neurological assessment fernando alvarez, Émile …...8 neurological assessment from birth to 6 i...
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Neurological Assessmentfrom Birth to 6
Second Edition
Julie GosselinClaudine Amiel-Tison
How to make simple in clinical neurology in the first years of life? Perinatal insults occur on a brain which is in rapid development. The clinical presenta-tion of these pathologies is thus changing, particu larly in the neuromotor domain during the first two years. Therefore, the clinician needs precise landmarks to detect possible deviancy at each stage of development.
In the first edition, published in 1998, we proposed a single and unique assessment tool applicable from birth to 6 years of life. This first edition already included the technical description for each maneuvers, scoring and coding system.
After 10 years of use in clinical research as well as in regular follow-up, the current edition is improved:
• research data collected at the corrected age of 2 years have allowed to identify a spectrum of neurological disabilities, from disabling cerebral palsy to more minor signs;
• the proposed 5-level categorization of neuromo-tor disabilities has shown significant correlation with developmental and intellectual performances both at preschool and school age, providing a link between early perinatal insults and different neurodevelopmental disabilities of late emergence.
This assessment tool should be systematically used with high risk infants to better understand the course of their development in order to implement early inter-vention when neurocranial signs are present. It should also be used to assess current perinatal practices.
ISBN 978-2-89619-447-6
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Couv_Évaluation neuro_ang.indd 1 11-06-21 14:09
Neurological Assessment from Birth to 6 years
Second edition
From the same authors
Éditions Elsevier-Masson
Démarche clinique en neurologie Du Développement, par C. Amiel-Tison, J. Gos-selin. 2004, 240 pages.
l’infirmité motrice D’origine cérébrale, par C. Amiel-Tison. 2005, 2e édition, 336 pages.
neurologie périnatale, par C. Amiel-Tison. 2005, 3e édition, 320 pages.
Other publications :
conDuite Du bilan neuropsychologique chez l’enfant, par M. Mazeau. 2003, 264 pages.
électro-encéphalographie De l’enfant, par D. Samson-Dollfus. 2001, 2e édi-tion, 152 pages.
fœtus et nouveau-né De faible poiDs, par F. Gold. Collection de Périnatalité. 2000, 2e édition, 152 pages.
neurologie péDiatrique, par P. Landrieu, M. Tardieu. Collection Abrégés de Médecine. 2001, 2e édition, 208 pages.
neuropéDiatrie, par G. Lyon, P. Evrard. 2000, 2e édition, 568 pages.
péDiatrie en maternité. réanimation en salle De naissance, par F. Gold, C. Lionnet, M.-H. Blond. Collection Abrégés de Périnatalité. 2002, 2e édition, 400 pages.
soins aux nouveaux-nés. Avant, pendant et après la naissance, par J. Laugier, J.-C. Rozé. 2006, 2e édition, 880 pages.
soins intensifs et réanimation Du nouveau-né, par F. Gold, Y. Aujard, M. Dehan et coll. Collection de Périnatalité. 2006, 2e édition, 624 pages.
urgences péDiatriques, par A. Bourrillon, G. Chéron. Collection Urgences. 2005, 3e édition, 752 pages.
Éditions du CHU Sainte-Justine
l’épilepsie chez l’enfant et l’aDolescent, par A. Lortie, M. Vanasse et coll, 2006, 208 pages.
les malaDies neuromusculaires chez l’enfant et l’aDolescent, par M. Vanasse, H. Paré, Y. Brousseau, S. D’Arcy, 2004, 376 pages.
urgences et soins intensifs péDiatriques, par J. Lacroix, M. Gauthier, P. Hubert, F. Leclerc, P. Gaudreault et coll, en coédition avec Elsevier Masson, 2007, 1368 pages.
les soins palliatifs péDiatriques, par N. Humbert et coll, 204, 656 pages.
Neurological Assessment from Birth to 6 years
(Original French Version Published in 2007)
Second edition
Julie GosselinClaudine Amiel-Tison
Translated by Lesley Kelley-Régnier
Bibliothèque et Archives nationales du Québec and Library and Archives Canada cataloguing in publication
Gosselin, Julie, 1961-
Neurological assessment from birth to 6 years [electronic resource]
2nd ed.
(Collection Intervenir)
Translation of: Évaluation neurologique de la naissance à 6 ans, 2e éd.
Includes bibliographical references and index.
ISBN 978-2-89619-447-6
1. Developmental neurobiology. 2. Nervous system - Growth - Evaluation. 3. Nervous system - Diseases - Diagnosis. 4. Movement disorders in children - Dia-gnosis. 5. Pediatric neurology. I. Amiel-Tison, Claudine. II. Title. III. Series: Collection Intervenir.
QP363.5.A4413 2011 612.8 C2011-941578-X
Graphic design : Madeleine Leduc
Cover illustration : Annette Tison
Éditions du CHU Sainte-Justine 3175, chemin de la Côte-Sainte-Catherine Montreal (Quebec) H3T 1C5 Phone : (514) 345-4671 Fax : (514) 345-4631 www.chu-sainte-justine.org/editions
© Éditions du CHU Sainte-Justine, 1998, 2007, 2011 ISBN 978-2-89619-447-6 (pdf format)
Table of contents
Preface 1st edition - ann L. stewart .................................... 7
Preface 2nd edition - MariLee c. aLLen ................................ 13
introduction ...................................................................... 17
chaPter 1 - Basic Notions Concerning Motor Activity Two systems of motor control: brainstem and
cerebral hemispheres ........................................................... 21
Maturation and neurological evaluation: three periods, three tools .......................................................................... 23
Perinatal hypoxic-ischemic injury: predominantly hemispheric 27
Passive muscle tone: physiological and pathological aspects ..... 28
Motor activity .................................................................... 37
Interpretation difficulties related to muscle shortening ............ 40
Missing signs related to young age ........................................ 42
Special case of unilateral abnormality ................................... 42
chaPter 2 - Presentation of the Method A Single tool used throughout infancy and childhood ......... 43
Structure of the examination ........................................... 45
Recent modifications ....................................................... 46
Training in use of the method .......................................... 48
chaPter 3 – Presentation of the Examination Chart
Description of the examination chart ................................ 51 Choosing the appropriate column ...................................... 53 Corrected age up to 2 years ............................................... 53 Scoring and recording results ............................................ 53
chaPter 4 - Technical Description: Definitions, Observations, Maneuvers and Scoring
Head circumference and growth ...................................... 55
Cranial examination ................................................ 58
Neurosensory investigations ...................................... 60
Observations and interview data about the period since the previous examination .................................. 65
Gross motor development milestones ............................. 67
Fine motor milestones .................................................. 71
Passive muscle tone .................................................... 75
Motor activity ............................................................ 88
Primitive reflexes ......................................................... 92
Protective reactions ..................................................... 98
Deep tendon reflexes .................................................... 100
Neuromotor abnormalities and acquired deformities ....... 101
Abnormal movements, rigidity, dystonia ......................... 109
chaPter 5 - From Analysis to Synthesis
Data interpretation at each evaluation .......................... 111
Definition of cerebral palsy (CP) .................................. 115
Spectrum of neuromotor abnormalities at 2 years ............ 118
Categorization of motor disabilities ............................... 121
Expanding the examination to other fields, other tools ..... 123
chaPter 6 - Usefullness of the Neurological Assessment in Research
Historical background ...................................................... 125
Research results ................................................................ 126
Psychometric characteristics of the assessment ................ 127
Complementary studies ................................................ 129
On-going studies ......................................................... 130
concLusion .................................................................. 133
BiBLiograPhy................................................................. 137
List of figures and taBLes ............................................. 147
aPPendix i – Examination Chart ................................ 153
index ............................................................................ 173
Preface 1st edition Ann L. Stewart
No single person has made a greater contribution to the understanding of neonatal neurology than Claudine Amiel-Tison. I am both honoured and delighted to write the Foreword to the English edition of this schedule for evaluating the neu-rological development in children from birth to 6 years.
Shortly after she graduated in Medicine, Dr. Amiel- Tison decided to specialize in Pædiatrics. Early on, she was influenced by André-Thomas and his assistant, Suzanne Saint-Anne Dargassies. On retiring, André-Thomas said he was going to devote the rest of his life to understanding the maturation of the central nervous system. He set up a study of newborns with Julian de Ajuriaguerra and later with Suzanne Saint-Anne Dargassies. Dr. André-Thomas’s first task was to define the terms passive tone and active tone, then he set out to devise reproducible methods for measuring them. Claudine Amiel-Tison and her collaborator, Julie Gosselin, use the same definitions and methods in their sophisticated schedule, presented in this book.
Dr. Amiel-Tison was impressed by the findings of her study of cerebral damage in full-term infants in the 1960s, and she published the data in a paper in 1969 (1). She found that if the infant was fully breast or bottle fed by 10 days of age, the outlook was good, no matter how seriously compromised the infant had been at birth; otherwise, one could not be certain of the outcome until the child was past 9 months of age. We still cite that paper today. Dr. Amiel-Tison was determined to devise an assessment for clinicians to use at the cotside that would be reproducible, predictive and user-friendly.
8 Neurological Assessment from Birth to 6
I first met Dr. Amiel-Tison at a conference in 1972, at which she was speaking on the follow-up of infants presenting with neurological abnormalities in the first days of life. Shortly after, she visited our group in the Department of Pædiatrics, University College London Medical School and demonstrated her techniques. We were so impressed with these techniques that when we set up a study into the outcome of brain lesions detected by ultrasound in very preterm infants, we incorpo-rated them into our methods.
The assessment schedule has undergone many changes. Dr. Amiel-Tison published the original assessment, for infants from birth to one year, in 1976 (2) and then in 1978 she began a long and fruitful collaboration with Dr. Albert Grenier. Together, they published the first version of the assessment schedule in French in 1980 and a revised version in 1985; the latter was translated into English by Roberta Goldberg (3-5).
When, in 1979, we began our study in the Department of Pædiatrics, University College London Medical School, on the outcome of brain lesions detected by ultrasound in the newborn, in very preterm infants, we used the assessment schedule published by Dr. Amiel-Tison in 1976 (2). Over the following years, we modified the schedule, with the help of Dr. Amiel-Tison, to include assessments at 30 months and 4 years of age and we published our findings on the prediction of neurodevelopmental status at four and eight years of age from neurodevelopmental status at one year of corrected age
(6,7). Together with Dr. Amiel-Tison, we recently published an abstract on the prediction of school performance at 14 to 15 years of age from neurodevelopmental status at one year of corrected age (8).
Dr. Amiel-Tison had always regretted that the assessment published in 1976 was applicable only up to one year of age. She realised that between us, we had collected a lot of data on 4 year olds and we combined these with the data collected by Suzanne Saint-Anne Dargassies on two year olds to form a single database covering birth to 4 years. We discovered, for
9Preface 1st edition
example, that in measures of passive muscle tone, the angles changed gradually up to 18 months and little thereafter up to 4 years of age. For the first time, we included a scoring system strictly for research purposes. Shortly after this analysis, we were invited to write an «Experience and Reason» article published in 1989 which included assessments for children up to five years old (9). In 1990, we made a video in London (English and French versions) with Dr. Amiel-Tison, demons-trating the methods on children in our ultrasound cohort (10).
Dr. Amiel-Tison has long been interested in the effect of subtle neurological signs and their role in determining even-tual outcome. She was impressed by the paper published by Cecil Drillien (11) which gave the first description of apparently transient neurological signs. Dr. Drillien had found that such signs were associated with poor school performance, and Dr. Amiel-Tison postulated that these subtle neurological signs would predict moderately low IQ and sub-optimal school performance – and she was right (7,8). We have called the children with this constellation of minor signs «the apparently normal survivors» (12). Dr. Amiel-Tison believes that the subtle neurological signs are actually permanent (12) and that examiners can find them if they look for them, at least in adolescents.
Neurological development from birth to 6 years is very clearly written and beautifully illustrated by both Claudine Amiel-Tison and her sister, Annette Tison. The «evaluation grids» in the examination chart are clear and ready to use. This English translation will allow the schedule to be used world-wide; it is a great achievement and I wish it every success.
Ann Stewart FRCP
Honorary Senior Lecturer
Department of Pædiatrics,
University College London
10 Neurological Assessment from Birth to 6
References1. Amiel-Tison, C. Cerebral damage in full-term newborns: ætiolo-
gical factors, neonatal status and long term follow-up. Biological Neonatorum 1969; 14: 234-250.
2. Amiel-Tison, C. A method for neurologic evaluation within the first year of life. In: Current problems in pediatrics, VII, no 1, pp. 1-50. Year Book Medical Publishers, Chicago, 1976.
3. Amiel-Tison, C., Grenier, A. Évaluation neurologique du nouveau-né et du nourrisson. Paris, Masson, 1980.
4. Amiel-Tison, C., Grenier, A. La surveillance neurologique au cours de la première année de la vie. Paris, Masson, 1985.
5. Amiel-Tison, C., Grenier, A. Neurological assessment during the first year of life. New York, Oxford University Press, 1986.
6. sTewArT, A.l., CosTello, Amdel, HAmilTon, P.A., BAudin, J., BrAd-ford, B.C., reynolds, e.o.r. Relation between neurodevelop-mental status at one and four years in very preterm infants. Dev Med Child Neurol 1989; 33: 756-765.
7. roTH, s.C., BAudin, J., PezzAni-GoldsmiTH, m., Townsend, J., reynolds e.o.r., Stewart, A.L. Relation between neurodevelop-mental status of very preterm infants at one and eight years. Dev Med Child Neurol 1994; 36: 1049-1062.
8. roTH, s., BAudin, J., Townsend, J., rifkin, l., rusHe, T., Amiel- Tison, C., sTewArT, A. Prediction of extra educational provision at 14-15 years from neurodevelopmental status at one year of corrected age in subjects born before 33 weeks gestation. Ped Res 1999: 45: 904 (abstr).
9. Amiel-Tison, C., sTewArT, A. Follow-up studies during the first five years of life: a pervasive assessment of neurological function. Arch Dis Child 1989; 64: 496-502.
10. Amiel-Tison, C. And sTewArT, A. Neuromotor assessment during the first five years of life. (video, English and French versions) UCL Images, London, 1990.
11Preface 1st edition
11. drillien, C.m. Abnormal neurologic signs in the first year of life in low birth weight infants: possible prognostic significance. Dev Med Child Neurol 1972; 14: 572-584.
12. Amiel-Tison, C. And sTewArT, A. Apparently normal survi-vors: neuromotor and cognitive function as they grow older. In: Amiel-Tison,C., sTewArT, A. (eds.) The Newborn Infant: one brain for life. Les Éditions INSERM, Paris, 1994, pp. 227-237.
Preface 2nd edition Marilee C. Allen
The most remarkable aspect of this book is its simplicity. It is the culmination of Claudine Amiel-Tison’s lifetime of work examining infants and children. She has integrated her clinical experience with knowledge of neurophysiologic maturation to develop an elegant clinical examination. Julie Gosselin has contributed her extensive clinical experience with the exam and described its psychometric properties. The result of this collaboration is a very practical book that describes a concise, elegant and valuable examination.
Claudine Amiel-Tison represents a distinguished heritage in the study of the development of central nervous system (CNS) function, initiated in the middle of the 20th century by French neurologist André-Thomas.1 He tackled the very difficult problem of describing one of the most important aspects of the neurological examination: muscle tone, which changes as infants mature. Muscle tone is controlled by the brain, and thereby provides an important window on brain maturation. His pupils, Suzanne Saint-Anne Dargassies and Claudine Amiel-Tison, have furnished meticulous descrip-tions of how muscle tone, reflexes and responses evolve over time in preterm and fullterm infant.2-6 Detailed descriptions of the neuromaturation of infants with CNS injury provide clues as to which clinical findings best predict long-term neurodevelopmental disabilities, as well as insight into causes of brain injury and the relationships between struc-ture and function of the developing brain.6-8 The examination described in this book by Claudine Amiel-Tison and Julie Gosselin is a distillation of these years of work: a practical, efficient and elegant method for assessing neurodevelopment in newborns, infants, and children to age 6 years. Thorough descriptions of examination maneuvers make this exam
Neurological Assessment from Birth to 614
accessible and easy to master for any clinician who works with young children. Its great value lies in the continuity it pro-vides for following high risk infants through early childhood. During this critical time, brain injury can be detected and its recovery followed, allowing for early intervention strategies to minimize neurodevelopmental disabilities.
This book, first published in English in 2001, clearly filled a clinical need, a need great enough to warrant publi-cation of this second edition. Neonatologists, pediatricians, midwives, nurse practitioners and primary care providers in clinical practice have used the examination method des-cribed in this book. This examination fills a need in clinical outcomes research, by providing a continuous outcome measure for neuromotor abilities from birth to 6 years. This characteristic also makes it ideal for use as a more immediate measure of early CNS function in randomized clinical trials of medications and treatment strategies used in neonatal intensive care. The ability to recognize adverse drug effects on early CNS function improves the safety of clinical drug trials. Furthermore, the ability to identify neonates at high risk for neurodevelopmental disability facilitates selection of the best candidates for clinical trials and early inter- vention programs.
To better illuminate the background and context for their examination, the authors have revised and added to this second edition. They expanded the section describing the neurophysiological basis for the examination. The most important new section incorporates the results of clinical research by Julie Gosselin and her graduate students in Mon-tréal and a description of the psychometric properties of the examination. The authors describe a spectrum of neuromotor abnormalities at 2 years corrected for degree of prematurity, ranging from disabling cerebral palsy to mild cerebral palsy to minor neuromotor dysfunction. The spectrum of neuro-motor abnormalities significantly correlates with neuroco-gnitive outcome at school age. This work underscores the
15Preface 2nd edition
concept of a continuum of developmental abnormalities described by Arnold Capute and Pasquale Accardo.9 Unders-tanding this relationship helps optimize the use of early intervention resources, especially with regard to language acquisition.
As modern medicine continues to develop and employ diagnostic technologies, much of medical training is devoted to learning how to use this technology. The art of medicine is often overlooked. Medical schools still teach physical examination, but fewer physicians than in the past are given the time for comprehensive histories and thorough physical examinations. If physicians do not hone their own expertise, who will teach the next generation?
By providing a simple, intelligent guide to examining central nervous system function in infants and children, this book takes an important step towards ensuring that future clinicians can develop into skilled examiners. There is no doubt that mastering the exam described in this text is something to which clinicians who work with neonates should aspire, and that it should be part of the core curriculum for pediatricians. Only by adding expertise in neurological exa-mination to our state-of-the-art neuroimaging and other dia-gnostic technologies will we realize our potential for critical insight into how the developing brain recovers from injury, and the miracle of healthy neuromaturation.
Marilee C. Allen, M.D.
Professor of Pediatrics
The Johns Hopkins School of Medicine
Baltimore, MD, U.S.
Neurological Assessment from Birth to 616
References1. Andre-THomAs, CHesni, y., & sAinT-Anne dArGAssies, s. The Neurolo-
gical Examination of the Infant. Little Club Clinics in Developmental Medicine No. 1. London: National Spastics Society, 1960.
2. sAinT-Anne dArGAssies, s. Neurological Development of the Full-Term and Premature Neonate. Amsterdam: Elsevier/North- Holland Biomedical Press; 1977.
3. Amiel-Tison, C. A method for neurologic examination within the first year of life. Curr Probl Pediatr 1976; 7(1):1-50.
4. Amiel-Tison, C. & Grenier, A. Neurologic Assessment During the First Year of Life. New York: Oxford University Press; 1986.
5. Amiel-Tison, C. (2003). Neurologic maturation of the neonate. NeoReviews; 2003; 4: e199-e206.
6. Amiel-Tison, C., Clinical assessment of the infant nervous system. In m.i.levene, f. A. CHervenAk, m. J. wHiTTle, m. J. BenneTT, & J. PunT (Eds.), Fetal and Neonatal Neurology and Neurosurgery (Third ed., pp. 99-120). London: Churchill Livingstone; 2002.
7. Amiel-Tison, C., CABrol, d., denver, r., JArreAu, P. H., PAPiernik, e., & PiAzzA, P. v. (2004). Fetal adaptation to stress. Part I: accelera-tion of fetal maturation and earlier birth triggered by placental insufficiency in humans. Early Hum.Dev, 2004; 78: 15-27.
8. Amiel-Tison C, CABrol d, denver r eT Al. Fetal adaptation to stress: Part II. Evolutionary aspects; stress-induced hippocampal damage; long-term effects on behavior; consequences on adult health. Early Hum Dev; 2004; 78(2):81-94.
9. CAPuTe, A.J., & ACCArdo, P.J. (Eds.). Developmental Disabilities in Infancy and Childhood. Second edition. Baltimore: Paul H. Brookes Publishing Co.; 1996.
Introduction
Nothing is ever cast in stone, even a neurological examina-tion technique. And fortunately so, because everything is in constant flux. Since the publication of the first edition of our book, Neurological Development from Birth to Six Years (Amiel-Tison & Gosselin, 1998), a number of essential questions have been answered.
� A more precise study of neurological signs has brought to light the notion of a spectrum of neuromotor disor- ders, from disabling cerebral palsy (CP) to isolated signs. Classifying minor forms has allowed a little order to be introduced where confusion abounded before.
� Patient clinical research validated the earlier intuitions as described in the first edition of 1998. As a result, the neurological and cranial signs that had been detected and classified have at last lost their status as ‘soft signs’ and become the markers that can be tracked from the perinatal period to school age.
� This development opens up several new perspectives: first, a more precise and earlier identification of the dif-ficulties that at-risk neonates have to face and, second, a better targeted early intervention. (We never imagined back in 1998 that finding a bilateral or right stretch reflex at the level of the triceps surae would justify early speech therapy). And along with this improvement in the identification process come the hope for a more precise definition of selection criteria for sampling in the context of evaluative studies to successfully demonstrate the effectiveness of early intervention: for that, we had to start by separating the wheat from the chaff before conducting clinical tests.
Neurological Assessment from Birth to 618
Is this boasting? Absolutely not. It is rather the satisfaction of better understanding so that we can help these children with difficulties that weigh so heavily on their learning and that they themselves certainly do not consider minor. As early as 1947, Gesell and Amatruda had written:
“In the case of major brain damage, the child is usually so obviously handicapped that his/her difficulties naturally draw offers of help and sympathy. In the case of minor cerebral damage, the child has exactly the same need for considera-tion and understanding. He also has a greater than-average need to be protected from stress and competition… In all these cases, we are dealing with an extremely complex interaction between development potential and dynamic forces. Despite the minor nature of initial motor dysfunction, the damage to the personality can be considerable and more or less perma-nent. Psychiatric concepts are often less useful for interpreting these pathologies than a thorough understanding of the neuro-logical development.” (Gesell and Amatruda, 1947, p. 248).
This neuromotor examination and its application derive from the French school of André-Thomas and Saint-Anne Dargassies (1952; Saint-Anne Dargassies 1982). The method became the heritage of Claudine Amiel-Tison, the first author of the 1998 edition of this book. As a result of Julie Gosselin’s exacting measurements and ten years of patient work vali-dating the signs, this method has now become hers and the signatures have been inverted in this second edition, a reflec-tion of their fruitful collaboration and friendship. Their hope is to renew the pediatric community’s interest in this clinical study of signs using the keys that a thorough understanding of the neuromotor maturation and other brain functions pro-vides. Being easy to perform and fast enough to be included in their routine practice, such a screening assessment is aimed to pediatricians. In case of abnormalities, the child will be referred to a neurologist.
The authors are passionately committed to sharing this clinical method with others so that it can be used in daily clinical practice as well as in research and in regional health-care networks. The core of this work is a basic study of signs,
Neurological Assessmentfrom Birth to 6
Second Edition
Julie GosselinClaudine Amiel-Tison
How to make simple in clinical neurology in the first years of life? Perinatal insults occur on a brain which is in rapid development. The clinical presenta-tion of these pathologies is thus changing, particu larly in the neuromotor domain during the first two years. Therefore, the clinician needs precise landmarks to detect possible deviancy at each stage of development.
In the first edition, published in 1998, we proposed a single and unique assessment tool applicable from birth to 6 years of life. This first edition already included the technical description for each maneuvers, scoring and coding system.
After 10 years of use in clinical research as well as in regular follow-up, the current edition is improved:
• research data collected at the corrected age of 2 years have allowed to identify a spectrum of neurological disabilities, from disabling cerebral palsy to more minor signs;
• the proposed 5-level categorization of neuromo-tor disabilities has shown significant correlation with developmental and intellectual performances both at preschool and school age, providing a link between early perinatal insults and different neurodevelopmental disabilities of late emergence.
This assessment tool should be systematically used with high risk infants to better understand the course of their development in order to implement early inter-vention when neurocranial signs are present. It should also be used to assess current perinatal practices.
ISBN 978-2-89619-447-6
Sous
la d
irec
tion
de
Fern
and
o A
lvar
ez, É
mile
Lev
y et
Mat
hie
u R
oyP
édia
trie
et o
bés
ité
Un
co
nfli
t en
tre
nat
ure
et
cultu
reÉ
dit
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s d
u C
Hu
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e-J
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Couv_Évaluation neuro_ang.indd 1 11-06-21 14:09