A CHRONICLE OF SECLUSION AND RESTRAINT IN AN INTERMEDIATE-TERM CARE FACILITY

Adolescent Psychiatry, 2003 by Petti, Theodore A, Somers, John, Sims, Linda

The following case represents a significant, small percentage of patients referred to our service. Chantelle was a large-for-her-age 15-year-old African American female when she was court-committed to Youth Service. During her 16-month residence in a for-profit hospital, her violence and aggression resulted in the hospitalizations of several staff members and peers. Her presenting symptoms included explosive, violent, and self-injurious behaviors. She had been hospitalized at the age of 13 for aggressive behavior, and two times thereafter. Her history was significant for suicidal ideation, homicidal threats, acute anxiety attacks, dissociative episodes, flashbacks, memory lapses, and trauma induced by sexual and physical abuse. Behavior problems of temper outbursts and stubbornness dated to the age of two. At the time of admission to LCH, she was on thiothixene 15 mg three times per day and albuterol as needed for asthma. Shortly after admission, she attacked and severely injured a nurse and assaulted a peer, who was not so badly injured. No psychotic symptoms were present, nor did she show remorse at the time of either attack. Her admission Axis I diagnoses were conduct disorder, mixed type, severe, and a number of rule-outs for depressive and anxiety disorders. She received an Axis II diagnosis of borderline personality disorder.

Chantelle came from a chaotic home situation. Her family of origin was very violent, abusive, and dysfunctional. Both parents had served prison time for violent acts. Removed from her mother's care as a baby because of the mother's physical abuse of Chantelle and her siblings, she lived with relatives for several years before returning to reside with mother in preadolescence. Following this, she reported being sexually abused by her mother, her mother's lesbian lover, and, at the age of 13, by her uncles. The family denied this and reported that they were afraid of Chantelle because she had threatened to kill them and had lied about them. During Chantelle's hospitalization on Youth Service, her mother was very inconsistent in her visits and phone contacts, which created a significant Stressor for Chantelle and often served as a trigger for aggressive behavior.

Upon admission, Chantelle was evaluated on a number of measures. Her projective assessment showed significant deficits in connecting cause and effect, attaching to others, engaging in empathy or understanding the perspective of others, and coping with intense emotions. Her thinking was contaminated by strong interfering emotions that prevented her from processing reality accurately, although she showed no psychotic symptoms. She viewed her external environment as being restrictive and dangerous; she appeared to be evasive and defensive and gave up quickly on challenging tasks. Her resources to cope with emotions were impoverished and her thinking rather concrete in nature. On communication assessment, she showed significant verbal language deficits in both receptive and expressive domains. Such deficits compromised her ability to process emotions and express them in a socially acceptable manner. It was also noted that she had difficulty retrieving information efficiently and in a timely manner, which made her school experience problematic and challenging. Chantelle was enrolled in intensive language therapy to address these deficits as well as a number of other communication issues.