Sedatives ABSTRACT Reviewed on a Layman'slevel Was Research on Psychopharmacology with Theemotionally and Behaviorallydisturbed

Home , Azacyclonol, Deserpidine, Oxanamide, Phenaglycodol

DOCUMENTRESUME EC 041 170 ED 058 694 McClain, William A.; Jerman,George AUTHOR Behaviorally Disturbed: A TITLE Psychopharmacology with the Review. Childrens Center, Laurel,Md.; INSTITUTION District of Columbia Howard County Board ofEducation, Clarksville,Md. PUB DATE [7 0] NOTE 39p.

PRICE MF-$0.65 HC-$3.29 EDRS Therapy; *Emotionally DESCRIPTORS *Behavior Problems; *Drug Disturbed; *ExceptionalChild Research; *Research Reviews(Publications);Sedatives ABSTRACT Reviewed on a layman'slevel was research on psychopharmacology with theemotionally and behaviorallydisturbed. that the effect General conclusions drawnfrom the man y studies were functioning had not beendetermined and that of drugs on intellectual the learning process was there was littleevidence to indicate that consistently and reliablyaffected in certainpredictable ways. It informed when a subject was was advised thatthe psychologist be receiving drug medication,the drug name, anddosage. The review tranquilizers, and sedativesfrequently used by concerned stimulants, included pediatricians. Stimulantsreferred to in research dextroamphetamine, D-amphetamine,methylphenidate, rnonoaminoxidase inhibitors, amitriptyline,proamitriptyline, and cholinergics; methylphenidate was the drugused most often.Tranquilizers cited were thioridazine,chlorpromazine, reserpine,phenothiazines, hydrochloride, chlorprothixene diphenylmethanes, fluphenazine drugs hydrochloride, primazinehydrochloride, and thiorpropazate; advisable treatment forbehaviorally disordered were found to be an sodium and children. Sedatives coveredincluded diphenylhydantoin captodiamine hydrochloride. (CB) TiWjUPHARMACOLOG/ KTHaHE BEHAVICRALLYDISTUEBED: A -Et.TIEVI

William A. McClain,Ph.D. .Counseliwr Psychologist D. C. Children'sCenter Laurel, Maryland 20810

Georse Jerman, M.Ed. Schcol Psychologist Howard County Board ofEducation Clarksville, Maryland

U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE OFFICE OF EDUCATION THIS DOCUMENT HAS BEEN REPRO. DUCE() EXACTLY AS RECEIVED FROM THE PERSON OR ORGANIZATION ORIG- INATING IT. POINTS OF VIEW OR OPIN IONS STATED DO NOT NECESSARILY REPRESENT OFFICIAL OFFICE OF EDU- CATION POSITION OR POLICY. I.

INTROLUCTION

Treatment for behaviorallydisordered children can be

separated into three generalcategories: psychotherapy,

milieu or environmentaltherapy, end chemotherapy. It is this

latter group that isexplored in this paper.

The paper originated fromthe writere' interest over

the increasimc number ofchildren found in both thepublic

schools and Institutionswho were receiving orhad recently

been receiving some kindof internal medication of adrug form.

Many reasons could beoffered to account forthis state of

affairs. Several of the moreimportant ones include: samples supplied to 1. Overabundance of pomplimentary

physicians by pharmaceuticalhouses make prescriptionof same

a very.convenientchoice. workers, adequate pro6rams, 2. Shortages of mental health

and child specialists havecreated "time" premiumsand priorities.

In short, when case loadsbecome excessively large,and the

demand, for long or shortterm therapy, althoughneeded, cannot "better than be provided, chemotherapyis sometimes used as a nothing" technique. Frequently, too, prescribersof drugs

are not fullycognizant of the emotionalreferents underlying

a problem. What occurs is treatmentof the major physical 2

the true emotional symptom(s), at the expenseof neglecting pathOlogy under1yine3 thesymptom(s). 3 Psychologicalpredispositions anddependencies instantaneous and existing in ourculture that aim for therapies may require a impulsive cures. Where traditional becomes overtly large number ofsessions before progress known phenomena of apatient visible, in additionto the well before gettingbetter, the characteristicallybecoming worse typically creates an use of drugs,in contradistinction, This occurrencebecomes a immediate diminuationof symptoms. and the doctorsuch that when reinforcer forteachers, parents, student or child success in drugtherapy is found for one to other there are oftenheard clamors forits dissemination of different students and children,frequently irrespective reflected by recentarticles behavior problems. The press, as television media to a in popular newsperiodicals, and the popularized to their lesser extent have,in many instances, results" of certaindrugs respective audiencesthe "miracle Likewise, apsychological in remediatingbehavior. problems; parcel of set to takemedication when"sick" is part and

American tradition. to be an exhaustive 'These factors arenot meant in any way rather serve as astarting or mutuallyexclusive list, but specialists to add point for hiEhlightingthe need for child 3 3 to their professionalarmamentarium of skills. Nor are the writers questioning thelegitimacy of such prescriptions after careful study of theproblem, other alternatives, and in,consultation with a professionalteam. Rather, emphasis is placed on suggestingthat if drug therapy continues to increase in popularity asthe treatment of choice, then definite implications emergefor the role and functionof the psychologist. In short, he will needto be minimally conversant in the basicterminology of psychopharmacology, and to some degree beable te assess theanticipated effects, purposes, advantagesand disadvantages of aparticular drug

in relation to thelearning process. This dissemination of

factual information andconsultation may occur with aphysictan, a teacher,and/or parent. As a member of apsychological services team he may onoccasion even initiatereferrals for

possible drug therapy, orsuggest other, more efficient

alternatives in its place..

Review of the availableresearch did produce anumber of

sources thatdescribed the drugs andtheir observed effects that are in present usefor treating disturbedand. socially

disordered youngsters. Although far short of acomprehensive reView of chemotherapeutic agentsfor psychiatric disorders,

a numberof'studies are reportedthat deal with many of the drugs that are inregular pediatric usageand that have been encountered frequently by thewriters. L.

This review is organized in the threegeneral drug classes: stimulants, tranquilizers, and sedatives. It appears that this arrangement give greatestconsideration to presenting studies in an order that allows somecomparison of their respective behavioral effects. The drugs have been referred to by their generic or chemical namesin this treatment. To facilitate brandnaMe associations and to encourage continued reference to this work, a table isincluded that lists the generic name alphabetically accordingto general drug groups.

This name is followed by thebetter known brand or trade name of the drug. All efforts have been made toreduce the technical aspects of this scientific field to aminlmum so that drug therapy can be understood on afp.irly basic level. For this reason little mention is made ofphysiological or anatomical effects. Certainly the behavioral elements give Usenough concern to warrantcentering this investigation there. 5

STIMULANTS

It has been knoim for some yearsthat stimulant drugs, such asdextroemphe.tamine, may have a beneficial effect onschool performance of hyperkinetic oremotionally disturbed children

(Bradley, 1937). Children treated with thesestimulants rarely be:lome excited, butrather tend to become more calm, purposeful, and organized intheir behavior. In some children

the alteration in behaviorhas been described as truly remarkable. Side effects -- other thanmild anorexia and insomnia -- are rare, andthese tend to diminish inmost

children, even with highdosage of.the medication(Bradley,

1951; Bradley, 1958).

A recent study appearsto lend strong support toclaims

that this drug action has itsmain behavioral effect on increaSing drive level and response vigorin children.

Fifty-eight children from a publicschool system, who had

been selected by teachers ashaving serious learningproblems,

were randomly assignedto two groups. One group received a

daily treatment of'dextroamphetamine, the other amatched

placebo for onemonth. At the end of this time,the treatments

were switched. All treatments weredouble-blind. Measures obtained by .of intellectual performanceand ar,sertiveness were

objective, factor analyzedtest measures. Teachers also rated 6

The results after eachtreatment. the childrenbefore and performance andclassroom indicated thatimproved school the objectivetest changes behavior wassubstantial, but (Connors et.al.,1967). werequestionable discussed someadditional changes Solomons(2965) has therapy andcites loss of produced bydextroamphetamine interference withsleep activity, appetite,restlessness and and nervousnessafter pale and sallowfacial appearances,

certain kindsof activities. D-Amphetaminewith other Zrull et.al.,(1963) compared 7 to 14 ofoverall average drugs. Sixteen children ages medications in adouble-blind, intelligencereceived three eight-week period. A battery of cross-oyerpattern for an and teachersand medicalpeople, tests, ratingsby parents physical changeswereanalyzed. and laboratoryfindings of all children werenoted and Considerableimprovements in children. The D-Amphetamine continued tosustain in some chlordiazepoxide inthe was judged moreeffective than the hyperkineticsyndrome. reduction ofmanifestations of significantly moreeffective than Bothdrugs.appeared to be

the placebo. successfully usedat times Amphetamines havealso been been in usefor behavior. They have in modifyinghyperactive 1930) in thetreatment of many years(since approximately (Bradley, 1958;Denhoff, 1961; brain dnmagebehavior symptoms -`' ... .

Laufer, et.al., 1937). This stimulant or activator drug

has a similar paradoxical effect in seemingto calm and organize behavior in some children byreducing fluctuations

in vigilance and alertness andIncreasing attention span

(Bradley, 1951; Paine, 1962).

Other investigators have foundamphetamines expecially

helpful in cases of dyslexia wherethere is a short attention

span or distractibilitybut np hyperactivity (Clements and

Peters, 1962). Teachers reported that the child"seemed more interested in his work," or "atleast had begUn to show some

progress in readinw:.." The drug was administered atbreakfast

and at lunch and two forms ofamphetamine sulfate were used.

These authors maintain that racemicamphetamine sulfate acted

differently from dextroamphetamineand was superior in its effecton some children.

A study by Lauferet.al. (1937) produced a significant

improvement in the "hyperkineticallyimpulse disordered

child" when treated withamphetamines and followed over a

three-year period. In this study, attention span,hyperactivity, 4

and berlavioral ratings byteachers and neighbors could be manipulated in a positive wayby increasing and decreasing

dosages. Other investigators do notconfirm these findings although it should be notedthat they used only 20 mg. per

day as a total dosage comparedto'Laufer's use of up to

40 mg. per day (Bender & Nightern,1956, Fish, 1960, Freedman, 1958). 8

It has been suggestedthat the amphetamines actto alter organic ormaturational impairments ofbrain functioning, but this hypothesishas not been supportedby EEG changes accompanying behavioralimprovements following drug administration (Lindsley &Henry, 1942).

Clement .et.al..(1970) in arecent article articulated many of theabuses of amphetamineand amphetamine-like wide variety drugs. It was noted thatthese drugs possess a recommended dosage levels. of undesirable sideeffects even at Specifically, the authorsstated: wakefulness, the patient maycomplain Instead of alertness, or and ex- of nervousness, insomnia,headache, irritability, activity. The peripheraladr,Ane-gic cessively ine..reasPrl moto7. dilated pupils effects may cause blurredvision, excessively rate, palpitations, with photosensitivity,too rapid a heart hypertension. The patient often cardiac arrhythmias, and diarrhea, complains of a very drymouth. Nausea and vomiting, may.all occur.Difficulty in urinating may or constipation (P. 13 be due to interferencewith bladderslphincter control as appeared inMental Health Digest,1970, 2). The authors go on toconclude that thesecomplications have

been responsible forthe gradual decreasein therapeutic indications for theamphetamines in favorof safer drugs with the fewer side effects. To furtherciuote from the article, indicated in a few authors state thatamphetamines are "now hyperactive brain- rare conditions(Narcolepsy, and some of the dangers damaged children)." The'increasing awareness The British of amphetamines wasreflected from themarket. supplies to all government, for example,cut off methedrine physicians, dentists,and chemists withhospitals given a one year's grace. Another alerting drug,methylphenidate, at dosages of up.to 80 to 100 mg. perday, has been reportedto have similar In a well- beneficial effects(Knobel, et.al., 1959). controlled study by Connersand Eisenberg(1963) significant improvement in behavior,learning, and maze performancewas demonstrated in a group ofemotionally disturbedchildren following a ten-dayperiod of treatmentwith methylphenldate. individual variation TheseinveStigators commented on the wide They cautioned that in responsiveness amongtheir patients. must be determined the practical orclinical value of a drug further studies in groups of carefullyselected patients, and influencing responsive- of 'the personalityand other factors ness to the drug areneeded before it canbe clinically controlled study of 30' recommended. Another short term children with hyperactivityand signs of minimalbrain dysfunction has shownthat small but meosurableimprovements attributable to methylphenidatemay be expectedin tests'of

general intelligenceand visual motorperception (Millichap,

et.al. 1968). Knights and Hinton.(1969) found thatmethylphenidate

apparently improves theattention .span of childrenwith study of behavior and learningdisorders. In a double blind 10

using placebo 40 children withminimal brain dysfunction that both controls over a six-weekperiod, the authors found

parents and teachersrated. the children asbeing less

distractible and moreattentive when receivingthe drug motor control wasconsidered to therapy. The improvement in

thee improvedattention span. - be secondary" to Sprague, Barnes, andWerry (1970) evaluatedthe effects

(a of methylpheniciateincomparisonto thioridazine tranqltilizer) on the behaviorof emotionallydisturbed, under-

acheiving bo7s with amean ag. of94.2 months-, and a mean learning (a one- IQ of 98.6. Three dependent measures -- activity level -- trial learning,task) reaction time, and It were taken in ahighly structuredlaboratory situation. that was found usingboth laboratoryand clinical measures while thioridazine methylphenidate improvedlearning performance, Also with theimprovement in decreased learningperformance. activity. Their performance,methylphenidate reduced attention.The findings indicatemethylphenidateimpxoved

111 corroborated the classroom behaviorobservation measures in67ieased findings from the laboratoryin that methylphenidate quality of the child's attention to school workand improved the

behavior that day asrated by the teacher. the beneficial Despite the numerousclinical reports on controlled 'response to centralnerVous system stimulants, 11

there is littlesatisfactory studies arelimited and by which thesedrugs act. Also, explanation ofthe mechanism to the typeof behavionallydis- reports areconflicting as favorably.Many investigators orderedchildlikely to respond system stimulantsareparticularly consider thecentral nervous organic conditionbut that effective inpatients with an emotional disorderis unresponsive hyperkinesisattributed to 1967). to this therapy(Conrad & Insel, discovered that usethe drugs A few studieshave been Freedman commonly classed asmonoaminoxidaseinhibitors. iproniazid to a groupof autistic (1958) administered increased awarenessof schizophrenic childrenand reported of language in some. their surroundingsand, a greater use imipramine and the Bender and Faretra(1961) stated that promising inwithdrawn, monoaminoxidaseinhibitors seem children. Fish (1960) depressed adolescentsand autistic children's behaviordisorders in a reviewofdrug therapy in anti-depressants has not stated that theeffectiveness of the In their study yet beenestablished in thesesituations. L,awler et.al.(1963) of suicidal.attemptsin children, drugs reported usingimipramine andother anti-depressant sufficient data in some oftheir patientsbut did not give A different useof to draw anypositive conclusions. it imipramine wasreportedby MacLean (1960) who found

12 12 effective in the treatment of enuresis inchildren.

A controlled study by Lucas et.al.(1965) was under- taken to evaluate amitriptyline effects on a groupof symptoms relating to depression in children. Fourteen children and adolescents were selected from a residentialtreatment center population and administered the drug in aplacebo controlled double-blind study.The subjects were of various neurotic and psychotic diagnoses and ranged in age from10 to 17.

Behavioral changes were rated daily on afour point scale in nine categories. Of the ten patients completing this study, six showed significant improvementby needing fewerexternal' controls or by responding better tocontrols while reóeiving the active drug. Two patients needed more control orresponded more poorly to controls. Three of the ten patients showed a diminution in the frequencyof somatic complaint and two patients participated more easily inactivities while one became worse in this category. Peer relationships were rated significantly improved in only two patients. The drug, however, did not appear to diminish severeanxiety or serious acting-out behavior.It was concluded that this drug may be useful in certain mrefullyselected depressed children btit must be considered as only part of a totaltreatment 17rt`14.1..JR700,0rtvrefarel.

Krakowski (1964) reports a pilotstudy with amitriptyline

involving 122 randomly selectedpatients ranginrc from 2 to

18 years representing variousdiagnostic categories with behavioral disorders inpredominance referred to a child

guidance clinic. Varying amitriptyline dosages wereadmin- istered from 1 to 12 monthswith observational reports made

every week.Habit and conduct disordersappeared to diminish

o significantly and, anxiety andacting-out symptoms as well as

some neurotic traitsseemed to decrease althoughthere was

a confusion.withanother treatment(psychothanapy) that some chronic neurotics andschizophrenic children were receiving.

The same author, however,duplicated the pilot study with a double-blind cross-over controlledstudy providing a medicated period of 4 to16 weeks (Krakowski, 1965). Overall

satisfactory responses were obtainedduring drug treatment that

was not obtainedduring the placebo period.The investigator concluded that the study confirmedthe results obtained

previously during the pilotstudy ana showed amitriptyline

.0 to be a safe, active andeffective agent markedly reducing

ymptomsin'emotionally disturbed hyperkinetio children when applied as part of a therapeuticapproach used in a child

.guidance clinic. Kraft et.al. (1966).reports onthe use of amitriptyline

with 123 children whopi.esentad a variety of behavioral and 14

103 boys and 20 other disorders. The subjects included girls ranging in agefrom.2 to 14 who were seenin a child

psychiatric clinic andtreated on an out-patientbasis.

The dosage ranged from30 mg. to 80 mg. daily. The patients'

progress wasfollowed closely by phoneduring the administration interpreted of the medication. The overall results were of the by the investigators as"promising" since 60 percent by clinical 123 patients showedimprovement as determined consider study; This led to thesuggestion that physicians children with the drug as useful agent in treating adjustment reactions ofchildhood and those withmaturational

brain dysfumtion. Nineteen briefs of researchstudies of foreign and house (Dr. Richard domestic origin suppliedby a pharmaceutical Information T. Smith, Merck, Sharpand Dohme Professional Consultant) showed 11 studiesto favor amitriptylineand promitriptyline, a derivativeof the former, astherapy for anti- enuresis. Most of these studiesshowed accompanying depressant outcomes ofpositive Value. However, three of adult patients.as the studies mereconducted with elderly or The subjects and one studyuited Severely retardedchildren. interpretation seemd tobe:that these.drugs canbe' side effects .tried-under:pedicalsuperVision bUt':that.:(1..7aStic

might be*KPected.:' rt 15

One study was founddealing with another drug group,the the L.coblem solving and cholinergics. The effect of deanol on emotional behavior of42 children between the agesof 6 and

13 was investigated. Both medical andpsydhological appraisals

were used to diagnosecentral nervous system orbehavior design disorders.A cross-over,double-blind experimental was used, withthe drug being administeredin a dosage of

100 mg. daily. The drugs didnot-produce significantly different scores on the measuresemployed, over the scores

obtained during plabebotreatment. Side effects were non-

existing (Kugel &Alexander, 1963).

The data collectedand reviewed indicatedthat methylphenidate is thestimulant drug of choiceand that the

amphetamines were second inmost reported success(Connors &

Eisenberg, 1963; Millichap& Fowler,1967). It is probably of these drugs for fair to say, however,that the use of most damage has rarely behavior disturbances inchildren with brain

been shown to be acompletely successfulventure unless other stimulants medication is administered. Central nervovs system

appear to be theagents of choice butfurther research

efforts are necessarybefore adequateresults can be obtained. 16

IRANQUILIZERS

Some of these drugshave long been used. asanti-anxiety Although they can bedivided. on and, anti-psychoticagents. the the basis of chemicalstructure into many main groups, to be most derivatives of thephenothiazine compound appear disordered child useful in the therapyof the behaviorally effective (Kraft & Battin,1969). Phenothiazines appear very with "primary behavior in severelydisturbed children (Fish, 1960). disorders" and organicschizophrenic disease because of unexpected Extreme cautl.on isencouraged however, (Schiele & Benson,1962). and. erraticbehavioral changes Thioridazine has beenmentioned as aneffective medication a such as epilepsy, in regard to variouschildhood difficulties and, emotional mental retardation,perceptual disorders, studies disturbance (Zarling &Hogan, 1960). In addition, EEG of groups have shown significantdifferences in the response and/or acombination of receiving treatmentby thiorid.azine sedative (Boelhouwer, this drug withdiphenylhydantoin, a attempted. to t ftt.al., 1968; Ingram,1964). These authors relationship of examine the diagnosticand therapeutic The drug certain EEG patternsand behavioraldisorders. both the abnormalEEG 'appeared to have apositive effecton behavioral problems. patternandthe incidence of 17

and reserpine, Additional drugsincluding chlorpromazine studied but it wasconcluded a rau wolfiaalkaloid, were also not determined and that the signtficanceof these effects were chronic effect ofthese drugs that furtherstudies of the patterns should becompleted. onelectroencephalographic alkaloids are (Hollister & Barthel,1 959). The rau wolfia action and aregenerally drugs that haveless reliable which do not reserved for severeschizophrenic disorders to be much less respohd tophenothiazines. These drugs appear often produce seriousside potent than.thephenothiazines, but effects when givenin large dosages(Fish, 1963). that thioridazine is Some evidence isexisting to show patients with mentalretardation. of benefit inthe treatment of of 97institutionalized LeVann (1961)investigated a group well as emotionally children, comprisedof retarded as No side effects, disturbed cases withadequate intelligence. observed. The the principal concernof this study, wore has control over awide writers determinedthat thioridazine They A variety of abnormalbehavioralPatterns in children. could be discontinued further concludedthat medication continuum of symptoms because the drug aidedin breaking the treatment and made thechildren mireaccessible for'other of effects techniques,There appeared tobe little difference intelligence. with retarded orchildren of average

18 ls

Badham and his associates(1963) treated both child and adult mental deficientswith thioridazine and found itto be effective in controllingbehavior disorders in asignificant proportion of the patients. They felt this drug was particularly useful withsubnormal children.

A smaller but bettercontrolled study essentially produced the same resultsbut the authors noted asignificant difference between thelevel of measuredintelligence and response to thedrug (Allen et.al.,1963). Children who were moderatelyand mildly retardedresponded significantly better to the use ofthe drug. Very seriously retarded children did not respond aswell. .

An evaluation ofthioridazine in a seriesof 141 familial in age from and organic mentallyretarded patients ranging

6 to 60 showed the drug toeffect improvementthroughout improvement in an additional the I.Q. level in54% and marked

34% of the patients (Abbottet.ai, 1965). Hyperactivity, temper tantrums, andself abuse were thesymptoms most absence ofundesirable favorably decreased. There was a relative drug effects and theeffect on behaviorencouraged the investigators to suagestthioridazine as a means offacilitating child so as to home management ofthe mentally retarded

avoid comMitment to aninstitution. This same intent was

discussed by two medicaldoctors in theirarticle concerned 19 with the office managementof behavioral disorders(Oettinger descriptive study Simonds, 1962). Their presentation of a practice led them to of their use ofthe drug in medical

conclude that thioridazineis successful intreating the They hyperkinetic behaviorproblems associatedwith seizures. determined that the drug canbe faithfully used inpediatric broaden the effective office practice, andwill substantially

limits of thepediatrician in dealingwith children's supported by the behavior problems. These conclusions were

findings Of.a surveyof pediatricians inCanada (Doyle,

et.al., 1969). has Connors & Eisenberg(1963).report that thioridazine

been valuable in themanagement of severelyretarded indiv- Seventy-two percent ofthe iduals in a 1,250bed institution. judged to be greatlyimproved patients receivingthe drug were hyperactivity, and because of thereduction in aggressiveness, were able toderive temper tanl;rums. Many patients thereby

greater benefitsfrom the trainingard other therapeutic -41 side effects was anoticeable programs. The absence of outcome of this drugtherapy. beneficial outcomes. Other litenaturehas shown similar investigative groups .Sandison, et.al.,(1960) used four thioridazine including a placebo groupand found that only Hbllister and MadDonald(1959), gave .significantimprovement. 20

controls, concluded employinq otherphenothiazines as active advantages over the that thioridazine was anactive drug with that over two- other phenothiazines. Ostfeld (1959) reported thirds of 117 patientswere improvedwhen studied under He also felt blind placebo cross-overdesign conditions. the phenothiazines. that thioridazine wasthe least toxic of et.al., (1958). These conclusions wereconfirmed by Fleeson, study undertook to A recentdouble-blind cross-over examihe the effectsof thioridazineand methylphenidate, retarded males a stimulant;and a placebo innine severely decreased (Davis, et.al.,1969). Thioridazine significantly non-stereotyped stereotyped behaviorwithout affecting drug in the presentstudy lends behavior. The effect of this behavioral arousal support to the theorythat characterized result. as a causeof stereotypyrather than its With regard to the useof thioridazine inepileptics, have freouently it should be notedthat the phenothiazines threshold been suspected ofbeing capable ofreducing beizure it has been in susceptiblesubjects. FortSis reason

prevent increase inseizure q- 4 considered pertinentto attempt to the use of thesedrugs wherever patterns by withholding Mkt' possible and byrecommerlding .that*antiseizure medication A Previously be continuei(Millichap & Fowler,1967). onnthe ,cited ,studY indicateda,redUctionnin seizure threshold

n.; ,manowthigMstIt

while the numberof cases administration ofthis drug and. this led to therecommend- exhibiting this isextremely small, medication bemaintained or ation thatanti-convulsant overt seizures orsuspected instituted inpatients exhibiting if thioridazineis to be of latentepilepsy respectively employed(Hollister & Barthel,1959). effects of pheno- Experimental studiesexploring the and quite varied thiazines on humanEEG's have been numerous EGG may take one oftwo and indicate thatalteration of the properties of thephenothiazine forms. The, tranquilizing EEG.resembling appear to bemanifest .as aneffect on the the subject couldbe that of lightdrowsiness from which increased synchronization and easily aroused.- Afinding of indicative normalization of theEEG has beeninterpreted as the reticularactivating of .a slightdepressant aCtion on

system (Itil,et.al., 1967). particularly, interesting A paper by Pauig,et.al.. (1961) is to the incidentsof because of theattention it .devotes uSed for ,treatment epileptic seizureswhere thioridazine was

. The conclusion of behavior.disordersin such patients. 'disorders obtained was reachedthat the controlof behavior effeCt:_. OA the con- with thioridazine:alsohao a salutary .patient but it is vulsions previouslyexperienced by. the important to notethatanti-cCrivulsant-medicationwas It °was determined.that maintained'.thiioughout* 22

that combinationtherapy has thepatient againstseizures and rehabilitation ofepileptic greater potentialfor' total patients thatseizure controltherapy only. of thioridazinein severelY Frain (1960)evaluated the use Using a group of70 disturbedepilepticswith psychoses. changes inphysiological white females,thisinvestigator charted tranquilizer period,a and psychologicalbehavior during a and a treatment period of treatmentwith chlorpromazine, Physiological symptomswere period withthioridazine. traits weresignificantly decreased andpositive personality treatment period. increased duringthe thioridazine the findings ofthe Paulson and Buffaloe(1964) sunned up that ". .the lack of previous studywhen they concluded for morepatients appears any apparentepileptogenic effect when a tranquilizer to makethioridazine areasonable choice seizure tendency." is needed forthepatient with a the presence of Unfortunately, most ofthe studies mask .be the case in some latent activity, aswould appear to the institutionof a patients exhibitingseizures following

phenothiazine. in- Hinsley(1963)studied 20adolescent psychiatric of thiortdazinedaily for patients receiving100 to 800 mg. that the lowincidence of a two-yearperiod. He concluded, improvement ininteractive side effects andthe great 23

therapeutic staffjustified relationshipswith peers and for thispopulation. the drug agent ashighly effective from a studyby Statistical analysisof the data correlation between Itil et.al.(1967) revealssignificant both qualitativelyand behavior alterationsand EEG changes, disturbed childrenand quantitatively. Twenty behaviorally treated with acombination adolescents withabnormal EEG's were Behavior was of thediphenylhydantoin andthioridazine, months afterdrug treatment. EEG rated. beforeand three time behavior recordings were carriedout at the same after treatment,fifteen ratinFs weredone. Three months and fourteen patients showedmoderate to maricedimprovements Although only apilot study,it does of them weredischarged. indicate thatbehavioral substantiate previousfindinFs that disorders and EEGpatternsare linked. that the useof a major In appears inrecent years childhood behaviordisorders tranquilizer,thioridazine, in As a result,this drug has beenextensivelyinvestigated. effective agentwith a minimal has beenrecommended. as an from this overview incidence of sideeffects. It is apparent to be incontinued use by that this drug canbe considered maintaining controlwith a a numberof medicalpeople in but its effect on number ofbehaviorallydisordered children, and as a resultof educational what occurs inthe clasSroom primary concern. intervention neednot be of the minortranquilizers have Studies concerningsome-of primarily it is founithat thesedrugs are also beenreviewed and severeneurotic and"primary useful in mildto moderately ,Prepubertychildren do behavior disorders"(Fish, 1963). Children addicted or"drug regulated." not appearto become schizophrenicreactions are with moderatelysevere and medications(Fish, 1960). frequentlyhelped by these having extrastrong stimulatory Trifluoperazine isreported as (Fish, 1963). and autisticchildren effects onseverely withdrawn this drugziven in doses However, Smith(1965) finds that 1Tought varyingdegrees of rangin3 from1 mg. to15 mg. daily disturbed children. All improvement to 30 of38 emotionally considered moderateto severe 38 of thepatients were hyperactivity,aggressiveness, behavior problems,expressed in Therapy sometimesbetwetting. insamia,nightmares, and these childrenreceptive to withtrifluoperazinehelps make measures; schooling, work counseling andother supportive Chlordiazepoxide, therapy, andinterpersonalrelations. of been favorablycompared to some another.phenothiazine, has, agents but somestudies the better.knownchemotherapeutic has adverseexcitatory effects have indicatedthat this.drug 1963)., (Fish, 1969;Zrullet.al., another minortranquilizing drug ThediphenylMethanes, Diphenyl- group, also areused in therapyfor children. successfully for overa ten-year hydramine hasbeen used 25 period to treatbehaviorally disordered andemotionally This drug disturbed children(Denhoff, 1961; Fish,1960). has been found mostuseful in behaviordisorders associated young children with hyperactivity,to reduce anxiety in very moderate who are nothyperactive, and helpfulin controlling other than schizophrenic disorders. Little side effects fatigue have beenfound. .Therefore, itis used also as a bedtime.sedative (Fish,1960). Hydroxyzine and azacyclonol are similarcompounds but appearto be slower acting and weaker in effects(Fish, 1963) Meprobamate, a propanediol, and behavior disorders is reported aseffective with neurotic including those associatedwith mild organicbrain disease

.(Bender & Nightern,1956). It:appears,less effective for (Fish, 1963). hyperactive syndromesthan the diphenylmethanes A'recent review of additionalanti-anxiety and anti- and psychotic agents includedfluphenazine hydroalloride and chlorprothixene hydrochloride promazine hydrodhloride trcied on too fewpatients thiorpropazate. These drugs were Fowler, 1967). for adequate appraisal.,however (Millichap & of these drugs in It appears quiteapparent thdt the use child is widespread. therapy for thebehaviorally disordered

Pediatric and clinicalpractice as well aspharmaceutical

research has morethan adequatelyindicated the advisability

of drug therapywith many types.ofbehavior problems.

26 26

SEDATIVES

medication in The use ofsedativeb oranti-convulsant variety, with orwithout children withseizures of any the mandatory. In such caJes behavioral symptoms,is usually The mainrationale for- aim of therapyis seizurecontrol. prevention ofthe possibleorganic such therap.yis the repeated episodesof anoxia and cerebraldeterioration that the patientwith uncontrolled possible headtrauma may cause drug controlof seizures onthe epilepsy. The effects of disorders may vary,however. This interictal behavior unchanged(Glaser & behavior may worsensimprovel,or,remain diPhenylhydantoin andprimidone Dixon, 1956)..In general, seizures(Pincus & are thedrugs of choicein psychomotor seems tolead to Glaser,.1966). Phenobarbital often symptoms,although it maybe an exac.erbation ofbehavioral have been foundto effeCtiveanti-convuls'ant.,.Barbituates severely disturbed .increase anxiety"and'disorganization in

children .(Fish,1960. the treatmentof children The place 6fanti-convulsants in electroencephalograms with behaviordisorlers and abnormal Early studies gavegood who havenoseizures isless certain. compounds in the evidence for useofdiphenylhydantoin sodium behavior disorderswere not treatm'ent ofchildren whose (Lind iey & associated withspecific EEGabnormalities Later treatments of Henry, 1942; dalker& Kirkpatrick,1947). the earlier findings, the use of thissedative do not confirm however (Fish,1963;Freeman, 1966). anti-convulsants on 'Green (1961)studied the effect of associated with non-epileptic childrenwith behavior disorders Of five a focalelectroencephalographicabnormality. attention span, ancl children withhyperactivity, short two were "less intellectual deficits,two were unchanged, hyperactive," and one"related better." In three others of

normal intelligencewho had variedbehavioral problems, and to relate to two improved theirability to concentrate qualitative results arethe others. These unimpressive general experience, andthe use of anti-convulsantsto

modify behaviors insuch cases is usuallyunsuccessful. Reports of the efficacy.of anti-convulsantsin the control

of hyperactivity arelikewise limited and areconcerned primarily with trials inchildren whose behaviorand learning

problems are complicatedby convul ive seizures..Primidone,

found effective in 7.of10 patients in onestudy, has been

recommended for use inchildren with majorconvulsions and

hyperactive behavior(Millichap & Fowler,1967). biphenylhydantoin sodium was relativelyineffective in two

studies that included atotal of only 28 patients but the'

necessity for furthertrial is suggested bylaboratory Mr"'

activity of.animals was investigations inwhich locomotor compounds (Millichap reduced by thisand other related

et.al., 1968). of ten casestudies Gross and Wilson(1964), in a report behavioral outcomesand EEG profiles, of medicationeffects on useful and determined:that some of theamphetamines were patient worse, butthat that phenobarbitaloften made the In fact, these diphenylhydantoin wasrather effective. effective thanplacebo medications werefound to be less

administrations. reported to be Captodiaminehydrochloride has been (Low & Myers, 1958). effective in organicbrain disorders patterns.of organicbrain Forty hyperkineticchildren with doses (lo-250 mg,daily) damage weretreated with varying from 3 to 17months. of this drug for aperiod ranging signifimnt toxic Striking improvementin behavior with no Conclusions weredrawn giving' reactions weredocumented. with testimony to thevalue of thisdrug for the use

hyperkineticchildren with brain damage. 29

CONCLUSION

if From our review,drUgs seem to have a definite, circumscribea, role to play inhelping children overcome One and succeed inspite of theirlearning handicaps. "Drugs are reviewer provides anencouraging prospective.

obviously not panaceas,though our needs andfrustrations New and may incline usto cast them inthis image. continual work inpsychopharmacology and thephysiology

of learningallows us to havecautiously optimistic expectations for thefuture.'' (Freeman, 1966, p.37).

Several comments canbe made that areapplicable As we have to the general areaof psychopharmacology. e available research, learned from thisreview, most of the clinical nature. has dealt withproblems that are of a Research regarding the effectsof drugs on thelearning pointed this out process is verylimited. Freeman (1966) past thirty years. after reviewing theresearch for the the need. Werry and Quay in1970 also speakto corroborate more facetsof More studies areneeded that employ one or in drug the .learning process asa dependent measure using some aspect of evaluation. Even in those studies measure, it is common the learning process asa dependent timebeund, the task to find that thecriteria employed is Hence artificial, andoccurring in alaboratory situation. 30 setting is oftenimpaired. generalizability tothe classroom research has usedunrepresentative Also, much ofthe available to which the ex- Ss especiallyin view ofthe populations .The choice ofSs in most perimenters hopeto generalize. (Alderton & Hoddinott, studies come fromadult populations Conspicuously scarcein 1964; Connors &Eisenberg,-1963). that attemptto assess this field arelongitudinal studies drug action.Studies long-term effectsof a particular of drugs usedin focusing on thesynergistic effects threats to combination are alsolimited..Likewise,.so many uninterpretable. For internal validitymake manystudies history, maturation,instrumen- example, validityfactors of regression areoften not tation, mortality,testing, and

controlled for. considerations that are -There are alsomethodological in researchdealing particularly relevantto control for effects ofpsychopharmacology. specifically withassessing the the common sourcesof Sprague, eI.4.1.(1970 list three of

error as:

.1. Observer.bias. and/or insensitivemeasures. 2. Use of error-prone optimal drugdosage; for Ignoring thenecessity for height of drugaction; and tobe sure .testing.at the taken and at thetime that medicationis both being indicated.

31 optiMism in regards tothese thtee The writer's seereason for A definite,observable sources of errorbetng controlled. and more trend in thisdirection ofbetter controlled and is reflectedby the spphisticated studiesis appearing this area. recent researchpublications in that the effectdrugs have on In summary,it .appears has to bedetermined. There intellectualfunctioning still in thls surveyto indicate was littleevidence uncovered consistently andreliably that the learningprocess is ways.At this pointit might affected incertain predictable most effectiveway'to be tentativelyconcluded that the psychologically is tobe evaluate the drugmedicated child

and manifestbehavioral . moreconcerned abouthis observed drug symptoms.and not todepend toocompletely.on expected highly advisablethat the induced changes. It seems is receivingdrug psychologist be awarewhen a subject drug name anddosage. 'Withthis medication aswell as the and using knowledge and theawareness ofpossoible effects psychologist appropriate clinicalskill, theexperienced for teachers, could serve as a moreeffective resource 'etc., in assessingindividual parents,para-professionals, provide the besteducational .learning modesthat can help

paacement andprovisions. a *: 32

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37 APPENDIX

I.Stimulants(Activators) Amphetamine(3enzedrine) Dextroamphetamine(dexedrine) Nethamphetamine(Methedrine) Methylphenidate(Rita lin) Pipradrol(Ne'ratran) Iproniezid Isocarboxazid(Marplan) Nialamide(Niamici) Tranylypromine(Parnatq Diisopropylfluorophosphate(DPP) Eserine Orphenadrine(Disipal)

II.Tranquilizers(Anti-anxiety -Anti-psychotic) Azacyclonol(Frenquel) Benactyzine(Deprol,Suavitil) Captodiamine(Suvren) Hydroxyzine(Atarax,Ivistaril) .Deserpidine(Harmonyl) Rescinnamine(lioderil) Reserpine(Sepasi,l) Chlordiazepoxide(Librium) Chlorpromazine(Thorazine) Mepazine(Pacatal) Perphenazine(Srilafon) Prochlorperazine(Compazine,Stemetil) Promazine(Sparine) Promethazine(Phenerxan) Thiopropazate(Jartal) Thioridazine(Eellaril) Trifluoperazine(Litelazine) Triflupronazine (Vesprin) Meprobamate(Niltown, Equanil)

38 Appendix (continued.)

Sedatives (Anticonvulsants)

Phenaglycodol (Ultran) Butabarbital Sodium (3utisol Sodium) PentobarlAtal Sodium (Hembutal) Phenobarbital (Luminal) Secobarbital Sodium (Seconal) Amobarbital Sodium (Amytal Sodium) Captodiamine (Suvren, Covatix) Diphenylhydantoin sodium (Dilantin) Ectylurea (Nostyn) Ethchlorvynol (Placidyl) Glutethimide (Doriden) Meparfynol (Dormison) Nethyprylon (Noludar) Oxanamide (Quiactin) Primidone (Mysoline)