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Objectives: The COVID-19 crisis dramatically broke down the administrative, technological and clinical barriers that previously existed in the field of telemedicine. There is an important need to define standards for remote clinical observation, for instance in case of suspected autism spectrum disorder (ASD). Describing tools for the remote assessment of children with ASD and reflecting upon the ethical aspects of this practice will improve the quality of care with telemedicine., Method: Since 2013, we have conducted clinical evaluations by means of telemedicine at the center for diagnostic and evaluation of autism of the GHU Paris Psychiatry and Neurosciences which have afforded us opportunities to develop information tools and specific procedures. This clinical procedure is associated with ethical reflections that we included in our procedure., Results: Benefits and risks are presented to families, and informed consent is obtained. The use of validated tools is privileged and their results are analyzed in light of the clinical experience of the professional. Privacy for persons and professionals is preserved, and the patient-doctor relationship is reinforced because of the ability of the patient to make decisions and feel more empowered in the context of the videoconsultation., Conclusion: The COVID-19 crisis was the impetus for a dramatic increase in the use of telemedicine with a potential risk because of the broad and blurry framework of its application. Clinical and ethical concerns must be studied. Moving forward, societal reflection about the accessibility of telemedicine will be necessary: telemedicine for all should be a future perspective., (© 2021 Elsevier Masson SAS. All rights reserved.)

The hypothesis of cerebral plasticity in psychiatric disorders has encouraged clinicians to develop cognitive remediation therapy (CRT), a new therapeutic approach based on attention, memory, planning, and mental flexibility tasks. The first cognitive remediation programs were developed and validated for adults with schizophrenia and were shown to have a positive impact on executive functions as well as on quality of life. In children and adolescents, researchers emphasized the existence of executive dysfunction in neurodevelopmental disorders such as autistic spectrum disorder, attention deficit disorder, and eating disorders. For these disorders, neuropsychological studies suggest that memory, planning, attention and mental flexibility are impaired. Despite the paucity of studies on cognitive remediation (CR) in children, preliminary results have suggested, as in adults with schizophrenia, good compliance and optimization of executive functioning. Consequently, programs dedicated to young subjects were developed in English-speaking countries, and the Department of Child and Adolescent Psychiatry of Sainte Anne Hospital (Paris) developed a new CR program for children with attention deficit disorder, academic problems, or eating disorders. These programs complete the field of CRT proposed by Sainte Anne Hospital's Remediation and Psychosocial Rehabilitation Reference Center, initially designed for adults with schizophrenia. Our team used and adapted validated tools such as Delahunty and Wykes's CRT program (translated and validated in French by Amado and Franck) and Lindvall and Lask's CRT Resource Pack. One program was developed for an adolescent with anorexia nervosa and applied to the subject and her family, but the purpose of this paper is to present a CR approach for children with attention deficit disorder or academic disorder, a 6-month program based on paper-pencil tasks and board and card games. The team was trained in different kinds of cognitive remediation, and the program was applied by a clinical nurse with the supervision of a child and adolescent psychiatrist and the department's neuropsychologists. Paper-pencil tasks were adapted from the CRT program for adults; the card and board games used were geometric figures, illusions, Rush Hour(®), Set(®), Jungle Speed(®), Color Addict(®), etc. These games are available in stores and the program can be applied at home, which helps families set aside their preoccupations with their child's academic performance. Diagnostic and neuropsychological evaluations were done before the beginning of the therapy and repeated at the end of the 6-month program. This program does not ignore the metapsychological impact of the therapy, and work on self-esteem is also done. The presence of the therapist is necessary, which seems better than a computer program, which cannot encourage the young subject in the same personalized and empathetic way. We therefore conducted the first clinical feasibility trial of cognitive remediation in young subjects and present a clinical case of a 6-year-old boy with attention deficit disorder and academic disorder. The results of neuropsychological evaluations before and after therapy suggest improvement in executive functions and better self-esteem. Satisfaction for the boy and his family was high. Even if these results need to be replicated, cognitive remediation appears to be a new therapeutic tool, complementary to classical approaches used in childhood psychiatric disorders. The Department of Child and Adolescent Psychiatry will submit this program to a research program conducted by the National Health Department to study the impact of this approach in a controlled study., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Unlabelled: CLINICAL BACKGROUND: Autism is a developmental disorder that is usually diagnosed in early childhood. According to ICD-10 criteria, autism can be characterized by delays in language skills, by impaired social interaction, verbal or non-verbal communication and by repetitive, stereotyped or severely restricted activities and interests. The causes of autism are not yet elucidated, but both genetics and environment seem to play a role in 10 to 25% of autism cases. Several biochemical abnormalities, such as impairment of serotoninergic, catecholinergic, dopaminergic, and opioid systems have been reported. Autism therapies are designed to treat symptoms, and medication can be associated with psychoeducational and environmental interventions. Generally, the medications that are currently used are not intended for autism, and must be used with caution and selected according to the type and intensity of symptoms. The most common medication consists of psychotropic therapies by administration of dopaminergic and/or serotoninergic receptor antagonists (haloperidol, risperidone, clomipramine). Several drugs, such as anxiolytics (buspirone), mood stabilisers (lithium, sodium valproate), vitamins (vitamins B6, B12) or opioid antagonists (naltrexone) can be prescribed, in second intention, in cases of severe behavioural disorders. The prescription of opioid antagonists is based on the possible implication of an opioid system disorder observed in some cases. Nevertheless, several clinical studies reveal its variable effectiveness. Naltrexone is a competitive antagonist of opioid receptors OPRM1, OPRD1 and OPRK1. In France, this drug is prescribed for treating opioid and alcohol dependence. Moreover, several studies describe naltrexone as a possible treatment of autistic children in cases of developmental disorder and hyperactivity., Clinical Case: In the Child and Adolescent Psychopathology Department of Sainte-Anne's Hospital, autistic children benefit from a multidisciplinary treatment program that sometimes includes the administration of psychotropic medication. One of these children presented with a severe autistic disorder according to the Childhood Autism Rating Scale (CARS). Considering ICD-10 criteria, he benefited from a multidisciplinary program, associating cognitive psychotherapy, psychomotor rehabilitation, speech therapy and educational intervention. However, persistent sleep disorder and motor instability led to successive prescriptions of several different psychotropic drugs. Initial treatment by thioridazine (10mg per day) followed by propericiazine (2.5mg per day) improved sleep, but was not efficient in reducing self-mutilating behaviour. A new treatment by risperidone (from 0.5mg to 1.5mg per day) was therefore chosen; however it lost its efficacy after five months. Finally, an anxiolytic (cyamemazine) and a thymoregulator (sodium valproate) were successively tried without yielding any clinical improvement. Owing to the persistence of communication difficulties, major instability, self-mutilating behaviour and heteroaggressiveness, treatment with naltrexone was subsequently chosen with parental consent. In France, naltrexone hydrochloride is only available in tablet form (Nalorex 50mg and Revia 50mg), which is not adapted to children at the efficient dose. Consequently, an oral suspension form marketed in Spain (Antaxone 50mg) was imported, having obtained the Afssaps' (the French drug administration) authorisation for its temporary use. The Connors and Nisonger scales were used as outcome measures of behavioural symptom change. The Conners scale is used to assess attention deficit and hyperactivity, whereas the Nisonger scale analyses social skills and behaviour disorders in children and adolescents with mental retardation. The onset of treatment, at a dose of 1mg/kg/day, led to a transitory increase in negative behaviour. However, a dose of 0.75mg/kg per day subsequently led to significant improvements, as shown by outcome measurements. Self-mutilating behaviour disappeared completely. Certain side effects were observed, namely transitory sedation at the beginning of treatment and moderate constipation., Conclusion: This clinical case confirms that treatment of a serious autistic disorder in children using Naltrexone in oral suspension form is a potentially interesting therapeutic alternative for treating behavioural symptoms resistant to classical drug therapy.

Introduction: Autism is a developmental disorder that requires specialized therapeutic approaches. Influenced by various theoretical hypotheses, therapeutic programs are typically structured on a psychodynamic, biological or educative basis. Presently, educational strategies are recommended in the treatment of autism, without excluding other approaches when they are necessary. Some authors recommend dietetic or complementary approaches to the treatment of autism, which often stimulates great interest in the parents but also provokes controversy for professionals. Nevertheless, professionals must be informed about this approach because parents are actively in demand of it., Literature Findings: First of all, enzymatic disorders and metabolic errors are those most frequently evoked in the literature. The well-known phenylalanine hydroxylase deficit responsible for phenylketonuria has been described as being associated with autism. In this case, adapted diet prevents mental retardation and autistic symptoms. Some enzymatic errors are also corrected by supplementation with uridine or ribose for example, but these supplementations are the responsibility of specialized medical teams in the domain of neurology and cannot be applied by parents alone. Secondly, increased opoid activity due to an excess of peptides is also supposed to be at the origin of some autistic symptoms. Gluten-free or casein-free diets have thus been tested in controlled studies, with contradictory results. With such diets, some studies show symptom regression but others report negative side effects, essentially protein malnutrition. Methodological bias, small sample sizes, the use of various diagnostic criteria or heterogeneity of evaluation interfere with data analysis and interpretation, which prompted professionals to be cautious with such diets. The third hypothesis emphasized in the literature is the amino acid domain. Some autistic children lack some amino acids such as glutamic or aspartic acids for example and this deficiency would create autistic symptoms. However, for some authors, these deficits are attributed to nutritional deficits caused by the food selectivity of children. A fourth hypothesis concerning metabolic implication in autism is the suspicion that a food allergy phenomenon could interfere with development, and it has been observed that Ig levels are higher in autistic children than in control children. Autistic children with a positive reaction to food Ig would have a more favourable outcome with diet excluding some kinds of food; but most of those diets are drastic and ethically debatable. Fifth, glucidic catabolism could be deleterious with an excess of ketonic products that will initiate comitial seizures. Few studies with ketogenic diet have been conducted but, as it has been described with epileptic subjects, those diets would diminish autistic symptoms. Not enough studies have been conducted that would allow one to draw any firm conclusions. The sixth hypothesis is linked with vitamin deficiencies that are a notably important area of research in the treatment of autism. Vitamin B12 or B6 deficiencies have been studied in several articles, and many of them were controlled studies. French teams also emphasize an interest in supplementation with B12 or B6. The two last hypotheses concern auto-immune patterns and the toxic effects of heavy metals like mercury. There is a paucity of methodologically satisfying studies that support these two hypotheses and diet recommendations. Following these assumptions, some dietetic approaches have been recommended, even though the methodological aspects of supporting studies are poor. The most famous diet is the gluten-free and/or casein-free diet. Only two controlled studies attracted our attention. Even if for some autistic children such a diet was positive, for others, gluten-free or casein-free diets were poorly tolerated and, for some authors, not without considerable side effects, the more prejudicial of which was the Kwashiorkor risk. Ketogenic diets have been studied in one non controlled study, but even if positive results have been noted by the authors, the ketogenic diet is very restricting and the long term effects have not been evaluated. Vitamin supplementation is the one and only diet domain where there have been many repeated and placebo-controlled studies. Side effects are rare and mild even if high doses of vitamin B6 are advocated in these studies. In total, as evoked by Rimland, 11 controlled placebo-blind studies have been conducted and 50% of autistic children with this supplementation had improved autistic signs. However, these results still remain debated. Finally, more rarely, enzymatic abnormalities need specific diets which have some positive consequences, but such diets could not be applied by parents alone and are the responsibility of specialized teams. For discussion purposes we can emphasize that, in spite of the amount of studies concerning the effects of specialized diets, few are methodologically satisfying. We can not ignore that some side effects are possible with such approaches and parents need to be informed of them. Some are even potentially serious, such as diets with metal chelators. In spite of those results, vitamin supplementation seems to be the only one that some specialized teams in autism could apply, always with parent agreement. In conclusion, within this scientific field, studies on eating habits of autistic children should be conducted because of their food selectivity or avoidance.