Stephen Sulzbacher

Phenobarbital for febrile seizures--effects on intelligence and on seizure recurrence.

Phenobarbital is widely used in the treatment of children with febrile seizures, although there is concern about possible behavioral and cognitive side effects. In 217 children between 8 and 36 months of age who had had at least one febrile seizure and were at heightened risk of further seizures, we compared the intelligence quotients (IQs) of a group randomly assigned to daily doses of phenobarbital (4 to 5 mg per kilogram of body weight per day) with the IQs of a group randomly assigned to placebo. After two years, the mean IQ was 7.03 [corrected] points lower in the group assigned to phenobarbital than in the placebo group (95 percent confidence interval, -11.52 to -2.5, P = 0.0068 [corrected]). Six months later, after the medication had been tapered and discontinued, the mean IQ was 5.2 points lower in the group assigned to phenobarbital (95 percent confidence interval, -10.5 to 0.04, P = 0.052). The proportion of children remaining free of subsequent seizures did not differ significantly between the treatment groups. We conclude that phenobarbital depresses cognitive performance in children treated for febrile seizures and that this disadvantage, which may outlast the administration of the drug by several months, is not offset by the benefit of seizure prevention.

Psychosocial Adjustment in Long-Term Survivors of Childhood Medulloblastoma and Ependymoma Treated with Craniospinal Irradiation

Improved prognosis for pediatric brain tumors has stimulated research into the quality of life of survivors. To assess cognitive function and psychosocial and family adjustment among this population, 18 long-term survivors of childhood medulloblastoma or posterior fossa ependymoma treated with surgical resection and craniospinal irradiation were interviewed and administered achievement tests and psychosocial questionnaires. A majority of parents reported significant difficulty caring for their child with a brain tumor, but no significant adverse effects upon the family. Academic achievement was significantly impaired in 12/18 subjects. Psychosocial adjustment was normal in 10/18 subjects. Although specific treatment variables (radiation dosage, chemotherapy, etc.) were not significantly related to these two outcome measures, impaired academic achievement was correlated with young age at diagnosis (p < 0.05) and impaired psychosocial adjustment was correlated with greater time since diagnosis (p < 0.05). Overall quality of life reported by these individuals appears to be acceptable but neuropsychological and psychosocial examination is clearly indicated as part of the follow-up program.

First Febrile Seizures Characteristics of the Child, the Seizure, and the Illness

Through interviews with parents, data were gathered about 910 first febrile seizures in children aged 8 to 34 months. A male preponderance of 57% was found (P <.001). In 29% of cases, there was a family history of febrile seizures. Eighteen percent of seizures were focal, and 7% lasted 15 minutes or more. Focal seizures were much more likely to be of long duration (P <.001). Otitis media was diagnosed in 32% of cases, and tonsillitis or upper respiratory infection in 12%. When compared to febrile seizures after the first birthday, febrile seizures in children aged 8 to 11 months were more than twice as likely to be longer than 15 minutes (P= .015). They were also much more likely to be followed by further seizures in the same illness (P <.001). Thus, febrile seizures in children younger than 1 year are more likely to have the characteristics known to increase the risk of later nonfebrile seizures.

Telepsychiatry improves paediatric behavioural health care in rural communities.

In the US, children with special health care needs are underserved by both the medical and educational systems. This problem is especially serious in rural states. Telemedicine is a technique that can reduce these gaps in service and help connect the two systems. The technology required has become cheaper and more accessible. Progress on reimbursement for such services has also been made. For some years, we have provided telepsychiatry for children in Washington State using videoconferencing. Interviews with families and service providers were conducted in Washington and Missouri. Some parents reported that their child actually preferred telepsychiatry to conventional consultation. The telepsychiatry service model was built on the existing system of outreach clinics, thus involving specialists who were familiar with the community and who were known and trusted by the community. Before starting, we ensured that all relevant service delivery agencies and providers were comfortable about using videoconferencing as a method of service delivery. In the 18-month period ending in March 2003, three providers in Seattle saw 159 patients by telepsychiatry and 210 patients face-to-face at the hospital clinic. The main barrier to further growth of the telepsychiatry service is the absence of reimbursement for telepsychiatry.

Use of CNS Stimulant Medication in Averaged Electroencephalic Audiometru with Children with MBD

Averaged electroencephalic audiometry (AEA) was conducted on 12 children diagnosed as having minimal brain dysfunction (MBD). Each child was tested on three separate days to permit a double-blind evaluation of responsiveness to no-drug, placebo and CNS stimulant drug conditions. In addition, 9 of the 72 children were tested a fourth time to permit an examination of the two dosage levels. Lower thresholds were recorded when the subjects were tested on medication. This finding suggests that AEA with MBD children can be enhanced by taking advantage of the medication prescribed to counteract hyperactivity. It was also observed that the AEA performance of children on whom medication had a favorable behavioral effect was different from that of poor drug responders, even in the no-medication conditions.

Crossed dominance and its relationship to intelligence and academic achievement

Measures of handedness have long been utilized as part of the neuropsychological assessment due to evidence that hand preference is related to cerebral dominance for language. Many lateral dominance examinations also include measurement of eye, ear, and/or foot preference, presumably for assessment of crossed laterality. Although a reliable relationship between crossed laterality and intelligence or achievement has not been demonstrated, the assumption that crossed eye/foot or eye/hand dominance predicts poor intelligence or achievement persists. In the present study, a group of 93 normal children between the ages of 2 and 8 years old were followed longitudinally. No relationship was found between crossed laterality and intelligence or achievement.

Does phenobarbital used for febrile seizures cause sleep disturbances

The effect of phenobarbital on total sleep time, night awakenings, and lengthy awakenings was examined as part of a randomized trial of children with febrile seizures; information about sleep patterns was gathered by parental observation. Children were between ages 8-36 months at enrollment and were examined subsequently for 2 1/2 years. Night awakenings were not more common in children assigned to phenobarbital except for those who were poor sleepers at the beginning of the study. Total sleep time was no different in children assigned to phenobarbital than in those assigned to placebo. It is concluded that sleep problems reported in most young children with febrile seizures treated with phenobarbital did not exceed those reported in children treated with placebo, but a subset of predisposed children did experience an increase in night awakenings.

Use of Medication Versus Reinforcement to Modify a Classroom Behavior Disorder

Contingency management procedures and psychotropic medication (diphenhydramine hydrochloride) were both applied in an attempt to decelerate facial grimaces by a five-year-old language and learning disabled boy. Effects of self-recording, teacher praise, and candy were compared with effects of self-recording and praise only; grimacing in the classroom setting decelerated using both procedures. A doubleblind, placebo-controlled study of the effects of diphenhydramine on grimacing was also conducted in the childs classroom and the medication was found not to significantly affect the behaviors rate of occurrence. The childs arithmetic performance was also unaffected by the medication. It was concluded that the behavioral effects of drugs could be measured in the same fashion as the effects of other behavior modification procedures.

Assessing the association between pesticide exposure and cognitive development in rural Costa Rican children living in organic and conventional coffee farms.

We examined the association between pesticide exposure and cognitive development among rural Costa Rican children in a cross-sectional study. Study participants aged 4-10 years included 17 children whose parents worked in La Amistad organic coffee plantation and 18 Las Mellizas children whose parents worked in their own small conventional coffee farms. Two spot-urine samples were collected from each participant and analyzed for organophosphorus and pyrethroids pesticide metabolites. We administered the computerized Behavioral Assessment and Research System (BARS), a figure-drawing task, and a long-term memory test to evaluate study participants cognitive development. Although urinary pesticide metabolite levels did not vary considerably between these two groups of children, we found that Las Mellizas children performed better in BARS and the figure drawing tests than did La Amistad. The results from the linear mixed-effects models suggested that family socioeconomic status (SES) might be a significant contributor to the variation of the outcomes of the neurobehavioral tests. The effect of pesticide exposure, however, as measured in a snapshot fashion, did not play a significant role to the performance of the cognitive development evaluation. Regardless of the study limitations, needed effort should be devoted to the improvement of the SES on the La Amistad families so that their childrens cognitive development would not be compromised further. Additionally, future studies should focus on addressing the limitations imposed on the snapshot assessment of pesticide exposure and on conducting cognitive development evaluation so the link between childhood pesticide exposure and their cognitive development can be thoroughly investigated.

The generalization of newly acquired behaviors by parents and child across three different settings. A study of an autistic child.

The generalization of newly learned behaviors to different settings on the part of an autistic child and his parents was investigated by means of a multiple baseline design. Contingency management techniques were taught to the parents while they interacted with their child in a training apartment equipped with observation facilities. In order to assess whether the parents generalized the use of these techniques, data were gathered at their own home. Data were also gathered in the childs school in order to ascertain whether changes brought about in the childs behavior in the training apartment generalized to the school situation. It was concluded that the childs behavior was responsive to the contingencies of each particular environment. Generalization did not occur until the contingencies and stimulus cues were specifically designed to promote a change in behavior in each setting.