David L. Wodrich

Use of Positron Emission Tomography for Presurgical Localization of Eloquent Brain Areas in Children with Seizures

Successful surgical management of a neoplastic or nonneoplastic seizure focus in close proximity to or within eloquent brain areas relies on precise delineation of the relationship between the lesion and functional brain areas. The aim of this series was to validate the usefulness and test the efficacy of noninvasive presurgical PET mapping of eloquent brain areas to predict surgical morbidity and outcome in children with seizures. To identify eloquent brain areas in 15 children (6 female and 9 male; mean age 11 years) with epileptogenic lesions PET images of regional cerebral blood flow were performed following the administration of [(15)O]water during motor, visual, articulation, and receptive language tasks. These images with coregistered magnetic resonance (MR) images were then used to delineate the anatomic relationship of a seizure focus to eloquent brain areas. Additional PET images using [18F]fluoro-2-deoxy-D-glucose (FDG) and [11C]methionine (CMET) were acquired to help localize the seizure focus, as well as characterize the lesion. Patient surgical management decisions were based on PET mapping in combination with coregistered MR images, PET-FDG findings, and the anatomic characteristics of the lesion. At follow-up 1-26 months after surgery, all patients that underwent temporal lobectomy (9 patients) and extratemporal resection (4 patients) for a neoplastic or nonneoplastic seizure focus are seizure-free with minimal postoperative morbidity. Of prime importance, no child sustained a postoperative speech or language deficit. PET imaging was also well tolerated without procedural complications. Based on PET mapping, a nonoperative approach was used for 2 children and a biopsy only was used in one child. When cortical injury involved prenatally determined eloquent cortex, PET demonstrated reorganization of language areas to new adjacent areas or even to the contralateral hemisphere. Integration of anatomical and functional data enhanced the surgical safety, defined optimal surgical approach, delineated the seizure focus from eloquent brain areas, facilitated maximum resection and optimized the timing of surgery, thereby minimizing surgical morbidity while maximizing surgical goals. PET measurements of FDG and CMET uptake were also helpful in localizing the seizure focus and grading the tumors. PET used for brain mapping in children provides the surgeon with strategic preoperative information not readily attainable with traditional invasive Wada testing or intraoperative cortical stimulation. PET mapping may also improve the outcome of extratemporal resections by allowing aggressive seizure focus resection. In addition, serial brain maps may optimize timing for surgical intervention by demonstrating reorganization of eloquent cortex often seen in younger children after cortical injury. Our results suggest that noninvasive presurgical brain mapping has the potential to reduce risk and improve neurologic outcome.

Positron Emission Tomography in Children With Neurofibromatosis-1

Neurofibromatosis-1 is an autosomal dominant genetic disorder commonly associated with neuropsychological complications. Focal areas of high signal intensity on magnetic resonance imaging (MRI) scans occur commonly but have shown inconsistent correlation with neuropsychological problems. Positron emission tomography (PET) scans utilizing [18F]fluoro-2-deoxy-D-glucose and MRI studies were performed on 10 children with neurofibromatosis-1 and multiple focal areas of high signal intensity to evaluate the regional cerebral metabolic rate for glucose of these lesions and other central nervous system structures. Co-registered PET and MRI studies confirmed reduced glucose metabolism of large focal areas of high signal intensity. Visual inspection and semiquantitative analysis of PET images demonstrated thalamic hypometabolism and varying degrees of cortical inhomogeneity in all cases of neurofibromatosis-1 compared to normal controls. Although a primary defect of the thalamus or cerebral cortex has not been defined, the metabolic abnormalities of this study suggest a potential relationship between these structures and the neuropsychological dysfunctions noted in neurofibromatosis-1. (J Child Neurol 1997; 12:499-506).

Type 1 diabetes mellitus and school: a review

Wodrich DL, Hasan K, Parent KB. Type 1 diabetes mellitus and school: a review.

Type 1 diabetes mellitus and school: a comparison of patients and healthy siblings

Children and adolescents with type 1 diabetes mellitus (T1DM) are at risk for a variety of problems at school. Well‐controlled studies using data collected in schools, however, are limited. The purposes of this study are to determine whether selected school problems are associated with T1DM and to investigate an association between these problems and medical variables. Teachers rated 95 diabetic students (M = 11.8; SD = 3.0 yr old) and 95 of their siblings (M = 12.1; SD = 3.0 yr old) regarding academic skills, work completion, day‐to‐day variability, and classroom attention. Medical and school records also were accessed. The T1DM group had lower academic skills ratings overall (p < 0.02), especially in writing (p < 0.01), a trend toward poorer classroom attention (p < 0.08), and many more missed school days (p < 0.001). Diabetics on intensive therapy protocols had better academic ratings overall (p < 0.02), including in math (p < 0.03) and fewer missed school days (p < 0.03), but they unexpectedly were rated as having more classroom behaviors that jeopardize work completion (p < 0.05) than counterparts on conventional therapy. Among all diabetics, glycated hemoglobin (HbAlc) levels were moderately related to each academic skill rating (r = −0.34 to −0.37; p < 0.01) and strongly related to classroom attention (r = 0.53; p = 0.000). T1DM itself appears to be a relatively minor influence to several important aspects of school. Furthermore, although intensive therapy alone may well promote school success, meticulous glycemic control, however achieved, appears more important in mitigating prospective classroom attention and academic problems.

School Psychologists: Strategic Allies in the Contemporary Practice of Primary Care Pediatrics

Immense changes in the developmental/behavioral aspects of primary care pediatrics have resulted from revisions in special education laws, introduction of managed care, widened dissemination of information about disabilities to parents, and the changing character of American society. Challenges associated with contemporary pediatric practice can be diminished by routine collaboration with school psychologists. An alliance with school-based psychologists permits pediatricians access to children in their natural environments and potential collaboration for preventing illness and emotional/behavior problems. Further, school psychologists can provide a partner for assessing and treating both common and low-incident disorders without the constraints imposed by managed care.

Predictive Validity of the Boehm Test of Basic Concepts for Achievement in First Grade

The relation between performance on the Boehm Test of Basic Concepts (BTBC) and achievement in the first grade was examined. The BTBC was administered in September and the Stanford Achievement Test (SAT) in May to 278 first-grade pupils. The correlation between BTBC and SAT total test scores was .56. The median correlation between scores on the SAT subtests and BTBC total test was .47. Despite limited variability in BTBC scores, the findings have supported Boehms assertion that mastery of the concepts is related to achievement in the first years of school.

The Other Health Impairment Category and Health-Based Classroom Accommodations: School Psychologists' Perceptions and Practices.

Abstract School psychologists (N = 161) completed a questionnaire regarding the category of other health impairment (OHI) and classroom accommodations for children with health conditions. School psychologists indicated that they were familiar with OHI and often used the category. More school psychologists were involved in OHI placements for students with attention-deficit/hyperactivity disorder (84.3% during the past 12 months) than for the next most cited disorders (viz., 26.7 and 21.4% were involved in at least one placement for a student with epilepsy or asthma/pulmonary disease, respectively). Participants generally perceived educators as capable of making classroom accommodations, although they viewed both limited knowledge of the implications illness and problems consistently applying knowledge about illness as moderate to severe barriers to accommodations. Findings such as these may help school psychologists to continue to embrace health issues in their practices.

Tourette’s Syndrome and Tics: Relevance for School Psychologists

Abstract Tourette’s syndrome (TS) and tic disorders have been studied intensively but most findings appear in the medical rather than school psychology literature. A strong knowledge base exists regarding the etiology and manifestation of TS/tics and their co-existence with learning and behavioral-emotional problems. In this article, it is argued that TS/tics occur commonly among school age children, that students affected with the condition often experience recognizable school, behavioral- emotional and interpersonal difficulties, and that many would benefit if school psychologists identified the disorder and participated in treatment. It is suggested that by identifying and treating this condition school psychologists fulfill an important opportunity to solidify their role as health service providers.

A Survey of School Psychologists' Practices for Identifying Mentally Retarded Students.

Surveys containing questions about identifying mentally retarded students were mailed to 500 randomly selected school psychologists, of whom 160 (32%) returned completed, usable forms. The Wechsler scales were the most frequently used tests for deriving IQ scores, which together with adaptive behavior scale scores were rated as most influential in identification-placement decisions. The Vineland Adaptive Behavior Scales were rated as the most used instruments for assessing adaptive delays. School psychologists were in less accord on issues such as the use of alternative norms for minority and lower SES students (35% confirmed their use), the application of an adaptive behavior standard score of 70 (47.7% indicated such use), and whether an established IQ score, such as 70, could be treated flexibly (27.2% stated they sometimes identified students with scores above the cut-off value). Suggestions are made for future research and current practice.

Indications for Seeking a Medical Consultation

Abstract Recognizing barriers to academic success and full student development, some of which are medical in nature, is a primary task of school psychologists. Expanding biomedical information compels school-based psychologists to collaborate with medical professionals when their input can clarify diagnostic issues and expand treatment choices. This article specifies five indications, or red flags, that typically warrant a medical consultation: (a) paroxysmal changes in consciousness, (b) acute changes in functioning, (c) progressive loss of previously mastered developmental milestones or skills, (d) behavioral or attention problems with possible organic bases, and (e) the presence of physical stigmata or dysmorphic features. The article reviews the rationale for seeking medical consultations and suggests with whom school psychologists might consult. In addition, several questions are posed whose answers could inform practice.