Anxiety and Depression Symptoms in At-Risk Pregnancy: Influence on Maternal-Fetal Attachment in Tunisia.

OBJECTIVES: To investigate maternal prenatal anxiety and depression in high-risk pregnancies and examine their influence on maternal-fetal attachment. METHODS: We included 95 hospitalized high-risk pregnant women. The Hospital Anxiety and Depression Scale (HADS) and the Prenatal Attachment Inventory (PAI) were used to assess the primary objective. Internal consistency and construct validity of the PAI were investigated. RESULTS: The average age was 31 years and gestational age ranged from 26 to 41 weeks. Prevalence of depressive symptoms was 20% and anxiety symptoms 39%. Cronbach alpha coefficient of the PAI Tunisian version was 0.8 and the construct validity in favour of one factor model. PAI scores correlated negatively and significatively with the HADS total score (r = - 0.218, p = 0.034) and was attributed to the depression dimension only (r = - 0.205, p = 0.046). CONCLUSIONS FOR PRACTICE: Emotional wellbeing of pregnant women especially in high-risk pregnancies should be explored in order to prevent consequences on women, their growing fetus, and prenatal attachment.

What is already known? Maternal prenatal emotional well-being influences maternal­fetal attachment which has important implications on postnatal bonding. Anxiety and depression disorders during pregnancy could affect women's attachment to their unborn child in a negative way. Research has largely been conducted with the general pregnant population with little focus on at-risk pregnancies, which are associated with increased levels of mood disorders. What this paper adds? This study highlights the impact of depression but not situational anxiety on maternal­fetal attachment in women with high-risk pregnancies, highlighting the importance of assessing and managing psychological disorders during pregnancy to enhance the quality of prenatal bonding.

Highlighting successes and challenges of the mental health system in Tunisia: an overview of services, facilities, and human resources.

BACKGROUND: Tunisia is a lower-middle-income country located in North Africa with strengths and challenges to its mental health system. AIMS: We present an overview of available services, facilities, and human resources to offer mental health care in Tunisia. METHODS: We conducted a cross-sectional study, where data for the year 2017 was collected between May 2018 and May 2019 by consulting stakeholders involved in the health field in Tunisia. We compare this information with data published in the WHO-AIMS report (2008), which presents mental health data in Tunisia for the year 2004. RESULTS: Successes of the mental health system in Tunisia include an increase in the ratios of psychiatrists and psychologists, with these ratios being higher than those of other lower-middle-income countries; a flourishing child-psychiatry practice; and an increase in people being treated for mental health conditions. Challenges include psychiatrists being over-represented in large cities along the coastline and in the private sector, and most people receiving treatment in specialized mental health facilities. CONCLUSIONS: The further operationalization of the National Strategy for Mental Health Promotion is envisioned, through the training of non-specialists in mental health care and incentives offered to psychiatrists to work in the country's interior and the public sector.

Tunisian maltreating mothers characteristics.

Introduction: the aim of our cross-sectional study was to compare the sociodemographic and clinical characteristics, the social support, the personal history of abuse, and the parental bonding style of maltreating Tunisian mothers to those of nonmaltreating mothers. Methods: this was a cross-sectional study carried out on the child psychiatry department of Mongi Slim Hospital in Tunisia. A data-collection sheet was designed to collect sociodemographic and clinical data about the child and the maltreatment (type, frequency, and duration), the mother of the child (sociodemographic and clinical data) and the family (socioeconomic situation and conjugal violence). Results: the sample was composed of 167 mothers. Children were significantly more maltreated when their ages were between 6 and 12 years (p=0.004) and less maltreated when they had been born prematurely (p=0.007). Also, the higher the level of the mother´s education, the less the child was maltreated (p=0.007). In addition, maltreated mothers more frequently had a history of physical abuse, emotional abuse, or emotional neglect during their childhood (p values were respectively 0.002, 0.05, and 0.007). Thus, when mothers maltreated their children, a perception of optimal grandmother-mother parenting was significantly less frequent, and a perception of an affectionless-bonding grandmother-mother was significantly frequent (p = 0.019). Conclusion: we conclude that it is important to consider individual, relational, communal, and social factors to elaborate efficient strategies for preventing children maltreatment.

Preterm birth, mother psychological state and mother- infant bonding.

BACKGROUND: The preterm birth represents a stressful situation that can lead to questions about the survival of the child and the possible consequences. AIM: To examine the interactions between mothers and premature babies in the neonatal care unit (NCU) and assess the psychological state of the mothers. METHODS: Cross-sectional study conducted from March to May 2017 in the Department of Pediatrics and Neonatology of the Mongi Slim Hospital (Tunis, Tunisia). Ten mothers of premature babies hospitalized in NCU were involved and responded to the Postpartum Bonding Questionnaire (PBQ), the Edinburgh Postnatal Depression Scale (EPDS) (cut off≥10) and the Hospital Anxiety and Depression Scale (HADS). RESULTS: The mean age of the mothers was 31 years. A personal history of depression was found in two mothers. The current pregnancy was not desired in three cases, two corresponded to mothers with a history of depression. According to interactions, the median PBQ score was 11. The EPDS median score was six; four mothers had a score greater than 10. A high level on the anxiety sub-scale of the HADS was found in the two mothers who had a personal psychiatric history. The more depressed or anxious the mothers were, the higher the interaction scores (p = 0.012 and p = 0.032, respectively). CONCLUSION: Preterm birth seems to affect the psychological state of mothers and their interactions with their baby.

Covid-19 and mental disorders in children and adolescents: Experience of the child and adolescent psychiatry department of the Mongi Slim Hospital of Tunis.

The Covid-19 pandemic had a major psychosocial impact on the mental health of children and adolescents, especially when the childhas mental health problems. During containment, the healthcare structures were subject to a significant restriction of their activities. The child and adolescent psychiatry department of the Mongi Slim Hospital in Tunis has set up telephone follow-up for patients deemed to be at risk. This follow-up involved 166 cases, the majority of them were suffering from neurodevelopmental disorders, followed by depressive disorders and adjustment disorders. A third of the patients had reported a worsening of the symptoms during the containment and a third had reported clinical improvement. During this follow-up, recommendations were made to parents to limit the negative impact of Covid-19 pandemic. Maintaining follow-up of patients with mental disorders by telemedicine is a major challenge in order to prevent the repercussions of this pandemic in the long term.

[Epidemiological and clinical profile of suicide attempts in Tunisian children and adolescents after the revolution]. / Profil épidémiologique et clinique des tentatives de suicide chez l'enfant et l'adolescent en Tunisie en post révolution.

BACKGROUND: Suicidal behaviors are increasing in Tunisia at younger and younger ages. This study aims to describe the sociodemographic and clinical profile of suicide attempts in children and adolescents. METHODS: We conducted a cross-sectional and descriptive study, including 50 suicidal individuals, recruited in the Child Psychiatry Department at the Razi Hospital in Manouba and in two Departments in Tunisia (Intensive Care and Reanimation Department and Department of Pediatrics) between July 2012 and June 2013. We identified the socio-demographic and clinical factors, the histories of abuse, subjects' education, the characteristics of the attempted suicides (TS), suicidal ideation assessed by the Suicidal Intent Scale and psychopathological disorders diagnosed using the Mini-International Neuropsychiatric Interview. RESULTS: The sex-ratio was 0.56, the average age was 12.4 years ranging from 7 to 16 years. School failure or dropout were found in 86% of suicidal individuals. In 38% of cases suicidal behavior was recurrent; the subjects had a history of self-mutilation to the same extent. A context of abuse was reported in 46% of cases. Drug ingestion was the most common means of suicide, psychotropic drugs were the most common substances used. There was a significant gender difference in the use of the means of suicide: the boys mainly used physical means (P=0.04) while the girls poisoning (P=0.001). Suicidal intent was high in 44% of cases. A major depressive episode and adjustment disorder were the most common disorders found (58% and 24% of cases respectively). CONCLUSION: Depressive disorders and abuse are risk factors of TS in children and adolescents, these factors should be considered when implementing suicide prevention strategies for this population.

Epigenetics and ADHD: Toward an Integrative Approach of the Disorder Pathogenesis.

OBJECTIVE: Epigenetic hypothesis is one of the research pathways used to explain the complex etiology of neurodevelopmental disorders. This review highlights the findings of recent studies in the field of epigenetics in ADHD. METHODS: An electronic literature search using Medline. RESULTS: In the Gene × Environment interaction model, several clinical, genetic and molecular arguments support the epigenetic hypothesis in ADHD etiology. Environmental ADHD risk factors including toxic, nutritional factors and stressful life events lead to changes in DNA methylation and in histone modification levels. One critical CpG site located in the promoter of the DRD4 gene exhibited a specific pattern in ADHD children. A methylome wide exploration of DNA showed decreased methylation in vasoactive intestinal peptide receptor 2 gene, which was not replicated by further research. CONCLUSION: Current data require consolidation and could lead to the identification of biomarkers and the introduction of new modalities of treatment.

Homozygous 2p11.2 deletion supports the implication of ELMOD3 in hearing loss and reveals the potential association of CAPG with ASD/ID etiology.

Autism spectrum disorder (ASD) is a set of neurodevelopmental conditions characterized by early-onset difficulties in social communication and unusually restricted, repetitive behavior and interests. Parental consanguinity may lead to higher risk of ASD and to more severe clinical presentations in the offspring. Studies of ASD families with high inbreeding enable the identification of inherited variants of this disorder particularly those with an autosomal recessive pattern of inheritance. In our study, using copy number variants (CNV) analysis, we identified a rare homozygous deletion in 2p11.2 region that affects ELMOD3, CAPG, and SH2D6 genes in a boy with ASD, intellectual disability (ID), and hearing impairment (HI). This deletion may reveal a new contiguous deletion syndrome in which ELMOD3, known to be implicated in autosomal recessive deafness underlies the HI of the proband and CAPG, member of actin regulatory proteins involved in cytoskeletal dynamic, an important function for brain development and activity, underlies the ASD/ID phenotype. A possible contribution of SH2D6 gene, as a part of a chimeric gene, to the clinical presentation of the patient is discussed. Our result supports the implication of ELMOD3 in hearing loss and highlights the potential clinical relevance of 2p11.2 deletion in autism and/or intellectual disability.

[Tunisia: nursing practice of cognitive remediation in child psychiatry]. / Tunisie : pratique infirmière de la remédiation cognitive en pédopsychiatrie.

Cognitive remediation is today afforded a significant place in the treatment of neurodevelopmental disorders. A hospital team, comprising in particular a nurse offering consultations in a child psychiatry unit in a public hospital in Tunis, shares its experience with regard to this technique which aims to restore impaired cognitive functions in order to improve the efficiency and quality of life of young patients.

Atopic dermatitis and mother-child interaction: a comparative study of 48 dyads.

BACKGROUND: Psychological factors and family environment may play a role in the pathogenesis and the persistence of atopic dermatitis (AD). AIM: To evaluate the interactions between mothers and their children suffering from AD and to look for the presence of maternal depression and anxiety. METHODS: A sample of 24 children with AD and their mothers and 24 matched control dyads participated in the study. Maternal depression and anxiety were assessed using the Beck Depression Inventory-short form (BDI) and the Hamilton Anxiety Rating Scale (HAM-A). The mother-child interaction was evaluated by video recording, and through scores established after analyses of the video: M-score for the mother's attitude towards the child and C-score for the child's behavior. RESULTS: AD group mothers showed significantly higher scores on the HAM-A,but not on the BDI. The analysis of the video recording conveyed a significant difference in M-scores between the two groups but no difference in C-scores.. M-score was correlated with the mother's anxiety. CONCLUSION: Our study found evidence in favor of a disturbance of the mother- child interaction in the case of AD, noted on the mother's side, and more anxiety in AD group mothers than in the control group. Our findings suggest the need for psychological support for mothers of children suffering from AD.

Parental satisfaction of an assessment unit for autistic spectrum disorders.

Background - Based on the recognized principles of assessment of autistic disorders, the child and adolescent psychiatry department in Razi Hospital developed an assessment unit with diagnostic as well as therapeutic roles. The aim of this work was to examine its functioning and to analyze the parents' perceptions about the unit services. Methods - We gathered the parental satisfaction about the unit by the means of a hetero-questionnaire. Results - Fifty-two parents of children evaluated within the unit were included.  Patients had received the diagnosis of Autistic Disorder, Pervasive Developmental Disorders Not Otherwise Specified and Asperger Syndrome in accordance with DSM IV criteria, and than that of Autism Spectrum Disorder after DSM 5 publication. The overall satisfaction rate was 63%. Most parents (84.6%) rated the Psycho Educative Profile examination positively, 75% appreciated the neurological examination and the final report steps, 55.8% appreciated step of the Autism Diagnostic Interview revised and 42.3% the genetic exploration. 67% of the parents reported an improvement of their child following the evaluation. This improvement was attributed to the unit in 57.7% of cases. Parents whose children did not have associated disorders such as intellectual disability (p = 0.02), aggressive behavior (p = 0.04), affective disorder (p = 0.01) and sleep-related disorders (p = 0.03) were the most satisfied. Parents of children with epilepsy comorbidity were the least satisfied (p <10-3). 96% of parents suggested repeating the assessment once a year. Conclusion - Assessment units are based on international recommendations. However, it would be interesting to adapt assessments and orientation to the parents' expectations.

Catatonia in adolescents: series of 12 inpatients.

BACKGROUND: Catatonia is one of the most severe psychiatric syndromes that might be caused by many medical as well as psychiatric conditions. Catatonia in adolescents is rare and largely understudied. AIMS: This papers aims to examine cases of catatonia among adolescent psychiatric inpatients, and to scrutinize both the etiologies and the management options. METHODS: A retrospective descriptive study involving all cases of catatonia among adolescents admitted to the Department of Child and Adolescent Psychiatry in Razi Hospital - Manouba - Tunisia between January 2006 and December 2013. Catatonia was confirmed by Bush-Francis Catatonia Rating Scale. Medical records were examined for gender, age, clinical presentation, medical or psychiatric diagnosis as well as management. Psychiatric diagnoses were made according to the DSM-IV criteria. RESULTS: Our series consisted of 12 cases, aged between 12 and 16 with a sex ratio male/female of 0.5. Catatonia was due to a medical condition in three cases and to a psychiatric disorder in the other nine cases. Psychiatric diagnoses included: manic episode (n=3), major depressive episode (n=2), schizophrenia (n=2), pervasive developmental disorder (n=1) and conversion disorder (n=1). CONCLUSION: Catatonia is rare yet life-threatening. Careful and thorough examination is needed to determine the etiological disorder, on which depend both treatment and prognosis.

[The Tunisian Revolution in the eyes of children]. / La revolution tunisienne dans le regard des enfants.

BACKGROUND: The child uses drawing as a language. By reflecting faithfully all that is involved in the psychic life of the child, the drawing participates in the diagnosis and plays a role in the therapeutic management of young people suffering from psychological difficulties. AIM: To analyze the drawings of children and adolescents followed at the department of Child and Adolescent Psychiatry, further to the events of the Tunisian Revolution. METHOD: it is about a cross sectional study conducted among outpatients consulting the department of Child and Adolescent Psychiatry at Razi hospital in Manouba during the period from January 25 to February 28, 2011. These patients were divided into two groups with a specific instruction for each, to represent the events experienced by the patient and his family for the first group and to do a free drawing for the second. RESULTS: both groups consisted of 16 patients each with successively average age of 10, 5 and 10.33 years and sex ratio of 2.20 and 1.25. Patients in both groups were exposed to different stressors. The first group of children used in their drawings few colors, mostly black and red. The instruments of war such as bullets, guns, tanks and military helicopters were well represented. The characters were mostly male who were angry and looking for leakage. The drawings depicted scenes of war and conflict with people in distress or dead. The drawings of the second group were essentially about nature. CONCLUSION: We find that the instruction has significantly changed the behavior of children from the sheet. The instruction in this context seems to be a necessary to help these children overcome their concerns and express their pain.

Exploring the 7p22.1 chromosome as a candidate region for autism.

A high incidence of de novo chromosomal aberrations in a population of persons with autism suggests a causal relationship between certain chromosomal aberrations and the occurrence of autism. A previous study on a Tunisian boy carrying a t(7;16) translocation identified the 7p22.1 as a positional candidate region for autism on chromosome 7. The characterization of the chromosomal breakpoints helped us to identify new candidate regions on chromosome 16p11.2 which contain no known genes and the other one on 7p22.1 containing a portion of genes (NP 976327.1, RBAK, Q6NUR6 also called RNF216L and MMD2). We proposed Q6NUR6 (RNF216L) as a candidate gene for autism due to its vicinity to the translocation breakpoint on the chromosome derivative 7. Q6NUR6 is predicted to be an E3ubiquitin-ligase. Quantitative PCR demonstrates that Q6NUR6 gene has an ubiquitous expression and that it is strongly expressed in fetal and adult brain. The Q6NUR6 expression is increased in the patient blood cells in comparison to controls. This is the first report of Q6NUR6 gene (E3 ubiquitin ligase TRIAD3 EC 6.3.2) increasing blood levels in a patient with autism. It's probably caused by a position effect involving this gene and modifying its expression.

Association of a functional deficit of the BKCa channel, a synaptic regulator of neuronal excitability, with autism and mental retardation.

OBJECTIVE: Autism is a complex, largely genetic psychiatric disorder. In the majority of cases, the cause of autism is not known, but there is strong evidence for a genetic etiology. To identify candidate genes, the physical mapping of balanced chromosomal aberrations is a powerful strategy, since several genes have been characterized in numerous disorders. In this study, the authors analyzed a balanced reciprocal translocation arising de novo in a subject with autism and mental retardation. METHOD: The authors performed the physical mapping of the balanced 9q23/10q22 translocation by fluorescent in situ hybridization experiments using bacterial artificial chromosome clones covering the areas of interest. RESULTS: Findings revealed that the KCNMA1 gene, which encodes the alpha-subunit of the large conductance Ca(2+)-activated K(+) (BK(Ca)) channel, a synaptic regulator of neuronal excitability, is physically disrupted. Further molecular and functional analyses showed the haploinsufficiency of this gene as well as decreased activity of the coded BK(Ca )channel. This activity can be enhanced in vitro by addition of a BK(Ca )channel opener (BMS-204352). Further mutational analyses on 116 autistic subjects led to the identification of an amino acid substitution located in a highly conserved domain of the protein not found in comparison subjects. CONCLUSIONS: These results suggest a possible association between a functional defect of the BK(Ca) channel and autistic disorder and raise the hypothesis that deficits in synaptic transmission may contribute to the physiopathology of autism and mental deficiency.

[A clinic and a paraclinic study of Tunisian population of children with autism. About 63 cases]. / Etude clinique et paraclinique d'une population d'enfants autistes Tunisiens. A propos de 63 cas.

Autistic disorder is a pervasive developmental disorder which starts before the age of 3. The clinic features of autism are variable; the autonomy degree, the speech quality, the mental retardation associated and specially the existence of an organic disease change its clinic expression. A good knowledge of the basic signs is important to put diagnosis. This work, propose to describe a clinic and a Para clinic profile of Tunisian population of children with autism. The study included 63 children referred to the child psychiatry department between January 1998 and September 2003 and diagnosed with autistic disorder according to DSMIV and ADI-R criteria. The population profile studied is drawn as following : The sex ratio was of 3/1, the average age was of 8 years+/-3 years. Parents were related in 39.3% of cases. On the clinical plan, 51.2% of children with autism studied did not have expressive speech. They presented a mental retardation associated in 60.8% of cases. Epilepsy was presented in 21 children out of 63. This profile links literature study except in 2 points: - The rate of relatives with autism (8.6%) is superior to the rate found in literature(3%). This result can be explained by the high rate of consanguinity in the Tunisian studied population (39.3%). - Importance of associated organic pathologies (mental retardation).