CHILDHOOD PSYCHOSES: RESULTS OF DRUG TREATMENT

WITH DOWN AND NON-DOWN SUBJECTS

Renato COCCHI, a neurologist and a medical psychologist.

(Italian translation) // Testo in italiano

Summary

After 3-94 months of individualized drug therapy, the results of 44 psychotic Down children and 29 psychotic non-Down children were compared. The Down group (PDG) comprised 28 M and 16 F; average age at first consultation, 7;3 +/- 3;9 years; chromosomal diagnoses, 42 pure trisomy 21, 1 mosaicism and 1 not known; DSM-III, R diagnosis, 40 early onset and 4 late onset Pervasive Developmental Disorder.

The non-Down group (PnDG) comprised 16 M and 13 F; average age at first consultation, 7;3 +/- 3;8 years; DSM-III, R diagnosis, 19 early onset and 3 late onset Pervasive Developmental Disorder and 7 atypical Pervasive Developmental Disorders.

One Down child and 3 non-Down children definitely came out of their psychoses and the results werå_ directly correlated to the length of the drug therapy.

The high number of therapy interruptions, especially with the Down children, may have various explanations, among wich that of null or negative results does not seem the most prominent.

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

Autism

Down syndrome

Drug modulation of stress reactions

Mental retardation

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The possibility of comparing directly a group of psychotic Down children (PDG) with a group of psychotic non-Down children (PnDG), both tretaed by the same child psychiatrist, has already allowed comparisons of notable interest in epidemiology and clinical features (Cocchi, 1988), in the area of self-injurious behaviour (Cocchi & Bonaduce, 1988) and susceptibility towards upper tract respiratory diseases (Cocchi & Bonaduce, 1988).

On first consultation the proposal of drug treatment had been made in the case of every subject in the two groups, although not necessarily accepted for various reasons (Cocchi, 1990c).

I therefore considered it of interest to compare the results obtained with children whose parentó accepted the treatment set along the guidelines adopted (Cocchi, 1990c).

As for fuller information, the two groups will be described complete with all the psychotic children diagnosed as such on first consultation.

Materials and method.

All the clinical records of psychotic Down and non-Down subjects who consulted me between 1979 and the end of September 1990 were re-examined.

The records of all those over 15 years of age (180 months to be precise) on first consultation were disregarded, despite their being clearly autistic or suffering from a long lasting atypical childood psychosis, having considered this age as the conventional limit of competence as regards pediatrics anä child neuropsychiatry.

The reords selected were those in which the assessment carried out during the first consultation revealed the following symptoms, in differently composed combinations:

• social isolation;
• language regression, echolalia or other language impairments of psychotic nature;
• motoric stereotypes;
• sudden unmotivated anxiety;
• mood troubles;
• need for sameness;
• sensory hypo- hypersensitivity;
• self-injurious behaviour;
• gaze aversion;
• rituals.

Other information asked and noted: sex, age at firts consultation, chromosomal diagnose (for the Down subjects, and also for the other children, if performed); age at which the parents first noted the abnormal behaviour in their child.

Hallucinations, delusions, incoherence or marked loosing of associations were never noted down, either at first visit or during following consultations.

The diagnosis of early onset or late onset or atypical Pervasive Developmental Disorder was made according to the DSM-III, R (1987).

Results

According to the diagnoses made during first consultation, 2 groups of children records were assembled.

1. Psychotic Down children group (PDG).

Nr. of Ss	44 Ss = 100.00 %.
Sex:	M = 28 e F = 16
	M/F ratio = 175/100
Chromosomal anomalies:
Standard trisomy 21	42 Ss = 95.45 %
Translocations	0 " =  0.00 %
Mosaicisms	1 " =  2.27 %
Only clinical diagnose	1 " =  2.27 %
Average age at 1^st consult (years)	7;3 +/- 3;9
Diagnosis according to DSM-III, R
Early onset PDD	40 Ss = 90.91 %
Late onset PDD	4 " = 9.09 %

Table 1: Length of drug therapy in the PDG.

Subgroup	Nr. of Ss and %
0. Non started	8 Ss =  18.18%
1. from 3 to 6 months	3 " = 6.82%
2. from 7 to 12 months	5 " =  11.36%
3. from 13 to 24 months	10 " =  22.73%
4. from 25 to 36 months	8 " =  18.18%
5. from 37 to 60 months	6 " =  13.64%
6. from 61 to 84 months	4 " =   9.09%
Totals	44 Ss = 100.0 %

Table 2: results; keys: (-) worsening; (=) null; (+) slight improvement; (++) marked improvement; (+++) very marked improvement; (++++) normalized behaviour.

Order nr.	Isolat.	Linguage	Stereotip.	Sameness	Mood	Self-aggr.	Soc. bhv.	Learn. bhv.
Subgr.. 1
182	=	+	+		=	+	=	= (*)
353	+	=	+		+	++	+	+ (*)
455	=	+	=		+	++++	+	=
Subgr. 2
32	=	=	-	+	+		+	= (*)
34	+	++	++	+	+		+	= (*)
316	+	=	+		++	-	+	(*)
332	+	+++	=		+		++	+ (*)
430	+	++	++	++	++	+	++	++
Subgr. 3
124	+	++	+		ì	++	++	(*)
173	+	+	+		- (#)		+	= (*)
186	+	+	++		+	++++	++	+ (*)
289	+	+	+		=	=	++	= (*)
325	+	+	+		+	+++	++	+ (*)
330	=	=	-		+	-	=	+ (*)
333	+	=	=		-	-	+	= (*)
345	++	++	++	++	++		++	++ (*)
400	+++	+++	+++	+++	++		+++	+++
433	++	+++	++	++	+++	++++	+++	++
Subgr. 4
93	+++	++	+++	+++	++	++++	+++	++ (*)
101	++	++	+	++++	++		+++	++ (*)
120	+	=	++		++	++	++	= (*)
191	+	=	+	+	+	++	++	= (*)
225	+	=	=		+	++	+	+ (*)
281	+++	++	++		++		++	+ (*)
319	+	+	+	++	+	+++	+	= (*)
372	+++	+++	+++	++++	++++	++++	+++	++
Subgr. 5
49	+++	++	+++		+++	++++	+++	++
85	+	=	++	+	++		++	= (*)
242	++	+	++	++	++		++	=
268	++	++	++		++		+++	+
284	+++	+	++		+++	++++	+++	++
308	+	=	+	=	+	+	+	=
Subgr. 6
7	+++	+++	+++	++++	++++	++++	+++	+++
206	++++	+++	++++	++++	+++	++++	+++	++
217	++	+++	++		+	- @	++	+
226	+++	+++	+++		+++		+++	++

(*) therapy interrupted by the parents; (#) repeated episodes of manic excitment; (@) onset of severe aggressiveness against the mother.

2. Psychotic non-Down group (PnDG).

Nr. of Ss	29 Ss = 100.00 %.
Sex:	M = 16 e F = 13
	M/F = 123/100
Average age at 1^st consult (years)	7;5 +/- 3;8
Diagnosis according to DSM-III, R
Early onset PDD	19 Ss = 65.52%
Late onset PDD	3 " = 10.34%
Atypical PDD	7 " = 24,14%

Table 3: Lenght of drug therapy in the PNDG.

Subgroup	No. of Ss and %
0. Non taken	5 Ss =  17.24%
1. from 3 to 6 months	4 " = 13.79%
2. from 7 to 12 months	3 " =  10.34%
3. from 13 to 24 months	6 " =  20.69%
4. from 25 to 36 months	2 " =   6.90%
5. from 37 to 60 months	5 " =  17.24%
6. from 61 to 84 months	4 " = 13.79%
Totals	29 Ss = 100.00 %

Table 4: results; keys: (-) worsening; (=) null; (+) slight improvement; (++) marked improvement; (+++) very marked improvement; (++++) normalized behaviour.

Order nr.	Isolat.	Linguage	Stereotip.	Sameness	Mood	Self-aggr.	Soc. bhv.	Learn. bhv.
Subgr.. 1
F	+	+	=	+	+	=	+	=
M	=	=	+		+		*	=
F	+	++	+		+	++	+	=
M	=	=	+	=	+	++	=	=
Sottogr.2
M	++	+	++	+	++	++	++	+ (*)
M	++	++	+		++		+	+
M	++	=	+		++		++	+
Sottogr. 3
F (#)	+	-	-		++	++++@	-	(*)
F	++	=	++		++		++	+ (*)
M	+	++	++	++	++	++	++	+
F	++	=	+		++	+++	++	+ (*)
F	++	++	+	+++	++	++++	++	=
M	++	+	++	+++	++	++++	++	+
Sottogr.4
M	+++	++++	+++		+++		+++	++
M	++	+	++	++	++		++	+
Sottogr. 5
M	++	++	++		+	++	++	= (*)
M	+++	+++	++++	+++	+++		+++	=
F	+	+	++		++	+	+	=
F	++++	++++	++++		++++		++++	+++
F	+	=	=		+	=	+	+ (*)
Sottogr. 6
M	++	=	+++		+++		++	+
M	++++	++++	+++	++++	++++	++++	++++	+++
F	+++	+++	++++	++++	+++		++++	+++
F	+++	+	+++	++++	++++		+++	+

(*) therapy interrupted; (#) Rett's Syndrome (diagnosis made during the drug therapy); (@) it could be an outcome of the motory regression.

Table 5: comparison of the lenghts of the therapies

Field investigated	PDG / Ss nr.	%	PnDG / Ss nr.	%	% Diff.
0. Non started	8	18.18	5	17.24	- 0.94
1. from 3 to 6 months	3	8.28	4	13.79	+ 6.97
2. from 7 to 12 months	5	11.36	3	10.34	- 1.02
3. from 13 to 24 months	10	22.73	6	20.69	- 2.04
4. from 25 to 36 months	8	18.18	2	6.90	-11.20
5. from 37 to 60 months	6	13.64	5	17.24	- 3.60
6. from 61 to 84 months	4	9.09	4	13.79	+ 4.70

Table 6: comparison of the results" keys: (+) = improvement (any degree), (=) = null and (-) = worsening) according to groups and length of the therapy.

Group	PDG	PnDG	PDG	PnDG	PDG	PnDG	PDG	PnDG	PDG	PnDG	PDG	PnDG
Therapy mnts	6		12		24		36		60		84
Evaluation	+ =	+ =	+ = -	+ =	+ = -	+ = -	+ =	+ =	+ =	+ =	+ = -	+ =
Isolation	1 2	2 2	4 1 0	3 0	9 1 0	6 0 0	8 0	2 0	6 0	5 0	4 0 0	4 0
language	2 1	2 2	3 3 0	2 1	8 2 0	3 2 1	5 3	2 0	4 2	4 1	4 0 0	3 1
Stereotypies	2 1	3 1	3 1 1	3 0	8 1 1	5 0 1	7 1	2 0	6 0	4 1	4 0 0	4 0
sameness		1 0	3 0 0	1 0	3 0 0	3 0 0	5 0	1 0	3 1	1 0	2 0 0	3 0
mood	2 1	4 0	5 0 0	3 0	7 1 2	6 0 0	8 0	2 0	6 0	5 0	4 0 0	4 0
self.aggres.	3 0	2 1	1 0 1	1 0	4 1 2	5 0 0	6 0		3 0	2 1	2 1 0	1 0
social bhv.	2 1	3 1	5 0 0	3 0	9 1 0	5 1 0	8 0	2 0	6 0	5 0	4 0 0	4 0
learn. bhv.	1 0	0 4	2 0 0	3 0	7 3 0	4 1 0	5 3	2 0	3 2	2 3	4 0 0	4 0
% of +	.62	.57	.76	.95	.79	.86	.88	1.0	.88	.82	.97	.96
% of =	.38	.43	.18	.05	.14	.09	.12	0.0	.12	.18	0.0	.04
% of -			.06		.07	.05					.03

Table 7: comparison of % positive results when the improvement degrees are summed up [e.g.: (+++) + (+) = 4 out of 8] according to the length of drug taking.

Group	PDG	PnDG		PDG	PnDG		PDG	PnDG		PDG	PnDG	PDG	PnDG	PDG	PnDG
Therapy mnts	6			12			24			36		60		84
Isolation	.08		.13	.20		.50	.33		.42	.47	.63	.50	.55	.75	.75
language	.17		.19	.35		.25	.35		.21	.31	.63	.25	.50	.75	.67
Stereotypies	.17		.19	.25		.33	.33		.33	.41	.63	.50	.60	.75	.81
sameness			.13	.33		.25	.58		.67	.70	.50	.25	.75	.75	1.0
mood	.17		.25	.36		.50	.20		.50	.47	.63	.54	.55	.69	.88
self.aggres.	.50		.33	.13		.50	.46		.85	.71		.75	.19	.67	1.0
social bhv.	.17		.19	.40		.42	.45		.42	.53	.63	.58	.55	.69	.65
learn. bhv.	.08		0.0	.15		.25	.28		.25	.25	.50	.21	.20	.50	.50
%average	.19		.18	.27		.38	.37		.46	.48	.59	.45	.49	.69	.68

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 exclusively descriptive, so much so that for each case the clinical evaluation of the results has been reported here (Tables 2 & 4).

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 externaì observers (Bondanini, 1990; Grasso Rossetti, 1990) and one by laboratory parameters (Cocchi, 1990b).

As for the length of the drug therapies, for the many cases in which it was interrupted and the considerable number in which it was never started, I can only confirm here what has already stated elsewhere (Cocchi, 1990c).

The lack of results or the worsening of the condition, which oæ course can exist and are reported here, are not the main cause of this event.

The phenomenon is similar in both groups, as regards not starting the cure, but is much more evident in the PDG for its interruption.

It is possible, while on the subject, that the double pathological condition of Down's syndrome and psychosis, adds to the questionable external inflences a parental discouragement.

One child from the PDG and 3 from the PnDG came out of their psychotic state (the absence of at least one of the 3 chief symptoms: social isolation, language impairments, stereotypes, and a very marked reduction of the other two or the other one).

As is evident from table 2 & 4, the results are the outcome of therapy duration; at least 5 years in 3 cases and at least 3 years in the remaining one.

Table 6, in which the results are indicated along the lines of positive, null, and negative, is meant to show how already after a brief period of cure it is possible to see some improvement in the areas summarised, and how the number of positive results increase with the length of drug therapy.

Table 7, which shows the percentage of positive results evaluated taking into account the degree of improvement, confirms in no mean terms the relationship between these positive results and the length of therapy.

The results on the symptom "self-aggression behaviour" also termed "self-abuse" has already been the subject of specific research (Cocchi, 1990a).

Conclusion.

The hypothesis that it is possible to tackle the therapy of child psychosis as a stress response _therapy which can be improved through the use of drugs, does not seem lacking in empirical verification.

Eight years of experience in this field and the full application of this to 2 groups of psychotic children, one of which also affecteä by Down's syndrome, would seem to confirm its practicability, and the poor relationship between DSM-III, R diagnosis and therapeutic results.

Since however stress responses differ from individual to individual, and are dependent upon genetical and remote or recent acquired factors, any therapy tryinç to act on these can be nothing else than very personalised, according to individual variables present at the beginning and which modify, sometimes for the worse, during the cure itself.

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

Cocchi R.: Drug therapy in self-abuse behaviour. Proceedings of the VIIIth World Congress of Psychiatry, ICS 900, Elsevier, Amsterdam 1990a.

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

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

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.: 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. 1990, 3: 195-202.

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

41100 Reggio Emilia (Italy)

renatococchi@libero.it

Italian translation  // Testo in italiano 
Autism

Down syndrome

Drug modulation of stress reactions

Mental retardation

Home Page  // Pagina iniziale