[Telepsychiatry at the service of autism]. / La télépsychiatrie au service de l'autisme.

INTRODUCTION: The authors report on the set-up of a telehealth system developed to facilitate exchanges between the Autism Resource Centre of Brittany (centre de ressources pour l'autisme [CRA]) located in Brest and an adult psychiatry structure of Vannes' Hospital in the Morbihan region, these sites are about 200 kilometres distant. OBJECTIVES: This coordinated work using computer networks aims at sustaining the action of a unit specialised in autistic patients. The goal is to both render a precise diagnostic (teleexpertise) and favour assistance and support to residents and their families while instituting a medical education tool for the health professionals of this unit. METHODS: The creation of this telehealth experience, using multiple contact video conferencing, was possible thanks to the existence of the Megalis network, a high speed telecommunication system deployed in the Britanny and Loire region. The connexion of the two sites is made through Cisco type routers. Both sites are linked to the network through urban fiber optics (2-40 MMytes/s output) or Integrated Services Digital Network (ISDN) Access (64 or 128 kbytes/s output). This virtual private network (VPN) style high speed link offers a transparent and secure connexion through the service provider (Novasight) which supervises the technical organisation and the management of the address books of the various listed sites, controls access to the network and manages the network speed. As far as appliances are concerned, (video camera, LCD screen, microphone, maintenance, training), the cost is about 11,000 euros. From their experience, the authors develop the following applications: tele-staffs are meetings of about 2hours in length. DISCUSSION: The authors insist on some essential rules, such as putting on the agenda the items to be discussed at the meeting, handing out to everyone the documents needed for the meeting, and designating someone in charge of guaranteeing the good progress of the meeting. His/her functions are to guarantee a precise format for the meeting, to distribute speaking time fairly, to clearly formulate the decisions made (organisation of results, summing up diagnostic results and evaluation of competencies, common institutional actions, arrangement of projects, university research and trainings, scheduling future meetings). Still using their experiences, the authors put forward several recommendations on technology, video and audio links (framing, sound checks, multidirectional microphones, video quality - forcing people to limit rapid gestures…) but also insist on having fit for purpose rooms (soundproofing, neutral decor, homogenous lighting, neon for example…). Contact with patients and their family through video-conference: despite being used less, this technique has shown its pertinence especially for the evaluation of diagnostics and competencies. In practice, the families are joined by the health professionals in charge of the patient in that institution. A meeting chair must be nominated, in our case the doctor in charge of the unit for autistic persons. The doctor from the CRA sits in on the meeting as consulting expert and intervenes at the invitation of the chair. The plan for the meeting and the must-ask questions have to be determined beforehand by the two doctors, so as make sure the meeting will be fast flowing and all the relevant clinical and biographical data are collated. Families, seeing different institutions working together to help their family member despite the distances using high tech solutions, were very satisfied. CONCLUSION: On the whole, the authors help us to have good insight into the obstacles (cultural, administrative, technological) and the benefits (availability of consultants with specific competencies, reduction in the waiting time, more efficient use of resources, reduction in costs and risks of travel and of CO(2) emissions…). They believe that health professionals cannot and should not completely avoid travel to the other sites because it is important to get to know the teams well, which is a prerequisite to a good video-conference meeting. This helps creating new directions for the future.

[Kleine-Levin syndrome: a case report]. / Le syndrome de Kleine-Levin: à propos d'un cas.

The purpose of this article is to report an original clinical case whose symptoms suggest a very peculiar pathology, because of its rarity, symptomatic expression and unclear etiopathogenesis: the Kleine-Levin Syndrome (KLS). During the regression of tonsillitis concomitant with an emotional shock, the 15-year-old patient exhibited a dramatic change in behaviour, at odds with his previous state, and accompanied by hypersomnia and confusion, megaphagia, irritability, hypersexuality and mood disorders. We observed a spontaneous and total regression of the symptoms after 12 days, except for the incomplete amnesia that proved to be persistent. Four months later, further to an ethylic drunkenness, the patient presented with a new and similar episode. The patient benefited from no medicinal treatment, even in the course of hypersomnia episodes and asymptomatic periods. After a clinical presentation of this patient, we will consider this case study from a more psychopathological angle by questioning the existence of a facilitating psychological profile. The discovery of an IQ equal to 86 from the scores of WISC-IV, and the identification of constructive visual difficulties made us suspect neurological disorders, but these abnormalities were not found during the completion of the Rey Complex Figure Test. The personality profile issued from the scores at the MMPI-A assessment was ranked as barely significant (type 2-4): indeed, it showed nothing specific to this patient. Literature data show that most of the patients presenting with a KLS have been seen by a psychiatrist at the time of the disease and diagnosed as suffering from hysteria, or schizophrenia, or bipolar disorders... Because of diagnostic wanderings, some patients have, hence, received inappropriate treatments. One should pay close attention to this very rare syndrome, on the border between neurology and psychiatry, since its diagnosis is essentially based on clinical features, and carefully think about the implementation of a medicinal treatment. This unique case seems unable to support our working hypothesis about the identification of a particular psychological profile in the KLS, but the question of an underlying fragility is still worth considering. We personally think that, even though links between the KLS and bipolar disorders have been suggested, this disease has to be considered as a separate entity.

[Evolution and description of a complete hospitalisation unity in child and teenager psychiatry]. / Hospitalisation en pédopsychiatrie : description et évolution d'une unité.

The university department of child and adolescent psychiatry of Brest Hospital (a medium size town of 200,000 inhabitants) has at disposal a 14 in-patient emergency care unit, where young people under 16, mostly in crisis (individual and/or family and/or institutional crisis) are admitted. This unit opens 24h a day throughout the year, and patients with any type of pathology are admitted for a short stay, mainly with no demand for care. After a description of this unit with its modalities of functioning, the authors will report on its activity assessed from sets of data pertinent to the last 8 years. One thousand two hundred and twenty-five admittances were recorded over these 8 years. A very strong increase in the number of hospitalisation over the years (+201.4%) was also noticed. However, the sex-ratio remained quite alike with a majority of boys (55.3%), as well as the average stay duration (15.5 days in 2007). About the age at admittance, one should note that, after the relative stability observed in the first years, the average age has been decreasing regularly for the last 3 years to pass from 13.2 years for girls and 12.7years for boys in 2005 to 12.6 years (girls) and 11.2 years (boys) in 2007. Despite a rise in the number of children under placement in this region (Finistère) between 2001 and 2006, the origin of the admittances has remained quite stable over 8 years: in 2007, 64.9% of the accepted children were living in their family, 24.6% in a foster care and 10.4% in a foster family. The evaluation of this hospitable cohort over several years allowed the authors to highlight various trends such as the explosion of the demand for medical care in both sexes, the rejuvenation of mental disorders, evolution in the motives for admittance with an important increase of psychomotor instability and externalised behavioural problems as well as the occurrence of new demands for care, e.g. the weaning of "on-line" video games or Internet. The growing expansion of NICT (new information and communication technologies) would invite them to appropriate them as tools in the meetings and to reconsider their restrictive position with respect to them. Finally, this rejuvenation of mental disorder(s), the occurrence of adolescent problems at an earlier age, together with their observation of the lengthening of the oedipian phase, whose elaboration seems more problematic than previously, have made them wonder about the contemporary characteristics of the phase of latency and the modalities of negotiation of this stage by their cohort of young people. These modifications have incited the authors to reconsider their offer of care and to propose alternatives to the hospitalisation through the recent development of a structure of home psychiatric-care. This new unit caused no arrest in the massive influx of the patients in complete hospitalisation, but it allowed them to optimise the care for some young people in complex situations through improvement of relationships with their various partners of the sanitary and socio-educational world (listening and support by the partners, exchanges of know-how in full awareness of complementarity, and work in the continuity during the stay at hospital [better prepared hospitalisation together with a better understanding of its interest by the child/teenager and the partners]).

[New society, new families: a new basic personality? From the neurotic to the narcissistic-hedonistic personality]. / Nouvelle société, nouvelles familles: nouvelle personnalité de base? De la personnalité névrotique à la personnalité narcissico-hédoniste.

BACKGROUND: In Occidental countries the frame of modern families has been reshaped, and vast economical and social changes have taken place over the last thirty years. They have been marked by the disengagement of the State in the marriage, a giant evolution in conjugality which is becoming privatized and made insecure, changes in gender relations, new motives and conditions for the arrival of the child in the couple, i.e. planned birth, wished or desired infant, infant conceived for oneself, and parenthood has been turned upside down through the extensive evolution of its laws and symbolic-landmarks as well as in practical experience. As these new coordinates of the family are now centred on the consensus instead of authority for the organisation of relationships between its members and on hedonism instead of duty as main value, with a child issued from the desire and acknowledged, from the onset, as a full person "the baby is a person" a child made "for oneself and for him/herself" (and not for the society), brought up in an environment where the media can be considered as a "third parent" because of it's growing importance, the structure of the child's psyche no longer matches the neurotic model. LITERATURE FINDINGS: Studies made by anthropologists have led us to hypothesise a new "basic personality" in order to reflect the consequences of the new landmarks in society and the new family, as well as the outcome of new educational practices; this new "basic personality" would replace the basic normal/neurotic one, which dominated over the first half of the twentieth century. CLINICAL ASPECTS: This basic personality, which could be termed as "narcissistic-hedonistic", is characterized by few internalizations, a poorly efficient Superego, nearly no guilt feeling, a weakly socialized Ideal Self suggesting more the Ideal Self of the early childhood, and finally a difficulty in experiencing or testing oneself as a free subject. The resulting narcissistic fragility leads the subject to be more dependent on external objects, to be allergic to frustration, to find delay in the achievement of instinctive aims hard to take, to develop an exaggerated pursuit of perception and sensations. The relation to time is also affected through a privileged investment in the present and the shading off of historical time. These changes must lead to a different subjectivity stemming from a new basic personality. Disorders may stem from three axis of this new basic personality: dependency with attachment disorders, narcissistic fragility, and a high risk of depression; guilt-free "narcissistic perversion" with people, who use other people for their own and exclusive interest, without real empathy; "light" psychopathy, with people capable of social integration for shorts periods of time, with a lot of breaking off in love, friendship, and professional ties. CONCLUSION: This new configuration where specific pathologies are associated with a new basic personality implies serious thought with regards to care practices so as to adapt them to the patterns of patients.

What happens to children with PDD when they grow up? Prospective follow-up of 219 children from preschool age to mid-childhood.

OBJECTIVE: To describe the psychological development of children with pervasive developmental disorders over a period of 3 years and to identify the factors linked to their developmental paths. METHOD: The study was a collaborative and prospective follow-up study of 219 preschoolers. Retrospective data and enrollment data were collected at the beginning of the study and 3 years later. RESULTS: We observed high variability in the short-term outcomes of preschoolers. In line with previous research, our results showed that intellectual, linguistic and adaptive functioning were useful for predicting outcome. The severity of a child's autistic symptoms appears to be related to his or her future development. These variables can therefore be used as predictors of outcome for preschoolers with autism. CONCLUSION: Developmental and symptom changes in young children with autism should not be overlooked and need to be assessed regularly in view of choosing suitable servicing programs.

[Consensus, hedonism: the characteristics of new family and their consequences for the development of children]. / Consensus, hédonisme: les coordonnées de la nouvelle famille et ses conséquences sur le développement de l'enfant.

Over the last three decades, the marital family model described by Durkheim at the end of the nineteenth century has undergone numerous changes, e.g. questioning about the principle of authority, women emancipation, occurrence of the "new fathers", the growing influence of the media on the daily life of families, the less frequent and most precious child (due to the reduced number of children per family),... Through clinical, psychoanalytical and developmental models we, here, analyze these changes together with their impact on child. Historical and sociological approaches also allowed us to examine some of the effects induced by consensus and hedonism, the new familial parameters, on the child's life and development. The modern family being classically founded upon duty (central value) and the principle of authority to settle relationships between individuals, its main features are opposed to those of the contemporary family. The latter, which started to emerge over the sixties, is characterized by both the prevalence of parent-child relationships symmetrization and the emergence of the search for immediate pleasure. The change from parental authority to consensus as a principle ruling the relationships within families leads to many consequences later noticed through changes in the construction of the child's psyche along his development and in the relationships dynamics. Authority imposes on child to submit to the parents-mediatized requirements of the society and implies a change in impulses through the setting of Superego agencies and Ego Ideal, which (both ?) represent taboos and social ideals in the psyche. When consensus is at the center of the family, and according to concrete meetings with the other offered by the thousand and one situations met in the daily life, the aims and satisfaction modalities of the child's impulses will evolve into a relation often based on either strength or seduction. As a result, the settlement of classical instances will be affected. It will result in. Considering hedonism as the central value in child education leads one to support the pleasure principle and contributes to making more difficult the switching to the reality principle. The couple " I want, I don't want" is at the origin of most behaviors, and then further leads to the development of the assertive agency, "I do what I want, and thus I am". The libidinal excitation is, therefore, little restricted and reinforced by the media-based environment. The child's Superego is built on the concrete practices of his parents, but not on their Superego, whereas the Ideal of Ego is poorly socialized and driven towards the ideal Ego, early narcissist formation with the signs of child megalomania. Due to these early years of life throughout which the pleasure principle has been favored by their environment, the children are not prepared for life with its restrictions and unavoidable frustrations possibly experienced as persecutions. In the same way, when they have to meet the requirements of life in community, eg the discipline imposed within a college, these rules are more and more often felt by a pupil as unfair, arbitrary persecutions sometimes related to his own personality, "the teacher doesn't like me" of course, it is all the more legitimate to rebel against them as the charter of the pupils' rights, posted up in the school, has been read through very quickly by the teenagers. This mechanism takes one back to the archaically perception of environment by the very young child and to the projection developed by S. Freud in his description of the building "Ego-pure pleasure", (moi-plaisir purifie) (The Ego and the id, 1920). The opposed mechanism is expressed through an experience of shame felt by the subject when he is unable to satisfy, not the requests of his own impulses, but the social group's requirements. From the libidinal point of view, advertisements stimulate one's desires, incite one to consume and are at the origin of consumer needs. As a consequence, there is a resonance between the individual pleasure principle and the promotion of hedonism suggested by the society. The modern children have their mastery of impulse motions hampered by this phenomenon. The temporality of , new children " in new families sounds centered on the present, which is made of moments of eternity, always restarted (cyclic time of the first ages of life) ; it overrides historical time with a start, an end and references to intergeneration difference and filiations. This prevalence of present offers few support to neurotic defenses, with predictable problems in social interactions due to an inability to manage the tensions issued from the time discrepancies between one and his alter ego. Tran cultural studies have shown that to any social and cultural organization corresponds one or several basic personalities; among them, modem society has exuded the standard neurotic personality characterized by an ample mental space, a strict modulation of behaviors governed by the representations play and spreading out in Le théâtre du Je (The I theatre, Mac Dougall, 1982), a conflict between desire and internalized taboo, and the problematic of transgression and guilt. The modern family produces different personality structures. This led us to assume new basic personalities as follows, and to envision some psychopathological consequences: The passive dependent personality with an extreme narcissist fragility and at high risks of depressive disorders; The perverse-anarchistic personality characterized by subjects unable to feel guilty, taking at the best advantage of others to achieve his own ends thanks to his grasping of social situations and to his own seduction, lacking of true empathy; The slightly-psychopathic personality: these subjects can integrate well, but for a short time, in a social structure. They need to frequently find a new job, move in another place or country. Their relationships with others are always disrupted and changing for they can be involved in only short commitments. They are very susceptible to immediate gratifications.