Occupational identity crisis of professionals dealing with difficult adolescents.

This study tests the hypothesis of vulnerability in health and social care professionals dealing with difficult adolescents. This vulnerability appears to be underpinned by an occupational identity crisis that seems to diminish the ability of these professionals to recognize the suffering of these adolescents. A questionnaire was developed and then distributed during a network day bringing together members of various institutions and bodies working with difficult adolescents. Ninety-three professionals responded. Occupational identity weaknesses were identified: inadequate basic training, experiences of solitude, feelings of powerlessness and exposure, inadequate personal and institutional resources. Actors involved express their need for inter-institutional and inter-sectoral network but find it uneasy to implement. Some changes can be recommended to reduce this occupational identity crisis: increased efforts towards continuing training, development of possibilities of reflection within institutions, and more structured partnerships and actions.

[Does the islet of ability on visuospatial tasks in children with high-functioning autism really indicate a deficit in global processing?]. / Le pic d'habileté aux tâches visuospatiales chez les autistes de haut niveau désigne-t-il vraiment un déficit du traitement global ?

OBJECTIVE: The literature on autism reports regularly the presence of a peak of ability on the visuospatial tasks. The classic interpretation of this result refers to the theoretical model proposed by Frith (1989) who evokes a "lack of central coherence" in persons with autism that is a deficit in the mobilization of global processing. The research reported here has for objective to propose a reflection on the relevance of this model by asking the following question: is global processing impaired in autism or simply not mobilized for the benefit of the almost exclusive appeal to local treatment? METHODS: A group of children with high-functioning autism was compared with normally developping children (n=15 per group), matched on age and global level of intelligence. The clinical group, 14 boys and a girl, had received a diagnosis of typical autism according to the criteria of the ICD-10 (F84.0) confirmed by ADI-R. These children all used a functional language at the time of inclusion within the study, however all of them initially presented a delay in language (mean age: 8 years and 6 months; mean total IQ: 98.07). The typically developping group, 12 boys and three girls, were from ordinary school (mean age: 9 years, mean total IQ: 106.2). Two tasks were employed for the collection of data: the Wechsler Intelligence Scale for Children-Third Edition (WISC-III) was used to estimate the total-, verbal- and performance-IQ scores of every child and to match both groups. It also permitted the evaluation and comparison of the performances of the children on the following visuospatial tasks: "picture completion", "object assembly" and "block design". The NEPSY scale permitted the estimation and comparison of the levels of performance of both groups on visuospatial functions. RESULTS: In terms of scores, the tasks of the WISC-III, requiring visiospatial processing as well as the global evaluation of the visiospatial functions with the NEPSY, showed the absence of significant differences between children with high-functioning autism and typical children of the same age. However, differences of strategies appeared both between the groups and, in children with autism, according to the tasks to resolve. The comparison of subtests, "arrows" and "picture completion" on one hand, and "object assembly" and "block design" on the other, showed that children with autism are capable of mobilizing correct configural processing in the first ones but not in the second. The only factor which differentiates these tasks is the appeal or not to a motor coordination. It is possible that the lack of motor ease, often described in this type of children, sometimes leads them towards strategies of low level, i.e., to local adjustments, unlike the typical children who mobilize a strategy supported on a global representation of the purpose to be reached. CONCLUSION: If our results confirm the capacities of children with autism to resolve the tasks requiring a visiospatial processing, the strategies which they mobilize do not support the existence of a weakness of the central coherence. We suggest, in persons with autism, the idea of a priority granted to the local information treatment in the absence of a deficit of global or configural processing.

[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.

[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.

[Not Available]. / La méthode structurale de Arne Björk et Vibeke Skieller.

Traditionally, the orthodontists evaluate the modifications made by the general growth of the face by superimposing "as well as possible" (best fit) the serial head-films of beginning and end of treatment on easily locatable anatomical points of the cranial base. Many authors showed that this evaluation method of the development of the facial skeleton is vague and thus generator of considerable errors of appreciation. The process of superimposition of profile head-films on stable structures of the former base of cranium rests primarily on the observation made by De Coster in 1952 on "the immutability of the basi-cranial line", confirmed histologically by Melsen in 1971. In 1972, the longitudinal studies undertaken by Björk and Skieller using metal implants on more than 200 cases highlighted the stability of certain anatomical structures within the maxilla and the mandible. The "Structural Method" of general and local superimpositions, thus developed starting from these discoveries, brought a new vision of the different facial growth patterns and allowed a greater comprehension of the effectiveness of the orthodontic techniques.

[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.

Power of expression in the electronic patient record: structured data or narrative text?

This paper presents the authors' experience with the development and use of a document-centered electronic patient record (EPR) in a large teaching hospital. The development of the document-centered EPR began with the formulation of a set of critical hypotheses to facilitate both the continuation of the best medical practice and the implementation and use of the EPR. An alternate and more conventional approach - the data-centered EPR - is compared with the document-centered EPR. Various benefits and pitfalls are discussed. Finally, the choice was to offer both solutions in a tightly linked system. The need for an EPR which combines the document and data centered approaches is a reflection of the more general discussion of what the medical record will be in the future. All too often, the need for structured data conflicts with the need for free texts and the power of expression. It is not easy to evaluate the consequences of this initial decision. However, changing the foundations of the EPR after its implementation is difficult and expensive. Therefore, the selection of the correct orientation in a given hospital requires a broad-based discussion.

[Recurrence]. / La récidive.

Relapse is a multi-factorial phenomenon to which, in the absence of universally accepted finishing criteria, each practitioner tries to oppose through some references which he is closely following to. The author lists his personal references.