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ADOPTION IN BOYS WITH GENDER IDENTITY DISORDER
LETTERS TO THE EDITOR
ADOPTION IN BOYS WITH GENDER IDENTITY DISORDER To the Editor: Rosenberg (2002a) commented on Menvielle and Tuerk’s (2002) observation that 50% of their sample of gendernonconforming boys (total N = 12) were adopted. The boys themselves were not seen, but rather their parents were in a support group, of whom half were recruited through a newspaper announcement. Rosenberg countered this finding by noting that none of the 28 children with “gender identity issues” in her practice were adopted (Rosenberg, 2002b). Rosenberg (2002a) failed to note that Menvielle and Tuerk’s (2002) decision to report on the adoptive status on their boy patients may have been influenced by our earlier report that in a consecutively referred sample of 238 boys with gender identity problems, 18 (7.6%) had been adopted or taken into permanent foster care prior to age 2 years (Zucker and Bradley, 1998). We classified these youngsters as “early adoptees” and noted that, in all cases, the adoption preceded the emergence of behavioral symptoms pertaining to gender identity disorder. We compared this percentage of early adoptees with the percentage of boys adopted in the province of Ontario prior to age 2 years between 1965 and 1989 (the birth-year range of the early adoptees), which was 1.49% (24,613 of 1,651,266 male live births). The difference was highly significant at p < .00001, with a χ2 test. Rosenberg’s (2002a) skepticism about the possible relation between adoption and gender identity disorder is, perhaps, premature because she would have needed a sample of about 70 patients to detect an effect as large as ours with a power of 80% at p < .05 (two-tailed) and, given her sample size of 28 patients, her power at p < .05 (two-tailed) to detect a difference as large as ours is less than 45%. Kenneth J. Zucker, Ph.D. Susan J. Bradley, M.D. Child and Adolescent Gender Identity Clinic Child Psychiatry Program Centre for Addiction and Mental Health-Clarke Division Toronto Menvielle EJ, Tuerk C (2002), A support group for parents of gender-nonconforming boys. J Am Acad Child Adolesc Psychiatry 41:1010–1013 Rosenberg M (2002a), Gender-nonconforming boys (letter). J Am Acad Child Adolesc Psychiatry 41:1394 Rosenberg M (2002b), Children with gender identity issues and their parents in individual and group treatment. J Am Acad Child Adolesc Psychiatry 41:619–621 Zucker KJ, Bradley SJ (1998), Adoptee overrepresentation among clinicreferred boys with gender identity disorder. Can J Psychiatry 43:1040–1043 DOI: 10.1097/01.CHI.0000046852.56865.59
ZIPRASIDONE IN AUTISM To the Editor: In the recent article by McDougle et al. titled, “Case Series: Use of Ziprasidone for Maladaptive Symptoms in Youths With 622
Autism,” among the six nonresponders, two are worthy of further consideration (McDougle et al., 2002). These patients, numbers 6 and 12 in Table 1, were described as becoming worse on ziprasidone. In addition to having diagnoses of pervasive developmental disorder not otherwise specified or autistic disorder, they were also described as having bipolar I disorders. In both cases, ziprasidone (80 mg/day) was used in conjunction with several other psychotropic medications. From this presentation, one might conclude that ziprasidone is not effective in the treatment of bipolar type I disorders. Adult studies have demonstrated the efficacy of ziprasidone in the treatment of schizoaffective and bipolar type I disorders (Keck et al., 2001, in press). Ziprasidone dosing of 80 and 160 mg were compared, with 160 mg shown to be superior. Furthermore, despite 200 mg being a maximum recommended dose, select populations have been shown to require higher doses (Citrome and Volavka, 2002). I would like to report on three adolescent bipolar I cases in which ziprasidone was successfully used during the acute as well as the maintenance phase of treatment. Two 15-year-old males and one 17-year-old female, who had previous histories of unresponsive mania and psychosis, were started on ziprasidone. Ziprasidone was begun at 20 mg b.i.d. and increased over 2 to 4 weeks to levels of 200 to 240 mg/day. All patients received either lithium or a combination of lithium and valproic acid, but all had not shown significant clinical responses when other atypical antipsychotics were used with concomitant mood stabilizers. All had adverse effects (in particular, marked weight gain). On the ziprasidone, they showed decreases in psychosis and a reduction in manic symptoms at lower doses, but at higher doses the psychosis, especially auditory hallucinations, were significantly reduced and eliminated in two cases. In addition, all have been described as having better concentration and improved socialization. The principal side effect was sedation, which lessened over a 4-week period. Serial QTc measures did not demonstrate a significant prolongation in any of the patients, and none have had any weight gain with the use of the ziprasidone. These patients were begun conservatively at dosage levels as indicated by Dr. McDougle of 40 mg twice a day (for a total of 80 mg). In each case, higher doses were required. With this dosing, there were initial periods of somnolence and tiredness, but these symptoms abated with few side effects. Unlike the cases noted in McDougle’s report, concomitant antipsychotics were not used. These three cases demonstrate that the response of the psychosis associated with bipolar I disorders is comparable with that seen in the literature for the treatment of schizoaffective and bipolar disorders in adults. This raises the potential efficacy of ziprasidone in the treatment of adolescents with bipolar I disorders and the need for further research using ziprasidone to understand its pharmacokinetic and clinical applicability in children and adolescents with severe psychiatric disorders.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 6 , J U N E 2 0 0 3
ADOPTION IN BOYS WITH GENDER IDENTITY DISORDER To the Editor: Rosenberg (2002a) commented on Menvielle and Tuerk’s (2002) observation that 50% of their sample of gendernonconforming boys (total N = 12) were adopted. The boys themselves were not seen, but rather their parents were in a support group, of whom half were recruited through a newspaper announcement. Rosenberg countered this finding by noting that none of the 28 children with “gender identity issues” in her practice were adopted (Rosenberg, 2002b). Rosenberg (2002a) failed to note that Menvielle and Tuerk’s (2002) decision to report on the adoptive status on their boy patients may have been influenced by our earlier report that in a consecutively referred sample of 238 boys with gender identity problems, 18 (7.6%) had been adopted or taken into permanent foster care prior to age 2 years (Zucker and Bradley, 1998). We classified these youngsters as “early adoptees” and noted that, in all cases, the adoption preceded the emergence of behavioral symptoms pertaining to gender identity disorder. We compared this percentage of early adoptees with the percentage of boys adopted in the province of Ontario prior to age 2 years between 1965 and 1989 (the birth-year range of the early adoptees), which was 1.49% (24,613 of 1,651,266 male live births). The difference was highly significant at p < .00001, with a χ2 test. Rosenberg’s (2002a) skepticism about the possible relation between adoption and gender identity disorder is, perhaps, premature because she would have needed a sample of about 70 patients to detect an effect as large as ours with a power of 80% at p < .05 (two-tailed) and, given her sample size of 28 patients, her power at p < .05 (two-tailed) to detect a difference as large as ours is less than 45%. Kenneth J. Zucker, Ph.D. Susan J. Bradley, M.D. Child and Adolescent Gender Identity Clinic Child Psychiatry Program Centre for Addiction and Mental Health-Clarke Division Toronto Menvielle EJ, Tuerk C (2002), A support group for parents of gender-nonconforming boys. J Am Acad Child Adolesc Psychiatry 41:1010–1013 Rosenberg M (2002a), Gender-nonconforming boys (letter). J Am Acad Child Adolesc Psychiatry 41:1394 Rosenberg M (2002b), Children with gender identity issues and their parents in individual and group treatment. J Am Acad Child Adolesc Psychiatry 41:619–621 Zucker KJ, Bradley SJ (1998), Adoptee overrepresentation among clinicreferred boys with gender identity disorder. Can J Psychiatry 43:1040–1043 DOI: 10.1097/01.CHI.0000046852.56865.59
ZIPRASIDONE IN AUTISM To the Editor: In the recent article by McDougle et al. titled, “Case Series: Use of Ziprasidone for Maladaptive Symptoms in Youths With 622
Autism,” among the six nonresponders, two are worthy of further consideration (McDougle et al., 2002). These patients, numbers 6 and 12 in Table 1, were described as becoming worse on ziprasidone. In addition to having diagnoses of pervasive developmental disorder not otherwise specified or autistic disorder, they were also described as having bipolar I disorders. In both cases, ziprasidone (80 mg/day) was used in conjunction with several other psychotropic medications. From this presentation, one might conclude that ziprasidone is not effective in the treatment of bipolar type I disorders. Adult studies have demonstrated the efficacy of ziprasidone in the treatment of schizoaffective and bipolar type I disorders (Keck et al., 2001, in press). Ziprasidone dosing of 80 and 160 mg were compared, with 160 mg shown to be superior. Furthermore, despite 200 mg being a maximum recommended dose, select populations have been shown to require higher doses (Citrome and Volavka, 2002). I would like to report on three adolescent bipolar I cases in which ziprasidone was successfully used during the acute as well as the maintenance phase of treatment. Two 15-year-old males and one 17-year-old female, who had previous histories of unresponsive mania and psychosis, were started on ziprasidone. Ziprasidone was begun at 20 mg b.i.d. and increased over 2 to 4 weeks to levels of 200 to 240 mg/day. All patients received either lithium or a combination of lithium and valproic acid, but all had not shown significant clinical responses when other atypical antipsychotics were used with concomitant mood stabilizers. All had adverse effects (in particular, marked weight gain). On the ziprasidone, they showed decreases in psychosis and a reduction in manic symptoms at lower doses, but at higher doses the psychosis, especially auditory hallucinations, were significantly reduced and eliminated in two cases. In addition, all have been described as having better concentration and improved socialization. The principal side effect was sedation, which lessened over a 4-week period. Serial QTc measures did not demonstrate a significant prolongation in any of the patients, and none have had any weight gain with the use of the ziprasidone. These patients were begun conservatively at dosage levels as indicated by Dr. McDougle of 40 mg twice a day (for a total of 80 mg). In each case, higher doses were required. With this dosing, there were initial periods of somnolence and tiredness, but these symptoms abated with few side effects. Unlike the cases noted in McDougle’s report, concomitant antipsychotics were not used. These three cases demonstrate that the response of the psychosis associated with bipolar I disorders is comparable with that seen in the literature for the treatment of schizoaffective and bipolar disorders in adults. This raises the potential efficacy of ziprasidone in the treatment of adolescents with bipolar I disorders and the need for further research using ziprasidone to understand its pharmacokinetic and clinical applicability in children and adolescents with severe psychiatric disorders.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 6 , J U N E 2 0 0 3