Trastorno del espectro autista en menores con superdotación intelectual: descripción de un diagnóstico complejo / Autism Spectrum Disorder among intellectually gifted minors: Description of a complex diagnosis

Introducción: Se pretende analizar las características clínicas de menores con superdotación intelectual y autismo, planteando que la identificación temprana de superdotación no se acompaña de un diagnóstico temprano de TEA.Material y métodosAnálisis descriptivo de una muestra de pacientes (n=8) de 7 a 16 años, con Altas Capacidades identificadas, derivados a una consulta específica de autismo infantil para evaluación diagnóstica.Resultados6 de los pacientes recibieron diagnóstico clínico de TEA. Solo 3 de los pacientes superaron el punto de corte de espectro autista en la evaluación ADOS-2. La edad media de detección de Altas Capacidades fue de 5,88 años, y la de TEA fue de 9,83 años, transcurriendo un tiempo medio de 4,83 años. Todos habían sido evaluados en Servicios de Salud Mental, y 7 habían recibido, al menos, un diagnóstico psiquiátrico previo, así como tratamiento psicofarmacológico.DiscusiónPosiblemente, la superposición de características clínicas de las Altas Capacidades con los síntomas TEA retrase el diagnóstico del segundo cuando se han detectado las primeras, tanto por un fenómeno de enmascaramiento, como por un sesgo de atribución, debido a que la categoría de Altas Capacidades sea mejor aceptada. El deterioro clínicamente significativo de estos pacientes parece agravarse en la adolescencia. La conceptualización incompleta de la neurodivergencia podría estar dificultando a los profesionales clínicos la identificación y clasificación de menores con neurodesarrollos atípicos.ConclusionesLa identificación de una superdotación podría retrasar el diagnóstico de TEA. Se debe ampliar la investigación sobre neurodesarrollo y neurodiversidad, la inteligencia y su relación con el TEA. Es imprescindible la formación específica en neurodesarrollo de psiquiatras infanto-juveniles. (AU)

Introduction: We intend to analyze the clinical characteristics of intellectually gifted minors with autism spectrum disorder (ASD), stating that early identification of giftedness is not linked to an early ASD diagnosis.Material and methodDescriptive analysis in a sample of n=8 patients ages 7 to 16, with identified giftedness refered to a medical consultation specialized in infantile autism for a diagnostic evaluation.Results6 of the latter referred patients received an ASD clinical diagnosis. Only 3 of the patients were above the cut-off point for autism spectrum on the ADOS-2 evaluation. The average age of detection was 5’88 for Giftedness and 9’83 for ASD, with an average time of 4’83 years elapsed in between. All of them had been previously evaluated in Mental Health Services and 7 had received at least one previous psychiatric diagnosis, as well as psycho-pharmacological treatment.DiscussionIt is possible that the superimposition between the clinical characteristics of Giftedness and ASD symptoms may delay the latter’s diagnosis when the previous have been detected, be it due to a masking phenomenon, an attribution bias, or that the Giftedness category is better accepted. This patients significant clinical deterioration seems to worsen during adolescence. The uncompleted conceptualization of neuro-divergence may be hampering the clinicians ability to identify and classify minors with an atypical neurodevelopment.ConclusionsGiftedness identification may delay ASD diagnosis. We must improve investigation about neuro-development and neuro-diversity, as well as intelligence and its connection to ASD. Child and Adolescent psychiatrists’ specific training in neuro-development is therefore essential. (AU)

¿Mantenimiento o retirada? Pericarditis en un paciente en tratamiento con clozapina: a propósito de un caso / To persist or to withdraw? Pericarditis in a patient undergoing treatment with clozapine: report of a clinical case

Introducción: La pericarditis inducida por clozapina es un cuadro raro, pero potencialmente grave para cuya resolución se recomienda la discontinuación del tratamiento con clozapina. Presentación del caso Se trata de un varón de 17 años en tratamiento con clozapina por el fracaso de 3 líneas antipsicóticas previas, con una buena respuesta terapéutica, que 2 meses después del inicio del fármaco desarrolla un cuadro de pericarditis. En la evaluación multidisciplinar, se decide conjuntamente con la familia el tratamiento de la pericarditis, manteniendo clozapina en dosis menores, con la resolución de la misma y conservando la estabilidad psicopatológica. Discusión La miocarditis y pericarditis inducidas por clozapina son efectos adversos graves que aparecen en su mayoría en el primer mes de tratamiento. La actitud generalizada frente a la pericarditis inducida por clozapina es su retirada. Esta retirada puede plantear un dilema ético y debe ser valorada cuidadosamente, ya que el riesgo de descompensación psiquiátrica y pérdida de la calidad de vida debe ser tenido en cuenta. Conclusión Este caso resalta la importancia de realizar un balance riesgo/beneficio en cada caso complejo, reflejando la encrucijada ética del manejo de los efectos adversos de clozapina, puesto que su retirada puede comprometer negativamente la estabilidad psicopatológica y la calidad de vida del paciente. (AU)

Introduction: Clozapine-induced pericarditis is a rare but potentially serious condition for which discontinuation of clozapine treatment is recommended for resolution. Presentation of the case A 17-year-old male under treatment with clozapine due to failure of three previous antipsychotic lines, with good therapeutic response, who two months after starting the drug developed pericarditis. Discussion Clozapine-induced myocarditis and pericarditis are serious adverse effects that appear mostly in the first month of treatment. The generalized attitude towards clozapine-induced pericarditis is its withdrawal. This withdrawal may pose an ethical dilemma and should be carefully assessed, as the risk of psychiatric decompensation and loss of quality of life should be taken into account. Conclusion This case highlights the importance of performing a risk/benefit balance in each complex case, reflecting the ethical conflict of the management of clozapine adverse effects, since its withdrawal may negatively compromise the patient's psychopathological stability and quality of life. (AU)

Differences in mother-to-infant bonding according to type of C-section: Elective versus unplanned.

Aim To compare the mother-to-infant bond of mothers who gave birth by elective C-section versus urgent C-section in the first 48-72h of life and 10-12weeks after delivery. METHODS: This is a cohort prospective study of women giving birth by C-section. 48-72h after delivery, sociodemographic variables were collected, Mother-to-Infant Bonding Scale and newborn's response to separation test were performed. 10-12weeks after delivery Mother-to-Infant Bonding Scale and questions about baby's feeding were completed. RESULTS: A total of 116 dyads were recruited, 58 in each group. No significant differences between the two C-sections in bonding, newborn response to separation or type of feeding were observed at any time points. However, those dyads presenting with an abnormal bond at time 1 had more frequently an abnormal bond at time 2 (50% versus 8.1%, p=0.000). CONCLUSIONS: No differences in mother-to-infant bond were found according to type of C-section.

Prevalence and Risk Factors of Prolonged Corrected QT Interval Among Children and Adolescents Treated With Antipsychotic Medications: A Long-Term Follow-Up in a Real-World Population.

PURPOSE: This study aimed to describe the prevalence of corrected QT (QTc) interval disorders and the possible predisposing factors in children and adolescents treated with antipsychotic (AP) medications in a real-world population with a long-term follow-up. METHODS: Data were obtained from the SafEty of NeurolepTics in Infancy and Adolescence (SENTIA) registry (https://sentia.es). The SENTIA includes patients younger than 18 years who are currently taking or initiating treatment with AP medications and have agreed to participate in the registry. The SENTIA's follow-up includes an electrocardiogram (ECG) assessment before starting treatment and at 1, 3, and 6 months after treatment initiation or after any changes in the patient's AP medication treatment. Thereafter, all participants undergo an ECG every 6 months. A QTc interval more than 450 milliseconds, increases in QTc interval of 60 milliseconds or more, or QTc dispersion more than 100 milliseconds were considered abnormal. RESULTS: Since January 1, 2011, 101 patients have been enrolled in SENTIA and have had at least 1 ECG assessment. The mean age at inclusion was 11.5 years; 75% of the patients were men. The mean follow-up time was 20.0 ± 15.1 months. The most frequently prescribed AP medications were risperidone (52.2%) and aripiprazole (45.5%). Seven patients (6.9%) had abnormal changes in QTc. No patient had a QTc interval more than 500 milliseconds. All patients were asymptomatic. The QTc changes were observed at different times of exposure, with a range of 1 to 39 months after beginning AP treatment. Concomitant use of attention deficit and hyperactivity disorder drugs seemed a possible factor associated with QTc disorders. CONCLUSIONS: Patients should undergo a baseline ECG assessment before starting AP medication treatment, particularly patients with concomitant use of attention deficit and hyperactivity disorder drugs or a family/personal history of heart disease.

SENTIA: a systematic online monitoring registry for children and adolescents treated with antipsychotics.

INTRODUCTION: Despite drastic increases in antipsychotic prescribing in youth, data are still limited regarding their safety in this vulnerable population, necessitating additional tools for capturing long-term, real world data. METHODS: We present SENTIA (SafEty of NeurolepTics in Infancy and Adolescence; https://SENTIA.es), an online registry created in 2010 to track antipsychotic adverse effects in Spanish youth <18 years old currently taking or initiating with any antipsychotic treatment. SENTIA collects information on sociodemographic, diagnostic and treatment characteristics, past personal medical/psychiatric history, healthy lifestyle habits and treatment adherence. Additionally, efficacy and adverse effect data are recorded including the Children's Global Assessment Scale; Clinical Global Impressions scale for Severity and Improvement, the Safety Monitoring Uniform Report Form, Simpson-Angus Scale, Abnormal Involuntary Movement Scale, vital signs, blood pressure, and EKG. Finally, fasting blood is drawn for hematology, electrolytes, renal, liver and thyroid function, glucose, insulin, lipid, prolactin and sex hormone levels. Initially, a diagnostic interview and several psychopathology scales were also included. Patients are assessed regularly and followed even beyond stopping antipsychotics. RESULTS: Since 01/17/2011, 85 youth (11.5 ± 2.9 (range = 4-17) years old, 70.6% male) have been included at one inaugural center. After a mean duration of 17 ± 11 (range = 1-34) months, 78.8% are still actively followed. For feasibility reasons, the diagnostic interview and detailed psychopathology scales were dropped. The remaining data can be entered in <30 minutes. Several additional centers are currently being added to SENTIA. CONCLUSIONS: Implementation of a systematic online pharmacovigilance system for antipsychotic adverse effects in youth is feasible and promises to generate important information.

Trichotillomania, bipolar disorder and white matter hyperintensities in a six-year old girl.

A six-year-old girl was referred to our child psychiatry outpatient clinic by the Pediatric Neurology Unit with a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) and trichotillomania. She had neither eyebrows nor eyelashes. The clinical picture was of irritability, frequent tantrums, and aggressive behaviour. During the following year she presented several brief episodes of intense mood changes, which typically started with night-time onset trichotillomania and sleep disturbance. The episodes lasted no longer than five days and recurred within one or two months. A diagnosis of pediatric bipolar disorder (BD) was made after the first months of clinical follow-up. An MRI showed focal white matter hyperintensities (WMH) in T2.

Breastfeeding following emergency peripartum hysterectomy.

Emergency peripartum hysterectomy (EPH) is usually performed in cases of intractable obstetric hemorrhage unresponsive to conservative treatment. EPH is associated with a high incidence of maternal morbidity and mortality. Most of these women do not have the opportunity to even start breastfeeding. We report a case where breastfeeding was attempted after EPH. The mother spent 6 days in the intensive care unit and suffered several medical and surgical complications. On day 7 she was reunited with her baby. One month later, a diagnosis of post-traumatic stress disorder was made. Breastfeeding became very important, with the patient frequently expressing that this was the most healing aspect in her recovery from the traumatic EPH. At 3 months, five daily feeds were supplemented with formula. Breastfeeding, principally nocturnal, continued 6 months after childbirth, with the baby being weaned at 7 months. Women who undergo EPH need psychological support. The option of breastfeeding should be considered even days or weeks after the surgical intervention as it can be a healing experience for some women who are grieving the loss of their fertility. Professional specialized breastfeeding support should be offered in these cases, and the possibility of reuniting mother and infant even when the mother is in the intensive care unit should be considered.