Prenatal ultrasound screening: false positive soft markers may alter maternal representations and mother-infant interaction.

BACKGROUND: In up to 5% of pregnancies, ultrasound screening detects a "soft marker" (SM) that places the foetus at risk for a severe abnormality. In most cases, prenatal diagnostic work-up rules out a severe defect. We aimed to study the effects of false positive SM on maternal emotional status, maternal representations of the infant, and mother-infant interaction. METHODOLOGY AND PRINCIPAL FINDINGS: Utilizing an extreme-case prospective case control design, we selected from a group of 244 women undergoing ultrasound, 19 pregnant women whose foetus had a positive SM screening and a reassuring diagnostic work up, and 19 controls without SM matched for age and education. In the third trimester of pregnancy, within one week after delivery, and 2 months postpartum, we assessed anxiety, depression, and maternal representations. Mother-infant interactions were videotaped during feeding within one week after delivery and again at 2 months postpartum and coded blindly using the Coding Interactive Behavior (CIB) scales. Anxiety and depression scores were significantly higher at all assessment points in the SM group. Maternal representations were also different between SM and control groups at all study time. Perturbations to early mother-infant interactions were observed in the SM group. These dyads showed greater dysregulation, lower maternal sensitivity, higher maternal intrusive behaviour and higher infant avoidance. Multivariate analysis showed that maternal representation and depression at third trimester predicted mother-infant interaction. CONCLUSION: False positive ultrasound screenings for SM are not benign and negatively affect the developing maternal-infant attachment. Medical efforts should be directed to minimize as much as possible such false diagnoses, and to limit their psychological adverse consequences.

Depression during pregnancy: is the developmental impact earlier in boys? A prospective case-control study.

OBJECTIVE: Animal studies have shown sex differences in the impact of prenatal maternal stress on the offspring. The aim of this prospective case-control study was to assess the effect of prenatal depression on newborn and 1-year-old infant characteristics as related to gender, controlling for confounding variables. METHOD: We screened 205 pregnant women from April 2004 to November 2006 for depressive symptoms. Inclusion in the prenatal depression group (n = 34) was based on meeting DSM-IV criteria for major depressive episode. We excluded postnatal depression from the control group (n = 79) by routine screening at 2 and 6 months. Newborn and 1-year-old infant characteristics were evaluated with the Neonatal Behavioral Assessment Scale (NBAS) and the Infant-Toddler Social and Emotional Assessment, respectively. RESULTS: Despite our use of numerous exclusion criteria (eg, at-risk pregnancy, preterm delivery), prenatal depression highly correlated with anxiety and stress scores. Male newborns of mothers with prenatal depression had lower scores than controls on the motor skills and regulation of states NBAS clusters (P = .03 and P = .026, respectively). At 1 year, infants of prenatally depressed mothers presented higher scores on generalized anxiety (P = .002), particularly in males (P = .009); activity/impulsivity (P = .042); and sleep problems (P = .023) than controls. CONCLUSIONS: As in animal studies, depression during pregnancy may affect infant development in a way that is related to gender. Early gender differences observed to be associated with depression, stress, and anxiety during pregnancy may be a key to understanding the higher prevalence in males of child psychiatric disorders.

Phenomenology, psychopathology, and short-term therapeutic outcome of 102 infants aged 0 to 12 months consecutively referred to a community-based 0 to 3 mental health clinic.

Infants ages 0 to 1 year consecutively referred for psychiatric treatment during the year 2005 were followed, and variables associated with diagnosis and short-term outcome were assessed. Infants were evaluated using the Psychiatric Infant Navigator Chart and Evaluation that includes nosological diagnoses [Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, (DC 0-3), Zero to Three, 1994] as well as risk and protective factors, treatment procedure, and outcomes. Seventy-six percent of the infants had an Axis I diagnosis, with anxiety disorders and a mixed disorder of emotional expressiveness being the most frequent. Twenty-five percent had an Axis II diagnosis. Multiple correspondence analyses showed that two dimensions corresponding grossly to DC 0-3 Axes I and II emerged. They emphasized three clinical profiles characterized by (a) good infant functioning, parent's awareness of their own difficulties, and a good outcome; (b) moderate child symptoms, overinvolved relating, and a good/intermediate outcome; (c) severe child symptoms, underinvolved relating, and a less favorable short-term outcome, signaling the risk for developmental disorders. Among the associated risk factors were cumulative parental stress, maternal psychopathology, and family dysfunction. Clinical implications of these findings indicated that infants under the age of 1 year who are referred for mental health evaluation and intervention are a heterogeneous group in terms of both severity and prognosis. Clinicians should differentiate subgroups of young children to detect those infants at risk for persistent psychopathology.

Individual cognitive training of reading disability improves word identification and sentence comprehension in adults with mild mental retardation.

Reading therapy has been shown to be effective in treating reading disabilities (RD) in dyslexic children, but little is known of its use in subjects with mild mental retardation (MR). Twenty adult volunteers, with both RD and mild MR, underwent 60 consecutive weeks in a cognitive remediation program, and were compared with 32 untreated control subjects. The experimental group showed a significant improvement in word identification, as measured by oral production (p=0.0004) or silent reading (p=0.023), and sentence comprehension (p=0.0002). Adults with MR appear to benefit from new approaches in the field of RD.

Treatment refusal in adolescents with severe chronic illness and borderline personality disorder.

INTRODUCTION: The aim of this study is to address the complex psychopathologic factors involved in treatment refusal observed in adolescents suffering from a severe chronic illness. METHOD: We report on five chronically ill adolescents (2 diabetes mellitus, 1 maple syrup urine disease, 1 bird fancier's lung, 1 HIV infection) who were consecutively admitted to an inpatient psychiatric service as a result of a life-threatening refusal to comply with outpatient management of their medical illness. Case material is analyzed and discussed in the context of a review of the literature. RESULTS: Each subject was further characterized by: (1) the diagnosis of Borderline Personality Disorder; (2) severe family dysfunction (e.g. abuse, neglect and abandonment); and (3) frequent and prolonged pediatric hospitalizations. During their psychiatric hospitalization, the patients' initial opposition to treatment shifted to mentalization and psychological questioning. From a psychodynamic perspective (attachment theory), we hypothesized that this behavior represented an attack on parental figures as embodied in the suicidal comportment. CONCLUSION: Case material is presented to underline the possibility of co-occurring Borderline Personality Disorder when treating youths suffering from chronic illness and refusing treatment. Awareness of Borderline Personality Disorder may help pediatric staff when dealing with this refusal.

Cotard's syndrome in adolescents and young adults: a possible onset of bipolar disorder requiring a mood stabilizer?

This paper reviews all reports of Cotard's syndrome (délire de négation) in adolescents and young adults and summarizes four consecutive cases seen at our institution during the past 10 years. Cotard's syndrome occurs infrequently in young people (19 cases have been reported so far, including a 15-year-old boy who died at hospital) but appears to be a severe syndrome in adolescents of both genders. Ten patients received electroconvulsive therapy (ECT) despite their young age. Among the 14 cases reported with at least a 2-year follow-up, 13 patients (93%; 11 female) exhibited a bipolar outcome. The use of mood stabilizers should be considered in this rare, but potentially severe, condition.

Cognitive control in childhood-onset obsessive-compulsive disorder: a functional MRI study.

BACKGROUND: Failure to resist chronic obsessive-compulsive symptoms may denote an altered state of cognitive control. We searched for the cerebral regions engaged in this dysfunction. METHOD: Differences in brain regional activity were examined by event-related functional magnetic regional imaging (fMRI) in a group of adolescents or young adults (n = 12) with childhood-onset obsessive-compulsive disorder (OCD), relative to healthy subjects. Subjects performed a conflict task involving the presentation of two consecutive and possibly conflicting prime and target numbers. Patients' image dataset was further analysed according to resistance or non-resistance to symptoms during the scans. RESULTS: Using volume correction based on a priori hypotheses, an exploratory analysis revealed that, within the prime-target repetition condition, the OCD subjects activated more than healthy subjects a subregion of the anterior cingulate gyrus and the left parietal lobe. Furthermore, compared with 'resistant' patients, the 'non-resistant' OCD subjects activated a bilateral network including the precuneus, pulvinar and paracentral lobules. CONCLUSIONS: Higher regional activations suggest an abnormal amplification process in OCD subjects during the discrimination of repetitive visual stimuli. The regional distribution of functional changes may vary with the patients' ability to resist obsessions.

Clinical relevance of chronic catatonic schizophrenia in children and adolescents: evidence from a prospective naturalistic study.

The paper examines the phenomenology, diagnosis, and course of catatonia in children and adolescents. From 1993 to 2003, 21 boys and 9 girls, aged 12 to 18 years, were admitted for a catatonic syndrome (0.6% of the total inpatient population). Phenomenology and associated diagnoses were similar to those reported in the adult literature but relative frequency differed, with schizophrenia being the most frequent diagnosis. Comparison of patients with schizophrenia (n=17) to those with other diagnoses (n=13) showed that the two groups differed in terms of sex ratio, type of onset and phenomenology of catatonic symptoms, duration of hospitalization, and severity at discharge. Using discriminant function analysis, the combination of three clinical variables--male gender, duration of catatonic episode, and severity at discharge--correctly classified 100% of cases in the schizophrenia group. Catatonia is an infrequent but severe condition in young people, and is usually associated with schizophrenia. There is a need for research in the field of catatonic schizophrenia in adolescents as it appears to be a clinically relevant but understudied subgroup.

Specific genetic disorders and autism: clinical contribution towards their identification.

Autism is a heterogeneous disorder that can reveal a specific genetic disease. This paper describes several genetic diseases consistently associated with autism (fragile X, tuberous sclerosis, Angelman syndrome, duplication of 15q11-q13, Down syndrome, San Filippo syndrome, MECP2 related disorders, phenylketonuria, Smith-Magenis syndrome, 22q13 deletion, adenylosuccinate lyase deficiency, Cohen syndrome, and Smith-Lemli-Opitz syndrome) and proposes a consensual and economic diagnostic strategy to help practitioners to identify them. A rigorous initial clinical screening is presented to avoid unnecessary laboratory and imaging studies. Regarding psychiatric nosography, the concept of "syndromal autism"--autism associated with other clinical signs should be promoted because it may help to distinguish patients who warrant a multidisciplinary approach and further investigation.

Treatment of a suicide attempt through psychodynamic therapy in a 17-year-old boy with depression: a case study.

We report the case of a 17-year-old boy hospitalized after a violent and dramatic suicide attempt and the interpretative therapy that helped him overcome his depression. His course appeared to be typical of the difficulties encountered by clinicians when in charge of a severely depressed teenager, and of the liability of therapeutic treatment as the patient failed to improve with two consecutive antidepressant trials, and with a first attempted treatment by psychodynamic therapy. The present report stresses that: (i) in some cases, prolonged hospitalization might be helpful in managing treatment of acute phases; (ii) every effort should be made to help a depressed adolescent who attempts suicide to verbalize his experiences and give them meaning, whatever the psychotherapeutic technique. In the case of a suicide attempt with a staged component, the psychodynamic approach appears to be an interesting option as it may help the patient understand his pathological behavior as if it were a dream.

Pharmacological treatment of adolescent major depression.

Antidepressant agents are widely prescribed for adolescents, although specific data regarding their efficacy in this age range are limited. The aims of the present article are to review research findings regarding the use of antidepressant drugs for adolescent depression and to discuss the main results in light of our clinical experience. Only 13 controlled trials on the use of antidepressant drugs for adolescent major depression are available in the literature. Six studies evaluated the efficacy of tricyclic antidepressants, yet they only included 196 adolescents altogether. Seven studies, including a total of 1,403 patients, evaluated the efficacy of three specific serotonin reuptake inhibitors: fluoxetine, paroxetine, and sertraline. Based on published data, serotonin reuptake inhibitors appear to be the first-line psychopharmacologic treatment for adolescent depression, as three compounds (fluoxetine, paroxetine, and sertraline) appeared to be effective in this indication. Conversely, all published studies failed to demonstrate that the tricyclic antidepressants were superior to placebo. Several questions remain open and are discussed: How should we use available scientific data in clinical practice? Are there nonspecific factors implicated in treatment response? Is there a serotonin hypothesis for juvenile depression? What are the priorities for future research?

Tardive dystonia induced by atypical neuroleptics: a case report with olanzapine.

We report the case of a 17-year-old-boy with schizophrenia who developed tardive dystonia after 9 months of treatment with olanzapine. This case and the relevant literature show that when neuroleptic treatment is indicated, switching to another atypical neuroleptic might be helpful for both tardive dystonia and schizophrenia. In such a case, clozapine appears to be the first-line therapeutic option.

Case study: effectiveness of plasma exchange in an adolescent with systemic lupus erythematosus and catatonia.

Catatonia is a rare but severe condition in adolescents that can be associated with both psychiatric and organic causes. The present report notes that systemic lupus erythematosus should be considered among possible causes of catatonia and shows that plasma exchange could be an efficient treatment option for such neuropsychiatric manifestations of systemic lupus erythematosus, to avoid the use of electroconvulsive therapy in young patients.

Drug treatment of conduct disorder in young people.

Although conduct disorder (CD) is the most common psychiatric disorder in youth from the community and encompasses one third to one half of all referrals to child and adolescent clinics, there is no licensed drug, to date, for treatment of CD, neither in Europe nor in the US. The aims of this paper are to review research data available on the use of medication for CD in young people and to identify future directions for research. We review 17 controlled studies and six open trials. Investigated compounds mainly belong to three classes of psychotropic drugs: mood stabilizers, neuroleptics and stimulants (six, five and six controlled studies, respectively). Lithium is the most documented treatment (3/4 positive studies). Conventional neuroleptics have been most commonly prescribed (3/3 positive studies), atypical neuroleptics appear promising (2/2 positive studies). Methylphenidate improves some CD symptoms, even in the absence of ADHD (6/6 positive studies). Sparse research has been conducted on response to antidepressants. The evidence for an effective role of pharmacotherapy in CD is still limited. Treatment should be multimodal and individualized to each patient's specific condition.

El aporte de la observación de las interacciones precoces en la comprensión de las primeras relaciones del niño con sus padres / The contribution of the observation of early interactions in understanding the child's early relationships with parents

A partir del marco conceptual que se esquematiza en una figura, el autor revisa nociones teóricas relacionadas con la interacción del niño prequeño (bebe) con sus acompañantes más cercanos (preferentemente, la madre). Se pone de relieve que estas interacciones tienen lugar en tres niveles: comportamental (a nivel de cuerpo, la voz y las palabras y la mirada); afectivo (en que se rescata la necesidad de una armonización suficiente entre ambos participantes de la relación) y de carácter imaginario, en el que distingue un subnivel consciente y otro inconsciente o fantasmático, más cercano a la formación psicoanalítica del autor. Se ilustra esta exposición con una viñeta clínica acerca de la vinculación de una madre con sus bebe y su propio padre, de la que se infiere la múltiple importancia e estas interacciones en el diagnóstico y las intervenciones terapeúticas pertinentes.

From the theorical framework shown in figure 1, the author makes a conceptual update on parent-child interactions, stressing early reationships with the mother. Three levels of theese interactions are marked down: behavioral (focused on body, voice and words and mutual glances); affective (where the need of a sufficient harmonization between partners is pointed out) and the imaginary one, splitted in a conscious plane and an unconscious or phantasmal other, akin to the autor's analytical trainning. A clinical vignitte illustrating the kind of attachement of some mother with his baby and her own father is portrayed, to ellicit the multiple interest of interactions in diagnostic and the therapeutic endeavors.