Semantic Processing and Thought Disorder in Childhood-Onset Schizophrenia: Insights from fMRI.

Impairments in language processing and thought disorder are core symptoms of schizophrenia. Here we used fMRI to investigate functional abnormalities in the neural networks subserving sentence-level language processing in childhood-onset schizophrenia (COS). Fourteen children with COS (mean age: 13.34; IQ: 95) and 14 healthy controls (HC; mean age: 12.37; IQ: 104) underwent fMRI while performing a semantic judgment task previously shown to differentially engage semantic and syntactic processes. We report four main results. First, different patterns of functional specialization for semantic and syntactic processing were observed within each group, despite similar level of task performance. Second, after regressing out IQ, significant between-group differences were observed in the neural correlates of semantic and, to a lesser extent, syntactic processing, with HC children showing overall greater activity than COS children. Third, while these group differences were not related to effects of medications, a significant negative correlation was observed in the COS group between neuroleptic dosage and activity in the left inferior frontal gyrus for the semantic condition. Finally, COS children's level of thought disorder was significantly correlated with task-related activity in language-relevant networks. Taken together, these findings suggest that children with COS exhibit aberrant patterns of neural activity during semantic, and to a lesser extent syntactic, processing and that these functional abnormalities in language-relevant networks are significantly related to severity of thought disorder.

Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study.

BACKGROUND: We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm. METHOD: Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months. RESULTS: Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0.78, 95% CI 0.53 to 1.14, P=0.20). CONCLUSION: Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

Making sense during conversation: an fMRI study.

Although language is thought of as a left hemisphere function, there is increasing evidence that the right hemisphere contributes to language processing by identifying the theme of spoken and written language. Using fMRI, we examined the role played by the right and left hemispheres in making sense of a conversation. When this process involves implicit appraisal of changes in the conversation's topic, the neural network has a right hemisphere bias and includes Broca's and Wernicke's areas, their right hemisphere homologues, right dorsolateral prefrontal cortex, and the cerebellum. When making sense of conversation involves appraisal of the conversation's reasoning, however, the network includes Broca's and Wernicke's areas. Thus, right and left hemisphere systems contribute uniquely to the linguistic skills involved in making sense of a conversation.

Medial temporal lobe in childhood-onset schizophrenia.

The majority of anatomic and neuroimaging studies in adult-onset schizophrenia demonstrate decreased volumes of the medial temporal lobe when compared with findings in normal individuals. The goal of this study was to investigate the hypothesis that subjects with childhood-onset schizophrenia would show decreased volumes of the medial temporal lobe when compared to normal children. Thirteen children meeting DSM-III-R criteria for schizophrenia (mean age 14.2+/-3.8 years) and 20 normal children (mean age 12.0+/-2.8 years) were investigated. MRI scans were performed on a 1.5-T GE Signa MR scanner using a coronal plane SPGR at 1.4-mm slice thickness. Volumes were assessed by manually tracing bilateral hippocampus, amygdala and temporal lobes. After adjustment for age and total brain volume, the amygdala was significantly larger in the schizophrenics than in the control subjects, and this volume increase was more pronounced on the left side. Hippocampus volumes did not differ significantly across groups. There was a nearly significant left-greater-than-right asymmetry of the amygdala in the schizophrenic group but not in the normal group. A nearly significant right-greater-than-left asymmetry was found in the anterior hippocampus for both schizophrenic and control groups. These findings are consistent with previous reports of at least initial sparing of temporal lobe regions in childhood-onset schizophrenia.

Measures of psychopathology in children with complex partial seizures and primary generalized epilepsy with absence.

OBJECTIVE: This investigation examined psychopathology in 48 children with complex partial seizures (CPS), 39 children with primary generalized epilepsy with absence (PGE), and 59 nonepileptic children, aged 5 to 16 years, by comparing the Child Behavior Checklist (CBCL) and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). METHOD: The CBCL was completed by parents and the K-SADS was administered to both parent and child. RESULTS: The CBCL identified psychopathology in 26% and the K-SADS in 51% of the CPS and PGE patients (kappa = 0.32). The CPS and PGE groups had significantly higher mean CBCL scores, as well as higher rates of psychiatric diagnoses and symptoms of psychopathology, compared with the nonepileptic group. However, the CPS and PGE groups did not differ in these measures. Within each patient group, Full Scale IQ, but not seizure control, was associated with these measures of psychopathology. CONCLUSION: These findings suggest that the K-SADS identifies more children with psychopathology than the CBCL in children with CPS and PGE.

Thought disorder in attention-deficit hyperactivity disorder.

OBJECTIVE: This study compared thought disorder and associated cognitive variables in attention-deficit hyperactivity disorder (ADHD) and schizophrenia. METHOD: Speech samples of 115 ADHD, 88 schizophrenic, and 190 normal children, aged 8 to 15 years, were coded for thought disorder. A structured psychiatric interview, the WISC-R, the Continuous Performance Test, and the Span of Apprehension task were administered to each child. RESULTS: The ADHD and schizophrenic groups had thought disorder compared with the normal children. However, the subjects with ADHD had a narrower range of less severe thought disorder than did the schizophrenic subjects. The younger children with ADHD and schizophrenia had significantly more thought disorder than did the older children with these diagnoses. IQ, attention, and working memory were associated with thought disorder in the ADHD but not the schizophrenic group. CONCLUSIONS: Thought disorder in childhood is not specific to schizophrenia and reflects impaired development of children's communication skills.

Conversational repair in pediatric epilepsy.

This study examined if children with complex partial seizures disorder (CPS) and primary generalized epilepsy with absence (PGE) were impaired in the use of self-initiated repair during a conversation compared to normal children. Transcriptions of speech samples of 92 CPS, 51 PGE, and 65 normal children, ages 5-16 years, were coded for self-initiated repair according to Evans (1985). The WISC-R, a structured psychiatric interview, and seizure-related information were obtained for each child. We found impaired use of repair in both the CPS and PGE groups compared to the normal subjects. The CPS patients, particularly those with a temporal lobe focus, overused self-initiated corrections of referents and syntax compared to the PGE and normal subjects. The CPS and PGE patients with frontal lobe involvement underused fillers compared to the normal children. These findings provide additional evidence that both CPS and PGE impact the ongoing development of children's communication skills.

Behavioral aspects of epilepsy in children with mental retardation.

Epilepsy and mental retardation, two relatively common childhood conditions, are both associated with a wide range of behavioral disorders. This article reviews the behavioral disturbances found in children with epilepsy, mental retardation, and both conditions. The behavioral disturbances found in children with epilepsy are associated with seizure-related, cognitive, developmental, and psychosocial factors. Although children with mental retardation also demonstrate a broad spectrum of behavioral disturbances, children with specific mental retardation syndromes have better-defined patterns of psychopathology. The presence of epilepsy and mental retardation seems to increase the severity of psychopathology. Further studies are needed, however, to define better the interaction of these two conditions and how they impact the behavior of children.

Brain abnormalities in early-onset schizophrenia spectrum disorder observed with statistical parametric mapping of structural magnetic resonance images.

OBJECTIVE: The purpose of this study was to assess neuroanatomic abnormalities in children and adolescents with childhood-onset schizophrenia by using whole-brain voxel-based morphometric analyses. Previous volumetric studies of brain abnormalities in childhood-onset schizophrenia have revealed anomalies similar to those in subjects with adult-onset schizophrenia. Specifically, low cerebral volume, high ventricular volume, and thalamic, basal ganglia, callosal, and temporal lobe abnormalities have been observed in childhood-onset schizophrenia. Relatively few anatomical structures have been delineated and measured in this rare population, partly because of the labor involved in the slice-by-slice region definition required of conventional volumetric image analyses. METHOD: The subjects were 10 normal children and adolescents and nine children and adolescents with early-onset schizophrenia (mean age at diagnosis, 11.0 years; range, 7-16 years). The authors conducted voxel-by-voxel and volumetric statistical analyses of high-resolution structural magnetic resonance images. RESULTS: Statistical parametric maps of gray matter, white matter, and CSF differences between the groups revealed that the subjects with early-onset schizophrenia had larger ventricles, predominantly in the posterior horns of the lateral ventricles, and midcallosal, posterior cingulate, caudate, and thalamic abnormalities. Volumetric analyses of the lateral ventricles in native image data space confirmed significantly higher volume in posterior, but not anterior, regions. Randomization tests confirmed the overall statistical significance of the group differences and validity of the parametric maps. CONCLUSIONS: These findings are generally consistent with the findings of other research groups, but localization of enlarged ventricles specific to the posterior region may be a new finding in the literature on childhood-onset schizophrenia.

Depression and control beliefs in relation to reemployment: what are the directions of effect?

Depressive symptoms, locus of control, and reemployment were assessed over the course of 1 year among 254 recently unemployed men and women. Individual growth curve modeling and discrete-time survival analyses were used to examine (a) whether reemployment resolved depressive symptoms or affected control beliefs, (b) whether depressive symptoms or control beliefs predicted time to reemployment, and (c) if these relationships changed over time. Depressive symptom declines were predicted by reemployment, but initial depression was completely unrelated to time to reemployment. Control beliefs were stable over time and thus not affected by reemployment. Instead, they predicted early reemployment. These processes varied according to reemployment type and time period. Implications for intervention and for stress and coping theory are discussed.

Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry.

BACKGROUND: The Pediatric Perioperative Cardiac Arrest (POCA) Registry was formed in 1994 in an attempt to determine the clinical factors and outcomes associated with cardiac arrest in anesthetized children. METHODS: Institutions that provide anesthesia for children are voluntarily enrolled in the POCA Registry. A representative from each institution provides annual institutional demographic information and submits anonymously a standardized data form for each cardiac arrest (defined as the need for chest compressions or as death) in anesthetized children 18 yr of age or younger. Causes and factors associated with cardiac arrest are analyzed. RESULTS: In the first 4 yr of the POCA Registry, 63 institutions enrolled and submitted 289 cases of cardiac arrest. Of these, 150 arrests were judged to be related to anesthesia. Cardiac arrest related to anesthesia had an incidence of 1.4 +/- 0.45 (mean +/- SD) per 10,000 instances of anesthesia and a mortality rate of 26%. Medication-related (37%) and cardiovascular (32%) causes of cardiac arrest were most common, together accounting for 69% of all arrests. Cardiovascular depression from halothane, alone or in combination with other drugs, was responsible for two thirds of all medication-related arrests. Thirty-three percent of the patients were American Society of Anesthesiologists physical status 1-2; in this group, 64% of arrests were medication-related, compared with 23% in American Society of Anesthesiologists physical status 3-5 patients (P < 0.01). Infants younger than 1 yr of age accounted for 55% of all anesthesia-related arrests. Multivariate analysis demonstrated two predictors of mortality: American Society of Anesthesiologists physical status 3-5 (odds ratio, 12.99; 95% confidence interval, 2.9-57.7), and emergency status (odds ratio, 3. 88; 95% confidence interval, 1.6-9.6). CONCLUSIONS: Anesthesia-related cardiac arrest occurred most often in patients younger than 1 yr of age and in patients with severe underlying disease. Patients in the latter group, as well as patients having emergency surgery, were most likely to have a fatal outcome. The identification of medication-related problems as the most frequent cause of anesthesia-related cardiac arrest has important implications for preventive strategies.

Thought disorder in childhood schizophrenia: replication and update of concept.

OBJECTIVES: To examine whether measures of thought disorder differentiated schizophrenic from normal children and to examine the relationship of these measures with developmental and cognitive factors. METHOD: The speech samples of 88 schizophrenic and 190 normal children, aged 9 to 13 years, were coded with the Kiddie Formal Thought Disorder Rating Scale and Halliday and Hassan's analysis of cohesion. RESULTS: Above and beyond differences in mental age, gender, and neuroleptic status, the patients had significantly more formal thought disorder (FTD) and cohesive deficits than the normal children matched by mental age. The younger schizophrenic and normal children had significantly more thought disorder than the older children with these diagnoses. Combined FTD and cohesion scores correctly identified 76% of schizophrenic and 88% of normal children with little variability across mental age. The thought disorder measures generated 2 independent components: FTD and cohesion. CONCLUSIONS: Thought disorder measures that include both FTD and cohesion provide a quantitative diagnostic tool of childhood-onset schizophrenia.

Childhood schizophrenia: responsiveness to questions during conversation.

OBJECTIVES: This study characterized further the communicative deficits associated with childhood-onset schizophrenia. It examined the use of speech functions that involve responses to Yes/No and Wh- questions in children with schizophrenia and normal children during conversation. It also ascertained the relationship of these speech functions with cognition and thought disorder. METHOD: Speech function variables, formal thought disorder, and cohesion were coded in 32 schizophrenic and 34 normal children, aged 5.6 to 12.4 years, from speech samples elicited with the Story Game. RESULTS: The schizophrenic children were significantly more impaired in the use of speech functions than the normal children. Other than the association of a subset of the speech functions with distractibility and loose associations, the speech function measures were unrelated to cognitive and thought disorder measures. CONCLUSIONS: Speech function analysis detects communication deficits not captured by thought disorder measures in children with schizophrenia.

Principles of community psychiatry.

Our primary goal in community psychiatry is to satisfy the service needs of a bounded population for whose mental health we have accepted responsibility and accountability. We base our programs on public health practice models: These direct us to focus on segments of our population which are currently exposed to harmful biopsycho-social factors that increase their risk of becoming mentally ill. We focus on preventing psychosocial problems or their consequences by reducing their population rates: either the incidence of new cases (primary prevention), the prevalence of all existing cases (secondary prevention), and the rates of residual disability (tertiary prevention). We increase our efficiency and effectiveness by organizing our program on the basis of crisis theory which demands that we reach out to people in crisis and provide them with immediate guidance and help to master their current difficulties during the short period when they are open to influence and amenable to change in ways that have long term mental health consequences. We spread our own influence by organizing support groups and we multiply many-fold our impact on the huge problems involved in covering the needs of our population by recruiting the collaboration of other professional caregivers and non-professional helpers. We enhance the mental health component in the daily work of all caregiving agencies and institutions and individual professionals in the community through education and mental health consultation and collaboration. We also reach out to assist non-professional caregiving individuals and organizations, especially those who provide mutual help to fellow sufferers. In our latest work we are currently identifying harmful practices in our caregiving systems that actually harm those people whom we are trying to help. We are in the process of developing methods for reducing this system-generated damage.

Efficient evaluation of thyroid nodules by primary care providers and thyroid specialists.

OBJECTIVE: To determine whether primary care providers and thyroid specialists at Gundersen Lutheran Medical Center are evaluating thyroid nodules efficiently by following recently published clinical guidelines. STUDY DESIGN: One-year retrospective chart review. PATIENTS AND METHODS: We reviewed patient records from 1996 and tabulated the use of fine-needle aspiration cytology, radionuclide scanning, and thyroid ultrasonography by 49 primary care physicians evaluating 81 thyroid nodules and by 5 thyroid specialists evaluating 29 thyroid nodules. The results were compared with our previous findings and those recently reported by others. RESULTS: Fine-needle aspiration cytology was widely used by both groups of Gundersen Lutheran healthcare providers. Primary care physicians used imaging studies modestly and generated $106 per patient in unnecessary costs. Thyroid specialists occasionally used radionuclide scanning but did not use thyroid ultrasonography; they generated $41 per patient in unnecessary costs. Overall, the introduction of fine-needle aspiration cytology at our institution has reduced the use of radionuclide scanning from 90% to 12% and the use of thyroid ultrasonography from 30% to 10%. We also found that the frequency of surgery in patients with thyroid nodules fell substantially, yet detection of thyroid cancer in the operative specimens increased from 16% to 43% while the cost of removing a thyroid carcinoma decreased from $64,000 to $25,000. CONCLUSIONS: Fine-needle aspiration cytology, adopted as the initial test for diagnosing thyroid nodules by most of our healthcare providers, has reduced the use of imaging studies far below the frequency reported by others and has substantially decreased the cost of thyroid nodule management.

The development of evidence-based clinical practice guidelines. Integrating medical science and practice.

Practice guidelines are rapidly becoming preferred decision-making resources in medicine, as advances in technology and pharmaceutics continue to expand. An evidence-based approach to the development of practice guidelines serves to anchor healthcare policy to scientific documentation, and in conjunction with practitioner opinion can provide a powerful and practical clinical tool. Three sources of information are essential to an evidence-based approach: a) an exhaustive literature synthesis; b) meta-analysis; and c) consensus opinion. The systematic merging of evidence from these sources offers healthcare providers a scientifically supportable document that is flexible enough to deal with clinically complex problems. Evidence-based practice guidelines, in conjunction with practice standards and practice advisories, are invaluable resources for clinical decision making. The judicious use of these documents by practitioners will serve to improve the efficiency and safety of health care well.

Airway injury during anesthesia: a closed claims analysis.

BACKGROUND: Airway injury during general anesthesia is a significant source of morbidity for patients and a source of liability for anesthesiologists. To identify recurrent patterns of injury, the authors analyzed claims for airway injury in the American Society of Anesthesiologists (ASA) Closed Claims Project database. METHODS: The ASA Closed Claims database is a standardized collection of case summaries derived from professional liability insurance companies closed claims files. All claims for airway injury were reviewed in depth and were compared to other claims during general anesthesia. RESULTS: Approximately 6% (266) of 4,460 claims in the database were for airway injury. The most frequent sites of injury were the larynx (33%), pharynx (19%), and esophagus (18%). Injuries to the esophagus and trachea were more frequently associated with difficult intubation. Injuries to temporomandibular joint and the larynx were more frequently associated with nondifficult intubation. Injuries to the esophagus were more severe and resulted in a higher payment to the plaintiff than claims for other sites of airway injury. Difficult intubation (odds ratio = 4.53, 95% confidence interval [CI] = 2.36, 8.71), age older than 60 yr (odds ratio = 2.97, 95% CI = 1.51, 5.87), and female gender (odds ratio = 2.43, 95% CI = 1.09, 5.42) were associated with claims for pharyngoesophageal perforation. Early signs of perforation, e.g., pneumothorax and subcutaneous emphysema, were present in only 51% of perforation claims, whereas late sequelae, e.g., retropharyngeal abscess and mediastinitis, occurred in 65%. CONCLUSION: Patients in whom tracheal intubation has been difficult should be observed for and told to watch for the development of symptoms and signs of retropharyngeal abscess, mediastinitis, or both.

Infantile spasms: the development of nonverbal communication after epilepsy surgery.

The postoperative development of nonverbal communication was studied in 29 children, aged 18.2 (SD = 11.54) months, who underwent multilobar resection or hemispherectomy for intractable symptomatic infantile spasms (IS). Using the Early Social Communication Scale, the IS subjects had little, if any, social interaction, joint attention or behavior regulation before surgery. After a mean follow-up of 24 months, most of the children continued to have delayed nonverbal communication skills compared to normal children. Seizure-related, surgical and cognitive factors were unrelated to the postsurgical development of nonverbal communication. The children with right-sided surgery had a statistically significant increase in the use of social interaction but not in other gestural behaviors. Removal of the frontal lobe was not related to the nonverbal communication outcome. The study's findings suggest that impaired use of nonverbal communication might be a feature of surgically treated children with medically intractable IS.