Blog: What is Normal Part III

What is Normal? Part three

Can a medical condition ever be normal?
Sometimes this is a matter of semantics. I would argue that technically, autism is not normal, in that it is clearly a statistical outlier. However, there are many adults with autism who are living fully independent lives, including raising a family of their own. For practical purposes, I consider such a person as ‘normal.’

The more important question for me, in deciding normalcy when there is a medical diagnosis, is whether treatment is required. Some have argued that autism should not necessarily be treated, and that making a child with autism ‘normal’ is a bad thing. However, the goal of treatment should not be to normalize someone, but to enhance functioning. If someone with autism can communicate their needs well, even if in a quirky fashion, that does not require treatment, but if they cannot communicate, they do. The goal is not to make the person normal, but to enable normal functioning.

How to decide if a condition requires treatment? My mantra is ‘it’s a problem if it’s a problem.’ Looking at myself, I was a clumsy child who did not like tags on the back of my shirt, or finger painting; nowadays that would be considered a sensory processing issue. We did not have occupational therapists back then, so how was this handled? My parents cut the tags out of my shirts, and the school said I could do a different arts project than finger painting. One area where I did need help was in writing, which was an essential skill back then: writing for me was a problem because it was a problem. I had to practice this often, and eventually my writing became, for a while, legible.
Even abnormal conditions for which we have medications do not necessarily mandate them. Perhaps the most common is ADHD. Most (but by no means all) children with ADHD have problems both in school and with some interpersonal interactions. We can treat ADHD with medicine, effectively in most cases; adding counselling works even better. However, if a child with ADHD is functioning well, getting by at school, making friends, etc., they do not require medicine, even if they are not ‘performing up to their potential’ (after all, does anybody truly perform up to their potential?). Medicine is not a cure here, but only treats symptoms, and it is also not useful as prophylaxis to prevent problems down the road. One can hold off on treating ADHD with medicine in such a child until problems warrant it later on, if ever.

Another abnormal condition we see in children is migraines. Some children may have a migraine twice a year. My recommendation for such children is to take ibuprofen, go into a dark room, try and fall asleep, and write the day off. Other children may get migraines once a week, which is clearly too often and disruptive, and for those children I prescribe medicine. How do I decide how often for a migraine is too often? I don’t – I let the family tell me, since they are the ones living with it, and migraines are not life threatening.

Many other conditions, especially ‘psychiatric’ ones, fall into the category of ‘it’s a problem if it’s a problem.’ If a child has an obsession and can only ride in the right rear seat in a car, that is unlikely to be unmanageable, and does not necessitate treatment; however, if they can only ride in a blue Volvo in a right rear seat with Daddy and nobody else driving, now it’s a problem. Is your child just shy, or do they have social anxiety? Are they prone to moods, or clinically depressed? For close calls, that’s for the family, not me, to decide.

Looking at the other side of the coin, are there pediatric conditions which are not causing any problems, but still need treatment? The answer is yes. I am going to circle back once more to perhaps the most important of these today, by looking at body mass index (BMI). Elevated BMI is a potential marker for prediabetes, an asymptomatic condition. However, many of these children will go on to develop diabetes, a serious condition with lifelong complications including liver, heart, kidney, and many, many other problems. It is much easier, and better, to try and prevent diabetes before it occurs, by dropping the BMI (and only slight changes here can often succeed).

Bottom line, when I look at children through the spectrum of normal/abnormal, my focus is not specifically on achieving ‘normalcy,’ although that concept does play a role in my thinking in many cases. Rather, what I am focusing on is trying to ensure that every child, to the greatest extent possible, is able to live as independent and healthy an adult life as they can; normal and abnormal are just useful constructs on the way to achieving that goal