Neuropsychiatry of childhood and adolescence

Dr Francesco Somajni – Le Betulle Medical Center

Head

Dr. Francesco Somajni

profile »

Dr Elisabetta Guida – Le Betulle Medical Center

Assistant Head

Dr. Elisabetta Guida

profile »

Assistant:

Dott. Massimo Del Vecchio

Clinical Pychologist

Our Service deals with prevention, diagnosis and care of neurological, psychiatric and psychological disorders in the field of paediatrics.

In particular, the Service is specialized in:

Neuropsychiatric child evaluation is complicated by the fact that some neurological diseases may also manifest psychiatric symptoms, and that psychological discomfort sometimes presents with different symptoms, often somatic, such as headaches, eating disorders (refusal of food, selective diet, nausea, vomit), gastrointestinal ailments (stomach ache); asthma, allergies, sleep disorders (returning to parents’ bed); failure to achieve developmental stages in motor skills (crawling position, walking); speech disorders, sphincter control problems (difficulty in weaning off nappies, enuresis.)

Often a child (up to preadolescence) uses the body to communicate psychological discomfort, therefore physical disorders must be considered with attention, because they may be an indicator of psycho-affective suffering. Physical disorders are expressed unconsciously, the child is not really aware of them, and they are meant to bring parents closer, making them more sensitive and attentive (in the eyes of the child).

Later, during adolescence, discomfort finds other ways of expression:

  • “depressive” mode, with social esclusion, poor communication within the family, opposition to the family, tendency to isolate through music or computer, inability to pursue their studies and find possible alternative interests (such as professional ones);
  • “toxic” mode, with recourse to alcohol, cannabis and other drugs;
  • antisocial mode, with aggressive behaviours at home, against objects or loved ones; thieving at home and elsewhere, lies, drug abuse, selling drugs, behaviours dangerous to themselves and others;
  • “mixed” modes, with coexistence of several pathological modes.

Depending on age and clinical picture, evaluation can be conducted through neurological, neuropsychological, psychological/psychiatric examinations, individual explanatory in-depth interviews, tests and questionnaires to assess personality and achievement.

In adolescence the evaluation necessarily requires team work, with therapists supervising the child and other therapists assisting parents.

Furthermore, when necessary, we contact schools in order to guarantee integrated support to the therapeutic plan.

The definition of a therapy is, as usual, linked to the diagnosis. During childhood, neurological diseases require specific measures, such as antiepileptic drugs in case of epilepsy, or physiotherapy in case of paresis. Psychological discomfort can be dealt with through psychomotility, counselling sessions and parental support, very seldom with drugs.

For adolescents, therapy usually requires an integrated approach, with a therapist (psychologist, or neuropsychiatrist) for the adolescent and one to help the parents and, in case, keep in touch with the school. In some instances, prescription of medicines may be necessary for outpatients or even hospitalization, if the clinical picture is of severe psychiatric imbalance (psychosis), if there is a risk of suicide (depression), or a risk of intoxication by psychotropic drugs.

LEARNING DISORDERS

“Le Betulle” Medical Center follows the directives of Law 170/2010 which requires, in order to obtain certification, the presence of a neuropsychiatrist, a psychologist and a speech therapist in the diagnostic team and the use of diagnostic instruments suggested and approved by the national scientific community (Consensus Conference of 2010).

Specific Learning Disorders (or Disabilities) are a heterogeneous group of disorders of neurophysiological origin, which influence cognitive processes involved in the learning of reading, writing and calculation. These disorders are intrinsic to the individual, presumably linked to central nervous system dysfunctions, and have evolutionary features which are expressed varyingly in a child’s developmental stages.

The abilities involved cause the following pathological manifestations:

  • reading, dyslexia
  • writing, dysorthography and dysgraphia,
  • calculation, dyscalculia.

Learning Disorders are diagnosed when results obtained by the individual in standardized tests, individually administered, for reading, calculation, or written expression report significantly lower scores than those expected based on age, education and IQ level. Learning issues significantly interfere with school results, or with daily activities which require reading, writing, or calculation skills. Learning Disorders may persist during adulthood.

THERAPIES

Patient evaluation is conducted by a team of professionals specialized in the Age of Development (Child Neuropsychiatrist, Psychologists trained in Psychology of Learning, Pedagogist, Speech therapist, Paediatrician), for a diagnostic and therapeutic plan developed into two phases:

Primary prevention phase

Objectives:

1. Assisting teachers within the child’s school also during the first two years of Primary School to carry out screening tests in the presence of early signals of possible Learning Disability development, such as:

  • speech difficulties persisting beyond the age of 4;
  • inadequate phonological mastery;
  • difficulty with delicate manual tasks;
  • clumsiness in dressing, tying shoelaces, tidying up;
  • short term memory disorder (forgetting assignments);
  • attention difficulties;

2. Encouraging the development of speech, dialectic, written and calculation skills in children with atypical profiles, by means of targeted didactic and pedagogical activities, conducted by teachers in collaboration with specialists.

Secondary phase

Objectives: early diagnostic evalutation

  • WISC-R Wechsler Intelligence Scale for Children (standardized intellect test);
  • Achievement tests

For younger children (4-5 years) there is the possibility to evaluate the prerequisites for appropriate learning with PSCR-2 (reading and writing) and BIN (maths) tests;

For Primary School children reading, writing, mathematical and visual-spatial skill tests are set up.

Treatment
  • reading, writing and calculation rehabilitative treatment is carried out, also using dedicated computer software;
  • an integrated plan between specialists and teachers aimed to applied use of compensative and exemptive strategies in order to obtain a study program “made to measure” for the child;
  • parent training;
  • structuring appropriated workshops within the school;
  • retesting after treatment to evaluate the evolution of the therapeutic and rehabilitative path;

ATTENTION DEFICIT HYPERACTIVITY DISORDER

To formulate a diagnosis, certain clinical criteria must be satisfied, i.e. inattention, hyperactivity, acting impulsively. A marked impairment following symptoms is usually present in two or more environments (i.e. school, work, home). There has to be an evident, clinically significant impairment on social, school or work function.

Inattention

Six (or more) of these inattention symptoms have persisted for at least 6 months with an intensity which causes maladjustment and contrasts with the developmental stage:

Inattention symptoms

  • 1. often the individual is incapable of paying attention to details or makes mistakes from lack of concentration in schoolwork, at work or in other activities;
  • 2. often the individual finds it difficult to keep his attention focused on homework or play;
  • 3. often the individual seems not to listen while someone is speaking to them;
  • 4. often the individual doesn’t follow instructions and doesn’t finish schoolwork or work duties (not caused by resistance or inability to understand instructions);
  • 5. often the individual has difficulties in organizing tasks and activities;
  • 6. often the individual avoids, feels aversion or is reluctant to undertake tasks which require a prolonged mental effort (such as work at school or homework);
  • 7. often the individual loses objects required for tasks and activities (i.e. toys, homework, pencils, books or instruments);
  • 8. often the individual is easily distracted by external stimuli;
  • 9. often the individual is careless or clumsy in daily activities.

Hyperactivity – Impulsiveness

Six (or more) of the following symptoms of hyperactivity-impulsiveness have been persisting for at least 6 months, with an intensity that causes maladjustment and contrasts with the developmental stage:

Hyperactivity symptoms

  • 1. often individuals fidget restlessly with hands or feet, or squirm in their seat;
  • 2. often they leave their seat in class or in other situations where they are expected to stay seated;
  • 3. often the individual moves and dashes around excessively when inappropriate (in adolescents and adults this may limit to subjective emotions of restlessness);
  • 4. often the individual shows difficulty in playing or quietly devote themselves to fun activities;
  • 5. often the individual is “under pressure” or is constantly in motion;
  • 6. often the individual talks too much;

Impulsiveness symptoms

  • 1. often the individual blurts out answers to questions which haven’t yet been completed;
  • 2. often the individual is incapable of waiting for their turn;
  • 3. often the individual interrupts others or is invasive towards them (i.e. breaking into conversations or games).

CAUSES

Causes of ADHD remain unknown. Some hypotheses are of genetic, biological and environmental nature, more likely of multi-factorial origin.

Some factors linked to the pathology include premature birth; use of drugs, alcohol and tobacco by the mother; exposure to high levels of lead during early childhood, and brain lesions (in particular those involving the pre-frontal cortex).

Environmental factors don’t seem to have a relevant pathogenic role in the occurrence of attention disorder.

However, the existential experience of a child with an attention deficit disorder, characterized by relational, social and scholastic failures, could cause secondary behavioural disorders.

THERAPIES

Individuals affected by ADHD can be treated with different kinds of therapy:

  • psycho-behavioural
  • psycho-pharmacological
  • combined
Psycho-behavioural therapy

Behavioural therapy includes a course of Parent Training sessions (group or individual, based on parents’ characteristics) and periodic counselling for teachers (Teacher Training). Parent Training is based on semi-structured sessions including detailed information on ADHD, and other educational activities relative to the understanding of the problem and the application of behavioural strategies. Counselling also involves sessions aimed to observe and understand each child’s peculiarities, so as to be able to adjust their teachers’ demands and reduce dysfunctional behaviours.

Pharmacological Therapy

Pharmacological therapy is based on drugs registered and approved in Italy for ADHD treatment. These drugs may cause undesired side effects and their use must always be assessed and monitored by specialists. In particular, before considering treatment with medication, it is necessary to carry out an accurate physical examination, a scrupulous evaluation of all possible psychopathological aspects (including suicide risk) and a cardiovascular risk evaluation. Therefore, during monitoring of medication therapy, we must carry out an evaluation of cardiac and hepatic function, always bearing in mind the risk of aggressive or suicidal behaviours.

Combined Therapy

The best results in the treatment of ADHD are obtained with a combined therapy. Pharmacological therapy and environmental support (both in the family and at school) must go hand in hand, modulated by therapists and shared with the whole team of specialists.