Crescer sem violência: um desafio para educadores / Growing up without violence: a challenge for educators

Este trabalho é um dos frutos da pesquisa "Violência, Criança e Comportamento" realizada por Simone Gonçalves de Assis, no CLAVES-Jorge Careli, da Escola Nacional de Saúde Pública, da Fundaçao Oswaldo Cruz. Trata-se de um estudo sócio-epidemiológico, visando conhecer a magnitude do proble da violência doméstica em escolares e o impacto da violência no comportamento infanto-juvenil. Pela relevancia do tema, a pesquisa mereceu o apoio financeiro da Organiçäcao Pan-Americana de Saúde. Realizado no município de Duque de Caxias, o estudo abrangeu 2.125 escolares de estabelecimentos públicos e particulares

Briquet's syndrome, dissociation, and abuse.

OBJECTIVE: To help clarify the complex association between childhood abuse and adult psychopathology, the authors examined the relationship among abuse, Briquet's syndrome (somatization disorder), and dissociative symptoms. METHOD: Ninety-nine female psychiatric clinic outpatients with a history of somatic complaints were assessed for Briquet's syndrome, dissociative symptoms, adult and childhood sexual abuse, childhood physical abuse, and childhood emotional abuse. RESULTS: Women with high dissociation scores and many somatic symptoms were more likely to report abuse than were subjects with low dissociation scores or with few somatic complaints. CONCLUSIONS: Briquet's syndrome, dissociation, and abuse are significantly associated. Awareness of this association may have a significant effect on the treatment of psychiatric patients.

Domestic violence victims in a hospital emergency department.

OBJECTIVE: To determine the prevalence and predictors of domestic violence victims among attenders at the emergency department at Royal Brisbane Hospital in 1991. DESIGN: Cross-sectional study in which randomly selected nursing shifts were used to screen attenders. RESULTS: Of all attenders at the emergency department, 14.1% disclosed a history of domestic violence. Women were more likely than men to disclose domestic violence ("raw" relative risk, 2.31; 95% confidence interval [CI], 1.83-2.91; relative risk adjusted for age and history of child abuse, 4.50; 95% CI, 3.02-6.71). The greatest risks for being an adult victim of domestic violence were being female and having experienced abuse as a child. Most of those who had experienced domestic violence within the last 24 hours (1.1% of attenders) came to the department after-hours when social work staff were unavailable for referral. CONCLUSIONS: The prevalence and risk factors have implications for the training of doctors and nurses in domestic violence problems and for the provision of adequate resources to deal with the psychosocial aspects of domestic violence.

Inflicted versus accidental head injury in critically injured children.

OBJECTIVES: To assess the frequency of inflicted head injury in critically injured children; the severity of neurologic injury; the neurologic outcome; and the historical, socioeconomic, physical, and radiologic factors associated with inflicted head injury. DESIGN: Prospective clinical study. SETTING: Multidisciplinary pediatric intensive care unit (ICU). PATIENTS: Consecutive cases (n = 40) of severe head injury admitted to a pediatric ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fourteen (35%) of 40 cases of head injury were due to inflicted head injury. Eleven (79%) of 14 inflicted head injury cases were due to child abuse and three (21%) were due to neglect. The severity of neurologic injury, as measured by the admission Glasgow Coma Scale, was worse in cases of inflicted head injury (7.1 +/- 0.7 [SE] [inflicted] vs. 9.9 +/- 0.8 [accidental]; p = .04). Glasgow Outcome Scores were worse after inflicted head injury (2 +/- 1 inflicted] vs. 4 +/- 1 [accidental]; p = .004). In victims of child abuse, we found the combination of any two of the following three factors was associated with inflicted head injury: an inconsistent history/physical examination; retinal hemorrhages; or parental risk factors (alcohol or drug abuse, previous social service intervention within the family, or a past history of child abuse or neglect). CONCLUSIONS: This study confirms that severity of neurologic injury and neurologic outcome in cases of inflicted head injury are worse than in any other type of childhood head injury. We believe that a combination of any two of the above three risk factors may prove to be a reliable marker of inflicted head injury in children admitted to a pediatric ICU and will lead to an early and definitive diagnosis.

Intergenerational transmission of child abuse: rates, research, and clinical implications.

OBJECTIVE: The author reviews current wisdom concerning the rates and mechanisms of intrafamilial components of intergenerational transmission of child abuse and illustrates the unreliability of basic data and of assumptions made by reviewers and partisan advocates, most of whom underestimate the importance of intrafamilial factors in child abuse. METHOD: The information in the report was derived from original research plus a recently prepared compilation of 60 studies, mainly from the United States and the United Kingdom. RESULTS: The crude rates of intergenerational transmission of child abuse according to the studies reviewed are as follows: one-third of child victims grow up to continue a pattern of seriously inept, neglectful, or abusive rearing as parents. One-third do not. The other one-third remain vulnerable to the effects of social stress on the likelihood of their becoming abusive parents. Intrafamilial factors appear to be the cause of personally directed, as opposed to culturally condoned, child abuse. Broad social factors, and some medical and psychiatric conditions, lower or raise thresholds in which family and personal vulnerabilities and propensities operate. CONCLUSIONS: There is no justification for any extremist advocacy in apportioning responsibility between the "sins of the parents" and the failings of society. The contention that clinical research on abuse is inferior to, and must give way to, large-scale or statistically balanced self-report and questionnaire surveys is plausible, popular, convincing, and wrong.

[Child abuse: a disturbing problem]. / Maltrato infantil: un problema inquietante.

This current information on "battered child syndrome" (BCS) was obtained during 1990 from nine institutions in Tijuana, Baja California; 549 cases of BCS were studied, of which 338 were female, 203 male, eight of indeterminate sex due to loss documentation. Child abuse was manifested in all its forms: beatings, sexual abuse, neglect, and affective indifference. The victim's and perpetrator's characters were analyzed together with other factors which had to be taken into consideration in order to detect results which were similarly described in the literature. It is of utmost importance to alert all medical staff to this terrible social problem for the complete treatment of the affected child and the family environment. Community support, and legislation to adequately cover rights of minors and their protection are imperative to elimination of the battered child syndrome.

Dissociative symptoms in a substance abuse population.

OBJECTIVE: This study was intended to examine the extent of dissociative experiences that exist within a substance abuse population and to determine how demographic and clinical variables affect these experiences. METHOD: A total of 265 male veterans being treated on an inpatient substance abuse unit completed a standard test battery that included the MMPI-2, the Shipley-Hartford Institute of Living Scale, and the Dissociative Experiences Scale. Additional demographic and clinical information was obtained from the patients' medical records. RESULTS: Over 41% of the cohort had scores on the Dissociative Experiences Scale that suggested the need for further evaluation of a dissociative disorder. A stepwise multiple regression analysis revealed that level of psychological discomfort, IQ, and race accounted for more than 24% of the variance in Dissociative Experiences Scale scores. CONCLUSIONS: Substance abuse populations may need to be routinely screened for dissociative symptoms just as they are for depression and anxiety.

Correlates of dissociative symptomatology in patients with physical and sexual abuse histories.

Recent studies have demonstrated a high prevalence of sexual and physical abuse histories and high levels of dissociative symptoms in psychiatric inpatients. We examined whether severity, frequency, and age of onset of abuse correlated with subjects' levels of dissociative symptoms. Sixty-four women reporting a lifetime history of physical and/or sexual abuse were recruited from consecutive admissions to three wards of a psychiatric hospital. Subjects completed the Life Experiences Questionnaire (LEQ) and the Dissociative Experiences Scale (DES). Subjects' self-reports of severity, frequency, and age of onset of abuse were analyzed for correlations with DES score. More invasive sexual abuse was associated with more dissociation. Higher-frequency physical abuse was associated with more dissociation, but no conclusion could be drawn about the impact of frequent sexual abuse due to missing data. An inverse correlation was found between age of onset of abuse and degree of dissociative symptomatology. These preliminary findings are consistent with hypotheses linking more severe, more chronic, and earlier abuse to the greater development of dissociative symptoms. The findings further emphasize the importance of recognizing dissociative symptoms in the clinical setting, and of continued study into the effects of childhood trauma.

Association between borderline personality structure and history of childhood abuse in adult volunteers.

Childhood abuse has been implicated as a leading factor in the development of borderline personality disorder (BPD). Data in this report, drawn from an ongoing study of the therapeutic effect of fluoxetine in BPD patients, were gathered in an attempt to replicate previous findings indicating a history of physical abuse in 71% and sexual abuse in 67% of adult BPD subjects. Thirty-one subjects for a study of the pharmacological treatment of BPD or BPD traits met criteria for the study. Those who had been previously hospitalized for a psychiatric disorder, who had recently been suicidal, or who had recent histories of self-mutilation were excluded. Specific information about childhood abuse was gathered using questions from a previous study of abuse histories in BPD patients. All subjects were then interviewed in greater depth regarding past experiences of abuse as part of the ongoing study of the relationship of childhood attachment experience and adult psychopathology. Six of 31 subjects (19.4%) reported a definite history of childhood physical and/or sexual abuse. Four of these subjects met criteria for full BPD, and two met criteria for BPD traits. Three of 31 subjects reported a history of physical abuse (9.7%); five reported a history of sexual abuse (16.1%). Two of the six who reported abuse reported both physical and sexual abuse. A history of childhood abuse is not necessarily linked to the development of BPD or BPD traits in all individuals. The following hypothesis is suggested: BPD may represent a spectrum of symptomatic severity.(ABSTRACT TRUNCATED AT 250 WORDS)

Racial inequality and child neglect: findings in a metropolitan area.

Despite contradictory evidence, child neglect is often believed to occur more frequently in the African American than in the Caucasian population. This article reports findings on the racial differences among 182 families referred for neglect in a large metropolitan area. Although almost all of the families were poor, African American families in the neglect sample suffered even more from economic inequality than those in the general population. Implications of the findings for social welfare policy and child welfare practice are discussed.

Psychological child maltreatment. A developmental view.

This article explores the concept of psychological child maltreatment. It begins with a definition of psychological maltreatment in terms of care-giver behavior that thwarts the meeting of the needs of children. It focuses on five forms of psychological maltreatment that are of concern to the practitioner: rejecting (sending messages of rejection to the child), ignoring (being psychologically unavailable to the child), terrorizing (using intense fear as a weapon against the child), isolating (cutting the child off from normal social relationships), and corrupting (missocializing the child into self-destructive and antisocial patterns of behavior).

Child physical abuse.

Child abuse is an age-old problem for which we have had documentary records for as long as we have had recorded history. This article reviews the ethical dilemmas, diagnosis, interviewing guidelines, physical examination, and treatment for child physical abuse. Also discussed are unusual manifestations and differential diagnosis.

Community responses to violence.

Community level efforts are effective in the reduction of violence. Community-level interventions have three goals: to prevent the escalation of risk for violence among the families in the community, to assist families at risk of or using violence, and to protect victims of abuse. To prevent violence or reduce its prevalence, community groups need to collaborate to reduce the community-level risk factors. Assisting families and protecting victims of violence requires coordination of community services, including law enforcement, schools, therapists, courts, child care, and social services. All of these goals can best be achieved through the efforts of a community level, multidisciplinary council or board that directs the programs. A community process to establish an integrated program involves several steps. The leaders that are identified need to represent all the disciplines and the entire geographic area involved in the project. Once the leaders start meeting, the baseline information and plan can be developed. Then the project itself can be undertaken, with the support of the media and other appropriate organizations. Several examples of effective projects document this process and its success; the best efforts involve coalitions of private and governmental agencies working together. Physicians are integral to this process. The practice of medicine provides opportunities every day to prevent and intervene in potential cases of abuse and violence. Also, by participating actively in the community, physicians can be effective leaders to change attitudes and behaviors and institute programs toward reducing violence.

Children of people with somatization disorder.

OBJECTIVE: The author investigated psychopathology, suicidal behavior, child abuse, somatization, and health care utilization in 34 children with a parent who has somatization disorder (SD-P) and two comparison groups: 41 children with a somatizing parent (SOM) (fewer symptoms than required for diagnosis of SD-P), and 30 pediatrically ill controls (CON). METHOD: Child and parent versions of the Diagnostic Interview for Children and Adolescents were scored for diagnosis and symptom counts in specified categories. Medical records were obtained and abstracted. RESULTS: Children of SD-P had significantly more psychiatric disorders and suicide attempts than did children of SOM or the CON. SD-P and CON had significantly more unexplained physical symptoms than SOM. SD-P showed a trend toward more hospitalizations and experienced significantly more maltreatment. CONCLUSIONS: Children of SD-P are at significant risk in several respects. Clinical implications of these findings include a need for awareness and cooperation among general psychiatrists, primary care physicians, and child and adolescent psychiatrists to facilitate detection and treatment of these children's problems.

Reporting of child maltreatment: a secondary analysis of the National Incidence Surveys.

Reports to CPS agencies of child maltreatment cases come from a variety of community sources. Which kinds of cases are underreported, overreported, or not reported at all, and why? We address these questions by examining the discrepancies between cases known to CPS agencies and those known to professionals who regularly come into contact with children: teachers, hospital personnel, law enforcement officers, court personnel, and social service workers. The analysis is based on the 1980 and 1986 National Study of the Incidence and Prevalence of Child Abuse and Neglect. Our research yielded three major findings. First, older victims were less likely than younger victims to be known to CPS agencies. Second, there is a hierarchy of type of abuse reported to CPS agencies, with sexual abuse being at the top of the list and educational neglect at the bottom of the list. Third, the victims' race, sex, and income did not play a role in whether or not a case was reported to CPS agencies.

A prospective study of secondary prevention of child maltreatment.

This study sought (1) to retest an approach to the prediction of risk of child maltreatment and (2) to test the effect of a comprehensive prenatal and pediatric health services program on the rate of maltreatment. Of 2585 women screened at their first prenatal visit, 1154 qualified for the study. Risk assignment was determined by a structured interview. High-risk women (n = 314) were assigned to receive standard (high-risk control group; n = 154) or intervention (high-risk intervention group; n = 160) services throughout the prenatal period and during the first 2 years of their infants' life. A third group (low-risk control group; n = 295) was selected among low-risk women and received standard care without intervention services. State records were searched for substantive reports of child maltreatment up to 36 months after birth. Physical abuse was found for 5.1% of the study population; neglect was substantiated for 5.9%. Prediction efforts were effective in identifying risk of physical abuse but not of neglect. Comprehensive health services did not alter the reported abuse rate for high-risk parents and was associated with an increased number of neglect reports. Intervention reduced subject attrition and appeared to serve as a bias for detection of maltreatment. Thus this long-term, prospective approach was ineffective for child abuse prevention, perhaps because of detection biases and societal changes.