For obvious reasons I can’t give too many specifics, and I’ve changed some minor details so patients can’t be identified. But I need to get some of this off my chest. Medical school doesn’t prepare you for the things you will see in real life.

Case 1: Miranda was a 5 year 4 month old Caucasian female with no prior psychiatric history. I was working hospital consults at the time. She was admitted to the peds floor earlier in the week for seizure-like activity, and I was consulted by her primary team for evaluation of “odd behavior.” You never know what you’ll be walking in to with a vague consult like that, and usually I’ll try to get more details, but the resident requesting the consult had a tone in his voice of restrained terror and urgency, so I decided to just come see for myself.

Miranda was small for her age, thin and waif-like with pale milky white skin and long dark hair. When I entered the room she was lying in bed watching cartoons, a blank expression on her face. Mom was in the corner in a chair, knees pulled up to her chest, a vacant stare on her face. When she noticed me she jumped up and swiftly walked over. “Please don’t make any loud sounds doctor, she doesn’t like that,” she said in a small voice. I introduced myself and started to take a history. Miranda had reportedly been a normal, chatty little girl until 2 weeks ago, after she came home from visiting her father in another state. Mom noticed right away she was acting differently. She was quiet, talked very little and never smiled. When she called the father to ask if anything happened he said nothing out of the norm. The night before hospital admission mom said she walked into the kitchen to get a glass of water around 2am, flipped on the light, and Miranda was just standing there facing the refrigerator. Mom screamed because she wasn’t expecting to see anyone there, and Miranda turned her head sharply toward her and said in a deep voice, “BE QUIET.” She then went back to staring at the fridge. Mom was speechless. After a moment she walked up to Miranda and gently guided her back to her bedroom. She thought maybe she was sleep walking. Mom told me, “I’ve never heard that voice come out of her before. It didn’t sound anything like my daughter. It was deep, almost like a grown man trying to sound like a little girl.”

The next night mom couldn’t sleep. She kept hearing the voice echoing in her head. She decided to get up and check to see if Miranda was in bed. Her door was open and by the sliver of light from the hall she could see a body on the floor. Alarmed, she flipped on the light and shrieked, as she saw Miranda on the floor, her back completely arched, her face upside down, contorted and frozen and if she were caught mid-scream, though she was silent. Then the voice came again, deep and masculine, “BE QUIET YOU WHORE.”

Mom was tearful and shaking as she recounted the story. She had no idea where Miranda could have heard that language, and she had never said anything like it before. She was usually a polite and happy child. Mom had gathered her up and taken her directly to the emergency room after this incident. They admitted her for long term EEG monitoring to assess for seizures, but so far everything was normal. If you’ve never experienced EEG monitoring, it’s basically where they attach a bunch of electrodes to your head, monitor you on 24 hour video feed and try to capture a seizure. Apparently this process had not been going well.

The resident showed me a few clips from the week. It usually happened around 2 or 3am. Miranda would get up from bed, lie on the floor and arch her back. The nurse would come in and try to get her back into bed. If anything loud happened the child would scream in an unearthly deep voice, curse, and call the nurse unpleasant names including “whore, beast, and cunt.” It was unnerving to hear this adorable little child say such vile things… and that voice. The testing showed she was not having a seizure during the episodes. Her vital signs were all stable and so far all the lab work was normal.

I spoke to Miranda for a while. She was soft spoken, and answered my questions in a flat, unemotional tone. Her eyes were vacant, like looking into the eyes of a veteran in the middle of a PTSD flashback. The eyes looked at you, but seemed to be seeing beyond you, through you, to somewhere else. I decided to try an experiment. As we talked I slowly dialed up the volume on the TV. Once it started getting louder than normal speaking volume, Miranda stopped midsentence and stared me right in the eyes. I froze. I’ve seen a lot of shit in my line of work. I’ve seen people in violent psychotic episodes, people smearing their feces on the walls, people cutting themselves, spitting, screaming, punching… You name it. But something about the way she looked at me scared the shit out of me. I turned the volume back down. She looked away and finished answering the question.

I felt bad for the mom. It was like one day she had a sweet, normal daughter and the next day… It was very unusual. I didn’t know what was wrong or how to help. I recommended therapy. I never saw them again, but I think about her often.

Edit: just to clarify, abuse and/or trauma was high on the differential in this case, but there was nothing we could find while she was inpatient. CPS was involved but I don’t know if they ever found anything either. Hopefully if something did happen it came out in the course of therapy. I’m still friends with the psychologist I referred her to… I’ll email her and see if I can get an update.

(part 2)

For those of you who read the first post, I have an update on Miranda. Unfortunately it’s not very happy. She saw my therapist friend for a few months after she left the hospital, but they didn’t make much progress. The abuse allegations were never substantiated, and her behavior continued to deteriorate (yelling obscenities at mom, having non-epileptic seizures) until finally she actually stopped talking altogether. The last time they saw the therapist their plan was to follow up at Mayo clinic for further evaluation. My friend never saw or heard from them after that. If we want to be optimistic, maybe Mayo figured out how to help her and that’s why she never returned to therapy…?

I wanted to say thanks everyone for the positive response to my first post. I feel encouraged to share more, so hopefully you’ll find this interesting too. Again names and details have been changed for anonymity.

Case 2: I first saw Jason when he was 6 years old. He came from an amazing home, from what I could tell. Mom was a teacher and dad an engineer. They seemed kind and loving, and had already raised 2 polite, well adjusted kids. Then they had Jason. I see a lot of kids with aggression. Usually it is impulsive, in the moment, emotional dysregulation leading to violent acting out of some sort. Not so with Jason. He was, for lack of a better term, calculating. For example, this is the incident that lead the parents to seek professional help… On a Thursday afternoon his 3 y/o sister, Amy, grabbed one of the toys he was playing with and refused to give it back. Well, he didn’t react at the time. He waited until that Saturday to exact revenge, as it was the first opportunity he was alone with his sister unsupervised. They were in the front yard playing when mom ran inside to grab her phone. She was only gone about 30 seconds, but when she came back Amy was unconscious in the driveway, bleeding from a wound in her head, Jason standing over her with a tricycle in his hands. He had smashed her over the head, with a tricycle. On the way to the emergency room mom frantically asked him why he had done this. He very calmly and matter-of-factly replied, “She took my Batman when we were at Nana’s. Batman is mine.”

Now, I get parents in my office all day long who tell me how bad their kid is, how he was just born to be oppositional and destructive despite all their wonderful parenting. 99 times out of 100 that is weapons grade bullshit. Without realizing it of course, the parents or teachers are doing something to reinforce the kid’s behavior, or we find out there has been abuse, or neglect, or an underlying medical issue, etc. There is almost always a reason the kid is “bad.” Jason was the first child I ever treated who I thought was actually just born that way. He was born entirely without the capacity for empathy. That scares me, because it means you can do absolutely everything right as a parent, and still end up with a future serial killer for a child. You may think I’m being dramatic, but let me tell you a bit more about Jason.

When he was 5 years old he spent the weekend at grandma’s house. She was your typical sweet little old lady, weighing in at about 95 pounds. She baked a batch of sugar free cookies for the weekend with her grandson, and planned some wholesome activities like puzzles and coloring. The first day went pretty well, until Jason tasted one of the cookies she made after dinner. He spit it out onto the floor, looked grandma intensely in the eyes, and said, “I’m going to cut your face off.”

She was quite shaken by this, and put him to bed early in the guest room. That night at 3:30 AM, grandma suddenly awoke to the sound of breathing close to her ear. When she opened her eyes Jason was kneeling beside her in bed, watching her sleep, a blank expression on his face. Startled and disoriented, she tried to get up quickly and tumbled onto the floor. She realized she couldn’t stand up, so she called out to Jason to go grab the phone. She looked up helplessly as he peered down at her from atop the bed. He didn’t say a word, and didn’t go for help, even as she started to cry and beg. After a few minutes of watching her, he stood up and walked out of the room, closing the door behind him. Grandma lay there in pain for the rest of the night and half of the following day. Finally Jason’s mom came by the house to check on him around noon. She walked in to find Jason sitting in front of the TV with a bowl of cereal. She could hear whimpering coming from the bedroom. Grandma was taken to the ER with a broken hip. When asked why he didn’t get the phone for grandma, he answered, “I don’t like her. Her cookies taste like sand.” Jason was not invited back for another sleepover.

There are more examples of disturbing things Jason did, but they all involve animals and to be honest, I can’t stomach thinking about it, let alone retelling it. Suffice it to say several lizards, numerous insects, 1 hamster and 1 cat met a very unpleasant demise at the hands of Jason. And that’s just the ones we know about. He has been in intensive therapy for the past 5 years, but it has not seemed to make a difference. If anything, I’m afraid it may be making him even more dangerous. He is very intelligent, and he’s learning to feign the normal human reactions and emotions he is supposed to have. He is getting better at hiding the parts of himself that make other people uneasy. He’s becoming a very charming little sociopath. Even his mom thinks he’s getting better and outgrowing his old habits. But he still confides in me that deep down he feels nothing. Watching another human or animal suffer is fascinating to him, and it’s the only thing that gives him a small thrill while the rest of life is utterly numb and boring. He tells me he has stopped killing animals, but I don’t believe it for a second. I try to have hope for all of my patients, but deep down I truly think he will move on to killing humans some day. And absolutely no one will see it coming. I guess, except me.

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