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Robin M, Surjous L, Belbèze J, Bonnardel L, Varlet M, Silva J, Lamothe J, Essadek A, Falissard B, Cohen D, Corcos M. Influence of at-risk family interactions on the course of psychiatric care in adolescence. Eur Child Adolesc Psychiatry 2024; 33:2847-2857. [PMID: 38305891 PMCID: PMC11272672 DOI: 10.1007/s00787-023-02330-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/28/2023] [Indexed: 02/03/2024]
Abstract
Dysparenting, referring to inappropriate parental attitudes, is a vulnerability factor for mental disorders during adolescence and a therapeutic leverage, yet clinicians lack reliable tools to assess it in daily clinical practice. Moreover, the effect of this dysparenting on the amount of psychiatric care remains unclear. The Family and Care study aims to develop the at-risk family interactions and levers (ARFIL) scale, a comprehensive 30-item clinical scale, and to assess in a cross-sectional design, the impact of these at-risk family interactions on the care of adolescents (n = 425) hospitalized in psychiatry and aged 13-19 years old. Factorial analysis shows that the ARFIL scale consists of three main dimensions associated with cohesion/conflicts, love/hostility, and autonomy/control with good psychometric properties. Multivariate regressions show that the ARFIL intensity score predicts the duration of hospital care, regardless of age, gender, medical severity on admission, assessed by the Global Assessment of Functioning scale, the presence of maltreatment and psychiatric diagnoses. Moreover, the ARFIL diversity score (number of items present regardless of their severity) predicts both the number and duration of hospitalizations. At-risk family interactions are a determining dimension of psychiatric adolescent care, and the ARFIL scale could constitute a valuable tool, not only for holistic evaluation and treatment, but also for prevention.
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Affiliation(s)
- M Robin
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.
- Paris-Saclay University, UVSQ, INSERM U1178, Team PsyDev, Villejuif, France.
- Paris Descartes University, Sorbonne Paris Cité, Paris, France.
| | - L Surjous
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - J Belbèze
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - L Bonnardel
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - M Varlet
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - J Silva
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - J Lamothe
- Group for Research and Intervention on Children's Social Adjustment (GRISE), Sherbrooke, Québec, Canada
| | - A Essadek
- Interpsy Laboratory, University of Lorraine, Nancy, France
| | - B Falissard
- Paris-Saclay University, UVSQ, INSERM U1178, Team PsyDev, Villejuif, France
- AP-HP, Hôpital Cochin, Maison de Solenn, Paris, France
| | - D Cohen
- Department of Child and Adolescent Psychiatry, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - M Corcos
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
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Barton BB, Ehring T, Reinhard MA, Goerigk S, Wüstenberg T, Musil R, Amann BL, Jobst A, Dewald-Kaufmann J, Padberg F. Effects of resilience and timing of adverse and adaptive experiences on interpersonal behavior: a transdiagnostic study in a clinical sample. Sci Rep 2023; 13:18131. [PMID: 37875505 PMCID: PMC10598007 DOI: 10.1038/s41598-023-44555-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 10/10/2023] [Indexed: 10/26/2023] Open
Abstract
Adverse childhood experiences (ACE) have been linked to less prosocial behavior during social exclusion in vulnerable groups. However, little is known about the impact of the timing of ACE and the roles of protective factors. Therefore, this study investigated the association of the behavioral response to experimental partial social exclusion with adverse and adaptive experiences across age groups and resilience in clinical groups with persistent depressive disorder and borderline personality disorder, i.e., groups with high ACE, and in healthy controls (HC) (N = 140). Adverse and adaptive experiences during childhood, youth, and adulthood were assessed with the Traumatic Antecedents Questionnaire, and resilience was measured with the Connor Davidson Resilience Scale. A modified version of the Cyberball paradigm was used to assess the direct behavioral response to partial social exclusion. In patients, adverse events during youth (B = - 0.12, p = 0.016) and adulthood (B = - 0.14, p = 0.013) were negatively associated with prosocial behavior, whereas in the HC sample, adaptive experiences during youth were positively associated with prosocial behavior (B = 0.25, p = 0.041). Resilience did not mediate these effects. The findings indicate that critical events during youth may be particularly relevant for interpersonal dysfunction in adulthood.
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Affiliation(s)
- Barbara B Barton
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich, Germany.
| | - Thomas Ehring
- Department of Psychology, LMU Munich, Munich, Germany
| | - Matthias A Reinhard
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich, Germany
| | - Stephan Goerigk
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich, Germany
- Charlotte Fresenius Hochschule, Infanteriestrasse 11A, 80797, Munich, Germany
- Department of Psychological Methodology and Assessment, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Torsten Wüstenberg
- Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Richard Musil
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich, Germany
| | - Benedikt L Amann
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich, Germany
- Centre Fòrum Research Unit, Hospital Del Mar Research Institute, Barcelona, Spain
- Mental Health Institute, Hospital Del Mar, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
| | - Andrea Jobst
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich, Germany
| | - Julia Dewald-Kaufmann
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich, Germany
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich, Germany
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Shen JE, Huang YH, Huang HC, Liu HC, Lee TH, Sun FJ, Huang CR, Liu SI. Psychometric properties of the Chinese Mandarin version of the Borderline Symptom List, short form (BSL-23) in suicidal adolescents. Borderline Personal Disord Emot Dysregul 2023; 10:23. [PMID: 37553717 PMCID: PMC10411024 DOI: 10.1186/s40479-023-00230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND The short form of the Borderline Symptom List (BSL-23) is a self-rated instrument developed from the initial 95-item German version of the Borderline Symptom List (BSL-95). It is widely used among Chinese adults, but its applicability, factor structure and validity remain uncertain in adolescents. This study aimed to evaluate the psychometric properties of the Chinese Mandarin version of the BSL-23 in a sample of suicidal adolescents. METHODS The Chinese Mandarin BSL-23 was given to 279 outpatient adolescents with self-injurious thoughts or behaviors. The factor structure, reliability, convergent validity, criterion-related validity and cut-off value were investigated. RESULTS The Chinese Mandarin version of the BSL-23 demonstrated a one-factor structure and replicated the original version. The scale had high reliability and good test-retest stability. The Chinese Mandarin BSL-23 was correlated with depression, hopelessness, impulsivity, emotional dysregulation, self-esteem, loneliness, childhood trauma and parental bonding patterns evaluated with a variety of scales. The measure showed good criterion-related validity and predictive accuracy (AUC = 0.87) for self-injurious and suicidal adolescents with borderline personality disorder (BPD) at a cut-off point of 60/61 (mean score 2.60/2.65), with a sensitivity of 0.76 and specificity of 0.83. CONCLUSIONS The Chinese Mandarin version of the BSL-23 is a reliable and valid self-reported instrument to assess BPD symptomatology among suicidal adolescents.
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Affiliation(s)
- Jui-En Shen
- Department of Psychiatry, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yu-Hsin Huang
- Department of Psychiatry, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Hui-Chun Huang
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Hui-Ching Liu
- Department of Psychiatry, MacKay Memorial Hospital, Taipei, Taiwan
| | - Tsung-Han Lee
- Department of Psychiatry, MacKay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Chiu-Ron Huang
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
| | - Shen-Ing Liu
- Department of Psychiatry, MacKay Memorial Hospital, Taipei, Taiwan.
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.
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Robin M, Bellone L, Belbèze J, Kazemian K, Radjack R, Corcos M. Three-level containment model of hospitalized adolescents with borderline pathology: a holistic therapeutic perspective. Front Psychiatry 2023; 14:1110788. [PMID: 37608992 PMCID: PMC10441123 DOI: 10.3389/fpsyt.2023.1110788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 06/16/2023] [Indexed: 08/24/2023] Open
Abstract
Borderline personality disorders account for 50% of adolescent hospitalization cases in psychiatry. The severity and psychopathological complexity of these symptoms indicate the need for inclusive models of understanding. Adopting a holistic approach allows for the consideration of not only the patient's environment, but also their position within that environment and their life history. In this article, a model based on the concept of therapeutic containment at three levels is presented. Global containment refers to the mindset and organization of the institution that provides care, which is itself a part of society at a specific time. Local containment focuses on understanding and therapeutic interventions within the immediate social environment of the individual. Lastly, individual containment encompasses the development of independent processes during the course of care. These three levels are integrated in the hospital treatment of borderline personality disorders, forming a trans-theoretical approach.
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Affiliation(s)
- Marion Robin
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
- Paris-Saclay University, UVSQ, CESP, INSERM U1178, Team PsyDev, Villejuif, France
- Paris Cité University, Paris, France
| | - Laura Bellone
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
- Paris Cité University, Paris, France
| | - Jean Belbèze
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
- Paris Cité University, Paris, France
| | - Koucha Kazemian
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
- Paris Cité University, Paris, France
| | - Rahmeth Radjack
- Paris-Saclay University, UVSQ, CESP, INSERM U1178, Team PsyDev, Villejuif, France
- Paris Cité University, Paris, France
- Maison de Solenn, Department of Adolescent Psychiatry, Cochin Hospital, AP-HP, Paris University, Paris, France
| | - Maurice Corcos
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
- Paris Cité University, Paris, France
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Albermann M, Emery S, Baumgartner N, Strumberger M, Erb S, Wöckel L, Müller-Knapp U, Rhiner B, Contin-Waldvogel B, Bachmann S, Schmeck K, Berger G, Häberling I. Executive functions and borderline personality features in adolescents with major depressive disorder. Front Hum Neurosci 2023; 17:957753. [PMID: 37425294 PMCID: PMC10325791 DOI: 10.3389/fnhum.2023.957753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 05/26/2023] [Indexed: 07/11/2023] Open
Abstract
Background Executive functions (EF) consolidate during adolescence and are impaired in various emerging psychiatric disorders, such as pediatric Major Depressive Disorder (pMDD) and Borderline Personality Disorder. Previous studies point to a marked heterogeneity of deficits in EF in pMDD. We examined the hypothesis that deficits in EF in adolescents with pMDD might be related to comorbid Borderline Personality features (BPF). Methods We examined a sample of 144 adolescents (15.86 ± 1.32) diagnosed with pMDD. Parents rated their child's EF in everyday life with the Behavior Rating Inventory of Executive Function (BRIEF) and BPF with the Impulsivity and Emotion Dysregulation Scale (IED-27). The adolescents completed equivalent self-rating measures. Self- and parent-ratings of the BRIEF scores were compared with paired t-Tests. Correlation and parallel mediation analyses, ICC, and multiple regression analyses were used to assess symptom overlap, parent-child agreement, and the influence of depression severity. Results Over the whole sample, none of the self- or parent-rated BRIEF scales reached a mean score above T > 65, which would indicate clinically impaired functioning. Adolescents tended to report higher impairment in EF than their parents. Depression severity was the strongest predictor for BPF scores, with Emotional Control predicting parent-rated BPF and Inhibit predicting self-rated BPF. Furthermore, the Behavioral Regulation Index, which includes EF closely related to behavioral control, significantly mediated the relationship between depression severity and IED-27 factors emotional dysregulation and relationship difficulties but not non-suicidal self-injuries. Conclusion On average, adolescents with depression show only subtle deficits in executive functioning. However, increased EF deficits are associated with the occurrence of comorbid borderline personality features, contributing to a more severe overall psychopathology. Therefore, training of executive functioning might have a positive effect on psychosocial functioning in severely depressed adolescents, as it might also improve comorbid BPF. Clinical trial registration www.ClinicalTrials.gov, identifier NCT03167307.
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Affiliation(s)
- Mona Albermann
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zürich, Switzerland
| | - Sophie Emery
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zürich, Switzerland
| | | | - Michael Strumberger
- Research Department of Child and Adolescent Psychiatry, Psychiatric University Hospitals Basel, University of Basel, Basel, Switzerland
| | - Suzanne Erb
- Child and Adolescent Psychiatric Services St. Gallen, St. Gallen, Switzerland
| | - Lars Wöckel
- Research Department of Child and Adolescent Psychiatry, Psychiatric University Hospitals Basel, University of Basel, Basel, Switzerland
- Clienia Littenheid AG, Littenheid, Switzerland
| | | | - Bruno Rhiner
- Child and Adolescent Psychiatry Thurgau, Weinfelden, Switzerland
| | | | - Silke Bachmann
- University Clinic of the Martin-Luther University Halle – Wittenberg’s Medical Faculty, Halle, Germany
- Département de Psychiatrie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Klaus Schmeck
- Research Department of Child and Adolescent Psychiatry, Psychiatric University Hospitals Basel, University of Basel, Basel, Switzerland
| | - Gregor Berger
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zürich, Switzerland
| | - Isabelle Häberling
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zürich, Switzerland
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Robin M, Surjous L, Belbèze J, Bonnardel L, Lamas C, Silva J, Peres V, Corcos M. Four attachment-based categories of emotion regulation in adolescent psychic troubles. Front Psychol 2023; 14:1133980. [PMID: 37275718 PMCID: PMC10237043 DOI: 10.3389/fpsyg.2023.1133980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/06/2023] [Indexed: 06/07/2023] Open
Abstract
Introduction Emotion regulation is altered in many psychiatric disorders in adolescence, but the understanding of mechanisms that underlie this alteration is still poor. Methods The PERCEPT study explores alexithymia, empathy, facial emotion recognition (FER) and defence mechanisms in a sample of adolescents in psychiatric care (n = 61, 74% of girls, mean age = 15.03 y.o.), in relation with participants' attachment styles. Results Results revealed correlations between attachment dimensions and all of the emotion regulation variables, suggesting that attachment modalities have functional links with emotional regulation at its different levels: FER accuracy was inversely correlated with avoidant attachment, while affective empathy, difficulty in identifying feelings (alexithymia) and immature as well as neurotic defence mechanisms were positively correlated with anxious attachment. Moreover, attachment categories delineated distinct emotional perception profiles. In particular, preoccupied attachment included adolescents with the highest levels of facial emotion perception (sensitivity and accuracy) and of affective empathy, whereas detached attachment included adolescents with the lowest levels of these variables. Neurotic defence mechanisms and difficulty to identify feelings were correlated with preoccupied attachment; immature defence mechanisms and difficulty to describe feelings to others characterized fearful attachment. Discussion These results suggest that attachment categories underlie emotion regulation processes in psychiatric disorders in adolescence. Theoretical and clinical implications are discussed.
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Affiliation(s)
- Marion Robin
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
- CESP, INSERM U1178, Paris-Saclay University, Villejuif, France
| | - Luc Surjous
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
- Paris Cité University, Paris, France
| | - Jean Belbèze
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
- Paris Cité University, Paris, France
| | - Lucile Bonnardel
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
| | - Claire Lamas
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
| | - Jérôme Silva
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
| | - Victoire Peres
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
| | - Maurice Corcos
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
- Paris Cité University, Paris, France
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Robin M, Schupak T, Bonnardel L, Polge C, Couture MB, Bellone L, Shadili G, Essadek A, Corcos M. Clinical Stakes of Sexual Abuse in Adolescent Psychiatry. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1071. [PMID: 36673831 PMCID: PMC9858972 DOI: 10.3390/ijerph20021071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND The extent and nature of sexual abuse (SA) and its consequences in psychiatry are still poorly described in adolescence. OBJECTIVE This article describes the frequency of SA reported in an adolescent population hospitalized in psychiatry, and assesses its links with the severity of mental disorders and the medical issues of these adolescents. METHODS The study includes 100 patients for whom SA has been mentioned, among all patients aged 13 to 17 years old hospitalized for about 4 years. The characteristics of sexual abuse were correlated with the medical severity of the patients, as well as the number, the duration of their hospitalization(s), and the time until disclosure. RESULTS The results show the central place of SA in adolescent psychiatry, with a prevalence of 28.5% and a cumulative hospital stay which is five times longer than average. Correlations have been observed between the number of suicide attempts and the number of abuses reported. The medical severity of patients is significantly increased when the named aggressor is an adult. The number of hospitalizations is positively correlated with the number of reported abuses, as well as with the intrafamilial and adult status of the perpetrator. Finally, an early age of onset, repeated abuse, and the intrafamilial nature of the abuse are associated with a longer time to disclosure. CONCLUSIONS The severity of adolescent psychiatric situation is statistically in favor of a history of SA, which should therefore be actively explored during care.
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Affiliation(s)
- Marion Robin
- Département de Psychiatrie de L’adolescent et du Jeune Adulte, Institut Mutualiste Montsouris, 75014 Paris, France
- Centre de Recherche en Epidémiologie et Santé des Populations, INSERM U1178, Team PsyDev, 94807 Villejuif, France
| | - Thomas Schupak
- Département de Psychiatrie de L’adolescent et du Jeune Adulte, Institut Mutualiste Montsouris, 75014 Paris, France
| | - Lucile Bonnardel
- Département de Psychiatrie de L’adolescent et du Jeune Adulte, Institut Mutualiste Montsouris, 75014 Paris, France
| | - Corinne Polge
- Département de Psychiatrie de L’adolescent et du Jeune Adulte, Institut Mutualiste Montsouris, 75014 Paris, France
| | - Marie-Bernard Couture
- Département de Psychiatrie de L’adolescent et du Jeune Adulte, Institut Mutualiste Montsouris, 75014 Paris, France
| | - Laura Bellone
- Département de Psychiatrie de L’adolescent et du Jeune Adulte, Institut Mutualiste Montsouris, 75014 Paris, France
| | - Gérard Shadili
- Département de Psychiatrie de L’adolescent et du Jeune Adulte, Institut Mutualiste Montsouris, 75014 Paris, France
- Centre de Soins, d’Accompagnement et de Prévention en Addictologie, Émergence Espace Tolbiac, 75013 Paris, France
| | - Aziz Essadek
- Laboratoire Interpsy, Université de Lorraine, 54015 Nancy, France
| | - Maurice Corcos
- Département de Psychiatrie de L’adolescent et du Jeune Adulte, Institut Mutualiste Montsouris, 75014 Paris, France
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