Spécificités de l’approche psychothérapique d’inspiration analytique à l’adolescence

The commitment of a teenager in an individual psychotherapeutic work often faces multiple obstacles, related to incompatibilities inherent to the process of adolescence, but that often reflect the ups and downs of the work of psychic separation or the vicissitudes of “subjectivation”. Therapeutic setting adjustments, made necessary by the psychic and relationship operating constraints of the concerned adolescents, have been proposed by psychoanalysts, intended to take into account the narcissistic vulnerability of their young patients, and also to put their own associative abilities at their disposal. Exciting contributions of several psychotherapists working with teenagers on these issues will be summarized and extended by the reflections of the author based on his own experience as a psychotherapist and that derived of different supervisory groups he facilitated for several years. Some designs may thus be summarized, illustrated and reformulated in the light of the clinic. In this perspective the issues inherent, to the objectives of the psychotherapeutic work at this age, to the levers that can be used, to the obstacles related, not only to the process of adolescence challenges, but also to parental positions, to the nature of the underlying psychopathological organization and to the counter-transferences reactions of therapists, will be re-examined. In order to better control the potential risks of such an encounter, and to increase profits for young patients, it turns finally essential to rethink the design, and to advocate the strong practitioners’ commitment.     

Rôle de la génétique et de l’épigénétique dans l’obésité de l’enfant et de l’adolescent

Obesity is a complex, multifactorial disease due to a dysfunction of the hypothalamic control of weight and food intake. The contribution of genetics is constant, but its impact is variable depending on the situations ranging from rare genetic obesities (around 5% of cases) to more frequently polygenic obesity (or common obesity) (95% of cases). Other factors as pre- and post-natal, societal or psychological determinants always interact closely with these genetic factors explaining the high variability of the phenotype and the complex pathophysiology. A true continuum exists between all these situations through the involvement of more or less rare genetic variants located in genes encoding key proteins in the central regulation of food intake. Rare forms of obesity are characterized by their common phenotype including a very early-onset severe obesity (BMI Z score greater than + 3 SD early before the age of 3 years) with resistance to medical treatment, and major eating disorders characterized by difficulties in voluntary control of food intake. Central endocrine abnormalities such as hypogonadotropic hypogonadism or GH deficiency for example, and metabolic abnormalities due to abnormal adipose tissue distribution are also associated with variable degrees (Alström syndrome for example). Neuropsychological abnormalities are also present such as neurodevelopmental disorders (intellectual disability with variable intensity and/or adaptive development disorders which are part of many syndromes such as in Prader-Wili Syndrome; autism spectrum disorders (in SH2B1 or MYT1L deficiency for example), cognitive disorders with difficulties in emotional regulation (eg: Bardet-Biedl Syndrome or specific rare variants located on genes of the melanocortin pathway), behavioral or psychiatric disorders, sleep disorders and major hypothalamic dysfunctions (eg: Prader-Willi Syndrome, Smith Magenis syndrome). This better understanding of the mechanisms has made it possible to better precise the associated phenotypes and, recently, to lead to therapeutic innovations targeting these key genes. This evolution helps to quickly envisage the development of a real personalized medicine in early onset obesity using the combination of drug treatments targeted according to the identified genetic anomaly and/or a multidisciplinary global approach targeting the patient's phenotype or even the bariatric surgery in specific situations.     

Prise en charge de la violence et du décrochage scolaire à l’école I. Revue de la littérature

Background

Violence at school and school dropout constitute a big concern as well for the teachers, for the parents as for the clinicians. Several explanatory factors are proposed: individual, familial, school climate or factors in connection with the group of peers. These factors impact on the psychic, school and social health of the child. Coverages are proposed at the national and international level and seem to give convincing results. Each of these initiatives implied in a differentiated way to parents, pupils and teachers. None put in the work a project integrating the educational triangle that is at the same time the parents, the children and the teachers within the school. The objective of this work is to make a theoretical current situation on the school dropout and the violence to the school and to present some devices of coverage of the pupils concerned by these difficulties.     

Conséquences psychosociales de l’exposition à une catastrophe technologique à l’adolescence : l’exemple de la tragédie ferroviaire de Lac-Mégantic

BackgroundIn 2013, a train derailment in Lac-Megantic (Quebec, Canada) caused significant human and material losses. This study documents the consequences of exposure to this disaster on the psychosocial functioning of adolescents.MethodsThree and a half years after the tragedy, 689 students aged 12 to 18 completed a self-administered questionnaire at their school, for a response rate of 85.3%. The questionnaire included multiple choice questions designed to describe the sociodemographic, family, educational and social characteristics of the respondents as well as their psychological health. It was designed using scales or questions that were previously validated with young people during national surveys.ResultsThe study shows that teenagers exposed to such a disaster are more at risk of developing psychological health problems than their unexposed peers. Significantly, more students exposed to the train derailment than unexposed youth saw a decrease in the quality of life in their community (12.9%). They also scored significantly lower for their resilience and for three of the five resilience protection factors measured using the Resilience Factors Inventory (IFR – 40). They had more psychological difficulties, including manifestations of post-traumatic stress (15.6%). They also had suicide thoughts in the 12 months prior to the survey (38.9%) and had lower self-esteem compared to their unexposed peers. Finally, significantly more exposed teenagers reported personal, family and school difficulties due to their alcohol consumption.ConclusionThe study shows that in the long term after a technological disaster, teenagers who have been directly or indirectly exposed are more affected than their unexposed peers. In light of the results obtained, research must continue in order to guide professionals in setting up psychosocial interventions that adequately respond to the experiences and needs of these young people.     

Prise en charge de la violence et du décrochage scolaire à l’école II. Résultats d’une recherche–action sur le modèle triangulaire au sein d’un collège à Grenoble

Background

Violence at school and school dropout constitute a big concern as well for the teachers, for the parents as for the clinicians. Several explanatory factors are proposed: individual, familial, school climate or factors in connection with the group of peers. These factors impact on the psychic, school and social health of the child. Coverages are proposed at the national and international level and seem to give convincing results. Each of these initiatives implied in a differentiated way parents, pupils and teachers. None put in the work a project integrating the educational triangle that is at the same time the parents, the children and the teachers within the school. The objective of this work is to report results of a research–action which took place during 5 years within a college of the academy of Grenoble and which put in the work on this lapse of time, in this college, the pupils, the parents and the teachers.

Interrelations entre l’âge et les conduites délinquantes : la question de la maturité psychosociale et ses implications

Background and objectiveThis study aims to determine whether differences in psychosocial maturity within a male sample aged 14 to 30 years are more related to a developmental variable (age) or to the behaviors expressed by the study participants.PopulationA sample of 180 French Belgian males (mean = 21.78 years, s.d. = 5.26) was interviewed and divided into two subsamples: an offending and incarcerated subgroup (from detention centers and prisons) and a non-offending subgroup (from schools, leisure and social networks).MethodStandardized measures were used (self-reported delinquency and the 6 identified factors of psychosocial maturity) via an individual questionnaire survey. Univariate and inferential analyses were conducted to test whether differences between the two subsamples on the psychosocial maturity factors were related to age and/or offending status. The main results from the Ancova show that 3 factors of psychosocial maturity (impulse control, suppression of aggression, and personal responsibility) are explained exclusively by the participants’ behaviors, with significantly higher means in the non-offending subgroup, whereas one factor (future orientation) seems to be explained more by the participants’ age, independently of the behaviors presented.Conclusion and implicationsPsychosocial maturity appears to be a relevant dimension to be integrated into juvenile justice, particularly in terms of interventions. Practical and theoretical implications are discussed.     

Déficits précoces de l’empathie et psychopathologie

Empathy is a complex social-cognitive ability that is best understood by distinguishing its emotional, cognitive and motivational dimensions, which from early childhood interact between the child and her/his social environment. To date, among the many factors that are acknowledged to influence the development of empathy, children's temperament and parenting behaviors have been identified as interacting in predicting the extent to which children demonstrate empathic responses. Recent studies in developmental social neuroscience cast light on the neural networks engaged in the development of each of the dimensions that constitute empathy, which are needed to navigate social interaction and establishing positive social relationships. Indeed, early deficits in empathic processes can lead to difficulties in socialization, particularly associated with reduced attention to others’ emotions, especially when they are suffering, a lesser degree of remorse and guilt, and a greater tendency to ignore social norms or break the rules. Difficulties in socialization are particularly visible in two well-known developmental disorders: children with autism spectrum disorders (ASD) and children with conduct disorder and callous unemotional traits (CU). This paper provides a critical and selective review of recent empirical studies in psychopathology and developmental neuroscience by addressing the dimensions underlying empathy, specifically emotional sharing and caring for others. For children with ASD, some studies report that they pay less attention to another person in distress. However, functional neuroimaging studies conducted with ASD adolescents indicate that the emotional dimension appears to be preserved, but a lack of emotional self-regulation may impair them from experiencing empathic concern. Children with conduct disorder and CU traits clearly manifest a reduced autonomic nervous system response to others’ distress or suffering. This may account for their disregard or contempt for others’ well-being and social norms. Functional neuroimaging studies show that atypical patterns of brain activity at 15 months of age can predict later severe conduct disorder. Neural regions engaged in emotional processing such as the anterior cingulate cortex, insula and amygdala shown reduced activation to empathy-eliciting stimuli in children with CU. Finally, the genetic nature of CU traits is highlighted in several studies. We conclude by proposing several avenues for developmental research to identify biomarkers from an early age and by inviting to focus on psychological interventions with those populations accordingly.     

Transformer les pratiques entre la psychiatrie de l’enfant et de l’adolescent et la psychiatrie de l’adulte pour une réelle prévention

It is estimated that around 20% of children in the general population have a parent affected by a major psychiatric disease such as schizophrenia, bipolar disorder or recurrent major depressive disorder. Nevertheless, we face the “medical paradox” in which these children most at risk, born to an affected parent, are overlooked by our health systems. These children are indeed 15 to 20 times more likely to develop a psychiatric disorder as young adults, and 50% of them present childhood developmental or behavioural problems deserving treatment. Several indicators of brain dysfunctions, or risk endophenotypes, carried by adult patients can be detected early in the life of these children, thus making it possible to differentiate the child at highest risk among the siblings in the same family. These discoveries support the neurodevelopmental hypothesis of schizophrenia, bipolar disorder and recurrent major depression and the partially shared origin of these three disorders. In this selective scientific review, we will discuss data suggesting that, among children at risk, those who progress towards the illness cumulate risk indicators during their early trajectory. This aggregation phenomenon can serve as an empirical ground for the definition of preclinical stages in the risk trajectory and the development of clinical practice guidelines regarding surveillance or prevention in these children. Governmental legislations have already been promulgated in several countries with mitigated success to change the situation for these high-risk children and families. Based on existing scientific data, we thus propose that clinical practice guidelines be delivered by national medical academies so as to bring about the needed changes, improve communication between primary care, and specialized care and foster functional connections between child and adult psychiatry.     

Le trouble déficitaire de l’attention avec hyperactivité : données récentes des neurosciences et de l’expérience nord-américaine

Attention-deficit/hyperactivity disorder (ADHD) is considered to be the most common neuropsychiatric disorder of childhood in USA with a prevalence rate of approximately 7–9 %. Psyschostimulants are widely prescribed to ADHD children since three decades in USA. Here, we review neurobiological hypotheses about ADHD aetiology and about the North American experience regarding psychostimulant medication. Recent data show that the classical hypotheses positing that ADHD is caused by an underlying dopamine and/or noradrenaline deficit are weak. Although we have no better theory that might receive a general consensus, the high heritability of ADHD is often put forward to support its biological aetiology. However, “heritable” does not mean “genetic” and numerous environmental factors contribute to ADHD aetiology. Recent studies confirm that psychostimulants are safe, well tolerated and efficient regarding the core symptoms of ADHD as ascertained by proper diagnostic procedures. However, children with ADHD are at risk of later development of antisocial behavior, substance abuse and significant academic underachievement. Recent studies show that psychostimulant medication does not affect these long-term risks. In contrast, psychosocial interventions directed towards ADHD children and their parents significantly decrease these risks as well as other comorbid disorders often associated with ADHD (anxiety, depression, conduct disorder). Thus, psychosocial treatments now represent the first-line intervention for ADHD. Therefore, dogmas regarding ADHD are now questioned and this re-examining should lead to look more favorably on the French clinical experience about pediatric psychiatry and psychopathology.     

Non-binarité et transidentités à l’adolescence : une revue de la littérature

BackgroundRecently international scientific literature has been increasingly interested in situations where gender identity is unconventional – neither male nor female, part-time male part-time female, male and female. Binary transgender identity and gender dysphoria are now well recognized. However, this is not the case for non-binary gender identities.ObjectiveIn the current report, we aim at reviewing the literature on non-binary gender and genderqueer identities in order to appreciate the interest of this recognition in medicine and its understanding by the health professionals.MethodsThe article is based on a literature review on non-binary gender and genderqueer identities and on the accompaniment of binary and non-binary transgender youth. The results are presented within different themes.ResultsResearch shows that non-binary/genderqueer people tend to be young, urban, have a higher level of education, and to remain often as students or unemployed. If non-binary trans people are mostly teenagers and young adults between the ages of 14 and 25, it is not simply a question of considering non-binary gender identity as an adolescent process, or even simply a recent societal phenomenon. Indeed, the issues that are facing these adolescents and young people are very specific, starting with marginalization and precariousness. According to previous studies, psychic difficulties (including self-aggressive gestures, suicidal thoughts and behaviors, eating disorders, anxiety and depression) are more or less equal or superior to those of binary transgender people. It is necessary to consider the different methodological biases, or the cultural and geographical context of a study. The rate of indecision is particularly high among non-binary youth, but access to care is more complicated when they are ready to make a change. Then, the physical transformations desired will vary, depending on the needs, but frequently only the cross-sex hormones and/or top surgery are needed. In that way, non-binary gender youth tend to have a better relationship with their own bodies than binary transgender youth.ConclusionThe scientific literature is increasingly trying to raise the question of the inclusivity of all genres in national surveys and in the accompaniment of people. A better understanding of these questions will allow better support of young people questioning their gender in a binary or non-binary perspective.     

L’eSoi : de l’hypotrophie de la représentation du corps à l’hypertrophie de l’image du soi

Screens bring a new element to the environment of the child and even more to that of the adolescent. As a new partner in their development, screens are increasingly retaining the child's attention, and have multiple effects. They alter the relationship to space, time and attention and introduce a new dimension in the construction of the sexuality of young people. They are challenging–for the moment–educational practices. But the impact of screens on young people also depends a lot on the context of use and the environment in which they live. Alongside the child, there are parents, with their educational practices and their own use of screens, and there is society, with its values, the benchmarks it offers to its members, its culture and its models. Screens have become ubiquitous and invite humans to interact through their accessibility, the amusing simplicity of their job and their possibilities of interactivity. This tool will promote and even stimulate the child's empowerment vis-à-vis parents in his discovery and exploration of the world. Access to a screen connected to the Internet explodes the possibilities of interactions and exploration of a virtual space that is almost infinite. More and more, there is a striking contrast between the increasing spatial framing of the child confined in socially dedicated places, the room, the parental apartment, then the school, spaces set up for his protection… and his freedom to explore and interact with the virtual environment made possible by the connected screens that parents offer him. For safety reasons, children, especially younger ones, are no longer being opened to the streets, and they spend less and less time in parks or natural spaces (forests, fields, rivers, etc.). Children are increasingly reclusive in the interior spaces of homes and in playgrounds designed for their safety, which sanitizes the encounter with the natural environment. In contrast to this physical framing, the child's framing in the discovery and exploration of the virtual world increasingly escapes parents, despite the “parental control” devices. In this article, we try to identify some of the effects of the significant use of screens by children and adolescents on the construction of space and on the relationship to their bodies illustrating it in clinical vignettes. Indeed, the body-environment interaction is at the basis of the construction of the representation of one's own body, as well as that of space, essential for the building of identity.     

Données d’imagerie cérébrale dans l’anorexie mentale à début précoce

Structural and functional brain alterations in the structures involved in taste processing, emotions regulation and the reward system have been described in anorexia nervosa. The neurodevelopmental origin of this disorder has been recently discussed. In this article, brain-imaging data in early onset anorexia nervosa will be recalled and the relationship between clinical symptoms, normal brain maturation and brain imaging data in adolescents and adults will be discussed.     

Adaptation des soins et télémédecine en période de confinement et de pandémie de COVID-19 : retour d’expérience d’une Maison des Adolescents

BackgroundThe COVID-19 sanitary crisis has imposed a major reorganization of the health care system in France. Lockdown could be a factor in the emergence or deterioration of psychological disorders; it can be even more fragilizing during the specific period of adolescence. The « Maisons des Adolescents » (Teenagers’ Houses) had to urgently adjust their practices to provide continuity of care for adolescents suffering from physical or mental disorders. The « Maisons des Adolescents » are pluridisciplinary care centres for adolescents and their families that provide assessments and services for medical, psychological, socio-educational, educational and legal needs. How did care continue for adolescents during lockdown? What adjustments occurred in the « Maisons des Adolescents » during the health crisis?MethodsThis article presents the case of an adolescent who suffered a significant deterioration of her anorexia nervosa during confinement. Through this case, we describe the reorganization of care within the different units (consultations - day hospital - hospitalization unit) of a Parisian « Maison des Adolescents » during the COVID-19 pandemic.FindingsIn this service, the rapid implementation of the telemedicine system in the context of the COVID-19 pandemic made possible provision of continuity in care for vulnerable adolescents and families. Based on the existing literature, we discuss the advantages and limitations of telemedicine and the practical issues for the future organization of care for adolescents.PerspectivesIn contrast to pediatric medicine or child psychiatry, there is no protocol describing the application of telemedicine in adolescent medicine and psychiatry. There is an urgent need for further evaluation of the use of telemedicine for this population. This kind of research will improve knowledge about the effectiveness, acceptability and limitations of using a teleconsultation device in adolescent psychiatry in a crisis context. Certain remote care modalities implemented during the sanitary crisis could thus be maintained over time and become routine in the field of adolescent medicine and psychiatry.     

Évaluation des connaissances et pratiques sur le dépistage de l’hypercholestérolémie familiale hétérozygote chez l’enfant

Introduction

Dominant heterozygous familial hypercholesterolemia (FH) is frequent (prevalence, 1/500 to 1/250) and leads to severe and premature cardiovascular complications. It is easily detected, and its treatment is effective. However, recommendations for screening are not followed worldwide.