In the annals of conflict between the concept of mind and
the concept of brain, nowhere has the divide been clearer than in
the field of childhood psychiatric disorders.
The first notion, of mind, has led to a rich clinical literature of psychopathology, while investigators of the brain have been equally fecund in relating aberrant behavior to cerebral abnormalities. Yet, until recently, the two camps seemed to have little to say to each other.
Now a growing number of researchers have begun to work at bridging the distance between mind and brain in childhood psychiatric illness. The result is an emerging clinical specialty that promises to bring new insights--and new modes of treatment-- to children suffering from inherited and environmentally caused disorders.
Known as developmental neuropsychiatry, this new field has helped reunite psychiatry and neurology by demonstrating that there is a developmental origin underlying many disorders.
But in order to fully synthesize this new information and establish the field, a new text was needed. In 1989, James Harris, an associate professor of psychiatry, pediatrics and mental hygiene and director of developmental neuropsychiatry in the School of Medicine, set out to write that text.
He thought, initially, he could do it in a couple of years and about 350 pages. Six years and two volumes later, his Developmental Neuropsychiatry was published by Oxford University Press. It was, as they say, an instant classic, garnering rave reviews in publications ranging from the Journal of the American Academy of Childhood and Adolescent Psychiatry to the New England Journal of Medicine.
Last month, Doody's Rating Service, generally acknowledged to be the premiere rating service used by medical libraries and related institutions in book selection, published its Buyer's Guide to the 250 Best Health Sciences Books of the previous year. It selected Developmental Neuropsychiatry "Book of the Year" from nearly 2,500 titles, noting enthusiastically that "it will absolutely be the standard in the field. Anyone who is involved in the mental health care of children and adolescents should read this book."
For Harris, the praise, while gratifying, does not diminish the fact that the two-volume book was a continuation of a Hopkins tradition, rather than a departure. "When I was a resident in psychiatry, we used Adolph Meyer's formulation of the idea of psycho-biology as a primary orientation to the patient," he said. "I have always admired how Meyer starts at the molecular level, then moves up through brain circuitry and on to the whole person and manages to integrate all these various levels of organization. I used that as a model, and consider this effort a modern synthesis of Meyer's approach."
The first textbook of child psychiatry was written at Hopkins by Leo Kanner in 1935. It used psychobiology as a model. Harris dedicates his book to Kanner, whom he sought to emulate.
It is rare today for medical texts--especially those attempting to be the primary text in a particular field--to be written by a single author. Harris said he undertook the somewhat daunting task in order to preserve a consistent authorial voice in a subject matter that is, at times, exceptionally complex.
"When I wrote the book I was trying to create a text where none existed, and I wanted to make sure the emphasis and focus remained on developmental neuropsychiatry," he said. "I wanted the consistency of the developmental perspective to be retained throughout."
Volume 1 of Developmental Neuropsychiatry covers the fundamentals, starting with basic neuroscience and proceeding to the developmental perspective. Volume 2, subtitled "Assessment, Diagnosis, and Treatment of Developmental Disorders," covers methodology, treatment, legal aspects and specific behavioral characteristics of developmental disabilities, child onset psychopathology and gestational substance abuse. What makes the book seem so accessible--even to the non-specialist--is Harris' succinct prose and deft touch with details.
In the section on language, for instance, he relates how pharaoh Psamtik I of Egypt became the first language theorist when he placed two infants in isolation in a shepherd's hut, fed them a diet of goat's milk and forbade speaking in their presence. After two years, the children reportedly ran to the shepherd demanding bekos, the Phrygian word for bread, thus leading the pharaoh to the interesting conclusion that Phrygian was the mother of all languages.
The book reflects Harris' extensive clinical background--he has evaluated and treated hundreds of children and adolescents with neurodevelopmental disorders for two decades--and his unapologetic belief in the efficacy of treatment for all children.
"You have to understand that child psychiatry in this country developed through the Child Guidance Clinics, and this movement tended to focus almost exclusively on children with behavioral and emotional problems who could participate verbally in therapy," he said. "If you were retarded, if you were severely handicapped, you were referred elsewhere."
In recent years, new systems of testing have been introduced that provide a much more comprehensive view of child psychiatry. "The developmental perspective focuses on the motivation to master developmental tasks that are appropriate to each phase of the life cycle," Harris said. "It takes into account a child's social and intellectual capacity and allows us to tailor an individual program to each person. Many of these children weren't eligible for assistance for a long time because the paradigm was focused entirely on talking therapy."
In the new approach, treatment programs are focused on various aspects of development, such as brain maturation, environmental experience and developmental task mastery. As children grow older the intervention level grows. "We now try to focus on helping children meet their potential at every level of capability," he said. "What we are doing is helping people find meaning in their lives, no matter how constrained those lives may seem to others."
A champion in the cause of a new psychiatric understanding of mental disorders, Harris brings his own unique perspective to the mind/brain dichotomy. "Developmental disorders, in a sense, are an experiment in nature," he said, and quotes an 1880 statement by British psychiatrist Henry Maudsley that "anomalies when rightly studied yield rare instruction; they witness and attract attention to the operation of hidden laws or known laws under new and unknown conditions; and so set the inquirer on new and fruitful paths of research."
Harris believes developmental disorders afford researchers unique opportunities to study genetic, enzymatic and other influ-ences on personality. His own research into Lesch-Nyhan disease, a rare disorder first described at Hopkins in 1964 by Michael Lesch, then a medical student, and faculty member William Nyhan, is an example of a single gene deficit that creates an extremely complex behavioral disorder syndrome.
Recently he received funding from the National Institute of Child Health and Human Development to continue these studies.
Very rare and tending to occur in conjunction with, or cause, mild to moderate mental retardation, the disease manifests itself most notably in compulsive self-injury in which children will bite off their lips, fingertips or injure other parts of their bodies. The self-mutilation is a compulsive behavior the child tries to control but is generally unable to resist. At adulthood, compulsively self-harming or compulsively aggressive behavior generally persists, and those affected will often request help from others to prevent these impulses.
"With Lesch-Nyhan disease and similar disorders we are gaining an increasingly better understanding of the links between the brain and behavior," Harris said. "The progress we are making in this arena leads me to conclude that we should be adding a developmental component to the mind/brain discussion in research."
Developmental Neuropsychiatry is Harris' attempt to highlight the scientific implications in such syndromes, while providing clinicians and care providers with the most current information on treatment and therapy.
"I wanted not only to focus on children and adolescents who I felt weren't getting the proper emphasis, but also to show that it's not enough merely to diagnose a disease," he said. "All the ramifications of illness need to be taken into account. The major message I hope people will bring away from my books is that we ought to be able to provide programs that will free our patients to act to develop their own full potential. They can't, perhaps, make complex choices, but they can make meaningful choices and thereby live their lives with a certain sense of dignity. I believe we need to foster this approach."
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