professionals less respect for "low"-functioning p

Post Reply New Topic

Becoming A Doctor: A Journey of Initiation in Medical School, Melvin Konner, M.D., United States: Penguin Books, 1987, pages 191-92:

' . . . The following morning I attended a clinic in pediatric neurology and saw a patient for whom there was no parental anxiety because there were no parents. He was a twenty-four-year-old “boy” brought to the clinic by an attendant from the state residential school for the severely disturbed and mentally ret*d, for a regularly scheduled appointment with his neurologist. The original diagnosis in the chart, “childhood schizophrenia,” had been made at a time when this diagnosis had been popular and was considered meaningful--the time when, as a high school student, I had been working with similar children. His diagnosis was more properly something like autism combined with broad-spectrum retardation. Oddly, he had always been exceptionally good at arithmetic calculations. At the age of seventeen he had begun to assault people. Nevertheless, his mother continued to keep him at home with her for another five years until she was finally forced to give him up to the state school. He had lived there for two years.

‘Petey was a well-formed, slow-moving, small but slightly overweight boyish man with restless brown eyes. He had difficulty initiating movements. His neurologist, Dr. Silverman, wanted to show me Petey’s calculating ability, and I encouraged this. There were always conflicts for me between the need to learn and the injunction to protect the patient from unnecessary indignities, but in this case it seemed all right from Petey’s viewpoint to get him to show off the one thing he could really do well.

'So Dr. Silverman gave him a three-digit number which he easily and quickly squared in his head. On the second and third numbers, however--all were of comparable difficulty--he was wrong, and he knew it without being told. He looked frustrated. On the fourth number he thought for five or ten seconds, mumbling to himself. Then he looked up, jumped out of the chair, and attacked Dr. Silverman.

'Amid Petey's flying fists, three of us--the attendant from the state school, Dr. Silverman, and I--managed to get him under control and pinned down on the couch. There, held down gently by the attendant, he began to talk to himself aloud, with an edge of anger, referring to himself in the second or third person: "He's a big man now. Petey's not a baby. O.K. Time out. You're not a baby. Take it easy. Yes. O.K. You're a big man now. Take it easy." This touching discourse had obviously been absorbed from all the stock phrases used by his mother and his caretakers in the past. At length he settled down and had his examination. No changes were seen since his last visit six months before, so no changes were made in his medication. As I saw him and the attendant to the door, Petey was as calm as he had been when he came in. The attendant, a strong young man, was trembling. He said. "This was my first time taking a patient out by myself."

'"You did well," I said, and thought, all of us are learning. . . '

Becoming A Doctor: A Journey of Initiation in Medical School, Melvin Konner, M.D., United States: Penguin Books, 1987, pages 193-94:

'Cindy, thirteen, was brought in by anxious middle-class parents who insisted that she had no attention problem except when dealing with subjects that did not interest her. This seemed to me a valid challenge until Dr. Silverman patiently explained that by definition, "Attention deficit is a lack of capacity to pay attention to something that doesn't turn you on." It suddenly occurred to me that I might have it. I certainly varied widely in my ability to pay attention in medical school lectures, depending on how interested I was in the subject. But of course, I wouldn't have got this far unless I had managed to attend to a great number of things I didn't care for much. Cindy was much more restricted. She could pay attention to almost anything about horses. But could this get her through school and through a modern American life? Of course Dr. Silverman could have recommended that she plan her future around horses, but this obvious solution did not appeal to her or to her parents. She got a trial of Ritalin, the standard therapy, and an instruction to come back in two weeks.

'The second girl was an extremely charming and pretty ten-year-old with a much subtler attention deficit. A year earlier she had been failing in school, and her attention problem had shown up on the test battery. Ritalin had greatly improved her concentration and her school performance. At the beginning, after it had begun to succeed, she had had a two-week trial with a placebo, and her parents and teacher all agreed that her problem had reemerged during the trial. Reinstituting the drug eliminated the problem again. She was back for her first six-month reevaluation. Now she would have another such "off-trial," to be repeated every six months until the problem might be (as it often was) outgrown.

'I entertained doubts about these children. They were not obviously "bouncing off the walls." They had subtle problems that many people, including many experts, would interpret in psychological terms. But the drugs in use for this purpose had been shown to be effective, though the long-term gains were more controversial. There did not seem to be any highly undesirable side effects. And Dr. Silverman at least was using them in a responsible way, testing them regularly for continued effectiveness and using them only in children who showed themselves on the test battery to have a particular problem with attention. Still, I wondered whether it would really be so terrible if Cindy were somehow to try to make a life for herself with horses. . . '

Now, this is more like it.

And maybe Petey could be treated in a similarly respectful manner as Cindy. For example, maybe university math students on work-study could be hired to be his caretakers some of the time. And why not?

The students might find interesting aspects in his calculating ability and/or Petey might find interesting things in what they are doing. Somewhere I read, at least in some cases, that a person starts to lose some of a specialized ability as he or she branches out, begins to enter or re-enter the world, and learns more generalized skills. And the upside is that this transitionary period can potentially be very productive. The famous mathematician Paul Erdos is probably an example of a person on the spectrum who found ways to be communicative enough. And we don’t need to lay this on Petey as yet another obligation, but it’s nice to keep the door open and let him develop in ways and directions he wishes to develop in. Give him a variety of opportunities and see which ones he rolls with.

I don't disagree with what you said about Petey, I do disagree with the quote you selected being used as a "good" example, though.

I was (I believe incorrectly) diagnosed with ADHD when I was 5, and was put on ritilin for almost 10 years. It made me feel not-myself, gave me a stigma about myself that I still have (even though I've always been odd, being told "there is something wrong with you, and you need medication to be normal" and still not being normal afterwards is traumatizing for a child) and it does have many major side-effects, such as appetite suppression and growth delay. All these children need is someone willing to *work with them* and work toward their strengths!

If all she liked was horses, work that into her studies "If I have one horse, and you give me another horse, how many will I have?" "this type of horse comes from this part of the world, which is also where --- is" etc.

ADD/ADHD is so ridiculously over-diagnosed these days, when it's really prolly not that common (I'm not saying it doesn't potentially exist, but it certainly isn't half or two thirds of the population, whatever the dx rate is these days), and the vast majority of children don't need medication, they need BETTER PARENTS AND TEACHERS. H*ll, every child needs good parents and teachers or the lot of them will end up with issues. It sounds to me like Cindy had pretty not-awesome parents, since they didn't want to encourage their child to pursue what she was interested in, and that's the whole problem.

Of course the drugs "work", you give the same medications to a completely normal college student, they will have *THE SAME REACTION* (increased focus, decreased potential for outburst)

Sorry, that just struck closer to home then I like.. I used to get punished all the time when I was on ritilan because I couldn't eat more then a bite or two, at best, until the meds wore off (11 PM, LONG after they were necessary for the "intended purpose") not to mention being punished for being so bored with school's pace that I just didn't want to pay attention. There were far, far more interesting things I could have been learning about (and let's face it, the fact that I always had a book WAY above my expected reading level -college-level reading and comprehension, any subject that I sort of understood, in 4th grade, would look up words and ask questions when I found something I didn't understand- pretty much derailed the whole "can't pay attention" thing...)

[Edit] -I understand his viewpoint being a "more positive" reaction, I should have mentioned, but the whole deal just stinks.

. . . All these children need is someone willing to *work with them* and work toward their strengths! . .

. . . She told me I hadn't read it - until she grilled me. Then, since this was a fairly recent and obscure textbook I'd obviously never seen before, she called up my mother to tell her the problem was that I was bored to death. That teacher had the sense to see it. The principal that year had the sense to, as well. . .

Such a common sense approach. And yet my guess is that only about 1 out of 5 teachers or principals would do so. (the others more concerned with 'orderly,' 'fitting in,' going through the motions, etc)

I'm pretty sharp academically, and you guys might be even smarter than I am. And that's fine. I welcome that.

Okay, we moved when I was in 2nd, 3rd, and 5th grade. Several times I made friends with older kids, but . . . but, they didn't fully accept me, more like I was a mascot and a settle-for.

At times, I was a leader with kids my own age, organizing these great tag games in this tall grass, taking a snake bite kit when we went hiking in the woods.

I wish we could communicate to advanced and bright kids, the idea that people have a lot to contribute and are smart in a lot of different ways kind of like multi-dimensional hyperspace. Or that it's valuable to make this betting play. For example, the last couple of years with my writing, I try and assume my readers are slightly smarter than I am, they simply don't happen to know this particular subject. And I feel this has made a big difference.

ADD/ADHD is so ridiculously over-diagnosed these days, when it's really prolly not that common (I'm not saying it doesn't potentially exist, but it certainly isn't half or two thirds of the population, whatever the dx rate is these days), and the vast majority of children don't need medication, they need BETTER PARENTS AND TEACHERS. H*ll, every child needs good parents and teachers or the lot of them will end up with issues. It sounds to me like Cindy had pretty not-awesome parents, since they didn't want to encourage their child to pursue what she was interested in, and that's the whole problem.

Of course the drugs "work", you give the same medications to a completely normal college student, they will have *THE SAME REACTION* (increased focus, decreased potential for outburst)

Such a common sense approach. And yet my guess is that only about 1 out of 5 teachers or principals would do so. (the others more concerned with 'orderly,' 'fitting in,' going through the motions, etc)

Sometimes the lack of a label is as harmful as the worst interpretation of a label. If you're not told you've got ADHD or whatever, and blamed for all that disorganization and distraction--told you're rebellious, lazy, stupid--well, that's way worse than being told you have ADHD. It implies that you're willfully doing that stuff, that it's a moral failing that you've just got to overcome by trying harder. So you try harder until you burn out, and you hate yourself. I'd rather be labeled any day.

ADHD is not overdiagnosed. All evidence currently suggests that it is underdiagnosed in children and adults. There are some areas where it appears to be overdiagnosed, but as an overall trend it's not. That doesn't mean it's never misdiagnosed, but it's not an endemic problem people seem to believe it is.

Also, giving those meds to a neurotypical college student, they won't have the same reaction. They will have increased focus and be able to cram a bit better, but it won't, for example, improve their grades by much, if at all. By comparison, someone with ADHD will see a marked improvement as the medication brings them closer to functioning at their full potential.

Half to two thirds of the population are not diagnosed with ADHD.

I do actually agree with you on this.

But I think the point of objecting to labels is that it's fine to say: "This label describes how you, as an individual, work." But it is abusive and bigoted to say, "Because you, as an individual, don't work the way most of us do, there's something 'wrong' with you." So I'm fine with the first statement, and yes, that is helpful. But those who'd say the second can take a long walk off a short pier that extends into a very polluted lake, in my opinion.

With piranhas in it.

If it were up to me, I'd tell everybody to focus on how the label can help you rather than how it describes you. After all, you are who you are with or without the label--it's just that the label tells you that you are one of a group of people with similar traits, that the problems you face have been solved by others, and that what you're dealing with is a natural human variation rather than a moral defect.

When I said half to 2/3, I followed it by "or whatever the current DX rate is" indicating that I didn't actually know the numbers.

Objective: According to the DSM-IV TR, approximately 3 to 7% of school-age children meet the criteria for ADHD. However, there is a common conception that ADHD is overdiagnosed. The purpose of this article is to evaluate the evidence for and against overdiagnosis. Method: Recent prevalence studies and research on factors affecting diagnostic accuracy were reviewed. For ADHD to be overdiagnosed, the rate of false positives (i.e., children inappropriately diagnosed with ADHD) must substantially exceed the number of false negatives (children with ADHD who are not identified or diagnosed). Results and Conclusion: Based on the review of prevalence studies and research on the diagnostic process, there does not appear to be sufficient justification for the conclusion that ADHD is systematically overdiagnosed. Yet, this conclusion is generally not reflected in public perceptions or media coverage of ADHD. Potential explanations for the persistence of the belief in the overdiagnosis of ADHD are offered. (J. of Att. Dis. 2007; 11(2) 106-113)

And I strongly disagree about it being underdiagnosed. Sure, if you say that every child who doesn't want to focus or who doesn't have enough structure to focus has ADD/ADHD, then absolutely, it's underdiagnosed. The problem isn't ADD, it's that schools, parents and doctors don't bother with useful therapies, they just medicate and change a couple small things in a broad "this seems to work" sort of way.

And yes, I understand that grades for college students don't improve; I've read the studies. The difference is that those students are old enough and mature enough to actually do their work and pay attention, children are not. Giving them a medication that makes them focus will obviously improve grades, but so will structure and a proper system for encouragement, in most cases.

You almost never hear about children with ADHD/ADD symptoms throughout history, because parents weren't afraid to discipline their children when they acted out or didn't do what they were supposed to.