Martin J. Lubetsky

Efficacy of Methylphenidate among Children with Autism and Symptoms of Attention-Deficit Hyperactivity Disorder.

Thirteen children (ages 5.6 to 11.2 years) with autism and symptoms of attention-deficit hyperactivity disorder (ADHD) participated in a double-blind, placebo-controlled crossover study of methylphenidate (0.3 and 0.6 mg/kg per dose). Eight subjects responded positively, based upon a minimum 50% decrease on the Conners Hyperactivity Index. Ratings of stereotypy and inappropriate speech, which are often associated with autistic core features, also decreased. However, no changes were found on the Child Autism Rating Scale, a global assessment of autistic symptomotology. Significant adverse side effects occurred in some children including social withdrawal and irritability, especially at the 0.6 mg/kg dose. Results suggest that methylphenidate can be efficacious for children with autism and ADHD symptoms. However, this group of children seems to be particularly susceptible to adverse side effects.

Double-blind, placebo-controlled study of amantadine hydrochloride in the treatment of children with autistic disorder

OBJECTIVE To test the hypothesis that amantadine hydrochloride is a safe and effective treatment for behavioral disturbances--for example, hyperactivity and irritability--in children with autism. METHOD Thirty-nine subjects (intent to treat; 5-19 years old; IQ > 35) had autism diagnosed according to DSM-IV and ICD-10 criteria using the Autism Diagnostic Interview-Revised and the Autism Diagnostic Observation Schedule-Generic. The Aberrant Behavior Checklist-Community Version (ABC-CV) and Clinical Global Impressions (CGI) scale were used as outcome variables. After a 1-week, single-blind placebo run-in, patients received a single daily dose of amantadine (2.5 mg/kg per day) or placebo for the next week, and then bid dosing (5.0 mg/kg per day) for the subsequent 3 weeks. RESULTS When assessed on the basis of parent-rated ABC-CV ratings of irritability and hyperactivity, the mean placebo response rate was 37% versus amantadine at 47% (not significant). However, in the amantadine-treated group there were statistically significant improvements in absolute changes in clinician-rated ABC-CVs for hyperactivity (amantadine -6.4 versus placebo -2.1; p = .046) and inappropriate speech (-1.9 versus 0.4; p = .008). CGI scale ratings were higher in the amantadine group: 53% improved versus 25% (p = .076). Amantadine was well tolerated. CONCLUSIONS Parents did not report statistically significant behavioral change with amantadine. However, clinician-rated improvements in behavioral ratings following treatment with amantadine suggest that further studies with this or other drugs acting on the glutamatergic system are warranted. The design of these and similar drug trials in children with autistic disorder must take into account the possibility of a large placebo response.

Abuse and Neglect in Psychiatrically Hospitalized Multihandicapped Children.

Medical charts of 150 consecutive admissions of multihandicapped children to a psychiatric hospital were examined to determine the extent and characteristics of abuse and neglect. Results indicated that 39% of the sample experienced or had a history that warranted suspicion of past and/or current maltreatment. Physical abuse was the most frequent type of maltreatment, followed by neglect and sexual abuse. Maltreated multihandicapped patients admitted to the psychiatric unit were less likely to receive diagnoses of organic brain syndrome or profound mental retardation than nonmaltreated multihandicapped counterparts on the same unit. Moreover, data indicated that less severely impaired patients were more likely to be maltreated than were the more severely impaired. Particularly striking was the severity of maltreatment in this multihandicapped sample and the relatively high percentage (40%) of sexually abused patients who were assaulted by multiple perpetrators.

Efficacy of Methylphenidate and Behavioral Intervention on Classroom Behavior in Children with ADHD and Mental Retardation

Using a combination of an alternating treatment and double-blind placebo-controlled drug design, the independent and combined effects of two behavioral interventions and two doses of methylphenidate (MPH) in 3 children with Attention Deficit Hyperactivity Disorder (ADHD) and mental retardation (MR) were assessed. In this single subject design, 2 of the 3 subjects responded positively to medication as measured by increased on-task behavior. The first behavioral intervention, a token economy for on-task behavior, was ineffective for increasing either on-task behavior or work accuracy when combined with placebo. However, improvement in work accuracy was realized with implementation of a second behavioral intervention that specifically targeted accuracy independent of drug conditions. The current findings highlight both the positive effects and limitations of the two commonly used treatment modalities for ADHD. Future studies should continue to extend this area of investigative efforts to produce more data-based knowledge as to the appropriate doses of treatment, both pharmacological and behavioral, with children with both ADHD and mental retardation.

Case Study: Inpatient Psychiatric Treatment of a Young Recidivist Firesetter

The inpatient psychiatric treatment and 1-year follow-up of a recidivist child firesetter with multiple clinical and behavioral problems is described. This case was unique due to the childs young age and both the severity and frequency of firesetting. The focus of therapy was on teaching fire safety skills and concepts to alter the childs interest in and involvement with fire. Other elements of the therapy targeted associated antisocial behavior and depression. At 1-year follow-up, the child had not engaged in additional firesetting. This case highlights the need to provide a comprehensive assessment of firesetting, understand its relationship to psychopathology, and offer specialized interventions.

Affective disorders in hospitalized children and adolescents with mental retardation: A retrospective study

We contrasted a sample of children and adolescents with affective disorders and mental retardation with a comparison group on behavioral symptoms, associated diagnoses, and psychopharmacologic treatment. Fifty consecutive patients with both impaired intellectual functioning and at least one affective disorder admitted to a psychiatric inpatient unit for children and adolescents with developmental disabilities and psychiatric disorders were matched to a group of 50 inpatients without depression. Behavioral symptoms such as suicidal ideation or gestures, crying, irritability, sleep problems, agitation, mood lability, and social withdrawal/isolation occurred significantly more often in the affective group than in the comparison group. Aggression, however, was the most frequent behavior concern for both groups, whereas disruption/destruction was identified significantly more often in the comparison group. Regarding Axis I diagnoses, the comparison group was more often identified with externalizing disorders (ADHD, ODD), though there was a high rate of comorbidity in the affective disorder group. The behavioral symptoms used to diagnosis normally developing children and adolescents appear to be applied in making affective disorders diagnoses in this sample of children and adolescents with mental retardation.

Use of naltrexone in reducing self-injurious behavior: A single case analysis

The efficacy of the opiate antagonist, naltrexone, in the treatment of self-injurious behavior (SIB) was examined in a 10-year-old mildly mentally retarded boy with SIB of 9 years duration. Naltrexone was demonstrated to be effective in both an open trial (100 mg of naltrexone resulted in a 69.3% decrease in SIB from baseline), and in a double-blind, placebo-controlled trial using a B1-B2-A1-B2 design (B1=100 mg naltrexone; A1=placebo; B2=200mg naltrexone). A dose-response relationship was demonstrated insofar as the greatest decrease in SIB of 92.1% was achieved at 200 mg of naltrexone. This study lends clinical support to the hypothesis that the endogenous opiate system may be involved in the maintenance of SIB and suggests that naltrexone may be effective in the treatment of severe SIB.

Comprehensive management of trichotillomania in a young autistic girl

The coexistence of trichotillomania and autistic disorder has rarely been reported in psychiatric literature. The current study describes successful treatment of trichotillomania in a young autistic girl, using combined clomipramine and behavioral therapy. Neither behavioral therapy, clomipramine, methylphenidate, buspirone, nor naltrexone was effective in monotherapeutic trials. We postulate a synergistic effect of combined treatment with clomipramine and behavioral therapy, suggesting that both pharmacological and behavioral treatment of hair pulling may be necessary for many patients. This model is consistent with the extant literature and suggests that future clinical trials of clomipramine for trichotillomania, in both developmentally disabled and normal subjects, must evaluate this multimodal approach.

Stimulant drug treatment of four multihandicapped children using a randomized single-case design

Single case methodology was employed to assess effects of methylphenidate on the Attention Deficit Disorder with Hyperactivity (ADDH) symptoms of four multihandicapped children. Several doses, ranging from 0.3 mg/kg to 0.9 mg/kg, were randomly administered to each child in a double-blind place bo study. All children demonstrated increased percentage of time on-task in a school setting on methylphenidate as contrasted to placebo, although optimal drug doses varied. Positive changes were also noted on the Abbreviated Conners Teacher Rating Scale (ACTRS), percentage of accurate response to task, and duration of task completion for some children. Negative change in social behavior (i.e., interactive to isolative) with increasing dosages of stimulants was also noted. Implications of these findings were discussed with respect to idiosyncratic dose response, changes in affect, and the utility of single case methodology.

Maltreatment ofchildren and adolescents with multiple handicaps: Five case examples

Little attention has been directed toward abuse and neglect in children and adolescents with multiple handicaps. This population, however, may be at especially high risk for maltreatment. Factors contributing to added risk include: (a) disruption in mother-infant attachment, (b) greater stress related to care needs and difficult to manage behavior problems, and (c) increased vulnerability due to communication and/or cognitive limitations. Five cases are presented involving abuse and neglect in psychiatrically referred children with multiple handicaps. Cases are discussed in terms of: (a) difficulties in identifying maltreatment in those with multiple handicaps, (b) the need for multidisciplinary intervention with families who engage in maltreatment, and (c) suggestions for future directions that research might take.