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.     

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.     

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.     

Échelle d’attitudes à l’égard des personnes présentant un trouble de personnalité limite : structure factorielle et validation préliminaire

Objectives

Studies have shown that negative attitudes on the part of mental health professionals are often held toward people suffering from borderline personality disorder (BPD). These negative attitudes heighten the risk of stigmatization and rejection of these patients. Many publications have focused on the clinicians’ attitudes toward patients with personality disorders, and on the development of questionnaires meant to assess these attitudes. While some of these questionnaires have used semi-structured interviews in a qualitative framework, others have resorted to quantitative questionnaires. However, only one of these instruments has been developed with the specific purpose of evaluating the clinicians’ attitudes toward patients with BPD. The existing measures, developed in English, were validated among clinicians working outside Quebec. The present study exposes a factor analysis and preliminary validation of a French language instrument specifically designed to measure mental health professionals’ attitudes toward patients with BPD.

Method

A multidimensional and attitudinal model was chosen for the development of the scale. Twenty items were elaborated by Bouchard and grouped into four different scales: Negative attitudes (four items), Positive attitudes (five items), Caretaking necessity (five items), and False perceptions about BPD (six items). A total of 416 mental health professionals completed the questionnaire. Demographic data is available for 236 participants (178 women): mean age is 42, 1 year and 70% are university graduates.

Results

Preliminary factor analysis confirmed the existence of two main factors. The scales Positive attitudes and Negative attitude were grouped into factor 1, which was labelled Comfort when interacting with someone who has BPD. The items associated with the scales Caretaking necessity and False perceptions about BPD were grouped into factor 2, labelled Positives perceptions about BPD. The internal consistency indexes of the scale as well as the two distinct factors are satisfactory. Linear regressions were computed in order to assess whether sex, age, and level of education of participants are good predictors for the total score of the scale but the results are not significant; these variables are not good predictors for the total score of the scale.

Conclusion

Results constitute a first step toward the validation of a measure of the attitudes towards people with a diagnosis of BPD. The instrument could be also used to assess the effect of training workshops aimed to change mental health professionals’ attitudes toward this clinical population.     

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.     

Manifestations psychopathologiques dans la maladie de Gilles de la Tourette

Psychopathological and psychiatric comorbidities occur in approximatively 90% of patients suffering from Gilles de la Tourette's syndrome. Attention-deficit/hyperactivity disorders and obsessive-compulsive disorders are the most common syndromes. Troubles in controlling impulses and self-mutilation behaviors also constitute major handicaps that may lead to the social isolation of patients.     

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).     

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.     

Évaluation du bullying scolaire (harcèlement scolaire) chez les adolescents français : validité de l’adaptation française du questionnaire Agresseur/Victime révisé d’Olweus (1996)

Bullying is a widespread problem in schools. There would be a benefit in the availability of a valid instrument for its measurement in France. The Olweus Bully/Victim Questionnaire revised (BVQr) (Olweus, 1996) [21] is one of the most widely used bullying self-report in the world, but no data are available on its validity for its use with French adolescents.