Antonella Gritti

Clinical, morphological, and biochemical correlates of head circumference in autism

BACKGROUND Head growth rates are often accelerated in autism. This study is aimed at defining the clinical, morphological, and biochemical correlates of head circumference in autistic patients. METHODS Fronto-occipital head circumference was measured in 241 nonsyndromic autistic patients, 3 to 16 years old, diagnosed according to DSM-IV criteria. We assessed 1) clinical parameters using the Autism Diagnostic Observation Schedule, Autism Diagnostic Interview-Revised, Vineland Adaptive Behavioral Scales, intelligence quotient measures, and an ad hoc clinical history questionnaire; 2) height and weight; 3) serotonin (5-HT) blood levels and peptiduria. RESULTS The distribution of cranial circumference is significantly skewed toward larger head sizes (p < .00001). Macrocephaly (i.e., head circumference >97th percentile) is generally part of a broader macrosomic endophenotype, characterized by highly significant correlations between head circumference, weight, and height (p < .001). A head circumference >75th percentile is associated with more impaired adaptive behaviors and with less impairment in IQ measures and motor and verbal language development. Surprisingly, larger head sizes are significantly associated with a positive history of allergic/immune disorders both in the patient and in his/her first-degree relatives. CONCLUSIONS Our study demonstrates the existence of a macrosomic endophenotype in autism and points toward pathogenetic links with immune dysfunctions that we speculate either lead to or are associated with increased cell cycle progression and/or decreased apoptosis.

Psychological impact of liver transplantation on children's inner worlds

Abstract: We carried out an in‐depth evaluation of psychosocial status in a sample of 18 children (mean age 6.8 yr, range 4.4–10.8 yr) who had suffered from severe liver disease and undergone orthotopic liver transplantation (OLT). Mean age at OLT was 3.4 yr. The assessment was psychoanalytically oriented and included individual sessions and testing procedures for children – the Children Apperception Test (CAT), the Weschsler Intelligence Scale for Children (WISC‐R), the Weschsler Preschool and Primary Scale of Intelligence (WIPPSI), and the Human Figure Test – and a semi‐structured interview with a separate questionnaire for parents. Patients were compared with an age‐ and gender‐matched control group. The main findings in patients compared with controls were: IQ 91.6 (range 70–117) vs. 118 (range 94–135) (p<0.0001); immaturity of ego and drives (72.2% vs. 27.7%; p=0.018), fear of death (61.1% vs. 11.1%; p=0.04), anxiety of loss (50% vs. 27.7%; p=NS), and depressive feelings (61.1% vs. 22.2%; p=0.04); a mild defect of body image (44.4% vs. 33.3%; p=NS) associated with recurrent representations of motionless (72.2% vs. 38.8%; p=NS) and inexpressive (88.8% vs. 16.6%; p<0.0001) human figures. Fantasies about OLT as a ‘magic rebirth’ or a ‘body transformation’ were detected in few patients (30%). Although a recurrent set of feelings, conflicts, and fantasies about OLT were expressed by children, individual specific psychological responses to this experience were often detected. In spite of the fact that ≈ 50% of the parents mentioned emotional or behavioral disturbances of their child, only three parents were seriously concerned about this problem. The theme of transplantation was most often absent from communication between the child and their parents. Our results suggest that psychic ‘working through’ of the chronic liver disease and OLT experience is difficult for children. Further studies are necessary to verify whether changes of parental attitude to OLT as a ‘family secret’ may facilitate integration of the OLT experience in the childs personality development.

Can headache impair intellectual abilities in children? An observational study

Background The purpose of this study was to assess the cognitive functioning of children affected by headache, pinpointing the differences in intelligence style between subjects affected by migraine without aura and subjects with tension-type headache. Methods The study population consisted of 147 children (mean age 10.82 ± 2.17 years) with headache, recruited from the Headache Center for Developmental Age, Child and Adolescent Neuropsychiatry Clinic, Second University of Naples. Cognitive profiling was performed using Weschler Intelligence Scale for Children Third Edition throughout the sample. According to the International Classification of Headache Disorders II criteria for pediatric age, subjects were divided into a migraine without aura group (n = 75; 43 boys, 32 girls) and a tension-type headache group (n = 72; 49 boys, 23 girls). The results were compared with the findings obtained from a sample of 137 healthy control subjects recruited from schools in the Campania region, matched for age and gender. Results No difference in full intelligence quotient was found between the groups, but the children with tension-type headache had a lower verbal intelligence quotient and a higher performance intelligence quotient than the healthy controls and children with migraine. Factor analysis data showed that the children with migraine seemed to have lower perceptual organization than the children affected by tension-type headache. Conclusion To our knowledge, studies on cognitive functioning in children affected by headache in the interictal phase are scarce, and our results suggest a new perspective in understanding of the neuropsychological aspects of young patients affected by headaches.

Emotional and behavioral problems after pediatric liver transplantation: A quantitative assessment

Abstract:  Several uncertainties regarding psychological problems in children who underwent liver transplantation and the need to differentiate these disturbances from those related to the underlying previous chronic liver disease itself exist. This background triggered the present pilot study to investigate, using quantitative assessment methods, the incidence and the type of emotional and behavioral disturbances after liver transplantation. Sixteen liver transplant recipients (aged 5.7–14.4 yr) and 12 age‐matched controls with stable chronic liver disease were assessed through the parent report form of Child Behavior Checklist/ 4–18. The mean time elapsed since transplantation was 8.1 yr. No patient or family had received psychological support during chronic liver disease or at any phase of the transplantation process. Transplanted children scored within borderline range for Internalizing and Total Behavioral Problems and within pathological range for Competences, except for the Activity Scale. Transplanted children showed more Total Behavioral (p = 0.005) and Externalizing Problems (p = 0.0005) than controls. Both groups scored within the pathological range for Total Competences with no significant differences between the two groups. Our findings suggest that in the absence of support programs a psychological risk does exist for a long period of time, after transplantation. Regarding Total Behavioral Problems and Externalizing Problems, this risk is higher than in children with chronic liver disease.

Maternal stress and childhood migraine: a new perspective on management.

Background Migraine without aura is a primary headache which is frequent and disabling in the developmental age group. No reports are available concerning the prevalence and impact of migraine in children on the degree of stress experienced by parents. The aim of this study was to evaluate the prevalence of maternal stress in a large pediatric sample of individuals affected by migraine without aura. Methods The study population consisted of 218 children (112 boys, 106 girls) of mean age 8.32 ± 2.06 (range 6–13) years suffering from migraine without aura and a control group of 405 typical developing children (207 boys, 198 girls) of mean age 8.54 ± 2.47 years. Mothers of children in each group answered the Parent Stress Index-Short Form (PSI-SF) questionnaire to assess parental stress levels. Results The two groups were matched for age (P = 0.262), gender (P = 0.983), and body mass index adjusted for age (P = 0.106). Mothers of children with migraine without aura reported higher mean PSI-SF scores related to the Parental Distress domain (P < 0.001), Dysfunctional Parent-Child Interaction domain (P < 0.001), Difficult Child subscale (P < 0.001), and Total Stress domain than mothers of controls (P < 0.001). No differences between the two groups were found for Defensive Responding subscale scores. Conclusion Our study may be the first to highlight the presence of high levels of stress in parents of children affected by migraine without aura.

Update on the safety of second generation antipsychotics in youths: a call for collaboration among paediatricians and child psychiatrists

During the past decade, a substantial increase in the use of second generation antipsychotics (SGAs) has occurred for a number of juvenile psychiatric disorders, often as off-label prescriptions. Although they were thought to be safer than older, first generation antipsychotics, mainly due to a lower risk of neurological adverse reactions, recent studies have raised significant concerns regarding their safety regarding metabolic, endocrinological and cardiovascular side effects. Aim of this paper is to update with a narrative review, the latest findings on safety of SGAs in youths. Results suggest that different SGAs may present different safety profiles. Metabolic adverse events are the most frequent and troublesome, with increasing evidences of heightened risk for type II diabetes mellitus. Results are discussed with specific emphasis on possible strategies of an active monitoring, which could enable both paediatricians and child psychiatrists to a possible prevention, early detection, and a timely management of such effects.

Antipsychotic-Induced Dyslipidemia Treated with Omega 3 Fatty Acid Supplement in an 11-Year-Old Psychotic Child: A 1-Year Follow-up

Antipsychotic-induced weight gain and dyslipidemia are hard-to-fight threats that can arise during treatment with second generation antipsychotic drugs (De Hert et al. 2011). The youth population is probably at higher risk than adults for antipsychotic-induced metabolic adverse events, because they are more likely drug naı̈ve (Correll et al. 2009; Roy et al. 2010, De Hert et al. 2011). The concern about metabolic complications in youth derives from evidence that metabolic abnormalities and weight gain during childhood strongly predict obesity, metabolic syndrome, hypertension, cardiovascular morbidity, sleep apnea, osteoarthritis, and malignancy risk in adulthood (De Hert et al. 2011; Maayan and Correll 2011). The mechanism of action that lead to metabolic abnormalities is still poorly understood (Roerig et al. 2011), as is what to do to prevent or to treat these adverse events. Guidelines published in 2009 and in August 2011 suggest strictly monitoring patients receiving atypical antipsychotics (De Hert et al. 2009; Ho et al. 2011). Common strategies currently implemented to moderate weight gain and other metabolic changes consist in encouraging a healthy lifestyle and switching to a lower metabolic impact drug (Correll et al. 2011; De Hert et al. 2011). Concomitant metformin administration is used in adults, but data regarding children and adolescents are limited (Newall et al. 2012). Many other psychopharmacological interventions have been suggested, but, although promising, none of those drugs have been demonstrated to be able to entirely reverse weight gain or reduce cholesterol and triglycerides (TG) (Maayan et al. 2010). Omega 3 fatty acids are becoming more frequently used in all fields of medicine, including child psychiatry (e.g., Gabbay et al. 2012). Use of well-timed controls of bleeding time are encouraged, but, generally, omega 3 use is considered safe (Emsley et al. 2008). In general medicine, the effects on lowering triglyceride levels are described, as well as small evidences of reducing obesity and metabolic syndrome symptoms (Balk et al. 2006; Buckley and Howe 2010; Poudyal et al. 2011). The use of omega 3 in antipsychotic-induced metabolic syndrome is only suggested, but no controlled or naturalistic studies are known by authors at the time of this report. An urgent need for evidence-based strategies to reduce metabolic symptoms in children and adolescents taking antipsychotic drugs is an opinion shared among experts (Correll et al. 2009; De Hert et al. 2011; Maayan and Correll 2011).

Health-related quality of life in pediatric liver transplanted patients compared with a chronic liver disease group

BackgroundAchieving a good health-related quality of life (HRQoL) is currently one of the main aims in long term survival of liver transplanted children (PLT). Purpose of our study is to compare HRQoL of PLT patients (N = 33, mean age 12.8 y) vs. sex and age matched patients with compensated and clinically stable chronic liver disease (CLD) (N = 25, mean age 11.9 y).MethodsHRQoL was measured from both patient and parental perspectives using the CHQ-CF87 and CHQ-PF50 questionnaires, respectively.ResultsGeneral Health Perception scores of PLT subjects resulted significantly lower than those of CLD both at self- and parental report (p < 0.05 and p < 0.01, respectively). No other significant differences in other HRQoL domains were found between groups.ConclusionOur results suggest that the two populations are quite similar regarding HRQoL, but both parents and children of PLT group perceive a worse general health. Further studies are needed to confirm these results.

Subject at Risk for Eating Disorders: Study of a Population of Children Aged between 8 and 13 Years

Subject at Risk for Eating Disorders: Study of a Population of Children Aged between 8 and 13 Years Background: early onset eating disorders (EOED) are increasing. Epidemiological studies provided that the overall prevalence is estimated at around 10% in the school population. The present study aims to evaluate those at risk for EOED in a population of students from Campania Region, Italy and to identify some correlated factors associated with the disorder (BMI, age, gender, sport/activities involvement, meal-time characteristics). Method: sample consisted of the students of the primary and secondary schools in six municipalities near the city of Caserta (Campania-Italy). Children eating attitude test-26 (Ch-EAT-26) has been used to collect data on eating disorder behaviors and attitudes. Results: 137 subjects, 61 female and 76 male composed the sample. Mean age was 115,38 months (SD: 10,4). Mean BMI was 20 (SD: 5). The means score at the ChEAT was 13.25 (SD: 9) and 30 children exceeded the clinical cut-off score (>20). There was no correlation between ChEAT score and BMI and age. Sport/activities outside the school and key figure for the child at meal time were significantly different between the clinical and non-clinical group (Ch-EAT score). Conclusion: data showed that our sample had a higher risk for EOED compared to the overall prevalence. Dance and physical exercise were confirmed such as risk factors for eating disorders. Finally according to the results of our research, the presence of the mother at the meal- time may be a protective factor for the risk of developing and eating disorder in childhood.

Psychiatric and neuropsychological issues in Marfan syndrome: A critical review of the literature.

The cooccurrence of Marfan syndrome and psychiatric disorders has been reported for many years. Furthermore, neuropsychological deficits have been shown to be associated with Marfan syndrome. The aim of the present article is to summarize findings from the sparse studies and case reports available. The results hold clinical and therapeutic implications and suggest that psychological and neuropsychological domains in Marfan syndrome patients should be carefully assessed. In particular, some patients may require specific rehabilitation programs. On this basis, a multidisciplinary approach to Marfan syndrome treatment seems mandatory.