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.     

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.     

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).     

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.     

Facteurs de risque environnementaux à la schizophrénie

Schizophrenia is currently a major concern, its prevalence being estimated at around 1% and its social consequences being severe. The elucidation of the pathophysiology of the disease is difficult due to the great variability of clinical expressions, the instability of the clinical symptoms during the evolution and the absence of reliable biological markers. The existence of a familial aggregation in schizophrenia is well known, the risk of presenting the disease for first-degree relatives of patients being 5 to 10 times higher than the risk observed in the general population. The genetic component was further confirmed by twin and adoption studies. Although the concordance for the disease is higher (40 to 70%) among monozygotic twins as compared with dizygotic twins (15%) it does not reach 100%, which implies that environmental factors modulate the effects of the genotype. However, the role of these factors and especially their interaction with genetic factors remain unclear but the implications of some specific environmental factors are well documented by recent research data. The current literature on sex differences in schizophrenia is consistent. Several studies have suggested that male and female patients may differ in age at the onset and expression of clinical symptoms. Complications during pregnancy or birth-giving may increase the risk of developing schizophrenia later in life. The major complications are oxygen deprivation during pregnancy, bleeding, maternal malnutrition or infection (exposure to influenza, for example). A low birth weight is associated with an increased risk of schizophrenia. Psychoses are more common among people living in an urban environment and among those born during winter months. Schizophrenia is probably more prevalent in people who are living promiscuously, are subject to toxic abuse, poor nutrition and stress but here more precise data are needed. Moreover, immigrants have a higher risk of developing psychotic disorders. In addition, head traumas are associated with an increased risk of schizophrenia. Though they are contentious, some studies suggest that substance abuse (cannabis use in European countries) is related to the development of schizophrenia, especially in people with genetic vulnerability. Moreover, substance misuse may worsen the symptoms. If the environment is sufficiently stressful, people with a high genetic vulnerability will develop some degree of mental illness, including schizophrenia. Conversely, a less stressful or a protective environment may decrease the risk of its onset in persons with a predisposition to schizophrenia.     

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.     

Expression phénotypique du TDAH en fonction de l’âge

Attention-deficit/hyperactivity disorder is considered as a developmental disorder, with inappropriate levels of inattention and hyperactivity/impulsivity, which typically emerge during preschool-age and often persist into adulthood, causing functional disability throughout the lifespan. ADHD and comorbid disorders symptoms variability depend on the age group affected. Developmental models of ADHD and assessment of phenotypic expression of ADHD according to age, offer new therapeutic and preventive issues in ADHD.     

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.     

Apport de la génétique dans les études sur la résilience : l’exemple de l’autisme

Resilience refers to patterns of positive adaptation in the context of significant risk or adversity. In the early 1970s, researchers began to discuss the importance of observing why some individuals did not develop psychopathological troubles in spite of being at risk. Over the past 30 years, real advances have occurred in understanding the complexity of causality and the interaction of multiple risks and protective factors in the process of resilience.Two major approaches have characterized the research in this domain: the variable-focused approach and the person-focused approach. Many variable-based models conceptualized interactions and/or correlations between individual environmental risk and protective factors. These models have been extended with recent studies investigating the link between genetic risks and resilience. From a genetic perspective, resilience could be understood as the extent to which an individual who possesses a genetic risk for psychopathology does not develop troubles. But, even if most studies have been concerned with dividing population variance into effects attributable to genes and those attributable to environment, it now seems clear that other effects exist. Examples of correlation models (rGE) underline the need to differentiate the genetic and environmental mediation of risk processes and of moderation or resistance to them.To clarify this new framework, an example of study of resilience in families having an autistic child was proposed. Data from twin studies and family studies offered strong support for the genetic contribution to autism. Studies in relatives of autistic persons extended these results by indicating a similar pattern of social and/or communication difficulties in first degree or more distant relatives of the child (the broader autism phenotype). In addition to genetic factors, growing up with an autistic sibling is expected to cause psychological and emotional difficulties in family members. Studies in siblings of autistic individuals have shown that they were at risk of psychiatric disorders as major depression and anxiety disorders in these subjects have been found to be twofold greater than in controls. However, studies investigating the psychological adjustment in siblings of autistic individuals showed no significant differences with controls. Some of these contradictions may be attributed to methodological issues, but the question remains concerning the validity of employing the term of ’resilience’ in this research domain. There is a growing acceptance of the need to study and question the various methodological hazards that could lead to false impressions of resilience. Studies in the area of resilience should follow interdisciplinary and multiple levels of analysis perspectives. Such investigations may reveal that genes may also serve as a protective function for individuals facing adversity. Resilience could help to broaden the understanding of developmental processes that may not be so evident in normative environments.     

Trouble déficit de l'attention-hyperactivité de l'enfant et l'adolescent : du diagnostic à la prise en charge

What is the scientific evidence to support ADHD as a disorder? What are the risks of the use of stimulant medication? These questions are frequently discussed and often with passion. The objective of this article is to present the conclusions and recommendations relative to these questions. The International Diagnosis criteria retained are those of DSM-IV which describe three subtypes of ADHD : ADHD primarily of the inattentive type ; primarily of the hyperactive-impulsive type and a combined type. Establishing a diagnosis of ADHD requires a rigorous strategy, and it should be operated by stages: one to receive requests, one to collect information, and one to confirm the diagnosis. The use of scale is a clinical option but cannot be a substitute to clinical diagnosis. A therapeutic approach must combine several modes of intervention such as the use of stimulants and psychosocial treatment. The treatment will have to be revised regularly according to beneficial effects.     

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.     

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.