LETTERS TO THE EDITOR Cure for Overhospitali~ation?
REFERENCES
Darnton, N. (1989), Committed youth, Newsweek. July 31:66-72. Patterson, G. R. (1976), LivingWith Children-Revised. Champaign, IL: Research Press.
To the Editor:
Have you been reading the recent articles about the growth of the psychiatric hospital industry andthe waymany patients aresupposedly •'turfedout" whentheirinsurance expires (Darnton, 1989)? Haveyou noted themonthly f~s for thisservice-s-between $12,000 and$20,OOO? Do you worry that these charges will lead to the defunding of psychiatric care for children and adolescents? Whatfollows is a proposal to putthe mental health careof children andadolescents on II different footing. Suppose that when a psychiatric provider initiates care with a conductdisordered patient that he/she has to agree to treatthe patient and his/her family for 2 years for a fixedprearranged sum. Funding would be determined aftera thorough diagnostic evaluation of treatment needs and would vary from case to case, Additionally, treatment would be subject to periodic case reviews to establish treatment efficacy. This proposal would be consonant with the view that conduct disorders require long-term care and would allow clinicians to employ various treatment strategies, besides hospitalization, which have already beenexperimented with, such as (1) partial hospitalization, (2) in-home treatment, (3) parent training-a la Gerald Patterson (1976), (4) case coordination and management, (5) in-school treatment, and (6) vocational training and job placement. Sucha program would limit (a) potential abuse of hospitalization, (b) so-called "walletectomies" where brief, high-cost treatment is provided without therapeutic benefit, and (c) nonproductive therapies. At the same time, research studies could compare the results of various packages of care and offer incentives to hospitals and providers, andpatients and theirfamilies, to use programs that havebeen proven to be efficacious. At the end of the 2-year program, if the care system could show that the behavior disorder had improved or remitted for the money budgeted, then the family would receive a rebate on their health insurance, and the provider would be targeted as a "favored" provider. Additional 1 or 2 yearextensions of the agreement couldbe negotiated as well, depending on the efficacy of the provider'S treatment and the motivation of the patient and his/herfamily for continued treatment. Thisplan would recognize the following clinical realities which are not built into the current fee-for-service system:
Tourettes and School Refusal To the Editor:
1. Long-term treatment at some level is usually indicated for the treatment of behavior disorders. 2. Motivation from parents and children, as well as providers, is needed for a successful outcome. 3. The "businessof psychiatry" should be dictated by the efficacy of treatment. 4. The profit motive in care should not only provide an incentive to the providers of care, but also the recipients. 5. If we do not develop a packaged approach to the treatment of these disorders, we willbe at the whimof funding agencies who are looking to cut costs, and treatment modalities which may address one component of care (like parent troubles), and leave others (likegroup and academic skills) untouched. The netresult would be that treatment would be successful, but the patient would fail.
Kim J. Masters, M.D. Asheville, North Carolina
School refusal in children or adolescents has not been specifically associated withTourette'ssyndrome (TS), although somecasereports havebeensuggestive, Severe school phobia wasnoted in a malecousin of a patient with TS by Comings and Comings (1987), and Linet (1985) reported "relatively subtle separation anxiety difficulties such as reluctance to sleepover at friends' homes" (p. 614) in an l l-yearold boy with TS who later developed school phobia after treatment with plmozide. Rather thanconsidering an existing association in some childand adolescent patients between TS and anxiety disorders, Mikkelson et al, (1981) and Linet (1985) argued that the treatment of TS with haloperidol may precipitate school avoidance and school phobia. Three cases seen at this Unit and diagnosed by psychiatrists using DSM-/ll criteria support an association between TS and schoolavoidance. These young males developed school refusalwithanxiety, were initially referred and diagnosed with this problem, and were later diagnosed withTS. Case 1: A 12-year-old boy was referred with a 2.year history of inability to attend school. He described acute episodes of anxiety suggestive of panic attacks and said part of his worry about going to school was his frequent need to go to the toilet and embarrassment about this. During assessment, involuntary, though at timescontrolled, repetitive rapidandpurposeless movements, mainly of his pelvis,were observed. Thesemovements had begunat the same time as his panic attacks. Upon questioning, the parents alsodescribed repetitive coughing and sniffing witha history of about2 years. No family history of tics or anxiety disorder could be elicited and EEG and CT scan investigations proved normal. Birth and early development were unremarkable. A report of a psychiatric interview held 1 year previously at another center stated the mother had said, " ... he sniffs all the time and this drives us up the wall." Sniffing was also recorded as present in that psychiatric interview. Following a second psychiatric consultation, a diagnosis of anxiety disorder with panic attacks was made and treatment commenced with alprazolam, A subsequent referral wasmade for residential treatment and only following this third psychiatric assessment was a diagnosis of TS made. The patient was admitted to a residential adolescent unit and haloperidol (:~.5 mg/day) prescribed. There wasan almost complete cessation of tics, and panic attacks did not recur. The patient was discharged after approximately 4 months of residential treatment including milieu and family therapy as well as attendance at school. After returning home he maintained satisfactory school attendance and there were no further episodes of anxiety, although continuation of haloperidol was needed to control the tics. These improvements were maintained at an additional 12month follow up. Case 2: A 14-year-old boy was referred because of aggressive behavior toward his mother and refusal to attend school. He was frequently telephoning his mother anxiously from schoolasking to come home. Diagnoses of separation anxiety disorder and conduct disorder were made and the boy was admitted to residential treatment, where he proved difficult to manage at times because of defiance. After discharge, and following further school refusal, he confessed to his mother that his reluctance to attend school had beendue to teasing by
149
LEITERS TO THE EDITOR
peers about tics. At a subsequent psychiatric interview, it emerged that these had been facial, arm, head, and thoracic tics under variable control, often accompanied by grunting and swearing. Embarrassment about them had prevented him from disclosing them previously. No positive family history of tics could be obtained. This boy's birth had been difficult, with an instrument delivery and 3 days of intensive care. However, a CT scan was normal at the time of psychiatric assessment. Following the diagnosis of TS, this boy was prescribed carbamazepine 200 mg., with the rationale for this choice ofmedication being the presence of aggressive outbursts. His tics then disappeared, and although by this time he had left school there was improvement in his functioning in all areas that was maintained following cessation of medication after 2 months and over an additional follow-up period of 6 months. Review of the boy's file revealed that at the time of initial presentation the mother had noted on a symptom checklist that from 4 to 7 years of age he had exhibited nervous habits consisting of convulsive jerking and loud noises that had continued. Case 3: A lO-year-old boy was diagnosed with separation anxiety disorder after a long history of school reluctance and school refusal. On school days he had temper tantrums, headaches, difficulty breathing, throat clearing, and abdominal pains which subsided as soon as his parents agreed that he could stay home. He became verbally and physically aggressive to his mother when she tried to enforce school attendance. He was observed to sleep walk and to talk about his fears of school during sleep; over the previous year his mother had been staying with him at night until hefellasleep. In a follow-up interview I year later, the mother described her son's "nervous gestures" (subsequently observed during interviews), namely a nervous blinking that at times developed into a more complex upward movement of the eye and jerking of the head, frequent throat clearing, and utterance of a squeaky, guttural sound. Though present for some time, these symptoms had recently worsened. The boy could control them for short periods of time; they appeared to become worse in the evening, and they were a continuing source of irritation at home and at school when the boy did attend. Frequent swearing was also noted. EEG and CT scans results were normal, but birth history had been difficulty, with a prolonged labor and subsequent 24-hour admission to intensive care. Inquiry revealed a family history of tics, with at least a maternal nephew and maternal cousin having developed tics during adolescence but recovered. Subsequent treatment of this boy with haloperidol resulted in a reduction of tics but did not alter overall functioning or school attendance (compliance with medication also was poor). A review of this boy's file revealed that in a questionnaire completed by his mother at initial presentation she had noted among the reasons for referral: "Nervous, makes noises with throat." These cases differ from those described by Mikkelson et al. (1981) and Linet (1985) in that initial presentation involved anxious school refusal rather than TS symptoms, and also in that treatment with haloperidol (in two cases) did not exacerbate school avoidance. School refusal, separation anxiety, and social anxiety may develop from experiences of loss of control and peer ostracism resulting from TS symptoms, just as agoraphobia may develop following a panic attack. All childhood TS patients reported by Cohen et al. (1978) were described as having often been humiliated and involved in angry interchanges with peers, in addition to experiencing interference with speech and smooth performance of motor activities, academic performance, and concentration. Suggestions that a diagnosis of TS is often missed are supported by these cases. Describing 90 TS cases meetingDSM-lll-R criteria, Robertson et al. (1988) found that although mean age of onset of tics was 7 years and of onset of vocalizations was 10 years, mean age at diagnosis was not until 21 years. In her review ofTSafter 12 years of experience with more than 300 patients, Brunn (1984) observed that missed diagnoses may be a result not only of unfamiliarity with
150
C
the condition' but also because patients will ordinarily try to control their symptoms.during clinical examination. Jon M. Plapp, Ph.D. Rivendell Adolescent and Family Service New South Wales, Australia REFERENCES
Bruun, R.D. (1984), Gilles de la Tourette's syndrome. I. Am. Acad. . Child Psychiatry, 23:126-133. . Cohen, D. J., Shaywitz, B. A., Caprulo, B., Young, J. G. & Bowers, M. B. (1978), Chronic; multiple tics of Gilles de la Tourette's disease. Arch. Gen. Psychiatry, 35:245-250. Comings, D. E: & Comings, B. G. (1987), Hereditary agoraphobia and obsessive compulsive disorder in relatives of patients with Gilles de la Tourette's syndrome. Br. I. Psychiatry, 151:195-199. Linet, L. S. (1985), Tourette syndrome, pimozide, and school phobia: the neuroleptic separation anxiety. syndrome. Am.. I. Psychiatry, 142:613-615. Mikkelson, E. J., Deltor, J. &Cohen, D. J. (1981),School avoidance and school phobia triggered by haloperidol in patients with Tourette's disorder. Am. I. Psychiatry, 138:1572-1576. Robertson, M. M., Trimble, M. R. & Lees, J.(1988), The psycho" pathology of Gilles de la Tourette syndrome. Br. I. Psychiatry, 152:338-390.
Violence and Conduct Disorder To the Editor: The article, "Toward a Theory of the Genesis of Violence: A Follow-up Study of Delinquents," by Dr. D. O. Lewis and her associates (Lewis et aI., 1989) presents a convincing case that violent behavior in severe and repetitive form has, with a highly disproportionate frequency, a combination of two antecedents. One is special instability or vulnerability of the nervous system of the violent individual as indicated by (a) episodic psychotic symptoms, and/or (b) neurological/ limbic dysfunction, and/or (c) cognitive impairment. The other is an abusive, violent family. The point is effectively made that the effects of these contributing factors are not merely additive. The increased
violence with a combination of such vulnerability, plus such a violent abusive family, is greater than can be accounted for by mere addition and is taken as evidence of an interaction between them. However, Dr. Lewis should have been content to have presented a theory of a genesis of violence, not the genesis of violence.. Can violence have only one cause? Conductdisorder is a behavioral diagnosis, not an organic diagnosis, nor a psychotic diagnosis. Under the direction of DSM-IlI-R, all warranted diagnoses should be made. The diagnosis conduct disorder may or may not be accompanied by a neurological or psychotic diagnosis. There is clear evidence presented in this article that not all violence has in its background such vulnerabilities, and not all violence has in its background a violent family. We all know this. Also, there are many with organic diagnoses involving the central nervous system or psychotie diagnoses who are never violent. We all know that. It is unfortunate that Dr. Lewis did not withdraw or correct her 1984 complaint that "With its focus on manifest behaviors and its lack of clear exclusionary criteria, the conduct disorder [emphasis added] diagnosis obfuscates other potentially treatable neuropsychiatric disorders" (Lewis et aI., 1984, p. 514). Dr. Lewis does clearly recognize that an organic or psychotic diagnosis does not determine (nor does it contradict) behavioral symptoms of violence. Presumably, Dr. Lewis' impatience with the diagnosis conduct disorder reflects a belief (perhaps justified) that this diagnosis may lead to a premature abandonment of psychiatric or neurological diagnostic effort. It should not. Under DSM-lll rules, one should make all the diagnoses warranted.
I.Am.Acad. ChildAdolesc. Psychiatry, 29:1 .Jan. 1990
REFERENCES
Darnton, N. (1989), Committed youth, Newsweek. July 31:66-72. Patterson, G. R. (1976), LivingWith Children-Revised. Champaign, IL: Research Press.
To the Editor:
Have you been reading the recent articles about the growth of the psychiatric hospital industry andthe waymany patients aresupposedly •'turfedout" whentheirinsurance expires (Darnton, 1989)? Haveyou noted themonthly f~s for thisservice-s-between $12,000 and$20,OOO? Do you worry that these charges will lead to the defunding of psychiatric care for children and adolescents? Whatfollows is a proposal to putthe mental health careof children andadolescents on II different footing. Suppose that when a psychiatric provider initiates care with a conductdisordered patient that he/she has to agree to treatthe patient and his/her family for 2 years for a fixedprearranged sum. Funding would be determined aftera thorough diagnostic evaluation of treatment needs and would vary from case to case, Additionally, treatment would be subject to periodic case reviews to establish treatment efficacy. This proposal would be consonant with the view that conduct disorders require long-term care and would allow clinicians to employ various treatment strategies, besides hospitalization, which have already beenexperimented with, such as (1) partial hospitalization, (2) in-home treatment, (3) parent training-a la Gerald Patterson (1976), (4) case coordination and management, (5) in-school treatment, and (6) vocational training and job placement. Sucha program would limit (a) potential abuse of hospitalization, (b) so-called "walletectomies" where brief, high-cost treatment is provided without therapeutic benefit, and (c) nonproductive therapies. At the same time, research studies could compare the results of various packages of care and offer incentives to hospitals and providers, andpatients and theirfamilies, to use programs that havebeen proven to be efficacious. At the end of the 2-year program, if the care system could show that the behavior disorder had improved or remitted for the money budgeted, then the family would receive a rebate on their health insurance, and the provider would be targeted as a "favored" provider. Additional 1 or 2 yearextensions of the agreement couldbe negotiated as well, depending on the efficacy of the provider'S treatment and the motivation of the patient and his/herfamily for continued treatment. Thisplan would recognize the following clinical realities which are not built into the current fee-for-service system:
Tourettes and School Refusal To the Editor:
1. Long-term treatment at some level is usually indicated for the treatment of behavior disorders. 2. Motivation from parents and children, as well as providers, is needed for a successful outcome. 3. The "businessof psychiatry" should be dictated by the efficacy of treatment. 4. The profit motive in care should not only provide an incentive to the providers of care, but also the recipients. 5. If we do not develop a packaged approach to the treatment of these disorders, we willbe at the whimof funding agencies who are looking to cut costs, and treatment modalities which may address one component of care (like parent troubles), and leave others (likegroup and academic skills) untouched. The netresult would be that treatment would be successful, but the patient would fail.
Kim J. Masters, M.D. Asheville, North Carolina
School refusal in children or adolescents has not been specifically associated withTourette'ssyndrome (TS), although somecasereports havebeensuggestive, Severe school phobia wasnoted in a malecousin of a patient with TS by Comings and Comings (1987), and Linet (1985) reported "relatively subtle separation anxiety difficulties such as reluctance to sleepover at friends' homes" (p. 614) in an l l-yearold boy with TS who later developed school phobia after treatment with plmozide. Rather thanconsidering an existing association in some childand adolescent patients between TS and anxiety disorders, Mikkelson et al, (1981) and Linet (1985) argued that the treatment of TS with haloperidol may precipitate school avoidance and school phobia. Three cases seen at this Unit and diagnosed by psychiatrists using DSM-/ll criteria support an association between TS and schoolavoidance. These young males developed school refusalwithanxiety, were initially referred and diagnosed with this problem, and were later diagnosed withTS. Case 1: A 12-year-old boy was referred with a 2.year history of inability to attend school. He described acute episodes of anxiety suggestive of panic attacks and said part of his worry about going to school was his frequent need to go to the toilet and embarrassment about this. During assessment, involuntary, though at timescontrolled, repetitive rapidandpurposeless movements, mainly of his pelvis,were observed. Thesemovements had begunat the same time as his panic attacks. Upon questioning, the parents alsodescribed repetitive coughing and sniffing witha history of about2 years. No family history of tics or anxiety disorder could be elicited and EEG and CT scan investigations proved normal. Birth and early development were unremarkable. A report of a psychiatric interview held 1 year previously at another center stated the mother had said, " ... he sniffs all the time and this drives us up the wall." Sniffing was also recorded as present in that psychiatric interview. Following a second psychiatric consultation, a diagnosis of anxiety disorder with panic attacks was made and treatment commenced with alprazolam, A subsequent referral wasmade for residential treatment and only following this third psychiatric assessment was a diagnosis of TS made. The patient was admitted to a residential adolescent unit and haloperidol (:~.5 mg/day) prescribed. There wasan almost complete cessation of tics, and panic attacks did not recur. The patient was discharged after approximately 4 months of residential treatment including milieu and family therapy as well as attendance at school. After returning home he maintained satisfactory school attendance and there were no further episodes of anxiety, although continuation of haloperidol was needed to control the tics. These improvements were maintained at an additional 12month follow up. Case 2: A 14-year-old boy was referred because of aggressive behavior toward his mother and refusal to attend school. He was frequently telephoning his mother anxiously from schoolasking to come home. Diagnoses of separation anxiety disorder and conduct disorder were made and the boy was admitted to residential treatment, where he proved difficult to manage at times because of defiance. After discharge, and following further school refusal, he confessed to his mother that his reluctance to attend school had beendue to teasing by
149
LEITERS TO THE EDITOR
peers about tics. At a subsequent psychiatric interview, it emerged that these had been facial, arm, head, and thoracic tics under variable control, often accompanied by grunting and swearing. Embarrassment about them had prevented him from disclosing them previously. No positive family history of tics could be obtained. This boy's birth had been difficult, with an instrument delivery and 3 days of intensive care. However, a CT scan was normal at the time of psychiatric assessment. Following the diagnosis of TS, this boy was prescribed carbamazepine 200 mg., with the rationale for this choice ofmedication being the presence of aggressive outbursts. His tics then disappeared, and although by this time he had left school there was improvement in his functioning in all areas that was maintained following cessation of medication after 2 months and over an additional follow-up period of 6 months. Review of the boy's file revealed that at the time of initial presentation the mother had noted on a symptom checklist that from 4 to 7 years of age he had exhibited nervous habits consisting of convulsive jerking and loud noises that had continued. Case 3: A lO-year-old boy was diagnosed with separation anxiety disorder after a long history of school reluctance and school refusal. On school days he had temper tantrums, headaches, difficulty breathing, throat clearing, and abdominal pains which subsided as soon as his parents agreed that he could stay home. He became verbally and physically aggressive to his mother when she tried to enforce school attendance. He was observed to sleep walk and to talk about his fears of school during sleep; over the previous year his mother had been staying with him at night until hefellasleep. In a follow-up interview I year later, the mother described her son's "nervous gestures" (subsequently observed during interviews), namely a nervous blinking that at times developed into a more complex upward movement of the eye and jerking of the head, frequent throat clearing, and utterance of a squeaky, guttural sound. Though present for some time, these symptoms had recently worsened. The boy could control them for short periods of time; they appeared to become worse in the evening, and they were a continuing source of irritation at home and at school when the boy did attend. Frequent swearing was also noted. EEG and CT scans results were normal, but birth history had been difficulty, with a prolonged labor and subsequent 24-hour admission to intensive care. Inquiry revealed a family history of tics, with at least a maternal nephew and maternal cousin having developed tics during adolescence but recovered. Subsequent treatment of this boy with haloperidol resulted in a reduction of tics but did not alter overall functioning or school attendance (compliance with medication also was poor). A review of this boy's file revealed that in a questionnaire completed by his mother at initial presentation she had noted among the reasons for referral: "Nervous, makes noises with throat." These cases differ from those described by Mikkelson et al. (1981) and Linet (1985) in that initial presentation involved anxious school refusal rather than TS symptoms, and also in that treatment with haloperidol (in two cases) did not exacerbate school avoidance. School refusal, separation anxiety, and social anxiety may develop from experiences of loss of control and peer ostracism resulting from TS symptoms, just as agoraphobia may develop following a panic attack. All childhood TS patients reported by Cohen et al. (1978) were described as having often been humiliated and involved in angry interchanges with peers, in addition to experiencing interference with speech and smooth performance of motor activities, academic performance, and concentration. Suggestions that a diagnosis of TS is often missed are supported by these cases. Describing 90 TS cases meetingDSM-lll-R criteria, Robertson et al. (1988) found that although mean age of onset of tics was 7 years and of onset of vocalizations was 10 years, mean age at diagnosis was not until 21 years. In her review ofTSafter 12 years of experience with more than 300 patients, Brunn (1984) observed that missed diagnoses may be a result not only of unfamiliarity with
150
C
the condition' but also because patients will ordinarily try to control their symptoms.during clinical examination. Jon M. Plapp, Ph.D. Rivendell Adolescent and Family Service New South Wales, Australia REFERENCES
Bruun, R.D. (1984), Gilles de la Tourette's syndrome. I. Am. Acad. . Child Psychiatry, 23:126-133. . Cohen, D. J., Shaywitz, B. A., Caprulo, B., Young, J. G. & Bowers, M. B. (1978), Chronic; multiple tics of Gilles de la Tourette's disease. Arch. Gen. Psychiatry, 35:245-250. Comings, D. E: & Comings, B. G. (1987), Hereditary agoraphobia and obsessive compulsive disorder in relatives of patients with Gilles de la Tourette's syndrome. Br. I. Psychiatry, 151:195-199. Linet, L. S. (1985), Tourette syndrome, pimozide, and school phobia: the neuroleptic separation anxiety. syndrome. Am.. I. Psychiatry, 142:613-615. Mikkelson, E. J., Deltor, J. &Cohen, D. J. (1981),School avoidance and school phobia triggered by haloperidol in patients with Tourette's disorder. Am. I. Psychiatry, 138:1572-1576. Robertson, M. M., Trimble, M. R. & Lees, J.(1988), The psycho" pathology of Gilles de la Tourette syndrome. Br. I. Psychiatry, 152:338-390.
Violence and Conduct Disorder To the Editor: The article, "Toward a Theory of the Genesis of Violence: A Follow-up Study of Delinquents," by Dr. D. O. Lewis and her associates (Lewis et aI., 1989) presents a convincing case that violent behavior in severe and repetitive form has, with a highly disproportionate frequency, a combination of two antecedents. One is special instability or vulnerability of the nervous system of the violent individual as indicated by (a) episodic psychotic symptoms, and/or (b) neurological/ limbic dysfunction, and/or (c) cognitive impairment. The other is an abusive, violent family. The point is effectively made that the effects of these contributing factors are not merely additive. The increased
violence with a combination of such vulnerability, plus such a violent abusive family, is greater than can be accounted for by mere addition and is taken as evidence of an interaction between them. However, Dr. Lewis should have been content to have presented a theory of a genesis of violence, not the genesis of violence.. Can violence have only one cause? Conductdisorder is a behavioral diagnosis, not an organic diagnosis, nor a psychotic diagnosis. Under the direction of DSM-IlI-R, all warranted diagnoses should be made. The diagnosis conduct disorder may or may not be accompanied by a neurological or psychotic diagnosis. There is clear evidence presented in this article that not all violence has in its background such vulnerabilities, and not all violence has in its background a violent family. We all know this. Also, there are many with organic diagnoses involving the central nervous system or psychotie diagnoses who are never violent. We all know that. It is unfortunate that Dr. Lewis did not withdraw or correct her 1984 complaint that "With its focus on manifest behaviors and its lack of clear exclusionary criteria, the conduct disorder [emphasis added] diagnosis obfuscates other potentially treatable neuropsychiatric disorders" (Lewis et aI., 1984, p. 514). Dr. Lewis does clearly recognize that an organic or psychotic diagnosis does not determine (nor does it contradict) behavioral symptoms of violence. Presumably, Dr. Lewis' impatience with the diagnosis conduct disorder reflects a belief (perhaps justified) that this diagnosis may lead to a premature abandonment of psychiatric or neurological diagnostic effort. It should not. Under DSM-lll rules, one should make all the diagnoses warranted.
I.Am.Acad. ChildAdolesc. Psychiatry, 29:1 .Jan. 1990
