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When science doesn't have all the answers



By Louise Kinross

It’s on the list.

My son’s rare genetic deletion is on the list of disorders identified by microarray analysis of a fetus’s DNA

It was a surprise to find it there, but given the dizzying speed of prenatal testing advances, it shouldn't have been.

It makes me sad to think that the lives of children like my son are being targeted for termination. Is this a step forward? Something that will make the world a better place?

We can identify more and more genetic disorders, but can we use this information in an enlightened way to help families make decisions about raising or terminating children with disabilities?

Microarray analysis is a new technique that compares a fetus’s DNA with a normal DNA, identifying genetic duplications or deletions too small to be detected by karyotyping (the microscopic analysis of chromosomes that picks up larger changes like those seen in Down syndrome).

That's why when I had an amniocentesis over 20 years ago I was told the child I was carrying was "normal," when in fact he had a genetic change too subtle to be detected.

I've written about that experienceHow an elevated blood test led us to a genetics counselling appointment where there was no counselling: no discussion about our values, what parenting meant to us, or how we felt about screening for and aborting a fetus with genetic disabilities. Other than a recounting of the dry statistics (that I had a 1 in 200 chance of having a child with Down syndrome and a 1 in 200 chance of miscarrying as a result of the amnio), there was no discussion at all.

When I couldn't make a decision, an obstetrician was sent in to berate me, referring to a child with Down syndrome as "a burden you'll live with for the rest of your life."

In a 2012 study published in the New England Journal of Medicine, the new microarray testing picked up the kind of genetic change my son has in six per cent of fetal samples with normal karyotypes from women who were referred when a structural problem was seen on ultrasound, and in 1.7 per cent of samples with normal karyotypes from mothers who were referred because they were older or had had a positive screening test.

Microarray currently requires fetal cells that are taken through amniocentesis or chorionic villus sampling, so it comes with a risk of miscarriage.

But the researchers look to a non-invasive blood test being developed, with hopes that "every woman who wishes will be offered microarray, so that she can have as complete information as possible about her pregnancy," says lead investigator Dr. Ronald J. Wapner in a related news release. Dr. Wapner is professor and vice chairman for research at the Department of Obstetrics and Gynecology at Columbia University Medical Center.

Who can argue with complete information?

But is it complete?

What kind of counselling is offered today to the parents of a fetus that is diagnosed with a micro-deletion or micro-duplication? Even less is known about some of these conditions because they're just being named.

Is a medical description of the condition paired with information from families raising children with the same disorder? Or affected adults? 

In my son's condition, there's huge variation in how children are affected and microarray can't predict whether the symptoms will be mild or severe. And what about the human side of the equation, the joy that a child, regardless of ability, brings to a family. That can't be conveyed by a professional who has no firsthand experience with disability, and may well view disability as a medical failure.

"Women often terminate a pregnancy without knowing what life would be like with and for an anomalous child," writes Far From The Tree author Andrew Solomon in this New Yorker piece. "It is worth publicizing the satisfaction that the experience may entail, so that the pro-choice movement becomes the pro-informed-choice movement."

Parents-to-be often "confuse how it feels to lose an ability (to be suddenly bereft of hearing) with how it feels to live healthily with a variant body (to be deaf all your life)," he writes. "Further, they confuse their own discomfort with their child’s."

Yesterday one of our readers sent me a study called Posttraumatic growth in parents and pediatric patients in the Journal of Palliative Medicine. The study is a review of 26 journal papers on positive psychological change that results in parents or children after a child's traumatic medical event (including cancer, prematurity, and acquired and congenital disability).

"Posttraumatic growth is the positive psychological change that results from a struggle through a life-altering experience" and may include "greater appreciation of life, improved relationships, greater personal strength, recognition of new possibilities in one's life course, spiritual or religious growth, and reconstruction of a positive body image."

The authors conclude that posttraumatic growth is an important, little studied and poorly understood phenomenon affecting children with serious pediatric illness and their families. They suggest research is needed on how professionals can positively intervene "to facilitate families' movement away from dysfunction or deterioration and toward growth." 

I include this paper because it demonstrates that traumatic experiences that shake up our worldview are not wholly negative. Life is more complicated than that.

The technical side of prenatal testing is the easy part. It's how we use that information to benefit families and the culture as a whole that's complex.

A paper on the use of microarray in prenatal diagnosis by the American Congress of Obstetricians and Gynecologists (ACOG) raises some important points.

"The potential for complex results and detection of clinically uncertain findings identified by [microarray testing] can result in substantial patient anxiety," write the authors. 

They note that women in the New England Journal of Medicine study who received abnormal results “reported a lack of good understanding of the potential for uncertain results and noted feeling great distress on receiving such information and then needing to decide how to proceed with the pregnancy.”

The ACOG recommends that women understand that prenatal microarray "will not identify all genetic disorders." 

This is a point true of amniocentesis, but when I was counselled, no one ever explained it to me. My understanding was that a clear amnio result meant a genetically-intact child. After my son was born, I stopped counting the doctors who exclaimed, in disbelief: "But you had a normal amniocentesis!"

Further, the ACOG notes that "diseases may be identified for which the clinical presentation may vary greatly and range from mild to severe. It may not be possible to predict what the outcome will be in a given patient." 

So how will identifying these problems prenatally help?

We are way better able to counsel parents about what [development issues] would mean for the child," Dr. Wapner says in this CNN story. "We can modify the course and improve the outcome for the child. 

I hate to be cynical, but there aren't any fetal interventions that can improve my son's condition, or many of those I see on the list.

It would be useful to know what happened next in the cases of the women in the study whose fetus's received diagnoses. Did any of them benefit from fetal interventions that changed their outcome? Were the fetuses carried to term followed to see how they and their families fared? How many were terminated? 

Oddly, the paper doesn't mention anything about termination.

How come there is no research on the "after" side of the prenatal-testing equation?

For example, how do parents rate the counselling they received? How could it be improved? Did parents feel equally supported by professionals in choosing to carry a child to term or terminate the child? What supports are provided to parents who terminate and what supports are provided to parents who don't?

We know that 85 per cent of women who receive a prenatal diagnosis for Down syndrome choose abortion.

Do they feel it's a choice, or a social responsibility?

This study in the Journal of Applied Social Psychology looks at how people judge women who carry a baby with an identified disability to term or refuse prenatal testing.

The survey asked 281 staff at a Canadian university and 341 Canadian doctors who work in obstetrics to rate three scenarios in which a woman's child is born with a disability. Both the university community and the doctors rated the woman who chose not to abort her disabled fetus and the woman who refused prenatal testing as more responsible, more to blame, less deserving of sympathy, and less deserving of social and financial support for their child's care than a woman who wasn't offered testing.

"This examination is of pragmatic relevance because of a growing sentiment that prenatal testing can and should be used to meet public economic goals by reducing the financial burden that disability places on the medical and social welfare systems, and that women who do not use it to prevent the birth of a disabled child should be held financially or legally accountable," writes the author.

I'm grateful that microarray testing didn't exist when I was pregnant with my son. I didn't have the life experience to make an informed choice, and the genetic clinic didn't provide me with any family stories to give me a picture of what real life could be like. Most importantly, I couldn't predict my ability to cope with my son's disabilities and to parent a child who's different. 

I believe the front-end of prenatal testing is proceeding at a pace way beyond our ability to understand its ramifications. 

It's how we support families after the diagnosis that needs study.

Science must be used to our benefit, not just because the knowledge and technology exist.

One humanity, one voice



















Being different is isolating, but if we join with others who are perceived as undesirable we find community and a powerful voice for social change, says Andrew Solomon, author of Far From The Tree, at a talk at the Toronto Reference Library yesterday.

"It's important to establish the commonality of difference," Solomon says, speaking of his new book that explores families of children who appear "alien" to their parents because they have conditions like Down syndrome, dwarfism, deafness and schizophrenia, or are transgender, child prodigies or conceived in rape.

"It's all one battle," Solomon says. "If you take every [person] who experiences themselves as somehow different from the mainstream, that's more people than in the mainstream. All of us should be addressing the questions and advocating together for a more just world."

Solomon is referring to the way minority groups have historically split off from each other in their advocacy efforts. People with physical disabilities don't want to be identified with those with intellectual disabilities, or people with mental illness object to being compared to those with autism, or someone who's transgender doesn't see any common experience with a person with dwarfism. As he notes in his book, the parents of child prodigies didn't want to be included in a book with families of severely-disabled children, people with autism insisted that those with Down syndrome had lower intelligence than them, and deaf people didn't want to be associated with people with schizophrenia.

I think Solomon has nailed the problem of discrimination within the disability community -- and how it fractures all of our attempts to achieve equality as humans.

"Being blind and being gay are different, but having a selfhood that others perceive as undesirable is identical," Solomon writes in Far From The Tree.

Solomon admits that before writing the book he was "somewhat afraid or uncomfortable" with the groups of people he'd be interviewing. "Then I got to know people and hear the stories of people and I felt a glowing humanity...The experience of habit makes these syndromes different from how one imagines them from the outside."

Solomon first became interested in writing about parents whose children appear to be unlovable when he wrote Defiantly Deaf for the New York Times Magazine. In researching the piece, he realized that his experience growing up gay with straight parents had parallels to what it felt like to be a deaf youth living with hearing parents. "I saw people who were deaf didn't experience it as 'lacking hearing' but as having membership in a good and valid culture" centred around sign language, Solomon said. "I became interested in the tension between the ideas of illness and identity.

Solomon contrasts how being gay in the 1970s was perceived as an illness and criminal act while his life today as a husband with children is seen as an identity. "I thought if people can make that switch from illness to identity, then where else is [that change] possible?"

Solomon's book focuses on what he calls horizontal identities -- "when a child is a member of a culture with which the parents have no previous experience and needs to learn identity from a new peer group." In contrast, vertical identities are traits that are passed down generationally, like race and language.

Horizontal identities are central to a person, Solomon says. "They are inherent to someone's whole personality and you can't cordon them off," as some parents attempt to do -- refusing to allow a deaf person to sign, for example, trying to turn a gay child straight, or insisting that a child with dwarfism have their arm and leg bones broken in a dozen places, and stretched in a painful, even "barbaric" he says, procedure.

"When parents say 'I wish my child didn't have autism,' what they're really saying is 'I wish the autistic child I have did not exist, and I had a different, (non-autistic) child instead," is how a man with autism describes it to Solomon. "...This is what we hear when you pray for a cure...that one day we will cease to be, and strangers you can love will move in behind our faces."

Solomon notes that at a time when life for people with Down syndrome is better than it's ever been -- "they live longer, have more intellectual accomplishments, function better and have greater education opportunities" they are at risk of being eradicated through prenatal testing and termination. He doesn't argue against prenatal testing but believes "a lot of the decisions are made from a standpoint of ignorance." He admits that his decisions on such matters would have been different before his indepth exposure to people with disabilities.

He stresses that cultural perceptions about what's a disability and what's an identity are fluid. "These things change. What seems today to be a disability 10 years from now might not be seen as a disability."

Social progress in how we view difference is as important as medical progress, he says. With the advent of "designer children" he hopes that "social mores will also progress, so that when we're given more choice, we won't all make the same choice." He calls for an "opening or expanding of our idea of normality."

Solomon says institutional and home care should be options for families and we have to recognize that while some families are suited to heavy caregiving, others are "barely holding on."

Typically the interests of non-disabled siblings are put first in decisions about where the disabled child lives. For many years, he says, it was standard practice to send disabled children to a home "in order to ensure siblings didn't have attention taken away from them." Now standard practice is that it's better for siblings to keep the disabled child at home so they don't later in life blame themselves for being the cause of the child's abandonment. But in either case "the focus is on the siblings and their mental health" Solomon says, rather than on the child with disability.

Parents with a lot of privilege in life tend to be perfectionistic and it was in these families where he saw the strongest attempts to "fix" the child, he says. In contrast, in families that didn't have the means to invest in intensive rehab programs, parents were more accepting of the child's differences.

He notes that while the siblings he met sometimes experienced their brother's or sister's care as draining, or felt parents were preoccupied with it, they loved their sibling deeply and did not wish that the child didn't exist. He came to the conclusion that the disability experience made siblings "more humane and kinder."

He encourages people to describe those with differences in a way that respects, rather than denigrates, while noting that we often become ludicrously rigid about language and intention is most important.

Solomon says that human diversity is what makes the world rich and is as important as diversity in animals or flora.

"Even when everything went wrong, people find meaning in the experience of being parents," he says. "This is not a Hallmark card and I'm not suggesting we go around saying 'What a shame that child isn't disabled.' But, as in looking at depression, it's possible to look deep into difficulty to find meaning and it's possible to grow. These are challenging and shocking experiences that call on people to undergo a profound transformation."

Andrew Solomon won a national book award for The Noonday Demon, An Atlas of Depression in 2001.