Electro convulsive therapy in a pre-pubertal child with severe depression.PS Russell, P Tharyan, K Arun Kumar, A Cherian
Department of Psychiatry, Christian Medical College, Vellore - 632 002, India. , India
Electro Convulsive Therapy (ECT) in pre-pubertal children is a controversial and underreported treatment. Even though the effectiveness and side effects of ECT in adolescents are comparable with those in adults, there is a pervasive reluctance to use ECT in children and adolescents. We report the case of a pre-pubertal child in an episode of severe depression with catatonic features, where a protracted course of ECT proved life-saving in spite of prolonged duration of seizures and delayed response to treatment. The case illustrates the safety and efficacy of ECT in children. Relevant literature is also reviewed along with the case report.
Keywords: Case Report, Child, Depressive Disorder, therapy,Electroconvulsive Therapy, Female, Human, Retreatment,
The effectiveness and side effects of Electro Convulsive Therapy (ECT) in adolescents are comparable with those in adults.  There is little evidence that this therapy is abused or misused in young people. Although ECT is not contraindicated in prepubertal children, there is a pervasive reluctance to use ECT in children and adolescents.,, In this report we document the successful use of ECT and problems encountered in the treatment of a 9-year-old child.
A nine-year-old girl presented with a 7-month history of fearfulness, irritability and social withdrawal progressing to mutism, refusal of food, crying spells, deteriorating scholastic performance, school refusal and regression in self-care. Her developmental, family, scholastic as well as medical history was unremarkable and she was drug naive. There was no history of traumatic or exit life events, other stressors, body image disturbances, excessive weight loss to suggest reactive depression or anorexia nervosa.
Data were collected from parents and clinical observation, as her retardation and mutism limited psychological testing. Her baseline score on the Children’s Depression Rating Scale-Revised was 51, and on the Children’s Global Assessment Scale was 11, revealing the need for considerable supervision.
Investigations including a complete haemogram, serum chemistry screen, copper, ceruloplasmin and thyroid hormone assays, sleep-deprived electro-encephelography and computed tomography were normal.
A presumptive diagnosis of severe depression with possible psychotic symptoms was made and, with her parents’ consent, outpatient treatment was started with syrup fluoxetine 10 mg after breakfast and tablet haloperidol 0.75 mg twice daily. Emerging extra-pyramidal symptoms were relieved by the addition of oral trihexphenidyl 2 mg/day. Psychotherapy was precluded by her mutism and psychomotor retardation. A single dose of 1 mg oral lorazepam neither altered her catatonic symptoms nor was informative about the nature of her catatonic state. Her condition markedly deteriorated with decreasing food intake, increasing psychomotor retardation, and extreme fearfulness. The concurrence of two consultants experienced in treating psychiatric disorders of children was sought for giving ECT; the risks and benefits of ECT were discussed with the parents and with her parents’ consent (as recommended by American Psychiatric Association) she was admitted for supervised naso-gastric tube feeds and a course of ECT.
We gave her 11 twice-weekly ECT over 6 weeks using bi-directional, brief pulse, constant current stimulation via bilateral, fronto - temporal electrodes from a MECTA JR2 ECT (MECTA Corporation, Portland, Oregon, USA) device. Thiopentone sodium [mean dose 85 (SD 11.1) mg] was used for induction anaesthesia, succinylcholine [mean dose 13.6 (SD 1.5) mg] for muscle relaxation and atropine 0.5 mg to reduce secretions. During the procedure, the patient was ventilated with 100% oxygen until spontaneous respiration resumed. Seizure duration was monitored in a cuffed upper limb. Motor seizure duration increased from 33 seconds with the lowest energy level at the first treatment to 133 seconds by the fourth ECT at the same energy level, necessitating abortion of seizures with intravenous thiopentone sodium after subsequent treatments. Since the existing policy in the department was to terminate prolonged seizure activity with the same medication used to induce anaesthesia, thiopentone was used instead of diazepam.
During her stay in the hospital the symptoms of persistent tearfulness, diminished interest in games and activities during her occupational therapy sessions, psychomotor retardation, decreased appetite as well as her indecisiveness confirmed a DSM-IV diagnosis of Major Depressive episode with catatonic features.
Her depressive symptoms remained unchanged till after her eighth ECT. Her clinical improvement commenced with a decrease in psychomotor retardation and irritability followed by increase in food intake. The nasogastric tube feeding were withdrawn after the 10th session. The last symptom to improve was mutism and at the time of dicharge she spoke in a whisper but answered without prompting.
Children’s Depression Rating Scale score, assessed weekly on a non-ECT day, also declined from the eighth week onwards and remained at 7 during the first six months of follow-up. At the end of the course of ECT, her rating on the Children’s Global Assessment Scale was 90. The mini mental status examination for children score varied between 22 and 26 over the course of ECT. Her full scale IQ on the Binet-Kamat Intelligence Scale administered after recovery from the episode showed her to be of average intelligence.
She refused to attend school for a week following discharge but reintegrated into her previous school when encouraged with differential rewards. Haloperidol was stopped 2 months after discharge. She remained well on fluoxetine and supportive psychotherapy at 12 month follow up visit before dropping out of treatment. During her follow-up visits she was also scored on the mini mental status examination for children which remained at 32, indicative of no gross long term cognitive side effects.
ECT is less frequently used in adolescents and children as compared to adults. This is related as much to lack of experience and limited knowledge and fears of damaging the developing brain as to negative media reports and the inclination of child and adolescent psychiatrists towards family therapy. Two other factors that could potentially bias child and adolescent psychiatrists and proscribe the use of ECT is the prolonged seizure duration and delayed clinical response with ECT in children.
There are conflicting reports on the number of ECT treatment sessions needed to achieve clinical improvement in children. We are unclear why there was a delayed clinical improvement in spite of bilateral electrode placement, and probable supra threshold stimulus intensity. Some workers recommend that young children require more, while others maintain that the average number required is similar to that in adults.
There is evidence to suggest that adolescents have increased rates of prolonged ECT seizures compared to adults and contrary to our observations herein, this is usually noted during the initial treatments because of the increasing seizure threshold over the course of ECT. Prolonged seizure duration in this pre-pubertal child could be explained by factors like younger age, female gender, small head size, pre-ECT and concurrent pharmacotherapy (Fluoxetine and Trihexphenidyl), bilateral electrode placement, and supra threshold stimulus intensity.
We administered bilateral ECT despite the reported comparable efficacy of unilateral treatment, as rapid recovery was sought. The principle of changing from bilateral to unilateral placement after the initial treatments was not pursued, as there was neither cognitive impairment nor significant clinical improvement. This possibly contributed to the persistence of prolonged seizures.
Stimulus intensity dosing is advocated for children because of the low initial seizure threshold, but even the lowest energy level of 25 millicoulombs in many brief-pulse machines appears excessive for pre-pubertal children. Machines capable of delivering lower stimulus intensities are required for treatment to avoid excessively supra-threshold stimuli.
We found ECT to be a useful treatment modality for treating catatonic depression in this pre-pubertal child and corroborate the promising results reported elsewhere., Anticipating prolonged seizure duration, secondary to the factors discussed, and a delayed onset of therapeutic response in some children would obviate premature abandonment of this otherwise effective and lifesaving treatment.