ISSN 0103-863X
GRADUATE PROGRAM IN PSYCHOLOGY FACULTY OF PHILOSOPHY, SCIENCES AND LETTERS AT RIBEIRﾃグ PRETO UNIVERSITY OF Sﾃグ PAULO
VOLUME ISSUE MAY/AUGUST
26 64 2016
Paidéia
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Paidéia Volume 26, Issue 64, May-August 2016 CONTENTS
Articles Consistencies and Discrepancies in Communication Between Parents and Teenage Children About Sexuality Consistências e Discrepâncias na Comunicação Sobre Sexualidade Entre Pais e Filhos Adolescentes Congruencias y Discrepancias en la Comunicación Sobre Sexualidad Entre Padres e Hijos Adolescentes Teresita María Sevilla, Juan Pablo Sanabria, Linda Teresa Orcasita, Diana Marcela Palma Pontificia Universidad Javeriana de Cali, Cali, Colombia
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Portuguese Older Gay Men: Pathways to Family Integrity Homens Idosos Homossexuais Portugueses: Caminhos Para a Integridade Familiar Hombres Gay Mayores Portugueses: Vías Para Acceder a la Integridad Familiar Filipa Daniela Marques - Instituto Politécnico de Coimbra, Coimbra, Portugal Liliana Sousa - Universidade de Aveiro, Aveiro, Portugal
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Interpersonal Conflicts Among Family Caregivers of the Elderly: The Importance of Social Skills Conflitos Interpessoais no Cuidado de Idosos: Importância das Habilidades Sociais do Cuidador Conflictos Interpersonales en el Cuidado de Personas Mayores: La Importancia de las Habilidades Sociales del Cuidador Francine Náthalie Ferraresi Rodrigues Pinto, Elizabeth Joan Barham, Zilda Aparecida Pereira Del Prette Universidade Federal de São Carlos, São Carlos-SP, Brazil
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Psychometric Analysis of Disordered Eating in Sports Scale (DES) Análise Psicométrica da Escala de Atitudes Alimentares no Esporte (EAAE) Análisis Psicométrico de la Escala de Actitudes Alimentarias en el Deporte (EEAD) Leonardo de Sousa Fortes - Universidade Federal de Pernambuco, Vitória de Santo Antão-PE, Brazil Sebastião de Sousa Almeida - Universidade de São Paulo, Ribeirão Preto-SP, Brazil Maria Elisa Caputo Ferreira - Universidade Federal de Juiz de Fora, Juiz de Fora-MG, Brazil
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Self-Compassion in Relation to Self-Esteem, Self-Efficacy and Demographical Aspects Autocompaixão e Suas Relações com Autoestima, Autoeficácia e Aspectos Sociodemográficos Autocompasión y Sus Relaciones con Autoestima, Autoeficacia y Aspectos Sociodemográficos Luciana Karine de Souza, Claudio Simon Hutz Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
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Bayley-III Scales of Infant and Toddler Development: Transcultural Adaptation and Psychometric Properties Escalas Bayley-III de Desenvolvimento Infantil: Adaptação Transcultural e Propriedades Psicométricas Escalas de Desarrollo Infantil Bayley-III: Adaptación Transcultural y Propiedades Psicométricas Vanessa Madaschi - Universidade Presbiteriana Mackenzie, São Paulo-SP, Brazil Tatiana Pontrelli Mecca - Centro Universitário FIEO, São Paulo-SP, Brazil Elizeu Coutinho Macedo - Universidade Presbiteriana Mackenzie, São Paulo-SP, Brazil Cristiane Silvestre Paula - Universidade Presbiteriana Mackenzie, São Paulo-SP, Brazil
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Validity Evidence of the Z-Test-SC for Use With Children Evidências de Validade do Zulliger-SC Para Uso com Crianças Evidencia de Validez de la Prueba Zulliger-SC Para Uso con los Niños Anna Elisa de Villemor-Amaral, Pâmela Malio Pardini Pavan - Universidade São Francisco, Itatiba-SP, Brazil Raquel Rossi Tavella - Centro Universitário Nossa Senhora do Patrocínio, Itu-SP, Brazil Lucila Moraes Cardoso - Universidade Estadual do Ceará, Fortaleza-CE, Brazil Fabiola Cristina Biasi - Universidade São Francisco, Itatiba-SP, Brazil
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Parental Stress and Social Support of Caregivers of Children With Cerebral Palsy Estresse Parental e Suporte Social de Cuidadores de Crianças com Paralisia Cerebral Estrés Paternal y Soporte Social de Cuidadores de Niños con Parálisis Cerebral Mayara Barbosa Sindeaux Lima, Vagner dos Santos Cardoso, Simone Souza da Costa Silva Universidade Federal do Pará, Belém-PA, Brazil
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Visual-Motor Maturity and Executive Functions in Schoolchildren Maturidade Visomotora e Funções Executivas em Escolares Madurez Visomotora y Funciones Ejecutivas en Escolares Ana Luisa Silva de Oliveira, Vanessa Kaiser, Thamy de Oliveira Azambuja, Laura Uberti Mallmann, Janice Luisa Lukrafka, Caroline Tozzi Reppold Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre-RS, Brazil
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Emotional and Behavioral Problems in Children Living With Addicted Family Members: Prevention Challenges in an Underprivileged Suburban Community Problemas Emocionais e Comportamentais de Crianças que Convivem com Familiares Dependentes Químicos: Desafios de Prevenção em uma Comunidade Suburbana Desfavorecida Problemas Emocionales y de Comportamiento en Niños que Viven con Familiares Adictos: Desafios de Prevención en una Comunidad Suburbana Desfavorecida Thaís dos Reis Vilela, Rebeca de Souza Silva, Camila Garcia Grandi Universidade Federal de São Paulo, São Paulo-SP, Brazil Marina Monzani Rocha - Universidade Presbiteriana Mackenzie, São Paulo-SP, Brazil Neliana Buzi Figlie - Universidade Federal de São Paulo, São Paulo-SP, Brazil
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Aggressive Behavior of Children in a Daycare Center Comportamento Agressivo de Crianças em um Centro de Educação Infantil Comportamiento Agresivo de Niños en una Guardería Sidnei Rinaldo Priolo Filho, Henrique Mesquita Pompermaier, Nancy Vinagre Fonseca de Almeida, Débora de Hollanda Souza Universidade Federal de São Carlos, São Carlos-SP, Brazil
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Assessment of Patient, Family and Staff Satisfaction in a Mental Health Service Avaliação da Satisfação dos Pacientes, Familiares e Profissionais com um Serviço de Saúde Mental Evaluación de la Satisfacción de los Pacientes, Familiares y Profesionales con un Servicio de Salud Mental Kênia Izabel David Silva de Resende, Marina Bandeira, Daniela Carine Ramires Oliveira Universidade Federal de São João del-Rei, São João del Rei-MG, Brazil
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Uncovering Interaction Structures in a Brief Psychodynamic Psychotherapy Desvelando Estruturas de Interação em uma Psicoterapia Psicodinâmica Breve Descubriendo Estructuras de Interacción en una Psicoterapia Psicodinámica Breve Fernanda Barcellos Serralta - Universidade do Vale do Rio dos Sinos, São Leopoldo-RS, Brazil
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Publication Guidelines
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Paidéia may-aug. 2016, Vol. 26, No. 64, 139-147. doi:10.1590/1982-43272664201601
Article
Consistencies and Discrepancies in Communication Between Parents and Teenage Children About Sexuality1 Teresita María Sevilla2 Pontificia Universidad Javeriana de Cali, Cali, Colombia
Juan Pablo Sanabria Pontificia Universidad Javeriana de Cali, Cali, Colombia
Linda Teresa Orcasita Pontificia Universidad Javeriana de Cali, Cali, Colombia
Diana Marcela Palma Pontificia Universidad Javeriana de Cali, Cali, Colombia
Abstract: The family is one of the most important socializing agents in adolescent sex education. However, multiple barriers to communication within families have been identified. Therefore, this study aimed to characterize and understand the processes by which parents and their adolescent children communicate about sexuality. Two questionnaires were completed by 711 fathers/ mothers and 566 male/female students in 21 schools in Cali (Colombia), and 15 discussion groups were formed. The results showed that conversations about sexuality focused on protection for women and on sexuality promotion for men. Furthermore, it was found that greater fluency exists in father/son and mother/daughter conversations. The largest discrepancy between parents and teenagers was the adults’ belief that it is sufficient to mention certain topics in a directive manner and the children’s expectations that parents will discuss the value and dynamics of the sexual experience. Embarrassment and lack of communication tools hinder communication processes. Keywords: family, sexuality, communication, adolescence
Consistências e Discrepâncias na Comunicação Sobre Sexualidade Entre Pais e Filhos Adolescentes Resumo: A família é um dos principais agentes de socialização na formação da sexualidade adolescente. No entanto, diferentes barreiras de comunicação são identificadas. Esta pesquisa tem por objetivo caracterizar e compreender os processos de comunicação sobre sexualidade entre os pais e seus filhos adolescentes na cidade de Cali, Colômbia. Dois questionários foram aplicados a 711 pais/ mães e 566 alunos homens/mulheres em 21 escolas em Cali (Colômbia). Foram também conduzidos 15 grupos focais. Foram encontrados discursos de proteção sobre a sexualidade, no caso das mulheres, e incitamento para os homens. Foram relatadas mais frequentemente as conversas entre pai/filho do que entre mãe/filha. A principal discrepância é que os adultos consideram que é suficiente apresentar de maneira imperativa alguns tópicos, enquanto os seus filhos/as esperam discussões reais sobre valores e dinâmicas da experiência sexual. A vergonha e a falta de ferramentas de comunicação impedem estes processos. Palavras-chave: família, sexualidade, comunicação, adolescência
Congruencias y Discrepancias en la Comunicación Sobre Sexualidad Entre Padres e Hijos Adolescentes Resumen: La familia es uno de los agentes socializadores más importantes para la formación en sexualidad de los adolescentes. Sin embargo, se han identificado múltiples barreras en los procesos de comunicación. Por este motivo, esta investigación tuvo como objetivo caracterizar y comprender los procesos de comunicación en sexualidad entre los padres de familia y sus hijos adolescentes en la ciudad de Cali, Colombia. Se aplicaron dos cuestionarios a 711 padres/madres de familia y 566 estudiantes hombres/mujeres en 21 colegios de Cali (Colombia) y se desarrollaron 15 grupos de discusión. Se encontraron discursos de protección frente a la sexualidad hacia las mujeres y de incitación hacia los hombres. Además, se identificó que existe mayor fluidez en las conversaciones entre padre/hijo y madre/hija. La mayor discrepancia es que los adultos consideran suficiente mencionar de manera directiva ciertos temas, mientras que sus hijos/as esperan discusiones en torno a valores y dinámicas de la experiencia sexual. La vergüenza y falta de herramientas de comunicación dificultan estos procesos. Palabras clave: familia, sexualidad, comunicación, adolescencia This article is part of a study entitled “Characterization of social knowledge, attitudes, practices, and meanings present in sexual communication processes between parents and adolescent children in two Colombian cities”. Support: This study is financed by the Office of Research, Development, and Innovation, Pontificia Universidad Javeriana, Cali (Protocol n. 020100298). 2 Correspondence address: Teresita María Sevilla. Pontificia Universidad Javeriana de Cali. Facultad de Humanidades y Ciencias Sociales. Calle 18 n. 118-250. Cali, Colombia. E-mail: tsevilla@javerianacali.edu.co 1
Available in www.scielo.br/paideia
Adolescence is a period in which biological, psychological, and social changes put youth at risk for sexually transmitted diseases (STDs) and unplanned pregnancies that compromise their sexual health and quality of life (Lavielle-Sotomayor et al., 2014). In Colombia, according to the 2010 data obtained by the Demographic and Health Survey (Encuesta Nacional de Demografía y Salud
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[ENDS]), only 52% of women who had become sexually active used condoms, and 61% of women between the ages of 15 and 24 had sexual intercourse before the age of 18 (Profamilia, 2010). Although a decrease in the adolescent pregnancy rate was identified, it is still estimated that this figure is approximately 20% (Profamilia, 2010). According to recent reports provided by Profamilia (2010), adolescents who become sexually active possess general knowledge about Sexual and Reproductive Health (SRH), but gaps in their knowledge prevent self-care. One of these gaps is ignorance about the functions of social networks in providing information, emotional support, and material support. These functions allow social networks to respond to the high demand created by the concerns that arise during the sexual exploration and sexual experiences that are typical of the adolescent stage of development (Sevilla & Orcasita, 2014). Studies have found that some of the barriers to accessing health services and communicating with support networks include discomfort talking about sexuality, fear that the information could reach parents, limited negotiation skills, and the perception of these spaces as unfriendly (Regmi, van Teijlingen, Simkhada, & Acharya, 2010; Sevilla & Orcasita, 2014). Researchers such as UrreaGiraldo, Congolino, Herrera, Reyes, and Botero (2006) have identified differences in access to health care based on gender, reporting that adolescent females are more likely to access these resources. Family is one of the most important socializing and educational agents in sex education because life lessons and behavior patterns are learned in the family context (M. Montañés, Bartolomé, J. Montañés, & Parra, 2008; Orcasita & Sevilla, 2014; Uribe & Rodríguez, 2014). Thus, it has been found that adolescents’ perception of emotional closeness with their parents determines how they communicate about sex-related topics and influences their decision making (Barrera & Vargas, 2005). Additionally, it was found that parents’ main barriers to talking about sexuality include their feelings of discomfort when addressing the topic (Seloilwe, Magowe, Dithole, & Lawrence, 2015); parents’ fear of embarrassing their children (Jones, 2010); lack of knowledge about the characteristics of contemporary sexual life and their children’s forms of communication (Sevilla & Orcasita, 2014); and the perception that their children are too young to receive sex education (Elliott, 2010). Adolescents, in turn, perceive that sexuality is a personal topic that should not be discussed with their parents. This assumption of independence in adolescents is presented as one of the most outstanding discrepancies between parents and children (M. Montañés et al., 2008). However, protective factors are more prevalent among youth who experience more family acceptance and better family dynamics (Lavielle-Sotomayor et al., 2014). Some studies have found that the topic of sexuality is approached differently depending on the sex of the child and of the parent. Women are more likely to talk about the topic with their parents, especially with their mothers, than men (Jones, 2010; Kapungu et al., 2010). Although previous studies have established that parent-child communication
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about sexuality is limited, abstinence, menstruation, and prevention of sexually transmitted diseases have been identified as the topics most often addressed by parents (Manu, Mba, Asare, Odoi-Agyarko, & Asante, 2015). When discussing abstinence, female sexual activity is represented as rational only when the relations are based on love and a stable partnership (Jones, 2010). When this topic is broached with male children, the bond with their partner and the necessary motivation for becoming sexually active are not emphasized; rather, it is more common for them to be given condoms, implying approval and encouragement to initiate sexual activity (Jones, 2010). Seloilwe et al. (2015) emphasized that these conversations are based on characteristics of practices and do not reflect the values or motivations associated with lived experience of those practices. It is necessary to recognize two characteristics that shape adolescents’ current approach to sexuality. The first aspect is the diversity of family type, leading to diversity in the specific dynamics, forms of communication, norms, standards, and levels of cohesion that permeate sex education within the family (M. Montañés et al., 2008). These families include (a) traditional nuclear families consisting of a married couple and, typically, children; (b) blended families formed by family ties that are not necessarily biological (stepmother, stepfather, stepson/stepdaughter, stepbrothers/stepsisters); and (c) singleparent families, that is, a family in which only the father or mother is present as a consequence of death, separation/ divorce, abandonment, etc. (Agudelo Bedoya, 2005). Second, although there are gender and cultural differences in the way the topic is addressed, it has been found that parents are not the main source of information about sexuality for adolescents (Manu et al., 2015). However, the information about sexuality provided by peers and the media, whether due to ease of access or proximity, can be stereotyped, inaccurate, and encourage the creation of distorted representations (Martino, Collins, Elliott, Kanouse, & Berry, 2009; Regmi et al., 2010). According to Sevilla and Orcasita (2014), sexual initiation and the use or nonuse of condoms in adolescence are more related to friends’ attitudes than to messages promoted by parents. It is essential to emphasize that new information technologies allow adolescents to interact, explore, and easily access information and resources about sexuality. These new possibilities indicate the necessity of considering the new approaches to knowledge about sexuality in this population and invite us to rethink the potential social and health implications (Wolak, Finkelhor, & Mitchell, 2012). Therefore, this study aimed to characterize and understand the sexual communication processes that occur between parents and their adolescent children in the city of Cali, Colombia. Furthermore, the consistencies and discrepancies between the type and content of these educational practices were analyzed based on parents’ reports and children’s perceptions. Consistencies were defined as similarities in the topics, knowledge, practices, and meanings that parents and children reported; discrepancies were the differences identified. This study also included traditional nuclear, single-parent, and blended families to study the
Sevilla, T. M., Sanabria, J. P., Orcasita, L. T., & Palma, D. M. (2016). Parent-Child Communication About Sexuality.
consistencies and discrepancies in gender discourses linked to sexual communication processes.
This study was conducted using a mixed methods approach. This approach allows methodological triangulation and facilitates the study of the general trends and particular details of the population’s processes, thus enriching the perspective provided by the contributions and scope of each design component (Bergman, 2011).
different parts of the city). These groups included participants who, during the quantitative component, expressed interest in participating in this phase. The qualitative data collection facilitated the exploration of common values and comparison of similar cases and investigation of the proposed categories (concepts associated with sexuality, sources and content of information about sexuality, and communication process characteristics) based on the perspectives and experiences of the participants themselves – their feelings, meanings, and senses, taking their perspectives and language into consideration (Bonilla-Castro & Rodríguez Sehk, 1997).
Participants
Procedure
The sample comprised 566 students (315 women and 251 men) between the ages of 11 and 20 (M = 14.7; SD = 1.6) from 21 private (46.7%) and public (53.3%) educational institutions in the city of Cali. In addition, 711 parents of students participated (540 mothers and 171 fathers); the adults’ ages ranged between 21 and 78 years (M = 42.2; SD = 8.0). In terms of socio-economic status, according to the national system for socio-economic stratification, 53.8% of the participating families belonged to the lower class (strata 1 and 2), 29.1% to the middle (strata 3 and 4), and 17% to the upper class (strata 5 and 6). It was found that 37.3% of mothers were homemakers, while only 4.8% of fathers did this type of work. A total of 34.7% of fathers were stable employees, and 40.3% were self-employed; these percentages are lower among the mothers. School selections were performed randomly using a database provided by the city’s Secretariat of Municipal Public Health (Secretaria de Salud Pública Municipal [SSPM]).
Data collection. In the quantitative phase, a pilot test of the instruments was performed, and the personnel responsible for data collection were trained. The questionnaires were distributed, first to the parent group and subsequently to their children, in institutional spaces designed for this purpose and after obtaining informed consent. For the qualitative phase, the participants who had expressed interest in attending the discussion groups were contacted. The parent discussion groups, conducted in each of the five areas of the city, included five to seven participants each. The aim was to work with mixed groups (fathers and mothers), and couple participation was allowed. Two student discussion groups of five to seven participants (men and women) were organized in each of the five areas of the city. Discussion was guided by a moderator (principal investigator) and was supported by a rapporteur (research assistant) who was responsible for audio recording the session (with prior participant consent). Data analysis. Data processing was supported by quantitative (SPSS V17) and qualitative (ETHNOGRAPH V 5.0) analysis software. Quantitative data were derived from descriptive and interpretative analyses (correlations). To identify the consistencies and discrepancies between parents’ and children’s responses, parent-children dyads were analyzed in a nested manner using the non-parametric Wilcoxon test. The main trends discovered during the quantitative component were taken into account in the preparation of the final version of the discussion group guidelines to enable the in-depth study and interpretation of the complex symbolic levels represented by the numerical figures. The qualitative data analysis followed a procedure involving organization, segmentation, and correlation, after which the initial concise transcription and coding was performed for each segment, followed by work on the various analytic categories. The final step involved the construction of the final analysis, in which in the triangulation of the quantitative and qualitative data was governed by the central research question.
Method
Instruments Quantitative data collection was performed by distributing two questionnaires: the Knowledge, Attitudes, Practices, and Social Meanings Questionnaire (Sevilla & Orcasita, 2014), designed specifically for this research study, and the Confidential Questionnaire of Sexual Activity (Cuestionario Confidencial sobre Vida Sexual Activa [CCVSA]; Ministerio de Salud, 1997), which has been validated in previous studies. In this article, the data collected from the first instrument is presented. This instrument possesses the following characteristics: Knowledge, Attitudes, Practices, and Social Meanings Questionnaire (Sevilla & Orcasita, 2014). This questionnaire contains 47 questions designed to explore the main practices used in sexual communication processes between parents and children. The questions gather data about (a) demographic information, (b) family communication about sexuality, (c) sexual educational practices, and (d) family dynamics. The response format was multiple choice. Prior to distribution to study participants, the instrument was reviewed by a panel of three expert judges responsible for the validation and approval of its use (validation by judges). Qualitative data were collected from 15 discussion groups (10 with youth and five with fathers/mothers from
Ethical Considerations This study was guided by the scientific, technical, and administrative standards for health research in effect at the national level under Ministry of Health resolution n. 008430 (1993), which regulates research involving human subjects. In the case of research involving minors, an informed consent form must be signed and a guardian’s consent must also be given.
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Results Sources of Information About Sexuality Reported by Adolescents and Parents The results showed that adolescents obtain information about sexuality primarily from family members (men: 44.9%; women: 52.9%), friends (men: 34.8%; women: 39.4%), and health professionals (men: 27.5%; women: 37.1%). In contrast, the least consulted sources were neighbors (men: 2.8%; women: 2.3%), radio programs (men: 6.5%; women: 5.8%), and the Church (men: 6.1%; women: 6.8%). The sources most frequently reported by parents were health professionals (fathers: 41.1%; mothers: 47.9%), television shows (fathers: 40.2%; mothers: 41.9%), and the Internet (fathers: 29%; mothers: 24.8%). The least consulted sources were neighbors (fathers: 0%; mothers: 1.3%) and the Church (fathers: 15.9%; mothers: 10.2%). The qualitative data detailing the spaces and direct sources through which information about sexuality is acquired coincide with the numerical data in indicating that the most significant education about values and guiding principles is received through direct interactions with peers and family members. Adolescent males perceive that there is a greater emphasis on formal preventative accounts about sexuality than on relational and emotional aspects. For adolescent males, it is clear that parents want to prevent early pregnancy. This is communicated not only in open and detailed conversations with fathers but also through specific actions, such as dispensing condoms. Mothers, in contrast, talk to male children in terms of personal care, their life plan, and maintaining control over their futures. One adolescent male remarked, “at home, my dad is mainly the one who says that you have to be careful, about all the women he’s had children with (...) He’s made a lot of mistakes having children like that. So, protection”. Adolescent females consider their parents, their friends, and health services as their primary sources of information. Their conversations with their fathers, which are based on their masculine experience and a sense of protection towards vulnerable women, differ from their conversations with their mothers, which are more directive and focus on values and morals. Health services are perceived as places in which one can ask open questions and receive both guidance and direct support with planning. As one adolescent female commented, “(...) I think that you learn the most from your friends and also if you want to know something, you can look it up on the Internet”. For participating mothers, discussions about access to information included both the education they received as adolescents and the information they seek and receive now that they are mothers. Such information typically includes matters related to intimacy and female conversation. The father’s presence was remembered as directive and aimed at preventing “something evil” that was not identified. The permanent idea that “you should be careful” was not broken down into specific dangers or controllable situations but remained vague and generic, producing anxiety regarding
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intimacy and the body. At other times, the mothers remembered that their own mothers referred to negative events that they had experienced to draw general conclusions that sexuality and interaction with the opposite sex should be avoided. One mother reported, “when I was 10 years old, which was when my period started, that was a dilemma because nobody had talked to me about that; when my period came, how frightening! Because it started when I was sleeping and I almost died when I got up”. In their experience as mothers, most of the women claim to have sought information at school or from health institutions. However, for most of them, this knowledge was not as valued as having clear principles with which they could educate their daughters. Some participants described strategies they had developed to educate their daughters with accurate information, while others preferred to tell their daughters to get information at school or from health institutions. Mothers with sons had difficulty recognizing what their sons needed to know, indicating knowledge gaps and a lack of clarity about available resources. Sexual Communication Dynamics Between Children and Parents Overall, adolescents reported less difficulty talking to the parent of their same sex. Approximately 76% of adolescent males reported difficulty talking to their mothers and 63% to their fathers, while 64.1% of the adolescent females reported such difficulties with their mothers and 86.5% with their fathers. Generally, adolescent males and females reported that they do not talk to their parents about this topic primarily because it embarrasses them (with their fathers: 37.3%; with their mothers: 45.1%), they do not trust their parent enough (with their fathers: 27.4%; with their mothers: 20.4%), or they do not know how to address the topic (with their fathers: 12.9%; with their mothers: 18.8%). From the parents’ perspective, 13.1% have difficulty talking about sexuality with their children, and 36.3% sometimes have difficulty talking about these topics. Nevertheless, there is a greater percentage of mothers (51.5%) who do not have difficulty talking to their children about sexuality than fathers (46.5%). The main reasons for this difficulty are that they do not know how to address the topic (34.5%) or it embarrasses them to talk about it (11.9%). Topics Addressed in Conversations About Sexuality The adolescents reported that they talk to their mothers more frequently than to their fathers. The most frequent sexuality-related topics discussed with their parents included partner relationships (with their fathers: 55.2%; with their mothers: 78%), self-care (with their fathers: 51.0%; with their mothers: 72.4%), faithfulness (with their fathers: 44%; with their mothers: 71.8%), and sexual prevention (with their fathers: 72.4%; with their mothers: 71.8%). The topics least discussed with their parents were sexual relations, including vagina to vagina (with their fathers: 4.6%; with their mothers: 8.7%), anal (with their fathers: 6.9%; with
Sevilla, T. M., Sanabria, J. P., Orcasita, L. T., & Palma, D. M. (2016). Parent-Child Communication About Sexuality.
their mothers: 11.1%), and oral (with their fathers: 7.7%; with their mothers: 13.2%). On average, fathers talk about 13.7 topics with their sons (SD = 7.2) and 13.6 topics (SD = 7.4) with their daughters, a difference that is not statistically significant (p = .98). Similarly, though mothers talk about approximately one more sexuality topic with their daughters (M = 15.4; SD = 6.1) than with their sons (M = 14.1; SD = 6.6); this difference is not significant (p = .095). However, the differences for sons and daughters were significant. Adolescent males reported talking to their mothers about 10.2 topics on average (SD = 6.2), and females reported talking to their mothers about 12.2 topics (SD = 5.7), with a difference of p = .000. In total, males talk about 7.9 topics on average (SD = 6.7) with their fathers, while females talk about 6.2 topics (SD = 5.7) with their fathers, with a difference of p = .042. Therefore, when comparing communication about sexuality topics between a father and his children and a mother and her children, it becomes apparent that adolescent males perceive that they talk about more sexuality topics with their mothers (M = 10.2; SD = 6.2) than with their fathers (M = 7.9; SD = 6.7). The same pattern is found among adolescent
females and their mothers (M = 12.2; SD = 5.7) and fathers (M = 6.2; SD = 5.7). Consistencies and Incongruities in Sexual Communication Processes Table 1 shows the discrepancy percentages between the topics that fathers and mothers and their adolescent sons and daughters report discussing with each other. The topics in the table were those that participants reported being addressed in conversation at home by one of the parties (father/ mother or son/daughter); the discrepancy results when the other party claims that this topic was not discussed. The topic of conversation with the largest discrepancy between mothers and sons/daughters was virginity (56.3%); between fathers and male/female adolescents, it was pregnancy and promiscuity, both with a percentage of 55.6%. The responses of mothers and their children with respect to whether they talk about the topic of abortion were inconsistent in 52% of cases. Overall, a higher discrepancy rate was exhibited between the reports given by fathers and their sons/daughters than between mothers and their sons/daughters.
Table 1 Percentage of Discrepancy Between Sexuality Topics Discussed, as Reported by Parents and Children Topics
Mother and children
Father and children
Virginity
56.3
50.0
Abortion
52.0
46.0
Physical changes experienced during adolescence
49.7
53.2
Vaginal intercourse
48.0
46.0
Pornography
47.5
39.5
Promiscuity
45.7
55.6
Family planning methods
42.9
49.2
Pregnancy
40.4
55.6
Sexual abuse
39.8
48.4
Sexual orientation
39.8
43.5
Sexual practices via Internet, telephone, or other means
39.8
40.3
Sexually transmitted diseases
39.6
44.4
Sexual intercourse and alcohol
39.3
44.4
Sexual intercourse and drugs
39.1
45.2
Anal intercourse
38.8
29.8
The decision to have children or not
37.6
44.4
Psychological changes experienced during adolescence
36.3
52.4
Pleasure
36.3
27.4
Self-care and sexual prevention
35.5
40.3
HIV/AIDS
35.0
42.7
Masturbation
32.2
38.7
Fidelity
31.7
54.0
Partner relationships
30.7
45.2
Sexual intercourse: penis to mouth or vagina to mouth
19.0
19.4
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By reviewing the specific processes and spaces in which the topic of sexuality is addressed in detail, important patterns are revealed in which certain features correlate with the adolescents’ sex and peculiarities emerge in the perspectives of participating fathers and mothers. Adolescent males indicate addressing their first sexual experiences and emphasize the erotic dimensions of sexuality as their primary interest. However, the majority of their encounters with fathers, mothers, and other adults tend to be marked by distrust and embarrassment. The fact that an affective bond exists, especially with their mothers, produces a distance that discourages discussion of these topics. Notably, many of the boys perceived their mothers as possessive or invasive. Thus, the mother’s interest in being present and offering guidance is not always received positively. In these cases, adolescent males seek fathers or other older men to offer guidance without interfering in their lives. As one adolescent male commented, “they [parents] are used to you being the child, and they don’t accept that you’ve already grown up and want to be free”. Adolescent females indicate that conversations with their parents are marked by what they considered to be a clash of perspectives between past and present eras. Thus, they note that their parents seek to find similarities between their own experiences and those of their daughters. They also perceive their parents as feeling fearful about the early pregnancy rate, a fear that causes them to address the topic in a tone of constant warning and presenting it as something that can happen at any time. However, this interest is not necessarily accompanied by prevention-oriented actions; when daughters ask for guidance, many mothers fail to provide it, feeling that they would be granting permission for uncontrolled sexuality. One adolescent girl said, “well, with my grandmother, but she doesn’t understand me because she’s from another time, so she says that you can't do that and that you can when you finish with school, when you’re 30 years old”. Girls expressed that their parents are poorly oriented and that their approach to the topic is outdated. The majority feel that when they ask their parents questions, their parents do not know how to respond, partly due to lack of knowledge and partly due to lack of trust. They also note that when they use precise terms like “vagina” or “masturbation” that their parents feel uncomfortable, prefer not to talk about it, or use euphemisms. With respect to such questions, one adolescent female commented, “(...) will it hurt? I mean, I think that’s the most frequent doubt that most people have”. Likewise, the processes and experiences described in adolescent females’ accounts are strongly marked by gender socialization in an environment in which what is expected of men and women is highly differentiated. Reflecting on interactions with parents on the topic of sexuality, the first sensations mentioned are those of embarrassment and avoidance. Unlike among boys, this feeling is not informed by respect or caused by a distance from the opposite sex. Rather, it is the result of fear of revealing their interest in the topic, which violates expectations about appropriate female behavior. Therefore, many girls refrain from discussing sexuality or asking questions about it because they fear they
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will be judged or that their parents will assume that they have begun to be sexually active. One adolescent female related, “one time he started talking about that (...) that ‘he went through the same thing’ and that ‘sometimes they want to sleep with girls’, and I was like ‘are you insinuating that all he wants is to sleep with me?’ and he said: ‘no, I’m just saying’”. In particular, adolescent females indicate that direct or indirect discussions of sexuality focus on protection against pregnancy, the initiation of sexual intercourse, and some diseases. Although they recognize that their parents are more open about these topics than what they believe was typical in the past, they feel that many of their conversations are immediate reactions to current situations, such as someone they know becoming pregnant or the beginning of a dating relationship, rather than being consistent and planned. In such conversations, the mother is the strongest role model and is also responsible for conveying the father’s feelings – fathers rarely address the topic directly. As a result, daughters feel that the mother tends to mediate between what she thinks, what she is obligated to say as the father’s messenger, and the girl’s situation. One of the adolescent females confirmed, “there’s more trust with my mom, and with my dad, there’s times when he touches on the topic, but it’s like he’s embarrassed, not of asking me, but of how I would react”. The mothers’ accounts are marked by a constant concern about how to communicate with their sons and daughters in a more empathetic and effective way and by a great fear of unplanned pregnancy. They would like to have more up-todate information on practices, prevention strategies, and, in general, the social context and interests of their sons and daughters. Additionally, they feel that it is necessary to improve the strategies they use to begin conversations on these topics, especially with their sons. This difficulty is consistent with quantitative findings and the parents’ accounts in general. Thus, the results indicate weaknesses not only in cognitive terms – the content of sexuality education – but especially in terms of communication and the optimization of these interactions.
Discussion Consistent with previous studies, a noticeable difference was observed in this study between the sexual communication processes that fathers and mothers report and what is perceived by their sons and daughters (Jones, 2010; Kapungu et al., 2010). As noted by Jones (2010), adolescent males tend to talk about sexuality-related topics more often with their fathers, while females are more likely to discuss them with their mothers. However, an increasing number of adolescent females talk to their fathers about their sexual experiences. The dialogues that occur between daughters and fathers, however, are limited to topics related to infections and unplanned pregnancies and are framed by the father’s concept of a relationship. Indeed, the results of both studies revealed differentiation between mothers’ discourse directed to adolescent females, which is more directive and focuses on values and morals, and the discourse offered by fathers, which is based on their male experience and a sense of
Sevilla, T. M., Sanabria, J. P., Orcasita, L. T., & Palma, D. M. (2016). Parent-Child Communication About Sexuality.
protection. Though adolescent women would like to speak more about the topic, they express fear that their parents will confuse this interest in sexuality as an indicator of having become sexually active (Seloilwe et al., 2015). Parents’ advice to adolescent males does not emphasize the type of bond necessary to initiate a sexual relationship, and implicit approval is given to initiate sexual activity (Jones, 2010). In general terms, adolescent males perceive a greater emphasis on formal prevention than on the relational and emotional aspects of sexuality. Consistent with the results obtained by Kapungu et al. (2010), it was found that adolescent females tend to rely most on family members as sources for information about sexuality. Unlike Kapungu et al.’s study, however, the results of this study showed that males consulted a greater range of sources. Similarly, the results indicated that adolescent females who communicate most about sexuality with their mothers were more likely to delay sexual initiation and use contraceptive methods. Although an increasing number of studies have emphasized the role of the social network of friends, schoolmates, and media as socialization agents in this population (Orcasita Pineda & Uribe Rodríguez, 2010), the findings of this study indicate the importance of parents and family as the sources most frequently consulted by adolescents (Martino et al., 2009). However, the need to study the type of communication occurring between parents and children is crucial because the quality of communication is more important than the frequency with which it occurs (Jones, 2010). The results of this study showed that although there are other sources of information on sexuality, parents continue to be the preferred source (Manu et al., 2015). Likewise, it was found that peers and the media are alternative sources of information about sexuality that adolescents, especially women, trust more and experience less prejudice from (Martino et al., 2009; Regmi et al., 2010). The current generation of youth has interacted with information technologies since they were born and is familiar with the language and the management dynamics of these media. Cyberspace provides them with new opportunities to interact with their peers with “certain autonomy”, to explore new identity codes, and to freely – and anonymously – access information from abundant and various sources that attract them and are of interest (Wolak et al., 2012). Parents emphasized the importance of social networks, television shows, and the Internet as sources of information free of barriers, allowing them to avoid the embarrassment that talking about the topic entails. Some strategies developed to counteract embarrassing situations include informing themselves using the sources consulted by their sons and daughters. This strategy allows them to understand their children’s concerns, learn the language to use in approaching them, and learn other management techniques. Thus, such materials should be designed with parents’ use in mind. Furthermore, it was found that the interactions between parents and children are informed by the experiences, behaviors, expectations, fears, and apprehensions that adolescents have about their partner relationships (Barrera
& Vargas, 2005). In this study, differences were found regarding openness to information: clear and non-judgmental information sources were prioritized, such as media or peers (Martino et al., 2009). Nonetheless, adolescent males and females seek advice from their mothers and fathers about values, relationship management, and the consolidation of action models with respect to gender. In general, the questions that adolescent males and females have about the practical aspects of sexuality are associated with lifestyle and optimizing their experiences. Hence, they do not speak to their parents about these subjects but instead seek professionals or explicit sources, such as the Internet (Martino et al., 2009). This gap in the sexual communication process between parents and adolescent children, marked in many cases by communication difficulty, embarrassment, and the perception of a lack of control over specific issues, suggests to adolescents that sexual behavior is something that belongs in private and therefore is not a subject that should be discussed with parents (M. Montañés et al., 2008). As observed in the study conducted by Elliott (2010), mothers and fathers exhibit a level of consciousness about the exposure of their sons and daughters to topics related to sexuality and are sensitive about the vulnerability of women. As Kapungu et al. (2010) state, the idea of protecting women persists, although the nature of the topic is never specific, and the situations in which protection is needed are never described. This concept invites adolescents to be evasive rather than negotiate their ideas and prevents the same empowerment for women that men receive from the teaching of self-care tools or strategies. This leads to a large number of parents refusing to engage or reacting in a negative manner when asked to talk about the topic. It is important to note the positive impact that reinforcement provided by institutions can have on families that are open to talking about the topic. Additionally, adolescent attendance at such institutions with their mothers has been reported, indicating a change in attitude from what has been reported in previous studies (Urrea et al., 2006). Upon analyzing the topics covered, addressing the changes associated with puberty and adolescence emerged as transversal. This was especially true for physical changes, which indicates the emphasis on the biological and reproductive function of sexuality (Seloilwe et al., 2015). Mothers were found to address more topics associated with relationships, such as infidelity, self-care, and prevention, especially of pregnancy, while fathers prioritized topics associated with physical aspects, including the effects of psychoactive substances. In contrast, the topics least discussed with men and women include the erotic and pleasurable dimensions of sexuality. Thus, the use of pornography, relationships with same-sex partners, or selfstimulation were seldom addressed by fathers and mothers. The discrepancies found in the sexual communication processes between parents and children suggest that it is not enough to briefly mention the subject, as mothers and fathers believe. Instead, there is a need to discuss it, confront it, and communicate properly from personal positions that allow life and experience models for sexuality to be constructed
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in their different dimensions. This involves qualifying one’s perception of the discourse, the communication process, and education for adolescent males and females who are increasingly eager to explore their own sexuality and establish life plans independent of the predetermined accounts and roles of their fathers and mothers. In the development of this study, various circumstances determined its scope. For example, it was difficult to develop individual or collective conversations with parents. Because youth as a population are easy to contact, they did not pose difficulties; however, achieving this same access to parents continues to be a major challenge for future research. Female majority participation and the effort made to respond to these calls are in themselves important findings that indicate the reproduction of structures in which this topic is not considered a priority, and when it is, it becomes the responsibility of mothers. The spaces in schools that are allocated for these types of activities and parents’ time limitations also hindered the development of the qualitative component. Therefore, the considerations for future research include (a) studying a greater diversity of family structures, (b) emphasizing the development of individual interviews and not just collective ones in discussion groups, and (c) seeking more equal participation by sex, enabling both caregivers to be represented. Finally, a latent need for the development of support programs that emphasize strengthening sexual communication between parents and children is revealed, as well as the need to promote a responsible sexuality that optimizes adolescent autonomy in the face of various risk factors.
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Linda Teresa Orcasita is an Assistant Professor in the Faculty of Humanities and Social Sciences at Pontificia Universidad Javeriana de Cali.
Teresita María Sevilla is an Associate Professor in the Faculty of Humanities and Social Sciences at Pontificia Universidad Javeriana de Cali.
How to cite this article: Sevilla, T. M., Sanabria, J. P., Orcasita, L. T., & Palma, D. M. (2016). Consistencies and discrepancies in communication between parents and teenage children about sexuality. Paidéia (Ribeirão Preto), 26(64), 139147. doi:10.1590/1982-43272664201601
Juan Pablo Sanabria is an undergraduate student in the Faculty of Humanities and Social Sciences at Pontificia Universidad Javeriana de Cali.
Diana Marcela Palma is a Young Researcher in the Faculty of Humanities and Social Sciences at Pontificia Universidad Javeriana. Received: Feb. 16, 2015 1st Revision: Aug. 17, 2015 2nd Revision: Sep. 7, 2015 Approved: Sep. 9, 2015
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Article
Portuguese Older Gay Men: Pathways to Family Integrity1 Filipa Daniela Marques2 Instituto Politécnico de Coimbra, Coimbra, Portugal
Liliana Sousa Universidade de Aveiro, Aveiro, Portugal
Abstract: Research in the field of older gay men remains scarce. This exploratory study examines older gay men’s experiences in the construction of family integrity (versus disconnection and alienation). The family integrity approach is a developmental perspective that links ego integrity to a larger process of constructing meaning within the family system. The sample comprises ten participants (from 60 to 88 years old). A semi-structured interview was conducted and submitted to content analysis. The main findings suggest three experiences in older gay men’s construction of family integrity: (i) influence of homosexuality throughout life; (ii) establishing a family of choice; (iii) creating a legacy associated with homosexuality. Family integrity in older gay men seems to evolve from disclosure at a young age to making homosexuality a legacy in old age. Keywords: old age, homosexuality, family relations, identity
Homens Idosos Homossexuais Portugueses: Caminhos Para a Integridade Familiar Resumo: A investigação centrada em homens idosos homossexuais ainda é escassa. Este estudo exploratório analisa especificidades da homossexualidade na construção da integridade familiar (versus desconexão ou alienação). A integridade familiar é uma perspectiva de desenvolvimento que associa a integridade do ego a um processo mais vasto de construção de significado dentro do sistema familiar. A amostra reúne 10 participantes (60-88 anos). A entrevista semi-estruturada foi administrada e submetida à análise de conteúdo. Os principais resultados sugerem três especificidades na construção da integridade familiar: (i) influência da homossexualidade ao longo da vida; (ii) formar uma família de escolha; (iii) formar um legado associado à homossexualidade. A integridade familiar em idosos homossexuais parece evoluir da divulgação (da homossexualidade) na juventude, ganhando ascendência na velhice quando a homossexualidade se torna um legado. Palavras-chave: velhice, homossexualidade, relações familiares, identidade
Hombres Gay Mayores Portugueses: Vías Para Acceder a la Integridad Familiar Resumen: La investigación cuanto a los hombres gay mayores sigue escasa. Este estudio exploratorio examina especificidades de la homosexualidad en la construcción de la integridad familiar (vs desconexión o alienación). La integridad familiar es una perspectiva de desarrollo que vincula la integridad del yo con el amplio proceso de construcción de significado dentro del sistema familiar. La muestra reúne 10 participantes (60 a 88 años). Una entrevista semiestructurada fue administrada y sometida al análisis de contenido. Los hallazgos sugieren tres especificidades en la construcción de la integridad familiar: (i) influencia de la homosexualidad durante la vida; (ii) formar una familia de elección; (iii) formar un legado asociado con la homosexualidad. La integridad familiar en los hombres gay mayores parece evolucionar de la divulgación (homosexualidad) en la juventud para convertirse en un legado en la vejez. Palabras clave: vejez, homosexualidad, relaciones familiares, identidad
Older homosexual people are still an invisible group and have been relatively ignored in gerontological research (Mabey, 2011). Ageing involves normative challenges that are similar for homosexual and heterosexual people, but there are enough differences to warrant discussion of the homosexual challenges (Barrett, Whyte, Comfort, Lyons,
Paper taken from the first author’s doctoral dissertation under the second author’s supervision, defended in 2013, in the Doctoral Program of Gerontology and Geriatrics at Universidade de Aveiro in cooperation with Universidade do Porto. Support: Fundação para a Ciência e Tecnologia (Scholarship - SFRH/ BD/45318/2008). 2 Correspondence address: Filipa Daniela Marques. Escola Superior de Educação de Coimbra – Instituto Politécnico de Coimbra. Portugal. Rua Dom João III – Solum, 3030-329. Coimbra, Portugal. E-mail: fdmarques@esec.pt 1
Available in www.scielo.br/paideia
& Crameri, 2015). Furthermore, older age has mainly been explored in terms of pathology, dependence and caregiving; however, development is coextensive to life, demanding the study of older people and their families from a developmental perspective (Marques, 2013; Marques & Sousa, 2011, 2012a, 2012b; Silva, Marques, Santos, & Sousa, 2010). Family integrity offers a developmental approach to ageing, associating the construction of the self (E. H. Erikson, 1950) with a vaster process of relational development within the family system (King & Wynne, 2004). Therefore, this exploratory study focuses on older gay men and examines specificities in the construction of family integrity (versus disconnection or alienation). Results are relevant for the better understanding of how homosexuality influences the development and identity of older gay men, particularly regarding their family relationships.
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Ageing and Homosexuality: The Case of Older Gay Men
Family Integrity
Literature that addresses homosexuality and ageing simultaneously is non-extensive and tends to fall into the following topics (Cahill & Valadéz, 2013; Czaja et al., 2015; Grossman, D’Augelli, & O’Connell, 2002; Muraco, Le Blanc, & Russell, 2008; Owen & Catalan, 2012): (a) myths and stereotypes about older lesbians and gay men; and (b) experiences of gay and lesbian seniors and their families avoiding health and social services in the community out of fear of discrimination. Scarcity of research on homosexual older people has been justified by many reasons (Berger, 1982; Berger & Kelly, 2002; Minichiello, Plummer, & Loxton, 2004): (i) gerontology, a young science, has had to deal with some of the many challenges of ageing (such as chronic disease or informal caregiving); (ii) homosexuals, in particular older ones, are still a population difficult to involve in research (mainly due to the fear of discrimination); and (iii) in general, society tends to stereotype older people as “asexual”, so that the sexual orientation would be of no interest. Yet, as the aged population increases and a higher numbers of gays, young and older, assert their sexual identity and their rights, knowledge about older homosexuals needs to go deeper. The current generation of older homosexual people was raised during a historical period when (Barrett et al., 2015; Grossman et al., 2002): (i) they could not share their homosexuality with others without fear (or certainty) of rejection and even persecution; (ii) they were afraid to admit their homosexuality even to themselves, since they had internalized society’s negative stereotypes about homosexuality, developing feelings of unworthiness and selfhate. Older homosexuals, who lived their youth under highly discriminative standards, are now facing gradual acceptance of homosexuality, which constitutes a new challenge. For instance, homosexual marriage is now legal (even though not always socially accepted) in many countries (the first country to legalize marriage between members of the same sex was the Netherlands in 2001 and the most recent countries were Ireland and United States of America, in 2015; in the case of Portugal – the country in which this study was undertaken – in February 2010), leaving homosexual couples for the first time in a legal relationship. Studies on ageing families have rarely focused on homosexuality, most probably because it challenges contemporary definitions of family (for instance, there are no norms or appropriate family roles for same-sex relationships) (Istar Lev, 2010a). Family studies tend to focus on homosexuality as a stressor that can disrupt traditional patterns of family life rooted in heteronormative norms (Muraco et al., 2008). Older homosexuals lived a life of challenges regarding their individual and family identity (Gabrielson, 2011); therefore, it is relevant to better understand how they are constructing their family integrity, which constitutes the older adult’s effort to achieve ego integrity, linked to a larger process of constructing meaning and relational development within the family system (King & Wynne, 2004).
Family integrity was introduced by King and Wynne (2004), and associated the construction of the self (E. H. Erikson, 1950) with a vaster process of relational development within the family system. This approach posits that the process involved in attaining ego integrity is inextricably bound up with the broader processes of constructing meaning and relational development at the family level. As such, the process of developing a sense of ego integrity is an individual, subjective experience, taking place within the context of family relationships, which in turn affects perceptions of family integrity. The process of constructing family integrity is a continuum involving two main pathways (King & Wynne, 2004): (i) family integrity, which constitutes the positive outcome striving toward meaning, connection, continuity and feelings of satisfaction within the multi-generational family; (ii) family disconnection and alienation (the negative side of this process), which describes a prevailing sense of isolation and disengagement between the older person and his/her family (disconnection), which may achieve a state of lack of family identity (alienation). An older person’s ability to achieve family integrity depends on three functions of the family system (King & Wynne, 2004): transforming family relationships; resolution or acceptance of past losses, disappointments or conflicts; creation of meaning and legacy. Family integrity (versus disconnection or alienation) is an epigenetic process (E. H. Erikson, 1950); it is constructed throughout life, since each stage contributes to the development of the following stages. Thus, individual identity is a hierarchical continuum, starting in the earlier stages of individual and family life cycles, but can only be concluded in later life, as this is the period of “grand generativity” (E. H. Erikson, J. M. Erikson, & Kivnick, 1986). in which older people assume the role of “keeper of meaning” (embodying traditions of the past, thus providing vital family and social links between the past, present and future; Vailland, 2002). Marques (2013) and Marques and Sousa (2011, 2012a, 2012b) studied the processes leading to family integrity (versus disconnection and alienation) considering different contexts. Marques and Sousa (2012a) analyzed life trajectories of elderly persons who had always lived in poverty; the main findings suggested that the risk of family disconnection and alienation is greater in these persons; however, family integrity is achieved by those who develop a philosophy of life that emphasizes the acceptance of the past. Furthermore, Marques and Sousa (2011) examined the trajectories of persons, now elderly, who emigrated and returned to the country of origin (Portugal): former Portuguese emigrants – to understand how life events associated with emigration influenced the construction of family integrity versus family disconnection and alienation. The main findings suggest that maintaining emotional and relational closeness with family during migration periods enriches and protects the sense of family identity, and thus family integrity. This exploratory study examines older gay men’s experiences in the construction of family integrity (versus disconnection and alienation).
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Method Participants The sample (Table 1) comprised 10 gay men between 60 and 88 years old. The sample involved four participants who “work at night”, in professions usually associated with gay men (drag queen). Regarding the household composition, five lived alone, four lived with a same-sex partner (one was married); the relationships have lasted from two years to 31
years; and one lived with his mother. Eight reported they had had heterosexual relationships during their lives; one stated he had only had homosexual relations and one did not answer this question. Eight were single (but two were living with a partner) and one was married; one was divorced from a heterosexual marriage. Three participants had children from heterosexual relationships (one had been married; the other two, after their girlfriends got pregnant, decided not to get married due to their sexual orientation).
Table 1 Sample Age
Profession
Household
Academic qualifications
Marital status
Heterosexual relationships
Children
Francisco
64
Drag queen
alone
4 years
Single
Yes
0
Rodrigo
61
Drag queen
with mother
4 years
Single
-
0
João
60
Accountant and drag queen
alone
Higher education
Single
Yes
2 biological
Filipe
60
Drag queen
alone
4 years
Single
Yes
Yes
António
65
Teacher
with husband
Higher education
Married (same-sex)
Yes
0
Marco
88
Retired teacher
alone
Higher education
Single
Yes
0
Tomás
60
Retired doctor
with same-sex partner
Higher education
Single
Yes
0
Paulo
61
Retired national with same-sex guard partner
Secondary
Divorced (heterosexual marriage)
Yes
2 biological
José
60
with same-sex partner
Secondary
Single
No
0
Participants
Entrepreneur
The criteria for inclusion in this study were: male; selfidentified as homosexual; ≥ 60 years old. It was decided to include participants younger than 65 years old (the chronological age standard for old age in Portugal) since ageing in this population tends to be perceived as occurring earlier than in the non-gay community; the gay subculture assumes and expects older individuals to fade into the outer perimeters upon evincing the physical signs of aging (Peacock, 2000; Smith, 1982). Instruments The instruments comprised: a questionnaire to collect socio-demographic data (age, profession, household composition, academic level, marital status, previous heterosexual relationships throughout live); and a semistructured interview to explore the construction of family integrity, based on (King & Wynne, 2004; Marques, 2013; Marques & Sousa, 2011, 2012a, 2012b; Silva et al., 2010). For this study, one question was added at the end of each domain, focusing on the influence of homosexuality: “Is there any event associated with your homosexuality that you think has influenced (positively or negatively) any of these aspects?”
Procedure Data collection. Participants were recruited using a series of procedures. Initially, the first author contacted ten community institutions and non-governmental gay-related organizations in Portugal, aiming to identify and get access to old gay men (aged over 60 years old); all organizations responded that they did not have members with that age. Then, researchers tried to contact known self-identified homosexuals by email provided by the Internet, but received no answers. We then decided to approach participants using the author’s personal and social networks, using a snowball approach; researchers’ acquaintances with gay contacts identified eligible participants (homosexual men aged ≥ 60 years old); to those who were available to cooperate with the study, they asked permission to give their telephone number and/ or their e-mail to the researcher. Then, the first author proceeded as previously established; the study objectives and the required collaboration were explained. Some individuals refused to participate. The participants spontaneously provided a number of justifications: due to the study focus on family relationships, they would not feel comfortable talking about it because of current family conflicts. Those who agreed to participate also helped to identify other participants. The interview was scheduled after the first telephone or email contact or after a face-
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to-face meeting and took place in private settings, chosen by the participants (at their homes or work office). Informed consent was obtained. Ten participants were interviewed (Table 1); the interviews lasted between 33 minutes and 84 minutes, and all were conducted by the first author. All participants’ names were changed to pseudonyms for confidentiality purposes. Sample collection stopped at ten participants, as no further participants could be identified. Interviews took place between May 2010 and November 2011. Data analysis. The interviews were audio-recorded, transcribed and subject to content analysis, taking family integrity as the conceptual framework (King & Wynne, 2004; Silva et al., 2010; Table 3). First, two independent judges (first and second authors) classified each participant into family integrity versus disconnection/alienation, based on (King & Wynne, 2004; Silva et al., 2010; Table 2): integrity, overall satisfaction with life and family relationships; disconnection, general dissatisfaction with life and family relationships; alienation, separation from the family. The process was as follows: first, each judge independently read the interviews and attributed one route to each participant; then they gathered to compare and discuss their proposals until agreement was reached. The analysis continued to identify the experiences that emerged in older gay men’s
construction of family integrity. It consisted of a process of successive refining, involving two independent judges (the authors). The process was as follows: (i) the authors started by reading all the interviews and highlighted the participants’ features; (ii) then the judges met and discussed the contents; (iii) this process was repeated until agreement was reached. After the data analysis, all participants were contacted to give their opinion and agreement about the study; everyone agreed with the study. Ethical Considerations This particular kind of research does not require the approval of an ethics committee in Portugal. Notwithstanding, the procedures used in this study complied with the ethical guidelines of The Helsinki Declaration.
Results Classification among the different routes shows that: seven participants were classified in family integrity and three in disconnection; no participant was classified in the route of alienation (Table 2).
Table 2 Participants’ Classification on Sub/categories Sub/categories
Family Integrity (n = 7)
Family disconnection (n = 3)
Rodrigo, João, António, Marco, Tomás, José
-
Filipe
Francisco, Paulo, Álvaro
Rodrigo, António, Tomás, José
-
João, Marco
-
Rodrigo, João, Filipe
Francisco, Paulo, Álvaro
Rodrigo, José
Francisco
António, Marco, Tomás, José
-
General Integrity 1. (Not) coming out 1.1. Coming out 1.2. Not coming out 2. Homosexuality (not) acceptance 2.1. Self-acceptance 2.2.Self-rejection 2.3. Rejection by others 3. Struggling to prove gender identity as male to others Transformation of family relationships 4. (Not) coming out influence on family relationships 4.1. Positive influence 4.2. Negative influence 4.3. Establishing a chosen family
Rodrigo, João, Filipe
Francisco, Paulo, Álvaro
Rodrigo, João, Filipe, António, José
Francisco, Paulo, Álvaro
Filipe, António
Francisco, Paulo, Álvaro
João, Marco
Francisco, Paulo, Álvaro
António, Rodrigo
Francisco
-
Francisco, Álvaro
Resolution of past losses/conflicts 5. Mutual progressive disengagement after disclosure 6. Regrets related with homosexuality Creating a Legacy Associated With Homosexuality 7. Helping other homosexuals 8. Disillusion for not fulfilling parents’ wishes
Participants’ discourses in each pathway showed both differences and similarities: those going through the route of family integrity tended to be more concise and direct
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when answering the questions; therefore, interviews had a shorter duration (mean of 48.6 minutes; 34 to 84 minutes), while those trailing family disconnection tended to focus on
Marques, F. D., & Sousa, L. (2016). Older Gay Men: Pathways to Family Integrity.
family conflicts that were repeated throughout the interview, regardless of the question and commonly punctuated by feelings of anger and/or crying; therefore, interviews had a longer duration (mean of 55.7; 46 to 75 minutes). The similarities are in the topics they (did not) want(ed) to address: all said they were more comfortable talking about
themselves and their homosexuality than about their biological family relationships. Overall, data suggests a strong influence of homosexuality throughout participants’ lives (Table 3): “Being homosexual has influenced my whole life! But it hasn’t influenced me, because I deal well with my sexual orientation and I couldn’t live another way” (Rodrigo, 61 years old).
Table 3 Categories and Subcategories Categories and subcategories
Definition
Examples
General Integrity 1. (Not) Coming out
(Not) disclosure of homosexuality to the family.
1.1. Coming out
Coming-out decision tends to occur after falling in love which is assumed as the definitive criterion of sexual orientation. Coming out occurs in two forms: i) explicitly: this involves a formal conversation with the parents (usually, coming out first to the mother for help and guidance), or only coming out to a few trusted family members; ii) implicitly: this applies to those who never directly addressed the issue in the family in order to avoid confrontation, although they are sure family knows.
1.2. Not coming out
Not coming out is associated with: (i) fear of rejection from the family, in (i)“I would never tell to my parents, why would I particular from parents, because it may well hurt them?! I always heard them say that they would cut off relationship (involves avoiding themes rather a dead son than a homosexual son” (Filipe). around sexuality and dating); (ii) form of protection of themselves and their (ii) “I never told my parents, I was scared . . . until relatives, because of societal prejudices. my father saw a photograph of me kissing a boy and In some cases homosexuality was discovered drove me out of the home” (Francisco). by the family, causing conflicts.
“I came to Lisbon to study, I fell in love with my boyfriend and I came because it allowed me to live my homosexuality more freely. I live away from them, but I call them every day, and whenever is possible I go there with my partner” (José).
2. Homosexuality (not) acceptance Self and others (not) acceptance of homosexuality.
2.1. Self-acceptance
Participants report feeling good/“normal” with their own homosexuality; this tends to occur in particular after finding a partner with whom they share intimacy on a physical, emotional and spiritual level. This is also associated with less worry about exposure.
“I always dealt well with homosexuality . . . finding my mate, I realized my orientation, . . . now everyone knows!” (António).
2.2. Self-rejection
Participants describe feeling unhappy (related with negative past experiences of rejection from society), embarrassed (“I’m the shame of the family!; João) or regretting (feeling at fault for being gay, as if it was a choice) being homosexual.
“I regret that I have dedicated myself only to men, the ideal is bisexuality” (Marco).
2.3. Rejection by others
Participants feel rejected by others, including family, friends and co-workers, due to their sexual orientation.
“I had to retire due to my choices; prejudice was such that there was not enough to keep me there” (Paulo).
continued...
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Paidéia, 26(64), 149-159 ...continuation Categories and subcategories
Definition
Participants describe they have a clear gender self-identity as being male with 3. Struggling to prove gender identity gender-conforming behaviour; however, they as male to others feel the need to prove to others that they are men, because society expects gay men to show numerous female traits.
Examples “I do not consider myself feminized! I was born a man and men want to die! In my head I'm a man, I'm not a woman! . . . Here at home there are two men who do household chores and help” (Francisco).
Transformation of family relationships 4. (Not) coming-out influence on the quality of family relationships
4.1. Positive influence
Positive influence is associated with: (i) not coming out, since things would be rather bad if they had come out; (ii) coming out explicitly because it promoted more secure “Not telling my parents positively influenced our and affectionate interactions with parents; relationship because they were gradually accepting” strengthened relationships with the family (Tomás). members who had a good reaction and accepted boyfriends; there is a first shock leading to some distance, but the end is happy, because parents finally accept the son’s sexual orientation; (iii) coming out implicitly “My mother said she was not interested in whether because it helps family acceptation. I was gay or not; what mattered was that I was serious, hardworking and never gave her any grief ” Acceptance is promoted by family values (Francisco). (honesty and hard work) and relatives’ personality (generous and loyal).
4.2. Negative influence
Negative influence (disengagement or cut-off) is associated with coming out or discovery of homosexuality. It is portrayed as a long-term distressing experience, highly influenced by the social prejudice towards homosexuality that confuses the family. It is characterized by: A total separation (cut-off) that compels the gay person to learn to live alone, grieving for family identity. Some family values – mainly machismo and conservative attitudes – make the acceptation of homosexuality difficult.
4.3. Establishing a chosen family
It comprises whose without blood ties who view their homosexuality without prejudices. The gay community emerges as a chosen family, a place to express themselves and feel better (facilitated by the recent increase in the number of gay bars), what is more common for those that have faced family and friends rejection.
“I lived my teens stuck in the closet, I’m afraid . . . from there I learned to be alone . . . Now I have a friendship with the family, not love” (Álvaro). “My father was one of those macho conservative: A gay son would be a shame for the family! He fainted because it was a shock – no one suspected” (Francisco).
“When we gathered with friends, we listened and shared experiences, and that made us understand better and encouraged us to go ahead . . . there (in the gay bar), I can speak as I please; there is my home and I do what I want who feels bad withdraws up! . . . When my father kicked me out of the house after discovering my homosexuality, there were not these gay bars and friendships; today everything would be easier” (Francisco).
Resolution of past losses/conflicts Conflicts that emerged in the past but that are still alive Some relatives have not fully accepted the homosexuality, although they maintain some contact. Disengagement is progressive since the coming out or discovery of the homosexuality. 5. Mutual progressive disengage- For instance: because the family prohibits the ment after disclosure gay relative to be acquainted with new family members (such as newborn children or inlaws), the gay relative becomes outraged with that behaviour, leading to a progressive mutual disengagement and consequent family cut-off
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“Since they discovered my homosexuality they never talk to me (his ex-wife and his sons), and my grandchildren have been born and they will not let me see them” (Paulo). “I feel that with the exception of my parents, my family never accepted my homosexuality, and I moved away too” (António).
continued...
Marques, F. D., & Sousa, L. (2016). Older Gay Men: Pathways to Family Integrity. ...continuation Categories and subcategories
6. Regrets related to homosexuality
Definition
Examples
(i) “If I had known, I would have revealed my Participants regret past decisions or choices homosexuality to my parents later, so they would not related to their homosexuality, in particular: have been so shocked . . . I regret it, but at 19 you (i) Coming out too early. don’t always use your head” (João). (ii) “False” wedding; i.e. had been married (ii) “I married my ex-wife; I was very scared because because of the social pressure, and I had to pretend I liked women . . . but I regret having subsequently divorced. done it because it hurt her and my children” (Paulo).
Creating a Legacy Associated With Homosexuality 7. Helping other homosexuals
(i) “I want to help young, single gay men . . . I’m Participants highlight how their here to say that you can be gay, happy and fulfilled. homosexuality experience may gain meaning If parents do not like it, patience, not worth wasting and contribute to others: time trying to be what we are not” (Francisco). (i) Intention of helping the younger (ii)“I’d like to be remembered as someone who was generations in the coming-out process. able to develop a robust, mature and generous (ii) Desire to be remembered as an example relationship with my partner always want what of homosexuality. we build” (António).
Participants report some disillusion for not 8. Disillusion for not fulfilling parfulfilling their parents’ desires, in particular ents wishes those related to not perpetuating the generation.
Family Integrity All participants mentioned that disclosure was an important and stressful moment (mostly occurring in participants’ early twenties), one of the most significant experiences they had had during their entire life course, consisting in revealing their homosexuality to others; these might include parents, other relatives, close friends and/ or the general community (by exchanging expressions of affection towards everyone). All mentioned an intrinsic need to disclose to their family, because it is a pillar from which nothing should be hidden. The disclosure decision is instigated by falling in love, and not just by the assumption of a homosexual identity. “After falling in love for the first time, at my 15 years old, I immediately talked to my parents. It was very difficult because at that time no one talked about homosexuality!” (António, 64 years old). Six participants in the route of family integrity came out to their parents and/or other relatives: four of them (António, Rodrigo, João, Marco) did it explicitly, involving a formal conversation; the other two (Tomás and José) revealed it implicitly (the family already knew they were homosexual because of their behavior, such as sleeping with their partners in the same bedroom at the parents’ home, but the topic was never directly discussed because it would make relatives feel quite uncomfortable). The seventh participant in family integrity (Filipe) did not disclose to his family, but was discovered by the parents (when he was young and dating his boyfriend). Four participants (Rodrigo, António, José and Tomás) who somehow came out to their parents currently describe secure and affectionate relationships with both parents. These participants who came out described feelings of selfacceptance, associated with a sense of accomplishment,
“My father would have liked me to have given him a grandson, to have got married, and it never happened, and was never going to happen” (Francisco).
pride and honesty related to their lifestyle and conduct as homosexuals. They stated that they lived their homosexuality without disappointing or embarrassing their family, defining themselves as honest and hard workers, and people who care for the family; therefore, the family accepts them as homosexual. “My mother told me: My son, you never gave me displeasure, you always respected yourself and the others, so, you being gay is irrelevant to me” (Rodrigo, 61 years old). Coming out seems to be associated with “positive influence in family relationships” and “create a chosen family”. A chosen family has blood ties, consisting of friends, partners, co-workers and everyone who unconditionally accepts participants’ homosexuality. It functions as a defense ghetto and as a substitutive family who compensates for the less good aspects of family relations and is a balance that makes them feel good. Participants mentioned a chosen family-based on the support of those who view their homosexuality without prejudices, which was crucial to facilitate (help and guide) the process of disclosure; i.e. the tie with other homosexuals and/or others who unconditionally accept their homosexuality is an important part of selfacceptance, giving strength and courage before and/or after the disclosure. Rodrigo, José and Filipe, who at first faced rejection by their fathers, compensate for these family conflicts with the help of (homosexual) friends. António did not face rejection, but he explains: When I was a teenager, and realized I was homosexual, there were no role models, I didn’t know what being homosexual meant; I needed to have contact with someone like me, feel free, so I went to California . . . to grow up!
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“Create a chosen family” seems to be associated with “self-acceptance”. In fact, four of the five participants who mentioned “create a chosen family” (Rodrigo, António, José and Filipe) showed self-acceptance; despite not mentioning a chosen family, Tomás showed self-acceptance. Their self-acceptance highlights how their homosexuality experience may gain meaning and contribute to others: (i) Intention of helping the younger generations in the comingout process: “I want to help young, single gay men . . . I’m here to say that you can be gay, happy and fulfilled. If parents do not like it, patience, not worth wasting time trying to be what we are not” (Francisco, 64 years old); (ii) Desire to be remembered as an example of homosexuality: “I’d like to be remembered as someone who was able to develop a robust, mature and generous relationship with my partner” (António, 64 years old). Family Disconnection The four participants in the course of family disconnection emphasized that disclosure was very stressful, because the environment was predominantly heterosexual, so they were a minority; this explains why they did not disclose themselves to their relatives. Francisco, Paulo and Álvaro did not come out to their relatives; however, their family members (parents and ex-wives) discovered their homosexuality. All participants on the path of family disconnection felt they were/are rejected by others (especially at work); for instance, Paulo, an ex-national guard, who interacted with macho men all day long, faced co-workers’ pressure that led him to pre-retirement. Daily rejection by others reinforces: (i) the fear of being rejected by those who are really important (family); (ii) the fear of hurting them, and/or having the family being judged by others. This makes them try to hide their homosexuality until they are discovered. However, despite good intentions, the discovery of homosexuality is perceived by the family as a betrayal of family members; participants faced rejection and felt misunderstood by relatives, describing conflicts as longlasting. All participants stated that not coming out had a negative influence on family relationships: “The discovery of my homosexuality brought conflicts related with prejudices and disappointment that moved my family away . . . but this happened because they didn’t understand me!” (Francisco, 64 years old). Participants reveal a mutual disengagement after disclosure to relatives who did not accept their homosexuality. This disengagement is accentuated by the disillusion of not fulfilling parents’ wishes. Francisco states: “After my father discovered that I was gay, he also knew that I would never give him the grandchildren he wished for . . . and that hurt him”. In this context of rejection (by family and by others), participants try to cope by compensating with the support of chosen family members: (i) Francisco goes to gay bars where he can express himself without bias, (ii) Paulo protects himself from the “family conflict” by getting closer with his partner; (iii) Álvaro avoided family contact to be and behave
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as gay and related with anyone he wanted (so as not to hurt the family with his homosexuality).
Discussion This study offers important specificities related to older gay men’s construction of family integrity: (i) influence of homosexuality throughout life; (ii) establishing a chosen family; (iii) creating a legacy associated with homosexuality. Influence of Homosexuality Throughout Life The influence of homosexuality during life seems to involve mainly the disclosure event, and the acceptance of one’s own homosexual identity. The disclosure event punctuates participants’ further life experience, emphasizing the epigenetic nature of family integrity process. It was not possible to tell whether parents’ reaction to their adult child’s sexual orientation disclosure would still be influencing that child as many as 10-20 years later (Rothman, Sullivan, Keyes, & Boehmer, 2012); yet, our data strongly suggest that that influence remains until old age. In general, participants in the route of family integrity had disclosed their sexual orientation to their parents in two main ways: explicitly or implicitly. Some authors (Chaudoir & Fisher, 2010) believe that the implicit way is not a form of disclosure, which is reserved for verbal revelation. Our participants assumed it to be a form of disclosure, however, chosen or constructed with respect for the feelings of oneself and the others (“the gentlest way”). Still, participants classified in family disconnection did not disclose to parents: most were discovered by parents. Concealing and being discovered (by one’s parents or ex-wife) seems to bear the burden of betrayal (include shock, loss and grief, damaged self-esteem and anger), in the sense of being harmed by intentional actions or omissions of a trusted person, comprising disloyalty and dishonesty (Rachman, 2010). Nevertheless, the discovery of homosexuality suggests that parents already suspected (in a more or less conscious way) and were looking for confirmation (Moreira & Dócolas, 1999). In fact, usually, there are no secrets of this dimension in a family (Imber-Black, 2010). The disclosure moment is part of the sexual identity development that implicitly involves acceptance of one’s homosexual identity and thus allows it to be shared with other individuals (Chaudoir & Fisher, 2010; Gardner, de Vries, & Mockus, 2014). Participants in family integrity, who had mostly disclosed to parents, seemed to have previously accepted better both themselves and their sexual orientation. They probably had a more accepting family, which permits more confidence to disclose; some studies suggest that family relations can significantly and positively influence identity expression (Gabrielson, 2011). In general, disclosure is associated with positive influence in family relationships; with a posture of greater honesty and openness, which increases intimacy with the family of origin and leads to a true autonomy and intimacy with partners (Gardner et al., 2014; Moreira & Dócolas, 1999). In fact, these findings suggest
Marques, F. D., & Sousa, L. (2016). Older Gay Men: Pathways to Family Integrity.
that participants’ relations with the biological family were maintained with those who accepted their sexual orientation, and restrained with who did not. Those in family disconnection tended to conceal their homosexual identity while struggling to conciliate their identity by combining being gay and men; the inner experience hiding a concealable stigma has been called a “private hell” (Meyer, 2003). In general, concealing one’s stigma is used as a coping strategy, aimed at avoiding negative consequences of stigma, but it can backfire and become stressful. Establishing a Family of Choice Participants from both pathways mentioned a chosen family and underlined its relevance during their lives. It comprises those without blood ties (friends, partners, coworkers; homosexuals or not) who view their homosexuality without prejudices and accept it; it always includes other homosexuals, since it permits having “someone like me” (Domínguez-Fuentes, Hombrados-Mendieta, & García-Leiva, 2012; Peetz & Wilson, 2013). Participants recognize the chosen families as necessary regardless of the relationships with the family of origin and play two main functions (Gabrielson, 2011): (i) support, which comprises protection from a harsh, homophobic world, and a means of coping with a socially stigmatized identity (a place of acceptance that facilitates selfacceptance); (ii) role model, i.e. providing interactions with someone who is homosexual. Some implications in terms of redefining family in the contemporary world may lead to the further development of two topics: (i) defining the family beyond legal and blood ties to include just affective connections (the relevance assumed by the chosen family in homosexual people may support the broader recognition of significant ties and also better understand its role in all families); (ii) getting a deeper understanding of norms and appropriate family roles for same-sex relations/families (Istar Lev, 2010b). Creating a Legacy Associated With Homosexuality Creating a legacy is a normative developmental task in old age, associated with the desire to protect the family (particularly the descendants), giving meaning to life (leaving a legacy of values and assets) and symbolically surviving death (making a contribution; King & Wynne, 2004). Participants (family integrity and disconnection) reveal the desire to leave a legacy (even those who have no descendants), which includes their experience as gay men: being role models for younger homosexuals, and helping them in their disclosure is an altruistic intergenerational contribution by helping young gay men to find their self-identity and cope with stigmatization (Dooley, 2009). This underlines that citizens, practitioners, policymakers and researchers need to move from viewing minority group members as passive victims of prejudice to viewing them as actors who interact effectively with society (Meyer, 2003). In fact, the process of constructing family integrity seems to be a process that comes from disclosure (revealing/assuming homosexuality) to closure (using homosexuality as a legacy). Older homosexual people are still an invisible group,
making them less accessible for research; in particular, they avoid family-related topics. Thus, our study offers the possibility for alternative contemporary understandings of the life trajectories and the construction of family integrity for this common minority group in gerontology research – homosexuals. These findings may assist researchers, health professionals and age care services to further understand the needs and experiences of this older generation of gay men. This study suggests three experiences in older gay men’s construction of family integrity: influence of homosexuality throughout life; establishing a family of choice; creating a legacy associated with homosexuality. The main study limitation is the small sample size (10); procedures to recruit larger samples need to be discussed and improved. Difficulty finding participants is a problem that seems to have plagued most research on homosexuality in the past and will most likely persist in the near future; due to the social constraints of a homophobic society, the population under investigation is necessarily hidden. Drawing a sample from a hidden and, to a great extent, undefined population posed a serious problem. The participants in this study were mostly educated, employed and mostly high-functioning men with considerable social support. Future research should do better at gathering information on all older homosexuals, including low-income and immigrant populations. Future studies need to address lesbians, since research with older women is even scarcer compared to gay older men (Berger, 1982; Grigorovich, 2015). In general, research needs to enhance the knowledge on how a gay identity alters the family life course. It is also essential to acknowledge the meaning of family for gay people/couples/families, which will facilitate a deeper understanding of contemporary family life.
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53(3), 109-129. Retrieved from http://iduc.uc.pt/index. php/psychologica/article/viewFile/1082/530 Smith, E. J. (1982). Counseling psychology in the marketplace: The status of ethnic minorities. The Counseling Psychologist, 10(2), 61-68. doi:10.1177/0011000082102010 Vailland, G. E. (2002). Aging well: Surprising guideposts to a happier life from the landmark Harvard study of adult development. Boston, MA: Little, Brown. Filipa Daniela Marques is an Adjunct Professor at Escola Superior de Educação de Coimbra of the Instituto Politécnico de Coimbra, and a Researcher at UNIFAI/CINTESIS (Center for Health Technology and Services Research). Liliana Sousa is an Auxiliary Professor at the Universidade de Aveiro and member of CINTESIS (Center for Health Technology and Services Research). Received: May 15, 2015 1st Revision: Sep. 18, 2015 Approved: Oct. 6, 2015
How to cite this article: Marques, F. D., & Sousa, L. (2016). Portuguese older gay men: Pathways to family integrity. Paidéia (Ribeirão Preto), 26(64), 149-159. doi:10.1590/1982-43272664201602
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Paidéia may-aug. 2016, Vol. 26, No. 64, 161-170. doi:10.1590/1982-43272664201605
Article
Interpersonal Conflicts Among Family Caregivers of the Elderly: The Importance of Social Skills1 Francine Náthalie F. Rodrigues Pinto2 Universidade Federal de São Carlos, São Carlos-SP, Brazil
Elizabeth Joan Barham Universidade Federal de São Carlos, São Carlos-SP, Brazil
Zilda Aparecida Pereira Del Prette Universidade Federal de São Carlos, São Carlos-SP, Brazil
Abstract: Caring for someone, even when this person is highly regarded, can be stressful, resulting in a decrease in the caregiver’s quality of life. The aim of this study was to identify the main conflicts involved in the task of caring for an elderly relative, reported by caregivers, elderly care-recipients and professionals in the field of aging, and to identify social skills (SS) considered as being important to accomplish this task, helping to minimize the conflicts in this context. We interviewed 50 caregivers of the elderly, 25 elderly care-recipients, and 25 professionals in the field of aging, who answered questions about conflicts linked to this context and about SS that are important when taking care of an elderly person. The main conflicts involved difficulties to reconcile differences of opinion, or financial issues. The SSs considered most useful included: expressing positive feelings, controlling aggressiveness, and discussing problems. It will be important to verify if caregivers who develop their SS repertoire also improve their quality of life. Keywords: caregivers, aged, social skills, conflict, quality of life
Conflitos Interpessoais no Cuidado de Idosos: Importância das Habilidades Sociais do Cuidador Resumo: Cuidar de outro, mesmo sendo alguém que se estima, pode ser estressante e levar à diminuição na qualidade de vida. O estudo teve como objetivos identificar os principais conflitos envolvidos na tarefa de cuidar de um idoso, relatados por cuidadores, idosos e profissionais da área do idoso e levantar as habilidades sociais (HS) consideradas importantes para realizar esta tarefa e que auxiliem a minimizar os conflitos neste contexto. Foram entrevistados 50 cuidadores de idosos, 25 idosos cuidados e 25 profissionais da área do idoso, que responderam a um roteiro com perguntas sobre conflitos ligados a este contexto e HS importantes para cuidar de um idoso. Os principais conflitos envolviam dificuldades para conciliar opiniões e questões financeiras. As HS apontadas como importantes foram: expressar sentimentos positivos, controlar a agressividade e conversar para resolver problemas. Será importante verificar futuramente se cuidadores que aprimoram seu repertório de HS melhoram sua qualidade de vida. Palavras-chave: cuidadores, idosos, habilidades sociais, conflito, qualidade de vida
Conflictos Interpersonales en el Cuidado de Personas Mayores: La Importancia de las Habilidades Sociales del Cuidador Resumen: Ocuparse de otro, incluso alguien que se estima, puede ser estresante y conducir a disminución de la calidad de vida. Este estudio tuvo como objetivo identificar los principales conflictos en la tarea de cuidar de un anciano, reportados por los cuidadores, ancianos y profesionales de la vejez y identificar las habilidades sociales (HS) importantes para lograr esta tarea y que ayuden a minimizar los conflictos en este contexto. Fueron entrevistados 50 cuidadores de ancianos, 25 ancianos cuidados y 25 profesionales de la vejez que respondieron preguntas sobre conflictos en este contexto y acerca de HS importantes para cuidar de un anciano. Los principales conflictos fueron dificultades para conciliar diferentes opiniones y las cuestiones financieras. Las HS identificadas como importantes fueron: expresar sentimientos positivos, controlar la agresividad y hablar para resolver problemas. Será importante verificar en el futuro se cuidadores que mejoran su repertorio en HS mejoran su calidad de vida. Palabras clave: cuidadores, adultos mayores, habilidades sociales, conflicto, calidad de vida
One of the consequences of increased life expectancy is the high prevalence of chronic diseases (Kuchemann,
Article derived from the first author’s doctoral dissertation, under supervision of the second and co-supervision of the third co-authors, and defended in 2016 in the Graduate Program in Psychology at the Universidade Federal de São Carlos. Support: São Paulo Research Foundation (FAPESP Grant # 2012/00907-3). 2 Correspondence address: Francine N. F. R. Pinto. Rua Novo Horizonte, 164, apt. 224, Chácara da Barra. CEP 13090-768. Campinas-SP, Brazil. E-mail: francinenaty@yahoo. com.br 1
Available in www.scielo.br/paideia
2012). As such, it has become increasingly common to spend several years caring for a highly dependent elderly person (Kuchemann, 2012; Wang, Robinson, & Carter-Harris, 2014). Caring for an elderly relative is a complex task that affects the caregiver’s life trajectory. Thus, the identification of conditions that contribute to obtaining positive results in this context is a way of promoting healthy adult development. Researchers show that caring for an elderly relative is a risk factor for caregivers’ wellbeing. Tomomitsu, Perracini, and Neri (2014) investigated the association between life satisfaction and sociodemographic variables, health status,
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functional status, social engagement and social support for caregivers and non-caregivers of the elderly. Using a larger database, they selected 338 caregivers and 338 noncaregivers who had similar income, gender and family characteristics. They collected data using questionnaires and self-report scales. The authors concluded that, compared with non-caregivers, a higher percentage of caregivers reported insomnia, fatigue and illness, in addition to higher levels of stress and lower life satisfaction. Other researchers also found differences between caregivers and those who do not care for an elderly relative, noting that the caregivers had a higher probability of presenting negative psychological, physical and social changes, such as higher rates of depression, feelings of burden, higher likelihood of acquiring coronary disease, social isolation, and a significant increase in expenses (Gervès, Bellanger, & Ankri, 2013; Li, Cooper, Bradley, Shulman, & Livingston, 2012; Wang et al., 2014). These data point to the importance of investigating the skills that are needed, to manage the task of caring for a dependent elderly person. In this respect, Tomomitsu, Perracini and Neri (2014) found that caregivers who reported receiving greater social support also reported lower levels of stress. Other researchers have shown that, when caregivers lack this support, problems often arise in their relationships with other people who are involved in the elderly person’s or the caregiver’s routines, creating resentments and a negative emotional environment (Pedreira & Oliveira, 2012; Pinto, Barham, & Albuquerque, 2013; Van Groenou, Boer, & Iedema, 2013). Pedreira and Oliveira (2012) interviewed eight family caregivers, to identify the key changes that had occurred in their family relationships, since their elderly relative developed health problems. Although their sample size was small, the results indicated a strong influence of the quality of their social interactions on the caregivers’ wellbeing. A preexisting family history of cooperation was associated with greater support and more sharing of responsibilities among family members. However, most of the caregivers felt burdened and alone when facing the demands of caring for a dependent elder, and conflicts emerged when the help that the caregiver requested from a family member was denied. The key situations reported as involving conflicts included: lack of family support, decreased tolerance (reactivation of unresolved problems), having to relinquish social, leisure or paid work to care for the elderly person, as well as social isolation and new expenses. These data about relationship problems suggest that caregiving entails demands for social skills that can contribute to minimizing conflicts and maximizing the quality of life of the caregivers, elders and other people involved in this context. Despite the lack of studies on the social skills of those who care for the elderly, research conducted in other contexts indicates that people with well-developed social skills are more likely to establish good quality relationships, leading to better health (Bandeira, Tostes, Santos, Lima, & Oliveira, 2014; Lima, Bandeira, Oliveira, & Tostes, 2014; Pinto & Barham, 2014b). Thus, research focused on the social skills of those who care for the elderly could contribute
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information to guide the development of programs to support caregivers who need to manage the demands and interpersonal difficulties that appear in this context, contributing to a better quality of life for caregivers. Social Skills
The concept of social skills refers to behaviors that exist in the repertoire of an individual and that are used in interactions with other people (Del Prette & Del Prette, 2013). According to Del Prette and Del Prette (2001), the concept of social competence involves an assessment or judgment about the adequacy of a person’s performance and the effects that it produces in a given situation. These authors propose that the specific situation and cultural context must also be taken into consideration, to assess people’s social competence. Thus, a person who is socially competent in a professional role, may or may not be equally competent in the context of caring for an elderly family member, and vice versa. Social skills involve various classes of social behavior, including: self expression, coping skills, expressing positive emotions, social interaction and conversational skills, establishing new relationships or adapting to new situations, and controlling aggressive reactions (Del Prette & Del Prette, 2001). To meet social competence criteria, competent caregivers must reconcile their own needs and interests with those of their elderly relative, along with those of other family members who help with the elderly person’s care. As such, to be socially competent, caregivers may need to use greater self-control to avoid reacting aggressively to hostility from the other person, to identify factors that are contributing to the problem, and to calm down the other person and themselves, so they can decide the best way to solve the problem. Depending on people’s emotional arousal during a conflict and causal attribution errors, based on a history of family interactions, the caregiver may be unable to analyze the problem and think of solutions, straight away. As an alternative, withdrawing from the conflict and returning to the issue after time for reflection may be a more effective, or more socially competent, response. Given that social skills, as well as maladaptive behaviors (such as avoiding social contacts, not voicing opinions, attacking other people’s ideas), are learned behaviors (Del Prette & Del Prette, 2008, 2013), strongly affected by immediate consequences, it is possible to understand why many caregivers exhibit behaviors that do not solve the interpersonal problems that arise in this context. Maladaptive behaviors can also generate positive, short-term consequences, such as reducing the caregivers’ anxiety or momentary frustrations (Gresham, 2010), but these behaviors do not lead to medium or long-term solutions to problems. In terms of evidence concerning the importance of social skills for people who care for the elderly, researchers have shown that socially responsible caregivers with good interpersonal relationships tend to have a higher quality of life than caregivers with a limited repertoire of social skills (Bandeira et al., 2014; Muela, Torres, & Peláez, 2001; Pinto & Barham, 2014b). In a study with 20 caregivers of
Pinto, F. N. F. R., Barham, E. J., & Del Prette, Z. A. P. (2016). Social Skills and Caregiving.
elderly family members, Pinto and Barham (2014b) found that those who had better social skills reported lower perceptions of burden and better quality relationships with their elderly relative, indicating fewer care-related conflicts. The key social skills associated with these results were: self-control of aggressive reactions, expressing positive feelings, and refusing unreasonable requests. In two studies on the effects of social skills training for caregivers of the elderly (Robinson, 1988; Robinson & Yates, 1994), those who participated in training programs reported less burden, following the intervention, and demonstrated more socially competent behaviors in their daily lives. Thus, it appears that good social skills, which translate into socially competent behaviors, can positively affect the wellbeing of those who care for the elderly, and the quality of their interpersonal relationships. However, there is still little information about this context. Thus, this study aimed to identify the main conflicts involved in the task of caring for the elderly, as reported by caregivers, elderly people, and professionals from the field of gerontology, and to identify the social skills considered as being important when dealing with this task, which help to minimize conflicts.
Method Participants There were three groups of participants in this study: 50 caregivers who assisted an elderly relative, 25 elderly care recipients, and 25 healthcare professionals who worked with the elderly. The participants were not matched, that is, the elders and caregivers did not necessarily belong to the same family. The inclusion criteria, for the caregivers, included being relatives or having another emotional (unpaid) relationship with the elderly person; for the elderly care recipients, to not have cognitive impairments that would invalidate their participation in the study, and to be receiving care from a family member; and for the professionals, to be working in the field of gerontology or geriatrics. All the elderly participants had received routine medical checkups via an in-home public healthcare service, to monitor their physical health and cognitive status. The caregivers were 45 years of age, on average (44 women and 6 men), with varying degrees of kinship, including: 21 children, 12 grandchildren, 7 spouses, 6 daughters, 2 neighbors, 1 brother and 1 nephew. The caregivers’ educational levels were varied: 10 who had not completed their elementary-school education, 14 who had completed elementary school, 11 who had not complete high school, 7 who had completed high school, 4 who had not completed tertiary-level studies, and 4 who had completed university studies. The elderly respondents were 73 years of age, on average (15 women and 10 men), with different degrees of kinship, including: 13 children, 10 spouses, and 2 siblings. In this group, educational levels included 10 who had not completed their elementary-school education, 7 who had completed elementary school, 4 who had not complete high school, 2 who had completed high school, and 2 who
had completed university studies. The professionals (22 women and 3 men) were 39 years of age, on average, and had all completed university studies. There were five participants from each of the following professions: psychology, medicine, social work, physiotherapy, and nursing. Instrument Interview schedule. The interview questions were developed by the researchers, based on clinical experience, and addressed the following topics: Participant data. Name, age, sex, level of education, relationship between the caregiver and the care recipient or, in the case of the professionals, their profession. Difficulties and conflicts. Open-ended questions about the demands, difficulties or conflicts that arise when caring for an elderly person, and possible relationships with social skills, in this context. Social skills. Explanation of this concept, followed by a request for examples of social skills that are important in caring for the elderly, to reduce conflicts associated with this task. Classes of social skills. Explanation of classes of social skills, based on Del Prette and Del Prette (2001): (a) coping and self-expression (which require assertiveness skills), (b) expressing positive feelings (the expression of positive affect or of regard for another person), (c) conversational and social interaction skills (in accordance with norms for everyday relationships, and in response to demands to show social sensitivity), (d) interacting with new people or in new social situations (interactions with strangers), and (e) self-control of aggressiveness (dealing with negative situations that require controlling one’s anger or aggressiveness). Importance of social skills. Questions about the importance of each class of social skills, to minimize the conflicts that arise in the context of caring for an elderly person, and a request for examples of how to use of the social skills that they rated as being important, while caring for an elderly person. Procedure Data collection. The study was conducted in a city in the interior of the state of São Paulo, Brazil. The director of a publicly-funded in-home healthcare-service in this city agreed to provide information to contact service users who met the inclusion criteria. A home visit was arranged to interview the caregivers and the elderly people who agreed to participate in the study. Interviews with the professionals were performed at the healthcare centers where they worked. Initially, all participants signed an Informed Consent Form. After answering the sociodemographic questions, each participant was asked to describe conflicts that occur when caring for a dependent elderly person. Next, the definition of social skills was read aloud, and any doubts about this concept were clarified. The researcher then asked if the participant considered it important that caregivers of the elderly use these skills in their daily lives, and if they could give any examples of social skills that are important to use, in
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this context. Next, the interviewer read the definitions of the five classes of social skills, one at a time, and, for each one, asked the participant if it would be important for a caregiver to use these skills when interacting with an elderly care recipient. If the participant said yes, the researcher asked for an example of a behavior from this class. All interviews were recorded and, in addition, the researcher took note of the key information provided by each participant. Dada analysis. Two experts in the field, working individually, were asked to perform a content analysis of the responses (examples of conflicts and of important social skills) given by the participants (Anfara Jr., Brown, & Mangione, 2002; Strauss & Corbin, 1994). For the social skills, they were asked to categorize each response into one of the social skill classes used in the IHS-Del-Prette (Del Prette & Del Prette, 2001); if they felt that some of the responses did not fit in any of these classes, they were to group these into new categories. After this, the experts were asked to compare their decisions and, when in disagreement, to reach a consensus on how to classify each answer and on any additional categories
to include, such as “obtaining information about a health condition”. Based on the consensus reached by the experts, this material was then analyzed to identify the major conflicts involved in the context of caring for a dependent elderly person, and the social skills that were identified as being important, according to the study participants. Ethical Considerations This project was approved by the Ethics Committee of the Universidade Federal de São Carlos (Protocol n. 144507/2012 - CAAE n. 02010312.0.0000.5504.).
Results In Table 1, the conflicts involved in the context of caring for a dependent elderly person are presented, based on the analysis of the participants’ responses, along with examples of some of the responses provided, in each group of participants.
Table 1 Examples of Conflicts Reported by Caregivers, Elderly Care-Recipients and Geriatric or Gerontological Professionals Conflict
Caregivers
Elderly
Professionals
“Lack of respect and “Overwork, lack of support, [caregiver] thinks that the understanding of each other, lack Lack of support from other understanding, interest” (P 39) “She have to pay more of moral support” (P76) family members “The others [siblings] do not other children attention” (P53) “Difficulty in asking for ... help” visit” (P48) (P84)
Financial
“Financial” (P1)
Uncooperative care recipient
Different ways of among caregivers
“Stubbornness of the elderly person” (P15) “The elderly person wants everything her own way” (P22)
“She [caregiver] spends a lot” “Lack of financial support” (P76) (P58)
“My stubbornness” (P62) “When I complain” (P63)
“Taking care of her in a different way: bathing, food, changing “Differences of opinion” (P54) thinking, clothes, getting her out of bed” “The siblings who always seem (P6) to criticize” (P57) “Thinking differently than the other” (P30)
“Elder does not accept his dependence on the caregiver” (P96)
“Family does not agree” (P80)
Caregivers’ lack of time for “Having time for themselves” themselves (P13)
“Parallel demands faced by the caregiver” (P83)
[elderly person’s] preference Care recipient’s preference for “His for a child, and the other is hurt” one child (P4)
“Preference of the elder for a child” (P81)
Alcoholism
“Alcoholism, excessive drinking” (P59)
No conflicts
went through this situation. “I have no conflicts, because “I There is a lot of exchange of love people trust me” (P19) and affection” (P61)
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Pinto, F. N. F. R., Barham, E. J., & Del Prette, Z. A. P. (2016). Social Skills and Caregiving.
In general, the conflicts involved issues such as insufficient support for the caregivers, lack of financial support, lack of cooperation on the part of the elderly care recipient, lack of time for the caregivers to look after themselves, and the elderly people’s preference for only one of their children. A comparison of the conflicts reported by each group of respondents indicates
that the elderly care recipients did not mention problems owing to a lack of time among the caregivers, or due to their preference for one of their children. Some caregivers and elderly respondents reported that they did not experience conflicts in their family. In Table 2, the frequency of these conflicts is indicated, as reported in each group of participants.
Table 2 Frequency With Which Each Type of Conflict Was Reported, in Each Group of Respondents Group of Respondents
Conflict
Caregivers (n = 50)
Elderly (n = 25)
Lack of support from other family members
20 (40%)
8 (32%)
10 (40%)
38 (38%)
Financial
10 (20%)
5 (20%)
11 (44%)
26 (26%)
Uncooperative care recipient
13 (26%)
4 (16%)
2 (8%)
19 (19%)
Different ways of thinking, among caregivers
12 (24%)
3 (12%)
1 (4%)
16 (16%)
Caregivers’ lack of time for themselves
3 (6%)
0 (0%)
1 (4%)
4 (4%)
Care recipient’s preference for one child
2 (4%)
0 (0%)
1 (4%)
3 (3%)
Alcoholism
0 (0%)
2 (8%)
0 (0%)
2 (2%)
No conflicts
3 (6%)
4 (16%)
0 (0%)
7 (7%)
Considering the statements of all the participants (total), the most frequent conflicts involved a lack of support for the caregiver, financial issues and a lack of cooperation on the part of the elderly care-recipient. The conflicts that the caregivers most commonly reported involved a lack of support from other family members, a lack of collaboration on behalf of the elderly care recipient, differences of opinion with other caregivers about what care to provide, and financial issues. For the elderly care recipients, the conflicts most frequently reported involved their reluctance to collaborate, differences of opinion with
Professionals (n = 25) Total (N = 100)
or among those who cared for them, a lack of support from family members, and financial issues. Note that 16% of the elderly participants reported no conflicts in their families, compared with 6% of the caregivers. The perceptions of the professionals were similar to those of the caregivers; their responses highlighted conflicts related to the lack of support for the caregivers and difficulties involving financial issues. In Table 3, the examples provided illustrate the social skills that the participants said should be used when someone is assisting a dependent, elderly, family member.
Table 3 Social Skills Identified as Important for Those Who Care for an Elderly Person, in Each Group of Respondents Skills
Group of Respondents Caregivers
Elderly
Professionals
Obtain information about the health condition
“To better take care of the elderly person, for example, [find out] about treatment” (P31)
“Yes…how the illness works, what you’re thinking, so you can understand” (P51)
“Looking for information, knowledge, understanding the situation” (P82)
Express positive feelings
“Giving kisses, being playful and affectionate to make her feel better” (P5) “When the other is taking good care” (P6)
“Making food for myself, even though I am old and have health problems” (P54)
“When the health condition of the elderly person improves, or he can stay calm” (P82)
Control aggressiveness
“When the person who helps me talks too much, and irritates the elderly person; with family members who do not help” (P25)
“When I don’t want to do the things that she wants to do” (P62)
“Aggressiveness of the elderly person, family members who criticize, patients who shout and talk a lot” (P84)
Talk through problems
“Sitting down and talking to other family members to solve the problems” (P4)
“Say what you think calmly, without getting angry, caring with love” (P53)
“Sitting down and talking and trying to resolve the situation as best as possible, listening to the other” (P76) continued...
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Paidéia, 26(64), 161-170 ...continuation Skills
Group of Respondents Caregivers
Elderly
Professionals
“Take the elderly person to a skilled physician, even if my siblings do not want me to” (P19)
“With me, because I am a difficult person” (P56)
“Check what is important for the elderly person, even if the family is against it” (P80)
“To dialogue, talk, ask for support when you need it” (P32)
“Asking for help from the children, when needed” (P55)
“Asking for help from siblings…” (P97)
Arrange time for yourself
“[Time] with friends, at the gym… it is important to maintain your life, so you don’t get sick” (P37)
“Getting out to talk to others, explain what is good for her, going to church, praying” (P60)
“Opportunity for the caregivers to interact socially and de-stress, have time for themselves” (P97)
Express opinions
“Telling him [care recipient] that he has to shower, take his medicine” (P29)
Use coping strategies
Ask for help
Most of the social skills indicated as being important for someone who cares for an elderly family member involved dealing with conflict (control aggressiveness, talk through problems, use coping strategies), together with skills that contribute to organizing adequate and sustainable routines (obtain information about the care recipient’s health condition, express positive feelings, ask for help, and make arrangements with others in order to have some “time for themselves”). Obtaining information about the elderly person’s health problems and the caregivers being able to have
“To express his feelings” (P80)
time to themselves are not social skills, per se. However, accomplishing these tasks involves communication skills (to gain information, or to arrange with others to stay with the elderly person). The perceptions of the professional group were very similar to those of the other two groups. However, it is noteworthy that no elderly respondents stated that it was important for caregivers to express their opinions. In Table 4, information is presented about the frequency with which the skills presented in Table 3 were used, and how important they were, for each group of respondents.
Table 4 Frequency With Which the Social Skills Were Rated as Important, in Each Group of Respondents Group of Respondents Social skill
Caregivers (n = 50)
Elderly (n = 25)
Professionals (n = 25)
Total (N = 100)
Obtain information about the health condition
35 (70%)
15 (60%)
17 (68%)
67 (67%)
Express positive feelings
34 (68%)
14 (56%)
11 (44%)
59 (59%)
Control aggressiveness
33 (66%)
9 (36%)
14 (56%)
56 (56%)
Talk through problems
15 (30%)
10 (40%)
9 (36%)
34 (34%)
Use coping strategies
11 (22%)
4 (16%)
6 (24%)
21 (21%)
Ask for help
12 (24%)
1 (4%)
7 (28%)
20 (20%)
Arrange time for yourself
10 (20%)
3 (12%)
6 (24%)
19 (19%)
Express opinions
11 (22%)
0 (0%)
1 (4%)
12 (12%)
Based on Table 4, the social skills considered as most important, according to the caregivers, were: obtaining information, expressing positive feelings, and controlling aggressiveness. Among the elderly care-recipients, the social skills considered as most important for caregivers were: obtaining information, expressing positive feelings and talking through problems.
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Discussion The aims of this study were to identify the conflicts that most commonly arise when a family member cares for a dependent elderly person, from the point of view of caregivers, elderly care recipients, and professionals working in the field of geriatrics or gerontology, and to identify the
Pinto, F. N. F. R., Barham, E. J., & Del Prette, Z. A. P. (2016). Social Skills and Caregiving.
social skills that are considered important in accomplishing this task, to minimize these conflicts. The three groups of respondents reported similar sources of conflicts. However, an important difference was that no elderly person reported problems related to the caregivers needing to take time to care for themselves, which may indicate difficulties that the elderly care recipients had, to understand the caregivers’ needs. Considering the responses of the study participants, collectively, the most frequent conflicts involved: lack of support from other family members, financial issues, the uncooperative behavior of the elderly care recipient, and conflicts of opinion about caring. These results are consistent with findings reported by Pedreira and Oliveira (2012) and by Carneiro and França (2011). The lack of support from other family members can cause perceptions of caregiver burden (Gratão et al., 2013; Novelli, Nitrini, & Caramelli, 2010; Pinto & Barham, 2014a; Wang et al., 2014) and over time, this can contribute to the caregiver developing health problems (Horiguchi & Lipp, 2010; Pedreira & Oliveira, 2012; Wang et al., 2014.). With respect to financial conflicts, caregivers often have to quit their jobs or decrease their hours of paid work to take care of elderly relatives, reducing their income just when financial expenses tend to increase, to purchase medicines and geriatric diapers, for example, along with other specialized products and services (Gervès et al., 2013; Pedreira & Oliveira, 2012; Smith et al., 2010). Thus, the family’s financial reserves tend to be depleted, after an elderly family member develops health problems (Gervès et al., 2013; Smith et al., 2010; Wang et al., 2014). According to the literature, it is relatively common that one person is left largely on their own to take full responsibility for caring for the elderly family member and for managing this person’s financial resources (Pinto et al., 2013; Smith et al., 2010). This situation leads to conflicts with other family members who do not help, who have different opinions, or who expect some share of these resources (Areosa, Henz, Lawisch, & Areosa, 2014; Carneiro & França, 2011; Gervès et al., 2013; Pedreira & Oliveira, 2012). These same sources of conflict also emerged in the present study: the participants reported conflicts due to differences of opinion among family members, disagreements over the management of financial resources, divergences between the elderly person and the caregivers themselves with respect to the caregivers’ needs, among others. The lack of cooperation on the part of the care recipient, and the fact that either the care recipient or the caregiver may be willing to accept help from only certain people, can also contribute to the occurrence of conflicts (Areosa et al., 2014). In the current study, 16% of the caregivers admitted to having difficulty accepting the opinion of or help from others. Even caregivers who willingly chose to undertake this role can end up feeling burdened by incompatibilities with their elderly family member, or feeling discouraged, if their elderly relative is frequently upset or constantly criticizes them (Areosa et al., 2014; Carneiro & França, 2011; Pedreira & Oliveira, 2012). Moreover, only 6% of the caregivers and 16% of the elderly care recipients did not report conflicts related to eldercare issues in their families, which strengthens the hypothesis that caring for a dependent, elderly, family
member usually involves conflicts and difficulties, as many of the interpersonal strategies that people use in this context are not very effective in handling these problems. Knowledge about aging and about workable strategies to respond to the needs of older people are still insufficient, in Brazil, especially with respect to helping elderly people with health problems, perhaps because the aging of the Brazilian population is a relatively recent phenomenon (Kuchemann, 2012). However, laws to protect the rights of the elderly have already been established (Estatuto do Idoso [Statute for the Elderly]) by the Brazilian Ministry of Health (1999), which aim to ensure that family members, particularly adult children, support their elderly relatives. This legal obligation is positive, on the one hand, as a way to guarantee that older people receive assistance. On the other hand, it may contribute to increased conflict in families with weak emotional ties, as caring for the elderly person is nothing more than a requirement, and is not a choice based on a history of positive family relationships (Pinto et al., 2013). Given the likelihood of needing to manage conflicts, a caregiver who has stronger social skills and who uses them in a socially responsible way should be better able to deal with difficult interpersonal issues (Lima et al., 2014; Muela et al., 2001; Pinto & Barham, 2014a; 2014b; Robinson, 1990). For example, caregivers with greater social competence developed a better relationship with the elderly care-recipient and reported lower levels of burden, to the extent that they were able to express positive feelings, turn down unreasonable requests, ask others to change their behavior, ask for help from friends, and control aggressive reactions (Muela et al., 2001; Pinto & Barham, 2014b; Robinson, 1990). The data from the current study confirm these earlier findings, as the social skills considered most important for someone who cares for an elderly family member included: obtain information about the care recipient’s health condition, express positive feelings, control aggressiveness, talk through problems, use coping strategies, ask for help, and arrange some time for yourself. The ability to obtain information entails requesting this information from other people, such as other caregivers or professionals who work in the field of geriatrics or gerontology. Arranging time for yourself may depend on the caregiver’s ability to request other people’s help to take care of the dependent, elderly person, or to require other family members to share these tasks. When thinking about the caregiver’s role in assisting someone who has health problems, it is clear that the caregiver could benefit from learning more about their elderly family member’s health condition. Having the ability to do this was considered highly relevant for caregivers, mentioned by 67% of the participants in this study, and requires that the caregiver is able to gain information through interactions with other people, such as physicians, other caregivers and other family members. When these other people interact with the caregiver using socially competent behaviors, these exchanges also create opportunities for the caregivers to improve their social skills. Another skill reported as being important was expressing positive feelings. This ability, in conjunction with the caregivers’ ability to control aggressive reactions, assists
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them in establishing healthier relationships, because, the warmer they are, the more likely it is that they will receive help, compared to those with a more forceful approach (Pinto & Barham, 2014a; Robinson, 1988, 1990; Robinson & Yates, 1994). As such, controlling aggressive reactions when criticized, even if the criticism is unwarranted, is highly relevant to the caregiver’s ability to establish good quality relationships with their elderly relative and with other people who are also involved in caring for the older person (Pedreira & Oliveira, 2012; Pinto & Barham, 2014b; Robinson, 1990). In the present study, although the majority of participants reported needing more support, only 20% stated that the ability to ask for help is important. That is, although they realized they needed more support, 80% did not think of the ability to ask for help as a skill that a caregiver should use. As such, in addition to helping caregivers develop their ability to ask for help, it may also be important to help caregivers evaluate their situation, so they can more clearly discriminate when they should ask for help. In the current study, only 4% of the elderly care-recipients reported that caregivers should use their ability to ask for help, which, once again, seems to reflect the difficulty they have to understand the caregiver’s perspective. In previous studies, the ability to ask for help was depicted as essential to caregivers’ quality of life (Muela et al., 2001; Pinto & Barham, 2014b; Robinson, 1988, 1990; Robinson & Yates, 1994), and those who could ask for help in an appropriately assertive manner obtained more frequent assistance and felt less burdened, compared with those who did not have this ability or in whom this skill was poorly developed (Muela et al., 2001; Pinto & Barham, 2014a; Robinson & Yates, 1994). In addition, caregivers with more highly developed social skills had higher self-esteem (Robinson, 1988, 1990; Robinson & Yates, 1994). Considering some of the difficulties that the elderly care-recipients seemed to have, to understand the caregivers’ perspective, and the sense of burden that caregivers feel when they can’t find a way to ask for help and are not able to express positive feelings towards their family members (creating an emotional distance between themselves and other people involved in this context), it may be possible to improve this situation using intervention programs to help both caregivers and elderly care-recipients improve their social skills. Given this demand, programs to help professionals develop their social skills would also be of critical importance, as healthcare workers act as models for elderly people and their caregivers. Professionals who are adequately qualified to work on relationship issues would then be able to offer the intervention programs that would help caregivers improve their social skills. Such training programs would be important because the use of social skills affects an individual’s ability to maintain positive relationships (Bandeira et al., 2014; Lima et al., 2014.). Caregivers who can be assertive and talk through problems with the elderly care- recipient, as well as with other people involved in the situation, are usually more successful and feel less burdened by their routine of caregiving activities (Muela et al., 2001; Robinson, 1990). Thus, social skills may be a protective factor for caregivers’ health, helping
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them to establish positive connections with others and to obtain greater social support in performing tasks related to their elderly relative’s needs, as well as in other situations outside this context (Braz, Del Prette, & Del Prette, 2011; Carneiro & Falcone, 2013; Lima et al., 2014). Maintaining healthy relationships that allow caregivers to engage in other activities can help them improve their self-esteem, develop a greater sense of personal efficacy, and construct a positive identity during this stage of their lives (Carneiro & Falcone, 2013; Robinson, 1988, 1990). In addition, a well-developed repertoire of social skills that are specific to caregiving (such as being able to raise the spirits of an older person who is experiencing an irreversible health decline, to express positive feelings in this context, and to be empathic) may be essential in mitigating the psychological impacts of dealing with the challenges that are inherent in this activity (Pinto & Barham, 2014a, 2014b). Thus, studying the specificities of the social skills that are needed in the context of caring for a dependent elderly relative is needed, given that research shows that socially competent people have a better quality of life, as well as lower rates of anxiety and depression, compared to the general population (Carneiro & Falcone, 2013; Del Prette & Del Prette, 2013). The caregivers’ coping strategies, which are affected by their social skills, in conjunction with support from their social network, affect their resilience and selfefficacy in managing the demands of caring for a dependent elderly person (Horiguchi & Lipp, 2010). In addition, helping caregivers improve their social skills can increase their ability to obtain support from a greater number of people, which can relieve some of the pressure on their relationships. It is also essential to develop a reliable and valid instrument to assess caregivers’ social skills, which can be used to evaluate the effectiveness and efficiency of interventions to improve these skills among those who care for an elderly relative. One of the key strengths of this study was its focus on an issue that has received little attention in the scientific literature, even at an international level. Although the results are clearly important, the limitations of this study must also be recognized. One such factor is the small number of elderly care-recipients and professionals who were interviewed. Elderly people who have no cognitive impairments, and who depend on a family member for assistance, constitute a population that is difficult to access; many of them prefer to have the caregiver answer questions for them. Most older people have a full-time caregiver only when they begin to develop some form of dementia or a disabling disease that leads to a state of dependency. The number of professionals who participated in the study was also small, as there are still relatively few trained professionals working in the field of geriatrics and gerontology, in Brazil, which makes it difficult to recruit these participants. A further limitation was the fact that the interview schedule had to be developed based on the clinical experience of the researchers, as the number of publications on the social skills of caregivers is very meagre. However, this situation also points to why it is important to develop a tool to evaluate social skills in the specific context of caring for an elderly
Pinto, F. N. F. R., Barham, E. J., & Del Prette, Z. A. P. (2016). Social Skills and Caregiving.
family member, as a person who is socially skilled in one context may not be skilled when performing other tasks, given the situational nature of social skills (Del Prette & Del Prette, 2013; Lima et al., 2014; Pinto & Barham, 2014b). A standardized instrument to assess the social skills resources and difficulties of caregivers who assist an elderly family member would contribute to obtaining more accurate and valid data that can guide the work of professionals. Thus, professionals conducting social skills training programs could increase the quality of their efforts to help caregivers manage their responsibilities and, at the same time, enable them to better care for themselves, avoiding or reducing declines in their physical and emotional wellbeing, and contributing to a greater quality of life for these caregivers.
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cuidadores e não cuidadores [Factors associated with life satisfaction among elderly people who are caregivers and non-caregivers]. Ciência & Saúde Coletiva, 19(8), 34293440. doi:10.1590/1413-81232014198.13952013 Van Groenou, M. I. B., Boer, A., & Iedema, J. (2013). Positive and negative evaluation of caregiving among three different types of informal care relationships. European Journal of Ageing, 10(4), 301-311. doi:10.1007/s10433013-0276-6 Wang, X. R., Robinson, K. M., & Carter-Harris, L. (2014). Prevalence of chronic illnesses and characteristics of chronically ill informal caregivers of persons with dementia. Age and Ageing, 43(1), 137-141. doi:10.1093/ ageing/aft142 Francine Náthalie Ferraresi Rodrigues Pinto is a Doctoralstudent Researcher at the Universidade Federal de São Carlos. Elizabeth Joan Barham is an Associate Professor at the Universidade Federal de São Carlos. Zilda Aparecida Pereira Del Prette is a Full Professor at the Universidade Federal de São Carlos. Received: Feb. 18, 2015 1st Revision: June 2, 2015 2nd Revision: July 31, 2015 Approved: Aug. 3, 2015
How to cite this article: Pinto, F. N. F. R., Barham, E. J., & Del Prette, Z. A. P. (2016). Interpersonal conflicts among family caregivers of the elderly: The importance of social skills. Paidéia (Ribeirão Preto), 26(64), 161-170. doi:10.1590/198243272664201605
Paidéia may-aug. 2016, Vol. 26, No. 64, 171-180. doi:10.1590/1982-43272664201603
Article
Psychometric Analysis of Disordered Eating in Sports Scale (DES)1 Leonardo de Sousa Fortes2 Universidade Federal de Pernambuco, Vitória de Santo Antão-PE, Brazil
Sebastião de Sousa Almeida Universidade de São Paulo, Ribeirão Preto-SP, Brazil
Maria Elisa Caputo Ferreira Universidade Federal de Juiz de Fora, Juiz de Fora-MG, Brazil
Abstract: There is no specific psychometric scale that addresses disordered eating among Brazilian athletes. This study’s aim was to analyze the psychometric properties of the Disordered Eating in Sports Scale (DES) among Brazilian athletes. A total of 1,338 athletes, both sexes, from various sports participated in the study; 141 were excluded. The DES and the Eating Attitudes Test (EAT26) were used to assess disordered eating among the study participants. Exploratory factor analysis revealed a factor structure that explains more than 40% of the scale’s variance. The final version’s items presented factors loadings greater than .3. The Pearson correlation showed a statistically significant relationship between the DES and EAT-26 subscales. No differences were found in the mean scores of DES in an interval of two weeks. The findings indicate differences in DES scores due to body adiposity. The conclusion is that DES showed satisfactory concurrent and discriminant validity and reproducibility. Keywords: eating behavior, athletes, psychometrics
Análise Psicométrica da Escala de Atitudes Alimentares no Esporte (EAAE) Resumo: Não existe escala psicométrica específica que avalie atitudes de risco para os transtornos alimentares em atletas brasileiros. O objetivo do estudo foi analisar as propriedades psicométricas da Escala de Atitudes Alimentares no Esporte (EAAE). Participaram 1.338 atletas de ambos os sexos de diversas modalidades esportivas, no entanto, 141 foram excluídos. Utilizaram-se a EAAE e o Eating Attitudes Test (EAT-26) para avaliar atitudes de risco para os transtornos alimentares nos participantes da pesquisa. A análise fatorial exploratória demonstrou estrutura fatorial que explicou mais de 40% da variância da EAAE. Os itens da versão final da EAAE demonstraram cargas fatoriais superiores a 0,3. A correlação de Pearson indicou relação estatisticamente significante entre a EAAE e as subescalas do EAT-26. Não se identificou diferença das médias dos escores da EAAE no intervalo de duas semanas. Os achados revelaram diferença dos escores da EAAE em função da adiposidade corporal. Concluiu-se que a EAAE demonstrou validade concorrente, discriminante e reprodutibilidade satisfatórias. Palavras-chave: comportamento alimentar, atletas, psicometria
Análisis Psicométrico de la Escala de Actitudes Alimentarias en el Deporte (EAAD) Resumen: No existe una escala psicométrica específica para evaluar las actitudes de riesgo de trastornos alimentarios en atletas brasileños. El objetivo del estudio fue analizar las propiedades psicométricas de Escala de Actitudes Alimentarias en el Deporte (EAAD). Participaron 1.338 atletas hombres y mujeres de diferentes deportes, aunque 141 fueron excluidos. Fueron utilizadas EAAD y la Eating Attitudes Test (EAT-26) para evaluar las actitudes de riesgo de trastornos alimentarios en los participantes de la encuesta. El análisis factorial mostró estructura que explica más del 40% de la varianza. Los ítems de la EAAD mostraron un factor de carga superior a 0,3. La correlación de Pearson mostró una relación estadísticamente significativa entre la EAAD y las subescalas de la EAT-26. No se encontraron diferencias en las puntuaciones medias de la EAAD. Los resultados indicaron diferencia de las puntuaciones de EAAD como una función de la grasa corporal. Se concluyó que la EAAD demostró validez concurrente, discriminante y reproducibilidad satisfactoria. Palabras clave: conducta alimentaria, atletas, psicometría
Anorexia and bulimia nervosa are the most commonly known eating disorders (Ekeroth & Birgegård, 2014). From 1% to 4% of the population in general is affected by anorexia and bulimia nervosa, respectively (Ekeroth & Birgegård, 2014). More specifically, studies indicate that the prevalence of these psychiatric syndromes is even greater among athletes (Fortes, Ferreira, Oliveira, Cyrino, & Almeida, 2015; Francisco, Narciso, & Alarcão, 2013; Plateau, McDermott, Arcelus, & Meyer, 2014). This paper derived from a doctoral dissertation defended by the primary author under the supervision of the third author in 2015 in the Graduate Program in Psychology at the Universidade Federal de Juiz de Fora. 1
Correspondence address: Leonardo de Sousa Fortes. Rua Clóvis Beviláqua, 163/1003, Madalena. CEP 50710-330. Recife-PE, Brazil. E-mail: leonardo.fortes@ufpe.br 2
Available in www.scielo.br/paideia
In fact, many athletes adopt behavior that is typical of patients diagnosed with eating disorders, namely: restricting the intake of food for long periods, self-inducing vomiting, using laxatives/ diuretic drugs to lose body weight, and strenuous physical exercises (Fortes, Kakeshita, Almeida, Gomes, & Ferreira, 2014), behaviors known as “disordered eating behaviors” (El Ghoch, Soave, Cafugi, & Dalle Grave, 2013). Research has shown that approximately 40% of athletes adopt disordered eating behaviors (Galli, Reel, Petrie, Greenleaf, & Carter, 2013; Petrie, Galli, Greenleaf, Reel, & Carter, 2013) and the prevalence of this behavior may vary due to the sport’s characteristics (Fortes, Almeida, & Ferreira, 2014). For instance, scientific studies report that the athletes more susceptible to disordered eating are those competitors wearing athletic apparel
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that emphasizes the body (e.g., acrobatic diving or artistic gymnastics; Fortes et al., 2015) or those sports in which body weight is key to maximize performance (e.g., boxing, judo, or taekwondo; Rouveix, Bouget, Pannafieux, Champely, & Filaire, 2007). Nonetheless, existing psychometric tools used to assess disordered eating behaviors are not specific for the athletic population. Various instruments written in English have been developed in the last 30 years to assess disordered eating behaviors in the population in general, including the Eating Attitudes Test - EAT-26 (Garner, Olmsted, Bohr, & Garfinkel, 1982), Eating Disorders Inventory - EDI (Garner, Olmsted, & Polivy, 1983), Bulimic Investigatory Test - BITE (Henderson & Freeman, 1987), and the Eating Disorder Examination - EDE (Fairburn & Cooper, 1993). These scales address general information concerning symptomology or identify eating disorders. In Brazil, only the EAT-26 (Bighetti, C.B. Santos, J.E. Santos, & Ribeiro, 2004) and BITE (Ximenes, Colares, Bertulino, Couto, & Sougey, 2011) were translated and validated while the EAT-26 was validated only for women and, even though the BITE was validated for both sexes, its items are more directed to the female sex, indicating that there is a need for instruments directed to the male population. Moreover, all these scales were created to identify eating disorders in the population in general. It is not advisable to identify athletes at risk of experiencing disordered eating behaviors using psychometric tools not sensitive to their peculiarities. Note that the environment of sports presents characteristics (e.g. pressure from coaches to improve performance and apparel that highlights the body shape) that, according to Fortes et al. (2015), render athletes vulnerable to eating disorders. Hence, it is extremely important to devise instruments with specific items addressing the environment of sports to more reliably analyze the frequency of disordered eating behaviors among athletes (Galli et al., 2013; Petrie et al., 2013). In this sense, we intended to create and validate the Disordered Eating in Sports Scale (DES) to be used in the context of sports. Its items are classified on a five-point Likert scale (0 = never to 4 = always) and are intended to analyze the frequency of disordered eating behaviors among athletes. The items of the DES male version are more related to increased muscle mass, while those from the female version focus on decreased body weight. It is worth noting, however, that both versions present items addressing weight loss and increased muscle mass. Finally, this study’s objective was to analyze this scale’s psychometric properties (validity, concurrent, discriminant and reproducibility).
Method Development of DES Items The deductive method (DeVellis, 2003) was used to develop the DES. Hence, the items were initially based on the findings of two qualitative studies (De Bruin, Oudejans, Bakker, & Woertman, 2011; Plateau et al., 2014) and reports of two systematic reviews (Bratland-Sanda & Sundgot-Borgen, 2013; El Ghoch et al., 2013). The DES initial version was composed of 31 items (female and male versions). Six professionals with a PhD degree (two nutritionists, two psychologists, and two physical educators),
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experts in the field of disordered eating, were invited to compose the group of experts. The experts were asked to carefully analyze the items of the instrument’s initial version, using standardized forms in order to determine whether the items assessed disordered eating behaviors. The instrument’s second version containing 36 items was developed based on reformulations and additions suggested to the initial version. The experts were asked to analyze the clarity and level of understanding of each of the instrument’s items. The experts were asked to carefully read each item and answered a verbally adapted scale according to the following question: “Did you understand the question?” on a Likert scale: 0 = I did not understand, 1 = I understood a little, 2 = I understood somewhat, 3 = I understood almost everything but still have doubts, 4 = I understood almost everything, 5 = I understood perfectly well and have no doubts. Answers zero, one, two and three refer to insufficient understanding. We also asked the experts to suggest changes and justify their suggestions whenever they did not understand a question or when the language did not seem appropriate. All the scale’s items reached a mean equal to or greater than 4 (I understood almost everything), as recommended by DeVellis (2003), so that the DES second version was applied in a diversified sample of athletes and coaches. The athletes and coaches were asked to fill out a scale concerning the items’ verbal comprehension (0 = I did not understand anything, 1 = I understood just a little, 2 = I somewhat understood, 3 = I understood almost everything but still have doubts, 4 = I understood almost everything, 5 = I understood perfectly well and have no doubts). The entire process of the scale’s development took five months. Participants The population was composed of professional and amateur Brazilian athletes aged 12 years old or older. The sample size was calculated based on the report of a psychometrics expert (DeVellis, 2003) and considering that the scale has 36 items. A minimum sample size of 360 athletes of each sex was established for the psychometric validation. Considering sample losses reported by other studies addressing Brazilian athletes (Fortes, Almeida, et al., 2014; Fortes, Kakeshita, et al., 2014), we decided to add a percentage of 20%. Hence, a number of 432 athletes of each sex was established as this study’s sample size. The following inclusion criteria were adopted: (a) signing a free and informed consent form (or having it signed by a legal guardian in case of minors) and an agreement form; (b) systematically training the sport for at least six hours per week (e.g. at least three days per week for two hours per session or at least six days per week for one hour per session); (c) having participated at least of one regional competition in 2014; (d) be willing to answer the questionnaires and take part in the anthropometric assessment. Exclusion criteria were: (a) having some physical or intellectual disability (reported by the coach); or (b) having used psychoactive medications in the last six months (self-reported). A total of 854 male athletes and 556 female athletes were
Fortes, L. S., Almeida, S. S., & Ferreira, M. E. C. (2016). Eating Attitudes in Athletes.
included, but 141 male athletes and 72 female athletes were excluded for not having completed the entire questionnaire and/or for not having participated of the anthropometric measurement, so that a final sample of 713 male athletes were included [Track and Field (n = 19), Basketball (n = 68), Boxing (n = 12), Canoeing (n = 9), Cycling (n = 16), Soccer (n = 83), Handball (n = 29), Equestrianism (n = 5), Jiu-Jitsu (n = 39), Judo (n = 38), Olympic weightlifting (n = 6), Swimming (n = 136), Water Polo (n = 24), Rowing (n = 23), Rugby (n = 17), Acrobatic diving (n = 6), Surf (n = 69), Taekwondo (n = 12), Tennis (n = 5), Triathlon (n = 15), Sailing (n = 9), Volleyball (n = 52), and Beach volleyball (n = 21)]. The male athletes’ mean age was 17.38 years old (SD = 1.34), 6% presented incomplete middle school and 6% had completed middle school, 19% reported incomplete high school and 24% reported complete high school, 31% had attended some college and the remaining 24% had a bachelor’s degree. The other 484 athletes were women [Track and Field (n = 8), Basketball (n = 34), Boxing (n = 6), Cycling (n = 11), Soccer (n = 36), Artistic Gymnastics (n = 28), Rhythmic Gymnastics (n = 11), Handball (n = 33), Jiu-Jitsu (n = 26), Judo (n = 30), Synchronized Swimming (n = 38), Swimming (n = 84), Figure Skating (n = 17), Water Polo (n = 15), Remo (n = 6), Acrobatic Diving (n = 4), Surf (n = 10), Taekwondo (n = 7), Tennis (n = 8), Triathlon (n = 4), Vela (n = 3), Volleyball (n = 57) and Beach Volleyball (n = 8)], with a mean age of 17.11 (±1.55) years old, 3% of which presented incomplete middle school, 14% had attended complete middle school, 10% reported incomplete high school, 21% reported complete high school, 36% attended some college and the remaining 16% had a bachelor’s degree. All the athletes were associated to the athletic clubs of eight Brazilian states: Ceará (n = 83), Minas Gerais (n = 256), Paraíba (n = 109), Pernambuco (n = 287), Paraná (n = 42), Rio de Janeiro (n = 161), Rio Grande do Sul (n = 58), and São Paulo (n = 201). Instruments Disordered Eating in Sports Scale – DES. It was used to assess disordered eating behaviors among athletes. It is a selfreporting scale composed of 36 items, classified in a five-point Likert scale (0 = never, 1 = rarely, 2 = sometimes, 3 = almost always, 4 = always), intended to assess behavior, attitudes and disordered eating behaviors in the field of sports. The higher the score, the greater one’s vulnerability to disordered eating. Eating Attitudes Test - EAT-26 (Garner et al., 1982). This instrument was applied to assess disordered eating behaviors. The EAT-26 final score results from the sum of its 26 items. There are six options of responses that range from 0 to 3 (always = 3, many times = 2, frequently = 1, a few times = 0, almost never = 0, and never = 0). The version used was validated for the Brazilian population (Bighetti et al., 2004) presenting an internal consistency equal to .82. The Cronbach’s alpha for this study was equal to .88 for men and .89 for women. A (caliper) scientific compass LANGE® (Cambridge Scientific Industries Inc.) was used to measure the thickness of skin folds and calculate percentage of body fat (%BF). Measurement of skin folds was performed according to standard procedures recommended by the International Society for Advancement for
Kinanthropometry (http://www.isakonline.com). %BF was estimated according to the protocols proposed by Slaughter et al. (1988) – taking into account ethnicity and maturational stage based on chronological age (pubescent - 12 to 14 years old; post-pubescent - 15 to 17 years old) –, and by Jackson and Pollock (1978) and Jackson, Pollock and Ward (1980) for male and female adolescents and adults, respectively. Note that body adiposity was classified according to cut off points established by Lohman (1987) (male sex: < 6% = very low; > 7% and < 12% = low; > 13% and < 18% = normal; >19% and < 25% = moderately high; > 26% and < 32% = high; > 32% = very high; female sex: < 11% = very low; > 12% and < 15% = low; > 16% and < 25% = normal; > 26% and <30% = moderately high; > 31% and < 35% = high; > 35% = very high). The classifications very low and low were grouped together in the category low body adiposity, normal and moderately high were grouped in normal body adiposity, and high and very high were grouped in high body adiposity. Body mass was measured using a portable digital scale Tanita® with accuracy of 0.1 kg and maximum capacity of 220 kg. A portable stadiometer with accuracy of 0.1 cm and maximum height of 2.20 m Tonelli® was used to measure the height of athletes. Body Mass Index (BMI) was obtained using the formula: BMI = body mass (kg)/height (m2). Procedure Data collection. The researchers identified coaches of various teams from various sports to explain the procedures and the study’s objectives. After the coaches’ agreement was obtained, a meeting was scheduled with each team to talk with the athletes and explain the study’s ethical procedures. The study was divided into two stages. The first comprised the application of DES and EAT-26. Note that only one researcher was responsible for the application of these questionnaires, so that the procedure was standardized and participants were not influenced by differences in the explanations of other researchers. The athletes received verbal orientation and written orientation was also provided in the questionnaires. The researcher responsible for applying the instruments clarified doubts and no communication among the study’s participants was allowed. The questionnaires were distributed when the athletes entered the room and participation was voluntary. No time limit was established for the completion of the questionnaires. The second stage initiated immediately after the application of the questionnaires and included anthropometric measures (body mass, height, and skin folds). The athletic clubs included in the study provided appropriate rooms for the assessments. The measurements were performed individually to avoid interferences from other members of the teams. These procedures were performed in the clubs and/or competitive events of 11 cities in eight Brazilian states during ten months until the desired sample was achieved. Each team was visited only once. In order to assess the reliability of DES, a retest was applied two weeks later according to what is recommended by DeVellis (2003). Therefore, 100 athletes of each sex from various sports (soccer, judo, swimming, and volleyball) were randomly chosen to answer DES a second time.
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Data analysis. Exploratory factor analysis with principal-axis factoring and Varimax orthogonal rotation was used to extract the DES factors, as suggested in the scientific literature (DeVellis, 2003). The factor solution that explained a variance greater than 40% of the scale was used, replicating the method used by another study addressing athletes (Galli et al., 2013). Additionally, the factors were only considered if composed of three or more items with loading greater than .3, according to other studies validating psychometric scales to identify disordered eating (Fairburn & Cooper, 1993; Henderson & Freeman, 1987). Also, the DES items that presented factor loadings greater than .3 in more than one factor were excluded from the analysis. Cronbach’s alpha was used to analyze the instrument’s and its subscales’ internal consistency. The Kolmogorov-Smirnov test was used to verify distribution of data. Parametric techniques were chosen due to the distribution of the DES scores and Pearson’s correlation was used to verify concurrent validity (relationship between the DES subscales with those of EAT26). To assess the DES reproducibility, dependent Student’s t-test was performed to compare the DES scores in the testretest (interval of two weeks). Intra-class correlation (rintra-class) was performed to relate the scores obtained in the DES items in the test-retest. Discriminant validity was verified with the univariate analysis of covariance (ANCOVA), controlling for age to compare the DES scores of classifications regarding fat percentage (low, normal and high). We chose to control age because other studies indicate there is a relationship between
age and disordered eating behaviors among athletes (Fortes, Almeida, et al., 2014; Fortes et al., 2015). The Bonferroni post hoc test was used to identify the groups that differed. Additionally, the Cohen size effect, represented by d, was calculated to indicate the importance of the findings from a practical point of view. Data analysis was performed using SPSS 21.0 and 5% was the level of significance adopted. Ethical Considerations The project was approved by the Institutional Review Board at the Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto of the Universidade de São Paulo (CAAE n. 05166712.8.0000.5407). The legal guardians of athletes younger than 18 years old signed free informed consent forms that contained the study’s objectives and procedures. All the athletes (adults and minors) signed a consent form agreeing with voluntary participation. Confidentiality of the participants’ identities and data was ensured.
Results The demographic characteristics of the athletes addressed in this study are presented in Table 1. The factor analysis conducted with the 36 items in the DES male version indicated problems with 15 items, namely: 2 (“My diet is so well-balanced that I do not
Table 1 Demographic Characteristics of Athletes Participating in the Study Sex Variable
Female (N = 484)
Male (N = 713)
M (SD)
Min - Max
M (SD)
Min - Max
17.11 (1.55)
12.00 - 36.00
17.88 (1.34)
12.00 - 41.00
Duration of sports practice (years)
8.76 (2.33)
3.00 - 24.00
9.60 (1.95)
2.00 - 28.00
Weekly training regimen (hours)
12.71 (2.89)
6.00 - 36.00
13.51 (2.24)
6.00 - 42.00
Percentage of fat
21.60 (4.48)
9.23 - 32.45
17.73 (5.01)
4.31 - 29.70
Body Mass Index (kg/m²)
22.97 (1.32)
15.29 - 30.10
23.56 (1.22)
16.39 - 30.85
N
%
N
%
12 – 18 years old
262
54
359
50
18 – 25 years old
145
30
230
32
> 25 years old
77
16
124
18
Regional
93
19
46
7
State
160
33
250
35
National
104
22
231
32
International
127
26
187
26
Caucasian
288
60
306
43
Afro-descendant
81
16
214
30
Asian
44
9
61
9
Mixed
71
15
132
18
Age (years)
Age
Competitive level
Ethnicity
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need to take medications and/or supplements to improve my performance”), 3 (“I do not usually eat much before training sessions”), 5 (I think my coach is satisfied with my diet”), 6 (“I eat a lot before training sessions”), 10 (“I guess my coach wish I were stronger”), 13 (“My teammates push me to become more muscular”), 14 (“I do not believe that dietary supplements, for instance Whey Protein, Creatine, BCAA, or L-Carnitine would improve my performance”), 16 (“I keep exercising when I am hurt”), 17 (“I think that my diet is appropriate to improve my performance in competitions”), 21 (“I think that my teammates find my eating habits healthy”), 23 (“I use laxatives and/or diuretics before competitions to loose weight”), 27 (“I feel guilty when I eat in excess after competitions”), 28 (“I use steroids
to improve my athletic performance”), 29 (“I think my opponents would like to have a diet like mine”), and 33 (“I think my opponents find me weak”). Factor analysis with 21 items was performed afterwards, which showed a solution of five factors that explained 51.15% of the variance in the DES male version. KMO was equal to .89 and Bartlett’s sphericity test indicated a value of 2,871.90 (p = .001). The commonalities of all items were greater than .25. The factor loadings of all items were greater than .3. Additionally, the findings of all the items show factor loadings in a single factor, as indicated in Table 2. The factor analysis performed with the 36 items of the DES female version revealed problems with 17 items, namely: 2 (“My diet is so well-balanced that I do
Table 2 Analysis of Factors of the DES Male Version Items
Questions
1
I do not usually eat before training.
4
I eat any type of food before training
7
I practice beyond the necessary to burn calories
.64
8
I like to feel my stomach empty after training sessions
.59
9
After training I eat until I feel satiated
11
I wear warm/plastic clothes during training to lose weight
12
I eat more than necessary after training sessions
15
I avoid eating in the weeks that precede competitions
18
I always feel hungry after training
19
I refuse using steroids when my peers offer
20
I eat in excess on days that precede competitions
22
I eat food I like after competitions
24
I think I should change my eating habits due to the demands of my sport
25
I eat foods that favor weight gaining on the eve of competitions
26
I think that using substances to lose weight, laxatives and diuretics for instance, would compromise my sports performance
30
I usually eat nothing after competition
31
I would like to use food supplements that can improve my performance during training.
32
I eat an amount of food that is considered to be normal for athletes that practice my sport
34
I exercise beyond the recommended by my coach to gain muscles
35
I do not eat beyond what my stomach can take before competitions
36
I train on days when I am supposed to rest to increase my muscle mass
% of the variance explained Cronbach’s α Kaiser-Meyer-Olkin (KMO) Bartlett’s test
Factor 1
Factor 2
Factor 3
Factor 4
Factor 5
.46 .59
.67 .66 .67 .65 .73 .49 .79 .67 .62 .73 .60 .51 .67 .67 .64 .75 .59 16.95
15.97
7.32
6.26
5.33
.78
.66
.75
.73
.66
.89
p < .001
2,871.90
p < .001
Note. Name of the subscales: Factor 1 = Binge eating in the field of sports, Factor 2 = Food restriction and weight reduction, Factor 3 = Healthy eating behavior in the sports context [all the items present an inverted score (4 = never, 3 = rarely, 2 = sometimes, 2 = almost always, 1 = always)], Factor 4 = The use of substances/drugs and satiety in sports [all the items present inverted scores (4 = never, 3 = rarely, 2 = sometimes, 2 = almost always, 1 = always)], Factor 5 = Behaviors and cognitions directed to increased muscle mass/performance.
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not need medications and/or supplements to improve my performance”), 4 (“I eat any type of food before training”), 5 (I think my coach is satisfied with my diet”), 6 (“I eat a lot before training sessions”), 7 (“I practice beyond the necessary intending to burn calories”), 8 (“I like to feel my stomach empty after training sessions”), 12 (“After training sessions I eat more than the necessary”), 13 (“My teammates push me to become more muscular”), 14 (“I do not believe supplements would improve my performance”), 15 (“I avoid eating in the weeks that precede competitions”), 16 (“I keep exercising when I am hurt”), 20 (“I eat compulsively on days that precede competitions”), 22 (“I eat food I like after competitions”), 24 (“I realize I should change my eating habits due to the demands of my sport”), 25 (“I eat food that favor weight gaining on the eve of competitions”),
35 (“Before competitions I do not eat more than what my stomach tolerates”), and 36 (“I train on days I am supposed to rest to decrease my body fat”). Afterwards, factor analysis was conducted with 19 items, forcing a solution of 4 factors, which explained 45.24% of the variance in the DES female version. KMO was equal to .76 and the Bartlett’s sphericity test indicated a value of 1,980.78 (p = .001). The communalities of all items were greater than .24. The factor loadings of all items were greater than .3. Additionally, the findings of all the items showed factor loading in a single factor, as indicated in Table 3. With regard to the internal consistency, Cronbach’s alpha obtained by the DES male version was .74 and the Cronbach’s alphas obtained by factors 1, 2, 3, 4 and 5 were .78, .66, .75,
Table 3 Analysis of Factors of the DES Female Version Items
Questions
1
I do not usually eat before training.
.76
3
I do not usually eat much before training
.62
9
After training I eat an amount of food that satiates me
.52
10
I think my coach would like I were skinner
11
I wear warm/plastic clothes during training to lose weight
17
I think my diet is appropriate to improve my performance in competitions
18
I always feel hungry after training
19
I refuse using steroids when my peers offer
21
I guess my teammates think my eating habits are healthy
23
I use laxatives and/or diuretics before competitions to lose weight
26
I think that using substances to lose weight, laxatives and diuretics for instance, would compromise my sports performance
.51
27
I feel guilty when I eat in excess after competitions
.68
28
I use laxative and/or diuretics to improve my athletic performance
29
I think my opponents would like to have a diet like mine
30
I do not usually eat after competing
.43
31
I would like to use food supplements to improve my performance during trainings.
.34
32
I eat an amount of food that is considered to be normal for athletes that practice my sport
33
I think my opponents think that I am fatty
.73
34
I exercise harder to stay skinny
.66
% of the variance explained Cronbach’s α Kaiser-Meyer-Olkin (KMO) Bartlett’s test
Factor 1
Factor 2
Factor 3
Factor 4
.74 .60 .68 .38 .46 .82 .71
.86 .63
.69
16.25
12.24
9.03
7.72
.60
.71
.82
.78
.76
p < .001
1,980.78
p < .001
Note. Name of the subscales: Factor 1 = Perception of pressure to become skinny and use substances [items 19 and 26 present inverted score (4 = never. 3 = rarely. 2 = sometimes, 2 = almost always, 1 = always)], Factor 2 = Perception of healthy diet [items 17 and 21 present inverted score (4 = never, 3 = rarely, 2 = sometimes, 2 = almost always, 1 = always)], Factor 3 = Pathological methods to reduce body weight, Factor 4 = Healthy diet in the sports field [all items present inverted score (4 = never, 3 = rarely, 2 = sometimes, 2 = almost always, 1 = always)].
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.73 and .66, respectively (Table 2). The DES female version obtained an internal consistency of .75, while factors 1, 2, 3 and 4 obtained .60, .71, .82 and .78, respectively (Table 3). Table 4 presents the results concerning the scale’s concurrent validity. Pearson’s correlation showed a
statistically significant relationship between DES and EAT26 (p ≤ .001). With regard to the scale’s reproducibility, no differences were identified between the means of scores obtained in the male (F(2, 710) = 3.14, t = 1.44, p = .39, d = .1) and female versions
Table 4 Statistical Data Concerning Concurrent Validity (DES vs. EAT-26) and Reproducibility (T1 vs. T2) Analysis
Variable
Parameter
p
Male sex Correlation
Reproducibility (T1 vs. T2)
Pearson Factor 1 DES vs. EAT-26
r = .17
.001
Factor 2 DES vs. EAT-26
r = .23
.001
Factor 3 DES vs. EAT-26
r = .12
.001
Factor 4 DES vs. EAT-26
r = .09
.08
Factor 5 DES vs. EAT-26
r = .12
.001
EICCE vs. EAT-26
r = .26
.001
DES score
Student’s t
t = 1.44
.39
DES items
ricc
r = .86
.001
Factor 1 DES vs. EAT-26
r = .35
.001
Factor 2 DES vs. EAT-26
r = .10
.28
Factor 3 DES vs. EAT-26
r = .39
.001
Factor 4 DES vs. EAT-26
r = .07
.28
EICCE vs. EAT-26
r = .44
.001
Female sex Correlation
Reproducibility (T1 vs. T2)
DES Score
Student’s t
t = 1.33
.31
DES items
ricc
r = .90
.001
Note. DES = Disordered Eating in Sports Scale; EAT-26 = Eating Attitudes Test.
(F(2, 482) = 2.13, t = 1.33, p = .31, d = .1), applied at a two-week interval. The effect size was low for both sexes, indicating that it is likely that no differences will be found in the scores obtained in the DES when applied in samples similar to the one addressed in this study within a period of two weeks. Additionally, the intra-class correlation coefficient was statistically significant for the male (r = .86, p = .001) and female (r = .90, p = .001) versions, indicating good reproducibility. Despite discriminant validity, ANCOVA indicated statistically significant difference in the scores obtained in the male (F(3, 710) = 56.91, p = .001, d = .6) and female versions (F(3, 481) = 37.24, p = .01, d = .5) due to the classifications of body adiposity. High body adiposity in the male group scored higher than normal body adiposity (F(2, 711) = 37.05, p = .01, d = .5), and low body adiposity (F(2, 711) = 76.50, p = .001, d = .6). Likewise, the category normal body adiposity scored higher than low body adiposity (F(2, 710) = 42.17, p = .01, d = .5). High body adiposity in the female sex scored higher than the normal body adiposity (F(2, 344) = 31.57, p = .01, d = .5) and low body adiposity (F(2, 290) = 53.01, p = .001, d = .6).
Similarly, normal body adiposity scored higher than the low body adiposity category (F(2, 360) = 31.87, p = .01, d = .5). Note that age revealed collinearity with DES scores for the male sex (F(1, 712) = 12.35, p = .01), which did not occur with the female sex (F(1, 483) = 2.09, p = .28).
Discussion The study’s primary goal was to analyze the DES’ psychometric validity among Brazilian athletes. The findings present a factor structure that explains more than 40% of the scale’s variance and internal consistency, with values greater than .60 in all the subscales. Additionally, the DES findings indicated concurrent validity as well as appropriate reproducibility, assessed in an interval of two weeks. Finally, the results show discriminant validity based on the classifications of body adiposity. The DES male version revealed a five-factor structure that explains 51.15% of its variance, as recommended by DeVellis (2003). A total of 15 items were excluded from the
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scale because they did not present a minimum factor loading of .30, or factor loading was equal to or higher than 0.30 in more than one factor. The DES female version showed a structure distributed into four factors that explained approximately 46% of its variance. A total of 17 items were excluded, as they presented factor loading equal to or higher than .30 in more than one factor. Note that another study addressing the development of a psychometric scale for athletes also reports the exclusion of items to achieve the scale’s final version (Martinsen, Holme, Pensgaard, Torstveit, & Sundgot-Borgen, 2014). Additionally, the cut off point of .30 for the factor loading was also adopted by another study validating a psychometric scale directed to athletes (Scoffier, Paquet, Corrion, & d’Arripe-Longueville, 2010), corroborating this study’s findings. Nonetheless, other studies addressing the validation of psychometric tools intended to identify eating disorders in the Brazilian population did not perform factor analysis (Bighetti et al., 2004; Ximenes et al., 2011) hindering further comparisons. The internal consistency presented by the DES male version was greater than .65 for the total scale and subscales. Thus, it is in agreement with the recommendations of experts in psychometrics (DeVellis, 2003). The internal consistency of the DES female version was also equal to or greater than .65 for all the factors except for Factor 1, the internal consistency of which was .60. Authors emphasize that the number of items influences the internal consistency of a subscale (Galli et al., 2013; McNamara & McCabe, 2013), thus, a subscale with few items can reach internal consistency below .70. This was identified for Factors 2 and 5 of the male version and Factor 1 of the female version, that is, a small number of items were presented in these factors. Another study addressing a psychometric validation for the population of athletes revealed internal consistency below .70 for some subscales (McNamara & McCabe, 2013), corroborating this study’s findings. The findings indicate there is a significant statistical relationship (between .12 and .26) between the DES male version and EAT-26. The results also indicate a statistically significant relationship (between .35 and .44) between the DES female version and EAT-26, which is in agreement with the concurrent validity processes of other studies addressing psychometric instruments aimed to identify disordered eating (Fairburn & Cooper, 1993; Henderson & Freeman, 1987). These findings indicate that the higher the score obtained in the DES, the higher the scores obtained in another psychometric tool that assess disordered eating behaviors. Note that other studies addressing the validation of psychometric scales directed to athletes also reveal concurrent validity (Martinent, Decret, Isoard-Gautheur, Filaire, & Ferrand, 2014; McNamara & McCabe, 2013). It is worth noting that Factor 4 (“The use of substances/ drugs and satiety in sports”) of the DES male version does not relate to EAT-26. This finding may be explained by the fact that the DES Factor 4 is intended to analyze the refusal of individuals to use anabolic steroids/drugs and satiety while the EAT-26 assess food restriction, purging and environmental forces that encourage food intake. Hence, because these are
178
different constructs, the results do not indicate a statistically significant relationship, which is in agreement with the findings of other studies addressing athletes (Besharat, 2010; Martinent et al., 2014). Likewise, no relationship was found between Factor 2 of the DES female version and EAT-26, or between Factor 4 and EAT-26. These results can be explained by the fact that Factor 2 analyzes the perception of athletes with regard to their diet and Factor 4 assesses healthy eating habits in the sports environment, while the EAT-26 assesses food restriction, purging and forces from the environment encouraging food intake. Hence, the constructs are different and the results do not reveal statistically significant relationships, which is in agreement with the results reported by other studies addressing athletes (Besharat, 2010; Martinent et al., 2014). With regard to the scale’s reproducibility, no differences were found in the DES test-retest. The intra-class correlation coefficient was significant for both the male (r = .86) and female (r = .90) versions. These findings indicate the DES’ good stability in a period of two weeks, corroborating the recommendations of a psychometrics expert (DeVellis, 2003). Other studies also report good stability of other psychometric tools to identify eating disorders (Fairburn & Cooper, 1993; Henderson & Freeman, 1987). Note, however, that other studies addressing the validity of scales directed to athletes did not analyze the stability of the psychometric tool (Galli et al., 2013; Martinsen et al., 2014; McNamara & McCabe, 2013), which hinders comparisons with the results presented by this study. The results concerning discriminating validity reveal differences in the scores obtained in the DES due to the body adiposity classifications, that is, the higher one’s body adiposity, the higher the DES score. This finding indicates that the instrument has good discriminant validity, since the findings of other scientific investigation indicate that athletes with greater body adiposity more frequently present disordered eating behaviors (Fortes, Almeida, et al., 2014). In the study validating the EAT-26, Garner et al. (1982) addressed a group of women with clinical diagnosis of anorexia nervosa as discriminant validity criterion. According to DeVellis (2003), researchers should adopt a criterion of discriminant validity of the new psychometric tool capable to discriminate individuals with distinct characteristics regarding the phenomenon under study. Therefore, based on this study’s findings, we consider it important to use body adiposity as a criterion of discriminant validity for DES. Even though this study reveals unpublished results, some limitations need to be acknowledged. One limitation refers to the use of questionnaires as the primary instruments. Researchers state that individuals may not reliably answer self-reporting instruments (Fortes, Almeida, et al., 2014; Thompson & Sherman, 2014). Therefore, the results may not reliably reflect the context under study as they refer to subjective responses. Researchers, however, emphasize these instruments are relevant as long as psychometric qualities are ensured (Fortes et al., 2015). Additionally, some sports were represented by a small sample size, which may have biased the results, while this study’s sample may not be
Fortes, L. S., Almeida, S. S., & Ferreira, M. E. C. (2016). Eating Attitudes in Athletes.
representative of the population of Brazilian athletes. Despite these limitations, we believe that both versions (male and female) of DES met psychometric requirements, justifying its use with athletes. The results indicate that the DES female and male versions present satisfactory factor structure, concurrent and discriminant validity, and reproducibility. Hence, DES is a good instrument to analyze behaviors that favor disordered eating among athletes. This new scale can be used in research and practical (coaches) contexts to analyze disordered eating behaviors in the population of athletes. Additionally, further studies are needed to assess DES’ external validity. Finally, we recommend that the DES versions be adapted and validated in other languages and cultures to favor comparisons of disordered eating behaviors among athletes from different countries.
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McNamara, J., & McCabe, M. P. (2013). Development and validation of the Exercise Dependence and Elite Athletes Scale. Performance Enhancement & Health, 2(1), 30-36. doi:10.1016/j.peh.2012.11.001 Petrie, T. A., Galli, N., Greenleaf, C., Reel, J., & Carter, J. (2014). Psychological correlates of bulimicsymptomatology among male athletes. Psychology of Sport and Exercise, 15(6), 680-687. doi:10.1016/j. psychsport.2013.09.002 Plateau, C. R., McDermott, H. J., Arcelus, J., & Meyer, C. (2014). Identifying and preventing disordered eating among athletes: Perceptions of track and field coaches. Psychology of Sport and Exercise, 15(6), 721-728. doi:10.1016/j.psychsport.2013.11.004 Rouveix, M., Bouget, M., Pannafieux, C., Champely, S., & Filaire, E. (2007). Eating attitudes, body esteem, perfectionism and anxiety of judo athletes and nonathletes. International Journal of Sports Medicine, 28(4), 340345. doi:10.1055/s-2006-924334 Scoffier, S., Paquet, Y., Corrion, K., & d’Arripe-Longueville, F. (2010). Development and validation of the French Selfregulatory Eating Attitude in Sports Scale. Scandinavian Journal of Medicine & Science in Sports, 20(4), 696-705. doi:10.1111/j.1600-0838.2009.00984.x Slaughter, M. H., Lohman, T. G., Boileau, R. A., Horswill, C. A., Stillman, R. J., Van Loan, M. D., & Bemben, D. A. (1988). Skinfold equations for estimation of body fatness in children and youth. Human Biology, 60(5), 709-723. Thompson, R. A., & Sherman, R. (2014). Reflections on athletes and eating disorders. Psychology of Sport and Exercise, 15(6), 729-734. doi:10.1016/j. psychsport.2014.06.005 Ximenes, R. C. C., Colares, V., Bertulino, T., Couto, G. B. L., & Sougey, E. B. (2011). Versão brasileira do “BITE” para uso em adolescentes [Brazilian version of “BITE” for use in adolescents]. Arquivos Brasileiros de Psicologia, 63(1), 52-63. Leonardo de Sousa Fortes is a Professor of the Núcleo de Educação Física e Ciências do Esporte of the Universidade Federal de Pernambuco. Sebastião de Sousa Almeida is a Full Professor of the Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto at Universidade de São Paulo. Maria Elisa Caputo Ferreira is an Adjunct Professor of the Faculdade de Educação Física e Desportos at Universidade Federal de Juiz de Fora Received: May 18, 2015 1st Revision: Sep. 9, 2015 Approved: Oct. 7, 2015 How to cite this article: Fortes, L. S., Almeida, S. S., & Ferreira, M. E. C. (2016). Psychometric analysis of Disordered Eating in Sports Scale (DES). Paidéia (Ribeirão Preto), 26(64), 171-180. doi:10.1590/1982-43272664201603
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Article
Self-Compassion in Relation to Self-Esteem, Self-Efficacy and Demographical Aspects1 Luciana Karine de Souza2 Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
Claudio Simon Hutz Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
Abstract: This study investigated relationships between self-compassion, self-efficacy, and self-esteem, as well as age and sex differences and other sociodemographic variables in relation to self-compassion. Four-hundred and thirty-two Brazilian adults (50% women) from nearly all country states participated in the study filling out a sociodemographic survey and three scales: self-compassion, self-efficacy, and self-esteem. Comparisons of means between self-compassion and pairs of groups designed by sociodemographic data showed higher self-compassion in men, people aged from 31 to 66 years-old, not under psychiatric medication, without a job, and with children. Results also showed that self-compassion is highly correlated with self-esteem and self-efficacy. We highlight that results are sample dependent and further studies on self-compassion need to be conducted in Brazil. Keywords: self-compassion, self-esteem, self-efficacy
Autocompaixão e Suas Relações com Autoestima, Autoeficácia e Aspectos Sociodemográficos Resumo: O presente estudo teve por objetivo investigar as relações entre autocompaixão, autoestima e autoeficácia e diferenças de sexo, idade e de outras variáveis sociodemográficas na autocompaixão. Participaram 432 adultos (50% mulheres), de 24 estados brasileiros, preenchendo dados sociodemográficos e um conjunto de três escalas: autocompaixão, autoestima e autoeficácia. Comparações de médias da autocompaixão por grupos compostos a partir dos dados sociodemográficos permitiram observar maior autocompaixão em: homens, com idade entre 31 e 66 anos, sem uso de medicação psiquiátrica, sem atividade remunerada e com filhos. Os resultados também mostraram que autocompaixão apresenta correlações elevadas com autoeficácia e autoestima. Salienta-se que os resultados são atinentes a esta amostra e que mais estudos precisam ser conduzidos no Brasil sobre autocompaixão. Palavras-chave: autocompaixão, autoestima, autoeficácia
Autocompasión y Sus Relaciones con Autoestima, Autoeficacia y Aspectos Sociodemográficos Resumen: El presente trabajo investigó las relaciones entre autocompasión, autoestima y autoeficacia y las diferencias entre sexo, edad y otras variables sociodemográficas en la autocompasión. Participaron 432 adultos (50% mujeres) de 24 Estados brasileños, llenando datos sociodemográficos y un conjunto de tres escalas: autocompasión, autoestima y autoeficacia. Comparaciones de promedios de la autocompasión en grupos compuestos a partir de los datos sociodemográficos, permitieron observar mayor autocompasión en: hombres con edad entre 31 y 66 años, sin uso de medicamento psiquiátrico, sin actividad remunerada y con hijos. Los resultados también mostraron que autocompasión presenta correlaciones elevadas con autoeficacia y autoestima. Se resalta que los resultados son relacionados con esta muestra y que más estudios necesitan ser conducidos en Brasil, con respecto a la autocompasión. Palabras clave: autocompasión, autoestima, autoeficacia
Study derived from the post-doctoral research project “Adaptation and Validation of the Self-Compassion Scale”, conducted by the first author, under the supervision of the second author. Acknowledgement: We would like to thank K. Neff, L. Taborda, J. Natividade, J. Rique, A. Antoniazzi, J. Sarriera, and the 2012 team of Laboratory of Measurement at Universidade Federal do Rio Grande do Sul (UFRGS). Institutional support: Psychology Department at Universidade Federal de Minas Gerais and Programa de PósGraduação em Psicologia at UFRGS. Support: National Council for Scientific and Technological Development CNPq (Grant # 159687/2011-0). 2 Correspondence address: Luciana Karine de Souza. Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Psicologia. Rua Ramiro Barcelos, 2600. CEP 90035-003. Porto Alegre-RS, Brazil. E-mail: lukarides@gmail.com 1
Available in www.scielo.br/paideia
Self-compassion is compassion placed on the person himself. It is not self-pity, self-commiseration or selfindulgence. Medeiros and Sougey (2010) have used the expression “self-compassionate thoughts” (p. 29) to describe a certain cognitive distortion typical of depressed patients. Nevertheless, an expression such as “self-pity thoughts” (pensamentos de autopiedade) would better describe this attitude. Self-compassion does not mean that. Neff (2003a), inspired by a Buddhist concept of selfcompassion (SC), pioneered in both providing an operational definition and a measure for SC. While compassion entails
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openness and allowing oneself to be in touch with someone else’s suffering in such a way that one wants that suffering to be relieved, SC is a self-understanding attitude which requires to allow oneself to be in touch with one’s own suffering, manifest openness towards it while seeking not to turn away or to be disconnected from it. This openness should lead to the wish to assuage the suffering, to heal oneself with kindness, without judgments, through the understanding of one’s sorrows, inadequacies and failures. In this way these experiences will, through SC, be recognized as part of a broad human experience. Furthermore, feelings of SC, when genuine and complete, awaken one’s desire for one’s health and well-being (Neff, 2003a, 2003b). SC has six elements: self-kindness, self-judgment, isolation, common humanity, over-identification, and mindfulness. Self-kindness means applying kindness and good-will towards oneself, avoiding harsh judgments and self-criticism. Common humanity implies one understands one’s own experiences as part of a wider human experience, refraining from grasping them as separate, isolating them. Mindfulness, on the other hand, is to maintain a balanced awareness of painful feelings and thoughts, instead of overidentifying with or denying them (Neff, 2003a). These elements work together in the manifestation of SC. At the outset, the first step for SC to develop is a balanced mental state originated in mindfulness, which allows for a more universal understanding of suffering, and for the emergence of self-kindness; moreover, this mental state reduces self-criticism and increases self-understanding. The balanced point-of-view that comes through mindfulness hinders self-centeredness, which leads to the idea of isolation within the experience of sufferings, errors and failures. It fosters feelings of connection through awareness of common humanity in the context of a universal understanding of negative experiences. Also both self-kindness and awareness of common humanity help reducing harsh self-criticism and severe judgment directed towards oneself, allowing for the emergence of self-acceptance, which then reduces the emotional load concomitant with the experience of suffering, and thus facilitating the maintenance of a well-balanced consciousness between thoughts and feelings (Neff, 2003a). Self-pity, on the other hand, distances one from others, engulfing one in one’s own problems. In doing that, the subject disregards that others may face similar or even more severe difficulties, allowing one to be overcome by negative feelings. Thus the experience of suffering is exaggerated, leading to an over-identification with it. In contrast to that, SC allows for the recognition of relatedness between humans and a sense of shared experiences (both good and bad). In this way over-identification with suffering is avoided, reducing egocentrism and promoting a sense of interconnectedness with others (Neff, 2003a, 2003b). Neff (2003b) has created and validated the SelfCompassion Scale (SCS). The author has found significant negative correlations with self-criticism, and positive ones with social connection; with good performance in a testretest within a three week interval, showing correlations between .80 and .93; and a moderate correlation (r = .59)
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with Rosenberg’s Self-Esteem Scale (RSES). Comparisons with anger, anxiety and life satisfaction have confirmed SCS ability to predict aspects of psychological health. Finally, Neff (2003b) has, in the same research, investigated 43 practicing Buddhists that, compared to college students, showed significantly more SC. Detailed analysis indicated that Buddhist practice wielded a greater effect on SC than on self-esteem. A significant positive correlation was found between SCS scores and how long Buddhism had been practiced. SCS was adapted and validated for use in Brazil by Souza and Hutz (in press), and named Escala de Autocompaixão (EAC). The 26 items on the original scale were maintained and internal consistency was .92. A search for self-compassion on the title of English language peer-reviewed articles published over the last 10 years, and available on Portal Periódicos CAPES, results in almost 100 studies on SC, though none of them with a Brazilian sample. Studies correlate SC (almost all using SCS) with constructs such as optimism, hope, subjective well-being, empathy, resiliency, body image, stress, coping, homesickness, academic failure, and depression. As the article compilation showed, many aspects are suitable for analysis with SC. It seems pertinent to ask, for example, if there are differences between SC in men and women, or between teenagers, adults and the elderly. What follows is a summary of available studies that deal with different age and gender aspects, as they relate to SC. Self-Compassion and Age and Gender Differences Neff (2003b) found significantly lower SC scores on women. Women scored higher than men in self-criticism, isolation and over-identification, and had lower mindfulness scores. On the Buddhist practitioner’s sample, however, the absence of gender differences was an indication for the author that such practice fosters mental health in both men and women. Neff, Rude and Kirkpatrick (2007) and Iskender (2009) have failed to detect SC gender differences. However, Neff and McGehee (2010), while comparing adolescents and adults, did not found SC gender differences related in the former, while detecting lower SC in adult women. Research results suggest SC gender differences remain an open issue. On the topic of age differences, Neff (2003a, 2009) resorts to Elkind (1967) to argue SC is challenging for teenagers. According to the latter, at this stage in life the individual is immersed in self-reflections, self-evaluations and comparisons with expected social standards. In his concept of teenage egocentrism, the mechanisms of personal fable (the certainty that what passes happens only to the individual and nobody else) and imaginary audience (constant sensation of being in a stage with an audience, watching) contribute to this self-immersions, as well as a heighten self-monitoring of magnified defects and imperfections. These cognitive distortions contribute to the sudden changes of humor teenagers experience in a single day. In this sense, teenage egocentrism would empower isolation, self-criticism and over-identification – three elements of SC. Neff and McGehee (2010), in a study that compared teenagers and young adults, did not find significant SC
Souza, L. K., & Hutz, C. S. (2016). Self-Compassion, Self-Esteem, Self-Efficacy.
differences related to age. Neither such differences were found by Neff e Pommier (2013), in a research with college students and adults that were not enrolled in higher education. The issue of age therefore also still needs to be investigated. SC is a psychological health construct that seeks to contribute for the understanding of how the subject sees herself and deals with herself when faced with his own life’s difficulties and sufferings. It seeks to show how the subject evaluates herself when confronted with mistakes and failures. Self-esteem is another concept related to the way people value themselves in relation to others, and how they evaluate their lives. In the next section we discuss the concept of selfesteem in contrast to SC. Self-Compassion Versus Self-Esteem in Evaluating a Healthy Attitude Hewitt (2005) states self-esteem as culturally based, originating from “a culture that nourishes a belief in the importance of the individual self even while making the self problematic” (p. 135) – the US culture. People follow social expectations in order to be accepted, and thus increase their self-esteem; they develop close relationships with those who evaluate them in a positive light; in order to increase their self-efficacy they engage in tasks in which they believe they can be successful. This bias, which continuously serves the self, protects self-esteem, allowing people to receive credit for their successes and blame others for failures. Neff (2003a, 2003b) develops four arguments against self-esteem. First, due to its change-resistant character, it seems difficult for self-esteem to be increased. Second, excessive emphasis on self-esteem can lead to narcissism, self-absorption, absence of care/concern towards others, distorted self-perception and egocentrism. In third place, the wish to increase self-esteem can, on the other hand, lead one to seek out the worst in others so that one may positively stand out in contrast. The fourth argument comes from research showing positive association between high selfesteem and xenophobia: an inflated sense of self-esteem can lead to aggression and violence against those perceived as a threat. In bullying, for example, the aggressor acts that way in order to feel good (Neff, 2009). With SC it is not necessary to resort to social comparison for self-acceptance, nor to run the risk of creating numerous or unreal expectations in an effort to get approval or reinforcement – which are all possibilities in self-esteem (Neff, 2003a, 2003b). To accept one’s own mistakes and failures, to bestow kindness upon oneself, to balance thoughts and feelings over experienced suffering and to recognize oneself as a member of a human community (fallible and able to learn through errors and sorrows) allows for an accurate view of experiences and subjective states, a realist perspective over difficulties, faults and inadequacies, as well as over potentialities for change and the pursuit of happiness. Indeed, considering these points, it appears that promoting SC is more desirable than increasing self-esteem. While working on the validation for the SCS, Neff (2003b) ascertained a significant positive correlation (r =
.59) between RSES and SCS, suggesting that they are similar constructs, with distinctions. The result was also interpreted as evidence that we should expect self-compassionate people to have a greater sense of self-worth in contrast to those who disallow themselves to err, believe their own suffering is unique, and over-identify with their own feelings – that is, people with low SC. Significant positive correlations were found between self-esteem and narcissism, while non-significant positive ones were found between narcissism and SC. According to Leary, Tate, Adams, Allen and Hancock (2007), “when people high in self-esteem encounter negative life events, they sometimes engage in self-serving biases (…), presumably because reactions help to make them feel better about themselves” (p. 902). This defensiveness contributes to the argument that SC and self-esteem engender different processes. Neff and Vonk (2009) compared three instruments of self-esteem (global, contingent and state self-esteem) to SCS and self-worth measures, social comparison, public self-consciousness, rumination, narcissism, anger, need for cognitive closure, optimism, happiness and positive affection. SC, better than self-esteem, predicted stability of self-worth feelings; it had significant and negative association with anger, social comparison, public self-consciousness, rumination and the need for cognitive closure; and it was able to predict significant additional variances over happiness, optimism and positive affection, while controlling for selfesteem. Narcissism was shown to be positively associated with self-esteem, but not to SC, as in Neff (2003b). According to Neff (2011), SC “is available precisely when self-esteem fails us – when we fall flat on our face, embarrass ourselves, or otherwise come in direct contact with the imperfection of life” (p. 6). While self-esteem leads to feelings of superiority and self-confidence, SC promotes a sense of safety and protection. Vonk and Smit (2012), in a recent study correlating SC and self-esteem, sampled 3.575 Netherlanders aged from 16 to 83 years old. The self-esteem scale created by the authors correlated significantly and positively both with RSES (r = .86) and SCS (r = .62). In Brazil RSES seems to be the preferred choice for research. Hutz and Zanon (2011) work pointed out that people between 20 and 30 years of age show less self-esteem than other age groups, and that men aged 16 to 19 years old present higher scores. An important psychological construct associated with the way people think about seeking personal goals is self-efficacy. If one completely identifies with an illness one is facing (overidentification), severely criticizes one’s own incapacities, even when they are transitory (self-criticism), mistreats oneself (shows no self-kindness), avoids interaction (isolation), does not think clearly or is not able to measure emotional reactions (without the balance of mindfulness), and believes to be the only one to suffer this way (no sense of common humanity), how one’s self-efficacy belief can take hold? Self-Efficacy and Self-Compassion Self-efficacy involves beliefs held by people over the ability to achieve desired goals through their own actions
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(Bandura, 1997). It is the belief that one can achieve something through one’s own resources, and in some circumstances, that one can perform the behavior that leads to the desired goal. It is influenced by attempts to control environments, observation of other people’s behavior, imagining hypothetical situations, reactions and physiological states, and by other people’s perspective over what we believe we can achieve. It is negatively associated with depression, anxiety and avoidance, and positively associated with self-confidence and attempts to overcome issues with drugs and food. It influences the adoption of healthy behaviors, withdrawing from harmful behaviors and the perseverance on changes made even when faced with challenges and difficulties. Self-efficacy beliefs affect physiological response to stress, and their promotion effectively helps with actions that improve health (Maddux, 2002). Over the last 10 years there’s been a perceptible increase in investigations about self-efficacy, both general and domain specific. There is works on self-efficacy on insulin management in patients with diabetes, in patients with chronic pain, and self-efficacy focused on student performance. On the topic of general self-efficacy, Pacico, Ferraz, and Hutz (2012) have developed a general scale of self-efficacy which shows good performance (alfa = .87). The most recent work on the general self-efficacy scale is Pacico et al. (2014); in it the researchers detected a .89 index of internal consistency. Only one single study was found dealing with both SC and self-efficacy. Iskender (2009) included in his study a measure of control belief for learning. SC was evaluated with SCS and selfefficacy was analyzed by a subscale taken from an instrument of motivation strategies. The sample was composed of Turkish college students, and the reliability of the self-efficacy subscale for the population under study was .86. A positive association was found between self-efficacy, control belief for learning, self-kindness, sense of common humanity and mindfulness. On the contrary, isolation, self-criticism and over-identification were negatively associated with self-efficacy. Thus, for this author, in outlining interventions, an increase in self-efficacy would lead to decreases in social isolation, over-identification with problems, and severe self-judgment. In discussing influences on self-efficacy, Maddux (2002) notes that successful attempts in situations in which the person is in control, and for which the result is attributed to their own efforts, increase the sense of self-efficacy. On the other hand, a perception of failure in these circumstances reduces self-efficacy. This way, it makes sense to bring a SC attitude to foreground. In such situations, the most self-compassionate individuals will be able to perceive their own failure as something also present in the lives of others, and will be able to bestow kindness on themselves when dealing with their feelings and thoughts in a balanced way. So it can be concluded that a self-compassionate attitude is relevant, so to say, for the journey of self-efficacy – bearing on its increase or reduction. Seeking Relationships Between Self-Compassion, SelfEsteem, Self-Efficacy, and Sociodemographic Aspects As we have argued, the SC concept, though not new, is seen as a novelty within studies that focus on the subjective
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evaluation of processes connected to how we deal with the self. SCS, originally published in 2003, has been used in correlation to positive and negative aspects in the field of psychological health. In following with the current discussion in the literature available, the present study sought to verify correlations between SC, self-esteem and self-efficacy, as well as an examination of aspects such as religion, experience with psychotherapy, the use of psychiatric drugs, involvement in paid occupation and having children. With respect to religion, Neff (2003b) studies with Buddhist practitioners indicated differences in SC – after all, it is a construct based on a Buddhist concept. Psychotherapy and the use of psychiatric drugs are options of treatment used on more lasting experiences of psychological suffering, and as such, can show a relationship with the SC score. Paid occupation bear on involvement in work contexts in which individuals widen their network, including hierarchies, as well as deal with successes and failures that can influence in one’s wellbeing. In this way, the self-compassionate individual should be able to better deal with mistakes and faults at the work environment. On the topic of raising children, it is a significant change in someone’s life, very common in the adult phase, for which the literature signals increased SC. Furthermore, parenting strategies are prone to successes and failures, hits and misses, and thus suitable for relationships with SC. From the proposed landscape, this study has for goal the investigation of relationships between self-compassion, self-esteem and self-efficacy, gender and age differences, as well as other sociodemographic variables in self-compassion. It is an exploratory study, with both correlation and group comparison.
Method Participants The sample has enlisted 432 people (50% of them women), presenting an average of 32.5 (SD = 11.1) years of age, ranging from 18 to 66 years old, from several Brazilian states. Most participants were from Minas Gerais, São Paulo, and Rio Grande do Sul; the only states with no participants were Acre, Roraima, and Piauí. As for involvement in a stable romantic relationship, 39% were married or living with someone in the equivalent of a common-law marriage and 24% were seeing someone; there were also 32% of single people, 4% of divorced or separated and 1% of widowers, that is, groups of participants with no stable romantic involvement during the data collection. To participate in the research it was necessary to be at least 18 years old, to have been born in Brazil, and to have secondary education. Participants who did not meet these criteria were excluded from the sample. Instruments The sociodemographic survey was customized for the research and asked for the following information: gender, age, nationality, place of birth, current city of residence, stable
Souza, L. K., & Hutz, C. S. (2016). Self-Compassion, Self-Esteem, Self-Efficacy.
romantic relationship (married, seeing someone, divorced, etc.), religion and engagement in religious practice, going through psychotherapy, level of education, job occupation, having children, and using psychiatric drugs. The Self-Compassion Scale (SCS) was adapted for use in Brazil by Souza and Hutz (in press) with approval by the author, Kristin Neff. The construct validation suggested all 26 original items to be retained. The internal consistency was .92. The subscales envisage SC components: self-kindness, sense of common humanity, mindfulness, over-identification, isolation, and self-criticism. The Rosemberg’s Self-Esteem Scale (RSES) used here incorporates both the versions published by Hutz and Zanon (2011) and by Hutz, Zanon and Vazquez (2014), comprised of 10 items, five of which being positive affirmations about the self, while the remaining five being negative ones. The General Self-Efficacy Scale (GSES) applied here was the Pacico et al. (2014) version, which is comprised of 30 items. Procedure Data collection. Data were collected through the Survey Monkey platform with a link for the research form sent by e-mail. The link first led to an informed consent agreement page that offered options to accept or decline in participating of the research. A click on the accepting link led the participant to the first page of instruments, consisting of the sociodemographic survey. The following page presented SCS, followed by RSES, and concluding with GSES. The Informed Consent Agreement was set up according to current Brazilian regulations on research with human subjects.
Data analysis. Descriptive statistics and Pearson correlations within the main scales were applied. T tests for group comparison were made on gender, age range (groups of 18-30 years and 31-66 years), religious practice, previous or current experience with psychotherapy, current use of psychiatric drugs, involvement in paid occupation and having children. In group comparison, the effect size was calculated according to Cohen’s d, according to Magnusson (2014) suggested interpretation. Ethical Considerations This study was approved by the Research Ethics Committee of the Instituto de Psicologia at Universidade Federal do Rio Grande do Sul (UFRGS; Protocol n. 04345112.5.0000.5334).
Results The SC average for SCS was 3.18 (SD = 0.70). Concerning self-efficacy, the sample average for GSES was 3.53 (SD = 0.57). Regarding self-esteem, the detected average for RSES was 3.04 (SD = 0.31). Table 1 presents the significant differences of SC via SCS for the following groups: women and men, age group (17-30 and 31-66), current use of psychiatric drug, paid occupation and having children. Comparisons on current or previous experience with psychotherapy and religious practice did not indicate significant differences on SC, and are thence not presented on the table.
Table 1 Mean Comparisons With the Self-Compassion Scale Self-Compassion Scale M (SD)
t
p
d
2.581
.01
.26
-4.158
.001
.40
3.048
.002
.38
2.714
.007
.32
-3.673
.001
.39
Gender Women (n = 216)
3.09 (0.74)
Men (n = 216)
3.27 (0.66)
Age range 18-30 years (n = 228)
3.05 (0.66)
31-66 years (n = 204)
3.33 (0.72)
Medication use Yes (n = 61)
2.93 (0.83)
No (n = 371)
3.22 (0.67)
Paid occupation Yes (n = 98)
3.01 (0.67)
No (n = 334)
3.23 (0.70)
Offspring Yes (n = 122)
3.37 (0.66)
No (n = 310)
3.10 (0.71)
Note. M = mean, SD = standard deviation, d = Cohen’s d.
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Differences indicated on Table 1 show that the current sample presented higher SC scores for the following groups: men, age between 31 and 66 years old, no use of psychiatric drugs, no current engagement in paid occupancy and with offspring. The compared averages found size effects (Cohen’s d), of .26 for gender differences, and between .32 and .40 for the remainder. Correlations between total averages (N = 432) were all positive and significant for the three main scales (p < .001). The correlation for SC and self-esteem was .47, and for SC and self-efficacy it was .50. Moreover, the correlation between self-efficacy and self-esteem was .62. Thus they are related constructs, but do not represent the same phenomenon. Religions provided by participants on the sociodemographic survey were grouped as follows: none (no religion, atheist, skeptic, agnostic; n = 109), Catholic, Protestant (Protestant, Evangelic, Lutheran, Presbyterian, Adventist, Baptist), Spirits, Buddhist, other religions (the term Christian was most used, with n = 13, in 27 answers), and other answers (e.g., “I believe in God” and “I have an inner god”; n = 12). It is opportune to detail averages for SCS according to the four religious groups showing higher frequency for the acquired sample: Catholic (n = 186) with an 3.18 (SD = 0.73) average; Spiritist (n = 60) and 3.18 (SD = 0.69) average; Protestant (n = 30) and 3.09 (SD = 0.74) average; and Buddhist (n = 8) with the highest average, 3.32 (SD = 0.84). Averages were not compared due to the uneven distribution of participants per group. Regardless, Buddhists stood out with the highest SC score.
Discussion Results show that SC was higher in the following groups: men, people between 31 and 66 years of age, participants not currently using psychiatric drugs, with no current engagement in paid occupancy and with offspring. Furthermore, correlations between SC, self-esteem and self-efficacy were significant, positive and with results attesting the fact they measure similar aspects, yet remain distinct constructs. The lower SC scores on women, compared to men, detected in this study, follow the previous findings mentioned in literature (Neff, 2003b; Neff & McGehee, 2010). This result may be connected to, as Neff (2003b) argues, the excessive self-criticism usually scored by women in this construct. Given this result, SCS’s self-criticism factor was then compared by gender. T testing confirmed higher selfcriticism on the feminine sample: t (309) = 1.91; p = .05. Women’s average was 2.77 (SD = 0.88; n = 169) while men’s was 2.96 (SD = 0.86; n = 142). This difference suggests programs dedicated to promote self-compassion, when dealing with women participants, should give more attention to aspects of self-criticism, which might overcome self-kindness, sense of common humanity, mindfulness and modest levels of isolation and over-identification. Regarding age differences and SC, this study detected a higher score for the older group. Even considering the younger group was not comprised of adolescents, who for
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Neff (2003a, 2009) did not perform well in SC, the results showed a higher score for adults aged 31 to 66 years-old. Further studies with longitudinal detailing and emphasis on this issue will be needed to determine if the difference is due to developmental aspects. Neff and McGehee (2010) and Neff and Pommier (2013) did not find age differences in their studies. Still it is worthy to consider, for example, the possibility that adult life after 30 years of age presents more concurrent challenges, and as such has in its favor previous experiences that can prove useful both for the approach of new issues as well as for becoming self-compassionate in dealing with failures, sufferings and faults. Further studies, as already said, should approximate the detection of more specific aspects, in order to help elucidate the findings in differences related to age. The other detected significant differences in averages are not sufficient to posit that having children, engaging in paid occupation or using psychiatric drugs should be aspects firmly associated with higher SC. These data were, as a matter of fact, characteristic for the current sample. Furthermore, there are no previous studies on SC using these variables. An estimate of the benefits of parenthood, nevertheless, shows people raising children with ages up to 5 years old to have higher self-esteem, higher self-efficacy and less depression than people raising older children (Nomaguchi, 2012). In the present study, the age of children being raised was not collected, but it seems to be a relevant consideration for, at least, selfesteem levels. On account of that, given the correlations found for self-efficacy and SC, clear hypothesis could be delineated for connecting parenthood with self-compassion. The SC concept used on this research is based on Buddhist knowledge, as explained by Neff (2003a), and we thus also sought to assess the participant’s religion. Still, the very considerable size differences among groups by religion did not allow for useful average comparisons within well-grounded statistics. Nevertheless, it is interesting to take notice of SC differentiation among the groups. The Buddhist group stood out with the highest SC score, which fits the philosophical background employed by Neff (2003a) as basis for the operational definition of SC. The relationship between religiosity and psychological adjustment is attested by Gebauer, Sedikides and Neberich (2012), who verified psychological benefits (including self-esteem) for the inhabitants of countries where religiosity is more deeply valued. Of the 11 European countries studied, only Sweden showed similar scores for people who either practice or do not practice a religion. Future work should thus bring accurate data related to the relationship between SC and distinct religious practices. This study is the first to correlate SC, self-esteem and general self-efficacy. The results suggest they are three different yet related constructs; ultimately they all refer to how the subject deals with his own self. The correlation found between SC and self-esteem was lower (.50) than the one detected by Vonk and Smit (2012) (.62), yet still adequate. In this way, there is support for the understanding that someone who values herself (self-esteem), that believes she can achieve her goals through her own abilities (sense of self-efficacy) and that has self-compassion – that is, reaches a wider and balanced perspective regarding thoughts
Souza, L. K., & Hutz, C. S. (2016). Self-Compassion, Self-Esteem, Self-Efficacy.
and feelings (mindfulness) when facing sufferings, failures and errors; understands that these are part of the human experience; avoids egocentrism and the sensation of isolation from others; blocks over-identification with her own problems; reduces severe self-criticism that distorts the perspective of herself, of the world and of the future; allows self-kindness and self-acceptance as someone who also fails and errs, decreasing the emotional load of blame and other negative feelings; allows for a clearer self-image and understanding of her own difficulties (Neff, 2003a). Lastly, the only work we found that sought to correlate a self-efficacy measurement with SCS was Iskender (2009); nevertheless, only the SC dimensions were correlated, separately, with self-efficacy. It is worth noting that our research and Iskender study did not use the same self-efficacy instrument. About our work contributions, most of all we tried to verify the relationships between SC, self-esteem and selfefficacy in literature, as well as to investigate the performance of a Brazilian sample with respect to the connections between SC and age, gender, general self-efficacy and a set of sociodemographic variables. The results were interesting particularly in relation to age and gender issues, truly accruing knowledge to the existing studies about SC. As to the limitations of this study, firstly it is understood that the sample, even though representing a wide range of ages, was mainly with participants from the southeast and south regions of Brazil. This was the case especially due to the fact that our colleagues, who greatly helped spreading the link for data collection, mostly worked from these two regions. Secondly, as previously announced, the study was exploratory in nature, above all in considering sociodemographic variables, and dealing with almost nonexistent literature in Brazil. Therefore the results need to be contextualized on those grounds, and also the fact that it was not specifically conceived to ascertain issues of religion, paid occupation, involvement in psychotherapy and pharmacotherapy and family formation. The Self-Compassion Scale for use in Brazil became available just as the number and acceptance of studies on mindfulness – an aspect of SC – grow in this country. Examples are the Works of Barros, Kozasa, Souza, and Ronzani (2014) and Hirayama, Milani, Rodrigues, Barros, and Alexandre (2014). Research groups in health sciences have been developing interventions using mindfulness and self-acceptance in patients with chronic diseases. The measurement of SC could be a great addition to these studies. Besides working with mindfulness and attitudes such as self-kindness, SC incorporates the perspective that suffering is a human experience, and that this way it should be understood for working against self-blaming attitudes and the feeling of being the “chosen one” while enduring some particular suffering or other. Since published research on SC is almost nonexistent in Brazil, the present work contributes Brazilian data for a construct that merits attention and research funding in this country.
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Barros, V. V., Kozasa, E. H., Souza, I. C. W., & Ronzani, T. M. (2014). Validity evidence of the Brazilian version of the Five Facet Mindfulness Questionnaire (FFMQ). Psicologia: Teoria e Pesquisa, 30(3), 317-327. doi:10.1590/S0102-37722014000300009 Elkind, D. (1967). Egocentrism in adolescence. Child Development, 38(4), 1025-1034. Gebauer, J. E., Sedikides, C., & Neberich, W. (2012). Religiosity, social self-esteem, and psychological adjustment: On the cross-cultural specificity of the psychological benefits of religiosity. Psychological Science, 23(2), 158-160. doi:10.1177/0956797611427045 Hewitt, J. P. (2005). The social construction of self-esteem. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 135-147). New York, NY: Oxford University Press. Hirayama, M. S., Milani, D., Rodrigues, R. C. M., Barros, N. F., & Alexandre, N. M. C. (2014). A percepção de comportamentos relacionados à atenção plena e a versão brasileira do Freiburg Mindfulness Inventory [The perception of behavior related to mindfulness and the Brazilian version of the Freiburg Mindfulness Inventory]. Ciência & Saúde Coletiva, 19(9), 3899-3914. doi:10.1590/1413-81232014199.12272013 Hutz, C. S., & Zanon, C. (2011). Revisão da adaptação, validação e normatização da Escala de Autoestima de Rosenberg [Revision of the adaptation, validation, and normatization of the Rosenberg Self-Esteem Scale]. Avaliação Psicológica, 10(1), 41-49. Retrieved from http://pepsic.bvsalud.org/pdf/avp/v10n1/v10n1a05.pdf Hutz, C. S., Zanon, C., & Vazquez, A. C. (2014). Escala de Autoestima de Rosenberg [Rosenberg Self-Esteem Scale]. In C. S. Hutz (Org.), Avaliação em psicologia positiva [Assessment in Positive Psychology] (pp. 8594). Porto Alegre, RS: Artmed. Iskender, M. (2009). The relationship between selfcompassion, self-efficacy, and control belief about learning in Turkish university students. Social Behavior and Personality, 37(5), 711-720. doi:10.2224/ sbp.2009.37.5.711 Leary, M. R., Tate, E. B., Adams, C. E., Allen, A. B., & Hancock, J. (2007). Self-compassion and reactions to unpleasant self-relevant events: The implications of treating oneself kindly. Journal of Personality and Social Psychology, 92(5), 887-904. doi:10.1037/00223514.92.5.887 Maddux, J. E. (2002). Self-efficacy: The power of believing you can. In C. Snyder & S. Lopez (Eds.), Handbook of positive psychology (pp. 277-287). New York, NY: Oxford University Press. Magnusson, K. (2014). Interpreting Cohen’s d effect size: An interactive visualization. Retrieved from http:// rpsychologist.com/d3/cohend/ Medeiros, H. L. V., & Sougey, E. B. (2010). Distorções do pensamento em pacientes deprimidos: Frequência e tipos [Distortions of thinking in depressed patients: Frequency and type]. Jornal Brasileiro de Psiquiatria, 59(1), 28-33.
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doi:10.1590/S0047-20852010000100005 Neff, K. D. (2003a). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2(2), 85-101. doi:10.1080/15298860390129863 Neff, K. D. (2003b). The development and validation of a scale to measure self-compassion. Self and Identity, 2(3), 223-250. doi:10.1080/15298860390209035 Neff, K. D. (2009). The role of self-compassion in development: A healthier way to relate to oneself. Human Development, 52(4), 211-214. doi:10.1159/000215071 Neff, K. D. (2011). Self-compassion, self-esteem, and wellbeing. Social and Personality Psychology Compass, 5(1), 1-12. doi:10.1111/j.1751-9004.2010.00330.x Neff, K. D., & McGehee, P. (2010). Self-compassion and psychological resilience among adolescents and young adults. Self and Identity, 9(3), 225-240. doi:10.1080/15298860902979307 Neff, K. D., & Pommier, E. (2013). The relationship between self-compassion and other-focused concern among college undergraduates, community adults, and practicing meditators. Self and Identity, 12(2), 160-176. doi:10.1080 /15298868.2011.649546 Neff, K. D., Rude, S. S., & Kirkpatrick, K. L. (2007). An examination of self-compassion in relation to positive psychological functioning and personality traits. Journal of Research in Personality, 41(4), 908-916. doi:10.1016/j. jrp.2006.08.002 Neff, K. D., & Vonk, R. (2009). Self-compassion versus global self-esteem: Two different ways of relating to oneself. Journal of Personality, 77(1), 23-50. doi:10.1111/j.14676494.2008.00537.x Nomaguchi, K. M. (2012). Parenthood and psychological well-being: Clarifying the role of child age and parentchild relationship quality. Social Science Research, 41(2), 489-498. doi:10.1016/j.ssresearch.2011.08.001 Pacico, J., Ferraz, S., & Hutz, C. S. (2014). Autoeficácia – Yes we can! [Self-Efficacy – Yes we can!] In C. S. Hutz (Ed.), Avaliação em psicologia positiva (pp. 111-119). Porto Alegre, RS: Artmed. Souza, L. K., & Hutz, C. S. (in press). Adaptation of the Self-Compassion Scale for use in Brazil: Evidences of construct validity. Temas em Psicologia. Vonk, R., & Smit, H. (2012). Optimal self-esteem is contingent: Intrinsic versus extrinsic and upward versus downward contingencies. European Journal of Personality, 26(3), 182-193. doi:10.1002/per.817 Luciana Karine de Souza is a Professor at Universidade Federal do Rio Grande do Sul. Claudio Simon Hutz is a Professor at Universidade Federal do Rio Grande do Sul. Received: Mar. 30, 2015 1st Revision: Aug. 16, 2015 Approved: Sep. 9, 2015
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How to cite this article: Souza, L. K., & Hutz, C. S. (2016). Self-compassion in relation to self-esteem, self-efficacy and demographical aspects. Paidéia (Ribeirão Preto), 26(64), 181-188. doi: 10.1590/1982-43272664201604
Paidéia may-aug. 2016, Vol. 26, No. 64, 189-197. doi:10.1590/1982-43272664201606
Article
Bayley-III Scales of Infant and Toddler Development: Transcultural Adaptation and Psychometric Properties1 Vanessa Madaschi Universidade Presbiteriana Mackenzie, São Paulo-SP, Brazil
Tatiana Pontrelli Mecca Centro Universitário FIEO, São Paulo-SP, Brazil
Elizeu Coutinho Macedo Universidade Presbiteriana Mackenzie, São Paulo-SP, Brazil
Cristiane Silvestre Paula2 Universidade Presbiteriana Mackenzie, São Paulo-SP, Brazil
Abstract: Scales with evidence of validity and reliability are important to evaluate child development. In Brazil, there is a lack of standardized instruments to evaluate young children. This study investigated the psychometric properties of the Bayley Scales of Infant Development, Third Edition (Bayley-III). It was translated into Brazilian Portuguese, culturally adapted and tested on 207 children (1242 months of age). Evidence of convergent validity was obtained from correlations of the Bayley-III with the: Peabody Developmental Motor Scale 2, Leiter International Performance Scale-R, Expressive Vocabulary Assessment List and Peabody Picture Vocabulary Test. Exploratory factor analyses showed a single component explaining 86% of the variance, supported by goodness-of-fit indexes in confirmatory factor analysis. The Bailey-III demonstrated good internal consistency with alpha coefficients greater than or equal to .90 and stability for fine motor scale only. These robust psychometric properties support the use of this tool in future national studies on child development. Keywords: childhood development, psychometrics, intellectual development, language, motor skills
Escalas Bayley-III de Desenvolvimento Infantil: Adaptação Transcultural e Propriedades Psicométricas Resumo: Escalas com evidências de validade e precisão são importantes para avaliação do desenvolvimento infantil. No Brasil, há escassez de instrumentos padronizados e normatizados para a primeira infância. Este estudo investigou as propriedades psicométricas da Bayley Scales of Infant and Toddler Development, terceira edição (Bayley-III) que foi traduzida, adaptada para o português e testada com 207 crianças (12-42 meses). Evidências de validade convergente foram observadas entre a Bayley-III e: Peabody Developmental Motor Scale-2, Escala Internacional de Inteligência Leiter-R, Lista de Avaliação de Vocabulário Expressivo e Teste de Vocabulário por Imagens-Peabody. Análise fatorial exploratória indicou componente que explica 86% da variância, corroborado por bons índices de ajustes na análise fatorial confirmatória. A Bayley-III apresentou boa consistência interna com coeficientes alfa a partir de 0,90 e boa estabilidade teste-reteste apenas para a escala motora fina. Estas adequadas propriedades psicométricas podem contribuir para o avanço nas pesquisas em contexto nacional na área de avaliação do desenvolvimento infantil. Palavras-chave: desenvolvimento infantil, psicometria, desenvolvimento cognitivo, linguagem, habilidades motoras
Escalas de Desarrollo Infantil Bayley-III: Adaptación Transcultural y Propiedades Psicométricas Resumen: Escalas con evidencia de la validez/fiabilidad son importantes para la evaluación del desarrollo infantil. En Brasil, faltan instrumentos estandardizados/normalizados para la evaluación en la primera infancia. Este estudio investigó las propiedades psicométricas de las Bayley Scales of Infant and Toddler Development-III, traducida y adaptada al portugués. Se evaluaron 207 niños (12-42 meses). Evidencias de validez convergente se observaron entre Bayley-III con: Escala de Desarrollo Motor de Peabody 2, Escala de Inteligencia Internacional Leiter-R, Lista de Evaluación de Vocabulario y Prueba de Vocabulario Expresivo Imágenes Peabody. El análisis factorial exploratorio indicó un componente que explica el 86% de la varianza, corroborado por buenos índices de ajuste en el análisis factorial confirmatorio. Bayley-III mostró buena consistencia interna, con coeficientes alfa de 0,90. La adecuación de las propiedades psicométricas puede contribuir al avance de la investigación en el contexto nacional en el área de evaluación del desarrollo infantil. Palabras clave: desarrollo infantil, psicometría, desarrollo cognitivo, lenguaje, destreza motora
Paper derived from the first author’s master’s thesis under supervision of the fourth author, defended in 2012, at the Graduate Program in Developmental Disorders of the Universidade Presbiteriana Mackenzie. Support: Coordination for the Improvement of Higher Education Personnel (CAPES/Mackenzie-IPM, Cod Mat 71051791). 1
Available in www.scielo.br/paideia
Correspondence address: Cristiane Silvestre Paula. Universidade Presbiteriana Mackenzie, Programa de Pós-Graduação em Distúrbios do Desenvolvimento. Rua da Consolação, 930, prédio 28. CEP 01302-000. São Paulo-SP, Brazil. E-mail: csilvestrep09@gmail.com 2
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Reliable scales with evidence of validity and reliability are important for the clinical investigation of early developmental delays (Santos, Araújo, & Porto, 2008). In Brazil, the challenge of identifying developmental disabilities in young children is worsened by the lack of standardized instruments. One of the only validated tools available for the assessment of child development in Brazilian Portuguese is the Escala de Desenvolvimento do Comportamento da Criança no Primeiro Ano de Vida (Pinto, Vilanova, & Vieira, 1997). However, this instrument only assesses motor and communication development and is restricted to the first 12 months of life; therefore it cannot be used in toddlers or in longitudinal studies. The Bayley Scales of Infant Development, currently in its third edition (Bayley-III), is internationally recognized as one of the most comprehensive tools for the assessment of young children. It is widely used in research, in clinical practice, and to evaluate interventions, because it assesses several developmental domains and has a solid theoretical background with robust psychometric properties (Bayley, 2006). Although the Bayley-III has been used to assess child development in many countries, recent studies have shown that it tends to estimate differently children with typical development and at risk for developmental delay depending on geographic location (Acton et al., 2011; Milne, McDonald, & Comino, 2012; Moore, Johnson, Haider, Hennessy, & Marlow, 2012; Reuner, Fields, Wittke, Löpprich, & Pietz, 2013; Yu et al., 2013). Consequently, the use of the original American Bayley scale without adaptations is not recommended, because economic, ethnic and cultural factors can lead to the incorrect assessment of developmental delays (Fleuren, Smit, Stijnen, & Hartman, 2007). In the last five years, there have been several publications using the Bayley scales to assess developmental delays in Brazilian children (Eickmann, Malkes, & Lima, 2012; Fernandes et al., 2012; Ferreira, Melo, & Silva, 2014; Hentges et al., 2014; Silveira & Enumo, 2012). However, there are no studies about the translation and transcultural adaptation of the Brazilian Portuguese version of the Bayley-III scale, or its psychometric properties. There is a single study about the Bayley Infant Neurodevelopment Screener for children aged 12-24 months) (Guedes, Primi, & Kopelman, 2011). Therefore, studies on these topics are still necessary. Due to the importance of this instrument in assessing child development, the objectives of this study were to translate, culturally adapt and validate the Brazilian version of the Bayley-III in a sample of children in daycare centers in a city in the greater São Paulo area. Specifically, this study aimed to investigate the internal consistency and item homogeneity as well as evidence of validity based on internal structure and in relation to external variables.
Method We first obtained formal permission to translate and validate the Bayley-III scale from the American publishers of this tool (NCS Pearson). We then started the process of developing a Brazilian version of Bayley-III, following the
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recommendations of Hambleton and Patsula (1999) and Herdman, Fox-Rushby and Badia (1998) for translation and adaptation of a test, considering conceptual, item, semantic, operational, measurement and functional equivalences. Each step of the process will be presented in the results section. Participants Barueri is a city with approximately 260 thousand inhabitants located in the metropolitan region of São Paulo. For data collection, we selected two out of the 21 daycare centers in the city. There were 350 children aged 12-42 months registered in the two selected centers. Children who were born at term, without any chronic diseases and known developmental disorders were eligible for inclusion. Three children were excluded: one with autism spectrum disorder and two with cerebral palsy. From the total eligible families of 347, 101 refused to participate (sample loss of 29.1%), and from the remaining 246, we randomly recruited 207 children (49.27% girls) aged 11 to 42 months to include in the study. They were distributed according to the categories proposed in the Bayley-III technical manual: 9 children aged 12 months to 13 months and 15 days; 9 children aged 13 months and 16 days to 16 months and 15 days; 9 children from 16 months and 16 days to 19 months and 15 days; 9 children from 19 months and 16 days to 22 months and 15 days; 33 children from 22 months and 16 days to 25 months and 15 days; 34 children from 25 months and 16 days to 28 months and 15 days; 34 children from 28 months and 16 days to 32 months and 15 days; 35 children from 33 months and 15 days to 38 months and 15 days; 35 children from 39 months and 15 days to 42 months and 15 days. All the children attended the daycare center full time, most of them were Caucasian (74%), belonging to families with the following income: 28% receiving between 1-2 times minimum monthly wage, 56% with 3-4, and only 16% higher than that. The majority of mothers (58%) and fathers (53%) had completed high school or had a lower level of study (19% of mothers and 27% of fathers). Ten out of the 207 children (4 children 12-24 months of age, and 6 children 25-42 months of age), half boys and half girls, also participated in the test-retest reliability study. All of them were first evaluated by one expert, and 15 days later, by another to avoid memory contamination and contamination among evaluators. Instruments The Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) is an individually administered scale that assesses five key developmental domains in children between 1-42 months of age: cognition, language (receptive and expressive communication), motor (gross and fine), social-emotional and adaptive behavior. The first three are assessed through direct observation of the child in test situations, while the last two are assessed through questionnaires to be completed by the main caregiver. These last two scales are considered complementary and are less
Madaschi, V., Mecca, T. P., Macedo, E. C., & Paula, C. S. (2016). Adaptation, Reliability and Validity of Bayley-III.
used in clinical and research settings. Bayley-III motor scale assesses axial motor abilities like sitting, standing up and walking, as well as fine motor control abilities. Its cognition scale assesses the child’s performance in several areas, such as, visualization, memory and attention, while the language scale assesses two major aspects of language, receptive and expressive communication skills, including a child’s ability to recognize sounds and receptive vocabulary; the expressive communication subtest assesses preverbal communication, vocabulary use and morpho-syntactic development (Bayley, 2006). Bayley-III does not provide an overall total score, but separate raw and scaled scores for each domain as well as composite scores and percentile ranks for each scale. At the end of the process, the development of the child is classified as being on one of seven levels (extremely low, borderline, low average, average, high average, superior or very superior), based on the American population (Bayley, 2006). Bayley-III normative data were collected in the US in 2004 with 1,700 children aged 16 days to 43 months and 15 days. The reliability coefficients for Bayley-III subtests are .86 for fine motor, .87 for receptive communication and .91 for cognitive, expressive communication and gross motor (Bayley, 2006). The Peabody Developmental Motor Scale 2 (PDMS-2) is composed of six subtests that measure interrelated abilities in early motor development: Reflexes, Stationary, Locomotion, Object Manipulation, Grasping, and Visual-Motor Integration. PMDS-2 results give a Total Motor Quotient, as well as, a Gross Motor Quotient and a Fine Motor Quotient. It was designed to assess the axial and appendicular motor ability of children up to 6 years of age, and was normed on 2,003 children residing in 46 states of the US and one Canadian province. The PDMS-2 has very good to excellent internal consistency (r = .89 – .97), test-retest reliability (r = .89 – .96), and interrater reliability (r = .96 – .99). Validity was examined for age differentiation. The correlation coefficients determined for 12-month age intervals ranged from r = .80 to .93, indicating that the subtests were associated with age, consistent with the developmental pattern of motor behaviors (Connolly, McClune, & Gatlin, 2012). At the time of the data collection, no instrument to assess motor development had been translated, adapted or validated for use in Brazil so the English version of PDMS-2 was used. The Brazilian version of the Visualization and Reasoning Battery of the Leiter International Performance Scale Revised - Leiter-R is a nonverbal intelligence measurement tool that can be used in children starting at 2 years of age. It includes 6 subtests to assess visual processing and fluid reasoning of preschoolers: Figure-Ground (to evaluate visual discrimination and exploration), Form Completion (to assess visual synthesis ability), Matching, Classification (to evaluate the child´s categorization capacity), Sequential Order (to assess sequential reasoning) and Repeated Patterns (to assess inductive reasoning). The translated version of this instrument has good validity and reliability for preschoolers. The Spearman-Brown coefficients ranged from .85 to .94 and Cronbach’s alpha between .81 and .86 for the Leiter-R subtests, indicating good accuracy (Mecca, Antonio, Seabra, & Macedo, 2014). The Leiter-R predicted 24% of the arithmetic performance and
almost 31% of the read performance in schoolers (Mecca, Jana, Simões, & Macedo, 2015). The Language Development Survey (LDS) checklist is a questionnaire, developed in Brazil, assessing expressive vocabulary by checking which words a child uses spontaneously. The mother/caregiver chose these from a list of 309 words categorized into 14 semantic groups, compiled from lexical development studies. This test is standardized for children aged 2 – 6 (Capovilla & Capovilla, 1997). The LDS manifested excellent concurrent validity with a brief direct screening measure of expressive vocabulary. The LDS test-retest reliability was from .97 to .99. The LDS correlated highly with The Reynell Receptive and Expressive Language Scale scores, The Bayley Mental Development Index and The Vineland Adaptive Behavior Composite (.66 – .87). Sensitivity was > 80%, specificity was > 85%, positive predictive value, and negative predictive value between the LDS screening and the follow-up Reynell Expressive Language Scale were generally impressive (Rescorla & Alley, 2001). The Peabody Picture Vocabulary Test (PPVT) consists of 144 items and evaluates the receptive vocabulary ability of children between 2 years and 6 months and 18 years of age. The PPVT was translated, adapted, validated and standardized to the Brazilian preschoolers (Capovilla & Capovilla, 1997). It covers a broad range of receptive vocabulary levels, from content areas (e.g., actions, vegetables, tools) and parts of speech (nouns, verbs, or attributes) across all levels of difficulty (Macedo, Capovilla, Duduchi, D’Antino, & Firmo, 2006). The test can be scored by hand or by computer. The internal consistency reliability is .94; the test-retest reliability is .93. The validity correlations with EVT-2: r = .82 (Dunn & Dunn, 1997). Procedure Data collection. All tests were performed individually, in the presence of a daycare teacher, at the place and time that were most convenient for the child. A professional trained in the Bayley-III scales conducted all the evaluations (expect in the second phase of test-retest assessments), which took an average of 60 minutes per child. All other tests (PDMS-2, Leiter-R, LDS and PPVT) were performed by trained psychologists and lasted an average of 2 hours and 30 minutes per child. These four instruments were conducted and interpreted according to the age group of the child, using data from validation and normative studies. Out of the 207 participants, 81 were also tested with the PDMS-2, 58 with the Leiter-R, 69 with the LDS and PPVT language tests and 10 participated in the test-retest. Data collection took nine months to complete, from January to September 2012. Data analysis. The raw scores of each of the Bayley-III scales and the total scores of the Leiter-R were used for descriptive and inferential analyses. Spearman correlation coefficients were calculated to assess convergent validity between the Bayley-III scales and the other instruments. Coefficients between .70 and 1 were considered to be of high magnitude; between .40 and .69 to be of moderate magnitude; and between .10 and .39 to be of low magnitude (Dancey & Reidy, 2013). Exploratory factor analysis was used to assess the internal structure of the instrument. Principal component and oblique
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rotation techniques were employed. This type of rotation is usually employed when there is a high correlation between subtests (Hair, Black, Babin, Anderson, & Tatham, 2009). For applicability, the following criteria were considered: KaiserMeyer-Olkin values > .70 significant Bartlett spherical test results (p ≤ .001). Eigen values greater than or equal to one were used to select the number of components (Marôco, 2007). In order to verify the adequacy of the factorial structure, a confirmatory factor analysis (CFA) was performed in accordance with the original validation study of Bayley-III conducted with an American sample. The CFA was done using AMOS IBM SPSS® version 20. In this way, the adjustment indices for the 1 factor (5 subtests on a general factor) and the 3 factor model (2 motor subtests on the 1st factor; 2 language subtests on the 2nd factor; and the cognition scale on the 3rd factor) were verified. The adequacy of the confirmatory indices were considered according to the following criteria: (1) Root Mean Square Error of Approximation (RMSEA) < .05 (Hair et al., 2009), (2) Comparative Fit Index (CFI) > .95 (Hu & Bentler, 1999), and (3) Tucker Lewis Index (TLI) ideally > .90 (Bentler & Bonett, 1980). To assess the reliability of the Brazilian Bayley-III, we evaluated the stability of the instrument based on Spearman correlation analyses between the first and second tests. A non-parametric test was used due to the small number of participants in the retesting conducted nine months after the first test. Internal consistency was assessed using Cronbach’s alpha coefficients and the Split-Half method with the Spearman-Brown formula being used. Analyses were performed using IBM SPSS® version 21.0 and p-value < .05 were considered statistically significant. To evaluate stability, Spearman correlation coefficients were calculated to assess test-retest reliability.
back-translated and the original English versions were sent to P2 who analyzed and made a few minor adjustments to create the final version of the instrument. This text was sent back to the authors of the original American scale who analyzed and approved the final official Brazilian version of the BayleyIII, specifically for use of the cognition, language and motor scales with children between 12 and 42 months of age. The following section presents evidence of the validity and reliability of the results of the Brazilian version of Bayley-III. Table 1 presents mean and standard deviations, the minimum and maximum scores of participants in BayleyIII, PDMS-2, Leiter-R, LSD and PPVT. Table 1 Descriptive Statistics of Measures Instrument
M (SD)
Min
Max
Receptive Languege
26.87 (10.09)
17
49
Expressive Language
27.58 (8.16)
20
47
General Language
54.45 (18.10)
37
94
Fine Motor
33.43 (9.20)
22
64
Gross Motor
48.49 (8.68)
35
71
Global Motor
81.93 (17.78)
57
135
Cognition
64.78 (10.85)
53
88
Prehension
12.60 (4.95)
5
24
Perceptual-motor integration
35.63 (13.32)
3
61
Bayley-III
PDMS-2
Static positioning
13.16 (2.71)
4
16
Ethical Considerations
Locomotion
53.15 (22.73)
6
86
The study protocol was approved by the Research Ethics Committee of the Universidade Presbiteriana Mackenzie (CAAE n. 0041.0.027.000-11) and authorized by the two daycare centers. Written informed consent was obtained from the legal guardians of all participating children.
Object manipulation
15.11 (7.55)
0
28
General fine motor
48.23 (17.43)
9
83
General gross motor
81.42 (32.56)
10
130
PDMS-2 Total
129.65 (49.56)
19
212
Leiter-R_Raw Score
54.38 (17.92)
11
88
LDS
121.22 (53.40)
50
256
PPVT
27.86 (7.38)
13
44
Results Translation of the scale from English to Brazilian Portuguese was done by a researcher fluent in both languages specialized in special education and is experienced in the use of the Bayley-III. This translated version was first submitted to a panel (P1) of two specialists in child development who independently provided practical and semantic suggestions to improve the text. These suggestions were sent to a second panel (P2) comprising two other specialists in child development, who analyzed and reviewed, their suggestions to produce a preliminary Brazilian version of the instrument. At this stage, some modifications were necessary to culturally adapt the Brazilian version of the scale, especially in respect of the traditional children’s games and songs used in the language scales, to ensure the adequacy of the translated version. This preliminary Brazilian Bayley-III was then back-translated to English by another individual fluent in both languages. The
192
Note. LDS: Language Development Survey Checklist. PPVT: Peabody Picture Vocabulary Test.
Spearman correlation tests were conducted between the raw scores in Bayley-III for the motor, cognition and language domains in relation to the other instruments which assess the same domains. The results showed that there was a significant and strong positive correlation between the Bayley-III fine, gross and global motor scales scores and the specific and general domain scores of the PDMS-2 (Table 2). Bayley-III cognition domain scores were overall positively correlated with the subtests and total Leiter-R scores. There was a moderate correlation between BayleyIII scores and the subtests Figure-Ground, Form Completion,
Madaschi, V., Mecca, T. P., Macedo, E. C., & Paula, C. S. (2016). Adaptation, Reliability and Validity of Bayley-III.
Matching and Classification. The first two subtests assess visual processing, including discrimination and synthesis, and the last two assess the ability to categorize color, shapes, sizes or semantic associations. There was a low correlation between the Bayley-III cognition scores and the Leiter-R Sequential Order subtest and no significant correlation with the subtest Repeated Patterns which assesses inductive reasoning. This result suggests that the Bayley-III cognition
scale is more related with the performance of categorization and visualization tasks than with sequential or inductive reasoning (Table 2). As also presented in Table 2, there was a strong correlation between Bayley-III receptive, expressive and general language scores and LDS and PPVT scores. The high degree of correlation between the different Bayley-III domain scores and the various other instruments indicates convergent validity.
Table 2 Correlation Analyses Between Bayley-III Cognition and Language Scores With Leiter-R, LDS and PPVT Scores Bayley-III Cognition Scale
Receptive Language
Expressive Language
General Language
Fine motor
Gross Motor
Global motor
LDS
.94*
.96*
.96*
PPVT
.86
.85
.86*
Prehension
.84**
.84**
.84**
Perceptual-motor Integration
.83**
.89**
.86**
Static positioning
.71**
.77**
.74**
Locomotion
.84**
.89**
.87**
Object manipulation
.88
.93
**
.91**
General fine motor
.87**
.92**
.90**
General gross motor
.85**
.90**
.88**
.87
.92
.90**
Leiter-R Figure-Ground
.56*
Form Completion
.48*
Matching
.60*
Sequential Order
.37*
Repeated Pattern
.14
Classification
.60*
Total Leiter-R score
.61*
Language *
*
PDMS-2
**
PDMS-2 Total *p ≤ .05. **p ≤ .01.
**
There was also a strong positive correlation among specific scales (score domains) of the Bayley-III tool. The strongest correlations were between the receptive and
**
expressive language domains and the gross and fine motor domains (Table 3). The fine motor domain had the strongest correlation with the cognition domain.
Table 3 Correlation Analyses Between Individual Bayley-III Score Domains Receptive L. Receptive L. Expressive L. General L. Fine motor Gross motor General motor Note. L. = language. *p ≤ .05.
Expressive L.
General L.
Fine motor
Gross motor
General motor
Cognition
.96*
.99*
.89*
.82*
.86*
.71*
.89*
.88*
.82*
.86*
.77*
.89*
.83*
.87*
.75*
.97*
.99*
.83*
.99
.77*
*
.81*
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Paidéia, 26(64), 189-197
The criteria for the factor analysis were met with KMO values = .764 and Bartllet’s Sphericity > .001. The exploratory factor analysis used the component and oblique rotation techniques (direct oblimin) and identified only one component with an eigenvalue of 4.29, which explained 86% of the variance. This indicates that the instrument in fact assesses a general dimension of child development. These five components had a high factorial weight, loading a single factor: Fine motor = .96, Gross motor = .91, Receptive language = .91, Expressive language = .94 and Cognition = .88. The results obtained from the CFA showed high factor loadings for each scale in general factor, considering the model with one factor. All correlations were significant (p ≤ .001), as illustrated in Figure 1. The good-fit index for the model indicated a factor with RMSEA < .001; CFI = 1.00; TLI = 7.73. These results show good fit index for the model with just one factor. It was not possible to estimate the 3 factors model with the sample data of the present study. .96 e1
LR .96
.98 .98
Development
.99
EX .98
MF
.97 .97
e2
e3 .95
MG
e4 .95
COG
e5
Figure 1. Confirmatory Factory Analysis according to a model of one factor (5 subtests on a general factor). Note. LR = receptive language; EX = expressive language; MF = fine motor; MG = gross motor; COG = cognition.
Reliability of the Bayley-III tool was assessed by measuring the stability (test-retest) of all domains. It was not possible to assess the test-retest scores of the expressive and receptive language domains because the children had the same score in the first assessment and therefore we could not calculate a variance. We did not find a significant positive correlation between the test-retest scores for cognition (Rho = -.34; p = .449) or for gross motor (Rho = -.39; p = .375). There was a positive correlation for fine motor scores between the two assessments (Rho = .89; p = .007). Table 4 presents the internal consistency results for each Bayley-III domain and also for the total score using Cronbach alpha coefficients and the Split-Half method using the Spearman-Brown formula. The results indicate low measurement errors for the Bayley subscales and the tool in general.
194
Table 4 Internal Consistency Analyses of the Brazilian Version of Bayley-III Scales Cronbach’s alpha coefficient
Split-Half by SpearmanBrown
Correlation between the two halves
Fine motor
.95
.98
.97
Gross motor
.95
.99
.98
General motor
.98
-
-
Receptive language
.96
.99
.99
Expressive language
.96
.98
.97
General language
.97
-
-
Cognition
.96
.98
.96
Bayley-III
.90
-
-
Variable
Discussion The increasing number of recent Brazilian studies that used the Bayley-III scales indicates the importance and usefulness of this instrument in the diagnosis of motor, cognitive and language delays in young Brazilian children (Ferreira et al., 2014; Hentges et al., 2014). However, the authors of previous studies used the original English version of the Bayley-III or non-validated translations that did not follow the guidelines for the process of cross-cultural adaptation (Hambleton & Patsula, 1999) and with unknown psychometric properties. These limitations could have influenced the reliability of the scores and the interpretation of the results provided in these studies (American Educational Research Association [AERA], American Psychological Association [APA], & National Council on Measurement in Education [NCME], 1999). Taking this into account, one of the main goals of the present study was to translate and adapt the Bayley-III to Portuguese following the best evidence-based guidelines for the translation, cross-cultural adaptation and assessment of psychometric properties, in addition to using the equivalence criteria proposed by Herdman et al. (1998). Future studies using the translated and adapted version of Bayley-III can help to improve it further and contribute to the research and clinical fields, helping health professionals to better identify young children at risk of developmental delay. We first assessed the convergent validity of the BayleyIII scales by correlating it with other instruments that, in theory, measure the same abilities as in its domains (AERA et al., 1999). We found a high positive correlation between the Brazilian version of the Bayley-III motor domains (total, fine and gross) and the specific and general PDMS-2 scores. Thus, both instruments seem to be of good quality, but Bayley-III is briefer and easier to administer. Similar results were identified in the language domains of the Bayley-III tool compared with LDS and PPVT scores. These results indicate that Bayley-III evaluates in a different way, almost the same skills as the other instruments. It is important to note that LDS is an indirect assessment
Madaschi, V., Mecca, T. P., Macedo, E. C., & Paula, C. S. (2016). Adaptation, Reliability and Validity of Bayley-III.
tool applied to a child’s caregiver. But the PPVT is an instrument composed of items in the same format, i.e., the child’s receptive vocabulary is assessed from the figures of choice when they hear the target stimulus. One of Bayley's advantages is not only that it makes a direct assessment of the child and looks at younger age groups in comparison with others instruments, it also assesses a range of diverse items, including the reaction to ambient sounds, recognition of familiar words and more complex levels like sentence comprehension. There was a moderate positive correlation between the Brazilian Bayley-III cognition scores and the Leiter-R scores. Since the Leiter-R tool has subtests that assess different cognitive abilities (Mecca et al., 2014) the correlation differed between specific subtests. Stronger correlations were found for categorization and visual processing abilities than for tasks related to fluid intelligence. The common variance observed between the Bayley-III Cognitive Scale and the visual processing and categorization tasks of the Leiter-R was expected, since the items in Bayley-III require the child to have the capacity to visual explore stimuli and knows how to sort them according to certain categories. These skills are developed very early on and increase significantly during the preschool years (Mecca et al., 2014). On the other hand, there are few items in the Bayley-III requiring sequential and inductive reasoning, which are the last items in the Cognitive Scale and therefore the most difficult, because they are the skills that develop more fully from 5 to 6 years of age (Mecca et al., 2014). The exploratory factor analyses of the internal structure of the Brazilian version of the Bayley III scales found that a single component explained 86% of the variance and this result was corroborated by good fit indices shown by the CFA. This result allows us to conclude that the total score of this version of the Bayley-III reflects the general component of child development and that the total score of this instrument can be interpreted as a global measure of child development. Due to the high correlation between specific domains, future studies are needed to confirm if these specific factors are present in other samples and ages. If future studies corroborate our findings it may be possible to produce a reduced version of the Bayley-III, decreasing the number of items per domain or even excluding entire domains. This would be an advantage in a version adapted to Portuguese, since several studies show the benefit of using brief or short assessment tools (Coutinho & Nascimento, 2010; Mello et al., 2011). A short version of the Bayley-III could reduce the time required not only for research but also in the case of a need for screening when there is suspected developmental delay. In the present study, the model with three factors cannot be estimated and the one factor model fits better than reported in Bayley (2006). These findings differ from those reported by Bayley, who identified three different factors for language, cognitive and motor performance. This discrepancy can in part be explained due to the much larger number of participants in Bayley’s study and to the type of analysis performed. However, in the original Bayley-III manual, it remains unclear whether the raw or standardized
scores were used in the analysis, and whether they were based on the individual items of the instrument or on the total scores. In addition, there may also be an issue in terms of the differences between the studies related to the selection of participants. The original study used a stratified sample of 1,700 children (Bayley, 2006), whereas in the present study we used a convenience sample whose participants had similar socioeconomic aspects. This is one of the main limitations of the study, especially regarding the generalization and comparison of findings. An additional limitation of the current study is that the children’s health information (chronic diseases and developmental disorders), used for exclusion criteria were based on the records of the daycare centers without any independent clinical evaluation. Besides, we did not performed analyses based on sociodemographic characteristics of the children or their families, because the group was considered mostly homogenous. We also did not collect data about environmental stimulation, although it is important to note that all the participants were exposed to the same level of stimulation in the day care centers, since all of them stayed there full time. The reliability of the Brazilian version of the Bayley III was good, with excellent internal consistency and item homogeneity (AERA et al., 1999). The results of the score stability were less robust. These data may be due to the age group of our participants. In very young children, the development of abilities is not as stable as in older preschoolers and in school age children (Griffiths, 1996). The lack of stability of scores over time indicates that BayleyIII may not be a good tool for identifying the effects of interventions or for predicting future performance with the same scale. The Brazilian version of the Bayley-III instrument had high convergent validity and good internal consistency and item homogeneity for children aged 12-42. This version can be useful for research purposes. Further studies with this version of the Bayley-III are needed, involving larger random samples from different regions of the country, as well as cohort studies to establish development curves comparing the performance in different age groups. There is also a need to perform more studies to assess the internal structure of this version of the Bayley-III using item analyses instead of total scores, as well as confirmatory factor analyses according to age groups with a higher number of participants, as was done in the original version of this instrument. Finally, this first study on the psychometric properties of the Brazilian version of the Bayley-III instrument will be useful for future studies comparing the development of normal versus high-risk children or those with specific clinical conditions. Thus, the present study contributes to advances in the assessment of child development in Brazil, a country without any similar validated tools.
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Cristiane Silvestre de Paula is an Associate Professor of the Universidade Presbiteriana Mackenzie. Received: Mar. 20, 2015 1st Revision: Nov. 6, 2015 Approved: Nov. 9, 2015
How to cite this article: Madaschi, V., Mecca, T. P., Macedo, E. C., & Paula, C. S. (2016). Bayley-III scales of infant and toddler development: Transcultural adaptation and psychometric properties. Paidéia (Ribeirão Preto), 26(64), 189-197. doi:10.1590/1982-43272664201606
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Article
Validity Evidence of the Z-Test-SC for Use With Children1 Anna Elisa de Villemor-Amaral2 Universidade São Francisco, Itatiba-SP, Brazil
Pâmela Malio Pardini Pavan Universidade São Francisco, Itatiba-SP, Brazil
Lucila Moraes Cardoso Universidade Estadual do Ceará, Fortaleza-CE, Brazil
Raquel Rossi Tavella Centro Universitário Nossa Senhora do Patrocínio, Itu-SP, Brazil
Fabiola Cristina Biasi Universidade São Francisco, Itatiba-SP, Brazil
Abstract: In Brazil, there is a lack of tools to assess the children’s affective and cognitive dynamics and investments are needed in research that seeks evidence of validity of some assessment tools for that public. The Zulliger test in the Comprehensive System (Zulliger-SC) evaluates the adequacy of reality perception, affects, self-perception, interpersonal relationship and cognitive processing and can be used with children, although there are few studies with this purpose in Brazil. Thus, the aim was to contribute in this field, comparing the performances in different stages of development. The participants were 103 children aged 6 and 12 years old, students from public schools in the state of São Paulo, who answered the test individually in the schools. The Zulliger-SC distinguished the children consistently with what is theoretically expected for their age, bringing some evidence of the Zulliger’s validity with children. Keywords: Zulliger Z test, test validity, childhood development
Evidências de Validade do Zulliger-SC Para Uso com Crianças Resumo: No Brasil, há uma escassez de instrumentos para avaliar a dinâmica afetiva e cognitiva de crianças, sendo necessário investir em pesquisas que busquem evidências de validade de técnicas de avaliação para esse público. O Teste de Zulliger no Sistema Compreensivo (Zulliger-SC) é um instrumento que avalia o modo de apreensão da realidade, afetos, auto-percepção, relacionamento interpessoal e funcionamento cognitivo, sendo indicado para uso com crianças, embora sejam escassos os estudos que demonstrem sua validade. Buscou-se contribuir para preencher essa lacuna, comparando os desempenhos de crianças em diferentes etapas do desenvolvimento. Participaram da pesquisa 103 crianças de 6 e 12 anos, estudantes de escolas públicas do interior do estado de São Paulo, que responderam ao instrumento individualmente, na própria escola. O Zulliger-SC diferenciou os participantes de modo coerente ao esperado teoricamente para suas idades, contribuindo com evidências de validade de uso do Zulliger-SC com crianças. Palavras-chave: teste de Zulliger, validade do teste, desenvolvimento infantil
Evidencia de Validez de la Prueba Zulliger-SC Para Uso con los Niños Resumen: En Brasil, hay relativa falta de herramientas para evaluar la dinámica afectiva y cognitiva de niños, siendo necesario invertir en investigaciones que buscan evidencias de validez de algunas técnicas para esa población. El Zulliger - Sistema Integrado (Zulliger-SI) es un instrumento que evalúa el modo de percibir la realidad, los afectos, la autopercepción, la relación interpersonal y funcionamiento cognitivo y puede ser utilizado con niños, pero hay pocos estudios con ese propósito en Brasil. Por lo tanto, el objetivo fue contribuir en este campo, comparándose las respuestas de niños con distintas edades. Participaran 103 niños de 6 e 12 años, estudiantes de escuelas públicas en el estado de São Paulo, que respondieron al test individualmente en la propia escuela. El Zulliger-SC ha diferenciado los niños consistentemente a lo esperado teóricamente para las edades, contribuyendo para validez de su uso con niños. Palabras clave: test de Zulliger, validación de test, desarrollo infantil
Childhood is marked by different development phases with distinct characteristics, demanding refined resources from psychologists to assessing the cognitive and emotional aspects relatively expected for each phase, which permits an appropriate investigation of the child’s potentials
Support: National Council for Scientific and Technological Development CNPq (Grant # 475633/2006-7). 1
Correspondence address: Anna Elisa de Villemor-Amaral. Universidade São Francisco. Rua Alexandre Rodrigues Barbosa, 45, Centro. CEP 13251-900. Itatiba-SP, Brazil. E-mail: anna.villemor@usf.edu.br 2
Available in www.scielo.br/paideia
and limitations (Nascimento, Pedroso, & Souza, 2009). According to Semer (2008), although the child’s personality is being established, the use of psychological assessment tools permits a more appropriate understanding of their characteristics, considering the peculiarities of the different phases of childhood development. Different theoreticians have studied childhood development, appointing different phases in cognitive and affective development. Among experts in the area, Piaget is mentioned, for example, who offered important understandings with his epistemological theory of human development. In this theory, the author explains that, in
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the course of their development, the children go through different cognitive stages that directly influence the way of relating with the world. In Piaget’s epistemological theory (1978), cognitive development is marked by four stages that are characterized by a series of behaviors typical of each period. Therefore, it is very important for the psychologists to be able to count on methods that satisfactorily apprehend the characteristics of the phases the children being assessed go through, as these are in constant emotional, social and cognitive development (Nunes, Teixeira, & Deakin, 2010). Different authors have appointed the Rorschach Method as a highly useful instrument, as it permits the understanding of emotional, social and cognitive functioning (Fernandes, 2010; Hisatugo & Custódio, 2013; Jacquemin, 2012; Nascimento et al., 2009; Raspantini, 2010; Resende, Carvalho, & Martins, 2012; Ribeiro, Semer, & Yazigi, 2011; Semer, 2008). Despite using different interpretative systems of the Rorschach, all of these studies have indicated possibilities to use the same method with children. According to Viglione (1999), for example, in the Rorschach, age is associated with the complexity of the answers, so that the evolution of development is evidenced in the increasingly complex answers the subjects provide. Even if the interpretative meanings of the RorschachSC involve universally applicable descriptive aspects, the interpretative meaning of the indicators depends on normative standards. Hence, justifying the lack of normative standards to apply the Rorschach Method with children in Brazil, Ribeiro et al. (2011) intended to set standards for the use of the RorschachSC for male and female children between 7-10 from public and private schools, totaling 221 participants. The authors initially developed a consistency study between evaluators and the coefficient ranged between .65 and .97, varying between average and excellent. Most variables obtained an agreement coefficient superior to .90 in practically all variables, except for the determinants and formal quality. The comparative analyses of the children from public and private schools revealed statistically significant differences in some variables, indicating that the children from private schools demonstrated greater facility to associate and produce answers, higher situational stress rates and better capacity to cope with complex affective situations and to intellectually manipulate the affection. These characteristics reveal that the children from more privileged social classes deal with complex situations more easily. They were also more anxious, perhaps because they felt greater pressure and because they have to spend time on different extracurricular activities, as reported by the children’s parents. The children from public schools, on the other hand, presented a more formal attitude and less variable reactions, demonstrating less involvement and a more simplified perception. The results revealed that boys and girls tend to obtain similar results in the variables Rorschach Comprehensive System. Finally, the authors created the normative tables for the variables Rorschach Comprehensive System per age range between 7 and 10 years and according to the origin from public or private schools. Resende et al. (2012) developed a similar study when they analyzed the performance on the Rorschach-SC method of 201 children and adolescents between 5 and 14 years of age,
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separated in three age groups. The participants were randomly selected based on public and private schools from nine regions in Goiânia-GO. Based on the inter-rater agreement analysis of 25% of the sample, it was observed that the agreement percentages varied between .89 and .99 and the Kappa coefficients between .78 and .98. The descriptive and inferential statistics of the Rorschach variables were also calculated. Among the results presented, it was verified that variables related to the coherent and precise processing of information, indicated by the good formal quality of the answers (FQ+ and FQo), the appropriate perception of more obvious situations in the global answers and simple details (WDo), the efficiency and complexity in information processing (DQ+) and availability for cooperative and welcoming attitudes (COP) obtained a high frequency as age advances. In addition, the variables WDA, WDA%, DQ+, DQo, FQo, R, D, SumSh, the latter related to the presence of anxiety, were significantly increased in the higher age range (12-14 years), are in accordance with the earlier assertions. The authors concluded that, as the participants’ age advances, the answers to the Rorschach gain complexity and precision, contributing to the assessment of children with different age ranges. Another tool, with a structure very similar to the Rorschach and potential for use with children is the Zulliger Test. The Zulliger Test is an expressive method, like in the Rorschach, composed of unstructured stimuli aimed at producing information on the assessed person’s personality. It was created by the psychologist Hans Zulliger, who needed to assess a large group of people and had to develop a simplification of the method to reduce the application time and analysis. Thus, he created new inkblots and concluded his work with a set of three inkblots presented as slides and printed on cards (Villemor-Amaral & Primi, 2009). After the publication of the Rorschach in the Comprehensive System, studies started in different countries to adapt the Comprehensive System to the Zulliger test (Fazendeiro & Novo, 2012; Mattlar et al., 1990; Zdunic, 1999). In Brazil, the Zulliger had been used collective as well as individually and, as from 2003, there was a progressive increase in the standardization and validation studies to use the Zulliger in the Comprehensive System model, practically all in the adult population. The verification of its validity for use with children is also justified by the reduction of the application and analysis time. It can be used to assess a larger number of individuals in school or institutional contexts, but also as a complementary tool, included in a larger test battery, without putting too much a strain on the child. A search in the databases of the Virtual Health Library in Psychology (BVS-Psi) and PsycINFO on the studies developed in the childhood population, few studies were found. The studies using the Zulliger with children (Biasi & Villemor-Amaral, in press; Tavella & Villemor-Amaral, 2014; Villemor-Amaral & Quirino, 2013) will be detailed next. Tavella and Villemor-Amaral (2014) developed a study to verify whether the cognitive and affective indicators on the Zulliger Test which, as a hypothesis, are correlated with creativity, contribute to distinguish children with different creative potentials, identified by the Test of Figural Creativity for Children (TCFI). Ninety children participated, between
Villemor-Amaral, A. E., Pavan, P. M. P., Tavella, R. R., Cardoso, L. M., & Biasi, F. C. (2016). Zulliger-SC With Children.
11 and 12 years old, male and female, from public schools in a city in the interior of São Paulo. The Zulliger Test-SC and the TCFI were used. The main variables of the Zulliger that were statistically significant to distinguish the two groups were the number of answers produced (R), which indicates the capacity to be productive from the intellectual viewpoint; the human movement responses (M), which suggest creativity, imagination and empathy; the popular responses (P), which are associated with conventionality and perceptive adequacy; the negative formal quality (FQ-), which refers to errors in the individual’s perceptive adjustment. This set of variables demonstrated that the most creative children demonstrated greater production and creation skill on the Zulliger, constituting evidence of validity to use this test in the childhood population. The goal in the study by Villemor-Amaral and Quirino (2013) was to identify correlations between the Pfister and Zulliger test concerning the integration of Color and Form as predictors of distinguished emotional control and cognitive development levels. Therefore, the tools were administered in 60 participants, being 30 six-year-old children and 30 12-year-old adolescents. Concerning the correlations between the two tools, the authors identified an increase in the responses on the structure formal aspects of the Pfister, accompanied by an increase in pure color (C) answers on the Zulliger, suggesting that, although the group of adolescents presented greater cognitive development than the children, the former’s emotional expression tends to be less controlled and in a way unpredictable, being compatible with the instability commonly observed in puberty and adolescence. Biasi and Villemor-Amaral (in press) sought validity evidence for the use of the Zulliger-SC in children, specifically focusing on the interpersonal relationship indicators. The proposal was to verify whether the interpersonal relationship indicators on the Zulliger-SC managed to distinguish two groups, constituted by the results of a sociogram that appointed popular children and children rejected by their colleagues at a school. Initially, 119 male and female children participated in the research, from the fourth, fifth and sixth year of primary education, from public schools in an interior city in the state of São Paulo. Forty-eight children were selected who obtained a higher score for preferences and rejections and the Zulliger Test was applied individually. In conclusion, the variables related to human movements - Mp and p and to human contents - H, and the proportion H < (H) + Hd + (Hd), was more significant in popular children. In the Rorschach as well as in the Zulliger, these variables identify answers that contain human movements and human content responses, whose quantity and quality predict the interpersonal relationship capacity. In that research, these indicators distinguish the groups in a statistically significant manner, demonstrating that more popular children also have more relational skills than the less popular group. The conclusion was that the Zulliger was able to identify children who performed better or worse on a sociogram, showing evidence of validity for the tool regarding this personality aspect. The three studies cited focused on specific aspects, such as creativity, cognitive and emotional development and interpersonal relationship of children and adolescents. Based
on the promising results cited above, this study intended to proceed with the verification of cognitive and affective variables that, related to development, could reveal different frequencies in the comparison of 6 and 12-year-old children. The study was specifically focused on the variables related to the way the reality is apprehended (W, D, Dd and S, DQ and Z); to contact with the reality (FQ+, FQo, FQu and FQ); to changes in perception and thought, such as the special codes DV, DR, INC, FAB, CONTAM, ALOG, PSV, which in general lines represent inappropriate forms of expression or combinations of ideas or images incompatible with the reality. In addition, greater capacity was verified to control the emotions and tensions through the variables M, FM, m, C’ T, V, Y and, finally, the presence of some more primitive contents, such as Food (Fd), Anatomy (An) and blood (Bl).
Method Participants To develop this research, a database was used that is being constituted to compose the normative samples of the Zulliger Test for children. The base contained 622 Zulliger Test protocols administered in interior cities in the state of São Paulo. For this study, all protocols of children aged 6 and 12 years old were selected, being in different development stages, favoring the comparison of the results. Thus, 38 protocols of children aged six years old and 65 protocols of participants aged 12 years old were used, totaling 103 protocols. All children included in the sample had no history of psychiatric or psychological treatment and were regularly enrolled in the expected grade for their age, that is, they had no history of school repetition. To participate, both the person responsible for the child and the child him/herself had to agree to participate in the research voluntarily. The sample consisted of male and female children. Among the participants aged six years, 23 (61%) were female and, among the participants aged 12 years, 35 (54%) were female. Instruments Zulliger Test. The tool consists of three cards of 24 x 17 centimeters, each of them with an inkblot. The application of the Zulliger is divided in two phases. In the first, the individual is expected tell for each of the three cards what the inkblots look like. Then, the person’s answers are read and (s)he is expected to say where (s)he saw and what is in the blot that makes it look like the object or element identified. This information permits the coding and appropriate interpretation of the answers, considering quantitative and qualitative aspects. The application time is approximately 30 minutes. As the literature mentions important changes in the affective and cognitive development in the period between 6 and 12 years, all variables of the Zulliger were addressed. Thus, the indicators related to resources and control, self-perception, affection, interpersonal relationship, processing, mediation and ideas described by Villemor-Amaral and Primi (2009) were assessed and interpreted according to the Comprehensive System (SC).
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Procedure Data collection. The protocols stored in the databases were used to compose a normative sample of the Zulliger Test for children and adolescents. The research team, trained for the applications and analyses, elaborated the database, thus guaranteeing the uniformity of the data collection procedures. The applications happened at public schools located in the interior of the State of São Paulo. In all cases, the Zulliger Test was administered during an individual session that took approximately 30 minutes. The authors of the study classified the answers according to the criteria of the Comprehensive System. Aiming for greater precision of the research data, 25% of the protocol was drafted for blinded coding by an independent judge, also one of the authors, so that the agreement level of the coding could be verified. Any disagreements were discussed to define the most correct coding, with the help of a third judge. Data analysis. To seek the evidence of validity on the use of the Zulliger-SC with children, descriptive statistics were used. Next, Student’s t-test was used to compare the performance on all variables of the tool according to age,
and Cohen’s d to check the magnitude of the differences. Parametric and non-parametric analyses were applied to compare the two groups. As both analyses produced the same result, Student’s t coefficients were maintained, being a more robust analysis than non-parametric statistics. Ethical Considerations The results presented derive from two pre-existing databases. The studies that permitted the composition of the database complied with all ethical precautions in accordance with CNS resolution 196/96, with approval from the Ethics Committee for Research involving Human Beings at Universidade São Francisco (CAAE n. 0078.0.142.000-07).
Results To seek evidence on the validity of the use of the ZulligerSC with children, descriptive statistics were applied, followed by Student’s t to compare the performance on all variables of the tool according to age. Table 1 shows the frequency of the coding variables of the answers with significant differences.
Table 1 Comparison of Frequency of Zulliger Coding Variables Between 6 and 12 Years Variables M C’ FY FT FD FQ(H) Ls Fd Anatomy DV
Age
N
M
SD
6
38
0.42
0.76
12
65
0.80
0.97
6
38
0.16
0.44
12
65
0.00
0.00
6
38
0.08
0.27
12
65
0.23
0.63
6
38
0.00
0.00
12
65
0.11
0.36
6
38
0.00
0.00
12
65
0.06
0.24
6
38
1.89
1.18
12
65
1.23
1.27
6
38
0.53
0.73
12
65
0.22
0.48
6
38
0.03
0.16
12
65
0.14
0.35
6
38
0.13
0.34
12
65
0.02
0.12
6
38
0.63
0.75
12
65
0.20
0.59
6
38
0.74
0.98
12
65
0.32
0.62
t
p
d
-2.06
.042
0.42
2.23
.032
0.60
-2.31
.024
0.28
-2.42
.018
0.38
-2.05
.045
0.31
2.62
.010
0.53
2.35
.022
0.53
-2.22
.029
0.37
2.02
.050
0.48
3.04
.003
0.66
2.35
.022
0.54
Note. M = human movement; C’ = achromatic color; FY = Diffuse form and Shading; FT = Texture form and shading; FD = form dimension; FQ- = uncommon and distorted formal quality; (H) = complete parahuman; Ls = landscape; Fd = food; Anatomy = anatomy; DV = deviating verbalization.
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Villemor-Amaral, A. E., Pavan, P. M. P., Tavella, R. R., Cardoso, L. M., & Biasi, F. C. (2016). Zulliger-SC With Children.
In Table 1, it is observed that the six-year-old children had significantly higher averages on the usage frequency of the determinant chromatic color (Câ&#x20AC;&#x2122;), of the formal quality minus (FQ-), of parahuman contents [(H)], food (Fd) and anatomy (An) and the special code deviating verbalization (DV), while the 12-year-old participants presented a significant increase in the determinants human movement (M); diffuse shading (FY); texture shading (FT); form dimension (FD) and landscape content (Ls). In addition, it is important to highlight that it is not enough for the results to reveal statistically significant differences. The effect size of this difference should also be
verified. For this end, Cohen (1992) suggested that d = .20 is considered of small size, d = .50 intermediary and d = .80 small. Thus, the variables with a small effect were FY, FT, FD and Ls and with an intermediary effect: M, Câ&#x20AC;&#x2122;, FQ-, (H), Fd, Anatomy and DV. Only the intermediary-effect indicators were discussed, as shown in the Discussion. In the Zulliger test, data can be inferred about the person through the frequency of certain indicators, but even better when the associations among these indicators are considered, based on formulae, indices and proportions. These variables deriving from calculations that showed significant results can be observed in Table 2.
Table 2 Comparison of Interpretative Calculations of Zulliger Between 6 and 12 Years of Age Variables S-% Color with FQSum of FQAn+Xy Sum of H content M with FQu WD with FQY T WSum6 XA% WDA% X+% X-%
Age
N
M
SD
6
38
0.37
0.40
12
65
0.15
0.44
6
38
0.37
0.54
12
65
0.08
0.27
6
38
1.26
0.98
12
65
0.75
0.87
6
38
0.42
0.55
12
65
0.05
0.28
6
38
0.39
0.55
12
65
0.17
0.38
6
38
0.05
0.23
12
65
0.18
0.43
6
38
1.42
1.03
12
65
0.60
0.79
6
38
0.08
0.27
12
65
0.38
0.76
6
38
0.00
0.00
12
65
0.11
0.36
6
38
1.18
1.23
12
65
0.57
1.02
6
38
0.69
0.16
12
65
0.80
0.15
6
38
0.71
0.18
12
65
0.86
0.14
6
38
0.38
0.18
12
65
0.47
0.23
6
38
0.29
0.15
12
65
0.17
0.15
t
p
d
2.07
.042
0.46
3.10
.003
0.74
2.74
.007
0.56
3.91
< .001
3.47
2.25
.029
0.49
-2.04
.044
0.35
4.55
< .001
0.93
-2.92
.004
0.48
-2.42
.018
0.38
2.74
.007
0.55
-3.53
.001
0.72
-4.85
< .001
0.96
-2.00
.048
0.42
3.91
< .001
0.80
Note. S-% = sum of answers with blank space and with uncommon and distorted formal quality; Color with FQ- = chromatic color response with uncommon and distorted formal quality; An+Xy = sum of anatomy response and X ray; Sum of H content = sum of complete human content; M with FQu =total human movement response with uncommon and distorted formal quality; WD with FQ- = total global and usual response with uncommon and distorted formal quality; Y = ; T = texture response without form; WSum6 = weighted sum of special responses; XA% = percentage of response sum with elaborated or super-elaborated, ordinary and uncommon formal quality; WDA% = sum of XA% with global and usual response; X+% = percentage of sum of response with elaborated or super-elaborated and ordinary formal quality; X-% = percentage of sum of response with uncommon and distorted formal quality.
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In Table 2, it is observed that the six-year-old children obtained an increase by S- % (sum of locations that included blank space, associated with formal quality minus), Color with FQ-, Sum of FQ-, An+Xy, Sum of content H, WD with FQ- (sum of W and D location answers, associated with formal quality minus), WSum6 (sum of weighted values of special codes) and X-% (formal quality minus). The 12-yearold children presented an increase in the variables M with FQu, Y, T, XA%, WDA% and X+%. Cohen’s d coefficients indicated that the variables M with FQu and T presented a small effect size and, therefore, the choice was made not to discuss them in this research.
Discussion To verify to what extent the Zulliger-SC test permits identifying the cognitive and emotional differences expected according to the child’s development phases, the data obtained through the application of the Zulliger to six and 12-year-old children were compared. Among the variables with significant differences observed in Table 1, the discussion can start with the determinant M, which appeared higher in the 12-year-old group. According to Weiner (2000), this determinant indicates the presence of projective loading in the response, representing psychological activities that involve the evocation of mental registers of the experiences and their attribution to the stimulated area. Hermann Rorschach himself already considered M a sign of greater maturity and intelligence. It should be reminded that the determinant M was also higher in the group of creative adolescents in the study by Tavella and Villemor-Amaral (2014), and ranked as one of the most popular in the research by Biasi and Villemor-Amaral (in press). On the other hand, it should be highlighted that the increase in M for the 12-year-old children in this sample is associated with the increase in FQu, as can be observed in Table 2, suggesting a more personal form of using the ideas without necessarily indicating disorder. This more peculiar mode of observing the facts in adolescence is typical of the need to grow and constitute one’s own identity, which may be associated with frequent conflicts in this development period, as shown further ahead. The variable C’ was more frequent in the six-year-old group. This variable indicates an involuntary and automatic process of internalization of feelings that may increase an internal unease due to the brake on emotional expression, being hardly effective from the adaptation viewpoint (Weiner, 2000). Although an isolated piece of information does not permit many inferences (Exner & Sendín, 1999), everything depending on the context, it is verified that, somehow, the younger children are more prone to this type of emotional response, which is less mature. The Formal Quality (FQ) indicators provide information on the degree of perceptive adequacy between the stimulus of the inkblot and the subject’s mnemonic associations. FQsuggests a distorted or hardly effective perception of the reality (Exner & Sendín, 1999). In a way, younger children are expected to tend to provide more FQ- answers than 12-year olds. Similar results were obtained in the study by Resende et al. (2012), using the Rorschach-SC in children.
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According to Piaget (1978), around the age of six years, for example, children have more magical and egocentric thinking, marked by the child’s own and not socially shared logic. In this phase, children have not appropriated themselves of the more socialized mode of thinking yet, which is expected to have occurred by the age of 12 years, when the child is already in the so-called formal operative period. Concerning Zulliger’s content variables, it is interesting to note that six-year-old children presented a significant increase with intermediary effect size in (H), Fd and An. The first indicator supposes that the child has an imaginative and fanciful conception of the human relations. The second expresses more dependent behavior and a certain expectation that others will satisfy their needs, in line with Piaget’s proposals (1978), while the responses by An suggest concern with the body. This combination of phenomena is coherent with what is expected for six-year-old children, who naturally have a more immature view of themselves and the other, present magical thinking in which fantasy prevails and are hardly able to take on the correct mindset, granting the body a more preponderant presence in the infant mind (Marty, 1998). Finally, the increase in DV was observed in the six-yearold children. DV answers may imply the distorted use of verbalizations, reducing the clarity of communication (Exner & Sendín, 1999). Six-year olds are expected to have a more limited vocabulary than 12-year olds, as the vocabulary tends to grow considerably in the course of the education process. This can lead to the mistaken use of words and concepts, a limitation that is characteristic of development, which would not constitute a pathological change of thought. At the age of 12 years, language gains a fundamental role, serving as conceptual support to be able to develop more abstract thinking, typical of the formal operative stage. Thus, the language can get more appropriate and precise than that of younger children. S-%, which indicates the extent to which emotional interferences can distort the subject’s perceptive processes (Exner & Sendín, 1999), was another more frequent variable among the younger children in this study. Its increase in sixyear olds can derive from the emotional immaturity that makes a negative feeling compromisse an objective understanding of the facts. This result is associated with the concomitant sum of color answers with FQ-, which is also higher in the group of six-year-old children, and may suggest the child’s failure to control emotional impulse, associated with the distortion of reality or with a trend to draw precipitated conclusions (Villemor-Amaral & Primi, 2009). As mentioned, the increase in An, now in combination with x-ray answers (Xy), indicates concerns with the body, which may point towards changes in the self-image and the attitudes towards oneself (Exner & Sendín, 1999), mainly for adults. These indicators together reinforce the hypothesis of a more primitive functioning for six-year-old children, which may be related to the immaturity characteristic of who has not properly imagined the mental and affective difficulties yet, maintaining them at a more bodily level, as mentioned. The increase in the sum of H content should be considered in relation to the type of H content. In Table 1, it
Villemor-Amaral, A. E., Pavan, P. M. P., Tavella, R. R., Cardoso, L. M., & Biasi, F. C. (2016). Zulliger-SC With Children.
was observed that the six-year olds presented an increase in (H), suggesting distancing from the reality, indicating greater investment in fantasy when coping with the perceptions of oneself and the other (Exner & Sendín, 1999). This idea seems to strengthen the characteristics mentioned earlier that children in the preoperative period tend to focus more on self-oriented functioning, with a still limited understanding of the surrounding world. In the study by Biasi and VillemorAmaral (in press), the group of children considered unpopular also presented increased (H), (Hd) and Hd answers. Associated with a significantly higher FQ-, WD in sixyear olds strengthens the increase in distorted perceptions when compared to 12-year-old adolescents, even under the most common circumstances. WSum6 results from the weighted sum of the critical Special Codes and, therefore, its increase should be considered in function of which of the codes this increase occurs in. In this study, returning to Table 1, it is verified that this increase among the younger children is due to the rise in DV, which also, as discussed, may simply identify language errors characteristic of children who are gaining literacy. The increase in XA%, WDA% and X+% in older when compared to younger children suggests a more appropriate and realistic perception of the context among the older children, as a natural consequence of development. O XA% refers to the sum of formal quality answers that are considered appropriate answers to the contours of the inkblot, independently of being common or not (FQo + FQu + FQ+), and WDA% refers to the appropriateness of the formal quality of the answers in W and D, excluding Dd (Nascimento, 2010), while X+% superior to the expected average suggests hyperconventionality, indicating submission to external standards (Exner & Sendín, 1999). Thus, XA%, WDA% and X+% answers provide information on the perceptive appropriateness of reality (Nascimento, 2010). The fact that these variables are increased in the 12-year-old group suggests that the Zulliger reflects the extent to which the perceived external reality is balanced with development, according to Piaget. In other words, the young people in this research assimilate and accommodate a larger amount of cultural information, adapting to the social conventions. Similar data were found in Rorschach-SC studies involving children (Resende et al., 2012). The Y answers were also more frequent in the adolescent group. These answers emerge in response to external situations that cause tension or discomfort, suggesting increased suffering and the presence of paralyzing emotions (Exner & Sendín, 1999). Their greater appearance at the age of 12 than at the age of six years strengthens the idea that the onset of adolescence is naturally full of conflicts that cause anguish and contributes to demonstrate that the Zulliger permits the expression of these developmental characteristics. The set of variables highlighted in this study made it possible to distinguish emotional, social and cognitive aspects of childhood development typical of the different age ranges, contributing to evidences of validity of the ZulligerSC (Villemor-Amaral & Primi, 2009) when used with children and young adolescents. These findings follow the same sense of
studies using the Rorschach for children, in line with the research by Nascimento et al. (2009), Resende et al. (2012), Ribeiro et al. (2011), Semer (2008) and Viglione (1999) on the Rorschach-SC and indirectly with the findings by Fernandes (2010), Hisatugo and Custódio (2013), Jacquemin (2012) and Raspantini (2010), which indicated the possible use of the inkblots method to assess children. Hence, like in the Rorschach, it is considered that the Zulliger permits an appropriate assessment of the children and can be used mainly in situations in which a larger group of individuals is assessed. The Zulliger test permitted distinguishing two groups of distinct age ranges, contributing to the initiative to introduce, in Brazil, the use of the Zulliger in the Comprehensive System to assess children. The number of participants in this research can be considered consistent for studies using expressive methods, but restricted for the establishment of normative standards, also keeping in mind that, although the sample consisted of individuals from different cities in the interior of São Paulo, it was limited to a small part of the Brazilian territory. Despite the positive results presented, it is fundamental to develop further research to seek further evidence on the validity of the Zulliger Comprehensive System for use with different age ranges. One important suggestion that would significantly contribute to understand the range and limits of the Zulliger as a psychological assessment tool is the development of not only cross-sectional studies like the study presented in this paper, but also longitudinal studies.
References Biasi, F. C., & Villemor-Amaral, A. E. (2016). Evidências de validade do Zulliger-SC para avaliação do relacionamento interpessoal de crianças [Zulliger - SC validity of evidence to evaluate the interpersonal relationship of children]. Psico, 47(1), 13-23. Cohen, J. (1992). A power primer. Psychological Bulletin, 112(1), 155-159. Exner, J. E., Jr., & Sendín, C. (1999). Manual de interpretação do Rorschach para o Sistema Compreensivo [The Rorschach: A Comprehensive System: Interpretation] (A. C. P. Silva Neto, Trans.). São Paulo, SP: Casa do Psicólogo. Fazendeiro, H. M. M., & Novo, R. J. F. (2012). Versão coletiva do teste de Zulliger segundo o Sistema Compreensivo do Rorschach [Zulliger group test according to the Rorschach Comprehensive System]. Avaliação Psicológica, 11(3), 407422. Fernandes, S. (2010). Normas do Rorschach em crianças de seis a oito anos [Norms for the Rorschach in six to eight-year-old children] (Master’s thesis). Retrieved from http://www.teses.usp.br/teses/disponiveis/59/59137/tde23102013-150520/en.php Hisatugo, C. L. C., & Custódio, E. M. (2013). Avaliação psicológica e da personalidade e o estudo normativo do Rorschach para o uso em crianças brasileiras [Psychological assessment and personality and study
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of regulatory Rorschach for use in Brazilian children]. Psicólogo inFormação, 17(17), 79-86. doi:10.15603/21760969/pi.v17n17p79-86 Jacquemin, R. C. P. (2012). Padrões normativos do psicodiagnóstico de Rorschach em adolescentes de 12 a 14 anos [Normative data for the Rorschach psychodiagnostic test in adolescents aged 12-14 years] (Master’s thesis). Retrieved from http://www.teses.usp.br/teses/ disponiveis/59/59137/tde-10072013-161031/pt-br.php Marty, P. (1998). Mentalização e psicossomática [Mentoring and psychosomatic] (A. E. V. A. Güntert, Trans.). São Paulo, SP: Casa do Psicólogo. Mattlar, C.-E., Sandahl, C., Lindberg, S., Lehtinen, V., Carlsson, A., Vesala, P., & Mahmood, Z. (1990). Methodological issues associated with the application of the comprehensive system when analysing the Zulliger, and the structural resemblance between the Zulliger and the Rorschach. British Journal of Projective Psychology, 35(2), 17-27. Nascimento, R., Pedroso, J. S., & Souza, A. M. (2009). Método de Rorschach na avaliação psicológica em crianças: Uma revisão de literatura [Rorschach in children psychological assessment: A literature revision]. Psico-USF, 14(2), 193200. doi:10.1590/S1413-82712009000200008 Nascimento, R. S. G. F. (2010). Sistema Compreensivo do Rorschach: Teoria, pesquisa e normas para a população brasileira [Comprehensive System of Rorschach : Theory, research and standards for the Brazilian population]. São Paulo, SP: Casa do Psicólogo. Nunes, M. L. T., Teixeira, R. P., & Deakin, E. K. (2010). Técnicas projetivas e avaliação de psicoterapia psicanalítica com crianças [Projective techniques and evaluation of psychoanalytic psychotherapy with children]. In M. L. T. Nunes (Org.), Técnicas projetivas com crianças [Projective techniques with children] (pp. 145-170). São Paulo, SP: Casa do Psicólogo. Piaget, J. (1978). A epistemologia genética / Sabedoria e ilusões da filosofia / Problemas de psicologia genética [The genetic epistemology / Wisdom and illusions of philosophy / psychology genetic problems] (N. C. Caixeiro, Trans.). São Paulo, SP: Abril Cultural. Raspantini, R. L. (2010). O psicodiagnóstico de Rorschach em crianças de 9 a 11 anos: Um estudo normativo [Rorschach’s psychodiagnostic test in 9 to 11-yearold children: A normative study] (Master’s thesis). Retrieved from http://www.ffclrp.usp.br/imagens_ defesas/01_02_2011__08_50_55__61.pdf Resende, A. C., Carvalho, T. C. R., & Martins, W. (2012). Desempenho médio de crianças e adolescentes no método de Rorschach Sistema Compreensivo [Average performance of children and adolescents in the Rorschach Comprehensive System]. Avaliação Psicológica, 11(3), 375-394. Ribeiro, R. K. S. M., Semer, N. L., & Yazigi, L. (2011). Rorschach Comprehensive System norms in Brazilian children from public and private schools. Psicologia: Reflexão e Crítica, 24(4), 671-684. doi:10.1590/S010279722011000400007
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Semer, N. L. (2008). A utilização do Rorschach em crianças e adolescentes [The use of Rorschach in children and adolescentes]. In A. E. Villemor-Amaral & B. S. G. Werlang (Orgs.), Atualizações em métodos projetivos para avaliação psicológica [Updates on projective methods for psychological evaluation] (pp. 95-106). São Paulo, SP: Casa do Psicólogo. Tavella, R. R., & Villemor-Amaral, A. E. (2014). O teste de Zulliger-SC: Avaliação da criatividade em crianças [The Zulliger-SC test: Assessment of children’s creativity]. Estudos de Psicologia (Campinas), 31(4), 489-497. doi:10.1590/0103-166X2014000400003 Viglione, D. J. (1999). A review of recent research addressing the utility of the Rorschach. Psychological Assessment, 11(3), 251-265. doi:10.1037/1040-3590.11.3.251 Villemor-Amaral, A. E., & Primi, R. (2009). Teste de Zulliger no Sistema Compreensivo ZSC: Forma individual [The Zulliger test the Comprehensive System: individual form]. São Paulo, SP: Casa do Psicólogo. Villemor-Amaral, A. E., & Quirino, G. S. (2013). Estudo comparativo entre indicadores afetivos das técnicas de Pfister e Zulliger [Comparative study between the affective indicators of Zulliger and Pfister tests]. Avaliação Psicológica, 12(1), 1-7. Weiner, I. B. (2000). Princípios de interpretação do Rorschach [Principle of Rorschach interpretation] (M. C. V. M. Silva, Trans.). São Paulo, SP: Casa do Psicólogo. Zdunic, A. L. (1999). El teste de Zulliger en la evaluación de personal: Aportes del Sistema Compreensivo de Exner. Buenos Aires, Argentina: Paidós. Anna Elisa de Villemor-Amaral is a Professor of the Universidade São Francisco. Pâmela Malio Pardini Pavan is a M.S. candidate of the Graduate Program in Psychology of the Universidade São Francisco Raquel Rossi Tavella is a Professor of the Centro Universitário Nossa Senhora do Patrocínio. Lucila Moraes Cardoso is a Professor of the Universidade Estadual do Ceará. Fabiola Cristina Biasi is a Professor of the Universidade São Francisco. Received: Apr. 8, 2015 1st Revision: Aug. 25, 2015 Approved: Sep. 18, 2015
How to cite this article: Villemor-Amaral, A. E., Pavan, P. M. P, Tavella, R. R., Cardoso, L. M., & Biasi, F. C. (2016). Validity evidence of the Z-Test-SC for use with children. Paidéia (Ribeirão Preto), 26(64), 199-206. doi:10.1590/198243272664201607
Paidéia may-aug. 2016, Vol. 26, No. 64, 207-214. doi:10.1590/1982-43272664201608
Article
Parental Stress and Social Support of Caregivers of Children With Cerebral Palsy1 Mayara Barbosa Sindeaux Lima2 Universidade Federal do Pará, Belém-PA, Brazil
Vagner dos Santos Cardoso Universidade Federal do Pará, Belém-PA, Brazil
Simone Souza da Costa Silva Universidade Federal do Pará, Belém-PA, Brazil
Abstract: Stress and social support are relevant variables for understanding the impact of disability on the care relationship. Thus, this study investigates the association between the parental stress index, social support indicators, and the sociodemographic variables of caregivers of children with cerebral palsy in a capital city of the Eastern Amazon. The following instruments were applied to 100 caregivers: the Sociodemographic Inventory, the Gross Motor Function Classification System, the Parenting Stress Index, and the Medical Outcomes Study Social Support Survey. For data analysis, descriptive statistics were used, in addition to techniques of multivariate analysis. It was found that most participants had high parental stress and a high perception of social support. Specific aspects of the perception of social support and sociodemographic indicators were associated with stress. This knowledge favors the design of more assertive interventions because it outlines the aspects of these variables that appear to have a more effective impact on parental stress. Keywords: children, cerebral palsy, caregivers, parental stress index
Estresse Parental e Suporte Social de Cuidadores de Crianças com Paralisia Cerebral Resumo: O estresse e o suporte social são variáveis relevantes para se compreender o impacto da deficiência na relação de cuidado. Neste sentido, este estudo investigou a existência de associação entre o índice de estresse parental e indicadores de suporte social e variáveis sociodemográficas de cuidadores de crianças com paralisia cerebral em uma capital da Amazônia Oriental. Cem cuidadores responderam aos instrumentos: Inventário sociodemográfico, Sistema de Classificação da Função Motora Grossa, Índice de Estresse Parental e Medical Outcomes Study Social Support Survey. Para a análise dos dados, utilizou-se a estatística descritiva com técnicas de análises multivariadas. Verificou-se que a maioria dos participantes apresentou um alto estresse parental e a percepção de elevado suporte social. Aspectos específicos da percepção de suporte social e de indicadores sociodemográficos estiveram associados ao estresse. Este conhecimento favorece o planejamento de intervenções mais assertivas, pois delineia que aspectos parecem impactar mais efetivamente no estresse parental. Palavras-chave: crianças, paralisia cerebral, cuidadores, índice de stress parental
Estrés Paternal y Soporte Social de Cuidadores de Niños con Parálisis Cerebral Resumen: El estrés y el soporte social son relevantes para comprenderse el impacto de la deficiencia en la relación del cuidado. En ese sentido, investígase la asociación del índice de estrés paternal e indicadores de soporte social y variables sociodemográficas de cuidadores de niños con parálisis cerebral en una capital de Amazonia Oriental. Cien cuidadores contestaron los instrumentos: Inventario sociodemográfico, Sistema de Clasificación de Función Motora Gruesa, Índice de Estrés Paternal y Medical Outcomes Study Social Support Survey. Para el análisis de los datos, se utilizó la estadística descriptiva con técnicas de análisis multivariadas. Verificase que la mayoría de los participantes presentaron alto nível de estrés paternal y alta percepción de soporte social. Aspectos específicos de la percepción de soporte social y de indicadores sociodemográficos estaban asociados al estrés. Este conocimiento favorece la planificación de intervenciones más asertivas, una vez que delinea qué aspectos de estas variables parecen impactar más efectivamente el estrés paternal. Palabras clave: niños, paralísis cerebral, cuidadores, índice de estres parental
The birth of a child involves the addition of a new social role to its parents and can represent the beginning of a new life cycle. This event acquires unique characteristics when the child is disabled, an unexpected and potentially anxiogenic situation (Dantas, Pontes, Assis, & Collet, 2012).
Support: This study was funded by the National Council for Scientific and Technological Development - CNPq, Universal call 2013 (Grant # 486017/2013-3), and by the Dean of Research and Graduate Studies at the Universidade Federal do Pará. 2 Correspondence address: Mayara Barbosa Sindeaux Lima. Av. São Paulo, nº 142, Bairro Belo Horizonte. CEP 68502-380. Marabá-PA, Brazil. E-mail: mayarasindeaux@ unifesspa.edu.br 1
Available in www.scielo.br/paideia
Cerebral palsy is the most common cause of motor impairment in childhood and may be associated with sensory and intellectual disabilities. The term cerebral palsy (CP) encompasses several different clinical conditions that share in common the presence of motor/postural problems due to chronic, non-progressive neurological injury occurring during the development of the central nervous system (Cans, 2000). The care burden imposed by a disabled child can have negative repercussions on his or her parents’ health. Some studies have indicated that, in general, the parents of children with CP perceive their own health as unsatisfactory, including symptoms of depression, stress, muscle pain, and diminished quality of life (Freitas, Rocha, & Haase, 2014; Guyard, Fauconnier, Mermet, & Cans, 2011).
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According to the literature, caregivers of children with CP generally exhibit impairments in physical and mental health; however, there is little agreement regarding the relationship between such impairments and the child’s degree of motor deficiency (Al-Gamal & Long, 2013; Byrne, Hurley, Daly, & Cunningham, 2010; Ribeiro, Sousa, Vandenberghe, & Porto, 2014). This lack of agreement suggests that other variables in addition to those directly related to the child and his or her disability influence the mutual adjustment between parents and children (Dantas et al., 2012; Glenn, Cunningham, Poole, Reeves, & Weindling, 2009; Guyard et al., 2011). According to Carona, Crespo, and Canavarro (2013), theories that seek to understand the family’s adaptation to disability or chronic diseases in childhood consider several variables, such as family functioning, social support, and parental stress, within the context of the child’s care, suggesting the relevance of these variables in the process of coping with disability. In adequate levels, parental stress is a motivational factor that drives parents to use resources that help them to parent. Parental stress is the result of the parents’ self-assessment of their commitment to their idealized parental role, which includes their goals and expectations for themselves and the child, in addition to the resources that they perceive as available to them for the performance of this role (Abidin, 1992). High levels of parental stress have been associated with impaired mental health, poorer quality of life, and dissatisfaction with the social support perceived by the parents or primary caregivers of children with CP (Al-Gamal & Long, 2013; Guyard et al., 2011). Social support seems to both prevent and attenuate stressful situations, and its absence can lead to feelings of abandonment, sadness, and anger, which can have negative repercussions for the family’s experience in the face of disability (Polita & Tacla, 2014; Whittingham, Wee, Sanders, & Boyd, 2013). Social support refers to the material and psychological resources that a person deems to be available to him or her via his or her interpersonal relationships. In turn, satisfaction with social support concerns the perception that such resources and the bonds with the members of the support network are adequate to the existing demands (Rodriguez & Cohen, 1998). Pfeifer et al. (2014) argue that perceived social support seems to exert more influence on the adaptation to stressful experiences than the social support that is actually received or the number of members of the support network. The relevance of social support for families of children with CP was noted in a literature review conducted by Oliveira and Dounis (2012). These authors performed a search for Brazilian articles published from 2000 to 2010, and only 18 studies met the selection criteria. The results indicated that quality of life tended to be poorer and that the levels of stress and depression tended to be higher among the caregivers of children with CP who had an incipient family and professional support network compared to those who had a fully developed network. The aforementioned considerations lead to the conclusion that the social support perceived by caregivers of children with CP is an important variable for understanding the impact
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of the disability on the care relationship and parental stress. An investigation of the association between parental stress and perceived social support and sociodemographic aspects may improve the knowledge on the processes of caregiver development and provide grounds for the formulation of public policies and more effective services that target this population. In this context, the aim of the present study is to describe sociodemographic, parental stress and perceived social support indicators for primary caregivers of children with CP from a capital city in the Eastern Amazon and to investigate whether these variables are associated.
Method Participants The sample comprised 100 primary caregivers of children with CP from one to 12 years of age cared for at a university hospital in Belém, the capital of the state of Pará, in 2014. A total of 98 participants were female. Nonprobabilistic and convenience sampling was used. The criteria for participant selection were as follows: being of legal age and a relative or guardian of a child with CP from one to 12 years of age; being the child’s primary caregiver, defined as the person charged with providing informal child care most of the day for at least one year; having the sufficient verbal and/or writing skills to complete the instruments; and the CP child cared for should not have any autism spectrum disorder, genetic syndromes, or mental disorders as comorbidities. Instruments Sociodemographic Inventory (SDI). This instrument was elaborated by the investigators to collect sociodemographic data relating to both caregivers and children with CP. It comprises objective questions about the caregivers’ gender, age, educational level, family income and composition, marital status and occupation, and the clinical manifestations of the child with CP. Gross Motor Function Classification System - GMFCS. This instrument makes it possible to classify the gross motor function of children with CP into five levels of severity based on their age and ability to self-initiate movements related to sitting and walking. An increase in level indicates greater impairment; thus, Level I is the mildest (no restrictions but with limitations in some movements), and Level V is the most severe (the child is transported in a wheelchair and exhibits many limitations even with the use of assistive technology) (Russell, Rosenbaum, Avery, & Lane, 2011). The crosscultural adaptation of the GMFCS for Brazil was performed by Hiratuka, Matsukura, and Pfeifer (2010). The results indicated semantic and conceptual equivalence, sufficient inter-rater reliability, excellent construct correlation, and internal consistency, with an intraclass correlation coefficient of .945 and a Cronbach’s alpha of .972. Parenting Stress Index - PSI (Abidin, 1995). This instrument measures parents’ self-perceived stress. The short
Lima, M. B. S., Cardoso, V. S., & Silva, S. S. C. (2016). Caregivers of Cerebral Palsy Children.
form comprises 36 items to be answered on a Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree). The present study used the PSI-Short Form/SF adaptation described by Minetto (2010). Based on a sample comprising 120 respondents, the author found that the reliability of the instrument was satisfactory, with a Cronbach’s alpha ranging from .85 to .86. The PSI comprises three 12-item domains: (a) Parental Distress, which assesses parents’ perceptions of their own feelings as fathers/mothers; (b) the Parent-Child Dysfunctional Interaction, which investigates whether the parents’ perceptions of their child agree with their expectations, in addition to whether their interactions with their child reinforce their role as fathers/ mothers; and (c) the Difficult Child, which concerns several behavioral aspects of children that define them as easy or difficult to handle. In the present study, domains a, b, and c exhibited satisfactory internal consistency, with a Cronbach’s alpha of .82, .89, and .85, respectively. The intensity of parental stress on the global scale and relative to each particular domain may be categorized as Clinical Stress and Subclinical Stress. Medical Outcomes Study Social Support Survey - MOSSS (Sherbourne & Stewart, 1991). This scale, adapted for the Brazilian population by Griep (2003), measures structural and functional social support. It comprises 20 questions, 19 of which address perceived social support and are the questions used in the present study. The questions begin with the following phrase: “If you needed it, how often is someone available?” The respondents are required to mark their answers on a Likert scale ranging from none of the time (1) to all of the time (5). This instrument exhibited satisfactory reliability and validity indicators both in its original version (test-retest: .78; internal consistency: .91 and higher) and in Griep’s (2003) study, with a Cronbach’s alpha higher than .83 and the measures of concordance, including the kappa and weighted kappa statistics, higher than .70. Factor analysis (FA), a multivariate statistical technique, was applied to the instruments with Likert scales, i.e., the PSI and the MOS-SS, to reduce the variables to smaller linear combinations (dimensions), albeit with greater explanatory power to validate the instruments. First, the reliability of the items was assessed by using Cronbach’s alpha; the result was .75 for the PSI and .92 for the MOS-SS, which indicates that these scales are consistent. Next, the viability of FA was assessed based on the following: visual inspection of the correlation matrix, which detected a substantial number of correlations with values over .30; application of Bartlett’s test of sphericity (p = .000 for the PSI, p = .001 for the MOS-SS); the Kaiser-Meyer-Olkin test, which yielded results of .75 for the PSI and .82 for the MOS-SS; and Measure of Sampling Adequacy, the values of which were higher than .50 for both instruments. These analyses indicated that FA was viable. Next, FA was performed by means of the principal components mathematical method and factor extraction via varimax orthogonal rotation. The criteria adopted to select the number of factors to be extracted were the latent root criterion (an eigenvalue greater than 1) and the percentage of explained variance (the sum of explained variance ≥ .70).
In the case of the PSI, a four-factor model with nine items was sufficient to represent the initial covariance structure, explaining 72.85% of the total variability of the original items. Relative to the MOS-SS, a four-factor model with 14 items was sufficient to represent the initial covariance structure, explaining 70.6% of the total variability of the original items. The internal consistency of the items after FA was analyzed by using Cronbach’s alpha; the results indicated satisfactory levels of adequacy of the measure to the investigated population for both the PSI, with values varying from .70 to .77, and the MOS-SS, with values ranging from .75 to .86. Procedure Data collection. The present study was a crosssectional exploratory/descriptive study that was conducted at a university hospital in the city of Belém, the capital of the state of Pará, in the Eastern Amazon. This institution is a reference for the multi-professional care of children with atypical development, who are provided neurological, orthopedic, and physical therapy care, among other services, through a specific program. Initially, the objective of the study was to cover the full population of primary caregivers of children with CP cared for within the context of the aforementioned program in 2014. However, the number of patients could not be established. For this reason, the investigators applied the following procedure to recruit the study sample: they visited the program waiting room and invited the primary caregivers of children with CP who were encountered to participate in the study. Sample saturation was achieved eight months after the start of data collection, with the frequency of new participants gradually declining until further attempts revealed that the individuals encountered had already been included in the study database. The caregivers who met the selection/exclusion criteria and who agreed to participate signed an informed consent form; subsequently, they individually completed the instruments applied by one of the investigators in the waiting room. The level of motor impairment according to the GMFCS was established based on direct observation of the child. Data analysis. The data were entered into the Statistical Package for the Social Sciences (SPSS 20.0 for Windows) software to perform statistical analysis by using the tools that it provides. The procedure for PSI correction followed Minetto’s (2010) instructions; the participants’ scores on all of the PSI items were added, resulting in the Parenting Stress Total score; the score of each PSI domain was similarly calculated, i.e., by adding the scores on the corresponding items. Score inversion was performed for items that required it. Next, the Parenting Stress Total score and the scores of each individual domain were compared to a percentile table; based on this procedure, they were categorized as Clinical Stress when they fell into the 90th percentile or above and as Subclinical Stress when they fell under the 90th percentile. For the MOS-SS, the scores corresponding to the four factors suggested by factor analysis were calculated; these
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factors were named Affectionate Support, Emotional Support and Positive Social Interaction, Informational Support, and Tangible Support. Due to the variation in the number of items allocated to each factor, the scores were standardized, as suggested by Griep (2003): the sum of the scores in each factor was divided by the corresponding maximum possible score; for example, given that the responses were distributed across a five-point scale, the maximum possible score of a two-item factor was 10. The results were then multiplied by 100 to convert them to percentages. The same procedure was performed to calculate the scale total percentage score. Given that no cutoff points are available for the MOS-SS, it is considered that the closer to 100% that the percentage obtained is, the better the perceived social support. Because the MOS-SS does not make it possible to categorize the respondents, the Perceived Social Support Index (MOS-SS Index) was calculated based on a linear combination of the factor scores and the proportion of variance explained by each factor. The resulting indexes were distributed across two equal intervals (.344 |-- .654 and .655 |-- .748). Next, the data obtained through the SDI, GMFCS, MOSSS, and PSI were analyzed by using descriptive statistics (frequency, mean, and standard deviation). This step made it possible to establish the viability of statistical analyses that detect association between variables. Total Parenting Stress (categorized as Clinical Stress and Subclinical Stress) was tested against the MOS-SS Index, the GMFCS, and the sociodemographic variables (family income, marital status, occupation, and the presence of health problems in the child related to CP or appearing as comorbidities). Next, the presence of association between the PSI items and the MOS-SS Index and between the PSI items and MOS-SS items was investigated. All of the association analyses were performed by using the non-parametric chisquare (χ2) test at the significance level of 5%. Application of parametric tests, such as Pearson’s correlation coefficient, was unviable due to the large number of missing responses in several categories of the variables. The Total Parenting Stress data with significant results on the χ2 test were subjected to correspondence analysis, a multivariate statistical technique, to investigate the relationship between the variables and to visualize the association between the frequencies of the variable categories (Infantosi, Costa, & Almeida, 2014). First, the beta (β) criterion test was performed to investigate the dependence between the categories of the variables; the variables were considered to be dependent when β > 3. Next, the total sum of the percentage of inertia of dimensions 1 (Total Parenting Stress) and 2 (sociodemographic variables) was analyzed; its value should be greater than 70%. The last step consisted of estimating the confidence coefficient (γ) by calculating the standardized residuals; relationships were considered to be significant when γ ≥ 70%. Ethical Considerations The present study was assessed and approved by the Ethics Committee of the Health Sciences Institute of the
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Universidade Federal do Pará (Protocol n. 473.140). The study complied with the National Health Council/Health Ministry Resolution n. 466, December 12, 2012. Individuals who met the inclusion criteria were invited to participate in the study; those who agreed were asked to sign an informed consent form. At that time, they were informed about the confidentiality of information, the study aims, and the possible risks and benefits associated with participation in the study.
Results The sample mostly comprised mothers of children with CP (91%); the remaining participants were grandmothers (6%), fathers (2%), and one stepmother (1%). Their mean age was 33.3 years old (Min = 20, Max = 55, SD = 8.3). The family income was up to twice the equivalent of the minimum wage for most of the sample (81%), and in 49% of the sample, the family had five or more members. Most participants were unemployed; 80% reported being homemakers; 66% were in a steady relationship (married/civil union); and 25% reported being the single caregiver of the child. The educational level of the sample was low: only 41% of the participants had completed secondary education. Almost half of the participants (45%) resided in towns outside the Belém Metropolitan Area. Approximately 53.5% of the children with CP cared for by the participants were of school age; their mean age was six years old (Min = 1, Max = 12, SD = 3). Most of the children (63%) were classified under the most severe GMFCS levels of motor impairment, i.e., IV and V. Regarding the PSI, the mean Parenting Stress Total score was 88.4 (SD = 15.2); 42% of the participants were classified as having Clinical Stress on the global scale, given that their scores were 91 or higher, i.e., corresponding to the 90th percentile or over. Analysis of the PSI domains of Parental Distress, the Difficult Child, and the Parent-Child Dysfunctional Interaction showed that the latter was the main source of stress; 45% of the participants were classified as having Clinical Stress. The scores of 28 participants fell above the 95th percentile. Parental Distress had the second highest proportion of participants classified as having Clinical Stress (33%). Finally, 22% of the participants were classified as having Clinical Stress based on the scores corresponding to the Difficult Child domain. Regarding the perception of social support indicated that the participants were satisfied with the support they received, with the percentage score on the MOS-SS of 81%. The Affectionate Support factor received the highest score, 92%, followed by Tangible Support, 82%. The lowest scores were exhibited by the factors of Emotional Support and Positive Social Interaction and Informational Support, at 76% for both. Some MOS-SS items exhibited a considerable degree of concordance among the participants: at least 85% answered that someone is available “all of the time” or “most of the time” to “love and make you feel wanted”, “show you love and affection”, and “hug you”. For a portion of the participants, some social support aspects were practically inexistent, given that they answered
Lima, M. B. S., Cardoso, V. S., & Silva, S. S. C. (2016). Caregivers of Cerebral Palsy Children.
that someone is available “none of the time” or “little of the time” to “get together with for relaxation” (26%), “understand your problems” (24%), “confide in or talk to about yourself or your problems” (23%), or “share your most private worries and fears with” (22%). The results of the analyses that investigated the association between Total Parenting Stress and the MOS-SS Index showed that these variables did not exhibit a relationship of dependence in the studied sample, given that the p-value found through application of the chi-square test was more than .05. Nevertheless, crossing the PSI items with the MOSSS Index revealed that the latter seemed to be influenced by PSI items 11 and 34: “I am not as interested in people as I used to be” (p = .023) and “My child does a few things that bother me a great deal” (p = .006), respectively. The χ2 test allowed detecting that some PSI and MOS-SS items were significantly associated. The results suggest that the response to the statement “I am not as interested in people as I used to be” (PSI item 11) influenced the respondents’ perception of having someone available to “take you to the doctor”, “count on to listen to you when you need to talk”, “confide in or talk to about yourself or your problems”, “understand your problems”, “do things with to help you get your mind off things”, and “get together with for relaxation” (MOS-SS items 2, 8, 9, 11, 17, and 18). PSI item 29 (“My child reacts very strongly when something happens that my child doesn’t like”) seemed to influence the respondents’ perception of having someone available to “help you if are confined to bed”, “take you to the doctor” and “offer advice you really want” (MOS-SS items 1, 2, and 14). Regarding the association between Total Parenting Stress and the sociodemographic characteristics, significance was found for marital status (p = .04), caregivers’ educational level (p = .022), and presence of health problems in the child related to CP or appearing as comorbidities (p = .000). No association was found for family income, caregivers’ occupation, or the GMFCS. The multivariate statistical technique of correspondence analysis could be applied between the categories of Total Parenting Stress (Clinical Stress and Subclinical Stress) and the sociodemographic characteristics, which were found to be associated, given that they met the technique criteria: the beta (β > 3), percentage of inertia (≥ 70%), and confidence coefficient (g ≥ 90%). The sociodemographic variables were classified as follows: a) educational level (β = 3.92), subdivided into Incomplete Primary Education (IPE), Complete Primary Education (CPE), and Complete Secondary Education (CSE); b) marital status (β = 7.26), subdivided into With spouse, when married or in a civil union, and Without spouse, when single or divorced; and c) health problems in the child related to CP or appearing as comorbidities (β = 12.93), subdivided into Presence of Problems (PP) and Absence of Problems (AP). The perceptual map resulting from correspondence analysis is depicted in Figure 1. The analysis revealed two participant profiles: (a) caregivers with Clinical Stress, in general, had a low educational level and were not in a stable relationship,
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Figure 1. Perceptual maps resulting from correspondence analysis between Total Parenting Stress (Clinical Stress and Subclinical Stress) and the following sociodemographic variables: educational level (CSE – Complete Secondary Education, CPE – Complete Primary Education, and IPE – Incomplete Primary Education); caregivers’ marital status (With Spouse and Without Spouse); and the presence of health problems in the child related to CP or appearing as comorbidities (AP – Absence of Problems and PP – Presence of Problems). Source: raw data.
and the child under their care had other health problems or dysfunctions in addition to motor disorders; and (b) caregivers with Subclinical Stress, in general, had completed secondary education, were married or in a civil union, and provided care to children without health problems related to CP or appearing as comorbidities.
Discussion The caregivers’ socioeconomic profile suggests that most of them lived under conditions of social vulnerability. One further aspect that warrants attention is that almost
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half of the participants lived in towns outside the Belém Metropolitan Area, which implies the need to travel, with consequent financial, physical, and/or emotional costs. Financial difficulties and a low educational level may be hindrances to a more effective social integration of the child and his or her family and may restrict access to only certain healthcare services and the purchasing of equipment to facilitate accessibility and communication (Ribeiro et al., 2014). This situation is even more serious because we found that more than half of the children had severe motor impairment. Public health strategies and the actions of professionals can attenuate the impacts of social vulnerabilities on the families of children with CP. One of the mechanisms for such attenuation to occur is to make available social support and orientation on how to access formal support networks. In this manner, family resources are boosted, and other resources become accessible (Ribeiro et al., 2014). The children’s degree of motor impairment seemed to have little influence on parental stress, given that these two variables were not associated. There is little agreement in the literature regarding the relationship between the child’s motor functioning and the parents’ stress and/or health (Byrne et al., 2010; Guyard et al., 2011; Ribeiro et al., 2014). Byrne et al. (2010) and Ribeiro et al. (2014) find results similar to those of the present study and argue that these findings reinforce the idea that the impairments to health and quality of life seem to depend more on how the child’s family copes with adverse situations and organizes itself as a system, in addition to the resources available to it, than on the child’s disability itself. The considerations above are even more worrisome in the case of the investigated sample, given the high levels of parental stress it exhibited, agreeing with the findings reported by Dang et al. (2015) and Ribeiro et al. (2014). Almost half of the participants have stress levels requiring clinical evaluation and probably need therapy assistance. Regarding the PSI domains, stress was detected more often in the Parent-Child Dysfunctional Interaction domain, which concerns the caregivers’ expectations for the child to meet the idealized image of him/her that they have built (Ribeiro et al., 2014). In this regard, it may be assumed that the greater the discrepancy is between the child’s skills as perceived by the caregiver and those that the caregiver would like the child to have, the greater the difficulty of the caregiver to accept the child’s disability. According to Minetto (2010), high scores in this domain may be associated with the idea that the child is a negative element in the life of the caregiver, who may feel disappointed or rejected/maltreated by the child. This domain was described as the domain most directly associated with the phenomenon of neglect. Scores above the 95th percentile, which were found in more than one-fourth of the participants in the present study, “suggest the possibility of abuse, neglect, rejection or physical injury episodes derived from feelings of frustration” (Minetto, 2010, p. 67). The domain of Parental Distress ranked second in frequency of caregivers with clinical stress. This domain investigates the presence of feelings of incompetence in the performance of the parental role, depression, and whether the child’s demands
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make his/her parents suffer and restrict their social participation (Minetto, 2010). Ribeiro et al. (2014) also found a high percentage of clinical stress in the Parental Distress domain. The changes in the caregivers’ life plan and the high levels of parental investment demanded by the child’s disability, combined with low self-esteem and financial difficulties, may cause stress (Dantas et al., 2012; Polita & Tacla, 2014). In addition, these factors favor the development of feelings of being incompetent to provide support to the child, which negatively affects the parents’ satisfaction with their parental role (Ribeiro et al., 2014). If parental stress was a risk factor for the caregivers, and consequently also for the family system, then the perceived social support behaved as a protective factor, given that the percentage scores on the MOS-SS were high; this finding agrees with that reported by Pfeifer et al. (2014). However, although the participants reported being satisfied with the social support they received, it did not seem to sufficient to reduce the level of parental stress. The high percentage score exhibited by the Affectionate Support factor suggests that the participants feel loved whenever they need to. However, Lima, Afonso, and Silva (2015) observe that having someone available to provide this type of support does not mean that the demands for affection and understanding are actually met because the person in question may not always be the individual who the caregiver would like, that is, generally his or her spouse. The social support provided by spouses seems to be an important element in the family dynamics of the participants because the lack of a spouse was associated with clinical stress. In Glenn et al. (2009), low spousal support and poor family cohesion are shown to favor the occurrence of higher levels of maternal parenting stress. Although perceived social support was high in all four scale factors, item analysis showed that a considerable proportion of the participants (approximately 23%) did not have anyone available to share private issues with and to provide emotional comfort. The data above make it possible to raise several hypotheses: (a) caregivers may avoid talking about their problems not to overload the members of their support network, given that the latter already provide other types of support; (b) practical issues may be considered more urgent or a more likely reason to ask for help at the expense of emotional issues; (c) caregivers may have difficulty organizing emotion-related thinking and also have poor verbal ability to express their intimacy due to their low educational level; (d) sharing one’s intimacy may be perceived as an aversive stimulus because others may lack empathy, call into question the truth of what they are told, or make negative judgments, such as considering the caregivers to be incompetent in the performance of their social roles; (e) the social support network may have difficulties of its own in making this type of support available, either to avoid subjects likely to generate negative emotions or because it fails to detect the existence of, or underestimates, this particular demand. According to Whittingham et al. (2013), the excessive avoidance of contact with painful emotions, sensations, and
Lima, M. B. S., Cardoso, V. S., & Silva, S. S. C. (2016). Caregivers of Cerebral Palsy Children.
memories favors the development of a maladjusted behavioral repertoire and psychological problems among parents of children with CP. In this regard, frequent attempts to control the form of, frequency of, or sensitivity to private events associated with sadness or anguish impair psychological well-being. The lack of association between the Total Parenting Stress and Perceived Social Support indicators is considered an uncommon result in the literature (Al-Gamal & Long, 2013; Guyard et al., 2011). This finding may be explained by the constructs that ground the MOS-SS, given that this instrument investigates the respondents’ perception of the availability of various types of support without considering the specific demands associated with parenthood. It may be assumed that the caregivers were satisfied with the types of support that they were asked to evaluate. However, an important type of support demand, such as sharing carerelated tasks, may not have been adequately investigated and may have impaired the analysis of the impact of perceived social support on parental stress. Nevertheless, the MOS-SS provided data relevant for the understanding of parental stress. For instance, it showed that the perception of disruptive behaviors in the child had an impact on the perception of social support. The behavioral/ emotional problems and cognitive impairments of children with CP have been associated with parental stress and were even included in the predictive model of stress (Freitas et al., 2014; Glenn et al., 2009; Whittingham et al., 2013). The child’s intellectual, emotional, and behavioral problems further increase the burden of caregivers and may negatively influence their quality of life and health (Carona et al., 2013; Glenn et al., 2009; Guyard et al., 2011). Carona et al. (2013) study parents of children with and without CP and conclude that an increased caregiving burden seemed to elicit a negative perception of social support, which in turn impaired the parent’s psychological adjustment. In addition to the behavioral problems, the presence of pain and sensory impairments in the child were also associated with a higher risk of clinical stress among parents of children with CP (Al-Gamal & Long, 2013). Similar findings were identified in the investigated sample, with presence of health problems in the children influencing the occurrence of clinical stress among the caregivers. The results of the present study point to the need to include caregivers in the protocols of the services made available to children with CP. According to the literature, the efficacy of child-centered cared models is lower compared to ecological models, in which actions target the family system (Byrne et al., 2010; Carona et al., 2013). Aiming at describing and investigating the presence of association of parental stress with perceived social support and the sociodemographic indicators of caregivers of children with CP from a capital city in Eastern Amazon, the present study established which specific aspects of these variables were related. In addition, it found that most participants had high levels of perceived social support, even when they parented with inadequate levels of stress. The results of the present study are helpful for the development of strategies for the prevention and reduction
of parental stress because they show which aspects of the investigated variables seem to have a more effective impact on the others, in addition to identifying risk and protective factors for caregivers. Moreover, the results suggest further topics relevant for the study of the targeted caregivers, such as the structure of their social support network and the quality of the support provided by spouses. Concerning the limitations of the present study, lack of knowledge of the population size did not make it possible to estimate the optimal number of individuals who should have been included in the study, in addition to the need for caution in the generalization of the results. Given the panorama described here and the assumption that children are part of an integrated and dynamic system, it is important for future studies to seek to understand how the psychosocial profile of the families of children with CP, parental stress, and social support associate in the various Amazonian settings.
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dos preditores do estado psicológico das mães de crianças com paralisia cerebral [Analysis of predictors of psychological status of mothers of children with cerebral palsy]. Estudos e Pesquisas em Psicologia, 14(2), 453473. Retrieved from http://pepsic.bvsalud.org/pdf/epp/ v14n2/v14n2a05.pdf Glenn, S., Cunningham, C., Poole, H., Reeves, D., & Weindling, M. (2009). Maternal parenting stress and its correlates in families with a young child with cerebral palsy. Child: Care, Health and Development, 35(1), 7178. doi:10.1111/j.1365-2214.2008.00891.x Griep, R. H. (2003). Confiabilidade e validade de instrumentos de medida de rede social e de apoio social utilizados no estudo pró-saúde [Reliability and validity of measurement instruments of social network and social support used in the Estudo Pró-Saúde] (Doctoral dissertation). Retrieved from http://arca.icict.fiocruz.br/ bitstream/icict/4487/2/157.pdf Guyard, A., Fauconnier, J., Mermet, M.-A., & Cans, C. (2011). Impact sur les parents de la paralysie cérébrale chez l’enfant: Revue de la littérature [Impact on parents of cerebral palsy in children: A literature review]. Archives de Pédiatrie, 18(2), 204-214. doi:10.1016/j. arcped.2010.11.008 Hiratuka, E., Matsukura, T. S., & Pfeifer, L. I. (2010). Cross-cultural adaptation of the Gross Motor Function Classification System into Brazilian-Portuguese (GMFCS). Brazilian Journal of Physical Therapy, 14(6), 537-544. doi:10.1590/S1413-35552010000600013 Infantosi, A. F. C., Costa, J. C. G. D., & Almeida, R. M. V. R. (2014). Análise de correspondência: Bases teóricas na interpretação de dados categóricos em ciências da saúde [Correspondence analysis: A theoretical basis for categorical data interpretation in health sciences]. Cadernos de Saúde Pública, 30(3), 473-486. doi:10.1590/0102-311X00128513 Lima, M. B. S., Afonso, T., & Silva, S. C. (2015). Cuidadores primários de crianças com autismo na Amazônia: Suporte social e estresse [Primary caregivers of autistic children in the Amazon]. Apae Ciência, 2(1), 21-36. Retrieved from http://apaeciencia.org.br/index.php/revista/article/ view/62/30 Minetto, M. F. J. (2010). Práticas educativas parentais, crenças parentais, estresse parental e funcionamento familiar de pais de crianças com desenvolvimento típico e atípico [Parenting practices, parental beliefs, parental stress and family functioning of parents of children with typical and atypical development] (Doctoral dissertation). Retrieved from https://repositorio.ufsc.br/ xmlui/handle/123456789/94159 Oliveira, F. L., & Dounis, A. B, (2012). As alterações na dinâmica familiar diante do diagnóstico da criança com paralisia cerebral: Estado da arte [Changes in family dynamics before the diagnosis of cerebral palsy child: State of the Art]. Revista de Psicologia, 3(1), 18-27. Retrieved from http://www.periodicos.ufc.br/index.php/ psicologiaufc/article/view/101/100
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How to cite this article: Lima, M. B. S., Cardoso, V. S., & Silva, S. S. C. (2016). Parental stress and social support of caregivers of cerebral palsy children. Paidéia (Ribeirão Preto), 26(64), 207-214. doi:10.1590/1982-43272664201608
Paidéia may-aug. 2016, Vol. 26, No. 64, 215-223. doi:10.1590/1982-43272664201609
Article
Visual-Motor Maturity and Executive Functions in Schoolchildren1 Ana Luisa Silva de Oliveira2 Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre-RS, Brazil Laura Uberti Mallmann Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre-RS, Brazil
Vanessa Kaiser Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre-RS, Brazil Janice Luisa Lukrafka Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre-RS, Brazil
Thamy de Oliveira Azambuja Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre-RS, Brazil Caroline Tozzi Reppold Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre-RS, Brazil
Abstract: Visual-motor maturity and executive functions are closely related in the child development process. This study aimed to investigate the relation between visual-motor abilities and executive functions in 83 healthy children between 7 and 10 years old. The tools used were the Bender Gestalt Visual-Motor Test - Gradual Scoring System (B-GSS), Wisconsin Card Sorting Test (WCST), Raven’s Progressive Matrices (RPM), and Rey-Osterrieth Complex Figure (ROCF). The correlation between the B-GSS and WCST scores was significantly negative (r = -.23, p < .033), while ROCF variables, such as Total Memory and Total Copy, had a moderate, significant correlation with total B-GSS score (r = -.55, p < .001; r = -.44, p < .001, respectively). The results empirically show the relation between executive functions and visual-motor maturity and are discussed in face of developmental neuropsychology. Keywords: perceptual motor development, cognitive neuropsychology, Bender-Gestalt Test, Wisconsin card sorting test
Maturidade Visomotora e Funções Executivas em Escolares Resumo: A maturidade visomotora e as funções executivas estão intimamente relacionadas no processo de desenvolvimento infantil. O objetivo deste estudo foi investigar a relação entre habilidades visomotoras e funções executivas em 83 crianças hígidas, de 7 a 10 anos. Os instrumentos utilizados foram Teste Gestáltico Visomotor de Bender – Sistema de Pontuação Gradual (B-GSS), Teste Wisconsin de Classificação de Cartas (WCST), Matrizes Progressivas de Raven (RPM) e Rey- Osterrieth Figura Complexa Test (ROCF). A correlação entre os escores de B-GSS e WCST foi negativa e significativa (r = 0,23, p < 0,033) e variáveis do ROCF, como Cópia Total e Memória Total apresentaram correlação moderada e significativa com o escore total do B-GSS (r = -0,55, p < 0,001; r = -0,44, p < 0,001, respectivamente). Os resultados evidenciam empiricamente a relação entre funções executivas e maturidade visomotora e são discutidos à luz da neuropsicologia do desenvolvimento. Palavras-chave: desenvolvimento percetomotor, neuropsicologia cognitiva, Teste Gestáltico de Bender, teste Wisconsin de classificação de cartas
Madurez Visomotora y Funciones Ejecutivas en Escolares Resumen: La madurez visual-motora y las funciones ejecutivas están estrechamente relacionados en el proceso de desarrollo del niño. El objetivo de este estudio fue investigar la relación entre habilidades visomotoras y funciones ejecutivas en 83 niños sanos, de 7-10 años. Los instrumentos utilizados fueron Prueba Gestáltica Visomotora de Bender - Sistema de Puntuación Gradual (B-GSS), Prueba Wisconsin de Clasificación de Cartas (WCST), Matrices Progresivas de Raven (RPM) y Prueba Rey- Osterrieth Figura Compleja (ROCF). La correlación entre las puntuaciones B-GSS y WCST fue negativa y significativa (r = 0,23, p < 0,033) y ROCF variables, como Copiar y Memoria Total mostraron correlación moderada y significativa con la puntuación total de la B-GSS (r = -0,55, p < 0,001; r = -0,44, p < 0,001, respectivamente). Los resultados demuestran empíricamente la relación entre las funciones ejecutivas y la madurez visomotora y se discuten a la luz de la neuropsicología del desarrollo. Palabras clave: desarrollo perceptomotor, neuropsicología cognitiva , test de Bender-Gestalt, Wisconsin
Paper derived from the first author’s master’s thesis under supervision of the sixth author, defended in 2013, at the Graduate Program in Rehabilitation Sciences of the Universidade Federal de Ciências da Saúde de Porto Alegre. Support: Productivity scholarship by the National Council for Scientific and Technological Development (CNPq) made available to the sixth author (Grant # 304204/2013-7). 1
Correspondence address: Ana Luisa Silva de Oliveira. Rua Sarmento Leite, 245, Centro Histórico. CEP 9005-170. Porto Alegre-RS, Brazil. E-mail: analuisa_fisio@yahoo.com.br 2
Available in www.scielo.br/paideia
Throughout life, human beings gradually acquire the necessary visual-motor skills for recognizing objects, including their own bodies, and how to position themselves according to the objects. This action implies not only being able to recognize spatial parameters of the objects (volume, direction, movement) and their affinities with the surrounding world, but also knowing how to move around a previously explored space (Chiappedi et al., 2013; Gil, 2002). Visuoconstructive abilities are related to the capacity to perform formative and constructive activities that allow
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carrying out actions with motor purposes (Malloy-Diniz, Fuentes, Mattos, & Abreu, 2010). For an individual to perform such functions, the following processes must be consolidated: visual perception, spatial reasoning, establishing plans or goals, adequate motor behavior, and ability to monitor selfperformance (Malloy-Diniz et al., 2010). The progressive maturation of the cerebral cortex, especially in the first 24-36 months of life, gradually improves the organization of psychomotor functions. This evolution of the central nervous system (CNS), associated with motor skills acquired by environmental stimuli which develop sensorimotor experiences, visualmotor coordination, visuospatial perception, balance, and consciousness for the constitution of the body schema, along with social interactions that are indispensable for the processes of learning and literacy (Bonifacci, 2004; Passos, Caramelli, Benseñor, Giatti, & Barreto, 2014; Van Waelvelde, De Weerdt, De Cock, & Smits-Engels, 2004). Souza and Capellini (2011) pointed out that the visual-motor perception process results from the combination of multiple neurocognitive skills, namely: visual-motor maturity, visual perception capacity (such as eye-hand coordination), visuospatial relations, figureground perception, and shape constancy. A relation can be traced between perceptual and motor aspects (especially visual-motor coordination) and learning difficulties. This association has been widely discussed in the literature (Bartholomeu & Sisto, 2008; Böhm, Lundequist, & Smedler, 2010; Martin, Tigera, Denckla, & Mahone, 2010; Schreiber, Possin, Girard, & Rey-Casserly, 2014; Silva, Beltrame, A. V. P. Oliveira, & Sperandio, 2012) in order to detect deficits in school performance early on, since children face new challenges as they grow. The interplay between perceptual and motor aspects, especially visual-motor coordination and learning disabilities, is well discussed in the literature (Carvalho & Magalhães, 2004; Souza & Capellini, 2011; Silva et al., 2012). Such data indicate the importance of assessing the perceptuomotor performance not only in populations of individuals exposed to risks but also in children whose development is considered typical (Carvalho & Magalhães, 2004). There are several specific tools to evaluate visual-motor skills. One system proposed for assessing the perceptuomotor skills of schoolchildren is the Bender Visual-Motor Gestalt Test (BVMGT) (Noronha & Mattos, 2006). Since Bender figures were created, several interpretation systems have been developed, including the Koppitz version, which is one of the main and most widely used correction methods in clinical psychology. Some studies correlate the neuropsychology data and Bender’s test, e.g., Bartholomeu and Sisto (2008), in which the authors sought evidence of convergent validity between BVMGT, assessed by the B-GSS, and the Human Figure Drawing (HFD), an intelligence test. On the other hand, executive functions (EFs) consist of a set of cognitive skills that, when associated, are designed to execute an oriented behavior towards previously established purposes, thus allowing the individuals to directly interact with the world and to organize tasks, such as setting goals,
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evaluating the efficiency and adequacy of the behavior according to situations, and abandoning improper strategies for the sake of more appropriate or convenient ones to solve problems (Cruz, Camargos-Junior, & Rocha, 2013; MalloyDiniz et al., 2010; Sesma, Mahone, Levine, Eason, & Cutting, 2009; Tonietto, Wagner, Trentini, Sperb, & Parente, 2011; Yasumura, Inagaki, & Hiraki, 2014). EFs are responsible for articulating subordinated functions such as thinking, working memory, planning, attention and inhibitory control, and cognitive flexibility, among others, which guide the execution of a behavior with specific aims (Ferrier, Bassett, & Denham, 2014; Miyake & Friedman, 2012; Olaithe & Bucks, 2013; Skogan et al., 2015). The psychiatric assessment of EFs involves several procedures, including the use of validated tools – through specific test batteries which comprise all the subdomains of the EFs, or more flexible batteries defined by the examiner – and complementary procedures through interviews, cognitive tasks, observation, and functional assessment of the individual. Given the extent of the skills that depend on EFs, it is not expected that a single type of assessment will be able to evaluate the most complex cognitive aspects of an individual. Therefore, the use of multiple techniques is required for the assessment of the distinct EF subdomains, considering that their deficit may either affect all the executive processes or act in a selective way, affecting only some of the subfunctions (Drake, 2007; Malloy-Diniz et al., 2010). Among the reasons that have led to the growing interest in studies on child development, the parallels between motor and cognitive development stand out, showing the close relation between what children can learn and what they can accomplish. In face of that, the following are pointed out to justify the present study: (a) the relevance of interdisciplinary action in scientific research; (b) the need for knowing children development stages and the close relations between cognitive and motor functions; (c) the use of validated assessment tools in children interventions so as to investigate and understand the cognitive-motor functioning inherent to the intellectual acquisition process; and (d) the benefits of a detailed assessment of such capacities, which enables the establishment of coherent instructive and interventionist strategies that respect the concepts of continuity (typical maturation process) and individuality of the individuals assessed. Regarding these topics, the main goal of the present study was to look for evidence of an association between aspects of visual-motor perception and executive functions, investigated by specific neurological tests standardized for the Brazilian population, in a sample composed of schoolchildren with typical neurologic development.
Method Participants This is a cross-sectional study with 83 healthy children, aged between 7 and 10 years, from two public elementary schools in Porto Alegre, Brazil. Schools were chosen by convenience. The exclusion criteria for the sampling were:
Oliveira, A. L. S., Kaiser, V., Azambuja, T. O., Mallmann, L. U., Lukrafka, J. L., & Reppold, C. T. (2016). Visual-Motor Maturity in Schoolchildren.
(a) Children diagnosed with cognitive and neurological disorders according to the score obtained in Raven’s Progressive Matrices test (those who scored five or less were considered “intellectually disabled”); (b) Children with other biophysical conditions that prevented them from performing psychological tests; (c) Children who did not have the Informed Consent Form signed by their parents or guardians; and (d) Children who did not agree to participate, refusing to sign the Informed Assent Form. The data were collected from 94 participants, but only 83 met the inclusion criteria. Instruments The Neuropsychological Assessment Battery was composed of the following tests adapted and standardized to Brazilian samples: Bender Visual-Motor Gestalt Test - Gradual Scoring System (B-GSS). Developed by Sisto, Noronha, and Santos (2006), the B-GSS is used to evaluate the maturational aspects of visual-motor skills of children aged six to ten years. In this system, the functions are measured only by analyzing the shape distortion of the images proposed by Bender. Application time usually does not exceed 15 minutes, although there is no predetermined time limit. Validity studies have been performed with respect to the internal structure and dimensionality of the items. The instrument has good internal consistency with Cronbach’s alpha for “all ages” estimated at .80. Rey-Osterrieth Complex Figure Test (ROCF). Standardized by M. S. Oliveira and Rigoni (2010), ROCF allows assessing the visual-spatial organization skills, planning and development of execution strategies, as well as non-verbal memory. It consists of a complex geometric figure – a large rectangle, horizontal and vertical bisectors, two diagonals, and additional geometric details in and outside the large rectangle. The instrument has good internal consistency with Cronbach’s alpha estimated at .897 in “copy” and .831 in “reproduction of memory”. Wisconsin Card Sorting Test (WCST). With norms proposed by Trentini, Argimon, M. S. Oliveira and Werlang (2006), WCST is considered the gold standard for exams intended to assess executive functions. In this test, 128 cards are presented to the subjects (one at a time) and should be grouped with one of four target cards – the subject assigns cards with simple geometric shapes to three distinct categories: shape, color, and number. However, the classification principle is not revealed beforehand and the subject must establish it by trial and error. Each time the subject chooses a card, the examiner will inform him/her if the choice is “right” or “wrong.” Once the individual has learned how to choose a dimension and gets it right for 10 consecutive times within these same criteria, the examiner changes the rules without warning. In addition, the WCST also provides information about the cognitive inflexibility, categorization processes, impulsivity, and attention. The instrument’s manual presents the validity and reliability studies for the Brazilian population. The generalizability coefficients of WCST scores range from
.66 to .75, with a mean and median of .70 demonstrating satisfactory reliability in all scores. Raven’s Progressive Matrices Test (RPM). Standardized for the population of Rio Grande do Sul by Bandeira, Alves, Giacomel, and Lorenzato (2004), RPM is composed of three sets of 12 items: A, AB, and B, which are designed to measure only one component of the “g” factor, the educative ability. According to Angelini, Alves, Custódio, J. L. M. Duarte, and W. F. Duarte (1999) and Bandeira et al. (2004), educative ability refers to the ability to extract insights from previously known and perceived situations and to develop new understandings for what is not immediately obvious through non-verbal constructs. The instrument’s manual presents accuracy and validation studies, moreover, regarding internal consistency, all item-total correlations of the instrument are significant, with the largest share of item correlations between .30 and .80. Procedure Data collection. Data collection was directly performed in the schools included in this study. The tests were administered in classrooms made available by the principal of each institution, with the condition that the place had a tranquil and well-ventilated environment, with appropriate lighting and free of external interferences. Upon authorization, tests began being administered, in two meetings, individually (RPM, ROCF, and WCST), i.e., one examiner per examinee, and collectively (B-GSS). Data analysis. The results were initially included in a database in the software Excel (version 2010). Afterwards, they were analyzed using the software Statistical Package for Social Sciences (SPSS) version 20. To test for normality of the data distribution, the KolmogorovSmirnov test was applied. For the analyses of correlation between the scores, Pearson Correlation was employed in case of normal distribution and/or Spearman Correlation was employed in case of non-normal data distribution. Ethical Considerations This study was approved by the Research Ethics Committee of the Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) under protocol 1437/11 on September 15th, 2011. In the first contact with the classes, the Informed Consent Form and the Informed Assent Form were distributed. The neuropsychological evaluation was done by researchers trained by a psychologist regarding the administration and interpretation of tools, with the objective of attaining satisfactory interobserver reliability.
Results Results were analyzed according to the intended objectives, employing descriptive and inferential statistical methods. Table 1 shows the sample characterization regarding
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PaidĂŠia, 26(64), 215-223 Table 1 Sample Characterization for Age, Gender, Laterality, and Schooling Absolute Frequency
Relative Frequency (%)
7
24
28.92
8
22
26.51
9
26
31.33
10
11
13.25
Female
50
60.2
Male
33
39.8
2nd Grade
33
39.8
3rd Grade
23
27.7
4th Grade
27
32.5
Variables Age (years)
Gender
Schooling
Table 2 Description of Variables in the B-GSS and WCST Test
Laterality Right
78
94
Left
5
6
age, gender, laterality, and schooling, demonstrating that the sample had non-normal data distribution. The children had an average total score (A+AB+B) of M = 24.83 (SD = 5.33) in RPM, with the task execution time estimated at 6.16 (3.56-15.32). Twenty-eight (33.7%) children were classified as level II, indicating aboveaverage intellectual capacity. None of the children was classified as level V (score equal to or less than 5), which indicates an intellectually deficient pattern and would have excluded the child from this study. The ROCF scores had a parametric distribution, represented by mean (SD): Total Copy M = 17.80 (SD = 6.082); Copy Time M = 6.30 (SD = 2.623); Total Memory M = 8.20 (SD = 5.158); and Memory Time M = 3.69 (SD = 2.366). Table 2 shows the scores obtained in assessments of visual-motor maturity and EFs, respectively. The mean score in the B-GSS was 11.19 with SD = 3.93. The median value was 11, indicating that 50% of the sample scored up to 11 points and the minimum and maximum scores were 1 and 21. In the sorting of the quartiles, the least representative score was 4 (4.8%), indicating a quartile below 25, and the most representative was 19 (22.9%), indicating a quartile above 90. Most of the answers were classified as above quartile 75. Considering the performance in the WCST, not all the aspects showed normality of data; therefore, data were expressed as median (min-max). Those which had parametric distribution were expressed as mean (SD), and the total correct number was M = 53.98 (SD = 23.189). In order to verify a possible relation between the B-GSS and RPM, a proof of correlation was proposed, considering the scores obtained in these two tests, taking into account
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the age variable for possible differences in the test results. There was a significant positive correlation between RPM and B-GSS total scores only in the 7-year-old group (r = -.59, p < .002). No significant correlation between the scores was found in other age groups. To investigate the relation between the constructs visuomotor maturity and EFs, associations between the B-GSS and WCST scores were sought by correlating the total score of the former with the total values of the latter. The result of the correlation between the B-GSS and WCST (total number of correct answers) was weak, negative, and significant (r = -.23, p < .033), suggesting that the higher the maturation state of EFs, the lower the number of errors or distortions in the Bender-Gestalt test, as shown in Table 3. The results regarding conceptual level (r = -.27, p < .01) and number of completed categories (râ&#x20AC;&#x2122;= .30, p < .006) in the WCST are also significantly correlated with the total B-GSS scores.
Variable
Results
B-GSS Total
M = 11.19, SD = 3.93 Quartile
Less than 25
4 (4.8%)
Equal to 25
5 (6%)
Between 25 and 50
6 (7.2%)
Equal to 50
7 (8.4%)
Between 50 and 75
11 (13.2%)
Equal to 75
8 (9.6%)
Between 75 and 90
16 (19.3%)
Equal to 90
7 (8.4%)
Above 90
19 (22.9%)
WCST Number of assays administered Total correct number
M = 53.98, SD = 23.189
Total number of errors
M = 59.34, SD = 27.845
Perseverative answers
39 (0-127)
Perseverative errors Non-perseverative errors Conceptual level
29 (0-115)
128 (0-128)
M = 24.1, SD = 18.841 M = 36.93, SD = 24.241
Number of completed categories
M = 2.53, SD = 2.068
Assays to complete the 1st category
2 (0-6)
Failure to maintain context
1 (0-5)
Learning to learn
1 (-17-21)
Note. Data with parametric distribution are expressed as mean (SD). Values with nonparametric distribution are presented as median (minimum-maximum). In quartile categorization, the results are presented as absolute and relative frequencies (n/%).
Oliveira, A. L. S., Kaiser, V., Azambuja, T. O., Mallmann, L. U., Lukrafka, J. L., & Reppold, C. T. (2016). Visual-Motor Maturity in Schoolchildren. Table 3 Correlation Between the B-GSS and WCST WCST
B-GSS Total
Total correct number Non-perseverative errors Total number of errors
r
-.234
p
.033*
r
-.025
p
.826
r
.118
p
.289
Conceptual level
r
-.279
p
.011*
Number of completed categories
r’
.301
p
.006**
Number of assays administered
r’
.049
p
.659
Perseverative answers
r’
.144
p
.193
Perseverative errors
r’
.158
p
.154
Assays to complete the 1st category
r’
.017
p
.881
Failure to mantain context
r’
-.028
p
.8
Learning to learn
r’
-.144
p
.194
Note. r = Pearson correlation; p = significance level; r’ = Spearman correlation. *Significant correlation at .05 level. **Significant correlation at .01 level.
Regarding the values obtained by correlation between the B-GSS and ROCF (memory), the scores for Total Copy (r = -.55, p < .001) and Total Memory (r = -.44, p < .001) had a moderate, significant correlation with the total B-GSS score, indicating that working memory is related with the maturation of visual-motor skills. That is, the better the performance in the ROCF, both in copy execution and in memory reproduction, the fewer the errors in the B-GSS. Table 4 describes the comparisons among the total scores of all the tools composing the neuropsychologic battery of this study regarding the children’s age. Results were analyzed by one-way ANOVA, which indicated statistic significance, with p < .001 for all the tests (B-GSS, ROCF, and RPM) except for the 11 components of the WCST. To verify the statistically significant
differences among age groups, Tukey’s post-hoc test was applied. For the Bender-Gestalt test, there was no difference only between the groups aged 7 and 8. Yet, for RPM, the 7-year-old group differs from all the others, but the other three groups do not differ among themselves. For Rey-Osterrieth Complex Figures, differences were found in the measurement of copy accuracy comparing the means of the 7-year-old group with the 8-, 9-, and 10-yearold groups. For memory measurement, differences were found comparing the means of the 7-year-old group with the 9- and 10-year-old groups, while the 8-year-old group differed from the 9- and 10-year-old groups. The performance did not differ when comparing the groups aged 7 and 8 or when comparing the groups aged 9 and 10.
Table 4 Comparison Among Tests According to Children Age B-GSS Total
RPM Total
ROCF Total Copy
ROCF Total Memory
Age
N
M
SD
M
SD
M
SD
M
SD
7
24
13.67cd
3.73
20.5bcd
4.98
14.83cd
4.95
6cd
3.77
8
22
12.36cd
3.20
26.55a
5.61
16.02c
5.57
6.43cd
4.09
9
26
9.88
2.64
26.42
3.57
20.52
5.58
10.23
5.43
abd
a
ab
ac
10 11 6.54abc 3.14 27.09a 3.67 21.36a 6.52 11.73ab 5.78 Note. a, b, c, and d refer, respectively, to the groups of 7, 8, 9, and 10 years of age and indicate which groups were statistically different when the means were compared by Tukey’s test (p < .05). The results of the WCST are not shown in the table because no significant differences were found among age groups.
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Paidéia, 26(64), 215-223
Discussion The main goal of the present study was to investigate the relation between visual-motor abilities and executive functions through the Bender Gestalt Visual-Motor Test - Gradual Scoring System (B-GSS) and Wisconsin Card Sorting Test (WCST). Several studies have applied the Bender Visual-Motor Gestalt Test to assess the perceptive and motor aspects both on healthy children and populations with diverse deficits, such as academic (learning, intelligence) and other cognitive/behavioral (Attention Deficit Hyperactivity Disorder) disabilities, using not only the B-GSS system (Bartholomeu & Sisto, 2008; Sisto et al., 2006) but also the Koppitz version (Noronha & Mattos, 2006). However, it is important to point out that no studies were found relating the B-GSS with WCST. In order to study the development of visual-motor skills and executive functions in schoolchildren, searching for evidence of relations between these tools, the results of the neuropsychological assessments performed in this study will be discussed hereafter. The B-GSS is related with intelligence measures, such as the g factor, through Raven’s Progressive Matrices Test (Sisto et al., 2006). Therefore, RPM was used, in this study, to measure the IQ of the individuals and to serve as exclusion criteria for those participants who scored 5 or less in this test, which would indicate an intellectually deficient IQ. The method of RPM score interpretation has the advantage of not assuming that, during childhood, the development of intellectual capacity must necessarily be uniform or symmetrically distributed (Angelini et al., 1999). The research carried out by Bartholomeu and Sisto (2008), in which the authors looked for evidence of validity between the Bender Visual-Motor Gestalt Test, assessed by the B-GSS, and Human Figure Drawing (HFD), according to criteria by Sisto, assumes that the Bender-Gestalt Test could be used to assess intelligence in children. Among the main results of such research is the statistically significant difference (r = -.56; p < .001) regarding age in the performance of both tools. Older children made fewer errors than younger ones. In this regard, the age-related results match the data in the present research, in which significant differences were found for mean total B-GSS scores in the 7-year-old group compared to the older groups. This indicates that older children make fewer distortions in B-GSS figures. The authors of that study concluded that the B-GSS estimates children’s intellectual capacities and distinguish the ones with above-average intellectual development from those with lower intelligence scores. The results also suggest that intelligence and maturity are interconnected. This is confirmed by the HFD results, which contribute a key amount to Bender variance. Another skill required for a good cognitive performance is the comprehension of new pieces of information and the ability of remembering the most relevant ones. Regarding this relation, this study sought to assess the working memory, one of the components of executive functioning, through the Rey-Osterrieth Complex Figure Test, as an additional measurement to be related with the B-GSS test. According to M. Oliveira, Rigoni, Andretta, and Moraes, (2004), who
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validated the ROCF for the Brazilian population, this tool is capable of assessing, besides memory, the visual perception and the development of visual-motor coordination. The results obtained in this study showed that the most common copy type in the ROCF was type IV, indicator of juxtaposition of details. The pattern of juxtaposition of details is characterized by the absence of base tracing, ending in a more or less coherent set (M. S. Oliveira & Rigoni, 2010, p. 42). According to the manual (p. 42), the pattern of juxtaposition of details is dominant among children from five to ten years of age, with an increasing frequency from four to seven years, reaching its higher frequency at eight and decreasing steadily until it reaches its lower frequency in adulthood. Since there are several studies carried out with the Bender-Gestalt test, proving that this is a sensitive tool for the assessment of visual-motor maturity. The evolutionary character of the test originally proposed by Bender (1955) has been observed in different correction systems and such character was maintained in the B-GSS. Besides, it is noteworthy that visual perception is intimately connected with the proper development of motor behavior, especially in bimanual tasks or tasks involving the eye-hand system. This important relation may be assessed by the Bender-Gestalt test through the results of task execution. Regarding executive functioning, the neuropsychological assessment of these functions, per se, is not an easy task, since there is no unique standard tool capable of evaluating them. The WCST is a complex test that demands the regulation and control of several components of EFs for its resolution. Although it was developed and used as a measurement of abstract thinking in normal adult populations, the WCST has been increasingly employed in child neuropsychological assessments, being also one of the gold standards for diagnosing frontal lobe lesions (Cunha et al., 2005). To measure the EFs of the children in this study’s sample, the WCST was administered and its scores identified that the children had a poor performance in task execution. This may be justified by the fact that the subjects of the age group assessed still have immature cortical regions upon which the executive functioning depends. Because various skills involve EFs, a unique tool to assess them is not easily found. According to the literature (Bull, Espy, & Wiebe, 2008; Drake, 2007; Malloy-Diniz et al., 2010), the tests intended to measure executive functioning should require cognitive effort, use working memory, and be a novel task for the examinee. Thus, the WCST fulfills the requirements for an adequate neuropsychological assessment, allowing the subjects to solve their tasks in a flexible and organized manner. Most of the correlations between the mean total score in the B-GSS and the WCST components were not significant. The significant correlations were weak, indicating that the higher the brain maturational stage of an individual, the fewer the number of distortions in the figures of the B-GSS test. Among the few studies found that assessed and related the visual-motor maturity and executive function constructs is the one by Böhm et al. (2010), which investigated the relation between these functions in a longitudinal prospective research in a group of 175 preterm infants and a control
Oliveira, A. L. S., Kaiser, V., Azambuja, T. O., Mallmann, L. U., Lukrafka, J. L., & Reppold, C. T. (2016). Visual-Motor Maturity in Schoolchildren.
group of 125 infants born at term within the Neonatal Project of hospitals Karolinska and Löwenströnska in Stockholm. The research by Böhm et al., employed a broad battery of neuropsychological tests, among which the Bender-Gestalt Test. The results by Böhm et al. (2010) showed that the scores in the Bender-Gestalt test for preterm infants were below average compared with the control group, indicating that the premature infants had delayed visual-motor competency development and that such delay persists at pre-school age. The data found by Böhm et al. match those in the present study, in which the relation between the visual-motor maturity and executive function constructs, investigated from the association between B-GSS and WCST scores, indicate that the greater the executive function maturity status, the fewer the errors or distortions in B-GSS figures. As mentioned, EFs articulate subordinated functions such as thinking, attention and inhibitory control, and working memory in order to direct the behavior to task execution (Bull et al., 2008; Tonietto et al., 2011). For a more specific assessment of the working memory of the subjects in this research, the Rey-Osterrieth Complex Figure Test was employed (M. S. Oliveira & Rigoni, 2010). The precise cognitive operations required for an adequate performance in this tool include visual perception, visuospatial organization, motor functions, and memory reproduction. In this context, the present study proposed to also relate the scores of the B-GSS and ROCF tests. Copy reproduction reflects the percentage of visuospatial organization, whereas memory reproduction reflects the amount of information that is stored and recovered from memory. The results indicate that there was a statistically significant correlation between the total score in the BenderGestalt test and the richness and accuracy in the ROCF. An inverse correlation was found, indicating that the better the perceptual data grasped by the subject in the copy reproduction in the ROCF test, the lower the total score in the Bender-Gestalt test. These tools had similar features regarding skills assessed by both, such as visuoperceptive functions and visuospatial organization, and they also provided an innovative character through the copying of novel figures. When comparing the total score of the Bender-Gestalt test, the older children, on average, perform better in test execution. This result indicates that the gradual scoring system is able to differentiate children regarding the severity of the errors committed and their developmental capacity. Analyses showed that there are significant differences between the 7- and 8-year-old age groups when compared to the 9- and 10-year-old groups. These data corroborate the maturational assumption of the tool, which estimate that, as age advances and cognitive functions are typically developed, the performance of visuoperceptive functions and motor coordination are progressively improved. These findings are supported by the current literature (Souza & Capellini, 2011), as they indicate that the cognitive developmental process is intrinsic to the motor development, and both systems, associated with the environmental stimuli, provide a wide range of experiences not only in the behavioral scope, through
social interactions indispensable to the learning and literacy processes, but also in the sensory-motor scope, responsible for decision-making and constitution of the body schema. The results concerning the comparison of RPM scores among different age groups show that intellectual capacity improves as age advances. Such differences in scoring are more pronounced when comparing the 7-year-old group with the others. Raven’s Progressive Matrices measure not only the individual’s intelligence, but also the capacity to reduce relations. Such competencies are related with, but not restricted to, the successful academic performance, and also depend on cerebral maturation. No studies were found correlating the B-GSS and WCST tests for evaluation of, respectively, the visual-motor maturity and executive functioning constructs. Therefore, the present research is innovative and points out the importance of further studies in order to improve the knowledge on this subject. Besides the relation proposed as the main objective of the study, another relevant piece of data of this research, which was also not found in previous studies, was the relation between the B-GSS and the Rey-Osterrieth Complex Figure test. Results pointed to a moderate correlation between visual-motor maturity and some constructs which the ROCF aims to assess, such as visual apperception, visual-spatial organization, and working memory, the last of which one of the most important subfunctions of EFs. This result justifies the impairment in memory richness and accuracy exhibited by the children evaluated. Among the study limitations, the fact that the analyses did not consider gender differences and also that there were no private school students in the sample can be mentioned. Another point is the fact that visual-motor maturity was assessed by a recent test, which makes it difficult to find studies with which to compare results. Further research expanding the sample scope and the age of the assessed individuals is suggested.
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de escolares com distúrbios de aprendizagem [Visual perception of students with learning disabilities]. Revista de Psicopedagogia, 28(87), 256-261. Tonietto, L., Wagner, G. P., Trentini, C. M., Sperb, T. M., & Parente, M. A. M. P. (2011). Interfaces entre funções executivas, linguagem e intencionalidade [Interfaces among executive functions, language and intentionality]. Paidéia (Ribeirão Preto), 21(49), 247-255. doi:10.1590/ S0103-863X2011000200012 Trentini, C. M., Argimon, I. I. L., Oliveira, M. S., & Werlang, B. G. (2006). O desenvolvimento de normas para o teste Wisconsin de classificação de cartas [Development standards Wisconsin card sorting test]. Avaliação Psicológica, 5(2), 247-250. Van Waelvelde, H., De Weerdt, W., De Cock, P., & SmitsEngels, B. C. M. (2004). Association between visual perceptual deficits and motor deficits in children with developmental coordination disorder. Developmental Medicine & Child Neurology, 46(10), 661-666. doi:10.1111/j.1469-8749.2004.tb00978.x Yasumura, A., Inagaki, M., & Hiraki, K. (2014). Relationship between neural activity and executive function: An NIRS Study. ISRN Neuroscience, 2014. doi:10.1155/2014/734952 Ana Luisa Silva de Oliveira holds a Master’s degree from the Graduate Program in Rehabilitation Sciences of the Universidade Federal de Ciências da Saúde de Porto Alegre. Vanessa Kaiser is an undergraduate student in Psychology at the Universidade Federal de Ciências da Saúde de Porto Alegre. Thamy de Oliveira Azambuja is an undergraduate student in Psychology at the Universidade Federal de Ciências da Saúde de Porto Alegre. Laura Uberti Mallmann is a Speech-language pathologist graduated from the Universidade Federal de Ciências da Saúde de Porto Alegre. Janice Luisa Lukrafka is an Associate Professor at the Universidade Federal de Ciências da Saúde de Porto Alegre. Caroline Tozzi Reppold is an Associate Professor I at the Universidade Federal de Ciências da Saúde de Porto Alegre. Received: Aug. 4, 2015 1st Revision: Nov. 16, 2015 Approved: Nov. 18, 2015
How to cite this article: Oliveira, A. L. S., Kaiser, V., Azambuja, T. O., Mallmann, L. U., Lukrafka, J. L., & Reppold, C. T. (2016). Visual-motor maturity and executive functions in schoolchildren. Paidéia (Ribeirão Preto), 26(64), 215-223. doi:10.1590/198243272664201609
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Paidéia may-aug. 2016, Vol. 26, No. 64, 225-234. doi:10.1590/1982-43272664201610
Article
Emotional and Behavioral Problems in Children Living With Addicted Family Members: Prevention Challenges in an Underprivileged Suburban Community1 Thaís dos Reis Vilela2 Universidade Federal de São Paulo, São Paulo-SP, Brazil
Rebeca de Souza e Silva Universidade Federal de São Paulo, São Paulo-SP, Brazil
Marina Monzani da Rocha Universidade Presbiteriana Mackenzie, São Paulo-SP, Brazil
Camila Garcia de Grandi Universidade Federal de São Paulo, São Paulo-SP, Brazil
Neliana Buzi Figlie Universidade Federal de São Paulo, São Paulo-SP, Brazil
Abstract: Children living with substance abusers are more likely to experience negative outcomes. Our goal was to compare caregivers’ reports on the Child Behavior Checklist (CBCL) and a socioeconomic and risk form of psychological aspects of children exposed to substance abuse assisted versus not assisted by a preventive intervention program in an underprivileged community. This observational intervention study was conducted with 66 caregivers of children who attended the program and 35 caregivers of children from the same community who did not attend. Ages ranged between six and 11 years old. Chi-square and logistic regression tests indicate that children exposed to substance abusers have more mental health problems than the general population and those who did not participate in the preventive intervention program presented worse outcomes, with higher rates of behavioral/emotional problems and exposure to risk situations. Results suggest that preventive actions might be helpful to promote the mental health of children at risk, validating the need for public policies and services. Keywords: substance-related disorders, child behavior checklist, mental health, risk factors, drug abuse prevention
Problemas Emocionais e Comportamentais de Crianças que Convivem com Familiares Dependentes Químicos: Desafios de Prevenção em uma Comunidade Suburbana Desfavorecida Resumo: Crianças que convivem com usuários de substâncias psicoativas são mais propensas a apresentar problemas. O objetivo deste estudo foi comparar, a partir dos relatos dos cuidadores no Child Behavior Checklist (CBCL) e numa ficha de dados sociodemográficos e de fatores de risco, aspectos psicológicos de crianças expostas ao abuso de substâncias assistidas e não assistidas por um programa de intervenção preventiva, em uma comunidade desfavorecida. O estudo observacional de intervenção foi conduzido com 66 cuidadores de crianças que passaram pela intervenção e 35 da mesma comunidade que não foram atendidas. A faixa etária era de seis a 11 anos. Os testes qui-quadrado e regressão logística indicaram que as crianças expostas ao abuso de substâncias apresentaram mais problemas de saúde mental do que a população geral e que aquelas que não participaram do programa preventivo apresentaram desfechos piores, com escores mais elevados de problemas emocionais/comportamentais e maior exposição a situações de risco. Sugere-se que ações preventivas podem contribuir para a promoção de saúde mental em crianças em situação de risco, validando a necessidade de políticas e serviços públicos. Palavras-chave: transtornos relacionados ao uso de substâncias, lista de verificação comportamental para crianças, saúde mental, fatores de risco, prevenção do abuso de drogas
Problemas Emocionales y de Comportamiento en Niños que Viven con Familiares Adictos: Desafios de Prevención en una Comunidad Suburbana Desfavorecida Resumen: Los niños que viven con consumidores de drogas son más propensos a tener problemas. Nuestro objetivo fue comparar, a partir de los informes de los cuidadores en el Child Behavior Checklist (CBCL) y en una hoja de datos sociodemográficos y de factores de riesgo, aspectos psicológicos de niños expuestos al abuso de sustancias, con y sin la asistencia de un programa de intervención preventiva en una comunidad desfavorecida. Este estudio de intervención observacional fue realizado con 66 cuidadores de niños que pasaron por la intervención y 35 de la misma comunidad que no fueron atendidos. Las idades oscilaran entre seis y 11 años. Las pruebas de chi-cuadrado y regresión logística indicaron que los niños expuestos al abuso de sustancias tenían más problemas de salud mental en comparación con la población general y que aquellos que no participan del programa de prevención tuvieron peores resultados, con una puntuación más alta de problemas emocionales y de conducta y una mayor exposición al riesgo. Se sugiere que las acciones preventivas puedan contribuir a la promoción de la salud mental en los niños en situación de riesgo y se valida la necesidad de políticas y servicios públicos. Palabras clave: trastornos relacionados con sustancias, lista de verificación del comportamiento infantil, salud mental, factores de riesgo, prevención en el abuso de drogas Article derived from the third author master’s thesis under the supervision of the fifth author, defended in 2012, in the Graduate Program in Psychiatry and Medical Psychology at the Universidade Federal de São Paulo. Support: Scholarship granted by the Coordination for the Improvement of Higher Education Personnel (CAPES) to the third author. 1
Available in www.scielo.br/paideia
Correspondence address: Thaís dos Reis Vilela. Av. Corifeu de Azevedo Marques, 3202, apt 174-D, Jardim das Indústrias. CEP 12241-040. São José dos Campos-SP, Brazil. E-mail: thaisvilela1@gmail.com 2
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The impact of alcohol abuse and substance dependence in children exposed to them has been widely researched and reported in international literature. However, in Brazil, this population has only recently started to receive attention, which makes it impossible to estimate how many children live with this problem. International prevalence studies of child mental health found rates ranging from 9% to 20% of psychiatric disorders in developed countries (Fleitlich & Goodman, 2002). Although there is a paucity of epidemiological research in developing countries, preliminary studies indicate rates on the same range. Specifically in Brazil, different rates of mental health problems have been reported. Feitosa, Ricou, Rego, and Nunes (2011) found a 10% rate when studying children from middle class urban and underprivileged rural areas. Paula, Duarte, and Bordin (2007) identified a 24.6% rate of prevalence of mental health problems on the outskirts of Sao Paulo city. Vitolo, Fleitlich-Bilyk, Goodman, and Bordin (2005) indicated a 35.2% prevalence of clinical cases in a school-based sample from Taubaté-SP, while Assis, Avanci, Pesce, Oliveira, and Furtado (2007) found the occurrence of 3.5% for internalizing problems, 4% for externalizing and 1.3% for attention problems in a school-based sample from São Gonçalo-RJ. The discrepant rates found on these studies suggests that we still do not understand the global impact of child mental health in Brazil. On the other hand, associations between behavior disorders and family environment variables have been found consistently. The amount of negative family events is pointed out as particularly harmful to children’s development, being a factor that leads to behavior problems, altogether with exposure to poverty, maternal psychiatric illness and domestic violence (Fatori, Bordin, Curto, & Paula, 2013). Besides, the association between domestic violence and community problems with internalizing and externalizing problems is observed in the literature. This indicates a strong relation between community violence and mental functioning of the child, since in this context the sense of security can be jeopardized, yielding negative effect on his/ her development (Huculak, McLennan, & Bordin, 2011; Murray, Anselmi, Gallo, Fleitlich, & Bordin, 2013). Parental addiction is associated with several negative outcomes on the child development. Investigations from the last three decades have shown that having a substance abuser parent increases from two to nine times the risk of developing substance misuse later, despite the good results of adaptive behavior of many of these children (Beard et al., 2010; Kumpfer & Johnson, 2007). Children of substance abusers were found to be more likely to consume and face substance use related problems (Buu et al., 2012). Moreover, these individuals tends to start the consumption of alcohol and drugs earlier, when compared to children of non-addicts and, in early adolescence, have significantly higher odds of drinking alcohol, using illicit drugs, drinking heavier, and presenting addiction symptoms (Adkison et al., 2013). Besides the risk for addictive behaviors, children of substance abusers are also at higher risk of developing
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emotional, behavior, academics, criminal and other social problems (Barnow, Ulrich, Grabe, Freyberger, & Spitzer, 2007). Some authors report an increasing frequency of delinquency, social inadequacy and somatic problems (Serec et al., 2012; Temple, Shorey, Fite, Stuart, & Le, 2013), while others also report that these children show high levels of anxiety, depression, and show widespread stress, depressive humor and attention deficit-hyperactivity disorder (Chen et al., 2013; Klostermann et al., 2011; Mackrill & Hesse, 2012). It is well recognized by health professionals that children from substance-affected families are in a vulnerable condition for developing substance related problems or other mental health issues. On the other hand, few preventive programs targeted at this specific group have been scientifically studied. Bröning et al. (2012) conducted a systematic review of the literature on this subject and found nine programs – four school based intervention, one community based intervention and four family-based interventions – with preliminary evidence of effectiveness. All programs were conducted in the United States, except for one adaptation of an American program conducted in Spain and in Canada. In Brazil, reports of programs designed specifically for children of substance abusing parents were not found. In 2001, a pioneer selective prevention program was implemented in the outskirts of São Paulo city focused on children between zero and 17 years-old, living with addicted family members (CUIDA – Utility Intervention and Support Center for Children of Substance Abusers). It main concerns were: to promote protection of emotional and behavioral problems and coping skills for stressful situations; to prevent psychoactive substances consumption and exposition to drugs trafficking; to ensure educational conditions, social and recreational integration; to strengthen the social networking between the families; and to provide damage reduction associated to the consumption of substances by the addicted family members (Figlie, Milagres, & Crowe, 2009). Figlie, Fontes, Moraes, and Payá (2004) conducted the first study describing CUIDA and characterizing children of substance abusers in Brazil. The authors reported that children assisted by the program showed behavioral characteristics similar to those found in the international literature, with predominance of feelings of insecurity and inadequacy associated with depression, apathy and repression. They also noted the presence of fights, difficulties in family relationships and aggressive behavior, in addition to lowered self-esteem, high rates of affection privation, use of defenses such as problems denial, impoverishment in the ability to solve problems, isolation and early maturity. This first study not only described the children and adolescents treated at CUIDA but also emphasized the need of a preventive intervention program for this population. Apart for that, this is one of the first studies conducted in Brazil aimed to assess the social and psychological aspects of children living with addiction in their families. Our
Vilela, T. R., Silva, R. S., Grandi, C. G., Rocha, M. M., & Figlie, N. B. (2016). Children Living With Addicted Family Member.
purpose was to compare caregivers reports of psychological aspects of children exposed to substance abuse assisted versus not assisted by a preventive intervention program in an underprivileged community of São Paulo, Brazil.
Method Participants This is an observational intervention study that included 101 caregivers of six to 11 years old children exposed to substance abuse in their families. Inclusion criteria were: the child had to live with at least one addicted family member; to reside in Jardim Ângela neighborhood; to be a volunteer. They were divided in two groups, 66 caregivers of children (M = 9.41 years, SD = 1.51) who attend CUIDA for at least one year (Intervention Group) and 35 caregivers of children (M = 8.69 years, SD = 1.73) from the same neighborhood who attend municipals Centers for Children and Adolescents (CCA), but not CUIDA or any other preventive intervention center for substance abuse (Control Group). CUIDA offered mental health assistance and other activities, such as educational, recreational, musical, sports and computational. Psychologists, social workers and a pediatrician carried out the assistance individually or in groups. All activities took place outside the regular school time-period and all participants received nourishment. The Control Group children attended CCA, which main goal is to be a place where children be together and interact in a health way through recreational, cultural and sportive activities, not to give any substance abuse preventive program. The present study was conducted in two services offered by a non-governmental organization in the neighborhood of Jardim Ângela, on the outskirts of São Paulo. This area comprised the highest alcohol outlet density reported in the medical literature. A study revealed the proportion of approximately one alcohol selling point per twelve properties. In the late 90s, the United Nations ranked this area as the most violent neighborhood in the world (Laranjeira & Hinkly, 2002).
& Monteiro, 1983). The used cut-offs correspond to an affirmative answer. The Child Behavior Checklist Ages 6 to 18 (CBCL/618) was used to assess emotional and behavioral problems. The CBCL is a questionnaire developed in the United States, and validated for different cultures, in which parents evaluate their child behaviors (Achenbach & Rescorla, 2001). Two areas are assessed: Competences and Behavioral/Emotional Problems, being this last one divided in three large scales: Total Problems, Internalizing, and Externalizing. Raw items scores are converted in T-scores, which are classified as normal, borderline or clinical in comparison with a normative sample of children not referred for mental health services. In Brazil, its psychometric proprieties has being stablished by a few studies. The first indicated high sensitivity of the instrument in comparison with psychiatric assessment: 87% of the clinical cases were identified (Bordin, Mari, & Caiero, 1995). This was confirmed in comparison with results found using a semi-structured psychiatric interview (K-SADS-PL): 82.4% of children with psychiatric disorders achieved clinical scores on the CBCL (Brasil & Bordin, 2010). Using the latest version of the CBCL, Rocha et al. (2013) reported the validity of its factorial structure (RMSEA = .023), the discriminative capacity of the instrument (p < .001), and suggested more appropriate normative standards for assessing our population. A review article giving detailed information on the development of these forms in the United States and Brazil was recently published (Bordin et al., 2013). Considering Rocha et al. (2013) findings regarding norms and cutoff points for the clinical range, group 3 norms, indicated by Achenbach and Rescorla (2007) multicultural study, were used. Besides, borderline and clinical range scores were grouped following Achenbach and Rescorla (2001) instructions to avoid false negatives. Moreover, questions aimed at sociodemographic description of the sample concerning gender, age, color, religion, educational level, socioeconomic status, family substance abuse, and stress situations experienced were asked. Procedure
Instruments In order to assess child’s exposure to addiction, it was used the familiar CAGE questionnaire (acronym of its four questions: Cut down on drinking; Annoyed by criticizing about drinking; Guilty about drinking; had an Eye-opener first thing in the morning), a screening tool, which consists of four items that aim to detect family problems related to alcohol consumption. This instrument was found to be a consistent and effective measure of alcohol misuse in families. Originally aimed to measure alcohol consumption, it was changed to include other drugs (marijuana, cocaine and crack). Studies demonstrate internal consistency of 84% to 89% (Frank, Graham, Zyzanski, & White, 1992). The version used was based on the validation in which was found 88% of sensitivity range for the CAGE (Masur
Data collection. The study was carried out from August 2010 to December 2011. According to CUIDA’s records, 791 children and adolescents attended the service and 174 were aged six to 11 when data collection was conducted. Researchers tried to locate all Intervention Group potential participants by either phone or home visits. A total of 66 (38%) caregivers accepted to participate in the research and completed all forms, 38 (22%) refused to participate, 37 (21%) were not located, nine (5%) had moved to another city and two (1%) reported their children had never attended CUIDA. Besides, 22 (13%) of the children were institutionalized and were not living with their originated family. To compose the Control Group children from the same region were allocated from social work services, community-based recreation activities and leisure services
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specially designed for children. For both groups, data were collected by a psychologist who conducted a 60-minute face-to-face interview with the informant at the preventive service location, as well as at the social work services designed for the child, or during home visits. All forms were filled out during this interview. Data analysis. Data were analyzed using the Statistical Package for the Social Sciences (SPSS 15.0) and involved descriptive and inferential statistics. Initially, descriptive statistics regarding sociodemographic characteristics and CBCL scores of both groups were performed. Chisquare tests were used to compare the distribution of all variables on both groups. Then a logistic regression model was adjusted to understand the relationship between both groups, their characteristics and CBCL scores. All sociodemographic variables were included in the model as independent variables, in addition to the Internalizing, Externalizing, Total Problems and Total Competence Scales, whereas group (Intervention vs. Control) were included as dependent variables. Analysis was controlled for gender, age, Brazil Economic Classification Criteria, type of drug (alcohol or illicit) and substance abuser family member. The covariates above were retained regardless of significance and variables not significant at 5% (p < .05) were eliminated by the stepwise selection method. Odds ratio were used to assess the risk of not attending CUIDA. Values bellow 1 were considered protective factors, while values above 1 were considered risk factors. Ethical Considerations The study was approved by the Ethics Committee of the Universidade Federal de SĂŁo Paulo (EPMedicina/ UNIFESP - CEP n.1843/09) and by the Ethics Committee in Research of the Municipal Health Department of SĂŁo
Paulo (CAAE n. 05.174/11) and contemplated all ethical guidelines in Resolution No. 196/96 of the National Health Council of the Ministry of Health. All protocols contained an informed consent form properly signed ensuring the anonymity of the participant and confidentiality of information. All of the participants were informed of the nature, content, and propose of the interviews and requested to sign an Informed Consent for Participation.
Results Descriptive statistics with sociodemographic data and the family stressful situations reported by the participants of the two groups are presented in Table 1. Groups were equivalent in most of the variables. Chi-square test indicated significant differences regarding age, religion, education and stress in the following situations: suicide, attempted suicide and family member death, all occurring in the year preceding the interview. The age difference between the groups is due to the different configuration: Intervention Group has more children between 9-11 years old than the Control Group (77.3% vs. 57.1%). Intervention Group has also the highest number of people who have a religion (91.8% vs. 62.9% in Control Group). Regarding education, the significance also takes place due to the age difference, since the percentage of grade repetitions is minimal. Since there is no significance in the variable number of repetitions and all children in the sample are in school, there is no significant school delay in either group. In relation to situations of stress experienced by the child, there was significant difference in the items suicide, suicide attempt and death of family member. In all three cases, there are a greater number of occurrences in the Control Group.
Table 1 Distribution of Sociodemographic Characteristics and Stressful Situations (N = 101) Intervention Group (n = 66) N
%
Control Group (n = 35) n
%
Total (n = 101) n
p
%
Gender
.929
Female
27
40.9
14
40.0
41
40.6
Male
39
59.1
21
60.0
60
59.4
Age*
.035
6 to 8 years old
15
22.7
15
42.9
30
29.7
9 to 11 years old
51
77.3
20
57.1
71
70.3
Color
.072
White
29
43.9
09
25.7
38
37.6
Non-white
37
56.1
26
74.3
63
62.4 continued...
228
Vilela, T. R., Silva, R. S., Grandi, C. G., Rocha, M. M., & Figlie, N. B. (2016). Children Living With Addicted Family Member. ...continuation Intervention Group (n = 66) N
%
Control Group (n = 35) n
%
Total (n = 101) n
p
%
Religion*
.000
Yes
56
91.8
22
62.9
78
81.3
No
05
8.2
13
37.1
18
18.8
Children Educational level*
.007
Up to E.F.1 Completed (equivalent to 3rd grade)
47
71.2
33
94.3
80
79.2
Up to E.F.2 Uncompleted (equivalent to 5th grade)
19
28.8
02
5.7
21
20.8
School Repetitions
.961
None
64
97.0
34
97.1
98
97.0
One
02
3.0
01
2.9
3
3.0
Brazil Economic Classification Criteria
.692
Class B
01
1.5
01
2.9
02
2.0
Class C
46
70.8
22
62.9
68
68.0
Class D
18
27.7
12
34.3
30
30.0
Parentsâ&#x20AC;&#x2122; marital status: Married?
.579
Yes (married or living together)
34
51.5
16
45.7
50
49.5
No (single, divorced, separated)
32
48.5
19
54.3
51
50.5
Number of substance abusers who coexists
.522
One substance abuser
47
71.2
27
77.1
74
73.3
More than one substance abuser
19
28.8
8
22.9
27
26.7
Substance Abuser Member
.068
First-degree relatives
57
86.4
25
71.4
82
81.2
Second-degree relatives
09
13.6
10
28.6
19
18.8
Type of drug consumed
.159
Alcohol
38
57.6
15
42.9
53
52.5
Illicit drug
28
42.4
20
57.1
48
47.5
Psychiatric hospitalization
07
11.5
09
25.7
16
16.7
.072
Family severe disease
19
30.6
13
37.1
32
33.0
.513
Suicide*
01
1.6
08
22.9
09
9.3
.001
Attempted suicide*
04
6.5
11
31.4
15
15.5
.001
Police problems
10
16.1
09
25.7
19
19.6
.253
Death of a family member*
12
19.422
15
42.9
27
27.8
.013
Physical aggression between family
14
.6
14
40.0
28
28.9
.069
Stressful situations
*p < .05.
Table 2 shows the frequency of clinical and nonclinical CBCL scores. The percentage of children with scores in the clinical range on Internalizing, Externalizing and Total Problems scales at Control Group
is considerably higher in comparison to Intervention Group (51.4% vs. 13.6%, 60% vs. 30,3% and 62.9% vs. 28.8%, respectively). The Total Competence Scale has not shown significant difference.
229
Paidéia, 26(64), 225-234 Table 2 Distribution of CBCL Scores in the Groups (N = 101) Intervention Group (n = 66)
Control Group (n = 35)
Total (N = 101)
p
n
%
n
%
n
%
57
84.4
17
48.6
74
73.3
09
13.6
18
51.4
27
26.7
Internalizing Scale **
.000
a
Non-clinical Clinical§ Externalizing Scale **
.004
b
Non-clinical
46
69.7
14
40.0
60
59.4
Clinical§
20
30.3
21
60.0
41
40.6
Total Problems Scale **
.001
c
Non-clinical
47
71.2
13
37.1
60
59.4
Clinical§
19
28.8
22
62.9
41
40.6
Total Competencies Scale
.050
d
Non-clinical
44
66.7
28
79.4
72
71.3
Clinical§
22
33.3
07
20.6
29
28.7
Scores in the clinical range in comparison to Group 3 cutpoints (Achenbach & Rescorla, 2007). Includes Anxious/Depressed, Withdrawn/ Depressed, and Somatic Complaints subscales. bIncludes Rule Breaking Behavior and Aggressive Behavior subscales. cIncludes all problems items of the CBCL. dIncludes Activities, Social and School subscales. **p < .01. §
a
Results achieved in the logistic regression test can be observed in Table 3. Among the significant variables in chisquare test, age (WaldX2 = 8.570; p = .003), religion (WaldX2 = 8.985; p = .003) and family stress situation death of family member (WaldX2 = 7.253; p = .007) remained significant in logistic regression model.
The control variable substance abuser member, who did not appear significant in the chi-square test, has achieved significance in the logistic regression model (WaldX2 = 5.546; p = .019). From CBCL Scales a significant difference was observed between the Intervention and Control Group on the Internalizing Scale (WaldX2 = 8.5971; p = .003).
Table 3 Results of Logistic Regression and Odds Ratio (OR) With the Sociodemographic Variables, Stressful Situations and Scores From CBCL (N = 101) Variables
WaldX2
p
OR
95% CI
.391
.532
.666
[.186, 2.382]
8.570
.003
7.483
[1.945, 28.794]
Religion
8.985
.003
.095
[.021, .443]
Brazil Economic Classification Criteriaa
.157
.692
.780
[1.345, 25.516]
Type of drug (alcohol or illicit)a
1.089
.297
.538
[.168, 1.725]
5.546
.019
5.859
[.228, 2.669]
Stress Situation: Death of a family member
7.253
.007
.161
[.043, .608]
Internalizing Scaleb
8.971
.003
.376
[.198, .713]
Sex
a
Ageab b
Substance Abuser Member
ab b
Control variables. Significant variables.
a
b
Discussion Mental health problems of children exposed to substance abuse assisted versus not assisted by a preventive intervention program in an underprivileged community of São Paulo, Brazil were assessed. Results show that, despite the presence of small sociodemographic differences, since Intervention Group was older and more religious, caregivers of the Control Group reported worst mental health indexes
230
and exposure to risk situation. For instance, children that attended the preventive service achieved, on average, normal scores on three of four CBCL scales analyzed: Internalizing, Externalizing and Total Problems, with a greater emphasis towards the Internalizing Scale, which remained in the model logistic regression with significance (p = .003, OR = .376). Considering the number of children with clinical scores, Intervention Group also had fewer for all problems scales: 13.6% vs. 51.4% for Internalizing, 30.3% vs. 60%
Vilela, T. R., Silva, R. S., Grandi, C. G., Rocha, M. M., & Figlie, N. B. (2016). Children Living With Addicted Family Member.
for Externalizing, and 28.8% vs. 62.9% for Total Problems. These numbers suggest an association between participating of preventive intervention and caregivers reporting less behavioral problems, which also suggests the importance of psychosocial preventive action involving this population. The implementation of preventive services aimed at children of substance abusers may be key to care for the population living in a low-income area, especially considering the easy access to alcohol and other drugs (Laranjeira & Hinkly, 2002) and that it is cheaper to implement preventive than curative actions (Robertson, David, & Rao, 2003). CUIDA’s strategies included all sorts of health care professionals to give the children the possibility of developing higher tolerance while dealing with their reality and improve the problem solving capacity. This kind of program is conform to Trim and Chassin (2008) suggestion that multidisciplinary teams should include Psychologists, Psychiatrists, Occupational Therapists, as well as any other professional that could help improve the patients’ mental health. Although caregivers of children from Intervention Group reported less problems than those from Control Group, both groups have higher rates of behavioral problems than found as epidemiological rate for mental health problems in children from urban and poor areas in Brazil, which is 20% according to Fleitlich and Goodman (2001). The same happens considering the rate of 24.6% indicated by Paula et al. (2007). On our sample, 26.7% of the children scored in the clinical range for Internalizing, 40.6% for the Externalizing, and 40.6% for the Total Problems. These findings converge with those found by Vitolo et al. (2005), which showed a 35.2% prevalence rate of mental health problems in a school population, indicating the need for assistance of this population, notably lacking this type of intervention. Another important result was that Control Group had higher number of children who exposed to suicides (22.9% vs. 1.6%), suicides attempts (31.4% vs. 6.5%) and death (42.9% vs. 19.4%) in the family during the previous years. Death of a family member entered the logistic regression model with significance (p = .007), being the children of the Intervention Group more protected regarding this fact (OR = .161). These results may demonstrate that Intervention Group had a better family structure, protecting its members from these types of occurrences. This healthier family structure may also explain the fact that children were taken to CUIDA. It is interesting to notice that the variable “Substance Abuser Member” entered the logistic regression model with significance (p = .019, OR = 5.859). Although for both groups the number is very high, Intervention Group has a greater number (86.4%) of first-degree relatives (mother, father and/ or siblings) suffering from addiction than the Control Group (71.4%). It is possible to hypothesize that the greater proximity to the substance abuser, the greater the losses of affected children. On the other hand, our data have shown that the caregivers of these children report less emotional/behavioral problems than caregivers from Control Group, which may suggest that preventive intervention acts as a protective factor, showing that prevention services like CUIDA are likely to be effective on underprivileged communities.
It is worth mentioning, however, that although families from the Intervention Group may be considered more protected, since they have sought assistance, they were still families in need of this kind of assistance, because of all the risk factor they experience by having a substance abuser within them. This fact highlights the need for such intervention to be carried out on a large scale, especially when observing the differences in rates of mental health problems found in the sample that participated in the preventive program in comparison to who did not participate, and also in epidemiological studies with the general population conducted in our country (Feitosa et al., 2011; Paula et al., 2007; Vitolo et al., 2005). Noteworthy among the results is the variable Religion, which showed high significance level (p = .003), indicating to be a protection factor for the Intervention Group (OR = .095). It can be inferred that having a religion is associated with a better outcome with regard to children's mental health, which was also observed in a study of Cucchiaro and Dalgalarrondo (2007). Although there was no difference between the groups with regard to socioeconomic status, this should certainly be a concern, since adverse economic conditions collaborate to worse prognosis in mental health problems (Feitosa et al., 2011). The vulnerable social condition of the population studied is added to the vulnerability of being children of substance abusers, dealing with violence of which children are usually direct or indirect victims. This scenario further increases the risk of psychological and psychiatric problems (Kumpfer & Johnson, 2007). Both groups were composed of children who live in the same neighborhood, regulars of centers from the same institution, with similar economic status and living with users of the same type of drugs (alcohol or illicit). Thus, potential biases in the study were minimized. However, there are limitations involving the presented study that must be addressed to delimitate the reach of the results found. Data from CBCL are not provided by the children, but rather by their mothers or guardians. Researches (Linares et al., 2006) consider essential to ponder over the effect that the informants have in the assessment, because information given by parents about children behavior problems are affected by their own psychological problems. Since we were not able to assess informant’s mental health status, this is a bias to be considered, although CBCL is a world known instrument with proven sensitivity and widely used for such studies (Achenbach & Rescorla, 2007). Another issue is a constraint on the number of participants. Having this population high-risk of vulnerability, a great level of difficulty was found in establishing contact with the families who have been monitored by CUIDA. Many had changed their address and telephone number, making it impossible to reach them. Therefore, it was not possible to contact the entire population that received the intervention, but only 38% of those who were within inclusion criteria. And even when reached, a selection bias is noteworthy, since the participation was voluntary and 22% refused to participate. Besides, the number of participants on the
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Paidéia, 26(64), 225-234
Control Group is lower and it was not possible to pair them with the Intervention Group regarding all variables, which definitely would enhance the legitimacy of the mental health differences found on our study. In addition, the methodology does not allow causality relation; however, it indicates the presence of an association, as well as directions for further studies within this population. Nevertheless, despite any attention given to children in Brazil, no research, up to the present moment, has presented results from a prevention intervention program with children exposed to substance abuse in their families. In line with international and national studies, implications can be found for the mental health of children living in a poor environment with substance abusers, domestic violence and social risk. Knowing the severity of impact of mental disorders in childhood and, as well as the high rates of these disorders especially in poorer regions, our findings highlight the need for deployment and implementation of preventive mental health centers (Curto, Paula, do Nascimento, Murray, & Bordin, 2011; Paula, Lauridsen-Ribeiro, Wissow, Bordin, & Evans-Lacko, 2012). According to Fleitlich and Goodman (2002), these centers should be concentrated on the areas of lower socioeconomic level, where prevalence rates of mental health problems are higher, as in the region of this study. They should also prioritize prevention and treatment of the most common disorders, offering standardized tested treatments and diagnostic assessment. In addition to the implementation of prevention and care centers, further research should also be conducted, both to investigate the impacts of adverse problems for the development of children, and to develop strategies for prevention and health promotion aimed to mental health. Thus, apart from immediately improve the quality of life of these children, it shall be observed an impact on the future of these young people by favoring the reduction of school failure and dropout, criminality, substance abuse, development of personality or other mental disorders and the feasibility of preventive health care against the use of psychoactive substances and mental health (Fatori, EvansLacko, Bordin, & Paula, 2012). In conclusion, it is noteworthy that being CUIDA a one of a kind facility in Brazil, there are no other studies to compare the data with. The research here presented is one of the few conducted in the country regarding prevention on children exposed to substance abusers and it points to a positive association between preventive intervention program and protection of emotional and behavioral problems in children. These first results should collaborate with the literature findings concerning this theme. For this reason, it validates the importance of investing in services and public policies in order to promote the mental health of those children at risk, direct victims of alcohol and drugs abuse by their families.
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Frank, S. H., Graham, A. V., Zyzanski, S. J., & White, S. (1992). Use of the Family CAGE in screening for alcohol problems in primary care. Archives of Family Medicine, 1(2), 209-216. Huculak, S., McLennan, J. D., & Bordin, I. A. S (2011). Exposure to violence in incarcerated youth from the city of São Paulo. Revista Brasileira de Psiquiatria, 33(3), 314-320. doi:10.1590/S1516-44462011000300011 Klostermann, K., Chen, R., Kelley, M. L., Schroeder, V. M., Braitman, A. L., & Mignone, T. (2011). Coping behavior and depressive symptoms in adult children of alcoholics. Substance Use & Misuse, 46(9), 1162-1168. doi:10.3109/10826080903452546 Kumpfer, K. L., & Johnson, J. L. (2007). Intervenciones de fortalecimiento familiar para la prevención del consumo de sustancias en hijos de padres adictos [Strengthening family interventions for the prevention of substances abuse in children of substance abusers parents]. Adicciones, 19(1), 13-25. Retrieved from http://www. redalyc.org/pdf/2891/289122034004.pdf Laranjeira, R., & Hinkly, D. (2002). Evaluation of alcohol outlet density and its relation with violence. Revista de Saúde Pública, 36(4), 455-461. doi:10.1590/S003489102002000400011 Linares, T. J., Singer, L. T., Kirchner, H. L., Short, E. J., Min, M. O., Hussey, P., & Minnes, S. (2006). Mental health outcomes of cocaine-exposed children at 6 years of age. Journal of Pediatric Psychology, 31(1), 85-97. doi:10.1093/jpepsy/jsj020 Mackrill, T., & Hesse, M. (2012). Suicide behavior in parents with alcohol abuse problems and suicide behavior in their offspring-adult offspring and counselor perspectives. Nordic Journal of Psychiatry, 66(5), 343-348. doi:10.310 9/08039488.2011.650196 Masur, J., & Monteiro, M. G. (1983). Validation of the CAGE alcoholism screening test in a Brazilian psychiatric inpatient hospital setting. Brazilian Journal of Medical and Biological Research, 16(3), 215-218. Murray, J., Anselmi, L., Gallo, E. A. G., Fleitlich-Bilyk, B., & Bordin, I. A. (2013). Epidemiology of childhood conduct problems in Brazil: Systematic review and meta-analysis. Social Psychiatry and Psychiatric Epidemiology, 48(10), 1527-1538. doi:10.1007/s00127-013-0695-x Paula, C. S., Duarte, C. S., & Bordin, I. A. S. (2007). Prevalence of mental health problems in children and adolescents from the outskirts of Sao Paulo city: Treatment needs and service capacity evaluation. Revista Brasileira de Psiquiatria, 29(1), 11-17. doi:10.1590/ S1516-44462006005000012 Paula, C. S., Lauridsen-Ribeiro, E., Wissow, L., Bordin, I. A. S., & Evans-Lacko, S. (2012). How to improve the mental health care of children and adolescents in Brazil: Actions needed in the public sector. Revista Brasileira de Psiquiatria, 34(3), 334-351. doi:10.1016/j. rbp.2012.04.001 Robertson, E. B., David, S. L., & Rao, S. A. (2003). Applying prevention principles to drug abuse prevention
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programs. In Preventing drug abuse among children and adolescents: A research-based guide for parents, educators, and community leaders (2nd ed., pp. 18-25). Bethesda, MD: National Institute on Drug Abuse. Rocha, M. M., Rescorla, L. A., Emerich, D. R., Silvares, E. F. M., Borsa, J. C., Araújo, L. G., . . . Assis, S. G. (2013). Behavioural/emotional problems in Brazilian children: Findings from parents’ reports on the Child Behavior Checklist. Epidemiology and Psychiatric Sciences, 22(4), 329-338. doi:10.1017/S2045796012000637 Serec, M., Svab, I., Kolšek, M., Svab, V., Moesgen, D., & Klein, M. (2012). Health-related lifestyle, physical and mental health in children of alcoholic parents. Drug and Alcohol Review, 31(7), 861-870. doi:10.1111/j.14653362.2012.00424.x Temple, J. R., Shorey, R. C., Fite, P., Stuart, G. L., & Le, V. D. (2013). Substance use as a longitudinal predictor of the perpetration of teen dating violence. Journal of Youth and Adolescence, 42(4), 596-606. doi:10.1007/s10964012-9877-1 Trim, R. S., & Chassin, L. (2008). Neighborhood socioeconomic status effects on adolescent alcohol outcomes using growth models: Exploring the role of parental alcoholism. Journal of Studies on Alcohol and Drugs, 69(5), 639-648. Vitolo, Y. L. C., Fleitlich-Bilyk, B., Goodman, R., & Bordin, I. A. S. (2005). Crenças e atitudes educativas dos pais e problemas de saúde mental em escolares [Parental beliefs and child-rearing attitudes and mental health problems among schoolchildren]. Revista de Saúde Pública, 39(5), 716-724. doi:10.1590/S0034-89102005000500004 Thaís dos Reis Vilela is a Ph.D. candidate of the Graduate Program in Psychiatry and Medical Psychology at the Universidade Federal de São Paulo. Rebeca de Souza e Silva is a Full Professor at the Universidade Federal de São Paulo. Camila Garcia de Grandi is a M.S. in Psychiatry and Medical Psychology from Universidade Federal de São Paulo. Marina Monzani da Rocha is a Professor of the Centro de Ciências Biológicas e da Saúde at the Universidade Presbiteriana Mackenzie. Neliana Buzi Figlie is an Affiliated Professor of the Escola Paulista de Medicina at the Universidade Federal de São Paulo. Received: June 2, 2015 1st Revision: Oct. 24, 2015 Approved: Dec. 15, 2015 How to cite this article: Vilela, T. R., Silva, R. S., Grandi, C. G., Rocha, M. M., & Figlie, N. B. (2016). Emotional and behavioral problems in children living with addicted family members: Prevention challenges in an underprivileged suburban community. Paidéia (Ribeirão Preto), 26(64), 225-234. doi:10.1590/1982-43272664201610
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Article
Aggressive Behavior of Children in a Daycare Center1 Sidnei Rinaldo Priolo Filho2 Universidade Federal de São Carlos, São Carlos-SP, Brazil
Henrique Mesquita Pompermaier Universidade Federal de São Carlos, São Carlos-SP, Brazil
Nancy Vinagre Fonseca de Almeida Universidade Federal de São Carlos, São Carlos-SP, Brazil
Débora de Hollanda Souza Universidade Federal de São Carlos, São Carlos-SP, Brazil
Abstract: The present work examined aggressive behavior in a sample of children attending a child daycare center in relation to their teachers’ behaviors and the types of activities proposed by them. Four teachers and their respective students were observed for an average of six sessions, during which they performed activities, which could be free (without instruction) or guided. The most frequent behaviors were pushing/pulling, fighting over objects/taking an object from someone else, and kicking/throwing objects, with 77.61% of the aggressive behavior occurring during the free activities. An association between free activities and aggressive behavior was found. The categories kicking/throwing, fighting over objects/taking an object from someone else and slapping the face were associated with free activity. These results indicate the need for more attention directed toward children’s free activities, providing them with adequate space for play and diverse opportunities for exploration and object manipulation. Keywords: aggressiveness, early childhood education, teacher-student interaction
Comportamento Agressivo de Crianças em um Centro de Educação Infantil Resumo: O presente trabalho examinou, em uma amostra de crianças de uma instituição de educação infantil, a relação entre comportamentos agressivos e os tipos de atividade propostos pelas educadoras. Quatro educadoras e seus respectivos alunos foram observados, em média, por seis sessões, durante as quais realizavam atividades que podiam ser livres (sem instrução) ou dirigidas. Os comportamentos mais frequentes foram os de puxar/empurrar, disputar/tirar objeto do outro e chutar/jogar objetos, sendo que 77,61% das ocorrências de comportamento agressivo foram observadas nas atividades livres. Houve associação entre as atividades livres e comportamentos agressivos. As categorias chutar/jogar objetos, disputar/tirar objetos dos outros e tapas no rosto foram as que apresentaram associação com a atividade livre. Esses resultados apontam a necessidade de se dispensar maior atenção às atividades livres das crianças, propiciando-lhes espaço adequado para o brincar e oportunidades variadas de exploração e manuseio de objetos. Palavras-chave: agressividade, educação infantil, interação professor-aluno
Comportamiento Agresivo de Niños en una Guardería Resumen: El presente trabajo examinó comportamiento agresivo en una muestra de niños que frecuentan una guardería en relación a conductas de sus maestros, así como los tipos de actividades propuestas por ellos. Observamos cuatro profesores y sus respectivos estudiantes, en promedio seis sesiones durante las cuales se realizaron actividades, que podrían ser libres (sin instrucción) o guiadas. Los comportamientos más frecuentes fueran empujar/halar, disputar objetos/tomar objeto de otra persona, y patadas/tirar objetos, con 77,61% de la conducta agresiva ocurriendo durante actividades libres. Una asociación entre actividades libres y comportamiento agresivo fue detectada. Las categorías patadas/tirar, disputar objetos/tomar objeto de otra persona y bofetadas en la cara se asociaron con la actividad libre. Estos resultados apuntan a la necesidad de mejor atención a las actividades libres en la educación infantil, así como espacio adecuado y material para exploración y juego. Palabras clave: agresividad, crianza del niño, interacción profesor-estudiante This paper is based on the first author’s bachelor’s thesis (Psychology Undergraduate Program, Universidade Federal de São Carlos), under the supervision of the third author. Support: During preparation of this manuscript, the fourth author was funded by Instituto Nacional de Ciência e Tecnologia sobre Comportamento, Cognição e Ensino (INCT-ECCE), which is supported by the National Council for Scientific and Technological Development (CNPq Grant # 573972/2008-7), and by the São Paulo Research Foundation (FAPESP Grant # 08/57705-8). 2 Correspondence address: Sidnei Rinaldo Priolo Filho. Universidade Federal de São Carlos, Programa de Pós-Graduação em Psicologia. Rodovia Washington Luís, Km 235, s/n, Jardim Guanabara. CEP 13565-905. São Carlos-SP, Brazil. E-mail: sdpriolo@gmail.com 1
Available in www.scielo.br/paideia
The number of national and international studies on aggressive behavior and violence has increased exponentially in recent years. This growth reflects a tireless search by psychologists, educators and health professionals to understand violence as a phenomenon, as well as their investigation of its nature and origins and the most adequate methods to attenuate, prevent and even eliminate these behaviors from social life (Bandeira & Hutz, 2012; Borsa, Souza, & Bandeira, 2011; Hanish, Sallquist, DiDonato, Fabes, & Martin, 2012; Liu, Lewis, & Evans, 2013; Vieira, Mendes, & Guimarães, 2010; Williams & Araújo, 2010).
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In addition to efforts made to increase scientific production on aggressiveness, there is also a growing concern from many sectors of the population related to the prevention of violence in different social contexts. However, despite important advances in research on aggressive behavior in the family and school environments (McCartney et al., 2010; Souza & Castro, 2008), aggressive behaviors in the context of early childhood education have not been investigated as frequently as should have been the case in recent years. The growing number of children attending child daycare centers in the country (Finkelhor, 2008; Monks, 2011; Pellegrini et al., 2011) and in particular, the observation that such events in very young children are not being treated as a form of violence (Finkelhor, 2008) need to be considered. In the present work, we interpret aggressive behaviors as antagonistic interactions, considering the children’s reactions, the type of activity and the antecedent and consequent events of the behaviors, as proposed by Tremblay (2008). It is important to make a distinction between the type of behavior known as Rough and Tumble Play (RTP), which is characterized by the use of behaviors involving motor activity that resembles aggressiveness (e.g., pulling, running and knocking down), but in reality, constitutes part of a context of play (DiCarlo, Baumgartner, Ota, & Jenkins, 2015). Aggressive behaviors were identified based on criteria established by Garcia, Almeida and Gil (2013), that is, a behavior was considered aggressive when it was directed from one child to the other or directed toward objects and followed by reactions of discomfort, such as crying and verbal complaints. Recent studies have contributed to a better understanding of changes associated with aggressive behavior in typically developing children. More specifically, longitudinal studies show that the first manifestations of aggression by a child occur, in general, between the first and second years of life and there is a peak of aggressiveness between the end of the third and beginning of the fourth year (Alink et al., 2006; Côté et al., 2007). Furthermore, in contrast to the popular belief that aggressiveness always increases with age, there is strong evidence suggesting that aggressive behavior tends to decrease with time, as children acquire self-regulation strategies during preschool and, consequently, learn to inhibit aggressiveness (Nagin & Tremblay, 1999; Thompson & Goodwin, 2007). Following this direction, in one longitudinal study, Nagin and Tremblay (1999) investigated the trajectory of aggressive behaviors in a sample of 1037 boys who were assessed at various moments, between 6 and 15 years of age. Participants with a high frequency of aggressive behaviors in the first years of the study (in comparison to the mean of their age group) presented a distinct developmental trajectory: these children kept showing a higher frequency of aggressive behaviors when compared to their peers during subsequent years. On the other hand, children showing moderate aggressiveness (in comparison to the mean of their age group) presented a brief decrease in the frequency of aggression. In addition to the fact that more studies on aggression in the preschool period are needed, there is also an important gap in the literature with regard to our current knowledge of the specific situations or events that can trigger an increase in aggressive behavior, and about the gravity of its consequences
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(Finkelhor, 2008). The later the intervention with aggressive children, the less powerful its efficacy, which is supported by evidence of low success rates of some programs directed toward reduction of aggressiveness in adolescents (Tremblay, 2008). As the majority of children learn to inhibit physical aggression during preschool years, this particular age is considered the best period for intervention (Finkelhor, 2008; Monks, 2011; Ormeño & Williams, 2006; Tremblay et al., 2004). What is most concerning, however, is that many children present risk factors for the development of aggressiveness, as well as difficulties in learning effective self-regulation strategies. For example, in the longitudinal study mentioned before, conducted with 504 families in Canada, Tremblay et al. (2004) tested children over a period of 37 months, between 5 and 42 months of age, identifying their trajectory of physical aggression during this period. These researchers showed that 58% of the children followed a rising trajectory of moderate physical aggression (in comparison to their age group) and 14% presented a rising trajectory of high aggressiveness. Another important contribution of the longitudinal study by Tremblay et al. (2004) was the identification of important risk factors for the development of physical aggression associated with the environment of the child, for example, poverty, mothers with a history of antisocial behavior, dysfunctional families and coercive parenting style. In addition to the contribution of different risk factors, social learning plays a fundamental role in originating and maintaining aggressive behavior (Vieira, Mendes, & Guimarães, 2010; Widom, 2014). Being exposed to domestic violence can also contribute to an increase in aggressive responses in children (D’Affonseca & Williams, 2003; Ormeño & Williams, 2006), more specifically, an environment in which aggression has reinforcing consequences may increase the likelihood that the child will reproduce aggressive behaviors (D’Affonseca & Williams, 2003). It is important to note, however, that children will not necessarily repeat their parents’ pattern of behaviors, although the probability is higher (Calvete & Orue, 2011). These risk factors are present from early on, even before the child starts school. Thus, a child who already presents frequent aggressive behavior in preschool and has one or more of the mentioned risk factors, has a greater chance of presenting an increasing trajectory of moderate or high levels of physical aggression and not the expected decrease resulting from the acquisition of self-regulation skills. Furthermore, if there is not some type of intervention, this same child will have a higher risk of presenting school problems in the future, such as learning difficulties and dropping out from school (Lisboa & Koller, 2001; Marinho, 1999; Train, 1997). For this reason, some authors treat child aggression as a public health issue, not only considering its future effects, but also because of the risk of possible physical harm to the children themselves when they engage in aggressive behaviors (Finkelhor, 2008; Tremblay et al., 2004). Until the present moment, studies trying to understand aggressiveness in preschool children have primarily focused on the development of techniques or training directed toward its extinction or reduction (Ormeño & Williams, 2006;
Priolo Filho, S. R., Pompermaier, H. M., Almeida, N. V. F., & Souza, D. H. (2016). Aggressive Behavior in a Daycare Center.
Webster-Stratton, 1997). These studies, however, have not tried to understand the phenomenon in different environments, such as during the years of early childhood education, and they do not seem to consider the reality of each country (Finkelhor, 2008). Furthermore, it is important to note that significant advances in executive functioning, language and social cognition characterize the preschool period, with this consequently being an important moment for the development of self-regulation (Hrabok & Kerns, 2010). Following this direction, the present work aims to contribute to the field of study on aggressive behavior in young children with the hope of providing useful data for future intervention programs focused on prevention. More specifically, this study aimed to identify the types of aggressive behaviors in children attending a daycare center, as well as to examine their relationship to the type of activity proposed by the teachers.
Method Participants Four teachers and their respective students, attending a philanthropic child daycare center in a small town located in the state of São Paulo, participated in this study. The children were distributed in different classes according to their age group, as the institution did not have, at the time of data collection, a pedagogical project to guide this distribution. The number of children in each of the participating classes varied from 12 to 18, totaling 60 children, 35 girls (58.33%) and 25 boys (41.67%). The mean age of participants was 4 years and 1 month (SD = 1.05 years), with the age range being 2 years and 5 months to 5 years and 9 months. The child day care center had, at the time of data collection, approximately 200 children distributed in twelve classes. The institution, according to criteria established by Centro de Políticas Sociais da Fundação Getúlio Vargas (2011), was located in a neighborhood of low-income families and was selected because it had a collaboration agreement with Universidade Federal de São Carlos. It is a philanthropic daycare center that is supported exclusively by donations, with human and financial resources being limited. Several teachers had previous experience in early childhood education, however, few had university level education. The toys available at the daycare center during activities did not belong to the children and the number of toys made available during free activities was, during the majority of sessions, less than the number of children. Instruments Two Sony DCR-HC21 video cameras were used, which were positioned by the experimenters in strategic places in order to best register the number of interactions involving the children or between the teacher and the children. The videos were coded and all occurrences of aggressive behavior were registered and classified using the registration protocol created by Ormeño e Williams (2006), which is directed toward
obtaining the frequency of the occurrence of different categories of aggressive behaviors. The instrument presents different categories of behaviors and the judge registered the moment at which the behavior occurred (time elapsed in the session) and the type of activity taking place when the aggressive behavior occurred. Thus, the instrument provided the possibility of verifying the frequencies of aggressive behaviors, the moment at which they occurred and the type of activity (free or guided) associated with each of these behaviors. Procedure Data collection. After a familiarization phase with the children and teachers, the principal researcher began the data collection. The children and their respective teachers were observed for an average of six sessions (number varied from five to seven). All observation sessions lasted 30 minutes each and were conducted at different times and days of the week, so that different activities could be observed. The sessions were videotaped using two video cameras located diagonally in opposite corners of the classroom. This positioning provided the best possible angle of the room and, as a result, it was possible to capture the greatest possible number of interactions. The experimenter interacted only sporadically with the children during the data collection, given that his presence was necessary so that the video cameras remained in an adequate and safe position. The children were observed in two distinct contexts: during activities of free play and during activities guided by the teachers (for example, the teacher presented a picture and asked the children to draw the same picture with washable paint on boards). Free play was play created by the children themselves, this being a frequently used practice in the context of the daycare center. Data analysis. In order to obtain the frequency of the categories of aggressive behavior, the videos from both cameras were coded simultaneously and in an uninterrupted manner. The frequencies of these categories were obtained for each participating class, considering the type of activity taking place (free or guided) in each session. A second judge reviewed all observation sessions in order to verify whether the behaviors registered by the first judge did in fact occur. When there was disagreement between the two judges, the item would be excluded, however, the level of agreement between judges was 98.6% and the Kappa was 0.9, which is considered excellent by Landis and Koch (1977). Guided activities involved one of the following procedures: (a) the teacher requested attention and explained to the children what would be done next or (b) the teacher distributed all material to be used in a given activity, which would only start when the last child received the material and the instructions had been given. Free activities were those for which there was no plan or those that were initiated by the children themselves, with no intervention or instruction from the teacher. In the same session, there could be both free and guided activities. These were categorized based on whether the teacher provided instructions or not, i.e., an activity would be considered guided when the teacher gave explicit instructions about
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how the activity should be conducted and the activity would be considered free when the teacher did not provide any instruction and allowed the children, by their own initiative, to decide what to do. During free activities, the teachers, in general, engaged in other activities that were not related to what the children were doing, for example, filling out school reports or writing notes to parents in children’s notebooks, among other chores not related to the activities children were engaged in. Data were coded and analyzed using the statistical program Statistical Package for the Social Sciences (SPSS), version 20. A paired samples t-test was conducted in order to test for possible differences regarding mean duration time of aggressive behaviors in the two types of activity. In order to test for an association between specific aggressive behaviors and type of activity (free or guided), considering that these variables were categorical, Fisher’s exact tests were conducted (p < .05). Ethical Considerations This study was approved by the Human Research Ethics Committee of Universidade Federal de São Carlos
(Case n. 415/2010, CAAE n. 4294.0.000.135-10). Only children whose parents signed the terms of consent were allowed to participate in the study. The four participating teachers also signed the informed consent form before data collection started.
Results Table 1 shows the total frequencies of aggressive behaviors during free and guided activities, with the behaviors that occurred most frequently being pulling/ pushing (82), fighting over/taking an object from another child (68) and kicking/throwing objects (57). There was no register of aggressive interactions between students and the teacher in any of the sessions. During guided activities, a total of 81 manifestations of aggressive behavior occurred, with 267 during free activities; the most frequent behavior in both activities was pulling/pushing, with 61 occurrences during free activities and 21 during guided. When comparing free and guided activities, the largest differences in frequency were related to behaviors involving disputes over objects or the manifestation of frustration or anger related to that dispute: fighting over/
Table 1 Absolute and Relative Frequency (%) of Aggressive Behaviors During Free and Guided Activities Behavior
Guided Activity
Free Activity
Total
Destroying friends’ objects
0 (0%)
1 (100%)
1
Punching
0 (0%)
4 (100%)
4
Choking
1 (25%)
3 (75%)
4
Slapping the face
1 (16.7%)
5 (83.3%)
6
Kicking another child
2 (33.3%)
4 (66.6%)
6
Yelling at another child
3 (50%)
3 (50%)
6
Pinching
4 (50%)
4 (50%)
8
Physically confronting another
4 (36.4%)
7 (63.6%)
11
Hitting another child
5 (27.8%)
13 (72.2%)
18
Slapping the body
9 (37.5%)
15 (62.5%)
24
Hitting another with an object
4 (8.2%)
45 (91.8%)
49
Kicking/Throwing objects
4 (7.0%)
53 (93%)
57
Fighting over/Taking objects
19 (27.9%)
49 (72.1%)
68
Pushing/Pulling another child
21 (25.6%)
61 (74.4%)
82
Total
81 (23.3%)
267 (76.7%)
348
taking objects from another child, kicking/throwing objects and hitting another child with an object. Table 2 presents the total time of observation for each activity in each class, the total number of aggressive behaviors and the interval time between occurrences of aggression. As can be observed in the table, the time teachers
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dedicated to guided activities was greater (M = 29888 s) than the time dedicated to free activities (M = 13312 s). A paired samples t-test revealed this difference was significant (t (7) = -5.175, p = .001). Nonetheless, despite the greater time spent on guided activities, 268 occurrences of aggressive behavior were observed, from a total of 348 (77.61%), during free activities.
Priolo Filho, S. R., Pompermaier, H. M., Almeida, N. V. F., & Souza, D. H. (2016). Aggressive Behavior in a Daycare Center. Table 2 Total Time, in Seconds, of Observation During Each Activity, Total Number of Aggressive Behaviors per Activity and Mean Time, in Seconds, of Interval Time Between Aggression Occurrences Grade Maternal I (3 year olds) Maternal II (3 year olds) Jardim I (4 year olds) Jardim II (4 year olds) Total
Activity
Time (s)
Total
Free
2400
29
Guided
10200
8
Free
1800
20
Guided
7200
5
Free
6743
175
Guided
5857
17
Free
2369
43
Guided
6631
47
Free
13312
267
Guided
29888
77
Fisher’s exact test was conducted in order to test for possible associations between type of activity (free or guided) and categories of aggressive behaviors. As can be observed in Table 3, there was a significant association between the type of activity taking place in the classroom
and the children’s behavior (p < .01), that is, free activities were associated with aggressive behaviors in the day care center. Aggressive behaviors occurred in 38% of free activities and in 16% of guided activities, with this difference being significant.
Table 3 Absolute and Relative Frequency (%) of Sessions During Which There Was Manifestation (or Not) of Aggressive Behavior Activities
Aggressive actions (in general) Did Not Occur
Occurred
Guided
229 (84%)
44 (16%)
Free
104 (62%)
65 (38%)
Finally, Fisher’s test was conducted in order to test for a possible association between activity type (free or guided) and the different types of aggressive behavior, as presented in Table 4. The categories kicking/throwing
p-value < .01
objects, fighting over/taking objects from other children and slapping the face occurred with a significantly greater frequency during free play in comparison to guided activities.
Table 4 Percentage of Occurrence of Each Class of Aggressive Behavior per Type of Activity Aggressive Behavior
Free Activity
Guided Activity
p-value
Hitting another child
46.2%
14.6%
.06
Hitting another with an object
46.2%
14.3%
.06
Pinching
15.4%
14.3%
.99
Kicking
15.4%
4.8%
.54
Kicking/Throwing objects
53.8%
9.5%
.01*
Physically confronting another
31.8%
14.3%
.39
Punching
15.4%
0%
.14
Destroying friends’ objects
7.7%
0%
. 38
Fighting over/Taking objects
84.6%
38.1%
.01*
Yelling at another child
15.4%
14.3%
.99
Pulling/Pushing another child
84.6%
57.1%
.14
Slaps on the face
23.1%
9.5%
.02*
Slaps on the body
61.5%
19%
.34
*Values less than p < .05 suggest an association between variables.
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Discussion Although the present study was conducted with children only in the context of classroom activity in an early childhood education institution, our data revealed important associations between aggressive behavior and the type of activity proposed by the teacher. Firstly, data analysis revealed a clear association between the type of activity being conducted and the frequency of aggressive behaviors. More specifically, the children engaged in aggressive behavior more frequently during free activities. Additionally, the teachers needed to intervene in order to resolve conflicts with a higher frequency during free play. One possible explanation for this association is related to the contingencies at work in the two situations: during free play, there was no guidance or instruction from the teachers, whereas during the planned activities, children were instructed by teachers to emit specific behaviors. Although the total time of interaction between teacher and children in the two activities was not recorded, there may be an important difference in the amounts of attention given to the children by the teachers in the two situations. The very nature of free activity (play constructed by children themselves) may induce greater interaction between children and less between children and the teacher. It is important to note, however, that the mediation of the teacher/adult during free activities is essential so that child-child interactions can effectively become an opportunity for the development of prosocial behaviors and not for the emergence of aggressive responses. Future studies should investigate, therefore, possible effects of time of interaction and monitoring in each activity and, in particular, they should examine further the behaviors of the teachers (antecedents and consequents of the child’s aggressive response) in the two types of activity (free and guided). It is also important to remember that the reduction of close monitoring during free activities may lead to a decrease in the number of opportunities to provide consequences for children’s behaviors. In this study, we found that during free activities the children were positively reinforced many times for their aggressive behavior (e.g., getting the desired toy, pushing away the child with whom they were fighting for an object), without any kind of consequence that could reduce the frequency of this group of behaviors. For example, the teacher could introduce alternative reparative behaviors, such as returning the desired toy to the upset child or providing a model of desirable behavior when disagreements occur. Future studies should investigate the effects of planning activities for children, not only during the implementation of pedagogical activities in the classroom, but also during free or recreational periods. In the same direction, future research should investigate whether greater engagement and more monitoring/supervision from teachers during free activities could contribute to a decrease in the number of aggressive episodes in the daycare center. It is important to note that participants’ mean age was 4 years and 1 month, and the literature has shown that children between 2 and 4 years of age present a higher frequency of aggressive behaviors when compared to younger children,
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between 0 and 2 years (Alink et al., 2006; Côté et al., 2007). Conversely, from the age of 4, it is possible to notice a decline in the number of aggressive events, mainly due to advances in self-regulation, associated, in turn, to the development of executive functioning and social cognition, typical of this age. In other words, as the children of the present study had a mean age of only 4 years, it is possible that they may have presented an even higher frequency of aggressive responses, as they had not yet acquired effective self-control skills. Prior to this occurring, it is possible that teachers will still encounter difficulties, corroborated by the data of Tremblay et al. (2004), which suggests an increase in the frequency of aggressive behaviors in more than 70% of children throughout the second and third years of life. Our results are in agreement with previous findings on the incidence of bullying and aggressive behavior in young children attending childcare centers (Smith, 2011; Vlachou, Andreou, Botsoglou, & Didaskalou, 2011). For example, Craig, Pepler, and Atlas (2000) found that the incidence of aggressive behavior and the duration of aggression are higher in the playground than in the classroom environment. As in the free activities observed in the present study, the playground is a context in which there is less supervision of children and where the activities are less structured. Other studies have contributed with the design of instruments and with teacher training in order to prevent and fight bullying in environments where supervision is less than adequate, such as the playground or the cafeteria (Leff, Power, Costigan, & Manz, 2003). Secondly, the results of the present study suggest that one of the most frequent types of aggressive behavior during free activities is that involving fighting over objects, which is consistent with data from Garcia, Almeida and Gil (2013). Previous studies suggest that the majority of conflicts involving young children revolve around toys (Hay, Hurst, Waters, & Chadwick, 2011), however, the results of this study suggest that these conflicts are more frequent during free play. Recent studies have shown that peer conflict in childcare centers occurs less frequently when there is a previous determination of the ownership of the toys. More specifically, conflict is accentuated when children are in a toy room, where nobody knows who the owner of each toy is (Ross & Friedman, 2011). With regard to the toys available in the child daycare center, all were manufactured and of small size, which, according to Garcia, Almeida and Gil (2013), is a variable that plays an important role in children’s antagonistic behaviors. Therefore, conflicts about the more desirable toys, such as pushing and pulling to keep children who want the same toy at a distance, become frequent. Thus, there were a greater number of behaviors related to conflict over objects during free activities, as shown in Table 1. During guided activities, however, the amount of materials and toys was adequate to serve the needs of all children. It is possible, therefore, that this difference in the number of toys available contributed to the increased conflict over objects during free activities. At the same time, the very nature of guided activity may result in an encouragement for cooperation and other prosocial behaviors in children (e.g., a painting session during which children can share the colored
Priolo Filho, S. R., Pompermaier, H. M., Almeida, N. V. F., & Souza, D. H. (2016). Aggressive Behavior in a Daycare Center.
pencil case). Teachers’ reinforcement of desirable behaviors during guided activities, greater availability of materials and closer supervision by teachers may thus have helped to inhibit conflict over objects in this condition. Another promising line of research would be to analyze children’s prosocial behaviors during free activities, given that these activities seem to contribute to the process of social learning, in particular, by encouraging collaboration, rule following, empathy, self-regulation or self-control (Zigler & Bishop-Josef, 2006). As a result, it would be possible to examine whether free activities can also provide a good context for non-aggressive behavior in young children attending childcare centers. In summary, aggression is a multifactorial behavior (Tremblay, 2008), which can cause physical and psychological damage to children in the short, medium and long-term (Finkelhor, 2008). At the same time, it represents a stress factor for teachers who need to solve the problems resulting from aggression episodes (e.g., helping the child victim, dealing with parents’ reactions, notifying the directors/ coordinators of the institution). Our results suggest that during free activities teachers do not mediate many interactions between children and, consequently, they are not able to inhibit the occurrence of various aggressive behaviors. Furthermore, if the teacher is not aware of the occurrence of an aggressive interaction, he/she will not be able to implement the appropriate consequences. There is a clear and urgent need, therefore, for a deeper discussion of how daycare centers can contribute to the control and prevention of aggressive behavior. Training and guidance work directed toward the monitoring and regulation of aggressive behavior in young children is still very limited (Finkelhor, 2008). As revealed by the literature of the area, it is during the preschool years that children acquire several selfregulation skills (Nagin & Tremblay, 1999), with teachers playing a particularly important role in this developmental process. For example, when they talk about feelings, teach strategies for the regulation of emotions and when they reinforce prosocial behaviors, teachers can contribute more effectively to the development of children’s emotional competence and, consequently, to the control and prevention of aggression (Denham et al., 2003). Furthermore, the planning of pedagogical actions in early childhood education should consider the differences between the contingencies of free and guided activities, as shown in the present study; in particular, the need for closer monitoring of children and provision of an adequate amount of materials and toys for the children, thus avoiding an increase in conflict over objects. It is important to note that one limitation of the present study is the fact that our data is representative of an institution, which can be characterized by offering less than ideal service (e.g., high number of children in each classroom, teachers with little formal training, limited number of toys available to children). It is possible that, in childcare centers with more human and material resources, the differences found between these two types of activities would be less pronounced. A second limitation of the present study is that other variables
that could be associated with aggressive behavior were not investigated, such as the level of teachers’ formal training, quality and quantity of available toys, time spent by teachers with children during the free and guided activities and conflict resolution in the classroom. Despite the increasing interest from different researchers in the development of aggression, our knowledge of aggressive behavior in preschool children is still limited (Monks, 2011). The present study aimed, therefore, to contribute to our current understanding of the phenomenon and of the possible variables controlling aggressive behaviors in young children in the context of Brazilian early childhood education.
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Priolo Filho, S. R., Pompermaier, H. M., Almeida, N. V. F., & Souza, D. H. (2016). Aggressive Behavior in a Daycare Center.
Zelazo, P. D., Boivin, M., . . . Japel, C. (2004). Physical aggression during early childhood: Trajectories and predictors. Pediatrics, 114(1), e43-50. Vieira, T. M., Mendes, F. D. C., & Guimarães, L. C. (2010). Aprendizagem social e comportamentos agressivo e lúdico de meninos pré-escolares [Social learning and aggressive and playful behaviors of pre-school boys]. Psicologia: Reflexão e Crítica, 23(3), 544-553. doi:10.1590/S010279722010000300015 Vlachou, M., Andreou, E., Botsoglou, K., & Didaskalou, E. (2011). Bully/victim problems among preschool children: A review of current research evidence. Educational Psychology Review, 23(3), 329-358. doi:10.1007/s10648011-9153-z Webster-Stratton, C. (1997). Early intervention for families of preschool children with conduct problems. In M. J. Guralnick (Ed.), The effectiveness of early intervention (pp. 429-454). Baltimore, MD: Paul H. Brookes. Widom, C. S. (2014). Varieties of violent behavior. Criminology, 52(3), 313-344. doi:10.1111/17459125.12046 Williams, L. C. A., & Araújo, E. A. C. (2010). Um número especial da revista Temas em Psicologia para enfrentamento da violência [A special number of the Journal Trends in Psychology on coping with violence]. Temas em Psicologia, 18(1), 7-10. Zigler, E. F., & Bishop-Josef, S. J. (2006). The cognitive child versus the whole child: Lessons from 40 years of head start. In D. G. Singer, R. M. Golinkoff, & K. Hirsh-Pasek. Play = learning: How play motivates and enhances children’s cognitive and social-emotional growth (pp. 1535). New York, NY: Oxford University Press. Sidnei Rinaldo Priolo Filho is a Ph.D. candidate in the Graduate Program in Psychology at Universidade Federal de São Carlos. Henrique Mesquita Pompermaier is a Ph.D. candidate in the Graduate Program in Psychology at Universidade Federal de São Carlos. Nancy Vinagre Fonseca de Almeida is a Professor at Universidade Federal de São Carlos. Débora de Hollanda Souza is an Associate Professor at Universidade Federal de São Carlos. Received: Dec. 9, 2014 1st Revision: Apr. 30, 2015 2nd Revision: Nov. 20, 2015 Approved: Dec. 4, 2015
How to cite this article: Priolo Filho, S. R., Pompermaier, H. M., Almeida, N. V. F., & Souza, D. H. (2016). Aggressive behavior of children in a daycare center. Paidéia (Ribeirão Preto), 26(64), 235-243. doi:10.1590/1982-43272664201611
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Paidéia may-aug. 2016, Vol. 26, No. 64, 245-253. doi:10.1590/1982-43272664201612
Article
Assessment of Patient, Family and Staff Satisfaction in a Mental Health Service1 Kênia Izabel David Silva de Resende2 Universidade Federal de São João del-Rei, São João del Rei-MG, Brazil
Marina Bandeira Universidade Federal de São João del-Rei, São João del Rei-MG, Brazil
Daniela Carine Ramires Oliveira Universidade Federal de São João del-Rei, São João del Rei-MG, Brazil
Abstract: Psychosocial Care Centers (CAPS) provide care to people with psychiatric disorders and aim to reinsert them into the community. Assessing these services is important to maintaining quality. This study assessed the satisfaction level of 84 patients, 84 family caregivers and 67 professionals from a large center of mental health care center (CAPS-III). Structured interviews were individually held by applying the Satisfaction with Mental Health Services Scales (SATIS-BR) and socio-demographic questionnaires. Overall scores were high for family caregivers and moderate for the patients and professionals. The family caregivers were satisfied with all the service’s dimensions; patients were satisfied with help received, and professionals were satisfied with their relationships with co-workers. Patients were dissatisfied with the service’s infrastructure, while professionals were dissatisfied with working conditions and infrastructure. The results indicate a need for investment in the service’s infrastructure and to improve working conditions. Keywords: mental health service, community mental health, public health services, satisfaction
Avaliação da Satisfação dos Pacientes, Familiares e Profissionais com um Serviço de Saúde Mental Resumo: Os Centros de Atenção Psicossocial (CAPS) visam o tratamento de pessoas com transtornos psiquiátricos e sua reinserção na comunidade. As avaliações destes serviços são importantes para a manutenção da sua qualidade. Este estudo avaliou a satisfação de 84 pacientes, 84 familiares e 67 profissionais com um CAPS III. Foram realizadas entrevistas individuais estruturadas, com aplicação das Escalas de Satisfação com os Serviços de Saúde Mental (SATIS-BR) e questionários sociodemográficos. Os escores globais de satisfação foram elevados para os familiares e moderados para os pacientes e profissionais. Os familiares estavam satisfeitos com todas as dimensões do serviço, os pacientes com a dimensão do acolhimento e os profissionais com o relacionamento entre colegas no trabalho. Pacientes e profissionais estavam insatisfeitos com a infraestrutura e os profissionais com as condições de trabalho. Os resultados apontaram para a necessidade de investimentos em infraestrutura e a melhoria das condições de trabalho dos profissionais. Palavras-chave: serviços de saúde mental, saúde mental comunitária, serviços de saúde pública, satisfação
Evaluación de la Satisfacción de los Pacientes, Familiares y Profesionales con un Servicio de Salud Mental Resumen: Los Centros de Atención Psicosocial (CAPS) son servicios comunitarios para el tratamiento de las personas con trastornos psiquiátricos e su integración en la comunidad. Las evaluaciones de estos servicios son importantes para mantener la calidad. Evaluó la satisfacción de 84 pacientes, 84 familiares y 67 profesionales de un centro de referencia en salud mental (CAPS III). Fueron realizadas entrevistas individuales estructuradas, con aplicación de las Escalas de Satisfacción con El Servicio de Salud Mental (SATIS-BR) y cuestionarios sociodemográficos. Los escores globais foram altos para os familiares e moderados para los pacientes e profesionales. Los familiares estaban satisfechos con todas las dimensiones del servicio, los pacientes estaban satisfechos con la acogida y los profesionales con la relación entre compañeras en el trabajo. Los pacientes e profesionales estaban insatisfechos con la infraestrutura y los profesionales con las condiciones de trabajo. Los resultados mostraron la necesidad de inversiones en infraestructura de los serviços y la mejora de las condiciones de trabajo. Palabras clave: servicios de salud mental, salud mental comunitaria, servicios de salud pública, satisfacción
This paper is derived from the master’s thesis of the primary author under the supervision of the second author. It was defended in 2015, in the Graduate Program in Psychology at the Universidade Federal de São João del-Rei (PPGPSI-UFSJ). Support: Foster Program directed to the Graduate Program at the Universidade Federal de São João del-Rei (PIPG-UFSJ) Decree/MEC 2.684, from September 25, 2003 (Report n. 006 de 25/02/2013 CONDI-UFSJ). 2 Correspondence address: Kênia Izabel David Silva de Resende. Rua Santa Catarina, 603/202, Senhora das Graças. CEP 32604-625. Betim-MG, Brazil. E-mail: keniaizabel@ gmail.com 1
Available in www.scielo.br/paideia
Psychiatric Reform, implemented according to Law No. 10,216 (2001), profoundly changed Brazilian public health policies so that treatment protocols for psychiatric patients, the role of families, and the practice of healthcare workers changed, as well. The treatment of patients no longer prioritized symptoms but also addressed functional recovery, focusing on autonomy, independence, social reinsertion and quality of life (Cardoso, 2014; Delgado et al., 2007;
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Thornicroft & Tansella, 2010). The participation of families became essential for the attainment of these goals. One relative became the primary informal caregiver of patients, providing assistance in daily living activities, administering medication, supervising problematic behavior, and supporting the autonomy of patients (Barroso, 2014; Tessler & Gamache, 2000). The family caregiver is, therefore, able to assess improvement presented by the patient in response to the treatment and to collaborate in the treatment designed by health providers (Bandeira, Silva, Camilo, & Felício, 2011; Perreault, Rousseau, Provencher, Roberts, & Milton, 2011). The responsibilities of the mental health staff became more diversified and intensified (Bandeira, 2014; Rebouças, Legay, & Abelha, 2007; Santos et al., 2011). Healthcare workers became responsible for a larger number of patients’ needs concerning more varied interventions, for dealing with a new work context, both clinical and organizational, and supporting families in their new roles as informal caregivers (Ishara, Bandeira, & Zuardi, 2014; Leal, Bandeira, & Azevedo, 2012). Assessing, monitoring and ensuring the quality of new treatment devices in the mental health services became essential (Bandeira, 2014; Kantorski, 2012; Oliveira et al., 2014; Silva, Melo, & Esperidião, 2012). In Brazil, CAPS (Psychosocial Care Centers) became dedicated mental health centers within the public network, providing community treatment to people with severe and persistent psychiatric disorders. These centers are important components of the Psychosocial Care Network, connecting different devices within the health network, such as primary health care and hospital care, among other services, such as Living Centers and Therapeutic Residential Services (STR) (Costa, Figueiró, & Freire, 2014). The services can be assessed at three levels: structure, process and results (Donabedian, 1990) and this study presents an assessment of the results. The level of results is related to the effects of interventions and treatments on the health and lives of patients (Donabedian, 1990). At this level, changes perceived by patients, their level of satisfaction, impact perceived on their quality of life, and more importantly, whether their needs are met, can be verified (Donabedian, 1990). The results should be assessed through reliable subjective and objective measures (Ruggeri, 2010). Among the subjective measures, satisfaction is considered the best indicator of quality of care (Ruggeri, 2010). The satisfaction of patients has been associated with improved treatment adherence, more frequent use of services, and a low rate of treatment abandonment (Einsen, 2010; Ruggeri, 2010). Information obtained from satisfaction surveys enable the reorganization of health care, and the improvement of quality of treatments and interventions. As a consequence, they contribute to the quality of life of those using the services (Ruggeri, 2010). Satisfaction is considered a multidimensional construct that requires multifactorial instruments to measure it accurately (Ruggeri, 2010). Multifactorial instruments present subscales that detect specific dimensions regarding satisfaction and dissatisfaction (Bandeira & Silva, 2012;
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Silva, 2014). Certain requirements, such as psychometric features of validity and reliability, need to be met for satisfaction assessments to have credibility (Bandeira & Silva, 2012). Various studies have assessed mental health services using satisfaction measures and most focused on patient satisfaction (Blenkiron & Hammill, 2003; Gani et al., 2011; Heckert, Teixeira, & Trindade, 2006; Holikatti et al., 2012; Kantorski et al., 2009; Silva, Bandeira, Scalon, & Quáglia, 2012), followed by that of healthcare providers (De Marco, Cítero, Moraes, & Nogueira-Martins, 2008; Evans et al., 2006;Hannigan, Edwards, Coyle, Fothergill, & Burnard, 2000; Ishara et al., 2014; Pelisoli, Moreira, & Kristensen, 2007; Rebouças et al., 2007). The satisfaction of families was the least studied (Bandeira et al., 2011; Perreault et al., 2011; Santos & Cardoso, 2014; Stengard, Honkonen, Koivisto, & Salokangas, 2000). In recent years, the World Health Organization (WHO, 2001) has encouraged assessments from multiple or integrative perspectives, including the simultaneous participation of all stakeholders: patients, their families, and the workers responsible for providing care. This type of assessment is considered the most appropriate for examining the complexity of these services (Thornicroft & Tansella, 2010; WHO, 2001). We found two studies, an international and a Brazilian one, published in indexed scientific periodicals, simultaneously assessing the satisfaction of patients, their families and mental health service workers, using validated instruments (Camilo, Bandeira, Leal, & Scalon, 2012; Lasalvia et al., 2012). The Brazilian study was conducted in a small service (CAPS I) with the capacity for care delivery and interventions,with a different number of professionals than that of the service assessed in this study. Due to a lack of studies assessing services from multiple perspectives, this study’s objective was to assess the satisfaction of patients, their families, and professionals from a CAPS III.
Method Participants This study’s target population was composed of patients, their families, and the healthcare workers of a CAPS III from a city of approximately 375,000 inhabitants in the Southern region of Brazil. The three samples totaled 235 participants. A non-probabilistic, accidental sampling was used. In this type of sampling, the subjects are recruited based on their presence in specific place and time (Contandriopoulos, Champagne, Potvin, Denis, & Boyle, 1994); in this case, it was days patients attended psychiatric appointments at CAPS. The sample size was determined by statistical computations, seeking a statistical power of 90% (Snedecor & Cochran, 1971). A total of 84 patients with diagnoses of schizophrenia, schizotypal disorders, delirious disorders (F20 to F29), or mood or affective disorders (F30 to F39), participated in the study. The diagnoses were obtained from the service’s medical records and were classified according to the International Classification of Diseases (ICD-10) (WHO,
Resende, K. I. D. S., Bandeira, M., & Oliveira, D. C. R. (2016). Assessment of Satisfaction in a Mental Health Service.
1994).Inclusion criteria were being 18 years old or older, both genders, attending the psychiatric appointment accompanied by a family caregiver, and undergoing treatment at the service for at least three months. This minimum duration of treatment was adopted because, according to Melo and Guimarães (2005), it is shorter than the period in which most patients abandon treatment (four months). Exclusion criteria included severe psychiatric comorbidities, such as the use of psychoactive drugs or alcohol, cognitive deficits, neurological problems and difficulty in understanding the questions contained in the instruments used. The sample of family caregivers was conditioned on the sample of patients, so that one family caregiver was selected for each participant patient. A total of 84 family caregivers were included according to the following inclusion criteria: being 18 years old or older; living in the same residence as the patient; and being the primary caregiver. Family caregivers who found it difficult to understand the instruments’ questions or presented psychiatric disorders, as indicated by the services’ professionals, were excluded. The entire target population working in the service was used to select the professionals at the time of data collection. A total of 67 workers who met the inclusion criteria (having worked in the service for at least six months) were included. Instruments Satisfaction with Mental Health Services Scales (SATIS-BR), versions for patient, family caregiver and staff. These instruments were developed in a multicenter study conducted by the World Health Organization’s Department of Mental Health and validated for Brazil (Bandeira, Mercier, Perreault, Libério, & Pitta, 2002; Bandeira, Pitta, & Mercier, 2000; Bandeira & Silva, 2012). The SATIS-BR/ Patients has 12 items distributed into three subscales: (1) Staff expertise and understanding; (2) Staff ’s helpfulness and the helpfulness of the services received; (3) Service’s appearance and level of comfort. The SATIS-BR/Family caregiver has eight items distributed into three subscales: (1) Results of treatment provided by the service; (2) Staff ’s helpfulness and expertise; and (3) Service’s privacy and confidentiality. The SATIS-BR/Staff has 32 items grouped into four subscales: (1) Quality of services provided to patients; (2) Participation in the service; (3) Working conditions; and (4) Relationship at work. Answers for the three scales are classified on a five-point Likert scale according to the following: 1 = very dissatisfied, 2 = dissatisfied, 3 = regular, 4 = satisfied, and 5 = very satisfied. These five options for answers can be grouped into three categories in which 1 and 2 represent very dissatisfied and dissatisfied, 3 represents moderately satisfied, and 4 and 5 represent satisfied and very satisfied with the aspects under assessment. All the scales present appropriate psychometric qualities. Reliability was verified through internal consistency analysis using Cronbach’s alpha, which presented the following values for the overall scores in each of the scales: SATIS-BR/Patients, .88; SATIS-BR/Family caregivers, .79; SATIS-BR/Staff, .89.
Sociodemographic questionnaires, in three versions, were prepared: one for each of the samples. The questionnaires were developed by LAPSAM (Laboratory of Research in Mental Health) at the Universidade Federal de São João del-Rei (UFSJ), based on the literature in the field. The questionnaires were submitted to a pilot-study intended to assess its adequacy for and comprehension on the part of the populations under study. Procedure Data collection. The interviewers were previously trained to apply the instruments in order to standardize application. The patients and families were informed about the study on the day they attended their psychiatric appointment at CAPS and were invited to participate after it. The instruments were applied in individual interviews held at the mental health service. According to inclusion criteria, only patients accompanied by a family caregiver were interviewed. The Probing Technique was used to verify the level of understanding of both patients and family caregivers regarding the instruments. In this technique, the respondents are asked to explain each of their responses. This allows the interviewers to verify whether the questions were properly understood (Guillemin, Bombardier, & Beaton, 1993). The staff members were contacted at the mental health service and self-administered the instruments during work breaks or at the end of the workday. Data analysis. Data analysis was performed using SPSS, version 20.0. Descriptive statistical analyses were conducted, including means, standard deviations, and percentage to describe the samples and satisfaction scores. Non-parametric tests were used for the statistical analysis of samples. Intragroup analyses were conducted to compare subscales of satisfaction and identify the dimensions that presented the highest scores for each group. For that, the Kruskal-Wallis and multiple comparison tests (Siegel & Castellan, 2006) were used to identify differences among subscales. Ethical Considerations This study was approved by the Institutional Review Board (CEPES) at the Universidade Federal de São João del-Rei (UFSJ, Process n. 023/2013) and by DESA (Board of Education in Health), the agency responsible for the mental health service under study. The participants signed free and informed consent forms. The study’s objectives and procedures were clarified and confidentiality of both participants’ identities and information provided were ensured according to Resolution n. 466, from December 12, 2012, National Council of Health.
Results Description of the Samples The average age for the sample of patients was 43.46 years old, ranging from 20 to 65 years old. Most were women
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(51.20%), single (54.7%), presented incomplete primary or middle school (50%), had no paid job (86.90%), had their own income (63.1%) of 1 times the minimum wage (50.9%), provided by Social Security (34%). In regard to the patients’ clinical characteristics, most were diagnosed in category F20 (69%), presented psychiatric comorbidities (83.3%), and had no physical diseases (64.3%). In regard to the patients’ clinical histories, the average age of the patients at the onset of the psychiatric disorder was 26.55 years old and the duration of treatment was 10.23 years on average. Most had not experienced psychiatric episodes in the last year (53.6%) and were never committed to a psychiatric hospital (73.8%). Among those who had been hospitalized, 40.9% were hospitalized only once. All the patients received psychiatric care with the administration of medication and 39.3% also received psychological support. Most (72.6%) took oral medication and administered the medication themselves. In regard to the sample of family caregivers, the average age was 51.48 years old, ranging from 22 to 84 years old. Most were women (73.8%), married (57.1%), with children (91.7%), were the mothers (41.7%) of patients, while incomplete primary or middle school predominated (46.4%). Most had a paid job (56%), their own income (76.2%), below 2 times the minimum wage (35.9%), and the primary source of income was their jobs (54.7%). In regard to the family caregivers’ conditions of life, most cared for the patients for more than 11 years (59.5%), had some physical disease (60.7%), and reported already feeling ill because of the task of providing care to the patient (65.5%). Most reported other concerns/activities besides caring for the patient (73.8%), having received information regarding the problem presented
by the patient (65.5%), and that the information provided was mostly provided by healthcare providers (92.7%). Most reported they could rely on the mental health service whenever needed (92.7%). In regard to the staff, the average age was 41.28 years old, ranging from 24 to 60 years old. Most were women (70.10%), single (50.70%), were nursing technicians (41.8%), followed by psychiatrists (16.4%) and nurses (11.9%), respectively. Most had from one to five years of experience in the mental health service (52.2%), had a workload of 30 hours (67.2%), and had another paid job (68.7%). Among those with a second job, most considered the mental health service to be the most consuming (58.7%), and had already considered the possibility of changing jobs (47.8%). Analysis of the Level of Overall Satisfaction and by Subscales The overall level of satisfaction manifested by patients and the staff in regard to the service was classified as moderate, with mean scores of 3.69 and 3.14, respectively. The overall mean score obtained by the family caregivers (4.37) indicates this group was satisfied with the service under study. Table 1 presents the results from the Kruskal-Wallis test and multiple comparisons concerning the mean scores obtained by the patients in the satisfaction subscales. The analyses showed statistically significant differences between subscales 1 and 3, and between subscales 2 and 3 (values of the differences between ranks are greater than 28.66), indicating that the patients’ levels of satisfaction varied according to the aspects assessed.
Table 1 Analysis of the Mean Scores Obtained in the Subscales Addressing Patient Satisfaction (SATIS-BR), According to Kruskal-Wallis Test and Multiple Comparisons Multiple Comparisons: Dif = 26.88* Subscale M (SD)
Dif (1-2)
Dif (1-3)
Dif (2-3)
1. Staff expertise and understanding.
3.96 (0.58)
9.62
102.78*
112.4*
2. Helpfulness of the servisse.
4.06 (0.63)
3. Service’s physical conditions.
2.19 (0.98)
Overall scale
3.69 (0.53)
Note. Kruskal-Wallis bilateral test: Chi-square = 123.613; degrees of freedom = 2; p = .000; Dif (1-2) differences between the mean ranks of subscales 1 and 2; Dif (1-3) differences between the mean ranks of subscales 1 and 3; Dif (2-3) differences between the mean ranks of subscales 2 and 3. *Value obtained from the expression of multiple comparisons of Kruskal-Wallis test (Siegel & Castellan, 2006).
The score (3.69) concerning the dimension staff expertise and understanding, assessed by subscale 1, was higher than the service’s appearance and level of comfort, assessed by subscale 3 (2.19). The dimension concerning helpfulness of the service, assessed by subscale 2 presented a higher score (4.06) than the service’s appearance and level of comfort, assessed by subscale 3 (2.19).
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Table 2 presents the results of the analysis of mean scores obtained in the subscales concerning the family caregiver satisfaction (SATIS-BR) using the Kruskal-Wallis test. The comparative analyses showed no significant statistical differences among the subscales (p = .08). All the dimensions presented average scores of 4, indicating that family caregivers were equally satisfied with the service’s various features.
Resende, K. I. D. S., Bandeira, M., & Oliveira, D. C. R. (2016). Assessment of Satisfaction in a Mental Health Service. Table 2 Analysis of the Mean Scores Obtained in the Family Caregiver Satisfaction (SATIS-BR), According to the Kruskall Wallis Test Subscales
M (SD)
p
1. Level of family caregiver satisfaction in regard to the treatment results.
4.45 (0.78)
.088
2. Level of family caregiver satisfaction in regard to the staff ’s expertise and helpfulness.
4.30 (0.74)
3. Level of family caregiver satisfaction in regard to the service’s privacy and confidentiality.
4.34 (0.72)
Overall scale
4.37 (0.64)
Note. Kruskall-Wallis: Chi-square = 4 .857; degrees of freedom = 2; p = .088.
Table 3 presents the results of the analysis of the mean scores obtained by the staff on the subscales (SATISBR) according to the Kruskal-Wallis test and multiple comparisons. The results show statistical differences in regard to the comparisons of all four subscales (p ≤ .05). The mean scores obtained for most subscales (1, 2 and 4) was 3,
indicating regular satisfaction with the service. Subscale 3 (Working conditions) was an exception with a mean score of 2, indicating dissatisfaction with the aspects under study. None of the subscales scored 4 or 5, which would have indicated the staff was satisfied or very satisfied with the aspects under study.
Table 3 Analysis of Mean Scores Obtained in the Subscales Addressing the Staff Satisfactions (SATIS-BR), According to the Kruskal-Wallis Test and Its Multiple Comparisons Multiple Comparisons: Dif = 35.195* Subscales
M (SD)
1. Quality of care delivery.
3.39 (0.56)
2. Participation in the service.
3.11 (0.67)
3. Working conditions.
2.69 (0.53)
4. Relationship at work.
3.87 (0.70)
Overall scale
3.14 (0.48)
Dif (1-2)
(1-3)
(1-4)
(2-3)
(2-4)
(3-4)
29.45
75.21*
44.57*
45.76*
74.02*
119.78*
Note. Kruskal-Wallis bilateral test: Chi-square = 84.988; degrees of freedom = 3; p = .000; Dif (i-j) differences between the mean ranks of subscales i and j; SD = standard deviation. *Value obtained from the expression of multiple comparison of the Kruskal-Wallis test (Siegel & Castellan, 2006).
The scores of professionals in the dimension concerning the quality of services provided (subscale 1) was higher (3.39) than that obtained in the dimension regarding participation in the service (3.11) and working conditions (2.69). The score (3.11) obtained in the dimension of participation in the service (subscale 2) was higher than the score obtained in the dimension concerning working conditions (2.69). The dimension regarding the relationships established among coworkers at the workplace (subscale 4) presented the highest score (3.87) among the four subscales, that is, higher than the quality of the services provided (3.39), participation in the service (3.11), and working conditions (2.69).
Discussion The results showed both convergences and divergences in the dimensions that assessed the level of satisfaction of patients, family caregivers, and the staff of the mental health service. These results reinforce the importance of
assessments addressing the perspectives of these stakeholders (Thornicroft & Tansella, 2010; WHO, 2001). The results concerning the patient sample that indicate moderate overall satisfaction with the service contradict those of international (Blenkiron & Hammill, 2003; Gani et al., 2011; Holikatti et al., 2012) and Brazilian studies (Heckert et al., 2006; Kantorski et al., 2009; Silva et al., 2012), which report high levels of satisfaction. One potential explanation for this difference, especially in comparison to Brazilian studies, may be related to the type of service assessed. This study assessed a large community mental health service (CAPS III), while the other Brazilian studies assessed smaller services (CAPS I). These services differ in regard to their capacity, dimensions, number of interventions implemented and professionals. CAPS III are more complex services because they also have psychiatric hospital beds, provide care to patients during psychiatric episodes, allow brief hospitalizations, have 24-hour clinical support, and night shifts. This diversified supply of services may have
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generated overestimated expectations regarding the quality of service. Part of this expectation may not have been met so that patients’ satisfaction was only regular. The theoretical model Addressing Expectations used to assess satisfaction, especially in the Contrast Model, explains this kind of finding. According to this model, an individual compares his/ her prior expectations with concrete reality when assessing a service. Low satisfaction results when expectations are higher than the service’s performance (Ruggeri, 2010). Another potential explanation is that patients’ conditions were stable at the time of data collection and they were able to properly distinguish the service’s features, which enabled them to critically assess the quality of service provided. Additionally, the Probing Technique used at the time of data collection in this study may have also contributed to increasing the patients’ discriminatory abilities because, in this technique, the patients are asked to justify their responses (Guillemin et al., 1993). The need to present justifications may have contributed to showing the discrepancies between expectations and reality, resulting in a more accurate analysis of this service. The results concerning the sample of family caregivers contradict the findings of two international studies (Perreault et al., 2011; Stengard et al., 2000), which report high levels of dissatisfaction and corroborate Brazilian studies (Bandeira et al., 2011; Camilo et al., 2012; Santos & Cardoso, 2014). The family caregivers presented a high level of overall satisfaction and satisfaction according to the service’s dimensions. The aforementioned Contrast Model may explain this result. The family caregivers addressed in this study tended to compare the mental health service with Immediate Care Units and Healthcare Units. They highlighted the qualities of the mental health service, such as ease of scheduling consultations, closer proximity to the staff, and greater access to care whenever necessary, which contrasts with the difficulties faced in healthcare services in general. This type of comparison is also reported by a Brazilian study (Bandeira et al., 2011); however, the level of satisfaction manifested by the family caregivers may not necessarily indicate a high quality of service. Mental health care services are compared to services with different objectives, different types of patients, and different care delivery. Mental health care services have specific interventions that are not included in the repertoire of activities of healthcare services in general and the family caregivers seemed to have overlooked these elements. The staff expressed moderate level of overall satisfaction in regard to the mental health service under study. These results corroborate Brazilian studies (De Marco et al., 2008; Ishara et al., 2014; Rebouças et al., 2007) and contradict those of international studies reporting high levels of dissatisfaction (Evans et al., 2006; Hannigan et al., 2000). The highest mean score concerned the relationship established with coworkers, while the mean scores concerning the service’s infrastructure and working conditions were the lowest. Other Brazilian studies (De Marco et al., 2008; Ishara et al., 2014; Rebouças et al., 2007) report similar results. This consensus reveals poor working conditions, such as deficient infrastructure, lack of security, and low salaries, which compromise the delivery
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of quality care. None of the subscales addressed in this study obtained scores that indicate the staff was satisfied or very satisfied (scores 4 and 5, respectively), while the subscale concerning working conditions obtained the lowest score in comparison to other Brazilian studies (Camilo et al., 2012; De Marco et al., 2008; Ishara et al., 2014; Rebouças et al., 2007). Being satisfied at work is essential for those working in large services, otherwise their actions cannot be efficient; these professionals provide care to patients experiencing psychiatric episodes on a daily basis, which requires a high level of energy and willingness on the part of the staff. Some similarities were observed in the three samples. The service’s appearance and comfort level caused dissatisfaction among patients and workers. Other Brazilian studies also found moderate or low levels of satisfaction among patients (Camilo et al., 2012; Heckert et al., 2006; Kantorski et al., 2009) and workers concerning this aspect (De Marco et al., 2008; Ishara et al., 2014; Rebouças et al., 2007). These findings may be explained by a lack of public investment in the proper maintenance of these services (Andreoli, Almeida-Filho, Martin, Mateus, & Mari, 2007). The levels of satisfaction of patients and family caregivers differed in regard to the amount of information provided to the patients and families concerning the disease and treatment. The availability and quantity of information should be seen from a psychoeducational perspective, designed to improve quality of life and treatment adherence, so as to encourage autonomy and involvement with the treatment (Perreault, Katerelos, Sabourin, Leichner, & Desmarais, 2001). The information provided this way is more coherent with the principles of the Psychiatric Reform. The family caregivers were satisfied with information received; however, 58% of the patients were moderately satisfied or dissatisfied with this aspect. Other studies (Kantorski et al., 2009; Silva et al., 2012) also found low levels of satisfaction among patients in regard to information received. According to Ruggeri (2010), the quantity and quality of information provided to patients is a predictor of the level of satisfaction. For Perreault et al. (2001), information is one of the dimensions concerning mental health services that determines satisfaction. This study presents some limitations. The samples were not randomly selected from the target population, which limits the generalization of results. Additionally, this is a crosssectional study,thus monitoring how satisfaction behaves at different points in time over the course of the treatment is not possible. Despite these limitations, this study highlights the importance of assessments from multiple perspectives to obtain information that contributes to the improvement of mental health services. This study’s results highlighted the dissatisfaction of patients in regard to the mental health service’s level of comfort, appearance and overall infrastructure and the dissatisfaction of workers in regard to the same aspects and also in regard to working conditions, which agree with the findings of other Brazilian studies. The conclusion is that financial investments are imperative in these services, as is valuing the professionals working in the mental health field. These elements are essential for the Psychiatric Reform to
Resende, K. I. D. S., Bandeira, M., & Oliveira, D. C. R. (2016). Assessment of Satisfaction in a Mental Health Service.
effectively become a public health police capable to enable care delivery, social insertion, active citizenship, and quality of life of those using and working in these services.
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Lei n. 10.216, de 6 de abril de 2001. (2001, 9 de abril). Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental [Provides for the protection and rights of people with mental disorders and redirects the mental health care model]. Diário Oficial da União, seção 1. Melo, A. P. S., & Guimarães, M. D. C. (2005). Factors associated with psychiatric treatment dropout in a mental health reference center, Belo Horizonte. Revista Brasileira de Psiquiatria, 27(2), 113-118. doi:10.1590/ S1516-44462005000200008 Oliveira, M. A. F., Cestari, T. Y., Pereira, M. O., Pinho, P. H., Gonçalves, R. M. D. A., & Claro, H. G. (2014). Processos de avaliação de serviços de saúde mental: Uma revisão integrativa [Assessment procedures of mental health services: An integrative review]. Saúde em Debate, 38(101), 368-378. doi:10.5935/0103-1104.20140034 Organização Mundial da Saúde. (1994). CID-10: Classificação estatística internacional de doenças e problemas relacionados à saúde [International classification of diseases and related health problems statistics] (Centro Colaborador da OMS para a Classificação de Doenças em Português, Trans., 10th ed.). São Paulo, SP: Edusp. Pelisoli, C., Moreira, A. K., & Kristensen, C. H. (2007). Avaliação da satisfação e do impacto da sobrecarga de trabalho em profissionais de saúde mental [Assessment of satisfaction and impact of work overload among mental health professionals]. Mental, 5(9), 63-78. Retrieved from http://pepsic.bvsalud.org/pdf/mental/v5n9/v5n9a05.pdf Perreault, M., Katerelos, T. E., Sabourin, S., Leichner, P., & Desmarais, J. (2001). Information as a distinct dimension for satisfaction assessment of outpatient psychiatric services. International Journal of Health Care Quality Assurance Incorporating Leadership in Health Services, 14(3), 111-120. doi:10.1108/09526860110391586 Perreault, M., Rousseau, M., Provencher, H., Roberts, S., & Milton, D. (2011). Predictors of caregiver satisfaction with mental health services. Community Mental Health Journal, 48(2), 232-237. doi:10.1007/s10597-011-9403-z Rebouças, D., Legay, L. F., & Abelha, L. (2007). Satisfação com o trabalho e impacto causado nos profissionais de serviço de saúde mental [Job satisfaction and work impact among providers of a mental health servisse]. Revista de Saúde Pública, 41(2), 244-250. doi:10.1590/ S0034-89102007000200011 Ruggeri, M. (2010). Satisfaction with mental health services. In G. Thornicroft & M. Tansella (Eds.), Mental health outcome measures (pp. 99-115). London, United Kingdom: RCPsych. Santos, A. F. O., & Cardoso, C. L. (2014). Familiares cuidadores de usuários de serviço de saúde mental: Satisfação com serviço [Family caregivers of mental health service users: Satisfaction with the service]. Estudos de Psicologia (Natal), 19(1), 13-21. doi:10.1590/ S1413-294X2014000100003 Santos, A. M., Cardoso, D. A. J., Vieira, D. P. B., Araújo, F. C., Farias, H. S., Mota, S. P., . . . & Bahia, S. H. A. (2011).
Resende, K. I. D. S., Bandeira, M., & Oliveira, D. C. R. (2016). Assessment of Satisfaction in a Mental Health Service.
Análise dos níveis de satisfação de trabalhadores de saúde mental de um hospital público de referência psiquiátrica em Belém, PA [Analysis of levels of satisfaction of mental health workers of a reference psychiatric public hospital in Belém, PA]. Revista Baiana de Saúde Pública, 35(4), 813-825. Retrieved from http://inseer.ibict.br/rbsp/index. php/rbsp/article/viewFile/256/pdf_69 Siegel, S., & Castellan, J. N., Jr. (2006). Estatística nãoparamétrica para ciências do comportamento [Non parametric statistics for behavioral sciences] (S. I. C. Carmona, Trans., 2nd ed.). Porto Alegre, RS: Artmed. Silva, M. (2014). Satisfação dos usuários com os serviços de saúde mental [User satisfaction with mental health services]. In M. Bandeira, L. A. Lima, & S. Barroso (Orgs.), Avaliação de serviços de saúde mental: Princípios metodológicos, indicadores de qualidade e instrumentos de medida [Mental health services evaluation: Methodological principles, quality indicators and measurement instruments] (pp. 55-86). Petrópolis, RJ: Vozes. Silva, M. A., Bandeira, M., Scalon, J. D., & Quaglia, M. A. C. (2012). Satisfação dos pacientes com os serviços de saúde mental: A percepção de mudanças como preditora [Patients’ satisfaction with mental health services: The perception of changes as predictor]. Jornal Brasileiro de Psiquiatria, 61(2), 64-71. doi:10.1590/S004720852012000200002 Silva, N. D. S., Melo, J. M., & Esperidião, E. (2012). Avaliação dos serviços de assistência em saúde mental brasileiros: Revisão integrativa da literatura [Assessment of mental health services in Brazil: An integrative literature review]. Revista Mineira de Enfermagem, 16(2), 280288. doi:S1415-27622012000200018 Snedecor, G. W., & Cochran, W. G. (1971). Métodos estatísticos [Statistical methods] (J. A. Reinosa Fuller, Trans.). México: Continental. Stengard, E., Honkonen, T., Koivisto, A. M., & Salokangas, R. K. R. (2000). Satisfaction of caregivers of patients with schizophrenia in Finland. Psychiatric Services, 51(8), 1034-1039. doi:10.1176/appi.ps.51.8.1034 Tessler, R. C., & Gamache, G. (2000). Family experiences with mental illness. Westport, CT: Greenwood. Thornicroft, G., & Tansella, M. (2010). Boas práticas em saúde mental comunitária [Better mental health care] (M. T. Muramoto, Trans.). Barueri, SP: Manole. World Health Organization. (2001). The world health report: 2001: Mental health: New understanding, new hope. Geneva, Switzerland: WHO. Kênia Izabel David Silva de Resende is a M.S. in Psychology from Universidade Federal de São João del-Rei and a Professor of the Centro Universitário de Lavras (UNILAVRAS). Marina Bandeira is a Professor of the Universidade Federal de São João del-Rei. Daniela Carine Ramires Oliveira is a Professor of the Universidade Federal de São João del-Rei.
Received: Feb. 18, 2015 1st Revision: July 8, 2015 Approved: Sep. 2, 2015
How to cite this article: Resende, K. I. D. S., Bandeira, M., & Oliveira, D. C. R. (2016). Assessment of patients, families and staff satisfaction in a mental health service. Paidéia (Ribeirão Preto), 26(64), 245-253. doi:10.1590/1982-43272664201612
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Paidéia may-aug. 2016, Vol. 26, No. 64, 255-263. doi:10.1590/1982-43272664201613
Article
Uncovering Interaction Structures in a Brief Psychodynamic Psychotherapy1 Fernanda Barcellos Serralta1 Universidade do Vale do Rio dos Sinos, São Leopoldo-RS, Brazil Abstract: Interaction structures refers to the repetitive ways of interaction between the patient-therapist dyad over the course of treatment. This construct is operationalized by the repeated application of the Psychotherapy Process Q-Set (PQS) to psychotherapy sessions. Studies in this line of research have so far focused only on long-term treatment. The present study examines whether interaction structures can be detected empirically in short-term psychotherapies. All sessions (N = 31) of a successful case of brief psychodynamic psychotherapy were coded with the Psychotherapy Process Q-Set (PQS). The application of Q type factor analysis procedures with varimax rotation revealed five interaction structures: resistance, alliance, facing depression, expectation of change, and introspection and hearing. The analysis of variation of these structures over the course of the treatment showed that these interactions are nonlinear, may be positively or negatively protruding in different sessions, or be predominant at some treatment phase. Keywords: brief psychotherapy, psychotherapeutic processes, psychoanalytic psychotherapy
Desvelando Estruturas de Interação em uma Psicoterapia Psicodinâmica Breve Resumo: Estruturas de interação designam os funcionamentos repetitivos da díade paciente-terapeuta ao longo do tratamento. O constructo é operacionalizado pela aplicação repetida do Psychotherapy Process Q-Set (PQS) às sessões de psicoterapia. Estudos nesta linha de investigação até agora focalizaram somente tratamentos de longa duração. Esta investigação examina se estruturas de interação podem ser detectadas empiricamente em psicoterapias breves. Todas as sessões (N = 31) de um caso bem-sucedido de psicoterapia psicodinâmica breve foram codificadas com o PQS. A aplicação de análise fatorial do tipo Q com rotação varimax revelou cinco estruturas de interação: resistência, aliança, enfrentado a depressão, expectativa de mudança, e introspecção e escuta. A análise da variação destas estruturas ao longo do tratamento mostrou que as mesmas não são lineares, podem estar positiva ou negativamente salientes em diferentes sessões, ou predominar em alguma etapa do tratamento. Palavras-chave: psicoterapia breve, processos terapêuticos, psicoterapia psicanalítica
Descubriendo Estructuras de Interacción en una Psicoterapia Psicodinámica Breve Resumen: Estructuras de interacción designan los patrones repetitivos de interacción de la díada cliente-terapeuta durante el tratamento. El constructo se operacionaliza mediante la aplicación repetida del Psychotherapy Process Q-Set (PQS) a las sesiones de psicoterapia. Los estudios esta línea de investigación hasta ahora se centraron sólo en tratamientos de largo plazo. Esta investigación examina si las estructuras de interacción se pueden detectar empíricamente en psicoterapias breves. Todas las sesiones (N = 31) de un caso exitoso de psicoterapia psicodinámica breve se codificaron con el Psychotherapy Process Q-Set (PQS). La aplicación del análisis factorial del tipo Q con rotación varimax reveló cinco estructuras de interacción: resistencia, alianza, enfrentando la depresión, expectativa de cambio, y introspección y escucha. El análisis de la variación de estas estructuras durante el tratamiento mostró que las interacciones no son lineares, pueden ser positiva o negativamente sobresalientes en diferentes sesiones, o predominar en alguna etapa del tratamiento. Palabras clave: psicoterapia breve, processos terapéuticos, psicoterapia psicoanalítica
Explaining the process of change in psychotherapy is a common challenge for clinicians and researchers. However, in the ambit of psychodynamic psychotherapies, the hiatus between practice and empirical investigation is clear. Psychotherapists and researchers seem to inhabit different universes, there being little synergy between the two fields (Fonagy, 2004; Kernberg, 2015). Although psychoanalytical concepts and treatments have solid empirical support, few psychotherapists are familiar with the studies undertaken in this approach (Shedler, 2010). We believe that researchers must prioritize empirical methods which are capable of capturing the complexity of the phenomena Support: National Council for Scientific and Technological Development (CNPq Grant # 401268/2011-0) and Foundation for Research Support of the State of Rio Grande do Sul (FAPERGS Grant # 12/1551-6). 2 Correspondence address: Fernanda Barcellos Serralta. Rua Alfredo Shuett, 927, Três Figueiras. CEP 91330-120. Porto Alegre-RS, Brazil. E-mail: fernandaserralta@gmail.com 1
Available in www.scielo.br/paideia
which characterize the therapeutic encounter, such that they may respond to questions relevant to the psychoanalytical clinical practice. In this article, we highlight the potential of the Psychotherapy Process Q-Set (PQS; Jones, 2000) for producing relevant knowledge regarding the therapeutic process in individual cases. The PQS (Jones, 2000) is a Q-sort type instrument which provides quantifiable descriptions of the behaviors and attitudes of the therapist, of the patient, and of the interaction between both in the therapeutic session. This instrument has already been adapted for various languages and has been used for over 25 years to study the therapeutic process in different approaches of psychotherapy. Studies with the PQS follow two distinct, but complementary, lines: that of the prototypes, which adopts a nomothetic perspective for examining the relationship between the adherence of psychotherapies to ideal models (constructed through the responses to the items of the PQS of experts
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from different theoretical orientations) and the results of the treatment; and that of the interaction structures, which adopts an ideographic perspective for revealing the ways in which the patient and therapist interact over the course of the treatment (Smith-Hansen, Levy, Seybert, Erhardt, & Ablon, 2012). Interaction structures constitute patterns of interaction of the dyad which occur during psychotherapy, sometimes, without the patient and/or therapist consciously noticing. The concept is part of a model of therapeutic action which seeks to overcome the interpretation/insight versus relationship dichotomy which has, sometimes, divided clinicians and researchers of psychoanalytic orientation. The construct, which integrates other concepts such as that of enactment, intersubjectivity and role-responsiveness is operationalized empirically through the repeated application of the PQS to the sessions of a psychotherapy (Jones, 2000). The interaction structures are an essential part of the process and contribute to facilitating or impeding the therapeutic process (Ablon & Jones, 2005). Through the application of Q type factor analysis procedures to the codifications of the therapeutic process undertaken using the PQS, various single and multiple case studies have identified interaction structures in long-term psychodynamic psychotherapies (Jones, Ghannam, Nigg, & Dyer, 1993; Jones & Price, 1998; Pole & Jones, 1998) and also in psychoanalysis (Ablon & Jones, 2005). Generally speaking, these revealed a limited number of factors (between 3 and 5), including both patterns which are unique to the specified dyad and patterns which are repeated in various cases (Goodman, Edwards, & Chung, 2014). One search carried out by ourselves in the main psychotherapy databases (PsycINFO and PubMed) confirmed that, at the time of writing, there are no studies on interaction structures derived from PQS in brief psychotherapies. Specifically, we do not, therefore, know with certainty whether the above-mentioned patterns also occur in shortterm psychotherapies. Hence, this exploratory study seeks to examine the presence of interaction structures in a short term psychotherapy. Specifically, its objective is to describe which interaction structures characterize the process, and to ascertain how these structures vary over the course of the treatment.
Method This is a systematic single-case study (Edwards, 2007). The case is that of the psychotherapy of Maria (fictitious name), already analyzed with the aim of investigating the effects of the adherence to prototypes regarding the results of the psychotherapy (Serralta, Pole, Nunes, Eizirik, & Olsen, 2010). In the present reanalysis, the ideographic perspective of the interaction structures will be adopted.
clinic. The treatment planning included the elaboration of past bereavements with the aim of helping Maria to face major heart surgery which was necessary, but which she had been refusing. The psychotherapy was successful. At the end of the treatment, Maria presented clinically significant and reliable change, according to Jacobson & Truax’s Reliable Change Index (RCI; 1991), in social adjustment (Social Adjustment Scale, SAS; Weissman, Prusoff, Thompson, Harding, & Meyers, 1978), in the symptoms of depression (Beck Depression Inventory, BDI; Beck & Steer, 1993), somatization and anxiety, as well as in general psychological distress (Symptom Checklist 90 Revised, SCL-90-R; Derogatis & Savitz, 2000). The gains were maintained in the eight weeks of follow-up (Serralta et al., 2010). Instruments The Psychotherapy Process Q-Set - PQS (Jones, 2000) is an instrument of the Q-sort type. The Q method was invented in the 1930s by William Stephenson in order to study subjectivity in the perspective of the subject herself, this being adapted in the 1960s by Jack Block to be applied by external judges. A Q set is made up of a series of statements which describe a specified condition or situation, which must be ordered in terms of their greater or lesser relevance to the person who is being assessed. This ordering is ipsative, that is, each item is compared in relation to the others, and not in relation to any external criteria. The PQS has 100 items which express the attitudes, behaviors or experience of the patient, the therapist, and the interaction between the two. It is a holistic measurement of the process, which has, as its unit of analysis, the therapeutic session recorded on audio and/or video. After examining the session, judges order the items on a nine point scale which varies from the extremely characteristic (category 9) to the extremely uncharacteristic. The number of items to be arranged in each pile is fixed, following the normal curve. There are two ways of carrying out this ordering: on a worktable, with the help of printed cards, or using an electronic database of the Excel type, developed specifically for this end. In any one of the situations, training is necessary to apply the instrument. The original version of the PQS has good inter-rater reliability, construct validity and discriminant validity (SmithHansen et al., 2012). The factorial validity is irrelevant, as measurements of the Q sort suppose independence between the items. The Brazilian version of the PQS and of its manual were developed by Serralta, Nunes and Eizirik (2007). It is culturally equivalent to the original instrument, and presents good inter-rater reliability (Serralta et al., 2007), as well as being able to distinguish between treatments with different theoretical orientations (Serralta, 2014). Procedure
Participants The patient (Maria) is an adult woman, with higher education, who sought psychotherapeutic attendance due to complaints of anxiety and depression. The therapist is a psychotherapist with training in psychoanalytically oriented therapy and over seven years’ clinical practice. The case is of a brief psychotherapy of 31 sessions attended in a private
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Data collection. The 31 psychotherapy sessions were recorded on audio, transcribed in full, and codified using the PQS by pairs of independent judges. When the reliability between raters was not considered satisfactory (r ≤ .5), a third rater was added. The average scores of the two judges in agreement for each item of the PQS in the session formed the composite score which was used in the subsequent analyses. As already
Serralta, F. B. (2016). Interaction Structures in Brief Psychotherapy.
mentioned, various outcome measures were systematically applied during the course of the treatment. These instruments and procedures are not described here, as the present study does not describe the progress and the outcome of the treatment. Data analysis. The first stage of the analysis involves the description of the process’s general characteristics, obtained through the identification of the most and least characteristic items of the PQS in the treatment sessions. Based in this result, a narrative was made which characterizes the general process. In this, when the item’s score is in the uncharacteristic or negatively salient end of the scale, the item’s number is followed by the letter ‘r’, to indicate that the reverse of the item was used. The next step was to submit the assessments of the 100 items of the PQS in each one of the 31 treatment sessions to a Q type factor analysis of principal components, with varimax rotation in order to identify the sets of items which most explain the variance in the process of therapy, that is, the patient-therapist interaction structures. The Q methodology was created for the systematic study of human subjectivity. Its characteristics can be better understood in comparison with the more known methods of data analysis, generically termed as the R method, in reference to the Pearson product-moment correlation coefficient. The R methods seek to establish relationships between variables in a sample of people. In the Q methodology, on the other hand, the sample constitutes not a population of people, but a population of points of view. As a result, differently from what occurs in the R methods, in the Q methodology, the researchers are interested in examining the relationships between a large set of data (variables which reflect distinct perceptions, opinions, experiences or processes) in a single subject or in a small number of subjects. The Q set is the items which are ordered. The P set corresponds to the respondents who will undertake the ordering. The P set is always smaller than the Q set. Typically, the analysis and interpretation of data includes the calculation of the correlation matrix of all the orderings (Q-sorts) obtained. This represents the degree of agreement or disagreement between the respondents’ points of view. The following step is generally the application of the procedure of factor analysis, in order to identify the natural groupings of orderings. In this way, people who share the same point of view are in the same factor (Van Exel & Graaf, 2005). In using the PQS to examine the process of a single case of psychotherapy, we adopt the perspective of external raters (judges) in order to describe what occurs in each treatment session. In the examination of the therapeutic process, it is not the characteristics of different people which are being evaluated, but, rather, the multiple sessions of a single therapeutic process which is systematically examined with repeated applications of the same Q set of variables. Thus, in this case, for each session one obtains an ordering (calculated using the average individual orderings undertaken by two or more external judges). The set of sessions which makes up the process of the psychotherapy corresponds to the P set, that is, the sessions are the units of analysis. The correlation matrix identifies the processes which stand out positively or negatively in the sessions. The factor analysis serves to identify the natural groupings of variables of the patient and of the therapist, which make up the psychotherapy. These groupings or factors represent the interaction structures. In the present study, the best solution found was that of five factors. The reliability of each factor (interaction structure) was
ascertained using the Cronbach alpha coefficient. As some items of the PQS have a negative relationship with the factor, these items were inverted for calculating the means of the factors in each session. The variation of the factors over time was examined visually using a scatterplot. All the statistical procedures were undertaken using the SPSS software, version 21.0. Ethical Considerations The protocol of the case study of Maria’s psychotherapy was approved in the Ethics Committee of the Universidade Federal do Rio Grande do Sul (CEP UFRGS, n. 03129). The reanalysis of this case was authorized by the Research Ethics Committee of the Universidade do Vale do Rio dos Sinos (CEP UNISINOS, n. 11/133). The psychotherapy sessions were recorded using audio, with the participants’ authorization, obtained through the terms of free and informed consent.
Results The general description of the therapeutic process of Maria’s psychotherapy is based in the ten most and least characteristic items of the PQS in the set of the treatment sessions (N = 31). One must remember that the least characteristic items are equally relevant for the description of the process, as they represent what it is in this that is negatively salient. In addition to this, the meaning of the reverse item is not always the opposite of the original item, as it may have various meanings. For this reason, the items will be described in such a way as to respect their meaning in the context of the interaction in question. Generally speaking, the treatment sessions have a specific focus (PQS 23), the predominant themes being health (PQS 16) and the situations of the patient’s current or recent life (PQS 69). The patient expressed herself clearly and in an organized way (PQS 54), was committed to the therapeutic work (PQS 73), collaborated with a therapist (PQS 87 r), and brought significant issues and material to the session (PQS 88). The patient did not present difficulties for initiating the sessions (PQS 25 r) and, in reality, tended to initiate the topics actively (PQS 15). She did not show resistance to examining thoughts, reactions and motivations related to her problems (PQS 58 r). Silences occurred frequently (PQS 12), possibly reflecting the patient’s tendency for introspection and for the exploration of her internal world The therapist communicated clearly and coherently (PQS 46) and was easily understood by the patient (PQS 5 r). The therapist demonstrated sensitivity and tact in dealing with the patient (PQS 77 r) and seemed to be emotionally involved in the process (PQS 9 r), accepting the patient without being critical (PQS 18). The patient, in her turn, felt understood (PQS-14 r), confident and secure in the interaction (PQS 44 r), and tended to accept the therapist’s comments and observations (PQS 5 r). In this process, through the application of the Q type factor analysis of principal components, we found five factors (interaction structures) which, together, explained 46.31% of the variance. These are: 1 – Resistance, 2 – Alliance, 3 - Facing depression, 4 - Expectation of change, and 5 Introspection and hearing.
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The interaction structure Resistance (alpha of .86) explained 12.22% of the variance of the therapeutic process, and is made up of 15 items with factor loadings between -.757 and .652. The items which make up this interaction
structure, and its respective factor loadings, are presented in Table 1. The mean score of this interaction structure was 4.67 (SD = 0.77), with scores varying between 3.53 (session 17) and 6.37 (session 24).
Table 1 Resistance Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation PQS Items
FL
PQS 68: Real vs. fantasized meanings of experiences are actively differentiated
-.757
PQS 40: T makes interpretations referring to actual people in the P’s life
-.668
PQS 5: P has difficulty understanding the T’s comment
.652
PQS 87: P é controlling
.645
PQS 82: P’s behavior is reformulated by the T
-.635
PQS 29: P talks of wanting to be separate or distant from someone
.585
PQS 80: T presents a specific experience or event in a different perspective
-.542
PQS 69: P’s current or recent life situation is emphasized in the session
.541
PQS 71: P s self-accusatory; expresses shame or guilt
.539
PQS 56: P discusses experiences as if distant from his or her feelings
.533
PQS 92: P’s feelings or perceptions are linked to situations of the past
-.531
PQS 96: There is discussion of scheduling of hours, or fees
.529
PQS 34: P blames others, or external forces, for difficulties
.508
PQS 18: T conveys a sense of non-judgmental acceptance
.493
PQS 58: P resists in examining thoughts, reactions or motivations Note. FL = factor loading, P = patient, T = therapist.
.492
The interaction structure “Alliance” (alpha of .85) explained 11.78% of the variance of the therapeutic process, and is made up of 16 items with factor loadings between .790 and .843. The items which make up this interaction
structure, and its respective factor loadings, are presented in Table 2. This interaction structure’s mean score was 4.26 (SD = 1.07), with scores varying between 2.97 (session 6) and 6.56 (session 18).
Table 2 Alliance Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation PQS Items
FL
PQS 51: T condescends to or patronizes the patient
.843
PQS 93: T is neutral
-.790
PQS 24: T’s own emotional conflicts intrude into the relationship
.763
PQS 28: T accurately perceives the therapeutic process
-.733
PQS 81: T emphasizes patient feelings
-.722
PQS 27: T gives explicit advice or guidance
.651
PQS 37: T behaves in a teacher-like (didactic) manner
.623
PQS 32: P achieves a new understanding or insight
-.613
PQS 6: T is sensitive to the patient's feelings; empathic
-.611
PQS 15: P does not initiate or elaborate topics
.600
PQS 49: P experiences ambivalent or conflicted feelings about T
.576
PQS 77: T is tactless
.559
PQS 17: T actively exerts control over the interaction
.521
PQS 42: P rejects T’s comments and observations
.511
PQS 14: P does not feel understood by T
.507
PQS 66: T is directly reassuring
.507
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Serralta, F. B. (2016). Interaction Structures in Brief Psychotherapy.
The interaction structure Facing depression (alpha of .78) explained 9.19% of the variance of the therapeutic process, and is made up of 13 items with factor loadings between .674 and .726. The items which make up this interaction structure
and its respective factor loadings are presented in Table 3. This interaction structure’s mean score was 5.74 (SD = 0.74), with scores varying between 3.96 (session 28) and 6.96 (session 21).
Table 3 Facing Depression Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation PQS Items
FL
PQS 16: There is discussion of physical symptoms, or health
.726
PQS 67: T draws P’s attention to unconscious wishes, feelings, or ideas
-.674
PQS 36: T points out P’s defenses
-.639
PQS 76: T suggests that P accept responsibility for his or her problems
-.625
PQS 89: T acts to strengthen the P’s defenses
.624
PQS 83: P is demanding
.610
PQS 2: T draws attention to P’s non-verbal behavior
.602
PQS 23: Dialogue has a specific focus
.592
PQS 94: P feels sad or depressed (vs. joyous or cheerful)
.582
PQS 62: T identifies a recurrent theme in the P’s experience or conduct
-.576
PQS 54: P expresses himself or herself in a clear and organized fashion
.544
PQS 98: The therapy relationship is a focus of discussion
-.533
PQS 47: When the interaction with the P is difficult, the T accommodates
.507
The interaction structure Expectation of change (alpha of .64) explained 7.14% of the variance of the therapeutic process, and is made up of 6 items with factor loadings between .713 and .718. The items which make up this
interaction structure and its respective factor loadings are presented in Table 4. This interaction structure’s mean score was 4.66 (SD = 0.84), with scores varying between 3.17 (session 13) and 6.92 (session 3).
Table 4 Expectation of Change Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation PQS Items
FL
PQS 4: The P’s treatment goals are discussed
.718
PQS 61: P feels shy and embarrassed (vs. unselfconscious and assured)
-.713
PQS 94: P feels sad or depressed (vs. joyous or cheerful)
-.679
PQS 26: P experiences discomforting or troublesome (painful) affect
-.676
PQS 55: P conveys positive expectations about therapy
.669
PQS 59: P feels inadequate and inferior (vs. effective and superior)
-.617
The interaction structure Introspection and hearing (alpha of .68) explained 5.99% of the variance of the therapeutic process, and is made up of 3 items with factor loadings between .547 and .507. The items which make up
this interaction structure and its respective factor loadings are presented in Table 5. This interaction structure’s mean score was 6.43 (SD = 0.81), with scores varying between 4.67 (session 15) and 7.83 (session 20).
Table 5 Introspection and Hearing Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation PQS Items
FL
PQS 97: P is introspective, readily explores inner thoughts and feelings
.547
PQS 50: T draws attention to feelings regarded by the P as unacceptable
.524
PQS 35: Self-image is a focus of discussion
.507
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Discussion This study is the first to investigate the presence of interaction structures detected empirically by the PQS in a brief psychotherapy. The results found demonstrate that in this therapeutic modality, the patient and therapist establish repetitive patterns of interaction and relationship, as in the example of what happens in long-term psychotherapies (Jones et al., 1993; Jones & Price, 1998; Pole & Jones, 1998) and in psychoanalysis (Ablon & Jones, 2005). Hence, independently of the frequency or duration of the psychotherapy, the set of the studies undertaken in this line of investigation shows that each therapeutic pair interacts repeatedly in different ways over the course of a single treatment. This conception of the therapeutic process presupposes that patient and therapist influence each other mutually, which is in accordance with the intersubjective orientation dominant in the most up-todate schools and psychoanalytic currents (Bohleber, 2013). Technique and relationship are only artificially disassociated. In this regard, we agree with the premise of McAleavey and Castonguay (2015), that the specific and common factors most probably function in a symbiotic (or even parasitical) way. Our hypothesis is that these two modes of therapeutic action are interdependent and, therefore, are unlikely to produce change in isolation. The global description of Maria’s treatment, undertaken through the PQS, shows high levels of collaboration between a patient who was inclined to explore her internal world and an empathetic therapist. In this process, five interaction structures were found, which represent the distinct means of patienttherapist interaction which characterized the psychotherapy. The structure Resistance covers not only the patient’s attitudes which are opposed to the process of change, but also the patient’s mental states, the attitudes of her therapist, and specific characteristics of the therapeutic dialog. The patient’s negative feelings predominate in this, in particular the self-accusations (shame and guilt). Such manifestations are accompanied by the therapist’s attitudes of non-critical acceptance and formulation of more general interpretations. One can note, however, that, taking into account the Q scale of 9 points, the resistance was present, predominantly in a slightly negative way, in the process (M = 4.67; SD = 0.77), indicating the presence of a collaborative work directed towards the examination of the patient’s internal world. Small amounts of resistance, accepted and understood by the therapist, were present in various sessions of Maria’s treatment and may indicate the therapeutic work underway, as helping the patient overcome inevitable resistance is essential work of the psychodynamic therapist. Resistance entails varying levels of ambivalence on the part of the patient in relation to change, which are, to a large extent, determined by the quality of the therapeutic relationship. The results of studies suggest that more empathetic and supportive therapists help their patients to reduce the levels of resistance (Ribeiro et al., 2014). This seems to have occurred in Maria’s treatment. The second structure, Alliance, seems to be compatible with the notion of ruptures and repairs in the therapeutic alliance. Ruptures in the therapeutic alliance are episodes of
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tension or breaks in the collaborative work being undertaken by the patient-therapist pair. Repairs in the ruptures in the alliance are associated with positive results in psychotherapy (Safran, Muran, & Eubanks-Carter, 2011). Considering the outcome of the case studied, in conjunction with the elements which are more characteristic of the global process, and with the visual inspection of this structure’s variation in the process, what is ascertained is the existence, in a general way, of a collaborative work supported by a solid therapeutic alliance, although, on average, the alliance was slightly negative (M = 4.26; SD = 1.07). It is not the presence of ruptures that is associated with negative outcomes in psychotherapy, but rather the non-resolution of these. In the case of Maria, it is only in a few sessions that the conflict in the dyad is slightly characteristic (as in session 18, which presented the highest score in this interaction structure). In the majority of sessions, what was observed was this structure’s negatively salient presence, which indicates a positive interaction marked by empathy, sensitivity and neutrality on the part of the therapist, accompanied by the feeling on the part of the patient that she was being heard and understood, as her feelings were explored, favoring new insights. As is known, brief psychotherapies are generally focal. Among their central characteristics, emphasis is placed on the work geared towards the expression of emotions, the exploration of the defenses to avoid thoughts and feelings, the identification of repetitive patterns of functioning and the relationship between the present and past (Abbass et al., 2014). The third interaction structure found, Facing depression, was positively present in a large majority of the sessions at a slight or moderate level and depicts the central theme related to the patient’s issue (health problems) and the efforts made by the therapist in adjusting to her depressive functioning, pointing out aspects of the nonverbal behavior and promoting or reinforcing more adaptive defenses, instead of interpreting unconscious defenses and desires. It is possible that the choice of this strategy may have occurred in order not to further disturb the patient, as the predefined limitation of the therapy time, and the patient’s need to have the operation, are elements of the context which seems to contra-indicate, in this case, a deeper analysis of the unconscious determinants of her psychopathology. In this regard, when Maria showed herself to be more depressed, the therapist tended to adopt a more supportive stance. This stance is consistent with the recommendation that, when the patient’s health capacities are more compromised, the psychotherapist must prioritize strategies which promote the strengthening of the alliance and the resources of the ego (Barber, Muran, McCarthy, & Keefe, 2013). The fourth structure found, Expectation of change, was, in general, slightly low (M = 4.66; SD = 0.84). The visual inspection revealed that this interaction structure had its highest scores in the initial sessions of the psychotherapy. In this interaction structure, the patient’s positive feelings, and her optimism in relation to the therapy’s progress, are evident. Both – patient and therapist – work focused on the objectives established for the treatment. The expectation of change, and the optimism in relation to the therapeutic results, are generic factors which are indicative of therapeutic success
Serralta, F. B. (2016). Interaction Structures in Brief Psychotherapy.
(Krause et al., 2006), in particular when present in the initial phase of treatment. In this context, expectation of change and therapeutic alliance are practically indistinguishable, principally when one considers the affective-relational component of the alliance (Hersoug, Høglend, Gabbard, & Lorentzen, 2013). The last interaction structure found was Introspection and hearing. Of the interaction structures which characterize Maria’s therapeutic process, this was the one which was the most positively salient and constant (M = 6.43; SD = 0.81). In this mode of interaction, the therapeutic work seems to be taking place in a fluid way: the patient explores her internal world, the therapist helps the patient to become aware of avoided feelings, and the dialog concentrates on the patient’s view of herself. The exploration, through introspection, of unconscious aspects or aspects which are unknown by the self itself, is the basis of the work of the patient in psychoanalytic therapy, being the examination of the attempt, on the part of the patients, to avoid disturbing thoughts and feelings – which is one of the specific factors of the psychodynamic technique (Shedler, 2010). We understand that this interaction structure represents the psychodynamic factor of the therapeutic process in question. It is possible that its striking presence in Maria’s treatment may be an explanatory factor for the significant changes that the patient presented at the end of her treatment and during the follow-up undertaken. It is emphasized, however, that the psychodynamic factor cannot be considered independently of the other factors of the process. Combinations of significant interventions and support interventions, which are characteristic of the brief psychodynamic psychotherapies (Town, McCullough, & Hardy, 2012; Yoshida, 2012), were found in Maria’s case. Although the identification of the mechanisms of therapeutic action still represents a challenge for researchers, there is evidence that psychotherapists’ flexibility to provide interventions which are adjusted to their patients is beneficial for the results of the psychodynamic psychotherapies (Owen & Hilsenroth, 2014). This seems to have occurred in this case. Through the analysis of the case of Maria, this study presented and illustrated the concept of interaction structure and its operationalization, through the application of Q type factor analysis to the evaluations of the therapeutic process obtained with the PQS. Generally speaking, the study showed that it is possible to identify patient-therapist interaction structures in brief psychotherapies, using empirical procedures previously consolidated in the study of the process of long-term psychotherapies. The structures found reflect the different modalities of patient-therapist relationship which are expressed over the course of the treatment. The analysis of the variation of these structures in Maria’s treatment indicates that the modes of interaction are not linear and can be positively or negatively salient in different sessions (such as “resistance”, for example), or predominate at some stage of the treatment (such as “expectation of change”, for example). In this successful process of brief psychodynamic psychotherapy, the more accentuated and constant presence of Introspection and hearing suggests that this mode of interaction was the driving force for the therapeutic action.
However: without the analysis of the contribution of the different interaction structures found to treatment progress and results – by using time series analysis, for example – it cannot be asserted whether and how this or other structures have contributed to the outcome of the psychotherapy. As this is a case of a brief psychotherapy, Maria’s case has a small number of sessions. Although the Q method ensures the normality of the data due to the ipsative scale used, the results of the statistical analyses must be interpreted with some caution, bearing in mind the low number of observations made. Nevertheless, all the sessions were examined, rather than a sample of them. The interaction structures revealed in the study showed clinical validity (they are easily interpretable in the context of the case examined) and are consistent with the global description of the process obtained using the PQS. The replication of the study and other psychotherapies could help to better understand its unique processes, as well as the processes which are common to various cases. We believe that this study, when examined together with those already undertaken with long-term psychotherapies, shows that therapist and patient influence each other mutually and develop modes of interaction which are repeated over the course of the treatment. As a consequence, we consider that studying an isolated aspect of the process (for example, a specific intervention such as interpretation) in relation to another (for example, the patient’s emotional states) can lead to the false premise of a direct influence of one element of the dyad on the other. On the other hand, examining the nature of the dyad’s interaction, one breaks with the patient and therapist dichotomy and extends the ability to understand what takes place in the privacy of the therapeutic encounter. In this way, it is possible to distinguish the “live” process, this shared field or space which is created and re-created by both, patient and therapist, in relationship to each other.
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M. P. Yoshida (Orgs.), Psicoterapias breves nos diferentes estágios evolutivos [Brief psychotherapies in different evolutionary stages] (pp. 1-17). São Paulo, SP: Casa do Psicólogo. Fernanda Barcellos Serralta holds a Ph.D. in Psychiatry from Universidade Federal do Rio Grande do Sul and is a Professor at Universidade do Vale do Rio dos Sinos (UNISINOS). Received: Mar. 24, 2015 1st Revision: Aug. 1, 2015 Approved: Aug. 27, 2015
How to cite this article: Serralta, F. B. (2016). Uncovering interaction structures in a brief psychodynamic psychotherapy. Paidéia (Ribeirão Preto), 26(64), 255-263. doi:10.1590/198243272664201613
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- Word file with the manuscript; - Declaration of Responsibility and Assignment of Copyright (available in http://www.ffclrp.usp.br/divulgacao/ paideia/ttdaEN-US.pdf, scanned and signed by all authors). Portuguese version available in http://www.ffclrp.usp.br/ divulgacao/paideia/ttda.pdf and Spanish version available in http://www.ffclrp.usp.br/divulgacao/paideia/ttdaES-ES.pdf; - Digital file with IRB approval (when the research involves human beings), in accordance with section III of these guidelines. Manuscripts submitted online received a numerical identification protocol. Paidéia fully adopts the publication standards of the Publication Manual of the American Psychological Association (6th edition, 2010). It is important to observe some steps before submitting the manuscript: (1) carefully revise the text for grammatical correction, typos and bibliographic errors, also considering the items included in the submission; (2) check whether all requisites of the Publication Guidelines were complied with. When submitting online, the manuscript should be submitted to Paidéia in one of the following languages: Portuguese, English or Spanish. Texts should be formatted as follows: double lining (distance of 1 cm between lines), justified, in font Times New Roman, size 12, across the text, especting the page limit. The manuscript should be number as from the title page, which will receive page number 1. The A4 format should be adopted, with 2.5cm margins (upper, lower, left and right) and indentation of the first line of the paragraph: tab = 1.25cm. The presentation of the papers has to follow a specific order, considering: 1. Title page without personal data, including: 1.1. Full title in Portuguese, not exceeding 12 words; 1.2. Full title in English, compatible with the Portuguese version; 1.3. Full title in Spanish, compatible with the Portuguese version; 1.4. Suggested running title in English, not exceeding 50 characters (including letters, punctuation and spaces). Attention: As the manuscript is submitted to blind review, the authors are responsible for checking that there are no elements capable of identifying them in any part of the text. Paidéia is not responsible for procedures by authors who do not comply with this guideline. The author’s name should be removed from the file properties, using the tool “Properties”, in the file menu of MS Word, and from any other part of the submitted manuscript. No attachments and appendices will be accepted, nor colored illustrations, reproductions of photographs, shadowed tables or footnotes in the text. Reproduction of any part of published Works will only be permitted if accompanied by the authors’ authorization for publication in Paidéia. In case of approval, papers will be published in the full version in English (in print and online). In other words, for publication, the authors have to provide for the translation of the manuscript (as approved) to English and cover the costs of this translation. To guarantee the quality and uniformity of texts translated into English, only accredited translators are allowed to perform these translations. The Committee of Accredited
Translators comprises highly qualified professionals with proven experience in scientific translations. 2. Abstract, in Portuguese. The abstract limit is 150 words. In case of research reports, the abstract should include: a short description of the research problem, purpose, relevant sample characteristics, data collection method, results and conclusions (or final considerations for qualitative studies). Final considerations should present the implications or applications of the produced knowledge. For research reports, the method should provide consistent information about the participants, instruments and procedures used. Only the most important results, which respond to the research purposes, should be mentioned in the abstract. No references should be included. The abstract has to be followed by three to five keywords for indexation, which should accurately classify the paper, permitting a fast recovery with similar papers in case of a bibliographic research. Keywords have to be selected through the instrument available at: http://www.bvs-psi.org. br/ – consult: Terminologies and Psi Terminology, where the Vocabulary of Terms in Psychology is available. Abstracts of systematic literature reviews or theoretical studies should included: topic addressed (in a statement), objective, thesis or construct under analysis or study organizer, used sources (e.g., an observation made by the author, published literature), and conclusions. 3. Abstract.The abstract limit is 150 words. It should comply with the same specifications as the Portuguese version, including the Keywords, in accordance with the Vocabulary of Terms in Psychology. 4. Resumen. The abstract limit is 150 words. It should comply with the same specifications as the Portuguese version, including the Palabras clave, in accordance with the Vocabulary of Terms in Psychology. 5. The text itself. The organization of the manuscript should be easy to recognize, signaled by a system of titles and subtitles that reflect this pattern. The text should start with an introduction and include the following headings: Method, Results and Discussion. As the introduction of the manuscript is easily identified by its place in the text, the heading Introduction is not necessary. In the research reports, the Method section must include the following subheadings: Participants, Instruments, Procedure (the latter subdivided into Data collection and Data analysis) and, finally, the subheading Ethical Considerations, in which the authors should mention the approval of the Research Ethics Committee, the name of the institution the committee is affiliated with and the protocol number. Authors should finish the Discussion section with a well reasoned comment, justifying the importance of the study findings. In this section, the authors should present the main contributions the research offers to the knowledge area within Psychology. Besides the implications and possible applications of the knowledge produced, authors should also point out the limitations of the study and its consequences in terms of prospects for future investigations. Suggested places to include figures and tables have to be indicated in the text. Quotations of other authors have to be done according to APA standards, as exemplified under
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section VII. Full transcriptions of a text have to be delimited by quotation marks and reference to the author, followed by the number of the page referred to. A literal quotation with 40 or more words has to be presented in a single block, starting with a new line, 05 (five) spaces from the border, in the same position as a paragraph. The font size should be 12, similar to the rest of the text. This type of citation should be avoided Authors are fully responsible for the contents and exactness of citations. 6. References. The references used should be coherent with the study’s theoretical-methodological framework. In this sense, literature on the research theme should be recovered, privileging scientific papers to the detriment of other publication modes. References should be up-todate. At least 50% should date back to the last five years, counted from the submission date. Non-compliance with this guideline implies return of the manuscript to the authors. The Editor, with support from the Editorial Board and ad hoc reviewers, can judge special cases that do not strictly fit into this criterion. 7. Figures and Tables should be inserted after the References section. The suggested place of insertion should be indicated in the body of the text though. The words Figure and Table in the texts should always be spelled with the first letter in upper case, followed by the respective number they refer to. Expressions like “the Table above” or the “Figure below” should not be used, as locations can change during the editing process. APA standards do not include the names Charts and Graphs, but only Tables and Figures. Figures and Tables should be presented with their respective legends and titles, one per page. 7.1 Figures, including subtitles, in black and white. As the published version cannot exceed 8.3 cm width for single figures and 17.5 cm width for complex figures, the author should make sure that no subtitle quality is lost in case width reduction is necessary. Reproductions of drawings will not be accepted. The quantity of figures and tables cannot exceed five. 7.2 Tables, including titles and notes, should be produced in black and white, one per page. The published table cannot exceed (17.5 x 23.7) cm (width x length). When preparing them, the author should limit the width to 60 characters for single tables to occupy a printed column, including three character-spaces between table columns, limiting complex tables to a 125-character width to occupy two printed columns. The table length cannot exceed 55 lines, including title and footnotes. For other details, especially for anomalous cases, please refer to APA’s manual. The quantity of figures and tables cannot exceed five units. Numerical and statistical information should be presented in compliance with the Publication Manual of the American Psychological Association (6th edition, 2010). For manuscripts written in Portuguese, numerical information should be standardized in line with Carzola, Silva and Vendramini (2009) in the book Publicar em Psicologia: Um Enfoque Para a Revista Científica, which can be accessed free of charge at the following electronic address: http://www.ip.usp.br/portal/ images/stories/biblioteca/Publicar-em-Psicologia.pdf In case of papers written in Portuguese, the authors should solve occasional inconsistencies between APA
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standards and writing in Portuguese, in view of general rules for writing in that language. Formatting of the manuscript, tables, figures and other elements should strictly comply with the APA manual. Before submitting, the authors should assess whether the manuscript complies with the checklist displayed on pages 241-243 of the APA manual. Non-compliance with these elements can represent a reason for the Editorial Board to reject the manuscript. As a complementary source, authors should access online ifnromation on the APA manual at: http://www. apastyle.org/ VII. EXAMPLES OF CITATIONS IN THE BODY OF THE MANUSCRIPT Citation of papers with multiple authors 1. Two authors Authors’ last name is explicit in all citations by using and or & as mentioned below: The method proposed by Siqueland and Delucia (1969) but “The method was initially proposed for sight study (Siqueland & Delucia, 1969). 2. From three to five authors Every author’s last name is explicit in the first citation, as above. From the second citation on, only the first author’s surname is explicit, followed by “et al.” and the year, if it is the first citation of a reference inside the same paragraph: Spielberg, Gorsuch and Luschene (1924) verified that [first citation] Spielberger et al. (1924) observed that [next quote, first in the paragraph] Spielberg et al. verified that [the year is omitted in the following citations when in the same paragraph] Exception: If the abbreviated form results in identitcal references to two papers with different co-authors, authors’ names are mentioned to avoid any mix-up. Hayes, S. C., Brownstein, A. J., Hass, J. R., & Greenway, D. E. (1986) and Hayes, S. C., Brownstein, A. J., Zettle, R. D., Rosenfarb, I., & Korn, Z. (1986) papers are mentioned as follows: Hayes, Brownstein, Hass et al. (1986) and Hayes, Brownstein, Zettle at al. (1986) verified that… In the References section, all names are mentioned. 3. Six or more authors In the text, from the first citation onwards, only the first author’s surname is mentioned, followed by “et al.”, except in case of ambiguities, when the same procedure described above is used. In the References section, all names are mentioned. Citation of papers based on a secondary source The paper uses a reference that discusses another reference, without having fully read the original one (e.g. Flavell’s study, cited by Shore, 1982). This kind of citation
should be avoided and limited to specific cases, which should be informed and justified to the editor in a separate message. In the text, the following citation format should be used: Flavell (as cited by, 1982) adds that those students… In the References, inform the secondary source (in that case, Shore), using the appropriate format. Citation of re-edited century-old publication Author (date of original publication / date of consulted edition), as in Franco (1790/1946). Citation of private communication This type of citation should be avoided, as it does not provide information obtained through traditional methods. If unavoidable, it can appear in the text, but not in the References. C. M. L. C. Zannon (private communication, October 30th 1994) VIII. ORIENTATIONS REFERENCES
FOR
BIBLIOGRAPHIC
References should be arranged according to the following general rules. Papers by a single author and the same authors are ordered per publication year, from older to newer publications. Single-author precedes multiple-author publications if the surname is the same. Papers in which the first author is the same but the co-authors differ are arranged by the co-authors surnames. Publications with the same multiple authorship are arranged per date, from the older to the newer. Papers with the same authorship and data are displayed alphabetically by the title, ignoring the first word if that is an article or pronoun, except when the title itself contains an indication of order; the year is immediately followed by lower-case letters. When repeated, the author’s name should not be replaced by a hyphen or other signs. The formatting of the bibliographic list should be appropriate for review and editing, with double lining and font 12. Each reference should be placed in a new paragraph, with an indentation of half centimeter from the left margin on the second line. Carefully check the Publication Guidelines before preparing the references. The authors are fully responsible for the exactness of references. Below are examples of common reference types. 1. Technical report Birney, A. J., & Hall, M. M. (1981). Early identification of children with written language disabilities (Rep. No. 811502). Washington, DC: National Education Association. 2. Proceedings of meetings and symposia Paidéia does not accept references to studies presented at meetings and symposia, even if they were published in the proceedings. We suggest replacing these references by papers published on the same theme.
3. Doctoral dissertations and master’s theses References to dissertations and theses should be avoided. Instead, the papers they originated, i.e. the indexed publications should be preferred. If no paper was published deriving from the dissertation or thesis, cite another article on the same theme. If the citation of dissertations or thesis is inevitable, they should be available on-line in an institutional or commercial database: 3.1 Master’s thesis available in commercial database McNiel, D. S. (2006). Meaning through narrative: A personal narrative discussing growing up with na alcoholic mother (Master’s thesis). Available from ProQuest Dissertation and Theses database. (UMI No. 1434728) 3.2 Doctoral dissertation available in institutional database Juran, R. (2013). The relationship between perceived thought control ability, mindfulness, and anxiety (Doctoral dissertation). Retrieved from https://etd.ohiolink.edu/ If the dissertation or thesis used as a source is not in English, inform the original title, followed by the English title as mentioned in the original document between square brackets: Sá, E. M. M. (2012). Habilidades sociais, bem-estar psicológico e rendimento escolar [Social skills, psychological wellbeing and school performance] (Doctoral dissertation, Universidade de Aveiro, Aveiro, Portugal). Retrieved from http://ria.ua.pt/handle/10773/9222 4. Books Arendt, H. (1998). The human condition (2th ed.). Chicago, IL: The University of Chicago Press. If the book used as a source is not available in English, inform the original title, followed by the translation to English between square brackets: Pitiá, A. C. A., & Santos, M. A. (2005). Acompanhamento terapêutico: A construção de uma estratégia clínica [Therapeutic accompaniment: Building a clinical strategy] (2nd ed.). São Paulo, SP: Vetor. 5. Book chapter Blough, D. S., & Blough, P. (1977). Animal psychophysics. In W. K. Honig & J. E. Staddon (Orgs.), Handbook of operant behavior (pp. 514-539). Englewood Cliffs, NJ: Prentice-Hall. If the book chapter used as a source is not available in English, inform the title of the original chapter, together with the title of the original book, followed by the translation of both titles to English between square brackets: Hoffman, L. W. (1979). Experiência da primeira infância e realizações femininas [Early childhood experience and female achievements]. In H. Bee (Org.), Psicologia do desenvolvimento: Questões sociais [Developmental psychology: Social issues] (pp. 45-65). Rio de Janeiro, RJ: Interamericana.
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6. Translated book Kuhn, T. (1996). A estrutura das revoluções científicas [The structure of scientific revolutions] (B. Boeira & N. Boeira, Trans.). São Paulo, SP: Perspectiva. (Original work published 1970) Salvador, C. C. (1994). Aprendizagem escolar e construção de conhecimento [School learning and knowledge building] (E. O. Dihel, Trans.). Porto Alegre, RS: Artes Médicas. (Original work published 1990) If the translation to Portuguese of a book in another language is used as a source, inform the year of the translation to Portuguese and indicate the publication year of the original work at the end of the reference. In the body of the text, cite the year of the original publication and the year of the translation: (Salvador, 1990/1994). Include the original title, followed by the translation to English between square brackets. 7. Re-edition of century-old publication Franco, F. M. (1946). Tratado de educação física dos meninos. Rio de Janeiro, RJ: Agir. (Original work published 1790) 8. Corporate authorship American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Conselho Federal de Serviço Social. Conselho Federal de Psicologia. (2007). Parâmetros para atuação de assistentes sociais e psicólogos(as) na política de assistência social [Parameters for social workers and psychologists’ performance in the Social Assistance Policy]. Retrieved from http://site.cfp.org.br/publicacao/parmetros-paraatuao-de-assistentes-sociais-e-psiclogosas-na-poltica-deassistncia-social/ For material available online, do not include the access date unless the source of the material changes over time (ex. wikis). 9. Journal article (with and without DOI) If the paper used as a source is not in English, inform the original title, followed by the translation to English as mentioned in the article between square brackets: Dugnani, K. C. B., & Marques, S. L. (2011). Construção e validação de instrumento para prática interventiva na adoção [Construction and validation of an instrument for intervening practices in adoption]. Paidéia (Ribeirão Preto), 21(50), 317-328. doi:10.1590/S0103863X2011000300004 Articles published in bilingual journals, in which English is one of the languages, should be referred to using the title in English: Castaño-Perez, G. A., & Calderon-Vallejo, G. A. (2014). Problems associated with alcohol consumption by university students. Revista Latino-Americana de Enfermagem, 22(5), 739-746. doi:10.1590/01041169.3579.2475
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If the article published on-line does not have a digital object identifier (DOI), inform the URL. Do not inform the access date. Kirst-Conceição, A. da C., & Martinelli, S. de C. (2014). Análises psicométricas iniciais de uma Escala de Empatia Infantojuvenil (EEmpa-IJ) [Initial psychometric analysis of an Child and Youth Empathy Scale (EEmpaIJ)]. Avaliação Psicológica, 13(3), 351-358. Retrieved from http://pepsic.bvsalud.org/scielo.php?script=sci_ serial&pid=1677-0471&lng=pt&nrm=iso 10. Journal article in press Avoid this type of reference. If it is inevitable, do not include the year, volume or number of pages until the article has been published. Respecting the order of names, this should be the final reference to the author. Carvalho, L. F., & Primi, R. (in press). Development and internal structure investigation of the Dimensional Clinical Personality Inventory. Psicologia: Reflexão e Crítica. 11. Legal documents Decreto No. 3.298. (1999, 20 de dezembro). Regulamenta a política nacional para a integração da pessoa portadora de deficiência, consolida as normas de proteção e dá outras providências [Regulates the national policy for the integration of the disabled person, consolidates norms of protection and other measures]. Brasília, DF: Presidência da República. Lei No. 9.394, de 20 de dezembro de 1996 (1996, 23 de dezembro). Estabelece as Diretrizes e Bases da Educação Nacional [Establishes the Guidelines and Bases of the National Education]. Diário Oficial da União, seção 1. Constituição da República Federativa do Brasil. (1988, 5 de outubro). Recuperado de http://www.senado.gov.br/sf/ legislacao/const/ Communication may be done via Phone: 55 16 3315.3829 or e-mail: paideia@usp.br Paidéia Prof. Dr. Manoel Antônio dos Santos – Editor-in-Chief Psychology Department / FFCLRP-USP Avenida Bandeirantes, 3900 - Monte Alegre CEP 14040-901, Ribeirão Preto-SP, Brazil
PaidĂŠia Editorial Review Process
The author submits the manuscript to PaidĂŠia
Does the manuscript comply with all the publication guidelines?
NO
The Editorial Board calls for a review
YES The Assistant to the Editorial Board confirms the reception of the manuscript
The manuscript is analyzed by ad hoc consultants
Request for reformulation
The authors reformulate the manuscript Resubmission
Approved
Rejected
The Assistant to the Editorial Board requests the proofreading of the manuscript
Editing process
Abstract and Resumen review
In Print
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Editorial Board review
Design and composition of the issue
Conversion of the article to the SciELO method
Distribution of print copies to authors, ad hoc consultants and libraries
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