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.

Therapeutic alliance and glycaemic control in type 1 diabetes: a pilot study.

AIM: Effective diabetes care requires integrating physicians' clinical expertise with patients' concerns and resources. This prospective study examined whether or not two measures of therapeutic alliance could predict glycaemic control after 1 year of follow-up in patients with type 1 diabetes. METHODS: Consecutive type 1 diabetic outpatients were recruited, and their age, gender, level of education, marital status and age at the time of diabetes diagnosis were self-reported. The presence of diabetes complications was ascertained by the patients' physicians. Both patients and physicians completed the revised Helping Alliance Questionnaire (HAQ-R) and the 12-item Working Alliance Inventory (WAI-12) to assess therapeutic alliance. Patients also completed the Center for Epidemiological Studies Depression scale to assess depressive mood. HbA(1c) was measured at baseline and 1 year later. RESULTS: Sixty-four type 1 diabetic outpatients (32 men, 32 women; mean age±standard deviation [S.D.]: 38.2±8.0 years) were included. HbA(1c) level at follow-up (mean±S.D.: 7.56±1.18%) was positively correlated with the HbA(1c) level at baseline (r=0.698, P<0.001), and associated with presence of retinopathy at baseline (8.18±1.24% versus 7.41±1.13%, P=0.036). In addition, the HbA(1c) level at follow-up was negatively correlated with therapeutic alliance, as assessed at baseline by the physicians using either the HAQ-R (r=-0.431, P<0.001) or the WAI-12 (r=-0.365, P=0.003), even after controlling for the HbA(1c) at baseline. CONCLUSION: Although the observational nature of the present study prevents causal conclusions to be drawn, these preliminary results suggest that promoting therapeutic alliance can improve glycaemic control in type 1 diabetes.

[Construct validation study of the Relationship Scales Questionnaire (RSQ) on an adult sample]. / La version française du Relationship Scales Questionnaire de Bartholomew (RSQ, Questionnaire des échelles de relation): étude de validation du construit.

INTRODUCTION: The authors present the construct validity of the French version of the Relationship Scales Questionnaire (RSQ) designed by Griffin and Bartholomew (1994), which is the most widely-used self-report concerning adult attachment. OBJECTIVES: To improve knowledge on the psychometric properties of the RSQ by studying the construct validity on a sample of adults. METHOD: Subjects were recruited in a primary social care setting in Paris, France, and asked to fill in the RSQ twice: the first time just before meeting the social worker in charge, the second time, at home, with a prestamped form, two days later. A questionnaire on sociodemographic and economic variables was also filled in during the first time. Statistical analyses were conducted using Exploratory Factor Analysis with orthogonal rotation. The reliability was studied using Cronbach's coefficient for each new scale from the factor analysis. The test-retest reliability was studied for the prototypic scales and for the scales from the factor analysis, using the intra-class correlation method. RESULTS: One hundred and twenty-six subjects were recruited and completed the two forms (mean interval: 2.16 days). The factor analysis gives a three-factor structure explaining 48% of the total variance. The three factors were: factor 1 "Avoidance" with seven items explaining 21% of the total variance; factor 2 "Anxiety in the relationships" (five items) explaining 14% of total variance and factor 3 "Security" (five items) explaining 11% of the total variance. Cronbach's coefficient was low for the prototypical scales (0.41 for "secure", 0.54 for "fearful", 0.22 for "preoccupied", and moderate for "dismissive" (0.64). It was moderate for the scales designed from the factor analysis (0.66 for F1, 0.69 for F2 and 0 .60 for F3). The Intraclass Coefficients (ICC) were modest for the four prototypical scales (ICC<0.70) and were good for the scales designed from the factor analysis (F1: ICC=0.80; F2: ICC=0.85 and F3: ICC=0.78). DISCUSSION: The construct validity studied on an adult sample confirms the good psychometric properties of the RSQ considering the factor analysis, the test-retest short time reliability and the internal consistency. The factor analysis with three factors provides a different structure of classical descriptions with only two factors, but confirms the most recent results on Attachment Self-Reports that find a factor concerning security and two factors concerning management of insecurity (avoidance and anxiety in relationships). To be confirmed, the results require further research (confirmatory factor analysis, larger sample, other type of population).

[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.

[About offsprings of mothers with anorexia nervosa: what about clinical practice in pediatric settings?]. / Les enfants de mères anorexiques.

The authors first present the methodological issues raised by studies of the offspring of mothers with anorexia nervosa. Malnutrition and low weight appear to be the main consequences for the baby. Feeding mother/child interactions are more likely to be disturbed during later childhood. Emotional or psychological consequences are not well yet studied.

Contextual Assessment of the Maternity Experience: development of an instrument for cross-cultural research.

BACKGROUND: There is evidence that stressors may trigger the onset of a depressive episode in vulnerable women. A new UK interview measure, the Contextual Assessment of the Maternity Experience (CAME), was designed to assess major risk factors for emotional disturbances, especially depression, during pregnancy and post-partum. AIMS: With in the context of a cross-cultural study, to establish the usefulness of the CAME, and to test expected associations of the measure with characteristics of the social context and with major or minor depression. METHOD: The CAME was administered antenatally and postnatally in ten study sites, respectively to 296 and 249 women. Affective disorder throughout pregnancy and up to 6 months postnatally was assessed by means of the Structured Clinical Interview for DSM-IVAxis I Disorders. RESULTS: Adversity, poor relationship with either a partner or a confidant, and negative feelings about the pregnancy all predicted onset of depression during the perinatal period. CONCLUSIONS: The CAME was able to assess major domains relevant to the psychosocial context of the maternity experience in different cultures. Overall, the instrument showed acceptable psychometric properties in its first use in different cultural settings.

Maternal attachment style and depression associated with childbirth: preliminary results from a European and US cross-cultural study.

BACKGROUND: Insecure attachment style relates to major depression in women, but its relationship to depression associated with childbirth is largely unknown. A new UK-designed measure, the Attachment Style Interview (ASI), has potential for cross-cultural use as a risk marker for maternal disorder. AIMS: To establish there liability of the ASI across centres, its stability over a 9-month period, and its associations with social context and major or minor depression. METHOD: The ASI was used by nine centres antenatally on 204 women, with 174 followed up 6 months postnatally. Interrater reliability was tested and the ASI was repeated on a subset of 96 women. Affective disorder was assessed by means of the Structured Clinical Interview for DSM-IV. RESULTS: Satisfactory interrater reliability was achieved with relatively high stability rates at follow-up. Insecure attachment related to lower social class position and more negative social context. Specific associations of avoidant attachment style (angry-dismissive or withdrawn) with antenatal disorder, and anxious style (enmeshed or fearful) with postnatal disorder were found. CONCLUSIONS: The ASI can be used reliably in European and US centres as a measure for risk associated with childbirth. Its use will contribute to theoretically under pinned preventive action for disorders associated with childbirth.

The Edinburgh Postnatal Depression Scale (EPDS) and the detection of major depressive disorders in early postpartum: some concerns about false negatives.

This paper presents a phenomenological study of three false negative cases according to the Edinburgh Postnatal Depression Scale (EPDS) of major depressive disorder identified by a semi-structured clinical interview. In a study of 87 unselected women with 23 of them suffering from a major depressive disorder (according to the Research Diagnostic Criteria), three cases of major depressive disorders were not identified as potential cases by the EPDS. The symptomatology of these three false negative cases was also assessed by a semi-structured interview (Present State Examination). Comparisons between EPDS scores and the scores of two other self report questionnaires (the General Health Questionnaire-28 and the Center for Epidemiologic Studies-Depression Scale) suggest that EPDS is better at identifying depressed postnatal women with anhedonic and anxious symptomatology rather than those whose depression presents mainly with psychomotor retardation.

Validation study of the French version of the Edinburgh Postnatal Depression Scale (EPDS): new results about use and psychometric properties.

The validation of the French version of the Edinburgh Postnatal Depression Scale (EPDS), conducted on a sample of 87 women in the first 4 months of post-partum, is presented. The study of the sensitivity, specificity and predictive values versus research diagnosis criteria provide the cut-off score of 10.5 as the best (sensitivity: 0.80; specificity: 0.92). The EPDS as an index of severity of postnatal depression (PND) also had good criterion validity compared to the psychiatrist's assessment. Factor analysis shows that the internal structure of the EPDS is composed of two subscales which underline a more accurate description of PND. The reliability study confirms the good internal consistency of the global scale (Cronbach's alpha: 0.76) and its good short term test-retest reliability (0.98).

[Depressed mothers: the impact of depression on early interactions. An analysis of Anglo-Saxon studies]. / A propos des mères déprimées: l'impact de la dépression sur les interactions précoces. Analyse des travaux anglo-saxons.

Maternal depression remains a public health problem as indicated by many studies focusing on depression in mothers of young children. Although the high prevalence of depression in mothers of infants and young children is now a recognized fact, the detection and management of maternal depression in everyday practice still raises significant problems. This initial review centers on studies providing diagnostic guidelines. The problem of maternal depression and of its impact on the offspring is relevant to the issue of how qualities, abilities, and vulnerabilities are transmitted from one generation to the next. Psychoanalysts, infant psychiatrists, and developmental psychologists show great interest in this field. The current review was restricted to recent Anglo-Saxon studies on depression-related changes in early maternal behavior. The most striking findings are as follows: although depression affects maternal behavior overall, there is considerable variation across mothers; timing alterations (in terms of micro and macro sequences) in mother-child interactions occur in every case and are among the obstacles to harmony and synchronization; subtle alterations in the mother's response to her baby's signals preclude flexibility and anticipation.

[Evaluation of the change process during treatment of adolescent psychotics]. / Evaluation des processus de changement au cours du traitement d'adolescents psychotiques.

This study rests on work comparing the processes of change in the mental functioning of eleven psychotic teenagers through two perspectives: a psychological perspective centered on the comparison of two psychological examinations carried out at intervals of one and a half and three years; a psychiatric perspective taking into account elements supplied by the doctor and the nursing staff in the facility and concerning the evolution of each patient between the first and second psychological examination. The evolution was judged according to three factors liable to explain the therapeutic effects: the ability of psychic movement through the appearance or the reappearance of a function in the primal process; setting up limits and defenses of a narcissistic order; the improvement in the ability to make bonds. In spite of the difficulties in regrouping the subjects, the comparative results between the tests and the clinical setting generally confirmed our initial hypotheses.

[Children of depressed parents]. / Les enfants de parents déprimés.

Children whose parents are depressed are the objects of numerous studies. In a critical study of literature, the author attempts to show the contributions and limits of present results. While it seems clear that children such as these are part of a group at risk, psychologically, the type and frequency have yet to be determined. The intricacies of innate and environmental factors takes the complexity of just such a situation into account. The impact of the mother's depression on her nurturing is also analyzed, along with its consequences on the infant's behavior.

[Apropos of mother-child hospitalizations: mother-child hospitalization in a child psychology service]. / A propos des hospitalisations mère-enfant: l'hospitalisation mère-enfant dans un service de psychopathologie de l'enfant.

Mother-child hospitalization is still rarely practiced in child psychiatric services. The experience of this kind of care in the child and adolescent psychopathology service in the Herold Hospital (Paris), however, demonstrates its interest. It permits one to respect the bond of attachment and proves to be a useful instrument of psychiatric evaluation of children, particularly in greater diagnostic precision to which the observation of the mother-child unit also contributes. The conjoint hospitalization, however, involves some risks, which can be anticipated in pre-hospitalization work up: repercussion on the family, difficulties in the functioning of the care taking team, and especially the impact on the mother of the hospitalization which creates a real crisis situation which must be handled in order to be able to use the maturative possibilities.