S B Guessoum

L Benoit

Isaiah Thomas

J Mallet

Jordan Sibeoni

Cyril Hanin

Je Remercie

Les Professeurs

Olivier Bonnot

Khadija Chahraoui

Malika Mansouri

Mario Speranza

Sevan Minassian

Fatima Touhami

Le Professeur Thierry

Jonathan Lachal

Les Étudiants

Madeline Digiovanni

Les Docteurs

Pauline De Staël

Dalila Rezzoug

Olivier Taïeb

Jean Pierre Benoit

Fumie Todo

Annexe 1. Article 6. Articulating biological and social approaches in child and adolescent

Keywords: Articulating biological and social approaches in child and adolescent psychiatry neurosciences, physiology, psychology (psychodynamic, systemic, cognitive-behavioral, psychoanalysis, etc), anthropology, sociology or education sciences. Integrating transdisciplinary child and adolescent psychiatry, transcultural psychiatry, biological psychiatry, social psychiatry, pluralist, complementarism, research design, psychiatry training Sommaire unaccompanied refugee minors, migration, psychotherapy, narrativity, trauma, transcultural psychiatry neuroscience, physiology, psychology (developmental, psychodynamic, systemic, cognitivebehavioral, etc.), anthropology, sociology, and education sciences child and adolescent psychiatry, transcultural psychiatry, biological psychiatry, social psychiatry, pluralistic, integrative, complementary, research design

knowledge in multi-level models is an ongoing challenge for the future, that is not immediately applicable in clinical practice and research. Articulating biological and social approaches in child and adolescent psychiatry is a daily challenge for clinicians and researchers. Research is often limited to specific fields whereas real-life clinical practice needs a pluralistic approach. Research designs, tools and clinical training need providing knowledge applicable to the necessarily pluralistic daily clinical practice. This thesis provides some perspectives on how to articulate biological and social approaches: pluralistic approach and multimodal interventions; pluralism and complementary frames of reference from clinical description to research; building appropriate tools ; providing articulated mental health care; training mental health professionals to pluralistic care. Suggestions to better articulate biological and social approaches are provided: (I) State that the research object can be approached from different theoretical, research and clinical angles and explain the one chosen ; (II) Propose synthesis articles that gather biological and social knowledge ; (III) Design biological studies that take into account cultural factors ; design social studies that take into account biological factors ; (IV) Design transcultural tools ; (V) Build pluralistic interventions, i.e. therapies and mental health settings that articulate biological and social approaches ; (VI) Develop trainings in pluralistic articulated care.

Titre : Articuler approches biologiques et sociales en psychiatrie de l'enfant et de l'adolescent

Résumé :

La psychiatrie de l'enfant et de l'adolescent a été fondée sur de multiples champs de recherche et théories, dont les neurosciences, la physiologie, la psychologie (développementale, psychodynamique, systémique, cognitivo-comportementale, etc), l'anthropologie, la sociologie ou les sciences de l'éducation. L'intégration des connaissances transdisciplinaires dans des modèles à plusieurs niveaux est un défi à relever pour l'avenir, mais n'est pas immédiatement applicable dans la pratique clinique et la recherche. Articuler les approches biologiques et sociales en psychiatrie de l'enfant et de l'adolescent est un défi quotidien pour les cliniciens et les chercheurs. La recherche est souvent limitée à des domaines spécifiques alors que la pratique clinique en situation réelle nécessite une approche pluraliste. Les

Mots clefs :

psychiatrie de l'enfant et de l'adolescent, psychiatrie transculturelle, psychiatrie biologique, psychiatrie sociale, pluralisme, complémentarisme, recherche, formation en psychiatrie

Introduction

La psychiatrie de l'enfant et de l'adolescent est la spécialité médicale qui entend traiter les troubles de la pensée, des émotions et/ou du comportement affectant les enfants, les adolescents et leurs familles.

Articuler les approches biologiques et sociales est nécessaire pour répondre à la réalité de la complexité des patients et de leurs troubles. Comme exemples de cette tension entre les approches biologiques et sociales, les trois cas suivants peuvent être cités : (1) La possession par les esprits (djinns) chez un adolescent issu d'une culture musulmane peut être un syndrome non psychotique culturellement signifiant ou un véritable trouble psychotique, ou les deux intriqués, ce qui peut conduire à des erreurs de diagnostiques (ou misdiagnoses) ; (2) L'anorexie mentale a des corrélats neurobiologiques clairs, y compris une forte composante génétique ; mais la thérapie familiale, qui se concentre sur les facteurs environnementaux, familiaux et sociaux, est un traitement de médecine fondée sur les preuves (Evidence-based Medicine) (de Jorge Martínez et al., 2022;Gorwood et al., 2016;Lock & Le Grange, 2019) ; (3) Les troubles du spectre autistique sont progressivement expliqués grâce à une connaissance approfondie aux niveaux génomique, moléculaire, cellulaire et des circuits neurologiques, mais les interventions thérapeutiques se concentrent principalement sur les niveaux interactionnel et communicationnel, avec les patients et les familles (Fuentes et al., 2021;Willsey et al., 2022).

La psychiatrie de l'enfant et de l'adolescent a été influencée par de multiples théories et domaines de recherche, notamment les neurosciences, la physiologie, la psychologie (cognitive et comportementale, développementale, psychodynamique, systémique, etc.). Dans l'histoire de la psychiatrie de l'enfant et de l'adolescent, les 70 dernières années ont été marquées par la disparition des "grandes" théories qui prétendaient fournir des explications globales et par le développement de multiples domaines de recherche qui proposent des stratégies pour résoudre des questions spécifiques (Rutter & Stevenson, 2009). Plusieurs domaines de la psychiatrie de l'enfant et de l'adolescent évoluent simultanément, avec des théories, des concepts, des représentations et des interventions thérapeutiques distinctes.

Dans cet article, nous choisissons de schématiser la diversité des approches en deux catégories : les approches (psycho)biologiques et les approches (psycho)sociales. Les approches biologiques renvoient à la conception de la psychiatrie en tant que science médicale basée sur la biologie, la physiologie et les neurosciences, ancrée dans l'idée que la biologie fonde la pratique médicale et que les autres sciences contribuent au rôle essentiel de la biologie, mais ne peuvent pas le remplacer (Guze, 1989). Les approches biologiques ont apporté des avancées majeures en psychiatrie de l'enfant et de l'adolescent, par exemple, les nombreuses recherches sur l'utilisation des psychostimulants pour le traitement du Trouble Déficit de l'Attention / Hyperactivité (Rutter & Stevenson, 2009). Les approches sociales renvoient aux domaines de la psychiatrie qui se rapportent aux sciences humaines, à l'anthropologie et à la sociologie ; elles reposent sur l'idée que les humains sont des êtres fondamentalement culturels et que les facteurs sociaux sont des déterminants clés de la santé (Kirmayer, 2019). Les approches sociales sont nécessaires en psychiatrie de l'enfant et de l'adolescent : l'enfant n'est pas seulement considéré comme un individu, il doit être appréhendé dans une perspective familiale, sociale et culturelle (Hirschberg, 1966).

La médecine fondée sur les preuves (Evidence-Based Medicine) a influencé les méthodes de recherche au cours des dernières décennies, favorisant la recherche quantitative, qui tend à exclure les facteurs culturels, donc les groupes minoritaires, pour obtenir des populations d'étude homogènes. Par conséquent, les données transculturelles en psychiatrie de l'enfant et de l'adolescent sont rares (Deriu et al., 2018 ;Martin et al., 2019). Fournir des connaissances en matière de recherche scientifique qui répondent aux besoins pluralistes de la pratique clinique est un défi pour la psychiatrie de l'enfant et de l'adolescent, de même que fournir des interventions tenant compte de l'état de l'art dans ces deux champs. L'approche pluraliste stipule que de multiples méthodes indépendantes sont nécessaires pour comprendre et traiter les maladies mentales et que nulle méthode unique n'est suffisante (Ghaemi, 2004).

La mise en oeuvre d'une approche pluraliste en psychiatrie de l'enfant et de l'adolescent est un défi car les obstacles sont nombreux : il existe des difficultés majeures pour identifier et traiter les maladies en psychiatrie de l'enfant et de l'adolescent ; les objets de la psychiatrie de l'enfant et de l'adolescent sont multiples et hétérogènes (se référer par exemple aux développements de Kleinman sur les concepts de disease, illness et sickness (Kleinman, 2017;Young, 1982)); il existe un certain clivage entre les pédopsychiatres d'orientation biologique et les autres (Rey et al., 2015); unifier les théories est loin d'être résolu tandis qu'une simplification pragmatique est opérée pour les besoins de la pratique clinique et de la formation (Lantéri-Laura, 2004). Les modèles transdisciplinaires intégratifs sont prometteurs et audacieux, mais ils ne sont pas immédiatement applicables dans la pratique clinique (par exemple : les neurosciences sociales translationnelles (Ford & Young, 2021); les neurosciences culturelles (Chiao, 2009); la neurophénoménologie (Nelson et al., 2020)). Nous pensons qu'il existe des frontières inadéquates entre les approches biologiques et sociales. L'objectif de cette thèse est de fournir des perspectives pratiques sur la manière d'articuler les approches biologiques et sociales en psychiatrie de l'enfant et de l'adolescent.

Dans ce travail de thèse, nous explorerons d'abord brièvement certaines définitions centrales telles que les notions d'approche pluraliste et complémentariste. Puis, dans une première partie, nous discuterons des besoins d'articulation des approches biologiques et sociales en recherche. Nous y présenterons l'exemple de la lycanthropie clinique, syndrome délirant rare qui présente des corrélats

Définitions

Les approches biologiques et sociales ont des théories et des concepts différents (self, troubles, émotions, etc.), mais aussi des méthodes différentes. La recherche en sciences biologiques est plus souvent quantitative et nomothétique, c'est-à-dire qu'elle fournit des connaissances standardisées et généralisables sur les troubles. La recherche en sciences sociales est souvent qualitative et idiographique, c'est-à-dire qu'elle fournit des connaissances approfondies et non chiffrables sur l'expérience des patients (Amir & McAuliffe, 2020 ;Oulis, 2013). Cependant, il existe également de nombreuses études quantitatives et nomothétiques en sciences sociales. Les méthodes nomothétiques ne prennent pas en compte les facteurs singuliers et subjectifs impliqués dans les troubles des patients.

Au contraire, les méthodes idiographiques, en partant du patient et de ses singularités, peuvent aider à identifier l'expérience socioculturelle de la souffrance psychique.

Nous discutons des définitions de trois concepts fondamentaux ici : complémentarisme, pluralisme, et intégratif. Des définitions supplémentaires des concepts fondamentaux sont disponibles en Annexe 2 (page 133).

Le complémentarisme est un concept issu de l'école française de psychiatrie transculturelle de George Devereux : il énonce la nécessaire utilisation non simultanée de plusieurs méthodes (à l'époque, l'anthropologie et la psychanalyse) (Devereux et al., 1972). Selon George Devereux : « L'ethnopsychiatrie est, en premier lieu, une épistémologie et une méthodologie, dont la pierre angulaire est le complémentarisme : le principe qui exige une séparation inconditionnelle entre le discours psychologique et le discours socioculturel, tout en affirmant qu'un fait humain ne devient scientifiquement et, (...) aussi cliniquement exploitable, que lorsque le fait en question est rendu complètement compréhensible à la fois dans le cadre du raisonnement psychologique et dans celui du raisonnement socioculturel. » [START_REF] Devereux | Ethnopsychoanalysis: Psychoanalysis and anthropology as complementary frames of reference[END_REF]. Le complémentarisme exige une séparation inconditionnelle entre les discours des disciplines. Dans cette thèse, nous discutons de la manière de relier ces discours.

La psychiatrie intégrative vise à fournir une approche synthétique des différents domaines de la psychiatrie (Oulis, 2013). Le terme est surtout utilisé en psychothérapie intégrativele terme « éclectisme » est aussi employé par les spécialistes de psychothérapie intégrativeet se caractérise par « l'insatisfaction des approches uniques et le désir concomitant de regarder au-delà des frontières de chaque école pour voir ce qui peut être appris d'autres façons de mener une psychothérapie » [START_REF] Norcross | A Primer on Psychotherapy Integration[END_REF].

Le pluralisme est, en philosophie, un concept « qui admet la nécessité de postuler plusieurs principes pour expliquer la constitution du monde, et affirme que les êtres qui le composent sont irréductibles à une substance unique et absolue »1 . Nous nous référons dans cette thèse à l'approche pluraliste (pluralistic approach) développée dans le livre de Nasser Ghaemi, The Concepts of Psychiatry : A Pluralistic Approach to the Mind and Mental Illness (2004). L'approche pluraliste stipule que de multiples méthodes indépendantes sont nécessaires pour comprendre et traiter la maladie mentale et qu'aucune méthode n'est suffisante (Ghaemi, 2004). Dans les approches pluralistes, les différences conceptuelles sont assumées comme nécessaires pour comprendre les phénomènes mentaux et cérébraux (Ghaemi, 2004). Les psychiatres et autres soignants peuvent combiner des actions issues de différents domaines et théories, en appréciant lesquelles sont pertinentes dans un cas donné (et non en appliquant un peu de chacune pour tous les troubles).

Schématiquement, deux options sont possibles : (2) Construire des modèles intégratifs (intégratif au sens de synthétique et non de éclectique) dont les théories englobent des domaines traditionnellement séparés. Cette deuxième option nécessite une refondation théorique. Il s'agirait, à notre avis, de la mutation la plus ambitieuse et la plus importante pour l'avenir de la psychiatrie (Kirmayer et al., 2020). Tout comme les processus biologiques, les facteurs sociaux influencent le développement du cerveau. Par exemple, les enfants en situation d'isolement social grave présentent un développement cérébral anormal et des troubles du langage (Kirmayer & Crafa, 2014). Proposer des modèles sociobiologiques pourrait constituer l'avenir de la psychiatrie de l'enfant et de l'adolescent (Baptista et al., 2021). Cependant, dans l'attente de leurs applications, les cliniciens et les chercheurs ont besoin de perspectives pour faire face à la coexistence des approches sociales et biologiques.

En résumé, nous pouvons simplifier les définitions ainsi :

-Le complémentarisme est une méthode qui postule l'utilisation obligatoire mais non simultanée de deux approches théoriques, il a pour principe une séparation inconditionnelle entre le discours psychologique et le discours socioculturel.

-L'approche intégrative peut soit être considérée comme une approche synthétique des différents domaines et interventions de la psychiatrie, soit comme une approche éclectique en psychothérapie.

-L'approche pluraliste postule que de multiples méthodes indépendantes sont nécessaires à la compréhension et au traitement des maladies mentales.

Dans cette thèse, nous utilisons le terme « approche pluraliste » pour désigner l'usage de plusieurs méthodes, articulées rationnellement, non simultanément mais avec un chevauchement possible, en suivant à la fois les principes de la médecine fondée sur les preuves et de la médecine centrée sur le patient. Dans le paragraphe suivant, nous questionnons la mise en oeuvre de ce pluralisme en recherche.

Recherche : articulation des approches biologiques et sociales de la description clinique à la recherche

L'articulation des approches sociales et biologiques doit se faire dès les phases de description clinique. Sinon, si les psychiatres suivent une approche critériologique descriptive standard, seule une partie de l'expérience des patients -les aspects objectifs, standardisés et généralisables -sera rapportée et cela conditionnera les perspectives de recherche. De plus, l'expression de la détresse mentale varie au sein des populations et entre les cultures en fonction de facteurs sociaux et biologiques, et se caractérise également par des présentations culturelles singulières qui imposent une évaluation sociale aux psychiatres (par exemple le syndrome de Hikikomori chez les adolescents (Kato et al., 2012).

Rassembler les connaissances socioculturelles et les connaissances neurobiologiques sur un sujet dans une seule synthèse n'est pas une démarche évidente. Nous pensons qu'elle devrait être faite plus fréquemment. Nous avons rencontré un adolescent présentant un syndrome appelé lycanthropie clinique. La lycanthropie clinique est un syndrome dans lequel les patients ont la conviction délirante de se transformer en loup (Guessoum et al., 2020 ;Guessoum et al., 2021). Nous avons publié ce cas clinique avec revue de la littérature sur les cas de lycanthropie clinique chez l'adolescent (Article 1). Les prochaines étapes consistent à proposer des perspectives multi-niveaux qui incluent le cerveau et son environnement (Kirmayer et al., 2020).

Article 1. First Reported Case of Clinical

Nous formulons les propositions suivantes : (1) inclure toutes les données socioculturelles et biologiques disponibles dans les descriptions cliniques et les case reports. Les psychiatres devraient faire preuve de la même précision dans la description des caractéristiques (neuro)biologiques que les premiers psychiatres dans leurs observations cliniques méticuleuses, ainsi que des caractéristiques socioculturelles ; (2) les études biologiques devraient tenir compte du contexte social ; les études sociales devraient tenir compte du contexte biologique ; (3) les synthèses scientifiques (par exemple les revues de littérature) devraient rassembler les données biologiques et sociales.

Cependant, pour développer des recherches qui articulent approches biologiques et sociales, des instruments (questionnaires, échelles) appropriés sont nécessaires, ce que nous discutons dans le paragraphe suivant. Little is known on its clinical or therapeutic correlates.

Methods: We conducted a systematic review (PRISMA) on PubMed and Google Scholar, until January 2021. Case reports, data on neurobiological hypotheses, and cultural aspects were included.

Language was not restricted to English.

Results: Forty-three cases of clinical lycanthropy and kynanthropy (delusion of dog transformation) were identified. Associated diagnoses were schizophrenia, psychotic depression, bipolar disorder, and other psychotic disorders. Antipsychotic medication may be an efficient treatment for this rare transnosographic syndrome. In case of depression or mania, the treatment included antidepressants or mood regulators. The neuroscientific hypotheses include the conception of clinical lycanthropy as a cenesthopathy, as a delusional misidentification of the self-syndrome, as impairments of sensory integration, as impairments of the belief evaluation system, and right hemisphere anomalies.

Interestingly, there is a clinical overlap between clinical lycanthropy and other delusional misidentification syndromes. Clinical lycanthropy may be a culture-bound syndrome that happens in the context of Western cultures, myths, and stories on werewolves, and today's exposure to these narratives on cultural media such as the internet and the series. We suggest the necessity of a cultural approach for these patients' clinical assessment, and a narrative and patient-centered care.

Conclusions: Psychiatric transtheoretical reflections are needed for complementaristic neurobiological and cultural approaches of complex delusional syndromes such as clinical lycanthropy. Future research should include integrative frameworks.

Construire des instruments appropriés

Des outils appropriés et validés (par exemple, des questionnaires et des échelles), conçus pour la recherche ou la pratique clinique, sont des clés de voûte pour articuler les approches biologiques et sociales. Les échelles d'évaluation standardisées peuvent refléter une représentation nomothétique des variables mesurées, tandis que la question de la validité transculturelle inclut une perspective idiographique. Une approche sociale est nécessaire dans la création d'outils valides d'un point de vue transculturel car elle permet de répondre à certains défis tels que l'adéquation de la traduction et la correspondance conceptuelle entre les cultures.

Les outils disponibles contribuent à façonner les plans de recherche et les représentations des cliniciens, notamment en rendant saisissables -ou au contraire invisibles -certaines formes culturelles d'expériences de souffrance psychique. En psychiatrie de l'enfant et de l'adolescent, il y a un manque d'instruments culturellement appropriés et valides d'un point de vue transculturel (Guessoum, et al., 2021;Kaiser et al., 2019).

Certaines échelles déforment ou manquent certaines dimensions culturellement spécifiques de la souffrance psychique, induisant une forme d'erreur de mesure de l'expérience des patients, en assimilant à tort l'expérience occidentale (car de nombreux outils sont construits dans des populations occidentales) de la souffrance psychique à celle d'autres cultures (induisant une sorte d' "experience measure fallacy", en parallèle à la description de "category fallacy" de Kleinman) (Kleinman, 1977;Phan et al., 2004). Ces instruments sont limités par les visions culturelles dans lesquelles ils s'inscrivent.

Par exemple, une échelle occidentale en psychiatrie adulte passerait à côté d'une forme de dysphorie culturellement significative que l'Afghan symptom checklist permet de repérer chez un patient de culture afghane : le jigar khun, littéralement " sang de foie ", est une dysphorie intense et persistante qui reflète le chagrin consécutif à une perte interpersonnelle mais qui peut aussi être une réaction à toute expérience profondément décevante ou douloureuse (Rasmussen et al., 2014). Les échelles doivent être validées dans d'autres contextes culturels, afin de diminuer les biais culturels (voir par exemple la validation transculturelle de l'échelle des syndromes positifs et négatifs PNSS (Khan et al., 2013).

À titre d'exemple en psychiatrie de l'enfant et de l'adolescent, pour l'autisme, plusieurs outils ont montré des propriétés psychométriques moins élevées au sein de populations de minorités culturelles ou de pays non occidentaux, attestant un manque global d'outils de dépistage et de diagnostic validés et culturellement appropriés (de Leeuw et al., 2020). Par exemple, l'Autism Diagnostic Interview-Revised (ADI-R) a montré dans une population hispanophone des États-Unis une sensibilité et spécificité inférieures à celles de la validation originale, qui ne comprenait que des personnes de langue maternelle anglaise (Vanegas et al., 2016). La version hispanophone de l'ADI-R peut être moins valide lorsque les compétences linguistiques en espagnol du parent et de l'enfant diffèrent ; si le parent parle principalement l'espagnol et que l'enfant parle principalement l'anglais avec ses pairs et à l'école, les questions de communication verbale de l'ADI-R peuvent être moins valides. L'entretien de formulation culturelle du DSM-5 comprend des questions idiographiques intéressantes sur la définition culturelle du problème, les perceptions de la cause, du contexte et du soutien, les facteurs culturels affectant les stratégies d'adaptation et de recherche d'aide, les représentations de la détresse psychique, le contexte et les préférences de soins, ainsi que des modules complémentaires ; certains auteurs suggèrent le développement d'un module complémentaire spécifiquement conçu pour les jeunes enfants (American Psychiatric Association, 2013; La Roche & Bloom, 2020). Davantage d'outils sont nécessaires pour évaluer d'autres aspects, par exemple les aspects interactionnels en fonction du contexte culturel, ou comment distinguer le normal du pathologique en tenant compte des facteurs culturels. Les cultures changeant avec le temps, et le besoin de réactualisation de ces outils peut être une difficulté supplémentaire.

Certains chercheurs ont conçu des échelles culturellement pertinentes : Phan et al. ont conçu une échelle psychiatrique dérivée des idiomes vietnamiens et de la compréhension culturelle de la souffrance psychique et émotionnelle identifiée dans la littérature vietnamienne et en utilisant des méthodes ethnographiques (en psychiatrie de l'adulte) (Phan et al., 2004).Une autre option consiste à proposer des adaptations transculturelles des échelles. Une solution appropriée consiste à développer des outils transculturels, utilisables dans plusieurs cultures, et qui cherchent à être transculturels dès leur conception, tels que : le PSYca, un outil conçu pour dépister les difficultés psychologiques chez les enfants âgés de 6 à 36 mois (Nackers et al., 2019); ou l'échelle ELAL (Evaluation Langagière des ALlophones et primo-arrivants) [START_REF] Rezzoug | L'elal d'Avicenne[END_REF], un instrument conçu pour évaluer les compétences en langue maternelle, dans n'importe quelle langue minoritaire grâce à la conception de la passation avec un interprète, et par conséquent mieux diagnostiquer les troubles du langage. Ces échelles, comme l'échelle ELAL, offrent une interface intéressante pour les études à méthodes mixtes (Guessoum et al., 2021).

Les instruments sont encore peu nombreux en psychiatrie de l'enfant et de l'adolescent, et leur utilisation et validité est compliquée par l'aspect dynamique du développement, et la nécessaire adaptation des instruments à l'âge et au développement des individus. Ces difficultés peuvent amener certains cliniciens à simplement éviter l'utilisation d'échelles et questionnaires.

Les instruments transculturels en psychiatrie de l'enfant et de l'adolescent sont rares. Kohrt et al. proposent des critères pour évaluer la validité transculturelle des instruments en psychiatrie de l'enfant et de l'adolescent, tels que la mention des idiomes locaux employés, et la comparaison avec d'autres phénomènes mesurables (Kohrt et al., 2011). Il existe des inégalités en matière de santé mentale dans certains groupes minoritaires, tels que les enfants de migrants : la promotion de l'équité en matière de santé et d'accès aux soins est un impératif de santé publique (cf. la recherche concernant les effets des discriminations sur la santé mentale) (Moro & Radjack, 2022). Promouvoir des soins de santé adaptés est un enjeu éthique. Rendre ces inégalités mesurables, et fournir des outils adaptés aux patients quelles que soient leur culture est une nécessité. Participants included 30 children aged 4 to 6 years, born in France, and their bilingual French-Maghrebi Arabic-speaking parents. Children's bilingual language profiles were assessed with the ELAL Scale for Maghrebi Arabic (minority language) and the Neel Scale for French (majority language). Mothers participated in qualitative interviews about cultural and language practices and representations. Interview contents were compared with the children's language profiles. Results indicated that parents closely associated the transmission of the Arabic language with their cultural heritage transmission. The parents of fluent bilinguals had a strong desire to transmit the minority language. Mothers of minority language dominant bilingual children reported little perception of change in their lives since migration. Half of the mothers of majority language dominant bilingual children reported relationship or emotional difficulties with their children. Four minority language transmission types were identified: direct parent-child transmission; indirect transmission through private classes; indirect transmission through visits to family in the parents' native countries; and alternative transmission by another family member. Direct parent-child transmission was most frequent among the fluent bilinguals. Families' processes of hybridity were related to language transmission and bilingual development of children. Parental cultural affiliations to native country were related to minority language transmission. Perception of change since migration and affiliation to host country may also play a role in harmonious bilingual development. Moreover, the quality of family relationships can affect minority language transmission. affiliations culturelles, la famille, et les soins traditionnels), et une approche narrative (narration de l'histoire du jeune, de la migration et du traumatisme). MUCTUM vise à fournir une approche pluraliste permise par deux thérapeutes aux formations différentes (un psychiatre et un psychologue), enrichie par la participation d'un interprète et de l'éducateur du jeune. MUCTUM est cohérent avec l'idée que l'approche pluraliste nécessite une coopération étroite entre les psychiatres, les psychologues et les travailleurs sociaux (Ghaemi, 2004). Dans cette étude, nous émettons l'hypothèse qu'un axe pour articuler ces interventions est de suivre une hiérarchie des besoins, à travers une approche centrée sur le patient et la résolution de problèmes. Nous formulons en outre l'hypothèse que l'approche pluraliste est justifiée par des interventions distinctes, dans une seule consultation, de plusieurs soignants ayant des formations aux approches biologiques et culturelles. Des recherches sur la mise en oeuvre des approches pluralistes, de type implementation research ou Recherche de Mise en OEuvre, seraient justifiées en psychiatrie de l'enfant et de l'adolescent (Proctor et al., 2009). Cette étude contribue donc à la réflexion sur les soins pluralistes :

Pratique clinique : dispenser des interventions articulant approches biologiques et sociales

-en étudiant et décrivant un dispositif articulant plusieurs approches, -en rapportant l'expérience des patients de ce dispositif, -en discutant les résultats et en formulant des hypothèses pour soutenir la mise en oeuvre de soins pluralistes.

La question des interventions thérapeutiques articulant approches biologiques et sociales soulève celle du besoin de formation des professionnels, ce que nous discutons au paragraphe suivant.

Tableau 1. Exemples

A. Une illustration avec un cas commun de trouble psychotique

Un garçon de 14 ans originaire du Maroc reçoit un diagnostic de trouble schizophrénique, caractérisé par un délire de possession (djinn) ; la famille n'accepte pas le traitement antipsychotique.

Approche biologique

-Des altérations génétiques, moléculaires et fonctionnelles cérébrales sont retrouvées dans la schizophrénie (Lakhan & Vieira, 2009) -Recherche d'une étiologie spécifique par des examens complémentaires biologiques et neurologiques (Kurukgy et al., 2021) -Traitement antipsychotique (Driver et al., 2020) Approche sociale -La migration est un facteur de risque de trouble schizophrénique (Chen et al., 2018) -La possession par un djinn est une étiologie culturelle courante des symptômes positifs dans les cultures liées à l'islam (Lim et al., 2018) -Le représentation et narrations familiales et culturelles de la maladie sont centrales dans l'expérience de la maladie et l'adhésion aux soins (Rodolico et al., 2022 ;Tranulis et al., 2011) Apports

Methods

MUCTUM is a co-therapy program for unaccompanied minors, with a psychiatrist, psychologist, native-language interpreter, and caseworker for each patient. In this qualitative study, we interviewed adolescents about their experiences with MUCTUM and analyzed these semi-structured interviews using a phenomenological framework (Interpretative Phenomenological Analysis).

Results

Qualitative

Conclusion

This study suggests that MUCTUM therapy may efficiently support unaccompanied minors' mental health by acknowledging their hierarchy of needs. Psychotherapeutic strategies include creating a safe place, providing culturally appropriate care and patient-centered therapy, addressing concrete problems, supporting relationships, and making use of limited reparenting in therapy. Delayed and progressive

Introduction

Unaccompanied refugee minors -or unaccompanied minors (UM) -are children and adolescents who have been separated from both parents and other relatives and are not being cared for by an adult. 1 The refugee population included an estimated 153,300 UM worldwide in 2019. 2 UM are a vulnerable group of refugees and experience a high rate of psychiatric symptoms with intricate post-traumatic, transcultural, family, educational, and legal struggles. 3 The cultural and political backgrounds of UM's native countries are often very different from those of their host countries, and these cultural differences can confuse caseworkers and care providers, who are often untrained in caring for adolescents in a migratory context.

UM frequently exhibit mental health problems, with a high prevalence of anxiety (10-85%), depression (12-76%), post-traumatic stress (17-85%), and behavioral problems, and these symptoms are often chronic. 4-8 UMs' post-traumatic symptoms are complex, and standard nosographies capture only partial features of their clinical expression. 9 Moreover, some adolescents face specific challenges: debt, prostitution, human trafficking, acute stress related to the asylum process, 10 and the risk of "aging out" of the Child Status protection. Such factors aggravate the psychological vulnerability of these adolescents, but UM can have positive long-term outcomes if they are provided with appropriate health and psychosocial protection. 2 Providing appropriate care for UM is a challenge for healthcare institutions due to cross-cultural factors.

UM's personal trajectories can affect the acquisition of certain competencies in their native culture and may create difficulties with acculturation. 5 Cultural misunderstandings between UM and care teams can create barriers and misunderstandings at the educational, behavioral, psychological and emotional levels. Regarding psychiatric care, high rates of misdiagnosis are observed in migrant populations. 11 Therefore, there is a need for specialized mental health care for UM, with cross-cultural competencies and a focus on the migration experience and complex trauma.

To date, few studies have been published on therapies for UM, 12-14 requiring further evaluation of informed strategies for these young patients. Quantitative assessments of interventions designed for UM have failed to provide significant findings, due to small samples and heterogeneous populations.

Similarly, migrant patients tend to be excluded from prospective cohorts particularly because of language barriers, leading to insufficient scientific knowledge on early mental health care for these minority groups. 15,16 Qualitative research appears an effective framework to overcome this challenge, as it highlights the singularity of individual views and helps refine patient-centered approaches. 17 We designed this qualitative study to address another shortcoming in regard to UM's mental health care:

most standardized mental health screening tools did not undergo transcultural validation, are biased if used with interpreters, refer to concepts that are hardly understood by some UM, and are not always culturally appropriate. 14 In the Adolescent Medicine department of Cochin Hospital, Paris, France, 18 a specific co-therapy was created to meet the special needs of UM, titled Multimodal Co-Therapy for Unaccompanied Minors (MUCTUM). It consists of monthly consultation with a psychiatrist, a psychologist, an interpretermediator, a social work caseworker, and the patient. Every meeting provides a combination of approaches: the psychiatric and psychological assessment, the transcultural psychiatry approach, the pharmaco-biological approach through medications, the institutional approach with the participation of the UM's caseworker, and a narrative approach. The objective of this study is to explore patients' experiences of MUCTUM to identify the possible beneficial features of this set-up and possible shortcomings, share this knowledge, and improve interventions for UM.

Methods

Multimodal co-therapy description

Set-up and first consultations MUCTUM operates monthly, or weekly during acute phases. The team includes ethnically diverse providers and consists of a psychiatrist, a psychologist, the caseworker assigned to the adolescent, and an interpreter. The interpreter is a professional translator who is also trained in cultural mediation and attends every session. 19 MUCTUM aims to provide a pluralist approach in which mental health providers efficiently integrate the psychiatric and psychological assessments and interventions including biological, institutional, transcultural and narrative approaches. 3,20,21 During the first session, care providers introduce themselves and the purpose of MUCTUM. Care providers explicitly welcome the patient ("we are happy to receive you, be welcome"), and explain the set-up and the "rules" of the program (confidentiality, kindness, consistent interpreter presence, and ability to speak in both languages whenever). Up to three sessions are dedicated to creating a safe place for the patient, psychiatric and psychological assessment, and first-line therapeutic actions. The remainder of MUCTUM is implemented following the course described in Figure 1.

Biological approach

Care providers accomplish the usual biological approach by performing a standard psychiatric assessment, but the multimodal emphasis allows psychiatrists to include social factors. Facilitated by the caseworker and the interpreter, care providers are therefore able to relate the UM's symptoms to social factors and respond accordingly, rather than having a solely pharmacological approach.

Institutional approach

An institutional approach is accomplished by the caseworker, who provides a link with the Children's

Foster Home, and who can help address the patient's behavior, daily life and school problems, and administrative aspects.

Transcultural approach

In addition to speaking the UM's native language and being from the patient's cultural group, the interpreter is preferably trained as a cultural broker. 19 This allows for a better understanding of the patient's needs and suffering by clarifying culturally-coded representations and symptoms, so that providers can give appropriate care. The interpreter is a link with the native country, ancestors, and childhood, and allows the team to navigate linguistic nuances and cultural misunderstandings.

Narrative approach

The co-therapy model includes a narrative approach: Narration is based on positive life events, positive attachment figures, good memories in the native country (i.e, feasts, food), personal affiliations (i.e.

namesakes, parents, grandparents), and verbalization of the UM's competencies. For example, some adolescents initially deny ever attending school, but are then able to clarify that they acquired some education at religious school. UMs narrate their migratory journey, including adverse life events if comfortable doing so, and set the pace of this sharing process. Being allowed to narrate only positive life events for several sessions promotes a feeling of safety in the therapy setting.

Narration is supported by two exercises that materialize the patient's journey. First, in the "circles of time," the patient draws three circles, one for the past, present, and future, and attributes colors to each.

The UM then explains why they drew, shaped, and colored the circles in such a way, as a support of narration of their path. Second, in the "three objects," the patient is invited to bring (or think about) three objects that symbolize past, present, and future, to support the narrative process. 21

Qualitative research description

This qualitative monocentric study follows the consolidated criteria for reporting qualitative research (COREQ, Supplementary Materials) and has been approved by the Ethics Committee of Paris University (CEEI/IRB n° 00012021-57). We provided clear oral and written information about the study and obtained verbal and written consent.

Population, data collection and analysis

We recruited volunteer participants through purposive sampling among UM who attended MUCTUM therapy in Cochin University Hospital, Paris, France. We stopped recruiting new patients when data saturation was reached, meaning that the analysis of new interviews no longer provided new findings.

Three trained researchers conducted semi-structured interviews, either face-to-face or online.

Researchers introduced themselves to participants before the day of the interview, and informed UM of the research purpose. Interpreters participated in the interview as needed. The interview guide was adapted iteratively during the study and included sensitizing questions about the following topics: the representation of psychiatric symptoms and care in their home countries and the host countries, what

happens and what patients experience during therapy, how patients talk about themselves, the role of the caseworker and interpreter, and how family issues are discussed during therapy. The interviews were audio recorded, anonymized, and transcribed, then analyzed using interpretative phenomenological analysis, 22 a method used to understand how people subjectively perceive and make sense of an experience. 23 In this method, researchers read the interviews several times and then annotate and code them in order to identify emerging themes. To ensure a rigorous "triangulation" process, 22 three researchers (PDS, SBG, SM) analyzed each interview independently and searched for connections between these emerging themes. Reflexivity was discussed in team meetings, considering that some researchers were part of the hospital institution, and others originated from other teams and countries.

Then, we compared the results between interviews to identify recurring themes and integrate new emerging elements. The team (PDS, SBG, SM, LB) then constructed a comprehensive description of participants' experiences. Themes were organized into overarching domains, and supported by specific quotes from the interviews. A safe space for unaccompanied minors A secure therapeutic framework. The perception that caregivers were compassionate, engaged in care, and steadily present despite repeated missed sessions was cited by participants as a major factor in building therapeutic alliance. Participants considered their care providers "trustful," "skilled," "deeply caring," "generous," knowledgeable on their culture, and always providing "thorough explanations." mentioned that the presence of four adultstwo care providers, one caseworker and one interpreterled them to feel "afraid" or "lost" at the beginning. Despite being overwhelming, the presence of several adults was overall seen as helpful to discuss a variety of opinions.

Results

One

"
"At first, I thought it was too much. I said to myself: there are too many people. But then I realized that when there are several people, we talk more. When there are several people, we discuss more, everyone gives their opinion. That's good. That's really good. I think that... Just at the beginning… I thought it was too much, but then I saw that it's better, when there are several people, each one speaks. They also, they talked a little bit about themselves. That's good."

The interpreter prevents misunderstandings and is a reassuring link with the native country.

Participants perceived interpreters as instrumental in achieving full understanding of their identity, origins, language, and culture. Interpreters prevented possible misunderstandings ("so that I don't understand the opposite meaning") and helped overcome language barriers.

"With them, I was not alone, we were several. In addition, there was someone who spoke..., who interpreted, who was there, who knows me well, who knows where I come from. He knows the place, he knows my culture and everything."

Participants also valued interpreters' ability to help them articulate difficult subjects to the care providers.

" For many, interpreters illustrated a bond with the native country, especially for UM who had not seen "anyone from the same country" since arriving in the host country.

"I am of Somalian origin and I am in France since I was little and also when I arrived I did not see Somalian people. So when I see the interpreter every time here it was a pleasure to see a person from the same country as me (...) I felt sometimes that I spoke the same language and all that sometimes I asked questions about my country because I was little when I left my country (...) [the interpreter spoke] about the cultures of the villages, all that, all that, all the things, the food to eat"

A support to caseworker-youth relationship. Some participants identified caseworkers as a reassuring support during sessions.

"In fact, at the consultation when I go there, when they send me to the consultation, but sometimes when I arrive at the consultation, when we speak, I don't really like it, so I let my caseworker talk, as I really trust her, when we speak. After that, that's when I can talk."

However, for some participants, the caseworker's continuous presence was perceived as intrusive and created a disincentive to talk, especially about very "personal" migratory life events. Some participants criticized the framework as too rigid, preferring to be "asked" if they consented to the caseworker's presence during therapy.

Helpful interventions during MUCTUM therapy

Participants identified several helpful interventions during their follow-up.

Behavioral guidance promotes feelings of safety, self-confidence, and self-care practices.

Participants valued education on coping skills and appropriate behaviors, especially during conflicts. In another example, one participant's need for privacy due to his traumatic history was acknowledged, and he obtained access to an individual room. In addition to collaborating with the social workers, care providers use a problem solving approach to address social, educational and legal problems. One participant reported how care providers supported her to pursue her academic studies and advocated for her with social services. Another reported that he felt supported for minority recognition administrative procedures with his lawyer, to whom he "did not say everything" previously because of fear and uncertainty.

Family issues were often discussed during therapy, such as the violent loss of parents, or the family relational difficulties that had led the UM to exile.

"There were problems with the family. My mother, who was not present, left us long ago. I was with my aunt and her children. Often it was not going well. That's why I left there. There is all that, we talked about all that too, with them."

In particular, participants valued phone calls and advice from the care team to family back home. In the case of one participant who had previously been sending money home due to being a victim of prostitution, care providers called the participant's mother to explain that her daughter, now in school with no income, could no longer send money back home:

"I told all my stories to Mrs. X. In any case, she found some words. She called my mother to explain something to her. She made it clear that I don't work here, that I'm studying, that I won't have enough money, as much as she asks, that I won't be able to finance everything. So my mother, I don't know, but she has trouble understanding, my mother. She had a hard time."

This communication induced a change in parental expectations, which "relieves more and more" for adolescents seeking reassurance that it is okay to refuse to send money to over-demanding family members. For another participant, interpreters facilitated a conversation with the participant's mother back in Somalia in order to restore family links, relationships, and childhood memories, which had been erased because of traumatic amnesia: "All my culture (...), when I was a child, lullabies, all this." For this participant, finding her mother was a "huge relief" and allowed this adolescent to "reconnect to reality." Now, the ability to call her mother frequently has "changed" and "energized" the participant:

"It gave [me a] smile, me who was always sad."

Cultural focus enables traditional care implementation. Cultural etiology and treatment were acknowledged and employed as needed, as cultural etiologies had variable importance for participants across the sample. Most participants did have representations of their conditions in their native culture (e.g. kénu in Soninke language, a certain conception of worry, or undusu, a "heart discomfort" in Malenke language), or explanations for certain phenomena (e.g. djodjo, witchcraft in Nigeria) and their cures. Some had no cultural hypothesis because they had left their country too young and their only solution was to "talk to my parents, and they will take care of me." Other participants knew traditional etiological explanations, such as possession by spirits, like djinns, but associated djinns with problems more severe than their own. Participants also described various traditional treatments, specific to their home countries, including herbal treatments, massages, reading the Bible and listening to music, reading, and alms ("I buy stuff and give to the poor, give to people, and I ask God to protect me"). Some participants reported that their families in the native country recommended these traditional treatments, which they completed in France or their native country with the support of their MUCTUM care providers, such as prayers, alms, and sacrifices.

"I had a dream about an old man (...) I had to get out the alms and I managed to call my mother to do that alms and since then it's been fine."

Help with medications. Participants mentioned the value of medications, which reportedly helped with anxiety and sleep problems, but did not elaborate further on this topic. MUCTUM follows the fundamental teaching of Maslow's hierarchy of basic needs. 24 Maslow's seminal theory on the hierarchy of human needs, motivations and goals reminds care providers to address their young patients' basic needs before focusing on elaborate therapy goals. As an example, a UM who arrives at therapy after fasting all day will be unable to benefit from cutting-edge trauma-focused therapy if care providers do not feed them first. We present an illustration of the hierarchy of actions for UM in Figure 2. This is not a rigid hierarchy, as some higher-level needs, such as self-esteem and respect from others, can be supported quickly, restoring a sense of security for UM who have lost confidence in themselves or others. If these principles may appear obvious, they are not always followed in Western health care systems where professionals are encouraged to give their patients only limited time slots and thus rely increasingly on highly standardized interventions. Underrepresented minority groups such as UMs challenge the current expectation of a straightforward and time-limited traumafocused therapy. In the remaining discussion, we explore how MUCTUM addresses the hierarchy of needs of UMs: creating a safe space, providing patient-centered therapy, solving concrete problems, improving communication with caseworkers, making use of limited reparenting in therapy, providing culturally appropriate care and focusing on narrativity of trauma when basic needs have been addressed.

"
Working on family relationships and with families remains relevant, despite the apparent isolation of UMs.

Figure 2. Addressing unaccompanied minors' needs hierarchically

Fear of stigma, suspicion, misunderstandings and negative cultural representations of mental health problems cause denial of mental suffering and are a barrier to mental health care of adolescent refugees.

These results are consistent with a qualitative Australian study among 85 refugees aged 13 to 17, in which stigma and misbeliefs about psychiatric conditions were identified as barriers to mental health care. 25 Participants in Anstiss and Ziaian's study dissimulated disorders to preserve their social status and marriage opportunities. Suspicion towards mental health care has also been found in a UK study among 15 UM, mostly boys from Afghanistan. 26 The study's title, "This doctor, I not trust him, I'm not safe," shows how trust in care providers is a prerequisite to experience a sense of safety, which is consistent with the results we described in MUCTUM therapy. The therapeutic alliance then allows UM adolescents to welcome explanatory hypotheses, both from the care providers in their host country and from their families back in their country of origin. This process allows them to make sense of their suffering and to accept treatment.

A warm and reliable setting, including care providers' long-standing commitment despite missed appointments, is a key ingredient for safety and trust, especially for UM who feel lonely and misunderstood. Other studies describe how to create spaces that allow UM to feel comfortable and valued, to speak openly, and to recover a sense of self. 27,28 Kohli explores the concept of safety for asylum-seeking children: predictable patterns in daily rhythm, going to school, receiving medical care and "finding trust-worthy, reliable and companionable people, adults and peers." 29 Similarly, creating a safe place for UM is central in MUCTUM.

Patient-centered therapy is a relevant approach for UM, as suggested by our study, because UM have very heterogeneous profiles, and treatment should therefore be based on their unique experience and social situation. This is consistent with Van Es et al.'s study, which advocates for flexibility in treatment approaches for UM. 14 Similarly, MUCTUM provides UMs with a unique program to address and prioritize various problems according to a hierarchy of needs.

Solving concrete problems, e.g. housing, school or medical needs, is essential because it shows UM that care providers understand their priorities. Our participants perceived this problem-solving approach as a sign of their care providers' competence, leading to increased trust and therapeutic alliance. Other authors highlighted the importance of day-to-day stressors such as missing one's family, difficulties accessing education, homelessness, sleeping or somatic problems. 12,14 Together, these findings suggest that addressing physical or social concerns for migrants can be an important first step to their mental health care, in part by initiating a bond with providers. 30,31 Supporting communication with social workers and foster care providers appeared helpful for this study's participants. Alto et al. state that nurturing UMs' foster family environments is central, as enduring conflicts can exacerbate adolescents' symptoms. 32 The type of placement may also influence UM's prognosis. 33 Living in foster care is sometimes a protective factor, possibly due to higher level of social support, safety and stability within this setting. 34 Even if complex trauma explains some of the inconsistencies of refugees narratives, 35 difficulties in accessing UM's narrative can raise suspicion of lies and hinder care providers' and caseworkers' relationships with UM. 36 Additionally, some adolescents cannot share their personal story for various reasons including fear of insecurity, reprisal, sorcery, or severe trauma. MUCTUM therapy invites caseworkers to learn from UMs' perspectives by providing them with psychological and cultural skills relevant to the UM. In return, caseworkers can inform care providers on social and educational aspects that improve the team's overall comprehension of UM's experience and mental health.

Limited reparenting. Participants reported that they benefited from the reliability of care providers who appeared as secure figures, providing emotional and behavioral guidance. This finding suggests that limited reparenting may be a useful component of psychotherapy for UM. Arguably, UMs do not have their core emotional and educational needs met, as they do not have caregivers in the host country.

Schema psychotherapy argues that emotional deprivation has three components: deprivation of nurturance (absence of attention, affection, warmth, companionship), deprivation of empathy (absence of listening, understanding, mutual sharing of feelings from others), deprivation of protection (absence of guidance and direction from others) 37 . In the case of UMs, limited reparenting by a care provider might partially compensate for this deprivation, provided that appropriate professional boundaries are maintained. According to our participants' experience, creating "safety, stability, and acceptance" may require care providers to consider sharing their personal phone numbers with patients in case of crisis. 38 Culturally appropriate care is central in MUCTUM, with interpreters who double as cultural mediators.

This is consistent with other recent studies, which emphasize the importance of native language and cultural explanation across native and host countries' cultures, for the young patients and the professionals who care for them. 14,32 Transcultural psychotherapy is an essential component of MUCTUM, highlighting UMs' skills acquired in native countries, cultural affiliations to one's host country, culturally meaningful symptoms, and traditional care if valued by the patient. 39 Transcultural psychotherapy for children and adolescents is currently being assessed with randomized controlled trials. 40 Our results show that UM can give great importance to talking therapy, as proposed in MUCTUM. Although some authors suggest that psychiatric intervention may be deferred until language level of migrant patients has improved, 26,41 we believe that talk therapy can be implemented as soon as an interpreter allows the patient to talk in his/her native language, and as soon as basic needs are provided.

Sharing trauma experiences through narrative can have beneficial effects on health and well-being 42 .

In our exploration of how and when trauma should be addressed for UMs, our participants explain that narration of trauma should occur only after several steps of psychotherapy (building trust, concrete problem-solving). These findings suggest that a primarily trauma-focused therapy, as implemented by other programs, 14 may be suboptimal for UMs. We argue that when UMs first access care, they are too fragile and trauma symptoms too acute to enable safe and beneficial sharing. Participants in this study felt relieved by focusing on their present (current stressors) and their future (envisioning goals, understanding social, school and administrative procedures of the host countries), rather than traumatic past. Interestingly, this relief in focusing on the present is also experienced by international adoptees, who sometimes prefer to focus on their present life rather than thinking about their country of origin or their biological family. 43 When talking about their past for the first time, participants in our study recalled highlighting positive memories (e.g. important family figures, cultural affiliations to host country, skills acquired in the host country). We argue that addressing present stressors and needs, future expectations, and practical problems are a prerequisite to trauma therapy. Similarly, in their study assessing a primarily trauma-focused therapy for UMs, van Es et al. concluded that some therapies deviated from protocol to address current stressors (e.g. worries about family, school and housing) and current problems (asylum status, recent bereavement), fulfill psychoeducational needs, build trust, lay down a lifeline, and provide translation. 14 Our participants particularly appreciated caregivers' involvement, participative narration and rephrasing. Such psychotherapy techniques appear promising in the specific population of UM, and may require further standardization and assessment.

Working with families is a valuable aspect of UM's experience of MUCTUM. While UMs are perceived as isolated in the host country, they are often burdened by various family problems, fears, and requests, or traumatized by a complete separation from their families or the loss of relatives. Our participants reported that care providers' calls to their relatives to support and improve their relationship contributed greatly to their well-being.

Limitations. Our study possesses several strengths and limitations. The qualitative design allows indepth analysis of participants' unique experiences, which helps refine a patient-centered and flexible therapy for the culturally and psychologically heterogeneous population of UMs. Nonetheless, our participants faced challenges that impaired their ability to express themselves, resulting in fragmented answers that occasionally necessitated rephrasing as written text instead of direct quotations: Our participants were young people, were non-native speakers (some of them wanted to speak French despite the presence of an interpreter), had psychotrauma, and often had limited educational attainment.

These barriers to fluid communication raise the question of how to most accurately represent the perspectives of populations who may produce disjointed discourse within current qualitative research methods. Additionally, this study does not assess MUCTUM's efficacy. This objective could be addressed with a randomized, comparative, patient-goal-centered quantitative study, designed for a small population (i.e. using Bayesian statistics). Until then, the results of this qualitative study cannot be generalized. Another limitation is that no Asian UM consented to participate in the study, as most of them stated that they were afraid of speaking of bad memories. Future studies could determine more effective ways of recruiting Asian participants. Finally, some interviews were conducted within the hospital. Participants may not have dared to disclose negative opinions of MUCTUM in this setting.

Conclusion

Multi-modal Co-Therapy for Unaccompanied Minors (MUCTUM) aims to provide a pluralist approach in which care providers address biological, transcultural, institutional and narrative approaches. Our qualitative study analyzes the experiences of UM participating in this program, with main findings highlighted in Table 3. We identify possible strategies to address UMs' needs according to their own priorities, including creating a safe place, providing a patient-centered therapy, addressing concrete problems, improving relations with caseworkers, making use of limited reparenting in therapy, providing culturally appropriate care, and supporting family relationships. Inquiring about traumatic events may be beneficial only after these needs have been addressed.

Table 3. Highlights : multi-modal co-therapy for unaccompanied minors

• Commitment and reliability of care providers despite missed appointments helps build trust.

• Care providers address unaccompanied minor's needs hierarchically (e.g. housing first)

• An interpreter in native language is central for translation and cultural mediation

• Supporting the relationship with the family is experienced as helpful (e.g. through phone calls)

• Pharmacological treatment, and addressing social factors are perceived as helpful.

• Therapy focuses on trauma once primary needs have been addressed. The process may take months.

• Trauma narration is delayed, prudent, non-forced, and fragmented. If guided carefully, trauma narration is perceived as "freeing" by unaccompanied minors.

Formation: compétences pluralistes

Il serait utile d'établir un modèle de programme de formation sur les compétences pluralistes de base.

Alors que les approches biologiques sont reconnues en tant que psychiatrie standard, nous pensons que les programmes de formation des internes devraient également inclure la psychiatrie sociale, ainsi qu'une réflexion sur la manière d'articuler psychiatries biologique et sociale dans la pratique clinique.

Des formations aux approches sociales sont dispensées dans plusieurs universités, notamment des formations aux compétences (trans)culturelles et les compétences structurelles (Hansen et al., 2018 ;Ogrizek et al., 2022). La faculté de médecine de McGill, au Québec, offre une formation aux bases des sciences sociales (Kirmayer et al., 2008). Les compétences culturelles comprennent la sensibilisation à l'impact de la propre identité ethnoculturelle du clinicien sur les patients, la reconnaissance de la langue et du contexte culturel des groupes culturels rencontrés dans la pratique clinique et leurs interactions avec les problèmes de santé mentale et de traitement, les compétences pour travailler avec des groupes spécifiques, et le développement d'organisations ou systèmes capables d'offrir une équité d'accès de soins aux diverses populations (Kirmayer et al., 2021). A l'Université de New York, aux Etats-Unis, la formation aux compétences structurelles repose sur la capacité à identifier comment les conditions sociales, économiques et politiques produisent des inégalités en matière de santé, et peuvent façonner les symptômes et les maladies (Hansen et al., 2018 ;Metzl & Hansen, 2018). Les cliniciens se mobilisent alors pour corriger les inégalités dans les interactions clinicien-patient et dans la vie des patients. En France, la compétence transculturelle, décrite selon l'approche de la psychiatrie transculturelle développée en France (Moro & de La Noë, 2004) est la capacité des cliniciens à fournir des soins culturellement appropriés, permettant la coexistence des représentations de la maladie et des soins des patients et des médecins. La formation en psychiatrie transculturelle à l'Université Paris Cité, en France, est intégrée dans le programme d'études initiales et de formation continue ; elle est aussi dispensée dans des programmes ultérieurs pour les médecins et soignants, et des programmes de médiation culturelle (Ogrizek et al., 2022 ;Radjack et al., 2020). La formation s'effectue également par le biais du compagnonnage durant les consultations, de cours magistraux, de jeux de rôles ou de l'utilisation de consultations assistées par des seniors.

La compétence pluraliste consisterait à avoir des compétences de base dans les approches biologiques et sociales, ce qui permettrait d'identifier l'approche la plus appropriée pour un patient donné, et (5) créer un programme d'études modèle sur les compétences pluralistes.

Discussion

Cette thèse traite de l'articulation des approches biologiques et sociales en psychiatrie de l'enfant et de [START_REF] Devereux | Ethnopsychoanalysis: Psychoanalysis and anthropology as complementary frames of reference[END_REF]. Cependant, nous avons préféré insister dans cette thèse sur la dimension de l'articulation des approches, afin de discuter la manière de les relier.

Promouvoir la mise en oeuvre de soins pluralistes en psychiatrie nécessite de questionner son coût économique. Il existe des preuves de l'intérêt économique et social d'interventions spécifiques en psychiatrie de l'enfant et de l'adolescent (Skokauskas et al., 2018). Certaines études suggèrent que proposer des soins transculturels spécialisés, en plus des approches standard, est rentable pour les systèmes de santé (Lachal et al., 2019).

Les questions éthiques pourraient être examinées sur la manière dont la qualité des soins devrait guider la promotion et le financement de la recherche -et pas seulement les facteurs économiques (Dakić, 2020;Dumit, 2018 ;Rutter & Stevenson, 2009) between biological and social approaches, one can cite the three following: [1] Possession by spirits in an adolescent from a Islamic culture could be a culturally meaningful non-psychotic syndrome or a psychotic disorder or both could be interrelated with one another; such complexities can lead to misdiagnosis; [2] Anorexia nervosa has clear neurobiological correlates, including a strong genetic component, but family therapy, which focuses on environmental, familial, and social factors, is an evidence-based treatment (1-3); [3] Autism spectrum disorder has been progressively explained through in-depth knowledge at the genomic, molecular, cellular, and neural-circuit levels, yet interventions focus on improving interactions and communication between patients and their families (4,5). Further examples are detailed in Table 1.

-Insert Table 1 around here -Child and adolescent psychiatry has been based on numerous fields of research and theories, including neuroscience, genetics, physiology, psychology (developmental, psychodynamic, systemic, cognitivebehavioral, etc.), anthropology, sociology, and education sciences. Over the past 70 years, we have witnessed the demise of "big" theories in CAP purporting to offer overarching explanations and in its place the development of specialized research fields that provide strategies for tackling particular questions (6). Various fields in CAP are evolving simultaneously, with distinct theories, concepts, representations, and interventions. In this article, we schematize the diversity of approaches into (psycho)biological approaches vs (psycho)social approaches. Biological approaches refer to the conception of psychiatry as a medical science based on biology, physiology and neuroscience. This perspective posits that biology grounds medical practice and that other sciences can contribute but cannot displace biology from its central role (7). Biological approaches have brought important changes to CAP, such as the vast body of research on the use of stimulants to treat ADHD (6). Nevertheless, social approaches, such as sociology and anthropology, are critical in CAP: These approaches are grounded in the concept that humans are fundamentally social beings, and that social factors are key determinants of health (8). Thus, in the context of CAP, the child is not only an individual and must be viewed within a larger familial, social, and cultural context (9).

Evidence-based medicine (EBM) has influenced research methods in the last few decades, promoting quantitative research, which tends to exclude cultural factors, and thus minority groups, in order to obtain homogeneous study populations. Consequently, there is scarce transcultural data in CAP (10,11).

This lack of research knowledge and the need for updated and integrative diagnostic and interventional models remains a challenge in the field. A pluralistic approach argues that multiple independent methods are necessary in the understanding and treatment of mental illness and that no single method is sufficient (12).

There are numerous obstacles that impede the implementation of a pluralistic approach in CAP: the difficulty of identifying and treating diseases in CAP; objects in CAP are multiple and heterogeneous (e.g., Kleinman's developments on the personal and social meanings disease, illness, and sickness (13,14)); the divide between biologically oriented child psychiatrists and other types of child psychiatrists (15); the lack of unifying theories and the pragmatic oversimplification for the sake of practice and training (16). Integrative transdisciplinary models in research are promising, but they are not immediately applicable to clinical practice (e.g., translational social neuroscience (17); cultural neuroscience (18); neurophenomenology ( 19)). In our opinion, significant gaps persist between biological and social approaches, and between theory, research, and clinical practice. The objective of this article is to provide practical perspectives on how to articulate (i.e., to connect, to be jointed) biological and social approaches in CAP.

Definitions: pluralistic articulated approach

Biological and social approaches have not only different theories and concepts (self, disorders, emotions, etc.), but also different methodologies. Biological research is more often quantitative and nomothetic, i.e., it provides standardized, generalizable knowledge on disorders. Social research is often qualitative and idiographic, i.e., it provides in-depth knowledge on the experience of patients (20,21), though numerous nomothetic studies also exist in the social sciences. Nomothetic methods do not take into account the personal and subjective factors involved in patients' disorders. In contrast, idiographic methods, based on the patient and his or her particular features, can help identify the social experience of mental disorders.

We provide brief definitions of some important concepts in the supplementary materials, and we highlight three of them here: pluralistic, complementary and integrative. A pluralistic approach states that multiple independent methods are necessary in the understanding and treatment of mental illness and that no single method is sufficient (12). In pluralistic approaches, the conceptual differences are assumed to understand mental and brain phenomena (12). Care providers can combine actions from different fields and theories, wondering which ones are relevant in a given case (rather than applying a little of each for every disorder). Complementary frames of reference (complémentarisme) is a concept historically based on George Devereux's French school of transcultural psychiatry: it argues for the necessary non-simultaneous use of several methods (at the time, anthropology and psychoanalysis) (22).

Integrative psychiatry aims at providing a synthetic approach to the distinct psychiatry fields (21). In this article, we use the term pluralistic approach to refer to the use of multiple independent methods, articulated rationally and non-simultaneously but with possible overlap, in accordance with both evidence-based and patient-centered medicine.

There are essentially two options: [1] To assume a pluralistic approach with separated concepts and research methods, or [2] To build models whose theories encompass the traditionally separated fields.

With the first option, one can study a single theme with two or more methods via distinct research protocols. For example, one can perform, on the one hand, biological studies on adolescent depression and, on the other hand, social research on this topic (23,24). The objects, methods, and theories would be distinct between these methods. As another example, within a single team, in adult psychiatry, we performed, on the one hand, a quantitative epidemiological study and, on the other hand, a qualitative psychological study on care providers' mental health during the COVID-19 pandemic (25,26). The second option, integrating typically separate fields, requires a wider and deeper theoretical foundation.

Achieving this goal would be, in our opinion, the most ambitious and important transformation for the future of psychiatry (27). Like biological processes, social factors influence the brain's development and functioning. For example, children in situations of severe social isolation demonstrate abnormal brain development and language impairments (28). Proposing sociobiological models could constitute the future of CAP (29). Until then, clinicians and researchers still require perspectives to grapple with the coexistence of social and biological approaches.

Research: Pluralism and complementarity from clinical description to research

The articulation of social and biological approaches should be carried out starting from the clinical description phase. Otherwise, if psychiatrists follow a standard descriptive criteriologic approach, only a part of the patients' experience-the objective, standardized, generalizable and observable aspectswill be reported and thus shape the research perspectives. Additionally, the expression of mental distress varies within populations and across cultures, depending on social and biological factors, and is also characterized by distinct cultural presentations that demand a social assessment by psychiatrists (e.g., hikikomori syndrome in adolescents ( 30)).

Collecting and synthesizing both sociocultural knowledge and neurobiological knowledge on a subject is not an obvious approach, but we argue that it should be more widely utilized. We applied this synthetic approach to study clinical lycanthropy, a syndrome in which patients have the delusional belief that he or she is turning into a wolf (31,32). We conducted a systematic review of medical publications and linked together biological and cultural knowledge (33). The reader thus witnesses the clear necessity of both approaches: clinical lycanthropy is related to neuropsychiatric disorders, but it occurs in a particular environmental and cultural context. Consequently, we hope that any reader on this topic will have a representation of clinical lycanthropy that integrates both approaches. Next steps consist of offering multilevel perspectives that include the brain and its environment (27).

We offer the following suggestions: The tools available to us shape research designs and clinicians' representations, notably by capturing some cultural forms of mental health experiences, while rendering others invisible. In standard evidence-based and nomothetic CAP approaches, there is a lack of culturally appropriate and transculturally valid instruments (34,35). Some Western-derived scales distort or miss some culturally specific dimensions of mental distress, inducing a form of experience measure fallacy, or an error in measuring the experience of patients by superimposing Western experiences of mental distress (as a parallel to Kleinman's category fallacy, referring the application of a nosological category developed for a particular cultural group to the members of another culture for whom it lacks coherence and validity has not been established) (36)(37)(38). A Western scale in adult psychiatry would miss a culturally meaningful form of dysphoria that the Afghan symptom checklist does capture: jigar khun, literally "liver blood," is an extreme and persistent dysphoria that includes grief following interpersonal loss but that may also be a reaction to any deeply disappointing or painful experience (39).

As an example in CAP, several tools for autism spectrum disorder showed lower psychometric properties among immigrant minority groups, non-native speakers, and other cultural minorities from non-Western countries, attesting to a worldwide scarcity of validated and culturally attuned screening and diagnostic tools (40,41). For example, the Autism Diagnostic Interview-Revised (ADI-R) in a Spanish-speaking population in the U.S. showed lower sensitivity and specificity rates than in the original validation that included only native English speakers (42). The Spanish version of ADI-R may be less valid when the parent and child's Spanish language proficiencies differ; if the parent speaks mostly Spanish and the child speaks mostly English with peers and at school, the ADI-R verbal communication questions may be less valid.

The cultural formulation interview of DSM-5 includes interesting idiographic questions on cultural definitions of the problem, and some authors have suggested developing a supplementary module specifically for young children (43,[START_REF] Roche | Examining the effectiveness of the Cultural Formulation Interview with young children: A clinical illustration[END_REF]. More tools are needed to assess other factors such as interactional aspects within a particular cultural context. The matter is complicated further by the changes that inevitably occur in culture over time, resulting in the need for regular reassessments and revisions of these instruments.

Some researchers have designed culturally pertinent scales: Phan et al. designed an adult psychiatric scale that is derived from Vietnamese idioms and cultural understandings of psychiatric and emotional distress identified in Vietnamese literature and using ethnographic methods (37). Another option is to propose transcultural validations and adaptations of existing scales (e.g., cross-cultural validation of the Positive and Negative Syndrome Scale ( 45)). A third option is to intentionally develop tools, from their conception, to be applicable across cultures, such as: the PSYca, a tool designed to screen for psychological difficulties among children aged 6 to 36 months [START_REF] Nackers | A screening tool for psychological difficulties in children aged 6 to 36 months: cross-cultural validation in Kenya, Cambodia and Uganda[END_REF], and the ELAL scale , an instrument designed to assess language skills in any minority language and consequently better diagnose language disorders across various populations [START_REF] Kohrt | Validation of crosscultural child mental health and psychosocial research instruments: adapting the Depression Self-Rating Scale and Child PTSD Symptom Scale in Nepal[END_REF]. Kohrt et al. propose criteria to evaluate the cross-cultural validity of CAP instruments, such as the incorporation of mention of local idioms employed, the structure of response sets, and comparisons with other measurable phenomena [START_REF] Kohrt | Validation of crosscultural child mental health and psychosocial research instruments: adapting the Depression Self-Rating Scale and Child PTSD Symptom Scale in Nepal[END_REF]. Within a health justice framework, it is our ethical responsibility as child psychiatrists to develop tools that are adaptable to the needs of different patient populations.

Clinical practice: Provide pluralistic articulated interventions

In clinical practice, it remains a challenge to implement this plurality of approaches and develop different narratives of a patient's condition that can coexist. Articulating pluralistic care in clinical practice can be promoted through the following axes: encourage diverse care teams with psychiatrists trained in distinct approaches (for complex patients).

For example, the management of eating disorders requires a pluralistic approach as well as a transdisciplinary care team [START_REF] Rezakhany | Severe nondiabetic plantar mal perforant in an adolescent girl with anorexia nervosa[END_REF][START_REF] Collet | Acute metabolic acidosis in an adolescent with anorexia nervosa: A transdisciplinary approach[END_REF]. Autism spectrum disorder is another example of a disorder that is explained with a biological approach, treated with interactional and behavioral treatments, and influenced by important cultural and social factors [START_REF] Kang-Yi | Influence of Community-Level Cultural Beliefs about Autism on Families' and Professionals' Care for Children[END_REF] (see Table 1). Some authors have proposed integrative frameworks that encompass developmental, multidimensional, eco-systemic, and multifactorial approaches and are associated with pluralistic interventions [START_REF] Cohen | Debate: Developmental and integrative approaches in child and adolescent psychiatry inpatient facilities: the case of a tertiary university hospital in Paris[END_REF].

As an illustration of a pluralistic intervention, we carried out a study on a specific mental health care program for unaccompanied immigrant minors: Multimodal Co-Therapy for Unaccompanied Minors (MUCTUM) (Guessoum et al., under review). This monthly consultation brings together a standard biological approach (including pharmacological treatment), an institutional approach (aiming to improve caseworker-youth relationships and communication as well as solving stressful daily life problems), transcultural psychiatry (providing an interpreter who speaks the patient's native language and acts as a bond with the patient's native country, cultural affiliations, family, and culturally meaningful care), and a narrative approach (narration of the youth's story, immigration, and trauma).

MUCTUM aims to provide a pluralistic approach through the use of two therapists with different backgrounds (a psychiatrist and a psychologist), further enriched by the participation of an interpreter and the youth's caseworker. MUCTUM is consistent with the idea that pluralism requires close collaboration among psychiatrists, psychologists, and social workers (12). In this study, we hypothesize that following a hierarchy of needs, through a patient-centered and problem-solving approach, could be one axis by which to articulate these interventions. We also hypothesize that a pluralistic approach could be provided through interventions in a single consultation with several care providers with both biological and cultural backgrounds. Implementation research for such approaches is much needed in CAP [START_REF] Proctor | Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges[END_REF]. Training in social approaches is provided at several universities, such as (trans)cultural competency and structural competency [START_REF] Hansen | From Cultural to Structural Competency-Training Psychiatry Residents to Act on Social Determinants of Health and Institutional Racism[END_REF][START_REF] Ogrizek | Perspective changes through transcultural mediation training: A qualitative study of trainees, instructors, and experts[END_REF]. McGill University's medical school curriculum provides training grounded in basic social science perspectives [START_REF] Kirmayer | Training clinicians in cultural psychiatry: a Canadian perspective[END_REF]. Cultural competency notably includes an awareness of the impact of the clinician's own ethnocultural identity on patients, knowledge of the language and cultural background of groups seen in clinical practice and their interactions with mental health issues and treatment, and skills for working with particular groups [START_REF] Kirmayer | Guidelines for Training in Cultural Psychiatry[END_REF]. Structural competency training relies on developing a capacity to identify how social, economic, and political conditions produce health inequalities and can shape symptoms and diseases [START_REF] Hansen | From Cultural to Structural Competency-Training Psychiatry Residents to Act on Social Determinants of Health and Institutional Racism[END_REF][START_REF] Metzl | Structural Competency and Psychiatry[END_REF]. After identifying such factors, the clinician would then mobilize to address the inequities in the clinician-patient dynamic or in the patient's life.

Transcultural competency developed in France [START_REF] Moro | Manuel de psychiatrie transculturelle: travail clinique, travail social[END_REF], describes the ability of clinicians to provide culturally appropriate care, allowing the co-existence of medical and patients' cultural narratives and treatments. Training in transcultural psychiatry in Université Paris Cité in France is embedded in the early curriculum and provided in later programs for care providers and cultural mediation [START_REF] Ogrizek | Perspective changes through transcultural mediation training: A qualitative study of trainees, instructors, and experts[END_REF][START_REF] Radjack | Cultural Competence of Professionals Working With Unaccompanied Minors: Addressing Empathy by a Shared Narrative[END_REF].

Training also occurs through mentoring during consultations, lecture courses, role-playing, or use of senior resident-assisted consultations.

Pluralistic competency would call for basic skills in both biological and social approaches, which enables one to identify the most suitable approach for a given patient and refer patients to specialists when necessary, e.g., having basic skills in transcultural psychiatry allows any clinician to seek for a cultural etiology of the disease and evaluate its importance in the patient's and their family's narration of the disorder and the need for specialized transcultural therapy if available. Another central aspect is dialogue, self-esteem, and collaborative work among care providers from different disciplines to achieve a pluralistic approach, including multidisciplinary staff meetings.

Discussion

This article discusses the articulation and implementation of a pluralistic approach. There is still a lack of appropriate tools, pluralistic syntheses, integrative knowledge, and training for professionals in these approaches. More biological studies should be conducted in non-Western countries to obtain results applicable in these settings and address the population homogeneity needed in many biological studies.

Distinct avenues for cross-cultural perspectives allow for the comparison of data from disparate item 123 sets and response formats, such as mega-analyses of aggregated heterogeneous data from many individuals [START_REF] Mansolf | Extensions of Multiple-Group Item Response Theory Alignment: Application to Psychiatric Phenotypes in an International Genomics Consortium[END_REF] .

Promoting the implementation of pluralistic care in psychiatry requires assessing its financial cost.

Evidence exists for the economic and social value of specific interventions in CAP ( 61), e.g., proposing specialized transcultural care, in addition to standard approaches, may be cost-effective for health systems [START_REF] Lachal | Transcultural mediation programme in a paediatric hospital in France: qualitative and quantitative study of participants' experience and impact on hospital costs[END_REF].

From an ethical standpoint, the driving force behind such research should be improving the quality of health care, not economic factors only (6,[START_REF] Dakić | Mental health burden and unmet needs for treatment: a call for justice[END_REF][START_REF] Dumit | The Infernal Alternatives of Corporate Pharmaceutical Research: Abandoning Psychiatry[END_REF]. Promoting pluralistic research that includes social factors is necessary to provide just and equitable health care [START_REF] Moro | Vers une équité en santé mentale pour les enfants de migrants : propositions transculturelles[END_REF]. This includes ethically justified exclusion criteria [START_REF] Dakić | Mental health burden and unmet needs for treatment: a call for justice[END_REF]. Promoting such approaches requires that they be available and accessible to both patients and professionals, and supporting free online access to diverse tools may be a simple contribution.

Articulating biological and social approaches in CAP in clinical practice and research is an ongoing challenge. As a conclusion, we provide highlights in Table 2.

-Insert Table 2 around here -Tables Table 1. Examples

A. An illustration via a common case of psychosis A 14-year-old boy from Morocco is diagnosed with schizophrenia characterized by a delusion of spirit possession (djinn); the family does not accept/support antipsychotic treatment.

Biological approach -Genetic, molecular, and neurologic impairments are found in schizophrenia ( 66 A categorical approach establishes predefined diagnostic categories. Psychiatric diagnosis aims to identify the presence or absence of a psychiatric disorder in a patient and then to classify the patient's disorder into a diagnostic category according to pre-established criteria.

A dimensional approach is based on the conception of symptoms as a continuum between normal and pathological and as not being exclusive across diagnostic categories. Psychiatric diagnosis aims to evaluate the different dimensions of the patient's symptoms and to nuance them according to their intensity.

These definitions are a synthesis of the data found in this article's references and in dictionaries (12,22,[START_REF] Devereux | Essais d'ethnopsychiatrie générale[END_REF](78)[START_REF] Collet | La transdisciplinarité dans le champ des troubles des conduites alimentaires: un modèle innovant pour le soin et la recherche[END_REF][START_REF] Guessoum | Approche dimensionnelle des symptômes négatifs: revue de la physiopathologie et étude clinique transnosographique dans les premiers épisodes psychiatriques[END_REF].

normal et le pathologique et comme non-exclusifs entre les catégories diagnostiques. Le diagnostic psychiatrique vise alors à évaluer les différentes dimensions des symptômes du patient et à les nuancer en fonction de leur intensité.

(Blanchet- Collet, 2019;Devereux et al., 1970Devereux et al., , 1972;;Guessoum, 2019;Wharton, 2006;Ghaemi, 2004)

  designs de recherche, les instruments et la formation clinique doivent fournir des connaissances applicables à une pratique clinique quotidienne qui est nécessairement pluraliste. Cette thèse propose des perspectives sur la manière d'articuler les approches biologiques et sociales : approche pluraliste et interventions multimodales ; pluralisme et complémentarisme de la description clinique à la recherche ; construction d'instruments appropriés ; offre de soins de santé mentale ; formation des psychiatres. Des propositions pour articuler les approches biologiques et sociales sont formulées : (I) Indiquer que l'objet de la recherche peut être abordé sous différents angles cliniques, de recherche et théoriques et expliquer celui choisi ; (II) proposer des articles de synthèse qui articulent les connaissances biologiques et sociales ; (III) concevoir des études biologiques qui tiennent compte des facteurs culturels ; concevoir des études sociales qui tiennent compte des facteurs biologiques ; (IV) concevoir des outils transculturels ; (V) concevoir des interventions thérapeutiques pluralistes, c'est-à-dire des thérapies et des dispositifs de soins de santé mentale qui articulent les approches biologiques et sociales ; (VI) développer des formations aux approches pluralistes.

( 1 )

 1 Adopter une approche pluraliste avec des concepts et des méthodes de recherche distincts. Par conséquent, on peut étudier un même thème avec deux ou plusieurs méthodes dans des protocoles de recherche distincts. Par exemple, on peut réaliser, d'une part, des études d'approche biologique sur la dépression des adolescents et, d'autre part, des études d'approche sociale sur ce sujet (Rose-Clarke et al., 2021 ; Zajkowska et al., 2021). Les objets, les méthodes et les théories sont alors différentes. Autre exemple, au sein d'une même équipe, en psychiatrie adulte, nous avons réalisé d'une part une recherche épidémiologique quantitative et d'autre part une recherche psychologique qualitative sur la santé mentale des soignants durant de la pandémie de COVID-19 : 1) D'une part un angle qualitatif et idiographique de l'expérience psychologique singulière des soignants mobilisés dans une unité COVID donnée : The experience of anaesthesiology care providers in temporary intensive care units during the COVID-19 pandemic in France: a qualitative study Sélim Benjamin GUESSOUM, Maxime MARVALDI, Isaiah THOMAS, Jonathan LACHAL, Emilie CARRETIER, Marie Rose MORO, Laelia BENOIT Anesthesia Critical Care & Pain Medicine, 2022 (impact factor : 7) 2) D'autre part un angle quantitatif et nomothétique, sur les données épidémiologiques sur la santé mentale des soignants durant la pandémie de COVID-19 : Anxiety, depression, trauma-related, and sleep disorders among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis, Maxime MARVALDI, Jasmina MALLET, Caroline DUBERTRET, Marie Rose MORO, Sélim Benjamin GUESSOUM Neuroscience & Biobehavioral Reviews, 2021 (impact factor : 9)

1 )

 1 Lycanthropy in a 12-Year-Old Adolescent: From Culture-Bound Syndromes to Internet-Mediated Delusions Sélim Benjamin GUESSOUM, Jasmina MALLET, Fumie TODO, Jean-Pierre BENOIT, Marie Rose MORO Psychiatry and Clinical Neurosciences, 2021 (impact factor : 12.Ce cas illustre pourquoi, selon nous, ce syndrome doit être regardé selon une approche biologique et une approche sociale, justifiant l'intégration du cas clinique dans cette thèse. Ce cas clinique intègre une revue systématique de la littérature sur les cas de lycanthropie clinique chez les adolescents. Cependant, les données étant limitées, nous avons décidé d'élargir la revue de la littérature sans limite d'âge des patients (Article 2Cet article est une illustration de revue systématique de la littérature rassemblant les connaissances médicales d'un même syndrome sous deux angles théoriques : d'une part les connaissances biologiques et d'autres part les connaissances sociales. Cet article propose donc au lecteur de regarder ce syndrome sous deux angles séparés mais complémentaires, dans l'espoir que tout lecteur puisse concevoir la lycanthropie clinique comme un syndrome avec des corrélats neurobiologiques, mais qui apparaît dans un contexte socioculturel donné. Nous espérons qu'en conséquence, tout lecteur sur ce thème bénéficiera d'une représentation de la lycanthropie clinique qui intègre les deux approches. Il constitue, nous espérons, une illustration de la manière dont les choix dans la description des connaissances peut offrir un regard pluraliste au clinicien ou au chercheur. Par ailleurs nous avions aussi publié une lettre à l'éditeur comme réponse à un cas clinique publié dans Psychiatry Research et qui présentait la lycanthropie clinique sous un angle exclusivement psychanalytique. Nous y présentions les principales hypothèses neurobiologiques liées à la lycanthropie clinique (Article 3). Article 3. The Neurobiological Hypotheses on Clinical Lycanthropy Sélim Benjamin GUESSOUM, Jasmina MALLET, Marie Rose MORO Psychiatry Research, 2020 (impact factor : 11.2)

  can affect psychiatric disorders. Clinical Lycanthropy is a rare syndrome, described since Antiquity, within which the patient has the delusional belief of turning into a wolf.

L'Article 4

 4 de cette thèse, porte sur une étude qualitative utilisant l'ELAL. Cette recherche est chronologiquement la première de ce doctorat. Elle s'inscrit dans une recherche plus large, à l'intersection de la recherche quantitative et qualitative et des approches idiographiques et nomothétiques. Le programme hospitalier de recherche clinique dont elle fait partie visait à : -construire une échelle pour évaluer les compétences langagières de base des enfants dans n'importe quelle langue minoritaire, et ainsi plaider contre les diagnostics erronés et les fausses croyances selon lesquelles les enfants migrants ont de faibles compétences langagières -alors qu'en réalité, ils sont multilingues et leurs compétences langagières suivent une dynamique différente par rapport aux enfants monolingues, pour lesquels la plupart des études et des échelles sont conçues, -étudier les pratiques familiales et les représentations maternelles et les comparer aux profils de bilinguisme des enfants.

Article 4 .

 4 Transcultural and familial factors in bilingualism and language transmission: A qualitative study of maternal representations of French-Maghrebi Arabic bilingual children Sélim Benjamin GUESSOUM, Dalila REZZOUG, Fatima TOUHAMI, Olivier TAIEB, Thierry BAUBET, Marie Rose MORO Transcultural Psychiatry, 2021 (impact factor : 2.39) Cette étude est une partie qualitative d'un projet hospitalier de recherche clinique plus large. Une analyse quantitative de trois types de bilinguismes est en cours sur la population complète (enfants de langues française-arabe, française-soninké et française-tamoul). Cet article contribue au travail de thèse en illustrant comment une échelle spécifique (l'ELAL) et un design d'étude spécifique (étude de méthodologie mixte, dont est présentée ici une partie qualitative) peuvent produire des connaissances sur les facteurs sociaux du développement du langage : il met en perspective les profils de bilinguisme, les facteurs environnementaux et les facteurs psychologiques parentaux et explore leurs possibles liens. Ce type d'étude est une illustration de recherche à l'intersection entre approche biologique (développement cognitif) et approche sociale. L'objectif fondamental de l'articulation des approches biologiques et sociales est celui de la santé des patients et de la qualité des soins, c'est pourquoi nous discutons dans le paragraphe suivant des interventions thérapeutiques et de la manière d'articuler approches biologiques et sociales auprès des patients. Dans la partie suivante, nous étudierons en particulier un dispositif de co-thérapie multimodale.

  study examined transcultural and familial factors involved in bilingualism and minority language transmission among French and Arabic-speaking children.

  Dans la pratique clinique, mettre en oeuvre cette pluralité d'approches et faire coexister ces différentes narrations de la maladie sont des défis. L'articulation des soins pluralistes dans la pratique clinique pourrait être favorisée par certains moyens : (1) former les cliniciens aux approches pluralistes ; (2) garantir la disponibilité de ces interventions pour les patients ; (3) acquérir les compétences nécessaires pour déterminer la séquence temporelle des soins : quelle intervention est prioritaire et/ou peut faciliter l'autre (par exemple, une intervention familiale peut être indispensable avant l'acceptation d'un médicament, ou inversement) ; (4) promouvoir des débats et échanges en staffs de psychiatres formés à des approches distinctes (pour les patients complexes). Nous proposons deux exemples portant sur la schizophrénie et l'autisme, que nous développons dans le Tableau 1 ci-après. Les troubles du comportement alimentaire sont un exemple de trouble dont la prise en charge nécessite une approche pluraliste. Elle requiert, plus largement, une approche transdisciplinaire entre psychiatres, pédiatres, endocrinologues et professions paramédicales (Blanchet-Collet, 2016; Rezakhany et al., 2022). Les troubles du spectre autistique sont un autre exemple de troubles expliqués par des théories biologiques, mais pris en charge notamment par des interventions psychothérapeutiques ciblant les aspects comportementaux et interactionnels, et comportant des facteurs culturels et sociaux qui influencent les croyances communautaires et la compréhension de l'autisme par les familles (Kang-Yi et al., 2018) (voir Tableau 1). Certains auteurs ont proposé des modèles intégratifs qui englobent des approches développementales, multidimensionnelles, écosystémiques et multifactorielles et qui sont associés à des interventions pluridisciplinaires (Cohen et al., 2021). Comme illustration d'une intervention pluraliste, nous avons mené une recherche sur un programme spécifique de soins de santé mentale pour les mineurs non accompagnés : la Co-thérapie Multimodale pour les Mineurs Non Accompagnés (MUCTUM) (Article 5publication dans la revue Child and Adolescent Psychiatry and Mental Health, 2022 (impact factor : 7.5 ; rang A) Cette consultation combine une approche biologique standard (y compris traitement pharmacologique), une approche institutionnelle (visant à améliorer la relation et la communication entre l'éducateur et le jeune, et à résoudre les problèmes stressants de la vie quotidienne), une approche transculturelle (l'interprète parle la langue maternelle du patient et constitue un lien avec le pays d'origine, les

- 1 )

 1 La prise en compte de la narration du patient, de la famille et de la culture favorise l'alliance thérapeutique et l'adhésion aux soins, la collaboration avec les soignants et assure des soins éthiques -L'approche biologique est nécessaire dans la schizophrénie, mais inefficace (car inapplicable) sans l'alliance avec la famille et le patientB. Illustration avec l'exemple du trouble du spectre autistiqueApproche biologique-Des altérations au niveau génomique, moléculaire, cellulaire et des circuits cérébraux sont retrouvées dans l'autisme(Willsey et al., 2022) -Les traitements pharmacologiques sont utiles (exemple : les taux de mélatonine sont diminués dans l'autisme, et la mélatonine peut améliorer le sommeil et le comportement diurne(Reading, 2012 ; Schroder et al., 2019; Tordjman et al., 2005) Approche sociale -Les interventions se concentrent sur les niveaux interactionnels et communicationnels, avec les patients et leurs familles (Fuentes et al., 2021) -Les facteurs culturels et sociaux influencent les croyances communautaires et la compréhension de l'autisme par les familles (Kang-Yi et al., 2018) -Peu de connaissances sont disponibles sur les adaptations nécessaires pour rendre les interventions faisables, acceptables et efficaces dans les contextes à faibles ressources (de Leeuw et al., 2020) Apports d'une approche pluraliste -Des adaptations culturelles et contextuelles sont nécessaires et doivent être étudiées pour rendre les interventions réalisables, acceptables et efficaces dans les pays non occidentaux -la pratique clinique auprès des patients atteints de trouble du spectre autistique, un trouble biologique, est ancrée dans les interactions parentsenfants, qui varient selon les cultures refugee minors -or unaccompanied minors -are children and adolescents who have been separated from parents and other relatives and are not being cared for by an adult. Unaccompanied minors are a vulnerable population, with numerous stressors and complex psychiatric symptoms necessitating specialized mental health care. This study explores patients' experiences of a Multimodal Co-Therapy for Unaccompanied Minors (MUCTUM), which encompasses cultural, biological, narrative & institutional approaches to care. Methods: MUCTUM is a co-therapy program for unaccompanied minors, with a psychiatrist, psychologist, native-language interpreter, and caseworker for each patient. In this qualitative study, we interviewed adolescents about their experiences with MUCTUM and analyzed these semistructured interviews using a phenomenological framework (Interpretative Phenomenological Analysis). Results: Qualitative analysis of 16 interviews uncovered four overarching domains: (1) Unaccompanied minors' experience of mental health problems includes strangeness, loneliness, stigmatization, and distrust of mental health care; (2) MUCTUM creates a safe space through care providers who foster trust, adherence, and feelings of safety or self-acceptance; (3) Helpful interventions during therapy include the use of native language, cultural mediation, and supportive relationships with caseworkers and families; and (4) Narrating one's story and traumatic events is perceived as liberating if carefully guided and not rushed. Conclusion: This study suggests that MUCTUM therapy may efficiently support unaccompanied minors' mental health by acknowledging their hierarchy of needs. Psychotherapeutic strategies include creating a safe place, providing culturally appropriate care and patient-centered therapy, addressing concrete problems, supporting relationships, and making use of limited reparenting in therapy. Delayed and progressive inquiry about traumatic events may be beneficial. Replication of these findings and their field application is warranted. Department of Child and Adolescent Psychiatry, APHP, Cochin University Hospital, Paris, France 2) Université Paris Cité, PCPP, Paris, France 3) Université Paris-Saclay, UVSQ, Inserm U1018, CESP, Team DevPsy, Villejuif, France 4) Yale School of Medicine, Child Study Center, New Haven, USA *Corresponding author : Sélim Benjamin Guessoum; selim.guessoum@gmail.com; Tel: 0033158412814 Postal address: Cochin Hospital, Assistance Publique -Hôpitaux de Paris (APHP), Paris, France, 97 Boulevard Port-Royal, 75014 Paris, minors -or unaccompanied minors -are children and adolescents who have been separated from parents and other relatives and are not being cared for by an adult. Unaccompanied minors are a vulnerable population, with numerous stressors and complex psychiatric symptoms necessitating specialized mental health care. This study explores patients' experiences of a Multimodal Co-Therapy for Unaccompanied Minors (MUCTUM), which encompasses cultural, biological, narrative & institutional approaches to care.

Figure 1 .

 1 Figure 1. MUCTUM patient-centered treatment approach procedure

  d'orienter les patients vers des spécialistes si nécessaire. Par exemple, le fait d'avoir des compétences de base en psychiatrie transculturelle permet à un clinicien de rechercher l'existence d'une hypothèse étiologique culturelle de la maladie chez le patient, de s'interroger sur son importance pour le patient et sa famille, et sur la nécessité ou non d'une thérapie transculturelle spécialisée si elle est disponible. Un autre aspect central est le dialogue, l'estime et le travail collaboratif entre les soignants de différentes approches pour parvenir à une approche pluraliste. Suggestions pour la formation aux compétences pluralistes : (1) dispenser, dès le début des études médicales, une formation théorique pluraliste de base (introduction aux approches biologiques et sociales et leur articulation) ; (2) s'assurer que les internes effectuent des stages dans des services orientés vers la psychiatrie biologique et des services orientés vers la psychiatrie sociale ; (3) former les membres du corps enseignant des universités aux compétences cliniques et pédagogiques de base dans les deux approches, et promouvoir le dialogue entre les membres du corps enseignant de différents domaines ; (4) créer et enseigner des interventions qui articulent les approches biologiques et sociales ;

  l'adolescent à différents niveaux : description clinique, recherche, outils, interventions thérapeutiques. L'ensemble de ce manuscrit est présenté sous la forme d'une discussion des articles illustratifs que nous avons publiés. Nous ajoutons ci-après certains points de discussion qui n'ont pas été développés antérieurement. Cette thèse a la force d'illustrer notre propos de manière pragmatique, par des exemples d'articles, outils, recherches et dispositifs qui donnent à voir cette articulation entre approches biologiques et sociales. Mais elle a par conséquent pour limite son aspect généraliste sur ce sujet. Des travaux plus approfondis dans chacun des domaines cités mériteraient d'être entrepris. Au niveau de la recherche, si nous illustrons notre propos par l'exemple, en utilisant un outil transculturel et en proposant une recherche à l'intersection entre questions cognitives développementales et sociales (recherche ELAL), il n'en résulte pas moins qu'un exemple n'est pas suffisant. Il est nécessaire de construire davantage d'outils transculturels qui seraient utilisables pour la plupart des grands troubles psychiatriques, ainsi que des recherches qui fourniront des données scientifiques applicables dans différentes régions du monde (et pas seulement dans les populations majoritaires des pays à haut revenu). Les outils transculturels sont nécessaires tant du point de vue de la recherche que de la pratique clinique. Il existe d'autres pistes que celles développées dans cette thèse pour faire face aux décalages entre dimensions culturelles et biologiques, selon des axes de recherche très différents. Par exemple, davantage d'études avec des approches biologiques devraient être menées dans les pays non-occidentaux pour obtenir des résultats applicables dans ces contextes (et composer avec l'homogénéité populationnelle des designs d'étude). Une autre piste pour les perspectives transculturelles est de rendre comparables certaines données provenant de questionnaires et de formats de réponse disparates, comme les méga-analyses sur des données individuelles hétérogènes agrégées (Mansolf et al., 2020). Concernant les dispositifs cliniques articulant plusieurs approches, notre travail sur la co-thérapie multimodale pour les mineurs non accompagnés n'a pu soulever que quelques questions au sein d'une problématique très large. Notre étude sur la co-thérapie multimodale pour les mineurs non accompagnés a en particulier présenté l'intérêt de soulever des points originaux et centraux qui offrent des perspectives utiles pour l'articulation de ces approches, en particulier l'enjeu de la séquence temporelle des interventions, en proposant une approche centrée sur le patient avec l'idée d'une intervention graduelle suivant une hiérarchie des besoins du patient, en accord avec la faisabilité et la disponibilité des interventions. Il a laissé d'autres enjeux de côté, en particulier le sujet essentiel de la preuve d'efficacité. Cela souligne la question du design des études ayant pour objectif de démontrer l'efficacité d'une intervention, quand celle-ci est basée sur des populations hétérogènes, de petits effectifs, et que les interventions elles-mêmes sont individualisées et donc peu reproductibles. Par exemple, pour étudier l'efficacité de la psychothérapie transculturelle dans la dépression en psychiatrie de l'enfant et de l'adolescent, un Programme Hospitalier de Recherche Clinique est en cours. Les populations sont culturellement hétérogènes. Le design d'étude suit le modèle d'un essai contrôlé randomisé utilisant des méthodes mixtes et une approche bayésienne (Lachal et al., 2020). Une autre méthode intéressante pour évaluer l'efficacité d'interventions sur des petits nombres de participants serait l'étude expérimentale en cas unique (Single-Case Experimental Study, ou SCED). Cette méthode permet de tester une intervention sur un petit nombre de patients (généralement un à trois), en utilisant des mesures répétées, l'introduction séquentielle (+/-aléatoire) d'une intervention et une analyse des données spécifique à la méthode, y compris une analyse visuelle et des statistiques spécifiques (Krasny-Pacini and Evans 2018). Il est nécessaire d'explorer plus en profondeur les aspects épistémologiques et conceptuels des sujets liés à la frontière et à l'articulation entre approches biologiques et sociales, ce qui n'était pas le coeur de ce travail. Si nous avons évoqué des références liées aux approches complémentaristes, pluralistes et intégratives, le travail épistémologique et conceptuel est un champ à part entière, qui mérite des recherches spécifiques. Dans cette thèse, nous avons en particulier évoqué les définitions des termes pluralisme, complémentarisme et intégratif pour tenter de qualifier notre approche. Le choix du terme adéquat reste en discussion. Nous avons retenu le terme « pluralisme » en se référant à la définition philosophique de pluralisme, et au travail de Nasser Ghaemi. Concernant le concept de complémentarisme, George Devereux stipulait que les discours des deux méthodes (psychanalyse et anthropologie) doivent être séparés de manière inconditionnelle, alors que nous tentons dans cette thèse de les relier. D'autres chercheurs ont eu des difficultés similaires puisque nous avons trouvé des articles où plusieurs termes étaient utilisés simultanément, tels que « pluralistic integrating transdiscipinary approach ». De plus, la traduction en anglais de « complémentarisme » pose question. De manière intéressante, Devereux avait publié en anglais en utilisant dans le titre d'un ouvrage le terme « Complementary Frame of Reference » (

  [I] All available sociocultural and biological data should be included in clinical descriptions and case reports. Psychiatrists should exhibit the same precision in describing both the biological (neurological) and social features of disease as early psychiatrists did in their meticulous clinical observations; [II] Biological studies should consider the social context, and social studies should consider the biological context; [III] Scientific syntheses (e.g., reviews) should gather both biological and social data. Tools: Build tools that meet the needs of pluralism Pertinent validated tools (e.g., questionnaires and scales), designed for research or clinical practice, are keystones to articulating biological and social approaches. Instruments are scarce in CAP, and their use is complicated by the dynamic aspect of development and the necessary adaptation of instruments to the age and developmental stage of each patient. Standard rating scales can reflect a nomothetic representation of the measured variables, whereas transcultural validity includes an idiographic perspective.

  [I] train clinicians in pluralistic care; [II] ensure that these interventions are accessible to patients; [III] develop competency in determining the temporal sequence of care: which intervention is prioritized and/or can facilitate other interventions (e.g., family intervention is sometimes necessary before a patient can accept medical treatment, or vice versa); [IV]

Training: pluralistic competency

  Suggestions for training in pluralistic competency: [I] Provide a basic pluralistic theoretical training (introduction to biological and social approaches and how to articulate them in clinical practice) early on in medical school; [II] Make sure residents complete internships in both biological psychiatryoriented and social psychiatry-oriented services; [III] Train faculty members in basic clinical and teaching skills for both approaches and promote dialogue among faculty members from different fields; [IV] Develop and teach interventions that articulate biological and social approaches; [V] Provide a model curriculum for pluralistic articulated training.

)---Table 2 .V

 2 Research on the specific etiology through biological and neurological testing[START_REF] Kurukgy | Implementing organicity investigations in early psychosis: Spreading expertise[END_REF] -Antipsychotic treatment[START_REF] Driver | Childhood-Onset Schizophrenia and Early-onset Schizophrenia Spectrum Disorders: An Update[END_REF] Social approach-Imigration is a risk factor for schizophrenia[START_REF] Chen | Risk factors in early and late onset schizophrenia[END_REF] -Possession by a djinn is a common cultural etiology (i.e., cultural representation of the cause) of positive symptoms (70) -Family and cultural representation and narration of the disease are central in the experience of disease and adherence to care (71,72) Addressing patient, family and cultural narration supports the therapeutic alliance, adherence to care, and collaboration with care providers, and ensures ethical care -A biological approach is necessary in schizophrenia but ineffective (because inapplicable) without family and patient adherence B. An illustration via autism spectrum disorder Biological approach -Knowledge of genomic, molecular, cellular and neural-circuit impairments (4) -Pharmacologic treatments are useful (e.g., melatonin levels are reduced in autism, and providing melatonin may improve sleep and daytime behavior (73-75)) Social approach -Interventions focus on interactions and communication with patients and their families (5) -Cultural and social factors influence community beliefs and families' understandings of autism (50) Cultural and contextual adaptations are required and need to be studied to make interventions feasible, acceptable, and effective in non-Western countries, e.g., Sub-Saharan Africa (40) -The clinical management of autism, a biological disorder, is embedded in parent-child interactions, which vary across cultures (76) Highlights: articulating biological and social approaches in child and adolescent psychiatry I State that the research object can be approached from different clinical, research, and theoretical angles and explain the chosen approach and why. II Propose synthetic articles that articulate biological and social knowledge. III Design biological studies that consider social factors. Design social studies that consider biological factors. IV Design transcultural tools. Develop pluralistic interventions that articulate biological and social approaches VI Develop training in pluralistic articulated care A transdisciplinary approach integrates distinct fields of study and crosses their traditional boundaries.

Table 1 .

 1 hundred and eighteen patients participated in MUCTUM from June 2016 to April 2022. Analysis revealed that participants described strangeness and loneliness in relation to psychiatric symptoms, often feeling misunderstood before participating in MUCTUM. Several youth experienced triple stigmatization: of being UM, of suffering from psychotrauma, and of being mental health patients. Some reported feeling suspicious of care providers, due to negative cultural representations of mental health care or limited background knowledge of mental illness. As therapeutic alliance built up, participants felt increasingly helped by the consultations. They no longer experienced suspicion towards care providers, but rather trust. We identified three themes that reflect how UM feel supported, hoping

	to further improve caregivers' interventions for UM: (1) A safe space for unaccompanied minors; (2)
	Helpful interventions during therapy; and (3) Narrating one's story can "set us free'' if guided carefully

Participants were aged 11 to 17 yo and came from the following areas: Western Africa (Mali, Ivory Coast, Guinea, Senegal), Central Africa (Nigeria, Congo, Congo Kinshasa, Somalia), Northern Africa (Morocco, Algeria, Tunisia), Asia (Afghanistan, Pakistan, Bangladesh), and Europe (Albania). Most participants suffered from anxiety, depressive, or post-traumatic disorders, with a few experiencing psychotic disorders and addictive disorders. Sixteen interviews were conducted from April 2021 to April 2022, ranging from 20 minutes to one hour. Participants' characteristics are described in by care providers. Themes and subthemes are summarized in Table

2

.

Table 1 . Sociodemographic characteristics of participants

 1

	Age at	Gender Disorder	Birth	Mother tongue	Duration of
	interview			country		care (months)
	n°1	♂	PTSD	Guinea	Susu	> 12
	n°2	♀	eating disorder unspecified,	Somalia	Somali	> 12
			depression, PTSD, post-
			traumatic amnesia
	n°3	♂	PTSD	Ivory Coast Dyula	> 12
	n°4	♂	PTSD, suicidality	Burkina	Mooré	> 12
				Faso
	n°5	♀	PTSD, depression	Ivory Coast French	> 12
	n°6	♂	depression, suicidality	Mali	Soninke	< 6
	n°7	♂	depression, social withdrawal	Guinea	Fula	> 12
	n°8	♂	PTSD, depression	Cameroun	English, French,	6
					(Banyang, Pidgin,
					Sawa)
	n°9	♂	depression & anxiety disorder	Mali	Soninke,	> 12
					(Bambara)
	n°10	♀	externalizing disorder,	Nigeria	Urhobo, Pidgin,	> 12
			PTSD		English, (Edo)
	n°11	♂	psychotic depression,	Guinea	Jakhanke	< 12
			psychosomatic symptoms,
			(drepanocytosis)
	n°12	♀	PTSD	Congo	Lingala	6 to 12
				Kinshasa
	n°13	♂	anxiety disorder,	Congo	Lingala	< 6
			dissociative disorder	Kinshasa
	n°14	♀	PTSD, depression	Ivory Coast Koroka, (Bambara,	< 6
					Dyula)
	n°15	♀	depression, PTSD	Nigeria	Pidgin	> 12
	n°16	♂	schizophrenic disorder	Guinea	Fula	< 6
	Interpreters took part in interviews for participants n° 1, 3, 11, 16.

*PTSD: Post Traumatic Stress Disorder

Table 2 . Themes and subthemes A safe space for unaccompanied minors a. A secure therapeutic framework b. The interpreter prevents misunderstandings and is a reassuring link with the native country c. A support to caseworker-youth relationship Helpful interventions during MUCTUM therapy a. Behavioral guidance promotes feelings of safety, self-confidence, and self-care practices b. Care providers facilitate links with the other institutions c. The work on family issues d. Cultural focus enables traditional care implementation e. Help with medications Narrating one's story can "set us free" if carefully guided by care providers a. Unaccompanied minors valued a delayed, progressive, and fractionated narration b. Care providers provide active, participative and empathetic listening to narration c. Sharing one's story is "painful" but "sets us free"

 2

  According to UM, care providers offered much-needed guidance, giving advice and helping to find concrete solutions to daily life problems. They were perceived as role models, and even compared to a parent by some participants, "like a mother." Several participants reported having the personal phone numbers of care providers (which is unusual in France) in case of crisis: "I could call or send a message (...) and that's what helped me even more, that made things easier for me." All participants stressed that feeling welcomed at the first session had been essential: "The first time I came, it was great, I felt at ease just like at home." Laughter was a notable event during the first meeting: "The first day, I was with my caseworker. It worked out well. [Care providers] had a good laugh with me too." According to participants, consistency of care increased adherence, even despite some missed appointments. Said one participant, "Only God knows how many times I didn't come," with continuation of MUCTUM contrasting sharply with previous care that canceled follow-ups after only two missed sessions. Care providers became secure references during transfer of care, sharing "knowledge" about participants with new care providers who "don't know how to handle [them] yet." Nevertheless, some participants

	Dr. Y... anger and everything.... It was something that I couldn't handle... It allowed me to...
	really deal with some of the things about myself that I didn't like…"

I can have problems in my life and I call Mrs. X on her number. It's really... I don't know about the others, but for me, it's not only a follow-up at the hospital, it's really a follow-up that

was really very thorough (...) I improved a lot of things, like anger. I, I worked with that with

  I can explain to him what I have. I speak French but I don't really speak, there are things I don't know in French. With him, I can explain and he can understand me. I don't know how to tell you. (...) Often, when I spoke with him in my language, when I explain it to him, the explanation he gives... If it had been me, it would not be the same explanation. He knows the French language well. He explains well, in fact. He explains well compared to me and I wouldn't have explained well like him."

  " I am someone, I get very, very angry. Even sometimes when I speak, I get angry very, very quickly. So Mrs. Y taught me and I'm learning to breathe and not to get angry very quickly. If someone comes to get me, I will try to speak calmly to these people, so as not to be very aggressive. (...) Once she finds that the situation is very hard, she tells me that I take a breath,

	participants said that inclusion of their caseworker in MUCTUM unlocked communication and
	improved the relationship with the caseworker.
	"I was the one who was really struggling and uh it was really really um... The follow-up that
	allowed us to tighten up.... Strengthening the ties, no but... Allowed me to have… uh… a
	discussion with [my caseworker] because having a discussion with her was not possible...
	Researcher : Yes.
	Participant : We couldn't understand each other at all.
	Researcher : Yes.
	Participant : Because here I was really saying everything I wanted to say and who I really
	was... [care providers] had the ability to transmit that to another person, so that the person
	could understand me too…
	Researcher : Yes.
	One participant explained that she continues to apply these negative affect regulation techniques now
	since there are certain things that I don't want to tell them about. So I invited them to come and
	that she is a mother, which increases her self-confidence. "I worked [on] self-confidence a lot (...) and
	participate in my sessions. That way, they will hear certain things. So, when we go back [home],
	it is going very well".
	[if] there are certain things that they don't (...) understand or that kind of thing, they call me,

I drink a glass of water, that it calms me down and then I speak again. Sometimes when I'm upset or sad, even when I'm at home, I take a drink of water and my throat feels better." Skills that participants cited included emotional regulation, relaxation methods (e.g. breathing exercises, drinking a glass of water), planning (e.g. writing to-do lists in a notebook), and reflection (e.g. "practicing speech in front of [a] mirror"). Participants who had experienced violence and detention also explained how the care providers' explanations about security in France increased their feeling of safety:

"It didn't really go away but I evolved a lot on it because before, it was due to everything I had been through, I had the feeling that I was going to be found, no matter what. So that's a little bit of what fueled that feeling too... But then I was made to understand that this is France and all... I was reassured a lot by Mrs X and Dr. Y too and uh I started to let go a little bit, they made me understand that I wasn't going to be attacked overnight in the street... Or kidnapped and everything... So that kind of... calmed me down a bit…" Care providers facilitate links with the other institutions caring for UM, particularly social workers, who facilitate support for the youth at Children's Foster Home and school. Although some participants initially expressed displeasure at the presence of caseworkers in therapeutic sessions, most Participant : So uh, [my caseworker] had to go through them to understand how I functioned and me too how she functioned and sometimes we had big meetings where there were people and uh... It was partly thanks to them that I was able to establish a link with my caseworker..."

For others, MUCTUM provided a place to air discontents about their caseworkers, such as daily conflicts or misunderstandings. Some UM "felt bad" at the Children's Foster Home, and shared that MUCTUM allowed them to express this opinion. Participants identified that the care providers could help the caseworkers learn how to navigate certain situations more effectively, such as one participant experiencing social withdrawal or mutism:

"Basically, you know as I said, basically, I didn't talk to anybody. So everybody was like, how do I talk to this individual? (...) So it was complicated for them... And in the end uh... (...) So, we talk about it, they ask me questions.

And I answer, if I feel it.

.. I answer. And so with that, it allows them to know how (...) to talk to me, how, how to handle the situation with me."

story can "set us free" if carefully guided by care providers UM valued a delayed, progressive, and fractionated narration.

  Several participants said that the narration of their story at a slow pace was important, once a relationship of trust had been established with care providers. The narration was described as progressive, fractionated, prudent and non-forced: "That's the hardest part. But once you get it all out, you feel good about your body. Plus, we open up to people and they give us ideas, advice on how to be able to deal with our past." Sharing one's story was experienced as "painful" ("it makes me sad," brings back "weird memories") but provided relief and allowed care providers to find solutions. "It feels good to talk about the things that are in your heart. When you've told someone, it's like everything has gone from your heart." Narrating one's story, though painful, reduced participants' feeling of pain and loneliness.

	Care providers provide active, participative and empathetic listening to narration. Although this
	would seem self-evident for most practitioners, participants frequently and independently volunteered
	these reflections on providers' attitudes during narration of traumatic events, making it a notable theme
	in UM's experiences. Care providers were described as empathetic and non-judgmental, which
	"It was a little bit each session. Just a bit, a bit... and then the whole thing and that's it. It wasn't contributed to trust and openness. Participants described how narration involved rephrasing by care
	like 'you have to tell us what you've been through right away.'" providers, creating active, participative, and empathetic listening by care providers: "It was really like,
	"It hurt and at the same time, when I was talking, that's when I was able to work on it. When I
	Participants appreciated the care providers' attention to preventing participants from sharing "too much" 'I experience the story with you. It helps you to let it go." Care providers with knowledge of the "sea
	was able to talk to people where at the same time it relieves my heart and it relieves me in my
	at once: crossing" helped participants feel understood, as did using "images" when they talked.
	head."
	Before… I was awake… every hour… I tried to sleep at night but I couldn't sleep… I had
	Care providers helped UM stop feeling guilty and provided explanations that helped participants "talk
	nightmares even if the door is open. I got out at night like people who walk at night, I sleep but
	was it…" more openly." Said one participant, "When I would say that when I was in Italy, I was prostituting, they
	I got out at the beginning. As I spoke to the psychologist and the psychiatrist, it stopped, I took
	Narration encompassed both positive and negative life events: "I talked about my memories, times that would say, 'yes, we know you were forced. How did this happen to you?'".
	medicine to sleep.
	went well and times that didn't go well, too." Some UM, on the contrary, did not narrate adverse life

Researcher : Okay

Participant: And that stopped and even if I have a bad memory, a nightmare, well I still sleep but before I didn't sleep and all that." Narrating one's "If we manage to empty ourselves of this, in fact we empty our heads. When I was able to clear my past with Mrs. X, she found solutions, words and things that could calm me down. (...) They know their work well and they know very well that when it goes too far, they also know how to stop the person when it goes too far. So I like that."

Consequently, narrating one's history was not perceived as obligatory, and in fact some participants recalled relief at being explicitly asked not to talk about their story during early stages of therapy, because it was too painful.

"Participant: As I said earlier, I'm not someone who likes to re-explain that part.

Researcher: Yes

Participant: But afterwards, it was really a moment when you had to talk.

Researcher: Yes. Participant: It was really. They gave me time, they let me... I think it took a year and a half before... That we really got into it. We only talked about myself, my fears, my mother. And then we really went through the process where ... well I had to explain my story to them and that events: "I didn't tell my story to them." Narration was at times difficult for participants whose memories remained mostly "images" rather than easily-verbalized stories. "Participant: It was very, very, very hard. Uh to say again what I... I had experienced, uh... You had to respect… and especially that they, when you explained, they illustrated for you. Researcher: That is to say? Participant: In itself... they take examples from you or do as if I tell them, for example, I crossed the sea: they tell you: by boat, the sea? Basically, to make you really live the thing, but in an intense way so that you can free yourself once and for all, and I think it was not bad for me anyway… Researcher: Yes… Participant: Because when I said uh when I took the example of Italy with the prostitution, really it was illustrated to me... And that was really what I wanted to say. So I was led to say what I had inside me without forcing myself.For example, a person can't understand your past, he's not in your shoes, but in fact, he tries to put himself in your shoes and all that, it feels good." Sharing one's story is "painful" but "sets us free." Several participants mentioned a feeling of "liberation" in relation to the therapy, particularly through the ability to "talk." It was often the first time they shared what they had endured with someone. "That way, at least someone knows." Discussion In this qualitative study of semi-structured interviews of UM participating in MUCTUM (Multimodal Co-Therapy for Unaccompanied Minors), we explored participants' experiences of this therapeutic approach : how UM experience mental health problems, what contributes to creating a safe place, what interventions are helpful during therapy, and UMs' experience of the narrative approach supported by care providers. An important finding is the importance of implementing interventions successively within this multimodal therapy, i.e. the narration of trauma occurs after other interventions. In this sense,

2. Tableau 2. Points forts : articuler les approches biologiques et sociales en psychiatrie de l'enfant et de l'adolescent

  . La promotion d'une recherche pluraliste, qui inclut les facteurs sociaux liés à la santé mentale, est une nécessité de justice et d'équité (par exemple, équité de qualité des soins pour les groupes minoritaires et les populations migrantes ; effets des discriminations sur la santé)(Moro & Radjack, 2022). Cette réflexion inclut la sélection de critères d'inclusion et d'exclusion justifiés sur le plan éthique(Dakić, 2020), et plus généralement des soins centrés sur le patient, sur ses besoins et sur le principe d'équité(Dakić, 2020). La promotion de ces approches implique une disponibilité des interventions pour les patients et les professionnels, dans différents pays et régions. Soutenir l'accès en ligne gratuit à divers instruments est un exemple de mesure simple pour assurer cette disponibilité. Articuler les approches biologiques et sociales en psychiatrie de l'enfant et de l'adolescent dans la pratique clinique et la recherche est un défi pour le futur. En conclusion, nous présentons les principales propositions suivantes dans le Tableau Dans cette thèse, nous avons proposé une réflexion sur l'articulation des approches biologiques et sociales en psychiatrie de l'enfant et de l'adolescent. Nous avons proposé plusieurs axes de réponse et les avons illustrés avec des recherches originales. Indiquer dans un travail de recherche que l'objet de la recherche peut être abordé sous différents angles cliniques, de recherche et/ou théoriques et expliquer celui choisi pourrait être un préalable élémentaire. Nous suggérons que soient publiés plus d'articles de synthèse qui rassemblent les connaissances biologiques et sociales. Nous illustrons ce point par l'écriture et la publication d'une revue de littérature rassemblant les données biologiques et culturelles disponibles dans la littérature médicale au sujet d'un syndrome psychiatrique, la lycanthropie clinique (Articles 1,2, 3). soutenons l'idée que les études biologiques devraient tenir compte des facteurs sociaux, et que les études sociales devraient tenir compte des facteurs biologiques. A titre d'illustration, l'étude ELAL dont nous avons publié un volet (Article 4) montre une recherche qui prend en compte d'une part le profil Pour développer cette articulation des approches biologiques et sociales, il convient aussi de promouvoir ce regard pluraliste sur la psychiatrie de l'enfant et de l'adolescent, ce que nous avons voulu faire en soumettant à la revue Frontiers in Child and Adolescent Psychiatry une synthèse de notre réflexion sous la forme d'un article de type « Perpective Article » :

	8. Conclusion
	Nous bilingue des enfants (aspects cognitifs) et d'autre part les facteurs sociaux (environnement et
	représentation des parents). Cette recherche sera davantage étayée par la publication prochaine de son
	volet quantitatif.
	Nous défendons le besoin d'outils transculturels (questionnaires et échelles), qui peuvent constituer un
	I point de liaison, au niveau clinique et de la recherche, entre approches biologiques et sociales. L'échelle Indiquer que l'objet de la recherche peut être abordé sous différents angles cliniques, de
	recherche et théoriques et expliquer celui choisi ELAL, une échelle d'évaluation transculturelle des compétences langagières d'un enfant dans sa langue
	II maternelle, constitue une illustration d'outil transculturel qui nous semble pertinent. Proposer des articles de synthèse qui articulent les connaissances biologiques et sociales
	III Nous explorons le besoin, selon nous, de construction d'interventions thérapeutiques qui articulent les Concevoir des études biologiques qui tiennent compte des facteurs sociaux
	Concevoir des études sociales qui tiennent compte des facteurs biologiques approches biologiques et sociales. Nous illustrons ce point par l'étude d'un dispositif thérapeutique
	multimodal, le dispositif de Co-Thérapie Multimodale pour les Mineurs Non Accompagnés, dans lequel
	IV nous étudions l'expérience des mineurs non accompagnés d'un dispositif pluraliste et formulons des Concevoir des outils transculturels
	V pistes pour la mise en oeuvre d'une intervention pluraliste (Article 5). Construire des interventions thérapeutiques pluralistes, qui articulent les approches
	biologiques et sociales
	Enfin, nous soulignons le besoin de formation des professionnels aux approches biologiques, aux
	VI approches sociales, ainsi qu'à la manière de les articuler. Développer des formations aux approches pluralistes

Articulating biological and social approaches in child and adolescent psychiatry

  (Article 6 en annexe, page 113).

	Annexe 1.
	Nous espérons que cette thèse et ces articles participeront à promouvoir les approches pluralistes et
	l'articulation des approches biologiques et sociales, en offrant notamment des propositions concrètes,
	dans le but de s'ajuster à la réalité complexe des patients et à l'impératif éthique de proposer des soins
	évalués, acceptables et efficients au sein de populations hétérogènes.

Article 6. Articulating biological and social approaches in child and adolescent psychiatry Articulating biological and social approaches in child and adolescent psychiatry Sélim Benjamin GUESSOUM, Laelia BENOIT, Isaiah THOMAS, Jasmina MALLET, Jordan SIBEONI, Cyril HANIN, Marie Rose MORO Soumis en octobre 2022 à la revue Frontiers in Child and Adolescent Psychiatry Introduction Child

  and adolescent psychiatry (CAP) aims to treat disorders of thinking, feeling, and/or behavior affecting children, adolescents, and their families. Articulating biological and social approaches is necessary to grapple with the complexities of patients and mental disorders. As examples of this tension

neurobiologiques mais survient dans un contexte socioculturel donné. Nous y décrirons par l'exemple la manière dont on peut rassembler plusieurs approches, de manière pluraliste, dans une même revue systématique de littérature. Dans une seconde partie, nous décrirons l'importance de la constitution des outils d'évaluation (questionnaires et échelles) pour proposer des recherches et des évaluations cliniques cohérentes, non seulement avec les enjeux des approches biologiques, mais aussi avec les approches sociales et les diversités culturelles des populations. Nous illustrerons notre propos en présentant une recherche portant sur le bilinguisme des enfants de migrants. Dans une troisième partie, nous discuterons de la construction et de la mise en oeuvre d'interventions thérapeutiques pluralistes. Nous présenterons une recherche qualitative portant sur une co-thérapie multimodale pour les mineurs non accompagnés. Enfin, nous discuterons de la question de la formation des psychiatres à ces approches biologiques et sociales.

Centre National de Ressources Textuelles et Lexicales, définition de « pluralisme » (www.cnrtl.fr)

Remerciements Acknowledgements : Supported by QUALab, the Qualitative & Mixed Methods Lab, a collaboration between the Yale Child Study Center (New Haven, CT), and CESP, the Centre de recherche en Epidémiologie et Santé des Populations (Paris, France).

Acknowledgements

To Hajar Chokairi, Tania Sanchez and Thomas Bazeille, for their kind help by critical comments on the manuscript.

Annexe 2. Définitions de certains concepts fondamentaux

Une théorie est une idée ou un ensemble d'idées qui vise à expliquer des faits ou des événements.

L'approche biologique porte sur la dimension médico-biologique de la santé mentale et s'appuie sur les sciences biologiques et du cerveau.

L'approche sociale porte sur les dimensions sociales et culturelles de la santé mentale et s'appuie sur les sciences humaines et sociales.

L'approche pluraliste stipule que de multiples méthodes indépendantes sont nécessaires à la compréhension et au traitement des maladies mentales.

L'approche intégrative vise à fournir une approche synthétique des différents domaines et interventions de la psychiatrie.

L'approche complémentariste est une méthode consistant en l'utilisation obligatoire mais non simultanée de plusieurs disciplines.

Availability of data and materials : The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate : This study has been approved by the Ethics Committee of Paris University (CEEI/IRB n° 00012021-57).

Consent for publication : Oral and written consent were provided.

Competing interests : None

Funding : None Authors' contributions : SBG conceived and planned the study. PDS, SBG and SM carried out the interviews, PDS, SBG, SM, LB coded the interviews and analyzed the data. All authors contributed to the interpretation of the results. SBG, SM, LB, PDS took the lead in writing the manuscript. All authors provided critical feedback and helped shape the research, analysis, and manuscript. Supplementary materials: Brief definitions of some core concepts A theory is an idea or set of ideas that is intended to explain facts or events.

Annexes

A biological approach focuses on the biomedical dimension of mental health and is grounded in human biology and neuroscience.

A social approach focuses on the social and cultural dimensions of mental health and is grounded in the social sciences and the humanities.

A pluralistic approach states that multiple independent methods are necessary in the understanding and treatment of mental illness.

An integrative approach aims to provide a synthetic approach to the distinct fields within psychiatric research, diagnosis, and treatment.

Complementary frames of reference involves the obligatory but non-simultaneous use of several disciplines.

Nomothetic describes an object or method that enables one to establish repeatable and generalizable patterns, is concerned with general laws and theories, and is represented by constant relations between the observed phenomena.

Idiographic describes an object or method within social research that focuses on specific elements, individuals, events, entities, situations, documents, and works of art and culture and concentrates on what is particular to these.

Multimodal describes a combination of several interventions or treatments.

A multidisciplinary approach is based on the knowledge of different disciplines while respecting their delineations.

An interdisciplinary approach analyzes, synthesizes, and harmonizes the links between disciplines into a coordinated and cohesive whole.

Nomothétique qualifie un objet ou une méthode qui permet d'établir des données reproductibles et généralisables, relevant de lois et de théories générales, représentées par des relations constantes entre les phénomènes observés.

Idiographique qualifie une approche ou un type de recherche en sciences sociales qui se concentre sur des éléments particuliers, des individus, des événements, des groupes et des situations, des documents et des oeuvres culturelles ou artistiques et se concentre sur ce qui leur est propre.

Multimodal qualifie une combinaison de plusieurs interventions ou traitements.

L'approche multidisciplinaire se base sur les connaissances de différentes disciplines tout en respectant leurs délimitations. L'approche interdisciplinaire vise à analyser, synthétiser et harmoniser les liens entre les disciplines en un tout coordonné et cohérent. L'approche transdisciplinaire intègre des domaines scientifiques distincts et dépasse leurs frontières traditionnelles.

L'approche catégorielle établit des catégories diagnostiques prédéfinies. Le diagnostic psychiatrique vise alors à identifier la présence ou l'absence d'un trouble psychiatrique chez un patient, puis à classer le trouble du patient dans une catégorie diagnostique selon des critères préétablis. L'approche dimensionnelle repose sur la conception des symptômes comme un continuum entre le