Classification, prevalence and integrated care for neurodevelopmental and child mental health disorders: A brief overview for paediatricians

Unraveling genetic etiologies in complex pediatric neurological diseases: A genetic investigation using whole exome sequencing

Pediatric neurological disorders are a diverse group of conditions affecting the nervous system in children, often challenging to diagnose due to their nonspecific and overlapping clinical features. Advances in molecular diagnostics, particularly whole exome sequencing (WES), have significantly improved the identification of genetic causes, enabling precise diagnoses and personalized treatments. This study explores the application of WES in diagnosing pediatric neurological disorders within Moroccan childrens with undiagnosed or challenging pediatric neurological conditions to uncover genetic causes of complex pediatric neurological conditions unresolvable by traditional diagnostic methods. The study included 188 pediatric patients with complex neurological conditions from the Children's Hospital of Rabat who underwent exome sequencing to investigate suspected genetic causes. WES revealed a diagnostic yield of 45%, identifying conditions such as intellectual disabilities, hereditary metabolic disorders and epilepsies. It also uncovered neurodevelopmental and neurodegenerative disorders, neuromuscular diseases, and genetic syndromes. A total of 157 variants were detected: 34% were classified as pathogenic, 28.5% as likely pathogenic, and 37.5% as variants of uncertain significance (VUS). These findings underscore the utility of WES as a robust diagnostic tool, providing insights into genetic causes and enabling tailored treatment strategies. They also highlight the importance of expanding genetic research to improve diagnostic accuracy and clinical management of pediatric neurological disorders.

Subthreshold Autism and ADHD: A Brief Narrative Review for Frontline Clinicians

Background: Epidemiological studies have shown that neurodevelopmental disorders (NDDs), such as autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) are more prevalent in the general childhood population, compared to cases that are formally diagnosed in clinical cohorts. This suggests that many children and youths have NDD which are never diagnosed clinically, causing impairments in some domains of their daily life. There is increasing recognition of the concept of a "subthreshold" condition, sometimes used to describe the presence of potentially impairing variations in the neurodevelopmental profile that do not meet criteria for a diagnosis. The aim of this narrative review is to appraise the published literature about common themes regarding subthreshold conditions in relation to autism and ADHD, identifying any practical lessons that may be applicable to frontline neurodevelopmental clinicians. Methods: We searched electronic databases including PMC and PubMed using various combinations of keywords, including "Subthreshold", "subclinical", "neurodevelopmental", "childhood", "ADHD" and "ASD". Results: The identified themes include definitions, prevalence, assessment tools, lifetime impairments, NDD classification models, management, raising public awareness, and future research directions. Conclusions: The authors propose that a "subthreshold condition" should be recorded when NDDs do not meet current diagnostic criteria if there is evidence of significant, persisting impairment in at least one setting.

Behavioral Phenotypes and Comorbidity in 3q29 Deletion Syndrome: Results from the 3q29 Registry

3q29 deletion syndrome (3q29del) is associated with a significantly increased risk for neurodevelopmental and neuropsychiatric disorders. However, the full spectrum of behavioral phenotypes associated with 3q29del is still evolving. Individuals with 3q29del (n = 96, 60.42% male) or their guardian completed the Achenbach Child or Adult Behavior Checklist (CBCL/ABCL) via the online 3q29 registry (3q29deletion.org). Typically developing controls (n = 57, 49.12% male) were ascertained as a comparison group. We analyzed mean performance on the CBCL/ABCL for individuals with 3q29del and controls across composite, DSM-keyed, and developmental scales; and the relationship between CBCL/ABCL performance and clinical and developmental phenotypes for individuals with 3q29del. Individuals with 3q29del showed significantly elevated behavioral and developmental impairment relative to controls across CBCL/ABCL domains. A substantial proportion of study participants with 3q29del scored in the Borderline or Clinical range for composite and DSM-keyed scales, indicating significant behavioral problems that may require clinical evaluation. We found that the preschool CBCL DSM-keyed autism spectrum problems scale is a potential screening tool for autism spectrum disorder (ASD) for individuals with 3q29del; CBCL/ABCL DSM-keyed scales were not accurate screeners for anxiety disorders or attention-deficit/hyperactivity disorder (ADHD) in our study sample. We identified a high degree of psychiatric comorbidity in individuals with 3q29del, with 60.42% (n = 58) of individuals with 3q29del scoring in the Borderline or Clinical range on two or more DSM-keyed CBCL/ABCL scales. Finally, we found that the degree of developmental delay in participants with 3q29del does not explain the increased behavioral problems observed on the CBCL/ABCL. The CBCL/ABCL can be used as screening tools in populations such as 3q29del, even in the presence of substantial psychiatric comorbidity. These results expand our understanding of the phenotypic spectrum of 3q29del and demonstrate an effective method for recruiting and phenotyping a large sample of individuals with a rare genetic disorder.

Child outcomes after prenatal exposure to platinum and taxane-based chemotherapy: an unplanned interim analysis of the international network on cancer, infertility, and pregnancy study

Background

Platina and taxanes are frequently used chemotherapeutic agents to treat cancer, also when diagnosed during pregnancy. This report presents an interim analysis of the largest series of children prenatally exposed to platinum and/or taxane agents and aims to determine their physical health and neurocognitive outcomes.

Methods

As part of a multicentre, prospective cohort study (ClinicalTrials.gov: NCT00330447), children born between 2000 and 2022 were assessed between 2005 and 2024 at ages 1.5-18 years (interim analysis; median length of follow-up, 3.2 years (IQR 3.0-6.4)) by a comprehensive neurocognitive test battery, parent-reported questionnaires, and a physical assessment. Mixed-effects regression and Type III Analysis of Variance models were used to investigate associations between these outcomes and platinum/taxane cumulative dose and agent type, with best-fit models corrected for age and covariates (gestational age at birth, chemotherapy timing, other chemotherapy, sex, parental education level, maternal death).

Findings

In total, 144 children were included (13% exposed to platinum, 62% to taxanes, 25% to both). Of these, 101 were assessed at age 1.5 years, 96 at age 3, 63 at age 6, 32 at age 9, 18 at age 12, 7 at age 15, and 2 at age 18 years. Neurocognitive outcomes were within normal ranges across all ages, compared with test-specific normative data. Eight children (6%) reported ototoxicity, seven (5%) reported chronic medical conditions, three (2%) had congenital malformations, and two (1%) were diagnosed with Attention-Deficit Hyperactivity Disorder. Thirty-three children (23%) needed extra neurocognitive support, of which 64% were born preterm. Children prenatally exposed to paclitaxel scored lower on visuospatial (β = 0.64 ± 0.21, p = 0.0052) and verbal memory (β = 0.68 ± 0.27, p = 0.015) than those exposed to docetaxel.

Interpretation

In this interim analysis, we found normal neurocognitive outcomes and no increase in congenital malformations nor medical conditions after prenatal exposure to platinum/taxane-based chemotherapy. However, owed to the limited number of older children, further investigation regarding their potential neurotoxicity and its long term effects is necessary in follow-up studies with larger samples.

Funding

Kom Op Tegen Kanker, KWF Kankerbestrijding, Stichting Tegen Kanker, Cooperatio program, Research Foundation Flanders.

Prenatal PM2.5 Exposure Associated with Neonatal Gut Bacterial Colonization and Early Children's Cognitive Development

Previous research indicated that fine particulate matter (PM2.5) exposure affected both offspring neurodevelopment and the colonization of gut microbiota (GM), while the underlying mechanism remained unclear. Our study aimed to evaluate the impacts of prenatal PM2.5 exposure on child cognitive development and investigate the role of neonatal GM colonization in the association. Based on the Shanghai Maternal-Child Pairs Cohort, 361 maternal-child pairs were recruited. Prenatal PM2.5 exposure concentrations were estimated using a high-spatial-resolution prediction model, and child neurodevelopment was assessed by the Ages and Stages Questionnaire. Multivariable linear regression models, logistic regression models, linear discriminant analysis effect size, and random forest model were applied to explore the associations among PM2.5 exposure, GM colonization, and children's neurodevelopment. The present study revealed a negative correlation between PM2.5 exposure throughout pregnancy and child neurodevelopment. Prenatal PM2.5 exposure was associated with an increased risk of suspected developmental delay (SDD) (OR = 1.683, 95% CI: 1.138, 2.489) in infants aged 2 months. Additionally, potential operational taxonomic unit markers were identified for PM2.5-related neurotoxicity, demonstrating promising classification potential for early SDD screening (AUC = 71.27%). Prenatal PM2.5 exposure might disrupt the composition, richness, and evenness of meconium GM, thereby influencing cognitive development and the occurrence of SDD in offspring. Seven PM2.5-related genera, Ruminococcus gnavus group, Romboutsia, Burkholderiaceae Caballeronia Paraburkholderia, Blautia, Alistipes, Parabacteroides, and Bacteroides, were validated as correlated with prenatal PM2.5 exposure and the occurrence of SDD. Moreover, alterations of GM related to PM2.5 exposure and SDD might be accompanied by changes in functional pathways of amino acid, lipid, and vitamin metabolism as indicated by differentially enriched species in the Kyoto Encyclopedia of Genes and Genomes.

Predictive validity of the Standardized Infant NeuroDevelopmental Assessment (SINDA) to identify 4-5 year-old children at risk of developmental delay in a low-risk sample

BACKGROUND

Early detection of developmental problems is important as it allows for early intervention. Previous studies, in high-risk infants, found high predictive values of atypical scores on the Standardized Infant NeuroDevelopmental Assessment (SINDA) for later neurodevelopmental disorders (i.e., cerebral palsy, intellectual disability).

AIMS

The present study explored SINDA's predictive values to identify risk of developmental delay at 4-5 years.

STUDY DESIGN

Cohort study.

SUBJECTS

786 low-risk Dutch children (367 boys; median gestational age: 40 (27-42) weeks; mean birth weight: 3455 (SD 577) grams).

OUTCOME MEASURES

The SINDA was assessed at 2-12 months and risk of developmental delay was assessed using the Ages and Stages Questionnaire (ASQ) at 4-5 years. SINDA's predictive values were determined for five ASQ domains and the total ASQ score for children at risk of marked (all ASQ domains deviant) and any (one or more ASQ domains deviant) developmental delay.

RESULTS

Presence of one atypical SINDA scale score showed low to moderate sensitivities (12-88 %, depending on the SINDA scale and ASQ domain involved), moderate to high specificities (66-94 %), low positive predictive values (PPVs; 3-16 %), and high negative predictive values (NPVs; 95-100 %) for children at risk of marked and any developmental. Presence of multiple atypical SINDA scale scores predicted deviant ASQ domains slightly better (sensitivities = 11-62 %, specificities = 90-98 %, PPVs = 6-30 %, and NPVs = 95-100 %).

CONCLUSIONS

In low-risk infants, SINDA's predictive value is low for detecting children at risk of marked and any developmental delay at 4-5 years, as reflected by the low sensitivities. One of the explanations is the relatively low prevalence of developmental delay in low-risk populations. This might have consequences for the application of the SINDA in general healthcare settings (e.g. child health clinics), but further studies are needed to draw this conclusion.

Towards system redesign: An exploratory analysis of neurodivergent traits in a childhood population referred for autism assessment

BACKGROUND

Children's health services in many countries are moving from single condition diagnostic silo assessments to considering neurodevelopment in a more holistic sense. There has been increasing recognition of the importance of clinical overlap and co-occurrence of different neurotypes when assessing neurodivergent children. Using a cross-sectional service evaluation design, we investigated the overlap of neurodivergences in a cohort of children referred for autism assessment, focusing on motor, learning, and attention/activity level domains. We aimed to determine what proportion of children in a cohort referred for an autism assessment showed traits of additional neurodivergences, and what proportion were further investigated.

METHODS

We evaluated anonymised medical records of children aged between two and 17 years referred for autism assessment. We used validated questionnaires to assess for neurodivergent traits. A weighted scoring system was developed to determine traits in each neurodevelopmental domain and a score above the median was considered to indicate a neurodivergent trait. Evidence of further investigations were recorded. We then examined the relationships between autism traits and traits of additional neurodivergence.

RESULTS

114 participants were included for evaluation. 62.3% (n = 71) had completed questionnaires for analysis. Of these, 71.8% (n = 51) scored greater than the median for at least one additional neurotype, indicating the presence of other neurodivergent traits, and 88.7% (n = 64) attracted a diagnosis of autism. Only 26.3% of children with evidence of additional neurotypes were further investigated beyond their autism assessment.

CONCLUSIONS

Our results demonstrate the extensive overlap between additional neurodivergent traits in a population of children referred with suspected autism and show that only a small proportion were further investigated. The use of standardised questionnaires to uncover additional neurodivergences may have utility in improving the holistic nature of neurodevelopmental assessments.

Integrated Care in Epilepsy Management: A Scoping Review of the Models and Components of Health and Social Care Delivery

Introduction

Epilepsy is the most common neurological condition globally. Integrating health and social care is fundamental in epilepsy management, but the scope of progress in this area is unclear. This scoping review aimed to capture the range and type of integrated care components and models in epilepsy management.

Methods

Four databases were searched for articles published since 2010 that reported on integrated care in epilepsy. Data were extracted and synthesised into components of integrated care that had been implemented or recommended only. Models of integrated care were identified, and their components tabulated.

Results

Fifteen common and interrelated components of integrated care emerged that were aligned with four broad areas: healthcare staff and pathways (e.g., epilepsy nurses); tasks and services (e.g., care coordination); education and engagement (e.g., shared decision making); and technology for diagnosis and communication (e.g., telehealth). Twelve models of integrated care were identified; seven were implemented and five were recommended.

Discussion

There is a growing evidence-base supporting integrated, person-centred epilepsy care, but implementation is challenged by entrenched silos, underdeveloped pathways for care, and deficits in epilepsy education.

Conclusion

Integrating epilepsy care relies on changes to workforce development and policy frameworks to support whole-of-system vision for improving care.

A systematic review of cannabidiol trials in neurodevelopmental disorders

Cannabis-derived compounds, such as cannabidiol (CBD) and delta-9-trans-tetrahydrocannabinol (THC), are increasingly prescribed for a range of clinical indications. These phyto-cannabinoids have multiple biological targets, including the body's endocannabinoid system. There is growing scientific interest in the use of CBD, a non-intoxicating compound, to ameliorate symptoms associated with neurodevelopmental disorders. However, its suitability as a pharmaceutical intervention has not been reliably established in these clinical populations. This systematic review examines the nine published randomised controlled trials (RCTs) that have probed the safety and efficacy of CBD in individuals diagnosed with attention deficit hyperactivity disorder, autism spectrum disorder, intellectual disability, Tourette Syndrome, and complex motor disorders. Studies were identified systematically through searching four databases: Medline, CINAHL complete, PsycINFO, and EMBASE. Inclusion criteria were randomised controlled trials involving CBD and participants with neurodevelopmental disorders. No publication year or language restrictions were applied. Relevant data were extracted from the identified list of eligible articles. After extraction, data were cross-checked between the authors to ensure consistency. Several trials indicate potential efficacy, although this possibility is currently too inconsistent across RCTs to confidently guide clinical usage. Study characteristics, treatment properties, and outcomes varied greatly across the included trials. The material lack of comparable RCTs leaves CBD's suitability as a pharmacological treatment for neurodevelopmental disorders largely undetermined. A stronger evidence base is urgently required to establish safety and efficacy profiles and guide the ever-expanding clinical uptake of cannabis-derived compounds in neurodevelopmental disorders. Prospero registration number: CRD42021267839.

Serious Games in the new era of digital-health interventions: A narrative review of their therapeutic applications to manage neurobehavior in neurodevelopmental disorders

Children and adolescents with neurodevelopmental disorders generally show adaptive, cognitive and motor skills impairments associated with behavioral problems, i.e., alterations in attention, anxiety and stress regulation, emotional and social relationships, which strongly limit their quality of life. This narrative review aims at providing a critical overview of the current knowledge in the field of serious games (SGs), known as digital instructional interactive videogames, applied to neurodevelopmental disorders. Indeed, a growing number of studies is drawing attention to SGs as innovative and promising interventions in managing neurobehavioral and cognitive disturbs in children with neurodevelopmental disorders. Accordingly, we provide a literature overview of the current evidence regarding the actions and the effects of SGs. In addition, we describe neurobehavioral alterations occurring in some specific neurodevelopmental disorders for which a possible therapeutic use of SGs has been suggested. Finally, we discuss findings obtained in clinical trials using SGs as digital therapeutics in neurodevelopment disorders and suggest new directions and hypotheses for future studies to bridge the gaps between clinical research and clinical practice.

Organization of rehabilitation services for youth with physical disabilities and mental health problems: A scoping review

Introduction

Youth with childhood-onset physical disabilities receiving rehabilitation services often present with many complex needs. Emerging evidence confirms co-occurrence of mental health problems in this population is common, and mental health is often overlooked during rehabilitation for chronic physical conditions. For example, symptoms of depression and anxiety are frequently present in adolescents with physical disability such as spina bifida or Duchenne muscular dystrophy, and access to mental health services is often limited. Addressing mental health concerns for this age group is particularly critical as it encompasses a challenging transition to adulthood.

Objectives

Building upon findings from a recent scoping review on the co-occurrence of physical disabilities and mental health problems, this paper synthesizes scientific literature related to the organization and delivery of services for youth with co-occurring childhood-onset physical disabilities (e.g., cerebral palsy, spina bifida) and mental health problems (e.g., depression, anxiety).

Methods

A scoping review protocol stemming from Arksey & O'Malley's framework and updated guidelines from the Joanna Briggs Institute was developed. Four databases (Medline, PsycINFO, CINAHL, Embase) were searched. The search was limited to French or English peer-reviewed articles published between 2000 and 2021. Articles included were primary papers addressing: 1) youth aged 15 to 24 with a childhood-onset physical disability, 2) mental health problems, and 3) healthcare service organization or delivery. They were screened by two reviewers and discussed with a third to establish consensus on the inclusion criteria and resolve disagreements.

Results

Sixteen articles were retained from the 1,010 screened. Many (9/16) were from the United States. Two models were found: the Biopsychosocial, Collaborative, Agency-Based Service Integration Approach (including psychiatry in a pediatric rehabilitation hospital) and the Client Network Consultation (an interagency collaboration in mental health care for children with complex healthcare needs). Twelve key principles for service organization and delivery were identified and categorized into: collaboration and coordination, training and support, and delivery of care.

Conclusion

Identified principles can guide improved service delivery for this population. Highlighted research gaps include the need for developing models of collaborative healthcare delivery and subsequently evaluating their effectiveness.

Maternal PM2.5 exposure during gestation and offspring neurodevelopment: Findings from a prospective birth cohort study

Emerging data have suggested the potential role of prenatal PM2.5 exposure as a neurotoxin for offspring. However, the existing results are equivocal, and no study has examined the effects of complex chemical constituents of the particular matter on offspring neurodevelopment. Therefore, in a prospective birth cohort study conducted in Jiangsu, China, we aimed to investigate the association between prenatal exposure to PM2.5 and the neurodevelopment in infants, and further assess the effects of specific chemical constituents of PM2.5. A total of 1531 children who had available data on daily prenatal PM2.5 exposure and completed assessment on neurodevelopment at 1 year old were enrolled. We used the high-performance machine-learning model to estimate daily PM2.5 exposure concentrations at 1 km × 1 km spatial resolution. The combined geospatial-statistical model was applied to evaluate average concentrations of six chemical constituents [organic matter (OM), black carbon (BC), sulfate (SO42-), nitrate (NO3-), ammonium (NH4+), and soil dust (Dust)]. The neurodevelopment of children was assessed using Bayley-III Screening Test. After adjusting for confounding factors, the risk of non-optimal gross motor development increased by 31 % for every 10 μg/m3 increase in average PM2.5 exposure during gestation (aRR: 1.31; 95 % CI: 1.04, 1.64). Further analysis of PM2.5 constituents showed that prenatally exposed to high SO42- was associated with the risk of non-optimal gross motor development (aRR: 1.40; 95 % CI: 1.08, 1.81). Null associations were observed for the rest four neurodevelopment domains. Collectively, our study suggested that prenatal exposure to PM2.5, particularly with high SO42- concentration, was associated with children's non-optimal gross motor development at 1 year old. The short- and long-term influences of perinatal PM2.5 exposure on children's neurodevelopment warrant further investigation.