My next case study begins with a canceled appointment. Dr. J was called away on a family emergency and I had the office to myself for a week. Cecilia Moreno and her son, Ramon, came to the office to discuss the aftermath of domestic abuse by Miguel, Ramon’s father.
The session began with Cecilia while Ramon waited outside. She was hesitant to leave the boy alone but I assured her that it was safe in the waiting room. She was one of those overprotective types of mothers, smothering their children away from the world in paranoid fear. Hoping their kids never experience the pain and suffering of the real world. I could diagnose this right off the bat. She reminded me of my own mother.
She began the session with a defense of Ramon. This was an attempt to show that she had done something right for the boy, despite the troubles in his life. She described him as quiet, distant, and sometimes emotionally cold, but still a sweet boy, nonetheless. This behavior is normal considering the relationship both Cecilia and Ramon had with Miguel. The father of the boy was addicted to narcotics, driving a wedge in the family dynamic. Cecilia went on about the physical and emotional abuse the family endured at the hands of the man they had trusted to protect them.
As a result of the drug abuse, Miguel’s behavior became more unstable and unpredictable. His dependency on the chemicals overshadowed his judgment until the family was destitute. Cecilia and Ramon fled the broken household and have been living on their own since. Miguel has attempted to reconcile the family but Cecilia does not want to subject Ramon to abuse again. Ramon, however, still feels a need to see his father and rekindle the relationship.
During this tumultuous time, Ramon had become problematic at school and home. Academically, Ramon was flunking his classes and teachers were saying he was easily distracted, over energetic, and did not follow directions. Socially, he did not have any friends and was the victim of bullying. This had resulted in several altercations resulting in violence against other students.
As the session with Cecilia concluded, it was a text book case of a child acting out after being traumatized by violence at the hands of his father. However, the final part of the Cecilia’s story bought me to another conclusion. While cleaning Ramon’s room, her sense of smell was assaulted by a horrible stench. She checked if he had wet the bed, which he sometimes did, but it was dry. The smell was coming from the inside of his closet. She discovered the source of the stench in a lunch box at the bottom of a clothes pile. When Cecilia checked inside, the contents spilled out onto the floor along with her lunch.
The decayed remnants of a kitten fell to the ground along with a knife. The kitten had been eviscerated. Its limbs barely remained attached to the corpse and its eyes had been removed. Ramon had been enthralled with the neighbor’s pregnant cat. He had asked for one of the kittens but Cecilia did not allow him to have one. When she confronted Ramon, he did not show signs of sadness or acknowledgement of his wrong-doing. He apologized and continued with his day as if nothing had happened. Cecilia made an appointment with Dr. J, the following morning.
If Ramon was younger, I would have attributed it to morbid curiosity but a child his age should know the fundamental differences between right or wrong. He should understand the suffering of the kitten. The most chilling factor was his lack of empathy or regret. Paired with the violence at the hands of his father and the bed wetting, I saw there was a serious cause for concern. Ramon was exhibiting the symptoms of a conduct disorder. For the layperson, that is the precursor to antisocial personality disorder, which is a diagnosis given to most serial murderers.
Cecilia left the room and Ramon was an opportunity to address his mother’s suspicions. Our discussion began with his school troubles. He blamed the teachers for being unskilled at their jobs and the subjects did not interest him. The boy further proved his point by asking me if I had used everything I learned in school in my life. I cannot say that I didn’t agree with the boy.
The aggressive behavior in school was a result of classmates discovering Miguel’s drug addiction. They bullied him until it became physical and he defended himself. His predatory behavior was an intimidation tactic to prevent others from joining. If he played the part of the tough, aggressor, fewer children would be inclined to join the bullies. Most importantly, it was following the advice his father had given to him before their separation.
My main concern about the kitten was the end of our session. Ramon wasn’t as eager to answer or as forthcoming. He writhed uncomfortably on the couch and averted looking into my eyes. He felt shame and embarrassment from his actions. This was no sociopath. He was only a boy afraid of his mother finding out he disobeyed her.
The kitten situation was a misunderstanding. The kitten was sick and the mother cat had removed it from the litter. Without help, the kitten would die and Ramon took it upon himself to help the poor animal in secret as his mother said he couldn’t have an animal. He bought the kitten inside the lunchbox and attempted to care for it himself. With no money for a veterinarian, he looked online at treatments but it only grew weaker.
Ramon used the knife in an attempt to unseal the newborn’s eyes that had been infected. His unsteady, nervous hands had slipped and he hurt the kitten’s eyes. With the realization that it wouldn’t survive, he tried to show it mercy by ending it’s suffering with a stab through the heart. He botched the euthanization as well, leaving the kitten with its entrails hanging out.
He put the box inside the closet and under the clothes pile to hide away his shame until he could sneak it out of the house but Cecilia discovered it before he had time. Ramon apologized and wished that he could bring it back to life or he had taken it to the vet. I asked him to leave the room and bring his mother back inside.
Cecilia and I had assumed the worst of the child when it was a simple misunderstanding. Despite the relief of Ramon not having a conduct disorder, the boy was still at risk for behavioral issues in the future. I gave Cecilia the following recommendations:
First and foremost, he needed to socialization with children that had no knowledge of his family history. This would allow him to drop his guard and focus on building healthy relationships.
Second, a special education program will allow him to develop an interest in the course work and he may benefit from the individual attention.
Third, allow Ramon to have a pet. He will learn responsibility, proper care of an animal, and he will form a bond with a creature that will love him unconditionally.
With those recommendations, I told them to come see me in two months time for an update.
Two weeks later, I received a heart-wrenching phone call from Cecilia. She had been hospitalized for three days after having excoriating pain in her stomach and vomiting blood. The doctors feared that she had been poisoned. The police were contacted and when asked if she had any enemies or suspected anyone of poisoning her, she immediately accused Miguel.
Hours later, the police returned and informed her that Miguel could not have poisoned her. He’d been found dead in his apartment with a syringe near him. They suspected the cause of death was drugs laced with other chemicals. Miguel had been rotting in his apartment for days and was discovered when a neighbor complained about the smell. With Miguel dead, there was only one person left, Ramon. The day before she got sick, he had been asking to see his father, and she had said no.
When she got out of the hospital, there was a voice mail left on her phone from a veterinarian’s office. Ramon had gone to his office with the dog that they had adopted, and it had been poisoned too. The vet was forced to put it down as it suffered immensely and its organs failed. The vet noted how disturbing it was that Ramon did not have a reaction to the suffering of the animal. He had even volunteered to put the injection into it.
Cecilia arrived at home and Ramon was not there. She ransacked his bedroom until she discovered two more dead animals and bottles of ammonia and bleach under his bed. With no other choice, Cecilia made the decision to call the public health department.
The police picked up Ramon on the side of a road, where he was poking road kill with a stick. He was committed to a psychiatric hospitalization for evaluation. While the police investigated the poisonings and Miguel’s death, they would hold Ramon in captivity at his mother’s request.
Cecilia asked me to visit Ramon at the hospital but I declined as I had other patients that required my attention. I told her the doctors in the hospital were better equipped to handle the situation than I was. I hung up with her and sat in the office stunned that Ramon had been able to mislead me. He seemed like such a normal, charming young man too. In the end, I had no other choice but to continue my work and consider this as another example of rule number one: You cannot help those that do not want your help.