Kids Called Nerds: Challenge and Hope For Children With Mild Pervasive Developmental Disorders
Kids Called Nerds: Challenge and Hope For Children With Mild Pervasive Developmental Disorders
Michael was a handsome seventeen-year-old high school senior who was referred to me by another psychiatrist because of a treatment resistant depression and school failure. His parents, both teachers, told me that Michael had for some time been enrolled in special classes as a result of difficulties in school performance, despite his above-average intelligence. His adjustment to school had deteriorated rapidly during his junior year, and, on a number of occasions, he simply refused to attend. He complained that he was either ignored or picked on by other students and even by a few teachers. The teasing led to periods of extreme dejection and eventually to crying spells, first only when he was alone in his room, but eventually at school also, leading to more scapegoating.
His parents were a happy couple who set aside a great deal of time for family activities and led an active social life. They had always been aware of Michael's lack of friends, but they were increasingly alarmed as his depression progressed and he began to threaten suicide. He said he saw no future for himself. He feared his senior year in high school would "not be anything like it is supposed to be--like it was for my brother." Michael was referring to the high school experience of his more socially facile older brother, who dated girls and had numerous friends.
Michael was seen by a number of physicians, diagnosed as suffering from a major depressive disorder, and treated with antidepressants. When that was not entirely successful, he was treated with a major tranquilizer for anxiety and agitation, and eventually he was placed on lithium for mood swings. When I first saw him, Michael was on a high dose of imipramine, an antidepressant, had a therapeutic serum level of lithium, and had Mellaril prescribed as needed. He had been seen by competent clinicians who had recognized the extreme disturbance in his mood, along with his "odd personality," but who had failed to recognize the underlying cause of this boy's poor adjustment in school.
When I asked, "How are you?" Michael responded with speech that was mechanical and poorly modulated. With a strange smile, he replied, "This has not been a good day for me." Asked to elaborate, he noted that the school had had an end-of-the-year swimming party earlier that afternoon. He had always admired one of the more popular boys in the class and had approached him at this party, hoping to say hello. As the boy emerged from the swimming pool, Michael commented, "My! You certainly are wet!" On hearing this, the boy grabbed Michael by the arm and threw him into the pool. Michael, who was not wearing a swimsuit, was acutely embarrassed by this incident and immediately left the party. When I asked him to explain why the boy had thrown him in the pool, he seemed bewildered. He said, "I guess I just put my foot in my mouth." I asked what he meant by that, and Michael told me that, as he was thrown into the water, the other boy had said, "Of course I'm wet, I just got out of the pool, Dork. See what I mean?"
There are children in every large neighborhood and nearly every classroom who are easily recognized as different by other youngsters and often by adults as well. Eventually they are given a label: nerds. They suffer from an often-serious handicap that can go unrecognized by teachers, doctors, counselors and, at times, even parents.
This handicap can have tragic results. Surprisingly, the label "nerd" carries fairly precise connotations. "Nerd" appears in several dictionaries. The American Heritage Dictionary (Morris 1985) defines "nerd" as "a socially inept, foolish, or ineffectual person." Webster's Ninth New Collegiate Dictionary (Mish 1987) expresses a view of nerds that alludes to the contempt often felt toward these youngsters: "Nerd...slang (1965): "an unpleasant, unattractive, or insignificant person." The most obvious quality that nerdy children share is a lack of social and emotional intelligence.
For years doctors have had a hard time finding a diagnostic category for these children that could be helpful in organizing research, evaluating the results of treatment, and mobilizing funds for special services. Clearly, these youngsters are not autistic, yet on closer inspection they seem to have many of the traits of high functioning autistic children, but to a much lesser degree. They seem to be suffering a form of what child psychiatrists call a pervasive developmental disorder or PDD.
PDDs are defined by the American Psychiatric Association as characterized by qualitative impairment in the development of reciprocal social interaction, verbal and nonverbal communication skills, and imaginative activity. These PDDs actually lie along a continuum. Some forms are quite severe. These youngsters are often diagnosed as suffering from autism. Many autistic individuals have special skills, for example, in reading or mathematics, as illustrated by Dustin Hoffman's character in the movie Rainman. Some of the PDDs are less severe or are mitigated in some way by a particular child's cognitive and temperamental strengths, as illustrated by Tom Hank's lead character in Forrest Gump. Cantwell and Baker (1988) note that recent research supports a number of subtypes of autistic-like syndromes, ranging from severely retarded autistic children to high-functioning children with so-called atypical personality development.
The fact is that PDDs occur in attenuated forms that are not uncommon. I believe that the youngsters who are labeled as "nerds" by their peers actually suffer from a mild PDD (MPDD). Their handicap may go unrecognized by treating clinicians who fail to address the primary source of the considerable pain these youngsters experience. The results of failing to attend to these youngster's special needs can be tragic for them and for society as a whole and they often grow into isolated, depressed, and even dangerously angry young adults who may be at risk to harm themselves or others. The depression and anger is not a part of the original problem that these children are born with. It develops over time in response to the way these children, mostly but not always boys, are treated by other human beings.
Nerds are frequently featured on television, in movies, and in cartoons. In the popular Far Side cartoons, Larson illustrates "nerd convoys" and "nerd roundups." In the Revenge of the Nerds movie (now with four sequels) the protagonists are immediately identified as nerds; their appearance, mannerisms, and speech clearly mark them from the moment they appear on the screen. They are the object of derision and abuse until they exact their "revenge." Although nerds generally figure as comic characters, under stress real nerds can decompensate, resulting in significant morbidity and even mortality.
Before taking a look at the realities of these children's lives in a world where emotional intelligence is an essential survival skill, the following definition of this MPDD syndrome can be offered:
The syndrome is first apparent in the preschool years, when, in the presence of average or above average intelligence, children exhibit difficulties with reciprocal social relationships, despite a definite desire for companions. These difficulties are manifest in an inability to make and keep friends, in problems understanding and responding to social cues, and in showing little empathy for the feelings of others. The syndrome is accompanied by deficits in pragmatic language skills, often including poorly modulated speech and an inability (rather than an unwillingness) to adopt contemporary jargon successfully. There is, in addition, a difficulty in appreciating the arts, aesthetic pursuits, and other creative, imaginative endeavors. The syndrome is often associated with some degree of clumsiness.
This definition is similar to descriptions of Asperger's syndrome (Wing 1981). Asperger's syndrome, an autistic-like disorder, lies within the spectrum of the PDDs. Because this disorder is "less pervasive" than autism, it is easy to misdiagnose in an adolescent with a personality disorder, such as schizoid or schizotypal (Munro 1987). Individuals with Asperger's syndrome characteristically are socially isolated and display abnormal social interaction (Szatmari 1986). They may be not just shy but also abnormally garrulous or intrusive; their behavior is often not appropriately modified to suit the social situation. There are impairments in nonverbal communication and oddities in the speech of persons with Asperger's syndrome. There is frequently a history of problems beginning in the preschool years, such as an unwillingness or inability to engage in cooperative or imaginative play.
Perhaps many of the youngsters with MPDD fit the criteria of Asperger's syndrome. Until recently even professionals were not familiar with Asperger's syndrome. Now there is increasing public awareness of this disorder and any Internet search engine will find numerous references to web sites dealing with Asperger's. The term "MPDD" may have some advantages as a clinical designation of nerdiness because it implies that there is a continuum of children with dysfunction in language and social development. Use of the term "MPDD" avoids splitting this group of individuals into specific diagnostic categories, at least until there is more of a basis in clinical research to do so.
Nerds and Adolescence
Adolescence, because of its demands in the areas of social and language functioning, is a period of great risk for individuals with MPDD. When an individual suffers from a severe pervasive developmental disorder such as autism, it is common knowledge that, during adolescence, "there is often an exacerbation of aggressive, oppositional, or other troublesome behavior, which may last for many years" (p. 36). Contrary to the stereotype of the bookish nerd who stays out of trouble, these boys have a very difficult time with their adolescence.
Youngsters with mild pervasive developmental disorders will experience a crisis in adolescence because the skills that are necessary to accomplish adolescent developmental tasks are dependent on rather high-level functioning in the very areas in which these youngsters have deficits. Junior high school students have perceptual motor skills that far exceed those of the average adult. (Just try to compete with them at the video arcade!) Likewise, they exhibit sensitivities to social nuances and variations in language patterns that go well beyond their parents' abilities. Here is where the problem lies, as we shall see, because, nerds lack the ability to respond to subtle social cues appropriately and the ability to use language to establish identity and, later, intimacy.
During early adolescence, children display a wide range of social abilities. At one end of the spectrum are the popular, socially facile children, including both delinquent and non-delinquent youngsters proficient in manipulating their social environment. Next in line are the vast majority of children, who are skilled enough to avoid much of the teasing and social pain so common in junior high school. Then, along come the nerds, who occupy a place in the spectrum well short of the autistic extreme. Whereas autistic individuals, even the high functioning ones, have trouble from infancy or soon thereafter, the major problems for nerds begin in the older primary grades and intensify in junior high school. Nerds suffer enough limitations in their social awareness and social effectiveness to become the object of rather severe scapegoating, even among adults. They themselves are painfully aware that there is something wrong, yet they and their parents often cannot define the problem.
Secondary symptoms such as depression or conduct disturbance may begin to emerge, often obscuring the MPDD (or Asperger's), increasing difficulty with clinical recognition. When the coping mechanisms that these children employ fail, as they frequently do during adolescence, they may develop secondary psychiatric problems ranging from aggressive behavior to depression to psychoses. Clinicians tend to focus on these secondary symptoms, ignoring the primary syndrome.
When I began to write this chapter, I decided to do a literature search to find out what had been written lately on related topics. I called a friend I had known well since junior high school. He is a physician in his forties, single, living with his parents. He makes a living providing lawyers and others research services using his home computer and the Internet. I told him that I was interested in Asperger's syndrome and I asked him to see whether much had been written about "nerds."
When my friend sent me a printout of the results of the computer search, he included a note: "Your discussion triggered off a whole flood of memories of mine from junior high school. I can recall how I was accused of being from Mars and of reading the dictionary. I did not read the dictionary and was never conscious of speaking in a different vocabulary than my peers, but I assume my accusers were correct and what were ordinary words for me were peculiar polysyllable, pedantic nerdisms to them. Occasionally, I would flat-out misuse words or mispronounce them, which you and others called me on several occasions."
My friend's strongly positive reaction at feeling understood is a reaction that I have had repeatedly from older adolescents and their parents when I discuss these problems of nerds in developmental terms. I have come to believe that these individuals have felt stigmatized for a long time. Because they are rarely understood, they are relieved and appreciative when someone can say to them, "I think I know what the problem is here, even if we do not have a very good name for it."
My friend's comments brought back some of my own memories of him in junior high school. He was right. He was the object of unrelenting teasing not only for his vocabulary but for his speech, which was mocked for its atonal quality, his mannerisms, his utilitarian way of dressing (with the almost emblematic front-pocket plastic pencil holder), and his lack of athletic skill. He was ridiculed in the cruel manner of which perhaps only seventh and eighth graders are capable. I remember an occasion when a group of boys pushed his head through a hole in a concrete wall in front of the school. I remember also how confused and embittered he became, to the point eventually of assisting some of the more antisocial boys in placing homemade explosives down a school toilet, an activity that somewhat broke the ice for him socially. In high school, he was better accepted and even appreciated for his wide range of knowledge, but he never found social situations easy, and friends arranged the only date he had with a girl. In adult life, he has often been severely depressed.
Holistic versus Sequential Thinking
In order to understand better the particular handicap that plagues these kids called nerds, it is necessary to review a number of concepts presented by Tanguay (1984). He pointed out that, among those with PDDs, each child has his own profile of cognitive strengths and liabilities. The more we understand these children and their specific cognitive profiles, the more difficult it is to classify them together, as "autistic," for example.
It appears to be more useful to look at their ability to function along a number of cognitive parameters and to discern patterns in functioning that affect adjustment and clinical outcome for these youngsters. Tanguay suggested that it is important to recognize that neuropsychologists have identified two distinct forms of cognitive processing, the "holistic" and the "sequential" modes of thought. One may imagine that there is a spectrum of social adjustment among adolescents related to social intelligence, which is related to holistic thinking (and perhaps to right brain functioning). Social intelligence is the ability to read subtle, often nonverbal, social cues, to use social context appropriately in order to modulate behavior, and to use language in socially significant ways. Tanguay (1984, p. 377) writes:
Holistic thinking is nonverbal, and is presumably carried out using visual, kinesthetic, tactile and auditory images, with multiple parallel information inputs being synthesized and compared. It is particularly well adapted to activities such as facial recognition, spatial manipulation, or processing of the auditory "gestalt" of familiar words and phrases. Holistic processing may play an important role in the manner in which one deals with words in a punning, changing, metaphoric, creative, symbolic fashion, rather than in strict lexical and syntactic terms...sequential processing, in contrast, deals with the coding and decoding of meaning in terms of the relationship of elements within a sequence.
Sequential thinking is logical, both analytic and deductive. Explaining holistic thinking to patients with MPDD and their parents can be difficult. Although facial agnosia is not part of the MPDD syndrome, a discussion of the way in which the brain can recognize faces is often helpful when teaching these adolescents and their parents about holistic thinking. These patients often cannot imagine any mental activity that a computer could not be programmed to accomplish, yet facial recognition, thus far, cannot be computer simulated in the way that the human brain accomplishes it.
The relation of holistic processing to MPDD is fairly complex. Many youngsters with PDDs have an ability to use simple holistic skills and may even show superior skills in visual-spatial operations, yet they show significant deficits in complex holistic-processing abilities. The latter abilities include the use and understanding of subtle forms of nonverbal communication such as facial expression or gesture.
It is interesting to speculate about why most nerds are boys. It may be that the cognitive pattern associated with MPDD is in some ways an exaggeration of the normal male pattern. Indeed, fathers seem to relate more easily with their children who are nerds, and mothers of nerds often have difficulty in understanding why their sons have such poor social skills. Women with highly developed capacities for holistic, intuitive thinking may have the most difficulty in understanding MPDD children.
It is appealing to think of this in terms of right-brain versus left-brain functioning. Nerds are often capable of superior analytic (left-brained) skills. My friend knew a lot of good words. He just could not understand when or how to use them. Nerds' ability to use the right brain--in the arts or in social situations--is often impaired. They may learn music theory and learn how to operate a musical instrument, but they may find their best niche in the school band by becoming a manager keeping track of equipment and travel arrangements. In fact, nerds gravitate toward such jobs. In the past, it was operating the audiovisual equipment: a special card was issued, lending some prestige, and there was assured involvement with peers who could socialize and perform.
Brothers (1989) recently utilized a broad biological approach in considering the role of empathy in the development of clinical psychopathology. Brothers notes that "a defect of empathy (has been) a primary criterion for diagnosis of autistic disorder" (p. 13) and describes laboratory studies that could someday reveal the neural substrate of empathy--possibly involving the amygdala.
Nerds and Computers
For some teenagers, computers provide an escape from challenging social situations and a partial cure for the loneliness of MPDD. The computer itself provides a predictable pseudo-companionship, and computer users can also band together in common-interest clubs. Such teenagers can become involved with computers to the exclusion of almost all other interests. At an early age, they may reach high levels of proficiency with programming and even make contributions to computer technology.
Even though there is a great deal of chaos on the Internet, inter-personal contact on the Internet can offer a nerdy youngster a relative degree of protection from actual face to face social contact. For example, in "chat rooms" body language, facial expression, and intonation, pacing, and timing of speech are all eliminated from the social interchange. In role playing games the relationships between players are dictated by elaborate rules relating to objective traits the virtual individual has accumulated in the course of play. A boy who is "just a nerd" at school can become a powerful and feared warrior in an Internet fantasy game.
Because many of these youngsters are so hungry for social interaction, many of them spend an enormous amount of time at their computers, ignoring family, homework, and much of the "real world." Worse yet, for their sleep patterns, the computer is "always open." Many of these boys go to sleep later and later, especially in the summer, eventually shifting their cycle such that they sleep when the rest of the family is up. This only worsens their real social problems, no matter how successful their virtual character has become in a fantasy game.
Interaction with computers is satisfying because computers (usually) reward analytic thinking with success. This is not true of the adolescent social world. Long gone is the special status conferred on the boy who could run the projector, but a "computer wizard" usually feels good about himself. Since computers are not primarily mechanical devices and are often used for recreation today, such mastery often carries with it a certain mystique and status.
The popular youngsters in junior high school have an uncanny ability to negotiate the complex social maze. Appearance, which includes but is not limited to physical attractiveness, is instrumental in attaining social well being. This involves knowing how to dress and how to dress when. Nerds are easily recognized by their clothes. Front-pocket plastic penholders are practical, but only a nerd would wear one to junior high school. The same is true for eyeglass cases or eyeglass safety straps unless they are used for sunglasses).
Early in adolescence, youngsters must learn to make subtle distinctions between what is right to wear and what is not. Will you look better in tight or loose-fitting jeans? Should you let your pants sag? A little or a lot? Should you turn your cap backwards? Some boys can and some cannot. An entire industry closely watches (and perhaps helps create) such changes in adolescent fashion. Appearance is extremely important in determining one's acceptance among peers, and many youngsters are extremely sensitive to subtle and rapidly changing cues regarding their appearance. Much of this information related to fashion cannot be reduced to logical bits, and the ability to see the whole gestalt requires holistic thinking.
Just as wives often have useful suggestions for their husbands about colors and patterns in clothing, older sisters can be a big help to boys who "dress like a nerd." Still, changing appearance can occasionally make things worse. A nerd who dresses like a skater, for example, but cannot skateboard, runs the risk of eliciting even more teasing and being labeled a "wannabe skater."
Speech and Language
Shapiro (1985) has pointed out that adolescent speech includes endless variations on the theme of establishing group identity, so important to the psychological development of the adolescent. Litowitz (1985) describes three functions of language that are particularly pertinent for adolescents: the use of language to establish one's identity, including gender identity; the use of language to establish closeness of relationships; and the use of language for phatic communication, that is, the socially ritualized and reassuring use of language, as in "Hi, how are you?" or "Have a nice day" for us and "Dude!" for the seventh grader. Litowitz points out that adolescents realize that every utterance embodies two different forces: what one is trying to do with language and what one is trying to get others to do.
These communication tasks, as well as the effective use of language, require the use of both sequential and holistic modes of cognition. Perhaps one part of the brain provides the words and syntax, and another part provides the intonation and emphasis and helps ensure that what is said takes into account the complex social context of the conversation, with emotional tone regulated at still another neuroanatomical site. The individual who experiences difficulties in holistic processing is surely at a disadvantage in both generating utterances and producing appropriate speech acts.
Most of the evidence necessary to make a diagnosis of MPDD was apparent to me within the first three minutes of my interview with Michael. His attempt at social contact, both with the psychiatrist and with the boy at the party, required the use of speech for what is known as phatic communication, the establishment of an atmosphere of sociability. At the party, depending on what was "in" at the time, it might have been better for Michael to say, "What's up, Dude?" Just saying the proper words, however, would not have saved Michael, as nerds are notorious for saying the words in a mechanical way. The language of teenagers is especially dependent on pitch, tone, and rhythm. In fact, the entertainment industry continuously markets specific new speech patterns, such as "rapping," and vocabulary, such as "bad" meaning "good," as they emerge among adolescents. Michael could not even hope to say " What's up, Dude?" in a way that might have elicited acceptance from his peer.
These skills are called "pragmatic" language skills and youngsters with shortfalls in this area experience difficult situations several times a day. The social consequences are disastrous. Michael had a birthday shortly after he began seeing me and invited twenty other teenagers to the party. Such "social optimism" is typical of nerds. (Nerds will ask the most sought after girl in the school for a date.) Despite the fact that his family was able to offer a nice setting for the party, only two youngsters attended. It is no wonder that Michael was unhappy. continual rejection can lead to withdrawal or even the symptoms of a major depression, which Michael manifested.
Psychiatrists frequently mistake MPDD youngsters for schizoid or schizotypal teenagers. Both nerds and schizoid youngsters often have no close friends of a similar age other than a relative or a similarly socially isolated child (the first criterion for diagnosis of schizoid disorder). Schizoid children, however, have no apparent interest in making friends and do not derive pleasure from the usual peer interaction. They generally avoid nonfamiliar social contacts, especially with peers. Nerds, on the other hand, are painfully aware of their difficulties in establishing normal peer relationships. They may have a great deal of interest in making friends and, until their failures become too unbearable, will seek out social contacts. For a nerd, it is better to be at the party, operating the stereo or helping start someone's car, than not to be there at all.
The Revenge of the Nerds movies are full of examples of nerds' deep desire for normal social contact. In the first movie, for example, the older adolescent nerds eagerly anticipate an enjoyable college social life, including heterosexual experiences. Both movies demonstrate repeatedly how difficult it is for somebody to escape the social stigma of being a nerd, how easy it is for people to recognize nerds, and how little nerds seem to be able to do about changing their image. Nevertheless, the movies emphasize that, in spite of these obstacles, the nerds have a strong interest in social relationships.
Another part of the differential diagnosis is avoidant disorder. Avoidant teenagers may appear awkward socially as a result of extreme anxiety. This anxiety may make them feel like nerds and even act like nerds. If they can overcome their anxiety, it becomes clear that they have more than adequate social intelligence and normal speech and language development. Nerds do not avoid social situations. They often seek them out, particularly in adolescence, but they misread the social situation miserably. After repeated, painful rejection they may withdraw. It is during these times that they may begin to think about harming themselves or others.
Thus, the schizoid youngster does not particularly want to go to the prom and asks nobody to go to the prom; the avoidant youngster may want to go to the prom but is too shy to ask. If a date is arranged with whom he is comfortable, then he may well go to the prom and enjoy himself. The nerd may ask one of the cheerleaders to go to the prom and is unable to understand why she laughs at him. The avoidant adolescent must learn to overcome the anxiety that surrounds social interactions; the nerd requires specific training in how to understand and negotiate the social maze of adolescence.
Some might argue that nerds are simply extremely intelligent, somewhat eccentric youngsters. For some time now, it has been known (Terman 1925) that bright youngsters are typically healthy and well adjusted. They use both sides of the brain well. While many nerds are blessed with superior analytic skills, particularly those skills important in science and mathematics, they lack social intelligence. The writers of Head of the Class, a television situation comedy about a classroom filled with extremely bright youngsters, have recognized the distinction between the nerd and the intelligent young person. They have included one or two boys whose social ineptness provides a great deal of the humor in the series; however, other equally bright adolescents in the class are socially quite adept. Wood Allen is able to identify with the bright but socially inept nerd and can humorously portray a nerd, yet he obviously is an extremely skilled observer of relationships and subtle social cues and could not himself be called a nerd.
MPDD and the Media
Many of the situation comedies on television include a nerd, usually as a friend of the family. Nerds provide a constant source of humor, but, when this form of dysfunction happens to teenagers in real life, it is not at all funny. One reason for the heavy use of nerds in television and movies is that many people identify in some way with nerds. We all can feel nerdy at times. We all have taken things a little too literally, have misread social cues, or have stuck our foot in our mouth. It reassures us to see someone on television who behaves inappropriately in the extreme. Perhaps because of feelings of discomfort over our occasional social miscues, we also enjoy seeing socially inept persons reap revenge, as they do in many television dramas.
Years ago there was a television sitcom, Small Wonder, about a little girl who is actually a robot created by her parents and programmed to perform all the functions of an ideal child. She also provides humor in the show by misreading social situations. Tact is something that is difficult to teach. In all these television sitcoms, the person who plays the role of the nerd will frequently be too candid in situations that cause embarrassment to others and eventually to himself. Another television show from the past employed an extraterrestrial, Alf, who was quite engaging and had the potential to learn appropriate earth social behavior, but he has many of the difficulties that nerds have with understanding family life. He is constantly "in the doghouse," so to speak, with his adopted, earth family. The Conehead fammily, also from "outer space" on Saturday Night Live is yet another of many examples of humor derived from a characters poor pragmatic speech skills plus an inability to properly read social cues.
Adjustment to New Family Situations
There are special problems for kids with MPDD whose lives lead them into complicated family situations, as occurs so frequently today with the high rate of divorce and remarriage. It is extremely difficult for a healthy adolescent to deal with all the complex social changes that arise following a divorce, but it is even harder for an adolescent who is a nerd. Two teenagers whom I saw recently had parents who had remarried; both boys were living with their fathers, stepmothers, and stepsiblings. In each case, not only were the new stepsiblings embarrassed to be associated with these youngsters at school, but also both boys found it almost impossible to develop relationships with their new stepmother and stepsiblings. They each quickly became the family scapegoat, blamed for nearly all the tension inevitable in blended families. These youngsters had special difficulties with stepsisters, and, interestingly, both went through periods of hostile acting out toward these girls.
Nerds in School
Although the social problems of nerds with peers are obvious, they may also have significant problems in the classroom, which is usually seen as their "home turf." Educators are well aware that, beginning in preadolescence, students are expected to practice various levels of higher-order thinking. Rather than merely decode information, the fourth grader is expected to put information together in interesting and informative packages. This involves the ability to encode information already learned and produce an original product. It also involves the ability to identify with a potential reader of one's work, to evaluate the work of others critically but sympathetically, and to develop skills such as persuasion.
In adolescents with MPDD, teachers may notice either undue formality or familiarity with adults in the school. The teen may continue to raise his hand with the answers when it is clear to all that he has already had his fair share. He may not know when to stop with his answers, exploring every aspect of the question to the exasperation of all. He may direct poorly tempered criticism at the creative projects of other youngsters.
From a diagnostic standpoint, written material may not reveal the problem, as it might with a thought disorder or a language disability. One needs to know the nature of the assignment in order to judge the writing of a child with MPDD. For example, in English class, the assignment might have been to write about an experience that the child had over the summer. Expecting a personal reply, the teacher may receive, instead, a science article on the recent heat wave and changes in climate caused by a hole in the ozone layer.
In the movie Back to the Future, the protagonist, played by Michael J. Fox, is an adolescent cursed with a socially inept father. While the father sits glued to reruns of situation comedies, laughing periodically in the same bizarre way that the nerds in Revenge of the Nerds do, the mother has turned to drinking. When this teenager is able to travel back in time, he meets his parents as they were as adolescents. He discovers, to his dismay, but not his surprise, that his father was a nerd. He spends much of the movie teaching his teenage nerd father social skills in order to make him attractive to his mother and thereby ensure his own eventual birth. When he returns to the present, he finds that the social skills he taught his adolescent father have resulted in a radical change in his adult father's new present life: an improved marriage and participation in sports and social activities.
In theatrical presentations, there is often the implication that beneath the exterior of a nerd is a warm, empathic individual. The male nerd need only remove his eyeglasses; the female nerd need only let down her hair (as Marian the librarian does in The Music Man). Social skills training with real adolescents is rarely as easy as it appears in the movies. However, social skills training can help a great deal. Rather than remaining discouraged and hopeless, parents need to know there is much they can do to improve their MPDD youngster's social skills. One can tell people that this kind of a problem is not so much an illness as it is a handicap, and, as with other handicapping conditions, one can work to minimize its effect and hope for improved functioning over time.
Many schools are beginning to recognize that there are children whose adjustment to school and to life will be enhanced by social skills training programs. Some schools offer groups that specifically assist youngsters with pragmatic language skills, such as asking someone to join you at the movies. Some colleges actually offer special programs for young adults with PDDs. As a part of these programs, a big-brother-type relationship is developed for the impaired freshman to provide him with an adviser about college social life. Such advisers teach these young adults how to avoid scapegoating (which, sadly, can continue into college) and how to develop appropriate friendships with the opposite sex.
The treatment of this disorder begins with treatment of any secondary psychiatric disorder that is present. This could include psychiatric hospitalization and medication when severe psychiatric complications are present. Next, it is important to provide therapy in pragmatic speech skills. Social skills effectiveness training includes a number of topics: how to begin a conversation, how to maintain good eye contact, how to request something from a peer, how to listen carefully to others, and many more skills that can be analyzed and taught. My patient, Michael, whom I have described, once said to me, "Notice how I'm making good eye contact?" (His rhetorical question suggests that he has learned social skills mechanically, in much the same way that autistic youngsters learn social skills.)
Finally, it is necessary to manipulate the home environment to enhance social success. Although there is often more than one nerd in a family, particularly a father/son combination, it has been my experience that many MPDD children have parents and siblings who are quite adept socially. Reframing the patient's problem for other family members can decrease scapegoating within the family so that siblings may become more sympathetic and less isolating or hostile toward the MPDD youngster. Family members can engage in role-playing with the adolescent, teaching him how to deal with typical social snags that occur in the course of daily living. The child can be encouraged to join special interest groups that provide for social contact around a particular, well-defined activity. Stamp, chess, train, and computer clubs are all examples. Some of these youngsters do well in scouting because the merit-badge system is structured to enhance self-esteem in highly defined ways. Sports activities that involve clear, simple goals, such as body building or blocking on the offensive football line, and minimize teamwork and instinctive sports skills, such as anticipating an opponent's behavior, can enhance self-esteem. Some of these youngsters recently seem to be attracted to paint ball games, despite the requirement for some teamwork. The more accepting and adult supervised the group is, the better, and church youth groups are often ideal, with minimal scapegoating of unusual youngsters.
Hope for the Future
For years we have disparaged a group of people by referring to them as nerds. They have been the objects of our laughter on cartoons, the stage and our screens, big and small. I am suggesting that nerds suffer from a syndrome that is actually quite painful. For a number of reasons, the syndrome can be thought of as a mild but pervasive developmental disorder. In particular, nerds' notorious difficulties in holistic thinking appear to involve inadequate information integration, possibly involving a neuropsychological handicap. The core problems in these youngsters are often missed by clinicians. The diagnosis of a nerd as suffering from an MPDD does more than give him yet another label. It suggests possible interventions, and it can change the way the patient and his family perceive the way he functions.
Do nerds ever get revenge, as in the movies? Perhaps when we read about computer viruses or mail bombers, we are seeing the product of bright MPDD youngsters who harbor enormous anger at society. In fact, the cost to society of not providing help and sympathetic understanding to these youngsters may be bigger than we realize. Most nerds never do get revenge, nor do they seek it. Our goal as clinicians should be to avert the tragedy of emotional pain, loneliness, and secondary psychiatric disorders that have gone unnoticed in the past. I believe that this goal is worthwhile and that it can be accomplished with early recognition and appropriate response to the needs of these children. It is important that all who are in a position to help these children come to understand them better because without sensitive and effective intervention the lives of these children can take a tragic course.
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© Nicholas Putnam, M.D.
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