Obsessive-compulsive disorder in childhood and adolescence.

Obsessive-compulsive disorder (OCD) is a common psychiatric condition during childhood and adolescence, which continues to be underestimated and undertreated. For these reasons, it constitutes a primary cause of major disabilities in those ages and, sometimes, of permanent impairments later on. In these last few years, childhood and adolescence OCD has attracted an increasing focus which has promoted a deeper awareness of this illness, a better recognition with earlier interventions, as well as the set-up of more tailored and specific strategies, including psychotropic drugs. The aim of this paper is to present a critical review of paediatric OCD, with a special attention towards the most compelling reports available up to now and towards the most interesting areas for future research.

Depressive symptoms and academic self-image in adolescence.

The aim of this paper was to specifically analyse the relationship between the different components of academic self-image, defined as the way adolescents represent themselves as students, and self-reported depressive symptoms, assessed with the Children's Depression Inventory (CDI), in a non-clinical sample of 298 adolescents. We considered both adolescents' beliefs about their own cognitive functioning in academic performance and beliefs about their emotional attitude in achievement situations. Our data indicate that the pattern of correlation between emotional beliefs about schooling and learning are significantly related to CDI scores, but this correlation is not evident for the cognitive beliefs. This pattern of correlation is affected by actual school functioning, because correlation between CDI and beliefs is much more significant in subjects without school failure. Differences between gender in CDI scores, beliefs about schooling and learning, and pattern of correlation are considered. These results can enable to focus supporting psychological interventions on more specific targets.

Depression and school functioning in non-referred adolescents: a pilot study.

Self-image and self-perceived competencies have been considered to be related to depression in childhood and adolescence. Data from literature points to school functioning as one of the most important factors in self-esteem and self-worth during adolescence. Academic self image, defined as the way adolescents represent themselves as students, directly affects the global self-image; for this reason it has important psychopathological implications. The major aim of this preliminary report is to specifically analyze the relationship between academic self-image (assessed with a specific questionnaire), and self-reported depressive symptoms (assessed with the Children's Depression Inventory) in a school sample 150 adolescents. Our data indicate that the emotional beliefs about schooling and learning were significantly related to depressive symptomatology. Females scored higher in CDI and school anxiety. A real school failure did not affect the academic self image. These data seem to suggest that different components of the academic self-image can be differently associated with depressive feelings.

Neuropsychological follow-up in early-treated congenital hypothyroidism: a problem-oriented approach.

Screening programs for congenital hypothyroidism (CH) dramatically improved the neuropsychological prognosis in affected children. However, mild impairments in cognitive performances, poorer motor skills, defective language abilities, and learning problems have been reported in some studies of early-treated CH children. The occurrence of these defects makes neuropsychological follow-up mandatory. The aim of the present study was to identify those neuropsychological functions that are more frequently affected in early-treated CH children and that might require prompt rehabilitation treatment to prevent permanent defects. The study group involved 24 CH children. Levothyroxine (LT4) treatment (initial dose 8-10 microg/kg per day) was started at mean age of 28 days (range 15-45) and was then adjusted with the goal to keep thyrotropin (TSH) and free thyroid hormone levels in the normal range. Cognitive evaluation was performed at 3, 5, and 7 years of age and did not significantly differ from that of controls. Mean neurological scores were lower in children 5 years of age than in controls. Children with severe neonatal hypothyroidism (serum thyroxine [T4] < 2 microg/dL) had significantly lower neurological scores compared to less affected CH children and normal controls. The most affected functions were balance, extremity coordination, fine motricity, quality of movements, associated movements, and head movements. Language disorders were observed in half of CH children at 3 and 5 years of age, but moderately severe defects were restricted to those with severe neonatal hypothyroidism. In conclusion, a problem-oriented, simplified neuropsychological follow-up of early-treated children with CH should not systematically include the frequent repetition of time-consuming and expensive psychometric tests because individual IQ scores are in the normal range of tests in almost all CH children and can be differentiated from those of normal controls only on a population-statistic basis. Selected tests of motor proficiency are indicated at 3 and 5 years of age to detect those defects in motor skills that appear to be more specifically affected in CH children. Language performances are at particular risk in CH children, and should be always checked at 3 and 5 years of age. Children with even mild language disorders or delayed language achievements should be regularly reevaluated at 6-month intervals and, if no spontaneous improvement is observed, they should receive specific rehabilitation treatment. No further motor and language evaluation is warranted in CH children with normal tests at age 5 years.

School attainments in children with congenital hypothyroidism detected by neonatal screening and treated early in life.

OBJECTIVE: Evaluation of school attainments in children with congenital hypothyroidism (CH) detected by neonatal screening and treated early in life. PATIENTS AND METHODS: Text comprehension, mathematics, reading, writing and verbal and spatial memory, as indices of school learning, were evaluated in nineteen 5- to 10-year-old children with CH attending nursery or elementary school. l-Thyroxine substitution (starting dose 8-10 microg/kg body weight per day) was initiated at a mean age of 30+/-10 days of life. The control group included 298 unaffected children matched with the CH children for age and school grade. Thirty per cent of controls were classmates of CH children. Intelligence quotients (IQ), language performances and motor development were evaluated in CH children at age 5 years, and were related to their school attainments. School performances of CH children were also compared with their neonatal serum thyroxine (T4) concentration, and with the social-cultural level of the family. RESULTS: Four out of 19 (21%) children with CH, 3 in the nursery and 1 in the elementary school, displayed a generalized learning disorder. Symbol copy, geometric copy, phrase repetition, dictation writing and spontaneous writing were particularly defective in nursery school CH children, while orthographic error recognition was defective in elementary school CH children. School learning disorders in CH children were significantly correlated with a borderline-low IQ, poor language performances and a low social-cultural level of the family, but not with motor skills or neonatal T4 concentration. CONCLUSION: School attainments of early treated CH children were within the normal range in most affected cases. However, about 20% of CH children, most of them attending nursery school, showed a generalized learning disorder. Low IQ scores and poor language performances at age 5 years were associated with defective learning, mainly in CH children living in a poor social-cultural environment. In this subset of CH children, prompt initiation of speech and psychomotor rehabilitation therapy is recommended in order to prevent subsequent school learning disorders.

Adolescents with borderline intellectual functioning: psychopathological risk.

This paper presents a qualitative analysis of cognitive and emotional functioning in intellectually borderline adolescents (IQ ranging from 71 to 84) and the consequences for personality and social development. Psychopathological risk, particularly in terms of mood disorders, conduct disorders, and intellectual deterioration, is analyzed, with the distinction made between "excited" and "inhibited" forms. Conceptualizations intellectually borderline adolescents have of their own mental functioning are described in light of the notion of cognitive self--the ability to understand and control internal and external reality. The implications for psychotherapy and rehabilitation are discussed.

[Early treated congenital hypothyroidism. Evaluation of school learning]. / Ipotiroidismo congenito precocemente trattato. Valutazione dell'apprendimento scolastico.

BACKGROUND: The aim of this paper was to evaluate school learning in early treated CH children in order to investigate whether and how this pathology influences school performance. METHODS: Using a sample of 50 early treated CH children who have received regular follow-up at our Institute, 20 subjects attending primary (grade) school or the final year of nursery school for assessment of school learning have been selected. Results were compared with a class/grade matched control group. Evaluations of cognitive, motor and language development, T4 level determined at birth, thyroid disorder and socio-cultural level of the family background were examined in relation to the school performance of each child. RESULTS: The evaluations showed that out of 20 CH children, 5 (25%) presented generalized learning disorders. This percentage is higher than in the normal population (3.4%). When learning disorder findings were correlated with data pertaining to motor, speech and cognitive development, socio-cultural level and thyroid disorder, it was found that children with generalized learning difficulties presented more severe motor and speech disorders, a lower intelligence quotient and a lower socio-cultural background than children achieving higher scores in school tests. CONCLUSIONS: The conclusion is drawn that early treated CH children of same age have more learning difficulties during nursery school, while they have normal learning performances during primary school.

Paroxetine in depressed adolescents with intellectual disability: an open label study.

The aim of this study was to evaluate the efficacy and side-effects of paroxetine treatment in adolescents with mild intellectual disability and major depressive disorder (MDD). Seven adolescents (14.7-18.4 years of age) were treated with paroxetine (dosage 20-40 mg day-1). Clinical changes were assessed at the beginning of the pharmacological treatment and after 9 weeks utilizing the DSM-IV diagnostic criteria and the Montgomery-Asberg Depression rating Scale (MADRS). Four out of the seven subjects did not fulfil the DSM-IV diagnostic criteria after the 9-week treatment. The mean decrease in the total score on the MADRS was significant (41%). Some items of the MADRS showed significant improvement: inner tension (66%); lassitude (55%); apparent sadness (53%); inability to feel (44%); and reported sadness (43%). Three subjects showed sedation, two subjects gastrointestinal complaints and one subject insomnia; all these symptoms were transitory and not severe. No behavioural activation was evident. This preliminary, uncontrolled study of a few cases suggests that adolescents with intellectual disability and MDD may respond to paroxetine, and that adverse side-effects are mild.

Impulsive-reflective cognitive style, metacognition, and emotion in adolescence.

The study investigated the relationship between reflective or impulsive cognitive style, metacognitive functioning, and depression in young adolescents. Metacognitive functioning (metacognitive knowledge about reading and memory, monitoring of text comprehension) and self-reported depressive feelings were analyzed in a group of subjects who showed a Reflective or Impulsive cognitive style. The sample consisted of 56 junior high-school students (Grades 6, 7, and 8) selected from a larger original group of 61 subjects. We excluded from the original group those with an IQ below 75 on both the Verbal and Performance subscales on the short form of the WISC-R, those reported by teachers to have a severe learning disability, and those that did not complete the test battery due to long absences from school. The reflective-impulsive cognitive style was identified with the Matching Familiar Figures Test-20. Using the median of the distribution for both Latency (17 sec. per item) and Errors (9 errors) on this task, the sample was divided in four partially overlapping subgroups: 16 with Impulsive cognitive style (Latency below the median, Errors above the median), 13 with Reflective cognitive style (Latency above the median, Error below the median), 4 fast and accurate (both scores below the median), and 11 slow and inaccurate (both scores above the median). Twelve subjects with one or both scores coinciding with the critical value (median) were excluded. Analysis showed that subjects with Impulsive cognitive style had significantly lower scores than those with Reflective cognitive style in monitoring of comprehension of text. No differences were found on monitoring by eighth graders, irrespective of cognitive style. No differences between the two groups were found in metacognitive knowledge. Subjects with Impulsive cognitive style had significantly higher scores than subjects with Reflective cognitive style on a self-rating scale for childhood depression, the Children's Depression Inventory. The implications of these data are discussed.

Neuropsychological development in a child with early-treated congenital hypothyroidism as compared with her unaffected identical twin.

OBJECTIVE: Neonatal screening for congenital hypothyroidism (CH) prevents the serious neuropsychological features of CH, but the question remains whether intelligence and motor skills of CH children treated early are completely normal. DESIGN: In this report we describe the rare case of two genetically identical twins, only one of whom was affected by CH due to thyroid agenesis. L-Thyroxine (9 microg/kg body weight/day) therapy was initiated at 27 days of age and was adequate throughout the follow-up. METHODS: Neuropsychological evaluation was performed on the twins in parallel from 3 months to 8 years of age. RESULTS: The CH twin (NB) did not show major neuromotor impairments but, compared with the unaffected twin (EB), she had a slight delay in postural/motor achievements and in language development that completely disappeared at 8 years of age. On standardised tests of intelligence, NB was indistinguishable from control children but, compared with her twin, she had lower IQ scores in most testing occasions up to 7 years of age (NB = 108 vs EB = 115). School achievements of NB did not significantly differ from those of her classmates but, compared with her twin, she scored worse in writing, mechanical reading, verbal memory, and possibly in arithmetic. CONCLUSIONS: Because the twins were genetically and phenotypically identical, were raised in the same environment, and received a similar education, it is concluded that hypothyroidism in utero and in the first neonatal month was responsible for the lower neuropsychological achievements of the CH twin. While foetal hypothyroidism is at present unavoidable, earlier diagnosis and initiation of treatment in neonates with CH are important and highly recommended.

[Missed diagnosis: a case of congenital hypothyroidism treated after three years]. / Una diagnosi mancata: un caso di ipotiroidismo congenito trattato a 3 anni.

Congenital hypothyroidism (CH) is the most common cause of preventable mental retardation. Thyroid hormone deficiency in utero and in the first neonatal months is responsible for permanent damage. While foetal hypothyroidism is at present unavoidable, earlier diagnosis and initiation of treatment in neonates with CH is important and highly recommended. At the moment, the Italian screening program for CH allows diagnosis and treatment within the first month of life. In Italy, screening programs became obligatory only a short time ago. In some regions, they started a few years ago, whereas in others they have been carried out only in an irregular way and only a part of the population has been investigated. Therefore CH was diagnosed just on the basis of clinical signs, with a consequent delay in the initiation of substitutive therapy. We describe the case of a little girl with CH diagnosed when she was three years old. We report the results of this case follow-up study and we describe the features of her neuropsychological development to point out her improvement and permanent disorders. The little girl was clearly hypothyroid with delayed achievement at three, but with pharmacological treatment she showed a dramatic amelioration in growth, language, motor skills and cognitive performances.

[Congenital hypothyroidism. Comparison of neuropsychological development of monozygotic twins]. / Ipotiroidismo congenito. Confronto dello sviluppo neuropsichico di due gemelle monozigoti.

Early treated congenital hypothyroidism (CH) allows a normal neuropsychological development in many cases, but sometimes light neuromotor, linguistic, behavioural disturbances are described. In this work we compare two 9 year old twins to study the direct influence of CH in the neuropsychological development, eliminating variables linked to environment and the genetic aspects; one of the twins is affected by early treated congenital hypothyroidism, the other doesn't show any somatic, motor, linguistic, cognitive or behaviour affection. Our intention is to value the influence of CH in the neuropsychological development eliminating the variables linked to environment and to the genetic aspects. From this study emerges that both the somatic and neuropsychological development of the two twins are globally identical still, slight differences could possibly be pointed out during the evaluations, in the their neuropsychological performances. The psychomotor development of the hypothyroid twin resulted to be normal, but slower than the normal twin in any time. In the light of these results we can hypothesize that the differences in the global development are linked to the presence of congenital hypothyroidism although early treated in one of them, because the other variables linked to the genetic, environmental and socio-cultural factors are of no relevance whatsoever in this case. The two sisters are actually genetically and phenotypically identical, and both subject to the same familiar dynamics and receive the same education.

Psychotropic medication in adolescence: psychodynamic and clinical considerations.

This study discusses the psychodynamic implications of psychopharmacological treatment in adolescence. A series of clinical situations are presented to illustrate how psychotropic medication may modify the adolescent's relationship with the mental and bodily self, the second separation-individuation process within the family, and the therapeutic relationship between adolescent and psychiatrist. Methodological issues are discussed for fostering a positive treatment outcome. The study suggests that pharmacotherapy should follow a psychopathological evaluation of adolescents and their families.

[Antidepressive drugs in children and adolescents]. / I farmaci antidepressivi in età evolutiva.

The aim of the review is to define the specificity of the response to pharmacotherapy in child and adolescent mood disorders. Methodological issues, nosographic definitions and developmental modifications in neurotransmitters and neuroreceptors are discussed; these three factors can account for the apparent inefficacy of antidepressive pharmacotherapy in children and adolescents. Specific indications, dosage and administration, side effects and the clinical examinations to prevent them, are analyzed for the following antidepressants: tricyclics, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, lithium, anticonvulsants, trazadone, benzamides.

[Cognitive and affective characteristics of children with malformation syndrome]. / Considerazioni sulle caratteristiche cognitive e affettive del bambino con sindrome malformativa.

The aim of this paper is to study the psychological and relational aspects in children suffering from specific malformative syndrome and precisely Down s., Sotos s., X-Fragile s. and Williams s. Indeed literature provides much data related to the phenotype, to the organic-biological characteristics, but little or nothing is known about the affective structure, the episodes and to the particular dynamics that emerge in he relation between the parents and the malformed child. A protocol was applied to our sample group (16 subjects). This protocol includes laboratory and instrumental tests (chromosome test, neurometabolic screening, EEG, CT or cranial MRI, cardiac and abdominal ultrasonography, ear and eye test) aspects. This evaluation is carried out through the proposal of standardized situations (psychometric tests) and a use of a freer observational setting. This permits us to understand how the child perceives himself the awareness and the image he has of himself and how able he is to integrate his illness experiences and his way of relating with the environment. The data of our observations are thus used to compile a grill for the structural diagnosis of the personality. Besides, this evaluation is flanked by the observation of the family in order to explore the psychological image that parents have of their child, his character, his good points, his bad points, his similarities, how he relates to them, any educational problems and the emotional reaction that the communication of the diagnosis has raised in them. The videotaped observations are subsequently evaluated through the application of a grill for the study of the mother-child relationship. The results obtained from the psychological research underline a reasonable heterogeneity both of the intellectual level and of the metapsychological profile. Twelve subjects were mentally retarded (5 with mild mental retardation, 7 with moderate mental retardation); the remaining 4 had a normal cognitive development (3 with Sotos s., 1 with Williams s.). Psychological disturbances are present and thus divided: light disturbances (affective immaturity, neurotic-depressive organisation) in 11 subjects. Average disturbances (dysharmonious structure, and borderline personality) in 4 subjects; severe disturbances (psychosis) in 1 subject. Besides, above all in the group of subjects with X-Fragile s. and Down s., the tendency to assume behaviour of a regressive type, also postural, emerges. Among the 4 groups it is frequent to resort to defence mechanisms of hypomaniac type, accompanied by the denial of the patient's "sick parts". Another common characteristic concerns the quality of imaginary life which is shown to be repetitive and stereotype in content. Indeed these children's play activity characterized by a limited capacity of symbolization. Instead, when the symbolic process is more developed, contents concerning a deteriorated and destructive image of the Self emerges. Through the evaluation of family dynamics what is more noticeable is that the parent-malformed child interaction appears to be quite nonstimulating and noninvolving or incoherent, lacking in harmony and empathy towards the child's inner world. Indeed we can notice a lack of both verbal and extraverbal exchange of communication and brief interactive sequences which do not usually take into account the child's proposals and an affective tonality of depressive and nonaffective type. Therefore it may be concluded a certain smoothness in the clinical expression of the syndromes considered, both as far as the cognitive deficit entity and the psychic problems are concerned. Referring to the interactive dynamics between parents and children with dismorphic syndrom it seems that the child's pathology becomes the organizational summit of the above-mentioned relational dynamics among most of the patients examined...

Mild iodine deficiency during fetal/neonatal life and neuropsychological impairment in Tuscany.

The neuropsychological performance of schoolchildren living in areas with present and past iodine deficiency in Tuscany was investigated. Children were submitted to: a) block design subtest of the Wechsler Intelligence Scale for Children-Revised (WISC-R) and a modified version of the WISC-R coding subtest which evaluate the general neuropsychological and cognitive performance, independently from familial cultural background; b) simple reaction time (RT) session which evaluates the efficiency of the whole information processing and nervous transmission mechanisms. Neuropsychological performance was tested in 107 children living in Borgo a Mozzano, an area of mild iodine deficiency (IDA) with a median urinary iodine excretion (UIE) of 64 micrograms/L (mean +/- SD: 80.1 +/- 57). One hundred and six sex and age-matched children living in Marina di Pisa, an iodine sufficient coastal village of Tuscany (ISA) with a median UIE of 142 micrograms/L (mean +/- SD: 173 +/- 95) were used as controls. Tests for neuropsychological performance were performed in 57 children living in the village of Vagli, an area with past iodine deficiency (PIDA): 30 children born before iodine prophylaxis (Group 1), when the median UIE was 32 micrograms/L (mean +/- SD: 47 +/- 22), 27 children born after the institution of iodine prophylaxis (Group 2), when the median UIE was 109 micrograms/L (mean +/- SD: 130 +/- 73). Sex and age-matched ISA-children were used as controls for each group. RTs were significantly delayed (p < 0.05) in IDA than in ISA children, while block design and coding subtests showed no significant difference.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cognitive functioning in adolescent depression]. / Funzionamento cognitivo nella depressione adolescenziale.

In childhood and adolescent depression, the interaction between cognitive and emotional disorders is particularly evident: intellectual dysfunctioning often accompanies and integrates the clinical symptomatology. The studies on cognitive functioning have focused their attention on basic cognitive abilities; relatively fewer studies have analyzed other dimensions, such as logical reasoning. Furthermore, most studies have compared depressed patients to normal controls; this methodology tends to obscure the specific effect depression may have on cognitive functioning. The aim of our study is to analyze whether specific patterns of cognitive organization underlie adolescent depressive disorders. Cognitive functioning was assessed both with psychometric tests (WISC-R) and Piagetian logical reasoning tasks (Longeot Logical Thought Scale). The performance of depressed adolescents was compared to that of neurotic patients without depressive symptomatology. To evaluate the course of cognitive organization in relation to depressive symptomatology, some of our patients were studied in follow-up. Thirty-eight adolescents admitted to our Institute participated in the study. The experimental group consisted of 24 depressed adolescents; sixteen subjects were classified as neurotic depressives, eight were diagnosed as depressive personality disorder. The control group consisted of 14 subjects diagnosed as neurotic without depression. At the WISC-R the performance of depressed and controls adolescents were compared in: Full Scale IQ, Verbal and Performance IQ, Verbal-Performance discrepancy; single subtest scores; Bannatyne's four categories. Statistical analyses did not yield any significant differences between groups for any of the WISC-R measures. At the Logical Thought Scale Full Scale scores of the experimental group were significantly lower than controls'.(ABSTRACT TRUNCATED AT 250 WORDS)

[Neuropsychological follow-up in congenital hypothyroidism]. / Il follow-up neuropsichico dell'ipotiroidismo congenito.

Thyroid hormones play a key role in a number of critical neuromaturational processes, including neurogenesis, neuronal migration, synaptogenesis and myelination. Even in case of early treated CH children we cannot exclude the consequences of thyroid hormones deficiency in the critical pre and post-natal period. So, it is still useful to follow-up the neuropsychological development of CH children. IRCCS "Stella Maris" has been involved in research in this subject for several years with the collaboration the Institute of Endocrinology and of the Institute of Pediatrics (University of Pisa). According to our experience and to the results literature we propose to continue the follow-up studies with a simple, unique methodology that could be diffused to every screening center in Italy.

[Neuropsychological development in children with focal brain injury]. / Neuropsicologia delle encefalopatie focali non evolutive dell'infanzia.

The study of children with focal brain injury has important implications from a clinical and theoretical perspective. Clinical data on children with congenital or early acquired lesions indicates that the cognitive sequelae are different from those resulting from similar damage sustained in adulthood. These differences depend in part on the differential effect that damage has on ongoing developmental process and in part on the different recovery capacity of the Central Nervous System of the child. From a theoretical perspective, focal lesion data is important for analyzing the issues of early neuropsychological functioning (especially in terms of early hemispheric specialization) and of plasticity and recovery of function of the CNS. This review analyzes the possible causes of this heterogeneity, that seems in part dependent on the interindividual variability of early neuropsychological organization and in part related to methodological factors such subject inclusion criteria and nature of neuropsychological measures. The review also discusses the role during development of the principal inter and intrahemispheric recovery mechanisms (special attention is given to intrahemispheric mechanisms which have been considered in the past as less determinant with respect to interhemispheric mechanisms). Furthermore, the role of lesion side as a prognostic parameter is discussed, specifically in terms of the evidence of a differential recovery capacity of left hemisphere with respect to the right. Various hypotheses have been put forward as possible interpretations of these data (maturational gradient, different neuropsychological organization of the two hemispheres), yet evidence is still controversial. If one considers the prognostic parameter--age of lesion onset--recent evidence does not confirm the hypothesis that the earlier the lesion, the greatest the recovery of function. Rather, it seems that relating age of lesion onset to other parameters, such as lesion side or size, has a greater and more reliable prognostic value. Another aim of the review is to analyze the effect that focal damage has on the dynamics of development. The fact that the effects of early damage might manifest themselves later in development, when the function in question is reaching a higher level of organization, underlines the importance of a longitudinal approach that assesses the developmental patterns of specific functions. Another issue discussed is the role of lesion side in determining specific cognitive impairment.(ABSTRACT TRUNCATED AT 400 WORDS)