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LETTERS TO EDITOR
Year : 2015  |  Volume : 24  |  Issue : 2  |  Page : 211-212  Table of Contents     

Biological correlates of attention deficit hyperactivity disorder and specific learning disability, following stroke in a young child


1 Department of Psychiatry, Institute of Human Behavior and Allied Sciences, New Delhi, India
2 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Department of Psychiatry, ESI Post Graduate Institute of Medical Sciences and Research, Basai Darapur, India
4 Department of Neurology, B. L. Kapoor's, New Delhi, India

Date of Web Publication4-May-2016

Correspondence Address:
Praveen Tripathi
Department of Psychiatry, Institute of Human Behavior and Allied Sciences, New Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-6748.181716

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How to cite this article:
Tripathi P, Kar SK, Goyal P, Kumar D, Panda AK. Biological correlates of attention deficit hyperactivity disorder and specific learning disability, following stroke in a young child. Ind Psychiatry J 2015;24:211-2

How to cite this URL:
Tripathi P, Kar SK, Goyal P, Kumar D, Panda AK. Biological correlates of attention deficit hyperactivity disorder and specific learning disability, following stroke in a young child. Ind Psychiatry J [serial online] 2015 [cited 2020 Jan 25];24:211-2. Available from: http://www.industrialpsychiatry.org/text.asp?2015/24/2/211/181716

Sir,

Stroke or cerebrovascular vascular accident in children is a rare entity, the incidence being 1.2–13/100,000 children under 18 years of age.[1] As per studies, up to 66% of children with a stroke encounter difficulties due to persistent neurological deficits or developed poststroke seizure, learning difficulties.[2],[3],[4] Studies have found that as many as 46% of children who had a stroke develop attention deficit hyperactivity disorder (ADHD).[5],[6] There is a paucity of literature attempting to correlate specific lesions in the brain with ADHD symptoms. The recent studies point that ADHD results from multifaceted morphological alterations in a complex network of brain regions rather than dysfunction of discrete brain regions.

Initial investigations which attempted to find structural correlates of ADHD pointed toward frontostriatal circuitry; however, it has since become clear that other regions of the brain may exhibit morphological alterations including areas of the cerebellum and temporoparietal lobes,[7] basal ganglia, and corpus callosum.[8] There are also certain correlations of structural anomaly of amygdala and thalamus with ADHD.[9],[10] Specific learning disability (SLD) has a strong neurobiological basis. Patients with reading disorders have inactivation of left inferior frontal cortex, left temporoparietal cortex, and left temporo-occipital cortex with hyperactivation of corresponding cortical regions of right hemisphere which seems to be a compensatory effect.[11] Dominant hemisphere (left cerebral hemisphere) being the primary locus of phonological and lexical processing which was affected in our patient and might have attributed to patient's current psychiatric manifestations. Patients with writing disorder and dyscalculia have involvement of parietal lobe, cingulate cortex, temporal and frontal lobe.[11]

This case illustrates a 17-year-old male who presented with complaints of poor academic performance with difficulties in reading, writing, arithmetic skills, and making frequent spelling mistakes for nearly 12 years. He also had a history of hyperactivity, inattention, and impulsive behavior, approximately from the age of 6 years. History revealed that multiple episodes of transient ischemic attacks within 1 month which were characterized by sudden onset giddiness, blurred vision, ataxic gait, and focal neurological deficits at the age of 5 years. The initial three episodes resolved spontaneously within 3–6 h without any sequel, so no medical help was sought for the first them. The child then developed a stroke for which medical opinion sought and was characterized by left ataxic hemiparesis and left upper motor neuron facial palsy. Magnetic resonance imaging of brain had revealed the involvement of both anterior and posterior circulation with acute infarct in bilateral deep temporal, parietal, and thalami with chronic infarcts in bilateral cerebellar hemispheres. Magnetic resonance angiography and venography were unremarkable. The cardiac status and coagulation profiles were normal. He was treated conservatively for stroke and had improved without any focal neurological deficits. Family history was not significant. The child had a normal birth and developmental history with all milestones being achieved at appropriate ages. After detailed clinical evaluation (on Conners rating scale for ADHD) and psychometric assessment (NIMHANS battery for SLD), child was diagnosed with specific learning disabilities (mixed disorders of scholastic skills) with ADHD and was treated with methylphenidate 20 mg/day with significant improvement in the symptoms of ADHD. However, the symptoms of SLD had persisted for which cognitive remediation was suggested.

Various psychiatric disorders are seen in children after stroke. The children with focal stroke lesions provide a potentially useful model for the investigation of psychiatric disorders after brain injury. The involvement of specific brain regions might also provide insight into pathogenesis of psychiatric disorders. Our patient had ADHD which is the most common psychiatric comorbidity with SLD may be due to overlapping neurobiological phenomenon.

SLD is very difficult to be diagnosed before the age of 6 years; however, ADHD can be easily diagnosed before the age of 6 years. In our patient, as the symptoms of ADHD and SLD were noticed simultaneously after the cerebrovascular accident, it can be said that they might be the sequelae of stroke. Patients with stroke may have a several type of language disturbances such as – aphasia, alexia, acalculia, or agraphia. They can exist together or in different combinations.[12] Children with left hemisphere stroke have a large discrepancy in the verbal IQ and performance IQ; however, in our case, there was no major difference in the performance and verbal IQ.[13] The reading difficulties following stroke, mostly have ocular cause,[14] however, in our patient, it was of nonocular cause.

Neurobiology of developmental disorders is a potential area of research. More biological research is needed to establish the accurate association of lobar pathology with psychopathology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Tsze DS, Valente JH. Pediatric stroke: A review. Emerg Med Int 2011;2011:734506.  Back to cited text no. 1
    
2.
Lanthier S, Carmant L, David M, Larbrisseau A, de Veber G. Stroke in children: The coexistence of multiple risk factors predicts poor outcome. Neurology 2000;54:371-8.  Back to cited text no. 2
    
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deVeber GA, MacGregor D, Curtis R, Mayank S. Neurologic outcome in survivors of childhood arterial ischemic stroke and sinovenous thrombosis. J Child Neurol 2000;15:316-24.  Back to cited text no. 3
    
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DeVeber G. In pursuit of evidence-based treatments for paediatric stroke: The UK and Chest guidelines. Lancet Neurol 2005;4:432-6.  Back to cited text no. 4
    
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Max JE, Mathews K, Manes FF, Robertson BA, Fox PT, Lancaster JL, et al. Attention deficit hyperactivity disorder and neurocognitive correlates after childhood stroke. J Int Neuropsychol Soc 2003;9:815-29.  Back to cited text no. 5
    
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Max JE, Mathews K, Lansing AE, Robertson BA, Fox PT, Lancaster JL, et al. Psychiatric disorders after childhood stroke. J Am Acad Child Adolesc Psychiatry 2002;41:555-62.  Back to cited text no. 6
    
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Cherkasova MV, Hechtman L. Neuroimaging in attention-deficit hyperactivity disorder: Beyond the frontostriatal circuitry. Can J Psychiatry 2009;54:651-64.  Back to cited text no. 7
    
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Giedd JN, Rapoport JL. Structural MRI of pediatric brain development: What have we learned and where are we going? Neuron 2010;67:728-34.  Back to cited text no. 8
    
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Plessen KJ, Bansal R, Zhu H, Whiteman R, Amat J, Quackenbush GA, et al. Hippocampus and amygdala morphology in attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 2006;63:795-807.  Back to cited text no. 9
    
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Ivanov I, Bansal R, Hao X, Zhu H, Kellendonk C, Miller L, et al. Morphological abnormalities of the thalamus in youths with attention deficit hyperactivity disorder. Am J Psychiatry 2010;167:397-408.  Back to cited text no. 10
    
11.
Sadock BJ, Sadock VA, Ruiz P. Learning disorders – Reading disorder. In: Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 9th ed., Vol. 2, Ch. 38. Lippincott Williams and Wilkins; 2009. p. 3475-500.  Back to cited text no. 11
    
12.
Sinanovic O, Mrkonjic Z, Zukic S, Vidovic M, Imamovic K. Post-stroke language disorders. Acta Clin Croat 2011;50:79-94.  Back to cited text no. 12
    
13.
Funnell E, Pitchford NJ. Reading disorders and weak Verbal IQ following left hemisphere stroke in children: No evidence of compensation. Cortex 2010;46:1248-58.  Back to cited text no. 13
    
14.
Rowe F, Wright D, Brand D, Jackson C, Price A, Walker L, et al. Reading difficulty after stroke: Ocular and non ocular causes. Int J Stroke 2011;6:404-11.  Back to cited text no. 14
    




 

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