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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

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Picture from a local young artist: Samuel Barata, Paúl, Covilhã – Portugal

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Year I, Vol. II, n 4, 2014


Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN Director-in-Chief Luis Alberto Coelho Rebelo Maia

Associated Editors Ana Amaro – Beira Interior University Clara Margaça - Beira Interior University Daniel Martins – Coimbra University Filipa Míriam – ISMAI – Maia Superior Institute Mónica Sousa – Aveiro University Sofia Silva - Beira Interior University

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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Scientific Board

- J.E. Pinto-da-Costa, PhD., Forensic Medicine, Full Professor of Neuropsychopathology, Psychofarmacology, Universidade Lusíada, Porto and Judicial Psychology and Forensic Medicine in University Portucalense Infante D. Henrique, Porto – Portugal - Albertino Graça, PhD., Principal of UNI-Mindelo University, Cape Verde Islands - M. Joaquim Loureiro, PhD., Full Professor in Psychology, University of Beira Interior - Portugal - J.L. Sánchez Rodríguez. PhD., Dr. Medicina y Cirugía. University of Salamanca. Profesor de la Facultad de Psicología. Departamento de Psicología Básica, Psicobiología y Metodología de las C.C. – España - José Vasconcelos-Raposo, PhD., Full Professor in Psychology, Sports & Health. University UTAD - Vila Real - Portugal - Pedro Guedes de Carvalho, PhD., CIDESD, Beira Interior University - Portugal - Daniel Marinho, PhD., CIDESD, Beira Interior University - Portugal - Luísa Branco, PhD., Professor in Education, Philology & Citizenship Education - Portugal Beira Interior University - Portugal - J. Marques-Teixeira, PhD., Psychiatrist and Psychotherapist, Professor of Neurosciences in University of Porto - Portugal - J.M. Barra da Costa, PhD., Former Inspector Chief of Judicial Police - University Professor and Criminal Profiler - Portugal - Jorge Oliveira, PhD., Professor School of Psychology and Life Sciences – ULHT - Director of Centre for the Study of Cognitive and Learning Psychology (ULHT) – Portugal

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- Luísa Soares, PhD., University of Madeira, M-iti (Madeira Interactive Technologies Institute) – Portugal - Paula Saraiva Carvalho,PhD., Professor in Psychology, University of Beira Interior - Portugal - Nuno Cravo Barata, PhD., Research Assistant and Professor at Universidade Portucalense¸ Instituto Piaget; Faculdade de Medicina da Universidade do Porto - Portugal - Paulo Lopes, Psychologist, PhD., Neuropsychology Salamanca University, Professor at School of Psychology and Life Sciences and Director of the MSc of Applied Neuropsychology (ULHT); Ares do Pinhal - Addiction Rehabilitation Association – Portugal - Pedro Gamito, PhD., (University of Salford, UK), Title of Aggregate in Rehabilitation (Technical University of Lisbon, Portugal). Full Professor and Head of Computational Psychology Laboratory of Psychology School and Life Sciences and Associate Director of COPELABS – Portugal - Ricardo João Teixeira, PhD., Main Researcher at Aveiro University; Psychologist/Psychotherapist at Clínica Médico-Psiquiátrica da Ordem (Porto); Invited Assistant Lecturer at School of Allied Health Sciences, Polytechnic Institute of Porto; PhD in Psychology by Minho University - Portugal - Graziela Raupp Pereira, PhD., Professor at Santa Catarina State University - Brasil

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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Author Guidelines Papers will be valued by the Editorial Board and referees The

Iberian

Journal

of

Clinical

and

Forensic

Neuroscience publish papers on a broad range of topics of

in terms of scientific value, readability, and importance to a wide-ranging circulation.

general interest to those working on the neuroscientific field.

Papers should be submitted following APA norms (APA Publication

The

Journal

of

Clinical

and

Forensic

Neuroscience publishes theory-driven patient studies, studies about forensic field applied to neuroscience as well as basic studies in the large neuroscience area.

The journal publishes group and case studies addressing fundamental issues concerning the brain functional

Manual

published

by

the

American

Psychological Association), and preferentially presented in written English language. Abstracts should be available in English, Portuguese and Spanish idiom as well as key words.

The Journal operates in a policy of anonymous peer review.

relations with behavior, epidemiology, basic science, etc.

487 Each submission should follow the procedure of sending

The journal is dedicated to a fast and proficient turnaround of papers, targeting to complete reviewing in under 60 days. Submissions should be made in a word format document (editable) to

by email two documents: a) a Title page with all information about authors’ affiliations and indications of the correspondent author; b) a second document, containing

the

entire

article,

WIHTOUT

ANY

IDENTIFICATION of the authors, to assure the blind review process. luismaia.gabinete@gmail.com (Luis Maia, Editor in Chief), or iberianneuroscience@gmail.com.

After the effective publication of articles, authors assume that the copyright are totally trespassed to Iberian Journal of

Clinical

and

Forensic

Neuroscience

editors.

We invite you to discuss, exchange ideas and have free access to the journal also in facebook page https://www.facebook.com/iberianjournalofclinicalandforensicneuroscience?fref=ts

or the official internet page http://luismaiagabinete.wix.com/iberianneuroscience

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Editor: Éditos Prometaicos – Portugal

Editorial

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

The

Strengthening of a new era in Neuroscience in Portugal and Worldwide

survey

of

the

magazine's

website

http://luismaiagabinete.wix.com/iberianneuroscien ce, allow colleagues understand our lines of editorial guidance. Efforts will be made to reach the

With the launch of this fourth scientific periodic we intended to be accessible to all readers (scientists or not) and we are aware that the project proposed is of great magnificence. We do it because it is not understandable that in Portugal (in particular) and in Iberian Peninsula, as well as even worldwide, there are many reasons to refer to the initiatives of the Portuguese level research projects and subsequent disclosure might abound.

maximum possible audience so try that, over time, to develop a culture of publication of articles in English language, and may opt for a bilingual edition, English - Portuguese, given the versatility that online publication allows. Thus, please, invite anyone, even anyone to submit their articles for publication in our emails at iberianneuroscience@gmail.com

or

luismaia.gabinete@gmail.com. The only conditions we put while we ensure is that only papers with

Much less can it be said when mentioning the private

high scientific quality are published - literary, may

initiative of a group of colleagues in the public and

come from various quarters and collaborations

private sector representation and without support of

(students, home schooled, researchers, teachers,

a public institution (such as a university, institute or

etc..). One thing we assure you, we are tired of

foundation).

"Sacred Cows", and at this stage, as Chaplin referred,

With this fourth copy of the Iberian Journal of Clinical

everyone must submit their tune as soon as possible

and Forensic Neuroscience we intend to strenght a

before, when they realize, the curtains have been

new cycle.

closed but the audience already has abandoned the

We are a humble group, supported by a more humble editor (Edicts Prometáicos), however we

auditorium and the "Holders of Knowledge" be afraid of the darkness of his own loneliness!

realize our value. What we want to assign to us, and

We end with the allusion to one of the most known

at the same time, how much we can work with and

neuropsychologists of the World, for many, the true

for you, demonstrate captivating our colleagues and

Father of Neuropsychology: Alexander Romanovich

friends ... even more.... We are so humble and small,

Luria – “A neuropsychologist should be able to

but at the same time as small as what our eyes can

evaluate a patient with what can only press the gown

reach: the infinity!

itself!” So, again we let a challenge, a neuroscientist should be able to present only what neuroscience

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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

has more valuable, the mind, and therefore your CNS, your brain, or, if you will, in ordinary language, only need your head!

Luis Maia, PhD, Editor-in-Chief, Iberian Journal of Clinical and Forensic Neuroscience. Covilhã, Portugal, February, 28th, 2014.

A kiss and a hug to all neuroscientific colleagues.

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Contents

Editorial --------------------------------------------------------------------------------------------------------------------------- -------------- 488

Special Invited Article - Crisis Intervention: a therapeutic approach - women victims of violence and suicide. Clara Margaça & Donizete Rodrigues ------------------------------------------------------------------------------------------------------------ 493

Original Article - Satisfaction of basic psychological needs and self-determination in people with schizophrenic psychosis and depression. Rita Sousa, Ana Allen Gomes & Susana Veloso ------------------------------------------------------ 512

Executive neuropsychological aspects of individuals with cleft lip palate. Rui Mateus Joaquim & Maria de Lourdes Merighi Tabaquim ---------------------------------------------------------------------------------------------------------------------------- 525

The impact of four stimulation sessions in older people in retirement homes. Mónica Sousa --------------------------- 537

Invited Letter / General Psychology - The importance of music for a comprehensive training of children in kindergarten. Débora Munhoz Barboni ------------------------------------------------------------------------------------------------- 553

Therapeutic approaches - Drug Abuse – From Diagnosis to Treatment in 2014. Ana Amaro ----------------------------- 560

Therapeutic approaches - Pharmacological Therapy in Children and Adults with Hyperactivity Disorder Attention Deficit (ADHD): Current Issues. Sofia Bento Silva ------------------------------------------------------------------------------------- 601

Newcomers in Scientific Writing - Neuropsychology: a conceptual review. Jorge Mimoso & Rui Pais ----------------- 624

Original Article - Study of Delinquent History and auto / hetero perception in subjects under Educational Guardianship Institution. Filipa Marques Varandas & Luis Alberto Coelho Rebelo Maia ----------------------------------- 642

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Special Invited Article Crisis Intervention: a therapeutic approach - women victims of violence and suicide. Clara Margaça (1) & Donizete Rodrigues (2).

(1) Degree in Psychology and Master Student in Clinical and Health Psychology, University of Beira Interior. Correspondent author: claramargaca@gmail.com (2) Associate Professor of Anthropology (with Aggregation in Sociology) in the Department of Sociology, University of Beira Interior.

----------------------------------------------------------------------------------------------------------------------------------------------Abstract Crisis intervention is characterized as a form of assistance to a people who suffered a traumatic situation, mitigating the negative effects (physical and mental injuries), fostering the possibility of growth and acquisition of new coping strategies. It is a procedure to influence the psychological functioning during the period of imbalance, relieving the direct impact of the traumatic event. The objective is help to actuate the preserved healthy part of the individuals, as well as their social resources, dealing in the adaptive way the effects of stress. In intervention with women, victims of violence, is important to highlight that a primary advantage of this intervention is a clear understanding that the moment of disclosure/complaint of facts is for most part of the victims - particularly problematic, a truly moment of crisis. The self-destructive behaviors, like suicide, are related to the inability of the individuals to find different alternatives to address their conflicts, and consequently they choosing the death. The negative resolution of the crisis, which could happen by the lack of immediate intervention, leads the person to develop suicidal behavior. A historical of attempts and the presence of suicidal ideation confer a predictive form to evaluate the risk of suicide; thus, the intervention in the moment of hopelessness and confusion is decisive for the positive resolution of the crisis. Key Words: crisis, intervention, victims, violence, suicide.

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Resumo A intervenção em crise pode ser caracterizada como uma forma de auxílio a uma pessoa que encara uma situação traumática, abrandando os efeitos negativos (danos físicos e psíquicos), fomentando a possibilidade de crescimento e aquisição de novas estratégias de coping. É um procedimento para exercer influência no funcionamento psicológico, durante o período de desequilíbrio, aliviando o impacto direto do evento traumático. O objetivo é ajudar a ativar a parte saudável preservada da pessoa, assim como os seus recursos sociais, enfrentando de maneira adaptativa os efeitos do stress. Na intervenção em crise, com mulheres vítimas de violência, é importante destacar que a primeira vantagem desta intervenção advém da clara compreensão de que o momento da revelação/denúncia dos factos é – para a generalidade das vítimas – particularmente problemático, um verdadeiro momento de crise. Os atos autodestrutivos, como o suicídio, estão relacionados com a impossibilidade de o individuo encontrar diferentes alternativas para enfrentar os seus conflitos, optando, finalmente, pela morte. A resolução negativa da crise, que pode acontecer pela falta de intervenção imediata, leva o sujeito a desenvolver um comportamento suicida. Um histórico de tentativas e a presença de ideação suicida conferem um valor preditivo à avaliação do risco de suicídio; assim, a intervenção no momento de desesperança e confusão pode ser determinante para a resolução positiva da crise. Palavras-chave: crise, intervenção, vítima, violência, suicídio.

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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Resumen La intervención en crisis se puede caracterizar como una forma de ayuda a una persona que sufre una situación traumática, atenuando los efectos negativos (daños físicos y mentales), promoviendo la posibilidad del crecimiento y la adquisición de nuevas estrategias de afrontamiento. Es un procedimiento para influir en el funcionamiento psicológico de la persona durante el período de desequilibrio, aliviando el impacto directo del evento traumático. El objetivo es ayudar a activar la parte sana de la persona, así como sus recursos sociales, enfrentando de forma adaptativa los efectos del estrés. En la intervención en crisis con mujeres víctimas de la violencia, es posible destacar que una primera ventaja de esta intervención viene de una comprensión clara de que en el momento de la revelación o queja de lo ocurrido es - para la mayoría de las víctimas - particularmente problemático, un verdadero momento de crisis. Los actos autodestructivos, como el suicidio, están relacionados con la incapacidad del individuo para encontrar diferentes alternativas para hacer frente a sus conflictos, optando, finalmente, por la muerte. La resolución negativa de la crisis, que podría ocurrir por la falta de una intervención inmediata, lleva el individuo a desarrollar un comportamiento suicida. Un historial de los intentos y la idealización suicida confiere un valor predictivo para evaluar el riesgo de suicidio; así como la intervención en el momento de la desesperación y la confusión puede ser decisiva para la resolución positiva de la crisis. Palabras clave: crisis, intervención, víctima, violencia, suicidio. -----------------------------------------------------------------------------------------------------------------------------------------------

Introduction The Sanskrit word for crisis is kri or kir, which means to ‘clean’, ‘purify’ (Boff, 2002). The concept ‘crisis’ comes from the Greek word krisis - that means ‘decision’ - and derives from the verb krino - “I decide, I divide, I judge" (Moreno, Peñacoba, Gonzalez-Gutierrez & Ardoy, 2003). In Latin definition is a ‘decisive phase of the disease’. Therefore, originally the word crisis is permeated with elements that bring a broad sense: separation, change, transitional imbalance, with a opportunity for growth. It was further defined as a state of emotional imbalance, in which the people find themselves unable to deal with the resources that they usually use in situations that affect them emotionally (Parada, 2004). According to Moebus & Fernandes (sd), the introduction of the concept crisis, in the Psychology, is originally attributed to Erich Lindermann. In 1944,

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he developed a "theory of crisis", as a psychological consequences caused in people after tragedies or disasters;

a

conception

that

considers

the

psychological problem as exclusively provoked by external or social causes. Foucault

(2004),

in

History

of

Madness,

demonstrates how the concept of madness - and consequently the concept of crisis - was, is and always will be historically and culturally constructed according to the social context. He states that, over the past few centuries – eighteenth century, in particular - what is today denominated psychosis crisis was understood as a manifestation of wisdom, demonic possession, witchcraft, and also subversion of the social order. The crisis is an experience that reflects the inconstancies of the people to find a balance between themselves and the social environment

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that surrounds them. If the balance is disrupted, the

assault, in particular. This sensitive situation need a

crisis is established, as a violent and sudden

pronto attendance, with a supportive attitude,

manifestation of this disruption. The changes in the

respect and sensibility from the therapists involved

balance, provoked by a failure to resolve the

in the treatment (Faúndes, Roses, bedone & Orozco,

problems, causes feelings of disorganization,

2006).

hopelessness,

The concepts traditionally considered as ‘crisis

sadness,

confusion,

and

panic

(Wainrib & Bloch, 2000).

intervention’ presents differences in its application

Emotional disorder is characterized as a collapse of

in emergency situations and in clinical practices, due

the previous coping strategies. According to Wainrib

to

& Bloch (2000), the state of crisis is limited in time,

psychological/psychiatric care and also because is

usually expressed by a trigger and precipitating

difficult establishes an appropriate protocols for this

event. And the final resolution depends on the

particular type of interventions. It influences the

severity of the event and personal and social

psychological functioning of the individuals, during

resources.

the period of imbalance, relieving the consequences

Nowadays, issues as overwork, consumerism, fear of

of the traumatic event. The objective is to preserve

loneliness, the concepts of happiness and quality of

the healthy part of the patients - as well as their

life, the complexity and ephemerality of the

social resources – and help them to deal with the

emotional relationships, reveal new problems, which

effects of the stress. It is important to note that, in

require new solutions, but not available to everyone,

moment of crisis, the defenses are more vulnerable.

precipitating

such

In such circumstances, it should facilitate the

circumstances, the crisis intervention contributes to

conditions to (re)establish, by their own (re)action, a

the better understanding of the emotional reactions,

new mode of interpersonal and social psychological

decreasing of the pain, and even the prevention of

functioning (Wainrib & Bloch, 2000; Liria & Veja,

the mental disorders.

2002).

The crisis intervention is characterized as a form of

The response to a crisis generally is evoked by an

assistance to a person who suffered a traumatic

unexpected situation and it has the following

situation, mitigating negative effects (both physical

characteristics: a) a cognitive level - the capacity to

and mental injuries), fostering the possibility of

resolve problems and the defense mechanisms are

growth, and acquisition of new coping strategies (Sá,

temporarily burdened; b) psychologically - a

Werlang & Paranhos, 2008). The importance of

temporary state of shock may be followed by denial,

emergency care in emotional crisis is particularly

confusion,

relevant in cases of psychological trauma, sexual

numbness, disbelief, excitability and restlessness;

a

process

of

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crisis.

In

specificities

fear,

of

terror,

the

urgency

sadness,

in

emotional

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these reactions can compromise the psychological

depression, eating disorders, ulcers, and other

balance; and c) physiological level - general stress

disabling conditions. Examples of this category of

reactions, such as changes in the heart rate,

crisis are the (expectation of) work promotion or

breathing, and excessive sweating. The quality and

pregnancy. Preventive objective: accept (or waive)

the kind of response will accrue according to the

realistically the gain and deal with the predominant

interaction between the patients, the event and

feelings.

their social milieu. It may also be related to the

However, adopting an inappropriate strategy, the

records of their life, stage of development and other

situations described above may provoke decreased

risk factors (Wainrib & Bloch, 1998).

of the adaptive efficacy. Thus, the aim of the

Based on the theory of adaptation, Simon (1989, p.

prevention is precisely to avoid this negative

62) classifies the crisis according to the etiology: loss

situation.

or threat of loss and gain or expectation of gain,

Caplan (1964, cited by Younes, 2011) says that the

factors that affect the adaptive balance of the

situational crisis refers to situations related to: a loss

patient. In this situation, there are predominant

of a source of satisfaction of basic needs, triggered

feelings that determine preventive procedures,

by a death, loss of physical integrity as a crippling

which are specific for each type of crisis:

disease, a (or threat) dangerous situations, a

1. Significant loss or threat of loss - in case of

challenge that exceeds the individual capabilities.

predominant feelings of depression and guilt, exist

The crisis of development can be defined as a

the risk of self-harm, self-mutilation, suicide, and

situation caused internally due to physiological or

projection of blame. It may occur in the following

psychological disorders related to the development,

situations: family breakups, sexual violence, serious

biological transitions or transitions of roles. Thus,

illness, floods, fires, communities living in dangerous

these events in normal physical and psychological

and violent areas, loss of significant other.

development may trigger a response to the crisis

Preventive objective: to accept the loss, renew

(Clapan 1964 cited by Younes, 2011).

interest

According to Gilliland and James (1993), the

by

personal

issues

and

deal

with

predominant feelings.

situational crisis appears with the occurrence of

2. Per acquisition or expected acquisition – in case of

unusual and extraordinary events, in which an

prevailing feelings of insecurity, inferiority or

individual does not foresee nor has control, such as:

inadequacy. The individuals do not know how to deal

accidents, kidnappings, rapes, loss of job, sudden

with a particular problem. The patients may accept

illness, and death. The key to differentiate a

more responsibility than they are able to take, which

situational of the developmental crisis is because the

can lead to psychosomatic problems, such as

first is random, sudden, shocking, intense, and

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catastrophic. The authors further developed also the

transient destabilization or can remain and hinder

concept of existential crisis - internal conflicts and

the state of equilibrium of the people in relation to

anxieties that accompany human issues, such as

their body and the social environment. It may surge

responsibility, purpose, independence, freedom,

due to an unpredictable situation - sickness,

and commitment.

unemployment, and death - or predictable adolescence, pregnancy, aging. It is important to

Crisis: expanding concepts.

note that the crisis may also have a positive and

As we noted above, the word crisis include social,

adaptive form, when exist a singular and significance

historical, familial, and personal aspects. However, in

temporal

the specific field of mental health, there are different

(Knobloch, 1998).

characterizations of the crisis: psychoanalysis and

According to Dell’Acqha (1988), can be characterized

psychiatry do not speak the same language; for

as crisis the situation with, at least, three of the five

instance, there is no unique perspective about what

following

is considered a moment of outbreak. There are

symptoms; 2) severe disruption in the family and/or

different

an

social context - state of anomie, in the Durkheimian

experience can be considered a crisis or not. Many

sense; 3) refusal of the treatment; 4) stubborn

authors, with psychotherapy orientation, relate the

refusal of contact; and 5) alarm situations in the life

concept of crisis to the concept of trauma1. The

context and personal inability to manage the

trauma is a moment of crisis, which is defined by its

problem. Although all these factors consider crisis

intensity, the inability that affects the individual to

as something beyond the symptoms - including

respond adequately, the nuisance, and by the lasting

aspects of familial, social, and relational contexts -

pathogenic effects that it provokes (Laplanche &

this concept could be improved through a better

Pontalis, 1986, p.678).

understanding of the subjective experience of the

Caplan (1980) and collaborators developed studies

crisis and its uniqueness for each one affected.

on 'crisis theory', which can be defined as a period of

According to Knobloch (1998), the crisis may be

disorganization of an open system. The crisis is

designated as an experience in which there is an

precipitated by one or more circumstances that,

unbearable situation - in the literal sense, there is no

sometimes, exceed the capacity of the people (or the

support - an ‘abysm’, a loss of sense, when the

system) to maintain their homeostasis. It may be a

individuals missed their crucial connections. This

1

criteria

to

determine

whether

meaning

for

parameters:

the

1)

person

severe

affected

psychiatric

- The notion of trauma was taking from medicine by Freud to

describe an experience that brings a large increase of excitation of psychic life in a short time.

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‘gap’ manifests as an excess of pulsional force, which

the inexistent content representation does not mean

disrupts the capacity of symbolization, yet at the

absence of sensations and emotions.

same time introducing a requirement to restore missing connections. The crisis is considered a

The phases of the crisis

threshold experience, not because is an experience

Basing on Horowitz (1976), Slaikeu (1996) highlights

that challenges the limit, but because exceeds the

the following types of phases of the crisis: faced with

delimited. It is an experience that brings an excess of

the condition that triggers the process of crisis, the

unbearable and intolerable things; a rupture in

individuals present first a disorder, originated by the

which are redistributed, in a highly significant

initial reactions to the impact of the situation. After

manner, the conditions of reality, installing an

the disorder, the individuals move to a denial stage,

unsustainable situation to the person (Knobloch,

trying to absorb the impact (for instance, they do not

1998). All these situations transform the relations of

think about what happened or try to continue their

the usual time, introducing the individual in ‘another

activities as if nothing had happened). The third step

world’, outside of the ordinary space and time.

is the intrusion: the emergence of involuntary ideas

Because of the mental condition, individuals in crisis

of pain related to the event that occurred; recurring

do not apprehend any concept and have judgment

nightmares, images and other concerns are

capacities. It provokes in the victims many problems:

characteristic of this stage. The next is the

immense distress, the feeling of loss of control of

elaboration; they begins identify and communicate

their own life, personal attribute, and even loss of

their thoughts and feelings experienced during the

identity reference (Birman, 1983, cited by Knobloch,

period of crisis. Finally, the end stage, is the moment

1998).

in which the individuals integrated/assimilated the

Lobosque (2001) points out some common

event in their life, because the experience was faced,

characteristics of the personal crisis experiences: the

feelings and thoughts identified, enabling them to

character of imposition and invasion - which even

reorganize their life.

exceeds the level of psyche and achieves the body -

The crisis can be triggered by several circumstances.

the loss of privacy; to be exposed or in vulnerable

However, it is not only the event that triggers such

situation to stranger people; questioning about all

process. The crisis may also happen due to the

things and affecting the fundamental convictions. It

meaning that the people ascribe to the facts, in

originates and reproduces agony, which triggers an

terms of threat or damage to themselves, and also

incomprehensible

the evaluation of the available resources to face the

pain,

without

content

representation and, therefore, unattainable by

situation (Liria & Veja, 2002).

consciousness. However, it is important to note that

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Traumatic events may be decisive for the

consequence of a rare and an extraordinary event,

development of an 'acute stress disorder'; situation

situation in which the individual cannot predict nor

characterized by intense anxiety, fear, impotence,

has control, such as: losing a source of basic

and horror, associated with dissociative symptoms,

satisfaction, unemployment, sudden death, loss of

such as: lack of emotional response, disconnection

bodily integrity, disease, natural disasters, violations,

feelings, reducing the environmental recognition,

and accidents. According to Wainrib and Bloch

unreality, and dissociative amnesia. In some cases,

(2000), the point of difference between this type of

without appropriate treatment, the 'acute stress

crisis and others is because, in such cases, the

disorder' persist and even can progress to the 'post-

circumstances are unexpected, emotive, intense,

traumatic stress disorder', which is characterized by

and dangerous. Although the focus is a person who

persistent re-experiencing of the traumatic event,

experiences a crisis situation, it is relevant to note

systematic avoidance of stimulus associated with

that some people, facing traumatic events, have the

trauma and increased arousal symptoms (DSM IV TR,

ability to withstand emotionally the problems; this

2002).

special capability is named 'resilience’2. Thus,

This issue can be better understood distinguishing it

resilient people are able to maintain a stable balance

in

The

without be affected their competence and life;

evolutionary crisis are relates to unsatisfactory

actually, despite the traumatic experience, they

passages of the development of the individual, which

remain in the functional level (Poseck, Baquero and

can be predictable - the growth and decisive

Jiménez, 2006).

evolutionary

and

situational

crisis.

circumstances that occurs in each stages are well known and it happens in the most of people. The

Crisis: evolution

situations created internally by physiological and

The development of a crisis follows a stepwise

psychological changes may trigger a crisis response,

process, which usually taken less than eight weeks.

such as: the conception or sterility, pregnancy and

According to Caplan (1964), the phases are: shock or

childbirth, childhood, adolescence, the transition to

acute impact - something occurs suddenly or, at

retirement, aging, and death (Slaikeu, 1996; Wainrib

least, the person has this perception and cannot

& Bloch, 2000).

avoid it or overcome it. Combined with the stress

There is also the circumstantial crisis, which is

derived from this situation, emerge feelings of

related to the social environment. It results as a

confusion,

2

impotence,

abandonment,

and

- In physics, resilience refers to the capacity that an object/body

the psychological point of view, is defined as the ability in which

must reacquire totally its previous properties after an external

the individual has to deal with the problems, overcome obstacles

agent ceases its action on it, action which modified, suppressed

and resist the pressure of the adverse situations, without getting

or added some property. Taken from the physics, resilience, from

into a crisis or outbreak.

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depreciation

(Rivera

at

al.,

1993);

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critical

According to Moreno et al. (2003, cited by Sá, Werlag

disorganization - when all coping strategies and

& Paranhos, 2008), professionals that work with this

usual resolution fail and the emotional tension

type of intervention should be active and direct,

increases.

oriented to achieve rapid, agile, and with flexible

In case of apparent insufficiency of personal

solutions. The purpose is develop direct actions to

resources to deal with the situation appear feelings

solving problems and to overcome the multiple

of helpless, failure, and depression; resolution – in

difficulties that can arise, trying to satisfy the

the typical development of a crisis, the first attempts

immediate needs of the person, putting into

of the individuals to emerge from the crisis usually

operation some activities with the available

fail. Without a solution, they continue under

resources, in a short period of time.

increasing internal pressure. This phase is the core of

To prevent this type of pathological relations, there

the crisis, because this is the moment to make

are some measures that would prevent or, at least,

decisions, which mean the resolution of the

hinder the treatment guided by the domineering

problem, through the creation of new personal

and/or coercive practice and, at the same time, do

resources; the end of the crisis - in this final stage,

not have a tutelar/paternalistic character. The

France (1982) draws attention to occurrence of

patient in crisis, in distress, needs an urgent

suicide attempts3, which may be ‘only’ draw

intervention. For this reason, Saraceno, Asioli and

attention or the decision to solve definitely the

Tognoni (2001) define the psychiatric emergency as

personal problem.

an unexpected event that requires immediate intervention.

Crisis: how to respond?

According to Knobloch (1998), the professionals that

The therapy to deal with crisis situations implies

works daily with attendance of crisis events, faces

necessarily remembering and recalling the event. It

situations of disruption of representational world; in

is very important first the oral report, in order to

this case, the therapists acts as a ‘bridge’ between

clarifies and organizes the therapeutic process (Sá,

the patient and the reality; their attitude must be

Werlag

and

primarily based in the support. The support implies

disorganization (crisis) are limited in time, and the

consider the crisis as the patient feels it, i.e., as a ‘real

main goal of the intervention is to help the people to

factor’, the event really happened.

recover their psychological situation that they had

In

before the event.

professional ought to demonstrate very interested,

3

himself, which he knows will produce this result" (Durkheim, 1987, p. 44).

&

Paranhos,

2008).

Instability

- "Suicide is applied to all cases of death resulting directly or indirectly from a positive or negative act of the victim

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emergency

therapies,

in

particular,

the

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available and participant. In moments of crisis, the

therapeutic efficacy that can be classified as

therapist is an agent that binds and cements the

symptomatic, curative or preventative. In psychiatry,

fragments of the individual (Knobloch, 1998). It is

predominates the use of drugs with symptomatic

necessary to valorize the person in crisis, the

therapeutic efficacy; i.e., when the objective of the

individuality and singularity of the situation. It

intervention is to control or suppress an expression

implies taking into account the human condition, the

of the patient's problem that is harmful or causes

idiosyncrasies, and not only considered the

significant distress (Saraceno et al., 2001).

individual as a sick person (Sterian, 2000).

In the mental health, beyond the reduction of the

A listen narrative of pain, of anguish, with no

symptomatology, medication does not change the

apparent meaning, is not an easy task; it requires

natural course of the patients’ problem. However, it

especial abilities and a specific ethical attitude. The

determines the condition of a different relationship

importance are not in the symptoms, but what it

between patients with their problem, with the

means to the person who lives the experience

professional and social environment. Thus, the

(Dolto, 1983, cited by Sterian, 2000); providing a

decision of a pharmacological intervention must be

listening mechanism, the therapist create an ideal

included in a strategy that privileges the therapeutic

situation, in which the individual in crisis feel

treatment proposed, especially for each patient, and

comfortable for talking and be helped. Another

not the mere elimination of symptoms (Saraceno et

crucial factor is to differentiate the specificities of

al., 2001).

501

the self (therapist) from the other (patient) in order to avoid the subjectivity in the therapeutic process.

Women victims of violence - a therapeutic

Finally, although what the therapist hears seem

approach

meaningless, what is said by the patient always have a meaning. According to Birman (1983, cited by Knobloch, 1998), putting this content in question, the meaning can be restored and, thus, the possibility of find a solution to the conflict that underlies the crisis. The pharmacological effect is a demonstrable change that the medicament provokes in the humans bodies. It can be expressed in the biochemical or functional level and is clearly related to drug administration. The different drugs have a

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In this particular category of violence, the primary advantage of the crisis intervention is a clear understanding

that

the

moment

of

revelation/denouncement of the event is - for most of the victims - particularly problematic, a really moment of crisis that induces disorganization in the personal and familial contexts (Walker, 1994). The disorganization also appears because, unfortunately, the revelation of the violence often is negatively received by the family and social environment, aggravating the feeling of stigmatization, shame and

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guilt feelings by the victims. It breaks the myth of

helping women to find their own capacities,

unity and functionality, often preserved during long

involving independence and interdependence with

time by hiding the traumatic experience and the

others people (restore the self-confidence and in

social isolation of the family. And, in particular, the

others and mobilize the social support network);

isolation imposed or self-imposed to the victim. This

validate the victim's rights (to be treated with

dysfunctionality requires new equilibrium in the

respect); trace short-term goals, planning the day-to-

family, which need to deal with the (negative)

day life (retake gradually daily activities); emphasize

publicity of the problem, as well as the configuration

the capabilities and resources in decision making for

changes of the family; normally because the

the empowerment; alerting for the criminal

individual (the offender or victim) leaves home and

responsibility of the offender; reduce the acceptance

the consequent redistribution of the family roles and

or tolerance of the use of physical force in the

functions.

interpersonal dispute or conflict; in a self-respect

In Portugal, some therapeutic modalities have an

process, reduce the psychological dependence in

increasingly important place in working with victims

relation to the offender; deconstruct the feeling of

of domestic violence, in particular, the crisis

self-blame; address that the victims do not have the

intervention (Matos & Machado, 2001), the

control of the situation; engagement against the

narrative psychotherapy in individual plan4 (Matos &

stereotypes of the ‘traditional’ gender roles (for

Gonçalves, 2005) and the intervention in group5

instance, women should always be sexually

(Machado & Matos, 2001).

available to their husband); inform about the

Crisis intervention is based on some primordial tasks

existence of association and institutions with specific

(Webb, 1992): defining with the victims what

work to help the victim, including provide legal

constitutes the crime and explain to them the

support. Indeed, the general objective of this type of

dynamics associated with the problem (for instance,

intervention is to provide mechanism to the victims

the aggressor strategies) and characterize the

for recover their abilities and skills. It is appropriate

normal reactions to this type of situation; prevention

to solves immediate crises, focusing on precipitate

of the re-victimization of women and their children

events or situations and seeking to develop coping

(elaborate

strategies and solves immediate problems of the

a

safety

plan,

temporary

accommodation); empowerment, which involves

victim (Matos, 1999; Matos & Gonçalves, 2005).

4

5

- Narrative therapy, in general, offers new possibilities in terms

- The aims of the intervention in group is the increased of the

of purpose of the therapeutic process, the conceptualization of

self-esteem and self-concept, planning of the personnel security,

the problems, the therapist-client relationship, mechanism, and

education on the cycle of violence, the promotion of decision

the interventional proposals.

making, solving problem, awareness about male and female roles in society, assertiveness training, and empowerment.

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The sexual crime, albeit with more consequences to

In the acute reaction, immediately after the sexual

the victim, must be understood as a social

assault, the victim's feelings include shock, unbelief,

phenomenon and, thus, with public and collective

dismay, anxiety, and fear. During this phase is

responsibilities. Considering the guarantee and

extremely important to encourage the victim to talk

defense of individual rights, this issue requires

about the aggression. The therapist should help

constant and long-term measures and, therefore, an

with: health care, formal complaint, legal assistance,

institutional framework, articulating state and

notification of family and friends, relevant and useful

society. In Portugal, however, the intervention

information related to the problem, emotional

measures often have an emergency nature and seek,

response and psychiatric consultation.

in particular: interrogate; collecting evidence; write

The way that the victim deals with the practical

the report; open the judicial process; psychological

problems and the various psychological mechanisms

treatment of victims; remove the victim or the

- such as denial, suppression, and rationalization -

offender from the house; and preventive detention

are treated in the second stage. During the

for the offender (Rodrigues, 1997).

integration

The experience of sexual abuse causes a state of

depressed and needs to talk about their feelings.

imbalance (Caplan, 1964). Crisis intervention is

However, they are usually reluctant to receive

considered

focused

intensive help and should not be criticized for their

intervention, with the aim of stabilizes the victims

feelings. The victims gradually reassume their

and helps them to manage the situation. It is very

normal activities and seem to be handling the

important an immediate intervention, in order to:

situation; the interest is seeking help and to talk

correct distorted perceptions about what happened,

about their experience. The proper attitude of the

reduces guilt feelings and "self-censorship", mobilize

therapist is the support and encouragement to the

skills, coping strategies, and facilitates the re-

victims to keep the therapeutic monitoring and

integration of the victims in their family and in the

works with the patients’ families and friends.

social support network (Raphael, Meldrum, &

Often a specific incident precipitates the phase 3: for

McFarlane, 1995).

example, the patient discovers that she is pregnant,

In case of sexual abuse, Scherl & Fox (1972)

receives a judicial notice or sees a man with

suggested that the crisis intervention can be

appearance of the aggressor. In such cases, the

categorized into three stages: 1) acute reaction; 2)

therapists should direct their initial efforts to help

external adjustment; and 3) integration and

the patients to deal with the precipitating factor. At

resolution of experience.

this stage, two principal issues must be worked with

as

a

rapid,

brief,

and

phase,

the

patients

usually

feel

the victims: their feelings about themselves (usually

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the victim feels guilty and dirty) and about the

marital status, divorce, social isolation, familial and

aggressor (usually odium).

economics problems, unemployment, etc (Gunnel &

After the crisis, provoked by the revelation of a

Frankel, 1999).

particular sexual abuse, occur a (re) accommodation

The feelings of a suicidal person are usually a triad of

to the anterior conditions, a ‘back to normal’ state,

hopelessness, helplessness and despair. According

including both the people involved in the situation,

to Gunnel & Frankel (1999), the three most common

as well as the professionals who have worked in the

states are: a) ambivalence - there is a dilemma

case (Faleiros, 1997).

between the desire to live and desire to die. If this ambivalence is considered by the therapist to

Suicide - a therapeutic approach If the patient is under psychiatric treatment, there is more risk in those who have a history of suicide attempts. According to Werlag (2000), selfdestructive acts are related to the inability of the people to find different alternatives to cope with their conflicts, and they choose the death. The negative resolution of the crisis, which can happen by the lack of the immediate intervention, it leads the individual to develop suicidal behavior. This behavior can be classified into three categories: suicidal ideation, suicide attempts, and consummate suicide. A historical of attempts and suicidal ideation confer a predictive factor to evaluation the risk of suicide. Thus, the intervention at the time of hopelessness and confusion is decisive for the positive resolution of the crisis (Borges, 2004).

increase the desire to live, the suicide risk can be reduced; b) impulsivity: suicide is an impulsive phenomenon and the impulse is normally transitory. If the help is provided at the time of the impulse, the crisis can be avoided; c) rigidity: suicidal people normally have thought, affection and actions reduced. The therapist should explore the various alternatives to death, showing to the patients that there are other options, even those considered by the patients as not ideal for them. In the suicidal behavior is important to consider the influence of variables, such as: impulsivity, low capacity to solve problems, the existence of meanings, attitudes and subjective purposes, defeatist or inappropriate; and the existence of factors related to socio-economic problems, loss of significant other, etc (Borges, 2004).

Individual and socio-demographic factors may increase the risk of suicide and are very useful clinically, especially in cases of: psychiatric disorders (depression, alcoholism, and personality disorders), physical illness, suicide attempts, family history of suicide, and bereavement, and social factors as

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The principal aspects to focus on in an interview with

intervention (Bongar, 2002). The efficiency of the

the suicidal patient are: the problem experienced6;

therapeutic treatment is one of the most important

suicidal attitudes7; presence of psychopathology8;

aspects. It is relevant to manage adequately the

and social-familial support9.

counter transference; the patient provokes a strong

A model of crisis intervention with victims of suicide

counter-transference in the therapist (fear, anxiety,

- yet always considering the individuality/specificity

anger, helplessness or resignation). And the

of the patient (development, culture, cognitive

therapist should impose strict control. After

limitations) - consist of seven steps: 1) assess the

normalize the situation, the patient begins to feel

lethality; 2) establish therapeutic alliance; 3) listen

safe and then it is important to talk openly and

the story of the situation; 4) managing feelings; 5)

honestly about suicide (suicidal thoughts and

explore alternatives; 6) use behavioral strategies;

behaviors), normalize the associated guilt and

and 7) follow up10 (Granello, 2010).

shame, which reduce the risk of suicide (Chiles &

The first and most important step is an accurate

Strosahl, 2005). It is convenient to speak calmly, with

evaluation of the victims. Although it could be a

short sentences. Rather & Jobes (2006, cited by

lengthy process, the information that they provide is

Granello,

a representation of the level of lethality of their

approach, in which the therapist and patient work

actions. They should never be alone because suicide

together.11

can happen rapidly (Granello, 2010).

In the third phase of the proposed model, listening,

The second step is the most significant factor in the

understanding and validation, is a useful mnemonic

assessment of suicide risk and the success of the

(Echterling, Presbury & McKee, 2005). The therapist

6

8

- Using a semi-structured interview, is important to register the

report on the difficulties that led the patient to seek and see the

recommend

a

collaborative

- It is important also to obtain information about personal and

familial historical of suicidal, and whether the patient has a mental disorder (depression, for example) or chronic pain.

solution in suicide. 7

2010)

- Taking in attention the suicidal ideation and purpose. It is

pertinent formulate the following questions: "do you think frequently in commit suicide?"; "Are you convinced that the suicide is the only solutions to your problems?". It is also important to consider how the patient plans to suicide, questioning: "how will you kill yourself?” “And when?";"You will warn someone before commit suicide?"; “Who will find your body?";" Who will claim your dead body?". And finally, suggest the patient to think about the consequences of the suicide, questioning: "Do you really think that your death will not affect anyone?"; "Do you never thought to find other solutions?”.

9

- The social and family supports are very important to maintain

balance of the patient with suicidal ideation, as well as after the treatment/therapy. 10

- The ‘follow-up’ (sequential evaluation) aims to monitor, over

time, the results of an intervention. This task is one of the big challenges of the process. Yet it provides a new opportunity to the patient identify the implementation of changes/overcoming (Matos, Machado, Santos & Machado, 2012). 11

- The therapist may suggest to the patient the following

interpelative methodology: "I need you to do a therapeutic journey with me. On this trip, you’ll be the driver and I’ll be the passenger. I've done this trip countless times, I know the roads well and I have excellent maps; however, the journey is always unique to the driver".

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listens to the patients’ stories, conveys a deep

Following a behavioral strategy, in the sixth phase, it

understanding of the intent and validates their

is important to elaborate a short-term plan to

psychological pain. At this moment, it is crucial to

minimize the risk present in the continuum

create a ‘therapeutic window’12 and a categorization

behavioral of people with ideation/suicidal attempt.

of the problems13.

It should be inserted small steps, with significant

The management of the emotions, the fourth stage,

impact on the quality of the patients’ life, which lead

is essential, because the patients are overloaded of

them to yearn for major changes15 (Chiles & Strosahl,

(ambiguous) feelings and emotions and should be

2005).

encouraged the emotional ventilation, which allows

And the last stage, the follow up. To prevent a

to express their emotions (Rather & Jobes, 2006,

relapse, can be make an intensive follow up

cited by Granello, 2010).

(including the management of the case, telephone

In the fifth stage, other alternatives can be explored.

contact and even home visit), a safety plan in case of

During the crisis, the patients usually do a selective

imminent

abstraction,

negative

therapy, all procedures to improve the resolution of

generalizations about themselves and social reality

the problems and reduce the suicidal ideation

(Granello,

(Rather & Jobes, 2006, cited by Granello, 2010).

using

filters

2010).

The

to

make

simple

strategy

of

risk

and

brief

cognitive-behavioral

communication is an option to discuss alternatives14.

At the end, is important to establish a ‘no-suicide

It is also important to establish strategies of solving

contract’, as a useful technique for prevention;

problems, which includes: the identification of the

other familiar and close people to the patient may be

problems, identify alternatives strategies and

included in the negotiation. It must promote

solutions, evaluating

a

discussion of relevant aspects, taking into account

technique for a specific problem and formulate a

that, in most cases, the patient accepts the

plan of action and implement this technique and

therapeutic resolutions. However, is relevant to note

evaluate its effectiveness (Chiles & Strosahl, 2005).

that the establishment of a contract is valid only

At the end, it is important to restore the hope and

when the patients have total control over their

resilience, as well as directing the patients to their

actions (Borges, 2004).

alternatives, selecting

reintegration into the social support network. 12

- It helps the patient to deviate from suicidal thoughts, which

your plan A in the table and we’ll try to draw a plan B". The goal

induce the patient believes that the suicide is the only solution.

here is to find alternatives to the suicide, using only language

13

strategies.

- There is a strong possibility of the suicidal patient manifests

the following problems: personality and mood disorders, and

15

previous suicide attempts.

do you think that this could be a sign of progress in your life?” and

14

“If you do X, in the next few days, do you think that this can

- I understand that the suicide is an option for you, but I do not

agree that it is the only and best choice possible. Therefore, put

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- Key-questions: “If you’re able to do X, in the next few days,

change what you feel in this moment?".

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Final Considerations A better understanding of how crisis are constituted and an appropriate intervention are crucial to solve the problem, in a quick and effective way. If the resolution is makes in an adaptive form, it could generate three opportunities: understand the crisis occurred in the past; have control of the present situation; and develop better strategies to deal with probable future problem (Parada, 2004). In this context, it is important to understand that crisis is part of the life: cannot be avoided, but rather explored, assumed, accepted in its enriching value for new forms of life and enrichment (Boff, 2002, p.26). The crisis is not an arbitrary cutoff in the history of life or the last stage of the existence; even in moment of crisis, the people are able to express affection, creativity, discernment, and desires. If the purpose of an intervention is only to resolve the problem originated by the crisis, this option forbids them to have new experiences, a better selfknowledge and personal enrichment (Knobloch, 1998). Slaikeu (1996, cited by Sá, Werlang & Paranhos, 2008) presents three principles in the clinical practice of crisis intervention: a) opportunity calculates and reduces the risk, evaluating also the patients' motivation to find a new coping strategy, according to their current life circumstances; b) goal - help them to regain the equilibrium level that they had before or reach the level to overcomes the critical moment; c) evaluation - comprise the strong,

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but also the weak aspects of each factors involved, as well as information about what is functional and dysfunctional in the people's lives. Erikson (1971) considers the crisis as a critical event, yet necessary for the development of the people, which leads them to take a certain direction, in order to forward resources for their growth, recovery, and positive differentiation. In the specific case of sexual crime (rape), this traumatic event precipitates the individual in a state of imbalance (Caplan, 1964). Crisis intervention must be focused, fast, and brief, with the aim of stabilize the patients and help them to manage the situation. Immediate intervention is useful for: corrects misperceptions about what happened, reduce the guilt feelings and the ‘self-censorship’, develop skills and

coping

strategies,

and

promote

the

reintegration of victims in their social support networks, especially in the family (Raphael, Meldrum, & McFarlane, 1995). An advantage of crisis intervention, in the case of victims of sexual violence, is the clear understanding that the moment of revelation/denouncement of facts is (for most of the victims) particularly problematic, a really moment of crisis (Walker, 1994). It has also the advantage of possess pragmatic features; to ensure a deeper intervention, it should be preceded by the stabilization of symptoms of the patients and the provision of a minimum condition for living (Machado, 2004). Another important area of intervention is the suicide. Suicide results from the inability of the

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people to find other alternatives to face and solve

(2ªEd), (pp. 213-261). Washington, DC: American

their problems. The historical attempts and suicidal

Psychological Association.

ideation provide a predictive value for assessing the suicide risk. Therefore, immediate intervention is crucial for a positive resolution of the crisis (Borges, 2004).

Borges, V. (2004). Ideação suicida na Adolescência. Dissertação

de

Mestrado

não

publicada.

Universidade Católica do Rio Grande do Sul Porto Alegre.

The effectiveness of the therapeutic procedure and the management of emotions are essential aspects in the treatment. The patient is overloaded by (ambiguous) feelings and emotions; thence, is important encourage the 'emotional ventilation', using language strategies, in order to discuss new

Campos, G. (2003). A clínica do sujeito: por uma clínica reformulada e ampliada. In G. Campos, (Ed.), Saúde Paidéia. São Paulo: Hucitec. Caplan,

G.

(1980).

Princípios

de

psiquiatria

preventiva. Rio de Janeiro: Zahar.

alternatives to solve the problems, fostering the

Chiles, J. & Strosahl, K. (2005). Clinical Manual for

restoration of hope and resilience of the patient and

assessment and treatment of suicidal patients.

finally the process of follow-up (Granello, 2010).

Washington, DC: American Psychiatric Press.

It is relevant also to note that the intervention in a crisis signify to act in an active way in a vital situation for the patients and help them to mobilize their own resources to overcome the problem and recovering the emotional balance (Raffo, 2005). Crisis intervention is, therefore, a primordial factor

Dell’Acqha, G., & Mezzina, R. (1998). Resposta à crise. Per la salute mentale – pratiche ricerche culture dell’ innovazione, 1(1). Durkheim, E. (1997). Suicide: a study in sociology. Glencoe: The Free Press.

for the treatment and recovery of people who

Echterling, L., Presbury, J. & McKee, J. (2005). Crisis

suffered traumatic events, as discussed in this

intervention: promoting resilience and resolution

article: women victims of violence and suicide.

in troubled times. Columbus, OH: Prentice Hall. Erikson, E. (1971). Infância e sociedade. Rio de Janeiro: Zahar.

References Boff, L. (2002). Crise - oportunidade de crescimento. Campinas: Verus. Bongar, B. (2002). Risk management: prevention and

Faleiros, V. (1997). Estratégias em Serviço Social. São Paulo: Cortez. Faundes, A., Rosas, C., Bedone, A. & Orozco, L.

postvention. In B. Bongar (Ed.), The suicidal

(2006).

patient: Clinical and legal standards of care

indicados e seus resultados no atendimento de

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Violência

sexual:

procedimentos

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Wainrib, B. & Bloch, E. (1998). Crisis intervention and trauma response: theory and practice. New York: Springer. Walker, L. (1994). Abused women and survivor therapy: A practical guide for the psychotherapist. Washington, D. C.: American Psychological Association. Webb, W. (1992) Treatment issues and cognitive behavior techniques with battered woman. Journal of family violence, 7, 205-217 Werlag, B. (2000). Proposta de uma entrevista semiestruturada para a autopsia psicológica em casos de suicídio. Tese de Doutoramento não publicada. Universidade de Campinas – São Paulo. Younes,

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Original Article Satisfaction of basic psychological needs and self-determination in people with schizophrenic psychosis and depression Rita Sousa (1), Ana Allen Gomes (1,2) & Susana Veloso (3) 1. Aveiro University, Department of Education. Correspondent author: rita_sousa25@hotmail.com 2. I&D Unit of FCT IBILI (FM-UC) 3. Universidade Lusófona de Humanidades e Tecnologias. Centre for Malaria and Other Tropical Diseases UNL

------------------------------------------------------------------------------------------------------------------------------------------------Summary: insufficient motivation, typical in schizophrenia and depression has serious psychosocial damage. The self-determination theory states that the optimal motivation requires the satisfaction of three basic psychological needs (NPB) associated to a mode of self-determined function, psychological well-being and optimal functioning. This study examined the satisfaction levels of NPB and self-determination in patients diagnosed with depression and schizophrenia, comparing them with a non-clinical sample. The 91 participants were between 21 and 71 years, 29 with schizophrenic psychosis, 29 with depression and 33 without selfreported current mental disorder. Portuguese versions of the satisfaction scale of NPB, Self-Determination (EAD / SDS) and the Beck Depression Inventory were used. The results showed lower levels of satisfaction of NPB and self-determination in the groups with no current psychopathology compared to pathology. We discuss the value of the translation of these findings into clinical practice. Keywords: psychological needs, self-determination, schizophrenia, depression. Resumo A insuficiente motivação, típica na esquizofrenia e depressão, tem sérios prejuízos psicossociais. A teoria da autodeterminação estabelece que a motivação ótima exige a satisfação de três necessidades psicológicas básicas (NPB) associadas a um modo de funcionar autodeterminado, ao bem-estar psicológico e o funcionamento ótimo. Este estudo analisou os níveis de satisfação das NPB e de autodeterminação em doentes com diagnóstico de depressão e esquizofrenia, comparando-as com uma amostra não clínica. Os 91 participantes tinham entre os 21 e os 71 anos, 29 com psicose esquizofrénica, 29 com depressão e 33 sem autorrelato de perturbação mental atual. Foram usadas versões portuguesas da escala de satisfação das NPB, de Autodeterminação (EAD/SDS) e do Inventário de Depressão de Beck. Os resultados mostraram menores níveis de satisfação das NPB e de autodeterminação nos grupos com psicopatologia comparativamente ao sem patologia atual. Discutimos o valor da tradução destes resultados na prática clínica. Palavras-chave: necessidades psicológicas; autodeterminação; esquizofrenia; depressão. Resumen: La motivación insuficiente, típica en la esquizofrenia y la depresión tiene un daño psicosocial grave. La teoría de la autodeterminación establece que la motivación óptima requiere la satisfacción de tres necesidades psicológicas básicas (NPB) asociados a un modo de la función de auto-determinación, el bienestar psicológico y el funcionamiento óptimo. Este estudio examinó los niveles de satisfacción de NPB y la libre determinación de los pacientes diagnosticados con la depresión y la esquizofrenia, comparándolos con una muestra no clínica. Los 91 participantes tenían entre 21 y 71 años, 29 con psicosis esquizofrénica, 29 con depresión y 33 sin trastorno mental actual de auto-reporte. Se utilizaron versiones en portugués de la escala de satisfacción de NPB, Autodeterminación (EAD / SDS) y el Inventario de Depresión de Beck. Los resultados mostraron niveles más bajos de satisfacción de NPB y la autodeterminación de los grupos sin psicopatología actual en comparación con los con patología. Se discute el valor de la traducción de estos resultados a la práctica clínica. Palabras clave: necesidades psicológicas, autodeterminación, esquizofrenia, depresión. -------------------------------------------------------------------------------------------------------------------------------------------------

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Motivation appears to be an important variable in the functioning of people with psychopathology that influence the efficacy of the treatment (Choi, Mogami & Medalia, 2009; McBride, Zuroff, Ravitz et al., 2010; Madalia & Saperstein, 2011). The functional outcome in schizophrenia is influenced by intrinsic motivation, identified as an important mediator of neuro-cognitive and psychosocial results

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However,

accompanying

the

forms

of

psychopathology is the dissatisfaction of these needs (Ryan, Deci, et al. Cited by Deci & Ryan, 2000). According to ADT, the origin of some forms of psychopathology is primarily the dissatisfaction of these needs (Ryan, Deci, et al. Cited by Deci & Ryan, 2000). According to this theory, a chaotic parental and educational environment, controlling, punitive, neglectful, can stop the satisfaction of NPB and self-

(Choi, Mogami & Medalia, 2009).

determined regulation, resulting in psychological Motivation is an internal state that initiates, directs, and sustains certain conduct until achieving objectives (Velligan, Kern, & Gold, 2006). In 1975, Deci and Ryan, in the book, Intrinsic Motivation, said that people that are intrinsically motivated needed to feel competent and self-determined (Ryan & Deci, 2000). The concept of basic psychological needs, identified as determinants of intrinsically motivated

dysfunction. Self-determination can be considered as one of the core values in any program of psychosocial rehabilitation of people with mental illness (SAMHSA, 2006 cit. Marques, Queiroz, & Rock, 2006). In this sense, having self-determination means to, have the freedom of being responsible for his own life, to choose where to live, whom to 513

relate and what to do.

behavior, appears to better explain the results of research on intrinsic motivation, contrary to previous ideas that all behavior would be due to the satisfaction of physiological needs (Deci & Ryan,

A TAD further stipulates that the NPB competence (i.e,, sense of personal efficacy in interaction with the environment) , autonomy (i.e., perception of freedom of choice and act according to their own

2000).

interests and values), and belonging relationship According to Self-Determination Theory (TAD) (Deci & Ryan, 1985) the three basic psychological needs (NPB), competence, autonomy and relationships of belonging,

are

essential

nutrients

for

the

development of psychological integrity, being associated to a self-determined way of working

(i.e., feeling be connected to other significant stable and genuine way) will determine the regulation of behavior, based on a motivational continuum ranging from more or less self-determined forms, i.e., controlled versus autonomous, and to help selfunderstanding of the components of extrinsic

optimal psychological well-being (Deci & Ryan,

motivation (i.e., action performed by internal or

2000).

external pressures) versus intrinsic (i.e. , action taken by pleasure or satisfaction inherent challenge) (Deci

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& Ryan , 1985; Deci & Ryan, 2000). In this sense, the

of remission of depression in both groups with

optimal development of the individual assumes that

higher and lower number of depressive episodes.

this continuum translate a process of internalization

The study concludes that we need differential

of behavior that passes less self-determined forms

strategies treatment when working with these two

for more self-determined forms of regulation of this

distinct populations, and the therapists who work

behavior (Ryan & Deci, 2000).

with patients with less recurrent depression, may

Studies comparing people with self-motivation with others whose behavior is controlled by external

focus on ways to enhance autonomous motivation (McBride et al., 2010).

factors, show that the first denote more interest,

TAD constructs are widely studied in community

enthusiasm

samples,

influence

and confidence, which positively the

performance,

persistence

but

very

little

in

people

with

and

psychopathology. In recent years research in the

creativity (Deci & Ryan, 1991; Sheldon, Ryan,

population were emerging with psychological

Rawsthorne & Ilardi, 1997; cit. by R. Ryan & Deci,

disorders, including in our country – Portugal (Brekke

2002).

& Medalia, 2010; Yamada, Lee, Dinh, Barrio, &

A study of adapting a rating scale of intrinsic

Brekke, 2010; Soares 2009).

motivation within the TAD showed the applicability

A study in Portugal, which demonstrates the

of the theory to people with schizophrenia (n= 73)

importance of studying motivation in clinical

(Choi, et al., 2009), the motivational explanation

samples, with the participation of 95 subjects, 51

allowing deficits in schizophrenia through concepts

with schizophrenia and 44 without schizophrenia,

of autonomous motivation, self-regulation and

had as main objective validation for the Portuguese

external

population of a scale to evaluate motivational

motivation

and

good

influence

on

internalization.

orientations (Causality Orientations Scale) of people

A study with 74 depressed patients showed that independent motivation appears to be a promising

with

psychopathology,

mentioned

in

the

rehabilitation process (Smith, 2009).

variable on efficacy in the treatment of depression,

Thus, investment in increasing motivation in people

to add to the therapeutic alliance (McBride et al.,

with psychopathology is a matter of interest to the

2010). The increase in the number of episodes of

present study. It is noted that no studies on the

depression suffered decreases, however, the

satisfaction of basic psychological needs and level of

influence of that variable, is associated with less

self-determination

recovery

psychopathology, which motivated this investigation

of

those

episodes.

Moreover,

the

controlled motivation showed a negative predictor

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in

samples

with

were found.

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The main objective of this study was to determine

primary education, 12 (41.4%) with the first cycle, 7

the degree of satisfaction of basic psychological

(24.1%) with second cycle and 2 (6.9%) with a college

needs (NPB) and levels of self-determination (SDS) of

degree. In the group of 29 subjects with depression,

people with clinical depression and schizophrenia,

10 (34.5%) has primary education, 7 (24.1%) first

and compare them with those of individuals without

cycle, 6 (20.7%) the second cycle, five (17.2%) a

current psychopathological diagnosis. Additionally,

college degree and 1 (3.4%) a master degree. Of the

we will evaluate to what extent the existing level of

33 participants without pathology, 1 (3.4%) did not

depressive symptoms in each group, with or without

complete any cycle of education, 15 (45.5%)

pathology, showed associations with the satisfaction

completed primary education, 9 (27.3%) the first

of NPB and SDS.

cycle, 3 (9.1%) the second cycle, 1 (3.0%) the bachelors and 4 (12.1%) licensure.

Methodology Instruments

Participants The study included 91 participants in total, among which 29 (31.9%) had a diagnosis of schizophrenic psychosis (10 women and 19 men), other 29 (31.9%) had a diagnosis of depression (21 women and 8 men), to be followed at the Hospital Magalhães Lemos in Porto and, lastly, 33 (36.3%) participants (23 women and 10 men) did not have any diagnosed psychiatric disorder at the time of data collection.

- Beck Depression Inventory - BDI (original version: Aaron Beck, 1961; Portuguese version: Vaz Serra and Pio de Abreu, 1973). The BDI consists of 21 symptomatic and attitudinal categories, selected from the attitudes and symptoms that appeared to be more specific of depression (Diegas & Cardoso, 1986). Of these 21 categories, 11 are related to cognitive aspects, 5 with symptomatic aspects, 2 with observable behaviors, 2 with warmth and 1 with

The ages of the participants ranged between 21 and 71 years (M = 50.3, SD = 11.14) in the global, and more specifically between 25 and 69 years (M = 47,

interpersonal symptoms. In our study, we found a value of .92 for Cronbach's alpha coefficient, an indicator of high internal consistency.

SD = 11.8) in the group diagnosed with schizophrenic psychosis, between 21 and 71 years (M = 53, SD = 11.1) in the group diagnosed with depression and between 25 and 70 years (M = 50, SD = 10.1) in group with no current diagnosis of psychiatric illness.

- Scale of Self-Determination - EAD / SDS (original version: Sheldon & Deci, 1993, English version: Ribeiro, Palmeira, Teixeira, Silva & Sousa, 2012). The Self -determination Scale measures individual differences in the self-determined functioning,

Of the 29 participants with schizophrenic psychosis,

considered as a relatively enduring aspect of

1 (3.4%) presents with no schooling, 7 (24.1%) with

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personality that reflects (1) be more aware of own feelings and own consciousness and (2) a sense of choice with regard to their behavior , i.e. " perceived their own behavior in relation to choice" Sousa , et al . , submitted). EAD / SDS is a 10-item scale comprising two subscales with 5 items each, and the response scale for each item is Likert type 5 points, rated 1-5. The first subscale is the awareness itself, and the second refers to the perception of choice of actions. In the present study we found values of Cronbach's alpha of 0.72 in perceived choice subscale, indicating adequate internal consistency, but only 0.38 in the subscale of self-awareness.

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Procedures We first requested authorization to authors of the original instruments and upgraded versions to Portugal, for the use of instruments in this study. Then were asked, through written research project, released for the Ethics Committee of the Hospital Magalhães Lemos (SEE) for administration of questionnaires in hospitals presentation, once the participants of the clinical groups in this study was collected in the Rehabilitation department of a hospital. Subsequently we proceeded to the delivery of

the

respective

individual

self-report

questionnaires to participants, explaining the

- Scale of satisfying basic needs (in general) - BNSG

instructions and the intended goals with the

(original version, Basic Need Satisfaction in General

investigation. Along with the questionnaires was

Scale Deci & Ryan, 2000; Portuguese version: Sousa,

handed a record of informed consent that explained

Ribeiro, Palmeira, Teixeira & Silva, 2012). This scale

all the conditions of participation in this study. As

has 21 items divided into three subscales that

regards the collection of the control group, it is

correspond to the three basic psychological needs (a)

noted that care was taken to match the education

competence, (b) autonomy and (c) relations of

and age of the participants of these clinical groups as

belonging.

much as possible. The control group was taken for

For

each

statement

placed,

the

participant is asked to respond on a 7-point scale from 1= not true, to 7= totally true. In the present study, the values of Cronbach's alpha coefficients were .62, .52 and .48, respectively, and .66 on the global scale, standing so below the range commonly considered desirable, as has occurred in other studies with this scale

convenience at various places. The results of the various questionnaires were analyzed using the Statistical Package for Social Sciences (SPSS), version 17, using the data distribution depending whether or not were presented with an approximately normal curve, the parametric tests for scale satisfaction of basic psychological needs and nonparametric tests for the scale of self-determination, respectively. To make comparisons between diagnostic groups resorted to ANOVA and nonparametric Kruskal Wallis and Mann

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Whitney. Even correlations, Pearson or Spearman

and sex, the overall sample and in each group, we

were determined according to the distributions

found that there were no statistically significant

found for age, BDI and several subscales of the

mean differences in the subscales of NPB for sex, no

instruments mentioned above.

significant correlations between subscale scores with age, so we'll present the results for each diagnostic group, cf. Table 1. comparing the average

Results

of the three groups by means of ANOVA, autonomy,

Basic Psychological Needs

competence and relationships of belonging, we

As for the satisfaction of basic psychological needs

observe statistically significant differences (it should

(NPB), considering the totality of the participants, a

be noted that we begin to see that there were no

normal distribution appears in the three subscales of

significant interaction effects for diagnostic group

the NPB. In a preliminary analysis of scores by age

sex *).

Table 1 - Means (standard deviations) for the subscale of NPB, in function of diagnosis group.

Autonomy

Schizophrenic Psychosis (n=29) 4,42 (1,03)

4,49 (1.02)

Competence

4,24 (1,23)

Relations of Belonging

4,97 (0,72)

Through Turkey (Honestly

Depression (n=29)

No Pathology (n=33)

F

f.d.

P

5,15 (1,03)

4,71

2; 88

0,011

4,03 (1,17)

5,23 (1,01)

9,47

2; 87

0,000

5,05 (0,87)

5,54 (0,69)

4,58

2; 80

0,013

post hoc HSD

517 Significant Differences), test for homogeneous variances, it is noted that in the autonomy subscale, subjects

with

Schizophrenic

psychosis

and

depression have significantly lower levels than participants without pathology (p= 0.020 and p= 0.037, respectively), succeeding even as regards competence subscales (p= 0.004 and p= 0.000, respectively) and relations of belonging (p= 0.020 and p= 0.046, respectively) and there were no significant differences between the two groups with

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pathology. Regarding the magnitude of the significant associations were found Eta squared values of 0.099 for the autonomy subscale, 0.182 for the competence subscale and 0.105 for subscale relations of belonging. These values refer to low effect sizes in the first case and moderate in the remaining cases according to the criteria proposed by Ferguson (2009) or, following the criteria of Cohen (1992), to moderate associations in the former and high in the second and third cases.

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subscales of consciousness (Md= 21.0 and M= 43.8

Self-determination

in men: Md= 20, 0 and M= 39.5 for women) and The scores on the self-determination (SDS) strayed from a Gaussian curve, so it was necessary to resort to non-parametric tests, and in addition to the averages

indicate

medians

and

percentiles

respectively as measures of central tendency and

perceived choice (Md= 15.5 and M= 41.3 in men: Md= 16.0 and M= 40.7 for women), sex differences assume statistical significant only for the choice and perceived only in the group of participants with schizophrenic psychosis (U= 39.0, p= 0.048).

dispersion. We then compare the scores of the scale of selfIn a preliminary analysis by age and sex, the overall sample and in each group, we found no significant associations between scores on the SDS and age (Spearman correlation coefficients). The Mann Whitney tests used for comparisons between sexes, revealed that although the men present in the overall sample medians and averages higher on the

determination among the three groups of interest. It can be seen from the Table 2 that the median subscales obtained awareness and perceived choice SDS level is always higher in the case of participants without pathology. However, it is noteworthy that this difference only reached statistical significance in one's own consciousness subscale (p= 0.007).

Table 2 - Results of the subscales on Self-Determination by diagnostic groups Schizophrenic Psychosis (n=29) Md (P25; P75)

Depression (n=29)

No Pathology (n=33)

Md (P25; P75)

Md (P25; P75)

χ2

d.f.

p

SDS_Total

35,0 (29,0; 39,0)

33,5 (25,0; 42,0)

38,0 (34,0; 44,0)

5,05

2

0,080

Conscience

19,0 (16,2; 22,7)

17,0 (13,0; 21,0)

21,0 (20,0; 24,0)

9,98

2

0,007

Perceived

15,0 (13,0; 19,0)

15,0 (11,5; 21,0)

18,0 (14,5; 22,0)

2,72

2

0,256

Choose χ2: Kruskal Wallis test. Md = median. P25 = 25th percentile, P75 = 75th percentile.

Then, in performing nonparametric Mann-Whitney test to compare groups, two by two, with regard to awareness subscale, was observed in participants without pathology a trend near the threshold of

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significance to report higher levels of consciousness that participants with schizophrenic psychosis (U= 276.5, p= 0.085) and significantly higher compared to the depressed group (U= 187.5, p= 0.002). Between

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the two groups with disease, there were no

the considered group (schizophrenia, depression with

statistically significant differences.

or without current psychopathology), as depressive

Finally, we considered of interest to determine in each of the three groups, whether there are associations between depressive symptoms (as measured by the BDI) and the scores on the scales of Basic Psychological Needs and Self-Determination. The correlation coefficients found are indicated in Table 3, most of which, according to the criteria of Cohen suggest strong associations between the variables concerned (Cohen, 1992). As can be seen, whatever

symptoms as assessed by the BDI increases, there are significant declines at the level of satisfaction of the needs for autonomy, competence and relationships of belonging. It also appears, as it rises depressive symptoms, a decrease in the subscales of selfdetermination, evident in all the scores in the group with schizophrenic psychosis, while groups without depression and pathology correlations are statistically significant only in the case of perceived choice.

Table 3: Correlations of the BDI by diagnostic group and subscales of NPB and SDS. Autonomy

Competence

Rel. Bel.

Conscience

Perceived

SDS_Tot.

Coice Schizophrenic Psychosis

-0,642***

-0,680***

-0,417*

-0,759***

-0,475*

-0,704***

Depression

-0,695***

-0,549***

-0,540**

-0,338

-0,431*

-0,381

No Pathology

-0,540**

-0,655***

-0,334

-0,289

-0,452*

-0,481*

* P <0.05, ** p <0.01, *** p <0.001. Notes: ª Variables which were determined with Pearson correlation coefficients. In other cases form used Spearman correlation coefficients. Autonm = Autonomy. Compet = Competence. Rel Pertç. = Relationship of Belonging; Awareness. = Awareness; Choose = Choose Perceived Perceiving. SDS_tot: Global Self-Determination Scale score.

Conclusions

Self-determination expressed in their components

In the present investigation we studied three groups

"conscience" and "perceived choice".

of individuals (with depression, schizophrenia and no

In the case of satisfaction of basic psychological

current pathology), the degree of satisfaction of

needs, participants diagnosed with depression and

three basic psychological needs, and the degree of

participants with schizophrenia have lower levels than participants who did not suffer from any

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disease diagnosed at the time of data collection. It

(Med= 19.0) and depressed (Med= 17.0), and in

seems quite obvious that the pathologies in question

relation

lead to significant loss of autonomy, competence

differences were found. One could raise the

and relationships of belonging.

possibility of participants with schizophrenia,

With regard to depression, the Global Burden of Diseases and the World Health Organization (WHO) recognize that depression is one of the most disabling health problems and increased overhead imposes worldwide (Gusmão et al., 2005), precisely for lost productivity and treatment costs that affect the country’s economy. It seems understandable

to

perceived

choice,

no

significant

presents lack of insight inherent to their disease, own symptoms (APA, 2002) and decrease "selfconsciousness". As for the patients with depression it appears that the inability caused by illness, feelings of worthlessness, lack of confidence and selfesteem, and feelings of guilt (APA, 2002), may explain the poor "self-consciousness".

that the significant decrease in the satisfaction of

Regarding the variable "perceived choice" it is noted

basic psychological needs evidenced by our

that the participants in this study were integrated in

participants

with

a rehabilitation service, and most individuals with

participants without pathology is closely related to

schizophrenia, therapy performed over half a year

the underlying and well justified disability that this

ago and, therefore, a stable phase of their disease.

condition arises.

As for individuals diagnosed with depression, it was

with

depression

compared

With regard to schizophrenia, this condition it is known that the impairment, and social disability (Marques-Teixeira, 2007) of these patients lead to lower levels of marriage, a minor employment compared to normal population, and have a poor social behavior, and underperform in social roles (Wykes & Reeder, 2005), which in our view reinforces the results of less autonomy, competence and relationships of belonging, clearly visible in the social and labor difficulties on this population level. As the scale of self-determination our results indicate that the group without pathology presents a "self-consciousness" statistically superior (Med = 21.0) compared with participants with schizophrenia

found that they were attending a weekly intervention program for depression (over a month) and that others were already accompanied by service a few months ago. As such, we can conclude that the results in terms of "perceived choice," no significant changes in our sample, because they may have been influenced by the frequency of activities aimed at symptom remission and guidance in solving problems. In the final analysis of this study, we found that, whatever the group considered (with or without psychopathology), the more depressive symptoms are present the more affected self-determined behavior of the person, as well as the eventual satisfaction of basic psychological needs. This result

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reinforces, once again, recognized disabling nature

autonomy and relationships of belonging (Ryan &

of depression (WHO, S / d) to discourage the

Deci, 2000), which allows the definition of new

individual for their own recovery, regardless of other

therapeutic strategies.

conditions that may be associated.

It is a caveat to doing some limitations that should be

It seems to us that the study of these aspects may

taken into account in the analysis and generalization

have several implications for therapeutic and

of the results presented here. Firstly, it should be

rehabilitation.

with

noted the number of participants somewhat

schizophrenia, point to the existence of an

reduced in all groups, so extreme caution is required

impairment in executive functions, but that some

in generalizing these results until they are replicated.

cognitive deficits are secondary to a motivational

Also highlighted the possible bias caused by the need

deficit associated with lack of intrinsic motivation

for some flexibility in the application procedures

(Barch, 2005 cit. Soares, 2009) or even even the lack

questionnaires in the three study groups (e.g.,

of extrinsic motivation (Green et al., 1992, Hellman

variation in local administration, more or less

1998, cit in silverstein & Wilkniss, 2004 cit. Soares,

assistance

2009). This is why it is crucial to think about

questionnaires). We may also ask whether the

interventions that increase motivation is priority

cognitive changes in people with schizophrenia

before any other intervention. Reflecting on

influence

extrapolating findings from studies such as this and

questionnaires used. Finally, the lack of research in

objectify clinical interventions involving motivation

meeting the NPB in mental pathology, not allowed to

is considering an investment by clinicians, in order to

compare our results with those of other studies.

In

fact,

some

studies

test what results can be achieved (Yamada et al., 2010).

required

or

limit

by

the

participants

application

to

of

the

the

Would be important in future research to increase the clinical samples and periodically studying issues

Motivational interviewing is a possibility, among

involving motivation because patients today are not

others, which presents some empirical evidence on

patients of the near future.

their effectiveness in promoting intrinsic motivation, essentially proven with evidence in the case of patients with schizophrenia (Kemp et al, 1996; Barrowclough et al, 2001, cit . by Yamada et al, 2010) or cases of multiple diagnoses (Drake et al, 2001;. Ziedonis et al, 2005, quoted by Yamada et al, 2010)...

To finish and making our own words those of Yamada et al. (2010), it seems that the translation of research results on intrinsic motivation for clinical practice is potentially useful to improve the functional outcomes of interventions. However, this is a matter that needs further study.

According to the TAD to promote intrinsic motivation is necessary to guide the satisfaction of competence,

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Acknowledgements

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Deci, & Ryan. (2000). The “What” and “Why” of Goal

Work based on the dissertation by the first author under the Aveiro University Master in Psychology

Pursuits:Human

Needs

and

the

Self-

Determination of Behavior. Psychological Inquiry, 11(4), 227-268.

(specialty of clinical psychology and health).

Deci, E. L., & Vansteenkiste, M. (2004). Selfdetermination theory and basic need satisfaction: Contact for correspondence

Understanding human development in positive

Rita Sousa, Ponte de Caninhas nº541 Escamarão, 4690-673

Souselo,

Cinfães,

Viseu,

Portugal.

rita_sousa25@hotmail.com

psychology. Ricerche di Psicologia, 27(1), 23-40. Diegas, M., & Cardoso, R. (1986). Escalas de autoavaliação da depressão (Beck e Zung) Estudos de correlação. Psiquiatria Clinica, 7(2), 141-145.

References

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Structure in

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Schizophrenia.

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Choi, J., Mogami, T., & Medalia, A. (2010). Intrinsic

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(s/d). Motivação sob a Perspectiva da Teoria da in

Autodeterminação: Um estudo da motivação de

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Universidade Estadual de Montes Claros.

Cohen,

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Quantitative

Methods

Deci, & Ryan. (1990). A Motivational Approach to

Ryan, R. M., & Deci, E. L. (2000). Self-determination

Self: Integration in Personality. In R. A. Dienstbier

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(Ed). Perspectives on Motivation. Nebraska

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Symposium on Motivation., 237-288.

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Ryan, R., & Deci, E. (2002). Self-Determination

Velligan, D., Kern, R., & Gold, J. (2006). Cognitive

Theory and the Facilitation of Intrinsic Motivation

Rehabilitation for Schizophrenia and the Putative

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Schizophrenia Bulletin, 32, 474-485.

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of

Motivation

and

Expectancies.

Witter., Porto, G., Lomônaco., & Bitencourt, J.

Soares, D. (2009). Motivação e Esquizofrenia: Avaliação

de

Défices

Amostra

Portuguesa

Motivacionais de

Pessoas

numa com

Esquizofrenia em Contexto de Reabilitação Psicossocial: Contributo para a Validação da

(1984). Psicologia da Aprendizagem: 9 ed. São Paulo:EPU. Wykes,

T., &

Reeder,

C.

(2005).

Cognitive

Remediation Therapy for Schizophrenia: Theory and Practice (Vol. 49). London: Routledge.

General Causality Orientations Scale (GCOS). Faculdade de Psicologia e Ciências da Educação,

Yamada, A., Lee, K., Dinh, T., Barrio, C., & Brekke, J. (2010). Intrinsic Motivation as a Mediator of

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Relationships Sousa, S. S., Pais Ribeiro, J. L., Palmeira, A. L., Teixeira, P. J., & Silva, M. N. (2012). Estudo da Basic Need Satisfaction in General Scale para a língua portuguesa. Psicologia, Saúde e Doenças,

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depressão de Beck – BDI. Coibra: Hospitais da Universidade de Coimbra.

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Executive neuropsychological aspects of individuals with cleft lip palate Rui Mateus Joaquim Maria de Lourdes Merighi Tabaquim

University of São Paulo - Brazil Hospital for Rehabilitation of Craniofacial Anomalies - HRAC / USP Laboratory of Neuropsychology Contacts: ruimateus@usp.pr malu.tabaquim @usp.br ----------------------------------------------------------------------------------------------------------------------------------------------Summary: Studies of neuropsychological assessment in individuals with cleft lip and palate have shown that a significant portion of this population presents a neuropsychological functioning similar to that of individuals without cleft, however, with significant neurocognitive deficits in functions such as language, memory and attention. The objective of this paper is to present executives cleft lip palate neuropsychological aspects as well, increasing concepts that can support the development of future research. Keywords: Neuropsychology, Cleft Lip and Palate. Resumo: Estudos de avaliação neuropsicológica em indivíduos com fissuras labiopalatinas tem demonstrado que uma parcela significante dessa população apresenta um funcionamento neuropsicológico semelhante à de indivíduos sem fissura, porém, com déficits neurocognitivos importantes de funções como linguagem, memória e atenção. O objetivo deste artigo é apresentar aspectos neuropsicológicos executivos das fissuras labioplatinas, bem como, incrementar conceitos que possam subsidiar o desenvolvimento de futuras pesquisas.

525

Palavras-chave: Neuropsicologia, Fissuras Labiopalatinas.

Resumen: Los estudios de evaluación neuropsicológica en personas con labio leporino y paladar hendido han demostrado que una parte importante de esta población presenta un funcionamiento neuropsicológico similar a la de los individuos sin fisura, sin embargo, con los déficits neurocognitivos significativas en funciones como el lenguaje, la memoria y la atención. El objetivo de este trabajo es presentar los ejecutivos labioplatinas grietas aspectos neuropsicológicos, aumentando así los conceptos que pueden apoyar el desarrollo de la investigación futura. Palabras clave: Neuropsicología, Paladar Hendido. ------------------------------------------------------------------------------------------------------------------------------ -----------------

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Introduction

Iberian Journal of Clinical and Forensic Neuroscience â&#x20AC;&#x201C; IJCFN

Although intellectual ability is in the expected range

The Cleft lip and palate represent an important category of birth defects due to its high morbidity at high frequency in the population and causing significant interference in the overall development of the affected individuals. In view of the high prevalence and associated diseases, there is a growing global concern for the understanding of the functional needs and improvements in managed primary care, physical, cognitive, emotional, social and educational. Each type of slot brings with specific consequences. Comparatively isolated and incomplete cleft lip are somewhat subject to the

for a large share of the population with CLP, especially without syndromic involvement, another significant percentage demonstrates low academic performance, with levels lower than expected for age and education, with impairment in functions such as attention, memory and language, academic activities in reading, writing

and arithmetic

(Marcellin, 2009; Fenimam and Lemos, 2010; Nardi & Tabaquim , 2011; Aquino et al., 2011) . Level of cognitive impairment differences were found based on the type of cleft (Richman, 1980; Richman & Eliason, 1984, 2001; Richman et al., 1988).

resulting morbidities , feeding difficulties , to harmful

In a comparative study, Conrad and colleagues

surgical procedures or restrictive impairment of

(2009) found that children with cleft lip and palate

maxillary growth and dentition , which had a

have a lower neuropsychological functioning when

significant impact on the prognosis for rehabilitation

compared to children without cleft, especially on

purposes . In the group of pre - foramen cleft lip, fall

measures of expressive language and memory skill.

- those whose defect is restricted to the primary palate, involving the lip and / or alveolar ridge.

Among the various changes that cause learning difficulties, is the executive function, with a major

In general, affected individuals tend to have lower

impact on child development. A study analyzing the

functional difficulties, compared to those with post-

performance of executive functions showed a trend

foramen cleft, as part intact palate contributes to the

toward worse performance in executive functioning

maintenance of intra -oral negative pressure and

in adult males with cleft lip and palate in the Stroop

allows the child a better response pattern.

task. Recent studies suggest that frontal lobe

Regardless of the type, condition of cleft lip and

functions and prefrontal may be impaired in a

palate (CLP) requires dynamic, individual cognitive

considerable proportion of children with cleft,

and behavioral efforts that are changing constantly

suggesting the need to further examine executive

for the management of internal and / or external

functions. Neuropsychological studies of children

adaptation and psychosocial context demands.

who have cleft lip and palate have indicated that

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these subjects present problems in expressive

the orbital frontal cortex of men with cleft shows up

language and associative factors as well as

small when compared to a control group.

difficulties in naming skills (Richman & Nopoulos, 2008).

The ventral frontal cortex constitutes a key area of management behavior (Adolphs, 2001). In a study by

Such studies have also shown that children with cleft

Aiello et al (2000) found that adult subjects with cleft

labioplatinas present similar difficulties to children

had complex psychosocial problems arising from

without cleft, however, difficulties with verbal

morphological and functional changes , carrying

fluency and deficits in short-term memory. Children

since childhood striking the stigma able to change

with cleft lip and palate have demonstrated

future behavior. The social inhibition and shyness are

neuropsychological and similar to the standard

common behaviors in individuals with cleft lip and

reading of children with dyslexia but not cracked.

cleft. Nopoulos et al., (2005) assessed individuals

These findings indicate that cleft lip and palate may

with cleft lip and palate and have identified

be

of

reductions in orbitofrontal cortical volume. Across a

neuromaturation. Nopuolos et al., (2002) in a study

range of social dysfunction observed a positive

using neuroimaging, measured the size of the brain

correlation between social dysfunction and reduced

of adult males with cleft compared with the brains of

morphology in orbito frontal cortex.

associated

with

atypical

patterns

adult men without cleft. Despite not find differences in overall brain size observed some differences in specific areas: significant reduction in the volume of the cerebellum (gray matter); frontal and parietal abnormally dilated while the posterior lateral portions, temporal and occipital lobes were presented reduced compared the control group; features temporal lobe volume reduction (both in white as gray matter). These findings of structural abnormalities in the brains of subjects with labioplatinas cracks seem to relate to deficits in cognitive

functions

and

strengthen

the

understanding of the etiology of cognitive deficits in children with clefts labioplatinas is associated with primary

problems

of

structuring

and

brain

functionality. The literature has also pointed out that

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The cerebral cortex is made up of the outer layer of the cerebral hemispheres responsible for higher mental functions. Phylogenetically is the brain area most recently developed in the evolutionary history of humans and has been widely investigated by modern neuroscience (Kandel 2003). The cerebral cortex has a convoluted morphology and consists of depressions (grooves) separating high regions (gyri). The likely explanation for its shape is that probably during the evolutionary process this has been a way to accommodate a substantial increase in the number of neurons. The cerebral cortex in different species has a thickness having a range between 2 and 4 mm has a surface area greater extent in higher primates, particularly humans. The cerebral cortex is also called the "neocortex" because of its recent

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development and is related to complex cognitive

mixes the white substance that forms the deep limit

functions such as language and information

cortex containing the afferent and efferent axons.

processing. The neocortex is organized into functional layers, and is divided into four lobes, so called due to the similar location of the lining of the skull bones: Frontal, parietal, temporal and occipital. Each lobe includes different functional domains. There are two additional regions of the cerebral cortex called the cingulate cortex and the insular cortex. The first involves the dorsal surface of the corpus callosum. The second is not visible due to overgrowth of the frontal, temporal and parietal lobes. Wolves are defined by specific sulcus cortex, because they have a relatively consistent position on human brains. The cerebral cortex is organized into cell layers.

The functional organization of the brain occurs systemically due to the interaction of different neural networks located in different brain regions by setting dynamic functional systems that produce cognitive activity responsible for the adaptation and survival of the organism in its environment. Behaviors that allow the individual an intentional interaction, planned involve developing a strategy based on both previous experience as the demands of the environment in this action. Such activities need to be flexible, adaptive and monitored at every stage of execution. These operations are called executive functions (Gazzaniga, Ivry and Mangun, 2002).

Typically the neocortex has six layers listed from surface (Pia mater) of Cortex to the white matter. Layer I is a cellular layer called molecular. Basically consists of dendrites of cells located in other layers of the cortex and axons that connect this layer. Layer II consists of spherical cells called “granular “. The layer III contains various types of cells many of which have pyramidal shape; neurons located deeper in the layer III are generally higher than those located on the surface. This layer is called the outer layer of pyramidal cells. The layer IV as in II has more granular cells and is called an inner granule cell layer. The V layer is the inner layer of pyramidal cells contain considerably larger than the pyramidal cell layer III.

The executive functions are related to the control and regulation of information processing in the brain. The literature presents a variety of processes included in the category as: problem solving, selective inhibition of behavior, decision, cognitive flexibility (Majolino, 2000). Executive functions are directly related to voluntary and conscious of behavioral and cognitive actions for environment control. It consists of a set of cognitive conditions necessary to manage contingencies and demands in terms

of

a

goal.

Historically

the

field

of

neuropsychology executive functions are associated anatomically to the frontal lobes of the cerebral cortex.

The VI is a layer called heterogeneous neurons that

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Aleksander Romanovich Luria (1981) one of the roots

The concept of executive function lies in the

of Neuropsychology and chief representative of the

dissociation between cognitive abilities and applied

Soviet school neuropsychological describes brain

categorical.

activity “working in concert”. According to Luria in

characterized by the set of mental operations that

the waking brain activity of the cerebral hemispheres

organize and direct various cognitive domains to

is done by integrating three major cerebral

function in biologically adaptive manner, in patients

functional units (CFUs). The first corresponds to the

with lesions in the frontal cortex is impaired. Modern

reticular formation (1 CFU), the sensory area of the

neuropsychology understands that giving autonomy

posterior cortex, and the 3rd UFC, the associative

to the individual in relation to their environment is

center of the anterior cortex. The three units are

their executive functioning. When the proper

always in constant operation providing operational

functioning of the executive functions fails, the

support each other. The 1st unit has a regulatory

individual loses autonomy.

function, the 2nd of information integration and 3rd of

action

execution.

Each

unit

provides

a

contribution producing as a result of coordinated activity systems of the unification of dynamic brain activity in functional systems (Luria, 1984).

Executive

functions,

which

are

Although , historically , the frontal lobes have been related to executive function , topographical relations of certain cognitive syndromes weaken the attempt

to

associate

disexecutive

syndromes

with

frontal

such

as

lesions amnesia

Luria (1981) correlated the frontal lobe function

(anterograde or retrograde), agnosia , aphasia ,

planning, verification and control of behavior. The

apraxia ; Syndrome disexecutive; Disorder Attention

concept of executive function began to be used from

Deficit Hyperactivity Disorder . Although extensive

the second half of the twentieth century.

lesions of the frontal lobes can develop without

Clinical studies in neurology of behavior observed cases of patients with severe personality changes and behavior, but paradoxically had normal or

symptoms, disexecutive syndromes are observed in patients with lesions or dysfunction outside the frontal lobes.

superior performance on standardized cognitive

Understanding the occurrence of disexecutive and

tests. Those of Phineas Gage literature (Damasio,

extra frontal syndromes was facilitated by the

1994) and Mr. EVR (Damasio, 1985), Classic cases are

availability

similar in the fact that these individuals faced with

psychophysiology which revealed that even distant

enormous difficulties when seeking to apply their

extra frontal lesions may have connections with

cognitive skills in real life situations.

regions profusely connected to the front. From there

of

neuroimaging

techniques

and

emerged the notion that good executive functioning requires the integrity of the “frontal networks” and

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not just the frontal lobes. Executive functions

of the stock market. Studies have suggested that

manifest themselves in environments that require

subjects could become aversive at risk when cortisol

creativity, fast answers, new and challenging

levels were elevated for an extended period of time,

problems requiring the individual, planning and

indicating a chronic stress condition.

cognitive flexibility, everyday situations that are difficult to transpose and play in investigative demands. Rate isolated elements like the memory of an individual with a complaint of “forgetfulness “considered relatively simple, compared to the

A

study

by

Arnsten

(1998)

had

already

demonstrated, through the Iowa Gambling Test is evidence that individuals with higher baseline cortisol levels were more aversive to risk than individuals with lower baseline cortisol levels.

assessment and documentation of this” forgetting" occurs in your everyday life. This difficulty occurs because the various areas of memory must be appropriate to the needs of the individual to solve specific problems which are difficult to transpose to

Neuropsychological research on decision making has been based on tasks with explicit rules involving gains and losses, which can generalize the situations individuals can generalize the calculation of risks associated with each choice. In neuropsychological

a standard query.

terms , the process of decision making depends on a good executive functioning and higher functions Rehabilitation, stress and executive functions

such as planning , working memory , etc. (Brand et

process

al., 2005 ). However, humans do not always take

The literature has demonstrated the activation of the hypothalamic - pituitary - adrenal ( HPA ) as a result of stress, whose circuit activation triggers production

of

the

hormone

make

decisions

based

on

intuitive

trends

(Gigerenzer & Todd, 1999).

and

The possibility of dual decision making resulted in an

neurotransmitter that affects how you think, decide

integrative theory called “theory of dual processing "

and behave. Recent studies show that stress alters

, which points out that humans make strategic

the decision-making, often affecting people's choices

decisions both as intuitively (Epstein et al., 1996).

(Brand & Starcke, 2012) , and indicating the

The analytical - rational system (SAR) decision

existence of intertwined connection between stress

making is slower and more controlled, flexible,

and decision-making process at the neural level.

neutral, governed by rules and intuitive - experiential

Coates and Herbert (2008) showed that the daily

system (EIS) is a type of processing characterized by

levels of the hormone cortisol in traders who worked

being fast, parallel, and associative. Both models of

in the city of London varied according to the volatility

information

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cortisol

well- calculated decisions exclusively, since they also

processing

are

useful

and

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complementary. When situations present some

harmful alternative and thus chooses the most

degree

conflicting

advantageous. Such somatic response depends on

information, both the mechanism of intuitive -

the past experience of each individual, and the

emotional processing as the rational - strategic,

processed and categorized by each as pleasurable or

operating in the human brain, working in an

not memories experiences.

of

uncertainty

or

offer

integrated way in an orchestra concert.

One of the key brain structures involved in this

Emotions are critical to the process of decision

mechanism of choice is the ventromedial prefrontal

making and no consensus on the understanding that

cortex (Damasio 1994; Tranel, Denburg & Bechara,

affective states and emotional bodily responses

2003), and therefore, patients with ventromedial

unconsciously influence the process of decision

lesion would markedly disadvantageous choices in

making (Damasio, 1994; BECHARA et al., 2000;

life, marked by repertoire behavioral impulsivity,

Adolphs and Damasio, 2000; Rolls, 2000; Tranel,

difficulties in strategic planning and anticipation

Denburg and Bechara, 2003; Kjome et al., 2010). The

choice or consequences of adaptive responses

influential "Somatic Marker Theory" proposes the existence of the covert activation of somatic sensations, not in conscious human decisions, where each behavioral option in situations of decision making would be paired to an unconscious somatic response (neural response) evoked by previous experience. This association of somatic responses, or “somatic markers” would be activated by thought regarding an option that can motivate a choice or not. Thus, decision making is made up of a mechanism that requires a complex network of cognitive functions, outlining the process of choosing opposite options that are configured in a particular course of action. According to this theory, when a person needs to make a decision, before being aware of the best alternative, and, starting from an unconscious mechanism, triggers an emotional response (somatic) forward to choice options that arise. The guy drops the more risky or potentially

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This hypothesis was initially inspired by the observations of decision-making tests in patients with frontal damage. In Brazil, Malloy - Dinniz and colleagues (2008) developed a study of adaptation and validation of the Iowa Gambling Task for the Portuguese. Divided 75 adult Brazilians were investigated in 3 groups of 25 subjects, Group 1, with healthy volunteers proficient in English, evaluated with the original English version, Group 2, normal volunteers not proficient in English, assessed with the Portuguese version; group 3, with adult volunteers Disorder Attention Deficit Hyperactivity Disorder ( ADHD ) , assessed with the Portuguese version . According to the results, there was no difference between groups 1 and 2, however, found significant differences when compared to Group 3 (ADHD), with significantly worse the performance of the control groups. The researchers concluded that it is valid adaptation of the Iowa Gambling Task for

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the Portuguese as an efficient tool in the evaluation

findings of that research has revealed about

of the components of executive function, which the

neuropsychological aspects related to cleft lip and

decision is making.

palate (Nopoulos, 2002; 2005; Richman & Nopoulos,

The lack of assertiveness in the decision- making process has been reported as a major problem in child development (Smith et al., 2012), underlying

2008) it appears increasingly the need for studies investigating

the

complex

neuropsychological

functions, such as executive functions.

risk behaviors, leading teens to make bad choices

Thus, the analogies between the functioning of the

that could be detrimental lifelong. Young people

brain and other complex systems are based on the

with cleft lip and palate in chronic rehabilitation

assumption that they possess certain fundamental

process from childhood to adult, born with facial

characteristics in common and understanding of a

disfigurements life, are often exposed to go through

specific complex system helps in the understanding

multiple surgeries and medical consultations. The

of others. It is important, however, consider that

condition of chronic rehabilitation, plus the

ideas (cognitive) are better understood when

anomalous appearance of the face and functional

grounded in the context in which they emerge.

impairment of speech, you can configure a particular

Situation with obstacles to overcome, in the chronic

source of stress.

rehabilitation process may represent an opportunity for the development of executive skills, or help to intensify the vulnerability of behavior. In due time,

Conclusion

there can be greater understanding of the

The character of the long process of rehabilitation of

contribution of neural differences for cognitive

cleft lip and palate requires both patients and their

differences.

parents adequate adhesion to the requirements and recommendations of the whole multidisciplinary team. However noncooperation or effectuation of

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The impact of four stimulation sessions in older people in retirement homes Mónica Sousa Psychologist and PhD student at University of Aveiro Corresponding author: monic4sous4@gmail.com ----------------------------------------------------------------------------------------------------------------------------------------------Summary: This research is part of a project that is still ongoing and known as Psychological Support Program for the Elderly (PAPI) (Sousa & Costa, 2013). In this article, we are trying to determine how the implementation of a project for four sessions of cognitive stimulation influences cognitive and emotional functioning of institutionalized elderly. This is a quasi-experimental study, a descriptive cross-sectional, with pre-and post-test, carried out in individuals on social response that underwent two applications of the battery of neuropsychological tests, which consisted of: Depression scale geriatric (Simões et al., 2010), Geriatric anxiety inventory (Ribeiro, 2011), Montreal cognitive assessment (Freitas, Simões, Alves & Santana, 2011), Rey complex figure (Rey, 1988) and Rey 15 item test (Simões et al., 2010). Cognitive intervention consisted of four individual per week sessions of 60 minutes each. The pre-and post-test showed an increase of about 80% of cognitive performance and psycho-emotional balance. In conclusion cognitive stimulation must be a key element to integrate into routine retirement homes, in order to promote and enhance the quality of life of its users. Keywords: Old people; Cognitive Stimulation; Institutionalization. Resumo Esta investigação insere-se num projeto que ainda decorre e que se designa por Programa de Apoio Psicológico ao Idoso (PAPI) (Sousa & Costa, 2013). Neste artigo, procurou-se determinar de que forma a implementação de um projeto de estimulação cognitiva de quatro sessões influencia o funcionamento cognitivo e emocional de idosos institucionalizados. Trata-se de um estudo quasi-experimental, com pré e pós-teste, do tipo descritivo, de corte transversal, levado a efeito em indivíduos em resposta social que foram submetidos a duas aplicações da bateria de testes neuropsicológicos, que era constituída por: Escala de Depressão Geriátrica (Simões et al., 2010), Inventário de Ansiedade Geriátrica (Ribeiro, 2011), Montreal Cognitive Assessment (Freitas, Simões, Alves & Santana, 2011), Figura Complexa de Rey (Rey, 1988) e Rey 15 Item Test (Simões et al., 2010). A intervenção cognitiva consistiu em quadro sessões individuais semanais de 60 minutos cada. A comparação pré e pós-test relevou um aumento em cerca de 80% da performance cognitiva e o equilíbrio psicoemocional. Conclui-se que a estimulação cognitiva deve ser um elemento fulcral a integrar na rotina dos lares, de modo a promover e a potencializar a qualidade de vida dos seus utentes. Palavras-chaves: Idosos; Estimulação Cognitiva; Institucionalização. Resumen Esta investigación es parte de un proyecto todavía ocurre y lo que se conoce como Programa de Apoyo Psicológico para Ancianos (PAPI) (Sousa y Costa, 2013). En este artículo, hemos intentado de determinar cómo la implementación de un proyecto de cuatro sesiones de estimulación cognitiva influye en el funcionamiento cognitivo y emocional de los ancianos institucionalizados. Se trata de un estudio cuasi - experimental con pre y post -test, del tipo descriptivo, de corte transversal, afecto en individuos sobre la respuesta social que se sometió a dos aplicaciones de la batería de pruebas neuropsicológicas , que consistía en: Depression scale geriatric (Simões et al., 2010), Geriatric anxiety

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inventory (Ribeiro, 2011), Montreal cognitive assessment (Freitas, Simões, Alves & Santana, 2011), Rey complex figure (Rey, 1988) y Rey 15 item test (Simões et al ., 2010). Intervención cognitivo consistió en sesiones semanales marco individual de 60 minutos cada una. El pre -y post -test relevó un aumento de alrededor del 80% del rendimiento cognitivo y el equilibrio psicoemocional. Se concluye que la estimulación cognitiva debe ser un elemento central para integrar la rutina en los hogares de ancianos, con el fin de promover y mejorar la calidad de vida de sus usuarios. Palabras clave: Anciano; Estimulación Cognitiva; Institucionalización. ------------------------------------------------------------------------------------------------------------------------------ -----------------

factors for unsuccessful aging, which may be

Introduction

associated The advancement of medical and economic development made possible the increasing aging of the

Portuguese

population

(Sequeira,

with

cognitive

decline

and

neurodegenerative diseases (Wimo and Prince, 2010).

2010).

Preliminary results of the latest census reveals that 2.022.504 (19.1%) of the 10.562.178 individuals of the population resident in Portugal are elderly (INE,

Numerous

investigations

in

the

area

of

rehabilitation/stimulation neuropsychological have shown that this plays a crucial role in improving the cognitive, social and emotional functioning, with

2012).

particular emphasis on the recovery of cognitive Aging may be described as an adaptive, slow and continuous process, potentiated by a series of changes,

which

are

involved

in

biological,

psychological and social factors (Burns & Zaudig, 2002; Charchat-Fichman, Caramelli, Sameshima, & Nitrini, 2005; Petersen, 2004).

cognitive functions such as attention, memory, language and executive functions (OMS, 2012; Yassuda et al, 2006. WHO, 2012). According to Ardila (2007) and Verhaeghen (2001) this cognitive decline can partly be alleviated by the ability of cognitive plasticity. Moreover, several studies suggest that the very advanced age, female gender, low education, isolation,

psychiatric

promoting psycho emotional balance (Amodeo, Netto, & Fonseca, 2010; Smith et al, 2009). Due to the importance of active aging, several national and European policies have been developed and implemented.

In healthy aging occurs the natural decline of

social

impairment, the dementia process stabilization and

symptoms

and

institutionalization (Buchman et al, 2010; Naismith

538

At national level, stands out the Portuguese National Health Plan (NHP, 2012) and the Programme of Social Energy (Ministry of Labour and Social Solidarity (MSS 2012). At European level, the Europe 2020 (European Commission, 2010) presents as general objective to until the year 2020 the increase in nearly two years of active life expectancy of citizens, which includes the elderly. This general objective is associated at several specific objectives, of which stands out the improvement of health

et al, 2007; Stein et al 2012) can be considered as risk

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condition and quality of life of European citizens and

defined by the researcher, since it is intended to

the implementation of programs that enable

study a subgroup of the population, specifically,

sustainability of the health system and social action.

institutionalized elderly and / or attending nursing

In Portugal, the city of Coimbra in 2012 was considered European Region Referral for Active and Healthy Ageing. In this context, the Ageing@Coimbra tries to integrate European with national policies in order to identify, implement and replicate innovative projects and good practices in the field of Active and Healthy Ageing programs. The Psychological Support Program for the Elderly (PAPI) (Sousa & Costa, 2013) is a good example of one Portuguese good practice

home. The following inclusion criteria were established: (1) interment at least 1 day in the nurse home, (2) users of both genders, (3) user with a level of education that would allow them to understand and answer all questions placed, (5) users with no neurological damage. Whereas exclusion criteria were: (1) illiterate, (2) alexia; (3) aphasia, (4) substance use, (5) psychopathological antecedents (psychiatric disorder).

recognized by the European Union for the

Taking account of the exclusion criteria, a total of 64

prevention and early diagnosis of frailty and

subjects, 56 were excluded and 3 subjects died

functional decline, both physically and cognitive in

during the investigation, being reduced to 5 subject

older people (Action Group A3).

sample.

As part of this project, this study presents the

This population was mostly male (60%) are between

preliminary results of one of its axes of intervention

the ages 53 and 93 years (M = 74.20, SD = 15.71).

that seeks to investigate the influence of a cognitive

Regarding marital status, two participants were

stimulation program of four sessions on cognitive

single (40%), two are widowed (40%) and married

and emotional functioning of institutionalized

(20%).

elderly.

With regard to qualifications, it appears that the level of education is low because 60% of the subjects have four years of schooling, 20% of subjects have 6

Methodology

years of schooling and 20% of the subjects have 12 This is a quasi-experimental study, a descriptive

years of schooling.

cross-sectional, with pre-and post-test. The sampling was convenience. That is a sample previously

The predominant clinical diagnosis Hypertension (n = 3), followed by diabetes (n = 2) (see Table 1).

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Table 1 - Demographic Characteristics for the socio-sample total.

Gender Marital status

Age

Years of schooling

Clinical Diagnosis

Feminine Masculine Never been married Currently married Separate Widower Cohabitation Total 53 69 70 86 93 Total 4 6 9 12 Total Glaucoma cardiac insufficiency Macrocytic anemia AVC Rheumatoid arthritis Renal Insufficiency Diabetes Hypertension Adenoma

N 2 3 2 1 0 2 0 5 1 1 1 1 1 5 3 1 0 1 5 1 1 1 1 1 1 2 3 1

% 40 60 40 20 0.0 40 0.0 100.0 20 20 20 20 20 100.0 60 20 0.0 20 100.0 -

540

Instruments

Scale of Life Satisfaction

Questionnaire socio-demographic information

The Scale of Life Satisfaction of Diener Emmons,

The socio-demographic information was obtained in a study using a questionnaire constructed for this purpose.

This

questionnaire

includes

closed

questions relating to age, sex, marital status, literary and clinical diagnostic skills.

Larsen and Griffin (1985) had 48 items and was subsequently reduced to 5 items, but maintaining acceptable levels of fidelity and validity (Slater, 1992). According to Slater (1992), the English version also ran a reduction in the Likert scale of 7 answer choices for 5alternatives [somewhat disagree (1) or

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agree (2), not disagree (3), somewhat agree (4), strongly agree (5)].

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Geriatric Depression Scale (GDS) The Geriatric Depression Scale (GDS) (Simões et al,

As regards the scores, they range 5-25 points, with

2010) is a scale that aims to identify the symptoms

the existence of a direct proportionality, in other

of depression in the elderly. This scale of 30 items

words, the higher the score means greater

caring for the elderly about their status in recent

satisfaction with life.

weeks. The scores 0-10 reflect the absence of depression, between 11 and 20 indicate "mild depression" and, in the range of 21 to 30 suggest the presence of

Scale Memory Complaint

"severe depression" (Simões et al., 2010).

Resorted to the Memory Scale wanted (Gino, Warrior & Garcia, 2008) to assess the perception of subjective memory complaints. This scale consists of

Geriatric Anxiety Inventory

ten items from the Cambridge Examination for

The Geriatric Anxiety Inventory allows evaluating the

Mental Disorders of the Elderly (CAMDEX), where

severity of the common symptoms of anxiety in the

the score of each item may vary from 0 to 3 points

elderly population in various contexts such as day

for a total of 21 points. For the Portuguese

centers, community services (health centers) and

population, exceeding 3/4 figures are indicative of

communities. Corresponds to an instrument

the presence of significant memory complaints (Gino

composed of 20 items of dichotomous response

et al., 2008).

[agree and strongly disagree]. According to Ribeiro, Paul Slater & Firmino (2011), the cut-off point for the Portuguese population is 8/9, suggesting the presence of severe anxiety symptoms, these can be potentially pathological.

Montreal Cognitive Assessment The Montrel Cognitive Assessment (MoCA) is a brief screening test for detecting Mild Cognitive Deficit, validated for the Portuguese population by Duro, Simões, Ponciano and Santana (2010). It was specially developed to evaluate 8 cognitive domains:

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executive functions, visuo-spatial ability, short-term memory, attention, concentration and working memory, language and orientation (temporal and Rey 15 Item Test

spatial) (Freitas, Simões, Alves & Santana, 2011).

The Rey 15 Item Test evaluates the short-term memory and effort to the task ("simulation" or Rey Complex Figure

"reduced effort"), consisting 15 items (letters,

Corresponds to a geometric figure with no obvious

numbers and symbols) arranged in three rows with

meaning, easy graphical accomplishment , but with a

five columns each. Only involves memorization of

set structure sufficiently complex to require an

five units (15 elements are grouped into five

activity of analysis and organization (Rey, 1988).

conceptual categories). To be presented to the

This figure consists of 40 segments, comprises several geometric figures (rectangle, circle, square, triangle, diamond) and combines segments of straight lines (horizontal, vertical, oblique) that intersect each other. Evaluates a diverse set of psychological constructs, such as the visuo-spatial organization,

visual-spatial

organization,

examination as a task of memorizing 15 different elements, makes it look harder than it actually is (Simões et al., 2010). In the Rey 15 Item Test Recognizing the examinee will have to recognize, in the 30 items presented, the original 15 (Simões et al, 2010.).

visual

memory, attention, planning (executive functions);

542 Method

solving problems; motor function. With the consent from the institution to the study This test consists of a copying followed by a test

sample has been selected.

recall after 3 minutes. The domains assessed by the copying are the visuo-constructive ability, spatial analysis and capacity planning of the design, for example. While in the recall are the visuo-spatial organization

and

selective

memory,

the

consolidation

of

long-term

memory

and

susceptibility to interference (Rey, 1988).

Approximately one month after the first moment of evaluation we started the second and final moment of evaluation. This coincided with the frequency of 4 sessions

approximately

one

hour

cognitive

stimulation. The protocol adopted in the present study aims to conduct a more thorough neuropsychological exploration, but also will fit a stimulatory context, corroborating the theoretical postulates of Maia, Leite & Correia (2009). In this perspective, cognitive

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stimulation sessions were based on the results of the first evaluation, each activity stimulation was to

Results

benchmark the activities that have been applied in Preliminary results show that the elderly in this study

studies with similar goals, such as the studies

are moderately satisfied with life, with its increase

conducted by Willis et al. (2006), Smith et al. (2009),

from the first to the second assessment, except for

Spector, Orell, Woods (2010) and Tsai, Yang Lan and

subject 2 which maintained the same score (see

Chen (2008).

Table 2). Before the beginning of the first evaluation of the Through the analysis of Table 2 it appears that the

study were presented the objectives, the interests of the

administration

confidentiality

of

and

the

responses.

same Requests

Scale Memory Complaints (Gino et al., 2008) the

strict

presence of excess of the cutoff point for the

for

Portuguese population results (Gino et al., 2008) in

collaboration from participants were presented, as

two stages assessment, which results in indication of

well as the guarantee of anonymity. All participants

the presence of memory complaints with relevance.

were provided informed consent according to the Declaration of Helsinki. The mean duration of each

As the core of the Geriatric Depression Scale (Simões

session (evaluative and/or interventional) was sixty

et al., 2010) and the Geriatric Anxiety Inventory

minutes or so.

(Ribeiro, 2011) both suggest the presence of depressive

Data analysis was performed using the Statistical

and

anxious,

respectively,

in

all

participating symptoms (see Table 2).

Package for Social Sciences (SPSS) version 20.

543 Table 2 - Cognitive and emotional performance of sample in the two time points (n = 5). Instruments

Scale of Life Satisfaction Simões (1992) Scale Memory Complaint (Ginó, Guerreiro & Garcia, 2008) Geriatric Depression Scale (Simões et al., 2010) Geriatric Anxiety Inventory (Ribeiro, 2011) Montreal Cognitive Assessment (Freitas et al., 2011) Rey Complex Figure Copy (Rey, 1988) Rey Complex Figure Delayed recall (Rey, 1988) Rey 15 Item Test (Simões et al., 2010) Rey 15 Item Test Recognition (Simões et al., 2010)

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1 17

Evaluation Moment I Subject 2 3 4 5 1 23 8 14 13 22

Moment II Subject 2 3 4 23 9 17

5 16

9 20 14 26 26

18 15 14 13 0.5

6 22 16 26 26

8 21 18 20 13.5

14 17 7 18 11

10 18 13 29 32

19 13 13 21 4.5

9 19 15 30 28.5

9 20 16 28 26.5

11 12 12 22.5 20.5

8

0

15.5

0

2

17.5

2.5

23

7.5

7.5

14 29

5 9

12 24

3 3

5 6

15 30

6 18

15 30

13 28

6 10

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The Montreal Cognitive Assessment (Freitas et al., 2011) suggests the presence of mild cognitive impairment in 3 of the 5 participants. Also in 3 of the 5 participants Rey Complex Figure (Rey, 1988) indicates the presence of moderate to severe difficulties in: visuo-spatial organization, visual-spatial organization, visual memory, attention, planning (executive functions); troubleshooting: consolidation of long-term memory (cf. Table 2).

Moment I Results of the Rey Complex Figure Copy

Results Rey Complex Figure - Evocation Deferred

544

Moment II Results of the Rey Complex Figure Copy Results Rey Complex Figure - Evocation Deferred

It is emphasized that the Rey 15 Item Test (Simões et al., 2010) suggests the absence of insufficient effort or malingering by all participants (see Table 2).

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Zandi (2004) institutionalization increases the

Discussion of results

problems of subjective memory and objective The importance of this project was enlarged with the

memory deficits.

results obtained by participants in all instruments used, these results are consistent with studies already carried in this area (Amodeo, Netto, &

A closer analysis of the results obtained in the Geriatric Depression Scale (Simões et al., 2010) and the Geriatric Anxiety Inventory (Ribeiro, 2011)

Fonseca, 2010; Smith et al, 2009.).

reinforces Considering

the

analysis

of

the

results

of

revaluations made at different times over about three months, they allowed measuring the increase in cognitive performance, as well as the increase in psycho-emotional balance.

are consistent with the literature, indicating that older people who are reasonably satisfied with their lives are able to face institutionalization positively et

al.,

2001).

importance

of

continued

development of strategies for prevention and support to the integration of the elderly in several physical and cognitive stimulation activities to promote quality of life of this population (Fiske, Wetherell & Gatz, 2009).

Regarding to life satisfaction, the results of this study

(Simões

the

For

Lovell

(2006)

institutionalization apparently a less favorable solution can provide benefits to the elderly if have been given a choice and adaptation to the new

In other words, the results suggest the presence of depressive and anxiogenic symptoms. However, these results are consistent with other studies in the elderly (Blazer, 2009; Djernes, 2006; Marsh, 1993; Santos, 2002), since these are preliminary results should be explored further the process of institutionalization (Cardão, 2009; Junior Silva Gomes, Paes & Bastos, 2010).

environment. Thus, in keeping with the literature review, it is Having as reference values the cutoff point for the Portuguese population, it was found that the presence of memory complaints with relevance to all participants (Gino et al., 2008). It is believed that the increase obtained in Scale Memory Complaints (Gino et al., 2008) for four of the five participants may be due to increased insight and critical judgment, strongly

associated

with

participation

of gradual decline (Plati, Priscilla, Lukasova & Macedo, 2006; Spar & Rue, 2005), particularly with regard to cognitive domains such as attention , concentration, memory (short-term and working memory), executive functions and visuospatial ability.

in

neuropsychological rehabilitation program (Willis et al, 2006; Smith et al 2009; Spector, Orell & Woods, 2010; Tsai, Yang, Lan & Chen, 2008). However, for

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observed in the present study, a generalized pattern

Through

the

Montreal

Cognitive

Assessment

(Freitas, 2011) it was possible to verify the presence of mild cognitive impairment in three of the

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participants. For several authors (Burns & Zaudig,

protocol. The low performance achieved by some of

2002; Charchat-Fichman, Caramelli, Sameshima, &

the participants may be explained by the presence of

Nitrini, 2005; Petersen, 2010), mild cognitive decline

cognitive deficits, injury, or brain dysfunction as has

can be considered as an invariable consequence of

been pointed out above, the physiological process of

physiological aging process. These data are also

aging itself.

corroborated by the results achieved by the participants in the Rey Complex Figure (Rey, 1988) and reinforced by Plati et al. (2006), referring, for example, memory impairment in the elderly living in nursing homes.

Preliminary results of this study are in agreement with the literature (Junior & Tavares, 2005; Junior et al, 2010;. Porcu et al, 2002;. Silva Menezes, Santos Carvalho & Barreiros, 2006), suggesting that the institutionalization it may involve higher rates of

In the Rey 15 Item Test (Simões et al., 2010) none

depression, negative affect, anxiety, cognitive

participant scored below the cutoff point for the

impairment,

Portuguese population, indicating the absence of

problems more subjective and objective memory

simulation (or insufficient effort) throughout the

deficits.

decreased

socialization,

memory

stimulation in promoting cognitive performance and psycho-emotional balance. Conclusion Portuguese

The results also reinforce the relevance of

population may be associated with healthy aging,

considering the stimulation/cognitive rehabilitation

and

cognitive

as a key element to integrate into routine nursing

capabilities. Aspects that elevate the importance of

home or day center, in order to promote and

psychological support as well as neuropsychological

potentiate the cognitive and emotional health of

stimulation on health promotion in the old people.

users (Junior & Tavares, 2005; Junior Silva Gomes,

The

increased

longevity

consequently,

the

of

the

decline

of

Paes, & Bastos, 2010). According to Vaz (2009), these institutions The PAPI, as its name suggests, seeks to provide services ranging from assessment to intervention as well as prevention and rehabilitation of emotional, cognitive and behavioral problems programs. Neuropsychological stimulation for the elderly is therefore one of the axes of intervention, and the preliminary results emphasized the importance of

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must

not

allow

the

physical,

psychological and social deterioration in the elderly. The PAPI, as its name suggests, aims to provide services that go from assessment to intervention as well as prevention and rehabilitation of emotional, cognitive and behavioral problems programs. Neuropsychological stimulation for the elderly is therefore one of the priorities for intervention, and

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the preliminary results highlighted the importance of

Rights of the European Union and Freedom senior

stimulation in promoting the health of the elderly.

resident of institutions that respect, since 24

Also reinforced the relevance of considering the

September 1993, that the institutions should

stimulation / cognitive rehabilitation as a key

promote and improve the quality of life and

element to integrate into routine nursing home or

minimize the inevitable limitations brought about

day center, in order to promote and potentiate the

life in the institution, maintain the independence of

cognitive and emotional health of users (Junior &

older people; favoring free expression of their will

Tavares, 2005; Junior Silva Gomes, Paes, & Bastos,

and develop their capacity, enabling freedom of

2010). According to Vaz (2009), these institutions

choice, as well as respecting privacy and maintaining

must not allow the physical, psychological and social

their social role (Born & Boechat, 2006).

deterioration in the elderly.

It is expected that the continuation of this project,

Following the results achieved to date, it is

still at an early stage, will provide appropriate

considered to be essential the continuation of this

assistance to the needs of the geriatric population as

project with the elderly population, in order to

well as evident benefits and a consequent evolution

increase the bio-psycho-social balance (WHO, 2012).

in health care provided to the elderly.

But also by meeting with the Charter of Fundamental

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Invited Letter

General Psychology

The importance of music for a comprehensive training of children in kindergarten Débora Munhoz Barboni Professor of Colégio Visconde de Porto Seguro, Brazil, degree in Art with an emphasis in Music. Post – Graduation in Educational Psychology and Early Childhood Education. Brazil. Contact: email dbarboni1@hotmail.com

Human history shows us, that music starts with the history of humankind. Since prehistoric times, it is

him to action and promoting a plurality of conduits of different qualities and degrees".

likely that the man watched the sounds of nature,

Music has become a universal language that brings

animals and imitated them, seeking to communicate

people together, which is part of the cultural identity

and produce activities that were based on the

of each people, a way to communicate, to celebrate,

organization of sounds. There are records of musical

can influence our emotions, print facts in our

instruments made 40,000 BC, such as the flute Divje

memory, our thoughts and bring us feelings of

Babe taken with a bone of an animal discovered in a

welfare.

cave in Slovenia. The man was already trying to create your own melodies and rhythms already in prehistory.

The famous philosopher of ancient Greece, Plato in his "Republic" said: "Let me write the songs of a country and do not worry who makes its laws". This

As anthropological data, the first songs were used in

shows how in his view, he considered the power of

rituals like birth, wedding parties, funerals, religious

music to influence society.

rituals, etc. The music has expanded over the years and currently, there is no knowledge of any civilization that does not have its own music.

Long ago, researchers study about the influence of music on brain activity. Proven studies shown that people who practice music with pleasure hear the

The Argentine expert specializing in musical

music they like, leads the brain to produce

Psychopedagogy Violet Gainza (1988, p.22) points

endorphins and serotonin, which act bringing

out: "The music and sound, while energy, stimulate

relaxation, mental and emotional balance. Music

internal and external movement of the man, driving

also activates the pleasure neurotransmitter in the brain, dopamine. This helps to explain why music has

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always been part of people's lives and is often used

Music can strengthen important areas in the early

at parties, movies and the marketing. Besides

years, when neuroplasticity (the ability to change its

contributing to the welfare of human beings, music

structure and function through previous experiences

can help improve the functioning of our brain,

brain) is higher, but it should be noted that plasticity

especially when practiced regularly.

continues into adulthood. It is never late to practice

Recent research shows us that the brain can change its own structure, through the thoughts and stimulating activities. At the same time the brain is vulnerable to external influences and may be

music. By learning to play a musical instrument, for example, we are exercising our mental skills, refining our ability to listen and developing fine motor control, which will help in firming balance and mobility. It means that, developing this new skill, will

exercised like a muscle.

program our brain to age in better condition. The fact is that music surrounds us on many levels and through their practice, develop motor, cognitive and language skills. Everyone can develop musical

Music is accessible to everyone, no matter the age. Moreover, as earlier we start the better.

talent, since they have contact with music in a pleasant way and practice enough. It is the same to state that in order to child wants to learn we need to be motivated in an environment

Music to encourage child’s skills

that fosters their emotional development. Children from very small, show a natural interest in music. In general, express their emotions more easily

554

through music than through words. Through this so

Music usually attracts children of all ages because it

compelling language we can use it as a powerful tool

is a language that they soon identify. Since from the

for

fifth month of uterine life, the baby has come into

expanding

the

cognitive

and

emotional

development of children. The famous Swiss epistemologist Jean Piaget in his research on the construction of knowledge by the child, proof in how much affection is needed to

contact with the world of sound and birth, in the first days of life many are already packed and cherished by the sound of lullabies, with great affection load being established between adult and child.

provide the energy and willingness to want to learn.

Edgar Willems, great pioneer of music education in

On the other hand, the structure provides the

its

intelligence to build the action of learning.

development of musical language is the same as the

methodology,

which

punctuated

the

native language. All knowledge in their method must be from the practical activity, reaching the

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abstraction of theoretical knowledge. According to

Therefore, the external stimuli that cause the so

him, before learning to play a musical instrument, it

called sensory perceptions are extremely important

is important to musical practice singing because

for development, particularly in childhood. The more

when we sing, we are developing our auditory

enhance their perceptions, more intelligence will be

perception, our musical ear. According to Willems

developing.

cited in Drummond (2005) the song is the most complete form of musical expression, seen hugging the three building blocks of language: rhythm, melody and harmony. According to him, the rhythm

According to Piaget, "the child himself opens the door to the outside world". That is, as it will receive stimuli through diverse musical experience, she builds her knowledge, in a pleasant way.

is related to the physiological aspect of the human being, the melody to emotional and harmony to the

By providing a space where the child can express themselves and interact in a playful way, we will be

intellectual.

providing conditions for the child to feel stimulated This process is called music to children, which are proposed that aims to contribute to the overall development of the child, where the child will have the opportunity to experience musical language through games, music games, in a space of awareness, where she can construct their own knowledge through practical and musical reflections. Music

naturally

globalize

aspects

of

child

development: emotional / social, cognitive / linguistic and psychomotor. All these aspects of development are interrelated and learning is only possible if the maturation and neurological organization is assembled. For that to happen, you need external stimuli that are captured by our senses. After transformed into electrochemical impulses, stimuli pass the receptor nerve cells to the central nervous system, where impulses are redirected to different areas of the brain where they are decoded and interpreted (Pimenta, 2007).

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to want to take ownership of the musical language. Music is a very dynamic process because it involves singing, listening, movement, body sounds, melody, rhythm, music appreciation, i.e., offers many sensory perceptions. Through many varied activities, offering stimuli with different coordination, we are enhancing the development of children in socialaffective, psychomotor and cognitive-linguistic areas. Through group activities, children will form their identity, learn to relate and cooperate with others. Jokes, rhymes and rhymes, for example, are activities that promote a great stimulus in the brain therefore need different coordination. You must sing, dance, synchronize the movement for the wheel to turn in the proper way, pay attention to the commands suggested during the song, and on cooperation among all your friends who are playing and socializing. Thus, the child exercises his creativity and

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imagination, their disinhibition and also learn to

listens well, will be easy to learn in any area and, if

respect the rules and cooperate, in addition to

that learning to play a musical instrument, have a

presenting the child cultural values of their

much easier to understand a score, because it will

environment. Those are essential activities, including

have already experienced the characteristics of

to the acquisition of speech and prepare the child for

sound, through play and music games.

writing.

The psychoanalyst and educator Rubens Alves

The music teacher at the Federal University of Ceará - Brazil, Elvira Drummond, underscores the ludic space as the propellant of creation: "It is therefore, between the real and the imaginary artist and child pass during their activities, which suggests the pun: art is the photographer toy and play is the art of the child".

masterfully summarizes what was said above: "If you were to teach a child the beauty of the music does not start with music notes and staves. We would hear together the hottest and tell you about the instruments that make the music melodies. Then, enchanted by the beauty of music, she will ask me herself that taught her the mystery of those black

Musicalizacion activities that explore the sonic

dots written on five lines. Because black polka dots

universe are also part of the routine work as the

and the five lines are just tools for the production of

focus, attention, analysis for sound phenomena,

musical beauty. The experience of beauty has come

developing listening skills to analyze and select

before".

various sounds and contributing to the social

556

adjustment of the child. One of the strategies are the music stories (“voiced”) where can sonically portray

Music for psychomotor development

the family environments of children, as sounds of the

The neuroscientist Viviane Blonde says: The basic

countryside, the beach, musical instruments, etc.

principles of psychomotor skills are implicit in each

The teacher can use both own voice to make sounds,

item of musical learning, whether theoretical or

but can also vocalize with musical instruments,

practical. To be able to play the piano, strong notions

sound objects, or the sound of the character

of spatiality and temporality will be necessary as well

previously recorded on a CD ROM disc itself. Children

as defined lateralization. Missing any of these

can also produce sound design story or a song, with

prerequisites, students face many difficulties in

the same objects, thus developing their imagination

learning.

and research of various timbres (sound we hear) and

In classes of musicalizacion, using games and songs,

through this, the other parameters of the musical

adapted to age, the student will have the

language can be exploited then making for the child

opportunity to properly experience the body,

the world sound rich and full of detail. The child who

explore the space around, experience different

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locomotors movements, which contribute to the

It is essential that the music educator has a thorough

natural

knowledge of the fundamental principles of music as

development

of

neurological

and

psychomotor functions.

a pedagogical level and also depth study of child

Musical instruments are also widely used in music classes, whether in stories where they are displayed, brought by teachers or built by them with recyclable materials, thus stimulating children's interest by

development, so that it can provide the music properly, to benefit the welfare and development of students, including for children who have special needs.

sound research of various materials and relating the

Therefore, the musical play is of paramount

acoustic principles with the elements of basic sound.

importance to child development and from musical

The most widely used in early childhood, are usually

experiences, the child will be organizing thought and

small percussion (drums, rattles, clubs, rattles ...) as

knowledge will be developed.

they are lightweight, easy to handle and perfect for working psychomotor development. These activities make the child develops motor skill and rhythmic development plays a key role in the formation and balance of the nervous system. When you practice a pace adapted to a motion, the child practice different coordination: how to dance / sing, sing /

By age 4-5 years, children are already able to play more elaborate arrangements, with division of suits. This experience is very important, as she learns to wait your turn, instead of the other, play in a group, focus and experience to perform properly in practice, the elements of musical language that was previously learned, through play and music games.

make gestures, playing / singing, playing / singing / dancing, etc. Developing skills that will assist the child in several other areas, beyond the musical one.

The child who experiences this whole process from very small, develop several skills that will assist fully. For example, she will have a much easier time

It is of utmost importance to provide a curriculum that the children have highlighted the development activities

that

provide

perceptual-motor

and

emotional partner as a basic aspect of language in different ways, because with female advancement on the labor market, children are increasingly early in schools and family today has less able to supply all the needs of the child. Music can be considered as a

learning to play a musical instrument, it will have a more accurate auditory perception, fine motor skills and be able to read music more easily. Above all, it will be a human being who will be able to enjoy a musical

performance

with

active

listening,

identifying musical elements like instruments, quality execution, technique, and finally, a much broader musical consciousness.

facilitator of the educational process.

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Final conclusions

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Barreto,

Music education has many proven long-term benefits to people's lives, so it is a fundamental one,

S.

de

Jesus.

(2000.)

Psicomotricidade: educação e reeducação. 2. ed. Blumenau: Acadêmica.

more balanced in their integral formation better

Bréscia, V.L.P. (2003). Educação Musical: bases

human element. In a fun way, the child will develop

psicológicas e ação preventiva. São Paulo: Átomo.

various skills, assist in their uninhibited behavior and contribute to the increase of its sensitivity and selfesteem.

Campbell, L., Campbell, B. & Dickinson, D. (2000). Ensino e Aprendizagem por meio das Inteligências Múltiplas. 2. ed. Porto Alegre: Artmed,

Above all, the guiding principle of quality music education is to develop a love for music, so that language becomes a companion and friend of all

Gainza,

V.

Hemsy

de.

(1988).

Estudos

de

Psicopedagogia Musical. 3. ed. São Paulo: Summus.

time, one that can tell us more difficult and joyous moments of being human. Is this the power that

Gardner, H. (1995). Inteligências Múltiplas: a teoria na prática. Porto Alegre: Artes Médicas.

music has!

Gregori,

M.L.P.

(1997).

Música

e

Yoga

Transformando sua Vida. Rio de Janeiro: DP&A. Supporting References Suzigan, G. de Oliveira, & Suzigan, M.L.C. (1986). Doidge, N. (2011). O cérebro que se transforma. Ed. Record.

Educação Musical: um fator preponderante na construção do ser: São Paulo.

Drummond, E. (1988). A Tessitura estética dos Brinquedos cantados: Fortaleza. Drummond, E. (2005). Colorindo sons: Fortaleza, Almeida, B de. (2009). Encontros musicais: São Paulo. Brito, T.A (2001). Koellreutter Educador - O ser

Alves, R. (2003). Quando eu era menino. CampinasSP: Papirus. Louro, V. (2012). Fundamentos da aprendizagem musical da pessoa com deficiência: São Paulo. Weigel,

A.M.G.

(1988).

Brincando

de

humano como objetivo da educação musical. São

Música: Experiências com Sons, Ritmos, Música e

Paulo: Peirópolis.

Movimentos na Pré-Escola. Porto Alegre: Kuarup.

Brito, T.A. (2003). Música na Educação Infantil:

Pimenta,

D.C.O.

(2007).

Desenvolvimento

da

Propostas para a formação integral da criança.

Psicomotricidade - Educação Psicomotora e

São Paulo: Peirópolis.

desenvolvimento. Módulo II. Curso de PósGraduação Latu Sensu. Instituto A Vez do Mestre.

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Therapeutic approaches Drug Abuse – From Diagnosis to Treatment in 2014 Ana Amaro Clinical Psychologist & Drug Abuse Treatment Specialist: ----------------------------------------------------------------------------------------------------------------------Summary: Alcohol, tobacco and other psychotropic drugs has become a worldwide public health concern. In recent decades, research on the biological, psychological and sociological field increased knowledge about this subject and allowed the development of approaches afmsma@gmail.com and prevention methods and more effective treatments (Ribeiro & Marques, 2006). The present work provides a set of therapeutic methods available to professionals who want to intervene in the area of addictive behaviors, in order to assist the treatment and prevention of addiction. Goodwill, interest and dedication are important, but not sufficient. Such qualities must be associated with objective and affirmative approaches based on scientific evidences. Key – words: Alcohol; tobacco; psychotropic drugs; treatment and prevention of addiction. Resumo: Álcool, tabaco e outras drogas psicotrópicas tornaram-se uma preocupação mundial de saúde pública. Nas últimas décadas, as pesquisas no campo biológico, psicológico e sociológico providenciaram um maior conhecimento sobre este assunto e permitiu o desenvolvimento de abordagens e métodos de prevenção e tratamentos mais eficazes (Ribeiro & Marques, 2006). O presente trabalho Fornece um conjunto de métodos terapêuticos disponíveis para profissionais que querem intervir na área de comportamentos aditivos, a fim de auxiliar no tratamento e prevenção da dependência. Boa vontade, interesse e dedicação são importantes, mas não suficientes. Essas qualidades devem ser associadas afirmativamente com evidências objetivas e baseadas em abordagens científicas. Palavras - chave: álcool, tabaco, drogas psicotrópicas, tratamento e prevenção da dependência. Resumen: El alcohol, el tabaco y otras drogas psicotrópicas se ha convertido en un problema de salud pública en todo el mundo. En las últimas décadas, la investigación en el campo biológico, psicológico y sociológico tomo mayor conocimiento sobre este tema y ha permitido el desarrollo de enfoques y métodos de prevención y tratamientos más eficaces (Ribeiro y Marques, 2006). El presente trabajo proporciona un conjunto de métodos terapéuticos disponibles para los profesionales que quieren intervenir en el ámbito de las conductas adictivas, con el fin de ayudar al tratamiento y la prevención de la adicción. El fondo de comercio, el interés y la dedicación son importantes, pero no suficientes. Estas cualidades deben estar asociados a los enfoques objetivos y afirmativas basadas en evidencias científicas. Palabras - clave: Alcohol, tabaco, drogas psicotrópicas, prevención y tratamiento de la adicción. ------------------------------------------------------------------------------------------------------------------------

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Introduction

threatened. The apparent “shut down” of

Alcohol, tobacco and other psychotropic drugs has become a worldwide public health concern. In recent decades, research on

the

biological,

psychological

and

sociological field increased knowledge about this subject and allowed the development of approaches and prevention methods and more effective treatments (Ribeiro & Marques, 2006).

some addicts from their lives, jobs and family generates anger and prejudice. Such behaviors, however, aren’t only restricted to the will, but inserted in a complex network of biological, psychological and social factors that take back the freedom of choice from the addict. Thus, phrases like “stop now”, “stop using or you’ll die”, “see what you did to your life”, turn out to be absolutely harmless. Therefore, treatment

Previously, this consumption was seen on the premise of “all or nothing”. The “junkie”, “addict” or “alcoholic” was always described as absolutely dependent without substance control, whose only treatment was an intensive and prolonged treatment.

is one way to minimize the damages that may occur in the life of chemical addicts, being indispensable to motivate him to change, remove barriers and actively help him on the search of a new lifestyle without substance (Leite, 2000).

Much has changed since then. It’s known that the intensity and complications of substance consumption on mood change vary along a continuum of severity. As with all chronic diseases, treatment is now focused on symptoms reduction, which affect, not only the patient, but also family members, significant others on his life and all the community around it.

The present work provides a set of therapeutic

methods

available

to

professionals who want to intervene in the area of addictive behaviors, in order to assist the treatment and prevention of addiction. Goodwill, interest and dedication are important, but not sufficient. Such qualities must be associated with objective and affirmative approaches based on

A first question that emerges on this

scientific evidences.

sensitive topic is: why treat? It’s still common to find people who think that alcohol and other psychotropic drug addicts need to “hear the truth”, be scolded and

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The

psychological

treatment

involves,

among other things, listening carefully to what the patient has to say and finding

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personal “aspects”, family, social, etc.,

In addiction, on the other hand, there’s an

which are responsible for addiction. Assist

exponential and gradual increase demand

the level of informal support, such as the

for a specific psychological effect, and an

resolution

problems,

increasingly marked tolerance (achieved

question erroneous beliefs and social skills

through the substance, object or behavior)

training

(Arcolese, 1989).

of

interpersonal

are

examples

of

specific

psychological techniques in the treatment of

addictive

behaviors.

Thus,

the

psychological treatment is done by clinical psychologists, experts in the problems of human evaluation

behavior,

using

techniques

specialized

and

treatment

Addiction is then conceptualized as a chronic

psychological

or

behavioral

addiction that can evolve into a recurring feeling where a substance/ object/ behavior are required for the individual organism to function properly.

whose effectiveness has been proven in numerous

scientific

investigations

(Labrador, Vallejo, Matellanes, Echeburúa, Bados & Fernández-Montalvo, 2003, cit. in Horcajadas et al., 2010).

Therefore, according to Gossop (1989), the history

of

addiction

is

apparently

“attached” to the history of human being. Smoking

cigarettes,

drinking

alcohol,

inhaling psychoactive substances, smoking hashish or marijuana, etc., are well known 1. The Addiction

examples of some substances that the human being has been using throughout history, and continues to use. Beyond the

First, it’s important to understand and distinguish the concepts of dependence and addiction. An individual can be dependent on a particular psychoactive substance or behavior, not yet being an addict. In dependence there’s a need for a certain behavior or substance, but with no increased tolerance to it, there’s no addictive behavior (Scharfetter, 2002).

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substances described above, at present, stand out the so calls “new addictions”. Some derived directly of substances (such as heroin, cocaine or LSD), while others are behavioral addictions without substance – a result of our technologically evolved society, highlighting the addiction to the internet,

cellphone,

sex

or

shopping

(Gossop, 1989).

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But a common and central feature of

a) Use – use of psychoactive

addictive behaviors is loss of control. The

substances is defined as the

addict has no control over his behavior and

consumption of a substance

eventually be led to dependence, tolerance,

that

withdrawal

effects on the individual, or, he

syndrome

or

negative

consequences in his life.

produces

no

adverse

doesn’t identify them. This’s the most common type of

Gossop (1989) defined as characteristic

consumption when consuming

elements of addiction:

sporadically. 1. A strong desire or sense of

b) Abuse (or harmful use) – is

compulsion, in order to carry

meant by abuse when there’s

out the particular behavior;

continued and excessive use of

2. Impaired ability to control his

a substance despite negative

act;

consequences

3. Malaise and altered state of

c) Dependence

prevented or fails to be made;

evidence

that’s

the

term

dependence arises with the

4. Persistence in keeping the despite

derive

thereof.

mind, when the behavior is

behavior,

which

excessive use of a substance

clear

that causes significant negative

producing

consequences for a wide period

severe consequence for the

of

individual (Gossop, 1989).

time.

Can

also

intermittently

occur

continued

consumption (eg: on weekends) (Dupont, 1997).

1.1. Use, Abuse and Dependence

It’s indeed essential to clarify what

Abuse

and/or

substance

dependence

constitutes the use, abuse and substance

criteria, according to DSM-IV-TR, are

dependence. So, we then present the main

enlightening as well (APA, 2002):

differences between use, abuse and substance dependence:

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A. Maladaptive

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of

4. There’s a persistent desire

to

or unsuccessful efforts to

impairment or distress clinically

reduce or control the use of

significant, as manifested by

the substance;

substance

pattern use,

leading

three (or more) of the following

5. Much time is spent in

criteria, occurring at any time in

activities

the same 12 month period:

obtain the substance (eg:

1. Tolerance defined by any of

consultations with multiple

the following:

substance

to

doctors or take long car

a. The need for markedly increased

necessary

amounts to

intoxication

or

of

trips), the use of the substance

(eg:

group

achieve

smoking) or recover from

desired

its effects;

effect;

6. Important

b. Markedly diminished effect

social,

occupational

or

with continued use of the

recreational activities are

same amount of substance;

given

2. Withdrawal, as manifested by either of the following aspects: a. The

because

or of

reduced substance

abuse; 7. The

characteristic

up

substance

continues

use despite

withdrawal syndrome for

knowledge of having a

the substance;

persistent

or

recurrent

b. The same substance (or

physical or psychological

closely related substance) is

problem that tends to be

taken to relieve or avoid

caused or exacerbated by

withdrawal symptoms;

substance

(eg:

current

3. The substance is often

cocaine use, although the

taken in longer amounts or

individual recognizes that

over a period longer than

his depression is induced by

intended;

it,

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or

continued

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consumption of alcoholic

realm (Becoña, 2008). Originated by the

beverages, although the

previous or interacting with these, is often

individual recognizes that

found

an ulcer was made worse by

psychological

alcohol consumption) (APA,

(Jacobs, 1989).

the

presence or

of

organic,

psychiatric

disorders

2002). 1.2. The neurobiology of addictions The first aspect present in all addictive behaviors is the compulsion or loss of control being, probably, the main feature of this problem. The second point to note is the symptoms of dependence. Dependence syndrome refers to a clinical state (set of signs and symptoms) that’s manifested due to

the

appearance

psychological

of

disorders

physical with

and

different

intensity upon discontinuation of the substance or antagonist – calling itself by a withdrawal syndrome. The third aspect is tolerance – the process by which the addict feels the need to increase substance consumption to achieve the same effect it

To be an addictive relationship with a substance, there’s a basic process that begins with minor consumption – favoring the compulsion to continue consumption (so called priming effect), then ending with the appearance of craving – also known by the urgent need to consume. When the substance consumption becomes chronic, is produced in the brain one neuroadaptation, causing the addict to feel the effects of tolerance and abstinence. Thus, is defined the dependency phenomenon (Horcajadas et al., 2010).

would have originally. The fourth aspect t

These

point out is the intoxication that all

tolerance and dependence) have, in the

chemicals produce, a state in which the

central nervous system, a physiological

subject appears to be “beside himself” or as

relationship. The circuit of pleasure or the

if it were another person. As the fifth pretty

reward pathway plays a key role, both in the

significant aspect we stand out problems

development of substances dependence, as

that arise at the level of the physical,

in the initial stage of relapse maintenance.

personal, family, professional and labor

It’s an existing brain circuitry not only in

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clinical

findings

(abstinence,

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humans, but shared with the majority of

neurotransmitter – dopamine. The hedonic

animals. It’s therefore, a primary system.

effect is increased and the pleasurable

Naturally, this circuit is essential to the

sensation causes the subject to consume

survival of the individual and the species,

again.

since it depends on pleasurable activities such

as

feeding,

reproduction,

etc.

(Damásio, 1994; Verdejo & Bechara, 2009).

Dopamine is the key neurotransmitter in the reward circuit (especially on projections and dopaminergic connections between

The activation of the reward circuitry

vental-tegmental

facilitates learning and maintenance of

accumbens). Is of the nucleus accumbens

approaching behaviors and consumption,

that feelings of euphoria depend, critical

important and useful for adaptation and

place within the reward circuit, as it’s also

survival. Somehow, substance use just

triggered by the conductive effects of

“kidnap” “steals” or perverts the said

addictive substances.

pleasure circuit, causing the individual to learn and consume substances, as well as keep in his memory contextual stimuli that may subsequently trigger the consumption. This way, the reward circuit is a common way of reinforcement, whether natural or artificial

(Damásio,

1994;

Verdejo

&

Bechara, 2009). This same pathway appears

area

and

nucleus

The role of dopamine is to establish and regulate synapses of the reward circuit. In a normal situation, the arrival of a pleasurable stimulus requires the release of dopamine into the presynaptic cleft, stimulating postsynaptic receptors. Upon completion of its purpose, is reintroduced into the neuron of origin (Koob & Blom, 1998).

to be common to other types of addictions, as is the fallen of gambling addiction (compulsive gambling), internet addiction,

In acute substance use is assumed to be an increase in dopamine release, leading toward intensification of the feeling of

etc.

pleasure. However, the chronic use of The ultimate objective of the reward system is then perpetuating the pleasurable behaviors for the subject. Directly or indirectly, the substance use supposes the increase

of

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this

system

basic

substances no longer seems to produce more

dopamine

changes

occur

release, at

the

but

rather,

level

of

neurotransmitter receptors. Clinically, this condition is manifested at the level of

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tolerance, which is to say that there’s a

pleasure. These individuals were raised in

need to increase the consumption of

families where they’ve been taught no to

substances to achieve the same effect.

trust others, and instead should rather

Decreased dopamine and neuroadaptive

suspect. The emptiness and loneliness has

changes make the subject potentiates

set in and the way was open for the

substance use in order to maintain a

addictive logic to progressed (Nakken,

constant level of stimulation (Bardo, 1998;

1996).

Kelley, 2004).

The learning theories explain the behaviors as having been acquired by the learning of

1.3. The addictive personality

classical conditioning, operant conditioning or social learning. In the case of addiction is thought that if the behavior is socially

One of the characteristics of the addict is

learned, the same can happen in reverse,

that their wills are priority because they’re

unlearn it (Nunes & Jolluskin, 2007).

used to relate to objects/behaviors and obviously the addict in this relationship always comes first. Not trusting people and seeing them as a threat, he just trusts in his addiction. It’s very dishonest to think that an object/behavior may bring more than a temporary mood change, moreover, these objects are easily replaced by more effective ones. Jump from object to object, from behavior to behavior creates the illusion that the situation is resolved, this is a way to ensure that people around him aren’t after him. The addictive personality settles in the person and controls the situation with priority, the normal desire to live life with minimal pain and maximum

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Psychological theories which are based on intrapersonal causes include a range of perspectives and one of them the Kapplan approach (1998, cit. in Nunes & Jolluskin, 2007), which appears as an integrative theory of deviant behavior. To this author conducting a deviant action is adaptive to the person, however depending on the reference standard or on expectations that define the action as adaptive. Self-esteem is crucial, because if the individual doesn’t feel accepted, ultimately engages in deviant activities,

seeking

new

experiences,

reinforcement and self-esteem through the use of drugs, since there’s a distancing of adults who were his reference. Kaplan

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(1998) believes that the maintenance of

up this process for loss of control. The

these

positive

constant avoiding of the surrounding

reinforcement by peers and an increasing

reality, obsessive thoughts, concerns and

difficulty

conventional

rationalizations, lead him to act on feelings

standards since they have their needs met

in order to change them momentarily.

approval (Becoña & Martin, 2004, cit. in

Family members desperate question where

Nunes & Jolluskin, 2007).

they went wrong and why this behavior.

behaviors

to

is

due

return

to

to

Theories grounded in family, on systemic approach, explain drug use as a mismatch of one of the elements by reason of a family dysfunction (Waldren, 1998, cit. in Nunes & Jolluskin, 2007). Facing the family as a set of related individuals with each other and where they carry a number of interactions, this problem is no longer exclusively the individual, going through the entire family

However these are questions to which the addict has no answer, because he himself often questions about the pathological relationship that’s forming inside him. It’s because of this that the question called addictive logic develops, because there’s an attempt to justify all changes, though never based on fact, but rather in relation misleading (Nakken, 1996).

while irreducible system, that for their style

The addiction becomes a way of life changes

of communication generated and kept the

in individual give up on a deep level,

problematic behavior of the elements. This

changing the personality permanently. Like

problematic behavior is where the addictive

all other diseases, addiction develops

personality emerges, i.e., as a way to avoid

inside, long before it’s recognizable by him

suffering,

and by others.

addiction

settles

and

consequently ends up creating suffering, also because the distancing of family members is already too big.

The

mood

changes

caused

by

object/behavior, provides the illusion of control, comfort and perfection. The

The addict reacts like a child, follows

intensity of the addictive process is

impulses and feels himself the center of the

confused with intimacy, self-esteem and

world. We now have an almost constant

social

internal conflict between the self and the

relationship

is

addict and the winner is the addict – calling

attachment,

addiction

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comfort.

While based

the on is

natural emotional

based

on

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emotional

withdrawal,

and

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physical

There’re various forms of psychotherapy

dependence on object/behavior. The trend

based on different theoretical frameworks.

of blurring the self leads to an increase of

Basically, were recognized 5 major groups

the addict personality (Nakken, 1996).

(see Figure 1), classified according to their appearance in the history of psychotherapy.

2. Intervention in addictive behaviors psychoeducation Precontemplation

motivational interviewing

psychoeducation Contemplation motivational interviewing

awareness Preparation Stages of change

crisis intervention containment strategies

569

craving management

Action

prevention of relapse

Change

Prevention of relapse

Figure 1. Integrated Model of Intervention on Addictions (Sánchez-Hervás et al., 2004)

Using literature review, it appears that

literature review also states that behavioral

virtually all psychological interventions

techniques are the ones that empirically

show some efficacy in the treatment of

shown greater efficacy in the treatment of

addictive behaviors. However the same

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addictive disorders (Horcajadas et al.,

Therapy:

circumstances

don’t

disturb

2010).

people, but people are dismayed by their vision of the circumstances (a principle later adopted by Beck in his Cognitive-behavioral

2.1.Ellis Cognitive Therapy (Rational Emotive Therapy)

Therapy). The therapy proposed by Ellis is based on the ABC emotions theory, where A

The rational emotive therapy was founded

designates the event, B refers to the belief

by Professor Albert Ellis. Influenced by

that’s formed in the mind of the patient and

Greek and Roman stoic philosophy, Ellis

C is the emotional result of this belief

adopted its essence and developed the

(Dryden, Neeman & Yankura, 1999).

fundamental principle of Rational Emotive

Belief/Thought

Emotion

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Behavior

Figure 2. ABC emotions theory, proposed by Ellis (Dryden, Neeman & Yankura, 1999)

Refute irrational beliefs involves three steps: 

Discuss with the patient the validity of his hypotheses, teaching him to

Encourage the patient to discover

discriminate and recognize the

irrational beliefs that support his

irrationality of certain beliefs and

emotional

assumptions – empirical debate;

problems;

and

behavioral 

Develop with the patient a socratic dialogue, whose aim is to question

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the patient, encouraging him to

problems (eg: “I want to use by

realize his distortions, through

being anxious”);

generating appropriate beliefs and

react appropriately.

Establish

flexible

goals,

conceptualize the symptom profile according to the ABC model and

This therapy primarily employs a fast attack methodology, directive in high degree and persuasive which emphasizes the cognitive aspects (Patterson & Eisenberg, 1998).

define with the patient possible and recommended options; 

Elaborate

events

log

sheet

(according to the table below): A. Situation (eg: I went to the bar and had a desire to drink).

The steps of Rational Emotive Therapy: 

B. Irrational thoughts (eg: I’m

1st stage – the Psychodiagnostic

worthless, I’ll never be able to

Objectives: 

stop). Identify dysfunctional beliefs that produce

emotions

C. Emotional

and

consequences

counterproductive behavior; 

and

Behavioral

(eg:

anxiety,

sadness).

571

Understand how they contribute to the patient’s problems;

Point out realistic goals (agreed between patient and therapist).

Tasks: 

After completion of this step, we get a general idea of the major emotional and behavioral problems of the patient.

 Classify the patient’s problems in

Supposed to clarify the following concepts:

external and/or internal;  

Detect through the report of the

2nd stage – Intellectual Insight

Irrational beliefs are the main

patient, their irrational beliefs;

determinants of emotional and

Detect “problems or issues” that

behavioral problems;

are irrational ideas about primary

Acknowledge

the

patient

that

there’s no evidence to support the

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irrational beliefs and that these

Given each new problem that arises, the

beliefs are harmful;

patient should be encouraged to follow

Understanding (by the patient) that

three steps:

changing their irrational beliefs,

-

their behavior will change.

Identify problematic emotions and behaviors (B), interconnected with the situation (A) and identify

3rd stage – emotional Insight: attitude change

irrational beliefs that sustain them; -

Therapist and patient work together, in order to replace irrational beliefs by rational ones. This step can utilize a most complete event record sheet, which includes alternative rational thoughts (D) and desirable consequences therefore (E): A- Situations

-

and

identify

rational

Protect

rational

alternatives,

Final step: Strengthen rational habits

rational

thoughts E- Emotional

beliefs

572

The main objectives are:

consequences adaptive

counterproductive

through the execution of tasks.

C- The emotional and behavioral

D- Realistic

the

alternative beliefs (D);

B- Irrational thoughts

Refute

Prepare the patient to empower changes acquired in therapy;

and

behavioral

consequences

Structure of the sessions:

Prepare him to be his own therapist in the future.

For monitoring the therapeutic process we

Some therapist begin the session by asking

suggest

the patient how he felt during the week and

dysfunctional thoughts (Figure 3) and daily

begin therapy based on issues that concern

record of dysfunctional thoughts (Figure 4).

self-monitoring

records

of

him at the moment or that are contained in self register. Other therapists prefer to work one problem at a time until it’s resolved.

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Automatic thoughts Situation (describe the event that causes a negative emotion)

Date

Emotion(s) (specify emotion and quantify it 1-100)

(write automatic thoughts that precede emotions and quantify them in terms of belief from 1 to 100)

Figure 3. Registration of self-monitoring of dysfunctional thoughts (Maia, Correia & Leite, 2007)

Situation

Emotion

Automatic thoughts

Challenges

Describe a current event direct to an unpleasant emotion or trends of thoughts

Sadness, guilt, anxiety

Write automatic thoughts that preceded the emotion and identify dysfunctional thoughts

Challenge dysfunctional thoughts

Results or alternatives

573

Date Figure 4. Daily log of automatic thoughts (Maia, Correia & Leite, 2007)

a) Dispute the uncomfortable anxiety

discomfort regarding something

(the tendency for the addict to

perceived as horrible to something

exaggerate

experienced

that can be supported, showing, for

discomfort). Help the individual to

example, how to exaggerate his

modify

discomfort and how to define an

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their

the

assessments

of

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unpleasant situation in intolerable

because I often don’t solve

terms

them, I’m no good at all”.

make

less

extreme

evaluations about himself. Help the individual to develop a “hedonic

c) Dispute the self-condemnation: the

calculus” – refers to the process

irrational

through

individual

characterize the self-condemnation

analyzes costs/benefits of a bonus

are two types: the first is an

in a short and long term (think

absolute

positive and negative points of a

conditions under the abuse of drugs

bonus in the short and long term).

should never have occurred in the

which

the

beliefs

that

requirement

can

that

all

past and shouldn’t occur in the b) Compete discouragement: consists in

changing

substance

dichotomy reasoning whereby the

dependence belief that “there’s

chemically dependent identifies

nothing to do” in order to rapidly

himself as being or not a consumer.

acquire

a

the

future; the second involves a

“sense

Importance

of

of

hope”.

self-fulfilling

prophecy.

d) Disputing irrational beliefs about troubled emotions (Ellis et al., 1988):

Main cognitive distortions: 

addicts

should

avoid

emotional discomfort associated

generalization:

with negative emotions like guilt or

“Since I failed in trying to

depression. One objective is to help

solve my problem, I myself

the addict deal with negative

am a loser”.

emotions resulting from the abuse

Thinking “all or nothing”: “If

of alcohol and/or drugs (Ellis et al.,

I don’t have control over

1988).

Abusive

drug use is because I’m unable to control myself”. 

Selective

abstraction:

“Sometimes I adequately solve my problems, but

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2.2. The cognitive-behavioral therapy

confrontation, honesty

and

without sincerity

forgetting that

the

should

characterize him, but eases the concept of Cognitive-behavioral

therapy

is

the

integration of principles from behavioral theory, the social learning theory and

dependence or motivates the patient in seeking treatment (Prochaska, DiClemente & Norcross, 1992).

cognitive therapy. General characteristics of In the contemplation stage (“This is starting

cognitive-behavioral therapy, include:

to bring me problems”), the ambivalence of

Addressing the current problems;

Consensual and realistic goals with the patient;

Use

of

to

Although he perceives some losses, he argues by minimizing them, or contrasting

empirically

tested

techniques to increase the patient ability

the addict in relation to his issue prevails.

“drive”

their

own

problems (Iglesias et al., 2008).

the benefits from the consumption of substances. At this stage it’s essential to balance the advantages and disadvantages of

the

use

and

abstinence,

usually

confronting the maintenance of drug use Prochaska,

DiClemente

and

Norcross

proposed in 1992, several stages related to

with the plans that the patient presents for the future.

575

addictive behaviors, which define the

Then is the stage of preparation. At this

readiness of an individual in abandoning the

point the addict understands the extent of

use of substances.

his problem and asks for help. The role of

According to these authors, there’s a first stage called pre-contemplation in which the subject doesn’t believe that alcohol or drugs will be harmful. There isn’t the slightest motivation to change, either abstinence or reduction in the frequency or intensity of consumption. There’s often an idealization of the effects (“I’m more creative when I consume”).

The

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professional

the professional is to assist him in developing reality check strategies, identify and work dysfunctional beliefs (“If I don’t use, I can’t work”), favoring the onset and/or increased self-sufficiency. Basically, should offer solutions and lower barriers quickly, since the return to earlier stages is very common.

avoids

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After this moment, begins the action stage,

sufficiency (autonomy and independence)

where the chemically dependent begins to

worked in previous phases, shouldn´t be

implement the plans developed in the

exaggerated, being possible a real risk of

previous phase. The psychologist provides

relapse (Prochaska, 1992).

the necessary support, seeking to involve

Lather authors added a final stage, called

the nuclear family and closer social support

termination

network.

indicating

the

changes

obtained enough stability, allowing the

The maintenance stage seeks at this stage

individual to feel secure that the pattern of

the disease stabilization, making the

previous behavior will not return. Also

changing already made in the previous

designated the drug addict will eventually

phase, in a new and healthier lifestyle.

use mood altering substances, putting into

Prevention of relapse is one of the directive

question the work done in previous stages

techniques most widely studied, as well as

(Prochaska, 1995).

self-help groups (Narcotics Anonymous, Alcoholic Anonymous), since they provide 576

essential social support network. The self-

Precontemplation

End vs Relapse

Contemplation

Maintenance

Preparation

Action

Figure 5. Motivational stages proposed by Prochaska (1995)

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In each session there’re actions designed

appropriate

according to the patient’s stage of change.

(depending on the shift stage at which the

Thus, the stage of pre-contemplation, the

patient lies) (Prochaska & DiClemente,

therapeutic task is to raise doubts. In the

1983).

contemplation stage, it’s desirable that the therapist point the lack of balance providing reasons to change or not. In the action stage it’s desirable to help the patient move toward change, appreciating his efforts. In the maintenance stage, it’s expected that the therapist assists the patient to identify strategies for relapse

prevention, as

strengthening self-efficacy. The stage of

intervention

strategies

View of other directives interventions, motivational interviewing aims to identify problems, encourage the patient to find solutions, accepting that there may be ambivalence and there may be different points of view. The objective is to allow the patient’s progress through the various change

stages

accompanied

by

the

therapist.

completion and if there’s relapse, the therapist must help the patient to start the process by assessing whether or not he has developed a satisfactory coping response (Prochaska, DiClemente & Norcross, 1992).

Motivate the addict to break the cycle of substance use is the primary objective of this phase. There’re 6 basic rules that need to be clarified and communicated to the patient: 

2.2.1. Motivational Interviewing

The

time

stop

is

now

increases

the

consequences

of

(postponement negative

It was designed by Miller and Rollnick (1991) for people with problems with alcohol, and

to

substance use); 

Should

stop

consuming

once

then expanded to other areas within the

(reduce consumption is a thankless

psychological treatment (Rollnick, Miller &

and fruitless task);

Butler, 2008). This therapy basics of “clientcentered therapy”, applied to the stages of

Stop consuming all the mood altering

substances

(avoid

change of Prochaska and DiClemente (1983), aims to define and select the most

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memories 

associated

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

with

consumption);

the treatment, describing the methods of

Change lifestyle (avoid people and

assessment and intervention (Maia, Correia

situations

& Leite, 2007).

associated

with

substance use); 

Seek sources

treatment should be outlined and explained

other of

The Psychoeducation as treatment for rewards/healthy

pleasures

(physical

chemical dependence is chosen as a treatment for the ethical control and

activity, movie);

methodological appropriate, besides being

Personal care: appearance, food,

a standard type of intervention found on

etc.

several studies with adolescents (Smith,

Studies indicate that the motivational

Sells, Rodman & Reynolds, 2006). This is an

interventions are useful for increasing the

intervention

motivation, but this motivation decreases

information on drugs and its problems

over

time. Such interventions aren’t

(Kaminer, Burleson & Goldberger, 2002). So

sufficient for the addict to stop using, but

psychoeducate on chemical dependence is

appear to be useful to increase participation

to address topics, such as:

and

treatment

motivational

adherence.

Therefore,

interventions

are

to

Drugs and their effects;

Concept

of

use,

provide

abuse

and

dependence; 

motivation levels (Prochaska & DiClemente, 1983).

aims

complementary to other treatments and should be structured to patients with lower

that

Concept

of

psychoactive

substances; 

Deconstruct

myths/dysfunctional

beliefs; 2.2.2. Psychoeducation The Psychoeducation provides through a

Consequences at short, medium and long term.

behavioral treatment, identification of

Importantly,

after

each

session

of

patient’s problems and, concomitantly, the

Psychoeducation, the patient is instructed

explanation of the nature of their illness and

to perform household chores, as the case of

why its symptoms. In this phase of

reading information (such as therapeutic functions), as serving as an important tool

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for the development of self-reflection by

which often ends by increasing severity by

motivational

not being, resolved (Pereira & Souza, 2010).

aspect

of

the

vicarious

experiences, helping the sick in his behavior to change and reinforcing social patterns of desirable behavior (Kaminer, Burleson & Goldberger, 2002).

Generally, family members are the “primary victims” of addiction, beyond the patient. Victimization, overprotection, guilt, anger, deprivation

and

despair

are

feelings

observed on the dependent’s family members that started treatment. Physical

2.2.2.1. Family Psychoeducation

assaults, thefts and neglect make even Family therapy is a psychotherapeutic method that uses, as an intervention, joint sessions with the entire family.

more difficulty the family situation, with direct consequences on all their personal relationships. Thus, the family becomes a

The family, in family systemic therapy is

significant part of the problem and its

considered as a system, that is, a set of

amplification factor (Patterson & Eisenberg,

elements

1998).

connected

by

a

set

of

relationships in continuous relation with the exterior and which keeps its balance over a development

process,

driven

through

diverse stages of evolution (Sampaio & Gameior, 2002).

When the addict just cuts pleasure or a sense of liberation from his conduct, is unlikely to feel any reason to change. Therefore, is important to be firm. Faced with nonsensical applications, it must be

Being family the primary socialization cell of

said “no, I can’t” (without explaining why)

the individual and taking into account the

(Pereira & Souza, 2010).

fact of addiction involves a number of contexts, groups and persons, it becomes important to understand how a therapeutic monitoring subsidizes drug addict’s families and people close to them, in order to deal with addiction and to cooperate in treatment. Also noteworthy is the family disintegration due to chemical dependence,

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However, a major reason that allows the progression of addiction is the fact that family members deny what’s evident. In this field,

there’re

reluctance

of

some families,

difficulties such

as

and the

difficulties in talking about feelings and emotions (culturally, more in men that in women). On the other hand, when parents

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seek help, they believe they can learn how

counseling to wives (husbands) or parents,

to cure their addict rather than learn

and/or interventions for guidance and

different ways to deal with his behavior (but

support. It’s through family care that family

facilitate the dependence of the addict)

members

(Patterson & Eisenberg, 1988).

assistance, as well as basic guidelines for a

It’s important to put the emotional recovery first and start thinking positively about

can

attention

and

better understanding of the framework for chemical dependence and, thereby, an improvement

taking care of yourself.

receive

of

the

family

system

(Patterson & Eisenberg, 1988). Equally important is to change attitude because previous didn’t work. This indeed, is one of the most important steps to take: understand the difference between healing and intervene in disease; stop helping the addict; practice steadfast love; intervene

A family assessment can be a great aid in treatment planning, either in providing data on the diagnosis, either as an indicator of the most appropriate type of intervention for the family. The American Society of Medicine proposes three stages to the

legally; take the initiative.

treatment of addict’s families, whereas the Initially, the availability of members is an important factor for good monitoring, however, isn’t always possible. Therefore, some interventions that precede this process are favorable, such as individual

intervention level varies according to the established treatment goal, as well as the needs of the family. The following table summarizes the level of family intervention, 580

according to stages:

Stages

Goals

Main target of intervention

Stage I

1.Working denial;

Individual

2.Stop the consumption of substances Stage II

1.Prevent relapse;

Family of origin; Family of procreation

2.Stabilize the family, improving their functioning Stage III

1.Increase the couple’s intimacy, on emotional and

Couple

sexual level Figure 6. Levels of family intervention according to stages

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Stage I aims to ensure abstinence from

some relationships are still worn. At this

chemical dependence. To this end it’s

stage, the treatment aims to increase the

important

couple’s intimacy and the participation of

to

assist

him

to

take

responsibility for his behaviors and feelings. Sometimes attended

some

members

together,

may

emphasizing

be the

decreased reactivity of the impact of a family member on the others. In the systemic framework, the focus centers on the wife (husband), so to break the repetitive circle of family functioning and

both is essential (Figlie, 2004). The family relationship is the support and foundation for good emotional structures of the patient, both to prevent a relapse and for

his

maintenance

and

recovery.

Whereby, it’s essential to participate in all therapeutic processes in which the patient is in (Colvero et al., 2004).

thus, help patients in their recovery, the behavioral framework works with the prospect of viewing spouse behaviors that reinforce addictive behavior, aiming for the replacement

behaviors

that

reinforce

In stage II the focus is identify dysfunctional patterns in the family as a whole, both in the family of origin and family of procreation. At this stage it’s important to resume family “rituals” and according to the degree of forward

guidelines

psychoeducational to

dependent’s

the

substance

family

(inactive

substance use): It’s known that people who are connected

sobriety and abstinence.

difficulty,

a) Practice

to

a

family

psychotherapy.

to addicts can be, in a way or another, “trapped” by the addiction, depending on the emotional bonds that bind them to the addict. Family members allow themselves to engage in the addiction problem through many of the same ways in which are involved in other family problems. Every addict has a significant and direct impact on

Stage III is defined as a new frontier in the treatment of chemical dependence, one of the least explored areas, and perhaps the

the lives of several other people, and all these, in turn, influence the addict (Williams & Swift, 1997).

most controversial. Long after the cessation of the use of mood altering substances,

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Each family is witness to how addiction

him of cash, credit cards, and

wore their life quality. As the signs of

valuables.

addiction become visible, the problem

substance use;

becomes central in the family, becoming prisoners

of

destructive

patterns,

Money

induces

Initially, the addict rarely accepts help, since he doesn’t admit that he

determined by severe, recurrent and

lost

predictable

family,

substances. Generally, the addict

eventually, convince themselves that if they

says “I stop when I want”. It’s

tolerate, things will be different – for next

important to show him how much

time.

he has lost and how much he will

Even when the family really sees what’s

lose;

situations.

The

happening, the decision to do anything

control

on

the

use

of

The drug addict doesn’t attach to

about the addictive behavior of another

material and financial losses, but to

person is often difficult to take. Often the

the people around him and the

right time to make decisions is far reaching.

ones that show him love. For the

Other times not enough (Williams & Swift,

addict, losing his wife (husband),

1997):

children, parents are often painful.

Sometimes only the loss (even Don’t expose the addict to places

temporary)

and situations where alcohol, drugs or other mood altering substances,

to

counteract

place itself in the condition of “poor thing” is mainly in order to achieve

Buy drugs or alcohol to the addict, in order to keep him at home or to deprive

him

from

hostile

environments, will enhance the consumption of substances; 

It’s important to help the addict govern his financial life, depriving

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One must have attention to selfpity on the part of the addict. To

the

behavior; 

seeking

people;

because the “strong will” often is insufficient

influence

other’s attention; 

Many addicts are unable to stop using substances. Thus, it’s for the family to prove the contrary, encouraging

him

accompanying treatment

to

recovery,

him

to

the

indicated

for

him

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(medical,

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hospitalization,

and

psychotherapy, ambulatory).

Many families continue to look the addict as irresponsible, more out of habit

than

conscious

motives.

Sometimes the family can’t believe b) Practice guidelines

psychoeducational to

the

that

substance

believe that they wish back the old

relate with a “new person”, new

forgiven

and

“bad times”; 

forgotten

the same time and immediately, at

The recovering addict loses its

the very time the addict is starting

status as a “scapegoat”, often

to learn to take small steps on the

ending the family replacing him

road to recovery, it’s also a

with another. Thus, there’s always a

common mistake. It may take time

reason for things to go badly. It’s

until

important that family members

stead, learn a way to clearly see the outer circumstances that cause problems;

starts receiving compliments, which were previously uttered to the family and he often rebels. Thus, to avoid adding insult to harm caused addiction,

family

members

shouldn’t lay claim to all the merit of addict’s recovery;

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family

adapts

and

capable of flying itself; 

It’s important to make a special appeal to those who for so long despaired and yearned, so that

When the drug addict recovers,

by

the

recognizes that the addict is

recognize this attitude and in its

Angrily insisting on immediate atonement for sins of the past, all at

(Williams & Swift, 1997); 

indeed,

unconsciously, lead the addict to

new reality. It takes time to learn to

ones

has,

suspicion, denote anxiety and,

Families need time to adjust to a

attitudes have to be learned and old

addict

changed. Maintain the standard of

dependent’s family (in recovery): 

the

matters can be resolved, not to mention the physical, psychological and financial damage they suffered. Recovering an addict is also, regain family. It’s essential to follow therapeutically those who suffered for a prolonged period, with the disease of addiction in their family,

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in order to recognize their own

reasons: may have never learned effective

need to learn, grow and change, in

strategies to deal with challenges and life

order to fully live – even if the

problems; may have acquired effective

addict doesn’t (Williams & Swift,

strategies, but these skills may have

1997).

deteriorated. These patients, essentially, forget to use effective strategies due to chronic involvement in a decadent lifestyle,

2.2.3. Social Skills Training

where most of the time is spent on the acquisition, consumption and recovery of

This technique is based skills training

the effect produced by the consumption of

considered to be deficient in the addict,

substances (National Institute on Drug

because there’s scientific evidence to put

Abuse - NIDA).

into

inhibitory

What differentiates social skills training

mechanisms related to the high activation

from other approaches is the fact that it

levels of anxiety in situations of possible

focus on the difficulties in dealing with

consumption. Based on social learning

specific situations, considering that the

theory, this group of techniques aims to

main skill difficulties are given in the

increase and strengthen the patient abilities

following situations: 1) negative feelings; 2)

to cope with high risk situations that initiate

assertiveness; 3) to criticize; 4) receive

and maintain addictive behavior (Iglesias et

critics; 5) communication; 6) refuse drugs;

al., 2008).

7) say no; 8) socialization; 9) frustrations;

practice

due

to

the

with

10) postpone pleasurable situations; 11)

substance use and learn or relearn healthy

recognize and deal with risk; 12) fissure; 13)

habits are, undoubtedly an individualized

conduct planning. The techniques used in

workout. The moment the level of

social skills training are verbal and drama

substance use is severe enough to warrant

(role play) (Silva & Serra, 2004).

treatment the addict is more likely to use

The

psychoactive substances, as a way to deal

accomplished in the context of group

with a wide range of interpersonal and

therapy. In each session, the group chooses

intrapersonal

one of the situations listed and performs a

Unlearn

old

habits

associated

problems,

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for

various

social

skills

training

are

often

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role play. The group plans a scene in which

position when he realized he wasn´t

appears one or more of the situations listed.

being heard?

During the representation isn’t necessary to be

faithful

to

established

4. Criticizing: 1) reassured himself

script.

before speak?; 2) set the criticism

Improvisation is important because it

as a personal opinion, not an

stimulates creativity. It’s advisable to switch

absolute fact?; 3) criticized the

characters, asking the group who would

behavior and not the person?; 4) his

give a different answer to the staged

voice was firm and not angry?; 5)

situation. Thus, the patient acquires

proved willing to listen to the

flexibility of responses and develops new

other?; 6) was clear in the question

skills. For each situation, a list of skills is

criticized, leaving no doubt on what

compiled and professional stimulates these

was the criticism?

skills training during the role play. Next, we

5. Receive critics: 1) managed to listen

selected only a few examples on the skills

without being defensive?; 2) was

list to be trained in some situations:

able to assess the criticism clearly

1. Verbal communication skills: 1) heard

and

watched

before

speaking?; 2) made open or close questions?; 3) the questions were asked politely? 2. Nonverbal communication skills: 1) what was the attitude?; 2) there was visual contact?; 3) which facial expression?; 4) what tone voice was used?; 5) how feet, hands and head moved? 3. Assertiveness: 1) thought before speak?; 2) was objective and clear in what he said?; 3) assured himself of being heard?; 4) reaffirmed the

and select the relevant points?; 3) was able to explore critical issues to make sure that was clear which was the other’s critique? 6. Refuse drugs/alcohol: 1) was able to say “no”?; 2) by deny, was clear, firm

and didn’t hesitate?;

maintained suggested

eye

contact?;

alternatives

3) 4) to

alcohol/drugs?; 5) said to the person

to

don’t

offer

him

substances again?; 6) avoided vague answers? 7. Say no: 1) did a review of what’s a priority?; 2) decided, in fact, to refuse?; 3) made it clear he

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understood the request, but still

It’s also important to develop techniques

refused?; 4) was firm, clear, brief

for solving problems, so that the patient

and decided?; 5) what was his

learns how to cope in risk situations. Daily

posture

(nonverbal

records of thoughts faced with rational

communication)? Was consistent

answers can help to “govern the cracks”.

with the verbal communication?

When

(Silva & Serra, 2004).

recommended to postpone them for 5

dealing

with

“cracks”

it’s

minutes, 10 minutes 1 hour, etc., trying to take the focus of the impulse (watch TV, use Obviously, don’t end here all desired skills for the listed situations, but the aim is to clarify which situations should be worked and a set of skills should be practiced (Silva & Serra, 2004).

the computer, do some relaxation, talk to someone, cleaning or repairing things at work or at home). It’s extremely important to focus in goals in short and long term, instead of looking for immediate rewards

The basic techniques of social skill training

(Rangé & Marlatt, 2008).

for alcohol/drugs seek, in first place, strengthening the therapeutic alliance through an empathic understanding of the

2.2.4. Crisis Intervention

client’s problem, in combination with unconditional acceptance. The therapeutic relationship ant the conceptualization of the case, play an important role. It’s through them that the therapist can understand the pain and fear behind the hostility and resistance of the patient. Learn how to use unpleasant feelings (in collaboration

on

the

therapeutic

relationship as something useful and profitable) to the therapeutic process is a very valuable skill (Rangé & Marlatt, 2008).

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Most addicts, when begin their recovery process, do it as a result of any intervention, believing that at the right time and place, with the right help is possible to recover. The theme of addictive behavior is a very specific problem and it needs a very specialized and personalized interventions since every person is different from all others and hence the need to develop a unique plan – work in each case (Wainrib & Blach, 2000).

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The concepts that have traditionally been

1. Establish psychological contact;

marked as “Crisis Intervention” show

2. Analyze the problem;

differences

in

3. Examine possible solutions;

emergency

situations

their

application and

in

in

clinical

practice, due to the specific characteristics of urgency in psychological/psychiatric care and the difficulty in establishing appropriate protocols for such interventions. Crisis intervention is a procedure to influence the psychological functioning of the individual during the period of imbalance, relieving the direct impact of traumatic events. The goal is to help to drive the person’s preserved healthy part, as well as his social resources, adaptively facing the effects of stress. At that time, one should facilitate the necessary conditions in order to establish

4. Implementation

of

concrete

actions; 5. Verification process. Crisis intervention is a strategy of assistance shown to help a person, family and/or group, facing a traumatic event mitigating the negative effects, such as physical and psychological damage and increasing the possibility of growth of new coping skills and options and life prospects. The sort of crisis doesn’t matter because the event is emotionally significant and generates a radical change in one’s life (Sá, Werlang & Paranhos, n.d).

on the person, by his own actions, a new mode of psychological, interpersonal and social functioning, given the new situation. It’s worth remembering that at that time efforts can have maximum results (Wainrib

In general, individuals who are in crisis are flooded with thoughts and feelings that hamper the establishment of priorities; end up more concerned with things that can’t be solved immediately and ignore the most

& Bloch, 2000).

immediate problems and easiest solutions Although there’re a number of different treatment models, they’re a number of common elements consistent among the various

theories

of

crisis

therapy,

mentioning five key components that must

at the moment. So it’s also necessary that the technician helps the patient to organize his thoughts into two groups: one for short term goals and one for long term (Benveniste, 2000).

be present, following a sequence of phases or stages:

Note that sometimes, intervene in the crisis involves stabilization of the patient using

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pharmacotherapy. In those cases the

craving to the external world

technician must refer the patient to the

(performing

family physician, for a Psychiatrist of for a

example); 

hospital stay.

an

activity,

for

Coping Cards: are portable chips with phrases of impact and serve to motivate the subject to not use

2.2.5. Craving Management

drugs; 

Relaxation:

are

trained,

Craving, a term commonly used by addicts,

consultation,

concerns an intense desired to consume

techniques

substances, relieve the symptoms of

breathing and muscle strain);

addiction,

often

associated

with

an

in

relaxations (diaphragmatic

Refocusing: the individual must

irresistible urge. This desire can occur both

focus his thoughts on a phrase like

at the beginning of abstinence, and after a

“Stop!” or on a specific image not

long period without substance use (Araújo

compatible

et al., 2008).

substances;

According to Marlatt and Gordon (1993),

the

craving

is

a

use

of

Substitution with negative image:

image that would be associated

motivational state influenced by the

with substance use, by other

expectations associated with a positive

which the desired behavior is involved.

the

the patient must replace a positive

subjective

result, a state that can induce a response in

with

negative connected to the damage; 

Replacement by positive image: a view of himself as a winner, should

As the craving has been considered as an

important

factor

in

maintaining

abstinence, should be applied strategies for control

(Ferguson,

2009).

Some

key

techniques are: 

be done; 

“Test by vision”: use to prepare the individual to face risky situations. The drug addict must be guided by the therapist to image himself in a

Distraction: it’s proposed that the

dangerous situation, acting in an

individual shift the attention of his

assertive

way

without

using

feelings and thoughts related to

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substances, working thoughts and

participate in role playing (National Institute

emotions arising therefrom, until

on Drug Abuse - NIDA).

he feels confident to face it; 

The duration of treatment is about 12

Dominion View: is used when the

weeks, in order to produce the total

addict is unable, to imagine himself

withdrawal

resisting the craving. It’s aided by

Preliminary data suggest that patients who

the therapist to imagine himself as

achieve three or more weeks of continuous

a winner of a generating anxiety

abstinence from psychoactive substances

situation (Ferguson, 2009).

during the 12 week period, a priori are able

The use of psychotropic drugs to control the

to maintain a good result during the 12

craving has been subject of several studies.

months following completion of treatment.

However there seems to be limitations as to

For

its

relapse

treatment isn’t sufficient to produce

prevention: the combination of psychiatric

stabilization or improvement. In these

drugs with psychotherapy seems to be the

cases, the CBT is seen as a preparation for a

therapy that brings better results (Araujo et

long term treatment. Further treatment is

al., 2008).

recommended directly when the patient

usefulness

as

unique

in

and

many

patient

patients,

stabilization.

however,

brief

isn´t capable of achieving 3 or more weeks of withdrawal (National Institute on Drug 2.2.6. Group Psychotherapy

Abuse - NIDA). Group

therapy

offers

addicts

the

Although individual treatment provides

opportunity to know themselves and learn

greater flexibility in the sessions, a number

about their addiction. The benefits of this

of

therapy are the following:

researchers

and

clinicians

have

emphasized the unique benefits of the addict’s

treatment

in

group

format.

opportunity

to

share

their

personal

experiences, experiment identifications and

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and

mutual

acceptance with who has similar

Sessions last between 60 and 90 minutes in order to allow all members to have an

Identification

problems; 

Opportunity for confrontation of ambivalent attitudes and defense mechanisms;

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Confrontation, immediate feedback

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

2.2.7. Relapse Prevention

and positive peer pressure to

Relapse is a major challenge in the

maintain withdrawal;

treatment

Cohesion, identification and social

Individuals working with behavior change

support while the addict learns to

are faced with exigencies, triggers and

identify feelings and emotions;

automatic thoughts regarding maladaptive

Structure, discipline and limits,

behaviors that try to change. Several

while learning about the recovery

authors have described relapse as complex,

and relapse prevention;

dynamic and unpredictable (Marlatt &

Hope, inspiration for the future and

Gordon, 1985). The Relapse Prevention

search for goals in the short,

(RP), developed by Marlatt and Gordon

medium and long term (Galarza,

(1985), is a widely used approach in the

2010).

treatment of addictive disorders. It’s

of

all

behavior

disorders.

In therapy groups, there’re individuals who

characterized by combining behavioral skills

are at different stages of continuous

training,

change. Also, often, patients are having very

changes in the lifestyle. In Relapse

similar problems and achieve to face them

Prevention, relapse is considered as part of

effectively. Group members have a strong

the change process that often can be seen

belief that they can only understand

as the way in which the patient resumes the

someone who has traveled the same path

treatment, more aware of his problem

as them and found an exit. Thus, the aim is

(Oliveira, Jaeger & Schreiner, 2003). Relapse

to create positive and constructive bonds

is considered a process in which one can

between group members and the therapist.

identify the antecedents and, consequently,

Fundamental elements to work in groups

allows him to predict and avoid them.

are the unconditional acceptance and the

Within the RP model, it’s understood that

positive feedback among all. Should be

the return to drug use occurs in high-risk

taught to identify circumstances that lead to

situations, which lowers their sense of self-

consume psychoactive substances and

efficacy and increases the likelihood of

outline alternative strategies (Galarza,

returning to the basic targeted behavior.

cognitive

interventions

and

2010).

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High-risk situation

, Increased selfefficacy

Decreased self-efficacy expectation of positive results (for initial substance effects)

Coping response Initial substance u

Decreased likelihood of relapse

Abstinence violation effect conflict of dissonance and self-attribution (guilt and sense of loose control)

Increased likelihood of relapse Figure 7. Cognitive- behavioral model of the relapse process, proposed by Marlatt and Gordon (1993)

Due to its chronic nature, addiction to mood altering substances has a key feature that’s

experience a sense of mastery or perceived

in

return

control (Scott & Mark, 1994). Marlatt and

certain

Gordon (1993) demonstrated that the

periods of one’s life. The dependence is, by

relapse prevention program is one of the

its very nature, a disorder with relapses.

instruments

One of the principles of any model of self-

outcomes for addict’s disorders. Claim that

reliance is that relapse may be an

the program consists of a self-control that

opportunity for further learning and not an

seeks to improve the maintenance stage of

indication of failure. When the individual

the process of changing habits. The goal is

deals effectively with the situation, tend to

to teach individuals who try to change their

high

probability

symptomatology

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(relapses)

of in

that

promote

positive

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behavior to predict and deal with the

beyond his personal control (Ramos &

problem of relapse. In a very general sense,

Bertolote, 1997).

relapse refers to a breakdown or setback in a person’s attempt to change or modify any targeted behavior (Marlatt & Gordon,

3. Ethical aspects of the therapeutic work in addiction behaviors

1993). Ramos and Bertolote (1997) summarize the

To help addicts and their families, the guide

goals of preventing relapse in: 

Change beliefs and expectations

no harm first). Ethics comprises the

about the use of drugs; 

Identify

and

anticipate

risk

situations for relapse;  

is the old motto “primum non nocere” (do

principles of morality, knowledge of good and the nature of law (Galarza, 2010).

Learn skills and coping strategies

As in other “high risk” professions, we

and management of risk situations;

can count on same strategies that promote

Promote comprehensive changes in

protective factors against exposure, the

lifestyle.

stories

The client is helped to generate alternative interpretations

and

self-positive

affirmations and select the most effective self-declaration. Can be applied modeling techniques,

relapse

test,

cognitive

restructuring techniques. Cognitive behavioral self-control strategies (where the individual is trained to use deep breathing, relaxation and coping selfstatements) have the intention to enable the individual to exercise control over emotions that were previously, as believed,

of

suffering

and

trauma

of

psychotherapy clients (Mahoney, 1991; Miller, 1998; Hesse, 2002; Newman & Gamble, 1995; Miller, 1998, cit. in Fernades & Maia, 2008). The authors argued that all therapists should establish and maintain a balance between their personal and professional lives. The care, routine, exercise, searching for rest, programming-a-weekend or midterm holidays, participation in leisure and pleasure activities, may contribute to the psychotherapist to keep his health in good condition (Astin, 1997; Hesse, 2002, cit. in Fernandes & Maia, 2008).

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The involvement and development of a

work of the clinician in making decisions

spiritual and/or social life has been reported

should always be based on ethical issues,

as important for the care of the therapist to

i.e., what’s beneficial for the patient. It’s

himself, by favoring the recovery of a sense

often a difficult task, because practically all

of hope and the meaning of life projects

the work moves in the “realm” of

(Levine, 1996 cit. in Fernandes & Maia,

subjectivity: these are attitudes, self-

2008).

discipline, beliefs and values system. The

The daily routine of the psychotherapy should include activities to reduce anxiety, the demand for formal or informal social support, as well as contact with friends and family, helps maintain and ensure a sense of continuity and personal identity (Saakvitne & Pearlman, 1996; Hesse, 2002; Fernandes & Maia, 2008). Moreover, Conrad and Perry (2000) stress the importance of the psychotherapist to allow himself to be alone, to experience and process his own emotions, whether they are about stories heard, his own memories activated by the purpose of their customers reports. It’s important that therapists have critical awareness of their vulnerability to the impact of their work (Fernandes & Maia, 2008).

therapist is expected to make an effort to separate his personal clinical belief of the patient, maintaining the critical skills necessary to recognize the best for the patient or family, referencing or releasing to another program or therapy (Galarza, 2010). The

power

of

the

patient/therapist

relationship can be dramatic. Clinicians may consciously

or

unconsciously,

exert

influences on vital and existential aspects of patients. There’s a sense of “inflated power”, although not recognized. When the therapist doesn’t confront the patient, there’re moral responsibilities that aren’t being resolved. The patient isn’t responsible for having the disease, but the therapist has an obligation to say and do something with it. The ethical obligation of therapists is to

In order to ensure the quality of services provided to the user, it’s essential to adhere

help the patient to face this responsibility with his actions.

to all rules and governmental laws governing the service provision – acting in accordance with ethics and deontology. The

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For the professional who works in the context of addictive behaviors, it is essential

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the

continuity

of

his

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

personal

and

worldwide. According to the WHO 2009

professional growth – through experience

report, the consumption of tobacco, alcohol

or training. Accordingly, the possibility of

and illegal substances are among the top 20

obtaining supervision or continuing training

risk factors for health.

has been often recommended.

Moreover,

excessive

consumption

of

The supervision requires, in addition to all

substances is also an important risk factor

the technical guidelines, that talk is good,

for a wide variety of social, economic and

also the psychotherapist! It’s important to

legal problems for the individual and

speak in a professionally appropriate and

community, as well as in interpersonal and

safe context, about the story heard and

family relations.

especially about the emotions and thoughts that, that story activated, especially in cases of physical, emotional or sexual abuse. One of the factors mentioned by the authors as useful is the continuity of either training or supervision, and the opportunity that these therapists have to, theoretically, frame their intervention, structure and distance in a healthy way, the different

emerging

The growing trend for consumption of multiple substances at once or at different moments, may increase the risk even more. Considering the gravity of the problem, it’s vital

that

behaviors

individuals and/or

with

addictive

dependencies

be

guaranteed easy access to treatment and rehabilitation

services

and

specialized

therapeutic interventions.

emotional experiences during their work (Hesse, 2002 cit. in Fernandes & Maia,

But, since the abuse of mood altering substances has so many dimensions and

2008).

changes so many life aspects of the subject, treating it becomes essential. Effective Conclusion Health

problems

treatment programs should incorporate related

to

the

consumption of psychoactive substances are a reason for frequent consultation in

multiple components, each directed to a specific aspect of the disease and its consequences.

everyday clinical practice and its dimension

The addiction treatment to help the patient

implies a serious problem of public health

stop using drugs, maintain a healthy

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lifestyle in order to achieve productive

which is also immersed in a particular social

functioning in the family, at work and in

context.

society. Because the disease of addiction is

therapy is modulated by an appropriate

a chronic disease, the addict can’t stop

therapeutic relationship established with

using drugs for a few days and be cured –

the patient. The psychological science

most patients require long term care or

advances with the evidence that psychology

treatment (psychotherapeutic monitoring,

practice requires professional know-how.

outpatient

The science and practice have the same

or

inpatient)

to

achieve

therapeutic gains (Becoña, 2008).

The

successful

psychological

desire: understand human behavior and

To treat chemical dependence, as well as

alleviate suffering.

other mental and behavioral

sphere

So

pathology,

Clinical

professionals and students of the human

Psychology must make decisions about the

psyche, is strive to meet people, trying to

diagnosis,

most

understand and learn more about the

appropriate psychological intervention for

problems or diseases that affect them, in

the patient. The solution isn’t easy and

order to offer the most suitable solutions

should be made, taking into account both

and treatments, for which we have

clinical

sufficient

professionals

prognosis

judgment

experience,

certainly

or

and

in

the

professional

considering

the

individual preferences of each patient,

our

jobs

as

technicians,

information

to

base

health

our

treatment decisions fairly and effective (Horcajadas et al., 2010).

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Care. Helping patients change behavior.

Trauma: teoría y práctica. Bilbao:

New York: The Guilford Press.

Desclée de Brouwer

Sá, S., Werlang, B. & Paranhos, M. (n.d.).

Williams, M. & Swift, A. (1997). Livres para

Intervenção em crise. Acedido em

amar: Recuperação para toda a família.

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Edição revista. Sintra: ATT – Associação para

o

Tratamento

das

Toxicodependências. Hazelden.

599

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Therapeutic approaches Pharmacological Therapy in Children and Adults with Hyperactivity Disorder Attention Deficit (ADHD): Current Issues Sofia Bento Silva Degree in Clinical Psychology Master in Management of Health Units Post – Graduation in Pediatric Neuropsychology; Neuropsychological Evaluation and Rehabilitation; Neuroeducation Email: sofiasilva1982@gmail.com ----------------------------------------------------------------------------------------------------------------------Summary: Background: It is increasingly marked the entry of drugs for the treatment of PHDA in the market. The growing awareness of the persistence of PHDA beyond childhood and adolescence has led to an increase of pharmacotherapy in adulthood. Thus it is necessary to understand how it looks at present in PHDA pharmacotherapy. Aim: This article aims to discuss current issues concerning the possible pharmacological treatment in children, adolescents and adults, the guidelines for treating PHDA and pharmacoepidemiological current concerns regarding the drugs used. Methods: To realize this article a literature search was carried out in various online databases with a few key – phrases, such as: position of pharmacotherapy in PHDA; treatment guidelines on PHDA; pharmacoepidemiological trends; current concerns in relation to drugs used to treat PHDA. Results: According to current guidelines, the treatment of PHDA in children consists in psychosocial interventions in combination with pharmacotherapy, when necessary. Stimulants are the drugs most used in the treatment of PHDA in children, despite some side effects they can cause, such as sleep disturbances and loss of appetite. With regard to the treatment of adult PHDA, stimulants are often singled out as the only possible treatment. In children or in adults there may be an emphasis on the prescription of noradrenergics, which is often interpreted as a sign of the tendency to overdiagnose PHDA. Despite the frequent use of stimulants, there is still a lack of clarity with regard to their long – term effects on growth and nutritional status of children. Although more rarely, they are also pointed as a reason for cardiovascular complications. Specifically in the case of atomoxetine, is reported in the literature that this may be associated with suicidal ideation in children. Conclusion: It is a fact that pharmacotherapy is increasing in the treatment of PHDA in children or in adults. However, some questions are still unanswered regarding the side effects of drugs and wich is the best way to combat them. There arises a need for constant monitoring children and adults treated with stimulants or atomoxetine. Keywords: Adults; Attention deficit hyperactivity disorder; Children and adolescents; Pharmacotherapy.

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Resumo: Antecedentes: É cada vez mais marcada a entrada de medicamentos para o tratamento de PHDA no mercado. A crescente consciência da persistência na infância e adolescência de PHDA levou a um aumento da farmacoterapia na idade adulta. Malthus refere ser necessário entender como se olha para a presente farmacoterapia na PHDA. Objetivo: Este artigo tem como objetivo discutir questões atuais sobre o possível tratamento farmacológico em crianças, adolescentes e adultos, as diretrizes para o tratamento da PHDA e preocupações farmacoepidemiológicas atuais a respeito das drogas utilizadas. Métodos: Para realizar este artigo a pesquisa bibliográfica foi realizada em diversas bases de dados on-line com algumas chaves - frases: tais como: posição da farmacoterapia na PHDA; diretrizes de tratamento de PHDA, as tendências de farmacoepidemiologia, preocupações atuais em relação aos medicamentos usados para tratar PHDA. Resultados: De acordo com as diretrizes atuais, o tratamento de crianças em PHDA consiste em intervenções psicossociais em combinação com a farmacoterapia, quando necessário. Os estimulantes são as drogas usadas no tratamento da PHDA na maioria das crianças, APESAR de poderem causar efeitos colaterais, tais como: distúrbios do sono e perda de apetite. No que diz respeito ao tratamento da PHDA no adulto, os estimulantes são muitas vezes apontada como o único tratamento possível. Em crianças ou adultos existe uma maior ênfase na prescrição de noradrenérgicos, que muitas vezes é interpretado como um sinal da tendência para superdiagnosticar PHDA. Apesar do uso frequente de estimulantes, ainda existe uma falta de clareza no que diz respeito a efeitos a longo prazo sobre o crescimento e estado nutricional de crianças. Embora mais raramente, eles também são apontados como razão para complicações cardiovasculares. Especificamente no caso de atomoxetina, relatada na literatura como podendo ser associada com ideação suicida em crianças. Conclusão: É um fato que se verifica um aumento crescente da farmacoterapia no tratamento da PHDA em crianças ou em adultos. No entanto, algumas questões ainda estão sem resposta em relação aos efeitos colaterais das drogas e qual é a melhor maneira de combatê-las. Surge a necessidade para as crianças e adultos de monitoramento constante tratados com estimulantes ou atomoxetina. Palavras-chave: Adultos, déficit de atenção e hiperatividade, crianças e adolescentes; farmacoterapia.

Resumen: Antecedentes: Se marca cada vez más la entrada de fármacos para el tratamiento del TDAH en el mercado. La creciente toma de conciencia de la persistencia del TDAH más allá de la infancia y la adolescencia ha llevado a un aumento de la farmacoterapia en la edad adulta. Por lo tanto, es necesario entender cómo se ve en la actualidad la farmacoterapia del TDAH. Objetivo: El presente artículo tiene como objetivo discutir temas de actualidad relativos a el posible tratamiento farmacológico en niños, adolescentes y adultos, las directrices para el tratamiento del TDAH y los problemas actuales de farmacoepidemiología cuanto a los fármacos utilizados. Métodos: Para realizar este artículo la búsqueda bibliográfica se realizó en diversas bases de datos en línea con unas cuantas teclas - frases, tales como: la posición de la farmacoterapia en el TDAH; directrices sobre el tratamiento del TDAH, las tendencias de farmacoepidemiología, las preocupaciones actuales en relación con los medicamentos usados para tratar el TDAH. Resultados: De acuerdo con las directrices actuales, el tratamiento del TDAH en niños consiste en intervenciones psicosociales en combinación con la farmacoterapia, cuando sea necesario. Los estimulantes son los fármacos más utilizados en el tratamiento del TDAH en niños, a pesar de algunos efectos secundarios que pueden causar, tales como trastornos del sueño y pérdida de apetito. En relación con el tratamiento de adultos con TDAH, los estimulantes son los señalados a menudo el único tratamiento posible. En los niños o en adultos puede

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haber un énfasis en la prescripción de noradrenergicos, que suele interpretarse como un signo de la tendencia a sobre diagnosticar el TDAH. A pesar del uso frecuente de estimulantes, todavía hay una falta de claridad con respecto a su tiempo - efectos a largo plazo sobre el crecimiento y el estado nutricional de los niños. Aunque con menor frecuencia, también se apuntaron a la causa de complicaciones cardiovasculares. Específicamente en el caso de la atomoxetina, se reporta en la literatura que puede ser asociada con la ideación suicida en niños. Conclusión: La farmacoterapia tiene un aumento cada vez mayor en el tratamiento del TDAH en niños o en adultos. Sin embargo, algunas preguntas siguen sin respuesta respecto a los efectos secundarios de los medicamentos y cuál es la mejor manera de luchar contra ellos. Surge la necesidad de los niños de monitoreo constantes y adultos tratados con estimulantes o atomoxetina. Palabras clave: Adultos, Déficit de Atención e Hiperactividad, niños y adolescentes; Farmacoterapia. ------------------------------------------------------------------------------------------------------------------------

The hyperactivity disorder attention deficit

Although for a long period of time ADHD has

(ADHD) is the most common psychiatric

been considered a unique problem of

disorders among children and adolescents

childhood is increasingly recognized its

(Rodrigues, 2008). With a prevalence of

existence in adulthood (Wender et al.,

between 3 % and 7 % in school-age children,

2001; Weiss & Murray, 2003; Ghuman et al.,

is considered a public health problem

2008). Although it is difficult to estimate its

because of its close association with high

continuation

rates of morbidity and disability in young

studies indicate that one to two thirds of

adults (Goldman et al., 1998), however the

children with ADHD continued to show this

highest prevalence rates is in males (5%).

symptomatology

Although the diagnostic criteria for school

(Rasmussen & Gillberg, 2000; Wender et al.,

children are the same, taking into account

2001; Weiss & Murray, 2003; Kessler et al.,

gender and varying age, there are more girls

2005). Part of this persistence can be

(3%) in epidemiological studies (Cole et al.,

explained by variations in diagnostic

2008; Ghuman et al., 2008; Walshaw et al.,

criteria, with regard to the selection criteria,

2010). Part of this difference may be

information sources and changes in them

explained by an educational component

and inherent changes in diagnostic criteria

which is predominant inattention, however,

over time (Biederman et al., 2000; Riccio et

less common among girls (Bren, 2004). This

al., 2005; Ghuman et al., 2008). Thus,

subtype of ADHD is called Attention Deficit

depending on the clinical measures used

Disorder (PDA).

and how the diagnostic criteria were

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into

adulthood,

over

the

life

several

cycle

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applied, the prevalence of ADHD in adults is

current trends in pharmacological ADHD

estimated to be between 1 % and 4 % (Kooij

adverse drug use in ADHD effects.

et al., 2005; Kessler et al., 2006; Fayvad et al., 2007; de Graaf et al., 2008).

After a careful reading of all selected articles, the information was organized

The main objective of this paper is to

according to three age groups: children,

present an overview on various current

adolescents and adults.

issues around the pharmacotherapy in ADHD. Thus is presented a brief explanation of

several

possible

pharmacological

treatments for the disorder in children,

Psychopharmacology in ADHD Children and Adolescents

adolescents and adults. Also, is presented some concerns caused by the trend in the use of medication, taking into account the developmental

prospects

as

well

as

concerns regarding the medication itself, in different age groups.

Pharmacological therapy in children with behavioural

problems

resulting

from

psychiatric disorders is a matter of extreme sensitivity. With regard specifically to ADHD, the guidelines suggest a combination of pharmacotherapy and psychosocial

Methods As the developments shown in various areas related to therapy for ADHD is not intended here to do a systematic review of

interventions (Braga, 2000; Kutcher et al., 2004; Taylor et al., 2004; Capovilla et al., 2007; Cordinhã & Boavida, 2008; Moura, 604

2008).

the same. Thus, a review of the literature

With regard to therapy with children, and

with regard to drug therapy for ADHD in

since they occur comorbidities with other

various scientific basis for online available

disorders,

data, such as PubMed and Science Direct

pharmacotherapy with other forms of

was performed. So some expressions were

treatment is the most appropriate situation

introduced - key to guide research, such as:

(Braga, 2000; Taylor et al., 2004; Cordinhã &

pharmacotherapeutic options in ADHD,

Boavida, 2008).

ADHD in pharmacoepidemiological data,

According to the European and American guidelines,

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the

combination

stimulants,

such

of

as

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methylphenidate and dexamphetamine,

After said period of time, the children

are mentioned as first choice in the

included in the group of pharmacotherapy

pharmacological treatment in ADHD (Braga,

and combination of pharmacotherapy with

2000; Kutcher et al., 2004; Taylor et al.,

behavioural

2004; Capovilla et al., 2007; Cordinhã &

significant improvements compared to

Boavida, 2008; Moura, 2008).

those included in the group of community

Several clinical short-term studies have shown a significant reduction in symptoms of ADHD in children and adolescents compared to placebo groups (Spencer et al., 1996;

Schachter

et

al.,

2001).

In

approximately 70 % of children with ADHD with

stimulant

treatment

improved

symptoms of hyperactivity, impulsivity and inattention (Spencer et al., 1996). In addition to an improvement in the core symptoms of ADHD, stimulants were shown

therapy,

showed

more

therapy (Builelaar & Medori, 2010). At 24 months, the trend of greater improvement was in the group of children with drug therapy or drug therapy combined with behavioral therapy, although this difference reduces slightly from the community therapy group (Daviss, 2008). After 36 months this improvement was no longer significant and all groups showed significant improvements over the period of initiation of treatment (Jensen et al., 2007).

to have a beneficial effect on behaviour,

In the Netherlands, methylphenidate is the

academic

most widely used stimulant, and the only

performance

and

social

functioning in the short term in children. A research study regarding the long-term effects of behavioural and pharmacological therapy in children with ADHD was conducted by Builelaar & Medori (2010). During the first 14 months, children aged 7

officially licensed for children between 6 and 17 years old. The dexamphetamine is only available in capsules prepared in pharmacies, and oral liquids or chewable tablets are not available in the Dutch market (Purdie et al., 2002).

to 10 years old were included in one of four

The only non – stimulant drug licensed for

possible treatments: pharmacological and

the treatment of ADHD is atomoxetine a

community intensive behavioural therapy,

noradrenergic

intensive drug therapy and combination of

Netherlands since 2005. For its effects are

behavioural therapy and pharmacotherapy.

required, one to two daily doses to get the

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drug,

available

in

the

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maximum benefits. Several studies have

stimulants

and

27

been undertaken in respect of a final

pharmacotherapy

with

comparison between the benefits of

drugs.

atomoxetine

in

noradrenergic (atomoxetine) and some

children with ADHD. In the study resulting in

antidepressants (desipramine) had quite a

the most recent six weeks of such

substantial beneficial effect on adults with

treatment, the effects of atomoxetine and

ADHD (Wilens, 2003).

and

methylphenidate

methylphenidate were compared with placebo, revealing that methylphenidate was more effective than atomoxetina. This study also reveals that 40 % of children who have not responded to each of the treatments, answered the other, which reveals different types responders in

Accordingly,

studies

on

non-stimulant

stimulants

and

In the Netherlands, or the methylphenidate or dexamphetamine are formally derived for the treatment of ADHD in adults. Atomoxetine is indicated only in cases in which drug therapy was initiated before the age of 18 (Purdie et al., 2002; Hosenbocus & Chahal, 2009).

children with ADHD (Newcorn et al., 2008). Increased use of stimulants and concerns Adults

arising

In contrast to several existing for the treatment of ADHD in children guidelines, there is only one published guideline for the treatment of ADHD in adults: A Guideline from

the

British

Association

for

Psychopharmacology (Nutt et al., 2007). Thus, either pharmacological interventions or

psychological

interventions

In the 90s there was a rapid increase in the use of stimulants in Western countries for the treatment of ADHD both in children, adolescents or adults (Safer et al., 1996; Zito et al., 2000; Miller et al., 2001; Schirm et al., 2001; Reid et al., 2002; Zito et al., 2003; Meijer et al., 2009).

are

recommended for adults, and stimulants indicated

as

first-line

treatment

in

accordance with this guideline. In a literature

review

on

the

use

of

pharmacology in adults with ADHD, Wilens

Children and Adolescents In the U.S., the prevalence of the use of stimulants

to

treat

ADHD

increased

between 3-7 times among children and

identified 15 studies on the effectiveness of

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adolescents under 18 in the period from

women than for men (Castle et al., 2007;

1987 to 1996. Another study estimated that

Cole et al., 2008).

the prevalence of ADHD in children and adolescents

younger

than

19

years

increased from 2.8% in 2000 to 4.4% in 2005, whereas the rates of successful treatment grew faster in girls than in boys (Castle et al., 2007; Cole et al., 2008).

Discussion The increased use of stimulants found in recent years was probably due to the increasing number of children, teenagers and adults to be diagnosed with PHD

A study conducted in the northern part of

(Ghuman et al., 2008; Meijer et al., 2009)

the Netherlands in children and adolescents

but also the prolonged duration of

less than 19 years showed that the

stimulant use (Schirm et al., 2001). This

prevalence of stimulant use increased

overall increase in the use of stimulants

0.15% in 1995 to 0.74% in 1999 and 1.2% in

raised global concerns and brought the

2002 (Schirman et al., 2001; Miller et al.,

issue to public and political debates (Safer,

2001; Reid et al., 2002; Zito et al., 2003;

2000; Buitelaar et al., 2001; Rey & Sawyer,

Faber et al., 2005; Castle et al., 2007).

2003; Buitelaar et al., 2004; Coghill, 2004;

Another study also reveals a significant

Marcovitch, 2004). These discussions were

increase in the prevalence of stimulant use

centered on issues such as the validity of

from 0.15% in 1995 to 1% in 2001. In this

ADHD

case rates rose faster for boys (Hugtenburg

overdiagnosis, overtreatment of ADHD

et al., 2004; Meijer et al., 2009).

potential and risks of treatment with

as

a

psychiatric

disorder,

stimulants (Safer, 2000; Accordo & Blondis, Adults

2001; Miller et al., 2001; Meijer et al., 2009).

In the aforementioned study of Castle et al.

Was walking questioned whether the use of

(2003) the prevalence of drug use in adults

stimulants in children is a facilitator of

with ADHD concluded that this doubled

abuse of other illicit substances (Biederman

from 0.4% to 0.8% between 2000 and 2005.

et al., 1999; Barkley et al., 2003).

The treatment rate increased more rapidly for adults than for children and faster for

When using the term over-diagnosis, this is referred to in the context of the number of children diagnosed with ADHD, but it should

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be specifically used as a reference to false

where

positives, or wrongly diagnosed children

methylphenidate caused additive effects.

with this disorder. It was suggested that

Most children diagnosed with ADHD treated

ADHD is the diagnosis "day" (Bogas, 1997)

with stimulants, have a lower tendency to

and that in some cases, the same diagnosis

substance abuse compared to those

is desirable for some parents (Smelter &

untreated (Biederman et al., 1999; Barkley

Rasch, 1996).

et al., 2003).

Sciutto

and

reviewed

prescribed

use

of

the

The results of a meta - analysis confirms this

evidence for and against the overdiagnosis

evidence (Wilens et al., 2003). However, the

of ADHD (Sciutto & Eisenberg, 2007) and

literature is not enough to suggest that the

concluded that there appears to be

use of stimulants is done wrongly in

sufficient

the

subjects with and without ADHD. In a recent

being

literature review, the use, misuse and

perception

Eisenberg

the

evidence

to

support

that

ADHD

is

systematically overdiagnosed. However, overdiagnosis is only one side of

diversion of stimulants facilitate the desire to try other substances (Wilens et al., 2008).

the coin regarding the issue of misdiagnosis

As shown above, the main concerns about

of ADHD. There will be, in fact, children with

errors in prescribing stimulants are not

a justifying diagnosis of ADHD, but that does

completely proven, however, this does not

not happen, they are false negatives.

diminish the discussions around the use of

Accordingly, scientific evidence indicate an

this medication. In addition to the concern

under-diagnosis and in girls, as these

with psychiatric illness is a disturbance in

highlight the most often neglect factor,

the social environment, parents and

which is less disturbing and more difficult to

physicians should be warned about the

identify (Biederman et al., 2002; Gershon,

adverse effects of stimulants long term

2002; Meijer et al., 2009).

effects on children's development. Such

As already mentioned above, the increased prescription of stimulant led to the assumption that these drugs could facilitate the abuse of other illicit substances. However, there are no reported cases

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adverse effects can be very hard either to children or to their parents, the latter being a more sensitive issue when it knows that stimulants do not cure the disease, but only treat the symptoms, which leads to long-

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term use of this type substances. In a study

Sleep disturbances secondary to drug use in

conducted in the Netherlands among

ADHD appear to be increasingly treated

parents of stimulant users under 16 years

with melatonin. In 2003 Dutch study, 11 %

old, 29% of parents report that the child

of parents of these children, under 16, show

suffers from adverse effects, which sleep

that their children are treated with

disturbance is the most referenced problem

melatonin (Faber et al., 2006). Little is

(51%) and loss of appetite (42%) (Faber et

known about the efficacy of melatonin in

al., 2006).

children with ADHD. However, one study

Insomnia is a common problem in children treated and not treated with ADHD, which causes sleep disturbance. This is a strong reason for the study of adverse effects of pharmacotherapy in this disorder (Graham & Coghill, 2008). In the same study

revealed that this compound increases endogenous rhythms and accelerates cycles sleep - wakefulness. This same study shows no benefits of this substance in behavior, cognitive performance and quality of life of these children (Van der Heijen et al., 2007).

physicians reveal that 22% of children

Prescription stimulants can also affect

treated

sleep

appetite and growth of children with ADHD,

disturbance as adverse effects. Since

although the magnitude of this effect is not

between 18% to 25% of physicians surveyed

well investigated, however this same loss

did not indicate whether or not the child

was observed among 13 % to 60 % of

was suffering from sleep problems, this

pediatric

percentage may be even higher (Faber et

(Biederman et al., 2002; Gershon, 2002;

al., 2006).

Wilens et al., 2003; Cortese et al., 2006;

with

stimulants

have

The literature on children with ADHD and without ADHD, medicated with stimulants reveals that children with ADHD have higher

patients

with

the

disorder

Faber et al., 2006; Zachar et al., 2006; Van der Heijen et al., 2007; Wilens et al., 2008; Graham & Coghill, 2008).

rates of sleep apnea, however no significant

Two recent reviews reveal that the use of

differences were verified with regard to the

stimulants may be associated with a

onset of sleep and the difficulties and

reduction in the expected height for age,

resistance to bedtime (Cortese et al., 2006).

especially in the first three years of treatment (Poulton, 2005; Faraone et al.,

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2008). However, deficits in height and

A literature review conducted by the "Food

weight does not seem to be a relevant

and Drug Administration" (FDA) concluded

clinical concern for most children (Faraone

that the rate of sudden death caused by the

et al., 2008). A study revealed that the slight

use of stimulants in children with ADHD do

reduction in height and weight of these

not exceed the levels of the general

children may be related to the prescribed

population and that the use of stimulants in

dose (Charach et al., 2006), something

children heart disease with pre - existing

which can be controlled with a reduction of

must be highly controlled (Zachar et al.,

that dose (Moura, 2008). It is also

2006).

ambiguous effect on the growth of small stops taking the medication (Pliszka et al., 2006; Spencer, 2006).

The prescription of atomoxetine has been associated with an increased rate of suicidal ideation

among

children

with ADHD

With a lack of clarity about the magnitude

(Wooltorton, 2005). Literature data support

of the effects of using stimulants to treat

this hypothesis come, revealing that

children with ADHD should be recommend

although the rate of suicidal ideation and

to parents who regularly measure the

even suicide rates are low, its occurrence

height and weight of their children and to

was significantly higher in children with

promote good nutrition. It is therefore

ADHD subject to prescription atomoxetine

worrying that the results of this Dutch study

than those subject to placebos (Bangs et al.,

reveals that almost a fifth (19 %) of children

2008).

treated with stimulants has not been properly monitored for those parameters (Faber et al., 2006; Meijer et al., 2009).

Although the probability of occurrence of these possible situations is reduced, studies are needed to investigate these effects

More uncommon, but on the other hand,

caused by stimulants in children, as they can

are

potential

have very serious repercussions. As far as

stimulants,

we know there is no large-scale study

including blood pressure, heart rate and

published that documents the existence of

rhythm, although not reach a clinically

significant adverse effects on medication

significant level (Rapport & Hoffitt, 2002;

use in adults with ADHD. However, some

Wernicke et al., 2003).

studies point to a lesser extent a decrease in

the

most

cardiovascular

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serious

effects

of

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appetite, headache and insomnia in adults

in adults in most cases, with some of the

treated

same

with

methylphenidate

or

factors

predictors

(severity

of

amphetamine (Kooij et al., 2004; Weisler et

symptoms, existence of co-morbidities and

al., 2006; Spencer et al., 2007; Hosenbocus

psychosocial

& Chahal, 2009).

conditions). Although

presence

of

pharmacologic

adverse

therapy

is

increasingly used in adolescents and adults,

Conclusion

there are still many publications about their Some studies make it clear that ADHD involves a set of organic implications associated with functional phenomena of emotional origin. High levels of energy keeps individuals operating in "high voltage", responding to the middle with

efficacy and adverse side effects in these populations. In general, it seems consistent to conclude that the use of stimulants to treat ADHD has increased over the years, but further studies are still required about its long-term effects at all ages.

hyperactivity, inattention and impulsivity. In the specific case of atomoxetine, and In general and based on the literature here, seems

proven

the

efficacy

of

pharmacotherapy in children with ADHD, the discussion of the adverse effects notwithstanding these children. As regards the use of stimulants and in the case of methylphenidate appears to be largely

since this is a new little used drug, information about its adverse effects is scarce.

This

nuance

Atomoxetine

vs

stimulants thread can carry between the scientific body in favor of the former, in order to ascertain clearly the benefits and adverse effects in the treatment of ADHD.

proven its effectiveness. Although stimulants have been used The ADHD is one of the most common psychiatric disorders in childhood. Until recently it was believed that this was a disease of spontaneous resolution during the teens and twenties, with little or no impact on adult life. Current evidence,

increasingly over the past few decades time, health professionals must be well aware of its potential, although rare adverse effects, since there is a probability that these arise. In addition, the increased longevity of prescription drugs in ADHD may lead to new

however, indicates the persistence of ADHD

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concerns,

which

involves

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

constant

treatment,

whether

the

drug

monitoring its use in long period of time.

psychotherapy.

Despite the lack of an absolute consensus,

It appears that the drugs used in therapy are

over the last decade, it seems clear the

effective, particularly in the case of

growing awareness of the persistence of

methylphenidate. However, efforts to

ADHD into adulthood. As such there is a

introduce new medicines in the alternative

need for studies on the symptoms, early

there to, especially those with a single daily

treatment and adverse effects of drug

dose

therapy, in order to obtain more accurate

methylphenidate hydrochloride.

evidence about its efficacy in this specific population.

has

been

gathered,

such

as

In the specific case of a child with ADHD is considered the most effective method of

It seems accepted that the prescription of

using medication to control hyperactive and

stimulant medications or other adults with

inattentive symptoms, associated with the

ADHD require special considerations, such

use of behavior management strategies,

as the fact that adults often require

trained in psychotherapy and general

medication for other health issues, which

environment to day - to - day life overactive.

may negatively interact with the stimulants.

Psychotherapy plays a key role in the

Through the literature review conducted, it

adaptation of adults with ADHD organize

was found that the prescription of

your daily life as well as in adjusting to

methylphenidate in the treatment of ADHD

changes resulting from the treatment, such

is effective and safe, and that, despite the

as thinking before acting or resist the need

side effects, in most cases, they go into

to take unnecessary risks.

remission,

meaning

benefits

widely

described in the literature. However, the use of methylphenidate, it was found that it has been prescribed as the single most effective form of treatment in patients with ADHD for a long period of time. This means a clear need for health professionals to take

The therapeutic approach of ADHD involves two

equally

important

psychosocial treatment.

and The

components:

pharmacological

ADHD

requires

a

comprehensive intervention, at home, at school and in the community, where a longterm strategy is established. In relation to

into account the various possibilities of

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the

prescription

of

the

have complex pictures that require the

effectiveness of psychostimulant is well

technician to confront several clinical and

established, checking in 80% of cases. These

therapeutic dilemmas. Thus, the correct

drugs are effective in improving attention,

diagnosis

which has positive consequences to school

assessment of the population, as well as the

performance level, bringing benefits in

appropriate use of medication, allowing not

reducing hyperactivity and impulsivity. It is

only the reduction of symptoms related to

important,

the disorder itself, as well as decreased

however,

medication,

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

noted

that

the

is

essential

medication is rarely indicated as a first line

those

of action and should never be used in

comorbidities.

isolation but in combination with measures of behavioral modification.

associated

for

a

with

correct

frequent

Current guidelines advocate a multimodal approach to disease, including psycho –

Other therapeutic approaches are the

education of the patient and family, drug

appropriate advice and clarification of the

treatment, coaching, cognitive behavioral

situation to the child, family and teachers.

therapy and family therapy. Drug therapy is

These should be supported and informed

the

about treatment, prognosis, particularly on

methylphenidate as first treatment option.

the effects that ADHD can have on learning,

The atomoxetine and dexamphetamine are

behavior, self -esteem, social competence,

options if the patient is unresponsive or

and family function. There are several

intolerant to methylphenidate. Where

therapies, including behavioral therapy and

there

Psychomotor, which aim at the reduction of

atomoxetine is the first-line drug. Individual

undesirable behaviors, and should always

or

be accompanied by experts. A very general

recommended for patients who refuse

way, one of the main objectives is to reduce

diagnosis or pharmacological treatment,

the frequency of inappropriate behaviors

present poor adherence, poor response to

and increase the frequency of desired

drugs or retaining significant functional

behaviors.

limitations.

There is, according to some studies

Despite

reported that patients with ADHD often

research and innovation therefore theory

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first

is

line

risk

group

of

of

treatment

substance

psychological

continued

with

abuse,

support

developments

is

and

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construction, at present there is a unit for

attention and complete tasks that tend to

therapeutic intervention in ADHD model.

be forgotten or left half, they do not help to

What prevails at a theoretical level is

improve the academic skills or knowledge,

widespread

agreement

where

it

is

can’t also help these guys to feel better

considered

that

treatment

is

about themselves or to confront their

the

implemented in a complementary and

problems,

coordinated multidisciplinary level.

importance

Due to the crux of the problem, there is clearly a need for an intervention involving different at the same level professionals

stressing of

once

again

the

psychotherapeutic

monitoring, absence of fast but with more significant and long-lasting benefits that arise from this combination cures.

from various fields such as education,

As we can see in the given models of

educational psychology, clinical psychology,

therapeutic intervention is possible to

medicine, among others. The authors argue

conclude that the choice of a specific form

that by failing to take into account an

of treatment will depend on the different

integrated

approach,

agents or factors that are causing the

there are patients who manifest this and

overactive behavior. Thus, in certain cases,

other deficits that turn out to be more

the administration of drugs may be needed,

strongly affected.

however, is always necessary psychological

multidisciplinary

Pharmacotherapy stands out as an option for first-line treatment for patients with ADHD

of

all

ages.

In

particular,

psychostimulant drugs are those most widely prescribed, either for children or

support, behavioral and cognitive nature behavioral, which will primarily focus on overcoming and improving interpersonal relations and academic functioning and/or professional.

teenagers. However, despite its efficacy in

A variety of psychological interventions

adults with ADHD, studies of medication use

have shown positive short-term effects on

in adults are comparatively narrower and

the symptoms of ADHD and associated

less detailed than in children.

problems. Therefore, the psychological

Drug therapy does not cure the disorder, however, help control the symptoms. Although these drugs help you pay more

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treatment involves the patient focused interventions (training of social skills, self – training and contingency management),

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focused family interventions (behavioral

American

training for family members, training of

Adolescent Psychiatry, 47(2): 209 – 218.

communication skills, training strategies troubleshooting and family therapy) and combined interventions with the patient, with his family and, if possible, to their academic and/or employment context. Looking ahead, the need arises to conduct new studies, possibly targeted for families of individuals with ADHD since it is known that the structure and family functioning exert a very significant influence on the symptoms and the perception of the disorder. In the particular case of children,

Academy

of

Child

&

Barkley, A.; Fischer, M.; Smallish, L. & Fletcher, K. (2003). Does the treatment of

attention-deficit/hyperactivity

disorder with stimulants contribute to drug use/abuse? A 13-year prospective study. Pediatrics, 111(1): 97–109. Biederman, J.; Wilens, T.; Mick, E.; Spencer, T.

&

Faraone,

Pharmacotherapy

V. of

(1999). attention-

deficit/hyperactivity disorder reduces risk

for

substance

use

disorder.

Pediatrics, 104(2): 20.

the research aimed at teachers are an asset, since these are the first source of information and are often those who request a psychological evaluation of the child or adolescent.

Biederman, J.; Mick, E. & Faraone, V. (2000). Aged-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. American Journal of Psychiatry, 157(5): 816 – 818.

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Newcomers in Scientific Writing Neuropsychology: a conceptual review Jorge Mimoso (1) & Rui Pais (2) (1) Psychology Bachelor Student at UBI (Beira Interior University – Portugal)

jemimoso@gmail.com (2) Degree in Psychology and Neuroscience MsC Student at Neuroscience Institute of Castilla Y Leon – University of Salamanca, Spain rui_carlos_pais@hotmail.com --------------------------------------------------------------------------------------------------------------------------------Abstract: This paper aims to elucidate the methodologies used in neuropsychology as a science and a scientific discipline, which will serve to clarify some aspects regarding the neuropsychological practice nowadays, including neuropsychological rehabilitation, suggesting as well , a theoretical framework that will seek to define its borders with other sciences. Areas that contributed to its claim as a science, as well as, the most relevant figures and landmarks in the history of the same. The authors also consider, the role of the neuropsychologist regarding psychology, seeking to highlight the contributions and importance of neuropsychological knowledge to clinical practice, and, in a more comprehensive way to psychology itself. Keywords: neuropsychology; neuropsychological rehabilitation; neuropsychological practice; neuropsychology theoretical framework. Resumo: Este trabalho tem como objetivo elucidar as metodologias utilizadas em neuropsicologia como uma ciência e uma disciplina científica, que servirão para clarificar alguns aspectos em relação à prática neuropsicológica nos dias de hoje, incluindo a reabilitação neuropsicológica, sugerindo também, um quadro teórico que vai procurar definir as suas fronteiras com outras ciências. Áreas que contribuíram para a sua afirmação como ciência, bem como, as figuras mais relevantes e marcos na história da mesma. Os autores consideram ainda, o papel do neuropsicólogo sobre psicologia, procurando destacar as contribuições e importância do conhecimento neuropsicológico para a prática clínica, e, de uma forma mais abrangente para a própria psicologia. Palavras-chave: neuropsicologia, reabilitação neuropsicológica; prática neuropsicológica; quadro teórico neuropsicologia. Resumen: Este documento tiene por objetivo aclarar las metodologías utilizadas en la neuropsicología como una ciencia y una disciplina científica que irá servir para aclarar algunos aspectos sobre la práctica neuropsicológica de hoy, como la rehabilitación neuropsicológica, sugiriendo también un marco teórico que tratará de definir sus fronteras con otras ciencias. Los campos que hayan contribuido a su afirmación como una ciencia, así como las cifras e hitos más relevantes en la historia de la misma. Los autores también consideran el papel del neuropsicólogo en la psicología, tratando de poner de relieve las contribuciones y la importancia de los

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conocimientos neuropsicológicos en la práctica clínica, y, de manera más amplia a la psicología en sí. Palabras clave: Neuropsicología; rehabilitación neuropsicológica; práctica neuropsicológica; marco teórico neuropsicología. ---------------------------------------------------------------------------------------------------------------------------------

Before any introduction to Neuropsychology, and

What is neuropsychology?

all that underlies the same as a science or discipline, let’s start by actually defining the meaning of the word science. According to Augusto Santos Silva and José Madureira Pinto (2001), we can

define

science

as

a

representation,

intellectually constructed from reality. In this way great part of the specialists puts various sciences main purpose, as the explanation of the phenomena, taking into account various types of

As

a

science

or

specific

area

of

study,

Neuropsychology has a fairly recent development, although its origins date back to antiquity with the first brain studies of which there are records, originating in Sumer, and whose reasoning and scientific statement is the result of several decades of studies and investigations (Semple, Smyth & Burns, 2005).

approaches and explanations, to make them

Neuropsychology is defined as the study of

understandable. To do it so, any science begins by

relationships between brain function and human

defining itself rationally, building his own object of

behavior (Kolb & Whishaw, 2003), however it

study and standing at a level of abstraction that

focuses mainly on investigating the relationship

allows it to formulate laws and trace interpretative

between different brain lesions and deficits

models, as well as developing concepts and

underlying psychological effects. This branch of

theories, technical tools and search methods for its

knowledge aims the development of a science of

application, and also the various validation tests,

human behavior based on brain functioning, thus

because any explanation is indeed scientific, only if

enabling us to understand, from the knowledge of

it is testable and verifiable (Silva & Pinto, 2001) .

the normal functioning of the brain, cognitive and behavioral dysfunctions resulting from illness, injury or non-normal development (Maia, Correia, & Leite, 2009). Like humans, in an ethical point of view

cannot

be

exposed

to

experimental

treatments that may endanger the normal brain

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functioning , the neuropsychological study relies

However it is essential to refer that the

exclusively on case studies and semi - experimental

contributions from the various sciences mentioned

studies in patients with brain injuries – where the

and Neuropsychology are mutual, in other words,

main contributions of this discipline are found - or

also the neuropsychological research and studies

with certain pathologies (Pinel, 2005) .

contribute to other sciences and disciplines,

In practical terms Neuropsychology born junction of 2 major areas, Psychology and Neurology, but

contributing to a better understanding of the human being.

his overall framework involves a more specific form

The main objective of this scientific discipline

a huge variety of disciplines and sub - disciplines.

according to Luria (1973, cited by Maia, Correia &

Psychology, one of the main areas that allowed its

Leite, 2009) "is to investigate the role of particular

creation contributes very significantly to the

brain systems in complex forms of mental activity"

particular level of Evolutionary Psychology,

(p. 3). Still, we can explain a set of general

Cognitive Psychology, Behavioral Psychology,

objectives of Neuropsychology, all of them of high

Experimental

importance. Among the various objectives we can

Psychology,

Psychometrics

of,

Differential Psychology, Psychopathology and

find:

Psychological Diagnosis. On the other hand, the

manifestations of the disease as well as the higher

Biomedical Sciences also have a key role,

nervous activity; knowledge of the mechanism

encompassing various fields of study of high

leading to the onset of disease or pathophysiology

importance for the creation and implementation of

of

Neuropsychology. Among the various sciences is

neuropsychological and brain topography that its

imperative to highlight the role of medicine,

underlying a particular disorder or behavior

especially in terms of Neurology, Neuroanatomy,

modification; the study of the influence of

Neurophysiology,

Nuclear

experience and learning in their neurofunctional

Medicine . We also can’t ignore the role of

bases, the study of internal representations of

Embryology and Physics, Pharmacology and Cell

mental phenomena, rational therapeutic and

Biology or Chemistry Development and in

pathophysiological as well as rehabilitation, and

particular the Biochemistry and Neuromolecular

conducting research plans ( Bartolomé et al. 2001).

Neuroradiology

or

Chemistry among others (Bartolomé, Fernandez & Ajamil, 2001).

evidence-based

the

observed

description

changes,

the

of

the

clinical,

At last it remains to make an approach to the different application fields of Neuropsychology. As regards Pinel (2005) Neuropsychology is the most

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applied discipline among the biopsychological field

Sports,

Neuropsychology

of

terrorism,

law

because, even when it’s part of a program of pure

enforcement, and military (Zillmer et al., 2007) .

research, always tries to help the subject in any way, moreover the various neuropsychological tests facilitate the diagnosis, and therefore provide a valuable assistance to physicians for directing an effective treatment according to test results and neuropsychological studies.

Historical context The term neuropsychology is relatively recent, having been originally quoted by Sir William Osler in 1913, at a conference held in the United States, yet as regards David & Halligan (2000) it began only

But on the contrary to what one might think, the

to be noted and spread, from the publication of

development

by

Donald Hebb in 1949, as well as the periodic

consequence, its application, did not occur in

publication of the journal Neuropsychologia in

isolated but directly related to the development of

1963 (Kristensen, Almeida & Gomes, 2001).

other

of

areas,

Neuropsychology

including

the

and

Clinic,

where

neuropsychological assessment has played, and still plays an essential role in the creation and evolution

of

Clinical

Neuropsychology.

The

neuropsychological evaluations led to the drafting of important information about the diagnosis and about the impact of the limitations that the subjects had, in social, vocational and educational context, and also in terms of adaptation of such contexts.

But

the

contributions

of

neuropsychology are not limited only to the field of clinical application, these extend to other areas such as education or gerontology or in the field of experimental sciences such as neuroscience

However the roots of Neuropsychology are found in the antiquity, long before it was considered science ... long before there was science or scientific thinking. That early our ancestors spent their time creating complex theories about human behavior, about everything around them, about life and existence. It then becomes necessary for a better understanding of Neuropsychology, to search the milestones in history and some of the men who made possible its existence, whom so much contributed to the view of human beings as we know it today. It is time to look to the past and marvel ourselves with the genius of the men who made the history of this science.

(Zillmer, Spiers & William, 2007). In addition to the above there are three areas that are at the

The first brain studies of which there are files

forefront of applied Neuropsychology, are they

dating from roughly 4000 BC , with written records

Forensic Neuropsychology, Neuropsychology of

of Sumer civilization on the euphoric and

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hallucinogenic effects of Poppy (Semple et al,

bizarre behavior, including, what we now call

2005). Yet many authors point out the papyri

schizophrenia or even epilepsy (Zillmer et al.,

purchased by Edwin Smith in Luxor, dating back to

2007).

16:17 centuries BC, about brain functions, as the beginning (Walsh, 1987). Others have considered that all began with Pythagoras , when he said that reason lies in the human brain. Still others argue that it was Galen (130-200 AD), a physician who lived in the era of the Roman Empire which held that the mind was located in the brain, thus refuting the theory of Aristotle (Trull, 2005). The truth is that regardless of what you defend, or more or less chronological order of events, the man from the earliest ages seeks to discover more about the mind, brain and behavior, as well as the relationship between this triad.

Later in Ancient Greece, we can find the first written records of the relationship between mind behavior. A Greek philosopher named Heraclitus, who lived in the century VI BC, argued that the mind was a giant space whose boundaries would be unattainable to man. Pythagoras (580-500 BC) became the first to point out the brain as the center of human rationality, and as having a crucial part on the soul level (Zillmer et al., 2007). On the other hand we also cannot forget the contributions of Alcmeon (V th century BC), a Greek physician after performing dissections on animals and verify the functions of the optic nerves and optic chiasm,

A clear example of this concern, as well as

said the brain then the body would be responsible

recognition on the mind – behavior dichotomy, is

for creating mind, and thus beyond the role of

an ancestral surgery called trepanation, the oldest

receiving

records not only suggest that this type of

responsibility for the creation of thought and

intervention or ritual dates from the Mesolithic

memory (Jr., 2005). It is also important to mention

period, as was also practiced by some Worldwide

the contributions of Hippocrates (460-377 BC) and

(Scheparts, Fox & Bourbou, 2009). This consisted of

Plato (420-347 BC), the first to recognize the fact

a chirurgical removal of a portion of the skull bone,

that the pleasure or the pain came from brain

to create an opening to relieve the pressure

among other things, and regarding Plato, many

derived from brain swelling, the tools used to drill

historians believe that he was the first to propose

were often spindle bones. However the reasons for

the concept of mental health, as he advocated

trepanning are not entirely clear, many claim that

health as harmony between mind and body.

it had a purely medical purpose, others suggest

However not all ancient philosophers recognized

that magical rituals were based, as a treatment for

the brain as a source of emotions, and being

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the

sensations,

would

have

the

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directly related to the behavior of man , Aristotle

tests and decided to adapt them into his own

(384-322 BC) for example, claimed that the organ

studies. Among the many contributions, stand out

responsible for emotions and feelings was the

experiments on the central nervous system, in

heart as he believed, thus creating what it’s called

terms of anatomical structures. At the ventricular

"Cardio Hypothesis".

level is to emphasize, his experiences with the

Galen ( 130-200 AD) , probably one of the most influential physicians of the Roman Empire , from the observation of brain lesions of ancient

injection of melted wax in the ventricles of cattle, providing a better understanding of these structures.

gladiators, not only rejected the hypothesis

But it was Andreas Vesalius (1514 - 1564) who

defended by Aristotle, he also believed that from

performed the first corrections to the model

changes in the cerebral level, notably also occurred

proposed by Galen, particularly to the role of the

personality changes, behavior and the ability of

ventricles on the behavior level. Its graphics

reasoning. But not only were these the reasons

through its extreme accuracy also contributed to a

that

to

better understanding of brain anatomy (Zillmer et

Neuropsychology, the doctor also believed that the

al., 2007). Worth of notice is the role of the Dutch

vital spirits were produced in the left ventricle of

Anton van Leeuwenhoek (1632 - 1723) that with a

the heart and were later taken to the brain, more

"kind" of a primitive microscope could see the

precisely until the ventricles, which would be

blood vessels of a veal and its blood flow

transformed into high spirits (Jr. , 2005). It was the

(Gazzaniga, Ivry & Mangun, 2002).

made

Galen

so

important

beginning of “Ventricular Theory”. This theory has been widely accepted for several centuries, according to Maia (2007), it was assumed that colleges like sensations, cognitions or memory habited in the cerebral ventricles.

The Post – Renaissance age was marked by the geniality and prominence of the "founder of modern philosophy", Rene Descartes (1596-1650). The knowledge acquired during the period of the Renaissance was mediated largely, with a

For several centuries Ventricular Theory survived,

disagreement with the rules and ideologies of the

but over time has suffered changes by other

Catholic Church, yet such bickering was somehow

scholars, including Leonardo da Vinci (1452 - 1519),

resolved by the French philosopher. Descartes

famous painter, sculptor, architect and scientist.

proposed a division between mind and body,

According to Pevsner (2002), Da Vinci became

attributing part of the universe to the church and

interested in the study of Galen, read part of his

to the field of religion, that which had no physical

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substance, or obeyed the laws of Nature, and

Although heretofore had been already, recorded

giving the other part, the physical matter to what

several oppositions between conceptions of the

was governed by natural laws of science (Pinel,

brain and its functions, only in the nineteenth

2005). The Cartesian Dualism would be widely

century would occur the first great relative theory

known throughout the world, dividing mind and

on the working of the mind. Phrenology was a

body. Descartes saw the body, in functional terms,

theory created by Franz Joseph Gall (1758 - 1828)

similar to a machine, and mind as that which

German anatomist and physician, which consisted

decided how the machine would behave, creating

in the organization of the brain in 35 functions,

a dualistic theory that went against what many

which

other philosophers argued, and called monism. For

According to this concept if one utilizes one of the

the monist, body and mind are two words to

options with greater regularity than the other, the

describe the same thing (Kolb & Whishaw, 2003).

part corresponding to that same brain function

But this was not the only contribution of Descartes to Neuropsychology. He proposed that the mind interacted with the body through the pineal gland, stating that due to the fact that being in the center of the brain and for being the only brain structure in the nervous system, that it was not composed by two bilateral parts.

grow,

correspond

forming

a

to

specific

cranial

brain

irregularity.

areas.

This

materialistic view of mind would persist for several years, until it began to emerge empirically based theories that began to demonstrate that the theory of Gall was not as precise as appeared. Jean Marie Flourens (1794 - 1867) was among those who rejected Gall’s localizationist theory. Through studies with birds, Flourens found that lesions in

Later Luigi Galvani (1737 - 1798) would be famous

specific cortical areas did not cause predicted

for his studies of the electrical activity in nerves of

behavioral changes, discovering that the brain

frogs, which served to eradicate old terms used as

participated as a whole, indivisible, holistic, in

spiritual entities or fluids (Maia, 2007). Although

behavior and cognitive faculties ( Gazzaniga et al .,

heretofore

2002) .

had

already

recorded

several

oppositions between conceptions of the brain and its functions only in the nineteenth century would occur the first great theory on the workings of the mind

Meanwhile in France, a surgeon named Pierre Paul Broca (1824 - 1880) reported what is probably the most high profile case in the history of neuroscience. Broca examined a patient who had suffered a stroke, this patient could understand

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language but could not speak fluently. This patient

would result in another pathology, called

was known as "Tan Tan" because it was the only

conduction aphasia , which was a production of

thing she could verbalize. The damaged brain area

incoherent speech despite verbal abilities remain

in the case of this patient, was the left side of the

intact, as well as comprehension skills. (Gazzaniga

frontal lobe. More precisely what we would later

et al, 2002;. Kolb & Whishaw 2003). The German

designate Brodmann area 44, or Broca's area

became known by the discovery of so-called

(Gazzaniga et al., 2002). The impact of this

Wernicke - Korsakoff syndrome, which is a

discovery was huge in the scientific community,

common disorder of memory in people who

through his investigations Paul Broca described

consume large amounts of alcohol (Pinel, 2005).

this condition as aphasia, the inability to speak due to injury in that particular region of the brain. This came to support localizationists theories, since it had been established that there was a particular brain

area

that

effectively

controlled

the

production of speech (Zillmer et al., 2007). This issue has sparked interest in the German Karl Wernicke (1848 - 1905) that realized that a case of a subject who, unlike the cases discovered by Broca, could speak fluently in return but his speech did not make much sense, as the subject seemed not to understand spoken or written language. This patient had a lesion in the posterior part of the left hemisphere, in the area near the junction between the parietal and temporal lobes. This aphasia later became known as Wernicke's aphasia, but besides from having made this important discovery, the German scientist proposed another type of injury. He suggested that if the fibers that bound both areas, Broca's area and Wernicke's area (as they would be called later) suffered some kind of injury,

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Such discoveries have revolutionized the vision that existed of the brain and its functions, and have become precious to the development of various surgical techniques and later neurosurgery itself as we know it today. Let us now proceed to the analysis of a case that sparked an enormous interest in the scientific community, the famous case of Phineas Gage (1823-1860). The September 13, 1848 , Phineas Gage , a laborer who worked in the railways, railway construction Rutland and Burlington, had been commissioned to make holes in the rock to later throw powder in each of those holes and tamping the material with a large iron before proceeding with detonation. Behold, on that fateful day gunpowder exploded, which caused an iron rod with around 90cm high and 3cm thick to pierce his skull on the left side, under the eye and leave the calvaria region, punching a side and out the other. But the most extraordinary of this bizarre incident, was that despite being in brain

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tissue of the left prefrontal lobe almost completely

analyze the human brain. According to Gazzaniga

destroyed Gage never lost consciousness and even

et al. (2002), among several scholars we can find

walked after being transported in a "bullock cart"

the name of Korbinian Brodmann (1868-1918),

until the house where was examined by the

who made his mark in neuroscience to analyze the

physician Dr. John Harlow .

cellular organization of the cortex, which could

According to the records, Harlow could play with the index finger of one hand from the hole in the top of the head Gage, the forefinger of the other hand, placed at the bottom where the iron bar

distinguish 52 different areas. Through the dye developed by Nissl (1860 - 1919) Bordmann could observe how the corks cells differ from region to region (Gazzaniga et al., 2002.).

entered finger. Gage survived this incident, and

But the real turning point in the way we view the

lived for another 12 years, but from that day was

nervous system, was about to happen in the

not the same man. Apparently the intellectual and

countries of southern Europe, specifically in Italy

physical level he showed to be with the same

and Spain. The revolutionary vision of two great

capabilities as before, but on an emotional level,

anatomists would forever change our conception

the level of his personality, everything became

about the nervous system, and how it actually

different. Had become unable to control or

works.

modulate their emotions, became one impulsive and disrespectful, stubborn and capricious subject, characteristics not possessed before the fateful day (Bear, Connors & Paradiso, 2006; Maia, 2007; Pinel, 2005)

In Italy a man named Camillo Golgi (1843 - 1926) used a revolutionary method that earned him the Nobel Medicine Prize in 1906, jointly with another great Spanish scientist of which name, we will mention later. In 1875 when he tried to stain the

This case provided a valuable data, for the

meninges, exposing a portion of the neural anitrato

understanding of the importance of pre-frontal

potassium dichromate and silver tissue, Golgi

lobes, especially on the behavioral, emotional and

noticed something striking, the substance resulting

personalistic level. And in an unarguably way,

from the chemical reaction between the two initial

contributed

substances, invaded some neurons of the tissue

to

the

later

development

of

neuropsychology as a science. Let us now return to Germany, where several anatomists began using microscopes to view and

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samples and colored them. This technique allowed Golgi, to view in a full perspective all the component parts of the neuron (Pinel, 2005).

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Such discovery sparked the interest in Santiago

propose invertebrates such as study models for a

Ramón y Cajal (1852 - 1934), a Spanish anatomist,

better understanding of the nervous system and

and dubbed by many as the father of neuroscience.

brain mechanisms of vertebrate (Gazzaniga et al.,

According the explanation of Gazzaniga et al.

2002).

(2002), Cajal had his first contact with this method in Madrid, at the home of his colleague, who had learned this technique in one of his trips. By the method developed by Golgi, the Spanish began to study the cells of the nervous system, and drew neurons in various stages of their development. Cajal also discovered that in opposite, to the view defended by Golgi neurons were independent entities, not seeing any connections between the cells. This theory was antagonistic to the Golgi, which argued that the neurons were connected forming a sort of network of axons. The studies and work by both eventually assert them the Nobel Prize together in 1906 as mentioned above, despite all the disagreements and conflicts between the two anatomists (Kolb & Whishaw, 2003; Gazzaniga et al., 2002).

Karl Lashley (1890 - 1958) was a student of the famous John Watson, the founder of behaviorism, and one of the most influential men in the history of modern neuropsychology. Lashley developed several concepts, among the most important stands out from Equipotentiality, which according to Gardner (1987) translates into the ability of any part of a particular functional area of the brain is involved in more than a given action. Thus showing a concern in differing from previous localizationists theories that prevailed at that time, having therefore an integrative and functional model of different brain areas. The North - American despite accepting that certain sensory and motor functions correspond to certain areas in the brain, believed there was a dynamic between different parts constituting the nervous system, assuming a

There were several scientists who were involved in

different perspective of accepted theories until

various discoveries about the nervous system,

then. According to Lashley theory, if a particular

among them stands Johannes Evangelista Purkinje

brain injury occurred, the remainder of the

(1787 - 1869) and Ludwig van Herman Helmholtz

nervous system would therefore have a limited

(1821-1894). The first was known for discovering

plasticity as to whether to take control of the

the Purkinje cells in the cerebellum as well as a

functions of the damaged region. This was also

series of events that occur at the level of vision

known by the notion of Engram, a representation

(Maia, 2007). Helmholtz was already down in

of the neuronal level of certain memories, ideas,

history among other things for being the first to

concepts or even behaviors. A sort of map in which

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cells acquire the ability to react in certain patterns

applied simple, complex and integrative skills

(Gardner, 1987, Zillmer et al., 2007).

(VanderPloeg, 2000; Zillmer et al., 2007.).

Alexander Romanovich Luria (1902 - 1977) is

It is, in 1967 that the first scientific meeting of the

considered by many as the first neuropsychologist,

INS (International Neuropsychological Society), in

and profoundly changed the way we view the

conjunction with the annual meeting of the APA

brain,

Russian

(American Psychology Association), in Washington

neuropsychologist argued that there were three

D.C., U.S.A. occurs. In 1973, the INS is officially

functional systems, essences for any kind of mental

established at APA, in 1974 Luria and Weigl are

activity, to which he himself called "units". The first

honored with the title of honorary members and in

unit consisted in the regulation of muscle tone and

1979 the Neuropsychology division is created in

the level of brain stimulation. The second unit

APA (Kristensen et al., 2001).

mind

and

behavior.

The

pointed to the posterior area of the cortex, subsequently designated by (parietal- occipital temporal) POT as having a key role in the reception, integration and processing of sensory information from the outside and inside of the body itself. The third unit, responded to the executive functions of the prefrontal and frontal lobes, resulting in the programming and regulation of mental activity of the subject as well as his behavior. Luria stated that all types of behavioral

Also relevant are the names of Norman Geschwind (1926 - 1984), the first to discover that certain brain connections underlie various behavioral disorders, among other topics, through his study of brain morphology with 100 brains and Oliver Zangwill

(1913

-

1987),

the

founder

of

neuropsychology in Britain, which also confirmed the dominance of the right hemisphere for certain linguistic functions (Zillmer et al., 2007).

patterns required the interaction of these three

The

90s

have

witnessed

tremendous

basic units, so this would reflect that the brain

developments in the field of neuropsychology,

functioned as a whole, but at the same time, there

numerous studies and scientific advances in this

were certain unique features that only determined

area, such as the beginning of the XXI century. If we

areas had, playing an important role in behavior,

look to the past of this science, we realize how rich

giving birth to the concept of pluripotency. For

and fruitful it was, as full of achievements,

Luria, assessments and examinations made to

difficulties and even some conflict. However these

patients should consist of tests in which they

were just some of the events of the men, who made this science and academic discipline what it

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is today , was due to their determination , their

Howieson & Loring, 2004 cited by Capovilla,

curiosity and insight that made possible numerous

Alessandra, 2006).

discoveries about our brain and functioning. Dualists or monists, Localizacionists or Unitarians, they all gave their contribution. As in any science or art, the forces opposed and antagonized serve as the engine to produce more knowledge. But the story of Neuropsychology is not something merely contemplative, on the contrary, it is available to all who embark on its path and follow the rails already outlined. That it is done every day by thousands of professionals worldwide and while man exists, it will always exist the search for knowledge and understanding of this extraordinary universe of 3.5kg that resides within each of us.

The neuropsychological method, take this matter to an intrinsic duality of the shape and neuropsychological methodology in assessment terms, regarding the use of psychometrics and its purpose. Facing the psychometric tests as a means or as an end, allows us to address a widely discussed topic (Maia et al. 2009). Considering the numerous information at the level of psychological processes and cognitive functioning that standard tests can provide to the neuropsychologist, its use is assumed as a tool of such importance in the evaluation

process

neuropsychological

and

intervention.

subsequent (Junqué

&

Barroso, 1995 cited by Maia et al. 2009). According Neuropsychological assessment and intervention

to José Pinto da Costa (in Maia, Correia & Leite,

Meeting its object of study, neuropsychology

2009) despite the precious value of the word as a

extends its evaluation method in order to study the

top tool in the understanding of the human person,

behavioral expression of brain dysfunction. (Maia,

the tests are a valuable auxiliary material of

Correia & Leite, 2009). This is essential not only for

psychological measurement.

the formulation of a proper diagnosis, but also to establish an effective rehabilitation and cognitive stimulation program (Ardila & Ostrosky-Solís, 1996 cited by Maia et al. 2009). Based on this assumption

neuropsychological

assessment

focuses on six essential needs and questions: a) diagnosis, b) individual care c) identification of necessary treatment; d) assessment of the effects of treatments, and) research f) legal issues (Lezak,

It is legitimate to say that the neuropsychological assessment, stems from a union between the application of normative tests and mediation of these through the interview / anamnesis process allowing the verification of relatively accurate performance (Lezak, 1995). As such, the formal neuropsychological evaluation proceeds to the use of standardized tests while simultaneously a detailed observation should be performed on

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general responses expressed by the patient

Before scrutinizing an approach related to

assessed. (Ardila & Ostrosky-Solís, 1996).

neuropsychological methods, is necessary to skip

Importantly is the reference, of the non-invasive nature

of

both

intervention

and

neuropsychological assessment. Being that fact verified, by the range of instruments at its disposal and that somehow features it. Along with these, is essential to the neuropsychologist in order to be able to determine which instruments will use, according to his hypotheses and suspicions about the disturbances of the patient, taking into account the information expressed by the same, trough to the evident signs and symptoms, or by his medical history (Capovilla, 2006; Bartolomé, Fernandez & Ajamil, 2001).

the Neuropsychological barrier and look to the neuroscientific tiny horizons, even if in a relatively distant position, which leads us to the evolution of numerous attempts and possible ways, of obtaining a photographic access to the background of Neuroscience main star. Until the 70's this was not possible, making the means of neuroscience research highly conditioned, despite its progresses. Contrary to conventional techniques of X- ray available, X- ray contrast would become the primary mechanism (although somehow a bit rudimentary) in the detection of brain lesions . Subsequently by mid-1970 the study of the living human brain was driven by computed tomography

Analyzing the set of possibilities that are within the

and other techniques ensued highlighting the

reach of a neuropsychological knowledge, it is

image by functional magnetic resonance imaging

almost obligatory to mention the importance they

(Pinel, 2005). With the advances in neuroimaging

had in the catapult of neuropsychology as a field of

and laboratory examination, the need for

neuroscience. The first neuropsychological tests

neuropsychological evaluation for the diagnosis of

were developed with the aim to evaluate brain

lesions and neurological dysfunction reduced,

abnormalities, at the expense of changes to the

however, this assessment is still crucial in certain

level of behavior. Although the "architects" of the

conditions such as dementia, cranial trauma,

genesis of such methods established as the main

certain encephalopathies, as these are not easily

goal, the pretension to create a single test, with

detected in the usual techniques. Moreover, even

sufficient efficacy in order to distinguish accurately

when neuroimaging detect the presence of lesions,

the threshold between a holder of a pathologic

neuropsychological assessment is essential to

brain, with whom had not been targeted with such

clarify their behavioral correlates, and is still

misfortune, soon it was found that this aim would

important to establish the prognosis of patients in

not be possible (Kolb & Whishaw, 2003).

certain frames and for the early identification of

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certain disorders in its early stages, that show no

activity of the nervous system and in this sense,

obvious neurological abnormalities.

affected as little as possible by sociocultural and

Considering the neuropsychological assessment and intervention, countless batteries of tests can be used according to the clinical needs required highlighting the neuropsychological battery of Luria - Nebraska, being one of the instruments of neuropsychological assessment, that is certainly most used in clinical practice, and is characterized also by being a testing method that integrates qualitative information (Maia et al., 2009). In the clinical setting at an early stage the examiner proceeds

this

evaluation

using

a

basic

neuropsychological battery addressing key areas of cognitive

operation,

thereby

influencing

subsequent decisions on the need to use more specific and refined instruments. The areas commonly assessed in basic neuropsychological batteries are spatial processing, memory, oral and written linguistic functions, calculation, executive functions, concept formation, motor skills and emotional state (Lezak, 1995 cited in Capovilla, 2006). A primary battery is not intended to be

educational factors, 3) apply with a minimum of help and verbal instructions, allowing the evaluation of patients with severe language disorders, 4) criteria clearly defined with an direct assessment, enabling some quantification that allow to obtain indices of validity and accuracy, 5) require a minimum of resources , devices and materials for the application . According to Golden (1991), the results of children undergoing neuropsychological evaluation must be analyzed even

more

developmental

cautiously, and

considering

environmental

the factors

involved. Generally its interpretation is more complex than the interpretation of results in adults with brain injuries but with a history of normal development (Capovilla, 2006). It is also important to emphasize the utility revealed by these methods in child context because through them it is possible to establish some relationships between higher cortical functions with symbolic learning (Maia et al., 2009).

exhaustive, and the operator must decide again on

Demonstrated the capacity to act and "room for

the use of other assessment tools. According to

maneuver" of Neuropsychology, is highlighted

Ardila and Ostrosky - Solis (1996), a battery of

what

neuropsychological assessment should have the

neuropsychological assessment and intervention.

following characteristics: 1) solid theoretical

In a very direct and explicit way, it seeks to achieve

foundation , 2) allow exploring basic functions, like

two objectives badly needed in the field of

fundamental forms of behavior, resulting from the

neuroscience: a neuropsychological rehabilitation

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might

be

called

the

purpose

of

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and stimulation. The first enables the reintegration

knowledge and methods of Biomedical sciences,

of the individual, which possesses a cognitive

particularly of Neurology?

deficit, in society, in the resumption of his daily activities by maintaining his psychological wellbeing, enabling the maximization of cognitive functions.

The

rehabilitation functional

second

process,

cognitive

demands, the

in

the

stimulation

functions

to

of

generate

compensation mechanisms in order to eliminate the gaps in the brain caused by certain diseases and / or cognitive deficits.

Since the knowledge of Neuropsychologist are an asset to Psychology itself, as it provides an extension of the action spectrum, considering the level of skills usually attributed to professionals in this area, it seems that is not the case.

It is

paradoxical, but the specialization, usually related to Neuropsychology, allows an expansion of the clinical

psychologist’s

action

spectrum.

Neuropsychology seems to push the limits stipulated by traditional psychology, focusing

Reflection

primarily on the behavioral manifestations level of of

the subject, and then correlating the behavior and

Neuropsychology toward Psychology itself. A

brain structures involved, being a psychologist,

professional of Neuropsychology, is or is not a

with a broader knowledge of man and its primary

Psychologist? Let's start by defining in a simple

mechanism of action: the brain.

It’s

time

to

reflect

about

the

role

way, Psychology and Neuropsychology. According to Zillmer et al. (2007) psychologists study the behavior, since the neuropsychologists study the relationship between brain and behavior. Although many authors defend that is a sub-discipline within the great mother and “hub science”, psychology, neuropsychology specialization

can of

be

interpreted

psychology,

as

where

a a

Neuropsychologist has a much greater anatomical and functional knowledge compared to a psychologist

due

to

their

knowledge

in

Neuroscience. But will the Neuropsychology be a

Offering resistance to this fact not only reveals fragility of Psychology as a science but also its limitations. Any psychologist should necessarily have knowledge at the level of Neurosciences, at the level of neuropsychological assessment and intervention, being an asset for patients and for the professional himself. Such division, or concept becomes less and less useful for clinical intervention, being necessary the knowledge from neuropsychology into psychology itself, regardless the field of action that it may find.

renegade of Psychology simply because "drink" the

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fundamentos

References Bartolomé, M.ª V.P., Fernandez, V.L. & Ajamil, C.E. (2001). Neuropsicología: Libro de trabajo. (2ª

Bear, M.F., Connors, B.W. & Paradiso, M. A. (2006). Neuroscience: exploring the brain. (3rd ed.).

neuropsicologia cognitiva. Psicologia: Reflexão e crítica, 14, 259-274.

satisfações: As neurociências e o MEU ensaio inacabado. Covilhã: Éditos Prometaicos. Maia, L., Correia, C. & Leite, R. (2009). Avaliação e

Philadephia: Hearthside Publishing Services. Capovilla, A.G.S (2006). Contributions of cognitive and

da

Maia, L. (2007). Psicologia e liberdade: angústias e

ed.). Salamanca: Amarú Ediciones.

neuropsychology

metodológicos

neuropsychological

intervenção Neuropsicológica. Lisboa: Lidel. Pevsner,

J.

(2002).

Leonardo

da

Vinci’s

assesment to human cognitive processing

contributions to neuroscience. Trends in

comprehension, 6 (11) retrieved at 2007,

Neurosciences, 25 (4): 217-220.

http://pepsic.bvsalud.org/scielo.php?pid=S167 6-10492007000100005&script=sci_arttext

Alegre: Artmed.

Gardner, H. (1987). The mind's new science: a history of the cognitive revolution. EUA: Paperback Edition.

Cognitive neuroscience: The biology of mind. (2nd ed.). New York: Norton & Company Inc. Jr., R. M. (2005). As novas descobertas da neurociência a respeito da fé humana. (4ª ed.). São Paulo: Editora Gente. Kolb, B., & Whishaw, I.Q. (2003). Fundamentals of human neuropsychology. (5th ed.). New York:

Kristensen, C.H, Almeida, R.M & Gomes, W.B.

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New directions in the skeletal biology of Greece.

Silva, A.S & Pinto, J.M. (2001). Metodologia das ciências sociais. Porto: Afrontamento. Semple, D., Smyth, R. & Burns, J. (2005). Oxford handbook of psychiatry. New York: Oxford University Press. Trull, T.J. (2005). Clinical Psychology. (7th ed.). Belmont: Wadsworth. Vanderploeg, R.D. (Eds.). (2000). Clinician's guide

Worth Publishers Inc.

Desenvolvimentos

Scheparts L.A., Fox, S.C. & Bourbou C.F. (2009).

New Jersey.

Gazzaniga, M.S., Ivry, R.B. & Mangun, G. R. (2002).

(2001).

Pinel, J. (2005). Biopsicologia. (5ª ed.). Porto

históricos

e

to neuropsychological assessment. (2nd ed.). Florida: Tampa.

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Walsh, K.W (1987). Neuropsychology: A clinical approach. Melbourne: Churchill Livingstone. Zillmer, E., Spiers, M. & William, C.C. (2007). Principles

of

neuropsychology.

(2nd

ed.).

Belmont: Wadsworth.

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Original Article Study of Delinquent History and auto / hetero perception in subjects under Educational Guardianship Institution Filipa Marques Varandas (1) & Luis Alberto Coelho Rebelo Maia (2) (1) Degree in Psychology and Master Student in Clinical and Health Psychology, University of Beira Interior: f.m.varandas@gmail.com (2) PhD In Clinical & Forensic Neuropsicology: lmaia@ubi.pt --------------------------------------------------------------------------------------------------------------------------------------------------------------Summary: In the present study we sought to examine the influence of psychological variables and relational in juvenile delinquency, focusing on other variables such as behavior problems, delinquency, self-esteem and social desirability. We also analyzed the influence of sociodemographics and criminal type of subject. The sample consists of 99 participants, aged between 14 and 19 years old. Of these 33 subjects were adolescent offenders to abide Guardianship Educational Measurements in Educational Center in the Interior of Portugal and 66 were not criminals. In this study were used: the demographic questionnaire and four instruments of psychological measure, both the subsamples of subjects, Rosenberg Self-Esteem Scale, the Aggression Questionnaire, Behavior Inventory offenders and Social Desirability Scale Marlowe – Crowne. The results highlight the influence of the family as the primary socialization agent, respondents who have divorced parents are the ones who give more input on new educational center since it has a higher average (72.7). Adolescence with criminal behavior come from families with low levels of education, more than 35 % are illiterate, the remaining oscillate between the 1st and 3rd basic education. There seems to be an association between levels of education and the various factors related to criminal behavior , respondents who have only the 2nd cycle on aggressiveness scale shows the highest rates ( 98.00), as well as analysis of the scale of crime , respondents with 1 cycle which give more importance to the crime , and the higher average (73.61). At the level of negative self-esteem , group 1 had a mean of 9.79 ( SD = 3.542 ) and group 2 had an average of 9.6 ( SD= 1.767 ), observing a large statistically significant difference ( t = -2089 , p = 0.037 e t = -2652 , p = 0.008) , with a mean difference of pairs was 0.73 ( SD = 2.655). We think this study is relevant because allows us to understand the magnitude with which delinquent and violent behavior reach the younger and have a huge impact on our society. Keywords: Behavior problems; Self teem; Juvenile delinquency, social desirability, deviant behavior and / or Conduct Disorder.

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Resumo: Na presente investigação pretendeu-se analisar a influência de algumas variáveis psicológicas e relacionais na delinquência juvenil, focando também outras variáveis como problemas de comportamento, delinquência auto relatada, autoestima e desejabilidade social. Foi também analisada a influência de variáveis sociodemográficas e de tipo criminal dos sujeitos. A amostra é constituída por 99 participantes, com idades compreendidas entre os 14 e os 19 anos de idade. Desta amostra 33 sujeitos eram adolescentes delinquentes, a cumprirem Medidas Tutelares Educativas num Centro Educativo do Interior de Portugal e 66 eram não delinquentes. No estudo foram aplicados um questionário sociodemográfico e quatro instrumentos de medida psicológica a ambas a subamostras de sujeitos, Escala de Autoestima de Rosenberg, Questionário de a Agressividade, Inventário de Comportamentos delinquentes e a Escala de Desejabilidade Social de Marlowe-Crowne. Dos resultados obtidos destacam-se a influência da família como agente da socialização primária, inquiridos que possuem os pais divorciados são os que dão entrada mais novos no centro educativo uma vez que possui uma média superior (72.7). Os jovens com comportamentos delitivos são oriundos de famílias com níveis educativos baixos, mais de 35 % são analfabetos, os restantes oscilam entre o 1ºCEB e o 3º CEB. Parece haver uma associação entre os níveis de escolaridade e os diversos fatores ligados ao comportamento delitivo, os inquiridos que possuem apenas o 2º ciclo na escala de agressividade apresenta maiores índices (98.00), bem como na análise da escala da delinquência, os inquiridos com 1º Ciclo que dão mais importância à delinquência, tendo a média superior (73.61). Ao nível da autoestima negativa, o grupo 1 obtiveram uma média de 9.79 (DP=3.542) e o grupo 2 obtiveram média de 9.06 (DP=1.767), observando-se uma grande diferença estatisticamente significativa (t=-2.089; p=0.037 e t=-2.652; p=0.008), sendo que a média da diferença de pares foi de 0.73 (DP=2.655). O presente estudo torna-se pertinente na medida em que permite compreender magnitude com que os comportamentos delinquentes e violentos atingem a população mais jovem e se repercutem na sociedade dos nossos dias. Palavras-chave:

Problemas

de

comportamento;

Autoestima;

Delinquência

juvenil;

Desejabilidade

social;

Comportamento desviante e /ou Perturbação do Comportamento.

Resumen: En el presente estudio hemos tratado de examinar la influencia de algunas variables psicológicas y relacionales con la delincuencia juvenil y otras variables, como los problemas de conducta, delincuencia auto informado, autoestima y deseabilidad social. También se analizó la influencia del tipo de variables sociodemográficas y delictivas de tema. La muestra consta de 99 participantes, con edades entre 14 y 19 años de edad. De estos 33 sujetos eran delincuentes adolescentes, a cumplir Medidas Tutelares Educativas en un Centro Educativo en el interior de Portugal y 66 no eran sujetos criminales. En el estudio se utilizó un cuestionario sociodemográfico y cuatro instrumentos de medida psicológica: Escala de Autoestima de Rosenberg, el Cuestionario de Agresión, inventario de conductas de los delincuentes y la Escala Marlowe - Crowne de Aceptación Social. Los resultados ponen de manifiesto la influencia de la familia como agente de socialización primaria; los encuestados que se han divorciado los padres están dando nueva entrada en el centro educativo, ya que tiene un promedio más alto

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(72.7). Los jóvenes con conductas criminales provienen de familias con bajos niveles de educación, más del 35% son analfabetos, los restantes oscilan entre el primero y el tercero CEB. No parece haber una asociación entre los niveles de educación y los diversos factores relacionados con comportamiento delictivo, los encuestados que tienen sólo el segundo ciclo en la escala de agresividad se muestran las tasas más altas (98.00), así como el análisis de la escala de la delincuencia, los encuestados con primero ciclo que dan más importancia a la delincuencia, con el promedio más alto (73.61). A nivel de autoestima negativa, el grupo 1 tuvo una media de 9,79 (SD = 3,542) y el grupo 2 tuvo promedio 9,6 (DE = 1,767 ) , observándose una importante diferencia estadísticamente significativa ( t = -2.089 , p = 0.037 y = -2.652 , p = 0.008 ) , con una diferencia media de pares fue de 0,73 ( SD = 2,655 ) . Este estudio es relevante, ya que nos permite entender la magnitud con la que los delincuentes y los comportamientos violentos afectan a la población más joven y se reflejan en la sociedad actual. Palabras clave: problemas de conducta; autoestima, la delincuencia juvenil, la deseabilidad social, conducta desviada y / o trastornos de conducta. ---------------------------------------------------------------------------------------------------------------------------------------------------------------

The theory, research / scientific studies in the area, identify practical antisocial attitudes and beliefs, i.e. beliefs, values and rationalizations, as an important risk area with regard to juvenile delinquency and deviant behavior; so the application of guardianship measures is a relatively recent topic in Portugal and difficult to access, even if the courts are the institutions that advocate more transparency in decision-making, as it is easier to know the word of minors to the word of instances of formal social control (Alão, 2009). According to Steiner (2007) the intensity and seriousness of juvenile offenses are generally determined by social, economic and cultural conditions often practiced in the country. There is evidence that universal increase in juvenile crime takes place in parallel with the economic decline, especially in poor neighborhoods of large cities.

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Juvenile Delinquency and Delinquent Behavior: Conceptualization The term "juvenile delinquency" usually has a stark legal connotation, it is not a psychological term, and translates the acts committed by an individual who is below the age of criminal responsibility, which violates the established rules and laws (Martins, 2005; Negreiros 2001). However, what is considered delinquent at a given time and place, may possibly be according to law in a different time or place, being that the teenagers called delinquents or offenders are those who actually committed illegal acts, translated as felonies or misdemeanors (Silva, 2002). Negreiros (2001) simultaneously considers two factors: the acts committed by the subject which may be subject to a criminal penalty and age of the person who commits the acts. The acts committed by criminal law will be typified as a crime and age refers to the age range up to the legal age for criminal responsibility. According to Ferreira (2000) the concept of delinquency from a sociological view, is indispensable to the existence of different models on the diversion of young people: the "control" and the "subculture". In the second model, associated with the explanations of cultural or subcultural order, the deviation is seen as a predisposition for adherence to standards, expectations and definitions

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that differ from the standards, expectations and definitions into force in society, and ultimately makes the young is adverse to them. These behavioral disorders were subjected to various classifications, such as: juvenile delinquency, antisocial behavior, deviant behavior, aggressiveness, hostility and disruptive behaviors (Fonseca, Simões, Rebelo, Ferreira & Yule, 1995). However, these terms are not strictly synonyms (although they may overlap in some respects), nor correspond to the same conceptual framework. (Delles, 2001; União Europeia, 2001 cit in Simões, Matos, & BatistaFoguet, 2008; Emler & Reicher, 1995 cit in Tarry & Emler, 2007; Farrington, 2004; Negreiros, 2008; Silva, 2002; Seabra, 2005; Fonseca, 2004; Faria, 2008; Agra, 2008; Negreiros, 2008). Portugal is no exception, and this problem becomes more visible in the nineties (1990), due to media coverage of cases of juvenile crime (Agra, 1997; Benavente, 2002; Rosado, 2004). The media coverage of juvenile delinquency and consequently increased visibility among the population leads to increased feelings of insecurity (Carvalho, 2000; Lourenço, Lisboa, & Frias, 1998) that according to Carvalho (2000) increases social intolerance against the delinquent behavior. Juvenile delinquency is one of the areas political and social of concern (Luzes, 2010; Matos, Negreiros, Simões, & Gaspar, 2009, Fernandes, 2008; Benavente, 2002). Despite the absence of an agreed definition of delinquency, according Negreiros (2008) the term antisocial behavior is broader, encompassing acts and deviant behavior ie who break social rules (Negreiros, 2008). The antisocial behavior is a spectrum of disruptive behaviors interconnected by act of transgression of social norms (Stoff, Beriling & Maser, 1997), however there are limits to consider someone as offender (Carvalho, 2005). According to Laranjeira (2007), delinquent behavior can present itself in various forms of maladjustment or disturbing behavior that does not depend only on the internal characteristics of the individual (development / psychological organization), as well as the level of external influence, thus, there may be the occurrence of psychopathological situations related and determined by psycho phenomena, which influence the uptake values and norms of society, but also adversely affect the ability of school adjustment (Laranjeira, 2007). Farrington (1995 cited by Pacheco et al.,2005) refers to some studies conducted in the last decade have indicated an increasing prevalence and intensity of behavioral problems and more specifically antisocial behavior, both in childhood and in adolescence, adds that the characteristic delinquent behavior in these adolescents, we see an antisocial pattern that began in childhood and deviant behaviors and includes acts prohibited by laws, such as theft, assault, vandalism and drug use; it is essential that to be parsed as a heterogeneous and complex phenomenon (Farrington, 1987; Fonseca, 2004; Agra, 2008; Negreiros, 2008), result of multiple bio psychosocial influences (Lösel, 2003; Costa & Porto, 2008).

Theory of lettering, social tagging, or labeling approach According to Araújo (2010) theory of lettering or labeling approach emerged in the mid-twentieth century in the United States. From this new vision, a new way of thinking about crime. The criminal is no longer seen as a good or bad to be alone, or provided with bio psychological factors that cause them to be labeled as delinquent, and are therefore the

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result of a social construction. Thus, the deviation is not the quality of the act the person commits, or is just a consequence of the application by others of rules and sanctions to an offender (Andrade, 1995; Colet & Moura, 1995; Almeida, 2001; Avellar, 2007; Araújo 2010).

Delinquency as a behavioral disorder Negreiros (2001, p 12-13) characterizes the juvenile, at the psychopathological level, as a conduct disorder which notes one: "(...) Persistent pattern of antisocial behavior and may interfere with various aspects of life of the individual. It is thus a set of anti-social behavior and opposition (theft, physical violence, cruelty, trails) characterized by constant conflicts with others. " To DSM-IV-TR (American Psychiatric Association, 2002) adolescents who commit delinquent acts may have a diagnosis of conduct disorder, so this picture is one that has deserved more attention and may also be referred to delinquent behavior, characterized essentially by presenting a consistent pattern of antisocial behavior, aggressive and challenging; they violated the basic rights of others or major existing standards and appropriate social rules will age. According to Bordin and Offord (2000), the behavioral disorder is characterized by permanent tendency to present socially inappropriate behaviors that go against the rules of social interaction and eventually transgressed the laws of the State. Regarding associated with behavioral disorders in adolescents, Cruzeiro and colleagues (2013) consider the factors associated with conduct disorder in male adolescent risk behaviors that may enhance the vulnerability to physical and mental health of children and adolescents, and can provide as determinants in the development of antisocial behaviors and aggravation factors. Within these factors include socioeconomic status, alcohol consumption, drugs and early

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violence. According to Silva (2011) the age of onset of conduct disorder is important for the development of strategies for treatment and prevention factor. Thus, recognition of mental disorders in childhood and adolescence becomes fundamental as regards Dias (2012), to the process of personal development, the management of these disorders within the family and school skills enable a development of the child and adolescent to the extent that interfere with learning and socialization and personality formation.

The delinquent and antisocial conduct in youth The definition of antisocial behavior is quite large, however, which is covered by a larger number of authors with respect to reference to violations of rules and regulations in society (Baker, Jacobson, Raine, Lozano & Bezdjian, 2007; Sobral, Romero, Luengo & Marzoa, 2000). In this direction lies the study of Pacheco, Alvarenga, Reppold & Piccinini (2005), centered on the description of antisocial behavior as a measure of behavioral disorders in the period of change from childhood to adolescence, the researchers sought to understand the behavioral changes to during this period of

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development. The study specifically found that delinquent behavior and persistence of illegal acts are important predictors of the severity and continuity of the practice of antisocial behavior and other psychosocial problems such as social isolation, school dropout and drug use. To Moffitt (1993) antisocial behavior is perceived from two different points of view: shows a marked relationship with age, increasing during the period of adolescence, however, how the young will behave will depend largely on their individual characteristics, which will determine whether the transgressive behavior of young keeps in adolescence or will accompany him into adulthood. Deviant behavior can be considered behaviors of diversion to social norms and expectations, without necessarily a legal infraction, such as delinquency (Sanches & Gouveia-Pereira, 2010). In turn, the delinquent conduct is defined as "legal name, usually based on contact with the laws of the country in which justice is the child or adolescent" in this sense is also important to note that "the delinquent conduct is not a psychological construct without a judicial-legal category, because it is not possible to group the young people in the same category, without regard to their individual specifications, given the fact that they all have in common is having committed a delinquent act " (Kazdin & Buela-Casal, 1996 cited by Sanabria & Rodriguez, 2009). Breen, Díaz, Àngel & Vàzquez (2002), concluded in his study with 523 Spanish subjects of both sexes aged between 9 and 18 that the majority of young people with antisocial behaviors showed lack of civic and ecological awareness, internal conflict, economic motivation behaviors, tendency to vandalism and consumption of illegal substances. It should be noted that in the literature the terms crime and antisocial behavior are often used as synonyms, the first being applied in clinical and criminological research as if it were a clinical diagnosis, the term delinquency is a legal designation, referring to the transgression of the laws while the term antisocial behavior is broader, referring to transgressive acts or violations of social norms or expectations that are considered inappropriate because they damage others and society (Lemos, 2010). The stability of antisocial behavior has been investigated by a number of longitudinal studies that seek to understand the variables that contribute to the maintenance and development of this behavioral pattern; several studies indicate that the evolution of these problems in girls, though less prevalent, are also worrisome (Pacheco, 2005).

Aggressive and violent behavior According to Anderson & Bushman (2002), human aggression is any behavior directed toward another individual that is made with the intent to cause damage, taking the perpetrator to believe that their behavior will be detrimental to the target pertente achieve. Meanwhile, violence is an extreme form of aggression that have harmful effects on the target you want to achieve effects, particularly when their self-image is at risk (Sisto, Silveira & Fernandes, 2012; Ferraril, 2006). Many authors have distinguished two types of aggression, reactive or hostile and instrumental aggression. The first relates to aggressive behavior used as a means to achieve a goal, yet are intended to damage the target for which is directed generally acquires a relational or social form and not explicit (Chertok, 2009; Papalia, 2010).

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Iberian Journal of Clinical and Forensic Neuroscience â&#x20AC;&#x201C; IJCFN

In this context, it is important to note that aggression and violence involved in youth crime are a sign of a negative adjustment before circumstances and challenges experienced by the young. Loeber & Hay (1997 cited by Hutz, 2002) describe antisocial behavior as a necessary response to the young man to resist and survive where the dangers are strong and threat are common.

Factors impacting on Aggressive and violent behavior According to Brouwers, Appelo and Oei (2010) impulsive or aggressive behavior is a phenomenon that occurs frequently in our society and is a feature that is part of a set of psychiatric diagnoses, moreover, is associated with a number of risk including neurobiological one, where psychological, cognitive, affective and social factors are included factors. With regard to social factors the same authors reported belonging to a violent social group and facilitated access to weapons, as a cause of increasing violence. Other factors, such as family circumstances do not seem to relate to the practice of aggressive and violent behavior (Brouwers, Appelo & Oei, 2010). According Borum (2000), the assessment of risk of violence among young people is subject to continued review of Psychologists and other professionals, and includes three key to prevention and intervention in risk situations: a) in the first place should be considered to analyze the behavior of the child, recognizing that violence comes in ideas that include planning later translated into action, b) Violence occurs in the potential interaction between the aggressor and the target of violence. Understanding and preventing violence should include exploration of relevant risks and behaviors of young offenders, c) the act of violence is the result of a process often noticeable and understandable of thought and behavior. Professionals working very closely with youth tendency to antisocial and violent behavior believe that the cessation of these behaviors should be drawn up jointly in several areas, such as judicial, educational and mental health of young (Wasserman, Miller & Cothern, 2000). According to Hawkinse and colleagues (2000) and Flores (2003), among the factors that seem most relevant to the development of violence among the younger generation, we highlight five areas: Individual, Family, School, Group Peer and Community and Society.

Adolescence and the Risk During the period of childhood, the children have as a reference point parents and later in adolescence their references focus on peer group and whole school environment that surrounds her (Born, 2005). The process of socializing is how the individual adapts to the environment in which it is inserted, this is where we live and interact in influencing the formation and consequently suffering his influence, according to Oliveira (2002) "while the child modifies its environment, is changed by it" (Oliveira, 2002, p. 126). The school is a privileged place to reflect on issues involving children and young people, parents, educators and students, as well as social relations and society (Njaine, Minayo, 2003).

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Adolescence is a particularly vulnerable stage of development for many, since in this period, take place physical and psychological changes that often not which sometimes young people do not deal easily (Sapienza & Pedromônico, 2005; Berger, 2003). Personality development, identity and family socialization and peer group plays an important role, these figures may even dictate much of the future behavior of the individual (Born, 2005; Martinho, 2010). The socialization process is an interaction between the child or young person with the environment, how these agents act depends on numerous contextual factors such as social class, country, city or geographical area in which the development process and occurs certain personal factors such as gender, physical and psychological skills as well as their social skills (Benedict, 1938; Kohlberg, 1958; Bronnfrenbrenner, 1979). Adolescence as a period of great change appears to be a phase that has implied greater emotional vulnerability and a higher reactivity with respect to authority figures, and greater difficulty in dealing with the imposition of limits, which may be related to the fact that adolescents have the need to mark their identity. In addition, the need for affirming the teen before the group and their need for constant adjustments can create some situations of internal and external conflict, although transitory can lead to situations of anxiety and depression, which can be translated on the way aggressive behavior transmitted to the surroundings of the young (Pral, 2007). Martins (2005) claims that the construction of a positive identity shows that the individual develops their training while being individual and participates in the construction of "I", even if it is a phase of changes as have been explored, the subject must still prove a boundary of internalized and undertakes with choices that ensure the coherence of the self, which is denoted by the school, sexual polarization and the ability to consciously take ideological commitments of political, social, religious or parental images. These experiences according to Monteiro and Ferreira (2007) can trigger aggressive tendencies, conflict against the authority figure and the opposition, mainly directed to the parental figures. These authors reported that this opposition can even express themselves through antisocial and deviant behavior. The variable that increases the possibility of the individual to acquire certain disease when exposed to it is defined as a risk factor. Risk factors may include genetic, biological and psychosocial (Pedromônico & Sapienza, 2005) variables. That is, each individual is a unique being, with individual and inserted into a particular cultural, social and family environment, which is influenced and influences young features. To Buela-Casal and Kazdin (2001), the risk factors for juvenile delinquency is a broad spectrum covering the individual, family and social nature, which often will underpin the adoption of deviant behavior, these factors incorporate the so-called risk factors (Buela-Casal & Kazdin, 2001). According to depicting Feijó & Oliveira (2001), risk behaviors can also be defined as participation in activities that somehow could compromise the physical and mental health of adolescents. One of the factors that contributes to the development of situations that expose youth to situations of risk and vulnerability is depression, which may possibly be related to the increase in stress situations in everyday life, combined with declining standards of tolerance situations of frustration (Hutz, 2002). Besides this, we highlight malnutrition, low birth weight, brain damage, developmental delay, dysfunctional family, social minority, unemployment, poverty, and poor access to health and education (Pedromônico & Sapienza, 2005).

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Among the risk factors we found individual aspects such as temperament as their low self-esteem, aggression and impulsivity may be factors that contribute to a greater propensity to criminal practice (Buela-Casal & Kazdin, 2001). According to Farrington (1996), high levels of anger and anger can increase the propensity for antisocial practice. To Bogt and Engels (2001, cited by Tomé, 2011), thus understood, that within the main reasons why your teen to choose risky behaviors are related to the fact that the adolescent need for approval and fear rejection by social groups.

The Social Development of Adolescents The adolescent development happens in a delicate process of interaction with the social elements of their environment, as has reference not only their individual biography but also the history and actuality of society (Krauskopf, 1994, 1995). Mediators and moderators of effects of self-esteem were related to loneliness and global life satisfaction in adolescents, a study by Civitci and Civitci (2009) involving 439 students aged between 15 and 18 years who attended different high schools in Turkey. Data were collected using the UCLA Loneliness Scale, the Rosenberg Self-Esteem Scale and the Scale of Life Satisfaction - SWLS. The analysis performed for the collected data allowed to demonstrate that when the loneliness decreases the overall life satisfaction increases as self-esteem plays a mediating role in this increase. The authors Civitci and Civitci (2009) and Demir and Urberg (2004) also concluded that satisfaction with life is an important positive indicator to the psychological level and social development of adolescents and that is a key concept in the social construction of the adolescent. In the study by Loureiro, Frederico-Ferreira & Santos-(2013) it was possible to identify the main difficulties in interaction with other social competence, such as public speaking and responding appropriately to teasing, and even the inability to deal with emotions accompanied by some emotional suffering to himself, aware of this, there is a growing need for social acceptance in the peer group and friends are a fundamental base for personal recognition, as support that allow a sense of belonging and solidarity and contribute to a sense of personal well-being for young people. The study also concluded that huge times young people tend not to act according to their beliefs and convictions to not feel bad before peers and to have their approval and acceptance, referring to themselves many times to a second plane.

The role of family and peer group

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In the evolution of society it appears that the concept of family and its role takes various definitions and functions taking into account the cultural and social environment (Parsons, 1952; Sampaio & Gameiro, 1985, p.11-12). It is within the family that emerges primary socialization, where young people construct their identity and develop their personalities through various experiences and learnings. It is adjacent to the first families that appear intentional and interrelational relationships through body contact or communication, and the earliest affective relations (Alarcão, 2006; Monteiro & Ferreira, 2007; Pral, 2007). Many times it is found that the process of primary socialization has severe shortcomings, which may arise in family structure (large families), parental neglect, lack of or weakness of family ties, the socio-economic aspects of families

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

with economic scarcity, separation or other homeostatic imbalances as the death of relatives or institutionalization. All these factors can be seen as risk factors of juvenile delinquency (Buela-Casal & Kazdin, 2001; Hutz 2002; Thornberry & Krohn, 2004). "The researchers measured social integration of young people by involving them in the family, the school and later to work. Demonstrate that the stronger this integration, less likely to commit crimes (...). The rooting of an individual in a community context gives it a strong motivation to take into account the expectations of the medium, which is in keeping with the laws" (Cusson, 2002, p.202; Spillane-Grieco, 2000 cited by Carvalho, 2004). With the socially unstable environment associated with disadvantaged economic backgrounds, flanked by social or even physical degradation, the youth are easily faced with trafficking in substances, theft, prostitution and a whole wide range of delinquent behavior which may provide a positive character of crime may lead to the need of the young to experience such behaviors (Loeber & Farrington, 2001). According to Andrews et al (cited by Oetting & Donnermeyer, 1998) the quality of family ties, the transmission of norms, parental modeling, family dysfunction are relevant involvement in substance use. Many researchers agree in stating that the family have a crucial role as an explanatory factor of the delinquent behavior of adolescents in many of these studies, it was found that the negative and adverse family aware of the difficulties of communication with parents and the environment are a determining factor for the existence of this type of behavior (Caldwell, Beutler, Ross & Silver, 2006; Jiménez, Murgui, Estévez & Musitu, 2007). The school environment and peer groups also have a very important role for the development of new relationships with peer group, school is a diverse context for development and learning, ie, a site that brings together diverse expertise, seizure of standards and values, it is still often the space where young adults find reference models (Pral, 2007; 2005; Resgate, 2001; Gouveia-pereira, Pedro, Amaral, Alves-Martins & Peixoto, 2000; Selosse (2001). The need to break with the father figures (Tomé, 2011), autonomy and demand pushes the adolescent transgression of existing limits, can lead these behaviors be infringe as theft of antisocial acting out (Anne Freud & Helene Deutch in Malpique & Queirós, 1984), as a way to exteriorize his internal conflict and assert their autonomous will. So, Pingeon (1982), Marques (2001), Aguilar, Sroufe, Egeland & Carlson (2000), Benavente (2002), Agra (2008) among others, consider that there is a strong relationship between adolescence and transgression, inevitable and necessary for the development and the acquisition of new forms of socialization. Despite the emergence of these behaviors, Braconier and Marcelli (2000) argue that they are not only necessarily pathological in nature, but rather an adaptive process to its new condition. Blumstein and Cohen (cited by Capaldi & Stoolmiller,1999) found that delinquent behavior is expressed mainly between 15 and 17 years, with a decline of the same with the entry into adulthood, being this study corroborated by other studies (Bachman, Fréchete, Le Blanc, cited by Pingeon, 1982). To Benavente (2002) these offenses are strategies to organize internal tensions, to coordinate mental and temporary disorganization. However, the identification of a group of deviant peers, which have dominated the various criminal behaviors explains the expansion of criminal practice to newcomers young people within these groups. Young people are poorly adapted

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to another peer group, tend to feel rejected and aggressive, increasing the likelihood to integrate with deviant groups; on the other hand, we find other young people with risk trends inadequate to choices of their peers, young having an education too punitive or permissive (Bagwell et al., 2001). Membership in this group of teenagers are organized in an aggressive / defensive manner, structured hierarchically, with attitudes against social norms and values, allows them to get a sense of belonging, recognition and independence (Selosse, 2001), making to feel it as a social support entity (Emler and Reicher 1995 system; Petersen and Wainer (2011).

Social desirability The term is usually used to describe situations where individuals act on the social pressures of social desirability, some authors as Leenders and Brugman (2005), have focused on the importance of the perception of young people in relation to delinquent behavior, a study in which the main research question concerns the role of emotional processes in moral judgments that categorize an action as a moral transgression. According to several authors, Lemos (2005), Paulhus (1984, citeed by Guedes, 2012), Ribas, Moura & Hutz (2004) and (Senos & Diniz, 1998) social desirability produces a distorting effect on personality questionnaires, to the extent that participants tend to respond tendentiously to questions, in regards to working with children, the influence of social desirability has a great, a great impact, once children usually strive to give a better picture about themrself in order to please others and be accepted socially, rejecting socially undesirable behaviors (Formiga & Gouveia, 2005). Most studies highlights the influence of social desirability on personality measures, since, as previously mentioned subjects tend to respond according to social conformity and implicit rules and norms in the society in order to convey a positive image of themselves. The group with which the individual identifies or can be connoted already belongs to a positive or negative valence also giving a positive or negative social identity (Senos & Diniz, 1998). However, social desirability has an impact on other behaviors strongly disapproved by society such as direct and indirect aggression and impulsivity (Vigil-Colet, Ruiz-Pamies, Anguiano-Carrasco & Lorenzo-Seva, 2012; Jackson, 2007).

Evolution of criminal trajectories Until very recently the experience of institutionalized adolescents was largely ignored and undervalued part, since their opinions were seen in the form of distrust and ignorance, leading to many of the professionals involved in the processes of decision making, were taken to act without understanding the systems and experiences involved in the process of institutionalization by young people (Frechette & le Blanc, 1979). Thus, to understand the way young people view their trajectory of delinquency from the point of view of their individual characteristics, can be a strong indicator of how they will behave in the face of situations and experiences (Shubert, Mulvey, Loughran & Losoya, 2011). According to Formiga and Diniz (2011 cited by Formiga, 2012) the increase in antisocial and delinquent behavior among young people, even those who have no history of delinquency at the present time, is due to a cultural shift that occurs in Western countries is based on the increase of individualism.

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Iberian Journal of Clinical and Forensic Neuroscience â&#x20AC;&#x201C; IJCFN

Regarding the persistence of delinquent behavior of youth to adulthood, the opinions of researchers and the general public are divided, while some agree in stating that the delinquent behavior in adolescents should be welcome to childhood problems, other authors consider that juvenile delinquency is the result of the surroundings and the environment to which the subject is exposed throughout life (Loeber, Farrington, & Redondo, 2011). Similarly, research has shown a relationship between the adversities experienced in adulthood and symptoms and current issues (Maia et al., 2007; Kruh, Frick & Clements, 2005). Loeber and Farrington (2001 cited by Pechorro, 2012) acknowledge in their study the existence of three distinct trajectories in the evolution of delinquent behavior: a) aggressive / versatile, b) non-aggressive c) exclusively from drug abuse. Each of these trajectories have distinct characteristics. In aggressive / versatile, for example, there would be problems of childhood behavior, aggressive behavior, very poor relations, problems of hyperactivity / impulsivity / attention, poor social skills. These authors conceive the existence of three lines of evolution in delinquency: a) conflict with authority, b) covert c) open. On the development of delinquent activity Moffit (1993) established two different groups of offenders: the limited delinquency adolescence that appears in early adolescence, accompanied by remission of delinquent activity during adulthood, characterized by a widespread prevalence, but tend not to have continued to be a temporary phenomenon and adaptive. The persistent antisocial behavior characterizes itself by early antisocial manifestations extending due to its severity in adulthood, they probably have a neurobiological basis. This second group represents a small fraction of those who commit delinquent acts. Concomitantly, Loeber (1997) is based on the assumption that the subject according to their individual characteristics tends to build a path deviating individual treatment and clinical readings arise in this way the response to the deviant individual drive.

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Farrington (2004), part of non-theoretical study, longitudinal 50-year duration, held in a suburb of Cambridge, to establish the birth, continue and end of a criminal career. Presents a set of interdependent factors among themselves, in which includes family, school, community and peer individual variables. Studies have shown that the criminological context, the preponderance of young males compared with females, the trend for early criminal activity, is situated around 14 years and still, the propensity for delinquent activity peak is situated around of 17, 18 years old (Caspi, 2000; Loeber, & Farrington, & Waschbusch, 1998; Moffit, 1993; Patterson & Yoerger, 2002 cited by Lemos, 2010). The highest rates of antisocial and violent behavior were identified among the most disadvantaged social classes living in urban areas (Elliott & Huizinga, 1980 cited Fonseca, 2000) are tendentiously male (Farrington, 2000, cited by Rutter, 2004). These factors are not tied to a social class according Formiga and Gouveia (2005) the media coverage of cases, makes visible the participation of young people from middle and upper classes, this way the offenders and / or antisocial behavior cannot be attributed solely on the basis of an indicator is the socio-economic status, family counseling or in terms of social exclusion.

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Formiga and Gouveia (2005) indicate that risk behaviors seem to be legitimated as seeking new experiences of pleasure and excitement out of the monotony, etc.., which can permeate antisocial behaviors. By his way Hoge (2010) states that the main reason that most young people opt for criminal behavior associated with curiosity for situations representing break the rules, be exposed to risks and challenge the norms in society, and it is not the continuous practice of serious crimes, and predictably end up abandoning the practice of criminal activities (Formiga, Aguiar & Omar, 2008). A study by Sampson & Laub (2003) in a longitudinal study, collected a large number of data on the development of trajectories of crime and delinquency over the life of a group of young offenders concluded that, regarding the evaluation of age, individual differences and family relationships. The explanations of delinquents developing stories have indicated variables that indicate problems since the structure and functionality of the family, human and cultural values, moral development, leisure habits and structure, and finally, since personality traits to genetics (Formiga, Aguiar & Omar, 2008). Canterras, Molina, & Cano (2011), developed a study that aimed to assess the variables at the household level, and personal variables related to enforcement of the measure were related to the recurrence of crime, for this, we analyzed all offenders whose case was filed in the Department of Spanish Justice, the results show that variables such as family destructurization, criminal record, drug use and existence of the history of crime in the family, were positively related to recidivism, with regard to personal characteristics data show that young who are repeat offenders in activities are characterized by having more difficulty in social relationships, lower self and violent behaviors including low frustration tolerance.

From delinquency to criminality in adult According to Farrington, Loeber and Howell (2012) in the evolution of the trajectories of juvenile to adulthood there are several hypotheses that justify differential treatment between adults and young offenders, among which stand out the least developed emotional maturity in the case of young people, a poorer self-concept and lower capacity of auto regulation (Frechette, 1987). On the other hand, some authors consider that the relationship between adolescence and transgression is necessary and inevitable not necessarily being of pathological or criminal nature, but rather an adaptive process of the new condition (Pingeon,1982; Marques, 2001; Aguilar, Sroufe, Egeland & Carlson, 2000; Braconier e Marcelli, 2000; Benavente, 2002; Agra, 2008).

Development factors of juvenile delinquency The experience of great economic hardship, increased unemployment, precarious work and of course poverty, social exclusion and enhances emergency delinquency behaviors by adolescents (Sanches & Gouveia-Pereira, 2010).

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Several studies have shown that there is a set of factors that may be predictors of delinquent behavior (Perista et al., 2012, Rijo, 2001), revealing cognitive and social factors play a major role in the initiation and maintenance of antisocial behavior (Nardi & Dell’aglio, 2010). Thus, the problem of juvenile delinquency stands in the family and the school, because it is easy to associate the cause of juvenile delinquency will poor ability of these two structures will be organized to give children and adolescents the necessary mechanisms to enable them to acquire the social and personal responsibilities level. The lack of monitoring and supervision by adults is often attributed to the onset of delinquent trajectories, leading to the need for the intervention of other complementary social structures (Ferreira, 1997; Nardi & Dell’aglio, 2010; Tomé, 2011). Analysis of factors that influence the offender practice should also include biological and psychological factors as well as the contribution of biological theories of crime and delinquency that the considered delinquent behavior was caused by a single internal mechanism. Being that the crime had a biological cause was hereditary (Sampaio, 2010; Silva, 2002). According to Perista, Cardoso, Silva & Carillho (2012) the relationship between biological factors and delinquent behavior would be constrained by environmental factors, which could thus alter the biological conditions and their influence on behavior. Gallo, Cavalcanti & Williams, (2005) can divide the risk factors for delinquent in biological or environmental factors conduit nature, though this division is purely fictional, since these variables interact to determine the form of multiply conduct. Adolescents who despite gradually exposed to risky behaviors that have not violate the prevailing social norms, may reflect the action of protective factors, and even mirror their effectiveness (Cavalcanti & Williams (2008).

Trajectories of Juvenile delinquency and abuse (alcohol) substances According to Pechanskya, Szobota & Scivolettob, (2004) and Paulhus (1984, cited by Guedes, 2012) alcohol consumption is increasingly widespread among young people, starting early which increases the future risk of the young person will become dependent. Concomitant consumption of alcohol is associated with violent behavior, poor school performance, losses in memory and impulse control. According what is sustained by Wainer and his team (2003 cited by Santana e Negreiros, 2008), have been noted a strong relationship between comorbid major depression (mood disorder) and anxiety disorders with substance abuse, situations that lead the individual to a framework of greater vulnerability. In this sense, it is important to note a study of 311 patients with varying levels of dependence, which indicated that negative emotional states were responsible for 35% of relapses, interpersonal conflicts by 16% and social pressure by 20% of the research universe (Scott, Williams & Beck, 1994 cited by Santana & Negreiros, 2008). It is necessary to understand the context of codes and meanings that involve society at large network, specific within particular historical time groups (Schenker & Minayo, 2005), thus taking the impact that socio cultural variables can take.

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The teenage smoking is a very prevalent problem worldwide, according Malcona, Menezesb e Chatkinb (2003) a third of young people start smoking at age 18. With regard to alcohol, Martins and Pillon (2008) demonstrate that it is one of the earliest consumed psychoactive substances by young people. Good relationships with parents and school decreases the risk of adolescent behavior problems and present use of alcohol and other drugs. The first contact is when your teen has friends who use drugs, which generates a pressure group towards its use. Several studies indicate that aggressiveness predisposes to drug use and delinquent behavior precedes. There is evidence from several studies that demonstrate the existence of determinants on consumption of chemicals such as (Brunelle, Cousineau e Brochu, 2005). According to Simões, Matos e Batista-Foguet (2006) within these factors that are related to alcohol or drugs are the family, the peer group and the school. These contexts are the primary socialization contexts, it is then natural that also function as risk or protective behaviors for the development of risk factors, and determine a greater or lesser involvement of young people in this type of behavior.

Portuguese Legal Framework In Portugal the legal age begins at 16, with young people from this age criminally chargeable under the provisions of Article 19. Penal Code, this means that the legal frameworks relating to issues of delinquency and crime delimit as the minimum threshold for criminal responsibility at the age of 16, two years below the legal age that one reaches age 18. (Neves, 2008). According to depicting Carvalho (2002), the child or adolescent does not have enough emotional maturity, there is therefore no need to impose a code in execution of a sentence, more than that, we understand the importance of applying a measure guardian to act in order to shape the behavior of the young, and promote non-recur. Thus, these young people are subject to specific legislation, specifically young people aged between 12 and under 16 who have committed acts punishable by law as crimes are under the jurisdiction of the Guardianship Act Education (Law No. 166/99, September 14), however, the "execution of guardianship measures may extend up to 21 years, time of termination must” (Educational Guardianship Law, Article 5).

Educational Guardianship Law The Educational Guardianship Law is an umbrella law, as it integrates in constitutional protection of children and young people by the State, is an educational law because you want to prevent future breaches and ensure the safety of society, still developing in young integrative skills to change maladaptive behaviors, and encourage the acquisition of norms in society. The Act establishes a number of measures, designated as educational guardianship measures "aimed at the education of the child to the right and its inclusion in a dignified and responsible manner, in community life" (Educational Guardianship Law, Article 2). Application of Educational Guardianship Law presupposes the existence of appropriate conditions for the implementation of educational guardianship measures and other judicial decisions, particularly those

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involving the admission of children and youth in institutions of the justice system (Alão, 2009). Law 166/99 of 14 September states that the entry into force of the new legal regime will occur with the onset of effectiveness of a regulatory act of the Government establishing educational centers and establishes its rating and the ordinance approving general and disciplinary regulations of the educational centers. According to the Educational Guardianship Law, educational centers are organic equipment and hierarchically dependent on social reintegration services and is intended solely for the implementation of the safeguard measure of internment, the implementation of the precautionary measure of custody in an educational center at the hospital to perform expertise on personality when lies with the probation services. Your operating system and the degree of openness is conditioned by their classification - open, semi-open or closed - according to the rules implementing the measures of internment. In this context, the internment in Education Center was established as the only measure of institutional character provided for the youth who demonstrate 'special educational needs' involving temporary departure from his usual environment 'and use the' programs and teaching methods being applicable (tutelary Education Law, Article 17, paragraph 3). The number of youth involved in delinquent and criminal activity has increased, resulting in an attitude of exclusion and insecurity on the part of communities. It is important to find the balance between community protection and the development of better socialization and development of youth at risk, and the privatization of liberty must in any event be the last resort (Karamanli, 2011). In Portugal the young adolescents have new growth in the number of measures in upholding institutional arrangements applications. Data from the Office of Legislative Policy and Planning of the Ministry of Justice for the young subjects and ended tutorial educational processes to which a tutelary measure was applied in 2001 and 2002, the residence of the vast majority of young offenders was situated on the coast the country (73.4%). Most districts population of coastal regions have a higher number of young people in education and tried to protect them some measure which was applied process. Among the different districts represented, we find first Lisbon (with 218 measures in 2001 having increased to 249 in 2002) followed by the port (236 cases in 2001 and a slight decrease of 2 cases in 2002). Looking for a more comprehensive analysis of crimes committed by young people, according to the Office of Legislative Policy and Planning of the Ministry of Justice (GPLPMJ) and for the years 2001 and 2002, in addition to the damage crimes, simple and qualified theft were the most practiced (49%). Analyzing the data in Table 3, it appears that crimes related to trafficking in narcotic represents 2.6% of the crimes, so assuming a very low weight, as well as violations of households (1.2%). The data of GPLPMJ reveal that there are differences between the crimes committed by gender, crimes of physical integrity form practiced predominantly by young people, for young males stand out in simple, damage crimes qualified as crimes of driving without legal authorization.

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Iberian Journal of Clinical and Forensic Neuroscience â&#x20AC;&#x201C; IJCFN

The measure of stronger institutional character provided for an Educational Guardianship Law is the relocation in Educational Center (Article 4) implies the temporary removal of / the young from the wild life. As mentioned above, the internment in Education Center can take place under, open, closed or semi-open. The measure of internment in semiopen regime is applicable to / the young man who has practiced as a qualified crime against people, or two or more offenses of crimes, to which corresponds the maximum sentence applicable abstractly, more than three years (Educational Guardianship law, Article 17, para. 3). The application of the safeguard measure should be educational in any case driven by interest / a minor and enabling accountability acts committed by the minor (Gomes et al, 2004).

Self-esteem Self-esteem is defined in a literal way, the importance and value that one gives to itself. Most people gives it great importance, being almost impossible to ignore the significance it has for the development of the individual features, and the way you behave emotionally (Baumeister, Campbell, Krueger & Vohs, 2008). According to Coopersmith (1967, in Avanci, Assis, Santos & Oliveira, 2007) self-esteem concerns will review the individual makes of himself. The way expresses an attitude of approval or disgust of himself and includes the self-judgment regarding competence and value (Coopersmith, 1967 in Avanci, Assis, Santos & Oliveira, 2007). To Vaz Serra (1986), self-esteem is the most important facet of the self, lying evaluative aspects associated with the subject elaborates about them based on their abilities and performances. So, is linked to the phenomena of compensation or emotional imbalance of the individual. Self-esteem can be defined as the result of the value that a person assigns to the social and emotional elements of the representation that has about itself (Avanci, Assis, Santos & Oliveira, 2007; Feldman, 2002; Pedro & Peixoto, 2006). It is a subjective experience accessible to people through verbal reports and observable behaviors (Coopersmith, 1967; Rosenberg, 1989). The definition proposed by Coopersmith (1967) analyzes the self-esteem before four components: (a) power: the ability to influence and control others, (b) significant others: acceptance, attention and affection to others, (c) the virtue: moral and ethical principles that govern; (d) high and successful, taking place in an attempt to gather and look set goals and achieve high levels of excellence competence. According to this definition, self-esteem allows the subject to evaluate it yourself and give yourself a sense of value, through an attitude of approval or disapproval. Wells and Marwell (1976) consider that there are two types of self-esteem: (a) based on a sense of moral virtue or value, (b) and a sense of competence, power or effectiveness. Following the above, the construct of self-esteem can be evaluated according to three levels: low, medium and high. Low self-esteem is determined by feelings of incompetence, inadequacy, to life and inability to overcome challenges, high expresses a sense of confidence and competence, and the average is the middle ground between the sense of appropriateness or inappropriateness, manifesting this inconsistency in behavior (Rosenberg, 1956 em Avanci, Assisa, Santosa & Oliveira, 2007; Mruk (1995; Auerbach & Gardiner, 2012).

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Self-esteem and self-concept are often seen as synonymous, and are associated to the maximum enhancement of the capacities of the subject, are still essential for personal development from birth to end of life, as they are responsible for the relationship we build with us ourselves and with others, a broader reality (Rosselló, 1980; Solís, 1996; in Pecchorro, 2012), although these two concepts are distinct they complete each other: self-control refers to the cognitive level aspects of the subjects in relation to knowledge of self and yet at the trial that the subject elaborates on its way to be, and what we think what others think of us and also would like to be. Self-esteem is more related to cognitive aspects of knowledge of self-evaluative and affective aspects (Martinez, Rosello, & Alfonso, 2010). Self-esteem has been investigated as an important construct in the construction of self, and a way to feel self-worth, many times associated with maladaptive behaviors and healthy lifestyles, finding themselves associated with emotional stability (Brown, 2010; Boden, Fergusson & Harwood, 2007; Santos, 2006). Whereas low self-esteem associated with mental illness and psychopathology, such as depression and anxiety, and eating disorders (Polivy & Herman, 2002 cited by Santos, 2006). As regards the assessment of self-esteem according to gender differences, it is possible, according Bolognini, Plancherel, Pettschart & Halfon (1996) can be said that girls tend to have significantly lower levels of self-esteem than boys, whereas the levels of self-esteem are also reflected in significantly lower levels of humor, again in the case of girls. The global self-esteem of adolescents was analyzed by Walker & Greene (1985) taking into account two aspects of their daily lives, will be the first perception of the quality of relationships with parents and peer group refers, while the second is refers to its self-evaluation on their performance at school level and level of popularity.

659 Development of Self-esteem in adolescence According to Briggs (2000), self-esteem is not formed only in one phase of development, but ever built and subject to change, so the family and school background should be safe and confident to help you overcome life's difficulties more easily. Self-esteem is shown to be one of the factors with the greatest impact on the physical and social well-being as well as on the welfare of the subject in the developmental stage of adolescence (Heinonem, Raikkonen, Keskivaara, KeltikangasJarvinen, 2002). According to Erikson (1972) it is during adolescence that the construction of identity is central closely related to self-esteem, which is fundamental to the psychological and social adjustment (Antunes et al., 2006; Quiles & Espada, 2009) and the realization of the potential of the individual (Baumeister, 1993) during this developmental period. Self-esteem is a central dimension to successfully achieve identity in adolescence (Quiles & Espada, 2009). Erol & Orth (2011), Feliciano and Afonso (2012), Harter (1990) Robins, Trzesniewski, Tracy, Gosling and Potter (2002) consider that the study of development around self-esteem during adolescence is not consensual, however consider that there is a decrease when the child moves into adolescence.

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Some authors as Erol e Orth, (2011), Auerbach and Gardiner (2012) Birkeland, Melkevik, Holsen, Wold (2012) Jiménez, Murgui, Estévez e Musitu (2007) report that low self-esteem in adolescence and young adulthood is a risk and also a relevant factor for the negative results in several important domains of life In adolescence, the areas with a relevant role in building self-esteem include body image, acceptance of peer group, school performance, athletic competence and general behavior, in which the non-acceptance of social norms is often valued (Bizarro, 1999 citado por Lila, 2009). In general, children with high self-esteem are expected adolescents with high self-esteem, since according to Silva (2002), self-esteem increases significantly in the second decade of life, but this increase is preceded by a decline in early adolescence, associated with the rapid changes that are characteristic of puberty, often seen as uncontrollable by the adolescent, and the period in which there are greater fluctuations in self-esteem is about 12, 13 years of age.

Factors influencing self-esteem A review of the implications and effects of self-esteem is complex because it is influenced by a variety of individual and contextual characteristics. Antunes et al., 2006; Baumeister, Campbell, Krueger and Vohs (2003), Hutz, (2002) reported that the self-esteem is not correlated with high school performance, however, generally positive school results rise to a high self-esteem. I.e., self-esteem reveals itself as satisfaction with the good schools and the personal pride of the subject. On the other hand, the consequences of self-esteem may arise from the fact that life events or circumstances predict the results. Self-esteem is highly correlated to complex behaviors and forms (Emler, 2001). According to Branden

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(2002), "When self-esteem is low, often fear manipulates us. Fear of reality, to which we feel inadequate. Fear of the truths about ourselves - or on others - we have denied, rejected or repressed. Fear of the collapse of our pretenses. Fear of exposing ourselves. Fear of failure and humiliation, sometimes the responsibilities of success. We live more to avoid pain than to experience pleasure" (p. 77).

Parental Relationships and Self-Esteem Adolescence can be a great test for the teenager in regards to how you see yourself, at a time of major changes to the physical and emotional level. Rosenberg (1979 cited by Lila, 2009) confirms that adolescents who have closer relationships with their parents are more likely to have higher levels of self-esteem. Indeed, several empirical studies indicate that parental support, encouragement and affection are positively associated with the child's self-esteem (Walker & Greene, 1985). In the study by Peixoto (2004), the results reveal that the association between self-esteem and quality of family relationships undergoes some changes during adolescence, i.e., the quality of operation of some families who predictably would not have much chance of organization and relationship leads to feelings that arise efficacy and competence, creating a positive self-esteem.

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

A family atmosphere of dialogue and understanding, accompanied by an empathetic attitude reveals the development of a positive self-esteem and in this sense, the adoption of appropriate behaviors and adjusted (Jiménez, Murgui, Estévez & Musitu, 2007; Laible, Carlo & Roesch, 2004).

Self-esteem and antisocial and delinquent behaviors Several researchers who consider self-esteem as an important factor in the development of externalizing behaviors such as aggression, delinquency, and the adoption of antisocial behaviors, and many studies have confirmed the relationship between low self-esteem with externalizing behaviors as processes linking environment social and cultural, often resulting as a form of social protection (Donnellan, Trzesniewski, Robins, Moffitt, & Caspi, 2005; Mathias, Biebl, Dilalla, 2011; Baumeister, Campbell, Krueger, & Vohs, 2003 cited by Antunes et al., 2006). People with lower self-esteem have the greatest difficulties in dealing with situations of rejection than those who have higher self-esteem (Sommer & Baumeister, 2002; Gomide, 1998; Gabarino, 1999). Regarding the relationship of self-esteem with violent behavior, it is common for aggressive individuals with high selfesteem feel superior to others in some way and thus legitimize the use of violence (Mathias, Biebl & Dilalla, 2011). Baumeister, Jennifer, Campbell, Krueger e Vohs (2008), states that assessing the effects of self-esteem is complex due to several factors, among which the fact that many people with high self-esteem tend to exacerbate their successes and positive features making it more difficult to perception. According to Crocker, Brook, Niiya & Villacorta (2006), the fact that individuals are faced with failures and difficulties that often lead to strive in finding coping strategies and achieving goals, achieving positive results leads the individual to attain a high level of satisfaction for their effort to avoid failure and achieve a self-regulation that leads to increased self-esteem. Paradoxically adoption of risk behaviors may be a way of maintaining self-esteem, anchoring it in counterculture behaviors when their success in areas in need of social approval (Antunes et al., 2006; Donnellan, Trzesniewski, Robins, Moffitt, & Caspi, 2005; Mathias, Biebl & Dilalla, 2011; Boden, Fergusson & Harwood, 2007; Woessner & Schneider, 2013). Accordingly, the study accomplished by López, Ferrer and Ochoa (2005), aimed to analyze the differences in terms of self-esteem among adolescents with aggression problems at school. The sample consisted of these young people while aggressors and victims within the school context and the family, school, social and emotional dimensions were analyzed. Participated in research 965 adolescents aged between 11 and 16 years old. From the results it was concluded that there are differences between perpetrators and victims of violence. With regard to self-esteem, offenders have higher levels of social and emotional self-esteem, while the group of bullies have higher scores on I will respect the family and school self-esteem. Research carried out by Aguirre, Castillo e Zanetti (2010), aimed to investigate the relationship of self-esteem and alcohol consumption in adolescents, made for such a descriptive cross-sectional study with a sample of 109 students aged between 17 and 20 years, in which the Rosenberg self-esteem questionnaire was applied for the validation of global self-esteem. It was found that demonstrated almost all teenagers, having a high self-esteem, and none have demonstrated a low self-esteem.

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Iberian Journal of Clinical and Forensic Neuroscience â&#x20AC;&#x201C; IJCFN

Methodology Thus, based on the theoretical assumptions made, this work has as main objective to characterize the differences of the young profile with delinquent behavior in a sample of institutionalized youths protect an educational center, and investigate possible bidirectional relationship between this behavior and self-esteem, as well as the role of social desirability in the onset or maintenance of these behaviors.

Method The choice of a quantitative approach is related precisely with the fact that if you want to access the phenomenon by proximity to the context in which actors are embedded in what is currently its natural context, promoting direct contact, facilitating the emergence the attribution of meanings and references not standardized with respect to the studied phenomena. These investigations require by the researcher greater flexibility in the quest for data collection in the context you want to study.

Sample Selection According to the objectives and design previously presented some criteria for selecting participants, within individuals of both groups, were established; the selection of the sample depended on the number of participants in tutelary

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educational center, the second sample tried to be a reflection level it is essential that: a) All elements of the sample wanted to participate freely in research, b) Had aged 14 to 19 years c) Submit equivalent socio-educational and social characteristics d) Group 1 were under guardianship measures e) Group 2 had never filed criminal behavior nor have suffered any type of guardianship measures

The sample is divided into 2 groups, the first is composed of 33 individuals admitted to a tutelary Educational Center in the central region of the country (this is one of the nine institutions prepared to accommodate young offenders in particular inpatient operating in Portugal), the second group of 33 individuals selected from the normative sample, without any indication of criminal behavior.

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Sample Characterization Our sample consists of 66 young people (Table 1), all of the male gender, it appears that group 1, the youth education center (EC) has an average age of 16.55 years (SD = 1.175), on the other hand, the average age of group 2 is 16.13 (SD = 1.362) in both situations with the minimum of 14 and maximum of 19 years. Table 1 Characteristics of the sample according to age groups Age

Group 1 Group 2

Mean

SD

16.55

1.175

16.13

1.362

Minimum

Maximum

14

19

14

19

Following the characterization of the sample in relation to the environment, in accordance with the data presented in Table 2, it appears that the 1st group (educational center) most of the actors are from the urban areas (97%) and only the remaining (3.0%) of the sample resides in middle rural. Taking into account the data of the table in relation to the 2nd group does not appear as striking imbalance, so it appears that there is 59.4% originating from urban areas and the remaining 40.6% of the rural environment. Table 2 Characterization of the sample according to age, education, social environment (for groups) Group 1 n

Age

Education

Environment

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Group 2 N

%

14

1

3.0%

4

12.5%

15

5

15.2%

6

18.8%

16

11

33.3%

12

37.5%

17

8

24.2%

3

9.4%

18

7

21.2%

6

18.8%

19

1

3.0%

1

3.1%

1º Ciclo

28

84.8%

1

3.1%

2º Ciclo

2

6.1%

13

40.6%

3º Ciclo

3

9.1%

18

56.3%

Rural

1

3.0%

13

40.6%

32

97.0%

19

59.4%

Urbano

%

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Moreover, the level of education, subjects of group 1 have low levels of schooling: 28 attend the 1st cycle of basic education ( 84.8 % ), the remaining attending the 1st cycle (6.1%), and attending the 3rd CEB are three subjects ( 9.1 %) of the sample. The sample group 2 has a higher level of education, only 3.1 % have only the 1st CEB, 13 respondents are in the 2nd CEB, and the remaining in the 3rd CEB (59.4 %). Regarding parents' marital status (Table 3), 24 subjects are children of separated / divorced (72.7%) parents. Of the remaining 6 subjects have married parents (18.2%), and the situations in which the father or mother has died respectively represent (6.1 %), where the father had already passed away, and (3.0 %) if the mother have already died. Regarding the age at which the subjects were hospitalized the first time in Educational Center, there is an average age of 15 years, and the age at which the subjects were admitted mainly in the Education Center is located between 11 and 17 years. Table 3 Characteristics of the sample according to the family environment (for groups) Group 1

Parents Relationship

Problematic

Group 2

n

%

n

%

Married

1

3.0%

4

12.5%

Fact Union

5

15.2%

6

18.8%

Divorced

11

33.3%

12

37.5%

28

84.8%

1

3.1%

2

6.1%

13

40.6%

3

9.1%

18

56.3%

Alcoholism Addiction

664 Regarding how the subject will characterize the relationship with the mother most of the stands as good (42.4%), while as regards the relationship with the father-notes that most of the subjects (48.5%) turns out to have a bad relationship. As for the concern about the image that the subjects convey to others, almost the entire sample of subjects Education Center have revealed a high level of concern (90.0%) compared to the image you want to convey to others. Alcoholism seems to be the main problem that affects the family members of the subjects of criminal sample (45.5%), however, other reasons such as drug addiction (18.2%) were reported by the subjects (Table 3).

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Instruments Rosenberg Self-Esteem Scale (RSES) (Carvalho, 2009). Inventory of 30 items relating to delinquent behaviors, built by Lago (2009) The variable of aggression was operationalized through the Aggression Questionnaire (Buss & Perry, 1992 cited by (Vieira & Soeiro, 2002), adapted for the Portuguese population by Simões (1993). The Social Desirability Scale Marlowe-Crowne (Crowne Marlowe Social Desirability Scale) was originally designed to assess the tendency that some people have to make their qualities inflated or exaggerated, while minimizing their weaknesses, i.e., try to introduce themselves to be within the ideal norms of their society. Ballard (1992), taking the 33 dichotomous items of the original Marlowe-Crowne scale and a sample of 399 college students, built several short versions, with the most widespread in terms of use, consisting of 13 items, was known as composite subscale (MarloweCrowne Social Desirability Scale - Short Form - MCSDs-SF; Ballard, 1992).

Procedures The first stage of the procedure of this work consisted in the preparation of an application for authorization to carry out the academic study, sent simultaneously to the General Directorate of Social Welfare and the Director of the Educational Center were the data were collected. Authorization of Educational Center occurred in November 2012. Data collection started in January 2013; during the collection of informed consent, participants and tutelary guardians were informed about the content of this study, the confidentiality procedures and free choice of participate in the study. Statistical analyzes were performed and the resulting data analyzed using the Statistical Package for Social Sciences (SPSS), version 22, we proceed with the calculations required for descriptive and inferential statistics. In their descriptive statistics, frequencies, percentages, means and standard deviations of variables characterizing were calculated.

Results Table 4 presented the T-Test to verify that the mean of the two groups, educational and normative center, are significantly different considering the age and education of respondents. Accordingly, and once made this analysis we find that the only factor of importance is the education since the same is pvalue <0.001 and less than 0.05 in this manner. The age has values greater than 0.05 p.value, namely 0.187, then there are no significant statistical differences.

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Table 4 Compared to age and education of individuals. (T test) N

Mean

Standard Deviation

Group 1

33

16.55

1.175

Group 2

32

16.13

1.362

Group 1

33

1.24

0.614

Group 2

32

3.53

0.567

Age

Schooling

t

P

1.334

0.187

-15.601

<0.001

Regarding the Education we found that there is evidence of statistically significant differences between the average educational center (1.24) and the normative sample (3.53) average, thus concluding that the normative respondents not only give more importance to education and have higher education. The relative respondents of the educational center do not give that importance since they have a higher average having a value of -15 601 t. In Table 5, in relationship to schooling sample. We can check that only the scale of desirability has no statistically significant differences compared with schooling. As determined by one-way ANOVA on the scale of self-esteem (F = 4.039, p = 0.011), aggression (F = 3.231, p = 0.028) and delinquency (F = 25,131, p <0.001) and are less than 0, 05.

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Table 5 Scales vs Schooling level (ANOVA) Subject

N

Mean

Standard Deviation

1 cycle

28

25.00

4.489

2 cycle

3

16.33

14.224

3 cycle

16

24.38

2.849

secondary

19

25.37

1.862

1 cycle

28

5.93

2.433

2 cycle

3

5.67

1.528

3 cycle

16

5.75

1.528

19

5.05

1.129

Self - Esteem

Desirability

secondary

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F

P

4.039

0.011

0.842

0.476

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Iberian Journal of Clinical and Forensic Neuroscience â&#x20AC;&#x201C; IJCFN

1 cycle

28

74.11

19.027

2 cycle

3

98.00

38.974

3 cycle

16

82.75

6.170

secondary

19

83.05

7.268

1 cycle

28

73.61

19.401

2 cycle

3

59.67

21.502

3 cycle

16

44.00

16.829

secondary

19

54.89

2.104

Aggressiveness

Delinquency

3.231

0.028

25.131

<0.001

Analyzing measures of central tendency , we found that respondents who have secondary education level give more importance to self-esteem verifying that they actually have a higher level of self-esteem than other respondents since they have a higher average (25.37) compared to the other. Regarding the aggressiveness scale, we found that respondents are having only the 2nd cycle which give more importance to this scale, compared with the remaining respondents, since they have a higher average (98.00). Finally, the analysis of the scale of delinquency found that respondents are from the 1st cycle which give more importance to the crime, and the higher average (73.61).

In Table 6 it appears that the illegal activities versus schooling of our full sample may show that there is evidence of statistically significant differences between the mean of respondents who have been involved in illegal (1.26 ) and the mean activities of the respondents who have never engaged in illegal activities (3:40), thus concluding that respondents who have never engaged in illegal activities not only give more importance to education and higher education have relatively respondents who have been involved in illegal activities since they have an average above having a value t of -11 857 and p.value of < 0.001. Table 6 Illegal activities vs schooling - T TEST Illegal activities

N

Mean

Standard Deviation

Yes

31

1.26

0.631

No

35

3.40

0.812

Schooling

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T

P

-11.857

<0.001

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Comparing self-esteem versus social desirability (Table 7), it was found that the scale of self-esteem showed a statistically significant average of 24.56, SD = 4.565 and scale of social desirability showed mean 5.62, SD = 1.887, observing a big difference (t = -7060, p <0.001), with a mean difference of pairs was 18.94 and SD = 3.226.

Table 7 Self-esteem vs. Social desirability WILCOXON N

Mean

Standard Deviation

Self-esteem

66

24.56

4.565

Social desirability

66

5.62

1.887

Z

P

-7.060

<0.001

Comparing the age at first with illegal activities with the image (Table 8), it was found that respondents who were involved in illegal activities obtained an average of 11.96, SD = 1.990 and respondents who were not involved in illegal activities obtained a mean of 11.67e SD = 2.887, observing a large statistically significant difference (t = -4798, p <0.001), whereas the mean difference of pairs was 0.29 and SD = 2.439. Regarding the use of drugs, it appears that respondents who were involved in illegal activities obtained average 12.00, SD = 0.000, and respondents who have never been involved in illegal activities had a mean 11.93, SD = 2.069, with an average of difference pairs 0.07, SD = 1.035, verifying statistically significant differences (t = -4795, p <0.001).

668 Table 8 Age illegal activities vs image and psychiatric medications - WILCOXON N

Mean

Standard Deviation

Yes

27

11.96

1.990

No

3

11.67

2.887

Yes

1

12.00

0.000

No

29

11.93

2.069

Image

Medications

T

P

-4.798

<0.001

-4.795

<0.001

In Table 9, the T-test was applied in order to verify if the average of the two groups, educational and normative center, are significantly different considering the problems of respondents.

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Thus we find that there is evidence of statistically significant differences between the average educational center (2.55) and the normative sample (4.00) average since the p value is <0.001, thus concluding that the normative respondents have fewer problems than respondents educational center as they have an average top and having a t value of -7111. As can be seen by the standard deviation (0.000) and mean (4.00) has no normative individual problems, be they drug addiction, alcoholism or depression while in respondents from the educational center just 36% did not have any problem.

Table 9 Family problems (drugs, alcoholism) vs Subjects - T TEST Subjects

N

Mean

Standard Deviation

Education Center

33

2.55

1.175

Normal

33

4.00

0.000

Problems

T

P

-7.111

<0.001

As can be seen from Table 10, compared the drugs that respondents versus subjects taking the educational and normative center verified that there are no significant statistical differences since the p value is greater than 0.005,

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namely (F = 1.000, P = 0.321) . Regarding Physical Aggression Scale, it was found that respondents from the education center had an average of 22:41, SD = 8,348 respondents obtained and the normative average of 21:15, SD = 3.337, observing a large statistically significant difference (t = - 2.233, p = 0.026), with a mean difference of pairs was 1.26 and SD = 5.843.

Table 10 Psychiatric medications vs subjects - ANOVA Subjects

N

Mean

Standard Deviation

Education Center

33

1.97

0.174

Medications Normal

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33

2.00

F

P

1.000

0.321

0.000

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In Table 11 it appears that, as the verbal aggressiveness scale, the educational center obtained average 11:29, SD = 2.312, and the normative subjects had an average of 12:48, SD = 1.503, with a mean difference of pairs of -1 19, SD = 1.908, verifying statistically significant differences (t = -2625, p = 0.009). In irritability, the educational center, got an average of 20.86, SD = 4,468 and regulatory subjects achieved average 22:45, SD = 2.526, and there was no statistically significant differences. In relation to hostility, the educational center, got an average of 20.14, SD = 3.819, and the normative subjects had a mean 20.64, SD = 2.655, with a mean difference of -0.5, SD = 3.237, and there were no statistical significant differences.

Table 11

Factors aggression vs subjects - TEST SIGNALS N

Mean

Standard Deviation

Educational Center

33

22.41

8.348

-2.233

0.026

Normal

33

21.15

3.337

-1.044

0.296

Educational Center

33

11.29

2.312

-2.625

0.009

Normal

33

12.48

1.503

-1.591

0.112

Educational Center

33

20.86

4.468

-1.125

0.261

Normal

33

22.45

2.526

-1.591

0.112

Educational Center

33

20.14

3.819

-0.248

0.804

Normal

33

20.64

2.655

-0.530

0.596

Z

P

Physical Assault

Verbal Aggression

Irritability

Hostility

With regard to negative self-esteem scale (Table 12), it was found that respondents from the education center had an average of 9.79 and SD = 3.542 and normative respondents had an average of 9:06, SD = 1.767, observing a large statistically significant difference (t = -2089, p = 0.037 and t = -2652, p = 0.008), whereas the mean difference of pairs was 0.73 and SD = 2.655. As for positive self-esteem scale, the educational center obtained average 14:18, SD = 4.019, and the normative subjects had average 16:09, SD = 1.721, with a mean difference of -1.91 pairs, SD = 2.87, not checking statistically significant differences.

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Table 12

Factors vs. self-esteem subjects - TEST SIGNALS

Negative Self Esteem

Positive Self Esteem

N

Mean

Standard Deviation

Educational Center

33

9.79

3.542

-2.089

0.037

Normal

33

9.06

1.767

-2.652

0.008

Educational Center

33

14.18

4.019

-0.718

0.472

Normal

33

16.09

1.721

0.000

1.000

Z

P

Discussion Studies on the etiology of delinquent behavior seem to have acquired a new interest by researchers, partly in an attempt to understand the characteristics and profile of the population of interest, on the other hand by media projection that the last decade has shown. In a way these studies generally aim to derive data for the general population and enhance existing prevention programs to respond to the real needs of the individuals who comprise them. Based on the analysis of the results was performed earlier, a major objective would be to identify the profile of the youth with behavior problems, specifically the young offender. Thus, in this study, in relation to delinquent behavior, it appears that there is a greater tendency, and individuals with low education, changes in family dynamics and previous exposure to risk factors. The data corroborate other studies that report that during the transition period between childhood and adolescence begins the period of self-assertion and family rupture (Martins e Pillon, 2008) emerging at around 14 years of age the propensity for delinquent activity (Caspi, 2000; Loeber, & Farrington, & Waschbusch, 1998; Moffit, 1993), having the period between adolescence and emerging adulthood, i.e., between 17 and 25 years old, a new peak of delinquent activity (Lemos et al., 2006; Lomba, 2006), increasing prevalence with increasing age (Coon & Mitterer, 2008; Reich et al., 2010; Lomba et al., 2011). The data presented corroborate the study by Elliott and Huizinga (1980) showing that the socioeconomic environment influences the appearance of this type of behavior, but are not entirely confined to one social class (Formiga & Gouveia, 2005) the media coverage of cases, makes visible the participation of young people from middle and upper classes, this way the offenders and / or antisocial behavior cannot be attributed solely on the basis of an indicator is the socioeconomic status, family counseling or in terms of social exclusion.

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Zuckerman and Kuhlman (2000), which concluded family or agents of primary socialization commit failures in the transmission of values, seeming to assume the role of disinhibition of alcohol and drugs, and seem to have a leading role in engaging in risky behaviors (Hayaki et al., 2006; Lomba, 2006; Bellis & Hughes, 2004; Calafat, Juan, Becoña, & Mantecón, 2008) The emotional, affective and personal development (self-esteem) changed that may arise during the development state (Reich et al, 2010; Monteiro et al, 2009), according to the literature, may potentiate the delinquent or deviant behavior, looking at this disinhibiting effect that they can trigger. However, the data do not allow us to infer that there is a direct relationship between self-esteem and delinquent behavior while maintaining many authors doubt about who assumes the role of cause and consequence despite relational data do not allow us to conclude a relationship between the two factors, we find that the values of self-esteem presented by admitted protect individuals in the education center (group 1) present below the negative group indices, seeming to corroborate other studies by Erol e Orth, (2011), Auerbach e Gardiner (2012) Birkeland, Melkevik, Holsen, Wold (2012) Jiménez, Murgui, Estévez e Musitu (2007), which emphasize their low levels during adolescence as well as reveal a physical and mental health, seems to be a strong indicator of a greater predisposition to criminal activity. The link between global self-esteem and aggression (another factor studied) is defended by several referenced authors (Donnellan, Trzesniewski, Robins, Moffitt, & Caspi, 2005; Mathias, Biebl & Dilalla, 2011; Boden, Fergusson & Harwood, 2007; Woessner & Schneider,2013) that a self-esteem enhances externalizing problems of the real world, such as delinquency and antisocial behavior, we found that individuals with low self-esteem have higher rates of aggression and equally note the presence of some delinquent behaviors. In several dimensions the studied sample revealed significant differences in aggression, delinquency, social desirability, self-esteem factors as well as the level of parental relationships. A share of work done in the field of crime and of the above factors highlight that offenders subject tend to reveal a personal history marked by changes in family structure, either as a severely this figure either absent or lax in monitoring child development (Andry, 1960; Berzansky, 1981). This is often accompanied by family maladjustment aggression and delinquent behaviors (Peixoto, 2004). The present study has some limitations, among which the restriction of the sample to a tutelary educational establishment would therefore pertinent that the study should extend to other establishments, looking this way develop a delinquent and particularly the risk profile coming to be so. On the other hand, the second group, despite having a balance between urban and rural areas is also limited to one area of the country, within the center, thus not allowing to generalize the data, and compares them with other young coast, however we believe it would be interesting to extend the geographical areas. Thus, a longitudinal study may be an asset in order to verify the integration of young people after the frequency of the educational center in the society as well as the influence of this, the attitude towards diversion, dissipation of maladjusted or delinquent behavior, and the likelihood of acquiring behavior emerge new deviant behavior.

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