DRUG THERAPY IN AN AUTISTIC CHILD OF 7 YEARS AT THE FIRST CONSULTATION:
THE UPDATED CASE HISTORY (Updated October 2007).
Renato
COCCHI, a neurologist and medical psychologist.
Summary.
It is
reported the case history of 48 months of antistress drug therapy (with
carbamazepine, pyridoxine, glutamine and a benzodiazepine ) in an autistic
child of seven years and four months at the first consultation. The
development's disorder is suggested as a catastrophic reaction from internal
stress, with the consolidation of the brain functionality to a level, fitting
the unbalance of her brain neurotransmitters.
The
autism was typical (DSM IV: F84.0) with previous regression even of the
language on about the three years. The patient was born premature at 36 weeks,
with caesarian section for maternal blood hypertension. He had neonatal
respiratory distress. In the first year life, he was constipated, pale, cried
for no apparent reason, and started to catch illnesses from cooling (four
stress symptoms). Walking and language came out late.
A
hyperkinetic syndrome, treated with amantadine, was also found.
Now
there are evident improvements as for sociability and the scholastic behaviour,
the motor hyperactivity reduced, but less for motor stereotypies, and the
language passed from the vocalization to some word-sentences.
Key
words: Autism, child, male, stress, drooling, masturbation, squint, drug
therapy, glutamine, pyridoxine, carbamazepine, benzodiazepine, amantadine,
clonidine, results.
Autism
Drug
modulation of stress answers
Home Page / / / Pagina iniziale
In this
site <Www.stress-cocchi.net> I posted primarily theoretical articles (
Cocchi, 1990c; 1996b), or about epidemiological statistics, or of comparison (
Cocchi, 1989; 1990d Cocchi; 1991a; 1991b; 1991c; 191d), or survey reports of
autistics who became adult (Cocchi, 1994; Cocchi, 1995). Previously I carried
out other theoretical studies (Cocchi, 1988a; Cocchi, 1992a), epidemiological
and comparative research (Cocchi and Bonaduce, 1988b; Cocchi and Bonaduce
1988c) and even reports of single cases (Grasso Rossetti, 1990a; Cocchi, 1990b;
Cocchi, 1990e; Cocchi, 1991e; Cocchi, 1992b; Cocchi, 1993; Cocchi and Carbone,
1993; Cocchi, 1995b; 1996a Cocchi; 1996c).
In spite
of being published, I wanted not to post even the case histories of single
autistic children treated with drugs. I always preferred to post in Internet
the treatments of groups, with statistical analysis.
The case history.
A child
of 7 years and 4 months to the first consultation. He comes from
When he
was about three years, he spoke, then he regressed and now he does not have
anymore the verbal language either expressive and receptive. He is doing
psychomotor rehabilitative therapy and speech therapy with very poor results,
if not null. He is attending the first class of the primary school, where he
has a support teacher and an assistant.
September
2003, the first consultation.
Autistic
symptoms: His behaviour and his history are typically autistic. He shows hands'
stereotypies, needs to hold always some thing in hand, beats with his hands on
the objects. Rocking frequently appears, and he has an alternate side version
of his head. He has the habit of ribbing some paper into narrow strips, which
then waves before his right ear. Often close his ears with his hands, as if
wanted to decrease the environment's sounds. When he is boring or has temper
tantrums, he reacts with self aggression by biting the index of his left hand
(fewer times, he does it on the right index). The left finger shows an evident
callus. Gaze aversion is frequent behaviour, as well as tiptoing. His social
isolation with adult and children is evident.
With his
parents, to times he shows as affectionate. "He seems to live in a full
own world", says his mother. Poorly present difficulty or adaptation
refusal to new situations (sameness). He doesn't look for light stimulation,
sometimes stimulates with his flat hand the mouth internal surface. The
language is limited to some vocalization.
Stress
symptoms: Daily bruxism occurs, but not frequent; he has oversweating; he is
indifferent to warm and to cool. Some days he has some pallor with eye sockets.
In the morning he doesn't want to eat. He inclines to not appreciate sweet
foods, while he likes the meat broth. He indulges in the masturbation for
manipulation, and so he is reaching the orgasm.
Sometimes,
when he is tired or more nervous, he reacts by weeping.
Other
symptoms: He sleeps well, with some awakenings, and without bedwetting.
Usually, he sniffs the things he has to eat. Usually he brings to his mouth any
object. Paresthesias to the nape do not occur. He is afraid when he has to go
down the stairs (Fears he the void?). Hyperkinesis is evident.
Pathological
remote history: The mother has suffered from blood tension increasing in the
last month of pregnancy. The delivery was with caesarian section, for the
appearance of maternal hypertension.
Premature
born at the 36th pregnancy week, his birth weight was
Test
therapy (daily doses, by the oral via): Glutamine 125mg; Pyridoxine 75mg;
Carbamazepine 50mg; Diazepam 0.6mg; Amantadine 50mg.
January
2004, the first checkup after 93 days of drug therapy. As for the parents, he
changed in better. Now, he is more quiet, more calm, with more attention to
what happens around him, and he bears more the others watching at him. Even at
school the teachers observed some positive changes. Since last December he is
more troubled and he has self aggression. Now he usually cries, when he comes
back from the school. No toe walking occurs. Masturbation decreased. Sometime
he wakes still at night, 1-2 times in a month.
During
the day, he eats a few, and in the morning he doesn't want to eat anything. Perhaps
he is less pale, but surely less oversweating. To bring objects to his mouth is
going on. The hands' stereotypies unchanged. He is less closing his ears with
his hands. The bruxism stopped. The rocking is decreased. Even the relationship
with his peers improved.
Therapeutic
variation (daily doses, by the oral via): Amantadine 100mg; Diazepam 1mg;
Carbamazepine 100mg.
End April
2004, the second checkup. Since 15 days he restarted to bite the indexes, so
the checkup was advanced. Still, motor stereotypies occur. Now, he is more calm
and more paying attention. At school the teachers found him better. He bears
more the direct look and he observes more. No more toe walking was shown. The
masturbation is nearly missed. At night he has a continuous sleep. His face is
more rosy, even if he has still some days of pallor. Usually he is eating more,
even in the morning. Perhaps he is less oversweating. Perhaps he has less the
habit of putting objects in his mouth. Now, he closes less the ears.
The
bruxism stopped. The rocking reduced, (he lifts a little with his bottom, then
he sits at a hit, which probably is a form of rocking). He is much more
affectionate, but does not look for much to be patted. At school he stays more
with his classmates. The language did not vary, but he does a kind of
continuous complain. He moves the head before-back and from one side to the
other. He has serious atonic constipation.
He
attends gladly the school and does it to be understood. Never he has pointed
out one classmate. Now, he is more serene but in the church he finds himself
worse. At the supermarket he takes the commodities and puts them into the cart.
He has become taller. He doesn't appreciate much to have washing and combing.
When he has his hair dried with the hairdryer, he bears it better. Now, he has
become touchy and does labour to accept the reproach, because he became more
sensitive and reacts by withdrawing or crying. As for his health, he did well
with some cold and some days of flu.
Therapeutic
variation (daily doses, by the oral via): Glutamine 250mg; Diazepam 1.2mg;
Clonidine 0.037.5 --> 0.075mg.
Half
September 2004, the third checkup. He gives many pinches to his father. As for
motor stereotypies, now he goes on sometimes, but altogether their frequency of
them reduced. Sometime he bits his fingers. He abuses much his genitalia. He
inclines more to try to speak. Usually, he has much hunger. The attention
increased. Sometimes, he is a little boring, is more touchy, and he looks more
in the others' face. The sameness did not be ever a problem. Toe walking did
not reappear. His sleep does not show any waking. Not always he has breakfast.
Some moments, he can stay at rest.
He puts
always things in his mouth, perhaps lesser, and he closes less his ears. The
bruxism seems definitely missing.
Rocking
unchanged. Affectionate. His tears go down to him as the last checkup. The
language seems little developing. He does always the whining and is Less
constipated. He attends gladly his school, but he doesn't point up his classmates.
Now, he takes for hand the older persons. Now, he rests more into the classroom
and he works all the time. He became taller, his mother observed it on the
suits. Washing and combing him is always difficult, but his hair can be dried
easily. As for his health, he did well. His face is more rosy. He sweats when
he forces himself to do something.
Current
therapy (daily doses, by the oral via): Glutamine 250mg; Delorazepam 0.5
-->0.4mg; Clonidine 0.075mg; Carbamazepine 100mg; Amantadine 150mg; Pyridoxine
75mg.
Half
December 2004, the fourth checkup. He stopped to give pinches to his father.
Drooling reduced after diminution of the delorazepam daily dose. Sometimes he
bites his fingers, usually soon after the dinner. Never he does it at school.
The masturbation decreased. In the morning he doesn't want to have breakfast.
His attention improved. Now, he looks at the other's eyes. At school the
teachers found him as improved in the concentration. He is less boring. Now, he
wants much to play. The rocking did not change as for the movement to get up a
little on the chair and to leave him gone.
Sometimes
he wakes at night. He does some games with his fingers, but not always as
stereotypies. He did not stop the habit to bring objects to his mouth, even if
he does it lesser. Now he is little more calm. Constipation still occurs,
usually of spastic, sometimes of atonic type. He stays more with the other
children. Vocalization increased, but the lallation came out. Less grumbling.
He bears more to be washed and combed. The parents did not observe him who
closes his ears with his hands. As for health, he did well with an only short
lasting cold. His appetite is good but he is hyponeophagic and refuses to eat
the fish.
Therapeutic
variation (daily doses, by the oral via): Delorazepam 0.3mg.
Beginning
April 2005, the fifth checkup. Still improved, he pays more attention and
learns at once. The teachers of the second year of the elementary school found
him much changed. The behaviour in the classroom improved and now he closes the
door when it is even open. As for the masturbation, it has some times, and he
reaches the orgasm. Stereotypies also occur, that of the chair and rocking too,
which reduced if the child is distracted or busy. At home, about the evening, some
time he bites his fingers.
He is a
little aggressive with the children with whom he would like to play, and these
withdraw. As usual, he doesn't want to have breakfast. He has irritability
moments. Towards evenings he whines, but that reduced much. Now, he can sit at
the table during the whole meal, and he succeeds to sitting for 10-15 minutes,
in front of the television, when he watches at cars' or motorcycles' races.
Once for
each night he wakes for going in the bathroom, and has rarely bedwetting. Always
he brings some objects to the mouth. He puts his flat hand till the throat,
then the sniffs it. Now he is little more calm.
Heavy
constipation persists, mainly in this springtime. Surely he is more sociable.
In the evening, after he has taken the therapy, he much sleepiness, Now he let
him well washed and bathed. As for his health, he is doing well. In this time,
he closes more the ears. There is always labour to taste a new food. Among
fishes, he eats only canned tuna. At school he remains seated in his place. The
language does not overcome the vocalization and the lallation. Some time sings
softly, but less. His face is more rosy. His mother denies having seen days of
pallor. He is more sensitive and touchy, more affectionate, and more smiling.
Therapeutic
variation (daily doses, by the oral via): Amantadine 200mg; Glutamine 125mg;
S-adenosil-l-methionine 100mg.
Beginning
July 2005, the sixth checkup.
He
improved. Perhaps he says AO for CIAO, and he modulates the vocalization and
can sing in the same tune way he has heard it. He was much calm. Now he is more
affectionate and answers by caressing to the caresses. His face is rosy, and he
did not show any day of pallor. Surely he understands the simple orders. He
observes more and he looks more. If his mother reproaches him, he assumes a
look counteractive.
This
year, by the sea, he wanted to go less in the water but to stay more with other
people on the beach. Usually, he sleeps well all the night. He eats fruit and vegetable.
Now he is not more aggressive towards his parents, to whom he doesn't give any
pinches. He spends more time without his "transitional" object.
Lately he had some constipation.
Hands'
stereotypes persist. The rocking diminished. When he is has on her father car,
some head banging episodes occur. Any masturbation, but he persisted still in
beating his breast, behaviour not decreased in the three past months.
He put
still his fingers into his ears. In the last week he had some nervousness. He
inclines to get away the little crusts on his skin, till to do bleeding. Lately
he had a period of constipation.
Therapeutic
variation (daily doses, by the oral via): Retinol acetate 35000UI; delorazepam
0.5mg.
End
November 2005: The seventh checkup.
Motility: There are still
motor stereotypies. He sucks his forearm back, at the level of the wrist, from
both sides. The self-aggression is subsequently diminished. Skip about of less
on the chair, with his buttocks. The masturbation reduced. He uses to remain seated
on the ground.
Language: He vocalizes
always much and frequently repeats some syllables (ie. the lallation).
School
behaviour: At school the teachers see him better. When he goes out of the school
he is troubled [excited?]. The classroom behaviour improved and he pays much
more attention.
Home
behaviour: Now, he obeys more. He is not more counter aggressive against his
mother, and he has become touchy. Even against his father he stopped aggressive
behaviour. He inclines to sniff his fingers, after having put them in his
mouth. In the car, he wants to seat in the front, and has stopped head banging.
Hew has always a transitional object. Now he used to throw objects on the
floor.
Other: At night he
sleeps well. In the mornings, nine times out of ten he has breakfast. His bowel
function is much constipated. His health is going well, he had only some cold.
Current
therapy (daily doses, by the oral via): Glutamine 125mg;
S-adenosil-l-methionine 100mg; amantadine 200mg; carbamazepine 150mg; clonidine
0.075mg; pyridoxine 75mg; clonazepam 0.5mg.
First ten
days of May 2006, the eighth checkup.
Presumably
psychotic symptoms: He shows still motor stereotypies and the
transitional object, but perhaps they are less insistent. He skips about on the
chair with his bottom, as first, with equal frequency and length. No more gaze
aversion occurs. Self-aggression reduced, but has some aggression in the game
(he doesn't understand that it may hurt the other one). Till now, he sniffs
always the fingers, after having put them into his mouth. He is more present,
and he doesn't give any problems when we are going out. Now he understands the
simple orders and some double order. Usually, he mumbles much more as if he
wanted to say something: Perhaps he uses "ao" for saying "ciao".
It happens more in the afternoon.
Inadequate
behaviour: The masturbation is practically stopped, and he sucks much less the
back of his forearm. Even now, he puts in his mouth many objects. When he is in
the car by sitting forwards, he has not head banging. He throws fewer objects
on the ground. Sometimes his inferior limbs are a little rigid. When he comes
out from his school, he is much vivacious, but not angry. Some days he has some
pallor, but fewer eye sockets. He inclines to stay seated on the floor.
Mood: He
has become touchy, and he doesn't smile more, but sometimes he laughs for no
reason. He is more happy with his father.
Adjustment
to the environment: He pays more attention, and obeys much. At school he
increased attention and he may learn more quickly. He does difficulty to set
the photo of the object on the related object, while the contrary succeeds
well. As usually, he always listens to the music. Of television programs, he
likes cars' and motorcycles' races. Now he identifies well the persons.
Other: He sleeps well at
night. In the morning, he has always breakfast. Still, spastic constipation
occurs. In the winter season, he had some cold. The squint is missing.
Therapeutic
variation (daily doses, by the oral via): Clonazepam 0.7mg.
Third ten
days of August 2006, the ninth control. The child improved.
Presumably
psychotic symptoms: Motor stereotypies still occur. He skips about on the
chair with his bottom, as first. The gaze aversion is now much rare, and during
the consultation he has long maintained the eye contact. He puts less his
fingers into his mouth, and then he sniffs them. The transitional object is
always kept. Self-aggression reduced, but he shows a little more aggression. He
would like to play with others children, but perhaps he does them pain, and the
mother refrains him.
The
language: He sings softly. His understanding is not varied. Now, he starts to
say his name, even if pronounces it with a little volume of voice. He says
"Yes". In the evening he "mumbles" more.
Inadequate
behaviour: He is much vivacious. Usually he puts the objects in his mouth, as
first or throws objects in the floor as first, but now he picks up them.
Laughing for no reason occurs as he did habitually. In the car, when he is
sitting backwards, he moves much his head for no reason, but when he is sitting
of beside the driver, his head is not in motion. He inclines to be in the
floor, as first. The masturbation disappeared. Perhaps he shows less pale, but
he has always eye sockets. His legs incline to be hypertonic, as first.
Adjustment
to the environment: He is more prone to obey. Out of his house he behaves
well. On television he wants to see car and motorbike racing.
Mood:
Calm. He smiles as first. He is happier with his father. Now, he has become more
touchy. By the sea he is well off, and likes to be in the water.
Cognitive
abilities: Now he combines the photo to the respective object. He recognizes 10-15
people.
Health: Of health he was
doing well, and he did not catch any cold. He sleeps well, is constipated as
first, his squint seems definitely missing, he has a regular breakfast. He
doesn't eat milk and dairy products.
Other: To listen the
music seems always a pleasure for him.
Therapeutic
variation (daily doses, by the oral via): Carbamazepine 200mg.
Third ten days of May 2007: The
tenth checkup. He is standing, if not
worsened, as his mother says.
Presumed
psychotic symptoms: He uses laughing at more, without an evident reason.
Motor stereotypies persist. Since one month he has increased rocking, which,
sometimes, he does even during the night. He rolls objects as first. The habit
of putting his bottom up and down on the
sitting place of the chair, lasts as previously. Gaze aversion is hardly
observable.
Rarely, he/has put his fingers in his mouth,
and then he has sniffed them. He always need some the transitional object.
Self-aggression, as in form of slaps to his temples reappeared, and he is more
aggressive, for which he pinches, even with the fingernails and seems to hurts
the other people.
Language: No new words,
distinguishable for meaning, in spite of the inaccurate pronunciation, did come
out, but lallation increased a lot.
Inadequate
behaviour:
Since about a month he returned seriously disturbed, a fact observed also at
school. Often he is sitting on the floor or
lies down there. He brings less
the objects in his mouth. He throws even fewer objects to the ground, and he nearly always picks up
them. The disappearance of masturbation
is lasting. Some pallor returned, and he has always eye sockets. The hypertonus
at the legs is very rare, if not missed. Sometimes he does some cry.
Mood: Perhaps he is more
irritable, but he accepts of more the extraneous persons. He does not bear that his mother speaks with other
people, and so he does have all to dissuade her.
Cognitive
ability: He has difficulty to pair the same letters. The coupling of the
colours succeeds better. He tries to
done the homework of the school.
Health: As for his health, he
was doing well, and he got neither a
cold. He sleeps well, and hi bowel function improved, and by which he is less
constipated. He always liked candies, but
now he searches directly them. He has grown in height.
Therapeutic variation: (tdaily
doses, by the oral via): Diazepam, 2mg.
Between the last checkup and the next one,
diazepam hanged and substituted with delorazepam 0.3mg / daily.
First ten days of May 2007, the eleventh checkup.
Inadequate
behaviour:
He has moments of psychomotor restlessness. He beats always his buttocks
against the seat of the chair. In the classroom is even much hyperactive, and
the teachers do arguments about it.
It is not spiteful. He shows
stereotypies of flex-extension of the hands. Often he used to do some damage, apparently without wanting
it.
Cognitive
ability: Memory is growing. At school he has not drowsiness.
Mood: Now he is more
irritable, he has become very touchy, he cries silently.
Language: The use of the lallation
is much more.
Health: At night he sleeps well. The
appetite is good and the bowel
function works normally. The colour of
the face has always a tendency to the pallor, to days as marked.
Therapeutic variation: (daily doses,
by the oral via ): Delorazepam 0.5mg.
Third ten days of October 2007, the twelfth checkup.
Inadequate behaviour: Since a month he has
become again self-aggressive, but not excessively. He mainly beats in his
breast, less on his face. Still, stereotypies occur.
He has still the habit of doing some pain to others. Sometimes he closes
his ears, has daily bruxism, but hardly has ever sensory stimulation into his
mouth.
Cognitive ability: The comprehension,
mainly about round situations, generally
improved.
Language: He has increased the comprehension
of the oral language. He does long
incomprehensible speeches.
Mood: Now, he is more serene, and he
tries to have more cuddles. His relationship with other persons improved. He
cannot bear of being excluded, when his mother speaks with anoother (with the physician, as for example). He
wants the attention for himself.
When he cries, he does it in
silence. To the mornings, he is more agitated. Even at school he is now
agitated.
Health: His appetite is well. He sleeps
well. His face is less pale. The bowel function is irregular. He improved his
endurance.
Other : He has not always taken the whole
drug therapy of the mornings, for choice of the parents.
Current therapy (daily doses, by the oral via): Delorazepam 0.8mg;
Clonidine 75mcg; Carbamazepine 200mg; S-Adenosil-l-methionine 100mg; Glutamine
125mg; Pyridoxine 75mg; Amantadine 200mg.
Discussion.
The
Pervasive Developmental Disorder has the Autism form (DSM-IV: F84.0). The child
had several risk factors: Prenatal as insurgent maternal hypertension;
Perinatal as prematurity and caesarian section, and neonatal as respiratory
distress.
Out of
six possible signs of brain suffering confirmation, in the first year of life,
related to the pre- peri- and neonatal stress, he had four of them, missing the
trouble of the feeding and that of the sleep.
For what
is my clinical experience, already two of them are meaningful of a brain stress
that did not compensate. The delayed walking and language acquisition are two
other confirmations. I recall that his autistic regression happened in about
his three years. Clearly he was suffering from previous childhood depression of
somatic origin (Cocchi, 1985). Why from an already morbid but not excessive
situation, he went into the autism, the opinions are many, and all
unsatisfactory.
There is
a fact. The autistic regression usually has nearly an established epoch, even
noted by the DSM IV, 1996. This leads to think that on the three years, even in
the normal child, it happens something that requires a greater availability of
"energy" produced by neurotransmitters.
As it was
sure in this child, there was already a deficit that, well or badly, laboured
to maintain as compensated the brain areas recruited for the current abilities
( think even only to the walking and language delays). The new demand subtracts
a share of "energy" to these working areas, though being insufficient
for the new tasks.
And here
the regressive catastrophe. The drainage of energy leads out of use several
functions previously got, even if not soundly,
and does
not work the latest recruited. Of course this is only a suggestion, but it
needs a lower number of other hypotheses to be confirmed.
I found
stress symptoms even during the first consultation. This permitted to set up a
drug therapy that has the task of correcting the stress answers (Cocchi,
1990c). That is to say, to strengthen the individual resistance. Recently, I
approached the theoretical grounds of the approach to the aspecific increasing
of the individual resistance (Cocchi, 2003).
Compensation
symptoms were detected and the rocking is the more evident of them (the
self-sustained "cradle". Cocchi, 1997), but the same is for the masturbation
as adrenergic compensation (Cocchi, 1977; Cocchi and Ghiglione Rocca, 1977),
and about surely it is even for the stimulation of the internal mouth surfaces,
as stimulation of ample cerebral areas and increasing of the consumption of the
glutamate.
For the
feeding, I did not set up a diet without gluten, as considered fully useless in
mostly cases (Cocchi, 1996b). Even for the troubles of bowel function, already
statistically scored, I considered them as stress symptoms (Cocchi, 1997).
As for
the drug therapy, I acted with interventions aiming to:
-
increase the type A GABAergic inhibition;
-
decrease the type B GABAergic inhibition;
-
increase the GAD efficiency.
By them
same interventions lead even to:
-
reduction of the cortisole incretion and of the peripheral adrenergic
compensation, by reduced activation of the
hypothalamus-hypophysis-corticosuprarenal axis (Buckingham, 1998; Schedlowski
and Schmidt, 1996);
-
reduction the possible glutamate excess for its increased transformation into
GABA;
-
reduction of the GABAergic B inhibition on the acetylcholine and serotonin
turnovers" (Cocchi, 1999).
I used
the clonidine to reduce the self-aggression, as a probable symptom of
adrenergic compensation.
Conclusions.
After 48
months of antistress drug therapy in an autistic child of 7 years and 4 months
at the first consultation, the improvement is evident even to other persons
without any knowledge of the dug therapy. The developmental disorder was
suggested as catastrophic reaction due to the internal stress, with the
replacement of the brain functionality, according to a level as compatible with
the unbalance of the brain neurotransmitters. The patient suffered even from a
hyperkinetic syndrome, treated with amantadine.
Till now,
there are improvements in the sociability and in the school behaviour, the
hyperactivity reduced, but less for what concerns the motor stereotypies, and
the language passed from the vocalization to word-sentences It is possible that
it needs long times before the brain "be aware" that it can work to a
more sophisticated level.
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American Psychiatric Ass.: DSM-IV, Diagnostic and statistical manual of mental
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Buckingham J.C.: Stress and the
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23-34.
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R. L'ipotesi di sostituzione adrenergica-noradrenergica nella masturbazione
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Posted on Internet on 8
June 2005. Copyright by Renato Cocchi 2005.
Author's address: dr Renato Cocchi, via Rabbeno, 3
42100 Reggio Emilia
renatococchi@libero.it
Autism
Drug
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