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The Use of Long - Acting Tranquilizers with Hyperactive Children
The Use of Long -Acting Tranquilizers with Hyperactive Children HOUSTON BRUMMIT,
• The Child Guidance Clinic of the BrooklynCumberland Medical Center is one of the three municipal O.P.D.'s in Brooklyn, New York and serves approximately one-third of tIl(' community. Our chief referral source is tht' New York Public School System and the presenting problem is generally "conduct disorder." The most common symptoms is hyperactivity. Solomons t • distinguishes four types of hyperactivity in children: 1) the constitutionally overactive child whose motor pattern has a faster tempo than that of the parents; 2) the i IIII/Ulture child (Maturation lag) whose behavior is more typical of a younger group; 3) the child with an emotional disturbance du(' to neurotic or psychotic causes; 4) the child with diffuse brain damage due to trauma or encephalitis. Werry, et a1.,' described "a hypprkinetic syndrome" characterized by chronic sustained hyperactivity, marked distractihility to extraneous stimuli, very short attention span, irritability and hyperexcitability. have also found hyperactivity to be associated with thyrotoxicosis. Hyperkinesis is manifested in classrooms by children who are talkative, talking out of [Ilrn, are Ollt of their seats, wandering around the classroom or through the halls, touching everyone and everything, not functioning up to academic potential, retarded in reading and arithmetic, drumming or tapping, biting fingernails, fidgeting and fighting other children. These children are frequently suspended from school. \fany psychologists, guidance counselors and parents view a neurological evaluation as the way to solve the problem of these chil-
"'e
Dr. Brummit is Director. Child Guidance Program, Cumberland Hospital ~Iental Hygiene Clinic, Brooklyn-Cumberland ~Iedical Center, 39 Auburn Place, Brooklyn, ~. Y. 11205. May-June, 1968
M.D.
dren and assume that with an EEG the specific medication can be determined. Our experience has been that when there are no obvious physical deficits, such as cerebral palsy, hyperactive children are neurologically negative. Likewise, perceptual distortion on a psychological testing, rotation of the Bender Gestalt, mixed dominance, history of premature birth, etc. are common findings in both overly active and normally active children, yet do not pin-point a reliable neurological entity. Without a clinical history of seizures, an abnormal electroencephalogram does not indicate the need for anticonvulsants. RATIO!\ALE FOR A
LO~G-ACn]l;C
~lEDiCATIO~
Although tranquilizers calm the hyperactive child, their administration is not always constant. Tablets given in divided dosages may be effective during the morning hours, however, when they wear off at 12 or 1 o'clock at school, hyperactivity returns. With a clientele in which 35 per cent of our patients break appointments, adequate tranquilization is not given to many children because of the inability of the parents to cooperate. These mothers, who are often unwilling and unable to follow "complicated" medical routines, become impatient and abandon the effort. Long acting sustained release capsules ("Spansule" capsules) were utilized in our clinic because they simplified management and had minimal side effects. 3 The novelty of a capsule lasting 10 to 12 hours pleased the parents. They did not have to attend to administering medication two or three times a day. In 421 new cases seen at our Child Guidance Clinic, 134 were "hyperactive." The diagnosis in 53 per cent was "adjustment reaction of childhood, conduct disturbance." :Sine per cent (13) were schizophrenic. The children were screened by the Pediatric Clinic and managed by the pediatricians when indicated. Blood counts and an electroencephalogram 157
PSYCHOSOMATICS
were performed on each child. Twenty-one (16.4% ) were girls and 113 (83.6%) were hoys. Hyperactivity occurred at a later age in the girls. The mean age for the 21 girls was 11.5 years with an age range of 4 to 15 years. For the 113 boys, the mean age was 7.05 years with an age range of 2~ to 15 years. Treatment was oriented towards control of hyperactivity, and all 134 hyperactive children were placed on chlorpromazine sustained release capsules. Dosages were determined by the amount required to hring hyperactivity under control. For examplt>, a 3-year-old hoy who had failed to respond to amphetamine, diphenhydramine and chlorpromazine tablets, eventually required a 75 mg sustained release capsule of chlorpromazine in the morning and a 25 mg tablet in the evening. On this schedule, he never slept during the day, was able to benefit from remedial therapy and suhsequently entered nursery school. RESULTS
Of the 134 children placed on chlorpromazine sustained release capsules, 20 did not return after the initial contact nor respond to three subsequent appointments by mail, requesting them to return. Of the remaining 114, 81 or 71 per cent improved, and 43 or 29 per cent were failures. l':ine of those who did not respond required institutional placement. Sixty-nine (or 51%) received 75 mg or more of chlorpromazine each morning. The mean age of these patients was 7.8 years. Sixty ( 44%) received 30 mg of chlorpromazine in the morning; their mean age was 8.1 years. The other children were given two 30 mg capsules in the morning with the exception of the one child who required a 75 mg capsule in the morning and a 25 mg Thorazine tablet in the evening. Of the 13 schizophrenic children, six improved and seven did not respond. Stomach upset occurred in three children and cleared with the discontinuation of the medication. In two severely defective girls (one did not know her own name) there were convulsive seizures. With the brighter of the two, convulsive seizures also recurred while she was on thioridazine. The second child had been 158
hospitalized at nine months of age for convulsions of unknown etiology. Although the 114 children had no specific evidence to suggest epilepsy, a review and correlation of all EEG findings will be reported in a subse(jucnt paper. Drowsiness around 1 or 2 o'clock was sometimes a reaction to the drug and usually disconcerting to teachers and parents alike. The effect generally wore off within two days of continued medication. If it persisted, the dosage was reduced. Occasionally some children were active before noon and sleepy after lunch, which suggested that some of the capsules may have been uneven in their effect. As an adjunct! to the medication, parents were instructed to urge their children to be better behaved and to see tranquilization as making it easier for them to instill "self-control" in their children. In many instances parents were satisfied with the use of the sustained release capsules of chlorpromazine; class performance improved, fighting ceased or was cut down and the schools complained less. Failure of the children to respond was sometimes due to the non-specificity of chlorpromazine for the particular child to whom it was given, as well as to unreliable parents who were not consistent in giving the medication. The unreliable parents returned to the clinic for more medication only when the school authorities threatened to suspend the child. Reduction in dosage and eventual termination of the sustained release capsules of chlorpromazine was possible on favorable response of the child. The average length of therapy was 3 to 9 months, but in some it was considerably longer. Although we have not completely evaluated our data, it was noted that after 6 to 12 months some developed a toleranc& to chlorpromazine. In such cases the dosage was increased or another drug substituted. Frequently, after an interval of one or two months, the chlorpromazine could be reinstituted. CONCLUSIONS
Chlorpromazine sustained release capsules can offer sustained control of hyperactive children for 6-12 months or even longer. The need for reduction of hyperactivity determines the dosage. It is not related to age, size or body weight. Volume IX
TRANQUILIZERS-BRUMMIT
In time the child mav become tolerant to chlorpromazine and may respond better to an increase of chlorpromazine or to another drug. Frequently after 1 to 2 months the chlorpromazine can be reinstituted. There were more boys than girls, in the ratio of 6 to 1. Hyperactivity occurred later in girls (mean age U.S years) than in boys (mean age 7.05 years). Although we have not completed the evaluation of EEG data on these children there has been no indication that an abnormal EEG is an important part of the hyperactivity syndrome. ACK/I;OWLEDGME:-;T
~lrs.
Ethelle Shatz helped to correlate the data in the records for this study. Smith, Kline and French, through Miss Margarette Aeugle, supported this study by
providing funds to carry out the correlation of the data. REFERENCES
1. Fish, B.: "Treatment of Children." Supplement to Internal. Psycho. CHn., 2/4. Psychoplwrmacology. Little, Brown and Company (Inc.) 1966.
2. Freedman, A. ~1., Effron, A. S. and Bender, L.: Pharmacotherapy in Children with Psychiatric Illness. ]. Nerv. Ment. Di~·., 122:464-469, August 1985. 3. Hunter, H. and Stephenson, G. ~1.: Chlorpromazine and Trifluoperazine in the Treatment of Behavioral Abnormalities in the Severely Suhnormal Child. Brit. ]. Psych., 109:411-417, ~tay 1963. 4. Solomons, G.: The Hyperactive Child. ]. larva !lied. Soc., 55:464-469, August 1965. 5. Werry, J. S., Weiss, G. and Douglas, V.: Studies on the Hyperactive Child, Some Preliminary Findmgs. CaruJd. Psych. A~s. ]., 9: 120-130, April 1964.
39 Auburn Place Brooklyn, N. Y. 11201
Things cannot always go your way. Learn to accept in silen<..-e the minor aggravations, cultivate the gift of taciturnity and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaints. -LIFE OF SIR WILLIAM OSLER
May-June, 1968
159
• The Child Guidance Clinic of the BrooklynCumberland Medical Center is one of the three municipal O.P.D.'s in Brooklyn, New York and serves approximately one-third of tIl(' community. Our chief referral source is tht' New York Public School System and the presenting problem is generally "conduct disorder." The most common symptoms is hyperactivity. Solomons t • distinguishes four types of hyperactivity in children: 1) the constitutionally overactive child whose motor pattern has a faster tempo than that of the parents; 2) the i IIII/Ulture child (Maturation lag) whose behavior is more typical of a younger group; 3) the child with an emotional disturbance du(' to neurotic or psychotic causes; 4) the child with diffuse brain damage due to trauma or encephalitis. Werry, et a1.,' described "a hypprkinetic syndrome" characterized by chronic sustained hyperactivity, marked distractihility to extraneous stimuli, very short attention span, irritability and hyperexcitability. have also found hyperactivity to be associated with thyrotoxicosis. Hyperkinesis is manifested in classrooms by children who are talkative, talking out of [Ilrn, are Ollt of their seats, wandering around the classroom or through the halls, touching everyone and everything, not functioning up to academic potential, retarded in reading and arithmetic, drumming or tapping, biting fingernails, fidgeting and fighting other children. These children are frequently suspended from school. \fany psychologists, guidance counselors and parents view a neurological evaluation as the way to solve the problem of these chil-
"'e
Dr. Brummit is Director. Child Guidance Program, Cumberland Hospital ~Iental Hygiene Clinic, Brooklyn-Cumberland ~Iedical Center, 39 Auburn Place, Brooklyn, ~. Y. 11205. May-June, 1968
M.D.
dren and assume that with an EEG the specific medication can be determined. Our experience has been that when there are no obvious physical deficits, such as cerebral palsy, hyperactive children are neurologically negative. Likewise, perceptual distortion on a psychological testing, rotation of the Bender Gestalt, mixed dominance, history of premature birth, etc. are common findings in both overly active and normally active children, yet do not pin-point a reliable neurological entity. Without a clinical history of seizures, an abnormal electroencephalogram does not indicate the need for anticonvulsants. RATIO!\ALE FOR A
LO~G-ACn]l;C
~lEDiCATIO~
Although tranquilizers calm the hyperactive child, their administration is not always constant. Tablets given in divided dosages may be effective during the morning hours, however, when they wear off at 12 or 1 o'clock at school, hyperactivity returns. With a clientele in which 35 per cent of our patients break appointments, adequate tranquilization is not given to many children because of the inability of the parents to cooperate. These mothers, who are often unwilling and unable to follow "complicated" medical routines, become impatient and abandon the effort. Long acting sustained release capsules ("Spansule" capsules) were utilized in our clinic because they simplified management and had minimal side effects. 3 The novelty of a capsule lasting 10 to 12 hours pleased the parents. They did not have to attend to administering medication two or three times a day. In 421 new cases seen at our Child Guidance Clinic, 134 were "hyperactive." The diagnosis in 53 per cent was "adjustment reaction of childhood, conduct disturbance." :Sine per cent (13) were schizophrenic. The children were screened by the Pediatric Clinic and managed by the pediatricians when indicated. Blood counts and an electroencephalogram 157
PSYCHOSOMATICS
were performed on each child. Twenty-one (16.4% ) were girls and 113 (83.6%) were hoys. Hyperactivity occurred at a later age in the girls. The mean age for the 21 girls was 11.5 years with an age range of 4 to 15 years. For the 113 boys, the mean age was 7.05 years with an age range of 2~ to 15 years. Treatment was oriented towards control of hyperactivity, and all 134 hyperactive children were placed on chlorpromazine sustained release capsules. Dosages were determined by the amount required to hring hyperactivity under control. For examplt>, a 3-year-old hoy who had failed to respond to amphetamine, diphenhydramine and chlorpromazine tablets, eventually required a 75 mg sustained release capsule of chlorpromazine in the morning and a 25 mg tablet in the evening. On this schedule, he never slept during the day, was able to benefit from remedial therapy and suhsequently entered nursery school. RESULTS
Of the 134 children placed on chlorpromazine sustained release capsules, 20 did not return after the initial contact nor respond to three subsequent appointments by mail, requesting them to return. Of the remaining 114, 81 or 71 per cent improved, and 43 or 29 per cent were failures. l':ine of those who did not respond required institutional placement. Sixty-nine (or 51%) received 75 mg or more of chlorpromazine each morning. The mean age of these patients was 7.8 years. Sixty ( 44%) received 30 mg of chlorpromazine in the morning; their mean age was 8.1 years. The other children were given two 30 mg capsules in the morning with the exception of the one child who required a 75 mg capsule in the morning and a 25 mg Thorazine tablet in the evening. Of the 13 schizophrenic children, six improved and seven did not respond. Stomach upset occurred in three children and cleared with the discontinuation of the medication. In two severely defective girls (one did not know her own name) there were convulsive seizures. With the brighter of the two, convulsive seizures also recurred while she was on thioridazine. The second child had been 158
hospitalized at nine months of age for convulsions of unknown etiology. Although the 114 children had no specific evidence to suggest epilepsy, a review and correlation of all EEG findings will be reported in a subse(jucnt paper. Drowsiness around 1 or 2 o'clock was sometimes a reaction to the drug and usually disconcerting to teachers and parents alike. The effect generally wore off within two days of continued medication. If it persisted, the dosage was reduced. Occasionally some children were active before noon and sleepy after lunch, which suggested that some of the capsules may have been uneven in their effect. As an adjunct! to the medication, parents were instructed to urge their children to be better behaved and to see tranquilization as making it easier for them to instill "self-control" in their children. In many instances parents were satisfied with the use of the sustained release capsules of chlorpromazine; class performance improved, fighting ceased or was cut down and the schools complained less. Failure of the children to respond was sometimes due to the non-specificity of chlorpromazine for the particular child to whom it was given, as well as to unreliable parents who were not consistent in giving the medication. The unreliable parents returned to the clinic for more medication only when the school authorities threatened to suspend the child. Reduction in dosage and eventual termination of the sustained release capsules of chlorpromazine was possible on favorable response of the child. The average length of therapy was 3 to 9 months, but in some it was considerably longer. Although we have not completely evaluated our data, it was noted that after 6 to 12 months some developed a toleranc& to chlorpromazine. In such cases the dosage was increased or another drug substituted. Frequently, after an interval of one or two months, the chlorpromazine could be reinstituted. CONCLUSIONS
Chlorpromazine sustained release capsules can offer sustained control of hyperactive children for 6-12 months or even longer. The need for reduction of hyperactivity determines the dosage. It is not related to age, size or body weight. Volume IX
TRANQUILIZERS-BRUMMIT
In time the child mav become tolerant to chlorpromazine and may respond better to an increase of chlorpromazine or to another drug. Frequently after 1 to 2 months the chlorpromazine can be reinstituted. There were more boys than girls, in the ratio of 6 to 1. Hyperactivity occurred later in girls (mean age U.S years) than in boys (mean age 7.05 years). Although we have not completed the evaluation of EEG data on these children there has been no indication that an abnormal EEG is an important part of the hyperactivity syndrome. ACK/I;OWLEDGME:-;T
~lrs.
Ethelle Shatz helped to correlate the data in the records for this study. Smith, Kline and French, through Miss Margarette Aeugle, supported this study by
providing funds to carry out the correlation of the data. REFERENCES
1. Fish, B.: "Treatment of Children." Supplement to Internal. Psycho. CHn., 2/4. Psychoplwrmacology. Little, Brown and Company (Inc.) 1966.
2. Freedman, A. ~1., Effron, A. S. and Bender, L.: Pharmacotherapy in Children with Psychiatric Illness. ]. Nerv. Ment. Di~·., 122:464-469, August 1985. 3. Hunter, H. and Stephenson, G. ~1.: Chlorpromazine and Trifluoperazine in the Treatment of Behavioral Abnormalities in the Severely Suhnormal Child. Brit. ]. Psych., 109:411-417, ~tay 1963. 4. Solomons, G.: The Hyperactive Child. ]. larva !lied. Soc., 55:464-469, August 1965. 5. Werry, J. S., Weiss, G. and Douglas, V.: Studies on the Hyperactive Child, Some Preliminary Findmgs. CaruJd. Psych. A~s. ]., 9: 120-130, April 1964.
39 Auburn Place Brooklyn, N. Y. 11201
Things cannot always go your way. Learn to accept in silen<..-e the minor aggravations, cultivate the gift of taciturnity and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaints. -LIFE OF SIR WILLIAM OSLER
May-June, 1968
159