Cristiane Silvestre de Paula

Global prevalence of autism and other pervasive developmental disorders.

We provide a systematic review of epidemiological surveys of autistic disorder and pervasive developmental disorders (PDDs) worldwide. A secondary aim was to consider the possible impact of geographic, cultural/ethnic, and socioeconomic factors on prevalence estimates and on clinical presentation of PDD. Based on the evidence reviewed, the median of prevalence estimates of autism spectrum disorders was 62/10 000. While existing estimates are variable, the evidence reviewed does not support differences in PDD prevalence by geographic region nor of a strong impact of ethnic/cultural or socioeconomic factors. However, power to detect such effects is seriously limited in existing data sets, particularly in low‐income countries. While it is clear that prevalence estimates have increased over time and these vary in different neighboring and distant regions, these findings most likely represent broadening of the diagnostic concets, diagnostic switching from other developmental disabilities to PDD, service availability, and awareness of autistic spectrum disorders in both the lay and professional public. The lack of evidence from the majority of the worlds population suggests a critical need for further research and capacity building in low‐ and middle‐income countries. Autism Res 2012, 5: 160–179.

International Variations in Harsh Child Discipline

BACKGROUND: Although the history of recognition of child abuse in Europe and North America extends over 40 years, recognition and data are lacking in other parts of the world. Cultural differences in child-rearing complicate cross-cultural studies of abuse. OBJECTIVE: To ascertain rates of harsh and less-harsh parenting behavior in population-based samples. METHODS: We used parallel surveys of parental discipline of children in samples of mothers in Brazil, Chile, Egypt, India, Philippines, and the United States. Data were collected between 1998 and 2003. The instrument used was a modification of the Parent-Child Conflict Tactics Scale, along with a study-developed survey of demographic characteristics and other parent and child variables. Women (N = 14 239) from 19 communities in 6 countries were surveyed. We interviewed mothers aged 15 to 49 years (18–49 years in the United States) who had a child younger than 18 years in her home. Sample selection involved either random sampling or systematic sampling within randomly selected blocks or neighborhoods. RESULTS: Nearly all parents used nonviolent discipline and verbal or psychological punishment. Physical punishment was used in at least 55% of the families. Spanking rates (with open hand on buttocks) ranged from a low of 15% in an educated community in India to a high of 76% in a Philippine community. Similarly, there was a wide range in the rates of children who were hit with objects (9%–74% [median: 39%]) or beaten by their parents (0.1%–28.5%). Extremely harsh methods of physical punishment, such as burning or smothering, were rare in all countries. It is concerning that ≥20% of parents in 9 communities admitted shaking children younger than 2 years. CONCLUSIONS: Physical and verbal punishments of children are common in high-, middle-, and low-income communities around the world. The forms and rates of punishment vary among countries and among communities within countries. A median of 16% of children experienced harsh or potentially abusive physical discipline in the previous year.

Severe physical punishment: risk of mental health problems for poor urban children in Brazil

OBJECTIVE To examine the relationship between specific types of child mental health problems and severe physical punishment, in combination with other important known risk factors. METHODS We conducted a cross-sectional study in Embu, São Paulo, Brazil, as the Brazilian component of a multicountry survey on abuse in the family environment. From a probabilistic sample of clusters that included all eligible households (women aged 15-49 years with a son or daughter < 18 years of age), we randomly selected one mother-child pair per household (n = 813; attrition rate: 17.6%). This study focused on children aged 6-17 years (n = 480). Child Behaviour Checklist CBCL/6-18 was used to identify children with internalizing problems only, externalizing problems only, and both internalizing and externalizing problems (comorbidity). Severe physical punishment was defined as being hit with an object, being kicked, choked, smothered, burnt, scalded, branded, beaten or threatened with a weapon. We examined other potential correlates from four domains: child (gender, age, ever witnessing marital violence); mother (education, unemployment, anxiety or depression, marital violence); father (absence, drunkenness); and family (socioeconomic status). The WHO Self-Reporting Questionnaire (SRQ-20) was used to identify maternal anxiety or depression (score > 7). Backward logistic regression analysis identified independent correlates and significant interactions. FINDINGS Multivariate modelling showed that severe punishment was an independent correlate of comorbid internalizing and externalizing problems but was not associated with internalizing problems only. It increased the risk of externalizing problems alone only for children and adolescents not exposed to maternal anxiety or depression. Maternal anxiety or depression increased the risk only for children or adolescents not exposed to severe punishment. CONCLUSION Severe punishment may be related to child mental health problems, with the mechanism depending on the type of problem. Its influence persists in the presence of family stressors such as the fathers absence and maternal anxiety or depression.

Brief Report: Prevalence of Pervasive Developmental Disorder in Brazil: A Pilot Study

This pilot study presents preliminary results concerning the prevalence of Pervasive Developmental Disorder (PDD) in South America. It was a three-phase study conducted in a typical town in Southeast Brazil. Case definition was based in a combination of standardized instruments and clinical evaluations by experts. The prevalence of PDD was 27.2/10,000 (95% CI: 17.6–36.8) and some hypotheses were raised to explain this low frequency. Clinical findings of PDD cases were consistent with previous data, such as, male preponderance, more children diagnosed with PDD-NOS than with autistic disorder, and half of them born from older mothers. Moreover, the study raised concerns about treatment of cases, because identification of PDD had been late and access to services has been very limited.

Severe physical punishment and mental health problems in an economically disadvantaged population of children and adolescents

OBJECTIVE To estimate the prevalence of severe physical punishment of children/adolescents in a low-income community, and to examine child mental health problems as a potential correlate. METHOD This study is a Brazilian cross-sectional pilot study of the World Studies of Abuse in Family Environments. A probabilistic sample of clusters including all eligible households (women aged 15-49 years, son/daughter < 18 years) was evaluated. One mother-child pair was randomly selected per household (n = 89; attrition = 11%). Outcome (severe physical punishment of children/adolescents by mother/father) was defined as shaking (if age <or= 2 years), kicking, choking, smothering, burning/scalding/branding, beating, or threatening with weapon. Three groups of potential correlates were examined: child/adolescent (age, gender, physical/mental health); mother (education, unemployment, physical/mental health, harsh physical punishment in childhood, marital violence); father (unemployment, drunkenness). Severe marital violence was defined as kicking, hitting, beating or use of /threat to use a weapon. The following standardized questionnaires were applied by trained interviewers: World Studies of Abuse in Family Environments Core Questionnaire, Child Behavior Checklist, Self-Report Questionnaire. RESULTS Outcome prevalence was 10.1%. Final logistic regression models identified two correlates: maternal harsh physical punishment in childhood (total sample, OR = 5.3, p = 0.047), and child/adolescent mental health problems (sub-sample aged 4-17 years, n = 67, OR = 9.1, p = 0.017). CONCLUSIONS Severe physical punishment of children/adolescents is frequent in the studied community. The victims have a higher probability of becoming future perpetrators. When intrafamilial violence occurs, child/adolescent mental health may be compromised.

Child Behavior Checklist (CBCL),Youth Self-Report (YSR) and Teacher's Report Form(TRF): an overview of the development of the original and Brazilian versions

O Sistema de Avaliacao de Base Empirica de Achenbach para criancas/adolescentes em idade escolar inclui tres instrumentos para avaliar problemas emocionais e/ou comportamentais: Child Behavior Checklist (CBCL) [pais], Youth Self-Report (YSR) [adolescentes] e Teachers Report Form (TRF) [professores]. Este artigo de revisao fornece informacoes detalhadas sobre o desenvolvimento desses instrumentos nos Estados Unidos e no Brasil, descrevendo as principais alteracoes em itens, escalas e pontos de corte na pontuacao, ocorridas nas versoes originais de 1991 a 2001, e o processo de traducao, retrotraducao e adaptacao cultural dos questionarios originais para desenvolver as atuais versoes brasileiras oficiais do CBCL, YSR e TRF. A utilidade desses instrumentos em pesquisa e na pratica clinica e salientada, mencionando estudos epidemiologicos e de avaliacao de intervencoes conduzidos no Brasil. Pesquisadores e clinicos sao instruidos a respeito do uso correto das atuais versoes brasileiras oficiais, dando exemplos de perguntas frequentes, relevantes para o contexto brasileiro.

Partner Violence as a Risk Factor for Mental Health Among Women From Communities in the Philippines, Egypt, Chile, and India

Although studies have documented the association between Intimate Partner Violence (IPV) and mental health, few have been done in developing countries. In this study, the association between IPV and mental health in women from different developing countries was established. Women, 15 to 49 years old with at least one child 18 years old or younger, were randomly selected from communities in Chile, Egypt, India, and the Philippines (N = 3974). The Self Report questionnaire (SRQ) was used to assess mental health. Women with a score on the SRQ of 8 or more, or who reported ever attempting suicide, were classified as having poor mental health. Physical IPV was defined as being slapped, hit, kicked, beaten or threatened by a male partner during the past year. Psychological violence included being insulted or belittled, threatened or abandoned. Between 22.5% (in Egypt) to 41% (in Chile) of participating women reported a score of eight or more on the SRQ. High scores on the SRQ were significantly associated with current physical and psychological IPV in the samples from all participating countries except Chile. Twelve percent of women in Chile, 2.6%, in Egypt, 7.5% in India and 1.6% in the Philippines reported attempting suicide. Suicide attempts were also associated with current physical IPV in the Philippines, Egypt, and India, and with psychological violence in Egypt and India. IPV is a significant risk factor for poor mental health in these developing countries. Efforts to reduce IPV should be considered as part of a mental health program.

Violência conjugal física contra a mulher na vida: prevalência e impacto imediato na saúde, trabalho e família

OBJECTIVES To estimate the lifetime prevalence of domestic violence against women (DVAW) in a low-income urban community and evaluate the immediate impact of DVAW on health, work, and family life. METHODS The present cross-sectional study was carried out in the city of Embu (state of São Paulo, Brazil) as part of an international multicenter project (World Studies of Abuse in the Family Environment, WorldSAFE). A probabilistic sample of census sector-based clusters including all eligible households identified was used. A total of 784 women (age 16-49 years) with at least one child younger than 18 years and a lifetime resident husband/partner were included. We evaluated the occurrence of any kind of DVAW (slapping, kicking, hitting, beating, threatening to use or using a weapon, other aggressions mentioned spontaneously), of severe DVAW (same items, except slapping and other aggressions informed spontaneously), and of immediate impacts on the health, work, and family of the victims. RESULTS The prevalence of DVAW was 26.0% for any kind of violence and 18.5% for severe DVAW. Among the victims of any kind of DVAW, 38.7% judged that they needed medical care, 4.4% were hospitalized, 18.1% were incapacitated for work (paid work or household chores), 51.5% left their partner due to the aggression and 66.7% had children who witnessed the violence. For severe violence, these rates were 51.0, 5.5, 23.4, 59.3 and 75.9%, respectively. Shame and fear of retaliation obstructed access to medical care. CONCLUSIONS The frequency of DVAW is high in the studied community and produces immediate impacts on the victims health, work, and family life. These impacts decrease the victims ability to look for help and hinder the breaking of the cycle of violence.

Lifetime prevalence and help seeking behavior in physical marital violence

OBJECTIVE To estimate the lifetime prevalence of physical marital violence among women from a low-income urban community and to investigate help-seeking behavior among victims. METHODS This is the Brazilian pilot cross-sectional study for an international multicenter study conducted in 1999, and is based on a probabilistic cluster sample from the municipality of Embu, São Paulo State. We considered as eligible women aged 15 to 49 years, living with children under age 18 years, who had lived with a husband or partner in lifetime. Information was collected using standardized questionnaires (n=86), administered by trained interviewers. We investigated three types of physical violence: severe (kicking, hitting with fist, beating, and/or use/threat to use weapon), non-severe (slapping in the absence of severe violence), and any type (severe and/or non-severe and/or other physical aggressions spontaneously referred), as well as the type of help sought by the victim (from people or institutions). We calculated frequency and 95% confidence intervals for each type of violence. RESULTS Subjects reported slapping (32.6%), hitting with fist (17.5%), beating (15,2%), use/threat to use weapon (13.9%), and kicking (10.6%). Prevalence of marital violence was high: 22.1% (13.3-30.9) for severe violence, 10.5% (4.0-17.0) for non-severe violence, and 33.7% (32.7-34.7) for any type of violence. Victims of severe violence were more likely to seek help from the police (36.8%) or from traditional healers (21.1%) than from health care facilities (5.3%), despite the availability of these services in the area. CONCLUSIONS Physical marital violence is frequent and severe among the population studied, and help was sought preferentially from the police or traditional healers rather than from health care services.

Saúde mental e violência entre estudantes da sexta série de um município paulista

OBJETIVO: Analisar fatores de protecao e de risco para problemas de saude mental entre adolescentes. METODOS: Estudo transversal realizado com amostra aleatoria (N=327; perda=6,9%) de estudantes da sexta serie de todas as escolas publicas e privadas de Barretos, SP, em 2004. Os fatores examinados foram: exposicao a violencia domestica e urbana, nivel socioeconomico familiar, sexo, morar sem a mae, participar de atividades sociais (fator de protecao). As associacoes entre esses fatores e problemas de saude mental foram analisadas por meio de modelos de regressao logistica. Todos os fatores de risco e protecao independentes foram incluidos no modelo inicial de regressao logistica, permanecendo no modelo final apenas a variavel com nivel de significância inferior a 0,05. RESULTADOS: Verificou-se que apenas exposicao a violencia permaneceu no modelo final como fator associado a problemas de saude mental (p=0,02; IC 95%: 1,12;4,22). Criancas expostas a violencia domestica tinham tres vezes mais chances de apresentarem estes problemas do que aquelas expostas a violencia urbana (p=0,04; IC 95%: 1,03;7,55). CONCLUSOES: A violencia domestica associou-se a problemas de saude mental nos adolescentes do estudo, podendo ser mais importante que a violencia urbana em cidades de medio porte.