Psychotic and Autistic Children

Enfants psychotiques et autistes

Psychotic and Autistic ChildrenHistory:

In the 1950s, early childhood psychoses were slowly emerging from the catch-all of mental retardation, a specific subject for child psychiatrists and psychoanalysts. A separation then took place between the domain of the “simple” intellectual deficit, abandoned to the medico-educational (and above all educational) institutions of maladjusted childhood, as well as to the specialized classes of the National Education, Prepsychoses or dysharmonies of evolution claimed by psychiatric institutions. The time was at a critical juncture in the approaches to educational learning, in the approach of psychotic children, and in a faith in the virtues of the psychoanalytic cure alone capable of mobilizing the rigid defenses built up by the ” Child against archaic anguish. These oppositions of deficiency-psychosis, psychotherapy-education, however, must be qualified. Very early on, Mises had shown that the mentally deficient child could be approached dynamically and that it was possible to harmonize educational approach and psychotherapeutic approach. From Lebovici’s creation of the first day-care hospital for children, under the auspices of the Rothschild Foundation, teachers from the Ministry of Education had come to work with the healthcare teams. Several conceptions of the institution then developed, both in adult psychiatry and in child psychiatry. Three main currents can be seen schematically:

– that of the “founding fathers” (Tosquelles, Bonnafé, Daumezon) who, at the beginning of institutional psychotherapy, sought above all to neutralize the destructive effects of the asylum and to reintroduce duration into an entropic space fixed by chronicity. In this revitalized space, some envisaged undertaking psychoanalytic cures stricto sensu, where others had more confidence in the relational network, the so-called Anglo-Saxon “therapeutic community”, made up of caregivers and cared for and who Was supposed to function as a place for mutual social learning, based on transparency and democracy. The educational experiences of Neill in Britain, those of Fernand Oury in France are part of this context;

– the current illustrated by Racamier who considered the institution in its functions of reception and support of the ego and which distinguished the form of the specific treatments of the general caregiver on which these treatments develop;

– the current, finally, of institutional psychotherapy properly so called, which together with Jean Oury and Guattari, held the institution for a great psychoanalytical divan on which developed a generalized transfer and counter-transfer called institutional.

We will see (cf infra) that these three currents contributed to the current conception of institutional treatment. We may be surprised by the highly hexagonal character of these contributions. While French child psychiatry was once the inspiration of Leo Kanner’s descriptions and the practices and theories of Margaret Mahler, Bruno Bettelheim, Winnicott, Bion, Frances Tustin or Donald Meltzer, we must note the gulf that has developed in recent years between her and Anglo-Saxon child psychiatry. Focusing almost exclusively on etiological, nosological or epidemiological research, contemporary English or American authors are now far removed from the institutional practices that form the core of our technical and theoretical concerns.

Definition:

The institutional approach is now based on a more precise definition of the term. In the area of ​​childhood, it is often meant in the sense of settlement, more particularly a residential establishment, to designate an architectural and human set, defined by walls, by a certain number of people ( Of the “head of institution”, of which Littré speaks, to agents of various qualities) organized by a hierarchy which regulates their exchanges and by a timetable. The institution is then only a framework, more or less amorphous, where a cure can develop but which is most often supposed to be an obstacle to therapeutic processes. It is with this reference that a practice known as “deinstitutionalization” of the mentally ill has spread, especially in the United States. It essentially consists of closing down psychiatric hospitals and replacing them with places of reception, as little as possible medical care, feeder places, sheltered apartments, and so on.

But the institution also designates the instituted thing, that is to say, a certain codification of social relations in the service of a function: hospitals and schools are, as Littre tells us, “useful institutions”. More generally, this codification, invented and established by men, makes it possible to oppose to the state of nature what belongs to culture. Thus the institution of marriage is a human attempt to regulate and socialize sexuality. We have

In this sense, to consider the excess of the code as a factor of sterilization of creativity and to describe the institution as a principle of the group’s death.

Finally, and this is the first meaning given by the Littre, the institution refers to the action by which we institute, establish, and in a derivative and now unusual sense, by which we instruct, from whence The word “teacher”.

It is in this dual sense of instituted and instituting that we will study the institutional approach of psychotic children.

Recent developments in institutional frameworks:

In a well-documented general review, Bourcier characterized the 1980s by the multiplication of institutional actions part-time and by a growing disaffection for residential institutions. He noticed a virtual disappearance of the publications in which the boarding school was mentioned. While part-time institutions have continued to develop and diversify, there is now a renewed interest in renewed boarding arrangements and in the specific therapeutic processes involved.

Internat:

Although the numerical size of the boarding school has decreased from the time when it was the almost necessary response to psychosis, it continues to exist and is still an indication in cases where behavioral disorders of the child And the bankruptcy of the family, natural or substitute, require the setting up, for a longer or shorter period, of a container capable of resisting all the destruction companies. His misdeeds are known:

– disconnection from the social environment of origin;

– immersion in an anonymous space marked by the interchangeability of caregivers, maintained by the system, difficult to avoid, teams, holidays, weekly rest;

– the continual encroachment of the collective on the intimacy of the individual;

– institutional totalitarianism;

– confusion and lack of differentiation of time, place and people, etc.

C and P Geissmann have devoted several works to the criticism of this “asylum” process. They show the harmful role of the instability of the reference staff, the insecure nature of the nights when the child does not know in advance who will be there in the evening, the perpetuation of the rejection of the child by the family, Institution, which accommodates the heaviest cases, functioning then as a place of discharge, a materialization complicit of the pathological representation of the “breast-bin”, according to the expression of Meltzer. From an economic point of view, they insist on the call function of the bed, as a vacuum to fill, resulting in a self-engenderment of hospitalization.

To others, these criticisms appear exaggerated. Most of the negative aspects of the institution can be corrected by an energetic practice of disalienation, of which Mises had given the example of the Vallée Foundation as early as the 1950s. ForMy Horassius, he enters into these excessive condemnations of the ideological elements infiltrated by collective guilt. Referring to dynamic practices, such as the well-known practice in Bettelheim, they stress the importance in some cases of separation from the family environment and the positive aspects of hospitalization which they Should not be reserved for the most severe cases, which has the effect of maintaining the negative image of the hospital. This specific work of separation, which allows the child and his family to escape from the fusional elements underlying pathological projective identifications, has been particularly studied in recent years, especially in sequential residential institutions. It contributes to the consideration of the child as a subject by his family. The sequential hospitalization then functions like a real psychodramatic actuation which allows to speak the separations and the reunion after having lived them. This separation function, theorized on the model of the work of mourning, represents even for some authors the main institutional work, especially in adolescents. The boarding school can function as an excitation barrier, sheltering the child from excessive social stimulation and a separation between the therapeutic environment and the family environment. Using the privileged moments of meals or bedtime, the residential institution promotes the revival of a process of development through infra- or non-linguistic communication actions that allow the building of a transitional space. This plea for the favorable effects of hospital culture, which is reminiscent of the doctrine of the isolation of Pinel and Esquirol, is accompanied by a certain skepticism about the ability of natural or substitute families to resist The destructuring that entails cohabitation with psychosis. While some authors admit the need to go beyond the classical hospital setting to the benefit of a complex where full-time hospitality articulates educational and occupational locations differentiated from the place of life, they worry about the “satellisation” The fragmentation of the institution into localities and activities that are too heterogeneous and too remote from one another.

Is not one way of overcoming the quarrel between supporters and critics of hospitalization with the question of indications? For Marcelli et al, from a general hospital experience, it may be worthwhile to offer hospitalization to children during periods of massive regression requiring global restraint. It is preferable that this restraint, the deconditioning and the restructuring which accompany it, is ensured by other interlocutors than the usual therapist who will later find the child, for long-term care. This conception of the hospital as a crisis center and of the distinction between a team temporarily devoted to responding to emergencies and shortcomings in the family and social environment and the team responsible for long-term care, shared. It is opposed to the industry’s traditional view that the same team provided all residential and non-residential care. It should be noted that the therapeutic family placement and the associated formula of crisis centers, successfully inaugurated by pioneering teams, such as those of C and P Geissmann in Bordeaux and Lainé in the Essonne, make it possible in many cases to limit considerably , Or even reduce the use of hospitalization.

Day hospital:

Associated or not with these formulas and initially presented as an alternative to full-time hospitalization, it is now the reference institution for most children with severe personality and developmental disabilities. Its interest is no longer to be demonstrated. It is a place of reception and symbolization, a unifying container that facilitates the child’s investment in his body and inaugurates, through learning and care experiences, a process of internalization and articulation Of internal objects. Ferrari et al insist on the link between the educational dimension and the therapeutic dimension as well as on the work of narcissistic restoration of the parents who, identifying with the team, find their child a capacity for anticipatory illusion. For Lachal et al, the interest of the day hospital is mainly in discontinuity. The child learns to separate himself in order to learn to find oneself and to experiment concretely, through different moments that arouse and maintain his interest, to oppose the inside and the outside. These turns and returns constitute, according to the expression of Vaneck “an irreplaceable game with several reels”.

Thus two orientations are drawn which are not, however, exclusive of each other:

– an emphasis on continuity of care;

– another on the dynamizing function of situations of rupture and lack.

For PGeissmann, this double polarity is embodied in the opposition between the team of caregivers who ensures the permanence of the “holding” and the intervention of the psychoanalyst who introduces provocation to change and appears, with his interpretations, as a source of Discrete information that comes to be framed in the calming, continuous and exciting noise of institutional life. For these authors, the day hospital thus constitutes a neutral environment, a pole of security, an “external framework”, which also allows the development of the analytical or psychotherapeutic cure three to five times a week. Despinoy shares this conception of the day hospital as a “supportive” environment that supports intensive psychotherapy, without neglecting the therapeutic effects and the adapted pedagogy that the institutional environment provides. Defined as “a group of groups” (class group, group of activities using various mediations, group of speakers in institutional meetings), the day hospital nevertheless leaves room for individual care-nurse relationships. Increasingly, there is a need for a caregiver, designated for each child, as a reference person, accompanying his client in the different places and moments of institutional life and ensuring reception, departure and all transition times . After the quasi-incantatory invocation of the “team”, during the years 1960-1970, as an univocal therapeutic agent, there is a growing personalization of the care, and the development, inside the day hospitals, of genuine Individual therapies carried out, with their own techniques, by nurses or educators.

Today is the time for evaluation. In the absence of highly reliable means of measurement, descriptive approaches are required in this area.

The survey of the XIII th arrondissement in Paris concerns a cohort of 283 children followed for more than 20 years. It shows the numerical importance of psychotics, which account for half of the total admissions (78% of boys) and three-quarters of admissions in recent years. Three-quarters of the leavers are recycled in the national education system but remain in the specialized course of the improvement classes.

In Geneva, Manzano tries to distinguish, among the children listed initially as psychotic, several profiles. Children with narcissistic personality quickly invest the relationship with others. We note in them an appearance of ambivalence, a development of the fantasmatic life supported by signifying persons. Children with schizoid personality, after a period of disorganization, do not attach themselves preferentially to a person but use inanimate objects as their first identifying medium. Children with a loss-making organization are not interested in inanimate objects, nor in people, and do not constitute differentiated relationships. Despite the indisputable achievements of the invention of the day hospital, these generally positive results

Nevertheless to questions. Would the day hospital be outdated or would it be appropriate today to limit and clarify the indications of an institution that has become universal and whose specificity in relation to medico-educational institutions is not always obvious? The multiplication of other forms of part-time institutions explains these questions.

Institutional actions on a part-time basis:

In 1982, René Diatkine and Claude Avram presented their first achievements as part of the evening unit of the 13tharrondissement. The child was welcomed at the end of the school by a group of therapists who presented him with different ways of meeting. The child moved freely from one therapist to another, from one workshop to another, according to the variations of his psychic tensions. The work of the team, apart from the presence of the children, restored, with the thread of its existence in the institution, a narrative continuity that gave meaning to its comings and goings, breaks, repetitions, A spatiotemporal organization created every evening between adults and children. This story was continuously tied to the context of the child through close ties with families and with the school. Eight years later, the authors sought to evaluate not only the results but also what remained as a memory in the children of this experiment. They mainly consider the preventive role of this institutional care which has helped, in their opinion, the children to discover and to prolong their pleasure of mental functioning. Since then, part-time therapeutic reception centers (CATTPs) have multiplied. The aim of these new therapeutic modalities is to fill the vacuum existing between the consultation center and the day hospital and to work more specifically on the continuity-discontinuity dialectic as well as the articulation of the place of care with the others Interlocutors of the child: school, family. The prolonged practice of day hospitals has, in fact, led the psychiatric teams working in the community to question the risks of reproduction of the segregation and the chronicity of the residential institution. In some cases, the part-time therapeutic action is purely and simply a substitute for the day hospital, which saves money. The precariousness of the setting, the discontinuity of care, the importance given to everything that is on the edge of the therapeutic space (neighborhood, school, parents, external psychotherapist), all work on lack, absence, In order to initiate the processes of symbolization. Elsewhere, the part-time institution prepares for day hospitalization and represents an intermediate time of de-dramatization and elaboration of demand or a particular modular modality of day hospitalization. Many authors insist on the interest of a joint schooling, outside the walls of the therapeutic institution, and on a school integration.

For some, CATTP is more appropriate in borderline organizations. It is then an “evening unit” or a “therapeutic study” working in collaboration with the school where the child pursues normal schooling. For others, CATTP welcomes autistic or psychotic children daily for individual and group care. Children are also enrolled in specialized classes in mainstream schools. They are also accompanied by caregivers in different cultural or social settings. Intensive work with families allows them to stay at home. The circulation between these different sites, clearly differentiated but closely articulated, facilitates the formation of a history thanks to the attention paid by all institutional agents to the moments of passage, to the transfer of information and to a work of art, Joint development.

Among the discontinuous actions, we must mention the hospitalization at home, which makes it possible, through the sending of “institutional emissaries” to the children’s home, to physically incarnate the links and the articulations between the nursing home and the family space . In some cases, it is the origin of a work of observation of the interactions and brings to some mothers in great psychological difficulty a support and possibilities of identifying models. Houzel, inspired by the technique of psychoanalytic observation of the baby developed by Esther Bick, particularly developed this work in infant psychiatry. A nurse comes home to observe in a neutral but still empathic way, the interactions between the mother and her baby. She then reports on her observations in a weekly group supervised by a psychoanalyst.

This framework has not only a scientific interest and a training value for the staff, it is proving mobilizing maternal attitudes. In Villeurbanne, André Carel and his collaborators developed a similar work.

These various practices lead to the fragmented institution advocated by Mannoni. It articulates, in a care system, different places, each having its own specificity. The sector policy provides an administrative framework that is particularly well adapted to this “multi-institutional” or “plurifocal” system by which “the institution ceases to be a closed citadel”.

The multiplication of “discontinuities and gaps” and the organization of a community network protect then against institutional stagnation.

This system, in which the history of the patient and his family is interwoven with institutional history, realizes, according to Constant, a metaphor of the fragmented body of the psychotic child that the connections between the constituents of the network contribute to reconstructing. Between the institution (or the pieces of institutions articulated to each other) and the outside world a protective surface is formed, a skin which is at the same time a member of capacity, capable of a certain seal and a zone of Exchanges accepting inputs and outputs.

Institution and psychoanalysis:

In France, the whole institutional psychiatric movement has been, if not totally, totally inspired and fertilized by psychoanalysis and continues to remain faithful to this inspiration.

Many authors, taking up the distinctions of Racamier, still attribute to the institution a simple function of caregiver, within which psychotherapeutic or psychoanalytic enterprises are housed. This is the case of C and P Geissmann.“The phantasmic problem and the effects of transfer,” they write, “are the object of an analytical reflection in the whole of the institution which obeys a certain number of strictly psychoanalytic rules. But inside this institutional system, the individual relationship of the child with his therapist, in the place deprived and “monacal” of the box of psychotherapy, is established under the sign of special rules that the child recognizes very Quickly “.

It is also in this perspective of a separation between psychotherapy and everyday life in the institution that Despinoy and Stoloff are located, insisting on the secrecy of the sessions. The institution then becomes merely a means of avoiding breaches of contract and of obliging children to follow their psychotherapeutic treatment. One can, with Mannoni and elsewhere, Graber, ask the question of the validity of psychoanalytic cures thus imposed, without any possible escape. It is also questionable whether the “monastic” atmosphere and the secrecy surrounding the cure (a one-way secret, since caregivers and teachers must be transparent and “non-omitting” Of the psychoanalyst) do not maintain in the institution this suspicious fascination for the psychoanalyst and this attribution of all power of which C and PGeissmann complain. One can especially wonder about the future of the most undifferentiated and most archaic part of the personality of children which, according to Bleger’s work, is enclosed in the form of primitive symbiotic links in the institutional framework. Proponents of a rigorous separation between institutional care and psychotherapeutic cure may be lacking, at least with the most regressed of psychotic children, those who have hardly emerged from the primary symbiosis and who are virtually Entirely alienated. If child psychoanalysis and the rules of abstinence and secrecy are its own, it is not certain that it applies to the mass of seriously psychotic or autistic children who populate the institutions psychiatric. It is possible that, as Diatkin and Simon had already shown, it requires a mental apparatus that is already relatively organized and positively invested by the subject as a possible source of pleasure to think and to dream. It also requires particularly well-trained therapists. Nothing is so heart-rending as to see in many institutions young psychologists or young doctors, still on the couch of their personal analyst or without any analytical training, self-imposed to impose Their patients and their families a caricature of the constraints of the analytic framework that dry up all relationships. The acerbic criticisms of psychoanalysis are based more on these pseudo-treatments, generating aggressiveness and boredom, than on analytic cures, conducted in a rigorous way. “The binding reference to a psychoanalytic purity merely introduces an ideology of the all or nothing, which is highly questionable, which condemns megalomania or impotence,” Mises reminds us opportunely. Psychoanalysis finds much better place in institutions as an instrument for the elaboration and analysis of the counter-attitudes of caregivers than as a psychotherapeutic technique.

Analysis of counter-attitudes:

The revival of the concept of countertransference is one of the major advances in psychoanalysis of recent years. In the study of institutional processes, there has also been a lot of thought about decrypting and countering the attitudes induced by psychotic children and at the origin of “asylum”. (We prefer here the term counter-attitude, leaving that of countertransference and the related term of transfer to their domain of election: the psychoanalytic cure). Taking up Searles’ descriptions of the effort to make the other mad and the conceptualization of Bion, C and P Geissmann show how the institution defends itself by disinvesting relations with the outside world, stopping time, Repetition, against a painful rupture of symbiotic link induced by a

Change in children. They analyze elsewhere the importance of the phenomena of projective identification on the leader and their deleterious effect on the thinking and creativity of institutional agents. Psychoanalytic theory is then a way to revive the bond of Bion, the taste for reflection and knowledge, which is undermined by the envious attacks of psychotics and by their tendency to reproduce with their entourage a kind of closed dual unit, an autism To two exclusive of any other relation with the environment. It allows for an opening and, as Diatkin says, a reinvestment of thought, that of the carer as well as that of the children, in favor of a common elaboration. It is more another way of hearing and seeing, a third-party reference to emerge from specular chains, than another way of doing things. Cahn emphasizes this point very strongly and emphasizes the re-activation of archaic interactions that the child may have had with his family and that he is skilled at re-engaging In his therapeutic entourage.

By allowing a mutative gap, a game (in the mechanical and playful sense at the same time), the apprehension, thanks to the psychoanalytic theory, of these re-editions promotes other responses, the setting up of a “transformational object” Within a transitionalized space. Institutional festivals, moments of collective transgression in which fantasies and myths are brought into play, institutional crises, real psychodrams in real decoration, are moments when this psychoanalytic elaboration after the fact finds itself particularly to be exercised.

Today, it focuses on the importance of original fantasies (primitive scene, seduction and castration) in the life of the institution, on their reactivation through prolonged contact with psychosis and on the mechanisms of defense Specific measures put in place by the institution to defend themselves against the anxiety associated with them. Institutional activism, the maniacal escape into restorative activities, are the best known of these defensive modalities. Generally, they generate an expenditure of energy and, when the time comes for disillusionment, a depressive reaction. We would like to emphasize another form of activism, theoretical activism, which has given psychiatric institutions a certain hostility on the part of the parents of psychotic children, accusing psychiatry globally of making them feel guilty. This form of theoretical activism, favored by the extended practice of family therapies, is embodied in the distraught and often unwarranted search for transgenerational processes in the outbreak of child psychosis. From this modern resurgence of the theory of degeneration, the famous phrase “the psychosis of the child is the daughter of maternal perversion”, or this quote with a punch that we borrow without comment from Dolto: “All Not to say concerning the grandparents, like any unsaid concerning one of the unknown parents of a child, constitutes a symbolic amputation in this child who in the unconscious, that is to say in its somatolanguage structure, Has long-term repercussions, at the level of sexuality in the Freudian sense of the term “.

Institutional therapeutic process:

Institution, let us not forget, is defined not only as a framework instituted and materialized by walls and schedules; It is also, above all, an instituting action, a practical attitude based on a theory, in short, as we have called it, a “mental institution”.

Paradoxically, it is at the moment when institutions are alleviated, when the institution instituted in them becomes less and less apparent, that the importance of the institution is manifested.

The psychotic child may be regarded as a subject in which all energy is bound against the inevitable fact of thinking and against the existence in him of an apparatus to think of the thoughts which he tries to destroy, Unsuccessfully sometimes in deficit forms. It is because thinking is wrong, insofar as every thought, every representation, implies the absence (and therefore the loss) of what is represented. If we are not all psychotic is that we have found, perhaps in an early identification with the maternal reverie described by Bion, a capacity to dream, that is to say to take pleasure in the evocation And in putting lost objects into words. This capacity is lacking to the psychotic child and the goal of care, before any interpretation of the mental contents in terms of conflicts of instances or drives, is first to make it recover. Even before an analysis is possible there must be something to analyze, that is to say that the mental apparatus harbors thoughts without first trying to dissolve them into small fragments and to expel them . This work of reconciliation with a part of oneself, this reappropriation of the psychic organ, which is the objective of the institutional care, passes by an identification with the mental apparatus of the caregivers, in the course of functioning. The increasingly lacunar character of the institutions which, as we have seen, marks the present evolution, corresponds to this need for space and time which give cause for thought. The same is true of the current emphasis on the differentiation of places of life, places of care, places of education or leisure, on the structuring of a “community network”. By going from one to the other, by differentiating them from one another (the speech therapy of psychotherapy, the psychiatric center of the school, the school of the social center, the outside of the city Of the interior of the family), the child builds systems of distinctive oppositions in which each situation, as a unity of language, takes on meaning only in opposition to another. That is to say, he continually experiences loss, since every present situation forces him to evoke another absent situation from which he is distinguished. In this work of significant contrasts, which makes him emerge from the psychotic homogeneity, he is continually supported by the presence of his reference caregivers. These, guaranteeing a transitional space, true connective tissue or better conjunction of coordination, ensure a linkage from one situation to another and allow to overcome, by a dissolve chained, the cleavages that would otherwise give life to the The appearance of a succession of slides.

The story-telling of this journey, first in the team and then in its restitution to the child, is a story in which the transgenerational myths to which it has been referred may take their place, but as myths and not as explanations Causal processes of a morbid process whose origin remains enigmatic.

In the final analysis, this narrative represents the institution, containing it for thoughts in search of an author who, by coming to live there, can be recognized by the subject as his own. The many synthesis meetings, the supervisions, are the places of elaboration of this narrative. They are the occasion for a well-tempered use of theory, equidistant from a fetishized, dogmatic and mortifying use, and from a manic flight denying any reference to reality.

Thus, institutional work is based first and foremost on a series of “faire”, on practical commitments theorized after the fact, that is, taken secondarily in a history that gives them meaning and is at the service, Says Mises, of a reinvestment of the psychic apparatus. It is important in this context to insist on everyday life in the institution, on the set of events that punctuate this everyday life and which are subject to narration. For an institution to be therapeutic, as in a certain department store, something must happen every day, but it is also necessary that what happens there should be continually articulated and put into history. In this context, Pierre Delion insisted on the triple function of institutional daily life: it is phoric (it supports and secures the child), it is semaphoric (it beckons), it is metaphorical (it refers to something ‘Absent which is not it and which it allows to evoke).

Place of pedagogy:

The definition of institutional care that we have just defended is, with a few nuances, that of the great majority of psychiatrists of French children. Otherwise, in the opinion of their opponents, who caricature their positions in order to attack them better, there is hardly among them any supporters of pure and hard psychoanalysis, exclusive of any other approach, particularly educational. Everyone agrees to defend the principle of a global approach, combining care and education from a dialectical perspective where the two approaches complement and illuminate each other.

Mises has been the best advocate of this multidimensional cure that addresses all aspects of the child’s pathology.“The part,” he says, “is played out in the dialectical link established between these two dimensions, without there being any rupture or confusion between them.” The notion of “frame”, which he proposes to designate what we have described as the articulation of an institutional language, is particularly heuristic. In this framework, the pedagogical elements and the properly caring elements are intercalated and intertwined with the chain of events that punctuate the life of the child. First located within day hospitals, educational facilities are increasingly integrated into public schools.Sometimes children, with the individual support of specialized teachers, attend regular classes or school integration classes. Sometimes they are enrolled in specialized classes for psychotic children in an ordinary school and share some of the sports or waking activities of other children their age. They can also be integrated part-time into regular classes, while retaining the support of the specialized class for another time.

This global approach is distinguished from the purely educational one advocated in the United States and Great Britain by authors who draw their inspiration from behavioral or cognitivist models. These models, “easily understood, which are based on a simple rational, make it easy to train cothérapeutes”, as their French defenders say, not without some naivety. Developed especially in South Carolina, in recent years they have enjoyed great success with certain parents’ associations which have campaigned to replace them with the multidimensional French institutional project.

We will add that any consideration of the institutional dimension, in the sense we have just heard, is absent from these projects whose polemical intention is translated into violent diatribes against a psychoanalysis apparently very little known.

Easy to evaluate, focusing on target behaviors to be eliminated to adapt the child to his environment and on the use of the remaining capacities according to the model of the education of the disabled, they appeal to a society Dominated by pragmatism, the idea of ​​yield, and the “do it yourself”. They are based on a deficient conception of infantile psychoses related to a congenital brain disorder that would have harmed one of the great cognitive functions, such as language or the perception of faces. However, they must be recognized as having formalized, with the notions of structured environment and emerging capacities, a concern to get within reach of the autistic child and to take into account its specific mode of operation that can be found In other less schematic approaches.

It is to be hoped that the coming years will see the sketching of the rapprochement between positions still very distant.The recent experimental work of cognitive psychologists and the need to formalize the inner reality of their subjects (the famous black box in which behavioralists refused to enter) show that this hope is not utopian.

Working with Families:

In part to overcome these polemics and misunderstandings, but also because the development of part-time institutional work required much greater collaboration with families, relationships with parents of psychotic children have become much narrower. Their suffering is much better taken into account by caregivers who tend to neglect it.Their requirements, particularly in terms of diagnosis and guidance, are better understood and their desire for information better recognized. This is evidenced by their growing importance in the various scientific congresses devoted to the psychosis of children. The need to establish a therapeutic alliance with them and to support them in the psychological work imposed on them by the care of their child is at the origin of many forms of support ranging from the individual interview to the group of parents, Different models of family therapies. An abundant bibliography on the subject begins to accumulate.