Evaluation of a medically coordinated care program in the management of autism.

Autism spectrum disorders (ASD) are neurodevelopmental disorders of varying intensity and disability. The reference health strategy in France for the care of young children with autism is day care hospital (DCH). As the number of places in DCH is insufficient, medically coordinated care programs by the mental health consultation centers (MHCC) are being developed in response. OBJECTIVES: Our objective is to evaluate the effectiveness of a medically coordinated care program in a MHCC versus the care in DCH of child psychiatry. METHODS: Non-inferiority retrospective study comparing the evolution after one year of care of 20 ASD children divided into two groups DCH and MHCC. In the DCH ASD group, the child is taken care of two half-days a week in a day hospital with individual educational care. In the MHCC ASD group, the child benefits from a medically coordinated care program. The medical care is reinforced by more frequent and longer consultations with guidance offered to parents. In both groups, the child receives speech therapy and psychomotor therapy in private practice at the same rate. Comparison is made using a composite criterion associating CARS-2 and VABS-II. Non-inferiority of the medically coordinated care program in autism in reference to DCH was tested on the difference between the changes (DCH group variation - MHCC group variation) with a non-inferiority threshold of 10% of the initial value of each score. RESULTS: We observed a reduction in autism severity at the CARS-2 and a moderate improvement in socio-adaptive behavior at the VABS-II in both groups. This trend was even more pronounced in the MHCC group than in the DCH group, but only the greater reduction in CARS-2 severity in the MHCC was statistically significant. CONCLUSIONS: As it is necessary to integrate the two scales into the composite criterion, it is not possible to retain the non-inferiority of the MHCC with care program. However, both those children followed in DCH and those in the MHCC care program progress. This shows the relevance of the care offered at the MHCC for children suffering from ASD, in the context of a growing lack of space in DCH. The continuation of this research work through multicenter studies with larger numbers could demonstrate the non-inferiority of coordinated care programs in the MHCC versus DCH. It would also allow subgroups to be set up, taking into account the initial characteristics of the children in order to have more precise indications concerning the relevance of each treatment.

Effect of physical therapy on 7- to 10-year-old children with autism spectrum disorder: A retrospective study in a university day hospital.

More than half of children who have autism spectrum disorder (ASD) suffer from motor impairment. In a retrospective study, the authors investigated the effect of a body-mediated workshop with dance movement therapy (DMT) on the motor skills and social skills of children with ASD by comparing 10 autistic children aged 7 to 10 years who benefited from DMT with 10 autistic children in a control group. Scores on the Movement Assessment Battery for Children and the Vineland Adaptive Behavior Scale were compared. The body-mediated workshop had significant benefits for motricity, especially manual dexterity, and for relational skills. A body-mediated workshop may have a multimodal effect and requires transmodal training. Regarding the mechanisms that explain the benefits and the cascading effect, the roles of imitation and multimodal connections are important.

Views of Medical Examiners and Psychiatrists on the Compatibility of the Mental State with Detention in Police Custody in Marseille University Hospital.

Police custody is detention in response to a suspicion of crime. A person in custody has the right to be examined by a physician, who is responsible for determining whether the person's medical condition allows him/her to continue to be held in detention. However, there is no consensus on the definition of compatibility of the mental state with custody. Our objective was to determine the relevant criteria for compatibility and incompatibility of the mental state with detention in police custody according to medical examiners and psychiatrists. A descriptive study using a semi-structured questionnaire was conducted from November 2016 to May 2017 with medical examiners and psychiatrists who examined detainees in police custody in Marseille. We recruited 17 medical examiners and 43 psychiatrists. We identified three sets of criteria used to determine a mental state compatible with custody: care, pathology/disorder, and the context of police custody. The primary determinant of incompatibility was a need for immediate hospitalization, followed by a high suicide risk, psychiatric dangerousness, delusional symptomatology, an inability to understand questions, and an inability for the detainee to defend him-/herself. The psychiatrists and medical examiners differed significantly in their views of suicide risk, delusional symptomatology, and psychiatric diagnosis. Our work has permitted identification of the main determinants of incompatibility of the mental state with custody according to psychiatrists and medical examiners in Marseille. It offers preliminary results to reach a consensus and provide an inventory for physicians to use regarding police custody.

Early-Onset Schizophrenia in a paediatric population of French psychiatric and medico-social care centres: A cross sectional study.

BACKGROUND: Early-Onset Schizophrenia (EOS) is rare but severe mental health disorder in children and adolescents. Diagnosis of schizophrenia before the age of 18 years remains complex and challenging, especially in young children. In France, there are no recent reliable epidemiological data about the prevalence of EOS. The present study evaluates the EOS rate in a target clinical population of children and adolescents in psychiatric and medico-social care centres in the South-East of France. METHODS: Psychiatric and medico-social centres for children and adolescent in the geographical area have been contacted, and after receiving their agreement to participate in the study, eligible patients corresponding to inclusion criteria were selected based on patients' medical records. Main inclusion criteria were age 7 to 17 years and intelligence quotient > 35. EOS categorical diagnosis was assessed by Kiddie-SADS Present and Lifetime psychosis section. RESULTS: 37 centres participated and 302 subjects have been included in the study. The main result was the categorical diagnosis of EOS in 27 subjects, corresponding to a rate of 8.9% in the study population. Half of the patients presented mild to moderate intellectual deficiency. Interestingly, only 2.3% had a diagnosis of schizophrenia spectrum disorder noted in their medical records before standardized assessment. CONCLUSIONS: The results of the study highlight the importance of using a standardized diagnostic tool for the diagnosis of schizophrenia in the paediatric population. In fact, EOS might be underdiagnosed in children and adolescents with neurodevelopmental disorders and subnormal cognitive functioning. TRIAL REGISTRATION: NCT01512641. Registered 19 January 2012; https://clinicaltrials.gov/ct2/show/NCT01512641.

Infant psychomotor development in cases of maternal postpartum depression: Observation of a mother and baby unit.

Studies of the first year of infant psychomotor development in cases of maternal postpartum depression are lacking. The mother and baby unit (MBU) is a healthcare system available to infants and their mothers during the postpartum period in a psychiatric hospital, which provides support and preserves the parent's role in the child's daily care. The aim of the paper is to describe the developmental profile of babies of mothers with severe postpartum depression treated in an MBU through the developmental quotients. Using the Brunet-Lézine scale, we studied six-month-old infants whose mothers were hospitalized. The study population consisted of 15 infants. The mean global developmental quotient score was 96.7. A developmental quotient lower than 80 was not observed for any of the children. We found no global psychomotor developmental delays. Despite this, the posture subscore was the area in which we observed the most difficulties. It is possible that the tonic dialogue between the mother and infant is disrupted by maternal depression.

Exploration and characterisation of the phenotypic and genetic profiles of patients with early onset schizophrenia associated with autism spectrum disorder and their first-degree relatives: a French multicentre case series study protocol (GenAuDiss).

INTRODUCTION: Early-onset schizophrenia (EOS) is a rare and severe condition. A higher rate of neurodevelopmental abnormalities, such as intellectual or communication impairments as well as attention deficit hyperactivity disorder, is observed in EOS compared with adult-onset schizophrenia. Early signs of autism spectrum disorders (ASD) are present in about 30% of patients. Genetic abnormalities, including copy number variations, are frequent in neurodevelopmental disorders and have been associated to ASD physiopathology. Implicated genes encode proteins involved in brain development, synapses morphology and plasticity and neurogenesis. In addition, an increasing number of genetic abnormalities are shared by EOS and ASD, underlying the neurodevelopmental hypothesis of EOS.The main objective of our study is to identify disease-causing genetic mutations in a cohort of patients affected by both EOS and ASD. Special attention will be paid to genes involved in neurodevelopmental pathways. METHODS AND ANALYSIS: We describe a multicentric study in a paediatric population. The study started in April 2014. Inclusion criteria are: age 7-22 years, diagnosis of EOS with comorbid ASD and IQ >50; Parents and siblings are also enrolled. We perform psychiatric assessments (Mini International Neuropsychiatric Interview, Kiddie Schedule for Affective Disorders and Schizophrenia -Present and Lifetime Version, Positive and Negative Syndrome Scale and Scale for the Assessment of Negative Symptoms) together with neurocognitive evaluations (IQ, Trail Making Test A/B and verbal fluency). Then, we study variants of the coding part of DNA (exome), using next-generation sequencing process on trio (mother, father and child). Bioinformatics tools (RVIS and PolyPhen-2) are used to prioritise disease-causing mutations in candidate genes. The inclusion period will end in November 2019. ETHICS AND DISSEMINATION: The study protocol was approved by the Local Ethic Committee and by the French National Agency for Medicines and Health Products Safety. All patients signed informed consent on enrolment in the study. Results of the present study should help to unravel the molecular pathology of EOS, paving the way for an early therapeutic intervention. TRIAL REGISTRATION NUMBER: NCT0256552; Pre-results.

An atypical autistic phenotype associated with a 2q13 microdeletion: a case report.

BACKGROUND: Autism spectrum disorders are serious neurodevelopmental disorders that affect approximately 1% of the population. These disorders are substantially influenced by genetics. Several recent linkage analyses have examined copy number variations associated with autism risk. Microdeletion of the 2q13 region is considered a pathogenic copy number variation. This microdeletion is involved in developmental delays, congenital heart defects, dysmorphism, and various psychiatric disorders, including autism spectrum disorders. There are only 34 reported cases with this chromosomal deletion, and five cases of autism spectrum disorders have been identified among them. The autistic phenotype associated with this microdeletion has never been described. CASE PRESENTATION: We describe the case of a 44-month-old Caucasian girl with the 2q13 microdeletion and autism spectrum disorders with global development delay but no associated organ anomalies. We examined the autistic phenotype using different workups and observed an atypical phenotype defined by relatively preserved relational competency and imitation abilities. CONCLUSIONS: The main contribution of this case report is the precise description of the autistic phenotype in the case of this deletion. We observed some atypical clinical features that could be markers of this genetic anomaly. We have discussed the pathophysiology of autism associated with this microdeletion and its incomplete penetrance and variable expressivity.

Impact of an implicit social skills training group in children with autism spectrum disorder without intellectual disability: A before-and-after study.

INTRODUCTION: Children with Autism Spectrum Disorders (ASDs) have problems with social skills. Social skills training groups are among the proposed therapeutic strategies, but their efficacy still needs to be evaluated. OBJECTIVE: To evaluate the efficacy of an implicit social skills training group in children with ASDs without intellectual disability. METHODS: A before-and-after study of children with ASD without intellectual disability was conducted in a child psychiatry day hospital, where they participated in an implicit group with cooperative games. Their social skills were assessed using the Social-Emotional Profile (SEP), the Childhood Autism Rating Scale (CARS), and the empathy quotient (EQ) before and after 22 weeks. RESULTS: Six patients aged 9 to 10 years old were evaluated. A significant increase in overall adaptation and social skills (median 8 and 7.7 points) in the SEP was demonstrated in addition to a significant reduction in the CARS score (median: 4 points), including in the field of social relationships. The EQ increased two-fold. DISCUSSION­CONCLUSION: This implicit group improved the children's social skills. It would be interesting to evaluate the maintenance of these skills over time, examine more widespread results, and compare implicit and explicit groups.

Localized Misfolding Within Broca's Area as a Distinctive Feature of Autistic Disorder.

BACKGROUND: Recent neuroimaging studies suggest that autism spectrum disorder results from abnormalities in the cortical folding pattern. Usual morphometric measurements have failed to provide reliable neuroanatomic markers. Here, we propose that sulcal pits, which are the deepest points in each fold, are suitable candidates to uncover this atypical cortical folding. METHODS: Sulcal pits were extracted from a magnetic resonance imaging database of 102 children (1.5-10 years old) distributed in three groups: children with autistic disorder (n = 59), typically developing children (n = 22), and children with pervasive developmental disorder not otherwise specified (n = 21). The geometrical properties of sulcal pits were compared between these three groups. RESULTS: Fold-level analyses revealed a reduced pit depth in the left ascending ramus of the Sylvian fissure in children with autistic disorder only. The depth of this central fold of Broca's area was correlated with the social communication impairments that are characteristic of the pathology. CONCLUSIONS: Our findings support an atypical gyrogenesis of this specific fold in autistic disorder that could be used for differential diagnosis. Sulcal pits constitute valuable markers of the cortical folding dynamics and could help for the early detection of atypical brain maturation.

How do children with autism spectrum disorders express pain? A comparison with developmentally delayed and typically developing children.

There is a lack of knowledge about pain reactions in children with autism spectrum disorders (ASD), who have often been considered as insensitive to pain. The objective of this study was to describe the facial, behavioral and physiological reactions of children with ASD during venipuncture and to compare them to the reactions of children with an intellectual disability and nonimpaired control children. We also examined the relation between developmental age and pain reactions. The sample included 35 children with ASD, 32 children with an intellectual disability, and 36 nonimpaired children. The children were videotaped during venipuncture and their heart rate was recorded. Facial reactions were assessed using the Child Facial Coding System (CFCS) and behavioral reactions were scored using the Noncommunicating Children's Pain Checklist (NCCPC). A linear mixed-effects model showed that children's reactions increased between baseline and venipuncture and decreased between the end of venipuncture and the recovery period. There was no significant difference between groups regarding the amount of facial, behavioral and physiological reactions. However, behavioral reactions seemed to remain high in children with ASD after the end of the venipuncture, in contrast with children in the 2 other groups. Moreover, we observed a significant decrease in pain expression with age in nonimpaired children, but no such effect was found regarding children with ASD. The data reveal that children with ASD displayed a significant pain reaction in this situation and tend to recover more slowly after the painful experience. Improvement in pain assessment and management in this population is necessary.

Predictors of infant foster care in cases of maternal psychiatric disorders.

PURPOSE: Our aim was to investigate the factors associated with mother-child separation at discharge, after joint hospitalization in psychiatric mother-baby units (MBUs) in France and Belgium. Because parents with postpartum psychiatric disorders are at risk of disturbed parent-infant interactions, their infants have an increased risk of an unstable early foundation. They may be particularly vulnerable to environmental stress and have a higher risk of developing some psychiatric disorders in adulthood. METHODS: This prospective longitudinal study of 1,018 women with postpartum psychiatric disorders, jointly admitted with their infant to 16 French and Belgian psychiatric mother-baby units (MBUs), used multifactorial logistic regression models to assess the risk factors for mother-child separation at discharge from MBUs. Those factors include some infant characteristics associated with personal vulnerability, parents' pathology and psychosocial context. RESULTS: Most children were discharged with their mothers, but 151 (15 %) were separated from their mothers at discharge. Risk factors independently associated with separation were: (1) neonatal or infant medical problems or complications; (2) maternal psychiatric disorder; (3) paternal psychiatric disorder; (4) maternal lack of good relationship with others; (5) mother receipt of disability benefits; (6) low social class. CONCLUSIONS: This study highlights the existence of factors other than maternal pathology that lead to decisions to separate mother and child for the child's protection in a population of mentally ill mothers jointly hospitalized with the baby in the postpartum period.

Do children perceive features of real and cartoon faces in the same way? Evidence from typical development and autism.

In the current study, typically developing children and children with autism spectrum disorders (ASD) were presented with a facial-feature discrimination task including both real and cartoon faces, displayed either upright or inverted. Results demonstrated that typically developing children were more accurate at discriminating facial features from upright than from inverted faces and that this effect was specific to real faces. By contrast, children with ASD failed to show such a specific pattern of performance for processing facial features displayed in real faces. Findings of the current study suggest that face type (real vs. cartoon) does not affect perceptual ability in children with ASD as it does in typically developing children.

Emotion understanding in children with ADHD.

Several studies suggest that children with ADHD tend to perform worse than typically developing children on emotion recognition tasks. However, most of these studies have focused on the recognition of facial expression, while there is evidence that context plays a major role on emotion perception. This study aims at further investigating emotion processing in children with ADHD, by assessing not only facial emotion recognition (Experiment 1) but also emotion recognition on the basis of contextual cues (Experiment 2). Twenty-seven children and adolescents with ADHD were compared to age-matched typically developing controls. Importantly, findings of this study show that emotion-processing difficulties in children with ADHD extend beyond facial emotion and also affect the recognition of emotions on the basis of contextual information. Our data thus indicate that children with ADHD have an overall emotion-processing deficit.

When depression mediates the relationship between entity beliefs and performance.

The aim of this study was to determine whether depression can explain the negative relationship between academic performance and the belief that intelligence is a fixed trait, i.e., entity belief. A sample of 353 French volunteer adolescents (age 11-16) completed questionnaires assessing entity theory and depressive symptoms (Children Depression Inventory: CDI). Academic performance was assessed by math performance while controlling for baseline level of math ability. Results of this study revealed that entity theory is a significant negative predictor of academic performance and a significant positive predictor of depression. Importantly, our findings also show that depression plays a significant mediating role between entity theory and academic performance. Our findings indicate that individuals who consider their abilities to be non-malleable are more likely to develop depressive symptoms which, in turn, decrease academic performance. These findings contribute to tailoring specific prevention and treatment programs for childhood and adolescent depression.

The impact of weight normalization on quality of recovery in anorexia nervosa.

BACKGROUND: There is little agreement on what constitutes remission in anorexia nervosa. OBJECTIVE: This study compared the medical, psychological, and social status of 2 female populations previously treated for anorexia nervosa and differing in their achievement of normal weight. DESIGN: One hundred forty-one patients responded to a questionnaire documenting morphometric parameters, subjective perception of outcome, concerns about body shape and diet, and quality of familial, emotional, and professional life. Two groups were defined according to body mass index (BMI): normal (n = 69) with BMI > or = 18.5 kg/m(2), and subnormal (n = 72) with BMI < 18.5 kg/m(2). In addition, subgroups (21 in each category) were interviewed. An age-matched control population composed of 156 women, either students or Health Services employees, responded to a similar questionnaire. RESULTS: Only a minority of patients assessed themselves as recovered, and there was no statistically significant difference in perception of recovery between normal BMI and subnormal BMI groups (27.5% and 15.3%, respectively). As expected, underweight patients reported significantly more frequent purging behaviors, amenorrhea, recent hospitalization, and prolonged student status. In contrast, there were no significant differences in terms of pregnancy rate, psychiatric comorbidities, social integration, sexual activity, and self-assessment of professional and familial life. In comparison to control subjects, former anorexia patients with normalized BMI more frequently reported vomiting, fear of high-calorie foods, and treatment for depression. CONCLUSIONS: These few long-term advantages observed after BMI normalization suggest that normalization of nutritional status remains an important target in anorexia nervosa. However, the persistence of psychological distress after nutritional recovery confirms that more effective treatments are needed that target long-term psychological recovery.

[Schizophrenia or Asperger syndrome?]. / Schizophrénie ou syndrome d'Asperger?

Patients with Asperger syndrome are often diagnosed late or are wrongly considered to have schizophrenia. Misdiagnosing Asperger syndrome creates serious problems by preventing effective therapy. Several clinical signs described in Asperger syndrome could also be considered as clinical signs of schizophrenia, including impaired social interactions, disabilities in communication, restricted interests, and delusions of persecution. A number of clinical features may facilitate the differential diagnosis: younger age at onset, family history of pervasive developmental disorder, recurring conversations on the same topic, pragmatic aspects of language use, oddities of intonation and pitch, lack of imagination, and incomprehension of social rules are more characteristic of Asperger syndrome. Accurate distinction between Asperger syndrome and schizophrenia would make it possible to offer more treatment appropriate to the patient's functioning.