Management of Self-injurious Behaviors in Children with Neurodevelopmental Disorders: A Pharmacotherapy Overview.

Neurodevelopmental disorders (NDDs), a group of disorders affecting ~1-2% of the general population, are caused by changes in brain development that result in behavioral and cognitive alterations, sensory and motor changes, and speech and language deficits. Neurodevelopmental disorders encompass a heterogeneous group of disorders including, but not limited to, Smith-Magenis syndrome, Lesch-Nyhan disease, cri du chat syndrome, Prader-Willi syndrome, pervasive developmental disorders, fragile X syndrome, Rett syndrome, Cornelia de Lange syndrome, and Down syndrome. Self-injurious behaviors (SIBs) are common in children with NDDs; depending on the specific NDD, the incidence of SIBs is nearly 100%. The management of SIBs in this population is complex, and little high-quality data exist to guide a consistent approach to therapy. However, managing SIBs is of the utmost importance for the child as well as the family and caregivers. Behavior therapies must be implemented as first-line therapy. If behavioral interventions alone fail, pharmacotherapy becomes an essential part of management plans. The limited available evidence for the use of common pharmacologic agents, such as second-generation antipsychotics, and less common agents, such as clonidine, n-acetylcysteine, riluzole, naltrexone, and topical anesthetics, is reviewed. Additional data from well-designed studies in children with NDDs are needed to gain a better understanding of this common and troublesome problem including efficacy and safety implications associated with pharmacotherapy. Until then, clinicians must rely on the limited available data, clinical expertise, and ongoing systematic monitoring when managing SIBs in children with NDDs.

Addressing Early Childhood Emotional and Behavioral Problems.

More than 10% of young children experience clinically significant mental health problems, with rates of impairment and persistence comparable to those seen in older children. For many of these clinical disorders, effective treatments supported by rigorous data are available. On the other hand, rigorous support for psychopharmacologic interventions is limited to 2 large randomized controlled trials. Access to psychotherapeutic interventions is limited. The pediatrician has a critical role as the leader of the medical home to promote well-being that includes emotional, behavioral, and relationship health. To be effective in this role, pediatricians promote the use of safe and effective treatments and recognize the limitations of psychopharmacologic interventions. This technical report reviews the data supporting treatments for young children with emotional, behavioral, and relationship problems and supports the policy statement of the same name.

Disability, family and society: new thinking of an old debate.

The debate about disability, family and society is an old one. The needs of individuals with disabilities have not been a priority in most societies. However, this population is increasing with the advances in our medical technology and we can no longer ignore them. Overall care, from diagnosis to treatment and integration into society has been fragmented and disorganized. Thus, new thinking about individuals with disabilities has to take place. This article suggests the need for a paradigm shift has to how individuals with disabilities should be viewed and suggests a different model for the development of systems to meet the needs of this growing population.

Neurogenic thoracic outlet and pectoralis minor syndromes in children.

Brachial plexus compression (BPC) occurs above the clavicle as neurogenic thoracic outlet syndrome (NTOS) and below as neurogenic pectoralis minor syndrome (NPMS). It was recently noted that 75% of the adults seen for NTOS also had NPMS and in some this was the only diagnosis. This is also true in children but has not yet been reported. Because surgical treatment of NPMS is a minimum risk operation for pectoralis minor tenotomy (PMT), recognition of NPMS and distinguishing it from NTOS becomes important. In this study, 40 operations, 20 PMT and 20 NTOS procedures, were performed. Success rate for PMT was 85% and for thoracic outlet decompression was 70%. It was concluded that in children, as in adults, BPC is more often due to combined NTOS and NPMS. Surgical PMT should be considered first as the treatment of choice for children with NPMS. Thoracic outlet decompression is available if PMT is unsuccessful.

Situational analysis of poverty and violence among children and youth with disabilities in the Americas an agenda proposal / Análise da situação da pobreza e da violência entre crianças e jovens com deficiência nas Américas uma proposta de agenda debate debate

This article reviews the prevalence of poverty in Latin America and the Caribbean discussing the cycle and culture of poverty, their links to violence and maltreatment among disabled children and youth, from 1990 to 2006. There is a discussion of child maltreatment both of typical and disabled children taking into consideration the disabled child's unique needs, the impact on the family and society and the availability of supports and resources. Finally, an agenda is set forth to address poverty and violence, seeking to diminish the prevalence of maltreatment of all children, but especially children with disabilities. In addition, there is the hope of breaking the cycle of poverty and supporting disabled and marginalized individuals. This agenda speaks to the need for multidisciplinary collaboration as well as collaboration regionally and locally among governmental and non-governmental agencies, advocacy groups and the community at large.

Esse artigo revisa a prevalência da pobreza na América Latina e no Caribe, discute o ciclo e a cultura da pobreza e sua interface com a violência e os maus tratos contra crianças e jovens com deficiência, de 1990 a 2006. A discussão sobre os maus tratos focaliza crianças com e sem deficiência, levando em consideração a especificidade e necessidades singulares das crianças com deficiência, o impacto na família e na sociedade e a disponibilidade de suporte e recursos. Finalmente, uma agenda é proposta para abordar o tema da pobreza e violência, ao procurar diminuir a prevalência de maus tratos entre todas as crianças, especialmente as crianças com deficiência, ao quebrar o ciclo de pobreza e dar suporte para indivíduos com deficiência e marginalizados. Essa agenda aponta a necessidade de colaboração multidisciplinar, como também colaboração regional e local entre organizações governamentais e não-governamentais, grupos de auto-ajuda e a comunidade mais ampla.

Situational analysis of poverty and violence among children and youth with disabilities in the Americas -- an agenda proposal.

This article reviews the prevalence of poverty in Latin America and the Caribbean discussing the cycle and culture of poverty, their links to violence and maltreatment among disabled children and youth, from 1990 to 2006. There is a discussion of child maltreatment both of typical and disabled children taking into consideration the disabled child's unique needs, the impact on the family and society and the availability of supports and resources. Finally, an agenda is set forth to address poverty and violence, seeking to diminish the prevalence of maltreatment of all children, but especially children with disabilities. In addition, there is the hope of breaking the cycle of poverty and supporting disabled and marginalized individuals. This agenda speaks to the need for multidisciplinary collaboration as well as collaboration regionally and locally among governmental and non-governmental agencies, advocacy groups and the community at large.

Guidelines for the care of the child with special health care needs.

CSHCN present a challenge to the primary care provider. These children are medically complex, require services and supports well beyond those that typically developing children require, and command a considerable proportion of the pediatric health care budget. How clinics are organized can have a considerable impact on the delivery of care to this heterogeneous group of complicated children. In this article, the authors articulate the philosophic underpinnings of one clinic-the SCC-located in an academic tertiary care center. Establishing a multidisciplinary medical home with a noncategoric approach to health care is one way of serving patients who have special health care needs. The more common medical problems encountered in the SCC are identified, along with strategies to address them. The ethics of caring for CSHCN are complex and controversial and have only been touched on in the context of providing a medical home. It is clear that CSHCN are going to increase in numbers as technology and medical care change. Thus, it is incumbent on child health care providers to develop resources to meet the needs of this complicated population. There needs to be a change in the way CSHCN and their families are addressed, accepting them as individuals worthy of the same care, concern, and respect that typically developing children receive. The establishment of a medical home with a noncategoric approach to care may be one step in achieving comprehensive care for this population of underserved children.

A successful international child health elective: the University of Colorado Department of Pediatrics' experience.

OBJECTIVES: To describe the organizational features of an international child health elective (ICHE) and to document the diversity of diagnoses observed by residents. DESIGN: Faculty from the Department of Pediatrics, University of Colorado Health Sciences Center, Denver, created a steering committee in 1999 to develop and direct an ICHE, including selecting residents, selecting and organizing sites, and creating objectives and a year-long preparatory curriculum. The elective was piloted in 2000 and repeated in 2002 and 2004. SETTING AND PARTICIPANTS: Residents chose from 4 ICHE sites in Peru and Guatemala, where they observed clinical care in various clinical settings during a 4-week elective. MAIN OUTCOME MEASURES: The ICHE was evaluated via written evaluations by faculty and residents as well as written and oral reports by participating residents. RESULTS: During the 2000 and 2004 electives, residents recorded clinical cases in a data-entry log. Of the patients logged, 18% had illnesses never seen before by the residents and 5.6% had illnesses in advanced stages not previously seen by the residents. Strong reciprocal relationships were created between the department and participating international institutions. Residents reported uniformly that the elective was a valuable element of their training. CONCLUSIONS: Planning and faculty involvement in ICHEs helps to ensure achievement of elective objectives. Well-organized ICHEs have the potential to augment resident education. The experience at our institution demonstrates that ICHEs can provide experience with a variety of medical systems, exposure to diverse pathophysiologic conditions, and opportunities for collaboration with international colleagues.

Repetitive behaviors in autism: relationships with associated clinical features.

Relationships between repetitive behaviors (RBs) and associated clinical features (i.e., cognitive and adaptive functioning levels, sleep problems, medication use, and other behavioral problems) were examined in two groups (High nonverbal IQ > or = 97 versus Low nonverbal IQ < or = 56) of children with autism spectrum disorders (n = 14; mean age = 10 years, 7 months). For the group as a whole, nonverbal cognitive ability (NVIQ) (as measured by the Leiter-R), adaptive functioning level, the presence of sleep problems, and three scales of the Aberrant Behavior Checklist (ABC) (Irritability, Lethargy, and Hyperactivity) were highly correlated with total RB scores on the Repetitive Behavior Scale-Revised (RBS-R). After controlling for NVIQ, adaptive level, sleep problems, and two scales of the ABC (Irritability and Lethargy) were not significantly associated with RB scores. However, there remained a significant positive correlation between the presence of RBs and the Hyperactivity scale of the ABC. Parent ratings of their stress levels and the presence of RBs in their children were highly correlated. The relationship between RBs and associated clinical features in autism is complex and future studies should control for cognitive ability when examining the direct and indirect relationships of these variables with RBs.

Influence of stimulants on electrodermal studies in Fragile X syndrome.

Attention Deficit Hyperactivity Disorder (ADHD) is seen in the majority of children with Fragile X Syndrome (FraX). Previous work has documented an enhanced sweat response to stimuli in children with FraX compared to controls utilizing electrodermal response (EDR) measures. The present study assesses the EDRs both on and off stimulants in 19 children with ADHD and FraX compared to 17 age- and IQ-matched control patients with ADHD and developmental delays. Although the baseline EDRs were comparable between FraX patients and controls, the patients with FraX had a significant decrease in EDR amplitude and number of peaks when treated with stimulants compared to controls. This suggests that patients with FraX are more responsive to the enhancement of inhibitory systems that occur with stimulant use for ADHD. The use of a quantifiable measure, such as EDR, is recommended in future studies of treatment efficacy.

Maltreatment among children with developmental disabilities.

Arquivos de áudio e texto contendo a palestra do Médico do Hospital da Criança da Escola de Medicina da Universidade do Colorado (EUA), Edward Goldson, que abordou o impacto da violência na saúde de crianças portadoras de deficiência. O palestrante destaca que os valores culturais da sociedade na qual vivemos e o preconceito em relação ao "diferente", são fatores causadores da violência contra os portadores de necessidades especiais. Edward também enfatizou a necessidade de se preservar a saúde dos cuidadores que, por muitas vezes, vivem em situações de estresse, além dos familiares do paciente que em alguns casos devem mudar a visão sobre o portador de deficiência. Os arquivos estão disponíveis para leitura, audição e/ou download nos ícones ao lado.

Impacto da Violência sobre a saúde dos idosos - debate

O debate discutiu o impacto da violência na saúde de homens, mulheres, idosos, deficientes físicos e seus familiares. Os debates contaram com as presenças de Edinilsa Ramos de Souza e Fátima Gonçalves Cavalcante, Pesquisadoras do CLAVES, Antonio Moya Bernal, do Observatorio de Personas Mayores (Espanha), Romeu Gomes, Pesquisador do IFF, Lilia Blima Scharaiber, da Faculdade de Medicina da Universidade de São Paulo e Edward Goldson, do Hospital da Criança da Escola de Medicina da Universidade do Colorado (EUA). O arquivo está disponível para audição e/ou download no ícone ao lado.