CHALLENGING CASE: CHRONIC DISEASE—DEVELOPMENTAL AND BEHAVIORAL IMPLICATIONS

Persistent Cough in an Adolescent*

CASE with a peak flow meter. The cough persisted, and the Jessica, a 14-year-old girl with a history of asthma, peak flow recording showed normal airway resis- went to her pediatrician’s office because of a persis- tance. At this time, Jessica’s pediatrician suspected a tent cough. She had been coughing for at least 3 conversion reaction and contemplated the next best months with occasional cough-free periods of less therapeutic strategy. than a few days. The cough was nonproductive and Index terms: psychogenic cough, conversion disorder, habit cough, vocal was not accompanied by fever, rhinorrhea, or facial tic. or chest pain. Jessica and her mother observed that the cough increased with exercise and typically was Dr. Martin T. Stein not present during sleep. She has used two metered- dose inhalers—albuterol and cromolyn—without A single symptom or a cluster of symptoms that any change in the cough pattern. do not fit neatly into a recognizable pattern of illness For the past 5 years, Jessica has had mild asthma is not an unusual occurrence in a medical practice. responsive to albuterol. She enjoys running on the Further investigation into historical data or selected cross-country team, soccer, and dancing. She is an laboratory tests usually reveal the etiology of the average student and denies any change in academic problem. At other times, only the generation of a performance. She has never been hospitalized or had new hypothesis leads to an acceptable explanation an emergency department visit for asthma or pneu- for the symptoms. Patients like Jessica who present monia. There has been no recent travel or exposure with a common symptom that is stubbornly unre- to a person with a chronic productive cough, tobacco sponsive to standard medical interventions are not smoke, or a live-in pet. Jessica lives with her mother uncommon occurrences in primary care practice and and younger sister in a 10-year-old, carpeted apart- challenge the diagnostic and therapeutic skills of the ment without any evidence of mold or recent reno- most seasoned clinicians. vation. Jessica’s symptom, a persistent cough, is associ- In the process of taking the history, the pediatri- ated with a prior history of mild asthma but is un- cian noticed that Jessica coughed intermittently, with responsive to standard medical interventions. Im- two or three coughs during each episode. At times, portant developmental information includes her the cough was harsh; at other times, it was a quiet status as an early adolescent (we do not know her cough, as if she were clearing her throat. She was Tanner stage, menarche history, or sexual history), cooperative, without overt anxiety or respiratory dis- average and consistent academic performance, and tress. After a complete physical examination with active participation in a variety of activities. Jessica’s normal findings, the pediatrician interviewed Jessica parents have been divorced 6 years. During weekend and her mother alone. visits to her father’s new family, she experiences a Jessica’s parents had been divorced for the past 6 feeling of discomfort in response to “tension. . . and years. She lived with her mother but visited her arguing when the kids are around.” father, and his new family with two young children, Although the information about Jessica in the case every weekend. She spoke about this arrangement scenario is sparse, it is a reasonable amount of data to comfortably and said that she loved her father and obtain from an initial visit to a pediatrician. Subse- mother but didn’t like the tension she experienced at quent office visits focused on discovering the cause her father’s home. “I don’t like adults arguing when for the chronic cough while simultaneously trying kids are around.” When asked why she thought the other therapeutic interventions. It was only after the cough persisted so long, she commented in a neutral failure of those treatments and the reassessment of tone, “I don’t know. It’s never been like this before.” the psychosocial history that her pediatrician consid- Jessica’s pediatrician prescribed an inhaled steroid ered a conversion reaction. with the albuterol. When the cough did not respond Dr. Gordon Harper, an Associate Professor of Psy- after 1 week, he ordered a chest radiograph (normal) chiatry at Harvard Medical School, begins the dis- and a tuberculin skin test (purified protein deriva- cussion. Dr. Harper completed residencies in both tive-negative), and he added montelukast (a leuko- pediatrics and psychiatry, as well as training in psy- triene inhibitor) and monitored airway resistance choanalysis. He has been an active medical educator for more than two decades, past director of inpatient psychiatry at Boston Children’s Hospital, and is cur-

* Originally published in J Dev Behav Pediatr. 1999;20(6) rently medical director of Child and Adolescent Ser- PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- vices, Massachusetts Department of Mental Health. emy of Pediatrics and Lippincott Williams & Wilkins. Dr. Jane Chen recently completed her pediatric res-

Downloaded from www.aappublications.org/news by guest onPEDIATRICS September 24, 2021 Vol. 107 No. 4 April 2001 959 idency and chief residency at the University of Cal- ingless at best and offensive at worst (“they think ifornia, San Diego after graduating from the Stanford there’s nothing wrong with me”).4 The pediatrician School of Medicine. As chief resident, Dr. Chen was proceeds here indirectly, with open-ended questions: known as an advocate for psychosocial issues of “I’m interested in hearing more about how things children and families as she guided conferences and have been going for you.” Follow-up questions may teaching rounds. Currently, she is a member of a elicit unrecognized meanings, possibly in the onset primary care group pediatric practice. Following the or variability of the cough (looking for meaningful comments of Drs. Harper and Chen, selected com- associations, such as anniversary reactions). Al- ments are presented from the discussion of this case though an isolated cough would be an unlikely pre- on the Developmental and Behavioral Pediatrics web sentation of depression, in asking these questions, site. the pediatrician can also assess mood. To explore conscious psychological processes, the Martin T. Stein, MD pediatrician will ask what the symptom means to Professor of Pediatrics Jessica. What does she think is going on (explanatory University of California, San Diego model)?5 Does she think she has an infection? Some- San Diego, California thing difficult to talk about, like a sexually transmit- Dr. Gordon Harper ted disease? Has she known or heard of anyone with As an initial approach to Jessica’s persistent and such a cough (looking for possible identification, not unexplained cough, the pediatrician may consider for infectious source)? Has she noticed anything factors at several levels: about the variability of the cough? The case protocol lets the pediatrician hear the patient’s concerns in Neurophysiological expressing Jessica’s voice: she does not like tension Psychological—unconscious or adults arguing. The pediatrician can ask, Who Psychological—conscious (experiential) argues? Who is tense? Do they know it bothers her? Social How does Jessica feel about asserting her wish for less fighting? On the neurophysiological level, the “involunta- In picking up Jessica’s own complaints, we move risms” of Tourette syndrome (TS) and obsessive- to the social dimension. Although much of the liter- compulsive disorder (OCD) need to be included in ature on conversion focuses on intrapsychic pro- the differential diagnosis. A tickling sensation and cesses, all physicians who have dealt with epidemic the “need” to cough to relieve it are not infrequently hysteria (mass sociogenic illness) know that social seen among children and adolescent patients with context shapes these symptoms and often offers the symptoms in the TS- OCD spectrum.1 With the re- arena in which interventions, including behavioral cently reported association between these symptoms therapies, effect relief.6,7 Jessica has come to the pe- and postinfectious immunological changes (so-called diatrician’s office with her mother; her father and pediatric autoimmune neuropsychiatric disorders as- stepmother are also mentioned. They should be in- sociated with streptococcal infections [PANDAS]),2 terviewed. What about context? Does the cough vary clinicians are increasingly entertaining the possibility with place (school, home, mother’s or father’s place) of TS and OCD in children formerly thought to have or situation (open conflict, smothered conflict)? purely “functional” disorders, those conditions Keeping possible factors at all of these levels in whose biological mediation we have not yet under- mind, the pediatrician can develop a management stood. plan that explores one or several of these. Hospital- Unconscious psychological processes (i.e., patho- ization is indicated only for the most afflicted who genic processes in which unrecognized meanings of fail to respond to other treatment.8,9 With whichever events or feelings play a part) have, since the time of interventions one begins, the plan should have a time Freud, been implicated in the origin of conversion line, including a date fixed in advance at which, if no symptoms. “Conversion” expresses the idea that change has occurred, all parties agree that a referral psychological conflicts are “converted” into somatic to a child psychiatrist will be made. symptoms. Conversion is the only category in the DSM-IV, otherwise rigorously nonetiological, in Gordon Harper, MD which a causal mechanism is specified.3 Jessica Associate Professor of Psychiatry shows one of the classic features of conversion, la Harvard Medical School Boston, Massachusetts belle indifference: she does not seem to be troubled by her symptom. Such apparent indifference suggests that the symptom has “solved” an intrapsychic con- REFERENCES flict that would otherwise be causing distress. Clar- 1. Leckman JF, Walker DE, Cohen DJ: Premonitory urges in Tourette’s ification of such conflict is sometimes associated with syndrome. Am J Psychiatry 150:98–102, 1993 2. Swedo SE, Leonard HL, Garvey M, et al: Pediatric autoimmune neuro- dramatic relief of the symptom. But even if such a psychiatric disorders associated with streptococcal infections: Clinical theory is ultimately “right,” the pediatrician must description of the first 50 cases. Am J Psychiatry 155:264–271, 1998 not lead with it. Offering the patient a psychological 3. American Psychiatric Association: Diagnostic and Statistical Manual of attribution (“I think you’re having trouble with your Mental Disorders, 4th ed. Washington, DC, American Psychiatric As- sociation, 1994 feelings”), in advance of the patient’s (or parent’s) 4. Harper G: Psychosomatic illness, in Parker S, Zuckerman B (eds): Be- indicating that she is actively entertaining such a havioral and Developmental Pediatrics: A Handbook for Primary Care. possibility, will strike patient (and parent) as mean- Boston, MA, Little, Brown, 1995

960 SUPPLEMENT Downloaded from www.aappublications.org/news by guest on September 24, 2021 5. Stoeckle JD, Barsky AJ: Attributions: Uses of social science knowledge status, and in individuals less knowledgeable about in the “doctoring” of primary care, in Eisenberg L, Kleinman A (eds): medical and psychological concepts. Conversion The Relevance of Social Science for Medicine, ch 10. Boston, MA, Reidel, 1981, pp 223–240 symptoms in children tend to be limited to gait prob- 6. Boss LP: Epidemic hysteria: A review of the published literature. Epi- lems or seizures. It is diagnosed more commonly in demiol Rev 19:233–243, 1997 women, and the prevalence is reported to be 11 to 7. Gooch JL, Wolcott R, Speed J: Behavioral management of conversion 300 per 100,000 people in the adult populations. The disorder in children. Arch Phys Med Rehabil 78:264–268, 1997 8. Zeharia A, Mukamel M, Carel C, Weitz R, Danziger Y, Mimouni M: prevalence in childhood is unknown, and in chil- Conversion reaction: Management by the paediatrician. Eur J Pediatr dren, there may not be an overrepresentation of fe- 158:160–164, 1999 males.1 9. Brazier DK, Venning HE: Conversion disorders in adolescents: A prac- The typical onset is in late childhood to early tical approach to rehabilitation. Br J Rheumatol 36:594–598, 1997 adulthood and generally with a sudden presentation. Generally, there is a better prognosis for children Dr. Jane Chen than for adults and in presentations of more recent Psychogenic cough is often described as a barking onset, although in all groups, recurrences are com- or honking cough that is persistent, interferes with mon. Because these patients are very suggestible, it is normal activities, and is without an organic etiology. important that there is a unified approach of the It is described most commonly in children and ado- medical team. Patients should be told that there is lescents. The cough may remit during sleep or dur- treatment, and that through behavior therapy they ing pleasurable activities. Children initially may can exert voluntary control over their symptoms. have a preceding respiratory infection with a cough They should be offered psychosocial evaluation in a which then persists. Treatment generally is more nonthreatening manner to facilitate acceptance of the favorable in pediatric than in adult populations. Be- diagnosis, such as being told that the illness is not havior modification and either resolution or manage- “all in their head” and that these symptoms often ment of psychological stressors is the focus of treat- occur on a subconscious level.3 Evidence-based stud- ment. ies do not support a specific behavioral therapy. The pattern of a psychogenic cough in children Occasionally, asking the patient to repeat to them- and adolescents often has features consistent with a selves on a daily basis that they will not have any conversion disorder. The DSM-IV describes the es- spells or symptoms may improve the condition. Spe- sential features of conversion disorder as symptoms cific treatments for psychogenic cough reported in affecting voluntary motor or sensory function that the literature include teaching the patient to mouth- suggest a general medical condition with associated breathe (others suggest preventing mouth-breathing) psychological factors.1 These stressors are often elic- and wrapping bed sheets tightly around the chest. ited on the basis of observations that the initiation or Bronchoscopy, when associated with the patient’s exacerbation of the symptom is preceded by psycho- misunderstanding that the procedure was performed logical conflicts. Symptoms are distressful to the in- for therapeutic reasons, has also been reported to dividual with some impairment in functioning; they resolve chronic cough.4,5 are not intentionally produced or feigned as in ma- In a recent review of children with pseudo-sei- lingering. Other medical and psychiatric conditions zures who received a diagnosis of conversion disor- are excluded. der, secondary psychiatric diagnoses were common, The term conversion derived from the hypothesis as well as severe psychosocial stressors. Thirty-two that the individual’s somatic symptom represents a percent had a history of sexual abuse, which should symbolic resolution of an unconscious psychological be further addressed in the evaluation of a child or conflict, reducing anxiety and serving to keep the adolescent with a conversion disorder.6 Other med- conflict out of conscious awareness. Symptoms of a ical conditions may precede or coexist with the pre- conversion disorder are variable and may include senting symptom, such as in Jessica, who had a his- persistent cough, paroxysmal sneezing, sighing dys- tory of reactive airway disease. pnea, hoarseness, paralysis, aphonia, difficulty swal- lowing, urinary retention, loss of touch or pain sen- Jane Chen, MD sation, visual complaints, deafness, hallucinations, or Camino Medical Group seizures. The diagnosis should be made only after an Sunnyvale, California appropriate medical investigation.2 Psychosocial factors may be associated with the REFERENCES onset or exacerbation of symptoms. Patients may 1. American Psychiatric Association: Diagnostic and Statistical Manual of show “la belle indifference” or a relative lack of Mental Disorders, 4th ed. Washington, DC, American Psychiatric As- concern about the symptoms, whereas in some teen- sociation, 1994 agers, symptoms may be described with elaborate 2. Hodgman CH: Conversion and somatization in children. Pediatr Rev and exaggerated detail. A personality disorder may 16:29–34, 1995 3. Gold M, Friedman SB: Conversion reactions in adolescents. Pediatr Ann be associated with a conversion disorder, especially 24:296–306, 1995 the histrionic or the passive-dependent types. Pa- 4. Gay M, Blager F, Bartsch K, Emery CF: Psychogenic habit cough: tients with conversion disorder are often suggestible, Review and case reports. J Clin Psychiatry 48:483–486, 1997 and symptoms may be modified on external cues 5. Butani S, O’Connell J: Functional respiratory disorders. Ann All Asthma Immunol 79:91–101, 1997 that may be used in treatment. 6. Wylie E, Glazer JP, Benbadis S, Kotagal T, Wolgamuth B. Psychiatric Conversion disorder is more common in rural features of children and adolescents with pseudoseizures. Arch Pediatr populations, in those having a lower socioeconomic Adolesc Med 153:244–248, 1999

Downloaded from www.aappublications.org/news by guest on September 24, 2021 SUPPLEMENT 961 Web Site Discussion a personal insight into her thoughts and feelings about the di- vorce, as they evolved over the past 6 years. Two participants in the cyberspace discussion of I agree with the observations of other participants in this dis- the case on the Developmental and Behavioral Pedi- cussion that Jessica’s cough could be a tic, a sign of a tic disorder. atrics web site* provided thoughtful commentaries Though this would not be my first choice, it would be prudent to that complement those of Drs. Harper and Chen: obtain a complete family history for evidence of tic or Tourette Dr. Daniel P. Kohen, a behavioral and develop- syndrome in family members, as well as evidence of any other tic behaviors that Jessica may have experienced previously. mental pediatrician from the University of Minne- Robert D. Wells, Ph.D., a clinical child and ado- sota, wrote: lescent psychologist at the Valley Children’s Hospi- This is a very interesting and not terribly unusual situation. I have seen many young adolescents with this kind of history, some tal in Fresno, California, commented: with a known history of asthma as an antecedent, and others with When I am considering a conversion disorder diagnosis, I have a history of pneumonia or bronchitis which was treated success- found it helpful to use the following IM HELPLESS criteria: fully but in which the cough lingers, as in Jessica’s situation. The Idiopathic: This may be true with Jessica as no cause is yet dis- pattern of the cough then changes in character somewhat, partic- covered. ularly when careful observation elicits the description we hear Model of symptom: Jessica could be her own model due to her from the pediatrician at the end of the case, i.e., “that Jessica asthma. coughed intermittently with two or three coughs during each Histrionic: The history does not reveal whether she has histrionic episode. At times, the cough was harsh; at other times, it was a features. quiet cough, as if she were clearing her throat.” Jessica’s case Enmeshed family relationships: The history does not reveal this seems to be quite consistent with a diagnosis of so-called “habit process. cough,” “psychogenic habit cough,” or “cough tic.” While I don’t Life event: Jessica may have recent stressors from postdivorce know that the precise pathophysiology has been worked out, it conflict. has been clear that these cases have all been responsive to self- Primary gain: It is unclear how this symptom is alleviating an regulation training, i.e., training the patient in relaxation and unconscious conflict mental imagery/self-hypnosis, with or without the use of biofeed- La belle indifference: Is she concerned about her symptom? back. (see Gay M, Blager F, Bartsch K, Emery CF, Rosenstiel-Gross Exaggerated need for attention and affection: It is not clear from AK, Spears J: Psychogenic habit cough: Review and case reports. the history, but it is a possible contributing factor. J Clin Psychiatry 48:483–486, 1987; Olness K, Kohen DP. Hypnosis Secondary gain: Is the symptom helping her gain reinforcement? and Hypnotherapy with Children, 3rd ed. New York, NY, Guil- Somatically focused family: Excessive and persistent attention to ford Press, 1996, pp 154–155; and Laurence Sugarman, M.D., physical and mental symptoms is not mentioned in the history. “Imaginative Medicine”—a videotape that demonstrates self-reg- ulation techniques in primary care office practice for a variety of Looking at these criteria makes me think that conversion dis- common conditions, including habit cough. For information about order is not a likely explanation for Jessica’s persistent cough, but this videotape, contact Laurence I. Sugarman, M.D., General & the history regarding these components may need to be explored Behavioral Pediatrics, 2233 Clinton Avenue South, Rochester, NY further. I also wonder about initial onset of a tic disorder which 14618-2632, tel: 716-271-0860, fax: 716-271-1383.) Jessica’s life is most commonly begins with a barky, throat-clearing, vocal tic. certainly a “set-up” for conversion disorder. However, the fact that she has initiated talking about socioemotional stressors (“I Dr. Martin T. Stein don’t like adults [at my father’s home]arguing when kids are Adolescence is a vulnerable time for the develop- around.”) would argue against a conversion disorder, since there is at least in part a conscious expression of difficult feelings, ment of a psychosomatic condition. It is a predictable whereas in conversion disorder, physical symptoms develop pre- moment in development when excessive attention to cisely because the difficult feelings are not easily accessible or body sensations occurs with rapid physical and emo- amenable to conscious expression, and the patient therefore de- tional changes. Approximately 20% of adolescents velops a physical symptom. While this diagnosis is a judgment worry about their health “all the time,” whereas only call and ought to be considered, I would argue more strongly for a diagnosis of “habit cough” and for training in self-management 15% “never give their health a thought.” Prazar pro- as noted above. Unlike a diagnosis of conversion disorder, which vides definitions and examples of five psychoso- often by its very nature suggests the need for long-term psycho- matic disorders in adolescents (Table 1). Although therapy, most patients with a habit cough experience relief of some of the specific categories of conditions are dif- symptoms rather quickly in response to varying types of sugges- tion therapy. These approaches make use of the clinician’s under- ferent from those proposed by the discussants (as standing of pulmonary physiology; in particularly, consideration well as variations of the categories found in the of the distinction between cough-variant asthma which is often DSM-IV), I have found this framework to be useful in worse at night and patients with a psychogenic habit cough, most understanding patients with physical symptoms that of whom, like Jessica, sleep through the night without coughing. cannot be explained by biomedical findings and that Self-regulation and suggestion interventions emphasize develop- ment of mind-body techniques to focus on development of a sense are associated with psychosocial factors (Table 1). of mastery over and disappearance of the symptom. The discussants considered the possibility of a tic In addition to a behavioral approach to her habit cough, Jessica disorder as an explanation for Jessica’s persistent deserves an opportunity to explore her ambivalent and apparently cough. A transient tic disorder (lasting longer than 4 unresolved feelings regarding the current visitation arrangements, the tension she describes between adults in her life (dad and weeks and less then 1 year) is consistent with Jessi- stepmom), and her role in each family. She might also benefit from ca’s history of a 3-month duration. Tourette syn- drome (TS) is a consideration only if we hypothesize that this case may be the first stage of the disorder. TS is defined as severe multiple motor tics of at least *A bimonthly discussion of an upcoming challenging case takes place at the Developmental and Behavioral Pediatrics web site. This web site is spon- 1 year’s duration with less than a 3-month remission. sored by the Maternal and Child Health Bureau and the American Acad- Vocal tics are associated with motor tics in children emy of Pediatrics section on Developmental and Behavioral Pediatrics. and adolescents with TS, but not necessarily contem- Henry L. Shapiro, M.D., is the editor of the web site. Martin Stein, M.D., the poraneously. A knowledge that tics, in some cases, Challenging Case editor, incorporates comments from the web discussion into the published Challenging Case. To become part of the discussion at are a genetic disorder should encourage the pursuit the Developmental and Behavioral Pediatrics home page, go to http:// of a complete family history. The gene for TS seems www.dbpeds.org. to be autosomal dominant with a high variability for

962 SUPPLEMENT Downloaded from www.aappublications.org/news by guest on September 24, 2021 TABLE 1. Categories of Psychosomatic Disorders Disorder Definition Examples Conversion Presence of a physical symptom that unconsciously Some cases of limb paralysis and blindness, reactions communicates unpleasant emotions; the patient recurrent headache, recurrent abdominal displays little or no anxiety associated with the pain symptom; physical findings are inconsistent with physiological concepts Psychophysiological Presence of a physical symptom that is precipitated Some cases of diarrhea and palpitations; symptoms by activation of biological systems (autonomic exacerbation of inflammatory bowel nervous system and/or neuroendocrine system); disease, asthma, and peptic ulcer disease the symptom is organic in origin and is associated with unpleasant feelings with which the patient can easily identify; physical findings are consistent with organic illness Hypochondriasis Presence of a physical symptom that is associated Some cases of recurrent headaches, with extreme concern by the patient; the patient recurrent abdominal pain, diffuse pain is preoccupied with physical disease; physical findings do not substantiate organic illness Malingering Display of a physical symptom that the patient Some cases of skin infections, recurrent creates consciously to avoid unpleasant headache, and recurrent abdominal pain; situations, physical findings often corroborate self-administration of excess medication factitious illness Somatic delusions A symptom of psychosis; other signs of thought Patients complaining of their heart disorder are present; physical symptoms are shriveling up, or patients complaining of bizarre and not substantiated by physical something wrong the blood flowing findings through their body Reprinted with the permission of the publisher from Prazar: Psychosomatic disorders and conversion reactions, in Friedman SB, Fisher M, Schonberg SK: Comprehensive Adolescent Health Care, 2nd ed, St. Louis, MO, Mosby, Inc., 1998, pp 902. expression.1 The mild and transient forms of tics seen taps into unconscious psychological processes men- in many relatives suggest the existence of both pro- tioned by Dr. Harper, in which “unrecognized mean- tective and risk factors. As pointed out by Dr. ings of events or feelings play a part” in the origin of Harper, ongoing research into the immune-regulated conversion symptoms. Counseling in contemporary association between Group A ␤-hemolytic strepto- pediatric practice is consistent with Freud’s sugges- coccal infection and movement disorders suggests a tion that “the patient. . . gave verbal expression to the potential infectious etiology for tic disorders (and affect.” The progress made in the past century since obsessive-compulsive disorder) among children and Freud’s observations is reflected in the expanded 2 adolescents. Although I have never observed a tic in paradigm available to clinicians when faced with a any of the pandas at the San Diego Zoo, this condi- persistent and unexplained symptom—a consider- tion has taken on the name pediatric autoimmune ation of factors that may be neurophysiological (e.g., neuropsychiatric disorders associated with strepto- PANDAS), psychological (either unconscious or ex- coccal infections (PANDAS). At present, preliminary periential), and social. studies on the use of prophylactic antibiotics in chil- dren with tic disorders has not been proven to be 3 beneficial in the alleviation of symptoms. REFERENCES History repeats itself, even when we consider the 1. Cohen DJ, Leckman JF: Developmental psychopathology and neurobi- tremendous advances in twentieth-century medi- ology of Tourette’s syndrome: Advances in treatment and research. cine. In 1895, Sigmund Freud wrote about a variety J Am Acad Child Adolesc Psychiatry 33:2, 1994 of physical symptoms (especially motor symptoms 2. Garvey MA, Giedd J, Swedo SE: PANDAS: The search for environmen- and often with an onset in adolescence) that he clas- tal triggers of pediatric neuropsychiatric disorders—Lessons from rheu- sified as “hysterical phenomena,” a precursor to the matic fever. J Child Neurol 13:413–423, 1998 origin of conversion symptoms. Freud wrote that 3. Garvey MA, Perlmutter SJ, Allen AJ, et al: A pilot study of penicillin prophylaxis for neuropsychiatric exacerbations triggered by streptococ- “we found, at first to our greatest surprise, that the cal infections. Biol Psychiatry 45:1564–1571, 1999 individual hysterical symptoms immediately disap- 4. Freud S, Breuer J: The psychic mechanism of hysterical phenomena, peared without returning if we succeeded in thor- Studien Uber Hysterie (1895), reprinted in Adler MJ (ed): Great Books of oughly awakening the memories of the causal pro- the Western World, vol 54. Chicago, IL, Encyclopaedia Britannica, Inc., cess with its accompanying affect, and if the patient 1992, pp 26 circumstantially discussed the process in the most detailed manner and gave verbal expression to the 4 affect.” Dr. Kohen’s recommendation to use to men- Address for reprints: David Elkind, Ph.D., Department of Child Develop- tal imagery and teach patients self-hypnosis, while ment, Tufts University, 105 College Avenue, Medford, MA 02155-5583; fax: not directly focusing on “awakening the memories,” 617-627-3503.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 SUPPLEMENT 963 Authority of the Brain

In our postmodern society, the brain has become tices or products. Popular magazine articles such as the ultimate scientific authority. Over the past de- “Fertile Minds”10 and “How To Build a Baby’s cade, neuroscientists have learned an enormous Brain,”11 Internet articles such as “Building a Better amount about the growth and functioning of the Baby Brain,” national television programs such as brain. Most of this research, however, has been done “Building Brains: The Sooner the Better” and “Your on animals: rats, cats, and primates. New knowledge Child’s Brain,” and computer programs such as Baby has been obtained in three main areas: synaptogen- Wow, Jumpstart Baby, and Future Bright offer inter- esis, critical periods, and the effects of enriched en- pretations that go far beyond what the data warrant. vironments. These advances reflect new technologies There is some good news and some bad news that make it possible to obtain accurate counts of associated with this heightened, brain-driven interest brain cells, to measure brain activity, and to identify in infant learning and development. Many of the those areas of the brain responsible for many mental suggestions for infant stimulation, supposedly stem- functions. Much of this information has now been ming from brain studies, were in fact arrived at on popularized in the media and has created a whole the basis of clinical experience and developmental new enterprise zone of infant stimulation products. research. For example, in a recent monograph titled Before reviewing and evaluating some of these Rethinking the Brain,12 the author argues that the fol- products, it might be helpful to briefly summarize lowing are “key findings” of recent brain research: some of our new knowledge about brain growth and activity.1 First, when discussing synaptogenesis, it is • Human development hinges on the interplay be- important to note that at birth the infant has far tween nature and nurture. fewer synapses than does the adult. During the first • Early care and nurture have a decisive and long- few years of life, however, synapses proliferate ex- lasting impact on how people develop, their abil- ponentially with the result that the brain of infants ity to learn, and their capacity to regulate their and young children is host to vastly more synapses emotions. than is the adult brain. This early explosion of syn- • The human brain has remarkable capacity to apses is followed by a period of synaptic pruning change, but timing is crucial. that is largely regulated by experience. As a result of • There are times when negative experiences or the this selective thinning, the adult brain has fewer absence of appropriate stimulation are more likely synaptic connections than does that of the child. It is, to have serious and sustained effects. however, the pattern of connections rather than their • Evidence amassed over the last decade points to number which makes the adult brain so much more the wisdom and efficacy of prevention and early capable than the brain of the infant.2 With respect to intervention. critical periods, there are age windows during which certain types of stimuli seem to be essential for nor- These ideas are neither new nor grounded in neu- mal brain development. The age at which these win- roscience. Presenting such well-entrenched develop- dows open varies with different functions and abil- mental principles as those originating from brain ities. To illustrate this point, consider that the critical studies presumably lends them more authority and period for the attainment of some visual skills, such makes them more persuasive. Although misleading, as tracking and shape discrimination, occurs during invoking the authority of the brain to support the first year of life.3 On the other hand, the window healthy childrearing is excusable. If it encourages for higher-level functions, such as planning and fore- parents and infant caregivers to use more develop- sight, does not seem to open until adolescence. Fi- mentally appropriate childrearing practices, then no nally, animal studies suggest that an environment serious damage has been done, and some benefits rich in sensory stimulation and full of opportunities may well accrue. for motor activity is more conducive to brain growth There is, however, also some bad news from this than is an environment which lacks these possibili- new appeal to the authority of the brain. Although ties.4 Shore,12 like Diamond and Hopson,7 Jensen,8 and Although these findings are suggestive, neurosci- Greenspan,9 calls upon the authority of the brain in entists are cautious about extrapolating from these support of well-established practices, writers for the animal studies to human brains and human behav- popular press are not bound by similar scruples. In ior.5,6 Several responsible, balanced books for the lay the Time article, Nash10 has no hesitation in offering public such as Magic Trees of the Mind,7 Teaching With parents advice on the basis of our new knowledge of the Brain in Mind,8 and The Growth of the Mind9 detail how rapidly the brain grows during the early years: these cautions. Unfortunately, others writing for par- “Loving care provides the baby’s brain with the right ents have not shown similar restraint, particularly kind of stimulation. Neglecting a baby can produce those advocating or selling infant stimulation prac- brain wave patterns that dampen happy feelings.

964 SUPPLEMENT Downloaded from www.aappublications.org/news by guest on September 24, 2021 Abuse can produce heightened anxiety and stress tions from brain research to education: “Anything responses.” that people would say right now has a good chance After describing how the brain progressively re- of not being true two years from now because the fines the circuits for reaching, grabbing, crawling, understanding is so rudimentary and people are walking, and running, the author suggests that par- looking at things in such a simplistic way.”13 Like- ents do the following10: wise Greenough,5 one of the leading researchers Give babies as much freedom to explore as safety permits. Just demonstrating the effects of enriched environments reaching for an object helps the brain develop hand-eye coordina- on animal brains, cautions that there is no reason to tions. As soon as children are ready for them, activities like draw- ing and playing the violin and piano encourages the development believe that there are critical periods for socially of fine motor skills. transmitted skills such as reading, mathematics, and How are parents to interpret these recommenda- music and that these skills can be acquired at any tions? What constitutes neglect and abuse? If you do age. Other researchers also indicate that the empha- not respond every time a baby cries, is that neglect? sis on the infant brain ignores the important findings Are you abusing a child and causing bad brain wave to the effect that the mature brain has the ability to patterns if you restrain the infant from engaging in a change and reorganize.6 potentially dangerous activity? Likewise, how is a My own sense, after reviewing this material, is that parent to know when a youngster is ready for draw- we should move slowly and carefully when intro- ing and playing the violin and the piano? If parents ducing infant stimulation on the basis of the author- do not give their child these lessons, are they harm- ity of the brain. Before we make that enormous leap, ing the brain of their offspring? Recommendations we need to build some bridges between the elec- such as these are clearly irresponsible. They are too tromicroscopic events of the brain and the life-sized general to be helpful and yet specific enough (violin happenings of human thought and behavior. and piano lessons) to create parental anxieties. Un- fortunately, this is but one example of many articles David Elkind, PhD in the print media which attempt to translate brain Department of Child Development Tufts University research into childbearing practices. The results are Medford, Massachusetts often more confusing and stress-provoking than they are helpful. Perhaps the most controversial derivative of the REFERENCES authority of brain research is the proliferation of 1. Bruer JT: Education and the brain: A bridge too far. Educ Res 26:4–16, computer programs for infants. Indeed, the fastest- 1997 growing field of software development is so-called 2. Goldman-Rakic PS, Bourgeios JP, Rakic P: Synaptic substrate of cogni- tive development in the prefrontal cortex of the non-human primate, in “lapware” for infants aged 6 months to 2 years. The Krasegnor NA, Lyon GR, Goldman-Rakic PS (eds): Development of the term “lapware” comes from the consideration that to Prefrontal Cortex: Evolution, Biology and Behavior. Baltimore, MD, get infants to look at a computer screen, parents have Paul H. Brooks, 1997, pp 27–47 to sit the baby on their laps. If lapware were simply 3. LeVay S, Wiesel T, Hubel DH: The development of ocular dominance a way for parents to cuddle their children, probably columns in normal and visually deprived monkeys. J Compr Neurol 191:1–51, 1980 no harm would be done. But the writers of these 4. Greenough WT, Black JE, Wallace CS: Experience and brain develop- programs have grander expectations: “Nine months ment. Child Dev 58:539–559, 1987 to three years is the only age that matters in terms of 5. Greenough WT. We can’t just focus on the ages zero to three. APA real brain development” said BabyWow founder and Monit 28:19, 1997 6. Nelson CA, Bloom FE: Child development and neuroscience. Child Dev CEO Tony Fernandes. “BabyWow takes the com- 68:970–987, 1997 puter and turns it into a stimulation machine for 7. Diamond M, Hopson J: Magic Trees of the Mind. New York, NY, really young kids.” Other programs such as Jump- Dutton, 1998 start Baby and Future Bright suggest that these pro- 8. Jensen E: Teaching with the Brain in Mind. Alexandria, VA, Association grams help children make discriminations, track pat- for Supervision and Curriculum Development, 1998 9. Greenspan S: The Growth of the Mind. Reading, MA, Addison-Wesley, terns, and increase their attention spans. None of 1997 these claims have been demonstrated experimen- 10. Nash M. Fertile minds. Time February 3, 1997:48–56 tally. 11. Bagley S. How to build a baby’s brain. Newsweek Spring/Summer Neuroscientists are much more restrained in their 1997:28–32 12. Shore R: Rethinking the Brain. New York, NY, Family and Work Insti- interpretations of brain research. For example, Susan tute, 1998, pp ix–xi Fitzpatrick, a neuroscientist at the McDonnel foun- 13. Fitzpatrick S: Smart brains: Neuroscientists explain the mystery of what dation, had this to say about the rash of extrapola- makes us human. Am Sch Board J Nov 1995 p 21

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