Le trouble déficit de l’attention/hyperactivité à l’âge adulte : concept, tableau clinique, stratégies diagnostiques et thérapeutiques

Attention Deficit/Hyperactivity Disorder (ADHD) was considered, for a long time, as a disorder affecting children and adolescents, and was most often identified in the early development. It was less known that ADHD can be found in adults. Several arguments (clinics, neuropsychology, neuroanatomy, genetics, longitudinal studies and pharmacology) confirm that ADHD persists in adulthood for most of children and should be still treated, as long as the disorder leads to impairments. Nevertheless, ADHD in adults is considerably misdiagnosed in France. In fact, this can be explained by controverse, by its difficulty to be diagnosed, by a lack of consideration of developmental aspects… Diagnosis is based on clinical aspects, developmental and familial histories, adaptative strategies and functional alteration. Clinical interview put forward particularities in adulthood: decreasing (or change) of hyperactivity and impulsivity, persistance of attentional deficit, increasing of dysexecutive syndrome because demands in planification, social relationships and emotional management are often higher when people grow up. Several domains can be impaired: raising children, driving cars, working, taking care of themselves, daily managing… One of the most difficult issue about adult ADHD concerns criteriology. Although some authors (Wender, Hallowell and Ratey) have developped criteria based on more specific features of adulthood than those described in DSM-IV, criteria have still to be discussed: age-of-onset, number of symptoms required… Assesment scales can help clinicians to evaluate ADHD symptoms and impairments of their adult patients. Main scales are: Conners Adult ADHD Rating Scale (CAARS) and Adult ADHD Self-Report Scale (ASRS) for detection, ADHD behaviour checklist and ADHD rating scale IV for diagnosis, Wender Utah Rating Scale (WURS) for retrospective diagnosis in childhood and Brown Attention Deficit Disorder Scale for a better evaluation of executive functions. This evaluation should be completed by neuropsychological testing. The results can confirm the diagnosis and guide the treatment according to the neuropsychological profile. The more salient tasks for the diagnosis of adult ADHD seem to be: Continuous Performance Test (CPT) for selective and sustained attention, Trail making Test part B for cognitive flexibility, Stroop color/word interference test for inhibition capacity, verbal fluency and processing speed in WAIS-R. It is thus extremely important: (i) to recognize that ADHD affects also adults, at high rate (4% of general population), (ii) to keep in mind that developmental particularities make the disorder more “cognitive” than “behavioral”, (iii) to clarify the link between adult ADHD and the others psychiatric disorders, especially bipolar disorder, (iv) and to know that most of the adults with ADHD can be successfully treated by psychostimulants and psychotherapy, as in childhood. In France, only few teams evaluate ADHD in adulthood. So, one of the purpose of our article is to enable a better consideration of adult ADHD in our country.     

Trouble déficit d’attention/hyperactivité (TDA/H) et émotions : de la labilité émotionnelle au trouble bipolaire

This article aims to review the literature about emotional symptoms associated with ADHD. Emotional symptoms are frequent in Attention Deficit Hyperactivity Disorder (ADHD) and range from mild/moderate to severe emotional lability, but are not specific to ADHD. Severe emotional lability in ADHD patients or association between emotional under-control and mood symptoms should urge clinicans to screen for co-occurring oppositional defiant disorder, mood disorders (depressive disorders, bipolar disorder) and disruptive mood dysregulation disorder. Although this latter diagnosis still lacks validity and may be difficult to differentiate from severe oppositionality in ADHD patients, it will draw attention to the emotional aspects of disruptive behavior disorders and the need to implement specific treatments for emotional hyperreactivity and under control. A better understanding of the relationships between behavior and mood and of the role of environmental stressors is needed to improve prevention of full-blown mood disorders in children with ADHD and emotional lability.     

Comorbidité TDA/H (Trouble du Déficit de l’Attention avec ou sans Hyperactivité) et TSA (Troubles du Spectre autistique)

The publication of the fifth version of the DSM in May 2013 officially recognized comorbidity between Attention-Deficit Disorder with or without Hyperactivity (ADD/ADHD) and Autism Spectrum Disorders (ASD). Indeed, the DSM-IV didn’t allow concomitant diagnosis. However, there is a clinical, neuropsychological and genetic overlap between these two disorders. Thus, 30–80 % of patients with ASD fill criteria for ADD/ADHD and in 20–50 % of patients with ADD/ADHD are found the diagnostic criteria for ASD. These observations raise the question of the link between ADD/ADHD and ASD: Is ADD/ADHD a minor form of ASD? Are ASD and ADD/ADHD different manifestations from a single neurodevelopmental disorder? Finally, are they two distinct developmental disorders whose clinical expressions would approach? Recent studies seem to distinguish two types of situations: Comorbid patients with less severe symptoms of ASD do not differ qualitatively from ADD/ADHD patients alone, which argues for a continuum between ADD/ADHD and ASD. Patients with ASD symptoms predominate are qualitatively different subjects from ADD/ADHD alone, thus corresponds to the hypothesis of two distinct nosological entities. Anyway, when ADD/ADHD and ASD are associated, there are specific clinical expression of developmental pathways and prognosis. Thus, these comorbid patients suffer more frequently from other psychiatric disorders, have a poorer quality of life, poorer adaptive functioning and clinical expression is more persistent over time. The modalities of treatment of comorbid patients may associate psychoeducational, psychotherapeutic approaches and medication (methylphenidate, atomoxetine, guanfacine, risperidone, aripiprazole).     

Facteurs de risque précoces et trajectoires développementales du trouble déficit de l’attention/hyperactivité (TDAH)

Attention Deficit/Hyperactivity Disorder (ADHD) is associated with a set of early genetic and environmental risk factors. Genetic risk factors, of which existence is supported by genetically informed (i.e. Twin) and molecular studies, are yet partially identified. They do not constitute diagnostic markers or therapeutic targets for preventive interventions. Early environmental risk factors exist and could represent targets for early interventions. However, their causal nature is not determined yet. In addition, early environmental risk factors are distal factors compared with later risk factors, which makes difficult the understanding of their direct links with the ADHD phenotype. Developmental trajectories of ADHD are interesting to study in order to take into account the dimensional and developmental nature of ADHD. Investigating the link between early risk factors and developmental trajectories could allow a better understanding of their interactions along time. The experiment of preventive interventions of ADHD could lead to disentangle mechanisms and provide new tools to treat ADHD.     

Clinique du syndrome de Gilles de la Tourette et comorbidités psychiatriques associées chez l’enfant

Tourette's syndrome is recognised of affecting one per cent of school-aged children. Its severity ranges from mild and simple motor and vocal tics, to severely intrusive movement disorder, with marked fluctuations. It frequently cooccurs with attention deficit/hyperactivity disorder and obsessive compulsive disorder, and mood and anxiety disorders. These comorbid conditions are often the major source of impairment for the affected child.     

Actualité en neuro-imagerie du Trouble Déficit d’Attention/Hyperactivité

An increasing number of neuroimaging (in particular, magnetic resonance imaging [MRI]) studies has been published in the last two decades with the aim to elucidate the brain correlates of Attention-Deficit/Hyperactivity Disorder (ADHD). The amount of available evidence has allowed researchers to pool such body of studies in meta-analyses, which provide more reliable information than single and often underpowered studies. Meta-analytic evidence from structural MRI studies shows that, compared to non-ADHD controls, individuals with ADHD present with significant differences in the volume of fronto-parietal, striatal, thalamic and cerebellar regions, involved in inhibition, self-adjustment and goal-directed behaviors, functions typically impaired in ADHD. Converging evidence from diffusion tensor imaging studies also shows ADHD-related white matter alterations in fronto-striatal-cerebellar circuits as well as in parieto-temporal-occipital regions. Evidence from structural studies has been complemented by task-based functional MRI studies pointing to dysfunctions in the same brain regions. The relatively recent introduction of resting-state MRI has allowed the detection of complex patterns of dysfunctional interactions, at rest, among several brain networks, including the default and task-positive networks, in individuals with ADHD. To date, most of the neuroimaging literature in ADHD has focused on group comparisons; therefore, its results are not applicable at the single-patient level. However, the recent development of support vector machine and similar analytical approaches promises to turn the field towards useful application in terms of diagnosis and prognosis at the single-patient level, thus being informative for daily clinical decisions.     

Le trouble disruptif avec dysrégulation de l’humeur

Disruptive mood dysregulation disorder (DMDD) is a new DSM 5 diagnosis specifically addressing children and adolescents. DMDD belongs to the category of mood disorders and has been created to improve recognition of a condition characterized by both mood and behavioral symptoms and to avoid a diagnosis of bipolar disorder in children and adolescents with severe chronic irritability and temper tantrums. Its validity and possible overlap with disruptive behavior disorders such as oppositional defiant disorder or conduct disorder and neurodevelopmental disorder such as attention deficit hyperactivity disorder – especially in children with severe emotional liability or comorbidities – are still subject to debate. This review addresses the background of DMDD, diagnosis and neuropsychological correlates.     

Mise au point des études cliniques sur le rapport « veille-sommeil » dans le trouble déficit de l’attention/hyperactivité de l’enfant

Since 1970, a certain number of studies have reported sleep disturbances in children with ADHD. Data from questionnaires and parental reports showed behavioural difficulties occurring at wake-sleep transition such as bed-time refusal, delayed sleep-onset, early awakenings, suggesting the occurrence of specific abnormalities in the mechanisms of alertness maintainance.Few polysomnographic studies have been conducted in ADHD children considering the prevalence and the importance of the disorder in the field of child psychopathology. The majority of these studies produced heterogenous and conflicting data and no clear abnormalities of non-rapid eye movement or REM sleep were found.Polysomnographic data, however supports the evidence of sleep-wake-transition abnormalities in ADHD children. Modifications in sleep-onset-latencies, number of stage shifts, have previously been reported using all-night polysomnography.One study performed Multiple latency tests in ADHD children and concluded that ADHD had daytime sleep abnormalities when compared with controls.One other important issue concerns motor activity during sleep in hyperactive children which was found to be increased in studies using actigraphy or video analysis. These findings could lead to important clinical and therapeutic applications as stimulants could help to normalise sleep or motor behaviour during sleep in some ADHD children.     

Trouble de l’identité et de l’intégrité corporelle : interrogations pathogéniques et enjeux éthiques autour d’une pathologie émergente

A forty-year-old, socially well-adapted mother with no medical background comes to the emergency room after willingly exposing her leg to severe burns. She clearly and quietly explains that she wants to have both her legs amputated. She has never felt like those legs actually belonged to her physical integrity even though she clearly perceives their being attached to her body. This feeling appeared back when she was six years old; the desire to become an amputee aroused later, when she was around 12. She has already repeatedly consulted surgeons and submitted to various psychiatric and psychological evaluations that did not discern any clear psychiatric pathology. The paradox here is that of an apparently psychically normal woman asking surgeons to perform an abnormal procedure consisting in removing a healthy part of her body. To grant such a demand is mostly unorthodox nowadays even though some surgeons do publicly comply. Scientific publications on the subject are still scarce since the phenomenon itself is rather recent. However, a community of patients acknowledging the same challenge - which consists in not accepting a healthy part of their body - and making the same demand - which is to have such part of their body removed - has developed through the modern medium of the Internet. Outside of the medical and academic field, a rather elaborate discourse on the subject has thus appeared. A new and precise vocabulary was created so as to distinguish between various clinical situations, involving patients diagnosed with a pathology now known as “Body Identity Integrity Disorder”. The specific case of the aforementioned patient resembles other Internet compiled cases and raises pathogenic, therapeutic, medico-legal and ethical issues. From the pathogenic point of view, and after positively ruling out any psychotic pathologies, these clinical cases could be compared to the case of transsexuals since they both involve acknowledging one's anatomical reality while failing to identify with it. In such cases, despite the lack of clear medical explanations of such confusion, therapeutic procedures have been established, eventually allowing surgical, therefore mutilating, rectifications. From the therapeutic point of view, it may all be about choosing the lesser of two evils: rather an operation by a competent surgeon than death from self-inflicted injury. On the other hand, nothing proves that amputation is the best answer and care; thus it seems important to offer a necessarily long psychological undertaking previous to any surgical decision. From the medico-legal point of view, the law states that one's body integrity can only be impaired in case of medical necessity, which leads to ponder on the definition of such “necessity”, since its limits seem to vary according to place, time and cultural values. At that point, the ethical debate finally rises. It exceeds the simple issue of freedom and the right of any mentally healthy person to dispose of one's body; it also involves a debate between practitioners, psychiatrists and surgeons on the enigma of an up-to-now unheard-of symptom requiring enlightened therapeutic answers.     

Neurofeedback dans le trouble déficit de l’attention avec hyperactivité : de l’efficacité à la spécificité de l’effet neurophysiologique

Clinical guidelines for attention deficit/hyperactivity disorder (ADHD) recommend a multimodal treatment encompassing pharmacological medication with methylphenidate, cognitive-behavioral therapy (CBT) and family treatments. Methylphenidate is the most effective treatment, though the relatively high rate of partial responders, and the possible parental reluctance against the pharmacological treatment. Thus, it is interesting to consider new non-pharmacological therapies based, such as CBT, on the learning capacity of children to self-regulate their behavior. Neurofeedback is interesting insofar as it would allow children to acquire self-control over certain brain activity patterns to improve the regulation of their behavior in daily-life situation. Early studies on neurofeedback in ADHD are nearly 30 years old. Two training protocols were created, based on EEG abnormalities in ADHD. First training allows the modulation of EEG frequency bands: increased activity in the beta band, or decreased activity in the theta rhythm. The second allows an increase in a slow cortical potential. In both protocols, feedback of the brain activity patterns is given to children in real time as a kind of computer game, and changes that are made in the desired direction are rewarded, i.e., positively reinforced. The evidence-based level of the neurofeedback is still unclear. But, unlike other mental disorders, many studies have investigated the effect of this treatment on symptoms of ADHD. Thus, we propose to analyze the data of literature and especially recent studies. A meta-analysis and randomized controlled studies seem to confirm the efficacy and the possible place of neurofeedback in the multimodal treatment strategies of ADHD. But, if this treatment supposes to allow self-regulation of children behavior by learning the control of EEG activity, the specific mechanisms of action on brain activity remains problematic. Thus, we propose to identify methodological and neurophysiological areas for future research on this therapy involving the subject and electrophysiology in psychiatry.     

Embryofœtopathie alcoolique (syndrome de Lemoine)

Review of the alcohol foetopathy syndrome (Lemoine’s syndrom) with its four sections (facial dystrophy, growth deficiency, organic defects, mental deficiency, behavorial abnormalities) and of its acceptance in the medical community.     

Recherches actuelles sur l’intelligence sociale et les troubles envahissants du développement (TED)

Social intelligence in pervasive developmental disorders and in pervasive developmental disorder not specified. This article is a review of the literature on the neuropsychological and cognitive hypotheses which explain pervasive developmental disorder not specified's (PDD-NS) social intelligence presented with experiences. Works ask on the evaluation of social intelligence and the difficulties for diagnosis PDD-NS.     

Prise en charge d’un état de mal épileptique de l’enfant (nouveau-né exclu)

Convulsive status epilepticus in childhood is a life threatening condition with serious risk of neurological sequelae which constitutes a medical emergency. Clinical and experimental data suggest that prolonged seizures can have immediate and long-term adverse consequences on the immature and developing brain. So the child who presents with a continuous generalized convulsive seizure lasting greater than five minutes should be promptly treated. The outcome is mainly determined by the underlying etiology, age and duration of status epilepticus. In children the mortality from status epilepticus ranges from 3 to 5% and the morbidity is two-fold higher. Mortality and morbidity are highest with status epilepticus associated with central nervous system infections, which is the most important cause of status epilepticus. There are few evidence-based data to guide management decisions for the child with status epilepticus. Immediate goals are stabilization of airways, breathing and circulation and termination of seizures. Benzodiazepines remain the first-line drugs recommended for prompt termination of seizures. As intravenous lorazepam is not available in France, we suggest clonazepam as the best choice for initial therapy. Rectal diazepam or buccal midazolam remain important options. Intravenous phenytoin/fosphenytoin and phenobarbital are the second-line drugs. Phenytoin is being increasingly substituted by fosphenytoin, but pediatric data are scarce and fosphenytoin is not authorized for use in France below five years old. In children, phenytoin is often preferred to phenobarbital, even though no comparative studies have demonstrated a better efficacy. To manage status epilepticus refractory to a benzodiazepine and administration of phenytoin and/or phenobarbital, many pediatricians today prefer high-dose midazolam infusion rather than thiopental to minimize serious side effects from barbiturate anesthesia. There is no benefit/risk ratio to support the use of propofol for children with refractory status epilepticus.     

Apnée du sommeil et paralysie cérébrale à l’âge adulte. À propos de trois observations

Respiratory disorders are frequent in cerebral palsy with restrictive and also obstructive disorders. Obstructive sleep apnea has been described in childhood but there are few data about this problem in adults. Usually clinical symptoms are snoring, apneas, nycturia, sleepiness, awakenings, headache, cognitive disorders, and depressive syndrome. Obesity is a strong risk factor. Moreover, prevalence increases with age in adults. We report three cases of adults with cerebral palsy suffering from obstructive sleep apnea. Particularities of this syndrome are discussed in cerebral palsy. Diagnosis may be difficult because of the existing impairment, which can mask specific clinical signs. According to the risk of impairment worsening and of cardiovascular disease, obstructive sleep apnea must be evoked in case of any doubt. Individuals who are suspected of having obstructive sleep apnea should undergo polysomnography to confirm the presence and severity of sleep disordered breathing.     

Évaluation de l’intelligence sociale chez l’enfant présentant des troubles spécifiques du langage oral : Présentation d’une échelle d’évaluation clinique

Performances in social abilities of everyday life were studied in children with specific language impairment or PDD (pervasive developmental disorders). Comparison was made with normal children, children with intellectual deficiencies and dyslexic children. Results concerning children with language impairment confirm a relationship exists between language abilities and social cognition abilities, development of theory of mind being likely to go along with the development of language. The second objective is to establish normative values for the EASE scale. Hence, 327 normal children of various ages were tested. Results show a significant effect of age on mentalization development and results confirm that this ability is acquired between three and five years old. Normative values have been thus established. This study may allow to propose the EASE scale as a tool to help diagnosis, in particular to help make differential diagnosis of pathologies leading to troubles of language and personality in young children, such as “PDD” (atypic autism among others) and “SLI”, as well as to have clinical tools which enable to make a diagnosis in younger children. The EASE scale therefore presents greatest importance.     

Accès aux soins en psychiatrie du bébé et de l’enfant : diversification des demandes et des offres de soins

The author explains the innovations of care systems in child psychiatry relative to the approach of babies (psychiatry in paediatrics, in therapeutic centres for babies) and to the access of young children (management of emergencies and crises, linked to the sociocultural innovations of the 21^st century).     

Aspects psycho-développementaux de la douleur chez l’enfant

It has been believed that newborns could not feel acute pain. However, controlled laboratory studies do not support this belief. In fact, this population is especially vulnerable. Children's memories of painful experiences can have long-term consequences for their reaction to later painful events and their acceptance of later health care interventions. Also we need to know the cognitive development of children in order to be more effective in pain assessment and management for young children. Concept of pain for children corresponds to successive stages of cognitive development of Piaget. This paper focuses on the impact of cognitive development in perception and expression of pain and describes the different stages and gives some skills to help children in pain.