"Watch Me Grow- Electronic (WMG-E)" surveillance approach to identify and address child development, parental mental health, and psychosocial needs: study protocol

Background

The COVID-19 pandemic and the associated economic recession has increased parental psychosocial stress and mental health challenges. This has adversely impacted child development and wellbeing, particularly for children from priority populations (culturally and linguistically diverse (CALD) and rural/regional communities) who are at an already increased risk of health inequality. The increased mental health and psychosocial needs were compounded by the closure of in-person preventive and health promotion programs resulting in health organisations embracing technology and online services. Watch Me Grow- Electronic (WMG-E) – developmental surveillance platform- exemplifies one such service.

WMG-E was developed to monitor child development and guide parents towards more detailed assessments when risk is identified. This Randomised Controlled Trial (RCT) aims to expand WMG-E as a digital navigation tool by also incorporating parents’ mental health and psychosocial needs. Children and families needing additional assessments and supports will be electronically directed to relevant resources in the ‘care-as-usual’ group. In contrast, the intervention group will receive continuity of care, with additional in-person assessment and ‘warm hand over’ by a ‘service navigator’ to ensure their needs are met.

Methods

Using an RCT we will determine: (1) parental engagement with developmental surveillance; (2) access to services for those with mental health and social care needs; and (3) uptake of service recommendations. Three hundred parents/carers of children aged 6 months to 3 years (recruited from a culturally diverse, or rural/regional site) will be randomly allocated to the ‘care-as-usual’ or ‘intervention’ group. A mixed methods implementation evaluation will be completed, with semi-structured interviews to ascertain the acceptability, feasibility and impact of the WMG-E platform and service navigator.

Conclusions

Using WMG-E is expected to: normalise and de-stigmatise mental health and psychosocial screening; increase parental engagement and service use; and result in the early identification and management of child developmental needs, parental mental health, and family psychosocial needs. If effective, digital solutions such as WMG-E to engage and empower parents alongside a service navigator for vulnerable families needing additional support, will have significant practice and policy implications in the pandemic/post pandemic period.

Trial registration

The trial (Protocol No. 1.0, Version 3.1) was registered with ANZCTR (registration number: ACTRN12621000766819) on July 21st, 2021 and reporting of the trial results will be according to recommendations in the CONSORT Statement.

Predictors of developmental surveillance completion at six months of age in south western Sydney

BACKGROUND

While developmental surveillance programs promote early identification of child developmental problems, evidence has indicated suboptimal uptake. This study aimed to identify predictors of developmental surveillance completion at 6 months postpartum.

METHODS

Questionnaires were administered to the parents of 510 infants who were born in south western Sydney, Australia over a 22-month period. Attendance for developmental screening and completion of the Parents' Evaluation of Developmental Status (PEDS) at 6 months postpartum were modelled separately using multivariable logistic regression.

RESULTS

Developmental surveillance attendance was predicted by higher levels of maternal education, annual income and being informed about checks. PEDS completion at 6 months of age was predicted by higher income and being informed, as well as being married, employed, speaking English at home, full-term birth and the professional status of the practitioner completing the check.

CONCLUSIONS

Barriers to developmental surveillance included low socioeconomic status, linguistic diversity and possible gaps in parental knowledge and professional education. Developmental surveillance rates may be increased by the addition of targeted parental and professional support within current universal frameworks.

Gilles de la Tourette syndrome in a cohort of deaf people

We present six patients with Gilles de la Tourette syndrome (TS) who are also deaf. TS has been observed previously, but rarely reported in deaf people, and to date, so called "unusual" phenomenology has been highlighted. TS occurs almost worldwide and in all cultures, and the clinical phenomenology is virtually identical. In our cohort of deaf patients (we suggest another culture) with TS, the phenomenology is the same as in hearing people, and as in all other cultures, with classic motor and vocal/phonic tics, as well as associated phenomena including echo-phenomena, pali-phenomena and rarer copro-phenomena. When "words" related to these phenomenon (e.g. echolalia, palilalia, coprolalia or mental coprolalia) are elicited in deaf people, they occur usually in British Sign Language (BSL): the more "basic" vocal/phonic tics such as throat clearing are the same phenomenologically as in hearing TS people. In our case series, there was a genetic predisposition to TS in all cases. We would argue that TS in deaf people is the same as TS in hearing people and in other cultures, highlighting the biological nature of the disorder.

Developmental vulnerability--don't investigate without a model in mind

Children who are developmentally vulnerable are at risk of a difficult start to school, and ongoing educational challenges which may adversely impact on long term health outcomes. Clinicians, researchers and service providers need a thorough understanding of both risk and protective factors and their complex interplay to understand their impact on early childhood development, in order to plan effective and comprehensive prevention and interventions strategies. In this opinion piece we recommend that investigation of developmental vulnerability should only proceed if underpinned by both a theoretical model through which the interaction between risk and protective factors may be investigated, and analytical models that are appropriate to assess these impacts.

Cross-disorder genome-wide analyses suggest a complex genetic relationship between Tourette's syndrome and OCD

OBJECTIVE

Obsessive-compulsive disorder (OCD) and Tourette's syndrome are highly heritable neurodevelopmental disorders that are thought to share genetic risk factors. However, the identification of definitive susceptibility genes for these etiologically complex disorders remains elusive. The authors report a combined genome-wide association study (GWAS) of Tourette's syndrome and OCD.

METHOD

The authors conducted a GWAS in 2,723 cases (1,310 with OCD, 834 with Tourette's syndrome, 579 with OCD plus Tourette's syndrome/chronic tics), 5,667 ancestry-matched controls, and 290 OCD parent-child trios. GWAS summary statistics were examined for enrichment of functional variants associated with gene expression levels in brain regions. Polygenic score analyses were conducted to investigate the genetic architecture within and across the two disorders.

RESULTS

Although no individual single-nucleotide polymorphisms (SNPs) achieved genome-wide significance, the GWAS signals were enriched for SNPs strongly associated with variations in brain gene expression levels (expression quantitative loci, or eQTLs), suggesting the presence of true functional variants that contribute to risk of these disorders. Polygenic score analyses identified a significant polygenic component for OCD (p=2×10(-4)), predicting 3.2% of the phenotypic variance in an independent data set. In contrast, Tourette's syndrome had a smaller, nonsignificant polygenic component, predicting only 0.6% of the phenotypic variance (p=0.06). No significant polygenic signal was detected across the two disorders, although the sample is likely underpowered to detect a modest shared signal. Furthermore, the OCD polygenic signal was significantly attenuated when cases with both OCD and co-occurring Tourette's syndrome/chronic tics were included in the analysis (p=0.01).

CONCLUSIONS

Previous work has shown that Tourette's syndrome and OCD have some degree of shared genetic variation. However, the data from this study suggest that there are also distinct components to the genetic architectures of these two disorders. Furthermore, OCD with co-occurring Tourette's syndrome/chronic tics may have different underlying genetic susceptibility compared with OCD alone.

Copy number variation in obsessive-compulsive disorder and tourette syndrome: a cross-disorder study

OBJECTIVE

Obsessive-compulsive disorder (OCD) and Tourette syndrome (TS) are heritable neurodevelopmental disorders with a partially shared genetic etiology. This study represents the first genome-wide investigation of large (>500 kb), rare (<1%) copy number variants (CNVs) in OCD and the largest genome-wide CNV analysis in TS to date.

METHOD

The primary analyses used a cross-disorder design for 2,699 case patients (1,613 ascertained for OCD, 1,086 ascertained for TS) and 1,789 controls. Parental data facilitated a de novo analysis in 348 OCD trios.

RESULTS

Although no global CNV burden was detected in the cross-disorder analysis or in secondary, disease-specific analyses, there was a 3.3-fold increased burden of large deletions previously associated with other neurodevelopmental disorders (p = .09). Half of these neurodevelopmental deletions were located in a single locus, 16p13.11 (5 case patient deletions: 0 control deletions, p = .08 in the current study, p = .025 compared to published controls). Three 16p13.11 deletions were confirmed de novo, providing further support for the etiological significance of this region. The overall OCD de novo rate was 1.4%, which is intermediate between published rates in controls (0.7%) and in individuals with autism or schizophrenia (2-4%).

CONCLUSION

Several converging lines of evidence implicate 16p13.11 deletions in OCD, with weaker evidence for a role in TS. The trend toward increased overall neurodevelopmental CNV burden in TS and OCD suggests that deletions previously associated with other neurodevelopmental disorders may also contribute to these phenotypes.

Using whole-exome sequencing to identify inherited causes of autism

Despite significant heritability of autism spectrum disorders (ASDs), their extreme genetic heterogeneity has proven challenging for gene discovery. Studies of primarily simplex families have implicated de novo copy number changes and point mutations, but are not optimally designed to identify inherited risk alleles. We apply whole-exome sequencing (WES) to ASD families enriched for inherited causes due to consanguinity and find familial ASD associated with biallelic mutations in disease genes (AMT, PEX7, SYNE1, VPS13B, PAH, and POMGNT1). At least some of these genes show biallelic mutations in nonconsanguineous families as well. These mutations are often only partially disabling or present atypically, with patients lacking diagnostic features of the Mendelian disorders with which these genes are classically associated. Our study shows the utility of WES for identifying specific genetic conditions not clinically suspected and the importance of partial loss of gene function in ASDs.

Prevalence and correlates of conduct disorder among inmates of juvenile detention centres, United Arab Emirates

The prevalence of conduct disorder was assessed in 77 young people in 4 juvenile detention centres in the United Arab Emirates (UAE). The prevalence of conduct disorder was 24.7%, and recidivism, as indicated by repeat admissions to the centres, was found to be associated with conduct disorder. Having a diagnosis of conduct disorder was associated with a lower educational and occupational level of the father, as well as living with a single parent or relatives. Among UAE nationals, conduct disorder was also associated with having a mother who was a non-UAE national.

Correlation between hypertension and income distribution among United Arab Emirates population

To determine the correlation between hypertension and income distribution among United Arab Emirates (UAE) population. Case-control study matched for age, sex, nationality and education. The survey included 500 hypertensive adults aged 20-65 years ascertained from Primay Health Care (PHC) Clinics along with a randomly selected sample of 500 control subjects from the community. Face-to-face interviews were done where data were gathered on socio-demographic-economic status (SES) and lifestyle habits. Hypertension was defined according to WHO criteria as having Systolic Blood Pressure (SBP) > or = 140 mm Hg and/or Diastolic Blood Pressure (DBP) > or = 90 mm Hg and/or being on antihypertensive treatment. The survey was carried out in urban and semi-urban PHC Clinics. A total of 818 subjects were included in this study from a sample of 1000; 409 cases and 409 controls. There were 422 males and 396 females in this study, with 255 UAE nationals and 438 expatriates. Hypertension was found to be significantly higher among the low income group (35.2% vs. 24.9% controls, p = 0.002; while mean SBP in the low income group was 130.2 +/- 17.6 vs. 128.0 +/- 17.4 controls, p = 0.022). Among males, smoking and alcohol consumption were higher among the group with low income level but only smoking showed significant difference (p value = 0.016). Activity level was higher among the low income groups. This study supports the importance of socio-economic factors as an income distribution effect on life-style habits and hypertension.

Familial predictors of childhood shyness: a study of the United Arab Emirates population

OBJECTIVES

Phobic anxiety disorders generally breed true. In this regard, family studies have suggested an association between childhood shyness and maternal social phobia. In this study, the relationship between childhood shyness and maternal social anxiety was examined.

SUBJECTS AND METHODS

203 5-year-old children from an Arabian Gulf community and their mothers were evaluated. The children were assessed in stage 1 using the shyness scale of Stevenson-Hinde and Glover and the Preschool Behavior Checklist (PBCL), while mothers completed the Liebowitz Social Anxiety Scale. In the second stage, blind clinical interviews were carried out to ascertain the diagnosis of psychiatric diagnoses, if any, using DSM-IV criteria.

RESULTS

27% of the children were identified as shy using the shyness scale of Stevenson-Hinde and Glover and 19% scored above the cutoff for behavioral disturbance on the PBCL. Child shyness was associated with female gender and maternal social anxiety as indicated by scores on the Liebowitz Social Anxiety Scale, while an inverse relationship was noted with behavioral disturbance. The odds of the child having a high shyness score was increased if the mother had social anxiety (odds ratio = 2.14) and the child lived in a family that was 'not socially active' (odds ratio = 1.42).

CONCLUSION

Our initial findings suggest that there may be a complex interaction between maternal social anxiety and family sociability in childhood shyness. Prospective longitudinal work is indicated.

Some risk factors for hypertension in the United Arab Emirates

A case-control study evaluated the relationship between hypertension and socioeconomic and lifestyle factors in Al-Ain city. The survey included 426 hypertensive adults aged 20-65 years attending urban and semi-urban clinics and a randomly selected sample of 436 normotensive controls. Hypertension among cases was higher for men, age 40-49 years, non-UAE nationals, urban living, currently married, having children, illiterate, administrative/professional job, living in traditional house and low income. There were significant differences between cases and controls with regard to obesity, raised cholesterol level, low physical activity and family history of heart disease, kidney disease or diabetes. Multivariate logistic regression analysis revealed that obesity, medium/high income, history of diabetes, low physical activity and having 3+ children were significantly associated with hypertension

Screening for language delay in the United Arab Emirates

BACKGROUND

Developmental language delay (DLD) is frequent among two- and three-year-olds but little is known about this condition in the Arabian Peninsula. This paper forms part of a multipurpose community psychiatric survey conducted in the United Arab Emirates (UAE). The findings regarding the prevalence and psychosocial correlates of DLD are reported here.

METHODS

A total of 694 children, representative of the UAE 3-year-old population were screened using the Denver Developmental Screening Test (DDST) and the language screening procedure as used by Westerlund and Sundelin.

RESULTS

Of the 694 children screened for DLD at 3 years of age, 69 children (9.9%; CI 7.8-12.4) were found to have delays in the language sector of DDST. A total of 45 (6.5%; CI 4.3-8.7) were identified as having general language disability, both in comprehension and expression as per the language screening procedure. Language delay was found to be associated with rural living, mother being from a different nationality, non-involvement of domestic help in child care, family history of language delay, obstetric and perinatal problems and presence of behavioural problems in the child. Using stepwise multiple logistic regression analysis, two factors emerged as important with regard to general language delay, which were previous non-UAE nationality of the mother and total monthly income of the family.

CONCLUSION

The pattern and correlates of DLD found in this survey are in line with those reported by other surveys, but some unique socio-cultural risk factors specific to this community were identified. The implications of these findings to screening and referral for further evaluation and intervention are discussed.

Some risk factors for hypertension in the United Arab Emirates

A case-control study evaluated the relationship between hypertension and socioeconomic and lifestyle factors in Al-Ain city. The survey included 426 hypertensive adults aged 20-65 years attending urban and semi-urban clinics and a randomly selected sample of 436 normotensive controls. Hypertension among cases was higher for men, age 40-49 years, non-UAE nationals, urban living, currently married, having children, illiterate, administrative/professional job, living in traditional house and low income. There were significant differences between cases and controls with regard to obesity, raised cholesterol level, low physical activity and family history of heart disease, kidney disease or diabetes. Multivariate logistic regression analysis revealed that obesity, medium/high income, history of diabetes, low physical activity and having 3+ children were significantly associated with hypertension.

Clinical features and associated psychopathology in a Tourette syndrome cohort

OBJECTIVE

This study explored in detail the association between tic symptomatology, related clinical variables, and psychopathology in 91 consecutive adult TS subjects from a UK clinic.

METHODS

Consecutive patients from a specialized Tourette clinic who met the DSM-III criteria for TS were evaluated using standardized rating scales for Tourette syndrome and other psychopathology.

RESULTS

The male female ratio in our cohort was 1.8:1. Significantly more males had an earlier age at onset of TS and history of birth complications. Obsessive compulsive behaviors in the patient was positively correlated with presence of attention deficit hyperactivity disorder and self-injurious behaviors. With regard to adult psychopathology, principal components factor analysis yielded two factors, 'obsessionality' and 'anxiety/depression', which accounted for 72% of the variance.

CONCLUSION

Our results support the high occurrence of anxiety, depression and obsessionality in adult TS subjects.

Epilepsy in children with cerebral palsy

OBJECTIVES

To study the occurrence, associated factors, nature and prognosis of seizures in children with cerebral palsy (CP).

DESIGN

A prospective, descriptive, hospital-based, case-control study.

SETTING

Tertiary level University Teaching Hospitals in the Al Ain Medical District, United Arab Emirates.

PATIENTS

Fifty-six children with CP and seizures seen in the neurodevelopmental clinics at Al Ain and Tawam University Hospitals during the period of 1997-1999 were studied (group 1). Two control groups of 35 children with CP without seizures (group 2) and 50 children with seizures but no CP (group 3) were also studied.

RESULTS

Spastic tetraplegia was the commonest type of CP associated with seizures whereas spastic diplegia was the commonest variety of CP in group 2. Most children with CP had an early onset of seizures within the first year of life as against those without CP. The children in group 1 had a higher incidence of neonatal seizures (42.9% vs. 29.4% in group 2 and 0% in group 3), presence of significant developmental delay (98.2% vs. 20.0% in group 3), occurrence of significant abnormalities on brain imaging (94.6% vs. 19.6% in group 3) and a need for use of more than 1 antiepileptic drug (66.1% vs. 30.0% in group 3). Over half of children in the study group presented with generalized tonic clonic seizures; the electroencephalogram (EEG) showed focal epileptic discharges with or without secondary generalization in 39.3%. The overall outcome of seizures in children with CP was poor needing prolonged course of anticonvulsant medications, polytherapy and higher incidence of refractory seizures and admissions for status epilepticus compared to the control group.

CONCLUSIONS

Cerebral palsy is associated with a higher incidence of seizure disorders, which, in a majority, has its onset in the neonatal period; brain imaging showed abnormal pathology in most affected children, which possibly accounts for the tendency to more refractory seizures in these children.

Psychosocial correlates of paediatric cancer in the United Arab Emirates

To study the psychosocial factors and illness variables associated with children's and parents' perceptions of and ways of coping with cancer, in 38 childhood cancer patients aged 5-15 years, coping was studied in relation to sociodemographic variables and self-perception in terms of competence, behaviour and self-worth. Less optimal coping was found to be associated with poor family communications and lack of sharing/expression of emotions ( P=0.005), presence of behavioural and emotional problems in the child ( P=0.008) and parental lack of hope ( P=0.001). No association was found with gender, parental education or occupation, socioeconomic status, or child's self-perception including global estimation of self-worth. Furthermore, none of the illness variables was found to be associated with coping. Awareness about health-related issues was found to be strongly associated with parental education ( P=0.000). Our findings suggest that parental hope and both social and family communication are integral to helping patients and families cope with the illness experience.

Prevalence of tics and Tourette syndrome in an inpatient adult psychiatry setting

OBJECTIVE

Given the widely recognized genetic basis for Gilles de la Tourette syndrome (TS) and the suggestion that the putative TS gene(s) may be expressed as or associated with a variety of psychiatric illnesses, this study was undertaken to assess the prevalence of tics and TS in a psychiatric inpatient population.

DESIGN

Cross-sectional study.

SETTING AND PATIENTS

200 consecutive adult patients who were admitted to the psychiatric wards of University College London Teaching Hospitals.

OUTCOME MEASURES

TS and related behaviours, as assessed by the comprehensive semi-structured National Hospital Interview Schedule.

RESULTS

None of the 200 patients had definite TS, but 2 were observed to have motor tics; 10 had a history of tics (present for less than a year), and 7 reported a family history of tics. Thus, 19 (9.5%) inpatients qualified for inclusion in a broadly defined TS diathesis. These rates are significantly lower than those reported in a similar community based epidemiological study of adolescents (p = 0.018).

CONCLUSIONS

Our findings do not support the theory that TS and related behaviours are over-represented among adult inpatients with psychiatric illnesses.

Childhood behavioural disturbance in a community sample in Al-Ain, United Arab Emirates

The prevalence of behavioural and emotional problems was evaluated among 620 United Arab Emirates nationals aged 6-18 years using the Rutter Parent Questionnaire. Of these children, 11.8% scores above the cut-off point indicating behavioural disturbance. The prevalence of conduct problems was greater among boys, while emotional problems were more common among girls. Certain unspecified chronic life difficulties, parental distress in relation to their children, family history of psychiatric illness and alcohol or drug use in a family member were associated with behavioural disturbance, but no significant association was found with gender, socioeconomic status, family size or recent life events. Our findings suggest that behavioural disturbance exists among a substantial number of school-aged children in the community.

Prevalence and correlates of childhood fears in Al-Ain, United Arab Emirates

The prevalence of fear was explored in 340 adolescents in Al-Ain, United Arab Emirates. More than 50% reported feeling extremely frightened of 6 out of 60 fear items surveyed. These items were: someone dying in the family [66.5%], parents getting divorced [65.3%], the devil [63.8%], breaking a religious law [61.5%], being kidnapped [53.2%] and being adopted [49.9%]. The level of fear showed a significant positive correlation with female gender, parental death/divorce, living with a single parent/relatives, living in low income families and an adverse home environment. Nearly half of the children reported that the fear caused considerable distress and interfered with daily activities.

Prevalence and correlates of childhood fears in Al-Ain, United Arab Emirates

The prevalence of fear was explored in 340 adolescents in Al-Ain, United Arab Emirates. More than 50% reported feeling extremely frightened of 6 out of 60 fear items surveyed. These items were: someone dying in the family (66.5%), parents getting divorced (65.3%), the devil (63.8%), breaking a religious law (61.5%), being kidnapped (53.2%) and being adopted (49.9%). The level of fear showed a significant positive correlation with female gender, parental death/divorce, living with a single parent/relatives, living in low income families and an adverse home environment. Nearly half of the children reported that the fear caused considerable distress and interfered with daily activities.

Childhood behavioural disturbance in a community sample in Al-Ain, United Arab Emirates

The prevalence of behavioural and emotional problems was evaluated among 620 United Arab Emirates nationals aged 6-18 years using the Rutter Parent Questionnaire. Of these children, 11.8% scores above the cut-off point indicating behavioural disturbance. The prevalence of conduct problems was greater among boys, while emotional problems were more common among girls. Certain unspecified chronic life difficulties, parental distress in relation to their children, family history of psychiatric illness and alcohol or drug use in a family member were associated with behavioural disturbance, but no significant association was found with gender, socioeconomic status, family size or recent life events. Our findings suggest that behavioural disturbance exists among a substantial number of school-aged children in the community.

A controlled study of psychiatric morbidity among developmentally disabled children in the United Arab Emirates

A cross-sectional study of the prevalence of psychiatric problems among 26 children each with a learning disability (mental retardation) and specific speech disorder was conducted in an Arab population using the Rutter Behavioural Scale, and compared with a community sample of 100 control children matched for age. The prevalence of psychiatric problems, as identified by both the parents and the teachers was 35, 19 and 4 per cent respectively, in the learning disabled, speech impaired and control groups. Children with global disability or mental retardation showed significantly higher rates of psychiatric morbidity than those with specific speech disorder, both of which were significantly higher than that in the control group. Higher rates of psychiatric problems noted in the developmentally disabled children may be the result of specific socio-demographic and cultural factors in addition to neurodevelopmental factors and low IQ.

Cross-cultural validation of Harter's self-perception profile for children in the United Arab Emirates

BACKGROUND

Harterâs Self-Perception Profile for children (SPPC) is a self-reporting inventory for ascertaining childrenâs perception of themselves in various specific domains of their life, as well as their sense of global selfworth. A few studies have examined the psychometric properties of this instrument in the Western setting, but none have investigated this in an Arabic culture.

PATIENTS AND METHOD

Psychometric properties of the SPPC were examined, using a sample of 100 schoolchildren aged 8 to 16 years in the United Arab Emirates.

RESULTS

The internal consistency reliability was found to be excellent with Chronbachâs alpha, ranging from 0.86 to 0.92. Significant age and gender differences were found with the internal consistency reliability scores, being higher in children aged 13 to 16 years (0.88 to 0.93) when compared to younger children, especially boys aged 8 to 12 years (0.54 to 0.66), suggesting a need to exercise caution while using this scale in young boys in this culture. Behavioral conduct subscale was found to have the highest reliability score and the strongest correlation to global self-worth (r=0.54) for both younger and older children in our sample. This is in contrast to findings from similar studies carried out on American and Dutch samples, where this subscale was found to have the lowest reliability score and the weakest correlation with oneâs global self-worth.

CONCLUSION

The findings indicate that the SPPC is a reliable and internally valid instrument for use in the Arab culture.

Self-perception profile in children with cancer: self vs parent report

Self-perception about competence, behaviour, and self-worth were examined in 30 children (8 to 14 years) recently diagnosed as having cancer and were compared with that of their parents' perception. The poor agreement between parents' and children's ratings on physical appearance and social acceptance is noteworthy in that these two domains are particularly vulnerable in children with cancer, given the effect of chemotherapy on physical appearance and children's tendency to view themselves as socially undesirable or a burden to others. This finding, if replicated, can have implications for therapeutic intervention since the discrepancy score could be used to challenge children's negative views in the context of cognitive therapy to improve their self-esteem.

School mental health screening: a model for developing countries

Using the experience derived from a screening programme of all school-going children in the Al Ain District, United Arab Emirates, this article reports on a cost-effective model that can be used in other developing countries. The need for training child health and school professionals in identifying mental and developmental disorders is discussed.

Learning disorders in school-going children--detection and diagnosis

A screening programme was carried out among school-going children in Al-Ain, United Arab Emirates (UAE), to identify children with learning disorders. During the course of one academic year, 34 such children were identified. The cause was considered preventable in around half of the cases. In a third of cases with a genetic cause, prevention was possible with existing knowledge and practice.

Mental health problems among schoolchildren in United Arab Emirates: prevalence and risk factors

OBJECTIVE

To examine child psychiatric morbidity in an Arab culture.

METHOD

Emotional and behavioral problems were investigated in 3,278 schoolchildren aged 6 to 15 years using a two-stage epidemiological study in Al Ain District, United Arab Emirates. Children were screened using standardized questionnaires completed by parents and school physicians in the first stage, and a stratified random sample were interviewed by a child psychiatrist in the second stage.

RESULTS

23.9% of children were reported to have a mental health problem by either the parent or the school health physician. Boys were more often reported to be having problems than girls (1.8:1). Using the Rutter A2 scale for parents, the prevalence estimate for behavioral disorders was 16.5%. The weighted prevalence for DSM-IV disorders was 10.4% for the entire population. The presence of certain culture-specific risk factors such as male gender, number of children in the household, polygamy, and low socioeconomic status were identified for psychiatric disorders. A positive family history and consanguinity were the most significant factors associated with learning disorders.

CONCLUSIONS

The prevalence rates of child psychiatric disorders and the symptomatology observed in this Middle East community are similar to those reported in Western studies.

The prevalence of Tourette syndrome in a mainstream school population

The aim of this study was to ascertain accurately the prevalence of Tourette syndrome (TS) in a mainstream school population. All year 9 pupils (aged 13 to 14 years) in a mainstream secondary school were investigated using a two-stage procedure. Standardized questionnaires were completed by parents, teachers, and pupils. Class observations were also carried out to identify tics. Those pupils identified as having tics underwent a semistructured interview to determine whether they had TS according to DSM-III-R criteria. Data were available from at least one source (parent, teacher, or self-reports) on 166 of the 167 pupils in the year. Five subjects were identified as having TS according to DSM-III-R criteria, yielding a prevalence estimate of 299 per 10,000 pupils in this age group. The results of this study suggest that TS in the community as a whole is more common and milder than those prevalence estimates and descriptions of the disorder based on TS encountered in secondary or tertiary health-care service settings.

Tourette syndrome, epilepsy, and emotional disorder, a case of triple comorbidity

We present a case report illustrating the complexity encountered in the diagnosis and treatment of patients with multiple diagnoses. The clinical presentation in Tourette syndrome, and the behavioural manifestations in some cases of complex partial seizures can both be misunderstood and misdiagnosed. The paper, within the framework of a case, emphasises the need for a multidisciplinary approach in the assessment and management of such cases.

Frontal glioma presenting as anxiety and obsessions: a case report

A 53-year-old gentleman is described, who presented with acute onset of anxiety and obsessional symptoms. The clinical picture was complicated by the presence of mild alcohol withdrawal symptoms and history of excessive drinking for 20 years. A month later, he developed right hemiparesis. CT scan revealed a left frontal tumour, and on histology this was found to be Grade 4 astrocytoma.

United Arab Emirates population data on three DNA tetrameric short tandem repeat loci: HUMTHO1, TPOX and CSF1PO--derived using multiplex polymerase chain reaction and manual typing

Allele and genotype frequencies for three tetrameric short tandem repeat (STR) loci: HUMTHO1, TPOX, and CSFIPO, were determined in a United Arab Emirates (UAE) national population sample (n = 119). The loci were amplified simultaneously and the PCR products were separated in polyacrylamide DNA sequencing gels. Detection of the DNA fragments was accomplished using silver staining. Allele designations were determined by comparison to an allelic ladder. One allele at each locus was sequenced to confirm the nature of the repeats and their number. Alleles at the HUMTHO1 and TPOX loci were distributed bimodally, while CSF1PO showed unimodal distribution. The observed heterozygosities were 76% for HUMTHO1, 64% for TPOX, and 71% for CSF1PO. No deviation from the Hardy-Weinberg expectations was observed in the genotype distribution for the loci TPOX and CSF1PO, but the HUMTHO1 locus did depart from HWE based on the likelihood ratio and the exact test. No correlation was detected between the alleles at any of the three pairs of loci. The allelic frequency data of these three loci in the UAE population sample can thus be used in human identity testing.

Obsessive compulsive symptoms in Gilles de la Tourette syndrome and obsessive compulsive disorder: differences by diagnosis and family history

The distribution of obsessive compulsive symptoms was compared in 16 individuals with primary obsessive compulsive disorder (OCD) and 16 individuals with Gilles de la Tourette syndrome (GTS) and associated obsessive compulsive behaviors (OCB). The two groups showed significant differences in the distribution of OC symptomatology. Furthermore, those OCD probands who shared a similar symptom profile with GTS individuals all had a positive family history of OCD. All of the other OCD probands were isolated cases. Implications of this finding on the etiology and pathogenesis of the two disorders are discussed.

Gilles de la Tourette's syndrome in special education schools: a United Kingdom study

In order to determine the prevalence of tic disorders in children with severe school problems requiring a residential facility and comparison groups of children in regular day schools, we performed direct clinical examinations for the presence of tics and Gilles de la Tourette's syndrome (GTS) in 20 children from a residential school for emotional and behavioral difficulties (EBD); 25 children from a residential school for learning disabilities; 17 "problem" children (PC) (identified by teachers as having academic or behaviour problems) and 19 normal children (NC) selected at random (using random numbers) from a regular school. Of the EBD students, 65% were judged to have definite tics as compared with 24% of students with learning difficulties (P < 0.05), 6% of PC (P < 0.003) and none of the NC (P < 0.0006) group. Most of the affected students met diagnostic criteria for GTS. Our findings suggest that GTS is commonly associated with the need for special education and that this association is particularly robust for children with severe school problems. In these children, the presence of tics may be an indicator of an underlying dysfunction of neurological development.

HMPAO SPET does not distinguish obsessive-compulsive and tic syndromes in families multiply affected with Gilles de la Tourette's syndrome

BACKGROUND

Gilles de la Tourette's syndrome (GTS) is a familial neuropsychiatric disorder characterized by tics and obsessive-compulsive behaviours (OCB). Previous HMPAO SPET studies of subjects with GTS have shown hypoperfusion of striatal and frontal areas. Studies of patients with primary obsessive-compulsive disorder have shown, in contrast, hyperperfusion of similar areas.

METHODS

Twenty subjects from five families affected by GTS, including individuals with OCB but no tics, were examined using HMPAO SPET.

RESULTS

There were abnormalities of regional cerebral perfusion in individuals with GTS, OCB and tics. Hypoperfusion was in striatal, frontal and temporal areas. There was no hyperperfusion.

CONCLUSIONS

Regional cerebral blood flow patterns in individuals with OCB in families affected by GTS are comparable to their relatives with GTS and differ from individuals with primary OCD in the absence of a family history of tic disorders.

Sex of parent transmission effect in Tourette's syndrome: evidence for earlier age at onset in maternally transmitted cases suggests a genomic imprinting effect

Parent of origin effects caused by genomic imprinting may influence the phenotypic expression of a number of heritable human disorders. To test this phenomenon in Tourette's syndrome (TS), we studied 437 first degree relatives systematically ascertained through 57 probands. We compared age at onset, age at diagnosis, and phenotypic expressions as observed in the diagnosis of TS, chronic motor tics, and obsessive compulsive behavior in the offspring of affected males with the offspring of affected females. Of the 437 subjects, 16.7% had matrilineal inheritance and 13.9% had patrilineal inheritance, as determined by family history methodology. Chi-square analysis of the different phenotypic expressions and sex of the transmitting parent failed to provide evidence of significant group differences. We found no significant differences in the age at diagnosis either. However, the maternally transmitted offspring showed a significantly earlier age at onset. This points to a parent of origin effect on the putative TS gene that could be explained by meiotic events or even intrauterine environmental influences. These findings may help explain the hitherto conflicting reports about the nature of genetic transmission in TS, and suggest a need to re-examine family data separately for maternally and paternally transmitted cases, taking into account the possible role of imprinting.

Mass hysteria in an Arab culture

In this report we describe the circumstances surrounding an outbreak of mass hysteria among first year female university students. The outbreak was precipitated by a state of panic over the possibility of a fire which turned out to be harmless fumes from a locally used burning perfume. Twenty-three cases presented to the emergency room with symptoms of respiratory distress associated with marked emotional reactions. The outbreak was controlled by separating the patients, and the lack of media coverage facilitated this process. Cases with persistent and severe symptoms were those having physical and psychological problems prior to the occurrence of the outbreak. Individual vulnerability factors deserve special consideration in the management of mass hysteria since they are likely to influence the response to treatment.

The use of fluoxetine in Gilles de la Tourette syndrome and obsessive compulsive behaviours: preliminary clinical experience

1. Obsessive Compulsive Behaviours (OCB) occur in more than 50% of patients with the Gilles de la Tourette Syndrome (GTS) and in some cases these behaviours are more disabling than the tics themselves. 2. Fluoxetine, a specific serotonin reuptake inhibitor (SSRI) has been demonstrated to be effective in patients with Obsessive Compulsive Disorder. 3. The authors report on their clinical experience of fluoxetine in 30 GTS patients with OCB, in an open retrospective study. 4. There was an overall improvement in OCB as judged by the clinician in 76% of cases. Most patients received fluoxetine at a daily dose of 20 to 40mg for an average period of 6 months (24 +/- 4 weeks). In general, fluoxetine was well tolerated and further studies are indicated.

Risperidone in the treatment of Tourette syndrome: a retrospective case note study

Nineteen patients with Tourette syndrome (TS) were treated with risperidone, at a mean daily dose of 1.5 mg. Of those, 41% responded positively, 35% felt that it had made no difference, while it made 24% worse. Although 53% of the patients experienced side-effects, none had extrapyramidal side-effects. At follow-up, 8 to 11 months later, only two of 19 (11 %) patients were still taking risperidone. We suggest that risperidone does have a role in a minority of TS sufferers but it is not suggested as the first line treatment. More placebo-controlled studies using risperidone are clearly indicated.

Bilineal transmission in Tourette's syndrome families

We assessed the frequency of bilineal (from maternal and paternal sides) transmission of Tourette's syndrome (TS) in two groups of pedigrees: (1) 39 high-density families in which five or more relatives were reported to have TS, and (2) the families of 39 consecutively ascertained probands referred for evaluation of TS. We used two designations for the TS phenotype (tics, tics or obsessive-compulsive behavior [OCB]), and we attempted to verify bilineal transmission with direct examinations. For the high-density pedigrees, bilineal transmission was evident in 33% (considering tics) and 41% (considering tics or OCB) of families, which was confirmed by examination in 77% of the kindreds. For the consecutive pedigrees, bilineal transmission was seen in 15% (tics) and 26% (tics or OCB) of families, which was verified by examination in 66% of the kindreds. Both parents of the proband were affected (tics or OCB) in 38% of the high-density pedigrees and 10% of the consecutive pedigrees. For the high-density families only, the frequency of bilineal transmission appeared to be related to the proband's severity of TS, and for both pedigree groups, the frequency of both parents being affected was higher in families in which the proband's symptoms were most severe. Our findings support the contention that bilineal transmission and homozygosity are common in TS. These genetic phenomena might play a role in determining severity of illness and may explain current difficulties in localizing the gene defect by linkage analysis.

Stimulus induced behaviours in Tourette's syndrome

Three cases of Gilles de la Tourette's syndrome (GTS) who experienced different tic related behaviours in response to both external and internal stimuli are described. Such behaviours might represent sensory tics, reflex motor tics, exaggerated startle responses, or obsessive compulsive behaviours. It is suggested that there is a continuum of stimulus induced behaviours, and that, in some cases, separations into individual descriptive entities may be difficult. There also seems to be a continuum between internal and external phenomena that induce the behaviours. Implications for the relation between GTS and obsessive compulsive disorder are also discussed.

Evidence for autosomal dominant transmission in Tourette's syndrome. United Kingdom cohort study

Complex segregation analyses were performed on families ascertained through 40 unselected consecutive patients with Tourette's syndrome to examine the hypothesis that its transmission is consistent with genetic inheritance. Analyses were done using several diagnostic classifications. All results were consistent with an autosomal dominant gene with high penetrance. The penetrances ranged from 0.882 to 1.000 for males and 0.452 to 0.980 for females, depending upon the specific classification scheme incorporated into the analyses.

Sulpiride-induced tardive dyskinesia in a person with Gilles de la Tourette syndrome

A 48 year old man who had never been treated with any other major tranquilliser developed tardive dyskinesia (TD) while taking sulpiride for Gilles de la Tourette syndrome (GTS). To our knowledge, this is the first report of TD complicating the use of sulpiride in the treatment of GTS.

Pharmacologic controversy of CNS stimulants in Gilles de la Tourette's syndrome

The controversy of the use of stimulants in Gilles de la Tourette's syndrome (GTS) can only be understood by examining the relationship between GTS and attention deficit-hyperactivity disorder (ADHD), because the relationship between the two disorders is complex, and stimulants are used in the one (ADHD) and may be contraindicated in the other (GTS). This relationship therefore has to be viewed from several perspectives, including clinical, genetic, neurobiochemical, neurophysiological, and treatment strategies, to highlight the complexities involved, and reasons for controversy. The present review will examine these relationships, and thus the evidence for and against the treatment of GTS with stimulants.

Psychotherapy and childhood sexual abuse

Childhood sexual abuse may have a significant impact on psychological well being in later life. In this report, we describe 5 women who had a variety of psychological symptoms that were related to childhood sexual trauma. These factors were explored during psychotherapy. Persistent feeling of depression, anxiety and problems in socio-sexual functioning, were prominent. Therapy varied from counselling and ventilation, to prolonged dynamically oriented therapy.

Gilles de la Tourette syndrome in India: two cases

Two cases of Gilles de la Tourette syndrome from India are presented. The symptomatology of Tourette syndrome is the same as that documented in western populations which suggests biological factors in the aetiology of the syndrome.

Gilles de la Tourette syndrome-a case report from Guyana in South America

A case of the Gilles de la Tourette syndrome from Guyana in South America is presented. The patient had a positive family history as well as coprolalia, echolalia, and attention deficit disorder with hyperactivity. The family history and cross-cultural similarity emphasise the biological factors in the aetiology of the syndrome.