Psychomotor disorders in children

Introduction:

The presence of psychomotor disorders in a large number of psychiatric or neurological disorders has been mentioned since the end of the 19th century (Wernicke, Kleist then Dupré, Baruk among others) and is still a topical subject.Thus, Hymas et al studied the presence of psychomotor disorders (slowness, motor incoordinations, motor stereotypies, dystonias, echopraxia, syncinesis) in a subgroup of patients with obsessive-compulsive disorder (OCD). The same is true of a growing number of neurodevelopmental disorders. The need to detect, recognize and treat these manifestations early is therefore necessary, although the causal relationships are far from obvious and systematic.

Psychomotor disorders in childrenThe frequent coexistence of psychomotor disorders and psychiatric symptoms has indeed long accredited the still living idea that the former were merely a manifestation or a consequence of the latter. This hypothesis, verified in some cases, should not make us forget that the opposite, psychopathological disorders reaction to the presence of psychomotor difficulties, is frequently observed. Moreover, these disorders can coexist without any causal relationship being established between them or, again, depending on the same original factor (cerebral suffering, toxic substances).

Psychomotor disorders, as they appear in children, are often discrete and require, in addition to a thorough knowledge of normal development, specific investigations and the use of psychomotor examination. A number of signs of appeal thus cause doctors and members of the care teams to be concerned with manifestations which, although sometimes only situational, nevertheless constitute a source of maladjustment and suffering for the child and his family.

Early psychomotor development:

THEORETICAL ASPECTS:

Psychomotor development is a continuous process that starts at fertilization. Intentional motricity is constructed from the first moments of life and results from a reciprocal and complementary relationship between perception and action.

Different theories have underpinned and still underpin the conceptions of psychomotor development: maturational, cognitive and, more recently, dynamic and ecological.

These theories account for a set of facts and processes, constitute different facets of the same object and provide complementary points of view. In the maturation hypothesis, motor development is based on a total structure that gradually becomes individualized, as anatomical differentiation and maturation of the central nervous system (CNS) progress. This progression is done in the cephalocaudal direction for the axis of the body, proximodistal for the limbs   And dorsoventral for the trunk. These three laws are found in postnatal motor development, the law of endogenous motricity in stereotypies, the total structure law in the impulsive character of spontaneous motricity, and the cerebrospinal progression in the evolution of motor function and muscle tone. This point of view is found in Gesell and remains at the base of the main current development scales including the Brunet-Lézine.

Cognitive approaches consider development as the construction of cognitive structures, called according to the authors schemes, engine programs or representations, which will guide the selection, preparation and execution of motion patterns of increasing complexity. The individual is considered as a system that processes the information present in the environment, actively searches for it and compares it with information already acquired in accordance with a predetermined goal. These treatment capacities improve with the neurobiological maturation, the practice of the subject and the modification of the strategies used, leading to an increase in the speed and precision of the movements of the subject and to a diversification and a complexification of the motor repertoire. The progressive establishment of inhibition behavior towards irrelevant stimuli is an essential characteristic of the development of cognitive processes.

For the dynamic approach, the behavior emerges spontaneously, through a phenomenon called self-organization, of the interaction of a set of subsystems which are a function of the requirements of the task and which define the dynamics that governs the appearance and Behavior change. These subsystems include, but are not limited to, neuronal organization, muscle strength, biomechanical aspects, level of arousal, motivational processes, characteristics of the task and the environment in which it takes place. Behavioral patterns are not pre-represented in the brain, nor are they the mere result of CNS maturation.

This system is said to be nonlinear because it tends to suddenly and abruptly join one or more of these stable states, also called attractors. The spontaneous motor activity of the infant is no longer considered as the production of random and undifferentiated movements, but as the exploration of the dynamics of action which will gradually lead to the discovery of zones of stable behavior, the attractors precisely.

This approach originated in Bernstein’s work on degrees of freedom and movement coordination and in Gibson’s theory of “direct” perception (see Zanone in). The complexity of the organism in motion is linked to the control of the many degrees of freedom present which interact in multiple ways, even if synergies exist between them to reduce their number. Gibson’s perceptual emphasis is on what he calls “affordance,” namely, the coupling between the characteristics of the environment and the capacities of the subject to act. For example, the work on locomotion shows that the infant behaves differently when it is confronted with different surfaces (inclined surface, visual cliff, water mattress) depending on its locomotor capacities (walking or crawling) . Depending on the adequacy between what he can do with the surface presented and his psychomotor capacities, he favors a certain type of behavior.

DESCRIPTIVE ELEMENTS:

Reflexes and spontaneous motor skills:

Fetal motor activity is extremely varied, movements move rapidly from discernible movements to seven weeks of gestation to isolated movements of limbs (9 weeks) or eyes (16-23 weeks). The study of the qualitative aspects of these movements can provide indications of possible neurological disorders.

At birth, the motor control of the newborn is at a subcortical level. It is characterized by hypertonia of the flexors of the limbs, hypotonia of the trunk muscles, associated with archaic reflex activities caused by the touch or manipulation of a part of the body and visual and auditory stimulations. More than 70 reflexes have been described, they constitute a vast reservoir of elementary schemes which, with progressive corticalization, will play an essential role in the establishment of the subsequent coordinated movements, even if the exact relations between these two components of motor Are not fully elucidated. Streri’s work, however, focuses on the wide variety of responses to gripping and holding the object in terms of complexity and variability, which runs counter to the frozen conception of the driving behaviors of the new- Born that carries the term of reflex.

The main reflexes are buccal reflexes (sucking, swallowing, repression of the tongue, digging, hiccups, yawning), reflexes of rectification (Moro’s reflex, static straightening, automatic walking, spanning the foot) The reflex of Landau and the final reflexes tendinous (Achillian, patellar and upper limbs) and cutaneous (plantar and abdominal) reflexes. A disturbance in their appearance, intensity or persistence, despite the difficulties of appreciation and / or detection, is often the sign of a neurological disturbance. Gradually, these reflexes disappear for the most part between 3 and 6 months, the active movements replace them with the possibility of synergy between agonist and antagonist muscles.

The spontaneous motor activity of the newborn is made up of massive, diffuse movements which may interest the whole musculature but predominate at the level of the limbs. They appear at birth and are found, although slower, in premature infants. They are present, most often, when awakening: pedaling movements for example. The qualitative and quantitative interindividual variations are considerable. They disappear between 5 and 8 months and their lifetime is less in girls. According to the authors and the theoretical postulates, the meanings that can be assumed by this motricity have varied considerably: unnecessary vestiges of evolution, without an adaptive function for some or, on the contrary, indispensable premisses of the future activity or imperative discharge Of muscular energy stored for others.

Stereotypies are also encountered in the course of normal development; They appear about 6 months to 1 year and do not persist beyond the third year. Movements are sometimes rhythmic, involving the head or the whole body; They can relate to the mouth (tireless suction, bruxism) or the coating   (Touching sometimes accompanied by self-mutilation). Again, the meanings attributed are multiple: role in motor development, in the knowledge of the body and its limits, hedonistic function, expression of pleasure, compensatory or homeostasic mechanism, altering the level of vigilance.

Axial Tonus, Locomotion and Grip:

From a maturational point of view, from the moment when the higher centers of the brain take over, reflexes are gradually inhibited and three categories of movements must be controlled by the child for optimal adaptation to the environment: axial tonic control , Locomotion and gripping. The flexion which dominated the body gradually gave way to extension.

The evolution of the axial tone makes it possible to establish a control of the musculature to oppose the force of gravity according to a systematic sequence in which one sees the successive straightenings of the head towards 4 months of the trunk at about 7 or 8 months , Which allow the seated position without support, and lower limbs around 10 months allowing standing. Finally, about 12 months old, the child stands alone.

The displacements of the child are dependent on the development of the axial tone, and the distinction can be made between locomotor skills, consisting of horizontal movements culminating with the quadruped, and those which accompany the verticalization, leading to the definitive march.

With progressive control of the muscles of the head, neck and trunk, the child moves by crawling using essentially the upper limbs, while the abdomen and lower limbs are dragged. The displacement is of variable duration, depending very much on the purpose and motivation of the child, the nature of the soil and the constitution of the child. The reptation appears at about 6 months.

He succeeded, about 9 months, the quadruped march, the child moving on the hands and knees with a coordination of the four limbs. Sometimes, around 11 months, the child walks using the soles of the feet and the palms of the hands. Finally, some move on the hands and the posterior, once the seated station is mastered.

Walking along a support or held by both hands appears around 9 months, walking alone around 12 months. It requires an alternative propulsion of the lower limbs. The lift polygon is first expanded. Little by little, the speed increases, the length of the steps increases, their rhythm is regularized, the arms, in the high position at the appearance of walking alone, lower and synchronize with the lower limbs.

Gripping develops around three activities: reaching, grasping and releasing. Before 4 months, the child does not show any movement of approach to the object, even if one sees a visual localization which sometimes triggers “puppet” movements (alternation of pronation and supination). Little by little, the child directs his arms towards the object in a sweeping or wrapping movement in which dysmetry predominates, then the direct approach begins. During this period, it can grab an object placed in contact with the palm of the hand and play with it. After 5 months, the child catches the objects presented in his visual field and the synchronization between the visual and the manual inspections of the object, taking into account its characteristics (shape, texture), is effective. The grip is at first cubitopalmaire with taking the object between the hypothenar eminence and the last two fingers of the hand. About 7 or 8 months, the grip becomes radiopalmaire, the thumb and the lateral face of the index are used preferentially.

Finally, around 9 months, the object is taken with the aid of the thumb-index, it is the radiodigital grasp. Fine objects can be caught between these two fingers. Around 10 months, the object’s approach and capture are coordinated in a continuous motion. The catch of the object is totally controlled at around 14 months. Release involves the maturation of the flexor muscles of the fingers so that they can be relaxed on demand to turn the pages of a book or put pellets in a bottle, for example. At about 12 to 14 months, the first rudiments appear and at 18 months, the three aspects of grip are well coordinated; The child can then build a tower of three to four cubes.

Interindividual variations are important and depend on a multitude of factors that depend on the constraints of the environment (inclined surface, for example), the organism (dimensions of body segments, strength) and task (dimensions of the body) object). For example, children can be classified according to their degree of extensibility and distinguished at the two extremes: children who are not stretchy and who reach early standing and then walk, with significant mobility, violent stereotypes but whose grip Is later; In contrast, very stretchy children have an early grasp, little mobility, stereotypical exploration of the body and reach the standing and walking later.

Once acquired the basic mechanisms of axial tone, locomotion and grasping, the second stage is a diversification and improvement of these. During this second phase, which takes place from 18-24 months to 7 years, the subject improves precision and speed of execution, refines its motor skills and integrates the spatial dimension of new movements, increases its adaptation to various situations and combines these different elements . Different types of jumps (joint feet, height, length over an obstacle, from the top of a bench), lateral displacements, jumping and climbing are the main acquisitions in terms of locomotion.

The manipulations and uses of objects multiply: throw with the hand or with another object, catch with the hand or the foot, juggle, dribbler, roll a ball. The best control of the antigravity musculature allows new possibilities of balance, movements of all or part of the trunk and the upper limbs while remaining in the same place, balance on a foot, step on a beam, candle and roulade.

The third and final phase, starting at 6 or 7 years, corresponds to the practice of increasingly diversified and specialized activities that base the different sports aptitudes. The individual performance is obviously a function of the quality of the engine control and the optimal use of visual and proprioceptive feedback, the anticipation that allows a smooth movement and updating of the motor programs.

Perceptual development:

Underestimated for a long time because of the primacy of motor action, perceptual factors are now regarded as a fundamental element in the development of intelligence. The different sensory modalities of the newborn are operational at birth and, for some, for several weeks. The perception of the infant has some characteristics grouped by Gibson. Perception is an active process of exploration that results from motivation.

It is directed to external sources of stimulation even remotely. It uses and depends on the information given by the movement. The perceived space is a three-dimensional world. The perceptual constancy of the shape and size of the object exists before any approach or take of the object. Perception is coherent and focuses on structures. Finally, it has early transfer capacities between the various modalities, touch-vision at 2 months, apparently, from an initial amodality. The actions guided by perception are organized and flexible and do not occur only randomly or according to a stimulus-response scheme.

The newborn (Fantz and Bower’s works in the 1960s and 1970s) sees and prefers, in the first weeks of life, the varied images, new but related to what is already known (optimum novelty), Curvilinear, irregular, contrasted features. The information concerning the relief is differentiated after 2 months.

The permanence of the immobile object is present from 4-5 months, preceded by various manifestations indicating a process of maturation. The permanence of the moving object is later, around 6 months.

The consistency of magnitude would appear, according to the experiments, between 18 weeks and 6 months; That of the form was recovered at 2 or 3 months. Depth is detected around 4 months. The colors are discriminated from 3 months with a preference, reverse of that of the adult, for the warm colors: red and yellow.

Hearing is functional before term, but due to physical obstacles, the integration of external sounds with the mother’s body imposes relatively low frequencies and acoustic pressures such as cutaneous or even visceral receptors are probably more concerned By such sound vibrations.

The integration of inner sounds, especially the voice of the mother, is much clearer and allows the fetus of 7 to 9 months to be immersed in this experience and then, from the first hours, to recognize it or even to prefer To others a nursery rhyme to which it was exposed before birth. In any case, the sensitivity of the earliest days is 65 dB (that of an audible conversation at 3 m) and its hearing skills are such that it can better distinguish between Majority of existing phonemes, including those to which it has never been exposed since fertilization and which do not exist in mother tongue.

Preferring harmonic and natural sounds to artificial noises, it can, from birth, orient itself correctly to the sound sources that it will then localize as well as an adult from 18 months.

The development of the tactile sense is, too, early. At 2 months, a solid disk is preferred to a holed disk, at 4 or 5 months the distinction between square full and holed or between star and flower can be observed. At 1 year, no less than nine different forms can be distinguished tactilely.

One question remains unresolved: the relationship between perception and motor skills at different ages of early development, and especially during the first few weeks of life.

Concept of psychomotor disorder:

DEFINITION:

Psychomotor disorders are neurodevelopmental disorders that affect the adaptation of the subject in its perceptivomotor dimension. Their etiologies are multi-factorial and transactional, combining genetic, neurobiological and psychosocial factors that act at different levels of complementarity and expression. They are often situational and discrete, hindering the adaptation mechanisms as a source of discomfort and suffering for the wearer and the social environment.

HISTORICAL ELEMENTS:

The notion of psychomotor disorder has evolved since its appearance at the beginning of the century. On the one hand, with Baruk in particular, psychomotor disorders are studied within the framework of adult psychiatry. He defines them as disorders of the superior motorism, “voluntary”, not responding to a lesion in “focus” and that a healthy subject can perfectly imitate. He considers that the association with a psychiatric pathology is indisputable but the psychogenesis of the disorder is rejected because the CNS plays a primordial role. The relationship between psychomotor disorder, neurological disorder and psychiatric disorder are considered but a certain ambiguity remains which will be the source of many subsequent misunderstandings.

Moreover, the observation of post-encephalitis sequelae in children in the 1920s has aroused interest in manifestations which, for some of them, will be referred to as psychomotor disorders: hyperactivity, Attention, learning disabilities, emotional disturbances and aggressive behavior. In France, Wallon sets up a psychomotor typology in seven levels, transposing the adult neurological pathology to the child, which will be criticized several times (by Koupernik, Ajuriaguerra and Stambak) and will later be abandoned. The English-speaking authors will fall into the reverse, consisting in reasoning by analogy of seeing in these manifestations only one pathological entity which is known under the name of Strauss syndrome and which may be encountered in children who have suffered from Various neurological disorders but also with children apparently free from such ailments. Thus, the term “minimal brain injury”, used initially, is gradually neglected because evidence of a brain injury can not be administered, the diversity of clinical pictures is beginning to be underlined and the impact of this term on the Parents is at least negative. This notion is then replaced by that of “cerebral dysfunction at minima” (DCM). For a long time synonymous with hyperkinetic syndrome, DCM actually covers a wider field and is not confined to infantile pathology.

CEREBRAL DYSFUNCTION IN MINIMA:

The notion of DCM is inseparable from that of psychomotor disorders. The latter have three characteristics: the existence of symptoms of cerebral dysfunction, a psychopathological complex and a plurality of etiology which we find in the various disorders studied.

The soft signs, which suggest this neuropathy, can be differentiated into several groups:

– specific signs, called equivocal, as they may or may not result from neurological impairment: nystagmus or index deviation, for example;

– slight deviations from normality, difficult to detect: asymmetry of the tone, slightly abnormal reflexes;

– indications of a developmental delay which pose the problem of their interpretation: motor incoordination, retardation of language.

Their existence has been questioned and divergences in their meaning and etiology persist as they refer to heterogeneous factors (early brain damage, transient maturation phenomena, genetic origin). Nevertheless, they constitute a series of indices of future behavioral or cognitive disorders whose presence is relatively stable over time, signaling a kind of vulnerability to psychiatric disorders. They are also more frequently found in the difficulties of school learning, psychiatric disorders and cognitive disorders. The majority of these signs correspond to symptoms classically revealed by the psychomotor examination: abnormal movements, tone disorders (syncinesis, dysdiadocokinesis) and balance, motor incoordination, digital agnosia, right-left confusion, perceptivomotor disorders.

Attention Deficit / Hyperactivity Disorder:

According to the studies, attention deficit / hyperactivity disorder (ADD / ADHD) affects 2-3% of girls and 6-9% of boys in the 6-12 age group, Respectively from 1% to 2% and from 3% to 4.5% during adolescence and mainly boys with a sex ratio ranging from 9/1 in clinical samples to 4/1 in epidemiological studies. Often spectacular in its motor manifestations, hardly supported by the environment, it also includes a component that is less visible but equally destabilizing for the individual himself: the attention deficit.

The DSM III also distinguished between AD / HD and hyperactivity disorder, while DSM III-R emphasized hyperactivity because of the disruptive behavior while maintaining this distinction. It describes an attention deficit hyperactivity disorder in the context of disruptive behavior, the age of onset of which is in half the cases before 4 years, and an undifferentiated attention deficit disorder . In the most recent version of DSM, AD / HD is organized around two dimensions: attention deficit on one side and hyperactivity-impulsivity on the other.

ICD 10 distinguishes the category of hyperkinetic disorders that respond to the presence of inattention (six out of nine symptoms), hyperactivity (three out of five symptoms) and one in four (impulsivity) symptoms that are invasive, persistent And present in several situations and not due to another disorder (eg, autism or mood disorder). The symptoms are practically superimposable to those of DSM IV.

This disorder has three sets of signs that are: attention deficit, impulsivity and motor agitation or hyperactivity.

DEFICIT OF ATTENTION:

The subject does not listen, can not concentrate and persevere in the realization of his school work or in his games. Any effort of attention is difficult to him, and the least parasitic element quickly turns him away from the task in progress. It can thus focus on irrelevant elements of the work it is doing and lose sight of the main objective. He misplaces his belongings whether it be clothing, school supplies or toys. There are different degrees of severity from the tendency to episodic distraction to the impossibility of continuing for more than a few minutes the same activity. The subject’s motivation for the activity may also play a role and the manifestations may be situational.

Douglas speaks of their inability to “stop, watch and listen” (stop, look and listen). Attention disorders remain relatively stable during development, while other manifestations tend to decrease.

IMPULSIVITY:

This is an overly rapid response to a situation without taking into account the available information that could lead the child to change his or her behavior. It intervenes at the motor, social or cognitive level. Thus, jumping into a deep pool without even knowing how to swim or absorb the contents of a bottle of household products are the types of accidents that hyperactive children are often exposed to. They frequently make untimely or tactless interventions in school or in the family environment and have difficulty in waiting for their turn in a board game. They do not take time to think before answering and fail to inhibit their motor or verbal responses.

HYPERACTIVITY:

Less frequent in the female population, hyperactivity is the main grievance of the teacher or parents and motivates the consultation. The child is in perpetual motion and can not stop. This incessant motor activity appears even in a new environment as opposed to the non-hyperkinetic child who tends to calm down before an unknown environment. Everything that is within reach of the child is handled, carried to the mouth and just as quickly rejected. Abnormal wear of clothing, especially footwear, is mentioned by parents.

Quantitative actigraphic assessment indicates that children with AD / HD have few periods of activity reduction during the day, unlike other children, including those with manic bipolar disorder, a characteristic that persists In adult subjects with residual symptomatology.

These various behaviors often lead to conflicts with the people around them, and difficulties in learning that may lead to rejection or even exclusion from the school environment, sometimes accompanied by feelings of devaluation or loss of esteem Of reactive self.

EVOLUTION OF EVENTS:

During development, the hyperactive subject presents itself in various aspects. From an early age, the child experiences a number of disturbances during early learning, apparently little and bad sleep, food problems, and avoid contact and caress. Accidents and injuries are frequent as well as cries that prove difficult to calm. Outsourced manifestations are at the forefront.

About 3 or 4 years old, he is described as obstinate, authoritarian, angry, tolerant of even the most elementary frustrations. In kindergarten, he is noisy, rarely on his chair, walks in the classroom, disrupts the activities of other children. The adult, especially the mother, is the object of real harassment and can hardly devote herself to another person in the presence of the child. Socialization is extremely delicate.

At the age of 6, entry into primary school often results in the first consultation because the level of tolerance in the school environment is not the same as in the family, and behaviors previously accepted by parents are considered inadequate in The framework of the class. The child is remarkable for his indiscipline, his chatter, his reveries. His behavior disturbs and even destabilizes the class and the other children. Attention disorders occur around this age. The child has difficulty completing his / her assignments and committing himself / herself, both adults and peers, to organizing his / her work. Forgetfulness, both materially and socially, is frequent. Rejected from school, having little relationship with peers, the child tends to devalue and lose self-esteem. Numerous reactional manifestations may thus appear.

Symptoms persist in adolescence, especially as the level of hyperactivity-impulsivity is high, behavioral disorders or aggressive behavior are associated, and family conflicts are important. As adults, 30 to 50% of the subjects are still considered to have clear manifestations.

EVALUATION OF THE DISORDER:

In the case of Attention Deficit Disorder, psychomotor evaluation has three axes: behavioral study, specific tests and complementary tests.

Study of behavior:

It combines:

– the collection of data during a directed interview allowing to specify the circumstances of the appearance of the symptoms (intermittent or continuous character, discrete or invasive aspect, duration, frequency, presence of triggers, reactions of the environment) The history of the disorder, the strategies and treatments already in place before the consultation;

– Behavioral scales, such as those of Conners, Barkley, or the Brown scale for adolescents that provide a quantitative dimension and allow follow-up of treatment;

– contact with other caregivers, teachers and therapists (speech therapist and sometimes psychiatrist or neuropediatrician) who provides information on the occurrence of hyperkinetic manifestations in different settings and on the responses of The child to the therapeutic interventions in place.

Use of specific tests:

They highlight and make it possible to appreciate the intensity of the symptoms and their repercussions on a certain number of psychomotor activities.

– Assessment of attention deficit is carried out for sustained attention using dams tests in which the subject must identify and delete with a pencil a specific element within a set of Similar signs: the Corkum et al test, the test of the two Zazzo dams, the attention test d2. For selective attention, the Stroop test reveals a high sensitivity of the subjects during the interference condition (name the print color of a word corresponding to a different color name, red written in green for example ). The AD / HD child is slower and makes more mistakes than the control subjects in this situation.

The Porteus labyrinths measure both the subject’s attention to the material in order to find the output and the impulsiveness, since any incursion into a part of the labyrinth ending in a cul-de-sac is taken into account and leads a new test.

– For the impulsivity, the image matching test makes it possible to clearly differentiate the subjects TDA / H from the control subjects. It is a question of choosing from a group of images that which corresponds to the model. Subjects respond faster, give less often a correct first response and provide more erroneous answers. It is often difficult to separate the effects of impulsivity from the results of the examinations, and those from an attention deficit. On the one hand, tests measuring impulsivity are part of a set of tasks that also require a high degree of attention for optimum achievement. In addition, continuous attention tests show that substitution errors are significant for children considered impulsive.

– The level of agitation of the child in a structured situation is evaluated during the passing of the different scales of psychomotor development (LOMDS, WACS, Brunet-Lezine) which inform us how the child reacts to a command and Before a concrete situation; The appearance of parasitic motor sequences more or less important punctuates the realization of the items. These tests also show the ability to maintain or not focus on a task for a certain period of time.

Additional tests:

They do not explicitly measure the aforementioned disorders but certain manifestations encountered during their passing are characteristic of hyperkinetic syndrome. This is the case for the reversal test, a maturity test for reading which involves visual perceptual discriminations among pairs of signs oriented identically or differently. The child rarely succeeds in following the order of presentation of the figures and his gaze “flutters” from one end to the other of the sheet, which leads to numerous omissions. The same is true in some subtests of the Frostig visual perception development test, the reproduction of the Stambak rhythmic structures or the test of the identical forms of Thurstone. Details are forgotten in visuoconstructive tests like the complex figure of Rey.

COMORBIDITIES:

A number of morbid associations, the frequency of which is not due to chance, has been studied for 10 to 15 years.

The most frequent comorbidities are conduct disorder and oppositional defiant disorder, anxiety disorders, mood disorders, learning disabilities, Gilles de la Tourette syndrome and chronic tics. The percentages vary according to the method of recruitment of the population samples considered and the nature of the study. The presence of comorbidities makes the diagnosis more complex, requires a number of precautions to be taken during the assessment, and the implementation of the treatment. Thus, AD / HD comorbidity and depressive state increases the risk of suicide and, in addition, responds less well to psychostimulant treatments.

ETIOLOGICAL FACTORS:

The etiology of AD / HD is not known. A variety of factors play a role to varying degrees.

Genetic factors are considered in studies of twin and adopted groups, family distribution with an estimated heritability of 70%.

On the neuroanatomic level, magnetic resonance imaging (MRI) studies indicate some abnormalities: reduced volume of the frontal lobe and basal ganglia mainly, alteration of cerebellar vermis. An atypical development of the brain is invoked as an etiological factor in the frequent association of AD / HD with dyslexia and the disorder in the acquisition of coordination, an atypical development that manifests itself in multiple forms depending on the location, the moment Occurrence during development and the severity of the outcome.

Neurochemical data are derived from the positive effects of psychostimulants in the treatment of the disorder. Psychostimulants increase the level of extracellular dopamine by blocking the dopamine transporter and inhibiting its re-uptake, thereby prolonging the effects of the neurotransmitter at the synapse level. An action on noradrenergic neurotransmission is also mentioned.

The most convincing neurophysiological factors are those provided by the collection of cognitive evoked potentials. The latencies of the components P3a and P3b, which are associated with information processing stages such as stimulus evaluation and memory update, are longer in AD / HD than in controls, which disappears when Of treatment with methylphenidate. Other studies indicate decreased cerebral blood flow and glucose metabolism in some anterior regions of the brain in AD / HD patients.

Psychosocial factors appear more as contributing factors than as determinants. In addition, they are not specific to AD / HD. Biederman et al also show that the percentage of AD / HD increases with the number of risk factors, rising from 7.4% with a factor to 41.7% with four factors among the following six: significant conjugal disagreement, low socioeconomic level , Large family, paternal crime, maternal mental disorder, foster care. The same increase is found for a set of mental disorders.

Certain environmental conditions, however, play a role in the reduction or aggravation of the symptomatology. Moreover, identifying them can act on them during the treatment.

On the neuropsychological level, Barkley’s model emphasizes the lack of self-control and behavioral inhibition, with attention deficit disorder secondary. This deficit of inhibition is the first level and has implications for four neuropsychological abilities considered to be executive functions, namely, mental activities that occur within the delay before the response. These functions (second level) lead to observable effects at the third level, which is behavioral and in particular concerns engine control. The systems or executive functions are: working memory, self-regulation of motivations and awakening, internalization of language and reconstruction. The difficulties encountered in the working memory are the intrusion of irrelevant information that diverts the subject from the main task or the maintenance of a material that is no longer relevant and which can lead to perseveration. A lack of self-regulation of motivation and awakening leads, for example, to an extreme dependence on external reinforcements as opposed to an internal motivation before a task considered as binding. The internalization of the language refers to the observations made on the child who spontaneously uses the language to plan, regulate his behaviors and overcome the difficulties he encounters in solving a problem with a self-guiding function. The attainment of reconstitution refers to a lack of creativity and flexibility in the face of a new problem, in terms of motricity as well as language. These different functions allow the individual to control finalized behaviors, to be able to adapt to the changing conditions of the environment and to implement coordinated, complex and varied motor responses. The different manifestations and symptoms of AD / HD are the consequence of a malfunction, a delay in maturation or an attack of one of these modules. Barkley’s model emphasizes that AD / HD is more a deficit of behavioral inhibition than a lack of attention and even proposes to substitute a term such as “disorder of behavioral inhibition”.

Attention-deficit hyperactivity disorder is a highly disruptive psychomotor disorder with disastrous effects on academic and social adjustment. Excessive movement causes many conflicts with the environment and plays an important role in school failure due to its frequency in the general population. All this necessitates a multi-modal therapeutic intervention that combines, ideally, psychomotor rehabilitation, study and modification of family interactions, development of the school environment, without underestimating the usefulness of chemotherapy. Associated with other approaches, methylphenidate (Ritalin t ) is today the pharmacological treatment of choice. A review of 155 controlled studies involving 5,768 subjects (children, adolescents and adults) in total, concluded that psychostimulants were effective in 70% of cases. Benefits include a wide range of behaviors: decreased motor activity, especially outside the task, increased general attention and involvement in activities, decreased aggression , Improved parent-child interactions and relationships with siblings and peers. Side effects are limited (decreased appetite, insomnia, headache, gastralgia). The risk of subsequent drug addiction caused by the use of psychostimulants is to be found in the myths section, according to the longitudinal studies, that of Weiss having a duration of at least 30 years.

This prescription must be accompanied by two essential precautions: to maintain or implement non-medicated interventions (see above) and to take into account the comorbidities which, it must be remembered, are frequent. Finally, therapeutic windows permit the regular evaluation of the appropriateness of maintaining or stopping treatment.

Studies of the fate of the hyperactive child indicate that the manifestations, which have undergone some modification, often persist in adolescence and adulthood. There is sometimes a sociopathic component. Cognitive, emotional and behavioral difficulties are still encountered in many adults with their attendant disadvantage.

Disorders of intentional movement and motor coordination:

As a cardinal point of psychomotricity, intentional movement can be affected in many ways during the development of the child. Simple delay or disorder, the difficulties of motor coordination in the child have been described for a long time under various terminologies regrouping variable clinical realities. Among the different names, we retain the disorder of the acquisition of the coordination in which one can isolate the dyspraxias of development, and the dysgraphies.

The term, often used, as an “awkward” child, incorrectly suggests the existence of a unitary concept of clumsiness that does not correspond in any way to the multiplicity of clinical pictures and the heterogeneity of the population grouped under this term . In addition, as a result of Fleishman’s work, factor analyzes demonstrated the absence of a general psychomotricity factor, illuminating clinical variations. Thus, an individual may present motor incoordination in a particular area and be fully adapted in others. These findings have led to a change in evaluation tools and therapeutic methods, which now focus on the specific nature of the intervention to the detriment of the overall methods advocated up to now.

DISORDERS OF THE ACQUISITION OF COORDINATION AND DYSPRAXIES:

The observed disparities can occur in four areas. A first element of variation is encountered in the extent of coordination difficulties: some children are incapable of performing any motor action, perhaps referring to the otherwise questionable picture described by Dupré under the name of “motor debility” The language may also lack clarity, while for others the deficit is only manifested in certain daily activities or only on a manual level. The second level is the degree of severity of the problem, ranging from simple slowness in motor activities that hinders schooling, the total inability to learn certain things or to learn. Thirdly, the onset of the disorder may occur at the first movements of the newborn or, on the contrary, appear only at the moment of entry into primary school, when the degree of exigency increases. Finally, motor incoordination may be isolated or may be associated with other disorders such as AD / HD or dyslexia.

Signs of Appeal:

The following are found:

– difficulty in daily activities such as dressing, washing, using cutlery and delaying psychomotor development (walking, running, jumping, throwing or catching a ball, etc.). For the older ones, the visuoconstructive disorder is often at the forefront: puzzle, geometric figures, models are difficult, if not impossible, to realize;

– an important slowness in the various motor activities.

In the classroom, the child is noticed by his inability to do a job in the time allotted. If an increase in speed is imposed, it helps to promote awkwardness. Some saw in this manifestation an attempt to control motor incoordination by reducing the time of execution;

– a disorder of school learning with dysgraphy, difficulties in arithmetic, geometry, in learning to read and, in general, a disturbed schooling despite intelligence usually average.

Diagnostic criteria of DSM IV emphasize the delay in achieving the motor coordination necessary for daily activities, disrupting academic success or everyday activities and not due to a general medical condition.

The ICD 10 distinguishes between a specific disorder and motor development, the essential characteristic of which is an alteration in the development of motor coordination, not wholly attributable to a global intellectual retardation or to a specific neurological condition, congenital or acquired (…). Motor impairment is usually accompanied by a certain degree of impaired cognitive performance in the visuospatial domain “.

The alteration is variable in intensity, the manifestations differ according to the age. Under this term are included the appellations of motor deficiency, developmental dyspraxia and disorder of acquisition of coordination.

The prevalence of coordination disturbance is estimated to be 5 to 10% depending on the studies and the severity criteria used. The sex ratio varies from 2/1 to 7/1 according to the studies. Disorders persist in adolescence and adulthood as shown in longitudinal studies.

Clinically, the signs are found at various levels: psychomotor, neurological, intellectual.

Neurological signs are frequent, often mild signs that a specific examination highlights. Choreic movements, athetosics, unilateral tremors, disturbances of tone and balance, abnormalities of the electroencephalogram (EEG) are also mentioned.

On the intellectual level, a difference in WISC is found between the different scores. The performance quotient (QIP) is 20 points lower than the verbal intelligence quotient (QIV) and some performance-level subtests that measure a visuospatial dimension are particularly affected: cubes and assembly of objects. This difference does not appear to be systematic.

It is found only in 48% of the 82 subjects in the Albaret study and does not appear in some studies or is reversed.

Physical examination:

The psychomotor examination is primarily concerned with the exploration of motor coordination disorders, which are of particular interest to manual motor skills. For subjects aged 6 to 14, the Lincoln-Oseretsky psychomotor development scale is used; It consists of 36 items grouped into six factors (manual precision, global coordination, alternate activity of the two limbs, finger-wrist speed, balance and manual coordination), which are affected to varying degrees in dyspraxic children; The timed events reveal the slowness in the execution of the tasks. For the youngest, from 3 years and 6 months to 6 years, the Charlop-Atwell scale allows to appreciate four categories of motor coordination:

1. coordination between the upper limbs and the lower limbs grouping together the “puppet” and the “prehistoric animal”;

2. coordination of two simultaneous actions with “jump with a turn” and “twirl”;

3. dynamic equilibrium represented by “successive jumps on one foot”;

4. Static balance on tiptoe.

The turnover time is approximately 15 minutes. The objective criteria (objective score) determine the success and the level of precision of the performance. They take into consideration the number of tests required and the time. The qualitative criteria (subjective score) make it possible to specify the level of maturation and the way in which performance is achieved, which may vary for an identical objective score. The subjective score thus provides information allowing to approach in a less evasive way the tonic regulation of the gesture, the planning of sequences of a complex action, elements that account for motor incoordination.

The disorders of constructive and gestural praxies (ideomotor and ideation), constitutive of developmental dyspraxias, are abnormalities close to the apraxias of the adult. They are appreciated respectively by the copy of the figure of Rey or the forms of Bender-Santucci and by the test of imitation of gestures of Bergès-Lezine associated with the realization of symbolic and complex movements comprising a succession of simple movements. Constructive dyspraxia is very common (17 cases on 21 subjects in Gubbay), with difficulty or total inability to reproduce simple or complex geometric figures usually copied at the age under consideration, with a pencil or with rods. May explain the discomfort experienced by some children with a problem of geometry. The drawing of the fellow also includes anomalies: the drawing is poor, of smaller size, irregular with sometimes the observation of a tremor; The shapes are incomplete, the lines do not stop at the junction points and the pressure is irregular. The dyspraxia of the dressing is most evident in the activities of buttoning and lacing. Some parents spontaneously remedy this difficulty by dressing their children with tracksuits and shoes devoid of laces.

Facial dyspraxias are also related to coordination disorders. Fixed aspect of the facies, difficulties of imitation of the movements of the face, disorders of the phonatory, articulatory and respiratory systems can be found.

The facial motricity test may be used and a speech-language examination recommended.

The difficulties of writing are frequent, related to both visuoconstructive disorders and difficulties of motor coordination.

The digital gnosies and the verbal knowledge of the parts of the body are sometimes imperfect. The examination of lateral dominance may reveal an ambilaterality.

Clinical forms and etiology:

Several clinical forms have been described. These classifications emphasize the variety of clinical presentations with predominance of any of the symptoms, association of neurological disorders, neuropsychological disorders or personality disorders, but these clusters currently have little therapeutic implications. In fact, it appears that the disorder of acquisition of the coordination is a very vast set comprising several subgroups of which the development dyspraxias which are themselves heterogeneous.

 

The etiological factors mentioned are various: brain development disorder, hereditary factors, lack of stimulation and limitation of learning opportunities, motivation of the child. As with the majority of psychomotor disorders, the etiological plurality must therefore also be considered. Prematurity is a risk factor, especially for visuoconstructive disorders. Pre-, peri-neonatal or neonatal factors are present in a large number of dyspraxic children, up to 51% for Gubbay. Using CT-scan, a high rate of non-specific cerebral abnormalities, ventricular dilatation, cortical atrophy or demyelination has been reported as well as EEG abnormalities. Mild signs are frequently found; They may be in favor of dysfunction of the cerebellum or ganglia of the base.

The lack of use of feedback during psychomotor learning has been reported in dyspraxic children. The latter seems to place undue emphasis on visual feedback, which is useful at the beginning of the apprenticeship, but it hypothecs the automation phase and could explain the slowness of execution.

The dyspraxic child would thus be constrained to slowness by the necessity of using his attention to check incessantly movements which remain disorderly. However, incoordination is still present, even in slow subjects, as shown by the study of bimanual coordination (pronation-supination movements of the two forearms) within the dynamic systems theory with an inability to Maintain an antiphase coordination pattern. Perceptual deficits have also been incriminated: auditory, visual, intermodal transfer.

Associated Factors:

AD / HD is often associated with coordination disorder, which has led some authors to use the term Attention Deficit, Motor Control and Perception (DAMP). Disorders in school learning have also been found, particularly in relation to reading, as well as language impairment.

Moreover, several manifestations that seem to be reactive to the awareness of the disorders are noted: low self-esteem, loss of motivation, social isolation, even depression.

Treatment:

The modalities of care for children and adolescents with a disorder in the acquisition of coordination are numerous and varied. They insist on the specificity of the therapeutic approach, which is based here on graphomotor problems, on postural preparation for movement, again on digital untying, or on increasing the speed of movement . Depending on the magnitude of visuoconstructive disorders or disorders of tone, for example, the scenarios are different. Graphical disorders should be examined closely in order to determine their possible link with a wider praxic deficit possibly associated with visuoconstructive difficulties or with tone disorders. There is still much to do to systematize the psychomotor management of this type of disorder, the impact of which can be disastrous. It is therefore necessary to evaluate carefully the different sectors that may be deficient, given the heterogeneity of the disorder, and do the same for the therapies that have been put in place.

DYSGRAPHS:

The current classifications make little mention of the disorders of writing.

DSM IV refers to a “disorder of written expression” among the “learning disabilities” which refers to the orthographic and syntactic slope and refers the illegible writing to the “disorder of acquisition of coordination” without more precision.

The CIM 10 mentions an inadequacy for writing in the description of the motor development disorder. The work of de Ajuriaguerra et al, however, emphasized the dysgraphia defined as an impairment of the quality of writing without this deficiency being explained by a neurological or intellectual deficit. The writing is slow, tiring, not in conformity with the possibilities of instrumental behavior of the child and the age. They distinguished five types of dysgraphia, little individualized: slow and precise, stiff, soft, impulsive, clumsy.

Writing develops in a non-monotonic way: performance improves momentarily by deterioration. This characteristic of development is linked to the fact that the subject substitutes a new old strategy, a new strategy which, before it proves to be more effective in the long term, leads to a temporary disturbance. Thus, towards 5-6 years, a predominance of fast ballistic movements, of short duration with high peaks of speed. Between 7 and 8 years, there is a period of instability at the graphic level with movements decomposed into several sub-movements. From 9 to 10 years of age and up to age 15, ballistic movements of average speed, corresponding to the maturity of writing skills, appear and develop; The movements are then more fluid and the phases of acceleration and deceleration, as pronounced in the preceding stages, are no longer observed in the speed curves.

On the other hand, these changes in age strategy are not accompanied by significant differences in the duration, length and speed of the traits.

The perturbations of writing range from the mere substitution of letters to the total inability to write. They can be grouped into four headings:

– the alteration of the writing (tremors, badly formed letters, telescoping or absence of connection, absence of loops, ironed features, micrography for example);

– spatial disturbances (misalignment of letters, tight words, absence of margin, ascending or descending lines);

– syntactic disorders (difficulty in writing grammatically correct responses in response to a question while oral expression does not suffer from such a difficulty);

– reluctance to write.

Graphomotor alteration and spatial disorders constitute the psychomotor aspect. It is also common to distinguish between linguistic dysgraphia and motor dysgraphia, which refers to the distinction that can be made between declarative and procedural processes. The fact remains, however, that there is still some confusion in the so-called literacy disorders in children.

The modeling of writing as it can be found in cognitive neuropsychology suggests the existence of a succession of components involved in writing, as a result of studies carried out on adult patients with cerebral lesion. Three systems are distinguished among the engine modules: the grapheme system is concerned with the orthographic structure and directs the choice of letters, the allographic system manages the different ways in which the same letter can be written (lower or upper case, script or cursive) The graphomotor system precedes the execution of the writing on a neuromuscular plane and concerns the spatial data, the direction and the organization of the lines as well as their size.

These different systems can be achieved independently. It is still unclear whether, in children, any of these systems can account for the different forms of dysgraphia. Some hypothesize that the graphemic system is altered when the letters are properly formed but not placed correctly inside the word, as can be seen in children with ADHD, for example, or when letters are added.

The alteration of the allographic storage manifests itself in errors in the choice of the type of letters, letters of printing inserted in the middle of a cursive writing for example, which is encountered in learning disorders. Copying printed text encourages this type of error. The dysfunction or the lack of use of the graphomotor system could correspond to what is usually called dysgraphy in the French literature.

The main signs are a bad organization of the page, the clumsiness of the layout and the errors of form and proportion in the tracing of letters. The page gives the impression of neglected, dirty work, spaces between letters and words are not respected, the child does not follow the line. The lines move closer and farther apart, giving a sinusoidal appearance.

These manifestations are certainly linked to the spatial orientation difficulties experienced by some of these children. The movement is bumped, jerky, lacking fluidity, the line is irregular, the links between the letters are often absent. The letters are ill-proportioned, too large or too tall, or atrophied and deformed. The graphic gesture is very variable, with poor control of the gesture at the spatial, temporal and kinematic level.

Dysgraphics often present difficulties in the position of the hand and the fingers, the tightness of all or part of the writing member, an absence of digital movements and painful phenomena which cause the association to discuss a draft of cramps. But these aspects appear to be insignificant or secondary. The vision increases the discontinuous character of the movements of the wrist, while on the contrary improves the fluidity of movement of the fingers and participates in maintaining an appropriate pencil hold. During the writing, syncinesias appear as well as various abnormal movements (shakes, jerks, saccades), palmar hyperhidrosis.

The study by Cornhill and Case-Smith compares the performance of 48 subjects, aged 7 years on average and divided into two groups according to the quality of writing, in various tests that measure kinesesthesia, motor development, visual coordination , Visuoconstructive praxis and unimanual manipulation. The differences are significant for all the tests. Subjects considered to have lower quality writing have translational and rotational abilities of objects within the hand significantly reduced compared to subjects whose writing is of good quality. The authors believe that work on these in-hand manipulation skills is an element that should improve writing.

The evaluation focuses on different aspects: the position of the subject facing the table; Automation of graphic movement (decomposed or plotted letter to letter, hesitant – two to three letters, semi-automated, automated); Graphic trace quality; Pressure exerted on the sheet; Writing speed. The readability is observed in several situations: spontaneous writing, cursive writing, copy of a text printed in cursive writing, dictated by simple words and phrases, to locate the level (s) of dysfunction.

The use of digital tablets should make it possible to specify spatial data (trajectory, letter height and width, regularity of curvatures), temporal (reaction time, duration of movement, duration of breaks), kinematics (speed, continuous or discontinuous character Of the graphic production), dynamics (acceleration) as well as the importance of the pressure exerted on the sheet.

Disorders of writing can be observed in dyslexia. A lack of care in calligraphy is mentioned, the writing is blurred or even illegible, the links between the letters are too long or too short and telescoping between two letters producing a “bizarre” form are found.

In the dyspraxic child, there are also perturbations of writing: irregular letters in form and dimension, variable space between letters, words and lines, often illegible aspect of the whole. Compared to a control group, writing is significantly worse.

Muscle Tone Disorders:

DYSTONIES:

Dystonia is an abnormal and inadequate muscular contraction that occurs during a movement (professional cramp) or in the maintenance of an attitude (torticollis) and may be accompanied by spasms caused by a series of contractures.

Dystonias disappear when sleeping, are sensitive to social and emotional influences and fatigue, present themselves in very specific acts and may not appear in another act involving the same muscle groups.

Dystonias can begin in childhood around 6 to 10 years and progress very slowly. They sometimes lead to singular postures: anterololics, retrocolics, trunk in lordosis or scoliosis.

The earlier the onset of dystonia, the greater the risk of generalization to other bodily regions. When dystonia occurs in adulthood, it tends to remain isolated.

In children, Ajuriaguerra et al describe an array of cramps, the common signs of which are an intense contraction of the shoulder, forearm and fingers, or important tonic variations, phenomena Painful permanent during the graphic activity or occurring during a speed command, a forced stop of the graphic activity during which the subject rubs the wrist or shakes his hand. There may be a slowness of writing, incoordination of movements, syncinesis, palmar hyperhidrosis, poor performance of the instrument, which changes during writing and changes in the attitude of the subject Which seeks to compensate for the onset of symptomatology.

Cramps of the writer are found in children, the disorders begin before 19 years for eight patients out of 29 in the study of Sheehy and Marsden and may, at first, be intermittent. The disorder can be manifested as soon as the pencil is grasped with the closed fist or with dystonic postures of the hand and the wrist.

SYNCINEES:

Syncinesias, induced tonus disorders, are contractions or movements of interest to one or more muscle groups, while active or reflexive movements take place in another part of the body. This muscular and / or motor activity appears in regions not affected by the execution of the first movement.

They can be defined according to the region of the body that is subjected to parasitic movement, then they are homolateral when they appear in muscles adjacent to the inducing muscle or in the other member of the same side, contralateral when symmetric muscles Or generalized when the diffusion concerns the whole of the body.

The classification can be done according to the location of the inducing motion. They are peripheral as in the trial of “puppets” or axial, sought after by the progressive and then maximal opening of the mouth, sometimes accompanied by the fact of pulling the tongue as in the search for Becher’s orochiral syncineses consisting of a separation with Extension of the fingers of the hand. Axial syncinesia does not evolve with age and there is, according to Stambak, a link between the side where the first response is observed and spontaneous lateral dominance.

But it is above all the form taken by the syncinesias which is generally retained. De Ajuriaguerra distinguishes syncinesis   Of imitation called tonicokinetics or even reproduction and tonic syncinesis or tonic diffusion. The former are movements or sketches of movement of the passive opposite member. This movement may exactly imitate or differentiate the inductive motion. They are related to maturation and ontogenetic evolution. Significant at around 6-8 years, they decline sharply at 9 to 10 years and disappear normally at 12 years. The second consists of a stiffening of the passive limb with increased muscle tone. Without significance in terms of genetic evolution, they can be found, according to individuals, at all ages. At 10 years of age, 84% of children present against 52% for imitation syncinesias.

At 12 years of age, 64% and 44% respectively. Up to 9 years, girls are more synkinetic than boys and, from 10 years, the reverse happens.

They are mainly caused by the diadocokinesis test consisting of successive movements of pronation and supination of the forearm (movement of “puppets”). In addition to the syncinesis, the test allows the demonstration of dysdiadococinaesis or of adiadococinaesia which require a neurological examination. Other tests such as the Kwint facial motric test or the digital lift test are also used.

Syncinesia is frequently encountered in association with various psychomotor disorders, including dyspraxia and abnormal movements, stuttering and in learning disabilities. Parain and Moscato report the existence of imitation syncinesias called “mirror” movements that persist throughout life and may or may not correspond to a hereditary process or result from a neurological pathology (congenital hemiplegia).

PARATONIES:

Paratonia is an abnormality of background tone. It consists in an impossibility to realize the muscular resolution on command.

Instead of the desired relaxation, a contraction is established all the more irreducible as the subject makes more efforts to succeed in defeating it. As of the ninth month, the limbing of the limbs is possible in the young child.

The classical maneuver of emphasis is the trial of the ballant in which the subject is asked to “leave the soft arms like a rag doll” and where one observes the resistances opposed to the passive movement printed on the arm. When the arm is elevated horizontally and deprived of any support, it does not fall immediately or the fall is braked. The scalability review can also be used.

De Ajuriaguerra describes several types which range from normal paratonia to that which indicates a motor development disorder by way of the subnormal paratonies of situation and of presence. Others differentiate between background and action paratonies. From a clinical point of view, these phenomena present few distinctive characteristics and depend on the situation of the subject during the detection.

The presence of paratonia has been mentioned in the ticker, it may be associated with delays in psychomotor development, other tone disorders (syncinesis and cramps) or somatic manifestations of anxiety. Without much pathological significance, very rarely disturbing the subject, it nevertheless constitutes an indicator of poor tonic regulation which can intervene in the maintenance of the associated symptoms.

HYPERTONIES:

Certain changes in muscle tone may be associated with psychological factors of affective order. Tension headaches and certain dorsalgia fall within this framework. A precise observation of the symptomatology concerning the topography of the contraction, the associated pain and signs, their characteristics, the time of occurrence, the triggering factors and the intensity of the symptoms, the frequency of the accesses will allow, on the one hand, With the classical complementary examinations, to make a differential diagnosis and, on the other hand, to discuss the advisability of a psychomotor therapy (relaxation, EMG biofeedback or cutaneous conductance).

The mechanisms of abnormal tone of the dystonia or hypertonic type appear complex and can not be satisfied in any way with the psychogenetic conception which, in the line of Reich and his notion of “characteristic armor”, has long prevailed.

Abnormal psychomotor movements: tics and motor stereotypies

TICS:

The tic is a sudden, rapid, recurrent, non-rhythmic and stereotyped vocalization or movement (DSM IV). Once initiated, the tic can not be interrupted. It has sometimes, but not systematically, the appearance of an active movement that is directed towards a goal, expressive or defensive, in response to a physical injury or a psychological trauma, a character that it no longer possesses because of its automation . For some, it has a value in communicating with others, but this aspect only occurs secondarily when, as the environment has responded in a certain way to the appearance of tics, they become a means of engendering behavior in the environment, Surroundings. The tics form a continuum that goes from simple transient tics to the disease of Gilles de la Tourette.

Simple motor tics may be of interest to the head (blinking, ocular deviation, blepharospasm, face grimaces, head shaking, tongue protrusion, lip movements), neck, shoulder (shrug). Abnormal movements appearing in the upper and lower limbs are for the most part to be regarded as motor stereotypes and the notion of complex motor tics is sometimes used without much discernment.

The DSM IV indicates as an example of complex motor tic behaviors like pulling on his clothes, jumping, touching, trampling, sniffing an object.

Simple vocal tics are numerous: scraping, snorting, snorting, coughing, snoring, barking, shrill, exhale noises, whistling, laughing, sighing, guttural sounds, sucking, crackling, rumbling, clappiness, yelping, regurgitation and vomiting . Complex vocal tics include the repetition of words or phrases out of context, coprolalia (emission of obscene words), repetition of words or sounds emitted by the subject (palilalia) or heard (echolalia).

A number of factors aggravate tics, such as anxiety, fatigue, boredom, while sleep, relaxation, fever, concentration in pleasant activity, Sport or a musical instrument have the opposite effect.

Sleep disorders (parasomnias), associated with the presence of tics during the night, are numerous: enuresis, somnambulism, sleepiness, nightmares; Sudden awakenings during sleep phase IV with disorientation, confusion and motor stereotypies.

Tics may be transient or chronic, isolated or multiple, succeeding or manifesting simultaneously. About 15% of children have manifestations that disappear spontaneously after a few weeks or months. They are sometimes of early onset, from the age of 2 years, and usually begin in childhood or pre-adolescence. Tic is two to three times more common in boys.

In view of the therapeutic implications, tics have to be differentiated, despite the apparent difficulties, from a number of abnormal movements: choreiform and athetosic movements, hemiballic movements, myoclonus, spasms and cerebellar tremors.

Their etiology is multifactorial, as in the majority of psychomotor disorders and considering only the psychodynamic point of view or the neurological side is at the present time an obsolete position. Organic factors (basal ganglia, presence of EEG abnormalities), sometimes post-traumatic, hereditary, psychological or the role of the environment in maintaining the disorder, are mentioned and interact frequently. The pathogenic model of Gilles de la Tourette syndrome proposed by Leckman et al. Is an attempt to synthesize the known data; he relates: a genetic predisposition; Environmental factors that influence expression of the phenotype, such as hormonal impregnation, the presence of stressors during pregnancy, and after birth; A neurobiological substratum with the role of dopaminergic systems, alteration of the ganglia of the base and the corpus callosum; A clinical phenotype and its reciprocal influence with risk and protective factors.

The personality of the ticker has been the subject of several analyzes that bring very few pertinent and specific elements, often remaining within the framework of generalities that join the “common sense” without bringing decisive arguments. Ticks can be found in all psychopathological tables. The association of tics or Gilles de la Tourette’s syndrome to ADHD is often mentioned without any evidence of an etiological relationship between these two conditions. Learning disabilities are all the more common when AD / HD is associated. As with AD / HD, co-morbidity with OCD sometimes makes it difficult to diagnose and delineate the two entities. Among the subjects affected with Gilles de la Tourette syndrome, 30 to 40% would have OCD. The two disorders could refer to the same genetic vulnerability that would be actualized as a tic, more often in man, or as an obsession, more often in women. Compared to an isolated OCD, the association of these disorders is accompanied by differences in the content of obsessive thoughts, including sexual, religious and violent themes, as well as compulsions not preceded by thoughts and devoid of Painful affects.

During the clinical examination, the search for the circumstances of occurrence of the disorder, the reactions of the entourage, the possible attribution of a meaning by the child or the family, the associated symptoms make it possible to define a therapeutic Under no circumstances be univocal. It is necessary to specify the characteristics of tic: localization or verbal content, frequency, complexity. The psychomotor examination can find disorders of the tone to the type of syncinesis and paratonies as well as elements of developmental dyspraxia or ADHD.

GILLES DE LA TOURETTE SYNDROME:

Gilles de la Tourette syndrome, also called tic disorder, is characterized by the association of abnormal movements, imitation of words (echolalia, pallialia) or movements (echopraxia), as well as vocalizations. The DSM IV retains the following clinical criteria: presence of multiple motor tics and one or more vocal tics whose occurrence is not necessarily simultaneous and whose characteristics may vary over time, occurring daily or almost for more than 1 year , With no free interval of more than 3 consecutive months, starting before the age of 18 years, the disturbance not being due to the direct effects of a substance or to a general medical condition.

Itard, in 1825, reported the first precise medical description with the case of the Marquise de Dampierre who, due to the socially unacceptable character of her vocalizations (coprolalia), lived recluse until her death at 85 years after a The age of 7, which is the average age of onset.

A number of paintings were initially brought closer to the disease than tics, but considered as culturally linked syndromes: jumping Frenchmen in Maine, “myriachit”, “ikota”, “amurakh”, ” Olon “in Russia,” latah “in Malaysia,” bah-tsche “in Thailand,” mali-mali “in the Philippines,” imubacco “in Japan,” Lap panic “in Lapland, and” yaun “in Burma. They are now grouped under the term “pathology of the burst”, which consists of an exaggeration of the surge reaction in response to an unexpected stimulus.

The prevalence of the disease in the general population varies between 0.03 and 1.6%, but the exact proportion is difficult to establish due to the considerable variations in the intensity and occurrence of the manifestations which do not necessarily lead to a consultation in medical world. The gender distribution is three boys per girl. The first symptom presented is, in half of the cases, a tic isolated blink of the eyes, frequently a tic at the level of the face or the neck, more rarely a vocal tic (clearing of throat).

Coprolalia is very variable (4 to 60% depending on the crop, sociocultural milieu and age of the patients). It is mentioned in less than 10% of the cases in the DSM IV, even though it was the most notorious element of tics disease and a symptom of primary importance for Gilles de la

Tourette. It may be masked by another vocal tic or may contain only the partial emission of the word “garbage”.

The abnormal movements affecting the upper or lower limbs and the trunk are diverse: finger movements, hand shaking, arm projection, even stroke, trunk movements, pelvic advance, jumps, abrupt squatting, genuflection accompanied by Great movements of the arms, spinning, obscene gestures (copropraxia), sometimes self-mutilation. Other manifestations are less frequent.

Echopraxy is found in 11 to 35% of cases, echolalia in 20 to 44% of patients and pallialia in 6 to 15%. Mental coprolalia is mentioned in 5% of cases and consists of a sudden intrusion of phrases or rude words at the level of thought.

Kurlan stresses the “sensory tics” that he defines as “somatic sensations described in varying ways by patients in terms of impression of pressure, itching, heat, cold or any other abnormal sensation of the skin, Bones, muscles and joints “. The patient then seeks to eliminate these dysphoric tone sensations by movements which must be repeated because the induced sedation lasts a short time. Vocalizations would thus respond to unpleasant impressions of the oropharyngeal zone. These sensations generally appear around 9-10 years. Including prodromal symptoms, these sensations would be present in 50 to 80% of the patients with Gilles de la Tourette syndrome.

Neuropsychological studies indicate deficits in manual dexterity, visuoconstructive praxis and executive functions.

First-line psychomotor therapy, including relaxation, and psychotherapy, to deal with emotional and behavioral disorders secondary to the presence of tics and to reduce the possible secondary benefits of the disease, can reduce the intensity of Tics. An approach to the family environment can be useful, in particular to modify the attitudes towards the wearer. In the presence of persistent and disabling tics, the combination of a medication can be considered with the usual precautions. The most widely used molecules are haloperidol (Haldol t ), among dopamine antagonists, and clonidine (Catapressan t ), the latter when associated with AD / HD.

ENGINEERING STEEPOTYPIES:

They are complex, repetitive movements, devoid of purpose, despite their possible appearance of adapted movements, involving a larger number of coordinated muscle groups than in the case of tics, which are generally beyond the control of the subject. DSM IV, like ICD 10, refers to “stereotyped movement disorders” when these movements cause physical injury or discomfort to the subject and if there is no pervasive developmental compulsive disorder Or tic.

Motor stereotypies include manipulations of the body of the subject: suction of the thumb, twisting of the hair with the fingers or the mouth (titillomania), plucking of the hair (trichotillomania), bite of the skins, nails (onychophagy) (Bruxism), insertion of the fingers into the orifices (nose, ear, eye, anus) and scraping (excoriations). Others are constituted by generally rhythmic body movements: swinging of the head accompanied sometimes by a shock against a surface (crouomanie), rhythmic agitation of a part of the body or whole body. Finally, manipulations can interest objects (keys, pen) or part of the garment (button, tie).

Described for the first time in 1889 by Hallopeau, a French dermatologist, trichotillomania is today individualized as a disorder of impulse control. The subject is unable to resist the pulling impulses of the hair which leads to alopecia. A feeling of tension precedes the avulsion of the hair and gives way to a feeling of relief afterwards.

The frequency of the disorder is not known with certainty or its distribution by gender. The disorder begins in childhood (7 children for an adult) even if the starting age is variable, and can be found as early as 13 months. The disturbances of the mother-child relationship are frequent with hyperprotection and aggressiveness. The denial of the disorder is important. Its association with thumb sucking and onychophagia is often reported. The ingestion of the hair can lead to a trichobezoar with its train of gastrointestinal complications.

These abnormal movements cause a decrease in alertness, which has been compared to attachment behaviors of the child to the body of the mother who have this function when awakening is increased by the exploration behaviors. They appear in situations where awakening is stimulated (emotion, anxiety, sensory deprivation, boredom). On the other hand, Young and Clements consider that some stereotypies in the mentally retarded occur during a reduction in wakefulness and result in increased self-stimulation vigilance.

Motor stereotypes can be found in different mental illnesses, in subjects with mental retardation, especially since this delay is profound, in association with sensory handicaps or neurological disorders such as autism.

Their presence during the normal development of the child was mentioned even if some authors consider that these two behaviors, normal and pathological motor stereotypes, must be distinguished, in particular with regard to the topography of the movements.

Non-verbal learning disabilities (IANV):

IANVs have been described as the association of learning disabilities in mathematics or dyscalculia, psycho-perceptive-motor disorders, and social competence disorders, including the ability to decode and use non-verbal communication. The non-verbal aspect includes both perceptual mechanisms and communication systems, both of which are disorganized. It is therefore a sub-group of learning disabilities.

Difficulties in arithmetic are closely related to visuospatial disorders which would precede the former. There is poor spatial organization and poor writing of numbers, omissions (units, commas, restraint) and procedural errors, perseverance, and mathematical judgment disorders. We can add the defects of retention or placement in immediate verbal memory.

Psycho-perceptivo-motor disorders are varied: bad tactile discrimination more pronounced on the left side, manual incoordination (platechette with holes, labyrinths), visuoconstructive deficit accompanied by a QIP lower than the QIV to the WISC. For some, difficulties in general motor skills and sports activities are important without being generalized. The graphomotor difficulties are present from the beginning of the learning of the writing with slowness to the inscription, tensions, poor holding of the pencil, hesitations, variability of forms and spacing, but they improve during the schooling.

Disorders of social competence concern the following components:

– perceptual, with incorrect decoding of non-verbal communication, especially when it comes to the expression of emotions;

– cognitive, with a poor anticipation of the behavior of others and their motivations;

– expressive, with anomalies of visual contact that is diminished or avoided, poor emotional mimics, poor regulation of social space and aprosody in the early years, all the more disconcerting as verbal production is abundant.

IANV subjects are often described as immature, looking for younger children, lacking motivation and are often disoriented by the novelty of a task to which they respond in a stereotyped and inadequate manner, both cognitively and psychomotorically . They find it difficult to categorize and manipulate concepts. Studies of psychopathological symptomatology indicate that few subjects are lacking. The manifestations are numerous: anxiety, depression, avoidance behavior, social withdrawal, psychotic traits.

Prevalence is estimated at 1% of the population. Diagnosis is rarely made and confusion is frequent with pervasive developmental disorders or developmental dyspraxias. One can also wonder whether the group of seven children called “dyspraxias with severe personality disorders” of psychotic type in the study of Stambak et al does not refer to this pathology. Co-morbidity with AD / HD is also reported at the beginning of schooling, but the symptomatology is later internalised.

The sex ratio is estimated to be 1/1 contrary to what is found in the majority of psychomotor disorders and learning disabilities.

The different data are in the direction of a dysfunction of the right hemisphere and especially of the white substance.

IANV is found in a series of disorders and syndromes: head trauma, effects of irradiation used to treat acute leukemia, hydrocephalus, corpus callosum, Turner syndrome, fragile X syndrome, Asperger’s syndrome .

Disorders of lateral dominance:

Besides the subjects presenting a lateral dominance of the upper limbs that is homogeneous to the right or to the left, two scenarios can be present: ambidextrous who use in an undifferentiated manner one hand or the other for the same activity and the ambilaterals who, According to the activity, change hands. These two categories, which account for about 25% of the population, are generally confused in the various works dealing with this subject, limiting the interpretation and use of the results, or grouped under the most diverse terms: lateralization or mixed or mixed dominance, Predominance incomplete, ambivalence, dyslatéralité, children ill lateralized. Some authors also distinguish between strong and weak right or left handers, differentiate the neurological, spontaneous and usual lateralities or distinguish the laterality of the graphic from the usual laterality. Auzias finds a discrepancy between the latter two types of laterality in 16% of the children examined.

Hecaen considers that manual preference is generally well established by 3 years even if the degree of skill of the dominant hand increases with maturation. But fluctuations in the establishment of this dominance may appear until about 6-8 years, especially in the cases of senestrality, which requires a certain caution of diagnosis in cases of ambiguous dominance.

It is around six years of age, at the time of first school learning and entry into primary school, that the choice of hand for writing is paramount.

EVALUATION OF SIDE DOMINANCE:

The evaluation of lateral dominance can be carried out using several methods: questionnaires, the realization of usual praxis, the execution of tasks requiring a certain dexterity or by the observation of certain indirect elements (proprioceptive discrimination, Measure of the extensibility or sense of the syncinesis to the test of the “puppets”).

Questionnaires:

They are multiple, their sizes also, some going up to more than 50 questions. The most used are those of Oldfield and Annett, the most recent that of Dellatolas et al. The latter includes, in final form, ten questions: toss, draw, racket, razor / makeup, comb, toothbrush, knife without fork, hammer, screwdriver and match. The answers are coded 0 for the right hand, 1 for both hands and 2 for the left hand. The distribution in four classes (right-handers, right-handed ambidextrous, ambidextrous left-handers, left-handed), if practical, retains the ambiguity outlined above.

The Oldfield scoring system provides a lateral quotient with the formula:

QL = (hand responses D – hand responses G / hand responses D + hand responses G) X 100

It thus shows a continuum between the right-handed (+ 100) and the homogeneous left-handed (-100).

Realization of usual praxies:

It is used in the test of Auzias. It consists of 20 items, of which ten are strong differentiators, which the child must perform using the supplied equipment (matching, stitching, waxing shoes, transferring, pinning on a cork, tapping, erasing, brushing, dropper , Spoon, bell). In the lateral test of Harris, which also includes tests of dexterity and an appreciation of the ocular and foot dominance, ten actions must be mimed.

Dexterity tests:

They are multiple: writing speed, simultaneous writing of numbers, tapping or dotting for various periods, dart throwing, cutting, use of pliers to manipulate small metal rods. The aim is to compare the performance of both hands in terms of speed and accuracy.

Indirect Elements:

They are extremely varied. A number of studies show a correlation between lateral dominance and various measures, the conclusions of which have subsequently been reversed: size of the feet, direction of implantation of the hair, vascular network of the hands or of the nail matrix, time Of reaction. Studies of muscle tone show a relationship between the degree of extensibility, the sense of syncinesis that is “puppet-proof” and lateral. In a right-handed person, the degree of extensibility would be greater in the left arm and the latter would cause more syncinesis in the right arm. These elements constitute an index of laterality without there being a total correlation with the usual dominance. The discriminative sensitivity of weight attached to the index finger, the strength of the manual grip, the motor irradiation in a symmetrical muscle during muscle contraction were also studied.

DOMINANCE OF LOWER MEMBERS:

It is explored by a variety of tasks such as hitting a ball, pushing a puck along a hook line, crushing or grabbing an object with the foot, climbing on a chair or walking back to the wall with foot observation Which initiates movement, tapping speed. Discrepancies can be found between two activities, so Crichtley points out children who preferentially kick the right side and jump off the left foot. The question then arises whether the dominant foot is the one who realizes the movement (dynamic preference) or the one that maintains the equilibrium of the body (static preference). The relations between lateral preference of the hand and the foot have produced results which are sometimes contradictory because of the tests selected.

Correlation is more important in right-handers than in left-handers, with some authors even preferring a right foot in left-handed adults in a tapping test.

EYE DOMINANCE:

It can take on several meanings involving various mechanisms weakly correlated with each other and unrelated to manual dominance. Three factors were found by factor analysis. The dominance of sight or of monocular vision makes it possible to appreciate the greater capacity of an eye to point towards a particular point of the space. It is evaluated by tests such as those of the kaleidoscope or the telescope (Harris), or it can be seen through a cardboard with a hole in the center or inside a flask (Galifret-Granjon) Using a cone.

These are the tests most commonly used in lateral batteries, and those which correspond most in their form to tests of manual lateral dominance. Sensory dominance is found in trials of binocular rivalry. It is a dominance of perception of forms. Finally, the dominance of acuity concerns the eye which obtains the best results to the tests of visual acuity, in the capacity to differentiate an angle for example. Only an important asymmetry between the two eyes can interfere with the dominance of vision. Contrary to what happens for the hand, ocular dominance does not correspond to a hemispheric dominance.

SIDE DOMINANCE AND PSYCHOPATHOLOGY:

Hand-eye cross-lateralities have been found in greater numbers in some individuals with specific behavioral or psychiatric abnormalities: inpatient psychopaths, schizophrenics, children with affective disorders and learning disabilities. But some work is contradictory, especially those concerning difficulties in reading.

Ambilaterality is more frequently found in children with developmental delays. It is also associated with various disorders: stuttering, difficulties in language and reading, temporo-temporal disorders and visuoconstructive difficulties.

DETERMINISM OF LATERALITY:

The respective frequencies of left-handers (approximately 8%) and right-handers in the various populations studied, sometimes with variations reflecting the evaluation method and the existence of several factors, raise the problem of the factors that may influence, The given individual, the establishment of lateral dominance. The determinants of manual lateralisation are to be sought in two fields which are not mutually exclusive: the influence of the environment and genetic determinism. The role played by the environment has given rise to multiple theories where the emphasis has been placed on the need to adapt to objects whose increasing technology no longer allows undifferentiated manual use, the obligation to protect the heart With a shield in a sword fight, intrafamilial or school learning by imitation, previous performance, or religious and social influences by the meaning attributed to the right and left sides.

Genetic theories have referred to a model of the Mendelian type, a one-gene model with two different alleles (D and g), a model with two dialectical genes, one of which determines language control and the other controls motor control. But these models do not account for all the observed facts (different lateralization in monozygotic twins, correlations of relatives, collaterals). Some also spoke of the influence of genes on potential asymmetry. The significantly higher correlation between lateral dominance of parents and children in biological families compared to adoptive families does not rule out such a factor. The stability of the number of left-handers, whatever the age, also indicates that the pressure of the medium is not sufficient to explain lateralization.

LEFT MANUAL LATERALIZATION:

Manual awkwardness has been associated with a number of deficits and disorders. The work of Orton (1928 to 1937) emphasized the high number of left-handers among dyslexics, dysphasics or stammerers. But subsequent researches have given contradictory results which do not permit any definite conclusion. Percentages of left-handers greater than those of the general population are found in epilepsy, mental retardation, trisomy 21, autism, cerebral palsy, deafness, strabismus, schizophrenia, migraine.

On the other hand, disgruntled awkwardness could play a role in certain disorders of school learning. Mirror writing is also not the prerogative of left-handers, and is only found with a frequency slightly greater than that of right-handers in groups of children of the same age. Above all, it is necessary to differentiate left-handers with and without left-handedness, whose cerebral organization differs, which might explain some contradictory results.

Finally, a small degree of lateralization, more than being left-handed, would be associated with less good performances in spatial reasoning tests.

Right-left confusion:

Right-left discrimination occurs progressively in children and occurs on several levels. It begins on itself towards 6 years, on another, with the notion of reversibility, towards 8 years then on three objects, aligned in front of the subject, one with respect to the others, towards 10 or 12 years and finally with respect to objects Placed in front of others. The Piaget-Head test evaluates the development of these notions. The tests of Piaget relate to the right-left orientation on oneself, others, in relation to three objects.

Head’s tests consist of producing movements from one hand to an eye or ear through imitation of the observer, then a drawing as well as an oral instruction.

The spatial differentiation must also be done for signs with horizontal symmetry (u and n for example) and vertical signs (b and d). The main difficulty is to make the child admit that, for the graphic symbol, the identity is linked to the orientation in space whereas the objects usually retain the same properties whatever the orientation . Until about 5 years old, the child is familiar with the constancy of the object: a chair remains a chair, whether its back is on the right or left side, whether it is at the top or the bottom. From the moment when the learning of reading begins, it is no longer the same, “b”, “p”, “d”, “q” are not interchangeable elements. These prerequisites for reading are appreciated using the Reversal test which comprises 84 pairs of figures including 41 identical and 43 different. Of the different figures, eight have no element of symmetry, five have both left-right and top-bottom symmetry (d and p), five have horizontal symmetry and vertical symmetry.

Right-left confusion is mentioned in the learning disabilities, dyspraxias, developmental delays.

Problems related to geographical orientation, phenomena of mental rotation and spatial reasoning are found in some children, but their integration is still to come.

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Editor-in-chief of the Medical Actu website; general practitioner graduated from the Faculty of Medicine of Algiers in 2005 currently practicing as a liberal.

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