Ep. 192: Movement disorders in children and adults: different or the same?

00:00:00: Welcome to EANcast, your weekly source for education research and updates from the European Academy of Neurology.

00:00:15: Hello!

00:00:15: And welcome to the EANCast's Weekly Neurology.

00:00:19: My name is Natalia Schenckow.

00:00:21: I'm a neurologist and board member in the European Society For The Study Of Tourette Syndrome.

00:00:31: Today we have a pleasure to welcome two great experts, which is part of the podcast series Our Children's Small Adults.

00:00:42: In todays episode will talk about similarities and differences in movement disorders between children and adults.

00:00:49: My guests are Dr Tami Hederli and Professor Alexander Munchel.

00:00:54: Dr.

00:00:54: Hadley is a pediatric neurologist working at the King's College London and Edelina, London Children's Hospital in London UK.

00:01:03: Professor Alexander Munchow is a neurologist specialized in systems motor science And movement disorders and director of Institute of Systems Motor Science University Medical Center Schleswig-Holstein University of Lubeck in Germany.

00:01:17: Welcome dr.

00:01:18: Hadaly and professor moonshow and thank you for joining us today.

00:01:23: Thank You for inviting us.

00:01:26: Thank you, yes it's an interesting topic too.

00:01:29: thank you!

00:01:30: Yes so yeah let's just start.

00:01:33: and first I wanted to ask Dr Heidelie what are the most common movement disorders in children?

00:01:41: Can you maybe highlight

00:01:42: for us?

00:01:43: Yes i mean as we work together in the European society presentations that we see in the pediatric neurology movement clinic is tick disorder or Tourette's.

00:01:59: And, we work with a high number actually of families and I'm really interested to talk to Alexandra about the concept of how ticks differ in children-to-adults because we tend to transition children who present usually between five onwards, but usually peaking around ten to twelve who then often gradually improve.

00:02:26: But we transition the children around sixteen-to eighteen.

00:02:29: so it's very interesting to hear from Alexandra about his experience with the adults with peak disorders...but that was one of

00:02:39: Yes, yes.

00:02:40: We will definitely talk about this topic too and about the transition because well it's very relevant.

00:02:45: I think there are significant differences in terms of their practices in different countries to Yeah so children ticks and probably stereotypies two are frequent.

00:02:56: And how about adults?

00:02:57: is that same Alexander?

00:03:00: No clearly not.

00:03:02: So depends off course on the age The population gets, the more you see people with Parkinsonism.

00:03:10: And in the thirties and forties... ...the majority of motorists is probably dystonia.

00:03:15: In children and adolescents as Temi already pointed out it's tics and dread syndrome so they vary.

00:03:21: So for older you get more Parkinsonistic You become and the younger your are the more likely to have tics.

00:03:28: This is a bit of a dichotomy but its gradual transition

00:03:33: It seems that there are significant differences.

00:03:36: It is also interesting to take a look into the course of movement disorders with onset in childhood.

00:03:42: So, what's the usual course for these disorders like ticks or stereotypies?

00:03:47: Tami...

00:03:49: I think i'd like to start with stereotypes because this has great interest at mine and we see it much more common than we know about but very frequently early onset stereotopies.

00:04:05: they usually start under one year of age and they're often seen as you know quirky, little funny normal behaviors or movements.

00:04:14: but sometimes children go on to get very stuck in their stereotipes.

00:04:20: And sometimes if we're looking for example at some of the primaries... We use the term primary but it's not very accurate because often stereotopes can be genetic.

00:04:30: But if we look at the

00:04:32: common

00:04:32: stereotypies, they sometimes become more florid around the ages of two three four.

00:04:39: Now what we expect?

00:04:40: that point is slowly between the ages five onwards start to privatise and often by fives not a prominent feature in child's movement presentation.

00:04:53: but occasionally you see children who really sort of seem to enjoy the stereotopies.

00:05:00: Obviously, it's not the case.

00:05:02: they're often very worried about them but their children carry on and become quite persistent.

00:05:09: And in these children They can go onto start school even secondary schools sometimes at age eleven and there doing very frequent complex motor stereotypes.

00:05:21: At that point Clear that for some children.

00:05:26: They're starting to want to stop because of stigma or worries about being bullied.

00:05:32: and Children then Often come to clinic, and say please can you help me learn?

00:05:37: To control them.

00:05:38: And we use a program called privatization and promotion of privatisation.

00:05:43: now interestingly having watched lots at these children then become later teenagers and adults.

00:05:51: the point transition commonly see that children can learn to privatise the movement.

00:05:58: But we reported not long ago, some of them have associated intense imagery with those movements.

00:06:06: and when they become teenagers I want to emphasise it's not all... They've become stuck in an intense imagery world or a daydreaming world.

00:06:23: If that becomes compulsive, some of the people experiencing it have termed this maladaptive daydreaming.

00:06:30: And this is a relatively recent concept that's come out and has linked to movement disorder or movements... ...and its really important for movement specialists to ask carefully about presence of intense imagery or daydreaming.

00:06:49: That's a very interesting point, and I know that Tami you're sort of specialized in this.

00:06:54: And it is great to highlight these important clinical features especially for us adult neurologists.

00:07:01: we forget about Yes!

00:07:02: How about the course of ticks?

00:07:04: Alexander can you highlight how is the course through the life and then are there any factors associated with persistence into adulthood?

00:07:17: Yes, there are probably some factors but we have not really understood this well.

00:07:20: I mean we see both children and adults with ticks... We all have clinics in the pediatric department and neurology department.

00:07:30: therefore we can follow these patients from childhood to adolescence as long as you live actually.

00:07:40: And what we see in ticks typically is that they are much more variable at a younger age, so fluctuating the repertoire.

00:07:49: At given time may be the same but it changes more across-time and seems to be more fixed.

00:07:56: not completely fixed on adults but sort of more stable than likely.

00:08:00: here I mean you can never say any different person.

00:08:03: your chances to get rid of the ticks is sixty-seven percent or something.

00:08:07: It's only a matter probability and if you look very closely in those who had ticks, although they feel that they don't have ticks anymore so it's a matter A of symptomatology and self perception and B objective assessment.

00:08:24: but overall there are great chance Much less when you get older, so after puberty or completely subside.

00:08:33: I mean to an extent where the patient other people are not really bothered by this anymore is about eighty percent also.

00:08:38: that's what we usually say and it's interesting too.

00:08:41: understand but we don't have understood yet who will sort of lose the tix?

00:08:47: I mean there are some risk factors, for instance having OCD is probably obsessive compulsive disorder.

00:08:53: It makes it more likely that you have persistent ticks and adulthood And if your environment surrounding that's very focused on this Is also more likely For some reason seems to be less likely If you had ADHD not very severe ADHD but some ADHD which might be related to tending to ticks, not attending to ticks.

00:09:12: But overall it's not completely clear and there are no biological markers telling us who will continue to have ticks or go into remission?

00:09:21: Yeah that is true!

00:09:22: There some studies but exactly I think a frequent question also of parents Can you tell me what gonna happen to my child?

00:09:32: But exactly, we don't really know yet.

00:09:35: And it's also very interesting that some... Well this is a small population although Me as again coming from the field of adult neurology We have these patients That there are some adults with tick-onsent well and maybe not as frequent but also stereotopies onset in their adult food.

00:09:55: right What do we know about them?

00:09:58: Why these exceptions occur?

00:10:00: because, you know... We just discussed that here.

00:10:02: basically this is usually a movement disorder.

00:10:05: That starts in the childhood but not always yeah maybe also Alexander.

00:10:09: as an adult neurologist

00:10:11: I can start.

00:10:12: and then first question I don't know, or have they started earlier?

00:10:17: but people haven't noticed.

00:10:19: Unless you've spoken to teachers and relatives in the family who observed a given person sort of forty years ago... You can never be certain!

00:10:27: This is point one.

00:10:29: The second point if there's really some very convincing, convincingly shown that an adult onset tick disorder then off course the question Is it typical classical tick belonging towards spectrum?

00:10:40: Or is this first sign for another disease?

00:10:43: I mean, there are some rare diseases including Neuroarchanthocytosis as an example where you have onset of facial tics and mouth tics.

00:10:50: And so on.

00:10:51: that heralds sort of chronic progressive neurodegenerative disease.

00:10:55: this is very rare but it can happen also if this could happen in Huntington's disease But typically these aren't the first signs.

00:11:01: This has to be considered.

00:11:03: Then which was much more likely Is a functional disorder That resembles tick like behavior And this has to be viewed against the background of someone who had ticks in the past, perhaps not very noticeable.

00:11:16: But then later develops a functional movement that resembles the tick set they took out previously.

00:11:22: So again... This is a common scenario and therefore because it's clinically relevant one has to consider functional disorders.

00:11:28: I

00:11:30: don't know Tami do you want add something or...?

00:11:33: Only that i agree with everything Alexander said.

00:11:35: It was interesting when we see this kind of late onset sudden presentation in teenagers of a very florid tick disorder, then what we're finding?

00:11:46: sometimes these children have undiagnosed neurodevelopmental condition.

00:11:50: They may have odd spectrum traits that haven't been identified and they are actually presenting with more functional Tick Disorder.

00:11:58: but it is interesting how often some asked that question, so there seems to be a vulnerability to functional tick disorder.

00:12:12: That includes the presence of unrecognised simple motor ticks in the past or phonic ticks in quite complex.

00:12:33: when we do get the biomarkers and we get a little bit more knowledge around the FTLB, the functional tick-like behaviour.

00:12:42: It's probably going to be more complicated I wouldn't... Well i think already would all agree.

00:12:48: that sort of overlap with things like autism spectrum and neurodevelopmental conditions is there in.

00:13:01: Yeah, that's a great point.

00:13:02: And it is true we are learning basically this overlap between ticks and functional tick-like behaviors much more frequent than what was before especially due to the pandemic.

00:13:19: So we talked about ticks and a little bit also, about stereotypes.

00:13:24: How about dystonia and Parkinsonism?

00:13:26: What are the differences between children and adults in this

00:13:29: regard?".

00:13:30: Yeah maybe who wants to start?

00:13:32: Maybe Alexander again...

00:13:36: Well I would say first of all if the child develops dystonian then the likelihood that is going be complicated scenario or severe disease much higher than an adult.

00:13:48: so generally So you much more often see metabolic diseases or degenerative disease compared to adults.

00:13:58: And then also the clinical causes is generally different, there's again a higher probability for dystonia to spread and generalize in children.

00:14:08: adolescents compare it with adult and adults its more folkloric mental.

00:14:12: these are sort of two rules that need be considered.

00:14:15: so it, this is the consequence.

00:14:18: It's usually necessary to thoroughly assess them as regards that the underlying cause now has many genetic of course and not so much new metabolic investigations and so on.

00:14:29: And in adults there's less likely chance to find anything different worlds.

00:14:39: I mean, the sign per se is very similar but with a meaning of the sign dystonia.

00:14:44: in children and adults it's different.

00:14:48: Tami do you have anything to add regarding the dystonian?

00:14:52: maybe first?

00:14:54: Well i just would agree that although rare representation than those...the more benign common pediatrics movements.

00:15:02: when it does occur as Alexander is saying, it's often very complex and severe in the management.

00:15:08: It's a very multi-system.

00:15:10: so we're looking at management of dental complications and gastrointestinal complications and ensuring that young person is well hydrated and well nourished.

00:15:21: And you are often involving the neurodisability team The complex motor disability team.

00:15:28: even deep brain stimulation when we identify particular types of genetic disorders that are going to, you know probably help be improved by this technique.

00:15:39: So the management is often multidisciplinary and the children can present with very severe pain and discomfort which obviously we work very hard.

00:15:55: And yes, the investigation can help guide prognosis.

00:16:00: but sometimes we're getting new genes presenting over each kind of few years that we practice.

00:16:08: We get even more genes where you think oh right now this gene causes this type presentation.

00:16:14: maybe a florid onset career with dystonia or so... So we are getting better at recognising phenotypes within the dystonias.

00:16:26: you know obviously with things like the location of the dystonia and the progression, whether they're rostrocordal or where they start but I would just agree that it's often complicated and difficult.

00:16:39: But obviously hopefully as new therapies come we'll look to the future hoping for more development gene therapy and things, we hope for a better future of the children with dystonia.

00:16:56: That's great point I think.

00:16:57: to summarise these differences.

00:16:59: And how about Parkinsonism?

00:17:02: Is it similar so that basically in children usually involves such complex phenotypes and genetic sense In adults is probably Parkinson disease or anything you want to add about Parkinson.

00:17:17: I

00:17:19: suppose from a pediatric perspective only that you have to be astute, to be aware of this.

00:17:25: It does exist in childhood so we teach pediatrics and as paediatric neurologists it can be difficult to identify Parkinsonism because were not really expecting it.

00:17:36: So You Have To Be Aware That We Do Have Things Like Rapid Onset Parkinson's Dystonia In Early Childhood Even In Infancy And movement disorders that are Parkinson's.

00:17:49: and I suppose once you're under a Movement Disorder, pediatric neurologist or specialist they would know.

00:17:56: but it can be tricky to identify in the combination of constellation other developmental difficulties or developmental delay.

00:18:08: Or the presence more complicated neurology.

00:18:11: so identifying for example the mast like face the hypokinetic components in a child that's presenting predominantly with developmental delay can be tricky.

00:18:25: And so, being aware it is important to identify because it can be part treatable as well of course and you need to know... It can help guide those principles of investigation looking for etiology For example, the neurometabolic disorders.

00:18:46: Yeah, that's a great point.

00:18:48: How about treatment approaches?

00:18:49: Do we generally treat movement disorders differently in children and

00:18:53: adults?".

00:18:54: Yes this is very broad topic.

00:18:56: maybe yeah let us first start with ticks and stereotopies.

00:19:00: Maybe Alexander... Is it similar

00:19:03: in child?

00:19:04: I would like to add as regards Parkinson's just two points.

00:19:10: Of course there is group of dopamine disorders like Zegawa's syndrome are in a hydroxylase deficiency, that usually can respond quite well to levodopa treatment and if you overlook this then when running into big problems.

00:19:25: And there is also the group of patients with defined neurodegenerative diseases including Huntington disease may present not just career but with Parkinson's and Mantystonia.

00:19:34: so unusual presentations on some rare diseases that in adulthood prevent different way need be considered in children.

00:19:42: sort of general theme, that is often quite puzzling.

00:19:45: That A given disease has a different presentation in childhood as compared to adulthood and why the diseases are not completely understood.

00:19:53: but it needs be considered.

00:19:54: therefore we have to consider different phenotypes in certain diseases.

00:19:59: this what I wanted add to Parkinson's.

00:20:01: Yeah, great.

00:20:02: Thank you very much.

00:20:03: These are great points indeed that often especially... That's true of myself in this younger patients exactly In the Huntington disease for example.

00:20:13: even as a teaching point I think For example residents it is important to remember there was this variant where Parkinsonism is more predominant in phenomenology than Korea coming to the treatment.

00:20:30: So yeah, are there any differences in treatment for children and adults with ticks and stereotypies?

00:20:37: Who wants to start?

00:20:37: maybe Tammy then?

00:20:42: Well I think it's very interesting because i think treatments of tic disorders we have some evidence base for good treatments things like cognitive therapy habit reversal, exposure response prevention.

00:21:01: And we have good evidence for psychoeducation which we usually start with.

00:21:07: and then we have the pharmacological strategies Which probably there is a big difference here because I think as a pediatric neurologist i'm much more likely to prefer these other techniques The psychological techniques and the psycho education techniques before considering medication.

00:21:26: In fact, I would say probably as few as one in ten of our patients would be on medication.

00:21:33: And i suspect that might be a bit different than the adult world but we can come to that idea...I think the other thing that we haven't done very widely ...that we probably should investigate more is the idea of promotion of acceptance The model of kind of

00:21:53: accepting

00:21:55: ticks and where possible, bigging up the self-esteem educating around feeling positive about ticks.

00:22:03: And we have this unique opportunity in early childhood when the ticks first present that it always surprised me if we can meet children quite early before their teens really promote acceptance model embracing tick personality happy about the ticks.

00:22:25: I'm working very much on the anxiety around the ticks or maybe at your obsessive compulsive disorder treatments, early if that's present managing ADHD for example.

00:22:37: then i find that the ticks themselves are less often a problem.

00:22:43: but you have an opportunity to get in there earlier with that and work together with young people and their families.

00:22:51: If children present much later with very florid and difficult ticks, so thirteen or fourteen onwards... ...and they haven't had that intervention.

00:23:00: Sometimes it can be tricky to use the psychological approaches And not always.

00:23:07: but I mean we obviously would try that first.

00:23:10: But then we start to move sometimes to children who are very upset annoyed by the ticks or aggravated by the tics themselves, all their movements.

00:23:19: So then we would move towards consideration of different tick pharmacological therapies and depending on the personality... We would choose a medication based around probably associated co-occurring conditions.

00:23:33: so if they were very ragey with the ticks that might consider Arapiprazole.

00:23:39: If it was someone who is having ADHD personality and they had ADHD, but there were more bothered by the ticks than the ADHD.

00:23:49: We might think about clonidine.

00:23:51: And if someone has OCD that was driving the ticks we might be thinking of SSRI But obviously is very tailored towards individual.

00:24:02: Yeah these are all great points It's true I think as an adult neurologist often forgets this acceptance.

00:24:12: There is also, unfortunately no time for this appropriate psychoeducation.

00:24:16: Also with parents and Alexander I wanted to ask you what your experience in terms of the differences?

00:24:24: In terms of treatment of ticks in children and adults especially given all these differences in medication because it was also trained in Canada For example.

00:24:33: there generally alpha agonists are more frequently used and in adults, neuroleptics.

00:24:42: But I think that there are significant geographical differences in this term...

00:24:48: I would like to also underline what Temi said.

00:24:52: It's very important to try to increase acceptance particularly in families as well school etc.

00:24:58: because if you ask children the question so If everybody was ticking Would it be a problem for you?

00:25:05: And they often say no, then this is not a problem.

00:25:07: or if you alone on your own and there are some ticks in the body.

00:25:10: You then off and I said No.

00:25:11: sometimes of course They do bother because they they distract other maybe painful and so on.

00:25:16: So There's no reason to romanticize it.

00:25:18: But but often It's actually Not A big Problem as Tammy Said and therefore i agree that acceptance Is a very important point?

00:25:25: And I could Say That There Are no Principle differences between children and adults as regards treatment.

00:25:33: But some of the medication seems to work less in adults, for instance, a Tia Prudex or Tia Priz which is not used in many countries outside Germany Switzerland and Austria I think but this usually works quite well on children that it doesn't really work an adult's.

00:25:48: And the alpha agonist treatment like Guantatine or Chloridine can be effective with children sort of effect.

00:25:58: For instance, aeropiprosol can be used both in children and adults.

00:26:04: so there are some subtle differences but not principle difference with respect to behavioral treatment.

00:26:11: I often meet adults who had tics for sometime particularly bothered by A or two or three ticks And for them behavior treatment is actually very helpful.

00:26:20: I have a reversal cognitive behavioural treatment And the children often see that it's quite variable, fluctuating and then sometimes is not so easy to get a handle on all different types of ticks.

00:26:31: So I usually wait and see before I embark or recommend behavioral treatment because in some children after sometime it subsides as no big problem anymore.

00:26:42: What do you want me say?

00:26:46: It does have meaning...it can be useful for behavioral treatments just as in children.

00:26:52: And it's always, you also said to tell me an individualized treatment so that needs to be tailored for personal preferences and needs.

00:27:01: We do sometimes interestingly do a combination of treatments.

00:27:05: So we presented this at the European conference but... ...we run something called Tick Toolkit Group Children.

00:27:14: Don't put everybody into this As you've said.

00:27:17: choose children who opt for, say management of one particular distressing tick or a few ticks that can be discreet and which might benefit from a common approach.

00:27:30: But this tick toolkit is very well received but part of the components of that seem to be children meeting each other knowing like you said they're not the only people affected.

00:27:43: Some bonding from that they get some, They fed back to us.

00:27:47: That like meeting other children with ticks in this setting.

00:27:50: we do the therapy online now In the groups and sometimes in person groups but This can be quite a nice approach.

00:27:58: I suspect is different to adults.

00:28:01: i'm not sure if people are doing adult group therapy.

00:28:05: Not really no it's.

00:28:07: but it seems to be quite a nice component and the parents also like what they report, sometimes enjoying meeting other parents who are going through similar struggles.

00:28:17: We cover things like sleep for children.

00:28:20: we'd cover the co-occurring conditions then different strategies which is that in fact you have peer mentor as well within one of our groups where we have a young person who has threats advising and being there to answer difficult questions, but also... We find the young people often giving each other tips which is very beneficial.

00:28:45: Wow!

00:28:45: Yeah thank you for highlighting all these fascinating points and different practices.

00:28:50: I think it's very helpful Also For People Who Wants To Develop Clinics In Their Home Countries And Learn From You As An Expert.

00:28:59: Finally,

00:29:00: let's talk about transition.

00:29:02: What difficulties have you encountered related to this topic?

00:29:06: Yeah maybe... Let's start with Tami.

00:29:08: like what are the practices in terms of the transition of care for these patients with movement disorders and are there any difficulty?

00:29:17: It is a very good question.

00:29:19: I think we're quite fortunate in our service.

00:29:22: We have some nice connections with the adult neurologist who specialise in Tourette.

00:29:27: but i find Probably one of the hardest things about transitioning from paediatric services to adult services is parents often report within the pediatric clinics, they feel very kind.

00:29:44: more... They get their regular appointments.

00:29:47: It's not so much driven by that person seeking the appointment and patient initiated access.

00:29:55: I think we have obviously school liaison.

00:29:58: We have a nurse specialist the psychologists.

00:30:01: And we are quite responsive to messaging and things, I guess in certain clinics it's that they're resources don't really want is obviously so different in different countries and model of care is very different across world.

00:30:17: In England you have the NHS So its not privately funded this government funders.

00:30:24: there always going to be resource limitations but challenges.

00:30:30: Well, I think it's that whole.

00:30:34: when young people go to university and they start... It is a question do you consider this be disability or not?

00:30:47: And Young People often come in say what we put on our forms What do we declare.

00:30:55: I usually respond by saying You know what difficulties Do you have in day-to-day life?

00:31:00: You know, what support do you need in day-to-day life as an adult?

00:31:03: Because we want young people to feel empowered.

00:31:08: We want people to be accepting and live a normal life... ...as normally life is possible And we want to enable people.

00:31:20: My principles are all about enabling or not disabling But I think this kind of then becomes a challenge doesn't it?

00:31:27: In different fields because People have different views.

00:31:32: I mean, the young people experiencing the ticks.

00:31:35: some people will opt because they need to for more support and Some people don't maybe claim enough support And there's a very wide range i find.

00:31:49: Yes yes?

00:31:51: So it is very individual right?

00:31:55: Do you have anything to add about transition of Kieran?

00:31:58: Yeah, I think it's very important and often very tricky.

00:32:02: In Lübeck we are lucky because we have a Center for Pediatric and Adult Movement Disorders so... We have a smooth transition because people who see children in adolescence then continue to see adults.

00:32:13: So if they want the children can be looked after by our team.

00:32:17: But that is different department.

00:32:19: when their children of course its the pediatric department.

00:32:21: When they get older It´s center for diseases.

00:32:23: or we also found an institute So a medical center for people with disability, which is sort of similar to the social pediatric centers in Germany.

00:32:32: And there's multidisciplinary multi-professional cabinet available at these centers because we can then realize this transition from childhood adulthood within the same team and I think that this very rewarding is also accepted.

00:32:48: it quite unusual in Germany as well.

00:32:50: but I would strongly promote like you know gps who may see children getting older and then becoming adults.

00:32:58: And this is sort of a specialized GP type setup, it's all surrounding inner expertise.

00:33:05: so those centers who gain expertise in pediatric neurology that needs some input from adult neurology and vice versa?

00:33:12: If that is realized given centers are also across centers.

00:33:16: I think these patients benefit most.

00:33:19: Yes, thank you again for these great points.

00:33:24: Is there anything we want to mention at the end?

00:33:27: take home messages for our listeners because

00:33:30: we will

00:33:30: wrap up now.

00:33:31: I think it was a great, really pleasure to talk with you both and have two different perspectives

00:33:37: but

00:33:37: at the end they're joined.

00:33:38: that's exactly an idea behind all this series of podcasts show children are not just small

00:33:46: adults

00:33:47: But

00:33:47: in the end there'll be adults.

00:33:48: so its important this transition.

00:33:51: Any talk or message Tami?

00:33:55: only that I think it's really great to work with, you know a great adult colleagues and we're very lucky in our community of movement soldiers where i think We do Work quite closely together the pediatric on the adults side because this is Very important too To just collaborate make bonds learn from each other.

00:34:19: So thank You for the invite today.

00:34:23: Yeah completely I completely agree.

00:34:25: So joining forces, coming together having joint conferences this cooperation sort of cannot be overemphasized and i think if we do that in the smaller or larger communities then this is really to the benefit of our patients.

00:34:37: Great!

00:34:38: I think these are great points And this also an invitation for our adult colleagues To join Child Neurology Panel Of The European Academy On Neurology.

00:34:48: You're both a great example For people who help neurologists you know, children and adults in transition of care.

00:34:57: Thank you again for your time, your dedication on everything that are doing also.

00:35:02: tick disorders clinical care and research care me as a tick disorder expert.

00:35:06: I'm very feel very fortunate to know you both And thank you.

00:35:11: all our listeners too listen to us and yeah have a nice day.

00:35:15: Thanks so much for the initiative!

00:35:16: Thank You and take care bye-bye.

00:35:27: This has been EANcast Weekly Neurology.

00:35:31: Be sure to follow us on Apple Podcasts, Spotify or your preferred podcatcher for weekly updates from the European Academy of Neurology.

00:35:39: You can also listen this and all our previous episodes in the EAN Campus to gain points.

00:36:01: Thanks for listening!