Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Editorials Marcel Kinsbourne To cite this article: Marcel Kinsbourne (1975) Editorials, Postgraduate Medicine, 58:3, 211-212, DOI: 10.1080/00325481.1975.11714153 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714153
Published online: 07 Jul 2016.
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Date: 18 August 2017, At: 21:51
~ilorials
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MBD-A FUZZY CONCEPT MISDIRECTS THERAPEUTIC EFFORT The terrn "minimal brain dysfunction" (MBD) is used to describe neurologie phenornena ranging throughout the various levels of neural organization, from reflex to cognitive function. The presence of such phenornena in an individual supposedly indicates sorne early noxious influence on the nervous system. A clinician rnight well suspect sorne underlying brain rnalfunction when faced with a child who unaccountably fails to learn in the expected rnanner but who has the usual opportunities for education, is apparently rnotivated, and is not notably ernotionally disturbed. Because clinicians were uncornfortable with the argument that the mere existence of such a selective learning deficit is in itself sufficient evidence of a darnaged brain, they searched for associated deviations that would incriminate nervous system damage. A somewhat undisciplined effort to this end has resulted in the proposai of rniscellaneous signs, including bath cognitive and sensorirnotor disabilities, as indicative of such damage. Cognitive disabilities affect either attention or mental processes. Sensorimotor disabilities represent either rninor instances of classic neurologie abnorrnality (hard signs) or sensorimotor development appropriate to a younger child (soft signs). The cognitive components of the MBD concept rnerely restate the ongoing problem that children given this diagnosis have in school. Selective difficulty in learning to read and write has categorically been included in the MBD syndrome, as bas the attentional disorder that
Vol. 58 • No. 3 • September 1975 • PDSTGRADUATE MEDICINE
characterizes so-called organie or developmental hyperactivity. Due to impulsive shifts in the focus of their attention, these children cannat concentrate on any one abject, event, or tapie for more than an unduly brief period of tirne. To include ali these deficiencies as signs of MBD, however, assumes that they ali originate in sorne similar brain abnormality. The hard signs of MBD are virtualiy ali rnotor defects, although rarely a patch of anesthesia rnight be included, or perhaps a visual defect. Typical hard signs are bilaterally exaggerated tendon reflexes, a minor degree of intention trernor of the painting band, or perhaps the slight, forced pronation and extension of the fingers indicative of rnild dystonia in a child picking up a srnall abject between finger and thurnb. Minor degrees of classic neurologie abnorrnality affecting the corticospinal, cerebellar, and extrapyramidal rnotor control systems are actually mild instances of various forrns of cerebral palsy. According to the MBD concept, however, it could be argued that such manifestations represent minor neurologie insults. Soft signs differ from hard signs in that the child's age is the factor that determines whether the sign represents an abnormality. These signs are ali normal at sorne stage of development. The abnorrnality consists not in their presence as such but in their undue persistence as the child grows aider. Soft signs represent relatively early stages of differentiation of motor control. Thus, they in-
211
Downloaded by [Australian Catholic University] at 21:51 18 August 2017
dOtE------------------elude synergisms-movement clusters sa linked that when the child attempts one movement, other movements necessarily accompany it. For instance, whereas a 1-year-old child is usually able ta oppose thumb and index finger differentially, younger babies also flex the other fingers and often even the other joints of that upper extremity. Such synergisms decrease in complexity as age increases. A special class of synergisms known as associated movements represent comparable innervations on opposite sides of the body. Undue persistence of soft signs represents a maturationallag in motor development. Clumsiness, often in itself a primary complaint, may be based on such immaturities. Maturationallag as inferred from soft signs, however, has also been enlisted ta explain an inability ta learn, even though learning has no connection whatever with the lower levels of motor control. The implicit assumption is that if motor control is subject ta a developmental lag, a coexisting intellectual problem must be similarly explicable. This may sometimes be so, but it certainly ts not always true. The concept of MBD is ill-defined and thus obscures precise diagnosis. Lumping together trivial findings such as brisk knee jerks with such vitally important ones as difficulties in maintammg concentration or lack of reading readiness tends ta divert the clinician's attention from the child's learning problems, which is where the focus should be. Pending the development of means for directly modifying central nervous system function, therapeutic effort should focus on the deviant behavior itself rather than on its hypothetical basis in neurologie abnormality. MARCEL KINSBOURNE, MD
Senior Staff Physician, The Hospital for Sick Children Pro/essor of Pediatries University of Toronto Toronto
Tenuatë€ (diethylpropion hydrochloride N.F.) BRIEF SUMMARY INDICATION: Tenuate is indicated in the management of exogenous obesity as a short-lerm adjunct (a few weeks) in a regimen of weight reduction based on calorie restriction. The llmited usefulness of agents of this class should be measured against possible risk factors Inherent in their use such as those described below. CONTRAINOICATIONS: Advanced arteriosclerosis, hyperthyroidism, known hypersensitivlty, or idiosyncrasy to the sympathomimetic amines, glaucoma. Agitated states. Patients with a history of drug abuse. Durlng or within 14 days following the administration of monoamlne oxidase inhibitors, (hypertenslve crises may result). WARNINGS: If tolerance develops, the recommended dose should not be exceeded in an attempt to increase the effect; rather, the drug should be discontinued. Tenuate may Impair the ability of the patient to engage in potentially hazardous activlties such as operating machinery or driving a motor vehicle; the patient should therefore be cautioned accordingly. Orug Dependenu: Tenuate has seme chemical and pharmacologie similarities to the amphetamines and ether related stimulant drugs that have been extensively abused. There are occasional reports of subjects dependent on amphetamine later chronically abusing diethylproplon. The posslbllity of abuse should be kept in mind when evaluating the desirability of including a drug as part of a welght reduction program. Abuse of amphetamines and related drugs may be associated with varying degrees of psychologie dependence and social dysfunction whlch, ln the case of certain drugs, may be severe. There are reports of patients who have increased the dosage to many times thal recommended. Abrupt cessation following prolonged hlgh dosage administration results in extrema fatigue and mental depression: changes are aise noted on the sleep EEG. Manifestations of chronic intoxication with anorectic drugs lnclude severe dermatoses, marked lnsomnla, irritabllity, hyperactivity, and personallty changes. The most severe manifestation of ch renie intoxications is psychosls, olten clinically indistlnguishable from schizophrenla. Un ln Pregnancy: Although rat and hu man reproductive studies have not indlcated adverse effects, the use of Tenuate by women who are pregnant or may become pregnant requlres thal the potential benefits be weighed agalnst the potential rlsks. Un ln Chlldren: Tenuate ls not recommended for use in chlldren under 12 years of age. · PRECAUTIONS: Caution is to be exercised in prescrlblng Tenuate for patients with hypertension or with symptomatic cardiovascular disease, including arrhythmias. Tenuate should not be administered to patients with severe hypertension. lnsulln requirements in diabetes mellitus may be altered in association wlth the use of Tenuate and the concomitant dietary regi men. Tenuate may decrease the hypotenslve affect of guanethldine. The least amount feasible should be prescrlbed or dispensed at one ti me in order to minimize the posslbillty of overdosage. Reports suggest that Tenuate may increase convulsions in seme epileptics. Therefore, eplleptlcs receiving Tenuate should be carefully monltored. Tltratlon of dose or discontinuance of Tenuate may be necessary. ADVERSE REACTIONS: C~rdiovoscu/~r: Palpitation, tachycardia, elevation of blood pressure, precordial pain, arrhythmia. One published report described T-wave changes in the ECG of a healthy young male alter ingestion of dlethylpropion hydrochlorlde. Centfll Nervous System: Overstimulatlon, nervousness, restlessness, dlzziness, jitteriness, insomnla anxiety euphoria, depression, dysphoria, tremor, headache; rarely psychot1c episodes at recommended doses. ln a few epileptlcs an increase in convulsive episodes has been reported. Gastrointestins/: Oryness. of the mouth, unpleasanttaste, nausea, v_om1!1ng, abdominal dlscomfort, diarrhea, constipation, ether gastrointestinal disturbances. Allergie: Urticaria, rash, ecchymosis, erythema. Endocnne. Impotence, changes ln libido, menstrual upset. Hemstopoietic System· Bene marrow depression, agranulocytosls, 1eukopen1a. M!Scellsneous: A variety of miscellaneous adverse reactions has been reported by physiclans. These lnclude complalnts such as dyspnea, hair loss, muscle pain, dysuria, and polyur~a.
MERRELL-NATIONAL LABORATORIES lnc. Gaye y. Puerto R1 co 00633 01rect MedicallnqulfJes to.
MERRELL-NATIONAL LABORATORIES Division of Richardson-Merrell lnc. Cincinnati, Ohio 45215 L1censor of
212
Merrell'~t
4-7665C [6B 14!
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Editorials Marcel Kinsbourne To cite this article: Marcel Kinsbourne (1975) Editorials, Postgraduate Medicine, 58:3, 211-212, DOI: 10.1080/00325481.1975.11714153 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714153
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 18 August 2017, At: 21:51
~ilorials
Downloaded by [Australian Catholic University] at 21:51 18 August 2017
MBD-A FUZZY CONCEPT MISDIRECTS THERAPEUTIC EFFORT The terrn "minimal brain dysfunction" (MBD) is used to describe neurologie phenornena ranging throughout the various levels of neural organization, from reflex to cognitive function. The presence of such phenornena in an individual supposedly indicates sorne early noxious influence on the nervous system. A clinician rnight well suspect sorne underlying brain rnalfunction when faced with a child who unaccountably fails to learn in the expected rnanner but who has the usual opportunities for education, is apparently rnotivated, and is not notably ernotionally disturbed. Because clinicians were uncornfortable with the argument that the mere existence of such a selective learning deficit is in itself sufficient evidence of a darnaged brain, they searched for associated deviations that would incriminate nervous system damage. A somewhat undisciplined effort to this end has resulted in the proposai of rniscellaneous signs, including bath cognitive and sensorirnotor disabilities, as indicative of such damage. Cognitive disabilities affect either attention or mental processes. Sensorimotor disabilities represent either rninor instances of classic neurologie abnorrnality (hard signs) or sensorimotor development appropriate to a younger child (soft signs). The cognitive components of the MBD concept rnerely restate the ongoing problem that children given this diagnosis have in school. Selective difficulty in learning to read and write has categorically been included in the MBD syndrome, as bas the attentional disorder that
Vol. 58 • No. 3 • September 1975 • PDSTGRADUATE MEDICINE
characterizes so-called organie or developmental hyperactivity. Due to impulsive shifts in the focus of their attention, these children cannat concentrate on any one abject, event, or tapie for more than an unduly brief period of tirne. To include ali these deficiencies as signs of MBD, however, assumes that they ali originate in sorne similar brain abnormality. The hard signs of MBD are virtualiy ali rnotor defects, although rarely a patch of anesthesia rnight be included, or perhaps a visual defect. Typical hard signs are bilaterally exaggerated tendon reflexes, a minor degree of intention trernor of the painting band, or perhaps the slight, forced pronation and extension of the fingers indicative of rnild dystonia in a child picking up a srnall abject between finger and thurnb. Minor degrees of classic neurologie abnorrnality affecting the corticospinal, cerebellar, and extrapyramidal rnotor control systems are actually mild instances of various forrns of cerebral palsy. According to the MBD concept, however, it could be argued that such manifestations represent minor neurologie insults. Soft signs differ from hard signs in that the child's age is the factor that determines whether the sign represents an abnormality. These signs are ali normal at sorne stage of development. The abnorrnality consists not in their presence as such but in their undue persistence as the child grows aider. Soft signs represent relatively early stages of differentiation of motor control. Thus, they in-
211
Downloaded by [Australian Catholic University] at 21:51 18 August 2017
dOtE------------------elude synergisms-movement clusters sa linked that when the child attempts one movement, other movements necessarily accompany it. For instance, whereas a 1-year-old child is usually able ta oppose thumb and index finger differentially, younger babies also flex the other fingers and often even the other joints of that upper extremity. Such synergisms decrease in complexity as age increases. A special class of synergisms known as associated movements represent comparable innervations on opposite sides of the body. Undue persistence of soft signs represents a maturationallag in motor development. Clumsiness, often in itself a primary complaint, may be based on such immaturities. Maturationallag as inferred from soft signs, however, has also been enlisted ta explain an inability ta learn, even though learning has no connection whatever with the lower levels of motor control. The implicit assumption is that if motor control is subject ta a developmental lag, a coexisting intellectual problem must be similarly explicable. This may sometimes be so, but it certainly ts not always true. The concept of MBD is ill-defined and thus obscures precise diagnosis. Lumping together trivial findings such as brisk knee jerks with such vitally important ones as difficulties in maintammg concentration or lack of reading readiness tends ta divert the clinician's attention from the child's learning problems, which is where the focus should be. Pending the development of means for directly modifying central nervous system function, therapeutic effort should focus on the deviant behavior itself rather than on its hypothetical basis in neurologie abnormality. MARCEL KINSBOURNE, MD
Senior Staff Physician, The Hospital for Sick Children Pro/essor of Pediatries University of Toronto Toronto
Tenuatë€ (diethylpropion hydrochloride N.F.) BRIEF SUMMARY INDICATION: Tenuate is indicated in the management of exogenous obesity as a short-lerm adjunct (a few weeks) in a regimen of weight reduction based on calorie restriction. The llmited usefulness of agents of this class should be measured against possible risk factors Inherent in their use such as those described below. CONTRAINOICATIONS: Advanced arteriosclerosis, hyperthyroidism, known hypersensitivlty, or idiosyncrasy to the sympathomimetic amines, glaucoma. Agitated states. Patients with a history of drug abuse. Durlng or within 14 days following the administration of monoamlne oxidase inhibitors, (hypertenslve crises may result). WARNINGS: If tolerance develops, the recommended dose should not be exceeded in an attempt to increase the effect; rather, the drug should be discontinued. Tenuate may Impair the ability of the patient to engage in potentially hazardous activlties such as operating machinery or driving a motor vehicle; the patient should therefore be cautioned accordingly. Orug Dependenu: Tenuate has seme chemical and pharmacologie similarities to the amphetamines and ether related stimulant drugs that have been extensively abused. There are occasional reports of subjects dependent on amphetamine later chronically abusing diethylproplon. The posslbllity of abuse should be kept in mind when evaluating the desirability of including a drug as part of a welght reduction program. Abuse of amphetamines and related drugs may be associated with varying degrees of psychologie dependence and social dysfunction whlch, ln the case of certain drugs, may be severe. There are reports of patients who have increased the dosage to many times thal recommended. Abrupt cessation following prolonged hlgh dosage administration results in extrema fatigue and mental depression: changes are aise noted on the sleep EEG. Manifestations of chronic intoxication with anorectic drugs lnclude severe dermatoses, marked lnsomnla, irritabllity, hyperactivity, and personallty changes. The most severe manifestation of ch renie intoxications is psychosls, olten clinically indistlnguishable from schizophrenla. Un ln Pregnancy: Although rat and hu man reproductive studies have not indlcated adverse effects, the use of Tenuate by women who are pregnant or may become pregnant requlres thal the potential benefits be weighed agalnst the potential rlsks. Un ln Chlldren: Tenuate ls not recommended for use in chlldren under 12 years of age. · PRECAUTIONS: Caution is to be exercised in prescrlblng Tenuate for patients with hypertension or with symptomatic cardiovascular disease, including arrhythmias. Tenuate should not be administered to patients with severe hypertension. lnsulln requirements in diabetes mellitus may be altered in association wlth the use of Tenuate and the concomitant dietary regi men. Tenuate may decrease the hypotenslve affect of guanethldine. The least amount feasible should be prescrlbed or dispensed at one ti me in order to minimize the posslbillty of overdosage. Reports suggest that Tenuate may increase convulsions in seme epileptics. Therefore, eplleptlcs receiving Tenuate should be carefully monltored. Tltratlon of dose or discontinuance of Tenuate may be necessary. ADVERSE REACTIONS: C~rdiovoscu/~r: Palpitation, tachycardia, elevation of blood pressure, precordial pain, arrhythmia. One published report described T-wave changes in the ECG of a healthy young male alter ingestion of dlethylpropion hydrochlorlde. Centfll Nervous System: Overstimulatlon, nervousness, restlessness, dlzziness, jitteriness, insomnla anxiety euphoria, depression, dysphoria, tremor, headache; rarely psychot1c episodes at recommended doses. ln a few epileptlcs an increase in convulsive episodes has been reported. Gastrointestins/: Oryness. of the mouth, unpleasanttaste, nausea, v_om1!1ng, abdominal dlscomfort, diarrhea, constipation, ether gastrointestinal disturbances. Allergie: Urticaria, rash, ecchymosis, erythema. Endocnne. Impotence, changes ln libido, menstrual upset. Hemstopoietic System· Bene marrow depression, agranulocytosls, 1eukopen1a. M!Scellsneous: A variety of miscellaneous adverse reactions has been reported by physiclans. These lnclude complalnts such as dyspnea, hair loss, muscle pain, dysuria, and polyur~a.
MERRELL-NATIONAL LABORATORIES lnc. Gaye y. Puerto R1 co 00633 01rect MedicallnqulfJes to.
MERRELL-NATIONAL LABORATORIES Division of Richardson-Merrell lnc. Cincinnati, Ohio 45215 L1censor of
212
Merrell'~t
4-7665C [6B 14!
