Case report: Preemptive intervention for an infant with early signs of autism spectrum disorder during the first year of life

Autism spectrum disorder (ASD) includes neurodevelopmental conditions traditionally considered to bring life long disabilities, severely impacting individuals and their families. Very early identification and intervention during the very first phases of life have shown to significantly diminish symptom severity and disability, and improve developmental trajectories. Here we report the case of a young child showing early behavioral signs of ASD during the first months of life, including diminished eye contact, reduced social reciprocity, repetitive movements. The child received a pre-emptive parent mediated intervention based on the Infant Start, an adaptation of the Early Start Denver Model (ESDM), specifically developed for children with ASD signs during the first year of life. The child here described received intervention from 6 to 32 months of age, in combination with educational services. Diagnostic evaluations performed at several time points (8, 14, 19, and 32 months) showed progressive improvements in his developmental level and ASD symptoms. Our case study supports the possibility of identifying ASD symptoms and providing services as soon as concerns emerge even during the first year of life. Our report, in combination with recent infant identification and intervention studies, suggests the need for very early screening and preemptive intervention to promote optimal outcomes.

Differences in clinical presentation, severity, and treatment of COVID-19 among individuals with Down syndrome from India and high-income countries: Data from the Trisomy 21 Research Society survey

Background

People with Down syndrome (DS) are one of the highest risk groups for mortality associated with COVID-19, but outcomes may differ across countries due to different co-morbidity profiles, exposures, and societal practices, which could have implications for disease management. This study is designed to identify differences in clinical presentation, severity, and treatment of COVID-19 between India and several high-income countries (HICs).

Methods

We used data from an international survey to examine the differences in disease manifestation and management for COVID-19 patients with DS from India vs HIC. De-identified survey data collected from April 2020 to August 2021 were analysed.

Results

COVID-19 patients with DS from India were on average nine years younger than those from HICs. Comorbidities associated with a higher risk for severe COVID-19 were more frequent among the patients from India than from HICs. Hospitalizations were more frequent among patients from India as were COVID-19-related medical complications. Treatment strategies differed between India and HICs, with more frequent use of antibiotics in India. The average severity score of 3.31 was recorded for Indian DS in contrast to 2.3 for European and 2.04 for US cases.

Conclusions

Presentation and outcomes of COVID-19 among individuals with DS were more severe for patients from India than for those from HIC. Global efforts should especially target vaccination campaigns and other risk-reducing interventions for individuals with DS from low-income countries.

Multidisciplinary early intervention in Down syndrome: a retrospective study

BACKGROUND

Scientific community agrees on the importance of early, global multidisciplinary family-based care in the neuropsychological development of children with disabilities, including those with Down Syndrome (DS). This study aim to assess whether a structured, multidisciplinary early intervention carried out at the outpatient service of Stella Maris I.R.C.C.S. can lead to better outcomes in children with DS, in development and cognitive functioning, compared to conventional care provided by the local health centres (ASL).

METHODS

We included in the study 20 children with DS. The experimental group received early treatment (0-36 months), while the control group only underwent cognitive assessments. In order to examine the outcome of long-term cognitive functioning, our study evaluated assessments of the children at 5 years of age, by administering the WPPSI-III scale.

RESULTS

In our result we can confirm the typical profile of children with Down Syndrome described in the literature. Comparing the results obtained in both groups, we see that the mean scores obtained by the experimental group, in all three of the quotients examined, are higher than the mean scores obtained by the control group.

CONCLUSIONS

This study makes it clear that early, structured, multidisciplinary interventions play a fundamental role in modifying neurocognitive outcomes in children with Down Syndrome. The results of this study thus confirm the usefulness of the outpatient service in the early management of individuals with DS, following a multidisciplinary, structured pathway focused on the child and his/her family.

COVID-19 Vaccination of Individuals with Down Syndrome-Data from the Trisomy 21 Research Society Survey on Safety, Efficacy, and Factors Associated with the Decision to Be Vaccinated

Individuals with Down syndrome (DS) are among the groups with the highest risk for severe COVID-19. Better understanding of the efficacy and risks of COVID-19 vaccines for individuals with DS may help improve uptake of vaccination. The T21RS COVID-19 Initiative launched an international survey to obtain information on safety and efficacy of COVID-19 vaccines for individuals with DS. De-identified survey data collected between March and December 2021 were analyzed. Of 2172 individuals with DS, 1973 (91%) had received at least one vaccine dose (57% BNT162b2), 107 (5%) were unvaccinated by choice, and 92 (4%) were unvaccinated for other reasons. Most participants had either no side effects (54%) or mild ones such as pain at the injection site (29%), fatigue (12%), and fever (7%). Severe side effects occurred in <0.5% of participants. About 1% of the vaccinated individuals with DS contracted COVID-19 after vaccination, and all recovered. Individuals with DS who were unvaccinated by choice were more likely to be younger, previously recovered from COVID-19, and also unvaccinated against other recommended vaccines. COVID-19 vaccines have been shown to be safe for individuals with DS and effective in terms of resulting in minimal breakthrough infections and milder disease outcomes among fully vaccinated individuals with DS.

COVID-19 in Children with Down Syndrome: Data from the Trisomy 21 Research Society Survey

Adults with Down Syndrome (DS) are at higher risk for severe outcomes of coronavirus disease 2019 (COVID-19) than the general population, but evidence is required to understand the risks for children with DS, which is necessary to inform COVID-19 shielding advice and vaccination priorities. We aimed to determine the epidemiological and clinical characteristics of COVID-19 in children with DS. Using data from an international survey obtained from a range of countries and control data from the United States, we compared the prevalence of symptoms and medical complications and risk factors for severe outcomes between DS and non-DS paediatric populations with COVID-19. Hospitalised COVID-19 patients <18 years with DS had a higher incidence of respiratory symptoms, fever, and several medical complications from COVID-19 than control patients without DS <18 years. Older age, obesity, and epilepsy were significant risk factors for hospitalisation among paediatric COVID-19 patients with DS, and age and thyroid disorder were significant risk factors for acute respiratory distress syndrome. Mortality rates were low in all paediatric COVID-19 patients (with and without DS), contrasting with previous findings in adults with DS (who exhibit higher mortality than those without DS). Children with DS are at increased risk for more severe presentations of COVID-19. Efforts should be made to ensure the comprehensive and early detection of COVID-19 in this population and to identify children with DS who present comorbidities that pose a risk for a severe course of COVID-19. Our results emphasize the importance of vaccinating children with DS as soon as they become eligible.

Medical vulnerability of individuals with Down syndrome to severe COVID-19-data from the Trisomy 21 Research Society and the UK ISARIC4C survey

BACKGROUND

Health conditions, immune dysfunction, and premature aging associated with trisomy 21 (Down syndrome, DS) may impact the clinical course of COVID-19.

METHODS

The T21RS COVID-19 Initiative launched an international survey for clinicians or caregivers on patients with COVID-19 and DS. Data collected between April and October 2020 (N=1046) were analysed and compared with the UK ISARIC4C survey of hospitalized COVID-19 patients with and without DS.

FINDINGS

The mean age of COVID-19 patients with DS in the T21RS survey was 29 years (SD = 18). Similar to the general population, the most frequent signs and symptoms of COVID-19 were fever, cough, and shortness of breath. Joint/muscle pain and vomiting or nausea were less frequent (p < 0.01), whereas altered consciousness/confusion were more frequent (p < 0.01). Risk factors for hospitalization and mortality were similar to the general population with the addition of congenital heart defects as a risk factor for hospitalization. Mortality rates showed a rapid increase from age 40 and were higher in patients with DS (T21RS DS versus non-DS patients: risk ratio (RR) = 3.5 (95%-CI=2.6;4.4), ISARIC4C DS versus non-DS patients: RR = 2.9 (95%-CI=2.1;3.8)) even after adjusting for known risk factors for COVID-19 mortality.

INTERPRETATION

Leading signs/symptoms of COVID-19 and risk factors for severe disease course are similar to the general population. However, individuals with DS present significantly higher rates of medical complications and mortality, especially from age 40.

FUNDING

Down Syndrome Affiliates in Action, DSMIG-USA, GiGi's Playhouse, Jerome Lejeune Foundation, LuMind IDSC Foundation, The Matthew Foundation, NDSS, National Task Group on Intellectual Disabilities and Dementia Practices.

An international survey on the impact of COVID-19 in individuals with Down syndrome

BACKGROUND

Health conditions and immune dysfunction associated with trisomy 21 (Down syndrome, DS) may impact the clinical course of COVID-19 once infected by SARS-CoV-2.

METHODS

The T21RS COVID-19 Initiative launched an international survey for clinicians or caregivers/family members on patients with COVID-19 and DS (N=1046). De-identified survey data collected between April and October 2020 were analysed and compared with the UK ISARIC4C survey of hospitalized COVID-19 patients with and without DS. COVID-19 patients with DS from the ISARIC4C survey (ISARIC4C DS cases=100) were matched to a random set of patients without DS (ISARIC4C controls=400) and hospitalized DS cases in the T21RS survey (T21RS DS cases=100) based on age, gender, and ethnicity.

FINDING

The mean age in the T21RS survey was 29 years (SD=18), 73% lived with their family. Similar to the general population, the most frequent signs and symptoms of COVID-19 were fever, cough, and shortness of breath. Pain and nausea were reported less frequently (p<0.01), whereas altered consciousness/confusion were reported more frequently (p<0.01). Risk factors for hospitalization and mortality were similar to the general population (age, male gender, diabetes, obesity, dementia) with the addition of congenital heart defects as a risk factor for hospitalization. Mortality rates showed a rapid increase from age 40 and were higher than for controls (T21RS DS versus controls: risk ratio (RR)=3.5 (95%-CI=2.6;4.4), ISARIC4C DS versus controls: RR=2.9 (95%-CI=2.1;3.8)) even after adjusting for known risk factors for COVID-19 mortality.

INTERPRETATION

Leading signs/symptoms of COVID-19 and risk factors for severe disease course are similar to the general population. However, individuals with DS present significantly higher rates of mortality, especially from age 40.

FUNDING

Down Syndrome Affiliates in Action, Down Syndrome Medical Interest Group-USA, GiGi's Playhouse, Jerome Lejeune Foundation, LuMind IDSC Foundation, Matthews Foundation, National Down Syndrome Society, National Task Group on Intellectual Disabilities and Dementia Practices.

Training RAN or reading? A telerehabilitation study on developmental dyslexia

Rehabilitation procedures recommended for developmental dyslexia (DD) are still not fully defined, and only few studies directly compare different types of training. This study compared a training (Reading Trainer) working on the reading impairment with one (Run the RAN) working on the rapid automatized naming (RAN) impairment, one of the main cognitive deficits associated with DD. Two groups of DD children (N = 45) equivalent for age, sex, full IQ, and reading speed were trained either by Reading Trainer (n = 21) or by Run the RAN (n = 24); both trainings required an intensive home exercise, lasting 3 months. Both trainings showed significant improvements in reading speed and accuracy of passages and words. Bypassing the use of alphanumeric stimuli, but empowering the cognitive processes underlying reading, training RAN may be a valid tool in children with reading difficulties opening new perspectives for children with severe impairments or, even, at risk of reading difficulties.

Visual assessment in Down Syndrome: The relevance of early visual functions

BACKGROUND

Children with Down Syndrome (DS) have a high prevalence of ocular disorders, and even when ophthalmological deficits (i.e. refractive errors or strabismus) are corrected, visual acuity seems to have a different developmental trend compared to typical children. Unfortunately, there is no consensus about the age at which it is fundamental to perform a first comprehensive visual assessment in this population.

AIMS

We analyzed early visual functions in a sample of 42 Italian children with DS, in order to achieve new insights for early surveillance and intervention.

MATERIAL AND METHODS

DS children were evaluated with the Early Neurovisual Assessment, including Teller Acuity Cards (at 6, 12 and 18 months of age) and the Pediatric Ophthalmological Examination (within the 36th months of age).

RESULTS

Visual acuity in our sample was lower than findings reported in the literature on healthy Italian children, but the values were within the confidence interval reported in previous studies on DS children. Moderate or severe refractive errors (> 3diopters) were present in five children (four had hyperopia and one myopia). Abnormalities in ocular motility were observed in 15 children and pathological findings for fundus oculi or lens were found in another eight. Furthermore, ophthalmological findings correlated with visual acuity at 18 months of age.

CONCLUSION

According to our results, the Early Neurovisual Assessment at 18 months of life is a reliable tool for early detection of visual disorders in children with DS and it is useful for programming early intervention to promote their neurodevelopment.

Complex Phenotype of a Boy With De Novo 16p13.3-13.2 Interstitial Deletion

Interstitial deletions encompassing chromosome 16p13.3-13.2 are rarely described in the literature, whereas terminal deletions or duplications involving this region are slightly more frequently described. The authors describe a boy harboring a de novo 16p13.3-13.2 interstitial deletion, with intellectual disability, verbal dyspraxia, epilepsy, and a distinctive brain magnetic resonance finding, namely a nodular heterotopia. The authors found partial genotype–phenotype correspondences regarding epilepsy and intellectual disability, which have been associated with 16p1 region. Conversely, nodular heterotopia and verbal dyspraxia have not been clearly related to this region. These data are in agreement with the emerging concept that similar copy number variants may be the general risk factors for distinct disorders. Verbal dyspraxia, which has not responded to speech therapy, is the child’s most disabling trait. In view of the above, genetic studies should be appraised in cases of serious speech difficulties, especially if they are associated with intellectual disability and epilepsy.

Effect of early multisensory massage intervention on visual functions in infants with Down syndrome

BACKGROUND

Down syndrome is a frequent cause of intellectual disability, with severe impact on the quality of life of affected individuals and their families, and high social costs. Intervention programs should start soon after birth but no consensus exists on specific types and timing of early interventions in this population.

AIM

This pilot study explores the effects of an early multi-sensory intervention, based on body massage, on the development of visual function in infants with Down syndrome.

METHOD

Infants were randomly allocated to either a massage or a control group. Intervention consisted of only standard care (Control Group) or standard care plus infant massage (Massaged Group). Visual acuity was assessed by Teller Acuity Cards and stereopsis by the Frisby Stereopsis Screening Test at 5, 6, 9 and 12 months.

RESULTS

Massaged Group Infants showed a significantly higher visual acuity at 6 months of age and an accelerated development up to at least 12 months; compared to Controls, stereopsis had an earlier onset in the Massaged Group followed by a faster maturation.

CONCLUSION

Environmental enrichment, in the tested form of infant massage, seems to affect maturation of visual functions in human infants, also in the presence of a genetic disability, when applied during a period of high brain plasticity.

Benign and periodic movement disorders in 2 children with Down syndrome

Children with Down syndrome show hypotonia and ligamentous laxity that are associated with motor development delay. Neurologic disorders are common in children with Down syndrome; however, in literature the presence of periodic movement disorders has not yet been described. We report 2 different types of periodic movement disorders in 2 infants with Down syndrome. In the first case, we described an 8-month-old girl with involuntary head nodding and absence of any other neurologic or ophthalmologic abnormalities. In the second case, we described a 6-month-old boy with abnormal but painless head rotation and inclination, alternating from side to side. Episodes of head tilting were often associated with a state of general uneasiness. Neurologic examination between attacks was normal. The aim of this paper is to provide practical information on recognition and management of movement disorders in Down syndrome.

The autistic phenotype in Down syndrome: differences in adaptive behaviour versus Down syndrome alone and autistic disorder alone

The autistic phenotype in Down syndrome (DS) is marked by a characteristic pattern of stereotypies, anxiety and social withdrawal. Our aim was to study adaptive behaviour in DS with and without autistic comorbidity using the Vineland Adaptive Behaviour Scales (VABS), the Childhood Autism Rating Scales (CARS) and the DSM IV-TR criteria. We assessed 24 individuals and established three groups: Down syndrome (DS), DS and autistic disorder (DS-AD), and autistic disorder (AD). The DS and DS-AD groups showed statistically significantly similar strengths on the VABS (in receptive and domestic skills). The DS and DS-AD subjects also showed similar strengths on the CARS (in imitation and relating), differing significantly from the AD group. The profile of adaptive functioning and symptoms in DS-AD seemed to be more similar to that found in DS than to the profile emerging in AD. We suggest that the comorbidity of austistic symptoms in DS hampered the acquisition of adaptive skills more than did the presence of DS alone.

Adaptive behaviour in Down syndrome: a cross-sectional study from childhood to adulthood

OBJECTIVE

Adaptive behaviour in Down syndrome is described to increase until middle childhood and to begin to decline in adolescence, whereas significant deterioration in middle adulthood has been attributed to early onset of dementia. Nevertheless, opinions diverge about when the slowing down of adaptive and cognitive abilities starts. Our aims were to describe the profile of adaptive behaviour in Down syndrome, the variability within different age-groups, age-related changes and the correlation to cognitive abilities.

METHODS

In a prospective cross-sectional study, individuals with Down syndrome all living in the family and without signs of dementia in 4 Italian sites were included and performed a detailed medical and neuropsychiatric work-up, as well as cognitive testing and adaptive behaviour, using the Vineland Adaptive Behaviour Scales.

RESULTS

Seventy-five individuals with Down syndrome from 4 to 52 years were included. Adults from 20 to 30 years showed the highest performance of all groups. The area of communication, always an area of strength, did not change over time, in childhood and especially in adolescence daily living skills (p = 0.012) and socialisation (p = 0.021) scored on average, whereas in young and middle adulthood performance in daily living skills and socialisation and were areas of strength.

CONCLUSIONS

Individuals with DS continue to increase competence in adaptive behaviour until 30 years, even when cognitive abilities reach a plateau. We found no major decline in middle adulthood. This may be due to exposure to daily life, but needs to be supported by further studies.

Polymorphisms in folate and homocysteine metabolizing genes and chromosome damage in mothers of Down syndrome children

We recently observed an association between combinations of polymorphisms in the methylenetetrahydrofolate reductase (MTHFR 677C > T or 1298A > C) and reduced folate carrier (RFC-1 80G > A) genes and the risk of a Down syndrome (DS) pregnancy in young Italian women. Others have observed an association between a methionine synthase (MTR 2756A > G) gene polymorphism and the risk of a DS offspring in Italy. Moreover, in a separate study, we observed an increased frequency of both binucleated micronucleated cells (BNMN) and chromosome malsegregation events in peripheral lymphocytes of mothers of DS individuals aged less than 35 years at conception (MDS) in respect to controls. The aim of the present study was to evaluate chromosome damage, measured by means of the micronucleus assay, in peripheral lymphocytes of a group of women (n = 34) who had a DS child in young age (<35 years) and in a control group (n = 35), and to correlate them with MTHFR 677C > T and 1298A > C, RFC-1 80G > A and MTR 2756A > G polymorphisms. We observed an increased frequency of BNMN in the MDS group compared to the control group (17.13 +/- 8.31 per thousand vs. 10.28 +/- 4.53 per thousand; P < 0.001), and, in the general population, a correlation between years of age and BNMN frequency (P = 0.05). A significant correlation between the frequency of BNMN and the MTHFR 677C > T polymorphism (P = 0.038) was also found. Present results indicate that MDS are more prone to chromosome damage than control mothers; moreover the contribution of folate and homocysteine metabolizing gene polymorphisms seems to have an effect on the baseline frequency of BNMN lymphocytes.

Folate gene polymorphisms and the risk of Down syndrome pregnancies in young Italian women

Maternal impairments in folate metabolism and elevated homocysteinemia are known risk factors for having a child with Down syndrome (DS) at a young age. The 80G>A polymorphism of the reduced folate carrier gene (RFC-1) has been recently demonstrated to affect plasma folate and homocysteine levels, alone or in combination with the 677C>T polymorphism in the methylenetetrahydrofolate reductase (MTHFR) gene. We performed the present study on 80 Italian mothers of DS individuals, aged less than 35 at conception, and 111 Italian control mothers, to study the role of the RFC-1 80G>A, MTHFR 677C>T, and MTHFR 1298A>C genotypes to the risk of a DS offspring at a young maternal age. When polymorphisms were considered alone, both allele and genotype frequencies did not significantly differ between DS mothers and control mothers. However, the combined MTHFR677TT/RFC-1 80GG genotype was borderline associated with an increased risk (OR 6 (CI 95%: 1.0-35.9), P = 0.05), and to be MTHF1298AA/RFC-1 80(GA or AA) was inversely associated with the risk (OR 0.36 (CI 95%: 0.14-0.96), P = 0.04). Present results seem to indicate that none of the RFC-1 80G>A, MTHFR 677C>T, and MTHFR 1298A>C polymorphisms is an independent risk factor for a DS offspring at a young maternal age; however, a role for the combined MTHFR/RFC-1 genotypes in the risk of DS pregnancies among young Italian women cannot be excluded.

[Neuropsychiatric outcome in patients with congenital hypothyroidism precautiously treated: Risk factors analysis in a group of patients from Tuscany]

AIM

In order to avoid an excessive medical monitoring and to obtain more functional medical controls for the outcome of children with early treated congenital hypothyroidism, the results of a neurological and psychiatric follow-up performed in area Pisana since 1990 are revised. This analysis gives some indications to get over the differences of the various methodological approaches and to get better rehabilitation treatment in respect to the individual needs.

METHODS

Our study group includes 52 children with early treated congenital hypothyroidism; a semiquantitative score was used to assess sociocultural level (SCL) of the family. Cognitive and language performances were evaluated by Griffiths Mental Development Scale and with Wechsler Intelligence Scale for Children (WISC-R).

RESULTS

Study group mean total scores in cognitive tests are within the normal range, motor and language impairments have been noted, instead. These skills are significantly correlated with pretreatment serum thyroxine (T4). In addition a low SCL is a great risk factor for the occurrence of mild impairments in neuropsychological development.

CONCLUSIONS

In arranging the neuropsychological follow-up in early treated congenital hypothyroidism it is recommended to keep in mind the importance of the combination of neonatal endocrinological factors (in particular, pretreatment serum thyroxine) and SCL on the cognitive, motor and language development.

Behavioural disorders in adolescents with early-treated congenital hypothyroidism

This study analyses the possible risk factors for the on-set of behavioural disorders and psychiatric disturbances in a group of 30 early-treated congenital hypothyroidism (CH) subjects (12 children and 18 adolescents) compared with a control group of 116 age-matched normal subjects (58 children and 58 adolescents). The study also allowed us to evaluate the possible age at onset of behavioural disorders. Both the sample's and the controls' behaviours were assessed using a specific diagnostic instrument: Achenbach's and Edelbrock's Child Behaviour Checklist (CBCL). A clinical structured interview, the Diagnostic Interview for Children and Adolescents--Revised (DICA-R) was also administered to 18 adolescents with early-treated CH, in order to determine the presence of psychopathological disturbances. In accordance with literature data, the children and adolescents with early-treated CH showed more behavioural problems than age-matched, normal controls. In the children, a statistically significant difference versus the controls emerged only in their higher delinquent behaviour score, while the adolescents gave, on the CBCL, significantly higher scores compared with controls in the withdrawal, anxiety/depression, thought problems, attention problems and aggressive behaviour scales. In the DICA-R, 44% of adolescents with early-treated CH showed symptoms of anxiety disorder, in particular, separation anxiety disorder with phobic components; 16% showed mood disorder and depression and 11% showed behavioural disorders with attention deficit.

Social adjustment in children with Down mental retardation (MRD) and Fragile-X mental retardation (MRX)

BACKGROUND

Since adjustment abilities became important in mental retardation (MR) diagnosis, it seemed interesting to study social adjustment in persons with MR Down (RMD) and MR Fragile-X (RMX). These two syndromes are the most common causes of MR of chromosomal origin. To evaluate the influence of temperament insofar as behavior and temperament are concerned in social adjustment, we studied temperamental dimensions (emotionality, activity, sociability and shyness) and social functioning (attention problems and withdrawal).

METHODS

Our study group was composed of 35 children with MR; 23 with RMD (F=14) age range 4 to 21, and 12 (F=1) with RMX age ranged from 5 to 19. #Social adjustment was evaluated by two scales: EAS and CBCL.

RESULTS

The six evaluated dimensions of adjustment functioning (emotionality, activity, sociability, shyness, attention problems and withdrawal) differ in the two MRD and MRX groups. MRX scores are all higher except for sociability; shyness, attention problems and emotionality show a significant difference.

CONCLUSIONS

The RMX group is that one may have more difficulty in social adjustment. This is because they are characterized by hyperactivity, withdrawal, low attention, low social function and high emotionality that are all negative symptoms for a social adjustment. In our study group MRD have higher values in the sociability area and they don't show relevant behavioral disorders and they have got more adaptive abilities. We may hypothesize that this attitude is a part of their genetic structure, and also that the best social adjustment of Down persons may be linked to a better interaction with the environment.

Neuropsychological follow-up in early-treated congenital hypothyroidism: a problem-oriented approach

Screening programs for congenital hypothyroidism (CH) dramatically improved the neuropsychological prognosis in affected children. However, mild impairments in cognitive performances, poorer motor skills, defective language abilities, and learning problems have been reported in some studies of early-treated CH children. The occurrence of these defects makes neuropsychological follow-up mandatory. The aim of the present study was to identify those neuropsychological functions that are more frequently affected in early-treated CH children and that might require prompt rehabilitation treatment to prevent permanent defects. The study group involved 24 CH children. Levothyroxine (LT4) treatment (initial dose 8-10 microg/kg per day) was started at mean age of 28 days (range 15-45) and was then adjusted with the goal to keep thyrotropin (TSH) and free thyroid hormone levels in the normal range. Cognitive evaluation was performed at 3, 5, and 7 years of age and did not significantly differ from that of controls. Mean neurological scores were lower in children 5 years of age than in controls. Children with severe neonatal hypothyroidism (serum thyroxine [T4] < 2 microg/dL) had significantly lower neurological scores compared to less affected CH children and normal controls. The most affected functions were balance, extremity coordination, fine motricity, quality of movements, associated movements, and head movements. Language disorders were observed in half of CH children at 3 and 5 years of age, but moderately severe defects were restricted to those with severe neonatal hypothyroidism. In conclusion, a problem-oriented, simplified neuropsychological follow-up of early-treated children with CH should not systematically include the frequent repetition of time-consuming and expensive psychometric tests because individual IQ scores are in the normal range of tests in almost all CH children and can be differentiated from those of normal controls only on a population-statistic basis. Selected tests of motor proficiency are indicated at 3 and 5 years of age to detect those defects in motor skills that appear to be more specifically affected in CH children. Language performances are at particular risk in CH children, and should be always checked at 3 and 5 years of age. Children with even mild language disorders or delayed language achievements should be regularly reevaluated at 6-month intervals and, if no spontaneous improvement is observed, they should receive specific rehabilitation treatment. No further motor and language evaluation is warranted in CH children with normal tests at age 5 years.

[Outpatient neuropsychiatric consultation in a pediatric hospital. Clinical considerations]

BACKGROUND

In this study, personal experience as neuropsychiatric consultants in a pediatric hospital is reported. Infancy and adolescence neuropsychiatrics' and pediatricians' common aim is to evaluate a child in his entirety and to protect his physical and mental health.

METHOD

327 patients (147 males and 180 females) aged ranged 0 to 18 years, address to hospital by their pediatricians from January 1993 to January 1998 have been evaluated.

RESULTS

Mental disorders have been diagnosed in 95% of the examined population (mental disorders classified by DSM IV criteria) the way in which mental disorders were distributed according to age and sex has been analyzed, and the therapeutic approaches discussed. Neuropsychiatric advice is requested especially for somatic and developmental disorders. Sex distribution is equal, apart from conduct disorders and pervasive developmental disorders, which are more frequent in males. Somatic, anxiety and mood disorders are more evident in children older than 6 years, developmental and neurological disorders are more evident in younger children.

CONCLUSIONS

Outpatient advice is a valid help to screen neuropsychiatric disorders and it offers the possibility to carry out short and effective evaluations and controls with a significant reduction of costs for medical assistance.

School attainments in children with congenital hypothyroidism detected by neonatal screening and treated early in life

OBJECTIVE

Evaluation of school attainments in children with congenital hypothyroidism (CH) detected by neonatal screening and treated early in life.

PATIENTS AND METHODS

Text comprehension, mathematics, reading, writing and verbal and spatial memory, as indices of school learning, were evaluated in nineteen 5- to 10-year-old children with CH attending nursery or elementary school. l-Thyroxine substitution (starting dose 8-10 microg/kg body weight per day) was initiated at a mean age of 30+/-10 days of life. The control group included 298 unaffected children matched with the CH children for age and school grade. Thirty per cent of controls were classmates of CH children. Intelligence quotients (IQ), language performances and motor development were evaluated in CH children at age 5 years, and were related to their school attainments. School performances of CH children were also compared with their neonatal serum thyroxine (T4) concentration, and with the social-cultural level of the family.

RESULTS

Four out of 19 (21%) children with CH, 3 in the nursery and 1 in the elementary school, displayed a generalized learning disorder. Symbol copy, geometric copy, phrase repetition, dictation writing and spontaneous writing were particularly defective in nursery school CH children, while orthographic error recognition was defective in elementary school CH children. School learning disorders in CH children were significantly correlated with a borderline-low IQ, poor language performances and a low social-cultural level of the family, but not with motor skills or neonatal T4 concentration.

CONCLUSION

School attainments of early treated CH children were within the normal range in most affected cases. However, about 20% of CH children, most of them attending nursery school, showed a generalized learning disorder. Low IQ scores and poor language performances at age 5 years were associated with defective learning, mainly in CH children living in a poor social-cultural environment. In this subset of CH children, prompt initiation of speech and psychomotor rehabilitation therapy is recommended in order to prevent subsequent school learning disorders.

[Early treated congenital hypothyroidism. Evaluation of school learning]

BACKGROUND

The aim of this paper was to evaluate school learning in early treated CH children in order to investigate whether and how this pathology influences school performance.

METHODS

Using a sample of 50 early treated CH children who have received regular follow-up at our Institute, 20 subjects attending primary (grade) school or the final year of nursery school for assessment of school learning have been selected. Results were compared with a class/grade matched control group. Evaluations of cognitive, motor and language development, T4 level determined at birth, thyroid disorder and socio-cultural level of the family background were examined in relation to the school performance of each child.

RESULTS

The evaluations showed that out of 20 CH children, 5 (25%) presented generalized learning disorders. This percentage is higher than in the normal population (3.4%). When learning disorder findings were correlated with data pertaining to motor, speech and cognitive development, socio-cultural level and thyroid disorder, it was found that children with generalized learning difficulties presented more severe motor and speech disorders, a lower intelligence quotient and a lower socio-cultural background than children achieving higher scores in school tests.

CONCLUSIONS

The conclusion is drawn that early treated CH children of same age have more learning difficulties during nursery school, while they have normal learning performances during primary school.

[Psychopathological aspects in a group of children and adolescent with insulin-dependent diabetes mellitus]

BACKGROUND

We have studied a group of children and adolescents with IDDM to evaluate their personality features and family relationship to point out elements of psychopathological risk or evident mental disorders. Our study group is composed of 30 subjects (age range 7-19 years) with IDDM for at least one year.

METHODS

The methods employed were interviews to patients and their parents for the attitude towards the illness (done separately), Rutter scale for parents, an anxiety scale for children and adolescents (Busnelli) and a questionnaire about knowledge of diabetes (GISED). In the interviews with parents anamnestic data were collected with particular attention to early symptoms of mental disorder. Metabolic control was tested by the HbA1c measure using high pressure column chromatography, in the same laboratory.

RESULTS AND CONCLUSIONS

On the basis of different results we divide our study group into three subgroups. The first (30%) present no mental disorder or at least reactive or transient disorder. The second subgroup (57%) show mild mental disorder. The third subgroup (13%) present severe mental disorder. In the first subgroup the adaptation to the illness was good, because of a normal personality, absence of past psychological disorders and good family relations. The second subgroup show a wider variability of symptomatology and 65% of these patients had some behaviour disorder in their past, which became more evident after diabetes onset. In the third subgroup diabetes seems to worsen pre-existing status of mental disorder. Metabolic control is better in the first subgroup than in the other two subgroups which do not differ too much one from the other. In conclusion, the better family relationship and personality history a patient had, the better adaptation to illness and metabolic control he had (1st Subgroup). The 2nd subgroup seems to be particularly at risk because it shows behaviour disorders and risk for future personality disorder. In the 3rd subgroup mental illness was already present even if not diagnosed at the onset of diabetes and needs to be treated anyway. As a matter of fact, it seems possible that the chronic illness points out and fixes perhaps pathological characteristics already present, which did not emerge until the traumatic onset of diabetes.

Neuropsychological development in a child with early-treated congenital hypothyroidism as compared with her unaffected identical twin

OBJECTIVE

Neonatal screening for congenital hypothyroidism (CH) prevents the serious neuropsychological features of CH, but the question remains whether intelligence and motor skills of CH children treated early are completely normal.

DESIGN

In this report we describe the rare case of two genetically identical twins, only one of whom was affected by CH due to thyroid agenesis. L-Thyroxine (9 microg/kg body weight/day) therapy was initiated at 27 days of age and was adequate throughout the follow-up.

METHODS

Neuropsychological evaluation was performed on the twins in parallel from 3 months to 8 years of age.

RESULTS

The CH twin (NB) did not show major neuromotor impairments but, compared with the unaffected twin (EB), she had a slight delay in postural/motor achievements and in language development that completely disappeared at 8 years of age. On standardised tests of intelligence, NB was indistinguishable from control children but, compared with her twin, she had lower IQ scores in most testing occasions up to 7 years of age (NB = 108 vs EB = 115). School achievements of NB did not significantly differ from those of her classmates but, compared with her twin, she scored worse in writing, mechanical reading, verbal memory, and possibly in arithmetic.

CONCLUSIONS

Because the twins were genetically and phenotypically identical, were raised in the same environment, and received a similar education, it is concluded that hypothyroidism in utero and in the first neonatal month was responsible for the lower neuropsychological achievements of the CH twin. While foetal hypothyroidism is at present unavoidable, earlier diagnosis and initiation of treatment in neonates with CH are important and highly recommended.

[Missed diagnosis: a case of congenital hypothyroidism treated after three years]

Congenital hypothyroidism (CH) is the most common cause of preventable mental retardation. Thyroid hormone deficiency in utero and in the first neonatal months is responsible for permanent damage. While foetal hypothyroidism is at present unavoidable, earlier diagnosis and initiation of treatment in neonates with CH is important and highly recommended. At the moment, the Italian screening program for CH allows diagnosis and treatment within the first month of life. In Italy, screening programs became obligatory only a short time ago. In some regions, they started a few years ago, whereas in others they have been carried out only in an irregular way and only a part of the population has been investigated. Therefore CH was diagnosed just on the basis of clinical signs, with a consequent delay in the initiation of substitutive therapy. We describe the case of a little girl with CH diagnosed when she was three years old. We report the results of this case follow-up study and we describe the features of her neuropsychological development to point out her improvement and permanent disorders. The little girl was clearly hypothyroid with delayed achievement at three, but with pharmacological treatment she showed a dramatic amelioration in growth, language, motor skills and cognitive performances.

[Congenital hypothyroidism. Comparison of neuropsychological development of monozygotic twins]

Early treated congenital hypothyroidism (CH) allows a normal neuropsychological development in many cases, but sometimes light neuromotor, linguistic, behavioural disturbances are described. In this work we compare two 9 year old twins to study the direct influence of CH in the neuropsychological development, eliminating variables linked to environment and the genetic aspects; one of the twins is affected by early treated congenital hypothyroidism, the other doesn't show any somatic, motor, linguistic, cognitive or behaviour affection. Our intention is to value the influence of CH in the neuropsychological development eliminating the variables linked to environment and to the genetic aspects. From this study emerges that both the somatic and neuropsychological development of the two twins are globally identical still, slight differences could possibly be pointed out during the evaluations, in the their neuropsychological performances. The psychomotor development of the hypothyroid twin resulted to be normal, but slower than the normal twin in any time. In the light of these results we can hypothesize that the differences in the global development are linked to the presence of congenital hypothyroidism although early treated in one of them, because the other variables linked to the genetic, environmental and socio-cultural factors are of no relevance whatsoever in this case. The two sisters are actually genetically and phenotypically identical, and both subject to the same familiar dynamics and receive the same education.

[Psychopathological risk in children with early onset of partial epilepsy]

In this study we compare the peculiarities of psychopathological risk in children with partial epilepsy versus children with chronic illness. Sixteen children affected by epilepsy with partial seizures, symptomatic or cryptogenetic (group A), are compared with 16 children affected by diabetes mellitus type 1 (group B) and with 16 early treated congenital hypothyroid children (group C). For the valuation we have used: 1) Rutter scales for parents; 2) questionnaire on maternal attitude towards epilepsy, modified for diabetes and hypothyroid children; 3) anamnestic interviews for epileptic patients; 4) individual observations. We have emphasized that: 1) the quality of life in children with epilepsy and their families is poorer compared to the ones of the other chronically ill children; 2) the attack is the most characterising factor of life quality of both group A and group B; 3) both group A and group B show an important anxiety for cognitive and behavioural disturbances; 4) in epilepsy families several factors contribute to the increased anxiety towards social life: occurrence of seizures, side effects of drugs, real or supposed underlying encephalopathy.

Mild iodine deficiency during fetal/neonatal life and neuropsychological impairment in Tuscany

The neuropsychological performance of schoolchildren living in areas with present and past iodine deficiency in Tuscany was investigated. Children were submitted to: a) block design subtest of the Wechsler Intelligence Scale for Children-Revised (WISC-R) and a modified version of the WISC-R coding subtest which evaluate the general neuropsychological and cognitive performance, independently from familial cultural background; b) simple reaction time (RT) session which evaluates the efficiency of the whole information processing and nervous transmission mechanisms. Neuropsychological performance was tested in 107 children living in Borgo a Mozzano, an area of mild iodine deficiency (IDA) with a median urinary iodine excretion (UIE) of 64 micrograms/L (mean +/- SD: 80.1 +/- 57). One hundred and six sex and age-matched children living in Marina di Pisa, an iodine sufficient coastal village of Tuscany (ISA) with a median UIE of 142 micrograms/L (mean +/- SD: 173 +/- 95) were used as controls. Tests for neuropsychological performance were performed in 57 children living in the village of Vagli, an area with past iodine deficiency (PIDA): 30 children born before iodine prophylaxis (Group 1), when the median UIE was 32 micrograms/L (mean +/- SD: 47 +/- 22), 27 children born after the institution of iodine prophylaxis (Group 2), when the median UIE was 109 micrograms/L (mean +/- SD: 130 +/- 73). Sex and age-matched ISA-children were used as controls for each group. RTs were significantly delayed (p < 0.05) in IDA than in ISA children, while block design and coding subtests showed no significant difference.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of L-thyroxine replacement therapy in children with congenital hypothyroidism

The outcome of L-thyroxine (L-T4) replacement therapy in children with congenital hypothyroidism (CH) remains to be completely evaluated. In this paper the overall pattern of response to L-T4 replacement therapy was studied in a group of 19 children with CH diagnosed by neonatal screening (10 with hypoplastic/aplastic thyroid disease, group H/A; 9 with gland ectopy, group E) who were followed-up for 60 +/- 27 months (mean +/- SD). With 1 exception serum T4 at diagnosis was greater than 2 micrograms/dl in children of group E and less than 2 micrograms/dl in those of group H/A. The initial dose of L-T4 (8-10 micrograms/kg BW/day) was modified in relation to age and weight in order to maintain serum TSH less than or equal to 5 microU/ml and FT3 in the normal range. A general inverse correlation between serum TSH and FT4 or FT3 concentrations was found, and the mean levels of serum FT4 and FT3 were significantly higher according to the following order of TSH results: low TSH (0-0.5 microU/ml) greater than normal (greater than 0.5-5 microU/ml) greater than elevated TSH (greater than 5 microU/ml). TSH levels less than or equal to 5 microU/ml were associated with FT4 values in the upper half of the normal range (54% of observations) or even higher (46%). Elevation of serum FT4 alone with FT3 values in the normal range did not result in clinical thyrotoxicosis, alteration of growth or premature craniosynostosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuropsychological assessment in schoolchildren from an area of moderate iodine deficiency

Neuropsychological assessment was carried out in schoolchildren from a montane area of Eastern Tuscany (Tiberina Valley). This area was found to be moderately iodine deficient (mean urinary iodine excretion: 39 micrograms/g creatinine), with a cumulative goiter prevalence of 51.9% in schoolchildren aged 6-14 yr (goiter prevalence in the control iodine-sufficient area: 5.6%). No significant differences in serum TT4, TT3, FT4I, TSH levels between the endemic and control areas were found, whereas serum thyroglobulin values were significantly higher in the iodine-deficient area (61 +/- 8 vs 17 +/- 1 ng/ml, p less than 0.01). No differences were found as to the height, body weight and pubertal development in the two areas. Neuropsychological assessment, performed in a representative sample of 50 schoolchildren from the endemic area and 50 schoolchildren from the control area, matched for age, sex and socioeconomical conditions, failed to show major differences between the two groups in the global neuropsychological performance and cognitive levels. However, minor but significant differences were noted in the information vocabulary and coding subtests, at least in children aged 8. Although familial cultural influences might play a role, it would appear that some marginal impairment, with particular regard to motor-perceptual functions, be present in areas of moderate iodine deficiency.