A dominating imaginary friend, cruelty to animals, social withdrawal, and growth deficiency in a 7-year-old girl with parents with schizophrenia.

Tessa is a 7-year-old girl with odd behaviors, worsening over the preceding year. She spends a significant amount of time alone in her room, talking to "Richard." Her father observed that Tessa is "in her own world." In school, she often glares at the teacher and refuses to work. She is alone at recess without any real friends. Her father reports that she eats little and only after he tastes the food. She is increasingly cruel to both real and toy animals. She tied a string around her cat's neck and swung it around, saying she wanted to punish it. She was heard to say to her stuffed cat, "Die, b ... .; die." Richard told her to do this and other "bad" things. Tessa has not had chronic health problems or developmental concerns. During the first 18 months of life, her height was between the 5th and 10th percentiles; it declined to below the 3rd percentile over the past 2 years. Weight has been consistently between the 3rd and 5th percentiles. Tessa's parents both have been diagnosed with schizophrenia. There are at least 7 first- and second-degree relatives with the same diagnosis. Both parents cared for Tessa for 4 years with a lot of support. Then, her father left the home, but he was in contact with her while managing his own illness. When the mother's illness and compliance worsened, Tessa was removed for neglect at 5 (1/2) years old. Two foster homes preceded Dad's award of sole custody 13 months ago. Mother's weekly visitations are quite upsetting to Tessa. Tessa is a verbal, solemn, small, well-dressed girl with no physical abnormalities. She talks with advanced vocabulary and syntax, with normal prosody and good conversational skills. She says Richard is a bad boy who gets her into trouble at school. She equivocates when asked if he is real or imagined or if others can see him. She says that she misses her mother.