Caring for the Most Vulnerable: A Model for Managing Maladaptive Behavior in Children with Mental Special Needs During the COVID-19 Pandemic.

Background: This article presents the results of a comprehensive national model developed for managing maladaptive behaviors (MBs) in children with mental special needs (CMSNs) during the coronavirus disease 2019 (COVID-19) pandemic that combines telehealth-based Applied Behavioral Analyses, psychiatric interventions, and support from local psychosocial teams. This study aims to determine the effectiveness of a system that combined telehealth applications with local psychosocial support teams, allowing services from video calls to emergency interventions. Materials and Methods: The system combines the telehealth applications with the services from local psychosocial intervention teams. In addition to system records covering sociodemographic variables and initial complaints, a telephone survey questioning the effectiveness and satisfaction of the system was used as the main outcome. Results: In total, 347 individuals used the system with mothers constituting the majority of applicants (88.7%, n = 332). The overall satisfaction of the system was 8.8/10. In terms of effectiveness, 63.3% (n = 237) of caregivers reported an improvement in the reason of application. Counselors decided on a need for follow-up visits for 36.6% (n = 137) of applications. A referral to a psychiatrist was asked for 40 patients (10.6%). Discussion: To our best knowledge, this is the first study presenting a model for managing MBs of CMSNs during the COVID-19 outbreak. In general, therefore, it seems that there is a need for unique systems to handle behavioral problems of CMSNs. Conclusions: The findings of this study suggest that it is possible to establish an integrative multistep multidisciplinary telehealth-based approach in a short while.

The affective temperament traits and pregnancy-related depression in mothers may constitute risk factors for their children with attention deficit and hyperactivity disorder.

We investigated whether the affective temperaments of mothers and maternal depression before and during the index pregnancy are related to the development of Attention-Deficit Hyperactivity Disorder (ADHD) in their children. One hundred and twenty children were screened for the diagnosis of ADHD. After exclusion and inclusion criteria were applied for children and their mothers, we compared the mothers of children with (n = 63) and without ADHD (n = 60) in terms of affective temperament traits, depression before and during the index pregnancy, and some environmental risk factors. The rate of boys were significantly higher among children with ADHD compared to healthy controls. The mothers of children with ADHD had significantly lower education levels, more cigarette consumption during pregnancy, and more depression rates before the pregnancy than those of healthy children. Male gender (p = .002), Hamilton Depression Rating Scale (HDRS) (p = .002), cyclothymic (p = .022), irritable (p = .035) and anxious temperament scores (p = .016) significantly predicted the association between the mothers and their children with ADHD. Our findings might suggest that male child gender, the severity of depression at index pregnancy, higher cyclothymic, irritable, and anxious temperament scores in mothers may constitute as important risk factors for the development of ADHD in their children.Impact statementWhat is already known on this subject? Although the effects of maternal depression on ADHD were extensively investigated, the relationship between affective temperament traits of mothers and ADHD in their children has not been sufficiently examined. To investigate the roles of maternal affective temperament traits and pregnancy-related depression on offspring ADHD would help us to understand the etiopathogenic bases of ADHD.What do the results of this study add? Cyclothymic, irritable and anxious temperaments of mothers were significantly associated with the offspring ADHD after adjusting for the gender, maternal smoking, prepartum and antenatal depression.What are the implications of these findings for clinical practice and/or further research? These findings might demonstrate that some maternal affective temperaments and depression during pregnancy are suggestive of an inherited predisposition to ADHD in offsprings. Longitudinal studies are required to demonstrate the relationship between maternal affective temperament features and the development of affective illness in children with ADHD.

Effect of Methylphenidate on Emotional Dysregulation in Children With Attention-Deficit/Hyperactivity Disorder + Oppositional Defiant Disorder/Conduct Disorder.

BACKGROUND AND AIM: Emotional dysregulation (ED) is a frequent feature of attention-deficit/hyperactivity disorder (ADHD). It can be observed as a dysregulation profile or a deficient emotional self-regulation (DESR) profile. Oppositional defiant disorder/conduct disorder (ODD/CD) comorbidity is prevalent in ADHD and known to be related with ED. The first-line treatment of ADHD includes psychostimulants, but their effects on ED are not well studied. This study aimed to evaluate the outcomes of methylphenidate (MPH) treatment on ED in ADHD + ODD/CD cases. METHODS: A total of 118 ADHD + ODD/CD patients with a mean age of 9.0 ± 1.9 years were treated with MPH for 1 year. Also, parents of cases were recruited for a parent-training program, which initiated after first month of MPH treatment. Symptom severity was assessed at baseline and 12th month by Turgay Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Based Child and Adolescent Behavior Disorders Screening and Rating Scale-Parent Form, Children Depression Inventory, Child Behavior Checklist 4-18 years, and Parental Acceptance and Rejection Questionnaire-Mother Form. RESULTS: Emotional dysregulation (DESR + DP) was present in 85.6% of cases. Conduct disorder was significantly higher in patients with DP, whereas ODD was significantly higher in the DESR and non-ED groups (P < 0.0001). Symptoms of ADHD and ED were significantly improved with 1-year of MPH treatment (P < 0.05). The improvement in ED was independent of improvement in ADHD symptoms and parent training (P < 0.05). CONCLUSIONS: Emotional dysregulation is highly prevalent in disruptive behavioral disorders as ODD and CD, which are comorbid with ADHD. The MPH treatment is effective on ED independently from other clinical determinants.

Successful Treatment Response with Aripiprazole Augmentation of SSRIs in Refractory Obsessive-Compulsive Disorder in Childhood.

The aim of this study is to evaluate the aripiprazole augmentation of selective seratonine reuptake inhibitors (SSRIs) in children and adolescents with treatment-resistant OCD. Forty-eight children and adolescents (14 girls, 34 boys), who are non-responders to treatment with at least two types of SSRIs and CBT, were administered a 12-week of augmentation. Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), and Clinical Global Impression-Severity and Improvement (CGI-S and CGI-I) sub-scales were used for evaluation of the treatment outcomes. The results showed that total CY-BOCS scores were decreased from 33.3 ± 7.5 to 11.7 ± 9.3 (p < 0.001), CGI-S scores decreased from 6.3 ± 0.9 to 2.7 ± 1.6 (p < 0.001), and CGI-I scores improved from 4.3 ± 0.6 to 2.2 ± 1.1 (p < 0.001). Sensitivity analyses in 29 patients without SSRI dose escalation along with aripiprazole augmentation have also revealed that improvement effect was still significant, and CY-BOCS scores were improved from 34.2 ± 7.9 to 13 ± 10.3, CGI-S improved from 6.4 ± 1.0 to 3.0 ± 1.7, and CGI-I improved from 4.4 ± 1.0 to 2.3 ± 1.1 (p < 0.001 for all). Analyses revealed that a significant clinical improvement has been observed with aripiprazole augmentation. Aripiprazole augmentation of SSRIs is a promising strategy in the management of treatment-refractory OCD children and adolescents.

Major depressive disorder in chronic heart failure patients: Does silent cerebral infarction cause major depressive disorder in this patient population?

OBJECTIVE: Depression frequently occurs in patients with heart failure as similar pathophysiological mechanisms present in both these diseases. Patients with dilated cardiomyopathy (DCM) have a high incidence of clinically asymptomatic silent cerebral infarction (SCI). This study aimed to evaluate the relation between SCI and major depressive disorder (MDD), and between MDD and clinical and biochemical parameters in DCM patients. METHODS: Patients with ischemic and non-ischemic DCM who had chronic heart failure (CHF) (39 male, 10 female, age 60±10 years) were included in the study. Mean patient ejection fraction (EF) was 34±10%. Patients had no localized neurological symptoms or stroke history. The etiology of DCM was ischemic in 40 and non-ischemic in 9 patients. Twenty-five age-matched healthy volunteers served as a control group for comparison of SCI and MDD prevalence. RESULTS: Patients had mild to severe CHF symptoms. Prevalence of SCI and MDD was significantly higher in patients with DCM than in the control group; 63% vs 8%; p<0.001, and 52% vs 20%; p<0.001 respectively. Patients with SCI had a higher prevalence of MDD than patients without SCI in DCM (61% vs 27%, p=0.02). CONCLUSION: CHF patients have an increased prevalence of SCI and MDD. Patients with SCI have a higher prevalence of MDD compared to patients without SCI in CHF.

Health-related quality of life outcome of children with prominent ears after otoplasty.

To investigate health-related quality of life changes that occurred in children with prominent ears applied pre- and postoperatively. A prospective study was performed in 67 consecutive children who underwent otoplasty procedures between April 2008 and July 2010 and followed up for more than 2 years. Evaluations and interviews performed in the pre-and postoperative periods included the patients' history, clinical and routine laboratory examinations. Glasgow children's benefit inventory was the basis of the used inquiry for detecting the changes in health-related quality of life after otoplasty. For the children's cohort, the mean total Glasgow children's benefit inventory score was 23.9 (p < 0.001), indicating a benefit from the operation. All Glasgow children's benefit inventory subscores (emotion, physical health, learning, and vitality) were raised (mean 30.84, 14.98, 18.89, and 23.96, respectively). The health-related quality of life was raised in 63 of 67 children (94.03%). Negative Glasgow children's benefit inventory scores or subscores were not found in a single case. Otoplasty can significantly increase patients' health-related quality of life and leads to a high rate of patient satisfaction in children with prominent ears.

Serum nerve growth factor levels in autistic children in Turkish population: a preliminary study.

BACKGROUND & OBJECTIVES: It has been hypothesized that abnormal levels of serum nerve growth factor (NGF) may represent a serological marker for autistic children who may develop cognitive impairment, regression and finally epilepsy. The objective of this preliminary study was to measure serum NGF concentrations of autistic children and compare these levels with those of healthy children. METHODS: Consecutive children who were referred to the Paediatric Neurology and Child Psychiatry Policlinics of Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Turkey between February and September 2008 were included in the study. Serum samples were analyzed for NGF levels using ChemiKine NGF Sandwich ELISA Kit. Comparisons between the study and the control groups were made using student's t test and Chi-square test. RESULTS: Forty-nine autistic children and an equal number of healthy children (control group) were included in the study. No significant difference was found between the study and the control groups in terms of children's age, while number of boys was significantly higher (P<0.05) in the study group. Average serum NGF concentrations were 46.94 ± 51.40 and 32.94 ± 12.48 pg/ml in the study and control group, respectively. Serum NGF concentrations were significantly higher (P<0.05) in the study group compared with the control group. INTERPRETATION & CONCLUSIONS: Our preliminary findings show that enhanced serum NGF concentration may be used as a potential diagnostic tool in autism, however, further studies including a large number of patients are required to confirm the findings.

Cyclic alternating pattern analysis in REM sleep behavior disorder.

OBJECTIVE: Rapid eye movement (REM) sleep behavior disorder (RBD) is a type of REM parasomnia characterized by complex motor activity during REM sleep. In this study, cyclic alternating pattern (CAP) in patients with idiopathic RBD was analyzed to evaluate the expression of arousal instability of NREM sleep. METHODS: A total of 31 idiopathic RBD patients and age- and gender-matched 21 control subjects were consecutively recruited. Conventional sleep polysomnographic recording parameters and CAP parameters were compared between RBD and the control group. RESULTS: The number of CAP cycles (120.13 ± 113.56, p = 0.007), CAP sequences (20.9 ± 18.15, p < 0.001), CAP index (25.14 ± 24.44, p = 0.017), and CAP rate (24.07 ± 13.22, p = 0.016) were all significantly higher in RBD patients compared to the control group. The increase in CAP sequences was observed in phase A2 and A3 subtypes while phase A1 subtype was significantly lower in RBD patients. A significant positive correlation was observed between disease duration with total CAP time (r = 0.289, p = 0.042) and A3 index (r = 0.32, p = 0.024). There was a negative correlation between the age and A1 index (r = -0.4491, p = 0.0001). CONCLUSION: To our knowledge this is the first polysomnographic clinical study which evaluated CAP parameters in RBD. Increased CAP rate found may be considered as a sign showing that NREM sleep may also be affected in RBD patients. Therefore, CAP analysis may be important to enlighten the pathogenesis of parasomnias.

Treatment with enhanced external counterpulsation improves cognitive functions in chronic heart failure patients.

OBJECTIVES: Chronic heart failure (CHF) has been associated with an increased risk of poorer cognitive performance in older adults. Reversibility of cognitive impairment after medical treatment has been reported, although the restorative effects of enhanced external counterpulsation (EECP) on cognitive performance have not been studied. We investigated the effect of EECP on cognitive functions in CHF patients. STUDY DESIGN: Thirty-six individuals (mean age: 66±8 years) who were diagnosed with CHF and were New York Heart Association (NYHA) Class II-III and Canadian Cardiovascular Society (CCS) Class II-III participated in this study. Neuropsychological assessment was performed in these patients. RESULTS: Patients in the EECP treatment group showed a statistically significant improvement in spontaneous naming (p=0.011) and forward row score of the attention subset among domains of cognition (p=0.020) and interference time of executive function (p=0.012). CONCLUSION: Enhanced external counter pulsation resulted in improvement in all domains of cognitive functions except verbal and visual memory tests.

Aripiprazole-Associated Rhabdomyolysis in a 17-Year-Old Male.

Rhabdomyolysis is a rare serious side effect of antipsychotic medication use. There are cases of rhabdomyolysis due to the use of clozapine, risperidone, olanzapine, and haloperidol in the literature. In this report, we describe a rhabdomyolysis case developed on the 13th day of using 2.5 mg /day aripiprazole in a 17-year-old male patient with a diagnosis of somatic symptom disorder. This case is one of the youngest in the literature to develop rhabdomyolysis after the use of aripiprazole. Moreover, this case is distinguished from the others with its low-dose, short-term and single antipsychotic use. In the child and adolescent age group, routine blood tests should be done before starting medication. Symptoms that appear to be nonspecific and that may be overlooked or may be thought to be caused by an existing psychiatric complaint should be carefully and thoroughly considered during follow-up.

Sleep quality and its correlates in patients on continuous ambulatory peritoneal dialysis.

OBJECTIVE: The aim of this study was to investigate demographic, clinical and psychosocial factors associated with sleep quality in patients on continuous ambulatory peritoneal dialysis (CAPD). MATERIAL AND METHODS: Demographic data, clinical and biochemical parameters of 112 CAPD patients (convenience sample of 52 women and 60 men, mean age 51 ± 15 years) were measured. In the same patients, the Pittsburgh Sleep Quality Index (PSQI) was used for assessing sleep quality, the Beck Depression Inventory (BDI) for severity of depressive symptoms, the International Restless Legs Syndrome Study Group criteria for the diagnosis of restless legs syndrome (RLS), and the Short Form-36 (SF-36) of Medical Outcomes Study questionnaire for quality of life (QoL). RESULTS: Patients with PSQI scores of > 5 ("bad sleepers") had lower serum albumin (p = 0.008), total cholesterol (p = 0.034), normalized protein equivalent of nitrogen appearance (p = 0.046) and residual renal function (p = 0.012), but higher serum ferritin (p = 0.016) and BDI scores (p < 0.001). No significant correlation could be demonstrated between sleep quality and other demographic and clinical parameters. Although the prevalence of RLS was higher in poor sleepers, the difference did not reach statistical significance (p = 0.067). In multivariate analysis, only elevated BDI was an independent predictor of poor sleep quality (p = 0.031). Compared with good sleepers, poor sleepers had significantly lower QoL scores in all subscales of the SF-36. CONCLUSIONS: Although poor sleepers had lower nutritional indices, an elevated BDI was the only independent predictor of poor sleep quality. Poor sleep quality was also associated with lower QoL in patients on CAPD.

Evaluation of Quality of Life and Psychiatric Aspects of Children with Epilepsy and Their Families Using Self-assessment Questionnaires.

OBJECTIVE: The aim of this study was to compare sociodemographic characteristics, quality of life, and levels of depression and anxiety of children with epilepsy and their families with a healthy control group. MATERIALS AND METHODS: In this study, 60 epileptic children and their families were included. The data of these patients were compared with 51 healthy children and their families. The Children's Depression Inventory, Beck Depression and Anxiety Scale, State-Trait Anxiety Inventory for Children, KINDL General quality of life scale, KINDL-epilepsy module, and short form-36 were used to determine the depression, anxiety, and quality of life levels of children and parents. RESULTS: Depression and anxiety scale scores of the epilepsy group were statistically higher than the control group (P < .05). In the epilepsy group, the emotional well-being dimension on the KINDL parent scale and the total health, emotional well-being, family, and friends dimensions on the KINDL child scale were statistically lower than the healthy control group (P < .05). Short form-36 scores of the parents of the epilepsy group were statistically lower than the parents of the control group (P < .05). As the KINDL epilepsy quality of life dimension scores increased, the scores of the parental short form-36 quality of life scale scores increased. KINDL parental total scores were statistically lower in those with comorbidities than those without comorbidities. CONCLUSION: Monitoring for psychiatric comorbidities and quality of life status for both the child and the parents is recommended. Also, it should be emphasized that it would be more beneficial to use self-answered scales when assessing the quality of life of epileptic children.

Correlations between alexithymia and pain severity, depression, and anxiety among patients with chronic and episodic migraine.

AIMS: Some studies have found elevated alexithymia among patients with chronic pain, but the correlations between alexithymia and the severity of pain, depression, and anxiety among migraine patients are unclear. The aims of the present study were to investigate whether individuals suffering from episodic migraine (EM) differ from those with chronic migraine (CM) in regards to depression, anxiety, and alexithymia measures and to investigate the association of alexithymia with the results of depression and anxiety test inventories and illness characteristics. METHODS: A total of 165 subjects with EM and 135 subjects with CM were studied. The Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and Toronto Alexithymia Scale (TAS) were administered to all subjects. The correlation between alexithymia and sociodemographic variables, family history of migraine and illness characteristics (pain severity, frequency of episode, duration of illness) were evaluated. RESULTS: Compared with EM patients, the CM patients had significantly higher scores on measures of depression but not alexithymia and anxiety. There was a positive correlation between TAS scores and age and education in both migraine groups, but there was no correlation between TAS scores and other demographic variables. Depression and anxiety were significantly correlated with alexithymia in both migraine groups. CONCLUSION: Our results indicate that CM patients are considerably more depressive than EM patients. In this study, depression and anxiety were significantly correlated with alexithymia in both migraine groups. Our results demonstrate a positive association between depression, anxiety, and alexithymia in migraine patients.

[Episodic paroxysmal hemicrania with seasonal waxing and waning pattern]. / Mevsimsel artma ve azalma gösteren episodik paroksismal hemikrania.

The chronic form of paroxysmal hemicrania was defined first. Although the episodic form was thought to be inevitably chronic, in time, episodic forms that never reach the chronic phase were identified. The supposed incidence of paroxysmal hemicrania is 1/50.000, and the ratio of the episodic to chronic form is 1:4. A seasonal type of episodic form, which is limited to three cases in the literature, has also been reported. In this article, a case who remained episodic for 40 years with seasonal waxing and waning attack variations is reported.

Orgasmic headache responsive to greater occipital nerve blockade.

We present a male with headache related to sexual activity. An injection of steroid and local anesthetic combination was applied to the greater occipital nerve of the symptomatic site. The orgasmic headache stopped after the procedure.

The subthreshold autistic traits in patients with adult-onset obsessive-compulsive disorder: a comparative study with adolescent patients.

OBJECTIVE: The primary objective of this study was to compare the adult-onset and adolescent obsessive-compulsive disorder (OCD) patients in terms of the subthreshold autistic traits. METHODS: 29 adolescent, and 45 adult-onset OCD patients were assessed by Autism-spectrum Quotient (AQ). RESULTS: The ratio of males to females, the frequency of ritualistic compulsions, and the mean number of lifetime compulsions were significantly higher in adolescents with OCD compared to adult-onset patients. Adult-onset OCD patients had significantly higher scores on total, social skills, attention shifting, and imagination subscales of AQ than adolescent OCD patients. The mean number of compulsions, attention shifting scores of AQ, and female gender significantly predicted the distinction between adolescent and adult-onset OCD patients. In adult-onset patients, there were significant correlations between the mean number of lifetime obsessions and total, social skills, attention switching, communication, and imagination subscale scores of AQ. CONCLUSIONS: We suggest that subthreshold autistic traits may play a significant role in the occurence of obsessive-complusive symptoms (OCS) in adult-onset OCD. Autistic traits seemed to be higher and had an closer relationship with the frequency of lifetime obsessions in AO-OCD patients than in adolescent patients.

Treating an Adolescent with Long QT Syndrome for Bipolar Disorder: A Case Presentation.

OBJECTIVES: Long QT syndrome (LQTS) is described as the development of sudden syncope attacks or death as a result of ventricular tachycardia (VT) episodes that might be observed as elongated QT interval in electrocardiography (ECG). Implantable Cardioverter Defibrillator (ICD) is recommended as first-line treatment for the condition in guidelines. We aimed to present an adolescent recently diagnosed with Bipolar Disorder (BD) who had LQTS that was treated with ICD, discussing her follow up and treatment along with relevant literature. METHODS: Psychiatric assessment of the case that applied to our child psychiatry unit due to manic symptoms were carried out by using Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) criteria. Symptom severity was monitored via Young Mania Rating Scale scores (YMRSS). RESULTS: The case met criteria for Bipolar Disorder Type I (BD-I). She had improvement in her mood symptoms with treatment regimen as risperidone 3 mg/day, valproate 1000 mg/day and lorazepam 1 mg/dayi after her 2-week follow up as well as no reported ICD activity, reflecting fine cardiac functions and rhythm. CONCLUSIONS: LQTS is a serious health issue for children and adolescents diagnosed with BD. This condition should be kept in mind especially in cases where familial risk factors are present and precautions need to be maintained upon required assessments. These cases need to be closely monitored due to risk factors related to both BD and LQTS, in a multidisciplinary fashion, involving both psychiatry and cardiology divisions.

Herpes encephalitis as a cause of nonconvulsive status epilepticus.

Nonconvulsive status epilepticus is a specific form of status epilepticus characterized by alteration in mental status and persistent seizure activity on EEG, with or without motor phenomena. Recognition of the consequences of nonconvulsive status epilepticus has attracted greater attention to this condition. We present a 24-year-old woman with epilepsy who developed nonconvulsive status epilepticus during pregnancy. Despite treatment with antiepileptic drugs, the seizures persisted and confusion deepened. Further workup to explain the etiology revealed the diagnosis as herpes encephalitis. She recovered completely by the third day of parenteral acyclovir administration. Herpes simplex encephalitis causing nonconvulsive status epilepticus in a pregnant, epileptic woman is an unfortunate and unusual condition, which was simultaneously complicated by the presence of multiple etiological factors.

Subacute sclerosing panencephalitis: a case with fulminant course after ACTH.

We report a 24-month-old male who developed rapidly progressive subacute sclerosing panencephalitis 17 months after measles infection. This patient had a history of measles infection at the age of 7 months and manifested acute encephalitis 1 month later. Developmental delay observed after encephalitis began to improve after a few months. His control electroencephalogram was normal at the age of 14 months. He was admitted to the hospital with flexor spasms and sudden head drops at the age of 24 months. His electroencephalogram revealed slow waves in the posterior regions of the brain. Vigabatrin was begun; his seizures increased with vigabatrin, and adrenocorticotropic hormone was added to the therapy. After five doses of adrenocorticotropic hormone, his clinical findings deteriorated rapidly. His second electroencephalogram revealed periodic discharges synchronized with myoclonias. He was diagnosed as having subacute sclerosing panencephalitis on the basis of clinical and laboratory findings. He lapsed into a vegetative state within a week and died at the age of 25 months. We report this rapidly progressive case to emphasize the importance of recognition of subacute sclerosing panencephalitis before applying steroids in children with myoclonic seizures.