Dyskinesia in Treatment-Naive and Stimulant-Treated Children With ADHD

Objective: Stimulants are safe and effective medications for the treatment of ADHD. There are a number of case studies that report stimulant-induced dyskinesia. The aim of this study was to compare dyskinesia in a treated and a treatment-naive group of children with ADHD, and a healthy control group. Method: Children aged 6 to 18 years were involved in the study (n = 158). Diagnosis of ADHD was measured with the Mini International Neuropsychiatric Interview Kid (MINI Kid). Dyskinesia was assessed with the Abnormal Involuntary Movement Scale (AIMS). Results: Before methylphenidate administration, the treated ADHD group showed significantly higher AIMS total score than the control group (p = .001) and the treatment-naive ADHD group (p < .001). We found the same pattern 1.5 hr after methylphenidate administration. Conclusion: These results call attention that clinicians should take special care for the possible development of dyskinesia during the treatment of their ADHD patients with methylphenidate.

[Clinical characteristics of children with Tourette's Syndrome]

INTRODUCTION

Tourette Syndrome (TS) is a neurodevelopmental disorder presenting with motor and vocal tics. Although TS influences the everyday life of children, we only have fragmented knowledge on the topic of the developmental and comorbidity profile, symptom severity and genetical/environmental background. The aim of this article is to present the demographical characteristics, comorbidity profile and the tic symptom types and severity of patients from the Tourette Syndrome Outpatient Clinic of Vadaskert Child and Adolescent Psychiatry Hospital, Budapest.

METHODS

Our sample consists of all the patients (N=137), who visited the Tourette Syndrome Outpatient Clinic between February, 2012, and July, 2013. Patients were in the age range of 3 to 18 years. We recorded demographical and tic-specific data (age, symptom onset, TS in the family, comorbidity, adverse pre-/peri-/postnatal events) of the participants, and administered the Yale Global Tic Severity Scale (YGTSS).

RESULTS

The average age at symptom onset was 5.9 years. Average symptom severity (measured by the YGTSS) was 22.4 points. Comorbid Attention Deficit and Hyperactivity Disorder (ADHD) was reported in 31%, Obsessive-Compulsive Disorder (OCD) in 10%, and Autism Spectrum Disorders (ASD) in 10% of the sample. The most common tic types were simple head tics (blinking, shaking of head). Symptom severity correlated positively with age (p <0.05), but not with gender, age at symptom onset, positive family history for TS, or adverse pre-, peri-, and postnatal events.

CONCLUSION

The characteristics of our sample does not show any major differences from international reports of similar samples. Comorbidity is an exception: our sample shows lower rates of comorbidities than usually reported.

Self- and Parent-Rated Quality of Life of a Treatment Naïve Sample of Children With ADHD: The Impact of Age, Gender, Type of ADHD, and Comorbid Psychiatric Conditions According to Both a Categorical and a Dimensional Approach

OBJECTIVE

Our aim was to evaluate the Quality of Life (QoL) of treatment naïve children with ADHD.

METHOD

Data from 178 parent-child dyads were analyzed using multiple regression to assess the relationships between QoL, and characteristics of ADHD and comorbid psychopathology.

RESULTS

Lower self-reported QoL was associated with female gender, higher age, more symptoms of anxiety and trauma-related disorders in dimensional approach, and with the comorbid diagnoses of trauma-related disorders and oppositional defiant disorder (ODD)/conduct disorder (CD) in categorical approach. Lower parent-reported QoL was related to older age and increasing number of symptoms of mood and anxiety disorders on one hand, and any diagnosis of mood and anxiety disorders and ODD/CD on the other.

CONCLUSION

Our results draw the attention to the importance of taking into account age, gender, and both self- and parent reports when measuring QoL of children with ADHD and both dimensional and categorical approaches should be used.

Why are children and adolescents referred for psychiatric assessment without fulfiling diagnostic criteria for any psychiatric disorder?

BACKGROUND

Clinicians often experience that children are referred for psychiatric evaluation without fulfiling the diagnostic criteria of any psychiatric disorders. This study investigates factors that might lead children to psychiatric referral without any psychiatric disorder.

METHOD

Children/adolescents who were referred for psychiatric assessment (referred group) (n = 418, mean age = 10.82 years, SD = 3.81) and a control group (n = 48, mean age = 10.38 years, SD = 3.77) were evaluated by the Mini International Neuropsychiatric Interview Kid (MINI Kid) and the Erfassung der Lebensqualität Kindern und Jugendlichen (Measure of Quality of Life for Children and Adolescents). The referred group was further divided into two subgroups: referred subgroup without MINI Kid diagnosis (n = 61) and referred subgroup with MINI Kid diagnosis (n = 357). Subjects less than 18 years old were included and there was no lower age limit.

RESULTS

Attention-deficit/hyperactivity disorder (ADHD) symptoms significantly increased the odds for referral as social phobia symptoms significantly decreased the odds for psychiatric referral. Regarding quality of life (QoL), the control group showed significantly less impairment when compared with the referred group; the two referred subgroup with and without diagnosis did not differ significantly.

CONCLUSIONS

ADHD symptoms, even in a subthreshold level and impaired QoL represent risk factors for psychiatric referral in children. Secondary prevention of children should target to screen subthreshold ADHD symptoms and QoL.

[Quality of life of newly diagnosed, treatment naive children and adolescents with attention-deficit hyperactivity disorder]

INTRODUCTION

Attention-deficit hyperactivity disorder (ADHD) is one of the most prevalent childhood psychiatric disorder, it affects around 3-12% of the children. ADHD is associated with numerous social and emotional impairments. Quality of life (QoL) studies of children with ADHD established low QoL in the most cases. Our aim was to examine QoL of children with ADHD according to the following aspects: age, children's self-report and parentproxy report, and we also would like to compare them with healthy control group along several dimensions of QoL.

METHODS

The clinical group consist of a treatmant naive group of children with ADHD, who were just diagnosed in the Vadaskert Hospital. The healthy control group consist of children from elementary schools. The children of control group do not have ADHD and do not stand under psychological or psychiatrical treatment. In our study we applied Mini International Neuropsychiatric Interview Kid and Intervertat Lebensqualitat Kindern und Jugendlichen questionare.

RESULTS

Compared children with ADHD to healthy control group they have significantly lower QoL at many areas (school, peer realtions, generally) due their self report. By parent's proxy report children with ADHD have lower QoL according to all of the QoL domains. Parents of children with ADHD reported significantly lower QoL for their children in the most areas (school, family, peer realtion, mental state, generally) then the affected children. Adolescent with ADHD have lower QoL in 3 domains (school, peer relations, generally) than children with ADHD, while children with ADHD have lower QoL in one dimension (being alone) compared with adolescents with ADHD.

CONCLUSION

Based on our results children with ADHD compared to healthy control group have lower QoL in many dimensions and there are age-related differences in the assessment of QoL. Additionally, our study draw the attention to the differences of QoL assessment between children and parents.

Gender interactions in the recognition of emotions and conduct symptoms in adolescents

BACKGROUND

According to literature data, impairment in the recognition of emotions might be related to antisocial developmental pathway. In the present study, the relationship between gender-specific interaction of emotion recognition and conduct symptoms were studied in non-clinical adolescents.

METHODS

After informed consent, 29 boys and 24 girls (13-16 years, 14 ± 0.1 years) participated in the study. The parent version of the Strengths and Difficulties Questionnaire was used to assess behavioral problems. The recognition of basic emotions was analyzed according to both the gender of the participants and the gender of the stimulus faces via the "Facial Expressions of Emotion- Stimuli and Tests".

RESULTS

Girls were significantly better than boys in the recognition of disgust, irrespective from the gender of the stimulus faces, albeit both genders were significantly better in the recognition of disgust in the case of male stimulus faces compared to female stimulus faces. Both boys and girls were significantly better in the recognition of sadness in the case of female stimulus faces compared to male stimulus faces. There was no gender effect (neither participant nor stimulus faces) in the recognition of other emotions. Conduct scores in boys were inversely correlated with the recognition of fear in male stimulus faces (R=-0.439, p<0.05) and with overall emotion recognition in male stimulus faces (R=-0.558, p<0.01). In girls, conduct scores were shown a tendency for positive correlation with disgust recognition in female stimulus faces (R=0.376, p<0.07).

CONCLUSIONS

A gender-specific interaction between the recognition of emotions and antisocial developmentalpathway is suggested.

[Conduct symptoms and emotional decision making in non-clinical adolescents]

BACKGROUND

In adults with antisocial personality disorder, literature data indicate alterations in emotional decision making and in the working of the prefrontal cortex. Similar alterations were described in adolescents with psychopathic traits, however, a dimensional link was not established between behavioral variables and variables associated with decision making. The aim of the present study was to describe the relationship between externalizing symptoms and emotional decision making in non-clinical adolescents.

METHODS

Originally 57, 7th-10th grade students between 13-16 years participated in the study after informed consent, but the data of 4 adolescents were not used because of incomplete data-set (N=53; 24 girls and 29 boys; age=14.7 ± 1.0 years, mean ± SD). The parent version of the Strengths and Difficulties Questionnaire (SDQ) was used to assess behavioral problems. The Iowa Gambling Task (IGT) performance and Raven IQ measures were also assessed.

RESULTS

The number of summarized risky choices was positively correlated with Conduct Problems Scale of SDQ (r=0.31, p<0.05). While the number of risky choices was not correlated with conduct problems in the first 20 selections (r=0.11, p=n.s.), a marked positive correlation was present in the above measures in the last 20 selections (r=0.28, p<0.05). The number of risky choices did not depend on Raven IQ, age, and other behavioral scales of SDQ.

CONCLUSIONS

Even subthreshold conduct symptoms are associated with altered emotional decision making in adolescents, what might be important in the development of antisocial behavior.

Attention-deficit hyperactivity disorder and suicidality in a treatment naïve sample of children and adolescents

BACKGROUND

The aim of the present study was to investigate the possible association between attention-deficit/hyperactivity disorder (ADHD) and suicidality.

METHODS

Using a structured interview (Mini International Neuropsychiatric Interview Kid), the authors examined 418 treatment naïve children/adolescents (aged: 3-18 years). Suicidality was defined by the M.I.N.I. Kid as having any current suicidal ideations and/or suicide attempts.

RESULTS

Two hundred and eleven children/adolescents fulfilled the DSM-IV diagnosis of ADHD and a further 105 showed symptoms of ADHD in subthreshold level. Multiple mediation analyses resulted in a moderated meditational model in which the relationship between symptoms of ADHD and current suicidality was fully mediated by the symptoms of comorbid conditions, but this was moderated by age. In children under 12 years, significant mediators were the symptoms of specific anxiety disorders, while in the adolescent group symptoms of major depressive episode and dysthymia and symptoms of substance abuse/dependence approved as significant mediators.

LIMITATIONS

As the study was cross-sectional, it did not reveal any causal relationship among the investigated factors. Furthermore, as the study population included a treatment naïve clinical sample, we can assume that adolescents, who and/or whose family seek for help at the first time in this age belonged to the less sever end of the spectrum.

CONCLUSIONS

ADHD symptoms are associated with an increased risk of suicidality in treatment naïve children/adolescents. The mechanisms of this relationship can be understood only when developmental factors are considered. Our findings suggest that clinicians should screen suicidality and comorbid symptoms routinely in patients with ADHD.

The relationship between conduct symptoms and the recognition of emotions in non-clinical adolescents

BACKGROUND

In adult individuals with antisocial personality disorder, impairment in the recognition of fear seems established. In adolescents with conduct disorder (antecedent of antisocial personality disorder), only sporadic data were assessed, but literature data indicate alterations in the recognition of emotions. The aim of the present study was to assess the relationship between emotion recognition and conduct symptoms in non-clinical adolescents.

METHODS

53 adolescents participated in the study (13-16 years, boys, n=29, age 14.7±0.2 years; girls, n=24, age=14.7±0.2 years) after informed consent. The parent version of the Strengths and Difficulties Questionnaire was used to assess behavioral problems. The recognition of six basic emotions was established by the "Facial expressions of emotion-stimuli and tests", while Raven IQ measures were also performed.

RESULTS

Compared to boys, girls showed significantly better performance in the recognition of disgust (p<0.035), while no significant difference occurred in the recognition of other emotions. In boys, Conduct Problems score was inversely correlated with the recognition of fear (Spearman R=-0.40, p<0.031) and overall emotion recognition (Spearman R=-0.44, p<0.015), while similar correlation was not present in girls.

CONCLUSIONS

The relationship between the recognition of emotions and conduct problems might indicate an important mechanism in the development of antisocial behavior.

[Aggressive and prosocial behavior in childhood psychopathology]

Aggressive/attacking and helpful/emphatic/prosocial behaviors are extremely important in human relationships. Both high levels of aggression and deficits of prosociality play important role in the development and conservation of mental disorders. We review the measurement options and clinical importance of aggressive and prosocial behavior. The typical developmental pathways and the genetic and environmental background of these behaviors are presented. The clinical tools used in the measurement of aggression and prosociality are summarized in the present paper, with specific attention on questionnaires applied in Hungarian practice. The connections between diagnostic categories (conduct disorder, oppositional-defiant disorder, attention deficit and hyperactive disorder, autism spectrum disorders) and the two behaviors are evaluated. In the end, we present those additional research projects that explore the cognitive-emotional background of aggressive or prosocial behavior with clinical relevance either in the diagnosis or in the treatment of child psychiatric diseases.

[The relationship between reactive/proactive aggression, callous/unemotional traits and behavioural problems in Hungarian adolescents]

INTRODUCTION

The relationship between the type of physical aggressive behavior, callous/unemotional traits and behavioral problems was extensively studied in the literature, but no similar data exist in Hungarian adolescents.

AIM

In the present study, the type of aggressive behavior was assessed in adolescents on a normative sample to study its relationship with callous/unemotional traits and behavioral problems.

SAMPLE

223 students were participated in the study after informed consent (girls, n=106, age: 14.2±1.5 years; boys, n=117, age: 13.9±1.6 years) from primary and secondary schools in Miskolc and adjacent areas.

METHODS

The Reactive/Proactive Aggression Questionnaire was used to assess the level of aggressive behavior, the Inventory of Callous Unemotional Traits was used to measure callous/unemotional traits, while behavioral problems were established by the means of the Strengths and Difficulties Questionnaire.

RESULTS

In the present non-clinical sample, the level of reactive aggression was higher than the level of proactive aggressive behavior. In boys, proactive and total aggression measures were significantly higher compared to girls. In both genders, reactive aggression was specifically associated with emotional and peer-related problems. Proactive aggression was correlated positively with callous traits in both genders, while self-reported prosocial behavior had an inverse correlation with proactive aggressive behavior in boys. Self reported conduct- and hyperactivity problems were positively correlated with both types of aggressive behavior in both genders. The strongest positive correlation was observed between self-reported conduct symptoms and both types of aggressive behavior.

CONCLUSIONS

Callous/unemotional traits were related with proactive forms of aggression, similar to literature data. Reactive aggressive behavior was related to peer-related and emotional problems, thus our data outlined the importance of the distinction between the two main types of aggression.

[Validation of the Hungarian version of the Strengths and Difficulties Questionnaire in an adolescent clinical population]

INTRODUCTION

The short Strengths and Difficulties Questionnaire (SDQ) available in parent, teacher and self-report versions, is used world-wide for assessing and screening childhood behavior and mental problems, as part of clinical assessments, therapy outcome evaluations, and research tool. The aim of the present study was to extend the use of Hungarian version to a clinical sample, to examine the clinical cut-off values suggested previously on the basis of a normative sample, and to test the questionnaire's sensitivity in differentiating between different psychiatric disorders.

METHOD

The parent and self-report versions of the five scale SDQ-Magy questionnaire was filled in by 716 parents and their children admitted to Vadaskert Child Psychiatry and Outpatient Clinic. Clinical (ICD) diagnoses were determined during psychiatric examination.

RESULTS

With a few exceptions, internal consistencies of the scales were satisfactory (0,55-0,79), the parent version showing greater reliability compared to the self-report version. Children's age, gender, and parents' level of education had some effect on the scale scores. The questionnaire's Total problem and symptom scale scores were very effective in discriminating between the control and the clinical sample. In the clinical sample, parents rated their children's behavior and mental problems as more severe. Profiles of scale scores distinguished the wider internalizing, externalizing, and co-morbid diagnostic categories, as well as the eight specific diagnoses. Based on the normal-abnormal cut-off values proposed earlier (Turi et al., 2011), the great majority of clinical cases were screened by the questionnaire.

CONCLUSIONS

The Hungarian version of the SDQ proved applicable in a clinical sample. Psychometric properties, variances due to age, gender and informant were consistent with international experiences. SDQ profiles related to clinical diagnoses and their difference from the control group show the sensitivity and discriminative power of the questionnaire, while the screening ability based on clinical cut-offs also supports the clinical use of the questionnaire.

[Comparing the comorbidity of attention-deficit/hyperactivity disorder in childhood and adolescence]

BACKGROUND

International researches found that comorbid psychiatric diagnoses are present in more than two-thirds of attention-deficit/hyperactivity disorder (ADHD) cases, and the patterns of comorbidity are influenced by developmental aspects. The aim of this study is to compare the comorbid diagnoses with ADHD on a Hungarian sample between a children and an adolescents.

METHODS

Children and adolescents (under the age of 18) with ADHD according to the Mini International Neuropsychiatric Interview Kid, hospitalized for the first time to Vadaskert Psychiatric Hospital for Children and Adolescents were included in the study. The study sample was divided into two groups: children (3-12 years) and adolescents (13-18 years). Descriptive statistics, Chi-square test and independent sample t-test were applied.

RESULTS

The most common comorbid diagnoses with ADHD were oppositional defiant disorder, conduct disorder and suicide behavior in both age-groups, as well as manic episode in the child group and generalized anxiety disorder in the adolescent group. In the adolescent group the number of comorbid diagnoses with ADHD (mean number of diagnoses= 4.30; SD=2.84) was significantly higher than in the child group (mean number of diagnoses=2.61; SD=1.73) (t=-3,726; df=50,202; p<0,001). Comparing the prevalence of comorbid disorders between the two age groups, we did not found any diagnosis which was significantly more common in the child group than in the adolescent group, while major depressive disorder, suicide behavior, dysthymic disorder, alcohol and psychoactive substance dependence, psychotic disorder and generalized anxiety disorder occured significantly more frequently in the adolescent group.

CONCLUSION

Our study draws the attention to the importance of the early recognition of ADHD, as well as the importance of the evaluation of comorbid externalizing and internalizing disorders in childhood and adolescence. Our result of the common co-occurrence of suicidal behavior and ADHD in both age-groups is of great clinical relevance. More studies are needed to investigate the frequent comorbidity of ADHD and manic episode in childhood, because of the several overlapping symptoms of these disorders.

[Symptoms of depression in children and adolescents in relation to psychiatric comorbidities]

INTRODUCTION

The lifetime prevalence of MDD before adolescence is 4-5%, while the symptoms concern 13-20% of the adolescents. In the development of suicidal behaviour the most important risk factors are the use of psychoactive drugs and smoking. Psychiatric comorbidities are aggravating significantly the major depression. The comorbidities are high among major depression, anxiety and disruptive disorders.

SAMPLE AND METHOD

We examined 649 children being in a depressive episode diagnosed by ISCA-D semi-structured interview, 45,9% of them were girls, and 54,1% were boys, the mean age was 11,7 years ( SD=2,00). The participants were enrolled into three groups according to their comorbidities: group with only depression without comorbidities, group with anxiety comorbidity, and group with disruptive comorbidity. We compared the three groups according to the frequency of their depressive symptoms.

RESULTS

Anxiety comorbidities increase the incidence of depressive symptoms. Among the criteria symptoms irritability where the most frequent symptom independently from the comorbidities, the depressed mood is the most frequent within the anxiety group, while anhedonia occurred with a moderate frequency in each groups. In the anxiety group the vegetative symptoms, while in the disruptive group the psychomotor agitation and the feeling of worthlessness are the most frequent symptoms. Comorbidities are increasing the incidence of the suicide symptoms. The incidence of impaired decision making was high in each group, the comorbidities didn't influence it's frequency. Among depressed boys irritability and feelings of worthlessness (low self-esteem) increase the presence of externalisation comorbidity. Among depressed girls guilt was significantly more frequent in the anxiety comorbidity group, and concentration problems are the most typical symptoms in the clear MDD group, without comorbidities.

Methylphenidate treatment and dyskinesia in children with attention-deficit/hyperactivity disorder

OBJECTIVES

Case reports suggest a relationship between methylphenidate treatment and dyskinesia in attention-deficit/hyperactivity disorder (ADHD). The aim of the current study was (a) to investigate abnormal involuntary movements of children with ADHD before and after the administration of methylphenidate and (b) to investigate the effect of a provocative assessment method used to make latent dyskinesia visible, which is included in the Abnormal Involuntary Movement Scale (AIMS).

METHODS

Participants, aged 6-18, were recruited from a Child and Adolescent Psychiatric Hospital and Outpatient Clinic (Vadaskert Foundation), Budapest, Hungary. Using a structured diagnostic interview (Mini International Neuropsychiatric Interview Kid), 37 children were included in the ADHD group and 34 children in the control group. The AIMS was used to observe and score dyskinesia.

RESULTS

There was a significant difference between the baseline total AIMS score in the ADHD and the control groups, with the ADHD subjects evidencing substantially higher severity than controls. Provocation, as applied with the administration of the AIMS, significantly increased the AIMS total score in both groups. The administration of methylphenidate had no effect on the total score of the AIMS. In the ADHD group, we observed a significant negative relationship between the patients' age and the overall severity on the AIMS. In contrast, in the control group we detected a significant positive relationship between the patients' age and the overall severity on the AIMS before and no relationship after provocation.

CONCLUSIONS

Methylphenidate-treated children with ADHD had more dyskinesia than children in the control group. Dyskinesia did not worsen after a single dose of methylphenidate. Higher dyskinesia scores in the methylphenidate-treated younger age group warrant caution in the methylphenidate treatment of ADHD; however, further studies are needed to clarify the possible causal relationship between dyskinesia and methylphenidate treatment and/or age and/or the disease itself.

[Investigation of callous/unemotional traits and interpersonal characteristics among Hungarian adolescents--preliminary research results]

In the understanding of aggressive behaviour an important role is contributed to callous/unemotional (C/U) traits (lack of guilty and empathy, grandiose self, manipulation). C/U traits are parts of psychopathy construct. There were a growing amount of researches in last decades connected to the appearance of C/U traits among children. Cognitive, behavioral and emotional features were identified among children with C/U traits which may contribute to the appearance of aggressive behavior.

AIM

Aim of this paper is to examine connection between C/U traits and interpersonal characteristics in normative population. This paper is a part of a publication serial taken by the Institution of Psychology at the University of Debrecen and Vadaskert Child Psychiatry Hospital and Outpatient Clinic about callous/unemotional traits.

METHODS AND SAMPLE

We studied 223 elementary and secondary school students using the Inventory of Callous Unemotional Traits and the Strenghts and Difficulties Questionnare.

RESULTS

In case of moderate appearance of callous/unemotional traits behavior problems, relationship problems and hyperactivity are more typical furthermore presence of prosocial behavior is less typical.

CONCLUSION

Results from normal population confirm assumption that C/U traits contribute to the appearance of juvenile aggression and antisocial behavior.

Reduced fronto-cortical brain connectivity during NREM sleep in Asperger syndrome: an EEG spectral and phase coherence study

OBJECTIVE

To investigate whether sleep macrostructure and EEG power spectral density and coherence during NREM sleep are different in Asperger syndrome (AS) compared to typically developing children and adolescents.

METHODS

Standard all night EEG sleep parameters were obtained from 18 un-medicated subjects with AS and 14 controls (age range: 7.5-21.5years) after one adaptation night. Spectral, and phase coherence measures were computed for multiple frequency bands during NREM sleep.

RESULTS

Sleep latency and wake after sleep onset were increased in AS. Absolute power spectrum density (PSD) was significantly reduced in AS in the alpha, sigma, beta and gamma bands and in all 10 EEG derivations. Relative PSD showed a significant increase in delta and a decrease in the sigma band for frontal, and in beta for centro-temporal derivations. Intrahemispheric coherence measures were markedly lower in AS in the frontal areas, and the right hemisphere over all EEG channels. The most prominent reduction in intrahemispheric coherence was observed over the fronto-central areas in delta, theta, alpha and sigma EEG frequency bands.

CONCLUSION

EEG power spectra and coherence during NREM sleep, in particular in fronto-cortical derivations are different in AS compared to typically developing children and adolescents.

SIGNIFICANCE

Quantitative analysis of the EEG during NREM sleep supports the hypothesis of frontal dysfunction in AS.

Association of the GABRD gene and childhood-onset mood disorders

The chromosome 1p36 region was previously indicated as a locus for susceptibility to recurrent major depressive disorder based on a linkage study in a sample of 497 sib pairs. We investigated the gamma-aminobutyric acid A (GABA(A)) delta receptor subunit gene, GABRD, as a susceptibility gene to childhood-onset mood disorders (COMD) because of substantial evidence implicating GABAergic dysfunction in mood disorders and the position of this gene near the 1p36 linkage region. Using a sample consisting of 645 Hungarian families with a child/adolescent proband diagnosed with a mood disorder with the onset of the first episode before age 15, we found some evidence for the association of two polymorphisms located within the gene, rs2376805 and rs2376803, as well as significant evidence for biased transmission of the haplotypes of these two markers (global chi(2) test for haplotypes = 12.746, 3 df, P = 0.0052). Furthermore, significant evidence of association was only observed in male subjects (n = 438) when the results were analyzed by sex (chi(2) = 9.000 1 df, P = 0.003 for rs2376805). This was in contrast with the previous linkage findings, as LOD scores exceeding 3 were only in female-female pairs in that study. These findings point to the GABRD gene as a susceptibility gene for COMD; however, this gene may not explain the previous linkage finding.

Mutation screen and association analysis of the glucocorticoid receptor gene (NR3C1) in childhood-onset mood disorders (COMD)

Depressive disorders are highly heterogeneous psychiatric disorders involving deficits to cognitive, psychomotor, and emotional processing. Considerable evidence links disruption to the hypothalamic-pituitary-adrenal (HPA) axis to the etiology of depression, with specific deficits reported in glucocorticoid receptor (GR)-mediated negative feedback. Given the role of GR-mediated negative feedback in mediating response to stress, and the clear link between stress and depression, it is plausible that polymorphisms in the GR gene (NR3C1) act to increase susceptibility. Maternal behavior in rats epigenetically alters a NGF1-A transcription factor binding-site in the promoter region of the GR gene, providing a mechanism by which environmental cues can regulate GR expression and thus response to stress. The analogous region of the human GR gene (NR3C1) has not been studied, but it is possible that polymorphisms in this region may alter the binding of transcription factors known to regulate GR expression. In this study, we have performed bioinformatic analyses on the promoter region of NR3C1 to identify conserved promoter sequences and predicted transcription factor binding sites. These regions were screened with denaturing high-performance liquid chromatography (DHPLC) and direct re-sequencing, and several novel polymorphic variants were identified. We genotyped nine polymorphisms across NR3C1 in a large sample of Hungarian nuclear families ascertained through affected probands with a diagnosis of childhood-onset mood disorders (COMD). Single-marker analysis provided little evidence for an association of this gene with COMD, but multi-marker analysis across a region of high linkage disequilibrium revealed modest evidence for the biased transmission of several haplotypes.

[Child-adolescent psychiatry to adult psychiatry: can we find those disorders in adulthood which are typically diagnosed in childhood?]

The aim of the current study is to provide a short overview on autism, attention deficit hyperactivity disorder (ADHD) and Tourette syndrome. According to international data, the prevalence of autism is 2-60/10000 and the symptoms persist during the entire life; the prevalence of ADHD among children and adolescents is 2,4-12,0% and the symptoms cause problem in 30-50% in adults as well; while the prevalence of tic disorder is 1-6,6% among children and adolescents and the symptoms persist in 10% in adulthood. According to Hungarian data, these disorders are relatively rare in adult psychiatric practice. Presenting case reports of adults with autism, ADHD and Tourette syndrome, we would like to demonstrate the symptoms, treatment possibilities of these disorders and how they can influence the patients' quality of life.

Tagging SNP association study of the IL-1beta gene (IL1B) and childhood-onset mood disorders

Given substantial evidence for IL-1beta involvement in the etiology of depression, the IL1B gene is a strong candidate for involvement in susceptibility to depressive disorders. However, association studies investigating this, to date, have been limited to just two polymorphisms (rs1143627[-31T/C] and rs16944[-511C/T]) that constitute only a fraction of the genetic variation that is actually present across this gene in the population. Here, in a family-based association study of childhood-onset mood disorders (COMD), characterized by onset of depression before the age of 15, we have used a gene-wide approach, employing a panel of five tagging SNPs spanning the entire gene. Based on TDT analyses of both individual alleles and haplotypes, in a study sample of 646 families (with 782 affected children), none of the SNPs, including those implicated in transcriptional regulation of the gene, showed evidence for association with COMD. This is the largest and most comprehensive study of IL1B in relation to mood disorders that has been carried out, to date. The results do not support the involvement of IL1B as a major factor in genetic risk for early-onset mood disorders.

Cytokine Genes TNF, IL1A, IL1B, IL6, IL1RN and IL10, and childhood-onset mood disorders

BACKGROUND/AIMS

Inflammatory cytokines induce a behavioral syndrome, known as sickness behavior, that strongly resembles symptoms typically seen in depression. This resemblance has led to the theory that an imbalance of inflammatory cytokine activity may be a contributing factor in depressive disorders. Support for this is found in multiple lines of evidence, such as the effects of cytokines on the activities of the hypothalamic-pituitary-adrenal axis, serotonin and brain-derived neurotrophic factor, and hippocampal function, all of which are implicated in the etiology of depression. In addition, associations between inflammatory activity and depressive symptomology have been documented in a number of studies, and the depressogenic effects of cytokine therapy are well known. Accordingly, given that depression has a substantial genetic basis, genes involved in the regulation of inflammatory cytokine activity are strong candidates for involvement in genetic susceptibility to depressive disorders. Here, we have tested 6 key genes of this type, TNF, IL1A, IL1B, IL6, IL1RN and IL10, as candidates for involvement in childhood-onset mood disorders.

METHODS

In this study of 384 families, each ascertained through a child with depression diagnosed before the age of 15 years, 11 polymorphisms of known or likely functional significance (coding and regulatory variants) were analyzed.

RESULTS

Testing for biased transmission of alleles from parents to their affected offspring, we found no evidence for an association between childhood-onset mood disorders and any of the polymorphisms, either individually or as haplotypes.

CONCLUSION

The present study does not support the involvement of the TNF, IL1A, IL1B, IL6, IL1RN and IL10 variants as major genetic risk factors contributing to early-onset mood disorders.

Association of the neurotrophic tyrosine kinase receptor 3 (NTRK3) gene and childhood-onset mood disorders

OBJECTIVE

Genome scans have revealed significant evidence for linkage of depression to chromosome 15q25.3-q26.2. The gene for neurotrophic tyrosine kinase receptor 3 (NTRK3), the receptor for neurotrophin-3 (trkC) and a key gene in neurotrophin signaling, is located within this region and, given evidence for synaptic plasticity as a mechanism in mood disorders, was considered a prime candidate. The authors investigated NTRK3 as a susceptibility gene for childhood-onset mood disorders.

METHOD

The study sample consisted of 603 families with 723 affected children and adolescents diagnosed with a mood disorder with onset of the first episode by age 15. The authors genotyped 18 polymorphic markers across the NTRK3 gene in this sample and tested for association.

RESULTS

Results identified significant evidence for association for five of the markers using the transmission disequilibrium test. Four of the five markers were located in a region of strong linkage disequilibrium and were highly correlated. Haplotype results provided significant evidence for association to haplotypes composed of markers located in two haplotype blocks.

CONCLUSIONS

The results for NTRK3 as well as the authors' previous finding for association to brain-derived neurotrophic factor in this sample support synaptic plasticity as a mechanism contributing to mood disorders that begin during childhood and adolescence and specifically implicate the NTRK3 gene as a contributing factor in the 15q-linked region.

Methylphenidate-induced orofacial and extremity dyskinesia

In this paper, we report the case of a 6(1/2)-year-old male patient diagnosed with attention-deficit/hyperactivity disorder (ADHD) who developed orofacial and extremity dyskinesias immediately after methylphenidate treatment. The episode lasted 5 hours, peaking in intensity 2 hours after the medication was administered before gradually subsiding. Five hours after the methylphenidate was administered, the child became extremely irritated and aggressive, which lasted approximately 2 hours. The patient's general intelligence (IQ) was measured to be below the normal range. The potential relationship between methylphenidate intake and the development of dyskinesia calls into question different mechanisms involving drug-receptor interaction or individual drug sensitivity related to a lower IQ. Our case report has practical implications for physicians by raising their awareness of dyskinesia as a potential side effect of methylphenidate treatment.

The relations of temperament and emotion self-regulation with suicidal behaviors in a clinical sample of depressed children in Hungary

Although major depressive disorder (MDD) is associated with suicidal behaviors, some depressed individuals are not suicidal and others evidence various forms of suicidality. We thus investigated whether aspects of temperament and self-regulation of dysphoria represent risk factors for DSM-IV suicidality (recurrent thoughts of death, recurrent suicidal ideation, suicidal plan, and suicide attempt) in depressed youths. Using a sample of children with MDD (N = 407; ages 7-14 years), recruited from clinical sites across Hungary, we tested the hypotheses that: (a) suicidality is related to higher levels of trait negative emotionality as well as more maladaptive and fewer adaptive regulatory responses to dysphoria and (b) as the severity of suicidal behavior increases, levels of trait negative emotionality and dysfunctional emotion regulation also increase. We also explored if other aspects of temperament relate to suicidality. Children's DSM-IV diagnoses were based on semi-structured interviews and best-estimate psychiatric consensus. Parents independently provided ratings of their children's temperament, and children separately completed an inventory of emotion regulation (ER). Using multivariate models, we failed to confirm the hypothesized relations of negative trait emotionality and suicidality, but confirmed that high maladaptive and low adaptive ER response tendencies increase the odds of suicidal behaviors, above and beyond the risk posed by depressive illness severity. Unplanned interaction terms between temperament dimensions (other than negative emotionality) and ER suggested that at some high-extremes of temperament, ER has no impact on suicidality but in their absence, adaptive ER lowers the risk of suicidality. The practical implications of the findings are discussed.

[Analysis of the dopamine D4 receptor gene variants in attention deficit hyperactivity disorder]

The human dopamine D4 receptor (DRD4) gene has been extensively studied as a candidate gene for attention deficit hyperactivity disorder (ADHD). Both the 5' regulatory region and the coding sequence contain a number of polymorphisms. The most widely investigated polymorphism of the DRD4 gene is the 48 bp VNTR (Variable Number of Tandem Repeats) in the third exon. The promoter variants have received particular attention in the past few years due to their possible role in the regulation of gene expression. In this study we describe an association analysis of the 120 bp duplication and three sequence variations (SNPs, Single Nucleotide Polymorphism; -616 C/G, -615 A/G, -521 C/T) in the 5' region of the DRD4 gene is presented among children with ADHD. In case-control approach, the 1-repeat form of the 120 bp duplication had a significantly higher frequency among ADHD children than controls, both in allele-(p=0.047), and genotype (p=0.019) distributions. There was no significant difference between the ADHD and control groups in the allele or genotype frequencies of the investigated SNPs. The transcriptional effect of the 120 bp duplication was analysed in luciferase reporter system. The different 120 bp duplication alleles (1-repeat, 2-repeat and the newly identified 4-repeat allele) was found to have an effect on transcriptional activity of the DRD4 gene in both neuroblastoma and retinoblastoma cell lines in a dose-dependent manner. The higher was the repeat number of the 120 bp sequence in the promoter, the stronger was the decrease of the gene transcription (1-repeat > 2-repeat > 4-repeat; p<0.01). These results of association and functional analyses suggest that the 1-repeat form of the 120 bp duplication might be a risk factor of ADHD.

[Executive dysfunction in frontal lesions and frontal epilepsy]

BACKGROUND

To explore the functions of the frontal lobe that are associated with high order cognitive and behavioral aspects such as the organization and execution of thoughts and behavior by neuropsychological methods is difficult. These so called executive functions are in close connection with the prefrontal thalamocortical circuits, damage of which can cause deficits in cognitive functions and even changes in personality.

METHODS

The aim of this study is to present a neuropsychological battery for testing frontal lobe functions. 31 patients (with frontal epilepsy and/or frontal lesion) and 38 healthy control subjects participated in the study. The control subjects were matched to the patient group in age, gender and education.

RESULTS

Comparing to the controls the patient group showed significant deficits in most of the measured executive functions, except two tests which show that the short time selective attention is preserved. We divided the patient group into three subgroups (frontal epilepsy only FLE, frontal lesion only FL, frontal lesion and epilepsy FLE+FL) and we found that except working memory deficits and problems in inhibition, there were no difference between the FLE patients and the control group. We found most frequently perseveration and errors in a strategy making task among the FL (mainly medial) patients. We didn't find any difference in these tests according to the lateralization of the lesion.

CONCLUSION

In conclusion we found that working memory deficits and problems in inhibition differentiated the frontal patient group from the controls in all cases. We emphasize that in frontal epilepsy (with no reported MR lesion) there are the same type, however more limited neuropsychological alterations as in lesional frontal dysfunction.

Association study of the adrenergic receptors and childhood-onset mood disorders in Hungarian families

The adrenergic system has been implicated in the etiology of depression based on a number of lines of evidence, particularly, the mechanism of some classes of antidepressants which increase the synaptic levels of norepinephrine. Further, several genome scans for mood disorders, both unipolar and bipolar, have indicated linkage to the chromosomal regions of 5q23-q33.3, 8p12-p11.2, 4p16, and 10q24-q26, the location of the adrenergic receptors alpha1B (ADRA1B), beta3 (ADRB3), alpha2C (ADRA2C), alpha2A (ADRA2A), and beta1 (ADRB1). In this manuscript, we report on the relationship of the adrenergic receptors and depression using a family based association approach and 189 families (223 affected children) with childhood-onset mood disorder (COMD) collected in Hungary. We found no significant evidence for an association with any of the 24 markers, in total, tested across these genes using single marker analysis or haplotypes of markers across these genes. The results in the present sample indicate that these nine genes are unlikely to be major susceptibility genes contributing to COMD.

[Neurocognitive symptoms of childhood attention deficit hyperactivity disorder]

OBJECTIVES

Attention Deficit Hyperactivity Disorder is the most common childhood-onset disorder that has been characterized with the dysfunction of executive functions. These functions are related to the frontal lobe, especially to different frontostriatal networks. The purpose of this study was to examine executive functions of 5-7 years old (non-literate) children with and without ADHD.

METHOD

We used well-known neuropsychological tests (and some other tests developed by us) which measure the organisation and execution of behavior and thinking. 31 children with ADHD and 26 healthy children without ADHD -- comparable to the other sample with respect to age and sex -- participated in this examination. We compared the two groups in terms of various aspects of executive functions, such as inhibition, attention, motor implementation and visual memory. The test battery used included the Colour Raven Test, a version of the Tower of Hanoi for children, the Bender A and B Test, the Block Design Subtest of the Wechsler Intelligence Scale, the children version of Rey Complex Figure Test, the Picture Attention Test and the Fruit Stroop Test. In order to explore the characteristics of the variables, the factor-analytic method was used by which the various aspects of executive functions could be separated.

RESULTS

Statistical comparison of the two groups revealed that several aspects of executive dysfunctions (strategy-constitution, inhibition, attention and motor implementation) can be seen in ADHD.

[Comorbidity in child psychiatry: is the comorbidity of pediatric mania and ADHD really that high?]

OBJECTIVE

The purpose of our study was to investigate possible reasons of diagnosing comorbidity in child psychiatric disorders, with special attention to the comorbidity of mania and attention deficit-hyperactivity syndrome (ADHD).

METHOD

Using a structured interview, the Mini International Neuropsychiatric Interview Kid (M.I.N.I. Kid) we examined 112 consecutive admitted children aged under 18 in the Vadaskert Children's Psychiatric Hospital. For all children, best-estimated diagnoses were made by an independent child-psychiatrist as well, who was blind to the diagnoses of the M.I.N.I. Kid. Six children were diagnosed as having pervasive developmental disorder by the independent clinician, their data were excluded. In this way the data of 106 children were included in the statistical analysis.

RESULTS

Comorbidity: Based on the M.I.N.I. Kid test comorbid diagnoses were found in 74.53% of the children and 51.90% of the children with comorbid diagnoses had three or more concomitant diagnoses. The maximum number of diagnoses obtained concomitantly by the M.I.N.I. Kid was 9. The M.I.N.I. Kid produced 2.58 diagnoses for one child on average. The independent child-psychiatrist found comorbid diagnoses in 25.47% of the children. The maximum number of diagnoses made by the independent child-psychiatrist for 1 child was 2. The independent child-psychiatrist established 1.25 diagnoses for one child on average. Manic/hypomanic episode: Based on the M.I.N.I. Kid manic episode was diagnosed in 14.15% of the children and hypomanic episode in 6,60% of them, while the independent psychiatrist did not diagnose these conditions in any of the children. 99.33% of the children with manic episode were diagnosed together with ADHD by the M.I.N.I. Kid. In 57.14% of those cases, where the M.I.N.I. Kid diagnosed a hypomanic episode, it found an ADHD at the same time. The independent psychiatrist found ADHD in 73.33% of the children with the diagnoses of manic episode and in 57.14% of the children with hypomanic episode determined by the M.I.N.I. Kid.

CONCLUSIONS

The considerable differences found in the number of diagnoses made by using the M.I.N.I. Kid and by the independent child psychiatrist may indicate the possible over-sensitivity of structured interviews and the characteristics of diagnostic systems: several disorders have overlapping symptoms, making the differential diagnoses difficult.

Suicidal depressed vs. non-suicidal depressed adolescents: differences in recent psychopathology

BACKGROUND

Few studies have focused on the differences between two depressed groups of patients in child psychiatry: the suicidal and the non-suicidal adolescent population. As in other countries, depression is one of the most prevalent diagnoses in adolescents in Hungary.

AIMS

The present study was designed to determine (a) whether there are specific symptoms to differentiate between two clinical samples of depressed children: patients expressing suicidal behaviour and their peers with no suicide attempts, and (b) if there are significant differences between parents' and adolescents' reports of the same symptoms.

METHODS

Using a recently developed semi-structured interview (Diagnostic Evaluation Schedule for Children and Adolescents-Hungarian version, ), 132 symptoms were assessed for two clinical groups of depressed adolescents: a suicidal group (N=54) [corrected], and a non-suicidal group (N=78) [corrected]. The suicidal group had all made an unsuccessful suicide attempt and/or had had frequent suicidal thoughts during the 6 months prior to the study. The non-suicidal group had neither attempted suicide, nor had had suicidal thoughts during the previous 6 months. All cases were selected from a larger sample of 490 consecutively referred new outpatient children over a 1 year period in five psychiatric facilities in Hungary. Only 13-17-year-old adolescents participated in the study. Both samples were identified using operationalised computer algorithm criteria of DSM-IV major depressive disorder episode (MDD) irrespective of the current clinical diagnosis of the patients. The Pearson Chi-square test with Monte Carlo correction was used to evaluate the differences between the suicidal and the non-suicidal depressed samples.

RESULTS

Hopelessness, negative self-esteem and violent behaviour were the only significant discriminators between the two study groups according to the parent interviews, with increased problem scores in the suicidal sample compared to the non-suicidal sample. Suicidal depressed adolescents view themselves as more depressed and violent than do non-suicidal depressed individuals and were less anxious about their parents.

CONCLUSIONS

The two depressed samples (suicidal vs. non-suicidal individuals) have only very few dissimilarities. There are, however, some essential differences between the parental and adolescent perceptions of the suicidal and depressive symptoms of the adolescent. The findings of the study underscore the necessity of collecting data from both the parent and the adolescent.

LIMITATIONS

Cross-sectional, no lifetime psychopathology, referred samples, no blind estimation of the suicidal status of patients.

[Multidisciplinary therapy of Tourette syndrome]

The marked fluctuation in symptoms with a spectrum of behavioral problems contribute to misdiagnosis of Tourette syndrome. The authors review the recent progress in diagnosis and management with an emphasis on multidisciplinary approach. Possible associations with various genes have been found in etiology of Tourette syndrome. Development of the disease comes of dopaminerg neurotransmission disorder resulting in cortico-striato-thalamic system dysfunction. Tics are brief movements or sounds that occur intermittently and unpredictably mimicking fragments of normal behavior. Diagnostic criteria are based on the motor and vocal phenomena and their dynamics. The key concept in management are the tic severity scaling correlating with quality of life measurements. Therapeutic interventions indicated at severe alteration in patient's quality of life. Treatment plan combines various drug protocols, psychotherapy and behavioral therapy which should be optimalized for most disabling symptom. Social isolation and self injurious behavior complicates the treatment resistant, severe cases. In these subgroup of patient, an adequate selection of stereotactic intervention could provide an effective control of tic severity or behavioral disorder. Tourette syndrome, as a typical neuropsychiatric disorder, is a striking example for improved efficacy of multidisciplinary approach.

Probabilistic classification learning in Tourette syndrome

Tourette syndrome (TS) is characterised by stereotyped involuntary movements, called tics. Some evidence suggests that structural and functional abnormalities of the basal ganglia may explain these motor symptoms. In this study, the probabilistic classification learning (PCL) test was used to evaluate basal ganglia functions in 10 children with less severe tics (Yale Global Tic Severity Scale (YGTSS) scores<30) and in 10 children with more severe symptoms (YGTSS score>30). In the PCL task, participants are asked to decide whether different combinations of four geometric forms (cues) predict rainy or sunny weather. Each cue is probabilistically related to a weather outcome, and feedback is provided after each decision. After completion of the probabilistic stimulus-response learning procedure, subjects received a transfer test to assess explicit knowledge about the cues. The children with TS exhibited impaired learning in the PCL task in comparison with the 20 healthy control subjects. This impairment was more pronounced in the TS patients with severe symptoms, and there was a significant negative relationship between the final classification performance and the YGTSS scores. The patients showed normal learning in the transfer test. These results suggest that the neostriatal habit learning system, which may play a central role in the acquisition of probabilistic associations, is dysfunctional in TS, especially in the case of more severe motor symptoms. The classification performance and the severity of tics were independent of the explicit knowledge obtained during the test.

Are microarousals preceded by electroencephalographic slow wave synchronization precursors of confusional awakenings?

The number of microarousals preceded by electroencephalographic (EEG) slow wave synchronization (MAS) and the number not preceded by EEG slow wave synchronization (K-complexes and/or delta groups) (MA) were analyzed during the first night of sleep in nine young patients with somnambulism and/or sleep terrors and in eight age- and sex-matched controls. While MAs peaked in REM ad intermediate sleep, MASs appeared as a phenomenon of NREM sleep, peaking in stage 2. The number of MASs was significantly greater in all stages of NREM sleep in the patient group, but number and distribution of MAs did not differ between the two groups. In the patient group, the MASs occurred in slow wave sleep (stages 3-4 of each sleep cycle); in controls, MASs occurred infrequently. MASs were frequently associated with automatic chewing movements. The higher frequency of microarousals in the patient group did not result in an increase in time awake during the night. The increase in number of microarousals supports Broughton's hypothesis of the presence of some "arousal disorder" in somnambulism and/or sleep terrors. MASs may be predictive markers of ensuing confusional awakenings.