Recurrent nightmares, aggressive doll play, separation anxiety and witnessing domestic violence in a 9 year old girl.

CASE: Sarah is a 9 year old girl who was brought to her pediatrician with sleep difficulties and repetitive nightmares. Her mother reported that Sarah had problems falling asleep for several years with recurrent nightmares about her mother getting hurt. Sarah also had difficulties with separation from her mother and refused to sleep in her own bed. Sarah was described by her mother as "irritable with poor concentration," and easily startled. The mother denied any recent stressful events or changes in the home environment. The parents had been divorced for two years; there was a prior history of domestic violence. Sarah was otherwise in good health. Sarah's mother was in treatment for depression. Sarah's father had a history of alcohol abuse. In the pediatrician's office Sarah appeared irritable and clingy. While the pediatrician spoke with Sarah's mother, Sarah began playing with dolls, pretending that one was hitting the other repeatedly and then rushing the injured doll to the hospital. After Sarah appeared more comfortable, the pediatrician interviewed Sarah alone. Late in the interview, the pediatrician asked Sarah if she had ever seen anything that scared her. Sarah did not reply immediately. "Have you ever seen grownups be mean to each other and fight?" She replied, "My daddy hit my mommy and made her go to the hospital in an ambulance." Sarah's mother reported that Sarah had witnessed many episodes of domestic violence several years ago, including one fight that resulted in the mother's hospitalization and father's incarceration. The mother seemed surprised that Sarah could remember these episodes or found them traumatic since she had never spoken about them and no longer had any contact with her father. Sarah's mother asked the pediatrician if these episodes could relate to Sarah's current sleep difficulties and nightmares.