The care relationship in child psychiatry confronted with violence andat the core of shared vulnerability : An ethnographic study of alternatives to control measures in the management of challenging behaviors in inpatients with autism and intellectual disability in France, Canada and the United States
Notice bibliographique
Résumé
In child psychiatric hospitalization units, healthcare professionals work with individuals with an intellectual disability (ID) and/or an autism spectrum disorder (ASD), who have challenging behaviors (CBs): self-injuries, aggression, uncontrollable psychomotor agitation, pica, restrictive and repetitive behavior, destructive or disruptive behavior. The injuries associated with the intensity of violent crises are problematic for patients, families and caregivers: their complications are numerous and the use of control measures (seclusion room, restraints) is frequent even though they should be limited. This doctoral research in ethics deals with alternatives to control measures in the management of CBs of patients with ID/ASD, when they are hospitalized in intensive and emergency care units. Its purpose is to identify each of these alternatives by looking at the use of security tools (e.g. helmet, gloves, sleeves, jacket, jumpsuit, splints, padded shield, mat, papoose board) and to examine the moral experiences of healthcare professionals directly exposed to the violence of these extreme situations. This prospective and ethnographic study is multicentric: France, Canada and the United States. It took place from 2017 to 2019 in three psychiatric inpatient units specialized in the assessment and treatment of CBs of individuals with ID/ASD. Data collection was based on participant observation, 37 interviews of healthcare professionals and the analysis of these three departments’ procedures. The international scope of this study has made it possible for us to question the local norms through their different care cultures and health policies. Firstly, we have generated an exhaustive inventory of personal protective equipment (PPE) and discovered the existence of other innovative safety tools. PPEs enable a more open care environment that respects freedom of movement within these closed units. The use of PPEs reassure caregivers and can contribute to the restoration of a clinical approach that makes it possible to identify CBs’ etiologies and to personalize support in order to set up more effective and more appropriate therapies. From an ethical point of view, the first step of this ethnographic study has highlighted the notion of « shared vulnerability ». Secondly, we have developed the participatory dimension of our study by using an interpretative framework based on Charles Taylor's hermeneutics. This methodological framework – participatory hermeneutic ethnography – has helped us to better understand the moral experiences of caregivers confronted with complex ID/ASD situations. This study has highlighted a neglected dimension of the care relationship: the caregivers' vulnerability. This vulnerability is characterized by the global impact of CBs and a moral distress associated with the restraint and exclusion of individuals with ID/ASD. A strong ambiguity between care and control measures, and a lack of inclusive approaches have been identified as the main barriers to alternatives to restraints. Conversely, the facilitators for alternatives to control measures are defined by professional integrity that simultaneously considers the protection of patients and caregivers, and a relational commitment that enables caregivers to adjust to the specific needs of individuals with ID/ASD to anticipate their crises. The completion of the study has highlighted a conflict of values that opposes two conceptions of autonomy: a rational autonomy, which is counterproductive to the reduction of control measures, and a relational autonomy based on a shared vulnerability. The recognition of a caregiver’s vulnerability is a benchmark to create de-escalation approaches and promote an ethics of care. This thesis defends a caring attitude based on cautiousness, shifting between refusing indifference as well as domination. Thus, caregivers’ self-concern can be understood as fostering mutual respect.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,002 | 0,006 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,001 |
| Méta-épidémiologie (sens large) | 0,001 | 0,000 |
| Bibliométrie | 0,001 | 0,001 |
| Études des sciences et des technologies | 0,011 | 0,007 |
| Communication savante | 0,004 | 0,002 |
| Science ouverte | 0,001 | 0,004 |
| Intégrité de la recherche | 0,001 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,002 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».