Paediatrics (Part 3/5, RETROSPECTIVE POST)

"Max" (ADHD): My most favourite interaction in Paediatrics was with an ADHD Child called “Max” (not his real Name).  When I opened the door, the first thing Max said to me was “Are you Somalian?” in which I said that I wasn't, without getting offended at all. Whilst the Paediatrician was talking to the Mother about Max's Medication regime, I tried to engage with him by asking him about school and his interests which included video games. I tried to ask questions about his favourite video games but soon exhausted my “Repertoire”. He quickly got bored and proceeded to play with a few styrofoam Cups.

I tried to engage him again by making up a little game where he had to stack the cups in various configurations of progressively increasing difficulty. Every time he successfully made a cup tower, I said “Well Done!”, and he called for his Mother's Attention for similar Praise. Eventually he reached a ceiling point of his ability, so to prevent him from feeling really bored again, I decided to show him how to make “Cup Wheels” by connecting two smaller Cup Ends together with Cellophane Tape, so they can roll on a flat surface smoothly. He got really excited about this novel invention and kept rolling the Cup Wheels down a slanted surface, and then decided that he could make a Cup Tower, so the Cup Wheels could smash into it, with the Cups spreading across the table. The stimulation was enough to sustain him for a few more minutes but soon he got bored again.

I tried asking about his interests, but surprisingly he remembered our conversation and said “You already asked that.” He then ran outside of the room and I went after him. He wanted to urinate but didn't want to use the normal Toilets, preferring to urinate outside. I asked if he wanted to wash his hands, but he didn't, saying that it's “yucky”, which I suspected was a sensory issue relating to water. He then wanted to race me back to the Outpatients room, and I agreed. I outpaced him and reached the room first, but he falsely accused me of having a Headstart.

I really didn't want his hands to contaminate anything else in the room, so I tried to get him to clean his hands with the Debug (an Alcohol / Chlorhexidine Hand Rub) by cleaning my hands with it to set an example. I asked Max if wanted to try catching the Debug while I squirted it like a game, and he said “Yes!”, so I kept on squirting it until he “scored” and was happy. But this happiness was shortlived, for the cut in his hand started to burn from the Alcohol, and he was moaning (LOL). By then the Paediatrician was done with the appointment and he had to go.

It turned out that Max didn't get an increase in his Medication as he desired. As the Paediatrician and Max's Mother exited the room, the lights were switched off, and Max was staring at the computer screen, totally silent. I looked at his face and it looked like a mixture of blankness and disappointment. I suspected that it was due to him ruminating over the Medication issue.

I said to him, 
“I know you are thinking about [ Medication ], and that you want more of it, right?” 

Max slowly said,

 “Yes.”

                         
“You didn't get what you want and that can make you sad or angry. Dr. X is the one who gives you the [ Medication ]. If you want a higher dose of [ Medication ], you have to tell him next time, and say why.” 
                          
"Ok."

            I wrote on a scrap piece of paper the Medication, the desired dose, and his reason as a memo for him to use in his next Appointment before leaving the Room and waving Bye Bye.

I was very pleased but drained that I was able to adequately distract Max during the entire appointment so he wouldn't disrupt the Paediatrician's consultation as usual. The Paediatrician said, 

“You did well, but this is one of his good days.” 

“Thanks”, I said. But I wonder how Max would've behaved if I wasn't there to distract him??? : P

ASD and Getting Bullied - ASD VULNERABILITY --> BULLYING: EXAMPLE (Part 4/7)

The Aspie’s initial “empty slate” regarding the facial expressions, tone of voice + body language disadvantages him. Insufficient recognition of such social cues in others, along with other differences (eg statistically reduced verbal fluency) predisposes him to bullying and/or manipulation by others.

Story of me being framed:

I skipped a grade and joined a class whose classmates I’ve seen numerous times, but never interacted with much before. I used to hang around by myself a lot, but I thought I’d feel more comfortable if I could be included. I used to say to the girls in that class, ‘Can I play with you?’, and they’d always say ‘No, you’re not old enough.’

This time though...

‘Ok, you’re in our class so you can join us. Let’s play tag.’

‘Ok.’

‘Ok, you're it. Count one two three before you go.’

‘Ok.’

The girls ran away, but I was relatively fast even though I was still kinda clumsy at the time. I tapped one of the girls on the shoulder.

‘You touched my butt!’

‘No I didn’t , I touched your shoulder.’

‘No, you touched my butt!’

‘No I didn’t, I touched your shoulder over here.’

The other girls who were playing tag, went up to the two of us.

‘Ken just touched me on the butt! Let’s go tell on him!’

I remember seeing the girls having angry/frowny facial expressions. I knew it meant angry/frowny coz I saw it in cartoons multiple times, and managed to associate it with the context. I didn’t understand WHY they were angry, even though I knew it was factually true that I touched her on the shoulder. 

They dobbed on me, and the teacher on recess duty told me that touching a girl’s butt is sexual assault, and for me not to do it again.

The next day, I wanted to play tag with them again, and they said I could join them. They made me ‘it’ at the start again.

I didn’t understand their intentions at the time. They made the game a little different.

‘This time because you run so fast, we’ll make you count to 10.’

‘Ok.’

               
I counted to 10, and ran after one of the girls hiding behind the school hall. I tapped her head.

               
‘I tagged you.’

               
‘You touched my butt! Didn’t Ms. Kogan tell you not to touch girls’ butts?!’

               
‘But I didn’t touch your butt, I touched your head. Your head is not your butt. Your butt is located down here.’

               
‘No, you touched my butt, and I’m telling on you.’

She told the other girls, followed by my class teacher, who already formed a negative impression of me, coz I was apparently smart but immature, and that I didn’t behave like a 5^th-grader.

He said to me ‘Ken, follow me into this room.’

The room was pleasantly dark, and he didn’t switch on the lights, but I didn’t know why.

He told me that the girls have reported multiple incidents of me touching their butts when playing tag and that it is illegal to touch that region, because it is sexual harassment, and in the adult world can be punishable by a jail term, and he use to work with juvenile criminals, many of whom have been convicted of sexual assault and rape. He said that what I did was wrong, and that he would give me several detentions, and physically segregated me from the rest of the females in the class for all activities, including computer skills, to think about my wrongdoings.

‘But I didn’t touch their butts.’

‘Yes you did, the girls said so.’

‘But I didn’t, they keep saying that when I touched their shoulder and heads.’

‘The girls have come up with the same story about you, so I’m inclined to believe them. You know what you did is wrong, and you are not going to get away with it.’

‘But I didn’t touch their butts, I didn’t actually touch their butts.’

‘Don’t lie to me Ken, I don’t want to set you up for failure when you become a grown up so you need to learn things now. See me after school at 3 PM.’

‘I really didn’t touch their butts, you don’t believe me.’

‘Stop talking about it. Now go back to Maths.’

All of my persistent claims of innocence were said with my usual flat affect and relatively monotone voice. At the time, I thought that because what occurred was factually true by my accounts, that I would be believable. But this wasn’t the case.

In retrospect, I realized that I was supposed to show facial expressions of anger, and be more vocal and eloquent about my innocence. I didn’t know what he knew, or the cause of incongruence between factual events and false accusations, which is related to the TOM deficit.

               
I didn’t know what sort of body language to show. And yet the girls were trusted coz they showed the typical facial expressions, body language and vocal tones of innocence and indignation. ‘HE TOUCHED ME HERE! HOW DARE HE!’

These girls can further fine-tune their manipulative/framing qualities over time, and could easily target an Aspie’s initial trustworthiness, and get him fired from jobs, arrested, or divorced (if married) with the settlement (+/- child custody) hugely in favour of her due to his apparent “abusive behaviour”.

I didn’t see the BIG PICTURE, that they didn’t want me to play with them, coz I was focusing on the DETAILS, such as counting to 10 instead of 3.

Of course, some Aspies may commit sexual harassment without realizing it, but that wasn’t the case in my situation.

My Experience from a Repetitive-Transcranial Magnetic Stimulation (rTMS) Trial for ASD (Part 1/2)

NOTE: My blog post/s regarding my experiences with Transcranial Magnetic Stimulation (TMS) is/are way overdue, so my apologies to fellow ASD comrades (non-Communism related) and other blog readers for not posting such TMS experiences in November or December 2010. I’ve been busy with work and also procrastinating with other activities during the time since then.

I have just completed my Orientation week at my Clinical School which was very busy and stressful but will write about that in a post after the TMS ones.

(I was doing some Medical Literature search for further details about the Neuroanatomy involved in this trial. I may have made a few errors in the descriptions, so this post may be corrected in the future.)

Last year, I was 1 of 20 people to take part in a Transcranial Magnetic Stimulation trial that was conducted at the Alfred Psychiatry Research Centre that also has connections with Monash University (both located in Melbourne, Australia).

The full project title is called “The use of rTMS to Improve Theory of Mind Among Adults with Autism and Asperger’s Disorder”. I personally would’ve preferred the term “Asperger Syndrome” over “Asperger’s Disorder”, but that was how they named the condition in the title. The principle investigator was Professor Paul Fitzegerald (whom I never met in person), but the major investigators who conducted the trial that I had frequent contact with were Dr. Peter Enticott, Ms. Peachey and Ms. Rhook.

Very brief synopses of this study and others conducted by the same people can be read at www.med.monash.edu.au/spppm/research/devpsych/neuro-tms.html

www.clrsasd.org.au/documents/MAPrcASDResearchUpdateJan2011.pdf

The project aimed to see if stimulation of a certain part of the brain via rTMS (repetitive TMS) would increase the intuitive social awareness, and hence Theory of Mind in individuals on the Autism Spectrum that were verbal (especially HFA/AS people). I dunno the results for the other individuals, so I can’t say if the rTMS trial was overall successful, but I’ll be talking about my own anecdotes/results later on.

TMS is a relatively recent (primitive TMS started in the 1980’s), non-invasive technique to induce weak electrical currents in a conductor (in this case a specific area of the brain). The weak electrical currents in the neurons are created from a rapidly changing magnetic field that is a result of insulated electrical coils that are arranged in a specific style (usually coils), placed near the "conductor" and rapidly change direction in current. The rTMS involves multiple pulses in one go (in my case 50 pulses/10 seconds, ie 5 Hz), as opposed to "normal" TMS which is just single or double pulse per go. rTMS involves far more pulses, and therefore is supposed to create a longer lasting effect.

Unlike Electroconvulsive Therapy, TMS is much more selective by activating a far smaller part of the brain and has a very low chance of triggering seizures in those who don’t have a history of Epilepsy, and is far less likely to trigger memory loss.

The brain area that was targeted in this trial was supposed to be the Anterior Cingulate Cortex (even though the Participation Information states “Medial Prefrontal Cortex” which is located very close to it, I’ll have to ask Dr. Enticott for clarification). The Anterior Cingulate Cortex is located in Brodmann’s Areas 24 and 25 IIRC, and from various studies is partially involved in “empathy”, emotional processing/regulation and Executive Functions.

I chose to take part in this trial because the only other place I was aware of that was also performing rTMS trials for ASD individuals at the time was at the Beth Israel Deaconess Medical Hospital (BIDMC) in Boston, Massachusetts, so this was the perfect opportunity to take part in a potentially life-changing experience. I refuse to be completely “cured” of my Asperger Syndrome as I have numerous positive traits from it (innate drive for honesty and integrity, lack of materialism, non-judgmental towards those with non-harmful differences, strong eye for detail, hyperfocus).

I was very sure that this wouldn’t be a complete cure because I read about the accounts of John Elder Robison (famous person with Asperger Syndrome, author of autobiography titled “Look Me in the Eye”) and his friend who took part in the rTMS trials at BIDMC and reported improved intuitive ability to read facial expressions, eye contact, production of “auto-appropriate” facial expressions in response to others, and slightly improved Executive Functioning, but still retained other ASD traits like having narrower interests, stimming, seeing detail, being non-judgmental, honesty, and still having to learn most other social skills at an intellectual level and not automatically.

I felt that rTMS may offer a potential reduction in some undesired traits that make it harder for me to function in my daily living (such as intuitive difficulty reading facial expressions and body language of Neurotypicals and dislike of eye contact although I could manage it) while preserving my other positive Aspie traits that I value (as mentioned above). I thought that taking part in the rTMS trial would mean that I’d be betraying my “pure” ASD-self and the ASD Community (especially those that are vehemently “Anti-Cure” and “Pro-Neurodiversity”), but it is indeed true that for many Higher Functioning adults on the Autism Spectrum, their condition is a mixture of both beneficial and disabling traits, and that to reduce the severity of the disabling traits while maintaining the beneficial ones *WITH THEIR CONSENT*wouldn’t be immoral or unethical imo. I do acknowledge that some of the disabling traits are more a result of ASD individuals being the minority group in society, but unfortunately we will always be a neurological minority group in the world and will have to conform to a degree : (

I also acknowledge that my strong attention to detail and my hyperfocus ability is actually an indirect result of my partial Executive Dysfunction (having “normal” Executive Functioning results in “higher levels” of information processing, such as seeing the big picture and being able to rapidly switch between tasks, both which I have difficulty with), but I didn’t think that the rTMS would significantly increase my Executive Function to the extent that I wouldn’t be able to strongly see detail anymore.

Asperger Syndrome and Patient Interactions (PART 1/2)

I haven’t had too much experience in talking to patients as I’ve only completed my Preclinicals (first 2.5 years of Med course). During the entire Preclinicals, I’ve visited different hospitals and GP clinics around 30 times and there, I had the opportunity to interact with patients. I know that it’s very petty compared to the Clinical rotations that I’ll experience later on, but I felt that I learnt a noticeable amount of communication skills that would benefit me professionally and also socially in non-medical situations, so it can gradually reduce my innate social difficulties due to my Asperger Syndrome to an extent.

Along with such visits, we had many tute classes for a component in our Health Practices subject called ICM (Introduction to Clinical Medicine). ICM teaches you basics in how to conduct medical conversations with patients, how to say certain things, and what to say in reaction to certain comments by a patient. I need rules and details (step by step) on how to talk to patients and people in general, so I found the booklets quite useful because it was well written despite not being specifically intended for people with an ASD.

For starters, it gave extra enforcement of the concept that patients have FEELINGS, and how you say certain things will impact on their mood and subsequent interaction with you, for the remainder of the interview and in further visits. I always knew that practically everyone (including me) had feelings, but my AS caused me to have a reduced Theory of Mind which impairs my ability to intuitively understand the feelings of Neurotypicals (who comprise the vast majority of patients) based on their body language, facial expressions, and subtle social cues. The AS also causes me to innately communicate in a more objective/pragmatic/blunt manner as opposed to a style that’s primarily sentimental, hence causing me to appear “rude”, “weird” or “insensitive” to many NTs.

The ICM booklets were helpful in that they explained the types of feelings that get ignited in patients when you use certain communication styles, because what you say SHOWS something to them, and they often don’t take things literally or word-by-word like people with ASDs tend to do. For example, I learnt that after a patient tells me a load of information about their condition/illness, it really helps for me to paraphrase or repeat what they said, to confirm the info AND TO SHOW that I’m proactively listening to what they’re saying, and that I’m not ignoring them. They can also correct any mistakes that I make, while FEELING less offended.

Another thing I learnt is that when patients are feeling anxious or upset because of their pain or illness, it helps to acknowledge their anxiety/depression by saying a sentence like “I’m sorry to hear that you’ve been having [X condition] for [Y amount of time], it would certainly affect [Z aspects of patient’s life], so I can imagine that this would be very frustrating/upsetting for you.” By saying such a sentence, it SHOWS to the patient that their illness isn’t trivial and that they’re being taken seriously. However, my problem is that my AS causes me to have difficulty with reading body language and facial expressions as previously mentioned, so it’s hard for me to figure out when people are a bit anxious/depressed, so I have to compensate by using more verbal info such as asking “How are you feeling today?” (near the very start of interview), “How’s Uni/work going for you?” or “How’s your family?”, and seeking for certain cue words in the patient’s answer to indicate their mood such as “pisses”, “sucks”, “hard time”, “bitch”, “tired”, “shit”. ICM also taught me that if I see a patient crying, that I should offer them a box of tissues.

ICM taught me that it can be helpful to say certain things in a more indirect manner to avoid offending or upsetting the patient, to avoid appearing aggressive and to SHOW that the patient plays a role in directing their own healthcare and that it’s not being forced on them. For example, if I spoke to a person who’s a chronic smoker, I learnt that I shouldn’t say “You should quit smoking coz it’s bad for you.” , but you suggest it by giving other alternatives or asking questions such as “Have you considered quitting smoking?” , “How do you feel about stopping smoking?”, “Have you tried Nicotine Patches or Zyban?”.

But it also states that at certain times, it’s better to be direct for certain sensitive questions (which I’m very grateful for coz I’m naturally blunt), because if you were to ask it another way, it can appear judgmental and offend the patient even more. For example, the ICM booklet states that when asking people about “illicit” drug use, it’s best to ask directly like “Do you use Cannabis/Marijuana?” instead of “You don’t happen to use Cannabis, do you?” because by asking it in the indirect manner, it actually ignites the patient into feeling like they’re being stereotyped or judged negatively. I also appreciate that ICM taught me how to ask questions in a specific order and explains why. For example in the area of “illicit” drug use, you start off by asking the usage of the most popular drug, progressively to the less popular ones. If the patient asks why you ask in such an order, you then have the medical excuse of stating that you’re asking in terms of epidemiological relevance, and that you’re not being judgmental. There are many “illicit” drugs in existence (in fact the list of “illicit” drugs is astronomical in Australia due to the ridiculously insane Analogues Act), so you only ask the top 5 or so, ie Cannabis --> Methamphetamine --> Ecstasy (MDMA) --> Cocaine --> Heroin (if I recall this order correctly).

So for some situations, it’s best to be indirect, but in others direct is better, and this is quite confusing for me as my AS causes me to have a naturally more rigid mindset. Hopefully as time goes on, I’ll gain more decent Clinical experience and learn to be more rapidly flexible in figuring out how which questions are asked more appropriately and in the least offensive manner.

Then there’s the case where I learnt that you have to be direct, but delicate with the words that you use, as verbal differences are converted into social subtleties that are intuitively noticed by NTs, igniting further emotions.

For example, when I begin to conduct a breast examination on a woman, I’m extremely tempted to say:

“I want to see and touch your breasts to see if you have Breast Cancer.”

coz it’s the direct/blunt Aspie method. If I was to say this to a woman with an ASD, she most likely wouldn’t be offended at all. HOWEVER in the minds of many NT women, the segment “I want to see and touch your breasts” is automatically correlated with sexual harassment despite this being a medical examination, and the segment “to see if you have Breast Cancer” is also alarming due to mention of the potential pathology, igniting fear/anxiety. Therefore I was taught instead to say:

“I want to inspect and palpate your breasts to make sure that they are healthy.”

The words “inspect” and “palpate” (both are synonyms of “see” and “touch” respectively) are used because these words are used less frequently in informal conversations and therefore have a more professional/clinical tone to it, hence having less correlations with sexual harassment. The segment “to make sure that they are healthy” is used instead because it avoids mentioning any pathologies, but it still directly retains the intention of the examination, ie just said differently. “Healthy” is considered by many to be a positive word and hence the breast examination APPEARS to have more positive connotations with it by NT women, and so they’re more willing to proceed.

I’ve learnt that not only do the majority of NTs care about substance, but the vast majority of them also care about APPEARANCES and what you SHOW to them by the way you talk (social subtleties), sometimes even more so than substance!!!

It appears that if you cater to the patients’ emotions to an extent, the entire conversation is more likely to be cordial. Although very tiring and difficult for me, I treat the talking in an “emotionally sensitive/empathetic” manner as a price to pay for a smoother medical conversation and for a politer relationship.