This paper explores a psychological case study on the character of Max from the film Where the Wild Things Are. By using various sources, it is asserted that Max may have suffered from a Brief Psychotic Break. This paper examines common diagnoses for children (ADHD, early acute schizophrenia), as well as treatment options. It will discuss making a diagnosis based on the DSM-IV criteria, as well as the importance of interviewing family members when it comes to childhood onset psychological disorders. It also discusses the various motivations for prescribing medication for children, as well as what the long term effects of these prescriptions may cause.
Max is an 8 year old boy who has been referred to me by a colleague. His mother has been worried about Max’s behavior over the last few months, and she has decided to seek help for Max after a particularly upsetting incident wherein Max disappeared from the house for an evening, and while gone experienced a series of vivid hallucinations.
Max grew up and currently lives in the suburbs. His parents separated three years ago. They are now divorced. His father is living in Australia at this time, and while he tries to remain active in the lives of his children, Max is unable to see or speak with his father whenever he wishes. His mother works full time, and has been working overtime for the past few months. She has recently started to date again. His older sister, Claire, is 14. Max and Claire used to play together, but over the last year Claire is spending more time with her friends. Both children have recently been to their pediatrician for yearly physicals, and are both healthy. Neither child is using drugs or alcohol. The mother drinks a glass of wine with dinner usually, but this is the extent of her drinking. This family has had no prior experience with therapy.
Max has always had a lot of energy, and is a very active boy. He spends a lot of time running around the house, crashing into the furniture, and play-wrestling with his dog. He is also a highly sensitive, creative child. He spends hours creating small models and figurines, hand crafting cards and gifts for his family members, and telling stories to his mother. He has often created his “own little worlds”, such as a fort made of pillows and blankets to protect against imaginary lava, or a small snow fort which he calls a kingdom. While he likes to create these crafts in a solitary environment, he is always eager to share his work, and can become disappointed and hurt when his mother and sister aren’t able to pay attention to his work (Martin 2009).
Methods of Assessment
The following information was gathered through a series of face to face interviews, both with Max and with his parents. In addition, Max was administered the WAIIS evaluative test by a consulting psychologist as I am unable to administer this test due to the fact that as a social worker, it falls outside my scope of practice.
The event that brought Max to my care was related to his need for validation, and his perception that he was being ignored. Max’s mother was entertaining her boyfriend, and preparing dinner. Max emerged from his room, wearing his wolf suit (a one-piece pajama style costume), and in an increasingly agitated state asked his mother where his dinner was. He became very distressed when he saw that his mother was going to be preparing frozen corn, and climbed up on the kitchen island. At that point, he shouted “Feed me, woman” and was escalating to a state of anger that his mother had never experienced. It was frightening to Max’s mother how he was equating her love with food (Gottleib 2009). She tried to persuade him to climb off the counter, and ended up losing her temper. She shouted at him to get down, and when he did he started running through the house. She grabbed him, at which point Max bit her on the shoulder, ran out the front door, and disappeared for several hours. She still does not know where Max went that evening.
During my interview with Max, he claims that he ran until he found a small boat on a pond. Upon climbing into the boat, the pond started getting bigger and bigger until it was an ocean. He sailed across the ocean, through storms, until he got to an island. The only inhabitants of this island were giant creatures that he calls the Wild Things. There were several Wild Things, and they all had distinctive personalities. The Wild Things made Max their king, and he tried to bring them together by having them build a fort. However, that did not make the Wild Things happy, so he tried having them fight each other, but that did not make them happy either. At that point, they realized that Max was not a king, and threatened to eat him. Max says was frightened, but he apologized and asked for forgiveness. The Wild Things forgave him, and Max sailed back home. Max claims he was gone for days, maybe even a week, but Max’s mother says he was only gone for 4 hours.
I have had several interviews with Max. During the first interviews, he was slightly withdrawn. He did not want to answer any questions, and when he would speak it was in a very quiet voice. Over time, we developed a rapport. He told me in detail about the island of the Wild Things, and has drawn several pictures of what the creatures looked like. He really responds to the art therapy, as he is already drawn to artistic endeavors (Martin 2009). Max is now comfortable telling me about his daily problems – how sometimes he feels insecure in terms of where his place is in his family. He is currently coming in for one hour of therapy a week, and that seems to be a beneficial schedule.
During his therapy, we discussed in detail the night that he ran away from home. His hallucination was extremely vivid: he believes he saw, heard, and felt the Wild Things, as well as the water from the storm and the heat of the sun. It was a tactile immersive hallucination. The Wild Things he encountered seem to be representations of himself and his family (Peele 2009). While it may have been a psychotic break, it did start Max on a path of coming to terms with his home life.
Examining Max with the DSM-IV, I have ruled out several diagnoses that his mother was researching. I do not see that Max has ADHD, as he is not displaying six or more of the symptoms of inattention table and hyperactivity-impulsivity table (APA 86). It is true that he sometimes runs around excessively, and is easily distracted at times. However, he does not meet enough of the criteria for any form of ADHD – and this is looking at codes 314.00, 314.01 or 314.9 (APA 86-89). Another thing to note is that Max’s teachers report that he is a good student, who is quiet and attentive in the classroom, and spends the recess period running around with his classmates. Therefore, since he does not exhibit enough of the symptoms both at home and school, he cannot be diagnosed with this condition. I also do not believe that Max has early onset schizophrenia (code 295.1), as he has had only the one delusional episode with the hallucinations.
I believe Max had a Brief Psychotic Disorder DSM-IV code 298.8 (APA ). This is a likely diagnosis as it covers hallucinations, delusions, and is one day but less than 30 days in length. This episode was short-term and short lived. There was quick onset, and also quick recovery. All of these traits fit into the diagnostic criteria. The DSM-IV verifies that a psychotic disorder can occur in response to undue stress. I believe that this psychotic break occurred because of the stress that Max was bottling up within himself. He was in a lot of mental pain because of the divorce, his mother’s new relationship, and what he perceived as the loss of his sister’s affections.
These are marked stressors that are common in the life of a middle class Caucasian child in the United States (Schmitt 2009). Now that the channels of communication have been opened in the home, as well as that a regular mental health care schedule has been established, I do not see another episode being likely. I do not think that this brief psychotic break has a co-morbidity with any other conditions. Even though Brief Psychotic Disorder is rare among adults, as well as quite uncommon among children, it is the best diagnosis for Max. No other diagnosis encapsulates his symptoms, and his disturbance is not better accounted for by a mood disorder, schizoaffective disorder, other medical condition or any drug abuse.
Max’s treatment plan will consist of therapy. We are doing weekly individual therapy sessions, and monthly sessions with the entire family unit (Max, his mother, and his sister). These group sessions are important, as they are allowing the family to discover ways of coping with everyday stress, as well as enhancing communication skills between family members. I believe that therapy will work as an early intervention treatment, and this cognitive behavioral therapy that we are exploring will help Max and his family better deal with stressors as well as provide an awareness for any sort of triggers for an episode like this (Hughes 72-74).
I’m not prescribing any anti-psychotic medication for Max at this time, as I do not think he would benefit from the drugs nor does his current condition warrant any prescriptions. The side effects from neuroleptics are too risky, the effects are long-lasting, and I am not willing to prescribe them to a child unless as a last resort. I am also not recommending any sort of atypical antipsychotic, such as clozapine. In fact, with a diagnosis of Brief Psychotic Disorder, an ongoing maintenance plan of medication would not be appropriate. A medical regimen of pills would suggest that a different differential diagnosis would have to be considered.
Prognosis and Areas for Concern
I have already seen improvements in Max’s behavior. He is more comfortable talking about his feelings, and more confident in expressing feelings of insecurity or loneliness. This level of openness has reduced the amount of stress and anxiety in his daily life. In fact, compared to his premorbid state, Max is happier and feeling more secure. He is still interested in making crafts and playing outside, and is starting to feel socially secure among Claire’s friends and his mother’s boyfriend. All in all, I feel Max has a positive prognosis for full recovery. In conclusion, I feel Max’s story is an interesting study for any child psychologist. While Max’s diagnosis ended up being a relatively rare disorder, the process of making that diagnosis came about through interviews with Max, his family, and his teachers. It would have been easy to say “Max has ADHD, here are some pills.”
Max’s mother was distraught, and just wanted answers. Many parents have been in that position, and they want a fast answer, a quick solution. This motivation does not come from a selfish place, it comes from a place of protection – they just want their child to be happy and healthy. That’s why many doctors are willing and able to make a quick diagnosis of ADHD, or even acute early-onset schizophrenia. It provides a label, and a course of treatment. There is nothing more terrifying for a parent than not knowing what is wrong with their child, and this labels and prescriptions can ease that pain.
But at what cost? The misdiagnosing and over-prescribing of children is becoming a large-scale problem. Long term effects of these medications can lead to social problems, health problems, and cognitive problems. Tardive dyskinesia is a common side effect, and is often irreversible. It is so common, it occurs in 1/5 of all users of neuroleptics (Nolen-Hoeksema 408). We are still unaware of the effects of neuroleptics on the long term development of children. Stimulants, a common medication for ADHD, are being overprescribed at an alarming rate, especially in rural areas (Nolen Hoeksema 469).
When it comes to children, the family and their therapist must work together. A full picture of the home life, school life, and child’s behavior must be given. With the potentially long-term effects of medication to consider, cognitive behavioral therapy should be used at first, rather than pills. By partnering with Max, and taking the time to talk to him and his family, I feel I came to a diagnosis that is correct. I also feel that the course of treatment we are currently on is doing good, and that we will be able to see Max flourish into a confident adolescent.
Courtney from Study Moose
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