April 29, 2009

Alan's Tears

Babies can’t tell what’s wrong with them, so it takes careful detective work, experience, skill and intuition to figure out if there’s a problem and where the problem is. They cry because it’s one of the main ways they have to communicate. Usually, that process is the hardest part from the doctor’s point of view. For many common problems, we have studied and have figured out what the best treatments are.

But Alan just turned 11. Though he’ll use a word or two with gentle prodding by his parents, he has almost no language. He understands a lot, we think, but exactly how much isn’t clear. It’s often difficult to get him in the car, and though he likes me, his parents and I try to handle as much as we can over the phone.

His father called, and told me that for the past several months, he’s been crying. At first it was just when he was at school, for a few minutes. Then it was at home also. Gradually, this behavior had increased to several times a day, for up to 30 minutes or more. He’d slump onto the floor and weep. When he did this, his facial expression was sad. His father said that initially he was very concerned that something bad was happening at school, whether someone was being mean to him or something was going on that the child didn’t like. But that didn’t lead anywhere after a lot of questions and meetings with teachers. It was only after that path had been exhausted that the father called me, wondering if Alan was in pain somehow.

One of my UC Berkeley students was observing the day that Alan came in with his parents. I examined him as much as I could, and found nothing physically to be concerned about. He was very interested in (and affectionate with) my student, and she was a good sport in letting him try to sit on her lap and climb on her back.

Alan’s parents explained that these bouts of crying seem to come without provocation, and without a pattern of time of day. He doesn’t hold his head or his stomach when they’re going on. Just talking about it made the parents and me sad. Was there some kind of bullying or abuse? Did he have migraines? They said that his teachers were very loving and there was no one at school that he used to warm up to but now does not. He still liked going to school. And it meant a lot to me that the expression on his face during these episodes was one of sadness.

After an hour of asking detailed questions, the most likely interpretation was that he was, in fact, depressed.

In fact, there’s some reason to believe that people with autism suffer at least as much as everybody else. Studies of those with autism spectrum disorders (with generally much less severe deficits than Alan) show they have higher rates of anxiety and depression than their peers. And those who are more socially isolated also have higher rates of depression. (By the way, it also seems to be true the other way around--depressed kids seem to have weaker social skills, more isolation, than their peers who aren’t depressed. Are social skills the product of the same gene that regulates depression? Or are depressed people just no longer interested in socialization? Or is it that people with poor social skills, being more isolated, end up feeling depressed about their isolation?)

At the big-picture level, an objective look at Alan’s life as an 11-year-old with severe autism is sobering. He has great difficulty making himself understood, and is not given a large number of choices to make. He really doesn’t have peer friends, though he has a team of loving adults he does care for. He is indeed isolated.

As I’ve said before, my job is occasionally to make a diagnosis and initiate treatment. But it is always to try and relieve suffering. I had no way to know for sure what was making Alan sad. But only a little empathy was needed to glimpse life from his point of view. I started him on an antidepressant.

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Please let me know what you think. Do you know a child or situation like this?