Humberto C. Párraga

Prevalence of Sleep Disorders and Sleep Behaviors in Children and Adolescents

Maternal reports were used to assess the prevalence of a comprehensive group of sleep disorders and behaviors in a rural population of school-aged children. Some sleep behaviors occurred in significantly greater numbers of subjects on the basis of age, sex, socioeconomic status, and chronic medical problems and/or ear, nose, and throat allergies.

Sleep behaviors and disorders in children and adolescents evaluated at psychiatric clinics.

The parents of 150 children and adolescents, evaluated at a university psychiatry outpatient clinic and a mental health center, were surveyed to determine the frequency of various sleep-related behaviors. This clinic sample was compared with a nonclinic sample of 309 subjects from the general population. A significantly higher incidence of restless sleep, limb movements, nightmares, night terrors, reluctance going to sleep, sleeping with others, fear of dying, fears of dark, and daytime overactivity differentiated the clinic population from the nonclinic population. there were no significant differences in the frequencies of sleep behaviors in the clinic sample due to chronic ear-nose-throat (ENT) problems, sex, or social class. However, bedwetting, sleeping with others, bedtime rituals, need for security objects, fears of the dark, and daytime overactivity were significantly more frequent in the younger age population. Nightmares and restless sleep were more likely to occur in patients having anxiety-affective disorder or conduct disorder DSM III diagnoses, as compared to clinic patients without psychiatric diagnoses. Patients with mental retardation were more likely to experience fears of the dark. A significantly greater number of patients with attention deficit disorder manifested problems with snoring, head banging, restless sleep, and nighttime awakening. There appeared to be an association between chronic ENT problems and daytime overactivity.

Quetiapine Treatment of Children with Tourette's Syndrome: Report of Two Cases

Two children with Tourettes syndrome and comorbid disorders were treated with quetiapine, an atypical antipsychotic successfully used in patients with psychoses and schizophrenia with low incidence of extrapyramidal side effects. Clinical observations and standardized rating scales suggested that this drug produced beneficial effects on tics and other symptoms. Adverse effects (at low doses) were minimal. Because it was suggested that tic efficacy of the newer antipsychotics was related to higher D2 occupancy (with the exception of quetiapine and clozapine, which have relatively low D2 activity), it is hypothesized that tic patients are D2 sensitive and need lower doses of medications. These children were treated naturalistically and were reported retrospectively because of their encouraging outcomes. However, these findings should be interpreted with caution, because no contrast groups, drug withdrawal, or placebo were utilized. Controlled studies are needed to determine the efficacy of quetiapine in the treatment of Tourettes syndrome.

Tic Exacerbation and Precipitation during Atomoxetine Treatment in Two Children with Attention-Deficit Hyperactivity Disorder

Stimulants have been the mainstay of treatment for children with Attention-deficit/hyperactivity Disorder (ADHD). However, stimulants have been controversially purported to precipitate and exacerbate tics. Atomoxetine, a selective norepinephrine inhibitor, was introduced as a safe non-stimulant alternative treatment for ADHD children with comorbid tics or TS. We are presenting two children with ADHD, in which atomoxetine, at relatively low doses, exacerbated and precipitated tics. The diagnoses of ADHD and tic disorder were based on clinical observations and standardized rating scales. Case 1, an 8-year-old boy, had history of stimulant-induced tics. This child was placed on atomoxetine reported to be safe for patients with tics. This patients tic control was adequate prior to atomoxetine treatment. However, while on atomoxetine, the patient promptly experienced tic exacerbation. Case 2, a 6-year-old boy, had no previous history of stimulant therapy and was receiving citalopram due to a comorbid anxiety disorder. Atomoxetine was initiated for the treatment of ADHD with improvement in the ADHD symptoms. But, upon a mild dose increase, the patient presented tic precipitation consisting primarily of neck twitches. Both cases experienced a decrease in tic activity when atomoxetine was discontinued, but tics did not fully resolve, causing psychosocial disturbance. Atypical neuroleptics were used with good results. Periodic assessments of the need for continued neuroleptic treatment were emphasized. These two children exemplify atomoxetines potential to exacerbate and precipitate tics in children with ADHD. Independent controlled studies are needed to determine if atomoxetine should be used in children with ADHD and comorbid tic disorders or TS.

Quetiapine treatment in patients with Tourette syndrome.

Most of the drugs avail able have been used to treat Tourette Syn drome (TS), with lim ited or non ex ist ent re sults un til the ad vent of the neu ro lep tics, which have dem on strated a dis tinctly higher range of ef fec tive ness. Even so, the medi cal treat ment of TS has con sisted of the ad mini stra tion of do pa mine an tago nists, pre domi nantly ha loperi dol, and cen trally act ing alpha-2 ad ren er gic re cep tor ago nists, pre domi nantly clo nidine. The use of these drugs, how ever, has been lim ited by their ad verse ef fects—mostly ex tra py ra mi dal, dys pho ric symp toms in the case of ha loperi dol (1) and car dio vas cu lar ef fects in the case of clo nidine (2).

An overview of the treatment of Tourette's disorder and tics.

OBJECTIVE The aim of this study was to review the efficacy of various treatments for Tourettes disorder (TD) and tics. METHOD This study is a historical review of the treatment modalities prior to the advent of neuroleptics. A review of double-blind and placebo-controlled clinical trials and open studies on the use of neuroleptics and selected reports was also carried out. RESULTS The literature review reveals that the treatment of TD and tics has evolved from an early history of marginally effective approaches to the advent of neuroleptics, which started a new era in TD and tic treatment, with a significantly broader range of effectiveness. CONCLUSIONS Although progress has been made, the literature review nevertheless reveals a great deal of confusion as related to the clinical heterogeneity of TD and tics, differences in populations, medication-dose combinations, and outcomes. However, a role for a limited number of pharmacologic agents, combined with psychosocial approaches, has been identified. There is a need for studies in larger, diagnostically homogenous samples and for the use of more sophisticated methodology, to identify intelligible models that would allow the development of more effective treatment approaches.

Treatment approach in a child with hysterical seizures superimposed on partial complex seizures.

This article reports the case of a 9½ year old child with a history of psychomotor epilepsy which was uncontrolled by multiple anticonvulsant medications. When admitted to the psychiatric inpatient service, he was treated with a combination of pharmacological, behavioural and psychodynamically oriented approaches. A period of intensive family counseling was conducted to clarify the parents’ concerns about causality of the seizures and methods for dealing with them. This combined approach led to a complete cessation of reported seizures and a decreased number and dosage of anticonvulsant medications. The authors discuss the reluctance of some physicians to accept the co-existence of neurogenic and psychogenic seizures in a given patient. Patients with pharmacologically uncontrolled seizures must be identified and accurately diagnosed (neurogenic and/or psychogenic) to prevent complications such as over-medication and to administer appropriate treatment. Multiple disciplinary therapy including psychodynamic, pharmacological, behavioural and educational approaches should be implemented.

Clinical differences between subjects with familial and non-familial Tourette's syndrome: a case series.

Objective: As many as 35 percent of Tourettes Syndrome patients do not acquire this disorder genetically. Since there has been little research conducted in this area, the purpose of this study was to compare the clinical differences between two groups of patients with Tourettes Syndrome (TS), one with family history of TS and one without. Method: Using data of eight previously diagnosed TS patients, the authors made comparisons of clinical and sociodemographic variables between a group of three patients with family history of TS and five with no family history. Results: There were no differences in clinical presentation, current age, age at diagnosis, gender, and socioeconomic status. There were differences in birth history, developmental milestones, I.Q., and neurological findings between patients with family history and no family history of TS. Conclusions: Our findings support the need for testing the hypothesis of a multidetermined origin of TS, a disorder in which hereditary, neuropsychological, and environmental factors play a role.

Iatrogenic behavioral and psychiatric symptoms in children with partial complex seizures.

Reports are presented of two children with partial complex seizures (PCS) who had a variety of behavioral and psychiatric symptoms that were related to toxic serum levels of anticonvulsants. Anticonvulsant toxicity should be considered in the differential diagnosis of psychiatric symptoms in all children with convulsive disorders. The traditional view that the psychomotor spells have behavioral and psychiatric components increases the complexity of the differential diagnosis. PCS in children present differences in symptomatology and more difficulties in diagnosis and treatment compared with adults.

Tourette's syndrome and anophthalmia in a girl: complex differential diagnosis.

This is a report of a 15 year old girl with anophthalmia who met the DSM-HI criteria for Tourettes Syndrome (TS). The case presented a complex differential diagnosis with previous diagnoses of behaviour disorder and schizophrenia, complicated by the issues of blindness, pharmacological, and environmental factors. Once the diagnosis was made, and due to intricate biopsychosocial interactions, a comprehensive treatment approach was adopted with good results. The authors comment on the non-existence of studies about the incidence of TS in blind children and recommend the discrimination between the motor behaviour of the tic disorder versus mannerisms associated with blindness. Thus a reasonable degree of suspicion is warranted in the treatment of blind children with severe behavioural disturbances.