Atypical neuroleptics in the treatment of early onset schizophrenia

The most complex problems in the use of neuroleptics for schizophrenia are the frequency of nonresponders, the severity of extrapyramidal side effects and tardive dyskinesia, especially in chronic treatment, the persistence of treatment-refractory symptoms, such as negative symptoms. All these problems are more frequent and severe in children and adolescents with early-onset schizophrenia. The classic neuroleptics act on the postsynaptic dopaminergic receptors, especially the D2 receptors, situated in various areas of the Central Nervous System. More recently, the so-called dopaminergic hypothesis of schizophrenia has been criticized and other neurotransmitter systems have been involved, particularly serotonin. The more recently synthesized neuroleptics, with combined action on dopamine and serotonin receptors, have been called atypical neuroleptics; the atypical neuroleptics currently used in clinical practice are clozapine and risperidone. These anti-psychotic drugs are known to be clinically more effective, especially on negative symptoms, have a lower incidence of extrapyramidal side effects, produce significant improvements in some refractory patients. A large number of the studies concern adults; the studies on young populations are much fewer and less rigorous. The aim of this critical review is to describe clinical use of atypical neuroleptics clozapine and risperidone in children and adolescents with early-onset schizophrenia.

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.

[Psychopathology of chronic diseases in children and adolescents. Congenital cardiopathies]

A most significant life event in the first years of life is a disease, especially if it is of early onset, severe, life threatening, with an uncertain prognosis, and with the necessity of frequent diagnostic and therapeutic interventions. Psychological implications are a significant parts of the illness, not a marginal component; they can affect prognosis and outcome. The authors describe the different psychological implications of an experience of chronic disease in children and adolescents and their families (parents and siblings). Congenital disease (for example congenital heart failure) has a peculiar significance: since it is diagnosed early, it influences mother-infant interactions from the beginning, in a crucial moment of the infant's psychological development; diagnostic and therapeutical interventions are early and frequent; congenital defects determine the strongest guilt feelings in the parents. Some specific psychological aspects can be described: the weakening of the Bodily self, the inhibition of thinking, the theories the child and the family formulates on the disease, the death feelings. Emotional features in children and adolescents with congenital cardiopathy are described: inhibition of emotions, marked anxiety, depressive reaction, with loneliness, low self-esteem and inadequacy, emotional lability, with oscillation between omnipotence and inadequacy; impulsiveness; weakness of self identity; especially in bodily Self. Some psychopathological aspects in children and adolescents with heart transplant and their families are also described. Intellectual level of patients with congenital heart disease is in the normal range, although significantly lower than normal controls. There is a positive correlation between worsening of intellectual functioning and clinical severity of the heart disease; this clinical severity is related both to restrictions in normal daily life activities, and blood oxygen saturation. It is hard to tease apart the role of early physical limitations versus the role of chronic hypoxia, in affecting intellectual development. Some methodological considerations are described, relating to the role of the physician, the psychological support to the children and adolescents and their families, the problem of the shared-cares between main centres and local hospitals, where primary health-care team operates.

[Cognitive organization in the motor pathology]

The aim of this paper is to describe intellectual performances in children and adolescents with cerebral palsy and with Duchenne muscular dystrophy. Three different forms of cognitive analysis are proposed: a quantitative analysis with the Wechsler scales; a qualitative analysis of reasoning in different levels of development, in a piagetian framework; an analysis of learning processes and school performances.

[Antidepressive drugs in children and adolescents]

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 functioning in adolescent depression]

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)

[Considerations of psychopathology in mental retardation]

There is a high incidence of psychiatric disorders in mentally retarded subjects: one third to two thirds of mentally retarded subjects exhibit psychiatric disorders, a proportion which is much higher than that found in subjects with normal intelligence. The issue is to clarify the nature of the relationship between cognitive and psychiatric disorders (generally analyzed in a dichotomous approach). A way to analyze the phenomenon is to consider a psychopathological approach, which can define the underlying mechanisms responsible for this incidence. The aim of this paper is to analyze the explicatory value of deficient cognitive development, as the main factor determining a specific personality organization. Direct and indirect effects of cognitive impairment on the development of personality disorders are described: the first, in terms of how cognitive deficit (i.e. severity, homogeneity in several cognitive domains, pattern of development) disorganizes personality; the second, in terms of impact that cognitive deficit could have on the child's relationship with the external world, especially with the mother. In order to illustrate these viewpoint, the paper discusses the role of cognitive functions in the development of personality. Specifically, the way the normal child processes his perceptual and motor experiences is analyzed, that is pursuit of new causal links in his knowledge seeking activity of mastering the world. The child's primitive relationship with the world is then aimed at learning, exploring and searching for new causal links. In the light of these considerations, what the child with Mental Retardation experiences is discussed. A series of psychopathological mechanisms in Mental Retardation are postulated. The organization of the Mentally Retarded child's internal world is described, as reflected in Rorschach protocols, which outline a chaotic and primitive internal world, but with a specificity of its own. Finally, the paper discusses the hampering effect that cognitive impairment has on the quality of the relationship with the caregiver. This effect can be seen in terms of the child's interactive capacity and, at the same time, in terms of the emotional impact on the caregiver that derives from interacting with a mentally retarded child. From the above considerations a global approach to the psychopathology of cognitive and affective aspects of Mental Retardation seems warranted. Both aspects acquire a specific significance when seen in light of a specific personality organization. Defining the characteristic of this specific organization seems to be the key to a more comprehensive approach to psychiatric disorders of Mental Retardation.

[Neuropsychological development in children with focal brain injury]

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)

[Totally implantable systems for long-term chemotherapeutic treatment]

The authors report their own experience with completely implantable systems for the long-term chemotherapeutic treatment, compared with a review of modern literature. The experience even if low demonstrates a good methodology in reducing the number of complications associated with the use of percutaneous catheters.

Sympathetic activation and muscle spindle

An adrenergic central control on fusimotor activity has been demonstrated since 1954. At peripheral level, a muscle spindle autonomic innervation is not clearly demonstrated in man, but several data seem to suggest a direct autonomic innervation of muscle spindle in cats and rabbits. Data obtained in patients with peripheral adrenergic denervation (Idiopathic Orthostatic Hypotension) suggest a prevalent control of central adrenergic pathways on muscle spindle sensitivity.

[Dermatopathies in those engaged in domestic work and related risks]

The AA., considering the skin diseases in the subjects employed in the domestic work and similar activity, in a more ample table of general medicine, produced a contribution to the study of etiopathogenetic and nosographic problems. They have estimated the role of the individual predisposition and the etiopathogenetic, chemical, physical, biotic, complex factors. They pointed out the various nosographic, skin expressions in range of contact irritant dermatitis, of contact allergic eczema, skin abrasion, of dermatitis by physical agents, of urticaria, of dermal alterations by infectious and parasitic agents and of various dermal, morbid expressions by chemical agents. They reported the direct experience of personal casuistry and called attention on multiple aspects of preventive medicine.