Snoring, sleep disturbance, and behaviour in 4-5 year olds

Parents of 996 children aged 4-5 years identified consecutively from the Oxford health visitor register were asked to complete a questionnaire about breathing disorders during sleep. A total of 782 (78.5%) was returned. Ninety five (12.1%) children were reported to snore on most nights. Habitual snoring was significantly associated with daytime sleepiness, restless sleep, and hyperactivity. The questionnaire responses were used to select two subgroups, one at high risk of a sleep and breathing disorder and a control group. These children (132 in total) were monitored at home with overnight video recording and oximetry, and had formal behavioural assessment using the Conners scale. Seven (7/66) children from the high risk group and none from the control group had obvious sleep disturbance consequent on snoring and upper airway obstruction. Thus our estimate of the prevalence of sleep and breathing disorders in this age group is 7/996 or 0.7%. The high risk group had significantly higher nocturnal movement, oxygen saturation dip rates, and overnight pulse rates than the controls. Maternal but not paternal smoking was associated with the high risk group. Parents and teachers thought those in the high risk group were more hyperactive and inattentive than the controls, but only their parents thought them more aggressive. Significant sleep and breathing disorders occur in about 0.7% of 4-5 year olds. Children whose parents report snoring and sleep disturbance have objective evidence of sleep disruption and show more behaviour problems than controls.

Melanin-concentrating hormone 1 receptor-deficient mice are lean, hyperactive, and hyperphagic and have altered metabolism

Melanin-concentrating hormone (MCH) is a cyclic 19-aa hypothalamic neuropeptide derived from a larger prohormone precursor of MCH (Pmch), which also encodes neuropeptide EI (NEI) and neuropeptide GE (NGE). Pmch-deficient (Pmch-/-) mice are lean, hypophagic, and have an increased metabolic rate. Transgenic mice overexpressing Pmch are hyperphagic and develop mild obesity. Consequently, MCH has been implicated in the regulation of energy homeostasis. The MCH 1 receptor (MCH1R) is one of two recently identified G protein-coupled receptors believed to be responsible for the actions of MCH. We evaluated the physiological role of MCH1R by generating MCH1R-deficient (Mch1r-/-) mice. Mch1r-/- mice have normal body weights, yet are lean and have reduced fat mass. Surprisingly, Mch1r-/- mice are hyperphagic when maintained on regular chow, and their leanness is a consequence of hyperactivity and altered metabolism. Consistent with the hyperactivity, Mch1r-/- mice are less susceptible to diet-induced obesity. Importantly, chronic central infusions of MCH induce hyperphagia and mild obesity in wild-type mice, but not in Mch1r-/- mice. We conclude that MCH1R is a physiologically relevant MCH receptor in mice that plays a role in energy homeostasis through multiple actions on locomotor activity, metabolism, appetite, and neuroendocrine function.

Dyskinesias following neural transplantation in Parkinson's disease

Severe dyskinesias during the 'off' phases (periods of increased Parkinson's disease (PD) disability) have been observed following intrastriatal transplantation of human embryonic mesencephalic tissue. Here we retrospectively analyzed 14 patients who were followed for up to 11 years after grafting, and found that dyskinesias (abnormal involuntary movements and postures) increased during postoperative off phases, but were generally of mild to moderate severity. Dyskinesia severity was not related to the magnitude of graft-derived dopaminergic re-innervation, as judged by (18)F-labeled 6-L-fluorodopa (FD) positron emission tomography (PET), indicating that off-phase dyskinesias probably did not result from excessive growth of grafted dopaminergic neurons.

Transgenic mice overexpressing glycogen synthase kinase 3beta: a putative model of hyperactivity and mania

Lithium is used as treatment for bipolar disorder with particular efficacy in the treatment of mania. Lithium inhibits glycogen synthase kinase 3beta (GSK-3beta) directly or indirectly via stimulation of the kinase Akt-1. We therefore investigated the possibility that transgenic mice overexpressing GSK-3beta could be of relevance to model bipolar disorder. Transgenic mice showed hypophagia, an increased general locomotor activity, and decreased habituation as assessed in an open field, an increased acoustic startle response, and again decreased habituation. The forced swim test revealed a reduced immobility in transgenic mice, but this is probably related to the hyperactivity of the animals. There were no differences in baseline and stress-induced increases of plasma adrenocorticotrophic hormone and corticosterone levels. Molecular analysis suggests compensatory mechanisms in the striatum of these transgenic mice for the overload of active GSK-3beta by dimming the endogenous GSK-3beta signaling pathway via upregulation of Akt-1 expression. Brain-derived neurotrophic factor protein levels were increased in the hippocampus of the transgenic mice. This suggests some kind of compensatory mechanism to the observed reduction in brain weight, which has been related previously to a reduced size of the somatodendritic compartment. Together, in mice overexpressing GSK-3beta, specific intracellular signaling pathways are affected, which is accompanied by altered plasticity processes and increased activity and reactivity, whereas habituation processes seem to be decreased. The behavioral observations led to the suggestion that the model at hand recapitulates hyperactivity as observed in the manic phase of bipolar disorder.

Conduct disorder and hyperactivity: I. Separation of hyperactivity and antisocial conduct in British child psychiatric patients

The distinction between hyperactivity and conduct disorder was explored in a mixed group of 64 children referred to psychiatric clinics because of antisocial or disruptive behaviour. A semi-structured interview measure (the Parental Account of Children's Symptoms, PACS) proved to have adequate inter-rater reliability, internal consistency and factorial validity. The PACS scales of defiance and hyperactivity, and similar subscales from Conners' Teacher Rating Scale, were tested against laboratory and clinical measures of activity, attention, cognitive performance, psychosocial background and family relationships. The hyperactivity (but not the defiance) scales were associated with greater activity, younger age, poorer cognitive performance and abnormalities on a developmental neurological examination. The defiance (but not the hyperactivity) scales were associated with impairment of family relationships and adverse social factors. It was concluded that a dimension of inattentive, restless activity should be separated from one of antisocial, defiant conduct in children with psychiatric disorder.

Natural history of snoring and related behaviour problems between the ages of 4 and 7 years

In 1989-90 a survey was carried out of the prevalence of snoring and related symptoms in 782 4 to 5 year old children. Two years later, in 1992, the same group of children was studied to gather information on the natural history of snoring and the related behaviour problems. A total of 507/782 (64.8%) completed questionnaires were received. Comparison of the responses with the 1989-90 survey showed that those who did not reply to the questionnaire were no different from the respondents in terms of the prevalence of snoring, daytime sleepiness, hyperactivity, and restless sleep. The overall prevalence of habitual snoring did not change between the two surveys (12.1% in 1989-90 v 11.4% in 1992), though more than half of the children who snored habitually in the original survey no longer did so. There was little change in the prevalence of hyperactivity (24.2% in 1989-90 v 20.7% in 1992) or restless sleep (both 39%) among the 507 who responded to the present survey. The prevalence of daytime sleepiness, however, did decrease substantially (20.7% in 1989-90 v 10.2% in 1992). There was moderate agreement between the individual questionnaire responses for the 1989-90 and 1992 surveys for snoring (weighted kappa 0.52), but poor agreement for the other symptoms (daytime sleepiness 0.37, hyperactivity 0.35, and restless sleep 0.38). Trend analysis showed that the increasing prevalence of sleepiness, hyperactivity, and restless sleep across the snoring categories was highly significant. Daytime sleepiness, hyperactivity, and restless sleep were all significantly more common in the habitual snorers than in those who never snored. Relative risks (95% confidence interval) were as follows: daytime sleepiness 6.13 (2.5 to 14.9), hyperactivity 2.78 (1.6 to 4.7), and restless sleep 2.3 (1.6 to 3.2). Though habitual snoring and the associated behaviour problems resolved spontaneously over two years in about half of the children with these symptoms, there is still the same overall percentage with these problems due to the emergence of new cases.

Transplantation in Parkinson's disease: two cases of adrenal medullary grafts to the putamen

Autologous adrenal medullary tissue was transplanted unilaterally to the putamen in two patients with severe Parkinson's disease. The first patient exhibited a transient, two-day improvement of motor performance in the limbs contralateral to the implantation site. He also had significantly longer episodes of normal function for about two months. The second patient reported a minor improvement of balance and gait, again lasting for two months. Electrophysiological studies of the motor readiness and auditory evoked potentials were consistent with increased catecholaminergic activity in the basal ganglia after transplantation in both patients. Positron emission tomography showed no postoperative alteration of receptor density in the putamen. No significant adverse effects of the transplantation were observed in the patients' performance on neurological and psychological tests or in their quantitative electroencephalogram and cerebral blood flow recordings. Immediately after the grafting, one patient showed transient signs of sympathetic hyperactivity, probably caused by release of catecholamines from the implanted tissue into the peripheral circulation. We conclude that catecholamine-rich cellular implants in the basal ganglia have transient beneficial effects in patients with severe Parkinson's disease.

Hyperkinetic movement disorders during and after acute stroke: the Lausanne Stroke Registry

BACKGROUND AND OBJECTIVE

To study consecutive patients with acute or delayed hyperkinetic movement disorders in the Lausanne Stroke Registry.

METHODS

We have identified 29 patients with acute or delayed movement disorders among 2500 patients who had their first-ever acute stroke in the Lausanne Stroke Registry.

SETTING

Department of Neurology, Lausanne University Hospital.

RESULTS

Our patients presented with hemichorea-hemiballism (11 patients), hemidystonia (5 patients), stereotypias (2 patients), jerky dystonic unsteady hand (3 patients), asterixis (2 patients), initial limb-shaking (2 patients), bilateral tremor (1 patients), bilateral jaw myoclonus (1 patient), hemiakathisia (1 patient) and dysarthria-dyskinetic hand (1 patient). On neuroimaging a lesion was found in 25 of the 29 cases in the territory of the middle cerebral artery (7 deep, 2 superficial and 2 complete), the posterior cerebral artery (11 patients), both middle and posterior cerebral arteries (2 patients) or the anterior cerebral artery (1 patient). The jerky dystonic unsteady hand syndrome was associated with a specific lesion, an infarct in the territory of the posterior choroidal artery. Presumed small-vessel disease was the commonest cause of stroke (15 patients). Only 3 patients had persistent movements (> 6 months).

CONCLUSION

Hyperkinetic movement disorders are uncommon in acute stroke (1%), the commonest types being hemichorea-hemiballism and hemidystonia. These movement disorders are associated with stroke involving the basal ganglia and adjacent white matter in the territory of the middle or the posterior cerebral artery. The jerky dystonic unsteady hand syndrome is specifically associated with a small infarct in the territory of the posterior choroidal artery. The abnormal movements usually regress spontaneously.

Mental and behavioural outcome of infantile epilepsy treated by vigabatrin in tuberous sclerosis patients

Vigabatrin (VGB) has demonstrated high efficacy in infantile spasms (IS) due to tuberous sclerosis. Our first objective was to evaluate the cognitive long term effect outcome of children whose refractory spasms definitely disappeared when VGB was given as an add on drug. Our second objective was to determine the response of generalized epilepsy (infantile spasms) compared to partial epilepsy on cognitive impairment. A non selected series of 13 children underwent psychometric and behavioural evaluation before VGB initiation at a mean of 3 years on VGB treatment. Eight of them could perform detailed neuropsychological tests at follow-up. Seven had infantile spasms (Group I), they all were spasm free before 2 years of age and five remained with rare partial seizures (mean age, 5.5 years). Six others had partial epilepsy without spasms (Group II) and five remained with rare seizures (mean age, 7.5 years). Patients of Group I experienced dramatic changes. Developmental quotient (DQ) significantly rose in six out of seven by ten to more than 45 points (P = 0.03) and autistic behaviour disappeared in five out of the six who presented with. The four tested children had normal verbal level after 5 years and could integrate at school but they remained with marked visuospatial disabilities. By contrast, patients of Group II remained with an unchanged DQ of about 60 so that both groups had similar DQ levels on follow-up. The cessation of spasms with VGB is therefore associated with significant improvement of cognition and behaviour in children with tuberous sclerosis. Controlling secondary generalization induced by infantile spasms seems to be a key factor for mental development.

The differential effect of right versus left hemispheric cerebral infarction on catecholamines and behavior in the rat

Following right middle cerebral artery ligation in rats, there is a 2-3 week period of spontaneous hyperactivity. Concomitant with this hyperactivity catecholamine concentrations decrease in several areas of the brain including both cortical and subcortical regions. In marked contrast, there are no demonstrable effects of left hemispheric infarction on either spontaneous activity or brain catecholamine concentrations. This asymmetry of behavioral and biochemical response to cerebral infarction cannot be attributed to differences in the lesion size produced in either hemisphere. Feeding and drinking are not affected but the asymmetrical effect on activity can be demonstrated in either a home cage running wheel or an open field environment. It is uncertain whether these findings are the result of hemispheric asymmetries in either catecholaminergic or non-catecholaminergic neurons.

Central pattern generators for a common semiology in fronto-limbic seizures and in parasomnias. A neuroethologic approach

Central pattern generators (CPGs) are genetically determined neuronal aggregates in the mesencephalon, pons and spinal cord subserving innate motor behaviours essential for survival (feeding, locomotion, reproduction etc.). In higher primates CPGs are largely under neocortical control. We describe how certain motor events observed in parasomnias and epileptic seizures could have similar features and resemble motor behaviours, which can be the expression of the same CPG. Both epilepsy and sleep can lead to a temporary loss of control of neomammalian cortex that facilitates through a common platform (arousal) the emergences of stereotyped inborn fixed action patterns. Therefore we suggest that, independently from the nature of the trigger, be it a seizure or a parasomnia, the same CPGs can be involved, "caught up", leading to a common motor semiology (the "Carillon theory").

The effects of a double blind, placebo controlled, artificial food colourings and benzoate preservative challenge on hyperactivity in a general population sample of preschool children

AIMS

To determine whether artificial food colourings and a preservative in the diet of 3 year old children in the general population influence hyperactive behaviour.

METHODS

A sample of 1873 children were screened in their fourth year for the presence of hyperactivity at baseline (HA), of whom 1246 had skin prick tests to identify atopy (AT). Children were selected to form the following groups: HA/AT, not-HA/AT, HA/not-AT, and not-HA/not-AT (n = 277). After baseline assessment, children were subjected to a diet eliminating artificial colourings and benzoate preservatives for one week; in the subsequent three week within subject double blind crossover study they received, in random order, periods of dietary challenge with a drink containing artificial colourings (20 mg daily) and sodium benzoate (45 mg daily) (active period), or a placebo mixture, supplementary to their diet. Behaviour was assessed by a tester blind to dietary status and by parents' ratings.

RESULTS

There were significant reductions in hyperactive behaviour during the withdrawal phase. Furthermore, there were significantly greater increases in hyperactive behaviour during the active than the placebo period based on parental reports. These effects were not influenced by the presence or absence of hyperactivity, nor by the presence or absence of atopy. There were no significant differences detected based on objective testing in the clinic.

CONCLUSIONS

There is a general adverse effect of artificial food colouring and benzoate preservatives on the behaviour of 3 year old children which is detectable by parents but not by a simple clinic assessment. Subgroups are not made more vulnerable to this effect by their prior levels of hyperactivity or by atopy.

Gestational age, birth weight, and the risk of hyperkinetic disorder

AIMS

To study the association between gestational age and birth weight and the risk of clinically verified hyperkinetic disorder.

METHODS

Nested case-control study of 834 cases and 20 100 controls with incidence density sampling.

RESULTS

Compared with children born at term, children born with gestational ages of 34-36 completed weeks had a 70% increased risk of hyperkinetic disorder (rate ratio (RR) 1.7, 95% confidence interval (CI) 1.2 to 2.5). Children with gestational ages below 34 completed weeks had an almost threefold increased risk (RR 2.7, 95% CI 1.8 to 4.1). Children born at term with birth weights of 1500-2499 g had a 90% increased risk of hyperkinetic disorder (RR 1.9, 95% CI 1.2 to 2.9), and children with birth weights of 2500-2999 g had a 50% increased risk (RR 1.5, 95% CI 1.2 to 1.8) compared with children born at term with birth weights above 2999 g. The results were adjusted for socioeconomic status of the parents, family history of psychiatric disorders, conduct disorders, comorbidity, and maternal smoking during pregnancy. Results related to birth weight were unchanged after adjusting for differences in gestational age.

CONCLUSIONS

Children born preterm, also close to term, and children born at term with low birth weights (1500-2499 g) have an increased risk of clinically verified hyperkinetic disorder. These findings have important public health perspectives because the majority of preterm babies are born close to term.

Behavioral responses to artificial food colors

Twenty-two young children, maintained on a diet that excluded certain foods, were challenged intermittently with a blend of seven artificial colors in a double-blind trial. Parents' observations provided the criteria of response. One child that responded mildly to the challenge and one that responded dramatically were detected. The latter, a 34-month-old female, showed a significant increase in aversive behaviors. These results further confirm previous controlled studies.

The offspring of alcoholics: a critical review

In their review of the literature on the effects of parental alcoholism on the offspring of alcoholics, the authors focus on sample collection, criteria used for the diagnosis of parental alcoholism, and definitions of "emotional disturbances." Studies are grouped according to age of offspring; within each age group, the various approaches to the issue are described. The authors suggest a need for more carefully controlled studies using blind data collection and clear operational definitions. In addition, the "risk" status of offspring of alcoholics should be compared to that of children whose parents have other types of serious psychiatric disturbance. Although the literature has focused on the "casualties," the authors note that much could be learned from studies of the "successes"--those children who do not seem to be at increased risk for pychosocial illness despite the alcoholism of their parents.

Vitamin D status in autism spectrum disorders and the efficacy of vitamin D supplementation in autistic children

OBJECTIVES

Autism spectrum disorder (ASD) is a developmental disorder characterized by pervasive deficits in social interaction, impairment in verbal and non-verbal communication, and stereotyped patterns of interests and activities. Vitamin-D deficiency was previously reported in autistic children. However, the data on the relationship between vitamin D deficiency and the severity of autism are limited.

METHODS

We performed a case-controlled cross-sectional analysis conducted on 122 ASD children, to assess their vitamin D status compared to controls and the relationship between vitamin D deficiency and the severity of autism. We also conducted an open trial of vitamin D supplementation in ASD children.

RESULTS

Fifty-seven percent of the patients in the present study had vitamin D deficiency, and 30% had vitamin D insufficiency. The mean 25-OHD levels in patients with severe autism were significantly lower than those in patients with mild/moderate autism. Serum 25-OHD levels had significant negative correlations with Childhood Autism Rating Scale (CARS) scores. Of the ASD group, 106 patients with low-serum 25-OHD levels (<30 ng/ml) participated in the open label trial. They received vitamin D3 (300 IU/kg/day not to exceed 5000 IU/day) for 3 months. Eighty-three subjects completed 3 months of daily vitamin D treatment. Collectively, 80.72% (67/83) of subjects who received vitamin D3 treatment had significantly improved outcome, which was mainly in the sections of the CARS and aberrant behavior checklist subscales that measure behavior, stereotypy, eye contact, and attention span.

CONCLUSION

Vitamin D is inexpensive, readily available and safe. It may have beneficial effects in ASD subjects, especially when the final serum level is more than 40 ng/ml.

TRIAL REGISTRATION NUMBER

UMIN-CTR Study Design: trial Number: R000016846.

Treatment with valproate after status epilepticus: effect on neuronal damage, epileptogenesis, and behavioral alterations in rats

Epileptogenesis, i.e. the process leading to epilepsy with spontaneous recurrent seizures, can be initiated by a number of brain damaging insults, including traumatic brain injury, status epilepticus (SE), and stroke. Such acquired epilepsy is often associated with memory impairment and behavioral problems. There has been a growing interest in the use of antiepileptic drugs (AEDs) for neuroprotection and prevention or modification of epileptogenesis induced by such brain insults. One promising candidate in this respect is valproic acid (VPA), a widely used AED that has been reported to exert neuroprotective activity in a number of in vitro and in vivo models. The present study investigated whether VPA reduces brain damage and improves functional outcome in a rat model of post-SE epilepsy. A self-sustaining SE was induced by prolonged electrical stimulation of the basal amygdala via a depth electrode. SE was terminated after 4 h by diazepam, immediately followed by onset of treatment with VPA. VPA was injected i.p. at a bolus dose of 400 mg/kg, followed by three times daily administration of 200 mg/kg for 4 weeks. A control group received vehicle instead of VPA after SE. Spontaneous seizures were recorded in all rats of both groups following termination of treatment, without significant inter-group difference in seizure frequency or severity. However, treatment with VPA after SE prevented the hyperexcitability and locomotor hyperactivity observed in vehicle-treated epileptic rats. Furthermore, VPA completely counteracted the neuronal damage in the hippocampal formation, including the dentate hilus. The data demonstrate that, although VPA does not prevent the occurrence of spontaneous seizures after SE, it exerts powerful neuroprotective effects and prevents part of the behavioral alterations, demonstrating that administration of VPA immediately after SE exerts a favorable effect on long-term functional outcome.

A lack of essential fatty acids as a possible cause of hyperactivity in children

The Hyperactive Children's Support Group (HCSG) in an organisation with over 70 branches in Britain devoted to helping such children and their families. We have carried out a detailed survey of the characteristics of many of our children and their families and have studied the literature in detail. We have come to the conclusion that many of these children have a deficiency of essential fatty acids (EFAs) either because they cannot metabolise linoleic acid normally, or because they cannot absorb EFAs normally from the gut, or because their EFA requirements are higher than normal. The main pieces of evidence are: 1. Most of the food constituents which cause trouble in these children are weak inhibitors of the conversion of EFAs to prostaglandins (PGs). 2. Boys are much more commonly effected than girls and males are known to have much higher requirements for EFAs than females. 3. A high proportion of our children have abnormal thirst and thirst is one of the cardinal signs of EFA deficiency. 4. Many of our children have eczema, allergies and asthma which some reports suggest can be alleviated by EFAs. 5. Many of our children are deficient in zinc which is required for conversion of EFAs to PGs. 6. Some of of our children are badly affected by wheat and milk which are known to give rise to exorphins in the gut which can block conversion of EFAs to PGE1. A preliminary study of EFA supplementation in a number of our children has given promising results. We hope that others with better facilities will be encouraged to test out this hypothesis.

Delayed melatonin administration promotes neuronal survival, neurogenesis and motor recovery, and attenuates hyperactivity and anxiety after mild focal cerebral ischemia in mice

Melatonin is a potent antioxidant with neuroprotective activity in animal models of ischemic stroke, which based on its lack of serious toxicity has raised hopes that it might be used for human stroke treatment in the future. This study investigated how subacute delivery of melatonin, starting at 24 hr after stroke onset, and continuing for 29 days (4 mg/kg/day; via drinking water), influences neuronal survival, endogenous neurogenesis, motor recovery and locomotor activity in C57Bl6/j mice submitted to 30-min middle cerebral artery occlusion. Histologic studies showed that melatonin improved neuronal survival and enhanced neurogenesis, even when applied 1 day after stroke. Cell survival was associated with a long-lasting improvement of motor and coordination deficits, evaluated by the grip strength and RotaRod tests, as well as with attenuation of hyperactivity and anxiety of the animals as revealed in open field tests. The robust functional neurologic improvements encourage proof-of-concept studies with melatonin in human stroke patients.