Narcolepsy in a child under 7 years old.

Case Report The patient was referred to the school medical officer at the age of 6 years as 'somewhat microcephalic' (head circumference 19 in.) 'and in need of special educational treatment'. Some months before he had been seen by an orthopaedic surgeon because of bad posture; he also had 'weak ankles and knees'. No organic disease was found. The advice that he should do postural exercises was not followed by the parents. Later the child was sent to an educational psychologist for further assessment, but he was variously assessed as having an I.Q. between 75 and 87, i.e. in the 'dull and backward' range. The I.Q. did not quite account for his poor school attainments and, in view of further reports received, my attention was drawn to him. His mother was thin and harassed-looking, of only moderate intelligence, less than sufficiently understanding of the child's needs, and she appeared inadequate. The health visitor had reported a lack of co-operation over measures suggested to raise the child's standard of wellbeing. 'She is willing, but does not seem able to get there'; 'has to have all arrangements made for her'. The family is well known to the local health authority. All six children in the family have poor health records. Three of them are of the mother's first marriage. The head teacher thinks they are all equally neglected. The psychologist's report described the father as 'oafish-looking, contributing little to the conversation. Mother did not talk freely in his presence'. Another report stated: 'There is mismanagement of money. They have sufficient income but seem to be in debt.' Another said that the father is an irresponsible man; he left the mother twice, and she expects him to do so again. They used to live in rooms. Whenever the child cried his mouth had to be pressed with a towel lest the noise should be heard. They were frequently evicted. The Assistance Board used to help when the father went off on his spring-time wanderings, and the family were left without food. The universal verdict of the reports on the boy seemed to be that 'He is shy and timid'. The head teacher described him as well-behaved because apathetic, sometimes stubborn, occasionally found to bully younger children, having a pinched and cowed look, and being ill-nourished and insufficiently clothed. He fell asleep at school each afternoon, which was thought possibly to be related to his not being sent to bed before the parents. The family doctor reported, apart from childish ailments, frequent colds and upper respiratory infections. He felt that the home conditions from the matrimonial and psychological points of view were very poor. 'All the children appear pinched and cowed.' My own examination did not contribute anything new. The child looked pale and in a poor state of nutrition; he was shy, fearful, and unintelligent. His gait was clumsy. He had a marked cervical and upper thoracic kyphosis, and the musculature was of poor tone. The slowly elicited history contained no mention of illness which could be said to resemble encephalitis. There had been no head injuries. The mother said that during the last two years the boy had been suddenly dropping off to sleep several times a day. He frequently walked about 'half-dazed' at night. No history of cataplexy, etc. was obtained. While I was talking to him and his mother on one occasion the boy sank forward in his chair, his eyes closed, his impassive face becoming completely blank. After about two to three minutes he opened his eyes, was perfectly conscious and orientated, and did not seem to suffer any after-effects. There was no visible change of colour, tonus, etc. He seemed to have been normally asleep. Narcolepsy was then diagnosed. A neurosurgeon, whose opinion was sought to exclude organic causes for the condition, reported a negative neurological examination. The electroencephalogram was reported to 'show a very slow tracing, mainly of 4 c/s with practically no alpha rhythm, without epileptic bursts'. The impression from the electroencephalogram was of a very immature cortex. Radiographs of the skull showed no abnormality. Long-acting dexamphetamine (Dexten), 25 mg. in the morning, was prescribed but, as might have been expected from the family history, the patient failed to attend again.