TREATMENT RESISTANT ATTENTION DEFICIT HYPERACTIVITY ...

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Abstract. West syndrome has been associated with cognitive decline and behavioural disorders like autism and attention deficit hyperactivity disorder.
TREATMENT RESISTANT ATTENTION DEFICIT HYPERACTIVITY DISORDER AN OUTCOME OF WEST SYNDROME: A CASE REPORT

prednisolone 20 mg per day given in four divided doses for 4 weeks, but it had to be tapered off as she had developed cushingoid appearance. She was again put on sodium valproate but without much benefit. However, her problems resolved spontaneously at the age of 2.5 years.

Vivek Agarwal* Adarsh Tripathi** Sivakumar T*** * Assistant Professor ** Senior Resident ***Junior Resident Department of Psychiatry, CSM Medical University UP, (Formerly King George’s Medical University) Lucknow-226003 Corresponding author: Dr. Vivek Agarwal B-1-10/69, Sector K, Aliganj, Lucknow-226024, INDIA Phone: 91-9839287480 E.mail:[email protected] (Date received: 08/05/2008 )

From 3 years of age her parents found her to be hyperactive and difficult to manage. She would not sit at one place and would keep moving around. She would also push other children around. She would talk a lot and would not wait for her turn in play or for any sweets given at home. She dropped out of school because of her hyperactivity. She did not sit still in the class and disturbed other children. She did not take interest in studies at home also. There was no family history of similar illness and her other siblings were normal.

Abstract West syndrome has been associated with cognitive decline and behavioural disorders like autism and attention deficit hyperactivity disorder. These disorders further impair the development of the child. However, the studies have not focused upon the prevention or management of these disorders in the course of west syndrome. We hereby report a case of treatment resistant attention deficit hyperactivity disorder as an outcome of west syndrome. Key words: West syndrome, Outcome, ADHD

Introduction Large numbers of children suffering from West syndrome have cognitive and behavioral problems. About 71-80% of children with West syndrome have mental retardation, 13% have infantile autism and 15% have hyperkinetic disorder (1,2). These behavioral disorders further impair the educational and social development of such children. However, there are no studies available about the management of hyperactivity in children with West syndrome. We are reporting a case of treatment resistant Attention Deficit Hyperactivity Disorder (ADHD) as an outcome of West syndrome.

Case report History A 10-year-old female was brought to child psychiatry OPD with complaints of inability to sit at one place, restlessness and beating other children. Her antenatal period was uneventful. She was a full term normal delivery and was delivered in a hospital. She started having salaam attacks at 5 months of age. Her EEG was suggestive of primary generalized epilepsy. CT scan head was normal. She was diagnosed to be a case of cryptogenic west syndrome by neurologist. She did not respond well to 400 mg per day of sodium valproate given for 1 year. She responded well to Annals of Neurosciences

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Examination Physical examination did not reveal any abnormality. On examination she was hyperactive and was difficult to control. She did not follow instructions and did not involve in tasks given. Her I.Q. was 60 on Seguin form board test.

Diagnosis and treatment She was diagnosed to be a case of attention deficit hyperactivity disorder- combined type with mild mental retardation as per DSM IV TR criteria (3). She was put on clonidine up to 8mcg/kg/day, atomoxetine up to 1.4 mg/kg/day, modafinil up to 400 mg/day and risperidone up to 1.5 mg/day subsequentially without any benefit. However, she showed improvement on 400 mg/day of carbamazepine in 4weeks. Her scores on ADHD Rating Scale decreased from 48 to 18 after carabamazepine was started. In neurologist’s opinion no active neurological management was required. She still has symptoms of ADHD but is much more manageable than before.

Discussion There is no literature about the treatment of ADHD in patients with west syndrome though it is reported to occur in 15% of patients with this condition. ADHD was difficult to treat in our patient. She did not show any response to specific medications for ADHD while she showed good response to carbamazepine. This shows that neural mechanism involved for causation of ADHD in children with west syndrome could be different from that of ADHD per se. The behavioral problems in these children could be due to the brain damage or dysfunction caused by epilepsy or the process leading to epilepsy (4). Epileptic syndromes are associated with large number of cognitive and behavioral problems, which should be recognized and treated. Although, Cryptogenic form of west syndrome has been associated with good outcome, our patient developed mild mental retardation as well as ADHD. Early medical and psychoeducational intervention will lead to better long-term outcome in these children. Then early, effective treatment of epileptic syndromes may be important in preventing a number of permanent cognitive and behavioral problems. 87

Future research should focus on the prevention as well as the treatment of behavioral problems in children with epileptic syndromes.

References 1.

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Caplan R, Gillberg C. Child psychiatric disorders. In Engel J, Pedley IA. (Eds)., Epilepsy: A Comprehensive Textbook. Vol. 2. Philadelphia: Lippincott Raven Publishers; 1997: 2125-39.

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Guzzetta F. Cognitive and behavioral outcome in West syndrome. Epilepsia 2006, 47:49-52.

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American Psychiatric Association. The diagnostic and statistical manual of mental disorders. 4th edition, text revision. Washington DC: American Psychiatric Press; 2000.

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Besag FM. Cognitive and behavioral outcomes of epileptic syndromes: implications for education and clinical practice. Epilepsia 2006, 47 :119-25

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