Praise for pediatric neuropsychiatry

Abstract

Italy is one of the few countries in the world where pediatric neuropsychiatry is still a united discipline not following the separation that has been underway for several years between adulthood neurology and psychiatry. However, in practice, many pediatric neuropsychiatrists here operate as if this separation was present, dealing with either neurologic or psychiatric pathologies of the developmental age. Indeed, due to the increasing hyperspecialization of skills, there are some pediatric neuropsychiatrists, in the field of neurology, who deal almost only with epilepsy or neuromuscular diseases, while there are others, in the field of psychiatry, who deal almost only with autism spectrum disorder (ASD). At least partially, this trend towards the hyperspecialization of skills is inevitable due to the recent great progress of neurosciences, but at the same time, this situation entails serious risks for adequate patient care. Each individual, particularly during development, should be considered as a single entity both in physiologic and pathologic situations. A clear distinction between normal neurologic and psychic development is very difficult and probably pointless, especially in the earliest stages of life. This distinction becomes almost impossible when, for some reason, the development of the individual shows domain-specific or global deficits. In this regard, there would be innumerable examples of pathologic conditions whose clinical picture at onset may appear misleading and requires a global neuropsychiatric approach; here we will mention only a few. The first example: a child aged around 2 years showing language delay, potentially the prelude to a specific language disorder, who unfortunately in the following months begins to present a series of signs such as epileptic seizures, ataxia, as well as cognitive, motor, and visual deterioration, leading then, based on the results of instrumental tests, to a diagnosis of neuronal ceroid lipofuscinosis type 2 disease. It is known that the first sign of this disease can be language delay (1). The second example: a boy aged 15 months presenting a mild motor developmental delay, but who after a few months starts to show the classic signs of ASD. A consistent series of data shows that, in ASD, motor type signs, including a delay in the gross motor and fine motor acquisitions, may occur even before the impairment of social communication skills (2, 3). The third example: a girl aged 18 months showing an apparently non-specific global developmental delay, whose clinical picture subsequently becomes more complicated following the loss of acquired skills and the appearance of symptoms including handwashing stereotypies, breathing abnormalities during wakefulness (hyperventilation alternating with apnea), and others, leading to a diagnosis of atypical Rett syndrome, whose onset is often difficult to identify (4, 5). These examples highlight that an overall picture of the developing individual, through a global approach combining both the neurologic and psychiatric perspective, facilitates an adequate diagnostic framework and therefore a correct management. The fact that pediatric neuropsychiatry remains a united discipline is not a legacy of the past, but reflects a modern way of dealing with the neuropsychiatric disorders of the developing individual.