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Background Hospitalization is rare in anorexia nervosa (AN) and local application of indications is heterogeneous. However, no study has evaluated the effect of these different treatment modalities on the mean length of stay. Our objective was to describe the context and modalities of a wide range of hospital care programs offered to patients with anorexia nervosa in eleven specialized French psychiatric centers for patients from childhood to adulthood. This work was carried out within the framework of the EVHAN (Evaluation of Hospitalization for AN, Eudract number: 2007-A01110-53, registered in Clinical trials) research program. The EVHAN program comprises five main lines: weight objectives at discharge, the practice or not of a separation period, the use of clear nutritional dietary objectives (cognitive/behavioral), the intensity of family involvement in treatment, and the existence or absence of a stabilization phase before ending inpatient treatment. These main lines will make it possible to study the impact of treatment modalities on the future of patients in the short and medium term (at discharge and at 1-year follow-up). Methods The eleven centers are located in France (Bordeaux, Nantes, Paris and Ile-de-France, Rouen and Saint-Etienne). Various staff members (psychiatrists, somatic doctors, nurses, dieticians, psychologists) from each center were interviewed using a semi-structured questionnaire. Data on operating modalities and context of care were collected and analyzed. Results Four of the eleven centers were exclusively child/adolescent centers, and seven of 11 were adolescent (from 11, 13 or 16 years) and young adult centers. All centers offered a graduated approach from outpatient to full hospitalization. The majority had a number of beds allocated for patients with eating disorders. The criteria for hospitalization were homogeneous with respect to somatic and/or psychic severity prefiguring the consensus criteria defined by the French Health Authority (HAS) in 2010. Child/adolescent units used the weight curve to set weight objectives at discharge (between the 10th and 50th percentiles). Most adult units used weight objectives at discharge corresponding to a body mass index between 17 and 20kg/m2. Nine centers used a written or oral care contract. One unit did not separate the patient from her/his usual environment, the others had a practice gradient of partial separation and total separation times. These were either short, lasting a maximum of 3 weeks, or long, lasting more than 3 weeks. Conversely, patients were not isolated within the unit, and benefited from a rich social life, depending on her/his physical condition. The patient's family was in contact with the team and fully supported. The longest periods of separation involved adolescents and adults. Nutritional support varied from a group approach (meals in the dining room, standardized meals of the care center) to very individualized approaches within a specific framework. All the units reported meeting with families at least once during the hospitalization; with the patient's parents for child/adolescent patients and/or unmarried patients and with the husband/wife for married patients. The majority of the centers requested a phase of weight stabilization, whatever the age before hospital discharge. Conclusion There is international and national consensus regarding the indications for hospitalization, and the main lines of multidisciplinary care to be developed within this framework. However, local application of these indications was heterogeneous resulting in diverse modalities of hospital care for anorexia nervosa in France. Specialized teams have developed management strategies arising from their "team culture". The complexity of the anorexic pathology, due to the psyche-soma intrication and the diversity of age groups, highlights the complexity of care available. The impact of this diversity of hospital care on patient outcomes will be studied as a result of this work.

Resume La grande heterogeneite symptomatique observee dans le trouble obsessionnel compulsif (TOC) explique tres probablement les resultats divergents des differentes etudes menees au plan cognitif chez ces patients. Etant donne l’importance de l’âge de debut des troubles dans les maladies complexes et heterogenes comme le TOC, l’objectif de notre l’etude a ete d’evaluer les performances cognitives de 30 patients atteints de TOC ayant soit un debut precoce, soit un debut plus tardif des troubles, a l’aide de tests appartenant au domaine des fonctions executives. Les patients atteints de TOC ont ete repartis selon leur âge de debut des troubles, 15 patients ayant un âge de debut du trouble prepubertaire 12 ans. Leurs performances cognitives sont comparees a celles d’un groupe de 22 temoins, avec un appariement moyen sur l’âge, le sexe et le niveau d’etude. Cinq tests appartenant au domaine des fonctions executives ont ete proposes : la Tour de Londres, le Trail Making Test, une fluence verbale, une fluence picturale et une fluence d’association. Les 30 patients atteints de TOC obtiennent des scores significativement inferieurs a ceux des temoins aux tests de la Tour de Londres et a la fluence d’association (p

Resume Le spectre des conduites a risques est tres etendu puisqu’il implique la prise de toxiques, les sports dit a sensations, le non port de preservatif, la conduite dangereuse en vehicule motorise eApres avoir defini le risque et la prise de risque, nous analyserons d’un point de vue developpemental les fonctions que peuvent prendre toutes ces conduites chez l’adolescent. Cependant, bien que la prise de risque puisse prendre pour le jeune une fonction personnalisante, les consequences en terme d’accidentologie sont preoccupantes. Nous prendrons pour illustrer ce constat, les conduites dangereuses et accidentelles en vehicules motorises. Nous analyserons les principaux facteurs de vulnerabilite specifiques et non-specifiques des jeunes preneurs de risques en automobile. Parmi ceux-ci, le besoin de stimulation caracterise par la dimension de personnalite recherche de sensations semble jouer un role preponderant. Dans la discussion, nous aborderons tant d’un point de vue preventif qu’heuristique la prise de risque en tant qu’induisant de forts eprouves mais aussi dans ses rapports avec l’accidentel et la dependance.

ResumenEl progreso en la identificación de los factores de vulnerabilidad genética en el autismo requiere la identificación correcta del fenotipo o fenotipos heredados. Esto se puede lograr no sólo por la descripción precisa del sujeto afectado, sino también por la identificación de los rasgos de vulnerabilidad en familiares no afectados de los probandos autistas. Esta revisión se centrará en esta última estrategia y principalmente en los rasgos clínicos, bioquímicos y cognitivos.

ResumenSe han formulado muchas hipótesis para explicar la elevada tasa de consumo de benzodiacepinas en Francia, incluida una tendencia cultural, familiar o de ambas clases para utilizar ciertos tipos de fármacos psicotropos. Este estudio exploró la asociación entre el uso de medicación de los padres y sus hijos. Se examinó a 221 pacientes jóvenes (158 chicos y 63 chicas) de 6 a 16 años de edad (media = 9,7 años) que acudieron a un departamento de psiquiatría del niño y el adolescente en cuanto al uso de fármacos psicotropos utilizando una entrevista estructurada. Se preguntó a los padres por su propio consumo, así como por el de sus hijos. Las tasas de consumo vital (al menos una vez) fueron 22,2% en los chicos y 20,6% en las chicas, y 19,6% en los menores de 11 años de edad. Se encontraron tasas más altas en los pacientes con trastornos emocionales (trastornos de ansiedad y depresión). En los progenitores, el 45,1% de las madres y el 24,1% de los padres comunicaron la utilización de medicinas al menos una vez. Se encontró una asociación significativa entre el uso de medicación de los hijos y los padres: el 34,1% de los niños tenía consumo positivo cuando sus madres habían utilizado también medicinas al menos una vez, frente a sólo el 13,6% en los otros niños (relación de ventaja = 3,31 [1,68-6,50]; P = 0,001). La asociación más significativa se encontró entre el uso de medicación por las niñas y sus madres (relación de ventaja =12,1 [2,38-61,5]: P = 0,003). Estos datos indican la existencia de un patrón familiar de consumo de fármacos psicotropos, especialmente en las mujeres.

fr Evoquer l'existence d'un deficit attentionnel chez l'enfant a l'heure actuelle implique de rechercher une manifestation comportementale qui lui est frequemment associee: l'hyperactivite. De fait, c'est cet aspect comportemental d'hyperactivite qui a ete initialement decrit, des 1845, dans les travaux de langues francaise, anglaise ou allemande, sous diverses appellations: instabilite psychomotrice, hyperkinesie, hyperactivite ou dysfonctionnement cerebral a minima («minimal brain dysfunction). Dans le DSM-II, de 1968 (4), le versant comportemental du trouble est seul pris en compte et decrit sous le terme de «reaction hyperkinetique de l'enfant. C'est dans le DSM-III, de 1980, que le trouble attentionnel devient le symptome majeur et trois categories diagnostiques sont retenues: u - trouble deficitaire de l'attention avec hyperactivite - trouble deficitaire de l'attention sans hyperactivite - trouble deficitaire de l'attention, type residuel.

In obsessive-compulsive disorder (OCD), clinical, neurobiological and genetic differences have been reported according to age at onset (AAO). Given the importance of identifying homogeneous subtypes in complex hete-rogeneous disorders such as OCD, it would be particularly useful to identify a specific cognitive profile associated with early-onset OCD. Although impaired cognition has repea-tedly been demonstrated in OCD patients, discrepancies between studies have hampered the identification of a precise cognitive dysfunction. Executive dysfunction has often been reported, but findings have not always been replicated. The aim of this study was to assess executive functions in 30 patients according to their AAO. The sample consisted of 15 early-onset and 15 late-onset OCD patients and 22 normal controls, matched for age, sex and socio-economic status. Various aspects of executive function were assessed with five neuropsychological tests: Tower of London, Trail Making Test, Verbal Fluency, Design Fluency and Association Fluen-cy. The 30 OCD patients obtained lower total scores than the controls in the Tower of London test and association fluen-cy task (p0.05 and p0.001, respectively). Impairments were more marked for the early-onset group, with no effect of gender or age at interview. Deficits in specific aspects of frontal lobe function were found in the OCD group and were particularly pronounced within the early-onset group. These findings confirm clinical data suggesting that OCD patients can be subtyped according to age at onset and that OCD patients present unusual cognitive characteristics. They also support the hypothesis that early-onset OCD might be a rele-vant subgroup characterised both by a particular clinical profile and by specific cognitive characteristics.

Evaluate the correlation between psychopathological disorders in type 1 insulin-dependent diabetic (IDD) children and adolescents and the occurrence of micro-angiopathic complications.Two hundred and five IDD children (104 girls and 101 boys with a mean age of 13.4 +/- 3.5 years on inclusion) were longitudinally monitored between 1994 and 2000. Somatic complications were systematically searched for during a yearly control visit to the day hospital. Psychiatric disorders had been assessed initially by self-administered questionnaires filled-in by the children (Spielberger's STAIC-Trait for anxiety, CESD for depression and Child-EAT for eating habits), by the parents (CBCL, CPRS or GHQ-28) or the principle teachers (CTRS) and diagnostic screening of psychopathological disorders every year.More than 140% of the IDD children (n = 86) were diagnosed DSM-IV, with predominant anxiety (n = 41), during the longitudinal evaluation. Positive screening was significantly associated with higher psychopathological scores before inclusion in the study, with children considered more perturbed by the parents, teachers and the children themselves and mothers who considered themselves more perturbed (GHQ-28 mean 5.6 +/- 7.5 vs. 3.5 +/- 4.8; t = 2.211 p = 0.028). These children were less compliant. Disorders were associated with metabolic imbalance, measured by HbA1c, overweight and an excess of micro-angiopathic, particularly retinopathic, complications.Our results show the frequency of mental disorders in IDD children, the importance of the parents' psychopathology and its association with increased somatic risk. The nature of this relationship requires clarification and the incidence of prevention measures targeted on the psychological problems. The interest of associating a paedopsychiatric element in the therapeutic management of these patients and their families is emphasized.

The purpose of this study was to evaluate the type and frequency of psychopathological disorders observed in obese children and adolescents. We also looked for a correlation between psychic disorders in the obese children, the degree of obesity and paternal psychopathology.The study group included 84 obese children and adolescents aged 5 to 16 years (mean age 10.9 +/- 2.8 years). There were 55 girls and 29 boys. The z-score expressing deviation from the ideal body mass index (IMC) varied from +2 to +10.6 (mean 4 + 1.9). Psychopathological disorders observed in these obese patients were compared in children and adolescents with insulin-dependent diabetes mellitus. The standard diagnostic interview (K-SADS PL) and self-administered questionnaires (Sielberger STAIC-Trait for anxiety and CDI for depression in children or CBCL or GHQ for their parents) were also used to evaluate psychic disorders.More than half of the obese children (47 out of 84) had a DSM-IV diagnosis, often involving anxiety (n = 28). The rate of internalized and externalized psychopathological disorders (measured by STAIC-Trait and CBCL) was higher in the obese children than in the diabetics. The children's psychopathological disorders were more marked if their parents were perturbed, particularly when their mother had an internalized disorder. No correlation was found between the degree obesity and psychopathological disorders in the obese children and adolescents.Our findings show the frequency of mental disorders in obese children and point out the importance of parental psychopathology. This underlines the usefulness of a pedopsychiatric approach implicating the entire family for therapeutic management of these patients.

Classical therapeutic recommendations requires that girls with anorexia nervosa be separated from their parents. Refeeding, and later individual psychodynamic approaches were also emphasized. These guidelines are now broadened towards psychotherapeutic approaches (psychodynamic, familial, cognitive-behavioral) associated with psychoeducational and dietetic strategies. In the Child and Adolescent Psychopathology Unit of Robert-Debre Hospital in Paris, individual therapeutic programs are applied to young anorectic girls and their families. These programs are implemented within an inpatient (full-time, part-time) or outpatient (consultations, weekly day-therapeutic program) framework. In order to forge a therapeutic alliance with parents and restore "parental competences" feelings, we do not separate any longer anorectic girls from their parents during hospitalization, and we have developed an alternative therapeutic model to full-time hospitalization.

Association between insulin-dependent diabetes mellitus (IDDM) and eating disorders (anorexia nervosa, bulimia nervosa) was recently described. We have reviewed the systematic studies that were conducted on this topic, particularly for prevalence of anorexia nervosa and bulimia nervosa and their relations with metabolic control (HBA1C) and somatic complications of insulin-dependent diabetes mellitus. We have discussed methodological problems of these studies and etiopathogenic aspects of eating disorders in this somatic disease.

The existence of depression in young individuals has often been denied or at least underestimated particularly during adolescence, to the benefit of such other concepts as morosity, inherent in this period of life, and from which depression should be differentiated. Recent epidemiological investigations in the general population have revealed an approximate 2% and 10% prevalence of depression in the child and the adolescent, respectively. This considerable increase in morbidity is associated with a modification of the sex ratio: more boys are affected before puberty, more girls after puberty. In the present work we shall first deal with the semiology and comorbidity of depression as related with the developmental changes occurring in the child and the adolescent. Thus, several studies have shown that the DSM III criteria for affective disorders are consistently applicable to pre-puberty children and adolescents as well. However, depression in the pre-puberty children may be more ostentatious, manifesting itself by psychomotor agitation, somatic complaints and anxiety comorbidity of the type: Separation Anxiety Disorder and phobias. Depressed adolescents may exhibit more anhedonia, more depressive cognition, hypersomnia, weight variations, more alcohol or drug abuse and suicide attempts, and, in one third of them, greater coexistence of anxiety disorders or behavioural disorders. The course of depression at this age is now known, owing to catamnestic studies that proved methodologically satisfactory (we personally managed the follow-up of 75 depressed adolescents over an average 45 months). Depression in the child and the adolescent is not a benign affection, it is a long-lived, recurrent and disabling illness.(ABSTRACT TRUNCATED AT 250 WORDS)

The separation anxiety disorder is defined as an excessive anxiety when the child is separated from significant persons. It needs however to be distinguished from normal development separation anxiety because of the later age at onset, its persistence and general impact. We shall discuss the clinical aspects of this disorders, its complications and the issues raised by its outcome. The interesting characteristics of separation anxiety disorder are its frequency and different treatments available.

The discovery of neuroleptics has certainly not had the same impact in child psychiatry as it has had in adult psychiatry. Yet, these substances are widely used with children. Prescription is generally based on a few simple rules: treatment is started with low doses which are progressively increased, so as to reach an optimal posology which establishes a balance between clinical efficiency and side effects; plasmatic levels may be monitored on a regular basis. The emergence of adverse effects continues to remain the essential preoccupation of the clinical practitioner; it is the reason why so many treatment plans are discontinued (on a short term basis, acute dyskinesia, sedation, hypotension, weight gain; on a long-term basis, passiveness, tardive dyskinesia, but this is seldom observed in children). As a result, one must be careful in prescribing neuroleptics to youngsters and consider other drugs whenever possible. Following a brief review of the kinetic specificities of neuroleptics in children, we describe the general modalities of prescription for this age group and give some personal results as illustrative examples. We then discuss the issue of tolerance and side effects.

The purpose of this article is to summarize those main indications where neuroleptics have been proven efficient in children. In some types of pathology (hyperactivity, conduct disorders, mental retardation with agressiveness...), their impact is purely symptomatic, generally sedative. In other cases (Tourette's syndrome, stuttering) they seem to have a more specific effect. Whichever may be the case, neuroleptics seem to be irremplaceable, whenever the symptoms become incapacitating such as when they hinder the person's social functioning and learning abilities. On a practical level, one has to avoid "poorly justified" prescriptions, including low-dose prescriptions. In children and adolescents, therapy cannot be considered for one angle only: the administration of neuroleptics has to be integrated into a general treatment plan which involves other therapeutic approaches which are not mutually exclusive.