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The EPICure study: associations and antecedents of neurological and developmental disability at 30 months of age following extremely preterm birth.

AIMS: To describe perinatal factors associated with later morbidity among extremely preterm children at 30 months of age corrected for prematurity. POPULATION: Of 308 surviving children born at <or=25 weeks gestation in the United Kingdom and Ireland from March to December 1995, 283 (92%) were evaluated at 30 months of age corrected for prematurity. METHODS: Cerebral palsy, severe motor disability, and Bayley scores were used as dependent variables in sequential multiple regression analyses to identify factors associated with adverse outcomes. RESULTS: Adverse outcomes were consistently more common in boys. Factors related to perinatal illness, ultrasound evidence of brain injury, and treatment (particularly postnatal steroids) were associated with adverse motor outcomes (cerebral palsy, disability or Bayley psychomotor development index). Increasing duration of postnatal steroid treatment was associated with poor motor outcomes. A score was developed for severe motor disability with good negative predictive value. In contrast, mental development was associated with a broader range of factors: ethnic group, maternal educational level, the use of antenatal steroids, and prolonged rupture of membranes in addition to chronic lung disease. CONCLUSION: Male sex is a pervasive risk factor for poor outcome at extremely low gestations. Avoidable or effective treatment factors are identified, which may indicate the potential for improving outcome.

Cerebral Palsy↗

Parentification of the child: a case study of Bowlby's compulsive care-giving attachment pattern.

Compulsive care-giving is a pattern of adult attachment behavior in which the person emphasizes the importance of giving care in relationships rather than receiving it. The developmental antecedent of this pattern derives from role reversal in the parent-child relationship. Since care-giving directed from the child to the parent was so constantly associated by the parent with attachment, the child too inevitably associates it with attachment. It is important to differentiate this care-giving from care-giving initiatives that arise properly later in life in reciprocal relationships and true parental relationships. These adult care-giving behaviors arise from the care-giving system, and are complementary to the attachment system. By contrast, care-giving behaviors directed from a child to a parent arise from the child's attachment system and lead to dysfunctional relationships later in life as the individual loses any ability to express need or ask for care, yet retains a pervasive, unsatisfied neediness and longing for care. For such an individual in adulthood, the attachment and care-giving systems do not balance each other to yield stable reciprocal relationships but rather reinforce patterns of exclusive care-giving and the suppression of care-seeking.

Adult↗

Health-related quality of life in parents of school-age children with Asperger Syndrome or High-Functioning Autism.

BACKGROUND: The estimated prevalence rate of Pervasive Developmental Disorders (PDD) in children is 6 per 1.000. Parenting children who are intellectually impaired and have PDDs is known to be linked to the impaired well-being of the parents themselves. However, there is still little available data on health-related quality of life (HRQL) in parents of children with Asperger Syndrome (AS) and High-Functioning Autism (HFA), or other PDD diagnoses in children of normal intelligence. The present study aimed to evaluate aspects of HRQL in parents of school-age children with AS/HFA and the correlates with child behaviour characteristics. METHODS: The sample consisted of 31 mothers and 30 fathers of 32 children with AS/HFA and 30 mothers and 29 fathers of 32 age and gender matched children with typical development. Parental HRQL was surveyed by the use of the 12 Item Short Form Health Survey (SF-12) which measures physical and mental well-being. The child behaviour characteristics were assessed using the structured questionnaires: The High-Functioning Autism Spectrum Screening Questionnaire (ASSQ) and The Strengths and Difficulties Questionnaire (SDQ). RESULTS: The mothers of children with AS/HFA had lower SF-12 scores than the controls, indicating poorer physical health. The mothers of children with AS/HFA also had lower physical SF-12 scores compared to the fathers. In the AS/HFA group, maternal health was related to behaviour problems such as hyperactivity and conduct problems in the child. CONCLUSION: Mothers but not fathers of children with AS/HFA reported impaired HRQL, and there was a relationship between maternal well-being and child behaviour characteristics.

Adolescent↗

Clinical characteristics of children with mental retardation of unknown etiology in Korea.

The purpose of this study was to investigate the clinical characteristics of children with mental retardation (MR) of unknown etiology for early recognition and intervention. In this study, we defined children with MR of unknown etiology as those without clear etiologies for MR despite extensive evaluation and were not associated with pathological behavioral problems such as pervasive developmental disorders and attention-deficit/hyperactivity disorder. The clinical characteristics of children with MR of unknown etiology were as follows. 1) MR of unknown etiology was 48.8% of all MR. 2) MR of unknown etiology was more common in males. 3) Delayed language development was a leading factor that made the parents of children with MR of unknown etiology seek help from physicians. However, most of the children with MR of unknown etiology showed a relatively uniform delay in several areas of development. 4) Most children with MR of unknown etiology were delayed walkers. 5) Most children with MR of unknown etiology were mild cases.

Child↗

Kleptomania: making sense of the nonsensical.

OBJECTIVE: Kleptomania, or the irresistible impulse to steal unneeded objects, is a poorly understood disorder. The objectives of this paper are to critically review and integrate existing data and to make suggestions for further research. DATA COLLECTION: Information was gathered by reviewing the English-language literature on kleptomania. Cases were chosen for review that approximated the diagnosis as defined in DSM-III-R. These cases were analyzed in terms of their relationship to previous theories about the disorder, and larger relevant studies were examined. Using the data organized into a table, the author explores areas of convergence and disagreement and discusses the methodological difficulties of the different studies. FINDINGS: Kleptomania is more common than previously thought. The "typical" individual with kleptomania is a 35-year-old woman who began to steal when she was 20 years old. Her thefts bring both relief and guilt. She probably has not sought treatment on her own but suffers from a necessary, pervasive, repetitive, and self-destructive act. She may have a history of sexual dysfunction or sexual preoccupation and may be unhappily married to an emotionally unsupportive husband. She has been labile and dysphoric for many years and may have a personality disorder. She has probably had a tumultuous, stressful childhood and may dissociate. CONCLUSIONS: The author proposes a biopsychosocial model of the etiology of kleptomania based on data from the literature. This model emphasizes possible childhood abuse as a precipitating factor in later development of kleptomania. More complete research is needed in the study of kleptomania.

Adolescent↗

Sudden infant death syndrome, child sexual abuse, and child development.

Since the introduction of the Back to Sleep Campaigns, there has been a dramatic reduction in sudden infant death syndrome in this country. Steven Blatt and Victoria Meguid review the literature surrounding sleep position. Investigators have continued efforts to find other modifiable risk factors of sudden infant death syndrome. A prospective study of more than 33,000 neonates found a link between a prolonged QT electrocardiogram interval and sudden infant death syndrome. Also discussed are investigations seeking to explain the relationship between smoking and sudden infant death syndrome. Ann Botash, Florence Jean-Louis and Mongkae Ploy Siripornsawan review the latest thinking on genital warts and their relation to specific viral etiologies and child sexual abuse. Other symptoms and signs of sexual abuse are the focus of a number of articles that can help the practitioner care for these unfortunate children. Catherine Church reviews medication options for children diagnosed with pervasive developmental disorders or autism spectrum disorders. Finally, in this article, risperidone, fluoxetine and naltrexone are reviewed.

Autistic Disorder↗

Disorders of regulation of cognitive activity in autistic children.

Infantile autism is a pervasive developmental disorder characterized by disturbances concerning not only the areas of socialization and communication ("aloneness") but also the ability to modify and change behavior ("need for sameness"). In most recent studies, various abnormal and deviant cognitive activities, such as the ability to regulate one's behavior, were considered as accounting for these signs. In this report, we examined the regulation of cognitive activity, from a developmental perspective in comparing autistic with mentally retarded children matched in a pairwise manner by global, verbal, and nonverbal developmental ages. All children were tested with tasks adapted from the Object Permanence Test which corresponds to Piaget's sensorimotor development Stages IV to VI. Results showed that autistic children had a pervasive difficulty in maintenance set, made more perseverative errors when the abstraction degree of task was higher, and were more variable in their behavioral strategies. Discussion is focused on the interests and limits of these tasks for the examination of regulation activity from diagnostic and developmental perspectives. Finally, interpretations about recent neuropsychological and neurophysiological works, and additional interdisciplinary studies are suggested.

Attention↗

Counting abilities in autism: possible implications for central coherence theory.

We examined the claim that children with autism have a "weak drive for central coherence" which biases them towards processing information at an analytic rather than global level. This was done by investigating whether children with autism would rapidly and automatically enumerate a number of dots presented in a canonical form, or count each dot individually to obtain the total. The time taken to count stimuli was compared across three participant groups: children with autism, children with moderate learning difficulties, and normally developing children. There were 22 children in each group, and individuals were matched across groups on the basis of verbal mental age. Results implied that children with autism did show a tendency towards an analytic level of processing. However, though the groups differed on measures of counting speeds, the number or children showing patterns of global or analytic processing did not differ significantly across the groups. Whether these results implicate a weak drive for central coherence in autism, which is both specific to, and pervasive in the disorder, is discussed.

Adolescent↗

Long-term consistency in speech/language profiles: II. Behavioral, emotional, and social outcomes.

OBJECTIVE: This study examined the 7-year behavioral, emotional, and social outcome of speech/language-impaired and control children selected from a community sample. METHOD: Speech/language and psychosocial measures were administered to the children at ages 5 and 12.5 years. Using children's age 5 speech/language test results, a cluster analysis was performed to ascertain whether specific linguistic subgroups would emerge. The association between speech/language cluster at age 5 and psychosocial functioning at age 12.5 was examined. RESULTS: Children with receptive and pervasive speech/language problems at age 5 demonstrated greater behavioral disturbance than children without such impairment. Controlling for initial behavioral status, early childhood language profile was still associated with behavioral and social competence ratings, 7 years later. Children without receptive language problems showed superior social adjustment. CONCLUSIONS: Empirically supported speech/language classifications identified as early as age 5 were associated with behavioral disturbance in late childhood. Receptive and pervasive speech/language impairment in early childhood was associated with the greatest risk at follow-up. Early auditory comprehension problems may be a specific risk factor for later aggressive and hyperactive symptoms. These findings identify the need for effective intervention with speech/language-impaired children.

Affective Symptoms↗

The emergence of psychopathology in a previously adaptive mother-infant dyad.

A mother and her six-week-old infant began attending group therapy sessions designed to raise awareness of developmental events. The mother consistently displayed a high degree of responsiveness and sensitivity to the infant's needs; in fact, her behavior served as a model of adaptive interaction for the entire group. After six months of sessions, when the infant manifested full-blown weaning patterns, the mother reported symptoms indicating a major depressive episode, such as pervasive dejection and rejection, listlessness, and anxiety attacks. After several individual sessions, during which discussion focused on the etiology of these emotions, the depression remitted and the mother was able to resume previous adaptive interaction designed to promote the infant's development. This case study reveals that highly adaptive parents may be susceptible to depression when developmental events that signify imminent separation from their infants or a similar dramatic change in their relationship occur.

Adaptation, Psychological↗

Prognostic significance of tuber count and location in tuberous sclerosis complex.

The objectives of this study were (1) to test the utility of tuber count and tuber location as biomarkers of disease severity in patients with tuberous sclerosis complex and (2) to examine the relationship between gene mutation, tuber count, and tuber location. We found that an increased tuber count per lobe and in total was associated with an increased risk of infantile spasms (P < .01). Increased tuber count in the occipital lobe was associated with an increased risk of pervasive developmental disorder (P = .0074). The mean tuber count per lobe and in total was higher in those with poorly controlled seizures and those with off-track development; however, these differences were not statistically significant (P > .01). The TSC2 gene mutation was associated with a significant increase in the tuber count per lobe and in total (P < .01). In summary, increased tuber count is strongly associated with infantile spasms and a TSC2 gene mutation. Seizure control and developmental delay do not show the strong association with tuber count suggested by the earlier literature.

Adolescent↗

Children with schizophrenia: clinical picture and pharmacological treatment.

Awareness of childhood-onset schizophrenia is rapidly increasing, with a more precise definition now available of the clinical picture and early signs, the outcome and the treatment strategies. Premorbid developmental impairments, including language, motor and social deficits, are more frequent and more pronounced in earlier- than in later-onset forms of schizophrenia. This 'pan-dysmaturation' is reported from the first months of life in more than half of the children who will develop childhood-onset schizophrenia, and it suggests a more severe and early disruption of brain development compared with the adolescent- and adult-onset disorder. The insidious onset in at least 75% of children, the high rates of premorbid problems and the hesitancy on the part of clinicians to make a diagnosis of schizophrenia in a child usually delay the recognition of the syndrome. Elementary auditory hallucinations are the most frequent positive symptom, while visual and tactile hallucinations are rarer. Delusions are less complex than in adolescents and are usually related to childhood themes. Negative symptoms are largely predominant, namely flat or inappropriate affect. A marked deterioration from the previous level of functioning is present in all these children, and an impaired outcome is reported in approximately 50-60% of them. The main diagnostic challenges are with differentiating childhood-onset schizophrenia from affective disorders (both depression and bipolar disorder) with psychotic symptoms, pervasive developmental disorders and severe personality disorders. Post-traumatic stress disorder and obsessive-compulsive disorder without insight may also be misdiagnosed as schizophrenia. Furthermore, approximately 10% of children from the community report nonpsychotic hallucinations or delusions. Finally, children with atypical psychotic features that do not strictly fit diagnostic criteria for schizophrenia have been described, and new labels have been proposed to categorise these clinical patterns, such as multidimensionally impaired disorder and multiple complex developmental disorder. In the context of a multimodal approach, including behavioral, social, scholastic and familial interventions, a pharmacological treatment is usually the core treatment. Available experience from the few controlled studies, open studies and case reports on pharmacotherapy in children with schizophrenia aged <12 years is critically analysed in this review, with particular reference to the use of atypical antipsychotics in clinical practice. To date, the major evidence supports the efficacy of risperidone and olanzapine, while clozapine seems an effective option in treatment-refractory cases. Published experience with newer atypical antipsychotics (quetiapine, ziprasidone, aripiprazole) is still lacking in this age range. Safety data (namely extrapyramidal symptoms, weight gain, hyperprolactinaemia, haematological adverse effects, seizures, hepatotoxicity, metabolic effects, neuroleptic malignant syndrome and cardiovascular effects) are reviewed and discussed, along with strategies for management.

Antipsychotic Agents↗

Screening for autism in young children: The Modified Checklist for Autism in Toddlers (M-CHAT) and other measures.

The literature on the importance of early identification and early intervention for children with developmental disabilities such as autism continues to grow. The increased prevalence of autistic spectrum disorders has fostered research efforts on the development and validation of autism-specific screening instruments for use with young children. There are currently several such autism-specific screening tools meant to be used with young children in various stages of development. Data from a few of these screening instruments have been published, and they include the Checklist for Autism in Toddlers (CHAT), Pervasive Developmental Disorders Screening Test (PDDST), Screening Tool for Autism in Two year olds (STAT), Checklist for Autism in Toddlers-23 (CHAT-23), and the Modified Checklist for Autism in Toddlers (M-CHAT). In this review, these five tools designed for use with children under three years old will be highlighted. In particular, the Modified Checklist for Autism in Toddlers (M-CHAT) will be discussed.

Age Factors↗

Effects of in-home training for culturally diverse fathers of children with autism.

Recently there has been mounting interest in the role of fathers and the effect of their increasing involvement on child development. However, to date, little has been reported regarding the role of fathers with developmentally delayed children (e.g., autism, pervasive developmental delays) and cultural influences on father-child interactions. In this article we address this knowledge gap by reporting four cases representing the major ethnic groups. For each case, we (1) define the concept of fatherhood in its cultural context, (2) review and summarize related father-child research, and (3) present findings from our study evaluating the effects of an in-home intervention for autistic children. While variability is noted within and among the culturally diverse father-child dyads, there are also similarities across ethnic groups. Results of this study are promising, demonstrating the value of single subject experimental methods in characterizing and beginning to understand complex father-child interactions in autism and related child psychiatric disorders.

Adult↗

Understanding childhood language disorders.

Developmental language disorders exist in 5% to 10% of preschoolers and have strong genetic implications. There are several variants of dysphasia: mixed receptive/expressive, expressive, or higher order language processing. Preschool children with pervasive developmental disorders are dysphasic as well as autistic. Some undergo a language and behavioral regression, most often as toddlers. The role of subclinical epilepsy in this regression is unknown because it is often ignored. Most dysphasic children speak by schoolage but are at substantial risk for reading/academic difficulty. Powerful new techniques to image the brain during language have no place in the routine workshop of children with dysphasia with or without autism.

Autistic Disorder↗

Neurophysiological assessment of brain function and maturation. II. A measure of brain dysmaturity in healthy preterm neonates.

Severe brain disorders can be expressed as markedly abnormal encephalopathic EEG patterns in neonates who are usually neurologically depressed, with abnormal levels of reactivity and tone. This symptomatic group is now a minority of medically ill neonates as a result of more vigorous fetal and neonatal resuscitative efforts. Most neonates alternatively express brain dysfunction as more pervasive alterations in EEG-sleep organization or maturation, usually in the absence or after resolution of abnormal clinical signs. One form of dysfunction is expressed as neurophysiologic dysmaturity. Brain dysmaturity may reflect altered rates of development in infants who sustained prenatal or postnatal stresses, as discussed in the first part of this review. We now summarize our findings of dysmature EEG-sleep development at conceptional term ages in an asymptomatic preterm cohort during a prolonged extrauterine period before discharge from the nursery. Dysmaturity of EEG-sleep function was expressed as delayed and/or accelerated physiologic behaviors, as compared with behaviors expected for the conceptional age. Dysmature brain function at conceptional term ages was also associated with poorer neurodevelopmental performances at 12 and 24 months of age. Neuronal pathways which subserve state-specific neurophysiologic behaviors will functionally adapt to stress by either slowing or accelerating neurological maturation. Through ontogenetic brain adaptation, which continues during postnatal development, a balance is maintained between the needs of the present developmental stage and anticipated needs during subsequent stages of maturation. How medical complications and environmental influences interact to promote greater brain dysmaturity in the neonate is still unknown. EEG sleep study can serve as a useful neurophysiologic screening procedure for the child suspected of having a subclinical presentation of an emerging static encephalopathy; longitudinal studies will then document deviations from expected ontogeny in the vulnerable child who is later stressed by environmental and socioeconomic factors.

Adaptation, Physiological↗

Parental recognition of developmental abnormalities in autism.

In order to identify factors associated with the early detection and referral of children with pervasive developmental disorders, a sample of 82 consecutive referrals to an outpatient diagnostic service was studied. All children were thoroughly assessed with the Autism Diagnostic Interview (ADI), standardized psychological tests and direct observations. Data from the ADI on the first symptoms to arouse parental concern and on the first professional advice sought were analyzed. The mean age of children was 19.1 months (SD = 9.4) when the parents first became concerned, and the first professional advice was sought when children were 24.1 months old (SD = 11.7). The most common parental concerns were for speech and language development, followed by abnormal socio-emotional response, and medical problem or delay in milestone. In both bivariate and multiple regression analyses, the mean age of children at first parental concern and professional advice was significantly lower in the presence of mental retardation in the child, of an older sibling in the family, and of first parental concerns for medical problem/delay in milestone. More specific autistic behaviours, child's gender, social class and place of residence did not influence the age of recognition of the disorder in this sample. Health visitors and general practitioners were the first professionals contacted by parents. The implications of these findings for early detection and diagnosis of autism are discussed.

Age Factors↗

Differentiating pervasive developmental disorder not otherwise specified from autism and language disorders.

Features useful in distinguishing children with pervasive developmental disorder (PDD) from those with autism or language disorder were developed from a retrospective chart review using groups of children with PDD-NOS and MA- and sex-matched autistic and language-disordered groups. Charts were reviewed using a list of 80 items compiled from various sources. Items that had adequate interrater reliability and significantly discriminated the PDD-NOS cases from the language-disordered or autistic cases were then evaluated using a second set of cases and signal detection methods. Fewer items significantly discriminated cases with autism from those with PDD-NOS as compared to cases with language disorder. Clinical implications are discussed.

Autistic Disorder↗