Das 22q11.2-Deletionssyndrom und seine Relevanz für die Kinder- und Jugendpsychiatrie

Non-pharmacological treatment of psychiatric disorders in individuals with 22q11.2 deletion syndrome; a systematic review

22q11.2 deletion syndrome (22q11.2DS) is associated with high rates of anxiety disorders, psychotic disorders, and other psychiatric conditions. In the general population, psychiatric disorders are treated with proven pharmacological and non-pharmacological therapies, such as cognitive behavioral therapy (CBT). To begin to assess the feasibility and efficacy of non-pharmacological therapies in 22q11.2DS, we performed a systematic search to identify literature on non-pharmacological interventions for psychiatric disorders in individuals with 22q11.2DS. Of 1,240 individual publications up to mid-2016 initially identified, 11 met inclusion criteria. There were five literature reviews, five publications reporting original research (two originating from a single study), and one publication not fitting either category that suggested adaptations to an intervention without providing scientific evidence. None of the original research involved direct study of the evidence-based non-pharmacological therapies available for psychiatric disorders. Rather, these four studies involved computer-based or group interventions aimed at improving neuropsychological deficits that may be associated with psychiatric disorders. Although the sample sizes were relatively small (maximum 28 participants in the intervention group), these reports documented the promising feasibility of these interventions, and improvements in domains of neuropsychological functioning, including working memory, attention, and social cognition. The results of this review underline the need for research into the feasibility and efficacy of non-pharmacological treatments of psychiatric disorders in individuals with 22q11.2DS to inform clinical care, using larger samples, and optimally, standard randomized, placebo-controlled, clinical trials methodology.

The 22q11.2 deletion syndrome as a window into complex neuropsychiatric disorders over the lifespan

Evidence is rapidly accumulating that rare, recurrent copy number variants represent large effect risk factors for neuropsychiatric disorders. 22q11.2 deletion syndrome (22q11DS) (velocardiofacial syndrome or DiGeorge syndrome) is the most common known contiguous gene deletion syndrome and is associated with diverse neuropsychiatric disorders across the life span. One of the most intriguing aspects of the syndrome is the variability in clinical and cognitive presentation: children with 22q11DS have high prevalence of autism spectrum, attention deficit, and anxiety disorders, as well as psychotic-like features, and up to 30% of adolescents and adults develop schizophrenia-like psychosis. Recently, cases of early-onset Parkinson's disease in adults have been reported, collectively suggesting a role for disrupted dopaminergic neurotransmission in the observed neuropsychiatric phenotypes. There is also some evidence that 22q11DS-associated autism spectrum disorder and schizophrenia represent two unrelated phenotypic manifestations, consistent with a neuropsychiatric pleiotropy model. This genetic lesion thus provides a unique model for the discovery of specific genomic risk and (potentially) protective factors for neuropsychiatric disease. Here, we provide an overview of neuropsychiatric findings to date, which highlight the value of this syndrome in mapping the developmental trajectory of dimensional phenotypes that traverse multiple diagnostic categories. Potential sources of genetic variability that may contribute to the disorder's heterogeneous presentation are reviewed. Because of its known genetic etiology, animal models can readily be developed that recapitulate specific aspects of the syndrome. Future research directions involve translational models and potential for drug screenable targets in the context of this human model system.

Genetic risk in autism: new associations and clinical testing

INTRODUCTION

Autism spectrum disorder (ASD) is prevalent in ∼ 1% of the population worldwide. It is also understood, through twin studies, that ASD has a heritability of 70 - 90%. Molecular genetic studies have presented some genetic risk factors associated with ASD that have potential implications in its diagnosis and genetic testing.

AREAS COVERED

In this selective review, the author refers to previous systematic reviews that consecutively cited all the published papers on ASD at that time. The article presents the replicated genetic risk factors for ASD and the clinical relevance of these findings focusing on rare copy number variations and single gene mutations. The author provides the reader with a deeper insight into the complexity of ASD genetics and its implications for diagnostic genetic testing in ASD. The author also provides the reader with an algorithm for clinical genetic testing in individuals who are clinically diagnosed with ASD.

EXPERT OPINION

Despite the high heritability of ASD and several replicated genetic risk factors, there is no clinical genetic test available that covers most genetic risk factors. Also, validity analyses on most available genetic testing procedures have not been performed so far. The variable risk genotypes, as well as related strongly variable phenotypes, have to be taken into account by genetic counseling.

[22q11.2 deletion: handicap-related problems and coping strategies of primary caregivers]

OBJECTIVE

To investigate handicap-related problems of children and adolescents with 22q11.2 deletion syndrome and their primary caregivers' coping strategies.

METHOD

Primary caregivers of 153 subjects aged 2-16 years were anonymously asked to fill out questionnaires, e.g., the Handicap Related Problems for Parents Inventory.

RESULTS

Primary caregivers of 96 subjects (53 males, 43 females; mean age: 7;0 [2;1-16;11] years) sent back questionnaires. Patient's behaviour and discipline were the most important handicap-related problems. Significant correlations could be found between the patient's age and his/her relationship with the primary caregiver (rho=0.228; p=.029) and other family members (rho=0.293; p=.004). Compared to other parents of physically handicapped children or those with multiple handicaps, these parents did not experience increased stress. The more the coping strategies "self-fulfillment" and "intensification of partnership" were used, the lower parental stress was (p=.012, p=.025, respectively). "Focusing on the handicapped child" was positively correlated with high parental stress (p=.000).

CONCLUSIONS

With regard to parental stress and coping strategies, primary caregivers of children and adolescents with 22q11.2 deletion do not significantly differ from other parents of physically handicapped children. As handicap-related family problems increase with the patient's age, a growing need for counseling, especially for aspects of parenting and discipline, and for treatment can be presumed.

22q11.2 deletion syndrome: behaviour problems of children and adolescents and parental stress

BACKGROUND

22q11.2 deletion syndrome can be associated with a variety of somatic symptoms, developmental delays and psychiatric disorders. At present, there is little information on behaviour problems, parental stress and possible relations between these factors. Therefore, this study investigates behaviour problems of children and adolescents with 22q11.2DS, and their primary caregivers' stress.

METHODS

Parents of 4-17 year old subjects known to the German 22q11.2 deletion syndrome foundation were anonymously asked to fill out several questionnaires, e.g. the Child Behavior Checklist 4-18 (CBCL/4-18).

RESULTS

The primary caregivers of 77/126 children [43 males, 34 females, mean age: 8;0 (4;0-16;11) years] sent back filled-out questionnaires. Forty-six of 76 subjects were rated as clinical on at least one of the CBCL-scales. Males had significantly higher scores on the total problems scale and the internalizing problems scale than females. The patients' age correlated with several CBCL-scales. Eleven of 49 subjects were suspicious of an autism spectrum disorder. Compared with the general population, but not with other parents of mentally and/or physically handicapped children, the primary caregivers experienced higher levels of stress, but showed normal life satisfaction.

CONCLUSIONS

In spite of high rates of clinical behaviour problems among children and adolescents with 22q11.2DS and despite increased parental stress, most primary caregivers seem to have effective coping strategies, e.g. partnership support, to sustain normal levels of life satisfaction.

Living with a child at risk for psychotic illness: the experience of parents coping with 22q11 deletion syndrome: an exploratory study

Patients with 22q11 deletion syndrome (22q11DS) have a 25-30% risk of developing schizophrenia, as well as an increased risk for other psychiatric illnesses including bipolar and schizo-affective disease. As a result, their families may be informed of a risk for psychotic illness years or even decades before the likely age of onset. We performed an exploratory study, surveying 41 caretakers of individuals with 22q11DS, and found that information about the association between 22q11DS and psychiatric disease was omitted at diagnosis a majority of the time and rarely addressed subsequently by pediatricians or other medical specialists, including medical geneticists. Families frequently received their information only from non-medical sources, principally the Internet. Individuals with 22q11DS often have many medical issues, but a majority of parents indicated that the risk of psychotic illness was their greatest source of anxiety. Looking at how predictive information affects those who receive it is an important adjunct to the development of genetic testing; the experience of these families suggests that in order to use the information to improve outcomes or modify risk it is necessary to receive it in the context of ongoing support and access to resources.

Deletion 22q11.2 und schizophrene Störungen im Kindes- und Jugendalter

Zusammenfassung: Die Deletion 22q11.2 (Del.22q11.2) ist die häufigste bekannte Mikrodeletion beim Menschen und einer der wichtigsten Risikofaktoren für die Entstehung schizophrener Störungen. Fallberichte zu schizophrenen Störungen bei Kindern und Jugendlichen mit Del.22q11.2 wurden bisher jedoch kaum veröffentlicht. Nach einem Überblick über den aktuellen Wissensstand zu psychischen Störungen bei Del.22q11.2 werden Diagnostik und Behandlung eines bei Ersterkrankung 12;10-jährigen Jungen mit paranoider Schizophrenie dargestellt. Erst ca. 3 Jahre nach Erkrankungsbeginn konnte bei dem genannten Patienten nach verschiedentlichem Wechsel des Neuroleptikums das prämorbide Funktionsniveau wieder erreicht werden. Infolge Hypokalzämie kam es unter Clozapin-Gabe einmalig zu einem Krampfanfall. Der Fallbericht spricht für die Notwendigkeit regelmäßiger Kalziumspiegel-Kontrollen bei Menschen mit Del.22q11.2 und gleichzeitiger Neuroleptika-Gabe. Kinder und Jugendliche mit Del.22q11.2 sollten idealerweise bei psychischen Störungen in kinder- und jugendpsychiatrischen Spezialambulanzen behandelt werden, wegen der häufigen somatischen Probleme ist eine gute interdisziplinäre Zusammenarbeit unbedingt erforderlich.

Psychische Störungen bei behinderten Kindern und Jugendlichen - Übersicht und Schlussfolgerungen für die Psychodiagnostik

Zusammenfassung: Es wird eine Übersicht über die Studien zur Prävalenz psychischer Störungen bei Hörschädigung, Blindheit, körperlicher oder intellektueller Behinderung gegeben. Neben Entwicklungseinschränkungen in Folge von organischen oder genetischen Bedingungen tragen Belastungen der Eltern-Kind-Beziehung und der Entwicklung sozialer Kompetenzen sowie der sozialen Partizipation zu einem deutlich erhöhten Risiko für die Ausbildung emotionaler oder sozialer Störungen bei. Probleme der psychopathologischen Beurteilung sowie der Differenzierung zwischen Auswirkungen der Behinderung und psychischer Störung werden diskutiert und Schlussfolgerungen für die Praxis gezogen.