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NORMAL DEVELOPMENT OF THE NERVOUS SYSTEM
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In relation to persistent traits of ADHD, several psychiatrists have pointed out that there may be an increase in drug and alcohol dependence among adolescents with the disorder (Zametkin and Ernst) and a connection in a few cases to tic disorders such as Tourette syndrome (page 95) However, it can be said from our general clinical experience that these problems do not arise in the great majority of such children
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Enuresis
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Voluntary sphincteric control develops according to a predetermined time scale Usually normal children stop soiling themselves before they can remain dry, and day control precedes night control Some children are toilet-trained by their second birthday, but many do not acquire full sphincteric control until the fourth year Constant dribbling usually indicates spina bi da or another form of dysraphism, but in the boy one must look also for obstruction of the bladder neck and in the girl for an ectopic ureter entering the vagina When a child 5 years of age or older wets the bed nearly every night and is dry by day, the child is said to have nocturnal enuresis This condition af icts approximately 10 percent of children between 4 and 14 years of age, boys more than girls, and continues in many cases to be a problem even into adolescence and adulthood Although mentally retarded children are notably late in acquiring sphincter control (some never do), the majority of enuretic individuals are normal in other respects The cause of this condition is disputed Often there is a family history of the same complaint It is our impression that night terrors are frequent in this group Some psychiatrists have insisted that overzealous parents pressure the child until he develops a complex about his bedwetting; this is highly doubtful Punishment, shaming, rewards, etc, may have this effect, but the underlying condition is believed by most neurologists to be a delay in the maturation of higher control of spinal re ex centers during sleep These and other abnormalities of bladder function in the enuretic child, as well as treatment, are discussed in the chapter on sleep (page 349)
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unusually tall males with severe acne vulgaris and aggressive sociopathic behavior may have a karyotype of XYY chromosomes is an example of a possible genetic relationship The patient with Turner syndrome in whom competent social adaptation is linked closely to an X chromosome of paternal origin is another example Further, there is no critical evidence to show that deliberate alteration of the familial and social environment or the mental hygienic measures now so popular have ever prevented a neurosis, psychosis, or sociopathy It is during the period of late childhood and adolescence, when the personality is least stable, that transient symptoms, many resembling the psychopathologic states of adult life, are most frequent and dif cult to interpret Some of these disorders represent the early signs of autism, schizophrenia, or manic-depressive disease Others are forerunners of sociopathy But many of the borderline personality traits have a way of disappearing as adult years are reached, so that one can only surmise that they represented either a maturational delay in the attainment of mature social behavior or were expressions of adolescent turmoil, or what has been called adolescent adjustment reaction Many issues that have been touched upon in the preceding discussion are considered more fully in the section on psychiatric disorders (Chaps 56 to 58)
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MENTAL RETARDATION
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The symptom complex of incomplete or insuf cient development of mental capacities and associated behavioral abnormalities (variously referred to as mental retardation, mental subnormality, or formerly, oligophrenia) combines many of the developmental abnormalities already discussed Mental retardation stands as the single largest neuropsychiatric disorder in every civilized society Its overall frequency cannot be stated precisely Rough estimates are that in a group of children between 9 and 14 years of age, about 2 percent or slightly more will be unable to pro t from public education or to adapt socially and, when fully grown up, to live independently Using any one of a number of indices of social and psychologic failure, two somewhat overlapping groups are recognized: (1) the mildly impaired (IQ 45 to 70), and (2) the severely impaired, corresponding to an IQ below 45 The second group, also called the pathologic mentally retarded, makes up approximately 10 percent of the subnormal population The more mildly affected rst group, which was formerly referred to as the subcultural, physiologic, or familial mentally retarded, is a much larger group Because of the objectionable implications of the previously used terms idiot, imbecile, and moron, the American Association on Mental De ciency proposed that the mentally retarded be grouped instead into four categories: (1) those with profound de ciency, incapable of self-care (IQ below 25); (2) those with severe de ciency, incapable of living an independent existence and essentially untrainable (IQ 25 to 39); (3) those with moderate de ciency, trainable to some extent (IQ 40 to 54); and (4) those with mild de ciency, who are impaired but trainable and to some extent educable The above terms, while in common use, satisfy neither neurologists nor psychologists because of their generality, embracing as they do any lifelong global de cit in mental capacities The terms convey no information of the particular type(s) of intellectual impairment, their causes and mechanisms, or their anatomic and pathologic bases Moreover, they express only one aspect of impaired mental function the cognitive and ignore the inadequate development of personality, social adaptation, and behavior Spe-
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