell us that bring one rupee coin from the bags – parents…we did that also…but it was not…it was not nice because that we again went home and watch TV and go to sleep.
Now, the watchman that our manager has kept, they are very nice. They take care of mango trees, they take care of us, when we fell down they called our mother, father that they have slipped off the garden. They help us to go to our home also. My sister doesn’t know how to… we are staying in 14number floor…the…my sister doesn’t know how to press the number 14. The…she tells the watchman…that please can you do it? The watchman do and call in our home that my sister is coming, we take her from the lift, otherwise she cries.
(The child wanders in various areas, changes from one subject to another, talks about random things, and does not provide any significant detail about herself. Does anything make sense to you while you are reading this case? I am sure even you are trying to make sense about what is happening. I had the same experience at my end when I understood this child.)
D: What else about you?
P: (Area: fear of dogs)
I’m scared of dogs because in our building the outside dog has team…that’s why we are scared…Now-a-days we don’t play hide and seek, badminton and all that. We go to the backside garden in our building; the dog comes with us there also. In our building first there were 2 dogs, 3 dogs…1 tail was cut…the…in our second floor there is V. aunty…whenever something is happened bad like the bird is…bird’s feather is cut, she helps us. That’s why she has a dog at her home. The dog’s name is Max. He plays football with all the boys and when our cock is fall down, he helps us…to give us but we all children don’t touch it because it is something…something happened to dog that’s why…2 dogs are white and 1 dog is brown. It’s in our ground…1 dog…1 white one was dead because something happened. One dog is there but one dog died then the other outside dogs come to our building; that’s why we didn’t come out of our homes also, because we were scared. When we run, the dogs come to us, that is why we didn’t go down. We didn’t play anything. We just talk with each other and go home.
(I thought this time, since the patient started to talk about her fear, the patient will give some more significant details about her individuality. However, the same happens. The patient starts with fear of dogs and then goes into playing games and then dogs come in their building, then the neighbor has a dog, and then ……..
The child’s talk goes on and on and on, her topics keep changing, however there is nothing really significant that I could gather from her talks. There are no expressions coming up where I can understand anything unique about her individuality, neither am I able to obtain a significant focus.)
AT THE END OF PASSIVE CASE WITNESSING PROCESS:
WHY TO END PASSIVE HERE:
Except for loquacity, changing topics randomly, talking about insignificant things, there is no other expression coming up in any area that she talks about. This is the time when there is a need to become passively active and take the child to other subconscious areas like fears or dreams.
OUT OF PLACE, OUT OF ORDER:
In every area I observe that the child is: