A CASE OF
DYSLEXIA IN A SCHOOL AGE BOY:
A TRIAL WITH DRUGS FOR 44 MONTHS. Renato COCCHI,
neurologist and medical psychologist
Other two cases treated by drugs
Summary
It is extensively reported a case of dyslexia, diagnosed in a boy of 10 years,
depressed, treated by polydrug therapy (glutamine, vitamins of the B group,
carbamazepine and diazepam), lasting three years and eight months, with total
disappearance both of the depression and of the dyslexia.
The
analogy and differences between this treatment and the American use of the
piracetam, as specific drug for the dyslexia, are specifically pointed up.
Key words: Dyslexia;
depression; drug therapy, GABA. glutamine, stress.
(Italian translation / traduzione italiana)
During the recent VIII World Congress of
Psychiatry, held in Athens on October
1989, among interesting new reports that
have gone around, one referred the favourable effect of the piracetam on the
dyslexia.
Since even I
had an experience of treatment with drugs in a boy with typical dyslexia, I shall report it here, for
various reasons too. First because it is commonly
thought, in Italy, that the dyslexia cannot be treated by drugs. On the other
hand, because the pharmacological approach, as I tried, although more complex
than that American is, goes exactly in the same direction, and it has many links with it. Finally because, as the piracetam treatments
have shown, it represents the logical following of a commonly admitted fact by
now, which is to say that a whole series dyslexia cases have neurobiogical
basic components (Duffy et al., 1980; Galaburda et al., 1985).
So, an attempt of
a biological treatment should be the more linear approach, even if not an
exclusive one.
The dyslexia.
We can define the dyslexia as a specific
trouble of reading where it is deficient
the integration between two necessary processes for the contemporary phonetic
and semantic decoding of the graphic symbols (Levi and Piredda, 1982 ).
This double
operation, which works in correct reading, allows on the one hand to convert
the written sign (or "grapheme") into the corresponding sound (or
"phoneme"). That occurs singularly, letter by letter, but even in
sequence, when it happens that the phoneme corresponds to many graphemes
(Eg., as for Italian: The hard c
and hard g, sc, gn, gl sounds
before to the vowels e and i) and in the words too.
Contemporarily
however a second process becomes activated and it is to advance semantic
hypotheses on the read words and to verify if the hypothesized word is
congruent with the read word. The
failure of one or both these processes gives the rise to dyslexia, which is frequent among all
populations where the discrepancy between written language and speech is larger
than occurs in the Italian language.
The typical errors
of the dyslexic person depend from troubles in these two processes. As for the Italian language, the phonetic
errors, by confusing among graphically equal letters, but with different
orientation on the space ( p, b, d, q; u, n ) or by alteration of the
sequence (capra - carpa ie. A goat - snatches) or by condensation (birillo-billo,
ie. A ninepin-nipin), depend from the
correct operation of the first mechanism of decoding.
The meaning errors
come when the substituted word has some somehow link in meaning with the true
meaning ( Eg., dog-cat). Mixed errors appear when the read word comes
out from a double - phonetic and semantic - error ( Eg., litre becomes lemon,
because, in Italian both start with the syllable li, as in litro
and limone).
We may surely speak of dyslexia if this type of
error persists after two years of learning of the reading ( According to
Debray-Ritzen, 1987, straight after one year ). Close to the reading trouble, often a trouble
of the writing appears too (bad-handwriting) which has similar features.
As for other
concomitants, as Bauduin and Geubelle reported (1980), the World Federation of
Neurology, in 1968, defined the dyslexia as
a trouble that presents reading
difficulties, in spite of exact teaching, enough favourable intelligence and
favourable social-economic background. Using these general premises to frame the
features that identify the dyslexic trouble, I will introduce now the clinical
and therapeutic history of a form of it
I casually treated, during my teaching,
childhood depression drug therapy.
The case history.
This boy came to
consultation when he was 10 years eight months old, in 1984. From the province
of Siena, he was referred to me by a speech therapist who had attended the
specialization course for support teachers of disabled children, I held in the
Urbino University.
He showed were
typical symptoms of dyslexia, and he had speech therapy by the person who
addressed the boy to me, with poor results. She
addressed him to me not because I had to treat the dyslexia, but for the evident
aspect of depression, a topic I extensively
lectured during my course. She
needed a great deal of time to convince the parents to undertake this
resolution. Even in the following of the treatment they will hold carefully
hiddenly to anybody, and even to the school, that their child was doing a drug
therapy.
The first
examination, in October 1984, took room when the boy had passed in the 5a
elementary class. He had already lost a scholastic year. Besides the dyslexia and the anorthography
symptoms, were then noted: In his past
pathological history:
- A
perinatal suffering, with intra-brain haemorrhage;
-
Convulsions in his second day of life;
- At the age of
six years, the EEG showed still a right parietal irritating focus.
Then no neurologic
problems persisted, and I did not detect
any visual or auditory trouble. The
symptoms of an evident childhood depression (Cocchi, 1985 ) were:
- A tendency
to the timidity and to the social isolation;
- Mood
variation, being better in the afternoon;
- Quite
childish behaviour;
- Difficulty
in falling asleep;
- Episodes
of sudden colic pain, with the need to approach immediately to the rest room;
- Days of
pallor;
- An abnormal sensitivity to cool.
Besides these symptoms
I wrote: Stuttering in past, and sometimes even to the present, wrinkled skin,
attributed to an allergy, allergic rhinitis and asthmatic bronchitis.
Therapy
prescription (daily doses): glutamine: 250mg; vitamins B1: 125mg; B6:
125mg; B12: 500mcg; tochopherole 50mg, carbamazepine 50mg; diazepam 1mg.
Five months later, in March 1985, I wrote in
his clinical report: He succeeded to read little better, improved even at
school, with fewer spelling mistakes. Now his thought is more logical. He has
grown in height. He nearly missed his allergies. Still difficulty in falling
asleep. Nearly missing the colic pain. He
had a month when stuttered, but either rhinitis either bronchitis disappeared.
In therapy I
modified the dosing of glutamine (375mg) and of carbamazepina (100 mg), and I
added 5-HTP (50mg ).
In July 85, during
the second checkup the parents reported: Definite school improvement, he overcame deservedly the examination for the
elementary school license. His reasoning is more suitable to his age.
The reading
improved, he has grown in height and now he has less inhibition. The skin
allergy went off. His falling asleep run better, no more colic pain, no more
stuttering. He caught two bronchitis in the winter season. As for his health,
he did better, with more appetite. More calm, at home.
Glutamine
reduced to 250mg and carbamazepina to 75mg, the 5-HPT stopped, the vit.
B1-B6-B12 were substituted with a polyvitaminic with even Vit. PP, pantothenate, vit. B2 and C (Berocca TM).
Fourteen
months later, in May 1986 I noted: The
stuttering disappeared, the reading still improved, the ability to reasoning is
decidedly more age-related. Some spelling mistake did remain. He doesn't
summarize well because he loses the
general picture. He has still some memory difficulties, also in English.
Allergies came again, and in last 20
days he suffered from two asthmatic fits. Since three-four months he has not
easiness to fall asleep, and since one moth ha became again constipated.
Currently his appetite is lacking, with several days of headache. Altogether he
is more serene and calm, at school he works better. Much improved the
relationship with his peers.
The 5-HTP ( 50 mg
) is again prescribed.
Checked again after
13 months, in June 1987. at school he goes well, his reading is good, mainly
when he reads quietly; now can summarize well. His composition goes better,
with rare spelling mistakes, his thought is more mature and age-related. The memory improved, as his ability in the
English language. He had the junior high school license, and he wants to enter
a technical institute, following the suggestion of his teachers. Appetite,
sleep and bowel function normalized; Even his healthy state runs better, not
more headache and asthmatic attacks. Calm and calm, he optimized his
relationship with the peers.
This was the last
checkup I did. I left him with the
recommendation to put forward the drug
therapy for one other school year, and then to stop it. He should come again
for a checkup only if in need, but 22
months later I did not have any information. For which I must suppose that all
is going well, even without any treatment, interrupted at least since June 1988.
He took the drug therapy three years and eight
months to the maximum, and his whole personality benefitted of it while the dyslexia disappeared.
Discussion.
There are various
considerations to do on this history. The
dyslexic phenomenon had a nearly sure base in a brain dysfunction from previous
brain haemorrhage, which had given even
convulsions and a still altered EEG, when the boy was six years old. We deal with events reported in the
literature on the dyslexia as possible precedents.
On the diagnosis,
no doubts I had about, either for the
typical case history, either because made independently by two different
professionals, one of them working as speech therapist. Moreover, the boy did reach any improvement following a therapy
based on learning. The
depressive picture, which drove to the drugs' choice, could even be considered
as the result of the school difficulty, and so as a secondary depression of
relational origin.
The perinatal
history did mainly think to a primary depressive component with biological origin. Then, the prescribed therapy, over to act
on the depression, and on the well-being, has even cleared up the dyslexia and
the accompanying anorthography. It was an unexpected result, although already
appeared clinical trials in favour of using piracetam in this reading
trouble (Wilsher, Atkins and Manfield,
1979; Volavka et al., 1981; Simeon et al., 1983; Conners and et al., 1984;
Chase et al., 1984; Helfgott, Rudel and Kriegel, 1984; Rudel and Helfgott,
1984).
All intellectual
abilities generally improved, so to allow a normal attending to the junior high
school and the suggestion to go on with studies, a fact that I must suppose is
going to a good end. As compared to the piracetam therapy, this
prescribed here is much more complex, specifically acting on: A GABAergic
inhibition; B GABAergic inhibition; synthesis of the GABA; synthesis of the
serotonin; reduction of a possible glutamate hyperfunction (Loescher, 1980;
Ebadi, 1981; Cocchi, 1985; Cocchi, Patrucco and Zerbi, 1987; Crowder and
Bradford, 1987).
The piracetam, in
its turn, is a quite physiological compound, with a molecule composed by the
amide of cycled GABA that, in this form, succeeds to cross the blood-brain
barrier (Sivadon and De Buck, 1972). Its
central action is not still entirely known. Someone affirmed that it favours
the transfer of the information between
the two half-brains, and its behavioural correlates (Buresova and Bures, 1976). As
for the restoring of the reading ability, although of the piracetam intake for
a whole school year has led to statistically meaningful results, as compared to
the placebo (Conners and Reader, 1987 ) it never drove to the disappearance of
that symptom. The lack, either for the reading accuracy either for the
comprehension, was always equal to two school years ( Conners and Reader, 1987).
We may ask if the result of total remission in
this case is i. an exceptional event; ii. or creditable to the greater therapy
duration; iii. or to the more adapted therapeutic prescription. We
may exclude the first hypothesis, because the progresses Conners and Reader,
1987, elicited do parallel what obtainable from normal subjects in a school
year (and a divergent course, in comparison with those obtained in dyslexic
children, when treated with the placebo).
If the variable
"therapy duration" were meaningful, we must have even a convergence
with the progresses obtainable in normal subjects, after one year of teaching.
Now, given that the results of Conners and Reader, 1987, are similar to those
reached by other researchers who took
part to this multicentered investigation (Wilsher, 1987), the reasons to refuse
the second hypothesis are rather
substantial.
The single case
study, for its nature, doesn't allow
univocal conclusions, even if, as ours, it is well inserted in the same context
(a dyslexia in a subject with certainty past difference in functioning between
the two half-brains, non-responder to traditional therapy) like the cases treated with piracetam.
From an other
point of view, we should ask now what should have been the future of this boy,
if he were abandoned, since the traditional therapy shown was impotent to
resolve his trouble. Certainly he would have had the
junior high school license, but he would have perhaps needed some years to get
it.
Surely the teachers
would not have recommended going on with the studies in rather binding school,
as the technical institute is. The
depression, the self-esteem loss, the poor relationship with his peers would
have been left, as the dyslexic and the anorthographic troubles too.
Which followings
would have had a similar result on the family atmosphere and on the adult life
of the boy, given the close bonds, seen at least retrospectively, between
reading difficulties and future psychiatric troubles (Kavanagh et al., 1980)?
This was a lucky
boy, because he has profited of a series of propitious circumstances: A speech
therapist aware of her limits and not only prone to admit her professional
impotence, but even to recommend the parents an alternative solution, for the
treatment of their son; Parents that were not terrified from uncritical
stupidities on the famous psychodrugs toxicity, and then decided to try, and
waiting no definite results in a month;
An expert that was using marketed drugs, according to a different hypothesis,
with low dosing and prevalence of physiological compounds.
As for the
parents, I think that their virtue has been a little casual. By wishing to
hide the fact that their son had
currently a drug therapy, they always bought drugs directly in pharmacy,
avoiding so the possible by ear
criticism of some family physicians or misinformed pediatricians.
How many cases that instead don't profit of similar propitious circumstances?
Many, as I can understand from the applications that I get about adolescents,
with even more heavy problems, for which unfortunately the better time to face them passed. In
all that, a misinformation or a refusal
to give a correct information for role jealousy, - I am referring to some
pediatricians, child neuropsychiatrists, psychologists and technicians of the
rehabilitation -, has serious responsibility, because are playing on the skin
of these children and on that of their families.
In this bad history, the teachers, and mainly the support teachers,
may have a positive role, if not other because in interest conflict. Even now
they become loaded of often impracticable tasks, and of moral responsibilities
that are not theirs. It
doesn't exist only the psychological approach or the pedagogical one, but even
the biological one.
To face such
troubles it is often the essential
premise for other interventions, which, anyhow, are not excluded neither
hindered in any way. Today, the biological approach is
not only possible, but is always more becoming the first choice in many fields
that, till recent times, in Italy, were thought exclusive dominion of the
psychology or the pedagogy and the dyslexia is an exemplary paradigm (Wilsher,
Atkins and Manfield, 1985; Helfgott, Runel and Kairam, 1986; Tallal et al.,
1986; Conners et al., 1987; Helfgott et al., 1987; Conners and Readers, 1987;
Chase and Tallal, 1987; Levi and Sechi, 1987; Wilsher, 1987).
Only an integrated
vision may allow, since now, fully or
partly to operate in a series of pathological situations that otherwise will
become chronic. Not only so, but they cannot be restored and are destined to
get further suffering to the child as the carrier, and to his parents.
Other
two cases treated by drugs
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Printed in Italian on Riv. It. Disturbo
Intellet. 1990, 3: 159-165. On Internet in November 2002.
Author's address: dr
Renato COCCHI, via Rabbeno, 3
42100 Reggio Emilia (Italy)
renatococchi@libero.it
Testo in italiano