Influence of psychosocial risk factors on the trajectory of mental health problems from childhood to adolescence: a longitudinal study

Background: Longitudinal epidemiological studies involving child/adolescent mental health problems are scarce in developing countries, particularly in regions characterized by adverse living conditions. We examined the influence of psychosocial factors on the trajectory of child/adolescent mental health problems (CAMHP) over time.Methods: A population-based sample of 6- to 13-year-olds with CAMHP was followed-up from 2002-2003 (Time 1/T1) to 2007-2008 (Time 2/T2), with 86 out of 124 eligible children/adolescents at T1 being reassessed at T2 (sample loss: 30.6%). Outcome: CAMHP at T2 according to the Child Behavior Checklist/CBCL's total problem scale. Psychosocial factors: T1 variables (child/adolescent's age, family socioeconomic status); trajectory of variables from T1 to T2 (child/adolescent exposure to severe physical punishment, mother exposure to severe physical marital violence, maternal anxiety/depression); and T2 variables (maternal education, child/adolescent's social support and pro-social activities).Results: Multivariate analysis identified two risk factors for child/adolescent MHP at T2: aggravation of child/adolescent physical punishment and aggravation of maternal anxiety/depression.Conclusions: the current study shows the importance of considering child/adolescent physical punishment and maternal anxiety/depression in intervention models and mental health care policies.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Mackpesquisa of the Mackenzie Presbyterian UniversityUniv São Paulo, Sch Med, Inst Psychiat, São Paulo, BrazilUniversidade Federal de São Paulo, Social Psychiat Div, São Paulo, BrazilUniv Prebiteriana Mackenzie, Dev Disorder Post Grad Program, São Paulo, BrazilUniversidade Federal de São Paulo, Social Psychiat Div, São Paulo, BrazilFAPESP: 00/14555-4Web of Scienc

Use of mental health services by children with mental disorders in two major cities in Brazil

Objective: The study examined lifetime use of mental health services among children diagnosed as having mental disorders in two major cities in Brazil and identified characteristics associated with unmet need. Methods: The data were collected as part of the High Risk Cohort Study, a community study conducted in Sao Paulo and Porto Alegre, Brazil. During the period from 2010 to 2011, a total of 2,511 children ages 6 to 12 were assessed, and 652 were given a diagnosis of at least one mental disorder. The current study analyzed data for a subsample of 651 children with complete information on use of mental health services. Results: Eighty-one percent of the children with mental disorders had not received mental health treatment in the past. The majority who received treatment were treated with psychotherapy or a combination of psychotherapy and medication. Mixed-race children were significantly more likely to have unmet need for treatment, compared with white children. Conclusions: The high rate of unmet need among children with mental disorders should be addressed with strategies to improve access to health care

Fatores de Risco para Problemas de Saúde Mental na Infância/Adolescência

A cross-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.  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. &nbsp

Influence of psychosocial risk factors on the trajectory of mental health problems from childhood to adolescence: a longitudinal study

Background\ud Longitudinal epidemiological studies involving child/adolescent mental health problems are scarce in developing countries, particularly in regions characterized by adverse living conditions. We examined the influence of psychosocial factors on the trajectory of child/adolescent mental health problems (CAMHP) over time.\ud \ud Methods\ud A population-based sample of 6- to 13-year-olds with CAMHP was followed-up from 2002–2003 (Time 1/T1) to 2007–2008 (Time 2/T2), with 86 out of 124 eligible children/adolescents at T1 being reassessed at T2 (sample loss: 30.6%). Outcome: CAMHP at T2 according to the Child Behavior Checklist/CBCL’s total problem scale. Psychosocial factors: T1 variables (child/adolescent’s age, family socioeconomic status); trajectory of variables from T1 to T2 (child/adolescent exposure to severe physical punishment, mother exposure to severe physical marital violence, maternal anxiety/depression); and T2 variables (maternal education, child/adolescent’s social support and pro-social activities).\ud \ud Results\ud Multivariate analysis identified two risk factors for child/adolescent MHP at T2: aggravation of child/adolescent physical punishment and aggravation of maternal anxiety/depression.\ud \ud Conclusions\ud The current study shows the importance of considering child/adolescent physical punishment and maternal anxiety/depression in intervention models and mental health care policies.We thank all study participants, professionals and employees from the health centre where data were collected, Embu Health Secretariat and Mental Health Coordination, and all research team members of the Brazilian Studies of Abuse in the Family Environment (BrazilSAFE) and it’s Follow-Up Study for the valuable collaboration.The study was financially supported by the São Paulo State Research Foundation (Fundação de Amparo à Pesquisa do Estado de São Paulo/FAPESP – Process no. 00/14555-4) in 2002/2003 and by Mackpesquisa of the Mackenzie Presbyterian University in 2007

Inattention symptoms in early pregnancy predict parenting skills and infant maltreatment during the first year of life

Objective: Maternal attention-deficit/hyperactivity disorder has not been investigated in relation to parenting skills in adolescent mothers. This study investigated whether maternal inattention and hyperactivity/ impulsivity symptoms early in pregnancy predict poorer parenting skills and infant maltreatment during the first year of life in adolescent mothers living in adverse environmental conditions. Methods: The participants in this study were 80 adolescent mothers aged 14-19 years and their babies who were taking part in a randomized controlled trial on the effects of a home-visiting program on infant development. Symptoms of maternal attention-deficit/hyperactivity disorder were assessed in the first trimester of pregnancy. Parenting skills (maternal competence, attachment to the baby, home environment) and child maltreatment were assessed when the infants were aged 6 and 12 months. Multilevel linear regression models were constructed to test the extent to which prenatal maternal inattention and hyperactivity/impulsivity symptoms predicted these parenting variables during the first year of the infant’s life. Results: Prenatal inattention symptoms significantly predicted lower maternal competence and attachment, a poorer home environment, and greater maltreatment during the first year of life. Hyperactivity did not significantly predict parenting skills or maltreatment. Conclusions: Our findings suggest that inattention symptoms may interfere with parenting abilities in adolescent mothers and should be considered in early intervention programs

Childhood mental health problems in primary care

The present population study aimed at identifying the prevalence of mental health problems (MHP) and describing health services use in a sample of children attending Primary Healthcare Units (PHU) in the city of Sao Paulo. Caregivers of 825 6-11 years old children were assessed. MHP were assessed with the Strength and Difficulties Questionnaire and health services use with an adapted version of the Client Receipt Inventory Children`s version. Prevalence of internalizing and externalizing MHP was 30.7% and 18.3%, respectively. Pediatricians were the most consulted health professional (56.7%) and psychologists the most consulted mental health professional (7.9%). Only 3 children were under medication treatment for MHP. The high prevalence of MHP among children in the primary care setting and the low rate of treatment constitute a public health problem. Training programs for health professionals are relevant to help identify and refer MHP cases.O presente estudo populacional de corte transversal teve como objetivo verificar a prevalência de problemas de saúde mental (PSM) e descrever o uso de serviços de saúde numa amostra de crianças atendidas em unidades de saúde (UBS) do município de São Paulo. Responsáveis de 825 crianças de 6-11 anos de idade foram entrevistados. PSM das crianças foram avaliados pelo “Strength and Difficulties Questionnaire” e uso de serviços por uma versão adaptada do “Client Service Receipt Inventory Children’s version”. A prevalência de PSM internalizantes e externalizantes foi de 30,7% e 18,3%, respectivamente. O pediatra foi o profissional de saúde mais consultado (56,7%), o psicólogo foi o profissional da saúde mental mais consultado (7,9%). Apenas 3 crianças estavam em tratamento medicamentoso para PSM. A alta prevalência de PSM em crianças atendidas na AP e o baixo número de atendimentos em serviços configuram um importante problema de saúde pública. Programas de capacitação para profissionais são importantes para aprimorar a identificação e o encaminhamento de casos de PSM

Fatores ambientais relacionados a problemas de saúde mental de crianças e adolescentes de comunidade urbana de baixa renda: um estudo longitudinal

Introdução: o conhecimento científico atual acerca do desenvolvimento dos problemas de saúde mental na infância e adolescência aponta para a necessidade de uma visão direcionada para o desenvolvimento humano, logo estudos epidemiológicos longitudinais são fundamentais. Contudo, no Brasil, estudos dessa natureza ainda são escassos, principalmente em regiões marcadas por condições adversas. Objetivo: (1) investigar a associação de fatores de risco e proteção com os problemas de saúde mental das crianças e adolescentes em um período de cinco anos; (2) descrever o curso longitudinal dos problemas de saúde mental das crianças e adolescentes. Método: Estudo epidemiológico longitudinal prospectivo. Amostra: 93 crianças e adolescentes (11-18 anos) que apresentavam problemas de saúde mental em 2002/2003 e foram reavaliados em 2007. Desfecho clínico: problemas de saúde mental das crianças e adolescentes da amostra na segunda avaliação em 2007 segundo o escore bruto da escala de total de problemas do Child Behavior Checklist (CBCL). Fatores de risco: (1) criança/adolescente: idade da criança/adolescentes em 2002/2003; trajetória da punição física severa (2) mãe: trajetória da violência física contra a mãe da criança/adolescente, trajetória dos problemas de saúde mental e escolaridade em 2002/2003; (3) família: classe social da família em 2002/2003. Fatores de proteção: criança/adolescente: suporte social e prática de atividades pró-sociais. Variável de controle: problemas de saúde mental das crianças e adolescentes em 2002/2003. Instrumentos: desfecho clínico e variável de controle: CBCL; fatores de risco: WordSAFE Core Questionnaire (dados de punição física severa e violência contra a mãe); Self-Report Questionnaire (avaliação de problemas de saúde mental maternos); Questionário de Classificação Econômica Familiar (nível socioeconômico da família); Fatores de proteção: Questionário de Fatores de Proteção (avaliação de fatores de proteção individuais). Análise estatística: correlação de Pearson e teste t para análise univariada e regressão linear múltipla para a análise multivariada. Resultados: a média dos problemas de saúde mental das crianças e adolescentes da amostra apresentou uma diminuição ao longo do tempo; o modelo final de análise multivariada apresentou os seguintes fatores: trajetória da punição física severa e trajetória dos problemas de saúde mental maternos e problemas de saúde mental das crianças e adolescentes em 2002/2003. Discussão: os resultados foram compatíveis com estudos nacionais e internacionais. Conclusões: o conjunto dos dados apresentados pela presente pesquisa, aliados a outros estudos epidemiológicos, formam um arcabouço teórico que permite direcionar estratégias de intervenção, prevenção e promoção de saúde mental baseadas em evidências científicas.Introduction: current scientific knowledge about the onset and development of child and adolescent mental health problems (CAMHP) requires a perspective based on the human development, therefore longitudinal studies are essential. However, studies based on this methodological approach are rare in Brazil, particularly in regions noticeable for adverse conditions. Objective: (1) to examine the association between risk and protective factors related to CAMHP in a period of five years; (1) to describe the longitudinal course of CAMHP. Method: an epidemiological prospective longitudinal study. Sample: 93 children and adolescents (aged 11-18 years) with mental health problems in 2002/2003 that were reassessed in 2007. Clinical outcome: CAMHP in 2007 according to the raw score of the total problems scale of the Child Behavior Checklist. Risk factors: (1) child/adolescent: age in 2002/2003 and trajectory of being victim of severe physical punishment; (2) mother: trajectory of being victim of physical marital violence, trajectory of maternal mental health problems and years of schooling in 2002/2003; (3) family: socioeconomic status. Protective factors: child/adolescent: social support and pro-social activities in 2007. Control variable: child/adolescent mental health problems in 2002/2003. Instruments: clinical outcome and control variable: Child Behavior Checklist; risk factors: WordSAFE Core Questionnaire (child/adolescent trajectory of being victim of severe physical punishment; maternal trajectory of being victim of physical marital violence); Self-Report Questionnaire (trajectory of maternal mental health problems); Questionnaire of family economical classification (family socioeconomic status); protective factors: Protective factors questionnaire (child/adolescent protective factor data). Statistical analyses: Pearson s correlation and Student s t-test for bivariate analyses and multiple linear regression for multivariate analyses. Results: the mean score of CAMHP decreased throughout the study; the best associative model included the following factors: child/adolescent severe physical punishment trajectory, maternal mental health problems trajectory and CAMHP in 2002/2003. Discussion: results were compatible with national and international studies. Conclusions: results of this research combined with other epidemiological studies build up a theoretical framework to guide the implementation of mental health intervention, prevention and promotion programs based of scientific evidence.Fundo Mackenzie de Pesquis

Cost-effective programs of treatment of the childhood with mental disorders and obsessive-compulsive disorder

Os transtornos mentais na infância são prevalentes e causam prejuízo para o indivíduo, família e sociedade. Informações acerca do custo dos transtornos mentais na infância são úteis para o planejamento do sistema de saúde, para auxiliar tomadas de decisão de gestores acerca de investimentos na área e para determinação de prioridades no orçamento público. No entanto, não há dados sobre o custo dos transtornos mentais na infância no Brasil. Já dados sobre o custo dos transtornos mentais na infância em nível subclínico são inexistentes na literatura nacional e internacional. Os objetivos centrais da presente tese de doutorado, dividida em Estudo I e Estudo 11, foram: estimar a média do custo do transtorno mental na infância em níveis subclínico e clínico, e estimar o custo total destes para o Brasil. O Estudo I teve como desfecho clínico qualquer diagnóstico de transtorno mental na infância; o Estudo 11, o transtorno obsessivo- compulsivo na infância (TOC), ambos em nível subclínico e clínico. A presente pesquisa é uma avaliação econômica de custo de doença de transtornos mentais na infância com utilização de método bottom-up retrospectivo. Foi baseada em dados de prevalência de um estudo populacional transversal de 2.512 estudantes de escolas públicas de Porto Alegre e São Paulo, selecionados por meio de duas técnicas: a) seleção aleatória de crianças e b) seleção de crianças com alto fiSCO para desenvolvimento de transtornos mentais (baseado no histórico psiquiátrico familiar). Para avaliação de transtornos mentais na infância, foi utilizado o instrumento Development and Well Being Assesment (DAWBA). Os custos de doença foram estimados a partir dos seguintes componentes: tratamentos em saúde mental (uso de medicamentos, psicoterapia, hospitalização), uso de serviços sociais (assistência social, conselho tutelar, medidas socioeducativas) e problemas escolares (suspensão, abandono e repetência escolar). A amostra final foi de 2.512 crianças, de 6-14 anos de idade. Resultados do Estudo I: o transtorno mental infantil em nível subclínico e clínico teve média de custo total ao longo da vida de $1.750,86 e$3.141,21, respectivamente (todos os valores em PPP, purchasing power parity). O custo nacional estimado do transtorno mental subclínico foi de $9,92 bilhões, enquanto do transtorno mental clínico foi de$11,65 bilhões (baseado nos dados de prevalência do presente estudo). Resultados do Estudo lI: o TOC subclínico e clínico apresentaram médias de custo total ao longo da vida de $1.651,81 e$3.293,38, respectivamente. O custo nacional do TOC subclínico foi de $6,71 bilhões, enquanto do TOC clínico foi de$2,02 bilhões (baseado nos dados de prevalência do presente estudo). Os dados apresentados nesta tese de doutorado fornecem evidências de que transtornos mentais subcltnicos e clínicos na infância têm grande impacto econômico na sociedade. O conhecimento acerca do grande impacto econômico dos transtornos mentais na infância pode informar gestores e políticos sobre a magnitude do problema, de forma que seja possível planejar um sistema efetivo de cuidados com programas de tratamento e prevenção. Recomenda-se que gestores públicos aumentem os recursos para os setores da saúde e educação no Brasil, para promover prevenção e assistência em saúde mental da infânciaChild mental disorders are prevalent and impairing, negatively impacting families and society. lnformation on child mental disorders costs is important to plan the health system and to show policy makers how plan and prioritize budgets. However, there are no child mental disorders cost studies in Brazil. The main objectives of the present thesis were to estimate the mean costs of subthreshold and clinical mental disorders in children living in Brazil and to estimate its national costs. Outcome of Study I was any child mental disorder, outcome of Study II was child obsessive-compulsive disorder (OCD), both subthreshold and clinical. The present study it is cost-of-illness study of child mental disorders using a retrospective bottom-up methods, based on prevalence data from a cross-sectional study of children registered at public schools in Porto Alegre and Sao Paulo. A total of 8,012 families were interviewed, providing information about 9,937 children. From this pool, two subgroups were further investigated using random- selection (n=958) and high-risk group selection procedure (n=I,514), resulting in a total sample of 2,512 subjects 6-14 years old. Mental disorder assessment was made using the Development and Well-Being Assessment (DAWBA). The cost of child mental disorders was estimated from the following components: use of mental health services, social services and school problems. Costs were estimated for each child and the economic impact at the national levei was calculated. Study I results: subthreshold and clinical disorder showed lifetime mean total cost of $1,750.86 and$3,141.21, respectively. The national lifetime cost estimate of clinical mental disorders in Brazil was $11.65 billion, whereas for subthreshold mental disorder it was$19.92 billion (alI values in PPP, purchasing power parity). Study 11: subthreshold and clínical OCD showed lifetime mean total cost of $1,651.81 and$3,293.38, respectively. The national lifetime cost estimate of clinical OCD in Brazil was $2.03 billion, whereas for subthreshold OCD it was$6.71 bilIion. The present study provides evidence about the economic impact of child mental disorders. This knowledge can inform about the magnitude of the problem, so that policy makers can make adjustments to better address these problems with cost-effective programs of treatment and prevention. It is recommended that health and education budgets in Brazil should increase to enhance prevention and treatment of children with childhood mental disorder

Replication of the Hindsight Bias and extension on the role of depressive symptoms

Replicability and reproducibility are essential for scientific credibility, promoted through open science practices. Mental health research often deals with variable and time-changing characteristics, making it challenging to implement these practices, especially in studies of social behavior and cognition. These studies must be investigated through replication-extension models to promote theoretical expansion and generalization. The seminal research by Fischhoff (1975) on hindsight bias is highly relevant, whereas evidence suggests interactions with depressive symptoms. However, few studies have explored such interaction and there are no replications with a Brazilian population. This project aims to conduct a replication of Experiment 2 of the Fischhoff study (1975) in hindsight bias in a Brazilian sample, including an extension to the original research to broaden its scope of clinical relevance in depressive symptoms. This will be a cross-sectional study conducted through a self-completed electronic form on the Qualtrics XM platform in a sample of 240 Brazilians over 18 years. The original material will be adapted to our population through cultural adaptation. Depressive symptoms will be evaluated through the Patient-Reported Outcomes Measurement Information System (PROMIS) Bank v1.0 (PT-BR version). Following the Transparency and Openness Promotion (TOP) Guidelines, the study will be pre-registered on the Open Science Framework (OSF) platform and the Data Management Plan Tool (DMP Tool) was used for data management. Statistical analysis (comparison between groups and mediation) will be conducted using the R software

A Smartphone-Assisted Brief Behavioral Intervention for Pregnant Women with Depression: a Study Protocol of a Randomized Controlled Trial

Background: Pregnancy is strongly associated with increased risk for depression. Approximately 25% of pregnant women develop depression. Treatment for depression during pregnancy has several complexities: the use of psychiatric medications during pregnancy might result in developmental problems in the child and must be used with caution. Psychosocial interventions are effective, but they require specialized professionals. Low- and middle-income countries (LMIC) countries such as Brazil do not have enough mental health professionals needed to meet this demand. In this context, smartphone-based interventions show immense potential. We developed Motherly, a smartphone application (app) designed to treat maternal depression. We aim to test the efficacy of Motherly in addition to brief cognitive-behavioral therapies (CBT) to treat maternal depression. Methods: We will conduct a 2-arm parallel randomized controlled clinical trial in which 70 pregnant women aged between 16-40 years with depression will be randomized to intervention or active control. The intervention group will have access to Motherly, a smartphone app based on three concepts: psychoeducation, behavior monitoring, and gaming elements. Motherly is composed of a package of interventions composed of modules: mental health, sleep, nutrition, physical activity, social support, prenatal/postnatal support, and educational content. The main focus of Motherly is delivering behavioral activation (BA), a brief and structured psychological treatment. The app allows participants to schedule and engage in, and monitor activities according to a plan to avoid acting exclusively according to their mood. The active control group will have access to a simplified version of the app consisting of educational content about various aspects of pregnancy, maternal physical and mental health, and infant development (BA, activity scheduling, sleep hygiene, among other functionalities, will not be present in this version). Both groups will receive four sessions of brief CBT in 8 weeks. Participants will be evaluated by assessors blind to randomization and allocation status. Assessments will occur at baseline (T0), midpoint (T1, week 4-5), posttreatment (T2, week 8), and follow-up (T3, when the child is two months-old). Maternal mental health (prenatal anxiety, psychological well-being, perceived stress, depression, depression severity, and sleep quality), quality of life, physical activity levels, and infant developmental milestones and social/emotional problems will be measured. Our primary outcome is the change in maternal prenatal depression from baseline to posttreatment (8 weeks). Discussion: The potential of digital technology to deliver mental health interventions has been increasingly recognized worldwide. There is a growing literature on interventions using smartphone applications to promote mental health, both with or without the intermediation of a mental health professional. Our study adds to the literature by testing whether an app providing an intervention package, including CBT, psychoeducation, nutrition, physical activity, and social support, can promote maternal and child health and well-being. In particular, we aim to treat depression, for which the use of digital technologies is still scarce. Smartphone applications designed to treat maternal depression are especially relevant because of the potential to circumvent barriers that prevent pregnant women from accessing mental health care