Ten
Years
of Experience
with
1,000
Hyperactive
Children
in a Private
Practice
Walter Eichlseder,
Dr Med
From Munich, West Germany
ABSTRACT. A summary of the author’s experience with 1,000 hyperactive children treated in a private practice
over a period of 10 years is presented. Of 1,000 children entering the office, 872 were treated with stimulants for more than 6 months. Of these 872 children, 137 (16%) were considered as treatment failures; 735 (84%) had a positive response to medication. A follow-up of 197
pa-tients in “remission,” after treatment, suggested that symptoms had reappeared in 20% ofthe cases. The length
of treatment in a group of 494 children still under obser-vation on Dec 31, 1981, indicated that the majority of
boys were treated for between 3 to 5 years; girls were
treated for 2 to 3 years. Approximately 10% of the chil-dren received medication for 1 to 2 years, whereas about
20% were treated for more than 6 years. It was concluded
that treatment with a stimulant for 5 to 10 years is a safe and efficient way to help hyperactive children during a difficult time of life. Pediatrics 1985;76:176-184; hyper-active children, attention deficit disorder.
This is a report on my personal experience with the first 1,000 hyperactive children entering my private pediatric practice between Nov 1, 1971, and Dec 31, 1981. It includes, as first patient, the au-thor’s 10-year-old son. It is a survey of accumulated clinical data, not designed for analysis from the beginning. It is an attempt to analyze the data gathered in the hectic office of a one-man general pediatric practice; this setting does not lend itself to a more generous inclusion of formalized
diagnos-tic techniques and structured procedures for moni-toring therapeutic efficacy and follow-up.
METHODS
Population
The clinical picture was as outlined in Diagnostic
Received for publication Nov 15, 1983; accepted Oct 23, 1984. Reprint requests to (W.E.) Parzivalstr 29, 8000 Munchen 40, West Germany.
PEDIATRICS (ISSN 0031 4005). Copyright © 1985 by the American Academy of Pediatrics.
and Statistical Manual of Mental DLsorders (DSM III) (314.0 and 314.O1X): attention deficit disorder without hyperactivity and attention deficit disorder with hyperactivity. The primary presenting symp-toms were attention deficit and the ensuing aca-demic difficulties and/or conduct problems arising from impulsive behavior. Hyperactivity per se,
a!-beit frustrating for the surrounding, rarely was a reason to seek help.
Nevertheless, of the first 88 children, 71 were
reported to be hyperactive at home and 57 in
school.’ All children had difficulties arising from short attention span, even those who primarily or solely came for behavior problems caused by their impulsivity. Younger children often had good rela-tionships in their family, and with friends and teachers; at puberty they developed the behavior profile typical for impulsive children.
These core symptoms were in some cases
asso-ciated with “soft” neurologic signs, problems in motor coordination, or perceptual difficulties lead-ing to more specific learning disabilities. One boy had EEG convulsive discharges for 6 years before therapy with stimulants was started; two were men-tally retarded. Frank depression was not encoun-tered.
Severity was moderate or severe with the excep-tion of 14 children, in whom symptoms were mild and for whom treatment was, therefore, not consid-ered.
Five percent of the patients came from my own clientele, 24% came from parent and physician referrals, and 71% had chosen to see me after having read my articles in parents’ journals.
Of the 1,000 children, 749 were between ages 7 and 12 years (Table 1). The greatest number for both boys and girls were 9 years old, and the ratio of boys to girls was 3.6 to 1.
TABLE I. Age distribution of 1
dren at First Visit
,000 Hyperac tive
Chil-Cohort Age at No. of Boys No. of Girls Total First Visit (N = 787) (N = 213)
(yr)
2 1 1
3 4 4
4 6 6
5 9 3 12
6 51 19 70
7 109 29 138
8 105 33 138
9 124 41 165
10 98 26 124
11 92 17 109
12 79 16 95
13 37 11 48
14 32 7 39
15 12 6 18
16 8 5 13
17 7 7
18 3 3
19 1 1
20-29 6 6
30 3 3
conditions in West Germany. To give a rough corn-parative estimate of the social status of the families of these hyperactive children, however, it can be safely stated that the vast majority of fathers had
occupations ranging from technical workers to
professionals. Very few fathers would be classified
as blue-collar, unskilled laborers.
Diagnosis
Diagnostic work-up included an intensive history (one to two hours), a routine physical examination, and a careful neurologic examination, a modified version of the Matching Familiar Figures (MFF) test, and, initially, an office version of the
Contin-uous Performance Test (CPT) or short-term mem-ory test developed by Robert L. Sprague.
Having one or more symptoms indicative of the core features of attention deficit disorder and im-pulsivity was accepted as sufficient for a diagnosis. When symptoms led to problems for the child, they were considered sufficiently severe enough for in-tervention.
According to DSM III, “diagnosis should not be made before the age of 5.” The few typical children for whom parents seek help at this early age are impulsive and hyperactive to a degree that is abso-lutely unbearable for everone around the child, and immediate action is imperative for the sake of the mother’s psychological well-being. The children’s
prompt response and normal physical and
emo-tional growth over the years did not furnish any valid reason to withhold stimulants until break-down of the whole family. Patients beyond puberty
reacted the same way as younger children did. In line with today’s medical practice, tests were applied to corroborate the clinical findings.
As used in this study, the power of the Continu-ous Performance Test (CPT) to discriminate be-tween hyperactive and normal children was so small that it was discontinued after several years’ usage.
The Matching Familiar Figures Test (MFF) (an
analysis of the data is in preparation) showed, in the majority of cases, an “impulsive”
pattern-either high error rate and short latency, or high error rate alone. Preliminary evidence indicated that the use of error rate alone was as useful as the
traditional impulsivity classification-a combina-tion of short latency and many errors.
Even though the literature suggests that these tests are the most discriminative of the practical measures that are available, they seem to be of little practical help, because it is the clinical symptoma-tology and the associated problems that demand alleviation2’3 that are most salient in pediatric prac-tice.
Medication
Interventions
Only stimulants were used. In West Germany, only DL-amphetamine-sulfate and methylpheni-date (Ritalin) are available. The children were given DL-amphetamine at a daily dose of 10 mg divided into two portions, increasing the daily dose at five to seven-day intervals until the needed reduction
of symptoms together with a tolerable minimum of side effects was reached. Most children did very well with 10 mg after breakfast and 5 to 10 mg after lunch.
West German children start school at 8 AM and return home between 1 and 2 PM for lunch and the remainder of the afternoon. In the early afternoon,
they do homework, thus enabling the mother to monitor on-task behavior, attitude toward work, proper performance of written tasks, and comple-tion of the home work assignment.
When, in the course of treatment, the arbitrarily
chosen upper limit of 25 mg of DL-amphetamine ceased to control symptoms or when side effects
were intolerable, the child’s medication was
switched to methylphenidate. Again, the daily dose was divided into two portions, morning and noon,
starting with 20 mg/d, increased according to needs, up to 40 mg/d. The introduction of methylpheni-date was usually accompanied by a dramatic rea-melioration of symptoms, comparable to the first introduction of a stimulant.
When, after months or years of further treatment with methylphenidate, the efficacy faded or into!-erable side effects emerged, the child was switched
proce-dure as at the very beginning. Again, the reintro-duction of the alternative drug brought about the desired effect.
To obtain an estimate of the frequency of these switches, the first 100 patients in an alphabetical order of all patients still under treatment were examined (Table 2). Of 100 patients, 37 had to have their medication switched. Only two patients had drug switches during the first year of medication. The longer the treatment lasted, the more likely and the more frequent the necessity of a switch became. It should be stressed that for patients
whose medication was switched more than once,
the intervals between switches remained about the same.
Drug holidays were granted only after a year or so of treatment, and only if the off-drug social behavior was satisfactory; that is, the child was able
to handle his impulsivity in dealing with himself and with others.
If there was substantial improvement of symp-toms after a period ranging from one to several years, the dose was reduced slowly until the medi-cation was withdrawn entirely. To make sure that symptoms did not reappear after cessation of med-ication, monitoring of the child’s behavior through my close contact with the parent and between par-ent and teacher was mandatory.
Because the dose had to be adjusted to the chang-ing needs and responsiveness of each child to the
drug, and this usually occurred several times in the course of treatment, it is not possible to group patients according to dosage levels.
The actual time the child was receiving medica-tion was much shorter than the time the child was considered as being “treated”. Meticulous notifica-tion of each day or period that the child was not receiving medication, such as holidays, illnesses, accidents, running out of medicine, periodic reluc-tance of a child to be taking a pill, and, finally, those periods when the child was intentionally not using the drug because of a substantial amelioration (Table 3), made it feasible to compare days with drug use with days of observation and no drug use. These records were maintained for the first four years at which point record keeping was stopped because of the amount of time required of the physician and the parents.
Behavioral
Interventions
During the first months, sometimes for as long as 1 or 2 years, medication alone brought such a dramatic change in behavior that no additional measures were necessary. But, in a number of cases (especially in older children), the social learning process, mediated by the drug, waned. Toward pu-berty, many children developed traits that needed
additional environmental management and
coun-seling as well as specific behavioral interventions.
TABLE 2. Number of Patients with One or More Drug Switches According to Duration of Treatment*
Duration of Treatment
in 3-Year Periods
No. of Switches No. of Patients Switched/Period
Total Patients/Period 2 3 4 5 6 7 8
Yearl
Years 2-4
Years5-7
Years 8-10
2
15
3
2 2
1
3
3
2 1
1
1 1
2
17
8
10
30
45
13
12
Total 22 6 5 1 1 1 1 37 100
* This sample of 100 children was obtained by examining the first 100 patients in an alphabetical order of all patients still receiving medication.
TABLE 3. Length of Observation and Duration of Treatment in 241 Children
Success-fully Treated with Medication Duration of
Treatment in Months (or Parts
Thereof)
Len gth of Observ ation in Mont hs (or Parts Thereof)
13 46 712 1318 1924 2530 3136 3742 4348 4951 Treatment Cumulative
1-3 61 3 6 5 4 4 1 1 241
4-6 9 23 11 4 3 1 156
7-12 1 14 25 13 11 3 2 1 105
13-18 1 13 7 2 2 3 1 35
19-24 1 2 1 6
25-30 1 1 2
Observable 241 180 167 124 82 48 22 15 12 4
The basis of my knowledge of the techniques used, admittedly fragmentary, was gathered from reading pertinent literature and from attending round table discussions and seminars at the yearly meetings of the American Academy of Pediatrics.
I also had the patients’ mothers read the German
editions of Wender and Wender,4 Patterson and Guillion,5 Patterson,6 and Becker.7 For manage-ment of these children, the discussions in Safer and Allen8 were helpful. I used environmental manipu-lation, social and token reinforcement, reward, pun-ishment, extinction, and time out; the latter was guided by two of my own handouts.
Monitoring Therapeutic Efficacy
For the assessment of intervention efficacy,
fre-quent telephone contacts with the parents were
used. These consultations occurred at fixed dates.
In order to make sure the dates were kept, the
mother was called and urged to contact the teacher prior to the next expected call.
As indicators of treatment effect, several types of
reports were used: (1) social behavior and learning performance in school, reported to the mother by the teacher; (2) academic achievement based on several verbal and written tests spread over the school year; (3) teacher grades given to the students twice a year together with comments on the social and the academic behavior of the child; (4) work attitude and achievement during homework in the early afternoon; (5) social behavior during lunch, during the late afternoon, in the evening, and dur-ing weekends and vacations.
Treatment was considered efficacious when there was a clear amelioration of one or more of the five indicators listed above. Treatment was continued when the shift to the positive side remained dis-tinctly observable, and there was counter-checking during drug-free hours or days.
Follow-up
of Children
After Termination
of
Medication
Follow-up after termination of medication was not difficult for children still under my routine pediatric care. Other patients were contacted once a year in order to get a progress report (in the early years by telephone, later by mailing a question-naire). In the first version of the questionnaire, a nine-question form was sent to the parents with a preaddressed, prepaid envelope. The return rate of about 50%, the incompletely filled out forms, and the comments of the parents were so discouraging that this procedure was abandoned. Instead, a letter was sent in January 1982, and the letter contained only three questions which could be answered by
“Yes” or “No”, or “Well” or “Poor”; there was space for comments on the back of the paper. The three questions were: “How does your child get along with family members and with friends?”; “How is he or she doing in school or in his or her job training?”; and “Is he or she content with himself or herself?” The return rate was much higher with this method and only a fraction had to be contacted by phone for follow-up or clarification.
RESULTS
Analysis
of Interventions
with Medication
Of the 1,000 hyperactive children for whom rec-ords were kept, treatment was indicated for 952 (Table 4, groups B, C, and D). The cooperative connection between patient, parent, and physician (necessary for a meaningful intervention) was es-tablished with 872 patients (groups C and D). There was a failure or limited success in 137 (16%) of all those treated (group C). A positive response was observed in 735 of the 872 (84%) who were success-fully treated (group D).
Concerning the refusal of medication (Table 5), most parents stated more than one reason, but each patient is listed only once, with the main reason
TABLE 4. Outcome for 1,000 Hyperactive Children
Ad-mitted to Treatment Between Nov 1, 1971 and Dec 31,
1981*
Characteristics of Children No. of Cases
Group A
Not entering treatment 48
Medication not indicated (14) Parents refused medication (30) Child refused medication (4) Group B
Medication stopped in the first few
months because of insufficient
in-formation and/or cooperation of 80 parents and/or teacher and/or
child Group C
Definite failure or limited success 137
Group D
Good response to medication (“posi- 735
tive responders”)
D-1. Contact lost during successful treatment (147) (for details, see
Table 3)
D-2. Lost to follow-up, while in remis-sion (94)
D-3. In remission, still under observa-tion (197)
D-4. Still under treatment (297)
* Groups may be defined as follows: groups A, B, C,and D = 1,000 children seen in office; groups B, C, and D =
TABLE 5. Reasons for Refusing Medication Reason Characteristics of Patients (Subgroup
D-1) Refusing Medication
No. of Cases
1 Side effects, although mild to moderate, not acceptable to parents or child
14
2 Parents prefer “causal” treat-ment, went to psychotherapist
11
3 Parents “warned of drugs” by me-dia, teacher, pharmacists, phy-sicians, psychologists, psycho-therapists, or other “experts”
38
4 Child “warned of drugs” by lesson
on drugs in school
20
5 Unknown; no reason given;
“no-show”
32
6 Moved and continued therapy with another physician
5
7 Child refused to continue to work in school and to do his home-work which led me to stop
medication
21
8 Did not pay bill, or bill “too high” 6
indicated by the parent. Of the reasons listed, 34 patients in group A stated that psychotherapy was the preferred intervention, that they were warned about drugs, or they gave no reason for refusing initiation of treatment; 80 patients in group B gave similar reasons and also indicated concerns about
side effects of medication.
Group C consists of 137 patients, in whom ame-lioration of symptoms was unsatisfactory and/or side effects were intolerable. The side effects most disturbing to the parents were the child’s inability to fall asleep and loss of appetite to a degree accom-panied by weight reduction. There were three pa-tients with jerky movements of lips or tongue. Sometimes, a mother complained about the child’s “depressive mood.” At first, it was quite difficult to elucidate the meaning of the word, “depressive.” One mother said: “The fire in his eyes disappeared.” One boy complained, “I can’t laugh any more about the teacher’s stupid jokes.” One boy who, prior to receiving medication, could not read more than half a page in a book, was called “depressive” by his
parents because of his unwillingness to go outdoors and play with his friends, but he sat in the house reading a book “for hours.”
Because the occurrence of these mostly minor side effects was not elicited and charted in a sys-tematic way, quantification was not possible. Also, as I learned later, some mothers stopped giving medication under the pretext that side effects had emerged when, in reality, friends had warned them of the dangers of taking drugs.
In the 735 children of group D, a positive
re-sponse was recorded when the child’s behavior-either academic or social, whichever was at stake-showed definite improvement. In reviewing these results, one must remember that there was always a certain instability among the subgroups of group
D. Some of the difficulties in assigning a patient to
a subgroup were: (1) patients who had been lost to follow-up (D-2) might show up and wish treatment; (2) children in remission (D-3), assumed to be asymptomatic and thus untreated, might have
dif-ficulties again and avoid admitting it although they were no longer in remission; (3) parents admitted that they had stopped administering the drug on the pretext that there was no effect, while in reality they had followed warnings about the dangers of medication; (4) someone who was taking
medica-tion quite successfully (D-4), might see a television program with a psychologist opposing medication and then decide to stop treatment; or (5) a teenager,
who may have stopped treatment after a school
lesson on drugs (D-4), might show up and want treatment again. The term “remission” (D-2) means, therefore, that the child’s behavior and
per-formance was acceptable, symptoms were mild or
minimal, and the behavior was satisfactory to
par-ents, teachers, friends, and to the child.
The continuous need for stimulants for the child was checked every 1 to 2 months using the criteria
previously mentioned, and continuation of treat-ment was reappraised at each contact with the mother. Thus, continued treatment meant
contin-ued efficacy.
The final follow-up data are shown in Table 6. There were 197 patients contacted at the January 1982 follow-up who are no longer receiving medi-cation. Of the 197 children in “remission,” 20% received negative comments by parents in the re-turned letter. Even one negative answer to the three questions was interpreted as a signal that the child was again showing symptoms and actually needed
TABLE 6. Age and Sex Distribution of All 197 Children Still Being Observed (in “Remission”) Including Those Not Treated Anymore, But Again Symptomatic
Age Boys Girls
(yr) No. in (Later No. in (Later
Remission Symptomatic) Remission Symptomatic)
:s5 6-7
8-9
10-11 5 (2) 1
12-13 16 (2) 13 (4)
14-15 39 (8) 17 (5)
16-19 67 (14) 29 (4)
20-29 6 3
30 1 (1)
treatment. One child had stolen a motorcycle and thus had contact with the police.
Length
of Medication
Interventions
In an attempt to answer the question about
length of treatment, the 494 children still under
observation (groups D-3 and D-4) are grouped
ac-cording to their cohort or the year they began
receiving medication (Table 7). Because the num-ber and the age and sex distribution varied from cohort to cohort, and cohort effects might influence the length of treatment, each year was examined separately, and the length of treatment was esti-mated by comparing the percentages of children still under treatment in each cohort. It became clear, as had been expected, that the longer the
observation time, the smaller the percentage of
children being treated.
Specifically, in patients entering treatment dur-ing the past 4 years, more than 77% of the boys and 50% of the girls were receiving drugs. Among patients entering treatment 5 to 7 years ago, 44% of the boys and 23% of the girls were still receiving medication. As for the children under observation for 8 to 10 years, 10/55 boys (18%) and 2/22 girls (9%) were still under treatment.
Effect
of Behavioral
Interventions
As this was not a clinical trial of the efficacy of medication, but a report on a pediatrician’s expe-rience with 1,000 hyperactive children over a dec.. ade, there are, of necessity, certain limitations to the generalizations that can be made about specific behavioral interventions. As the need for interven-tions other than and/or in addition to medication had to be explored in the overall medical manage-ment of the child’s case, they have been reported.
It was not possible, however, to evaluate the differential roles the medication and the behavioral measures played in decreasing the symptomatology, on two grounds. First, the child receiving stimulants is continuously supported by the drug. The drug curbs the child’s impulsiveness; it helps him to acquire expected behavior and to generalize newly
learned behaviors into other fields and over time. Therefore, acquiring as well as maintaining good behavior could be a drug effect intensified by psy-chological interventions or a successful behavior modification made possible by the drug’s action. Second, behavioral advice was given, often without notation in the patient’s chart; therefore, it was not possible to track it down retrospectively.
Effects
of Intervention
on Weight
and Height
In most cases, there was a slowing of weight gain, a maintenance of weight, or even a weight loss of 1 to 2 kg (2 to 4 pounds) within the first 4 to 6 months after medication was started, but thereafter, there was a continuous weight gain. Unfortunately, not all overweight children lost weight as was hoped, whereas slender ones lost weight sometimes to a point where parents worried.
Height, however, never seemed to be affected by the drug. The children always showed a height gain, even in the first months of treatment.
Despite regular measurements, however, incre-ments in height and weight could not be evaluated statistically because it was not possible to recruit an untreated control group of hyperactive children. It did not seem feasible to compare treated hyper-active children with standard growth charts since these patients typically show a special growth pat-tern. “Immaturity” is a common descriptor of by-peractive children used by parents and teachers. The physiologic immaturity of a great many of them is obvious in pediatric practice and has been ex-amined systematically.9
DISCUSSION
Definitional
Implications
The community of psychiatrists and psycholo-gists seems to agree that hyperactive children suffer from a variety of disorders of different origin, and, therefore, that specified interventions aimed at the disclosed disability have to be applied. Articles on this subject urge the clinician to differentiate be-tween the various nosologic entities, for instance, between the two forms of attention deficit disorder
TABLE 7. Actual Status of 494 Patients Still Being Observed: Children Receiving
Treatment/Children Being Observed Between 1972 and 1981
Year of Entry
1972 1973 1974 1975 1976 1977 1978 1979 1980 1981
Boys
Treated/observed 2/8 0/13 8/34 13/37 35/69 10/26 24/31 36/42 35/37 75/75
%beingtreated 25% 0% 24% 35% 51% 38% 77% 86% 95% 100%
Girls
Treated/observed 0/5 1/3 1/14 4/14 4/25 3/9 2/4 10/11 13/16 21/21
(ADD) without and with hyperactivity, further
be-tween various subentities based upon associated features such as difficulties in motor coordination and perceptual or cognitive dysfunctions. Most no-tably, the expanding field of learning disabilities with its multitude of therapeutic avenues ought to be separated before attention deficit disorder is considered.
The clinician is fully aware of the difficulties inherent in the conceptualization of psychiatric
disease entities, is familiar with the concept and pitfalls of a “syndrome” and its continuous suscep-tibility to change of definition. So, every practicing pediatrician knows the variety of pictures hyper-active children show, but, as the observer of thou-sands of normal and abnormal children, followed
over many years, he or she is also struck about the remarkable similarity of children with attention deficit disorder and their definite dissimilarity to emotionally disturbed or deprived, neurotic, men-tally retarded, or normal children.
In West Germany, where hyperactivity and/or attention deficit disorder is not well-known and where any control of children’s behavior through drugs is met with reluctance, these children are at
first sent to a child psychologist, who usually inter-venes with play therapy. Any deviance in learning is regarded as a case of specific learning disability and no attempt is made to rule out attention deficit disorder. These problems are approached with as-sumedly specific educational measures, remedial techniques, tutoring, and special schools. Before the pediatrician is consulted as the last resource, a prior selection has occurred and the children who came for treatment of their inattention and
impul-sivity are those for whom nonpharmacologic inter-ventions have failed. Such children fall into two main groups: first, those whose learning suffers from inattention and impulsivity or attention defi-cit disorder, and, second, those for whom attention
deficit disorder is associated with a perceptual dis-order. The first group responds to stimulants dra-matically; the behavior of the second group will be ameliorated by medication, especially in nonlan-guage subjects, and also by a reduction in
impulsiv-ity, but their reading, spelling, and other academic problems persist, albeit considerably less severe than without medication. When, after long, unsuc-cessful trials of specifically targeted former inter-ventions, 85% of these children react so favorably to a single pharmacologic agent, there is no wonder that the pediatrician feels inclined to question the necessity for subclassifications according to pat-terns of presenting symptoms. The basic similarity among these children is also suggested by the some-times complete remission of assumedly associated
features of attention deficit disorder when stimu-lants are used. Poor handwriting, skiing, or tennis play improve suddenly and considerably after med-ication. Mothers report: “I can tell the way he holds his fork or the way he walks whether he took his medicine this morning.”
Nonmedical
Benefits
of Medication
The 84% (735 of 812 treated) positive responders should not be expected to be “cured.” They should be considered as sufficiently helped to get over the most demanding period of life. Successfully sur-mounting the hurdles of school is a crucial outcome for children. Such success seemed less dependent on sheer intelligence, but on the child’s ability to use any given degree of it and to perform assigned tasks with improved attention span and concentra-tion. Sitting, writing, reading, and theoretical
prob-lem-solving are difficult for any child. At home, hyperactive children are required to comply with some standards and accept rules they have no in-sight for or that are contrary to their temperamen-tal configuration and their impulsivity. For these children, the years of childhood and adolescence
are much more demanding than anything coming
later, and more demanding than for the normal
child seen in a pediatric practice.
The pediatrician is asked to help these children through this extreme and long-lasting challenge. Thus, in judging our therapeutic efforts, we should not count grades and repeated classes, but value the child’s acceptance of medication as indicative of his or her desire to sustain better performance and good behavior. Of course, many of these
chil-dren may always perform somewhat below their
peers, but intervention will enable them to accom-plish more than before and they will be aware of it. The first signs of better problem-solving ability and peer acceptance are the strongest reinforcers to raising the child’s self-confidence and his goal-directedness. When one considers the resistance of some parents and children to medication, continued desire for treatment becomes an even more mean-ingful indicator of success.
Emerging
Resistance
to Medication
Treatment
did not even dream of without medication. Children who were well aware of how medication helped them reported that they did not like being turned into a state that could be best described as a state of being conscious about what was expected and what they themselves expected. They seemingly felt better being “playboys” than responsible members of so-ciety. This modulation of self-perception and the call to behave according to unaccustomed and more demanding standards appears to be one of the rea-sons why there was not a single case of addiction to these substances.
Decision
to Stop Medication
It was difficult to evaluate the decisions to stop medication because the impression prevailed that parents seldom unveiled the real reasons. Others
repeatedly warned them of “drugging a child,” “changing the child’s character chemically,” sub-duing boyish activity with “calming pills,” and con-trolling “natural impulses and originality.” In West Germany, psychologists and psychotherapists, in conjunction with the do-it-yourself-counselors in the media, form a phalanx of antagonists against medical therapy for such children.
Any exogenous distrust of medication by parents was intensified when they observed the child’s mood change toward the direction of less exuber-ance and more earnestness. Resulting distrust was further bolstered by a child’s unwillingness to take medicine. Having been relieved from the unruly and noisy behavior of the hyperactive child, the parents were inclined to call this positive change
toward formerly wanted behavior as “depressive.” The less formalized questions of the last follow-up, allowing for global answers, were obviously more acceptable to the parents and thus more likely to relinquish useful information. It could be spec-ulated that the higher response rate to the simpli-fled “questionnaire” reflected more readiness to tell the truth.
CONCLUSION
The outcome of treatment with these cerebral stimulants appears to be a chemically mediated advancement of the academic and the social learn-ing process. The newly acquired control of impul-sivity and new attentional capabilities lead to higher achievements in all realms of daily life and make available a repertoire of social skills that are necessary for a happy childhood and adolescence.
The modulated behavior appeared to generalize into other fields of life and into coming years. Instrumental for this stage of development are strong reinforcers such as success and winning peer
recognition. There was an interplay between stim-ulant medication enabling the child to attain more
cognitive efficiency and social learning on one hand and the readiness of a positively reinforced young-ster to accept medicine as a means to acquire more self-confidence and recognition. This could be re-garded as a nearly self-perpetuating circle of behav-ior modification and drug. It is the task of the pediatrician to evaluate the medication
continu-ously and to counsel and to reinforce not only the child but also the mother.
In a private practice, this procedure led to rea-sonable results. The vast majority of children showed improvement. Most of the boys needed about 5 years of intervention; girls needed 3 years. A minority needed a longer time, and of these latter ones, a fraction will possibly need life-long support.
Environmental manipulations and behavioral measures were interspersed during each consulta-tion. Educational interventions of all sorts had been applied before the child came to my office in prac-tically all cases. Most children seeking help had gone through a long, painful odyssey of professional interventions, such as play therapy, some environ-mental changes, remediation for specific learning disorders, tutoring, and special education. The strains on parents’ patience had reached the point
where the parents would not accept trials of
nonmedical remediation.
A design accepting global answers rather than detailed information was the only possible way to
cope with uncooperative parents and have their
reports available for the purposes of this study. Deliberate dishonesty or unconscious “forgetting” of details could disqualify any attempt to compile follow-up data. Specific data that were available for only a portion of the subjects were sacrificed in preference for complete, but more qualitative, in-formation for all subjects described.
ACKNOWLEDGMENTS
My work and success with these children was made
possible only by the research of an innumerable array of
American physicians and psychologists, whose some 600 original articles that I have been collecting form the body
of knowledge necessary for my introduction into the area
and provide continuous training. Above all, the invalua-ble work and personal advice of the following researchers
stands: Virginia Douglas, Hans Huessy, Maurice Laufer,
Leon Oettinger (deceased), K. Daniel O’Leary, Daniel Safer, Robert Sprague, and Paul Wender.
REFERENCES
1974;14:109-123
2. Huessy HR: Minimal brain dysfunction in children (hyper-kinetic syndrome): Recognition and treatment. Drug Ther 1973;52-63
3. Sleator EK, Ullmann RK: Can the physician diagnose hy-peractivity in the office? Pediatrics 1981;67:13-17
4. Wender PH, Wender EH: The Hyperactive Child and the Learning Disabled Child. New York, Crown Publishers, mc, 1978
5. Patterson GR, Guillion E: Living with Children. Champaign,
IL, Research Press, 1971
6. Patterson GR: Families: Applications of Social Learning to Family Life. Champaign, IL, Research Press, 1971
7. Becker WC: ParentsAre Teachers. Champaign, IL, Research Press, 1971
8. Safer DJ, Allen RP: Hyperactive Children: Diagnosis and Management. Baltimore, University Park Press, 1976 9. Oettinger L Jr, Majovski LV, Limbeck GA, et al: Bone age
in children with minimal brain dysfunction. Percept Mot Skill.s1974;39:1127-1131
WHY IS IT CALLED BIRTH INJURY?
It is irrational to ascribe a child’s so called ‘brain damage’ to labour or delivery without considering other factors. ‘Brain damage’ occurs without difficult labour or perinatal hypoxia and caesarean section is no guarantee against it. Severe difficulties in delivery and severe hypoxia at birth are in the great majority not
followed by evidence of ‘brain damage’. In the maternal history there is a
significantly greater incidence of relative infertility, and of pregnancies associ-ated with low birthweight or intrauterine growth retardation, postmaturity, antepartum haemorrhage, pre-eclampsia or infections. There are often genetic factors, more congenital anomalies and pathological evidence of underlying abnormality. There is an interaction of numerous factors, prenatal, perinatal and postnatal and it is simplistic to ascribe ‘brain damage’ to single factors, such as breech delivery or hypoxia at birth, without considering the antecedent causes of those factors.
