CHILDHOOD PSYCHOSES: RESULTS OF DRUG TREATMENT

ON LANGUAGE DEVELOPMENT IN DOWN AND NON-DOWN SUBJECTS

Renato COCCHI, a neurologist and a medical psychologist

 

(Traduzione italiana)

Summary

After 3-106 months of individualised drug therapies, the results on language development of 37 psychotic Down children and 30 psychotic non-Down children were compared. The Down group (PDG) comprised 24 M and 13 F; average age at first consultation: 6 +/- 3;2 years; chromosomal diagnoses: 35 pure trisomy 21, 1 mosaicism and 1 not known; DSM-III, R diagnosis: 34 early onset and 3 late onset Pervasive Developmental Disorder.

The non-Down group (PnDG) comprised 17 M and 13 F; average age at first consultation 6;11 +/- 3;2 years; DSM-II,R diagnoses: 21 early onset and 4 late onset Pervasive Developmental Disorder, 5 Atypical Pervasive Developmental Disorder.

Results on echolalia, understanding simple and double commands, the use of new words, the correct use of pronouns and the ability to say "yes", the use of verbal language to ask and to tell. Significant results (p < .001) in the understanding of simple and double commands in both groups, but also in the use of new words in the PDG. All the remaining investigated fields of verbal language showed a trend to improve in direct proportion to the duration of the drug therapy.

Key words: Childhood psychoses; Down children; non-Down children; drug therapy; individualised regimen; language development; results.

 Autism

Down's syndrome

Drug therapy

Mental retardation

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One of the most severe symptoms in the psychotic child's behaviour is the inability to use verbal language for normal communication. This disorder can manifest itself in various forms: language may not yet have been acquired or may have regressed after beginning to develop precociously.

It may remain at a rudimentary stage showing particular characteristics (immediate and delayed echolalia, inability to say "yes", pronoun reversal, etc.). Then again it may be structurally correct but inadequate for communication, as in Asperger's Autistic Psychopathy.

Verbal language impairment is constantly present and the fact that gestual language is a poor substitute strongly suggests that the impairment is active in the areas of both comprehension and production.

Any therapeutical approach towards curing childhood psychoses cannot afford to ignore verification of the results in this area. The detailed evaluation of the results obtained following drug treatment of a group of psychotic Down children (PDG) and a group of psychotic non-Down children (PNDG) treated for various periods of time continues.

After a global comparative evaluation (Cocchi, 1990), specific comparative evaluation of social behaviour (Cocchi, 1991a), the outcome on school achievement (Cocchi, 1991b) and on motory and vocal stereotypies (Cocchi, 1991c), in this research the therapy's effect on "abnormal language" symptoms was examined.

As the therapies were individualised, as reported in previous articles (Cocchi, 1990b, Cocchi 1991a and 1991b), the statistical comparison is prevalently descriptive, and for this reason the clinical evaluations of the investigated behaviour or symptom in each single case are shown here (Tables 3 and 4).

The children making up the survey groups are those whose the parents accepted drug treatment administered along the guidelines already described (Cocchi, 1990d). 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, 1991a & 1991b), were re-examined. To the PnDG were added the records of one subject escaped the previous survey.

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 or behaviours were evaluated:

- echolalia;

- performs simple verbal commands;

- performs double verbal commands;

- pronoun reversal;

- says "yes", when he/she agrees;

- uses language for asking;

- uses language for telling.

The presence of the verbal symptoms or behaviours was scored, before and after a therapy period by means of a five steps scale of intensity as follows:

0 = symptom or behaviour not present;

1 = rarely present;

2 = moderately present;

3 = very present;

4 = always present.

This scale works from 4 to 0 as for echolalia and from 0 to 4 for the other verbal symptoms.

For each child were also noted:

- sex;

- age at first consultation;

- chromosomal diagnosis (for the PDG).

For the statistical analysis the tests of Wilcoxon and the Chi Square were chosen.

Results

The results, up to the end of August 1991, were reported on tables 1-6.

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

1. Psychotic Down children Group (PDG): 37 Ss = 100.00% .

Characteristics of PDG are:

Sex: M = 24 e F = 13; M/F ratio = 184.62/100 .

Distribution of chromosomal anomalies:

Pure trisomy 21: 35 Ss = 94.59% ;

Mosaicisms: 1 S = 2.70% ;

Not known: 1 S = 2.70% .

Average age at first consultation: 6 years with SD = 3; 2 years.

Diagnosis, according to DSM-III,R:

Early onset Pervasive Developmental Disorder: 34 Ss = 91.89% ;

Late onset Pervasive Developmental Disorder: 3 Ss = 8.11% .

2. Psychotic non-Down group (PNDG): 30 Ss = 100.00% ;

Characteristics of PnDG are:

Sex: M = 17 e F = 13; M/F ratio = 130.77/100 ;

Average age at first consultation: 6; 11 years, with SD = 3; 2 years;

Diagnoses, according to DSM-III, R:

Early onset Pervasive Developmental Disorder: 21 Ss = 70.00% ;

Late onset Pervasive Developmental Disorder: 4 Ss = 13.33% ;

Atypical Pervasive Developmental Disorder: 5 Ss = 16.67% .

 

Table 1: Comparison of the length of the therapies.

Group /length

PDG Ss

%

PnDG Ss

%

<>%

1. from 3 to 6 months

2

5.41

4

13.33

+7.92

2. from 7 to 12 months

4

10.81

7

23.33

+12.52

3. from 13 to 24 months

10

27.03

5

16.67

-10.36

4. from 25 to 36 months

8

21.62

3

10.00

-11.62

5. from 37 to 60 months

5

13.51

7

23.34

+9.83

6. from + 60 months

8

21.62

4

13.33

-8.29

Totals

37

100.00

30

100.00

0.00

Chi Square = 6.43 with 5 dfl.; .30 > p > .20; N.S.

 

Table 2: PDG, risults on verbal language, before (bef.) and after (aft.) therapy.

.

 

Echolaly

Performs commands

Uses new words.

Pronoun reversal

Says "yes"

Spontaneous speech

Group

 

simple

double

 

For asking

For telling

S. nr.

Bef.

Aft.

Bef.

Aft.

Bef.

Aft.

Bef.

Aft

Bef.

Aft.

Bef.

Aft.

Bef.

Aft

Bef.

Aft

Gr. 1. (3-6 months therapy)

 

182

4

4

1

2

0

0

0

2

0

0

0

0

0

0

0

0 (*)

353

3

3

1

2

0

0

0

0

0

0

0

0

0

0

0

0 (*)

Gr. 2 (7-12 months therapy)

32

0

0

1

1

0

0

0

0

0

0

0

0

0

0

0

0 (*)

34

3

2

1

3

0

1

0

2

0

0

0

0

1

2

0

1 (*)

316

2

2

0

0

0

0

0

0

0

0

0

0

0

0

0

0 (*)

332

2

1

1

3

0

2

0

1

0

1

0

1

0

3

0

0 (*)

Gr. 3 (13-24 months therapy)

124

1

3

2

4

0

1

1

2

0

0

0

0

0

1

0

0 (*)

173

3

2

2

3

0

0

0

1

0

0

0

0

0

1

0

0 (*)

186

3

3

2

3

0

0

0

1

0

0

0

0

0

0

0

0 (*)

289

0

0

1

2

0

0

0

0

0

0

0

0

0

0

0

0 (*)

325

0

0

2

3

0

1

0

0

0

0

0

0

0

0

0

0 (*)

330

2

2

1

1

0

0

0

0

0

0

0

0

0

0

0

0 (*)

333

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0 (*)

345

3

1

2

3

1

2

1

3

1

4

0

1

1

2

0

0 (*)

430

2

3

1

3

0

2

1

3

0

1

0

0

1

2

0

0

455

0

0

1

2

0

1

0

1

0

0

0

0

0

0

0

0

Gr. 4 (25-36 months therapy)

93

0

0

3

4

2

3

1

3

0

0

0

0

0

2

0

0 (*)

101

3

0

2

4

1

3

1

3

0

2

0

2

0

3

0

2 (*)

120

0

0

1

2

0

0

0

0

0

0

0

0

0

0

0

0 (*)

191

3

4

2

2

1

1

1

1

0

0

0

0

0

0

0

0 (*)

225

0

0

1

2

0

0

0

0

0

0

0

0

0

0

0

0 (*)

281

0

0

1

3

0

1

0

2

0

0

0

0

1

2

0

0 (*

319

0

0

0

2

0

0

0

1

0

0

0

0

0

0

0

0 (*)

433

3

1

2

4

1

3

1

3

0

2

1

3

1

3

0

2 @

Gr. 5. (37-60 months therapy)

85

2

3

2

2

2

1

2

1

1

0

0

0

0

0

0

0 (*)

268

3

1

1

4

0

1

0

2

0

1

0

0

0

0

0

0

308

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0 (*)

372

3

1

1

4

0

3

1

3

0

2

0

3

0

2

0

1

400

4

2

1

3

0

1

1

3

0

1

0

2

0

1

0

0

Gr. 6. (61-100 months therapy)

7

4

1

1

4

1

4

2

4

0

3

0

4

0

4

0

2 @

49

3

1

1

3

0

2

1

3

0

2

0

2

0

3

0

3

206

0

0

0

4

0

3

1

4

0

3

0

4

0

4

0

3 @

217

4

1

0

3

0

2

1

3

0

2

0

2

0

2

0

1

226

2

0

1

4

0

4

1

4

0

4

0

4

0

4

0

2 @

242

0

0

0

3

0

1

0

0

0

0

0

0

0

0

0

0

284

0

0

0

2

0

1

0

2

0

0

0

0

0

1

0

0

312

4

1

0

3

0

2

1

3

0

2

0

2

0

2

0

0 (#)

P

 

.06

 

.001

 

.001

 

.001

 

.06

 

.06

 

.06

 

.06

(*) therapy interrupted by the parents. (@) Not yet psychotic. (#) Case escaped the previous surveys.

Table 3: PnDG, risults on verbal language, before (bef.) and after (aft.) therapy.

 

Echolaly

Performs commands

Uses new words.

Pronoun reversal

Says "yes"

Spontaneous speech

Group

 

Simple

double

 

For asking

For telling

S. nr..

Bef.

Aft.

Bef.

Aft.

Bef.

Aft.

Bef.

Aft

Bef.

Aft.

Bef.

Aft.

Bef.

Aft

Bef.

Aft

Gr. 1. (3-6 months therapy)

 

F

3

2

2

2

2

2

2

3

2

2

2

2

2

2

0

0 (*)

M

3

2

2

2

1

2

2

2

1

0

1

0

1

1

0

0

M

0

0

1

2

0

1

0

0

0

0

0

0

0

0

0

0

M

4

3

1

3

0

1

0

0

0

0

0

0

0

0

0

0

Gr. 2. (7-12 months therapy)

M

0

0

1

2

0

0

0

1

0

0

0

0

0

0

0

0 (*)

M

0

0

1

3

0

1

0

1

0

0

0

0

0

0

0

0 (*)

M

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0 (*)

M

0

0

0

3

0

1

0

0

0

0

0

0

0

0

0

0

F

2

1

1

3

0

1

1

2

0

2

0

0

0

2

0

0

F

3

0

1

3

0

2

1

3

0

0

0

0

0

2

0

0

M

0

0

1

3

0

1

0

2

0

0

0

0

0

0

0

0

Gr. 3. (13-24 months therapy)

F (#)

0

0

2

1

1

0

2

0

0

0

0

0

0

0

0

0 (*)

F

0

0

1

2

0

0

0

1

0

0

0

0

0

0

0

0 (*)

M

0

0

0

2

0

1

0

2

0

0

0

0

0

0

0

0 (*)

F

0

0

0

1

0

0

0

1

0

0

0

0

0

0

0

0 (*)

M

0

0

0

1

0

0

1

2

0

0

0

0

0

1

0

0

Gr. 4. (25-36 months therapy)

17

4

1

1

4

0

3

1

4

0

4

0

4

0

4

0

3 @

18

0

0

1

3

0

1

0

3

0

1

0

2

0

2

0

0

19

2

1

0

3

0

1

0

0

0

0

0

0

0

0

0

0

Gr.5. (37-60 months therapy)

M

0

0

0

2

0

0

0

1

0

0

0

0

0

0

0

0 (*)

M

0

0

0

2

0

1

0

0

0

0

0

0

0

0

0

0

F

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

F

2

0

1

4

0

4

0

4

0

4

0

4

0

4

0

3 @

F

0

0

1

1

0

0

0

0

0

0

0

0

0

0

0

0 (*)

F

3

1

0

3

0

2

1

3

0

2

0

2

0

2

0

1

F

4

1

2

4

1

3

1

4

0

3

1

3

1

4

0

2

Gr. 6. (61-106 months therapy)

27

0

0

0

3

0

2

0

0

0

0

0

0

0

0

0

0

28

3

0

1

4

0

4

1

4

0

4

0

4

0

4

0

3 @

29

2

0

1

4

0

4

1

4

0

4

0

4

0

4

0

3 @

30

3

1

1

4

1

3

0

1

0

0

0

0

0

0

0

0

P

 

.06

 

.001

 

.001

 

.06

 

.06

 

.06

 

.06

 

.06

(*) therapy interrupted; (#) Rett's syndrome (diagnosis mmade during drug therapy); (@) not yet psychotic.

 

Table 4: comparison of the results on verbal language, according to the length of therapy; keys (+) = any degree improvement in at least two of the investigated areas; (=) = 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

4

7

10

5

8

3

5

7

8

4

Evaluation

+ / =

+ / =

+ / =

+ / =

+ / =

+/ =

+ / =

+ / =

+ / =

+ / =

+ / =

+ / =

 

Verb. languag

0 / 2

4 / 0

2 / 2

6 / 1

7 / 3

4 / 1

5 / 3

3 / 0

3 / 2

5 / 2

8 / 0

4 / 0

% of + results

.00

1.00

.50

.85

.70

.80

.62

1.00

.60

.71

1.00

1.00

 

Table 5: Comparison of the results achieved in single areas of verbal language, according to the length of therapy; 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 (max-min)

2

4 - 3

4 -3

7 - 2

10 - 6

5

8 -3

3 - 2

5 - 4

7 - 3

8 - 5

4 - 3

Evaluation

+ / =

+ / =

+ / =

+ / =

+ / =

+ / =

+/ =

+ / =

+ / =

+ / =

+ / =

+ / =

 

Echolaly

0 / 2

4 / 3

4 / 3

7 / 2

10 / 6

5 / 0

8 / 3

3 / 2

5 / 4

7 / 3

8 / 5

4 / 3

Und. simp.com.

2 / 0

2 / 2

2 / 2

7 / 0

8 / 2

3 / 1

7 7 1

3 / 0

4 / 1

7 / 0

8 / 4

4 / 0

Und. doub. Com.

0 / 2

3 / 1

2 / 2

5 / 2

5 / 5

1 / 4

4 - 4

3 / 0

3 / 2

4 / 3

8 / 0

4 / 0

New words.

1 / 1

1 / 3

2 / 2

5 / 2

6 / 4

4 / 1

5 / 3

2 / 1

3 / 2

4 / 3

7 / 1

3 / 1

Pron. reversal

0 / 2

1 / 3

1 / 3

1 / 6

2 / 8

0 / 5

2 / 6

2 / 1

3 / 2

3 / 4

6 / 2

2 / 2

Says "yes"

0 / 2

0 / 4

1 / 3

0 / 7

1 / 9

0 / 5

2 / 6

2 / 1

2 / 3

3 / 4

6 / 2

2 / 2

Asks

0 / 2

1 / 3

2 / 2

2 / 5

4 / 6

1 / 4

4 / 4

2 / 3

2 / 3

3 / 4

7 / 1

2 / 2

Tells

0 / 2

0 / 4

1 / 3

0 / 7

0 /10

0 / 5

2 / 6

1 / 3

1 / 4

3 / 4

5 / 3

2 / 2

% + results

.19

.35

.42

.43

.37

.29

.47

.74

.54

.58

.85

.71

 

Table 6: % comparison of positive results, according to the investigated area.

Group

Echolaly

Performs commands

Uses new words

Pronoun reversal

Says "yes"

Spontaneous speech for

Months of therapy

 

simple

double

 

 

 

asking

telling

6. PDG (2 Ss)

0

2

0

1

0

0

0

0

6. PnDG (4-3 Ss)

3

2

3

1

0

0

0

0

12. PDG (4-3 Ss)

2

2

2

2

1

2

2

1

12.PnDG (7-2 Ss)

1

7

5

5

1

0

2

0

24.PDG (10-6 Ss)

3

8

5

6

2

1

4

0

24.PnDG (5-0 Ss)

4

1

4

0

0

1

0

0

36. PDG (8-3 Ss)

2

6

4

5

2

2

4

2

36.PnDG (3-2 Ss)

2

3

3

2

2

2

2

1

60. PDG (5-4 Ss)

3

4

3

3

3

2

2

1

60.PnDG (7-3 Ss)

3

6

4

4

3

3

3

3

+60 PDG (8-5 Ss)

5

8

8

7

6

6

7

5

+60PnDG (4-3 Ss)

3

4

4

3

2

2

2

2

% of + results

.65

.81

.59

.65

.38

.35

.57

.22

.80

.87

.67

.63

.27

.23

.33

.20

 

Discussion

Bearing in mind that the therapies are individualised, as can be seen from the case outlined in detail (Cocchi 1990d), the statistical analysis, although more advanced, is mainly descriptive, so much so that for each case the clinical evaluation of the results has been reported here (Tables 2-3). It should also be noted that 3 cases of the PNDG and 1 of the PDG have been cited in other papers, and so 3 have also been evaluated by external observers (Bondanini, 1990; Grasso Rossetti, 1990; Cocchi, 1990d) and one by means of laboratory parameters (Cocchi, 1990a).

As far as the length of the therapy is concerned, regarding the many cases where it was stopped, I must confirm here what has already stated in the previ-ous research (Cocchi, 1990b); 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 significantly differs (Table 1). The effect that drug therapy has on verbal language in both groups seems to be dependent on the length of the therapy itself (Tables 4-5). It is as well to make this statement cautiously in the case of the PDG because the numerous interruptions which occurred in the therapy may possibly have singled out the better subjects whose parents felt more motivated to continue the treatment being undertaken. This caution is not so necessary when consider-ing the PNDG as there were fewer overall interruptions in treatment. The effect of drug therapy has proven to be statistically significant in the areas of execution of simple and double commands as well as in the use of new words as far as the Down group is concerned (Table 2). In the PNDG significance was only achieved in the case of execution of single and double commands (Table 3).

The overall percentage of positive results in tables 5-6 for echolalia have been calculated on the basis of the number of subjects in which that particular behaviour was present. according to tables 2-3.

However long the therapy was maintained, it did not produce results in every subjects (Table 4), and neither was the total erasure of echolalia always achieved.

The recovery and/or development of verbal language seems to be a difficult ob-jective to reach, particularly in its verbal production aspects. Here too we find confirmation that psychotic Down children show less overall improvement that non-Downs, or if they do improve, they do so at a slower rate (Table 4). This fact is in keeping with the finding that language development in non psychotic Down subjects is still a complex goal and not always reached (Buckley et al., 1986). From the results achieved we can suggests, for now, that the most frequent acquisition are those concerning comprehension of the spoken language, the use of new words and the use of verbal language for asking purposes.

Phenomena such as the correct use of "yes" and the use of language for telling seem to be complex abilities and therefore more difficult to recover. However, the fact that these also showed positive progress in the 8 subjects which came out of their psychotic states, leads us to deduce that the drug therapy administered needs further individualised specification and modification.

Conclusion

A comparative evaluation of the results of individualised drug therapies on the reduction of echolalia and on the recovery and/or development of verbal language in one group of psychotic Down children and another group of psychotic on-Down children has brought to light common elements of undeniable interest.

The results seem to run parallel to the length of time the therapy was undertaken. The reduction of echolalia and improvement in the various aspects of verbal language investigated show similar trends in both groups.

The improvement rate, slower in the Down children, must be considered in the light of the usual difficulties they encounter in verbal language acquisition even in the absence of childhood psychosis.

Acknowledgement

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

References

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Printed on It. J. Intellect. Impair. 1991, 4: 167-174.

 

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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