Isobel Heyman

Progressive increase of frontostriatal brain activation from childhood to adulthood during event-related tasks of cognitive control

Higher cognitive inhibitory and attention functions have been shown to develop throughout adolescence, presumably concurrent with anatomical brain maturational changes. The relatively scarce developmental functional imaging literature on cognitive control, however, has been inconsistent with respect to the neurofunctional substrates of this cognitive development, finding either increased or decreased executive prefrontal function in the progression from childhood to adulthood. Such inconsistencies may be due to small subject numbers or confounds from age‐related performance differences in block design functional MRI (fMRI). In this study, rapid, randomized, mixed‐trial event‐related fMRI was used to investigate developmental differences of the neural networks mediating a range of motor and cognitive inhibition functions in a sizeable number of adolescents and adults. Functional brain activation was compared between adolescents and adults during three different executive tasks measuring selective motor response inhibition (Go/no‐go task), cognitive interference inhibition (Simon task), and attentional set shifting (Switch task). Adults compared with children showed increased brain activation in task‐specific frontostriatal networks, including right orbital and mesial prefrontal cortex and caudate during the Go/no‐go task, right mesial and inferior prefrontal cortex, parietal lobe, and putamen during the Switch task and left dorsolateral and inferior frontotemporoparietal regions and putamen during the Simon task. Whole‐brain regression analyses with age across all subjects showed progressive age‐related changes in similar and extended clusters of task‐specific frontostriatal, frontotemporal, and frontoparietal networks. The findings suggest progressive maturation of task‐specific frontostriatal and frontocortical networks for cognitive control functions in the transition from childhood to mid‐adulthood. Hum Brain Mapp, 2006.

A population survey of mental health problems in children with epilepsy

The 1999 British Child and Adolescent Mental Health Survey, a nationwide epidemiological study of rates of psychiatric disorder in children aged 5 to 15 years, provided the opportunity to investigate the mental health of children with epilepsy. These children and their families experience disability specifically because of additional emotional, behavioural, and relationship problems, and this is the first epidemiological study that directly measures these impairments. Information was obtained by interviewing a main carer and teacher for 10,316 children; 67 children with epilepsy were identified (35 males, 32 females; mean age 10 years 2 months, SD 2 years 11 months, range 5 to 15 years), and compared with the 47 children with diabetes (27 females, 20 males; mean age 10 years 4 months, SD 3 years 4 months, range 5 to 15 years) and 10,202 controls (50% male; mean age 9 years 11 months, SD 3 years 1 month, range 5 to 15 years). DSM-IV psychiatric diagnoses were derived from the Development and Well-Being Assessment in combination with the interview and a specialist clinician rating. Parental reports of emotional and behavioural problems, their impact, and associated peer problems were also obtained. Rates of psychiatric disorder were 37% (95% confidence interval [CI] 22 to 49) in epilepsy, 11% (95% CI 2 to 19%) in diabetes, and 9% (95% CI 9 to 10%) in control children. Parents of children with epilepsy consistently reported more problems, with greater impact and associated peer problems. Epilepsy, but not diabetes, was independently (adjusted for age, sex, and severe learning difficulties) associated with all behavioural variables in regression analyses. Emotional, behavioural, and relationship difficulties are common in children with epilepsy, and constitute a significant burden to the children and their families, indicating the need for effective mental health services for these children.

Disorder-specific dysfunction in right inferior prefrontal cortex during two inhibition tasks in boys with attention-deficit hyperactivity disorder compared to boys with obsessive-compulsive disorder

Inhibitory dysfunction is a key behavioral and cognitive phenotype of attention‐deficit hyperactivity disorder (ADHD) and obsessive–compulsive disorder (OCD). Both disorders show neuropsychological deficits and fronto‐striatal dysfunction during tasks of motor response inhibition and cognitive flexibility. This study investigates differences and commonalities in functional neural networks mediating inhibitory control between adolescents with ADHD and those with OCD to identify disorder‐specific neurofunctional markers that distinguish these two inhibitory disorders.

Structure of obsessive-compulsive symptoms in pediatric OCD.

OBJECTIVE It is unclear whether the structure of obsessive-compulsive disorder (OCD) symptoms seen in adults is preserved in pediatric samples. METHOD A total of 238 children and adolescents referred to a specialty pediatric OCD clinic were administered the Childrens Yale-Brown Obsessive Compulsive Scale Symptom Checklist, and its 13 major symptom categories were subjected to exploratory principal components analysis. The resulting factors were correlated with relevant clinical variables. RESULTS Principal components analysis identified four symptom dimensions explaining 55% of the total variance and broadly corresponding to those seen in adult samples. Boys were more likely to have sexual obsessions (34% vs. 18%, p = .01), whereas girls were more likely to endorse hoarding compulsions (53% vs. 36%, p=.009). High scores on the hoarding dimension were associated with increased levels of pervasive slowness, responsibility, indecisiveness, pathological doubt, depression and a variety of emotional difficulties, both self-rated and parent-rated. CONCLUSIONS The structure of OCD symptoms is similar across the lifespan. Hoarding symptoms are prevalent in pediatric OCD, especially among girls, and are associated with greater levels of disability.

Obsessive-compulsive disorder

Obsessive-compulsive disorder is one of the more common serious mental illnesses. The shame and secrecy associated with it, as well as lack of recognition of its characteristic symptoms, can lead to delay in diagnosis and treatment. Effective psychological and drug treatments are available for the distressing, time consuming, repetitive thoughts and rituals and the associated functional impairment. This article reviews the presentation and assessment of obsessive-compulsive disorder and discusses the current best treatment options, as well as directions for the future. We searched for the term “obsessive compulsive disorder” in electronic databases and referred to published systematic reviews, including the recently published guideline from the National Institute for Health and Clinical Excellence (NICE). Obsessive-compulsive disorder occurs throughout the life span, and children as young as 6 or 7 present with the characteristic impairing symptoms (box 1). At the other end of the age range, patients may present for the first time in old age. Most adults with the disorder report onset in childhood or adolescence. The condition can result in considerable disability; for example, children may drop out of education and adults can become housebound. The World Health Organization rates obsessive-compulsive disorder as one of the top 20 most disabling diseases. If untreated, it generally persists,1 yet effective, evidence based psychological and drug treatments are available. Recent epidemiological studies report prevalence rates of 0.8% in adults and 0.25% in 5-15 year old children,2 3 although earlier studies suggested rates as high as 1-3% in adults and 1-2% in children and adolescents. People of all ages with obsessive-compulsive disorder understand the senseless nature of their repetitive, unwanted behaviours and intrusive, recurrent thoughts. This may lead to shame, reluctance to seek help, and poor recognition by health professionals. People with the disorder have long delays in accessing effective treatments—17 years …

Changes in gray matter volume and white matter microstructure in adolescents with obsessive-compulsive disorder.

BACKGROUND There is a paucity of neuroimaging data in pediatric-onset obsessive-compulsive disorder (OCD). This multimodal neuroimaging study aimed to identify structural gray (GM) and white matter (WM) microstructure changes in pediatric OCD. METHODS We obtained structural and diffusion tensor magnetic resonance images from 26 OCD patients and 26 matched healthy adolescents. We carried out a series of image analyses including, volumetric and shape analysis of subcortical gray structures, as well as voxel-based morphometry on GM volume and fractional anisotropy of the WM. RESULTS Patients had increased GM volume in the caudate bilaterally and right putamen. Shape analyses revealed specific hypertrophy of the dorsal caudate in pediatric OCD. The striatum was larger in healthy boys compared with healthy girls, whereas such a gender effect was not seen in the OCD group. OCD subjects showed higher fractional anisotropy values in left inferior longitudinal fasciculus, bilateral superior longitudinal fasciculus, right inferior fronto-occipital fasciculus, bilateral corticospinal tract, corpus callosum splenium and genu, bilateral forceps major, bilateral forceps minor, left cingulum, and right uncinate fasciculus. OCD symptom severity was positively correlated with GM volume in right insula, posterior orbitofrontal cortex, brainstem, and cerebellum and inversely correlated with widespread reduction in cortical GM volume. Furthermore, symptom severity positively correlated with increased WM fractional anisotropy in various WM tracts, including the anterior limb of the internal capsule. CONCLUSIONS Adolescents with OCD had a wide range of GM and WM changes compared to healthy control subjects that are broadly consistent with those identified in the adult OCD literature but are more extensive.

Long-term outcomes of obsessive–compulsive disorder: follow-up of 142 children and adolescents

BACKGROUND Obsessive-compulsive disorder (OCD) often starts in childhood and adolescence and can be a chronic disorder with high persistence rates. There are few prospective long-term follow-up studies. AIMS To follow up young people with OCD to clarify persistence rates and relevant predictors, presence of other psychiatric disorders, functional impairment, service utilisation and perceived treatment needs. METHOD All young people with OCD assessed over 9 years at the National and Specialist Paediatric OCD clinic, Maudsley Hospital, London, were included. Sixty-one per cent (142 of 222) of all contactable young people and parents completed computerised diagnostic interviews and questionnaires. RESULTS We found a persistence rate of OCD of 41%; 40% of participants had a psychiatric diagnosis other than OCD at follow-up. The main predictor for persistent OCD was duration of illness at assessment. High levels of baseline psychopathology predicted other psychiatric disorders at follow-up. Functional impairment and quality of life were mildly to moderately affected. Approximately 50% of participants were still receiving treatment and about 50% felt a need for further treatment. CONCLUSIONS This study confirms that paediatric OCD can be a chronic condition that persists into adulthood. Early recognition and treatment might prevent chronicity. Important challenges for services are ensuring adequate treatment and a smooth transition from child to adult services.

Prevalence of obsessive-compulsive disorder in the British nationwide survey of child mental health

Obsessive-compulsive disorder (OCD) is a disorder that appears to be under-diagnosed and under-treated, despite the evidence for effective treatments. There are variable estimates of OCD prevalence in the under-16s and published rates give little indication of age trends. The aim of this study was to establish the prevalence and associates of OCD in young people aged 5-15 years. The method was a nationwide (UK) epidemiological study of rates of psychiatric disorder in 5-15 year olds (1999 British Child Mental Health Survey): 10,438 children were assessed. Twenty-five children with OCD were identified (weighted overall prevalence 0.25%; 95% CI 0.14-0.35), with prevalence rising exponentially with increasing age. Compared with normal controls, children with OCD were more likely to be from lower socio-economic class and of lower intelligence. Only three of these children had been seen by specialist childrens services. Although OCD is rare in young children, the rate increases towards the adult rates at puberty. Children with OCD have additional psychosocial disadvantage. The majority of the childhood cases identified in this survey appear to have been undetected and untreated.

Psychopathology in children with epilepsy before and after temporal lobe resection

The aim of this study was to establish the rate and spectrum of psychiatric disorder among children before and after temporal lobe surgery for epilepsy. Data were examined for associations between psychopathology and seizure outcome following surgery, or association between psychopathology and other variables, such as laterality of lesion, sex, cognitive level, and underlying pathology. Participants were 60 children (35 males, 25 females) who had focal seizures of temporal lobe origin and who had undergone temporal lobe resection between 1992 and 1998; mean age at time of operation 10 y 7 mo, (SD 4 y 11 mo) range 7 mo to 17 y 11 mo. Mean length of follow-up was 5.1 years (SD 2.3, range 2 to 10 y). Twenty-eight (47%) children had undergone right temporal lobectomy. Diagnosis of a psychiatric disorder was present in 50/60 (83%) children at some point, with high rates of psychiatric comorbidity. Common childhood psychiatric disorders of attention-deficit-hyperactivity disorder, oppositional defiant disorder/conduct disorder, and emotional disorders were present in about 25% of children. Disorders rarely seen in the general child population were over-represented: disruptive behaviour disorder--not otherwise specified (30/60 [50%]), and pervasive developmental disorder (autistic spectrum disorder; 23/60 [38%]). there was no significant relationship between pathology, sex, seizure frequency, or postoperative seizure outcome and psychiatric disorder, other than for pervasive developmental disorder. The same proportion of children had psychiatric diagnoses pre- and postoperatively (43/60 [72%] and 41/57 [72%] respectively). Although mental health problems are common in children undergoing temporal lobe resection, there are few predictors of psychiatric outcome following epilepsy surgery. Parents require counselling on these issues in the preoperative work-up.

Dyskinesias and associated psychiatric disorders following streptococcal infections

Background: The classical extrapyramidal movement disorder following β haemolytic streptococcus (BHS) infection is Sydenham’s chorea (SC). Recently, other post-streptococcal movement disorders have been described, including motor tics and dystonia. Associated emotional and behavioural alteration is characteristic. Aims: To describe experience of post-streptococcal dyskinesias and associated co-morbid psychiatric features presenting to a tertiary referral centre 1999–2002. Methods: In all patients, dyskinetic movement disorders followed BHS pharyngeal infection. BHS infection was defined by pharyngeal culture of the organism, or paired streptococcal serology. Movement disorders were classified according to international criteria, and validated by experienced child neurologists. Psychiatric complications were defined using ICD-10 criteria using a validated psychiatric interview. Results: In the 40 patients, the following dyskinetic movement disorders were present: chorea (n = 20), motor tics (n = 16), dystonia (n = 5), tremor (n = 3), stereotypies (n = 2), opsoclonus (n = 2), and myoclonus (n = 1). Sixty five per cent of the chorea patients were female, whereas 69% of the tic patients were male. ICD-10 psychiatric diagnoses were made in 62.5%. Using the same psychiatric instrument, only 8.9% of UK children would be expected to have an ICD-10 psychiatric diagnosis. Emotional disorders occurred in 47.5%, including obsessive-compulsive disorder (27.5%), generalised anxiety (25%), and depressive episode (17.5%). Additional psychiatric morbidity included conduct disorders (27.5%) and hyperkinetic disorders (15%). Psychiatric, movement, and post-streptococcal autoimmune disorders were commonly observed in family members. At a mean follow up of 2.7 years, 72.5% had continuing movement and psychiatric disorders. Conclusion: Post-streptococcal dyskinesias occur with significant and disabling psychiatric co-morbidity and are potential autoimmune models of common “idiopathic” movement and psychiatric disorders in children. Multiple factors may be involved in disease expression including genetic predisposition, developmental status, and the patient’s sex.