While still a junior faculty member on the
staff of the St Louis Children's Hospital,
Warren Weinberg startled the pediatric,
psychiatric, and neurologie communities in 1973
by publishing an article in The Journal of
Pediatrics in which he showed that depressive
illness occurred frequently in children with
school difficulties and that the diagnosis could
be readily made by applying specific criteria,
during a structured evaluation session. Weinberg
had taken a bold step: he regarded affective
illness (depression being one form) as a
neurobiologie condition that did not respect age
barriers and he then tailored for children the
already accepted criteria symptoms used to
diagnose depression in adults. Weinberg's
article so contradicted entrenched establishment
views that Waldo E. Nelson, editor of The Joumal
of Pediatcs, found it necessary to include along
with the article a disclaimer stating:
«Although this paper has been recommended
for publication (subject to revision of the
original manuscript) by two selected reviewers,
the Editor feels it necessary to stress extreme
caution in identifying any child as having a
depressive illness and in prescribing any
medication for such a disorder.
Slowly, over the next decade, the medical
community recognized the validity of Wemberg's
observations on childhood affective illness and
accepted that depression indeed could occur in
children, using what became termed the "Weinberg
Criteria" to diagnose childhood depression.
Petti even incorporated the Weinberg Criteria
into the Bellevue Index of Depression. As the
American Psychiatric Association progressed
through its Diagnostic and Statistical Manual
«Mental Disorders, 3rd edition (DSM-III),
DSM-IIIR, and DSM-IV nosologies, the diagnosis
of depression in children by physicians and
psychologists became acceptable and even
commonplace, such that the younger generation of
clinicians now cannot even conceive of the
controversy that surrounded the original
descriptions by Weinberg and his
colleagues.
Not being satisfied that affective illness
alone was sufficient to explain many of the
behavioral problems in children referred to his
offices, Weinberg continued his careful clinical
analyses. This meticulous observation and
documentation of neurobehavioral signs and
symptoms permitted Weinberg to identify a group
of inattentive children who previously had been
classified under the rubric of attention-deficit
disorder, but seemed unique. His careful study
revealed that this subgroup of children labeled
as having attention-deficit disorder
actually appeared to have an underlying problem
in sustaining wakefulness (or as Weinberg called
it, vigilance). A constellation of readily
recognizable signs and symptoms that were
consistent from patient to patient were evident
in these children with what Weinberg called a
vigilance disorder.The most obvious clinical
feature was the difficulty in maintaining
wakefulness and alertness as evidenced by motor
restlessness (fidgeting and moving about,
yawning
and stretching, talkativeness) and complaints of
tiredness. In tasks requiring concentration
(continuous mental activity) such as reading,
these chidren daydreamed, lost interest,
complained of boredom, and became increasingly
restless. Actual napping was infrequent, and
such naps tended not to be refreshing.
Interestingly, these children generally had a
very distinct personality described by family
members and friends as kind, affectionate,
compassionate, or "angelic." Through documenting
the family histories and often evaluating
several generations of family members, Weinberg
discovered a familial pattern that seemed to
suggest autosomal-dominant inheritance of
problems with vigilance.
Weinberg boldly proposed a new syndrome
characterized by a disturbance in vigilance and
again he gave The Journal of Pediatrics an
opportunity to publish his findings .As before,
the editor of the journal (this time Joseph M.
Garfunkel) felt compelled to add a disclaimer at
the top of the article: "We suspect that this
article will stir considerable controversy. Two
experienced and critical reviewers recommended
it for publication, and several of us concurred,
although an overlap with attention-deficit
hyperactivity disorder will occur to many
readers. " Although a few concerns were
subsequently raised by other investigators, by
and large there was no controversy but rather
apathy surrounding the description of Weinberg's
vigilance syndrome. This was mainly the result
of the blind faith shown by the medical and
mental-health communities in the concept of
attention-deficit disorder first introduced in
DSM-III (and later refined to
attention-deficit hyperactivity disorder
[ADHD] in DSM-IV). Thus, as
suggested by Garfunkel in his disclaimer, since
some children with Weinberg's syndrome just
fulfilled various criteria for the inattentive
form of ADHD, there was no need for any separate
characterization. However, there is no reason to
think that a syndrome such as ADHD, just as with
any medical disorder, should not after careful
observation be separable into distinct biologie
disorders that initially appear to be
phenotypically the same condition. This is what
Weinberg accomplished with his description of
problems with vigilance and now it is up to the
rest of the medical community to expand the
characterization of Weinbergs syndrome.
Duane has started this effort by using
pupillometry to demonstrate hypovigilance in
some children originally labeled as having ADHD.
Such physiologie studies substantiate earlier
investigations by Satterfield and colleagues
showing electroencephalographic, evoked
response, and skin conductance changes
indicating under arousal in some hyperactive
children. Additional neurophysiologic studies
with more modern technology are warranted in
Weinbergs syndrome to help understand the
pattern of altered wakefulness and the
associated inattention and restlessness.
Epidemiologic studies will also be important
in determining how often Weinbergs syndrome is
the cause of poor school performance or behavior
problems. In addition, the familial occurrence
of Weinbergs syndrome cries out for genetic
investigations, which might not only identify a
molecular biologie basis, but also could help to
explain the neurobiology of a variety of sleep
problems. Finally, detailed pharmacotherapeutic
studies will be important to identify the best
treatment approach for Weinberg's syndrome,
particularly whether the methylphenidate
commonly prescribed for ADHD is also optimal
therapy for this condition. More thorough
investigations of Weinberg's syndrome will help
to characterize this condition such that
presumably in the future the concept of a
disturbance of vigilance in children will be as
acceptable as the idea of childhood affective
disorders is now.
