[How do children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD) experience lockdown during the COVID-19 outbreak?] / Comment les enfants et adolescents avec le trouble déficit d'attention/hyperactivité (TDAH) vivent-ils le confinement durant la pandémie COVID-19 ?

OBJECTIVES: During the COVID-19 pandemic, the French government has decided a general lockdown. This unprecedented situation has raised concerns about children's and adolescent's mental health. Children and adolescents diagnosed with attention deficit hyperactivity disorder (ADHD) may find this context of restrained activity particularly tricky. The objectives of our study are to gather information about the well-being and global life conditions of children and adolescents with ADHD during the COVID-19 outbreak in France. METHODS: We designed a survey including both open-ended questions and questionnaire items for parents of children and adolescents with ADHD. Parents responded to the following open-ended questions: 1) "How is your child doing since the lockdown?" 2) "How is life at home since the lockdown?" 3) "If you had a remote service provision with a mental health professional (e.g. by telephone or video technology), please share your thoughts and any suggestions with us" 4) "Please share any other items that you think are important about ADHD symptoms of your child and the lockdown situation". This survey was posted on social media on the 6th of April and disseminated by French ADHD-parent and patient organizations. The present article reports the descriptive, qualitative and textometrical analyses of the survey. RESULTS: Between day 20 and 30 of lockdown, 538 parents responded to the survey, and we included 533 responses in the final analysis. The vast majority of responders were women 95 % (95 % CI 93,50; 97,18) with children whose mean age was 10,5 (95 % CI 7.58; 13.44). Since the lockdown, 34.71 % (95 % CI 30.70; 38.94) of children experienced a worsening in well-being, 34.33 % (95 % CI 30.34; 38.56) showed no significant changes and 30.96 % (95 % CI 27.09; 35.10) were doing better according to their parents. The thematic analysis showed that an improvement of their children's anxiety was one of the main topics addressed by parents. This improvement related to less school-related strain and flexible schedules that respected their children's rhythm. Improved self-esteem was another topic that parents linked with a lesser exposure of their children to negative feed-back. Parents repeatedly reported both inattention and hyperactivity/impulsivity. However, optimal lockdown life conditions seemed to compensate for the impact of ADHD symptoms (e.g. sufficient space at home, presence of a garden). Some parents reported worsening of general well-being in their children, and this manifested as oppositional/defiant attitudes and emotional outbursts. Parents also cited sleep problems and anxiety in this context. As regards everyday life during lock-down, at-home schooling was another major topic-parents described that their children struggled to complete school-related tasks and that teachers seemed to have forgotten about academic accommodations. The lockdown situation seems to have raised parents' awareness of the role of inattention and ADHD symptoms in their children's learning difficulties. Due to potential selection biases, the results of our survey may not be generalizable to all children and adolescents with ADHD. The main strengths of this rapid survey-based study lies in the reactivity of the participants and the quality and diversity of their responses to the open-ended questions. CONCLUSIONS: According to their parents, most children and adolescents with ADHD experience stability or improvement of their well-being. An improvement in school-related anxiety and the flexible adjustment to the children's' rhythms as well as parents' increased awareness of the difficulties their children experience are among the key topics in parents' descriptions.

Psychometric properties of the French Version of the Social Responsiveness Scale in autism spectrum disorder with or without attention deficit hyperactivity disorder.

OBJECTIVES: The Social Responsiveness Scale (SRS) is an instrument that is commonly used to screen for Autism Spectrum Disorder (ASD). Attention Deficit Hyperactive Disorder (ADHD) frequently occurs with ASD and both disorders share some phenotypic similarities. In the present study, we aimed to determine the psychometric properties of the French version of the Social Responsiveness Scale (SRS) and its 5 subscales (social awareness, social cognition, social communication, social motivation, and autistic mannerisms) to discriminate between children with ADHD and those with ASD (differential diagnosis) and children with ADHD from those with a dual diagnosis of ADHD and ASD (comorbid diagnosis). METHOD: SRS total scores and the 5 subscores of the SRS were compared between 4 groups of children: ADHD (n=32), ASD+ADHD (n=30), ASD (n=31) and typical neurodevelopment (TD; n=30) children. The discriminant validity was estimated using the Area Under the ROC Curves (AUC). RESULTS: SRS Social cognition (AUC=0.73) and Autistic mannerisms (AUC=0.70) subscores were the most discriminating for differential diagnosis of ASD and ADHD. SRS total scores (AUC=0.70), and Social communication (AUC=0.66) and Autistic mannerisms (AUC=0.75) subscores were the most discriminating for comorbid diagnosis of ASD among ADHD children. CONCLUSION: The SRS autistic mannerisms subscore was found to be clinically relevant for both differential diagnosis of ASD and ADHD and comorbid diagnoses of ASD among ADHD children but with a modest discriminant power.

[Suicide attempts in children under 12 years of age]. / Tentatives de suicide chez les enfants de moins de 12 ans.

Suicide attempts (SA) in children are often considered rare and poorly studied. The aim of this study was to explore the clinical characteristics of SA in children under 12 years of age. A retrospective assessment was conducted in 30 consecutive SAs reported in children under 12 years of age admitted to the emergency department at the Robert-Debré University Hospital (Paris, France) from 2007 to 2010 and the Regional University Hospital (Besançon, France) from 2000 to 2008. All suicide attempters were directly assessed at the somatic and psychiatric level. Patients were 8-11 years old (mean, 10.2±0.8). The sex ratio was 0.9 boys for 1 girl. The leading SA methods were poisoning by medication (53.3%), hanging or strangulation (23.3%), jumping from a height (16.7%), poisoning by chemicals (3.3%), and lesions inflicted by sharp objects (3.3%). In addition, SAs were characterized by high lethality (43.7%) contrasting with their low to moderate suicidal intentionality (43.8% and 56.2%, respectively). In conclusion, we reported that SA in children differs from those of adolescents by their greater lethality related to the methods used, but contrasting with the low intentionality mentioned by these patients.

[Cardiovascular risks and management during Attention Deficit Hyperactivity Disorder treatment with methylphenidate]. / 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.

[Off-label use of psychotropic medications in pediatric wards: a prospective study]. / Utilisation hors autorisation de mise sur le marché (AMM) des psychotropes en pédiatrie: une étude prospective.

PURPOSE: The aim of this study was to investigate the use of psychotropic medications for both labeled and off-labeled indications in a French paediatric teaching hospital. METHODS: A prospective analysis of all psychotropic drug prescriptions was conducted during a 6-month interval. Details were recorded from the computerized prescription order entry system. They included demographic data (sex, age and weight) and psychotropic medications (name, dosage, schedule, route of administration and indication). The physicians specified the indication when prescribing the psychotropic medication. All prescriptions were assessed for off-label use. Off-label prescriptions were defined as: use of a different dose or dose schedule, use for an indication not included in the license or approved for adults only, drug use outside the age range of the product license, use of medicines for which no paediatric information was available, use when the product was contraindicated, use of drug preparations that were manufactured by the hospital pharmacy, use of licensed drugs that were modified by the hospital pharmacy and use of new drugs available under a special manufacturing license. Each prescription was compared with data available in the National French Formulary. RESULTS: A total of 1629 drug prescriptions were written for 472 patients. Sixty-eight percent of all drug prescriptions were for off-label uses: indication not included in the license or approved for adults only in 40%, no paediatric information available in 37%, different dose or dose schedule in 7%, licensed drugs that were modified by the hospital pharmacy in 5%, administration to children outside the age range of the product license in 4%, drug preparations that were manufactured by the hospital pharmacy in 4%, contraindication in 2% and new drugs available under a special manufacturing license in 1%. Sixty-six percent of the patients were prescribed a psychotropic drug in an off-label manner. Over half of the off-label prescriptions were given to adolescents (62%), followed by children (29%), infants (8%) and neonates (1%). The percentage of off-label prescriptions by age was: neonates 91%; adolescents 74%; children 59% and infants 58%. The percentage of off-label prescriptions by medication class are presented in decreasing order of prescription frequency: anxiolytics 65%; antipsychotics 69%; antidepressants 92%; antiepileptics 51%; stimulants 30%; antiparkinsonians 100% and hypnotics 100%. The 5 drugs most commonly prescribed off label were risperidone (12%), clobazam (12%), amitriptyline (11%), hydroxyzine (10%) and diazepam (7%). Nearly half (47%) of all off-label prescriptions were associated with 3 indications: anxiety (24%), disruptive behaviour (12%) and pain (11%). CONCLUSION: The high rates of off-label prescription documented here and elsewhere highlight the need for further controlled clinical trials to evaluate the risks and benefits of psychotropic medication in children and adolescents.

Psychometric properties of a French version of the junior temperament and character inventory.

The junior temperament and character inventory (JTCI) has been developed for the assessment of temperament and character dimensions in childhood based on Cloninger's model of personality. We evaluated the psychometric proprieties of a French child and parent-rated version of the JTCI based on a previous German version, and assessed the correlations between the JTCI dimension scores and the scores on the child behavior checklist (CBCL) in a community sample of French children and adolescents aged 10-16 years. We used data from 452 child-rated and 233 -parent-rated JCTI. The psychometric properties (internal consistency and external validity in relation to the emotionality activity sociability (EAS) questionnaire) of the French JTCI were adequate in the parent-rated version. The parent-rated JTCI had overall better psychometric qualities than the child-rated version, but for both versions of the JTCI the confirmatory factor analysis showed low fit between the observed data and the original model. Dimensions of the EAS model were significantly correlated with the temperament scales of the JTCI. Further studies are required to improve the psychometric properties of the child-rated JTCI, and to provide insight about lacking fit of our data with the theoretical model.

Predictors of diagnostic delay in a clinical sample of French children with attention-deficit/hyperactivity disorder.

BACKGROUND: Early recognition of attention-deficit/hyperactivity disorder (ADHD) may improve the educational and psychosocial outcome of most affected children. To date, factors associated with diagnostic delay of ADHD have not specifically been addressed. Aims of this study were to evaluate the mean diagnostic delay (time between first consultation and definite diagnosis) in a clinical sample of French children with ADHD referred to an outpatient university clinic, and to determine associated factors. METHOD: A total of 129 consecutively referred ADHD patients aged 6-16 years. A detailed history of the children was obtained from their parents. The Kiddie-SADS-PL, the ADHD-Rating Scale, and the Clinical Global Impression Scale were used for clinical assessment. RESULTS: Mean diagnostic delay was 32.89 months. A previous suspicion of ADHD by any health care professional, therapist or teacher was significantly associated with a reduced diagnostic delay. Co-morbidity with anxiety/depressive disorders and previous contact with a mental health professional were associated with a significant delay in diagnosis. CONCLUSION: Delay in diagnosis of ADHD in France is among the longest reported. Children with co-morbid anxiety or depressive disorders are particularly at risk of having a significant delay in the diagnosis. Health professionals, therapists and teachers may play a relevant role to accelerate the diagnostic procedure.

Association between symptoms of attention-deficit/hyperactivity disorder and bulimic behaviors in a clinical sample of severely obese adolescents.

OBJECTIVE: Preliminary evidence suggests a comorbidity between attention-deficit/hyperactivity disorder (ADHD) and obesity. This study was carried out to identify the clinical characteristics of obese adolescents with a higher probability of ADHD and advance the understanding of the potential factors underlying the comorbidity between obesity and ADHD. We evaluated the association between ADHD symptoms and bulimic behaviors, depressive and anxiety symptoms, degree of obesity, pubertal stage, age and gender in a clinical sample of obese adolescents. DESIGN: Cross-sectional study. SUBJECTS: Ninety-nine severely obese adolescents aged 12-17 years. MEASUREMENTS: Subjects filled out the Bulimic Investigatory Test, Edinburgh, the Beck Depression Inventory and the State-Trait Anxiety Inventory for Children. Their parents completed the Conners Parent Rating Scale, which assesses ADHD symptoms. The degree of overweight was expressed as body mass index-z score. Puberty development was clinically assessed on the basis of Tanner stages. RESULTS: Bulimic behaviors were significantly associated with ADHD symptoms after controlling for depressive and anxiety symptoms. The degree of overweight, pubertal stage, age and gender were not significantly associated with ADHD symptoms. CONCLUSION: Obese adolescents with bulimic behaviors may have a higher probability to present with ADHD symptoms independently from associated depressive or anxiety symptoms. The degree of overweight, pubertal stage, age and gender might not be useful for detecting obese adolescents with ADHD symptoms. Therefore, we suggest systematic screening for ADHD in obese adolescents with bulimic behaviors. Further studies are needed to understand which specific dimension of ADHD primarily accounts for the association with bulimic behaviors. Future research should also investigate the causal link between bulimic behaviors and ADHD and explore potential common neurobiological alterations. This may lead to a better understanding of the effectiveness of stimulants for the treatment of bulimic behaviors in obese subjects.

Psychotropic combination in schizophrenia.

OBJECTIVE: To study adjunctive medications used with antipsychotic agents in schizophrenia via comparisons of antidepressant, anxiolytic and antiparkinsonian co-prescribing. METHOD: In the context of a national naturalistic prospective observational study, a database containing all the prescriptions from 100 French psychiatrists during the year 2002 was analysed. The inclusion criteria were a diagnosis of schizophrenia or schizoaffective disorder and age over 18. A log-linear model and generalised linear mixed models were used. RESULTS: In all 5,257 prescriptions for 922 patients were analysed. The proportion of patients who were prescribed an antiparkinsonian drug was 32.9%. Amisulpride, haloperidol, phenothiazines with a sedative action and depot typical antipsychotics proved more likely to be prescribed with antiparkinsonians. The frequency of antidepressant and anxiolytic prescriptions was 51.2% and 52.3%, respectively. Associations between atypical antipsychotics (except clozapine) and antidepressants were positive while associations between typical antipsychotics and antidepressants were not. There were no differences among antipsychotics for the prescription of anxiolytics. CONCLUSIONS: Atypical antipsychotics can be expected to be less likely associated with antiparkinsonians. This result is indeed found for olanzapine, clozapine and to a limited extent for risperidone. Furthermore, a trend towards a positive association between atypical antipsychotics and antidepressants appears. In view of the antidepressive action of certain atypical antipsychotics, this result is surprising. The increase in the prescriptions of anxiolytics concerns all types of antipsychotics. In view of the increase in associated medications in schizophrenia and the difficulty of estimating it in randomised trials, this study underlines the contribution of naturalistic studies on this score.

Pharmacodynamics and pharmacokinetics of single nasal (5 mg and 10 mg) and oral (50 mg) doses of ephedrine in healthy subjects.

OBJECTIVE: To determine the cardiovascular, subjective effects and potential of abuse liability of single dose (-) ephedrine (E) administered orally (50 mg) or intranasally (10 mg and 5 mg). METHODS: Sixteen healthy Caucasian men with no history of drug/alcohol/nicotine abuse or dependence received intranasal single doses of E 5 mg, 10 mg and oral doses of 50 mg and placebo in a double-blind, double-dummy, crossover study. Dependent measures included assessment of subjective feelings by Addiction Research Centre Inventory (ARCI). Profile of Mood States (POMS). visual analogue scales (VAS); "drug liking", "any drug effect", subjective quality of sleep and blood pressure and heart rate. Plasma E concentrations were also determined. RESULTS: (-) E increased supine systolic, diastolic blood pressure (P < 0.01). Changes in supine systolic blood pressure (areas under the 8 h of the experimental sessions) were -59 +/- 47 mmHgh with placebo, -59 +/- 57 mmHg-h with E5 mg by the nasal route, -18 +/- 48 mmHg x h with E 10 mg by the nasal route and 13 +/- 58 mmHgh with E 50 mg by the oral route (P<0.001). (-) E-induced orthostatic hypotension (P < 0.01) (maximal systolic blood pressure drop: E 50 mg 14 +/- 10 mmHg, P < 0.03; E 10 mg 11 +/- 6 mmHg, P = 0.08 compared with placebo) and resulted in decreased tiredness (placebo -2 +/- 39 mm x h, E 5 mg -17 +/- 39 mm x h, E 10 mg -30 +/- 42 mm x h, E 50 mg -24 +/- 35 mm x h; P < 0.03). E did not modify ARCI subscales--in particular the "amphetamine" subscale--but showed a tendency for drug liking (P= 0.09). On the "any drug effect" questionnaire, subjects could identify drug effect (P=0.007). Maximal plasma E concentration (Cmax) and areas under the curves for up to 8 h were proportional to the doses. Elimination half-life was approximately 6 h. A clockwise hysteresis was observed for systolic blood pressure in all but one subject with E 50 mg by the oral route. CONCLUSION: E even at low doses and by the nasal route can decrease tiredness in healthy persons; this is accompanied by a substantial increase in blood pressure and orthostatic hypotension exposing individuals in case of intensive physical exercise to cardiovascular risks. No clear evidence of abuse liability in healthy drug naive subjects was observed.

[Referral of drug addicts "in crisis" seen in the emergency room]. / Orientation des patients toxicomanes en crise vus aux urgences.

This survey was conducted to estimate the number of drug addicts seen in emergency care units in the Paris hospitals for a drug-related crisis and to analyze subsequent dispatching decisions made over a 14-day period. Twelve polyvalent emergency units participated in the study. These units cared for 116 drug abusers in a crisis situation during the 14-day study period. After initial assessment, the emergency care physician proposed a transfer center in 74% of the cases. Proposed referral centers included: an ECIMUD (Coordination and medical care team for drug addicts) for 27% of the patients, a psychiatric outpatient clinic for 33%, a CSST (Specialized center for drug abusers) for 2% and hospitalization for 11%. After a second assessment by a psychiatrist or an ECIMUD physician, 53% of the patients with a second assessment were referred to an ECIMUD, 32% to a psychiatric outpatient clinic, and 6% to a CSST; 26% were hospitalized. This survey points out the eminent role of psychiatric outpatient clinics and ECIMUD teams in providing emergency care for drug abusers.