LEITERS TO THE EDITOR REFERENCE
Everson, M. D. & Boat, B. W. (1990), Sexualized doll play among young children: implications for the use of anatomical dolls in sexual abuse evaluations. J. Am. Acad. Chi/dAdolesc. Psychiatry, 29:736742.
European Child Psychiatry To the Editor: Recently I had the honor of participating in the" Advances in Child Neuropsychiatry" course held February 2 to 8, 1991, at the EUore Majorana Centre for Scientific Culture at Erice, Italy. The course was organized by Professor Fabio Canziani of the Instituto Neuropsichiatria Infantile at the Universita in Palermo. Since I was the only child psychiatrist from the United States in attendance, I felt a brief review of the content and the character of the meeting would be of interest to members of the Academy. In part, this is due to an important difference between Italian and U.S. training that flavored the entire meeting. Italian child psychiatrists are also child neurologists and frequently see both types of patients. Though limited to about 100 individuals, the participants included senior and junior clinicians and researchers from most of the major centers in Italy. A few important French child psychiatrists and neurologists were present, and representatives from a diverse group of countries, including Bulgaria, Cuba, Greece, Spain, Tunisia, the U.S.A., and the U.S.S.R., also attended. The main topics of the course were autism, adolescent psychosis, cerebrovascular disorders, and brain tumors. Presentations ranged from general reflections on clinical experiences to didactic presentations and to indepth research reports. The quality of the presentations was as good as that of recent meetings I have attended in the U.S. An impressive feature of the course was the use of discussion periods. These frequently lasted longer than the presentations and examined problems from an extraordinary variety of clinical, philosophical, and research perspectives. Dinner was delayed several evenings by lively debates. For an American accustomed to 5-minute discussion periods and rather dispassionate presentations, this was an unusual and sometimes exhausting experience. Perhaps the most impressive aspect of the meeting was the interest and intelligence of the younger participants. They frequently displayed an ability to shift between fields, synthesize new material, and generate novel ideas. The major concern the senior faculty had for their proteges was one that is becoming more commonly heard among U.S. academics: There are few opportunities that match the serious intent of the next generation of child neuropsychiatric researchers. Richard D. Todd, Ph.D., M.D. Washington University School of Medicine St. Louis, Missouri
Fluoxetine and Suicidal Ideation
symptoms remained, and I Y2 years later, he was again seen by a child psychiatrist. He was started on a treatment of desipramine combined with behavior therapy and supportive therapy. He tolerated desipramine well at 150 mg/d. However, some symptoms still remained. At that time, clomipramine was not available in the market for this age group. He was switched to being treated with fluoxetine when fluoxetine became available (Turner et aI., 1985). At 20 mg/d he began to show much improvement in OCD as well as separation anxiety disorder (SAD) symptoms. At 40 mg/d, he started to show "hyperactivity" with "full-of-energy" and "clown-like" behaviors, which are some of the side effects reported among children and adolescents who are being treated with fluoxetine. The dosage was decreased gradually to 10 mg/d, and the side effects disappeared. However, a mild degree of OCD symptoms reappeared. He could not take 20 mg at once without becoming "hyperactive." Finally OCD and SAD symptoms were well controlled at 10 mg/d on even days and 10 mg/b.i.d. on odd days. Fifteen months after fluoxetine treatment was begun, he started to manifest explosive, angry outbursts over minor matters, which was totally unlike him. His school performance also started to decline. About 2 weeks later, he started to cry easily and frequently over minor matters. A few days after that, he started to hear a vague voice telling him to kill himself. He stated that he did not have any reason to kill himself and did not want to kill himself. Later he described this experience as "very weird." The fluoxetine was tapered off in 3 days, and the suicide thought faded away and completely disappeared in 10 days. However, obsession and compulsion started to emerge again, and he was started on a treatment of clomipramine, which had become available by then, and his OCD symptoms have been well controlled at 75 mg/d. I report this experience because I feel it is important for clinicians to be aware of the emergence of suicidal preoccupation in an adolescent during fluoxetine treatment, while fluoxetine is reported to be a good therapeutic alternative to clomipramine in adults (Pigott et a!., 1990). Hisako Koizumi, M.D. Harding Hospital Worthington, Ohio
REFERENCES
Pigott, T. A., Pato, M. T., Bernstein, S. E., Grover, G. H., Hill, J. L., Tolliver, T. J. & Murphy, D. L. (1990), Controlled comparisons of clomipramine and fluoxetine in the treatment of obsessive-compulsive disorder. Arch. Gen. Psychiatry, 47:926-932. . Teicher, M. H., Glod, C. & Cole, J. O. (1990), Emergence of Intense suicidal preoccupation during fluoxetine treatment. Am. J. Psychiatry, 147:207-210. Turner, S. M., Jacob, R. G., Beidel, D. C. & Himmelhoch, J. (1985), Fluoxetine treatment of obsessive-compulsive disorder. J. Clin. Psychoph7acol., 5:207-212.
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To the Editor: In February 1990, Teicher et a!. reported the emergence of suicidal preoccupation among adults during fluoxetine treatment. This letter is a report of a similar occurrence in an early adolescent boy. He is a 13Y2-year-old Caucasian boy (height, 162 cm; weight, 40 kg) who started to manifest symptoms of obsessive-compulsive disorder (OCD) at around 9V4 years of age. He also had symptoms of separation anxiety disorder and developmental reading disorder. He was treated with imipramine in combination with behavior therapy by a psychiatrist. He could not tolerate more than 20 mg/d because of the headache considered to be induced by the medication, and the treatment was discontinued by his parents. In the meantime, OCD J.Am.Acad. Child Adolesc. Psychiatry, 30:4, July 1991
Child Psychopharmacology To the Editor: I read with great interest your editorial note in the January 1991 issue of the Journal. I fully agree with the questions you raise and your concerns. There appear to be major gaps between theory and practice in relation to the use of psychotropic drugs in children and adolescents. Although our knowledge of pediatric psychopharmacology is relatively limited, I am concerned with the differences between what we already know and the application of this knowledge in clinical practice. Differences in clinical practice seem to exist between indi-
695
Everson, M. D. & Boat, B. W. (1990), Sexualized doll play among young children: implications for the use of anatomical dolls in sexual abuse evaluations. J. Am. Acad. Chi/dAdolesc. Psychiatry, 29:736742.
European Child Psychiatry To the Editor: Recently I had the honor of participating in the" Advances in Child Neuropsychiatry" course held February 2 to 8, 1991, at the EUore Majorana Centre for Scientific Culture at Erice, Italy. The course was organized by Professor Fabio Canziani of the Instituto Neuropsichiatria Infantile at the Universita in Palermo. Since I was the only child psychiatrist from the United States in attendance, I felt a brief review of the content and the character of the meeting would be of interest to members of the Academy. In part, this is due to an important difference between Italian and U.S. training that flavored the entire meeting. Italian child psychiatrists are also child neurologists and frequently see both types of patients. Though limited to about 100 individuals, the participants included senior and junior clinicians and researchers from most of the major centers in Italy. A few important French child psychiatrists and neurologists were present, and representatives from a diverse group of countries, including Bulgaria, Cuba, Greece, Spain, Tunisia, the U.S.A., and the U.S.S.R., also attended. The main topics of the course were autism, adolescent psychosis, cerebrovascular disorders, and brain tumors. Presentations ranged from general reflections on clinical experiences to didactic presentations and to indepth research reports. The quality of the presentations was as good as that of recent meetings I have attended in the U.S. An impressive feature of the course was the use of discussion periods. These frequently lasted longer than the presentations and examined problems from an extraordinary variety of clinical, philosophical, and research perspectives. Dinner was delayed several evenings by lively debates. For an American accustomed to 5-minute discussion periods and rather dispassionate presentations, this was an unusual and sometimes exhausting experience. Perhaps the most impressive aspect of the meeting was the interest and intelligence of the younger participants. They frequently displayed an ability to shift between fields, synthesize new material, and generate novel ideas. The major concern the senior faculty had for their proteges was one that is becoming more commonly heard among U.S. academics: There are few opportunities that match the serious intent of the next generation of child neuropsychiatric researchers. Richard D. Todd, Ph.D., M.D. Washington University School of Medicine St. Louis, Missouri
Fluoxetine and Suicidal Ideation
symptoms remained, and I Y2 years later, he was again seen by a child psychiatrist. He was started on a treatment of desipramine combined with behavior therapy and supportive therapy. He tolerated desipramine well at 150 mg/d. However, some symptoms still remained. At that time, clomipramine was not available in the market for this age group. He was switched to being treated with fluoxetine when fluoxetine became available (Turner et aI., 1985). At 20 mg/d he began to show much improvement in OCD as well as separation anxiety disorder (SAD) symptoms. At 40 mg/d, he started to show "hyperactivity" with "full-of-energy" and "clown-like" behaviors, which are some of the side effects reported among children and adolescents who are being treated with fluoxetine. The dosage was decreased gradually to 10 mg/d, and the side effects disappeared. However, a mild degree of OCD symptoms reappeared. He could not take 20 mg at once without becoming "hyperactive." Finally OCD and SAD symptoms were well controlled at 10 mg/d on even days and 10 mg/b.i.d. on odd days. Fifteen months after fluoxetine treatment was begun, he started to manifest explosive, angry outbursts over minor matters, which was totally unlike him. His school performance also started to decline. About 2 weeks later, he started to cry easily and frequently over minor matters. A few days after that, he started to hear a vague voice telling him to kill himself. He stated that he did not have any reason to kill himself and did not want to kill himself. Later he described this experience as "very weird." The fluoxetine was tapered off in 3 days, and the suicide thought faded away and completely disappeared in 10 days. However, obsession and compulsion started to emerge again, and he was started on a treatment of clomipramine, which had become available by then, and his OCD symptoms have been well controlled at 75 mg/d. I report this experience because I feel it is important for clinicians to be aware of the emergence of suicidal preoccupation in an adolescent during fluoxetine treatment, while fluoxetine is reported to be a good therapeutic alternative to clomipramine in adults (Pigott et a!., 1990). Hisako Koizumi, M.D. Harding Hospital Worthington, Ohio
REFERENCES
Pigott, T. A., Pato, M. T., Bernstein, S. E., Grover, G. H., Hill, J. L., Tolliver, T. J. & Murphy, D. L. (1990), Controlled comparisons of clomipramine and fluoxetine in the treatment of obsessive-compulsive disorder. Arch. Gen. Psychiatry, 47:926-932. . Teicher, M. H., Glod, C. & Cole, J. O. (1990), Emergence of Intense suicidal preoccupation during fluoxetine treatment. Am. J. Psychiatry, 147:207-210. Turner, S. M., Jacob, R. G., Beidel, D. C. & Himmelhoch, J. (1985), Fluoxetine treatment of obsessive-compulsive disorder. J. Clin. Psychoph7acol., 5:207-212.
/
To the Editor: In February 1990, Teicher et a!. reported the emergence of suicidal preoccupation among adults during fluoxetine treatment. This letter is a report of a similar occurrence in an early adolescent boy. He is a 13Y2-year-old Caucasian boy (height, 162 cm; weight, 40 kg) who started to manifest symptoms of obsessive-compulsive disorder (OCD) at around 9V4 years of age. He also had symptoms of separation anxiety disorder and developmental reading disorder. He was treated with imipramine in combination with behavior therapy by a psychiatrist. He could not tolerate more than 20 mg/d because of the headache considered to be induced by the medication, and the treatment was discontinued by his parents. In the meantime, OCD J.Am.Acad. Child Adolesc. Psychiatry, 30:4, July 1991
Child Psychopharmacology To the Editor: I read with great interest your editorial note in the January 1991 issue of the Journal. I fully agree with the questions you raise and your concerns. There appear to be major gaps between theory and practice in relation to the use of psychotropic drugs in children and adolescents. Although our knowledge of pediatric psychopharmacology is relatively limited, I am concerned with the differences between what we already know and the application of this knowledge in clinical practice. Differences in clinical practice seem to exist between indi-
695
