It has been a while since I reached retirement age and retired from the hospital where I worked. I now use one room in a private clinic where I humbly continue to see children with developmental disorders. On rainy days or cold or hot mornings, I suppress the feeling of wanting to stay in bed longer and stir up the energy in my aging body to go out.
However, this reluctant feeling quickly disappears when I treat truly troubled children and provide reassurance to the families. The other day, I saw several children in the morning and when the visits ended a little after noon, I was satisfied that I could still be of service to others. I was also bursting with energy feeling that I should not retire yet without pursuing the problems of medical treatment for developmental disorders in Japan, which I have continually pointed out that "something's strange."
I may have mentioned this in a previous blog post, but on the first visit by a child, before I read the letter of introduction and ask the accompanying parent the reason for the initial visit and consultation, I have a conversation with the child alone (with the parent in the room), asking various questions, showing picture books to the child and observing the child's response and behavior. In the case of children who show signs of delayed development or autism spectrum disorder, it is generally possible to make a rough diagnosis on the first visit.
The first child who came on this day was a seven-year-old boy. Following the example, I asked the boy several questions to see his understanding of the objective (being asked various questions) and moral dilemma questions, (in the presence of both parents, I ask "Who do you like better? Your mother or father?") Other questions included the names of friends, and finally, what the child would like to do in the future as an occupation, etc. I also carefully observed the child's eye contact and facial referencing when answering questions (action that show developed social skills).
The boy answered my questions briskly and in response to the question (moral dilemma) about which parent he liked better, he briefly glanced at their faces and answered "both," replying with ample understanding of the social reaction prompted by his remark. When asked about his future occupation, he answered "I don't know yet," another valid response. Most preschool children respond to such questions with a dream or aspiration of becoming a soccer player, a baker of cakes, or train driver. However, upon entering elementary school, they begin to see themselves more realistically and many come to answer, "I don't know yet."
After the short interview, I got the impression that the boy's apparent condition was not a type of developmental disorder (autism spectrum disorder or attention deficit hyperactivity disorder) nor something that gave the impression of an intellectual developmental delay.
Once again, I asked the child's parents the reason for coming and it was explained that the seven-year-old boy was currently attending a "special needs class" and according to the intelligence test (Tanaka-Binet Intelligence Scale), his IQ was 88. Before entering school, he had been diagnosed as having autism spectrum disorder (ASD) by a doctor at the local Child and Family Support Center and received documentation, but his parents were not able to accept that their child had been diagnosed as autistic. The reasons given for the diagnosis of autism were "does not follow instructions" and "does what he wants to do," which are non-specific symptoms and do not indicate a definite condition of autism according to the diagnostic criteria. This was the explanation written by the doctor who issued the medical certificate. At present, the child is a second-grade student in a special needs class, but from the teacher's point of view, the boy does not show behaviors that interrupt the class. Thus, they were told that from the third grade, he will still be enrolled in the special needs class, but will take all his classes now in regular classes.
When I asked if there was something difficult and troubling about him in child-rearing, nothing specific was cited. In particular, there was no mention of obsessive behavior or activity or hypersensitivity.
As far as child-rearing is concerned, there is nothing troubling about it, and while enrolled in a special needs class, he will be participating in regular classes from the third grade. Many of you might find this approach good and helpful and wonder what the parents are worried about.
However, upon listening to the parents talk, I felt a sense of déjà vu, a feeling that I had seen and heard this before! I asked them "What would you like me to do?" The parents then expressed their wish by asking, "Would it be possible for you to issue a new medical certificate?"
Fortunately, medical certificates written by doctors in Japan are recognized by society as highly credible documentation. However, misdiagnosis and overdiagnosis will sometimes occur, and for that reason, the system is arranged so that it is possible to seek and receive a second opinion. Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) both fundamentally involve genetic factors, and even among specialists in the field, many believe that the features will remain throughout one's entire life. However, in the case of ASD and ADHD, it is not unusual for deviations to arise between the disorder that is identified and printed on the medical certificate and the current condition of the patient. Sometimes, as time passes, the symptoms that determined the diagnosis become less severe, and regardless of the developmental disorder type, they will no longer hinder daily life. According to a book by Dr. Simon Baron-Cohen, an international authority on autism, the symptoms of ASD become almost indiscernible, and it clearly states that the diagnosis also then sometimes disappears clinically (see Something's Strange: Treatment of Developmental Disorders in Japan (5) Fixed Diagnosis).*1 The elimination of another diagnostic name which is similar to the example of the boy I recently saw, occurs when the initial diagnosis is overstated and exaggerated.
I reported that "at present, the diagnosis to be recorded on the child's medical certificate was "typical development," i.e., "healthy," and when I submitted the medical certificate, the parents were tearful with happiness. This may sound harsh, but a diagnostic name that no longer existed had been imprinted upon the patient due the existence of the medical certificate.
I have written "déjà vu" because in the past, a child with the same condition once came to me for treatment before starting school. At home and in daycare, there was no speech or conduct that indicated an impediment or a particular difficulty. When I consulted the doctor about rewriting the medical certificate of "autism spectrum disorder" issued in childhood, I was told that the term "developmental disorder" is a lifelong diagnosis and the term could not be rewritten. I recall the time when in response to my strong plea, the doctor made a strong parting remark and told me "Why don't you just throw away the medical certificate!"
Yoichi Sakakihara
