[Child psychiatric learning goals for general psychiatric training: a Delphi study]. / Leerdoelen over kinder- en jeugdpsychiatrie in de opleiding psychiatrie: een delphistudie.

BACKGROUND: The new Dutch training plan for psychiatrists puts more emphasis on life course psychiatry. Subsequently, adjustments in the educational program regarding child and adolescent psychiatric knowledge, skills and attitudes are needed. AIM: A broadly supported agreement and consensus on Dutch national learning objectives of education in child and adolescent psychiatry. METHOD: With a modified Delphi method, a set of preliminary learning objectives formulated by a working group of experts was presented to trainees (n = 9), adult psychiatrists (n = 12), child and adolescent psychiatrists (n = 17) and adult patients and their relatives (n = 15). In two rounds, the learning objectives were commented on, supplemented, scored for relevance and prioritized. RESULTS: Out of 27 original learning objectives, 20 were assessed as important or necessary by over 80% of the respondents (knowledge 7/9, skills 8/10, attitudes 5/8). Two learning objectives were rejected (less than 60% considered these to be important or necessary). Seven learning objectives were re-assessed in a second round as these were modified (5) or added (2). Four of them were rated as important or necessary by over 80% of participants. The following goals were most often prioritized: knowledge about healthy development and intergenerational issues; ability to make contact with children and families and to integrate protective and risk factors of the child and environment; and knowing one’s own limitations of child psychiatric themes. CONCLUSION: A Delphi study helped gain support from stakeholders for adjustments in training and education by creating consensus about child psychiatric learning goals for general psychiatric training.

Catecholaminergic and cholinergic neuromodulation in autism spectrum disorder: A comparison to attention-deficit hyperactivity disorder.

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental disorder characterized by social impairments and restricted, repetitive behaviors. Treatment of ASD is notoriously difficult and might benefit from identification of underlying mechanisms that overlap with those disturbed in other developmental disorders, for which treatment options are more obvious. One example of the latter is attention-deficit hyperactivity disorder (ADHD), given the efficacy of especially stimulants in treatment of ADHD. Deficiencies in catecholaminergic systems [dopamine (DA), norepinephrine (NE)] in ADHD are obvious targets for stimulant treatment. Recent findings suggest that dysfunction in catecholaminergic systems may also be a factor in at least a subgroup of ASD. In this review we scrutinize the evidence for catecholaminergic mechanisms underlying ASD symptoms, and also include in this analysis a third classic ascending arousing system, the acetylcholinergic (ACh) network. We complement this with a comprehensive review of DA-, NE-, and ACh-targeted interventions in ASD, and an exploratory search for potential treatment-response predictors (biomarkers) in ASD, genetically or otherwise. Based on this review and analysis we propose that (1) stimulant treatment may be a viable option for an ASD subcategory, possibly defined by genetic subtyping; (2) cerebellar dysfunction is pronounced for a relatively small ADHD subgroup but much more common in ASD and in both cases may point toward NE- or ACh-directed intervention; (3) deficiency of the cortical salience network is sizable in subgroups of both disorders, and biomarkers such as eye blink rate and pupillometric data may predict the efficacy of targeting this underlying deficiency via DA, NE, or ACh in both ASD and ADHD.

Empathy and prosocial behavior in response to sadness and distress in 6- to 7-year olds diagnosed with disruptive behavior disorder and attention-deficit hyperactivity disorder.

Empathy has been associated with decreased antisocial and increased prosocial behavior. This study examined empathy and prosocial behavior in response to sadness and distress in disruptive behavior disorder (DBD) and attention-deficit hyperactivity disorder (ADHD). Six- and 7-year-old children with DBD (with and without ADHD) (n = 67) and with ADHD only (n = 27) were compared to typically developing children (TD) (n = 37). Parents and teachers rated affective empathy in response to sadness and distress on the Griffith Empathy Measure. Children reported affective empathic ability in response to sad story vignettes. Empathy-induced prosocial behavior in response to sadness and distress was assessed with a computer task, the Interpersonal Response Task (IRT). Compared to TD, children with DBD (with and without ADHD) and those with ADHD only were rated as less empathic by their teachers, but not by their parents. No differences between groups were observed in children who reported affect correspondence. Children with DBD (with and without ADHD) showed less prosocial behavior in response to sadness and distress compared to TD. Children with ADHD only did not differ from TD. An additional analysis comparing all children with a diagnosis to the TD group revealed that the difference in prosocial behavior remained after controlling for ADHD symptoms, but not after controlling for DBD symptoms. These findings of impaired empathy-induced prosocial behavior in response to sadness and distress in young children with DBD suggest that interventions to ameliorate peer relationships may benefit from targeting on increasing prosocial behavior in these children.

Electromyographic responses to emotional facial expressions in 6-7 year olds with autism spectrum disorders.

This study aimed to examine facial mimicry in 6-7 year old children with autism spectrum disorder (ASD) and to explore whether facial mimicry was related to the severity of impairment in social responsiveness. Facial electromyographic activity in response to angry, fearful, sad and happy facial expressions was recorded in twenty 6-7 year old children with ASD and twenty-seven typically developing children. Even though results did not show differences in facial mimicry between children with ASD and typically developing children, impairment in social responsiveness was significantly associated with reduced fear mimicry in children with ASD. These findings demonstrate normal mimicry in children with ASD as compared to healthy controls, but that in children with ASD the degree of impairments in social responsiveness may be associated with reduced sensitivity to distress signals.

Differences between nicotine-abstinent smokers and non-smokers in terms of visuospatial attention and inhibition before and after single-blind nicotine administration.

The cholinergic system is implicated in visuospatial attention and inhibition, however the exact role is still unclear. Two key mechanisms in visuospatial attention are bias and disengagement. Bias refers to neuronal signals that enhance the sensitivity of the sensory cortex, disengagement is the decoupling of attention. Previous studies suggest that nicotine affects disengagement and (related) inhibition. However the exact relation is still unknown. Furthermore, nicotine-abstinence in 'healthy' smokers may resemble some anomalies of visuospatial attention and inhibition as seen in Attention Deficit/Hyperactivity Disorder (ADHD). Smokers and non-smokers (32 male students) performed in a visuospatial cueing (VSC) task, to assess bias and disengagement, and in a stop-signal task (SST) to assess inhibition. It was expected that nicotine abstinent smokers compared to non-smokers, would show poor disengagement (indicated by an enhanced validity effect) and poor inhibitory control (indicated by an enhanced stop-signal reaction time (SSRT)). It was expected that nicotine would positively affect disengagement and inhibition: hypothesis 1 stated that this effect would be larger in smokers as opposed to non-smokers, in terms of smoking-related deficient inhibitory control. Hypothesis 2 stated the exact opposite, in terms of drug-tolerance. Results indicated no baseline differences. Nicotine enhanced inhibition more in non-smokers relative to smokers. Integrating the results, nicotine-abstinent smokers do not seem to resemble ADHD patients, and do not seem to smoke in order to self-medicate a pre-existing deficit pertaining to mechanisms of visuospatial attention and inhibition. Nicotine may affect inhibition more in non-smokers relative to smokers, consistent with a drug-tolerance account.

The effect of enhancing cholinergic neurotransmission by nicotine on EEG indices of inhibition in the human brain.

The role of the cholinergic system in inhibition remains to be elucidated. Nicotine is a potent tool to augment this system, but most studies investigated its effects solely on behavior. Reference to brain activity is important to specifically identify inhibition-related mechanisms. In the current study the objective was to elucidate the role of the cholinergic system in inhibition. 16 healthy non-smokers performed in a stop task while EEG was recorded. A pre- versus post-treatment, within subjects, placebo controlled, single-blind design was used. It was hypothesized that nicotine would decrease stop-signal reaction time (SSRT) and increase the amplitude of inhibition-related event related potentials, the stop N2 and stop P3. Behavioral measures show nicotine shortened SSRT, but only when pretreatment values were not taken into account. On EEG measures, an enhanced stop P3 under nicotine was found, but only in a subsample sensitive to nicotine based on diastolic blood pressure. The results are indicative of enhanced inhibitory activity possibly reflecting enhanced activation in the superior frontal gyrus.

The effect of the augmentation of cholinergic neurotransmission by nicotine on EEG indices of visuospatial attention.

The cholinergic system has been implicated in visuospatial attention but the exact role remains unclear. In visuospatial attention, bias refers to neuronal signals that modulate the sensitivity of sensory cortex, while disengagement refers to the decoupling of attention making reorienting possible. In the current study we investigated the effect of facilitating cholinergic neurotransmission by nicotine (Nicorette Freshmint 2mg, polacrilex chewing gum) on behavioral and electrophysiological indices of bias and disengagement. Sixteen non-smoking participants performed in a Visual Spatial Cueing (VSC) task while EEG was recorded. A randomized, single-blind, crossover design was implemented. Based on the scarce literature, it was expected that nicotine would specifically augment disengagement related processing, especially manifest as an increase of the modulation of the Late Positive Deflection (LPD) by validity of cueing. No effect was expected on bias related components (cue-locked: EDAN, LDAP; target-locked: P1 and N1 modulations). Results show weak indications for a reduction of the reaction time validity effect by nicotine, but only for half of the sample in which the validity effect on the pretest was largest. Nicotine reduced the result of bias as indexed by a reduced P1 modulation by validity, especially in subjects with strong peripheral responses to nicotine. Nicotine did not affect ERP manifestations of the directing of bias (EDAN, LDAP) or disengagement (LPD).

Electromyographic responses to emotional facial expressions in 6-7year olds: a feasibility study.

Preliminary studies have demonstrated that school-aged children (average age 9-10years) show mimicry responses to happy and angry facial expressions. The aim of the present study was to assess the feasibility of using facial electromyography (EMG) as a method to study facial mimicry responses in younger children aged 6-7years to emotional facial expressions of other children. Facial EMG activity to the presentation of dynamic emotional faces was recorded from the corrugator, zygomaticus, frontalis and depressor muscle in sixty-one healthy participants aged 6-7years. Results showed that the presentation of angry faces was associated with corrugator activation and zygomaticus relaxation, happy faces with an increase in zygomaticus and a decrease in corrugator activation, fearful faces with frontalis activation, and sad faces with a combination of corrugator and frontalis activation. This study demonstrates the feasibility of measuring facial EMG response to emotional facial expressions in 6-7year old children.

[Stability of borderline personality disorder from childhood to adulthood: a literature review]. / Stabiliteit van de borderlinepersoonlijkheidsstoornis van de kinderjaren tot in de volwassenheid: Een literatuuronderzoek.

BACKGROUND: Borderline personality disorder (BPD) is a severe and frequent disorder. Little is known about its early stages, which can be in childhood or adolescence. AIM: To investigate to what extent BPD is stable from childhood through to adulthood. METHOD: The literature was systematically reviewed with the help of Medline, Psycinfo, embase and the Cochrane Library. RESULTS: Of children known to have BPD in the primary school age-group, 80% met the criteria for a personality disorder in adulthood and 16% met the criteria for BPD. In a population study of adults with bpd, 30% still met the criteria two years later. In groups of adolescents at risk the criteria were met by 15-30 % after two to three years. These groups also showed a low dimensional stability for BPD. The most stable symptoms were feelings of emptiness, anger, affect-instability and identity problems. Less stable symptoms were suicidality, self-harm, impulsiveness, unstable relationships, derealisation and paranoid thinking. CONCLUSIONS: Research into the stability of BPD that starts in children of primary school age has been too limited in a methodological sense for us to draw any firm conclusions. Research into BPD that starts in adolescence shows a low categorial and dimensional stability. Research into the onset of BPD in adults shows comparable low stability, but only after six years. In adolescents and adults impulsive and self-harm behaviour are probably the least stable symptoms and affective symptoms the most stable ones.