Andrew Ashikari, MD, FACS

• Assistant Professor of Surgery
• New York Medical College
• Westchester Medical Center
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Damage to the orbital frontal cortex has also been associated with akinetic mutism; however anti fungal wash 250mg fulvicin with mastercard, research (Bechara anti fungal uti purchase fulvicin 250 mg amex, Tranel antifungal baby cream buy discount fulvicin 250 mg, & Damasio fungus vegetable discount 250 mg fulvicin free shipping, 2002) suggests that the damage has to extend into regions of the anterior cingulate and/or basal forebrain for the syndrome to be evident trichophyton fungus definition 250mg fulvicin otc. Duffy and Campbell (2001) describe the following case of akinetic mutism: One patient fungus gnats white vinegar purchase fulvicin 250 mg on line, after a gunshot wound to both frontal lobes, was essentially inert when left alone. He denied boredom and described it as a "loss of motivation" in that he entertained numerous ideas for activities but felt no impetus to act on them. His facial expression was one of casual indifference, and he would often respond with simple gestures instead of speaking. Relation of Memory, Attention, and Executive Function Memory, attention, and executive function represent relatively distinct processes, although in some cases, there is disagreement whether a particular attentional or memory process is better classified as an executive function (for example, working memory). Clearly, these processes are inter-related, but specifying the exact nature of this inter-relation is hindered by our limited understanding of these domains, divergent definitions and conceptualizations, and varied theoretical perspectives. When experts from the fields of memory, attention, and executive function were asked to specify the behaviors denoted by the term executive function, no less than 33 different terms were generated with only 40% agreement for 6 of the terms (self-regulation, sequencing of behavior, flexibility, response inhibition, planning and organization; Eslinger, 1996). Nonetheless, there is some agreement that executive functions represent overarching controlling, organizing, integrating, and supervising computations. From a neuroanatomic perspective, memory, attention, and executive functions are served by relatively distinct, yet interconnected and overlapping, neural systems. Neuroimaging investigations demonstrate that different neural systems support executive, attention, and memory functions; yet, these neural systems coactivate in the performance of many executive, attentional, and memory tasks, indicating shared or distributed processing. Furthermore, the inter-relation of these functions is evident when one realizes that executive functions would be of little value if memory systems did not operate to register, store, and enable the retrieval of life experiences and knowledge, and if attentional systems did not support the processing of relevant or critical environmental and body events. Jointly, attention, memory and executive functions play a central role in thinking, reasoning, problem solving, language, and emotional and social behavior. Finally, human experience involves the capacity to represent and relate past, present, and future events. As you reviewed the effects of damage to the attentional, memory, and executive systems, you likely realized that there is typically either a direct or indirect disruption of emotional functioning. It is emotion that gives direction, drive, and value to our personal and social behavior. Emotions intimately affect that which we attend to , remember, and strive to achieve (goals). Neuropsychology of Emotional Processing Brain processing of emotion is an area that neuropsychology has largely ignored until recently. This neglect is partly a holdover from philosophical traditions of rational empiricism and from conceptualizations of the body and brain as being machine-like. People saw emotions as peripheral to understanding cognition, as being of a lower order of evolutionary development, perhaps even vestigial. In other words, humans had evolved to become rational, logical beings somehow above emotion. Such research is not straightforward, as is presenting a visual or auditory stimulus and recording activation of corresponding brain regions. Also, animal models can provide only limited information, because they cannot verbalize their feelings, and researchers must rely on motor behaviors to infer the expression of emotions as rage and fear. The emotional repertoire of humans is enormous, subtle, and much more complicated than a response to external threats to physical safety, such as embodied in the fight-or-flight response. In the television show Star Trek (and its spinoffs), the ultralogical characters Mr. Spock, Data, and Seven of Nine show that being human entails having "emotional equipment. Humans live in a social context where self-understanding and social skills are some of the most crucial factors in determining success in society. Researchers suggest that emotional intelligence accounts for just as much or more variance in determining success in life as traditionally measured general cognitive intelligence. One of the more interesting questions related to understanding emotions is to ask whether emotional processing is a type of cognitive processing that the cortex initiates, or whether emotion emerges without conscious thinking, and only secondarily becomes labeled. This dichotomy is a variation on an old debate emanating from the early twentieth century. The James­Lange theory of emotion, promoted by American psychologist William James and Danish psychologist Carl Lange (Lange, 1922), postulates that people consciously experience emotion as a reaction to physical sensory experience. That is, we feel fear because our hearts are racing; we are sad because we are crying. Although others saw this as an overstatement, the James­Lange theory does insist that sensory and cognitive experiences were intimately entwined and inseparable from each other. In other words, if all the physical sensations of fear disappeared, so would the cognitive experience of fear. Walter Cannon, and later Philip Bard, argued that the conscious emotional experience is separate from bodily sensation or expression. Although today most scientists agree that cognitive experience of emotion corresponds to sensory experience, much variation exists among types of emotion, emotional intensity, and individual variation. Joseph LeDoux (1992, 1996) describes emotion as a subjective state of awareness and suggests that only because people have a cortex can they label emotion and think about it, rather than just react to it as other animals might. Someone walking along in a forest might be startled by something that looks like a snake. Some scientists suggest that certain emotional responses, such as reactions to certain movements and noise, may be genetically "hardwired" as a protective mechanism. According to LeDoux (1996), after that initial lower order automatic processing, the cortex receives and further processes the information, perceiving the object as a snake or a stick, weighing options, and directing the body to take further action. The competing view argues that the person must first recognize something cognitively as a threat for the emotion to develop. However, in addition to subcortically initiated emotion, is it also possible to initiate an emotional response just by thinking? Considering an upcoming speech, thinking about running into a snake, feeling socially embarrassed, or anticipating a joyful reunion can all produce emotional responses in the body separate from immediate external threats or joys. This section examines both subcortical and cortical contributions to emotional behavior. Different and overlapping interconnected regions are involved in processing varied emotions, a clear indication that there is not a single "emotional system. Subsequently, MacLean (1949, 1952) extended the system to include the amygdala, orbital prefrontal cortex, and regions of the striatum. Advances in neuroscience do not fully support these earlier conceptualizations of the limbic system because we now realize that the hippocampus is more intimately involved in nonemotional memory processing, whereas the amygdala and related structures play a greater role in emotional processing. The two regions work in a complementary manner depending on the event being processed. For example, patients with damage to the amygdala without co-occurring hippocampal damage do not demonstrate a learned fear response to a conditioned stimulus. However, the patients are able to recall that the conditioned stimulus was associated with an unconditioned stimulus during training. In contrast, patients with the opposite lesion profile (damaged hippocampus preserved amygdala) exhibit a fear response to the conditioned stimulus without memory of the conditioned and unconditioned pairing (Armony & LeDoux, 2000). Thus, one region appears to underpin the learning of the declarative content (context), whereas the other supports the emotional learning associated with the event. Investigations of the effects of emotion on memory retention provide further evidence of the complementary relation of the hippocampus and amygdala. Studies (Cahill & McGaugh, 1998; McGaugh, 2004) of animals and humans show that the degree of activation of the amygdala during encoding of emotionally arousing material (positive or negative) correlates significantly with subsequent recall of the material. That is, as amygdala/emotional arousal increases, the retention of declarative information improves. It has been hypothesized that the amygdala enhances the consolidating processes of the hippocampus, and thus strengthens the retention of the declarative learning. High levels of adrenocortical hormones released during stress may account for this impairing effect. Primary Emotions Primary emotions are automatic, preorganized, arise from sensory experience, and are processed through the limbic system before or parallel to being recognized consciously. Emotions such as fear, disgust, surprise, anger, and joy appear to be universal, because people express and recognize them across all cultures of the world. Damasio (1994) suggests that these emotions are innate and primarily controlled by the amygdala and anterior cingulate of the limbic system. As we have discussed, sensory information first funnels through the thalamus, is relayed to the cortex, and then travels to the subcortical limbic system. Because of this anatomy, the general consensus was that conscious perception of an emotion preceded emotional limbic response. But LeDoux, who has studied fear conditioning, has suggested that projections from the thalamus to the amygdala provide a "shortcut" allowing the amygdala to process information directly, bypassing the cortical loop. This allows for an immediate, automatic, preconscious, and unconscious emotional response. In the hope that the knowledge of fearful emotions can aid in treating secondary emotions, such as human anxiety and post-traumatic stress disorders, Joseph LeDoux, who has done extensive work in the area of fear conditioning with animals, has studied how primary fear interacts with memory. Fearful behaviors are easily conditioned to a tone via shock, trauma, or loud noise. Researchers have long known that severing connections between the subcortical areas of the brain and the cortex does not eliminate the conditioned-fear response. Therefore, the learning and maintenance of fear conditioning must occur in the subcortical structures. Researchers then demonstrated that lesioning the amygdala in certain places did interfere with fear conditioning. Amygdala Third Hypothalamus ventricle Most notably, if they destroyed the central nucleus of the amygdala, animals no longer showed an autonomic fear response when presented with a tone (which previously had been associated with shock). LeDoux concluded that the cortex is not necessary to condition fear, but the amygdala is crucial. The first or direct route (thalamo-amygdala circuit) sends sensory information to the thalamus, which, in turn, transmits it to the amygdala. The second or indirect route (thalamo-cortico-amygdala), involves the transmission of sensory information to the thalamus and then to the cortex. After cortical processing, the information is returned to the thalamus, which directs it to the amygdala. The more direct route allows for rapid, although relatively imprecise, appraisal of the threat potential of a sensory event. The indirect route is slower but provides a more detailed representation of the event (Armony & LeDoux, 2000). Once the input is processed by the amygdala, it is transmitted via the central nucleus to various brain regions that instantiate autonomic, attentional, perceptual, cognitive, and behavioral response (Figure 9. This does not mean that processing of the emotional stimuli is not ultimately realized at a cortical level. Rather, the emotional state can Central nucleus Autonomic response Behavioral reaction c. Philadelphia: Lippincott Williams & Wilkins, by permission; [c] reproduced from Bear, M. Support has been provided for the involvement of the amygdala in the unconscious mediation of learned emotional responses. After the conditioning training, the faces were presented to the participants either masked or unmasked. Masking enables a stimulus to be processed, but without conscious awareness of the stimulus. None of the participants reported perceiving the masked faces, whereas all identified the unmasked faces. This finding suggests greater involvement of right hemisphere regions in unconscious emotional facial processing, whereas left hemisphere regions appear preferentially involved in conscious or cortically mediated emotional processing. Exemplifying this negative impact is a study (Adolphs, Tranel, & Damasio, 1998) of patients with complete bilateral amygdala damage. These patients were presented facial pictures and asked to rate the degree of positive/negative emotions represented by each face and the degree of approachability and trustworthiness of the person represented by the face. When contrasted to patients without lesions of the amygdala, the patients with bilateral amygdala damage rated the faces as expressing more positive emotions and as more approachable and trustworthy. This positive bias was particularly evident for faces considered to be most negative. The investigators pose that the positive bias related to the role of the amygdala in processing threatening and aversive stimuli. The loss of this input to cortical regions resulted in a shift to more positive ratings and increased approachability/trustworthy judgments by the bilateral amygdala group. Fear learning is not limited to subcortical amygdala action (direct sensory conditioning). For example, one can learn to fear a wild animal, such as a lion, without experiencing an attack by the animal. Support for involvement of the amygdala in fear learning without experiencing a noxious event is provided by Phelps and colleagues (2001), as well as other investigators. Yet, when the shock-specific stimulus was presented, there was significant activation of the amygdala, insular cortex, anterior cingulate, premotor cortex, and striatum. A measure of fear evocation (skin conductance) confirmed a fear response with the specified stimuli. The investigators pose that the insular cortex was central to the transfer of a cortical representation to the amygdala. Thus, fear learning was produced by an imagined or anticipated cognitive representation without actual contact with a negative sensory event. Secondary Emotions Secondary emotions require higher cortical processing, and according to Damasio (1994), this processing is orchestrated by the prefrontal cortical networks. Secondary emotions do not necessarily imply a separate "feeling" experience in the body. The difference is that secondary emotions are generated through higher cortical processes and arrive at the limbic system over a different route from that taken by primary emotions generated through sensory experience. Once in the limbic system, the brain processes the experience of primary and secondary emotions in a similar manner.

Pathogenesis: IgG autoantibodies to adhesion molecules desmoglein-1 and desmoglein-3 fungus names buy cheap fulvicin 250 mg on-line, which interrupts integrity of epidermis and/or mucosa and results in extensive blister formation fungus and animal predation order fulvicin 250 mg online. Clinical presentation: Flaccid bullae that start in the mouth and spread to face fungus gnats under skin cheap 250 mg fulvicin, scalp quadriderm antifungal cream generic fulvicin 250 mg without a prescription, trunk antifungal gel prescription purchase fulvicin 250mg online, extremities antifungal uk buy fulvicin 250mg free shipping, and other mucosal membranes. Can lead to impaired oral intake if there is significant oral mucosal involvement. Treatment: Immunosuppressants (systemic glucocorticoids, rituximab, intravenous immunoglobulin). Antibodies bind to the same antigen as in bullous impetigo and staphylococcal scalded skin syndrome, so lesions are superficial and rupture easily. Clinical presentation: Scaling, crusting erosions on erythematous base that appear on face, scalp, trunk, and back. Pathogenesis: Autoantibodies to the epithelial basement membrane that results in an inflammatory cascade and causes separation of epidermis from dermis and epithelium from subepithelium b. Clinical presentation: Prodrome of inflammatory lesions that progresses into large (1­3 cm), tense, extremely pruritic bullae on trunk, flexural regions, and intertriginous areas. Pathogenesis: Strong genetic predisposition and link to gluten intolerance/celiac disease. Clinical presentation: Symmetric, intensely pruritic papulovesicles clustered on extensor surfaces. Irritant dermatitis: Exposure to physical, chemical, or mechanical irritants to the skin. Pathogenesis: T-cell­mediated immune reaction in response to an environmental trigger that comes into contact with the skin. After initial exposure causes sensitization, an allergic response occurs with subsequent exposures. Clinical presentation: Pruritic erythematous dermatitis that can progress to a chronic stage involving scaling, lichenification, and pigmentary changes. Initial reaction occurs after a sensitization period of 7­10 days in susceptible individuals. For poison ivy contact, remove clothing and wash skin with mild soap and water as soon as possible. Pathogenesis: Due to impaired skin barrier function from combination of genetic and environmental factors, including a defect in filaggrin, a protein essential for keratinization and epidermal homeostasis. Epidemiology11: Affects up to 20% of children in the United States, the vast majority with onset before age 5 years. Many with other comorbidities including asthma, allergic rhinitis, and food allergies. Infantile form: Erythematous, scaly lesions on the cheeks, scalp, and extensor surfaces. Diaper area usually spared Childhood form: Lichenified plaques in flexural areas Adolescence: More localized and lichenified skin changes. May be predominantly on hands and feet Treatment11: Lifestyle: Avoiding triggers, including products with alcohol, fragrances, and astringents, sweat, allergens, and excessive bathing. Bathing time should be <5 minutes, skin should be patted dry (not rubbed) afterward and followed by rapid application of an emollient. Also helpful in children with concomitant environmental allergies or hives Treatment for inflammation: (1) Topical steroids12 (Table 8. Severe flares may require a higher-potency steroid for a longer duration of therapy, followed by a taper to lower-potency steroids. Depending on extent of infection, can be treated with topical mupirocin to systemic antibiotics. Can also take diluted bleach baths once to twice a week (mix 1/4 to 1/2 cup of bleach in full tub of lukewarm water and soak for 10 minutes, then rinse off with fresh water). Eczema herpeticum superinfection with herpes simplex virus-1 or -2, can cause severe systemic infection. Presents as vesiculopustular lesions with central punched-out erosions that do not respond to oral antibiotics. Cluster: Appear as "meal clusters" or "breakfast, lunch, and dinner" which are linear or triangular groupings of lesions. Also, Time: emphasize chronic nature of eruption and need for patience and watchful waiting. Confused pediatrician/parent: Diagnosis often met with disbelief by parent and/or referring pediatrician. Household: Because of the nature of the hypersensitivity, usually only affects one family member in the household. Management (the 3 Ps): Prevention: Wear protective clothing, use insect repellent when outside, launder bedding and mattress pads for bedbugs, and maximize flea control for pets. Ensure patients that their symptoms will resolve and they will eventually develop tolerance. Acute form: Caused by bacterial invasion after trauma to cuticle (1) Clinical features: Exquisite pain, sudden swelling, and abscess formation around one nail. Chronic form: May involve one or several nails, history of frequent exposure to water. Nail dystrophy: distortion and discoloration of normal nail-plate structure; often traumatic or inflammatory causes. Complications of underlying dermatosis: nail psoriasis, atopic nails Nail changes and systemic disease. Beau lines: transverse, white lines/grooves that move distally with nail growth; due to growth arrest from systemic illness, medications, or toxins. L) Congenital nail dystrophy: clubbing and spooning (koilonychia), maybe autosomal dominant with no other anomalies Congenital ingrown toenails: most self-limiting Genodermatosis and systemic disease. Freckles (ephelides): reddish-tan and brown macules on sun-exposed surfaces, usually 2­3 mm in diameter. S) (1) Pathogenesis: Develop in early childhood as flat lesions called junctional nevi, then develop into compound nevi when nevus cells migrate into the dermis and lesions enlarge and become papular. Diffuse hypopigmentation Albinism: Heterogeneous group of inherited disorders manifested by generalized hypopigmentation or depigmentation of skin, eyes, and hair. Dyspigmentation Blaschkoid dyspigmentation18: Congenital hypopigmentation and hyperpigmentation along the lines of Blaschko. X) Patterns of hyper- or hypopigmentation: Whorl shape on trunk, V-shape on the back, waves on the vertex scalp. Cancer concerns with topical immunomodulators in atopic dermatitis: overview of data and recommendations to clinicians. Recent insights into atopic dermatitis and implications for management of infectious complications. Analysis of 36 Cases of Blaschkoid dyspigmentation: reading between the lines of Blaschko. A calculation that reflects the rate of developmentinanygivenstream, andrepresentsthepercentageofnormaldevelopmentpresentatthe timeoftesting. Developmental surveillance should be included in every well-child visit, and any concerns should be addressed immediately with formal screening. Linguistic and auditory milestones during the first two years of life: a language inventory for the practitioner. Clinical Linguistic and Auditory Milestone Scale: prediction of cognition in infancy. Prevent overstimulation; swaddle infant; use white noise, swing, or car rides to soothe. May reassure verbally at regular intervals or place a transitional object in crib. Give guidance early; may introduce potty seat but avoid pressure or punishment for accidents. Developmental night waking Separation anxiety at night 12 mo Aggression Biting, hitting, kicking in frustration Need for limit setting Exploration of environment, danger of injury Occur with frustration, attention-seeking rage, negativity/refusal 18 mo Temper tantrums 24 mo Toilet training Child needs to demonstrate readiness: shows interest, neurologic maturity. Leave bedroom door open, use a nightlight, demonstrate there are no monsters under the bed. Prevention: For several nights, awaken child 15 min before terrors typically occur. Acute: Be calm; speak in soft, soothing, repetitive tones; help child return to sleep. Standardized developmental screening should be administered at 9-month, 18-month, and 30-month well-child visits,intheabsenceof developmentalconcerns. Prenatal and birth:Prenatalgeneticscreening,perceptionof fetalmovement,pregnancycomplications,toxins/teratogens, gestationalage,birthweight,daysinhospital,complications, newbornscreen 2. The Pediatrician and the Developmentally Disabled Child: A Clinical Textbook on Mental Retardation. Also, if circumference has crossed two percentiles (up or down) on the appropriate chart or is disproportionate to parental head circumference An assessing clinician who is uncertain about any aspect of assessment but thinks that development may be disordered Adapted from Bellman M, Byrne O, Sege R. Negative Indicators (Activities That the Child Cannot Do) Sit unsupported by 12 mo Walk by 18 mo (boys) or 2 yr (girls) (check creatine kinase urgently) Walk other than on tiptoes Run by 2. Whole exome sequencingisclinicallyavailabletoperform comprehensiveassessmentofthecodingportionofthegenomein Chapter 9 Development, Behavior, and Mental Health 241 c. Canbesubdividedintoreceptive/expressive language disorder [includes social (pragmatic) communication disorder], speech sound disorders, childhood-onset fluency disorder (stuttering), and voice disorders c. Achievementonstandardizedteststhatissubstantiallybelow expectedforage,schooling,andlevelofintelligenceinoneormoreof thefollowingareas:basicreadingskills,readingcomprehension, readingfluencyskills,oralexpression,listeningcomprehension, writtenexpression,mathematiccalculation,andmathematicproblem solving b. For school-aged children and adults, there are difficulties in learning academic skills involving reading, writing, arithmetic, time, or money, with support needed in one or more areas to meet age-related expectations. There is a somewhat concrete approach to problems and solutions compared with age mates. For school-aged children, progress in reading, writing, mathematics, and understanding of time and money occurs slowly across the school years, and is markedly limited compared with that of peers. For adults, academic skill development is typically at an elementary level, and support is required for all use of academic skills in work and personal life. Ongoing assistance on a daily basis is needed to complete conceptual tasks of day-to-day life, and others may take over these responsibilities fully for the individual. Communication, conversation, and language are more concrete or immature than expected for age. There may be difficulties regulating emotion and behavior in age-appropriate fashion; these difficulties are noticed by peers in social situations. There is limited understanding of risk in social situations; social judgment is immature for age, and the person is at risk of being manipulated by others (gullibility). The individual shows marked differences from peers in social and communicative behavior across development. Spoken language is typically a primary tool for social communication, but is much less complex than that of peers. Capacity for relationships is evident in ties to family and friends, and the individual may have successful friendships across life and sometimes romantic relations in adulthood. Social judgment and decision-making abilities are limited, and caretakers must assist the person with life decisions. Friendships with typically developing peers are often affected by communication or social limitations. Significant social and communicative support is needed in work settings for success. The individual generally has little understanding of written language or of concepts involving numbers, quantity, time, and money. Social Domain Spoken language is quite limited in terms of vocabulary and grammar. Speech may be single words or phrases, and may be supplemented through augmentative means. Relationships with family members and familiar others are a source of pleasure and help. The individual has very limited understanding of symbolic communication in speech or gesture. The individual expresses his or her own desires and emotions largely through nonverbal, nonsymbolic communication. The individual enjoys relationships with well-known family members, caretakers, and familiar others, and initiates and responds to social interactions through gestural and emotional cues. Profound Conceptual skills generally involve the physical world rather than symbolic processes. The individual may use objects in goal-directed fashion for self-care, work, and recreation. However, co-occurring motor and sensory impairments may prevent functional use of objects. Classification is based on physiologic and topographic characteristics as well as severity(Table9. Restricted repetitive patterns of behavior, interests, or activities Examples:Simplemotorstereotypies(handflapping,finger flicking),repetitiveuseofobjects(spinningcoins,lininguptoys), repetitivespeech(echolalia),resistancetochange,unusual sensoryresponses iii. Entitlesallchildrenwithqualifyingdisabilitiestoafree and appropriate public education inthe least restrictive environment. Head Start and Early Head Startareprogramsinstitutedbythefederal governmenttopromoteschoolreadinessoflow-incomechildrenaged 3­5yearsandyoungerthan3years,respectively,withintheir communities. Surveillance for mental health issues should occur at all routine well-child visits from early childhood through adolescence,including historyofmoodsymptomsandanybehavioralissues. Differentialdiagnosisinadditiontothoselistedaboveincludes obsessive­compulsivedisorder,post-traumaticstressdisorder,and acute stress disorder Chapter 9 Development, Behavior, and Mental Health 249 5.

The infants are then unable to make voiced sounds during the normal period of babbling fungus under eye 250mg fulvicin overnight delivery. The infant is like a person who has been given a complicated piece of audio equipment bristling with unlabeled knobs and switches but missing the instruction manual anti fungal yeast shampoo for dogs cheap 250 mg fulvicin fast delivery. In such situations people resort to what hackers call frobbing-fiddling aimlessly with the controls to see what happens antifungal for feet order fulvicin 250 mg with amex. The infant has been given a set of neural commands that can move the articulators every which way definition of mold fungus purchase fulvicin 250 mg otc, with wildly varying effects on the sound anti fungal shampoo india proven 250mg fulvicin. By listening to their own babbling fungus japan train buy fulvicin 250 mg line, babies in effect write their own instruction manual; they learn how much to move which muscle in which way to make which change in the sound. Some computer scientists, inspired by the infant, believe that a good robot should learn an internal software model of its articulators by observing the consequences of its own babbling and flailing. Shortly before their first birthday, babies begin to understand words, and around that birthday, they start to produce them. Words are usually produced in isolation; this one-word stage can last from two months to a year. About half the words are for objects: food (juice, cookie), body parts (eye, nose), clothing (diaper, sock), vehicles (car, boat), toys (doll, block), household items (bottle, light), animals (dog, kitty), and people (dada, baby). Finally, there are routines used in social interaction, like yes, no, want, bye-bye, and hi-a few of which, like look at that and what is that, are words in the sense of listemes (memorized chunks), but not, at least for the adult, words in the sense of morphological products and syntactic atoms. Children differ in how much they name objects or engage in social interaction using memorized routines. Psychologists have spent a lot of time speculating about the causes of those differences (sex, age, birth order, and socioeconomic Baby Born Talking-Describes Heaven 267 status have all been examined), but the most plausible to my mind is that babies are people, only smaller. Since word boundaries do not physically exist, it is remarkable that children are so good at finding them. A baby is like the dog being yelled at in the two-panel cartoon by Gary Larson: "Okay, Ginger! Then they look for matches to these words in longer stretches of speech, and find other words by extracting the residues in between the matched portions. Children announce when objects appear, disappear, and move about, point out their properties and owners, comment on people doing things and seeing things, reject and request objects and activities, and ask about who, what, and where. These microsentences already reflect the language being acquired: in ninety-five percent of them, the words are properly ordered. Even before they put two words together, babies can comprehend a sentence using its syntax. For example, in one experiment, babies who spoke only in single words were seated in front of two television screens, each of which featured a pair of adults improbably dressed up as Cookie Monster and Big Bird from Sesame Street. One screen showed Cookie Monster tickling Big Bird; the other showed Big Bird tickling Cookie Monster. The children must have understood the meaning of the ordering of subject, verb, and object-they looked more at the screen that depicted the sentence in the voiceover. When children do put words together, the words seem to meet up with a bottleneck at the output end. If we divide language development into somewhat arbitrary stages, like Syllable Babbling, Gibberish Babbling, One-Word Utterances, and Two-Word Strings, the next stage would have to be called All Hell Breaks Loose. Sentence length increases steadily, and because grammar is a discrete combinatorial system, the number of syntactic types increases exponentially, doubling every month, reaching the thousands before the third birthday. You can get a feel for this explosion by seeing how the speech of a little boy called Adam grows in sophistication over the period of a year, starting with his early word combinations at the age of two years and three months ("2;3"): 2;3: Play checkers. Can I put my head in the mailbox so the mailman can know where I are and put me in the mailbox? Can I Baby Born Talking-Describes Heaven keep the screwdriver just like a carpenter keep the screwdriver? Eve, another child Brown studied, was speaking in sentences like this before she was two: I got peanut butter on the paddle. The earlier sentences resembled telegrams, missing unstressed function words like of, the, on, and does, as well as inflections like -ed, -ing, and -s. By the threes, children are using these function words more often than they omit them, many in more than ninety percent of the sentences that require them. A full range of sentence types flower-questions with words like who, what, and where, relative clauses, comparatives, negations, complements, conjunctions, and passives. When researchers focus on one grammatical rule and count how often a child obeys it and how often he or she flouts it, the results are astonishing: for any rule you choose, three-year-olds obey it most of the time. Though our ears perk up when we hear errors like mens, wents, Can you broke those? The psychologist Karin Stromswold analyzed sentences containing auxiliaries from the speech of thirteen preschoolers. The auxiliary system in English (including words like can, should, must, be, have, and do) is notorious among grammarians for its complexity. There are about twenty-four billion billion logically possible combinations of auxiliaries (for instance, He have might eat; He did be eating), of which only a hundred are grammatical (He might have eaten; He has been eating). For virtually all of these patterns, she found no errors among the 66,000 sentences in which they could have occurred. Baby Born Talking-Describes Heaven 273 the three-year-old child is grammatically correct in quality, not just quantity. Languages with grammatical gender like French and German are the bane of the Berlitz student. In his essay "The Horrors of the German Language," Mark Twain noted that "a tree is male, its buds are female, its leaves are neuter; horses are sexless, dogs are male, cats are female-tomcats included. But little children learning German (and other languages with gender) are not horrified; they acquire gender marking quickly, make few errors, and never use the association with maleness and femaleness as a false criterion. It is safe to say that except for constructions that are rare, used predominantly in written language, or mentally taxing even to an adult (like the horse that the elephant tickled kissed the pig), all languages are acquired, with equal ease, before the child turns four. Often the errors follow the logic of grammar so beautifully that the puzzle is not why the children make the errors, but why they sound like errors to adult ears at all. Perhaps the most conspicuous childhood error is to overgeneralize- the child puts a regular suffix, like the plural -s or the past tense -ed. Thus the child says tooths and mouses and comes up with verb forms like these: My teacher holded the baby rabbits and we patted them. Once upon a time a alligator was eating a dinosaur and the dinosaur was eating the alligator and the dinosaur was eaten by the alligator and the alligator goed kerplunk. These forms sound wrong to us because English contains about 180 irregular verbs like held, heard, cut, and went-many inherited from Proto-Indo-European! Morphology is organized so that whenever a verb has an idiosyncratic form listed in the mental dictionary, the regular -ed rule is blocked: goed sounds ungrammatical because it is blocked by went. Since irregular forms have to be memorized and memory is fallible, any time the child tries to use a sentence in the past tense with an irregular verb but cannot summon its past-tense form from memory, the regular rule fills the vacuum. If the child wants to use the past tense of hold but cannot dredge up held, the regular rule, applying by default, marks it as holded. We know fallible memory is the cause of these errors because the irregular verbs that are used the least often by parents (drank and knew, for instance) are the ones their children err on the most; for the more common verbs, children are correct most of the time. The same thing happens to adults: lowerfrequency, less-well-remembered irregular forms like trod, strove, dwelt, rent, slew, and smote sound odd to modern American ears and are likely to be regularized to treaded, strived, dwelled, rended, slayed, and smited. Old English and Middle English had about twice as many irregular verbs as Modern English; if Chaucer were here today, he would tell Baby Born Talking-Describes Heaven 275 you that the past tenses of to chide, to geld, to abide, and to cleave are chid, gelt, abode, and clove. As time passes, verbs can wane in popularity, and one can imagine a time when, say, the verb to geld had slipped so far that a majority of adults could have lived their lives seldom having heard its past-tense form gelt. When pressed, they would have used gelded; the verb had become regular for them and all subsequent generations. The psychological process is no different from what happens when a young child has lived his or her brief life seldom having heard the past-tense form built and, when pressed, comes up with builded. The only difference is that the child is surrounded by grownups who are still using built. As the child lives longer and hears built more and more times, the mental dictionary entry for built becomes stronger and it comes to mind more and more readily, turning off the "add -ed" rule each time it does. Here is another lovely set of examples of childhood grammatical logic, discovered by the psychologist Melissa Bowerman: Go me to the bathroom before you go to bed. These are examples of the causative rule, found in English and many other languages, which takes an intransitive verb meaning "to do something" and converts it to a transitive verb meaning "to cause to do something": the butter melted. The causative rule can apply to some verbs but not others; occasionally children apply it too zealously. Only a few kinds of verbs can easily undergo the rule: verbs referring to a change of the physical state of an object, like melt and break, verbs referring to a manner of motion, like bounce and slide, and verbs referring to an accompanied locomotion, like race and dance. Other verbs, like go and die, refuse to undergo the rule in English, and verbs involving fully voluntary actions, like cook and play, refuse to undergo the rule in almost every language (and children rarely err on them). Englishspeaking adults, like their children, occasionally stretch the envelope of the rule: In 1976 the Parti Quebecois began to deteriorate the health care system. So both children and adults stretch the language a bit to express causation; adults are just a tiny bit more fastidious in which verbs they stretch. The three-year-old, then, is a grammatical genius-master of most constructions, obeying rules far more often than flouting them, respecting language universals, erring in sensible, adultlike ways, and avoiding many kinds of errors altogether. So how does experience interact with wiring to give a three-year-old the grammar of a particular language? We know that this experience must include, at a minimum, the speech of other human beings. For several thousand years thinkers have speculated about what would happen to infants deprived of speech input. There have also been occasional real-life cases, like Victor, the Wild Boy of Aveyron (the subject of a lovely film by Francois Truffaut), and, in the twentieth century, Kamala, Amala, and Ramu from India. Legend has these children raised by bears or wolves, depending on which one has the greater affinity to humans in the prevailing mythology of the region, and this scenario is repeated as fact in many textbooks, but I am skeptical. Though some species can be fooled by foster offspring, like birds by cuckoos, bears and wolves are predators of young mammals and are unlikely to be so gullible. Whatever innate grammatical abilities there are, they are too schematic to generate speech, words, and grammatical constructions on their own. The muteness of wild children in one sense emphasizes the role of nurture over nature in language development, but I think we gain more insight by thinking around that tired dichotomy. If Victor or Kamala had run out of the woods speaking fluent Phrygian or ProtoWorld, who could they have talked to? White once wrote: There is a very good reason why the erotic side of Man has called forth so much more discussion lately than has his appetite for food. The reason is this: that while the urge to eat is a personal matter which concerns no one but the person hungry (or, as the German has it, der hungrig Mensch), the sex urge involves, for its true expression, another individual. Though speech input is necessary for speech development, a mere soundtrack is not sufficient. Deaf parents of hearing children were once advised to have the children watch a lot of television. Without already knowing the language, it is difficult for a child to figure out what the characters in those odd, unresponsive televised worlds are talking about. Live human speakers tend to talk about the here and now in the presence of children; the child can be more of a mind-reader, guessing what the speaker might mean, especially if the child already knows many content words. They can be a bit more like the archeologists with the Rosetta Stone, who had both a passage from an unknown language and its translation in a known one. For the child, the unknown language is English (or Japanese or Inslekampx or Arabic); the known one is mentalese. Another reason why television soundtracks might be insufficient is that they are not in Motherese. Surely this makes Motherese easier to learn from than the kind of Baby B o r n T a l k i n g - D e s c r i b e s H e a v e n 279 elliptical, fragmentary conversation we saw in the Watergate transcripts. But as we discovered in Chapter 2, Motherese is not an indispensable curriculum of Language-Made-Simple lessons. In some cultures, parents do not talk to their children until the children are capable of keeping up their end of the conversation (though other children might talk to them). That impression is an illusion; grammar is so instinctive that we do not appreciate which constructions are complex until we try to work out the rules behind them. Motherese is riddled with questions containing who, what, and where, which are among the most complicated constructions in English. No mercifully designed language curriculum would use these sentences in Lesson 1, but that is just what mothers do when speaking to their babies. A better way to think of Motherese is to liken it to the vocalizations that other animals direct to their young. Motherese has interpretable melodies: a rise-and-fall contour for approving, a set of sharp, staccato bursts for prohibiting, a rise pattern for directing attention, and smooth, low legato murmurs for comforting. The psychologist Anne Fernald has shown that these patterns are very widespread across language communities, and may be universal. When given a choice, babies prefer to listen to Motherese than to speech intended for adults. Surprisingly, though practice is important in training for the gymnastics of speaking, it may be superfluous in learning grammar. For various neurological reasons children are sometimes unable to articulate, but parents report that their comprehension is excellent. Roger Brown divided the sentences of Adam, Eve, and Sarah into grammatical and ungrammatical lists. Brown also checked whether children might learn about the state of their grammars by noticing whether they are being understood. Baby Born Talking-Describes Heaven 281 Indeed, when fussy parents or meddling experimenters do provide children with feedback, the children tune it out.

Railroad conductors struck against management for the ten-hour day fungus wolf river trusted fulvicin 250mg, overtime pay fungus gnats lemon juice generic fulvicin 250mg with visa, and the right to unionize african violet fungus gnats purchase fulvicin 250 mg amex. Other unions joined in sympathy zeasorb-af antifungal powder buy generic fulvicin 250 mg on-line, white workers 148 t he deep s t o ry standing with blacks despite attempts to divide them fungus under nose discount 250 mg fulvicin amex. Today fungi questions buy fulvicin 250 mg line, although many such strikes continue-the Walmart strike of 2012, for example-many industrial work sites have been moved offshore to Mexico, China, Vietnam, and elsewhere. It focuses on conflict in the private sector between the very richest 1 percent and the rest of America. It is between haves and have-nots, the ever-more-wealthy 1 percent and the other 99 percent of Americans. What feels unfair to Occupy activists is not simply unfair recompense for work (the multi-million dollar bonuses to hedge fund managers alongside the $8. For the right today, the main theater of conflict is neither the factory floor nor an Occupy protest. For the left, the flashpoint is centered in the private sector; for the right, in the public sector. It is almost as if those I t alked with thought about the government and the market in the same way others think of separate nations. Just as various nations back different sides in a foreign war, fighting each other on a "proxy" 149 s t rangers i n t hei r o wn land battlefront, in the same way those I spoke with seemed to talk about the federal government and the free market. The free market was the unwavering ally of the good citizens waiting in line for the American Dream. Giant companies have grown vastly larger, more automated, more global, and more powerful. For them, productivity is increasingly based on cheap labor in offshore plants abroad, imported cheap foreign labor, and automation, and less on American labor. Thus, they have felt more free to allocate more profits to top executives and stockholders, and less to workers. But this is the "wrong" theater to look in for the conflict that absorbs the right-except when a company like Texas Brine causes a sinkhole like the one in Bayou Corne. Many members of the Tea Party run or work in a small business-oil company suppliers, trailer parks, restaurants, small banks, and shops. What is transpiring today, Robert Reich argues in Saving Capitalism, is t hat big monopolies support policies that help them compete against smaller businesses by rewriting property bankruptcy and contract laws that favor big business over small. Under recently revised bankruptcy laws, the billionaire Donald Trump can freely declare bankruptcy while insulating himself from risks to investment, while smaller businesses cannot. The choice is not, Reich argues, between a governed and an ungoverned market, but between a market governed by laws favoring monopolistic companies and one governed by those favoring small business. Ironically, the economic sector that stands to suffer most from big monopolies is small business, many of which are run by those who favor the Tea Party. Under the same banner of the "free market," the big are free to dominate the small. But it is very hard to criticize an ally, and the right sees the free market as its ally against the powerful alliance of the federal government and the takers. They rejected their own need of it-even to help clean up the pollution in their backyard. But that kind of extraordinary determination takes a c ertain kind of person-a deep story self. Next to her awards for outstanding service to her community and photos of relatives, the elephants had been gathered, over the years, from bake sales, luncheon raffles, and Republican conventions. She is a s hort woman with a purposeful handshake and a lively face who dresses in a no-nonsense gray pantsuit and practical shoes. She wears neither jewelry nor make-up; in this way, she "dresses Pentecostal," as she puts it. Across the desk, during our first of many meetings, she punches out a series of well-articulated opinions on a wide range of issues, and then comments humorously, aside, "You get me 153 s t rangers i n t hei r o wn land talking about all the burrs under my saddle. On a l ater visit to Lake Charles, I bring her a S an Francisco 49ers cap; she is a n ardent Dallas Cowboys fan. She oversees the management of 21,000 acres of land, long ago part of a r ice and soybean plantation. Throughout the years, the land has also been leased for hunting and oil and gas exploration. I ask Janice if we could visit her former school, church, and home in Sulphur, just west of Lake Charles. Fishing rods rattle in the back, along with a three-pound bag of pecans "crushed but not shelled" that she plans to give away to friends. My dad was the oldest of ten, and my mom was the youngest of seven, and everyone married and had kids. Not claiming to be a victim, accommodating the downside of loose regulations out of a loyalty to free enterprise-this was a tacit form of heroism, hidden to incurious liberals. Sometimes you had to endure bad news, Janice felt, for a higher good, such as jobs in oil. I was discovering three distinct expressions of this endurance self in different people around Lake Charles-the Team Loyalist, the Worshipper, and the Cowboy, as I came to see them. Each kind of person expresses the value of endurance and expresses a capacity for it. As the oldest of ten, he was forced to quit school early to help his father raise a garden to feed a family of twelve. These are to be used at a church supper to raise money for our troops in Iraq and Afghanistan. He could do a lot of things, like mend a hole in fishing net like no one you ever saw," she says. At nineteen he learned pipefitting, joined the local union, and worked for more than thirty years at Cities Service (now Citgo). This was where, as a small girl, Janice belonged to a f ull gospel church (which refers to speaking in tongues, prophecy, and gifts of healing) and attended Sunday morning, Sunday night, and Wednesday night-"no missing. Diligence, Industry, Party It was in church that Janice first learned the honor of work, she says. After high school, "I put myself through McNeese working forty hours a w eek as a t elephone operator. It was hard to work long hours and get up to go to school the next morning, hurrying to get your studying in between. Janice is stoutly proud that, like her dad, she never "took a dime from the government. Her feeling about work is part of a larger moral code that shapes her feelings about those ahead and behind her in line for the American Dream. Liberals-those associated with the social movements that brought in the line cutters-share a l ooser, less defined moral code, she feels. Janice opposes abortion except under certain circumstances, but imagines there are "fifty million abortions a year, probably all Democrats. The American Dream itself has become strange, un-Bibled, hyper-materialized, and lacking in honor. Even as she stands patiently in line, she is being made to feel a stranger in her own land. If you have a job, you should apply yourself to it, even if you face a little risk, Janice feels. For a period, she worked for the 158 t he t eam play er Lake Area Industry Alliance, visiting schools to explain the benefits of industry to students who might be getting another story from home or from the liberal media. The government is trying to get her to feel sorry for people like that, Janice feels. Looking away from the wheel for a moment, Janice stares at me with eyes wide, preparing for my shock. So for her, there was no paradox in Louisiana coming in 49th in the human development index and 50th in overall health and right-wing resistance to the idea of federal government aid. Having grown up blocks away from Citgo, Janice has bought a plot of land in north Sulphur so as to be far away from the plants-a retirement "barn," as she calls it. She is constructing it, room by room, with the help of her nephew, who is planning to live there too, with his family. Beyond that, her solution is to get children "churched" and to limit the fertility of poor women. Some people may just be destined to remain at the end of the line for the American Dream. As for government ownership of public lands, "We should hold on to the Grand Canyon, part of Yellowstone, a few others, but sell the rest of the national parks for development and jobs. Without imagining her view would surprise me, Janice argues that handing out guns is t he best way to create democracy in the Middle East. If the government takes our guns away, the same thing will happen here," she predicts darkly. Another man told me that a minister even led his congregation to Walmart to stock up. First, there was Solyndra, a solar company that wasted a $535 million federal loan. Then there was the National Endowment of the Arts­funded painting in which 161 s t rangers i n t hei r o wn land the artist Chris Ofili attached cow dung to the figure of the Virgin Mary. Faces in Line It is n ot just the moral laxity of the Democrats that galls Janice, but the imposition of such laxity on her. Janice had followed the story closely: "He was the cutest little girl on the show when I was growing up. But "they make what we need-plastic soda bottles, rubber-soled shoes, toothpaste. Janice had earlier told me a shocking story about a relative with a horse, and I wanted to talk with him directly, to hear the story again from him. But when Ted finally scrambled back out, he was coated all over with a strange film. As a child, she recalled hearing a great roar and seeing the daytime sky turn black. Today "industry is i n compliance with state-issued permits," and she sees no problems. We are coming up to the "barn," her dream retirement home, built on forty acres of former lumber company land, six miles from the Sasol expansion. Although single and childless, Janice has built a six-bedroom, four-bath estate with a l arge common family kitchen­living room where the whole clan can gather. This "barn" can house her two sisters-Joyce, who is r ecovering from hip surgery and is ready to move in, and maybe Judy, who lives in Texas, should she become widowed. Her nephew Kelly, helping to build the place, has his trailer on the premises and has just brought in a basket of fresh eggs along with a report that one chicken has died. One day he, his girlfriend, and his daughter, Mattie-of whom he has half-time custody and whom everyone adores- might move from the trailer to the house. She had made it out of the structural squeeze-aiming high on one side, facing a flat wage, uncertainty, competitors, and government aid on the other. To live with it, Janice managed anxiety nearly hidden to her, anxiety that now felt like second nature; it kept her steady and brave. It kept her focused on the good news of Citgo for her dad, Lacassane for herself, the "buckle in the energy belt," the free market. Indeed, she had to defend that devotion from a l iberal perspective, which she associated with a m orally lax, secular, coastal-based culture. It was one thing for certain categories of people to cut in line, but it was another to have false notions of the good and the true gain popularity and edge out her truer ones. Instead of the country agreeing with her community on the natural rightness of heterosexual marriage as the center of family life, she was now obliged to defend herself against the idea that these views were sexist, homophobic, old-fashioned, and backward. Not only her values, but even the kind of self she proudly exhibited-an endurance self-seemed to need defending, because it too seemed to be going out of fashion along with all the blue-collar jobs. Like her father and uncle, Harold Areno, Janice feels proud to have a rooted self, a self based in a busy, dense, stable community of relatives, co-parishioners, and friends. A newer cosmopolitan self, one that seemed uprooted, loosely attached to an immediate community, prepared to know a lot of people just a little bit, a mobile, even migratory self-this seemed to be coming into vogue. Such a self took pride in exposure to a diverse set of moral codes, but did a person with that kind of self end up thinking "anything goes"? Joyce had worked for Olin Chemical as a shipping supervisor checking train cars that had been filled with phosgene (used in making pesticides and, at room temperature, a p oisonous gas) without a f acial mask. She began to suffer from a d ebilitating autoimmune disease, had to cut her hours, and struggled to get better with prednisone and naturopathy. Janice herself also suffered from an ailment that she says "is probably related to growing up near the plants. She credits her team-her party and the industry she feels it represents-with all her good fortune in life. And with the fracking boom, other new plants might be creeping closer in the future too. We have just driven home from Sunday services at Trinity Baptist on my third visit with her. Jackie is a p etite, svelte, youthful forty-five, with shoulder-length dark hair, gold stud earrings, a pink cotton top and flats; casual dress and intense dark eyes. We enter a high-vaulted living room, where three antlered buck heads stare ahead from above a large stone fireplace. Jackie, Heath, their two children, and I sit down, pray, and enjoy the delicious fish.

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