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Tuesday, September 20, 2005

What is an illness? (II)

Wahj made an insightful comment on my previous post regarding the definitions of mental illness.

"There's an increasing tendency to "medicalise" things and treat them as disorders and sicknesses. While doing so gives recognition to the problem, and is helpful insofar as it highlights it, it moves into the medical realm (e.g. treat with drugs and chemicals) what used to be dealt with in the social realm (address with behavioural influences).

I was also thinking of the increasing number of kids now labelled ADD in our schools. I don't think there's something in the water thats causing it, for example: it's just a case of children who in the past would've been labelled "incorrigible" and undisciplined now being recognised as having a disorder.

What I worry about is that once we medicalise a person and his/her problems, we assume that the only solution is medication, and ignore the fact that these problems are part social, part pyschological, part physiological."

Now, I totally agree that some people, after being diagnosed with an illness, will automatically attribute all their life's tribulations to the workings of the disease. So many times, I have patients coming in to see me, expecting to see their social problems disappear with the treatment of their physical problems.

However, I think there is a case for identifying people who need assistance from a professional, and sometimes it helps to have a diagnosis, a label, because that gives an answer to the question "What is wrong with me?" and this is often the first step to recovery. People who come to see doctors often don't have an adequate social network that has the strength, knowledge or the resources to cope with their afflictions.

I am very glad that
Wahj has chosen to use ADD 'Attention Deficit Disorder' (also known as 'ADHD' or 'Attention Deficit and Hyperactivity Disorder') as a case to illustrate his point. I actually have a very deep personal interest in children with ADD, having had the opportunity to followup several children with this disorder over a minimum period of 5 years.

ADD defined as a triad of hyperactivity, impulsivity and distractability. It is only diagnosed in children of school-going age (ie. after the age of 5), which is why most teachers tend to view this disorder with rather a jaundiced eye. There are still alot of people out there who are very skeptical about the existence of ADD - but I can assure you that ADD is real and children who have it do need help.

ADD is a developmental disorder, much like autism. Unlike autism and other developmental disorders like dyslexia, ADD is not yet socially accepted. Autism when reduced to bare bones, is a failure of development of emotional centres - which is why children with autism often are unable to socially interact. ADD, however, is the failure of development of concentration.

The failure to develop adequate concentration skills means that the ADD child has learning difficulties. This does not only apply to learning from books, but also learning from observation and deduction. 'Behavioural influences' will not teach this child anything because they won't be able to pick up the subtle cues. Thus, the ADD child does not learn important and very basic social skills, and this leads to inappropriate behaviour.

Now, one of the differences between the ADD child and the 'incorrigible' child is that no amount of good parenting or discipline will change the ADD child. The ADD child does not understand when they have done a bad thing (good example: Getting up and walking around the class whilst the teacher is still talking) because they have not learned what is socially appropriate. They simply have not observed that nobody else behaves the same way they do because it is unacceptable to do so. Disciplining an ADD child often has little or no effect, because they have not fully understood why they have been naughty - so instead of feeling sorry or guilty, they feel incredibly maligned. Worst of all, because they still haven't learned what they did wrong, they are likely to repeat the bad behaviours time and again.

The ADD child is an exasperating child. They fiddle and fidget. They often do incredibly stupid things for no reason. They are easily provoked. They get into trouble. They don't know the difference between 'silly' and 'irritating'. Exasperated parents will say "Grow up!" or "When will you ever learn?", exasperated teachers will say "Apply yourself!", exasperated peers will say "I hate you, go away!".

The ADD child often does poorly in school and has no friends to speak of (it's difficult to tolerate their inept and awkward behaviour - especially their lack of respect for personal space, and their bizarre multi-conversations about several topics at once). Everyone around them appears to dislike them and yell at them alot. You can understand how the ADD child will have really low self-esteem. It's a pretty sad situation to be in for a small kid.

The second difference between the ADD child and the 'incorrigible' child is the effect of pharmaceutical treatment. The drugs used to treat ADD will only work on ADD children - in a normal person, the medication (which is similar to amphetamines or 'speed') will only worsen hyperactivity and impede concentration, but paradoxically, it works to calm down a person with ADD.

In calming the child, it gives them a greater ability to focus their minds so that learning can take place. I am always amazed at the efficacy of ADD treatment - results can be seen in less than a month (Fewer phone calls from angry teachers, fewer accidents in the household, grades at school seem to be picking up, child actually seems to be absorbing what you say).

This, of course, does not mean that all the changes can be solely credited to the effects of medication. It is up to parents and teachers to encourage the child's newfound focus in the right direction. It is totally up to the child to motivate themselves to work hard in order to change. The medication is used to 'buy time' whilst the child's concentration ability develops to a more age appropriate level.

It is probably true that ADD kids, if left to their own devices, may eventually develop enough concentration skills to be able to cope socially. But this could take years, and a kid with a poor school record will be greatly disadvantaged - especially in an unforgiving society like Singapore, where performance first few years of schooling has a great impact on the sort of educational opportunity a child will have in the future. What good would it have done to label the child 'incorrigible' or 'undisciplined'? Would that have brought any benefit to the child? At least with pharmaceutical intervention, we are giving that child a chance.

The idea of medical treatment is that it is used as a stepping stone, to bring a person to a level when they can begin to deal with the difficulties that they are facing. The medical profession is often used as a resource to access other services - counselling, behavioural therapy, support groups, social workers and health visitors - that can be helpful to the patients. But it is the patient who is ultimately responsible for their own personal trials. Doctors are only helpers; it is the patient who must battle their own demons.

It is also useful for a person to be able to name their afflictions. Naming it means that you have power over it. Having a diagnosis gives the person something more tangible that they can deal with. It gives a family hope that there is something that can be done and shows them what sort of special needs a person may have, and how to manage them. It also brings awareness to other people who can in turn respond with understanding, and maybe even a little forgiveness.


Anonymous mrs budak said...

What did you know - I have something to say about this as well.

I was, very recently, diagnosed with mild ADD. I was not a bad student per se but I had serious trouble keeping to the books. Being from the top schools did not help, for I could not do what the students there usually did, which was to sit at the table and read a chapter from beginning to end.

Since I did not have the "hyperactivity" part of the syndrome, most of my primary teachers did not think that I had any problem. Failure to submit homework was attributed to laziness. And because I was one of the brighter students then, nobody thought I had a problem. But I knew I was different, and I behaved in a way to boost my self-esteem.

The problem began showing up when I went to secondary school, and continued until today. It took me a great deal of courage to ask to be diagnosed, but strangely, there wasn't any sigh of relief when the therapist confirmed the diagnosis.

What I got, instead, was a sense of closure and a newly created need to learn how to cope with it. I decided not to go on medication, but to use coping strategies to deal with my work. It is a struggle but so far, I'm doing alright.

I don't want to call ADD an illness or a disease; I would rather see it as yet another "brain wiring". ADD symptoms are problematic only because of the way conventional lives are led. The structure of lessons favour a particular type of wiring; so does our general beliefs about work and working style. A good worker is one who sticks to the job from the beginning to the end; the ADD brain, however, works at different parts of the jigsaw puzzle in a seemingly haphazard manner and can produce a rather radical result. Yet the way we work is regarded as messy, disorganised.

I feel that I've been short-changed. I was forced to conform to the norm and had to endure names and jibes. I was fortunate that despite the difficulties, I was still fairly bright and could stumble through school. But not many are that lucky. The world may not change for people like us but I wish it would still make some allowances.

9:44 pm  
Blogger wahj said...

My mother-in-law, also a teacher, has a student that fits your description perfectly - the bit about getting up and walking around in class is something she has described.

I think there's a level of frustration from teachers and parents, as you've said. Teachers are at a loss: normal methods - persuasion and punishment - don't seem to work with these kids. For most teachers, with a classroom full of other kids (some of whom have behavioural problems of their own, though they may not be ADD) to deal with, I think a (tough) choice is eventually made to focus on the 30 other students rather than spend an inordinate amount of time on the one they can't deal with.

I don't think The System - schools, teachers, parents - has quite figured out how to deal with these kids yet. Most teachers wouldn't be able to diagnose ADD - or distinguish an ADD child from one that's merely remarkably badly behaved. That means that identifying them is already a problem. Counsellors are being attached to schools, and hopefully these people, better trained and equiped to handle this sorta thing, will be able to lend professional support.

Fundamentally, another question that this raises is whether you put children like this in the mainstream school system. Well, the easy answer is that you mostly have to because there isn't much choice at the moment, but if it is a mental disorder, then either teachers get training deal with it (at most to help them identify these kids), or schools get some professionals who can diagnose and treat, or we put them in schools that are equipped to help them.

Just some more rambling thoughts along the lines of the discussion. Thanks for the information about ADD as well. I actually have a friend who works in this line at the Ministry (though he's in a separate building from me so we don't get to meet that often) who'd probably have better information on how ADD cases are dealt with here.

9:53 pm  
Anonymous Anonymous said...

From what you wrote, I have a nagging feeling that I may have ADD. - D W

2:43 am  
Blogger tscd said...

mrs budak: I agree that ADD isn't an 'illness' or a 'disease' in the conventional sense. But I think it's important for ADD people to realise that their condition is not something that they should feel the need to apologise for. And for other people, it is helpful to understand ADD as a disease process - this depersonalises it. It's kind of like the difference between saying 'you're a SICK person' and 'you're a sick PERSON'.

wahj: I don't think that segregating ADD children from mainstream will do any good.

DW: I've simplified the diagnostic process for the purpose of this post - it's a lot more complicated than that! In any case, if you can even get to university on your own and you went through school with a decent bunch of chums, chances are that you don't have ADD.

12:29 am  
Anonymous Anonymous said...

I see. Thanks. :) - D W

1:42 am  

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