Psychiatry Case Challenge: A 9-Year-Old With Suicidal Behavior

James Robert Brasic, MD, MPH


January 25, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 9-year-old boy presents to the emergency department (ED) with his mother due to suicidal and homicidal actions he exhibited in his classroom for the past couple of weeks. He tried to scald himself on a radiator. He tried to impale a pencil in his hand. He assaulted an instructor. He hurled a chair at another child for no apparent reason and without provocation.

The boy was conceived during the rape of his mother by his father. Although the umbilical cord tightly encircled his throat at birth, his Apgar scores were 6 and 8. He had a cleft soft palate (an example is shown in Figure 1).

Figure 1.

High serum bilirubin levels were noted. He was septic at birth with Streptococcus viridans and diphtheroid infections.

Six and a half years prior to his ED presentation, he underwent surgical closure of his cleft palate and bilateral myringotomy tube placements (Figure 2) for many episodes of otitis media. Five years prior to presentation, he underwent a surgical correction of his right hydrocele (Figure 3).

Figure 2.

Figure 3.

Four and a half years prior to presentation, an audiologic examination demonstrated bilateral conductive hearing losses, mild on the left and mild to moderate on the right. Four years prior to presentation, he deliberately attempted to light a tree on fire. Two years prior to presentation, he attempted to choke a cat and also lit a fire in his bedroom. His mother reports that a local shop owner observed the boy frequently taking items without paying for them. He also commonly fights with other children in his family and his neighborhood. A month previously, while intoxicated, his mother's boyfriend hit the boy, leaving scars on his torso.

Both parents have a history of drug addiction. His mother had been raised in various different homes and locations after she was abandoned by her own mother. His mother has had mental disorders since childhood, resulting in multiple psychiatric hospitalizations and antipsychotic treatment. His father, a violent and abusive man, was not involved with the family. No family history of hearing disorders is noted. The child has no history of alcohol or drug abuse.

Because he represented a serious risk for death to himself and others, he was admitted to the inpatient child psychiatric service.


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