Viabilidade, aceitação e eficácia do tratamento familiar para anorexia nervosa em adolescentes: um estudo observacional no Brasil

OBJECTIVE: There is strong evidence that family-based treatment is effective in cases of adolescent anorexia nervosa. Although family-based treatment has been studied in English-speaking countries, there is a need to examine the generalizability of this approach to non-English speaking cultures. This pilot-study aimed to examine the feasibility, acceptability, and effectiveness of family-based treatment in Brazil. METHOD: Observational study of adolescents with anorexia nervosa (excluding menstrual criteria), as determined with the Diagnostic and Well-Being Assessment, referred for treatment at a specialized center in São Paulo, Brazil. The following data were collected at baseline, at the end of treatment, and after six months of follow-up: weight; height; body mass index; menstrual status; Eating Disorder Examination Questionnaire score; and Children Global Assessment of Functioning Scale score. RESULTS: Of 11 eligible patients/families, 9 (82%) enrolled in the study, and 7 (78%) completed the treatment. The mean patient age was 14.64 ± 1.63 years (range, 12.33-17.00 years). The Wilcoxon signed rank test showed statistically significant improvement in weight and body mass index at the end of treatment, as well as after six months of follow-up, at which point none of the patients met the diagnostic criteria for any eating disorder. CONCLUSION: The results suggest that family-based treatment is acceptable and feasible for Brazilian families. Outcomes suggest that the approach is effective in this cultural context, leading to improvements similar to those reported in previous studies conducted in other cultures.OBJETIVO: Estudos prévios demonstram fortes evidências de eficácia do Tratamento Familiar para anorexia nervosa em adolescentes. Os estudos disponíveis a respeito do tratamento familiar foram conduzidos em países de língua inglesa. É necessário avaliar a aplicabilidade deste método em países de língua não-inglesa. Este estudo piloto tem como objetivo avaliar a viabilidade, a aceitação e a eficácia do tratamento familiar no Brasil. MÉTODO: Estudo observacional de adolescentes com diagnóstico anorexia nervosa (exceto critério amenorréia) segundo o Levantamento sobre Diagnóstico e Bem-Estar de crianças e adolescentes encaminhadas para tratamento em um centro especializado na cidade de São Paulo, Brasil. Dados coletados no início do estudo, ao final do tratamento e seis meses após o término: peso, estatura, índice de massa corporal, menstruações, Questionário de Exame para Transtornos Alimentares e Escala de Funcionamento Global para Crianças. RESULTADOS: Nove de 11 famílias elegíveis entraram no estudo (82%) e sete (78%) completaram o tratamento. A idade média foi 14,64 anos (DP = 1,63; 12,33-17,00). Teste dos sinais de Wilcoxon demonstrou melhora estatisticamente significativa no peso e índice de massa corporal ao final do tratamento e seis meses após o término. Nenhum dos pacientes preencheu critérios diagnósticos para qualquer transtorno alimentar no seguimento. CONCLUSÃO: Os resultados sugerem que tratamento familiar é aceitável e viável para as famílias brasileiras. A evolução sugere que este método pode ser eficaz nesse contexto cultural com resultados positivos semelhantes a estudos prévios realizados em outras culturas

Prácticas agresivas en el aula, influidas por factores socioculturales y su relación con la construcción y desarrollo de la convivencia escolar. Estudio en 21 jóvenes del Grado Octavo de la Institución Educativa Corporación Colegio Bolivariano del Norte de la Ciudad de San José de Cúcuta.

Imágenes.La presente investigación, pretende la indagación de factores socioculturales, que influyen e intervienen directa o indirectamente, para que los jóvenes, manifiesten conductas agresivas en el aula, modificando así la convivencia escolar en el contexto educativo. Dichos factores, se organizan en categorías sociales, como: Familia, Contexto social, Contexto Educativo y Antecedentes personales. Y estos a su vez parten de subcategorías, como la violencia intrafamiliar, abandono paternal, modelos de aprendizaje familiar, conductas de aprehensión familiar; influencia de los medios de comunicación y redes sociales, de grupos urbanos, grupos armados, alcoholismo, drogadicción, conflictos urbanos; agresiones verbales, amenazas, burlas al interior del aula escolar, robo escolar, discriminación; y, formas de realidad social e imaginario de proyecto de vida, a través de los cuales se estudiarán los orígenes y justificaciones de las conductas agresivas en el aula, y la construcción de convivencia escolar, en los jóvenes de grado Octavo de la Corporación Colegio Bolivariano del Norte, en la ciudad de San José de Cúcuta.This research aims at the investigation of socio-cultural factors that influence and intervene directly or indirectly, for young, aggressive behavior manifestin the classroom, thus modifying school life in the educational context. These factors are organized into social categories, such as family, social context,educational context and personal history. And these in turn are based on sub-categories, such as domestic violence, parental neglect, family learningmodels, behaviors familiar apprehension; influence of the media and social networks, urban group, armed groups, alcoholism, drug addiction, urban conflicts , verbal abuse, threats, taunts inside the classroom, school theft, discrimination and forms of social reality and imaginary life project, throughwhich we will study the origins and justifications of aggressive behavior in the classroom, and construction of school life, in eighth grade youthCorporation Bolivarian North College, in the city of San Jose de Cucuta

Feasibility, acceptability, and effectiveness of family- based treatment for adolescent anorexia nervosa: an observational study conducted in Brazil Viabilidade, aceitação e eficácia do tratamento familiar para anorexia nervosa em adolescentes: um estudo

Abstract Objective: There is strong evidence that family-based treatment is effective in cases of adolescent anorexia nervosa. Although family-based treatment has been studied in English-speaking countries, there is a need to examine the generalizability of this approach to non-English speaking cultures. This pilot-study aimed to examine the feasibility, acceptability, and effectiveness of family-based treatment in Brazil. Method: Observational study of adolescents with anorexia nervosa (excluding menstrual criteria), as determined with the Diagnostic and Well-Being Assessment, referred for treatment at a specialized center in São Paulo, Brazil. The following data were collected at baseline, at the end of treatment, and after six months of follow-up: weight; height; body mass index; menstrual status; Eating Disorder Examination Questionnaire score; and Children Global Assessment of Functioning Scale score. Results: Of 11 eligible patients/families, 9 (82%) enrolled in the study, and 7 (78%) completed the treatment. The mean patient age was 14.64 ± 1.63 years (range, 12.33-17.00 years). The Wilcoxon signed rank test showed statistically significant improvement in weight and body mass index at the end of treatment, as well as after six months of follow-up, at which point none of the patients met the diagnostic criteria for any eating disorder. Conclusion: The results suggest that family-based treatment is acceptable and feasible for Brazilian families. Outcomes suggest that the approach is effective in this cultural context, leading to improvements similar to those reported in previous studies conducted in other cultures. (DP = 1,63; Descriptors Introduction Anorexia nervosa (AN) is a serious psychiatric disorder with a prevalence rate of 0.3% in adolescent females. 1 AN is associated with a high mortality rate and is often complicated by psychiatric and medical comorbidity. The accumulated evidence supports the hypothesis that outcomes are better when adolescent patients and their parents are treated together. Studies suggest that family-based treatment (FBT), a method developed and described in a manual written specifically for AN by Lock (J.L.), is an effective treatment for AN. 2-4 However, those studies were all conducted in Englishspeaking countries. The purpose of the current study is to examine the feasibility, acceptability, and effectiveness of this approach in Brazil. To date, there have been no studies examining FBT for AN in Brazil. Specialized clinical treatment for adolescent AN in Brazil in public care is limited to a multidisciplinary program either as an inpatient or outpatient in the hospital where this study was conducted and other outpatient programs in university hospitals. The alternative is treatment at private clinics, which are not accessible for most of the population. There is a need to examine treatment alternatives for AN in Brazil because of high costs, long waiting lists, and limited public resources. For example, the estimated average waiting time for treatment in a specialized center has been shown to be 22 months per patient. 2 Therefore, FBT might be a cost-effective alternative for the outpatient treatment of Brazilian adolescents with AN

Anorexia nervosa: Differences and similarities between adolescents with and without a history of obesity / Anorexia nerviosa: Diferencias y similitudes entre adolescentes con y sin antecedentes de obesidad

Abstract The aim of this study was to evaluate clinical differences and similarities between anorexia nervosa (AN) patients with and without a history of obesity. We evaluated 108 patients (10-18 years old) with the restricting or purging subtype of AN, treated at a public referral facility in Brazil. To evaluate clinical characteristics, we used a standardized psychiatric interview, the Development and Well-Being Assessment, the Children’s Global Assessment Scale, the Eating Disorder Examination Questionnaire (EDE-Q), and body mass index (BMI)-for-age percentile. The mean age was 14.8±2.5 years, and 95 (88.0%) of the patients were female. Of the 108 patients evaluated, 78 (72.2%) had restrictive AN and 23 (21.3%) had a history of obesity. Patients with and without a history of obesity were similar in terms of age at onset, time from symptom onset to treatment, duration of treatment, impact of the disease on global functioning, and comorbidities. At treatment initiation, those with a history of obesity were at a higher BMI-for-age percentile and scored higher on the Weight Concern subscale of the EDE-Q. We conclude that severe cases of AN can occur in patients with and without a history of obesity with no differences in terms of the baseline characteristics and the duration of treatment. The significantly higher BMI-for-age percentiles amongst patients with a history of obesity (at treatment initiation) suggests that the urge for treatment shouldn’t be based on BMI percentile only. Resumen El objetivo de este estudio fue identificar las diferencias clínicas entre pacientes con anorexia nerviosa (AN) con y sin antecedentes de obesidad. Se evaluaron 108 pacientes (10-18 años de edad) con AN del subtipo restrictivo o purgativo, tratados en un centro público de referencia en Brasil. Para evaluar las características clínicas, se utilizaron una entrevista estandarizada psiquiátrica, el Development and Well-Being Assessment, la Children’s Global Assessment Scale, el Eating Di- sorder Examination Questionnaire (EDE-Q), y el percentil del índice de masa corporal (IMC) para la edad. La edad media fue de 14.80±2, años, y 95 (88.00%) de los pacientes eran del sexo femenino. De los 108 pacientes, 78 (72.20%) tenían AN restrictiva y 23 (21.30%) tenían antecedentes de obesidad. Los pacientes con y sin antecedentes de obesidad eran similares en términos de edad de inicio de la enfermedad, tiempo desde el inicio de los síntomas hasta el inicio del tratamiento, duración del tratamiento, impacto de la enfermedad en el funcionamiento general y comorbilidades. Al inicio del tratamiento, los pacientes con antecedentes de obesidad estaban en un percentil más alto de IMC para la edad y puntuaron más alto en la subescala preocupación por el peso del EDE-Q. En conclusión, casos graves de AN pueden ocurrir en pacientes con y sin antecedentes de obesidad

Peculiaridades do tratamento da anorexia e da bulimia nervosa na adolescência: a experiência do PROTAD

Os transtornos alimentares são patologias severas, tendo aspectos especiais na adolescência. Este artigo objetiva apresentar a rotina de atendimento e as abordagens empregadas em um serviço de assistência brasileiro especializado no tratamento de transtornos alimentares nessa população.The particular aspects of eating disordes in adolescents are reviwed. This article presents the multidisciplinary approach used in this population

Desenvolvimento e aplicação da versão em português do instrumento de avaliação de qualidade de vida da Organização Mundial da Saúde (WHOQOL-100)

OBJECTIVE: The World Health Organization developed an instrument to assess quality of life in the framework of a collaborative multicentric project. The methodology and the different stages of developing the original instrument are described. Next, the developing of the portuguese version is presented as well as its application in 300 patients in Porto Alegre, south Brazil.MATERIALS AND METHODS: Through a singular methodology, translation, discussionin focal groups with community members, patients and health professionals was performed followed by back translation.RESULTS: The instrument showed a good psychometric performance with good internal consistency, discriminant validity, criterion validity, concurrent validity and reliability.CONCLUSIONS: The authors concluded showing that the instrument is ready to be used in Brazil, being important to evaluate its performance in other regions and different samples.OBJETIVO: A Organização Mundial da Saúde desenvolveu um instrumento para avaliação de qualidade de vida através de um projeto colaborativo multicêntrico. São descritas a metodologia e as diferentes etapas de desenvolvimento do instrumentooriginal. A seguir é apresentado o desenvolvimento da versão em português e a aplicação deste em uma amostra de 300 indivíduos na cidade de Porto Alegre, sul do Brasil.MATERIAIS E MÉTODOS: Através de uma metodologia própria foi realizada a tradução, discussão em grupos focais com membros da comunidade, pacientes eprofissionais de saúde seguida de retrotradução.RESULTADOS: O Instrumento mostrou um bom desempenho psicométrico com características satisfatórias de consistência interna, validade discriminante, validade de critério, validade concorrente e fidedignidade teste-reteste.CONCLUSÕES: Os autores concluem que o instrumento está em condições de ser usado no Brasil, sendo importante avaliar seu desempenho em outras regiões e em diferentes amostras de indivíduos

Índice compuesto de inequidad en salud para un país de mediano ingreso

Objetivo Desarrollar y validar un índice compuesto de inequidad en salud basado en mortalidad por grupos de causas.Métodos Estudio ecológico en país de mediano ingreso latinoamericano, con indicadores agregados disponibles de municipios y departamentos, que se seleccionaron a partirde observatorios de salud, grupos de investigación y autoridades sanitarias. Se dividen en intolerables y “no completamente evitables” según el avance científico actual, y se agregan en categorías: accidente de tránsito, agresiones, enfermedad renal, infección por VIH, parasitosis intestinal, sífilis, enfermedad de transmisión fecal/oral, tuberculosis, enfermedad transmitidas por vectores, enfermedad respiratoria, eventos hemorrágicos/ isquémicos cerebrales, mortalidad materna, mortalidad menores 5 años, meningitis. Luego de análisis de componentes principales se obtiene índice compuesto multidimensional de inequidad en salud (IIS) para hombres y mujeres. Consistencia interna se evalúamediante coeficiente Alpha de Cronbach. Se hace validación concurrente con proporción de personas en Necesidades Básicas Insatisfechas (NBI), Índice de Desarrollo Humano (IDH), Expectativa de Vida al Nacer (EVN) entre otros.Resultados Se construye IIS que muestra valores más altos para las mujeres en la mayoría de municipios y departamentos; y para lugares con IDH alto, EVN alta y NBI bajas. El alpha de Cronbach fue 0.6688, IIS-hombres y 0.725, IIS-mujeres.Conclusiones Se obtiene IIS factible, reproducible y mutidimensional. Se destaca el papel de las grandes ciudades en las inequidades en salud, probablemente por el efecto de los intolerables en salud.Objective To develop and validate a composite index of health inequity based on mortality by grouped causes.Methods An ecological study in a middle-income Latin American country, with aggregate indicators available from municipalities and departments, which were selected from health observatories, research groups and health authorities. They were divided into intolerable and "not completely avoidable" according to current scientific progress, and were added in categories: traffic accident, aggression, kidney disease, HIV infection, intestinal parasitic diseases, syphilis, fecal / oral transmission disease, tuberculosis,disease Vector-borne diseases, respiratory disease, cerebral hemorrhagic / ischemic events, maternal mortality, lower mortality 5 years, meningitis. After analysis of main components, a composite index of health inequity (IIS) is obtained for men and women. Internal consistency was evaluated using Cronbach's Alpha coefficient. Concurrent validation was done with proportion of people in Unsatisfied Basic Needs (UBN), Human Development Index (HDI), Life Expectancy at Birth (LEB), among others.Results IIS is built showing higher values for women in most municipalities and departments; And for sites with high HDI, high LEB and low UBN. Cronbach's alpha was 0.6688, IIS-men and 0.725, IIS-women.Conclusions An IIS was obtained, is valid and reproducible. The role of big cities in inequities in health is highlighted, probably due to the effect of intolerable health

The impact of psychiatric comorbidities and other risk factors on the response of children and adolescents with eating disorders to treatment

INTRODUÇÃO: Os transtornos alimentares (TA) incluem os diagnósticos de anorexia nervosa (AN), bulimia nervosa (BN) e transtorno alimentar não-especificado (TANE). Apresentam altas morbidade e mortalidade. Acometem indivíduos jovens, afetando amplamente o seu desenvolvimento. Na infância e adolescência, os TA possuem peculiaridades epidemiológicas, diagnósticas e clínicas que ainda são pouco conhecidas em pacientes jovens brasileiros. As comorbidades psiquiátricas podem interferir no curso do tratamento e na evolução dos TA, podendo aumentar sua letalidade. Outros fatores prognósticos dos TA também têm sido investigados e seu papel permanece indefinido. Os objetivos deste estudo foram investigar o perfil sociodemográfico e clínico dos pacientes com TA; identificar a prevalência de comorbidades psiquiátricas; investigar o impacto de comorbidades psiquiátricas e de outros fatores de risco na resposta ao tratamento de pacientes com TA que receberam o mesmo tratamento. MÉTODOS: Estudo realizado em um serviço multidisciplinar especializado no tratamento de crianças e adolescentes com TA (PROTAD IPq/HCFMUSP). A amostra consistiu de 100 pacientes de ambos os sexos, com idade até 18 anos e diagnóstico de TA, síndromes totais e parciais, segundo critérios do DSM IV - TR. Os dados foram coletados à entrada e à saída do tratamento. Os três tipos de resposta ao tratamento foram Alta Clínica, Abandono e Falha de Tratamento. Foram testados, também, quais fatores preditivos influenciaram no tempo de tratamento até a alta clínica dos pacientes pela análise de sobrevida. O nível de significância considerado em todos os testes estatísticos foi de 5%. RESULTADOS: A idade média dos pacientes foi de 15,41 anos, a média de idade de início dos TA foi de 13,5 anos e o tempo médio de duração do TA foi de 21,06 meses. Características da amostra: 82% de mulheres, 84% brancas, 64% das classes econômicas A e B; 69% de famílias tradicionais; 43% com diagnóstico de AN, 17% de BN e 41% de TANE; 56,8% admitidos na internação; 66% com tratamentos prévios; 88% cuidados pela mãe durante o tratamento; 75,7% com transtornos do humor (TH) que, em 81% dos casos, iniciaram durante os TA, e 54% com transtornos ansiosos que, em 75% das vezes, começaram antes dos TA; 60% com grande impacto dos TA, segundo a Escala de Avaliação Global de Crianças. Os pacientes do grupo AN eram mais jovens, pesavam menos, tinham menos tempo de TA, procuraram mais tratamentos prévios, apresentavam menos obesidade prévia, usavam mais os exercícios físicos excessivos como compensação e tinham mais amenorreia do que aqueles do grupo BN. Os sujeitos da enfermaria apresentaram menor índice de massa corporal, mais tempo de TA e maior impacto dos TA do que os do ambulatório. Na análise de sobrevida, os pacientes sem TH tiveram quase 3 vezes a chance de alta clínica do que aqueles que tinham TH. Os pacientes cuidados por suas mães apresentaram 4 vezes a chance de alta clínica do que os indivíduos que foram cuidados por outras pessoas. Pacientes do grupo abandono eram 12 meses mais velhos do que os dos outros grupos de resposta ao tratamento. O grau de instrução dos responsáveis pelos grupos abandono e falha de tratamento era maior do que do grupo alta clínica. Os outros fatores prognósticos investigados não tiveram impacto no tipo de resposta ao tratamento. CONCLUSÃO: Os pacientes jovens brasileiros com TA apresentaram características epidemiológicas e sintomatológicas muito semelhantes aos dados da literatura científica na mesma população, inclusive da alta prevalência de comorbidades psiquiátricas. A maior frequência das síndromes totais dos TA, o predomínio de quadros de início precoce, o longo tempo de duração até iniciar tratamento especializado e a maior gravidade dos pacientes da enfermaria, evidenciados nessa amostra, chamaram atenção por serem indicadores de maior gravidade em TA. A presença de TH e ausência de cuidados maternos aumentaram significativamente o tempo de tratamento até a remissão dos pacientes com TA. A idade mais avançada dos pacientes e maior nível educacional dos responsáveis estiveram associados com maior risco de abandono de tratamento. Os outros fatores preditivos investigados não tiveram impacto na resposta ao tratamento e no tempo de tratamento até a remissão. Os resultados podem contribuir para a estruturação de novos serviços direcionados às crianças e aos adolescentes brasileiros com TA e para o desenvolvimento de estratégias mais racionais e eficazes de diagnóstico e tratamentoINTRODUCTION: Eating disorders (ED), which present high morbidity and mortality, include anorexia nervosa (AN), bulimia nervosa (BN) and nonspecific eating disorder (EDNOS), and affect youth, greatly impacting their development. ED in childhood and adolescence, which involve epidemiological, diagnostic and clinical peculiarities, have been little studied among young Brazilians. Psychiatric comorbidities may also interfere with the treatment and progress of ED, and may increase their lethality. Other prognostic factors for ED have also been investigated, and their role remains undefined. The objectives of this study were to 1) investigate the sociodemographic and clinical profile of ED patients, 2) to identify the prevalence of psychiatric comorbidities, 3) to investigate the impact of such comorbidities on patient treatment response in comparison to that of patients without comorbidities under the same treatment conditions, and 4) to determine the impact of other risk factors on patient response to ED treatment. METHODS: The study was conducted at a multidisciplinary service specializing in the treatment of children and adolescents with ED (PROTAD IPq/HC-FMUSP). The sample consisted of 100 patients of both genders up to 18 years old who had been diagnosed with ED (either total or partial syndromes) according to DSM IV - TR criteria. The data were collected upon admission and at discharge from treatment. The three types of treatment response were: clinical discharge, abandonment and treatment failure. Based on the survival analysis, the patients were also tested regarding which predictive factors influenced patient treatment time until clinical discharge. A significance level of 5% was adopted for all statistical tests. RESULTS: The mean patient age was 15.41 years; the mean time since ED onset was 13.5 years and the mean duration of ED was 21.06 months. Sample characteristics: 82% female, 84% white, 64% from socioeconomic classes A and B; 69% from traditional families; 43% diagnosed with AN, 17% with BN and 41% with EDNOS; 56.8% admitted via hospital admission; 66% had previous treatment; 88% were assisted by the mother during treatment; 75.7% had mood disorders (MD) which, in 81% of the cases, began during the ED, and 54% had anxiety disorders that, in 75% of the cases, began before the ED ; 60% of patients had a great impact by the ED. Patients in the AN group were younger, weighed less, had less time of ED, had sought previous treatment more frequently, presented less previous obesity, more frequently resorted to excessive physical exercise as compensation and had more amenorrhea than those in the BN group. The patients from the hospital ward had a lower body mass index, longer time with ED and were more impacted by the ED than patients from the clinic. In the survival analysis, patients without MD were almost three times as likely to receive a clinical discharge as those with MD. Patients assisted by their mothers were four times as likely to receive a clinical discharge as those assisted by others. Patients from the abandonment group were an average of 12 months older than those in the other treatment response groups. The educational level of guardians in the abandonment and treatment failure groups was higher than that of parent/guardians in the clinical discharge group. The other investigated prognostic factors had no impact on treatment response type. CONCLUSION: Young Brazilian patients with ED present epidemiological and symptomatic characteristics very similar to those found in the scientific literature regarding similar populations, including a high prevalence of psychiatric comorbidities. The higher frequency of total ED syndromes, the predominance of cases with an early beginning, the long delay in beginning a specialized treatment and the more severe state of patients from the hospital ward attracted attention because these factors differed from what has been reported in reference studies and indicated greater ED severity. The presence of MD and the absence of maternal care significantly increased treatment time for ED. Greater patient age and higher guardian educational level were associated with higher risk of treatment abandonment. The other predictive factors investigated had no impact on treatment response or on treatment time until discharge. These results can contribute to the structuring of new services for Brazilian children and adolescents with ED and to the development of more rational and efficient strategies for diagnosing and treating E