As parents, it is important to ensure the health and safety of our children. With advances in health science, today more than ever, we have the tools and professionals that help us even with less common health conditions, including diseases and pathologies associated with the nervous system, which many times , develops from an early age.
Therefore, it is crucial to know what neurology is, how some neurological conditions can affect children, the role of health professionals such as neuropsychiatrists when treating these conditions and some of the most common pathologies associated with the nervous system and can affect the development of our children. In the following article we will explore this subjects.
Neurology is a branch of medicine concerning especially with the structure, function and diseases of the nervous system. Our nervous system is divided in Central Nervous System (CNS) and Periferic Nervous System (PNS). The first one includes the brain, cerebellum, medulla oblongata and spinal cord. The periferic nervous system includes all the extensions from central organs to muscles and periferic senses.
Neurology involves a wide range of CNS-PNS related diseases from cognitive conditions (related to memory processes and other brain functions such as writing, reading or calculations) to neuromuscle or movement diseases.
Child Neurology is also a widely diverse and extensive science. Child Neurology includes genetic conditions (such as Rett Syndrome or metabolic myopathies) nerodegenerative issues (such as multiple sclerosis) structural and biological illnesses (such as complex epilepsies) infectious diseases (such as meningoencephalitis) or neurodevelopmental conditions (such as Guilles Tourette Syndrome)
Neuropsychiatry is a branch of Neurology linked to Psychiatry. Currently, this subspecialty does not exist as such in Spain. However, neuropsychiatrists are widely recognised across most European countries including the UK and Germany. In these countries, all the professionals dedicated to Neuropsychiatry undertake specific training programmes for acquiring necessary skills for the manegement of patients with neuropsychiatric disorders. As a result, there is a shortage of Neuropsychiatrists in Spain, which is even more concerning in terms of neuropsychiatrists in children and adolescents. This results in an unacceptably high number of children and adolescents with undiagnosed/untreated neuropsychiatric conditions who also have very complex unmet needs in Spain. In other words, these patients seem to be neglected by the Spanish medical health system.
The interface between Neurology and Psychiatry is a random consensus by modern science, a simple response to professionals´ needs of categorizing conditions. Over the last few centuries, clinicians have made big efforts to better understand human body functioning. In order to do so, medicine has been artificially split up in different specialties. However, such an approach may have ignored close relationship between mind and body, which particularly applies to neuropsychiatric conditions.
So far, the division between Neurology and Psychiatry can be summarized as follows:
i.-Conditions in which organic alterations can be objectively shown by diagnostic tests (for example MRI, EEG or blood tests) belong to Neurology (such as epilepsy)
ii.-Conditions with no evidence of structural damage would fall under the scope of Psychiatry (such as bipolar disorder)
As noted above, bipolar disorder is one of the most common “mental” disorders. However, it is intriguing that first line treatment for bipolar disorder, that is so called mood stabilizers, includes several antiepileptic drugs such as valproate, carbamacepine and lamotrigine. Hence, it could be speculated that both conditions may share some neurobiological underpinnings. This said the link between neuropathology and psychiatry appears to be stronger tan previously thought. Also, well-known genetic vulnerability to bipolar disorder, including some candidate genes, suggests that currently available tests may fail to identify its neuroanatomical correlates.
In summary, our daily clinical practice in psychiatry is full of examples in which the interface between Neurology and Psychiatry is far from clear. Thus, the vast majority of patients with neurologicval and psychiqtric conditions present with very complex symptoms, which reflect the complexity of human brain rather than an arbitrary diagnostic category.
Over the last decade science paradigms have significantly changed. For instance, although genetic has been considered a major risk factor for developing mental disorders, this concept has evolved to so called epigenetic. In short, while genes were suggested to underlie stable markers of diferent diseases, that is, something that can not be modify through intervention, modern reasearch has shown that genes expression can vary depending on the influence of external factors, that is environment. The gen-environment interaction has been labelled as epigenetic. This model has had a real impact on today’s Neuropscyhiatry resulting in a more comprehensive approach to mental and neurological issues.
Child neuropsychiatric conditions are highly prevalent. These conditions involve a wide range of illnesses which share neurobiological factors and mental symptoms. Therefore, an integrative approach to treatment of child neuropsychiatric conditions is required. This approach should be provided by multidisciplinary teams integrated by Child Neurologists, Child Psychiatrists, Child Neuropsychiatrists, Child Psychologists and Family Therapists.
In addition, children present with special features which make the management of neuropsychiatric conditions even more challenging:
1.-CHILD NEURODEVELOPMENT: the majority of neuropsychiatric conditions are characterised by symptoms which partially overlap with features of normal development such as stereotyped movements, regressions or sleeping disturbances. A profound knowledge of child milestones is therefore required for making an accurate diferential diagnosis. In particular, distinguising normal signs of different madurative stages from pathological symptoms should characterised all the members of this multidisciplinary process.
2.- PLASTICITY OF CENTRAL NERVOUS SYSTEM DURING THE DEVELOPMENT: During the childhood CNS is a complex neuronal network with high levels of plasticity and astonishing malleability. That is, children´s brain continuosly changes during the first two decades of life. This means that the same structural damage in an adult brain can cause huge symptoms in comparison with minimal symptoms during the development. However, this results in an increasing complexity in the diagnosis process, management and treatment of child neuropsychiatric conditions.
3.- COLLATERAL INFORMATION FROM PARENTS:
When gathering information from parents, two steps need to be taken:
i.-Selecting those behaviours which may be associated with pathological symptoms as opposed to normal developmental features.
ii.-Among potential pathological symptoms, clinicians should be able to make the differential diagnosis and translate these symptoms to potential neuropsychiatric conditions.
For instance obssesive-compulsive behaviours vs repetitive play which is normal during the development or abnormal sensory experiences such as hallucinations vs imaginative play such as imaginary Friends.
In keeping with this, professionals such as GPs, teachers, counsellors or paeditricians play also an important role in early detection as the main referrals when picking up potential mental health related issues.
In order to provide a better understanding of the challenges above, we are going to summarise two major child neuropsychiatric conditions: epileptic syndromes during neurodevelopment and neurodevelopmental disorders.
In the two parts of this article we are going to develop some of the entities that can be treated by child neuropsychiatry. More specifically, we are going to talk about 4 diseases with a high prevalence in the population, we will start with 2 of the most common conditions:
1.- Epileptic syndromes during the neurodevelopment: these syndromes involve a number of neurological processes in which convulsive or non-convulsive seizures can emerge during the neurodevelopment. The vast majority of these conditions have been reported to have an impact on CNS maturation which suggests that patients with early epileptic syndromes can presetn with a combination of neurological issues namely seizures, epileptic status or postcrisis symptoms, and behavioural problems such as cognitive disorders, emotional dysregulation or communicative issues.
Temporal lobe epilepsy is the cornestone of epileptic neuropsychiatric síndromes which is commonly caused by a structural damage in the temporal lobe. Given the involvement of the temporal lobe in major cerebral functions such as audition, smells and emotions, temporal lobe epilepsy is not only characterised by seizures but also by psychiatric symptoms such as auditory and/or olfatory hallucinations, deja vù or deja vie phenomena or behavioral changes.
2.- Neurodevelopmental disorders:
While the specific origin of neurodevelopmental disorders remains unclear a number of factors such as genetic predisposition, environmental factors and structural brain damage, have been postulated. The most common age of onset is from 2 to 6-7 years, that is in early development. As a result, this children usually present with cognitive, metacognitive, emotional and communicative issues.
In the second part of this article we will provide more detailed information on three representative examples of neurodevelopmental disorders such as Guilles Tourette Syndrome, ADHD (attention deficit and hiperactivity disorder) and ASD (autism spectrum disorders) ,all of which are clinically characterised by a wide spectrum of symptoms despite their common neurodevelopment related origin.