The brain truly is a fascinating thing. Every single thing that happens in our lives, no matter how big or small, has an effect on us in some way. We might not even know that we are being affected by something, but we are. They amount of times we are told we are loved by our parents. The way a teacher looks at us with encouragement or disappointment. The way a coach tells you good job or makes you sit the bench when you’ve struck out twice in one game. The way something smells. The way something tastes. Music that was sung to you as a child or you heard in your car this morning on your way to work. The food you ate for breakfast or the food you never had as a child. Your bedtime routine. Someone’s smile. A tone in someone’s voice.
Every single thing. Every single day. Has an impact, no matter how minute, on your brain.
As a child, these things impact your brain at an even more exponential level. As an infant, these impacts set up your entire life; develop your entire brain. If you’re experiencing trauma and neglect as an infant or child, your brain development changes, laying the foundation for your life, whether you like it or not. And sometimes this can’t be completely changed.
It’s also unfortunate that so many people do not realize this. Then we wonder why these kids have so many struggles. In a future post, we will talk about trauma informed care so that everyone will have a better idea on how to address these kids and have a better understanding of life in general. These are things they need to be teaching kids in schools! Coping skills, loving each other, learning how to treat everyone kindly because you never know what someone is going through or has gone through.
This girl, we’ll call her Madison, was only eleven years old. There are a lot of reasons as to why someone develops a mental illness: genetics and environment, but it’s not an exact science. Not yet. You can’t diagnosis borderline personality disorder in a child, but as providers, we know when it’s there. Even though only eleven, Madison was borderline.
Everyone knows someone with borderline personality disorder, even if you don’t know it. They often have unpredictable and quickly changing moods, fear of abandonment, anxiety, poor self-image, self-harming behaviors, poor relationships, and impulsive behavior.
This was Madison. All day. Every day.
Many providers have a hard time working with personality disorders, especially borderline. It’s hard and exhausting and it often becomes like a broken record that continues to play even once it’s thrown out. People with borderline personality disorder will take whatever you say and turn it into something else. Everything is about them and what they need and they’ll do whatever they need to do to obtain that desired attention. It often comes from trauma which in children can lead to a desperation to feel loved and wanted. Often it leads to behaviors like this and no matter how dangerous they are to themselves, if they’re getting the attention that they so desperately want, they’ll do it.
When you break it down, it makes sense. Madison was sexually abused her entire childhood, by her brother, her grandpa, and her own father. When she was removed from her father’s care at the age of seven, she was raped by a foster brother. At ten, she was physically abused by another foster mother. Shortly after this, she was placed into residential ultimately because she started running away. I know we’ve already talked about this, but who wouldn’t want to run away from that?!
From day one, her mother left her with her dad who ruined her life. She had never known love or safety. She had never known what it was like to feel cared for or to go to sleep without having to worry about being raped. She never knew a life without fear.
When she came to residential, she was so far gone that most of the staff members were burnt out after only working with her for one day. She was in restraints nearly every day for hurting herself in some way. She was always arguing with someone then begging for forgiveness. She would hit you then cry and apologize and then laugh about it a few minutes later. Her mood was never stable and no matter what medications we tried, nothing seemed to get her out of her depression. She needed intensive therapy. Talk therapy, DBT, EMDR, CBT. Something that would rewire her brain to learn to trust again and to accept safety.
When you’ve never known what it feels like to be safe, your mind goes into freak out mode when safety finally presents itself. I’ve seen it happen so often working in residential. We would have kids from such horrible situations come to us and go into an even worse crisis. They did not know how to react when someone was trying to care for them. They didn’t understand what it was like to have a warm bed to sleep in that was theirs or three meals a day. Their minds had no idea what to do when someone told them that they had nothing to worry about at night because they were safe.
I remember working a second shift one night and it was a night from hell. I usually got off of work around ten at night, but it was well after midnight. I was on call that night anyway and figured I might as well stay and get everything done because if not, I’d be the one getting the phone calls! I headed over to this girl’s unit and I honestly can’t remember what for. But as I was walking back to the medication room on the unit, I saw multiple staff standing in Madison’s doorway. I walked over to see why and they were all concerned because she was sleeping on the floor. She had moved her mattress off the bed and put it on the floor, leaning against the wall at an angle. It was just enough to leave a tiny space between it and the wall and that was where Madison was sleeping in the corner of the room.
It wasn’t the first time I had seen this, either. When kids are abused at home, especially sexually abused, they hide. I’ve seen kids sleep in the cabinets where their clothes go, curled up in the corner of the room under blankets, under a pile of clothes. Anywhere where they felt that they couldn’t be seen; that they were harder to get to.
My heart broke for her. She looked so small sleeping under that mattress. We covered her up with a blanket and let her sleep. It was something that she was going to have to work through in counseling. It wasn’t something that would be fixed overnight and there was no way she would have complied if we would have waken her up and asked her to sleep on the bed.
Madison woke up mad every morning. She often refused to get out of her room. She refused to do her hygiene. She refused her meds. I remember more than once that she threw her meds at me and dumped her cup of water on my shoes. She always thought that people were out to hurt her and that everyone had bad intentions. She wanted friends but she wouldn’t let herself talk to people or trust the words anyone was saying to her.
She was also a really good liar. She could go off on these crazy stories like no one I had ever met before. She was really good at saying whatever someone else wanted to hear. It all goes back to her borderline behavior. Her mind was in constant chaos and I can’t even fathom trying to live a day to day life fighting such a battle in your own mind.
I like to think that every single patient I take care of comes out on the other side of treatment completely cured and able to live a normal life. I want everyone to overcome every obstacle they’ve ever had placed in front of them. I want happiness for every single person no matter where they’re at or what they’ve done. I want success for my patients.
I hate to say the harsh reality, but no matter how hard we try and no matter how much effort we put in, somethings you can’t fix. Every brain can’t be rewired. Every patient can’t be saved.
I’ll forever try to push that thought into the back of my mind and I hate to think about it. I like to think that all of the work we put into this girls’ care was life changing and she was going to be perfect. I know deep down this would probably never be the case.
At residential, there was room beside the nursing office that we always called the apartment. When a kid was in a crisis or having trouble with getting along with other kids on the unit, we would have them stay in the apartment for a few days until they were able to be stabilized a little better.
Madison had been in multiple restraints day after day after day and ended up in the apartment. We needed to give her a break from the other kids on the unit and she needed to be able to be closely monitored.
In the few months before she was placed in the apartment, she had been placing every object you can think of in her vagina and anus, as well as swallowing all sorts of batteries and plastic. She had placed marker caps, paperclips, pencil lead, paper, and who knows what else in these areas and had to be sent to the emergency room for surgical removal multiple times. So unfortunately, being in the apartment alone with a staff member was all that she could do. No crayons. No books. No radio. No toys. Nothing. For her own safety, she couldn’t have access to anything.
I felt sorry for her. I couldn’t imagine being stuck in a room for days with nothing but your own thoughts, which in her case, were never under control.
Multiple days went by where she was actually doing well in the apartment. She was talking with her clinician and doing everything that was asked of her. We were all so proud, but waiting for the storm. After she agreed to be safe, they decided that she could go back to her unit with the other kids. She was excited about this and I was too, because she needed something to do other than sit around!
Unfortunately, on the way back to her unit, she took off running and grabbed a sharp rock that was outside. She immediately dug it into her side creating a large wound in her lower right abdomen. She started laughing and then swallowed the rock. She had to have stitches put in and I knew that this was going to be a battle we wouldn’t be able to win.
She pulled her stitches out three times. After the third time, she did not get them replaced again. We covered the wound with gauze multiple times a day only for her to take it off a few minutes later. She had it so infected that she was on antibiotics for weeks with little improvement because she would not leave it alone.
One evening when I went to assess the wound and cover it for the millionth time, I was blown away by what I had seen. She had dug the wound so deep that it was like a pocket. She was able to stick three of her fingers it in, all the way up to the third knuckle. It was draining with green pus and she had a high fever. It had been way too long with no improvement that I knew she needed to go somewhere else for treatment. This infection was getting systemic and if it wasn’t treated, who knows what would have happened. She refused to keep her fingers out of the wound and I finally made the choice to have her restrained and taken to the hospital. It took multiple staff to restrain her and to keep her from putting her fingers in the wound. She was able to get out of the restraint and pushed through the door to the outside.
Madison put a handful of rocks into the wound. Probably ten small-sized rocks. She was restrained again and brought up to the nursing office as we waited for the squad to arrive. She was screaming and cussing at me, saying that the rocks were hurting her. I grabbed a pair of gloves and some tweezers and started pulling rocks out of her side. I had never seen anything like that before.
She cried and yelled when they put her on the stretcher and had to restrain her on it. It was hard for me to watch. She was so small. She was hurting. Watching them put her in the ambulance as she continued to cuss me out was heartbreaking.
She never came back after that night. She was admitted there and was placed on IV antibiotics. She was so unsafe that the residential facility was unable to take her back because we couldn’t keep her safe.
When I first started as a nurse, I spent a lot of time second guessing my decisions. I often found myself asking if I could have done something different? Was that the best option? Did I hinder the patients care in anyway? I spent a lot of time that following week wondering if I did the right thing that night by having her squaded to the ER for further treatment. We didn’t have the access to do IV’s in residential. It wasn’t a safe environment to maintain such. And I knew that was what she needed. But would I have ever had a breakthrough with her? If I wouldn’t have sent her in the squad and had our doctor in residential just prescribe more oral antibiotics, would the time I had spent with her made a difference? Would I have had the time to say something that would change her thought process? Help her to live a brighter life?
I’ll never know the answer to those questions, but I do know now that medically, I made the right choice. She needed more medical care than we were able to offer her. She had to be medically stable before we could focus on the mental health concerns because while treating the infection would take a few days, treating the mental health disorders would take years.
I always hoped that she would one day realize that it was okay to let someone take care of her and to feel safe. I wonder if she’ll ever life a normal life. I won’t let myself believe otherwise.