Richard A. Gardner, M.D., committed suicide in 2003 at the age of 72. Whether the violent manner in which he took his own life was due more to psychic pain or physical pain we’ll never know, but what interests us here is the legacy he left behind in child psychiatry before his professional life became embroiled in controversy. If his last name sounds familiar to you, it is because he is the author of a clinical probe that many developmental optometrists use to evaluate children with learning issues: The Reversals Frequency Test.
In 2010, Florence Springer died a peaceful and natural death at home at the age of 95. Her legacy is non-controversial, and should be better known in Optometry. As noted in her obituary, Florence was a respected teacher, mentor and therapist, and founder of the Learning Disabilities Unit at SUNY Optometric Center. The year before I was recruited to SUNY as Chief of the Vision Therapy Service, the University imported Harold Solan to team with Ms. Springer. And what a feisty pair they made! It was Florence and Harold who introduced me to Gardner’s battery of tests in 1982, of which Reversals Frequency was only one but would ultimately be the most enduring. His rationale and full battery were laid out in his textbook, The Objective Diagnosis of Minimal Brain Dysfunction.
Gardner would follow that up in 1987 with another book, Hyperactivity, the So-Called Attention Deficit Disorder, and the Group of MBD Syndromes. In 1989, Harold and I wrote a review article on Optometry and Learning Disabilities in which we made reference to Gardner’s model. At that point, in the 1980s, neither Florence nor Harold embraced the term Minimal Brain Dysfunction or MBD. Their feelings were similar to a synopsis by Goldstein and colleagues in the Handbook of Neurodevelopmental and Genetic Disorders in Children who wrote (p. 106):
“The terms minimal brain injury or MBD were used to describe children of normal intelligence who appeared similar to some individuals with known brain injury, in that they exhibited a combination of hard or soft signs of neurological deficiency concomitantly with educational and sometimes behavioral disorders. MBD was believed to be responsible for observed deficits in processes such as auditory and visual perception, symbol learning, short- and long-term memory, concept formation and reasoning, fine and gross motor functions, and integrative functions — deficits resulting in disorders of receptive and expressive language, reading, writing, mathematics, physical skill development, and interpersonal adjustment. In addition, behavioral traits such as distractibility, impulsivity, perseveration, and disinhibition were often found in children with MBD. Thus, from the first, the field of LD centered around a medical model, with the term MBD being applied to an extremely heterogenous group of individuals.”
And that paragraph preceded the following, which is bolded for emphasis:
“Johnson and Mykleburst discussed the limitation of extant terminologies. They suggested that minimal was inappropriate to describe individuals whose resulting disabilities had a much greater than minimal impact on their learning functions, and that the words brain injury or brain dysfunction were viewed as too stigmatizing by many affected individuals and their parents.”
Given that background, I will assert that we have come full circle. As evidenced through the VisionHelp Concussion Project, and encapsulated by in the Perspective by Ciuffreda, Ludlam, and Tannen, mTBI or mild Traumatic Brain Injury has been fully embraced by the public as well as by neuro-optometric professionals. Though we all recognize that there is nothing mild about its effects, that is the term that has been widely adopted. And the stigma associated with the term brain injury is gone. With that fact in mind, let’s go back to the observation by Goldstein and colleagues:
“The terms minimal brain injury or MBD were used to describe children of normal intelligence who appeared similar to some individuals with known brain injury, in that they exhibited a combination of hard or soft signs of neurological deficiency concomitantly with educational and sometimes behavioral disorders.”
My contention is that much of the population that we see have their constellation of signs and symptoms because, in fact, they have experienced a silent or under-recognized form of mTBI. That can range from difficult birth delivery, to repetitive traumas that are dismissed as “he’s just a boy and has experienced alot of falls or whacks on the head”. This may also account for the observation that the constellation of signs and symptoms subsumed under Gardner’s MBD model, similar to that seen in a variety of learning disabilities, traditionally occurs to a greater extent in males. One might anticipate that as girls progressively participate more in sports involving mTBI, the “natural” advantage they seem to have in early language and learning development, and inhibition of hyperactivity, may be disrupted.