Tourette syndrome and tics

Tic disorders are not uncommon in children. The classification of the disorders includes transient tic disorders, chronic motor or vocal tic disorders and Tourette syndrome. Tourette syndrome consists of the presence of motor and vocal tics and occurs in 0.5–1.85% of school children. The tics range from blinking and shoulder shrugging to more complex tics such as jumping and the use of inappropriate words. The condition may be associated with other disorders, such as attention deficit hyperactivity disorder and obsessive compulsive disorder. A detailed history is essential in making the diagnosis, and an assessment of the child's functioning and self-esteem is also important in relation to management. A full explanation of the condition to the child and family may be all that is required in mild forms of the disorder. Various forms of management include psychological techniques and medication as well as liaison with the school.     

Pediatric management of anxiety disorders

The first step in the pediatric management of anxiety disorders is to determine whether a child or adolescent has acute, situational anxiety symptoms or a pervasive, chronic anxiety disorder. Such anxiety symptoms can most frequently be handled with reassurance and practical advice to the child and the parents, and followed by monitoring. However, if an anxiety disorder is suspected, then referral to a mental health professional is in order for confirmation of the diagnosis and institution of comprehensive treatment. Medication currently has a limited role in the treatment of any anxiety disorder, although psychopharmacologic treatment may become part of the overall care of obsessive-compulsive disorder in the future. Pediatricians may wish to learn more about behavioral-cognitive treatment approaches used by mental health professionals in the treatment of anxiety symptoms and disorders in children and adolescents. An excellent general text has been edited by R. Gittelman, Anxiety Disorders of Childhood.     

Genetic counseling

Genetic counseling is a process of communicating medical aspects about a genetic disorder, especially the information regarding risk of occurrence as recurrence of the disease in the family and preventive options. Accurate diagnosis of the affected member is of paramount importance for genetic counseling. Special genetic investigations like DNA analysis and chromosomal analysis are essential for many cases and especially when prenatal diagnosis is necessary. It is essential for pediatricians to identify cases with genetic disorders or possibly genetic disorders. These cases should be adequately worked up to identify accurate etiology as far as possible. The investigations should be done even if they are not going to make any difference in the outcome of the child. The genetic disorders present not only in neonates, but also in children, stillbirths and fetuses. Hence, autopsy of stillbirth and fetuses terminated after prenatal diagnosis is essential for genetic counseling. The importance of genetic counseling as an integral part of management of genetic disorders has to be realized by all clinicians. Pediatricians with short training can take over the responsibility of providing counseling for common genetic disorders and may need to refer others to genetic centre for counseling and prenatal diagnosis.     

Assessment and treatment of attention deficit hyperactivity disorder in children with comorbid psychiatric illness

PURPOSE OF REVIEW: Attention deficit hyperactivity disorder (ADHD) frequently occurs with a wide variety of comorbid psychiatric disorders such as conduct disorder, depression, mania, anxiety, and learning disabilities. Because the vast majority of children with ADHD are treated in primary care settings, it is important that primary medical doctors be proficient in the diagnosis and initial treatment of children with ADHD and its commonly occurring comorbid disorders. ADHD research is beginning to focus on the treatment of these comorbidly ill children. This review will summarize the recent findings from the psychiatric literature in an attempt to provide the clinician with some initial diagnostic and treatment guidelines for ADHD and its comorbidities. RECENT FINDINGS: The NIMH Multimodal Treatment Study of ADHD found that children with other disruptive behavior disorders plus ADHD respond well to stimulant medications, with behavioral interventions reducing academic and social impairment. Children with anxiety and ADHD are very responsive across multiple dimensions to behavioral and pharmacological ADHD treatments. Much less is known about the impact of depression on ADHD, and significant debate exists surrounding the identification and treatment of bipolar disorder in children with ADHD. Children with learning disabilities respond well to stimulants but often require additional educational supports. New findings suggest that treating ADHD may prevent the development of future psychiatric disorders. SUMMARY: The presence of comorbid illness is associated with significant additional morbidity and complicates the diagnosis, treatment, and prognosis of ADHD. Therefore, it is important to identify and treat any comorbid psychiatric conditions in a child with ADHD.     

Attention deficits in school-aged children and adolescents. Current issues and practice.

Attention deficits in school-aged children and adolescents pose unique diagnostic and management challenges for the practitioner. While this symptom reflects a heterogeneous spectrum of disorders with varying etiologies, clinical manifestation, treatment needs, and outcomes, there are sufficient common attributes to enable identification and treatment. Accurate diagnosis relies on synthesis of information from history, rating scales, direct observations, and psychometric testing. Close attention must be paid to potential underlying or associated medical, processing, emotional, and psychosocial problems. Multimodal treatment is essential with close collaboration between the child, parents, and professionals. While there is a risk of negative outcomes if the symptoms are left unattended, many of these children also harbor strengths that need to be identified and nurtured.     

Evaluation of a Child with Cerebral Palsy

Evaluation of a child with cerebral palsy (CP) requires a multidisciplinary approach with a team of professionals comprising of a pediatrician or pediatric neurologist, occupational therapist, a physiotherapist, child psychologist, and a social worker. The assessment is necessary to confirm the diagnosis, determine the cause, assess the motor function and associated problems. The diagnosis of CP is clinical but selected investigations may be required for ascertaining the cause. Evaluation includes assessment for common medical problems of childhood particularly nutritional disorders and assessment of family functioning. Additional disabilities are common. Routine assessment of vision and hearing is required in children with CP. Since CP is a changing disorder, some limitations may not be evident early in life but manifest in the school age or later. The evaluation of a child with CP is an ongoing process and should be a part of continuing care as the child grows from infancy to adolescence     

A febrile child with seizure and hemiparesis

Febrile seizures are the most common neurological disorders in children and are among the more common symptoms that lead to an emergency department visit. Although most febrile seizures are simple and benign, these seizures can infrequently create a diagnostic dilemma. The diagnosis of cerebral venous thrombosis is challenging to emergency physicians because it can mimic the presentation of many other disorders, including ischemic and hemorrhagic stroke, tumor, and abscess. In addition, the broad variety of signs and symptoms makes the clinical diagnosis difficult. The patients may be presented with signs of increased intracranial pressure or focal neurological deficits. It is an uncommon but potentially dangerous cause of hemiparesis after seizure. Early recognition of this condition and appropriate management may reduce the mortality rate. We present a young child with dural sinus thrombosis who presented with seizures associated with fever and subsequent hemiparesis, and explained a possible mechanism of focal neurological deficit.     

Childhood organic neurological disease presenting as psychiatric disorder.

Over a period of one year 12 children with complaints which had been diagnosed as due to a psychiatric disorder presented to a paediatric neurological unit where neurological disease was diagnosed. The group was characterized by behavioural symptoms such as deteriorating school performance, visual loss, and postural disturbance, which are unusual in children attending child psychiatric departments. It is suggested that where there is diagnostic uncertainty the presence of these physical symptoms calls for periodic neurological reassessment, and attention is drawn to the rare but serious disorders which may thus be diagnosed. Making an organic diagnosis, however, should not preclude psychosocial management of emotional reactions in these families.     

Bed Wetting — Silent Suffering: An Approach to Enuresis and Voiding Disorders in Children

Bed wetting or nocturnal enuresis is a common problem among children. It is either monosymptomatic or may be associated with a voiding disorder. Many factors may contribute towards enuresis such as developmental delay, heredity, inappropriate nocturnal anti diuretic hormone secretion and reduced bladder capacity. Any child presenting with bed-wetting should be evaluated for any underlying bladder dysfunction before labeling as monosymptomatic enuresis. The evaluation consists of structured bowel and bladder history, detailed clinical examination, frequency volume record and appropriate investigations. The frequency volume diary is an indispensible component of evaluation and helps in establishing diagnosis and tailoring therapy. The treatment of monosymptomatic enuresis consists of positive psychological support, alarms and medication (desmopressin/ anticholinergics/ imiprammine). Children with features of underlying bladder dysfunction, anatomical anomalies and neurological disorders should be referred to a pediatrician without delay. The outcome of therapy is usually rewarding but varies, depending on the underlying etiology, motivation, compliance and family support. The cure rates with alarms are better than with desmopressin in monosymptomatic enuresis. Timely and appropriate therapy yields better outcomes. Thus, a thorough, scientific and evidence based approach is essential in children presenting with bed-wetting.     

Second trimester antenatal diagnosis in rare coagulation factor deficiencies

Prenatal diagnosis is sought after for those genetic disorders, whose management is not satisfactory either because of the outcome or owing to extreme cost involved in the management of the patients affected by a specific disorder. Severe hemophilia and homozygous thalassemia are the 2 disorders for which there is an increasing demand for prenatal diagnosis in India. Rare severe deficiencies of coagulation factor X (FX) and factor VII (FVII) may present with severe bleeding manifestations. Because of their rarity the laboratory offering prenatal diagnosis for severe hemophilia and thalassemia may not be in a position to provide genetic diagnosis in the fetus. In this communication, we describe 2 families, 1 with an index patient of severe FVII deficiency and the other with severe FX deficiency where successful prenatal diagnosis was given after cordocentesis between 17 and 19 weeks using a battery of coagulation factor assays. Follow-up studies were performed 3 to 4 months after delivery and the diagnoses were reconfirmed on these babies by a repeat factor assay for FX and FVII deficiency, respectively.     

Attention-deficit/hyperactivity disorder in preschoolers. Does it exist and should we treat it?

The diagnosis of ADHD in preschool-aged children is difficult. High activity level, impulsivity, and short attention span--to a degree--are age-appropriate characteristics of normal preschool-aged children. However, excessive levels of these characteristics impede successful socialization, optimal learning, and positive parent-child interaction. Environmental stressors, inadequate parenting skills, and other diagnoses such as oppositional defiant, posttraumatic stress, or adjustment disorders can mimic ADHD. Although labeling may be necessary to obtain services, the emphasis should be placed on symptom resolution, given the uncertainties of diagnostic accuracy in this age group. Deferring a specific diagnosis of ADHD until confounding issues are clarified should be considered. The evaluation of serious behavior problems in young children must include a comprehensive consideration of environmental, health, cognitive, educational, and behavioral interactions. Both assessment and intervention should focus on the interactions between the child and his or her environment to determine how they facilitate or hinder adaptive integration as both the child and surroundings change and evolve. Treatment invariably necessitates involvement of a child and family psychotherapist or counselor to address behavior management strategies as well as family dynamics, parental psychopathology, or life stress. Parents must understand that counseling is an essential component of treatment and that they must be active participants. Psychopharmacologic intervention may be appropriate in some instances, although conventional wisdom suggests caution in young children, given the limited information about safety and efficacy of many agents, especially in children younger than 3 years old. Stimulants appear to be safe in older preschool-aged children. Children started on medication should be monitored closely for both positive and negative effects. A double-blinded, placebo-controlled trial of medication is warranted in equivocal situations.     

Sensory integration therapies for children with developmental and behavioral disorders

Sensory-based therapies are increasingly used by occupational therapists and sometimes by other types of therapists in treatment of children with developmental and behavioral disorders. Sensory-based therapies involve activities that are believed to organize the sensory system by providing vestibular, proprioceptive, auditory, and tactile inputs. Brushes, swings, balls, and other specially designed therapeutic or recreational equipment are used to provide these inputs. However, it is unclear whether children who present with sensory-based problems have an actual "disorder" of the sensory pathways of the brain or whether these deficits are characteristics associated with other developmental and behavioral disorders. Because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed. Other developmental and behavioral disorders must always be considered, and a thorough evaluation should be completed. Difficulty tolerating or processing sensory information is a characteristic that may be seen in many developmental behavioral disorders, including autism spectrum disorders, attention-deficit/hyperactivity disorder, developmental coordination disorders, and childhood anxiety disorders. Occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan. However, parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. Important roles for pediatricians and other clinicians may include discussing these limitations with parents, talking with families about a trial period of sensory integration therapy, and teaching families how to evaluate the effectiveness of a therapy.     

CHILDREN WITH PSYCHIATRIC DISORDERS IN PRIMARY CARE

A substantial minority (23%) of children between 7 and 12 years of age attending general practice were found to have psychiatric disorders. Disturbance was slightly more frequent in girls than in boys, and emotional disorder was the most common diagnosis. Psychiatric disorder was associated with psychological disadvantage (broken homes, the child had lived away from the family, family history of psychiatric disorder) and with current high levels of parental stress in relation to their children. Disturbed children tended to present with symptoms of anxiety, bed-wetting, hayfever, nosebleeds or scabies. Amongst a subsample of children consulting in general practice, psychiatric disorder may be a relevant factor contributing to somatic consultation.     

Childhood epilepsy in relation to mental handicap and behavioural disorders

Epidemiological studies indicate that there is a high rate of mental retardation and behavioural problems in children with epilepsy. In some cases both the epilepsy and the mental retardation will have a common cause, such as a metabolic disorder or brain trauma. However, in other children, the epilepsy itself may cause either temporary or permanent learning problems. When permanent learning disability can be prevented it is important to treat the epilepsy early and effectively. Children with specific learning difficulties and memory problems can benefit greatly from appropriate management. There are many causes of behavioural disturbance in children with epilepsy. These causes include the epilepsy itself, treatment of the epilepsy, reactions to the epilepsy, associated brain damage/dysfunction and causes that are equally applicable to children who do not have epilepsy. Identifying the cause or causes in each child allows rational management to be provided. Antiepileptic treatment with medication or surgery can either improve the situation or make matters worse. The treatment should be tailored to the needs of the individual child. If surgery is required, there is a strong argument for performing this early in life, both to allow the greatest opportunity for brain plasticity and also to allow the child full benefit from the important developmental and educational years, without the problems that can be associated with the epilepsy. Skilled management of children with epilepsy who have mental retardation and/or behavioural problems can be very rewarding both for the family and for the professionals involved.     

Le rôle spécifique de la sensibilité maternelle comme facteur associé au risque de diagnostics cooccurrents chez l’enfant d’âge préscolaire

IntroductionCo-occurrence of mental health diagnoses (dx) refers to the presence of two or more dx in the same child and may imply a more complex profile of symptoms and be more difficult to treat. Treatments for children with co-occurring dx often appear successful for some of the symptoms, while other symptoms persist with clinical efforts. Although it is well documented that an early onset of disorders in the preschool period is associated with numerous adverse outcomes in the middle childhood or adolescence periods (e.g., antisocial behavior, peer rejection), little is known about risk and protective factors associated with the co-occurrence of psychopathological disorders in preschool children.ObjectiveTo better identify intervention leverages for the treatment of these children, this study examines whether the quality of the family environment (maternal sensitivity, stress and depressive symptoms) is associated with the presence of co-occurring psychiatric dx among preschool age children.ParticipantsDuring four years, parents and children (1–5 years old) were approached at a specialized psychiatric clinic at the Sainte-Justine University Hospital Center in Montreal. An assessment and observation protocol was administered to a third of these families. Our study comprises the 54 children and their parents who participated to this protocol. In this sample, 37% of the children were diagnosed with an attention deficit hyperactivity disorder, 24% with a disruptive disorder, 39% with an oppositional defiant disorder and 46% with an anxiety disorder. Overall, 42 children (78%) were diagnosed with two or more dx.MethodMaternal sensitivity was observed during the very well-validated Strange Situation Procedure. Mothers completed questionnaires on parental stress and their depressive symptoms. Children were diagnosed by the clinic's psychiatrists.ResultsAnalyses showed clinical level difficulties of sensitivity (39%), stress (67%) and depression (43%) in a significant portion of the mothers. Parental stress and depression were not associated with co-occurring dx in children; however, less sensitive mothers were more likely to have children with more than one dx. Precisely, children of less sensitive mothers were more than twice as likely to present co-occurring disorders as children with more sensitive mothers.ConclusionsParental sensitivity, i.e., the ability to observe, interpret correctly and respond in a timely and appropriate manner to the child needs, is more problematic in mothers of children with a more complex symptomatology. This study highlights the importance of parental involvement in the treatment of these preschool children. Parent–child dyadic interventions, such as the Attachment Video feedback Intervention (AVI), to optimize parental sensitivity are discussed.     

Syncope in Pediatric Practice

Syncope is defined as a sudden, self-limited loss of consciousness and postural tone followed by spontaneous and complete recovery without any neurological sequelae. It is one of the most common paroxysmal disorders in children and adolescents. The three major causes of syncope in children are neural, cardiovascular and other non-cardiovascular causes. The common unifying mechanism is transient global hypoperfusion of the brain. The diagnosis is primarily clinical and objective laboratory investigations add little to the diagnosis in children especially in neurocardiogenic subtype. Specific management depends on the underlying cause of syncope in children. For cardiac causes, management includes early referral to the pediatric cardiology specialist. When paroxysmal non-epileptic events are suspected, child psychology or psychiatry consultation should be sought to identify the stressors and counseling. For neurocardiogenic syncope, the main objective of treatment is to prevent recurrent events to improve the quality of life, psychological stress and school absenteeism by behavior and lifestyle modifications followed by drugs in refractory cases. The prognosis is excellent for neurocardiogenic syncope and is variable based on the underlying pathology in cardiogenic cases. As syncope is not a disease in itself but a symptom of an underlying disorder; hence, all children with syncope require assessment to exclude an underlying life-threatening cardiac or non-cardiac disorder.     

Evaluation of Suspected Cerebrospinal Fluid Shunt Complications in Children

The development and utilization of CSF shunts have saved the lives of countless children who would have otherwise died without treatment, and the widespread use of these devices has made the management of children with shunts one of the most common problems encountered by pediatric neurosurgeons. When children with shunts seek medical attention, it is frequently a pediatrician or an emergency physician who will be the first to evaluate the patient. The complications associated with shunting can lead to significant morbidity and even mortality if not recognized and treated promptly; therefore, an understanding of the common presentations and causes of shunt failure is critical for first-line providers. Neurosurgical consultation should be considered in any child with a suspected shunt malfunction or infection. The prompt recognition and treatment of these disorders have the potential to reduce the risk of neurological injury and even death in these children.     

Idiopathic gait disorder among in-patients with acquired gait disorders admitted to a children's hospital

Many children are admitted to hospital for treatment of an acquired gait disorder. Some gait disorders have a definite underlying physical cause and some are idiopathic. A literature review shows that there have been few attempts to estimate the incidence or prevalence of idiopathic gait disorder in children. The economic and social impact may be substantial with regard to therapy and investigations and school absence, respectively. This study attempted to estimate the incidence and impact of idiopathic gait disorder in a tertiary children's hospital. It evaluated prospectively all the children admitted with a gait disorder requiring physiotherapy treatment at Birmingham Children's Hospital, using a standardized pro-forma, during a 3-month period between March-June 1999. One hundred and three children (aged 2-16 years) were admitted with gait disorders (57 female and 46 male). Eight had an idiopathic gait disorder. All eight children exhibited significant functional impairment, pain and school absence. Idiopathic gait disorder accounted for 8% of children admitted to hospital with an acquired gait disorder and had an annual incidence of at least 2-4 per 100,000 children. The economic and social impact of these disorders is, therefore, substantial, especially with regard to diagnosis, investigations, treatment and school absence.     

Child and adolescent bipolar disorder

The present paper provides an overview of child and adolescent bipolar disorder for paediatricians. Epidemiology, premorbid characteristics, clinical characteristics, differential diagnosis, comorbidity, course, prognosis and multimodal treatment are reviewed. The rate of child and adolescent bipolar disorder appears to be increasing. It manifests with symptoms consistent with the developmental level of the patient, which can make diagnosis difficult. Compounding the diagnostic difficulty is the frequent presence of comorbid conditions. Early recognition and treatment are critical given the severe morbidity associated with this condition. Thus, it is essential that paediatricians and other primary care physicians are familiar with this disorder to recognize its presence and activate appropriate multimodal treatment.     

Diagnosis and management of childhood strabismus

Strabismus is one of the most common ocular disorders encountered in children. The misalignment may be manifest in any field of gaze, may be constant or intermittent, and may occur at near or distant fixation or both. Early detection of strabismus is essential for restoration of proper alignment of the visual axes and the establishment of binocular vision. The proper assessment and management of a child with strabismus requires knowledge of the various clinical types, methods of detection and principles of treatment.