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Fallbuch der klinischen Neuropsychologie.

Alessandro Versace

Praxis der Neurorehabilitation. Neuropsychologische Diagnostik. Weinheim: VCH; Kerkhoff G, Heldmann B. Nervenarzt ;— Repetitive optokinetic stimulation with active tracking induces lasting recovery from visual neglect. Restorative Neurology and Neuroscience, — Visuo-spatial neglect: A systematic review of current interventions and their effectiveness.

Neurosci Biobehav Rev ;— Meerwaldt JD, van Harskamp F. Spatial disorientation in right-hemisphere infarction. J Neurol Neurosurg Psychiatry ;— Recanzone GH. Where was what?

More Books by Georg Kerkhoff & Lena Schmidt

Trends Cogn Sci ;— Rizzo M, Robin DA. Visual search in hemineglect: what stirs idle eyes. Clin Vision ;Sci — Dual streams of auditory afferents target multiple domains in the primate prefrontal cortex. Nat Neurosci ;— Neck muscle vibration induces lasting recovery in spatial neglect. TENS and optokinetic stimulation in neglect therapy after cerebrovascular accident: a randomized controlled study.

Department of Neuroscience and Biomedical Technologies

Eur J Neurol ;— Raum- vs. J Neurol Neurochir Psychiatr ;— Recovery from hemineglect: differential neurobiological effects of optokinetic stimulation and alertness training. Cortex ;— Zihl J, Kennard C. Disorders of higher visual functions. Condylomata acuminata, also referred to as pointed condylomata or genital warts, are the most common types of benign tumour affecting the external anogenital region.

Histologically, they are fibroepitheliomas 1 , 2. Condylomata are virally induced. There may be great variation in the clinical appearance of an anogenital HPV infection. Most often, there are papules the size of a pinhead, up to several centimetres in size, which are generally whitish, grey-brown or reddish in colour Fig. Condylomata tend to disseminate and become multifocal, occasionally large tumorous masses form and rarely there is a single growth 3 , 4. Whereas in older children and adults the vulva, the perianal region, the urethra, the shaft of the penis and, more rarely, the inguinal and pubic region are known to be preferred sites, children in the first and second year of life are predominantly affected in the perianal region.

Girls are affected three times more often than boys 5 , 6 , 7. Condylomata are frequently asymptomatic and are only diagnosed as incidental findings. They can cause itching, burning or weeping in the areas of skin affected. Occasionally, slight bleeding on contact is observed. However, for adult patients the clinical manifestation of an HPV infection is associated with a definite reduction in quality of life 8.

This is seen in the stigmatisation of a disease transmitted by sexual intercourse and its negative effects on intimate contact. When there is evidence of anogenital condylomata in childhood, this uncertainty also applies to doctors who are not familiar with this subject in detail since, in the case of an infection which is predominantly transmitted by direct skin-to-skin contact and which is manifested in the anogenital region, inevitably the suspicion arises that the child involved has been subjected to sexual abuse, and the search for appropriate suspects starts.

The parents have a great need for information and communication with the treating doctor. They also want their child to have effective treatment which is not too stressful and is pain-free as far as possible. They fear that the treatment will not be successful, that there will be relapses and are worried about the uncertainty of the duration of the treatment. These fears often lead to psychosocial stress with a subjective reduction in quality of life 9 , Since , the incidence has increased by a factor of 11 in women and a factor of 8 in men 1 , The peak age for the disease is from the 20th to the 24th year of life Human papilloma viruses therefore represent a widely diffusive pathogen in the population as a whole.

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To date, there is little data on the incidence of anogenital condylomata in childhood. Up to , only 74 cases of the disease in infants had been published. After investigating a small collective of healthy male and female preschool children between 5 and 6 years of age, Myrhre et al 18 published the only study to date of the prevalence of anogenital condylomata in childhood in the normal population. The authors observed 4 girls 1. Infection is predominantly by direct skin-to-skin contact.

However, in addition to sexual transmission, which is the most frequent transmission route in adults, non-sexual transmission routes through close skin contact are also described. HPV infection can also occur in children through non-sexual transmission In this case, the infection route may be antenatal, perinatal or postnatal 20 , Transmission of the HPV infection from the mother to her child during birth can lead either to anogenital condylomata or to laryngeal papillomas 6 , This perinatal infection of the child can arise both from clinically manifest and from subclinical lesions.

Since the incubation time for condylomata can vary from a minimum of 3 weeks to several months, a manifestation in the first months of life does not exclude an infection which has already occurred in the antenatal period 21 , The clinical manifestation of an HPV infection is also dependent on predisposing local factors such as moisture, macerations or epithelial lesions, conditions which often occur with infants in nappies with physiological incontinence, frequently intermittent anogenital eczema or dermatitis 6 , The autoinoculation and heteroinoculation of human papilloma viruses, for example originating from warts on the fingers particularly HPV type 2 of the child himself or the reference person, also represents a non-sexual transmission route 21 , According to police criminal statistics, 11 cases of sexual abuse of children under the age of 14 were reported in Germany in In the same period, sexual violations of adolescents were recorded In addition to these known criminal offences against the sexual self-determination of children and adolescents, the estimated number of unreported cases is thought by experts to be 10—20 times higher 29 , 30 , 31 , The suspicion of sexual abuse can arise in various ways.

Direct or indirect statements by the child, abnormal behaviour, physical signs on the child, observations of caregivers or disturbed family interaction can lead to the suspicion of sexual abuse 26 , 30 , 31 , 33 , The symptoms noticeable in the paediatric gynaecological examination are only rarely pathognomonic of sexual abuse having taken place.

Thus, in most cases, the suspicion is based on a combination of non-specific individual symptoms Reductions of the hymenal edge no longer have a part to play in the diagnosis; however, clefts in the sense of complete transection of continuity are diagnostic and notches must be taken into account, depending on the location, the age group and depth in relation to overall height of the hymenal edge When investigating sexual abuse, care of the child concerned is paramount and takes precedence over the interests of parents and other persons involved with the child or institutions.

In addition to the professional uncertainty of persons who are only rarely confronted with this subject, personal concern is also always a factor. Therefore, anyone having professional contact with victims of sexual abuse should be aware that precipitous and overhasty remedial measures, prejudgement or speculations can do more harm than good. On the other hand, dealing with the child concerned empathetically and considerately, and carrying out a careful investigation with comprehensive documentation of the findings obtained are of great benefit The investigation with the largest collective of children examined was published by Ingram et al.

Although the acceptance criterion was suspected sexual abuse, it is not to be deduced from the methodology of this study, on which this suspicion is based, whether the history or clinical findings led to presentation at a special clinic. Of this total collective, 28 children were found to have condylomata acuminata in the anogenital region. This corresponds to a prevalence of anogenital condylomata in an at-risk collective of children questionably subjected to sexual abuse of 1.

Following differentiated multidisciplinary investigation, the suspicion of sexual abuse was not corroborated for 69 out of children 4. Of the total of 28 children with condylomata, 16 children were in this group. For 8 of these children, taking into account the available medical findings for the mother, perinatal transmission was plausible.

For the remaining children Of the 28 children with condylomata, 12 were in this group. For 2 of these children, taking into account the available medical findings for the mother, perinatal transmission was assumed. The age distribution of the 28 children with anogenital condylomata in relation to proven sexual abuse is shown in Fig. However, in the total collective of children with proven sexual abuse, the prevalence was only 0.


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Although there was rarely evidence of anogenital condylomata in children who were subjected to sexual abuse, the authors were able to establish a very significant relationship between the age of the children affected and the probability of sexual transmission. Age distribution of children with anogenital condylomata acuminata in relation to proven sexual abuse according to Ingram et al On analysing the 5 children who were 8 to 12 years old at the time of diagnosis, the HPV infections were caused by sexual abuse in each case.

A second extensive study was published by the working group Sinclair et al. Here, too, the collective investigated consisted of a total of girls and boys up to 13 years of age who presented to a special interdisciplinary clinic due to suspected sexual abuse. In 74 children 4. Only 55 of these 74 children were evaluated with regard to sexual abuse. The data published do not provide any detailed information regarding the prevalence of condylomata in the various age groups. An informative study was published by Jones et al.

All the children were taken for interdisciplinary examination to rule out sexual abuse. After careful paediatric psychiatric investigation, in only 3 of the children 2. Two of these children had a negative maternal history and siblings without condylomata. These and other investigations carried out on smaller collectives 38 , 39 , 40 , 41 have led to the recommendations of various professional associations which are basically in agreement.

These are summarised as follows:. The evidence is considered to be suspect if the child is older than 24 months. In the absence of a clear and unambiguous statement by the child, the evidence is to be treated as a dubious finding and should be carefully assessed.

Condylomata acuminata in children may be, but are not always, an indicator for sexual abuse. If this suspicion is corroborated abnormal behaviour by the child, signs of violence, etc. With their typical appearance, condylomata are generally diagnosed by clinical examination. Histological investigation is only indicated in the case of uncertain clinical diagnosis, resistance to therapy, early recurrence, ulcerations, increasing pigmentation, immunosuppression or isolated skin eruptions larger than 1 cm 1 , 2 , 45 , One exception which should be mentioned is the investigation of solitary verruciform genital warts as further clarification of possible malignancy 1 , 3.

Serological HPV investigation is not meaningful 1 , 3 , The routine use of acetic acid is not necessary and therefore, in view of the painfulness of this examination in a very sensitive area of the body, should be avoided, particularly in children. Molecular diagnostic HPV typing is also not indicated in the standard investigations. In the case of inoculation, HPV types 2, 27 and 57 can cause condylomata via warts on the fingers. Although in individual cases evidence of these types can undermine the suspicion of sexual abuse, as the specificity and sensitivity of the available tests has not been evaluated, they are not recommended for providing evidence in cases where sexual abuse is suspected 21 , 22 , 23 , 33 , 34 , Differential diagnoses, which must be taken into account in investigating anogenital verruciform lesions, are listed in Table 1 1 , 3 , 43 , Special attention should be paid to the anatomical deviation from the norm of micropapillomatosis, with which we see physiological skin appendages, so-called genital papillae How best to set the treatment - group, individual, in-patient, out-patient?

How to choose and assess the most effective treatment - verbal, non-verbal, behavioural? What should the criteria be for assessing treatment? All these questions are examined, often with instructive case vignettes, alongside the most recent research findings and assessment tools available. This will be essential reading for all mental health professionals involved in psychotherapy with young people.

Facilitating pathways : care, treatment, and prevention in child and adolscent mental health by Helmut Remschmidt Book 10 editions published between and in English and German and held by WorldCat member libraries worldwide "This book provides an up-to-date review of the current state of care, treatment and prevention in child and adolescent mental health from multidisciplinary and trans-cultural perspectives.

Systems of care, services and interventions in selected parts of the world are described by leading experts. Anorexia nervosa Book 6 editions published in in English and Undetermined and held by WorldCat member libraries worldwide. Klinische Psychologie und Psychopathologie in German and held by WorldCat member libraries worldwide. Child and adolescent psychiatry in Europe : historical development, current situation, future perspectives by Helmut Remschmidt Book 8 editions published in in English and German and held by WorldCat member libraries worldwide The book describes the current situation of child and adolescent psychiatry of the various countries.

Aspects including definition, historial development, current situation, diagnostic and therapeutic methods, the structure and organization of services, as well as the cooperation with medical and non-medical disciplines, medical education, research and future perspectives are discussed in each contribution.

Child and Adolescent Psychiatry in Europe therefore gives an extensive comparison of the "state of the art" in child and adolescent psychiatry in Europe.