Brief Behavioral Intervention for Disruptive Behavior in a Child with a Hypothalamic Hamartoma: A Case Report.

Most children with hypothalamic hamartoma (HH) manifest symptoms of epilepsy and associated cognitive deficits and behavioral difficulties as well as central precocious puberty (CPP). However, there is little to no research examining behavioral difficulties in children with HH without epilepsy, nor is there research examining treatments to address the behavioral difficulties of patients with HH without epilepsy. In the current case report, the authors implemented a validated parent management training program [the Brief Behavioral Intervention (BBI)], to treat symptoms of ADHD and disruptive behavior in a 6-year-old female patient with HH and CPP. The family participated in six BBI sessions over a period of 8 weeks. Parent behavioral ratings suggested significant reductions of symptoms of ADHD and disruptive behaviors to the normal range. The current case report demonstrates the effectiveness of the BBI program in the treatment of behavioral difficulties in a patient with HH and CPP. Further, the present study explores behavioral manifestations rarely explored in patients with HH without epilepsy.

The intellectual developmental disorders Mexico study: situational diagnosis, burden, genomics and intervention proposal / Estudio sobre trastornos del desarrollo intelectual en México: diagnóstico situacional, carga, genómica y propuesta de intervenciones

Abstract: Objective: This study aims to generate evidence on intellectual development disorders (IDD) in Mexico. Materials and methods: IDD disease burden will be estimated with a probabilistic model, using population-based surveys. Direct and indirect costs of catastrophic expenses of families with a member with an IDD will be evaluated. Genomic characterization of IDD will include: sequencing participant exomes and performing bioinformatics analyses to identify de novo or inherited variants through trio analysis; identifying genetic variants associated with IDD, and validating randomly selected variants by polymerase chain reaction (PCR) and sequencing or real-time quantitative PCR (qPCR). Delphi surveys will be done on best practices for IDD diagnosis and management. An external evaluation will employ qualitative case studies of two social and labor inclusion programs for people with IDD. Conclusions: The results will constitute scientific evidence for the design, promotion and evaluation of public policies, which are currently absent on IDD.

Resumen: Objetivo: Esta investigación busca generar evidencia sobre trastornos del desarrollo intelectual (TDI) en México. Material y métodos: La carga de la enfermedad por TDI se estimará con un modelo probabilístico usando encuestas poblacionales. Se estimarán costos directos e indirectos de gastos catastróficos de familias con un integrante conTDI. La caracterización genómica deTDI incluirá secuenciar exomas, realizar análisis bioinformático para identificar variantes de novo o heredadas a través de análisis de tríos, identificar variantes genéticas asociadas con TDI, y validar variantes aleatoriamente seleccionadas con reacción en cadena de polimerasa y secuenciación o qPCR. Se harán encuestas Delphi sobre mejores prácticas de diagnóstico y manejo de TDI. Una evaluación externa empleará estudios cualitativos de caso de dos programas de inclusión social y laboral para personas con TDI. Conclusiones: Los resultados serán evidencia científica que podrá ser la base para el diseño, promoción y evaluación de políticas públicas, actualmente ausentes para TDI.

Frequency, characteristics and management of adolescent inpatient aggression.

BACKGROUND: Inpatient aggression is a serious challenge in pediatric psychiatry. METHODS: A chart review study in adolescent psychiatric inpatients consecutively admitted over 24 months was conducted, to describe aggressive events requiring an intervention (AERI) and to characterize their management. AERIs were identified based on specific institutional event forms and/or documentation of as-needed (STAT/PRN) medication administration for aggression, both recorded by nursing staff. RESULTS: Among 408 adolescent inpatients (age: 15.2±1.6 years, 43.9% male), 1349 AERIs were recorded, with ≥1 AERI occurring in 28.4% (n=116; AERI+). However, the frequency of AERIs was highly skewed (median 4, range: 1-258). In a logistical regression model, the primary diagnosis at discharge of disruptive behavior disorders and bipolar disorders, history of previous inpatient treatment, length of hospitalization, and absence of a specific precipitant prior to admission were significantly associated with AERIs (R(2)=0.32; p<0.0001). The first line treatment of patients with AERIs (AERI+) was pharmacological in nature (95.6%). Seclusion or restraint (SRU) was used at least once in 59.4% of the AERI+ subgroup (i.e., in 16.9% of all patients; median within-group SRU frequency: 3). Treatment and discharge characteristics indicated a poorer prognosis in the AERI+ (discharge to residential care AERI+: 22.8%, AERI-: 5.6%, p<0.001) and a greater need for psychotropic polypharmacy (median number of psychotropic medications AERI+: 2; AERI-: 1, p<0.001). CONCLUSIONS: Despite high rates of pharmacological interventions, SRU continue to be used in adolescent inpatient care. As both of these approaches lack a clear evidence base, and as adolescents with clinically significant inpatient aggression have increased illness acuity/severity and service needs, structured research into the most appropriate inpatient aggression management is sorely needed.

Successful treatment of severe disruptive disorder featuring symptoms of the Klüver-Bucy Syndrome following a massive right temporal-parietal hemorrhage.

We know little about effective treatment for patients suffering from partial or complete Klüver-Bucy Syndrome (KBS) and other disruptive behaviors following a stroke. Reported cases have shown that certain medication, given alone or combined, can be partially effective. In this specific case study, we will try to demonstrate the effectiveness of a combination of carbamazepine, clonidine, quetiapine and methylphenidate in the alleviating of these symptoms. The wide range of symptoms found in KBS led us to use several kinds of psychotropic medication in spite of the inherent risks associated to polypharmacy.

Irritability in children and adolescents: past concepts, current debates, and future opportunities

Irritability is defined as a low threshold to experience anger in response to frustration. It is one of the most common symptoms in youth and is part of the clinical presentation of several disorders. Irritability can present early in life and is a predictor of long-term psychopathology; yet, the diagnostic status of irritability is a matter of intense debate. In the present article, we address two main components of the debate regarding irritability in youth: the misdiagnosis of chronic irritability as pediatric bipolar disorder, and the proposal of a new diagnosis in the DSM-5, disruptive mood dysregulation disorder, whose defining symptoms are chronic irritability and temper outbursts.

Inter-rater reliability of the Developmental Behaviour Checklist for Adults in community accommodation settings.

BACKGROUND: With the publication of the Developmental Behaviour Checklist for Adults (DBC-A), people of all ages with intellectual disability (ID) can now be assessed using a carer-completed screening checklist of emotional and behavioural disturbance. This provides a broad assessment framework across the life span, assists the process of clinical assessment, diagnosis and management, and, through efficient screening, helps ensure that people with ID and high levels of disturbed behaviour are more likely to receive the often scarce and costly behavioural and mental health services that are available. Earlier studies have reported acceptable results of test-retest reliability studies with family members and paid carers in community settings and the results of an inter-rater reliability study completed with family members. This study reports on another aspect of DBC-A reliability, inter-rater reliability with paid carers, in two small community-based accommodation settings. METHOD: Participants were 38 pairs of paid carers employed by two non-government agencies providing residential services in small group homes to 38 adults with ID in the community. RESULTS: An intraclass correlation coefficient (ICC) of 0.69 (n = 38, 95% CI 0.54-0.86) was found between pairs of paid carers employed in small group homes. DISCUSSION: Pairs of paid carers working with adults with ID in small group homes reliably completed DBC-A checklists. An ICC result of 0.69 compares favourably with the results of an earlier inter-rater study completed with the family members of people with ID living in the community. Inter-rater reliability on the six DBC-A sub-scales was also computed and the results were satisfactory. CONCLUSIONS: The carer-completed DBC-A provides a broad and comprehensive survey of the emotional and behavioural problems of adults with ID. It has satisfactory psychometric properties, which have been further extended. The DBC-A can be used in clinical, research and service settings to assess psychopathology across the adult life span in people with ID.

Effects of a universal classroom behavior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes.

BACKGROUND: The Good Behavior Game (GBG), a method of classroom behavior management used by teachers, was tested in first- and second-grade classrooms in 19 Baltimore City Public Schools beginning in the 1985-1986 school year. The intervention was directed at the classroom as a whole to socialize children to the student role and reduce aggressive, disruptive behaviors, confirmed antecedents of later substance abuse and dependence disorders, smoking, and antisocial personality disorder. This article reports on impact to ages 19-21. METHODS: In five poor to lower-middle class, mainly African American urban areas, three or four schools were matched and within each set randomly assigned to one of three conditions: (1) GBG, (2) a curriculum-and-instruction program directed at reading achievement, or (3) the standard program. Balanced assignment of children to classrooms was made, and then, within intervention schools, classrooms and teachers were randomly assigned to intervention or control. RESULTS: By young adulthood significant impact was found among males, particularly those in first grade who were more aggressive, disruptive, in reduced drug and alcohol abuse/dependence disorders, regular smoking, and antisocial personality disorder. These results underline the value of a first-grade universal prevention intervention. REPLICATION: A replication was implemented with the next cohort of first-grade children with the same teachers during the following school year, but with diminished mentoring and monitoring of teachers. The results showed significant GBG impact for males on drug abuse/dependence disorders with some variation. For other outcomes the effects were generally smaller but in the predicted direction.

Trastornos oposicional desafiante: enfoques diagnóstico y terapéutico y trastornos asociados / Oppositional defiant disorder: Diagnosis and therapeutic approaches, and associated disorders

Se define el trastorno oposicional desafiante (TOD) como un patrón recurrente de conducta negativista, desafiante, desobediente y hostil, dirigido a los padres y a las figuras de autoridad. Los estudios en países desarrollados han identificado factores cognitivos y conductuales errados, como los principales determinantes de una actitud negativa, opuesta y contraria a las normas establecidas; mientras que en países en vías de desarrollo, como Colombia, se destacan los factores ambientales como condicionantes de resiliencia y prosocialidad. En este artículo se presenta información general sobre el TOD, sus comorbilidades más frecuentes y su enfoque terapéutico.

Oppositional-defiant disorder is defined by a repetitive pattern of negative, defiant, disobedient and hostile conduct, against parents and other authority figures. Surveys in developed countries have identified cognitive and misconduct risk factors as the main determinants of a negative attitude, opposed and contrary to social laws; but in developingcountries, such as Colombia, environmental factors are the main determinants of resilience and prosociality. In this paper we present general information on TOD, its associated disorders, and its therapeutic approach.

Estudo da associação entre transtorno psiquiátrico e evento traumático na infância / Study of association between psychiatric disorder and event traumatic in childhood

Estudou-se a associação entre transtornos psiquiátricos e eventos traumáticos ocorridos na infância predominantes na literatura. Com o objetivo de avaliar a presença de certo transtorno psiquiátrico - Transtorno de Déficit de Atenção e Comportamento Disruptivo - TDACD - e certo evento traumático - abuso físico - foi investigada a população constituída de crianças entre três e doze anos, nos meses de outubro de 2006 a abril de 2007, referenciadas ao Serviço de Psiquiatria do Hospital Universitário Pedro Ernesto - UERJ, na cidade do Rio de Janeiro. Através de um estudo seccional encontrou-se relação de presença entre TDACD e abuso físico (OR=3,02; 95 porcento IC=1,05-9,02) e entre abuso físico e sexo masculino (OR=5,43; p=.001). Encontrou-se, também, uma relação de temporalidade entre TDACD e abuso físico (66,6 porcento). Este achado sugere que as crianças com TDACD provocam mais atitudes violentas nos pais/cuidadores. Propõem-se mudanças na direção do tratamento das crianças com TDACD, que além do diagnóstico precoce, os pais/cuidadores devem ser incluídos na proposta terapêutica, com intervenções e encaminhamentos adequados. Sugerimos a continuidade dos estudos sobre as relações do TDACD com o abuso físico em crianças.

Between 2006 and 2007 we studied the mental disorders more frequently associated with traumatic events in children. The study population was between three and twelve years old, referred to assistance at Psychiatry's service of the University Hospital Pedro Ernesto - UERJ. Our objective was to evaluate the presence of certain mental disorders - Attetion Deficit Disorder and Disruptive Behavior (ADDDB) - and certain traumatic events - physical abuse - developed during childhood. We found a presence relation between deficit disorder and disruptive behavior group and physical abuse (OR=3,02; 95 percent IC=1,05-9,02) and physical abuse and male sex (OR=5,43; p=.001). We found, also, a temporal relation between ADDDB and physical abuse (66,6 percent). Our findings suggest that children with ADDDB provoke more violent atitudes in fathers/caretakers. We suggest changes in the treatment for the children with ADDDB. In this population, finding a positive relation between mental disorders and trauma emphasizes the need of intensifying early diagnosis and treatment, demanding adequate intervention and referral. We suggest the further studies about the relation between ADDDB and physical abuse in chilfren.

Development of adaptable and flexible treatment manuals for externalizing and internalizing disorders in children and adolescents / Desenvolvimento de manuais adaptáveis e flexíveis para transtornos de externalização e internalização em crianças e adolescentes

In this paper we describe the process used to develop treatment manuals for internalizing and externalizing disorders in children and adolescents. These manuals were developed to offer health care providers and others working in child mental health a flexible intervention that could be adapted to different countries and localities based on: 1) the amount of health care and school resources that are available; 2) the nature and severity of the types of problems children have; and 3) the preferences and cultural factors that are important within these communities. We also discuss the experiences and cultural issues faced by sites in Egypt, Lebanon, Israel, and Brazil who volunteered to implement the manualized treatment programs. The feedback received from these sites indicates that the manuals can be implemented to help children with internalizing and externalizing problems.

Neste artigo, descrevemos o processo utilizado para elaborar manuais de tratamento para transtornos de externalização e intrnalização em crianças e adolescentes. Esses manuais foram elaborados para oferecer uma intervenção flexível para provedores de atenção à saúde e demais profissionais que trabalham com a saúde mental da criança, podendo ser adaptados a diferentes países e localidades, com base: 1) no nível de atenção médica e de recursos educacionais disponíveis; 2) na natureza e na gravidade dos tipos de problemas que as crianças apresentam; e 3) nas preferências e fatores culturais que são importantes nessas comunidades. Discutimos, também, as experiências e os problemas culturais enfrentados pelas localidades no Egito, Líbano, Israel e Brasil que foram voluntárias em implementar os programas de tratamento especificados nos manuais. O retorno recebido dessas localidades indica que os manuais podem ser implementados para auxiliar as crianças com problemas de externalização e internalização.

Adolescent outcome of disruptive behaviour disorder in children who had been treated in in-patient and day-treatment settings.

Although several studies have been conducted on the longitudinal course of childhood disruptive behaviours in community samples and in general psychiatric samples, little is known about adolescent adjustment in psychiatrically treated disruptive behaviour disorder (DBD) children. We examined a sample of adolescents (n = 47) who had been treated as children in an in-patient and/or day-treatment setting because of their severely disruptive behaviour. At follow-up, we found that half of the adolescents had a DBD diagnosis, and on average higher numbers of participants ever used soft drugs, had ever been in court, were not attending school when this was mandatory, and were smoking on a daily basis, as compared to comparison groups. There was, however, a large variance among the adolescents of our sample. When outcome was defined in terms of DBD diagnosis, living status, delinquency, school attendance, and smoking behaviour, 38 % had a positive outcome and 34 % had a poor outcome. For clinical purposes, it is important to recognise that there are large individual differences in outcome.

Deep brain stimulation as a functional scalpel.

Since 1995, at the Istituto Nazionale Neurologico "Carlo Besta" in Milan (INNCB,) 401 deep brain electrodes were implanted to treat several drug-resistant neurological syndromes (Fig. 1). More than 200 patients are still available for follow-up and therapeutical considerations. In this paper our experience is reviewed and pioneered fields are highlighted. The reported series of patients extends the use of deep brain stimulation beyond the field of Parkinson's disease to new fields such as cluster headache, disruptive behaviour, SUNCt, epilepsy and tardive dystonia. The low complication rate, the reversibility of the procedure and the available image guided surgery tools will further increase the therapeutic applications of DBS. New therapeutical applications are expected for this functional scalpel.

The effectiveness of parent management training in a Brazilian sample of patients with oppositional-defiant disorder

INTRODUÇAO: O transtorno desafiador de oposição (TDO) é considerado uma condição de difícil tratamento. O objetivo deste estudo foi avaliar a eficácia de um programa em grupo de treinamento de pais (TP) na redução dos sintomas de TDO e transtorno de conduta (TC) em crianças brasileiras com TDO. MÉTODO: conduziu-se um estudo naturalístico em que se analisou dados dos pais de cinco pacientes com TDO que participaram de um grupo de TP. Os sintomas de TDO e TC foram avaliados antes e pelo menos um mês depois de iniciarem a participação no grupo. As medidas utilizadas foram escalas baseadas nos critérios da DSM-IV para TDO e TC. RESULTADOS: A maioria dos pacientes continuou preenchendo critérios para TDO, mas a gravidade dos seus sintomas de TDO diminuiu 48,75%. A diferença entre as médias na escala de gravidade de sintomas desafiadores-opositivo foi estatisticamente significativa (p = 0,031). O número de critérios de TC preenchido pelos pacientes também foi largamente reduzido.CONCLUSAO: TP mostrou-se eficaz na melhoria de sintomas de TDO e TC em pacientes com TDO. TP pode ser uma opção terapêutica útil para o tratamento de TDO. Palavras-chave: Transtorno de déficit de atenção e disruptivos do comportamento, transtorno desafiador-opositivo, psicoterapia, tratamento.

Transtorno desafiador de oposição: uma revisão de correlatos neurobiológicos e ambientais, comorbidades, tratamento e prognóstico / Oppositional defiant disorder: a review of neurobiological and environmental correlates, comorbidities, treatment and prognosis

Transtorno desafiador de oposição (TDO) é uma entidade diagnóstica independente, mas é freqüentemente estudada em conjunto com transtorno de déficit de atenção/hiperatividade (TDAH) ou com transtorno de conduta (TC). O objetivo deste artigo é o de fazer uma revisão das evidências existentes, obtidas por meio da base de dados PubMed, sobre achados neurobiológicos no transtorno desafiador de oposição, funcionamento familiar e escolar, comorbidades, prognóstico e opções terapêuticas para transtorno desafiador de oposição. A evidência de correlatos hormonais, genéticos e neurofuncionais de transtorno desafiador de oposição, a conexão com a família, as relações e desempenho escolares, a associação com transtornos do humor, ansiosos e disruptivos, o risco de evolução para transtorno de conduta e de persistência de sintomas de transtorno desafiador de oposição são descritos. Uma revisão do efeito da Terapia Cognitivo-Comportamental e tratamento farmacológico é apresentada. A análise das evidências disponíveis mostra que o impacto de transtorno desafiador de oposição não deve ser ignorado e que o transtorno desafiador de oposição deve ser devidamente abordado. O impacto do tratamento de transtorno desafiador de oposição no prognóstico de longo prazo dos pacientes ainda precisa ser determinado.

Niños con Déficit de Atención e Hiperquinesis / Children with attention deficit disorder and hyperactivity

Los niños hiperactivos se han estudiado desde comienzos del siglo XX, especialmente en lo que se refiere a problemas educativos y limitaciones conductuales. En el presente trabajo se presenta en detalle el déficit de atención e hiperquinesis (TDA/H). Se coloca especial énfasis en el diagnóstico y la evaluación, en el tratamiento y en seguimiento. Los tratamientos pueden ser farmacológico, psicoterapéuticos, o basados en la modificación de conducta y en la terapia cognitiva. El trabajo se realiza en esta área, es interdisciplinar, incluye psicólogos, foliaturas, educadores, médicos y otros profesionales. En el momento actual los enfoques neurofisiológicos y genéticos se consideran muy promisorios

Prader-Willi syndrome.

Prader-Willi syndrome is a multi system disorder characterized by neonatal hypotonia, later obesity, hyperphagia and mental retardation. It occurs sporadically, either as a result of microdeletion of chromosome 15p (70%) or as a result of maternal disomy of chromosome 15 (30%). The major problems encountered by parents are those of hyperphagia, food-seeking and obesity, and conduct disorder, particularly tantrums or oppositional behaviour.