CHILDHOOD PSYCHOSES: RESULTS

ON SCHOOL ACHIEVEMENT

OF DOWN AND NON-DOWN SUBJECTS

TREATED BY DRUGS

Renato COCCHI, a neurologist and a medical psychologist

(Traduzione italiana)

Summary.

After 3-94 months of individualized drug therapies, the results on school learning 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.
Reading and writing performance and ability in elementary arithmetic have all been evaluated. Improvement in classroom behaviour and the increase in learning capacity are in direct proportion to the duration of drug therapy and follow the same sequence as a normal child on entry to elementary school.

School achievement tends to be slower and less frequent in the psychotic Down subjects compared to the psychotic non Down group.

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

Autism and other psychoses

Down's syndrome

Drug modulation of stress reactions

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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 epidemilogy and clinical features (Cocchi, 1988), in the area of self-injurious behaviour (Cocchi & Bonaduce, 1988b), in susceptibility towards upper tract respiratory diseases (Cocchi & Bonaduce, 1988a), in global results on psychotic symptoms (Cocchi, 1990c) and detailed results on social behaviours (Cocchi, 1991) following drug treatment.

In order to evaluate more precisely the therapeutic benefit obtained in the subjects who undervent drug treatment for at least 3 months, I thought it would be interesting to compare the scholastic achievements of Down and non-Down psychotic children whose parents had accepted this type of treatment, administered along the guidelines already described (Cocchi, 1990b).

The two groups therefore comprise only subjects assessible under these criteria.

Materials and method.

All the clinical records of psychotic Down and non-Down subjects who had been the object of the 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 terapy.

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. Information regarding classroom behaviour, reading, writing and elementary arithmetic ability was estracted. For each child sex, age at first consultation, chromosomal anomalies (for the Down subjects) were also collected.

Results

Results were reported on tables 1-6.

According to the diagnoses made during first consultation and the length of drug taking, 2 groups of children records were assembled:

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.

Distribution of chromosomal anomalies:

Pure trisomy 21: 34 Ss = 94.44 % ;

Mosaicisms: 1 " = 2.78 % ;

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

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

Diagnoses, according with DSM-III,R:

Early onset Pervasive Developmental Disorder: 33 Ss = 91.67 % ;

Late onset Pervasive Developmental Disorder: 3 " = 8.33 % .

Table 1: Results; keys: (=) inadequate or no learning; (+) slight improvement; (++) mild improvement; (+++) marked improvement; (++++) normalized behaviour.

S	classroom behaviour	reading		writing			elementary arithmetic
		syllabl.	words	Copy	dictatat.	invention	digits sequence	addition	subtraction
Group 1
182	++	=	=	=	=	=	=	=	= (*)
353	=	=	=	=	=	=	=	=	= (*)
Group 2
32	=	=	=	=	=	=	=	=	= (*)
34	=	=	=	=	=	=	=	=	= (*)
316	++	=	=	=	=	=	=	=	= (*)
332	+	=	=	=	=	=	=	=	= (*)
430	++	=	=	=	=	=	=	=	=
455	++	(pre-elementary school attendance)
Group 3
124	(no attendance to any kind of pre-elementary school, because very young)								(*)
173	++	=	=	=	=	=	=	=	= (*)
186	++	=	=	=	=	=	=	=	= (*)
289	=	=	=	=	=	=	=	=	= (*)
325	++	=	=	=	=	=	=	=	= (*)
330	+	=	=	=	=	=	=	=	= (*)
333	++	(pre-elementary school attendance)							(*)
345	+++	++	+	+++	++	+	++	+	+ (*)
400	++	+++	++	++	=	=	=	=	= (*)
433	+++	(attendance on a daily protected workshop)
Group 4
93	++	=	=	=	=	=	=	=	= (*)
101	++	=	=	=	=	=	=	=	= (*)
120	+	=	=	=	=	=	=	=	= (*)
191	++	=	=	=	=	=	=	=	= (*)
225	+	=	=	=	=	=	=	=	= (*)
281	++	+	+	+	=	=	+	=	= (*)
319	+	=	=	=	=	=	=	=	= (*)
372	+++	++	+	++	+	=	++	=	=
Group 5
85	+	=	=	=	=	=	=	=	= (*)
268	++	=	=	=	=	=	=	=	=
308	(no attendance to any kind of pre-elementary school)
Group 6
7	+++	++++	+++	++++	+++	++	++++	++	++
49	++	++	+	++	+	=	++	=	=
206	+++	++	+	++	+	=	+	=	=
217	+	=	=	=	=	=	=	=	=
226	+++	+++	++	+++	++	+	+++	++	+
242	+	=	=	=	=	=	=	=	=
284	++	=	=	=	=	=	=	=	=

(*) the therapy was stopped 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 = 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: Results; keys: (=) inadequate or no learning; (+) slight improvement; (++) mild improvement; (+++) marked improvement; (++++) normalized behaviour.

Sex	classroom behaviour	reading		writing			elementary arithmetic
		syllabl.	words	Copy	dictatat.	invention	digits sequence	addition	subtraction
Group 1
F	=	=	=	=	=	=	=	=	=
M	++	=	=	=	=	=	+	=	=
M	++	(pre-elementary school attendance)
M	+	=	=	=	=	=	=	=	=
Group 2
M	++	=	=	=	=	=	=	=	= (*)
M	++	=	=	=	=	=	=	=	=
M	+++	(pre-elementary school attendance)
M	(no attendance to any kind of pre-elementary school)
F	+	=	=	=	=	=	=	=	=
F	+++	+	=	+++	=	=	++	+	+
Group 3
F (#)	(because motory worsening, pre-elementary school attendance was stopped) (*)
F	++	pre-elementary school attendance)							(*)
M	++	=	=	=	=	=	=	=	=
F	++	pre-elementary school attendance)							(*)
M	++	=	=	=	=	=	=	=	=
Group 4
M	+++	+	=	=	=	=	=	=	=
M	+++	=	=	=	=	=	=	=	=
M	+++	=	=	++	=	=	=	=	=
F	+++	++++	++++	+++	++	+	++	+	=
Group 5
M	=	=	=	=	=	=	=	=	= (*)
M	+++	=	=	=	=	=	=	=	=
F	++	=	=	=	=	=	=	=	=
F	++++	++++	++++	++++	+++	++	++	++	+
F	+	=	=	=	=	=	=	=	= (*)
F	++	=	+	=	=	=	=	=	=
Group 6
M	+++	=	=	=	=	=	=	=	=
M	++++	++++	+++	++++	++++	++	++++	++	++
F	++++	++++	++++	++++	++++	+++	++++	+++	+++
F	+++	=	=	++	=	=	+	=	=

(*) therapy stopped by the parents; (#) Rett's Syndrome (diagnosis made during the drug therapy).

Table 3: Comparison of the lenght of the therapies.

Investigated length	PDG Ss	%	PnDG Ss	%	Var. %
From 3 to 6 months (group 1)	2	5.56	4	13.79	+ 8.23
From 7 to 12 months (group 2)	6	16.67	6	20.69	+ 4.02
From 13 to 24 months (group 3)	10	27.78	5	17.25	- 10.53
From 25 to 36 months (group 4)	8	22.22	4	13.79	- 8.43
From 37 to 60 months (group 5)	3	8.33	6	20.69	+ 12.36
From 61 to 94 months (group 6)	7	19.44	4	13.79	- 5.65
Totals	36	100.00	29	1000.00	0.00

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

Table 4: Comparison of the results on classroom behaviour; 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
No. of Ss	2	4	6	5	9	4	8	4	2	6	7	4
Evaluation	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =
Class. Behav.	1 1	3 1	4 2	5 0	9 0	4 0	8 0	4 0	2 0	5 1	7 0	4 0
% + results	.50	.75	.67	1.00	1.00	1.00	1.00	1.00	1.00	.83	1.00	1.00

Table 5: Comparison of the results on school learning 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	6		12		24		36		60		94
No. of Ss	2	3	5	4	7	2	8	4	2	6	7	4
Evaluation	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =	+ =
Read. syllabl.	0 2	0 3	0 5	1 3	2 5	0 2	2 6	2 2	0 2	1 5	4 3	2 2
Read. words	0 2	0 3	0 5	0 4	2 5	0 2	2 6	1 3	0 2	2 4	4 3	2 2
Writ. : Copy	0 2	0 3	0 5	1 3	2 5	0 2	2 6	2 2	0 2	1 5	4 3	3 1
Writ.: Dictat.	0 2	0 3	0 5	0 4	1 6	0 2	1 7	1 3	0 2	1 5	4 3	2 2
Writ.: Invent.	0 2	0 3	0 5	0 4	1 6	0 2	0 8	1 3	0 2	1 5	2 5	2 2
Ar. :Dig. seq.	0 2	0 3	0 5	1 3	1 6	0 2	1 7	2 2	0 2	1 5	3 4	2 2
Ar.: Addict.	0 2	0 3	0 5	0 4	1 6	0 2	0 8	1 3	0 2	1 5	2 5	2 2
Ar. Subtract.	0 2	0 3	0 5	0 4	0 7	0 2	0 8	0 4	0 2	1 5	2 5	2 2
% (+)	.00	.00	.00	.09	.18	.00	.12	.31	.00	.19	.45	.53

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

Field of investigation	Reading		Writing			Arithmetic
Ther. Months / Group	Syllab.	Words	Copy	Dictat.	Invent.	Digit seq.	Addition	Subtraction
6 mths / PDG (2 Ss)	0	0	0	0	0	0	0	0
6 mths / PnDG (3 Ss)	0	0	0	0	0	0	0	0
12 mths / PDG (5 Ss)	0	0	0	0	0	0	0	0
12 mths / PnDG (4 Ss)	1	0	1	0	0	1	0	0
24 mths / PDG (7 Ss)	2	2	2	1	1	1	1	0
24 mths / PnDG (2 Ss)	0	0	0	0	0	0	0	0
36 mths / PDG (8 Ss)	2	2	2	1	0	1	0	0
36 mths / PnDG (4 Ss)	2	1	2	1	1	2	1	0
60 mths / PDG (2 Ss)	0	0	0	0	0	0	0	0
60 mths / PnDG (6 Ss)	1	2	1	1	1	1	1	1
+60 mths / PDG (7 Ss)	4	4	4	4	2	3	2	2
+60 mths/ PnDG (4Ss)	2	2	3	2	2	2	2	2
% +	.26	.26	.26	.19	.10	.13	.10	.10
% +	.24	.20	.28	.16	.16	.24	.16	.12

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 for the length of the drug therapies, for the many cases in which it was interrupted I can only confirm here what has already stated elsewhere (Cocchi, 1990b).

The result that drug therapy has on scholastic achievement in both groups seems to be related to the length of the therapy itself (Tab. 4-5).

It is as well to make such a statement with caution as far as the PDG is concerned, because the many interuptions 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 there were generally fewer withdrawals from therapy.

Classroom behaviour improves progressively in proportion to the length of therapy (Tab. 4).

As far as actual achievements are concerned, here too there seems to be a parallelism with the length of therapy although more difficulty is found in the case of the psychotic Down children. This is however easily explained by the difficulty in scholastic achievement in any case, as a typical feature of Down children with no added psychoses.

The best results are obtained in syllabic reading, copy writing and memorizing the digits sequence. Since this is an acquisition which comes first even in normal children, it is quite probable that the recovery process of learning ability develops along the same lines, as in facts happens in the case of non-psychotic Down children (Buckley et al., 1986).

It is not possible for me to compare this with other research because in literature I have not found any similar, either regarding the method of treatment or the evaluation criteria for scholastic achievement. However, as I have already started to do (Cocchi, 1990d), the case histories of children who have come out of their state of childhood psychosis will be published in detail in this journal.

Of course, scholastic lag, due to the learning difficulties experienced during the psychotic state, also affects subjects who have completely come out of their psychoses (Cocchi, 1990d).

Conclusion

The comparative study of the results of individualized drug therapies on the scholastic achievement between a group of psychotic Down subjects and a group of psychotic non-Down subjects has highlighted common elements of undeniable interest. The results run parallel to the length of drug taking (it is too early to state that they depend up on the leghth of therapy, because I consider this to be a rather risky as yet), and develop in the same way that school learning comes about in the normal child. The rhythms are slow and the Down children achieve less positive results, almost certainly because of the learning difficulties of the syndrome 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.

Buckley S., Emslie M.. Haslegrave g., LePrevost P., The develpment of language and reading skills in children with Down's syndrome. PDSP, Portsmouth 1986.

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. 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.: Childhood psychoses: Results of drug treatment on the social behaviour of Down and non-Down subiects. It. J. Intellect. Impair. 1991, 4: 15-22.

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

Cocchi R., Bonaduce D.: L'autoaggressivita` nel bambino psicotico. Riv. It. Disturbo Intellet. 1988b, 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: 23-30.

Author’s address: dr. Renato COCCHI, via Rabbeno, 3

42100 Reggio Emilia
renatococchi@libero.it

Testo in italiano

Autism and other psychoses

Down's syndrome

Drug modulation of stress reactions

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