Paula Approbato de Oliveira

Estudos neuropsicológicos e de neuroimagem associados ao estresse emocional na infância e adolescência

CONTEXTO: A infância e a adolescencia sao periodos relevantes para a maturacao do cerebro. Experiencias no comeco da vida exercem influencia em padroes de comportamentos da vida adulta. OBJETIVO: Analisar estudos neuropsicologicos e de neuroimagem associados ao estresse emocional na infância e adolescencia que foram publicados na literatura nos ultimos 20 anos METODOS: Revisao da literatura na base de dados Medline/PubMed com os termos relacionados a neuropsicologia, neuroimagem e vivencia de abandono, violencia domestica, abuso fisico, abuso sexual e negligencia. RESULTADOS: Foram encontrados 607 artigos, dos quais 19 foram selecionados para analise por se adequarem ao tema proposto. Apesar das divergencias entre eles, ha evidencias de que grupos com experiencia de estresse emocional precoce (EEP) apresentam prejuizos em funcoes neurocognitivas como atencao, inteligencia, linguagem, funcoes executivas e tomada de decisoes, assim como alteracoes no hipocampo, corpo caloso, cortex pre-frontal e cortex cingulado anterior. A ocorrencia de transtornos psiquiatricos e de alteracoes comportamentais tambem e relevante nesses individuos. CONCLUSOES: Em virtude da diversidade de efeitos negativos do EEP no desenvolvimento neuropsicologico, considera-se fundamental a realizacao de pesquisas sistematizadas que possam nortear a elaboracao de estrategias de diagnostico e tratamento especificas, alem da implementacao de politicas publicas de prevencao a violencia na infância e adolescencia.

Intellectual deficits in Brazilian victimized children and adolescents: a psychosocial problem?

There were nearly 200 million children under 5 years of age in developing countries who did not attain their full evelopment potential due to poverty and other social factors, such as exposure to violence and child maltreatment Grantham-McGregor et al., 2007). Although some researchers have addressed the impact of these situations on cogniive functioning (DePrince, Weinzierl, & Combs, 2009; Nolin & Ethier, 2007), few studies have focused on exposure to altreatment and its association with cognitive abilities in developing countries like Brazil. In addition, the definition of hildhood maltreatment and its consequences differ from culture to culture, which calls for studies in different contexts Gomes, Deslades, Veiga, Bhering, & Santos, 2002). Recent studies have reported a high prevalence of child maltreatment in Brazilian population (Alexandre, Nadanovsky, oraes, & Reichenheim, 2010; Scivoletto, Silva, & Rosenheck, 2011; Tucci, Kerr-Corrêa, & Souza-Formigoni, 2010). It is mportant to consider that the available services designed for this population are frequently inadequate, fragmented, and oorly coordinated (Pumariega & Winters, 2003). This reality limits the development of reliable research and also impairs ccess to information about the profile of victimized children and adolescents residing in the slums, which are highly usceptible to various stressors from poverty to domestic violence. In São Paulo, “The Equilibrium Project” (TEP), a multidisciplinary mental health community service specialized in the utpatient treatment of children and adolescents with a lifetime history of maltreatment and social deprivation was founded, escribed by Scivoletto et al. (2011). In addition to clinical service, TEP also aims to study the global profile of the population, ncluding mental health and cognitive functioning. The purpose of this letter is to highlight and discuss preliminary data about xposure to maltreatment and its association with intellectual functioning in 150 patients. In the current data, Vocabulary nd Block Design subtests of WISC-III were used to measure estimated intellectual quotient (EIQ). Maltreatment history as assessed by reviewing all medical records in order to identify diagnoses related to socioeconomic and psychosocial ircumstances (ICD-10, Chapter 21). The sample was composed of 91 boys (60.7%) and 59 girls (39.3%); mean age was 12.29 (DP = 2.77). There was a higher perentage of Blacks (53.3%; N = 80) than Whites (46%; N = 69). All participants had at least 5 stressful events (social diagnoses); he most common are shown in Table 1. As in other countries, our population showed high cumulative levels of different types of victimization (polyictimization; Finkelhor, Turner, Ormrod, & Hamby, 2010; Grantham-McGregor et al., 2007). Average IQ was 87.25 lower-average; DP = 15.54), and a large number of patients (25.3%; N = 38) with below-average scores, contrary to what as expected (8.9%) according to the normal distribution (IQ test scores are distributed as a normal distribution, also known s Gaussian curve). Fig. 1 shows the curve expected for a normal population (blue) and the curve shown by TEP sample (red). he lower IQ was very remarkable in the victimized population. In addition to cognitive problems, psychiatric evaluation based on the ICD-10 found a high prevalence of psychiatric isorders (78.7%; N = 118). The most prevalent were: hyperkinetic disorders (20.7%; N = 31), nonorganic enuresis (13.3%; = 20), depressive episodes (10%; N = 42), and oppositional defiant disorder (9.3%; N = 14).

Community-Based Global Health Program for Maltreated Children and Adolescents in Brazil: The Equilibrium Program

The maltreatment of children and adolescents is a global public health problem that affects high- and low-middle income countries (“LMICs”). In the United States, around 1.2 million children suffer from abuse, while in LMICs, such as Brazil, these rates are much higher (an estimated 28 million children). Exposition to early environmental stress has been associated with suboptimal physical and brain development, persistent cognitive impairment, and behavioral problems. Studies have reported that children exposed to maltreatment are at high risk of behavioral problems, learning disabilities, communication and psychiatric disorders, and general clinical conditions, such as obesity and systemic inflammation later in life. The aim of this paper is to describe The Equilibrium Program (“TEP”), a community-based global health program implemented in São Paulo, Brazil to serve traumatized and neglected children and adolescents. We will describe and discuss TEP’s implementation, highlighting its innovation aspects, research projects developed within the program as well as its population profile. Finally, we will discuss TEP’s social impact, challenges, and limitations. The program’s goal is to promote the social and family reintegration of maltreated children and adolescents through an interdisciplinary intervention program that provides multi-dimensional bio-psycho-social treatment integrated with the diverse services needed to meet the unique demands of this population. The program’s cost effectiveness is being evaluated to support the development of more effective treatments and to expand similar programs in other areas of Brazil. Policy makers should encourage early evidence-based interventions for disadvantaged children to promote healthier psychosocial environments and provide them opportunities to become healthy and productive adults. This approach has already shown itself to be a cost-effective strategy to prevent disease and promote health.

Intellectual Disability and Psychiatric Diagnoses of Children and Adolescents with a History of Stressful Events and Social Deprivation in Brazil: Preliminary Results. IQ, Depression and Stress

Abstract: Background: Studies have shown that stressful events in childhood are associated with impairments in cognitive functions and intellectual disability. Objective: Compare the intellectual functioning in groups of Brazilian children and adolescents with a history of stressful events with lifetime history of depression and without lifetime history of depression. Method: 30 children and adolescents underwent psychiatric evaluation and neuropsychological assessment of estimated intellectual quotient (EIQ), verbal knowledge, and visuospatial skills. Results: 15 patients (50%) had EIQ within the average and 6 had EIQ in the lower average (20%) for Brazilian standardized norms. The other part had at least some degree of intellectual disability and they were classified as: 2 mild mental retardation (6.7%) and 7 borderline (23.3%). Also, half of the sample had at least one lifetime depressive episode, and the performance in EIQ and visuospatial skills was worse in this group. Conclusion : 50% of the children and adolescents with a history of early stressful events and social deprivation had at least some degree of intellectual disability. In addition, a subgroup with history of depressive episodes had worse EIQ performance when compared to those without depression, possibly due to a greater impairment in visuospatial skills. The specific role of impaired right cerebral hemisphere, corpus callosum, and prefrontal cortex associated with depressive disorders and maltreatment should be investigated in further studies.

The importance of multidisciplinary evaluation for differentiating between mental retardation and antisocial behavior in sex offenders: a case study

The World Health Organization considers sexual abuse in childhood to be a growing public health problem worldwide.1 The psychological and behavioral profile of sex offenders is a topic that has been widely investigated in the literature2-6 because the appropriate treatment of such individuals can prevent them from becoming repeat sex offenders. One important aspect of the aggressor profile is cognitive functioning.5,6 In some cases, sexual assaults are committed by individuals with intellectual disabilities that impair their capacity to critically analyze their actions.2 In other cases, sexual assaults can represent sadistic behavior related to antisocial personality disorder.2 The objective of this case report is to analyze the case of a teenager who was accused of sexually abusing a child and to determine whether the teenager should be diagnosed with mental retardation or early-onset antisocial behavior. This case exemplifies the need for multidisciplinary evaluation to establish a diagnosis and to develop appropriate treatments to prevent the recurrence of violence.