Acting early to prevent neurodevelopmental disability in young children
Press release from the French National Academy of Medicine (*)
June 29, 2022
In France, each year, more than 10% of newborns are affected by a neurodevelopmental disorder (NDD). This entity includes multiple impairments (sensory, neuro-visual, motor, language or cognitive disorders; autism; attention-concentration, learning or behavior disorders). Screening for high-risk factors for NDD (prematurity, history of NDD in siblings, exposure to some toxins or drugs during pregnancy, etc.) and early identification of these NDD are major prerequisites for the implementation of recommended interventions during the period of maximum brain plasticity, known as the “first 1,000 days” (1, 2, 3, 4, 5).
In this short time window, from conception to the first two years of life, the essential but not definitive stages of brain development take place: formation of neurons, migration and programmed death of a significant proportion of them; formation of axons and dendrites, and elimination of their excess; formation of synapses, contact areas between two nerve cells, the whole, exponential from the third trimester of pregnancy and during the first two postnatal years, key to the constitution of neuronal networks; angiogenesis and myelination. These stages of functional organization and maturation of the brain and cerebellum are controlled by genetically determined factors, but also by environmental factors, including stimulation, experience and learning. Modulation by environmental factors involves epigenetic mechanisms (6, 7, 8)
Dysfunction of brain circuits and synaptic connections is evoked in TNDs (9). For example, in autism, nearly 50% of the genes involved encode proteins expressed at the synapse.
It is therefore essential to detect early a gap in the developmental trajectory in order to implement preventive or therapeutic interventions and parental guidance as soon as possible (10). According to international recommendations, as soon as “risk of NDD” indices are identified, practitioners must implement a personalized global intervention plan without waiting for a formal diagnosis. This project, co-developed with the family, integrates therapeutic, educational and socialization approaches that complement and potentiate each other (3, 11, 12, 16, 17). Early interventions, through psycho-educational programs using play as a support and relying on sensory integration processes, allow the recovery of an optimal developmental trajectory and prevent over-disabilities.
Valuing and placing parents “at the heart of their child’s care” is a major challenge (15). A balance between individual family care and inclusion of the child in a peer group fostered by a childminder, in a crèche or a drop-in center and then, at a nursery school, with duly trained early childhood professionals) is a source of progress (2).
National programs have been implemented to structure a graduated transversal pathway of diagnosis, care and education: national strategy “autism within the TND”; “ handicap act early” campaign (5, 13). Throughout the country, TND coordination and referral platforms have been set up: these innovative systems enable early detection and promote links between all those involved in the child’s health, which is a major progress. Such systems need to be adequately sized and managed by medical and paramedical staff trained in these new practices (14,15)
In order to consolidate and expand early diagnosis, intervention and rehabilitation practices, as well as healthy prevention of neurodevelopment in young children, the French National Academy of Medicine recommends:
-to train early childhood health and education professionals in new neurodevelopmental knowledge, identification and recommended practices;
-to inform, guide and support parent care partners and caregivers (15), and to prevent breaks in the care pathway by promoting links between the family and other child health actors;
-to sustain monitoring networks for vulnerable newborns, including premature newborns at very high risk of TND;
-to increase the number of places in collective care structures;
-to guarantee rapid access to care by strengthening, in particular, the new TND coordination and referral platforms, the early medical and social action centers (Centres d’action médico-sociale précoces, CAMSP) and other early intervention health and medical-social structures;
– to accelerate biological and cognitive neuroscience research, by prioritizing studies on the developmental window of maximum brain plasticity of the first 1000 days.
References
1 Lord C, et al. The Lancet Commission on the future of care and clinical research in autism. Lancet 2022, 399: 271-334
2 Haute Autorité de santé. Neurodevelopmental disorders Detection and referral of at-risk children – Toolkit guide Février 2020
3 Fondation pour la paralysie cérébrale. Le livre blanc de la paralysie cérébrale. Octobre 2021
4 Kolb B, Harker A, Gibb R. Principles of plasticity in the developing brain. Dev Med Child Neurol 2017, 59:1218-1223
5 Commission des 1000 premiers jours. Rapport du président Boris Cyrulnik, Septembre 2020. htpps://solidarites-sante.gouv.fr
6 Molnár Z, Clowry GJ, Šestan N, et al. New insights into the development of the human cerebral cortex. J Anat 2019, 235: 432-45
7 Molnár Z, Luhmann HJ, Kanold PO. Transient cortical circuits match spontaneous and sensory-driven activity during development. Science 2020, 370:308
8 Wiśniowiecka-Kowalnik B, Nowakowska BA. Genetics and epigenetics of autism spectrum disorder – current evidence in the field-. J Appl Genetics 2019, 60:37
9 Goikolea-Vives A, Stolp HB. Connecting the neurobiology of developmental brain injury: neuronal arborization as a regulator of dysfunction and potential therapeutic target. Int J Mol Sci 2021, 22: 8220
10 Tebani A, Marret S. Early intervention in cerebral palsy and beyond. JAMA Pediatr 2012, 175:785-7
11 Haute Autorité de santé. Autism and other PDDs (pervasive developmental disorder) Coordinated education and treatment interventions in children and adolescents, March 2012
12 Gressens P. Neurodevelopmental and cognitive consequences of preterm birth. Bull Acad Natle Méd 2017, 201: 607-13
13 Campagne Handicap Agir-tôt. 12-18 octobre 2021
14 Inspection générale des affaires sociales. Rapport sur la pédiatrie et l’organisation des soins de santé de l’enfant en France. Mai 2021.https://www.igas.fr
15 Pickles A et al. Parent-mediated social communication therapy for young children with autism (PACT):long-term follow-up of a randomized controlled trial. Lancet 2016,388:2501-9
16 Darling SJ et al. Behavioral intervention for social challenges in children and adolescents: a systematic review and meta-analysis. JAMA Pediatr 2021,175 (12):e213982.
17 French National Academy of Medicine. Dedicated session of April 27, 2021, Bull Acad Natl Med 2021 ;205
(*) Press release from the Academy’s Rapid Communication Platform validated by the members of the Board of Governors on June 28, 2022.
