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Preface to:
Little Bubba's Not Ready For Nashville Yet
"Give a little love to a child, and you get a great deal back."
John Ruskin
In fifth grade I read every Sherlock Holmes' mystery I could get my hands on. The uncanny ability of
London's great detective to solve crimes with systematic observations and deductive logic opened a
world I'd never been exposed to in my grade school education in the South.
It wasn't until years later, when I was in graduate school, that I learned Sir Arthur Conan Doyle's
famous fictional character was based on one of his medical school professors at the Royal Infirmary in
Edinburg where he was a student in the late 1800's. Apparently, like Holmes, neurologist Joseph Bell
mystified Doyle and his fellow students with his gift for clinical diagnosis.
Like Yogi Berra says, "You can see a lot just by looking." Neurology and psychology have always
looked--looked and made their crude measurements on brain-behavior relationships.
Shortly before Doyle enrolled in medical school, Jean Charcot and his colleagues started documenting
the abnormal physical symptoms and behaviors in their patients at La Salpêtrière Hospital in Paris and
later correlating them with brain pathology found at autopsy. Sigmund Freud, Giles de la Tourette, and
other clinician/scientists came to Paris to study with Charcot, the most famous physician of the day.
Charcot, and the investigators who worked with him , described and named many of the classic
neurological and behavioral disorders we know today.
Recently, the way neurologists and psychologists look at the brain has changed. Congress and the
President declared the nineties as the Decade of the Brain and an explosion of research in the
neurosciences has toppled many old ideas about brain function. New technology has discovered brain-
behavior relationships we had no idea existed a decade ago.
Functional MRI's, which measure blood flow in the brain, have given us a window to examine the areas
of the brain, which are active when a person is involved in various sorts of mental or emotional activity.
With the completion of the Human Genome Project, neuroscientists are making progress in
understanding the role our genes play in brain development as well as brain pathology.
A lot more is also known now about how our genes and our environment manage the pre and
postnatal development of our brains. The mystery of how nature and nurture work together to
oversee the differentiation of billions of neurons (nerve cells) as they migrate to various locations in the
nervous system and fulfill their destiny in the countless neural circuits underlying our sensory,
intellectual, and motor functions is being solved.
Usually, the miraculous process of creating who we are and what we can do runs smoothly, but
occasionally there are glitches--glitches we are just beginning to understand. (Glitches may be too kind
of a word. If we look at the rather grim effect these glitches have on the child, crimes may be a better
word--horrific crimes committed against the child--crimes we may be able to solve one day soon.)
Besides a long list of genetic defects and inborn errors of metabolism, there are pre and postnatal
insults to the brain that come from the developing child's environment. Head traumas, infections,
toxins, heavy metal poisoning, drug abuse by the mother, and malnutrition can all cause brain damage.
The age of the child, the location in the brain of the damage, and the extent of the damage interact to
determine if the brain can compensate or if the damage will be irreversible and have a lifelong impact.
According to the Kennard Principle, the earlier in life brain damage occurs, the better the chance of
recovery. And generally this is true. As we grow older, our brains lose much of their plasticity and
there is less chance of the neural circuits reorganizing. Obviously, early intervention by physical
therapists, occupational therapists, speech language therapist, and psychologists makes sense and to
a certain extent is quite successful. But there's still too many unsolved mysteries in these young
children who present with neuropsychological disorders--mysteries that are caused by culprits that will
be every bit as formidable and difficult to track down as Holmes' nemesis, Dr. Moriarty.
While we may know more now about brain function and dysfunction, the treatment regimens for kids
with neuropsychological disorders hasn't changed much since I first started practicing thirty years ago.
In the small, rural, southern college town where I'm located or a large metropolitan hospital, applied
behavioral analysis and a handful of drugs continue to be the most effective weapons available for
treating neuropsychological disorders in these kids.
Neuropsychological disorders tend to be sexist. For example, autism is five to six times more likely to
occur in males than females. And there also seems to be sex differences in the severity of
neuropsychological disorders. Fragile X Syndrome is not nearly as disruptive in females as in males.
Seven of the nineteen cases presented in this volume are female, which is a slightly higher ratio of
females to males than is normally seen in a clinic for children with neuropsychological disorders at any
one time. (Race and ethnic background is not related to most of the common neuropsychological
disorders, however, socio-economic status is related to certain disorders, with the poor being overly
represented in the occurrence of certain types of mental retardation.)
A clinic for children with neuropsychological disorders quickly becomes theater, where every human
emotion, every plot and sub-plot, every possible ending seen on the stage of life is played out. What
has happened personally to these kids and their families is tragic, but in real life tragedies, just like
tragedies on the stage, we often find comic relief.
Unfortunately, many children with neuropsychological disorders first appear on the clinic stage in
disguise. And often, I do not know if all of the problems they present with are neurological or if their
social environment has caused them.
Naturally, parents, teachers, and clinicians do not have the same expectations for children with
neuropsychological disorders. These expectations of lower levels of performance are often
communicated to the child and rewarded. A child may quickly learn to play the role of a child with
autism who cannot pay attention or a child with mental retardation who does not follow simple
directions.
Deciding who is in disguise and acting and who is not in the play is the mystery I must solve. Not being
able to do something and refusing to do something are the same as far as clinicians and teachers are
concerned. I have seen many kids in special ed programs who are there simply because they are non-
compliant and not performing at their full potential.
Of course, names and other identifying details and events have been changed in all of the cases
presented here to insure confidentiality. And since so many of the kids who have come to my clinic over
the years have the same neurological and behavioral problems the syndromes alone and the behaviors
mentioned cannot identify any of the children. Any similarities are purely coincidental.
Five of the cases in this volume have been previously published in various formats. The Journal of
Behavior Therapy and Experimental Psychiatry published a scholarly account of "The Longest Running
Horror Movie". Abbreviated versions of "The Longest Running Horror Movie," "Wild Child," and
"Treasuring Touretts's" appeared in the online publication, The Write Brain. Another online journal,
Perspectives: A Mental Health Magazine published an early, abbreviated version of "The Trichee", and
The Humanist published "The Sometimes Son".
"The more I know the less I understand."
The Eagles
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