- Email: [email protected]
BABY JESSICA
LETTERS TO THE EDITOR Knell E, Comings, DE (1993), Tourette syndrome and attention deficit hyperactivity disorder: evidencefor a genetic relationship. ] Clin Psychiatry 54:331-337 Pauls DL, Hurst CR, Kruger SD, Leckman JF, Kidd KK, Cohen DJ (1986), Gilles de la Tourerte's syndrome and attention deficit disorder with hyperactivity: evidence against a genetic relationship. Arch Gen Psychiatry 43: 1177-1179 Pauls DL, Leckman JF, Cohen DJ (1993), Familial relationship between Gilles de la Tourette's syndrome, attention deficit disorder, learning disabilities, speech disorders, and stuttering. ] Am Acad Child Adolesc Psychiatry 32: 1044-1050 Pauls DL, Leckman JF, Raymond CL, Hurst CR, Stevenson JM (1988), A family study of Tourette's syndrome: evidence against the hypothesis of association with a wide range of psychiatric phenotypes. Am] Hum Genet 43:A64
Chase TN, Friedhoff AJ, Cohen DJ (eds) (1992), Tourette Syndrome: Genetics, Neurobiology and Treatment. New York: Raven Press Cohen DJ, Bruun RD, Leckman JF (eds) (1988), Tourette's Syndrome and Tic Disorders. New York: John Wiley and Sons Pauls DL, Leckman JF, Cohen DJ (1993), Familial relationship between Gilles de la Tourette's syndrome, attention deficit disorder, learning disabilities, speech disorders, and stuttering. ] Am Acad Child Adolesc Psychiatry 32:1044-1050
The authors reply:
Like many adoptive parents, I cried on August 2, 1993, when 2!h-year-oldJessica was ripped away from her adoptive parents in Michigan. The highest court in our land voted 6 to 2 in favor of blood ties over psychological attachment. Jessica had lived all of her 30 months with the DeBoers in Michigan. But the birth mother had changed her mind and enlisted the help of the birth father, who had not consented to the adoption. The appeal process dragged through the courts of Michigan and Iowa for 2!hyears. The Iowa courts awarded the girl to the now-married, biological parents. The U.S. Supreme Court refused to block the transfer. A media feeding frenzy was unleashed when Jessica was taken from her adoptive parents. The DeBoers' lawyer drove Jessica from their house to the Ann Arbor police station to surrender Jessica to her birth parents. Apparently, Jessica was shouting "I want my dad. Where's my dad?" When Jessica cried, we all cried. The legal system had failed another child. The public outrage was predictable and, surprisingly, sustained. There is widespread recognition that psychologically bonded children should not be shifted around from home to home. There is public interest in changing some of the legal pitfalls during adopting. In Ohio there is a 6"month waiting period before a final adoption decree is granted. The judge's ruling can be appealed up to 1 year later. In Kentucky, the waiting period is 60 days with a 30-day appeal period after the adoption decree. The briefer period would apparently be in the best interest of a child going through adoption. This "waiting period" puts adoptive parents through hell. No matter how well defended you are psychologically, you have to worry that the birth mother/father will have a change of heart and rip your baby away. My wife and I adopted a baby girl 7 years ago. During the forced "waiting period" I remember looking at a map to make an escape route for my new family. If the birth mother wanted Whitney back, would we run to Canada or cross the Atlantic? How can the courts expect adoptive parents to surrender children they love? As child psychiatrists, we must do something to prevent such court-effected kidnapping, abuse, and neglect. In the
The letter from Drs. David and Brenda Comings adds our ongoing dialogue concerning the relationship between Gilles de la T ourette's syndrome (TS) and attention-deficit hyperactivity disorder (ADHD) and other developmental disorders. We share their longstanding goal to understand the range of clinical manifestations of TS and the nature of the transmission of the underlying genetic diathesis. We appreciate the presentation from their studies and are pleased to confirm (partially) the view that some forms of ADHD are etiologically related to TS (Pauls et al., 1993). The findings by Comings and Comings in their letter are also consistent with other portions of our data. Where their findings differ from ours is in the increased rate of learning disorders, speech problems, and stuttering among their nonproband TS relatives. This difference may be a methodological one. In our studies, we have relied on personal interviews of the probands and their relatives as well as family history information to determine diagnoses. It is our understanding from their previous publications and presentations that their data have come from interviews with the probands and/or their parents but the data about relatives have come from self-report questionnaires. Along with the Drs. Comings, we and other researchers have discussed the multifaceted clinical features of patients with TS (see reviews and references in Cohen et al., 1988; and Chase et al., 1992). Yet, we and many others in the field remain cautious about the overextension ofthe diagnosis of TS as such. Additional research, including the more precise delineation of the genetics and the localization of the gene(s) conferring risk for TS and other behaviors, will greatly clarify these differences of opinion. Imaginative and competing hypotheses, such as offered by Comings and Comings, continue to help stimulate research in this area. David L. Pauls, Ph.D. James F. Leckman, M.D. Donald J. Cohen, M.D. Yale Child Study Center New Haven, CT to
430
J.
BABY JESSICA
To the Editor:
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994
LETTERS TO THE EDITOR
movie Citizen Kane, Orson Wells gripped his sled, Rosebud, when he was being dragged from his home. Now, Jessica, transported to a new family in Iowa, may be fixating on some transitional object toy left behind in Michigan. The Supreme Court did not send all her clothes, toys, bedroom, or her parents to her new home. The legal system actually kidnapped her. What can child psychiatrists do now? I have turned to some of my lawyer friends to get their advice about changing state laws that require such a lengthy waiting period before an adoption is final. I have written to the local papers and Bar Association about my professional and personal concern that the courts may be dangerous for adoptive families. I suppose the final solution will be political. Therefore, my next step will be to contact our state psychiatric association and medical association to plan an intervention with some important legislators. Jessica is crying. We must do something. Let me know what you are doing locally. Perhaps our Academy can make a political impact nationally so that our courts will make decisions based on the best interests of adoptive children. Until then, children like Jessica will fall asleep crying for their "real," bonded parents and home. Michael Maloney, M.D. Children's Hospital Medical Center Cincinnati, OH Fax (513) 559-7247
CLOZAPINE FOR SCHIZOPHRENIA To the Editor:
Clozapine is one of the first effective antipsychotic agents to have few of the extrapyramidal side effects typical of nearly all antipsychotic agents in adult psychiatry clinical use. Blanz et al. (1993) and Birmaher et al. (1992) report in recent articles successful trials of clozapine in schizophrenic adolescents who did not respond to conventional neuroleptic treatment. We used clozapine to treat 13 adolescents diagnosed as having adolescent-onset schizophrenia. The patients were between 14 and 17 years of age (mean age 16.6 years); seven were boys and six girls. Ten patients were experiencing their second hospital admission; three patients, their third one. Before clozapine all patients had received other neuroleptic drugs (average three neuroleptics) and none had responded to previously given antipsychotic drugs. The average daily dose of clozapine was 240 mg/day; the mean duration of intake was 245 days. Ten of these 13 patients improved significantly, with a decline of 50% in Brief Psychiatric Rating Scale after 2
months; 2 patients partly improved; and in 1 patient clozapine was discontinued because of symptomatic orthostatic hypotension after 2 days of treatment. Side effects were tiredness during daytime in four patients, hypersalivation in one patient, and elevation in temperature in one patient. We did not find any decrease in leukocyte count despite weekly blood sample examination. We concur, therefore, with the findings of Blanz et al. (1993) and Birmaher et al. (1992) regarding the usefulness of clozapine as an effective medication to schizophrenia refractory to other neuroleptic drugs.
Y. Levkovitch, M.D. N. Kaysar, M.D. Y. Kronnenberg, M.D. H. Hagai, M.D. B. Gaoni, M.D. Shalvata Mental Health Center Israel Birmaher B, Baker, R, Kapur S, Quintana H, Ganguli R (1992), Clozapine for the treatment of adolescents with schizophrenia. JAm Acad Child Adolesc Psychiatry 31: 160-164 Blanz B, Schmidt MH (1993), Clozapine for schizophrenia (letter). JAm
Acad ChildAdolesc Psychiatry 32:223-224
IMIPRAMINE AND ASPERGER'S To the Editor:
It has been proposed that Asperger's syndrome be included in the DSM-IV, within the Pervasive Developmental Disorder category of diagnoses (Volkmar, 1991). While it has been noted that comorbid mood and anxiety disorders do occur (Ryan, 1992; Szatmari, 1991), recognition of such conditions may be complicated by the features of Asperger's syndrome. Recently, a 15-year-old male patient diagnosed with the condition some 2 years ago was brought by his father on the basis of behavioral changes associated with school refusal: increased pacing at home, decline in self-care, initial insomnia/decreased appetite, and somatic complaints of a gastrointestinal nature. The patient has indicated to his father that he was amenable to being brought for help. However, at interview he was unable to verbalize his feelings despite being obviously distressed. This occurred on two separate occasions. On the second occasion we decided to commence a low dose of imipramine (25 mg at night). The next week, the father reported a marked improvement: the patient had returned to school, was sleeping better, had improved self-care, and generally was less agitated and was amenable to interaction. The dose of imipramine was increased to 50 mg at night, resulting in a return to premorbid levels of functioning and mental state over the next 2 weeks.
j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994
431
Chase TN, Friedhoff AJ, Cohen DJ (eds) (1992), Tourette Syndrome: Genetics, Neurobiology and Treatment. New York: Raven Press Cohen DJ, Bruun RD, Leckman JF (eds) (1988), Tourette's Syndrome and Tic Disorders. New York: John Wiley and Sons Pauls DL, Leckman JF, Cohen DJ (1993), Familial relationship between Gilles de la Tourette's syndrome, attention deficit disorder, learning disabilities, speech disorders, and stuttering. ] Am Acad Child Adolesc Psychiatry 32:1044-1050
The authors reply:
Like many adoptive parents, I cried on August 2, 1993, when 2!h-year-oldJessica was ripped away from her adoptive parents in Michigan. The highest court in our land voted 6 to 2 in favor of blood ties over psychological attachment. Jessica had lived all of her 30 months with the DeBoers in Michigan. But the birth mother had changed her mind and enlisted the help of the birth father, who had not consented to the adoption. The appeal process dragged through the courts of Michigan and Iowa for 2!hyears. The Iowa courts awarded the girl to the now-married, biological parents. The U.S. Supreme Court refused to block the transfer. A media feeding frenzy was unleashed when Jessica was taken from her adoptive parents. The DeBoers' lawyer drove Jessica from their house to the Ann Arbor police station to surrender Jessica to her birth parents. Apparently, Jessica was shouting "I want my dad. Where's my dad?" When Jessica cried, we all cried. The legal system had failed another child. The public outrage was predictable and, surprisingly, sustained. There is widespread recognition that psychologically bonded children should not be shifted around from home to home. There is public interest in changing some of the legal pitfalls during adopting. In Ohio there is a 6"month waiting period before a final adoption decree is granted. The judge's ruling can be appealed up to 1 year later. In Kentucky, the waiting period is 60 days with a 30-day appeal period after the adoption decree. The briefer period would apparently be in the best interest of a child going through adoption. This "waiting period" puts adoptive parents through hell. No matter how well defended you are psychologically, you have to worry that the birth mother/father will have a change of heart and rip your baby away. My wife and I adopted a baby girl 7 years ago. During the forced "waiting period" I remember looking at a map to make an escape route for my new family. If the birth mother wanted Whitney back, would we run to Canada or cross the Atlantic? How can the courts expect adoptive parents to surrender children they love? As child psychiatrists, we must do something to prevent such court-effected kidnapping, abuse, and neglect. In the
The letter from Drs. David and Brenda Comings adds our ongoing dialogue concerning the relationship between Gilles de la T ourette's syndrome (TS) and attention-deficit hyperactivity disorder (ADHD) and other developmental disorders. We share their longstanding goal to understand the range of clinical manifestations of TS and the nature of the transmission of the underlying genetic diathesis. We appreciate the presentation from their studies and are pleased to confirm (partially) the view that some forms of ADHD are etiologically related to TS (Pauls et al., 1993). The findings by Comings and Comings in their letter are also consistent with other portions of our data. Where their findings differ from ours is in the increased rate of learning disorders, speech problems, and stuttering among their nonproband TS relatives. This difference may be a methodological one. In our studies, we have relied on personal interviews of the probands and their relatives as well as family history information to determine diagnoses. It is our understanding from their previous publications and presentations that their data have come from interviews with the probands and/or their parents but the data about relatives have come from self-report questionnaires. Along with the Drs. Comings, we and other researchers have discussed the multifaceted clinical features of patients with TS (see reviews and references in Cohen et al., 1988; and Chase et al., 1992). Yet, we and many others in the field remain cautious about the overextension ofthe diagnosis of TS as such. Additional research, including the more precise delineation of the genetics and the localization of the gene(s) conferring risk for TS and other behaviors, will greatly clarify these differences of opinion. Imaginative and competing hypotheses, such as offered by Comings and Comings, continue to help stimulate research in this area. David L. Pauls, Ph.D. James F. Leckman, M.D. Donald J. Cohen, M.D. Yale Child Study Center New Haven, CT to
430
J.
BABY JESSICA
To the Editor:
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994
LETTERS TO THE EDITOR
movie Citizen Kane, Orson Wells gripped his sled, Rosebud, when he was being dragged from his home. Now, Jessica, transported to a new family in Iowa, may be fixating on some transitional object toy left behind in Michigan. The Supreme Court did not send all her clothes, toys, bedroom, or her parents to her new home. The legal system actually kidnapped her. What can child psychiatrists do now? I have turned to some of my lawyer friends to get their advice about changing state laws that require such a lengthy waiting period before an adoption is final. I have written to the local papers and Bar Association about my professional and personal concern that the courts may be dangerous for adoptive families. I suppose the final solution will be political. Therefore, my next step will be to contact our state psychiatric association and medical association to plan an intervention with some important legislators. Jessica is crying. We must do something. Let me know what you are doing locally. Perhaps our Academy can make a political impact nationally so that our courts will make decisions based on the best interests of adoptive children. Until then, children like Jessica will fall asleep crying for their "real," bonded parents and home. Michael Maloney, M.D. Children's Hospital Medical Center Cincinnati, OH Fax (513) 559-7247
CLOZAPINE FOR SCHIZOPHRENIA To the Editor:
Clozapine is one of the first effective antipsychotic agents to have few of the extrapyramidal side effects typical of nearly all antipsychotic agents in adult psychiatry clinical use. Blanz et al. (1993) and Birmaher et al. (1992) report in recent articles successful trials of clozapine in schizophrenic adolescents who did not respond to conventional neuroleptic treatment. We used clozapine to treat 13 adolescents diagnosed as having adolescent-onset schizophrenia. The patients were between 14 and 17 years of age (mean age 16.6 years); seven were boys and six girls. Ten patients were experiencing their second hospital admission; three patients, their third one. Before clozapine all patients had received other neuroleptic drugs (average three neuroleptics) and none had responded to previously given antipsychotic drugs. The average daily dose of clozapine was 240 mg/day; the mean duration of intake was 245 days. Ten of these 13 patients improved significantly, with a decline of 50% in Brief Psychiatric Rating Scale after 2
months; 2 patients partly improved; and in 1 patient clozapine was discontinued because of symptomatic orthostatic hypotension after 2 days of treatment. Side effects were tiredness during daytime in four patients, hypersalivation in one patient, and elevation in temperature in one patient. We did not find any decrease in leukocyte count despite weekly blood sample examination. We concur, therefore, with the findings of Blanz et al. (1993) and Birmaher et al. (1992) regarding the usefulness of clozapine as an effective medication to schizophrenia refractory to other neuroleptic drugs.
Y. Levkovitch, M.D. N. Kaysar, M.D. Y. Kronnenberg, M.D. H. Hagai, M.D. B. Gaoni, M.D. Shalvata Mental Health Center Israel Birmaher B, Baker, R, Kapur S, Quintana H, Ganguli R (1992), Clozapine for the treatment of adolescents with schizophrenia. JAm Acad Child Adolesc Psychiatry 31: 160-164 Blanz B, Schmidt MH (1993), Clozapine for schizophrenia (letter). JAm
Acad ChildAdolesc Psychiatry 32:223-224
IMIPRAMINE AND ASPERGER'S To the Editor:
It has been proposed that Asperger's syndrome be included in the DSM-IV, within the Pervasive Developmental Disorder category of diagnoses (Volkmar, 1991). While it has been noted that comorbid mood and anxiety disorders do occur (Ryan, 1992; Szatmari, 1991), recognition of such conditions may be complicated by the features of Asperger's syndrome. Recently, a 15-year-old male patient diagnosed with the condition some 2 years ago was brought by his father on the basis of behavioral changes associated with school refusal: increased pacing at home, decline in self-care, initial insomnia/decreased appetite, and somatic complaints of a gastrointestinal nature. The patient has indicated to his father that he was amenable to being brought for help. However, at interview he was unable to verbalize his feelings despite being obviously distressed. This occurred on two separate occasions. On the second occasion we decided to commence a low dose of imipramine (25 mg at night). The next week, the father reported a marked improvement: the patient had returned to school, was sleeping better, had improved self-care, and generally was less agitated and was amenable to interaction. The dose of imipramine was increased to 50 mg at night, resulting in a return to premorbid levels of functioning and mental state over the next 2 weeks.
j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994
431