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Quelle prise en charge du jeune présentant un premier épisode psychotique, quand la scolarité est mise à mal ? - 08/12/17

Doi : 10.1016/j.encep.2017.10.001 
M.-N. Vacheron , H. Veyrat-Masson, E. Wehbe
 Secteur 75G13, centre hospitalier Sainte-Anne, 1, rue Cabanis, 75014 Paris, France 

Auteur correspondant.

Résumé

Les pathologies psychiatriques (en particulier les troubles de l’humeur et les troubles psychotiques) représentent la première cause de handicap chez les jeunes. Le taux de chômage est de 75 à 95 % chez les personnes atteintes de schizophrénie. Il est associé à une moins bonne insertion sociale et économique, une symptomatologie plus grave, une perte d’autonomie et un mauvais fonctionnement global. Il représente aussi plus de la moitié des coûts liés à la maladie psychotique. Les pathologies psychiatriques surviennent pour la plupart des cas entre 25 et 35 ans, période pendant laquelle les jeunes sont en pleine construction de leur avenir social et professionnel. Malgré ces éléments, la prise en charge est souvent marquée par un retard ou un désengagement prématuré des soins, des traitements médicamenteux parfois non adaptés, une mauvaise évaluation de leurs difficultés sociales et cognitives, une insuffisance de relais spécifique après une hospitalisation notamment en ce qui concerne le cursus scolaire et professionnel. Or, l’investissement dans les études ou le travail sont une des clés du rétablissement fonctionnel et de la destigmatisation. L’objectif de ce travail est de définir le décrochage scolaire, d’en évaluer les causes et les conséquences en cas de premier épisode psychotique. Une fois la pathologie installée, comment aider le jeune à maintenir une scolarité ? Nous détaillerons les mesures permettant de soutenir l’insertion scolaire ou universitaire comme les programmes de soutien aux études qui se développent actuellement parallèlement aux stratégies thérapeutiques visant à obtenir la rémission symptomatique, souvent associés aux mesures de soutien à l’emploi en soulignant les particularités en France.

Le texte complet de cet article est disponible en PDF.

Abstract

Psychiatric disorders (more specifically mood disorders and psychosis) represent the 1st cause of disability among young people. Unemployment rate between 75 to 95% for the person with schizophrenia. It is correlated to poor social integration and bad economic status, worse symptomatology loss of autonomy as well as global bad functioning. It is responsible of more than half of the overall cost of psychosis. The onset of most of psychiatric disorders occur between the age of 25 and 35 years old, a critical time in young adult life when they should build their professional as well as social future. Without appropriate care, young adult are unable to build satisfactory emotional relationships, continue their studies, live independently or fit into life. They are frequently dependent on their environment. They also have an increased suicide rate and frequent comorbid substance abuse. Despite this context, their care pathway is often marked by a delay or premature stop of care, drug treatments not always suitable and a lack of specific relay post-hospitalization regarding continuity of professional training or studies. All factors impacting future employability of adolescents. Furthermore they spend most of their time in school and school plays a key part in an individual's development including peer relationships, social interactions, academic attainment, cognitive progress, emotional control, behavioral expectations and physical and moral development. These areas are also reciprocally affected by mental illness. The initial phases of FEP are characterized by impaired academic performance, change in social behaviors and increasing absences from school, reflecting the prodrome of the illness that leads to disengagement from education. Functional decline often precedes onset of clinical symptoms and many adolescents and young adults are therefore isolated from school before their illness is recognized. School support staff may fail to recognize those who are functionally impaired because of evolving FEP although school is a key setting for promoting positive mental health, fostering resilience, detecting and responding to emerging mental ill health. So, people with psychotic illness have low levels of secondary school completion. School dropout has been defined as leaving education without obtaining a minimal credential, most often a higher secondary education diploma. In France, the school is compulsory up to the age of 16. Consequences are significant: among young people without a degree out of initial training for one to four years and present on the labour market, 47% are unemployed. School dropout depends on a number of factors, including grades, family and social environment and the relationship with the school, but also the emergence of psychiatric disorders. For first episode psychotic patients, age of onset, lack of family support, longer duration of psychosis, levels of premorbid global functioning and education, negative and cognitive symptoms, addictions, depressive comorbidities and stigma plays an important role in school dropout. However, young adults have historically received less treatment than expected considering prevalence of mental illness at that age. In the last few decades, early intervention programs for psychosis have been developed all around the world in order to promote rehabilitation and prevent long-term disabilities. Early intervention programs focus on the special needs of young people and their families and engage in some form of assertive community treatment, which attempts to treat patients in the community rather than using inpatient services. For early intervention in psychosis programs, the goal is to keep patients engaged with treatment, prevent them from further psychotic episodes and hospitalizations and promote rehabilitation. The additional services of an early intervention program include staff specialized in psychosis treatment, family/group/individual counseling sessions, assertive case management, and low-dose second generation anti-psychotics. In these programs, psychiatric rehabilitation practitioners already use individual counseling and supported education programs (SEd) to improve postsecondary educational outcomes. The goals of SEd are for individuals with serious mental illness to successfully be able to set and achieve an educational goal (e.g., training certificate or degree), to improve educational competencies (literacy, study skills, time management), to navigate the educational environment (e.g., applications, financial assistance), and to improve motivation toward completing educational goals. These approaches are often combined with efforts to support transitions to sustainable employment. Current evidence of these interventions are weak with limited information on specific difficulties experienced by young adults with FEP in educational tasks. Adaptive strategies are needed by young adults with FEP to succeed in educational settings but most studies do not explore it with rigorous methodology. However, common SEd components emerge: specialized and dedicated staffing, one-on-one and group skill-building activities, assistance with navigating the academic setting and coordinating different services, and linkages with mental health counseling. Continued specification, and testing of SEd core components are still needed. It is important that occupational therapy researchers and practitioners develop, and evaluate effective interventions to improve education outcomes for young adults with FEP. The objective of this work is to define school dropout, assess causes and consequences of FEP. How to help young people to maintain education? We will detail measures to support the academic re-insertion in France.

Le texte complet de cet article est disponible en PDF.

Mots clés : Rétablissement, Premier épisode psychotique, Schizophrénie, Échec scolaire, Soutien aux études

Keywords : Recovery, First episode psychotic, School drop-up, Supported education, Schizophrenia


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© 2017  L'Encéphale, Paris. Publié par Elsevier Masson SAS. Tous droits réservés.
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Vol 43 - N° 6

P. 570-576 - décembre 2017 Retour au numéro
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