Thursday, February 28, 2013

NHS & Francis Report: Who gets promoted?

Did things just happen or was there a master plan?

The NHS has been subjected to reform, re-reform and re-re-reform over a number of years with little actual improvement in clinical care to patients. Yet the bonus culture has led to side effects that were normally the domain of bankers and financiers.

We have to remember that those high up were carrying out the Government’s Master Plan. That was why they were not sacked but promoted.

The Telegraph: Mid Staffs NHS trust: Why is nobody being punished for this disaster?

Between January 2005 and March 2009, the Mid Staffordshire hospital was a terrible place, where patients were left lying for hours in their urine and faeces. Those who tried to get out of bed and help themselves often fell, and their injuries went unrecorded. You see, old people drinking out of flower vases because nurse won’t bring water are of no concern. Not if you want to hit your targets and achieve the holy grail of Foundation Trust, which Mid Staffordshire most definitely did.

The Telegraph:
This is the central question that the Francis inquiry addressed. Why did a hospital – and, to a dismaying extent, other parts of the NHS – stop being sensitive to patients’ distress? What about consultants doing their ward rounds at Stafford every day? Did none of them hear the cries and smell the smells? What about Dr Helen Moss, the hospital’s director of nursing from 2006 to 2009, the worst period of neglect? Did she listen to Helene Donnelly, the shocked junior nurse who outlined her fears about lack of care? Or did Dr Moss believe, as most NHS managers seem to, that airing the hospital’s dirty linen in public was far worse than not bothering to change the dirty linen your patients were lying on?

Warning! You may want a gulp of gas and air before you read on. Yesterday, Dr Moss was cleared by her professional regulator. The Nursing and Midwifery Council (NMC) said that Dr Moss had “no case to answer”. The NMC refused to say how it had reached this remarkable conclusion, since all details of the case are “private”.

So a public servant who was in charge of nursing at a hospital that was complicit in the deaths of 1,200 people is not accountable to the people who paid her wages. If the buck doesn’t stop with Dr Moss, who the hell does it stop with? Certainly not Stafford’s former chief executive, Martin Yeates, who cut 150 jobs to save £10 million at a time when there were already serious safety concerns. An external report recommended that there was a case for disciplinary action against Mr Yeates, but the hospital board decided on “pragmatic and commercial grounds” to negotiate terms for an agreed departure. Therefore, unlike many of his former patients, Mr Yeates left Stafford hospital not in a wooden box, but with a £400,000 payoff.

Mr Yeates, who resigned with a pay-off of more than £400,000 and a £1 million pension pot from Mid Staffordshire Foundation Trust, which runs the hospital, told the inquiry he was too ill to appear in person.
Bereaved families said they were appalled to learn that Mr Yeates has now taken a job as chief executive of a health charity, Impact Alcohol and Addiction Services, which hold contracts with the NHS.<<<<

Do you need more proof that those involved were part of a master plan? Here they are in the Telegraph:

Cynthia Bower, who was head of the West Midlands strategic health authority at the height of Stafford’s inhumanity, dismissed the hospital’s alarmingly high death rates as “a statistical blip”. Satire lay down and died the day Ms Bower was appointed chief executive of the Care Quality Commission. If you wanted to stop a tragedy like Mid Staffordshire happening ever again, would you really choose a woman who failed to notice the abuse at Mid Staffordshire?
Just for good measure, Sir David Nicholson, who also ran the West Midlands strategic health authority, is now chief executive of the entire National Health Service. Small world, isn’t it? A former Communist, Sir David is said by critics to be the perfect man to ensure that Stalinist central targets are met, whatever the cost may be.

……What about the midwife who told the Today programme on Tuesday that “you are penalised for taking time to care”.

First Class Clinical Care:

I think that the wonderfully clear language of the NHS’s founders, expressing a profound moral good, has been replaced by management jargon of providers and drivers. That change is not cosmetic. Ugly language has created ugly thinking, with behaviour to match. Too many people going into a British hospital will encounter first-class clinical care in third-world conditions.

But really:
Dr Chris Turner told the Francis inquiry that when he started work at Stafford A&E in 2007, the place was “an absolute disaster”. It was so bad that no one could remember what good looked like. The overworked staff were constantly threatened with losing their jobs if they didn’t get patients through the department within the four-hour target. So when John Moore-Robinson was admitted after a cycling accident, he was swiftly diagnosed with bruised ribs and sent away with some painkillers. John died a few hours later from a ruptured spleen, which doctors could have spotted if they’d given the 20-year-old the tests he needed.

So there you have it, master plan or not, patients died unnecessary and those that comply with the Governments plan cuts and targets get promoted.

Medicine as I know no longer exists in many complying hospitals.

Please don’t cry!
© Am Ang Zhang 2012

The answers are complex and they are many, says Francis, but at their heart is a profound crisis of culture at every level of the NHS. The inquiry found a deep rooted, pernicious cult of management, obsessed with achieving ill-conceived targets yet isolated and wilfully oblivious to day-to-day operational reality, and fixated on image management and cultivating positive publicity while demonstrating little or no interest in acknowledging or addressing problems. Throughout the period considered by the inquiry, from 2005 to 2008, the executive management of the Mid Staffordshire Trust was blinded to the appalling care given to patients at their hospitals by their excessive focus on securing Foundation Trust status. An oppressive atmosphere in which intimidation and bullying were rife prevented staff from raising concerns, and, when they did, swept them under the carpet.
In parallel, the multiplicity of bodies with regulatory and oversight responsibilities in the NHS seemed to be asleep at the wheel. From health-care systems regulators and performance managers like Monitor, the Care Quality Commission, and the HCC, to professional bodies and regulators like the General Medical Council, the Royal College of Nursing, and the Nursing and Midwifery Council, “all such organisations have the responsibility to detect and redress deficiencies in local management and performance where these occur”, says Francis. “It does not need a public inquiry to recognise that this elaborate system failed dramatically in the case of Stafford. As a result, it is clear that not just the Trust's Board but the system as a whole failed in its most essential duty—to protect patients from unacceptable risks of harm and from unacceptable, and in some cases inhumane, treatment that should never be tolerated in any hospital.” Not a single person has yet been held accountable for what happened at the Mid Staffordshire Trust. Yet the systemic failures that the case has brought to light suggest that although atypical, Mid Staffordshire is unlikely to be unique.

Wednesday, February 27, 2013

Family & Healing: Who Is The Real Patient?

In an age when it has become more or less impossible to gear your intervention or non-intervention in the practice of Child Psychiatry because of rigid guidelines, I remember this family fondly.

From The Cockroach Catcher: Chapter 19   Who Is The Real Patient? Part 1

he early seventies was a very exciting time in London as the first ever course in Family Therapy in the U.K.was just launched.  Gregory Bateson just published Steps to an Ecology of Mind, which to this day still manages to be exciting for anyone interested in family systems – a term coined to describe the interaction within a family or extended family.   Of course years before that, Ibsen neatly observed family interactions in Ghosts and Wild Duck. 

©2006 Am Ang Zhang

         Catherine, aged fourteen, had not attended school for some time and all attempts by the school authority and educational psychologist failed to get her back to school. This was a pity as Catherine was really university material.
         She had eleven older brothers and sisters. Two older sisters were married.  One of them had a little baby of ten months. The other had two children at school. The youngest of the brothers attended a public school (i.e. an English private school) on a scholarship, and with financial assistance from the older siblings.
         After an initial visit by the social worker, the team decided to approach the case in a family therapy sort of way – big family therapy in every sense of the word.
         At that time, family therapy was a relatively new development and had probably grown out of some group therapy principles. One of the first courses was established at the Group Therapy Institute in London when I was still at the Tavistock. Little did I know then that it was history in the making. Of the people I was with then, either teachers or co-trainees, many have become prominent practitioners in the field.
         Even the rather adventurous social worker was feeling a bit dubious.  “Do you belong to the school that insists on everybody in the family attending?”  She asked, hoping I would be a bit eclectic about it.
         “Let’s try and get everybody at least for the first session.”
         “I will do my best,” she promised.
         Good old Miss Kimble. She always got things done.
         As some of the family were working, the session had to be organised for the evening.   There is so much mystique attached to our kind of work that families often oblige without asking too many questions, at least at the early stage.
         One of the older unmarried sisters took it upon herself to organise the meeting. The main one that caused some problem was the oldest brother who was a long distance lorry driver going all over Europe.  The meeting needed to be on one of those nights when he was back from his delivery tour. The brother at the public school had a cricket match and he was apparently one of their best bowlers. One of the other brothers agreed to go to the match and bring him to the meeting as soon as the match was over.  The sister with the baby would have to bring the little one but the older children would look after her at the meeting.
         I told them that they could all join in.
         Luckily with so many children the family had a reasonable sized council house and the family room was fairly long.  They moved the dining chairs through to provide seating for everybody.
         The scene was set. We just had to deliver the goods.
         “We have come this far.  We just have to do it,” I told Miss Kimble.  She probably had more faith in me than I had in myself.
         Father looked after the parks and gardens for the council and had been with them since leaving school. Mother had not worked outside of home since the first child was born. She used to work in the Council Offices and that was where she met her husband.
         All the unmarried children who had left school had jobs except for the one who organised the meeting. She was in fact the eldest sister. All hope was on the boy and Catherine, except now Catherine was not going to school and had not been for nearly a year.  Two of the sisters worked in an insurance company, which was a very important local employer. Three boys worked for the Parks and Gardens department. One girl was a life guard at the local public Sports Complex that just opened and one boy looked after the gymnasium. The parents had done well and you could see that it was a very close knit and caring family.
         Only the truck driver was absent. We chatted and waited. The baby in the meantime was crawling in the middle with the two older children fussing over her. Catherine sat close to mother and now and again would hold her hand. I was not too sure who was comforting whom but then family therapy was about observing the family interactions.
         Cricket boy was busy devouring a plate of food mum left for him as he missed his school dinner.
         Others were exchanging various gossips about boyfriends and girlfriends.
         I thought that this was fun but there was also a lot to take in. The traditional approach would have allowed one to be more focused but it would probably have taken a long time to get to where we wanted to get to quickly.
         When I heard air brakes, I knew that big brother had arrived. Everybody else knew as well. Swiftly Catherine let go of mum’s hand and went to the door.  One of the other sisters had the plate that had been kept warm in the oven set in a tray complete with a big can of beer.  I declined the offer of beer as I was working.
         Big brother was quite a big fellow but was friendly enough as he shook hands with me. After a few bites and some gulps of beer he turned to me and said:

 “We are all here now. What is this about?”
         To this challenge, I explained in a very simple fashion why I wanted to see the whole family. I went on to use what I had since described to my juniors as a journalistic approach to history taking, as distinct from the traditional topic-by-topic approach. With the journalistic mantra – Who?  What?  When? Where?  Why? How? – the patient or the family would just enter the conversation barely aware that you were taking a history. To keep focused, you do need to have clearly in your own mind the information you are seeking.
         If you are not experienced, you can follow a printed questionnaire and take three hours of history but you will just end up with loads of seemingly unrelated information.
         With my favoured journalistic approach you follow leads.  The whole session becomes more integrated and it is easier for patients and families as you are not likely to appear to be jumping from one thing to another. It also comes across as more professional.
         One thing led to another and my break came when one of the boys let slip that he remembered mother going into hospital after Catherine was born and big sister gave up a good job at the insurance company to stay home to look after the rest of them.
         Mother was in the local mental hospital and had electrical shock treatment.
         Mother started crying and big brother was rather upset and asked me what relevance this had except to upset mum.
         At this point, the little baby who had been crawling around stopped in her track and crawled to Grandma and started touching one of her slippers. She started crying too.
         I have my own theory that even before acquiring language, babies are able to retain emotional memory of early experiences. Later on in life it becomes difficult to grasp the source of the upset as there are no words to describe such emotional experiences. Traumas in early life have diffused effects; those happening later on in life are more focused and perhaps easier to deal with.
         One famous psychiatrist once talked about his own experience of his mother’s depression. He talked about having images of a wooden arm and it was through years of psychoanalysis that he reconstructed the whole image of his very depressed mother who had a rather catatonic posture in the deepest depth of her depression. He could remember himself as a toddler running into the house after play to be met with the wooden arm, sharply quietening down and then backing off. It was a rather moving seminar he gave at one of the conferences and a rare occasion when a British psychiatrist talked about psychoanalysis.
         Back with the big family – all went rather quiet. A couple of the girls were sobbing. Catherine tried to comfort mum who said she knew it was all her fault. The eldest brother thanked me for making things clear for him.
         All were relieved to hear that I would not be forcing Catherine back to school and that mother would not be prosecuted. 
         All agreed that Catherine would be wasting her brains if she did not have some form of education and I explained that I would be looking into alternatives.
         Miss Kimble told me later that I was lucky to have that break and that it was a good job the baby was there.
         It was uncanny that in my thirty plus years of experience, over half of the children who had problems attending school in a big way had mothers who had serious puerperal (post-natal) depression.  Was the school refusal (school phobia) a clinical manifestation of genetically transmitted depression, or was it the psychological effect of living with a depressed mother? I really do not know.
         Catherine never managed to return to “proper” school but with a fair bit of individual therapy we managed to get her to attend a tutorial unit. This we achieved by getting mother to find some part time work. Big sister too started working part time.
         It was daunting for me to think that a single family session brought about so much change, but then I was reminded that the strength was with the family – we just tried to tap it.
         Catherine had good exam results on the limited subjects she could sit but was immediately offered a trainee post at the insurance company.
         Years later I bumped into one of the older sisters at the Sports Centre.  She thanked me again for what I did for the family and told me that everybody was fine.
         I told her I was scared by the lot of them especially her big brother. She told me I did all right. Catherine was his favourite sister.
         I cannot remember seeing another big family since and with the disintegration of families it became increasingly difficult to do that type of family work.

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Tuesday, February 26, 2013

NHS: Granddad Why?

You should have listened to Baroness Kennedy of The Shaws  who neatly summarise what many bloggers and doctors were saying for months:

Care, not money:
My Lords, I make a declaration that I am a fellow of three royal colleges, too, like the noble Baroness, Lady Cumberlege. I should also say that I am married to a surgeon who has spent his life in the National Health Service. He is from a dynasty of doctors. His grandfather was a doctor, his mother a doctor, his aunt a doctor and now our daughter is entering medical school. They all entered medicine not because they are interested in making money but because they want to care for people. It is the idea of being at the service of others that draws most health carers into medicine. They do not want to run businesses; they do not see their patients as consumers or themselves as providers. They do not see their relationship as commercial and they do not want to be part of anything other than a publicly funded and provided National Health Service.

Private Providers and Secrecy:
Health professionals also feel proud, as all of my husband's colleagues do, that Britain is the only country in the industrialised world where wealth does not in some measure determine access to healthcare. They are saddened that the National Health Service is now facing the prospect of becoming a competitive market of private providers funded by the taxpayer. When we hear talk of accountability, they point out that nothing in the Bill requires the boards of NHS-funded bodies to meet in public, so there will be a lack of transparency. That will be complicated by the fact that private providers are not subject to the Freedom of Information Act, so they can cite commercial sensitivity to cover their activities.

Insurance-based model by stealth:
Others have spoken of the removal of the duty on the Secretary of State to provide healthcare services and pointed out that that duty is now to be with unelected commissioning consortia accountable to a quango, the national Commissioning Board. The Bill does not state that comprehensive services must be provided, so there may well be large gaps in service provision in parts of the country, with no Secretary of State answerable. Providers will be able to close local services without reference of the decision to the Secretary of State. Although the Government say that the treatment will be free at the point of delivery-we hear the calm reassurances-the power to charge is to be given to consortia. That paves the way for top-up charging and could lead eventually to an insurance-based model.

Monitor & family silver:
Monitor, the regulator, is to have the duty to sniff out and eliminate anti-competitive behaviour-and, of course, to promote competition. According to the Explanatory Notes to the original Bill, Monitor is modelled on
"precedents from the utilities, rail and telecoms industries".
How is that for reassurance to the general public? If anything should be a warning that this spells catastrophe, it should be that this is another step in the disastrous selling-off of the family silver to the private sector, with the public eventually being held to ransom and quality becoming second to profitability.

Monitor: Competition or integration.
The regulator, Monitor, will have the power to fine hospital trusts 10 per cent of their income for anti-competitive behaviour. Any decent doctor will tell you that for seamless, efficient care for patients, integration is key to improving quality of life and patient experience. The question is whether competition and integration can co-exist. Evidence from the Netherlands is that they cannot. There, market-style health reforms designed to promote competitive behaviour have meant that healthcare providers have been prevented from entering into agreements that restrict competition, so networks involving GPs, geriatricians, nursing homes and social care providers have been ruled anti-competitive. There is a fear that care pathways, integrated services and equitable access to care in this country will be lost when placed second to market interests.

Delusion of patient choice: Cherry Picking
Under the delusion of greater patient choice, people are to be given a personal health budget. I am interested to hear what happens if it runs out halfway through the year. Private hospitals will enter the fray as treatment providers and, as in other arenas, they will undoubtedly, as others have said, cherry-pick and offer treatment for cases where they can treat a high number of low-risk patients and make a profit-for example, hip and knee replacement, cataracts, ENT and gynae procedures.

NHS Hospitals: Undermined!
It is essential in an acute teaching hospital to retain the case mix, though, so it will be the teaching hospitals that will also provide the loss-making services such as accident and emergency and intensive care and deal with chronic illness and the diseases of the poor, such as obesity-we can name them all. These are essential services but they are also very costly. An ordinary hospital cannot provide them if it does not have the quick throughput cases as well to maintain a financial balance. If relatively easy procedures go to private providers, the loss of revenue to the trusts will eventually lead to them being unable to provide the costly essential services. It will mean that doctors trained in these places are not exposed to all aspects of patient care. Private companies cherry-picking services undermines and destabilises the ability of the NHS to deliver essential services like, as I have mentioned, intensive care units, accident and emergency, teaching, training and research.

Asset Stripping: as Southern Cross
Clause 294 allows for the transferring of NHS assets, including land, to third parties, and the selling off of assets. Clause 160 allows for the raising of loans by trusts, so hospitals taken over by the private sector could be asset-stripped and then sold on, as happened with Southern Cross homes.

Practice Boundaries:
The removal of practice boundaries and primary care trust boundaries will mean that commissioning groups will not be coterminous with social services in local authorities, so vulnerable people are more likely to fall through the gaps between GP practices. GPs will also be able to cherry-pick by excluding patients who cost more money and can lead to overspend.

Lawyer-multimillion-pound executive salaries, dividends and fraud:
Then there is the issue of the cost of market-based healthcare. Advertising, billing, legal disputes-I say this as a lawyer-multimillion-pound executive salaries, dividends and fraud could end up consuming a huge amount of the pot that can be spent on front-line services. We will end up, as in America, with that extra stuff taking up 20 per cent of the health budget. The downward spiral of ethics, the increase in dishonesty and the conflicts of interest become huge, and you see the destruction of the public service ethos.

Overdiagnoses, overtreats and overtests.
I want to scream to the public, "Don't let them do it"-and in fact the public are responding by saying in turn, "Don't let them do it". Market competition in healthcare does not improve outcomes. The US has the highest spending in the world and the outcomes are mediocre. The US overdiagnoses, overtreats and overtests. Why? Because that increases revenue. You change the nature of the relationship between doctors and their patients. You get more lawsuits and doctors therefore practise defensive medicine. You ruin your system.
I say this particularly to colleagues on the Liberal Democrat Benches. They may be being encouraged to think that voting against the Bill may bring down the coalition, but all I can say is that the electorate is watching. If people feel failed by the party on this, I am afraid that it will pay a terrible price.

McKinsey et al: 25 year plot:
This has been a 25-year project, done by stealth. It started with the internal market and is now moving to the external market. It was not thought up by mere politicians but by the money men, the private healthcare companies and the consultancies like McKinsey-the people, in fact, who in many ways brought us the banking crisis. They have funded pro-market think tanks and achieved deep penetration into the Department of Health, into many of our health organisations and right into some of the senior levels of my party as well as those on the other Benches.

The NHS is totemic. It is about a pool of altruism and it speaks to who we are as a nation. It is the mortar that binds us in the way that the American constitution does the American people. For us, it is about this system. It really is the place where we are "all in it together"-one of the few places, it would seem at the moment. Doctors get 88 per cent trust ratings with the public, while politicians get 14 per cent. The vast majority of doctors are saying to us, "Withdraw this Bill". We should be listening.

Granddad, I have read most of these behind your back via Twitter and many Blogs. You should have listened. Now we are paying dearly.

Hansard source (Citation: HL Deb, 11 October 2011, c1551

Friday, February 22, 2013

Autism: Leo Kanner

“In 1943 Leo Kanner published a paper that would, with Asperger’s work a year later, form the basis of present day understanding of Autistic Spectrum Disorder. He considered five features to be diagnostic. These were: a profound lack of affective contact with other people; an anxiously obsessive desire for the preservation of sameness in the child's routines and environment; a fascination for objects, which are handled with skill in fine motor movements; mutism or a kind of language that does not seem intended for inter-personal communication; good cognitive potential shown in feats of memory or skills on performance tests, especially the Séguin form board . He also emphasized onset from birth or before 30 months.” From the book, The Cockroach Catcher.

A case extract from his original paper:

Donald T. was first seen in October, 1938, at the age of 5 years, 1 month. "Eating,......has always been a problem with him. He has never shown a normal appetite. Seeing children eating candy and ice cream has never been a temptation to him."

At the age of 1 year "he could hum and sing many tunes accurately." Before he was 2 years old, he had "an unusual memory for faces and names, knew the names of a great number of houses" in his home town. "He was encouraged by the family in learning and reciting short poems, and even learned the Twenty-third Psalm and twenty-five questions and answers of the Presbyterian Catechism." The parents observed that "he was not learning to ask questions or to answer questions unless they pertained to rhymes or things of this nature, and often then he would ask no question except in single words." His enunciation was clear.
He knew the pictures of the presidents "and knew most of the pictures of his ancestors and kinfolks on both sides of the house." He quickly learned the whole alphabet" backward as well as forward" and to count to 100.

It was observed at an early time that he was happiest when left alone, almost never cried to go with his mother, did not seem to notice his father's home-comings, and was indifferent to visiting relatives.

He does not observe the fact that anyone comes or goes, and never seems glad to see father or mother or any playmate. He seems almost to draw into his shell and live within himself.

He seldom comes to anyone when called but has to be picked up and carried or led wherever he ought to go. In his second year, he "developed a mania for spinning blocks and pans and other round objects." At the same time, he had a dislike for self-propelling vehicles, such as Taylor-tots, tricycles, and swings.

He was always constantly happy and busy entertaining himself, but resented being urged to play with certain things. When interfered with, he had temper tantrums, during which he was destructive. He appears to be always thinking and thinking, and to get his attention almost requires one to break down a mental barrier between his inner consciousness and the outside world.

The father, whom Donald resembles physically, is a successful, meticulous, hard-working lawyer who has had two "breakdowns" under strain of work. He always took every ailment seriously, taking to his bed and following doctors' orders punctiliously even for the slightest cold. "When he walks down the street, he is so absorbed in thinking that he sees nothing and nobody and cannot remember anything about the walk." The mother, a college graduate, is a calm, capable woman, to whom her husband feels vastly superior.

When he desired to get down after his nap, he said, "Boo [his word for his mother], say' Don, do you want to get down?' "His mother would comply, and Don would say: "Now say 'All right.' "The mother did, and Don got down.

At mealtime, repeating something that had obviously been said to him often, he said to his mother, "Say 'Eat it or I won't give you tomatoes, but if you don't eat it I will give you tomatoes,' " or "Say 'If you drink to there, I'll laugh and I'll smile.' "And his mother had to conform or else he squealed, cried, and strained every muscle in his neck in tension. This happened all day long about one thing or another

When he wanted his mother to pull his shoe off, he said: "Pull off your shoe." When he wanted a bath, he said: "Do you want a bath?"

The word "yes" for a long time meant that he wanted his father to put him up on his shoulder. This had a definite origin. His father, trying to teach him to say "yes" and "no," once asked him, "Do you want me to put you on my shoulder?" *Don expressed his agreement by repeating the question literally, echolalia-like. His father said, "If you want me to, say 'Yes'; if you don't want me to, say 'No.' "Don said "yes" when asked. But thereafter "yes" came to mean that he desired to be put up on his father's shoulder. He paid no attention to persons around him.

He gave no heed to the presence of other children but went about his favorite pastimes, walking off from the children if they were so bold as to join him. If a child took a toy from him, he passively permitted it.

He was inexhaustible in bringing up variations: "How many days in a week, years in a century, hours in a day, hours in half a day, weeks in a century, centuries in half a millennium," etc., etc.; "How many pints in a gallon, how many gallons to fill four gallons?" Sometimes he asked, "How many hours in a minute, how many days in an hour?" etc.

When asked to subtract 4 from 10, he answered: "I'll draw a hexagon."
The paper is quite a gem and students of child psychiatry are well advised to read it. Leo Kanner continually questioned the given wisdom of the day; couple that with his keen observation power and curiosity and a natural irreverence to authority, it was only natural that he should have created history by being the first to describe Autism.

Leo Kanner “thought what nobody has yet thought, about that which everybody sees.”
Erwin Schrödinger Nobel Prize in Physics 1933


The following is an abstract taken form the DISCUSSION SECTION of Kanner's original paper. It may be useful to have another look at what Kanner observed all those years ago. Fortunately for us, he had no other motive except for his keen medical curiosity and observational power:
......The outstanding, "pathognomonic," fundamental disorder is the children's inability to relate themselves in the ordinary way to people and situations from the beginning of life. Their parents referred to them as having always been:

“self-sufficient"; "like in a shell"; "happiest when left alone"; "acting as if people weren't there"; "perfectly oblivious to everything about him"; "giving the impression of silent wisdom"; "failing to develop the usual amount of social awareness" ; "acting almost as if hypnotized."

It is therefore highly significant that almost all mothers of our patients recalled their astonishment at the children's failure to assume at any time an anticipatory posture preparatory to being picked up.

Eight of the eleven children acquired the ability to speak either at the usual age/or after some delay. Three (Richard, Herbert, Virginia) have so far remained "mute." In none of the eight "speaking" children has language over a period of years served to convey meaning to others.

Almost all the parents reported, usually with much pride, that the children had learned at an early age to repeat an inordinate number of nursery rhymes, prayers, lists of animals, the roster of presidents, the alphabet forward and backward, even foreign-language (French) lullabies.

Thus, from the start, language—which the children did not use for the purpose of communication—was deflected in a considerable measure to a self-sufficient, semantically and conversationally valueless or grossly distorted memory exercise. 

It is difficult to know for certain whether the stuffing as such has contributed essentially to the course of the psychopathological condition. But it is also difficult to imagine that it did not cut deeply into the development of language as a tool for receiving and imparting meaningful messages.

"Yes" is a concept that it takes the children many years to acquire. They are incapable of using it as a general symbol of assent.

The same type of literalness exists also with regard to prepositions. Apparently the meaning of a word becomes inflexible and cannot be used with any but the originally acquired connotation.

Personal pronouns are repeated just as heard, with no change to suit the altered situation.

The repetition "Are you ready for your dessert?" means that the child is ready for his dessert.

The pronominal fixation remains until about the sixth year of life, when the child gradually learns to speak of himself in the first person, and of the individual addressed in the second person. In the transitional period, he sometimes still reverts to the earlier form or at times refers to himself in the third person.

Our patients, reversely, anxious to keep the outside world away, indicated this by the refusal of food. One child had to be tube-fed until 1 year of age. Most of them, after an unsuccessful struggle, constantly interfered with, finally gave up the struggle and of a sudden began eating satisfactorily.

Another intrusion comes from loud noises and moving objects, which are therefore reacted to with horror. Yet it is not the noise or motion itself that is dreaded. The disturbance comes from the noise or motion that intrudes itself, or threatens to intrude itself, upon the child's aloneness.

The child himself can happily make as great a noise as any that he dreads and move objects about to his heart's desire.

There is a marked limitation in the variety of his spontaneous activities. The child's behavior is governed by an anxiously obsessive desire for the maintenance of sameness that nobody but the child himself may disrupt on rare occasions.

Changes of routine, of furniture arrangement, of a pattern, of the order in which everyday acts are carried out, can drive him to despair.

Once blocks, beads, sticks have been put together in a certain way, they are always regrouped in exactly the same way, even though there was no definite design. After the lapse of several days, a multitude of blocks could be rearranged in precisely the same unorganized pattern, with the same color of each block turned up, with each picture or letter on the upper surface of each block facing in the same direction as before.

This insistence on sameness led several of the children to become greatly disturbed upon the sight of-anything broken or incomplete.

A great part of the day was spent in demanding not only the sameness of the wording of a request but also the sameness of the sequence of events.

It was impossible to return from a walk without having covered the same ground as had been covered before.

Objects that do not change their appearance and position, that retain their sameness and never threaten to interfere with the child's aloneness, are readily accepted by the autistic child.

Two patients began in the second year of life to spin everything that could be possibly spun.

The children sensed and exercised the same power over their own bodies by rolling and other rhythmic movements.

Every one of the children, upon entering the doctor’s office, immediately went after blocks, toys, or other objects, without paying the least attention to the persons present.

The father or mother or both may have been away for an hour or a month; at their homecoming, there is no indication that the child has been even aware of their absence.

After many outbursts of frustration, he gradually and reluctantly learns to compromise when he finds no way out, obeys certain orders, complies in matters of daily routine, but always strictly insists on the observance of his rituals.

There is a far better relationship with pictures of people than with people themselves. Pictures, after all, cannot interfere.

The astounding vocabulary of the speaking children, the excellent memory for events of several years before, the phenomenal rote memory for poems and names, and the precise recollection of complex patterns and sequences, bespeak good intelligence in the sense in which this word commonly used.

They all come of highly intelligent families. All but three of the families are represented either in Who's Who in America or in American Men of Science, or in both.

Autism posts:
Autism: Somalis in Minnesota and Sunshine
Autism, the Brain and Tiger Woods
Autism and Money

Wednesday, February 20, 2013

Photoshop Fun: Metamorphosis!

Sometimes ii is best not to DELETE!
 ©Am Ang Zhang 2012

 ©Am Ang Zhang 2012
 ©Am Ang Zhang 2012
 ©Am Ang Zhang 2012
 ©Am Ang Zhang 2012

Modern Cameras have a tendency to overexpose by my standards. I shoot most of my shots at -0.7 to -1.0 most of the time and check image. This includes snow scenes. 


©Am Ang Zhang 2012

High End Photography & Wine

Photography: Tasmania & Bokeh!