L Youssouf

V Grandvoinnet

J Lalande

Catherine Couturier

Eckert

Frédéric Barbut
email: frederic.barbut@aphp.fr

Nesrine Day

Stéphane Bouée

Anlyata Youssouf

Laurence Grandvoinnet

Valérie Lalande

Jeanne Couturier

Catherine Eckert
email: catherine.eckert@aphp.fr

Toxigenic Clostridium difficile carriage in general practice: results of a laboratory-based cohort study

Keywords: Clostridium difficile, community, diarrhoea, general practice Clostridium difficile in general practice

scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Introduction

Clostridium difficile is a major enteropathogen which is responsible for 10-25% of antibioticassociated diarrhoea and for virtually all cases of pseudomembranous colitis (PMC) [START_REF] Leffler | Clostridium difficile Infection[END_REF][START_REF] Bartlett | Clostridium difficile Infection[END_REF]. It is the most frequent agent of hospital acquired diarrhoea in adults [START_REF] Lessa | Emerging Infections Program CdST. Burden of Clostridium difficile infection in the United States[END_REF], and Clostridium difficile infections (CDIs) are associated with prolonged hospital stay and excess mortality [START_REF] Barbut | Excess mortality between 2007 and 2014 among patients with Clostridium difficile infection: a French Health Insurance Database analysis[END_REF]. The clinical epidemiology and frequency of healthcare-associated CDI is well described [START_REF] Bauer | Clostridium difficile infection in Europe: a hospital-based survey[END_REF][START_REF] Davies | Underdiagnosis of Clostridium difficile across Europe: the European, multicentre, prospective, biannual, pointprevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID)[END_REF] whereas little is known about the true burden of the disease in the general practice. Currently, more than a quarter of all CDIs are estimated to be community-acquired [START_REF] Lessa | Emerging Infections Program CdST. Burden of Clostridium difficile infection in the United States[END_REF][START_REF] Khanna | The epidemiology of community-acquired Clostridium difficile infection: a population-based study[END_REF]. Therefore, our aim was to determine the incidence of toxigenic C. difficile carriage in patients who submitted a faecal stool sample for routine microbiological testing following a visit with their general practitioners (GP).

Materials and methods

Study design

This prospective cohort study was conducted in 15 different private laboratories in Paris (France) and the surrounding areas. During an eleven-month period (August 10 th 2015 to June 30 th 2016), all patients who submitted a faecal stool sample for routine microbiological testing following a visit with their GP for diarrhoea or other gastrointestinal disorders were consecutively included. All stool samples were systematically tested for C. difficile, irrespective of GP request. Duplicate stool samples (defined as a patient with a second stool sample) were excluded. For each patient, a standardized questionnaire including demographic data (gender, age, hospitalization in the previous 12 weeks) and clinical data (diarrhoea, CDI in the previous 8 weeks) was completed. Information about antimicrobial treatment in the month prior to obtaining the stool sample was also recorded.

The study protocol was approved by the local Research Ethics Committee and by the Comité consultatif sur le Traitement de l'Information en matière de Recherche dans le domaine de la Santé (CCTIRS n° 15.1021). Study information was given to the patients, and the patients signed an informed consent form.

Microbiological analysis

Stool samples were collected in 15 different laboratories and were sent within two hours to a central laboratory, which used a rapid simultaneous GDH and toxins A/B detection assay (C. Diff Quik Chek complete®, TechLab, Alere) for analyses according to the manufacturer's instructions: any positive result (GDH or toxin) was further confirmed by the stool cytotoxicity assay (CTA) and the toxigenic culture (TC) at the National Reference Laboratory for C. difficile.

CTA was performed using MRC-5 cells as described elsewhere [START_REF] Barbut | Does a rapid diagnosis of Clostridium difficile infection impact on quality of patient management?[END_REF]. Toxigenic culture was performed on the selective chromogenic medium ChromID C. difficile (bioMérieux, Marcy l'Etoile, France). Plates were incubated for 48 hours at 37°C in an anaerobic atmosphere. Black colonies or suspicious nonblack colonies (based on the morphological aspect) were analysed using Matrix Assisted Laser Desorption Ionisation-Time Of Flight (MALDI-TOF) mass spectrometry. DNA extraction from colonies of C. difficile was performed with the InstaGene Matrix TM kit (Bio-Rad Laboratories, California, USA).

The in vitro determination of the cytotoxicity of C. difficile isolates was performed by an in-house multiplex PCR assay detecting tpi, tcdA, tcdB, tcdC, cdtA and cdtB genes coding for triose phosphate isomerase, toxin A, toxin B, TcdC and the two components of the binary toxin, respectively (supplementary Table ).

C. difficile isolates were characterized by capillary gel electrophoresis-based PCR-ribotyping on the ABI 3500 sequencer (Applied Biosystems), using primers described by Bidet et al. [START_REF] Bidet | Development of a new PCR-ribotyping method for Clostridium difficile based on ribosomal RNA gene sequencing[END_REF]. PCR ribotypes At each sampling site, stool samples were also introduced into 2-ml Cary Blair broth using the Faecal Transwab (Medical wire mwe, Corsham, England) and into a selenite broth (Elitech, France). The broth samples were then sent to a central laboratory. Swabs were automatically plated (Kiestra, Becton Dickinson) on selective media, including Campylosel (bioMérieux), Hektoen (bioMérieux), Drigalski (bioMérieux), CIN (bioMérieux), and Sabouraud (bioMérieux) which were incubated for 24h at 37°C in an aerobic atmosphere (48h in microaerophilic atmosphere for Campylosel). Selenite broth samples were first incubated for 24 hours at 37°C, then plated on Hektoen. Identification of Salmonella spp., Shigella spp., Campylobacter spp. and Yersinia spp. was confirmed by MALDI-TOF mass spectrometry (Andromas, bioMérieux). Shigella sp. was also confirmed by biochemical strip (API 20E, bioMérieux) and latex agglutination (Bio-Rad).

Stool samples were also tested for the presence of Rotavirus and Adenovirus upon a physician's request using the Rapid Immunochromatographic Assay Rota/Adeno (Meridian Bioscience Europe) according to the manufacturer's instructions.

Parasitological stool examination

Parasitological stool examination was also performed upon a physician's request. Parasitic elements were observed by direct stool examination and after concentration with KOP-COLOR II (Fumouze Diagnostics, Levallois-Perret, France). Briefly, the sediment obtained after two-phase concentration (Bailenger's method) was resuspended with 1 or 2 drops of physiological saline. 25 µl of the suspension was mixed with 10 μL of KOP-COLOR II on a slide. A coverglass was placed over the sediment suspension, which was examined under a microscope using a white light (blue filter).

Case definition

A diarrheic stool sample was defined as a stool taking the shape of the container. Clinical diarrhoea was defined by the passage of 3 or more loose stools for at least 24 hours. C. difficile carriage was considered community-acquired if the patient had no hospitalization in the previous 12 weeks [START_REF] Krutova | How to: Surveillance of Clostridium difficile infections[END_REF].

C. difficile carriage was considered as healthcare-associated if the patient has been hospitalized in the previous 4 weeks, as "indeterminate" when the patient has a history of hospitalisation 4-12 weeks before stool sample collection and as 'unknown' origin when the exposure setting could not be determined because of lack of available data.

Statistical analysis

Statistical analyses were performed using the R software, version 3.

Results

In total, 2565 patients were invited to participate in the study: 24 patients were excluded because of duplicate stool samples (n=14), lack of consent (n=7), and error in stool labelling (n=3). In total, 2541 patients (1295 female, 1246 male, median age=38 years) were included. Among them, 106 (4.17%) were children less than 3 years old. Of the 2541 patients, 1264 (49.74%) reported clinical diarrhoea and 1253 (49.31%) had abdominal pain. Among the 1253 patients with abdominal pain, 331 (26.41%) did not present with clinical diarrhoea and among these 201 (16.04%) had no diarrheic stools. Only 120 patients (4.72%) had a previous hospital stay either in day-care (n=42), acute care setting (n=69), or in a long-term care facility (n=2). Two patients reported a CDI episode in the previous 8 weeks.

Comparison of EIA assay for GDH and toxins versus TC and CTA

Screening for C. difficile was performed by a central laboratory using EIA for GDH and toxins. Of the 2541 patients, 116 were positive for GDH: 112 were subsequently confirmed by culture on ChromID C. difficile and 4 turned out to be negative, despite several culture attempts. In addition, 33 patients were positive by EIA for toxins, of which 29 were confirmed by CTA and 4 were negative by CTA.

Among the 83 samples negative for toxins by EIA but positive for GDH, 17 were positive by CTA.

Incidence of enteropathogens

The incidences of patients with a positive TC and a positive stool CTA were 3.27% [83/2541, CI95% 2.61-4.03] and 1.81% [46/2541, CI95% 1.33-2.41], respectively (Figure 1). Among stool samples positive for toxigenic C. difficile, 7 (8.4%) were positive for other enteropathogens (3 Salmonella sp.,

1 Campylobacter sp., 1 Yersinia enterocolitica, 1 Giardia intestinalis, 1 Endolimax nana)
Of the 2541 patients, 2199 had a bacteriological stool culture, 2001 had a parasitological stool examination, 1663 had both, and 114 had viral testing for the presence of adenovirus and rotavirus antigens. Incidence of the different pathogens is reported in Figure 2. Among all the microorganisms detected, many (such as Blastocystis, Endolinax, Entamoeba coli, Trichomonas intestinalis, Chilomastix mesnili, Entamoeba hartmanni or Pseudolimax butschlii) have a doubtful or uncertain clinical significance.

Clinical characteristics of patients with toxigenic C. difficile carriage

Among the 66 patients ≥ 3 years old with a positive TC, 59 (89.39%) had either a clinical diarrhoea or a diarrheic stool and 43 (65.15%) had no history of hospitalization in the previous 12 weeks. Among these, 17 patients (25.75 %) were less than 65 years old, had not received antibiotic treatment in the month preceding the diarrhoea, and had no enteropathogens other than C. difficile. When restricting the analysis to the 41 patients with a positive CTA, 37 (86.04%) had either a clinical diarrhoea or a diarrheic stool and 24 (58.53%) had no history of hospitalization in the previous 12 weeks. Among these 6/41 (14.63%) were < 65 years, had not received antibiotic treatment in the month preceding the diarrhoea and had no enteropathogens other than C. difficile.

Using a multivariate logistic regression model, independent factors associated with positive CTA or positive TC in patients ≥ 3 years old were antibiotic treatment in the month prior to diarrhoea and hospitalization in the previous 12 weeks (Table 1).

Optimal algorithm for CD testing in patients from general practice

GPs requested CD testing in only 12.93 % of the stool samples, resulting in detection of 52.30 % of all TC-positive patients. We determined the performance of different testing algorithms based on risk factor identification (Table 2) and/or recommendations from the UK or the Netherlands [START_REF] Hensgens | Diarrhoea in general practice: when should a Clostridium difficile infection be considered? Results of a nested case-control study[END_REF]. If C. difficile testing were performed in patients ≥ 65 years old, with recent antibiotic use or with a history of recent hospitalization, only 29.53 % of stool samples of our population would have had to have been processed, and 70% of all toxin-positive cases would have been identified.

Characterization of C. difficile strains

In total, 83 C. difficile isolates were toxigenic and 29 were non-toxigenic. The toxigenic C. difficile isolates harboured both tcdA and tcdB genes and belonged to 36 different PCR-ribotypes, the complex 014/020 (n=11, 13.25%) being the most predominant (Figure 3). Eight isolates (9.63%) were positive for binary toxin (PR 019, PR 027, PR 126, PR 244). Only two patients were colonized by the epidemic 027 clone.

Discussion

Incidence of toxigenic C. difficile carriage and other pathogens

Our study showed that the overall toxin-positive assay incidence in patients from general practice ≥ 3 years old was 1.81% [CI95% 1.33-2.41] and that toxigenic C. difficile carriage was 3.27% [CI95%: 2.61-4.03]. This incidence was higher in elderly patients, as previously reported by others [START_REF] Soes | The incidence and clinical symptomatology of Clostridium difficile infections in a community setting in a cohort of Danish patients attending general practice[END_REF][START_REF] Kutty | Risk factors for and estimated incidence of community-associated Clostridium difficile infection, North Carolina, USA[END_REF].

Children under 3 years old were also frequently found positive for toxins and culture, but the presence of C. difficile in this population has often been considered as non-pathogenic [START_REF] Bolton | Asymptomatic neonatal colonisation by Clostridium difficile[END_REF][START_REF] Schutze | Clostridium difficile infection in infants and children[END_REF]. Toxigenic C. difficile represented the second most frequent bacterial pathogen isolated in patients from general practice after Campylobacter spp. (3.64%). Other recent studies reported a CDI incidence in the community ranging from 0.62% in a study from Kuwait using GDH detection followed by PCR [START_REF] Jamal | A prospective study of community-associated Clostridium difficile infection in Kuwait: Epidemiology and ribotypes[END_REF], to 5.5% in a small study including 288 Australian GP patients, suggesting that C. difficile is a significant cause of community-associated diarrhoea [START_REF] Riley | Diarrheal disease due to Clostridium difficile in general practice[END_REF]. A point prevalence multicentre European study of community-associated diarrhoea, where stool samples were investigated with the FilmArray GI Panel reported an incidence of 1.62% (BioFire Diagnostics, Salt Lake City, UT, USA) [START_REF] Spina | Spectrum of enteropathogens detected by the FilmArray GI Panel in a multicentre study of communityacquired gastroenteritis[END_REF].

In the Netherlands, the incidence of toxigenic C. difficile in 2710 patients who had visited their GP for gastrointestinal complaints was significantly higher compared to controls without gastrointestinal complaints matched on age and sex (4.2% versus 1.8%, p<0.001) [START_REF] Van Coppenraet | Case-control comparison of bacterial and protozoan microorganisms associated with gastroenteritis: application of molecular detection[END_REF].

The incidence of positive free toxins (1.81%) is consistent with that of 1.5% found by Hensgens et al. [START_REF] Hensgens | Diarrhoea in general practice: when should a Clostridium difficile infection be considered? Results of a nested case-control study[END_REF] who looked at 12 714 diarrhoeal stool samples requested by GPs and with Bauer et al. [START_REF] Bauer | Clinical and microbiological characteristics of community-onset Clostridium difficile infection in The Netherlands[END_REF] who looked at 2443 stool samples. In UK, a study based on 2000 patients > 2 years old who had visited their GP showed that the proportion of faecal samples positive for cytotoxin was 2.1% [START_REF] Wilcox | A case-control study of communityassociated Clostridium difficile infection[END_REF]. A more recent study indicated that C. difficile was a rare cause of community-associated diarrhoea [START_REF] Tam | Longitudinal study of infectious intestinal disease in the UK (IID2 study): incidence in the community and presenting to general practice[END_REF]. The strength of our study lies in the large recruitment of patients from Paris and the surrounding areas and the diagnostic strategy based on GDH screening followed by a highly sensitive method for toxin detection (the stool cytotoxicity assay), as recommended by the European guidelines [START_REF] Crobach | European Society of Clinical Microbiology and Infectious Diseases: update of the diagnostic guidance document for Clostridium difficile infection[END_REF]. This strategy is highly specific for CDI and the presence of free toxins in stools have been shown to better correlate to disease severity [START_REF] Polage | Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era[END_REF][START_REF] Planche | Differences in outcome according to Clostridium difficile testing method: a prospective multicentre diagnostic validation study of C difficile infection[END_REF] as compared to detection of toxigenic strain (by PCR or by culture), which detects carriage of toxigenic strain and is likely to overestimate the true incidence of CDI. In addition, 86.04% of patients ≥ 3 years old with a positive CTA presented with either a clinical diarrhoea or a diarrheic stool, suggesting that they were truly infected with C. difficile rather than simply colonized.

Clinical features of patients with toxigenic C. difficile carriage

The survey data of patients with a positive CTA or the presence of a toxigenic strain of C. difficile indicated that more than half of these patients had not been hospitalized within the 12 weeks preceding the symptoms, suggesting that C. difficile carriage was truly community-associated. In addition, among these patients, 14.65% (for CTA) to 25.75 % (for TC) were < 65 years old, had not received any antimicrobial treatment in the preceding month and tested negative for other enteropathogens in the stools. These data highlight that a substantial proportion of communityacquired toxigenic C. difficile carriage occurs in young patients without traditional risk factors for CDI, as suggested by others [START_REF] Wilcox | A case-control study of communityassociated Clostridium difficile infection[END_REF][START_REF] Gupta | Community-acquired Clostridium difficile infection: an increasing public health threat[END_REF].

Under-recognized toxigenic C. difficile carriage in general practice

In France, there are no specific guidelines for testing C. difficile in diarrheic patients who visit their GP. Therefore, it is not surprising that CD testing was requested by GPs in only 12.93% of cases.

However, the testing which was requested was well-oriented and relevant, resulting in detection of 52.3 % and 56.09 % of TC-positive and CTA-positive patients, respectively. Nevertheless, there remains an important under-recognized diagnosis of toxigenic C. difficile carriage. Although we did not assess the clinical outcome of these undiagnosed patients with toxigenic C. difficile carriage, it has been shown that missed CDI are associated with significantly increased length of diarrhoea than identified cases [START_REF] Davies | Adverse outcomes for missed cases of CDI, results from retrospective data collection on patients with samples received during the EUropean, multi-centre, prospective bi-annual point prevalence study of Clostridium difficile Infection in hospitalised patients with Diarrhoea[END_REF], emphasizing the risk of adverse outcomes if CDI diagnoses are missed.

If CD testing is restricted to patients ≥ 65 years or to patients with a history of antibiotic use or previous hospitalization, then only 29.5% of all stool samples would be tested for C. difficile, resulting in the detection of 63.07% of all TC-positive and 70.73% of all CTA -positive patients. This strategy, which is currently recommended in UK for samples from the community, would clearly outperform current practice and would represent the best cost-effective strategy for the identification of toxigenic C. difficile carriage. However, 30% of toxigenic C. difficile carriage cases would be still missed, underlining the limitation of this strategy.

PCR ribotypes

We found an increased diversity of PCR ribotypes among strains isolated in patients from general practice. There was also an overlap in the strains isolated from community-associated cases and healthcare-associated cases, suggesting an interconnection of these two settings. The most predominant PCR ribotype (PR 014/020) only represented 13.25 % of all the isolates. These 2 PCR ribotypes were also the most frequent ribotypes (28%) in a cohort of Danish patients who had visited their general practice [START_REF] Soes | Risk factors for Clostridium difficile infection in the community: a case-control study in patients in general practice, Denmark, 2009-2011[END_REF] and were the 3rd most frequently found PCR ribotypes in the EUCLID study [START_REF] Davies | Diversity of Clostridium difficile PCR ribotypes in Europe: results from the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID), 2012 and 2013[END_REF]. In the study published by Hensgens et al. [START_REF] Hensgens | Diarrhoea in general practice: when should a Clostridium difficile infection be considered? Results of a nested case-control study[END_REF], the most common PCR ribotypes were 002 and 078 (11% each) followed by PCR ribotype 015 (9%), 014 (8%), 001 (8%), 005 (6%), and 126 (4%). In France, a multicentre study conducted in 2009 in 78 healthcare facilities showed that the most prevalent PR were 014/020 (18.7 %), followed by 078/126 (12.1 %) whereas the prevalence of PR 027 strains remained low (3.1 %) [START_REF] Eckert | Clinical and microbiological features of Clostridium difficile infections in France: the ICD-RAISIN 2009 national survey[END_REF]. In the present study, we did not identify any PR 078, which has been frequently associated with community-associated CDI in a young population. PR 078 strains found in animals and in humans have been shown to be genetically highly related, suggesting a foodborne interspecies transmission of C. difficile [START_REF] Debast | Clostridium difficile PCR ribotype 078 toxinotype V found in diarrhoeal pigs identical to isolates from affected humans[END_REF]. In Canada, PR 078 epidemic strains were found in vegetables from grocery stores [START_REF] Metcalf | Clostridium difficile in vegetables, Canada[END_REF] and are thought to be implicated in a substantial portion of community-acquired CDI.

This study has several limitations. First, we could not calculate the incidence of communityassociated toxigenic C. difficile carriage per 100,000 inhabitants, because the catchment area was unknown. Moreover, the population included in this study lived in Paris and the surrounding areas, and the results of the study cannot be extrapolated to the whole country. Second, investigation of the incidence of enteropathogens other than C. difficile was not systematically performed, although 1663 samples were both cultured for bacterial pathogens and submitted for parasitological examination. Third, this study was not designed to monitor patients with toxigenic C. difficile carriage; therefore, we could not assess the impact of carriage in the community in terms of mortality, hospitalization or quality of life.

In conclusion, this study shows that toxigenic C. difficile carriage is the second most frequent pathogen found in stool samples from patients who visited their GP but remains under-recognized.

Physicians should be aware that CDI may occur outside the hospital in patients without traditional risk factors for CDI.

  3.3 (R Core Team (2017). R Foundation for Statistical Computing, Vienna, Austria). Patient demographic characteristics were described by their median and interquartile range (IQR) for quantitative variables and by the frequency for categorical variables. Quantitative and categorical variables were compared between patients with or without CDI by Mann-Whitney-Wilcoxon and Fisher exact tests. Factors independently associated with a CDI were identified in 2 steps: 1) Factors associated with CDI were first explored by performing bivariate comparisons; 2) All factors significantly associated with a CDI (p value <0.05) were then entered into a multivariate logistic regression model. A p value of <0.05 was considered significant.

Figure 2 :

 2 Figure 2: Incidence of the different enteropathogens found in stools submitted for routine microbiological testing from patients who visited their general practitioner (GP) for diarrhoea or other gastrointestinal disorders. Note that of 2541 patients, 2199 had a bacteriological stool culture for Campylobacter sp., Salmonella sp., Yersinia sp., 2001 had a parasitological stool examination, 1663 had both, and 114 had viral testing for the presence of adenovirus and rotavirus antigens.

Figure 3 :

 3 Figure 3: Distribution of PCR ribotypes isolated from healthcare-associated, community-associated C. difficile carriage and from patients < 3 years old.

Figure 1 [Figure 2 Other:

 12 Figure 1

Table 1 :

 1 Factors associated with positive CTA or positive toxigenic C. difficile (multivariate analysis) in patients ≥ 3 years old.

			Toxigenic culture			CTA
	Variables	OR	(95%CI)	p	OR	(95%CI)	p
	Age
	3-16	0.998	0.987-1.022	0.910	1.002	0.974-1.030	0.526
	17-45	ref			ref
	46-64	0.992	0.974-1.010	0.401	0.988	0.952-1.025	0.459
	≥ 65	1.00	0.977-1.022	0.993	0.989	0.964-1.015	0.425
	Gender (Male)	0.988	0.974-1.003	0.132	0.997	0.981-1.014	0.799
	Abdominal pain	0.997	0.981-1.013	0.758
	Antimicrobials in the previous
	month	1.078	1.056-1.101	<0.001	1.058	1.034-1.082	<0.001
	Hospitalization in the previous
	12 weeks	1.042	1.008-1.078	0.015	1.049	1.014-1.085	0.005
	Diarrhoeal stools*	1.017	1.002-1.032	0.025	1.004	0.986-1.022	0.635
	Stools with blood or mucus	-	-	-	1.979	0.911-1.053	0.582
	* taking the shape of the container

Table 2 :

 2 Performance of different algorithms for testing diarrhoeal stool samples for C. difficile in patients who visited their GP. Prevalence of toxigenic culture (TC) and stool cytotoxicity assay (CTA) according to patients' age group

						Detection of
						toxigenic CD	Detection of CD
		No	Patients tested	Positive	Positive	carriage	toxins
	Test algorithm for CDI in	patients	(% of all stool	results for	results for	(compared to all	(compared to all
	samples from GP	tested	samples)	CT (%)	CTA (%)	positive CT) (%)	positive CTA) (%)
	All ≥ 3 years	2435	100	2.67	1.68	100	100
	≥ 65 years	397	16.30	4.28	3.02	26.15	29.27
	Previous AB	324	13.30	9.57	6.79	47.69	53.65
	Previous hospitalization	113	4.64	8.84	6.19	15.38	17.07
	≥ 65 years OR previous AB	660	27.10	6.06	4.24	61.53	68.29
	≥ 65 years OR previous
	hospitalization	482	19.79	5.19	3.73	38.46	43.90
	≥ 65 years OR previous AB
	OR previous hospitalization	719	29.53	5.70	2.64	63.07	70.73
	Physician's request	315	12.93	10.79	7.30	52.30	56.09

Acknowledgements

We thank W. Castella and L. Sakka for their technical assistance with diagnostic tests Ethical approval: The study protocol was approved by the local Research Ethics Committee.

Informed consent: Yes

Funding/Support:

The study was sponsored by the Association Robert Debré pour la recherche médicale". Alere provided a research grant to the "Association Robert Debré pour la recherche médicale" based on the study protocol.

Alere had no role in study design and conduct, and was not involved in data collection, data management, or data analysis and interpretation. Alere provided editorial assistance with grammar and English language editing.

Conflict of Interest:

Frédéric Barbut reports grants, personal fees and non-financial support from Astellas, personal fees from Pfizer, grants and personal fees from Sanofi Pasteur, grants and non-financial support from Anios, grants, personal fees and non-financial support from MSD, grants from Biomérieux, grants from Quidel Buhlman, grants from Diasorin, grants from Cubist, grants from Biosynex, grants from GenePoc, grants from Alere, grants from Cepheid; Nesrine Day reports reports grants, personal fees from Alere Stéphane Bouée is an employee of CEMKA, who received a grant by Alere, to perform the statistical analysis.

Catherine Eckert reports non-financial support from Astellas and Mobidiag.

Anlyata Youssouf, Laurence Grandvoinnet, Valérie Lalande, and Jeanne Couturier has no conflict of interest


Brigitte Chamak
email: brigitte.chamak@parisdescartes.fr

The case of autism and the controversy over packing therapy in France

Keywords: France, social movements, lobbying, controversy, autism, psychiatry, packing, association leaders

The controversy over packing therapy used in psychiatry was studied here to illustrate how leading associations can influence public health policies. The main French associations of parents with autistic children succeeded in obtaining the prohibition of packing, announced by the French Secretary of State to the Ministry of Health in April 2016. Parents and professionals who had observed the positive effects of packing when nothing else worked for their part wondered what could be done for self-harming patients. The political authorities followed the opinion of the main associations of parents with autistic children at the expense of that of professionals. In this paper, the actions and discourse of the associations against packing are explored, as are the arguments of the psychiatrists who defend packing therapy.

The different phases in the controversy from the first opposition in 2005 and the role of opinion leaders in associations are analyzed. The strategies to discredit psychiatry and to promote behavioral methods are also studied to understand the shift in the balance of power from professionals to association leaders. The mobilization of the associations prompted some psychiatrists to conduct evidence-based research and to formalize their practice. The controversy over packing, involving political decision-making processes, ethical issues and clinical questions, enables us to illustrate a case of lobbying by associations.

Introduction

Social movements are increasingly contributing to the production of public action, and health social movements are an important political force for health access and quality of care [START_REF] Brown | Social movements in health: an introduction[END_REF]. Some of these movements have acquired a growing influence and have contributed to shaping the relationships between health professionals, politicians, and economic markets [START_REF] Callon | The Growing Engagement of Emergent Concerned Groups in Political and Economic Life. Lessons from the French Association of Neuromuscular Disease Patients[END_REF][START_REF] Epstein | Measuring success: scientific, institutional and cultural effects of patient advocacy[END_REF]. On the basis of their claim for collective representation, associations have gained increasing recognition in most Western countries in the last few decades [START_REF] Raz | Representing autism: challenges of collective representation in German and Israeli associations for and of autistic people[END_REF]). However, a representation gap between associations of people with disabilities and associations intended to support them has been evidenced [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF][START_REF] Chamak | Autism and social movements in France: exploring crosscultural differences[END_REF][START_REF] Raz | Representing autism: challenges of collective representation in German and Israeli associations for and of autistic people[END_REF]. There is a great heterogeneity across the different associations, from those that are powerful and wellestablished to newly-born associations. The most powerful organizations in some cases conduct lobbying activities with the government authorities, as already illustrated in the USA [START_REF] Canal | Autism in the US: social movement and legal change[END_REF].

Lobbying, once the preserve of economic and financial groups, is now currently used by a diversity of players, including associations [START_REF] Saurugger | Les groupes d'intérêts entre démocratie associative et mécanisme de contrôle[END_REF]. A recent theoretical model conceptualizes lobbying as a mechanism of persuasion [START_REF] Hall | Lobbying as legislative subsidy[END_REF]. Only a few studies have focused on the changes occurring in the associations of parents with autistic children, and the development of political lobbying [START_REF] Canal | Autism in the US: social movement and legal change[END_REF][START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF][START_REF] Rios | The changing face of autism in Brazil[END_REF]. Yet these changes provide useful information in understanding global changes in society, and the role of health social movements [START_REF] Brown | Social movements in health: an introduction[END_REF][START_REF] Snow | Mapping the Terrain[END_REF]. How do they succeed in influencing political decisions? Does this mean it is participative democracy, or is it political lobbying? In this paper, the controversy over packing in France has been used to provide an empirical starting point to scrutinize these issues. Eyal et al. (2010) and [START_REF] Silverman | Understanding autism: parents, doctors, and the history of a disorder[END_REF] stressed the crucial role of the parent movement in blurring the boundaries between experts and laypersons, and in extending the category of autism to include less typical manifestations. Eyal et al. (2010) underlined the central position of Bernard Rimland, a psychologist and parent of an autistic child, in a nascent parent movement, in a network of expertise around the parent-researcher-activist-therapist, and in the alliance with behavioral therapists. They showed how Rimland promoted alternative biomedical interventions in autism, in particular vitamin therapy, supplements, and special diets, and how he favored a coalition of parents, health practitioners and researchers interested in biomedical treatments for autism. This led to the formation of Defeat Autism Now! the main proponent of the link between autism and vaccination. [START_REF] Silverman | Understanding autism: parents, doctors, and the history of a disorder[END_REF] focused on the role of parent advocates in autism research, and their efforts to mobilize networks for information-sharing and lobbying. In the USA, the close working relationship between the Congressional Autism Caucus (known as CARE) and autism advocacy groups played a crucial role in this influence [START_REF] Baker | Comparative policy entrepreneurship: The case of autism-related policy in North America[END_REF].

Lobbying by associations in autism

Currently, large organizations such as Autism Society of America and Autism Speaks are at the center of autism activism in the USA. Autism Speaks set up a very active fund-raising strategy using the power of celebrities to draw attention to the condition [START_REF] Canal | Autism in the US: social movement and legal change[END_REF]. The fact that media moguls such as Bob Right have become personally involved in issues around autism has certainly changed the movement. Most funds collected for autism have been devoted to research. By depicting autism as a mainstream public health threat, the main lobbyist for Autism Speaks, Craig Snyder, persuaded the public authorities to devote a substantial amount of money to autism research [START_REF] Wayne | Spending surge on autism outpaces understanding[END_REF]. The 2006 Combating Autism Act allocated nearly one billion dollars over five years, approximately doubling expenditures on existing programs, including a significant increase in spending for biomedical research in autism. In addition, the US Department of Defense has established its own Autism research program [START_REF] Canal | Autism in the US: social movement and legal change[END_REF]. For Alex [START_REF] Wayne | Spending surge on autism outpaces understanding[END_REF], "Spending surge on autism outpaces understanding" and "the reason lies in an increasingly effective lobbying campaign" by parent associations. Following the declaration of a prominent parent-lobbyist: "This bill is a federal declaration of war on the epidemic of autism", Ari Ne'eman, the president of Autistic Self Advocacy Network (ASAN), criticized the Combating Autism Act, considering that the "War on Autism" approach is not in the interests of people on the spectrum. It offends and alienates the autistic community" [START_REF] Asan | Comments at November 30, 2007 IACC Meeting | Autistic Self Advocacy Network[END_REF]. However, the Combating Autism Reauthorization Act was voted in 2011 (900 million dollars), and the Autism CARES Act of 2014 authorized 1.3 billion dollars to fund autism research for the fiscal years 2015-2019 [START_REF] Marcos | House votes to reauthorize autism support programs[END_REF].

2. Parent associations and the context in France

Associations are historically linked to political actions, and are considered as spaces for mobilization, engagement, learning about collective action, and training of citizens. In France, the mobilization of parent associations followed different orientations. In the 1960s, the associations denounced the lack of funding and facilities devoted to autism, and set up the first day hospital for children in Paris [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF]. Since then, the proliferation of medico-social establishments for disabled people managed by associations receiving public funding has characterized the French system (currently, associations manage 87% of this nonprofit sector) [START_REF] Barreyre | Bilans et perspectives d'un secteur non identifié: le médico-social[END_REF][START_REF] Robelet | Les transformations des modes de contrôle croisés entre associations et autorités publiques dans le secteur du handicap[END_REF]. For a long time, autism expertise was the monopoly of psychiatry and psychoanalysis in France. Most French psychiatrists have favored a psychodynamic approach involving different professionals with the aim of fostering exchanges through different interventions in the fields of therapy, education, social interaction, sport and cultural activities [START_REF] Hochmann | Troubles envahissants du développement: les pratiques de soins en France[END_REF]. However, more and more parents have denounced the psychoanalytical approach as favoring feelings of guilt among parents [START_REF] Méadel | Le spectre "psy" réordonné par des parents d'enfant autiste. L'étude d'un cercle de discussion électronique[END_REF]. Etiological conceptions linking autism to maternal depression, such as the "refrigerator mother" theory, played a crucial role in parent mobilization to counter the stigmatization of mothers, and to promote intensive educational and behavioral methods [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF][START_REF] Méadel | Le spectre "psy" réordonné par des parents d'enfant autiste. L'étude d'un cercle de discussion électronique[END_REF][START_REF] Demailly | Le champ houleux de l'autisme en France au début du XXIème siècle[END_REF].

In the 1980s associations of parents founded institutions oriented towards educational programs [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF]. The adoption of the new American and international classifications of autism with enlarged diagnostic criteria in the 1990s and the development of behavioral methods in the USA gave rise to a large-scale mobilization around the changes in the definition of autism and related interventions in many countries. The psychoanalytic influence has persisted much longer in France than in the USA with a gap of approximately 20 years between the generalization of cognitive and behavioral methods in the USA compared to France [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF]. This context has induced a shift in the attitudes of the parent associations from an alliance with certain psychiatrists to an offensive posture against psychiatrists who draw on psychoanalysis [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF]. A new generation of associations that emerged in the 1990s and 2000s depicted autism as a major health issue, denounced the psychiatric monopoly by the French psychiatrists, refused the definition of autism as a psychosis, and the psychoanalytic orientation [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF][START_REF] Borelle | Diagnostiquer l'autisme. Une approche sociologique[END_REF]. The redefinition of autism as an organic condition was an important strategy to counteract the psychoanalytic hypotheses. Political lobbying by parent activist associations succeeded in gaining recognition of autism as a "disability" in 1996 (Chossy act of 11 December 1996), not only to guarantee social benefits but above all to move away from psychiatry, and enable the generalization of cognitive and behavioral methods [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF]. The same process and antagonism with mental health professionals was described in Brazil in 2012 [START_REF] Rios | The changing face of autism in Brazil[END_REF].

3. The controversy over packing therapy

The controversy over packing therapy that started in the mid-2000s is studied here to illustrate the role of the parent associations in influencing public health policies. Packing therapy consists in wrapping the patient in wet towels (cold or not), and then wrapping them in blankets to help the body warm up in a few minutes. This procedure lasts about one hour, and involves two to four therapists. Packing therapy is used in a few French or Swiss hospital units to treat catatonia, anorexia or severe self-injury, and when usual psychotropic drugs are not working [START_REF] Cohen | The use of packing in adolescents with catatonia: a retrospective study with an inside view[END_REF][START_REF] Consoli | Lorazepam, fluoxetine and packing therapy in an adolescent with disintegrative disorder and catatonia[END_REF][START_REF] Delion | Therapeutic body wraps (TBW) for treatment of severe injurious behaviour in children with ASD: a 3 month randomized controlled feasibility study[END_REF][START_REF] Goeb | Les enveloppements humides initialement froids (packings) sont efficaces dans les troubles graves du comportement chez les enfants et adolescents autistes[END_REF][START_REF] Opsommer | Therapeutic body wraps in Swiss public adult acute inpatient wards[END_REF]. Violence among mental health patients and the treatment of severe auto/hetero-aggressive behaviors is a complex issue in psychiatry, thus creating tension between care and control [START_REF] Brodwin | The practice of constraint in psychiatry: emergent forms of care and control[END_REF]Gansel and Lézé, 2015;[START_REF] Lobry | Effectiveness of wet sheet packs in children and adolescents with severe auto/hetero aggressive behaviours: an exploratory approach[END_REF]. Suffering, manifestations of extreme distress, and self-harm are difficult issues for professionals trying to relieve their patients, and packing therapy is sometimes prescribed to treat these symptoms.

However, recent controversies have emerged [START_REF] Spinney | Therapy for autistic children causes outcry in France[END_REF]. The main French associations of parents with autistic children are fiercely opposed to packing therapy [START_REF] Borelle | La controverse autour de l'autisme. Les associations de parents et la qualification du handicap de l'enfant[END_REF]. They consider that it is an unethical approach that lacks evidence-based studies to support the treatment. Despite the testimonies of parents who observed a real benefit for their children [START_REF] Allione | Autisme. Donner la parole aux parents[END_REF]Emeyé, 2015), hostility toward packing spread and the parent associations called for a ban. They succeeded in obtaining it in April 2016. The aim of this paper was to analyze the controversy over packing therapy, and the role of key association leaders in the ban on packing in France. We explored their actions and their discourse describing the packing method as horrible and risky. We also looked at the arguments of the psychiatrists who defend packing therapy as a useful tool when nothing else works. This controversy, involving political decision-making processes, ethical issues and clinical questions, enables us to illustrate a case of lobbying by associations.

Methodology

The controversy over packing was investigated through press coverage obtained using "packing" as the keyword in the main journals and magazines in France (about 60 press articles), on parent association websites (Autisme France, Vaincre l'autisme), and in 35 books by parents, as well as in discussions on an Internet Yahoo forum created for parents of children with autism (1327 email exchanges about packing from 2006 to 2017). On the Doctissimo forum (French-language website dedicated to health), the exchanges posted on the forum between 2007 and 2008 were followed on the topic: "What do you think of the practice of packing?" Preliminary coding involved reading the extracts multiple times to look for patterns in the data. Extracts, which talked about packing in a similar way, were grouped together. The most representative extracts of the exchanges have been quoted in the paper (part 3.3). 2014,2015). The interviews with psychiatrists enabled us to gather and analyze papers on packing published in international scientific journals (10). For the historical perspective, papers from [START_REF] Harmon | Nursing care in a state hospital before and during the introduction of antipsychotics, 1950-1965[END_REF][START_REF] Harmon | Hydrotherapy in state mental hospitals in the mid-twentieth century[END_REF] in Issues in Mental Health Nursing were helpful, and references from 1916 to 1990 (6 in French and 5 in English), were found in 12 books written by French professionals.

Reports produced by different institutions (Haut

Results

The history of packing

Different forms of wrapping have been used therapeutically for centuries in hospitals for mental illnesses [START_REF] Wright | Hydrotherapy in hospitals for mental diseases[END_REF]. This approach was considered as one of the main tools in psychiatry until the 1930s. In the first half of the 20 th century, nurses were the primary practitioners of wrapping and hydrotherapy in the USA [START_REF] Harmon | Hydrotherapy in state mental hospitals in the mid-twentieth century[END_REF]. Whether the nurse applied hot or cold sheets depended on what the physician prescribed [START_REF] Braslow | Mental ills and bodily cures: psychiatric treatment in the first half of the twentieth century[END_REF]. [START_REF] Harmon | Nursing care in a state hospital before and during the introduction of antipsychotics, 1950-1965[END_REF] found that all the nurses who had administered wet sheet wraps concurred on their calming effect. The retired nurses interviewed for this research believed they were helping, not hurting, patients with these treatments [START_REF] Harmon | Nursing care in a state hospital before and during the introduction of antipsychotics, 1950-1965[END_REF]. However, the sheet wraps were sometimes used not only as sedative therapy, but also as a method of therapeutic restraint [START_REF] Weiss | Attitudes in psychiatric nursing care[END_REF]. This approach declined in the middle of the last century, not due to a "lack of effectiveness" but because it was replaced by new pharmacological therapies that required fewer nursing staff (Braslow, 1997, p. 51).

In the 1950s, wrapping and hydrotherapy was viewed as a technological alternative to sedatives, barbiturates and more invasive methods. The American Michael Woodbury used wet sheet packs routinely at Chestnut Lodge, an asylum in Rockville, Maryland. The aim was to stimulate the body schema and to avoid self-injury without using drugs or isolation [START_REF] Woodbury | L'équipe thérapeutique : principe du traitement somato-psycho-social des psychoses[END_REF]. The French psychoanalyst Paul-Claude [START_REF] Racamier | L'enveloppement humide : souvenirs et perspectives[END_REF] remembered his first observation of wet sheet packs in 1961 when he was at Chestnut Lodge. He explained that no medication was used and "there was a need to cope with the agitation of some patients" (p. 286). At the end of the 1960s, Woodbury introduced the therapy to France and to Switzerland.

The arguments of the advocates of packing

In the 1980s, Pierre Delion, a child psychiatrist at Lille Regional University Hospital in northern France, pioneered packing for children, and especially for autistic children who selfharm. He explained that members of staff were constantly attentive to the patient during the packing session [START_REF] Delion | Le packing avec les enfants autistes et psychotiques[END_REF]. He argued that the wrapping and the warming up following the initial chill helped the patient achieve a sense of containment [START_REF] Delion | Le packing avec les enfants autistes et psychotiques[END_REF]. In order to explain the relief of symptoms obtained, he developed psychoanalytic interpretations. For him, packing reinforces the child's awareness of his bodily limits, and decreases the sense of fragmentation. Once calmer and more aware of his surroundings, the child is able to listen and talk [START_REF] Delion | Le packing avec les enfants autistes et psychotiques[END_REF]. Theoretical interpretations were developed in reference to the "Moi-peau" theory [START_REF] Anzieu | Le Moi-Peau[END_REF]. Reference to the concept of holding and the idea of a restructuring of the body map is widespread among occupational therapists and psychoanalysts. David Cohen is the head of the child and adolescent psychiatry department at La Pitié-Salpêtrière hospital in Paris, where packing is used alongside specialized education and medication for severely autistic and schizophrenic children (only a few cases). He considers packing not as a therapy for autism but as a form of "bodily mediation" used to relieve sensory problems and to prevent self-injury. For him, the history of packing is linked to the history of hydrotherapy [START_REF] Alberne | L'enveloppement humide thérapeutique[END_REF] and there is no need to call on psychoanalytic concepts to account for the improvement of patients who have experienced packing. David Cohen considers packing therapy as a sensory integration approach, useful for subjects who have a sensory integration dysfunction (autistic people, adolescents with catatonia). In his unit, occupational therapists and nurses carry out packing after having explained the procedure and obtained consent from parents and patients (Lefevre-Utile, 2015). David Cohen mentioned a 1988 paper published in the American Journal of Psychiatry, which concluded that the treatment was safe and had interesting and useful effects that went beyond mere restraint [START_REF] Ross | The psychiatric uses of cold wet sheet packs[END_REF].

Not only psychiatrists but also parents defend packing [START_REF] Allione | Autisme. Donner la parole aux parents[END_REF][START_REF] Éméyé | Le voleur de brosses à dents[END_REF].

The journalist Églantine Éméyé, mother of a disabled child with autism, wrote a book (Éméyé, 2015) and produced a film: "Mon fils, un si long combat" (France 5, January, 2014) in which she illustrated the difficulties in dealing with a child with a tendency to inflict severe self-harm, and the help of packing in this case. Her film triggered a backlash from parents and leading associations opposed to packing, as shown by the exchanges on the Internet Yahoo forum between January and February 2014. This example illustrates the tensions between parents who are convinced of the superiority of the cognitive and behavioral methods and parents who have not seen any improvement for their child with these methods, and experienced other approaches.

The arguments against packing

Various arguments have been put forward by presidents of associations and by parents on different forums (Yahoo group, Doctissimo). Ethical issues have been raised: 1) wrapping a patient in cold wet towels is perceived as ill-treatment; 2) children who cannot speak cannot give or withhold their consent; 3) some parents were not informed that packing was used for their children. Questions about health risks such as hypothermia or psychological risks have also been raised. Packing is particularly stigmatized as an archaic approach proposed by psychoanalytically oriented psychiatrists. Finally, the question of funding has been underlined: state money spent on packing would be better spent on educational and behavioral methods for teaching children to communicate. Applied Behavioral Analysis (ABA), conceived by Ivar Lovaas at the University of California, has been called for by parent associations. This method, used for young children, involves a professional who discourages behavior considered as bad, and reinforces anything good with smiles, sweets or other things the child enjoys [START_REF] Schreibman | The Science and fiction of autism[END_REF]. The behavioral method has evolved over time and more educative and cognitive approaches have been introduced. Anger was also expressed in terms such as "a revolting practice", "degrading treatment". In In France, the interventions on autism are mainly psychoanalytic. This approach has failed and is damaging since its monopoly has prevented the setting up of efficient interventions. On this forum, we are all against psychoanalysis used for autism. This is why your mention on the forum of harmful methods that we thought had disappeared, we were dismayed.

A mother expressed her disapproval of the aggressive reactions (I 02/16/2006):

Rather than jumping at her throat, we could have explained her why this website is so bad, and we could have suggested some books to get proper information. It is a mistake to say that this website is not useful because we have an enemy that we must fight and we need to know what it is. The psychoanalysts wanted the entire world to believe that we were responsible for our children's autism. Therefore, it is natural to want them to disappear. We are angry… On March 3, 2006, a circular from the president of the Léa pour Samy association aimed to mobilize opinion against hospitalization and the use of packing for an 8-year-old boy. The administrator of this association used the forum to disseminate the information (10/03/2006).

Throughout 2006, messages against packing were broadcast:

There's no need to think much about packing to realize the horror of the method. I feel upset to know that this method still exists, that children can be tortured without being able to say: "stop torturing me!" Just thinking about it makes me feel sick (MCB 10/15/2006).

In November, parents suggested writing negative comments on the websites selling Delion's books.

On March 27, 2007, it was announced that a legal action against the French State was to be undertaken by parents for neglect and ill-treatment towards children with autism. On April 17, 2007, parents posted opinion on the forum to express their anger. They were shocked by the documentary on packing broadcast on the channel France 5. A representative from Léa pour Samy wrote:

To respond to this shameful defense of incompetence and institutionalized sadism, we should write a letter to the editorial team of France 5. We also call parents to send letters to the Ministry of Health (K, 04/18/2007).

Exchanges on Doctissimo: "packing as an archaic method"

The forum about packing posted in May 2007 on Doctissimo involved parents and young professionals asking for information. Some parents who were also professionals in educational and behavioral methods explained what to do to other forum participants. One of them explained that behaviorism is the best approach to self-harm (Pos60wy, 05/30/2007).

Other exchanges on the same issue, published from March 2008 to May 2008, involved parents, a psychiatric nurse and a psychoanalyst. Both parents of children with autism and the psychiatric nurse who exchanged on the forum considered packing as an archaic method associated with psychoanalysis. A mother who saw the video on packing used in a day-care hospital considered that the child was not being forced and appeared calm and relaxed. She wondered whether this artificially initiated intimate moment might not be a good thing, but the other parents intervened to compare packing to a cold shower and to ill-treatment. Thus the interpretation of images differs with personal views and beliefs. When a psychoanalyst explained that packing had a calming effect on anxious children, one parent argued that there was no validation of this method. Those who expressed positive arguments on packing were criticized and mocked, and psychoanalysts were compared to gurus. Given the hostility towards their arguments, the advocates of packing rapidly gave up any attempt to argue.

The different phases of the controversy

No controversy over wet sheet packs was noted before the mid-2000s. The controversy was sparked when a short documentary (less than 8 min) was aired on French TV on 17 April 2007 (https://www.dailymotion.com/video/xpa9d7). A day-care hospital in Bordeaux using packing was the focus of this documentary, which triggered strong reaction from Autisme France and Léa pour Samy. Autisme France officially complained to the TV channel and to the French Health Minister in a letter entitled "Stop the ill-treatment of autistic children!" (18 April 2007).

Delion emphasized that parental consent was always sought, and that a psychiatrist would explain to the child what was going to happen, sometimes with the help of a doll. He argued that no child was forced to accept the pack. His book on packing was launched [START_REF] Delion | La pratique du packing: Avec les enfants autistes et psychotiques en pédopsychiatrie[END_REF] and a French hospital clinical research program (PHRC) entitled "demonstration of the efficacy of packing treatments in children with autistic disorder with severe behavioral impairments" was accepted. The protocol was approved in 2008 by the ethics committee of the University Hospital Centre (CHU) of Lille, and the research was undertaken by Delion and his collaborators. After numerous difficulties caused by the fierce opposition of the leading associations and the mobilization of their members, the results have recently been published [START_REF] Delion | Therapeutic body wraps (TBW) for treatment of severe injurious behaviour in children with ASD: a 3 month randomized controlled feasibility study[END_REF].

The mobilization of the associations against the use of packing spread (as illustrated by exchanges on the Yahoo forum). On 2 April 2009, the World Autism Awareness Day, M'Hammed Sajidi, the president of "Léa pour Samy" (in 2010, the association changed its name for Vaincre l'autisme), organized a demonstration on the Pont des Arts in Paris against packing, with demonstrators wrapped in sheets. He called for a moratorium on packing (see http://www.vaincrelautisme.org/content/action-contre-le-packing). In June 2009, the Health Minister, Roselyne Bachelot, asked for the opinion of the French High Council of Public Health, which in February 2010 published a report in favor of packing in controlled conditions, considering that to date packing did not pose any identified risk.

The parent associations were upset, and more and more letters were sent to the hospital directors to oppose packing. Evelyne Friedel, the president of Autism-Europe, seized the opportunity of the Autism-Europe International Congress in Sicily in October 2010 to recruit visiting specialists to publish a letter opposing packing in the Journal of American Academy of Child & Adolescent Psychiatry in February 2011. They "reached a consensus that practitioners and families around the world should consider this approach unethical" (Amaral, et al., 2011, p. 191).

In March 2011, on Sajidi's initiative, Pr. Christopher Gillberg, president of the scientific committee of Vaincre l'autisme, officially announced the launch of the Manifesto against packing at the Glasgow conference, "No Mind Left behind" (29-30 March). The participants were invited to sign the manifesto. In September 2011, a documentary about autism and against psychoanalysis, Le Mur, authored by Sophie Robert and funded by the association "Autistes Sans Frontières" was widely broadcast. This film was both an attack on psychoanalysis and a promotion of behavioral methods.

In December 2011, Vaincre l'autisme filed a procedure against Pierre Delion and David Cohen to the College of physicians. They were heard in April 2012. They explained their practices, and the case was closed. On 20 January 2012, a right-wing Member of Parliament, Daniel Fasquelle, who backed up the position of the associations, proposed a law to ban psychoanalysis for autism. On March 2012, the film against packing by Vaincre l'autisme (2012) was broadcast, with its horror-film overtones, despite the fact that the president of this association declared he had never witnessed, nor did he want to witness, any packing sessions [START_REF] Vincent | L'enveloppe qui déchire[END_REF]. Two days later, the Haute Autorité de Santé (HAS) (2012) published autism recommendations that classified packing as formally contra-indicated.

Testimonies from parents who were satisfied with the use of packing for their children had been published [START_REF] Allione | Autisme. Donner la parole aux parents[END_REF](Allione, : Éméyé, 2015) ) but the parent associations criticized these testimonies. On a TV show [START_REF] Canal | Autism in the US: social movement and legal change[END_REF], Églantine Éméyé mentioned the criticisms and even the threats against her because of her testimony in favor of the packing for her son. She was accused of mistreating her son. The mobilization of Autism Europe succeeded in prompting a visit from inspectors of the European Committee for the Prevention of Torture in 2012 to La Pitié-Salpêtrière hospital. They concluded that "there was no need for further investigations" (interview with David Cohen, 01/31/2016). During their visit in November 2013 to La Pitié-Salpêtrière hospital, the inspectors sent by the "Contrôleur général des lieux de privation de liberté" (in charge of inspecting prisons and other places of internment) found that the rights of children and adolescents were respected, as were the therapeutic and ethical procedures prior to the use of packing, which was implemented on medical prescription only and with the parental consent. Two Master theses in ethics produced by a psychiatric nurse, illustrated the precautions taken in La Pitié-Salpêtrière hospital when packing was used [START_REF] Lefevre-Utile | Enjeux éthiques de la pratique du packing en pédopsychiatrie[END_REF], 2015).

Under the chapter: "The time of hatred", Pierre [START_REF] Delion | Therapeutic body wraps (TBW) for treatment of severe injurious behaviour in children with ASD: a 3 month randomized controlled feasibility study[END_REF] Following the HAS recommendations, she adopted the UN position which considers packing as a form of maltreatment (The UN Committee on Children's Rights, 2016). On May 3, she addressed a circular to the regional public health agencies requesting them not to subsidize establishments that used packing, and to cancel any training or information sessions on packing. This decision was considered as a victory by the parent associations campaigning for the ban, but other parent associations, such as the RAAHP (Rassemblement pour une approche des Autismes Humaniste et Plurielle), and practitioners caring for patients rejected by schools and other services, were upset. The parents and the professionals who observed the positive effects of packing wondered what could be done for self-harming patients. Given the irreversibility of certain lesions and self-injuries, some medical practitioners took the view that banning packing treatment was a form of withdrawal of care.

The controversy and the mobilization of parent associations prompted psychiatrists to conduct "evidence-based research" and to formalize their practice. Since 2007, several papers have been published by authors who have investigated the use and efficacy of packing therapy among children and adolescents with severe self-harm behaviors or catatonia [START_REF] Cohen | The use of packing in adolescents with catatonia: a retrospective study with an inside view[END_REF][START_REF] Consoli | Lorazepam, fluoxetine and packing therapy in an adolescent with disintegrative disorder and catatonia[END_REF][START_REF] Delion | Therapeutic body wraps (TBW) for treatment of severe injurious behaviour in children with ASD: a 3 month randomized controlled feasibility study[END_REF][START_REF] Goeb | Les enveloppements humides initialement froids (packings) sont efficaces dans les troubles graves du comportement chez les enfants et adolescents autistes[END_REF][START_REF] Lobry | Effectiveness of wet sheet packs in children and adolescents with severe auto/hetero aggressive behaviours: an exploratory approach[END_REF]. These authors concluded that packing seemed to be a feasible and useful adjunct treatment for catatonia and could be effective in relieving auto and hetero-aggressive behaviors. A retrospective study on a cohort of 172 adult patients suffering from serious mental illness showed that body wraps were potentially associated with a reduction in the use of both anxiolytic and neuroleptic drugs [START_REF] Opsommer | Therapeutic body wraps in Swiss public adult acute inpatient wards[END_REF]. Despite these publications, the public authorities did not revise the ban on packing. Recently, a psychiatrist received a dismissal letter (01/10/2019) from a medical-educational center run by an association in the Paris urban area for offering packing sessions for an autistic teenager who had broken an educator's nose. The teenager was also kicked out of the center.

The increasing influence of lobbying by opinion leaders in associations

The packing ban is the result of intense lobbying by a new generation of parent associations that questions psychiatric authority and knowledge. Lobbying involves media actions. These associations increased their impact through websites and contacts with the media. They undertook legal actions via Autism Europe (complaint to the European Committee on Social Rights), and developed lobbying strategies with the political authorities, the decision makers, and the scientific community. They have succeeded in being present in the various committees in charge of political action on autism (national Autism plans), and in charge of developing and implementing recommendations (HAS, Centres Ressources Autisme, Agences régionales de Santé). They are also in the committees of foundations that fund research on autism (Fondation de France, Fondation Orange, etc.), and in the research [START_REF] Demailly | Le champ houleux de l'autisme en France au début du XXIème siècle[END_REF]. Their way of thinking is similar to that of political and health authorities, with a tendency to promote performance, competition, evaluation, and efficiency, with the assumption that we only manage well what we measure. In the scientific community, their allies are researchers who are demanding more funding for neuroscience and genetic research [START_REF] Demailly | Le champ houleux de l'autisme en France au début du XXIème siècle[END_REF]. There is a conjunction of interests between numerous actors: researchers in cognitive science, some psychologists and psychiatrists, certain geneticists, cognitive and behavioral methods practitioners, parents seeking solutions, political authorities who have to take decisions, and promote markets and job creation (private services).

Another lever was the training of parents and professionals in order to homogenize knowledge on autism. This training is a market, and some of the parents became professionals in autism. In the 2013-2017 Autism Plan, more than one million euros were devoted to parent training. The market for this training was however fraught with conflicts of interest, since the leader of one of the training companies financed by public funds is the life partner of the special advisor to the Secretary of State who prohibited packing. Some association leaders succeeded in convincing the parents, the media, and the public authorities that their definition of the problem of autism was the right one. The associations referred to international classifications and scientific publications, giving their demands more credibility [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF]. However, it is important to mention the great heterogeneity among associations. The local associations that collaborate with health care professionals are quite different from the associations engaged in the political lobbying described above. The objective of the local associations is to provide assistance for families and their children.

However the new government policies aiming to restructure the sector and favoring the large management agencies may force them to call upon the services of these agencies, such as AFG. The parents who succeeded in creating establishments and services realized that the orientation of their services could be controlled by management agencies, or directly by new managers trained in business school, with the main aim of rationalizing costs. When they discredit the public services and promote private services, the association leaders contribute to reinforcing the management trend in the medical and social sectors.

Conclusion

How do leading associations succeed in influencing political decisions?

Media and legal actions, lobbying strategies with the political authorities, the decision makers, and the scientific community, service management agencies, and training of parents and professionals are various ways used to influence political decisions, and to homogenize knowledge on autism. [START_REF] Baker | Comparative policy entrepreneurship: The case of autism-related policy in North America[END_REF] explored the question of the success of parent associations in orientating public policies on autism in Canada and the USA. By promoting the idea of autism as a treatable disease, and the use of ABA, some parent associations have simplified the issue. In the case of issues that are technically or scientifically complex, "the public and other stakeholders are (consciously or not) especially interested in simplification of the issue" (Baker & Steuernagel, 2009, p. 235). [START_REF] Hansen | Gaining access: congress and the farm lobby, 1919-1981[END_REF] argues that lobbies are influential "because they determine the kinds of information about constituents that are available and the kinds of information that are not" (p. 3). Lobbying is thus defined as a game with asymmetric information [START_REF]Interest groups: money, information and influence[END_REF].

Why are some organizations more successful than others? The success of certain organizations compared to others is linked to their long-established links with the political authorities, public managers, and the media. The parent association supporting packing therapy is a new association founded in 2014, and their arguments are not in accordance with the main claims of the leading parent associations followed by the political authorities in designing policy. Thus, a different point of view is problematic because it introduces complexity and calls into question the relevance of the policy. Parents who are grateful to psychiatrists who used packing because they noticed the positive impact on their children rarely speak up, and when they do they face great hostility from other parents (through the websites exchanges, and in the media). In addition, the psychiatrists who defend packing have become less numerous, since the new generation of psychiatrists are often not trained in this method, and increasingly subscribe to cognitive and behavioral approaches (interviews and publications). At international level, cognitive and behavioral methods are gaining momentum and support all over the world, and their limitations are underestimated [START_REF] Warren | A systematic review of early intensive intervention for autism spectrum disorders[END_REF].

Exchanges between parents and professionals have long been characterized by asymmetrical relationships. However, certain well-organized parent associations have been involved in decision-making processes, as shown by the fact that various countries have legislated on patient and parent involvement in joint governmental committees dealing with health policies [START_REF] Raz | Representing autism: challenges of collective representation in German and Israeli associations for and of autistic people[END_REF]. Several studies have shown that patient associations have joined forces with established actors in the production of medical and scientific knowledge [START_REF] Epstein | The construction of lay expertise: Aids activism and the forging of credibility on the reform of clinical trials[END_REF]Akrich, 2008[START_REF] Rabeharisoa | Evidence-based activism: patients', users' and activists' groups in knowledge society[END_REF]. The notion of "evidence-based activism" has been proposed to characterize the association between health activists and professionals in the production of scientific statements and political claims [START_REF] Rabeharisoa | Evidence-based activism: patients', users' and activists' groups in knowledge society[END_REF]. In our case study, association leaders joined genetic and cognitive science researchers in severely criticizing child psychiatrists who defend packing and a pluralistic approach to autism. These leaders have set up alternative mechanisms of data collection that by-pass the clinicians of the previous generation, and forge alliances with new generation psychiatrists.

With the example of autism and the controversy over packing, we have shown how leading associations were able to impose their points of view and to discredit alternative views from other parents and professionals, how they acted to mobilize their members, and how they influenced political decisions to alter the legislation. The absence of scientific demonstration of the efficiency of packing was one of the arguments pinpointed, but when positive results were published, the associations and the political authorities did not take them into account. For the public, parent associations have a positive image, and are not seen as having any conflict of interest. However, scrutiny of this controversy illustrates how some association leaders may use their professional training to impose their point of view on autism, and to gain professional benefit from their initiatives. They view themselves as fighters for the cause of autistic people. Yet the social construction of autism produced by parent associations does not always satisfy the people concerned [START_REF] Chamak | Autism and Social Movements: French Parents' Associations and International Autistic Individuals' Organizations[END_REF][START_REF] Raz | Representing autism: challenges of collective representation in German and Israeli associations for and of autistic people[END_REF]. Thus, Michelle Dawson considered that the parent associations had deprived autistic people of their right to speak, and she disapproved of the generalization of behavioral therapies [START_REF] Dawson | The misbehaviour of behaviourists. Ethical Challenges to the Autism-ABA Industry[END_REF].

The complex issue of the treatment of severe auto/hetero-aggressive behaviors with no therapeutic options has not been addressed by the association leaders or the HAS. Some professionals have raised the issue of responsibility, and underlined the fact that medicine is first and foremost a practice that is supposed to relieve pain and suffering whilst taking into account individual specificities (Lefevre-Utile, 2015). French and Swiss professionals have been almost the only ones to use packing because they were trained for it. Paradoxically, the association leaders have been strongly critical of these professionals more respectful of the patients and the families than ever before. The success of the associations in the ban of packing may also be understood in the general context of the French psychiatry crisis with a lack of professionals and resources, especially for child psychiatry (Inspection générale des affaires sociales, 2017).

Participative democracy or political lobbying?

Unlike other French sociological studies, which emphasize the contributions of associations, and in particular health associations, to describe their role in the development of a health democracy [START_REF] Akrich | L'expertise profane dans les associations de patients, un outil de démocratie sanitaire[END_REF], our study illustrates a case of lobbying by associations. This lobbying by associations of parents with autistic children has already been described in the USA by Caruso (2010) and [START_REF] Silverman | Understanding autism: parents, doctors, and the history of a disorder[END_REF] and in Brazil by Rios & Costa Andrade (2015). In France, sociological studies tend to highlight the positive aspects of social movements (Laville & Salmon, 2015;[START_REF] Akrich | L'expertise profane dans les associations de patients, un outil de démocratie sanitaire[END_REF][START_REF] Rabeharisoa | Evidence-based activism: patients', users' and activists' groups in knowledge society[END_REF]).

The association is perceived as the privileged place where many forms of public engagement are invented. Although Laville and Salmon (2015) recognize the instrumentalization of associations by the public administration as tools for dismantling public services, they choose to highlight positive experiences. In fact, the development of associations follows a plural dynamics with, on the one hand, centralized organized structures, a form of hybridization with the State and the market, and, on the other, associations of small size, with small budgets and small objectives, but where the people involved have a real power to direct the affairs that concern them.

  Conseil de la Santé Publique, 2010; Haute Autorité de Santé, 2012) were also analyzed. Videos of packing sessions carried out in different units (Bordeaux, Lille, Paris) were viewed. Twenty eight interviews were realized with psychiatrists. As the psychiatrists Pierre Delion and David Cohen were the most frequently attacked by parent associations, we examined their arguments in detail (emails exchanges from February to May 2016). The arguments against packing expressed by the association leaders were found on their websites and in the press. The use of therapeutic wraps for mental health patients was investigated via a bibliographical search of articles published in scientific and historical journals and perusal of books by advocates of packing, to analyze the way psychiatrists and mental health professionals describe their practices. The bibliographical searches were carried out from February to May 2016 using the French data base cairn.info (only 40 references) while the other papers were found in books, article references, and two Master theses (Lefevre-Utile,

  3.3.1. Exchanges on Yahoo group: "an enemy that we must fight" Since 2006, email exchanges between parents of children with autism on the Yahoo forum have illustrated the strong hostility toward packing and psychoanalysis. Parents, who are frequently members of associations such as Autisme France or Vaincre l'autisme, have used irony to discredit psychiatrists, psychoanalysts (referred to as "psykk") and packing.

  February 2006, the exchanges began with a question raised by a parent who asked what "packing" was. The response from another parent referred to the 2003 Delion book entitled "Packing with autistic and psychotic children" (FC, 02/13/2006). He criticized the title of the book and its author since "everybody should know that child psychosis does not exist". He was critical of the state funding of this technique which he considered "barbaric". All the exchanges were opposed to packing and when someone tried to have a more nuanced view, he was severely criticized. Merely indicating a website with psychoanalytical references launched aggressive responses discouraging any alternative view (exchanges from 13 to 16 February 2006). Some parents used the term "bullshit" to qualify the website indicated by a young woman who answered (E, 02/14/2006): I did not want to spark such anger […] I am neither a professional nor a parent, just a web user. I am only trying to get information for myself […] I regret that people are so rude… Laurent explained to her (02/14/2006):

  addressed the controversy over packing and described the "adverse reactions" on the internet, the refusal of the right to reply by the Journal of the American Academy of Child and Adolescent Psychiatry after the publication of the letter in February 2011, and the harassment by the president of Vaincre l'autisme who sent letters against him and David Cohen to the directors of Lille Hospital and La Pitié-Salpêtrière hospital respectively. This same association assigned them before the Council of the Order of French physicians. The case was closed but at the National Committee on Autism on April 21, 2016, Ségolène Neuville, Secretary of State to the Ministry of Health, in charge of Disabled Persons, decided to ban packing (however, packing could be used for research in hospital with protocol approved by an ethical committee).

  Institutes, such as INSERM Association network. The influence of the associations increased in 2002 when Evelyne Friedel, a lawyer and mother of an adult with autism, drafted the collective complaint (n°13/2002) that Autism Europe lodged against the French Government. In November 2003 the European Committee on Social Rights concluded that France had failed to respect its educational duties concerning autistic children. The decision of the Council of Europe published in 2004 upheld the collective complaint and forced the French Government to elaborate the first national Autism plan (2005-2007). Evelyne Friedel, a member of the international law firm Taylor Wessing and elected European Lawyer of the Year in 2016 and 2017, was the president of Autisme France from 2004 to 2006, and then president of Autism Europe from 2008 to 2011. Since 2003 she has been a member of the executive committee of Autism Europe. She is currently the Vice-President of Autism Europe. She organized the opposition to psychiatric care in autism, and has enabled private facilities to develop. Through a service management agency, Association française de gestion de services et d'établissements pour personnes autistes (AFG) founded in 2005 by Evelyne Friedel and her life partner, she has succeeded in generalizing the use of behavioral methods imposed in the structures managed by AFG. Service management agencies, communication and lobbying companies, and training companies have been used by some leaders of parent associations in France to discredit psychiatry and to promote behavioral methods, inclusive education, and privately-run services. A collective of parent associations succeeded in making Autism the "Great national cause" in 2012. The president of this collective, the manager of a communication and lobbying company, was in charge of the communication campaign on autism financed by the government. Through the Internet and other media, the associations succeeded in mobilizing their members and other players beyond. Beyond the role of an associative leader with a law background and expertise, those who run powerful associations are middle-and upper-class parents, competent to mobilize legal resources, use the media and networks, and intervene with representatives

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