CHILDHOOD PSYCHOSES: RESULTS OF DRUG TREATMENT ON SOCIAL BEHAVIOUR IN DOWN AND NON-DOWN SUBJECTS

CHILDHOOD PSYCHOSES: RESULTS OF DRUG TREATMENT
ON SOCIAL BEHAVIOUR IN DOWN AND NON-DOWN SUBJECTS

Renato COCCHI, neurologist and medical psychologist

(Italian translation)

Summary

After 3-94 months of individualized drug therapies, the results on social behaviour of 36 psychotic Down children and 29 psychotic non-Down children were compared.

The Down group (PDG) comprised 24 M and 12 F; average age at first consultation, 5;10 +/- 3;1 years; chromosomal diagnoses, 34 pure trisomy 21, 1 mosaicism and 1 not known; DSM-III,R diagnosis, 33 early onset and 3 late onset Pervasive Developmental Disorder. The non-Down group (PNDG) comprised 16 M and 13 F; average age at first consultation, 6;1 +/- 3;1 years; DSM-III,R diagnosis, 20 early onset and 4 late onset Pervasive Developmental Disorder and 5 Atypical Pervasive Developmental Disorders.

Social isolation, the relationship with people around and social play, have all been evaluated.

A reduction in isolation and the appearance of more complex forms of relationship and social play are in direct proportion to the duration of the drug therapy.

The psychotic Down subjects' learning of social skills is, however, a little slower than that of the psychotic non-Down group and this fact could reflect a stronger presence of cognitive deficit.

Key words: Childhood psychoses; Down children; non-Down children; drug therapy; individualized regimen; social behaviour; results.

Autism

Down's syndrome

Drug therapy

Mental retardation

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A lessening of social isolation together with the learning of relational skills is one of the basic objectives of any therapy to do with childhood psychoses.

Having treated with drug therapy, for various periods of time, a group of psychotic Down children (PDG) and a group of psychotic non-Down children (PNDG), the results, concerning this, have already been globally evaluted in the previous research (Cocchi, 1990c).

In order to evaluate more precisely the benefit obtained, I thought it would be interesting to compare the results more extesively.

The fields of investigation chosen for evaluation are that of social isolation, as a chief symptom of childhood psychoses, and the appearance or reappearance of social relationships with the various figures around the child.

Along with this areas, social play, one of the behaviours typical of childhood socialisation, has also been assessed.

The children making up the survey groups are those whose parents accepted drug treatment administered along the guidelines already described (Cocchi, 1990b).

The two groups involved comprise only subjects who undervent at least one check up of the therapy effects after a minimum of 3 months' treatment.

Materials and method

All the clinical records of psychotic Down and non-Down subjects who had been the object of previous research (Cocchi, 1990c), were re-examined. To the psychotic non-Down group were added the records of some new subjects whose progress had been checked after at least 3 months of drug therapy.

The clinical records selected were those cases where a diagnosis of childhood psychosis conforming to DSM-III,R (1987) had been made during the first consultation.

The following symptoms were evaluated:

- social isolation;

- social relationships: with parents,

with siblings, family relations,

with peers,

with teachers and therapists,

with strangers;

- social play: observation,

partecipation (if involved in the game),

requests to play.

For each child were also noted:

- sex;

- age at first consultation;

- cromosomal diagnosis (for the Down subjects).

Results

Results were reported on tables 1-6.

Two groups of subjects were identified on the basis of diagnosis at first consultation, and the length of time the drugs were taken:

1. Psychotic Down children group (PDG): 36 Ss = 100.00%.

Characteristics of PDG are:

Sex: M = 24 and F = 12; M/F ratio = 200/100.

Average age at 1st consultation: 5;10 years, with SD = 3;2 years.

Distribution of chromosomal anomalies: Pure trisomy 21: 34 Ss = 94.44% ;

Mosaicisms: 1 S = 2.78% ;

Unknown (only clinical diagnosis): 1 S = 2.78 %.

Diagnoses, according with DSM-III, R: Early onset Pervasive Developmental Disorder: 33 Ss = 91.67 % ; Late onset Pervasive Developmental Disorder: 3 Ss = 8.33% .

Table 1: PDG results; keys: (=) = no relationship or behaviour improvemennt; (=) = slight improvement; (++) = mild improvement; (+++) = marked improvement; (++++) normal behaviour.


	Social relationship with people around							Play
S. nr.	Isolation		parents	brothers	peers	teachers	strangers	observation	partecipat		request
				relatives		therapists					to play
Gr. 1
182	=	+		=	=	=	=	=	=		= (*)
353	+	+		=	+	+	=	=	=		= (*)
Gr.2
32	=	+		=	=	=	=	=	=		= (*)
34	+	++		+	=	+	=	+	+		= (*)
316	+	+		+	=	+	=	=	=		= (*)
332	+	+		=	=	=	=	=	=		= (*)
430	++	++		=	++	=	=	++	+		=
455	++	++		=	=	+	=	=	=		=
Gr.3
124	+	++		+	No nursery school nor rehabilitation						(*)
173	+	++		+	+	+	=	+		=	= (*)
186	+	+		+	+	+	=	+		+	= (*)
289	+	+		=	+	=	=	+		=	= (*)
325	+	++		+	+	+	=	+		+	= (*)
330	=	+		+	=	=	=	=		=	= (*)
333	+	+		=	=	=	=	=		=	= (*)
345	++	+++		++	++	+	=	++		+	+ (*)
400	+++	++		=	++	++	=	+++		++	+
433	++	+++		+++	+	++	+	No play, because he was too old
Gr.4
93	++	+++		++	++	+	+	++		+	= (*)
101	++	+++		++	++	+	=	++		++	++ (*)
120	+	++		+	=	=	=	+		=	= (*)
191	+	++		=	=	=	=	+		=	= (*)
225	+	+		=	+	=	=	=		=	= (*)
281	+++	+++		+++	++	+	+	++		++	+ (*)
319	+	++		=	=	+	=	+		=	= (*)
372	+++	+++		+++	++	++	+	++		+	=
Gr.5
85	+	++		=	=	=	=	+		=	= (*)
268	++	++		+	++	+	=	++		+	=
308	+	++		+	=	=	=	No nursery school			(*)
Gr.6
7	+++	+++		=	++	++	=	+++		+++	++
49	+++	++		+	++	+	=	+		=	=
206	++++	++++		++++	+++	+++	++	+++		+++	++
217	++	++		+	++	+	=	=		=	=
226	++	++++		+++	+++	+++	++	+++		+++	++
242	++	+++		++	=	=	=	+		=	=
284	+++	+++		+++	++	++	+	++		++	+

(*) therapy interrupted by the parents.

2. Psychotic non-Down group (PNDG): 29 Ss = 100.00%.

Characteristics of PNDG are:

Sex: M = 16 e F = 13; M/F ratio M/F = 123/100;

Age at first consultation: 6;10 years with SD = 3;1 years;

Diagnoses, according to DSM-III,R:

Early onset Pervasive Developmental Disorder: 20 Ss = 68.97 %;

Late onset Pervasive Developmental Disorder: 4 Ss = 13.79 %;

Atypical Pervasive Developmental Disorder: 5 Ss = 17.24 %.

Table 2: PNDG results; keys: (=) = no relationship or behaviour improvement; (+) = slight improvement; (++) = mild improvement; (+++) = marked improvement; (++++) normal behaviour.


	Social relationship with people around						Play
S. nr.	Isolation	parents	brothers	peers	teachers	strangers	observation	partecipat	request
			relatives		therapists				to play
Gr.1
F	+	++	+	=	=	=	+	=	= (*)
M	+	++	+	+	+	=	+	=	=
M	+	++	+	+	+	=	+	=	=
M	+	++	+	+	+	=	+	+	+
Gr.2
M	++	++	=	++	=	=	+	=	= (*)
M	+++	++	+	++	+	+	++	+	=
M	+	++	+	+	+	=	=	=	=
M	++	++	++	=	+	=	No nursery school
F	+	++	=	=	=	=	=	=	=
F	++	+++	+	++	++	=	++	+	=
Gr.3
F (#)	+	+	=	Since motor worsening, she stopped the nursery school attendance
F	++	++	+	+	+	=	+	=	+ (*)
M	+	++	+	=	+	=	=	=	=
F	+++	+++	++	++	+	=	++	+	= (*)
M	+++	+++	+	+	+	=	+	=	=
Gr.4
M	+++	+++	+++	+++	++	++	+++	++	++
M	+++	+++	+++	++	++	+	++	++	+
M	++	+++	++	+	++	+	++	+	+
F	+++	+++	+++	+++	+++	++	+++	++	++
Gr.5
M	++	++	+	+	+	=	+	=	= (*)
M	+++	+++	+++	++	++	+	++	+	=
F	++	++	+	=	=	=	=	=	=
F	++++	++++	++++	++++	++++	+++	++++	++++	+++
F	+	+	=	+	=	+	=	=	= (*)
F	+++	+++	++	++	++	=	++	+	=
Gr.6
M	+++	+++	++	++	+	=	+++	+	=
M	++++	++++	+++	+++	+++	+++	++++	+++	+++
F	++++	++++	+++	+++	++++	++	++++	+++	+++
F	+++	+++	+++	++	+++	++	+++	+++	+

(*) therapy interrupted;

(#) Rett's Syndrome (diagnosis made during the drug therapy).

Table 3: comparison of the length of the therapies


Investigated field	PDG Ss	%	PNDG Ss	%	<>%
1. from 3 to 6 months	2	5.56	4	13.79	+8.23
2. from 7 to 12 months	6	16.67	6	20.69	+4.02
3. from 13 to 24 months	10	27.78	5	17.25	-10.53
4. from 25 to 36 months	8	22.22	4	13.79	-8.43
5. from 37 to 60 months	3	8.33	6	20.69	+12.36
6. from 61 to 94 months	7	19.44	4	13.79	- 5.65
Totals	36	100.00	29	100.00	0.00

Chi Square = 4.7865 with 5 df; .50 < p > .30; N.S.

Table 4: comparison of the results on social isolation; keys: (+) = improvement (any degree), (=) = fully inadequate.


Group	PDG	PnDG	PDG	PnDG	PDG	PnDG	PDG	PnDG	PDG	PnDG	PDG	PnDG
Ther. Months	6		12		24		36		60		94
Nr. of Ss	2	4	6	6	10	5	8	4	3	6	7	4
Evaluation	+ / =	+ / =	+ / =	+ / =	+ / =	+ / =	+ / =	+ / =	+ / =	+ / =	+ / =	+ / =

Soc. isolation	1 / 1	4 / 0	4 / 1	6 / 0	9 / 1	5 / 0	8 / 0	4 / 0	3 / 0	6 / 0	7 / 0	4 / 0
% of + results	.50	1.00	.83	1.00	.90	.1.00	1.00	1.00	1.00	1.00	1.00	1.00

Table 5: comparison of the results on social skills according to the length of the therapy; keys: (+) = improvement (any degree), (=) = null.

Group

PDG

PnDG

PDG

PnDG

PDG

PnDG

PDG

PnDG

PDG

PnDG

PDG

PnDG

Ther. Months

Nr. of Ss (max-min)

6-5

10-8

5-4

3-2

Evaluation

+ / =

Rel / parents

2 / 0

4 / 0

6 / 0

10 / 0

5 / 0

8 / 0

4 / 0

3 / 0

6 / 0

7 / 0

4 / 0

Rel / sib.relat.

0 / 2

4 / 0

2 / 4

4 / 2

7 / 3

4 / 1

5 / 3

4 / 0

2 / 1

5 / 1

4 / 0

Rel / peers

1 / 1

3 7 1

1 / 5

4 / 2

7 / 2

3 / 1

5 / 3

4 / 0

1 / 2

5 / 1

6 / 1

4 / 0

Rel/ teach.ther

1 / 1

3 / 1

3 / 3

4 / 2

6 / 3

3 / 1

5 / 3

4 / 0

1 / 2

4 / 2

6 / 1

4 / 0

Rel / strangers

0 / 2

0 / 4

0 / 5

1 / 5

1 / 8

0 / 4

3 / 5

4 / 0

0 / 3

3 / 3

3 / 4

3 / 1

Play / observ.

0 / 2

4 / 0

2 / 4

3 / 2

6 / 2

3 / 1

7 / 1

4 / 0

2 / 0

4 / 2

6 / 1

4 / 0

Play / partecip.

0 / 2

0 / 4

2 / 4

2 / 3

4 / 4

1 / 3

4 / 4

4 / 0

1 / 1

3 / 3

4 / 3

4 / 0

Req. to play

0 / 2

0 / 4

0 / 6

0 / 5

2 / 6

1 / 3

2 / 6

4 / 0

0 / 2

1 / 5

4 / 3

3 / 1

% of + results

.25

.56

.33

.53*

.61^

.45"

.61

1.00

.48°

.65

.73

.94

* on 45 Ss; ^ on 70 Ss; " on 44 Ss; ° on 21 Ss.

Table 6: comparison of % positive results according to the field of investigation.


Field of investigat.	Social relationship with people around					Play
Group	parents	brothers	peers	teachers	strangers	Observation	partecipat	request
Months of therapy		relatives		therapists				to play
6. PDG (2 Ss)	2	0	1	1	0	0	0	0
6. PnDG (4 Ss)	4	4	3	3	0	4	0	0
12. PDG (6 Ss)	6	2	1	3	0	2	2	0
12.PnDG (6-5 Ss)	6	4	4	4	1	3	2	0
24.PDG (10-8 Ss)	10	7	7	6	1	6	4	2
24.PnDG (5-4 Ss)	5	4	3	3	0	3	3	1
36. PDG (8 Ss)	8	5	5	5	3	7	4	2
36. PnDG (4 Ss)	4	4	4	4	4	4	4	4
60. PDG (3-2 Ss)	3	2	1	1	0	2	1	0
60. PnDG (6 Ss)	6	5	5	4	3	4	3	1
+60 PDG (7 Ss)	7	5	6	6	3	6	4	4
+60 PnDG (4 Ss)	4	4	4	4	3	4	4	3
% of + results	1.00	.58	.60*	.63*	.20*	.70**	.45**	.24**
	1.00	.86	.82^	.79^	.39^	.81^^	.52^^	.33^^

* on 35 Ss; ** on 33 Ss; ^ on 28 Ss; ^^ on 27 Ss.

Discussion

Bearing in mind that the therapies are individualised, as can be seen from the case outlined in detail (Cocchi, 1990d), the statistical approach is nearly at all descriptive, so much so that for each case the clinical evaluation of the results has been reported here (Tables 1-2).

Besides this, another 3 cases in the PnDG and 1 in the PDG have been reported in other papers, 3 of them have been also evaluated by external observers (Bondanini, 1990; Grasso Rossetti, 1990) and one by laboratory parameters (Cocchi, 1990a).

As far as the length of therapy is concerned, regarding the many cases where it was interrupted, I must confirm here what has already stated in the previous research (Cocchi, 1990c): the lack of some results was the reason for it only in very few cases.

The length of therapy for the two groups does not vary significantly (Tab. 3).

The results that drug therapy has on socialisation in both groups parallels the length of the therapy itself (Tab. 4-5). It as well to make such a statement with caution as far as the PDG is concerned, because the many interruptions in treatment may have meant selection of the best subjects, whose parents felt more motivated to continue the treatment being undertaken.

This caution is not quite so necessary in the case of the PNDG as interruptions were generally fewer.

Social isolation reduces in proportion to the length of therapy (Tab. 4). As far personal relationships and behaviour in social play, here too there seem to be a parallelism with the duration of therapy, although a slower rhythm can be seen regarding the psychotic Down children.

This fact is not easily to understand other than to admit that the basic mental deficit also inhibits social behaviour.

The problem is the "shyness" of the Down child, a well known social feature about which only poor satisfactory explanations can be found.

Is their shyness a secondary relational problem? If so, we must conclude that the Downs are extremely sensitive, right from an early age, to comparison with their peers and to adults' reactions towards them. However, in saying this once more we destroy the common cliche` of their blissful ignorance.

If, on the other hand, we are dealing with an impossibility wich is apparently at least in part functional - given the improvements which can be achieved in this area (Cocchi, 1988) - it would mean that socialisation is also a cognitive ability. Common experience seems have chosen this second hypothesis: "good manners", as a tool for better socialisation, are thought and can be learnt. In this way though, it is taken for granted that whoever learns them is not only able to do so, but also knows how to assess the advantages of their relational use.

A third hypothesis is left. The problem is still a cognitive one, but with a lot of emotional aspects, and in this area too the Down child understands much more than he can do, the management of his emotions being a cognitive problem.

For both groups the results, concerning relationships with others and social play, are trivial. Both groups first of all recover relationships with the parents, then with siblings or relatives, with peers, with teachers and therapists. In play, the sequence of events passes from initial disinterest, to observation and curiosity, to take part to play, if some one invites them, and finally to request to play.

Conclusion

The comparative study of the results of an individualised drug therapy on the reduction of social isolation, on personal relationships and on social play, between a group of psychotic Down subjects and a group of psychotic non-Down

subjects has highlighted common elements of great interest. The results show a parallellism to the length of the therapy and the way in which personal relationships and social play activities are built (or, re-built) up exhibits exactly the same characteristics as in normal children. The slower developmental rhythm, in Down children, if confirmed by further research, could be suggested as dependent on the subjects' particular cognitive problems.

Aknowledgement

This research was supported by a grant no. PSS */0201/00 of the Commission of the European Communities, Bruxelles.

References

American Pschiatric Asociation: Diagnostic and Statistic Manual of Mental Disorders (3rd edition revised, DSM-III, R). APA, Washington D.C., 1987.

Bondanini M.: Storia di Nicola, che cerca il sole. Riv. It. Disturbo Intellet. 1990, 3: 95-101.

Cocchi R.: Esperienze di terapia farmacologica nell'adulto Down. Riv. It. Disturbo Intellet. 1988, 1: 57-69

Cocchi R.: Psicosi nel bambino Down e nel bambino normale: analogie e differenze. Riv. It. Disturbo Intellet. 1988, 1: 89-95.

Cocchi R.: Aminoacidi plasmatici in una bambina autistica prima e dopo 7 anni di farmacoterapia. Riv. It. Disturbo Intellet.9 1990a, 3: 127-130.

Cocchi R.: The pharmacological approach to treating childhood psychoses: Theoretical basis. It. J. Intellect. Impair. 1990b, 3: 185-193.

Cocchi R.: Childhood psychoses: Results of drug treatment with Down and non-Down subjects. It. J. Intellect. Impair. 1990c, 3: 195-202.

Cocchi R.: Autismo infantile e sordita` di trasmissione. Si puo` supporre una relazione temporale diversa? Riv. It. Disturbo Intellet. 1990d, 3: 313-320.

Cocchi R., Bonaduce D.: Suscettibilita` alle malattie infettive respiratorie in bambini psicotici Down e non Down. Riv. It. Disturbo Intellet. 1988, 1:173-178

Cocchi R., Bonaduce D.: L'autoaggressivita` nel bambino psicotico. Riv. It. Disturbo Intellet. 1988, 1: 185-191

Grasso Rossetti A.: Il disegno della casa e della figura umana in due soggetti psicotici trattati con farmacoterapia. Riv. It. Disturbo Intellet. 1990, 3: 119-126.

Printed on it. J. Intellect. Impair 1991, 4: 15-22.

Author's address: dr Renato COCCHI, via Rabbeno, 3

42100 Reggio Emilia (Italy)

renatococchi@libero.it

Testo in italiano

Autism

Down's syndrome

Drug therapy

Mental retardation

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