I E V E L O P M E N T A L MEDICINE AND CHILD NEUROLOGY.
1975, 17
The procedures of treatment advocated earlier we cannot abandon for the individual case, but I believe that one should try to minimise the procedures of diagnosis and treatment, sometimes just watching, sometimes tapping, but using radical surgery rarely. As this is my personal opinion and the subject is still controversial, I would like to put these three questions for debate: (1) Is the disease traumatic or not? (2) Is it justifiable to minimise the diagnostic procedures? (3) Should treatment consist in ( a ) masterly inactivity; ( h ) repeated subdural punctures; (c) drainage, internal or external; (d) radical surgery with stripping of the membranes: (e) ?. Being a neurosurgeon dedicated to paediatric service, I hope I shall get the final answer to this delicate problem of paediatric neurology. HUGOANDERSON Department of Neurosurgery, Sahlgrenska Hospital, 413 45 Gothenburg, Sweden. REFERENCES I . Bichat, X. (1800) ‘Traite des membranes en general et de diverses membranes en particulier.’ Paris: Veuve Richard. 2. Virchow, R. (1857) ‘Das Hamatorn der Dura Mater.’ Verhandlungen der Pliysikalisch-Medizinischen Cesellschafi zu Wiirzhurg, 7 , 134. 3. Trotter, W. (1914) ‘Chronic subdural haemorrhage of traumatic origin, and its relation to pachynieningitis haemorrhagica interna.’ British Joiirnal of’ Surgery, 2, 27 I , 520. 4. Verbiest, H. (1958) ‘History of the pathology of subdural fluid collections.’ FoliaPsyrhiafrica, Neurologica C I Neurochirrcrgica Neerlandira, 61, 652. 5 . Gardner, W. J. (1932) ‘Traumatic subdural haeniatonia with particular reference to latent interval.‘ Archives of Neirrology and Psychiatry, 21, 847. 6. Sherwood, D. (1930) ‘Chronic subdural hernatonia in infants.‘ American Journal of Diseases of Children, 39, 980. 7. Ingraham, F. D., Matson, D. D. (1949) ‘Subdural hematoma in infancy.’ .4dvanres in Pediatrics, 4,231.
Intelligence, Speech and Language Development of Hydrocephalic Children SIR-Hydrocephalic children have been reported to suffer from varying degrees of intellectual and language deficits. The intellectual impairments have ranged from minimal’ to severe2 and language abnormalities such as hyper~erbality~ and superficiality4 have been described as common occurrences. We have studied 35 hydrocephalic children, mostly with average or borderline levels of intelligence, who did not present any of the above-mentioned language characteristics. The children (20 boys and 15 girls) had a mean age of 7.2 years (range four to 1 1 years) and consisted of almost all children more than three years of age who had visited the follow-up clinic for hydrocephalic children for a routine check-up during the first five months of 1973. A further six children who were tested for intelligence but did not return for speech and language evaluation were excluded from the sample. In the majority of the families the parents were living together, with one or more other normal children. The mean education of the mothers was 11.25 years (SD 4.2 years) and 58 per cent of the families had an annual income in excess of 8000 dollars. All 35 children had been diagnosed early in life and had been provided with various types of shunts: the mean age at initial placement of the shunt was 5.7 months. Their diagnostic categories were: myelomeningocele (21), internal hydrocephalus ( I 0), external hydrocephalus (3) and Dandy-Walker cyst ( I ) . 1 I6
ILETTERS TO T H E EDI’I’OR
The results of intelligence testing (Stanford-Binet Intelligence Test, Form L-M) indicated that 50 per cent of the children were in the average or above-average ranges of intelligence. 30 per cent scored within the borderline range (IQ 68-83) and only 14 per cent were moderately to severely retarded. Some degree of articulation problems was exhibited by 65 per cent of the children. These were measured by the Arizona Articulation Proficiency Scale5, which evaluates different amounts of substitution, omission and distortion of phonemes. The scores indicate the percentage of defective speech according to one of three ranges: mild (10 to 15 per cent defective); moderate (I6 to 30 per cent) and severe (more than 30 per cent). 35 per cent of our children had normal speech, while43 per cent manifested a mild, 16 per cent a moderate and 6 per cent a severe defect in their speech The development of vocabulary (measured by the Peabody Picture Vocabulary Test6) was retarded to mild or moderate degrees in 53 per cent of the children. This was commensurate with their levels of intelligence. None of the children exhibited hyperverbality in informal conversational settings. A M A NU. KHAN PAGEENSOARE Department of Pediatrics, Northwestern Medical School, Children’s Memorial Hospital, 2300 Children‘s Plaza, Chicago, Illinois 60614. REFERENCES Fleming, C. P. ( 1968) ‘The verbal behaviour of hydrocephalic children.’ Developti~~~tital hfcvlicitic atid Child Neurulugy, 10, Suppl. 15. 74. 2. Hagberg, B. ( 1962) ’The sequelae of spontaneously arrested infantile hydrocephalus.’ Dcwluppmerital Mcdicine arid Child Nerrr-olugy. 4, 583. 3. Ingram, T. T. S., Naughton, J . A. (1962) ‘Paediatric and psychological aspects of cerebral palsy associated with hydrocephalus.’ Dtwloptnenial Medicine and Child Ncwrolugy, 4, 287. 4. Swishc-r,L. P.,Pinsker, E. J. ( 1 971) ‘The language characteristics of hyperverbal, hydrocephalic children.’ Dee~lupriientalMedicint, arid Child Neurology, 13, 746. 5. Fundala, J. B. (1963) A r i x t i u Ariicrrlaiion Proficiency Scale, Revised. Los Angeles: Western Psychologica: Services. 6. Dunn. L. M. ( 1959) Peahodr. Picirtre Vucahrrlary Tesl. Minneapolis: American Guidance Service. Inc. I,
The Use of Amphetamines in Hyperactivity SIR-I read with horror the statement of Christopher Ounsted in regard to d-amphetamine sulphate ( D M C N , 16, 685). There is no question that the amphetamines can be abused, but to refer to them as dangerous drugs is a drastic example of over-emphasis to make a point The relative level between effective dose and toxic reaction is probably one of the greatest in active pharmacological drugs. Dr. Ounsted’s comment ignores or shows lack of knowledge of the many double-blind controlled studies which have been done on the use of amphetamines in hyperactivity (or hyperkinesis if one prefers). If Dr. Ounsted has seen no child in more than 6,000 who showed improvement on the amphetamines, the questions might be raised as to how many did he treat with amphetamines and how astute were his observations? Dr. Samuel Livingston and others have found the amphetamines to have some anticonvulsant activity, particularly in petit mal. LEONOETTIIVGER, JK. Director. Pediatric Epilepsy Clinic: Associate Clinical Professor of Pediatrics; University of California. Los Angeles. 1I7
1975, 17
The procedures of treatment advocated earlier we cannot abandon for the individual case, but I believe that one should try to minimise the procedures of diagnosis and treatment, sometimes just watching, sometimes tapping, but using radical surgery rarely. As this is my personal opinion and the subject is still controversial, I would like to put these three questions for debate: (1) Is the disease traumatic or not? (2) Is it justifiable to minimise the diagnostic procedures? (3) Should treatment consist in ( a ) masterly inactivity; ( h ) repeated subdural punctures; (c) drainage, internal or external; (d) radical surgery with stripping of the membranes: (e) ?. Being a neurosurgeon dedicated to paediatric service, I hope I shall get the final answer to this delicate problem of paediatric neurology. HUGOANDERSON Department of Neurosurgery, Sahlgrenska Hospital, 413 45 Gothenburg, Sweden. REFERENCES I . Bichat, X. (1800) ‘Traite des membranes en general et de diverses membranes en particulier.’ Paris: Veuve Richard. 2. Virchow, R. (1857) ‘Das Hamatorn der Dura Mater.’ Verhandlungen der Pliysikalisch-Medizinischen Cesellschafi zu Wiirzhurg, 7 , 134. 3. Trotter, W. (1914) ‘Chronic subdural haemorrhage of traumatic origin, and its relation to pachynieningitis haemorrhagica interna.’ British Joiirnal of’ Surgery, 2, 27 I , 520. 4. Verbiest, H. (1958) ‘History of the pathology of subdural fluid collections.’ FoliaPsyrhiafrica, Neurologica C I Neurochirrcrgica Neerlandira, 61, 652. 5 . Gardner, W. J. (1932) ‘Traumatic subdural haeniatonia with particular reference to latent interval.‘ Archives of Neirrology and Psychiatry, 21, 847. 6. Sherwood, D. (1930) ‘Chronic subdural hernatonia in infants.‘ American Journal of Diseases of Children, 39, 980. 7. Ingraham, F. D., Matson, D. D. (1949) ‘Subdural hematoma in infancy.’ .4dvanres in Pediatrics, 4,231.
Intelligence, Speech and Language Development of Hydrocephalic Children SIR-Hydrocephalic children have been reported to suffer from varying degrees of intellectual and language deficits. The intellectual impairments have ranged from minimal’ to severe2 and language abnormalities such as hyper~erbality~ and superficiality4 have been described as common occurrences. We have studied 35 hydrocephalic children, mostly with average or borderline levels of intelligence, who did not present any of the above-mentioned language characteristics. The children (20 boys and 15 girls) had a mean age of 7.2 years (range four to 1 1 years) and consisted of almost all children more than three years of age who had visited the follow-up clinic for hydrocephalic children for a routine check-up during the first five months of 1973. A further six children who were tested for intelligence but did not return for speech and language evaluation were excluded from the sample. In the majority of the families the parents were living together, with one or more other normal children. The mean education of the mothers was 11.25 years (SD 4.2 years) and 58 per cent of the families had an annual income in excess of 8000 dollars. All 35 children had been diagnosed early in life and had been provided with various types of shunts: the mean age at initial placement of the shunt was 5.7 months. Their diagnostic categories were: myelomeningocele (21), internal hydrocephalus ( I 0), external hydrocephalus (3) and Dandy-Walker cyst ( I ) . 1 I6
ILETTERS TO T H E EDI’I’OR
The results of intelligence testing (Stanford-Binet Intelligence Test, Form L-M) indicated that 50 per cent of the children were in the average or above-average ranges of intelligence. 30 per cent scored within the borderline range (IQ 68-83) and only 14 per cent were moderately to severely retarded. Some degree of articulation problems was exhibited by 65 per cent of the children. These were measured by the Arizona Articulation Proficiency Scale5, which evaluates different amounts of substitution, omission and distortion of phonemes. The scores indicate the percentage of defective speech according to one of three ranges: mild (10 to 15 per cent defective); moderate (I6 to 30 per cent) and severe (more than 30 per cent). 35 per cent of our children had normal speech, while43 per cent manifested a mild, 16 per cent a moderate and 6 per cent a severe defect in their speech The development of vocabulary (measured by the Peabody Picture Vocabulary Test6) was retarded to mild or moderate degrees in 53 per cent of the children. This was commensurate with their levels of intelligence. None of the children exhibited hyperverbality in informal conversational settings. A M A NU. KHAN PAGEENSOARE Department of Pediatrics, Northwestern Medical School, Children’s Memorial Hospital, 2300 Children‘s Plaza, Chicago, Illinois 60614. REFERENCES Fleming, C. P. ( 1968) ‘The verbal behaviour of hydrocephalic children.’ Developti~~~tital hfcvlicitic atid Child Neurulugy, 10, Suppl. 15. 74. 2. Hagberg, B. ( 1962) ’The sequelae of spontaneously arrested infantile hydrocephalus.’ Dcwluppmerital Mcdicine arid Child Nerrr-olugy. 4, 583. 3. Ingram, T. T. S., Naughton, J . A. (1962) ‘Paediatric and psychological aspects of cerebral palsy associated with hydrocephalus.’ Dtwloptnenial Medicine and Child Ncwrolugy, 4, 287. 4. Swishc-r,L. P.,Pinsker, E. J. ( 1 971) ‘The language characteristics of hyperverbal, hydrocephalic children.’ Dee~lupriientalMedicint, arid Child Neurology, 13, 746. 5. Fundala, J. B. (1963) A r i x t i u Ariicrrlaiion Proficiency Scale, Revised. Los Angeles: Western Psychologica: Services. 6. Dunn. L. M. ( 1959) Peahodr. Picirtre Vucahrrlary Tesl. Minneapolis: American Guidance Service. Inc. I,
The Use of Amphetamines in Hyperactivity SIR-I read with horror the statement of Christopher Ounsted in regard to d-amphetamine sulphate ( D M C N , 16, 685). There is no question that the amphetamines can be abused, but to refer to them as dangerous drugs is a drastic example of over-emphasis to make a point The relative level between effective dose and toxic reaction is probably one of the greatest in active pharmacological drugs. Dr. Ounsted’s comment ignores or shows lack of knowledge of the many double-blind controlled studies which have been done on the use of amphetamines in hyperactivity (or hyperkinesis if one prefers). If Dr. Ounsted has seen no child in more than 6,000 who showed improvement on the amphetamines, the questions might be raised as to how many did he treat with amphetamines and how astute were his observations? Dr. Samuel Livingston and others have found the amphetamines to have some anticonvulsant activity, particularly in petit mal. LEONOETTIIVGER, JK. Director. Pediatric Epilepsy Clinic: Associate Clinical Professor of Pediatrics; University of California. Los Angeles. 1I7
