Fractura craneal deprimida congénita ("fractura ping-pong") en neonatos como diagnóstico diferencial de maltrato físico / Congenital depressed skull fracture ("ping-pong" fracture) in newborn infants as a differential diagnosis of physical abuse

Las fracturas con hundimiento de cráneo sin una explicación clara sobre su origen orientan al traumatismo con un objeto romo y a la sospecha de maltrato infantil. En el caso de los bebés recién nacidos, su corta edad es un factor de vulnerabilidad y obliga a una exhaustiva evaluación. Ante la sospecha de maltrato infantil, resulta importante evaluar los diagnósticos diferenciales para realizar la intervención más adecuada posible. Es necesario evitar tanto intervenciones excesivas como omitir la intervención que sea necesaria. Las fracturas craneales deprimidas congénitas, descritas como "fracturas pingpong", son raras (0,3 a 2/10 000 partos). Pueden aparecer sin antecedentes traumáticos o en partos instrumentalizados. Se describe en este artículo el caso de un recién nacido con una fractura ping-pong como ejemplo de una fractura no intencional.

Depressed skull fractures without a clear explanation as to their origin point to trauma with a blunt object and suspected child abuse. In the case of newborn infants, their young age is a vulnerability factor and requires an exhaustive assessment. When child abuse is suspected, an assessment of the differential diagnoses is required to make the most appropriate intervention possible. Both an excessive intervention and an omission of a necessary intervention should be avoided. Congenital depressed skull fractures, described as "ping-pong fractures", are rare (0.3 to 2/10 000 births). They may appear without any trauma history or in instrumentalized childbirth. Here we describe the case of a newborn infant with a ping-pong fracture as an example of an accidental fracture.

Violencia contra niños, niñas y adolescentes: actuación del odontólogo y nivel de conocimiento para la detección y atención de casos / Violence against children and adolescents: dentist´s performance and knowledge levels for case detection and care

Objetivo: Analizar el nivel de conocimiento del pro-fesional odontólogo sobre la violencia ejercida en niños, niñas y adolescentes, poniendo énfasis en la importancia de su actuación para la detección, aten-ción y derivación de potenciales casos que posibi-liten, dentro de un contexto multidisciplinario, una intervención oportuna y efectiva. Materiales y méto-dos: Se realizó una encuesta a 132 odontólogos, 123 mujeres y 9 hombres, con experiencia profesional de 2 a 43 años, profesores universitarios especialistas en odontopediatría, cursantes de carreras de espe-cialización y posgrados afines o aquellos que desa-rrollan sus actividades laborales en 2 hospitales pú-blicos de la Ciudad Autónoma de Buenos Aires aten-diendo a menores de edad. La encuesta totalizó 15 preguntas distribuidas en 3 categorías cuyos ejes te-máticos ahondaron respecto al conocimiento sobre violencia ejercida contra menores (Categoría 1), sos-pecha de un presunto maltrato infantil en la consulta (Categoría 2) y factores que condicionan la eventual derivación del caso (Categoría 3). Cada pregunta in-cluida en las 3 categorías se direccionó conforme a si el ámbito profesional del sujeto encuestado era es-pecialista/cursante de posgrado (Grupo 1) u hospi-talario (Grupo 2). Resultados: En la primera categoría se observó una significativa carencia de formación específica en la etapa de grado con un 89% para el grupo 1 y 93,75% para el grupo 2, aunque éstos úl-timos han accedido a cursos de perfeccionamiento y actividades tendientes a incrementar destrezas y aptitudes en un 71,87%, contrastando con el 24% del otro grupo. Asimismo, el 29% del grupo 1 y un 50% del grupo 2 conocían los protocolos establecidos en sus entornos profesionales. Ambos consideraron que el odontólogo no está capacitado para detectar conductas orientativas hacia posibles casos (89%, grupo 1; 87,5%, grupo 2). Para la segunda categoría, el grupo 1 respondió positivamente en un 73%, en tanto que el grupo 2 lo hizo en un 84,38%. En la ter-cera categoría se destacó para el grupo 1 un elevado porcentaje en las preguntas relacionadas al temor por parte del odontólogo de agravar las acciones Objetivo: Analizar el nivel de conocimiento del pro-fesional odontólogo sobre la violencia ejercida en niños, niñas y adolescentes, poniendo énfasis en la importancia de su actuación para la detección, aten-ción y derivación de potenciales casos que posibi-liten, dentro de un contexto multidisciplinario, una intervención oportuna y efectiva. Materiales y méto-dos: Se realizó una encuesta a 132 odontólogos, 123 mujeres y 9 hombres, con experiencia profesional de 2 a 43 años, profesores universitarios especialistas en odontopediatría, cursantes de carreras de espe-cialización y posgrados afines o aquellos que desa-rrollan sus actividades laborales en 2 hospitales pú-blicos de la Ciudad Autónoma de Buenos Aires aten-diendo a menores de edad. La encuesta totalizó 15 preguntas distribuidas en 3 categorías cuyos ejes te-máticos ahondaron respecto al conocimiento sobre violencia ejercida contra menores (Categoría 1), sos-pecha de un presunto maltrato infantil en la consulta (Categoría 2) y factores que condicionan la eventual derivación del caso (Categoría 3). Cada pregunta in-cluida en las 3 categorías se direccionó conforme a si el ámbito profesional del sujeto encuestado era es-pecialista/cursante de posgrado (Grupo 1) u hospi-talario (Grupo 2). Resultados: En la primera categoría se observó una significativa carencia de formación específica en la etapa de grado con un 89% para el grupo 1 y 93,75% para el grupo 2, aunque éstos úl-timos han accedido a cursos de perfeccionamiento y actividades tendientes a incrementar destrezas y aptitudes en un 71,87%, contrastando con el 24% del otro grupo. Asimismo, el 29% del grupo 1 y un 50% del grupo 2 conocían los protocolos establecidos en sus entornos profesionales. Ambos consideraron que el odontólogo no está capacitado para detectar conductas orientativas hacia posibles casos (89%, grupo 1; 87,5%, grupo 2). Para la segunda categoría, el grupo 1 respondió positivamente en un 73%, en tanto que el grupo 2 lo hizo en un 84,38%. En la ter-cera categoría se destacó para el grupo 1 un elevado porcentaje en las preguntas relacionadas al temor por parte del odontólogo de agravar las acciones de violencia familiar (64%) o represalias (55%) contra el niño si efectuaran la derivación. En los mismos ítems, el grupo 2 respondió con porcentajes disímiles (28,13% y 31,25%, respectivamente). Finalmente, se diferenciaron claramente los resultados en cuanto al desconocimiento de los procedimientos a seguir si amerita derivar un caso, con un 71% para el grupo 1 y un 34,38% para el grupo 2. Conclusión: Se hace imperioso instruir y capacitar al profesional odontólogo, concientizándolo sobre la necesidad de conocer la legislación vigente y los mecanismos de detección y ulterior derivación. Si bien aquellos que desempeñan su labor a nivel hospitalario aparecen como mejor preparados para actuar, existe un evidente desconocimiento general que conlleva el riesgo de no advertir o proceder inadecuadamente en casos de violencia que atenta contra la seguridad de niños, niñas y adolescentes (AU)

Objective: To analyze the level of knowledge of the dental professional about violence committed in children and adolescents, emphasizing the importance of their actions for the detection, care and referral of potential cases that allow, within a multidisciplinary context, an intervention timely and effective. Materials and methods: A survey was carried out with 132 dentists, 123 women and 9 men, with professional experience of 2 to 43 years, university professors in the specialty of pediatric dentistry, students of specialization course and related postgraduate courses or those who carry out their work activities in 2 public hospitals in the Autonomous City of Buenos Aires that care for minors. The survey included 15 questions distributed in 3 categories whose thematic axes delved into knowledge about violence committed against minors (Category 1), suspicion of alleged child abuses in the consultation (Category 2) and factors that condition the eventual referral of the case (Category 3). Each question included in the 3 categories is addressed according to whether the professional field of the surveyed subject was a specialist/graduate student (Group 1) or a hospitalist (Group 2). Results: In the first category, a significant lack of specific training is observed in the undergraduate stage with 89% for group 1 and 93.75% for group 2, although the latter have accessed courses and improvement activities aimed at to increase skills and abilities by 71.87%, in contrast to 24% in the other group. Likewise, 29% of group 1 and 50% of group 2 knew the protocols established in their professional environments. Both considered that the dentist is not trained to detect guiding behaviors towards possible cases (89%, group 1; 87.5%, group 2). For the second category, group 1 responded positively by 73%, while group 2 did so by 84.38%. In the third category, a high percentage stood out for group 1 in the questions related to the dentist's fear of aggravating the actions of family violence (64%) or retaliation (55%) against the child if he made the referral. In the same items, group 2 responded with dissimilar percentages (28.13% and 31.25%, respectively). Finally, the results were clearly differentiated in terms of lack of knowledge of the procedures to follow if a case warrants referral, with 71% for group 1 and 34.38% for group 2. Conclusion: It is imperative to instruct and train the professional dentist, raising awareness about the need to know current legislation and the detection and subsequent referral mechanisms. Although those who carry out their work at the hospital level seem to be better prepared to act, there is an evident widespread lack of knowledge that entails the risk of not announcing or acting inappropriately in cases of violence that threaten the safety of children and adolescents (AU)

Síndrome de Niño Agredido: aspectos médico legales y la importancia de los estudios radiológicos Reporte de caso / Battered Child Syndrome: medico-legal aspects and the importance of radiological studies Case report

Resumen El síndrome de niño(a) agredido(a) comprende múltiples aspectos desde la definición propia del abuso infantil, en donde se incluye tanto cualquier acto como la omisión que arremeta contra la salud o el desarrollo del menor. Siendo necesario la valoración integral de cada uno de los casos sospechosos abarcando tanto aspectos relacionados con posibles maltratos físicos como los correlacionables por omisión de cuido de menor. Se presenta el caso de una evaluada con denuncia por Abuso de Patria Potestad para ser valorada por sospecha de maltrato infantil.

Abstract The battered child syndrome encompasses multiple aspects from the very definition of child abuse, which covers any act or omission that affects the health or development of the minor. The comprehensive assessment of each of the suspected cases is necessary, covering both aspects related to possible physical abuse and those correlatable by omission of childcare. The case of female with a complaint for Abuse of Parental Authority to be assessed for suspicion of child abuse is presented.

Experiencias adversas en la infancia. Conocimiento y uso por médicos residentes de pediatría / Adverse childhood experiences. Knowledge and use by pediatrics residents

Resumen Introducción: Las experiencias adversas en la infancia (EAI) se han relacionado con la adquisición de conductas de riesgo y el desarrollo de enfermedades crónicas y mentales, desde la adolescencia y en la vida adulta. Objetivo: Identificar el conocimiento y la frecuencia con la que médicos residentes de pediatría interrogan sobre las EAI. Métodos: Mediante una encuesta en línea enviada a todos los médicos residentes del año académico 2017-2018 de un hospital pediátrico de tercer nivel, se recabaron variables demográficas, del conocimiento, uso, entrenamiento y barreras para interrogar sobre EAI. Resultados: 21 % de los residentes respondió la encuesta, la mayoría fue del sexo femenino (70 %), menos de 5 % de los participantes estaba familiarizado con las EAI, 31 % interrogaba sobre ellas a los padres e hijos y 71 % consideró que tiene alguna barrera para interrogarlas. Conclusiones: Los participantes de este estudio mostraron un conocimiento limitado sobre las EAI, lo que repercutió en la frecuencia con la que preguntaban al respecto a sus pacientes y padres; al menos la mitad tuvo la percepción que identificarlas está fuera del alcance del pediatra.

Abstract Introduction: Adverse childhood experiences (ACEs) have been associated with the acquisition of risk behaviors and development of chronic and mental diseases since adolescence and in adult life. Objective: To identify the knowledge and the frequency pediatrics residents ask about ACEs with. Methods: Through an online survey sent to all resident physicians of the 2017-2018 academic year of a tertiary care children’s hospital, demographic variables, knowledge, use, training and barriers to interrogate and search for ACEs were collected. Results: 21% of residents answered the survey; the majority were women (70 %), less than 5 % of participants were familiar with ACEs, 31 % enquired about them in parents and their children, and 71 % considered having some barrier to interrogate about them. Conclusions: Participants in this study showed limited knowledge about ACEs, which had an impact on the frequency they enquired about them with in their patients and their parents; at least half had the perception that it is beyond the reach of the pediatrician to identify them.

Escala para evaluar indicadores de reparación en niños, niñas y adolescentes que han vivido maltrato grave (I-REPARACIÓN): estructura factorial en Chile / Scale to evaluate the recovery process in children and adolescents exposed to serious abuse (I-REPARACION): factorial structure in Chile

En este estudio se ofrece un análisis psicométrico de un instrumento que evalúa la reparación de las consecuencias del maltrato infantil en una muestra de adolescentes chilenos/as. La reparación es un concepto controvertido y complejo que requiere de instrumentos que logren capturar sus distintas dimensiones. En total participaron 491 adolescentes (M = 14,32; DT = 1,70; 74,7% de sexo femenino y 25,3% de sexo masculino) que fueron evaluados/as con el I-REPARACIÓN. Los resultados del análisis factorial exploratorio y confirmatorio apoyan la validez del instrumento ya que este reconoce tres dimensiones de la reparación coherentes con la teoría y evidencia previa: fortalecimiento de la identidad, integración de la experiencia y ausencia de sintomatología. A su vez los análisis de consistencia interna (alfa de Cronbach) apoyan la fiabilidad del instrumento dado que sus ítems miden el constructo de forma consistente. Se considera que, aunque se trata de resultados preliminares, los resultados ofrecen garantías psicométricas para el uso I-REPARACIÓN en el monitoreo del avance de las intervenciones en adolescentes expuestos/as a maltrato infantil.

This study offers a psychometric analysis of an instrument that assesses the recovery process of the consequences of child abuse in a sample of Chilean adolescents. Recovery is a controversial and complex concept that requires instruments that can capture its different dimensions. In total, 491 adolescents (M = 14,32; SD = 1,70; 74,7% girls, 25,3% boys) participated and were evaluated with the I-REPARACIÓN. The exploratory and confirmatory factor analysis results support the instrument's validity since it recognizes three dimensions of recovery consistent with theory and previous evidence: identity strengthening, integration of the traumatic experience, and absence of symptoms. In turn, internal consistency (Cronbach's alpha) analyses support the instrument reliability since its items measure the construct consistently. Although preliminary research, it is considered that the results offer psychometric guarantees for the use of I-REPARACIÓN in monitoring the progress of interventions in adolescents exposed to child abuse.

Maltrato infantil: conocimiento y actitud del cirujano dentista: marco legal y revisión de la literatura / Child abuse: knowledge and attitude of the dentist: legal framework and review of the literature

El maltrato, abuso y la negligencia a los niños constituyen un fenómeno social que desafortunadamente está extendido por todo el mundo sin barreras étnicas, geográficas ni de contexto social. En Chile, hasta el año 2012 el 71 % de los niños sufría algún tipo de maltrato al interior de su familia. Las lesiones cráneo-faciales y de cuello ocurren en más de la mitad de los casos. El Odontólogo tiene la obligación legal, moral y ética como ciudadano y profesional de la salud de notificar a las autoridades competentes los casos sospechosos de maltrato. Objetivo: Evaluar cuál es el conocimiento del cirujano dentista sobre maltrato infantil y cuál ha sido su actitud frente a la detección y reporte del maltrato infantil. Búsqueda bibliográfica en PUBMED utilizando palabras clave: "child abuse" and "dentistry". Se encontraron 132 artículos, de los cuales fueron 15 atingentes con texto completo. Estudios realizados en varios países informaron de las dificultades de los odontólogos en el diagnóstico, la documentación y la denuncia de casos con sospecha de abuso a las autoridades, además de la necesidad de mayor formación en el tema. Dada la importancia del tema, el papel del odontólogo al trabajar directamente con niños y adolescentes, y el aumento en el reporte de casos sospechosos de violencia, se sugiere fuertemente realizar una vigilancia respecto a conocimiento y actitudes entre los odontólogos en Chile.

Abuse and neglect of children constitutes a social phenomenon that unfortunately is spread throughout the world without ethnic, geographical or social context barriers. In Chile, until 2012, 71 % of children suffered some type of abuse within their family. Skull-facial and neck injuries occur in more than half of the cases. The Dentist has a legal, moral and ethical obligation as a citizen and health professional to notify the authorities of suspected cases of abuse. The objective of the study was to evaluate the extent of the dental surgeons´ knowledge regarding child abuse and their attitude towards the detection and reporting of child abuse. Bibliographic search in PUBMED using keywords: "child abuse" and "dentistry". In the study, 132 articles were found, of which 15 were full text. Studies in several countries reported the difficulties of dentists in the diagnosis, documentation and reporting of cases of suspected abuse to the authorities, in addition to the need for further training in the subject. Given the importance of this issue, the role of the dentist working directly with children and adolescents, and the increase in the reporting of suspected cases of violence, it is strongly suggested to monitor the knowledge and attitudes among dentists in Chile.

Odontólogos y Obligación de Denuncia del Abuso Sexual Infantil en Chile: oportunidades perdidas / Dentists and Mandatory Reporting of Child Sexual Abuse in Chile: missed opportunities

RESUMEN: La obligación de denunciar representa la estrategia clave para abordar al abuso sexual infantil, y se encuentra justificada en la suposición de que la detección temprana ayudará a prevenir lesiones graves (incluso la muerte del niño), aliviará a las víctimas de tener que buscar ayuda por su propia cuenta, y potenciará la coordinación entre las respuestas legales, médicas y sociales. Entre los profesionales sanitaristas con esta obligación se encuentran los odontólogos, quienes se han visto firmemente comprometidos a nivel mundial en la detección, denuncia y la prevención del abuso sexual a partir de la asumida y demostrada presencia de lesiones en boca. Sin embargo, y aunque la legislación vigente manifiesta esta obligación de denuncia, los odontólogos en Chile aparentan no estar preparados ni conceptual ni técnicamente para asumir esta responsabilidad, con lo que este tipo de prueba jurídica se encuentra subvalorada, abordada mínimamente por otras disciplinas no idóneas para tal efecto y virtualmente desconocida en los medios judiciales. En resumidas cuentas, una "oportunidad perdida" en un escenario donde las profundas miradas críticas y el severo juicio social obligan a afinar la mirada y ajustar la totalidad de las herramientas disponibles para lograr suficiencia de la prueba.

ABSTRACT: Mandatory reporting represents the key strategy in child sexual abuse cases. It is based on the assumption that early detection will help prevent serious injuries (even the death of the child), will alleviate victims from the responsibility of asking for help themselves, and at their own risk, and will also encourage coordination between legal, medical, and social response units. Among health professionals with a reporting obligation are odontologists. Worldwide, dentists have actively committed to take part in the detection, reporting and prevention of child sexual abuse from presumed and proven lesions in the mouth. However, although current legislation explicitly states this mandatory reporting, it appears that Chilean dentists are neither conceptually nor technically prepared to take on this responsibility. Hence, this type of forensic legal evidence is undervalued, inadequately addressed within other medical professions, and practically unknown in the judicial system. In summary, this is a "missed opportunity" in circumstances that warrant serious scrutiny, resulting in severe social judgment and criticism. A complete review and regulation of the guidelines in this area must be carried out in order to use all means available, and apply legal measures to provide the necessary proof in these cases.

Suspicious scars: physical child abuse vs Ehlers-Danlos syndrome

Child abuse is a sensitive topic among many medical practitioners and the diagnosis of this entity requires awareness about conditions which can mimic physical child abuse. Here, the authors present a case of a 13-year-old school non-attendee who was referred due to multiple scars, over areas prone to accidental as well as non-accidental injury, who underwent medicolegal examination due to suspicion of physical child abuse. On further inquiry, it was discovered that she had easy bruising and poor wound healing. A diagnosis of Ehlers-Danlos syndrome was established and physical child abuse was excluded. This case emphasizes the importance of identifying conditions which may confound the diagnosis of physical child abuse. This is of utmost importance in avoiding adverse legal and psycho-social implications on the child, family and society.

Teoría de rango medio de enfermería para la adaptación de un menor ante discriminación y violencia familiar / Nursing theory of average range to for the adaptation of a minor to discrimination and family violence

El presente artículo desarrolla el proceso de valoración de enfermería en la práctica comunitaria y el análisis de una situación de enfermería en el proceso de adaptación de un menor ante discriminación y violencia familiar. El análisis se realizó desde la teoría de rango medio (TRM) de Afrontamiento de Roy, y se operacionalizó con el proceso de enfermería mostrando que es autónomo, fundamentado y dinámico, ubicada en una visión de mundo integrativa/interactiva; utilizando, además, los patrones de conocimiento de enfermería: empírico, estético, personal y ético. Se expone unas intervenciones y resultados que buscaron mediar el uso de las taxonomías del lenguaje estandarizados, con la meta desde un planteamiento teórico. Se concluye que es fundamental el uso de una TRM en la práctica tanto clínica como comunitaria, que conduzca y guíe la formación del profesional y la forma como se brinda cuidado. Adicionalmente se logra proponer un proceso de enfermería articulado y coherente con la teoría seleccionada, haciendo del presente análisis una estrategia novedosa de gran utilidad para la comprensión e intervención en la práctica, teniendo en cuenta que se parte de un contexto que involucra escuela, familia, hogar y persona que, al recolectar la información de la mayoría los participantes del proceso, se permite comprender y llevar a cabo las intervenciones.

This article develops the process of nursing assessment in community practice and the analysis of a nursing situation in the process of adaptation of a child in the face of discrimination and family violence. The analysis was made from Roy's Coping Medium Range Theory (TRM), and it was operationalized with the nursing process showing that it is autonomous, grounded and dynamic, located in an integrative / interactive world view; using, in addition, nursing knowledge patterns: empirical, aesthetic, personal and ethical. Some interventions and results are presented that sought to mediate the use of standardized language taxonomies, with the goal from a theoretical approach. It is concluded that the use of a MRS in clinical and community practice is fundamental, that it guides and guides the professional training and the way care is provided. Additionally, a nursing process articulated and coherent with the selected theory is proposed, making the present analysis a novel strategy of great utility for understanding and intervention in practice, taking into account that it starts from a context that involves school, family, home and person who, by collecting the information of the majority of the participants of the process, is allowed to understand and carry out the interventions.

Munchausen syndrome and Munchausen syndrome by proxy: a narrative review / Síndrome de Munchausen e síndrome de Munchausen por procuração: uma revisão narrativa

ABSTRACT The Munchausen syndrome and Munchausen syndrome by proxy are factitious disorders characterized by fabrication or induction of signs or symptoms of a disease, as well as alteration of laboratory tests. People with this syndrome pretend that they are sick and tend to seek treatment, without secondary gains, at different care facilities. Both syndromes are well-recognized conditions described in the literature since 1951. They are frequently observed by health teams in clinics, hospital wards and emergency rooms. We performed a narrative, nonsystematic review of the literature, including case reports, case series, and review articles indexed in MEDLINE/PubMed from 1951 to 2015. Each study was reviewed by two psychiatry specialists, who selected, by consensus, the studies to be included in the review. Although Munchausen syndrome was first described more than 60 years ago, most of studies in the literature about it are case reports and literature reviews. Literature lacks more consistent studies about this syndrome epidemiology, therapeutic management and prognosis. Undoubtedly, these conditions generate high costs and unnecessary procedures in health care facilities, and their underdiagnose might be for lack of health professional's knowledge about them, and to the high incidence of countertransference to these patients and to others, who are exposed to high morbidity and mortality, is due to symptoms imposed on self or on others.

RESUMO A síndrome de Munchausen e a síndrome de Munchausen por procuração são condições caracterizadas pela invenção ou pela produção intencional de sinais ou sintomas de doenças, bem como alterações de exames laboratoriais. Indivíduos com esta síndrome fingem que estão doentes e tendem a procurar tratamento, sem ganho secundário, em diferentes serviços de saúde. Ambas as síndromes são condições bem descritas na literatura desde 1951. Elas são frequentemente observadas pelas equipes de saúde em clínicas, enfermarias hospitalares e prontos-socorros. Conduziu-se revisão narrativa, não sistemática da literatura, incluindo relatos de caso, séries de relatos de caso, artigos de revisão indexados no MEDLINE/PubMed de 1951 a 2015. Cada estudo foi revisado por dois especialistas em psiquiatria que, por meio de consenso, escolheram quais estudos seriam incluídos nesta revisão. Apesar da síndrome de Munchausen ter sido descrita pela primeira vez há mais de 60 anos, a maioria dos estudos conduzidos sobre esta condição são relatos de caso e revisões da literatura. A literatura é carente de estudos mais consistentes sobre epidemiologia, manejo terapêutico e prognóstico da síndrome. Sem dúvida, tais condições geram altos custos e procedimentos desnecessários nos serviços de saúde. Seu subdiagnóstico pode se dar pela falta de conhecimento das síndromes por parte dos profissionais de saúde, e à alta incidência de contratransferência aos pacientes e a outros que são expostos à alta morbidade e à mortalidade é justificada pelos sintomas impostos em si mesmo ou em terceiros.

Protocolo de atención en salud integral de niñas y niños en situación de maltrato infantil / Comprehensive health care protocol for girls and boys in situations of child abuse

A partir de la premisa, que el maltrato infantil se está convirtiendo en un problema cada vez más serio a nivel nacional, situación que es avalada por la Organización Panamericana de la Salud (OPS) que considera que la violencia y sus diferentes manifestaciones son un problema que afectan a la salud y al desarrollo social y económico de amplios sectores de la población. Este protocolo considera que es importante que los proveedores de salud desarrollen habilidades y competencias que ayuden a detectar los casos de niños maltratados, así como conocer las mejores estrategias de intervención. El objetivo de este protocolo es proponer una herramienta que proporcione los elementos básicos a proveedores y proveedoras de salud para brindar atención de calidad en salud integral y realizar la notificación oportuna de los casos de maltrato infantil. Para ello han seleccionado un modelo basado en el triage del AIEPI (Atención Integral a las Enfermedades Prevalentes de la Infancia). Es una estrategia elaborada por la Organización Mundial de la Salud (OMS) y el Fondo de las Naciones Unidas para la Infancia (Unicef) presentada en 1996 como principal método para mejorar la salud en la niñez. La metodología del modelo se lleva a cabo por medio de tres componentes. El primero está dirigido a mejorar el desempeño del personal de salud para la prevención de enfermedades en la niñez y su tratamiento. El segundo se dirige a mejorar la organización y funcionamiento de los servicios de salud para que brinden atención de calidad apropiada; y el tercer componente está dirigido a mejorar las prácticas familiares y comunitarias de cuidado y atención de la niñez. Contiene un marco teórico, marco legal, así como una serie de anexos dirigidos a apoyar tanto el diagnóstico, como el seguimiento dado a las víctimas.

Conocimientos sobre maltrato infantil en adolescentes maltratados y padres o tutores / Knowledge on child maltreatment in maltreated adolescents and in parents or tutors

Introducción: el maltrato infantil es un problema universal y multicausal que involucra factores biopsicosociales, en el que intervienen las características del agresor, el agredido, el medio ambiente y otras, no siempre bien reconocidas.Objetivo: evaluar los conocimientos sobre maltrato infantil en adolescentes ingresados por lesiones, o circunstancias que hicieron sospechar presencia de maltrato infantil, y que después se confirmó, así como en sus padres y/o tutores legales.Métodos: estudio descriptivo transversal, en 50 adolescentes ingresados por lesiones o circunstancias que hicieron sospechar presencia de maltrato infantil, y que después se confirmó durante su estancia en los servicios del Hospital Pediátrico Juan Manuel Márquez, durante el período comprendido de octubre de 2013 a octubre de 2014. Se les aplicó encuesta confeccionada al efecto. Los datos fueron incluidos en una base de datos automatizada con la hoja de cálculo electrónica Excel 2003, resumidos y representados en tablas estadísticas, y expresados textualmente. Se utilizó la estadística descriptiva. Resultados: el 90 y 92 por ciento de los adolescentes y padres respectivamente no tenían conocimientos sobre el maltrato infantil. Los tipos de maltratos infantiles identificados fueron: el psicológico en 36 por ciento, la negligencia en 22 por ciento y el físico en 20 por ciento. El 78 por ciento de los adolescentes y el 84 por ciento de los padres no tenían percepción del maltrato recibido o impartido.Conclusiones: existe insuficiente conocimiento del maltrato infantil en los adolescentes, y sus padres o tutores((AU)

Introduction: child maltreatment is a universal multi-cause problem involving biopsychosocial factors that comprise the agressor's and the victim's characteristics, the environment and others not well-accepted causes. Objective: to evaluate the knowledge on child maltreatment in adolescents admitted to hospital on account of injures or circumstances that may arouse suspicions of child maltreatment as well as in their fathers and/or legal tutors. Methods: descriptive and cross-sectional study of 50 adolescents who were hospitalized because of injuries or circumstances that aroused suspicions of maltreatment, which were later confirmed in their stay at Juan Manuel Marquez pediatric hospital from October 2013 to October 2014. They were surveyed and the collected data were entered into a database with Excel 2003, summarized and represented in statistical tables and expressed in the text. Summary statistics was used. Results: ninety percent of adolescents and 92 percent of parents did not have any knowledge about child maltreatment. The identified types of child maltreatment were psychological in 36 percent of cases, negligence in 22 percent and physical in 20 percent. Seventy and eight percent of adolescents and 84 percent of parents did not have any perception of the maltreatment given or received(AU)

Childhood trauma and dimensions of depression: a specific association with the cognitive domain

Objective: To investigate associations between a history of childhood trauma and dimensions of depression in a sample of clinically depressed patients. Methods: A sample of 217 patients from a mood-disorder outpatient unit was investigated with the Beck Depression Inventory, the Hamilton Depression Rating Scale, the CORE Assessment of Psychomotor Change, and the Childhood Trauma Questionnaire. A previous latent model identifying six depressive dimensions was used for analysis. Path analysis and Multiple Indicators Multiple Causes (MIMIC) models were used to investigate associations between general childhood trauma and childhood maltreatment modalities (emotional, sexual, and physical abuse; emotional and physical neglect) with dimensions of depression (sexual, cognition, insomnia, appetite, non-interactiveness/retardation, and agitation). Results: The overall childhood trauma index was uniquely associated with cognitive aspects of depression, but not with any other depressive dimension. An investigation of childhood maltreatment modalities revealed that emotional abuse was consistently associated with depression severity in the cognitive dimension. Conclusion: Childhood trauma, and specifically emotional abuse, could be significant risk factors for the subsequent development of cognitive symptoms of major depression. These influences might be specific to this depressive dimension and not found in any other dimension, which might have conceptual and therapeutic implications for clinicians and researchers alike.

Measuring child maltreatment using multi-informant survey data: a higher-order confirmatory factor analysis / Dados de levantamento com múltiplos informantes para a mensuração de maus-tratos na infância: uma análise fatorial confirmatória de segunda ordem

Objective To investigate the validity and reliability of a multi-informant approach to measuring child maltreatment (CM) comprising seven questions assessing CM administered to children and their parents in a large community sample. Methods Our sample comprised 2,512 children aged 6 to 12 years and their parents. Child maltreatment (CM) was assessed with three questions answered by the children and four answered by their parents, covering physical abuse, physical neglect, emotional abuse and sexual abuse. Confirmatory factor analysis was used to compare the fit indices of different models. Convergent and divergent validity were tested using parent-report and teacher-report scores on the Strengths and Difficulties Questionnaire. Discriminant validity was investigated using the Development and Well-Being Assessment to divide subjects into five diagnostic groups: typically developing controls (n = 1,880), fear disorders (n = 108), distress disorders (n = 76), attention deficit hyperactivity disorder (n = 143) and oppositional defiant disorder/conduct disorder (n = 56). Results A higher-order model with one higher-order factor (child maltreatment) encompassing two lower-order factors (child report and parent report) exhibited the best fit to the data and this model's reliability results were acceptable. As expected, child maltreatment was positively associated with measures of psychopathology and negatively associated with prosocial measures. All diagnostic category groups had higher levels of overall child maltreatment than typically developing children. Conclusions We found evidence for the validity and reliability of this brief measure of child maltreatment using data from a large survey combining information from parents and their children.

Objetivo Investigar a validade e confiabilidade de uma abordagem de múltiplos informantes para a mensuração de maus-tratos na infância, composta por sete questões avaliando maus-tratos na infância respondidas pelas crianças e seus pais em uma ampla amostra comunitária. Métodos A amostra foi composta por 2.512 crianças com idades entre 6 e 12 anos e seus pais. Maus-tratos na infância foram avaliados com três questões respondidas pelas crianças e quatro respondidas pelos seus pais, investigando violência física, negligência física, violência emocional e violência sexual. Análises fatoriais confirmatórias foram utilizadas para comparar os índices de ajuste de diferentes modelos. Validade convergente e divergente foi testada utilizando escores de relato parental e de relato dos professores no Strengths and Difficulties Questionnaire. Validade discriminante foi investigada utilizando a entrevista Development and Well-Being Assessment para dividir os participantes em cinco grupos diagnósticos: controles com desenvolvimento típico (n = 1.880), transtornos do medo (n = 108), transtornos do estresse (n = 76), transtorno de déficit de atenção-hiperatividade (n = 143) e transtorno opositivo-desafiador/conduta (n = 56). Resultados Um modelo de segunda ordem com um fator de segunda ordem (maus-tratos na infância) englobando dois fatores de primeira ordem (relato da criança e relato parental) demonstrou o melhor ajuste aos dados, e os resultados de confiabilidade desse modelo foram aceitáveis. Como esperado, maus-tratos na infância estiveram positivamente associados a medidas de psicopatologia e negativamente associados a medidas pró-sociais. Todos os grupos de categorias diagnósticas tiveram níveis mais altos de maus-tratos na infância do que as crianças com desenvolvimento típico. Conclusões Foram encontradas evidências de validade e confiabilidade dessa medida breve de maus-tratos na infância utilizando dados de um grande levantamento combinando o relato de pais e seus filhos.

Cross-cultural adaptation of the Maltreatment and Abuse Chronology of Exposure (MACE) scale to Brazilian Portuguese / Adaptação transcultural da escala Maltreatment and Abuse Chronology of Exposure (MACE) para o português brasileiro

Introduction : There is strong evidence to indicate that childhood maltreatment can negatively affect both physical and mental health and there is increasing interest in understanding the occurrence and consequences of such experiences. While several tools have been developed to retrospectively investigate childhood maltreatment experiences, most of them do not investigate the experience of witnessing family violence during childhood or bullying exposure. Moreover, the majority of scales do not identify when these experiences may have occurred, who was involved or the feelings evoked, such as helplessness or terror. The Maltreatment and Abuse Chronology of Exposure (MACE) scale was developed to overcome these limitations. Objective : In view of the improvements over previous self-report instruments that this new tool offers and of the small number of self-report questionnaires for childhood maltreatment assessment available in Brazil, this study was conducted to conduct cross-cultural adaptation of the MACE scale for Brazilian Portuguese. Method : The following steps were performed: translation, back-translation, committee review for semantic and conceptual evaluation, and acceptability trial for equivalence. Results : Semantic and structural changes were made to the interview to adapt it for the Brazilian culture and all 75 of the items that comprise the longer version of MACE were translated. The results of the acceptability trial suggest that the items are comprehensible. Conclusion : The MACE scales may be useful tools for investigation of childhood maltreatment and make a valuable contribution to research in Brazil. Future studies should consider testing the availability and reliability of the three versions of the instrument translated into Brazilian Portuguese.

Introdução : Há evidências robustas na literatura indicando que os maus-tratos na infância podem afetar negativamente a saúde física e mental. Além disso, há um crescente interesse em compreender a ocorrência e as consequências dessas experiências. Vários instrumentos vêm sendo desenvolvidos para investigar retrospectivamente experiências de maus-tratos na infância, mas a maioria deles não investiga a experiência de testemunhar violência familiar durante a infância ou a ocorrência de bullying . Além disso, a maioria não identifica quando as experiências ocorreram, quem estava envolvido ou os sentimentos que evocaram, como desespero ou terror. A escala Maltreatment and Abuse Chronology of Exposure (MACE) foi desenvolvida para superar essas limitações. Objetivos : Considerando as vantagens dessa nova escala em relação aos instrumentos de autorrelato existentes e o reduzido número de questionários de autorrelato disponíveis no Brasil para avaliar maus-tratos na infância, este estudo teve como objetivo conduzir a adaptação transcultural da escala MACE para o português brasileiro. Método : Foram realizadas as etapas de tradução, retrotradução, análise de equivalência semântica e correspondência conceitual por um comitê avaliador e teste de aceitabilidade. Resultados : Adaptações semânticas e estruturais foram realizadas na entrevista para a realidade cultural brasileira, e todos os 75 itens incluídos na versão estendida da MACE foram traduzidos. Os resultados do teste de aceitabilidade sugerem que os itens foram adequadamente compreendidos. Conclusões : A escala MACE é uma ferramenta útil para a investigação de maus-tratos na infância, contribuindo para a pesquisa no Brasil. Futuros estudos devem considerar testar a validade e fidedignidade das três versões do instrumento traduzidas para o português do Brasil.

Co-occurrence of communication disorder and psychiatric disorders in maltreated children and adolescents: relationship with global functioning

Objective: To study the co-occurrence of psychiatric disorders (PD) and communication disorders (CD) and their relationship with global functioning in maltreated children and adolescents. Methods: The sample comprised 143 maltreated children and adolescents (55.8% male). All underwent clinical communication and psychiatric evaluations, as well as global functioning assessment using the Children’s Global Assessment Scale (C-GAS). Results: Four groups emerged from evaluation: Group 1 (n=7, 4.9%) did not exhibit any disorders; Group 2 (n=26, 18.2%) exhibited PD; Group 3 (n=34, 23.8%) exhibited CD; and Group 4 (n=76, 53.1%) exhibited both PD and CD on evaluation. Significant differences in global functioning scores were found between G1 and G2, G1 and G4, G2 and G4, and G3 and G4, with the highest C-GAS scores found in G1 and the lowest in G4. Conclusion: Rates of PD and CD are high in this maltreated population. The presence of PD has a major impact on C-GAS score, and the simultaneous presence of CD increases the already impaired function of PD. Demonstration of the additive effects of PD and CD on youth functioning suggests that professionals should be alert to the presence of both disorders to better act preventively and therapeutically in a high-risk population.