Jean-Louis Goeb

An 11-year-old boy with drug-resistant schizophrenia treated with temporo-parietal rTMS.

Very early onset schizophrenia is a psychiatric syndrome in children under 13 years of age that is characterized by a very poor prognosis, due to frequent resistance to treatment. We report here the case of a hospitalized 11-year-old child (YP), with a positive diagnosis of very early onset schizophrenia for the past 2 years (positive K-SADS-DSM-IV), without any previous sign of pervasive developmental disorder. YP experienced verbal auditory hallucinations, a delusion of alien control and heteroaggressive behaviour. Antipsychotic drugs were unsuccessful and furthermore, provoked severe acute dystonia. A 72-h EEG recording, an anatomical MRI brain scan and a complete set of metabolic analyses, were all negative. However, using data-driven analysis, we observed that YP’s functional MRI scan revealed bilateral neural activity in the auditory cortex during auditory verbal hallucinations (Figure 1). Ten sessions of fMRI-guided, low frequency (1 Hz), repeated trans-cranial magnetic stimulation (rTMS) over the left temporo-parietal cortex, were successful in stopping the verbal auditory hallucinations (Auditory Hallucination Rating Scale 47%). The improvement obtained with rTMS was maintained by repeating the sessions every 5 weeks. The clinical improvement was confirmed by a significant improvement of adaptative functions (Children’s Global Assessment Scale þ40%), and the fact that YP was able to go back home and attend school. Thereby, YP was able to receive education about his illness and to follow regular psychotherapeutic sessions. rTMS has been used for hallucinations in adults, and in children with attentional deficits and hyperactivity. To our knowledge, however, this is the first published case demonstrating the efficacy of fMRI-guided rTMS in the treatment of verbal auditory hallucinations in a child with schizophrenia. These results require replication.

Repetitive Transcranial Magnetic Stimulation to Treat Early-Onset Auditory Hallucinations

believe that research from LMICs also allows further understanding of emotional, behavioral, and intellectual abilities in a variety of risk and protective contexts, thus leading to a deeper understanding of the biological and psychosocial processes underlying mental illness and health in general. This will require an expansion in the output of high-quality research focused on those most vulnerable in areas where it is most needed.

Mise au pointStratégies diagnostiques et thérapeutiques face aux hallucinations de l’enfant et de l’adolescentHallucinations in children and adolescents: diagnostic and treatment strategies

Hallucinations are a common symptom in pediatric populations. Because spontaneous rapid recovery often occurs, routine medication with antipsychotic drugs should be avoided. An adequate initial etiological assessment requires a medical examination, a psychiatric interview, and a meeting with key adult informants. Laboratory testing and imaging may also be useful. The risk of self-injury or harming others must be systematically assessed and should determine the choice between prescribing a nonspecific anxiolytic medication or hospitalizing the child. Treatment should combine psychotherapy and psychoeducation, and antipsychotics should be given in case of prodromal psychotic presentation. In the years to come, randomized controlled trials should define the exact role that repetitive transcranial magnetic stimulation might play as a treatment of hallucinations in children and adolescents.

Stratégies diagnostiques et thérapeutiques face aux hallucinations de l'enfant et de l'adolescent

Hallucinations are a common symptom in pediatric populations. Because spontaneous rapid recovery often occurs, routine medication with antipsychotic drugs should be avoided. An adequate initial etiological assessment requires a medical examination, a psychiatric interview, and a meeting with key adult informants. Laboratory testing and imaging may also be useful. The risk of self-injury or harming others must be systematically assessed and should determine the choice between prescribing a nonspecific anxiolytic medication or hospitalizing the child. Treatment should combine psychotherapy and psychoeducation, and antipsychotics should be given in case of prodromal psychotic presentation. In the years to come, randomized controlled trials should define the exact role that repetitive transcranial magnetic stimulation might play as a treatment of hallucinations in children and adolescents.

Therapeutic body wraps (TBW) for treatment of severe injurious behaviour in children with autism spectrum disorder (ASD): A 3-month randomized controlled feasibility study

Introduction The use of therapeutic body wraps (TBW) has been reported in small series or case reports, but has become controversial. Objectives This is a feasibility, multicentre, randomized, controlled, open-label trial with blinded outcome assessment (PROBE design). Setting Children with autism and severe-injurious behaviours (SIB) were enrolled from 13 specialized clinics. Interventions Dry-sheet TBW (DRY group) vs. wet-sheet TBW (WET group). Primary outcome measures 3-month change in the Aberrant Behaviour Checklist irritability score (ABC-irritability) within per-protocol (PP) sample. Results From January 2008 to January 2015, we recruited 48 children (age range: 5.9 to 9.9 years, 78.1% male). Seven patients (4 in the DRY group, 3 in the WET group) were dropped from the study early and were excluded from PP analysis. At endpoint, ABC-irritability significantly improved in both groups (means (standard deviation) = -11.15 (8.05) in the DRY group and -10.57 (9.29) in the WET group), as did the other ABC scores and the Children Autism Rating scale score. However, there was no significant difference between groups. All but 5 patients were rated as much or very much improved. A repeated-measures analysis confirmed the significant improvement in ABC-irritability scores according to time (p < .0001), with no significant difference between the two groups (group effect: p = .55; interaction time x group: p = .27). Pooling both groups together, the mean 3-month change from baseline in ABC-irritability score was -10.90 (effect size = 1.59, p < .0001). Conclusions We found that feasibility was overall satisfactory with a slow recruitment rate and a rather good attrition rate. TBW was a safe complementary therapy in this population. There was no difference between wet and dry TBW at 3 months, and ABC-irritability significantly decreased with both wet and dry sheet TBW. To assess whether TBW may constitute an alternative to medication or behavioural intervention for treating SIB in ASD patients, a larger randomized comparative trial (e.g. TBW vs. antipsychotics) is warranted. Trial registration ClinicalTrials.gov NCT03164746.