16 8
Editorial correspondence
The Journal of Pediatrics January 1978
and/or identification of the compound is complete. If further specific therapy is needed at that time, it is then instituted. Harold E. Hestand, M.D. Douglas W. Teske, M.D. Department o f Pediatrics The Children's Hospital Columbus, OH 43205
REFERENCES
REFERENCES
To the Editor: We appreciate Dr. Hurst's interest in our report of handwriting improvement in children with minimal brain dysfunction (MBD) following administration of methylphenidate. Dr. Hurst is correct in his observation that letter reversals, inversions, and omissions by children with MBD may resolve following treatment with methylphenidate. However, it appears that he overlooked our comments in the third paragraph of page 130, where we stated that "as a group, those children with improvement in handwriting following treatment with methylphenidate showed rather uniform gains in all Of the measures listed in Table II." Letter reversals, inversions, and omissions were among the criteria reviewed in this group of patients. Since the completion of our study, we have gone back to our data and have quantitated the exact number of children exhibiting improvement in the above handwriting deficits. Seventeen of 26 children who initially reversed or inverted letters showed improvement after the administration of methylphenidate for four weeks. Twenty-three of 50 patients who had frequent omissions of letters or entire words exhibited improvement following methylphenidate. Since all subjects in ohr report were specifically selected for investigation because they exhibited severe handwriting deficits as part of the condition that, for lack of a better term, is known as MBD, we can make no statement regarding favorable response to stimulant drugs by a certain subgroup of MBD children. The terminology used to describe specific deficit areas in children with MBD is somewhat confusing. We prefer to limit the term dyslexia to those children who have deficits in reading. Patients with specific handwriting deficits are termed dysgraphic. Our subject population included many children with dyslexia, but we were unable to document differences in rates or degrees of improvement in handwriting in the dyslexic group. Of course, all of our patients had dysgraphia. Finally, we agree with Dr. Hurst's remarks about Dr. Garfunkel's commentary. Indeed, we observed considerable academic improvement in the children who improved their handwriting following methylphenidate therapy, Many teachers reported improvement in grades, particularly in subjects requiring handwritten classwork and homework. This information was anecdotal, and we did not feel that it merited inclusion in our report.
1. Goodman LS, and Gilman A: The pharmacological basis of therapeutics, New York, 1975, The Macmillin Company. 2. Rumack BH: Anticholinergic poisoning: Treatment with physostigmine, Pediatrics, 52:277, 1973. 3. Hestand HE, and Teske DW: Diphenhydramine hydrochloride intoxication, J PEDIATR 90:1017, 1977.
Effect of methylphenidate on academic progress To the Editor: Lerer and associates 1 recently reported improvement in the handwriting of children with minimal brain dysfunction (MBD) through the use of stimulant medication, methylphenidate. Although these results are impressive, a more significant finding was not mentioned in their paper. Figs. 1 and 2 in their article showed the handwriting of MBD patients before and after treatment. Handwriting samples of pretreatment and placebo patients showed letter reversals, omissions, and insertions. Handwriting samples after treatment showed no mistakes by one patient and only three mistakes by the other. The authors did note that number reversals and inversions diminished in their patients. Thus, it appears that some MBD patients may have a decreased incidence of reversals, omissions, and inversions with stimulant therapy. This is the first time this has been shown in the literature. Only some of the patients studied responded favorably to Ritalin, indicating that stimulants do not work in all patients diagnosed as having MBD. Dyslexia is often confused with MBD. In this study, dyslexic problems (letter reversals, omissions, and insertions) improved with stimulant treatment. This suggests that a specific subgroup of MBD patients, dyslexics, may preferentially respond to stimulants, whereas other forms of MBD do not. Does re-evaluation of the data in this study document clear-cut improvement only in those patients with dyslexic problems? In his commentary to the article, Dr. J.M. Garfunkel stated, "It is noteworthy that Lerer and associates have presented no hard evidence that therapy resulted in improved academic performance. ''~ To the contrary, improvement was shown. Figs. 1 and 2 document increased academic performance with therapy: the words are spelled correctly. Students do not get points for poor spelling or for inverting numbers. Daniel ~. Hurst, M.D. The Southwest Michigan Area Health Educatio~n Center Kalamazoo, M I
1. Lerer RJ, Lerer MP, and Artner J: The effects of methylphenidate on the handwriting of children with minimal brain dysfunction, J PEDIATR 91:127, 1977. 2. Garfunkel JM: Commentary, J PEDIATR 91:133, 1977.
Repty
Robert J. Lerer, M.D., F.A.A.P. M. Pamela Lerer, M.A. Jeanne Artner, M.S. Children's Hospital Medical Center 240 Bethesda Cincinnati, OH 45229 Mercy Hospital Hamilton, OH, 45014
Editorial correspondence
The Journal of Pediatrics January 1978
and/or identification of the compound is complete. If further specific therapy is needed at that time, it is then instituted. Harold E. Hestand, M.D. Douglas W. Teske, M.D. Department o f Pediatrics The Children's Hospital Columbus, OH 43205
REFERENCES
REFERENCES
To the Editor: We appreciate Dr. Hurst's interest in our report of handwriting improvement in children with minimal brain dysfunction (MBD) following administration of methylphenidate. Dr. Hurst is correct in his observation that letter reversals, inversions, and omissions by children with MBD may resolve following treatment with methylphenidate. However, it appears that he overlooked our comments in the third paragraph of page 130, where we stated that "as a group, those children with improvement in handwriting following treatment with methylphenidate showed rather uniform gains in all Of the measures listed in Table II." Letter reversals, inversions, and omissions were among the criteria reviewed in this group of patients. Since the completion of our study, we have gone back to our data and have quantitated the exact number of children exhibiting improvement in the above handwriting deficits. Seventeen of 26 children who initially reversed or inverted letters showed improvement after the administration of methylphenidate for four weeks. Twenty-three of 50 patients who had frequent omissions of letters or entire words exhibited improvement following methylphenidate. Since all subjects in ohr report were specifically selected for investigation because they exhibited severe handwriting deficits as part of the condition that, for lack of a better term, is known as MBD, we can make no statement regarding favorable response to stimulant drugs by a certain subgroup of MBD children. The terminology used to describe specific deficit areas in children with MBD is somewhat confusing. We prefer to limit the term dyslexia to those children who have deficits in reading. Patients with specific handwriting deficits are termed dysgraphic. Our subject population included many children with dyslexia, but we were unable to document differences in rates or degrees of improvement in handwriting in the dyslexic group. Of course, all of our patients had dysgraphia. Finally, we agree with Dr. Hurst's remarks about Dr. Garfunkel's commentary. Indeed, we observed considerable academic improvement in the children who improved their handwriting following methylphenidate therapy, Many teachers reported improvement in grades, particularly in subjects requiring handwritten classwork and homework. This information was anecdotal, and we did not feel that it merited inclusion in our report.
1. Goodman LS, and Gilman A: The pharmacological basis of therapeutics, New York, 1975, The Macmillin Company. 2. Rumack BH: Anticholinergic poisoning: Treatment with physostigmine, Pediatrics, 52:277, 1973. 3. Hestand HE, and Teske DW: Diphenhydramine hydrochloride intoxication, J PEDIATR 90:1017, 1977.
Effect of methylphenidate on academic progress To the Editor: Lerer and associates 1 recently reported improvement in the handwriting of children with minimal brain dysfunction (MBD) through the use of stimulant medication, methylphenidate. Although these results are impressive, a more significant finding was not mentioned in their paper. Figs. 1 and 2 in their article showed the handwriting of MBD patients before and after treatment. Handwriting samples of pretreatment and placebo patients showed letter reversals, omissions, and insertions. Handwriting samples after treatment showed no mistakes by one patient and only three mistakes by the other. The authors did note that number reversals and inversions diminished in their patients. Thus, it appears that some MBD patients may have a decreased incidence of reversals, omissions, and inversions with stimulant therapy. This is the first time this has been shown in the literature. Only some of the patients studied responded favorably to Ritalin, indicating that stimulants do not work in all patients diagnosed as having MBD. Dyslexia is often confused with MBD. In this study, dyslexic problems (letter reversals, omissions, and insertions) improved with stimulant treatment. This suggests that a specific subgroup of MBD patients, dyslexics, may preferentially respond to stimulants, whereas other forms of MBD do not. Does re-evaluation of the data in this study document clear-cut improvement only in those patients with dyslexic problems? In his commentary to the article, Dr. J.M. Garfunkel stated, "It is noteworthy that Lerer and associates have presented no hard evidence that therapy resulted in improved academic performance. ''~ To the contrary, improvement was shown. Figs. 1 and 2 document increased academic performance with therapy: the words are spelled correctly. Students do not get points for poor spelling or for inverting numbers. Daniel ~. Hurst, M.D. The Southwest Michigan Area Health Educatio~n Center Kalamazoo, M I
1. Lerer RJ, Lerer MP, and Artner J: The effects of methylphenidate on the handwriting of children with minimal brain dysfunction, J PEDIATR 91:127, 1977. 2. Garfunkel JM: Commentary, J PEDIATR 91:133, 1977.
Repty
Robert J. Lerer, M.D., F.A.A.P. M. Pamela Lerer, M.A. Jeanne Artner, M.S. Children's Hospital Medical Center 240 Bethesda Cincinnati, OH 45229 Mercy Hospital Hamilton, OH, 45014
