CASE: “Aabis” is a school-aged boy from a predominantly conservative Muslim nation who presented to a tertiary developmental-behavioral pediatric (DBP) clinic to seek “expert opinion” for significant social and learning difficulties in the context of a history of frequent falling and “clumsiness.” He was seen by a psychiatrist in his home country, who ordered an electroencephalogram and “brain map” (both normal), and received occupational and physical therapies. Frequent tantrums and intense emotional reactions to minor events—revealed to be related to a history of repeated physical beatings from groups of his “friends”—prompted referral to the DBP clinic. When asked why he did not fight back, Aabis said that he did not want to lose his friends. He and his parents further explained that this kind of organized aggression is considered part of normative development in their country and that Aabis needed to “toughen up.”
Aabis was described by his parents as being very “sensitive” when others raised their voices, shivering when reprimanded and profusely apologizing for real and imagined mistakes. He bit his nails until they bled, washed his hands repetitively, and changed his clothes several times per day. On witnessing his parents arguing, Aabis threatened to harm himself with a decorative knife.
The assessment presented with several procedural complications specifically the use of an interpreter and the cultural differences regarding many of the topics discussed. Aabis spoke very little English, and an interpreter was not available in person on the initial day of the assessment. Telephonic phone translation services were attempted, but there were concerns that Aabis would not feel comfortable with sharing his emotions over the phone with an unidentified individual. As feared, Aabis was resistant to discuss emotionally charged topics (e.g., feeling sad, being bullied, hearing or seeing things) and grew impatient and irritated with the phone interpreter. After some unsuccessful experimentation with a Google-based translation system (implemented at Aabi's request to help build comfort and rapport), a second telephonic interpreter was brought into the session, who Aabis later described to his parents as “mean.” (Aabis clarified that the second interpreter had been brusque and insensitive to his tentative attempts to express his feelings, e.g., by telling him to “Speak up. Spit it out.”)
Toward the end of the interview, Aabis seemed to dissociate and insisted anxiously that he did not want to relay certain information without his parents present in the room. What would you do next in this situation?
Details about this case, including name and age, have been altered to protect the child's identity.
*Division of Developmental Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA;
†Children's Physicians of South Texas, Driscoll Children's Hospital, Corpus Christi, Texas;
‡The Kelberman Center, Utica, NY;
§Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, MA.
Disclosure: The authors declare no conflict of interest.