Sex-specifics of ECT outcome

OBJECTIVE

Electroconvulsive therapy (ECT) is the most effective treatment for patients with severe major depressive disorder (MDD). Given the known sex differences in MDD, improved knowledge may provide more sex-specific recommendations in clinical guidelines and improve outcome. In the present study we examine sex differences in ECT outcome and its predictors.

METHODS

Clinical data from 20 independent sites participating in the Global ECT-MRI Research Collaboration (GEMRIC) were obtained for analysis, totaling 500 patients with MDD (58.6 % women) with a mean age of 54.8 years. Severity of depression before and after ECT was assessed with validated depression scales. Remission was defined as a HAM-D score of 7 points or below after ECT. Variables associated with remission were selected based on literature (i.e. depression severity at baseline, age, duration of index episode, and presence of psychotic symptoms).

RESULTS

Remission rates of ECT were independent of sex, 48.0 % in women and 45.7 % in men (X²(1) = 0.2, p = 0.70). In the logistic regression analyses, a shorter index duration was identified as a sex-specific predictor for ECT outcome in women (X²(1) = 7.05, p = 0.01). The corresponding predictive margins did show overlapping confidence intervals for men and women.

CONCLUSION

The evidence provided by our study suggests that ECT as a biological treatment for MDD is equally effective in women and men. A shorter duration of index episode was an additional sex- specific predictor for remission in women. Future research should establish whether the confidence intervals for the corresponding predictive margins are overlapping, as we find, or not.

Deficient Multisensory Integration with concomitant resting-state connectivity in adult ADHD

Introduction

ADHD patients often report that they are being flooded by sensory impressions. Studies investigating sensory processing show hypersensitivity for sensory inputs across the senses. While studying unimodal signal-processing is relevant and well-suited in a controlled laboratory environment, our daily interaction with our environment does not occur merely unimodal. A complex interplay of the senses is necessary to form a unified percept. In order to achieve this, the unimodal sensory modalities are bound together in a process called multisensory integration (MI).

Objectives

In the current study we investigate MI in an adult ADHD sample accompanied by resting-state functional magnetic resonance imaging (RS-fMRI).

Methods

Twenty-five ADHD patients and twenty-four healthy controls were recruited. MI was examined using the McGurk effect, where - in case of successful MI - incongruent speech-like phonemes between visual and auditory modality are leading to a perception of a new phoneme. Mann-Whitney-U test was applied to assess statistical differences between groups. Resting-state functional MRI was acquired to realize a seed-to-voxel analysis

Results

Susceptibility to MCGurk was significantly lowered for ADHD patients (ADHD_Mdn:5.83%, Controls_Mdn:44.2%, U= 160.5, p=0.022, r=-0.34). When ADHD patients integrated phonemes, reaction times were significantly longer (ADHD_Mdn:1260ms, Controls_Mdn:582ms, U=41.0, p<.000, r= -0.56). Seeded medio temporal gyrus was negatively associated in functional connectivity to primary auditory cortex, inferior frontal gyrus, precentral gyrus, and fusiform gyrus.

Conclusions

MI seems to be deficient for ADHD patients for stimuli that need late attentional allocation. This finding is supported for higher functional connectivity from unimodal sensory areas to polymodal, MI convergence zones for complex stimuli.

Disclosure

No significant relationships.

Virtual reality-based and eye tracking-assisted attention refocusing training for adult Attention-Deficit/Hyperactivity Disorder

Introduction

Neurofeedback regimes in the treatment of adult ADHD are commonly EEG-based and have several shortcomings, including a weak signal-to-noise ratio, low transfer rates from laboratory to everyday environments and ambiguous evidence in respect to adequate brain signals of interest.

Objectives

To investigate, if an eyetracking-based real-time feedback in a virtual environment can enhance attentional performance, as measured by behavioral, EEG and eyetracking parameters.

Methods

Overall, n=18 adult patients with ADHD and n=18 healthy controls (HC) performed a continuous performance task (CPT) in a virtual seminar room, while distracting virtual events occurred. In case the participant’s gaze drifted away from the task an automated audiovisual feedback indicated the participant to refocus on the task. Three 20-minutes blocks were presented in counter-balanced order, that differed in respect to whether real feedback, sham feedback or no feedback was additionally provided.

Results

Mixed ANOVAs with within-subject factors ‘Condition’ (real feedback, sham feedback, no feedback) and ‘Phase’ (distractor phases vs. non-distractor phases) and a between-factor ‘Group’ (ADHD patients vs. HC) revealed better task performances in HC than ADHD patients in respect to omission errors (p = .023), mean reaction times (p = .042) and reaction time variabilities (p = .007; cf. Figure 1). Moreover, omission errors turned to be higher during distractor-present than distractor-absent trials (p = .007), especially in ADHD.

Figure 1.

Conclusions

While the virtual CPT turns out to discriminate well between patients with ADHD and HC, the behavioral results do not indicate an attentional performance enhancement based on the gaze-dependent feedback.

Disclosure

No significant relationships.

German validation of the Conners Adult ADHD Rating Scales (CAARS) II: Reliability, validity, diagnostic sensitivity and specificity

Background

The German version of the Conners Adult ADHD Rating Scales (CAARS) has proven to show very high model fit in confirmative factor analyses with the established factors inattention/memory problems, hyperactivity/restlessness, impulsivity/emotional lability, and problems with self-concept in both large healthy control and ADHD patient samples. This study now presents data on the psychometric properties of the German CAARS-self-report (CAARS-S) and observer-report (CAARS-O) questionnaires.

Methods

CAARS-S/O and questions on sociodemographic variables were filled out by 466 patients with ADHD, 847 healthy control subjects that already participated in two prior studies, and a total of 896 observer data sets were available. Cronbach's-alpha was calculated to obtain internal reliability coefficients. Pearson correlations were performed to assess test-retest reliability, and concurrent, criterion, and discriminant validity. Receiver Operating Characteristics (ROC-analyses) were used to establish sensitivity and specificity for all subscales.

Results

Coefficient alphas ranged from .74 to .95, and test-retest reliability from .85 to .92 for the CAARS-S, and from .65 to .85 for the CAARS-O. All CAARS subscales, except problems with self-concept correlated significantly with the Barrett Impulsiveness Scale (BIS), but not with the Wender Utah Rating Scale (WURS). Criterion validity was established with ADHD subtype and diagnosis based on DSM-IV criteria. Sensitivity and specificity were high for all four subscales.

Conclusion

The reported results confirm our previous study and show that the German CAARS-S/O do indeed represent a reliable and cross-culturally valid measure of current ADHD symptoms in adults.

Psychotherapeutische Ansätze bei ADHS im Erwachsenenalter

Die ADHS im Erwachsenenalter stellt einen Risikofaktor für komorbide psychische Störungen und negative psychosoziale Konsequenzen dar. Daher wird nach den deutschsprachigen Leitlinien eine ergänzende Psychotherapie bei ADHS im Erwachsenenalter empfohlen. Der vorliegende Artikel gibt einen Überblick über wissenschaftlich evaluierte psychotherapeutische Behandlungsmöglichkeiten. Ziel der verschiedenen Konzepte ist der Umgang der Betroffenen einerseits mit der Kernsymptomatik der ADHS, andererseits aber auch mit assoziierten bzw. Rest- und Folgeproblemen. Dabei scheint eine Kombinationsbehandlung aus Medikation und Psychotherapie einer alleinigen Medikation überlegen zu sein. Kontrollierte randomisierte Studien zur Wirksamkeit einer Kombinationsbehandlung im Vergleich zu einer alleinigen medikamentösen und psychotherapeutischen Behandlung liegen nicht vor. Daher ist eine differenzielle Indikationsstellung gegenwärtig noch nicht möglich. Eine unter Leitung der Universitätsklinik Freiburg gegenwärtig mit Förderung des BMBF durchgeführte Multizenterstudie mit dieser Fragestellung wird zur Beantwortung einiger offenen Fragen beitragen können (Förderkennzeichen 01GV0606).

Non-Pharmacological Treatment of ADHD Across the Lifespan

Attention Deficit Hyperactivity Disorder (ADHD) is a serious risk factor for co-occurring psychiatric disorders and negative psychosocial consequences over the lifespan. Given this background, there is a need for an effective treatment of ADHD patients.

In the lecture, evidence-based psychosocial interventions for ADHD will be presented.

Disclosure of interest

Books and articles on ADHD.

Ad Boards, Phase-III Studies on ADHD in the last five years.

[ADHD in adulthood: Diagnostics and therapy]

Traditionally, attention deficit hyperactivity disorder (ADHD) was assumed to be a childhood disorder. In the meantime a persistence of symptoms into adulthood has been shown in 60% of those affected. Besides the core symptoms of inattentiveness, hyperactivity and impulsivity, adults with ADHD often suffer from comorbid disorders and functional impairment in multiple domains. In recent years diagnostic guidelines and standardized questionnaires have been developed, which facilitate the diagnostics of ADHD. In addition various therapeutic approaches have emerged and randomized controlled studies have demonstrated the efficacy. The aim of the article is to present the current standard of knowledge with respect to the diagnostics and treatment of ADHD.

Altered cingulate and amygdala response towards threat and safe cues in attention deficit hyperactivity disorder

BACKGROUND

Emotional dysregulation is becoming increasingly recognized as an important feature of attention deficit hyperactivity disorder (ADHD). In this study, two experiments were conducted investigating the neural response to either verbally instructed fear (IF) or uninstructed (classically conditioned) fear (UF) using the skin conductance response (SCR) and functional magnetic resonance imaging (fMRI).

METHOD

In the conditioning phase of the UF experiment (17 ADHD and 17 healthy controls), subjects experienced an unconditioned stimulus (UCS, unpleasant electrodermal stimulation) paired with a former neutral conditioned stimulus (CS+), whereas a control stimulus (CS-) was never paired with the UCS. In the subsequent test phase, only the CS+ and the CS- were presented. In the IF experiment (13 ADHD and 17 healthy controls), subjects were only told that an independently experienced UCS might occur together with the CS+ but not the CS- during testing. No UCS was presented.

RESULTS

Groups did not detectably differ in SCR or neural responses to UF. In IF, ADHD patients showed a trend-line decreased SCR and significantly decreased activation of the dorsal anterior cingulate cortex (dACC), a region prominently involved in fear responding, to the CS+. This was accompanied by higher amygdala activation to the CS-.

CONCLUSIONS

During IF, ADHD patients showed deficits in regions centrally involved in fear learning and expression in terms of diminished CS+-related dACC and increased CS--related amygdala signals. This suggests an impaired processing of verbally transmitted aversive information, which is central for conveying fear information in social contexts. This result extends the growing literature on emotional alterations in ADHD.

Reproducibility of ultrasonography for assessing abdominal fat distribution in a population at high risk of diabetes

Background:

Visceral fat plays an important role in the development of metabolic disease independently of the effect of overall abdominal fat. Ultrasonography is an accessible method of accurately assessing abdominal fat distribution in epidemiological studies, but few details about the reproducibility of this method have been published.

Objective:

The aim of this study was to investigate the reproducibility of ultrasonography in the assessment of abdominal fat distribution in a population at high risk of type 2 diabetes.

Design and Methods:

Ultrasonography was used to estimate visceral and subcutaneous abdominal fat. Intra- and interobserver variation, short-term variation and variation between estimates in the fasting and non-fasting state were examined in three samples of 30, 33 and 23 participants from the ADDITION-PRO study. A variance components model was used to calculate intra- and interobserver variation, and Bland–Altman plots were drawn for all three substudies.

Results:

Coefficients of variation for intra- and interobserver variation were in the range 3.4–6.1%, except for interobserver variation for subcutaneous fat (9.5%). Short-term variation over a median of 35 days had a coefficient of variation of 15%. The effect of a meal was primarily on the visceral estimates and did not extend beyond the first postprandial hour. Non-fasting visceral estimates were larger than fasting estimates.

Conclusion:

Both visceral and subcutaneous fat can be estimated with ultrasonography with adequate intra- and interobserver reproducibility by clinical researchers with limited training, making it a feasible method of assessing abdominal fat distribution in epidemiological studies.

Risky decision making in adults with ADHD

BACKGROUND AND OBJECTIVES

Risky decision making and disadvantageous choices constitute core characteristics of patients with attention-deficit/hyperactivity disorder (ADHD). Consequences include negative psychosocial and health-related outcomes. However, risky decision making and its interrelations with emotional states in ADHD are poorly understood. Therefore, the authors investigated risky decision making without and after boredom induction in adults with and without ADHD.

METHODS

In study 1, ADHD patients (n = 15) and age/education matched controls (CG; n = 16) were compared on the Game of Dice Task (GDT), an established task measuring decision making in unambiguous situations. In study 2, ADHD patients (n = 14) and CG (n = 13) underwent boredom induction prior to the GDT.

RESULTS

In study 1, ADHD patients selected the disadvantageous alternatives significantly more often than CG. In study 2, no significant group differences were found due to an increase in risky decision making in CG following the boredom induction.

LIMITATIONS

Even if severity of depression did not affect our results, it may be necessary to compare GDT responses in ADHD patients with and without current depression.

CONCLUSIONS

Risk as a motor of disadvantageous decision making needs to be taken into account in therapeutic contexts as a maintenance factor of dysfunctional behaviour. The findings of study 2 are in line with postulated alterations of emotional state adjustment in ADHD. The link between decisions making and emotional regulation in ADHD needs further attention in research.

Functional improvement and correlations with symptomatic improvement in adults with attention deficit hyperactivity disorder receiving long-acting methylphenidate

BACKGROUND

Data on the relationship between core symptoms and daily functioning in adults with attention deficit hyperactivity disorder (ADHD) are limited. Daily functioning was assessed as part of an open-label extension, and associations with symptom scores were evaluated.

METHOD

After a 5-week double-blind study with adults with ADHD receiving osmotic-controlled release oral delivery system (OROS) methylphenidate (MPH) 18, 36 or 72 mg/day, or placebo, participants were eligible for a 7-week open-label extension in which all patients received OROS MPH. Data for the Conners' Adult ADHD Rating Scale - Observer: Screening Version (CAARS-O:SV) (primary endpoint) have been presented previously. Secondary endpoints included the observer self-reported short version of the CAARS (CAARS-S:S) and the Clinical Global Impressions - Severity Scale (CGI-S). Daily functioning and quality of life were assessed using the Sheehan Disability Scale (SDS) and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) respectively. In post-hoc analyses, changes in CAARS-O:SV were evaluated in subgroups. Relationships between symptom and functional outcomes were evaluated in a multivariate regression analysis.

RESULTS

A total of 370 patients entered the open-label extension. Significant improvements from baseline in CAARS-O:SV were similar regardless of sex, ADHD subtype, prior treatment or psychiatric co-morbidity. Significant improvements from double-blind baseline were also seen for the CAARS-S:S, CGI-S, SDS and Q-LES-Q. Improvements in the CAARS-O:SV Hyperactivity/Impulsivity subscale were associated with improvements in SDS total and subscale scores, and in the Q-LES-Q score at open-label endpoint. Improvements in CAARS-O:SV Inattention subscale and CGI-S scores were not significantly associated with functional changes.

CONCLUSIONS

Improvements in ADHD symptoms relating to hyperactivity and impulsivity in adults receiving OROS MPH are associated with improvements in daily functioning and quality of life.

The german version of the conners adult ADHD rating scales (CAARS)

Introduction

Instruments for diagnosing Attention-Deficit/Hyperactivity Disorder (ADHD) in childhood are well validated and reliable, but psychometric assessment of ADHD in adults remains problematic. To date the Conners Adult ADHD Rating Scales (CAARS) are frequently used in the assessment of ADHD.

Objectives

The CAARS were translated into German and a series of studies planned to establish psychometric properties of the CAARS-self and -observer rating scales.

Aims

To evaluate the German version of the CAARS.

Methods

We recruited 847 healthy German subjects and 466 adult ADHD patients to fill out the CAARS-self report and questions on socio-demographic variables. Additionally, 896 CAARS-observer reports were filled out by significant others and clinical experts. Factor analyses were conducted to obtain factor structure and to replicate the structure of the original American-model. Comparisons between patients and controls, and analyses on influences of gender, age, and education level were calculated. Additional analyses established psychometric properties.

Results

Confirmative factor analysis based on the original American-model showed a high model-fit for both the German healthy control and the adult ADHD patient sample. Analyses of normative data showed significant influences of age, gender, and education level on the emerging subscales for the control sample only. Differences on all subscales were highly significant between patients and controls. Test-, test-retest-reliability was very high, and criterion validity could be established with DSM-IV based clinical interviews. Sensitivity and specificity ratings are overall very satisfying.

Conclusion

The German version of the CAARS is a cross-culturally valid instrument for the assessment of adult ADHD.

H¹-MR-spectroscopy of cerebellum in adult attention deficit/hyperactivity disorder

INTRODUCTION

Neurobiological research has implicated the cerebellum as one possible site of neurophysiological dysfunction in ADHD. Latest theoretical conceptualizations of the cerebellum as core site of the brain to model motor as well as cognitive behavior puts further weight to the assumption that it might play a key role in ADHD pathophysiology.

METHODS

30 medication free adult ADHD patients and 30 group matched (gender, age and education) healthy controls were investigated using the method of chemical shift imaging (CSI) of the cerebellum. The vermis, left and right cerebellar hemispheres were processed separately.

RESULTS

We found significantly increased glutamate-glutamine (Glx) to creatine (Cre) ratios in the left cerebellar hemisphere. No other differences in measured metabolite concentrations were observed.

DISCUSSION

To our knowledge this is the first evidence for neurochemical alterations in cerebellar neurochemistry in adult ADHD. They relate well to recent hypotheses that the cerebellum might control mental activities by internal models.

Group Therapy for Adults with ADHD

Adult ADHD is a serious risk factor for co-occuring psychiatric disorders and negative psychosocial consequences. Given this background, instead of or in addition to psychopharmacological treatment there is a need for effective psychotherapeutic treatment options for adults with ADHD. Previous trials on psychotherapeutic concepts were based on cognitive behavioural and/or dialectical behavioural approaches and showed significant effects. In a pilot study, our structured skills training group program for adult ADHD led to significant symptomatic improvements (Hesslinger et al. 2007). The following study evaluated the program's effectiveness, feasibility and patient acceptability in a multicentre setting (N = 72, Philipsen et al. 2007). The therapy was well tolerated and led to significant improvements of ADHD, depressive symptoms and personal health status (p < 0.001). Patients regarded the program topics “behavioural analyses”, “mindfulness” and “emotion regulation” as the most helpful. As in our initial study, patients in the multicentre study rated the group setting as highly effective. This might be explained as result of greater peer support and the opportunity of learning from positive role models (e.g. during homework discussion). Following our staged approach, we are currently running a large randomized multicentre placebo-controlled study for the evaluation of the efficacy of this structured group program in adult ADHD that has been approved by the German Federal Ministry of Research and Education. In this study we compare the effects of purely medical management, specific psychotherapy, and the combination of both, comparable with the Multimodal Treatment Study of Children with ADHD (MTA).

[Multimodal treatment of adult attention-deficit hyperactivity disorder]

The indication for treatment of adult attention-deficit hyperactivity disorder (adult ADHD) is derived not from the diagnosis itself but results from the severity of symptoms, comorbidities, psychosocial consequences, and a lack of defined resources for ADHD. The basis of therapy is psychoeducation that includes teaching about symptoms, models of the disorder, and options for treatment. The combination of pharmacotherapy and psychotherapy is recommended. Methylphenidate is considered the first-line therapy, because of its strong effect and modest side effects, but is not authorized in Germany ("off-label use"). Atomoxetine, which is authorized for continuing treatment into adulthood, is indicated if methylphenidate is insufficient or has unacceptable side effects and in case of comorbid substance use. Various psychotherapeutic interventions using available ADHD-typical resources have demonstrated positive effects. Psychosocial support and self-help groups complete the treatment concept. Persistence of the treatment indication has to be reevaluated at regular intervals. Disorder-specific multimodal therapy of adult ADHD conforms to the complex, primarily neurobiologic etiology and the psychosocial consequences.

Reduced cingulate glutamate/glutamine-to-creatine ratios in adult patients with attention deficit/hyperactivity disorder -- a magnet resonance spectroscopy study

BACKGROUND

The dopaminergic system is thought to be essentially involved in the pathogenesis of attention deficit/hyperactivity disorder (ADHD). However, there is also evidence for abnormalities in the glutamatergic system and recent theories focus on a disturbed interaction between the two systems as the essential pathogenetic mechanism of ADHD. In the present study, we wanted to test the hypothesis that prefrontal glutamate signals indirectly indicate dopaminergic dysfunction in adult patients with ADHD.

METHODS

Twenty-eight adult patients with ADHD and 28 group-matched healthy volunteers were studied clinically and using chemical-shift MR spectroscopy (MRS) of the prefrontal cortex covering the anterior cingulate gyrus.

RESULTS

A significant reduction of the combined glutamate/glutamine to creatine ratio in the right anterior cingulate cortex in patients with ADHD was found.

DISCUSSION

Glutamatergic alterations as measured with MRS might play a role in the pathogenesis of adult patients with ADHD.

Naloxone in the Treatment of Acute Dissociative States in Female Patients with Borderline Personality Disorder

BACKGROUND

Acute dissociative states are common in patients with borderline personality disorder (BPD). However, there are no established pharmacotherapeutic treatment options for this severe clinical condition.

METHODS

The effect of 0.4 mg naloxone administered intravenously in acute dissociative states was examined as compared to placebo in a double-blind crossover study in nine patients who met DSM-IV-criteria for BPD. Dissociative symptoms before and 15 min after a single dose of naloxone or saline placebo were assessed using a self-rating instrument for dissociation and aversive inner tension (DSS) and the observer-based items of the Clinician Administered Dissociative States Scale (CADSS).

RESULTS

Dissociative symptoms before treatment with naloxone or saline placebo were moderate to severe. After injection of either naloxone or placebo, dissociative symptoms significantly decreased on the DSS (p < 0.01) and the CADSS (p < 0.05). However, there were no significant differences between naloxone and placebo in the reduction of symptoms. Patients who showed the most prominent response to naloxone fulfilled the highest number of DSM-IV-criteria for BPD.

CONCLUSIONS

Although it is difficult to draw definite conclusions from this small sample of patients, this study does not support the assumption that naloxone in a single dose of 0.4 mg is superior to placebo in acute dissociative states in patients with BPD. Further studies will investigate whether patients benefit from naloxone in a higher dose or whether subgroups of patients with BPD profit from naloxone in acute dissociative states.

Interventional neuropediatrics: treatment of dystonic and spastic muscular hyperactivity with botulinum toxin A

Therapeutic effect of botulinum toxin A was studied in a group of pediatric patients (n = 28) aged between 6 months and 18 years. The patients were diagnosed with cervical dystonia (n = 6), adductor spasm of the hip (n = 8), spastic drop foot (n = 7) and various other focal motor problems associated with spastic muscular hyperactivity (n = 7). The mean dose of botulinum toxin A (Dysport) used to inject into the affected muscle was 22 U/kg body weight. Reduced muscular hyperactivity with a significant increase in joint mobility was achieved for dystonic (p < 0.0001) as well as for spastic conditions in patients with adductor spasm (p < 0.0002). For these patients the improved joint mobility represented a significant benefit for both daily activities and nursing care. Local paresis and local hematoma were observed in 1/28 and 1/28 patients, respectively; 1/28 patients developed a secondary non-response. However, apart from these side effects, no other adverse reactions to botulinum toxin A treatment were recorded during the treatment and observation period (12-64 months). Our results suggest that botulinum toxin A represents an effective and safe therapeutic substance for the treatment of pediatric patients suffering of focal motor problems due to dystonic or spastic muscular hyperactivity.

Treatment of cerebral palsy with botulinum toxin A: functional benefit and reduction of disability. Three case reports

Three patients with cerebral palsy are described suffering, respectively, of pes equinus, spasm of the m. teres major and flexion spasm of the hand, who were treated with botulinum toxin A. These patients demonstrate not only the local reduction of the muscular hyperactivity following treatment with botulinum toxin A but also the potential functional benefit resulting from such a treatment. Thus, local intramuscular injection of botulinum toxin A in children with cerebral palsy should be considered as part of a multidisciplinary treatment concept, since reduction of the disability and the functional improvements could have high impact on daily living activities.

[Primary assessment of X-ray images in a casualty department]

During a period of three months, the primary diagnoses made by the duty officer in the casualty department on x-rays taken on patients with orthopaedic conditions were compared with the definitive diagnoses made after a conference with the radiological department. The consequences of possible erroneous diagnoses were also recorded. A total of 634 regions were examined in 555 patients. Incorrect diagnoses were made in 55 regions (8.5%). In 21 of these, alterations in the primary treatment were required. All of the treatments could be corrected by telephone (7) or an additional visit by the patient (14). X-rays of the cranium and the spine are known to be difficult to evaluate by inexperienced doctors. This was also found to be the case in the present investigation.

Photographic screening for strabismus among mentally retarded children

The prevalence of squint among mentally retarded children is much higher than in the general population. A photographic screening method based on the positioning of the 1st and 4th Purkinje image was applied to 80 mentally retarded children. The method was validated against orthoptic examination of the children. Totally 320 exposures were taken. Fourth Purkinje image was visible on 73% of these. Five children were not evaluable from the 4th Purkinje image. The photographic technique was simple and easy to handle, but comparison between the clinical and photographic diagnoses were inconsistent in 12 out of 80 cases, which made the method unreliable. In some cases the clinical assessments also varied from time to time. A combination of clinical orthoptic assessment and the photographic method is suggested.