Studies on the hyperactive child. 3. The effect of chlorpromazine upon behavior and learning ability

Attention-Deficit Hyperactivity Disorder

Attention-deficit hyperactivity disorder (ADHD) is the most common of the childhood psychiatric disorders, with a prevalence rate of up to 20%, and is probably genetically transmitted. ADHD is characterized by impulsive behavior, hyperactivity, and decreased attention span. It is often extremely disruptive to the afflicted individuals social interactions and school performance. Therapeutic approaches to ADHD should be multimodal, including medications, family, and educational therapies. The pathophysiology of ADHD is not yet fully understood. Catecholoamines are believed to play a significant role with serotonin in an adjunctive role. Pathophysiological theories are supported by useful drug therapies that are known to affect dopamine and norepinephrine metabolism. Stimulants remain the drugs of choice, with methylphenidate most commonly used. Dextroamphetamine and pemoline are also effective. The rational use of these drugs is discussed. Antidepressants are second-line drug therapies; their usefulness is most apparent in patients who have high levels of anxiety and/or depression. Other potentially useful medications, including clonidine and the antipsychotics, are discussed. Adult populations can also express ADHD; treatment is similar to that used in children. Overall, ADHD is an important illness with significant morbidity. Pharmacotherapy is highly effective for its treatment and forms the cornerstone of therapy. This review of ADHD seeks to promote a greater understanding of this disorder and its appropriate drug therapy.

Antipsychotics in children and adolescents

OBJECTIVES

To present a critical overview of the available evidence for the efficacy and safety of antipsychotic agents in children and adolescents and to identify knowledge gaps and needs for further research. Data from adults that are relevant to children are discussed.

METHOD

Mainly reports of double-blind, placebo-controlled studies were reviewed.

RESULTS

In children and adolescents, antipsychotics are used to treat psychotic and a variety of nonpsychotic conditions. The amount of data based on well-designed, double-blind, placebo-controlled studies with satisfactory sample sizes in diagnostically homogeneous subjects is modest.

CONCLUSIONS

Currently available standard antipsychotics have a definite role in the treatment of children and adolescents. The use of these agents is limited mainly by tardive and withdrawal dyskinesias and, in some patients, by excessive sedation. The atypical antipsychotics should be critically assessed and compared with psychosocial interventions; if effective, the combination of both types of treatments should be evaluated.

Development after prenatal exposure to cocaine, heroin and methadone

In Amsterdam a longitudinal, prospective and multidisciplinary study on the development of infants of drug-dependent mothers (IDDM) was started in 1983: 35 IDDM and 35 reference infants were originally enrolled. The drug-dependent women had used combinations of methadone, heroin, cocaine and other drugs during pregnancy. Of the IDDM, 80% had to be treated pharmaceutically for neonatal abstinence symptoms (NAS). Physical, neurological, cognitive and the socio-emotional development of the children were studied regularly from birth until 5.5 years of age. Differences between the reference group and the IDDM were found most clearly in cognitive development. The IDDM also had more behavioural problems at some of the ages studied. No group differences were seen in motor development. So far the results of the study show that IDDM and their caregivers need extra support in order to improve early communication and the children's cognitive development.

Clinical effects of methylphenidate and thioridazine in intellectually subaverage children

Thirty children with subaverage IQs and psychiatric diagnoses of attention deficit disorder and/or or conduct disorder took part in a double-blind study of placebo, methylphenidate, and thioridazine, which were given for 3 weeks each. The results showed a consistent and highly significant effect of methylphenidate in reducing teacher ratings of problem behavior. Parent ratings showed no behavioral effects for the group as a whole. An attentional model of stimulant drug response was used to divide subjects according to a cognitive maturity domain presumed to reflect selective attention. When divided according to breadth of attention, mental age, and IQ level, higher functioning subjects were found to show a generally favorable response to methylphenidate on both teacher and parent rating scales, whereas children of low functional level typically showed an adverse or indifferent response. The present data suggest that mental age and IQ may be important determinants of drug response; below a given level, there was a greatly reduced likelihood of responding positively. Clinical response to thioridazine was substantially less than the response to methylphenidate, with significant improvements confined to conduct and hyperactivity problems on teacher ratings.

Development of infants of drug dependent mothers

Infants of mothers who used methadone, heroin, cocaine and other drugs during pregnancy were compared with a group of control infants over the first 30 mths of life. Results of repeated examinations with the Bayley Scales of Infant Development showed a difference between the groups in mental development. No differences were found in a non-verbal version of the mental scale, but infants of drug dependent mothers seem to have specific difficulties in early language development. In psychomotor development, in behaviour during testing and on a questionnaire on activity, infants of drug dependent mothers did not differ from the comparison children.

Controlled prospective fifteen year follow-up of hyperactives as adults: non-medical drug and alcohol use and anti-social behaviour

This is a fifteen year prospective controlled study of the non-medical drug and alcohol use and antisocial behaviour of 61 hyperactives, and 41 matched control subjects, (mean age 25 years). The data was collected from detailed interviews with the subjects as well as computerized court records to verify subjects reports. Generally hyperactives did not differ significantly from controls on current drug and alcohol use and antisocial behaviour. However one sees trends of greater drug alcohol and antisocial involvement in the hyperactive group. All the subjects who have antisocial behaviour at 15 year follow-up (mean age 25) had early and persistent histories of antisocial behaviour beginning at initial assessment (mean age 8) or at 5 year follow-up (mean age 13). However many hyperactives do not continue their antisocial behaviour into adulthood (mean age 25). There thus appears to be a small subgroup of hyperactive subjects who have more negative outcomes with significantly greater social, emotional and psychological difficulties. It is this subgroup which we need to identify early and treat vigorously.

Hyperactives as young adults: past and current substance abuse and antisocial behavior

In a ten-year prospective follow-up study, young adults who had been diagnosed as hyperactive in childhood were found to have had greater involvement with alcohol and drug use and with courts and police than did matched controls during the five years preceding evaluation. However, differences between groups were generally not significant in the year prior to evaluation, and tests indicate that they had attained similar levels of moral development. Results suggest a more encouraging adult outcome than has previously been expected for hyperactive children.

Contribution of predispositional factors to the diagnosis of hyperactivity

Hyperactivity is a complex childhood problem and may represent several groups or syndromes, each with its own etiological patterns. This paper presents results of analyses indicating that, although biological and demographic factors may predispose children to being identified and treated as hyperactive, the major contributions to the condition are early manifestations of temperament and the quality of the family's interaction with the child.

Long-term outcome of hyperactive children

A review of outcome studies of hyperactive children suggests that they experience significant academic, social, and conduct difficulties during adolescence, and that social, emotional, and impulse problems persist into young adulthood for the majority. While some hyperactive children were found to be functioning normally as adults, a troublesome minority were experiencing severe psychiatric or antisocial problems.

Effects of reinforcement on concept identification in hyperactive children

The effects of continuous and partial reward on the performance of hyperactive and normal children on a concept identification task were compared. Because reduction in information feedback is usually associated with partial reward schedules, the study was designed to yield information regarding the contribution of reduced feedback to performance in the partial reward condition. Previous findings of a performance deficit in hyperactives under partial reward were replicated. The findings help rule out an information feedback explanation for this deficit. The authors suggest that a motivational factor involving the elicitation of frustration when expected rewards fail to appear may be responsible for the poor performance of hyperactives on the partial schedule.

The efficacy of stimulant drug treatment for hyperactivity: a meta-analysis

This investigation reviews 135 studies examining the efficacy of stimulant drug treatment for hyperactivity. Meta-analysis, the analysis of analyses, is the methodological procedure used to integrate research findings. General findings indicate positive effects for drug intervention. In addition, subsets of data illustrating important behavioral, cognitive, and physiological outcomes were examined. Finally, variation among studies in terms of study features, subject characteristics, and design variables were investigated. Findings were compared and comrasted with previous reviews and showed that the extant literature provides a basis for concluding that stimulant drugs are an effective treatment for hyperactivity.

Psychotropic drugs and learning problems--a selective review

Past research into psychotropic drugs can be divided conveniently into laboratory studies that have generally looked at the more immediate effects on learning and follow-up studies that have investigated long-term effects as they pertain to academic attainment. Many of the commonly used drugs in childhood disorders appear to have beneficial effects in the short term and in the laboratory situation, though there are notable exceptions. Long-term assessments, however, have generally been unable to document lasting educational gains due to the psychotropic drugs.

Historically the application of diagnostic labels has frequently been inaccurate, giving vent to the false impression that certain drugs are of demonstrated benefit in children with specific learning problems. The research relating to drug effects on academic attainment in children with pronounced learning problems was reviewed. The evidence attesting to educational gains was found to be negligible, and possible directions for future research were indicated.

Construct validation of children's behavior problem dimensions: relationship to activity level, impulsivity, and soft neurological signs

A construct validation study of dimensions of children's behavior problems was carried out with use of multiple linear regression. The Ss were 76 latency-aged boys in residential treatment. The dimensions involved were Conduct Disorder and Inadequacy-Immaturity. The predictor variables were activity level, impulsivity, and soft signs of neurological damage. Results indicated that Conduct Disorder was significantly predicted by activity level, in combination with impulsivity. Inadequacy-Immaturity was significantly predicted by activity level and soft signs. A third dimension, Personality Disorder, was found to be uncorrelated with the three predictor variables.

The effects of frontal EMG biofeedback and progressive relaxation upon hyperactivity and its behavioral concomitants

Hyperactive children (N = 15) and nonhyperactive children (N = 15) were compared. Hyperactive children were found to possess significantly higher (p less than .002) muscular tension levels and, in addition, presented more behavioral problems and had lower test scores. Both electromyographic (EMG) biofeedback and progressive relaxation exercises were successful in the significant reduction of muscular tension, hyperactivity, distractability, irritability, impulsivity, explosiveness, aggressivity, and emotionality in hyperactive children. The greatest improvement was seen in the area of "emotionality-aggression" (irritability, explosiveness, impulsivity, low frustration tolerance, aggresion). No differences were seen in the EMG improvement of drug and nondrug hyperactive children; both made progress under these self-control techniques. However, nondrug children made greater improvements in the behavioral area. Both EMG biofeedback and progressive relaxation resulted in improvements on the test scores of hyperactive subjects (Bender-Gestalt, Visual Sequential Memory, Digit Span, Coding). The therapy would appear to be improved by the inclusion of mental relaxation, concentration, meditation, and mind-blanking exercises for mental control.

Are the effects of psychomotor stimulant drugs on hyperactive children really paradoxical?

The improved "attention" exhibited by hyperactive children treated with amphetamine-like compounds is postulated to be related to a normal action of these drugs in producing stereotyped behavior. Such activity can be conceptualised as an increased "focusing" of attention, which would be expected to aid performance in tasks involving sustained concentration of attention, but impair performance on tasks involving reversals in cognitive strategy. These behavioural actions of the drugs can be linked to the functioning of central dopaminergic mechanisms.

The effects of biasing information on behavioral observations and rating scales

The effects of biasing information on behavioral observations and rating scales were studied. Forty-one undergraduate students trained in making reliable behavioral observations were given differential expectations concerning the activity level of a target child. They then viewed videotape recordings of that child and tallied frequency counts of six behavioral categories simultaneously. In addition, subjects completed postexperimental rating scales composed of specific, identifiable behaviors in regard to the target child. Results indicated that, for the most part, neither the behavioral observations nor the rating scales were significantly affected by the biasing information. It is suggested that rating scales constructed of items as discrete and readily identifiable as those of behavioral observation measures may prove resistant to biasing effects.

Hyperactive children and the efficacy of psychoactive drugs as a treatment intervention

Characteristics of hyperactive children, including speculation in regard to etiology, are reviewed. Drug effects studies and drug treatment of hyperactive behavior are examined, and unresolved issues are discussed. Conclusions indicate that individual differences in hyperative children should form the basis for treatment planning, rather than simply treating groups of children under the rubric "hyperactivity."

An operant counting scale for children: A preliminary methodological psychoactive-drug case study

This pilot study is the first attempt at objective measurement of well-defined molecular behaviors through covert field observation. Though the main thrust is the development of a methodology for the clinical investigation of drug effects on children, a method that minimizes or overcomes many of the special problems that have plagued child drug research in the past, some preliminary data on the behavioral effects of haloperidol and imipramine were obtained. The technique developed is called an operant counting scale, and it promises to be useful in future full-drug studies.

Methylphenidate in children--effect of dosage

A clinical trial in two groups of hyperactive/ aggressive children showed that methylphenidate was superior to placebo for about 2/3 of the children, but that there was little difference in effectiveness between different dosage levels, especially once 0.3 mg/kg is attained. Mild side effects were common at higher dosages. Of a variety of physician, parent, teacher and psychological test and behavioral measures, teacher and physician ratings were the most sensitive to drug effects. No measures including neurological ones discriminated between responders and non-responders. It is concluded that methylphenidate is a useful treatment for hyperactive/aggressive children but that current doses may be too high and side effects more common than stated.

Psychotropic drugs in children. Pharmacotherapy as an adjunct to counseling or psychotherapy

Drug therapy in emotional disorders of children must be based on the experience of the therapist as well as the response desired in each individual patient. Psychopharmacotherapy is well within the range of the pediatrician—not limited exclusively to the child psychiatrist This up-to-date survey of the psychotropic drugs includes a summary of those most useful, with suggested dosages and possible toxic effects.