CD

LETTERS

TO

THE

EDITOR

LACTOSE IN BUSPIRONE

To the Editor: I read with great interest the psychopharmacology update in the May issue of the Journal and would like to alert you and other clinicians to the presence of lactose in buspirone (Physiciam' Desk Reference, 1999). Riddle et al. (1999) suggested buspirone will be used with increasing frequency in children and adolescents with overanxious disorder, avoidant disorder, social phobia, generalized anxiety disorder, depression, and obsessivecompulsive disorder. Side effects are generally mild and most often include gastric upset, dizziness, sedation, headaches, and insomnia (Kutcher et al., 1995). I am reporting a case of an adolescent with lactose intolerance treated with sertraline for generalized anxiety disorder. With the addition of buspirone for persistent anxiety, the adolescent's nausea and vomiting worsened. When buspirone was discontinued, her gastrointestinal symptoms abated. Acquired lactase deficiency is common, with prevalence rates of 0% in Dutch populations to 100% in Asian populations, with white Americans reported at 24% ( Riley et al., 1998). Since lactose intolerance is quite variable, buspirone use is not a contraindication in these patients, but clinicians should be aware of this possible side effect. Maryland Pao, M.D. Consultation Liaison Service Children's National Medical Center Washington, DC Kutcher S, Reiter S, Gardner 0 (1995), Pharmacotherapy: approaches and applications. In: Anxiety Disorders in Children and Adolescents, March J, ed. New York: Guilford, pp 341-385 Physicians'Desk Reference (1999), Montvale, NJ: Medical Economics Company, p 823 Riddle MA, Bernstein GA, Cook EH, Leonard HL, March JS, Swanson JM (1999), Anxiolytics, adrenergic agents, and naltrexone. JAm Acad Child Adolesc Psychiatry 38:546-556 Riley SA, Marsh MN (1998), Maldigestion and malabsorption. In: Sleisenger

and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management, Feldman M, Sleisenger MH, Scharschmidt BE eds. Philadelphia: Saunders

RISPERIDONE IN COMORBID ADHD AND ODD/CD

To the Editor: I would like to add our clinic's experience in the use of risperidone to that of Demb and Nguyen (1999). Although little has been written about its use in children, leaving clinicians

somewhat unsupported, many clinicians managing children and adolescents with complex attention-deficit/hyperactivity disorder (ADHD) find it a very effective medication. Our clinic specializes in the assessment and management of children and adolescents with ADHD and related conditions; we receive national and international referrals. We have found risperidone particularly useful in children with ADHD, comorbid with oppositional defiant disorder and conduct disorder (ODD/CD) of early onset. Some may have coexisting bipolar disorder. We have been using risperidone since 1993-combining it with methylphenidate or dextroamphetamine-when a psychostimulant to treat the core symptoms, plus the addition of clonidine or nortriptyline, plus psychosocial strategies, has not been effective in helping the ODDICD symptoms. Our recent audit data show that 38% of the 2,400 children assessed had combined ADHD with ODD or CD; about half of these cases were of early onset. With appropriate medication in this early-onset group it was possible to obtain a very good response in 92%. Seventy-three percent of the total group needed a second medication to obtain this result. Clonidine was the medication most used. When clonidine failed, risperidone was generally used. Thirty children were treated with risperidone. The ages ranged from 6 to 21 years. Twenty-eight had the diagnosis of combined ADHD, and 2 had inattentive plus impulsive ADHD. All had early-onset ODDICD as well. Twenty-nine of the 30 may have met the criteria for bipolar disorder, 50% had associated learning difficulties, 1 had associated Asperger's syndrome, and 3 had significant tics or Tourette's disorder in addition toADHD. The time interval berween making the diagnosis and the institution of risperidone treatment was berween 0 months and 6 years, in most cases berween 4 and 24 months. In the interim other strategies had been tried. For example, clonidine had been previously used in 28 of the 30 children. Only 2, because of the severity of their problems, were started directly on risperidone. The daily dosage used was berween 0.5 mg and 6 mg. The doses did not appear to be related to age or weight, but to individual response. Fifty percent of the children required a rwice-daily dosage, whereas in 12 children once daily was sufficient and 3 children required a three-times-daily regimen. Results show that 20 (67%) of the 30 children showed a very significant improvement in symptoms. Five of the 20 showed a moderate improvement and in 5 the risperidone was stopped, either because of no improvement (in 2) or

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 38:11, NOVEMBER 1999

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LETTERS TO THE EDITOR

excessive weight gain (in 3 ) . The most common side effect was excessive weight gain, occurring in 10 patients. Vomiting and drowsiness occurred in 1 patient each; 1 patient experienced withdrawal dyskinesia, but reinstitution of risperidone and slower withdrawal produced no recurrence. The higher incidence of dyskinetic side effects reported by Demb and Nguyen was not shown in this series. All patients were requested to have liver function tests. These were undertaken in 15 patients and all had normal results. The maximum period of treatment so far is 4 years. The impression is that most children have an ongoing need for risperidone and discontinuation of risperidone results in a recrudescence of symptoms. These preliminary audit data show that risperidone may have a place in the management of children with ADHD with associated severe early-onset O D D / C D , when other treatments have proved unsuccessful. It is associated with very significant improvements in a high percentage of this difficult-to-treat population. Excessive weight gain has been the main side effect, and concerns about a high incidence of dyskinesia have so far not been substantiated. The dosage of risperidone used is generally less than that suggested for schizophrenia. Further controlled studies are necessary. Untreated, this group of children and adolescents have an extremely high incidence of long-term educational, psychiatric, and antisocial morbidity, and any risks associated with the use of risperidone need to be balanced against the poor prognosis of the untreated disorder in this group.

Geoffrey D. Kewley, F.R.C.P. Learning Assessment Centre West Sussex, England Demb HB, Nguyen KT (1999), Movement disorders in children with developmental disabilities raking risperidone. 1Am Arud Child Adolesr PTrhiatry 38:5-6

HALLUCINATIONS IN NONPSYCHOTIC CHILDREN

To the Editor: We read Dr. Schreier’s Clinical Perspectives article on hallucinations in nonpsychotic children (May 1999) with great interest, in particular his reference to this phenomenon associated with Tourette’s disorder. For several years we have been intrigued by hallucinations reported by nonpsychotic children with Tourette’s disorder. A search of the literature on Tourette’s disorder and hallucinations revealed reports of Tourettekic disorder patients with schizophrenia as well as the occurrence of schizophreniform symptoms in children with Tourette’sdisorder (Comings, 1990; Kerbeshian and Burd, 1988). Kerbeshian and Burd (1987) described Tourette’sdisorder patients with “intense inner auditory

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or visual eidetic thought (which) may approximate hallucina-

tions” (p. 127).They postulated that “developmentallydisordered children with Tourette symptomatology and associated conditions such as attention-deficit disorder or obsessive-compulsive symptoms, are more likely to exhibit schizophreniform symptoms” (p. 127).They did not, however, report genuine auditory or visual hallucinations (Kerbeshian and Burd, 1987). Reporting on 2 cases of atypical tic disorder, these same authors suggested that “clinicians evaluating patients with tic disorders may wish to inquire routinely about unusual auditory experiences” (Kerbeshian and Burd, 1985, p. 398). Comings (1990) came closer to describing actual hallucinations by stating, “some TS patients have schizophrenia-like symptoms that are milder versions of those seen in schizophrenia itself” (p. 199). He cited a controlled study in which “hearingvoices was a symptom present in 2% of controls and 14.6% of Tourette patients” (Comings, 1990, pp. 200-201). As clinicians specializing in the treatment of Tourette’s disorder, we have not routinely asked about hallucinations. However, a number of patients or their parents have mentioned them in the course of treatment. A review of the 100 most recent Tourette‘s cases we have evaluated (ruling out cases with concomitant pervasive developmental disorders, schizophrenia, bipolar disorder, or possible seizure disorder) produced 5 who described auditory hallucinations. Two of these also described visual hallucinations. These were not eidetic images or “mental tics.” All 5 patients had anxiety symptoms; 1 had panic attach. Four had obsessive-compulsive disorder or obsessive-compulsive symptomatology. Four also had attention deficit disorder. Although all were talung medication, there was no indication that hallucinations were caused by medication. Dr. Schreier has previously found a positive correlation with migraine and nonpsychotic children who hallucinate (Schreier, 1998). However, only one of our patients complained of migraine symptoms. Auditory hallucinations experienced included hearing muffled voices, hearing 2 voices arguing (usually a good and an evil voice), and hearing music. Visual hallucinations consisted in one case of seeing bodies floating without heads. In another case a young boy saw a child, resembling himself, who was beckoning to him. In all cases these hallucinations were repetitive over a period of time. The source of these hallucinations is unclear and merits more investigation. We would like to join Dr. Schreier in recommending that physicians treating Tourette’s disorder begin to ask specifically about the occurrence of hallucinations.

Ruth Dowling Bruun, M.D. Cathy L. Budman, M.D. Department of Psychiatry North Shore University Hospital New York University Medical Center New York

J . A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 3 8 : 1 1 , N O V E M B E R 1999