After a challenging month in the Pediatric Intensive Care Unit with five deaths, multiple skull fractures, suicide attempts, and non-accidental traumas (the new politically correct term for child abuse), I am taking my own mental holiday on the psych ward. My Child Psychiatry rotation has been a welcome change this week, and I have already seen plenty of things to reflect upon.

One of the difficulties of Child Psych is recognizing what is truly pathological behavior versus normal adolescent behavior, pushing boundaries, experimenting with new personae, and experiencing mood swings. I can't help thinking about some of the people I knew growing up who were just as dramatic and rebellious as some of my patients and never ended up in a psych ward...Maybe they should have??

One girl is a 13-year-old drama queen who has been in a downward spiral since her tragic breakup last December. "He fell in love with me, and then I fell in love with him, but he broke up with me because his friends didn't like me." Subsequently, she has found a new boyfriend through various online chat rooms who lives in a neighboring state. "It's kind of like eHarmony, but not really. Because eHarmony is cheesy." Although they have never met in person, they talk on the phone and email, providing the basis for a deep interpersonal connection. Because of her mother's intrusiveness and limit-setting in regards to cell phone texting with her "boyfriend," she ran away from home, biking 15 miles to a friend's house in the rain on a dark country road in the middle of the night. So, now she is with us in the psych unit while we sort out her family issues.

I'm surprised at how functional some of our patients seem to be, but their biggest problems seem to revolve around the "chores" they are required to do at home. Granted, after meeting their parents/step-parents/foster parents, I can see why there are some problems at home. I mean, I would be confused, too, if I lived with my mother, her ex-husband (not my biological father), and her current husband, with kids from each in the same household. Who's the boss in a situation like that?

Of course there are some other kids who are much sicker. One poor 11-year-old girl is admitted for disturbing recurrent fantasies about a place called Wonderland where there are only kids and no parents. In order to obtain access to this place, you have to kill your parents by shooting them dead through the heart.

There is another 13-year-old girl who is truly psychotic, most likely schizophrenic, who was admitted for severe hallucinations shortly after finding her father following his overdose attempt. She sees, hears, feels, and even smells people...rotting dead flesh, people trying to rape her and watch her in the shower, collaborating with the nurses to make her look stupid. It is so sad to see her struggling with these delusions, literally swatting away these imaginary people around her all the time. We have to be on guard with this particular situation, since the voices have previously made her stab her mother and can be quite persuasive in bringing on violent behavior.

Then there is a highly intelligent 15-year-old boy admitted for something called reflex sympathetic dystrophy. He basically had a previously bacterial infection in his leg and now has post-traumatic stress disorder where he experiences intolerable leg pain all of the time with no organic basis. In essence, the pain is all in his mind, but he goes absolutely ballistic when anyone touches his leg. He has been hospitalized 15 times in the past year with no improvement. So, now he is in our unit. He screams like an animal, refusing to walk, writhing around on the floor, freaking out the other patients, but we have to respond "neutrally," meaning essentially not responding. We walk around him as if nothing is happening, encourage him to participate in the group meetings if he can physically get there, without acknowledging his outbursts, which can last for hours at a time. It is a very interesting environment, to say the least.

I absolutely love seeing how the psychiatrists, social workers, and psychiatric nurses interact and communicate with the patients and with each other. I have to smile every time a difficult patient angrily asks if they can call their mother, have computer time, etc., and my consultant calmly responds, "No, but thank you for asking." End of conversation. It works like a charm! I'm hoping to pick up some of their skills this month.