Lecture 13


Child Psychopathology and Cognitive Disorders


Dale L. Johnson


Child Disorders


††††††††††† In this course we barely touch on the abnormal psychology of children. There is a course at UH that deals exclusively with this topic. The textbook takes up Attention Deficit Hyperactivity Disorder, Learning Disorders, Autistic Disorder and Mental Retardation and touches on a few other disorders. It does not deal with obsessive-compulsive disorder, depression, schizophrenia or anxiety, to name but a few other disorders that affect children.


††††††††††† Classification Issues

††††††††††† On of the major problems in this field has been the question of how best to classify child disorders. The practice that has been adopted by the American Psychiatric Association is to use the same system thatis used for adults and to add a section on developmental disorders. There are problems with this approach. For example, in order to make a diagnosis of depression the examiner must talk with the person and ask that person to report on her or his affective experience. Observation alone is insufficient. This calls for reflecting on one's experience, that is mentally reviewing one's history, and comparing one's present affective state with what recalls about the state from the past. It also calls for making comparisons with the experience of other people. Very young children cannot do this, but adolescents can. This ability to reflect on one's experience is a developmental process takes place over the years. The DSM-IV does not handle this problem well.

††††††††††† There is another problem. Many educators and others are reluctant to assign a diagnostic label to a child. They know that this label will make its way into school or other records and the child may be stigmatized by this action. They usually just avoid the issue and if the child is in need of special attention is simply assigned to a special education class. This avoidance of classification results in uncertainty about the prevalence of child disorders.

††††††††††† Some of problems that children have are almost entirely developmental problems; that is, they appear in childhood and disappear as the child matures into adulthood. An excellent example of this is enuresis, or bed wetting. All infants wet the bed at night and almost no adults do. In part it is a social issue because it is expected by parents, and children, that they will have dry nights when they reach a certain age. What that age is varies from family to family, but there is some agreement that it should occur by age 5. The wetting rates (wet at least once per week) change as follows: age 3, 20%, age 4, 15%, age 5, 12%, age 6, 10% and age 7, 8%, age 14, 2%. Thus, most children are dry at night by age 3, but a few continue to have a problem. Boys are twice as likely as girls to be enuretic.

††††††††††† For many years enuresis was defined as a neurotic problem and was seen as an expression of repressed hostility toward the mother. Psychotherapy of the dynamic variety was prescribed. There have been many studies of its effectiveness and they in agreement that the method is not at all effective. In 1938 Hobart Mowrer, then a graduate student at Yale, defined the disorder as developmental and designed a new form of treatment: the bell and pad procedure. In this the parent is given a one-hour training session and is instructed to put the child to bed without pajamas. The bed has a sheet on top of a metal screen, then another sheet and another metal screen. Finally, there is another sheet and a waterproof pad. The two metal screens are connected to a bell. When the child urinates during sleep a circuit is completed between the two metal screens and the bell rings waking the child and the parent. The sheets are changed, the bell is reset and the child is put back to bed. The procedue is a clear instance of classical (associative or Pavlovian) conditioning. Bladder tension is the conditioned stimulus, the bell is the unconditioned stimulus and rhe response is waking up. There have been many studies of the effectiveness of this procedure. It is effective in producing dry nights for more than 80% of children. Thus, it is one of the most effective procedures ever developed by psychologists. It was not widely used until the 1970s because pscyhodynamic theorists insisted that when one symptom (bedwetting) was removed another symptom would take its place. Several studies have proved this wrong. Dry-night children tend to do better in all ways. Incidently, the apparatus for this procedure is available at a low cost at Sears (or it was when I last checked). Today, an alternatives to the bell-and-pad exists. It is the drug imipramine. Apparently, the drug affects the sleep pattern and the child sleeps less soundly and is more easily aware of bladder tension. It is effective, but not as effective as the bell and pad.

††††††††††† There is another problem about describing an abnormal psychology of children. Children are not fully autonomous beings. They tend much more than adults to be a part of the social context in which they live. For most children the important context is the child's family. Picasso's "The tragedy" wonderfully depicts this situation. In this Blue Period painting we see a woman, a man and a child who is about 10 years old. The scene is on a seashore. The woman and man have arms crossed and they are both looking down and away from each other. They stand near, but apart. The child also looks down, but his right hand is on the man's thigh. In this painting we see grief and sorrow, and we see the child's sharing of his sorrow, admittedly incompletely understood, with the adults. His hand on the man's thigh shows a connection with the adults. His own world is complete only when it is in connection with his family. Picasso, in a single painting, has expressed a fact that generations of psychologists have finally arrived at. To know the child one must know his/her context. There are many implications of this for the treatment of child psychological disorders. The main one is that one does not treat the child alone; one treats the child in and through the family. A flurry of research in the early 1970s made that clear. I would never treat a child individually in play therapy today, although I did in the past. The results are disappointing. I would treat the child with the family. One works not only to change the child, the way she or he thinks and feels, but one changes the social context of the child to be supportive of child well-being.


Disorders of Undercontrolled Behavior

††††††††††† Some researchers have divided the main types of child behavior problems into two types: those of undercontrolled behaviors and those that are overcontrolled. This leaves out much, but it is a starting point.


Attention Deficit Hyperactivity Disorder (ADHD)

††††††††††† Chief among the undercontrolled disorders is ADHD. The disorder is common, but the prevalence is difficult to know, in part because there has never been a national epidemiological study of child behavior problems in the United States. There have been in the Netherlands, Canada and several other countries, but not in the USA. Another problem is that there has been difficulty in arriving at an acceptable definition of ADHD. From the studies that we do have it appears that the prevalence is about 120-500/10,000 children; that is, 1.2% to 5% of children. There is a gender difference: boys are more likely to have the disorder than girlsby a ratio of about 2-3 to 1. The rates are boys 8.9% and girls 3.3%.

††††††††††† An early view of the disorder was that it was a problem of hyperactivity, but research carried out by Virginia Douglas in Canada showed that the disorder is basically one of an attention deficit. These children do not focus well on tasks at hand and because they do not focus well they skip from one thing to another and seem over-active.

††††††††††† There have been many theories of the cause or etiology of the disorder. These have included minimal brain injury, diet, lead, genetic, food addititives, florescent lighting, and, of course, family environment.

††††††††††† Genetics

††††††††††† Twin studies have offered some evidence that genetics may be involved. In one twin study the monozygotic concordance was 51% compared with the dizygotic rate of 33%. As you are aware, this is only suggestive of a genetic disorder. In addition there is evidence that a defective gene found in families of people with ADHD codes for a thyroid hormone receptor that causes generalized resistance to thyroid hormone.

††††††††††† Brain Involvement

††††††††††† Researchers at the National Institute for Mental Health using PET scans found children with ADHD showed less brain activity than normal children in the premotor cortex and the superior prefrontal cortex. The neurotransmitter dopamine plays a large role in the functioning of the prefrontal cortex.

††††††††††† Family Environment

††††††††††† As to family environment, I have seen many children with their parents in our clinic. A small number of them appear to have no control over their children, or even worse, they send their children such a mixture of messages that the child cannot know what is expected. In these cases parental management of the child appears involved in the disorder although it may not be the only element.

††††††††††† Other

††††††††††† There have been many fads in this area. Research has discounted claims that food additives (don't eat Fritos or drink Kool Aid) or refined sugar (Twinkies), or florescent lighting in schools are involved.

††††††††††† Minimal brain injury is associated with attention problems. There is little doubt today that there is brain involvement. Almost certainly there is some problem in the frontal-limbic and pefrontal cortices as shown by PET scans.

††††††††††† Fetal alcohol syndrome is definitely involved in the cause of some ADHD as is maternal smoking during pregnancy.

††††††††††† Ingestion of lead also results in ADHD-like conditions.


††††††††††† Treatment

††††††††††† Treatment should follow assessment. For details on the kind of assessment that is necessary see Barkley, R. A. (1990).Attention deficit hyperactivity disorder: a handbook for diagnosis and treatment. New York: Guilford. Assessment includes an interview with the child and parents, behavior rating scales completed by parents and teachers, and sometime psychological testing. One test used often is a computerized measure of attentional abilities. This assessment should lead to a correct diagnosis. It is unfortunate that too many children are given the diagnosis and are treated with stimulant medication, but do not actually have ADHD; they are just misbehaving.

††††††††††† There are also many types of attention deficit disorder. The most common type is that which includes hyperactivity, but there is another that includes only a kind of spaciness. The child does not pay attention. As one nine year old girl told me, "I cannot play soccer because the other girls don't want me. They say I don't pay atention to the ball. It's true. My mind wanders." It is not good for a nine-year-old to be rejected by her peers playing soccer because she does not pay attention. She did not pay attention to much of anything else either, but was helped a great deal by Ritalin and some attention training at the UH Clinic.

††††††††††† The only treatment that has been shown to have a positive effect on attention deficit is the use of stimulant medications such as amphetamine, methylphenidate and pemoline.Ritalin, the trade name for methylphenidate, is the most widely used medication. A new drug is rising fast in use. Concerta offers 12-hour effectiveness thus, if taken in the morning, eliminates the noon medication. Stimulants probably work by raising serotonin levels to counter the high dopamine levels and calm the child (Caron, 1999, Science, 283, 397).

††††††††††† Stimulants are not without side effects. There may be weight loss, mild insomnia, reduced appetite and even growth retardation. However, claims that this early (prescribed) drug intake leads to drug abuse are wrong. In fact, the opposite occurs. Children with ADHD on medication are less likely to abuse drugs later than children with ADHD who are not on the medication (Pediatrics, 1999, Aug. 2).

††††††††††† Stimulant medications are used a great deal in America today. Many people, and I am among them, believe they are the easy way out and are over-used. They are given to children who do not have ADHD and they are given without ancillary psychosocial treatments. They should only be given after a careful psychological examination by a competent examiner. Pediatricians should not prescribe the drugs without this examination.

††††††††††† UH clinical psychology graduate, Teodoro Ayllon, demonstrated years ago that while stimulants help children focus better and control their impulsivity they do not help with school performance or social skills. For these psychosocial methods are necessary. One of my favorite ADHD children was treated with Ritalin and family-oriented behavioral treatment when he was four just after being kicked out of his third day care center for bad behavior. The family followed through with treatment and thought it was quite effective. Today this boy is grown and is a financial consultant with several offices in the Houston area.

††††††††††† Current research on self-control will probably lead to improved treatments.


††††††††††† Prognosis

††††††††††† The treatments are usually only partly effective and a large numberof children grow to become adults who still have the condition. Although they are at risk for substance abuse and accidental death this is not the fate for all ADHD people. A son of friends of mine had ADHD and he was a poor student. His situation was made worse by the fact that his three siblings were all brilliant honors students. After doing badly in a succession of colleges he went into construction work. Today he owns a framing company and his wife handles all of the business side of it. He told me he always asks prospective employees if they have ever had ADHD. If they have he hires them. He said, "They'll drive nails all day without a break." In another example, Michael Zane, founder of the Kryptonite bicycle lock, has ADHD and he attributes his success to the disorder: "I have always been able to do more and think faster and in more directions at once than most people." (New York Times, 10/31/00)



††††††††††† Amer. Acad. of Pediatrics††††††††† www.aap.org/policy/ac0002.pdf

††††††††††† Amer. Psychol. Assn.†††††††††††††††† www.apa.org/releases/adhteens.html

††††††††††† UCLA School††††††††††††††††††††††††††† smhp.psych.ucla.edu/pdfdocs/Atention.pdf


††††††††††††††††††††††† †††††††††††

Disorders of Overcontrolled Behavior

††††††††††† Fears

††††††††††† Children have fears. Any parent knows that. Why do they fear, and what do they fear? There have been two major points of view. One is the nativist position which holds that certain fears are built in, a part of being a young human, and part of the path of evolution that provides self-protection. They cite evidence of the fear of depths such as the fear of falling. This is tested using a visual cliff at 6 months of age. There is no real cliff; it is only apparent,but young children who have never seen a cliff show fear of falling. In the development of emotions, positive emotions develop before negative. Signs of happiness appear very early. For the infant there is a perceived opening of the world, the world is right for them and they are happy. In fear there is a perceived threat to safety.

††††††††††† The other side has been taken by the empiricist position and they say fear is a product of conditioning. The classical study of this is of Little Albert who was conditioned to fear a pet rat by making a loud noise each time Albert approached the rat. Empiricists believe learn to fear certain objects and places because of painful experiences with them.

††††††††††† Clearly, both points of view are necessary to account for all cases of fears.

††††††††††† Perhaps the main fear held by children is that of loss of parents. This is the primary threat to safety.


††††††††††† Phobia

††††††††††† Fears are also phobias. One of the major ones of these is school phobia, also called school refusal. In this the child, usually quite young, refuses to go to school. If pressed he/she makes an enormous fuss and parents typically give in, "Just this once." Except it happens again the next day. I recently worked with a family who had a 6 year old boy who refused to go to school. Parents talked with the teacher and learned that nothing had happened and that the boy was an exceptionally good student. He liked to stay home with his mother. After checking out several possible reasons for his refusal and finding nothing of importance I had the parents tell the teacher that they would bring the boy to school and would then drive away. He would fuss, but they were not coming back until the usual post-school pick-up time. They did that and he fussed mightily for about 30 minutes. They did the same the next day and he fussed to 10 minutes. On the third day his heart was not in it and only fussed for a few minutes. On the fourth day he accepted school happily. There have been no relapses. In this we used exposure to the feared object, the school, and knew that by his living through his fear he would master it. It worked. Reearch has shown that it almost always works. It is a form of behavior therapy called exposure. Note, however, that in my example above there were no apparent adverse circumstances. If the parental marriage is breaking up and the child has fears about this it may require a different course of treatment. If the child is the object of bullying on the school ground, the bullying has to be managed. Learning about complicating circumstances calls for a careful assessment of the situation.

††††††††††† Treatment

††††††††††† The treatments for child anxiety disorders including phobias are similar to those for adults, except the parents are always included in the treatment plan. The methods include

††††††††††† Desensitization

††††††††††† ††††††††††† See textbook.

††††††††††† Modelling

††††††††††† ††††††††††† In dog phobia, for example, if a parent shows fear of dogs it is common for the the child also to show fear. Treatment consists of showing the child that the dog is not dangerous and actually fun to play with. Fear disappears rapidly.

††††††††††† Skill development

††††††††††† ††††††††††† Many phobias develop out of specific fears, such as the fear of water. Part of the treatment for this is to develop swimming skills. I recall when my wife was teaching swimming one of her students was a 6 foot 4 inch 20-year old man who has terribly afraid of water and wanted to overcome the fear. He chose to learn to swim from this 5 foot 1 inch instructor. He did well, was swimming up and down the pool and diving off the high board in a few days. It was a matter of getting into the water at the shallow end and working gradually, and with a series of successes, moving on to deep water.



††††††††††† As mentioned above the identification of depression in young children is difficult. I was once asked to help the staff at a Head Start center with a 4-year-old who was unusually violent. He would hit, kick and stratch other children and throw toys at the teachers. He was uncontrollable. After an observation period when it became clear that he was very angry I had one assistant teacher place herself within a step or two of him at all times. If he seemed ready to hit she was to engulf him with her arms and simply hold him for 30 seconds. His aggressive behavior stopped and he began spending all of his time under tables. The head teacher made a home visit and learned several things: the father and mother had had a noisy argument and the father had left home. Second, a little later, there was a fire in the family apartment and the baby sister died in the flames. The mother had stepped out for a few minutes. The little boy blamed himself for not saving the baby. We had the boy act out the fire with fire engines, etc., while the head teacher commented on what he was doing. She did not interpret. He got better. Then daddy came home and he got well. In this case with a very young child environmental manipulations were used with success. Note that the boy did not say that he was depressed; it is doubtful that he had any awareness of the concept. His world was wrong and he was unhappy with it and with himself. We inferred his depression from the circumstances that surrounded him and from his behavior that indicated he was not happy with the way things were going.

††††††††††† Older children and adolescents respond well to cognitive behavior therapy. There is much discussion now about the use of medication and clinical trials are underway. If it is found to be effective I would hope that it is used very carefully because of the unknown side effects, and because psychological methods work so well.


Serious Emotional Disorder

††††††††† Some children not only have severe disorders, but they tend to have symptoms of many disorders. They do not do well in school, they have no friends, and their parents do not know what to do. The causes of these disorders are many and effective treatments are few. Specifically this group includes children with childhood schizophrenia, some bipolar disorder, some obsessive compulsive disorder, and many with no easily named disorder.



††††††††††† The textbook has a good coverage of this topic. One thing: keep in mind that although there are many treatments for autism and they vary in popularity there is only one treatmentthat has had its effectiveness demonstrated through controlled clinical trials. That is the behavioral treatment developed by Ivar Lovaas at UCLA. One of the few places in the USA where this program is being applied is at the University of Houston by its Psychology Clinic. Dr. Gerald Harris directs the program. UH undergraduates do much of the actual treatment. Medical treatments have not been very effective. Anti-psychotic drugs have been used and they do help to control some symptoms, and antidepressant drugs such as Prozac suppress repetitive movements, but these drugs are no substitute for behavioral methods.

††††††††††† There has been much concern recently about an apparent increase in the incidence of autism. Parents of children with autism have taken up the idea that this increase is causedby vaccination that are given to all young children and some of the measles vaccinations have small amounts of mercury. The belief is that that the mercury causes autism. There are several interesting research questions in this line of reasoning. First, is it true that the incidence of autism is increasing? Unfortunately the United States Center for Disease Control cannot answer that question because the USA does not collect incidence data on developmental or psychiatric disorders. They record the incidence of measles, flu, etc., but not psychiatric disorders. Therefore, we look to countries that do record incidence, such as those in Scandinavia. A study in Finland showed an increase, but the authors attributed the increase, at least in part, to changes in ways of classifying the disorder and identifying it. There may be no real change, just that more cases are identified. A similar study in Israel found no increase above the expected 1:10,000 rate. Nevertheless, epidemiologists in California believe there is an increase, but do not know why.

††††††††††† What about the vaccination question? First, vaccinations are administered after the child is born, at about 18 months,and all evidence of the cause of autism is that it begins prenatally and symptoms are first noticed at about 18 months. Second, the amount of mercury is too low to have any effects on brains of animals or humans. Third, in Denmark and the United Kingdom, the prevalence of autism was examined before the introduction of the measles vaccine and after and no changes in prevalence were observed. Measles vaccinations do not cause autism and parents should make sure their children are vaccinated. There is an increase of measles in the USA, because parents have neglected or refused to have vaccinations.

††††††††††† I is increasingly clear from twin and family studiesthat autism is to a large extent a genetic disorder.Now it has been found that autistic children have a shortened form of the serontonin transporter gene. There is also evidence that the WNT2 gene, located on chromosome 7, is implicated.



††††††††††† National Academy of Sciences:††††††† www.nap.edu/books/0309072697/html

††††††††††† Pediatrics†††††††††††††††††††††††††††††††††††††††† www.pediatrics.org/cgi/content/full/105/5/e65

††††††††††† Amer. Acad. Pediatrics†††††††††††††††††††† www.pediatrics.org/content/full/107/5/e85

††††††††††† Natl. Instit. Mental Health††††††† www.athealth.com/consumer/disorders/autism.html





I can do anything now at age 90

that I could do when I was 18,

which only shows how pathetic

I was at 18.



Aging and Cognitive Disorders


††††††††††† The prportion of elderly people in America, and in much of the world, in relation to the rest of the population has grown rapidly. In 1900 only 4% of population were over 65 years of age. By 1987 this proportion had grown to 12% and it is predicted that by 2040 the percent will be in the 21-25% range. This increase in proportion of the population has important implications for the nation in terms of the workforce, but it also has public health implications.


††††††††††† Age, cohort and time of measurement effects

††††††††††† There are cohort effects to be considerd, that is effects related to the time a group of people are born and experience together certain social and environmental issues. Thus Americans those born in the 1950s were marked forever by the Viet Nam war experience. My generation can never forget their experience of both the Great Depression and WWII.

††††††††††† There are typically two kinds of research when looking at groups of people. First, there are cross-sectional studies. These are more common. In these one selects groups of people for research by age categories. Such studies typically have shown declines in intellectual functioning with aging. However much of this effect seems to be a matter of where the researchers found subjects; e.g., nursing homes where those with greatest disabilities are found.

††††††††††† Longitudinal studies follow the same individuals over time. These studies have found much less decline, and what did appear was associated with illness. The best examples of these two types of research have been in the study of intelligence. Cross-sectional studies consistenly found that as people aged they lost IQ points. Getting dumber was regarded as inevitable. Then, longitudinal research came along and the same people were followed from adolescence into their 90s. What the researchers found is that people did not get dumber and verbal abilities especially held up well. This is, of course, unless they developed a dementing illness such as Alzheimers.


††††††††††† Diagnosing psychopathology in later life

††††††††††† The DSM-IV is used in the the same way as with younger people. The range of problems is about the same, but some new disorders appear.


††††††††††† Old Age and Brain Disorders

††††††††††† The main new disorder is dementia, or literally, a loss of mind. It used to be called senility, but that term was too broad and vague to have much meaning and it has been replaced by several more specific names for disorders. As for dementia as a broad category it is found in approximately 30% of people over 80. Cerebrovascular accidents, orstrokes, are a major cause of dementia.


Dementia of the Alzheimerís Type

††††††††††† Alzheimerís (1860)(AZ) disease is involved in half of cases of dementia in the elderly. The diagnosis is made only my microscopic analysis of brain tissue in autopsy. To make a diagnosis while the person lives a process of exclusion is used to rule out other causes of psychological changes. Early diagnosis is based on psychological testing to detect memory problems, failure to integrate new information and failure to learn new associations. New brain imaging methods may make early diagnosis possible. For example, new PET scans show an excessive production of the neurotransmitter dopamine (Science, 1993, 259, p. 898).

††††††††††† Alzheimers can occur in a person's early 40s and is then called presenile dementia.

††††††††††† It is more common in poorly educated people, but highly educated people are not immune. One of the University of Houston Psychology professors after retirement developed Alzheimers. He had been called, "Mr. Psychology," because he had contributed so much to the field. His textbook was read by legions of undergraduate students all over the nation.He was brilliant, witty and a kind man. He lost his memory completely before he died.

††††††††††† There was, however, the famous study of nuns living together in same environment for many years. Now in their 80s, one third of them had developed AZ. Researchers looked at essays that had been written by the women when they were young. Those who did not get AZ wrote autobiographies that were more complex and had more ideas.

††††††††††† AZ is more common among women. It is less likely among Japanese, Nigerians, Native Americans and the Amish. For example, the more Cherokee one is, the less likely it is that one will develop Alzheimers. AZ is age-related. The older one becomes the more likely it is the AZ will develop. At age 90 the chances are 50-50.

††††††††††† It is a genetic disease. Chromosomes that may be involved are located on chromosomes 21, 19, 14, 12, 1,10. In a few days there may be more, or less. Chromosome 14 is involved in a large number of early cases.

††††††††††† The disease is caused by a buildup of amyloid protein which develops plaques in the brain. There are also neurofibrillary tangles composed of tau protein. There is a massive loss of brain cells.

††††††††††† AZ is related to Down syndrome. Both involve C-21.

††††††††††† Treatment

††††††††††† There is little effective treatment. However, the disease process can be slowed with vitamin E (2,000 I.U. daily or selegiline (Eldepryl- 10 mg. daily). These do not help cognitive function, but have a positive effect on ativities of daily living and so tend to delay nursing home placement.There is a keen interest in prevention with most emphasis placed on the use of antioxidants such as vitamin E or C. The herbal, gingko biloba, may be of some value in delaying deterioration of memory.

††††††††††† Caretakers of people with Alzheimers have a great burden. Because the typical time after diagnosis until death is 8 years and part of this requires nursing home care the financial burden is great. It is also difficult to see a loved one disappear as a person before ones eyes. The biorgrapher of former president Ronald Reagan said, "for the last 6 months he hasn't recognized me, and for the last 3 months I haven't recognized him."

††††††††††† Several acetylcholinesterase inhibitors are used in the early and middle stages to delay progression of the disease.

††††††††††† As many patients develop severe behavioral problems their management becomes a challenge. Antidepressant and anti-anxiety medications are used with some effectiveness. In extreme case anti-psychotic medications are used.



††††††††††† American Family Physician:www.aafp.org/afp/20020601/2263.html

††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††† www.aafp.org/afp/20020615/2525.html

††††††††††† Alzheimer's Association††††††† www.alz.org/famcare/overview.asp

††††††††††† National Institute of Aging††† www.nia.nih.gov/exercise/toc.htm

††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††† www.nia.nih.gov/heal/pubs/clinicians-handbook



(for Renee Mauger)


C. K. Williams

She answers the bothersome telephone, takes the message, ††††††††††† forgets the message, forgets who called.

One of their daughters, her husband guesses; the one with ††††††††††† the dogs, the babies, the boy Jed?

Yes, perhaps, but how tell which, how tell anything when all the nametags have been lost or switched,

when all the lonely flowers of sense and memory bloom and die now in adjacent bites of time?

Sometimes her own face will suddenly appear with terrifying inappropriateness before her in a mirror.

She knows that if she's patient its gaze will break, demurely, like a well-taught child's,

it will turn from her as though it were emarrassed by the secrets of this awful hide-and-seek.

If she forgets, though, and glances back again, it will still be in there, furtively watching, crying.


Atlantic Monthly, April, 1987.


Vascular Dementia

††††††††††† Stroke is the third leading cause of death. Many people survive strokes, but lose some cognitive functioning with each stroke. This disease affects 4.7% of men and 3.8% of women. Many cases diagnosed as Alzheimer's are later discovered on autopsy to be forms of vascular dementia


Dementia Due to Other General Medical Conditions

††††††††††† There are many other potential causes of dementia. Today, the most common of these is AIDs. Another obvious source of dementia is head trauma caused by accidents where these is brain damage. People of any age may be involved.


Parkinsonís Disease

††††††††††† This is abrain disorder involving the degeneration of dopaminergic neurons within the substantia nigra . The prevalence is about 1/1000 worldwide. It is the second most common degerative disorder after Alzheimers. It affects approximately 1% of the population over age 50. Among the symptoms are stooped posture, slow movements, jerkiness in walking and a soft monotone voice. A reduction in dopamine is involved. Some people develop dementia.

††††††††††† Some of you may remember the movie, Awakenings, with Robin Williams. It was about a particular form of Parkinson's disease that also involved exposure to the influenza epidemic of 1918.

††††††††††† Research has identified chromosome 4 as being involved, but is not a major factor. The susceptibility is largely unknown although it is clear that environomental factors play a role. One curious finding is that smoking reduces the risk of devleoping parkinson's disease. Possible environmental causes include exposure to chemicals such as pesticides and herbicides and diet. A drug--synthetic heroin--can cause PD-like symptoms, but the actual environmental causes are not known.

††††††††††† Treatment. As PD is caused by the death of cells in the substantia nigra which produces dopamine adding dopamine as levodopa was believed to help. However, while it did produce miracle cures in the short-run it didnít work over time.

††††††††††† There is aslo a surgical procedure: removal of the subthalamic nucleus. This procedure procuces remarkable results in some patients.


Huntingtonís Disease

††††††††††† Motor moverments are choreoformic; that is, it seems as though the person is dancing. People develop signs of the disease in their 30s and live another 20 years, although apparently people now live into their 60s. Most people with the disease eventually develop dementia. Many become psychotic.

††††††††††† Huntington's is a genetic dominant disease. The genetic cause is the only cause and only one gene is involved. Research instigated by Nancy Wexler whose family was involved with the disease has shown that the gene is located on chromosome 4. As 50% of people at risk for the disease, that is, who have a parent with the disease, will develop the disease prevention is possible. People at risk should not have children. However to say this is one thing, to convince people with the gene that they should not have children is another. Martindale (1987, British Journal of Psychiatry, 150, 319-323) found that professionals and people at risk showed considerable denial. By not reproducing the disease could be eliminated. As affected people do reproduce the disease continues. Fewer people who know they have the gene now have children.

††††††††††† A famous sufferer was Woody Guthrie.


Pickís Disease

††††††††††† This is a rare disease. It is a cortical dementia similar to Alzheimers. It begins in the person's 40s and 50s.



††††††††††† This disease is rare, but as you know from reading the papers, it may be caused by mad cow disease and has spread rapidly in Europe. Donít eat raw hamburger and avoid elk meat.


Good News

††††††††††† There is considerable evidence that people who have a positive outlook on life live longer. Pessimists die younger. Stay on an even emotional keel and live longer. These findings are based on psychological tests administered to young people and then, years later, death rates are examined. Older people who have a negative view of aging experience more events as stressful. As you know, people who are optimistic and see problems as a challenge, not as a source of debilitating stress, are healthier in general, and are so throughout their lives. If you can't be happy, be cantankerous; these argumentative,difficult people also live longer.