Predictive factors for the outcome of emotional and/or behavioural disorders in 18- to 48-month-old children after parent-child psychotherapy: Protocol of a European prospective cohort study.

OBJECTIVES: Several studies have shown that in young children, behavioural and/or emotional disorders are more difficult to manage than regulatory disorders. Moreover, data are lacking on outcome predictive factors. This article presents a short synthesis of previous research about outcome predictive factors in child psychiatry. It also describes the protocol of a longitudinal observational European multicentre study the main objective of which was to identify predictive factors of behavioural and emotional disorder outcome in toddlers after parent-child psychotherapy. The secondary objectives were to study predictive factors of the outcome in parents (anxiety/depression symptoms) and parent-child relationship. METHOD: In order to highlight medium-effect size, 255 toddlers (age: 18 to 48 months) needed to be included. Outcomes will be assessed by comparing the pre- and post-therapy scores of a battery of questionnaires that assess the child's symptoms, the parents' anxiety/depression, and the parent-child relationship. Multivariate linear regression analysis will be used to identify predictive factors of the outcome among the studied variables (child age and sex, socio-economic status, life events, disorder type, intensity and duration, social support, parents' psychopathology, parents' attachment, parent-child relationships, therapy length and frequency, father's involvement in the therapy, and therapeutic alliance). EXPECTED RESULTS AND CONCLUSION: This study should allow identifying some of the factors that contribute to the outcome of externalizing and internalizing disorders, and distinguishing between pre-existing and treatment-related variables. It should also help to identify children at higher risk of poor outcome who require special vigilance on the part of the therapist. It should confirm the importance of therapeutic alliance. TRIAL REGISTRATION: ID-RCB 2008-A01088-47.

[Infants' attachment security in a vulnerable French sample]. / Sécurité de l'attachement des jeunes enfants dans une population française vulnérable.

INTRODUCTION: Attachment is a long lasting emotional link established between infants and their caregivers. The quality of early relationships allows infants to safely explore their environment and contribute to the establishment of a broad range of social skills. Several intervention programs targeting infant attachment have been implemented in different contexts, showing diverse degrees of efficacy. OBJECTIVE: The present paper describes, for the first time, children's attachment quality distributions in a French multi-risk population, with a preventive intervention, usual or reinforced. METHOD: In the CAPEDP study (Parenting and Attachment in Early Childhood: reducing mental health disorder risks and promoting resilience), a sub-sample of 117 women was recruited to assess the effects of this home-visiting program on children's attachment security. With that intent, the Strange Situation Paradigm was used when infants were between 12 and 16 months of age. RESULTS: In the intervention group, 63% (n=41) of the infants were coded as secure, while 15% (n=10) of them were coded as insecure-avoidant and 22% (n=14) as insecure-ambivalent/resistant. 56% (n=29) of control group infants (usual care) were coded as secure, while 27% (n=14) were coded as insecure-avoidant and 17% (n=9) as insecure-ambivalent/resistant. Even if the percentage of children with a secure attachment in the reinforced intervention group was higher than that of the control group, this difference did not reach the threshold of significance [Chi2 (2)=2.40, P=0.30]. DISCUSSION: Intervention group distributions were closer to normative samples, and these distributions show the clinical impact of our program. In general, preventive interventions focused on attachment quality have moderate effects but, in our case, several factors might have contributed to lower the statistical impact of the program. Firstly, the control group cannot be considered has having received zero intervention for two reasons: (a) the French usual perinatal health system (Maternal and Infant Protection System) is particularly generous and (b) the effect of this usual system might have been increased by the project intensive assessment protocol (6 visits during 28 months). Secondly, it is possible that the full effect of the intervention had not yet been detected because, when a child's attachment was assessed, only two thirds of the intervention visits had been performed (29 of 44 visits). A "sleeper effect" is still possible: we hope that a more clear result will be seen when children are assessed again, at 48 months, in our follow-up study (CAPEDP-A II). By clarifying the mechanisms involved in the development of a secure attachment, our study aims to contribute and refine the development of early preventive intervention strategies in high perinatal and psychosocial vulnerability contexts.

[The impact of cleft lip and palate on the parent-child relationships]. / L'impact des fentes labiopalatines sur les relations parents-enfant.

Cleft lips and palates (CLPs) are the most common human facial malformations. Depending on the ethnic and/or geographical origin of the studied populations, they can affect up to 1/500 newborns. The treatment of these patients is multidisciplinary because these malformations have not only aesthetic consequences but also functional consequences as the phonation, hearing, deglutition, mastication and ventilation are altered. These consequences can also be psychological since the building of the body image, the way others perceive it, is likely to be seriously altered. In Europe there are over 210 reference hospitals for children affected by CLP. Besides, about 190 different protocols were identified. So far no generic protocol was recognized by the medical community as a whole. This discrepancy can be explained by the fact that the aesthetic and functional result of a protocol cannot be accurately assessed before adulthood when the child's growth is complete. Patients presenting with CLP don't usually seem to present with any serious psychological or psychiatric pathology. Yet a close review of the related literature shows that disorders are actually described: behavioural troubles, anxiety, depression and esthetic dissatisfaction with one's face in children as well as in adults. The difficulty in interpreting these disorders lies in the various factors that are likely to impact this condition (family setting, importance and type of the cleft, surgery protocol, growth, social environment). A multidisciplinary examination of the face and a careful consideration of concerned families show the importance of the psychological context and the risks of a dis-harmonious structuring of the parents-child relationships on the child's development. The identification of the difficulties faced by these families, depending on the child's age, can be easily identified. Of course they can be identified at birth when the family first sees the child and later on at each stage of the child's life cycle (when starting at kindergarten where the child socializes for the very first time, at the start of the first year in primary school where pupils learn how to read and then at the start of secondary school which is yet another crucial step for the child due to the adolescence period). It is also obvious that an adult affected by CLP has a particularly heavy medical history as the patient had to go through various treatments and surgical interventions during his childhood and adolescence, which is even sometimes maintained at adulthood. Repeated appointments with the different specialists involved in their treatment punctuate their life as well as their parents'. This medico-surgical setting for facial malformations i.e. the features of the patient's face which are largely involved in their interpersonal relationships and the expression of emotions can have serious consequences. Most children presenting with CLPs and living in France benefit from regular follow-up schemes carried out in competent reference centres by a multidisciplinary team whose members represent each of the fields of expertise involved in the correction of this malformation: infantile and maxillofacial surgery, otorhinolaryngology (or ENT), ortho-phony and dentofacial orthopedics. Only the two French reference centres benefit from the permanent presence of a psychologist. This raises the question whether every care centre should take into care these children and their parents' mental health by offering psychological support during the course of the therapeutic follow-up scheme for these children, and this from an early age on as is recommended by the American Cleft Palate Craniofacial Association.

[Attachment process between an infant and his/her mother: the first year]. / Développement du processus d'attachement entre un bébé et sa mère.

Attachment theory is focused upon the development of the attachment process organized jointly by the child and the environmental factors which contribute to the development of the feeling of security. The authors focus on the mother-baby relationships and describe the normative process of attachment relationships during the first year of life. The ethologic perspective of this development is also summarized. The steps of the developing attachment relationship are described. The description of motherhood is focused on the bonding process, which is a more immediate and biologically based process and on caregiving which is a symmetrical motivational system as complex as the attachment one. The main factors known as having an impact on the two processes are described.

Association between symptoms of attention-deficit/hyperactivity disorder and bulimic behaviors in a clinical sample of severely obese adolescents.

OBJECTIVE: Preliminary evidence suggests a comorbidity between attention-deficit/hyperactivity disorder (ADHD) and obesity. This study was carried out to identify the clinical characteristics of obese adolescents with a higher probability of ADHD and advance the understanding of the potential factors underlying the comorbidity between obesity and ADHD. We evaluated the association between ADHD symptoms and bulimic behaviors, depressive and anxiety symptoms, degree of obesity, pubertal stage, age and gender in a clinical sample of obese adolescents. DESIGN: Cross-sectional study. SUBJECTS: Ninety-nine severely obese adolescents aged 12-17 years. MEASUREMENTS: Subjects filled out the Bulimic Investigatory Test, Edinburgh, the Beck Depression Inventory and the State-Trait Anxiety Inventory for Children. Their parents completed the Conners Parent Rating Scale, which assesses ADHD symptoms. The degree of overweight was expressed as body mass index-z score. Puberty development was clinically assessed on the basis of Tanner stages. RESULTS: Bulimic behaviors were significantly associated with ADHD symptoms after controlling for depressive and anxiety symptoms. The degree of overweight, pubertal stage, age and gender were not significantly associated with ADHD symptoms. CONCLUSION: Obese adolescents with bulimic behaviors may have a higher probability to present with ADHD symptoms independently from associated depressive or anxiety symptoms. The degree of overweight, pubertal stage, age and gender might not be useful for detecting obese adolescents with ADHD symptoms. Therefore, we suggest systematic screening for ADHD in obese adolescents with bulimic behaviors. Further studies are needed to understand which specific dimension of ADHD primarily accounts for the association with bulimic behaviors. Future research should also investigate the causal link between bulimic behaviors and ADHD and explore potential common neurobiological alterations. This may lead to a better understanding of the effectiveness of stimulants for the treatment of bulimic behaviors in obese subjects.

[Management of pregnant women with chronic psychiatric disorders]. / Prise en charge des femmes enceintes ayant une pathologie psychiatrique chronique.

This paper describes the psychic changes occurring within motherhood and their effects on the various kinds of mental disorders. The necessity of a multidisciplinary preventive and intervention network is emphasized. However, prenatal assessment is not predictive of what will happen postnatally. Only with the birth of the infant will the assessment of parenting begin. Some modification of the infancy and childhood protective regulations could help improving this post natal assessment of parenting ability.

Antenatal diagnosis: what sometimes remains to be done after the birth of a normal child.

Although antenatal diagnosis has become a common procedure, it still raises much anxiety within the family. The level of anxiety may remain high even after the birth of a normal child, leading to relationship disorders with the infant. In this case study, antenatal diagnosis of a balanced translocation 3-14 resulted in anxiety disorders, attachment disorders and sleep disorders in the child. Parents with a persistent anxiety could be referred to a child psychiatrist or psychologist, as brief parent-infant therapy is rapidly effective in such cases, and represents an acceptable way for parents to seek psychological help.

[An update on merycism and early depression: a critical review of the literature and a psychopathological hypothesis]. / De l'actualité du mérycisme à l'actualité de la dépression précoce: une revue critique de la littérature et une hypothèse psychopathologique.

Merycism has always intrigued clinicians. A review of the recent literature reminds us of its characteristics. The auto-stimulation dimension appears important, whatever the underlying psychopathology of mericysm. The frequence of mericysm during early childhood seems to have considerably diminished, even almost disappeared. We will discuss the reasons why mericysm continues to exist in the anorexic and boulmic young adult. We will analyze the relationship of mericysm in early childhood to depression and to growth delay. The dimension of ascendency seems to help us understand this problem.

[Post-partum blues: a critical review of the literature]. / Le post-partum blues: une revue critique de la littérature.

The abundant literature dealing with the post partum blues has failed to describe a possible causing factor in these emotional and physical manifestations which are frequently observed in mothers during the first few days following delivery. The post partum blues has been considered as a promising model for depressive states but its function has never been clearly established. No agreement has been reached as to its physiological mechanism. Presently there is a renewed interest for the "third day blues" in relation to post-birth depression, which is known to be frequent, and to the early interactions. The authors present a review of the literature and emphasize the necessity to approach this issue from a new standpoint and with new conceptual and measurement tools. The role of post partum blues could well be, through a biological process involving the dopamine, to facilitate the establishment of early mother-infant bonds by provoking a decrease in blunted affect.

[Psychosomatic aspects of protein-calorie malnutrition in early childhood in a tropical environment. Facts and hypotheses]. / Les aspects psychosomatiques des malnutritions protéino-caloriques de la première enfance en milieu tropical. Faits et hypothèses.

After a brief look at the clinical descriptions of marasmus and kwashiorkor, and a summary of the physiopathological concepts of these protein calorie malnutritions (PCM), the author looks at arguments which suggest there is a change in the mother-child relationship at the onset of PCM, excluding, however, those malnutritions which appear in conditions of famine or catastrophe. These arguments are drawn principally from studies done in Africa, and are based on clinical, sociological, and ethnopsychiatric data. The contributing factor of maternal depression and that of relational characteristics of the child are considered, and an analysis is made of how these factors might converge at the onset of PCM. The author attempts to demonstrate the important role of a psychomotor retardation in the tableau of psychological troubles which present themselves during the course of Kwashiorkor. The role and importance of weaning, of the separation and the psychomotor retardation in the genesis of the "situation of malnutrition" are discussed. Finally, a parallel is established between PCM and early psychosomatic syndromes observed in the west, principally the anorexias and insomnias during the first year of life. The point in common between these situations and PCM is perhaps the onset of conditions having an upsetting and distorting effect on the mother-child relationship. The family and the entourage use certain collective representations in Africa ("Nit-KuBon", "Tjid-a-Paxer") to try and explain the onset of PCM. The description of these traditional representations is utilized as a materialization, by the mother and the social group, of an alteration of the mother-child relationship, and can be compared to representations which play the same role in the west.