Covid-19 y autismo: impacto en las personas con autismo y sus familias en Uruguay / Covid-19 and autism: impact on people with autism and their families in Uruguay

La pandemia de covid-19 y las medidas asociadas determinaron cambios profundos en los individuos con trastorno del espectro autista (TEA) y sus familias. Se busca explorar estos efectos a nivel de las emociones y comportamientos en esta población en Uruguay. Dentro de un estudio multicéntrico de ocho países de Latinoamérica, se utilizó la submuestra de Uruguay para analizar los cambios de los comportamientos exhibidos por los individuos con TEA sobre la base de género y edad. Entre los 269 cuidadores que completaron una encuesta anónima, el 43,9 % reportó mayores problemas de convivencia y el 75,4 % reportó retrocesos. El empeoramiento de los comportamientos externalizados fue mayor en el sexo masculino y de los internalizados, en los adolescentes de 13 a 18 años. Estos resultados deberían considerarse a la hora de tomar medidas que comprometen la continuidad educativa, apoyos terapéuticos y de asistencia a las familias con personas con TEA en Uruguay.

COVID-19 pandemic and its associated measures, determined pro-found changes in individuals with autism spectrum disorder (ASD) and their families. Authors explore consequences regarding emotions and behaviors in this population in Uruguay. Within a multicentric study of eight Latin American countries, changes in behaviors in individuals with ASD based on gender and age were analyzed in the Uruguayan sub-sample. Among the 269 caregivers who completed an anonymous survey, 43.9% reported greater problems in daily life and 75.4% reported setbacks. The worsening of externalizing behaviors was greater in males. The internalizing ones were higher in adolescents aged 13 to 18 years. These results should be considered when taking measures that compromise educational continuity, therapeutic supports and assistance to families with people with ASD in Uruguay.

Autistic spectrum disorders in brazilian primary care: telehealth and face-to-face training method / Treinamento sobre transtorno do espectro autista na atenção básica do Brasil: teleducação e presencial / Entrenamiento en transtorno del espectro autista en la atención básica brasileña: teleducación y presencial

Primary care professionals are usually the first ones to detect symptomns of autism. We have developed and evaluated an educational model via a combined telehealth and face-to-face approach to handle autism spectrum disorders (ASD) and child mental health. The training comprised two modules involving distance-learning and face-to-face teaching environments. A total of 150 healthcare professionals - 75 doctors and 75 nurses - from five Brazilian cities were trained. Videos about ASD and child mental health were developed for the distance-learning module. The face-toface module was based on training regarding "Mental health communication skills for child and adolescent primary care." The professionals were evaluated before and after training utilizing a specific knowledge questionnaire and surveys on Knowledge, Attitude, and Practice (KAP). Knowledge acquisition, practice, and attitude improved significantly after training (p < 0.01). Our results indicated that the use of interactive tele-education to train professionals in primary care is feasible and effective.

Os primeiros sintomas de transtorno do espectro autista (TEA) são detectados por profissionais da atenção básica. O objetivo deste estudo foi desenvolver e avaliar um modelo de treinamento via telemedicina e workshop presencial sobre TEA e saúde mental infantil para médicos e enfermeiros da atenção básica. Participaram do treinamento 150 profissionais de cinco cidades brasileiras. No módulo a distância, foram desenvolvidos vídeos sobre TEA e os principais transtornos da infância, e no presencial foi baseado no treinamento "Técnicas de comunicação para lidar com saúde mental de crianças e adolescentes na atenção primaria". Os profissionais foram avaliados antes e depois da capacitação com questionários específicos de conhecimento e o Questionário de conhecimento, atitudes e prática (CAP). Os resultados apontaram a aquisição de conhecimento, atitudes e prática tanto pelos médicos quanto pelos enfermeiros. Os resultados deste estudo mostram que o treinamento de profissionais da atenção básica é factível e efetiva.

Los profesionales que detectan los primeros síntomas de trastorno del espectro autista son los profesionales de la atención básica. Desarrollamos y evaluamos un modelo de educación vía tele-salude y taller presencial sobre TEA y salud mental infantil para médicos y enfermeros de la atención básica. 150 profesionales de 5 ciudades brasileñas participaron en el entrenamiento. Para el módulo a distancia se desarrollaron vídeos sobre TEA y los principales trastornos de la infancia. El módulo presencial se basó en el entrenamiento "Técnicas de comunicación para lidiar con la salud mental de niños y adolescentes en la atención primaria". Los profesionales fueron evaluados antes y después de la capacitación con Cuestionario Específicos de Conocimiento y el Cuestionario de conocimiento, actitudes, práctica (CAP). Los resultados apuntaron que hubo adquisición de conocimiento, actitud y práctica tanto por los médicos y por los enfermeros. Los resultados muestran que el uso de tele-educación interactiva para la capacitación es factible y efectiva.

Child and Adolescent Psychosocial Care Center service use profile in Brazil: 2008 to 2012

Objective: To describe the service use profile of Child and Adolescent Psychosocial Care Centers (Centro de Atenção Psicossocial Infanto-Juvenil [CAPSi]) in Brazil regarding diagnostic categories, sociodemographic aspects, and care modalities between 2008 and 2012. Methods: A descriptive, ecological study was performed using data from the Unified Health System regarding high-complexity procedure authorizations (Autorização de Procedimentos de Alta Complexidade [APAC]) for the period from 2008-2012. The variables sex, age, diagnosis (F00-F99 of ICD-10), and type of care provided were examined. The data were processed using TabWin and STATA version 12. Results: A total of 837,068 records were examined, each representing one visit to CAPSi. Most visits were by male users (68.8%). The most common diagnoses were hyperkinetic disorders (13%), pervasive developmental disorders (12.4%), and conduct disorders (8.4%). Conclusions: Behavioral and emotional disorders that usually appear during childhood or adolescence and psychological development disorders were frequent, with more than 50% of the latter comprising autism spectrum disorders. Regional differences were observed, with a higher presence of this diagnosis in the Southeast, while the North and Northeast had a high percentage of visits due to mental retardation.

Impact of a provider training program on the treatment of children with autism spectrum disorder at psychosocial care units in Brazil

Objective: To develop, implement, and verify the impact of a training program for health care providers working with children with autism spectrum disorder (ASD) in psychosocial care centers for children and adolescents (Centro de Atenção Psicossocial à Infância e à Adolescência - CAPSi) in São Paulo, Brazil. Methods: This quasi-experimental study was conducted with 14 professionals from four CAPSi units. The training program consisted of six phases: 1) pre-intervention observation; 2) meeting with staff to assess the main needs of the training program; 3) developing materials for training and evaluation; 4) meetings to discuss program implementation; 5) a final meeting for case discussion and evaluation; and 6) distance supervision. Three measures were used to evaluate the training program: i) the Knowledge, Attitudes, and Practices (KAP) questionnaire; ii) videos containing questions designed to assess program comprehension; and iii) a satisfaction survey. Results: Thirteen videos were produced to as visual aids for use during the training program, and a further 26 videos were developed to evaluate it. The program was well evaluated by the participants. The video responses and KAP questionnaire scores suggest that staff knowledge and attitudes improved after training. Conclusion: The positive findings of this study suggest that the tested training program is feasible for use with multidisciplinary teams working in the CAPSi environment.

Barriers to early identification of autism in Brazil

Objective: Parents of children with autism spectrum disorders (ASD) seem to perceive that their child's development is not following the normal pattern as early as the first year of life. However, ASD children may not receive a diagnosis until they are of preschool age, especially in low- and middle-income countries. The objective of this study was to evaluate the pathway between initial parental concerns about atypical child development and ASD diagnosis in Brazil. Methods: Nineteen mothers whose children had been diagnosed with ASD participated and were interviewed. The ASD group consisted of two girls and 17 boys, with a mean age of 93.0 months (SD 48.4 months; range 39-197 months). Results: Mothers had their first concerns regarding ASD when children were 23.6±11.6 months old, but formal diagnosis occurred at a mean ± SD age of 59.6±40.5 months, corresponding to a 3-year delay. Most mothers felt discouraged to address their concerns due to negative experiences with health professionals. Conclusion: In Brazil, mothers perceived the first signs of ASD in their children at an age similar to that reported in other countries, but the diagnosis of ASD seemed to be delayed. Consistent with the literature, mothers reported negative experiences with health professionals during the pathway to achieving ASD diagnosis.

Exposure to maltreatment and urban violence in children working on the streets in São Paulo, Brazil: factors associated with street work

Objective: To quantitatively study the exposure to childhood maltreatment and urban violence in children from families with at least one child working on the streets and to investigate the relationship between these factors and street work. Methods: Families who participated in a nongovernmental organization (NGO) program to eliminate child labor were included. Data concerning sociodemographic characteristics, punishment methods used in the family environment against the children, five types of abuse and neglect perpetrated by the caregivers, urban violence exposure and family functioning were collected. Results: The sample included 126 children who were working on the streets and 65 siblings who were not working on the streets. Caregivers reported high levels of severe physical punishment. The children reported high levels of abuse and neglect, and high levels of urban violence exposure. The families showed a predominance of dysfunctional and unsatisfactory relationships. A multiple logistic regression model showed that age older than 12 years and severe physical punishment at home were associated with street work. Conclusion: Interventions to decrease the risk of child street work should be family-focused and should aim to reduce violence in the family environment. .

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 / Child Behavior Checklist (CBCL), Youth Self-Report (YSR) e Teacher's Report Form (TRF): uma visão geral sobre o desenvolvimento das versões originais e brasileiras / Child Behavior Checklist (CBCL), Youth Self- Report (YSR) y Teacher's Report Form (TRF): una visión general sobre el desarrollo de las versiones originales y brasileñas

The Achenbach System of Empirically Based Assessment (ASEBA) for school-age children includes three instruments for assessing emotional and/or behavioral problems: Child Behavior Checklist (CBCL), completed by parents, Youth Self-Report (YSR), completed by adolescents and Teacher's Report Form (TRF), completed by teachers. This review article gives detailed information on the development of these forms in the United States and Brazil, describing the main changes to the items, scales and score cut-off points in original versions between 1991 and 2001, as well as the process involved in the translation, back-translation and cultural adaptation of the original questionnaires to develop the current official Brazilian versions of the CBCL, YSR and TRF. The utility of these tools for research and clinical practice is highlighted, mentioning epidemiological studies and evaluation of interventions conducted in Brazil. Researchers' and clinicians' doubts regarding the correct use of the current official Brazilian versions are answered, giving examples of frequently asked questions relevant to the Brazilian context.

O Sistema de Avaliação de Base Empírica de Achenbach para crianças/adolescentes em idade escolar inclui três instrumentos para avaliar problemas emocionais e/ou comportamentais: Child Behavior Checklist (CBCL) [pais], Youth Self-Report (YSR) [adolescentes] e Teacher's Report Form (TRF) [professores]. Este artigo de revisão fornece informações detalhadas sobre o desenvolvimento desses instrumentos nos Estados Unidos e no Brasil, descrevendo as principais alterações em itens, escalas e pontos de corte na pontuação, ocorridas nas versões originais de 1991 a 2001, e o processo de tradução, retrotradução e adaptação cultural dos questionários originais para desenvolver as atuais versões brasileiras oficiais do CBCL, YSR e TRF. A utilidade desses instrumentos em pesquisa e na prática clínica é salientada, mencionando estudos epidemiológicos e de avaliação de intervenções conduzidos no Brasil. Pesquisadores e clínicos são instruídos a respeito do uso correto das atuais versões brasileiras oficiais, dando exemplos de perguntas frequentes, relevantes para o contexto brasileiro.

El sistema de evaluación de base empírica de Achenbach para niños/adolescentes en edad escolar incluye tres instrumentos para evaluar problemas emocionales y/o de comportamiento: Child Behavior Checklist (CBCL) [padres], Youth Self-Report (YSR) [adolescentes] y Teacher's Report Form (TRF) [profesores]. Este artículo de revisión proporciona información detallada sobre el desarrollo de estos instrumentos en los Estados Unidos y en Brasil, describiendo las principales alteraciones en ítems, escalas y puntos de corte en la puntuación, que se realizaron en las versiones originales de 1991 a 2001, y el proceso de traducción, retrotraducción y adaptación cultural de los cuestionarios originales, con el fin de desarrollar las actuales versiones brasileñas oficiales del CBCL, YSR y TRF. La utilidad de estos instrumentos en investigación y en la práctica clínica se resalta mencionando estudios epidemiológicos y de evaluación de intervenciones, llevados a cabo en Brasil. Investigadores y personal clínico son instruidos en lo que se refiere al uso correcto de las actuales versiones brasileñas oficiales, dando ejemplos de preguntas frecuentes y relevantes para el contexto brasileño.

How to improve the mental health care of children and adolescents in Brazil: actions needed in the public sector / Como aprimorar a assistência à saúde mental de crianças e adolescentes brasileiros: ações recomendadas para o sistema público

INTRODUCTION: Child/adolescent mental health (CAMH) problems are associated with high burden and high costs across the patient's lifetime. Addressing mental health needs early on can be cost effective and improve the future quality of life. OBJECTIVE/METHODS: Analyzing most relevant papers databases and policies, this paper discusses how to best address current gaps in CAMH services and presents strategies for improving access to quality care using existing resources. RESULTS: The data suggest a notable scarcity of health services and providers to treat CAMH problems. Specialized services such as CAPSi (from Portuguese: Psychosocial Community Care Center for Children and Adolescents) are designed to assist severe cases; however, such services are insufficient in number and are unequally distributed. The majority of the population already has good access to primary care and further planning would allow them to become better equipped to address CAMH problems. Psychiatrists are scarce in the public health system, while psychologists and pediatricians are more available; but, additional specialized training in CAMH is recommended to optimize capabilities. Financial and career development incentives could be important drivers to motivate employment-seeking in the public health system. CONCLUSIONS: Although a long-term, comprehensive strategy addressing barriers to quality CAMH care is still necessary, implementation of these strategies could make.

INTRODUÇÃO: Problemas de saúde mental na infância/adolescência (SMIA) trazem diversos prejuízos e geram altos custos. A assistência precoce pode ser custo efetiva, levando a melhor qualidade de vida a longo prazo. OBJETIVOS/MÉTODO: Analisando os artigos mais relevantes, documentos do governo, base de dados e a política nacional, este artigo discute como melhor administrar a atual falta de serviços na área da SMIA e propõe estratégias para maximizar os serviços já existentes. RESULTADOS: Dados apontam evidente falta de serviços e de profissionais para tratar dos problemas de SMIA. Serviços especializados, como o CAPSi (Centro de Atenção Psicossocial Infanto-Juvenil) estão estruturados para assistir casos severos, mas são insuficientes e desigualmente distribuídos. A maioria da população já tem bom acesso às unidades básicas de saúde e um melhor planejamento ajudaria a prepará-las para melhor assistir indivíduos com problemas de SMIA. Psiquiatras são escassos no sistema público, enquanto psicólogos e pediatras estão mais disponíveis; para estes recomenda-se capacitação mais especializada em SMIA. Incentivos financeiros e de carreira motivariam profissionais a procurarem emprego no sistema público de saúde. CONCLUSÕES: Apesar de estratégias complexas e de longo prazo serem necessárias para lidar com as atuais barreiras no campo da SMIA, a implantação de certas propostas simples já poderiam trazer impacto imediato e positivo neste cenário.

Fatores de risco para problemas de saúde mental na infância/adolescência / Risk factors for mental health problems in childhood/adolescence

Estudo de corte transversal conduzido em comunidade urbana de baixa renda do município de Embu-SP com objetivo de identificar fatores associados a problemas de saúde mental em crianças/adolescentes (PSMCA) em amostra probabilística (N=67, faixa etária 4-17 anos). Foram aplicados instrumentos estruturados às mães: Child Behavior Checklist (PSMCA); WorldSAFE Core Questionnaire (dados sociodemográficos; violência doméstica; embriaguez do pai/padrasto); Self-Report Questionnaire (problemas de saúde mental maternos, ideação suicida materna). Os resultados do estudo apontaram fatores estatisticamente associados aos PSMCA: criança/adolescente ser do sexo masculino e sofrer punição física grave; ideação suicida da mãe e violência conjugal física grave contra a mãe; embriaguez do pai/padrasto. Concluindo, grupos vulneráveis com características individuais/familiares identificadas neste estudo devem ser considerados prioritários em propostas de prevenção/tratamento.

Across-sectional study was conducted in an urban low-income community in the municipality of Embu-SP with the objective of identifying factors associated with mental health problems of children and adolescents (MHPCA) in a probabilistic sample (N=67, aged 4-17 years). Standardized instruments were applied to mothers: Child Behavior Checklist; WorldSAFE Core Questionnaire (demographics, domestic violence, father/stepfather drunkenness); Self-Report Questionnaire (maternal mental health problems and suicide ideation). The results of this study identified factors statistically related to MPHCA: child/adolescent of male gender and severe physical punishment; maternal suicide ideation and severe physical marital violence; father/stepfather drunkenness. As a result, vulnerable groups with individual/family characteristics identified in this study should have priority in prevention/treatment programs.

Saúde mental e violência entre estudantes da sexta série de um município paulista / Mental health and violence among sixth grade students from a city in the state of São Paulo

OBJETIVO: Analisar fatores de proteção e de risco para problemas de saúde mental entre adolescentes. MÉTODOS: Estudo transversal realizado com amostra aleatória (N=327; perda=6,9 por cento) de estudantes da sexta série de todas as escolas públicas e privadas de Barretos, SP, em 2004. Os fatores examinados foram: exposição à violência doméstica e urbana, nível socioeconômico familiar, sexo, morar sem a mãe, participar de atividades sociais (fator de proteção). As associações entre esses fatores e problemas de saúde mental foram analisadas por meio de modelos de regressão logística. Todos os fatores de risco e proteção independentes foram incluídos no modelo inicial de regressão logística, permanecendo no modelo final apenas a variável com nível de significância inferior a 0,05. RESULTADOS: Verificou-se que apenas exposição à violência permaneceu no modelo final como fator associado a problemas de saúde mental (p=0,02; IC 95 por cento: 1,12;4,22). Crianças expostas à violência doméstica tinham três vezes mais chances de apresentarem estes problemas do que aquelas expostas à violência urbana (p=0,04; IC 95 por cento: 1,03;7,55). CONCLUSÕES: A violência doméstica associou-se a problemas de saúde mental nos adolescentes do estudo, podendo ser mais importante que a violência urbana em cidades de médio porte.

Prevalence of mental health problems in children and adolescents from the outskirts of Sao Paulo City: treatment needs and service capacity evaluation

OBJECTIVE: To estimate the prevalence of mental health problems in children and adolescents, with or without considering global impairment, within a low-income urban community; to estimate the public service delivery capacity in terms of mental healthcare; and to determine the relationship between delivery capacity and treatment demand. METHOD: Cross-sectional study. Probabilistic sample of clusters including all eligible households (low-income community - Embu, Southeastern Brazil). Participants: 479 children and adolescents (aged 6-17 years; attrition rate: 18.8 percent). Measurement: 1) Clinical mental health problems in children and adolescents using the Child Behavior Checklist and/or Youth Self-Report total problem scales; 2) Global impairment: positive score in the Brief Impairment Scale (total score > 15.5); 3) Care service capacity: total number of cases annually seen by psychologists/psychiatrists in the health, education, juvenile justice, and child welfare sectors. RESULTS: Prevalence of mental health problems in children and adolescents: 24.6 percent (20.7-28.5) without considering global impairment; 7.3 percent (5.0-9.6) with global impairment (cases in need of treatment). Current annual service capacity can only provide care for 14.0 percent of impaired cases; approximately seven years would be necessary for all to be treated. CONCLUSIONS: Mental health problems in children and adolescents are frequent in the studied community, and the current structure of the community's public service system is not prepared to treat impaired cases in an adequate timeframe.

OBJETIVO: Estimar a prevalência de problemas de saúde mental em crianças e adolescentes, com e sem prejuízo funcional global, em comunidade urbana de baixa renda; estimar a capacidade de assistência da rede pública de serviços do município; e relacionar a capacidade de assistência à necessidade de tratamento em saúde mental da infância/adolescência. MÉTODO: Estudo transversal. Amostra probabilística de conglomerados incluindo todos os domicílios elegíveis (bairro de baixa renda, Embu-SP). Participantes: 479 crianças/adolescentes (6-17 anos; perda amostral: 18,8 por cento). Medidas: 1) problemas de saúde mental em crianças e adolescentes em nível clínico pela escala de total de problemas do Child Behavior-Checklist e/ou Youth Self-Report; 2) prejuízo funcional global: escore total > 15,5 na Brief Impairment Scale; 3) Capacidade de assistência: total de casos atendidos anualmente por psicólogos/psiquiatras nos setores de saúde, educação, justiça e cidadania/assistência social. RESULTADOS: Prevalência de problemas de saúde mental em crianças e adolescentes: 24,6 por cento (20,7-28,5) desconsiderando prejuízo funcional global; 7,3 por cento (5,0-9,6) com prejuízo funcional global (casos que necessitam tratamento). A capacidade anual de assistência dos casos com prejuízo funcional global é de 14,0 por cento; sendo necessários cerca de sete anos para que todos possam ser tratados. CONCLUSÕES: Problemas de saúde mental em crianças e adolescentes são freqüentes na comunidade estudada e a infra-estrutura atual da rede pública de serviços do município não está preparada para atender em tempo hábil os casos que necessitam tratamento.

Saccadic movements using eye-tracking technology in individuals with autism spectrum disorders: pilot study / Movimentos sacádicos de indivíduos do espectro autista por varredura visual: estudo piloto

OBJECTIVE: To verify differences in the visual scanning strategies between pervasive developmental disorders (PDD) and controls when they are observing social and non-social pictures. METHOD: PDD group (PDDG) comprised by 10 non-retarded subjects (age from 4 to 41) and age-matched control group (CG). Nine social pictures with human beings (including two pictures of cat mask), and 3 nonsocial pictures of objects were presented for 5 seconds. Saccadic movements and fixation were recorded with equipment EyeGaze® (LC Technologies Inc.). RESULTS: PDDG (mean=292.73, SE=67.62) presented longer duration of saccadic movements for social pictures compared to CG (mean=136.06, SE=14.01) (p=0.04). The CG showed a higher number of fixations in the picture 7 (a women using a cat mask, with the eyes erased) (CG: mean=3.40; PDDG: mean=1.80; p=0.007). CONCLUSION: The results suggest differences in strategies that PDD explore human picture. Moreover, these strategies seem not to be affected by the lack of expected part of the face (the eyes.

OBJETIVO: Verificar diferenças nas estratégias de varredura visual de indivíduos com transtorno invasivo do desenvolvimento (TID) comparados a controles normais na observação de figuras sociais e não sociais. MÉTODO: Estudo caso-controle. Grupo TID: dez sujeitos com TID, inteligência normal e idade entre 4 e 41 anos; Grupo Controle: dez sujeitos pareados por idade. Os sujeitos observaram por 5 segundos 9 figuras de seres humanos e 3 figuras de objetos. Os movimentos sacádicos e o número de fixações foram gravados em equipamento EyeGaze® (LC Technologies Inc.). RESULTADOS: O grupo TID apresentou maior duração dos movimentos sacádicos na observação de figuras humanas [TID=292,73 (EP=67,62); controle= 136,06 (EP=14,01); p=0,04]. O grupo controle apresentou maior número de fixações na figura 7 (mulher com máscara de gato sem os olhos) (TID=1,8; controle=3,4; p=0,007). CONCLUSÃO: Indivíduos com TID parecem utilizar estratégias diferentes para explorar figura humana. Além disso, o padrão de investigação deles não se modifica quando observam uma figura que rompe com o esperado (a falta dos olhos.

Coordination of international multicenter studies: governance and administrative structure

A well-conducted multicenter study needs to assure standardization, uniformity of procedures, high data quality, and collaboration across sites. This manuscript describes the organization and dynamics of multicenter studies, focusing on governance and administrative structures among countries of diverse cultures. The organizational structure of a multicenter study is described, and a system for oversight and coordination, along with roles and responsibilities of participants in the multicenter study, are presented. The elements of a governance document are also reviewed, along with guidelines and policies for effective collaboration. The experience of an ongoing multi-country collaboration, the World Studies of Abuse in the Family Environment (WorldSAFE), illustrates the implementation of these guidelines. It is essential that multicenter studies have an objective coordinating center and that the investigators jointly develop a written governance document to enable collaboration and preserve collegiality among participating investigators