Assessing risk: Characterizing language performance in pediatric patients with intractable epilepsy pre- and post-surgical resection.

Neuropsychologists play an important role in assessing risk for post-surgical cognitive decline in pediatric patients with medically refractory epilepsy. Families, neurologists, and neurosurgeons are particularly concerned about the possibility for language decline for patients with a dominant, most often left, hemisphere epileptic focus and planned surgical resection. This study aims to describe language functioning in pediatric epilepsy patients following resection and evaluate the accuracy of a clinical approach of assessing risk. This study proposes a risk assessment method that considers a patient's pattern of lateralized dysfunction across cognitive domains, suspected neuroanatomical reorganization of language functions, and planned site of resection. Pediatric patients (N = 47) were dichotomized as being at minimal risk or at greater risk for post-surgical language decline based on the proposed risk assessment method. Retrospective chart review was utilized to obtain neuropsychological (Boston Naming Test and Weschler Vocabulary subtest) and clinical variables of interest. Patients in the minimal risk group demonstrated significantly improved BNT scores at post-surgery. Most patients remained stable in their Vocabulary knowledge. The proposed risk assessment method correctly classified patients 77% of the time based on BNT performance. Cluster analysis examining the individual components of the proposed method revealed three distinct patient subgroups. Clinical implications are discussed.

Stereotactic laser ablation for nonlesional cingulate epilepsy: case report.

Stereotactic laser ablation (SLA) is being increasingly used to treat refractory focal epilepsy, especially mesial temporal lobe epilepsy. However, emerging evidence suggests it can be used for extratemporal lobe epilepsy as well.The authors report the case of a 17-year-old male who presented with refractory nocturnal seizures characterized by bilateral arms stiffening or rhythmic jerking lasting several seconds. Semiology suggested an epileptogenic zone close to one of the supplementary sensory motor areas. Electroencephalography showed seizures arising from the central region without consistent lateralization. Brain imaging showed no abnormality. An invasive evaluation using bilateral stereoelectroencephalography (SEEG) was utilized in 2 steps, first to establish the laterality of seizures, and second to further cover the mesial cingulate region of the right hemisphere. Seizures arose from the middle portion of the right cingulate gyrus. Extraoperative electrical mapping revealed that the seizure onset zone was adjacent to eloquent motor areas. SLA targeting the right midcingulate gyrus was performed. The patient has remained seizure free since immediately after the procedure with no postoperative deficits (follow-up of 17 months).This case highlights the utility of SEEG in evaluating difficult-to-localize, focal epilepsy. It also demonstrates that the use of SLA can be extended to nonlesional, extratemporal epilepsies.

[Formula: see text]Congenital heart disease: A primer for the pediatric neuropsychologist.

Congenital heart disease (CHD) affects millions of people worldwide, including over one million children in the United States. Approximately 25% of children born with CHD require intensive surgical intervention within the first year of life. Despite improved rates of survival into adulthood - rates that exceed 90% in the modern era - children and adolescents with CHD remain at risk for neurological injury and a range of neurobehavioral and psychosocial challenges that pose a threat to quality of life across the lifespan. Consequently, as experts in both clinical psychology and brain development, neuropsychologists are becoming increasingly involved in cardiac follow-up and monitoring to promote optimal developmental outcomes. The primary objective of this paper is to provide an evidence-based, clinically-oriented primer on CHD for pediatric neuropsychologists working with this growing population of survivors. Following an introduction to current standard-of-care guidelines for managing children and adolescents with CHD, we present an overview of brain development within the context of CHD, review neuropsychological outcomes, examine factors influencing variability in outcomes, and discuss implications and strategies for clinical assessment.

Baseline Performance and Psychometric Properties of the Child Sport Concussion Assessment Tool 3 (Child-SCAT3) in 5- to 13-year-old Athletes.

OBJECTIVE: To determine the normative, baseline performance and psychometric properties of the Child Sport Concussion Assessment Tool 3 (Child-SCAT3) in 5- to 13-year-old athletes. DESIGN: Cross-sectional study. SETTING: Practice fields. PARTICIPANTS: Contact sport athletes (N = 155) 5 to 13 years old. INDEPENDENT VARIABLES: Age, gender, verbal intellectual functioning (receptive vocabulary). MAIN OUTCOME MEASURES: Child-SCAT3: self-reported and parent-reported symptoms, cognitive performance (child form of the Standardized Assessment of Concussion; SAC-C), and balance (modified Balance Error Scoring System, mBESS-C; tandem gait). A subset of the sample repeated the Child-SCAT3 at another date. Some subjects also completed the Adult-SCAT3 version of the symptom checklist and mBESS. RESULTS: Small-to-medium-sized effects of age were observed on all Child-SCAT3 components. Effects of gender and receptive vocabulary were observed on select components of the SCAT3. Younger age and lower receptive vocabulary were independently associated with greater symptom endorsement, yet parents rated higher symptom burden for older children. Internal consistency reliability and stability of symptom ratings was good to excellent. Stability was more modest for SAC-C and tandem gait scores and very poor for mBESS-C scores, perhaps due to restricted variance. Inter-rater reliability (self-rated vs parent-rated symptoms) was fair. CONCLUSIONS: The Child-SCAT3 self-report symptom checklist may be inappropriate to administer to younger school-aged children. Some of the age effects observed warrant use of demographically appropriate norms in Child-SCAT3 interpretation. The findings can provide guidance for clinicians assessing children of varying ages and point to directions for further development of refined approaches for pediatric concussion assessment.

The impact of early neglect on defensive and appetitive physiology during the pubertal transition: a study of startle and postauricular reflexes.

This study tested the effect of early neglect on defensive and appetitive physiology during puberty. Emotion-modulated reflexes, eye-blink startle (defensive) and postauricular (appetitive), were measured in 12-to-13-year-old internationally adopted youth (from foster care or from institutional settings) and compared to non-adopted US born controls. Startle Reflex: adopted youth displayed lower overall startle amplitude across all valences and startle potentiation to negative images was negatively related to severity of pre-adoption neglect. Postauricular reflex (PAR): adopted youth showed larger PAR magnitude across all valences. Puberty: adopted youth showed diminished PAR potentiation to positive images and startle potentiation during mid/late puberty versus the opposite pattern in not-adopted. Early neglect was associated with blunted fast defensive reflexes and heightened fast appetitive reflexes. After puberty, early neglected youth showed physiological hyporeactivity to threatening and appetitive stimuli versus heightened reactivity in not adopted youth. Behavioral correlates in this sample and possible neurodevelopmental mechanisms of psychophysiological differences are discussed.

Risk-taking and sensation-seeking propensity in postinstitutionalized early adolescents.

BACKGROUND: Youth with histories of institutional/orphanage care are at increased risk for externalizing and internalizing problems during childhood and adolescence. Although these problems have been well described, the related adolescent behaviors of risk-taking and sensation-seeking have not yet been explored in this population. This study examined risk-taking and sensation-seeking propensity, and associations with conduct problems and depressive symptoms, in early adolescents who were adopted as young children from institutional care. METHODS: Risk-taking and sensation-seeking propensities of 12- and 13-year-old postinstitutionalized (PI; n = 54) adolescents were compared with two groups: youth who were internationally adopted early from foster care (PFC; n = 44) and nonadopted youth (NA; n = 58). Participants were recruited to equally represent pre/early- and mid/late-pubertal stages within each group. Participants completed the youth version of the Balloon Analogue Risk Task (Lejuez et al., ) and the Sensation-Seeking Scale for Children (Russo et al., ). Parents completed clinical ratings of participants' conduct problems and depressive symptoms. RESULTS: PI adolescents demonstrated lower risk-taking than PFC and NA peers. Pre/early-pubertal PI youth showed lower sensation-seeking, while mid/late-pubertal PI youth did not differ from other groups. PI adolescents had higher levels of conduct problems but did not differ from the other youth in depressive symptoms. In PI youth only, conduct problems were negatively correlated with risk-taking and positively correlated with sensation-seeking, while depressive symptoms were negatively correlated with both risk-taking and sensation-seeking. CONCLUSIONS: Early institutional care is associated with less risk-taking and sensation-seeking during adolescence. The deprived environment of an institution likely contributes to PI youth having a preference for safe choices, which may only be partially reversed with puberty. Whether this reflects hyporesponsiveness to rewards and how it relates to psychopathology are discussed.

The effect of early deprivation on executive attention in middle childhood.

BACKGROUND: Children reared in deprived environments, such as institutions for the care of orphaned or abandoned children, are at increased risk for attention and behavior regulation difficulties. This study examined the neurobehavioral correlates of executive attention in post institutionalized (PI) children. METHODS: The performance and event-related potentials (ERPs) of 10- and 11-year-old internationally adopted PI children on two executive attention tasks, go/no-go and Flanker, were compared with two groups: children internationally adopted early from foster care (PF) and nonadopted children (NA). RESULTS: Behavioral measures suggested problems with sustained attention, with PIs performing more poorly on go trials and not on no-go trials of the go/no-go and made more errors on both congruent and incongruent trials on the Flanker. ERPs suggested differences in inhibitory control and error monitoring, as PIs had smaller N2 amplitude on go/no-go and smaller error-related negativity on Flanker. CONCLUSIONS: This pattern of results raises questions regarding the nature of attention difficulties for PI children. The behavioral errors are not specific to executive attention and instead likely reflect difficulties in overall sustained attention. The ERP results are consistent with neural activity related to deficits in inhibitory control (N2) and error monitoring (error-related negativity). Questions emerge regarding the similarity of attention regulatory difficulties in PIs to those experienced by non-PI children with ADHD.

Behavioral and emotional symptoms of post-institutionalized children in middle childhood.

BACKGROUND: Experience in institutional/orphanage care has been linked to increased mental health problems. Research suggests that children adopted from institutions experience specific difficulties related to inattention/overactivity. Evidence of internalizing and conduct problems relative to non-adopted peers has been found in early childhood and early adolescence, but problems may not differ from other adopted children. This study clarifies the understanding of behavioral and emotional symptoms of post-institutionalized (PI) children during middle childhood. METHODS: Eight- to eleven-year-old PI children (n=68) and two comparison groups, children internationally adopted from foster care (n=74) and non-adopted children (n=76), and their parents completed the MacArthur Health and Behavior Questionnaire related to attention-deficit/hyperactivity disorder (ADHD), externalizing, and internalizing symptoms. Group means for symptom level and number of children with symptoms above clinical cutoffs were compared. RESULTS: PI children displayed an increased level of ADHD symptoms per parent report. PI child and parent report indicated a higher number of PI children above clinical ADHD cutoff. Both groups of internationally adopted (IA) children had higher levels of externalizing symptoms relative to non-adopted children, with parent report indicating higher numbers of IA children above the externalizing clinical threshold. Informants differed in their report of internalizing symptoms. Parents indicated that both IA groups displayed increased internalizing symptom levels and greater numbers above clinical threshold; however, children reported this to be true only for the PI group. CONCLUSIONS: PI children differ from non-adopted peers across symptom domains in middle childhood. Whether these concerns were more broadly associated with international adoption rather than institutional care depended on symptom domain and informant. An understanding of this variability may be beneficial for treatment and intervention.

Neurodevelopmental effects of early deprivation in postinstitutionalized children.

The neurodevelopmental sequelae of early deprivation were examined by testing (N = 132) 8- and 9-year-old children who had endured prolonged versus brief institutionalized rearing or rearing in the natal family. Behavioral tasks included measures that permit inferences about underlying neural circuitry. Children raised in institutionalized settings showed neuropsychological deficits on tests of visual memory and attention, as well as visually mediated learning and inhibitory control. Yet, these children performed at developmentally appropriate levels on similar tests where auditory processing was also involved and on tests assessing executive processes such as rule acquisition and planning. These findings suggest that specific aspects of brain-behavioral circuitry may be particularly vulnerable to postnatal experience.

Early experience and the development of stress reactivity and regulation in children.

Children who spend early portions of their lives in institutions or those maltreated in their families of origin are at risk for developing emotional and behavioral problems reflecting disorders of emotion and attention regulation. Animal models may help explicate the mechanisms producing these effects. Despite the value of the animal models, many questions remain in using the animal data to guide studies of human development. In 1999, the National Institute of Mental Health in the United States funded a research network to address unresolved issues and enhance translation of basic animal early experience research to application in child research. Professor Seymour Levine was both the inspiration for and an active member of this research network until his death in October of 2007. This review pays tribute to his legacy by outlining the conceptual model which is now guiding our research studies.

Postinstitutionalized children's development: growth, cognitive, and language outcomes.

OBJECTIVE: Children adopted internationally from institutions are a growing population presenting to professional care providers. Although postinstitutionalized (PI) children are adopted from multiple world regions, current knowledge is predominantly based on those adopted from Romania and Eastern European countries. This study examines and compares developmental outcomes of PI children adopted from multiple world regions. METHOD: Five to 11 years after adoption, 8- through 11-year-old PI children (N = 91), children internationally adopted early from foster care (N = 109), and nonadopted children (N = 69) completed screening measures assessing vision, hearing, growth, and cognitive and language abilities. Parents completed questionnaires on service utilization, school performance, preadoptive history, and postadoption environment. RESULTS: Forty-four percent of PI children's growth was stunted (height <10th percentile) at adoption. At assessment, although physically smaller, nearly all PI children had average growth parameters. Relative to nonadopted children and children adopted early from foster care, PI children performed more poorly on cognitive and language screens with increased time in institution related to lower performance. Notably, group means on these measures were within the average range. PI children were more likely to be falling behind academically and to use intervention services. Family environment did not differ between PI and nonadopted children. There were few differences for PI children by world region of adoption once accounting for duration of institutionalization. CONCLUSIONS: Despite currently living in similar environments, PI children have specific needs that differ from early-adopted and nonadopted children. Consideration of multiple factors, including length of institutionalization, is essential when providing care for these children.