May 8th, 2017


Mind On The Run:

Theory of Mind — According to Dodger

By Anthony Kovatch, M.D., Pediatric Alliance — Arcadia



“He did not believe that he should ever again love anything, man or woman or his own child, as he had loved the yearling. He would be lonely his whole life. But a man took it as his share and went on.”

–from The Yearling by Marjorie Kinnan Rawlings



You never give me your money
You only give me your funny paper
And in the middle of negotiations
You break down

I never give you my number
I only give you my situation
And in the middle of investigation
I break down…

One sweet dream
Pick up the bags and get in the limousine
Soon we’ll be away from here
Step on the gas and wipe that tear away
One sweet dream came true today
Came true today
Came true today (yes, it did)

— “You Never Give Me Your Money” by The Beatles (covered here by Jody Cooper)



Part 1:  The Theory of Mind (ToM) is at the underpinnings of our understanding of autism, and refers to the notion that autistic individuals inherently do not appreciate that other people have their own thoughts, plans, and points of view. Furthermore, it appears that they have difficulties understanding other people’s beliefs, attitudes, and emotions (even love). This phenomenon appears to be unique to those with autism and independent of intelligence.

“Dodger” was a mongrel patient of sorts and the authorities were unsure which part of “Gaul” could best handle his multitude of psychiatric and medical needs. As is typical of kids who go from one institution to another, he had been labelled with just about every psychiatric diagnosis in the coding manuals, including autism. As skeptical as I was to become of these labels, one thing was very well documented: he had type 1 diabetes mellitus (since age 5) so poorly controlled on admission that his diabetic specialists classified him as a “Mauriac dwarf.” Fatty liver complicated the diabetes, as did compulsive stealing and hoarding of food, lying and psychosomatosis, and a mastery of wily and manipulative behaviors — hence his nickname after the “Artful Dodger,” the dude of honor and ringleader of Fagin’s band of delinquents in Charles Dickins sociologic novel Oliver Twist. Indeed, he was as crafty as Fagin himself; however, he was never mean-spirited in spite of being head-and-shoulders intellectually above his peers. His most creative endeavor was an attempted suicide with a megadose of insulin prior to admission.

This reputation preceded him and persisted, and the “Golden Girls” grew weary of his tricks and demands and considered him incorrigible — “he has not learned a single thing we have tried to teach him.” Between checking his blood sugars, shooting him up with insulin, and keeping hyper-vigilance around the clock for hoarding of food, Dodger was a sponge of everybody’s time and energy. He knew this, loved this, and was universally thankless. I argued that, although he was intelligent and garrulous, he did have an autism spectrum disorder.

The first time I met him, I found him quite engaging and cooperative, and passed it off as the delusion of the “honeymoon period” — a universal phenomenon in these types of facilities. He dodged all references to the past. “My youngest son has diabetes too and has had it since your age,” I told him. He histrionically performed for me how he felt when his blood sugar was high or low as if he wanted to entertain me.

Dodger had a husky voice with the inflection of a moan that was somewhere between annoying and endearing. A hailstorm of fairly large freckles gave his chubby face the appearance that it was splattered with mud. “My son had tons of freckles at your age, too,” I reassured him, “but gave them to me as ‘old age spots’ when he grew up!”

He wore his thick black hair in Mohawk style. He had a longstanding bump on the bridge of his small round nose, which he called his “button.” I recognized it as a neglected fibrous pyogenic granuloma and froze it off the following week — a residual “nubbin” remained. That and the fact that his desperate family gave up their parental rights several months into his institutionalization were the only strokes of good luck that little boy ever had.

He became an outright orphan just before the Christmas holidays and he was one of only a handful of inmates that had to spend the holidays in the RTF. By that time I had been filing down his residual “button” every Thursday when he passed the medical office to get his blood sugar checked. “Here’s a little Christmas present for you,” smiled my bleeding heart as I fit him with an old kid’s Pirates baseball jacket I had won in a raffle 20 years in the past, which had never been worn by a soul, and which I was convinced my wife would be including in the next Goodwill collection. He donned the apparel and brandished his guns (the shoulders of the jacket were padded). Against corporate privacy rules I took a picture for him with my cell phone, which was lost when I later absent-mindedly dumped the phone with my dirty clothes into the washing machine.

And as I should have expected from his reputation, every Thursday as he passed the clinic door he would poke in his freckled face and inquire, “Do you have anything for me today?” Against the protests of the “Golden Girls” that I do otherwise, I frequently relented and brought him the trinkets that he asked for — legos, bionicles, quixits, and other gadgets from Target and Five Below. He liked materialistic kind of junk because I believe he had lived on the streets much of his life. He cared little for objects with any emotional attachment, like my old race shirts. “Theory of Mind” at play. However, every Thursday I looked forward to our brief encounters where I filed his button or listened to his psychosomatic complaints — planning what I might teach him by Tuesday or Wednesday of that week. I began to realize that he was like the “Little Prince’’ of the Antoine de Saint—Exupery novelette — falling to our RTF world from his own tiny planet — and that I was the fox, his unwitting teacher.

“One only understands the things that one tames” said the fox. “You become responsible forever for what you have tamed.”


To be continued…

6 Responses to Mind On The Run

  1. I must admit that I always made excuses for Dodger’s behavior and gave him extra slack—believing there would never be any return on the investment.

  2. As always, very witty portrayal Dr. Kovatch! Enjoyable to read!

  3. Thanks, Lindsay—enjoyable to write, but sad to remember.

  4. I have read many of your “Mind on the Run” submissions, and they are very witty. Like every healthcare practioner, we all have stories from our past, that has helped mold who we are today. Once I read your articles, I feel let down, everytime. You have a brilliant mind for the issues that effect pediatric mental health, yet all that you share are antidotal stories of the past. I am the mother of an autistic child, I want you to impart some of your vast wisdom to me. I read your articles because I am looking for knowledge and guidance, not witty stories. I respect you immensely, so please share your true wisdom and talent with those who can benefit from it.

  5. Dear Pamela, Thank you for your comments, but I would never think of myself as being witty; I only try to inject humor into the narratives to throw some light into a situation of pathos.
    I am sorry to let you down, but I am not a scientist or a researcher, but merely a commentator on the suffering that I witness every day. That is why I try to be empathetic to families who suffer from the anxiety that has permeated the vaccination initiative.
    It has been said “The world is a comedy to those who think and a tragedy to those who feel.” The emphasis of this essay is that, although the medical community decrees that Autistic children are incapable of reciprocal emotion and understanding (even love), in my limited experience this is false, and that the basis of therapy may be reciprocal bonding with professionals in a style similar to parents and their autistic children; certainly, this was the case with “Dodger.” I know this sounds nebulous, but, as an outsider, it is the only guidance and wisdom I can provide–as one who “feels.”
    I am planning a scientific essay on PANDAS, a condition which is a challenge in many ways to children with developmental disorders and I think this may be more of what you are looking for from the Pediablog.

  6. Dear Pamela—I have taken your recommendations to heart. While I am planning a blog on PANDAS (Kristi Wees are writing together), I wanted to be sure you are aware of the many medical articles Kristi has written for Pittsburgh Parent magazine–I am sure you have shared some of her experiences, as she also has a child with Autism and runs an advocacy program. Here is the link:
    Thanks again for your comments!


    Ned Ketyer, M.D.

    Ned Ketyer, M.D.

    Dr. Ketyer has special interests in developmental pediatrics and preventative medicine, specifically how nutrition and the environment affect health. He earned his bachelor’s degree from the University of Vermont and his medical degree from Northwestern University Medical School. He completed his residency at Children’s Hospital of Pittsburgh.

    As one of the founding physicians of Pediatric Alliance, PC, Dr. Ketyer served as its president from 1997-2004. He has been practicing general pediatrics at Pediatric Alliance since 1990. Dr. Ketyer and his wife have three boys and live in Pittsburgh's South Hills. 

  • Note: The information included in these posts is for educational purposes only. It is not intended nor implied to be a substitute for professional medical advice.

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