A.C.d.Á. Jacintho

Violência doméstica contra crianças e adolescentes: um desafio

OBJECTIVE: To study children and adolescents victims of domestic violence treated at the Referenced Pediatric Emergency Unit of the Hospital de Clinicas of the Universidade Estadual de Campinas and its specialized outpatient clinic between January 2003 and December 2007, emphasizing sexual abuse. METHODS: The variables gender, age, origin, and classification were studied. For victims of sexual abuse, the following variables were also studied: type of abuse (rape), location (domestic/urban), duration (acute/chronic), perpetrator (known, incestuous), alterations at medical examination, notification to child protection agencies, and antiretroviral medication and serology (HIV, syphilis, hepatitis B and C). Patients were divided into two groups according to the type of abuse and type of perpertrator and they were associated with gender, age, and duration. For the comparison, chi-squared or Fishers exact test were performed (significance p < 0.05), as well as raw prevalence odds ratio. RESULTS: Of the total cases of abuse (551), neglect (33.9%) and sexual abuse (31.9%) predominated; the victims were female in 55.9% of the cases, and 50% were up to 5 years of age. Of the sexual abuse cases (95), 80% were female, and 58.9% were between 5 and 10 years of age. Rape was observed in 39% and indecent assault in 59.6%; 72.6% occurred in the domestic area, 81.1% by known perpetrator; 31.6% were incestuous, 47.4% were chronic, and 76.5% had no clinical alterations. 81.1% were referred to child protection agencies. Antiretroviral medication was prescribed to 49.1% of patients, and serological tests (HIV in 46 [48.4%], syphilis in 42 [44.2%], hepatitis B in 44 [46.3%] and hepatitis C in 45 [47.4%]%), all of which were negative, were more frequent in rape victims (p = 0.00). There was an association between rape and age (10 and 15 years, p = 0.01) and between incestuous perpetrator and chronic duration (p = 0.01). CONCLUSION: Although this study does not reflect reality, it can be used as a warning to pediatricians.

Atypical antipsychotics in the treatment of pathological aggression in children and adolescents: literature review and clinical recommendations

OBJECTIVE To review the literature about the use of atypical antipsychotics in the treatment of pathological aggression in children and adolescents. METHOD The databases MEDLINE, SciELO, and LILACS were searched for publications in Portuguese or English from 1992 to August 2011 using the following keywords: mental disease, child, adolescent, treatment, atypical antipsychotic, aggressive behavior, aggression, and violent behavior. RESULTS Sixty-seven studies of good methodological quality and clinical interest and relevance were identified. Studies including children and adolescents were relatively limited, because few atypical antipsychotics have been approved by the Food and Drug Administration (FDA). All the medications included in this review (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole and clozapine) have some effectiveness in treating aggression in children and adolescents, and choices should be based on clinical indications and side effects. CONCLUSIONS There are few studies about the effectiveness and safety of atypical antipsychotics for the pediatric population, and further randomized controlled studies with larger groups of patients and more diagnostic categories, such as severe conduct disorder and oppositional defiant disorder, should be conducted to confirm the results reported up to date and to evaluate the impact of long-term use.

Clozapine in Severe Conduct Disorder

METHOD An open, naturalistic observational study design was used, in which a sample of seven boys between 10 and 14 years of age was assessed over 26 weeks. RESULTS The subjects were all diagnosed with conduct disorder (CD) and exhibited high levels of aggression that were refractory to psychosocial approaches (parent counseling, school counseling, and psychotherapy) and to more than three pharmacological treatments. Levels of aggression, side effects, and hematological parameters were evaluated weekly. Clinical response was evaluated using the standardized instruments Clinical Global Impressions (CGI) and Child Behavior Check List (CBCL) 6-18 before starting medication and after 26 weeks. CONCLUSION We observed good tolerability of clozapine in doses from 100 to 600 mg/day with no significant side effects or hematological changes. The CGI and CBCL 6-18 scales indicated that clozapine led to a marked control of symptoms.

Domestic violence against children and adolescents: a challenge

OBJECTIVE To study children and adolescents victims of domestic violence treated at the Referenced Pediatric Emergency Unit of the Hospital de Clínicas of the Universidade Estadual de Campinas and its specialized outpatient clinic between January 2003 and December 2007, emphasizing sexual abuse. METHODS The variables gender, age, origin, and classification were studied. For victims of sexual abuse, the following variables were also studied: type of abuse (rape), location (domestic/urban), duration (acute/chronic), perpetrator (known, incestuous), alterations at medical examination, notification to child protection agencies, and antiretroviral medication and serology (HIV, syphilis, hepatitis B and C). Patients were divided into two groups according to the type of abuse and type of perpertrator and they were associated with gender, age, and duration. For the comparison, chi-squared or Fishers exact test were performed (significance p < 0.05), as well as raw prevalence odds ratio. RESULTS Of the total cases of abuse (551), neglect (33.9%) and sexual abuse (31.9%) predominated; the victims were female in 55.9% of the cases, and 50% were up to 5 years of age. Of the sexual abuse cases (95), 80% were female, and 58.9% were between 5 and 10 years of age. Rape was observed in 39% and indecent assault in 59.6%; 72.6% occurred in the domestic area, 81.1% by known perpetrator; 31.6% were incestuous, 47.4% were chronic, and 76.5% had no clinical alterations. 81.1% were referred to child protection agencies. Antiretroviral medication was prescribed to 49.1% of patients, and serological tests (HIV in 46 [48.4%], syphilis in 42 [44.2%], hepatitis B in 44 [46.3%] and hepatitis C in 45 [47.4%]%), all of which were negative, were more frequent in rape victims (p = 0.00). There was an association between rape and age (10 and 15 years, p = 0.01) and between incestuous perpetrator and chronic duration (p = 0.01). CONCLUSION Although this study does not reflect reality, it can be used as a warning to pediatricians.

P01-215 - Child sexual abuse: a literature review of psychosocial and psychodynamic aspects

Objectives To review the literature on child sexual abuse with emphasis on psychosocial/psychodynamic aspects.Methods Systematic literature review from the articles indexed in Medline, PSYinfo, Pepsic, Lilacs and Scielo in the last ten years. Terms researched were: child sexual abuse, psychosocial, psychodynamic and psychoanalysis.Results Child sexual abuse can have devastating consequences for the psychological functioning of children, possibly interfering with their proper process of development. It can contribute to violent behavior, acts of delinquency and mental disorders in adolescence and adulthood, as well as the development of comorbid post-traumatic stress and self-aggressive behaviors, risk behaviors and teenage pregnancy. Gravity of psychic consequences increase in relation to the frequency of abuse. Aspects of power, seduction and coercion are involved. Inequalities of age and gender are highlighted. Often practiced without the use of physical force, it may be difficult to be proven. A frequent abuser of familiarity with the child creates conditions that foster abuse. The revelation of the abuse may not occur, perpetuating the suffering and helplessness of the child. Sexually abused children may develop identification with the abuser and even become sexual offenders in adulthood. There are difficulties in the conceptual definition of abuse, the establishment of protocols for investigative and therapeutic management of cases and in predicting the immediate consequences along with the medium and long-term consequences.Conclusions Studies on the therapeutic practices used for the treatment of abused children and their families can help to construct therapeutic models, minimizing suffering in this terrible situation of violence.

P01-216 - Child sexual abuse: a socio-demographic and clinical data of 19 cases treated at a university hospital

Objectives To investigate socio-demographic and clinical trials of 19 sexually abused children. Methods Statistical analysis with SPSS of data on psychiatric and pediatric care of sexually abused children, aged 2-12 years old, treated at the Pediatric Service of University of Campinas-Brazil Clinical Hospital in 2007. Results From a total of 19 children, 2 (10.5%) were boys and 17 (89.5%) girls. The average age group was 7.4 years. Eleven (57.9%) attended regular school, one (5.3%) attended special school, one (5.3%) pre-school and six (31.5%) did not attend any school. Regarding ethnicity, 11 (57.9%) children were white and eight (42.1%) non-white. The abuse was committed with physical threats in nine (47.4%) cases, without threats in two (10.5%). Eight children were unable to define physical threat. The abuse occurred only once in 10 (52.6%) cases and several times in nine (47.4%). Prior psychiatric treatment occurred in two (5.3%) children and psychological treatment in six (31.6%). Twelve (63.2%) children had never attended psychological or psychiatric consultations. Eleven (57.9%) children received a psychiatric diagnosis and referral for treatment. In 13 (68.4%) attendance was diagnosed in the Z-code of the International Classification of Diseases-10. Family and people close to children appear as abusers in 15 cases (78.9%). Conclusions Despite the small sample, this study supports the literature in which child sexual abuse appears as a phenomenon more frequent in girls, dysfunctional families, and practiced mainly by family members or close friends of children. The relationship with psychiatric disorders was also highlighted.

P01-245 - Besides a waiting room: playroom as a diagnostic and therapeutic resource before psychiatric consultation

Objectives To evaluate the diagnostic and therapeutic applications of playrooms implemented in care services of childrens health, while waiting for a consultation appointment. Methods A playroom was developed in a child psychiatry outpatient service in a University Hospital, where spontaneous approaches, without educational or psycho-specific directing, were conducted by members of a multidisciplinary team of this service. The children had their attitudes and behaviors observed by these professionals during the playful waiting time in the playroom. Therefore, all observations have been used in subsequent discussions with the professional directly responsible for the childs care, in order to enrich and supplement the cases supervision. Results In spite of the spread of the playrooms, there are few studies about them, their objectives and key aspects for their creation and maintenance. It not only adds new elements to those given by family, teachers and patients, but also allows a free observation of the latent unspoken aspects that emerge during play and complement or even change the caregiver first impressions. Conclusion The experience of a playroom implemented in a child psychiatry outpatient service in a University Hospital agrees with the studies that indicate that through playful-creative activities children can make discoveries their own way, develop relationships and elaborate affective aspects of their psychic space. Rescue strategies in spontaneous play are essential elements for the childrens integral development, creativity, learning and socialization. Above all, playrooms also have a therapeutic and diagnostic role in childrens care.

P03-188 - Group therapy of adolescents arrested in a judicial institution and with disorders related to the consumption of psychoactive substances

Objectives To describe the experience of group therapy with offender adolescents in an Institution for minor violators (“Fundacao CASA”) and who have suffered from mental disorders related to psychoactive substance use. Methods “Fundacao CASA” is an institution created to shelter minor offenders. In 2008 some were judicially referred for treatment to a University Hospital Psychoactive Substance Outpatients Service. An operative and informative group was formed, since they have not adapted to the already existing adult group. This group met weekly, aimed to prevent relapse and initially planned to last 6 meetings. Results Soon there were 4 adolescents who had engaged with the group and requested to increase the number of sessions. Psychodynamic issues emerged during the sessions, which were well evaluated by all participants after 10 weeks, when the group had to be ended due to the completion of sentences of 3 participants. In 2009 only 3 of them were found. The first reported a relapse, but remains abstinent. The second started working as general assistant and remained abstinent. The third continued to consume crack and was arrested by the time he was 18. Conclusions This study showed the need for specific treatment for the group of juvenile offenders. Operative and informative groups create a communication space for drug users and other psychotic subjects. It permits group identification and allows the expression of mental suffering. Therefore this practice consists of a low complexity approach in an extremely vulnerable population, which is so prevalent in developing countries such as Brazil.

P02-11 - Psychiatric emergencies in children: demographic and clinical care in a university hospital

Objectives To analyze, for all the pediatric consultations in 2008 in the emergency ward of the Pediatric Hospital of the University of Campinas, the clinical and demographic profile of the consultations in which there was a possible psychiatric diagnosis. Methods Review of all forms of consultations for children enrolled in the unit during 2008, selecting those with the possibility of a psychiatric diagnosis. Results Of 21,811 consultations in 2008, 95(0.43%) included psychiatric complaints - 60(63.2%) girls and 35(36.8%) boys, aged 1-13 years(9±0.4). 70(73.7%) were white, 18(18.9%) mixed and 7(7.4%) black. A psychiatric evaluation was called for in 39(41.0%) cases. In 35(36.8%) sexual abuse was suspected. Other forms of violence were reported in 8(8.4%) cases. There were 6(6.31%) suicide attempts, 10(10.5%) cases of extreme agitation, 14(14.7%) consultations for extreme anxiety/dissociative symptoms, 5(5.3%) for depressive symptoms and 4(4.2%) for a psychotic condition. Twenty(21.1%) children were already using psychotropic drugs at the time of evaluation and in 29(30.5%) evaluations there were subsequent psychiatric interventions, with drug prescriptions in 11(37.9%). Nine(9.5%) children had clinical/pediatric conditions. Conclusions Children may need psychiatric care in emergency situations for various conditions. Despite the small percentage among the total number of pediatric emergency consultations, psychiatric evaluation, when necessary, can be useful and have an impact on diagnostic and therapeutic procedures. The plight of these children can be intense, demanding prompt and effective action. A psychiatrist can provide assistance that may help the pediatrician in the management of severe pathological conditions that affect the mental lives of children.

P03-379 - The use of Clozapine in children and adolescents with Serious Conduct Disorder for control of the aggressiveness

Objectives To analyze the use of Clozapine in six children and adolescents with Serious Conduct Disorder, whose symptoms had been refractory to other pharmacology treatment. Scalar analysis is supplied for the more important psychopathology aspects and the changes with therapeutic one. Methods Six patients diagnosed with Serious Conduct Disorder are described who had begun the use of Clozapine. They had been widely studied and received application of standardized instruments of infantile psychiatry (CBCL - Child Behavior Check List) before and after the use of this medication. Results The patients had mainly significant improvement in relation to the level of aggressiveness and social behavior. Conclusions Although ample studies on the use of this medication in children and adolescents do not yet exist, more precisely for cases of Serious Conduct Disorder, the preliminary results are very positive and indicate that Clozapine could be an important tool in the handling of the aggressiveness in those refractory patients with Serious Conduct Disorder.