TCC spécialisées pour le TOC et le syndrome de Gilles de la Tourette chez l’enfant et l’adolescent : état des connaissances

Abstract

Le trouble obsessionnel-compulsif (TOC) et le syndrome de Gilles de la Tourette (SGT) sont des troubles neuropsychiatriques qui touchent chacun environ 1 % de la population jeunesse et qui s’accompagnent de dysfonctionnements psychosociaux majeurs. En dépit des recommandations internationales, les traitements médicamenteux constituent la méthode de prise en charge la plus fréquemment proposée pour ces problématiques. Ceux-ci ont une efficacité limitée et s’accompagnent souvent d’effets secondaires indésirables. Les thérapies cognitives et comportementales (TCC) sont formellement indiquées comme traitement de première ligne pour les cas légers à modérés. Leur dissémination se heurte toutefois à un manque d’information et de formation des professionnels de santé. Le but du présent article est de fournir une synthèse de la littérature scientifique au sujet des TCC pour la prise en charge du TOC et du SGT chez les enfants et les adolescents. Les présentations, modèles théoriques, données d’efficacité et principales limites des traitements validés sont abordés. Trois nouveaux traitements développés pour répondre aux limitations des précédents sont ensuite mis en avant et illustrés à l’aide de cas cliniques. L’implication et l’importance de conceptualisations et de traitements psychologiques dans la prise en charge des troubles mentaux sont enfin discutées.

Obsessive-compulsive disorder (OCD) is characterized by recurrent, anxiety-triggering thoughts or images (obsessions), often accompanied by ritualized behaviors (compulsions) aimed at reducing the distress caused by obsessions. Tourette syndrome (TS) is the combination of multiple motor tics and at least one vocal tic. Tics are movements or vocalizations emitted in a repetitive, stereotyped and non-rhythmic fashion. Both neuropsychiatric conditions each affect around 1% of children and adolescents (Knight et al., 2012), are highly comorbid in the pediatric population and are associated with major psychosocial and functional impairment (Conelea et al., 2011; Ivarsson et al., 2008). Pharmacotherapy is the most utilized and available form of treatment for OCD and TS in youth. Yet, because medication has limited efficacy and frequently engenders undesirable side-effects (Franklin et al., 2015; McGuire et al., 2015), cognitive-behavioral therapies (CBT) are recommended as first-line treatments for mild to moderate cases (Verdellen et al., 2011). This paper reviews the scientific literature on existing CBTs for the management of OCD and TS in young people. Exposure and response prevention (ERP) and habit reversal (HR) techniques are outlined as the most empirically supported treatments (Piacentini et al., 2010; Rosa-Alcàzar et al., 2015). However, a substantial proportion of patients do not benefit from them. Reasons inherent to patients such as symptom severity, family accommodation or inability to identify antecedents to the symptoms might account for this. Besides, too restrictive theoretical conceptualizations of the disorders might result in limited treatment efficacy. Three new forms of CBT (for OCD, tics and explosive outbursts in TS) designed to overcome the limitations mentioned above are further presented and illustrated with clinical vignettes. These are underpinned by integrative models incorporating specific cognitive (O’Connor, 2002; O’Connor et al., 2005) and physiological factors into the previously dominantly behavioral conceptualizations of OCD and TS. Moreover, unlike ERP and HR that focus on problematic behaviors (i.e., compulsions, tics), CBTs based on the inference-based approach (IBA) and the cognitive-behavioral and physiological approach (CoPs) indirectly aim at a total reduction of overt symptoms by targeting the etiological processes underlying them. IBA and CoPs treatments have shown promising results in adults (Aardema et al., 2016; O’Connor et al., 2016) and their adaptations for children and adolescents indicated good feasibility and utility in case studies (Bombardier et al., 2018; Leclerc et al., 2016). At the time of the evaluation, Mathis was a 13-year-old boy with obsessions about causing harm to people as well as mental counting compulsions and accumulation. He received 14 sessions of the “Maître à Bord” therapy (adaptation of the IBA treatment for children and adolescents) which resulted in a total reduction of the mean time allocated to obsessive-compulsive symptoms per week after the 12th week of treatment (Bombardier et al., in preparation). Philippe was a 10-year-old boy diagnosed with TS marked by neck twitches at the age of 6. He benefitted from 13 sessions of the “Facotic” therapy (adaptation of the CoPs treatment for children and adolescents) that yielded a statistically significant decrease in Tourette's Syndrome Global Scale (TSGSS; Harcherik et al., 1984) scores between pre- and postintervention and between pre- and 3 months follow-up as reported by the child. Both parent and child also reported a significant decrease on the Yale Global Tic Severity Scale (YGTSS; Leckman et al., 1989) between pre-treatment and follow-up. Finally, Alex, 10 years old, received 8 sessions of the “Prends ton Tourette par les cornes” therapy, targeting explosive outbursts in children with TS. After the 4th week of therapy and until the end of the treatment, the number of explosive outbursts per week reported by the parents remained at 0. Larger trials with control conditions are currently in process to replicate the effects of these treatments in greater samples in order to determine their validity. All of the treatments and data presented shed light on the important role of psychological conceptualization and intervention in mental health. The present paper advocates for increasing communication about and dissemination of psychological treatments as valid alternatives and/or complements to traditional medical approaches.