His fingers flailing at the piano keys at a frenzied pace, Billy Joel’s Prelude to The Angry Young Man is a good construct for a special type of patient that we have seen in our practices over the past 15 or 20 years.
I’ve commented recently to my associate Dr. Montenare and our resident Dr. Kress that, as our practice has evolved, our patient population has become more complex. The “basic skills case” with a profile of normal development but isolated asthenopia or eye strain when reading as the sole presenting issue is as common to our practice as a -3.00 sphere OU with normal corneas is to a specialty contact lens practice.
As an example of the increasing complexities of our patient population, a current patient in our practice has a condition known as Reactive Attachment Disorder. RAD is a syndrome of aberrant attachment behaviors and other social abnormalities attributed to social neglect and deprivation. As is the case with many of our patients, we learn as much from their caretakers about the patient’s individual needs and profiles as they gain from our guidance. RAD can present in the inhibited or disinhibited form and in the latter, the child easily forms an attachment to a stranger and can wander off. Although we think it’s charming and take it as complement when a child new to the practice spontaneously comes right over and gives us a big hug, this isn’t always a healthy sign. Of course the inhibited form of RAD is more challenging, and the child with this condition can be very difficult to engage.
The social neglect and deprivation associated with RAD is classic in orphanages, but can also be seen in children who are adopted – particularly if the adoption took place after the infant had been in an institutional setting for a number of months. The primer for effects of early social deprivation on brain development and the struggle for recovery is detailed in Romania’s Abandoned Children, a new book by a group of neuroscientists who received a grant from the MacArthur Foundation to conduct a 10 year study on the subject. Consider these insights from Chapter 12, Putting the Pieces Together: “We begin with the observation, based on the evidence presented in this book, that exposure to early and profound psychosocial deprivation leads to a derailing of typical development. Why might this be? The brain’s initial architecture and wiring are orchestrated by a series of genetic scripts that begin a few days after conception and continue through the early postnatal period. However, whereas genes provide the framework for the brain-to-be, experiences fill in this outline, leading to the emergence of a mature brain toward the end of adolescence and the beginning of young adulthood … Inherent in experience-expectant development is the concept of a sensitive period. For development to proceed normally, elements of the expectable environment must be present when the brain can make best use of this information to assemble correctly. Should the timing be off – for example, a child does not have access to a particular environment or experience, or the brain or a sensory organ has been damaged so that it cannot make use of this experience – then development can be derailed, sometimes temporarily, sometimes permanently.”
This next passage caught my eyes. “Simply put, spending one’s early life in an institution leads to a violation of the expectable environment. For example, it is not uncommon among infants living in institutions through at least a year of age to spend much of their time lying on their backs in a crib, staring at a white (patternless) ceiling, which does little to stimulate the visual system, such as the movement of the eyes to explore visual patterns. This may explain why we saw so many young children with what looks like strabismus (though we have not formally investigated this observation).”