Fourteen In addition, 6 The response selection task is designed to measure suppression of a response to a competing response choice rule. The task consisted of the presentation of a digit, either 1, 2, 3, or 4. The subject's task was to press the corresponding 1, 2, 3, or 4 button on a keyboard whenever a digit appeared. To assess the ability to inhibit response tendencies, two conditions were run.
Variables included accuracy and RT for the control and suppression conditions. In addition, two additional variables were calculated: to determine the degree to which the differences in mean reaction time were driven by the suppression condition, we converted the two reaction times to difference scores; and to test whether greater difference scores for subjects could be explained simply by their larger overall reaction times, we scaled the difference score of each subject to his or her mean reaction time in the suppression condition.
Twenty-eight In addition, 5 In the stimulus selection task subjects were given a forced-choice visual discrimination task designed to measure suppression of response to a previously attended stimulus attribute. Three stimuli were presented in a row on a computer screen. The stimuli varied either in shape circle, triangle, and square or in whether they were filled or open. The subject's task was to determine which of the three stimuli was different from the other two. The stimuli remained until the subject responded by pressing the 1, 2, or 3 button of the keyboard to indicate which of the three stimuli was different.
To assess deficits specific to shifts in attention set rather than to the task, the stimulus attribute on which the subject determined uniqueness was either the same for a block of trials same trials or changed from trial to trial within a block mixed trials. The block pattern of each session was same-mixed-same-mixed, with each block consisting of 48 trials trials total. Outcome variables for this task were the same as those for the response selection task see above. Thirty-two Variables included categories completed, number of trials and errors, perseverative responses, and number of failures to maintain set.
Twenty-nine The Tower of Hanoi TOH is a disk-transfer task that evaluates a child's ability to plan and to organize a sequence of spatially controlled moves in an attempt to duplicate the goal state from the initial problem state.
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An individual's response in this task involves a sequence of spatially controlled motor moves, rather than discrete choices as in the WCST. It necessitates online representation of intermediate subgoals in working memory and is considered a measure of spatial planning ability, working memory, and behavioral suppression Baron, In part of the paradigm, subjects are presented with two problems, each of which can be completed in a minimum of seven moves.
For subjects who successfully completed only one of the two tasks, the values from that task were used to calculate the mean time and moves. Certain continuous variables i.
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The McNemar test was also used for the number of problems solved and problems completed in fewest moves in the TOH. The Bonferroni correction was applied to the significance values after analysis. In the first step, we entered clinical variables not used to match subjects in the comparison between PANDAS and HV groups in a stepwise fashion in order to select the best predictors of performance i. Last, we extrapolated from the results of the regression models which variables consistently predicted performance, and controlled for those variables in the comparison between PANDAS and HV groups.
We split the PANDAS-HV pairs into separate groups based on the median value of continuous predictor variables, and by group for categorical predictor variables. Within-subjects t -tests were conducted between the PANDAS-HV pairs of each subgroup to determine if there was a difference in significance between the subgroups.
After Bonferroni correction, only the former difference was significant. Results of the linear regression are summarized in Table 3. Because nearly a third of subjects in the PANDAS subgroup were taking a psychotropic medication at the time of testing, we conducted a hierarchical linear regression within the PANDAS subgroup for all outcome variables to examine the effects of medication use. The current study was designed to assess specific aspects of neurocognitive functioning of children in the PANDAS subgroup.
PANDAS subjects differed from matched controls on only one of the measures — the response accuracy in a test of attention and suppression. These results are consistent with previous studies of OCD, which have shown few or no deficits in attention e. Our results suggest that there may be an effect of age of symptom onset on attentional functioning, which has been studied directly by at least one study by Roth, Milovan, Baribeau, and O'Connor , who studied children with onsets either above or below age However, the results of this study are not directly applicable to our study group because the age of onset for most PANDAS subjects was below 12 years, and none were older than 15 at onset see Table 1.
Deficits may be a result of dysfunction within the orbitofrontal-striatal-thalamocortical circuitry, as has been demonstrated in functional imaging studies of OCD Saxena et al. Our results are reflective of the neuropsychological literature of TS in the executive functioning and attentional functioning domain. In a review of the literature, Como found the only reliable deficit in executive functioning including both tests of executive functioning and attention was increased time on the CPT.
When the PANDAS group was divided by primary psychiatric diagnosis, those with tics and OCD or TS performed significantly worse than their controls, while those with OCD without tics did not show a significant difference in performance from their matched controls. However, caution should be taken when interpreting these results because of the small sample size of each diagnostic group. Nevertheless, these results may be explained in part by Baron-Cohen et al. Further, results of intracortical transcranial magnetic stimulation in children with TS have shown reduced intracortical inhibition and a shortened cortical silent period, providing a neurological basis for decreased inhibitory control Moll et al.
Both of these results are supported by previous findings using this task by Casey, Durston, and Fossella In their study of typically developing children, age and RT were negatively correlated. In addition, in a group of 26 nonmedicated children with ADHD between the ages of 6 and 16 years, the authors found decreased performance on the response execution task as compared to matched controls.
With regards to the response selection task, the differences between low- and high-IQ subjects may be explained, in part, by the small sample sizes. The literature and results of our current investigation generally argue against a deleterious effect of medication use on neuropsychological performance; however, to our knowledge, there have been no long-term outcome studies evaluating this question.
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Strengths of our study included a well-defined set of subjects in the PANDAS subgroup, which were carefully matched to control subjects. This study is limited by the small sample sizes for some measures, and the secondary analyses are further limited by the division of the cohort into smaller samples.
The limited sample size can be explained by two factors: a some patients may not have been available to complete all tests because of time limitations imposed by the schedule of their primary treatment protocol, and b the battery of administered tests differed across the primary protocols into which the subjects were enrolled; the tests presented here represent those for which we had the largest sample sizes. In addition, data for some patients were no longer available at the time of analysis, so that sample sizes for individual tasks vary.
The power of this analysis and several others, including the regression analysis, to detect small differences is thereby reduced, requiring additional caution in interpreting the results. Lack of functional neuroimaging data also limited the specificity of our results. Otto points out that it is difficult to draw conclusions about specific dysfunction within the frontostriatal circuitry from cognitive test results without imaging data because caudate dysfunction can mimic frontal lobe dysfunction, other compensatory mechanisms in the brain may mask basal ganglia or prefrontal dysfunction, and cognitive dysfunctions may be secondary to the disorder itself.
Future investigations would be strengthened by the addition of neuroimaging data, such as event-related brain potential ERP. The results of this study reveal that subjects in the PANDAS subgroup do not exhibit specific executive functioning or attentional deficits, which may reflect diffuse, nonfocal dysfunction, similar to subjects with typical i. These findings may add weight to the suggestion by Swedo and Grant to treat patients with PANDAS according to standard practices for their primary psychiatric diagnosis. The authors thank Drs. Liv S.
Clasen and Joseph Snow for their assistance in organizing the neuropsychological data, and Dr. Teresa Huggins for her aid in the statistical analysis. In addition, we extend our gratitude to the children and their families who volunteered their time and efforts during these research protocols. This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
National Center for Biotechnology Information , U. Child Neuropsychol. Author manuscript; available in PMC Jun 9. Matthew E.
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Hirschtritt , 1, 2 Christopher J. Thurm , 1 B. Casey , 5 and Susan E. Swedo 1. Christopher J. Audrey E.
Executive and Attention Functioning Among Children in the Pandas Subgroup
Susan E. Author information Copyright and License information Disclaimer. Address correspondence to Dr. E-mail: vog. Copyright notice. The publisher's final edited version of this article is available at Child Neuropsychol. See other articles in PMC that cite the published article. Executive Functioning in OCD and Tic Disorders Executive functioning is thought to include the ability to plan, to organize, to reason, to shift, and to inhibit Baron, Table 1 Demographic Characteristics for the Study Sample.
Open in a separate window. Apparatus and Stimuli All tasks were programmed on either an IBM or Apple computer, and stimulus presentation, timing, and response collection were controlled by the computer. Abbreviations: D. Figure 1.
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Effects of Medication Because nearly a third of subjects in the PANDAS subgroup were taking a psychotropic medication at the time of testing, we conducted a hierarchical linear regression within the PANDAS subgroup for all outcome variables to examine the effects of medication use. Limitations and Future Directions This study is limited by the small sample sizes for some measures, and the secondary analyses are further limited by the division of the cohort into smaller samples.
Footnotes 1 Summary statistics for age and sex are given for pairs, and not for the PANDAS and HV groups separately, because pairs were matched exactly for age and sex. Pediatrics in Review. Diagnostic and statistical manual of mental disorders. Washington DC: Author; Neuropsychological performance in children and adolescents with obsessive-compulsive disorder and influence of clinical variables. Biological Psychiatry.
Neuropsychological evaluation of the child. New York: Oxford University Press; Can children with Gilles de la Tourette syndrome edit their intentions? Psychological Medicine. Neuropsychological study of frontal lobe function in psychotropic-naive children with obsessive-compulsive disorder. American Journal of Psychiatry. Neuropsychological characteristics of nondepressed adults with obsessive-compulsive disorder.
Neuropsychological performance in medicated and unmedicated patients with Tourette's disorder. Evidence for a mechanistic model of cognitive control. Clinical Neuroscience Research. Dysfunctional attention in autistic savants. Journal of Clinical and Experimental Neuropsychology. Everything about my life felt toxic and negative.
I had nothing left in me. I moved out.
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I found an affordable rental only a few minutes from the family home, still on the Gold Coast, and for months tried to adjust to life with children only part of the time. But that black cloud followed me everywhere I went. I struggled to find a balance of quality time with the kids and settle into the community.
I felt trapped with nothing left. So for the next 3 months, hospital was my home. The kids, family and friends came to visit regularly. After 3 years of experimenting with every medication combination under the sun, something started to work. I started smiling. I exercised daily. I lost some weight put on from previous medications. I started making friends. I attended regular therapy sessions and started planning my return to my work — which had been put on hold for 5 years.
This was an incredibly difficult decision moving 40mins away from the children and their lives but the only hope I had of a full recovery. I found a cute 3 bedroom cottage close to the city. I returned to work, reconnected with old friends and made new friends. While lonely during the week without my children while they attended school and kindy, I gradually grew back some confidence in parenting my children on weekends.
I enjoyed work. I socialised and met my forever partner. For the last 12 months, most days I am happy. My relationship with my kids is better than ever and we openly talk about how Mummy had a sore head and had to go to hospital. We talk about our worries and that its ok to make mistakes! There will always be bad days. I have glossed over a lot of the gory stuff retelling my story, but it came down to me facing two options — be a sick and helpless mother, physically living with my kids but emotionally not being there; or move away for proper medical and family support, not see the kids as much BUT work on a full recovery to provide them with a chance of a happy mumma bear.
I initially thought that in order to be the best parent that I could be, that I should choose Option 1. But over time and over a better understanding and worsening of my illness, I changed to Option 2. About Expand. Health Professionals Expand. Get Involved Expand. Awareness Expand. I was forced to face my vulnerabilities, accept help, and re-examine the set of beliefs that I was brought up with… My Story My second baby was born when my son clingy, helicopter parented, sleeping issues was 23 months.