Children on Medication

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AUTHOR Gadow, Kenneth D. TITLE Children on Modica A Pr it fors scholl Personnel. 7NsT 'TUT ID N council for Fxc) children, V( Information Services nn Putlicaticrs. sPONS kGFNCY NattonalTnst. of Educat on pH tOa's A - D.C. PUB DATE 79 NOTE 116p.;A Product of the'RIC C1 aringhou5P on Han dicapped and Gift ed Children AVAILABLE FROM The Council for ,-?xcepticnal Child Puhlica Sales Unit, 1920 Association Drive, Rrestor, Vir 22091( 7.50, Publication No. 191)

EDRS PRICE MF01/PO e l j Dist DESCFIPTCP.S *Behavior charge; Drug !ducat on; *DrugThy spy. Epileply; *4andicapred Childrn; Hypera - -Y; Mentally H4adicapped; School personnel;*5 Iciltiv7; *stimulants

TRACT Tnteaded asa prioer for chcol the book flscusses children vhose various disorders raqulr th -m to b,=7? on medication, and describes behavioral effects o these d.riigs along with their major 9 Pundamertal concepts= in pharmacotherapy are reviewed, including dosagp adjustment ancd side ofects, and a brief introduction to the different kinds of rdrugl ls presented.Fsarchinvestigating the Effects of stiuulants(p itilin, Dexedrine, and Cylert) on activity level, perceptual-motor sRills, learning performance, behavior problems, andschoolachievemnt of hyperactive children is rnviewel. Nonstimulart drugs occasionally used in the 1-ratmen,- of hyperactivity are also mentioned, and the Feirigold diet and behavior modification are briefly described. The various types-of epilepsy are examined, along with the drugs used to treat them. Also covered are fibrils ssizure, the management of seizure s in the classrom, and how a ntiepileptic drugs can affect classroom performance. The use of major tranquilizers in the treatment of behavior disorders associated with mental retardation is described. Other topics covered include the use of psychotropic drugs in the treatment of enuresis, school phobia, cerebral palsy, and . childhood psychosis. Included in the appendixns are a classification of psychotropic drugs, a classification of the epilepsies, arld Conners' Atbrev acher PAting Scale.A glossary is also included. (ELS)

* * * * * * Raprod uction s supplied y EDRS are the host t hat can be glade from the oriairal document. ********* *****#* ******** Children's Medication Chart

Developed by Kenneth D. Gadow and Robert L. Sprague

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975by the Board of Trustees of the University of Illinois Continued on inside back cover e edicati p rimer for sell°personel kenne h dl.gaclow

The Counctl f or Exceptional Children A product of the ERIC Clearinghouse on Handicapped andGifted ERIC'Children.

Published in 1979 by The Council for Exceptional Children, 1920 Association Drive, Reston, Virginia 22091

Library of Congress Number 79-51024

The material in this publication was prepared pursuant to a contractwith the National Institute of Education, US Department of Health, Education, andWel- fare. Contractors undertaking such projects under governmentsponsorship are encouraged to express freely their judgment in professional and technicalmat- ters. Prior to publication the manuscript was submitted toThe Council for Ex- ceptional Children for critical review and detorrnination of professional compe- tence_ This publication has met such standards. Pointsof view, however, do not necessarily represent the official view or opinions ofeither The Council for Exceptional Children or the National Institute of Education.

Printed in the United States of America. Contents

About the Author iv

Acknowledgments iv

Introduction 1 / Fundamental Concepts in Pharmacotherapy 5 2/ Hyperactivity 14 3/ Convulsive Disorders 33 4/ Mental Retardation 59 5/ Other Disorders 73

Appendixes 79

References 88

Glossary 100

Iji About the Author

Kenneth D. Gadow is an Assistant Professor in the Special Education Program at the State University of New York at Stony Brook. He completed his undergraduate and graduate studies at the University of Illinois receiving a B.S. degree in psychology, M.Ed. in early childhood special education, and Ph.D. in special education. His experience in education includes classroom teaching. inservice training, consult- ing, and teacher preparation. Dr. Gadow studied pediatric psychopharmacology at the University's Institute for Child Behavior and Development and became involved in drug research on hyperactive and mentally retarded children. He has served as a member of the Board of Directors of the Illinois Epilepsy Association. Dr. Gadow has directed three statewide studies of special education programs in Illinois to determine the pattern and prevalence of drug use and school involvement in drug therapy. The results of these studies have led him to believe that there are serious problems in the delivery of services to children who receive medication. Two of the major problems teachers encountered were exclusion from a meaningful role in what should be a team effort and less than adequate training about pharmacotherapy. In response to the latter; he and Dr. Robert L. Sprague developed one of the first comprehensive courses about medication and exceptional children offered in a College of Education. The two also collaborated on the development of an inservice training institute for The Council for Exceptional Children entitled "Drug Therapy with Children.- Dr, Gadow's current research activities include a followup study of hyperactive children treated with stimulant drugs. Some of the variables being investigated are drug abuse, reactions to taking medication, delinquency. and the impact medication has had on the child and family.

Acknowledgments

I would like to thank the following people for reading preliminary drafts of various chapters and making valuable textual suggestions: Laurence Becker, Ph.D.. Associate Professor of Pediatrics, University of California School of Medicine, Irvine; Mary Coleman, M.D., Clinical Assistant Professor. Georgetown School of Medicine, and Director, Children's Brain Research Clinic, Washington, D.C.;Frederick Green, M.D., Children's Hospital. Washington, D.C.; Leila Roberts. School Nurse. Lansdowne Middle School. Maryland; Esther Sleator, M.D.. Institute for Child Behavior and Development, Universityof Illinois at Urbana-Champaign; Robert L. Sprague, Ph.D., Director, Institute for Child Behavior andDe- velopment. University of Illinois at Urbana-Champaign; Bertrand Winsberg, M.D., Director. Division of Child Mental Health, Long Island Research Institute; and Sheila Wolfe, 0.T.R. I am grateful toSamuel Livingston, M.D., for permission to reprint various tables and for providing me with the latestresearch from his Epilepsy Diagnostic and Treatment Center.I would also like to thank Merle B. Karnes. Ed.D., for her role in making this book possible. I am very grateful to the literally hundreds of teachers and parents in Illinois who supplied the necessary information to describe therapeutic drug use patterns amongchildren in special education programs and to the Directors of Special Education, school administrators, andschool nurses who made these data collection efforts possible. A special thanks is extended to my interviewers,Jan Knecht, Tobey Furnento. and Norma Wilson. I am much indebted to Dr. Iry Dater, Research Scientist, Division of Child Mental Health, LongIsland Research Institute, who generously provided editorial assistance in revising preliminary versions of all chapters. The completion of this book was made much easier by his skillful efforts. I wish especially to express my appreciation to my colleagues at the Institute for Child Behavior and Development. Robert L. Sprague and Esther Sleator, for their encouragement and support overthe past five years. Kenneth D. Gadow

IV Introduction

The use of drug therapy in the management of WHY LEARN ABOUT DRUG TREATMENT? childhood behavior disorders has received much The use of medication in the management of attention in recent years. One can walk into al- learning. behavior, and convulsive disorders is of most any public school, and, after engaging interest to school personnel for several reasons. teachers and staff in a conversation about chil- First, the very behaviors that are affected by dren and medication, discover that this is quite a drugs are often interrelated with the educational controversial topic. Such discussions not only re- process. For example. the symptoms that char- veal a considerable interest in medication but acterize behavior disorders can interfere with the also a variety Of problems associated with drug child's ability to benefit from instruction, as well therapy. Unfortunately,itis difficult for people as hinder the teacher's efforts to teach other outside the medical professions to learn about children in the class. Physically aggressive acts the therapeutic use of drugs. It is not unusual, can actually place the welfare of. both teacher therefore,that many teachers are poorly in- and peers in jeopardy. formed about medication. This lack of knowledge Similarly, uncontrolled seizures can be a seri- is often accompanied by uncertainties and mis- ous impediment to learning for the child with epi- conceptions that are created, in part, by sensa- lepsy. If the attacks are frequent or severe, the tional articles aimed at parents and teachers. amount of time spent on instruction can be greatly The fact that researchers and clinicians simply limited. Seizures in the classroom can be quite do not know all the answers to frequently asked disruptive for peers as well if the situation is not questions about drug treatment also complicates handled -appropriately. Because these chronic matters. Highly biased articlesbothfor and childhood disorders oftenprecipitate serious against drug treatment have fueled a bitter con- emotional problems, the teacher can become in- troversy over the use of medication for childhood volved in another aspect of school learningso- behavior disorders. Because little is known about cial development, Another way learning and be- the origin(s) of behavior disorders (and many havior problems become a part of the teaching other maladies as well), a number of prophets process is when they are identified as instruc- have surfaced willing to lead us to the truth. They tional objectives. This is particularly true in spe- have claimed that everything from bad lighting to cial education settings. tight underwear is the cause of behavioral dis- Second. medication is of interest to teachers turbance. In the center of this confusion, contro- because the drugs used in the management of versy, and uncertainty are the family and school these disorders have a pronounced effect on be- trying to figure out what is the best thing to do for havior. In some children, medication suppresses their children. And, they are not always in agree- behavior that is perceived by caretakers as in- ment. compatible with accepted standards. For other 2 /CHILDREN DI%1 MEDICATION children. drug therapy appears to make them number of problems. Among other things, teach- more responsive totheir environment by en- ers indicate that they: hancing cognitive abilities. Parents comment, for 1. Are not well informed about the use of medi- example, "The child is easier to manage," You cation. can get through to him now," or "He cansit still 2. Are excluded from what should be a team ef- long enough to read to" (Gadow, 19774). Also fort. of importance to the teaching situation are the 3, Have little direct contact with the doctor. side effects of medication. Although many side 4. Are disturbed by side effects and overmedi- effects are benign or eventually go away, others cation. can be quite alarming if those responsible for the child's care are unprepared for what to expect. Perhaps the greatest single problem is a lack of When side effectsimpair classroom perfor- information about drug treatment. Teachers have mance or create emotional problems, they are many questions about what medication is sup- not only distressing to teachers and parents but posed to do to help children, side effects, ,rvhether raise serious risk-to-benefit questions. drugs can interfere with learning, dosage, what Third. studies have shown that relatively large teachers should do in various situations, drug in- numbers of school children are on medication for teractions, and what kinds of drugs are used for hyperactivity, behavior problems. and epilepsy. specific disorders, In fact. only a small percentage of teachers have Because there are few comprehensive refer- not had students who were receiving medication ences for parents and teachers about drug treat- for one of these problems. Exposure to pharma- ment. this primer was developed to answer these cotherapy is much greater for teachers in special and other questions about children on medica- education programs, particularly those for men- tion.It must be emphasized that making drug in- tally retarded. emotionally disturbed (behavior formation available in this format does not imply disordered). and learning disabled children. that caretakers should preempt a medical role, Finally, studies of treatment procedures for hy- School personnel should not make medical di- peractive children have clearly demonstrated the agnoses or recommend to parents that their child importance of school participation in drug treat- should be placed on medication. It is generally ment. Teachers can be helpful by providing the agreed, however, that teachers can be helpful to child's physician withbehavioral evaluations physicians by providing much needed feedback during the diagnostic. dosage adjustment, and about the response to treatment. The school is followup phases of drug treatment. Reports of but a part of a team effort that involves the family, side effects observed in the classroom are also health professions, psychological services, and valuable. Because medication does not teach social welfare agencies. It is hoped that by mak- the child anything, many children with learning ing drug information availabletoparents and and behavior problems will require educational nonmedical professionals, they will be more ef- programing as part of the total treatment plan, It fectiveinparticipatingin an interdisciplinary has been my experience that teachers are often treatment effort. interested in therapeutic measures concomitant The primary focus of this primer is a descrip- with their own instructional efforts. The effective tion of the behavioral effects of drugs and the management of other chronic childhood disor- major side effects observable to teachers and ders that respond to medication also involves the parents, Although questions are frequently asked school. For example, teachers can provide use- about how medication acts on the body to pro- ful diagnostic and drug response information for duce certain behavioral changes, this topic is not physicians about epileptic and mentally retarded discussed here. A lack of understanding on the children. part of the reader about how a drug works should not interfere in any way with the expressed objectives of this text. Of equal importance to discussing drug related OBJECTIVES OF THIS PRIMER changes in behavior is describing how doctors After conducting three statewide studies about use medication. This includes typical dosages, how medication was being used with exceptional the time of day medication is taken, how long children, I realized that teachers were interested treatmentwilllast. and under what circum- in drug treatment and were concerned about a stances medication is terminated. This is much INTRODUCTION /3

more difficult than it sounds because w people ers are of ten uncertain about what they should study the behavior of physicians (or teachers for Or should not do. Examples of ways in which that matter), Although there are many state- school personnel can help the physician adjust ments of clinical experience in the literature or dosage and monitor treatment are covered in -how to" articles, there is often a disparity be- Chapter 1. However, this is only a brief overview tween what experts say should be done and of several aspects of a complicated topic. Unfor- what really happens in everyday situations.In tunately. the focus of the test and space lirreta- order to create a more realistic picture of actual lions prevent a detailed discussion of the role of practices, the available data on everyday medi- school personnel in drug treatment. cal procedures are included in the text. Even though there is a technology of teaching. the effective use of instructional techniques is an art. Like fashion, medical technology is also an ORGANIZATION OF THE TEXT art. Physicians. like teachers, develop a variety The general outline of the primer is as follows. In of ways for handling similar problems based the first chapter,I have explained some of the upon the responses of previous patients. The fundamental concepts and terms relating to drug reader is cautioned, therefore, that the descrip- therapy. Each of the following chapters covers tions of medical practice presented in this text the use of medication with regard to specific are not necessarily what one might encour ter or childhood disorders. When available, prevalence what one should expect. figures are reported for the given disorder and By definition, a primer is an introduction to a for the use of drug therapy in the general school specific area of inquiry and, therefore, must be population and in special education programs. limited in both depth and detail. In order to pres- Both therapeutic and side effects of the drugs ent a more thoughtful discussion on medication. employed are described, along with pattern of some topics had to be omitted. Exclusion of a treatment. The latter includes age at which med- particular topic does not imply a value judgment ication is started, dosage, when during the day about worth or importance, but simply a practical medicine is administered, how long treatment consideration. Although the reader is provided will last, and drug combinations. Because drugs with a description of each disorder.I have not typically have many properties, they are often attended to etiological questions or diagnostic used in the management of more than one dis- procedures. The necessary focus on medical in- order. To prevent the redundancy that would re- tervention has precluded any explanation of the sult from describing the same drug in different social-emotionalproblemsassociatedwith chapters, only the primary drugs associated with chronic childhood disorders. Hopefully, this will the treatment of each disorder are discussed. not obscure the importance of psychosocial fac- Because each chapter is an overview of drug tors in the etiology, response to treatment, and treatment, a list of suggested readings is prolong term therapeutic outcome of behavior and vided at the end of each chapter for those inter- convulsive disorders. What may to some seem ested in pursuing a topic in greater depth. Each an even greater oversight is my exclusion of al- item in the list is coded for the audience for which ternative treatment procedures. It would be truly it is most appropriate: P = parent. T teacher, unfortunate to infer from this decision that drug and M e medical personnel. Please note that therapy is the sole treatment for learning and be- many items in the last category are suitable for havior disorders or even the best method for all graduate level students in special education. or most children. Because many books and arti- To repeat, by no means should this primer be cles are available about nonmedical techniques, misconstrued as implying that school personnel it seemed unnecessary to review them here. In- should assume the role of a physician. However, stead, publications discussing alternative mea- if it enables parents and nonmedical profession- sures are cited as references. als to ask more intelligent questions during inter- Undoubtedly, many readers will be interested disciplinary interaction and to focus more clearly not only in information about drug effects, but on educational issues, then this text will have ful- also in ways of handling different problem situa- filled its purpose. It is hoped one byproduct of tions that often arise with children on medication. this increased awareness will be better instruc- Because few guidelines are available from either tional decisions for the child, the true objective of local, state, federal, or private agencies, teach- our efforts as educators. 4/CHILDREN ON MEDICATION

Chapter 1: Fundamental Concepts in of what the seizures look like, age When attacks Pharmacotherapy usually begin, and type of drug that is most effective in controlling the seizures. The main focus of The first chapter is a brief introduction to the dif- this chapter is a description of the various types feret kinds of drugs that are used toeffect of epilepsy and the drugs used to treat them. changes in mood, thought processes, and be- Other topics include febrile seizures, the man- havior, Central to an appreciation for the com- agement of seizures in the classroom. the cir- plexity of drug treatment is a basic understand- cumstances under which drug treatment is ter- ing at the way drugs move through the body. minated, and how antiepileptic drugs can affect Other topics include dosage adjustment, drug in- classroom performance. Because many children teractions, tolerance, and side effects. Using the with epilepsy receive two or more drugs perday_, treatment of hyperactivity as an example, an ar- drug interactions are also discussed. gument is made for the importance of school participation in drug therapy. Chapter 4: Mental Retardation Chapter 2: Hyperactivity Drug treatment for behavior disorders, epilepsy, The most common childhood disorder for which and cerebral palsy is much more common among pyschotropic drugs are prescribed is hyperactiv- mentally retarded children in comparison to their ity. Hyperactivity is defined as a persistent de- nonretarded peers. Surveys show that stimu- velopmental pattern characterized by excessive lants are the most commonly prescribed drugs motor restlessness and inattentiveness. The lat- for behavior disorders in mentally retarded chil- ter may be the most important feature of the dis- dren in public school programs while major tran- order. Other behavioral symptoms are frequently quilizers are the preferred agents in residential associated withhyperactivity,including poor facilities. Some of the commonly reported rea- school achievement, conduct problems, imma- sons for administering medication are the control turity, impulsivity, and peer difficulties.In this of hyperactivity, aggressive outbursts, self inju- chapter, research investigating the effects of rious acts, and stereotyped movements. This stimulants (Malin, Dexedrine, and Cylert) on ac- chapter describes the use of major tranquilizers tivity level, perceptual-motor Skills, learning per- (e.g., Thorazine, Mellaril, and Stelazine) in the formance, behavior problems. and school treatment of behavior disorders associated with achievement is reviewed. The discussion in- metal retardation. Many of the issues concerning cludes studies that investigated the effects of psychotropic drugs and mental retardation are various doses of Ritalin on different types of be- discussed including recent litigation. havior. Nonstimulant drugs occasionally used in Chapter 5: Other Disorders the treatment of hyperactivity are also mentioned. The results of long term follewup studies The final chapter briefly describes the use of on hyperactive children are summarized. Re- psychotropic drugs for enuresis, school phobia search on two nondrug treatments, the Feingold (separation anxiety), cerebral palsy, and child- diet and behavior modification,is described hood psychosis. The antidepressant Tofranil has briefly. been used with some success in the treatment of enuresis (bedwetting) and school phobia. The Chapter 3: Convulsive Disorders two most commonly prescribed skeletal muscle Convulsive disorders can be separated into the relaxants for cerebral palsy are Valium and Dan- following five categories: grand real (major mo- trium. A variety of drugs have been used to treat tor). petit mal (absence), psychomotor (temporal childhood psychosis, but the major tranquilizers lobe), rnyoclonic, and autonomic. These forms of are generally considered the most effective epilepsy typically differ from one another in terms agents at the present time, 1/Fundamental Concepts in Pharmacotherapy

Pharmacology is the study of the chemical and Drugs that are prescribed primarily for their ef- physical properties of drugs; the effects of drugs fect on mood. thought processes. and behavior on body chemistry. physiology and behavior; the are collectively referred to as psychotropic drugs. mechanisms of action: the movement of drugs A number of different classification schemes have into, around, and out of the body: and their use been used to subdivide this category of drugs, in the treatment of medical disorders. One major and a variety of labels are used in the literature subdivision of this science is heuropharrnecol- to describe given subcategories (Leavitt. 1974; logy which investigates the effects of drugs on Usdin, 1970). To minimize confusion. the psy- the nervous system. As stated in the introduc- chotropic medications discussed in this text have tion, this topic is not covered here. However, the been grouped according to six categories pro- reader is referred toOakley S. Ray's Drugs. So- posed by Usdin and Effron (1972), These are ciety, and Human Behavior(1974) for an excel- stimulants, major tranquilizers, minor tranquiliz- lent discussion of how drugs used to modify be- ers. antidepressants, hyphotics, and sedatives. havior alter the functioning of nerve cells. certain An extensive listing of the drugs in each of these areas of the brain, and the autonomic nervous categories appears in Appendix A. A seventh system. A second major divisionis psychophar- category of psychotropic agents, the hallucino- macology, the study of how drugs affect behav- gens, have not proven effective in the treatment ior. Broadly defined, behavior includes thinking, of childhood disorders. feelings, mood, perceptions, motor activities. etc. Anticonvulsant or antiepileptic drugs, as the Because the bodies of children differ in many names imply, are used in the management of ways when compared to adults, there is a sepa- convulsive disorders. This class of drugs can be rate science concerning the behavioral effects of further subdivided according to similarities in drugs in children. This is known as pediatric psy- chemical structures (see Table 3-2). Because chopharmacology.The primary focus of this text many psychotropic drugs have anticonvulsant is on the latter, properties, there is considerable overlap be- There are approximately 10.000 prescription tween these two groups, To simplify matters, drugs available to American physicians, and an drugs used primarily for convulsive disorders will additional 100,000 products can be purchased be referred to as anticonvulsants and the rest as without a prescription (Silverman & Lee. 1974). psychotropics.It would be inappropriate, how- Of the prescription medicines, two categories are ever, to infer the reason for which a drug is pre- of particular interest here because they have scribed from its assigned categorical label. For pronounced effects upon behavior and are used example, the antidepressant Tofranil (imipra- frequently in treating chronic childhood disor- mine) is used not only in the management of ders. These are the psychotropic and anliepi- depression, but also to treat panic anxiety (Hon- leptio drugs. igf eld & Howard. 1973), enuresis (Blackwell &

5 6/ CHILEREN ON IVEDICATIGN

Currah,1972), hyperactivity (Rapoport, Guinn, riffle narn e. Thslisti gig is by no means comptete Bradbard, Riddle, Brooks,1974), separation since fore-ign tr=ade rsames have been excluded. anxiety(Gittelman-I-

properties. One category is the benzodiazepines ter 3). Examples of non barbiturate hyp noti cs are which includes Valium (diazepam), Librium Noctec (chloral hydrate).Paral (paraldehyde), (chlordiazepoxide).Clonopin (clonazepam). and Doriden (glutelhimide). Serax (oxazepam), and Tranxene (clorazepate). All have anticonvulsant properties, but Valium MOVEMENT OF DRUGS IN -THE BODY (the most frequently used prescription drug in the world) and Clonopin are more commonly used In order for a drug to exert its characteristic ef- with epileptic children, Valium is also the most fect. it roust be absorbed in to the body and trans- frequently prescribed skeletal muscle relaxant ported to the tissues and Organs ir wrpich i I typi- for children with cerebral palsy. At relatively high cally concentrates. For the effect to be termi haled. doses, Valium has hypnoticproperties and, the drug must be changed into an inactive sub- therefore, may be administered to induce sleep. stance or removed from the body. The rmove- Diphenylrnethane derivarios, a second cate- ment of drugs into, through, and out of the body gory of minor tranquilizers, include Atarax (hy- can be described i n terms of four processes;ab- droxyzine hydrochloride) and Vistaril (hydroxy- sorption (movement into the plood),distritvution zine pamoate). They are infrequently used to (concentration in body cornpartrne nts). *trans- control hyperactivity (see Chapter 2), and, in formation (breakdown of d rugs into compounds younger children, they may be administered to that can be more readily removed), and excre- induce sleep. A third category, propanediols, in- tion (movement out of the body). cludes Equani I (meprobarnate) and related drugs. Drugs can be administered either by mouth Although they Are frequently prescribed for anx- (orally) or by injection (parenterally). 'The latter iety in adults, surveys show they are not used method includes injecting the drug through three very often with children. The benzodiazepines different routes: intravenous(into me t-_,lood- are preferred over the propanediols for the treat- stream). subcutaneous (under the surface 41 the ment of anxiety because the latter are more apt skin). and intrahnuseular (into muscle ti ssue). In- to be fatal in suicide attempts and accidental poi- travenous injections can produce relative! y im- sonings (Goodman & Gilman, 1975). mediate effects because the process of ab.sorp- Among the antidepressant drugs. there are tioninthe gastrointestinal tractis lOypased. two major categories, one of which. the tricycl- When injected into a muscle, drugs are absorbed is relevant to this discussion, As previously into the bloodstream via thecapillaries Jr the stated, the name antidepressant is misleading muscle tissue. The rate of absorption can toe in- when one considers the variety of disorders for creased by adding a substance that dilates !blood which these drugs are used. In children, Tolranil vessels, or decreased with an agentthatcon- is the most frequently prescribed tricyclic drug. It stricts blood vessels. Occasionally, majortran- is used most often in the treatment of enuresis quilizersare administered intramuscularly in (see Chapter 5) and occasionally for hyperactiv- a form that is not very soluble. This 5lown the ity (see Chapter 2). Elavil (arnitriptyline) is an- rate of absorption which in turn prolongs tt-le ef- other tricyclic that may be used for hyperactivity fects of a single injection for several days,Sub- but is more commonly prescribed for the treat- cutaneous injections are not used very often in ment of depression in adults. The other category the treatment of childhood medical disorders. of antidepressant drugs is the menoamine oni- Psychotropic and antiepileptic d rugs arer usu- dase inhibitors, usually abbreviated MAO inhibi- ally taken orally. This is the oldest and pro bably tors. They are used primarily with adults, typi- easiest route of drug administration (Ray, 1 978). cally for the treatment of depression. To be absorbed, drugs in tablet or capSule form Sedative drugs are used to cairn anxious peo- must dissolve in the fluids of the stornach and ple and hypnotics are prescribed to induce sleep. intestine. Drug molecules then pass through the 'The separation of these two categories is some- cells that line the wall of the digestive tract and what artificial because higher doses of sore into the capillaries of the veins that lead horn the sedative drugs (e.g.. minor tranquilizers) have gut to the liver. hypnotic effects. One large group of hypnotic A number of factors influence the rate of ab- drugs, the barbiturates, has anticonvulsant prop- sorption including the chemical characterist ics of erties. In fact, phenobarbital, Mebaral (rnepho- the drug, changes in the acidity of the stomach, barbital). and Gemonil (rnetharbital) are all used other drugs present in the digestive tract,less primarily to treat epilepsy in children (see Chap- than adequate supply of blood, and illnessethat 8/CHILDREN ON MEDICATION result in a more rapid passage of food through the breakdown of drugs (biotransformation) into the gut. Natural and added chemicals in the food new compounds (metabolites). Substances (N- we eat may also slow down or speed up this pro- crosonial enzymes) within the cells of the liver cess, For example, dairy products, which are rich bring about or increase the rate of the chemical in calcium, slow down the absorption of tetracyc- reactions that transform drugs into metabolites. line, an antibiotic. Because it is difficult to predict Generally, an active drug is metabolized into an exactly how any change in the stomach or intes- inactive, more water soluble compound(s) that tine may affect absorption, it is best to avoid. can be excreted through the kidney. If lipid solu- when possible, anything that might interfere with ble drugs (e.g., Valium) were not transformed this process. For this reason, drugs are generally into water soluble metabolites, they would be administered at least 1hour before or 2 hours reabsorbed into the bloodstream by the kidney, after eating. and a single dose could, therefore, last indefi- Once in the bloodstream, drug molecules are nitely (Briant, 1978). distributed throughout the body concentrating in Not all drugs are metabolized into inactive various areas referred to as compartments. The substances within the body. Some are excreted characteristics of the drug determine the sites of unchanged while others are transformed from in- distribution and the degree of concentration. ert substances into active metabolites. An ex- Some agents are restricted primarily to the cir- ample of the latter is the antiepileptic drug My- culatory system. Others pass through the capil- soline (primidone) which does not appear to be lary membrane into the water that surrounds the effective in the treatment of epilepsy in its initial tissues and cells (the extracellular fluid) or con- form (Callaghan, Feely, Duggan, O'Callaghan, centrate in the water inside the cells (intracellular & Seldrup. 1977). However, drug metabolizing fluid) of specific types of tissue. enzymes in the liver convert My_ sohne into an ac- The molecules of most drugs combine with tive metabolite(s) which in turn controls seizures. large molecules in the blood (plasma protein). The rate of drug metabolism in the liver can be This process is referred to as plasma protein greatly affected by the presence of another drug binding. Bound molecules, because of their size. or chemical. For example, many drugs are known are unable to pass out of the bloodstream. and, to slow down the metabolism of Dilantin (pheny- unlike unbound (free) drug molecules, do not toin) (Kutt. 1972). This is one form of drug inter- have a pharmacological effect on the body. An action. Genetic factors also play an important equilibrium is established between bound and role in determining the speed at which com- unbound molecules. As free molecules pass out pounds are transformed. When the same drug is of the blood, bound molecules are released so administered to a number of different people, the the ratio of bound to unbound molecules in the rate of metabolism may vary greatly (Vessel! & blood remains the same. Although the maximal Page, 1968). effect of the drug is reduced by protein binding. The kidney is the primary organ responsible it prolongs the effect of the drug by creating a for the removal of drugs and their metabolites reservoir of bound drug molecules that are re- from the body in the form of water soluble com- leased over time (Briant, 1978), pounds. Other pathways of elimination are feces, The movement of drug molecules from the perspiration, and the milk of nursing mothers. bloodstream into the brain is made more difficult The rate of excretion can be influenced by the by the presence of a blood-brain barrier. This is pH of the urine. For example, basic drug mole- not an anatomical structure per se but refers to cules are excreted more rapidly when the urine the fact that the capillaries of the brain prevent is acidic, and vice versa. Therefore, the pres- certain classes of compounds from entering and ence of another drug or chemical that changes affecting brain neurones. A closeknit layer of ghat the pH of the urine could alter the rate of excre- cells surrounds the brain capillaries creating an tion. additional barrier for compounds that are not lipid soluble. Without such a barrier, many chemicals DOSAGE in the foods we eat could directly alter the function of the central nervous system. Examples of Before a drug is marketed, a considerable amount agents that do pass through the blood-brain bar- of information is collected about the effects of dif- rier are psychotropic and antiepileptic drugs. ferent amounts of the drug on laboratory animals The liver is the primary organ responsible for and people. From reports of accidental poison- FUNDAMENTAL CONCEPTS/9

ings and suicide attempts, it is even possible to is the amount of drug. in micrograms (ring or Mg) determine fatal human dosage levels. In adjust- for example, per milliliter (ml) of blood. These are ing dosage, the physician starts with a small very small amounts. For example. there are 1,000 amount of the medicationusually below the micrograms in1 milligram. therapeutic range. Over time, the dose is gradu- Monitoring blood levels of antiepileptic drugs ally increaseduntilthe desired response is is an important procedure in the effective man- achieved. This process is referred to as titration. agement of many children with epilepsy (Kutt, Recommended dosage limits, both minimum and 1974). In contrast, psychoaopic drug treatment maximum, guide the physician in this procedure. for learning and behavior disorders is not typi- If unwanted or intolerable side effects emerge, cally monitored in this w.y. In fact, procedures the dose may have to be reduced or the drug for determining blood levels are not yet available may be stopped completely and gradually rein- for many of these agents. It is noteworthy that a troduced. reliable method for assessing blood levels of Fii- Although we often do not consider this, people tan in children has only recently been devel- differ from one another internally as well as ex- oped for research purposes (Hungund, Hanna, & ternally, Individual variability in the way we react Winsberg. 1978). to drugs may reflect differences in the biological systems that are responsible for absorption, distribution,biotransformation, and excretion or DRUG INTERACTIONS simply differences in body size. In order to adjust dosage to physical size and thereby limit some Itis not unusual for children to receive two or of the variability in drug response, a measured more different drugs during the same day. Some disorders may require more than one medicine amount of medication is administered per unit of body weight in kilograms (kg). A kilogram equals to achieve a satisfactory therapeutic response. For example. surveys of epileptic children in spe- approximately 2.2 pounds. Medication is typically measured in milligrams cialeducation programs report that approxi- (mg). One milligram is equivalent to approximately half of the students receive two or more mately 1/28,000 of an ounce. The actual dosage anticonvulsant drugs per day (Gadow, 1976; 1977a). When more than one drug is used to in milligrams per kilogram of body weight (ingikg) can be calculated as follows OW M, where treat the same disorder, this is often referred to aspo/vpharrnacy. Children may also have more desired mg/kg dose, W weight in kilograms, than one disorder which requires long term drug M actual amount of medication in milligrams. For example, let us assume the physician de- treatment. Studies show that from 7 to 10% of cides to administer drug A at a dose of 0.3 mgi the children on medication in special education kg. A child weighing 88 pounds (40 kg) would programs receive drugs for both behavior and convulsive disorders (Gadow. 1976; 1977a). then receive 12 mg of drug P. (LAW M,- 0.3 x 40 12). For any given M. one can determine the Another situation for which a combination of mg/kg dose by a simple algebraic manipulation. drugs is used is the management of unwanted Thus, for a child who weighs 44 pounds (20 kg) drug reactions. For example, if a medicine causes and is receiving 12 mg of drug A each morning, serious side effects but cannot be stopped for therapeutic reasons, the physician may pre- the dose would be 0.6 mg/kg 12/20 =- scribe an additional drug specifically to control the side effect. There are also tens of thousands 0.6). of nonprescription products available to parents With some drugs, particularly the anticonvul- for the treatment of common childhood maladies sants, the amount of medication administered in such as colds, headaches, upset stomachs, and milligrams has little relationship with the amount so forth. We do not always regard these products in the blood. For example, if a number of people as "drugs," However, the concomitant admin- with epilepsy are given the same dose of Di lan- istration of a prescription and a nonprescription tin, the actual level in the blood would vary greatly medicine is a drug combination. In general, drug from patient to patient (Lascelles, Kocen, & Rey- combinations are an important consideration in nolds, 1970). Therefore, a more useful measure that the effects of one agent may be significantly than mg/kg for dose would be one that indicated altered by the presence of another. When this how much drug was in the blood. That measure does occur, it is referred to as a drug interaction. 10. CHILDREN ON fv1FDICATION

One way in which drugs interact is an altera- For such children, increasing the dose only helps tion in the absorption, distribution, biotransfor- for a short time, and medication must eventually mation, or excretion of one agent by another. be withdrawn. Fortunately, children also develop Changes in the rate at which these processes a tolerance for many side effects.For example, occur can result in an increase or decrease in antiepileptic drugs such as Mysoline and phen- the blood level of the altered drug. For example, obarbital almost always produce drowsiness if drug A slows down the rate at which drug B is when treatment first begins. Howover, after reabsorbed into the blood, it will take longer for ceiving medication for a couple of weeks, most drug B to reach an effective level. This could be children are not bothered by this reaction. very important if it is necussary to get a high level Because drugs often have many properties, of drug B into the bloodstream to be really effec- children may develop a tolerance for only some tive for medical treatment. The rate at which of them, As noted in the previous example, al- drugs are broken down by the liver can also be though children typically develop a tolerance for altered. As noted previously, many drugs inhibit the drowsiness produced by phenobarbital, the Dilantin metabolism (Kite, 1972). Because Di lan- seizure controlling properties of the drug may not tinis poorly soluble in water, drug molecules change. Adjustments are typically made in the must be transformed into water soluble metabo- dosage of antiepileptic drugs as the child grows lites before they can be excreted by the kidney. to accommodate for changes in body size, but Therefore, a drug that inhibits the metabolism of this is not the same thing as tolerance. lantin produces an increase in the blood level Tolerance to drug effects can be manifested in of the latter. Because there are now more Di lan- different ways (Ray. 1978), Behavioral tolerance tin molecules in general circulation, the effect is develops when an individual learns how to coun- greater. This could result in either unwanted side teract the behavioral effects of the drug,This effects, fewer seizures if attacks were not com- may explain, in part, the ability of somealcohol- pletely controlled when Dilantin was adminis- ics to diminish the effect of alcohol, or "to hold tered alone. or both. their liquor," Another type of drug interaction occurs when Repeated drug administrations may also in- two drugs with similar effects are given in com- crease the rate at which drugs movethrough the bination. For example. alcohol and batiturates body. This is referred to as drug disposition 01- both produce central nervous system depression erance. For example, the regularintake of some ranging from mild sedation to cOrila depending drugs actuallystimulates the metabolic pro- upon the amount consumed. When they are both cesses responsible for the breakdownof the used during the same period of time, their effects drug. To achieve the same effect. the dose must are additive and the outcome may befatal. The be larger than the previous one. This mayonly combination of the two substances is similar to a increase the rate of biotransformation and the much larger amount of either one ing,:,stsd alone. cycle is repeated. In one study of epleptic adults treated with Dilantin. 45% showed a drop in the blood level of the drug over several months of TOLERANCE treatment (Reynolds, Chadwick, & Galbraith, When the same dose of medication no longer 1976). In some cases, the level dropped so low has a characteristic effect after repeated admin- that seizures recurred in patients who were pre- istrations, this is referred to as tolerance. At the viously seizure free, The situation was remedied present, the exact mechanisms underlying this by increasing the dose. It should be noted. how- alteration in response are not well understood. ever. that in the treatment of epilepsy.this does Tolerance is reported in some children receiving not typically end in a vicious cycle of dosagein- Rita lin or Tofranil for hyperactivity who no longer crements. react to medication the same way as when treat- Psychodynarnic tolerance develops when the ment was first started. In the case ofRitafin, a cells of the nervous system actually adjust to the modest increase in dose is usually sufficient to presence of the medication. In order to achieve maintain the desired response (Sleator, von the same reaction to the drug, the dosage Must Neumann, & Sprague, 1974). Occasionally. some be increased to overcome the body's compen- hyperactive children show a dramatic therapeu- satory mechanisms. If a neurological adjustment tic improvement with stimulants but then develop is made to the larger dose. even more medica- a complete tolerance (Gross & Wilson,1974). tion will be required and so forth, This type of FUNDAMENTAL CONCEPTS/11

tolerance is encountered with the euphoric effect SIDE EFFECTS of opium and related drugs. Another reaction associated with the repeated No drug is completely free of side effects. There use of certain drugs is physical dependence. are a number of terms used to denote side ef- This occurs when an agent alters the physio- fects. including "untoward reactions." "toxic ef. logical state of the body. and, to prevent the ap- fects.- and "adverse drug reactions." Some pearance of a withdraws; syndrome, the drug side effects are trivial while others seriously im- must continue to be administered. Physical de- pair health. Adverse effects may go away after a pendence has been demonstrated with a num- period of time (self limiting) or they may persist. ber of drugs including opiates, barbiturates, al- If the disorder being treated is severe, side ef- cohol. amphetamines, and nicotine (Jaffe, 1975). fects that are not self limiting may have to be en- Because the symptoms that characterize the dured. Side effects may appear shortly after the withdrawal syndrome are associated with the onset of treatment or may go unrecognized f,x same area of the body that was initially altered months or even years. The pervasiveness of by the drug. they are sometimes referred to as side effects often alarms people. but one must rebound effects. For example, the ,sudden ces- realize that the body is an extremely complicated saron of an antiepileptic drug (e.g., phenobarbi- chemical system whose functions are highly in- tal) may precipitate a seizure. This can be avoided 1errelated and that the alteration of one process by simply lowering the dose of medication over affects others as well. It is noteworthy that what an extended period of time before stopping treat- is an adverse drug reaction for one person may ment. A similar type of reaction is also observed be the desired treatment response for another in some hyperactive children receiving short act- patient with a different disorder. ing stimulant medication. When a significant Adverse drug reactions can be categorizes into three groups (Zbinden. 1963). The first and amount of the drug has been removed from the generally least serious are functional side eff acts body, the child becomes more hyperactive than when he or she is off medication altogether. At which represent a change in the function of an organ. Examples of functional side effects of the this time, it is uncertain whether all the symptoms nervous system are headache, slurred speech, of a withdrawal reaction to opiates and central nervous system depressants ShOuld be comid- inccordination, and dizziness. Most functional ered rebound effects. side effects are r&i,orsible (i.e,, cease or gradually go away) when medicationisstopped. The difference between physical dependence Changes in the biochemical reactions associ. and drug addiction is not often made clear. Drug ated with various organs are a second category addiction refers to a "behavioral pattern of com- of side effects. Two examples are alterations in pulsive drug use, characterized by overwhelming the balance of hormones and changes in blood involvement with the use of a drug. the securing coagulation. Biochemical side effects are also of its supply, and a high tendency to relapse after usually reversed upon stopping treatment. A third withdrawal- (Jaffe, 1975. p. 285). It is important group. structural side effects, ''nvolves an actual to note that one can be physically dependent change in the structure of an organ. Examples of upon a drug and not be addicted_ or be addicted these are liver damage and cataracts. Obviously, and not be physically dependent. functional and biochemical effects may also be Parents and teachers often worry whether associated with organ dernage. The following children receiving psychotropic or antiepileptic chapters in the primer discuss mostly functional drugs for behavior or convulsive disorders are side effects that are clearly visible to parents and addicted, They are not! Nor are they more apt to teachers. Drugs that are known to cause bio- become drug abusers in later life. Followup stud- chemical and structural side effects must be ies of hyperactive children treated with medica- carefully monitored, tion show they are not remarkably different from their peers in illegal drug use patterns and may ROLE OF THE SCHOOL IN DRUG even abuse drugs to a lesser degree than non- TREATMENT hyperactive children (Beck, Langford. MacKay, & Sum, 1975; Gross & Wilson. 1974; Henker, 1979; Just the fact that psychotropic and antiepileptic Laufer. 1971; Safer & Allen, 1975; Weiss, Hecht- drugs have a powerful effect on behavior, and man. Perlman, Hopkins. & Werner, in press). that these agents are used relatively often with 12 /CHILDREN ON MEDICATION children (particularly those in special education drug effects must include reports from the programs), should make drug treatment of inter- teacher ifthe physician hopes to effec- est to teachers. However. combined with the re- tively treat school children with learning alization that the teacher can play a primary role and/or behavior disorders. (p. 579) in the treatment of children receiving medication Hyperactivity is a drug treated disorder for and that the exclusion of schbol input may limit which the efficacy of school :nvolvement has the effectiveness of drug therapy, this, then, be- been clearly documented. However, the role of comes a matter of considerable importance. The the school in other chronic childhood disorders usefulness of school participation in drug treat- that are treated with medication (e.g.. epilepsy) ment with children is most convincingly docu- has not been investigated as systematically for mented in the treatment of hyperactivity (Spra- at least two reasons (Gadow. 1978a). First, the gue & Gadow. 1976). treatment of other disorders is more generally The drug regimen consists of three stages: di- accepted as being the total responsibility of the agnosis. dosage adjustment. and followup. There medical profession. Even though there are im- is a period prior to refer-al and diagnosis when portant psychological aspects in all forms of ill- caretakers cope with the child's behavior and ness (Engel, 1977), they are more apparent in attempt educational programing, and a period the management of behavior disorders. Second, following the termination of drug treatment When therapeutic regimens (e,g, behavior therapy) other approaches are used to ameliorate learn- which may involve the school have been limited ing and adjustment problems. The predrug and primarily to behavior disorders. The opportuni- postdrug periods have generally been excluded ties for teacher participation in medical treatment from most scientific investigations although there programs are many when we consider that: is no shortage of discussion on this matter. particularly with regard to the events that lead to re- 1.Hyperactivity` is only one disorder for which ferral (Bosco & Robin, 1976). psychotropic and anticonvulsant drugs are A series of studies conducted at the Institute prescribed. for Child Behavior and Development at the Uni- 2. Other types of drugs can influence school versity of Illinois at Urbana-Champaign have performance. demonstrated the importance of teacher partici- 3. Teachers can perform important referral. di- pation in the treatment of hyperactive children agnostic. and roatment monitoring functions with stimulant medication (Sprague & Sleator. in the management of medical disorders for 1973, 1975, 1976). By simply completing a brief which drugs are not typically administered. behavioral rating scale, teachers can provide the physician with valuable diagnostic information. In Although most special education teachers fact, it is often difficult to make a diagnosis of agree they should have a meaningful role in drug hyperactivity from behavior exhibited in the phy- treatment (Gadow, 1978), what really happens in sician's office (Sleator & von Neumann, 1974). school settings is far short of their expectations. If a child is diagnosed hyperactive and the doctor After reviewing several studies about school in- decides to administer a trial dose of medication, volvement in drug treatment, Sprague and Ga- the teacher can help by evaluating the response dow (1976) reported that: (a) there is very little to medication. The importance of teacher evalu- direct coelmunication between the doctor and ations to the entire treatment program is force- the school, (b) teachers feel they should be no- fully conveyed in the following quote (Sleator & tified about drug treatment and the effects of the Sprague, 1978): medication used, and (c) the adequacy of current Remarkable sensitivity to drug effects on drug monitoring procedures is questionable. the part of the leacher has been replicated Even though most teachers demonstrate a regularly in our laboratory. No other clinical clear willingness to participate in the evaluation measure even appreache3 this sensitivity of the drug regimen (Gadow, 1976), they are and, in fact, we have found parents, on the poorly trained in the area of drug treatment, have average (although some parents are very little in depth knowledge about the effects of sensitive), unable to distinguish even be- drugs, and much of what they do know comes from personal experience. A content analysis of tween on-drug and placebo periods . . We recommend strongly that monitoring of the difficulties teachers encounter with children FUNDAMENTAL CONCEPTS/13 receiving psychotropic and antiepileptic drugs Goodman, L. S., & Gilman, A. The pharmacolog= revealed five major problem areas: ical basis of therapeutics (5th ed.). NewYork: MacMillan. 1975. (M) 1. The need for information about drug treat- Haslarn, R. h. A & Vanototti. P. J. Medical ment. problems in the classroom: The teacifer's 2. Improved communication between teacher, role in diagnosis and management. Baltimore: physician, and school, University Park Press, 1975. (T) 3. Guidelines for the involvement of school per- Honigfeld, G.. & Howard, A. Psychiatric drugs: A sonnel in the drug regimen. desk reference. New York: Academic Press, 4. Parent inconsistencies in administering med- 1973. (M) ication. Iverson, S. D., & Iverson, L. L. Behavioral phar- 5. Physician failure to adequately monitor drug macology New York: Oxford University Press. treatment (Gadow, 1977b, 1978a). 1975. (M) There appears to tie considerable disparity be- Leavitt, F. Drugs and behavior. Philadelphia. W. tween what researchers and clinicians perceive B. Saunders. 1974. (T) as proper treatment procedures and typical prac- Ray, 0. Drugs. society, and human behavior tices in real world settings. Unfortunately, space (2nd ed.). S(. Louis: C. V. Mosby, 1978. (T) limitations do not permit the in depth discussion Sleator, E. K., & Sprague, R, L. Pediatric dhar- this topic deserves. The reader who is interested macotherapy. In W. G. Clark and J. del Guld- in the role of the school in drug treatment, the ice (Eds.), Principles of psychapharrnacolOgy administration of medication at school. and sug- (2nd ed.). New York: Academic Press, 1978. gestions about how to resolve some of the prob- (M) lems teachers encounter are referred to the pa- Sprague. R. L., & Werry, J. S. Psychotropic pers by Gadow (1977b.1978a,1978b) and drugs and handicapped children. In L. Mann & Sprague & Gadow (1976, 1977). D. A. Sabatino (Eds.), The second review of special education. Philadelphia: JSE Press, SUGGESTED READINGS 1974. (T) Abel, E. L. Drugs and behavior: A primer in neu- Werry, J. S. (Ed.). Pediatric psychopharmacol- ropsychopharmacology. New York: John Wiley ogy; The use of behavior modifyingdrugs in & Sons, 1974. (M) children. New York: Brunner/Mazel. 1978. (M) 2/Hyperactivity

In recent years, no other childhood disorder has child. This chapter is a sincere attempt to present received as much attention, generated more an unbiased discussion of what is, to many par- controversy, or left educators and parents in ents and teachers, an emotionally charged topic: more confusion than the condition known as hy- drug treatment of hyperactive behavior in chil- peractivity. The vagueness of the term has re- dren. suited in an "epidemic" Of cases, causes, and cures (Freeman, 1976). Accusations have been DEFINITION OF TERMS made that teachers and physicians conspire to Several dozen labels have been used to de- enslave boisterous school children in chemical scribe what we commonly refer to as hyperactiv- straight jackets. It has been claimed that instead ity in children. To add to the confusion, overactiv- of accommodating our social institutions to the ity or motor restlessness is associated with a needs of these children, we take the easy way number of different behavior disorders. Also, the outpills. Physicians, under pressure from par- group of children who are described as hyper- ents and teachers, have been accused of capri- active is so varied in terms of symptoms that ciously "doping kids up." Critics say that creat- eventually it may be subdivided into different cat- ing medical disorders out of socially unacceptable egories as our knowledge of the condition inbehavior is a most hideous form of social control. creases (Loney, Langhorne, & Paternite, 1978). The emotional anguish that often accompan- Safer and Allen (1976) proposed the following ies uncertainty about what is the right thing to do definition: for our children is aggravated by a host of individuals proclaiming they have found the truth. Hyperactivity is simply defined as a long Eisenberg (1984) observed that the less that is term childhood pattern characterized by known about a particular aspect of drug treat- excessive restlessness and inattentive- ment. the stronger the convictions about what is ness. It is a developmental disorder which correct and about what should be done. AI- begins in early to rnidchitdhood (ages 2- though differing views may provide a healthy 8), and begins to fade during adoles- competition in the search for effective techniques cence..The only necessary feature .. and explanations, it is often difficult for parents to is developmental hyperactivity (which) even know where to begin. is best determined by history.It is a per- The school is often in the middle of this contro- sistent pattern of excessive activity in sit- versy because it is: (a) frequently the source of uations requiring motor inhibition. Persis- medical referral, (b) intimately involved in foster- tent means consistently, year after year. ing academic achievement, and (c) one of the Excessive means extreme (i.e., the most most challenging settings for the hyperactive restless 3-5%). (pp. 5-7)

14 HYPERACTIVITY /15

One of the more important distinctions in this ates opportunity for disagreement among par- definition is the fact that hyperactivity just does ents, teachers, and physicians as to whether or not pop up as a reaction to emotional stress, tight not a child is hyperactive. underwear, or fluctuations in blood sugar levels The use of the term hyperactivity as a diag- (Walker, 1974). It is a developmental disorder nostic construct is currently undergoing change. with an early onset. As an infant, the hyperactive This is due, in part. to the recognition that poor child may be fretful, colicy, and restless. Mothers attending skills rather than exessive motor rest- who have more than one offspring may even lessness may be the major obstacle to success comment that their hyperactive child was more in school (Douglas, 1972)In keeping with this restless than his or her siblings in utero. Hyper- observation, the American Psychiatric Associa- activity is usually first manifested during the pre- tion is changing its label for these children from school years, kindergarten, or first grade and is Hyperkinetic Reaction of Childhood to Attention particularly noticeablein settings that include Deficit Disorder with (or without) Hyperactivity. peers (e.g., day care and public schools). Older Two medical terms that are often used synon- children who develop conduct problems for the ymously with hyperactivity are hyperkinetic syn- first time between third and fifth grade should not drome and minimal brain dysfunction (NOD). be confused with children labeled hyperactive in Safer and Allen (1976) made a distinction be- this discussion (Safer & Allen. 1976). tween MBD and hyperactivity in that not all MBD Some clinicians may take issue with Safer and children are hyperactive, and not all hyperactive Allen's definition of hyperactivity as being too children have learning disabilities, an important broad. However, the problem lies not so much in feature of MBD. For educators, the distinction is the definition as in the ambiguities inherent in di- also useful because the term hyperactivity fo- agnosing the condition (Loney. in press). Their cuses in on a behavioral characteristic of the dis- definition does include two of the most widely ac- order. whereas MBD denotes etiology (cause). cepted criteria for a diagnosis of hyperactivity: MBD implies that a child has some form of mini- severe motor restlessness and a consistent de- mal brain damage. Critics have argued that this velopmental pattern. The former can be deter- is similar to having a "touch of pregnancy." Hy- mined with the use of a behavior rating scale. perkinetic syndrome implies a collection of Children receiving scores above a certain level symptoms that are often found in association are considered to be in the hyperactivity range. with one another. This expression has limitations A consistent developmental pattern can be es- in that the symptoms associated with hyperactiv- tablished with school reports from both present ity do not fall into a closely knit cluster (Safer & and prior teachers and from the child's parents. Allen, 1976). Although behavioral ratings and developmental The hyperactive child usually has a number of histories from both the home and the school are other problems along with excessive motor rest- two of the most frequently cited pieces of diag- lessness. Inattentiveness, one of the most com- nostic information in the medical literature, a va- mon problems, is defined by teachers as not riety of procedures and criteria are employed in being able to stay on a task for any length of time real world situations, What is diagnosed as hy- or follow directions. Parents stale that when peractivity by one physician may be considered younger the hyperactive child cannot sit and emotional disturbance or "spoiled child syn- watch TV like other children, is difficult to read to. drome" by another. and does not pay attention to what they say, Hy- Classroom situations that require sustained peractive children are often impulsive. They raise attention and sitting still typically differentiate the their hands in class in response to a question hyperactive child from his or her peers. However, without first determining if they know the answer, in other school settings (e.g.. playgrounds) the Impulsive children rush into activities without differences may not be apparent. While some thinking, and when younger, appear unable to children are considered hyperactive in the school, keep themselves from doing things they clearly the home. and the physician's office, others are know are wrong. Teachers and parents alike re- preceived as hyperactive only at home or only in port the hyperactive child jumps frorn one activity school (Lambert, Sandoval. & Sassone, 1978). to another in an erratic manner. Poor school per- This situational variability combined with the formance is also frequently associated with hy- subjective nature of judgments about what con- peractivity. Not only do these children achieve stitutes "excessive" motor restlessness cre- less well than expected, but often they have per- 16/CHILDREN ON MEDICATION ceptual-cognitive disabilities that hinder the de- At one time, itas believed that children sim- velopment of language skills. ply "grew out" of hyperactivity during adoles- Other common features associated with hy- cence (Laufer,Denhoff, & Riverside,1957). peractivity are conduct problems and immaturity, However, more recent studies have shown that Behavior problems at school take the form of hit- many of the problems associated with the disor- ting other children. not following classroom rules. der persist into adolescence and even into adult- disturbing others, and noisiness. Parents com- hood. (Safer & Allen, 1975; Weiss, Mincle, Werry, plain that the child is unmanageable. Because Douglas, & Nemeth. 1971; Wender, 1978). Al- many hyperactive children do not act their age. though hyperactive children become less rest- people think of them as being immature, Their less during their early teens, teachers still con- best friends may be several years younger and sider their activity patterns to be different from their interests may seem childish. Emotionally. those of their classmates. For many. impulsivity they are easily frustrated and have temper tan- and inattentiveness are still major problems. Even trums when other children have outgrown that as high school seniors. teachers rate the perfor- stage. mance of hyperactive students as inferior to that Some of the consequences of school failure of their peers. (Weiss, Hechtman, & Perlman, and behavior problems are peer difficulties and 1978). Hyperactive adults are more apt to see poor self image. Immaturity, restlessness, and themselves as being inferior in social interac- learning problems all contribute to the child's tions and have lower self esteem. Although they undesirability as a friend. One study of adults di- are still restless and impulsive, the level of edu- agnosed and treated for hyperactivity as children cation and degree of job satisfaction and job sta- reported that most considered their childhood to tus is not significantly different from that of nor- be unhappy (Weiss, Hechtman, Perlman, Hop- mal adu Its. (Weiss. Hechtman, Perlman. Hopkins. kins, & Wener, in press). As adults, they stated & Werner. in press). that family fights(usually concerning them- A frequently asked question is what causes selves), feeling different (inferior. dumb), and hyperactivity? Although there are a number of being criticized "made things worse" as a child. presumed causes. few are based on rigorous At one time, it was believed that children sim- scientific inquiry. After reviewing the literature, ply "grew outof hyperactivity during adoles- Freeman (1976) noted the following have been cence (Laufer.Denhoff, & Riverside.1957). identified as causes of hyperactivity: anoxia, ma- However, more recent studies have shown that turational lag. allergy. maternal smoking. genetic many of the problems associatedwith the disor- factors, temperament, eye problems, subclinical der persist into adolescence and even into adult- lead intoxication. starvatiOn, fluorescent lights, hood. (Safer & Allen, 1975; Weiss, Mende,Werry, and psychosocial factors. Although some of these Douglas. & Nemeth. 1971; Wender. 1978). Al- (e.ggenetic factors) may certainly have merit though hyperactive children become less rest- (Cantwell, 1975), others are truly questionable less during their early teens. teachers still con- from the standpoint of the research methodology sider their activity patterns to be differentfrom employed in determining their causal role. For those of their classmates. For many. impulsivity example, Ott (1976) argued that children can be and inattentiveness are still major problems.Even made hyperactive by fluorescent lighting in the as high school seniors. teachers ratethe perfor- classroom. This was based on a study that lacked mance of hyperactive students as inferior tothat even the most fundamental procedures for en- of their peers. (Weiss. Hechtman, &Perlman. suring an unbiased evaluation. Data were col- 1978). As adults. they are more apt to see them- lected using time lapse photography techniques. selves as being inferior in socialinteractions and Some of the footage appears in the film Explor- have lower self esteem. Although they arestill ing tl-e Spectrum, which has been widely shown restless and impulsive, the level of education to professional groups interested in learning dis- and degree of job satisfaction and job status is abled children. Later, a research team at the not significantly different from that ofnormal State University of New York at Stony Brook de- adults. (Weiss, Hechtman. Perlman, Hopkins. & signed a well controlled study to determine if Werner, in press). As adults, tney stated that Ott's claims had any basis in fact (O'Leary. Ro- family fights (usually concerning themselves). senbaum. & Hughes. 1978). They found that feeling different (inferior, dumb). and beingcriti- standard cool white fluorescent lighting did not ciaed "made things worse" as a child. have an adverse effect on children who scored HYPERACT,VITY 7

well within the hyperactivity range on a widely rive the placement (residential facility being the accepted behavior rating scale. Space limita- most restrictive), the greater the prevalence of tions do not permit an analysis of the research hyperactivity. At this pointitis unknown what concerning the other hypothesized causes of hy- percentage of these hyperactive mentally re- peractivity. but suffice to say that too littleis tarded children would be considered hyperactive known to provide any helpful information, in the same sense as nonretarded children. Di- agnostic problems aside, a large number of PREVALENCE OF HYPERACTIVITY AND school children in regular and special education DRUG TREATMENT classrooms have problems similar to those described by Safer and Allen in their discussion of One of the most common reasons for psychiatric hyperactivity. referral among children is hyperactivity. The ac- More children receive psychotropic drugs for tual prevalence figures of hyperactivity among hyperactivity than for any other disorder, The elementary school children varies from study to best available data about the extent of drug use study, but the generally agreed upon figure is be- for hyperactivity among elementary school chil- tween 5 and 10%. If learning disability and a pre- dren comes from Baltimore County, Maryland. school history of hyperactivity are required as Krager and Safer (1974) reported the prevalence part of the criteria, the figure is about 5% (Safer of drug treatment in that area was 1,1% in 1971 & Allen, 1976). This would mean that in a class- and 1.7% in 1973. By 1975, the prevalence of room of 30 students, an average of 1 to 2 pupils drug use was 2,1% but had increased only slightly would be characterized as hyperactive. All stud- in 1977 indicating a leveling off at approximately ies report that hyperactivity is much more corn- 2% (Krager. Safer. & Earhardt, 1977). In 1977, rnon in boys than girls. Ritalin (rnethylphenidate), by far the most fre- Lambert. Sandoval, and Sansone (1976) found quently prescribed drug for hyperactivity, was the prevalence of hyperactivity varied depending administered to 62% of the children on medica- upon who was asked to make the evaluation: tion. Approximately 9% were receiving Dexe- teachers, parents, or physicians. When the cri- drine (dextroarnphetarnine), 6% Cylert (perm- tehon for hyperactivity was agreement among all line), and 3% nonslirnulant drugs. Teachers three, approximately 1to 1 1/2% of students in frequently ask if older children receive medica- their sample of 5,000 elementary school children tion. These investigators reported that 0.66% of were considered hyperactive. However, the the students in middle and junior high schools prevalence of hyperactivity was 5% when based were on medication for hyperactivity, about one on all children considered hyperactive by either third the figure for elementary schools. Cylert teachers, parents, or physicians. Because the was used more frequently with teenagers than prevalence of hyperactivity is often based on with the elementary school population, presum- teacher ratings, they asked a sample of teachers ably because physicians want a a longer lasting to evaluate all the children in their class on a be- drug for the older children. havioral rating scale. A cutoff point for hyperac- The use of medication in the treatment of hy- tivity was determined from the scores of children peractivity is more extensive with children in spe- considered hyperactive by all three sources. Ap- cial education programs than in regular class- proximately 12 to 13% of the children were scored rooms. Gadow (1976) surveyed teachersin as being in the hyperactivity range, noncategorical early childhood special education Because hyperactivity is often associated with programs in Illinois about drug use, These pro- epilepsy, cerebral palsy, emotional disturbance, grams served children, aged 3 to 5 years, who learning disabilities, brain damage, and mental had learning problems. developmental delays, retardation, the prevalence of this disorder in and handicaps ranging from mild to severe.It special education programs may be quite high. was found that of the 2,559 children in these pro- For example, among mentally retarded children grams, 7.9% received medication for hyperactiv- (birth to 12 years of age) in residential, commu- ity at some time during the school year. By far nity, and home placements, the prevalence of the most frequently prescribed drugs were stim- hyperactivity ranges from 29 to 58% depending ulants (primarily Ritalin) which were adminis- upon the degree of retardation and the place- tered to 71% of the hyperactive children. Krager, rnent setting (Eyman & Call. 1977). The more se- Safer, and Earhardt (1977) also reported a higher vere the level of retardation and the more restric- prevalence of drug use in special education pro- 18 /CHILDREN ON MEDICATION grams. They found that 15.3% of the children in izing to the teachers. had not the improve- programs for the severely and profoundly men- ment been so gratifying from a practical tally retarded, physically handicapped. and emo- viewpoint. (p. 582) tionally disturbed were on medication for hyper- A decade later, epileptologists discovered that activity. Dexedrine was effective in the treatment of cer- The prevalence of drug use for behavior dis- tain types of seizures (Livingston. Kajdi, & Bridge, orders in public-school programs for the trainable 1948), and Bradley (1950) reported on the use mentally retarded (TMR) is less than for pre- of Dexedrine in the management of childhood school special education (Gadow, 1978a). Ap- behavior disorders. proximately 6.7% of the children in the TMR pro- Ritalin has been used to treat hyperactivity grams received drug_ s for behavior disorders in since 1956 and is now the primary drug used to 1977. The primary reason for medication was treat this disorder (Safer & Allen, 1976). In 1975, hyperactivity. As in the other studies, stimulants the Food and Drug Administration approved a were the most frequently prescribed drugs. Psy- long acting stimulant, Cylert, for use with hyper- chotropic drug treatment of mentally retarded active children. Cylert is now used as frequently students is discussed in greater detail in Chapter as or more often than Dexedrine (Gadow,1978a; 4. Kreger, Safer, & Earhardt, 1977). Considering Itis clear from these surveys that medication how long these drugs have been on the market, is used in the treatment of hyperactivity with chil- literally millions of American children at one time dren ranging in age from the preschool level or another have received stimulantdrug_ s for through adolescence. Based on national school either hyperactivity or seizure control, or to coun- enrollment figures for 1974, a colleague and I es- teract drowsiness produced by some .antiepilep- timated that between 600.000 and 700,000 school tic drugs (Kreger & Safer, 1974; Livingston, Her- children in kindergarten through 8th grade were man, & Pauli, 1973; Sprague & Gadow, 1976). on medication for hyperactivity (Sprague & Ga- Scores of studies have been published about dow. 1976). Although there are problems inher- the effects of drug treatment on hyperactive chil- ent in making national estimates from selected dren and thousands of articles have been written samples. it is certainly true that large numbers of about the disorder in general (Winchell, 1975). children receive stimulant drugs for this disorder, Because a number of excellent reviews of stimulant drug therapy are also available (Barkley, BEHAVORIAL EFFECTS OF STIMULANT 1976: Barkley & Cunningham, 1978; Cantwell & DRUGS Carlson. 1978; Conners, 1971; Eisenberg & Since stimulants are by far the most frequently Conners, 1971; Ross & Ross, 1976; Safer & Al- prescribed agents for hyperactivity. they are the len, 1976: Sprague & Sleator. 1973, 1975; Spra- only group of drugs discussed in this chapterin gue & Werry, 1974; Whalen & Henker,1976), any detail. The stimulants mostcommonly used this discussion of the behavioral effects of stim- are Ritalin, Dexedrine, and Cylert.Two other ulant drugs focuses on only some of the well stimulants, Benzedrine (amphetamine) and De- controlled studies. Changes in behavior that are aner (deanol), were also onceadministered for the result of medication can be divided into five hyperactivity, but they are rarely used now. areas: activity level, motor performance,learning Stimulant drugs have been administered to and cognitive performance, conduct problems, treat childhood behavior disorders for over40 and school achievement. years. Bradley (1937) was thefirst to report their effects on children with neurological and behav- Activity Level ior disorders in a residential school. He noted The effect of stimulants on activity level is not that about half of the children receiving aenze- just a simple matter of slowing the child down. drine showed a marked therapeutic improve- For example, there is no difference in the activity ment, and commented: levelof hyperactive childrenin a playroom To see a single daily dose of benzeOrino whether they are on placebo (fake pill) or taking produce a greater improvement in school Ritalin (Ellis. Witt, Reynolds, & Sprague, 1974). performance than the combined efforts of However, these same children are perceived as a capable staff working in amost favorable being much less active by the classroom teacher setting would have been all but derneral- (Sleator & von Neumann. 1974) and wiggle HYPERACTIVITY/19

measurably less in their seats when asked to formance (i.e., the children could hold the stylus perform a task that required concentration (Spra- longer without accidentally touching the sides of gue & Sleator, 1973). Stimulant drugs seem to the cutout maze and circle). Ritalin also facili- affect movement during tasks that require sitting tates the acquisition of motor skills. For example, still and paying attention, They help the child Wade (1976) asked children tobalance on a channel his or her activity to one event instead of tilted 3 by 3 foot board that rotated on a central flitting from one thing to another. However, the shaft. On medication, hyperactive children per- change appears to be more qualitative than formedmuchbetter than when on placebo. More quantitative. important, medication enabled hyperactive children to act more like their nonhyperactive peers. Motor Performance Thai is, they actually learned how to balance bet- A number of researchers have explored how ter over time (trials), Wade argued that Ritalin stimulants alter fine and gross motor coordina- helps the hyperactive child learn motor skills the tionandperformance on perceptual motor tasks. same way it affects the performance of cognitive Knights and Hinton (1969) investigated the effect tasks. of Rita lin on motor steadiness. Children were Ritalin canhave a pronouncedeffect on hand- asked to (a) move a stylus through a maze with- writing as is evidenced in spelling tests for a girl out touching the sides,and (b) hold astylus in in fourth grade treated at the Institute for Child the center of a hole without hitting the edge. On Behavior and Development (see Figure 2-1). For both tasks, medication improved fine motor per- the test dated January 20, this child was on med-

On Ritalin On Placebo

FIGURE 2-1 Handwriting sample of a child in 4th grade receiving long term drug therapy with an intermediate placebo period, (Courtesy of Dr. Esther Sleator. Institute for Child Behavior and Development, University of Illinois at Urbana-Champaign.) 20 CHILDREN ON MEDICATION

ication. The handwriting is clear and legible. screen then goes blank, and one picture Ila hes However, on placebo (February 7) writing skills on, e.g., a fire engine. If the fire engine wasin rapidly deteriorated after the third word. Lew, the previous array, the child presses the "Yes" Lerer, and Artner (1977) compared the effects of lever, but presses "No" ifit was not. A small placebo and Rita lin on the handwriting of 50 chit- green light flashes on if the child is correct, a red dren diagnosed as MBD. All had serious prob- light for a mistake. A counter adds up the number lems with handwriting according to their teach- of correct answers or points. The counter serves ers. Handwriting improved in 25 of the children as an incentive because the points can be ex- on medication while improvement was reported changed for items in the Toy Shop. Most children for only one child on placebo. In general, hand- find this activity enjoyable and interesting. Stim- writing deteriorated when children who showed ulant drugs enable hyperactive children to do improvement were taken off medication. How- much better on this task. ever, gains in handwriting improvement were One of the more fascinating aspects of this re- maintained for months in children who continued search employing the short term memory task is to receive Rita lin. the dose response relationship. In other words, how well a child does in trying to remember the Cognitive Performance pictures depends on the dose of medication Several different types of laboratory tasks re- (Sprague & Sleator, 1975). Most hyperactive peatedly demonstrate improvement on some as- children perform their best when the dose of Ri- pects of cognition with stimulant drugs. One of lair' is between .3 mg/kg and .5 mg/kg. If the these, the Porteus Maze Test, requires the child dose is increased to anywhere from .7 mg/kg to to trace his or her way through a maze on paper 1.0 mg/kg, children actually do worse on the using a pencil (Conners, 1971). The child must short term memory task. This simply indicates plan ahead a route through a maze to a finish that most children fit into this optimum dosage point. An impulsive child charges into the maze range for learning, and if such a child receives with his or her pencil, blundering into dead ends too much medication, it may not help him or her before reaching the goal. Stimulant drugs seem learn. In some children, a high dose may even to help the child focus attention on the maze, and impair cognitive performance (Swanson, Kins- under medication periomance appears more bourne, Roberts, & Zucker, 1978). At this point, thoughtful and reflective. Another task that clearly itis important to note that the relationship be- demonstrates stimulant drug effects is the Con- tween dosage level and improvements in behav- tinuous Performance Test (Conners & Roths- ior problems is another matter. child, 1968),It requires sitting and watching a Conduct Problems screen as stimuli (letters, numbers, etc.)flash by one at a time in rapid succession. One formof Suppression of behavior problems is a fourth this test asks the child to press a lever each time way in which stimulant drugs alterthe perfor- rating X follows a certain letter (e.g.. AX). The task soon mance of hyperactive children. Behavioral becomes boring, and the hyperactive child seems scales are the usual means by which such to lose interest and begins to make errors.On changes are documented. A number of rating in- stimulant medication, hyperactive children seem struments have been developed, but by far the to pay better attention, thus making fewer errors. most widely used is the Conners' Teacher Rat- An important feature of this type of activity is that ing Scale (Conners, 1969). An abbreviated ver- it is not self paced. sion (10 items) of the original 39 item scale ap- Teacher A third type of laboratory measure of cognitive pears in Appendix B. The Abbreviated performance is a short term memory task (Spra- Rating Scale (ATRS) is easy to complete and gue & Sleator, 1975). For this activity,the child takes only about 2 minutes. Each item is rated sits and faces what appears to be a television from 0 (never occurs) to 3 (occurs very often), screen. An array of pictures fromchildren's The ATRS has been completed for a number books are flashed on the screen. Each array of nonhyperactive children in central Illinois, and contains either 3, 9, or 15 pictures. The length of norms have been established, Therefore,the time each array is presented depends upon the AIRS can be used as a .screening device in the number of pictures, one second for eaLh. If an diagnosis of hyperactivity in that area of the array with 9 pictures flashes on the screen,the country (Sleator & von Neumann, 1974). Be- children child has 9 seconds to watch and memorize. The cause only 21/2% of elementary school HYPERACTIVITY/21

would receive a score of 15 or above, the physi- When medication is effective in suppressing cian can use the AIRS score as an indication of conduct problems, the impact on the child and school problems. However, this is only part of the family iikly be considerable. In clinical settings, diagostic process (Safer & Allen, 1976; Sleator & it is not unusual to hear parents rejoice after re- von Neumann, 1974). ceiving the first favorable report from school Using the ATRS, teachers have repeatedly (Sleator, 1978).I can recall a father explaining demonstrated thatstimulant medication sup- how drug therapy had changed his son's ability presses behavior problems in the classroom. to participate in Little League baseball. Prior to Even when teachers are not told if the child is on treatment, the child was unable to follow the placebo or medication, they are very accurate rules, wait his turn at bat, or play cooperatively evaluators of even small changes in dosage. with the other children. Reductions in the amount Figure 2-2 shows teacher ratings for hyperac- of conflict at home with siblings and neighbors tive children on placebo and on different doses as well as between parents over their child's of Rita lin. Moving from left to right, they score problems are also reported. After conducting inchildren the worst on placebo and best on the terviews with hundreds of parents of children on higher dose (0.7 mg /kg). Because certain school medication, it is clear that drug therapy may have situations present special challenges for hyper- a significant effect on behavior outside of the active children, it is not unusual for teachers to classroom (Gadow, 1977a, 1978c). see big improvements in behavior when parents Although the short term effects of stimulants observe little or no change. have been well documented, not all hyperactive

1 7 CONNERS' 40 GLOBAL

16 7 z 2 4 0CC 2 14 1

m 13 28 9 0

12 25

Placebo 0.1mg/kg 0.3mg/kg 0.7mg/kg DOSAGES FIGURE 2-2 In both the global improvement scale and the mean Conner's ratings, the numerical value decreases with improvement in the child's performance. (From Sleator, E. K., & von Neumann. A. W. Met hylphen- idate in the treatment of hyperkinetic children. Clinical Pediatrics, 1974, 13, 19-24. Copyright 1974 by J. B. Lippincott Company. Reprinted with permission.) 22 CHILDREN ON MEDICATION

children are benefited by these drugs. Studies information, con' rrehensien, and expressive skills indicate that about one-fourth of the children are improved in children with learning disabili- treated do not respond favorably (Barkley, 1977). ties, little hone of classroom change can be an- In such cases, the physician may try a variety of ticipated" (p. 863). other agents or even combinations of drugs (Katz. In order to determine if medication in combi- Saraf, Gittelrnan-Klein, & Klein, 1975). Even so, nation with special instruction would help learn- 10 to 20% of the children diagnosed as hyper- ing disabled children, an additional study was active will be untreatable, at least in terms of conducted by Gittelman-Klein (1978). Children conventional dosages and acceptable side ef- with reading deficits were divided into three fects. groups: (a) Ritalin plus reading remediation, (b) placebo plus reading rernediation, and (c) pla- School Achievement cebo plus tutoring in subjects other than reading. If stimulant medication produces such positive The latter was a control to assess the effect of changes in activity level, motor performance, so- the remedial reading program. The results cial behavior, and cognitive performance, what showed there was no significant difference be- does it do for school achievement? Unfortunately tween the first and second groups on measures the evidence that children actually do better in of reading achievement (.e., Ritalin did not im- school subjects is difficult to document. Although prove the child's ability to learn how to read). grades sometimes improve, this may simply be The first group did better than the third group, but a reflection of the fact the child is less of a prob- this was anticipated in that a specialized reading lem for the teacher. One would guess that it mini- program was expected to be better than just tu- ulants improved attention, then children taking toring. such medication would do better because they Although these studies answer questions about could focus in on instruction. However, after re- stimulant drug treatment for learning disabled viewing the literature. Barkley and Cunningham children, it is not known whether stimulants can (1978) concluded that there was little support for help hyperactive children learn to read by mak- the notion that stimulant drugs improved aca- ing them more responsive to instruction. One of demic performance. the problems in testing this hypothesis is that Many hyperactive children lag behind their placing a severely hyperactive child on placebo peers in school before drug treatment is started. for a few weeks, let alone months, is often un- As a result, any drug induced improvements in acceptable to both the family and the school. attention may have little consequence consider- Nevertheless, the short term effects are so striking the obstacles to achievement. Medication ing that many clinicians and researchers do feel may improve attention, but itis unrealistic to that stimulants help hyperactive children learn, think stimulants also help hyperactive children and that, if they are combined with specialized catch up to their peers. To repeat a point made instruction, stimulant drugs can facilitate more earlier, drugs do not teach the child anything. It normal development. is quite possible that without remedial instruction There appears to be some support for this no- medication may not facilitate school achieve- tion that stimulants can facilitate learning. Spra- ment. gue and Berger (in press) recently reported a The effect of Ritalin on school achievement in comparison between the effects of placebo and learning disabled children was investigated by Ritalin on different formsof an arithmetic Gittelman-Klein & Klein (1976). Children were achievement test in a 9 year old boy diagnosed randomly assigned to either a placebo or drug as hyperactive. The test was programed on a condition. Learning disability was defined as computer assisted instruction system. On medi- "being 2 years below reading grade level despite cation, the child gave a significantly greater num- average intelligence." None of the children were ber of correct answers to arithmetic problems hyperactive or exhibited behavior problems in than on placebo. Others have also reported im- school. Although Ritalin improved performance provements in arithmetic performance with hy- on a number of psychological tests of cognitive peractive childrenonstimulantmedication ability, there was no significant change in aca- (Bradley & Bowen, 1940; Christensen, 1975). demic achievement after 12 weeks of treatment. Although these data are suggestive, much re- The authors concluded that "unless vocabulary, search has yet to be done before the therapeutic HYPERACTIVITY/ 23 role of stimulant drugs in achievement on school Long Term Therapeutic Outcome related tasks is determined (Cantwell & Carlson. Because these drugs do effect striking behav- 1978). ioral changes in hyperactive children, it would be Clinicians have often stated that stimulants reasonable to conclude that treated children have a "paradoxical' calming effect on hyper- would do better years later than untreated chil- 1975). Because no active children (fv1illichap. dren. If stimulants enhance the ability to pay at- one had ever studied the effects of stimulants in tention, a child who followed rules better, got into normal children, it was unknown whether or not mischief less often, and generally acted more the decreased motor restlessness observed in -normal" would be expected to be better ad- hyperactive children receiving these drugs was justed. Therefore, with treatment, one would ex- truly "paradoxical." However, this question was pect a hyperactive child to have more friends, get recently resolved when a research team at the better grades, and be more popular than those National Institute of Mental Health administered who are not treated. both Dexedrine and placebo to 14 normal prepubertal boys (Rapoport. Buchsbaum, Zahn, Barkley (1976) reviewed six followup studies Weinganner, Ludlow, & Mikkelsen, 19781. The of hyperactive children who received medication. results showed that these nonhyperactive chil- Two of these studies included a group that did dren responded to stimulants in much the same not receive drug therapy (Riddle & Rapoport, way as do children diagnosed as hyperactive. 1976; Weiss, Kruger, Danielson & Elman, 1975). In general, the findings from these studies indi- On a dose of 0.5 mg/kg, nonhyperactive children were significantly less active than when on pla- cated that hyperactive children on medication cebo. They also had fewer errors on a continu- are still different from their nonhyperactive classmates. That is, stimulant drugs do not "cure" ous performance task (CPT) and they were able to learn and rememtvr more words on a short all the behavioral concomitants of hyperactivity. However, many clinicians who treat these chil- term memory task. In addition, language perfor- dren state they have had some cases who were mance was measured through picture descrip- literally made "normal- with drug treatment. tions, storytelling, and instructions to a listener. The drug seemed to help the child focus atten- One should not infer that, over time, the effects tion on these activities, as evidenced by in- of medication simply wear off. Even after several creased task related speech and decreased years of treatment, withdrawal of drug leads to nontask related speech. These results with non- rapid behavioral deterioration (Sleator, von Neu- mann, & Sprague, 1974). Although medication hyperactive students are clearly contrary to the continues to suppress deviant behavior, there is idea of 3 paradoxical effect of stimulant drugs for little change in peer relations or school achieve- hyperactive children. Some might infer that stim- ment. What is even more discouraging is the fact ulants are unwarranted as a treatment because that there is some evidence that treated children they do not affect hyperactive children in some special way. However this situation is not unu- are not significantly better off in the long run than hyperactive children who do not receive drugs. sual in medicine. For example, Rapoport et al. pointed out that diuretics are used in the treat- It must be emphasized, however, that these ment of congestive heart failure even though results are only suggestive. Not only do most of these drugs alter the bodily functions of normal the followup studies suffer from serious method- adults and cardiac patients in the same manner, ological problems, but some children may re- The data from these studies clearly indicate spond to treatment more favorably than others. that stimulant drugs diminish what Douglas (1972) Unfortunately, attempts to find variables that referred to as an inability to "stop, look, and lis- would predict a favorable response to treatment ten.- In fact, the evidence is so compelling that before therapy is begun have not been very suc- Gittelman-Klein, Klein, Abikoff, Katz, Gloisten, & cessful (Barkley, 1976; Loney, Prinz, Mishalow, Kates (1976) commented: & Joad, in press). Interestingly, there is some No rational, knowledgeable individual can support for the notion that the nature and degree dispute the efficacy of short-term stimulant of hyperactivity symptoms at referral are gener- treatment in the management of hyperki- ally unrelated to behavior at adolescence (Lo- netic children. Of all the therapies in child ney, Kramer, & Milich, 1979). In other words, psychiatry, it is the best documented. (p. whether or not a hyperactive child will have se- 362) vere problems during adolescence cannot be 24 CHILDREN ON MEDICATION

predicted from the severity of his or her restless- meals. Other minor side affects are also possi- ness, inattentiveness, or impulsivity when treat- ble. These include headache, stomach ache, ment first begins. However, hyperactive adoles- nausea, moodiness. irritability, and increased cents who do have serious problems tend to be talkativeness. Children typically develop a toler- more aggressive come from poorer homes, an ance for these side effects, but the dose may have less controlling fathers when they were first have to be reduced and gradually increased to referred for treatment.If these environmental lessen the decree of discomfort. Such possible variables do play an important role in therapeutic side effects as hallucinations and dyskinesia (im- outcome, this may explain, in part, why it is diffi- paired or abnormal motion of voluntary or invol- cult to document long term benefits from medi- untary muscle) are very rare (Lucas & Weiss, cation. Much more will be known about the fate 1971; Mattson & Calverley, 1968). of hyperactive children and the effects of stimu- Perhaps the ,-nost distressing side effects for lants on therapeutic outcome when the followup parents and teachers are changes in appear- studies presently being conducted at the Univer- ance and mood, and suppression of adaptive be- sity of Illinois, University of Iowa, McGill Univer- havior. Change in appearance has been de- sity, and other centers are completed. scribed as an "amphetamine look" by Laufer, Perhaps one of the more thoughtful conclu- Denhoff, & Riverside (1957): sions that can be drawn at this time is that care- A pale, pinched, serious facial expression takers should not become sanguine about the with dark hollows under the eyes. It is of needs of the hyperactive child just because med- no serious consequence but the parents ication is suppressing behavior problems. Spe- must be prepared for adverse comment cial efforts must be made to ameliorate learning concerning the child's appearance.(p, problems and developmental delays and to facil- 471) itate the acquisition of social skills. In their followup study, Weiss et al. (in press) asked their They also report a marked decrease in activity: hyperactive subjects 'what had helped them Sometimes, if too high a dosage (of Dexe- most during their childhood.' The commonest drine) is given, the counteraction of the responses were: one parent (nearly always the syndrome may go to the extreme of "freez- mother) who believed intheir final success; a ing the patient" or fixating him to what he teacher who seemed to turn the tide of failure: or is doing, and may even put him to sleep. discovering that they had some special talent." (p. 470) They go on to suggest that treatment programs for hyperactive children should have two goals: Changes in activity level are not always appre- (a) "to help the child (by means of the various ciatedifitis to an extreme degree. Parents therapies available) to adjust better to his home sometimes comment that their child is "overly and school environment" and (b) "to explore quiet." "stares into space," or "has a stillness how the school can accommodate to [his or her) about him that I don't like" (Gadow, 1977b, p. needs." 35). These extreme changes in activity level and mood prompt teachers and parents to describe some children treated with stimulants as looking SIDE EFFECTS OF STIMULANT DRUGS like "zombies" (Gadow, 1977b; Sprague & Ga- At moderate doses, stimulant drugs produce few dow, 1976), Interestingly, Rapoport et al. (1978) serious side effects and are generally consid- found in their study of normal boys that Dexe- ered to be quite safe. At the onset of drug treat- drine made them appear "unusually inactive, not ment, the two most common side effects are in- simply less restless" (p. 562). somnia and anorexia (loss of appetite). Insomnia Changes in mood may give the appearance of is typically not a problem if medication is admin- depression. Schain and Reynard, (1975)re- istered only in the morning. However, many chil- ported that 6.4% of the 6 to 12 year old children dren receive a dose at noon and some even get in his study became withdrawn, lethargic, and medication late in the day. If such a schedule is apathetic on Ritalin, The incidence of these re- necessary, the physician may prescribe an ad- actions is evidently higher among preschool age ditional drug in the evening (e.g., Benadiy) to children (Gadow, 1977a; Schleifer, Weiss, Cohen, induce sleep (Arnold, 1973). Anorexia can usu- Eiman, Cvejic, & Kruger, 1975), All but three of ally be managed by taking the pill just before the 28 children in the study by Schleifer et al. HYPERACTIVITY/ 25

(1975) were taken off Rita lin because of "less higher the dose of Ritalin the greater the effect. social behavior and interaction" or "sadness, At lower dosages (3 to .5 mg/kg), these side ef- irritability, excessive hugging and clinging, and fects are usually negligible. Researchers are un- increased solitary play" (p. 49).In his classic certain at this point about the long term conse- paper on hyperactivityinepileptic children, quences of these changes in cardiovascular Ounsted (1955) described the "depression re- function. action" with Dexedrine as follows: Parents are often concerned about the long term effects of stimulant drug use. Although the benign. short term side effects of Ritalin and One child aged E years 6 months... was Dexedrine are well documented, only a few stud- given 2.5 mg of dextroamphetamine orally ies have investigated long term adverse drug re- at 9:00 a.m. At 10:15 a.m. he sat down and actions. There are a number of problems inher- became abruptly still. At 10:30 a.m. he be- ent in conducting well controlled foilowup studies, gan silently to weep and his usual rosiness problems not peculiar to the investigationof was replaced by a grey pallor. He re- stimulants and hyperactive children. For exam- mained withdrawn. motionless, and weep- ple. littleis known about the long term conse- ing for four hours, and then reverted. over quences oftoxic blood levels of antiepileptic a period of two hours, to his habitual eu- drugs (Reynolds, 1975). This is interesting be- phoria and energy. (p. 305) cause Dilantin (pher,ytoin), one of the most frequently prescribed anticonvulsants, was first re- Drowsiness, a side effect one would not ordi- ported in the treatment of epilepsy only 1year narily associate with stimulants, is sometimes re- after stimulants were discovered to have a ther- ported by parents and teachers of young children apeutic effect on children with behavior disorders (Gadow, 1977b). This effect of stimulants also (Bradley, 1937; Merritt & Putnam, 1938). The appears in older children as well as in adults only long term side effects of Ritalin or Dexedrine (Montagu & Swarbrick, 1975; Tecce & Cole, that have been reported so far are small changes 1974). in height and weight gain (Safer & Allen, 1973a), The management of these reactions varies That is, children who receive Dexedrine or fairly depending upon the clinician. Some feel treat- high doses of Ritalin gain less height and weight ment should be discontinued when medication than expected if not placed on medication. How- producespronouncedmood changesor ever, when drug treatment is stopped, children suppression of adaptive behavior (Schein & show a growth rebound, an increase in growth Reynard. 1975; Schleifer et al.. 1975), while oth- rate that compensates for the slower rate while ers see this as an indication to decrease dosage on medication (Safer, Allen, & Barr, 1975). On (Safer & Allen, 1976). Esther Sleator, research the other hand, well controlled studies of hyper- pediatrican at the Institute for Child Behavior and active children receiving low and moderate doses Development, stated that she observed these re- of Ritalin have failed to demonstrate growth actions in hyperactive children primarily on higher suppression (McNutt, Boileau, Cohen, Sprague, dosages of Ritalin (greater than .7 mg/kg). She & von Neumann, 1977). also noted that reducing the dosage not only The Pediatric Advisory Panel of the Food and eliminates this side effect in most children but Drug Administration recently reviewed allthe produces a more desirable therapeutic response available literature about stimulants and growth from the standpoint of cognitive performance suppression (Roche, Lipman, Overall, & Hung, (Sleator. 1978). in press). It was concluded that "stimulant drugs, Stimulant drugs also have an effect on the car- particularly in the 'high normal dose range, diovanular system. Ritalin,for example, has moderately suppress growth in weight . but been shown to increase both blood pressure and early growth suppression during teatment is no heart rate (Ballard, Boileau. Sleator, Massey. & longer evident in adulthood." The evidence for Sprague, 1976). Unlike most other unwanted re- any suppressed growth in height is inconclusive. actions associated with stimulants, children do Because there may be some children who are not appear to develop a tolerance for these drug affected to a greater degree than others, treat- induced changes. Although there is considerable ment should be carefully monitored and drug variability across children in terms of the degree free periods (sLmmer vacation, holidays) should of change in heart rate and blood pressure, the be scheduled when possible. 26. CHILDREN ON MEDICATION

REBOUND EFFECT OF STIMULANT DRUGS a longer lasting effect than the tablets. Children on Ritalin show their best performance on learn- For parents, a most frustrating reaction to stim- ing tasks approximately 2 hours after taking ulant treatment is the rebound effect. which is re- medication (Swanson el al.. 1978). Four hours porledly not uncommon. This occurs when the after ingestion of ihe drug. it has already lost half therapeutic benefits of the drug wear off usually of its peak effectiveness, in the late afternoon or early evening. This may Using behavioral ratings, some researchers also be a problem when drug free periods are have demonstrated lhat one close of medication scheduled on weekends. Presumably, the level in the morning is adequate for an entire school of the drug in the blood drops, and the rebound day (Safer & Allen, 1973b; Sleator & von Neu- is a drug withdrawal reaction, When the medi- mann, 1974; Sprague. Christensen, & Werry. cation wears off, the child may be irritable and 1974). However, almost all hyperactive children even more hyperactive than usual. In their study treated with Ritalin or Dexedrine are given a of the effects of Dexedrine on normal (nonhyper- dose in the morning, and between 60 and 70% active) boys, Rapoport et al. (1978), found that receive an additional dose at noon (Gadow, 10 out of the 14 children demonstrated "behav- 1977a, 1978b; Kreger & Safer. 1974). Stimu- ioral overactivity" approximately 5 hours after lants are also given late in the day. One survey taking medication. Other signs of a rebound ef- of hyperactive preschoolers reported that 28% fect were "excitability. talkativeness, and for three of the treated children received Ritalin or Dexe- children apparent euphoria' (p. 562). Although drine in the evening (Gadow, 1977a). The par- there are reports in the literature describing this ents of these children said medication helped phenomenon in hyperactive children (Katz et al., their child go to sleep at night. Cyfert, which is a 1975; Werry & Sprague, 1974). the problems this long acting stimulant, is administered once each may cause the far-Filly are not always empha- day in the morning. The starling dose is usually sized. 37.5 mg which may be increased to 75 mg per day (Safer & Allen, 1976), PAITERN OF TREATMENT Itis common clinical lore that Dexedrine is Information from both the medical literature and twice as potent as Ritalin and. therefore, the av- various surveys indicate that stimulant drugs are erage dose of Dexedrine is half that forRitalin prescribed for people of all ages who are diag- (Safer & Allen,1976). However, comparisons nosed as hyperactive (Or MOD). There are sev- between the two drugs on laboratory learning eral reports of the use of stimulants with infants tasks show they are fairly equal in effect (Spra- and toddlers (Nichamin, 1972; Renshaw, 1974), gue & Sleator, 1976). In actual practice, thedaily and the author has conducted a few interviews dosages of Ritalin and Dexedrine prescribed by with parents of hyperactive children who began physicians are similar (Gadow, 1977a; 1978c). drug treatment between 12 an24 months of There is some disagreement as to what is the age (Gadow, 1977a). Two well controlled studies best dose or dosage range for Ritalin and Dexe- have investigated the use of Ritalin with pre- drine. Some clinicians have found that moderate schoolers (Conners, 1975; Schliefer et al., 1975), dosages (.3 mg/kg- .5 mg/kg) of Ritalin are quite but most research involves children between the effective, while other experts feel that low dosages of 6 and 12 years, Safer and Allen (1975) ages account for many of the cases of drug fail- reported that stimulants had therapeutic value ure (Sprague & Sleator, 1975). Children dodiffer for hyperactive adolescents, and others have greatly in terms of optimal dosage, Some do found these agents to be useful in the treatment quite well on a low dose while others appear un- of adults with MOD (Mann & Greenspan. 1976; changed unless the dose is very high. For this Wender, 1978). reason, most studies on the use of medication Stimulants are relatively short acting drugs. with children start out with a small dose that is Their behavioral effects can be observed within gradually increased until the desired effect is a half hour after taking the medicine orally. A 10 achieved. There are obviously general guide- mg tablet of Ritalin produces a therapeutic effect lines for maximal and minimal limits. The aver- for approximately 3 to 4 hours, and a 20 mg tab- age daily dose of Ritalin is usually 20 to 30 mg let lasts for at least an hour longer (Safer & Allen, with a morning dose of 10 to 20 mg and a noon 1976). There is a time release form of dextroarre dose of 10 mg (Safer & Allen, 1976).Itis not phetamine (Dexedrine Spansule) that produces unusual. however, to find reports that state that HYPERACTIVITY/ 27

the average daily dose of Rita lin is 60 mg or that dose of Ritalin for classroom behavior is, there- some children are receiving as much as 120 to fore, clearly different than that for concentrating 110 mg per day (Gittelman-Klein & Klein, 1976; on a laboratory learning performance task. Al- Renshaw, 1974). though the dosage differences for these two vari- Approximately 10% of the children on medi- ables are significant in and of themselves, side cation for hyperactivity in special education pre- effects are also important. As illustrated, heart grams receive two or more different drugs per rate (dashed line) increases as the dose be- day (Gadow, 1977a; 1978c). The additional drug comes larger, The point where teachers perceive is usually administered in the evening to induce the most improved classroom behavior is also sleep and may be a minor tranquilizer (Atarax, associated with side effects. Vistarit, or Valium), Benadryl, or a hypnotic. Some The results of the Sprague and Sleator (1977) children, however, are treated with a combina- study imply that careful consideration should be tion of; (a) Rita lin and Mellaril (thioridazine), (b) given to dosage adjustment and to the selection Rita lin and Tofranil (imipramine), and (c) Tofranil of treatment obje,:tives.If higher doses are re- and Mellaril (Gittelman-Klein, Klein, Katz, Saraf, quired to control severe behavior problems. side Pollack. 1976; Katz et al., 1975). However, these effects should be carefully monitored. One may combinations are used infrequently in every day well wonder what dosages are typically used by practice (Gadow, 1977a; 1978a). physicians in every day practice. Although data In an important series of studies conducted at are limited, it appears that physicians prescribe the University of Illinois, Sprague and Sleator conservativelyemploying low and moderate (1977) demonstrated that the optimal dose for doses (Gadow, 1977a; 1978d; Sprague & Slea- improving attention on laboratory tasks is differ- tor. 1975). ent than the optimal dose for suppressing behav- The length of time a particular child is treated ior problems. The relationship between dose of with medicatinn depends upon a number of fac- Rita lin and attention, classroom behavior, and tors. Because stimulants can ameliorate the heart rate is presented in Figure 2-3. Learning problems associated with hyperactivity at any (solid black line) refers to the child's perfor- age, it is possible that drug treatment could last mance (percent of correct answers) on the short for many years with some children. Gittelrnan- term memory task which has already been de- Klein. Klein, Katz, Saraf, & Pollack (1976) re- scribed. It is noteworthy that of the three matrix ported that 5% of the hyperactive children in their sizes (3, 9, and 15 pictures), the greatest differ- study no longer required medication after 3 ence in accuracy when dose was changed oc- months of treatment. Sleator, von Neumann, and cured for the group of 15 pictures. Obviously, the Sprague (1974), in a followup study of 42 hyper- larger matrix requires the most concentration be- active children, reported that 26% no longer re- cause the child has to remember a larger num- quired medication after 2 years of treatment, Sol- ber of pictures. Most (65%) hyperactive children ornons (1973) reported on a followup study of 97 gave more correct answers with a .3 mg/kg dose hyperactive children who were treated by family compared to both placebo (10%) and a higher physicians. In that study, the average duration of dose (25%), 1.0 mg/kg. h appears thatif the treatment was 39 months for children still on dose is increased even more, Rita lin will signifi- medication and 27 months for those no longer cantly impair performance on the short term receiving drug treatment. Itis clear that while memory task. This same dose relationship also some children require drug therapy for relatively holds for latency of response (the amount of time short periods, others are maintained on medica- that elapses before responding). In other words, tion either continuously or intermittently for many hyperactive children take less time to answer years. Pediatricians who treat relatively large and, therefore, appear less inattentive. Behavior numbers of hyperactive children have com- problems, on the other hand, become less and mented that many of their patients are main- less apparent as the amount of medication is in- tained on medication through high school and creased (dotted line). Using the AIRS, teachers into college if necessary. Because there is no rated 72% of the hyperactive children as behav- real way to tell if drug therapy is still necessary ing their best on the highest dose. Only 28% re- other than by a temporary break in treatment, ceived their best AIRS score on .3 mg/kg, and drug free periods are an important aspect of fol- none of the children showed their greatest im- lowup care. Some clinicians have argued that by provement in behavior on placebo. The optimal starting the child in school off medication, the 28/CHILDREN ON MEDICATION

Learning 010 Teacher ,e1.6 Heart Rate 73 95.7 7 71 9 70 69 10 68 67 66 CDi 0 65 13

0c 64 14 063 15 0-62 I6 61 60 17 5.2 59 `"`"---.nr 84.1 18 58 57

Placebo 0.3 1.0 Dose (mg kg)

FIGURE 2-3 Three different target behaviors produced threedifferent dose response curves. The learning curve represents accui :icy on a short term memory task(matrix size - 15 pictures); the teacher curve repre- smaller sents social behavior as rated by the teacher.who used a scale on which the numbers become as the child improves; and the heart rate curve(means placed on tke data points) indicates the number of beats per minute. (From Sprague, R. L., &Sleator, E. K. Methylphenidate in hyperkinetic children: Differences in dose effects on learning and socialbehavior. Science, 1977, 198, 1274-1276, Copy- permission.) right 1977 by the American Association forthe Advancement of Science. Reprinted with

3,, HYPERACTIVITY/29

continued need for treatment can be reasses cases, the physician may give an alternative on a yearly basis (Arnold, 1973), agent for a trial period. A wide variety of nonsti- Although there is no shortage of discussion mutant drugs have been used, including major with regard to placing a child on medication or tranquilizers, antidepressants, minor tranquiliz- making diagnostic decisions, there has been lit- ers, anticonvulsants, and others. Because major tle research about how to terminate treatment. tranquilizers are discussed at length in Chapter O'Leary and Pelham (1978) conducted a study 4 and anticonvulsants in Chapter 3, they will not in which seven hyperactive children receiving be further covered here. stimulants were taken off medication and sub- Tofranil (imipramine) is an antidepressant that sequently treated with behavior therapy, Before has been used to treat hyperactive children (Ra- treatrnent was started, each child was placed on poport. Quinn, Bradbard, Riddle & Brooks, 1974). placebo for a short time to determine how bad The total daily dose ranges from 50 to 180 mg his classroom behavior really was. When the usually divided into three doses of 50 mg or 7E., study began, medication was either stopped im- mg per day (Winsberg, Yepes. & E3ialer, 1976). mediately or terminated after gradual dosage re- The -major side effects are drowsiness, dizzi- duction. For 4 months, the child's teacher and ness, dry mouth, nausea, increased appetite, family were guided by a behavioral therapist and weight gain. Mar,children develop a toler- while implementing behavior modification tech- ance to the therapeutic response (Quinn & Ra- niques, The main focus of the treatment program poport, 1975). Some serious side effects have was the child's social behavior (conduct prob- been reported. For example, Tofranil may lower lems). The following month, both teacher and the seizure threshold, especially in brain dam- family carried out the program on theown. At aged children (Brown, VVinsberg, Pia ler, & Press. the end of the fifth month, the childrePti were re- 1973), Also one death has been reported in the evaluated. The results showed drarnatc im- case of a 6 year old girl who was administered provement in social behavior to the point where 300 mg (14 mg/kg) of Tofranil in one dose before the hyperactive children were not significantly bed (Saraf, Klein, Gittelrnan-Klein & Groff, 1974). different from their peers. The investigators noted A major use of Tofranil with children is in the that although the effects of their withdrawal and treatment if enuresis. This is discussed further treatment program were encouraging. "behavior in Chapter 5. therapy is more expensive than drug treatment The antihistamine Benadryl is sometimes used and should not be expected to benefit families with hyperactive children. Fish (1971) found the who are not well motivated to attempt such an drug particularly effective with children who had alternative to medication" (p. 216). severe behavior problems.It is also adminis- Very little information is available about how tered at bedtime to calm a child down (Arnold. and why medication is terminated in real world 1973; Gadow, 1977a), The dose to induce sleep settings. Two studies in which the parents of hy- is 50 to 100 mg, and, for daytime use, 100 to 200 peractive children on medication were inter- mg per day (Safer & Allen, 1976). viewed showed that therapeutic improvement Two minor tranquilizers. Atarax and Vistaril, was not the major reason for stopping drug ther- are used infrequently. Their effectiveness in the apy (Gadow, 1977a, 1978c). Parents often cite management of hyperactivity is questionable, side effects, rebound effects, acquired tolerance but they may be used in the evening to induce for therapeutic response, and failure of the drug sleep (Gadow, 1977a: Greenberg, Deem & to work effectively as reasons for taking their McMahon, 1972). child off medication. One of the major reasons why medication is stopped during adolescence is that teenagers often refuse to take pills be- OTHER TREATMENTS cause it sets them apart from their peers and contributes to feelings of being "different" (Safer A variety of other treatments have been pro- & Allen, 1975; Sleator, 1978). posed for the management ofhyperactivity. These include the use of coffee (caffeine), me- NONSTIMULANT DRUGS gavitamins, a diet free of food additives, and behavior therapy. As previously stated, not all hyperactive children Ross and Ross (1976) reviewed five studies in respond favorably to stimulant drugs, In such which coffee or caffeine was used as a treatment 30f CHILDREN ON MEDICATION of hyperactivity and found the results were in- of such cases than was originally claimed by conclusive. While some researchers found ther- Feingold. apeutic benefit, others showed that coffee was Feingold has also stated that if a child who is no better than placebo and certainly not aseffec- placed on the K-P diet and responds well eats tive as stimulants in controlling hyperactivebe- food containing artificial food colors and/or fla- havior. At this point, further research is neces- vors, his or her hyperactivity will reappear within sary to determine it coffee suppressesbehavior a few hours after the dietary infraction.Investi- problems and enhances the ability to pay atten- gations into this hypothesis using children who tion in hyperactive children. respond favorably to the diet are inconclusive. Cott (1972) hRs argued that megavitamins While the results of some studies support this should be used to treat hyperactive children. To claim, others do not (Conners, 1978). date, there have been no well controlled studies To date. there is only one report on the effec- that support this claim. tiveness of the K-P diet in comparison with an- Perhaps the most hotly debated treatment for other treatment (Williams, Cram, Tausig, & hyperactivity is the KaiserPermanente (K -P) diet, Webster, 1978). It was found that stirnulant drugs also called the Feirigoid diet (Feingold, 1974), were more effective in controlling the behavioral The diet consists of eliminating foods that con- symptoms of hyperactivity than a diet free of ar- tain artificial food coloring (especially redand tificial food colors and flavors. yellow dyes), BHT (butolated hydroxy torulene) People often ask, "What harm does it do to try a food preservative, and naturalsolicylates (in a particular unproven treatment?" Theprimary foods such as apricots, prunes, raspberries, to- problem with this point of view is that the use of matoes, and cucumbers). AlthoughFeingold a worthless method only denies the child a never conducted well controlled studies that doc- meaningful approach to his or her therapeutic umented the effectiveness of the diet, he claimed needs. One might wonder. "What's wrong with that 30 to 50%, of the hyperactive children would at least giving it a try?- The problem here lies show marked behavorial improvement on an ad- in the expectancy effect. If we want or expect ditive free diet. Surveys show that between 20 something to happen, it is not unusual to per- and 35% of the hyperactive children who have ceive events as Lying the way we think they been on medication were also placed on this diet should be, or want them to be, Therefore, a use- (Gadow. i978c; Lambert, Sandoval, & Sassone, less approach may appear to be a "cure." If the 1978). Ir., order to test this hypothesis scientifi- remedy is associated with a strong placebo ef- cally, a r,'- search team at the University of Wis- fect that benefits thechild, one might ask, consin conducted a study with 46 children diag- "What's wrong with that?" If there really is an nosed as hyperactive (Harley,Ray, Tomasi, improvement in the child's condition for what- Eichman, Matthews, Chum Cleeland, & Trais- ever reason, so much the better. However, if man. 1978), These researchers purchasedall problems persist, using the placebo is not a so- the groceries for the participating families during lution and its use may also serve to divert the the 8 week study as well as buying snacks for therapist's attention away from more germane special activities at school (e.g., birthday parties. remedies, holidays). To control for any biases the family re- Another approach to managing hyperactive ceived the K-P diet for 4 weeks and the fake (pla- children and one for which there is considerable cebo) diet for 4 weeks. In addition, the K-P diet support, clinical and research, is behavior modi- was disguised by using specially prepared com- fication(Ayllon,Layman, & Kandel,1975; mercial foods that normally contained additives O'Leary, Pelham, Rosenbaum & Price, 1976). but were really additive free. After collecting nu- Because behavioral techniques can be used merous measures on behavior at home,school, successfully with these children, many have ar- and in the laboratory, the researchers did not find gued that they should be tried before medication. the K-P diethelped hyperactive elementary In terms of educational programing, behavior school children. Because another researcher has modification is perceived by some as a "less re- found that the K-P diet works for some children strictive" approach than drugs to the ameliora- (Conners, Goyette, Southwick, Lees, & Andru- tion of learning problems. Research into the rel- lonis, 1976). the issue is still unresolved. If,for ative effectiveness of these two treatments is whatever reason, the K-P diet helps hyperactive certainly called for. However, at this writing, only eft i- children. itis so for a Much smaller percentage one study has been reported comparing the HYPERACTIVITY /31

cacy of medication, in this case (Rita lin), and be- which treatment approach is most appropriate? havior modification (Gittelman-Klein, Klein, Abi- In recent years. hyperactivity has been one of koff, Katz, Gloisten. & Kates, 1976). In that study. the most heavily investigated topics in pediatric severely hyperactive and disruptive children were medicine, child psychology, and education.It is assigned at random to one of three different hoped that the products of these efforts and fu- groups: (a) combination of Ritalin and behavior ture research will provide insight into the care of modification, (b) Ritalin alone, and (c) combina- these often unhappy children who frequently en- tion of placebo and behavior modification. All counter frustration and failure in an environment three treatments significantly reduced behavior poorly adapted to their needs. problems as measured on rating scales. How- ever, the group receiving only Ritalin was rated SUGGESTED READINGS as significantly more improved than the children in the behavior modification-placebo group. The Anesko. K.,O'Leary.B.G., & Shoiock, G. children in the combined Ritalin-behavior modi- Homework hassles: How to handle them. fication group were rated just slightly better than Available from Dr. Susan O'Leary, Dept. of those in the Ritalin only group. Psychology. Stale University of New York. While these results are interesting. they per- Stony Brook NY 11794. (P) tain to a specific group of children studied for an Barkley. R. A A review of stimulant drug re- 9 week period. If the dose of Ritalin were lower. search with hyperactive children. Journal of the children less hyperactive, or the behavior Child Psychology and Psychiatry. 1977, 18, modification program less intense, the outcome 137-165. (M. T) may have been different. It is not known what the Becker, W. C. Patents are teachers. Champaign comparative long range effects of these different IL: Research Press, 1971. (P) treatment approaches are for such studies have Bosco, J. J.. & Robin. S. S. (Eds.). The hyper- not been done. Itis possible that a long term active child and stimulant drugs. Chicago: study may show that behavior modification is University of Chicago Press, 1976. (M, T) equal or superior to Ritalin. However. there are Cantwell. D. P., & Carlson, G. A. Stimulants. In major problems with the 1:ng term implementa- J. S. Werry (Ed.), Pediatric psychopharma- tion of rigorous behavior modification both in cology: The use of behavior modifying drugs terms of research methodology and practical lim- in children. New York: Brunner/Mazel, 1978. itations in home and classroom settings (Mash & (M) Terdal, 1977). Gadow, K. D. Psychotropic and antiepileptic To restate a point discussed previously. long drug treatment with children in early child- term studies have not been conducted compar- hood special education. Final Report, Grant ing the effects of drug treatment and behavior No. 00-75-00-381, Office of Education, Bu- modification (or specialized learning programs) reau of Education for the Handicapped, Au- on school achievement, However, a growing gust 1977. (ERIC Document Reproduction number of investigators are demonstrating that Service No. (EDI 62494). (T) special training programs (Douglas, Parry, Mar- Loney, J. Childhood hyperactivity. In R. H. Woody ton, & Gerson, 1976), classroom organization (Ed,), Encyclopedia of clinical assessment. (Flynn & Rapoport, 1976) and modifications in San Francisco: Jossey-Bass, in press. (M, T) teaching methods (Zentall, 1977) can either ef- O'Leary. K. D.,& O'Leary, S. G. Classroom fect changes in the behavior of hyperactive chil- management: Successful use of behavior dren or create an environment more suitable to modification (2nd ed.). New York: Pergamon. the child's style of learning. Much research has 1977. (T) yet to be done in these areas. After effective Ounsted, C. The hyperkinetic syndrome in epi- techniques are developed, questions similar to leptic children. Lancet, 1955, 2, 303-311. (M) those posed about drug therapy will remain: Do Patterson. G. R. Families: Application of social these new methods make a difference in long learning to family life (Rev. ed.). Champaign term outcome with hyperactive children? How IL: Research Press, 1975, (P) effective are they in comparison to other thera- Patterson, G. R. Living with children: New meth- peutic measures (including medication)? And, ods for parents and teachers (Rev.ed.), are the differences among children,families. Champaign IL: Research Press, 1976. (P, T) schools, and physicians important in deciding Ross, D. M & Ross, S. A. Hyperactivity: Re- HILDREN ON MEDICATION

search, theory, and action. New York: John ders. Pediatric Clinics of North America, 1973. Wiley & Sons, 1976. (M. T) 20. 719-735. (M, T) Safer, D. J., & Allen, R. P. Hyperactive children: Sprague, R.L., & Worry, J.S. Psychotropic Diagnosis and management. Baltinicre: Uni- drugs and handicapped children. In L. Mann & versity Park Press, 1976. (M, T) D. A. Sabatino (Eds.), The second review of Sprague, R. L.. & Berger, B. D. Drug effects on special education. Philadelphia: JSE Press. learning performance: Relevance of animal re- 1974 (M, T) search to pediatric psychopharmacology. In R. Stewart, M. A., & Olds. S. W. Raising a hyper- M. Knights & D. J. Bakker (Eds.), Rehabilita- active child. New York: Harper & Row. 1973, tion, treatment and management of learning disorders. Baltimore: University Park Press, in (P) press. (M, T) Wender, P. H. Minimal brain dysfunction in chil- Sprague, R. L.. & Gadow, K. D. The role of the dren. New York: Wiley-Interscience, 1971. (M) teacher in drug treatment. School Review, Williams. D. L., & Jaffa, E. B. ice cream, poker 1976,85.109-140. (T) chips, and very goods: A behavior modifica- Sprague, R. L.. & Sleator, E. K. Effects of psy- lion manual for parents. College Park MD: chopharmacologic agents on learning disor- Maryland Book Exchange, 1971. (P. T) 3/Convulsive Disorders

Most discussions of medical disorders prepared oerience that many parents use terms such as for nonmedical audiences are encumbered with seizures, convulsions, and spells when referring the necessity to Jefine terms, and the topic of to their child's disorder. In addition, these terms convulsive disorders in children is no exception. seem to be more br,haviorally oriented in that The primary symptom of a convulsive disorder is they focus on the visible features of the disorder, a seizure. To an observer, a seizure is a sudden the reason for which drugs are prescribed, and attack, usually manifested by a complete or par- the yardstick against which the effectiveness of tial loss of consciousness and accompanied by medication is measured (i.e.. seizure suppres- involuntary muscle movement or a cessation of sion). body movement. If the seizure involves violent, Recurrent seizures are sometimes classified involuntary contractionsof skeletal muscles according to what is known about their cause. If (convulsion), it may be referred to as a convul- the cause of the seizures is unknown, they are ilve seizure. A distinction is sometimes made said to be idiopathic. In approximately one fourth between convulsive (grand mal) and nonconvul- to one half of all cases of epilepsy. the cause of sive (petit mai) seizures. In this discussion, the the seizures is unknown. Idiopathic epilepsy is :erms seizure and convulsion are used inter- more common among children with seizures, es- tangeably, pecially those over 4 years old, than among Seizures are caused by a sudden discharge of adults. Seizures that develop as a result of per- electrical energy in the brain. The actual reason manent, nonprogressive changes or damage to or these discharges and the greater susceptibil- the brain are called secondary or organic epi- ty to them for some people remains obscure. lepsy. For example, convulsions that develop knyone can have a seizure ifthe appropriate after a head injury sustained in an automobile itimulus Causes an electrical discharge in the accident would be secondary seizures. One wain. Such stimuli could be associated with cer. should not infer that the head trauma is the sole ain types of infections, poisons and drugs, aid cause of the disorder because not all children len oxygen deprivation, metabolic disturbances, with equal degrees of head injury develop sei- ind a number of other factors. Seizures are con- zures. It is quite possible there is a complex in- idered to represent a convulsive disorder only teraction between an unknown factor(s) and the Then they are recurring in nature. Recurring sei- trauma that causes a convulsive disorder. This ures are frequently referred to as epilepsy, and same unknown entity may also cause idiopathic ifs is the preferred term for designating such epilepsy. eizures according to groups such as the Epi- The actual sensory and motor phenomena as- )psy Foundation of America and the National sociated with the seizure depend upon which pilepsy League. However, it has been my ex- cells in the brain are affected by the electrical

1 34/CHILDREN ON MEDICATION

during their discharge. If only pan of the brain isaffected the leans will have epilepsy at some time the Epilepsy Foundation of resulting seizure is considered focal.Symptoms lives.Similarly, America (1975) has adopted a 2%prevalence of the attack might be thetwitching of a finger or rate for convulsive disorders inthe general pop- arm, a strange sensation, or achange in mood. If the electrical activity affectsthe entire brain, ulation. One of the reasons many studies haveunder- the resulting seizures are saidto be generalized. estimated the extent of this disorder isthat un- Examples of generalized seizures aregrand mal, treated persons are frequently excludedfrom petit mal, and myoclonic. It shouldbe noted that survey studies, and, of course, manycases go a seizure could originate as afocal seizure but undiagnosed. Recently, efforts have beenmade progress into a generalizedseizure. For exam- to detect undiagnosed and untreated casesof ple, a true Jacksonian seizure,rarely found in epilepsy. Using a combination ofdiagnostic and children, is a focal seizure that maybegin by a Penry, Markush, Rad- twitching in a finger of the right hand,which pro- survey techniques, Rose, loff, and Putnam (1973) reported a"reasonable" gesses to jerking movementsof the hand and prevalence rate of 18,6 cases of epilepsy per right arm, then to twitchingmovements on the right side of the face continuing ondown the 1,000 among third grade children. same side of the body(Livingston, 1972). The Although dozens of studies have been con- jerking movements then spread tothe other side ducted on the prevalence of epilepsy per se, the attack, the there are few published statements aboutthe of the body. During this part of disorder individual usually remains conscious.The sei- prevalence of drug treatment for this among school age children.Gadow (1976, zure is focal in thatspecific motor areas of the 1978a) reported that at least 6.6% of thechildren brain are affected. The electricaldischarge then spreads throughout the brainculminating in a in early childhood special education programs of the students in classrooms for the generalized grand mal seizure duringwhich the and11.9% trainable mentally retarded receivemedication individual is unconscious. for convulsive disorders at some timeduring the Much of the discussion in this chapteris based school year. Approximately 30% ofthe residents on the clinical experienceand research efforts of in facilities for the mentally retarded receivedrugs Dr. Samuel Livingston, Director,Samuel Living- Treatment Center. for seizure control (O'Neill, Ladon,Harris, Riley, ston Epilepsy Diagnostic and & Abelson, Baltimore, Maryland. Over the past40 years, he & Dreifuss, 1977; Pay_ ne, Johnson, 1969). Assuming the prevalence figuresbased has treated 38.000 epileptic patients,most of first began. on school children identified andtreated for con- whom were children when seizures de- His publications not only provide abroad data vulsive disorders are also a fairly accurate between 0.3 base, but also a consistentconceptualization of scription of the extent of drug use, of inconsisten- and 0.6% of the students in regularclassrooms the field. Because of the number (Force, 1965). It convulsive disorders are on medication for epilepsy cies in the literature about of children and the variety of treatmenttechniques em- is clear that a much greater proportion in special education programs receiveantiepi- ployed by physicians, Livington'sposition is used which other opinions are leptic drugs. as a standard against people with measured (Livingston, 1972, 1978a,1978b)- At least three-fourths of all the epilepsy experienced their first seizurebefore the age of 20 (Lennox, 1960). Thehighest inci- PREVALENCE OF CONVULSIVE dence rates (number of new cases) arefor in- DISORDERS fants from birth and 2 years, childrenbetween (the onset Due to a number of factors, there isconsiderable the ages of 5 and 7. and adolescents for fe- variability in the prevalence of epilepsy reported of puberty). The latter is particularly true with their from study to study. Actual prevalence rates males who may experience seizures range from 1.5 to 20 cases per 1,000with a me- first menstruation (Livingston, 1972). dian of 3.8 people with epilepsy for every1,000 in the general population (Meighan,Queener, & CLASSIFICATION OF CONVULSIVE Weitman, 1976). However, many epileptologists DISORDERS believe most prevalence studies underestimate Most convulsive disorders can be categorized as the true extent of convulsive disorders.Living- However, ston (1972), for example, feels that 1 in50 Amer-- belonging to one of several groups. CONVULSIVE DISORDERS/35

there are a number of different c'isification mal seizures. The actual seizure consists of two schemes, and often several different terms are phases: a tonic phase in which the body be- used to denote the same seizure type. For lay comes very rigid, followed by a clonic phase that people and professionals alike, this proliferation consists of jerking movements of the limbs (con- of terms creates both confusion and misunder- vulsions), Typically, there is a sudden loss of standing. This problem is not peculiar to the consciousness, the body stiffens (tonic phase), study of convulsive disorders, as one who has and, if standing, the child falls to the ground in familiarity with the literature about learning dis- the direction he or she is leaning. Breathing abilities and hyperactivity well knows. For many stops and the face may turn pale. This is fol- people, scientific jargon is both an inconven- lowed by jerking movements of the body and ience and an irritant. We often wonder if these limbs (clonic phase). The child's breathing makes name games are really necessary, and. if so, a snoringlike sound. During the convulsive phase how meaningful they are. However, in the case of the seizure, the child could bite his or her ton- of convulsive disorders, a convincing argument gue or cheek, urinate, or defecate. can be made for acquiring some basic informa- If the seizure is of short duration (3 to 5 min- tion about the different types of epilepsy and for utes), the child is usually able to resume his or categorizing them accordingly. her regular activities shortly after the attack.If Seizures differ in terms of their pattern, fre- the seizure is long lasting (up to an hour or quency. and duration as well as the age at which more), it may be followed by deep sleep. Itis they usually begin, The prognosis and response best to let the child sleep since attempts to to treatment varies depending upon the type of awaken him or her will not be successful. Many seizure, and, central to this discussion. the type children, after awakening from a post convulsive of drug the physician selects has a lot to do with sleep, will exhibit any of a variety of different re- the kind of seizure the child is being treated for. actions to the seizure, including fatigue and sore Because basic information about a child's sei- muscles, nausea or headache, and behavioral zures can provide the teacher with some under- changes such as irritability, restlessness, or even standing of the treatment process, particularly aggressivity, It does little good to scold or punish medication, the topic of classificationisdis. the child during this period. If the child's behav- cussed in some detail. ior is harmful to others, he or she may have to be In the not too distant past, seizures were gen- isolated from his or her peers until this phase of erally categorized as being either grand mal or the seizure passes. Postconvulsive reactions may petit mal. However, the development of more so- last from a few minutes to even a day or longer. phisticated diagnostic techniques, discovery of The frequency of major motor seizures varies new antiepileptic drugs, and a more rigorous in- greatly among children. Some have many con- vestigation of response to treatment prompted vulsions per day while other children have only an appreciation for the various types of seizures. one seizure every few years. There are at least three different approaches to classification: electroencephalographic readings It must be emphasized that what has been de- (EEG), presumed cause or origin of the electrical scribed here is a "typical" grand mal seizure. In discharge in the brain, and the outward appear- reality, the actual behavioral changes may vary ance of the seizures. Livingston (1972) proposed considerably. For example, the entire seizure five major types of childhood epilepsy based on may consist of only a tonic phase or only a clonic EEG findings and the overt appearance of the phase. Also,the child may simply go limp seizures: major motor (grand mal), petit mal, (atonic) dropping to the ground as if he or she psychomotor (temporal lobe), myoclonic and had fainted without either a tonic or clonic phase. autonomic. Each of these is described in the fol- Unconsciousness may be complete or partial. lowing sections in terms of the age at onset, fre- It is not unusual for a child with grand mal sei- quency and duration of seizures, and EEG find- zures to have a normal EEG reading. In one ings. These data are summarized in Table 3-1. study of 3,101 patients with major motor sei- Major Motor (Grand Mal) Seizures zures, a third had normal EEG patterns between seizures both while awake and during sleep (Liv- By far the most common type of seizure is major ingston, 1958). There are,of course, gross motor (grand mal). Approximately 80% of the changes in the EEG during the seizure as well children with convulsive disorders have grand as in the postconvulsive phase. TABLE 3-1 Clinical and EEG features of classificationsl types of epilepsy observed in children' . . EEG Findings Type of Epilepsy Age at Onset Seizure Pattern Duration of Seizure Frequency of Seizures Nonspecific" abnor- Motor Motor May occur at any age Generalized Variable: moat corn- Variable malities: inlerSeiZure (grand malt tonic-clonic manly. several to 5 tonic minutes or se: how- tracing may be normal dome ever may last as long atonic as one hour or longer Focal Petit Mal Usually between 4 andSimple staring (most 8 years, rarely before frequent) Always brief Daily. frequently as Diffuse. bilaterally 3 or after 15 Staring with clonic (momentary) many as 50 to 100 persynchronous spike and movements day wave forms usually Staring with automa recurring at frequency tisms of 3 per second

I daily in many patientsEpileptiform dis- Most Commonly in Manifestations vary Usually lasts seve Psychomotor charges. usually older children and considerably: most minutes or so (temporal lobe) spikes. from the ante- adults commonly autornatisms consisting of nor temporal areas in staring episodes with most patients. particu- smacking of lips larly in the older child and adult. In some pa- chewing movements tients. the EEG re- mumbled speech: confused states, bi- veals other types of zarre motor and or electrical abnormali- psychic performances ties: occasionally interseizure tracing is normal Individual spell very Usually daily Hypsarhythmia Myoclonic During the first year ofFlexor spasm of mus- Infants life most commonly culature resulting in brief. several seconds between 3 and 9 massive myocloriic or so. spells frequently months Seizure in recumbent recur in clusters last- position. and head ing several minutes dropping attack in sitting extensor spasm of musculature occurs less often

Modified hypsarhyth- fvtyolconic Ater 2 years of ago. Flexor spasm of mus- Very brief. several Daily. weekly Older Children most commonly be- culature resulting in seconds or so mm tween 3 and 7 years head dropping attack when mild. and pre- cipitous fall forward when severe; extensor spasm of musculature occurs less often 1972 Reprinted cuing y of Ohatlos C Thomas Peplishef. NateF tam S Lteinestco congrenenuse r.f.agementafeolopsy rn ifIlanevahrtatInad and adolescence. Sloop This etassihcatien is potently ereployed at the Sarinnei Lwalastan Cptlepsy Diagnose and Treatment Center By nonspecific we pearl electreencephaleptaphe annottnahhos new than (1) the classic dilluse. bilaterally synchronous spike =wavetoots which usually recut at a frequency E-J1 3 per shoos and rzr hyosathythoos These ten down& al:MOM/epos are. in our espetesece. found inessentially 011 potion with petit tool epilepsy and nlyodonic epilepsy: iv5pecwviv lope epilepsy. These eleetricot aberrations are Electrfeal annotetaleot usually C6113!throg of spruce, Folioed le the an$etrat temporal areas are relatively specific 10, pSythofflOtor pfflpOrgi occestonally assented in the eleconencephalogtnetS 01 patients who present clinical eyclenee of other types of epilepsy, paniptlany motmotor epilepsy. CONVULSIVE DISORDERS/37

A seizure is sometimes preceded by an aura seizures are associated with both diseases of or brief warning that an attack will follow. In fact. the brain (e.g., meningitis and encephalitis) and the aura is actually a part of the seizure. The epilepsy. aura may take many forms: (1) sensory auras, Grand mat status and prolonged grand mal which may be manifested by a "funny feeling in seizures are genuine medical emergencies. and my stomach," dizziness, tingling sensation. or caretakers should respond accordingly. Serial impaired vision; (2) psychic auras. examples of grand mal seizures. on the other hand. are not which are anxiety, fears, confusion, and aberrant life threatening but should receive immediate behavior; and (3) motor auras, which include medical attention. movements of the limbs, twitching, or jerking Petit Mal Seizures (Absences) movements resulting from contractions of the skeletal muscles. Auras can be very helpful to a Petit mal seizures (absences) are typically man- child by warning him or her that a seizure is im- ifest as a sudden. brief loss of consciousness. minent, thus allowing time to prevent a fall. (They The child stares vacantly into space for several may also provoke an anticipatory fear reaction.) seconds. and occasionally the eyes will roll back. Clearly identifiable motor auras have also been The actual seizure lasts from 5 to 30 seconds. used inbehavior modification programs de- with up to 50 or 100 "spells" per day. Petit mal signed to suppress seizures (Ziutnick, Mayville. spells may come in groups or "showers" partic- & Moffat. 1975). In one study, upon observing an ularly within a few hours after awakening in the aura, teachers and parents were able to prevent morning. In some cases. the staring episodes the seizure by simply holding the child and firmly are accompanied by slight clonic movements saying. "stop." Although this appears to be a (sudden contraction of the muscles) involving the promising new technique for some children with eyebrows, eyelids. head. and arms at a rate of uncontrolled seizures, much research remains to a rate of three per second. There may be rhythmic be done in this area (Mostofsky & Balaschale blinking of the eyes. Petit mat seizures may also 1977). be associated with automatisms which are motor Sometimes children will have one seizure after acts that appear purposeful but are exhibited in another (status) or one long seizure (prolonged) the wrong setting. Some examples of automa- for an extended period of time (Livingston. tisms in children are chewing and swallowing 1978b). These can be frightening experiences movements, lip smacking, and mumbled speech. for teachers, parents. and direct care personnel These are not to be confused with psychomotor in residential facilities. Grand mat status, com- seizures which are also manifested by automa- monly referred to as status epilepticus. is one tisms. complete grand mal seizure after another which Although many educators are aware of the continues from many hours to several days. The terms grand trial and petit mal, true petit mat sei- child does not completely regain consciousness zures are not very common. Only 2 to 3% of all between seizures. As the seizures persist. the individuals with epilepsy and 6 to 12% of the chil- child becomes more comatose. dehydrated. and dren with convulsive disorders have petit mai exhausted. Most children experiencing grand mai spells (Currier, Kooi, & Seidman, 1963). Petit status recover. however, death is possible. If the mai seizures are truly a disorder of childhood. child regains consciousness between attacks, The most common age at onset is between 4 the condition is referred to as serial grand mal and 8 years, and the disorder rarely lasts beyond seizures. They are frequently associated with the late adolescence. Few children with petit mal abrupt withdrawal of antiepileptic medication. epilepsy are brain damaged or mentally re- Prolonged grand mal seizures differ from status tarded. in that the child experiences one long seizure There is such a thing as petit mat status in lasting a few hours or even longer. The seizure which the child experiences almost continuous is a prolongation of the tonic or clonic phase. petit mat spells that may last from an hour up to usually the latter, followed by a longer than usual a day or longer. Livingston, Torres, Pauli, & Ri- postconvulsive state. Prolonged grand mal sei- der (1965) reported on a series of 117 patients zures differ from grand mai statusin that the with petit mai spells. Of the 111 who did not have people experiencing the former do not have a re- evidence of brain damage prior to the onset of currence of either the tonic or clonic phaseafter seizures, seven later exhibited intellectual im- the seizure has terminated. Prolonged grand mal pairment. Six of these children had frequent epi- 38 / CHILDREN ON MEDICATION

sodes of petit mal status. Although the causal tion with characteristic EEG discharges (Living- mechanisms are unknown. Livingston feels the ston, 1972). relationship merits consideration. Before aberrant behavior is considered a man- In the case of petit mal seizures, the EEG find- if estation of epilepsy. it must also be accom- ings are particularly diagnostic (three per second panied by epileptiforrn EEG findings during the spike-wave forms). This abnormality is detected behavior in question. If the child's EEG reading in most children in the resting state but can be is also abnormal between the behavioral events easily induced by a few minutes of hyperventila- that are under investigation, the diagnosis of tion. Petit mat spells are never preceded by an "behavioral disorder with abnormal EEG" is as- aura or followed by a postconvulsive state. signed. It is noteworthy that just because a child Many children with petit coal spells later de- with an abnormal EEG concomitant with a be- velop other types of seizures, typically grand havior disorder responds to anticonvulsants does mat, during adolescence. The highest incidence not mean he or she has epilepsy. Child and fam- rates are for children between 10 and 13 years ily expectations about improvement with medi- of age (Livingston, Torres, Pauli, & Rider, 1965). cation can produce behavioral change. Well con- The probability that a child will develop another trolled, double blind studies have failed to support seizure disorder is influenced both by the drug the effectiveness of anticonvulsants in the treat- regimen and the age at onset of petit mat epi. ment of behavior disorders. However. Schain sodes. Livingston et al. compared the drug regi- (1975) is of the opinion that the possibility of con- men for two groups of children treated for petit vulsive disorder should not be ruled out until fur- mat seizures. One group was administered a ther research is done in this area. drug specifically for petit mat. and the other group Livingston (1972) classified the pyschomotor received both a petit mat and grand mat agent. seizures of children into four categories based Of the group treated with only the antipetit mat on their outward appearance (clinical features): drug. 81% later developed grand mat seizures. 1. Arrest of activity with staring. The staring compared to 36% of the children receiving both episode is usually brief but longer than petit a grand mal and petit mal agent. mal spells. A differential diagnosis can be As noted, the other variable that increases the made from EEG findings. This type of psy- probability of developing other types of seizures chomotor seizure may last up to 5 minutes, is age at onset. Generally, the older the child at the time of the first petit mal spell, the greater the 2. Arrest of activity with staring followed by likelihood that another convulsive disorder will simple and /or complex automatisms. Im- eventually develop. It is noteworthy that children mediately following the staring episode, the who do develop grand mal seizures subsequent child exhibits automatisrns. As already dis- to petit mal spells have major motor seizures that cussed, these are behaviors that appear to are generally not as frequent, less severe, and be purposeful but are clearly out of context. easier to control with pharmacotherapy, com- Some examples are mouth movements pared to other children with grand mat epilepsy. (e.g.. chewing, lip smacking. drooling, and vocalizations such as mumbling or hum- ming). If the seizure does not terminate at Psychomotor (Temporal Lobe) Seizures this point, it may be followed by more com- Psychomotor (temporal lobe) seizures are man- plex automatisms. Some examples are ifest in a variety of ways including changes in be- picking at clothing or attempting to undress, havior, mood, or sensations. These changes are handling objects, searching for things, associated with a clouding of consciousness and moving around, and bizarre or abnormal a complete or partial loss of memory forwhat behavior. Automatisms are typically ster- happened during the seizure, Just about every eotyped behaviors varying little from sei- conceivable behavioral aberration has been de- zure to seizure. These episodes usually scribed in the literature at one time or another as last a few minutes, but, as with other types a manifestation of psychomotor seizures. In view of seizures, there is considerable variability of this, epileptologists have adopted more strin- in duration from one person to the next, gent criteria for the classification of psychomotor Awareness is almost always impaired to some degree during the seizure, and there seizures,limitingdiagnosis to"well-defined. classical seizure patterns" usually in combina- is no recollection of the attack when it is CONVULSIVE DISORDERS/39

over. Complex automatisms may include Myoclonic Seizures aggressive and antisocial acts. Diagnosis Myoclonic epilepsy is the fourth major group of may be quite difficult in the case of seizures convulsive disorders proposed by Livingston that simulate behavior disorders. Living- which he further subdivided according to age at ston points out that psychomotor seizures onset: infancy and early childhood. This is elab- start abruptly without any apparent precipi- orated below. Myoclonic seizures are manifested tating event, and there is usually no recol- by a twitching or jerking of skeletal muscles lection of the attack. Behavior disorders, on usually of the head, neck, and arms. Generally, the other hand, are often preceded by some they are sudden flexor spasms. An individual triggering event and the person usually re- muscle may contract or an entire limb may be members what he or she has done. involved. There is no apparent loss of conscious- 3. Arrest of activity with staring followed by ness during the attack. These seizures may oc- pulling of the head and body to one side cur a few at a time or in a series one after an- with concomitant automatisms. Following other. What the seizure will look like depends a brief staring episode, the muscles appear upon the age of the child and position of the body to tighten as the head and body turn to one when the seizure begins. A variety of different side. and an arm may extend in the direc- terms are used to denote seizures associated tion of the turn. As stated, this rotary move- with myoclonic epilepsy, and some clinicians ment is accompanied with simple automa- make distinctions among the seizures as sepa- tisms that may become complex ifthe rate types of myoclonic epilepsy. seizure does not terminate immediately. Myoclonic epilepsy of infancy (also known as The entire attack may be brief, lasting from infantile spasms, hypsarhythmia, massive my- 30 seconds to several minutes. The child oclonic seizures) develops during the first year, typically does not remember what hap- usually between the third and ninth month. If the pened during the seizure. child is lying down, seizures may take the following form: flexion of the head forward, outward 4. Psychic seizures. These consist of a vari- thrust of the arms, and flexion of the thighs up on ety of sensations (e.g., tingling, numbness, the abdomen. It may be Quite difficult to discrim- sensations of hot and cold. pleasure), dis- inate these seizures from normal infant activity torted thought (e.g., hallucinations, delu- or colic. The seizures are very brief, lasting a few sions). and changes in mood (e.g., laugh- seconds, and some infants may have up to 100 ing. crying). This is certainly one of the seizures per day. Seizures are exhibited in rapid more tenuous types of epilepsy, and in the succession, lasting from 1 to 2 minutes with no absence of clear EEG dysfunction, a diag- apparent loss of consciousness. If the infant is nosis of psychomotor epilepsy is question- sitting, the spell may be manifest as a sudden able. forward jerk of the head accompanied by an outward thrust of the arms (head dropping or head nodding spells). Psychomotor (temporal lobe) seizures are rarely found in children under 6 years of age. Myoclonic epilepsy of older children develops More commonly, they are exhibited in older chil- after 2 years of age, usually between 3 and 7 dren, adolescents, and young adults with a prev- years. The seizure pattern in the sitting position alence of 10 to 20% in older children with con- is similar to that described for infants who are vulsive disorders (Gold, 1974; Livingston, 1972). able to sit. The head suddenly jerks forward (oc- It should also be pointed out that, as with grand casionally backward), and the arms are thrust mal epilepsy, psychomotor seizures may be pre- outward. If the child is holding an obi,. it may ceded by an aura and followed by a postconvul- drop from his or her hands or, in some cases, sive state. may be thrown across the room. Again, these Although not very common, there is such a are referred to as "head-nodding" or "head- condition as prolonged psychomotor seizures. dropping" spells by some clinicians,In the For the most part, they are unresponsive to an- standing position, the sudden flexor spasm, often ticonvulsant drugs and are self limiting. The child associated with an outward thrust of the arms, should be watched during such an episode, and frequently results in a vehement fall forward. measures should be taken to prevent injury. However, the child is usually able to get up right

4 40/CHILDREN ON MEDICATION

after the attack. Such falls often result in lacera- ducted on children with myoclonic epilepsy, little tions of the forehead. nose. and chin. To prevent can be said about how the disorder changes dur- such injuries. the child can wear protective head ing adolescence and adulthood. Livingston (1972) gear similar to a football helmet, Such attacks found that many of the children whose seizures usually occur on a daily basis. Although each in- began in infancy continued to experience them dividual spell may last only a few seconds, they into childhood. Niedermeyer (1974) reported the often occur in groups or showers lasting several seizure pattern may be quite irregular, making minutes. This type of seizure may be referred to the evaluation of drug effectiveness difficult. The in the literature as akinetic. atonic-akinetic, petit older child may have a complete cessation of at- mal variant, or Lennox -Gastaut syndrome (Gas- tacks for several years, taut. 1971; Gibbs. 1971). The EEG of infants with myoclonic seizures Itis noteworthy that children with myoclonic 'gives the impression of nearly total disorgani- epilepsy frequently have other types of seizures zation of cortical voltage regulation" (Living- as well. particularly grand mal. Also, staring spells ston, 1974, p. 543). The actual EEG pattern is that appear.similar to petit rnal may precede my- referredto as hypsarhythmia. This pattern oclonic seizures or occur independently of other changes to modified hypsarhythmia as the child attacks. gets older. Jeavons (1977) argued that there may be as Most infants diagnosed as having myoclonic many as six different types of myoclonic epi- epilepsy show clear evidence of brain damage lepsy, four of which are noted here. One type. prior to the onset of seizures, and almost all are infantile spasms. is similar to Livingston's cate- severely mentally and/or motorically retarded. gory. myoclonic epilepsy of infancy. However. For the older children, the incidence of specific Jeavons divides myoclonic epilepsy of older-chil- brain damage prior to the onset of seizures and dren into two groups. The children in one group the severity of mental retardation is much less have a mixture of seizures. They include sudden than for the infants. The earlier the onset of these falls that may or may not be preceded by violent seizures, the poorer the prognosis in terms of jerks (drop seizures), absence seizures that are mental retardation and motor development. "It characterized by a cessation of motion (aki- has been our experience that the most serious netic). blinking of the eyelids, and upward move- hazard of childhood myoclonic epilepsy is not the ment of the eyes, head nodding seizures, sag- seizures per se, but the associated mental retar- ging (atonic)or loss of posture (astatic), and dation" (Livingston. 1972, p. 84). tonic-clonic (grand mat) seizures. Children ex- Autonomic Seizures hibiting this seizure pattern are usually mentally retarded. The attacks may be so frequent that The fifth category of convulsive disordersis the child tears walking alone. Children in the sec- autonomic epilepsy (also known as hypotha- ond group exhibit only myoclonic jerks, and men- lamic epilepsy. abdominal epilepsy, and epilep- tal retardation is rare. ticequivalent). Seizures may manifest them- Jeavons considers adolescents who develop selves as periodic episodes of abdominal pain, myoclonic jerks, typically involving the shoulders nausea, vomiting, and headache. When these and arms, as a fourth type of myoclonic epilepsy. symptoms precede a seizure (i.e.. aura) or follow The jerks are bilateral (e.g., simultaneous flexor an attack as part of the postconvulsive phase, spasms in both arms). Seizures begin around they are obviously seizure manifestations. How- puberty and are often associated with menstrua- ever. when these symptoms appear in the ab- tion. Intelligence is usually normal. sence of other clearly identifiable seizure pat- Niedermeyer (1974) reported a 2 to 3% prev- terns, diagnosis may be quite difficult. This type alence figure for myoclonic epilepsy of older chil- of seizure disorder is rare in children, and care dren (Lennox-Gastaut syndrome, petit mal var- must be taken to differentiate autonomic attacks iant) in a very active seizure clinic with a special from functional disorders and childhood migraine interest in seizure surgery. He feels the actual (Livingston, 1972; Walsh. 1974). prevalence in the general epileptic population is Febrile Seizures much lower, but the disorder is relatively common in residential facilities for mentally retarded There are a number of disorders that appear children. similar to epilepsy because they involve a loss of Because few followup studies have been.con- consciousness, are episodic in nature, or involve CONVULSIVE DISORDERS/41 convulsive body movements. Febrile seizures cence or early adulthood. Prevalence figures for are one such disorder, and. because these at- mixed epilepsy (more than one kind of seizure) tacks are relatively common among young chil- vary ranging from 40 to 60% of the people with dren, they are iecluded in this discussion. The convulsive disorders (Epilepsy Foundation of term febrile means fever, and febrile convulsion America, 1975). simply refers to seizures associated with a febrile In an attempt to standardize the terminology illness. and facilitate research, the International League Based on several studies of a large number of Against Epilepsy developed a clasSification younchildren exhibiting seizures in association scheme for the epilepsies based upon clinical with fever, Livingston (1972) identified two dis- and electroencephalographic data (Gastaut. orders: simple febrile convulsions and epileptic 1970). A simplified version of that report appears convulsions precipitated by fever. Simple febrile in Appendix C. The two major subgroups are: convulsions usually have their onset between 9 generalized seizures, in which the electrical dis- and 18 months of age and rarely begin after the charge affects the entire brain, and partial sei- child is 5 years old. They are associated with zures. in which only a certain area of the brain is childhood illnesses that do not involve the brain, involved.Comparisons between Livingston's such as upper respiratory infections. otitis media classification scheme and the one proposed by ( inflamation of the middle ear). and pneumonia the League can be made quite easily. The major (Nelson & Ellenberg, 1978). The convulsions are differences are that Livingston refers to massive always generalized (usually grand mal) and are epileptic myoclonus, infantile spasms, and aki- brief, lasting no longer than a few minutes. Typi- netic seizures collectively as myoclonic epilepsy, cally, the child has only one seizure per illness, and groups focal seizures with grand mal. In the and it occurs between 2 to 6 hours after the on- League's classification scheme, focal attacks set of the fever. The prognosis for simple febrile are "partial seizures with elementary sympto- seizures is excellent. Most children only have matology." Most physicians do not strictly ad- one to three seizures per year and the disorder here to the League's classification scheme and rarely lasts beyond 6 years of age. Simple febrile the terms adopted by Livingston are more com- seizures are relatively common. In one massive monly used to identify different types of epilepsy. followup study of approximately 54,000 children, Unfortunately, verbal descriptions of seizures it was reported that 3.5% of the White children are a far from satisfactory means of education. and 4.2% of the Black children experienced at To give teachers a better idea of what the differ- least one febrile seizure (Nelson & Ellenberg. ent types of seizures look like, I have used sev- 1978), eral films that are of value in this regard. One Epileptic seizures associated with fever (atyp- film. Modern Concepts of Epilepsy (Ayerst Lab- ical febrile convulsions) are quite different from oratories) is now somewhat dated but is quite simple febrile seizures in terms of treatment and useful in its graphic presentations of a variety of prognosis. According to Livingston (1972). the seizures. Another film that features Dr. Living- diagnosis of atypical febrile convulsion is made ston, Diagnosis and Medical Management of if the child has one or more of the following:-pro- Epileptic Seizures (Ayerst Laboratories), was longed seizures, focal convulsions of any dura- developed to train pediatricians about epilepsy. tion, febrile convulsions after the age of 5, and With appropriate preparation, it is also an excel- EEG findings that are characteristic of epilepsy. lent film for graduate level teacher training pro- The prognosis for children with epileptic seizures grams as is Complex Partial Seizures (Geigy associated with fever is similar to other children Pharmaceuticals). A number of other films about with epilepsy. epilepsy have been made, and information about Although this classification scheme may cre- their content and availability can be obtained ate the impression that children with convulsive from the Epilepsy Foundation of America. disorders fall neatly into a given category, such SEIZURES IN THE CLASSROOM is not the case. Children may have more than one type of seizure disorder during the same pe- For teachers, direct care personnel in residential riod of time, or one form of epilepsy may be fol- facilities, and many other caretakers, a grand lowed by another later inlife. As noted previ- mal seizure can be a frightening experience. Be- ously, petit mal spells in childhood may be cause there have been conflicting opinions about followed by grand Mal convulsions in adoles- how best to care for a person during a grand mal 42/ CHILDREN ON MEDICATION seizure, some confusion may exist as to what is Many children will be able to resume class- the proper thing to do. The following steps should room activities shortly after the convulsion.How- be taken during the course of a convulsion: ever, some children lapse into a deep sleep.At- tempts to awaken the child are futile, and he or 1. Remove any objects that the child may strike she should be allowed to sleep. Upon awaking, during the clonic phase (jerking movements) the child may be confused, afraid, upset, or ex- of the seizure. hibit unusual behavior. Scolding is of little value. 2. Loosen restricting clothing. 3. Turn the child on his or her side. (This will If the child's postconvulsive behavior is self in- allow saliva and vomitus to flow out of the jurious or harmful to others, appropriate measures must be taken. The same holds truefor mouth instead of being aspirated.) psychomotor seizures if complex automatisms 4. Do not try to restrain the child's movements during the active (tonic - clonic) phase of the are manifest as behavior disorders. Fortunately, attitudes about epilepsy have changed over the seizure. last half century, and attempts to conceal the dis- 5. Do not try to move the child during the active order are not as pervasive as they once were. phase of the seizure. 6. Do not insert any objects into the child's The school should definitely be informed of the convulsive disorder even if medication keeps the mouth. seizures completely under control. The aware- In case there is any confusion regarding the ness that a child has epilepsy may cause some last point, the following quote from Lombroso apprehension for school personnel especially if (1974) is quite emphatic: they are not informed about the type of seizure and degree of seizure control with medication or Most convulsive seizures are self-limiting have not been in such a situation before (Force, events terminating on their own accord be- 1965). To repeat, the easiest thing for the teacher fore specific medical treatment need or to do is simply ask the parents what theydo can be rendered. For these, positioning to when their child has a seizure. prevent aspiration of excessive secretions Unfortunately, space constraints do not permit and vomitus and prevention of self-injuries a discussion of the psychosocial aspects ofepi- is generallysufficient.Pryingopen lepsy. However, it must be emphasized that the clenched teeth f or the insertion of time-ho- teacher's reaction to a seizure greatly influ- nored tongue blades, pencils or fingers ences how classmates respond to the child with has no place in modern medicine. These epilepsy. In the case of a child with uncontrolled maneuvers are useless in the prevention seizures, the teacher can explain the disorder to of tongue biting (that will have occurred at the class (if necessary, in the child's absence), the onset of the initial tonic phase), but and even use classroom activities that sensitize may actually be harmful by dislodging loose students to the needs of exceptional children. It teeth, and by initiating nociceptive stimuli is the unexpectedness of the seizure and alarmed that reflexly can prolong the tonic phase. reap :' ion of the teacher and peers that makes the Likewise excessive restraining of convuls- situation tragic. Much of this can be avoided with ing patients may facilitate bone injuries. (p. a little preparation. Many teachers haveshared 536) with me anecdotes of how grand mal seizures Because there is some disagreement among can be made quite uneventful with appropriate epileptologists regarding the prevention of ton- peer sensitization and personal conversations gue and cheek biting (Livingston,1978b). the with the epileptic child. following procedure is suggested for school per- The probability of encountering children with sonnel. In those rare cases in which the physi- uncontrolled seizures is greatly influenced by the cian recommends that an object be placed in the educational setting. In regular elementary and child's mouth to prevent self injury. specific in- secondary schools where less than 1% of ihe structions should be obtained from the doctor on students are treated for epilepsy, the probability how this situation should be handled and by is low. Considering that at least 50% of such chil- whom. Simply asking the parents if any special dren are seizure free if they take their medication procedures are required to keep the child from regularly, a grand mal seizure at school may be hurting himself or herself during a seizure can a rare event. However, Force(1965) reported allay fears about what the school should do. that a third of the nonspecial education teachers

4 : CONVULSIVE DISORDERS/43

in his survey had witnessed a seizure at school the control of seizures. Because bromides and as did over 80% of the special education teach- phenobarbital often produced sedation (drowsi- ers. In another study, over half of the teachers ness, lethargy) at the same dosages required to had direct experience with grand mal seizures in control attacks, they were far from satisfactory their classrooms for mentally retarded (Gadow, for all people with epilepsy, In a paper published 1978a). For special education settings, the pro- in 1937. Putnam and Ntoritt observed that little portion of children treated for convulsive disor- progress had been made to develop more effec- ders who have seizures at school ranges from tive anticonvulsants. They also reported that Di- 27% in early childhood classes to 41% in pro- lantin (phenytoin), among other drugs they were grams for trainable mentally retarded children investigating, had anticonvulsant properties in (Gadow, 1976; 1978a). It is possible that the re- laboratory animals. Shortly thereafter, Dilantin cent emphasis on deinstitutionalization, main- was found to be quite effective in controlling streaming. and least restrictive alternative will grand mat attacks but had little effect on petit mal bring many more people into contact with chil- spells (Merritt & Putnam, 1938). It was not until dren who have seizures. 1945 that the first effective antipetit mat drug. Tri- dione (trimethadione) was discussed in the liter- MEDICATION FOR DIFFERENT KINDS OF ature (Lennox, 1945). Today there are hundreds SEIZURES of drugs known to have anticonvulsant properties; however, less than two dozen are used with By far the most common treatment for convulsive any frequency, and three or four drugs account disorders is drug therapy. Generally speaking, for most of all medication used in the manage- antiepileptic drugs are capable of rendering 50% ment of epilepsy. Before discussing the effects of the children with epilepsy seizure free. An- of Dilantin, Tridione. and other more recently de- other 25% have fewer and less severe seizures, veloped agents. it should be emphasized that leaving approximately 15% of the treatment pop- many antiepileptic drugs are truly miracles of ulation who are not helped with medication, Un- modern pharmacological research, fortunately. of the children with intractable (un- The commonly prescribed drugs for the control controllable) seizures, only a small percentage of seizures consist primarily of five groups of an- are good candidates for surgery, a treatment ticonvulsants (see Table 3-2), The drugs within rarely employed with children. Unless the exact each group have similar properties. A sixth cat- location of the abnormal electrical discharge (fo- egory of agents. made up of psychotropic and cus) can be identified, surgery is often impracti- assorted other drugs. have anticonvulsant prop- cal. Even when surgery is successful, antiepilep- erties but are also used for the treatment of other tic medication must continue to be administered. disorders. Other types of treatment are sometimes used As previously stated, the various types of sei- For example, a special diet may be quite helpful zures respond most favorably to different types for the child with myoclonic epilepsy, A relatively of anticonvulsants. Employing the same ration- new surgical technique involves placing inside ale for adopting Livingston's (1972) classifica- the body a small electrical device that stimulates tion scheme for seizures, the results of his re- the cerebellum, thus inhibiting seizures (Cooper, search on the safety (risk-to-benefit ratio). and Arnin. Riklan, Waltz. & Pool, 1976). As noted efficacy (effectiveness in suppressing seizures) previously, there is now much interest in investi- of anticonvulsant drugs is presented here. In Ta- gating psychological treatments for controlling ble 3-3, drugs are listed in order of preference seizures such as psychotherapy, behavior mod- for each of the four major groups of convulsive ification. and biofeedback (Mostofsky & Batas- disorders. For the fifthgroup. autonomic sei- chak, 1977). Although some children may benefit zures, the drugs of choice are the same as those from nondrug treatments, this section will focus for major motor (grand rnal) seizures. on medication, in keeping with the orientation of this text. Major Motor (Grand Mal) Bromides were found to be useful agents in Phenobarbital is the drug of first choice in the the treatment of epilepsy in 1853, and pheno- treatment of grand mat seizures. It is both the barbital was introduced in 1912 as an anticon- least toxic and least expensive of the major an- vulsant (Livingston. 1972). For many years, these ticonvulsants. However. there is disagreement were the only drugs that were truly effective in about the selection of phenobarbital as the first

Li 44 HI DREN ON MEDICATION

TABLE 3-2 Anticonvulsan rugs grouped according to similarities in chemical structure Barbiturates Ben2cmliazepines Gemonil (metharbital) Clonopin (clonazepam) Mebaral (mephobarbital) Valium (diazepam) Mysoline (prirnidone) Other Drugs phenobarbital ACTH (corticotropin) and Hydantoinates Corticosteroids Dilantin (phenytoin) Atabrine (Quinacrine) Mesantoin (mephenytoin) bromides Peganone (ethotoin) Depakene (valproic acid) Succinimides Dexedrine (dextroamphetamine) Celontin (methsuximide) Diamox (acetazolamide) Milontin (phensuximide) Phenurone (phenacemide) Zarontin (ethosuximide) Tegretol (carbamazepine) Oxazolininediones Paradione (paramethadione) Tridione (trimethadione)

TABLE 3.3 Drugs currently used ahe Samuel Livingston Epilepsy Diagnostic and Treatment Center forthe control of epileptic seizures' Myoclonic Psychomotor Major Motor Petit Mel (Temporal Older (Grand Mal) (Absence) Lobe) Infants Children KETOGENIC DIET' PHENOBARBITALLAFIONTIN TEGRETOL ACTH and (Mephobarbital)'DEPAKENE' Mysoline CORTICOSTE- ACTH and POIDS CORTICOSTE- MYSOLINE Indiana' Dilantin ROIDS DILANTIN Paradione4 Mesantoin2 Tegretol Celontin Phenurone2 Valium Bromide (for Milontih Bromide young children) Dexedrine Clonopin Peganone Atabrine, Depakene Gemonil Mesantoin2 Dexedrine (for sleep seizures) Diamox (for menstrual seizures) Note. Modified from Livingston. S. Comprehensive management of epilepsy ininfancy. childhood and adolescence. 1972, reprinted courtesy of Charles C Thomas, Publisher, Springfield. Mine's, Arranged in order of our preference. based on relative efficacy and toxicity. We uso this drug almost exclusively as a substitute barbiturate for patients whose seizures arebenefitted by dosages of phenobarbital that produce side reactions, such as marked drowsiness Or hyperactivity. These drugs possess potent anticonvuisant properties. but because ofpronounced toxicity. they should be presnnbed only to patients whose seizures are refractory to all other antiepileptic agents. Based on limited but encouraging experience. 4 These drugs are very effective in controlling petit real spells. but they appear tobe potent teratogens. All other antipetit mat agents should be given an adequate trial before prescribing these drugs to femalesof child bearing age. Atabrine is effective in the treatment of some cases, but its value is limited becauseit causes a yellowish discoloration of the skin in most patients. ° The Ketogenic diet is included because of its exceptionalvalue in controlling this form of epilepsy. 5 CONVULSIVE DISORDERS/45

agent to be tried. Some experts feel it should be line, Mebaral) are tried. Because Dilantin Dilantin because it is a more powerful drug. Liv- may exacerbate petit rnal attacks, it is tried ingston's (1972) opinion is that the large number only after other agents have failed. Once of side effects associated with Dilantin makes it the child has adjusted to the grand mal less desirable and that it should not be recom- agent (after about 1 month of treatment). mended for treatment in infants, adolescent fe- the petit mal drug is started. Zarontin should males, and children undergoing orthodontal care. be tried first.If this fails to control the petit The rationale for these exclusions are: (1)it is mal seizures. then other drugs must be at- difficult to evaluate side effects in infants; (2) the tempted (see Table 3-3). Drugs for both possibility of excessive growth of body hair and the control of grand mal and petit mel sei- gum tissue makes it undesirable for females; and zures are maintained until the child has (3) the growth of gum tissue interferes with or- been seizure tree for at least 4 years. If the thodontal treatments. Because phenobarbital may EEG no longer shows the characteristic cause hyperactivity or irritability as a side effect. petit mal pattern, the dosage of the petit Mebaral (mephobarbital) is listed as a possible mal drug is gradually reduced over a 6 to alternative. Mysoline (primidone) is the second 12 month period. The grand mal agent is most preferred agent for the treatment of grand continued until the age of 14. If the child mal epilepsy. Noteworthy is the fact that one of has not developed grand mal epilepsy by the metabolites of Mysoline is phenobarbital. then, the dosage of the grand mal drug is Diamox (acetazolamide) is recommended for the reduced over a one year period. and treat- management of major motor seizures associated ment is terminated. with menstruation. Prolonged grand mal seizures, serial grand Other anticonvulsant drugs are also recom- mal seizures, and grand mel status (status epi- mended for the treatment of petit mal epilepsy. lepticus) can be treated with intravenous injec- Millichap (1972). for example, reports that Dia- tions of Valium (diazepam), paraldehyde. or bar- mox isequally as effective as Zarontin and bituratesin an attempt to stop the seizure causes fewer side effects. However, some clini- (Livingston. 1978b). To repeat. a child experi- cians report that Diamox produces only tempo- encing any of these three types of prolonged sei- rary seizure control in many cases (Livingston, zures should receive immediate medical atten- 1978a). Clonopin (clonazepam) is another agent tion. Grand mal status. in particular, is a serious reported to be an effective antipetit mal drug medical emergency. (Mikkelsen et al..1976). Depakene (valproic Petit Mal acid). approved by the FDA in 1978, is the most recent addition to the list of drugs proven effec- The drug of first choice for the treatment of petit tive in the control of petit mal spells (Gram et al., mal seizures is Zarontin (ethosuximide). It was 1977; Jeavons & Clark, 1974). It may soon be- first reported to be an effective agent for this type come one of the more frequently prescribed drugs of seizure in 1958 (Zimmerman & Burgemeister, for this type of epilepsy. 1958). Although extremely effective in the con- Myoclonic trol of petit mal seizures, it is of little importance for other types of attacks. Because of the high Because myoclonic epilepsy is often unrespon- percentage of children with petit mat epilepsy sive to medication. this disorder with its concom- who develop other types of seizures later on, itant mental retardation may be a trying experi- Livingston (1972) recommended the following ence for the family. Huttenlocher, Wilbourn, and regimen: Signore (1971) reported a case study about en 11 year old girl with myoclonic seizures who re- Drug treatment should be initiated with sponded favorably to a special diet. However, re- phenobarbital as a prophylactic measure peated falls during childhood "led to widespread

for the control of grand mel seizures. The scarring of the face and chronic ulceration , of

physician observes if phenobarbital is well the skin over her forehead. Uncontrolled sei- tolerated in terms of side effects and to see zures made school attendance impossible. She that it does not increase the frequency of became withdrawn and self-conscious due to her petit mal spells. If phenobarbital is unsat- disfiguredface." The followingquotefrom isfactory. other grand mat agents (Myso- Niedermeyer (1974) aptly describes the serious- 46/CHILDREN ON MEDICATION ness of the situation from the standpoint of he children (Gadow. 1978a). Although the results of physician: the initial studies on Clonopin were met with much enthusiasm, it has not proven to be as ef- Desperate parents sometimes ask for neu- fective for myoclonic epilepsy as originally ex- rosurgical treatment but in view of the wide pected (Livingston. 1978a). spread LEG abnormalities, the neurosur- Livingston (1972) has been a strong advocate geon will have to resist. in most instances, of the ketogenic diet in the control of myoclonic the parental pressure to operate. Institu- seizures especially in children between 2 to 5 tionalization is very frequently the result of years of age. Briefly, the diet prescribes that the the severe mental defects which may lay amount (in grams) of fat consumed must be at an unbearable burden on the life of an oth- least four times greater than the amount (in erwise healthy family. (p.92) grams) of carbohydrates and protein combined. Obviously such a situation presents a number Although there are a number of problems inher- of risk-to-benefit questions about treatment itself. ent in this regimen. it has proven to be quite ef- As Niedermeyer (1974) put it: fective for many chldren with myoclonic (and grand mal) seizures. In some cases, however, Should the physician give medication at the benefits of the ketogenic diet are Short lived all?I feel one cannot negate this question. with a recurrence of seizures after several months especially because of the psychological of treatment. Two additional benefits of the diet impact of total therapeutic passivity on are (1) a marked tranquilizing effect on epileptic It may be wise to parents and relatives. children who are also hyperactive (even in the change medication from time to time, ac- absence of seizure control) and (2) an avoidance the generalrules of such cording to of the adverse side effects associated with anti- changes. . Adramatic struggle fora convulsant drugs. The readerisreferred to pharmacological enforcement of seizure- Livingston (1972, pp. 378-405) for a more de- freedom has to be strictly avoided; these tailed discussion. attempts always lead to drug toxicity and Recently, interest has been generated about enhancement of mental dullness. (p.92) the use of medium chain triglycerides (MCT) to Of all the types of epilepsy. myoclonic sei- provide the necessary fat content in the keto- zures carry the worst prognosis in terms of sei- genic diet (Huttenlocher, Wilbourn, & Signore, zure Suppression. In infants and young children. 1971; Signore, 1973). Advocates maintain that ACTH (corticotropin) and corticosteriods may be the use of MCT permits a more palatable diet effective in the control of seizures (Livingston. without loss of seizure control. Others, however, 1972). However, the relapse rate is high. and have not found the MCI diet to be as effective there is no beneficial effect on mental perfor- as the ketogenic diet in controlling myoclonic sei- mance. The best results are obtained with in- zures (Livingston, Pauli & Pruce, 1977). fants (less than a year old) when treatment be- Psychomotor (Temporal Lobe) gins soon after the onset of seizures. Livingston (1978a) considers Valium to be the The drug of choice in the treatment of psycho- drug of first choice in the treatment of myoclonic motor (temporal lobe) epilepsy is Tegretol (car- epilepsy of older children. It is also the preferred bamazepine) (see Table 3-3). It was approved agent for myoclonic epilepsy of younger children by the FDA for use in the treatment of epilepsy in when steroid treatment is not started shortly after 1974. Although it is considered superior to other the onset of seizures. Unfortunately, the benefi- agents in the control of psychomotor seizures cial effects of Valium are often short lived. After (Livingston, 1978a), some clinicians report Di- a few months of treatment, children typically de- lantin and Mysoline are equally effective (Living- velop a tolerance for the drug's seizure control- ston, Pauli, & Pruce, 1978; Rodin, Rim, Kitano, ling properties. Lewis, & Rennick, 1976). Clonopin is also effective in the treatment of Nocturnal (Sleep) Seizures myoclonic epilepsy (Fazio, Manfredi. & Piccinelli, 1973), and, like Valium. is a benzodiazepine. Nocturnal seizures typically occur soon after fall- Clonopin was approved by the FDA in 1975. By ing asleep or shortly before or after the usual the spring of 1977, it was prescribed as often as time of awakening. These seizures are usually Valium for epilepsy in trainable mentally retarded difficult to control with standard antiepileptic drugs CONVULSIVE DISORDERS/47

(phenobarbital, Dian lin.Mysoline).However, children.In general, "there is no empiric evi- Dexedrine (dextroarnphetamine) has been used dence that chronic treatment with anticonvulsant successfully in the management of nocturnal sei- medication influences, positively or negatively, zures. especially those that occur shortly alter the long-term prognosis of children with febrile falling asleep (Livingston & Pauli, 1975). It is no. seizures" (Nelson & Ellenberg, 1978, p. 726). tewonhy that after treating 10,000 epileptics with Treatment of epileptic seizures precipitated by amphetamines, particularly Dexedrine, Livings- fever, on the other hand, should be initiated im- ton reports these drugs are remarkably free of mediately and monitored like any other convul- side effects. He did not encounter drug addiction sive disorder. Considering the side effects asso- in a single case. ciated with Dilantin, phenobarbital should be Febrile Convulsions employed first in attempting to control seizures in infants. Perhaps one of the most debated topics in phar- In actual clinical practice, physicians may use macotherapy forconvulsive disorders is the drugs other than those employed by Livingston treatment of simple febrileconvulsions. The inthe treatment of certain types of seizures. source of the problem has a lot to do with the When frequently used agents fail to control sei- definition of febrile seizure. Because not all re- zures, other more powerful (and possibly more searchers use the sane criteria, children with toxic) drugs may have to be administered. When epileptic seizures precipitated by fever may be conventional anticonvulsants do not appreciably included in treatment samples. Another problem alter seizure activity, the physician may have no is parent compliance with the drug regimen (1.0 other alternative than to try drugs with known an- it is difficult to be certain if the treated group is liconvulsant effects but not speckically approved really receiving medication).ItisLivingston's by the FDA for the treatment of epilepsy. New (1972) position that drug treatment for simple fe- and experimental drugs are typically first used brile convulsions is neither necessary nor effec- with people whose seizures cannot be controlled tive. Such seizures appear to be unresponsive to With conventional anticonvulsants. continuous antiepileptic drug treatment (e.g., With phenobarbital), and giving the child phenobarbital at the onset of a fever is of little value because SIDE EFFECTS OF ANTIEPILEPT1C DRUGS the convulsion is often the first indication to the parent that the child has a fever. However, Liv- Unwanted antiepileptic drug reactions can be ingston maintains that administering phenobar- classified according to(1) intoxication due to bital and aspirin at the onset of a fever may be high levels of the drug in the blood, (2) common useful because "it provides the parents oith side effects that occur at normal dosages, and 'something to do' and may relieve some of their (3) idiosyncratic reactions that are unrelated to anxiety" (1972, p. 30), dosage (Kutt & Louis, 1972). The discussion of Wolf et al. (1977) also found that when phen- side effects focuses primarily on drug induced obarbital is given intermittently, it is no more ef- behavioral changes that impair performance and fective in preventing febrile seizures than when changes in bodily function that are observable to no medication is administered.Incontrast to caretakers. Livingston, however, they found that continuous Barbiturates (daily) treatment with phenobarbital did significantly reduce the occurrence of febrile seizures. The barbiturates (phenobarbital, Mysoline, and The major problems they encountered with pre- Mebaral) are among the most frequently prescribing phenobarbital for use on a daily basis scribed drugsforepilepsy. Phenobarbital is were parental resistance and failure to give med- the least likely to produce serious side effects of ication regularly and drug induced hyperactivity allthe antiepileptics. Livingston (1972) com- (see section on side effects). Attempts have been mented after treating 15,000 patients with this made to identify children who are at risk for de- drug, many for long periods of time, that "the veloping epilepsy subsequent to febrile seizures only significant untoward reactions we have ob- (Nelson & Ellenberg, 1978). However, itis not served in our patients are drowsiness, hyperac- known if continuous treatment with phenobarbi- tivity and excitation simuiating the hyperkinetic tal after the onset of febrile seizures will prevent syndrome and an occasional rash" (p. 174). the eventual development of epilepsy in high risk Drowsiness is a common side effect of phe- 48/CHILDREN ON MEDICATION nobarbital, but in many children this reaction dione agrees the! this side effect is more common minishes within a few weeks after the onset of ob oh evi or disordered children (Livingston. 1976) treatment. If drowsiness persists, the physician Phenobarbital induced behavioral disturbances may attempt to counteract it with a stimulantdrug are not dose related, but rather represent a spe- (e.g,, Rita lin or Dexedrine), However, if the drow- cific seesitivity to the drug. Livingston (1978b) siness does not abate, a decision will have to be suggested the physician should first seal( Ritalin made whether or not to select another agent, or Dexedrine is effective in controlling the behav- The pervasiveness of drowsiness with pheno- ior disorder. If unsuccessful, phe oobarbi tal should barbital treatment among children with convul- be gradually replaced with Mebaral. If the behav- sive disorders is demonstrated in threeseparate ior problems still do not abate. Mebaral should surveys. In a study of 101 childrenreceiving an- be substituted with Mysoline. ticonvulsants in earlchildhood special educa- Skin rashes are rare with phenobarbi tat. In tion programs (Gadow, 1977b), teachers rated general, when antiepileptics do produe skin re- 36% as being more drowsy or sleepy than their actions, the physician discontinues theoff ending peers. The figure for 241 mentally retardedpub- agent and substitutes another drug(Livingston. lic school children on medication for seizures is 1978b). Dosage reduction usually does; not help 37% (Gadow, 1978a). A survey conducted by because skin reactions are due to a speof is sen- the National Epilepsy League (Piettch, 1977) sitivity to the drug. found that 35 0/0 of the children on medication Compared to phenobarbital, Mebaral is much were considered drowsy by their parents.It less likely to produce drowsiness or a_ hyperac- should be emphasized that children may simu- tivity reaction (Livingston, 1972). late drowsiness as a device for manipulating The primary side effect of Mysolineis drowsi- both parents and teachers. However, the con- ness, particularly when the drug is firt taken. If sistency of these results across treatment popu- the reaction is persistent. treatment May have to lations indicates that this side effect has educa- be discontinued. Other possiblesidle effects tional implications for a large number of children (which usually disappear within a few wdeeks) are treated with anticonvulsants. dizziness, drp/opia (double vision), and ataxia (a Another side effect of phenobarbital inchildren staggered walk with a wide base, rnakieig a child is behavior disorder, which may be manifested appear asifhe or she is drunk), Cysarthria as irritability, aggressivity,excitability, overactiv (slurred speech), nystagnius (rapid, involuntary ity,and hyperactivity. Livingston (1972)esti- Movement of the eyeball), and headaches are mated that 15 to 20% of the children he treated also side effects associated with either early with phenobarbital had this type of reaction.Sim- treatment or overmedication. fvleasleFke rashes ilarly, Gadow (1977x) found that 20% of the pre- are occasionally reported witri Mysottine treat- schoolers taking phenobarbital for epilepsy ex- e nt hibited behavior problems as aresultof medication. The prevalence of drug inducedhy- ilydantoinates peractivity, aggressivity, and irritability in children -The hydantoinates (Dilantin. Mesantoin, and Pe- treated for febrile seizures was 25% in onestudy ganone) have very powerful antic onvulsant For- (Thorn, 1975) and 42% in another (Wolf & properties, but they also are associated with a dis- sythe, 1978). In some cases, the behavior wide variety of side effects. Di lantin is the least order is severe and becomes an even greater Wade of the three and can be prescribed for long problem than the seizures. Wolf and Forsythe periods of time without any apparent discomfort had (1978) reported that phenobarbital treatment (Livingston, 1972). Because Dilantin typically who de- to be discontinued in half of the children does not produce drowsiness, its discovery as veloped this reaction. They also noted a relation- an anticonvulsant was met with muchenthusi- ship between this side effect and preexistingbe- asm. havioral disturbance. Only 20% of thechildren whose behavior was normal before seizuresbe- Several disturbances are associated vvith ov- gan developed a behavior disturbance onphen- ermedication (Dilantin intoxication). -These in- obarbital compared to 80% for those whoexhib- clude ataxia, diplopia, nystagmus, a nddysar- ited behavior disorders prior to the onsetof thria. However, these side effects can usually be seizures. In the latter group, phenobarbital seems managed with dosage reduction. Unfortunately, to aggravate the situation. However, not every- the dosage that is effective in controlling sei- CONVULSIVE DISORDERS 4O

zures also frequently borders on the level that (nephenyloin) i5 drowsiness, Other untoward produces intoxication. reactions are the. sonic as those for Dilantin Excessive growth of gum tissue (gingival hy- teXtcation; however, they occur less often for perpla,sia) is also out to common. occurring in ap- Mesa nlo in.Sashes are also reported with this proximately 400:. of those treated with Dilanlin, elocfication. Visually. the gums enlarge and. in severe., cases. Peden one (OW., 010in) is not a very powerful an- they grow over the surface area of the teeth, cre- ficonvuls ant, and is relatively free of side effects. ating a mullberrylike appearance. Food particles Untoward reactions that have been reported in- and other irritants lodge in the gums causing] clude rashes, ataxia. diplopia, anorexia. nausea. them to redden or have a bluish cast. Meticulous drowsiness, headache, and dizziness. oral hygiene and gum massage areoften stressed. Although this can alleviate inflarnation SuecinenIctes arid Oxazolidinediones due to food particles, it does not slow down or The succeed-m(1o5 are used primarily in the man- lessen the growth of gum tissue (Livingston 8., agement of petitmat spells and consist of three Livingston. 1973)This reaction usually starts 2 dogs: Zarontie. ,Celontin, and Milontin (see Ta- to 3 months amen treatment and is more common ble 3-2), Possib to gastrointestinal side effects among children than adults. Livingston (1972) of Za reraninclude abdominal pain, nausea, reported that the growth of gum tissueis not voniiii ng. anorex la (lossof appetite), and hic- dose related. but there is some disagreement cups, Otherreported side effects are drowsi- (tattle, Girgis. & Masotti. 1975). The-gums return ness, headaches dizziness, and behavioral dis- to normal 3 to12 months after medication is turbance. Theamide effectsassociatedwith stopped. depending upon the severity of tissue C,elootii) and Milonlin are similar to those of Za- growth. For some children who must be main- rontin. However,Cotentin (methsuximide) and tained on Dilantin. excessive gum tissue may Nildntin ( phensuximide) are more likely to pro- have to be removed surgically, The growth of duce drmsiness. gum tissue alone is not sufficient reason to switch The oxaZolidin ediones(Tridione and Para- to other drugs. However. if the condition leads, to dione) are also a nlipetit sisal agents. Photopho- emotional problems. disfiguration of the teeth, or bia, an aversion to bright light because it is irri- related disorders, alternative agents may have to tating, IS the rrost common side effect of Tridione. be sought out. Other side offeCts include headache, diplopia. Ir- Hirsutisrn. or excessive growth of body hair, ritability, doorsiness, rash, nausea. abdominal occurs in about 504 of the children treated with pain. and hit-cues. The untoward reactions as- Dilantin. Change is most pronounced in arm and soclated with, Faradone (paramethadione) are leg hair. but the lace and trunk may also be al- similar le 11105o of Tridione, tected. The reaction is irreversible, that iseven if medication is stopped the increased hair growth Other Drugs will remain. For cosmetic reasons this may be a problem for teenage girls. Altheudh there was much concern initially about Measlelike rashes are common with Dilantin the side effects of Tegretral. Livingston (1976a) beginning within the first 2 weeks of treatment. commented thatalter "12 years' experience Such rashes are not dose related, and they clear with the useof carbamazepine in over 1,090 up when medication is withdrawn. epileptic patients.... we classify it to be a rela- Another skin reaction that has received atten- tively safe anticonvelsant drug- (p. 306). In one tion recently is coarse facies, a thickening of the study of 255 epileptic patients treated With Te- skin of the mouth. nose, and forehead (Falconer gretol.11;10 became drowsy and 29/0 exhibited & Davidson. 1973). Reports of the prevalence of ataxia (Living6lon & Berman. 1974). Pa- coarse fades range from 29 to 30% for mentally tients either developed a tolerance for the drow- retarded persons receiving Dilantin in residential siness Or the dosage was reduced. In all cases, facilities (Herberg, 1977; Lefebvre, Haining. & ataxia responded to dosage reduction. Labbe. 1972). Side effectare frequently reported for Clono- The primary gastrointestinal side effect of DI- pin but rarely arethey life threatening (Medical !antic is constipation, which is often encountered Letter, 1976). Severedrowsiness occurs in nearly In long term treatment. half of the i ndividualstreated with Clonopin, ataxia The most common side effect of Mesantoin in about a third, arid a quarter exhibit behavioral 501 CHILDREN ON MEDICATION

disturbance (aggressivity, irritability, hyperactiv- nolds, 1975). It has boon hypothesized that some ity, and agitation)- Other side effects include nys- anticonvulsants stimulate (induce) the metabo- tagrnus, slurred speech, and dysarthria. "Since lism of vitamin D, Thus, vitamin D is removed some patients with the types of seizures (my- from the body at a greater rate than normal. Vi- oclonic and akinetic) for which clonazepam is tamin D is important to bone development be- recommended are severely mentally retarded, cause it greatly accelerates the absorption of the adverse effects of the drug on the patient's calcium from the gastrointestinal tract, When the ability to perform personal tasks, walk, or com- body becomes deficient in vitamin 0, calcium is municate may outweigh the benefit of controlling absorbed from the bones. If this situation per- seizures" (p. 19), sists over several months, almost all the calcium No attempt will be made to discuss the rein the bones will be absorbed. Then the calcium maining agents with anticonvulsant properties in in the exlracellular fluid drops to very low levels_ the "other drugs" category (see Table 3 -2). This condition is called rickets, and is character- The interested reader is referred to more com- ized by a weakening of the bones. and, in the prehensive discussions of pharmacotherapy for later stages, tetany (muscle spasms). convulsive disorders (Goodman & Gilman, 1975: The prevalence of drug induced rickets and Livingston,1972; Niedermeyer, 1974; Stores, osteemalacia and the role of anticonvulsants is 1978; Woodbury, Penry, & Schmidt, 1972). controversial, Most reports for these disturbances are in mentally retarded and/or institution- Blood, Liver, and Other Disturbances alized people (Livingston,1978a). Livingston Certain antiepileptic drugs have an adverse ef- cited a study in progress that failed to show sig- fect upon blood, liver, and kidney functions (Liv- nificant differences in blood calcium levels be- ingston, 1972; Reynolds, 1975). These agents tween epileptic patients on medication and a Must be monitored closely both through physical control group not receiving antiepileptic drugs. examinations and laboratory tests (Livingston, One patient who did show abnormally low levels 1978b). Drugs known to produce blood disturb- of calcium was administered vitamin D. After re- ances in some individuals are Zarontin, Mesan- viewing the literature. Livingston concluded that tain, Paradione, Phenurone (phenacemide). and for most people with epilepsy, exposure to sun- Tridione, Routine laboratory tests of kidney func- shine during the summer months is a sufficient tion must also be conducted for the latter three source of vitamin D. Patients who are at risk "are drugs as well. Liver function tests must be con- those who, because of motor difficulties, severe ducted for Tegretol and Phenurone. The physi- retardation, or institutionalization, are unable to . vitamin cian may inform the epileptic child and/or his or take advantage of sunshine to form . her parents about the signs of possible disturb- D" (p. 442). ances to these body systems and request that Cognition, Learning and School they be reported immediately (Livingston, 1978b). Performance There is evidence that Dilantin, phenobarbital, and Mysoline interfere with the metabolism of Surprisingly little research has been conducted folic acid in a small percentage of people receiv- on the effects of anticonvulsant drugs on learning either one or a combination of these drugs ing. cognition. and school performance. Much of (Livingston, 1972; Reynolds, 1975). Folic acid is the information that is available appears as side needed by the bane marrow to form red blood effect reports in clinical trials or in case studies. cells. When this substance is not present in suf- Often. data on dosage. blood level. and rate at ficient quantity, the newly formed red blood cells which the reaction occurs are omitted. Many are much larger than normal, poorly formed, and studies are difficult to interpret because patients quite fragile. This condition is called megoblastic were on more than one drug. Following is a brief anemia, and it always responds to treatment with summary of the results of a few studies in this folic acid. In some cases, however, folic acid area and their implications for school perfor- treatment has increased seizure frequency. mance. For more detailed discussions of cogni- Some investigators have reported abnormally tive side effects see the literature reviews by Liv- low levels of calcium in the blood (hypocalcernia) ingston (1972) and Stores (1975,1978). and bone disorders such as osteornalacia and As already mentioned, drowsiness is a com- rickets in people receiving antiepileptic drugs. mon side effect of antiepileptic drugs (particularly particularlyDilantin(Livingston,1978b; Rey- phenobarbital and Mysoline). and many epileptic CONVULSIVE DISORDERS 51

children are considered by their parents and ceiving one or more of the following agents: teachers to be more drowsy than their peers phenobarbital. Mysoline. or Dilantin. Among the (Gadow. 1977b,1978a; Pietsch,1977).Al- tasks were a vigilance test (similar to the contin- though in some cases drowsiness is self induced uous performance test described in Chapter 2) as a manipulative device, others are truly se- and a reaction time test (pressing a button when dated and are occasionally reprimanded by poorly a light flashed on). Both are paced by the exper- informed school personnel forlaziness. Ob- imenter and require sustained attention. Each viously, a sedated, sleepy child will have greater patient was tested at the beginning of the study difficulty performing school activities,If a child and on two more occasions after a 30 to 50% does not develop a tolerance for the drowsiness change in dosage. The majority performed best within a couple of weeks after the onset of treat- on both the vigilance and reaction time tests ment, the physician can lower the dosage, ad- while on the lowest dose of medication. Eight of minister a stimulant (Ritalin or Dexedrine), or the patients felt better subjectively on the lower substitute another drug for the offending agent dose, six could not tell the difference between (Livingston1972), If the same dosage that con- doses. and one felt better on the highest dose. trols seizures also produces sedation, a difficult Dekaban and Lehman noted that heavy medi- risk-to-benefit decision will have to be made. cation can impair cognitive performance without there being any clear outward signs of intoxica- Some patients may be better off leading a tion (e.g., ataxia, diplopia, nystagmus), normal life between occasional seizures Mathews and Harley (1975) compared the than living seizure-free in a perpetual state performance of two groups of epileptic patients of drug-induced drowsiness and confu- on a number of cognitive and perceptual-motor sion. Both the physician and patient must tests. One group had blood levels of antiepileptic decide which is the greater handicap the drugs in the low toxic range, and the other had drowsiness or the recurrence of seizures. nontoxic blood levels. All patients were receiving (p. 356) one or more of the following drugs: phenobarbi- Another side effect of antiepileptic medication tal, Mysoline. or Dilantin. The most marked dif- (particularly phenobarbital) that can seriously im- ferences between the two groups were on ma- pair school performance is drug induced behav- sores of sustained concentration, attention span, ior disorders, usually hyperactivity. Ways in which motor coordination, and motor steadiness with the physician can manage this reaction have al- the nontoxic group performing superior to the ready been mentioned. There is also another toxic group. type of behavior disturbance that has not re- Memory processes may also be impaired by ceived much attention (Livingston. 1976). Some high therapeutic doses ofbarbiturates. Mac- behaviorally normal children become profoundly Leod, Dekabary and Hunt (1978) compared the restless, hyperactive, belligerent, and exhibit fre- performance of epileptic patients receiving a me- quent temper outbursts on medication, regard- dium and high dose of phenobarbital on short less of the type of drug. When medication is and long term memory tasks. The short term stopped or the dosage reduced to the point where memory task consisted of presenting a series of seizures reappear, the child's behavior returns one to six numbers on a visual display. After a to normal. In many cases, the behavior disorder brief pause. a probe number was presented. The is a greater problem than the seizures. "In such patient had to indicate by pressing a lever whether cases it is probably best to allow the child to have the probe number appeared in the previous dis- an occasional seizure and normal interictal (be- play. (There are a number of similarities between tween seizures) behavior than to be completely this and the short term memory task described in seizure free but with uncontrolled behavior- (p. Chapter 2). MacLeod et. al. found (relative to a 259). control group) that the high therapeutic dose of There are only a few systematic investigations phenobarbital impaired short term memory by of the relationship between high doses or toxic creasing the time it took for patients to press the levels of anticonvulsant drugs and cognitive per- lever. There were no dosage differences on the formance (Stores, 1975), In one study. Dekaban long term memory task. These results may have and Lehman (1975) tested 15 epileptic patients implications for school performance because on a number of laboratory tests. Each was re- "impairment of short-term memory may critically 52 'CHILDREN ON MEDICATION influence a person's ability to maintain attention, PATTERN OF TREATMEN-T a crucial ability when one is trying to acquire new Drug therapy should be initialed as soon as the information- (p. 1 104). diagnosis of epilepsyis made (Livingston, There are also a few reports of anticonvulsant 1978a). In general. the longer the seizures go drugs causing general mental slowing and retar- untreated. the more difficult they are to control. It dation. Cordes (1973) described a case study of is as if the brain gets into the habit of having con- a preschool girl who developed mild mental re- vulsions, Drug treatment should be initiated not tardation on antiepileptic medication. Termina- only to control seizures, but also to prevent sei- tion of treatment was followed by a marked de- zure related injuries, brain damageresulting from velopmental spurt About another preschool child status epilepticus. emotional disorders, and ad- receiving multiple drugs for minor motor sei- justment problems such as the loss of a job, re- zures. a mother commented, "Each time he vocation or denial of a driver's license, and un- comes off another pill learning increases and the desirability as a marriage partner. school has less problems" (Gadow. 1977b. p. Whether or not medication should be initiated 48): after only one seizure of unknown cause is con- For some children. impairment of cognitive troversial, Livingston (1958) reported a study of performance will be a necessary price that has 200 children who had only a single epileptic sei- to be paid for adequate seizure control, How- zure prior to diagnosis. Children were randomly ever, in certain treatment populations, special ef- assigned to one of two groups; continuous phen- forts must be made to prevent unnecessary ov- obarbital therapy or no medication. There was a ermedication. For example, a strong argument dramatic decrease in subsequent seizures for can be made for the necessity to improve exist- the drug treated group compared to children who ing drug monitoring procedures for mentally re- were not placed on medication. Livingston's tarded epileptic children and adults (Herberg. (1978a) position on this issue, presumably based 1977; O'Neill, at al 1977; Schein, 1975; Spra- in part on the above study, was as follows; gue,1977b). One of the anticipated consequences of such efforts would be a reduction in We assign the diagnosis of epilepsy to pa- the number of mentally retarded individuals made tients who have an unquestionable con- more intellectually impaired by their medication. vulsion of undetermined cause, and we Preschoolers constitute another group that re- continue with this diagnosis unless the sei- quires special attention (Cordes. 1973: Dekaban zure later proves to have been a manifes- & Lehman, 1975: Gadow, 1977b). Because de- tation of some other disorder. Our general velopment progresses at such a rapid rate during policyisto prescribe daily antiepileptic early childhood, parents, teacher, and physician medication for these patients .It is em- must seriously consider whether drug induced phasized, however, that a positive diag- mental impairment is a reasonable risk for ade- nosis of major motor epilepsy, for exam- quate seizure control. It must be reemphasized ple, should not be made at the time of the that the physical (through injury) and psycholog- initial "attack" in a person whose episode ical consequences of uncontrolled seizures can was not clearly defined by the observer as contribute to severe adjustment problems. a true convulsion unless the EEG reveals abnormalities such as are seen in patients Unfortunately, there are no standard proce- with grand mal epilepsy. (p. 301) dures for assessing possible impairment of cognitive performance by antiepileptic medication There is much controversy as to whether Di (MacLeod, Dekaban, & Hunt, 1978). It is imper- lantin and phenobarbital should be administered ative, therefore, that school input pe an integral in a single dose once a day or in divided doses pan of the drug evaluation procedure, both at the throughout the day. After reviewing the literature, onset of treatment and during alterations in the Livingston (1978a) concluded that Dilantin and drug regimen (Gadow. 1978a).Itis hoped that phenobarbital should be administered to both future research efforts will provide more infor- children and adults at least twice dailybecause mation about what to date has been a much ne- divided doses produce a more even bloodlevel glected topicthe behavioral side effects of an- during the day. He further stated that ifeither of ticonvulsant drugs. these drugs must be given only once a day, ap, CONVULSIVE DISORDERS/53 propriate blood level studies should be con- 71% in epileptic children surveyed by the Na- ducted, Interviews with parents indicate that al- tional Epilepsy League (Pietsch, 1977). The most most all children with convulsive disorders receive common drug combinations are Dilantin and a medication in divided doses two or three times barbiturate (phenobarbital or Mebaral), Dilantin per day (Gadow. 1977a. 1978c). and Mysoline. and Mysoline and phenobarbital Another characteristic of anticonvulsant drug (Gadow, 1977a, 1978c). The benzodiazepines, treatment is the use of two or more drugs for sei- succinimides, and oxazoladinediones are rarely zure control. The prevalence of polypharmacy used singly. Clinicians have questioned the ne- ranges from 50% in preschool special education cessity of all these drug combinations and point children (Gadow. 1977a) and 53% in trainable out that much polypharmacy can be avoided by mentally retarded children (Gadow, 197E1b), to monitoring drug blood levels (Shorvon & Rey-

TABLE 3-4 Average dosages of antiepileptic drugs' Maximal Dosage Age Starting DosageDosage Drug (Years) Mg Times/Day Mg Times/Day ACTH and Corticosteroids' Atabrine Under 6 50 50 (Ouinacnne) Over 6 50 2 100 Bromide Under 3 160 2 320 3 3 to 6 320 640 Over 6 320 3 1000 Celontin2 Under 6 150 3 300 4 (Methsuxirnide) Over 6 300 2 600 4 Glonopin3 (Clonazepam) Depakene5 (Valproic Acid) Dexedrine Under 6 2.5 1 2,5 (Dextroamphetamine) Over 6 2.5 2 7,5 3 Diarnox Under 6 125 3 250 3 (Acetazolarnide) Over 6 250 2 250 4 Dilantin4 Under 2 15 3 30 3 (Pheriytoin) 2 to 4 30 2 50 4 4 to 6 30 3 100 3 Over 6 100 2 100 4 Gemonil Under 6 50 3 100 3 (Metharbital) Over 6 100 3 200 3 Mebaral Under 2 32 3 50 4 (Mephobarbital) 2 to 4 32 4 82 4 to 6 50 4 100 Over 6 100 3 200 3 Mesantoin2 Under 6 50 3 200 3 (Mephenytoin) Over 6 100 3 400 3 Milontin2 Under 6 250 2 500 3 (Phensuximide) Over 6 500 2 1000 4 Mysoline Under 2 25 2 50 4 (Primidene) 2 to 4 50 3 125 4 4 to 6 125 3 250 4 Over 6 250 3 500 4 Paradione Under 6 150 2 300 3 (Pararnethadione) Over 6 300 2 600 3 Continued onnext page 54 /CHILDREN ON MEDICATION

TABLE 3- Continued Average dosages of antiepileptic drugs' starting Dosage Maximal Dosage Age Drug (Years) -0 Times/Day Mg Times/Day

Peganone' Under 6 250 3 750 4 (Ethotoin) Over 6 500 3 1000 4 Phenobarbital Under 2 16 3 32 3 2 to 4 16 4 32 4 4 to 6 32 3 48 3 Over 6 32 4 65 3 Phenurone2 Under 6 250 3 1000 3 (Phenacemide) Over 6 500 2000 3 Tegretol Under 6 100 1 100 3 (Carbamazepine) 6 to 12 100 2 100 4 Over 12 100 3 200 5 Tridione Under 6 150 2 300 3 (Trirnethadion Over 6 300 2 60C 3 Valium" (Diazepam) Zarontin Under 6 250 2 250 4 (Ethosuximide) Over 6 250 3 500 4 Note. Modified from Livingston, S. Comprehensive management of epilepsy in infancy, childhood and adolescence, 1972. Reprinted courtesy of Charles C Thomas. Publisher, Springfield, Illinois. This Table includes only the antiepileptic drugs used at the Samuel Livingston Epilepsy Diagnostic and Treatment Center, ' The patient should receive a daily intramuscular injection of 20 units of corlicotropin twice daily for 4 to 6 weeks, depending upon seizure response. If complete control of seizures and normalization of the EEG are obtained, no further therapy is indicated unless there is a recurrence of clinical seizures. Itafter 6 weeks of treatment with ACTH, clinical control of seizures is attained but the EEG remains abnormal, steroid therapy (cortisone or prednisone) should be instituted and continued for a prolonged period in anattempt to normalize the EEG, If there is no clinical response to 6 weeks of ACTH therapy, the patient may be given a trialof oral steroid therapy, administered daily for at least 2 months, It is important that oral sterotd therapy be discontinued gradually. The maximal dosages of these drugs for children over age 6 exceeds the manufacturers' recommendations. Therapy in younger children is initialed with a daily dose of 0,5 mg and increased by increments of 0,25 to 0.5 mg every 3 to 4 days to a maximum daily dosage of 3 mg. In the older child, 1 mg daily is prescribed initially and increased by0.5 mg to 1 mg every 3 or 4 days to a maximum daily dosage of 6 mg. In adults 1.5 ma is prescribed initially and increased by increments of0.5 to I mg every 3 or 4 days to a maximum daily dosage of 20 mg. We only rarely prescribe phonytoin for infants. Therapy IS instituted with a dose of 15 mg/kg/day and thiS dosage is continued for 2 weeks. If necessary, me dose is subsequently increased as indicated by clinical response or signs of toxicity by 5 to 10 mg/kg/day each week to a maximum of 50 mg/kg/day, The maximum daily dose recommended in the package insert is 30 rng/kg/day. ° Effective dosage of diazepam varies from patient to patient. We start treatment as follows children under age one 1 mg every 3 hours for 5 doses daily; young children 2 mg every 3 hours for 5 doses daily; older cildren, 5 mg. every 3 hours for 5doses daily. The daily dose is increased if necessary, by one dosage per week, depending on clinical response and tolerance to the drug,The appearance of marked drowsiness indicates that the maximal tolerable dosage has been surpassed, The maximal dailydosages we have employed: children under age one, 15 mg.: young children, 30 mg; older children, 50 mg. The package insert states that oral diazepam is contraindicated in children under age 6 months and that intravenous diazepam is contraindicated in infants under 30 days of age,

nolds, 1977). The usefulness of combining more necessary to achieve satisfactory seizure control than three different anticonvulsants has also been varies considerably from patient to patient. This questioned (Livingston, 1972; Wilson, 1969), but is due, in part, to large individual differences in it is easy to see how such a situation could de- the rate of drug metabolism and removal from velop for a child whose seizures remain uncon- the body. The same dose of Dilantin, for exam- trolled. ple, produces a wide range of blood levels in The average dosages for antiepileptic drugs people with epilepsy (Lascelles, Kocen, & Rey- used at the Samuel Livingston Epilepsy Diag- nolds, 1970). Therefore, whereas one person nostic and Treatment Center are listed in Table becomes seizure free on 200 mg per day of Di- 3-4. It must be emphasized these are average lantin, another may require 600 mg daily for ad- dosages, and that the actual dose of medication equate seizure control. CONVULSIVE DISORDERS/55

Parents and teachers should be aware of the control among young and mentally retarded chil- fact that the effect of a particular dose of Dilantin dreninspecial education programs (Gadow, or phenobarbital cannot be adequately evalu- 1976, 1978a), Comparative information about ated until a stable blood level is reached (Liv- epileptic children in nonspecial education class- ingston, 1978b). When medication is given orally rooms is not available. but there is no reason to on a daily basis. the drug gradually accumulates believe that signficiant differences do exist, Be- in the blood and eventually levels off. This pro- cause the collection of these data from special cess may take from 1 to 2 weeks for Dilantin and education programs either precedes or overlaps from 3 to 4 weeks for phenobarbital in adults. A the release of Tegretol, Clonopin, and Depa- stable blood level of phenobarbital is achieved Rene, these drugs are probably more widely used sooner in children than adults. Itis also recom- than indicated in Table 3-5. mended that dosage changes should not be Followup studies that investigated the termi- made until the blood level of the drug stabilizes. nation of medication show that as compared to Because each of the epilepsies responds best adults, the prognosis is much better for children to certain drugs. the extent to which individual who have become seizure free. After reviewing antiepileptic agents are used is determined. in the limited data available about the withdrawal of part, by the prevalence of the different forms of antiepileptic drugs. Holowach, Thurston, and epilepsy. Therefore, the major motor (grand mai) O'Leary (1972) reported the relapse rate for sei- drugs would be expected to be used frequently. zures ranged from 21 to 28% in three studies on and the antipetit mal agents much less often. children and from 40 to 46% in three studies that Surveys of drug use patterns among children primarily included adults. In their own study of treated for convulsive disorders reveal such a 148 cases of childhood convulsive disorders. distribution (see Table 3-5). It can be seen that they reported the prognosis for grand mal sei- by far the most commonly used antiepileptic zures was more favorable than for other types of agents are Dilantin, phenobarbital, and Myso epilepsy. The highest relapse rates were for chil- line. Collectively, they account for three-fourths dren with Jacksonian seizures (53%). mixed sei- of the total number of drugs used for seizure zures (40%). and psychomotor seizures (25%).

TABLE 3-5 Drugs reportedly used in the management of convulsive disorders with children in special education programs* Trainable Mentally Early Childhood Retarded Special Education Generic Trade (children - 332) (children = 140) Name Name 0/0 Phenytoin Dilantin 186 56.0 59 42.1 Phenobarbital 166 50.0 76 54.3 Primidone Mysoline 62 18,7 19 13.6 Carbarnazepine Tegretol 26 7.8 3 2.1 Acetazolamide Diamox 22 6.6 3 2.1 Ethosuximide Zarontin 22 6.6 2 1.4 Clonazepam Clonopin2 19 5.7 0 0.0 Diazepam Valium 18 5.4 11 7.9 Mephnbarbital Mebaral 13 3,9 7 5.0 Methsuximide Celontin 7 2.1 3 2.1 Other 28 8.4 22 15.7 Total' 569 171.2 205 146.3 Data about trainable mentally retarded children are from Gadow978a), and data about early childhood special education children are from Gadow (1977b). ' Totals are inflated because 177 of the mentally retarded children and 50 of the preschool children received more than one antiepileptic drug during the school year. Recently approved by the Food and Drug Administration for use in the management of convulsive disorders when the data were collected (in 1975) about the early childhood _sample, 56:: CHILDREN ON MEDICATION

Only one of the eight children with petit mat example. Kutt (1974) reported that blood levels spells. all of whom received phenobarbital as a from 10 to 40 µg ml are considered in the effec- prophylactic measure to prevent grand rnaL had tive treatment range for phenobarbital. Generally a relapse, If seizures have an organic cause and speaking. blood levels below 10 e,g/rnl are not the child is mentally or motorically retarded. the effective in seizure control, and levels above 40 probability of seizure relapse during drug with- eArril produce adverse reactions. Similar guide- drawal is greatly increased. The prognosis is lines are available for Dilantin. but for most other best for seizures that have an early onset and anticonvulsants, much has yet lo be learned are quickly controlled compared to seizures orig- about blood level and toxicity (Livingston, 1978b). inating during infancy or later childhood. and There are several situations in which deter- which are difficult to bring under control. In gen- mining the amount of drug in the blood can be eral, the longer a person is on medication and quite helpful (Livingston. 1978b). Perhaps the seizure free, the less likely there will be a relapse most important is when it is necessary to see if after drug therapy is withdrawn. With the excep- the childis actually taking medication as pre- tion of petit mal spells, the EEG is of lithe value scribed. If there is an increase in seizure fre- in the decision to withdraw drug therapy. quency. a blood level analysis can help deter- A general rule for the discontinuation of drug mine whether the drug is not controlling the treatment for convulsive disorders is to wait at seizures or the child is not taking (swallowing) least 4. years after the last seizure before consid- the Medication. If medication was administered ering the termination of medication (Livingston. as prescribed. a low blood level would indicate 1972. 1976b) An additional 1 to 4 years may be that the dosage should be increased. A second required for dosage reduction and gradual drug indication for monitoring blood level is when signs withdrawal, depending upon the initial dosage of intoxication appear at low doses and precise and severity of seizures. Sudden discontinuation adjustments have to be made. A third situation is of medication may precipitate seizures and pos- identifying which agent is producing intoxication sibly grand mal status. Occasionally. it is inure in a multiple drug regimen. Blood analysis can difficult to control a recurrence of seizures after determine who' her rice drug is raising or lower- a sudden withdrawal of medication with the same ing the blood level of another drug. .4, final indi- regimen that was previously effective. The actual cation for using blood monitoring procedures is seizure free period may be less than 4 years if in the treatment of children who cannot verbally report how the drug is affecting them (e.g., se- the anticonvulsant drugs are producing serious verely retarded individuals) or who exhibit be- side effects or impairing performance. Also, the stigma of taking medication may be difficult to haviors similar to intoxication (e.g.. young chil- live with, especially for teenagers. If the seizure dren learning to walk may appear ataxic). may free period overlaps the onset of puberty. DRUG INTERACTIONS be judicious to continue medication throughout adolescence. This is particularly relevant for fe- Anfiepileptic drugs may interact with one an- males. When the first seizure occurs in late ad- other, with psychotropic drugs, or with avariety olescence or early adulthood, it is quite likely that of other medicines. When one considers the ex- medication will have to be continued throughout tent of perlypharmacy in epilepsy, it would not be the person's lifetime.If seizures occur during unusual to occasionally encounter such reac- the period when the dosage of medication is tions in chileren. being reduced, continuous lifetime treatment eiso With anticonvulsant drugs, many of the Rey in- is very probable. teractions take place at the metabolic level. An anent that stimulates or inhibits the metabolism Anticonvulsant Blood Levels of an anticonvulsant will alter the level of the anti- The development of procedures for analyzing epileptic drug in the blood. An example may help the amount of anticonvulsant drugs in the blood clarify this relationship. The liver breaks down has had a marked effect on the ability to monitor Mysolineintophenobarbitalandphenyl- certain aspects of treatment. Although there is ethylrnalonamide. At this writing,itis believed quite a bit of variation from child to child and the that the phenobarbital accounts for the anticon- amount of drug in the blood necessary for sei- vulsant properties of Mysoline. If a child is taking zure control. there is a good relationshipfie- Mysoline but his or her seizures are still uncon- tween blood level and signs of intoxication. For trolled. the physician may add another drug, for CONVULSIVE DISORDERS/57 example, Dilantin. The Dilantin, however, could that dosage reduction or withdrawal of medica- stimulate the metabolism of Mysoline, resulting tion must be employed. in higher levels of phenobarbital in the blood (Callaghan,Feely,Duggan,O'Callaghan. & Seldrup.1977). The increased blood level of NATIONAL. ORGANIZATIONS phenobarbital may result in either better seizure Epilepsy Foundation of America control or noxious side effects. Suite 406 All the major anticonvulsants (phenobarbital. 1828 L Street, N.W. My-seline, Dilantin, and Tegretol) are powerful Washington. D.C 20036 stimulators of liver metabolic processes (Rich- 202'293-2930 ens, 1975). Space limitations do not permit a detailed discussion of all the possible interactions Epilepsy Foundation of America of clinical significance. However, in order to pro- (Formerly National Epilepsy League) vide an appreciation for the complexity of these 6 North Michigan Avenue reactions, another example will be given. Chicago, Illinois 60602 Many drugs can inhibit the metabolism of Di- 312/332-8888 lantin (Kutt, 1974). When the rate at w; tin is broken dOwn into inactive metabolites is The Epilepsy Foundation of America (EFA) is a slowed down, the level of the active drug in the major national agency for people with epilepsy blood increases. This could result in greater sei- sponsoring a wide variety of programs and activ- zure control if the child is still having attacks, Di- ities. The Foundation provides information on lantin intoxication, or both. It is noteworthy that if epilepsy and its consequences to any person or the blood level of Dilantin gets too high, the drug group requesting it, Areas include: may provoke a seizure or increase the frequency 1.Information on epilepsy for the patient. his of attacks (Levy & Fenichel. 1965). The reader family. and friends. who wishes additional information about drug in- 2.Educationalmaterialstoindividuals and teractions with antiepileptic agents should con- groups dealing with people with seizure dis- sult other authoritative sources such as Hoosh- orders. mend (1974). Kutt and Louis (1974), Pippenger, 3.Information on employment, including voca- Sins. Werner. and Masland (1075). Richens tional rehabilitation and training, rights, hiring (1975), and Woodbury. Remy. and Schmidt and insurance regulations, special programs. (1972), and the particular employment needs of some The way in which drug interactions are man- people with epilepsy whose seizures are not aged probably varies with the clinician. Shorvon fully controlled. and Reynolds (1977) argued that much unnec- 4. Specific information on the rights of persons essary polypharmacy might be the result of one with epilepsy as guaranteed by federal and drug simply elevating another drug to effective state statutes, levels in the blood. If this were the case. the best c,Housing information (mostly about discrimi- thing to do would be to increase the dosage of nation and alternative living arrangements, the effective drug and withdraw the drug that such as group homes), caused the interaction. Unfortunately, things are 6. Transportation information, includ''I federal not always that simple. Both drugs may be re- and state driving regulations. quired for treatment if one really is not com- 7.Health services information, including pre- pletely effective or if the drugs are being used to vention. diagnosis, treatment, rehabilitation, control two different types of disorders. In such and maintenance. cases, the dosage of one drug may have to be 8.Information on economic, social, and psycho- raised or lowered depending upon the situation. logical services, such as disability benefits The child and family may be so alarmed by the and supplemental security income. recrea- effects of the drug interaction that the parents tional services, and individual and group terminate the most recently added (presumably counseling programs as they might apply to offending) agent. It must be emphasized that al- persons with epilepsy and their families. though antiepileptic drug interactions are possi- 9. Information on the latest research into the ble, they only affect a small percentage of pa- causes, treatment, and prevention of sei- tients who receive multiple drugs in such a way zures. 58/ CHILDREN ON MEDICATION

10.Information on federal and state programs Livingston. S. Comprehensive management of that affect people with epilepsy. epilepsy in infancy, childhood and adolescence. Springfield IL: Charles C Thomas. 1972. Antiepileptic drugs can be very expensive. In (M) order to alleviate the burden placed upon fami- Livingston, S. Psychosocial aspects of epilepsy. lies by the cost of these drugs, the Epilepsy Journal of Clinical Child Psychology,1977, Foundation of America (Chicago office) has for 6(3). 6-10. (T. M) years maintained a Cooperative Pharmacy Ser- Livingston. S. Medical treatment of epilepsy: Part vice. All of the drugs and medicines prescribed I. Southern Medical Journal, 1978, 71, 298- in the treatment of epilepsy are available to any 310. (M) epilepsy patient below retail costs. Contact the Livingston, S. Medical treatment of epilepsy: Part Chicago office for more information about this II. Southern Medical Journal, 1978. 71, 432- service. 447. (M) Mostofsky, D. I.. & Balasehak. B. A. Psychobio- logical control of seizures. Psychological Bul- SUGGESTED READINGS letin, 1977, 84, 723-750. (M) Baird. H. W. The child with convulsions: A guide Reynolds. E. H. Chronic antiepileptic toxicity: A for parents. teachers, counselors, and medi- review. Epilepsia, 1975, 16, 319-352. (M) cal personnel. New York: Grune & Stratton. Stores. G. Behavioral effects of anti-epileptic 1972. (P. T) drugs. Developmental Medicine and Child Gadow, K. D. Drug therapy with trainable men- Neurology, 1975. 17, 647-658. (M) tally retarded children in public schools. Pa- Stores. G. Antiepiteptics (anticonvulsants). In J. per presented at the annual meeting of The S. Worry (Ed.), Pediatric psychopharrnacol- Council for Exceptional Children, Kansas City, ogy: The use of behavior modifying drugs in May 1978. (ERIC Document Reproduction children. New York: Brunner/Morel, 1978. (M) Service No ED 153 398) (T) Woodbury, D. M.. Peary, J. K.. & Schmidt, R. P. Livingston, S. Living with epileptic seizures. (Eds.). Antiepileptic drugs. New York: Raven Springfield IL: Charles C Thomas. 1963. (P. T) Press, 1972. (M)

0L, 4/Mental Retardation

Drug treatment with mentally retarded children It should be noted that psychotropic drugs are and adults is considered a separate topic in this not prescribed for mental retardation per se. The book for several reasons. First, many of the dis- objective of drug treatment is not to "cure" or orders for which psychotropic and antiepileptie change biochemical processes in such a fashion drugs are prescribed are prevalent among re- that a mentally retarded child can perform like tarded populations. This is particularly true for his or her nonretarded peers. Although medica- the more severely and profoundly impaired ir di- tion may improve learning and cognitive perfor- viduals, Second, it is often unclear as to whether mance, the typical reason for prescribing medi- some disorders associated with mental retarda- cation is the control of behavior disorders, notably tion are the same, both in terms of etiology and hyperactivity, aggressivity, self injurious acts, and response to treatment, as apparently similar dis- stereotyped motor movements. orders (e.g., hyperactivity) in nonretarded individuals (Fish, 1971). Third, some drug treated disorders, such as stereotyped behavior, are DISORDERS ASSOCIATED WITH MENTAL. commonly associated with mental retardation. RETARDATION Fourth, because several different types of disor- The prevalence of behavior problems is much ders are frequently found in a given retarded higher among mentally retarded children as child, the prevalence of combined drug regimens compared to their nonretarded age mates. A is also greater. For example, a mentally retarde-d study of 9 to 11 year old British children on the child may be treated simultaneously for epilepsy, Isle of Wight showed that this reiationship holds cerebral palsy, and behavior disorders. Associ- up whether the source of information is behav- ated with combined drug regimens, of course, is ioral ratings obtained from parents or teachers or the potential problem of drug interaction. And fi- psychiatric examinations (Rutter, 1971: Rutter, nally, the way in which social agencies and the Tizard, & Whitmore, 1970). general population respond to retarded people Payne, Johnson, and Abelson (1969) con- May interact in a complex fashion with decisions ducted what must certainly be one of the most about drug treatment. For example, the recent comprehensive surveys of mentally retarded emphasis on deinstitutionalization is bringing persons in residential facilities. Twenty-two insti- many severely and profoundly retarded persons tutions in the Western United States were asked into the mainstream of everyday life through to provide detailed data on a total of 24,257 re- community placements. The feasibility of such sidents in 1968. Ward personnel made behav- placements for some individuals with severe be ioral ratings using a four-point scale: never, sel havior problems may depend upon effective dom, occasionally, and frequently. Of primary pharmacotherapy. interest were behaviors considered maladaptive

59 CHILDREN ON MEDICATION

(i.e., those that interfered with institutional pro- treated with psychotropic drugs. Valium (diaze- graming). The most common behaviors rated pam) and Dantrium (dantrolene sodium), the most 'frequently" werehyperactivity,aggressivity, frequently prescribed skeletal muscle relaxants and running. Other "frequent" behaviors were used in the management of cerebral palsy. are self destructiveness,requiring restraints, de- discussed in greater detail in the next chapter. stroying clothing, and attacking other residents_ Of the residents, 21% were characterized as PREVALENCE AND PATTERN OF DRUG "occasionally" hyperactive and/or aggressive. TREATMENT IN RESIDENTIAL FACILITIES Eyrnan and Call (1977) studied the prevalence of maladaptive behavior in mentally retarded in- Lipman (1970) conducted a questionnaire sue. dividuals living in residential facilities, community vey on psychotropic drug use in state and private settings, or their own homes. Using a behavior institutions for the mentally retarded. Findings rating scale, social workers in community set- revealed that the extent of drug use was consid- tings and direct care personnel in institutions erable, and that 51% of the residents had re- evaluated 6,870 mentally retarded children and ceived psychotropic agents at some time. Two adults. Clients were divided into three groups ac- major tranquilizers,Mellaril (thioridazine) and cording to level of retardation' profound, severe, Thorazine (chlorpromazine), accounted for over and mild-moderate. Group comparisons re- half of all reported drugs, and they were the pre- vealed a greater frequency of behavior problems ferred agents in 91% of the institutions_ Some of in profoundly retarded as compared to mild-mod- the reported maximum dosages were quite high: erately retarded persons. The prevalence of be- 3,000 rng/day for Thorazine and 1,800 mg/day havior disorders was also much higher in insti- for Mellaril (see Table 4-1). Even more disturbing tutionsthan incommunitysettings, Three was the chronic nature of drug use: 25% of the behavior problems were quite common. with drug treated residents had received medication some variation across age and level of retarda- for 4 or more years. tion: stereotyped behavior,hyperactivity_, and ag- Recently, Sprague (1977a) reported data about gressivity. The latter was subdivided into vio- the extent and pattern of psychotropic and anti- lence toward others, violence toward oneself or epileptic drug treatment from the records of re- self injurious behavior, and the destruction of tarded residents in two midwestern facilities, one property. old and one new (see Table 4-1), The older in- Approximately half of the individuals under 13 stitution housed 1,639 residents in buildings with years of age ininstitutions had stereotypes day rooms and open wards- Residents ranged (repetitive. often bizarre motor activity). In pen- from moderately to profoundly retarded, with a eral, the figures were lower for those in commu- mean age of 27.4 years. The new (small) facility nity placements and for older, moderately re- housed 286 residents who lived in group homes tarded residents. Examples of such behavior are each designed for eight people. The entire facil- rhythmic rocking, head weaving, mouthing, hand ity was modeled after community living; and from or arm flapping, and rubbing parts of the body, outward appearances, it looked much like a sub- As with hyperactivity and behavior problems, urban housing division. Residents ranged from the prevalence of convulsive disorders among moderate to profoundly retarded with a mean moderate to profoundly retarded people is greater age of 29.4 years- Despite differences in the phi- than among the general population. Schein losophy and type of care represented by these (1975) described the relationship between the two facilities, the prevalence of drug treatment two disorders as "linked together epidemiologi- was quite similar: 66% in the older large institu- cally. etiologically, clinically and therapeutically_ ," tion and 65% in the new community styled facil- Although convulsive disorders do not appear to ity. Over half the residents on medication in both be more prevalent among borderline and mildly facilities were receiving two or more psycho- retarded individuals than in the general popula- tropic and/or antiepileptic drugs. The three most tion (Slater & Cowie, 1971), estimates for se- frequently reported drugs in both institutions in verely and profoundly retarded persons in resi- rank order were Mellaril, Dilantin (phenytoln), dential facilities are as high as 30% (Jasper, and phenobarbital. Ward, & Pope. 1969). Although there is an emerging picture of the Another disorder associated with mental retar- extent and pattern of drug treatment with men- dation is cerebral palsy, which may also be tally retarded individuals in residential facilities, TABLE 4-1 Drug survey results from two midwestern institutions for mentally retarded individuals Rank Drug N Daily mg dose Months WeightNumber ofNumber of daily Mg/kg administered (Kg) other drugs administrations Large institution (N-.100)

1 Mellen! 477 (43.4%) Mean 229.8 Mean 4.12 30.9 55.97 1.1 2.2 (thioridazine) Median 175 Median 3.07 Range 10-1200 Range .36-18.12 2 Dilantin 437 (39.7%) Mean 177.2 Mean 3.88 50.0 49.21 1.8 2.4 (phenytoin) Median 180 Median 3.70 Range 30-400 Range .44 -18.38 3 Phenobarbital 422 (38.4%)Mean 112.2 Mean 2.49 39.2 49.62 1.8 2.2 Median 95 Median 2.04 Range 15-400 Range .37=15.27

4 Thorazine 92 (4%) Moan 296.2 Mean 5.00 22.6 59.48 2.1 2.7 (chlorpromazine) Median 250 Median 4.49 Range 251200 Range .59-20.79 38.0 43 13 1.3 5 N./mum 89 ( 1 Mean 12.4 Mean .30 2.7 (diazepam) Median 10 Median .24 Range 2-40 Range .05-.96 Small institution (N,167)

1 Me 97 (51.9%) Mean 206.2 Mean 3.20 6.9 65.79 1.0 2.5 (thioridazine) Median 300 Median 2.76 Range 25-600 Range .54-10.67 2 Dilantin 61 (32.6%) Mean 217.7 Mean 3.50 7.7 64.21 1.9 2.3 (phenytoin) Median 300 Median 3.56 Range 50=400 Range .69-8.24 3 Phenobarbital 53 (28.3%) Mean 117.5 Mean 1.80 8.0 64.65 1.9 2.0 Median 120 Median 1.70 Range 30-300 Ranno .38-4.56 15 Thorazine 3 (1.6%) 325.0 3.96 3.0 70.41 1 2.7 (chlorpromazine)

'Vote. From Sprague, R. L. Overview of psychopharmacology for the retarded in the United Satus.in R Milner(Ld.), Res ,-:arch _ice in rnergal retardation (Vol. 3). Baltimore: University Park Press, 1977,0, 201. Copyright 1977 by the International Association Inr the Scientific Study of Bien' Delirsiency, Reprinted by permission. 62/CHILDREN ON MEDICATION

very little has been reported about the exact rea. foundly retarded level. Approximately- 30% were son these drugs are prescribed. Klebanoff, Di- receivingantiepitepticdrugs.Patigents were Mascio, and Lowe (1973) reported on one at- grou ped according to three categories of seizure tempt to determine why these drugs are control: controlled =no seizures for a. year par- prescribed by surveying 33 staff physicians tially controlledone to three seizuees in any working in state institutions in Massachusetts. qi tarter of the year, and uncontrolle,dfour or They reported that Mellaril and Thorazine were more seizures in any quarter of the rear. Using prescribed primarily for the control of agitated thiscriterion. 13% were classified as uncon- and/or aggressive behavior and of psychotic trolled, 24% as partially controlled, and 63Q/0 as states. However, drug use for the control of agi- controlled. The identity of specific drugs was not tation/aggression was reported twice as often as reported, however. the investigatorsnoted that for psychosis. The primary reasons for prescrib- polyoharrnacy was "commonplace." ing Valium were for epilepsy and as a muscle relaxant for cerebral palsy. Phenobarbital was PREVALENCE AND PATTERN QF DRUG used primarily as an anticonvulsant and second- TREATIMENT IN PUBLIC SCHOOLS arily to induce sleep. In another study on reasons for drug use in From a comprehensive survey Of public institu- mental retardation, Sewell and Werry (1976) sur- tions. private facilities, and state mentaLl hospital s veyed the records of 648 residents (mean age conducted in 1969 by the Office of Mental Retar- 22 years) in a facility in New Zealand. They dation Coordination (1972). it Was d eterrn ined found psychotropic drugs were actively being that 255,000 mentally retardedchildren and administered to 40% of the residents in this facil- adults were in residential facilities, Although sur- ity, with major tranquilizers being prescribed to veys of records from institutions tell us a great 61% of those on medication. Thorazine and Mel- deal about drug treatment With the severely and laril were the most frequently prescribed drugs. profoundly retarded residents, this population The target symptoms for which the major tran- accounts for a small part of the estimaated 2 to 6 quilizers were prescribed, in rank order of fre- million retarded persons in the United States quency, were hyperactivity, noisiness, aggres (Robinson & Robinson, 1976). siveness, destructiveness, self mutilation. and Data on the number of mentally retarded chil- perverseness. Polypharmacy was quite com- dren in public schools are becoming arailabi e as mon: 60% of the residents received two or more a result of requirements established ire lhe Edu- psychotropic drugs, and 20% received three or cation for All Handicapped Children Act, (Pi. 94- more. 142) by which special education programs may The extent and pattern of drug treatment receive federal support. In February 19-77, a total convulsive disorders with mentally retarded re- of 3,618,410 children were reportedreceiving sidents is even less well documented than for special education services in public school (Di- behavior disorders. However, anticonvulsant vision of Innovation and Develoornent, Eureau of medication, panicularly Dilantin, phenobarbital, Education for the Handicapped, 1 977), Of these Mysoline (primidone). and Valium, are among children. 866.556 were designated -esbeing the most frequently prescribed drugs in residen- served in programs for mentally retarded stu- tial facilities (Sprague. 1977a). Payne et al. (1969) dents. Unfortunately, there is no breakdown by reported that 26% of all the mentally retarded degree of impairment (i.e., educable, torainable), persons in the institutions they surveyed were This figure is somewhat conservative consider- receiving drugs for seizure control. Institutions ing that many exceptional children do netfall with the greater proportions of severe and pro- neatly into one category. Also, there are proba- found residents reported the most extensive use bly many mentally retarded children who se needs of drugs to control seizures. go unattended. Using the frequently sited 2 to A survey was conducted among the 3.000 re- 3% prevalence rate for mental retardaion (Ro- sidents of an institution in Virginia to identify eo; binson & Robinson, 1976), one would expect a Ieptics as pad of a program to improve health larger nu mber of children to be in heed &special care services (O'Neill, Ladon, Harris, Rile, & services. Regardless of the errors in etirnating Dreifuss, 1977). The residents were primarily the number of mentally retarded childrem in pub- adults, had been hospitalized for long periods of lic schools, little is known about the eyetent and time. and were functioning at the severely to pro- pattern of drug treatment with this popeelatien NENTAL RETARDATION/63

Trainable Mentally Retarded Students From both teactier ques:Onnaires and interviews vvith pa.rents of TMR children on medica- In general, programs for the trainable mentally tion, some generalizations can be made about retarded (TMR) pupil serve children and adoles- the pattern of tea/mere First, only a small per- cents who score between 30/35 and 50/55 on centage of children are actually placed on medi- standardized 10 tests. What is known about the cation during the school year The incidence pattern and prevalence of drug use among chil- in unlbe r of new cases) of drug treatment for be- dren in these programs comes from one state- havior disorders was 6.3 cases per 1,000. This wide study conducted in Illinois (Gadow. 197811 is a far cry from sone popu tar scenarios that de- 1978c). Teachersin TMR classrooms were pict teachers and doctors in a conspiracy to en- mailed questionnaires that requested informa- slave mentally retarded children in chemical tion about children receiving medication, and straight octets. Second, drug treatment often many of the parents of these children were inter- has an early onset and is rri aintained, sometimes viewed. The children served by these programs intermittently, for long periods of time. Although ranged in age from 3 to 21 years. differences among_ age groups in the prevalence The results of the study showed that of the of drug treatrnent vvere not significant, the trend 3,306 students in the programs surveyed, 18.10e was for increasectuse during adolescence. Fi- received psychotropic or antiepileptic drugs at nally, corntined drug regimens were relatively some time during the school year Approximately infrequent: only 13 °/o of the behavior disordered 10% of these children were receiving medication children were on rrr ore than one drug. Additional for the management of convulsive disorders, and drugs were Aurally prescribed to control the side 4.9% were receiving medication for behavior dis- effects produced by major tranquilizers or to help orders. An additional 1.8% of the sample re- induce sleep at nig ht. Of the few drug combina- ceived drugs for both behavior problems and sei- tions reported, thetwo most frequent were Ri- zures. Psychotropic drugs were also prescribed ta! in-Me flar it and Tolranil-Mellari I. for other disorders, the most frequent being The prevalence of drug treatment for convul- cerebral palsy, anxiety, and enuresis. sive disord ors among TMR children was almost Stimulants and major tranquilizers were the twice that for behavior disorders with 11.9% re- most commonly prescribed drugs for the man- ceiving antiepi %optic drugs._ Dilantin and pheno- agement of behavior disorders (see Table 4-2). barbital were the two most frequently adminis- It can be seen that, as a group. stimulants ac- tered drugs for the control of seizures, aceounting counted for 45% of the total number of psycho for 62% of all a ntiepileptic drugs (see Table 3-5). tropic drugs, and major tranquilizers accounted The incidence rate for the onset of drug treat- for 37%. The two most frequently administered ment for epilepsy dieing the school year was 3.9 drugs were Rita lin and Mel laril. However, almost new cases per 1,000. Paren ts reported the onset two dozen different drugs were reportedly used if treatment was usually quite early, often be- in the management of behavior disorders. tween birth and 2years of age. Polypharmacy The most common reasons for drug yeah-eel was common. with over half of the convulsive were hyperactivity, behavior problems, and ag- disordered children receiving more than one drug. gressivity. Other reasons for prescribing medi- OI that group elf children, 15% received three or cation were psychotic behavior and attentienel more drugs lor seizure control. deficits. When asked to list specific behavioral changes as a result of drug therapy. teachers most often reported less motor restlessness (hy- Educab leIert,tally Retarded Students peractivity), improved attention to tasks, fewer behavior problems. and greater manageability. In general, children who are referred to as ed- Compared to the prevalence of psychotropic ucable Mentally retarded (EMR) score between drug treatment in residential facilities, the use of 50/55 and 75180 on standardized IQ tests. As a drugs with TMR children is much less frequent. group, they constitute the largest number of chil- Also, when medication is prescribed for behavior dren in categoricalspecial education programs management. the TMR child in school is more for mentally retarded students. Although recent apt to receive a stimulant, whereas the institu- efforts in rn air) 5Ir e a ming have focused on EMR tionalized child will probably be given a major chi ldren. many remain in segregated programs tranquilizer. for at least en ofthe school day (Borginsky. 64/CHILDREN ON MEDICATION

OF 1974). Because teachers in categorical special DRUGS USED IN THE MANAGEMENT education programs frequently ask questions BEHAVIOR DISORDERS about medication in reference to the population of children with which they work, information As noted, surveys show that both stimulants and about drug treatment with different categories of major tranquilizers are frequently prescribed for exceptionality have been presented when avail- behavior disorders in mentally retarded children able. Unfortunately, there are n9 published re- and adolescents. These studies also report that for drug use is ports about the pattern and prevalence of drug one of the most common reasons use with children or adolescents inEMR pro- hyperactivity. Because hyperactivity is a symp- be- grams. Research on drug effects inthis popula- tom characteristic of at least several different tion is also limited (Blacklidge & Ekblad,1971; havior disorders, it would be inappropriate toin- fer that stimulants are the "drugs of first choice' Sprague & Werry, 1974).

TABLE 4-2 Drugs reportedly used in the management of behaviordisorders with children in special education programs:, Trainable Mentally Early Childhood Special Retarded Education (Children - 161) (children 175)

Cionerir: Name Trade Name 1. St/ Muient,J (90) 64.0 Methylphenidate hcl Rita lin 42.2 112 5 2.9 Magnesium pemoline Cylert 6.8 11 6.3 DeXtroamphetamine Dexedrine 9 5.6 2 1.1 Other 2 1.2 (23) 2= Major Tranquilizers (68) 10.9 Thioridazine Mellaril 40 24.8 19 7.5 2 -1.1 Chlorpromazine. Thorazine 12 1 0.6 Haloperidol Haldol 6 3.7 Trifluoperazine hcl St elazine S 3.1 0 0.0 0 0.0 Fluphenazine hcf Prolixin 3 1.9 1 0.6 Other 2 1.2 3, Minor Tranquilizers (12) 2.3 Diazepam Valiu m 7 4.3 1.7 Hydroxyzine hcl Atarax 2 1.2 0.0 Chlordiazepoxide het Librium 2 1.2 1.1 Hydroxyzine pamoate Vistaril 1 0.6 (44) 4. Miscellaneous (31) 3.4 Imipramine Tofranil 9 5.6 6 5 2.9 Phenobarbital 6 3.7 1.9 20 11.4 Phenytoin Dilantin 3 2.9 Diphenhydramine hcl Benadryl 2 1.2 5 0.0 Arnitriptylino Elavil 2 1.2 0 0.0 (Fixed Ratio Product) Phenergan 2 1.2 0 2.9 Other 3 1.9 5 Unknown 4 2.5 _3_ 1.7 206 117.7 Total° 201 124.5

education children are Data on trainable mentally retarded children are Inr1 Gadcw (1978a). and data on early childhood special from Ga. )w (1976). n Totals are inflated because 34 PAR children and 28preschool children received more than one drug during the school year MENTAL RETARDATION /68

in treating all hyperactive mentally retarded chil- the bizarre behavior of severely and profoundly dren (Fish, 1971). On the other hand, it is clear retarded persons and psychotics. One of the ob- that stimulants are used frequently for hyperac- jectives of pharmacotherapy with psychotics is tivity. behavior problems, and aggressive behav- the suppression of maladaptive behavior (i.e., ior with mentally retarded childreninpublic behavior that is injurious to self and others, is schools (Gadow, 1978a). In view of the effects socially unacceptable, and interferes with thera- of stimulants in adults (Turner & Carl, 1939; peutic progress). It is reasonable to assume that Weiss & Laties, 1962), hyperactive elementary drug therapy for severe behavior problems with school children (Ross & Ross. 1976; Safer & Al- mentally retarded children is similarly motivated. len, 1976), and normal preadolescent boys (Ra- However, because of the prevalence of psycho- poport et al., 1978), it should come as no sur- tropic drug use in residential facilities, a number prise that mentally retarded children respond to of researchers, clinicians, and educators have these agents in a way that is perceived as ben- seriously questioned whether or not the resi- eficial by parents and teachers. Because the ee dent's well being is always the overedino con- feet of stimulants is described in detail in Chapter cern (Sprague, 1977b, 1976), 2,only the major tranquilizers are discussed The major tranquilizers con lady of here. No attempt will be made to survey the lit- three subgroups: phenothiazioiffi6 Mellaril, erature about drug treatment with mentally re- Thorazine,Stelazine), butyr(',;(3170nus(e.g., tarded populations as there are already a num- Haldol). and thioxanthenes :'.''actin, Na- ber ofexcellentreview iesavailable vane). The phenothiazines are the most widely (Freeman,1966, 1970a,1 e /Ole, Lipman, Di- used major tranquilizers, and, for this reason, Mascio, Reatig, & Kirson,1978; Sprague & they are the primary focus of the following dis, Werry. 1971),Itis noteworthy that only a few cussion. There are two more categories of major psychotropic drug studies with mentally retarded tranquilizers (see Appendix A), but, at the pree- individuals have been published since Sprague ent, they are used infrequently with mentally re, and Werry's(1971) review oftheliterature tardedindividuals. Although there are some through 1970. marked differences in the prevalence of c.ertain The first report of the use of a major tranquil- adverse drug reactions, all the major traequiliz, izer (Thorazine) in the treatment of adult psychi- ers have similar effects on behavior disorders. atric disorders appeared in 1952. A year later, the first article about the use of Thorazine with DRUG USE WITH ADOLESCENTS AND children was published. Since then, literally doz- ADULTS ens of maior tranquilizers have been developed and mark rd. A listing of many of these agents The major tranquilizers have proven to be effec- appears in appendix A. Although it would seem tive in the suppression of symptoms associated that ample time has elapsed to collect a consid- with certain psychiatric disorders: schizophrenia,- erable amount of research information about the manic states, and agitated depression (Honig- effects of these agents in children, relatively few feld & Howard, 1973). These drugs can have a studies haveactually been conducted (Di- pronounced effect on disordered thought, hyper- Mascio, Soltys, & Shader, 1970, Sprague & active behavior, combativeness, and uncooper- VVerry, 1974). Much of what has been done con- ativeness. Patients who suffer dramatic changes tains serious methodological flaws and lacks in mood in a relatively short period of time are systematic documentation of side effects. In con- eso aided by these agents because of their trast to pediatric research, there is a voluminous ;ood regularizing effects, Other therapeutic ef- literature about the use of major tranquilizers in fects in schizophrenicinclude making patients the treatment of adult psychiatric disorders and lesswithdrawn -Jedmore responsive and information from these studies is referred to when suppreeeieg hallucinatens and delusions. Be- necessary to describe drug effects. cause many severely and profoundly mentally Major tranquilizers are used extensively with retarded individuals exhibit behaviors similar to mentally retarded children, particularly in resi those of people diagnosed as having certain dential facilities. Although it would be inappro- types of psychiatric disorders, it is not unusual priate to consider the behavior disorders of men- that a medical approach to the treatment of mentally retarded persons as identical to psychiatric tal retardation should draw heavily upon psy- disorders, there are many similarities between chiatry. 66/ CHILDFtEN ON MEDICATION

The general behavioral effects of the pheno- hon. In some people taking phenothiazines. ex- sunburn. thiazinesin normal adults are "psychomotor posure to the sun results in a severe slowing, emotional quieting, and affective indif- This can be prevented by simply keeping clothed ference" (Goodman & Gilman, 1975). To an areas well covered and using a sunscreen on observer, adults receiving phenothiazines are skin exposed to sunlight. Long term drug use at less active and movement appearssloWer. They high dosages can also produce a gray-blue pig- arenotupset by situationsor eventsthat mentation in skin areas exposed to the sun. would normally arouse them, perceiving the world After reviewing the psychiatric literature, Klein with a detached serenity. Although fully capable and Davis (1969) classified the frequency of side of thinking clearly and conversing, they appear effects as follows: very frequent-20% or more, indifferent tofeelings and express thoughts frequent-10 to 20%, occasional-5 to 10%. For without emotion. Spontaneous motor activity can Mellaril, the very frequent side effects were nau- be greatly reduced. People taking phenothia- sea, vomiting, drowsiness, dizziness,and dry zines perform less well on tasks that require sus- mouth. Frequent adverse effects were visualdis- tained attention, and there is a general impair- turbance and constipation; occasionally, patients ment in cognitive performance and learning at were confused or had urinarydisturbance. The higher dosages (Hart lege, 1965). Initially. Mel- very frequent side effects of Thorazinewere laril and Thorazine produce a considerable de- drowsiness. dry mouth, and weight increase. gree of sedation (drowsiness, lethargy)for which Frequent effects were depression, visual disturb- the patient usually develops a tolerance within ance, and constipation; occasionaleffects in- several days to a few weeks, often without a re, clude confusion, allergic reactions, and endo- duction in dosage. crine disturbances. In addition to their effects on behavior, pile, Dose and side effect information for frequently nothiazines modify some bodily functions. They prescribed major tranquilizers are presented in can affect the autonomic nervous system, pro- Table 4-3. Although the dosage information is in ducing a variety of reactions that include blurred reference to duipsychiatric disorders, listed vision. contractioa of the pupils, decreased doses are similar to those employed in residen- sweating and salivation, nasal stuffiness, dizzi- tial facilities for mentally retarded people (see ness, constipation, and inhibition of ejaculation Table 4-1). It is interestieq to note that a recent without interfering with erection (Goodman & Gil- survey of children in residentiel facilitiesreported man, 1975). The latter is particularly true ofMel- that the average dose in ree,/kg was higher for lard, The endocrine system can also be affected children than adults (Cohen, 1978). by treatment with the phenothiazines. In particular, changes in the release of gooadotropio hor- EXTRAPYRAMIDAL SYNDROMES mones may cause discharge from thenipples in males and females as well as breast growth, Perhaps the most disquieting and alarming side Drug induced changes in the release of growth effects of the major tranquilizers for children, hormones may account for frequent reports of intheir parents, and caretakers are the extrapyr- that increased appetite and weight gain. emidal syndromes. These are disorders The primary effect on the cardiovascular sys- volve, certain motor areas of the brain called the tem is low blood pressure (hypotension) which extrapyramidal tract. The various nuclei (group may cause fainting, particularly if a personrises of nerve cell:. and nerve fibers that make up this from a sitting position quickly, Jaundice is ob- structure control and coordinate motor activities, served in less than 2 to 4% of the patients treated especially walking, posture, muscle tone, and with Thorazine. This is generally mild and com- patterns of movement. Drugs that affect the ex- monly occurs between the second and fourth trapyramidal tract can cause spasms in skeletal week of treatment. If jaundice occurs, treatment muscles and changes in body posture, facial expression, and movement of the limbs. There is usually terminated and another drug is substi- fre tuted. Skin reactions are fairly common, with ur- are four different extrapyrarnidal syndromes ticatia or dermatitis reported in about 5% of quently associated with the use of major tran- those treated with phenothiazines. This usually quilizers: parkinsonian syndrome, akathisia, occurs within the first to fifth week of treatment acute dystonic reactions, and tardive dyskine- in clearing up when medication is discontinued. sia. These side effects are most common Photosensitivity is another type of skin reac- treatment with Haldol, Stelazine, and Cornpazine MENTAL RETARDATION /67

and are least likely to occur with Mellaril (see Ta- Acute dystonic reactions are a third type of ex- ble 4 -3). trapyramidal syndrome. Symptoms include one The parkinsonian syndrome caused by the or more of the following: facial grimacing. ocu/o- major tranquilizers appears similar to the symp- gyric crisis (fixed upward gaze), and tort/col/is. toms of Parkinson's disease. The syndrome is The latter refers to a twisting of the neck and an characterized by a decrease in spontaneous unnatural positioning of the head due to contrac- movements, The patient appears depressed, with tion of the neck muscles. The tongue may be a masklike facial expression which parents and protruded or teeth tightly clenched. In rare cases. caretakers may refer to as "looking like a zom- the patient may have difficulty swallowing. Al- bie." Associated withthisis muscle rigidity. though this reaction responds well to treatment. changes in posture. and tremor. Other features it can be terrifying for both patient and care- may include drooling. a shuffling walk without takers. Acute dystonic reactions are common free swing of the arms. and "pill-rolling,- The with Compazine and Stelazine. as compared to latter refers to movements of the hand as if the the other major tranquilizers, They are more apt patient is rolling a pill between his or her fingers. to occur in younger patients and when medica- There is disagreement as to the best way of tion is first initiated.I"; child having a severe re- managing this side effect. Some patients may reaction should receive immediate Medical atten- spond to dosage reduction while others may re- tion, The physician may use an intramuscular quire anticholinergic agents, such as Artane injection of Benadryl or of anticholinergic agents (trihexphenidyt) or Cogentin (benztropine). For for immediate relief of symptoms, and later pre- children. oral closes of 1 mg of Artane three limes scribe oral doses of Cogentin f7r Arlene for the a day or1 to 2 mg of Cogentin three times a day continued control of this reaction. rapidly alleviatethese symtponis (Winsberg, The fourth extrapyramidal syndrome, tardive Yepes, & Bialer, 1976). dyskinesia, typically appears late often months Akathisia refers to involuntary motor restless- after drug treatment has been initiated and may ness. The patient is unable to sitstill,is con- not be evident until medication is discontinued. stantly fidgeting. and appears to be agitated. The Tardive dyskinesia is characterized by rhythmic disorder responds to dosage reduction as well and repetitive stereotyped movements that ap- as to anticholinergic drugs. pear to be involuntary but can usually be inhib-

TABLE 4-3

Select Antipsychotic Drugs: Adult Doses and Side Effects. Dose Side Effects Antipsychotic Dose Range Daily Oral Dosage Hypoten- Generic Trade Usual Extreme SedativeExtrapyrami- sive Name Name (mg) (rig)' Effects dal Effects Effects 1. Phenortriazines Chlorpromazine hcl Thorazine 200=800 22000 4- 4 Thioridazine hcl Mellaril 100-600 5 O-600 + Prochlorperazine Compazine 7-100 1150 Fluphenazine hcl Prolixin 2-10 1 =25 ++ + Trifluoperazine hcl Stelazine 4=15 2=64 + 2. Thioxanthenes Chlorprothixene Taractan 50-400 30 =600 + + Thiothixene hcl Navane 6=30 6-60 -4to 4- + + + 3. Sutyroprienones Halopirdol Heide' 2 =6 1-30 Nate Adapted tre:n Goodman. 1. S an. A . ids) the pnarmacolopcal basis of therapeutics (5ed.) New York: Macmillan. 1975. pp 110-'71Reprinted by perm ion. Extreme dosage ranges should not be exceeded except when all other appropriate measures havtailed. 88/CHILDREN ON MEt 'CATION ited. Serve of the major features are sucking and children and adults in the prevalence of extrapyr- smacking movements of the lips and side to side amidal reactions ( Winsberg & Yepes, 1978). The shifts of the chin, giving the appearance of a cow perkinannian syndrome is most common among 'chewing its cud." The tongue may dart in and (*ter adult patients and is not often observed in out in a "fly catching" fashion. Other symptoms anildren. Wher it does occur in children. the re- include a sudden flying of the arms, up and down f-:tion is usuaky mild. Acute dystonic reactions movements of the toes, in and out movements at are found more often in children, and appear the fingers or "piano playing." and jerky body w thin 24 to 72 hours after the onsetof treatment. movements. (See Paulson. 1975, for a detailed The most common extrapyramidal syndrome in description of the syndrome.) Tardive dyskinesia adults is akathista which is typically seen in mid- is more common among patients who receive dle aged fomales. It is also reported in children, large dosages of major tranquilizers over ex- but the prevalence rate is difficult to determine. tended periods, Prevalence figures for this ad- Tardive dyskinesia seems to occur with similar verse reaction raege as high as 15 to 30% among frequency in both children and adults. especially psychiatric patients. At this writing, there is no at higher doses. In one study of schizophrenic one best method for treating tardive dyskinesia children receiving major tranquilizers at doses (Kobayashi, 1977). When the disorder appears comparable to those recommended for adults, while the person is on medication, treatment 48% exhibited neurological symptoms similar to should be stopped. if possible, or another agent tardive diskinesia upon withdrawal of medication selected if drug therapy is necessary. For indi- (Engelhardt, Folizos, & Waizer. 1975). viduals who develop the disorder alter treatment has been terminated, a variety of drugs which DRUG USE WITH CHILDREN have helped some people are available. Some Major tranquilizers have neen reported to be ef- are benefited by resuming the drug that caused fective in suppressing hyperactivity. aggressivity, the tardive dyskinesia. The disorder can persist and self injurious behavior in Mentally retarded indefinitely after medication is terminated, but for at least half of the patients. there is gradual im- children (Freeman. 1970a; Sprague & Werry. provement over time after medication has been 1971, 1974). It has been demonstrated that Mel- laril and Thorazine are effective agents in con- stopped. trolling stereotyped behavior (Davis, 1971; Davis. Several large studies of drug treatment with Sprague. & Werry, 1969, Hollis & Si. Omer, psychotic, emotionally disturbed, and mentally 1972), Because higher doses of the major tran- retarded children have clearly documented tar- quilizers can also suppress adaptive behavior dive dyskinesia in children (McAndrew, Case. & and can make children less responsive to edu- Trolled. 1972; Paulson, Fiizvi. & Crane. 1975; cation and training, concerns have been voiced Polizos, Engelhart. Hoffman, & Waizer, 1973). about the way in which major tranquilizers are Involuntary movements of the lips, tongue, and jaw are much leSs frequent among children than used. adults. Choreiforn (ceaseless rapid and jerky in- There are three good literature reviews about voluntary movements) movements of the arms, dose and side effects of major tranquilizers in legs. and head were the most frequently re- children (DiMascio, Soltys, & Shader, 1970; Ka- ported symptoms in children with tardive dyski- lachnik, 1977; Winsberg & Yepes. 1978). The in- nesia. For many children. the syndrome did not formation presented here is a brief summary of become apparent until medication was termi- these papers. There is a considerable range in nated. Off medication, some children improved reported dose across studies with children. The over time and others became worse. Resuming dose for Thorazine and Mellaril ranges from 10 drug treatment alleviated symptoms in many to 1.000 mg per day with an average daily dose children who remained unchanged or became of 75 to 200 mg. Some clinicians prescribe one worse when drug treatment was stopped. Mc- large dose at night while others divide the total Andrew. Case. and Treffert (1972) reported that amount into two or three doses during the day tardive dyskinesia was more common among (Katz et al.. 1975; Winsberg. Yepes. & children who received higher dosages for longer 1976). Most hyperactive children require no more periods of time than among children on short than 50 mg or 100 mg three times per day. Rela- term regimens at lower dosages. tive to body weight, the average dose is 3 to 6 There are some general differences between mg/kg per day. The effective dose of Haldol MENTAL RETARDATION/69 ranges from 2 to 5 mg per day which is divided kinsonian agent at the beginning of drug treat- into three daily doses. It is noteworthy that sig- ment, after symptoms appeared, or after the dis- nificant improvements in cognitive performance continuation of treatment. Although Haldol is have been reported with doses of Ha Idol as low usually not associated with sedative effects (see as 0.025 mg/kg in nonretarded hyperactive boys Table 4-3), drowsiness was sometimes reported (Werry & Amen, 1975). Daily doses for Stelazine in studies with children. Other side effects in- range from 2 mg to 50 mg per day with an aver- clude nausea, ataxia, slurred speech, and weight age of 6 to 15 mg per day. In most studies, med- gain. ication is given in divided doses, usually three At this point it would be desirable to provide times per day. information about the duration and termination of Side effects of major tranquilizers in children drug treatment for behavior disorders associated are similar to those reported for adults. Sedative with mental retardation. Unfortunately, there are effects (drowsiness, lethargy, apathy) are quite almost no data available on this topic and vir- common with Thorazine, but children usually de- tually no well controlled followup studies. TMR velop a tolerance for this reaction within several children who are treated for behavior disorders days to a few weeks. Dosage reduction may be often are placed on medication when younger necessary in some cases. It is noteworthy that and are treated for a number of years. In fact, the irritability and excitability are also possible. Skin median duration of treatment for children still on reactions are not frequent. Also reported are medication was approximately 4 years in one diarrhea, upset stomach, dry mouth, and blurred study (Gadow, 1978d). vision. A number of studies report increased appetite and/or weight gains during drug treatment. ISSUES RELATING TO DRUG TREATMENT Compared to Thorazine, side effects are less AND MENTAL RETARDATION frequent with Mellaril. Adverse drug reactions commonly associated with Metlaril are drowsi- Psychotropic and anticonvulsant drug treatment ness, lethargy. irritability, hyperactivity. ataxia, with mentally retarded people has been the fo- and dizziness. Increased appetite and weight cus of controversy for several reasons. First, as gains are also not unusual. Because Mellaril has pointed out above, after a review of the research been reported to have a favorable effect on sei- on the use of psychotropic drugs with mentally zure reduction. this drug can be used with some retarded individuals, Sprague and Werry (1971) confidence for the treatment of behavior disor- concluded that much of the data were of ques- ders in epileptic children (Kamm & Mandel, 1967). tionable value due to serious methodological Katz et al. (1975) stated that in their experi- flaws in most studies. Very little research has ence with hyperactive children the side effects of been conducted comparing drug therapy with Mellaril were frequent and severe. Drowsiness other treatment approaches (for example, be- was the most common adverse reaction that was havior modification), and there have been few difficult to manage. If the dose was reduced, the published accounts about how to improve the drowsiness was less severe but the therapeutic way in which pharmacotherapy is used with response was weaker. Many children developed mentally retarded children. Second, the manner enuresis and had to be taken off medication. In- in which these drugs are prescribed and admin- creased appetite was also common as was puf- istered(e.g., dosage, duration of treatment, finess around the eyes and mild dry mouth. monitoring) raises questions about possible drug Stomach ache. nausea, and vomiting necessi- misuse (Lipman. 1970; Sprague, 1977b, 1978). tated dosage reduction in a number of children. Third, recent court cases involving residential fa- Other side effects included nose bleed, mild cilities for mentally retarded persons have raised tremor, and orthostatic hypotension. Some chil- serious questions about the competence of care- dren who reacted well to Mellenl later developed takers (Sprague, 1977b. 1978). Some of the ma- changes in temperament. They became irritable, jor issues in these court cases are the focus on moody. and belligerent. Medication eventually symptom suppression instead of responsiveness had to be stopped for these children. to treatment, overmedication, poor monitoring Extrapyramidal syndromes are frequently re- procedures. and a cavalier approach to record ported in studies using Haldol to control behavior keeping about the use and effects of psycho- disorders in children. Clinicians managed these tropic drugs. Fourth, the exclusion of teachers in side effects by either administering an antipar- public schools and of direct care personnel in 70 /CHILDREN ON MEDICATION

residential facilities from meaningful participation interfere with the resident's habilitation pro- in the drug regimen is also a major problem (Ga- gram." dow. 1978e). Although psychotropic drugs affect Another case. New York State ARC v. Rocke- the very behaviors that often become objectives feller (1975), resulted in a consent decree which in educational programing, nonmedical person- also established standards for drug therapy. nel are frequently excluded from diagnostic and Among the guidelines were: drug evaluation procedures. Finally. because major tranquilizers can produce serious side ef- 1. "Only appropriately trained staff shall be al- fects when used for long periods of time at high lowed to administer drugs. dosages and can suppress adaptive behavior, 2. "Written policies and procedures that govern disagreements about the risk-to-benefit are un- the safe administration and handling of all avoidable. Central to this issue is whether or not drugs shall be developed." medication is being used in a manner that is in 3. "Medication errors and drug reactions shall the best interest of the mentally retarded child. be recorded and reported immediately to the Less than adequate drug monitoring proce- practitioner who ordered the drug." dures and the use of medication as a substitute for habilitation are two major problems in this The seriousness of poor monitoring proce- area. They have been attended to in several re- dures is evidenced in the following quote. Spra- cent court cases. In Wyatt v. Stickney, Judge gue (1977b), serving as an expert witness for the Frank M. Johnson ruled that retarded residents federal judiciary, was called upon to describe have a right to areacerate treatment (habilita- and evaluate procedures employed in residential tion) which he defined as "the process by which facilities for mentally retarded children. He said the staff of the institution assists the resident to in part: acquire and maintain those life skills which ena- I made site visits to many of the private fa- ble him to cope more effectively with the de- cilities far the Office of Special Litigation, mands of his own person and of his environment and I found intolerable conditions for many and to raise the level of his physical. mental, and of the children. In one facility for severely (Wyatt v. Stickney. 1972, p. social efficiency_ retarded children, the average stay for re- 395), The court developed a set of standards de- sidents was 7.8 years with 66% of the re- scribing what adequate habilitation of the men- sidents receiving regular anticonvutsant tally retarded person meant including a section medication. The monitoring of this medi- about drug treatment. Several of the items are cation was almost nonexistent in that the particularly noteworthy: physician _supervising these patients only "Residents shall have a right to be free from ordered one laboratory test to check the unnecessary or excessive medication. The physical effects of the medication once in resident's records shall state the effects of 184.3 patient-years (a patient-year is one psychoactive medication on the resident. patient in the facility for one year). (p. 146) When dosages of such are changed or other The importance of monitoring blood-serum psychoactive medications are prescribed. a level is discussed in greater detail in Chapter 3, notation shall be made in the resident's rec- but an example of the implications of improved ord concerning the effect of the new medica- or new dosages and the behavior monitoring procedures cited here for empha- tion sis. Two years after ieratuting an interdiscipli- changes, if any, that occur." nary pilot program to improve health care for 2, "Notation of each individual's medication shall epileptic mentally retarded residents, research- be kept in his medical records .. At least ers at the Lynchburg Training School and Hos- weekly the attending physician shall review pital in Virginia reported notable changes (O'Neill the drug regimen of each resident under his et al.. 1977). There was a significant reduction in care. All prescriptions shall be written with toxic blood levels of ant eenvulsant drugs, a 48% termination date, which shall not exceed 30 decrease in episodes of Status epilepticus, and days." a 73% decrease in seizure related deaths. As a 3. "Medication shall not be used as punishment, result of improved monitoring procedures, 33% the convenience of staff. as a substitute of the residents with uncontrolled seizures be- for a habilitative program. or in quantities that carne seizure free. MENTAL RETARDATIONr71

An excellent model for improving monitoring this topic (Gardner, 1971Thompson e Gra procedures in residential facilities was devel- bowski, 1977). oped at the Georgia Retardation Center in The author is aware of only one study that Chamblee. Georgia (Sprague. 1978). One of the compared behavior modification(tokenrein- more innovative aspects of the policy adopted by forcement) and medication (Rita lin) in hyperac- this facility is a Multidisciplinary approach to pre- tive, mentally retarded children (mean 10 of 51) scribing psychotropic drugs. Before such agents (Christensen, 1975). Behavior modification was are used. clear documentation must be pre- quite effective in controlling hyperactivity, and sented demonstrating that other less restrictive there was little difference whether or not the child techniques have failed. After passing the pro- was also receiving medication or placebo. Al- posal to prescribe medication through review though this study supports the efficacy of behav- procedures. the team, consisting of a physician ior modification. the decision to use medication and other direct care personnel. decide if psy- instead of behavior therapy or vice versa must chotropic drugs are to be administered. Through be based on a number of considerations. Two of detailed monitoring procedures, side effects. the more important in the case of behavioral suppression of rnaladaptive behavior, and ef- therapy are the availability of competent clini- fects on habilitation are documented. cians and the cooperation of caretakers. Another major issue concerns questions about Perhaps one of the more difficult questions the risk-to-benefit of drug treatment. As already posed by parents and teachers is, "How do you discussed. the courts have been quite ex- know when giving medication is the right thing to plicit about using medication as a substitute for do?" Considering the number of variables that treatment. Nor should psychotropic or antiepilep- influence therapeutic outcome, the inconsisten- tic drugs interfere with a resident's cognitive cies in research results, and disagreement among ability to such a degree that it prevents benefit experts, the reader should approach anyone who from habilitative efforts. We should not adopt an purports to know -the" truth with caution. attitude that because a person is mentally re- Although much of this discussion has focused tarded. impairment of learning ability is of little on private and public residential facilities, infor- consequence. Although this appears transpar- mation recently collected about TMR children in ent. statements in the literature by experts in pe- public schools is equally discouraging (Gadow, diatric psychopharmacology do not always give 1978a). In that survey, it was found that teachers this impression as exemplified in the following received very little formal tieining regarding psy- quote from Millichap (1969): chotropic and antiepileptic drugs even though they frequently encountered children on medi- In the hyperactive mentally retarded child cation. Nor were teachers provided basic infor- drugs are used primarily t© facilitate man- mation about the effects of medication on their agement. In the child of normal intelligence students' behavior. Interaction between school, it is important that the drug should have no parent, and physician was limited, and there was untoward effects on learning, and the con- almost no direct contact between the teacher trol of motor hyperactivity should be ac- and doctor. Inadequate monitoring procedures companied by improvement in attention. were the result of poorly developed channelsof memory. perception, and coordination. (p. communication, lack of standardized evaluation 1241) instruments. ambiguities in role behavior, and Unfortunately. some mentally retarded children failure to establish drug evaluation procedures. with severe behavior disorders cannot be treated As an example of the latter, only 19% of the chil- with stianteaets (Fish, 1971). In such cases, the dren treated with psychotropic drugs for the major tranquilizers may have to be employed. management of behavior disorders were sched- Central to the issue of risk-to-benefit is the avail- uled for a drug free period during the school year ability of effective treatments which are safe and to assess the continued need for treatment. If less restrictive than drugs. At present. there is a more children participated in such breaks, it was large number of published studies using behav- done without the teacher's knowledge. In gen- ior modification to control aggressive, hyperac- eral, teachers were excluded from what most ex- tive, self destructive, and stereotyped behavior perts in pediatric psychopharmacology believe in mentally retarded persons. The reader is re- should be an interdisciplinary team effort. One ferred elsewhere for comprehensive reviews of cannot help but draw comparisons between the 72/CHILDREN ON MEDICATION standards established as a result federal court eration of progress. New York: Raven Press, cases and the situation that exis in the public 1978. (M) schools. Sprague, R. L. Principles of clinical drug trials. In J. S. Werry (Eds.), Pediatric psychopharmacology: The use of behavior modifying drugs SUGGESTED READINGS in children. New York: Orunner/Mazel, 1978. (M) Freeman, R. D. Psychopharmacology and the Sprague, R. L.. & Werry, J. S. Methodology of retarded child, In F. Menolascino (Ed.), Psy- psychopharmacological studies with the re- chiatric approaches to mental retardation. New tarded. In N. R. Ellis (Ed.), International review York: Basic Books, 1970. (M) of research in mental retardation (Vol. 5). New Gadow. K. D. Drug therapy with trainable men- York: Academic Press, 1971. (M) tally retarded children in public schools. Pa- Thompson, T., & Grabowski, J. (Eds.), Behavior per presented at the annual meeting of The modification of the mentally retarded (2nd ed.). Council for Exceptional Children, Kansas City, New York: Oxford University Press, 1977. (M, May 1978. (ERIC Document Reproduction 1) Service No. ED 153 398) (T) Winsberg, B. G., & Yepes, L. E. Antipsychotics. Lipman, R. L., DiMascio, A., Reatig, N., & Kirson, In J. S. Werry (Ed.). Pediatric psychophar- T. Psychotropic drugs and mentally retarded macology: The use of behavior modifying children, In M. A. Lipton. A. DiMascio, & K. F. drugs in children. New York: Brunner/Mazel, Killarn (Eds.), Psychopharmacology: A gen- 1978. (M) 5 Other Disorders

There are a number of other disorders for which well and Currah (1972) stated that the tricyclic psychotropic and anticonvulsant drugs are pre- antidepress.mts are the only drugs that have scribed but which are less common than hyper- consistently proven to be more effective than activity or epilepsy. Those disorders, which are placebo for the treatment of nocturnal enuresis. briefly described in this chapter, include enu- Several different tricyclics are presently availa- resis. separation anxiety, cerebral palsy. and ble, but Tofranil (irnipramine) is the most com- emotional disturbance. In this context, the latter monly used for this disorder. it was first reported term refers to children described as -autistic." effective for the treatment of enuresis by Mac- "psychotic," and "schizophrenic." This focus Lean in 1960, and 13 years later was approved on severe behavioral disturbance is quite narrow by the FDA for use with this disorder. because it excludes a variety of less severe psy- When Tofranil works, the response is irernedi- chiatric disorders (e.g.. a transient reaction to ate. usually during the first we .i ant. stress) for which children and adolescents re- Hovvevee a complete zure. ceiv e mediw.tion. symptoms) is reported for lev:, children on medication. It sho!ilo loe,d that a ENURESIS less stringent criterion is used (e.g., 50% fewer wet nights), the "success" rate is much higher. Nocturnal enuresis refers to involuntary bedwetting during sleep. The disorder is relatively com- Unfortunately. "relapse tends to occur immedi- mon, affecting about 15% of the physically and 6.1ely ,following withdrawal after short periods of Mentally normal children at 6 years of age (Aron treatment, and long-term followup studies suggest that total remission (no wet nights) occurs & Thieries, 1978). From age 6 to 20 years. there is a decline in the prevalence of enuresis with In only a minority of patients" (Blackwell & Cur- few people bedwetting after 20 years of ace. ETn- rah. 1972. p. 253). uresis is usually not considered a problem until The total daily dose of Tofranil commonly re- a child is school age. Clinicians have arbitrarily ported in the literature ;s 25 to 50 mg, given in decided that by the time a child is 6 years old one oral dose at bedtime. For children over 12 something should be done (Werry, 1965). Enu- years of age. the dose may be increased to 75 resis is not usua:ly associated with organic pa- mg if the smaller amount is unsuccessful. The thology (Forsythe & Redmond, 1974), and psy- POP, recommends that the dose of Tofranil not exceed 2.5 mg/kg/day because of the possibility chopathology is negligible (VVerry. 1965).Ifleft untreated, there is usually a spontaneous remis- of severe side effects at higher doses (Robinson sion of sympomsthat is, the problem seems to & Barker. 1976). cure itself. The side effects encountered with Tofranil at In an excellent review of the literature, Black- doses used for enuresis are usually minor, and

73 74/CHILDREN ON MEDIC children often develop a tolerance for those that and conditioning techniques for the management do occur. The most common adverse reactions of enuresis as well as the existence of viable al- are nervousness. lethargy, drowsiness. and nau- ternatives to drug therapy. sea. Abrupt cessation of medication may produce withdrawal symptoms such as nausea al SEPARATION ANXIETY headache. One of the more serious side effects is an adverse effect on the heart (cardioloxic) at The distress reaction shown by infants when high doses (Robinson & Barker, 1976). Itis for they are separated from their mothers is referred this reason that low doses (2,5 mg/kg per clay or to as separation anxiety., In theory. this reaction less) are recommended for enuresis. Special is not limited to infants and may be manifest in care should be given to storing Tofranil outof the children and adolescents as school phobia and reach of children. In the United Kingdom. tricyclic in adult agoraphobics as panic anxiety (Gittel- antidepressants are second only to the salicy- man-Klein,1975). Agoraphobies "suffer from lates (e.g., aspirin) as the most common cause inexplicable panic attacks, accompanied by hot of death in children due to accidental poisoning and cold flashes. rapid breathing, palpitations, (Parkin & Fraser. 1972). Typically, the drug was weakness, unsteadiness, a feeling of impending prescribed for an adult, either parent or neighbor, death, and occasional depersonalization. They for a psychiatric disorder, However, in over a progressively constrict their activities until they fourth of the hospital admissions due to tricyclic are unable to leave the house independentlyfor poisoning, the drug was prescribed for the- treat- fear of being suddenly rendered helpless while ment of enuresis often to children under 5 years isolated from help" (Gittelman-Klein & Klein, of age. 1973. p. 200). For obvious reasons this phobia is A method that is considered by some to be quite disabling, however, it seems to respond to more effective for enuresis than drugtherapy is Tofranil treatment. Interestingly, many adult ago. a battery operated buzzer and paddevice, which raphobics also suffered from school phobia when is quite safe (Stewart, 1975). This method was they were younger. It was argued that drugs (i.e., first developed at the beginning of the century Tofranil) effective for the control of panic attacks only to be rediscovered in the late 1930's. The in adult agoraphobics might also be useful for the child sleeps on a pad containing two foil elec- treatment of school phobia (Gittelman-Klein, trodes. When a small amount of urine wets the 975). A well controlled study was conducted to pad, the circuit is closed. triggering analarm that test this hypothesis. Subjects were selected for awakens the sleeping child. In principle. bladder the study only after intense efforts were made to distention becomes associated with awakening force the child to return to school. It was found and with contraction of the bladder sphincter that Tofranil was clearly superior to placebo in muscle. In time, the reflex to urinate during sleep enabling school phobic children to attend school. is replaced with conditioned bladder control and When effective, medication "frees the child of an increased capacity to retain more urinewith- panicky responses to. and morbid fears during, out awakening (Mower, 1950, Stewart. 1975). separation" (Gittelman- Klein, 1975. p. 266). The relative efficacy of Tofranil, conditioning. The average dose of Tofranil for this disorder and placebo were investigated in a well con- is 75 to 100 mg/day with a maximum upper limit trolled study conducted by Ko 'yin, Taunch, cur. of 200 mg/day. Medication is often given before rah, Garside. Nolan. and Shaw (1972). Children bed to avoid side effects (e.g.. drowsiness, dry in the study were separated into three groups. mouth). Total duration of treatment, including a each receiving one of the aforementioned treat- gradual withdrawal period. lasts about 3 months, ments. Therapy for each group lasted 2 months. Side effects in school phobic children treated with the results being evaluated 2 months later. with Tofranil have been found to include dry Treatment was considered successful if there mouth, nausea, tremors, sweating, dizziness. was an 80% decrease in wet nights. Using this drowsiness, lethargy, and decreased appetite criterion. 42% of the placebo group. 30% of the (Saraf, Klein, Gittelman-Klein, & Groff, 1974). medication group. and 50% of the buzzer and To be truly effective, treatment must include pad group were considered improved, Although psychotherapy as well as the cooperation of the a number of research questions remain unan- school, family. and child. Behavioral intervention swered (Blackwell & Currah, 1972), this study strategies should be attempted before a trial of demonstrates the effectiveness of both placebo medication.It should be noted that many chil- OTHER DISORDERS/75

dren who have a complete remission of symp- slow, involuntary writhing movements in the af- toms with Tofranil later suffer relapses. fected limb. Approximately 15 to 20% of the children with cerebral palsy have athetoid move- CEREBRAL PALSY ments.Athetosis and spasticity areoften concomitant. Cerebral palsy refers to a variety of nonprogres- Behavior disorders (primarily hyperactiv:'y) and sive conditions characterized by impairment of epilepsy are frequently associated with cerebral motor control which is the result of damage to palsy. The prevalence rates for convulsive dis- the motor areas of the brain either before. during. orders range from 30 to 40% among people with or soon after the child is born. A number of fac- cerebral palsy (Cruickshank & Raus. 1955). The tors can produce this damage including prenatal relationship between IQ and epilepsy is striking diseases, lack of oxygen at birth, and other birth in this population. One survey of individuals with injuries. Approximately 0.3% of the school age cerebral palsy reported that 72% of those who children in the United States have cerebral palsy were mentally retarded (10 below 70) had epi- (Baker, 1959). Mental retardation is common: lepsy compared to 8% in the low normal range over half of the children with cerebral palsy score (10 between 85 and 99) (Dunsdon. 1952). 70 or below on standardized 10 tests. It is note- The skeletal muscle relaxants are the most worthy that accurate assessment of 10 in chil- commonly prescribed drugs for the symptoms dren with cerebral palsy can be quite difficult es- associated with cerebral palsy and are used to peciallyif the conditionis marked by severe treat spasticity. Historically, the most significant sensory or motor impairment. Many of ;. iese chil- early drug discoveries were Antodyne (noxypro- dren are served in special classes for mentally panediol)in 1910 and mephenesinin1949 retarded. physically (orthopedically) impaired, or (Domino. 1974). These agents were desirable multiply handicapped students. However, the re- because they did not produce sedation; but, un- cent emphasis on leas{ restrictive placement is fortunately, they were eventually proven to be of bringing children with cerebral palsy into the little value at tolerable dosage levels. People mainstream of school activities. The motor dis- have also ebs erved for some time the beneficial orders which are collectively called cerebral palsy effects of alcoholic beverages. Perlstein (1955) can be subdivided into several categories, two of noted that alcohol "shows the greatest specific

which (spasticity and athetcsis) are pertinent to effect . .. inreducingtensionsincerebral

this discussion. palsy, .. Many patients can walk with increas- Neural impulses are continually transmitted ing steadiness or write a more legible letter after from the brain to the skeletal muscles via the a cocktail- (p. 239). It was not until the 1950's, spinal cord. This creates a slight amount of ten- with the development of antianxiety agents. that sion (muscle tone) which keeps the muscle taut usable drugs became available. Both the propa- so it can react to stimuli more quickly. Damage nediols (Miltown. Equanil) and benzodiazepines to a certain area of the brain impairs normal mo- (Librium. Valium) are centrally acting skeletal tor control resulting in an excessive amount of muscle relaxants that benefit some people with muscle tension (hypertonioity). This condition is cerebral palsy. Although Valium is still used with referred to as spasticity, It primarily affects the some frequency, much work remains to be done muscles responsible for bending a joint (flexor in this area. Domino (1974) observed that Valium muscles) as opposed to muscles responsible for is of limited value as a skeletal-muscle relaxant extending a joint (extensor muscles). Even slight because itis a sedative and itis weak, even stimulation causes the muscle to contract mak- though it is clearly one of the most useful agents ing the person very rigid. Motor movements are now available" (p. 372). slow and spasmodic, and reflexes are often ex- Dantriurn (dantrolene sodium), a recently ap- aggerated. Deliberate efforts to control motor proved (1974) skeletal muscle relaxant, has been movements usually make things worse because demonstrated as more effective than placebo in the muscles tighten and become even more treating spasticity (Denhotf, Feldman, Smith, spastic. Spasticity is present in approximately Lachman, & Holden, 1975). It is often difficult to half of the children with cerebral palsy and is demonstrate benefit from muscle relaxants due more apt to be associated with mental retarda- to measurement problems. Also, there is often a tion than are the other varieties of this disorder. powerful placebo response in studies involving Athetosis refers to the ceaseless occurrence of people with cerebral palsy. The importance of 76 CHILDREN ON MEDICATION

y in behavioral data based procedures for evaluating theeffects There is considerable vanElii of muscle relaxants in habilitative settingshas symptoms among children diagnosed as psy- been advocated for same time (Phelps.1964). chotic. I lawyer. characteristics such as thefol- The daily dose of Valium ranges from 6 to15 lowing are fairly common. These chilaren: mg per day inthree divided ,doses (Kendall. Are withdrawn. aloof. and unresponsiveto 196). The most common side effects areleth- adults and friends. be- argy, drowsiness. depression.ataxia. nausea. 2 Manifest self injurious and self stimulating vomiting, and vertigo. havior. The daily dose of Dantrium employed by Den- 3 Show stereotyped preoccupationwith spe- hoff et al. (1974) was 12 mg;kg per day divided cific objects. into four doses. The side effects they reported 4. Have strong preference for sameness and re- were irritability, lethargy. drowsiness, and gen- sistance to change. eral malaise. All were transientdisappearing 5. Engage in stereotyped motor movement(e.g., within a week. After the Study was completed (6 rocking, body whirling). weeks on medication), nine children were kept 6 Have excessive or distortedfears even though on Dantrium. Of these, four showed an increase the offending object is not present. in seizures (all ;ere epileptic). The' 'fore. it was Speech and languk, tiers are typical concluded that this drug may lower the convul- and include motism. echo . delayed devel- sive threshold in some children. opment, and bizarre ane )aningless speech Very little survey data are available on the content. The mtelligence ley of of thesechildren prevalence of drug therapy for spasticity among is difficult to determine but almost all scorein the children who have cerebral palsy. In a survey of mentally retarded rande. The prognosisfor psy- 3,306 children in TMR programs, 22 reportedly chotic children is quite poor: and manywill re- received muscle relaxants for cerebral palsy ceive prolonged institutionalizationor community (Gadow, 1978b). The most frequently prescribed care. drugs, in rank order, were Valium. Dantrium. and Because childhood psychosis is so unrespon- phenobarbital. sive to treatment. it is not anexaggeration to say that almost every psychotropic andantiepileptic drug has been administered to thispopulation. EMOTIONAL DISTURBANCE At present, no drugs "cure" thesedisorders, Dreams, daydreams. and fantasy can be de- but symptom suppression is achievedin some scribed as types of distorted and self centered cases. Fish (1976) described therole of medi- thinking that bear little relationship to the real cation in treatment as follows: "I believethat any world (Ross, 1974). Such phenomena are con- child with a disorder as serious as autismde- trolled. in part, by the thinker's needs and deserves a trial of drug treatment.Only in much sires. Although daydreams and fantasies are milder atric conditions can social and ed- quite normal, they are maladaptive if one re- ucational measures completelyresolve the sponds to them as reality_ . When this happens. a symptoms and return the patient tonormal func- person is unable to cope with the demandsof the tioning" (p.108). There are several excellent environment and is considered psychotic. In reviews on this topic (Campbell, 1975a.1975b; nonverbal children. psychotic thought is inferred Fish. 1976). The following material is summa- from the way the child behaves. rized from these articles. Childhood psychosis is used here as a gen- Hypnotics and anticonvulsants are of no value and bar- eral term to refer to severely disturbed children. in the treatment of childhood psychosis. It is often used to describe a variety of disorders. biturates may only aggravate the disorder. Stim- including "childhood schizophrenia" and "early ulants (Benzedrine. Dexedrine, Ritalin) are gen- is a infantile autism.The latter is a rare disorder, erally not effective even ifhyperactivity accounting for approximately 10% of the children prominent problem. Often, these drugs make the diagnosed as psychotic (Rim land, 1971). Be- psychotic symptoms even worse by decreasing cause there islittle evidence that the various verbal output and making the child more with psychotic disorders of childhood respond more drawn. In general, the tricyclic antidepressan'.. favorably to different types of drugs, diagnostic (Tofranil) have not proven to be effective either, issues have not been included in this discussion. and they too may make things even worse. The OTHER DISORDERS; 77

helium( ens (e.g.. LSD-25) have bee n ae 1miny possibility. Campbell (1 975b) stated that "the 'stored to this population as well but with ilmited young child is often excessively sedated at doses success. that control certain psychotic symptoms. In our After reviewing the literature. the American experience. many of these children show sleep- Academy of Pediatrics (1976) reported that me- iness and psychomotor retardation even at very gavitamins were of little value in the treatment of low doses of chlorpromazine (Thorazine) and childhood psychosis. Recently. however. a well are not amenabi.to education arid other treat- controlled study demonstrated that a small per- ment. irrespective of body weight and the pres- centage of autistic children might benefit from ence or absence of hyperactivity and aggres- such treatment (Rirnland. Callaway. & Dreyfus. siveness" (pp. 240-241). 1978). Sixteen autistic children who appeared to Several additional comments are in order about improve in a previous study when receiving vita- drug management. First. children who respond min Be (pyridoxine) were selected for a B6 and favorably to one type of drug at an early age may placebo comparison. The investigators reported do much better on a different medication when a deterioration in EyMptoms for 11 of the children older. Also. the search for an effective agent may when placed on placebo. The dose of B6 ranged be a long and tedious process of gradually ad- from 2:4 to 94 3 mg:kg per day: median dose justing the dose and assessing therapeutic ben- was eepeoximately 6 mg/kg per day. efits. It may also require trials of several different Few agents have proven really helpful for psy- drugs. Second. the duration of treatment may chotic children. Benadryl, an antihistamine with last1 month for an acute psychotic episode or sedative properties, has been administered with years in the ...se of a chronic disorder. Finally, some success inseverely disturbed children little is knove-s, about the ese of major traequiliz- (Fish. 1971). The major tranquilizers. however. ers with young children. therefore, care, =1 moni- are the most effective and most frequently pre- toring is in order. Drug free periods should be scribed drugs for childhood psychosis. The phe- scheduled regularly to assess the continued need nothiazines (Thorazine. Mellaril, Stelazi.nee have for treatment. been quite effective with school age and adoles- Once a child s development has been cent schizophrenic children but are less desir- stimulated by using medication, and his able for young children because of side effects. speech or other performance has become Other major tranquilizers that are more "stimu- estahtished. these gains may continue lating"(e.g..Haldol and Navane) have also with Hdher medication. One does not been beneficial for some children. When etfec- w duce substances into the body five. the therapeutic response takes the form of ur are really necessary. (Fish. increased responsiveness and alertness and a brightening of mood. Some children are de- MISCELLANEOUS scribed as more talkative and less withdrawn. Suppression of undesirable behaviors such as There are other behavior disorders for which stereotypy, hyperactivity, aggressivity, and self psychotropic drugs are prescribed for children injury are also reported. Two drugs that have and adolescents. Kraft (1968) cited several case been studied more recently are lithium and lev- studies in which children and adolescents were °diva . treated with psychotropic drugs for short periods Guidelines for dosage with major tranquilizers to help them cope with family illness, marital con- are difficult to set down since there is a great flict, and stressful social situations. deal of variability across children. Titration is the Gilles de la Tourette's syndrome, another dis- recommended procedure. and the optimal dose order treated with medication, is characterized in mg/kg may be higt. r than for adults. This may by tics (muscle twitches or jerks) and involuntary be explained, in part, by the fact that children vocalizations (Rosenthal, Nicholson, & Collier, metabolize many types of drugs at a faster rate 1975). The disorder is rare and responds to Hal- than adults. dol. a nor tranquilizer. As noted in Chapter 4, side effects of the major A considerable amount of interest has been tranquilizers must be monitored quite carefully. generated recently regarding depression in chil- Even though the incidence of extrapyramidal dren (Conners. 1976; Rapoport, 1976), a condi- syndromes appears to be low in young children. tion some exerts report as being quite uncom- suppression of adaptive behavior is always a mon (Graham, 1974; Rutter, Tizard, & Whitmore, 78 CHILDREN ON MFI IrATION

1970). Although the cla6sicat pattern of depres- control and enuresis. London: William Heine- sion may be rare in children (Graham, 1974). a mann Medical Books, 1972. (M) number of child psychiatrists feel it occurs in a Dam; M. Psychopharmacology in childhood masked form with some frequency. A few of the psychosis.International Journal of Mental presumed symptoms are hyperactivity. aggres- Health, 1975, 4, 238-254. (M) sivity, delinquency, running away from school, Conners. C. K. Classification and treatment of enuresis. nail biting, anxiety, and daydreaming. childhood depression and depressive equiva- Not only is the existence of this disorderas lents,In D. Gallant & G. Simpson (Eds.), broadly definedbeing challenged, but the role Depression: Behavioral, biochemical, diag- York: of drug therapy isalso unclear. Sleator and no.slic, and treatment concepts. New Sprague (1973) commented that "assigning the Spectrum, 1976. (M) name 'depression' to symptoms which are com- Domino. E. F. Centrally acting skeletal-muscle mon to almost all psychiatricdisorders of chil- relaxants. Archives of Physical Medicine and dren does not automatically indicate that the Rehabilitation, 1974, 55, 369 -373. (M) Fish, B. Pharmacotherapy for autistic and schiz- ti'pressant drugsare therefore appropriate ophrenic children. In E. R. Ritvo, B. J. Free- the :pp. 589-59(1. man. E. M. Omitz. & P. F Ta.nquay(Eds.). Au- : m..Diagnosis,currentresearchand SUGGESTED READINGS management. New York: Spectrum, 1976.(M) Gittolman-Klein. R. Pharmacotherapy and man- Azrin. N. H.. & Thienes, P. M. Rapidelimination without a e.gement of pathological separation anxiety. of enuresis by intensive learning International Journal of Mental Health, 1975, apparatus. Behavior Therapy, conditioning 4, 255-271. (M) 1978, 9, 342-354. (T) Stewart. M. A. Treatment of bedwetting. Journal Blackwell. B., & Currah. J. The psychopharma- 1975, cology of nocturnal enuresis. In I. Kalvin,R. G. of the American Medical Association, MacKeith, & S. R. Meadcvv (Eds.),Bladder 232, 281-283. (M) Apinndixes APPENDIX A Classification of Psychotropic Drugs Liaerie Name Trade Name'

1.'timu!ants Amphetamine Benzedrine Deanol DEaner Dextroamphetamine Dexedrine Levaoamphetamine Cydril Methampni,.k.3mine Desoxyn Methylohen.Jate Ritalin Pemo line Cylert 2. Antidep-osaWs yr,,CS Arnitrip:ylir e Elavil, Endep Desipramine Norpramin, Pertofrane Doxepin Sine-, Adcoin lrnipramine Tofranil. Presamine Nortriptyline Aventyl, Parnelor Protriptyline Vivactil

Monoamine Oxir7ase _ s Isocarboz_zid N.arplan Phenelzine Nardil Tranylcyprorn'le Parnate Minor Tranquilizers (Antianxiety Agents) Propanediols Meprobarnate Equanil, Miltown Cipher ylmethene Hydroxyzine Atarax, Vistaril Benzodiazepines Chlordiazepoxide Librium Chlorazepate Tranxene Diazepam Valium Oxazepam Serax 4. Major Tranquilizers (Antip ychotic Agents) Phenothiazines a Aliphatic Chlorpromazine Thorazine, Sonazine Promazine Sparine Triflupromazine Vesp.in

Continued on next page 79 80 'CHILDREN ON MEDICATION

Classification of Psychotropic Drugs Continued Generic Name Trade Name' b. PIperidine Piperacetazine guide Mesoridazine Serentil Thiendazine Mellaril c.Piperazine Acetophenazine Tindal Rutaperazine Repoise Carphenazine Proketazine Fluphenazine Pro lixin, Permitil Perphenazine Trilafon Prochlorperazine Compazine Thiopropazate Dartal Trifluoperazine Stela.7:ne

Thlorprothixene 1 aractan Thiothixene Navane Butyrophenone Halopendol Ha Idol Dihycirnindolone Molindone Meban, Lidone Dibenzoxazepine Laxapine Loxitane, Daxolin 5. SedativeHypnotics Barbiturates Amobarbital Amytal Aprobarbital Alurate Butabarbital Sutisol Mephobarbital Mobaral Pentobarbital Nembutal Phenobarbital Luminal, E lob rb Secobarbital Seconal Nonbarbiturares Chloral hydrate Noctec Ethchlorvynol Placidyl Glutethimide Doriden Metnaqualone Quaalude, Sopor Methyp:ylon Noltiliar Fiurazepam Dalmane 6. Anticholinergie Drugs Benztropine Cogentin Biperiden Akineton Cycrimine Pagitane Trihexphenidyl Artane Procyclidine Kemadrin 7. Other Therapeutic Agents Lithium Carbonate Eskalith, Lithane Lithonate

trade name products mar,eted in the United States are le,led. in the case of drucr no longerprotected by patent !air. the inclusion of trade names other than the original was arbitrary. APPENDIXES 181

APPENDIX B Conners' Abbreviated Teacher Rating Scale ChiaName

Completed on by 5 fidllii!)

INSTRUCTIONS: Please consider the last (day. week, month) only in filling out the checklist. Check the appropriate box for each item. Nat at aii. Just a !IOW. Pretty much. or Very much. which best describes your as.!::o: ment of the child. Please complete all ten items.

Observation Degree of Activity Not at Just a Pretty Very all little much much

0 1 2 3

I. Restless (overactive) 2. Excitable, impulsive 3. Disturbs other children 4. Fails to finish things heishe starts (shod attention span) 5. Fidgeting

6.Inattentive. distractible 7. Demands must be met immediately gets frustrated r 8. Cries 9. Mood changes quickly 10. Temper outbursts iexplosi., ,,,., ne un- predictable behavior)

L1ER OBSERVATIONS OF TEACHERSUse Reverse Side. 82 CHILDREN ON MEDICATION APPENDIX C Classification of the Epilepsies* Seizure Typet Characteristics Various manifestations, generally without im- I.Partial Seizures A. Partial seizures with ele- (Focal Seizures) mentary symplomatol- pairment of consciousness, including con- ogy (cortical local) vulsions confined to a single limb or muscle group (Jacksonian motor epilepsy), specific and localized sensory disturbances (Jacksonian sensory epilepsy), and other limited signs and symptoms depending upon the particular cortical area producing the abnormal discharge

B. Partial seizures with Attacks of confused behay. -,enerally with complex syrnptomatol- impairment of conscious),-.,55, with a wide cgy (temporal lobe, variety of clinical manifestations, associ- psychomotor) ated with bizarre generalized EEG activity during tr,- :eizure with evidence of anterior ter 11 lobe focal abnormalities even in the interseizure period in many cases

C. Partial seizures second- arily generalized

II. Generalized SeizuresA. Absences (petit real) Brief and abrupt loss of consciousness asso- (Bilateral. Symmet- ciated with high-voltage, bilaterally syn- rical Seizures) chronous, 3-per-second spike-and-wave pattern in the EEG, usually with some symmetrical clonic motor activity va; ylilg from eyelid blinking to jerking of the entire body, sometimes with no motor activity

B. Bilateral massive epilep-Isolated clonic jerks associated with brief tic elviclorius bursts of multiple spikes in the= LEG

C. Infantile spasms Progressive disorder in infants with motor spasms or other convu' sign_ bizarre diffuse changes in the interseizure EEG (hypscrhythmia), and progressive mental deterioration

DTonic seizures In young children, rhythmic clonic contractions of all rnus,s, loss of consciousness, and rriard autonomic manifect-ons

ontinued on next page APPENDIXES/63 Classification of the Epilepsies*Continued SeizureTyret C,haracteristics E. Tonic !rt young children, opisthotorms, loss of con sciousness, and riisikcd wionothic manifestations

F. To- i-clonic seizures Major convulsions. 1,.ally a sequence of ( /7ar) maximal tonic spasm of ail body musculature followed by synchronous clonic jerking and a prolonged depression of all central functions a /Aloft( tires Loss of postural tone, with sagging of he head or falling

H. .tic seizures Impairment o consciousness and complete relaxation of all musculature, secondary to excessive inhibitory discharge Note From Goodman. L, S:. & Gilman. A lEds The oharmkfogitca/ baste of therapeutics (5th ed.). 1975. Courtesy Macmillan Putthshing Company. New York. New York moailea from Imo international Claificalion p 1,vt,c S,20r,5 !CiStalAt. 19701 Some classifications InClucle unilateral 5.-lizures as a distinct categnr? Additional seizure types are presently unclaSsified dui to it,_omplete data. 84 CHILDREN ON MEDICATION

APPENDIX D

Alphabetical List of Selected Psychotropic aiidAnticonvulsant Drugs by Generic Name, Trade Name, and DrugClassification

Generic Name Trade Name' Classification Acetazolamide Diarnox Anticonvulsant, Diuret Acetophenazine Tindal Antipsyciiotic Amitnptyline Elavil, Endep Antidepressant Arnobarbital Amytal Sedative. Hypnotic Amphetamine Benzedrine Stimulant Aprobarbital Alurate Sedative, Hypnotic Benztropine Cogentin Anticholinergic Biperiden Akineton Anticholinerg's Butabarbital Butisol Seoative, Hypnotic Butaperazine Repoise Antipsychotic Carbamazepine Tegretol Anticonvulsant Carphenazine Froketazine Antipsychotic Chloral hydrate Norton Sedative, Hypnotic Chtordiazepoxide Librium Antianxiety Chlorpromazine ThorazJ,=,, Antipsychotic Chlorprothixene Taractan Antipsychotic Clonazepam Clonopin Anticonvulsant Clorazepate Tranxene Antianxiety Cycrirnine Pagitane Anticholinergic Dantrolene Sodium Dantrium Skeletal Muscle Relaxant Deanol Deaner Stimulant Desipramine Norpramin. Pertofrane Antidepressant Dextroamphetarnine sulfate Dexedrine Stimulant

Dextroamphet mine tanner,- Obotan Stimulant Anticonvulsant. Skeletal Mu,: Diazepam Vaium Relaxant, Aritianxiety Diohenhydramine i=enadnil Sedative, Hypnotic, Antihistamine Diphenylhydantoin sodium Lklantin Anticonvulsant Doxepir. Sinequan. Adam Antidepressar.t Ethchlorvvnol Flacidyl Sedative, Hypnotic Ethosuximide Zarontin Anticonvulsant Ethotoin Peganone Anticonvulsant Fluphenazine Prolixin. Permitil Antipsychotic Flurazepam Dalmane Sedative, Hypnotic Glutethimide DOriden Sedative. Hypnotic Haloperidol Haldol Antipsychotic Hydroxyzine Atarax, Vistaril Sedative, Hypnotic, Antianxiety linipramine Totranil, Presamine Antidepressant Antidepressant Isocarboxazid Marplan Levoamphetarnine Cydril Stimulant Lithium Carbonate Eskalith, Labane. Lithonate Antipsychotic Loxapine Llxitane Daxolin Antipsychotic APPENDIXES 85

Alphabetical List of Selected Psychatropic and Anticonvulsant Drugs by Generic Name, Trade Name, and Drug ClassificationContinued Generic Name Trade Name' Classification Mephenytoo Mesantoin Anticonvulsant Mephobarbital Meharal Anticonvulsant Meprobamate Miltown. Eduanil Antianxiely Mesondazine Serentil Antipsychotic Methamphetamine Desoxyn Stimulant Methadualone Ouaaludc ___Dtopor Sedative. Hypnotic. Metharbital Gernonil Anticonvulsant Methsuximide Celontin Anticonvulsant Methylphenidate Rita lin Stimulant Methyprylon Noludar Sedative. Hypnotic tvlolindor,e Moban. Ldono Antipsychotic Norinpiylino Aventyl. Parneior Anndopros5ant Oxazepam Serax AntianxitfAy Pararrelhadionc, Paradione Anticonvulsant Remo line Cy len Stimulant Pentobarbital Neinuk_da: Sedative. Hypnotic Porphenazinc T rilafon Antipsychotic Phenacernde Phonumno Anticonvulsant Phenelziec., Nardi! Anti depressant Phenobarbital Luminal. Esk.a arr.) Anticonvulsant, Hypnotic Phensuxi:nide MIlentin Anticonvulsant PhenytoTi Dilantin Anticonvulsant Piperacetazine Guide Antipsychotic Pnrndone tvly line Anticonvulsant Prochlorperazine Antipsychotic Procyclidine Kfmadrin Anticholinergic Promazine Soanne Antipsychotic Promethazine Phenergan Sedative. Hvpnctic Protriptyline Vivactil Antidepressant Reserpine Serpasil Antipsychotic Sec' barbital Seconal Sedative. Hypnotic Thiopropazate Dartal. Antipsychotic Thioridazine Melted Antipsychotic Thiothixenc Navane Antipsychotic Tranylcypromine Parnate Antidepressant Trifluoperazine Stelazine Antipsychotic Trifiuptomazine Vespnn Antipsychotic Trihexphenidyi Artane Anticholinergic Trimethadione Tridione Anticonvulsant Valproic A, id Depakene Anticonvulsant

Only trade name prodecta niarVaed in the Unit States art hind in Me cas drug'; no longer protoo', patent lawr . the inclusion of trade names oteidi than tho or .;orlai w 7araaraty 86 CHILDREN ON MEDICATION

APPENDIX E Alphabetical List of Selected Psychotropic and Antiepileptic Drugs by Trade Name and Generic Name Trade Name' Get-t, "'time Tra Name' Generic Name Adapin Doxepin Lit)n to Lithium Carbonate Akineton Biperiden Lnt, Loxapine Alurate Aprobarbital Phenobarbital Amytal Arnobarbital isocarboxarid Artane 'fririexphenidyl Mephobarbital Atarax Hy. troxyzine ,Vii.Thril Thioridazine Aventyl Nortriptyline M, Meprobamate Benadryl Diphenhydramine r\i;inio;t Mephenytoin Benzedrine Amphetamine rrlilrintiii Phensuximide Benztropiriu Cogentin Meprobarnate Biperiden Akineton Moban Molindone Butisol Butabarbital Mysoline Primidone Celontin Methsuximide Nardil Phenelzine Clonopin Clonazepam Navane Thiothixene Cogentin Benztropine Nembutal Pentobarbital Compazine Prochlorperazine Norton Chloral Hydrate Cycrimine Pagitane Noludar Mcthvpryion Cydril Levoamphetamine Norprarr ri Desiprirnine Cy lert Pemoline Pagitane Cycrimine Dalmane Flurazepam Pamelor Nodriptynne Dantriurn Dantrolene Sodium Paradione Paramethadione Dartal Thiopropazate Parnate Tranylcypromine Deaner Deanol Peganone Ethotoin Depakene Valproic Acid Perm itil Fluphenazine Desoxyn Methamphetarnine Pertofrane Desipramine Dexamyl Dextroamphetamine and Phelantin Phenobarbital, phenytoin. arnobarbi and methamphetamine Dexedrine Dextroamr :Amine .nergan Promethazine Diamox Acetazolarrrt-4- trairone Phenacemide Dilantin Phenytoin Placidyl Ethchlorvynol Donnatal Belladonna atIctt and Fidsamine Imiprarrine phenobarbi,at Procyclidine Kemadrin Doriden Glutethimide Proketazine Carphenazine Ekko Phenytoin Prolixin Fluphenazine Elavil Amitriptyline Quaalude Methaqualone Endep Amitriptyline Quirle Piperacetazine Equanil rtAeprobamate Repoise Butaperazine Eskabarb Phenobarbital Ritalin Methylphenidate Eskalith Lithium Carbonate Seconal Secobarbital Gemonil fvletharbital Serax Oxazeparn Haldol Haloperidol seronoi Mesoridazine Imavate Imipramine SLrpasil Reserpine Janimine lmipramine Sinequan Doxepin Kemadrin Procyclidine SK-pramine Imipramine Librium Chlordiazepoxide Sonazine Chloropromazine Lidone Molindone Lithane Lithium Carbonate

Continued on next pager APPENDIXES/37 Alphabetical List c Selected Psychotropic and Antiepileptic Drugs by Trade Name and Generic NameContinued Trade t.1:)-riew Generic Name Trade Name' Generic Name Methaqualone Promazine Trifluoperazine Te,:actan Chlorprothixene Tegretol Carbamazepine Thorazine Chlorpromazine Tindal Acetophenazine Totrand Imipramine Tranxene Clorazepate Tnavil Perphenazine and amitriotyline rldioriu Trimethadione rnlafon Perphenazine Valium Diazepam Vesprin Tritlupromazine Viataril Hydroxyzine pamoate Vivactil Protriptyline Zarontin Ethosuxirnide

Only trade name products marketed in the United ,tat. -L, ar,z ;;- thc j:ase et drugs no longer protected by patent laws. the inclusion of trade names other than the ()rival wai arninry References

Abel. E. L. Drugs and behavior: A primer in neu- Journal of Abnormal Child Psychology, 1976, ropsychopharmacology. New York:John Wiley 4, 327-348. & Sons. 1974 Barkley. R. A. A review of stimulant drug re- American Academy of Pediatrics. Megavitamin search with hyoeractive children. Journal of therapy for childhood psychoses and learning Child Psychology and Psychiatry, 1977, 18, disabilities.Pediatrics,1976,58.910-912. 137-165. Anesko,K.,O'Leary. S.G.. & Shoiock, G. Barkley. R. A.. & Cunningham. C. E. Do stimu, Homework hassles: How to handle them. lant drugs improve the academic performance Available from Dr. Susan O'Leary. Depart- of r;yoerkinetic children? Clinical Pediatrics, ment of Psychology. State University of New 1978, 17, 8592. York, Stony Brook NY 11794. Becker, VI. C. Parents are teachers. Champaign Arnold. L. E. The art of medicating hyperkinetic IL: Research Press, 1971. children. Clinical Pediatrics, 1973, 72, 35-41. Boo!. Langford, W. S.. MacKay. M.. & Sum, AvIlon. T., Layman. D., & Kardel, H. J. A behav- G. Childhood chemotherapy and later drug ioral-educational alternative to driig control of abuse and growth curve: A follow-up study of hyperactive children. Journal of Applied Be- 30 adolescents. American Journal of Psychia- havioral Analysis. 1975, 8, 137-145, try, 1975, 132, 436-438. Azrin N. ri., & Thienes, P. M. Rapid elimination Blacklidge. & Ekblad, R. The effectiveness of of eouresis by intensive learning without a methylphenidate hydrochloride(FAJa.lir)on conditioningaparatus. Behavior Therapy, learning and behavior in public school educa- 1978, 9, 342-354. blementally retardedchildren. Pediatrics, Baird. H. W. The child with convulsions: A guide 1971, 47. 923-'126. for parents, teachers, counselors, and _medi- Blackwell. B., & Currah, J. The psychopharrna, cal personnel. New York: Grune & Stratton, cology of nocturnal enuresis. In I. Kelvin, R. C. 1972. MacKeith, & S. R. Meadow (Eds.). Bladder Baker, H. J. Exceptional children (3rd ed.), New control and enures. London: William Heine, York: Macmillan, 1959. mann Medical Books, 1972. Ballard. J. E.. Boileau, R. A. Sleator, E. K., Mas- Borginsky, M. E. Provision of instruction to hand- sey, B. H.. & Sprague. R. L. Cardiovascular icapped pupils in local public schools, Spring responses of hyperactive children to methyl- 1970, Washington DC: U. Office of Educa- phenidate. Journal of the American Medical tion, 1974. Association, 1976, 236, 2870-2874. Bosco, J. J.. & Robin, S. S. (Eds.). The hyper- Barkley. R. A. Predicting the response of hyperactive child and stimulant drugs. Chicago: kinetic children to stimulant drugs: A review. University of Chicago Press, 1976. 88ttj REFERENCES,' 30

Bradley. C. The behavior of chlioren receiving Cohen, M. Survey of psychotropic drug treat- Benzedrine. American Journal of Psychiatry. ment in residential facilities for the mentally re- 1937. 94, 577-585. tarded. Paper presented at the annual meet- Bradley, C. Benzedrine and dexedrinein the ing of The Council for Exceptional Children, treatment ofchildren's behavior disorders. Kansas City. May. 1978. Pediatrics. 1950. 5. 24-37. Conners, C. K. A teacher rating scale for use in Bradley. C.. & Bowen, M. School pert -.:rn i-ince of drug studies with children. American Journal children receiving amphetamine (Beaedrine) of Psychiatry, 196,j, 126, 884-888. sulfate, American Journal of Ochop,ycoiatry, Conners, C. K. Drugs in the management of chil- 1940, 10. 782-788. dren with learning disabilities. In L. Tarnopol Briant. R. H. An introduction to clinical pharma- (Ed.). Learning disorders in children: Diagno- cology. In J. S. Werry (Ed ). Pidiatric psychosis.medication,education.Boston:Little. pharmacology: The use of behavior modifying Brown, 1971. drugs in children. New York: Brunner Conners. C. K. Controlled trial of methylpheni- 1978. date in preschool children with minimal brain Brown. vWinsberg. B. G & Press. dysfunction. International Journal of Mental M. Irniprarriiiie therapy and seizures: Three Health, 1975, 4, 61=74. children treated for hyperactive behavior dis- Conners. C. K.. & Rothschild. G. H, Drugs and orders. American Journal of Psychiatry, 1977 learninginchildren.InJ.Hellmuth (Ed.). 130. 210-212. Learning disorders (vol.3). Seattle: Special Burack, R. B.. & Fox. F. J. The new Ilan, noc: of Child Publications. 1968. prescription drugs (Rev. ea.). New K 3,11- Conners, C. K. Classification and treatment of [amine Books. 1975, childhood depression and depressive equiva- Callaghan. N.. Feely. M.. Duggan, lents.InD. Gallant & G. Simpson (Eds.), O'Callaghan, M., & Seki up, S. The anect of Depression: Behavioral, biochemical, diag- anticonvulsant drugs which induce liver311Cro- nostic, and treatment concepts. New York: sornal enzymes oilderieed and ingested Spectrum, 1976. phenobarbitonelevels.Act, Neun 'ogica Conners, C. K. Paper presented at the NIMH Scandinavica, 1977. 56, 1-6. Vy'orkshop on Hyperkinesis. Washington DC, Campbell. M. Pharrnacotherapy in early iilantile June 15-16. 1978. autism. Biological Psychiatry. 1975.1 ". 399- Conners. C. K., Goyett, C. H,, Southwick, D. A., 423. (a) Lees. J. M.. & Andrulanis, P. A. Food additives Campbell. M. Psychopharimacolegy in childhood and hyperkinesis: A controlled double-b:ind psychosis, International Journal of Mental experiment. Pediatrics,1576, 58,154 -166. wealth, 1975, 4. 238-254. (b) Cooper, I. S.. Amin, I., RiKlan, M., Waltz, J. M.. & Cantwell. D. P. Genetic studies of hyperactive Poon, T. P. Chronic cerebellar stimulation in children. In B. R. Fie D. Rosenthal, & H. epilepsy. Archives of "-,urology,.1.57C 33. Brill(Eds.), Genetic research :n psychiatry. 559-570. Baltimc -:: Johns Hopkins University Press, Cordes, C. K. Chronic drug intoxication causing 1975. pseudo - retardation in a young child, Journal of Cantwell. D. P.. & Carlson, G. A. Stimulants. In the American Academy of Child Psychiatry, J. S. Werry (Ed.). Pediutric psychopharrna- 1973, 12, 215-222. cology: The use of behavior modifying drugs Cott, A. Megavitamins: The orlhornolecular ap- in children. New York: Brunner/Mazel, 1978. proach to behavioral disorders and learning Christensen, D. E. Effects of combining methyl- disabilities. Academic Therapy, 1972, 7, 245- phenidate and a classroom token system in 258. modifying :',yperactive behavior. American Cruickshank, W. M., & Raus, G. M Size and Journal of Mental Deficiency, 1975. 80, 266 scope of the problem. In W. M. Cruickshank & 276. G. M. Raus (Eds,). Cerebra; palsy: Its individ- Clements, S. D. Minimal brain dysfunction in ual and community problems (2nd ed.). Syra- children (NINDS Monograph No. 3, U.S. Pub- cuse: Syracuse University Press, 1955. licf-LIalth Service Publication No. 1415). Currier, R. 0 Kooi, K. A & Saidman, L. J. Prog- Washington DC: US Government Printing Of- nosis of "pure" petit rnal: A follow-up study. fice,'I 9,7-8. Neurology, 1963, 13, 959-967.

tr.

90/CHILDREN ON MEDICATION

Davis, K, V. The effect of drugs on stereotyped Englehardt, D. M., Polizos, P., & Waizer, J. CNS and nonstereotyped operant behaviors in re- consequences of psychotropic drugwith- tardates.Psychopharrnacologia 1971, 22, drawal in autistic children: A follow-up report. 195-213. PsychopharmacologyBulletin,1975. 1 1(1), Davis, K, V, , Sprague, R. L., & VVerry, J. 5. Ster- 6-11. eotyped behavior and activity level in severe Epilepsy Foundation of America. Basic statistics retardates: The effectof drugs. American On the epilepsies, Philadelphia : F. A. Davis, Journal of Mental Deficiency, 1969. 7a 721- 1975, 727. Eyman, R. K., & Call, T. Maladaptive behavior Dekaban, A, S., & Lehrnan, E. J, B. Effects of and community placementofmentallyre- different dosages of anticonvulsant drugs on tarded persons. American Journal of Mental mental performance in patients with chronic Deficiency, 1977, 82, 137-144. epilepsy. Acta Neurologica Scandinavica, Falconer, M. A., & Davidson, S. Coarse features 1975, 52. 319-330. in epilepsy as a consequence of anticonvul- Denhoff, E., Feldman, S., Smith, M. 0., Litch- sant therapy. Lancet, 1973, 2, 1 112-1114. man, H., & Holden, W. Treatment of spastic Fazio, C. Manfredi, M., & Piccinelli. A. Treatment cerebral-palsied children with sodium denim- ofepileptic seizures with clonazeparn. Ar- lene. Developmental Medicine end Child chives of Neurology, 1973 32, 304-307. Neurology, 1975, 17, 736-742. Feingold, S. F. Why your child is hyperactive. DiMascio, A., Soltys. J, J., & Shader, R. I. Psy- New York: Random House, 1974. ohotropic drug side effects. Baltimore: Wil- Fish, B. The "one child, one drug" myth of stim- liams & Wilkins, 1970. ulants in hyperkinesis. Archives of General Division of Innovation,and Development. Bureau Psychiatry, 1971, 25, 1 93-203. of Education for the Handicapped. Personal Fish, B. Pharmacotherapy for autistic and schiz- communication, October 11, 1977. ophrenic children. In E. R. FRitvo, B. J. Free- Domino, E.F. Centrally acting skeletal - muscle man, E. M. Ornitz, & P. E, Tanguay (Eds.), Au- relaxants. Archives of Physical Medicine and tism:Diagnosis,currentresearch and Rehabilitation, 1974, 55, 369-373. management, New York: Spectrum, 1976 Douglas, V. I. Stop, look, and listen: The problem Flynn, N. M., & Rapoport, J. L. Hyperactivity in of sustained attention and impulse control in open and traditional classroom environments. hyperactive and normal children. Canadian Journal of Special Education, 1976, 10, 285- Journal of Behaviour Science, 1972, 4, 259- 290, 282. Force, D. A descriptive study of the incidence of Douglas, V.I.. Parry, P., Marton, P., 8 Gerson, seizures and teachers' attitudes toward chil- C. Assessment of a cognitive training program dren with epilepsy in the Minneapolis, Min- for hyperactive children. Journal of Abnormal nesota Public Schools. Minneapolis: Minne- Child Psychology, 1976, 4, 369-410. sota Epilepsy League, 1965. Dunsdon, NI. I. The educability of cerebral pal- Forsythe, W. I., & Redrnond, A. Enuresis and sied children, London: Newnes Educational spontaneous cure rate- Archives c I Disease in Pub., 1952, Childhood, 1974, 49, 259-263, Eisenberg, L. Role of drugs in treating disturbed Freeman, R. D. Drug effects on learning in chil- children. Children, 1964, 11, 167-173. dren: A selective review of the past thirty years. 1966, 1, 17- Eisenberg, L., & Conners, C. K. Psychopharma- Journal of Special Education, cology in childhood. In N. B. Talbot, J. Kagan, 43. & L. Eisenberg (Eds.), Behavioral science in Freeman, R. D. Use of psychoactive drugs for N. R. pediatric medicine. Philadelphia: W. B. Saun- intellectually handicapped children.In ders, 1971. Bernstein (Ed.), Diminished people: Problems Ellis, M. J., Witt, P. A Reynolds, R, & Sprague, and care of the mentally retarded. Boston: Lit- R. L. Methylphenidate and the activity of hy- tle, Brown 1970. (a) peractives in the informal setting. Child Devel- Freeman, R. D. Psychoptlarrnacology and the opment, 1974, 45, 217-220. retarded child. In F. Menolascino (Ed.), Psy- Engel, G. L. The need for a new medical model: chiatric approaches to mental retardation. New A challenge for biomedicine. Science, 1977. York: Basic Books, 1970, (b) 1976, 129 -135. Freeman, R. D. Minimal brain dysfunction, hy- REFERENCES 1

poractivity, and learning disorders: Epidemic Classific ition rnf epileptic SolZures.Epilnp- or episode? School Review, 1976, 85, 5-30. sia. 1970, 11, 104-I13, Fromm, G. H., Arrnores, C. y & Thies, Vv, irni- Gastaut. H. Comments on "Petit mal variant re- pramine in epilepsy. Archives of Neurology, visited.- Fpdepsia. 1971. 12. 97-99. 1972. 27, 198-204. Gibbs. F. A. Petit mal variant revisited. Epilepsia, Gadow. K. D. Psychotropic and anticonvulsant 1971, 12. 89-96. drug usage in early childhood special edu- Gittelman-Klein, R. Pharmacetht rapy and man- cation programs, Phase One: A preliminary agement of pathological separation anxiety. report: Prevalence,attitude,training and International Journal of Mental Ffealfti, 1975. problems,Paper prosente6 at the annual 4. 255-271 Meeting of The Council for Exceptional Chil- Gittelman-Klein, R. Paper presented at the NIMH dren. Chicago, April 1976. (ERIC Document Workshop on Hyperkinesis. Washington DC. Reproduction Service No. ED 125 198) June 15-16, 1978. Gadow. 0. Psychotropic and anticonvulsant Gittelman-Kf ein, R., & Klein, O. F. School phobia: drug u,c000 in early childhood special edu- Diagnostic considerations in triolight of imi- cation programs Ill. A preliminary report; Par- pramine effects. Journal of Nervous and Men- ent interviews about drug treatment. Paper tal Disease., 1973, 156, 199-215. presented at the annual meeting of The Coun- Gittelman-KI ein, R., & Klein, D. F. Methylpheni- cil for Exceptional Children. Atlanta. Georgia. date effects in learning disabilities. Archives of April1977. (ERIC Document Rei ,oduction General Psychiatry, 1976, 33, 655-684, Service No. ED 139 192) (a) Gittelmar Klein, R Klein, D. F Abikoff,H Katz. Gadow. K. D. Psychotropic and ant/epileptic S., Gleisten, A. C., & Kates, W. Relative effi- drug treatment with children in early child- cacy of metflylphenidate and behavior inoclifi- hood special education. Final report. Grant # cation in hyperkinetic children: An interim re- 00-75-00-361, US Office of Education, Bureau port. Journal of Abnormal Child Psychology, of Education forthe Handicapped. August 1976. 4, 361-379, 1977. (ERIC Document Reproduction Service Gittelman-Klein, R., Klein, D. P., Katz, S., Saraf, No.. in pres) K.. & Pollack, E. Comparative effects of meth- Gadow. K. 0. Drug therapy with trainable men- ylphenidate and thioridazine in hyperkinetic tally retarded children in public schools, Pa- children. Archives of General Psychiatry, 1976, per presented at the annual meeting of The 33, 1217-1231. Council for Exceptional Children, Kansas City, Gold. A. P. Psychomotor epilepsy in childhood. Missouri, May 1978. (ERIC Document Repro- Pediatrics. 1974.53, 540-542, duction Service No. ED I 53 398) (a) Goodman. L. 5.. & Gilman. A. The pharrnacOlOg- Gadow. K. Q. Psychotropic and antiepileptic drug /cal basis of therapeutics (5th ed.). New York: treatment in programs for the trainable men- Macmillan. 1975. tally handicapped. (Doctoral dissertation, Uni- Graham, P. Depression in pre - pubertal children. versity of Illinois at Urbana-Champaign. 1978). Developmental Medicine and Child Neurol- Dissertation Abstracts International, 1978. 39. ogy, 1974. 16, 340-349. 2868,-A. (University Microfilms No. 7820938) Gram, L., Wulff. K Rasmussen, K. E.. Plachs, (b) H., Wirtz- Jorgensen, A., Sornmerbeek, K. W., Gadow, K. D. Drug treatment with mentally re- & Lohren. V. Valproate sodium: A controlled tarded children: Parent interviews. Unpub- clinical trial including monitoring of drug blood lished manuscript. 1978. (c) levels. Epi/epsia. 1977, 78, 141-148. Gadow, K. D. Prevalence and pattern of psy- ohotropic drug treatment for behavior disor- Greenberg, L. M., Deem, M. A., & McMahon, S. of dextroarnphotaMine, chlorproma- ders in special education settings. Paper pre- Effects zine. and hydroxyzine on behavior and perfor- sented at the NirviH Workshop on Hyperkinesis. hyperactive children. American Washington DC. June 16-16. 1978. (d) mance in Journal of Psychiatry. 1972, 129, 532-539, Gardner, W. I. Behavior modification in mental retardation: The education of the mentally re- Gross, M. D.. & Wilson, W C. Minimal brain dys- tarded adolescent and adult. Chicago: Aldine- function, New York: Brunner/Mazel, 1974, Atherton, 1971, Grossman, H. (Ed.), Manual on terminology and Gastaut, H. clinical and electencephalograph- classification in mental retardation. Washing- 92/CHILDREN ON MEDICATION

ton PC: American Association on Mental De- mooing y. Now York: Oxford Universe ficiency, 1973. 1975. Harley, J. P.. Ray, R. S., Tornasi, L., Eichinan, Jaffe, J. H. Drug addiction and drug abuse. In L. P. L.. M-thews, C, Q., Chun, R., Cleeland. C. S. Goodman & A. Gilman (Eds.), The phar- S., & Traisman. E. hyperkinesis and food ad- macological basis of therapeutics (51n. ed.). ditives: Testing the Feingold hypothesis. Po- New York: Macmillan. 1975. diatrics, 1978, 61, 518-828. ,Jasper, H. H., Ward, A. A., & Pope, A. ( Eds.). Heritage, L.C. Effects of chlorpromazine on Basic mechanisms of the epilepsies. Boston: learning. Psychological Bulletin,1965, 84, Little, Brown & Co., 1969. 235-245. Jeavons, P. M. Nosological problems of mY- Hastert). R. H.A.. & Valletutti,P. J. Medical oolonic epilepsies in childhood and addles- problems in the classroom: The teacher's cence. Developmental Medicine and Child role in diagnosis and Management. Baltimore: Neurology. 1977, 19, 3-8. University Park Press. 1975. Jeavons, P. M.. & Clark, J. E. Sodium valproate Honker, B. Licit and illicit drug use patterns in in treatment of epilepsy. British Medical Jour- stimulant treated children and their peers, In nal, 1974. 2. 584-586. K. P. Gadow (Chair), P!sychosocial a is Kalachnik. J. Side effects of selected psycho- of drug treatment for hyperactivity. Sy . tropic drugs with children' Chlorpromazine iurn presented at the meeting of the American (Thorazine), thioridazine (Mellaril), trilluoper- Association for the Advancement of Science, azine (Stelazine), and haloperidol (Haldel). Houston, January 1979- Unpublished manuscript, Institute for Child Herberg, K. P. Effects of diphenythydantoin in 41 Behavior and Development, University of Illi- epilepticsinstitutionalizedsincechildhood. nois at Urbana-Champaign. 1977. Southern Medical Journal, 1977, 70, 19-24, Kamm, I.. & Mandel, A. Thioridazine in the treat- Hollis, J. H.. & St. Omer, V, V. Direct measurement et behavior disorders in epileptics. Dis- ment of psychapharmaeologic response: Ef- eases of the Nervous System, 1967. 28, 46-- fects of chlorpromaZine on motor behavior of 48. retarded children. American Journal of Mental Katz, S., Saraf, K., Gittelman-Klein, R., & Klein, Deficiency, 1972. 76, 397407. F, Clinical pharmacological management of hyperkinetic children. International Journal of Holowach, J.,Thurston, D.L.& O'Leary, J. Mental Health, 1975, 4, 157 -181. Prognosisin childhood epilepsy: Follow-up study of 148 cases in which therapy has been Kendall. P. H. The use of muscle relaxants in suspended after prolonged anticonyulsant cereural palsy. In E. Denhoff (Ed.), Drugsin control. New England Journal of Medicine, cerebral palsy (Clinics in DevelopmentalMed- 1972, 286, 169174, icine No.16). London: William Heinemann Honigfeld, G., & Howard, A Psychiatric drugs: A Medical Books, 1964. desk reference. New York: Academic Press, Klebanoff, L. B., DiMascio, A., & Lowe, L. M. Re- psychophar- 1973. port on a survey of the use of Hooshrnand, H. Toxic effects of anticonvulsants: macological agents in Massachusetts state General principles. Pediatrics, 1974. 53, 551= residential facilities for the metalty retarded. 557. Unpublished manuscript. 1973. Hungund, B., Hanna, & Winsberg, B. A sen- Klein. D. F., & Davis, J. M. Diagnosis and drug sitive gas chromatographic method for the de- treatment of psychiatric disorders, Eialtirnore: termination of rnethylphenidate (Ritalin) and its Williams & Wilkins, 1969. Major metabolite a-pheny1-2.oiperidine acetic Knights, R. M.. & Hinton. G. G. The effects of acid (ritalinic acid) in human plasma using ni- rnethylphenidate (Ritalin) on the motor skills and behavior of children with learning prob- trogen-phospherousdetector. Communica- tions in Psychophannecology, 1973, 2, 203- lems. Journal of Nervous and Mental Disease, 208. 1969. 148, 643-653. Huttenlocher, P. EL, Wilboum, A. J., & Signore, Kobayashi, R, Drug therapy of tardive dyskine- J. M. Medium-chain triglycerides as therapy sia. New England Journal of Medicine,1977, for intractable childhood epilepsy. Neurology, 296, 257-260. R. F., 1971, 21, 1097-1103. Kolvin, I.. Taunch, J., Currah, J., Garside, Iverson, S. V., & Iverson, L. L. Behavioral phar- Nolan, J. & Shaw, W. B. Enuresis-a descrip- REFERENCES/ 93

live analysis and a controlled foal, Dovolop- Least-, 11..1.. Loos. P. M. & Artner, J. The effects mental Medicine and Child Neurology. 1972, of methylolionidate on the handwriting of chil- 14, 715-726, dren with minimal brain dysfunction. Journal of }

Hunt, E. Livingston, S., Kajdi. L.. & Bridge, E. M. The use MacLeod, C. M., Dekaban, A. S., & Memory impairment in epileptic patients;Se- of Benzedrine and Dexedrinesulfate in the concentration. treatment of epilepsy. Journal ofPediatrics, lective effects of phenobarbital Science. 1978, 202, 1102-1104. 1948, 32, 490-494. Mann, H B., & Greenspan, S. I. Theidentifica- Livingston. S., & Pauli, L. L.Dextroamphetarnine Medical tion and treatment of adultbrain dysfunction. for epilepsy. Journal of the American 133, Association, 1975, 233, 278-279. American Journal of Psychiatry, 1976, Livingston, S., Pauli, L. L., & Berman.W. Car- 1013-1017. dance is bernazepine (Tegretol) in epilepsy: Nine year Mash, E. J., & Terdal, L. G After the for follow- emphasis on un- over: Some issues and suggestions follow-tip study with special Psycho- toward reactions. Diseases of theNervous up assessment in behavior therapy. logical Reports, 1977, 41, 1287-1308. SYsfent 1974, 35, 103-107. Matthews. C. G.. & Haley, J. P. Cognitiveand Livingston, S.. Pauli, L. L., & Pruce,I.Letter: and non- Onedrug regimens for epilepsy. Lancet,1978. motor- senso -y performances in tox.c toxic epileptic subjects. Neurology. 1975, 25, I, 1407-1408. Livingston. S., Pauli. L. L., & Pruce. I.Ketogenic 184-188. Develop- Mattson. A. H.. & Calverley, J. R.Dextroamphe- diet in the treatment of epilepsy. ternine-sullateineuced dyskirwsias. Journal of mental Medicine and Child Neurology.1977. the American Medical Association, 1968,204, /9, 833-834 Livingston, S.. Pauli. L. L., & Pruce,I. No proven 400-402. McAndrew, J. B Case, 0., & Treffert, 0. A.Ef- relationship of carbomazepine therapyto blood fects of prolonged phenothiazine intake on dyscrosias. Neurology, January 1978. Livingston, S., Torres, I., Pauli, L.L.. & Rider, R. psychotic and other hospitalized children. Schizophre V. Petit rnal epilepsy; Resultsof a prolonged Journal of Autism and Childhood follow-up study of 117 patients.Journal of the ma, 1972. 2, 75-91. McNutt, B. A., Boileau, R. A., Cohen,M. N., American Medical Association,1985, 194, Sprague. R. L.. & von Neumann, A. The ef- 227-232. fects of long-term stimulant medication onthe Lornbroso, C. T. The treatment ofstatus epilep- growth and body composition ofhyperactive ticus. Pediatrics, 1974. 53,536-540. children: II, Report on two years. Psychophar- Laney, J. Childhood hyperactivity.In R. H. Woody rnacology Bulletin, 1977, 13 (2), 36-41. (Ed.). Encyclopedia of clinicalassessment. in press. Medical Letter, 1976, 18, 18-19. San Francisco: Jossey-Bass, M. Loney, J., Kramer, J., & Milich,R. The hyperki Meighan, S. S., Oueener. L., & Weitman. of symptoms, Prevalence of epilepsy in children of Multno- netic child grows up: Predictors 1976, 17, delinquency, and achievement atfollow-up. in mah County, Oregon. Fpilopsia, K. D. Dadow (Chair.). Psychosocial aspectsof 245-256. Merritt, H. H., & Putnam, T. J. Sodiumdiphenyl drug treatment for hyperactivity.Symposium hydantoinate in the treatment of convulsive presented at the meeting of the AmericanAs- sociation for the Advancement ofScience, disorders. Journal of the American Medical Association, 1938, 111, 1068-1073, Houston, January 1979. Mikkelsen, B., BirketSmith, E., Brandt, S..Holm, Loney, J., Langhorne, J. E., &Paternite, C. E. An P., Lund, M., Thorn, l., Vestmark, S., & Olsen, ernpirical basis for subgroupingthe hyperki, neticIMBD syndrome. Journal ofAbnormal P. Z. Clonazeparn in the treatment of epilepsy. Psychology, 1978, 87, 431-441. Archives of Neurology, 1976, 33, 322-325. Loney, J., Prinz, R. J., Mishalow, J., &Joad. J. Millichap, J. G. Management of hyperkinetic be- Hyperkinetic/aggressive boys intreatment: havior in children with epilepsy. ModernTreat- Predictors of clinical response to methylphen m -it,1969, 6, 1233-1246. of idate. American Journal of Psychiatry, in press. ktiflichap, J. G. Drug therapy: Drug treatment convulsive disorders, New England Journalof Lucas, A & Weiss, M. Methyiphenidatehallucj- nosis. Journal of the American MedicalAsso Medicine, 1972, 286, 464-469, CNS ciation, 1971, 217, 1079-1081. Millichap, J. G. The paradoxical effects of stimulants on hyperkinetic behavior. Interna- MacLean. R. E. G. Irnipramine hydrochlorideand enuresis. American Journal ofPsychiatry, tional Journal of Neurology, 1975, 10, 241- 1960, 117, 551, 251. REFERENCES! 95

Montagu, J. D., & Swarbrick, L. Effect of am- Medicine and Child Neurology.1972.14, phetamines in hyperkinetic children: Stimulant 727-730. or sedative. Developmental Medicine and Patterson, G. R Families: Application of social Child Neurology, 1975, 17, 293-298. learning to family life (Rev. ed.). Champaign Mostofsky, D. I., & Balaschak, B. A. Psychobiol- IL: Research Press, 1975. ogical control of seizures. Psychological Bul- Patterson, G. R. Living with children: New meth- letin, 1977, 84, 723-750. ods for parents and teachers (Rev.ed.). Mowrer, 0. H. Learning theory and personality Champaign IL: Research Press, 1976. dynamics. New York: Ronald Press, 1950. Paulson, G. W. Tardine dyskinesia. Annual Re- Nelson, K. B., & Ellenberg, J. H. Prognosis in view of Medicine, 1975, 26, 75-81. children with febrile seizures. Pediatrics, 1978, Paulson, G. W., Rizvi, C. A., & Crane, G. E. Tar- 61, 720-727. dine dyskinesia as a possible sequel of long- New York State Association for Retarded Chil- term therapy with phenothiazines. Clinical Pe- dren, Inc, v. Nelson Rockefeller, No. 72 356, diatrics. 1975, 14, 953-955. 72 357 (E,D. New York. 1975), Payne, D.. Johnson, R. C., & Abelson, R. B, Nichamin, S. J. Recognizing minimal cerebral Comprehensive description of institutional- dysfunction in the infant and toddler. Clinical ized retardatesinWestern United States. Pediatrics. 1972. 11, 255-257. Boulder CO: Western Interstate Commission Niedermeyer, E. Compendium of the epilepsies. for Higher Education, 1969. Springfield IL: Charles C Thomas. 1974. Perlstein, M. A.Infantile cerebral palsy. Ad- Office of Mental Retardation Coordination. Men- vances in Pediatrics, 1955. 7, 209-248. tal retardation activities of the Department of Phelps. W. Recording the progress of skills in Health, Education, and Welfare (DHEW Pub- cerebral palsy. In E. Denhoff (Ed.), Drugs in lication No. 05-72-27). Washington DC: US cerebral palsy (Clinics in Developmental Med- Government Printing Office. 1972. icine No16), London' William Heinemann O'Leary. S. G., & Pelham, W. E. Behavior ther- Medical Books, 1964, apy and withdrawal of stimulant medication in Pietsch, S. (Ed.), The person with epilepsy: Life hyperactive children. Pediatrics,1978, 61. style, needs, expectations. Chicago: National 211-217. Epilepsy League, 1977. O'Leary, K. D., & O'Leary, S. G. Classroom Pippenger, C. E., Sins, J. H., Werner, W. L., & management: Successful use of behavior Masland. R. L. The effect of psychotropic drugs modification (2nd. ed.). New York: Pergamon, on serum anti-epileptic levels in psychiatric 1977. patients with seizure disorders. In H. Schnei- O'Leary. K. D., Pelham, W. E., Rosenbaum. A., der, Janz, C. Gardner-Thorpe, H. Meinardi, & Price, G. H. Behavioral treatment of hyper- & A. L. Sherwin (Eds.), Clinical pharmacology kinetic children. Clinical Pediatrics, 1976. 15, of anti-epileptic drugs. Berlin: Springer-Ver- 510-515. lag, 1975. O'Leary. K. D.. Rosenbaum, A,, & Hughes, P. Polizos, P., Engelhardt. D. M., Hoffman, S. P., & C, Fluorescent lighting: A purported source of Waizer, J. Neurological consequences of psy- hyperactive behavior. Journal of Abnormal chotic drug withdrawal in schizophrenic chil- Child Psychology, 1978, 6, 285-289. dren. Journal of Autism and Childhood Schiz- O'Neill, 8, P., Ladon, B., Harris, L, M., Riley. H. ophrenia, 1973, 3, 247-253. L Dreifuss, F. E. A comprehensive, interdis- Putnam, T. J.. & Merritt, H. H. Experimental de- ciplinary approach to the care of the institu- termination of the anticonvulsant properties of tionalized person with epilepsy. Epilepsia. some phenyl derivatives. Science, 1937, 85, 1977, 18, 243-250. 525-526. Ott, J. N. Influence of fluorescent ;fights on hy- Quinn. P.O.. & Rapoport. J, L. One-year follow- peractivity and learning-disabilities. Journal of up of hyperactive boys treated with imipramine Learning Disabilities, 1976, 9, 417-422. or rnethylphenidate. American Journal of Psy- Ounsted, C. The hyperkinetic syndrome in epi- chiatry, 1975, 132, 241-245. leptic children, Lancet, 1955, 2, 303-311, Rapoport, J. Pediatric psychopharmacology and Parkin. J. M., & Fraser, M. S. Poisoning as a childhood depression. In D. F, Klein & R. Git- complicationofenuresis,Developmental telmal-Klein (Eds.), Progress in psychiatric 96/CHILDREN ON MEDICATION

drug treatment (vol. 2). NewYork: Brunner/ Rosenthal, J, H., Nicholson, R., & Collier, E. The syndrome of Gilles de la Tourette. Journal of Mazei, 1976. Rapoport J. L., Buchsbaum, M. S.. Zahn,T. P., Learning Disabilities, 1975, 8, 95-97. Weingartner, H.. Ludlow, C., & Mikkelsen,E. Ross, A. 0. Psychological disorders of children. J. Dextroamphetarnine: Cognitiveand behav- New York: McGraw-Hill, 1974, Ival effects in normal prepubertal boys.Sci- Ross, D. M., & Ross, S. A. Hyperactivity: Re- ence, 1978, 199, 560-563. search, theory, and action. New York: John Rapoport, J. L., Quinn. P.O.. Bradbard, G., Rid- Wiley & Sons, 1976. dle, K. 0., & Brooks, E. imipramine and meth- Rutter, M. L. Psychiatry, In J. Wortis (Ed.), Men- ylphenidate treatments of hyperactive boys. tal retardation.' An annual review (Vol. 3), New Archives of General Psychiatry,1974, 30, York: Grune & Stratton. 1971, 789-793. Rutter, M., Tizard, J., & Whitmore, K. (Eds.). Ed- Ray, 0. Drugs, society, and human behavior ucation. health, and behavior, London: Long- (2nd ed.). St. Louis: C. V. Mosby, 1978. mans, 197C1. Renshaw, D. C. The hyperactive child. Chicago: Saraf, K R., Klein, 0. P., GittelmanKlein. A., & Nelson-Hall, 1974. Groff, S. Imipramine side effects in children. Reynolds, E. H. Chronic antiepileptic toxicity: A Psychopharmacologia,1974, 37. 265-274. review. Epilepsia. 1975, 16. 319 -352. Safer, D. J.. & Allen, R. P. Factors influencing Reynolds, E H., Chadwick, D., & Galbraith, A. the suppressant effects of tv10 stimulant drugs Pediat- W, One drug (phenytoin) in the treatment of on the growth of hyperactive children. epilepsy. Lancet, 1976, 7966, 923-926. rics, 1973. 51, 664-667. (a) Richens, A. Drug interactions in epilepsy. Devel- Safer. D. J., & Allen, A. P., Single daily dose opmental Medicine and Child Neurology, methylphenidate in hyperactive children. Dis- 325- 1975, 17, 94-95. eases of the Nervous System, 1973, 34, Riddle. D., & Rapoport, J. A 2-year follow-up of 328, (b) 72 hyperactive boys. Journal of Nervous and Safer, D. J., & Allen, R. P. Stimulant drug treat- of Mental Disease, 1976, 162, 126-133. ment of hyperactive adolescents. Diseases Rimland, B. The differentiation of childhood psy- the Nervous System. 1975, 36, 454-457. choses: An analysis of 2218 psychoCcchil- Safer, D. J., & Allen. R. P. Hyperactive children: dren. Journal of Autism and ChildhoodSchiz- Diagnosis and management. Baltimore: Uni- ophrenia, 1971, 1, 161-174. versity Park Press, 1976, Rimland, B., Callaway. E.. & Dreyfus. P.The ef- Safer, D., Allen, R., & Barr, E. Growth rebound fects of high doses of vitamin B6 onautistic after termination of stimulant drugs. Pediat- children: A double-blind crossover study. rics, 1975, 86, 113-116, American Journal of Psychiatry, 1976,135, Schain, R, J. Problems in the use ofanticonvul- 472-475. sant drugs in the mentally retarded.Paper Robison, D. S., & Barker. E. Tricyclicantidepres- presented at the Workshop onPsychotropic sant cardiotoxicity. Journal ofthe American Drugs and the Mentally Retarded atthe meet- Medical Association, 1976, 236,2089-2090. ing of the American Association onMental De- Robinson. N. M. & Robinson, H. B. Thementally ficiency, Penland, Oregon, May 1975. 1976. retarded child. New York: McGraw-Hill. Schain, R. J., & Reynard. C. L. Observations on Overall, J.E., & Roche, A. F., Lipman, R. S., effects of central stimulant drug(methylpheni- medication Hung, W. The effects of stimulant date) in children with hyperactivebehavior. children. F. -di- on the growth of hyperkinetic Pediatrics, 1975, 65, 709-716. atrics, in press. M., Lewis, R., & Schleifer, M., Weiss, G Cohen, N.. Elman, Rodin, E. A., Rim, C. S., Kitano, H., Cvejic, H. & Kruger, E. Hyperactivity in pre- Rennick, P. M. A comparison of theeffective- carbamarepine in schoolers and the effect of methylphenidate. ness of primicione versus American Journal of Orthopsychiatry,1975, epileptic outpatients. Journal of Nervousand 45, 38-50. Mental Disease, 1976, 163, 41-46. in an Rose, S. W., Penry, J. K,, Markush, R. E.,Rad- Sewell, J., & Werry, J, S. Some studies Unpub- toff, L. A., & Putnam, P. L. Prevalenceof epi- institution for the mentally retarded. lepsy in children. Epilepsia, 1973, 14,133- lished manuscript, 1976. Shorvon, S. D., & Reynolds, E. H.Unnecessary 152. REFERENCES/97

polypharmacy for epilepsy.British Medical stimulant drugs in children, The Hague: Ex- Journal, 1977. 1.1635-1637. cerpta Modica, 1974. Signore. J. M. Ketogenic diet containing me- Sprague. P. L.. & Gadow. K. D. The role of the dium-chain triglycerides. Journal of the Amer- teacher in drug treatment. School Review, loan Dietetic Association, 1973. 62, 285-290, 1978. 8f109-140. Silverman. M., & Lee, P. R. Pills. pror.its, and pol- Sprague. R. L., & Gadow. K. D. (Eds.). Drug itics. Berkeley: University of California Press, therapy With children: An inservice training 1974. manual for teachers. Reston VA: The Council Slater. E., & Cowie. V. ThE. (7erieties of mental for Exceptional Children, 1977. Manual pre- disorders. London: Oxford University Press, pared for CEC's Training Institute Series in 1971, Early Childhood Education, Drug Therapy with Sleator, E. K. Personal communication. March Children. 816. 13. 1978. Sprague. R. L.. & Sleator. E. K. Effects of psy- Sleator. E. K.. & Sprague. R. L. Pediatric phar- chopharmacologic agents on learning disor- macotherapy. In W. G. Clark & J. del r3uidice ders. Pediatric Clinics of North America, 1973. (Eds.). Principles of psychopharmacology (2nd 20. 719-735. ed.). New York: Academic Press, 1978. Sprague, R. L., & Sleator. E. K. What is the Sleator. E. K., & von Neumann. A. Methylpheni- proper dose of stimulant drugs in children? In- dale in the treatrnent of hyperkinetic children. ternational Journal of Mental Health. 1975. 4, Clinical Pediatrics, 1974, 13, 19-24. 75-104. Sleator. E. K.. von Neumann, A. W.. & Sprague, Sprague. R. L.. & Sleator, E. K. Drugs and dos- R. L. Hyperactive children: A continuous long- ages: Implications for learning disabilities. In term placebo controlled follow-up. Journal Of R. M. Knights & D. J. Bakker (Eds.). Neuro- the American Medical Association 1974.229, psychology of learning disorders: Theoretical 318-317. approaches. Baltimore: University Park Press. Solomons, G. Drug therapy: Initiation and follow- 1976. up. Annals of the New York Academy of Sci- Sprague, R. L.. & Sleator, E. K. Methylphenidate ences, 1973, 205. 335-344. hyperkinetic children: Differences in dose Sonnenreich, M. R.. & Monger. J. M. State sub- effects on learning and social behavior. Sci- stitution laws: A lawyer's view. U.S.Phar- ence. 1977. 198, 1274 =1276. macist, April 1977, pp. 18-23. Sprague. R. L., & Werry. J. S. Methodology of Sprague. R. L. Overview of psychopharmacol- psychopharmacological studies with the re- ogy for the retarded in the United States. In P. tarded. In N. R. Ellis (Ed.), International review Mittler (Ed.). Research to practice in mental of research in mental retardation (Vol. 5). New retardation (Vol. III). Baltimore: University Park York: Academic Press. 1971. Press. 1977. (a) Sprague, R.L.. & Werry, J.S. Psychotropic Sprague. R. L. Psychopharmacotherapy in chil- drugs and handicapped children. In L. Mann & dren. In M. F. McMillan & S. Henao (Eds.), D. A. Sabatino (Eds.), The second review of Child psychiatry: Treatment and research. New special education. Philadelphia: JSE Press. York: Brunner/Mazel, 1977. (b) 1974. Sprague. IR L. Principles of clinical drug trials. In Stewart, M. A. Treatment of bedwetting. Journa J. S. Werry (Ed.), Pediatric psychopharma- of the Arlerican Medical Association, 1975, cology: The use of behavior modifying drugs 232, 281-283. in children. New York: Brunner/Mazel, 1978. Stewart, M. A.. & Olds, S. W. Raising a hyper- Sprague, R. L.. & Berger. B. D. Drug effects on active child. New York: Harper & Row. 1973. learning performance: Relevance of animal re- Stores, G. Behavioral effects of anti-epileptic search to pediatric psychopharmacology. In R. drugs. Developmental Medicine and Child M. Knights & D. J. Bakker (Eds.). Rehabilita- Neurology, 1975. 17, 647868, tion, treatment and management of learning Stores, G. Antiepileptios (anliconvulsants). In J. disorders. Baltimore: University Park Press, in S. Werry (Ed.). Pediatric psychopharmacol- press. ogy: The use of behavior modifying drugs in Sprague. R. L., Christensen, D. E.. & Worry, J. children. New York: Brunner/Mazel. 1978. S.Experimental psychology and stimulant Swanson, J., Kinsbourne. M., Roberts, W.. & drugs. In C. K. Conners (Ed.), Clinical use of Zucker. K. Time-response analysis of the ef- 98/CHILDREN ON MEDICATION Weiss. G. Kruger. E.. Danielson. U.. &Elman, red of stimulant medication on the learning M. Effect of long-term treatment of hyperactive ability of children referred for hyperactivity.Pe- Canadian diatrics, 1978, 61, 21-29. childrenwithmethylphenidate. Medical Association Journal. 1975, 112, 159- Tecce, J. J. & Cole, J, 0. Amphetamineeffects in man: Paradoxical drowsiness andlowered '165, Weiss. G., Mind& K., Worry, J. S.. Douglas, V., electrical brain activity (CNV). Science,1974, & Nemeth. E. Studies on the hyperactivechild 185, 451-453. VIII: Five-year follow-up. Archives ofGeneral Thompson. T., & Grabowski, J. (Eds.). Behavior modification of the mentally retarded (2nd ed.). Psychiatry, 1971. 24, 409-414. Wender, P. H. Minimal brain dysfunction in chil- New York: Oxjrd University Press, 1977. 1971. Thorn, I. A controlled study of prophylactic long dren. New York: Wiley-lnterscience, term treatment of febrile convulsionswith phe- Wender, P. Paper presented at the NIMH Work- noharbital. Acta Neurologica Scandinavica shop on Hyperkinesis. Washington. DC, June Supplernentum, 1975, 60, 6773. 15-16. 1978. Worry, J. S. Emotional factors and enuresis noc- Turner. W. D.. & Carl. G. P. Temporarychanges turna. Developmental Medicine and Child in affect and attitude followingingestion of various amounts of benzedrine sulfate (amphet- Neurology, 1965. 7, 563-565, amine sulfate). Journal ofPsychology. 1939. Worry, J. S. (Ed.). Pediatric psychopharmacology: The use of behavior modifyingdrugs in 8, 415-482. children. New York: Brunner/Mazel, 1978. Usdin, E. Classification ofpsychopharmaca. In Worry. J. S., & Amen. M. G. Methylphenidate W. G. Clark & J. del Guidice (Eds.),Principles and haloperidol in children. Archives ofGen- of psychopharmacology. NewYork: Aca- eral Psychiatry, 1975, 32, 790-795. demic Press. 1970. Usdin, E., & Efron, D. H. Psychotropic drugs Worry. J. S.. & Sprague, R. L.Methylphenidate and related compounds (2nd ed.. DHEW in childrenEffect of dosage. Australian and 1974. 8, Publication No. 72-9074). Washington DC: US New Zealand Journal of Psychiatry, Government Printing Office, 1972. Vessell, E.. & Page. J. Genetic control of drug Whalen. C. K.. & Henker, B. Psychostimulants Psycho- levels in man: Antipyririe. Science. 1958, 161. and children: A review and analysis. 72-73. logical Bulletin, 1976, 83, 1113-1130. Wade. M. G. Effects of methylphenidate on mo- Williams. D. L., & Jaffa, E. B. Ice cream, poker torskillacquisition of hyperactive children. chips, and very goods: A behavior modifica- MD: Journal of Learning Disabilities. 1976, 9, 443- tion manual for parents. College Park 447. Maryland Book Exchange. 1971, Walker, S. Drugging the American child: Were Williams. J.I., Cram. D. M., Tausig, F.T., & too cavalier about hyperactivity. Psychology Webster, E. Relative effects of drugs and diet Today, December 1974, pp. 43-48. on hyperactive behaviors: Anexperimental Walsh, G, O. Unusual presentations of epilep- study. Pediatrics, 1978, 61, 811-817. sies, Pediatrics, 1974, 53, 548-551. Wilson, J. Drug treatment of epilepsy in child- Weiss, B., & Laties, V. G. Enhancement of hu- hood. British Medical Journal, 1969, 4, 475- man performance by caffeine andthe amphet- 477, amines. Pharmacological Reviews, 1962. 14, Winchell, C. A. The hyperkinetic child: A bibli- 1-36. ography of medical, educational, and behav- Weiss, G., Hechtman, L., & Perlman,T. Hyper- ioral studies. Westport, CT: Greenwood Press, actives as young adults: School,employer and 1975. 10 year fol- self rating scales obtained during a Winsberg, B. G.. & Yepes, L. E. Antipsychotics. Ortho- low-up evaluation. American Journal of In J. S. Werry (Ed.), Pediatric psychophar- psychiatry, 1978, 48, 438-445. macology: The use of behavior modifying Hopkins, Weiss, G.. Hechtman, L., Perlman. T.. drugs in children. New York: Brunner/Mazel, J.. & Werner, A. Hyperactive children as young 1978. adults: A controlled prospective 10 yearfellow- Winsberg, B. G., Yepes, L. E., & Bia,ler. I. Phar- up of the psychiatric status of75 hyperactive macologic. management of children withhy- children. Archives of GeneralPsychiatry. in peractive/aggressive/inattentive behavior dis- press. REFERENCES/99

orders. Clinical Pediatrics,1976,15, 471- Wulff,K..Flacks, H., Wurtz-Jorgensen. A., & ,177: Gram, L. Clinical pharmacological aspects of Wolf, S. M. Effectiveness of daily phenobarbital valproate sodium. Epilepsia, 1977, 18, 149- in the prevention of febrile seizure recurrences 158. in "simple" febrile convulsions and "epilepsy Wyatt v. Stickney. 344 F. Supp. 387 (1972). triggered by lever." Epilepsia, 1977, 18, 95- Zbinden, G. Experimental and clinical aspects of 99. drug toxicity.In S. Cara & P. A. Shore Wolf, S. M., Carr, A., Davis, D. C., Davidson, S., (Eds.), Advances in pharmacology (Vol. 2). Dale, E. P., Forsythe, A., Goldenberg, E. D., New York: Academic Press. 1963. Hanson, R., Lulejian. G. A., Nelson, M, A., Treitman, P., & Weinstein, A. The value of Zentall, S. S. Environmental stimulation model: phenobarbital in the child who has had a single Exceptional Children, 1977, 43, 502-510. febrile seizure: A controlled prospective study. Zimmerman, F. T., & Burgemeister. B. B. A new Pediatrics, 1977, 89, 378-385. drug for petit mal epilepsy. Neurology, 1958, Wolf, S. M.. & Forsythe, A. Behavior disturbance, 8. 789-775. phenobarbital. and febrile seizures. Pediat- rics, 1978, 61, 728-731. Ziutnick, S., Mayville, W. & Moffat, S. Modifi- Woodbury. D. M.. Penry, J. K.. & Schmidt. R. P. cation of seizure disorders: The interruption of (Eds.). Antiepileptic drugs. New York: Raven behavioral chains. Journal of Applied Behav- Press, 1972. ior Analysis. 1975, 8, 1-12.

u Glossary

Abbreviated Teacher Rating Scale: a short- agitated: motor restlessness and increased ac- ened. 10 item version of Conners' 39 Item tivity level in association with anxiety and ten- Teacher Rating Scale (see Apendix E3), sion. abdominal epilepsy: same as autonomicepi- agitation: motor restlessness associatedwith lepsy. mental distress, aberrant: behavior that deviates markedly from akathisia: characterized by motor restlessness what is considered normal, arising from a compulsion to move about; an absence seizure: same as petit mal seizure. extrapyramidal syndrome produced by anti- absorption: the process whereby a substance is psychotic drugs. taken into or across tissues. e.g.. Intestine, the akinetic: cessation of movement, movement of a drug into the bloodstream. akinetic seizure: a term used inconsistently in ACTH: adrenocorticotropic hormone. the literature to refer to the seizures associ- acute: having a sudden onset and shortdura- ated with the Lennox-Gastaut syndrome; head tion. nodding spells. The seizures are brief and typ- acute dystonic reaction: characterized by un- ically consist of a sudden, violent jerk, either controlled muscle activity with stiffnessor forward or backward. If standing the associ- twisting of body parts; possible reactions in- ated fall may cause severe, repeated head include facial grimacing; torticollis, which may jury. Defined by The International League be associated with oculogyric crisis; and opis- Against Epilepsy as "loss of movement with- thotonos. A side effect of antipsychotic drugs out atonia" (Gastaut. 1970). occasionally seen with the initiation of treat- ambulatory: able to walk. anemia: below normal number of red blood cells, ment. adaptive: having a capacity for modification tofit amount of hemoglobin. or total drug volume. the demands of the environment. anorexia: a lack or loss of appetite for food. adrenocorticotropic hormone: a hormone se- anoxia: absence or loss of oxygen. ,creted by the anterior lobe of the pituitary antianxiety drug: same as minor tranquilizer. gland which controls the secretion of aelreno- antichollnergic: an agent that alters the effect cortical hormones by the adrenal cortices, cor- of acetylcholine in cholinergic synapses; anti- ticotropin; ACTH. cholinergic drugs are used in the management adverse reaction: same as side effect. of some extrapyramidal syndromes produced affective: pertaining to feelings or emotions. by antipsychotic drugs. affective disorders: characterized by changes anticonvulsant: an agent that reduces the fre- in mood as the primary symptoms, e.g., mania, quency, magnitude. or duration of convulsions depression. or seizures; antiepileptic,

100 GLOSSARY/ 101 antidepressant: an agent that prevents or sup- bolic learning processes, e.g., modeling, is presses the symptoms of depression: mood also recognized. l manner-it conditions ire ex- elevating. plicitly stated drill therapeutic outcomes are antieplleptic: an agent that reduces the fre- measured objectively. quency. magnitude, or duration of convulsions behavior therapy: same as behavior modifica- or seizures, anticonvulsant. tion. antipsychotic: an agent that prevents or sup- benign: having a favorable outcome; not recur- presses the symptoms of psychosis; major ring, tranquilizer, neuroleptic. benzodiazepines: a categoryofantianxiety anxiety: a feeling of uneasiness, apprehension. agents (minor tranquilizers) which includes di- and fear over an anticipated experience. azepam (Valium), chlordiazepoxide (Librium), ataxia: failure of voluntary muscle coordination; and clonazepam (Clonopin). gait ataxia: a staggered walk with a wide bilateral: pertaining to both sides. base. biotransformation: the chemical alteration of a athetosis:characterized byslow,writhing compound within the body, e.g the metabo- movements of peripheral parts of the body. lism of a drug by liver rnicroenzyrnes. atonic: loss of normal tone; atonic seizure: pa- blood brain barrier: refers not to an anatomical tient suddenly crumples and falls to the floor. structure but to the fact that the capillaries of muscles remain flaccid during the seizure. the brain prevent certain classes of com- AIRS: Abbrebiated Teacher Rating Scale. pounds from entering and affecting brain neu- atypical febrile convulsion: epileptic convul- rones. A closeknit layer of glial cells surrounds sion in association with a fever illess. the brain capillaries creating an additional bar- aura: a warning that precedes an epileptic sei- rier for compounds which are not lipid soluble. zure often manifest as a sensation or motor brand name: same as trade name. movement. butyrophenones: a category of antipsychotic autism: a subjective, self centered form of think- agents (major tranquilizers) which includes ing that is not correctable with information from haloperidol (Haldol). external reality. automatisms: seemingly puposeful involuntary cardiovascular: pertaining to the heart and blood behavior that is out of context: a manifestation vessels. of psychomotor epilepsy; simple automa- central nervous system: consisting of the brain tisms: repetitive smacking of lips, chewing, and spinal cord. mumbling; complex aUtornatisms: undress- cerebral palsy: a variety of syndromes, charac- ing, walking about. terized by a disorganization of motor control, autonomic nervous system: the part of the that are the result of damage to the motor nervous system that regulates the muscles of areas of the brain. the heart, smooth muscles, and glands. chorea: characterized by continuous, random, autonomic epilepsy: an uncommon form of uncontrolled contractions of different muscle epilepsy in which seizures may be manifest as groups. gastrointestinal disturbances (abdominal pain, chronic: persisting over a long period of time vomiting, nausea, etc.), headache, or other °Ionic: pertaining to a series of alternate muscle symptoms of autonomic dysfunction; thalamic contractions and relaxations. epilepsy_ , abdominal epilepsy, epileptic equiv- coarse facies: marked by swelling of the lips, alent, thickening of the subcutaneous tissue of the face and scalp, and broadening of the nose; behavior modification: a treatment approach adverse reaction associated with phenytoin based on a model that views abnormal behav- (Dilantin) treatment. ior as being acquired in response to environ- cognitive performance: performance on a mental stress and learned and maintained in specified task generally regarded to measure the same manner as normal behavior. The perception, thinking, and remembering. principles of experimental psychology are em- colic: acute abdominal pain. phasized, particularly classical and operant combined drug regimen: the simultaneous conditioning. The importance of the cognitive treatment of two or more disorders differ- mediation of behavior and vicarious and sym- ent drugs.

I u 102ICHILDREN ON MEDICATION

concomitant: accompanying; joined with an- drug interaction: the modification of theeffects other. of a drug by the prior or concurrent administra- convulsion: a violent and involuntary contraction of another drug. tion or series of contractions of the voluntary drug of (first) choice: the agent to beadminis- muscles, tered first in the treatment of a specific disor- convulsive disorder: recurrent seizures; epi- der. usually determined on the basis of safety lepsy. and efficacy. convulsive threshold: the point at which a stim- dysarthria: imperfect articulationof speech; ulus.e.g., electrical discharge, produces a slurred speech. convulsion or seizure. dyskinesia: fragmentary or incomplete move- corticotropin: same as adreocorticotropic hor- ments that result from a diminished powerto mone. control voluntary movements. dystonia: disordered muscle tone. dein stitutionalization: the transfer of individuals (e.g., mentally retarded. mentally ill) from early infantile autism: a rare disorderwith on- institutional or residental care to community set during early infancy and characterizedby placements (e.g.,half way houses. group autistic aloneness, absence of language or homes). developmental language disorders, insistence delusions: a false belief that cannot be changed on sameness, repetitive behaviors,and lack of by reason or evidence from the patient's own demonstrable physical defect. senses. echolalia: the reptition of words spoken by other depression: a psychiatric disorder character- people as if echoing what is said. ized by feelings of personal incompetence, edema: swelling resulting from an accumulation listlessness, insomnia, loss of appetite, and of fluid in subcutaneous tissues. psychomotor slowing. educable mentally retarded: an educational dermatitis: inflammation of the skin. classification for children whose 10's range diphenylniethanes: a category of antianxiety from 50 or 55 to 75 or 80. agents (minor tranquilizers) which includes hy- EEG: electroencephalogram. droxyzine hydrochloride (Atarax) and hydroxy- efficacy: effectiveness. zre panioate (Vistaril). electroencephalogram: a recording of the elec- the diplopia: double vision. trical current spontaneously generated by distribution: the movement of drug molecules in cells in the brain. the bloodstream to the site of drug action; con- EMR: educable mentally retarded. centration of drug molecules in body compart- endocrine system: the glands and structures ments, that produce hormones which arereleased diuretic: an agent that promotes the secretion of into the blood. urine. endoplasmic reticulum: ultramicrosc:loic net- dose: amount of medication administered. work of tubules and cavities within alriost all double blind: characterizing a study of a partic- cells; microenzymes in the endoplasmic ular treatment, e.g., drug, in which neither the ulum of liver cells break drugs down into II,' person administering (evaluating) orreceiving tabolites that are more easily removed from the agent is aware of whether the active or in- the body_ . active (placebo) drug is being given. enuresis: involuntary discharge of urine. drug: any substance other than food that has an enzyme: a protein that bringsabout or acceler- effect on living tissue. ates chemical reactions. drug addiction: "A behavioral pattern of com- epidemiology: the study of the factors thatinflu- pulsive drug use, characterized by overwhelm- ence the Incidence, distribution,and control of irsg involvement with the use of a drug, the se- disease. curing of its supply, and a high tendency to re- epilepsy: recurrent seizures that are due tosud- lapse after withdrawal" (Jaffe, 1975, p. 285). den electrical discharges in thebrain. drug tree period: a break in a chronic drug reg- epileptic equivalent: same as autonomic epi- imen fora period of time during which no med- lepsy. ioation is administered; drug holiday, drug holiday: same as drug free period. epileptic seizure precipitated by fever: form GLOSSARY/ 103

epilepsy characterized by seizures that are by tics. particularly of the facial muscles, and triggered by a fever illness. involuntary vocalizations. equilibrium: a state of balance between two op- gingival hyperplasia: an excessive growth of posing forces. gum tissue with a mulberry shaped appear- etiology: the causes of a disease; the study of ance. Irritants lodged in the tissue cause sec- the factors that cause disease. ondary inflammation resulting in a red or bluish- exacerbate: to make more severe or violent. red discoloration. This is an adverse reaction excretion: the elimination or discharge of sub- commonly associated with phenytoin (Dilan- stances, e.g.. wastes. rnetabolites. from the tin). cell, tissue. and blood; drugs are often ex- gonadotropic hormones: Three hormones se- creted as water soluble metabolites by the kid- creted by them anterior pituitary that have an in- ney. fluerte on the ovaries and testes extensor: a muscle that extends a joint. grand mal epilepsy: characterized by periodic extracellular fluid: fluid outside the cell. attacks of unconsciousness and generalized extrapyramidal syndromes: a group of disor- tonic and clonic movements frequently lasting ders characterized by abnormal involuntary from 3 to 5 minutes. Interseizure EEG findings movements. Extrapyramidal syndromes pro- may be normal and seizures can begin at any duced by antipsychotic drugs include parkin- age. Generalized seizures fall into four catgo- sonian syndrome, akathisia, acute dystonic re- ries: Tonic-clonic. clonic. tonic, and atonic. action. and tardive dyskinesia. growth rebound: an increase in growth rate fol- extrapyramidal tract: not an anatomical struc- lowing the cessation of stimulant drug treat- ture. but a group of nuclei (a nucleus is a mass ment in hyperactive children. of nerve cells) and fibers that control and coordinate motor activities. especially gross in- hallucination: perception of an object in the ab. tentional movements, patterns of movement. sence of corresponding stimuli. walkingmovements. and-background" hallucinogens: a category of psychotropic drugs muscle tone. capable of inducing hallucinations. hirsutism: abnormal hairiness; an adverse drug FDA: Food and Drug Administration. reaction associated with phenytoin (Dilantin) febrile: relating to or characterized by fever. therapy. Feingold diet: same as Kaiser-Permanente diet. hydantoinates: a category of antiepileptic drugs flexor: any muscle that bends a joint. with potent anticonvulsant properties that in- focal epilepsy: characterized by seizures asso- cludes phenytoin (Dilantin), niephentoin (Mes- ciated with an abnormal electrical discharge antoin). and etholoin (Peganone). originating in. or restricted to. a limited area of hyperactivity: a long term, persistent behavior the brain. disorder characterized by excessive restless- folic acid: substance used by the bone marrow ness and inattentiveness originating during to form red blood cells. early to middle childhood (2 to 6 years of age). hypertonicity: characterized by excessive skel- gastrointestinal: pertaining to the stomach and etal muscle tone: the muscle is more resistant intestines, to passive stretching. generalized seizures: seizures associated with hypnotic: a category of psychotropic drugs that abnormal electrical discharges that affect the induce sleep. entire brain; they may be focal at the onset and hypotension: abnormally low blood pressure. spread to become generalized or be general- hypothalamic epilepsy: same as autonomic ized from the beginning. Grand mal. petit mal. epilepsy. and rnyoclonic seizures are all generalized hypsarythmia: an exceedingly abnormal elec- seizures. troencephalographic pattern between seizures generic name: a drug name. not protected by a characterized by random. high voltage slow patent.that identifies a specific chemical waves and spikes that originate from multiple structure; official name. nonproprietary name. foci and spread to all cortical areas. This EEG Gilles de la Tourette's syndrome: a rare dis- pattern is associated with myoclonio epilepsy order with an onset in childhood characterized of young children (infantile spasms. salaam /CHILDREN ON MEDICATION

seizures, massive rnyoclonia). Severe mental learning performance: performance on a spec- retardation is common. ifiedtask generally regarded to measure learning rather than a more pure measure of idiopathic: a disease of spontaneous origin or the neural events associated with learning. unknown cause, least restrictive alternative: handicapped chil- incidence: the number of new cases, e.g., of a dren. including children in public and private disease. during a certain period of tirne. institutions, are educated as much as possible infantile spasms: same as myoclonic epilepsy with children who are not handicapped. Sepa- of young children. rate schools, special classes, or other removal induce: tobring about by stimulation: of any handicapped child from the regular pro- educa- something to occur. gram is appropriate only if the regular insomnia: inability to sleep. tional environment accompanied by supple- intracellular fluid: fluid within the cell. mentary aids and services is not adequate to intractable: resistant to control. give the child what he or she needs- Lennox - Gastaut syndrome; one type of my- intramuscular: within the substance of theWI oclonic epilepsy characterized by several types intravenous: within a vein. of seizures including staring spells, rnyoclonic seizures (sudden violent jerks with an associ- in utero: within the uterus. Isle of Wight: island off the southern coast of ated fall, sudden falls without jerks, head nodding seizures, and sagging attacks (atonic sei- England. zures). and generalized tonic - clonic seizures, Age of onset is usually between 3 to 5 years of age. Mental and motor retardation are com- JacKsonian seizure: a focal seizure character- mon. Interseizure EEG findings often show !Zed by unilateral clonic movements that start modified hypsarhythmia (2 per second spike in one group of muscles moving systematically to adjacent groups of muscles. The seizures and wave). Also called petit mat variant, myoclonic epilepsy of older children, are due to an abnormal electricaldischarge that originates in. and spreads across, the mo- lipids: a group of substances, such as fatty acids, that cannot be dissolved in water. Lipids tor cortex, and jaundice: a syndrome characterized by an ex- are stored in the body_ , are used as fuel, cess of bile pigment in the blood and yellow are an important part of all living cells. appearance of the skin resulting from the dep- lipid soluble: capable of being dissolved in lip- osition of bile pigments in the skin; icterus. ids.

Kaiser-Permanente diet: a treatment regimen mainstreaming: an approach to the deliveryof for childhood behavior disorders, especially special education services that emphasizes hyperactivity, which involves the elimination of the integration of the handicapped childwith low molecular weight chemicals, e.g., salicy- nonhandicapped peers in regular classrooms lateS and artificial colors and additives, from as opposed to segregationin self contained daily food intake; K-P diet, Feingold diet. special classes. The educational needs of the ketogenic diet: a dietary regimen in which the child are met through modifications in the reg- total daily consumption of fat (in grams) is at ular school program. least four toes greater than proteins and car- major motor epilepsy: same as grandmal epi- bohydrates combined (in grams). This main- lepsy. tains the state of ketosis achieved by a marked major tranquilizer: a category of psychotropic reduction in food intake at the onset of treat- drugs that includes the phenothiazines, thioz- effective in treating rny- ment. The diet is anthenes. and butyrophenones; antipsychotic eclenic epilepsy in young children. agents, neuroleptics. These drugs areused kg: kilogram. primarily in the treatment of psychotic disor- kilogram: a unit of weight in the metric system ders. being 1000 grams; equivalent to approxi- rrtaladaptive: not promoting or assisting adv. mately 2.2 pounds. K-P diet: same as Kaiser-Permanente diet tation. GLOSSARY/105 malaise: an indefinite feeling of bodily discom- milliliter: a Metric unit of capacity being one fort or lack of health. one-thousandth of a liter. MAO inhibitor: same as rnonamine oxidase in- minimal brain dysfunction: a syndrome found hibitor. "in children Of near average, average, or above massive myoclonic seizures: Same as my- average general intelligence" and character- oclonic epilepsy of young children. ized by "learning or behavioral disabilities mcg: microgram, ranging from mild to severe. which are asso- p.cg: microgram, ciated with deviations of function of the central mcg /ml: microgram per milliliter. nervous system. These deviations may mani- ikcg/rnl: microgram per milliliter. fest themselves by various combinations of MGT: medium, chain triglycerides. impairment in perception. conceptualization, megavitamins: massive doses of vitamins. A language. memory, and control of attention, treatment of questionable efficacy for learning impulse, or motor function.." (Clements, disabilities, hyperactivity, adult psychosis. and 1966. p. 9-10), convulsions consisting of large doses of nia- minor tranquilizer: a category of psychotropic cin. niaCinerniole. ascorbic acid, pyridoxine. and drugs with sedative and antianxiety properties calcium pantothenate or other vitamins either which includes the benzodiazepines, propa- individually or in combination. Possibly effec- nediol carbamates. and hydroxyzine, tive in the treatment of childhood psychosis. mixed epilepsy: two or more different types of mental retardation: "Significantly subaverage epilepsy manifest at the same time. general intellectual functioning existing con- rni: milliliter. currently with deficitsin adaptive behavior. nionoarnine oxidase inhibitor: a category of and manifested during the developmental pe- antidepressant drugs that includes tranylcy- riod" (Grossman, 1973, p. 11). Classification premine ( Parnate) and phenelzine (Nardil). according to the severity of symptoms (l0 motor cortex: the area of the brain that controls score) is as follows: mild (55--69). moderate discrete movements of the skeletal muscles. (40-54). Severe (25-39). and profound (be- muscle tone: a slight degree of muscle tension low 25). The terms borderline, dull-normal, produced by continuous neural stimulation. and slow learning are occasionally used to re- rnutism: inability or refusal to speak. fer to children with la's from 75 to 89. myoclonic epilepsy: consists of several differ- metabolism: the sum of the processes in the ent types of epilepsy including myoclonic epi- building up and maintenance ofliving sub- lepsy of young children (infantile spasms. West stance and the production of energy for vital syndrome) and myoclonic epilepsy of elder activities; the sum of the processes by Which children (LennexGastaut Syndrome, petit mal the body transforms a substance. e.g., drug. variant), both of which appear to be the same metabolite: any substance produced by a met- disorder but with different age at onset of sei- abolic process. zures. Classification of the other types of my- mg: milligram. oclonic epilepsy is incomplete but includes rng/kg: milligram per kilogram. children and adolescents with myoclonic sei- microgram: a unit of weight in the metric system zures who do not Manifest the symptoms as- being one one - millionth of a gram or one one- sociated with infantile spasms or the Lennox- thousandth of a milligram. Gastaut syndrom& microsornal enzymes: enzymes within the cells myoclonic epilepsy of older children: same as of the liver that participate in the metabolism of Lennox-Gestaut syndrome. many drugs, rnypcionic epilepsy of young children: char- migraine: a condition marked by periodic at- acterized by brief (several seconds) myoclonic tacks of severe headaches often associated seizures that usually Occur in clusters lasting with nausea and vomiting. The attacks are several minutes and abnormal interseizure preceded by constriction of cranial arteries EEG findings called hypsarhythrnia. Onset of and begin with the dilation of the arteries. seizures is commonly between 3 and 9 months milligram: a unit of weight in the metric system of age. Severe mental retardation is common. being one one-thousandth of a grain; equiva- Also called infantile spasms, West syndrome. lent to approximately one twenty-eight thou- myoclonic seizure: flexor spasm of the muscu- sandth of an ounce. lature: extensor spasms much less common. 106 /CHILDREN ON MEDICATION

narcolepsy: a condition characterized by an un- parenteral: administration by a route other than controllable desire to sleep or periodic attacks- the digestive tract: any of several routes of in- of deep sleep. 1,ction including subcutaneous, intramuscular, neuroleptic: same as antipsychotic agent. and intravenous. neuropharmacology: the branch of pharmacol- pathognomonic: characteristic of a disease; a ogy that investigates the effects of drugs on sign or symptom that is used to make a deg- the nervous system. nosise nocturnal: pertaining to night. pathology: the study of the structural and func- nonproprietary name: same as generic name. tional changes in tissues and organs of the nystagrnus; a rapid involuntary movement of body that are caused by disease; deviations the eyeball either horizontally. vertically. or in from the normal that characterize disease. pediatric psychopharmacology; the branch of a rotatory manner, pharmacology that investigates the behavioral logyric crisis: fixed upward gaze; a symp- effects of drugs in children. tom associated with acute dystonic reaction, petit mat epilepsy: characterized by periodic at- an extrapyramidal syndrome produced by tacks of altered consciousness usually lasting some antipsychotic drugs. from 5 to 30 seconds. The seizure is manifest official name: same as generic name. as a sudden cessation of movementand va- opiates: a group of drugs consisting of opium cant staring into space. In some children the be and its derivatives. eyes roll back into the head. Seizures may opisthotonos: a type of Muscle spasm in which associated with brief clonic movements that the back is arched, head and heels are bent usually recur at a frequency of 3 per second or backward, and the body bowed forward. autornatisms. An EEG finding of 3 per second organic: pertaining to, or arising from, the or- spike-wave forms is pathogromonic of petit gans; affecting the structure of anorganism, mal epilepsy. organic epilepsy: epilepsy that develops sub- petit mat variant: same as Lennox-Gastaut syn- sequent to permanent. nonprogressive dam- drome. age to the brain. e.g., head trauma. brainin- pharmacology: the science that deals with the chemical properties. biochemical and physio- fections. orthopedic: pertaining to the correction of mus- logicaleffects, absorption, distribution,bio- culoskeletal detorrnaties; marked by crippling. transformation, excretion and therapeutic uses orthostatic hypotension: weakness or fainting of drugs. on rising to an erect position, pharrnacotherapy: the treatment of disease with ornalacia: a Condition that results from vi- medicines. tamin D and calcium deficiency characterized phenothiarines: a group of antipsychotic drugs by softening of the bones, pain, anorexia, and which includes chlorpromazine (Thorazi ne) and muscular weakness, thioridazine (Mellen°. oxazolidinediones: a category of antiepileptic phobia; a persistent abnormal tear, drugs that includes tomethadione (Tridione) photophobia: abnormal intolerance to light. photosensitivity: abnormal reaction of the skin and paramethadione (Paradione). to sunlight. panic anxiety: a psychiatric disorder character- pigmentation: an abnormal increase of colora- ized by recurrent and unexplained panic at- tion by melanin. tacks with feelings of impending doom. The pill rolling: as if rolling a pill between the fingers: attacks may be associated withphysical a symptom of parkinsonian syndrome. symptoms such as breathing difficulties or heart placebo: an inactive medication administered to satisfy a patient's need for drug therapy; an palpitations. parkinsonian Syndrome: an extrapyramidal inert substance used to control for expectancy syndrome characterizedby psychomotor effects in pharmacological research; a proce- slowing, masklike facial expression, shuffling dure with no intrinsic therapeutic value. gait without free swing of the arms,rigidity, polypharrnacy: the simultaneous administration and tremor."Pillrolling- movements may of two or more drugs for the same disorder. post convulsive phenomena: disturbances fol- also be present. An adverse reactionassoci- lowing the active stages of a seizure including ated with antipsychotic drug therapy. GLOSSARY/1 07

weakness. nausea, fatigue, muscle soreness, relapse: a return of a disease after it apparently headache, irritability, confusion, and abnormal ceased. behavior, remission: the lessening or cessation of the post convulsive sleep: period of deep sleep fol- symptoms of a disease. lowing a seizure. rickets: a condition that results from vitamin D prevalence: total number of cases in a specific deficiency characterized by bending or distor- area during a certain period of time. tion of the bones. prolonged seizure: an individual seizure lasting for an uncharacteristically long time. salicylates: a group of drugs with analgesic, fe- propanediols: a group of antianxiety agents that ver reducing, and anti-inflammatory proper- includes meprobamate (Equanil. Miltown); ties, e.g., aspirin. propanediol carbamates. schizophrenia: a psychotic disorder character- prophylaxis: preventive treatment. ized by emotional distortion, ambivalence, dis- proteins: any one of a group of complex come turbances of thought. retreat from reality, de- pounds consisting of a combination of amino lusions,hallucinations. and withdrawnor acids: the principal constituents of all living bizarre behavior, cells, secondary epilepsy: same as organic epilepsy. psychic seizures: a type of psychomotor sei- sedative: a category of psychotropic drugs that zure manifest as changes in perception, reduce excitement and have a calming effect, thought, self awareness, mood, or affect. seizure: a sudden attack; fit. Epileptic seizure: psychonoter: relating to muscular actions re- a loss or alteration of consciousness associ- suiting from conscious mental activity. ated with involuntary muscle movement (or psychomotor epilepsy: characterized by peri- cessation of movement) and abnormal electri- odic attacks of altered consciousness lasting cal discharges in the brain; convulsion, spell, frorr one to several minutes. Seizures may be fit. manifest as a cessation of movement starting self limiting: limited by its own nature and not with or without autoMatisms or as changes in by outside influences. Self limiting side effects perception, thought, self awareness, mood, or run a limited course and terminate on their affect. EEG findings usually show interseizure own. temporal lobe abnormalities. Also called tem- separation anxiety: apprehension resulting from poral lobe epilepsy. loss of contact with significant persons or fa- psychomotor slowing: manifest as an inability miliar surroundings; common in infants 6 to 10 to respond spontaneously at a normal speed, months old. weak voice and labored speech, deliberate serial grand mat (major motor) seizures: char- body movements, fixed facial expression, and acterized by recurrent grand mal seizures dur- a slowed, dragging walk. ing which the person regains consciousness psychopathology: mental disorders; the study between attacks; frequently associated with of such dysfunctions. the abrupt withdrawal of anticonvulsant medi- psychopharrnacology the branch of pharma-- cation, cology that investigates the effects of drugs on side effect: a consequence other than that for behavior. which an agent or treatment is being used; ad- psychosis: a general term for any severe men verse reaction, toxic effects, untoward reac- tat disorder involving a loss of contact with tion. reality and usually associated with delusions, simple febrile seizure: a benign. noneoileptic hallucinations, or illusions. disorder characterized by brief generalized psychotropic drug: any agent that has its prin- seizures that occur usually 2 to 6 hours after cipal effect on mood, thought processes, or the onset of a fever. The disorder rarely lasts behavior; behavior modifying drug. beyond 6 years of age, rebound effect: reaction to the withdrawal of spasm: a sudden and involuntary muscle con- medication that may be manifest as an aggra- traction. vation of the symptoms of the disorder being spasticity: increase over normal muscle tone; treated. hypertonicity. refractory: unresponsive to treatment. sphincter: a muscle that forms a ring around a 108/ CHILDREN ON MEDICATION

body opening, e.g., urethra. and preventspas- drug. The initial dose, usually too small to pro- gradually in- sage via constriction. duce a therapeutic response, is spontaneous: occuring without externalinflu- creased over time until the desired effect is achieved or unacceptable adverse reactions ence; voluntary. status epilepticus: a series of seizuresin appear. Succession during which the persondoes not TMR: trainable mentally retarded. ef- regain consciousness betweenattacks; usu- tolerance: a lessened susceptability to the fects of the same dose of a drug over repeated ally refers to grand mal status. status seizere: a series of recurringseizures administrations. The during which the patient does not regain con- tonic: characterized by continuous tension. eciousness between seizures. tonic phase of a grand mal seizure is marked stereotyped behavior: repetitive and oftenbi- by boardlike rigidity, zarre motor movements such asrhythmic torticollis: characterized by contracted cervical rocking, head weaving, hand or arm flapping. muscles resulting in a twisting of the neck and and rubbing parts of the body; stereotypies, unnatural positioeing of the head. A symptom stereotypies: same as stereotyped behavior. of an acute dystonic reaction, an extrapyrarni- stiortilen a category of psychotropic drugsthat dal syndrome associated with antipsychotic includes ,methylphenidate (Rita lin), dextroam- drugs. ehetarrine (Dexedrine) and pemoline(Cy lert). toxic: poisonous; causing disturbance of body subcutaneous: beneath the skin. function or structural damage to organs and succlnirnldes: a category of antiepilepticdrugs tissues. particularly effective in the treatment ofpetit toxic reaction: same as side effect. mat epilepsy that includes ethosuximide(Za- trade name: a brand name protected by trade- rontie). methsuximide (Celontin). andphen- mark laws which restrict use to the original copyright holder indefinitely; nonproprietary suxirnide (Milontin). of a symptomatic epilepsy: seizures are oneof the name, unofficial name. The trade name symptoms of a specific disorder thatinvolves drug refers to a particular formulation of a generic drug made by a specific manufacturer, the brain. e.g.. cerebral generativedisease. syndrome: a set of symptoms that occur to- trainable mentally retarded: an educational gether and characterize a specific disorder. classification for children whose IQ's range from 25 or 35 to 50 or 55. tardive elyakinesite a late appearing extrapyr- trauma: a wound or injury. arnidal syndrome characterized byinvolun- tremor: an involuntary trembling or shaking. tricyctics: a category of antidepressant drugs tary. repetitive movements usuallyin the re- gion of the mouth but may involvethe limbs that includes imiprarnine (Tofran11). amitripty- and trunk as well. Movementsinclude tongue line (Elavil), and nortriptyline (Aventyl). protrusion, licking or smacking of the lips,side to side movements of the chin.blJwing of the unilateral: affecting but one side. blinking. A untoward reaction: same as side effect. cheeks, facial grimacing, and eye urticaria: a skin reaction marked by patches of drug side effect of long term antipsychotic skin either redder or paler than the surround- treatment. ing skin, usually associated with severe itch- temporal lobe epilepsy: same as psychomotor ing, and often caused by emotional stress or epilepsy. certain foods, drugs, or infections; hives. thlozarithenes: a category of antipsychotic vitamin D: a substance that greatly accelerates (Tarac- agents that includes chlorprothixene the absorb ion of calcium from the gut. tan) and thiothixene (Navane). water soluble: capable of being dissolvedin teratogen: a Substance that causes physical de- water. fects in the developing embryo. withdrawal syndrome: characteristic symptoms tie: spasmodic movement of a muscle; atwitCh- associated with the withdrawal of a specific ing movement especially of a facial muscle. drug. titration: a method for determining the strength of a solution or the concentration of asub- REFERENCES (25th stance in solution; used metaphoricallyto de- Dorland's Illustrated Medical Dictionary scribe a procedure for adjusting the doseof a ed.). Philadelphia: Saunders, 1974.

t- Children's Medication Chart

Continued from inside front cover

36 37 38

ilieSollP PS w*,,,ftemeiva . Sligtvi OS op) Miiisl. PS MP ma)

40 41 42 43

Mrookine. (Oa ntO Mrocilwa. Me FatoOkee.ti.0

A6 46 47 48 49

Powsromt. MO Mil proastort201 ql. mg)

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