Developmental outcome of isolated fetal macrocephaly.

OBJECTIVE: To evaluate the neurodevelopmental outcome of children with prenatally diagnosed head circumference greater than 2 SD above the mean for gestational age and no associated anomalies detected by ultrasound. METHODS: This was a retrospective study of 17 fetuses, diagnosed in the third trimester by ultrasound as having isolated macrocephaly, defined as head circumference greater than 2 SD above the mean for gestational age. We evaluated their performance on a standardized neuropsychological battery at age 2-7 years, and compared them with 17 normocephalic children. RESULTS: The range of fetal head circumference in the study group was 2.0-2.9 SD. There were no significant differences between the groups in cognitive, language and motor domains. The study group scored significantly worse than the control group on three parameters, reflecting executive functioning, behavior and social-emotional development. Children with familial macrocephaly showed significantly better executive functioning compared with children with non-familial macrocephaly. Multiple linear regression analysis found paternal head circumference to be the only significant variable in positively predicting the cognitive functioning of the child. CONCLUSIONS: The finding in utero of a head circumference 2-3 SD above the mean for gestational age with no associated anomalies does not appear to be a significant risk factor for abnormal long-term neuropsychological development. Our study provides information important for parental counseling prenatally.

Oral findings and periodontal status in children, adolescents and young adults suffering from renal failure.

AIM: Describe the oral condition of chronic renal failure and healthy subjects, and the relationship between oral variables, chronic renal failure (CRF) conditions, and their treatment. MATERIALS AND METHODS: Four renal failure groups: chronic renal disease (n=22); undergoing dialysis (n=22); after dialysis and transplant (n=21); and after transplant (n=32), and a healthy control (n=38) were examined. Caries, enamel hypoplasia, pulp obliteration, plaque index, gingival bleeding, recession, overgrowth and index, probing depths, attachment loss, renal treatments and their relations with the oral variables were analysed. RESULTS: The renal failure groups had higher gingival index (GI) and bleeding, probing depths, attachment loss, hypoplasia and obliteration and less caries, than the control. Plaque was higher in the dialysis and pre-dialysis (PD) groups. Overgrowth was evident after transplant. The PD group showed lower GI than other renal groups. Dialysis duration and end-stage renal failure significantly correlated with gingivitis, probing depth, attachment loss and enamel hypoplasia. Immuran correlated positively with probing depth, gingival recession and attachment loss. Normiten and Nifedipine had positive correlations with gingival overgrowth. CONCLUSIONS: CRF patients are characterized by pulp obliteration, gingival and periodontal diseases. Duration of end stage renal failure and type of systemic treatment have a significant influence on the oral condition.

Autism in the Haifa area--an epidemiological perspective.

BACKGROUND: Autism is a pervasive developmental disorder. The incidence rate and other related epidemiological characteristics of the Israeli population are not available. OBJECTIVES: To assess the incidence rate of autism in the Haifa area and to compare family characteristics with previous reports from other countries. METHODS: We approached facilities in the Haifa area that are involved with the diagnosis and treatment of autism. The study group comprised children born between 1989 and 1993. Records of the children were scrutinized and 69% of the mothers were interviewed. Live-birth cohorts of the same years were employed for incidence computation. RESULTS: An incidence rate of 1/1,000 was derived. Male to female ratio was 4.2:1. Pregnancy and perinatal periods were mostly uneventful. A low prevalence of developmental and emotional morbidity was reported for family members. CONCLUSIONS: The epidemiological characteristics found in the Haifa area are similar to those reported from non-Israeli communities. This finding supports an underlying biological mechanism for this disorder. These data can be used for future trend analyses in Israel.

Neurodevelopmental and behavioural characteristics in learning disabilities and attention deficit disorder.

Specific learning disability in childhood is frequently associated with attention deficit disorder. The distinction between children with and without such comorbidity is often difficult to make. Our aim was to delineate the neurocognitive and behavioural differences between children with specific learning disabilities, with and without attention deficit. Students diagnosed with learning disability, mean age 8.3, 1.4 SD (N-50), and students with learning disability and attention deficit disorder, mean age 8.7, 1.4 SD (N-50), were assessed. The Paediatric Early Elementary Examination and the Aggregate Neurobehavioural Student Health Education Review were administered and their scores as well as pattern of correlations within and between domains were analysed. Only few differences in neurocognitive functions between these groups were evident. Most neurocognitive domains were similarly intercorrelated in the two groups. However, recall was correlated with other neurocognitive domains only among the children with learning and attention deficits. A proportion of significant correlations between neurocognitive and behavioural domains was found among the children with learning disability and attention deficit disorder, but not among the children with learning disability only. It appears that while neurocognitive profiles are similar in these two groups, their interrelationship with behavioural patterns differ. These findings give support to the neurological origin of attention deficit disorder related behaviours among learning disabled children. Different interventions should therefore be considered for each of these entities.

Growth patterns among infants with language deficits: a case-control study.

We compared growth parameters in infants with language delay to those in children with global delay and to typical controls. Thirty infants with expressive language delay and 36 with combined expressive and receptive language delay were compared with 27 infants with general development delay and with 124 controls. Data on weight, height, head circumference, and feeding behavior were obtained from birth up to age 78 weeks, and converted to percentiles. Medical and sociodemographic data were also evaluated. The weight curves in the combined expressive and receptive language delay group were significantly lower than in the comparison groups, but no cases of failure to thrive were noted. Height and head circumference curves in the combined expressive and receptive language delay group were also lower than in the typical controls. Infants with combined expressive and receptive language delay were lighter and shorter than controls. However, none of the parameters were more than two standard deviations below the mean. It is possible that this finding is of constitutional origin.

Developmental regression in autism: maternal perception.

Developmental regression among children with autism is a common phenomenon of unknown origin. The purpose of this study was to identify the differences between children with autism who reportedly regressed with those who did not regress. A representative group of 39 mothers were interviewed (40 children--1 pair of twin girls) about familial, pregnancy, perinatal, as well as medical history and developmental milestones. The study focused on mothers' perceptions of developmental regression. Nineteen children (47.5%) regressed in verbal and nonverbal communication and social but not in motor abilities. Mean age of regression was 24 months, with 11 children who regressed before and 8 after this age. No significant differences were reported by mothers of children who did or did not regress. More mothers of children who regressed, than those of children who did not, expressed guilt feelings regarding the development of autism, and almost all of them had an "explanation" for the possible mechanisms that might have influenced their children's developmental course. In conclusion, developmental regression in our population appears to be a typical event in the natural course of autism. There is little difference between those children who regressed and those who did not regress in maternal perceptions and reports of development, family, and medical history.

The prevalence of attentional problems and the effect of methylphenidate in children with myelomenigocele.

The prevalence of attentional problems, and the effect of methylphenidate was evaluated in a clinic population of children with myelomeningocele. Families of 79 children between the ages of 6 and 15 years were screened for the presence of attention problems in their children, using Conners' questionnaires for parents and teachers, and/or the DSM-IV checklist. Thirty-nine per cent of the children exhibited attention problems, primarily without hyperactivity. Fourteen children with attentional problems were enrolled in a double-blind placebo-controlled trial methylphenidate. Response to methylphenidate was assessed with Conners' questionnaires, Conners' Continuous Performance Test, and a battery of selected neuropsychological tests. No statistically significant response was measured for the group while on methylphenidate. Four children were clinical responders to methylphenidate. The prevalence of attentional problems in children with myelomeningocele is high, and effective medication therapy needs to be studied further.

Learning disabilities with and without attention-deficit hyperactivity disorder: parents' and teachers' perspectives.

Our objective was to delineate the educational and behavioral differences between learning disabled children with and without attention-deficit hyperactivity disorder (ADHD). A restrospective (TROHOC) multimeasure comparative design was employed. Parents' and teachers' questionnaires (ANSER system) pertaining to attention-activity, associated behaviors, and scholastic achievements were compared. Parents' questionnaires failed to distinguish between the two groups. Teachers' questionnaires were significantly more sensitive. Significant correlations between educational achievements and attention-activity and associated behaviors scores among children with learning disabilities were evident, no such correlations were found in the group with learning disability with ADHD. The factor analysis identified different educational and behavioral aggregates with language related difficulties and externalizing behaviors more typically aggregated in the learning disabled group with ADHD and recall deficit and internalizing/neurotic behaviors in the group with learning disability only. ADHD appears to be an associated comorbidity and not necessarily a specific learning deficit. However, children with learning disability with ADHD possibly have a different underlying neurocognitive pattern than their peers with learning disabilities only.

Behavioural problems among visually impaired between 6 months and 5 years.

The prevalence and types of behavioural problems among legally blind children were assessed by employing a cohort study design in a well defined geographic area. One hundred and eighty two children between the ages of 6 months and 5 years were consecutively assessed over a period of 13 years. A standardized ophthalmological, neurodevelopmental and physical examination, a parental interview and video recording were employed. Diagnostic classification was based on the DSM-III-R criteria (American Psychiatric Association, 1987). Behavioural problems were documented in 49%. In 61% of these, three disorders were identified: (1) overanxious (n = 14), (2) oppositional with or without attention deficit hyperactivity (n = 15), and avoidant with or without stereotypy (n = 26). The first category is associated with partial sightedness and the third with neurodevelopmental deficits. The prevalence of behavioural problems among blind children is high and therefore a careful psychological monitoring and assistance should be offered to them and their parents.

Lower arch perimeter preservation using the lingual arch.

The purpose of this investigation was to determine whether the placement of a mandibular lingual arch maintained arch perimeter in the transition from the mixed to the permanent dentition, and if so, whether it was effective at preventing mesial migration of first permanent molars, or whether this migration still occurred en masse, by increased lower incisor proclination. Thirty patients were randomly assigned to either a treatment group (N = 14, mean age = 11.5 years) or a control group (N = 16, mean age = 11.3 years). Study models, cephalograms, and tomograms of the patients, taken at the beginning and at the end of the study period, were examined. Statistically significant differences between groups were found for positional changes of mandibular first molars and incisors, and changes in arch dimensions. The results indicate that the lingual arch can help reduce arch perimeter loss, but at the expense of slight mandibular incisor proclination.

The effects of lip bumper therapy in the mixed dentition.

A prospective clinical trial was undertaken to study the effects of 6 months of continuous lip bumper therapy on patients in the mixed dentition with mild-to-moderate mandibular arch perimeter deficiency. Thirty-four patients, ages 7.9 to 13.1 years (mean = 10.2), seeking treatment in the postgraduate orthodontic clinic of the Medical College of Virginia, presented possessing 3 to 8 mm of mandibular crowding, with both mandibular primary second molars, were randomly placed in either the treatment or nontreatment group. Treated subjects underwent continuous lip bumper therapy, whereas the control subjects were monitored without undergoing any active treatment, each for 6 months. Arch dimension changes were assessed with study models. Alterations of mandibular incisor position were measured from lateral cephalometric radiographs. Mandibular left permanent first molar position changes were determined from both lateral cephalometric and tomographic radiographs, with the resolution of each imaging technique in measuring molar tooth movement also compared. It was found that significant differences in mandibular incisor inclination, molar position, arch length, and arch perimeter existed between treated and untreated subjects. In addition, multiple observer analysis showed that cephalometric examination lacks sensitivity when used to measure molar movement.

Head circumference measurements in children with autism.

To assess head circumference in children with autism, 148 charts were retrospectively reviewed. All of the children met the Diagnostic and Statistical Manual of Mental Disorders (DSM-III or DSM-III-R) criteria for autism and had no known underlying condition that might affect head circumference. In addition, data were collected regarding height, weight, brain imaging, cognitive development, adaptive behavior, and language. The children were divided into two groups: those with head circumference at or above the 98th percentile (Group 1) and those with head circumference below the 98th percentile (Group 2). Group 1 consisted of 27 (18.2%) of the children. Height measurements were significantly higher in Group 1 as compared with Group 2 (P = .0006) as were weight measurements (P = .0003). Group 1 had a significantly lower percentage of females (P = .04) and lower adaptive behavior scores (P = .0067) than Group 2. Routine brain imaging studies could not explain the macrocephaly in Group 1. The etiology of large head circumference and increased growth indices in children with autism is unclear.

Condylar movement and mandibular rotation during jaw opening.

Inaccurate description of mandibular rotation can have profound effects on orthognathic surgical treatment planning and surgical outcome, as well as affect the precision of appliances fabricated on articulators. Disagreement exists concerning movements of the condyle during jaw opening. Although mandibular function is often described as rotation around an instantaneous center located outside of the condyle, many believe that jaw opening occurs around an axis of rotation that remains fixed at the center of the condylar head. In this study, condylar movements and centers of mandibular rotation during jaw opening were examined in normal subjects with the Dolphin Sonic Digitizing System. All of the subjects demonstrated both translation and rotation of the condyle during initiation of jaw opening, and none had a center of mandibular rotation located at the condylar head. The findings support the theory of a constantly moving, instantaneous center of jaw rotation during opening that is different in every person. There were also differences in movement within the subjects between experimental trials. The uncertainty of predicting mandibular rotation for a given patient should be considered when planning surgical treatment and fabricating orthodontic appliances.

The ground rules for arch wire design.

All force systems applied to a tooth are composed of either single forces and/or couples. The application of a force through the center of resistance of a tooth will result in translation of the tooth. The application of a force to act at points other than through the center of resistance of a tooth will produce different tendencies for rotation. Tooth rotation resulting from the application of a force always creates a simultaneous tendency to move the center of resistance of a tooth in the direction the force is acting. In contrast, the location of a couple on a tooth is irrelevant to the resulting tooth movement. A couple can never move the center of resistance, and with a couple the center of rotation and the center of resistance will always be coincident. The equilibrium forces, associated with a moment of a couple, also are single-point forces and can produce different tooth movements depending on where they are applied. All tooth movement must be either translation and/or rotation as defined at the tooth's center of resistance.

Two-couple orthodontic appliance systems utility arches: a two-couple intrusion arch.

The utility arch is a two-couple intrusion arch wire used for control of anterior deep overbite. It is similar to a one-couple intrusion arch in that it is commonly made with rectangular wire, attached to the teeth only at the molars and the incisors and is activated for incisor intrusion by a molar tip back bend. It differs from a one-couple intrusion arch by the insertion of the incisor segment into the incisor brackets. This results in a fixed point of application of the intrusion force anterior to the incisors and, therefore, incisor rotation by the moment of the force. In addition, insertion of the rectangular wire into the incisor brackets usually creates a third-order couple for incisor rotation. Depending on how it is used, the moment of this couple may be activated in either direction and the resulting associated equilibrium forces will either supplement or reduce the vertical equilibrium forces created by the activation bends at the molars.

Congenital toxoplasmosis: a significant cause of neurological morbidity in Israel?

The incidence of congenital toxoplasmosis in Israel is largely unknown, as is the impact of this condition on the neurological diseases of childhood. We examined the association between toxoplasmosis and three neurological disorders: epilepsy, cerebral palsy, and nerve deafness. Ninety-five children 1-15 years of age who had one of these three diagnoses but who had not had perinatal meningitis or anoxia and had no genetic predisposition for the documented neurological disorder were eligible for the study; 109 children hospitalized for elective surgery served as age-matched controls. Demographic and serological data were analyzed by logistic regression. The prevalences of serum antibodies to Toxoplasma gondii in the study and control groups were 22% and 9%, respectively. Children with one of the three neurological disorders were significantly more likely to have IgG antibodies to T. gondii (relative risk, 2.5; P = .03). The relative risk of seropositivity was remarkably high (7.1) among children with nerve deafness (P = .01). Large-scale prospective cohort studies of pregnant women are needed to substantiate the impact of congenital toxoplasmosis on the neurological diseases of childhood in Israel.

The relationship between joint hypermobility and neurodevelopmental attributes in elementary school children.

Joint hypermobility is associated with motor developmental delay in infancy. To assess this finding in school-aged children, 320 first- and second-grade elementary school children and 110 children attending a special education program were assessed. Joint hypermobility was found in 40 (12.4%) and seven (6.4%) of the children attending the regular and special education classes, respectively. No difference in the neurologic status or verbal and eye-hand coordination task performance was found between the children of the study group and their age- and sex-matched controls. It appears that joint hypermobility and neurodevelopmental dysfunctions are not causally related and have a different maturational course.