Multidisciplinary Diagnostic Assessment Research Articles

Syndrome d’Asperger avec Haut Potentiel Intellectuel : le camouflage à l’origine des diagnostics tardifs ?

BackgroundThe mission of our “Centre de référence des troubles du spectre autistique” is to evaluate children and adolescents for whom there is a suspicion of autistic spectrum disorder through a multidisciplinary diagnostic assessment. We encounter cases of patients presenting both Asperger syndrome and High Intellectual Potential. Those patients are frequently older than the norm. The objectives of our study are to understand the reasons leading to a late diagnosis for these patients and to question the value of giving such a diagnosis to children aged from eight to 18 years old. MethodsWe carried out a retrospective study based on the analysis of clinical files from patients presenting both AS and HIP, aged between eight and 18 years old. These patients were all previously seen in our center for a multidisciplinary diagnostic assessment. We analyzed several items from their clinical reports, such as the moment of and the motivation for the assessment; the person(s) asking for the assessment; the possible previous diagnosis; the evident and subtle characteristics of Asperger syndrome present in the speech, neuropsychological, and psychological (ADOS and projective tests) evaluations; psychomotricity; IQ score; the patients’ integration into their peer groups; and the possible associated psychiatric issues. ResultsWe examined the files of 17 subjects presenting both Asperger syndrome and High Intellectual Potential profiles, aged between eight and 18 years old. The results show that autistic traits are more easily observed during the ADOS test and the informal assessments rather than during the other standardized analysis. We also noticed the importance of the clinical intuition and experience of the examiner. DiscussionWe propose to extend the notion of “camouflage” strategies, previously used to describe women with Asperger syndrome, to children and adolescents presenting both an Asperger syndrome and a High Intellectual Potential profile. Their particularly high IQ could allow these patients to compensate for or to hide some of their impairments. ConclusionThe results seem to confirm our hypothesis, which is that thanks to their high intellectual functioning, patients presenting both AS and HIP profiles manage to compensate for or to camouflage some of their difficulties related to social adaptation and communication. Therefore, their impairment appears more subtle, leading to a late diagnosis. The quality of these camouflage strategies could depend on a high IQ score. For the future, it would be interesting to compare these results to a population of patients with AS and a normal IQ, in order to more clearly perceive the impact of IQ on camouflage strategies.

Mental disability management within occupational health surveillance.

«Mental disability management within occupational health surveillance».Introduction:The management of workers with mental disability is a current topic of great interest. The aim of the article is to report the experience of managing cases of employees with mental disabilities in an Italian university hospital and to describe the preventive measures adopted and the therapeutic programs carried out.Methods:A group of 100 workers suffering from psychiatric disorders has been included in a medical surveillance program lasting at least 6 months. The workers were followed up within a protocol that included psychiatric visits, psychotherapeutic interventions, visits by the occupational physician and medico-legal evaluations. Evaluation scales of disease severity and treatment efficacy (CGI) and overall functioning (GAF) were administered at the baseline and after 6 months of follow-up.Results:The sample was mainly composed of nurses (44%) and nursing assistants (24%) and the most commonly diagnosed disorders were mood and anxiety disorders. Participation in the medical surveillance program with the implementation of specific therapeutic strategies and organizational interventions resulted in a statistically significant reduction in the severity of the disease and an improvement in overall functioning and made it possible to keep the job and place of work in almost all cases.Discussion:The results of this experience allow us to affirm that the integration of skills is a valid tool both for the multidisciplinary diagnostic assessment and for the monitoring and management of workers with mental disability under periodic health surveillance.

Cost of assessing a child for possible autism spectrum disorder? An observational study of current practice in child development centres in the UK

ObjectiveUK guidelines recommend that diagnosis of autism in children requires assessment by a multidisciplinary team. With growing numbers of referrals for assessment, diagnostic services have been under increasing pressure to...

Health-Related Quality of Life in Older Persons with Medically Unexplained Symptoms

Research on health-related quality of life (HRQoL) in older persons with medically unexplained symptoms (MUS) is scarce, and, in contrast with younger patients, interactions with chronic somatic diseases are more complex. In the current study we compared HRQoL between older persons with MUS and older persons with medically explained symptoms (MES). Our study sample consisted of 118 older MUS-patients and 154 older MES-patients. The diagnosis of MUS was ascertained by the general practitioner and confirmed by a geriatrician within a multidisciplinary diagnostic assessment. Additional characteristics, including the HRQoL (Short Form-36), were assessed during a home visit. MES-patients received two home visits to assess all measures. Multiple linear regression analyses, adjusted for age, sex, education, cognitive functioning, and psychiatric diagnoses, were performed to assess the relationship between group (MUS/MES) and HRQoL. Analyses were repeated with additional adjustments for somatization and hypochondriacal cognitions. Older patients with MUS had a significantly lower level of HRQoL compared with older patients with MES. Even after adjustments, the presence of MUS was still associated with both a lower physical and mental HRQoL. These associations disappeared, however, after additional adjustments for somatization and hypochondriacal cognitions. Within the subgroup of MUS-patients, higher levels of hypochondriac anxiety and of somatization were significantly associated with both lower physical and mental HRQoL. Associations between HRQoL and late-life MUS disappear when corrected for somatization and hypochondriacal cognitions, which is in line with the DSM-5 classification of somatic symptom disorder. Appropriate psychological treatment seems needed to improve HRQoL in older MUS-patients.

Diagnosis, referral, and primary treatment decisions in newly diagnosed prostate cancer patients in a multidisciplinary diagnostic assessment program.

We aimed to report on data from the multidisciplinary diagnostic assessment program (DAP) at the Gale and Graham Wright Prostate Centre (GGWPC) at North York General Hospital (NYGH). We assessed referral, diagnosis, and treatment decisions for newly diagnosed prostate cancer (PCa) patients as seen over time, risk stratification, and clinic type to establish a deeper understanding of current decision-making trends. From June 2007 to April 2012, 1277 patients who were diagnosed with PCa at the GGWPC were included in this study. Data was collected and reviewed retrospectively using electronic patient records. 1031 of 1260 patients (81.8%) were seen in a multidisciplinary clinic (MDC). Over time, a decrease in low-risk (LR) diagnoses and an increase intermediate-risk (IR) diagnoses was observed (p<0.0001). With respect to overall treatment decisions 474 (37.1%) of patients received primary radiotherapy, 340 (26.6%) received surgical therapy, and 426 (33.4%) had conservative management; 57% of patients who were candidates for active surveillance were managed this way. No significant treatment trends were observed over time (p=0.8440). Significantly, different management decisions were made in those who attended the MDC compared to those who only saw a urologist (p<0.0001). In our DAP, the vast majority of patients presented with screen-detected disease, but there was a gradual shift from low- to intermediate-risk disease over time. Timely multidisciplinary consultation was achievable in over 80% of patients and was associated with different management decisions. We recommend that all patients at risk for prostate cancer be worked up in a multi-disciplinary DAP.

Deficits in response inhibition correlate with oculomotor control in children with fetal alcohol spectrum disorder and prenatal alcohol exposure

Children with fetal alcohol spectrum disorder (FASD) or prenatal alcohol exposure (PAE) frequently exhibit impairment on tasks measuring inhibition. The objective of this study was to determine if a performance-based relationship exists between psychometric tests and eye movement tasks in children with FASD. Participants for this dataset were aged 5–17 years and included those diagnosed with an FASD (n=72), those with PAE but no clinical FASD diagnosis (n=21), and typically developing controls (n=139). Participants completed a neurobehavioral test battery, which included the NEPSY-II subtests of auditory attention, response set, and inhibition. Each participant completed a series of saccadic eye movement tasks, which included the antisaccade and memory-guided tasks. Both the FASD and the PAE groups performed worse than controls on the subtest measures of attention and inhibition. Compared with controls, the FASD group made more errors on the antisaccade and memory-guided tasks. Among the combined FASD/PAE group, inhibition and switching errors were negatively correlated with direction errors on the antisaccade task but not on the memory-guided task. There were no significant correlations in the control group. These data suggests that response inhibition deficits in children with FASD/PAE are associated with difficulty controlling saccadic eye movements which may point to overlapping brain regions damaged by prenatal alcohol exposure. The results of this study demonstrate that eye movement control tasks directly relate to outcome measures obtained with psychometric tests that are used during FASD diagnosis, and may therefore help with early identification of children who would benefit from a multidisciplinary diagnostic assessment.

Klinischer Verdacht auf Kindesmisshandlung

Violence against children has many faces. Child physical abuse, neglect, sexual abuse and interparental violence can cause acute and permanent damage and affect children's development and their life plans in the long term. In industrialized nations almost 1 child in 10 is affected. Up to 10% of child physical abuse cases involve the central nervous system with 80% of these cases occurring during the first year of life. Worldwide more than 50,000 children die as a result of violence, abuse and neglect every year, according to the United Nations Children's Fund UNICEF. In Germany, there are about 120 cases of non-accidental head injury per year. In addition to the officially known cases there is a large grey area for all forms of violence. Recognition of these cases and the provision of help for the victims require an appropriate suspicion and understanding of the pertinent pathophysiology. Suspicion must be based on a well-documented medical history and multidisciplinary diagnostic assessment. Medical confidentiality prevents the disclosure of such information making early detection networks and guidelines for collaboration absolutely indispensable.

Chapitre C-2 E - Chirurgie prothétique de l’incontinence urinaire d’effort par insuffisance sphinctérienne neurologique

Neurogenic sphincter incompetence, in the absence of detrusor dysfunction, results in stress urinary incontinence. Management is exclusively surgical. The available artificial sphincters ensure continence, provided intermittent self-catheterization is performed when necessary for neurogenic bladder. Artificial urinary sphincter is the reference treatment, historically and based on published cohort studies. However, it is associated with a higher morbidity in this population than in the non-neurological population. Although the surgical implantation technique is not modified in females as a result of the neurological disorder it is modified in males, as periprostatic implantation may be necessary, requiring specific training in this technique and rigorous patient selection. Other more recent prosthetic treatments are being developed, but are still at the stage of evaluation: periurethral fascia sling, periurethral injections and periurethral balloon implantation. These techniques eliminate the need to manipulate a pump to open the sphincter for self-catheterization. They appear to be promising, but their long-term results are unknown. In conclusion, operative indications for SUI due to neurogenic sphincter incompetence must be based on a multidisciplinary diagnostic assessment and explicit patient information.

Neuropsychological performance in early and late onset Alzheimer's disease: comparisons in a memory clinic population

To compare the neuropsychological performance associated with early and late onset Alzheimer's disease (AD), in order to identify differences and compare these with previous reports. Patients attending a memory clinic were given a detailed multi-disciplinary diagnostic assessment, including a battery of neuropsychological tests. From those meeting ICD-10 criteria for Alzheimer's disease (AD), an early-onset (EO) group (n = 40) and a late-onset (LO) group (n = 90) were identified, and their performances compared. Patients with mixed dementia and co-morbid depression were excluded. After adjustment, the EO and LO groups performed at a comparable level on the majority of the neuropsychological tests. The LO group performed better on the WAIS digit span test, AMIPB Complex Design and the written picture description, and the EO group performed better on the WAIS similarities test and the Boston naming test. These findings suggest that, after adjusting for overall dementia severity and pre-morbid IQ, there is greater fronto-parietal/right hemisphere involvement in early-onset AD, and greater temporal/left hemisphere involvement in late-onset AD. This may be due to different genetic risk profiles for AD at different ages.

The interpretation of children's artwork in a paediatric disability setting

This article describes art therapy assessment in a paediatric disability setting. In this setting where the art therapist contributes to a multidisciplinary diagnostic assessment, neurology, the cognitive sciences and medical discourses shape diagnostic terms and an individual childs capacities and behaviours are judged against agreed norms. The psychodynamic discourses that often provide a foundation for practices in art therapy can seem redundant in this situation, where H is easy for the art therapist to lose interest in the art product. In an endeavour to acknowledge and explore the visual interest that the referred childrens art exhibits, the art therapist has begun a research project. This research project attempts to construct, what might loosely be called, a case study method, which aims to explain individual childrens use of art materials. This method explores processes and context without using the usual psychodynamic approach or using the approach developed by cognitive psychology. It is motivated by a feeling that the psychodynamic and the cognitive discourses are both inadequate to explain the artwork and the motivations of the child in this particular assessment situation. A brief consideration of discourses, the psychodynamic, the cognitive and the neurological, in their relation to the making of artwork, and in the production of subjects, is provided. A case presentation is given to show how the method has developed and how this has lead to a larger question, or group of questions. How do we conceptualise the relationship between the subject (client/patient/child) and the artwork that she or he produces and how does such theory influence our interpretations and our practices?

Neuropsychological performance in Alzheimer's disease and vascular dementia: comparisons in a memory clinic population.

To compare the performances of two matched groups of patients with Alzheimer's disease (AD) and vascular dementia (VaD) on a battery of neuropsychological tests. 325 patients attending a memory clinic were given a detailed multi-disciplinary diagnostic assessment, including a battery of neuropsychological tests administered by a psychologist and a speech and language therapist. The performances of two groups of patients meeting ICD-10 criteria for AD (n = 103) and VaD (n = 68) were compared, adjusting for age, gender, dementia severity and pre-morbid IQ. Patients with co-morbid depression and mixed AD+VaD were excluded. After adjustment, the AD and VaD groups differed significantly on the Graded Naming Test (VaD superior), AMIPB Complex Design immediate and delayed recall (VaD superior), the Trail Making Test error score (Part B) (VaD superior), and Verbal Picture Description (VaD superior). These findings support previous evidence that language function and non-verbal memory are selectively more impaired in AD. The better performance by VaD patients on the Trail Making Test (B) runs counter to previous suggestions that there is an excess of frontal executive dysfunction in this disorder. It may be that this test is more sensitive to the early impairment of concurrent manipulation of information in AD.

Practitioner review: Diagnosis of autism spectrum disorder in 2- and 3-year-old children.

Progress has recently been made in the earlier identification of children with autism spectrum disorder (ASD). Whilst being welcome, this progress to earlier referral and diagnosis presents new challenges to clinical practice, including the accuracy and stability of early diagnosis, the utility of standardised assessment instruments with young pre-schoolers and the ability to indicate prognosis. A selective review of recent research literature on the characteristic features of ASD in preschool children. Multidisciplinary diagnostic assessment should include detailed information on developmental history, parents' descriptions of the everyday behaviour and activities of the child, direct assessment of the child's social interaction style, including where possible with age peers, and formal assessment of communicative, intellectual and adaptive function. Clinical assessments need to concentrate on the identification of impairments in early non-verbal social communication behaviours that characterise children with ASD from the second year of life, including social orienting, joint attention, imitation, play and reciprocal affective behaviour. The particular pattern of symptoms that presents in a 2-year-old with ASD may differ from that seen at the more prototypic age of 4 or 5 years. In particular, overt repetitive and stereotyped behaviours may be less notable, although where these are seen alongside the social and communicative impairments they are highly indicative of ASD. The use of standardised assessment instruments and the strict application of the DSM and ICD diagnostic criteria need to be employed with caution, as an expert clinical view has been shown to be more accurate. An important aspect of early diagnostic consultation is an open and straightforward approach to the negotiation of the diagnostic view with parents over time. Earlier diagnosis and rising recognition of ASD have significant implications for primary healthcare and specialist diagnostic and therapeutic services.