Despite the Ministry of Health's revised treatment plan, France recently faced criticism by the Council of Europe for its discrimination against those with autism. Some rights groups are calling the state of autism treatment in France a “scandal” and claim the government's plan doesn't go far enough. Others say the continued use of psychoanalysis to treat autism is keeping France from advancing.
Elodie Nourrisson, from the suburbs of Paris, first got answers about her son Thomas's behaviour when he was 26 months old. Since birth, he did not move or cry much, had difficulties walking, and was not troubled when separated from his parents. Lately, he had become hyperactive and was not sleeping more than 2 h per night. A doctor from one of the French public sector's Medico-psycho-pedagogical centres (CMPP) said that Thomas simply had developmental delays. “At the beginning, we felt reassured”, says Nourrisson. “[The doctor said] there was a significant overall retardation but that they could help him.”
Waiting lists, ineffective treatments, and frustration ensued for Nourrisson. It was not until she went to a private specialist, when Thomas was nearly 3 years old, that she finally heard the word “autism” in reference to her son.
Since the beginning, Nourrisson says she has been left by the public health system to “manage things on her own”. M'Hammed Sajidi, the president of the autism rights organisation Conquer Autism, says this scenario is all too familiar for families of the estimated one in 68 children with autism in France. “It's an absolute outrage”, says Sajidi, whose own son has autism. “France is the most delayed country in Europe when it comes to autism treatment.” According to Sajidi, medical professionals and teachers do not receive enough specialised training to treat autism, the government funds ineffective treatment methods—such as psychoanalysis—and families are often left to their own devices to treat their children.
Sajidi's frustration led his organisation, along with several others, to file a collective complaint in April, 2012, at the Council of Europe to take France to task on its treatment of people with autism. The Council's response was made public in February, 2014, stating that France had failed in its obligations to provide these children with an appropriate education. It is the second time the Council has condemned France over its autism treatment, with a similar condemnation taking place in 2004.
Sajidi says his overall goals in filing the complaint were met, but that France's woes concerning autism treatment are far from over. He says that the Ministry of Health's Third Autism Plan, published in May, 2013, has not gone far enough to improve diagnosis and treatment. “The state is giving money where it shouldn't, and not giving money where it should”, he says. Although psychoanalysis is now “not recommended” by the government, most public hospitals still use the method and when used there, it is reimbursed by the national health coverage.
The government's autism plan follows two previous ones, running from 2005—07 and 2008—10, based on recommendations set forth by France's National Authority for Health (HAS). The current plan, which will run until 2017, focuses on five essentials for autism treatment: early diagnosis and intervention, lifelong accompaniment, support for caregivers, and increased research and training for medical professionals and educators.
The government has allocated €195 million to the project. However, its Health Advisor for Disabled Persons, Hélène Marie, says that money alone is not enough. “There is a huge job to be done nationally in terms of training people in all professional categories—teachers, doctors, specialised educators”, says Marie. “And the medico-social system is especially inadequate.” Marie says the state faces challenges because no single organisation is responsible. “It's very complicated to coordinate things on a regional level”, she says.
The government is also working to increase autism research, which is vital to improving treatment, according to some of France's psychiatrists who say there is a strong genetic component to the illness. “We're around 90% sure that there is a genetic cause”, says Stéphane Jamain, a researcher of human genetics at the Paris-based research institute INSERM.
Frédérique Bonnet-Brilhault is a child psychiatrist at the Regional University Hospital Centre in Tours, which has worked with groups at INSERM in leading the country in autism research. Their findings have shown that there might be differences in the brain between those with autism and those without the disorder, and that an integrated approach to treatment is necessary. “Our programme is more medical than behavioural”, says Bonnet-Brilhault. “We look at digestive and visual development, eye tracking, emotional behaviour, self-esteem, as well as at possible anxiety or depression.”
Bonnet-Brilhault says each programme must be individually tailored to the child, and thus does not favour one method over another. The centre incorporates methods such as TEACH—a therapeutic tool that helps people with autism understand and navigate their surroundings—and applied behaviour analysis (ABA), which applies behavioural principles to everyday situations to increase or decrease some behaviours. She is not entirely opposed to the use of psychoanalysis to help families if it is part of an integrated plan, but not in the way it has been used in the past. “Blaming the mother for autism? That's finished”, says Bonnet-Brilhault. “We can no longer continue with this idea. Making the mother responsible is ignoring all the medical knowledge we have now. Parents need to be informed and accompanied, not put at the root of autism.”
As part of the HAS's 2012 autism recommendations, psychoanalysis is not recommended as an exclusive treatment method for people with autism. “We established that we don't have enough data on its effectiveness. And since there's a divergence between families and professionals—and among professionals themselves—no conclusion could have been drawn.” says HAS project leader Joelle André-Vert.
Still, psychoanalysis that is performed by a psychiatrist within the public sector is included in the national health coverage. And despite calls from the HAS and the health ministry to favour new methods like TEACH or ABA, it has been slow to take.
Nourrisson was told to begin psychoanalysis when her son Thomas was first diagnosed with developmental delays. Thomas was put on a waiting list at the CMPP while Nourrisson was told to meet with a child psychiatrist for psychoanalytic sessions. “The psychiatrist would ask me questions about my relationship with my mother and about my pregnancy”, says Nourrisson. “I was shamed in several sessions by the psychoanalyst…I would walk out in tears, while Thomas was left unattended and causing a ruckus.”
One Paris-based psychiatrist has been outspoken in his support for psychoanalysis to treat the early stages of autism. Charles Melman is the co-founder of the Association Lacanienne Internationale, which follows the principles of Freud and Lacan. He says, “it's not a question of blaming mothers, but allowing them to live their parenthood in a better way”. Melman says there is “no proof” that autism has genetic origins but instead results from a mother's emotional state or behaviour during pregnancy or in early parenthood. “[Autism] stems from a mother's incapacity to take her child's birth as a joyous occasion”, says Melman. He recently treated one woman whose son was diagnosed with autism at 6 months, using psychoanalysis with the mother and psychotherapy sessions for the child. He says that the child, now 18 months, no longer needs therapy.
Melman says that early detection is key, and that if children with autism receive therapeutic treatment between 3 months and 2·5 years, they can recover completely and return to “normal”. Detection of autism in France is happening too late, says Melman, whose organisation lodged an appeal against the government's Third Autism Plan.
Melman and fellow psychoanalysts—who traditionally wield great power in France when it comes to the treatment of mental illness—have been met with heated criticism in the face of the autism debate. But although opinions differ on the use of psychoanalysis, early detection and diagnosis is deemed essential by both sides. Child psychiatrist Deborah Cohen, who specialises in the treatment of children with autism, says giving a diagnosis is essential. “It allows for the child to receive the appropriate treatment and if it's an early diagnosis, it allows for a better understanding of the person and his specific needs”.
But Sajidi of Conquer Autism says that educators and doctors are hesitant to diagnose children with autism because of the label children must carry with them. “Those who say they don't put labels on people are ignoring offering diagnosis and treatment to those affected. It's extremely problematic”, says Sajidi.
Nourrisson says that when Thomas was first diagnosed by the CMPP, her doctor told her that it was better not to use labels. “Madame, do you want your child to be labelled ‘handicapped’ for the rest of his life?”, she recounts. Doctors there also told her that Thomas would never be able to attend school. However, things changed once Thomas began seeing a specialised, private child psychiatrist, who used treatments like the ABA method and developmental therapy. Now 6 years old, Thomas is not only in school, but he is also thriving. “The teachers have told me that he could practically skip a grade”, says Nourrisson, who adds that it costs a “small fortune” to maintain Thomas's private treatments. Although her region provides her some financial aid, her costs would normally run upwards of €1800 per month—not covered by the social security.
However, Nourrisson's costs are small compared with the number of families who feel they have nowhere else to turn but Belgium, which opens its psychiatric hospitals to French children with autism. The hospital costs are reimbursed by French social security, but children are forced to live far away from their families and it is difficult to monitor treatment methods from across the border.
In its recent remarks about France, the Council of Europe criticised the country on the fact that children with autism were being forced to leave the national territory to receive treatment. For the Ministry of Health and its Third Autism Plan, change is hopefully in the air. “We want to finance this change, when it comes to diagnosis, treatment, etc”, says Hélène Marie.
This is all welcome news for families like Nourrisson. “There's a lot to do, a lot to look at again”, says Nourrisson. “It's going to be hard to implement [the Third Autism Plan] but we're very hopeful. It's evolved in the right direction but when it comes to putting things into action, we're still too far away.”