Jemma is a 15-year-old girl who lives at home with her mother. Her mother has asked for her to be seen at the child and adolescent mental health service. She states that Jemma has suffered bulimia nervosa for six months, starving herself in the early part of each day and bingeing in the evenings followed by vomiting. Her weight is within the normal range. Upon assessment the following information is elicited:
Jemma started a physical fight at the weekend with another girl after a dispute about a boyfriend. This occurred after she had been to a nightclub where she had been drinking. Neither of the girls was hurt during the fight. Jemma has not been involved in fighting before or since.

Jemma’s schoolwork has deteriorated recently. Her teachers complain about her attitude in class. She appears bored and last week one of her teachers noted that she appeared to be restless and not paying attention. On two occasions, in the last fortnight, Jemma has superficially scratched her legs with a pin drawing blood. There has been no evidence to suggest that she is at risk from more serious self-harm.

At weekends Jemma has been going to a nightclub where she drinks approximately 12 standard drinks. Her friends often take speed when they go to a nightclub. Jemma has tried it a few times but hasn’t taken any in the last two weeks. She had been drinking on the night when she was involved in the fight.

Jemma attends a private girl’s school and was expected to pass with good marks. She used to go to school reliably. Over the past six months she had started playing truant. Her work has deteriorated recently and teachers complain about her attitude. She occasionally misses school and goes to town with her friends. She has however been to school everyday in the past month.

Jemma has never suffered from any problems associated with hallucinations or delusions. Jemma complains of headaches, which occur mainly in the afternoons. She struggles getting to sleep at night. She often lays awake worrying about how she can lose weight. Jemma has felt low in mood for about the last six months. She believes that she is fat and ugly. She is becoming increasingly more anxious about eating and dieting and is preoccupied with fears about losing control of her weight.

Jemma socialises little with her old school friends preferring the company of aquaintances five years older. At weekend she regularly goes out with her older friends. Jemma has felt low recently but she does take care of herself and is very concerned about her appearance. She is organised and can take responsibility for herself.

Jemma’s father drinks heavily. He has had an affair recently and her parents are undergoing a trial separation. Jemma lives with her mother and is very angry with both her parents and says she can’t wait to leave home as soon as possible. Jemma’s mother is very distressed by Jemma’s behaviour and doesn’t know “what to do with the girl”. Jemma’s father says, “no one tells me anything”.

Adapted from NSW Mental Health Outcomes and Assessment training for Children and Adolescents (MH-OATCA) Facilitator's Manual, NSW Health Dept 2002

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