A 10-year-old boy presents to his pediatrician for evaluation. His mother reports significant changes to his behavior since he witnessed the death of his grandfather 6 months ago. The patient was very close to his grandfather. His mother reports that he experiences frequent nightmares that wake him during the night and cause him trouble sleeping. He also experiences irritability and has frequent outbursts of anger. At home, he is withdrawn and goes to his room when he comes home from school. He does not like to be disturbed and only comes out to eat meals, which he often takes back to his room. He regularly experiences headaches and stomach aches, which keep him home from school or get him sent home early. His teacher has reported that he seems withdrawn and has trouble paying attention during lessons. His grades have suffered. Previously an outstanding student, he is barely passing his classes. Other children at school have said they do not want to play with him because he only wants to play "sad" games including hospital, ambulance, and being sick. He does not like leaving the house or going on trips away from home. He does not want to sleep over at his best friend's house, which he used to do often.
His mother recounts that last summer, her father suffered a massive stroke while her son was away at sleepaway camp. Her son was brought home early to find his grandfather in the neurology intensive care unit, his head bandaged and hooked up to an electroencephalogram machine. From there, he was transferred to a rehabilitation facility. Because she had no childcare options and few friends who could help, she was forced to take her son along with her on visits to see her dad, which the patient also insisted on attending. Her father experienced several complications over many months and was eventually released to hospice care at the home of the patient and his mother, where he died 1 month later.
Physical exam reveals nothing remarkable, except that the patient's heart rate is slightly elevated on auscultation. The patient appears tired and anxious and fidgets in his seat. He does not look at the doctor during questioning and is reluctant in responding. He has a negative history for any underlying comorbidities and does not take any medications.
