Isabel Altenfelder Santos Bordin

Grand challenges in global mental health

A consortium of researchers, advocates and clinicians announces here research priorities for improving the lives of people with mental illness around the world, and calls for urgent action and investment.

Factors associated with stress in mothers of children with autism

The objective of this case-control study was to investigate the determinants of maternal stress in mothers of children with autism. Mothers of 31 children with autism from mental health clinics were matched by child age/gender and mother age to 31 mothers of children without mental health problems, drawn from public schools and a primary care unit. Logistic regression models showed that the presence of stress in mothers was primarily associated with having a child with autism. However, poor expression of affect, little interest in people, being an older mother, and having a younger child also contributed to increased stress levels. Although having a child with autism was the main factor responsible for stress, the presence of the other factors further increased maternal stress. The implication is that a subgroup of mothers of children with autism is more prone to experience stress, thus requiring special attention from mental health professionals.

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.

Convergent validity of K-SADS-PL by comparison with CBCL in a Portuguese speaking outpatient population

BackgroundDifferent diagnostic interviews in child and adolescent psychiatry have been developed in English but valid translations of instruments to other languages are still scarce especially in developing countries, limiting the comparison of child mental health data across different cultures. The present study aims to examine the convergent validity of the Brazilian version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version (K-SADS-PL) by comparison with the Child Behavior Checklist (CBCL), a parental screening measure for child/adolescent emotional/behavior problems.MethodsAn experienced child psychiatrist blind to CBCL results applied the K-SADS-PL to a consecutive sample of 78 children (6-14 years) referred to a public child mental health outpatient clinic (response rate = 75%). Three K-SADS-PL parameters were considered regarding current disorders: parent screen interview rates, clinician summary screen interview rates, and final DSM-IV diagnoses. Subjects were classified according to the presence/absence of any affective/anxiety disorder, any disruptive disorder, and any psychiatric disorder based on K-SADS-PL results. All subjects obtained T-scores on CBCL scales (internalizing, externalizing, total problems).ResultsSignificant differences in CBCL mean T-scores were observed between disordered and non-disordered children. Compared to children who screened negative, children positive for any affective/anxiety disorder, any disruptive disorder, and any psychiatric disorder had a higher internalizing, externalizing and total problem T-score mean, respectively. Highly significant differences in T-score means were also found when examining final diagnoses, except for any affective/anxiety disorder.ConclusionsEvidence of convergent validity was found when comparing K-SADS-PL results with CBCL data.

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.

Parental beliefs and child-rearing attitudes and mental health problems among schoolchildren

OBJECTIVE To verify the prevalence and identify the risk factors related to mental health problems among schoolchildren and its possible association with the beliefs and educational attitudes of parents/caretakers. METHODS Cross-sectional study with a stratified probabilistic sample (n=454) of first to third-graders from public and private schools in Southeastern Brazil. Standardized instruments were administered to parents/caretakers by trained interviewers, including screening questionnaires for mental health problems among children and parents/caretakers; a questionnaire on beliefs and attitudes; and a questionnaire for socio-economic status. Chi-square tests and logistic regression models were used for statistical analysis. RESULTS We found 35.2% prevalence of clinical/borderline cases among students. Parents/caretakers that believed in corporal punishment as a child-rearing method used physical aggression towards their children more frequently (64.8%). Logistic regression models showed that the act of hitting the child with a belt was associated to conduct problems and to overall mental health problems among schoolchildren in the presence of other risk factors: child gender (male), parents/caretakers with mental health problems, and adverse socioeconomic conditions. CONCLUSIONS The high prevalence of mental health problems among schoolchildren and its association with child-rearing methods and mental health problems among parents/caretakers indicate the need for psycho-educational interventions aimed to reduce physical abuse and mental health problems in childhood.

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.

Physical intimate partner violence in Chile, Egypt, India and the Philippines.

Background: Violence against women is recognized globally as a serious health and social problem that impedes development. Objectives: To determine the magnitude of physical intimate partner violence against women in six selected communities from Chile, Egypt, India and the Philippines. Design: Population-based household surveys. Settings: Selected urban communities in Temuco, Chile; Ismailia, Egypt; Lucknow, Trivandrum, and Vellore non-slum areas of India; and in Manila, the Philippines. Participants: Women aged 15–49 years who cared for at least one child younger than 18 years old. The number of participants per community was 442 (Santa Rosa, Chile), 631 (El-Sheik Zayed, Egypt), 506 (Lucknow, India), 700 (Trivandrum, India), 716 (Vellore, India) and 1000 (Paco, the Philippines). Main Outcome Measures: Lifetime and Current physical intimate partner violence (IPV) was measured using standard definitions and four behaviors or actions – namely slap, hit, kick and beat. Three derived variables for severity included: disabling IPV, IPV-related injury requiring health care and multiple severe IPV (presence of hit and kick and beat). Results: Percentages of lifetime and current physical intimate partner violence (IPV) against women in our sample of 3975 were as follows: 24.9 and 3.6 (Santa Rosa), 11.1 and 10.5 (El-Sheik Zayed), 34.6 and 25.3 (Lucknow), 43.1 and 19.6 (Trivandrum), 31.0 and 16.2 (Vellore), and 21.2 and 6.2 (Paco). Multiple severe physical IPV was more common in the three communities within India (9.0%, 5.9% and 8.0% in Trivandrum, Lucknow and Vellore) than the other three communities (Santa Rosa 2.1%; El-Sheik Zayed 2.9% and Paco 1.9%). Conclusions: Physical IPV was found to be a common phenomenon in all six communities. Overall, patterns of IPV behaviors were similar among the six communities.

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.