NEW SEGREGATION IN THE MENTALLY RETARDED:

BIOLOGICAL INTERVENTION DENIED.

Renato COCCHI, neurologist and medical psychologist.

(Italian translation) // Testo in italiano

Abstract.

According to a Judgement by psychologists, educationalists and rehabilitation professionals, the mentally retarded can be only treated with a psychological approach in a broad sense, also when there is an evident and demonstrable biological basic lesion, as for example Down's syndrome.

This choice, which for years seamed the only one possible, is not only wrong in conception, but it is damaging the mentally retarded.

The non-medical and often anti-medical ideology denies the possibility of a biological treatment to correct a neurological dysfunction responsib1e for a mental false-insufficiency, a share of which is always present in subjects with retard on sure lesional basis.

To have prevented or discouraged a possible biological treatment could have in fact lost many precious years, during which the brain plasticity is still suitable, at least as a possibility in developing dendritic arborization. A biological treatment in brain neuronal disorders is not a comprehensive solution of mental retardation, but is compatible with every other type of treatment.

Key words Mental retardation; psychology, rehabilitation, nonsense, biological intervention; deny.

Mental retardation

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Recently, making a comment to a book review on the evolution of a psychiatric institution in Bologna, for the admission of the mentally retarded, I anticipated as a hypothesis, a belief that begins to be ever more actual. I quote what I noted.

"As to the book itself, anti-medical ideology of the two authors leaves fortunately the time it finds with a fastidious "retro" effect of verbal stereotyped statements of saint-vincentism made by leftists, and appeals to future good intentions. Maybe it is time to start asking around a precise question. Is there also a sociologistic and/or a psycholoqistic segregation that stops the accomplishment of individuals' potentialities that can come to surface only if these persons modify their biological substratum? When we are always waiting for finding the "preceding" foreigner, has someone red "Awakenings" by 0. Sacks?'' (R.C., 1992).

An experience of over twenty years in the drug treatment on the mentally retarded, and over ten years Down's syndrome subjects (Cocchi, 1997; 1988, 1989; 1992) obliges me to make clearer the above. This polemical comment hides a nucleus of fundamental problems that touch the actual approach with the psychiatric patients, in general, and with the mentally retarded, adults or children, in particular. It is time to face these problems directly.

The rehabilitative approach to the mentally retarded: The beautiful story of a previous illusion that today, unfortunately, goes along too.

For years we have cherished a false belief. The mental retardation is a stable fact and only the rehabilitation, and/or the psychology and/or the pedagogy can, for a little, reduce the entity.

As the major part on the cases depend on causal pre-, peri- and neo-natal factors. In many subjects it becomes evident only from late the first year of life, as delayed motor and mental development, and from the second year as a delay in speech. Acquired facts, although being a much discussed statement, argue that a rehabilitative therapy, in cases of children palsy, is much more effective when early started.

The same, for extension, has been codified also in the mentally retarded. The intellectual development up to six years of age is a sensory-motor stage, according to Piaget, 1931. Then, the enlarging idea of it had the consequence that a psychomotor therapy or sensory stimulation (enrichment), would be the most reliable rehabilitative intervention suitable, if applied early in life. In later life pedagogy will bring a decisive contribution, and psychology reigns over everything benevolently.

Possible changes are only in the fineness that become part of the same approach. What we can obtain is a good result anyhow, since there is no other alternative available, out this pattern of treatment (Baldwin, 1994). In this rehabilitative program spread all over the world, there is already a series of fallacies on methodology if not true and real errors. We do not take them lightly, though these can mark the mentally retarded for the rest of his life.

This though ie all. The rehabilitation professionals, the pedagogists who have self-proclaimed psycho-educationalists, the non-medical psychologists, (but also many physicians as psychologists or not) did infer a more dangerous guideline from this approach. Every proposal that does not enter this recommended range, and in particular every biological approach either than a sedative one (Tu and Smiths 1979; Kirman, 1985) is surely the fruit of ignorance or of charlatanism (for Down's syndrome, see Cocchi, 1993).

An analysis of the phenomenon of the mental and its therapeutic and rehabilitative implication.

The actual idea if mental retardation turned to identification from a purely phenomenal point of view, is ambiguous and misleading. So because it includes at least two conditions, which are totally different as for aetiology and prognosis.

We can find mental retardation both in mental deficiency and in mental pseudo-deficiency. In the first case retardation is due to a lesion, in the second to a dysfunction. In mental pseudo-deficiency retardation is completely reversible, in mental deficiency in spite of the best possible treatment a share of the retardation will always remain (Cocchi, 1992). I will develop my argument concerning mental pseudo-deficiency which has depressive bases of somatic origin.

So I term depression as a deep inhibition of areas, structures or bran mechanisms in charge of cognitive functions. There is a great majority of mental pseudo-deficiency, and their casual factors are the same that give origin to mental deficiency - excluding, but not all, the genetic and chromosomal factors. We could remember some forms of phenylketonuria - which act in the same pathological way, but have not reached a lesion intensity (Kutter, 1978).

Also the mental pseudo-deficiency of this type has a biological base, like that of any true mental deficiency. At the difference of this last, not having a primary neuronal death, may have complete reversibility, but only if treated adequately for a due time. "Adequately" means to treat it with an approach able to modify the disorder.

There being a biological base, the approach which has more probability of success cannot be but biological. A rehabilitative or pedagogical, or psychological approach in wider sense, presumes that the stimulus that therapeutic professionals want to give, will be effective. Id est. It shall be regularly perceived and processed by areas that should be functional, in spite of dysfunction.

It is worth saying. I maintain that it is totally improbable that a biological trouble, when of intensity more than light, can be resolved with non biological means. "For a due time" signifies that we need to apply the treatment before the brain plasticity stops to act. With brain plasticity I mean at least the possibility of a recovery in the dendritic development on the neural cells. Once again the neuro-pathological investigation conducted by means of autopsies confirms what the clinics have been saying for some time (Iida et a1., 1993). Fifteen years of age appear the limit of the normal dendritic development.

Nevertheless, we must not forget that an eventual therapy, even biological, takes a long time. Therefore, it must be by force started years before this age limit. How many years before? If we consider common evidence, known to all teachers, that delay generates delays following a perverse cycle, then the recuperation will be much easier when the delay is less. According to that, we should start a biological therapy as early as possible in first years of life, as in other rehabilitation treatments.

Many people can object that a biological treatment is not necessary, since a rehabilitative treatment obtains some results in all mentally retarded, even with sure base lesions. That is true. We can always obtain something, because we can always act on a small share on mental pseudo-deficiency derived from secondary depression, of psychological origin, due to some awareness of his/her mental retardation. Like in all depression sufferers, it can drive to some inhibition of intellectual abilities. In the mentally retarded, there is therefore a second share of inhibition, of psychological origins in a broad sense.

Then a psychological treatment in a broad sense is therefore a form of approach adequate for such an allowance. Does exist this kind of awareness in one's own incapacity of the mentally retarded? We surely cannot ask them in these terms, but we had an extremely significant signal. When the child is aware of his difficulties, this fact disturbs him to a point to start an avoiding strategy, and refuses also to carry out tasks that he would have been well able to do. To make clear the fear of putting himself to the test and not succeeding, makes him refuse even simple tasks.

Is it a behaviour somehow clever - choice of the least difficulty - or is it simply a kind of conditioned reflex? This is also difficult to say, and its presence in severe mentally retarded makes one think that this behaviour does not solely derive from some form of intelligence, because its close relationship to emotions. A psychological treatment, in a broad sense, can obtain some results in the reduction of mental retardation but it will obtain so only in the share of secondary retardation, of "psychological" type.

Primary retardation of biological origin, like pure mental pseudo-deficiency, or like mental deficiency + mental pseudo-defsciency, will always remain unaffected because not being treated. That is said as a relevant result, but we must remember that now we can do much more. Today we can intervene directly, with biological means on the mental pseudo-deficiency which support completely or in part mental retardation. (Cocchi 1987, 1988, 1989, 1992).

The psychological, educational separation and the disagreed rehabilitation in the treatment of the mentally retarded.

We can be isolated for life within prison walls, but we can also be so in our own body or mind. Multiple sclerosis is a typical isolation due (principally) to our body, even if the scattered lesions are in the brain. The mentally retarded adult is not isolated in his body but prevalently in the mind, first as prisoner of an inability to understand.

Like any prison, this can be almost hard, according to the seriousness of the mental retardation (Coenen-Huther and Rusconi, 1986). The aim of every intervention in the mentally retarded cannot be but to reduce the extent of the known deficit and to improve the relationship of the mentally retarded and society. This can be a one and only task or they can be two separate tasks.

For the second task, being impossible to adapt easily the mentally retarded to society, the opposite way has been chosen, that to adapt society to the mentally retarded. This process, known as "social integration," has surely its own value and is a strategy that we need to follow but it cannot be the only one put into practice.

In fact it is not so. Rehabilitation comes first and later education, and in some way they try to reduce the difference between intellectual performances of each retarded and these usually maintained as normal, in a due social context. It is tried though to reduce also the intellectual deficit. These therapeutic techniques obtain some results.

So they have made the professionals who apply them to presume these as the only ones possible. But they presume also that every other should be excluded. Since the technicians of rehabilitation, the psychologists and the educationalists are rarely medical doctors, a methodology error added to non critical defence of their status let them to assume the principle of exclusion of any medical intervention.

From a biological point the reasoning at the base of this behaviour owns a coarse conceptual error. In spite of the fact many mentally retarded have a biological base, the biological interventions are considered useless, if not dangerous. In this sense a massive action of ill information to the families and school is carried cut. Many physicians are agreeing with this action, who reason by ear and do not fully value all implications of such similar conduct.

This conceptual position, broadly diffused, and the behaviour derived from it, let the outcome of several remarkable consequences, such to implicate the entire life of the mentally retarded. i. The results obtained are much smaller than one could obtain with an integrated approach. ii. School delay generated more school delay, as years go by, iii. The remediable retardation, if not confronted in time becomes irremediable, when the neuronal plasticity after 15 years, will not be an ever available resource. iv. With bad information, - drugs ALWAYS do more harm than good - one dissuades parents from trying an alternative treatment.

So one sentences their retarded children and the parents themselves to the worse condition of an individual and familiar handicap. v. Anyhow dissuading the parents from attempting a possible biological intervention, makes up a medical choice, which technicians who are not physicians cannot decide.

By the Italian law these technicians commit, in reality, an offence called "illegal exercise of the medical profession." As a diffused conviction, the anti-medical approach in the treatment of the mentally retarded as already hindered many subjects in recuperating a part of their intellectual development, although it was possible to do it.

So it has destined them to a more segregated adult life, due to a lesser ability than the biological brain base in the same subjects could have permitted. It exists and it continues to exist, at least in Italy, a diffused destruction of intellectual possibilities of the mentally retarded, who are prevented from developing their intelligence to a higher level by ignorance and a dominant anti-medical prejudice.

The most disconcerting fact of the entire problem is that the biological approach not is only it not in contrast with the other rehabilitative options, but it has not and cannot have any pretence of exhaustion. It can become the winning choice to modify favourably the ground that all rehabilitative and educational approaches apply (Cocchi, 1987).

Conclusions.

The non-medical and often anti-medical approach of psychologists, educationalists and rehabilitation professionals in the treatment of the mentally retarded is a wrong idea. Its pretence of being the only possibility has produced and goes on to produce a damage to the mentally retarded.

So because it prevents a recovery of biological functions that, as mental pseudo-deficiency, in total or in part sustain primarily the mental retardation. A biological treatment turned to restoration of areas not lesioned, but made unable to function by the same pathogenic agents of mental deficiency, has more probability of being effective if early applied. It means to say, as much we can exploit neuronal plasticity, as dendritic development.

Also recently it has been confirmed that this plasticity tends to reduce to nearly zero after 15 years of age. One mentally retarded on a biological base who has recuperated part of that retardation, because a share of it was not lesional, but functional, will be a minor burden for the family and society. Without consideration lesser emotional and social costs, he wi11 have economical costs lesser when he had reduced his mental retardation.

References.

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Cocchi R.: Esperienze di terapia farmacologica nell'adulto Down. Riv. It. Disturbo Intellet. 1988, 1: 57-69.

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Coenen-Huther J., Rusconi S.: Handicape' mental: Quel devenir scolaire et (pre')professionnel? Etude de la population qenevoise des handscapes mentaux susceptibles d'une integration prefessionnelle. Ann. Med.-psychol. 1986, 144: 807-832.

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First printed on It. J. Intellect. Impair. 1993, 6: 23-28.

Author's address: Renato COCCHI, MD, via Rabbeno, 3

42100 Reggio Emilia (Italy).

renatococchi@libero.it

Italian translation // Testo in italiano

Mental retardation

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