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
Bibliographic record
Abstract
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.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.006 |
| Meta-epidemiology (narrow) | 0.000 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.011 | 0.007 |
| Scholarly communication | 0.004 | 0.002 |
| Open science | 0.001 | 0.004 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".