Blood heavy metal levels in children with attention deficit hyperactivity disorder: an unsolved enigma

Background: The role of heavy metals in the etio-pathogenesis of attention deficit hyperactivity disorder (ADHD) is a burning enigma. The available studies with discordant results are from different geographical localities with different monitoring, regulations and sociocultural backgrounds. The differential association of heavy metals with ADHD severity and phenotypes has not been adequately examined. Also, there are concerns about laboratory quality control. Therefore, the present case control study was formulated.Methods: Thirty children with ADHD diagnosed by DSM IV criteria and thirty group age matched controls were enrolled. Detailed perinatal, past, developmental and possible exposure history to various heavy metals was taken. Severity of ADHD was assessed using ConnersTM Parent reporting questionnaire. Blood level of metals was estimated by inductively coupled plasma- atomic emission spectroscopy (ICP-AES).Results: The mean blood lead, mercury, cadmium, arsenic, zinc were comparable in children with ADHD and group age matched controls. The mean blood lead, mercury and cadmium levels in study population was higher than found in studies from developed countries. Elevated arsenic, mercury and cadmium were found in both cases and controls. Blood zinc correlated significantly with inattention T score and blood mercury with hyperactivity-impulsitivity T score of Conners parent rating scale. Blood cadmium was present in greater proportion of predominant hyperactive-impulsive type patients.Conclusions: Zinc deficiency correlates with inattention; cadmium and mercury toxicity correlate with hyperactivity. Mean blood levels of heavy metals is elevated in a substantial proportion of study population. So, there is an urgent need for sensitization and environmental control.

Development, Cognition, Adaptive Function and Maladaptive Behavior in HIV-infected and HIV-exposed Uninfected Children Aged 2-9 Years

Objectives: To compare development/cognition, adaptive function and maladaptive behaviorof HIV-infected and HIV-exposed uninfected children between 2 to 9 years with HIV-uninfected controls. Methods: This hospital-based cross-sectional study was conductedfrom November, 2013 to March, 2015. 50 seropositive HIV-infected, 25 HIV-exposeduninfected and 25 HIV-uninfected children between 2 to 9 years were administeredDevelopmental Profile 3, Vineland Adaptive Behavior Scale 2, and Child Behavior Checklistfor assessing development, adaptive function and maladaptive behaviour, respectively.Additional data were obtained by history, examination and review of records. Results:Significant developmental/cognitive impairment was observed in 38 (76%), 16 (64%) and 6(24%) HIV-infected, HIV-exposed uninfected, and HIV-uninfected children, respectively.Significant impairment in adaptive function was found in 12 (24%) and 2 (8%) HIV-infectedand HIV-exposed uninfected children, respectively. Maladaptive behavior was not seen in anygroup. Conclusions: High magnitude of impaired development/cognition and adaptivefunction in HIV-exposed and HIV-infected children warrants assessment of these domainsduring follow-up of these children, and incorporation of interventions for these deficits instandard care for this group.

Aetiology of global developmental delay in young children: Experience from a tertiary care centre in India.

Background. Global developmental delay is a common reason for referral to a paediatrician. We examined the aetiological yield of an extensive diagnostic work-up in young children with developmental delay in a tertiary referral centre. Methods. To assess the diagnostic possibilities, we systematically examined 100 consecutive children with global developmental delay (<5 years of age) who visited the paediatric outpatient department over a period of 18 months. An association between the presence of features at initial contact and aetiology was analysed by the 2-tailed Fisher exact test and chi-square test. Results. Of the 100 children, 65 were <2 years of age (mean age 23.6 months) at presentation. The presence of birth asphyxia, sepsis, seizures, abnormal neurological findings, and dysmorphism were significant predictors of aetiology. Four diagnostic categories—chromosomal disorders including Down syndrome, hypoxic–ischaemic encephalopathy, multiple malformation syndromes and cerebral dysgenesis—were the most common causes of global development delay in 20%, 15%, 14% and 11%, respectively. Moderate delay was seen in 42%, severe in 33% and mild in 25% of the patients. The aetiological yield did not differ with the severity of global developmental delay. Additional investigations such as neuroimaging, cytogenetic analysis, metabolic tests and specific molecular tests contributed to a diagnosis in 73% of the children, while in 23% these were the sole means of arriving at a diagnosis. Neuroimaging for a specific indication was almost twice more likely to yield an aetiology when compared with neuroimaging performed as a screening tool (65% v. 35%; p=0.003). Conclusion. The aetiological yield in this selected cohort with global developmental delay was 73%. A step-wise investigational approach is justified in all children with developmental delay, regardless of the severity of delay or the absence of findings on history and physical examination. This study is an attempt to formulate an investigative approach in a child with global developmental delay, especially in developing countries where advanced molecular and cytogenetic studies are not routinely available.

Follow-up of high risk neonates.

The improvement in perinatal care has led to increase in survival as well as reduction of morbidity in sick newborns. These babies need to be followed up regularly to assess growth and neurodevelopmental outcome and for early stimulation and rehabilitation. We present a protocol describing the various components of a follow up program, and services.

Behavioral problems in children with Down syndrome.

Forty consecutive children with Down syndrome were included as the Study Group (SG). The Control Group (CG) consisted of forty children attending the immunization clinic in pediatric OPD. Behavior Screening Questionnaire (BSQ) was used to screen the study groups as well as their siblings and control group for behavioral problems. The assessment of parental attitudes was done on Attitude Screening Questionnaire which includes 2 separate questionnaire for mother and father. Twenty two children (55%) with Down's syndrome showed behavioral problems as compared to 5 (12.5%) in control group. Children with Down's syndrome showed behavioral problems related to all the spheres (feeding, socialization, toilet training and sleep) as compared to control group. Mothers showed highly indulgent attitude as related to feeding to nearly total neglect as related to socialization and toilet training whereas in Paternal Attitude Screening Questionnaire, there was total neglect in all the spheres as compared to control group. There is higher prevalence of psychiatric disorders in children with Down's syndrome and their siblings.

Autism -- experiences in a tertiary care hospital.

Pervasive developmental disorders (PDD) or Autistic Spectrum Disorders (ASD) include Autistic Disorder (commonest), Asperger's syndrome, Childhood Disintegrative Disorders, Rett's syndrome and PDD-NOS (not otherwise specified). OBJECTIVE: Autism is an important cause of social disability and reported more often from the developed world than from the developing countries. The present study was aimed to establish the diagnosis of autism amongst children with derangements of language, communication and behavior; ascertain and treat the co-morbidities; identify underlying cause and create a sensitivity and awareness among various health care professionals. METHODS: Sixty-two of the seventy-five referred patients fulfilled the DSM-IV (Diagnostic and Statistical Manual of Mental Disorder) criteria for autism. Evaluation included a detailed history, clinical examination, IQ assessment, Connor's scoring for hyperactivity and Fragile-X screening. Management of co-morbidities was done. A follow up of these patients was done. Parents' assessment of the child was also done. A registry for autistic children was established at the Department of Pediatrics with other major institutions of Delhi. RESULTS : The male:female ratio was 8:1 and missed diagnosis was common. Professional awareness is merited. Behavioral modification by early intervention and stimulation improved the core symptoms of autism. Important co-morbidities included mental retardation (95%), hyperactivity (53%) and seizures (10%) cases. Control of co-morbidities in these children facilitated child's periodic assessment and implementation of intervention programmes. In the registry initiated 62 patients were enrolled at AIIMS and 6 were identified from other hospitals. CONCLUSION: Autism does occur in Indian children too. Diagnosis is often missed. Capacity building among health professionals by a more structured teaching of developmental disabilities in the medical curriculum is required. The need to attend to co-morbidities and associated symptoms was clear. The initiation of the registry and beginning of networking was important.