Dr Judith Guedalia

The third star had just begun to twinkle: A case of neuro/psychological detective work.

It was just about Motzei Shabbat, the third star (of the three required to signify the end of Shabbat) was barely twinkling when I received a phone call.  Thinking this must be from a family member, telling me 'something happened' over the past 26 hours when we were ‘out' of communication, I answered the phone by saying: "Shavua Tov, what happened?  I didn't expect to hear the voice of a somber Rav, who identified himself as a leader of a specific ultra orthodox group.   We had previously ‘met' by telephone over a case of a very troubled adolescent young man whose actions suggested a problem in the brain/behavior relationship, and as a neuropsychologist I tried to help out.  My guess was that he was calling about a similar situation.


Would I be able to see a nine year old girl right now!?  This is an emergency.   Well, to tell the truth, there are really no neuropsychological or even psychological emergencies.  There are Neurological and Psychiatric emergencies where the local ER (Emergency Room) is the address. "No, no", he insisted, "The Rebbe agreed, you should see the child tonight". I tried to convince him that I was not trying to shirk responsibility, but rather direct them to the truly correct address.  Would he be able to give me a run-down on what happened that made this such an emergency?

And so unfolded what was to be a twenty six hour marathon case.

On Thursday afternoon, after school, this nine year old, was feeling ill.  The Family Doctor's clinic was in the basement of the building in which they lived and the mother was comfortable in sending her down to wait on line for an appointment to see the doctor, she would follow soon.    One thing led to another, with seven other children to take care of, the mother did not start going downstairs until about a half an hour later, when she met her daughter walking up the steps.  Her behavior seemed a little odd; she was kind of skipping and singing to herself, no signs of the ear ache she had been complaining about. By dinner time, the young girl who we will call Malca, was talking about the doctor's appointment she had, and how Refael (let's say that this was the doctor's first name) was a great man, and liked her a lot too, more than anyone else.  The mother became very suspicious, what was this, her daughter speaking of a relative stranger using his first name, and a Doctor at that!  As night approached Malca was whispering to her sister that Refael had given her a gift.   The mother overheard this and questioned what this ‘gift' was.  He ‘put a ring on me'.  (You have to understand that in Hebrew that sentence can have two meanings.  Both utilize the word ‘tabaat'- ring, one can mean placing a ring such as a wedding ring, and the other, a ‘ring' usually internally placed by a specialist in female medicine.)  The mother looked at the girl's hand and saw no ring.

That is when the mother got really frightened.  She started to scream and cry, she called her husband to come home immediately as they had a major tragedy on their hands.  He came home and went to his Rav, and by three o'clock in the morning they had arrived at a plan.  They would send Malca to the local hospital to be ‘checked' (given an ultra-sound) by a female doctor to see if indeed any sign of a ‘ring' could be found.  This appointment was scheduled for 9 am.  At 8 o'clock in the morning, the doctor (Dr. Refael) arrived in his office without knowing anything about what was going on with Malca, or by now, the community of Rabbanim who were consulted. 

At about 8:30 a group of four or five, later Dr. Refael couldn't remember exactly how many, Haredi men appeared in his small office; they barged in past the waiting room, and began to beat him up!!  They were from ‘Mishmerret HaTznioot', literally the ‘watchers of modesty' and they were ‘punishing' him for his dastardly deed.  He had no idea what this was all about.  They accused him of denying it and hit him harder.  He dropped everything and ran out of the office.  He managed to put together some of the story and called the Rav of the community to beg for assistance in this terrible miscarriage of ‘justice'. The medical examination and ultra-sound revealed nothing was ‘in' the child.

It was close to Shabbat and all decided to wait until after Shabbat to continue. 

"So, you-(well really he spoke to me in the male plural form of grammar, for ‘modesty' sake)-have to help us", said the Rav.  By now it was close to eleven pm, Saturday night.   I called another Rav I know who works with troubled teen girls to meet with the father.  I wondered how a nine year old Haredi girl would think in terms that would be unfamiliar to many a Seminary girl.  I wondered if this ‘hyper-arousal' or ‘hyper-informativeness' could be a result of being exposed to an unhealthy environment at home.  Maybe Malca may have said ‘doctor' when possibly her father was being ‘untoward' to her. I felt that in a meeting with the person I sent them to, the father's relationship with his daughter would be assessed.  I gave them an appointment to come to the clinic (at the hospital) at 8:30 am.

By 7 a.m, I was told that the father seemed fine and very normally concerned with his daughter and this ‘situation'. 

The parents and Malca came on time.  I spoke to them for a short time together, and then told Malca that I understood she had an ear ache and saw the doctor, and then had another visit with another doctor on Friday.  I was a different sort of doctor and wouldn't be touching her at all, but rather we would draw pictures, speak and tell stories and work with blocks and other things.  She seemed relieved, and let her parents leave without as much as a goodbye. In light of her past three days I found that this, her being able to part with them so easily, was a little odd, to say the least.  I did my ‘thing' (psychological and neuropsychological assessments) and in the course of the three and a half hours began to get a more and more disturbing picture of this young girl.  The behavior I was seeing could be signs of some neurological disorder or (unfortunately more likely) fragmenting of her emotional state--a sign of psychosis.  Childhood psychosis is uncommon, but not rare.  As a last ditch effort to explain the behavior in neurological and not psychiatric terms, I spoke to the pediatric neurology department about doing an EEG - an electroencephalogram (EEG) which is a test to detect abnormalities in the electrical activity of the brain.  Maybe what I was seeing could be some form of epileptic seizure and not delusions.  By this time the father had gone home, and the mother had not come with enough cash or a ‘referral' to do this examination that would be covered by their medical insurance.  I was concerned that if they left, they wouldn't come back and that Malca's situation would deteriorate further without proper medical attention.  I took out my checkbook and paid for the EEG (the father later repaid me).

The neurologist looked at me after reading the EEG results, and said: "This is one for you, not me."

I set up an appointment with a child psychiatrist for the next morning,  if she confirmed the psychiatric diagnosis, would be able to begin treatment to stabilize Malca,  I sent them home and wrote up a report, it was now close to 7:30 pm on Sunday.  I called the Rav who had referred the case to me, by this time I had the parents' signatures on a confidentiality release, so that I could speak to him about their daughter.  He told me that they were getting a Beit Din together that evening to exonerate Dr. Refael.  

At close to midnight, I received a phone call, the Rav who interviewed the father was called to appear before the Beit Din to give his testimony, was there something I wanted to add, "Yeah", I said, "not only should they prepare a letter clearing the doctor's name, but they should also ‘slap' the proverbial hands of the Mishmeret HaTznioot, for taking the law into their own hands, or fists should I say!!"

"One more thing", I added, "Yes" he anxiously said, "why didn't they want to interview me?"  "Oh, Dr. G.", he said with exasperation, "when will you ever learn!!!??!!"

Tags: EEG | Electroencephalogram | Mishmerret HaTznioot | Psychosis