Behavioural problems and autism in children with hydrocephalus

Abstract

Aims: The main objective of this thesis was to explore the cognitive and behavioural consequences of hydrocephalus in children born at term and preterm, with or without myelomeningocele (MMC) and with or without concomitant neurological impairments, such as cerebral palsy (CP), epilepsy or learning disabilities. Material and methods:From a population-based cohort of all 107 children with hydrocephalus born in [1989][1990][1991][1992][1993] 73 of the surviving children were assessed with intelligence tests and most of them also using behavioural and autism rating scales. Thirty-six of 47 (77%) children with an IQ of ≥ 70 and eight children with MMC but no hydrocephalus were assessed with a neuropsychological test battery (NIMES) and compared with age-and gender-matched controls. Results:One-third of the children were normally gifted (IQ > 85), another 30% had a low-average IQ of 70-84 and 37% had learning disabilities (IQ < 70). An IQ of < 70 was found in 42% of children without MMC and in 29% of those with MMC. Children born preterm had a lower IQ than those born at term. Children with CP and/or epilepsy had significantly lower IQ scores than those without these impairments. Parents rated 67% and teachers 39% of the children as having behavioural problems. Learning disabilities increased the risk significantly. Almost all the children with CP and/or epilepsy had behavioural problems. Learning disabilities, CP and epilepsy significantly increased the risk of autistic symptoms, which were present in 13 %, in 4 % of those with MMC and in 20 % of those without MMC. Children with hydrocephalus both with and without MMC and with an IQ of > 70 performed significantly less well than controls on learning, memory and executive functions but not on registration skills. There were no differences between children with hydrocephalus in combination with MMC and those without MMC, whereas children with MMC but no hydrocephalus and normal intelligence performed as well as controls on all the neuropsychological functions. Conclusions:The majority of children with hydrocephalus had learning disabilities or a low-average IQ, as well as behavioural problems, and some had autistic symptoms. Despite average or slightly below average intelligence, children with hydrocephalus had major difficulties with learning and memory and with executive functions, regardless of the aetiology of the hydrocephalus. Only MMC did not appear to influence cognitive and neuropsychological outcome as much as the brain lesion causing or caused by the hydrocephalus.

Autism spectrum symptoms in children with neurological disorders

“…The elevated ASSQ total score in children with neurological disorders is in accordance with the high rate of ASD symptoms found in studies of children with hydrocephalus [7,9] and epilepsy [11]. Although our sample represented a heterogeneous group including a range of neurological disorders, the combined parent and teacher ASSQ of 14.1% scoring above the 98 th percentile is in agreement with studies indicating that certain diagnoses included in our sample, for instance cerebral palsy [15], entail a heightened risk of ASD.…”

“…Note that children may have more than one diagnosis, and that children with disorders co-existing with neurological disorders were classified as belonging to the neurological disorder group. It is also important to be aware that the presence of intellectual disability in children with neurological disorders is associated with increased risk of ASD [5,7,9,14,15,45]. We therefore controlled for the presence of intellectual disability (as reported by parents) in the present analyses.…”

“…One recent study showed that at 24 months of age, prematurely born children diagnosed with cerebral palsy were more likely than preterm babies without this diagnosis to screen positively for ASD on the Modified Checklist for Autism in Toddlers (M-CHAT) [4], when assessed at 24 months of age [5]. In studies of hydrocephalus, ASD as measured by the Autistic Behavior Checklist (ABC) [6] were present in 23% of children aged 6–17 [7], and autism as rated by the Childhood Autism Rating Scale (CARS) [8] was reported in 13% of children aged 5–12 [9]. In a study using the parent version of the Autism Screening Questionnaire (ASQ) in assessing symptoms of ASD [10], 32% of children aged 2–18 with epilepsy included from a tertiary care epilepsy clinic were found to fulfill the ASQ criteria for having an ASD [11].…”

Pervasive developmental disorders in individuals with cerebral palsy

“…Epilepsy, learning disability, language delay and tetraplegic, hemiplegic, and mixed types of CP were found to be associated factors for the coexistence of autistic disorder in our study. Several investigators have described a connection between autism and the severity of brain dysfunction 6,9 . In our study, autism was found to be more common in children with signs of a more extensive brain lesion, resulting in epilepsy, learning disability, or tetraplegic or mixed types of CP.…”

“…The second group includes studies of whether CP is associated with autism in various medical disorders. CP was found to be linked to autism in children with hydrocephalus, 9 retinopathy of prematurity, 10 and visual impairment 11 . Nordin and Gillberg 12 examined 177 children with heterogeneous clinical diagnoses causing learning or motor disability, or both, and found that four (10.5%) of the 38 children with CP had autistic spectrum disorders (ASD).…”