Handwriting in children with Attention Deficient Hyperactive Disorder: role of graphology.

BACKGROUND: Handwriting difficulties are common in children with attention deficient hyperactive disorder (ADHD). The aim of our study was to find distinctive characteristics of handwriting in children with ADHD by using graphology to analyze physical characteristics and patterns, and to evaluate whether graphological analysis is an effective ADHD diagnostic tool for clinicians. METHOD: The cohort included 49 children aged 13-18 years attending a tertiary neurology and epilepsy center in 2016-2017; 22 had a previous DSM-IV/V diagnosis of ADHD. The children were asked to write a 10-12-line story in Hebrew on a blank sheet of paper with a blue pen over a 20-min period. The samples were analyzed by a licensed graphologist blinded to the clinical details of the children against a predetermined handwriting profile of individuals with ADHD. Each ADHD characteristic identified in each sample was accorded 1 point, up to a total of 15 points. Patients with a graphology score of 9-15 were considered to have ADHD. RESULTS: There were 21 boys (43%) and 28 girls (57%) in the cohort; 15 boys (71.4%) and 7 girls (25%) had a DSM-IV/V diagnosis of ADHD. The mean graphology score was significantly higher in the children who had a DSM-IV/V diagnosis of ADHD than in the children who did not (9.61 + 3.49 vs. 5.79 + 4.01, p = 0.002, respectfully). Using a score of 9 as the cutoff, in the girls, graphology had a specificity of 80% (95% CI 59.2-92.8) and a of sensitivity 71.4% for predicting ADHD. Corresponding values in the boys were 75.0 and 76.2%. CONCLUSION: The handwriting of children with ADHD has specific characteristics. Graphology may serve as a clinically useful tool in the diagnosis of ADHD.

[EPIDEMIOLOGY OF RITALIN PRESCRIPTION IN 6-18 YEARS OLD ISRAELI CHILDREN - TIME TO CHANGE POLICY].

INTRODUCTION: Attention deficit hyperactivity disorder (ADHD) is a worldwide problem and treatment is controversial among physicians and parents. OBJECTIVES: To clarify the prescribing of methylphenidate to children in the center of Israel, the use and possible effect that gender, socioeconomic status (SES), ethnic and cultural characteristics play in the treatment of ADHD. METHODS: We assessed the prescription rate of methylphenidate in the years 2005, 2007 and 2011 in children and adolescents age 6-18 years provided from Sharon Shomron and Dan Petach Tikva Clalit Health Services pharmacies. RESULTS: Methylphenidate (MPH) prescriptions showed an increase in prevalence from 4.2% to 7.5% in the years 2007 to 2011, respectively. Jewish children were four times more likely to be prescribed MPH than Arab children, with significant discrepancies along SES and gender lines (p < .001). Higher socioeconomic status (SES) and male gender were associated with greater use of MPH. General pediatric prescription rates of MPH in all communities increased by 85%, compared with year 2007 statistics (p < .001). CONCLUSIONS: It is time to change policy. Efforts should be directed at over-treated and under-treated populations. DISCUSSION: Prescription patterns for MPH in children reflect diagnostic patterns of ADHD that appear to be heavily influenced by additive factors of SES, cultural attitudes and gender.

[ANTI-N-METHYL-D-ASPARTATE (NMDA) ENCEPHALITIS: THE ISRAELI PEDIATRIC MULTI-CENTER EXPERIENCE].

INTRODUCTION: Anti-N-methyl-D-aspartate (NMDA) encephalitis is a disorder characterized by acute neuro-psychiatric symptoms, appearing mostly after a recent febrile disease, with a gradual progressive course, associated with laboratory or radiologic evidence of active inflammation. Many of the patients will present with a continuous neuro-cognitive disorder which could lead to major morbidity and even mortality. It was recently reported that this disorder can present at childhood as a primary disease or as a secondary complication of herpes simplex infection. Early diagnosis and treatment have significantly improved the patients' prognosis and prevented chronic complications. We will present six pediatric patients at ages 1-14 years, followed from 2011-2014 in Schneider Children's Medical Center and Assaf Harofeh Medical Center due to acute encephalitis, with a clinical course under suspicion for anti-NMDA encephalitis. The article will review the clinical and diagnostic dilemmas and suggested guidelines. Pediatricians should be aware of this new emerging syndrome.

Auditory verbal memory and psychosocial symptoms are related in children with idiopathic epilepsy.

OBJECTIVE: Idiopathic epilepsies are considered to have relatively good prognoses and normal or near normal developmental outcomes. Nevertheless, accumulating studies demonstrate memory and psychosocial deficits in this population, and the prevalence, severity and relationships between these domains are still not well defined. We aimed to assess memory, psychosocial function, and the relationships between these two domains among children with idiopathic epilepsy syndromes using an extended neuropsychological battery and psychosocial questionnaires. METHODS: Cognitive abilities, neuropsychological performance, and socioemotional behavior of 33 early adolescent children, diagnosed with idiopathic epilepsy, ages 9-14years, were assessed and compared with 27 age- and education-matched healthy controls. RESULTS: Compared to controls, patients with stabilized idiopathic epilepsy exhibited higher risks for short-term memory deficits (auditory verbal and visual) (p<0.0001), working memory deficits (p<0.003), auditory verbal long-term memory deficits (p<0.0021), and more frequent psychosocial symptoms (p<0.0001). The severity of auditory verbal memory deficits was related to severity of psychosocial symptoms among the children with epilepsy but not in the healthy controls. SIGNIFICANCE: Results suggest that deficient auditory verbal memory may be compromising psychosocial functioning in children with idiopathic epilepsy, possibly underscoring that cognitive variables, such as auditory verbal memory, should be assessed and treated in this population to prevent secondary symptoms.

Brain imaging findings and social/emotional problems in Israeli children with neurofibromatosis type 1.

UNLABELLED: A potential association between brain MRI findings and social/emotional difficulties in children with neurofibromatosis type 1 (NF1) was examined. Twenty-eight children with NF1 filled in the Strengths and Difficulties Questionnaire (SDQ), and possible associations between their responses and findings in their brain MRI were sought. T2 bright foci were identified in MRI scans of 24 patients (85 %). There were no associations between the presence of the bright foci in any specific brain region and any of the SDQ scores for the emotional/behavioral measures. Male patients had significantly abnormal SDQ scores and peer problems. Patients with abnormal SDQ scores were younger than those with normal SDQ scores (mean 13.2 years vs 14.3 years, respectively; p = 0.23). A comparison of the scores obtained in ours and in another group of 11 children with NF1 yielded a significant difference between the groups. CONCLUSION: We believe that the lack of correlation between the MRI findings and the social/emotional parameters of the SDQ is another demonstration of the marked clinical variability characteristic of NF1.

Long-Term Functional Outcomes in Israeli Adults Diagnosed in Childhood with Attention Deficit Hyperactivity Disorder.

BACKGROUND: Childhood attention deficit hyperactivity disorder (ADHD) is a chronic health problem with significant risk for long-term morbidity in adulthood. OBJECTIVES: We examined long-term outcomes of ADHD in a population-based sample of childhood ADHD cases prospectively assessed as adults. METHODS: Long-term outcomes for 70 adults who were diagnosed with ADHD during childhood were examined and compared with data on the general population. RESULTS: Most subjects admitted to persistence of ADHD-related symptoms in adulthood, despite discontinuation of regular medical treatment and follow-up. Areas most severely affected by past and ongoing symptoms included driving performance and incidence of motor vehicle accidents, and rates of marriage stability over time. Relatively unaffected were occupational and academic achievements and military service. CONCLUSIONS: There is a need for outreach and better services for adults who were previously diagnosed with ADHD. This condition remains a marker of a certain degree of risk regarding marital stability, interpersonal relations and driving habits.

Suspected measles-mumps-rubella vaccine-related encephalitis: two cases.

The cases of 2 infants who developed acute encephalitis in close temporal proximity to receiving measles-mumps-rubella vaccination are described. One developed modified hypsarrhythmia and recovered completely with adrenocorticotrophic hormone protocol, while the other remains severely neurologically handicapped. The timing between vaccination and symptom onset raises suspicion of the vaccine as the possible cause.

[Infantile spasms and modified hypsarrhythmia].

The West syndrome was described by the physician West in his own son in 1841 and is defined as a triad of myoclonic seizures called "infantile spasms", electrographic abnormalities called "hypsarrhythmia" and arrest of psychomotor development and mental retardation. These symptoms are so pathognomonic that the impression is that the syndrome is caused by a single mechanism, but actually there is heterogeneity of etiologies, different recommendations of treatment and prognosis. The West syndrome was established as an infantiLe epileptic syndrome (ILAE Task Force, 1989). Infantile spasm is the most common epileptic syndrome during infancy and entails 50% of all epilepsies between ages one month to one year. Its incidence is 1:3200-3500 live births. Despite its absolute definition, the variability of etiologies, clinical presentation and electrographic make it difficult to set rigid, clear treatment guidelines and research methodology. This review aims to present modified hypsarrhythmia, the etiologies and prognosis of symptomatic infantile spasms, and emphasize the importance of early recognition of modified hypsarrhythmia by surveillance of electroencephalograms.

Rolandic Epilepsy - A Silent Enemy. An Instructive Case.

A child is described who was followed in our clinic due to attention deficit hyperactivity disorder (ADHD) and was found to have the following list of diagnoses: mild developmental delay, motor tics, learning disability, selective mutism and autistic-like features. These disorders became manifest and were diagnosed over a period of several years in the above-noted order. He never had seizures. Medical evaluation, which was initiated due to his learning disability, was negative. The last test which was done was EEG, and this revealed a very active picture compatible with Rolandic epilepsy. Eventually, this was the key for the understanding of his whole clinical picture. It is suggested that in children with learning disability, the possibility of having seizure-free Rolandic epilepsy be considered early in the course of evaluation.

[Developmental manifestation in children with neurofibromatosis type 1].

Neurofibromatosis type 1 (NF1) is an autosomal dominant condition that primarily involves the skin and the nervous system. It affects about 1 in 4000 individuals. NF1 is caused by a mutation in the nfl gene located on chromosome 17q11.2. Neurofibromin, the protein products of the normal nf1 gene, acts as a tumor suppressor and limits cell growth. Mutation in this gene leads to cell overgrowth and an increased risk of developing benign and malignant tumor. The diagnosis of NF1 is made in an individual with any two of the following clinical features: café-au-lait spots, intertriginous freckling, Lisch nodules, neurofibromas, optic glioma, distinctive bone lesions and first degree family relative with NF1. Learning and developmental disorders are the most common neurologic complication of neurofibromatosis type 1 and can be responsible for significant lifetime morbidity. This report provides a review on cognitive and developmental manifestation of children with NF1 and the importance of early diagnosis and treatment.

Prognostic Parameters of Acute Transverse Myelitis in Children.

Acute transverse myelitis is a rare and disabling disorder. Data on the imaging features in children are sparse. The aim of this study was to describe the clinical and magnetic resonance imaging findings characteristic of pediatric idiopathic acute transverse myelitis and to identify those with prognostic value. The database of a tertiary pediatric medical center was retrospectively reviewed for patients aged less than 18 years who were diagnosed in 2002-2017 with acute transverse myelitis that was not associated with recurrence of a demyelinating autoimmune event. Data were collected on clinical, laboratory, and imaging findings and outcome. A total of 23 children (11 male, 12 female) met the study criteria. Mean age at disease onset was 10 years, and mean duration of follow-up was 6 years 10 months. Spinal cord and brain magnetic resonance imaging scans were performed on admission or shortly thereafter. The most common finding was cross-sectional involvement, in 16 patients (70%). The mean number of involved spinal segments was 8. The most frequently involved region was the thoracic spine, in 17 patients (74%). Clinical factors predicting good prognosis were cerebrospinal fluid pleocytosis, absence of tetraparesis, and prolonged time to nadir. In conclusion, most children with acute transverse myelitis appear to have a good outcome. Prompt diagnosis and treatment are important. Further research is needed in a larger sample to evaluate the predictive value of imaging features.

Familial vasovagal syncope associated with migraine.

Syncope affects all age groups and is characterized by a brief sudden loss of consciousness followed by fast recovery. Vasovagal syncope, the most common type, is generally assumed to be due to venous pooling and an abnormal sympathetic response. In approximately 20% of cases, more than one family member is affected. Vasovagal syncope has been documented in a high proportion of patients with migraine. Three generations of a family with comorbid vasovagal syncope and migraine are described. Data were collected from the medical files (index patient and eight siblings) and interviews with the patient's mother. Information was available for 21 family members. Eleven of the 14 family members with a diagnosis of migraine (78%) also had vasovagal syncope, and 11 of the 12 family members with vasovagal syncope (92%) also had migraine. Age at first episode of syncope ranged from 2 to 7 years; age at first migraine headache was less than 10 years in most cases. The high incidence rates combined with the lack of gender predominance may point to a possible common pathophysiology of the two disorders and, perhaps, an autosomal dominant mode of inheritance. Further investigations are needed to corroborate a genetic link.

Vertebral artery dissection and posterior stroke in a child.

Vertebral artery dissection is a relatively rare disease. Its symptoms and signs can be misleading, making the diagnosis, even with imaging assistance, difficult. We describe an 8-year-old boy in whom a brain tumor was suspected because of neurological signs and findings on computerized tomography of the brain. The differential diagnosis was broadened with further imaging evaluation. Magnetic resonance angiography demonstrated vertebral artery dissection, which was attributed to a trivial trauma the child had experienced 1 week before presentation. During the follow-up period, the child recovered, except for residual right hemianopsia.

Lesions of the corpus callosum in children with neurofibromatosis 1.

Our aim was to determine the rate of focal lesions of the corpus callosum in children with neurofibromatosis type 1, and to characterize their natural history. Magnetic resonance imaging scans of the brain in 79 children with neurofibromatosis type 1 who were followed at the Neurology Clinic of Schneider Children's Medical Center (Petah Tiqwa, Israel) from 1990-2005 were reviewed. Focal lesions of the corpus callosum were identified in 11 (14%). These included unidentified bright objects in 7 patients (9%), and a neoplastic process in 4 (5%). Follow-up ranged from 1-16 years. Two of 4 tumors had enlarged during follow-up, and one was excised. Neurofibromatosis type 1 may be associated with a 14% prevalence of corpus callosum lesions. Owing to the apparently high frequency of callosal neoplasms in this population (5% in our series), and their tendency to enlarge, careful evaluation and prolonged follow-up are warranted.

[Epilepsy in Israel--2008].

The relatively high percentages of patients with epilepsy, in whom seizures are uncontrolled in spite of optimal antiepileptic drug use, lead to continuous struggles to improve the treatment of epilepsy. The advances in defining the genetic basis of epilepsy can potentially lead to better understanding of the disorder as well as to more effective treatment. An example is the finding of SCN1A gene mutations in association with a large spectrum of neurological diseases, from generalized epilepsy with febrile seizures plus (GEFS +) to severe myoclonic epilepsy of infancy and to vaccine-induced encephalopathy and Rasmussen encephalitis, Panayiotopoulos syndrome and familial hemiplegic migraine. In parallel, throughout the world, imaging modalities of very high technology are being used to define the epileptogenic focus. A description from The Hospital for Sick Children in Toronto, of a topographic movie of high frequency oscillations on the brain surface, which allows visualization of the dynamic ictal changes, is remarkable. The ketogenic diet is a significant treatment option. The John Freeman Epilepsy Center in Johns Hopkins Hospital leads the way in using the diet in very young infants, including West syndrome. The vagus nerve stimulation is being used as another relatively safe and effective treatment, while epilepsy surgery continues to be applied. Better matching of patients to each modality can be expected with increased success in seizure control.

Attention Deficit Hyperactivity Disorder in Neurofibromatosis Type 1: Evaluation with a Continuous Performance Test.

BACKGROUND AND PURPOSE: The objective of this study was to determine if the MOXO visual- and vocal-distractors-based continuous performance test distinguishes patients with attention deficit hyperactivity disorder (ADHD) and neurofibromatosis type 1 (NF1) from those without NF1. METHODS: Thirty-five patients (16 males; mean age 9.91 years) attending a multidisciplinary NF1 clinic completed the MOXO test. The findings were compared to 532 healthy age-matched standardized control subjects (285 males) without ADHD. RESULTS: The overall performance in the MOXO text was significantly worse in the NF1 group than in controls (p<0.01), but no group-specific pattern was identified. Impulsivity and hyperactivity were significantly more prominent in males than females (p<0.01). Compared to controls, the NF1 group exhibited significantly more failures to respond to target stimuli in the presence of visual distractors. CONCLUSIONS: MOXO scores are abnormal in patients with NF1, but the test cannot differentiate between NF1 with ADHD characteristics and ADHD. The test highlights sex differences in ADHD characteristics in NF1. Overreactivity to visual distractors may form part of the attention deficit in NF1.

Familial benign neonatal sleep myoclonus.

Benign neonatal sleep myoclonus is a nonepileptic syndrome characterized by myoclonic jerks during sleep. It occurs in the first weeks of life and disappears, in most cases, within 3 months. There are no sequelae, and psychomotor and cognitive development are normal. The syndrome is usually sporadic; only a few familial cases have been reported in the literature. This case report describes three members of a single family with benign neonatal sleep myoclonus and discusses its differentiation from other types of myoclonus.

Trauma-induced dystonia and camptocormia in a child.

A 14-year-old male sustained neck trauma during a fight at school. Torticollis developed immediately afterwards, followed by axial dystonia and camptocormia. Thorough evaluation for etiology or background disease, including psychiatric examination, was negative except for the recent trauma. Antidystonia medications, administered after significant worsening of the symptoms, led to improvement. Dystonia and camptocormia resulting from trauma are rare presentations in childhood and adolescence.

Changing Epidemiology of Methylphenidate Prescriptions in the Community: A Multifactorial Model.

OBJECTIVE: To examine dispensing patterns of methylphenidate (MPH) to determine how socioeconomic status (SES), ethnocultural affiliation, and gender affect the medical treatment of ADHD. METHOD: We reviewed MPH prescription records for year 2011 of children aged 6 to 18, from regional pharmacies serving homogeneous neighborhoods. RESULTS: MPH prescriptions showed an increase in prevalence from 4.2% to 7.5% in the years 2007 to 2011, respectively. Jewish children were four times more likely to be prescribed MPH than Arab children, with significant discrepancies along SES and gender lines ( p < .001). Higher SES and male gender were associated with greater use of MPH. General pediatric prescription rates of MPH in all communities increased by 85%, compared with year 2007 statistics ( p < .001). CONCLUSION: Prescription patterns for MPH in children reflect diagnostic patterns of ADHD that appear to be heavily influenced by additive factors of SES, cultural attitudes, and gender. Dispensing data provide valuable information for targeting underserved groups and defining potential areas of abuse.

Thick Corpus Callosum in Children.

BACKGROUND AND PURPOSE: A thick corpus callosum (TCC) can be associated with a very grave outcome in fetuses, but its clinical presentation in older children seems to be markedly different. METHODS: The corpus callosum (CC) was defined as thick based on observations and impressions. We reviewed cases of children who were diagnosed as TCC based on brain magnetic resonance imaging (MRI) studies. The pertinent clinical data of these children were collected, and their CCs were measured. RESULTS: Out of 2,552 brain MRI images, those of 37 children were initially considered as showing a TCC. Those initial imaging were reviewed by an experienced neuroradiologist, who confirmed the diagnosis in 34 children (1.3%): 13 had neurofibromatosis-1 (NF-1), 9 had epilepsy, 3 had macrocephaly capillary malformation (MCM) syndrome, 3 had autistic spectrum disorder, 1 had a Chiari-1 malformation, and 1 had increased head circumference. No specific neurologic disorder could be defined in seven children. The measured thickness of the CC in these children was comparable to those published in the literature for adults. CONCLUSIONS: A TCC is a rare brain malformation that can be found in neuropathologies with apparently diverse pathognomonic mechanisms, such as NF-1 and MCM. It is not necessarily associated with life-threatening conditions, instead being a relatively benign finding, different in nature from that reported in fetuses.