Toward an integrative socio-cognitive approach in autism spectrum disorder: NEAR method adaptation-study protocol.

Background: The cognitive impairments exhibited by people with ASD, threaten the development of social skills that are essential for establishing and maintaining harmonious social relationships. Cognitive remediation and social skills training are now considered as crucial therapeutic approaches in the management of these disorders. Several programs have already been validated and have shown improvements in social skills or cognitive performance. However, the effects of these training methods seem to be difficult to generalize to other everyday life. The aim of our study is to alleviate cognitive and social deficiencies by using a socio-cognitive framework to adapt the Neuropsychological Educational Approach to Remediation (NEAR) method for adolescents with ASD. Methods/design: Adolescents meeting the DSM-5 criteria for ASD, older than 13 years, and following a regular school curriculum will be recruited from clinical population at the Child and Adolescent Psychiatry in Razi University Hospital-Manouba- Tunisia. Our study is an open and non-randomized controlled trial including 30 patients: NEAR group / control group. The NEAR method combines computerized cognitive exercises and bridging groups inspired from cognitive behavioral therapy. NEAR group will be divided into three groups of five patients each. The duration of the sessions will vary according to the capacities of the participants and the exchanges between them (about 60­120 min). In our study, bridging groups will be amended by adding other tasks including planning role plays and scenarios of problematic social situations in autism, taking into account cultural particularities in order to promote social skills. Computerized exercises will be enriched by adding other tasks aiming to improve the recognition and expression of facial emotions by using digital videos and photographs expressing the six basic emotions. The duration of the program will be about 6 months. All selected patients will have an assessment of cognitive function: social cognition, neurocognition and pragmatic skills, social skills, self-esteem and global functioning at baseline, 1 week after the end of the NEAR program and 6 months later. Conclusion: This adaptive program is a promising socio-cognitive intervention that create new perspectives for adolescents with autism spectrum disorder.

Assessment of theory of mind in Tunisian verbal children with autism spectrum disorder.

The present study examined performance in Theory of Mind (ToM) in a group of 31 Arabic-speaking verbal children (7-12 years-old) with autism spectrum disorder (ASD), in comparison with neurotypical controls (NT) matched for age and for cognitive abilities. An innovative task in a digital format named "The Tunisian Social Situations Instrument" (TSSI) was used and allowed us to study four different subdomains of ToM: attribution of intention and epistemic ToM (cognitive ToM), affective ToM, and detection of faux pas (advanced ToM). Our study showed impairments in ToM in children with ASD, similar to those reported in the literature. Our findings additionally suggested that affective and advanced ToM, specifically the detection of faux pas, might be more challenging for ASD children than other components of ToM. Future studies with larger number of children may lead us to specify which subdomains are the most impaired in order to develop specific tools targeting these specific impairments.

A Randomized Trial of a Swimming-Based Alternative Treatment for Children with Attention Deficit Hyperactivity Disorder.

Attention deficit hyperactivity disorder (ADHD) is considered a highly prevalent neurodevelopmental childhood disorder extending from ages 1−2 to 12−13, associated with impairment across multiple domains, including social, emotional, and cognitive functioning. Little is known about alternative treatments for this disorder. Interest has grown in physical activity as a potential intervention for rehabilitating children with ADHD. This study aimed to investigate the impact of adapted swimming activity on cognitive functions, academic performance, and related behavior of Tunisian children with ADHD. The study was conducted on school children aged 9 to 12 years (n = 40, 5 female and 35 male) diagnosed with ADHD. They were randomly assigned to an experimental group (exercise intervention) or the control group. The Hayling test was used to assess cognitive performance, the Children Behavior Check List (CBCL) was used to assess ADHD-related behavior, and the change in reading and numeracy proficiency was assessed pre- and post-intervention. After 12 weeks of the intervention, the results revealed that there were significant improvements in behavior (p < 0.001), inhibition process (p < 0.001), and academic performance (p < 0.001) in the experimental group compared with the control group. These findings suggest that adapted swimming activity may have positive implications for cognitive function, behavior, and academic performance. This research may provide preliminary support for alternative therapeutic interventions that could be used by practitioners. Moreover, the results support active practice of recreational physical activities as a strategy to support children in overcoming ADHD deficiencies.

Cognitive deficits in children with autism spectrum disorders: Toward an integrative approach combining social and non-social cognition.

Autism spectrum disorder (ASD) is associated with neurocognitive impairment, including executive dysfunctioning and social cognition (SC) deficits. Cognitive remediation (CR) is a behavioral training-based intervention aiming to improve cognitive processes. Its first use in psychiatry interested patients with schizophrenia, in whom promising results have been shown. Integrated CR programs targeting both social and non-social cognition have demonstrated to be effective in improving both cognitive domains and functional outcomes. CR studies in children and adolescents with ASD are still new, those regarding CR approaches combining social and executive functioning remediation are scares. One study examining the efficacy of cognitive enhancement therapy (CET) for improving cognitive abilities in ADS adults, showed significant differential increases in neurocognitive function and large social-cognitive improvements. Therefore, taking into account the overlap between ASD and schizophrenia, and considering the close link between executive functions (EF) and SC, we suggest that integrative approach in ASD could result in better outcomes. The present perspective aimed to highlight cognitive remediation (CR) programs contributions in ASD (especially in children and adolescents), and to discuss the value of combining social and non-social programs.

Validation of the Tunisian Empathy Scale for Children (TESC) in General Population and Children With Autism Spectrum Disorder.

Background: Several empathy assessment tests have been proposed worldwide but none of them took into account cultural variations that seem to affect empathic manifestations. The aim of this study was to create and validate an empathy assessment questionnaire for school-aged Tunisian children entitled "Tunisian Empathy Scale for Children" (TESC). Methods: An evaluative cross-sectional study was conducted. The questionnaire was administered to parents of 197 neuro-typical children and 31 children with autism without associated intellectual deficits, aged between 7 and 12 years. Validation steps included: face validity, content validity, construct validity, and reliability study. A ROC curve analysis was used to investigate the diagnostic performance of the TESC. Results: Face validity was verified with an expert panel. Content validity was examined, and 11 items were removed as irrelevant or not assessable by parents. Exploratory factor analysis extracted four domains that explained 43% of the total variance. All these domains were significantly correlated with the total score (p < 10-3) and are, respectively: empathic behaviors, affective empathy, cognitive empathy, and a combined affective and cognitive domain. The reliability study showed a satisfactory level of internal consistency of the TESC, with a Cronbach's alpha of 0.615.The diagnostic performance of the TESC in relation to autism was evaluated by the ROC curve with a sensitivity and specificity of 84.3 and 62.1%, respectively, for a total score of 16. Conclusion: A 15-item questionnaire assessing empathy in a multidimensional and culturally adapted way was obtained. The psychometric qualities of the TESC were satisfactory.

Validation of the Tunisian Test for Facial Emotions Recognition: Study in Children From 7 to 12 Years Old.

Background: Facial expressions transmit information about emotional state, facilitating communication and regulation in interpersonal relationships. Their acute recognition is essential in social adaptation and lacks among children suffering from autism spectrum disorders. The aim of our study was to validate the "Recognition of Facial Emotions: Tunisian Test for Children" among Tunisian children in order to assess facial emotion recognition in children with autism spectrum disorders (ASD). Methods: We conducted a cross-sectional study among neurotypical children from the general population. The final version of or test consisted of a static subtest of 114 photographs and a dynamic subtest of 36 videos expressing the six basic emotions (happiness, anger, sadness, disgust, fear and surprise), presented by actors of different ages and genders. The test items were coded according to Ekman's "Facial Action Coding System" method. The validation study focused on the validity of the content, the validity of the construct and the reliability. Results: We included 116 neurotypical children, from 7 to 12 years old. Our population was made up of 54 boys and 62 girls. The reliability's study showed good internal consistency for each subtest: the Cronbach coefficient was 0.88 for the static subtest and 0.85 for the dynamic subtest. The study of the internal structure through the exploratory factor analysis of the items of emotions and those of intensity showed that the distribution of the items in sub-domains was similar to their theoretical distribution. Age was significantly correlated to the mean of the overall score for both subtests (p < 10-3). Gender was no significantly correlated to the overall score (p = 0.15). High intensity photographs were better recognized. The emotion of happiness was the most recognized in both subtests. A significant difference between the overall score of the static and dynamic subtest, in favor of the dynamic one, was identified (p < 10-3). Conclusion: This work provides clinicians with a reliable tool to assess recognition of facial emotions in typically developing children.

Impaired Recognition of Static and Dynamic Facial Emotions in Children With Autism Spectrum Disorder Using Stimuli of Varying Intensities, Different Genders, and Age Ranges Faces.

A multitude of research on facial emotion recognition (FER) in Autism Spectrum Disorders (ASD) have been published since several years. However, these studies have mainly used static high intensity stimuli, including adult and/or children facial emotions. This current study investigated FER in children with ASD using an innovative task, composed of a combination of static (114 pictures) and dynamic (36 videos) subtests, including children, adolescent, and adult male and female faces, with high, medium, and low intensity of basic facial emotions, and neutral expression. The ASD group consisted of 45 Tunisian verbal children, and the control group consisted of 117 tunisian typically developing children. Both groups were aged 7-12 years. After adjusting for sex, age, mental age, and school grade, the ASD group scored lower than controls on all tests except for the recognition of happiness and fear in the static subtest, and the recognition of happiness, fear, and sadness in the dynamic subtest (p ≥ 0.05). In the ASD group, the total score of both the static and the dynamic subtest were positively correlated with the school grade (p < 0.001), but not with age, or mental age. Children with ASD performed better in recognizing facial emotions in children than in adults and adolescents on videos and photos (p < 0.001). Impairments in FER would have negative impact on the child's social development. Thus, the creation of new intervention instruments aiming to improve emotion recognition strategies at an early stage to individuals with ASD seems fundamental.

Validation of the Tunisian Social Situation Instrument in the General Pediatric Population.

BACKGROUND: In order to better understand the deployment of the theory of mind (ToM) in Tunisian neurotypical children, we have developed a new tool of assessment of the ToM called the "Tunisian Social Situations Instrument" (TSSI). We opted for the creation of this test in view of the intercultural differences in the development of social skills. Our purpose was to validate this tool in general pediatric population. METHODS: It was a cross-sectional evaluative study that aimed to validate the TSSI in the general pediatric population. We initially conducted a beta test and a pre-validation study before taking the initial version of the TSSI on 123 neurotypical children. Then, we followed the typical validation procedure: appearance validity, content validity, construct validity, and reliability study. RESULTS: Regarding the validity of appearance, the TSSI was comprehensible and adapted to the Tunisian pediatric population. About content validity, the exploratory factor analysis extracted 6 factors that explain 69.3% of the total variance. These factors were respectively social clumsiness types 1 and 2, intention attribution, emotional ToM, epistemic ToM, and simple comprehension questions. The subdomains of social clumsiness (types 1 and 2) and emotional ToM had a Cronbach alpha higher than 0.8. This factor structure as well as the significant inter-correlation between subdomains and the global score were in favor of a good construct validity. The internal consistency study showed good reliability of the final version of the TSSI (alpha of Cronbach at 0,809). Regarding the performance of children at the TSSI, we have noticed a significant association between the global score, age, and verbal intelligence. CONCLUSION: This work offers valuable insights about ToM and provides clinicians with a reliable tool to assess social clumsiness and emotional ToM in typically developing children.

Rehabilitation of ADHD children by sport intervention: a Tunisian experience.

INTRODUCTION: Childhood attention-deficit/hyperactivity disorder is associated with impairment across multiple domains, including social, familial, emotional and academic functioning. Available therapies, and in particular medical treatment, fail to produce improvement in this impairment. In this context, interest has grown in physical activity and exercise as potential interventions for the treatment of children with ADHD. AIM: The present study investigates the effect of a recreational swimming program on cognitives functions on Tunisian children with attention deficit hyperactivity disorder (ADHD). METHODS: The study recruited school children aged 9 to 12 years (n total = 40) with diagnosis of ADHD. They were randomly assigned into exercise or control groups. Neuropsychological tasks; the complex figure of Rey (ROCF), the stroop test and the Hayling test were assessed before and after the exercise program. RESULTS: The results indicates that there were significant improvements in memory accuracy (p=0,000), selective attention (p=0,000), and inhibition process (p=0,000), in experimental group compared with the control group after the intervention. In the post-program, children experienced an overall shortening of task execution times with fewer errors of omissions. They also made fewer errors in interference situations, signaling better cognitive functioning. Conclusion These findings suggest that a recreational swimming program may have positive implications for cognitive function and may provide preliminary support for alternative therapeutic interventions that can be used by researchers, parents, educators, and clinicians and they support that  reinforcement approved by recreational program can normalize  cognitive deficiencies in children with ADHD.

Cognitive remediation therapy in autism spectrum disorder: Tunisian experience.

BACKGROUND: Cognitive dysfunctions associated with Autism spectrum disorder (ASD) are nowadays highlighted. These cognitive impairments include mainly executive dysfunctioning and are linked with academic difficulties, thus representing one of the treatment targets. Cognitive remediation therapy (CRT) is a new promising program aiming to remediate cognitive impairments by targeting executive functions. It attempts to teach information processing strategies through guided mental exercises. AIM: To assess the effectiveness of the cognitive remediation program CRT (Cognitive Remediation Therapy) on executive abilities and school results, in children and adolescents with ASD. METHODS: Cross-sectional study involving children and adolescents with ASD according to DSM-5. The CRT program was conducted individually at the rate of one session per week of 45 minutes each.  Outcome measures were intellectual abilities, cognitive flexibility, working memory and school performance. RESULTS: Of the 25/24 patients included, 16 had reached the end of the program. Their average age was 10.87 years. The mean number of sessions performed was 22.38. After completion of CRT, patients showed significant improvement on intellectual abilities (p<10-3), phonemic fluency (p=0.032), « animal ¼ category of semantic fluency (p=0.045), working memory (p=0.001 for forward digit-span and p=0.006 for backward digit span) and school results (p=0.001). Patients made more repetitive and intrusive errors in semantic fluency with significant increase in the "clothes" semantic category (p=0.019). CONCLUSION: Cognitive remediation enhances cognition directly and positively acts on clinical course. It appears to be a relevant new method in the management of ASD. Yet, further research is required in order to confirm the efficiency of this treatment and to better define its optimal settings.

Contributions of autism evaluation unit in the clinical diagnosis of autism spectrum disorders.

BACKGROUND: Based on the recognized principles of assessment of autistic disorders, the child and adolescent psychiatry department in Razi Hospital developed, in coordination with the department of neurology of Razi Hospital and the department of genetics of Charles Nicolle's Hospital an assessment unit for autism spectrum disorders. OBJECTIVE: To describe the clinical characteristics in terms of severity and comorbidities of children assessed for autism spectrum disorders. METHODS: We compiled data about clinical examination of autistic symptoms using the Autism Diagnostic Interview Revised (ADI-R) and the Childhood autism Rating Scale (CARS). Each child developmental age was determined using the Psycho Educative Profile (PEP-R). Neurological examination completed with electroencephalography and genetics testing (caryoptype and X fragile) were performed. RESULTS: Fifty-two children were included in our study. The mean age was 6.6 years with a sex ratio of 6.5. The severity of the clinical presentations was assessed through the following score means: CARS 35, ADI-B: 20, ADI-C: 13, ADI-D: 7, functional developmental age: 2.4 years. Comorbidity with epilepsy was present in 7% of cases and an intellectual disability was found in 80% of them. Genetic tests were normal. CONCLUSION: Our results will be discussed in the light of international recommendations.

[Epidemiological and clinical profile of suicide attempts in Tunisian children and adolescents after the revolution]. / Profil épidémiologique et clinique des tentatives de suicide chez l'enfant et l'adolescent en Tunisie en post révolution.

BACKGROUND: Suicidal behaviors are increasing in Tunisia at younger and younger ages. This study aims to describe the sociodemographic and clinical profile of suicide attempts in children and adolescents. METHODS: We conducted a cross-sectional and descriptive study, including 50 suicidal individuals, recruited in the Child Psychiatry Department at the Razi Hospital in Manouba and in two Departments in Tunisia (Intensive Care and Reanimation Department and Department of Pediatrics) between July 2012 and June 2013. We identified the socio-demographic and clinical factors, the histories of abuse, subjects' education, the characteristics of the attempted suicides (TS), suicidal ideation assessed by the Suicidal Intent Scale and psychopathological disorders diagnosed using the Mini-International Neuropsychiatric Interview. RESULTS: The sex-ratio was 0.56, the average age was 12.4 years ranging from 7 to 16 years. School failure or dropout were found in 86% of suicidal individuals. In 38% of cases suicidal behavior was recurrent; the subjects had a history of self-mutilation to the same extent. A context of abuse was reported in 46% of cases. Drug ingestion was the most common means of suicide, psychotropic drugs were the most common substances used. There was a significant gender difference in the use of the means of suicide: the boys mainly used physical means (P=0.04) while the girls poisoning (P=0.001). Suicidal intent was high in 44% of cases. A major depressive episode and adjustment disorder were the most common disorders found (58% and 24% of cases respectively). CONCLUSION: Depressive disorders and abuse are risk factors of TS in children and adolescents, these factors should be considered when implementing suicide prevention strategies for this population.

Bumetanide in the management of autism. Tunisian experience in Razi Hospital.

BACKGROUND: Autism is a multifactorial disease with multiple etiologic hypotheses. Some studies suggest changes in brain GABA mediated inhibition in autism, and a higher intracellular chlorine levels in autistic children. Given these data, clinical trials are conducted to test the efficacy of diuretics in improving clinical symptoms in autism. AIM: The aim of our study was to evaluate the effectiveness of Bumetanide in autistic children. METHODS: This is an experimental study of cross-type. We included children older than 5 years, with autistic disorder according to the diagnostic criteria of DSM- IV (Diagnostic and Statistical Manual of Mental Disorders, IV) and ADI-R (Autism Diagnostic Interview Revised), followed by the child psychiatry consultation Razi hospital. The subjects underwent assessment using the ADI-R, the behavioral scale CARS (Childhood autistic rating scale) and CGI (Clinical Global printing) prior to take diuretic (Bumetanide). In the protocol, the children received checks to day7, day14, day30, day60, day90 comprising: a clinical evaluation (weight gain, blood pressure, general examination for potential adverse effects); biological evaluation; and evaluations by scales (CARS and CGI) after every 3 months of evolution to objectively assess effectiveness. RESULTS: Twenty-nine children were included in our study. The average age was 7.9 years.Initiation of medication was carried out with a dose of    1 mg / day, in all children. The average duration of the protocol was 12 months. Sixteen children were excluded from the study for the following reasons: appearance of hypokalemia, poor tolerance of treatment, insufficient efficacy as estimated by parents. Measuring the effectiveness of diuretic, by studying correlations in the CARS showed an efficacy of this treatment at 3 months (p˂10-3), 6 months (p˂10-3), at 9 months (p = 0.010) and 12 months (p = 0.04), and this compared to the initial assessment. Significant improvement (p˂10-3) was found between the 3rd and 6th month. CONCLUSION: While our results seem to be promising. A larger sample and a medium and long-term evaluation after the end of treatment are needed.

[Tunisia: nursing practice of cognitive remediation in child psychiatry]. / Tunisie : pratique infirmière de la remédiation cognitive en pédopsychiatrie.

Cognitive remediation is today afforded a significant place in the treatment of neurodevelopmental disorders. A hospital team, comprising in particular a nurse offering consultations in a child psychiatry unit in a public hospital in Tunis, shares its experience with regard to this technique which aims to restore impaired cognitive functions in order to improve the efficiency and quality of life of young patients.

Sensitivity to pain in autistic spectrum disorders: Its links with self-gressivity.

OBJECTIVES: To investigate the link between pain sensitivity in autism spectrum disorders (ASD) and self-aggressive behavior. METHODS: we performed a cross-sectional study which involved 50 children fulfilling DSM-V criteria for ASD; confirmed by the Autism Diagnostic Interview Revised. The severity of autism was determined using the Childhood Autism Rating Scale (CARS).The psycho-educational profile (PEP-R) was used to assess the age of development and perception.  Sensitivity to pain was assessed with item IX of the CARS. Self-aggressive behavior was assessed by the Behavior Problems Inventory. RESULTS: Pain sensitivity was lowered in 40% and elevated in 4% of children. In the univariate analysis, no statistically significant association was found between normal sensitivity or hyper sensitivity to pain and the presence of auto-aggressiveness. A significant association was found between the presence of hypo-sensitivity to pain and the following variables: auto-aggression (p = 0.007, OR = 5.8, 95% CI = 1.5-21) , frequency of self-aggression (p = 0.001), intensity of self-aggression (p = 0.05), location of auto-aggressiveness at head and (P = 0.007, OR = 7.6, 95% CI = 1.8-14), higher score at CARS, and lower perception score at PEP-R (p = 0.012). Multiple-varied analysis identified risk factors for hypo-sensitivity to pain: lower perceptual score (p = 0.003, adjusted OR = 4.3, 95% CI = 1.9-54) and location of self-aggression at head and hands (p = 0.001, adjusted OR = 1.09, 95% CI = 1.02-1.09). CONCLUSION: It would be interesting to develop tools allowing a fine and precise evaluation of the painful sensation.

The Cognitive Remediation Therapy Program Among Children with ADHD: Tunisian experience.

BACKGROUND: Attention-Deficit Hyperactivity Disorder (ADHD) is associated with neuropsychological deficits including executive and attentional impairments. The cognitive remediation therapy is a new promising technique designed to improve the neurocognitive abilities damaged in ADHD. AIM: Adapt and apply the cognitive remediation program CRT (Cognitive Remediation Therapy) for children and adolescents with ADHD and to evaluate its effectiveness on attentional and executive abilities. METHODS: Children and adolescents with ADHD, diagnosed using the K-SADS-PL questionnaire was involved in the study. The CRT program was administered for an average period of fourteen weeks with a rate of one session per week of 40 minutes each. The Attentional Network Test was administered prior to the intervention and one week after. RESULTS: Of the 30 patients included, 14 had reached the end of the program. Among them, nine patients passed the attentional test post CRT, thus constituting our final sample. Their average age was 9 years. The mean number of sessions performed was 14.5. Post CRT, the mean of patient's response time was found to be shorter (p=0,004) and the frequency of omissions errors was also lesser than that found at the initial assessment. Patients also committed fewer errors in incongruent situations in post program, with a significant improvement of the conflict effect (p= 0.009) signing a better executive control. CONCLUSIONS: Cognitive remediation is a promising new modality in the treatment of ADHD. Further research is needed to better document its effects and the optimal conditions required for setting it up.

Quality of live among parents of children with autism spectrum disorders in Tunisia.

BACKGROUND: Studies on parents of children with autistic spectrum disorders' (ASD) quality of life (QOL) agree on its alteration and seek to identify risk factors in order to target interventions. AIMS: To study the QOL of a Tunisian population of parents of children with ASD and to look for risk factors specific to the Tunisian population. METHODS: We conducted a cross-sectional descriptive study of 50 parents of 50 children who met the DSM V criteria for autism spectrum disorder. A pre-established record was used to collect the biographical and clinical data. The severity of autism was determined using CARS. The SF-36, validated in Tunisia, made it possible to assess the QOL of the parents. RESULTS: The proportion of parents with impaired QOL was 64%. The average mental score was lower than the average physical summary score. Aggressiveness was the predominant factor that significantly altered parents' QOL at the total SF-36 score (p=0,03) and 5-dimensional levels (0.006

Theory of mind in adolescents with early-onset schizophrenia: correlations with clinical assessment and executive functions.

OBJECTIVE: We examined Theory of Mind (ToM) abilities in adolescents with early-onset schizophrenia (EOS) and their correlation with clinical findings and Executive Functions (EF). METHODS: The ToM abilities of 12 adolescents with EOS were compared with those of healthy participants matched in age and educational level. The Moving Shapes Paradigm was used to explore ToM abilities in three modalities: random movement, goal-directed movement and ToM - scored on the dimensions of intentionality, appropriateness and length of each answer. EF was tested using Davidson's Battery and the clinical psychopathology with the Positive and Negative Syndrome Scale (PANSS). RESULTS: Adolescents with EOS were significantly more impaired than controls in the three dimensions evaluated for the goal-directed and ToM modalities. Regarding the random movement modality, the only difference was in appropriateness (p<0.01). No correlation with age or level of education was evident for ToM skills. Total PANSS score was negatively correlated with appropriateness score for the goal-directed (p=0.02) and ToM modalities (p=0.01). No correlation existed between performance in the ToM Animated Tasks and positive, negative or disorganisation PANSS subscores. No correlations were found among the three scores in the Moving Shapes Paradigm and any measures of the accuracy of the three tasks assessing EF. CONCLUSION: Our results confirm previous findings of ToM deficits in adult individuals with schizophrenia and attest the severity of these deficits in patients with EOS.