Suivi à long terme des effets d’un entraînement de la mémoire de travail (Cogmed) auprès d’enfants présentant un TDA/H

BackgroundAttention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder associated with working memory deficits. In that optic, new interventions designed to train working memory have been developed. Cogmed Working Memory Training (CWMT) is a popular online training program that is said to increase working memory (WM) and related skills in the ADHD population. However, follow-up measures are not systematically included, and long-term effects of CWMT are controversial. Also, the number of studies examining transfer of learning and controlling for medication or comorbidities are limited.ObjectivesThis study investigates the long-term effects of CWMT combined with psychostimulant medication on WM and related skills.MethodsThis study included 31 participants aged 7 to 13 years, diagnosed with ADHD (mixed subtype) associated with learning disorders, oppositional-defiant disorder and/or Tourette syndrome. Participants first completed CWMT and were evaluated at follow-up six months later. We used a randomized, double-blind, placebo-controlled design.ResultsThe results found no significant impact of CWMT at follow-up. There were no improvements of WM nor transfer effects on related skills, academic achievement or ADHD symptoms at six months’ follow-up.ConclusionLong-term efficacy of CWMT is not demonstrated. We can’t support CWMT as an effective complementary treatment for children with ADHD and associated comorbidities.     

Les m��dicaments �� lib��ration prolong��e pour les enfants et les adolescents ayant un trouble de d��ficit de l��attention avec hyperactivit��

Attention-deficit hyperactivity disorder (ADHD) affects one in 20 Canadian children, and is associated with unfavourable academic and employment records, high rates of injury and substance abuse, poor interpersonal relationships, poor mental health outcomes and poor quality of life. Medications have been shown to be efficacious in treating ADHD symptoms in controlled trials, and are associated with better social and health outcomes in observational studies. Extended-release (XR) medications for ADHD are preferred over short-acting immediate-release medications by many families and their treating physicians. The XR preparations are often unaffordable for affected families who are disproportionally among the lower socioeconomic strata.The objective of the present statement was to critically appraise the evidence for the relative effectiveness of XR versus immediate-release medications, and to make recommendations for their appropriate use in the treatment of ADHD.When medication is indicated, XR preparations should be considered as first-line therapy for ADHD because they are more effective and less likely to be diverted. Future research and cost-benefit analyses should consider both efficacy and effectiveness, and the diversion and misuse potentials of these medications. Industry, insurance companies and government must work together to make these medications accessible to all children and youth with ADHD.De nombreuses familles touchées par le trouble de déficit de l’attention avec hyperactivité (TDAH), ainsi que leur médecin traitant possédant des compétences en matière de TDAH, préfèrent les médicaments à libération prolongée (LP) aux médicaments à action brève (1–4). Toutefois, les préparations à LP sont coûteuses et souvent inabordables pour les familles parce que la proportion de diagnostics de TDAH touche de manière disproportionnée les enfants des populations défavorisées (5) dans les pays industrialisés (6). Ce ne sont pas tous les régimes d’assurance publics et privés canadiens qui couvrent les médicaments à LP contre le TDAH. Le présent document de principes vise à examiner les données probantes à l’égard de l’efficacité relative des médicaments à LP par rapport aux médicaments à libération immédiate (LI) et à proposer des recommandations quant à leur utilisation convenable dans le traitement du TDAH.     

Les capacités mnésiques de l’enfant présentant un trouble déficit de l’attention : état des lieux

Attention deficit/hyperactivity disorder is a neurodevelopmental disorder marked by a strong heterogeneity of the cognitive and behavioral profiles of affected children. They can be diverse and have various repercussions in the child's daily life. An alteration of the working memory capacities is very often found. This impairment affects the central executive in a privileged way and could be consecutive to the symptoms of the disorder or constitutive of the disorder. The study of episodic memory performance gives less consensual results. Although secondary weakness can sometimes be observed, episodic impairment does not seem to be systematic. However, some authors believe that episodic impairment may be constitutive of attention deficit/hyperactivity disorder. The memory evaluation of attention deficit/hyperactivity disorder remains interesting from a functional point of view to propose personalized learning techniques. It is also important to look into the quality of memory of these children. Attentional and executive impairments could both falsify memory accuracy, while reinforcing the memory trace due to the processing of many contextual elements during encoding.     

Le psychotraumatisme chez l’enfant et l’adolescent est-il un facteur de risque d’émergence d’un trouble psychotique ? Une revue de la littérature

ObjectiveThis literature review aims to explore childhood and adolescent trauma as a risk factor for the emergence of psychotic disorders.MethodsThis literature review is based on PubMed and Google Scholar with studies selected after 1994 in order to use DSM-IV or DSM-5 criteria for Post-Traumatic Stress Disorder (PTSD). A total of 33 studies with a robust level of evidence were included in the current research, mainly prospective studies and meta-analyses of retrospective studies.ResultsTraumatic events in childhood and adolescent years were a risk factor for developing psychotic disorders with a 2-to-3-fold increase in risk compared to individuals without any trauma history. In addition, the accumulation of traumatic events increased this risk to more than 4-fold after 3 traumatic events. Furthermore, in patients with psychosis symptoms and a history of traumatic events, symptoms were more severe and more resistant. Finally, multiple dimensions of post traumatic symptoms appeared to mediate the relation between trauma and psychotic emergence.ConclusionSpotting traumatic events in life, taking care of chronic and repetitive trauma as soon as possible and preventing revictimization by building trauma sensitive institutions appear to be a way of preventing psychosis outcomes.     

Travail interprofessionnel et adaptations pédagogiques : qu’en est-il de l’accompagnement des enfants avec un trouble développemental de la coordination (TDC) ?

Purpose of the study

This work aims to question the perception of parents and teachers about the joint work implemented around instructional accommodations that can be proposed to pupils with Developmental Coordination Disorder.

Psychomotricité et trouble du déficit de l’attention/hyperactivité : évaluation d’un programme de rééducation basé sur des mises en situation rythmique

Aim of the studyThis study aimed at investigating the effects of a rhythm-based therapeutic program among ADHD children by assessing performance in attentional and executive domains.Participants and methodTwenty-one children (mean age: 9.1, SD: 1.8; 3 females) who previously received a diagnosis of ADHD benefited from a rhythm-based training program (8 to 12 training sessions) delivered during a psychomotor therapy. The program consisted of rhythmic perceptuo-motor exercises, including sensorimotor synchronization to external beats (metronome, music). Attentional and executive performances were assessed with a test-retest experimental design.ResultsAttentional and executive performance improved in different domains: inhibition, cognitive impulsiveness and visuo-spatial working memory. A slight improvement was visible for divided attention, whereas sustained auditory attention, selective visual attention and delay aversion did not change after intervention.ConclusionThese results are in favor of tight relations between a rhythmic training program and some attentional and executive functions among ADHD children, with beneficial effects of the training on a variety of cognitive performances. This study seems promising for the purpose of supplementing chemical treatments among a range of ADHD patients in cognitive domain.     

Risques cardiovasculaires et conduite à tenir dans le traitement du trouble déficit de l’attention/hyperactivité avec le méthylphénidate

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common of the pediatric neuropsychiatric disorders. Methylphenidate is an important element of therapeutic strategies for ADHD. Clinicians are interested in the safety of methylphenidate. Because this drug raises heart rate and blood pressure, concerns have been raised about its cardiovascular safety. Concerns were based on case reports of sudden cardiac death in methylphenidate users, plausible pharmacological pathways involving well-established stimulant effects on heart rate and blood pressure. Until recently, data were limited to a number of observational studies too small to examine serious cardiac events. In the past two years, large retrospective, population-based cohort studies were performed. These studies did not show any evidence that methylphenidate was associated with an increase in risk of myocardial infarction, sudden cardiac death, or stroke. Treatment of children with methylphenidate is not significantly associated with an increase in the short term or mid-term risk of severe cardiac events. For many, available data now will be seen as reassuring. But gaps persist in the methodical and comprehensive assessments of the safety of methylphenidate. Analyses cannot be generalized to children with long-term use of stimulants. Furthermore, long-term effects of slight increases in heart rate or blood pressure are unknown. Stimulant administration continues to have a detectable adrenergic effect even after years of treatment. In the MTA study, greater cumulative stimulant exposure was associated with a higher heart rate at years 3 and 8. Although less severe, such adverse cardiac events are nonetheless alarming to patients. This adrenergic effect may have clinical implications, especially for individual patients with underlying heart abnormalities and it deserves further investigation. More research is necessary to optimize a safe use of methylphenidate regarding its cardiovascular effects. In light of the controversies surrounding the increase in the number of children being diagnosed with ADHD, the broad use of methylphenidate in these patients, and cardiovascular concerns about it, this article addresses topics of clinical significance. For ease of use by practitioners, the article summarizes the guidelines stated by the European Medicines Agency over the appropriate pretreatment evaluation and cardiovascular assessment. It advocates a thorough history and physical examination before initiating methylphenidate to treat patients with ADHD, with an emphasis on the identification of risk factors for sudden death. A cardiac sub-specialist consultation is mandatory in case of history or physical examination findings. In other cases, an electrocardiographic screening is recommended in order to check out previously unrecognized heart disease.     

Transformer les pratiques entre la psychiatrie de l’enfant et de l’adolescent et la psychiatrie de l’adulte pour une réelle prévention

It is estimated that around 20% of children in the general population have a parent affected by a major psychiatric disease such as schizophrenia, bipolar disorder or recurrent major depressive disorder. Nevertheless, we face the “medical paradox” in which these children most at risk, born to an affected parent, are overlooked by our health systems. These children are indeed 15 to 20 times more likely to develop a psychiatric disorder as young adults, and 50% of them present childhood developmental or behavioural problems deserving treatment. Several indicators of brain dysfunctions, or risk endophenotypes, carried by adult patients can be detected early in the life of these children, thus making it possible to differentiate the child at highest risk among the siblings in the same family. These discoveries support the neurodevelopmental hypothesis of schizophrenia, bipolar disorder and recurrent major depression and the partially shared origin of these three disorders. In this selective scientific review, we will discuss data suggesting that, among children at risk, those who progress towards the illness cumulate risk indicators during their early trajectory. This aggregation phenomenon can serve as an empirical ground for the definition of preclinical stages in the risk trajectory and the development of clinical practice guidelines regarding surveillance or prevention in these children. Governmental legislations have already been promulgated in several countries with mitigated success to change the situation for these high-risk children and families. Based on existing scientific data, we thus propose that clinical practice guidelines be delivered by national medical academies so as to bring about the needed changes, improve communication between primary care, and specialized care and foster functional connections between child and adult psychiatry.     

Consensus international sur le dépistage,le diagnostic et le traitement des adolescents avec un trouble du déficit de l’attention avec ou sans hyperactivité en cas de comorbidité avec des troubles de l’usage de substances

BackgroundChildhood attention-deficit/hyperactivity disorder (ADHD) is a risk factor for substance misuse and substance use disorder (SUD) in adolescence and (early) adulthood. ADHD and SUD also frequently co-occur in treatment-seeking adolescents, which complicates diagnosis and treatment and is associated with poor treatment outcomes. Research on the effect of treatment of childhood ADHD on the prevention of adolescent SUD is inconclusive, and studies on the diagnosis and treatment of adolescents with ADHD and SUD are scarce. Thus, the available evidence is generally not sufficient to justify robust treatment recommendations.ObjectiveThe aim of the study was to obtain a consensus statement based on a combination of scientific data and clinical experience.MethodA modified Delphi study to reach consensus based upon the combination of scientific data and clinical experience with a multidisciplinary group of 55 experts from 17 countries. The experts were asked to rate a set of statements on the effect of treatment of childhood ADHD on adolescent SUD and on the screening, diagnosis, and treatment of adolescents with comorbid ADHD and SUD.ResultsAfter 3 iterative rounds of rating and adapting 37 statements, consensus was reached on 36 of these statements representing 6 domains: general (n = 4), risk of developing SUD (n = 3), screening and diagnosis (n = 7), psychosocial treatment (n = 5), pharmacological treatment (n = 11), and complementary treatments (n = 7). Routine screening is recommended for ADHD in adolescent patients in substance abuse treatment and for SUD in adolescent patients with ADHD in mental healthcare settings. Long-acting stimulants are recommended as the firstline treatment of ADHD in adolescents with concurrent ADHD and SUD, and pharmacotherapy should preferably be embedded in psychosocial treatment. The only remaining no-consensus statement concerned the requirement of abstinence before starting pharmacological treatment in adolescents with ADHD and concurrent SUD. In contrast to the majority, some experts required full abstinence before starting any pharmacological treatment, some were against the use of stimulants in the treatment of these patients (independent of abstinence), while some were against the alternative use of bupropion.ConclusionThis international consensus statement can be used by clinicians and patients together in a shared decision-making process to select the best interventions and to reach optimal outcomes in adolescent patients with concurrent ADHD and SUD.     

Signes cliniques précoces chez les enfants porteurs d’un TSA léger : description et effet de genre

BackgroundIn our Autism Spectrum Disorders Reference Center, we meet young people with mild autism spectrum disorder (ASD) with normal intellectual and language skills. The objective of this article was to characterize this population by analyzing the specific profile of these young people: first signs of concern, age of diagnosis in relation to more severe disorders, previous diagnoses, and reason for the assessment. In addition, we wanted to pay particular attention to the profiles of girls with mild ASD.MethodWe carried out a retrospective study based on the analysis of the clinical records of patients with a diagnosis of autism spectrum disorder of mild intensity according to the DSM-5, having benefited from a diagnostic assessment in our service. From the patient clinical files, we compared several elements: reason for the request, requesting persons, possible previous diagnoses, common early clinical signs. We have for each element distinguished girls and boys.ResultsWe studied a population of 33 young people with mild ASD. The assessment is most often requested by parents in the context of social interaction disorders. The average age of diagnosis is higher than in children with moderate or severe ASD, and young people have sometimes received other past diagnoses. We were able to highlight certain early signs in terms of language, sleep, food, sensory sensitivities, emotional regulation and socialization, signs that are, however, not very specific. No significant difference but rather tendencies were highlighted between girls and boys, probably related to the small size of the sample.DiscussionThe retrospective nature of this study, the sample size and the absence of a control group are limitations. However, a certain camouflage, early non-specific signs as well as sometimes less suitable diagnostic tools can explain a later diagnosis in young carriers of mild ASD, some of whom have also received another diagnosis in the past. An attitude of denial of the difficulties on the part of the parents is sometimes also mentioned. As far as girls are concerned, we found them in a higher proportion than expected, given the literature which describes a sex ratio quite different from ours.ConclusionIf the early and late clinical signs concerning mild ASD are better and better known from a theoretical point of view, the diagnosis does not seem to be facilitated for all that. Also, raising the awareness of parents and first-line caregivers is required to detect children with mild ASD early in order to refer them to specialists in this disorder. Given the number of girls in our sample, it seems that they likely benefited from effective screening. A future study could relate to a comparison of our population with a control group, in order to refine the specificity of any early symptoms.     

Le trouble déficitaire de l’attention avec hyperactivité : données récentes des neurosciences et de l’expérience nord-américaine

Attention-deficit/hyperactivity disorder (ADHD) is considered to be the most common neuropsychiatric disorder of childhood in USA with a prevalence rate of approximately 7–9 %. Psyschostimulants are widely prescribed to ADHD children since three decades in USA. Here, we review neurobiological hypotheses about ADHD aetiology and about the North American experience regarding psychostimulant medication. Recent data show that the classical hypotheses positing that ADHD is caused by an underlying dopamine and/or noradrenaline deficit are weak. Although we have no better theory that might receive a general consensus, the high heritability of ADHD is often put forward to support its biological aetiology. However, “heritable” does not mean “genetic” and numerous environmental factors contribute to ADHD aetiology. Recent studies confirm that psychostimulants are safe, well tolerated and efficient regarding the core symptoms of ADHD as ascertained by proper diagnostic procedures. However, children with ADHD are at risk of later development of antisocial behavior, substance abuse and significant academic underachievement. Recent studies show that psychostimulant medication does not affect these long-term risks. In contrast, psychosocial interventions directed towards ADHD children and their parents significantly decrease these risks as well as other comorbid disorders often associated with ADHD (anxiety, depression, conduct disorder). Thus, psychosocial treatments now represent the first-line intervention for ADHD. Therefore, dogmas regarding ADHD are now questioned and this re-examining should lead to look more favorably on the French clinical experience about pediatric psychiatry and psychopathology.     

Faut-il maintenir un dépistage de l’hyperplasie congénitale des surrénales pour les prématurés ?

Congenital adrenal hyperplasia neonatal screening has been introduced in France since 1995. A recent survey has questioned its relevance in premature infants because of a high number of false positives and a low positive predictive value of 17-hydroxyprogesterone dosage. A workgroup at the French screening association (Association française de dépistage et de prévention des handicaps de l’enfant) collected all the epidemiological, clinical and biological data of premature children presenting with adrenal hyperplasia from the national cohort. Their results were compared with those of healthy premature children. All the data showed that the screening in children born before 32 weeks of gestational age is irrelevant, but that it is efficient after this term. A pilot study has been implemented in population to evaluate the opportunity to discontinue this screening in extreme preterm neonates.     

Qualité de vie des fratries d’enfants avec un trouble du spectre de l’autisme. Revue de littérature

The national strategy “Autism within neurodevelopmental disorders” recommends providing support and assistance to the families. Indeed, families with a disabled child, and in particular a child with Autism Spectrum Disorder (ASD), must regularly adapt to the disorder and its manifestations. The concept of quality of life makes it possible to question the difficulties of families from the point of view of both parents and siblings. Yet, few studies have evaluated the quality of life of siblings, their needs and the effects of support measures if any. We therefore conducted a literature review on the quality of life of siblings of children with ASD (databases queried: PubMed, PsycINFO and Google Scholar). We identified 53 studies published between 1993 and 2019. The research shows very mixed results regarding the impact of ASD on the quality of life of siblings. We present the results here, with one-third of the studies finding no impact, another third observing overall negative effects, and the remaining third showing mixed negative and positive effects. The research highlights the particular effect of behavioral difficulties of children with ASDs on the experiences of their siblings. There are significant methodological differences between the studies, with qualitative or quantitative approaches, differences in the mode of data collection, and the choice of comparative dimension. The theoretical concepts used to measure a sibling's well-being vary across studies, but most focus on the social and behavioral adjustment of siblings which is only one aspect of the quality of life.