Case Study A Review of ECT for Children and Adolescents CAPT. MARK W. BERTAGNOLI , M .D. , AND CARRIE M. BORCHARDT, M .D .
Abstract. T wo cases of electroconvulsive therapy (ECT) in adolescence are presented and the literatur e on the use of ECT in childhoo d and adole scence is reviewed . ECT was effect ive in children and adolescents with bipolar d isorder and depr ession. Inadequ ate informat ion exists to make a j udg ment regard ing schizophrenia, delirium , and anore xia nerv osa. ECT is not effective in autism and chron ic organ ic brain syndromes. Complications cited include orga nicity and seiz ures in the period immedia tely after ECT, anxiety react ions, and dis inhib ition . Longterm memory deficit or cognitive impa irment has not been found, although further resear ch to rule out residual impairm ent is needed. J . Am . Acad. Child Adolesc . Psychiatry . 1990,29,2:302- 307. Key Words: electroconvulsive therapy, children, adolescents. adolescents and young adult s over the last 3 decades (We issman , 1974; Pfeffer, 1985; Kuperman et al., 1988), Studies of the phenomenology and course of child and adolescent mood disorders provide additional evidence of concern. Depre ssive disorders may be chronic (Kovacs et al ., 1984a, b) and bipolar disorders tend to be more severe varieties with psychoti c symptoms and mixed states being more common than in adult-onset illness (Ballenger et a!. , 1982; Akiskal et al., 1985), Adult outcome and family history studies show that earl y onset depressive disorders have a higher rate of conversion to bipolarity than those of later onset (Strober and Carlson 1982; Akiskal et al ., 1983), Psychopharmacologic treatment studies on the other hand, have not supported high success rates in treating these earl yonset disorders (Ryan et al., 1986; Campbell and Spencer, 1988) although pharmacologic research continues. Clearly , closer examination of a treatment modality with known high efficacy in adult patient s is timely and overdue. In this paper, we will descr ibe two previously unreported cases where ECT was used in the treatment of adol escents, review the available literature on this subject, and discuss directions for further work in this area.
Is electroconvulsive ther apy (ECT) a treatment option for children and adolescents ? A 1985 consensus conference on ECT (Electroconvulsive Ther apy-Consensus Conference , 1985) stated that ECT should be considered for " delusional and severe endogenous depre ssions, acute mania , and certain schizophrenic syndromes " because of its proven efficacy, or when there is a risk of suicide , contraindications to tricyclic antidepressants, monoamine oxidase inhibitors, neuroleptics and lithium , or a failure of pharm acologic and psychotherapeutic treatment modaliti es. Age was not mentioned as a factor in the decision to use ECT; however , the American Psychiatric Association ECT -Task Force Report (ECT-Task Force Report 14, 1978) stated that ECT in children and adolescents " has been acceptable to a small group of psychiatri sts on rare and exceptional occasions." A review of the literature on the use of ECT in children and adolescents revealed a paucit y of information compared with studies on its use in adulthood. The few systematic studies were all done prior to the early 1950' s while the more recent literature consists only of case reports. So little information on the use of ECT in children and adolescents is surprising given the recent interest and research of mood disorders in those age groups. That resear ch has created growing profe ssional and public concern over rates of depression and suicid es in young people . Klerm an (1988) recently provided a crit ical review of literature which suggests increased rates of depression in young people , with both higher prevalence rates and earlier age of onset in recent decade s than earlier in the century . There is also good evidence for higher rates of suicide and suicide attempts in
Case Reports Case 1-1980 The patient was a 15-year-old female who presented to the psychiatry servi ce because of sleep disturbance , agitation, visual hallucinations, and starting a fire in her room . Her parent s reported that as a child she was slow to ach ieve developmental milestones and was alwa ys regarded as shy and withdrawn. Two years prior to admiss ion she developed mood swings of I week duration. During her " lows " she became withdrawn , lost her appetit e , and was inattentive to her personal hygiene . Her " highs" were marked by agitation, talkativeness, and aggress ion. On the day of adm ission the patient was discovered by her older brother wandering through classrooms after school searching for the people in her visions. There was no past psychiatric history and no significant past medical history. The family history was significant for
Accepted September 11 , 1989. Dr . Bertagnoli is a Resident in Pediatrics at David Gram USAF Medical Center . Dr . Borchardt is all Assistant Prof essor ill the Division of Child and Adolescent Psychiatry at the University of Minnesota Hospital and Clinic. Reprint requests to : Dr . Borchardt, Division of Child and Adolescent Psychiatry, Box 95 . University of Minnesota Hospital and Clinic. Harvard Street at East River Road . Minneapolis . MN 55455 . 0890-8567 /90/2902·0 302$02 .0010© 1990 by the Ameri can Academ y of Child and Adolesc ent Psych iatry .
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treated depression in the father and a "nervous breakdown" in the mother. The patient had a history of sexual abuse (without intercourse) by a neighborhood boy. Mental status examination revealed a well-oriented, slender, and attractive girl who thought that she was at the hospital for a job interview, although she was slovenly dressed. Her speech was rapid and pressured. She was agitated. Affect was blunted and mood elevated. Thought form was tangential with flight of ideas. She thought everyone in the hospital was related to her, that she was really 60 years old, and that she was God. She stated that the fire she had started in her room would "cleanse the world." She denied auditory and visual hallucinations and was not suicidal. Insight and judgment were poor. Axis I diagnosis was bipolar disorder, initially manic, later depressed. Treatment included trials of thiothixene 5 mg for 5 days, haloperidol 10 mg for I month, trifluoperazine 8 mg b.i.d. for I month, loxapine 10 mg for 3 weeks, and when she became depressed, imipramine 100 mg for 2 weeks. During these trials she was also given a IO-week trial of lithium, up to 1,800 mg with a level of 1.1 meq/L. Because her thought disorder persisted and her depression was worsening despite antidepressant medication, she was treated with nine unilateral nondominant ECT treatments followed by lithium maintenance. After ECT her affect brightened and she was less agitated with no hallucinations and normal sleep. The patient was still oppositional at times. The patient was discharged on lithium and trifluoperazine. At 9-month follow-up she showed no evidence of depression or psychosis. The patient continued to have minor social and family problems.
Case 2-1978 The patient was an 18-year-old female who was brought to the psychiatry service because her parents could not cope with her "aggressive and delusional" behavior. She was normal until the 7th grade when she became withdrawn. The next year she was found laughing inappropriately at school and reported hearing voices. She was treated with haloperidol up to 30 mg per day. In the following years the patient was hospitalized twice and the haloperidol was increased. In the week before admission she experienced poor sleep, delusions, and disorganized thoughts. She called the local sheriff and claimed that her mother was going to hang her. The patient's past medical history, developmental history, and family history are unremarkable. Mental status examination revealed a young woman wearing jeans. She displayed psychomotor agitation, full range of affect, with some inappropriate laughing and smiling, and normal mood. The patient reported paranoia, auditory hallucinations, thought broadcasting and delusions of body control. She refused to elaborate on the content of the hallucinations. She denied suicidal ideation, but had poor insight and judgment. Axis 1 diagnosis was schizophrenia-hebephrenic type. Although the patient displayed affective symptoms at times during the hospitalization (agitation, rapid speech, withdrawal, hypersexuality), affective symptoms were not obl.Am.Acad. Child Adolesc. Psychiatry. 29:2. March 1990
served to be prominent enough to qualify this as a mood disorder. The most prominent features of her illness were the chronicity of the psychosis, the severity of the thought disorder, and the inability to have peer relationships. The patient was unresponsive to thiothixene 100 mg for 1 month, loxapine 125 mg for 3 weeks and trifluoperazine 20 mg for 2 weeks. The patient then received 20 unilateral nondorninant ECT treatments with initial decrease in agitation of about 50% and increased social activity. The effects were short-lasting and the patient again displayed psychotic thinking and agitation. The patient was discharged on trifluoperazine 20 mg with recommendations for residential placement should the home placement fail. No follow-up is available.
Diagnosis and ECT The small number of case reports in the review suggests that although sparingly used, children and adolescents are treated with ECT. Of 33,384 hospitalized patients who received ECT in 1980, approximately 500 (1.5%) were in the 11 to 20 years age range (Thompson and Blaine, 1987). In California an average of eight patients/year younger than 18 years old received ECT between 1977 and 1983 (Kramer, 1985). In a British report, 31 of 433 psychiatrists surveyed used ECT in children younger than 16 years old for psychotic depression, catatonic stupor, mania, and occasionally schizophrenia or anorexia nervosa (Pippard and Ellam, 1981). Of the 1,000 patients treated with ECT by physicians at Strong Memorial Hospital (Rochester, NY) only four were less than 15 years old (Guttmacher and Cretella, 1988). In a survey of metropolitan New York psychiatric facilities, all physicians reported occasionally treating adolescent patients with ECT, but only one physician treated a patient less than 13 years old (Asnis et aI., 1978). Forty-one of 89 members of the National Association of Private Psychiatric Hospitals reported no age limitation for using ECT (Levy and Albrecht, 1985), while others described 17 years as the lower age limit (McCabe, 1976; Bland and Brintell, 1985; Rich and Black, 1985). In the published case reports of ECT in children and adolescents, the diagnoses include schizophrenia, bipolar disorder, depression, anorexia nervosa, and Gilles de la Tourette's syndrome with pervasive personality disorder (childhood onset). Although the more recent case reports use DSM-111 criteria, the diagnostic criteria used in the earlier case reports differed from each other and were not always clearly stated. Outcome criteria were also not clearly defined. Treatment response uniformly represents the observer's clinical impression. The data from the case reports of ECT in children and adolescents is summarized in Table 1. A summary of the data according to diagnostic category is presented in Table 2. In Table 2, Bender's cases of schizophrenia are separated from those of other authors because they likely represent a different diagnostic group. The cases summarized in Table 2 were combi.ted into three groups for statistical analysis: (I) affective disorders, (2) schizophrenia with the exclusion of Bender's cases and (3) other disorders, which includes anorexia nervosa and
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BERTAGNOLI AND BORCHARDT TABLE I . Summary of Case Reports of ECT ill Children and Adolescen ts Study
N
Age
Diagnosis
No .lType ECT
Response
Bender , 1947 Heuyer et al., 1947
98 6 3 9 I 2 I 14 I I 3 2 I I I I 2 I I I I
5-11 5-15 5-15 15-18 1-14 14 , 16 12 7- 14 19 14 12-15 13, 15 12 17 II 18 12, 19 14 15 15 18
Schizoph renia Depression Mania Bipolar, depressed Bipolar, manic Schizophrenia Schizophrenia Schizophrenia Anorexia nervosa Bipolar, manic Bipolar, depressed Bipolar . manic Bipolar , manic Depression Depression Bipolar, rapid cycling Depression Schizop hrenia Tourette' s syndrome Bipolar, depresse d Schizophrenia
20 daily ?
95/98 improved 5/6 improved 3/3 improved 8/9 improved Improved 2/2 improved Improved 121\4 improved Impro ved Improve d 3/3 improved 212 improved Improved Improved Improved Impro ved 1/2 improved None None Improved None
Campbell , 1952 Gallineck , 1952 Gillis , 1955 Hift et al., 1960 Bernstein , 1964 Warneke , 1975 Hassanyeh , 1980 Carr et a!., 1983 Mansheim, 1983 Black et al., 1985 Berman & Wolpert , 1987 Guttmacher & Cretella, 1988
Bertagnoli & Borchardt
Tourette ' s syndrome . Benders cases were excl uded from the analysis because of the diversity of sympt oms treated and lack of information on what was considered a positive response. The three groups are significantly different (p < 0 .0001 , df = 2, X2 = 34. 554) with affecti ve disordered patients show ing the highest proport ion of positive response to ECT and the other disorders group the lowest. As reported by the authors , 98/ 103 patient s diagnosed with schizophrenia improved with ECT , but examination of the clinical descript ions of the schizophrenic children reveals this to be a mixed group of psychiatri c disorders by contemporary diagnostic crite ria. Bender (1947) define s childhood schizophrenia as a " clinical entity indicative of an encephalopathy expressing itself at different point s in the development curve before the age of 12 years, and revealing pathology in behavior at every level and in every area of integration or patterning within the functioning of the central nervous system," but this definition , plus the fact that 34/ 98 childhood schizo phrenics had their onset in the first two years of life , suggests that Bender' s group of children with schizophrenia was a mixed diagnostic group which included organic conditi ons and autism . Clardy and Rump f (1954) who followed some of Bender' s schizophrenic patients, provide evidence for other diagno stic entities which were included in that group . They state that of the 30 children they followed who had been diagno sed as schizophrenic by Bender , only nine had a final diagnosis of schizophrenia while others were d iagnosed as primary beha vior problems and psychopath ic personalities. They further state that " the effects of EST were tempo rary and resulted in no sustained improvement in the patternin g of behavior. " Other cases of schizophrenia appear to have been more in the spectrum of affec tive disorders. In a case report by Gillis (1955 ), a 12-year-old boy is described as unhappy, 304
2 6 15-1 8 2 2- 13 plus insulin shock 2 courses , 21 each 5 5-22 3-5 7 unilateral 7 unilateral 12 unilateral 6 9- 13 unilatera l/bilateral 12 7 bilateral 9 unilateral nondomi nant 20 unilateral nondomin ant
worried , without interest s, displaying excessive guilt (' 'I am not to blame . .. for letting the pigeons out . . . breaking lamps ... I did not do it"), semistuporous, and having a depressed mood , suggesting that this patient was psychotically depressed rather then schizophrenic . Similarly, Gallineck (1952) described a 14-year-old boy with deep guilt about sexual masturb ation who kept shaking his head and hitting his head with his hand s to "shy away sexual fantasies that he considered to be sinful." Although the diagnosis was schizophrenia, these symptoms strongly sugges t psychotic depression . Gallineck ' s other case of schizo phrenia was a 16-year-old boy with a history of avoiding school because he feared becoming nauseated. This escalated to a 2 year period where he "prevented his mother from leaving him even for minutes, going into a wild temp er tantrum whenever his mother tried to leave him . " The patient was desc ribed as " introverted, " "without friends," "skeptical," and approaching "anorexia nervosa . " This description is typical of school refusal and depr ession. Thus , the majority of the 103 schizophrenic patients likely had a diagnosis other than schizophrenia by current standards. Case 2 reported in this article and the case reported by Guttmacher and Cretella (1988), patients who met DSM -1II criteria for schizophrenia, showed little or no improvement from ECT. In a German study of childhood schizophrenia by Hift et al. (1960), 14 patients diagnosed as having schizophrenia were treated with ECT (some had additional insulin shock therapy). Twelve of the children were bet ween the ages of 12 and 14; all were described as having affective symptoms. Nine of these ear ly adolesce nts experienced improvement with ECT. There were two 7-year-old children who did not respond to ECT ; one had only two treatments becau se of excess ive confusion. The use of ECT in children and adole scents for bipolar l.Am.A cad . Child Adolesc . Psychiatry, 29:2, March 1990
ECT FOR CHILDREN AND AD OLESCENT S T ABLE
Diagnosis Bipolar Depressed Manic Rapid cycle Depression Anorexia nervosa Tourene' s syndrome with PPD' Schizophren ia (Bender) Schizophrenia (other authors) Other" Total s a
b
2. Summary of Cases According to Diagnostic Category Age Range (Yrs.)
N II
9 2 10 2 I
98 18 19 170
12-1 8 5-15 15-1 8 5-17 15-19 15 5- 11 7-1 8 5- 15 5-19
M/Ff? 4/7 3/3
0/2 111 /6 01111 I/O
70/28 9/9 0/0119 90/51/29
% Impro ved
100 89 100 80 100 0 97 61 0 80
PPD, pervasive personality disorder. Other: delirium, other organic conditions , and other psychiatric condit ions for which inadequate diagnostic description was provided .
disorder was described by Berman and Wolpert (1987), Carr et al. (1983), Warnek e (1975) , Hassanyeh (1980), and Campbell (1952). The presenting episodes included depression, mania , and rapid cycling. All authors reported improvement immediately post-ECT except in one case by Campbell where the patient required sedation and constant observation post-ECT and then had two hypomani c and four depressive episodes in the 5 years after treatment. Several other patient s were noted to have recurrent depressive and/ or manic episodes post-ECT which were managed without further ECT . Overall , ECT appeared beneficial. Case studies of depression being treated with ECT in children and adolescents were reported by Guttmach er and Cretella et al. (1988), Black et al. (1985), and Mansheim (1983). Guttmacher and Cretella used DSM -IIJ criteria to diagnose depression , while Black et al. and Mansheim presented histories consistent with depression. Of the four cases, three responded to ECT although the patient reported by Black et al. was hospitalized five times in the 8 years postECT. Single case reports of ECT being used for anorexia nervosa (Bernstein, 1964) and Gilles de la Tourette's syndrome with pervasive personality disorder (childhood onset) (Guttmacher and Cretella, 1988) have been reported . Although the patient with anore xia nervosa required two courses of ECT , she gained 39 pound s and then had a full-term pregnancy with only minor psychosomat ic compla ints. The patient with Gilles de la Tourette ' s syndrome received ECT after failure of medication trials. He had mood elevation during the course of treatment, but quickly deteriorated when ECT was discontinued . Heuyer et al. (1947) reported 29 cases of ECT being given to children and adolescents 5 to 15 years of age with mixed psychiatric diagno ses. Diagnostic criteria are not presented; however , five of six patient s with depression and three of three with mania improved , as did one of two with delirium and one with anorexia. Besides case reports, other works contain brief referenc es regarding the use of ECT in children and adolescents . Frommer (1968) reported ECT use in two girls ages 12 and 15 who were suicidal , and Campbell (1973) mention s two preschool schizophrenic children who failed to respond to other treatment modalities but displ ayed some transient behavioral improvement post-ECT. l .Am.Acad. Child Adolesc . Psychiatry, 29:2, March 1990
Complications of ECT Does ECT affect the developing brain differently than the adult brain? The literature was reviewed for report s of complications and neuropsychological testing. Usually ECT tempo rarily increases the seizure threshold (Lerer, 1987). However , that is not always true as several authors noted . Guttmacher and Cretella ( 1988) reported prolonged seizures lasting up to 7 minutes in three pubescent patients following both unilateral and bilateral ECT . Bender (1947) described one child who had a history of a grand mal seizure at I V2 years of age who developed recurrin g grant mal seizures 7 months post-ECT. Since some of the disorders that Bender was treating with ECT are associated with seizure disorders (autism, organic syndromes), it is not clear whether the seizures were a direct result of ECT . Organic impairment was demonstrated by neuropsychological testin g and clinical observation. In the case reported by Carr et al. (1983), neurops ychological testing the week after ECT showed no specific abnormality except for a delay in recall of auditory and visual information . Repe at testing after 9 months revealed improved visual memory thought to be associated with recovery from right-sided ECT . Poor verbal memory persisted and was believed to be secondary to left-sided abnormalities noted on EEG before ECT. Bender (1947) noted four children with "organic type mental disturbances" characterized by excitement and confusion which disappeared within 2 weeks. Clardy and Rumpf (1954) also noted an ••organic type reaction " with memory disturb ances and brief disorientation . In a study where Bender and Keeler (1952) had children draw human figures and perform the visual motor gestalt test (Bender) immediately before ECT and later the same day following ECT , result s sugge st organic impairment caused by ECT. The Bender Gestalt Test is described as showing a " marked regre ssion to prim itiveness" and perseverative features immediately after each ECT , which paralleled the degree of distortions in the body image of the human drawings. The effect s lasted up to 6 hours after the ECT , increased throughout the course of ECT , and cleared approximately 36 hours after the final ECT. Gurevitz and Helme ( 1954) studied the effects of ECT by administering the Revised Stanford Binet , the Non-Language Multi-Mental Test of Terman, McCall and Lorge,
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BERTAGNOLI AND BORCHARDT
the Bender Gestalt Test, and the Trees-Fence-Road Test. They found that "intellectual efficiency was significantly reduced immediately after shock, but recovered by the time of follow-up" 5 to 27 months later. Disinhibition is a potential complication of ECT related to temporary organic impairment. Clardy and Rumpf ( 1954) gave several examples of possible disinhibition. They described patients physically abusing their younger siblings and two preadolescent girls with histories of sexual activity who became "less inhibited in resuming similar conduct." Because of the potential for impulsive and self-destructive behavior, children should have close supervision for several months post-ECT. Despite the complications in the immediate treatment period, many of the authors claim no long-term effects. Black et al. (1985) noted no "confusion or memory loss" in a patient who received ECT. Warneke (1975) showed that the Wechsler Intelligence Scale for Children went from verbal score = 92, performance = 69, and total = 80 before ECT to verbal = 94, performance = 93, and total = 93 after ECT in a depressed bipolar patient receiving ECT. Bender (1947) reported on IQ testing before and after ECT in 54 patients and found the range of IQ to be 44 to 146 pre-ECT and 44 to 153 post-ECT with average values of 83 and 84.5, respectively. She concluded that there was a "lack of any evidence for lasting effect on intellectual functioning and development." Des Lauriers and Halpern (1947) stated that children and adolescents post-ECT showed greater capacity for concentration, a slight increase in IQ, and no change in reasoning and judgment. In a study of neuropsychological testing of 16 patients (age 6 to 13) pre- ECT, immediately post-ECT, and 5 to 27 months following ECT, Gurevitz and Helme (1954) noted a non-significant slight increase of IQ at follow-up. Clardy and Rumpf (1954) reported similar findings. These findings are comparable to what has been found in adults (Weiner, 1979; Kendell, 1981). Another complication of ECT could be classified as an anxiety reaction. Campbell (1952) reported that a bipolar patient experienced 4 to 5 months of residual anxiety postECT. Clardy and Rumpf (1954) noted that a patient attempted suicide post-ECT because he feared repeated ECT; he said he "was afraid of dying and wanted to get it over with fast." A sexually abused patient equated ECT with the electric chair and was fearful of treatment. Bender (1947) characterized the reaction of some of the youngest children receiving ECT as "negativistic and resistant-almost to the point of panic." The developmental consequences of such experiences is not known. A child's understanding of the treatment is likely to be influenced by such factors as his or her level of cognitive and emotional development, prior experiences, such age related factors as relative lack of autonomy, and lack of involvement in the treatment decision-making process. Acknowledging that there are complications to using ECT in children and adolescents, who should give consent for treatment of children and adolescents with ECT? The consensus conference on ECT in 1985 (Electroconvulsive Therapy-Consensus Conference, 1985) says "law requires, and 306
medical ethics demand, that the patient's freedom to accept or refuse treatment be fully honored. " There is no discussion of consent procedures for children and adolescents. It is probably acceptable to have parental consent for children who are pre-adolescent. The issue of consent in adolescence is complex and cannot be fully examined here. However, rights of adolescent patients to consent to some medical treatment, most notably reproductive, have been determined in the courts (Martin, 1982). Courts have also found adolescents in some circumstances to be able to refuse psychiatric hospitalizations (Hofmann, 1980; Weinapple et al. 1980). It seems reasonable, therefore, that consent for ECT should be obtained from both the adolescent and parents. In a case where the adolescent refuses treatment with ECT, the legal system may be consulted for help with the decision.
Conclusion Based on the case reports reviewed, ECT is beneficial to children and adolescents with bipolar disorder (depressed, manic, or rapid cycling) and depression. When compared to a group of nonaffective disordered patients, those with affective disorder were significantly more likely to benefit from ECT. Anorexia nervosa responded to ECT, but only two cases were reviewed. There is not enough data to know how beneficial ECT is for childhood schizophrenia because it is uncertain how many of the reported childhood schizophrenic patients actually had schizophrenia. ECT is not useful for chronic organic syndromes or autism. However, these conclusions must be viewed with caution given the subjective measure of outcome. The complications of ECT include a brief period of organic impairment, anxiety reactions, disinhibition, and alteration of the seizure threshold. The organic impairment clears markedly within a few days, but mild impairment, possibly with disinhibition, may persist for a few months. This review points out the need for continued study of ECT in children and adolescents. Systematic studies using established diagnostic criteria and clearly defined outcome would clarify potential benefits and risks. Neuropsychological testing should be done before, after, and at a distant follow-up when using ECT. Long-term follow-up should also examine the course of illness and psychological development post-ECT, with attention to the child's perception of the treatment and any residual anxiety. It is particularly important to investigate whether ECT can provide rapid resolution of symptoms in medication nonresponders and avoidance of subsequent chronicity of illness, an important goal for child psychiatrists. For the age group that we treat, chronic illness can have a devastating impact on the development and the future of the individual.
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New York hospitals-a survey of practice. Am. I. Psychiatry, 135:479--482. Ballenger, J. C., Reus, V. I. & Post, R. M. (1982), The "atypical" clinical picture of adolescent mania. Am. I. Psychiatry, 139(5):602606. Bender, L. (1947), One-hundred cases of childhood schizophrenia treated with ECT. Transactions of the American Neurological Association, 72:165-169. - - Keeler, W. R. (1952), The body image of schizophrenic children following electroshock therapy. Am. I. Orthopsychiatry, 22:335355. Berman, E. & Wolpert, E. (1987), Intractable manic-depressive psychosis with rapid cycling in an 18 year old woman successfully treated with ECT. I. Nerv. Ment, Dis., 175(4):236-239. Bernstein, I. C. (1964), Anorexia nervosa treated successfully with electroshock therapy and subsequently followed by pregnancy. Am. I. Psychiatry, 120:1023-1024. Black, D. W., Wilcox, J. A. & Stewart, M. (1985), The use of ECT in children: case report. I. Clin. Psychiatry, 46:98-99. Bland, R. C. & Brintell, S. (1985), Electroconvulsive therapy in a major teaching hospital: diagnosis & indication. Can. I. Psychiatry, 30:288-292. Campbell, J. D. (1952), Manic-depressive psychosis in childrenreport of 18 cases. I. Nerv. Ment. Dis., 116:424-439. Campbell, M. (1973), Biological interventions in psychoses of childhood. Journal of Autism and Childhood Schizophrenia, 3(4):347373. - - Spencer, E. K. (1988), Psychopharmacology in child and adolescent psychiatry: a review of the past five years. I. Am. Acad. Child Adolesc. Psychiatry, Carr, V., Dorrington, c., Schader, G. & Wale, J. (1983), The use of ECT in childhood bipolar disorder. Br. I. Psychiatry, 143:411415. Clardy, E. R. & Rumpf, E. M. (1954), The effect of electric shock on children having schizophrenic manifestation. Psychiatr. Q .. 28:616-623. Des Lauriers, A. & Halper, F. (1947), Psychological testing in childhood schizophrenia. Am. I. Orthopsychiatry, 17:57-67. ECT - Task Force Report 14, (1978), Am. Psychiatric Assoc. Electroconvulsive Therapy - Consensus Conference, (1985), lAMA, 254(15):3103-3108. Frommer, E. (1968), Recent developments in affective disorders of childhood. Br. I. Psychiatry, Spec. Pub #2:117-136. Gallineck, A. (1952), Controversial indications for electroconvulsive therapy. Am. I. Psychiatry, 10:361-366. Gillis, A. (1955), A case of schizophrenia in childhood. I. Nerv. Ment . Dis., 121:471--472. Gurevitz, S. & Helme, W. H. (1954), Effects of electroconvulsive therapy on personality and intellectual functioning of the schizophrenic child. I. Nerv. Ment . Dis., 1220:213-226. Guttmacher, L. B. & Cretella, H. (1988), Electroconvulsive therapy in one child and three adolescents. I. Clin. Psychiatry, 49:20-23. Hassanyeh, F. (1980), Bipolar affective psychosis with onset before age 16. Br. I. Psychiatry, 137:530-539. Heuyer , G., Dauphin, M. & Lebovici, S. (1947), La practique de l'electrochochez l'enfant. Zeitschrift fuel' Kinder-und Jugendpsychiatrie, Psychiatry, 14:60-64. Hift, E., Hift, S. & Spiel, W. (1960), Ergebnisse der schockbe-
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handlungen bei kindlischen schizophrenien. Schweiz . Arch. Neurol. Psvchiatr., 86:256-272. Hof~ann, A. D. (1980), A rational policy toward consent & confidentiality in adolescent health care. I. Adolesc. Health Care, (1):917. Mansheim, P. (1983), ECT in the treatment of a depressed adolescent with meningomyelocele hydrocephalus and seizures. I. Clin. Psychiatrv, 44(10):386-386. Martin, ·R. M. (1982), Law and the minor patient. South. Med. I., 75(10): 1245-1248. McCabe, M. S. (1976), ECT in the treatment of mania: a controlled study. Am. I. Psychiatry, 133(6):688-691. Pfeffer, C. R. (1985), Self-destructive behavior in children and adolescents. Psvchiat . Clin. North Am., 8(2):215-225. Pippard, J. & Ellam, L. (1981), Electroconvulsive Treatment in Great Britain, 1980. London: Headley Brothers, Ltd, The Invicta Press. Rich, C. L., & Black, N. A. (1985), The efficiency of ECT: II. Psychiatry Res. 16:147-154. Ryan, N. D., Puig-Antich , J., Cooper, T. et al. (1986), Imipramine in adolescent major depression: plasma level and clinical response. Acta Psychiatr . Scand. 73:275-288. Strober, M. & Carlson, G. (1982), Bipolar illness in adolescents with major depression. Arch. Gen. Psychiatry, 39:549-555. Thompson, J. W. & Blaine, J. D. (1987), Use of ECT in the United States in 1975 and 1980. Am. I. Psychiatry, 144:557-562. Kendell, R. E. (1981), The present status of electroconvulsive therapy. Br. I. Psychiatry, 139:265-283. Klerman, G. L. (1988), The current age of youthful melancholia. Br. I. Psychiatry, 152:4-114. Kovacs, M., Feinberg, T. L., Crouse-Novak, M. A., Paulauskas, S. L. & Finkelstein, R. (l984a), Depressive disorders in childhood I. a longitudinal prospective study of characteristics and recovery. Arch. Gen. Psychiatry, 41:229-237. - - - - - - - - Pollock, M. & Finkelstein, R. (l984b), Depressive disorders in childhood II. a longitudinal study of the risk for a subsequent major depression. Arch. Gen. Psychiatry, 41:643649. Kramer, B. A. (1985), Use of ECT in California 1977-1983. Am. I. Psychiatry, 142:1190-1192. Kuperman, S., Black, D. W. & Burns, T. L. (1988), Excess mortality among formerly hospitalized child psychiatric patients. Arch. Gen. Psychiatry, 45:277-282. Lerer, B. (1987), Neurochemical and other neurobiological consequences of ECT: implications of affective disorders. In: Psychopharmacology: The Third Generation of Progress, ed. H. Y. Meltzer. New York: Raven Press, pp. 577-588. Levy, S. D. & Albrecht, E. (1985), Electroconvulsive therapy: a survey of use in the private psychiatric hospital. I. Clin, Psychiatry, 46:125-127. Warneke, L. (1975), A case of manic-depressive illness in childhood. Can. I. Psychiatry, 20(3): 195-200. Weinapple, M., Keefe, J. E. & Manto, P. G. (1980), Legal & psychiatric issues on the hospitalization of children. Bull. Am. Acad. Psychiatry Law, 7(1):78-94. Weiner, R.· D. (1979), The psychiatric use of electrically induced seizures. Am. I. Psychiatry, 36(12):1507-1517. Weissman, M. M. (974), 'The epidemiology of suicide attempts, 1960-1971. Arch. Gen. Psychiatry, 30:737-746.
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Abstract. T wo cases of electroconvulsive therapy (ECT) in adolescence are presented and the literatur e on the use of ECT in childhoo d and adole scence is reviewed . ECT was effect ive in children and adolescents with bipolar d isorder and depr ession. Inadequ ate informat ion exists to make a j udg ment regard ing schizophrenia, delirium , and anore xia nerv osa. ECT is not effective in autism and chron ic organ ic brain syndromes. Complications cited include orga nicity and seiz ures in the period immedia tely after ECT, anxiety react ions, and dis inhib ition . Longterm memory deficit or cognitive impa irment has not been found, although further resear ch to rule out residual impairm ent is needed. J . Am . Acad. Child Adolesc . Psychiatry . 1990,29,2:302- 307. Key Words: electroconvulsive therapy, children, adolescents. adolescents and young adult s over the last 3 decades (We issman , 1974; Pfeffer, 1985; Kuperman et al., 1988), Studies of the phenomenology and course of child and adolescent mood disorders provide additional evidence of concern. Depre ssive disorders may be chronic (Kovacs et al ., 1984a, b) and bipolar disorders tend to be more severe varieties with psychoti c symptoms and mixed states being more common than in adult-onset illness (Ballenger et a!. , 1982; Akiskal et al., 1985), Adult outcome and family history studies show that earl y onset depressive disorders have a higher rate of conversion to bipolarity than those of later onset (Strober and Carlson 1982; Akiskal et al ., 1983), Psychopharmacologic treatment studies on the other hand, have not supported high success rates in treating these earl yonset disorders (Ryan et al., 1986; Campbell and Spencer, 1988) although pharmacologic research continues. Clearly , closer examination of a treatment modality with known high efficacy in adult patient s is timely and overdue. In this paper, we will descr ibe two previously unreported cases where ECT was used in the treatment of adol escents, review the available literature on this subject, and discuss directions for further work in this area.
Is electroconvulsive ther apy (ECT) a treatment option for children and adolescents ? A 1985 consensus conference on ECT (Electroconvulsive Ther apy-Consensus Conference , 1985) stated that ECT should be considered for " delusional and severe endogenous depre ssions, acute mania , and certain schizophrenic syndromes " because of its proven efficacy, or when there is a risk of suicide , contraindications to tricyclic antidepressants, monoamine oxidase inhibitors, neuroleptics and lithium , or a failure of pharm acologic and psychotherapeutic treatment modaliti es. Age was not mentioned as a factor in the decision to use ECT; however , the American Psychiatric Association ECT -Task Force Report (ECT-Task Force Report 14, 1978) stated that ECT in children and adolescents " has been acceptable to a small group of psychiatri sts on rare and exceptional occasions." A review of the literature on the use of ECT in children and adolescents revealed a paucit y of information compared with studies on its use in adulthood. The few systematic studies were all done prior to the early 1950' s while the more recent literature consists only of case reports. So little information on the use of ECT in children and adolescents is surprising given the recent interest and research of mood disorders in those age groups. That resear ch has created growing profe ssional and public concern over rates of depression and suicid es in young people . Klerm an (1988) recently provided a crit ical review of literature which suggests increased rates of depression in young people , with both higher prevalence rates and earlier age of onset in recent decade s than earlier in the century . There is also good evidence for higher rates of suicide and suicide attempts in
Case Reports Case 1-1980 The patient was a 15-year-old female who presented to the psychiatry servi ce because of sleep disturbance , agitation, visual hallucinations, and starting a fire in her room . Her parent s reported that as a child she was slow to ach ieve developmental milestones and was alwa ys regarded as shy and withdrawn. Two years prior to admiss ion she developed mood swings of I week duration. During her " lows " she became withdrawn , lost her appetit e , and was inattentive to her personal hygiene . Her " highs" were marked by agitation, talkativeness, and aggress ion. On the day of adm ission the patient was discovered by her older brother wandering through classrooms after school searching for the people in her visions. There was no past psychiatric history and no significant past medical history. The family history was significant for
Accepted September 11 , 1989. Dr . Bertagnoli is a Resident in Pediatrics at David Gram USAF Medical Center . Dr . Borchardt is all Assistant Prof essor ill the Division of Child and Adolescent Psychiatry at the University of Minnesota Hospital and Clinic. Reprint requests to : Dr . Borchardt, Division of Child and Adolescent Psychiatry, Box 95 . University of Minnesota Hospital and Clinic. Harvard Street at East River Road . Minneapolis . MN 55455 . 0890-8567 /90/2902·0 302$02 .0010© 1990 by the Ameri can Academ y of Child and Adolesc ent Psych iatry .
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treated depression in the father and a "nervous breakdown" in the mother. The patient had a history of sexual abuse (without intercourse) by a neighborhood boy. Mental status examination revealed a well-oriented, slender, and attractive girl who thought that she was at the hospital for a job interview, although she was slovenly dressed. Her speech was rapid and pressured. She was agitated. Affect was blunted and mood elevated. Thought form was tangential with flight of ideas. She thought everyone in the hospital was related to her, that she was really 60 years old, and that she was God. She stated that the fire she had started in her room would "cleanse the world." She denied auditory and visual hallucinations and was not suicidal. Insight and judgment were poor. Axis I diagnosis was bipolar disorder, initially manic, later depressed. Treatment included trials of thiothixene 5 mg for 5 days, haloperidol 10 mg for I month, trifluoperazine 8 mg b.i.d. for I month, loxapine 10 mg for 3 weeks, and when she became depressed, imipramine 100 mg for 2 weeks. During these trials she was also given a IO-week trial of lithium, up to 1,800 mg with a level of 1.1 meq/L. Because her thought disorder persisted and her depression was worsening despite antidepressant medication, she was treated with nine unilateral nondominant ECT treatments followed by lithium maintenance. After ECT her affect brightened and she was less agitated with no hallucinations and normal sleep. The patient was still oppositional at times. The patient was discharged on lithium and trifluoperazine. At 9-month follow-up she showed no evidence of depression or psychosis. The patient continued to have minor social and family problems.
Case 2-1978 The patient was an 18-year-old female who was brought to the psychiatry service because her parents could not cope with her "aggressive and delusional" behavior. She was normal until the 7th grade when she became withdrawn. The next year she was found laughing inappropriately at school and reported hearing voices. She was treated with haloperidol up to 30 mg per day. In the following years the patient was hospitalized twice and the haloperidol was increased. In the week before admission she experienced poor sleep, delusions, and disorganized thoughts. She called the local sheriff and claimed that her mother was going to hang her. The patient's past medical history, developmental history, and family history are unremarkable. Mental status examination revealed a young woman wearing jeans. She displayed psychomotor agitation, full range of affect, with some inappropriate laughing and smiling, and normal mood. The patient reported paranoia, auditory hallucinations, thought broadcasting and delusions of body control. She refused to elaborate on the content of the hallucinations. She denied suicidal ideation, but had poor insight and judgment. Axis 1 diagnosis was schizophrenia-hebephrenic type. Although the patient displayed affective symptoms at times during the hospitalization (agitation, rapid speech, withdrawal, hypersexuality), affective symptoms were not obl.Am.Acad. Child Adolesc. Psychiatry. 29:2. March 1990
served to be prominent enough to qualify this as a mood disorder. The most prominent features of her illness were the chronicity of the psychosis, the severity of the thought disorder, and the inability to have peer relationships. The patient was unresponsive to thiothixene 100 mg for 1 month, loxapine 125 mg for 3 weeks and trifluoperazine 20 mg for 2 weeks. The patient then received 20 unilateral nondorninant ECT treatments with initial decrease in agitation of about 50% and increased social activity. The effects were short-lasting and the patient again displayed psychotic thinking and agitation. The patient was discharged on trifluoperazine 20 mg with recommendations for residential placement should the home placement fail. No follow-up is available.
Diagnosis and ECT The small number of case reports in the review suggests that although sparingly used, children and adolescents are treated with ECT. Of 33,384 hospitalized patients who received ECT in 1980, approximately 500 (1.5%) were in the 11 to 20 years age range (Thompson and Blaine, 1987). In California an average of eight patients/year younger than 18 years old received ECT between 1977 and 1983 (Kramer, 1985). In a British report, 31 of 433 psychiatrists surveyed used ECT in children younger than 16 years old for psychotic depression, catatonic stupor, mania, and occasionally schizophrenia or anorexia nervosa (Pippard and Ellam, 1981). Of the 1,000 patients treated with ECT by physicians at Strong Memorial Hospital (Rochester, NY) only four were less than 15 years old (Guttmacher and Cretella, 1988). In a survey of metropolitan New York psychiatric facilities, all physicians reported occasionally treating adolescent patients with ECT, but only one physician treated a patient less than 13 years old (Asnis et aI., 1978). Forty-one of 89 members of the National Association of Private Psychiatric Hospitals reported no age limitation for using ECT (Levy and Albrecht, 1985), while others described 17 years as the lower age limit (McCabe, 1976; Bland and Brintell, 1985; Rich and Black, 1985). In the published case reports of ECT in children and adolescents, the diagnoses include schizophrenia, bipolar disorder, depression, anorexia nervosa, and Gilles de la Tourette's syndrome with pervasive personality disorder (childhood onset). Although the more recent case reports use DSM-111 criteria, the diagnostic criteria used in the earlier case reports differed from each other and were not always clearly stated. Outcome criteria were also not clearly defined. Treatment response uniformly represents the observer's clinical impression. The data from the case reports of ECT in children and adolescents is summarized in Table 1. A summary of the data according to diagnostic category is presented in Table 2. In Table 2, Bender's cases of schizophrenia are separated from those of other authors because they likely represent a different diagnostic group. The cases summarized in Table 2 were combi.ted into three groups for statistical analysis: (I) affective disorders, (2) schizophrenia with the exclusion of Bender's cases and (3) other disorders, which includes anorexia nervosa and
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BERTAGNOLI AND BORCHARDT TABLE I . Summary of Case Reports of ECT ill Children and Adolescen ts Study
N
Age
Diagnosis
No .lType ECT
Response
Bender , 1947 Heuyer et al., 1947
98 6 3 9 I 2 I 14 I I 3 2 I I I I 2 I I I I
5-11 5-15 5-15 15-18 1-14 14 , 16 12 7- 14 19 14 12-15 13, 15 12 17 II 18 12, 19 14 15 15 18
Schizoph renia Depression Mania Bipolar, depressed Bipolar, manic Schizophrenia Schizophrenia Schizophrenia Anorexia nervosa Bipolar, manic Bipolar, depressed Bipolar . manic Bipolar , manic Depression Depression Bipolar, rapid cycling Depression Schizop hrenia Tourette' s syndrome Bipolar, depresse d Schizophrenia
20 daily ?
95/98 improved 5/6 improved 3/3 improved 8/9 improved Improved 2/2 improved Improved 121\4 improved Impro ved Improve d 3/3 improved 212 improved Improved Improved Improved Impro ved 1/2 improved None None Improved None
Campbell , 1952 Gallineck , 1952 Gillis , 1955 Hift et al., 1960 Bernstein , 1964 Warneke , 1975 Hassanyeh , 1980 Carr et a!., 1983 Mansheim, 1983 Black et al., 1985 Berman & Wolpert , 1987 Guttmacher & Cretella, 1988
Bertagnoli & Borchardt
Tourette ' s syndrome . Benders cases were excl uded from the analysis because of the diversity of sympt oms treated and lack of information on what was considered a positive response. The three groups are significantly different (p < 0 .0001 , df = 2, X2 = 34. 554) with affecti ve disordered patients show ing the highest proport ion of positive response to ECT and the other disorders group the lowest. As reported by the authors , 98/ 103 patient s diagnosed with schizophrenia improved with ECT , but examination of the clinical descript ions of the schizophrenic children reveals this to be a mixed group of psychiatri c disorders by contemporary diagnostic crite ria. Bender (1947) define s childhood schizophrenia as a " clinical entity indicative of an encephalopathy expressing itself at different point s in the development curve before the age of 12 years, and revealing pathology in behavior at every level and in every area of integration or patterning within the functioning of the central nervous system," but this definition , plus the fact that 34/ 98 childhood schizo phrenics had their onset in the first two years of life , suggests that Bender' s group of children with schizophrenia was a mixed diagnostic group which included organic conditi ons and autism . Clardy and Rump f (1954) who followed some of Bender' s schizophrenic patients, provide evidence for other diagno stic entities which were included in that group . They state that of the 30 children they followed who had been diagno sed as schizophrenic by Bender , only nine had a final diagnosis of schizophrenia while others were d iagnosed as primary beha vior problems and psychopath ic personalities. They further state that " the effects of EST were tempo rary and resulted in no sustained improvement in the patternin g of behavior. " Other cases of schizophrenia appear to have been more in the spectrum of affec tive disorders. In a case report by Gillis (1955 ), a 12-year-old boy is described as unhappy, 304
2 6 15-1 8 2 2- 13 plus insulin shock 2 courses , 21 each 5 5-22 3-5 7 unilateral 7 unilateral 12 unilateral 6 9- 13 unilatera l/bilateral 12 7 bilateral 9 unilateral nondomi nant 20 unilateral nondomin ant
worried , without interest s, displaying excessive guilt (' 'I am not to blame . .. for letting the pigeons out . . . breaking lamps ... I did not do it"), semistuporous, and having a depressed mood , suggesting that this patient was psychotically depressed rather then schizophrenic . Similarly, Gallineck (1952) described a 14-year-old boy with deep guilt about sexual masturb ation who kept shaking his head and hitting his head with his hand s to "shy away sexual fantasies that he considered to be sinful." Although the diagnosis was schizophrenia, these symptoms strongly sugges t psychotic depression . Gallineck ' s other case of schizo phrenia was a 16-year-old boy with a history of avoiding school because he feared becoming nauseated. This escalated to a 2 year period where he "prevented his mother from leaving him even for minutes, going into a wild temp er tantrum whenever his mother tried to leave him . " The patient was desc ribed as " introverted, " "without friends," "skeptical," and approaching "anorexia nervosa . " This description is typical of school refusal and depr ession. Thus , the majority of the 103 schizophrenic patients likely had a diagnosis other than schizophrenia by current standards. Case 2 reported in this article and the case reported by Guttmacher and Cretella (1988), patients who met DSM -1II criteria for schizophrenia, showed little or no improvement from ECT. In a German study of childhood schizophrenia by Hift et al. (1960), 14 patients diagnosed as having schizophrenia were treated with ECT (some had additional insulin shock therapy). Twelve of the children were bet ween the ages of 12 and 14; all were described as having affective symptoms. Nine of these ear ly adolesce nts experienced improvement with ECT. There were two 7-year-old children who did not respond to ECT ; one had only two treatments becau se of excess ive confusion. The use of ECT in children and adole scents for bipolar l.Am.A cad . Child Adolesc . Psychiatry, 29:2, March 1990
ECT FOR CHILDREN AND AD OLESCENT S T ABLE
Diagnosis Bipolar Depressed Manic Rapid cycle Depression Anorexia nervosa Tourene' s syndrome with PPD' Schizophren ia (Bender) Schizophrenia (other authors) Other" Total s a
b
2. Summary of Cases According to Diagnostic Category Age Range (Yrs.)
N II
9 2 10 2 I
98 18 19 170
12-1 8 5-15 15-1 8 5-17 15-19 15 5- 11 7-1 8 5- 15 5-19
M/Ff? 4/7 3/3
0/2 111 /6 01111 I/O
70/28 9/9 0/0119 90/51/29
% Impro ved
100 89 100 80 100 0 97 61 0 80
PPD, pervasive personality disorder. Other: delirium, other organic conditions , and other psychiatric condit ions for which inadequate diagnostic description was provided .
disorder was described by Berman and Wolpert (1987), Carr et al. (1983), Warnek e (1975) , Hassanyeh (1980), and Campbell (1952). The presenting episodes included depression, mania , and rapid cycling. All authors reported improvement immediately post-ECT except in one case by Campbell where the patient required sedation and constant observation post-ECT and then had two hypomani c and four depressive episodes in the 5 years after treatment. Several other patient s were noted to have recurrent depressive and/ or manic episodes post-ECT which were managed without further ECT . Overall , ECT appeared beneficial. Case studies of depression being treated with ECT in children and adolescents were reported by Guttmach er and Cretella et al. (1988), Black et al. (1985), and Mansheim (1983). Guttmacher and Cretella used DSM -IIJ criteria to diagnose depression , while Black et al. and Mansheim presented histories consistent with depression. Of the four cases, three responded to ECT although the patient reported by Black et al. was hospitalized five times in the 8 years postECT. Single case reports of ECT being used for anorexia nervosa (Bernstein, 1964) and Gilles de la Tourette's syndrome with pervasive personality disorder (childhood onset) (Guttmacher and Cretella, 1988) have been reported . Although the patient with anore xia nervosa required two courses of ECT , she gained 39 pound s and then had a full-term pregnancy with only minor psychosomat ic compla ints. The patient with Gilles de la Tourette ' s syndrome received ECT after failure of medication trials. He had mood elevation during the course of treatment, but quickly deteriorated when ECT was discontinued . Heuyer et al. (1947) reported 29 cases of ECT being given to children and adolescents 5 to 15 years of age with mixed psychiatric diagno ses. Diagnostic criteria are not presented; however , five of six patient s with depression and three of three with mania improved , as did one of two with delirium and one with anorexia. Besides case reports, other works contain brief referenc es regarding the use of ECT in children and adolescents . Frommer (1968) reported ECT use in two girls ages 12 and 15 who were suicidal , and Campbell (1973) mention s two preschool schizophrenic children who failed to respond to other treatment modalities but displ ayed some transient behavioral improvement post-ECT. l .Am.Acad. Child Adolesc . Psychiatry, 29:2, March 1990
Complications of ECT Does ECT affect the developing brain differently than the adult brain? The literature was reviewed for report s of complications and neuropsychological testing. Usually ECT tempo rarily increases the seizure threshold (Lerer, 1987). However , that is not always true as several authors noted . Guttmacher and Cretella ( 1988) reported prolonged seizures lasting up to 7 minutes in three pubescent patients following both unilateral and bilateral ECT . Bender (1947) described one child who had a history of a grand mal seizure at I V2 years of age who developed recurrin g grant mal seizures 7 months post-ECT. Since some of the disorders that Bender was treating with ECT are associated with seizure disorders (autism, organic syndromes), it is not clear whether the seizures were a direct result of ECT . Organic impairment was demonstrated by neuropsychological testin g and clinical observation. In the case reported by Carr et al. (1983), neurops ychological testing the week after ECT showed no specific abnormality except for a delay in recall of auditory and visual information . Repe at testing after 9 months revealed improved visual memory thought to be associated with recovery from right-sided ECT . Poor verbal memory persisted and was believed to be secondary to left-sided abnormalities noted on EEG before ECT. Bender (1947) noted four children with "organic type mental disturbances" characterized by excitement and confusion which disappeared within 2 weeks. Clardy and Rumpf (1954) also noted an ••organic type reaction " with memory disturb ances and brief disorientation . In a study where Bender and Keeler (1952) had children draw human figures and perform the visual motor gestalt test (Bender) immediately before ECT and later the same day following ECT , result s sugge st organic impairment caused by ECT. The Bender Gestalt Test is described as showing a " marked regre ssion to prim itiveness" and perseverative features immediately after each ECT , which paralleled the degree of distortions in the body image of the human drawings. The effect s lasted up to 6 hours after the ECT , increased throughout the course of ECT , and cleared approximately 36 hours after the final ECT. Gurevitz and Helme ( 1954) studied the effects of ECT by administering the Revised Stanford Binet , the Non-Language Multi-Mental Test of Terman, McCall and Lorge,
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the Bender Gestalt Test, and the Trees-Fence-Road Test. They found that "intellectual efficiency was significantly reduced immediately after shock, but recovered by the time of follow-up" 5 to 27 months later. Disinhibition is a potential complication of ECT related to temporary organic impairment. Clardy and Rumpf ( 1954) gave several examples of possible disinhibition. They described patients physically abusing their younger siblings and two preadolescent girls with histories of sexual activity who became "less inhibited in resuming similar conduct." Because of the potential for impulsive and self-destructive behavior, children should have close supervision for several months post-ECT. Despite the complications in the immediate treatment period, many of the authors claim no long-term effects. Black et al. (1985) noted no "confusion or memory loss" in a patient who received ECT. Warneke (1975) showed that the Wechsler Intelligence Scale for Children went from verbal score = 92, performance = 69, and total = 80 before ECT to verbal = 94, performance = 93, and total = 93 after ECT in a depressed bipolar patient receiving ECT. Bender (1947) reported on IQ testing before and after ECT in 54 patients and found the range of IQ to be 44 to 146 pre-ECT and 44 to 153 post-ECT with average values of 83 and 84.5, respectively. She concluded that there was a "lack of any evidence for lasting effect on intellectual functioning and development." Des Lauriers and Halpern (1947) stated that children and adolescents post-ECT showed greater capacity for concentration, a slight increase in IQ, and no change in reasoning and judgment. In a study of neuropsychological testing of 16 patients (age 6 to 13) pre- ECT, immediately post-ECT, and 5 to 27 months following ECT, Gurevitz and Helme (1954) noted a non-significant slight increase of IQ at follow-up. Clardy and Rumpf (1954) reported similar findings. These findings are comparable to what has been found in adults (Weiner, 1979; Kendell, 1981). Another complication of ECT could be classified as an anxiety reaction. Campbell (1952) reported that a bipolar patient experienced 4 to 5 months of residual anxiety postECT. Clardy and Rumpf (1954) noted that a patient attempted suicide post-ECT because he feared repeated ECT; he said he "was afraid of dying and wanted to get it over with fast." A sexually abused patient equated ECT with the electric chair and was fearful of treatment. Bender (1947) characterized the reaction of some of the youngest children receiving ECT as "negativistic and resistant-almost to the point of panic." The developmental consequences of such experiences is not known. A child's understanding of the treatment is likely to be influenced by such factors as his or her level of cognitive and emotional development, prior experiences, such age related factors as relative lack of autonomy, and lack of involvement in the treatment decision-making process. Acknowledging that there are complications to using ECT in children and adolescents, who should give consent for treatment of children and adolescents with ECT? The consensus conference on ECT in 1985 (Electroconvulsive Therapy-Consensus Conference, 1985) says "law requires, and 306
medical ethics demand, that the patient's freedom to accept or refuse treatment be fully honored. " There is no discussion of consent procedures for children and adolescents. It is probably acceptable to have parental consent for children who are pre-adolescent. The issue of consent in adolescence is complex and cannot be fully examined here. However, rights of adolescent patients to consent to some medical treatment, most notably reproductive, have been determined in the courts (Martin, 1982). Courts have also found adolescents in some circumstances to be able to refuse psychiatric hospitalizations (Hofmann, 1980; Weinapple et al. 1980). It seems reasonable, therefore, that consent for ECT should be obtained from both the adolescent and parents. In a case where the adolescent refuses treatment with ECT, the legal system may be consulted for help with the decision.
Conclusion Based on the case reports reviewed, ECT is beneficial to children and adolescents with bipolar disorder (depressed, manic, or rapid cycling) and depression. When compared to a group of nonaffective disordered patients, those with affective disorder were significantly more likely to benefit from ECT. Anorexia nervosa responded to ECT, but only two cases were reviewed. There is not enough data to know how beneficial ECT is for childhood schizophrenia because it is uncertain how many of the reported childhood schizophrenic patients actually had schizophrenia. ECT is not useful for chronic organic syndromes or autism. However, these conclusions must be viewed with caution given the subjective measure of outcome. The complications of ECT include a brief period of organic impairment, anxiety reactions, disinhibition, and alteration of the seizure threshold. The organic impairment clears markedly within a few days, but mild impairment, possibly with disinhibition, may persist for a few months. This review points out the need for continued study of ECT in children and adolescents. Systematic studies using established diagnostic criteria and clearly defined outcome would clarify potential benefits and risks. Neuropsychological testing should be done before, after, and at a distant follow-up when using ECT. Long-term follow-up should also examine the course of illness and psychological development post-ECT, with attention to the child's perception of the treatment and any residual anxiety. It is particularly important to investigate whether ECT can provide rapid resolution of symptoms in medication nonresponders and avoidance of subsequent chronicity of illness, an important goal for child psychiatrists. For the age group that we treat, chronic illness can have a devastating impact on the development and the future of the individual.
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