REFERENCES
1. Krager JM, Safer DJ: Type and prevalence of medica-tion used in the treatment of hyperactive children.
ivFngl I .‘tlcd 291:1118, 1974.
2. Sroufe LA: Drug treatment of children with behavior
problems, in Horowitz FD (ed): Review of Child
Development Research. Chicago, University of Chicago Press, 1975, vol 4.
3. Sroufe LA, Stewart MA: Treating problem children
with stimulant drugs. N Engl I Med 289:407,
1973.
4. Safer DJ, Allen RP: Hyperactive Children: Diagnosis and Management. Baltimore, University Park Press, 1976.
5. Stewart MA, Olds SW: Raising a Hyperactive Child. New York, Harper & Row, 1973.
6. Rie HE, Rie ED, Stewart S, Ambuel JP: The effects of
methyiphenidate on underachieving children. I
Consult Gun Psychol 44:250, 1976.
7. Weiss G, Kruger E, Danielson U, Elman M: Effect of long-term treatment of hyperactive children with methylphenidate. Can Med Assoc I 112:159, 1975.
8. Rapaport JL, Quinn P0, Bradbard G, et al: Imipramine
and methylphenidate treatments of hyperactive
boys. Arch Gen Psychiatry 30:789, 1974. 9. Whalen CK, Henker B: Psychostimulants and children:
A review. Psychol Bull 83:1113, 1976.
10. Sleator EK, von Neumann AW: Methyiphenidate in the
treatment of hyperactive children. Clin Pediatr
13:19, 1974.
11. O’Leary KD, Pelham WE, Rosenbaum A, Price GH: Behavioral treatment of hyperkinetic children: An experimental analysis of its usefulness. Clin Pediatr
15:274, 1976.
12. Rosenbaum A, O’Leary KD, Jacob RG: Behavioral
intervention with hyperactive children: Group
consequences as a supplement to individual
contin-gencies. Behav Ther 6:315, 1975.
13. Ayllon T, Layman D, Kandel HJ: A behavioral-educa-tional alternative to drug control of hyperactive children. I Appl Behav Anal 8:137, 1975. 14. Gittelman-Klein R, Klein DF, Abikoff H, et al: Relative
efficacy of methylphenidate and behavior modifica-tion in hyperkinetic children: An interim report. I Abnorm Child Psychol 4:361, 1976.
15. Pelham WE: Behavioral treatment of hyperkinesis. Am I Di,s Child 130:565, 1976.
16. Conners CK: A teacher rating scale for use in drug
studies with children. Am I Psychiatry 126:884, 1969.
17. Sprague RL, Sleator EK. Effects of psychopharmacolog-ical agents on learning disabilities. Pediatr Clin North Am 20:719, 1973.
18. Routh DK, Schroeder CS, O’Tuama LA: Development
of activity level in children. Dev Psychol 10:163,
1974.
19. Conners CK: Symptom patterns in hyperkinetic,
neurotic, and normal children. Child Dev 41:667,
1970.
20. Becker WC: Parents Are Teachers: A Child Management Program. Champaign, Ill, Research Press, 1971. 21. Werry JS, Sprague RL, Cohen MN: Conners’ Teacher
Rating Scale for use in drug studies with chil-dren-an empirical study. I Abnorm Child Psychol 3:217, 1975.
ACKNOWLEDGMENT
We are grateful to Carol Friedling for her help in testing
and data collection and to Dr. Fred Mehihop, pediatric consultant.
Hyperactive
Children:
A Ten-Year
Study
James S. Miller, M.D.
From tI,e Department of Pediatrics, Loma Linda School of Medicine, Lame Linda, Galifornia
My experiences in practice during the past ten
years lead me to believe that “hyperactivity” is primarily an emotional problem. Currently, however, the diagnosis is often made-and drugs administered-on the basis of fragmentary infor-mation about the child’s behavior and with little attempt to explore the child’s inner state or the
family relationships.
These statements are based on observations made while following up 290 children whose
diagnosis was hyperactivity. I was the family
pediatrician in these cases and, as such, was
eventually admitted to the interior of the families. Additionally, I gathered school records for the children and medical records for most of the adult family members. This broad data base, combined
Received June 16; revision accepted for publication August 9, 1977.
ADDRESS FOR REPRINTS: (J.S.M.) 1225 East Latham, No.
with my long personal relationship with the families, is the basis for the conclusions I present here. I submit that the data base is both more
intensive and extensive than that which an
academic institution or clinic can usually achieve; that is why a relatively apparent aspect of hyper-activity has been, until now, neglected.
THE SAMPLE
The period covered is from July 1965 through
June 1975. My practice at that time was in
Hayward, a suburb of the east San Francisco Bay. Omitting consultations, I followed up 1,016 families with 2,427 children for a mean of 61
months (SD, 29 months). I have matched my
practice demographically to both the U.S. census and several regional surveys and have found the practice to be within 5% on occupational, man-tal, racial, and economic criteria. The diagnosis of hyperactivity for the 290 patients whose cases I will discuss had been made by either school personnel, parents, another physician, or, in some cases, all three.
These children fell into two groups. The great majority, 220, consisted of patients who, although their diagnosis was hyperactivity, were not clini-cally hyperactive when I examined them and did not consistently display the impulsivity, distract-ibility, or excitability that is generally considered to be part of the syndrome. ‘ A smaller group of 70
did show all, or most of, these criteria in the clinical setting; all of this group were also seen by a psychologist, and usually a neurologist. I consider this group as representing the “true” hyperkinetic syndrome; this article will largely be devoted to them.
The first group is an unclassifiable “grab bag.” With these children, the referring professionals had no clear idea of what diagnostic criteria to use, although generally the children were consid-ered to be disruptive and poor learners. A number of them were from overcrowded classrooms. Thin-teen were referred by a school psychologist who eventually was found to be schizophrenic. Some were what MacKeith has called “developmental-ly overactive.” In all cases I made sure that I had at least one conference with the parents and the school officials (and generally a psychologist) to air mutual opinions and differences. Relatively simple measures such as increased parental toler-ance, more physical activities, and tutoring greatly benefited the children in this group.
The prognosis in this group was good during a
mean five-year follow-up. The group was so
heterogenous, I do not think it can be
scientifi-cally discussed, except in terms of the sociology
and psychology of those who made the
diagno-sis.
The 70 children in the second group who
displayed hyperactivity in the clinical setting were quite different. They did show all or most of the criteria of impulsivity, distractibility, and excitability in the clinical setting.
They were followed up for a mean of 75.7
months (SD, 37. 1). There were 59 boys and 11 girls. Twenty-seven percent were seen from birth; 60% were seen at least one year prior to the diagnosis. Only four children were first seen at the time of, or after, the diagnosis of hyperactivity.
Five had organic brain disease by conventional criteria (that is, pathological reflexes or signs of cerebellar dysfunction). Soft neurological signs were not consistently present, either over time or between different examiners. Four others had
seizures, with results of the neurological
examina-tion being normal. Four more ultimately became
psychotic.
Twelve of the children were seen into
adoles-cence (past the age of 12), and all of them were doing poorly. Two, whose parents were receiving psychotherapy, were still in school, though in special classes. Ten were out of school; three of them had been institutionalized, and two others
were considered to be “pre-psychotic” by
consulting psychologists.
This poor prognosis was not because of social deprivation, since the 70 children, including the
12 seen into adolescence, statistically matched the practice as a whole socioeconomically and racially. The percentages of prematurity and
birth difficulties were also equal in all groups.
CASE EXAMPLES
Case 1
Patient 1, seen from birth, was the third of eight children.
Only physical problems presented until he reached age 6.
Then the family moved to a nearby community. When he
was in the first grade, the school and a pediatrician thought
he was hyperactive; Inethylphenidate (Ritalin) hydrochloride therapy, 40 ng daily, was started.
I began to see him again when he was 9, in connection with a serious physical illness in a sibling. He had by then
been receiving methyiphenidate for three years and was
thought to be doing well. The family changed school
districts, and the patient was expelled for fighting. At this point I was able to reconstruct the following. Three physi-cians had been giving him methylphenidate; his doses were close to 80 mg daily. His first school had simply been passing him from grade to grade when his achievement was actually only first- or second-grade level. A psychologist at his second
SChOOl recommended counselling, whereupon the parents
took him to a third, private school, which did not have a 1)sychologist. The parents told this school’s personnel that the boy was seeing a therapist, when, in fact, he was not. I
the patient methyiphenidate; the others were refilling the prescriptions over the telephone. A series of conferences was attempted, since the private school now wanted to expell the boy. His father was extremely angry because I refused to prescribe more methylphenidate without more insight into
the family and because I had closed his other avenues. Normally very suave and cheerful, the father said to me at this point, “That goddamn child made my wife spend all her time on him. We have eight kids; who the hell are you to withhold this dn’g and ruin my family?”
The patient was described by his parents as having been
“fierce” since infancy, “crying for hours,” and “uncontrolla-ble.” When I pointed out that I and my partner had seen the child regularly without any of this being brought out before,
I provoked a fresh outburst from the parents. The wife did
acknowledge that having five more children in seven years
had made her “nervous.” (Her medical records showed
obesity; hypertension; acute, recurring back pain;
“mi-graine” headaches; and prescriptions of tranquilizers, along
with thyroid supplement, for “chronic fatigue.”)
Three months later I again met with both parents. The
patient had been slashing curtains with a razor blade, and,
using a hammer, he had made several holes in the walls and shattered the windshield of his father’s car. His mother was frightened; his father defended these actions as “just growing
up,” and he went on to tell me how, when he was in the
seventh grade, he had shot out all the windows in his school with a rifle. He then cited his adult business success as proof that such actions as a child are “just those of a normal boy.”
The patient’s mother then saw and quit two psychiatrists
in rapid succession. The first thought the patient was
“childish, effeminate, and seductive” (with his mother); the
second thought the child was “severely disturbed and
noncommunicative.” At this time, the school principal described the patient as “a paranoid,” and the teacher said he was “very disturbed and emotional.” The patient was then seen by a general practitioner who prescribed methyl-phenidate as before. My last follow-up, three years later, found the patient out of school, with several juvenile court convictions for dnig use and assault.
Case 2
Patient 2, who was first seen at age 10, was at that time taking methylphenidate hydrochloride, 80 mg daily, and being seen in eight separate facilities, none of which was aware of the others. The child’s family was receiving welfare, and I obtained records through the Department of Social Welfare. His diagnoses during the previous 18 months had
been (1) severe character disorder; (2) severely regressed (at
age 10, the patient was described as primarily lying on the floor, sucking on a bottle); (3) hyperactive and “much happier on drugs”; (4) “moderate speech impediment” but
“doing beautifully”; (5) learning disability and “emotional
problems,” “not hyperactive, but manifests primarily mirror movements”; (6) psychotic, “has [sic] weird noises, facial contortions, hurts other children, caresses and explores adult female bodies”; (7) truant; “throws himself to the floor, chokes himself, cries; no effort to seek companionship of
peers.” Throughout all of the above, the pediatrician was
regularly writing, “doing beautifully.”
The patient changed schools a number of times, and his
parents consistently refused psychologic evaluation. The
written records of his previous pediatrician, who first saw him at age 2, were reviewed. There was no hint of problems
until the boy was 4 and in preschool. Then, methylphenidate
therapy was started. The patient’s office behavior was “normal” during the next six years.
When some of this history was discussed with the mother, she blamed yet another pediatrician who she said “refused to
let a psychologist test him.” She was then lost to follow-up;
the most recent school had also expelled patient 2.
FINDINGS
The following characteristics were found to be common to all 70 children and their families. These traits were not all brought out in the two case reports.
1. The children were not hyperactive prior to 3 years of age. Parents who complained of “hy-peractivity” in that age group had nervous, irnita-ble children, but these children did not become part of the 70. As noted, only four of the 70 were not seen before the diagnosis was proposed. It is often stated, retrospectively, that the child’s
behavior was distinctive from birth or early
infancy; this was not confirmed prospectively. 2. The second group of characteristics relates primarily to the families. There was evidence of a major psychologic disorder in the family: although most of the parents functioned well societally, one or both parents carried a formal
psychologic diagnosis or were receiving
consis-tent psychoactive drug treatment. Their
symp-toms were usually psychosomatic, although alco-holism, chronic anxiety, and recurrent maternal depression were also common. These diagnoses preceded the diagnosis of hyperactivity; this was rarely apparent until the parents’ medical records
became available, usually after some years.
3. There were multiple refusals of psychologic referral. Until the child became assaultive, school
expulsion was threatened, or the child appeared psychotic, the parents refused psychologic refer-rals. They also refused such referrals for them-selves, except during crisis periods such as suicide attempts; psychoactive drugs were used instead.
Again, such usage antedated the diagnosis of
hyperactivity in a child in the family.
4. Control and behavior were the framework of the parents’ complaints; the child’s feelings were not described. (The description of hyperac-tivity is, of course, entirely behavioral.) Parents of children whose diagnosis was neurosis, for exam-ple, did express concern over the child’s feelings. Prompting was required in the families of hyper-active children for this type of response.
5. The parents did not accept their role in the psychologic treatment of the child. The classic
quote was, “All right, I saw your damned
psychol-ogist; now you tell me what’s wrong.”
problem that did not occur consistently in the rest of my practice. (Obviously, however, if I had not ultimately achieved the trust of these families, I would not now be in a position to make this observation.)
7. Follow-up was difficult. My requests for
information were generally refused by the
parents; usually the more specific the data
requested, the more difficulty I experienced in
obtaining cooperation.
8. Multiple resources were used without coon-dination or reports. Although the families
initiated this problem themselves, it was
enhanced by this society’s high incidence of personal mobility and poor intenfacility coondina-tion.
The last two characteristics relate primarily to the treating professionals.
9. Multiple diagnoses were made. All the chil-dren were, at various times, given many diagnoses in addition to the one of “hyperactivity”; no child was consistently called hyperactive by all the examiners.
10. Multiple drugs were tried. All patients were given at least one other drug, and, by adolescence, none worked well to all observers.
Other traits of this group differed from the practice as a whole; however, they were not universal in the group. There was physical violence between the parents is 30% of the cases, as opposed to 8% in the remainder of the practice. Forty-eight percent of the siblings carried some
other psychologic diagnosis, chiefly
psychophy-siologic disorders, or were considered to be educationally handicapped; in the practice as a
whole 24% carried these diagnoses. Thirty
percent of the children were violent at one time or another; 1.4% of the practice showed this trait.
The parents of the 70 children were generally
angry at, and blamed their marital difficulties on,
each other. They did, however, superficially unite
concerning the child’s problems. Other problems
were minimized because “he needs us.” For
example, when I suggested marital violence might be looked into the help understand the hyperactivity, the violence was then denied. The parents did not express their angry feelings to each other; even divorce did not alter this. Most of the divorced parents had filed for divorce without prior discussion and without telling their
spouse; none seemed to know why they had
obtained the divorce. (The incidence of
divorce-about one in five cases-was the same in these families and in the practice as a whole.)
DISCUSSION
My suggestion that hyperactivity has a funda-mentally emotional core is not in accordance with
much of the recent literature. But the literature
has not looked into the areas I have considered,
and what has been written has, I think, certain weaknesses. These begin with the association between hyperkinesis and “brain damage,” later “brain dysfunction.” Rutten et a!. state this problem well:
The view that hyperkinesis was always an indication of
brain damage and that all brain damaged children were
hyperkinetic was becoming widely accepted, although it
bore no relationship to the relevant evidence. .. .The term
“brain damage” itself came to be regarded as a behavioral syndrome . . . [though] it runs counter to the available
facts . .. it is of considerable interest as an example of how
scientific myths can arise on the basis of equivocal findings
and persist in the face of results which contradict
them . ..the question had been put as to how it was possible
for studies so nearly devoid of scientific merit to gain so influential and respected a place within scientific disciplines and to hold this place for so long.4
There are many recent literature reviews.1-57 I will comment on only eight points about the
problems of the diagnosis.
1. “There is no scientific evidence linking behavioral disorders and independent signs of
neurological dysfunction 8 There is no
evidence of brain damage per se in the majority of hypenkinetic children, and no consistent neuno-logical, neunophysiological, on physical abnormal-ities have been found. Reports of these findings are all unconfirmed.16--9”#{176}
2. There is no agreement on the diagnostic
criteria.’ 2.3.9. 1 1 Studies showing “overactivity,” “hyperactivity,” “restlessness,” “disruptiveness,” etc., in 30% to 50% of elementary school pupils are ignored.’2 Also ignored are the effects of “labeling” on a student’s performance in the classroom, ‘‘ ‘
3. There are no studies of hyperactivity and
family dynamics, although the effects of the
family on children are heavily documented.15’8 The interior of the families should have been the
first place to look.
4. The psychologic tests in the literature deal with IQ, cognition, and achievement.1920 Evalua-tion scales are behavioral. The child’s inner state, measured through the more usual tools of child psychiatry, has not been reported. The
relation-ship of learning difficulties to the syndrome has
not been consistently shown, and no long-term
effects of any treatment on learning have been
shown.6-7-2021
5. There are no long-term studies, with
Follow-up studies are of selected populations and
use questionnaires with minimal or no
cross-validation. The studies of Minde et al.2’ and Weiss
et al.22 come closest to meeting these objections;
they show a generally poor prognosis, as do the
othens.2328
6. There are no prospective studies of hypenac-tivity beginning in infancy.6 Although it is often stated that the problem begins then and leads to the parents’ problems, there are no prospective data to support these ideas. There is evidence for a genetic component in hyperactivity.29 How-ever, this might well be manifested as a
tempera-mental difference, as Thomas et al. use the term.’0
Further, although the parents had preexisting psychopathology, I do not have good longitudinal data on the timing of the anger and aggression, as such, of the parents. Thus, it may be, as Malm-quist postulates in writing on childhood
depres-sion, that “A pattern of mutually reinforcing
hostility is set in motion that gains momentum. The child’s feelings of estrangement and anger are
superimposed on the disappointment of the
parent. . . . Repetitive acting out may
en-sue :31
Caution is needed. As Thomas et al. state: “These findings [of the interaction of temperament and environment in the development of behavioral disturbance] only reflect general conditions of increased risk of the
development of behavioral disturbance and in no way
support the view that a given organization of temperament is in itself directly pathognomonic or pathogenic. .. .
Behav-ioral disorders have multiple causes, and temperament, as such, is a style of functioning, not a behavioral distur-bance.3#{176}
Bell, the first to systematically raise the ques-tion of child-to-parent effect, says: “Demonstra-tion of a child effect indicates only that it plays some [italics his] role in parent behavior. The
development of the parent behavior is not
explained by such a demonstration.”32
7. There are no studies of the socialization
capacities of these children,’7 although, “Peer
relationships are probably the best single
mdi-caton of adjustment in the school-age child.”33 Further, other populations receiving CNS
stimu-lants have severe deficits in their capacity for
sustained personal interaction; this has been
cred-ited to preexisting intrapsychic problems, but there is no evidence to prove this idea.34 We do not know what effect long-term drug administra-tion has on immature organisms. There are only anecdotes: “They come off the drugs at 14 on so . . . the parents, who have forgotten what the
child’s real personality was like without the mask
of the drug, panic We do not know the
position the child may now be in.
8. There are no studies of the school environ-ment, where the diagnosis of hyperactivity is generally made. There are studies of this environ-ment in general, but they have not been related to the prevalence of this diagnosis or the criteria for its acceptance.36’37
At least two investigators are giving drugs to infants for this syndrome.2’8 In view of the above considerations, I question this course of action. In no other behavioral syndrome of childhood or
adulthood is long-term drug therapy advocated
without other treatment. No other syndrome has such a paucity of family on individual studies.
The hyperactive children in my practice have, I believe, problems with excessive internal anger, often self-directed, but intermittently directed outward. Hyperkmnesis is the outcome of this;
diffuse motor activity-not depressive affect-is
the characteristic response of preadolescents to internal anger without outlet or means of resolu-lion. Several lines of evidence suggest this.
In the study families, the parents did not express their anger to each other directly; it was displaced onto the child at an early age. This displacement apparently helped the parents’ nela-tionship to survive, but the child was scape-goated. In the nature of families, one of the few defenses open to the child is acting-out. These families permit a great deal of acting-out with each other, and the defense is thus successful until preschool, when the social dynamics alter and the defense is not generally acceptable. Juvenile delinquents from lower-class families have been
described as overactive and aggressive for 50
years.39’4#{176}It is new, though, to find this in families that are well integrated societally. One might say the societal role functions of the parents are competently maintained, but their intimate family functions have given way.
The condition where self-anger is also generally assumed to be present is depression’; surveys of childhood depression show marked overlap with
hyperactivity. There is general agreement that
depression with depressive affect is rare in child-hood.31-4243 In the 2,427 children in this practice, only two preadolescents showed affective depres-sion for longer than two weeks. In several articles on childhood depression, oven 80% were overtly aggressive on hypenactive.- Malmquist states: “Hyperactive behavior . . . brings parental
con-demnation and allows the parent to focus on such behavior . . . aggressive behavior may be used to
avoid depressive feelings . . . therapeutic work
the external aggressive display sees a denigrated self concept.”3’ It is not, in fact, clean whether the depression precedes the aggression.
In primates, social deprivation leads either to overt depression on overactivity, depending on the developmental timing.46’47
Both dextroamphetamine and methylphenidate are antidepressants and have been marketed as
such. Tnicyclic antidepressants have also been
used to treat hyperactivity. No good evidence exists for a “paradoxical effect” of these drugs in hyperactivity.7’ 19,20.48.49
Whatever the exact mechanism, on sequence, I believe from my observations that problems with handling anger within the family are central to the syndrome, and more long-term, intensive family observations are needed.
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47. Suomi SJ, Harlow HF: Abnormal social behavior in
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An evaluation of procedural biases in results of reported studies. Pediatrics 51:513, 1973.
INTRAVENOUS CANNULATION-PLASTIC CATHETERS OR SCALP
VEIN NEEDLES
Although there are no adequate studies comparing the incidence of
complications with plastic catheters versus scalp vein needles, a review of the
available literature does permit certain general observations. The use of plastic
catheters is accompanied by a high rate of phlebitis, catheter colonization and sepsis. In most studies the rate of these complications increased with the length
of time catheters were left in place; when catheters were left in longer than 48
hours, the associated septicemia rate ranged between 2% and 5%. In contrast, only one case of cannula-related septicemia was noted among 535 patients receiving intravenous therapy via scalp vein needles in 4 studies. Moreover, rates of phlebitis and cannula colonization are lower with scalp vein needles
than with plastic catheters. Suppunative thrombophlebitis has recently been
reported in association with IV therapy via scalp vein needles. In other words, serious infections may be rare, but they do occur, particularly in immunosup-pressed patients. The factors responsible for the relative safety of scalp vein
needles are unknown; it has been suggested that needles are safer because they tend to infiltrate quickly, forcing changes at frequent intervals. The small
teflon catheters now available may be less irritating than previously marketed
plastic catheters.
Present information strongly suggests that scalp vein needles should be used
for intravenous therapy whenever possible. If the cannula is to be used only for the periodic administration of medications such as antibiotics, a hepanin lock is preferred to a “keep open” infusion since intravenous fluid supports the growth of bacteria and thus increases the risk of intravenous-related sepsis. Plastic catheters should be used when a child’s life may depend on the reliability of the intravenous cannula as a route for the rapid administration of medications. Both scalp vein needles and plastic catheters should be changed every 48-72 hours.
DONALD A. GOLDMANN, M.D.
Noted by R.J.H.
