YOU, WHO?! | Peter Bingham
As a child neurologist, I am challenged to interpret episodic behaviors, puzzling paroxysms, sometimes called “zoning out” in children—though I’ve learned to avoid this vaguely derogatory term. The diagnostic question continually arises: “Is this child having epileptic seizures?” Our brains, the ultimate mediator of our behavior and our experience, deliver a diverse range of episodic symptoms, which I try to name to make the episodes seem less threatening. “Name it to tame it,” as the child psychiatrist Daniel Siegel emphasizes.
One day in December, an eight-year-old boy was brought in by his parents, referred by his 2nd grade teacher for staring events. When the teacher calls his name, there’s a delay before he responds, and then he can’t remember what just happened in the classroom. The episodes happen more at school, though his parents have now also noticed his “spacing, zoning out” and say it’s been going on since October. It often takes a few seconds, as they snap their fingers — “Yoo Hoo!”— before he “comes around.” Though he has otherwise been well, the parents feel concerned about a possible neurological problem.
I’m doing my job, looking for trouble. And I must be wary of my own confirmation bias: Each year, most frequently in October and November, I receive referrals from schoolteachers whose students are staring off, not paying attention, not responding to their names; almost none of these cases prove to have a neurologic diagnosis. Understandably, the teachers don’t want to overlook absence epilepsy, also known as “petit mal” epilepsy.
I ask my patient what he thinks is going on. “I don’t know, the teacher or my parents are suddenly looking at me, asking me to remember something.” “Is this a problem for you, does this bother you?” I ask. “No, not really, but I wish they wouldn’t keep asking me what’s going on," he answers. I turn to the parents and ask them about four aspects of these “spells” that help me distinguish the more common “zoning out” from absence epilepsy:
• Sentinel—how do people first notice the staring? Is there an interruption in the flow of my patient’s activity? Or is he more often “discovered” in the staring state?
• Context—is there a time or place where staring episodes tend to occur?
• Frequency—how much time could pass and no one has seen the staring?
• Duration—how variable is the duration of the staring (variable duration would weigh against an epileptic basis)?
For this young boy, the case for absence epilepsy “strikes out” on every point: When his parents and teacher notice the staring, he’s already staring. It doesn’t punctuate the flow of his activity. His staring events tend to occur at school, mid-morning; weeks could pass and it doesn’t occur; staring events may vary from 5 to 30 seconds, not the 2-5 seconds characteristic of absence epilepsy.
Classrooms, dinner tables, competitive sports, chorus concerts—these have been among the contexts prompting referrals of staring children to my office. But the reasons behind staring spells vary and can include poor sleep, an adverse experience or a medication side effect. In many cases, staring off in these contexts seems to be a sign of stress; we human beings may dissociate when encountering expectations we may not feel capable of fulfilling.
In the present case, accurately interpreting the “history of the present illness” begs the question: “Is my patient, in fact, suffering from an illness?” I’m in that familiar, happy place, that important role, as an academic, pediatric specialist, of reassuring my patient. “I think you have a beautiful, healthy brain; it’s normal that we human beings sometimes need to pull away from what’s going on around us for a few moments, and we often stare when we do that.” I explain to the parents that their child doesn’t have a neurological problem. But they still want answers.
I can only speculate about why their son stares and doesn’t respond for a few moments: How much noise was there? How has he been sleeping? Did he just need some quiet time? How is his learning at school—does he get confused, challenged, stressed in some way? Might he be overwhelmed, or perhaps simply be having a flight of imagination?
I’ve come to believe that our human tendency to stare off often signifies an adaptive, kind of forgetting in the present tense. The writer Michael Pollan wrote that "forgetting is crucial for our psychological health." And, quoting the writer and philosopher William James: "In the practical use of our intellect, forgetting is as important a function as remembering. If we remembered everything, we should on most occasions be as ill off as if we remembered nothing ...”
At this stage, I will spare my young patient an (often frightening) electroencephalogram, or any other tests. I avoid the terms “dissociation” or “behavioral,” words that may imply mental illness or willfulness, respectively. I suggest that sometimes we all need to pull away from the present moment, in some cases to make space for a flight of imagination. I encourage the family to gently ask for their child’s own account of their experience at the time the staring occurs.
Perhaps we can learn to appreciate our capacity to turn away from what is right in front of us. What is our mind trying to tell us when we are not truly present, when we are mentally “absent”? My patients have taught me to re-frame this scenario—for those children who do not prove to have absence epilepsy, staring off, zoning out, may simply be a way of taking care of themselves.
Peter Bingham serves as division head of Child Neurology at Vermont Children's Hospital in Burlington Vermont. He graduated from Columbia University College of Physicians & Surgeons where he learned of medical narrative as a potential path for his aspirations as a writer. His research activities have included various topics in neuro-rehabilitation. He is also a musician (classical guitar, singer-songwriter, Oud), father of 3, and an advocate for the containment of noise pollution for the benefit of children's neurodevelopmental and mental health.