LETTERS TO THE EDITOR that despite the improvement in her mood, J. F. had become "somewhat edgy ." At the next appointment a month later, her parents again reported that her mood was generally cheerful, but at times, she seemed to go through periods of anxiety and agitation. As nervousness and agitation have been listed as side effects of fluoxetine (Riddle et al. , 1990), we reduced the dosage of fluoxetine to 20 mg/d, Within 2 to 3 weeks of dosage reduction, J. F. became much more relaxed and stable in her mood . Her "edgy behavior" also decreased; however, the other autistic symptoms, such as stereotypies and compulsive behaviors remained unchanged.
to 30 mg/d, and clomipramine was added in the dosage of 25 mg/d. Within a week of starting this regimen, further worsening in her behavior was reported. She became restless and agitated, impulsively hitting others and throwing objects. Fluoxetine was decreased to 20 mg/d, and clomipramine was increased to 50 mg/d . Some improvement in her symptoms of agitation , irritability, and compulsive behavior was noticed 2 weeks after starting this regimen. Fluoxetine was further decreased to 10 mg/d, and clomipramine was maintained at the same dosage . When last seen , the patient was stable . It was planned to gradually stop the fluoxetine and leave her on an appropriate dosage of clomipramine.
Case 2 M. D., a 17-year-old male with autism and Down's syndrome, was treated in our clinic for symptoms of major depression . His symptoms were frequent crying spells , social withdrawal (for example, staying alone in his room for long periods of time, refusing to sit with the family at the time of meals), disturbance of sleep (going late to bed and waking up early at about 3 A.M.), irritability, and temper tantrums . In addition , he started complaining of vague physical symptoms, such as fatigue and facial pain. There was no family history of affective disorder. After a period of assessment , he began receiving fluoxetine, 20 mg/d. Four weeks later, he was reported to be much better . His crying spells decreased substantially, and for the first time in months, he was smiling. He started eating his meals with the family and was not spending as much time in his room as before . His irritability also decreased . During the course of the treatment, his medication was increased to 40 mg/d . He did not show any side effects, and 8 months after starting the drug, he continues to remain stable in his mood. However , his other deficits, characteristic of autism, including a tendency to ritualistic behavior , persist. Case 3
K. V., a 21-year-old male with Down's syndrome and moderate mental retardation, was referred by his parents for a diagnostic evaluation to rule out coexisting autism . Some of his other reported behaviors were repeated touching of objects and of people, ritualistic arranging of toys followed by their dusting , irritability , and some tearfulness. There was, however, no clear history of a persistently depressed mood nor of any vegetative symptoms of depression. After a comprehensive assessment, it was felt that K. V. met the criteria for autistic disorder . It was unclear , however, if he was also clinically depressed . He, nonetheless, started receiving fluoxetine , 20 mg/d . He has been followed now in our clinic for almost 3 months . In this period, there has been some decrease in his irritability , but his compulsive behavior and the other features of autism remain unchanged .
COMMENT
Based on the above cases, certain trends in the response of autistic patients to fluoxetine may be identified. First , fluoxetine seems to be most useful when a clear-cut superimposed depressive illness is present. This appears to be all the more true when there is a family history of affective disorder . Second, compulsive rituals and other nonspecific behaviors, such as stereotypies do not seem to respond well, although irritability might decrease (clomipramine might be a more suitable drug to use in such circumstances). Third, in some cases, as in Patients I and 4 above, there is a danger that side effects of the medication, such as agitation and nervousness, might be confused with symptoms. In view of the impairment of communication that is common in this population, special attention should be paid to monitor the side effects, especially those involving the patient's behavior. The risk of precip itation of suicidal thoughts, described as a side effect in the normal population (Teicher et aI., 1990), may be mentioned in this regard . Thus, in view of the limited experience with this drug in people with developmental disorders, a cautious approach is recommended. Mohammad Ghaziuddin , M.D. Luke Tsai, M.D. Neera Ghaziuddin, M.D . University of Michigan Ann Arbor, MI REFERENCES
Mehlinger, R., Scheftner, W. A. & Poznanski, E . (1990), Fluoxetine and autism (letter) . J, Am . Acad. Chi/dAdo/esc. Psychiatry , 29:985. Riddle, M. A., Hardin, M. T., King, R ., Scahill, L. & Woolston, J. L. (1990), Fluoxetine treatment of children and adolescents with Tourette's and obsessive compulsive disorders : preliminary clinical experience . J, Am . Acad . Child Ado/esc . Psychiatry. 29:45-48. Teicher, M. H., Glod, C. & Cole, J. O. (1990), Emergence of intense suicidal preoccupation during fluoxetine treatment. Am . J . Psychiatry, 147:207-210 .
Encopresis and Sexual Assault
Case 4
S. F., a l3-year-old autistic girl, was referred by her parents for the control of her behavioral symptoms . These consisted of irritability, occasional temper tantrums, and crying episodes . In addition , she was described as being "obsessive." For example, she would repeatedly open and close doors, shut drawers indiscriminately, and insist on arranging plates in a particular manner on the dining table at the time of family meals. There was no history of mental retardation or mental illness in the family. After assessment, it was concluded that S. F. did not suffer from any Axis I disorder as defined by the DSM-l/I-R . However , in view of her history of irritability, crying spells , and compulsive behavior, she began receiving fluoxetine, 20 mg/d . Two weeks later, some decrease in her compulsive behaviors and irritability was reported. However, the improvement was not sustained . In fact, her compulsive symptoms appeared to have increased . The fluoxetine was increased l.Am.Acad. Child Ado/esc . Psychiatry, 30:3, May 1991
To the Editor : Encopresis is a common problem in childhood (Bellman, 1966). Many authors, including Levine (1975), have described precipitating factors of secondary encopresis, such as parental divorce, sibling birth, and starting school. Not as well known is sexual abuse as a precipitating factor in the onset of secondary encopresis. Krisch (1980) described a l2-year-old boy who developed encopresis after anal sexual assault and hypothesized that the boy developed this symptom as a defense against further homosexual assault. Buchanan (1989) also suggested that soiling may be an indicator of sexual abuse but cautioned that it could be misdiagnosed in cases of encopresis because of shared risk factors, such as the presence of a stepfather, not being close to the mother, the mother not finishing high school, no physical affection from the father, and having two friends or less. Boon and Singh (in press), in proposing
509
LETTERS TO THE EDITOR
an integrated model for the treatmen t of encopresis, reported that the presence of comorbid psychiatric disorder may affect treatment and its outcome . In my review of the cases of 30 inpatients with encopresis in a children' s psychiatric hospital, 2 1 were of the secondary subtype. The precipitating factor in five cases was sexual abuse. Case I was a 12-year-old white male who was the victim of anal rape at age 7 by an older teenage male. The patient and his parents clearly linked the onset of encopresis to this incident. At the time of his admission, he was suicidal and withdrawn. Case 2 was a 6-year-old white male who had been admitted once before , II months before his second admission. Both admissions were for encopresis, physical aggression, and fire setting. However, it was only during his second admission that it was revealed that an adult male baby sitter had anal sex with him causing severe rectal bleeding before the onset of encopresis. Case 3 was a 9-year-old black male who was admitted for noncompliance, agitation, sexual acting out (approaching boys in the neighborhood for sex), and encopresis for 2 years. During treatment, he revealed that he had been sexually abused by his uncle; the abuse was reported to Child Protective Services, resulting in an investigation and the arrest of his uncle. Sexual abuse that involved both oral and anal sex preceded the onset of his symptoms. Case 4 was an 8-year-old white female who was aggressive , enuretic , and encopreti c. She had been removed from her home when allegations that her biological father had forced her to perform oral and anal sex were investigated and proved . Case 5 was a 7-year-old white female who was aggressive , hyperactive , and encopretic after an anal sexual assault by a male adult baby-sitter. Psychotherapy focused around the issue of the sexual assault proved successful in eliminating encopresis in the above cases. Sexual abuse was not identified at admission in two of these cases. In fact, it was only discovered during the second hospitalization in Case 2. Treatment was unsuccessful until the abuse was identified, and the treatment was focused on this aspect. Even though there is an increasing awareness
510
of sexual abuse in our society, it continues to be underreported . It is probable that many cases of secondary encopresis that have not responded well to standard treatments may be undiagnosed and, hence , untreated cases of sexual abuse. The author recommends that an inquiry into and exploration of possible sexual abuse should be conducted in all cases of secondary encopresis. Franklin Boon, M.D . Medical College of Virginia REFERENCES
Bellman, M. (1966), Studies on encopresis. Acta Paediatr . Scand. [Suppl .] 170:1-15 1. Boon , F. & Singh , N. (199 I) , A model for the treatment of encopre sis. Behav. Modif. (in press). Buchanan , A. (1989), Soiling and sexual abuse. The danger of misdiagnosis. Association f or Child Psychoanalysis Newsletter, 11:38. Krisch, K. (1980), Encopresis as protection from homosexual annoyance. Prax. Kinderpsychol. Kinderpsychiatr ., 37:260-265 . Levine , M. D. (1975), Children with encopresis: a descriptive analysis. Pediatrics, 56:412- 4 16.
Letters to the Editor are welcome. They will be considered for publication but may not necessar ily be published , nor will their receipt be acknowledged . Letters should, in general, not exceed 750 words, including a maximum of six references . They must be submitt ed in duplicate and typed double-spaced. All letters are subject to editing and shortening; the contents are the sole responsibilit y of the author. The Editor reserves the right to publish replies and solicit responses. Opinions expressed in this column are those of the authors of the letter s and do not reflect opinions of the Journal . Please direct your letters to John F. McDermott, Jr., M.D ., Editor , Journal of the American Academy of Child and Adolescent Psychiatry, University of Hawaii School of Medicine at Kapiolani Medical Center, 13 I9 Punahou St. , Honolulu , HI 96826-1032.
J .Am . Acad . Child Adolesc. Psychiatry, 30:3, May 1991
to 30 mg/d, and clomipramine was added in the dosage of 25 mg/d. Within a week of starting this regimen, further worsening in her behavior was reported. She became restless and agitated, impulsively hitting others and throwing objects. Fluoxetine was decreased to 20 mg/d, and clomipramine was increased to 50 mg/d . Some improvement in her symptoms of agitation , irritability, and compulsive behavior was noticed 2 weeks after starting this regimen. Fluoxetine was further decreased to 10 mg/d, and clomipramine was maintained at the same dosage . When last seen , the patient was stable . It was planned to gradually stop the fluoxetine and leave her on an appropriate dosage of clomipramine.
Case 2 M. D., a 17-year-old male with autism and Down's syndrome, was treated in our clinic for symptoms of major depression . His symptoms were frequent crying spells , social withdrawal (for example, staying alone in his room for long periods of time, refusing to sit with the family at the time of meals), disturbance of sleep (going late to bed and waking up early at about 3 A.M.), irritability, and temper tantrums . In addition , he started complaining of vague physical symptoms, such as fatigue and facial pain. There was no family history of affective disorder. After a period of assessment , he began receiving fluoxetine, 20 mg/d. Four weeks later, he was reported to be much better . His crying spells decreased substantially, and for the first time in months, he was smiling. He started eating his meals with the family and was not spending as much time in his room as before . His irritability also decreased . During the course of the treatment, his medication was increased to 40 mg/d . He did not show any side effects, and 8 months after starting the drug, he continues to remain stable in his mood. However , his other deficits, characteristic of autism, including a tendency to ritualistic behavior , persist. Case 3
K. V., a 21-year-old male with Down's syndrome and moderate mental retardation, was referred by his parents for a diagnostic evaluation to rule out coexisting autism . Some of his other reported behaviors were repeated touching of objects and of people, ritualistic arranging of toys followed by their dusting , irritability , and some tearfulness. There was, however, no clear history of a persistently depressed mood nor of any vegetative symptoms of depression. After a comprehensive assessment, it was felt that K. V. met the criteria for autistic disorder . It was unclear , however, if he was also clinically depressed . He, nonetheless, started receiving fluoxetine , 20 mg/d . He has been followed now in our clinic for almost 3 months . In this period, there has been some decrease in his irritability , but his compulsive behavior and the other features of autism remain unchanged .
COMMENT
Based on the above cases, certain trends in the response of autistic patients to fluoxetine may be identified. First , fluoxetine seems to be most useful when a clear-cut superimposed depressive illness is present. This appears to be all the more true when there is a family history of affective disorder . Second, compulsive rituals and other nonspecific behaviors, such as stereotypies do not seem to respond well, although irritability might decrease (clomipramine might be a more suitable drug to use in such circumstances). Third, in some cases, as in Patients I and 4 above, there is a danger that side effects of the medication, such as agitation and nervousness, might be confused with symptoms. In view of the impairment of communication that is common in this population, special attention should be paid to monitor the side effects, especially those involving the patient's behavior. The risk of precip itation of suicidal thoughts, described as a side effect in the normal population (Teicher et aI., 1990), may be mentioned in this regard . Thus, in view of the limited experience with this drug in people with developmental disorders, a cautious approach is recommended. Mohammad Ghaziuddin , M.D. Luke Tsai, M.D. Neera Ghaziuddin, M.D . University of Michigan Ann Arbor, MI REFERENCES
Mehlinger, R., Scheftner, W. A. & Poznanski, E . (1990), Fluoxetine and autism (letter) . J, Am . Acad. Chi/dAdo/esc. Psychiatry , 29:985. Riddle, M. A., Hardin, M. T., King, R ., Scahill, L. & Woolston, J. L. (1990), Fluoxetine treatment of children and adolescents with Tourette's and obsessive compulsive disorders : preliminary clinical experience . J, Am . Acad . Child Ado/esc . Psychiatry. 29:45-48. Teicher, M. H., Glod, C. & Cole, J. O. (1990), Emergence of intense suicidal preoccupation during fluoxetine treatment. Am . J . Psychiatry, 147:207-210 .
Encopresis and Sexual Assault
Case 4
S. F., a l3-year-old autistic girl, was referred by her parents for the control of her behavioral symptoms . These consisted of irritability, occasional temper tantrums, and crying episodes . In addition , she was described as being "obsessive." For example, she would repeatedly open and close doors, shut drawers indiscriminately, and insist on arranging plates in a particular manner on the dining table at the time of family meals. There was no history of mental retardation or mental illness in the family. After assessment, it was concluded that S. F. did not suffer from any Axis I disorder as defined by the DSM-l/I-R . However , in view of her history of irritability, crying spells , and compulsive behavior, she began receiving fluoxetine, 20 mg/d . Two weeks later, some decrease in her compulsive behaviors and irritability was reported. However, the improvement was not sustained . In fact, her compulsive symptoms appeared to have increased . The fluoxetine was increased l.Am.Acad. Child Ado/esc . Psychiatry, 30:3, May 1991
To the Editor : Encopresis is a common problem in childhood (Bellman, 1966). Many authors, including Levine (1975), have described precipitating factors of secondary encopresis, such as parental divorce, sibling birth, and starting school. Not as well known is sexual abuse as a precipitating factor in the onset of secondary encopresis. Krisch (1980) described a l2-year-old boy who developed encopresis after anal sexual assault and hypothesized that the boy developed this symptom as a defense against further homosexual assault. Buchanan (1989) also suggested that soiling may be an indicator of sexual abuse but cautioned that it could be misdiagnosed in cases of encopresis because of shared risk factors, such as the presence of a stepfather, not being close to the mother, the mother not finishing high school, no physical affection from the father, and having two friends or less. Boon and Singh (in press), in proposing
509
LETTERS TO THE EDITOR
an integrated model for the treatmen t of encopresis, reported that the presence of comorbid psychiatric disorder may affect treatment and its outcome . In my review of the cases of 30 inpatients with encopresis in a children' s psychiatric hospital, 2 1 were of the secondary subtype. The precipitating factor in five cases was sexual abuse. Case I was a 12-year-old white male who was the victim of anal rape at age 7 by an older teenage male. The patient and his parents clearly linked the onset of encopresis to this incident. At the time of his admission, he was suicidal and withdrawn. Case 2 was a 6-year-old white male who had been admitted once before , II months before his second admission. Both admissions were for encopresis, physical aggression, and fire setting. However, it was only during his second admission that it was revealed that an adult male baby sitter had anal sex with him causing severe rectal bleeding before the onset of encopresis. Case 3 was a 9-year-old black male who was admitted for noncompliance, agitation, sexual acting out (approaching boys in the neighborhood for sex), and encopresis for 2 years. During treatment, he revealed that he had been sexually abused by his uncle; the abuse was reported to Child Protective Services, resulting in an investigation and the arrest of his uncle. Sexual abuse that involved both oral and anal sex preceded the onset of his symptoms. Case 4 was an 8-year-old white female who was aggressive , enuretic , and encopreti c. She had been removed from her home when allegations that her biological father had forced her to perform oral and anal sex were investigated and proved . Case 5 was a 7-year-old white female who was aggressive , hyperactive , and encopretic after an anal sexual assault by a male adult baby-sitter. Psychotherapy focused around the issue of the sexual assault proved successful in eliminating encopresis in the above cases. Sexual abuse was not identified at admission in two of these cases. In fact, it was only discovered during the second hospitalization in Case 2. Treatment was unsuccessful until the abuse was identified, and the treatment was focused on this aspect. Even though there is an increasing awareness
510
of sexual abuse in our society, it continues to be underreported . It is probable that many cases of secondary encopresis that have not responded well to standard treatments may be undiagnosed and, hence , untreated cases of sexual abuse. The author recommends that an inquiry into and exploration of possible sexual abuse should be conducted in all cases of secondary encopresis. Franklin Boon, M.D . Medical College of Virginia REFERENCES
Bellman, M. (1966), Studies on encopresis. Acta Paediatr . Scand. [Suppl .] 170:1-15 1. Boon , F. & Singh , N. (199 I) , A model for the treatment of encopre sis. Behav. Modif. (in press). Buchanan , A. (1989), Soiling and sexual abuse. The danger of misdiagnosis. Association f or Child Psychoanalysis Newsletter, 11:38. Krisch, K. (1980), Encopresis as protection from homosexual annoyance. Prax. Kinderpsychol. Kinderpsychiatr ., 37:260-265 . Levine , M. D. (1975), Children with encopresis: a descriptive analysis. Pediatrics, 56:412- 4 16.
Letters to the Editor are welcome. They will be considered for publication but may not necessar ily be published , nor will their receipt be acknowledged . Letters should, in general, not exceed 750 words, including a maximum of six references . They must be submitt ed in duplicate and typed double-spaced. All letters are subject to editing and shortening; the contents are the sole responsibilit y of the author. The Editor reserves the right to publish replies and solicit responses. Opinions expressed in this column are those of the authors of the letter s and do not reflect opinions of the Journal . Please direct your letters to John F. McDermott, Jr., M.D ., Editor , Journal of the American Academy of Child and Adolescent Psychiatry, University of Hawaii School of Medicine at Kapiolani Medical Center, 13 I9 Punahou St. , Honolulu , HI 96826-1032.
J .Am . Acad . Child Adolesc. Psychiatry, 30:3, May 1991
