Clinical material

Clinical material

Background

Grace is a five-year-old girl, the eldest daughter in an intact white middle-class family. She is bilingual, as her mother is Northern European. Grace's father is a self-employed professional and her mother works part time. Because of complications in the pregnancy, Grace was born a month early and was very underweight. At this time, Grace's mother was largely unsupported by Grace's father because of his work commitments. Initially Grace was tube fed, and her mother later struggled to breastfeed her. Grace was then bottle-fed; however, this too proved problematic, with Grace often vomiting after a feed. She was hard to settle at night and apparently only slept through the night around the age of two years. Her other milestones appear to have been normal, and in fact she was described as being quite forward in some, such as walking and talking. I had the impression that Grace's mother found it difficult to acknowledge quite what a vulnerable baby Grace had been, and delighted in what she saw as Grace's superior intellect. Grace refused to use a potty to defecate and the difficulties appear to have worsened around the time her sister was born, two years ago. Grace was increasingly troubled with constipation and was referred to the paediatric service at the age of three. Laxatives and enemas were prescribed and for about 18 months, the family were offered advice and behavioural management. However, Grace steadfastly refused to use the toilet. She was eventually referred to her local CAMHS service at four and a half.

When I assessed the family, Grace's parents were very keen to impress upon me that they viewed her constipation as a symptom of a wider problem. They described their daughter as anxious and always expecting the worst in new situations. This description was in stark contrast to that of their sociable and robust second child. They also described Grace as being extremely sensitive to light and noise. She found playtimes at school esp