Final 3 ijcfn cc by Luis Maia

Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

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Even Kids Love Neuroscience!

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Year 0, Vol. I, nº 3, 2013

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Director-in-Chief Luis Alberto Coelho Rebelo Maia

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Scientific Board

- J.E. Pinto-da-Costa, PhD., Forensic Medicine, Full Professor of Neuropsychopathology, Psychofarmacology, Universidade Lusíada, Porto and Judicial Psychology and Forensic Medicine in University Portucalense Infante D. Henrique, Porto – Portugal - Albertino Graça, PhD., Principal of UNI-Mindelo University, Cape Verde Islands - M. Joaquim Loureiro, PhD., Full Professor in Psychology, University of Beira Interior - Portugal - J.L. Sánchez Rodríguez. PhD., Dr. Medicina y Cirugía. University of Salamanca. Profesor de la Facultad de Psicología. Departamento de Psicología Básica, Psicobiología y Metodología de las C.C. – España - José Vasconcelos-Raposo, PhD., Full Professor in Psychology, Sports & Health. University UTAD - Vila Real - Portugal - Pedro Guedes de Carvalho, PhD., CIDESD, Beira Interior University - Portugal - Daniel Marinho, PhD., CIDESD, Beira Interior University - Portugal - Luísa Branco, PhD., Professor in Education, Philology & Citizenship Education - Portugal Beira Interior University - Portugal - J. Marques-Teixeira, PhD., Psychiatrist and Psychotherapist, Professor of Neurosciences in University of Porto - Portugal - J.M. Barra da Costa, PhD., Former Inspector Chief of Judicial Police - University Professor and Criminal Profiler - Portugal - Jorge Oliveira, PhD., Professor School of Psychology and Life Sciences – ULHT - Director of Centre for the Study of Cognitive and Learning Psychology (ULHT) – Portugal - Luísa Soares, PhD., University of Madeira, M-iti (Madeira Interactive Technologies Institute) – Portugal - Paula Saraiva Carvalho,PhD., Professor in Psychology, University of Beira Interior - Portugal - Nuno Cravo Barata, PhD., Research Assistant and Professor at Universidade Portucalense¸ Instituto Piaget; Faculdade de Medicina da Universidade do Porto - Portugal - Paulo Lopes, Psychologist, PhD., Neuropsychology Salamanca University, Professor at School of Psychology and Life Sciences and Director of the MSc of Applied Neuropsychology (ULHT); Ares do Pinhal - Addiction Rehabilitation Association – Portugal - Pedro Gamito, PhD., (University of Salford, UK), Title of Aggregate in Rehabilitation (Technical University of Lisbon, Portugal). Full Professor and Head of Computational Psychology Laboratory of Psychology School and Life Sciences and Associate Director of COPELABS – Portugal - Ricardo João Teixeira, PhD., Main Researcher at Aveiro University; Psychologist/Psychotherapist at Clínica Médico-Psiquiátrica da Ordem (Porto); Invited Assistant Lecturer at School of Allied Health Sciences, Polytechnic Institute of Porto; PhD in Psychology by Minho University - Portugal - Graziela Raupp Pereira, PhD., Professor at Santa Catarina State University - Brasil

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Contents Editorial Humberto Rodrigues…………………………………………………………….…………………………………………………………………………… P.270-271

Visual Working Memory in Schizophrenia: Effect of Dimensionality on a Visual Task Daniela Macedo & João Marques-Teixeira ………………………...........................................................................……….P.273-291

The question of combined treatments in children an in adolescents: reflecting on the clinical and scientific evidence Carlos M. Lopes Pires & Paulo José Costa ……………………………………………………………………………………………………....…P.293-309

Goal agreement between client-therapist dyads Luísa Soares, Marina S. Lemos, Filipa Oliveira, Mónica Fernández & Catarina Faria ……………………………………….…P.311-328

Profiling: The mysterious case of Jack the Ripper Clara Margaça, Jorge Saraiva & Luis Maia …………………………………………………………………………………….……………....…P.330-350

Filicide: some contributions to the understanding of the phenomenon Eduardo Sá & Ana Carolina Pereira …………………………………………………………………………………………….………………....…P.352-388

Considerations on Death in the Process of Illness by Breast Cancer Nirã dos Santos Valentim, Kayoko Yamamoto & Maria Julia Kovács ……………………………………………………………....…P.390-401

Pilot study on the construction of a Screening of Neuropsychological Exploration, for evaluation of Cognitive Complaints and Dementia’s States Dulce Marques ……………………………………………………………………………………………………………………………………………....…P.403-418

Motivation for practice and not in school sports in youth of 2nd and 3rd cycle of basic education Júlio Martins, Samuel Honório, João Cardoso, Luís Duarte, Marco Batista & João Brito ………………………………....…P.420-443

Intervention group in individuals with cerebral palsy Nuno Cravo Barata …………………………………………………………………………………………………………………..…………………....…P.445-462

A hazard life after a massive Stroke – Angels and Demons of recovering Luis Maia ………………………………………………………………………………………………………………………….…………………………....…P.464-481

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Editorial Humberto Rodrigues Ph.D. Student – Salamanca University – Castilla y Leon Neuroscience Institute / Spain – Medicine College of Salamanca University. MsC and Psychology Degree in Aveiro University.

_________________________________________________________________________________

criticism and renewed construction of this mirror

Dear Readers

that reflects our humble but forceful insignificance. However, we wonder: what is need to psychology of A psychologist who only perceives psychology ... will or should have FREE ACCESS to knowledge?

the 21st century to become an "Open Acess Mind?" In our humble opinion, and although we stress the free and open line knowledge to all, we think it may

At the end of 2013, we are in an era of festive events,

only be compatible and possible when psychologists

whether established or experienced, whence

realize that psychology needs knowledge as diverse

emanate feelings and emotions as diverse that we

as biology, physiology, biochemistry, mathematics,

wonder what areas of knowledge will be necessary

… physics … why not?, etc.., without, however, fall

for us to enjoy the privilege that gives us knowledge:

into the temptation to slip into an established

A DOUBT! The "open access" knowledge will be as

knowledge in a mere reduction to number

equal or unequal installed in this festive feeling and

processes.

time? Are these democratic?

Thus, psychology today, makes it contribution in

Our journal "Journal of Clinical and Forensic

various areas of knowledge, enabling each area to an

Neuroscience" rests on the premise that knowledge

endless series of discoveries about the man and his

should be shared democratically and produced so

behavior, or expression in its external and internal

that everyone could have free access, so this can be

relations, such as: Experimental Psychology, Clinical

fully validated by their peers, independently of the

Psychology, Developmental Psychology, Sports

stage of the endless pursuit of knowledge.

Psychology, Forensic Psychology, Neuropsychology,

It makes no sense that scientific information

etc.

produced is enclosed in a bubble where only a few have access, and therefore we base our editorial way

Now, in this winter month, the third issue of this

in a free ride where everyone can walk to its heart's

Scientific Journal is born, where we discuss various

content in the sense of achieving knowledge,

topics of psychological knowledge; humbly thanking in advance to the AUTHORS for contributing and

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sharing invaluable, generous and tasty knowledge, that were shared specially to our delight.

With friendship, health and peace we endorse us to

Thus, in the context of Clinical, Forensic and

all of you… till the next number. With many, many

Experimental

thanks!

Psychology,

have

valuable

contributions of several authors, where are explored

Neuroscience will definitely set us free!

interesting areas of psychological knowledge.

Humberto Rodrigues. Ph.D. Student – Salamanca University – Castilla y Leon Neuroscience Institute – Medicine College of Salamanca University / Spain. MsC and Psychology Degree in Aveiro University.

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Clinical and Experimental Research Visual Working Memory in Schizophrenia: Effect of Dimensionality on a Visual Task Daniela Macedo (1) & João Marques-Teixeira (2) (1) Faculty of Psychology and Education Sciences, Oporto University. Portugal. Corresponding author: danielamacedo.psi@gmail.com (2) Faculty of Psychology and Education Sciences, Oporto University. Portugal. jemt01@gmail.com

____________________________________________________________________________________________________ Abstract The aim of the study was to examine whether the dimensionality of a visual working memory task interferes in the performance of patients with schizophrenia. The dimensionality of the Spatial Span test, which is composed by three-dimensional visual stimuli, was converted in two-dimensional stimuli. The performance from 20 patients with schizophrenia and 20 healthy controls was compared in the two versions of the test. It was also compared the global cognitive performance from the two groups. The results show an influence from the group with schizophrenia and from the control group in the two-dimensional version, and no effect of the version was observed in the performance of the groups. We propose the possibility of interference from visual processing impairment in schizophrenia, the visual system benefiting from the three-dimensional representation in working memory, and the three-dimensional stimuli having more salience to visual perception. Keywords: Visual Working Memory, Schizophrenia, Neuropsychological Assessment, Dimensionality, Visual Perception.

Resumo O objetivo do estudo foi avaliar se a dimensionalidade de uma tarefa de memória de trabalho visual interfere no desempenho de pacientes com esquizofrenia. A dimensionalidade do teste Spatial Span, o qual é composto por estímulos visuais tridimensionais, foi convertido em estímulos bidimensionais. O rendimento a partir de 20 doentes com esquizofrenia e 20 controlos saudáveis foi comparado entre as duas versões do teste. Também foi comparado o desempenho cognitivo global dos dois grupos. Os resultados mostram uma

273

influência a partir do grupo de esquizofrenia e do grupo de controlo na versão bidimensional, e não foi observado nenhum efeito desta versão no desempenho dos grupos. Propomos a possibilidade da interferência de deficit no processamento visual na esquizofrenia, tendo o sistema visual beneficiado da representação tridimensional na memória de trabalho, e os estímulos tridimensionais com mais relevância para a perceção visual. Palavras-chave: Memória de Trabalho Visual, Esquizofrenia, Avaliação Neuropsicológica, Dimensionalidade, Perceção Visual.

Resumen El objetivo del estudio fue examinar si la dimensionalidad de una tarea de memoria de trabajo visual interfiere en el desempeño de los pacientes con esquizofrenia. La dimensionalidad de la prueba de Localización Espacial, que está compuesto por estímulos visuales tridimensionales, se convirtió en estímulos de dos dimensiones. El rendimiento a partir de 20 pacientes con esquizofrenia y 20 controles sanos se comparó en las dos versiones de la prueba. También se comparó el rendimiento cognitivo global de los dos grupos. Los resultados muestran una influencia del grupo con la esquizofrenia y del grupo de control en la versión de dos dimensiones, y no se observó efecto de la versión en el desempeño de los grupos. Proponemos la posibilidad de interferencia de deterioro de procesamiento visual en la esquizofrenia, en que el sistema visual beneficia de la representación tridimensional en la memoria de trabajo, y los estímulos tridimensionales que tienen más relevancia a la percepción visual. Palabras clave: Memoria de Trabajo Visual, Esquizofrenia, Evaluación Neuropsicológica, Dimensionalidad, Percepción Visual.

_____________________________________________________________________________________________________

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Visual working memory impairments constitute a neurocognitive deficit in schizophrenia (Glahn et al., 2003; Tek et al., 2002), expressed by decreased performance in tasks addressed to this cognitive function (Barch, 2006; Gold, Wilk, McMahon,

Buchanan,

Luck,

2003).

source of the patient behavioral deficit as reflecting

attentional

fundamental impairment.

perceptual

effective

behavioral performance, these tasks require the integrated function of attention in the service of perception (Tek et al., 2002).

Particularly, the spatial working memory deficit

Gold et al. (2003) proposed that the formation

has been proposed as an endophenotype for

of integrated representations in visual working

schizophrenia (Glanh et al., 2003).

memory first occurs at the level of perception,

Visual working memory studies supported domain specificity, in which spatial and nonspatial domains are distinct (Anderson, Mannan, Rees, Sumner, & Kennard, 2010; Tek et al., 2002), according to the type of information stored. Location is related to spatial domain (Tek et al., 2002) that is the focus of this study. However, we opted for a general designation, which is concretized in visual working memory, to encompass perception and

and it is thought that spatially focused attention is required to achieve feature binding during perception. Deployment of attention to the target seems to be a central factor, because it mediates the encoding process by selection of the target or its features and contributes to active

visual

perception

the

internal

representations (Kim, Park, Shin, Lee, & Know, 2006). Attentionally salient targets can facilitate working memory (Lee & Park, 2005) and this

that The visual working memory deficit has been to

enhancement effect might stem from the fact

visuospatial information processing.

attributed

maintenance

(Butler,

Silverstein, & Dakin, 2008; Giersch, Assche, Huron, & Luck, 2011; Tek et al., 2002), corresponding to sensory modulation, and to high order cognitive functions, which include working memory, selective and sustained attention (Gold et al., 2003). Given the role of attention in the modulation of sensory

salient

targets

capture

visuospatial

attention, increasing the probability that they will be processed (Kim et al., 2006). In contrast, visual search can be slowed in schizophrenia when the target is less salient (Fuller, Luck, McMahon, & Gold, 2005). Thus, recent work has shown that top-down as well bottom-up cues can

influence

representations

the into

selective

transfer

working

memory

(Woodman, Vecera, & Luck, 2003).

processing, it is not possible to determine the

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Spatial Span task of the Wechsler Memory Scale

(Rocha et al., 2008) requires, at first, selective

– III (WMS-III; Rocha, Machado, Barreto,

attention as the operation for identifying

Moreira, & Castro, 2008) has been used to

relevant stimuli in environment, focusing on

assess the spatial domain of visual working

these stimuli and not in others. Then is required

memory in schizophrenia (Marques-Teixeira,

sustained attention, the ability to focus on a

2005). This is a complex task designed to assess

target and resist distraction over time, as

the extent of the working memory store (Glahn

suggested by Silver & Feldman (2005), until they

et al., 2003). Although this is a measure directed

are processed, to allow the transfer of stimuli

at visual working memory, the disruption of any

through more complex levels of information

of the cognitive processes involved in the task

processing (Marques-Teixeira, 2005). After

could lead to deficient performance and it is

focusing

unclear whether the sensivity of the deficits in

underlying processes are required, and these

Spatial Span (Rocha et al., 2008) is related with

involve visual-spatial information encoding,

spatial mnemonic processing, reduced visual

maintenance, manipulation, retention and

working memory capacity, or some other

rehearsal (Glahn et al., 2003).

nonmnemonic aspect of the task (Glahn et al., 2003).

stimulus,

working

memory

Once retained the visual stimulus, it follows planning, which is part of the executive function

Spatial Span task of the WMS-III (Rocha et al.,

(Marques-Teixeira, 2005). The task also covers

2008)

maintenance,

the motor plan, since it requires execution of a

manipulation, time-tagging of visualspatial

movement sequence (Rudkin, Pearson, & Logie,

information, and a complex motor response

2007) and the control of motor execution

(Glanh et al., 2003). This subtest is an

(Pearson & Sahraie, 2003) to achieve the

adaptation (Wilde, Strauss, & Tulsky, 2004) of

movements corresponding to the evocation of

the Corsi Blocks Task, and other variants of this

working memory.

requires

encoding,

task have been used to assess storage capacity of visual working memory (Gold et al., 2003).

Still with regard to the processes involved in the performance of the subtest and once the

In order to analyze the cognitive processes

perception of the stimulus proves relevant to

underlying

becomes

working memory (Tek et al., 2002), it should be

necessary to proceed to its decomposition. It is

noted that deficits in visual processing are

our understanding that the subtest Spatial Span

observed in schizophrenia (Butler et al., 2008),

test

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performance,

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and it is therefore necessary to consider the

brain to the perception of coherent 3D

interference of this dysfunction in visual

structures (Welchman, Deubelius, Conrad,

working memory.

Bulthoff, & Kourtzi, 2005).

Visual information integration deficits are seen

The representation of three-dimensional space

and motion

has been attributed to an additional cost, as

processing in schizophrenia, as a result of

opposed to two-dimensional space (Diwadkar,

disconnection of neuronal systems that code

Carpenter, & Just, 2000). According to the

local attributes into global complex structure,

authors, when the movement of an object in a

more suitable for the guidance of behavior

mentally generated array is signaled by auditory

(Butler et al., 2008).

cues, maintaining the object's location is easier

contrast,

contour, form

Given that working memory is related to the visual perception (Tek et al., 2002), it is also necessary to consider the effects of threedimensionality of visual stimuli that comprise the subtest Spatial Span (Rocha et al., 2008). This is due essentially to changes along the subtest review, since these changes have extended to dimensionality (Lezak, Howieson, & Loring, 2004), and its effects have not been

in a mentally generated 2D than 3D array (Kerr, 1993). In fact, studies of the interpretation of visual form also indicate that the construction of 3D space might be demanding (Diwadkar et al., 2000). Such studies suggest that perceptual interpretation of 3D space requires more computation

and

maintenance

than

interpretations. However, neural mechanisms which may involve working memory and mental manipulation of 3D objects have not yet been

explored.

examined (Tsutsui et al., 2005). The stimuli from real world are threedimensional (3D), but when projected to the retina it is reduced to a two-dimensional (2D) image (Tsutsui, Sakata, Naganuma, & Taira, 2002).

Therefore,

the

brain

must

reconstructing the 3D representation (Peuskens et al., 2004) from the 2D images on the retinae (Tsutsui et al., 2002). The information provided

In this sense, it seems appropriate to consider an interference of dimensionality in visual working memory. This interference can also lead

the

involvement

executive

functioning, since its efficiency may be essential for

spatial

abilities

(Miyake,

Friedman,

Rettinger, Shah, & Hegarty, 2001).

by different depth cues, namely binocular

In summary, in order to analyze the properties

disparity and perspective cues, is combined by

of the subtest and its interference in the

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processes involved in the performance, it is

resources that make it more complex); 3) both

necessary to control the three-dimensionality

versions have a discriminating index between

variable. This variable may require more

groups.

cognitive functions for processing, which restricts the obtainment of a more reliable METHOD

measure of visual working memory. The present study was designed, precisely, to

Participants

analyze how the dimensionality implicated in

Twenty patients meeting DSM-IV (APA, 2002)

the visual working memory task Spatial Span

criteria for schizophrenia and 20 healthy

(Rocha et al., 2008) interferes with the

controls participated in the study. The patients

performance in patients with schizophrenia. For

were clinically stable outpatients (16 male and

this purpose, the dimensionality of the test

4 female) and between 23 and 55 years of age

(composed, in its classic version, by three-

(M = 37.05, SD = 10.00). Diagnosis was

dimensional stimuli) was manipulated in order

established by psychiatrists and combining

to convert it into two-dimensional stimuli

information from past medical records.

presentation, maintaining other features, as

Twenty healthy control subjects (10 male and

color, number, block placement, size and the

10 female) between 23 and 53 years of age (M

extent

Once

= 35.20, SD = 9.86) were recruited from the

operationalizated the two-dimensional version

community by communications and direct

of the test, this was compared with the three-

requests word of mouth. In the selection of

dimensional

with

participants in the control group were used as

schizophrenia and controls. According to the

exclusion criteria, screened by self-report: a)

framework mentioned above, we hypothesized

existence of sensory or motor deficits that could

that: 1) in the performance of the visual working

interfere

memory task, the results of two-dimensional

experimental

test correlate with the three-dimensional one;

neurological or psychiatric disorder, c) drug use

2) for both groups, the two-dimensional version

that could interfere with performance of

would have higher scores than the three-

neuropsychological tests.

dimensional

the

version

sequences.

patients

(since

the

three-

dimensional version seems to require more

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with

the

protocol,

execution b)

the

presence

Demographic features are shown in Table 1, with significant between-group differences

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noted in the table. The groups were matched on

education (t (38) = - 3.766, p = .001) and gender

age in order to reduce the differences between

distribution (X2 (1, N=40) = 3.956, p = .047).

participants that may contribute to variability of performance.

Although

there

were

differences in age (t (38) = 0.589, p = .559), significant

differences

were

observed

Controls

Patients

Age

32.20 (9.86)

37.05 (10.00)

Education

15.40 (3.42)

11.00 (3.95) *

Gender (M:F)

10:10

16:4 *

Table 1. Demographic features of Participants - * p < .05

278 Materials and procedure

non-perseverative

errors

and

conceptual

responses level items; LM domain is assessed by All participants were screened for cognitive performance baseline of participants with Bateria de Avaliação Cognitiva Breve (BACB; Marques-Teixeira, 2005). BACB assess cognitive domains considered impaired in patients with schizophrenia, in which are included the Executive Function (EF), Learning and Memory (LM), Attention and Concentration (AC), and

Hopkins Verbal Learning Test – Revised (HVLT-R) on total recall, delayed recall and discriminative recognition index items; AC domain is obtained by the Trail Making Test (TMT) Part A and B scores, Letter-Number Sequence and Spatial Span from Wechsler Memory Scale – III; PS is assessed by Stroop Test on Word and Color items.

Processing Speed (PS). EF domains is assessed by Stroop Test on the subtests Word-Color and Interference items, Wisconsin Card Sorting Test (WCST) on subtests total number of errors, perseverative responses, perseverative errors,

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For the calculation of the indices of cognitive domains mentioned, after administration and quotation of tests and subtest that constitute BACB, direct scores were entered into the

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software that comes with the manual. This

performance associated with reduced capacity

program produces, in a synthesized and

(Glahn et al., 2003).

integrated form, a report that includes the synthesis of neuropsychological assessment. The report shows the scores of the domains mentioned above and the Test Battery Mean (TBM). The selection of this index comes from the assumption that the global analysis of

In order to assess the performance and to collect data on modified two-dimensional version, was used a two-dimensional frame, in which placement, color, block number, size and extent of sequences from Spatial Span were maintained.

battery performance is made by the mean of test domain, which is the most appropriated for

For the elaboration of the subtest Spatial Span modified version, was used Microsoft Word

assess cognitive dysfunction.

2007. The modification of the test was For the assessment of visual working memory and

data

collection

the

cognitive

conducted by manual arranging of display, corresponding to test features.

performance of participants in the classic version, we used the subtest Spatial Span from WMS-III (Wechsler, 1997), validated for the Portuguese population by Rocha et al. (2008). This subtest consists in numbered blocks in a three-dimensional

framework,

irregularly

arranged (Lezak et al., 2004). Given that this subtest integrates BACB, was administered with

The data collection of the patients group was conducted

cabinet.

Patients

were

referenced by psychiatrists to ensure that they met the diagnostic criteria for schizophrenia, according to DSM-IV (APA, 2002), and the control group was recruited among university students, with environment conditions held as constant as possible between collections. After

the battery.

hearing a detailed description of the study, each The subtest Spatial Span (Rocha et al., 2008) consists in a measure of visual working memory and therefore its rational of operations involves the

maintenance

visuospatial

and

manipulation

subject gave written informed consent to participate and, through this, was assured data confidentiality and voluntary participation.

information (Marques-Teixeira,

2005). This subtest was designed to assess the extent of the working memory store, with poor

The procedures for administration of tests that comprise BACB followed the instruction in the manual

(Marques-Teixeira,

administration of

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2005).

tests followed by

The an

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established order, and the versions of the test Spatial Span (Rocha et al., 2008) were counterbalanced to prevent learning effects form one version over the other. For this purpose, the order of administration of the test versions was alternated between participants.

Statistical methods Firstly, we proceeded to the processing of direct scores in T scores and, for that purpose, these were introduced in the manual software. This value emerged from the need for a common metric, as the condition which allows to ensure

Visual working memory assessment and data

the performance unit of the subject, with

collection on the cognitive performance of

normative values obtained from different

participants

was

methods. Moreover, this value is a score

conducted with the subtest Spatial Span (Rocha

normalizing criterion of the subject in different

et al., 2008). This test is divided in two phases,

battery tests. This criterion is reflected in the

and therefore in the forward order the

transformation of values into T scores,

participant was asked to repeat the sequence

considering as normative values the mean of 50

that the administrator performed, by touching

and a standard deviation of 10 (Marques-

the numbered blocks of a three-dimensional

Teixeira, 2005).

framework

the

classic

same

version

order

the

administrator. In the reverse order, the task was the same as the first phase, but the participant had to perform the sequence in reverse order to that performed by the administrator.

In order to compare the performance of patients and control group in tests from BACB, as the assumption of normality of the distributions required for the adoption of parametric

tests

was

accomplished,

independent samples t tests were used.

The collection of data regarding to the modified

Subsequently, using a correlation analysis, we

version of the subtest followed the procedures

sought to determine whether the three and the

mentioned above. Given that this version is

two-dimensional version of the subtest were

directed to the same cognitive function, the

correlated and, because of that, concerned the

subtest features, as well its administration

same cognitive function. This analysis was also

procedures were maintained.

conducted with groups as moderator, to analyze in more detail the effect described above.

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To verify whether there was a subtest version,

performance of the groups in a global way and

group and interaction effect between the

in the different cognitive domains.

version and the group an analysis of variance for repeated measures was used. This analysis was conducted by a combination of factors to analyze the variation in performance of the two groups in the two test versions.

To analyze the performance of patients and control group in the different domains and in the battery tests mean, 5 independent samples t test were used. In this regard, it was found that in the PS cognitive domain the SQZ group (M =

To verify whether there were differences

35.40, SD = 7.83) shows a significantly lower

between

group

performance that the CRT group (M = 48.20, SD

performance in three-dimensional version and

= 6.16, p < .001). In the AC domain, the SQZ

two-dimensional version of the subtest, we

group (M = 43.25, SD = 9.98) shows significantly

used an independent samples t test.

lower performance than the control group (M =

patients

and

control

56.06, DP = 7.62, p < .001). In the EF domain, the SQZ group (M = 41.11, SD = 6.61) shows a Results

significantly lower performance than the CRT

Cognitive performance analysis on battery

group (M = 46.90, SD = 7.00, p = .011). In the LM

tests

domain, the SQZ group (M = 34.10, SD = 10.32) research

shows a significantly lower performance than

hypothesis, the cognitive performance of the

the CRT group (M = 47.76, SD = 6.55, p < .001).

two groups in the different domains and in the

The SQZ group (M = 38.44; DP = 6.90) shows also

Battery Test Mean was subjected to an analysis.

a significantly lower performance than the CRT

In fact, it was assumed that the obtained scores

group (M = 49.74, DP = 4.94, p < .001) in BTM.

could be useful to establish the performance

Figure 1 shows the scores for the patients group

baseline of both groups, as well to assess the

and control group in the PS, AC, EF, LM cognitive

Although

not

covered

the

domains and TBM.

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Figure 1 Performance scores of the group of patients with schizophrenia and the control group in the cognitive domains PS, AC, EF, LM and in the BTM. PS = Processing Speed; AC = Attention and Concentration; EF = Executive Functions; LM = Learning and Memory; TBM = Test Battery Mean.

Analysis of the performance of visual working

in more detail the effect described above, to respond to the hypothesis that the two versions

memory in the versions of the test

measure the same cognitive function in the two To test H1, according to which the twodimensional test is correlated with the threedimensional

and,

therefore,

indicating

groups, we observed that the versions are correlated in the SQZ (r = 0.678, p = .001) and CRT group (r = 0.668, p = .001).

consistency between versions, we used a correlation analysis, taking as variable the test version. Correlation analysis showed that the versions of the test are moderately correlated (r = 0.687, p < .001).

To test H2, we used repeated measures ANOVA with the version as whithin-subjects factor and the group as between-subjects factor. We did not find an effect of version (F (1,38) = 0.572, p = .454) and of interaction between version and group (F

In order to verify whether the cognitive function measured is maintained in the two groups, a correlation analysis of the versions with the groups as moderator was used. When analyzing

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(1,38) = 0.754, p = .391). We found a group effect (F (1,38) = 4.258, p = .046). The detailed analysis of these effects shows that is not observed a version effect in SQZ group and that in 3D version

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were found differences between groups (Figure 2). Although there is a group effect on LM version, this is not sufficient for an interaction.

Figure 2. Performance variation of groups in the two versions of the test.

283 To test H3, by using a t test for independent samples, we found no significant differences in performance in 2D version between the SQZ group (M = 50.77, SD = 10.77) and the CRT group (M = 54.87, SD = 7.42). We observed significant differences in performance in 3D version between the SQZ group (M = 50.64, SD = 8.08) and the CRT group (M = 56.68, SD = 7.43). This result suggests that there is no overall effect of the 2D version and that when tested a version independently of the other, 3D version becomes more sensitive to differences between groups.

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DISCUSSION The results show that the three-dimensional and the two-dimensional version of the Spatial Span test are correlated, suggesting that they measure the same cognitive function (visual working memory), being an indicator of consistency between versions. We also observed that, in particular, versions are correlated in the two groups and, therefore, measure this function in the group of schizophrenia patients and in the control group, reinforcing the relation previously found.

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In this sense, the results allow us to confirm the

should be noted that only one dimensionality

first hypothesis formulated, and the alterations

variation was conducted between the two

made in the two-dimensional version seem to not

versions, and the other features of the test were

introduce

the

maintained, therefore the differences in the

performance of visual working memory, since this

performance would be due to that variable. This

varies consistently with the three-dimensional

alteration has the underlying assumption that

version

with

varying the dimensionality of the objects

schizophrenia and the control group. Given that

addresses whether representing two and three-

the

dimensional space imposes different spatial

noise

the

alteration

interfere

group

was

with

patients

restricted

the

dimensionality of the test and the other features were maintained, these condictions ensure that the performance of the two-dimensional test requires the same rational of operations that the three-dimensional test, although it may differ in perception of visual stimuli. The two-dimensional test addresses visual working memory, since it requires processing and serial recall of locations presented (Rudkin et al., 2007). The results show that there is no version effect, suggesting that the three-dimensionality is not a relevant feature for assessing visual working memory. Consequently, the scores of the threedimensional and two-dimensional version do not differ between them in the patients group and the control group. Therefore, the results do not support the second hypothesis, since a version effect was not found. We observed an effect of the group that is larger for the two-dimensional version, being an indicator of this version sensitivity to differences between groups. It

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demands (Diwadkar et al., 2000). The variation of relevant task parameters is precisely what is required for continued progress in delineating the cognitive processing operations underlying performance on this task (Berch, Krikorian, & Huha, 1998). Although a version effect was not found, the observed group effect implies differences between the patients group and the control group, deserving a more specific 284

analysis in future investigations. In the search for explanations, since a version effect was not found, it should be noted that the obtained results do not allow inferring about the effect of three-dimensionality of visual stimuli comprising the test. Due to that, it is not possible to establish a confrontation with studies that showed that the perception of three-dimensional space

requires

cognitive

processes

resources than the two-dimensional (Diwadkar et al., 2000). The additional effort suggested for the processing of three-dimensionality and the

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subsequent demand for executive processes

domains, patients with schizophrenia show a

would be reflected by differences in performance

significantly lower performance than the controls

between the three-dimensional version and the

in the executive functioning domain.

two-dimensional. However, this effect was not detected in the results and, in turn, does not allow to understand how they were recruited cognitive processes involved, so we can only infer that in this measure, the three-dimensionality is not an interference factor.

Additionally, results show also that significant performance differences were found on the twodimensional test between the group of patients and the control group, as opposed to what was observed on the three-dimensional test, in which no differences were found between the groups.

This explanation assumes that the varying of

More specifically, on the two-dimensional

dimensionality implemented in the test could be

version, patients with schizophrenia showed a

one factor that contributes to the group effect

significantly

found. Since patients with schizophrenia show

controls, and therefore it suggests that the two-

deficits in executive processes of working

dimensional test becomes more sensitive to

memory (Barch & Ceaser, 2012; Kim et al., 2004),

differences between the groups.

it seems appropriated to note that the efficiency of executive functioning may be essential to spatial abilities (Miyake et al., 2001). The relationship between visual scanning and higher order cognition is illustrated by the evidence that brain areas responsible for executive functions, such as the DLPFC, are activated when eye movements to locations of interest are generated (Minassian, Granholm, Verney, & Perry, 2005). Incoming visual signals progress through a complex neural circuit that includes the frontal eye fields and association regions such as the

lower

performance

than

the

An explanation involves assuming that the visual processing deficits in schizophrenia can interfere in the working memory performance on twodimensional test. Visual integration deficits are seen in contrast, contour and form processing in schizophrenia (Butler et al., 2008), required to the distinction of visual stimuli on the twodimensional test more than on the threedimensional, given the perceptual salience that the

latter

comprise,

and

therefore

the

differentiation between patients and controls may reflect such deficits.

DLPFC (Minassian et al., 2005). In fact, as demonstrated by the results of the assessment of performance of the groups in different cognitive

The results of this study suggest that the performance of patients shows no significant differences between the two versions. It seems

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plausible to assume that the visual system can

attentional deficit in schizophrenia may have

benefit from the structure of 3D space and its use

been attenuated by the enhancement effect

to organize the representation of objects in visual

conferred by the attentional salience of three-

working memory. In this way, if the objects are

dimensional

perceived as appropriately, the presence of 3D

approximation to the performance of controls.

surfaces cannot affect how the information is retained in visual working memory. Thus, the presence of 3D surfaces can affect perception, but not visual working memory.

stimuli,

resulting

the

This explanation assumes that the visual working memory

performance

patients

with

schizophrenia on three-dimensional test was more efficient due to the features of the visual

As an alternative to the proposed explanation,

stimulus, since the efficient use of working

the three-dimensional stimuli may be more

memory depends on effective use of attention

attentionally

and

(Gold et al., 2006). Thus, three-dimensional

enhancement effect conferred by visual input to

version may not show a discriminating index

selective attention capture may occur. In fact,

between patients and controls due to the

attentionally salient targets can facilitate working

enhancement effect from attention, conferred by

memory (Lee & Park, 2005). Such enhancement

three-dimensional stimuli that may have acted in

effect may stem from the fact that salient targets

order to reduce the differences between groups.

capture

salient

for

visuo-spatial

perception,

attention

thereby

increasing the likelihood that they will be processed (Kim et al., 2006). This influence of visual

stimuli

salience

attention

and

subsequently in visual working memory was demonstrated by other authors (Fuller et al., 2005; Rissman et al., 2009). Attention guides working memory encoding and attentiondirecting cues could influence which pieces of information are retained (Gold et al., 2006). In fact, patients with schizophrenia (see 3.1. Analysis) show a significantly lower performance than

controls

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attention

domain.

This

286 Regarding the limitations of this study, it should be noted, firstly, aspects related with the data collection procedure. Particularly, the fact that the tests have been administered in the same session could have potentiated a learning effect, leading to a bias in visual working memory performance. Although the administration of tests was counterbalanced, since the order of tests was alternated between participants, this procedure does not have a robust effect as the temporal distance. In fact, this limitation is due to clinical instability of patients with schizophrenia that would not allow a second contact for tests

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administration, with a time period properly to

requires cognitive processes involved in its

avoid learning effects. One way to bypass this

performance. In contrast to what was expected,

limitation may involve the achievement of

differences in performance corresponding to a

collection situations with lower rigidity on time

higher cognitive load on three-dimensional test

constraints, allowing broader conditions. It

compared to the two-dimensional were not

should also be indicated a limitation that is

observed. These differences would constitute an

related with the assessment of visual working

indicator of the presence of noise, due to the

memory, since no additional measures were used

involvement of additional cognitive processes.

for this cognitive function. More specifically,

The group effect found was reflected more clearly

there have not been used other measures that

in two-dimensional test, pointing to the sensivity

could allow to control visual working memory

of this test for differences between groups.

performance,

not

depending

this

dimensionality manipulation.

Given the results obtained, explanatory proposals that may contribute to the effect found, were

Given the mentioned limitations, future research

discussed:

visual

processing

deficits

on the measure discussed could consist of data

schizophrenia can interfere working memory

collection conditions that allow a temporal

performance on two-dimensional test; visual

distance between the administration of different

system can benefit from three-dimensionality to

versions, in order to ensure that the performance

the representation in visual working memory;

differences are not due to learning effects.

three-dimensional stimuli can be more salient for

Moreover, the use of complementary measures

visual perception, leading to a enhancement in

of visual working memory to enable data

capture of selective attention.

collection on this cognitive function and manipulation of properties, such as task difficulty and load of cognitive processes.

ACKNOWLEDGEMENTS To Psychiatry service of São João Hospital Center and to Neurobios – Neuroscience Institute,

CONCLUSIONS

Diagnosis and Integrated Rehabilitation.

This study aimed to determine how the dimensionality of visual stimuli contained in a measure directed to visual working memory

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Butler, P. D., Silverstein, S. M., & Dakin, S. C.

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Clinical

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539-549.

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Special Revision Article The question of combined treatments in children an in adolescents: reflecting on the clinical and scientific evidence Carlos M. Lopes Pires, PhD (1) & Paulo José Costa (2) 1. Faculty of Psychology and Education Sciences University of Coimbra, Portugal; Professor of Clinical Psychopharmacology for Psychologists; Clinical Psychologist in private practice. Corresponding author: cmpires@fpce.uc.pt 2. PhD student (University of Coimbra); Hospital de Santo André, Leiria – Portugal.

_________________________________________________________________________________ Abstract The combination of psychological and psychopharmacological treatments in children and in adolescents has become an issue of increasing relevance in the latest years. Although the combination of treatments is a commonplace, its real nature is not clear. We base our reflections in relevant authors on this specific subject, and also in our personal clinical practice. As a matter of fact, the usual practice has not been a combination of treatments, but rather cooperation between different health professionals. We also think that there is a bias in the research conceptualization which favors the medications. Besides, we can also formulate three empirical questions: (1) is it true that a combination of treatments is more effective than a single treatment? (2) What are the real costs considering the efficacy and the adverse reactions of psychopharmacological treatments? (3) are psychopharmacological treatments really so effective as habitually proclaimed? Instead of the common sense suggestion that “two things are better than one”, we conclude that clinical evidence and data from different studies points out that, with the exception of Psychotic Disorders and Attention Deficit Hyperactivity Disorder (APA Working Group on Psychoactive Medications for Children and Adolescents; 2006), the combination of pharmacological and psychological treatment in children and adolescents rarely produces supplementary benefits. In addition, the use of drugs frequently leads to increased problems, not only related to Adverse Reactions, but when it comes to ceasing its use, and also increasing the probability of relapsing. We conclude that combination therapies are essentially a research question, without relevance in clinical context, namely in private one. Key Words: Combined Treatments; Children; Adolescents; Adverse Reactions; Psychological Therapy vs Pharmacological Therapy.

Resumo A co mb in aç ão d e tr a tam en to s p s ic oló gi co s e p si co far m aco ló gi co s e m cr ian ça s e ad ol e sc en te s t e m - se to rn ad o u m p rob le m a d e i mp o rtân ci a cr e sc en te n o s ú lt i mo s an o s. E mb o ra a co mb i n aç ão d e tra ta me n to s s ej a c omu m, a s u a v er d ad ei ra n a tu r ez a n ã o é e vid en te . Ba s ea mo s a s n o s sa s r e f le xõ e s sob re au to r e s r e le v an t e s s ob r e e st e te ma e sp ec íf ic o, b e m co mo n a n o s sa p rát ica c lín ica . Por u m a q u e stã o d e fac t o, a p rát ica u su al n ão t e m s id o a co mb in a ção d e trat a men to s, ma s si m a c oop er açã o en tr e os d i f er en t e s p ro fi s s io n ai s d e saú d e . A cr ed ita mo s ta mb é m q u e ex i st e u m vi é s n a p e sq u i sa q u e d á ma i s i mp o rtân cia à m ed ic açã o. Al é m d i s so , ta mb é m p od e m os for mu lar tr ê s q u e s tõ e s e mp í ri ca s: ( 1) É v erd a d e q u e u m a co mb in a ção d e trata m en t o s é ma is e fi caz d o q u e u m ú n i co tr ata me n to ? ; ( 2 ) Qu ai s s ão os cu sto s r ea i s ,

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con sid e ran d o a e fi các ia e r e açõ e s ad ve r sa s d o s t rata m en to s p si co fa r ma col óg ic o ? ; ( 3) O s trata m en t o s p si co fa r ma col óg ico s são re al m en t e tão e fi caz e s co mo g era l m en t e é a l egad o ? E m v ez d e s e a c ei tar a s u ge s tão co mu m d e q u e " me lh o r é s er e m d o i s d o q u e u m " , p od e mo s con clu ir q u e a s e vid ên c ia s e d ad o s c lín ic o s , in d ic ia m q u e, co m e xc eç ão d o s t ran sto rn o s p s icó ti co s e Tra n s tor n o d e At en ção e Hip er ati v i d ad e ( T a sk Fo rc e p ar a d roga s p s ico ati v a s d a APA p ara Cr ian ça s e Ad ol es c en t e s, 2 0 06 ) , a c o mb i n aç ão d e tra ta m en t o far m ac oló gi co e p s ico ló gi co d e cr ian ç a s e ad o le s c en t e s rar am en te p ro d u z b e n e f íc io s ad i cion ai s. Al é m d i s so, o u so d e d r og a s, mu ita s v ez e s l e va a p rob l e m as c ad a v ez ma ior e s, n ão só em r e laç ão a rea çõ e s ad v er sa s , ma s tam b é m a q u an d o s e t ra ta d e d ei xar o s eu e mp re go, au m en t an d o tam b é m a p rob ab i lid a d e d e r e caíd a. Con clu i - s e q u e a s t er ap ia s d e c o mb in açã o são, e s se n c ial m en t e , a q u e st ão d e p e sq u i sa , se m r e l e vân cia n a p r áti ca c lín i ca , p ri n c ip al m en t e n o se tor p ri v ad o.

Pa la vr as -ch a ve: Tra ta m en to s Co mb in ad o s , Cr i an ça s e Ad o le s c en t e s, Re açõ e s A d ve r sa s, T era p ia P si col óg ic a v s F ar mac olo gi a.

Resu m en La co mb in ac ión d e l o s t r ata mi en t o s p si co ló gi co s y p si co far ma co ló gi co s e n lo s n iñ os y en lo s ad ol e sc en te s se h a co n v ert id o e n u n a c u e st ión d e cr e ci en t e re l e van cia e n lo s ú lt i mo s añ o s. Au n q u e la co mb in ac ión d e t rat am i en to s s ea u n lu g ar co mú n , s u v erd a d er a n at u ra le za n o e stá cla ra. Ba sa m os n u e st ra s r e fl ex ion e s e n au t ore s re l e van t e s sob re e s te t e ma e sp ec íf ic o, as í c o mo t am b i én en n u e str a p r áct ic a c lín ic a p e rs on al . Co mo cu e sti ón d e h e ch o , la p rá ct ica h ab i tu al n o h a s id o u n a co mb in ac ió n d e tr ata m ien to s, si n o má s b i en l a co op era ci ón en tr e l o s d i f er en t e s p r of e s ion a le s d e la s alu d . T a mb i én cr e em o s q u e h a y u n s e sg o en la i n ve s ti gac ión q u e d a má s i mp or tan c ia a lo s. Ad e má s, p od e m os ta mb i én f or m u lar tr e s p r e gu n ta s e m p íri ca s : ( 1 ) ¿E s c i erto q u e u n a co mb in a ci ón d e tr ata mi en to s e s má s e fi caz q u e u n s ol o trat a mi en to ?; (2 ) ¿Cu ál e s so n lo s co st os re al e s ten ie n d o en c u en ta la ef ic ac ia y l a s r e acc ion e s ad v e rs a s d e lo s tr ata mi en to s p s ico fa r ma col óg ico s ? ; (3 ) ¿Lo s t rata m ie n to s p si co fa rm ac oló gi co s son re al m en t e tan e fe ct i vo s co mo h ab it u al m en t e p roc la mad o ? E n lu ga r d e la su g er en cia d e s en t id o c o mú n d e q u e "d o s c o sa s son m ejo re s q u e u n o" , ll eg am o s a la con c lu si ó n d e q u e la e v id en c ia c l ín i ca y d at o s d e d i f er en te s p u n to s in d ic i en , con la ex c ep c ión d e lo s tra sto rn o s p si cót ic o s y Dé f ic it d e At en c ión e Hi p er act i vid ad ( Gru p o d e T rab a jo d e la AP A s o b re M ed ic a me n to s P si c oact i vo s p ar a N iñ o s y A d ol e sc en t e s, 2 00 6 ) , la c om b in a ci ón d e tr ata mi en to far ma co ló gi co y p s ico ló gi co en l o s n iñ os y ad ol e s c en te s rar a v ez p r od u c e b en e fi cio s su p le m en tar io s. A d e m á s, el u so d e d ro ga s c on d u c e con fr e cu en c ia a au m en t o d e l o s p rob l e ma s , n o só lo e n r ela c i ón con la s r ea cc ion e s ad v e rs a s , p e ro cu a n d o s e tra ta d e d ej ar su e mp l eo , y ta mb i én in cr e me n t a el au m en t o d e la p ro b a b ili d ad d e r eca íd a . Ll ega m o s a la c on c lu si ó n d e q u e la s t erap ia s d e co mb in ac ión son e se n c i al me n t e la p r e gu n ta d e in ve s ti gac ión , sin r e l e van cia e n el con t e xto c lín i co , p ar ti cu l ar m en t e el s e cto r p r i vad o . Pa lab r a s C la ve : T rata mi en to s C o mb in ad o s, Niñ o s, A d ol e s ce n t e s, R ea cc ion e s Ad v er s a s, T era p ia P si col óg ic a v er s u s T rata m ie n to F a rm ac o lóg ic o

_________________________________________________________________________________ In recent years, the combination of pharmacological and psychological treatments has been an emergent

well as in adults' treatment. In the present paper, our emphasis will be limited to the former.

subject in children and adolescents' treatment, as

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Symptomatically,

the

AMERICAN

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

PSYCHOLOGICAL

professional power relation. Many people (including

ASSOCIATION (APA) has issued two books (Phelps,

psychologists) still confuse these two ways of

Brown, & Power, 2002; Sammons & Schmidt, 2001),

considering combined treatment. We would like to

intending to update the present situation. We

draw the attention to the fact that in this dominant

believe that the advances in the acquisition of

case, psychologists are called to collaborate in the

prescriptive privileges by United States (USA)

treatment of someone who is already being

psychologists have most probably contributed to a

medicated or beinginitiated in it. In other words,

new interest about the therapeutic combination.

they are not being consulted in regard to the

Nevertheless, the idea of a combined treatment is clearly not new. Instead of assuming a new form, it gained impetus when both (pharmacological and psychological) approaches were given an empirical support, mainly, the psychological approach which was empirically evaluated effective in the treatment of most psychological disorders. The use of drugs in the treatment of psychological disorders has expanded along the last thirty or forty years, and both the marketing power and the power of the pharmacological industry have exemptmany of the scientific guidelines. In some cases they truly exaggerated the therapeutic effectiveness of drugs, and minimized adverse reactions (Healy, 2002;

psychopharmacological treatment of a particular individual. Psychologists are only instructed to use some psychological procedures in order to help the “real” (pharmacological) treatment. Contrarily, in the

truly therapeutic combination, the two

professionals discuss and establish together the best global approach, coming to an agreement regarding the

different

procedures

use,

whether

pharmacological, or psychological. Really, we don’t believe that such practice will be workable. So, we can suppose that here it is one of the reasons why the acquisition of prescriptive authority is so attractive for psychologists that, like the author of this article, work in private clinical practice.

Kirsch, Moore, Scoboria, & Nicholls, 2002; Pires,

Thus, laying aside the therapeutic combination

2003; Pires & Costa, 2005).

understood as a mere collaboration, some relevant

On the other hand, perhaps as result of the empirical validation

psychological

conceptualization developed

from

therapies,

combination collaboration

the

therapy between

psychologists and psychiatrists, into a combination of a parallel, or a sequential use of both therapies.

questions are raised: 1) is this combination generally desirable (and therapeutically effective)? 2) Are the pharmacological Adverse Reactions (ADRs) minor compared to their benefits? We will try to explore these questions, based on research and clinical evidence.

Nowadays, however, the former appears to be the dominant one, since it reflects, essentially, a

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APPEARANCE AND DOMINANCE OF DRUG THERAPY We must recognize that in the middle of the twentieth century drugs were considered as merely accessory

resources

the

treatment

psychological disorders (Healy, 2002). So, what happened that completely changed this scenario? The English psychiatrist David Healy (2002) explains that modern psychopharmacology begins, in the fifties, with the creation of the first neuroleptic named chlorpromazine (brand name Thorazine).

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

All

these

contributed to

the

present

high

prescription levels. Jensen et al., (1994, cited by Fisher & Fisher, 1996) refer to the fact that in the USA, in 1992, a few years after Prozac had been introduced, there were still about one million prescriptions, including prescriptions aimed at 0 to 4 year old children. More recently, Antonuccio, Danton and Macclanahan (2003) claimed that in the USA the revenues of pharmacological industry, antidepressants only, rose 25% per year, and that one out of eight Americans had already taken

It is possible to present a sequence of events mapping the medical and pharmacological evolution of the psychotropic drugs, from chlorpromazine to those massively used nowadays:

antidepressants at least for three months. In a recent European country epidemiological survey (Portugal), with university students, we found that 22,5% of the students are taking sedative-hypnotics, 11,5%

1) The synthesis of chlorpromazine, the first drug

antidepressants, and less than 10% are taking

really showing to control positive symptoms in most

antipsychotics

psychotic people.

stabilizers”).1

2) The production of new molecules classified as

Since the beginning of the 1990s, when Prozac had

antidepressants (like Monoamine Oxidase Inhibitors

its highest exposure, the prescriptions to children

- MAOIs).

and young adolescents have followed the general

3) The creation of the first benzodiazepine,

trend. This occurs despite the absence of empirical

chlordiazepoxide (brand name, Librium), with minor

evidence. Nevertheless, a number of independent

problems compared to barbiturates.

studies (Glenmullen, 2005; Healy, 2002; Kirsch, 2010;

4) At the end of the eighties, fluoxetine (brand name, Prozac) came into the market with the first great

and

anticonvulsivants

(“mood

Julien, 2005; Sharav & Cohen, 2004) show that they are no better than placebo.

marketing campaign in the pharmaceutical history,

Indeed, the use of psychopharmacs in the treatment

together with social and cultural changes (Healy,

of children and adolescents reflects the mere

2002; Pires, 2003).

transposition to children of data obtained with adults, most often only with a reduction of the doses,

Pires & Agostinho (2007).

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although it is quite usual to observe children and

nature of clinical trials, we only want to bring your

adolescents indulging in doses equal or superior to

attention to some points that in our opinion biases

those prescribed to adults (Pagliaro & Pagliaro,

the research results more favourable toward

1998). This can be dangerous. For example, in the

medications.

case of antidepressants there is an enhanced risk of fatal serotonin syndrome (Julien, 2005).

First, disorders are conceptualized as categories with symptoms that reflect a disease condition: this is

On the other hand, studies issued by the Journal of

why we use scales that reduce the evaluated

Medical American Association (Phelps et al., 2002)

phenomena to a group of symptoms (the items on

revealed that some psychotropic substances, such as

the scale). For example, to believe that scales of

metilphenidate (RITALIN) and antidepressants were

depression are the only and fundamental way to

prescribed in an uncontrolled way to preschool

evaluate the cure for depression is to believe in that

children. The number of children aged between 2

disease categorical model. As a clinical psychologist I

and 4 years indulging in these substances increased

know this is not true, because in the person’s life

drastically between 1991 and 1995.

there are another dimensions, not truly evaluated

Is has been generaly alerted to the fact that the use of psychotropics in children under 6 years old had been the target of neither any formal laboratory study, nor any health agency study. Nevertheless, the fact that this practice is carried out in children at a very early age raises very serious questions concerning the possible impact of these drugs on their general health (Breggin & Cohen, 1999).

with such scales. This is why other instruments are necessary to evaluate the impact of a treatment (a good example is the Q45; a questionnaire pretended to evaluate the treatment outcomes- Lambert & Burlingame, 1996). This is not the same to say that DSM-IV (APA, 2000) is without utility. Perhaps a good way to look at this is that of Widiger & MullinsSweatt (2007) that recommend the conversion of that categorical model to one more dimensional and

Finally, a systematically ignored aspect is the drug

also more quantitative - an “integrative” model.

psychological impact. It should be taken into account that the way a five-year-old child deals with emotions can be very different from that of an adult

Speaking about the use of scales to evaluate the treatment of depression: is there anybody who

(Pagliaro & Pagliaro, 1998). Before we look at the evidence coming from research we must say something about the nature of the

research

that

dominates

this

subject.

Considering this article does not aim to discuss the

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believes that a diminution of two-six points in the

been largely demonstrated (Pires, 2002; Pires &

Hamilton scale has any clinical significance?2

Costa, 2003; Sharav & Cohen, 2004).

Second, because psychological treatments are in

According to several reviews (Antonuccio & Danton

textbooks, in order to be like the pharmacological

2002; Julien, 2005; Katic & Steingard, 2001),

treatments (so excluding, for example, individual

numerous studies demonstrated the therapeutic

differences), we can ask if we are not losing

inefficacy of these substances in the treatment of

something vital to psychological therapies. The

mood disorders; it was also observed that the effect

question is that psychological factors are intrinsic to

of placebo was generally superior to more than 50%.

psychology and so, also to psychological therapies.

In contrast, the seriousness of the ADRs caused by

Why to exclude them? When the therapeutic results

such

of pharmacological and psychological therapies are

hypotension, blurred vision, urinary retention, and

compared, is this comparison really comparable?

delirium, among others), and their impact on the

A third important point: What should be taking into consideration when deciding what treatment to choose? We believe that information concerning the adverse reactions (like withdrawal symptoms) or possible

adverse

reactions

(ADRs)

can

determining in this choice.

substances

(sedation,

constipation,

cardiac and the hepatic systems is outstanding. Truly, in the mid-nineties some cases of death connected with the ingestion of DESIPRAMINE were reported in the USA. Also several sudden deaths of children treated with TCAs and also with FLUOXETINE and other SSRI have been reported, caused by heart problems and some types of intoxication as a result of the ingestion of these drugs (Fisher & Fisher,

THE MOOD DISORDERS

1996).

In 1996, Fisher and Fisher estimated that millions of

Committing suicide, a possible consequence of a

children all over the world are being medicated with

depressive condition, which is in the USA as one of

antidepressants, such as IMIPRAMINE and FLUOXETINE,

the main modern causes of death involving young

used for depression. As we will see, nowadays, the

people 5 and 24 years old, has increased dramatically

situation is even of greater prescription. Although

in recent years (American Academy of Children and

there are almost no approved antidepressants fewer

Adolescent Psychiatry, 2004).This has happened

than 18 (except FLUOXETINE, as we mentioned in the

since the usual use of antidepressants for depression

beginning)–their uselessness below this age has

(Fisher & Fisher, 1996). Besides, the authorities of

See Kirsch, Moore, Scoboria & Nicholls (2002a), about the case of clinical trials of antidepressants approved by the Food and Drugs Administration.

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the United Kingdom, the United States of America

mind. In this paper, Intoxication Anosognosia

and Canada (among many other health agency

(medication spellbinding), is an expression of this

authorities) have been alerting towards the relation

drug induced mental disability.

between antidepressants and the increase of suicides among children and teenagers. Antonuccio et al. (2003) said that the extension of this alert to the adult population would cause enormous financial damages to the pharmaceutical industry… However, in its release to physicians, the National Health Agency of Canada explicitly alerts that the problem is common to all ages (Health Products and Food Branch, 2004).

Even institutions with particular responsibilities in what concerns to health are becoming more objectives in what concerns to best options. For example, the National Institute for Health and Clinical Excellence (NICE), United Kingdom, presents the therapeutic guidelines to be used with children and adolescents: in all degrees of depression severity psychological

therapies

(cognitive

behavioural

therapy, interpersonal therapy or shorter-term

Therefore, the use of antidepressants, specifically in

family therapy) are proposed as first line treatment.

the treatment of children and adolescents, is a

About the use of antidepressants, its use is not

matter of concern. Sharav and Cohen (2004) argued:

recommended, but when used, this must be done

“Reports from clinical practice show the scope and

always with psychological treatments. Cautions are

severity

with

made about adverse reactions (NICE, 2005). Healy

antidepressant drugs: For example, an examination

(2002) also adverts about the use of SSRI in children

of the medical charts of children and adolescents

and adolescents and, corroborating the NICE

(age 8-19) who had been prescribed Prozac at a clinic

guidelines, when used, it’s necessary to monitor its

staffed by University of Pittsburgh psychiatrists

eventual problems.

the

problems

associated

shows that 23% of the children or adolescents developed mania or 'manic-like' symptoms, and another 19% developed drug-induced hostility and aggression, including a grinding anger with short temper and increasing oppositionalism. These dangerous effects may be precursors to suicidal or homicidal acts.” (Pp. 4).This idea is also supported by Breggin (2006), mentioning the drug-induced mental impairment and the brain-disabling principle of psychiatric treatment, that all somatic psychiatric

Concerning the bipolar disorder, Katic and Steingard (2001) referred to the fact that, although there are no controlled studies proving the effectiveness of MOOD STABILIZERS (CARBAMAZEPINE, LITHIUM andVALPROIC ACID)

being

in children and in adolescents such drugs are indiscriminately

prescribed

under

the

argumentation that their effect is similar to the adults’ one. A revision of published researches carried out by Fisher and Fisher (1996) concluded that there is no scientific evidence that supports the

treatments impair the function of the brain and

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use of substances as LITHIUM in the treatment of

Phobias, and Posttraumatic Stress Disorder. In fact,

bipolar disorder in children and adolescents.

the anxiety symptoms are relatively frequent in

There are frequent ADRs associated with the consumption of these substances, such as tremors, ataxia, sedation, unrealistic speech, deficient motor

children and adolescents (esteemed between 8% and 9%) and cause a significant level of psychosocial dysfunction (Phelps et al., 2002).

coordination, polidipsia and polyuria, nausea and

The psychopharmacological approach, which is most

diarrhoea. Other effects are weight increase, thyroid

frequently found in the treatment of the anxiety

hormonal alterations (hypothyroidism), fatigue and

disorders either in children or young people, is

dermatological

alterations

associated with BENZODIAZEPINES, and less frequently

(leucocytosis). In the long run some effects can also

with BUSPIRONE. Although studies that evaluate the

cause renal function reduction and gastrointestinal

effectiveness and safety of these pharmacological

disorders, cardiac arrhythmias and eventual coma

substances in children and adolescents do not

and death (Pagliaro & Pagliaro, 1998). There is no

support them, the prescription of such drugs rises

doubt that their prescription to children and young

every year (Pires & Costa, 2003). Curiously, with the

people should be very carefully considered, and non-

introduction

pharmacological alternatives should preferentially

INHIBITORS

be promoted. As Phelps et al. (2002) explain, beyond

started to be considered, in general, as potential

the non-existence of empirical support for the

causers of addiction, dependence, and severe

systematically use of these substances, they should

withdrawal

always be inserted by a psychological approach,

legitimating of those new antidepressants caused a

which is exactly the opposite of what frequently

negative opinion on benzodiazepines (Healy, 2002).

occurs. Interestingly, the leading rule of the current

Nevertheless, BENZODIAZEPINES are still regarded as a

health systems consists almost entirely in treating

faster reducing or relieving anxiety symptoms

everybody with drugs, whether adults, young

substance.

and haematological

people, or children.

SELECTIVE SEROTONINE REUPTAKE

(SSRI) antidepressants, BENZODIAZEPINES

problems.

The

emergence

and

Despite their approval for children and adolescents, there are many reserves and restrictions as a result of the research clinical limitations that try to find

THE ANXIETY DISORDERS

evidence for either their advantages or therapeutic There is a large consensus about the prevalence of Anxiety

Disorders

either

childhood

effectiveness. This situation also concerns the adult population (Pagliaro & Pagliaro, 1998; Pires, 2003).

adolescence. Some of them are more frequently found in children: Separation Anxiety Disorder,

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In respect to BUSPIRONE (a relatively recent drug with

psychological treatment, but only 50% reduction of

sedative proprieties, but not belonging to the group

symptoms in what concerns pharmacological

of BENZODIAZEPINES), it is useful to say that it unchains

treatment in one of the groups. In other two studies

frequently ADRs, such as migraine, nauseas,

the reduction for the groups in pharmacological

vertigoes, sleepiness, and sleeplessness. Besides,

treatment was almost 20% and 43% (Katic &

BUSPIRONE takes more time to start its therapeutic

Steingard, 2001).

effects than benzodiazepines. Otherwise, cognitive behavioral therapy (CBT) currently has the most research evidence for the treatment of general symptoms of anxiety in young people. This treatment can be administered in a variety of different formats, each of which has varying levels of research support (Silverman, Pina, Viswesvaran, & Chockalingam, 2008).

Several

reviews

pharmacological

and

psychological approaches to OCD treatment clearly reveal that the psychological therapy must be preferred, a fact which is recognized even by medical authorities (American Academy of Child and Adolescent Psychiatry, 1998). Specifically, exposition and response prevention are the most efficient treatment of OCD. Such data emphasize either the psychological

THE OBSESSIVE-COMPULSIVE DISORDER

therapy importance or even priority over the

OBSESSIVE-COMPULSIVE DISORDER (OCD) presents levels of prevalence among children-adolescent population esteemed between 2% and 4%, with a bigger incidence in male population (Phelps et al., 2002). Characterized as an anxiety disorder, it has some particularities in what concerns symptoms and treatment. The drugs regularly used in the treatment of this disorder are basically SSRI, such as FLUOXETINE,

pharmacological one. Despite this conclusion, we can also find those who state the possibility of using a

combined

treatment,

namely

cognitive-

behavioural therapy plus pharmacotherapy. The idea of a combination of treatments seems to be interesting. However, until now, support of this idea has only been found occasionally (see Phelps, et al., 2002).Naturally, the only valid conclusion is the one reported by Gadow (1997; cited by Phelps, et al.,

SERTRALINE, FLUVOXAMINE, and ESCITALOPRAM.

2002), when he says that even when medication is Different studies were developed regarding the comparison of the effectiveness of a therapeutic intervention protocol

based

(psychological

cognitive

behavioural

treatment)

versus

pharmacological treatment. They revealed almost 60% reduction of symptoms in what concerns

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necessary, the indiscriminate use of psychotropic agents in paediatric treatment is difficult to justify. Phelps,

al.

(2002)

also

argue

that

pharmacological treatment will not be efficient outside a psychological protocol. This is an important conclusion considering that most often rule and

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practice do not correspond. As we’ve mentioned

In the ADHD evaluation the therapist must take

previously about the Anxiety Disorders the Cognitive

different sources of information into account in the

Behavioral Therapy (CBT) currently has the most

establishment of such diagnosis, including an

research evidence for the treatment of young people

interview with the child's parents, school behaviour

with OCD (Freeman, et al., 2013).

reports, and any contacts with the child's teacher. The application of child behaviour checklists, as well as cognitive, neuropsychological and psychomotor

THE

ATTENTION

DEFICIT

HYPERACTIVITY

evaluations, must be implemented.

DISORDER ADHD is the children’s disorder for which THE ATTENTION DEFICIT / HYPERACTIVITY DISORDER (ADHD)is the most discussed psychological disorder nowadays. A prevalence of 3% - 5%, with a ratio of 4/1 between boys and girls (Popper & Steingard,

psychopharmacs are currently most often prescribed (Katic & Steingard, 2001), the ingredients used in its treatment being methylphenidate (trade name: Ritalin), dextroamphetamine and pemoline.

1994, quoted by Katic & Steingard, 2001) has been esteemed, even though such estimates vary according to the diagnosis criteria used in the

Thus, it is esteemed that about 80% of children diagnosed with ADHD improve their attention and movement, becoming quieter and more permeable

different researches.

to adults instructions (Pires & Costa, 2003). The In fact, the diagnosis of ADHD must be based on an important set of factors complete analysis, including the persistence and the generalization of symptoms to different situations, contexts and environments, and the functional reduction. Nowadays it seems very easy to diagnose ADHD and we must wonder, at least, if this disorder does not demand a more limited and careful diagnosis. In our clinical practice we observe children that came to us diagnosed as

Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity

Disorder

(MTA,

Cooperative Group, 1999) confirmed that stimulants are good in treating those symptoms. However, this research

shows

number

important

methodological problems and a bias favourable to medications that several authors pointed out (Phelps, et al., 2002; Carey, 2000). Some of the problems are:

hiperactive, frequently because they are irrequiet or inatentive. Most often, some weeks with a reformulation

rules

and

behaviour

family/adults, and all change for better. So, we believe it is necessary more rigour in doing

1. A design research favourable to medication (for

example,

parents

and

teachers

previously receive a lot of information about the efficacy and safety of these drugs);

diagnostic (Costa, Heleno, & Pinhal, 2011).

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2. At the medication group following up, some

cocaine showed great similarities. There is some

of the children are kept under medication; 3. Children receiving psychological treatment are later given stimulant therapy (Why not the other way round?).

evidence

suggesting

that

adolescents

under

methylphenidate since childhood may have more probability to become cocaine addicted (Breggin & Cohen, 1999). As for other situations, we wonder why the idea of combination therapy is so attractive concerning

In countries where these drugs are used during a long period of time (as for example in the USA), some problems (ADRs) happened associated with such drugs. So, we also need to consider the ADRs when taking the symptomatic control of children into account (American Psychological Association, 2006).

some psychological disorders that respond very well to psychological therapies, and so unattractive concerning these disorders were drugs seem to be a best solution... Even in cases of AD/HD where medication has a positive place it seems to us that a combination of therapies has, probably, more utility

In January 1997, the stimulant pemoline (Cylert)

(e.g. reducing medication or total time of taking

manufacturer warned that this substance could

medication). Additionally, we can see that once

cause hepatic dysfunctions in children. Ironically,

again empirical evidence supports that Behavior

families had denounced this problem many years

Therapy and Behavioral Parent Training for child and

before. Katic & Steingard (2001) assumed that 11 out

adolescent AD/HD has the most research evidence to

of 13 reported cases caused death, while the

date (Pelham & Fabiano, 2008).

survivors were submitted to liver transplants. Finally, it was withdrawn from US market by manufacturer SOME INCONGRUENCE

in March 2005. Other ADRs are common, but still associated with the use of psychostimulants, as methylphenidate and dexedrine: gastrointestinal suppression of appetite, headaches, migraine, sleep alterations, sudden weight loss, growth suppression, unstable mood, psychotic episodes, depression, agitation and tics (APA, 2006; Klein, Gittelman, Quinkin & Rifkin, 1980, quoted by Katic & Steingard, 2001).

There are several arguments against the massive prescription of psychotropic drugs in children and adolescents. The first argument refers to reports given out by psychologists, psychopharmacologists, paediatricians, psychiatrists and paedopsychiatrists, pointing out that the actual knowledge about the short, medium and long term effects caused by psychotropic substances is very limited, and so their efficiency is not strongly supported (APA, 2006;

On another side, studies by Volkow, et al. (1999) and

Pagliaro & Pagliaro, 1998). However, prescription

Rush & Baker (2001) about methylphenidate and

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continues to occur in unimaginable proportions in

consequences. Not only because of the fact that

children at very early ages.

medication is prescribed so easily, but also

A research carried out in the USA and issued by the ARCHIVES OF PEDIATRICS AND ADOLESCENT MEDICINE (Monitor, 2003) is elucidative concerning this issue. Julie Zito (2008) analysed 900,000 children data between 1987 and 1996. She stated that the psychotropic drug prescription triplicates between 1987 and 1996, stimulants and antidepressants

essentially because of inadequate attitudes caused by such diagnoses. Depression and ADHD are two of the most common diagnoses nowadays. For example, if a child is very restless, it is certain that she/he will not escape being subject to this diagnosis, as we have unfortunately been observing in our clinical practice.

being the most usually prescribed. It was possible to verify that this increase was especially high in what concerned 10 to 14 year-old children. The

SUMMARY AND DISCUSSION: IS THERE A “REAL” BASIS FOR THERAPEUTICAL COMBINATION?

prescription of hypnotics also increased significantly. Concerned with these findings, Zito (2008): "We can’t simply consider that children are small adult people (...). It’s necessary to be certain that it is the appropriate treatment to the certain person in the

As we explained before, the empirical research tendency is to demonstrate a psychotropic drug’s general inefficacy, in spite of the pharmaceutical lobby producing a biological psychiatry pseudo science (Ross, 1995). Also methodological and

certain time” (pp. 13).

clinical drug trials are far from being satisfactory On the other hand, whenever the pharmacotherapy

(Antonuccio, et al., 2003; Ross, 1995).

is recommended, parents (or their legal substitute) must give their agreement. This is a basic but often forgotten rule (Pagliaro & Pagliaro, 1998). Besides, the prescription of these substances should be carefully explained to the adolescent/child. The patient should also agree. Prescription requires a comprehensive education and a constant monitoring either by the therapist or the child/adolescent's

Another argument has to do with the concomitant easiness with which some diagnoses are made. This gives

rise

very

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professionals (including psychologists) insist on using them? This question makes sense and is tragically pertinent if we think about them being used in children and adolescents (Pires & Costa, 2003). Even in the few justifiable pharmacological interventions (such as ADHD treatment), there are some important aspects:

family, namely in what concerns ADRs.

frequently

Why do the general public and many mental health

undesirable

(1) The extremely broad and flexible diagnosis criteria; so, nowadays there's a growing number of potential “hyperactive” children, also potential

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candidates

receiving

pharmacological

prescription.

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

al. (2002b) of this subject is elucidative, as well as that of the tricks used as current practice in many

(2) The possible use of stimulants; why aren't they

clinical trials (Healy, 2002).

combined with psychological interventions? Could

So, how is it possible that different professionals still

drugs be discontinued to maintain good changes

simply believe in the effectiveness and safety of

with behaviour modification? Why do physicians

psychopharmacs? We think this is based either on a

always aim at trying another drug?

lack of independent data, or on undistorted data.

The combination therapy may obviously be an interesting strategy as it aims at getting the best results. However, the spreading of a drug therapy clinical practice invokes benefits that do not really

How is data about these drugs issued? When and how does it reach public opinion, including doctors and other professionals? We assume that the media frequently fulfil this aim without perceiving what they are doing.

exist. We also think that there is a bias in most research reported in medical papers: those who sponsor clinical trials are drug manufactures, which only sponsor research that confirms the drugs’ utility; only researches for the use of drugs are published (Antonuccio et al., 2003). This is neither new nor ilegal. But it is a scientific distortion that eventually contributes to our unreal beliefs about medicines. Clinical trials are biased and methodologically pitfalls. So why don't we do that? Because we believe that drugs are therapeutically effective and safe. Nevertheless, Kirsch et al. (2002a; 2008) reported two important studies carrying out a meta-analysis of all clinical trials of antidepressants approved between 1987 and 1999 by FDA. They found that 80% of their therapeutic effects were placebo. And, even when medication was better than placebo, it had no clinical consequences (two points in the Depression Hamilton Scale). The analysis of Kirsh et

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The article by Antonuccio and Danton (2002) issued by AMERICAN PSYCHOLOGIST reports a set of pharmaceutical industry strategies, set to create an opinion for the prescription and use of drugs, and sometimes it is not easy to distinguish legitimate news from advertising. For example, Antonuccio and Danton (2002) explains that in 1999, a New York public relations firm advertisement campaign involving newspapers, radio stations, TV channels, Internet, alongside with testimonials from advocates and doctors, indicated that social anxiety was highly prevalent. The campaign was so successful that social anxiety was mentioned in the news to over 1 billion times in 1999, compared to about 50 total news in 1997 and 1998. About 96% of the news claimed that the antidepressant PAXIL was the first and only FDA approved medication for the treatment of Social Anxiety Disorder (Antonuccio & Danton, 2002).

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FINAL REMARKS

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Journal of the American Academy of Child and

We conclude that, nowadays, the therapeutic

Adolescent Psychiatry, 37, 27-44.

combination, in general, is no more than an invalidated idea with a limited clinical utility. It is an interesting matter of research rather than a matter of clinical practice. In fact, a psychiatrist rarely envisages the possibility of a combination treatment;

American Academy of Child and Adolescent Psychiatry (2004).Teen suicide. Retrieved from http://www.aacap.org/publications/factsfam/sui cide.htm.

normally, he/she tries either a drug or a combination of drugs (polimedication). When a drug or a combination of drugs fails, he/she try another drug

American Psychological Association. (2006). Report of

the

working

group

psychotropic

medications for children and adolescents:

or another combination, and so on.

psychopharmacological, Psychologists must even think about the ethics existing in ignoring all the problems (ADRs) caused in many children and adolescents by drugs, and the

psychosocial,

and

combined interventions for childhood disorders: evidence base, contextual factors, and future directions.Retrieved September, 29, 2006.

absence of science in such practice. We believe that professional psychologists must base their theory and

practice

the

psychological

therapies

empirically validated, without losing the nature and identity of their science and profession.

Antonuccio, D. O., Danton, W. G., & McClanahan, T. M. (2003). Psychology in the prescription Era: Building a firewall between marketing and science. American Psychologist, 58(12), 10281043. Antonuccio, D.O., & Danton, W. G. (2002). A

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Original Article Goal agreement between client -therapist dyads Luísa Soares (1), Marina S. Lemos (2), Filipa Oliveira (1), Mónica Fernández (1) & Catarina Faria (1) (1) University of Madeira – Portugal. Correspondence concerning this article should be addressed tocorresponding author Luísa Soares, University of Madeira, Campus Universitário da Penteada – 9050 Funchal -Portugal. E-mail:lsoares@uma.pt (2) University of Porto - Portugal

_________________________________________________________________________________ Abstract The goal is to analyze the therapist-client agreement on goals for doing therapy, and to see if there is an association between goals’ agreement, and the cases of withdrawal from therapy. Thirty-nine client-therapist dyads participated in this study. The goals for therapy were assessed by the Goals for Therapy Questionnaire administered in 1st, 3rd, 5th and 8th session. Overall, the results indicated that there were divergent on goal agreement in the four sessions evaluated. Additionally, a mixed pattern of results were observed in terms of effects of goals agreement on dropout’s cases. Thus, the agreement on goals for doing therapy was not always linked with more positive therapeutic outcomes. The results highlight the importance of further studies with dyads of clients and therapists, in order to better understand this unique dynamic between them. Ke yw or d s: Goa l A gr e e m en t ; Dy ad s ; D rop o u t s ; P sy ch oth e rap y .

Resumo O objetivo é analisar o acordo terapeuta-cliente como meta para realizar terapia, e para ver se existe uma associação entre o acordo de metas, e os casos de desistência da terapia. Trinta e nove díades clienteterapeuta participaram deste estudo. As metas para a terapia foram avaliadas pelo Questionário de Objetivos de Terapia aplicado na 1 ª, 3 ª, 5 ª e 8 ª sessão. No geral, os resultados indicaram que houve divergência em acordo de objetivos nas quatro sessões avaliadas. Além disso, um padrão misto de resultados foram observados em termos de efeitos do contrato de metas em casos de desistência. Assim, o acordo sobre metas para fazer terapia nem sempre foi relacionado com resultados terapêuticos mais positivos. Os resultados destacam a importância de novos estudos com díades de clientes e terapeutas, a fim de entender melhor essa dinâmica única entre eles. Palavras-chave: Acordo de Metas; Díades; Dropouts; Psicoterapia.

Resumen E l ob je ti vo e s an al izar e l a cu erd o t er ap eu ta - cl ie n te e n l o s mo ti vo s p ar a h ac er t erap ia, y p ara v e r si ex is te u n a a so ci ac ión en tr e la s m et as d e a cu erd o , y lo s ca s os d e ab an d on o d e la t erap ia. Tr ei n ta y n u e v e d íad a s c li en te -t e r ap eu ta p art ic ip a ron en e st e e stu d io . L a s m eta s d e l a t erap ia fu e ron e valu ad a s p o r e l C u e st ion a rio d e Ob j et i vo s d e la T e rap i a ad m in i s trad o e n p r im e r a, t erc e ra, q u in ta y oc t ava s e s ión . E n g en er al, lo s r e su ltad o s in d i car on q u e fu e ron d iv e rg en t e s s ob r e e l a cu erd o d e m eta s en la s c u atro se s ion e s e val u ad a s . Ad e má s, u n p atrón mi xto d e l os re su lt ad o s s e ob s er v ó en cu an to a lo s e f e cto s d e lo s o b j eti v os d e u n a cu e rd o s ob r e lo s ca so s d e a b an d on o d e la t e ra p ia. Po r l o tan to, el a cu e rd o sob r e la s m eta s p ar a h ac er t era p ia n o e stu v o s ie mp r e vi n cu la d a con lo s re su ltad o s t er ap éu ti co s má s p o si ti vo s . L o s re su lt ad o s d e sta can l a i m p ort an ci a d e n u e vo s

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e stu d io s con d iad a s d e c li en t e s y t e rap eu ta s, co n el f in d e en t en d er m e j or e sta d in á mi ca ú n ic a en tr e el lo s . Pa lab r a s c la ve : A cu erd o d e Ob j et i vo s ; D iad a s ; D rop ou t s ; Ps i cot er ap ia .

_________________________________________________________________________________

It is believed that the nature of the relationship between therapist and client predicts, to a large extent, the quality of the

therapeutic

pro cess

and

outcome.

Tasks refers to the extend client and therapist agree o n therapy tasks. Bond addresses

the

sense

attachment

between the therapist and client.

Indeed, several investigations have shown

Evidence

the

consensus and collaborative invol vement

the

are important factors in determining the

positive

relationship

therapeutic

between

relat io nship

and

has

goals

quality

& Imel, 2007; Horvath & Bedi, 2002;

(Mackrill,

Martin, Garske, & Davis, 2000; Norcross,

Montgomery, 2010; Steering Committee,

2002; Schnur & Montgomery, 2010). So, it

2002; Tryon & Winograd, 2002não está nas

can

referencias). The essence of goal consensus

said

that

the

therapeutic

2010a,

2011b;

Schnur

the

therapy goals and the ways to accomplish

(Norcross,

them (Mackrill, 2010a, 2011b; Tryon &

specific

therapy

outcome

ingredients

than

2002; Shunr & Montgomery, 2010).

therapist

undo ubtedly

and

considered

client a

central

element of the therapeutic relatio nship (Baldw in, et al.,; Bordin, 1979; Horvath & Bedi, 2002; Luborsky, 2000; Martin et al.,; Norcross,

2002).

According

Bordin

(1979), the therapeutic alliance comprised three components: goals, tasks and bonds. Goals refer to the extend which therapist and client agree on go als for doing therapy.

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Winograd, 2002, 2011). In psychotherapy

The construction of therapeutic alliance between

agreement

therapy

therapist -client

outcome

relationship, itself, appears to influence the

the

psychotherapy

that

therapeutic o utcome (Baldwin, Wampold,

established

reaching such an agreement is not always easy and immediate

(Mackrill, 2011b),

because too often, clients do not know what they really want to achieve in therapy or the goals they formulated are not sufficiently

precise

and

realistic.

addition, clients’ goals for therapy may include specific goals to their concerns, problems and symptomatology but also broader

life

go als.

Given

this

great

variability, therapists and clients might not

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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

share common goals and expectations for

(M=32.9; SD=8.5). M ost therapists were

therapy. So, in order to minimize possible

psychologists (92 .9 %) and just only one

discrepancies between therapist and client,

was a psychiatrist (7.1%). Most therapists

and to enhance the therapeutic results, the

work in a center for drugs addition (78.6%)

goals for therapy sho uld be analyzed and

in a hospital, school/ university and in the

discussed

clinical

together

(Cooper &

Mcleod,

setting

(21.4%).

The

problems

2007; Tryon & Winograd, 2002, 2011 só

identified in therapy were: drug addiction

consta 2011 nas referencias). In fact,

(78.6%) and anxiety/depressio n (21.4%).

“psychotherapy is not something do ne to them but by them” (Mahoney & Granvold, 2004, p. 74).

From the clients’ sam ple, 20 were women and 19 were men. The clients’ age was 28.7 and standard deviant 6.9, ranging from 19

Assuming the importance of these variables

to 47 years. For the majority of clients

for

its

(74%) it was the f irst time in therapy

outcome, and the need to continue to

(74.4%). About 54% of them dropped out

understand

from

the

therapeutic

the

process

complex

and

unique

therapy.

the

dropouts,

47%

dynamic established between the therapist

occurred after 1st session, 29% after 3rd

and clients, this study aims to analy ze the

session and 24% after the 5th session.

therapist -client agreement on goals and, to

Measures

313

see if there is an association between the goal’s agreement for doing therapy and the

First, we applied a questionnaire to collect demographic data , in order to characterize

dropout of clients.

the sample. Subsequently, we applied the Goals METHOD

for

Therapy

Questionnaire,

developped by Soares and Lemos (2003), which

Participants

asses

the

therapist’

goals

and

client’s goals for therapy. There are two Thirty-nine

therapist -clients

dyads

(14

therapists and 39 clients) of the Northern Region of Portugal participated in this study.

versions of this questionnaire, one f or the therapist and another one for the client. Clients were asked to write down at least three goals they wanted to achieve while

From the therapists’ sample, thirteen were

doing psychotherapy. On the other hand,

women

therapists were asked to write down at

and

just

o nly

one

man.

The

therapist’s age ranged between 27 -59 years

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least three goals they wanted achieve with

The eight categories of the therapy goals

the client during the therapeutic process.

formulated were: (1) self -confidence; (2) problem solving; (3) emotional control; (4) psychological well -being; (5) interpersonal

Procedure

relationship;

(6)

prevention

drugs

The Goal for Therapy Questionnaire was

consumptio n; (7) therapeutic supp ort; and

applied at the beginning of sessions 1st,

(8) academic/professional adaptation.

3rd, 5th and 8th, with the prior informed consent

the

participants

and

the

institutio ns where the therapists works. Participants’ selection was based on their availability to participate in this study. All statistical analyses were performed using SPSS Statistics Program 17.0.

The presence of a common goal by an element

the

dyad

resulted

into

dichotomous variable (0,1), which allowed us

establish

disagreement

the

agreement

therapist -client

or dyad

regarding the the rapy goal category. We considered

goal

agreement

between

therapist and client, when both therapist and client set the same goal category for

Results We made a global list of the goals for therapy referred by therapists and by the clients. We

also

used a

non -selective

approach, opting to maintain the goals

therapy, in a specific session. On the contrary, when the elements of dyads mentioned different goals for therapy we considered a disagreement.

formulated by clients and therapists and

For the statistical analyzes it was excluded

grouped them into categories.

the cases where both client and therapist

The final an

did not mentioned such goal category (e.g.,

independent

the goal category prevention of drugs

observers. Each observer had pr evious

consumptio n was only common in those

formulated categories for the goals for

cases where clients were attending the

therapy

Center for drug users.

eight

categories

agreement

resulted

between

mentioned

from

clients

and

therapists, and these goals’ categories

In this study, the analysis focus was o n the

were share and discussed together. We

therapist -client agreement in each of the

defined the same categories of goals, for

four sessions evaluated of the therapeutic

both clients and therapists, to facilitate the statistical analysis.

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process (1st, 3rd, 5th and 8th) and not

quit and those who do not, have the same

throughout the all course of therapy.

distribution, for p values higher than 0.05

In order to

establish,

associatio n

between

if there

is an

client -therapist

agreement for the therapy goal and the cases that dropout from therapy, it was conducted the chi -square adjustment test. We intend to establish if, the distributio n

(Schinka,

Velicer,

2003).Agreement

& vs

Wayne,

disagreement

regarding the goals for therapy. First, we began the analysis of data regarding the frequency

the

agreement

and

the

disagreement (see Table 1).

of agreement and di sagreement between 315

dyads, in which clients dropped out and those who did not, is the same. Our hypothesis is: the dy ads in which clients Session 1

Session 3

Session 5

Session 8

Disagree

80.8

75.0

46.2

60.0

Agree (Yes)

19.2

25.0

53.8

40.0

Disagree

64.5

68.8

81.8

62.5

Agree (Yes)

35.5

31.3

18.2

37.5

Disagree

62.5

70.0

80.0

Agree (No)

37.5

30.0

20.0

Disagree

77.8

75.0

72.7

88.9

Agree (No)

22.2

25.0

27.3

11.1

Disagree

64.7

50.0

54.5

50.0

Agree (Yes)

35.3

50.0

45.5

50.0

Prevention of drugs

Disagree

60.0

57.1

100.0

50.0

consumption

Agree (Yes)

40.0

42.9

0.0

50.0

Therapeutic support

Disagree

80.0

85.7

100.0

66.7

Agree (No)

20.0

14.3

0.0

33.3

Disagree

66.7

75.0

55.6

57.1

Agree (Yes)

33.3

25.0

44.4

42.9

Self-confidence Problem solving Emotional control Psychological well-being Interpersonal relationship

Academic/professional adaptation

Table 1. Frequencies for session and categories of goals for therapy

In the first session, there were a greater agreement between client and therapist in the following categories of goals: solv ing problem, emotional control, interpersonal

relationship

prevention

drugs

consumptio n. In the third session, the goals’ agreement focused more on problem solving,

interpersonal

preventio n

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and

drug

relationship

and

consumption.

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observed that, between the first and third

regarding therapy goals’ and the dropouts

session, dyads basically agreed on the same

from therapy, we used the Chi -Square

goals for therapy. Yet, in the fifth session

Adjustment

there were more co ncordance regarding

presented for each category goals. Self-

self-confidence, interpersonal relationship

confidence. In the first session (see Table

and

adaptation

2), 10% of the dyads who continued the

goals’. In the eight session, the number of

therapy, agreed on self -confidence as a

concordance between therapist and client

goal for therapy, yet among those who have

was higher in self -co nfidence, prevention

given up therapy that percentage was 25% .

Regarding the goals for the 3rd and 5th

academic/professional

drug

consumption

and

academic/professional adaptation goals’.

and

therapist

res ults

were

between the two gro ups (X= 5.143, p <0.05 and X = 6 .250, p <0.05 ).

goals’ and dropout fro m therapy . To assess client

The

session, it was possible to see differences

Agreement vs disagreement on therapy

the

test.

agreement

Not give up

Give up

316

Chi-square adjustment test

Self-

Disagree

90.0

75.0

2.250

0.134

Agree (Yes)

10.0

25.0

Disagree

84.6

57.1

5.143

0.023

Agree (Yes)

15.4

42.9

Disagree

55.6

25.0

6.250

0.012

Agree (Yes)

44.4

75.0

Disagree

60.0

Agree (Yes)

40.0

confidence (session 1) Selfconfidence (session 3) Selfconfidence (session 5) Selfconfidence (session 8)

Table 2. Results of Chi-square adjustment test for Self-confidence goal in therapist-client dyads

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the 3rd and 5th sessio n, indicating that the

So, in the dyads of clients and therapists that did not give

disagreement

up the therapeutic

regarding

this

goal

was

related with the permanence in t herapy.

process, it was higher the number of disagreement, between them, in particular

Solving

on assuming the self -confidence as a goal

percentage of goal agreement was lower,

for

than the percentage of disagreement on

therapy.

the

5th

session,

this

percentage decrea sed to 55.6%. On the

problem.

both

groups,

the

this goal (see Table 3).

contrary, in dyads in which clients dropped out

from

therapy,

the

percentage

agreement was significantly different in

Not give up

Give up

Chi-square adjustment test

Problem solving

Disagree

58.3

68.4

2.579

0.108

Agree

41.7

31.6

Disagree

62.5

75.0

0.000

1.000

Agree

37.5

25.0

Disagree

71.4

100.0

Agree

28.6

0.0

Disagree

62.5

Agree

37.5

(session 1) (Yes) Problem solving (session 3)

317

(Yes) Problem solving

2.250

0.134

(session 5) (Yes) Problem Solving (session 8) (Yes) Table 3. Results of Chi-square adjustment test for Problem Solving goal in therapist-client dyads

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showed more concordance on goal, than

Emotional control. From the sixteen dyads

those observed among dyads of clients who

who considered the emotional control, as a

remained in therapy. Psychological well -

goal for do ing therapy in the 1st session,

being.

ten therapists and clients disagreed that this was a goal shared by them, and six of

Eighteen dyads indicated the psychological

them

well-being as a goal in the 1st sessio n. The

had

given

subsequent

sessions.

adjustment

test

therapy

the

chi -square

distribution

that

the

between the dyads who had given up the

agreement/disagreement

therapeutic process, and those who had

was substantially equal, in dyads where

not given up (see Table 5). In sixteen dyads

clients had quite therapy and those that

that indicated this goal, in the 3rd session,

had not (see Table 4). In the 3rd and 5th

we observed a good adjustment between

sessions, we found differences between

the dyads in which clients did not give up

these two gro ups of dyads. Therefore, the

therapy when compared to those dyads

dyads of clients who dropout from therapy,

that clients did.

percentage

The

showed

Not give up

was

Give up

statistically

equal,

Chi-square adjustment test

Emotional

Disagree

66.7

57.1

0.571

0.450

Agree (Yes)

33.3

42.9

Disagree

71.4

66.7

5.333

0.021

control (session 1) Emotional

318

control (session 3) Emotional

Agree (Yes)

28.6

33.3

Disagree

75.0

100.0

Agree (Yes)

25.0

0.0

Disagree

80.0

Agree (Yes)

20.0

18.000

0.000

control (session 5)

Emotional control (session 8)

Table 4. Results of Chi-square adjustment test for Emotional Control goal in therapist-client dyads

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Not give up

Give up

Chi-square adjustment test

Psychological

Disagree

75.0

80.0

0.400

0.527

Agree (Yes)

25.0

20.0

Disagree

77.8

71.4

0.571

0.450

Agree (Yes)

22.2

28.6

Disagree

75.0

66.7

8.333

0.004

Agree (Yes)

25.0

33.3

Disagree

88.9

Agree (Yes)

11.1

well-being (session 1) Psychological well-being (session 3)

Psychological well-being (session 5) Psychological well-being (session 8)

Table 5. Results of Chi-square adjustment test for Psychological Well-being goal in therapist-client dyads

319

referred interperso nal relatio nship as a goal for doing therapy. In six of them , it However,

observed

significant

differences, in eleven dyads that choose this goal in the 5th session, when compared

was

among those who gav e up and those who

therapist and client regarding this goal

remain in therapy . These differences were

category (see Table 6). In three of them, it

explained by the fact that 25% of the dyads

was

agreed that psychological well -being was a

therapist and clients on this goal for doing

goal in this session, while this percentage

therapy (p <0.05).

was 33.3% in dyads who did not end the therapeutic process.

observed

co ncordance

agreement

between

When compared with the 3rd ses sio n, just twelve dyads referred this as goal category,

Interpersonal Relatio nship. From thirty -

and in six of them, we registered therapist -

nine

client

dyads

this

study,

seventeen

agreement.

Additionally,

five

these six dyads, did not end prematurely

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the therapeutic process, and it represented

therapy. This difference explained the level

62.5% of the dyads that remain in therapy

of significance o bserv ed in the Chi -square

versus 25% of dyads in which client gave up

adjustment test.

Agree

50.0

(Yes) Not give up

Give up

Chi-square adjustment test

Interpersonal

Disagree

66.7

62.5

0.125

0.724

Agree (Yes)

33.3

37.5

Disagree

37.5

75.0

4.000

0.046

Agree (Yes)

62.5

25.0

Disagree

54.5

Agree (Yes)

45.5

Disagree

50.0

Agree (Yes)

50.0

relationships (session 1) Interpersonal relationships (session 3) Interpersonal relationships (session 5) Interpersonal relationships (session 8)

Table 6. Results of Chi-square adjustment test for Interpersonal Relationship goal in therapist-client dyads

Prevention of drug co nsumption. From the thirty-nine dyads, fifteen dyads considered the prevention of drug consumption as a goal in the first session. However, only six dyads had an agreement between the therapist and the client on this goal for therapy. When compared the two gro ups of

and those who remain in therapy, the distribution was sta tistically equal (see Table 7). In the 3rd session, seven dyads reported this as a go al for doing therapy , but among these, only 3 dyads agreed that the prevention of drugs consumption was a common goal for therapy.

dyads, the ones that dropped from therapy

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Table 7. Results of Chi-square adjustment test for Prevention of drugs consumption goal in therapist-client dyads Not give up

Give up

Chi-square adjustment test

Prevention

Disagree

83.3

44.4

1.000

0.317

Agree

16.7

55.6

Disagree

40.0

100.0

4.500

0.034

Agree

60.0

0.0

100.0

drugs consumption (session 1) (Yes) Prevention

drugs consumption (session 3) (Yes) Prevention

Disagree

drugs consumption

321

(session 5) Agree

0.0

Disagree

50.0

Agree

50.0

0.0

(Yes) Prevention

drugs consumption (session 8) (Yes)

Therapeutic Support. Ten dyads reported therapeutic support as a goal in the 1st session. It was also observed an agreement between therapis t and client regarding this

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category only in two of them (see Table 8). There was a perfect adjustment between the two groups, which was not observed in the 3rd session, so the agreement on this

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goal appears as a promo ter for client to

remained in therapy and two quit therapy.

remain in the therapy process.

Overall, these results indicated that the

Academic/professio nal

Adaptation.

effect of client -therapist goal agreement,

This

in each session, had less impact in the 1st

goal was mentioned in eighteen dyads, and

session than in the 3rd and 5th sessions.

we observed an agreement on such goal in six dyads (see Table 9). Fo ur of them Not give up

Give up

Chi-Square adjustment test

Therapeutic

Disagree

80.0

0.000

1.000

Agree

20.0

Disagree

83.3

100.0

25.000

0.000

Agree

16.7

0.0

100.0

support (session 1) (Yes) Therapeutic support (session 3) (Yes) Therapeutic

Disagree

support

322

(session 5) Agree

0.0

Disagree

66.7

Agree

33.3

0.0

(Yes) Therapeutic support (session 8) (Yes)

Table 8. Results of Chi-square adjustment test for Emotional Control goal in therapist-client

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Not give up

Give up

Chi-square adjustment test

Academic/Prof.

Disagree

60.0

75.0

0.500

0.480

Agree (Yes)

40.0

25.0

Disagree

71.4

80.0

0.800

0.371

Agree (Yes)

28.6

20.0

Disagree

50.0

66.7

3.000

0.083

Agree (Yes)

50.0

33.3

Disagree

57.1

Agree (Yes)

42.9

adaptation (session 1) Academic/Prof. adaptation (session 3) Academic/Prof. adaptation (session 5) Academic/Prof. adaptation (session 8)

Table 9. Results of Chi-square adjustment test for Academic/professional adaptation in therapist-client dyads

323 disagreement

DISCUSSION

goals

for

therap y,

between therapists and clients were higher As outlined previously, the main focus of this study was to analyse if clients and therapists tend to agree on goals for

than the percentage of agreement. This

therapy and explore its effects on dropouts

seems to be in line with some empirical

from therapy.

studies of therapist -clients dyads (e.g.,

The results showed that therapists and clients did not always share the same goals for therapy in the four sessions evaluated. Because

that,

the

percentage

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Fitzpatrick,

Iwakabe,

Stalikas, 2005;

Swift & Callahan, 20 09) that found that convergence in goals for therapy does not always

occur

between

therapists

clients.

This

evidence

needs

and be

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

discussed among therapists communities.

recovery, since according to literature, a

Are we working together, on the same

minimum of 11 to 13 sessions are needed

pathway

for

when

engage

psychotherapy process with our client? Or are we serving just as a hearing audience to his problems?

clients

complete

recovery

(Lambert, 1997). We also tried to analyse the effect of goal agreement in cases of withdrawal, since

From the eight categories of goals for do ing

various studies stated this element as

therapy analysed in this study, the goals

important ingredient for improving the

that clients and therapists seemed to show

global

greater

2010a, 2011b; Tryon & Winograd, 2011).

agreement

relationship

and

were

interpersonal

prevention

dr ug

therapeutic

Therefore,

fou nd

observed that when clients and therapists

four

sessions

evaluated. The

this

results

were

all

mixed

pattern

regard

(Mackrill,

consumptio n, since these goals categories mentioned

outcome

issue.

agreed o n specific goals for therapy such as

standard

categories

goals

for

therapy, set by therapists and clients, were more similar in 1st and 3rd sessions; however it changed somewhat between the 5th and 8th sessions (e.g., self -confidence,

interpersonal relatio nship and prevention of drug consumptio n in 3rd session, those clients

predicting

to so,

remain

eventually,

ther apy, better

outcomes. This result was consistent with prior

academic/professional adaptation).

tend

studies

(Mackrill,

2010a,

2011b;

Tryon & Winograd, 2 011) that indicated In terms of dropouts from therapy, we observed a total of 54%. These numbers were closer with tho se reported in prior studies, namely Weirzbicki and Pekarik (1999) that reported 46 .86% withdrawals from therapy and Garfield (1994) that pointed out more than 65% of clients dropped from psychotherapy before the 10th

session.

Given

that,

early

terminatio n of therapeutic process may prevent clients from reaching a desirable

ISSN: 2182 -0290

goals consensus as an important element to foresee the quality of the therapeutic process. Howeve r, we did not observe the same pattern regarding self -confidence, emotional

control

and

psychological

wellbeing goals category. In these latter cases, o n the contrary, the agreement on goals for therapy between therapists and clients were linked with cases of dro pouts. These mixed results highlight what Defire and Hilsenroth (2011) mentioned about the

Year 0, Vol. I, nº 3, 2013

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fact that the relatio nship between goal

Balaguer, & Saldanã, 2007; Barret et al.,

consensus and therapeutic outcome after

2008). That´s why it´s very complex to

the 3rd session of therapy was not so clear.

understand

All these results raised more que stions and hypotheses than answers. One possible hypothesis, for the fact that clients tend to

the

dynamic

dyads

therapists and clients, and therefore, the establishment

causal

relationships

concerning dropo uts.

continue the therapy when therapist had

Nevertheless, we cannot ignore the role of

different goals for therapy, is that clients

goal

had not yet found satisfactory answers for

establishment of therapeutic collaboration

their

and therapeutic process itself. Because of

problems

needs,

and

they

persisted.

facilitating

the

that, it is important that therapy privilege

In others cases, when clients gave up therapy, even when they share common goals with therapists, may be due their perception of recovery and improvement or low levels of motivation and commitment in pursuing their goals. As referred by some authors, clients may end the treatment when perceived that they reach some satisfactory

agreement

relieve,

despite

the dialogue, identification and discussion of expectations and go als for doing therapy between therapists and clients. Also, a regular reformulation, monitoring of those goals throughout the course of therapy, and

constant

feedback

essential

(Barrett et al., 2008; Defire & Hils enroth, 2011).

325

clinical

With this study, we intend to implement a

significant change or recovery have not

seed that rises the interest in studying

been met yet (see Barrett et al., 2008).

This mixed pattern o f results about goal consensus and its e ffects on dropouts from therapy, suggests a boarder influence of factors o n dropouts. As literature refers, there

are

many

variables

the

dynamic

dyads,

between clients and therapists, and not only of clients or therapists entity alone, as it is more common to found in other national studies.

Further work is needed, to understand

motivation, involvement in therapy, self -

about therapist -client goal agreement on

efficacy perception, external constraints

therapy goals and its effect on therapeutic

(e.g., financial issues) that in tervene in

outcome, in particular, with a much larger

outcome of therapeutic process (Bados,

sample. Dropouts on therapy need to be

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such

deeply

Year 0, Vol. I, nº 3, 2013

Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

further understood, and the paths that

D. (2008). Early withdrawal from mental

guide to better therapy outcomes.

health

Thus,

future

studies

would

interesting to analyse the development of

treatment:

implications

for

psychotherapy practice. Psychotherapy, 45(2), 247-267.

goal agreement between therapist and

Barrett, M . S., Chua, W. J., Crits -Christoph,

client across the therapeutic session and

P., Gibbo ns, M . B., & Thompson, D.

until

(2008). Early withdrawal from mental

the

last

session

therapeutic

process.

health

treatment:

Implications

for

psychotherapy practice. Psychotherapy: Refer ences Bados, A., Balaguer, G., & C., Saldaña (2007).

The

Efficacy

Cognitive -

Behavioral Therapy and the Problem of Drop-Out. Journal of Clinical Psycholo gy, 63, 585- 592.

The

efficacy

cognitive –

behavioral thera py and the problem of drop-o ut. Journal of clinical psychology, 63(6), 585-592. doi: 10.1002/jclp.20368 Baldwin, S., Wampold, B., & Imel, Z. (2007). Untangling

the

Correlatio n:

Exploring

Alliance –Outcome the

Relative

Importance of Therapist and Patient Variability in the Alliance. Journal of Consulting and Clinical Psychology, 75 (6),

Research,

45(2),

247.

Practice,

doi:

Training,

10.1037/0033 -

3204.45.2.247 Bordin, E.S. (1979). The generalizability of the

psychoanalytic

working

concept

alliance.

the

Psychotherapy:

Theory, Research, and Practice, 16, 252 –

Bados, A., Balaguer, G., & Saldaña, C. (2007).

Theory,

842–852.

doi:

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Modern Science applied to Forensic History Profiling: The mysterious case of Jack the Ripper Clara Margaça (1), Jorge Saraiva (1) & Luis Maia (2, 3) (1) Degree in Clinical Psychology and MsC Student at UBI (Beira Interior University – Portugal). (2) Auxiliar Professor - Beira Interior University; Clinical Neuropsychologist, PhD (USAL - Spain); Neuroscientist, MsC (Medicine School of Lisbon - Portugal); Medico Legal Perit (Medicine Institute Abel Salazar - Oporto, Portugal); Graduation in Clinical Neuropsychology (USAL - Spain); Graduation in Investigative Proficiency on Psychobiology (USAL - Spain); Clinical Psychologist (Minho University - Portugal); Professional Card from Psychologist Portuguese norm, number 102. All correspondence about this article should be sent to luismaia.gabinete@gmail.com. (3) Integrated Researcher in CIDESD - Center for Investigation in Sports, Education and Health - UBI _ Portugal

_________________________________________________________________________________ Abstract In the field of forensic psychology emerges a new criminal investigation technique –profiling - and stands, therefore, as a new type of technique and investigator - the profiler. To conduct a criminal profiling, the profiler must analyze various elements of the crime, among them the crime scene. In this context is relevant to show what the phases are, which issues need to be placed and what kinds of information the investigator can extract from profiling. The crimes of Jack the Ripper have been inspiring literature ranging from fiction to the field of forensic science, and the dividing line between the creative and the factual remains tenuous to the present time. This article aims to do a review of the scientific literature on profiling, analyzing, specifically, the mysterious case of Jack the Ripper. Keywords: Crime; Jack the Ripper; profiling; Forensic Psychology; Serial Killer; Witnesses.

Resumo No domínio da Psicologia Forense emerge uma nova técnica de investigação criminal – o profiling – e destaca-se, por conseguinte, um novo tipo de investigador – o profiler. Para a realização de um profiling criminal, o profiler deve analisar vários elementos do crime, entre eles a análise da cena do crime. Este trabalho visa mostrar quais seriam as fases, as questões que devem colocar-se e qual a informação que se pode extrair para a elaboração do profiling. Os crimes do Jack the Ripper têm vindo a inspirar a literatura que varia desde a ficção até ao campo da ciência forense, e a linha divisória entre o criativo e o factual permanece ténue até aos dias de hoje. O presente artigo tem como objetivo fazer uma revisão da literatura científica sobre o profiling, analisando, especificamente, o misterioso caso de Jack the Ripper. Palavras-chave: Crime; Jack the Ripper; Profiling; Psicologia Forense; Serial Killer; Testemunhas.

Resumen En el campo de la Psicología Forense surge una nueva técnica de investigación criminal - perfiles - y se sitúa, por lo tanto, un nuevo tipo de investigador - el generador de perfiles. Para la realización de un perfil criminal, el generador de perfiles debe tener en cuenta varios elementos del delito, incluyendo el análisis de la escena del crimen. Este trabajo tiene como objetivo mostrar lo que serían las etapas, las preguntas qué deberán colocarse y qué información se puede extraer para la preparación de perfiles. Los crímenes de Jack el Destripador han sido inspiradores en la literatura que van desde la ficción hasta el campo de la ciencia forense, y la línea divisoria entre la creatividad y objetividad sigue siendo retraído hasta la

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actualidad. Este artículo tiene como objetivo revisar la literatura científica sobre perfiles, analizando específicamente el misterioso caso de Jack el Destripador. Palabras clave: Crimen; Jack el Destripador; Perfiles; Psicología Forense; Asesino en Serie; Testigos.

_________________________________________________________________________________

The inference process of characteristics of

criminal people or actions (Wrightsman,

individuals responsible for the criminal acts

2001).

concerns the notion of profiling, which is one of the subcategories of the techniques of criminal investigation and that matches the personality and criminal behavior. Although this is a recent prediction model in developing, the object and the function of

this

technique

assume

the

understanding of crime and criminal acts/people (Correia, Lucas, & Lamia, 2007). Thus, profiling consists in a process of criminal analysis that associates the

The concept of profiling, which was developed in the scope of Forensic Psychology, corresponds to a field that, in various

countries,

developed

psychologists specialized in the forensic area (Wrightsman, 2001, cited in Correia et al., 2007) and join a set of methodologies that

appear

identified

diverse

assignments: psychological profile, profile of the offender, and profile of criminal personality.

abilities of the criminal investigator and the specialist in human behavior.

According to Agrapart-Delmas (2001, cited in Correia et al., 2007) profiling is constructed based on a complex skill that

In attempt of an enlarged definition,

involve multi-disciplinary work, in which

profiling consists of deducing and/or

the

inducing, in the most rigorous way, the

characteristics of the suspects people.

psychosocial image of an individual from

Profiling is consolidated through the

the analysis of a set of relative information

development of other areas of science, in

verified in the scene of crime and

particular:

psychology,

congregated criminal circumstances in

criminology,

anthropology,

instruction manual (Montet, 2002). The

geography (Spitzer, 2002). In such a way,

collection and the inference of data intend

profiling is seen as a specialization that fills

to supply specific information on potentials

a profession.

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criminal

investigator

expert

psychiatry, sociology,

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Montet (2001, 2002, cited in Correia et al.,

objective

2007) affirms that the expert who examine

questions: 1) what kinds of things were

the criminal phenomena can exert the

transferred in the crime scene; 2) the reason

activity of profiling to the level of education,

because these events had placed; 3) how

of skill, of inquiry, and contexts, becoming

type of individual can be implied.

profilers, whose technique demands an applied knowledge and integrated of the studies of the criminal behavior, which based

Criminology,

Psychology,

Psychiatry, and Forensic Sciences (Soeiro, 2009).

answer

three

essential

Some authors emphasize the value of a solid psycho-criminal profile, based on the interpretation of a violent act and a detailed examination of all tracks that could be found and collected in the place where the crime happened. This interpretation looks for the

Surely, the first approach of the profiles occurred

when

the

mental

correct determination of the suspected. It is

health

always inferred that the emphasis of these

professionals were asked to support the

studies is very relevant to the decode of the

criminal investigations, which involve often

thought of the criminal person, through the

unusual and apparently unsolved crimes.

behavior analysis, in order to depict the

There are the historical cases of Dr. Thomas

violent act, having in attention the diverse

Bond, with the inquiry on ‘Jack the Ripper’ –

variable as motivation, the use of a special

this case will be discussed further - and the

type of weapon, proofs found in the place of

case of Dr. James Brussels, with the inquiry

the crime, and others (Barra da Costa, 2012).

on ‘Wild Bomber’ (Mad Bomber) (Kocsis, 2006;

Weinerman,

2004a,

Torres,

Boccaccini & Miller, 2006). These efforts had

PROFILING: A HISTORICAL PERSPECTIVE

been in the direction to relate the

For the better understanding of the concept

knowledge

Psychology,

of criminal profile, its utility in the criminal

Criminology, and also the clinical experience

inquiry, as well as its future potential as an

with the criminal profiles.

investigation

Psychiatry,

Ainsworth (2001) adds that the profiles are a technique that aims to structuralize the analysis of the criminal person, with the

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tool,

necessary

understand the origins of this concept. The criminal profiles could have been originated in the fiction instead of real facts; it may

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have started in the creative mind of Edgar

There were three important dates in the

Allen Poe, as a tool for the amateur

development of this technique. In 1972, the

detective C. August Dupin, in 1841, and also

Federal Bureau of Investigation (FBI) had its

in the scientific explorations of Sir Arthur

beginnings making criminal profiling (Egger,

Conan Doyle, with his famous detective

1999;

Sherlock Holmes (Egger, 1999).

instructor of the FBI Academy, taught

The first use of the criminal profiles occurred when Dr. W. C. Langer, psychiatrist, was requested by the Office of Strategic Services to do a profile of Adolph Hitler. After collected all information about Hitler, Langer traced a psychodynamic personality profile, focusing on Hitler decisions and acts; this profile proved be very accurate (Egger, 1999; Pinizzotto & Finkel, 1990, cited in

Soeiro,

Howard

Teten,

Applied Criminology and started to develop profiles for agents, which crimes were still unsolved (“cold cases”). However, FBI established

the

official

Psychological

Profiling Program only in 1978. In 1982, the Behavioral

Science

Unit

received

fellowship from the National Institute of Justice (Department of Justice), enabling to expand its capacities to build a file of recorded

Torres, Boccaccini & Miller, 2006).

2009).

interview

with

convicted

murderers (Porter, 1983; cited in Egger, In 1957, James Brussels, a psychiatrist, was requested

New

York

City

Department, to help to identify the ‘Mad Bomber’, responsible for more than 30 bombing attacks throughout 15 years (Kocsis, 2006; Weinerman, 2004a, cited in Torres, Boccaccini & Miller, 2006). This psychiatrist studied the crime scenes and analyzed the letters that the bomber sent for newspapers. And, in 1964, he used a similar technique to make the profile of the ‘Strangler of Boston’ for the Boston Police Department.

1999).

333

Police In 1985, it appeared the second biggest development in the history of offense profiles. David Canter, psychologist of the University of Surrey (England), collaborated with the Policy of Surrey, the Policy Metropolitan of London, and the Policy of Hertfordshire, in the investigation of thirty rapes and two homicides. Canter made the profile of the rapist-murderer not yet identified, who will be nicknamed later by the press as the ‘railway rapist’. The Canter’s work was remarkably necessary and it

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proved to be extremely useful in the capture of the rapist-murderer John Duffy. After this work, in 1994, Canter created the first Graduated

Academy

for

Investigative

Psychology, in the University of Liverpool, England (Egger, 1999). Two

PROFILING: THE TECHNIQUE The technique of the criminal profiles, methodologically, is essentially subdivided in two approaches: clinical orientation and statistics orientation and both can coexist in the same practical application (Garrido,

2007). This last approach is centered in the

mentioned in the history of criminal profiles.

process to predict the characteristics of the

In the end of 80 years, the efforts of Dr.

criminal person in terms of behavior of

Milton Newton, with a preliminary analysis

people

of the entitled investigation “Identification

disclosing

Geoforense of Located Serial Crimes”, in

(Canter, 2004; Snook, Cullen, Bennell,

which was used geographic principles. And

Taylor, & Gendreau, 2008); sometimes, from

and

calculations of variables resultants of the

dissertation of Kim Rossmo, the creator of

analysis of solved crimes and also not

the Geographic Profiles (Egger, 1999;

unsolved case, for comparison with the

Rossmo, 2000).

criminal profiles generated through these

1995,

developments

appeared

the

must

inquiry

Finally, there is the investigation of the first

who

commit

typical

similar

crimes,

comparison

pattern

techniques (Barra da Costa, 2012).

case that was, possibly, the first serial killer,

Due to overspread of media (TV, Radio, etc.),

the Assassin of Whitechappel, well known as

these types of crimes have great impact in

“Jack,

investigation

the community, making the criminal activity

help

of a

more visible. This technique had been

psychiatrist, Thomas Bond, supplying the

provoked also an increasing interest in the

profile to the police with some description of

scientific publications. Consequently, the

the potential offender, based on the

addition of scientific works had been

behavior shown in the crimes (Weinerman,

facilitated the

2004a, cited in Torres, Boccaccini & Miller,

methodologies used in its application and

2006; Rumbelow, 1988, cited in Kocsis,

evaluation of its validity, functioning as

2006; Soeiro, 2009).

predictive instrument of the characteristics

the

involved

Ripper”. This

the

professional

development of some

of the offender – which could be associated

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to one particular criminal context (Soeiro,

& Soley, 1998, cited in Montet, 2002). While

2009).

prolongation of the criminal analysis,

Criminal profiles are defined as one technique of inquiry of the crime scene, used to analyze behavior pattern that better define a violent crime or a series of crimes that could be associated, with the intention to identify the characteristics of the

profiling aims to elaborate the criminal profile, whereby it appeals the analyses of most specific variables, such as: criminal profiling, offender profiling, psychological profiling, investigative profiling, crime scene profiling, criminal behavior profiling.

presumable offender (Kocsis, 2003, cited in

Summarizing, the main objectives of the

Soeiro 2009). This technique integrates

profiling are to guide the inquiries, to link

processes of retraction and analysis of the

the cases, to identify crimes with the same

crime scene, with the objective to predict

characteristics, to adjust the strategies for

the

make profiles of the criminal people, and to

personality and the socio-demographic

make recommendations in some domains of

indicators of the offender that committed

the criminology (Toutin, 2002). According to

this particular crime (Hicks & Sales, 2006;

Agrapart-Delmas (2001, cited in Correia,

Kocsis, 2006, cited in Soeiro 2009),

2007), and, in a general way, the profiles are

narrowing the profile of suspected and

the virtual construction of psychological,

helping in his/her detention (Beauregard,

typological, physical, and social profile of a

Lussier, & Proulx, 2007).

person not yet identified that could have

behavior,

the

characteristics

According to Montet (2002), profiling is one of the components of the criminal analysis, but also it functions as its prolongation. Many times, it is understood as “Criminal Investigative Analysis” (CIA) and defined as the

attempt

establish

hypotheses

committed a crime. According to Toutin (2002) and Correia et al.2007, the profiles are seen as psychological, psychiatric and psychoanalytical dimensions of the crime and as criminal analysis, regarding to the suggestions and committees investigation.

concerning a criminal subject, based on the analysis of the crime scene, the victimology,

DOMAINS AND APPLICATION

and the current state of the identification of

The study of this thematic, and its

the aggressors (Knight, Warren, Reboussin,

systematic application, only appears in

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middle of XX century, although do exist

demonstrated that exist a gap between its

registers that it goes back to XIX century. It

application and the insufficient of scientific

referring to the use of information of

support for use it (Snook et al., 2008). Some

psychological nature as instrument of

authors mention that there is an increase of

support to the inquiry of violent crimes,

the use of the technique of the criminal

perpetrated in the standardized form

profiles in countries as the United States of

(Tetem, 1989, cited in Soeiro, 2009). Since of

America and Canada or European countries

these

the

– United Kingdom, Holland, and Germany, in

professionals, who worked in the context of

particular (Snook et al., 2008). Is correct also

violent crime, focused on the development

to affirm that the same it occurs in the

of a field of scientific inquiry, applied to the

Portuguese reality (Soeiro, 2008, cited in

analysis of the behavior of the violent

Soeiro, 2009). Nevertheless, the acceptance

offender; initially guided for the crimes

of the criminal profiles from the part of

where the offender unknown the victim,

many policemen, psychologists, and the

that is, where there is no previous contact

public in general, is in disagreement with the

between the offender and the victim

absence of scientific evidences to confirm its

(Weiner & Wolfgang, 1989, cited in Soeiro,

validity and reliability (Snook et al., 2008).

years,

the

interest

2009).

Following the clinical orientation approach,

The criminal profiles, associated to the huge

the inquiry is based on the trainings,

work developed by FBI, since 1970, have had

experience,

an enormous evolution in terms of

“perception” of the investigators to deduce

spreading and use as instrument of support

the characteristics of the aggressor. All these

to the work of the criminal investigation

factors are developed from the clinical and

police. In fact, with the great impact in the

forensic practical experiences of the expert

community, due to the influence of media

who elaborates the criminal profile (Holmes

on the phenomena of crime, this technique

& Holmes, 1996; Turvey, 1999). The role of

has present an increasing interest and

the coroner expert in the resolution of a

investment in the scientific publications

crime is preponderant, particularly, for

context. However, the set of scientific works

his/her contribution for the elaboration of a

developed, in the last twenty years, has

psico-criminal profile, focusing on making

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knowledge

and

the

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observations in the study and analysis of the

evident that the cases that involved

result of a crime. The pathologists try obtain

behaviors of violence with repetition of

information for identify key-points that

crime are part of the initial context of its

allow, in the reliable way, the reconstruction

application (Burgess, Douglas, Hartman, &

of the crime or of the proper incident that

Ressler, 1986, cited in Soeiro, 2009). Thus,

resulted in death, i.e, the pathogenic of the

the traditional sectors, in which the profiles

circumstances of origin of the criminal act

are strongly associated, that usually apply

that always can be determined it (Adelson,

this technique are: violent crimes and serial

1974).

homicides, sexual crimes, rapes, sexual

Profiling is not a profession (Spitzer, 2002; cited in Correia et al., 2007). Therefore, so far and in international level, does not exist effectively a profession of profiler, in accordance with the judicial norms, legally unionized and regulated (Montet, 2001, cited in Correia et al.,2007). According to Montet (2002) cited by Correia et al. (2007), this

issues

handling

with

specialization, that fills a profession or an indispensable

work.

Nevertheless,

the

technique of the profiles can be apply by an investigator, a psychologist, a criminologist, and others professionals, who understand

crimes

against

children,

kidnapping,

homicides, fires, and assaults with firearms (Kocsis, 2003; Strano, 2004). In some cases, this technique has also been used to identify authors of anonym letters. So, the common characteristic in the analysis of the crimes using the technique of the criminal profiles is the serial crimes. Sometimes, the offender’s reasons in these kinds of crimes are

characterized

psychopathology

for (Strano,

underlying 2004).

This

perspective is present either in the assessment and diagnosis approaches either the statistical approach (Soeiro, 2009).

the criminal phenomena (education, inquiry,

Thus, the main objectives of the profiles are

skill, etc.), particularly, if this technique is

to guide the investigations, with the aid of

intrinsic to a liberal profession, being

Human and Criminal Sciences, to relate the

exerted as a profiler (Correia et al., 2007).

cases, to identify crimes with the same

Considering the reasons that the criminal investigation police promote and use the criminal profiles as instrument, it becomes

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characteristics, to mold the strategies to the profile of the criminal person and also to make recommendations in various domains

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of Criminology (Toutin, 2002, cited in Correia

An important mark of the actions of serial

et al., 2007).

killers is the signature, which concerns to the necessity to leave a mark on the crimes that he/she had committed; they are not only

SERIAL CRIMES

satisfy killing, but they need to make all

Serial killer is a murderer who commits two

ritual that ends as a mark - his/her signature.

or more murders, with a range that

The difference of Modus Operandi is that the

separates each of the crimes (Vellasques,

signature never change, because comes of

2008).

the desire of the criminal person, while the

The serial killing concept became the focus

Modus Operandi can change (Vellasques,

of numerous crime and fiction romances, TV

2008).

programs, movies, and several other forums

According to Casoy (2002), the principal

that aimed much more to entertain than to

characteristics are: maintain sexual activity

inform the people. Considering this trend,

in a specific order; repeatedly uses a specific

the majority of the cases on criminal profiles

type of tying the victim; inflicts in the

disclose a great contribution of forensic

different victims the same type of injury,

science. It seems to have, at least, two types

dispose of the body in a peculiar and

of perception on criminal profile and

shocking way; torture and/or mutilation

forensic science - the public perception and

their victims and/or maintain some other

the perception of application of the law

form of ritual.

(Lester, Gentile, & Rosenbleeth, 2011). According to these authors, the perception of the public concerning criminal profile, based on procedural information, collected from the televising dramas - as for example “Profiler” and “Criminal Minds” - probably is inexact, even that the historical facts on serial killers can be corrected in these TV series.

The research about the modus operandi, the geographical decision and the predatory behavior of offenders has been increasing over the past few years (Lopes, 2009). The modus operandi is defined observing and studying the gun, the victim and the crime scene; this may change in accordance with the practices of the crimes, because normally the killers will be more sophisticate and perfecting their methods.

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THE STRANGER CASE OF JACK THE RIPPER The first steps in the mysterious case of the

thoroughly the wounds of the victims' bodies (Sugden, 1995).

homicides of Whitechapel were made by

During the time, many researchers have

George Baxter Phillips, in 1888, played by

developed profiles in order to discover the

Jack The Ripper (Kocsis, 2006). On this date,

true identity of Jack the ripper. According to

it was first employed, scientifically, a

Olshaker and Douglas (2000), former FBI

psycho-criminal profiling in the famous case

agents, London's killer would be a male,

of the Ripper of London. Initially dubbed as

between 28 and 36 years old, who resided or

"Leather Apron" by the police and the press,

worked nearby Whitechapel. His mother

Jack terrorized the East End of London and

had a dominant personality and she would

committed, at least, five murders in the

be possibly alcoholic and his father could be

Whitechapel area, spreading fear through

weak or even absent from family. In his

the city (Barra da Costa, 2012).

childhood, Jack was a loner person, and had

George

Baxter

pathologist,

was

Phillips, the

forensic

specialist

that

autopsied some of the victims of Jack the Ripper. Based on his clinical experience, and some knowledge in the area of criminology, he sought to deduce some characteristics of his personality through the wounds inflicted on

the

victims

(Turvey,

1999).

The

examination of patterns of wounds is still highly valued. Thus, the combination of various forensic sciences supports, with scientific rigor, the work of any criminal investigator (Barra da Costa, 2012). In order to assess the personality of the killer, Phillips, instead of making comparisons with the behavioral patterns of other criminals

the pleasure of torturing animals, and burn things. Throughout his life, Jack has become a young man who sought power and domination over others and could work as a butcher's helper, or even in a burial ground, hospital or funeral preparation. Although having an antisocial personality, Jack was a married man, dressed strictly in order to show a high social status and always took a gun due to his paranoid ideation. He usually frequented

bars

and

pubs

the

Whitechapel area. Despite having been infected with a sexually transmitted disease he introduced himself as a socially peaceful person,

obedient,

timid

and

clean

appearance.

who committed similar crimes, examined

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Analyzing

the

dislocated some vertebrae and cut her

crimes

abdomen from the pelvic region until the

committed during this period, based on the

stomach. The autopsy revealed also that she

behavioral similarities that were identified.

suffered stab wounds in the vagina (Howells

The plan carefully architected by the

& Skinner, 1987).

investigators

Jack’s

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

linked

behavior, eleven

murderer reveal the full extent of the cuts, the positions in which the corpses were left and the mutilations presented in the bodies; all of these variables are key-points that were the subject of extensive study due to the similarity to some of these crimes presented together (Bull et al., 2006). The study allowed the confirmation that these similar mentioned behaviors did not appears in all crimes; five of the eleven homicides that had occurred at that time, in Whitechapel, had not been made in the 340

same way. Thus, at least, five of the eleven crimes have uneven characteristics that could be associated to the Modus Operandi of Jack the Ripper (Bull et al., 2006).

VICTIMS

Figure 1 - Mary Ann Nichols (Polly) lying in a coffin in the morgue. The photograph has

The first crime occurred in the Bank

poor quality, yet her general features can be

Holiday, Friday, August 31 of 1888, in the

clearly perceived. (Source - adapted: Public

Line of Buck. The victim was Mary Ann

Record Office; Eddleston, 2001).

Nichols (figure 1) - well known as Polly, alcoholic, 42, five children, divorced, with grayish hair and without five teeth of the

The next victim was found in a yard, at

front. Jack cut her throat from ear to ear,

Hanbury Street, Saturday, September 8th,

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1888. Annie Chapman (figure 2), 45, robust

- adapted: Public Record Office; Eddleston,

and without two teeth of the front,

2001).

alcoholic, divorced and separated from her two children, one of them mentally disabled. Annie was found with the neck cut so deeply that seemed that the head was almost separated from the rest of the body; the abdomen was displayed and the intestines placed on the shoulder; some parts of the vagina and the bladder were removed (Howells & Skinner, 1987).

On the Sunday, September 30th, 1888, a double murder happened. Ripper, in first place, attacked Elizabeth Stride (figure 3), in a courtyard next to the International Club to the Workers of the Education, at Berner Street. Stride, 45, alcoholic, without teeth of the front. The victim had nine children, yet her husband and two of the children have died in a boat disaster.

341

Figure 2 - Annie Chapman in the morgue. In this picture none of the terrible wounds inflicted on her body can be seen. The post mortem showed that she was very sick; thus, even if she had not found Jack the Ripper, she would not have lived many years (Source

Figure 3 - Elizabeth Stride’s body in the morgue. The only injury suffered was the cut of the throat (Source - adapted: Public Record Office; Eddleston, 2001).

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The Ripper attacked her, cutting the trachea.

Figure 4 - Catherine Eddowes lying in the

The mutilation of other parts of the body

morgue. She was certainly the second of two

was minimal, because the registers reveal

women killed by Jack, September 30th,

that he was interrupted by a car. One hour

1888.

later, another body was discovered in Mitre

mutilations (Source - adapted: Public Record

Square. Catherine Eddowes (figure 4), 43,

Office; Eddleston, 2001).

Catherine

suffered

atrocious

like others similar victims; she was a chronic alcoholic with a broken marriage. Her throat was deeply cut and the abdomen was open below of the breasts, with the viscera placed on the neck; her ear almost was cut. At this time, Jack took a kidney that he sent later to the authorities (Howells & Skinner, 1987).

The last and more terrible murder occurred in Miller's Court, Friday, November 9th, 1888. The younger Mary Kelly (figure 5), 20, and three months of pregnancy, she already was a widower with alcoholism problems. The bizarre vision terrified those that had discovered her body: the head and left arm almost was cut off, the disfigured face, breasts and nose cut, thighs and forehead skinned, viscera torn and body parts stacked on the bedside table, and her heart disappeared. Jack had all the time that he needed to satisfy his bizarre desires. While the debate elapsed on if he would be the responsible for other prostitutes murders occurred at the same time, the majority of the investigators believe that he stopped, by any reason, after the mutilation of Mary Kelly (Wilson & Odell, 1987).

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Figure 5- Mary Jane Kelly body lying on bed, November 9th, 1888. Parts of the body were placed between the legs, under her head and on the table (Source - adapted: Public Record Office; Eddleston, 2001).

THE (POSSIBLE) CRIMINAL PROFILE OF JACK

agglomeration, urbanization, and economic and social changes provoked the anomie

Nobody knows who was Jack the Ripper and nobody knows what motivated the crimes (Abrahamsen, 1992). Yet he was, in the awkward way, a man of his time. The turbulence of the Industrial Revolution in Great-Britain disturbed the standard of the social order, generating new ambitions, conflicts,

and

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frustrations.

The

(Durkheim’s sense) and the creation of solitary man, mentally ill, and alienated from reality.

The

adverse

and

inhumane

conditions, indifference with the children and a style of wild life had had conspired to create a propitious environment to the violence, and deviant sexual behavior. It is not surprising that the psychological and

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social infrastructures of the nineteenth

had some knowledge of human anatomy;

century had created the first modern serial

the blood of the victims was found in small

killer (Leyton, 1986).

areas; the offender removed rings of one of

In 1988, the FBI prepared a criminal personality profile for the crimes committed by Jack the Ripper (Begg, Fido, & Skinner, 1991; Douglas & Olshaker, 2000). After an analysis of the crime scenes, the authorities

the victims and his last victim was killed inside the house, with several mutilations, suggesting that the killer spent sufficient time at the crime scene. The victims’ bodies were found at dawn.

and the autopsies reports, photographs,

In the five cases described, the Modus

vitimology, and demography of the area,

Operandi of the assassin included attacks to

following the key-element of the crime

white

scene had been identified: violent attacks

between 24 and 45. The weapon used in the

and murders, showing high level of

crimes was a sharp and long knife. The

psychopathology in the crime scenes, no

evidence shows that when the women went

sexual

manual

up skirts in preparation for the sex, the

strangulation, postmortem and mutilation

assassin strangled their throats. The victims

of the parts of the body and its removal, but

were then lowered to the ground with their

not torture, elaboration of ritual, victims’

heads usually facing left killer; this fact is

selection, based on accessibility; all the

supported by the lack of hematomas,

crimes had occurred on a Friday, Saturday or

observed in the coroners reports and, also,

Sunday, in the early morning hours (Douglas

for the absence of blood in the ground and

& Olshaker, 2000).

in their clothes (Keppel, Weis, & Brown,

aggression

evidence,

Based on the medical reports, Douglas and

prostitutes,

poor

women,

and

2005).

Olshaker (2000) founded that there was no

In the Annie Chapman murder case, Dr.

evidence of sexual injuries; the victims were

Phillips repaired that the wounds indicated

murdered quickly, probably by manual

that the murderer has knowledge of the

strangulation; there was no evidence of

human anatomy due to precision of the cuts

physical torture before the death; the

and rigorous removal of organs, post

mutilation occurred post mortem, with

mortem (Barra da Costa, 2012). Following

surgical precision - this fact indicates that he

this idea, the Mary Kelly’ crime, did not obey

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the localization pattern. The previous ones

was of little more than half kilometer

had been committed in the street, taking a

squared.

few minutes; and the Mary Kelly’ murder occurred inside her house, which suggests that he was close to the victim and, therefore, had more time to committed the crime. Some probably

investigators intuit

Kelly

know

the

killer

that and,

therefore, exist the doubt of whether this crime has been committed by killer of London or not (Keppel et al., 2005).

cases

presented,

Ripper was produced based on where the bodies were founded. The top of the area of geoprofile focused on the place around the Flower Streets and Dean and Thrawal. The Flower and Dean and Thrawal streets do not exist today. Yet, in 1888, it were linking with Comercial Street for the west, and Brick Lane for the east, the north of Whitechapel (Fido,

It is possible to assess, through the described

In 1998, a geographic profile of Jack the

that

Jack

adapted his Modus Operandi to attack the victims for backwards and cutting their throats, in order to neutralize them, diminishing the amount of blood in their clothes and, the most important, reducing the possibilities to be identified (Keppel et al., 2005).

1986). All the victims of the Ripper inhabited to a few hundreds of meters ones of the others. Polly Nichols inhabited in the Thrawl Street. However, little before her death, she was displaced to the Flower and Dean Street, in a cheap place; the main residence of Annie Chapman was a lodging house, in the Dorset Street; Elizabeth Stride lived, occasionally, in a house of collective residence in Flower and

GEOGRAPHIC PROFILING, IN WHITECHAPEL

Dean Street and, supposedly, she was in her house in the night of her murder; Catherine

The

“topography”

concentration

of the

the

geographic

crimes

the

Whitechapel Ripper was made a long time. According to Fido (1986), the murders had all been committed one kilometer next to the other and the so called “hunting area”

Eddowes generally was staying in a lodging in the Flower and Dean Street, where she slept two nights, before be murdered; and Kelly lived and died in Miller's Court, next to Dorset Street; this last victim already had inhabited in George Street, between Flower and Dean and the Thrawal Street. In the

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night of the crime, Kelly was seen with a

(Fido, 1986). Although the geographic

man, in the Commercial Street (Fido, 1986).

profile of Whitechapel is interesting and

These residences were, mysteriously, next ones to the others, covering less than 1,5% of the “hunting area”. It is difficult to evaluate the importance of this fact; therefore, the concentration of houses in

with some credibility, it is not possible to evaluate its precision. The address of the murderer, as well as his identity remains unknown (Butts, 1994, cited in Rossmo, 2000).

this area served of lodging the prostitutes (Rossmo, 2000).

The localization, between Mitre Square and Flower and Dean Street, probably is in the same route of Jack’s house, supposing that Flower and Dean Street could be the epicenter where he hunted the victims

346

FINAL CONSIDERATIONS Profiling is applied in all and any situation where

localization

a person commits a violation of the law. Thus, it

corroborated the idea of Homant and Kennedy

becomes reducer to think that the ability and

(1997, cited in Montet, 2002). According to

profiler performance were limited to the cases of

them, profiling is a viable and fascinating

extreme crimes - serial killers (Montet, 2002). In

instrument that can be used inside of limits.

general, the profiling applies in the following

There is an effort towards improving it in cases of

cases: homicides and rapes, serial or not; serious

rapes and serial homicide and later could be used

voluntary violence and attempts of homicide;

in other crime categories.

sadist, cruel or perverse acts, even torture; ritual crimes; hostages; aggressions and disappearance of children; sexual harassment; denunciations and threats; kidnaping; terrorism and

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the

aggressor.

This

fact

It is not correct to say that the criminal profile is the only, total, and efficient form to detect the criminal person, but also cannot be rejected the importance of elaborating a criminal profile,

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because this technique can help to solve the

academics of the University of Washington and

crime; so, it must to be integrated in the

Sam Houston (U.S.A.), tried to understand if all

investigations. It cannot be expected that the

the crimes attributed to Jack have his signature

profile determine a unique or specific criminal;

(Hazelwood, 2003). On the other hand, some

elaborated by psychologists and psychiatrists, it

studies sustain that the serial crimes were

serves as exclusion, to select possible suspicious.

committed by the same and unknown assassin,

It is important to consider that the objective is

well known as Jack, the Ripper.

not only to solve the crime; this technique is also an important tool for the investigation, or even to prevent that criminal people come to act.

Jack was a cold murderer and very organized person. He planned the crimes with minimal details, looking for the perfect crime and without

According to Casoy (2002), for a correct and

vestiges. He prepared in advance the weapons

accurate profile, before trying to understand the

that could be used and the techniques for his

head of a serial killer, two concepts must be

ritual, allowing the meticulousness of the cuts.

taken in consideration by investigators and

The Ripper of London could, also, be considered

criminal attorneys: generally, he/she already

a territorial assassin; he established a territorial

planned the crime in his/her imagination, many

limit to act, inside of Whitechapel Road.

times, before carrying through with the real victim; and, the majority of his/her behaviors satisfies a desire or a pathological necessity. Accepting these two premises, the investigator can deduce the desires or necessities of a serial killer, from his/her behavior in the crime scene.

The analysis of the victims testify that he not suffer paraphilia. Considering that his victims were prostitutes, it was expected that the homicide could be committed sexual acts, with desire, feeling pleasure with differentiated objects or abnormal forms – but these elements

Between 1888 and 1891, eleven women were

were not verified in these crimes. The mutilation,

assassinated in the area of Whitechapel, in

which is common in sexual crimes, appears

London. At the time, it was not known if all

almost in all the victims; however, there is any

crimes were committed by the same killer. Until

kind of sexual vestiges in the Jack’s victims.

these days, persists an ample debate on this question: were the victims could be attributed to the same murderer or not; speculating about the true identity of Jack the Ripper. Recently,

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While some serial killers intends to obtain sexual satisfaction, through primary mechanisms (for example, sexual aggression), others claim to secondary

mechanisms,

with

the

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violence. Probably, Jack used the violence,

Barra da Costa, J. (2012). O perfil em homicídios

stabbing and cutting the victims with a knife as

múltiplos: O caso do estripador de lisboa.

forms to practice his power and control on them.

Departamento de Educação, Universidade

It can consider that the Ripper used a knife to

de Aveiro, Aveiro.

penetrate the victim (picherism) and had the pleasure with the erotic power of violence, the domination, the mutilation and the bleed of the victim, instead of a sexual relation.

Beauregard, E. & Leclerc, B. (2007).

application of the rational choice approach to the offending process of sex offenders: A closer look at the decision making. Sexual

Shortly, the criminal profile is defined as the

Abuse: A Journal of Research and Treatment,

interrelation between physical and psychological

19(2), 115-133. Doi: 10.1007/s11194-007-

proofs, being a tool used in development guides,

9043-6 .

narrowing, in this form, the focus of the suspects (White, Lester, Gentile, & Rosenbleeth, 2011). So, from a forensic point of view, the majority of

Begg, P., Fido, M., & Skinner, K. (1991). The Jack the Ripper A to Z. Londres: Headline Book Publishing.

the serial killers is psychopathic and/or sexual sadist, or has an antisocial personality disorder, depending on the circumstances of the homicide and the pain that they inflicted on the victim, which in later inquiries it will reflect the alleged offender profile.

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160–165. doi:10.1016/j.forsciint.2011.01.022 Wrightsman, L. S. (2001). Forensic psychology. USA: Wadsworth.

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Scientific Review Filicide: some contributions to the understanding of the phenomenon Eduardo Sá (1) & Ana Carolina Pereira (2) (1)

Professor at the Faculty of Psychology and Educational Sciences of the University of Coimbra and of the Higher Institute of Applied Psychology. eduardosa@fpce.uc.pt

(2)

Clinical psychologist, PhD Student in Clinical Psychology from the Faculty of Psychology and Educational Sciences of the University of Coimbra.

Abstract: The aim of this project is giving a contribution to the study of filicide based on the research of the risk and protective factors related to the phenomenon, commonly described in literature. In this context the research will aim to a critical analysis through the intersection of theoretical and the empirical data, in order to develop a systematical comprehension of filicide. This will allow drawing a comprehensive matrix of analysis and prevention of the phenomenon, distinguishing it from other homicides and maltreatment forms.

Resumo: Pretende-se, com o presente trabalho, contribuir para o estudo do filicídio, mediante a investigação dos fatores de risco e protetores, comummente descritos na literatura, relacionados com o fenómeno. Neste enquadramento, a presente investigação terá como objetivo uma revisão crítica para que, na intersecção entre a reflexão teórica e os dados empíricos, se possa desenvolver uma compreensão sistemática do filicídio, especificamente a possibilidade de esboçar uma matriz compreensiva de análise e prevenção do fenómeno, permitindo-o diferenciar de outros homicídios e fenómenos de maus-

352

tratos.

Resumen: Se pretende con este trabajo, contribuir al estudio del filicidio, a través de la investigación de los factores de riesgo y protectores, comúnmente descritos en la literatura relacionada con el fenómeno. En este contexto, la presente investigación tendrá como objetivo una revisión crítica de modo que, en la intersección entre la reflexión teórica y los datos empíricos, se pueda desarrollar una comprensión sistemática del filicidio, específicamente la posibilidad de elaborar una amplia gama de análisis y prevención de esto fenómeno, lo que se distingue de otros homicidios y fenómenos de maltrato.

Filicide, despite its scientific study have developed belatedly specifically with the pioneering work of Resnick (1969), is a phenomenon that dates back to the beginnings

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of humanity, having been justified, over the centuries, for various reasons, such as: congenital

defects,

superstitious

and

supernatural motives, difficulties and economic

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constraints, social events (illegitimate sons,

unwanted children were murdered by their

incest, for example), moral and religious issues,

parents and left to die (Mendlowicz et al, 1998.).

maternal disability (Lambie, 2001; Meyer &

The

Oberman, 2001; Resnick, 1970; West , 2007;).

phenomenon with the advocate “homeland

Lambie (2001) refers, in this regard, that

potestas”, which recognized the right of the

infanticide have been, throughout history,

father to kill his own son (Stanton y Simpson,

resulting from from two basic contexts: 1.

2002). Notwithstanding this right conferred to

parents who kill their children because they

parents, mothers were sentenced to death if

presented

that

they killed an illegitimate child (Mendlowicz et

supposed a disability (which referred to the

al., 1998). During the Middle Ages and the

supernatural and superstitious reasons) 2.

Renaissance, despite the important influence of

parents who kill their children as a result of

Christianity

social

economic

phenomenon as a kind of crime, filicide

difficulties, shame, for example. Filicide is,

remained a common practice to the extent that,

effectively, a phenomenon remote in time and

while on one hand, the murder of children was

practiced by many cultures (Sykora, 2000;

illegal for other, were punished parents who

Stanton Y Simpson, 2002). Oberman and Meyer

had

(2001) point out that infanticide is not a random

contributed to the exponential number of

phenomenon and a crime unpredictable.

children who were exposed and abandoned in

Instead, it is urgent to understand this

institutions) (Magalhães, 2002).

and

some

congenital

family

defect

pressures,

phenomenon taking into account the historical period and the societal context in which it occurs,

one

cannot

dissociate

the

relationship between the social construction of parenting

and

the

occurrence

the

phenomenon of infanticide. In this framework, anthropologists argue that prehistoric societies often practiced infanticide (loc.). In Athens during the classical period, there was no prohibition for a man who wanted to kill or sell

Roman

Law

came

the

illegitimate

formalize

recognition

sons

(which

this

inevitably

In the nineteenth century, Esquirol and Marce, French psychiatrists, advocated a causal relationship between pregnancy, childbirth and subsequent mental disorders in mothers, which have allowed either the scientific community or professional, underline the association between mental illness and practice of infanticide (Meyer & Oberman, 2001). Following this, emerged the English

Infanticide

Act,

1922,

which

recognized infanticide as a form of the

their own illegitimate children; at Rome,

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consequent impact of pregnancy and childbirth on the mental state of the mothers (idem). Currently, the scientific literature has scalped a range

variables

and

developmental

circumstances (of the perpetrators, the victims of crime and forensic characteristics) that lead to the occurrence of filicide, being this considered a complex phenomenon and multidetermined process (Mckee & Shea, 1998; Mckee, 2006; Meyer & Oberman, 2001; Oberman, 2003).

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

EPIDEMIOLOGY Currently, we see a decrease of cases of infanticide, filicide and neonaticide (which contributed greatly to the cultural and social developments, the use of contraception, abortion rights and recognition in many countries, especially, increasingly prominent in higher interests of the child). However, the literature emphasizes that, despite the reduced number of cases, this type of family violence (including filicide) is a major cause of death in children in developed countries. According to

THEORETICAL DEFINITION

Jason and colleagues (1983, cited by Freire & Figueiredo, 2006), homicide is the leading cause

Filicide, generally referring to the death of one or more children by one or both parents can be differentiated, adopting the perspective of Resnick (1969), according to the victim's age: neonaticide (death of a newborn born in the first 24 hours of life), infanticide (killing of a child under one year of age) and filicide (killing of children older than one year). Other authors (Sadoff, 1995, cited by Freire and Figueiredo, 2006) distinguish infanticide (murder of a child in the first year of life), early filicide (killing of a small child) and late filicide (killing of an older child or an adult).

of pediatric mortality. Indeed, more recent data (Flynn, Shaw & Abel, 2013) specify that homicide is the leading cause of childhood death in developed countries. Records obtained from UNICEF (2003) point out that about 3500 children die each year as a result of maltreatment. In the U.S., two children die each week as a result of aggressive behaviors. Literature allows emphasize that most children of murder victims are killed by their parents, and only a minority are murdered by other types of offenders. Within this minority are predominantly

older

children

who

are

victimized by men with a sexual motive (Freire & Figueiredo, 2006). In Canada, people under 18 accounts for 17% of homicides and 76% by a

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family member, and among the latter, 93% are

2006,

cases of filicide (Dubé & Hodgins, 2001).

approximately 6144 cases of persons convicted

Bourget and Gagné (2002, cited in Freire & Figueiredo, 2006) reviewing cases of filicide occurred in Quebec between 1991-1998, verified 34 victims killed by their mothers, most of whom are under the age of 6 and many cases in which several siblings are dead. Somander and Rammer (1991), analyzing a Swedish sample, also found that the pattern of homicide is the most frequent intra-familial one, especially in connection with the suicide of his father-perpetrator, being homicide rare in the extra-family pattern and usually are committed by male individuals. In the UK, from the 43

and

have

noted

that,

the

for murder, 297 constituted cases of filicide and 45 of filicide - suicide (2003) . Putkonen et al. (2009 )

studied all cases of filicides that

occurred in Austria and Finland, in 1995-2005, and found that most perpetrators of filicide were biological mothers (72 % of cases in Austria and 52 % in Finland). In this study, a considerable number of perpetrators of filicide committed suicide after the homicidal act (18 % in Austria and 30 % in the Finnish population). If these values are added the suicide attempts, the percentage amounted to 54 % in Finland and 32 % in Austria (idem).

children killed in 1995, most were victims of

The United States have the highest rate of

their parents or other family members. These

homicides of children under 4 years (Kaye,

values result in an annual homicide rate of 0.5

2005). Kids homicide rates are well known in

per 100,000 children, which corresponds to a

countries like Spain, Italy and Greece (Briggs &

dead child per year (Stroud & Pritchard, 2001,

Cutright, 1994). Somander and Rammer (1991)

cited in Freire & Figueiredo, 2006). In addition,

studied the homicide cases, intra and extra-

the data indicate that in Finland, between 1970-

familial patter of the child between 1971-1980

1994, from the 207 cases of total killing, about

in Sweden. They found a decrease in the

number of victims throughout the decade, with

corresponded to other cases of filicides and 75

an annual average of 0.6/100.000 children.

cases of suicide after filicide (Kauppi ,

According to the authors, this decrease may be

Kumpulainen , Merikanto, & Karkola, 2008) .

Adding to this, Flynn et al. (2013) examined all

(decreasing number of neonaticides), the

cases of filicide and filicide - suicide that

debate about the mistreatment and legal

occurred in England and Wales between 1997-

prohibition of corporal punishment. Contrary to

cases

were

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the

neonaticide,

the

legalization

abortion

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this reduction, in England and Wales, the rate of

motive why official figures underestimate the

child homicide has remained stable over the last

infant homicides are due to fatal abuse because

20 years (Home Office, 1994, cited by Freire &

it is difficult to legally prove that death is a

Figueiredo, 2006). For Portugal, in 1990, in the

consequence of it, or because the death of a

District Court of Porto, 53 homicides occurred

child for abuse can easily be misinterpreted as

and of these, in only 3 cases the victim was the

caused by accident diagnosed as SIDS, or lack or

mother of the perpetrator and in any case the

difficulty of identifying the body. The estimates

victim was the son of the aggressor (idem).

are also biased by the fact that many neonaticides are not detected. By the above, we must be thorough when analyzing statistical

INCIDENCE OF FILICIDE: SPECIFICITIES

data, taking into account that may not reflect

Among the cases of neonatal mortality (within

reality. In this context, it is plausible to consider

the first month of life) and postnatal (during the

that the phenomenon of filicide is being

twelve months following), a substantial number

underestimated

have no apparent explanation and corresponds

particularly in our country - Portugal (Freire &

to the sudden infant death syndrome (SIDS -

Figueiredo, 2006).

terms

incidence,

sudden infant death syndrome). Emery (1993) 356

assumes that a significant percentage (between 1/5 and 1/10) of deaths attributed to SIDS are cases of filicide (cited in Freire & Figueiredo, 2006). The difficulty in distinguishing between cases of SIDS that result from parental action or due to natural causes can skew the statistics. Sometimes, parents can fabricate and / or induce illness in their children, and even kill them (Fitzpatrick, 2004), a situation which is

The difficulties in studying the prevalence of this type of crime are intrinsically related to medical and legal factors, specifically: 1) the victim's body has been discovered and examined; 2) the exact cause of death must be investigated and, 3) the circumstances of the death, accidental or intentional, must be specified and parents convicted of killing their son (Mckee, 2006).

known as MSBP (Munchausen 's syndrome by

Indeed, it is not known, in fact, how many

proxy ). Sir Roy (1977) found that most victims

children die each year due to filicide once the

of MSBP are preschool children, and in 90 % of

documentation of a case of filicide is

cases the perpetrator is the mother (Emery,

determined only with the discovery of the body

1993). Creighton (1995 ) specify that one of the

of the victim (Crittenden & Craig, 1990;

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Overpeck, 2003). In this respect, according to

had unwanted children (Brown & Eisenberg,

the U.S. Department of Health and Human

1995), which may be reflected not only in

Services (quoted in McKee, 2006), about 21 660

negative maternal attitudes toward pregnancy

newborns had been abandoned by their

as being at the origin of a higher prevalence of

mothers in hospitals or other public places. In

newborns abandoned. These conclusions are

1998, the number of abandoned children

supported by the study of Meyer and Oberman

showed an increase of 40%. In this context, it is

(2001) that corroborate that many victims of

known that the number of children abandoned

neonaticide will never be discovered.

by their mothers who are never found, since newborns are thrown warehouses garbage left in empty houses. For example, in 1999, Texas became the first state to enact a law that allowed fathers or mothers, under special conditions, could legally deliver their children. This legal framework was approved following the discovery of a number greater than 800 abandoned babies in just one year, including 50 babies that were found abandoned in dustbins (Mckee, 2006).

The difficulty of establishing the prevalence of filicide underlies the complex process of establishing the cause of death of a child, even for experienced pathologists and medical specialists (McKee, 2006). For example, the death of children is often attributed to sudden death syndrome in infants / children, which is a diagnosis of exclusion. The high frequency of sudden death syndrome infant / toddler forced the American Academy of Pediatrics, in 1999, to recommend detailed investigation of sudden

The literature demonstrates that the mortality

infant deaths (American Academy of Pediatrics,

rate

1999).

abandoned

babies

found

environments outside the hospital context is astonishing.

sample

cases

neonaticides, over 64% of bodies of newborns were accidentally discovered on the beach or in the trash (Crittenden & Craig, 1990). None of these infants had been declared missing or confirmed, moreover, that the new mother had been intended to omit the birth and abandoned her baby. In 1987, 120 000 pregnant mothers

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Regardless how the cause of death can be established, the investigation of filicide is conditioned by the problems inherent in determining whether the child's death have been resulting from accidental or intentional murder by the alleged perpetrator (McKee, 2006). Moreover, the determination of the cause in the child's death is particularly difficult when the victim is a newborn. For example,

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Meyer and Oberman (2001) found that 84% of

particularities considering the intersection of

cases had been neonaticides consequent to

these vectors that have been developed. Recent

suffocation or drowning. In cases of suffocation,

studies (eg, McKee, 2006) emphasize the

is difficult to establish the circumstances in

complexity of the study of filicide, stressing the

which children are intentionally drowned by

need to understand a myriad of vectors

their mothers or killed accidentally.

underlying the phenomenon (personal history,

Studies

indicate

that

even

when

the

investigation finds subject matter of supporting the thesis of homicide, police records may not be complete or professionals are not prepared

contextual

analysis

the

perpetrators;

characteristics of children and the quality of the relationship

and

parental

role;

forensic

characteristics of the crime).

to record all the variables and circumstances of

Notwithstanding the fact that filicide is a

the

phenomenon known for societies throughout

underestimation of the prevalence of filicide

history, the systematic and scientific study of

(Overpeck, Brenner, & Cosgrove, 2002), which

filicide is relatively recent. The first systematic

impels an increasingly more expertise and

and scientific review is due to the American

consistent rigorous study of the phenomenon

forensic psychiatrist Philip Resnick (1969) that

(expert

services,

revised the world psychiatric literature on

technicians,

filicide and collected 155 cases registered and

researchers, security agents, for example) on a

documented in the period between 1751 and

holistic analysis of crime (Shelton, Corey,

1967. Resnick developed the first classification

Denninson, & Donaldson, 2011).

system based on parental maternal and

offense,

which

technicians

pathologists,

mental

will

result

health

paternal filicide motives: altruistic, acute psychosis, unwanted pregnancy, accidental or WHY

PARENTS

KILL

THEIR

CHILDREN?

Classification Systems of filicide

revenge against the woman. In altruistic filicide, it is considered that the death of a child will

Several investigators, using descriptive and

release a deep suffering, real or imaginary, or

retrospective studies attempted to study the

prevent suffering that might be caused to the

causes of filicide, more specifically, a set of

child, the suicide of his father / mother. Includes

ratings of the

characteristics of filicide

cases of suicide after the murder. For the

perpetrators and victims of crime, forensic

mother, filicide is not a terrible act up because

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she sees thus will have compassion and love for

The category of accidental filicide refers to the

her son. The category of filicide with acute

unintentional killing that occurs when physical

psychosis refers to parents who kill their

abuse to the child acquires a proportion that

children under the influence of severe mental

would culminate in the death of the child. In this

illness, such as postpartum psychosis, bipolar

particular case, the main reason is not the

affective disorder or schizophrenia. In this

child's death; instead, it results from parental

cases, in particular, contact of parents with

neglect, for example, the inability to have

reality is significantly affected and / or distorted

adequate supervision of the child, or extreme

by the development of paranoid delusions and

physical discipline, such as "child syndrome

command auditory hallucinations of violence

shaken”. Finally, the category of filicide as

against children.

revenge of spouse refers to parents who have

In cases of filicide of unwanted children, Resnick (1969) found that death occurred because parents do not wish to care for their children, either by issues of illegitimacy or unknown paternity (excluding, in these cases, the presence of psychosis). In this specific case, we

the pulse to murder the children to thus may cause pain in companion. Resnick (1969) considered this unusual type of filicide and subsequent investigations have postulated this category as the least prevalent in all cases of filicide. 359

should take into account that investigations of Resnick between the period of 1751 and 1967 during which time social sanctions against single mothers and illegitimate pregnancies were more prevalent. Although, recently, many children continue to be killed by their parents because of being illegitimate or subsequent children of unknown paternity, cultural norms

Researches from Resnick (1969) allowed the development of many other classification systems of filicide (eg., Baker, 1991; Bourget & Bradford, 1990; Scott, 1973; Wilczynski, 1997). These later studies showed evidence that the reasons for filicide of fathers and mothers, in essence, tend to differ.

are not as punitive as before, even if they are felt (being more prevalent in cases of neonaticide ).

In 1973, British psychiatrist, PD Scott, based on the typology of Resnick suggested that more than studying the reason that causes the filicide conduct, it would be important to study the origin of momentum killer. Therefore proposes

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the

following

categorization

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

filicide:

based on six main reasons: altruistic filicide,

unwanted children; belief in "compassionate"

filicide as revenge from spouse; filicide because

deaths; profound mental illness in parents,

of jealousy and rejection; filicide as a result of

parental revenge, or victims that precipitate

unwanted child; filicide related with discipline;

parental frustration (eg, child abuse). The

filicide consequent of self-defense.

definitions

and

characteristics

these

categories

were

quite

those

similar

suggested by Resnick (1969).

In turn, Baker (1991) found that the reasons why mothers and fathers commit filicide were distinct: the cases of filicide of unwanted

In turn, psychiatrists Dominique Bourget and

children

John Bradford, in their study with 13 parents

exclusively by mothers, while fathers were the

Filicides (1990 ) found the presence of four

ones responsible for perpetration of filicide as

motives for filicide : 1) accidental homicide

revenge, jealousy / rejection by wife, and also

because of abuse and extreme discipline, 2)

murdered the child by virtue of self-defense.

Homicide as a result of the presence of mental illness , 3) neonaticide; 4 ) retaliatory killings, the consequent desire for revenge in relation to the spouse / husband; 5 ) paternal filicide (once these authors could not fit the paternal filicide in the above categories ) .

(neonaticide)

were

committed

The classification system of parental filicide with a larger number of categories is authored by Anna Wilczynski (1997), through the study of a sample of British and Australian parents charged with the crime of murder of children. The author proposed that cases of filicide

Contrary to Resnick, Bourget, and Bradford

should be classified according to the primary

(1990) showed that less than 1/4 of cases of

and secondary reasons of parents. Defines

filicide were justified by the presence of mental

primary motive as the main cause of the

illness, advocating that most cases of filicide

occurrence of filicide. The secondary reasons, in

fitted the incidental filicide category. The group

turn, were described with the reasons as in the

with less expressiveness, according to authors

explanation of lesser importance filicide. To

of the study, was the retaliatory filicide, which

illustrate, if a mother with mental illness, for

in this particular case, was in line with the

example, has command auditory hallucinations

research of Resnick .

that give her orders to punish their children, and

In 1991, the Australian researcher, June Baker, developed a system of classification of filicide

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in that sequence, end up being killed because of severe physical aggression, the primary motive

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in this case, will be the presence of psychosis

are considered in two dimensions: 1) domain

and the secondary reason would be filicide as a

(individual, family of origin, situational context),

result of severe discipline. Wilczynski developed

2) stage (pre-pregnancy, pregnancy / childbirth,

a classification system based on 10 categories of

early postpartum, postpartum and post-

filicide: retaliatory filicide, filicide as a result of

childhood).

unwanted

children

(which

included

the

neonaticide); altruistic filicide, filicide as a result of severe discipline; filicide resulting from the presence of mental illness in parents; filicide without primary intent to kill (eg, due to negligence); filicide because of jealousy or rejection by the child victim; consequent filicide of child sexual or ritual abuse; consequent filicide of Munchausen syndrome by proxy; filicide as a result of unknown cause.

Mckee

(2006)

therefore

proposes

classification system based on maternal filicide numerous forensic psychological evaluations of adolescents and adult women who were arrested for the crime of filicide. Mothers were individually examined through the use of multiple clinical interventions and psychological assessments. Each evaluation consisted of an investigation and thorough investigation of the personal,

familial,

medical

mental,

Bourget and Gagné (2002) classified filicide

educational, vocational, interpersonal, health,

having considered four specific types and three

marital status, medical condition, substance

groups of unknown specification. The four types

abuse and criminal history vicissitudes of every

are specific mental illness, fatal treatment in

mother. The closest family members were all

relation

and

interviewed, in addition to carry out the analysis

compassion. In the three groups of unknown

of previous medical evaluations or information

specification are considered factors such as the

of health services, education, police documents,

presence or absence of suicide, the presence or

medical examinations and / or other documents

absence of substance abuse and predictability,

relevant to each case. That analysis resulted in

or not, of filicide.

a classification system based on the following

Mckee

with

(2006)

children,

retaliation

stresses that neonaticide,

categories:

infanticide and maternal filicide are a complex,

- Mothers 'untied' (mothers - detached

multifaceted phenomena. Develops in this

category) would refer to mothers whose

context, an array of risk of maternal filicide

relationship with the child is not developed or,

where the protective and risk factors of filicide

on the other hand, the child is unwanted. This

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category is sub - divided into four areas: denial,

reasons for this violent relationship with their

ambivalence, resentment and exhaustion,

children - financial, addition and narcissistic

which correspond to the occurrence of filicide

reasons.

motives that underlie this category of mothers.

Mckee (2006) points out that this new

- Abusive / neglectful mothers: the relationship

classification

between mother and child is marked by

relational,

excessive discipline or, in turn, by the absence

dimensions (different stages of pregnancy and

of any rules and discipline. This category is

post -pregnancy) of perpetrators of filicide in

divided into three types - applicant, reactive and

order to carry out an explanation and

inadequate - that describe the nature of

understanding of the motivations inherent in

inadequate parenting;

the phenomenon of maternal filicide. The name

- Depressed mothers / psychotic (psychotic / depressed

mothers):

This

categories

and

subcategories provides an understanding for the filicide momentum and suggests changes that should be identified in the prevention of death in children. Indeed, the classification of filicide based only on the age of the child's death (and refers

the

distinction between

neonaticide, infanticide and filicide) does not allow an identification of the characteristics of the perpetrators of this crime (mothers and fathers)

nor

the

understanding

the

circumstances in which the crime occurs. The couple did not conduct a comprehensive analysis on the risk factors of filicide and prevention strategies that can be drawn not only to the mother, the family and community as well as the initiated clinical work level (McKee, 2006).

maternal filicide, we can find the various types of classification of filicide studied similarities in main reasons why mothers kill their children (see Table 1). In general, the various explanatory models of the phenomenon stress the presence of mental illness, the lack of connection with the child or inadequate parenting as factors directly related to the occurrence of crime. In this framework, it is essential to consider the main reasons of occurrence of filicide, the intersection of the different

explanatory

models

the

phenomenon, in the sense of design a set of underlying risk factors for the murderous act and thus, accordingly, allow us a differential analysis and prevention of the phenomenon. Despite the clear importance of the types of filicide, will be essential to proceed an holistic analysis of the phenomenon (eg., McKee, 2006)

In conclusion, with respect to different types of filicide that were being developed in several studies,

note

that

the

researchers

attempted to study, first, that the occurrence of the phenomenon as inherent different reasons,

, which takes into account not only features (individual,

social,

for

example)

the

perpetrator and the child, as well as forensic features

contextual,

crime,

conceptualized

developmental

and

societal

dynamics.

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Author

Rejection

Resnick

Undesired

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Non intentional

Mental Illness Emphasis

Retaliation

Anti-Social

Accidental

Acute Psychotic Outbreak

Revenge on wife

___

Undesired

Battering

Mental Illness

Retaliation

___

Neonaticide

Fatal abuse

Filicide-Suicide

___

Ignored

Abuse /

Intentional

___

Psychotic/depressed

___

(1969) D’Orban (1979) Adler & Polk (2001) Meyer & Oberman Neglect

(2001) Mckee

Untying

Accidental /

Psychopathic

(2006) Neglect Wilcznski

Undesired

Discipline /

Munchausen Syndrome by Proxy

Retaliation/

___

(1997) Abuse

Jealousy

Table 1. Table-Summary adapted from McKee (2006)

364 married, unemployed, with a history of alcohol

MATERNAL AND PATERNAL FILICIDE

abuse and substance abuse throughout his life. Despite difficulties in establishing different types of filicide,

considering

that

most

studies

are

retrospective, a set of specific authors stressed the crime committed by mothers and fathers. Thus, Friedman and colleagues (2005) emphasized that in most cases (with the help of forensic records, criminal, medical and national statistics), mothers with higher risk of committing filicide were characterized, mostly by social isolation, and developmental histories, in its infancy, guided by family violence and often victims of domestic violence. Mothers diagnosed with mental illness

Mothers who were in prison were characterized, more commonly, as being unemployed, lack of social support, with low education and history of substance abuse. The authors add that although there are no systematic studies, the scientific literature supports the idea that younger children are exposed to a greater likelihood of abuse (which may refer to the accidental filicide), while older children have more likely to be victims of intentional homicide. Scott (1973) emphasizes the mother's childhood as a risk factor for the occurrence of filicide. Indeed, a number of women

and who had committed filicide were mostly

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who committed filicide had childhoods guided by

majority of the sample was victim of mental

parental abuse and inadequate care. Friedman, in

impairments resulting from psychosis, neurological

a review of 39 stories of women declared

disorders, substance abuse, or mental retardation.

incompetent of crime of filicide, found that about

They found that most homicidal actions resulted in

38 % had had a history of physical and sexual abuse

isolated explosive behavior (ibidem.). Harris,

(5 % being victims of incest) and 49 % had been

Hilton, Rice, and Eke (2006), a thorough analysis of

abandoned by their mother (2005). Numerous

378 cases registered, highlight differences in the

studies indicate the presence of a mental disease

occurrence of filicide, between biological parents

occurrence in breast filicide. Stone, Steinmeyer,

and stepparents. Realize that there is a higher risk

Drecher, and Krischer (2005) have found that

of filicide perpetrated by biological mothers.

mothers diagnosed with psychiatric illness, facing

Understood that biological mothers kill, especially,

the occurrence of crime with murder, kill in

young children, and have diagnoses of mental

general, children with older ages. There are studies

illness, and receive proportionally less severe

that fall within the probability of mothers commit

sentences if convicted. The filicide committed by

or attempt suicide after the murder of children.

biological fathers is characterized by conflicts in the

Regarding the forensic characteristics of the crime,

couple relationship and suicide. In contrast, filicide

the methods of murder, for mothers, are mostly:

committed by stepfathers seem to be associated

drowning, suffocation and strangulation. The study

with abuse and eventual death of physical violence.

of paternal filicide has had less attention by the

If parents, as well as biological children, have

scientific community (West, 2007). However,

stepchildren, they are at greater risk of being

parents are responsible for a large proportion of

abused and neglected before death. The authors

filicide crimes. As a specificity of paternal filicide, it

also add that more poor health of children may

is stressed that parents are rarely responsible for

constitute a risk factor for the occurrence of filicide

the occurrence of neonaticides. The diagnosis of

by biological mothers. Léveillée, Marleau, and

psychosis is common in Filicides parents. The

Dubé (2007 ), in their retrospective study (using

methods used by parents, in the occurrence of

official records of filicide committed in Quebec,

crime are, mostly, more violent, using weapons,

January 1986 to March 1994), sought to identify

stabbing, beating violently, for example (idem).

sociodemographic, contextual, situational and

Campion, Cravens, and Covan (1988) studied the

individual variables as well as signs of hazard

medical and legal records of a sample of 12 men

associated with filicide, taking into account the

who committed Filicides. They found that the

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gender of the perpetrator, and the presence or not

importance of considering the dynamics of filicide

of self-destructive behavior.

by gender for the perpetrators, thus preventive

With regard to the group of subjects who had committed self-destructive behaviors, the results indicated that men, compared to women, are more likely: to commit murder marriage; killing a greater number of victims, to encounter a process marital separation, have committed domestic violence, have attempted to commit suicide and tried to kill his wife. From the group of study subjects who had not committed self-destructive behavior after filicide, women were more likely to show a depressive disorder, while men are more likely to mistreat

their

children.

These

men

are

characterized specifically by being violent against children and prove a tyrannical discipline, while men who presented self-destructive behavior perpetrate filicide as revenge against their wives. Dubé, Marleau, and Hodgins (2005), in the comparative study of the phenomenon of maternal and paternal filicide occurred in Quebec, found that a higher percentage of women compared with men, killed their children for "altruistic" reasons or because they wanted them. Conversely, a higher percentage of men killed for reasons of revenge

work can be developed. Bourget and Gagné (2005), in

their

retrospective

study

examined

demographic, social and clinical variables in 77 cases of filicide, that occurred between 1991 and 2001, in Quebec and Canada. Of the 77 cases, 60 men had perpetrated the crime of filicide. The results of their study indicated that filicide fathers committed more crimes than mothers. The presence of a family history of abuse was significant in a substantial number of cases, with most cases involving violent methods of murder. Filicide was frequently followed by suicide of the perpetrator and most of the crimes involved multiple children. The abuse of drugs and alcohol was rare. At the time of the crime, the majority of perpetrators suffered from psychiatric illness, being

frequent

depressive

disorder.

Approximately one-third was in a psychotic state. The proportion of cases of fatal abuse was comparatively lower. Furthermore, many of the perpetrators of filicide had had contact with health services before the murder, although none has received treatment for psychiatric illness.

against his wife, and there is even a greater propensity for family homicide. Also, a higher

FILICIDE AND MENTAL ILLNESS

percentage of men than women were not living with their children at the time of the filicide act. The authors suggest that it falls within the

There is some discussion in the literature regarding the relationship between the presence of mental disorder and the occurrence of filicide. Not being

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able to identify a characteristic type of psychiatric

psychiatric illness, being more frequent depressive

diagnosis associated with the occurrence of filicide,

disorder. Approximately one-third was in a

it appears that most of the perpetrators has

psychotic state. The proportion of cases of fatal

personality disorders before the crime, and the

abuse was comparatively lower. They also reported

diagnosis of the symptoms is essential for the

that many of the perpetrators of filicide had had

prevention of filicide.

contact with health services before the murder,

Pitt and Bale (1995) emphasized the need to better understand the presence of mental illness of parents to identify potential perpetrators of filicide. The authors found that most male perpetrators are punished with imprisonment, while mothers are referred for psychiatric treatment to be monitored.

although none has received consistent treatment. Friedman, Sorrentino, Stankowski, Holden, and Resnick (2008) highlight that the number of children killed by their mothers with psychiatric illness is in fact a problem of public and psychiatry health. Indeed, several authors have studied samples of perpetrators of filicide mothers who are in psychiatric institutions reveal the presence of

Sadoff (1995) notes that mothers are more likely to commit filicide in a state of fear, panic, depression, psychosis or dissociative state. Mckee and Shea (1998) found that most of their study sample was characterized by the presence of a diagnosis of mental illness and perhaps was dealing with numerous stressors acute events without any kind of social support or family support. Social isolation and difficulty in having successful relationships were similarly described as risk factors for filicide (Simpson & Stanton, 2000). Mental illness, including psychotic symptoms and affective disturbance is often found on the perpetrators of filicide (male or female) (Farooque & Ernst, 2003). Bourget and Gagné (2005) found that, at the time of the crime, the majority of perpetrators who constituted the study sample suffered from

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psychosis, depression, suicide attempts, use of mental health services prior to filicide act. Recent studies show that thoughts of attempt on the life of a child are not uncommon. The study of Jennings, Popper, and Elmore (1999) documented that 41% of the sample of mothers with depression, caring for children older than 3 years, recorded thoughts of damage against their children, compared with 7% observed in the control population. The study of Chandra and Venkatasubramanian (2002) have revealed that the majority of the sample of mothers of children with colic, more than two-thirds experienced it 'explicit aggressive fantasies' and a quarter reported Filicides thoughts during the episode of colic.

Sorrentino et al. (2008) stressed the

importance of mental health professionals take

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into account in their professional practice, the

probability of having a diagnosis of serious mental

presence of Filicides thoughts. In an exploratory

illness, as well as absence of crimes previously

study, analyzed the responses of psychiatrists from

committed. To Marleau and colaboradores (1999),

2 academic institutions. The professionals were

cited by Freire and Figueiredo (2006), is not

asked whether they questioned mothers about

possible to identify a characteristic type of

motherhood and Filicides thoughts, and if so, if

psychiatric diagnosis associated with filicide, but it

they consulted, the psychotic, suicidal or depressed

turns out that most of the perpetrators has

mothers.

many

personality disorders. Pointed out that many of the

psychiatrists underestimated the frequency of

women who kill or attempted to kill their children,

depressed mothers who were experiencing

have a psychiatric history, represented on

thoughts of harming the lives of their children.

assessment and / or hospitalization.

The

results

showed

that

Approximately half of the sample said they did not ask about filicide ideation, questioning just about homicidal thoughts in general. The authors of this study highlighted the importance of considering, in mental health services, the prevalence of Filicides

Koenen and Thompson (2008), consider that a large percentage of occurrence of filicide is associated with parental mental illness, particularly depression and post-partum psychosis, or as stated Lewis and Bunce (2003) a combination of the two.

thoughts in clinical practice. Bourget and Bradford (1990) found that in the Stanton, Simpson, and Wouldes (2000) attempted to examine descriptions of maternal filicide in the context of severe mental illness. Sample of six women, found the presence of an intense investment in maternal care. The description of stressful external factors was not very prominent, but the experience of the disease was described as extremely stressful. Mothers confessed that not premeditated or planned the crime. Showed remorse for the crime and feelings of responsibility, even though they know that could be sick at the time of the crime. According to McKee and Shea (1998), women accused of filicide have a high

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sample of their study, 8% of women were diagnosed with a psychotic disorder, 31% suffered from Major Depression, 15% had one adjustment disorder, and 23% were abusing of alcohol or drugs. In the sample of d`Orban (1979), 16% of women were

psychotic,

21%

experienced

major

depression, and 9% were diagnosed with abuse and substance

dependence.

However,

the

data

obtained by Lewis and Bunce (2003) differ from those found by d´ Orban (1979), since 52.7% of women have psychotic symptoms at the time of filicide. McKee and Shea (1998) verified that 40% of women in their sample were diagnosed with

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psychosis or schizophrenia, 25% with major

Mendlowicz and colaborators (2002) show the high

depression, 10% with adjustment disorders, and

presence of amnesia in mothers who committed

5% with abuse and substance dependence.

neonaticide - symptoms most frequently reported

According to McGrath (1992), cited by Stanton et al. (2000), some of the women who commit filicide related to believe they did the best for her son and love him more than anything else. Resnick (1969) categorizes this type of filicide as "selfless Filicide."

by neonaticide mothers seems to be an indicator of a dissociative state. However, Resnick (1970) defends the absence of psychopathology in neonaticide mothers, highlighting not only the desire to be mothers. To Myers (1970) and Resnick (1969), the most common diagnosis among

McKee (2006) elucidated in the context of the relationship between mental illness and filicide, the presence, in his study of what he termed a 'category of psychotic / depressed mothers',

mothers Filicides is depression with psychotic features. According to Lewis and Bunce (2003) and Resnick (1969), psychosis rates are in the range of 52-73% (quoted by Koenen & Thompson, 2008).

characterized by the presence of maternal mental illness that unequivocally negatively influences the perceptions and the relationships that establishes with their children. This category is subdivided into

According to Palermo (2002), cited by Koenen and Thompson (2008), mothers kill often while in a state of postpartum depression or psychosis. The greatest risk for these disorders is when the child is

3 types - delusional, impulsive and suicidal.

very young, since ultimately spend much time with McFarlane (1998) considers that neonaticide women are in a kind of dissociative stadium at delivery,

and

the

affective

impulses

are

transformed directly into action. McKee and collaborators (2001), cited by Brito (2003), consider

her mother. With the growth of children, parents are given the greatest care and discipline. This high level of interaction may increase the likelihood of being killed by an angry, intoxicated or mentally ill parent.

that women who commit filicide may manifest psychotic behavior, hallucinations and altered

Numerous studies indicate that the fact that the mother has mental and emotional disorders is a

thinking.

significant risk factor for filicide. Many of maternal Spinelli (2001) points out that in mothers who committed neonaticide, is common to find a pattern

denial

pregnancy

and

disorganization of the self with dissociation.

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filicide

classification

systems

highlight

the

categories that reflect psychiatric illnesses. The emotional state would be a risk factor, as is the case with diagnoses of psychosis and depression, as

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well as abuse / dependency and personality

for the accidental deaths of children. In the samples

disorders (McKee, 2006).

of Stanton et al. (2000), the most common findings

Kendell, Chalmers, and Platz (1987), citaed by McKee (2006), claim that the pre-pregnancy stage notes the presence of severe mental illness, this may be aggravated in the conception and birth.

are: major depression, schizo-affective disorder (manic or depressive phase in before death) and schizophrenia. It is important to note that women who report a manic episode prior to committing filicide report the existence of incongruent

The American Psychiatric Association adopted a "postpartum onset specifier" that can be applied to the diagnosis of major depressive episode, bipolar disorder or brief psychotic disorder that can testify to the impact of childbirth on the emotional state of the mother (McKee, 2006).

hallucinations at the time who commit filicide. When

speaking

their

experiences

motherhood, some of these women showed their concern for not being good mothers and that this may have been affected by his illness. In this study it was found that women with depression refer to

The presence of psychosis and major depression,

her child to think about death with days or even

together with contexts of filicide-suicide during the

weeks in advance; unlike the psychotic women who

later stage of childhood, has also been widely cited

reported never having occurred to them the idea of

by many studies and classification systems of

the death of the son cannot even explain why the

maternal filicide (McKee, 2006).

act of murderer a child occurs. However, some

The emotional state of the mother as a risk factor

reports are evident by altruistic reasons, and for

or protective also includes abuse / dependence on

example a child’s mother killed only to ensure that

alcohol and drugs in the period prior to pregnancy,

it does not suffer. However, only one of the women

during pregnancy, childbirth, postpartum, in the

believes that her illness was the main responsible

late postpartum period and in the later stage of

for filicide (Stanton et al., 2000).

childhood. A frequent intoxication due to alcohol

According

and drugs in pre-gestational stage may put women

depression was considered, at different times and

at greater risk of an unwanted conception, forcing

places, a cause for neonaticide, infanticide and

her to consider an abortion or having an unwanted

filicide. This occurs for several weeks to several

child. In the later stage of childhood abuse /

months after birth in perhaps 1 in 1000 or 2000

addiction to alcohol and drugs often appear

cases, being used as a defense in cases where the

associated with physical child abuse as precipitants

mother kill her children.

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McKee

(2006),

postpartum

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To Rosenberg (1987), cited by Koenen and

mothers had made contacts for telephony services

Thompson

with

or public mental health technicians. The conditions

Munchausen syndrome are mostly women, many

deteriorated rapidly and mothers committed

of whom also meet criteria for narcissistic

filicide was when the mother was left alone with

personality disorder, borderline or histrionic. To

the baby against her will. Most mothers felt that

Bernet (2000), these women crave the attention

their own parents, especially mothers, were very

they get from having a sick child and clandestinely

demanding with themselves, emotionally unstable,

produce symptoms in its victims to put in that role.

and little caregivers. Moreover, the mothers of the

Often present themselves as concerned and loving

study also recorded traumatic experiences in their

mothers seeking treatment for their sick child, yet

childhood or in adulthood. The main result of the

when they realize they are not being observed,

study revealed that the children of these mothers

often seem indifferent or even abusive to their

were wished, did not presented health problems

child (Eisendrath, 2001Younger victims are often

and the mothers did not show difficulty of care for

stifled and older children are often poisoned,

their children, yet the feeling of being responsible

mostly with anticonvulsants or opiates (Alexander,

for the welfare of their children, their current

Smith, & Stevenson, 1990).

circumstances of life and depressive symptoms

(2008),

people

diagnosed

exacerbated the feeling of inability to cope with life and parenting (Kauppi et al., 2008). Previous Kauppi et al. (2008) developed a study that reported 10 cases of filicides committed by mothers who intentionally killed one or more children in the 12 months after childbirth. From the results, it was found that the average age of mothers was 28.5 and, with regard to the victims, four months, respectively. The presence of depressive

symptoms

this

sample

was

unequivocal: an irritable and severe depressive mood with crying spells, insomnia, fatigue, anxiety, and concern about the care of the baby and perception capacity for motherhood, or even suicidal ideation and psychotic thoughts. Most

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studies corroborate the aforementioned study. Indeed, Friedman and collaborators (2005, cited by Kauppi et al., 2008) studied a sample of 39 mothers with mental illness and found that they suffered from

depression,

hallucinations

and

had

experienced major stressful events in their lives, including the life history of their own childhoods were strong predictor factors. Indeed, about 50% of the mothers had been abandoned by their mothers (Friedman et. al., 2005, cited by Kauppi et al., 2008), similar aspect to the study of Kauppi et al.(2008). The mothers in the study sample of Kauppi et al. (2008) informed their husbands and

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authorities about the reluctance to be left alone

demographic, historical, clinical, and forensic

with the children. The fact of being left alone with

inherent characteristics of victims of crime in the

the children increased anxiety and hallucinations

group of mothers with mental illness and the

about the development of children throughout the

presence of the group of mothers without the

day. In this context, it is essential that mental

presence of mental illness characteristics. The

health clinicians take into account parents with

mothers perpetrators of filicide diagnosed with

clear

the

mental illness were characterized by older,

preponderance, or not, of depressive thoughts. The

married, with a more significant level of education

authors also emphasized that more attention to

and training and who were unemployed at the time

the life experiences of the perpetrators of filicide

of committing the act filicide. These mothers were

mothers should be given, as well as stories of life in

more likely to be integrated into psychiatric

their traumatic childhoods (Kauppi et al., 2008). In

outpatient treatment and a history of suicide

this regard, the study Haapasalo and Petaja (1999),

attempts. Mothers without a diagnosis of mental

with a sample of 48 Finnish filicide women revealed

illness revealed a higher probability of labor be

that most mothers had experienced childhood

performed in non-hospital environments and

abuse, being the most prevalent, psychological

contexts and have a victim with young ages. The

abuse. Crimmins and colleagues (1997, cited by

presence of mothers with mental illness and who

Haapasalo & Petaja, 1999) revealed that 64% of the

committed filicide evidenced more likely to confess

mothers in their study, sentenced for the crime of

to the crime even if, ultimately, had been acquitted

filicide were "motherless mothers", with unstable

for reasons of insanity and considered incompetent

and abusive mothers with alcohol problems,

(Mckee, & Bramante, 2010).

depressive

symptoms,

seeking

mental illness, or neglectful mothers who had died. Similarly, 63% of study of Haapasala and Petaja (1999) revealed that mothers who constituted the sample had experienced an abusive parenting in childhood.

Flynn et al.(2013), studying the relationship between filicide and mental illness at the time of the homicidal act and mental health care preceding the filicide behavior in a sample that included all cases of filicide and filicide-suicide occurred in England and Wales in the period time between

Mckee and Bramante (2010) developed a retrospective study that sought to examine the study of maternal filicide in Italy, comparing

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1997 and 2006, found that of 6144 people convicted for murder, 297 cases were cases of filicide and 45 cases of filicide-suicide. From those,

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195 (66%) of perpetrators were parents. Mothers

monitor services and supporting. Flynn et al. (2013)

had more influence than parents to have had a

emphasize that parents with a history of substance

history of mental disorder (66% versus 27%), being

abuse, violence or affective disorders and young

the most frequent, symptoms of affective

mothers at the time of the crime, with the presence

disorders. Up to 17% of mothers evidenced

of affective disorders should be a target population

schizophrenia or other delusional disorders. A total

for intervention. The presence of parents with

of 37% were mentally ill at the time of the crime.

mental illness should be asked about the presence

Up to 20% had used or had previous contacts with

of violent thoughts around children, particularly in

mental health services. Flynn et al. (2013)

cases

concluded, therefore, that in most cases, the

collaborators (1999, cited by Flynn et al., 2013)

presence of disease does not trigger alone, the

concluded that 41% of women admitted having

occurrence of filicide. However, demographic

negative

variables such as the presence of young fathers and

compared with the control group. In this context, it

mothers with severe mental illness, particularly

is important that professionals in mental health to

with affective and personality disorders, and who

explore the intensity and frequency of violent

are caring for children, require careful monitoring

thoughts, specifically when destructive thoughts

by mental health and other services that can

against children are present.

severe

thoughts

Borget & Gagné (1990)

D’Orban (1979)

Mckee & Shea (1998)

Resnick (1969)

31%

21%

40%

53%

Major Depression 23% Alcohol Abuse

15% Adjustment Problems

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Major Depression 16% Psychosis

9% Substance Abuse

Psychosis or schizophrenia 25% Major Depression 10% Adjustment Problems

depression.

towards

Jennings

children

and

when

373

Psychotic disorder 13% Major Depression 10% Adjustment Problems

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---

Psychotic disorder

---

Substance Abuse

Table 2. Table-Summary: Filicide and Mental Illness

NEONATICIDE,

INFANTICIDE

AND

FILICIDE:

younger, unmarried and dependent on their family of origin. Compounding, denied or

SPECIFICITIES

concealed their pregnancy and evidenced fewer Scientific research has shown us that neonaticide cases and other cases of filicide differ in particular with regard to certain types of variables.

psychological problems than mothers who kill older children. Non - neonaticide mothers were mostly married, with a set of stressful factors

Haapasalo and Petaja (1999), in a sample of 48

related to their family and were faced with

cases, carried out a comparative analysis of

numerous problems. 63 % of mothers in both

mothers who had committed neonaticide (N = 15)

groups of the sample had been abused in

and non-neonaticide mothers (N = 33). The

childhood - which is a denominator in both

neonaticide

her

sample groups. The group of non - filicide

pregnancy. Mothers were characterized by killing

mothers distinguished by the presence of

or attempting to kill their children below 12 years

impulsive, aggressive behavior and depressive

and above their first day after birth onwards. The

symptoms. In turn, the neonaticide group

age of mothers who constituted the sample was

mothers were characterized by be living with a

17 to 42 years, with a mean age of 26 years for

partner who did not agree with the child's birth or

the group neonaticide mothers and 30 years

mothers were living alone or with their parents.

average age for non-neonaticidas mothers. The

In this regard, Overpeck, Brenner, Trumble,

groups did not differ from each other with regard

Trifiletti, and Berendes (1998, cited by Haapasalo

to age, education, occupational state. Most

and Petaja, 1999) concluded that one of the most

mothers (77 %) had completed basic formal

prevalent risk factors for homicide of children

education and, additionally, 17 % had completed

resided in the fact that the mother, at the time of

secondary education. Of that study also was

delivery, presents a minimum of 20 years old.

mothers

often

omitted

found out that neonaticide mothers were mostly

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The scientific literature has highlighted the denial

pregnancy. In this context, understanding denial

predominantly

of pregnancy is essential for the prevention of the

characteristic of cases of neonaticide (Crittenden

phenomenon. Miller (2005) describes different

& Craig, 1990; Green & Manohar, 1990, cited by

types of denial of pregnancy, even considering

Haapasalo & Petaja, 1999). These studies show

the specifics of individual and sociocultural risk

that neonaticide mothers deny the pregnancy to

factors. Denial, in its clinical aspect, can occur

themselves and to others, manifest absence of

within psychiatric illness such as schizophrenia,

neonatal and perinatal care, and mostly have no

bipolar disorder, depression, anorexia nervosa, or

support or family support. Silverman and

post-traumatic stress disorder. Can occur without

Kennedy (1988, cited by Haapasalo & Petaja,

the manifestation of any psychiatric illness, in

1999) found also that 67% of the sample of non-

which case we may be talking about adjustment

neonaticide

illness,

disorders (Strauss et. al, 1990, cited by Miller,

compared with 36% of neonaticide mothers. The

2005). Denial of pregnancy occurs along a

study also revealed the presence of attempted

spectrum of severity. Sometimes awareness of

and / or suicide in the non-neonaticide mothers

pregnancy is cognitively known, but their

and the presence of suicidal thoughts are

emotional significance is denied. In other

relatively rare in neonaticide group mothers.

circumstances, knowledge of pregnancy is briefly

What seems to underline the fact that mental

acknowledged but quickly deleted to the point of

illness is more common in the group of non-

its lack of knowledge. Indeed, the presence and

neonaticide

severity of negation can vary in different stages of

mothers. One possible explanation for this

pregnancy. Miller (2005) proposes three types of

evidence seems to be the presence of a larger

denial of pregnancy, qualitatively distinct from

number of cases of delusional psychosis and

each other: affective denial, total / profound

severe depression around mothers who kill older

psychotic denial and negation. The affective

children. Moreover, the fact of non-neonaticide

denial is linked to feelings of indifference to the

mothers reveal the presence of mental illness

child. Many women throughout pregnancy,

previous to murderous act, compared with the

fantasize the child, imagine with whom the child

group of neonaticidae mothers, which may

will like, choose the appropriate name and talk to

explain the higher prevalence of mental illness in

the fetus. Moreover, many women change their

this group of mothers. The cases of neonaticide

lifestyle habits, physical activity modify, prepare

are mostly preceded by denial or concealment of

the arrival of the baby, they plan antenatal care

pregnancy

mothers

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factor

had

than

mental

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should

take

into

These

compromise fetal and maternal health due to the

manifestations of binding to the fetus may

decrease of antenatal care. It may also

include

indifference,

compromise and disable emotional adaptation of

detachment or irritation. Such ambivalence is

women to parenting in this case, may be

normative during pregnancy and may not indicate

experienced as an abrupt transition arising from

alone, the presence of denial of a clinically

a lived experience of pregnancy, in emotional

relevant point of view (Miller, 2005). The

terms, so dull and indifferent (Miller, 2005).

feelings

consideration.

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

transitive

affective denial occurs when a woman recognizes intellectually that is pregnant but experiences and / or expresses very little or virtually no behavioral

and

emotional

changes

that

characterize the period of pregnancy and the adaptation of women to pregnancy. It seems, in these cases, an affective blunting predominate towards the baby. Women with this type of denial continue to think, behave and feel as if they did not run into pregnancy. Do not fantasize baby, do not talk or interact with him. May even not make clothing patterns change, so continue to use the same type of clothes and do not change the lifestyle habits that kept. Do not do any kind of preparation, concrete, real and / or emotional, to the arrival of the baby, not adjusting to the presence of the baby (Miller, 2005). We stress that

women

with

substance

abuse

may

experience affective denial of her pregnancy (Spielvogel & Hohener, 1995, cited by Miller, 2005), and this may be due to an attempt to not feel any sense of guilt inherent in this destructive behavior perpetuated by mothers throughout

With respect to the total denial ("pervasive denial”), this happens not only when there is no emotional recognition of pregnancy and unaware of the existence of the pregnancy itself. In this particular

type

denial,

the

physical

manifestations of pregnancy are not only absent as are incorrectly interpreted. Women with a deep denial of pregnancy show few or less intense symptoms of pregnancy, compared with other women. There is little, if any, increase in body weight (Brezinka et al., 1994, cited by Miller, 2005) and, in this context, these women will ultimately not change costumes that resorted before pregnancy. In the case of somewhat increased weight, turns out to be attributed to other factors (Brozovsky & Falit, 1971, cited by Miller, 2005). In these women, the cessation of the menstrual cycle may not occur (Bascom et al.,,1977; Finnegan et. al., 1982 cited by Miller, 2005). Indeed, in a sample of 27 women with denial of pregnancy, most (about 18) recorded vaginal

bleeding

during

pregnancy

and

menstruation - regular or irregular, continuous or

pregnancy (Miller, 2005). The affective denial can

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discontinuous, - during pregnancy (Brezinka et al.,

Miller, 1998, cited by Miller, 2005). Indeed, some

1994, cited by Miller, 2005). When these women

women recurred to emergency services because

are faced with amenorrhea, attributed this fact to

of acute colic and, in this sequence, end up having

variables other than pregnancy, such as: stress,

the baby (Brezinka et al., 1994.), other women

travel or menopause (Bonnet, 1993; Brezinka et

may have births at home without any medical

al.,, 1994; Milstein & Milstein, 1983, cited by

assistance.

Miller, 2005). Furthermore, fetal movements can

pregnancy describe a sense of dissociation during

be, in these women, attributed to bowel

the birth experience (Finnegan et al., 1982;

movements (Jacobsen & Miller, 1998, cited by

Wilkins, 1985, cited by Miller, 2005). Denial of

Miller, 2005).

pregnancy does not necessarily end with the birth

The phenomenon of collective participation in the process of denial was evident in virtually all cases of deep denial of pregnancy. In a group of 27 cases of denial of pregnancy, less than half of the most significant people suspected vaguely of pregnancy and in the other, there was a total lack of pregnancy, and in no case had a total recognition of pregnancy (Brezinka et al., 1994, cited by Miller, 2005). The process of denial by relatives can be so overwhelmingly that even the partner may not have recognized the presence of pregnancy despite having had sex just hours before the onset of labor pains (Bonnet, 1993, cited by Miller, 2005). At the end of the period of pregnancy, deeply denied, the pain inherent to contractions may surprise these women (Bonnte, 1993, cited by Miller, 2005), and are interpreted as resulting from gastrointestinal symptoms or bowel

movements

(Arboleda-Florez,

1976;

Bonnet, 1993; Finnegan et al., 1982; Jacobsen &

Many

women

with

denial

of the baby. For example, in a case studied, the remnants of the placenta were found in the examination of a woman who resorted to emergency services with vaginal bleeding, and had no recognition that he had had the birth of your child (Bonnet, 1993, cited by Miller, 2005). Moreover, even women who, intellectually and rationally accept having a child sometimes still away,

themselves,

from

the

emotional

recognition of this reality (Bascom, 1977; Finnegam et al., 1982, cited by Miller, 2005). Regarding psychotic denial, women can deny the pregnancy of a delusional manner. In these cases, the symptoms and physical signs of pregnancy occur, but in an obvious way, are incorrectly interpreted, sometimes in a bizarre way. Therefore,

some

women

recognize

that

something is growing within them, but do not experience this fact as the presence of a fetus. May, instead, be felt by the mother as a blood clot (Miller, 1990, cited by Miller, 2005) or cancer

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(Cook & Howe, 1984). Psychotic fantasies about

however only in 3 cases the companions were

what is inside the body may reflect psychological

aware of the existence of pregnancy. The main

realities of women's emotional reactions to

reason for the denial of pregnancy (patent in 60.8

pregnancy. The psychotic denial can come and go

% of cases) was consequent fear of abandonment

throughout the course of pregnancy. Unlike other

and / or negative reactions from others. The

types of denial of pregnancy, women with

study also revealed that in cases of neonaticide,

delusional denial of pregnancy usually does not

the lack of knowledge about pregnancy, by the

omit pregnancy (Miller, 2005).

perpetrators as well as the recognition of

The study of Amon et al. (2012) sought to assess psychosocial factors of neonaticide, specifically the circumstances before delivery, relations of the pregnant with the environment and social and contextual recognition of pregnancy. The main objective was to identify and describe the risk factors of the phenomenon of neonaticide (psychological, social, economic and mental health), giving special attention to the period of pregnancy, including stressful circumstances and social and contextual recognition of pregnancy by these women. The national study sought to investigate all cases of neonaticides occurred in Austria and Finland from the time period of 1995 to 2005. The sample consisted of 28 cases of neonaticides, registered in the medico-legal departments, and analyzed along information and detailed records of each case. From the study, it could be seen that 17.9% (5/28 cases) of women admitted being pregnant, which was a

pregnancy before others appear to be the most relevant social variables in predicting this potential crime (Amon, et al., 2012). More specifically, the main conclusion of this study was that socioeconomic factors (including age of the mothers or their economic situation), described in the literature as predictors of the phenomenon of neonaticide, were not as predictive of a high risk of committing this crime as it was thought. Rather, the most associated variables in this study with the occurrence of neonaticide, refers to a high percentage of fertility (2.13), a high percentage of denial of pregnancy (82.1%), presence of a traumatic childhood in the lives of perpetrators (47.8%) and a lack of social recognition of pregnancy by mothers. It is possible to conclude, therefore, that these are important variables and factors to consider in the study and prevention of the occurrence of neonaticide (Amon et al., 2012).

low value. The majority (16/28 cases) of

The authors of this study, similar to what has

perpetrators of neonaticide was in a relationship,

been described in the scientific community

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maintain that one of the main characteristics of

typically with pregnancy. According to the

denial of pregnancy in neonaticide mothers is its

authors of this study, women could include

persistent failure to recognize the symptoms

family, friends, and in particular physicians in the

associated

most

process of denial of pregnancy, that is the same

perpetrators of said neonaticide study continued

to say, they were even able to influence doctors.

to deny the pregnancy, even in later stages of

The desire to not being pregnant, over this

pregnancy. The absence of physical symptoms

complex process of denial of pregnancy, receive

during pregnancy or lack of perception and

confirmation from the doctors who were making

correct interpretation of these symptoms cannot

be explained by the inexperience of these women

perpetuate the process of denial of pregnancy, as

with pregnancy. In fact, only half of the women in

a Vicious Cycle they were. The authors dig deep

the study had committed the crime after her first

into this iatrogenic involvement in pregnancy

pregnancy. The process of negation in this

using the concept of projective identification in

context, seems to have a big impact on the

psychoanalytic community introduced by Klein in

perception of pregnancy, so that even women

1946. Thus, the authors consider that, through

who had experienced previous pregnancies end

projection, pregnant women are able to

up not perceive or correctly interpret the

manipulate the doctors so that they match and

symptoms which, for those reasons, should be

perceive the experience according to their

obvious to these women (Amon et al., 2012).

intentions and desires, which feeds into

More recent studies have highlighted the

consciousness by physicians who women are not

occurrence of a very interesting phenomenon,

pregnant, working and engaging in misdiagnosis,

called “iatrogenic participate in denial of

conversely, a kind of 'service exchange'. Thus, the

pregnancy", which can be found in the study of

fact that these women receive confirmation

Wessel, Endrikat, and Kastner (2003). Indeed, in a

misdiagnosis by physicians, ultimately promotes

sample of 25 women with denial of pregnancy, it

denial of pregnancy from the mothers herselves

was found that they could transfer the attitude of

(Wessel et al., 2003).

with

pregnancy.

Indeed,

denying pregnancy to doctors that consulted, which eventually lead health professionals would fail to recognize the pregnancy, despite although somatic complaints that these women were

incorrect

diagnosis

allowing

thus

In the study of Ammon et al. (2012) of 28 women who constituted the sample, about 16 women who lived with a partner had had sex throughout pregnancy.

This

highlights

the

complex

heading for the medical services were associated

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psychological processes that underlie the denial

to this, virtually all studies have documented a

of pregnancy and the fact that people who are

lack of prenatal care around these mothers

closer to the reality of women who deny

(Friedman et al., 2005; Friedman & Resnick,

pregnancy cannot recognize the situation in

2009), which has been explained by the

which they find themselves.

preponderance of denial and / or concealment of

The neonaticide mothers have been described commonly in the literature taking into account not only social variables (such as: mothers of young

children,

single

relationships,

poor

education, low economic status, and so on), but also

the

characteristics

pregnancy

(unwanted pregnancy, denial of pregnancy, late physical manifestations of pregnancy, etc.). The average age of a neonaticide mother, as has been described by several studies, is between 13 and 20 years (Friedman & Resnick, 2009; HermanGuidens et al., 2003; Mendlowicz et al., 1998; Spinelli, 2001). Here probably due to the young age of the women, these mothers are, mostly single (Friedman & Resnick, 2009; HermanGuidens et al., 2003; Mendlowicz et al., 1998; Spinelli, 2001), and the vast majority live with the

pregnancy.

Friedam

and

Resnick

(2009)

emphasize that the denial of pregnancy is defined as a total lack of pregnancy, while the concealment of pregnancy implies an active process of hiding and omit pregnancy before others. Most studies on neonaticide not differentiate the processes of denial and concealment

pregnancy,

although

the

underlying psychological processes (affective intent of the mother, specific time periods and cognitive recognition) are different. In any case, the two processes tend, in general, co-occur (Friedman et al., 2007; Miller, 2003). Putkonen and colleagues (2007, cited by Amon et al., 2012) assert that the main reason for denial of pregnancy is the fear of negative reaction from others.

family of origin. The percentage of cases where

In short, the cases of neonaticides are

the baby was the first child varies throughout the

characterized by the presence of mothers who

various studies, varying between 35% and 82%

did not reveal emotional capacity to achieve

(Herman-Guidens et al., 2003; Mendlowicz et al.,

dealing with the challenges and pressures

1998; Spinelli, 2001). A low level of academic

inherent to motherhood. Mother who is often

education has been pointed out over the various

denied the pregnancy, not manifesting any

studies, as a decisive factor in the study of this

prenatal care or birth planning. The murder

phenomenon (Mendlowicz et al., 1998). Adding

occurs as a result of passive behavior by mothers

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or as an attempt to hide the baby, rather than a

Sevecke, & Steinmeyer, 2007; Meyers &

deliberate plan of killing children (Wilcynski,

Oberman, 2001; Resnick, 1969; Simpson &

1997). Studies that deal with the phenomenon of

Stanton, 2000; Spinelli, 2001). At the same time,

neonaticide

this

they find themselves studies which refer to a

phenomenon occurs more predominantly in

particular range of characteristics of filicide,

young women who manifest fear, often parents

taking into account the gender of the perpetrator

themselves, and feel they do not have the

(Bourget & Gagné, 2005; Bourget, Grace, &

capacity to assume responsibility for the

Whitehurst, 2007; Dubé & Hodgins, 2001; Dubé,

pregnancy. Mckee (2006), in studying the

Hodgins, Leveillée & Marleau, 2004; Campion,

phenomenon of neonaticide, included the

James, Cravens & Covan, 1988; Farooque & Ernst,

category of 'unwanted children' stating that after

2003; Koenen & Thompson, 2008; Léveillée et al.,,

childbirth, mothers can be characterized as

2007; Yourstone, Lindholm & Kristiansson, 2008).

have

pointed

out

that

ambivalent, without any binding, angry or exhausted and in that sequence, murder their children. In turn, mothers who kill older children reveal, more often, the presence of personality disorders, while older killer mothers, are usually married, dealing with a range of different ages and family socio-economic problems.

In fact, despite the similarity that exists on the perpetrators of filicide - manifest depression and / or psychosis, personality disorders, deal with traumatic events throughout life, social isolation, individual history of abuse (Bourget, Grace et al., 2007) - we note differences in crime committed by women and men, particularly with regard to the idiosyncrasies of the perpetrator, the forensic characteristics of crime and victims, and legal

RISK FACTORS FOR FILICIDE

decisions regarding crime. Filicide

complex

and

multifaceted

phenomenon. Several authors found specific to differentiate

between

the

neonaticide,

The literature review (Freire & Figueiredo, 2006; Koenen & Thompson, 2008; Mckee, 2006;

infanticide and filicide, in particular with regard to demographic, individual, situational variables of the murderer, and forensic characteristics of the crime itself (e.g. D’Orban, 1979; Friedman, Horwitz, & Resnick, 2005; Friedman & Resnick,

Simpson & Stanton, 2000; Spinelli, 2005) states that certain risk factors (whose study may allow a work of preventing the phenomenon, despite its complexity) seem to be particularly associated

2009; Haapasalo, & Petaja, 1999; Krischer, Stone,

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with filicide, namely: low socio - economic status,

Recent investigations (Mckee, 2006) studied the

family history marked by episodes of separation

phenomenon

and violence, early parenting, psychological

comprehensive approach, taking into account

distress

different

and

other

idiosyncrasies

the

vectors

filicide

adopting

analysis:

individual,

psychological functioning of aggressors level, and

contextual (family of origin) and situational

previous history

developmental

(quality and nature of relationships) variables

disorders and the lowest age of the victims. Flynn,

related to the perpetrator, as well as the

Windfuhr, & Shaw (2009 ) summarize as risk

interaction

factors for the occurrence of the phenomenon:

chronological and psychological development of

singles young parents, parents with a history of

each child and parental mutual adaptation. In this

previous contacts with social services and

context, McKee (2006) constructed a matrix of

protection services for children and youth,

risk of maternal filicide (see Table 3), indicating

domestic violence, economic and financial

the risk factors and protective factors for filicide

instability; suicidal ideation, presence of mental

along two dimensions: domain (individual, family

illness (depression and psychosis); postpartum

of origin and situational) and stage (pre-

disorders, illicit substance abuse and lack of social

pregnancy,

support parents.

postpartum, late postpartum, post-childhood).

abuse,

between

pregnancy

the

demands

childbirth,

early

382 Factor

Risc

Protectors

Individual Age

>16 years

Inteligence

Low IQ, Mental Retardation

Education <10 year in school Medical State Emotional Sate

Lack of medical care, HIV Postpartum mood disorders, psychosis, substance abuse,

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Exceeding 21 years Average or above Prenatal care in the 1st third period Absence of a diagnosis of

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Trauma History

history of suicide attempts

mental disorder

Maternal atitude

Sexual abuse, physical abuse, childhood with loss of mother;

No previous trauma

Family Origin

Mother Father Marital relationship / Family

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Denial of pregnancy; negative attitudes to pregnancy, childbirth without assistance; abuse; previous neglect of children; plans to abandon the child

Unwanted pregnancy; positive attitudes toward pregnancy, prenatal care and postnatal

Poor relationship with the child, history of mental illness, substance abuse, perpetrator of child abuse; missing or abandoning family;

Unwanted pregnancy, positive relationship with the child

Child abuse, abuse to companion; perpetrator of incest, mental illness;

Sufficient as a caregiver; positive relationship with the child

Frequent relatives separations, spousal abuse, divorce, financial

No violent relationship

383

Parenting Without Violence

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instability; replacements Contextual Marital relationship

Economic resources Care of children Child Temperament

Abusive partner; dependent on substances companion, unemployment, poverty; 2 or more children in mothers with <17 years; single caregiver, abuse of siblings, many children in the care of the mother; Disobedient; sleep problems for the mother; "difficult" to care for children prior history of abuse of babies / children

Absence of violence for the mother / child, lack of drug Economic resources Harmonious marital relationship; responsive parents, family responsive Secure attachment with children, healthy children, kids calm, quiet

384

Table 3. (Source - Mckee (2006). Why mothers kill. a forensic psychologist’s casebook. New York: Oxford University Press. pp 37-38)

By way of summary, the main risk factors in the occurrence of the phenomenon of filicide, should be considered the analysis of a range of variables covering not only demographic, family and socioeconomic variables of the perpetrators of

to crime victims and forensic characteristics of the

phenomenon,

being

investigated

simultaneously the intersection of all these factors throughout the pregnancy experience and the experience of parenting.

the crime, as well as the characteristics inherent

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CONCLUSION Filicide

investigations a

complex

and

multifaceted

phenomenon, which underlies a range of variables

(demographic,

Socioeconomic,

family,

contextual,

perpetrators),

conjunction with characteristics of victims and

pertaining

personality

assessment of perpetrators of filicide (Tronche, Villemeyer-Plane, Brousse, & Llorca, 2007), to investigate, in a rigorous and scientific manner, the crime of filicide, allowing it apart from other killings and mistreatment phenomena.

medical -legal and forensic crime context, allow us to elucidate the risk factors for the occurrence

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interface

between

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Clinical Research Considerations on Death in the Process of Illness by Breast Cancer Nirã dos Santos Valentim (1), Kayoko Yamamoto (2) & Maria Julia Kovács (3) (1) Student of the doctoral program in Clinical Psychology Institute of Psychology, University of São Paulo (IPUSP) - Brazil. Email: niravalentim@usp.br (2) Professor PhD Program in Clinical Psychology at the Institute of Psychology of the University of São Paulo (IPUSP), Coordinator of the Specialization Course in Psychoanalytic Psychotherapy IPUSP. Email: kayamato@terra.com.br (3) Professor PhD., free teacher of the Social Psychology and Learning at the Institute of Psychology of the University of São Paulo (IPUSP), Coordinator of the Laboratory for the Study of Death (LEM) in IPUSP. Email: mjkoarag@usp.br

Abstract The diagnosis of cancer reminds the patient with thinking about his own death. In breast cancer, the fear of dying is also related to the losses caused by the disease and treatment: removal of the breast or part thereof, loss of hair. The aim of this work is to analyze experiences related to death and mourning in patients with breast cancer. It is presented a case study of a patient treated in eight sessions by Operationalized Brief Psychotherapy (OBP) in an Oncology Center of São Paulo – Brazil. The OBP uses the adaptative diagnosis and the concept of “problem situation” for its planning, and uses as technical resource a theorized interpretation in counter transference. The adaptive diagnosis concluded that the patient was in Group 3 (moderate ineffective adaptation), and sectors Organic and Affective-Relational those most committed, and the losses during his lifetime which were revived in breast cancer, and precipitated a crisis by loss. The patient was regressed and scared because persecutory feelings associated with cancer and the idea of death, and needed to elaborate their body image after treatment. It was possible, with the therapeutic work, contribute to the legitimization of her mourning and help her manage troubles of recognition of herself. Keywords: Brest cancer; Death; Operationalized Brief Psychotherapy.

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Resumo O diagnóstico de câncer faz pensar sobre a própria morte. No câncer de mama, o medo de morrer está relacionado também às perdas que a doença e o tratamento ocasionam: retirada da mama ou parte dela e a perda dos cabelos. O objetivo desse trabalho é analisar as vivências relacionadas à morte e ao luto em paciente com câncer de mama. Para isso, apresenta-se um estudo de caso de paciente atendida em oito sessões de Psicoterapia Breve Operacionalizada (PBO) em Centro de Oncologia de São Paulo – Brasil. A PBO baseia-se no diagnóstico adaptativo e no conceito de “situação-problema” para seu planejamento, e utiliza como recurso técnico a interpretação teorizada na cotransferência. O diagnóstico adaptativo mostrou que a paciente encontrava-se no Grupo 3 (adaptação ineficaz moderada), sendo os setores Orgânico e AfetivoRelacional os mais comprometidos; e que esta vivenciou perdas importantes durante sua vida, as quais foram revividas no processo de adoecimento por câncer de mama, e precipitaram uma crise por perda. A paciente mostrou-se regredida e assustada em função dos sentimentos persecutórios associados ao câncer e à ideia de morte, e necessitou elaborar sua imagem corporal pós-tratamento. Foi possível, com o trabalho terapêutico, contribuir para a legitimação de seus lutos, e, ainda, ajudá-la a lidar com o reconhecimento de si mesma. Palavras-chave: Câncer de mama; Morte; Psicoterapia Breve Operacionalizada.

Resumen El diagnóstico de cáncer hace pensar en la propia muerte. El miedo a morir está relacionado con las pérdidas que causan tanto la enfermedad como el tratamiento: eliminación total de la mama (mastectomía) o parte ella, pérdida del cabello. El objetivo de este trabajo es analizar las experiencias de miedo a la muerte y el duelo, en paciente con cáncer de mama. Para ello, se presenta un estudio de caso de una paciente con cáncer de mama atendida durante ocho sesiones de Psicoterapia Breve Operacionalizada (PBO) en el Centro de Oncología de São Paulo - Brasil. La PBO está basada en el diagnóstico adaptativo y en el concepto de “situación-problema” para su planificación, utiliza como herramienta técnica la interpretación teorizada de la co-transferencia. Resultados: El diagnóstico adaptativo mostró que la paciente se encontraba en el grupo 3 (adaptación ineficaz moderada), siendo los sectores Orgánico y Afectivo-Relacional los más comprometidos, ya que la paciente ha experimentado pérdidas significativas durante su vida, que fueron revividas en el proceso de la enfermedad de cáncer de mama, anticipando crisis por la perdida. La paciente ha mostrado síntomas de regresión y miedo en función de los sentimientos persecutorios asociados con el cáncer, idea de muerte, además de ser necesaria la elaboración de su imagen corporal post tratamiento. Conclusiones: Fue

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posible, con el trabajo terapéutico, contribuir a la legitimación de sus duelos y el poder lidiar con el reconocimiento de sí misma. Palabras claves: Cáncer de mama; Muerte; Psicoterapia Breve Operacionalizada.

Faced with a cancer that makes the individual think about the process of dying itself; effectively makes you think about death as if it came to fruition on the subject, take shape and assume a while to happen, a

decomposition

the

dying

corpse,

the

representations of related to the acts and conduct of the individual final judgment, while alive, determining their fate after death. (Ariès, 2012, p. 50)

sentence. A relationship was then established

For Freud (1915a) distancing of man in relation to the

between cancer patients and death, perceived and

death occurred by an attempt to silence and eliminate

intuited as a "ghost" that haunts a "latent presence"

this, although we know that is a consequence of life.

that accompanies it. (Bromberg, 1995, p.185)

Silencing did not need to think about it and we have

The idea of dying with cancer leads the patient to panic especially at diagnosis, but we know that it is also related to losses which the disease and treatment

the illusion of eliminating it from our reality. Accept the idea of finitude not only ourselves but our loved ones is unpleasant and difficult task in modern times, as it seeks increasingly, prolonging life with new

cause.

discoveries of treatments for various diseases. Historically it was not always so. From the sixteenth century there was a gap and a breakup of familiarity that the man had so far with the experience of death. For the author, the middle age man loved life by accepting death. Ariès writes, "With death, man is subjected to one of the great laws of the species and was considering not to avoid it, nor exalt it. Simply accept [...]" With the changes that have occurred over the centuries, the process of dying has won more individual than collective contours being tied to a sense of failure shown in the representations of the

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In the mid-twentieth century was believed that even the very severely ill should not know that his end was near and the family concealed this knowledge, living a lie in order to maintain ignorance about the approach of death. Hide his pain and suffering was not showing what was expected from families who lost a loved one and thus the expression of grief was not encouraged as it was associated with feelings of shame and sense of failure in relation to death. (Ariès, 2012; Kovács, 2003).

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Currently, it is known that the person who is seriously

own mortality and finitude, how then deal with the

ill has the right to know the diagnosis itself. But when

pain of being seriously ill?

the silence is broken, especially in cases of illness from cancer, think about the possibility of death becomes inevitable and the idea of finitude itself permeates the feelings of the patient who reports "a shock" to get diagnosed.

One can think of a narcissistic injury that is seen in the individual patient, because the idea of immortality itself is broken, and the frustration with the body represented

indestructible

triggering

disappointment comes with the beloved object,

There is a stigma surrounding the disease, and that still

which, in our case, would be the very body / breast

exists in the present, that cannot survive a cancer

(Green, 1988).

time. Although it was justified long ago, when treatments were not as effective and the disease was usually discovered later, further hindering the

DEALING WITH DEATH

possibility of increased survival, now we know that we

The treatment of cancer, in many cases, has been

live another reality (Sontag, 1984).

carried out with the indication of surgery to remove

Prevention programs, especially gynecological and breast cancer, can anticipate diagnostic, and medical technology is developing increasingly along with

tumors that may cause mutilation in patients. Besides dealing with the "specter of death" coming from the cancer diagnosis, the patient still needs to deal with these losses. Studies of Alves (2008) suggest

effective drugs for various treatments.

that the mutilation caused by surgery may take the We believe that death personifies the horror of being ill with cancer, as this is recognized, often as "absence, loss, separation, and the consequent experience of helplessness

and

annihilation"

featuring

setting for the patient "kills himself in life," and we think that in cancer, especially breast cancer, can cause a bereavement for itself (p.130).

the

"unknown and evil." (Kovács, 1992, p. 3-4)

For Freud (1915b) grief is a conscious and natural loss of a loved one, or a representative of this reaction, and

See ourselves seriously ill makes us stand, then, on what is unspeakable, the unrepresented. Freud (1915b) states that there is no representation of death in the unconscious, because there are omnipotent and eternal. If it is difficult to accept the realization of our

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that would be considered normal being resolved with time. The author describes that in mourning, libido need to turn off the object and there is a depression in the outside world, which would be felt as empty for the fellow who feels unable for some time to put

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another object in place of the lost. A part of his ego identifies with the lost object and cannot reinvest in another libido object.

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

BREAST CANCER In breast cancer, several studies show that psychological, social, cultural and religious factors

Melancholy, however, would be a pathological and

influence significantly the way in which the woman

unconscious reaction to deal with the loss of ideal love

will deal with the diagnosis and treatment. Reactions

object shape. The lowering of self-esteem would be

appear as anguish and denial of the disease with

one of the conditions present in melancholia (and not

reports of prejudice in professional activities, and

in mourning), with a deep sense of inferiority and

reports of prejudice and discrimination in general life.

somatic symptoms including insomnia and loss of

(Lobo, Santos, Dourado, & Lucia, 2006).

appetite, resulting in feelings of guilt that are displaced from lost object to own individual. Freud says that the emptiness felt by the melancholy would be experienced within the ego.

Suffering is related to fear of death, and threat to the physical integrity of women. The radical or partial mastectomy surgery - removal of the entire breast or part of it - being one of the treatments for this cancer,

For Klein and Rivière (1975) in the paranoid-schizoid

brings feelings of fear of mutilation to be a very

position hatred and greed, representatives of the

valued part of the female body and one of the

death drive, take care of the baby when their desires

aspects of which defines female identity. (Lobo et al.,

are not fulfilled by the mother, because they create a

2006; Ramos & Lustosa, 2007; Loyola & Gonzáles,

sense of threat of death and destruction. Taken by the

2007; Esch, Roukema, & Vries, 2011)

destructive impulses fantasy baby attack the bad breast than gratifies his fantasy and believes having it attacked and destroyed.

The radical mastectomy may impair quality of life of women causing problems with body image, selfesteem and self-image changes from interfering in

In this case, then, the fear of dying would be the result

affective relationships and sexuality. The feelings that

of fear of annihilation of the ego by the destroyer bad

predominate in this phase are disability, low self-

object. There is a considerable increase in anxiety baby

confidence and sense of helplessness. Weight

for not feeling able to protect the good object - breast

changes, nausea and vomiting, fatigue and hair loss

- and the threat of losing it. This entire process is

caused by chemotherapy; also favor a reduction in the

revived in the process of mourning when the adult is

levels of quality of life. (Pinto & Gioia-Martins, 2006;

found the actual loss of the loved object.

Cantinelli et al., 2006; Gómez & Sánchez, 2011)

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It is important to give voice to the meanings of the body represented as body / subject that brings a psychic inscription and need to communicate their pain and suffering by illness. The identity of women

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

INSTRUMENTS The instruments used were the Brief Operationalized Psychotherapy (PBO) and Operational Adaptive Diagnostic Scale (OADS).

with breast cancer is compromised by a self-image that needs to be revisited and remixed to the self.

The BOP was developed by Simon (2005) using the adaptive diagnostics for your planning and presents as

(Zecchin, 2004)

a central concept to the problem situation, which induces the individual to find an answer or solution for METHOD

it. The past history and the solutions adopted so far are investigated in clinical interviews and evaluated

PARTICIPANT

according to the four sectors through adaptive We present a case study of a patient treated in Brief

Operational Adaptive Diagnostic Scale (OADS).

Operationalized Psychotherapy (BOP) on an Oncology Center of Greater São Paulo. We remember that Brazil provides care for the Unified Health System (SUS) that integrate this Center of São Paulo – The patient was seen by PBO performed after the treatments for breast cancer: Partial mastectomy with axillaries dissection, chemotherapy and radiotherapy sessions.

Affective-Relational (AR) Sector encompasses related attitudes and feelings of the individual responses with himself and people close to them, the Sector Productivity (Pr) is related to activities that are developed

and

source

the

individual's

occupation, the Sociocultural Sector (SC) covers how the individual relates to the institutions, values and

This case study is part of the clinical material that constitutes the PhD - in progress - held at the Graduate Program in Clinical Psychology at the Institute of Psychology of the University of São Paulo, with financing from CAPES (Coordination of Improvement of Personnel and Research Higher Education) of the Ministry of Education of Brazil. The doctoral research in question aims to investigate the therapeutic range of PBO in patients with breast cancer.

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customs aimed at society in which he lives, and the Organic Sector (Or) relates to how the individual deals with his own health and her body. The evaluation of the adaptation is performed by assigning points in Affective-Relational

Productivity

and

sectors

according to the solutions that can be: adequate, appropriate and very little bit appropriate. The Sociocultural and Organic sectors are analyzed qualitatively, receiving no score (Simon, 1989).

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From the review by OADS are possible identify five

to cope with the critical situation and decreased

adaptive groups: Group 1 - Effective Adaptation,

sensation of anguish and helplessness.

Group 2 - Light Ineffective Adaptation and Group 3 Adaptation Moderate Inefficient Group 4 - Adaptation Inefficacy and Group 5 - Ineffective Adaptation

PROCEDURE

Record. There is also the possibility of diagnosing the

The patient agreed to participate in this study by

crisis period in all groups (Simon, 1989, 2005).

signing the informed consent form (ICF). Three clinical

The PBO may be indicated for all adaptive groups and crisis situations. The attitude of the psychotherapist is actively seeking to clarify the patient through

interviews and assessment were made by OADS. The patient was seen weekly for a total of eight sessions of BOP.

theorized interpretations - that make connection between understanding the patient's history with the psychoanalytic theory - the psychodynamics that sustains the problem situation (Simon, 2005).

RESULTS The patient had been widowed for 20 years and had five children, all adults, all for the only marriage that

The cotransferencial relationship - side transfer -

she had. Two married children were still living with

which would be the transfer of feelings associated

her.

with parental figures and significant people from the past, not to the therapist, but for people of daily patient is crafted tried to modify the perception of reality and improving the adaptation (Simon, 2005). The negative transfer is always worked therapeutically to prevent deadlock, but the positive transfer with the therapist is not stimulated to prevent the transfer neurosis too soon as the only therapeutic process may last for up to 12 sessions. (Simon & Yamamoto, 2009; Gebara, 2011).

About the disease, the patient reports that when she was diagnosed with breast cancer she thought she would die. The news was so disturbing that she was "in bed" (sic). Then while doing chemotherapy and radiotherapy, she said Could Not "fall" (sic) needed "stay strong" (sic) to address the situation, and then had to "get up" (sic). Suffering was brought by the need of mastectomy to mutilate a part of your breast. Chemotherapy was also perceived as painful, due to hair loss, weight gain and the onset of reported

In situations which are characterized as adaptive crisis

fatigue.

psychotherapist directs his work in helping the patient

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Brought a complaint of extreme tiredness and

related to the illness itself, loss of breast and fear of

unwillingness very different layout and energy I did

death, predominantly depressive feelings and guilt.

before the illness which caused a feeling of

Sectors “Or” and “A-R” were the most committed to

strangeness to herself: "I'm not the same" (sic).

poorly appropriate solutions and Sector “Pr” showed

Regarding oddity born with different hair after

appropriate

chemotherapy complained: "this is not my hair" (sic).

adequate because patient was proud to work and

solutions.

Productivity

remained

support her children and her household after her husband's death. She was proud of the achievements His past history reports that very young moved to the South São Paulo (Brazil) and met her husband. Soon

obtained with the remuneration of her work and felt satisfied with it.

married, but he was an alcoholic and died, years later, leaving her with small children to support. While married was submissive to the wishes and needs of the husband. Experienced the mourning for his death with much pain and at that moment account that did not know what to do, and that "fell" (sic). After explains that stated "stand up" to work and care for their children and never accepted be romantically involved with someone (sic). She communicated their pain during interviews saying that she was afraid of "falling from bed and can no longer stand" (sic). Began to fear that the tests, which is periodically showed a "new" cancer and carried identification with the situation of a friend who had breast cancer and then a relapse that "leave bed without walking and without talk, "the approval the" living death "(sic).

To deal with the crisis had been necessary to give support and assistance to the patient during the clinical interviews, since the distress was extreme. With the adaptive diagnostic and psychodynamic understanding achieved and the problem situation confirmed - this was a crisis - the therapeutic contract was established with the patient and 8 sessions of BOP were programmed. 397 The theorized interpretation was constructed to show the patient to repeat her answer to meeting the expectations and desires of others was shown to be grieving for their own desires. As the eldest daughter, from her very small age, she took care of the brothers who were born, losing their space in the relationships with parents and for to be a child. She married, still very young, with a husband / father many years older than her. In this relation has accepted a position of

The evaluation with OADS showed that patient was in Group 3 with Ineffective Adaptation, and their

submission to the wishes of this man: accepting not working, although she could, not meeting the

problem situation to a crisis loss in sector “Or” was

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subsistence needs of the family, she accepted the rules dictated for the husband to dedicate herself only to childcare. When her husband died she faced the need to support their children, as this man did not leave her any feature, she focused her energy, alone, to work.

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

DISCUSSION The representations which were made by the patient about the disease showed that the cancer was perceived and experienced as an "insidious disease" that took over his body without warning, without notice and without control over his or her growth or

The fact that have to face the disease and be subjected

removal, showing the pain and suffering of illness

to medical and mutilating treatments, getting terrified

(Zecchin, 2004).

by fear of being crippled, dying, and facing the feeling of abandonment lived in childhood and relived in marriage, she thought it would not have anyone to take care of her and finally will succumb to the disease. She reported that could not "turn up alone" (sic) as happened since childhood and was terrified with that. With

the

interpretation

theorized

cross

transference, the patient was able to make contact with the anger felt by the abandonment of her parents and husband and bear the guilt of that feeling.

We realized that the patient showed a very similar position to the paranoid-schizoid psychic functioning, threatened by cancer as a persecutory object. The fear of being annihilated by the disease seemed to us related to persecutory fantasies of self-destruction in the face of suppressed anger, and the cancer itself in the imagination of the patient was reported in a few moments as a punishment (Klein & Rivière, 1975). The difficulty in facing this threat did look at some internal feature that could make "stand up" in this

Gradually, she began to bring to the sessions what she

situation, as when he stood her husband's death.

wanted to express, as their wishes for their children,

The solution that was adopted was previously the job,

for example, it would be no more "nanny" and ask

but with chemotherapy found no physical strength to

their grandchildren to organize themselves differently,

use the same solution.

including in relation to housing, so she could enjoy the house, the result of their work, like their space. That was understood by the therapist as a ransom of his desires: she was alive, was not going to "fall": die.

The strangeness of the self-showed intense suffering, but was not always legitimate, it also generated fault, since the patient was advised by doctors, by family and friends to consider mastectomy as a benefit to your health. And there is a paradox here: how to celebrate a surgery that excised the cancer, it delivered the "evil", but at the same time took with him such an

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important part, a beloved object by the self? There is

accordingly, "fall" would be a representation to die:

a sense of incompleteness that patient experience

lose energy, get depressed and not raise more.

when faced with the mutilation of her breast (Pinto & Gioia-Martins, 2006; Lobo, Santos, Dourado, & Lucia, 2006; Ramos & Lustosa, 2009).

The attendances at BOP sought help patients to cope with their inability to reinvest their libido in another object of love in their desires and needs that were

A sense of loss in the patient also appears when she

subdued to the needs of the brethren, the needs and

realized how she was different, not only in her body

desires of her husband and children. It could also work

image - different hair - but also on the depression and

for the feelings of anger from husband due to

tiredness (Loyola & González, 2007; Gómez & Sánchez,

disappointment with his alcoholism, but also for his

2011). We realized that the patient brings feelings of

death leaving her helpless and unable to support

loss related to itself, which makes us think in the

herself and the children.

studies of Alves.

We understand that the patient experienced

We understand that patient present feelings of loss

substantial losses during his life that were revived in

related to itself, what make we think in studies of Alves

the disease process for breast cancer precipitating a

(2008) who wrote about patients maimed as a result

crisis for loss (Simon, 1989, 2005). With the

of accidents, identifying a process of mourning for the

therapeutic work it was possible to contribute to the

lost part of themselves. It seems that the patient

legitimacy of the patient's grief and help her to deal

demonstrated experience a mourning for herself, not

with the shame of the suffering and guilt of hostile

only for the lost breast, but for what she believed

feelings by parents, by an alcoholic husband, and

constituted her as a mother, the nurturing bosom and

owing to illness, for having "fallen "(sic), for failing

layout needed when having to struggle to support her

to keep" standing "(sic).

children after the death of his mate.

It was necessary to promote a re-establishment of

The patient's pathological mourning for her husband

self-image, as well, as related to his wishes as a

can be understood in the light of melancholy

woman.

described by Freud (1915b), it did not accept the investment

into

another

relationship

after

Similar results have been reported in studies de Loyola and González (2007).

widowhood, denying her own desires. It seems also to have revived that first fight later in mourning for herself during the disease (Alves, 2008) and,

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Although we have illustrated one case, we noticed that the process experienced by this patient carries

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similarities to other patients seen, and the losses and

position and to move towards the depressive position

grief are recurring situations in the stories of these

(Klein & Rivière, 1975).

women. They presented themselves regressed and fearful, with persecutory feelings by cancer - internal tracker - need and make a new integration with the body. When psychotherapy was provided to them, they can share their sorrows, enabling use resources from the external environment to regain self-esteem

We believe that the BOP is an important tool for understanding the suffering of these patients, their fears and anxieties and that can help them develop and deal with conflicts that are implicated in how they handle and perceive the disease itself and the treatment process.

and overcome the pains of the paranoid-schizoid

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Pilot study on the construction of a Screening of Neuropsychological Exploration, for evaluation of Cognitive Complaints and Dementia’s States Dulce Marques Master in Clinical neuropsychologist and Clinical Psychologist: mdulce.marques@gmail.com Abstract In order to examine the impact that the Neuropsychological Exploration Screening (NES) has at the level of neuropsychological functioning, and at the same time verify if its construction, structures and entered variables had an optimal level of acceptance, in the present clinical sample, it was verified the performance of 66 adults, including individuals with neuropathologic diagnosis. It was considered to study all the variables included in the Structures: Language, Orientation, Attention, Memory, Praxis, Gnosis, Abstraction and Logical Reasoning, Mental and Written Calculation, VisuoConstructive Capacities, "prefrontal" Activities/executive functions, Hemineglect and Self Disorders. The most significant differences were found in language, attention, Gnosis and Mental and Written Calculation. The obtained results showed that NES evidences clinical utility and discriminating force in Neuropsychological Assessment and Exploration for dementia and cognitive complaints. Keywords: Neuropsychological Assessment; Neuropsychological Exploration Screening (NES); Cognitive complaints; Dementia.

Resumo Com o objetivo de examinar o impacto que o Screening de Exploração Neuropsicológica (SEN) tem a nível do funcionamento neuropsicológico, e ao mesmo tempo verificar se a sua construção, as estruturas e variáveis inseridas tiveram um nível de aceitação ótimo, na presente amostra clínica verificou-se o desempenho de realização de 66 adultos, entre os quais, indivíduos com diagnóstico neuropatológico. Foram consideradas para o estudo todas as variáveis inseridas nas Estruturas: Linguagem, Orientação, Atenção, Memória, Praxias, Gnosias, Abstração e Raciocínio Lógico, Cálculo Mental e Escrito, Capacidades Visuo-Construtivas, Atividades de tipo “pré-frontal”/funções executivas, Despiste de Heminegligência e Perturbações do Eu. A par da construção e desenvolvimento do SEN, foi elaborado o seu Manual tendo uma base teórica explicativa das estruturas constituintes e os procedimentos de administração dos exercícios. As diferenças mais significativas foram encontradas na Linguagem, Atenção, Gnosias e Cálculo Mental e Escrito. Os resultados obtidos permitem concluir que o SEN evidencia utilidade clínica e poder discriminativo na Avaliação e Exploração Neuropsicológica para as Queixas Cognitivas e Quadros Demenciais. Palavras-Chave: Avaliação Neuropsicológica; Neuropsicologia; Queixas Cognitivas; Quadros Demenciais. Resumen Con el fin de examinar el impacto que la evaluación neuropsicológica (NES ) tiene en el nivel del funcionamiento neuropsicológico, y al mismo tiempo verificar si su construcción, las estructuras y las variables tenían un nivel óptimo de aceptación, en la presente muestra clínica, se verificó el cumplimiento de 66 adultos, incluidas las personas con diagnóstico neuropatológico . Se consideró que estudiar todas las variables incluidas en las estructuras: lengua, orientación, atención, memoria, Praxis, Gnosis, la abstracción y el razonamiento lógico, mental y cálculo escrito, capacidades

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viso - constructivas, Actividades funciones " prefrontales " / ejecutivos, heminegligencia y Trastornos del yo. Se encontró que las diferencias más significativas son en el lenguaje, la atención, la Gnosis mental y cálculo escrito. Los resultados obtenidos mostraron que la NES evidencia la utilidad clínica y la fuerza exigente en la evaluación neuropsicológica y exploración de demencia y quejas cognitivas. Palabras clave: Evaluación Neuropsicológica; Neuropsicológica Exploración Screening (NES); Quejas Cognitivas; Demencia.

This Neuropsychological Screening Exploration As

the

neuropsychological

evaluation

(NSE) aims to be a strength in neuropsychological performed through a set of standardized tests assessment daily consultation. Built based on the and is particularly useful in cases of suspected difficulties inherent in clinical practice for cerebral deficits affecting cognitive function instruments measured for the Portuguese procedures, behavior or executive functions (i.e., population,

specifically

healthcare functions that enable planning and execution of

professionals who start their professional activity various tasks, and aims a particular purpose) (stage, first job), provides a manual for claim this protocol is to briefly facilitate the application and interpretation of each specific search and detection of symptoms inherent in cortical temporal

exercises and

areas

(frontal,

occipital),

parietal, these clinical pictures.

used

neuropsychological assessment. Its purpose is to facilitate the evaluation and neuropsychological intervention and master the areas of assessment, use this tool to search for and getting answers to existing questions, sensitivity in the analysis of case studies, building your own review, eliminate errors that may have been committed in the first instance and ultimately seeking to improve and strengthen

BRAIN AGING In the XXI century there has been an increase in population, especially the elderly population, and as such it appears that the aging process is a reality that will touch everyone. With the aging brain

arise

some

difficulties

in cognitive

functioning, such as decreased attention and immediate memory and slowing the speed of information processing.

their practice, their knowledge, as well as trying to find the professional in you, more capable, knowing this very important area of our current social context .

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But these are just some of the difficulties encountered in the elderly, because the aging brain as a biological, psychological and social

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phenomenon affects the human being in the that, in Portugal, more than 70,000 people suffers plenitude

its

existence,

changing

its from Alzheimer's Disease (Heitor dos Santos et

relationship with time, your relationship with the al., 2005). world and even his own life story (Teixeira, 2006).

According to the World Health Organization

The aging of the world population, and the (2002), an aging processes is declared in a Portuguese population in particular is a result of population and a phenomenon of a single person. the significant increase in average life expectancy As a phenomenon of a population expressed the of the respective populations as a result of health success of humanity, as it represents the result of improvements developed during the twentieth human discoveries and advances in hygiene, century, but also the reduction of the birth rate nutrition, (Ministry of Health, 2004).

medical

technology

and

social

achievements, among others. As an individual

The proportion of people aged 65 or more increased in Portugal of 100% over the last 40 years: in 1960 it accounted for 8% of the total population while it already represented 16% in 2001 and is expected for 2050 32% of total national population. Today the country has more

phenomenon, aging is a matter of bio-psychosocial study, i.e., the science of aging is multidisciplinary. The aging in humans cannot be described, predicted or explained without taking into account the three aspects of it: the biological, psychological and social.

than one and a half million people over 65 years During aging various physiological processes are (Rebelo & Penalva, 2004; Carrilho & Gonçalves, modified, for example, the nervous system 2004). This

reduces the volume of the central nervous system aging

population

has

important

consequences in the context of mental health of these people. In general, the prevalence of certain mental disorders tends to increase with age: depression is certainly the most common

(loss of neurons and other substances) and the fibers lose their myelin - responsible for nerve conduction velocity stimulus (Straub et al., 2001; Berger & Mailloux-Poirier, 1995; cit. in Pereita et al., 2004).

mental disorder among older people and more Intellectual functions also change if, for example, than 100,000 elderly suffer from this disease in difficulty in learning and memory processes, the country. Like, dementias also represent a which is probably related to the chemical, major burden for patients, their caregivers and neurological and circulatory disorders that affect for the community as a whole. It is estimated brain function, decrease the effectiveness of

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oxygenation and cellular nutrition and decrease (11 million today) will reach 24 million in 2025 in association with learning disabilities in the (Alzheimer’s Disease International, 2010). synapses

and

the

availability

certain

neurotransmitters (Braver & Branch, 2002).

For these reasons, and due to increased life expectancies in the world population in the last century, becomes an important social problem,

DEMENTIAS

as well as, in addition to age, the prevalence of dementia is influenced by other demographic

"Dementia" and "Insane" are, in common jargon, stigmatizing words, showing, in general, the lack of preparation to understand and accept the evils

variables, such as the education and socioeconomic levels (Jorm, 1990; Hofman et al., 1991, cit. in Herrera, Caramelli, Silveira, & Nitrini, 2002).

of the mind (Pontes, 2007). From this clinical point of view, dementia is considered a syndrome marked by the occurrence of multiple cognitive deficits or disorders of executive functioning.

According

the

International

Statistical

Classification of Disease Related Health Problems of the World Health Organization (2007a) dementia is a situation in which, in subjects

The term "dementia" does not define a single disease but a syndrome (defined set of clinical signs and symptoms), since there is a vast and heterogeneous group of pathological conditions that cause this clinical picture, there are numerous types of dementias (Massano, 2009; cit. in Sá, 2009).

without altered level of consciousness, there are changes in cognitive functions, called superiors, especially memory, thinking, orientation skills, learning and calculation, and difficulty in understanding and making critical judgments. Changes of language, oral or written, and behavioral changes are also common. In general,

The number of people affected by dementia has these disorders interfere with social activities, grown significantly with the aging of the world professional and even daily life (Pontes, 2007, population. It is estimated that in 2025 the WHO, 2007b). number of people with dementia is 34 million (currently about 18 million people suffering from this condition). The increase in the incidence of dementia is higher in developed countries, where the current population of people with dementia

The criteria of the Diagnostic and statistical of mental disorders manual (American Psychiatric Association, 2002), dementia is defined as a multiple cognitive deficit, which affects memory and is associated with at least one of four symptoms of intellectual disturbance: aphasia,

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agnosia, apraxia, or executive dysfunction, with ability or desire to do many of the activities of significant decline from the previous professional day-to-day difficulties in employment, social or social performance of the person, and that isolation, changes sleep - that these symptoms does not occur during a confusional state or may appear in a patient with dementia, even in depressive illness.

the early stages (Massano, 2009; cit. in Sá, 2009).

The process of diagnosing dementia is a complex Finally, it is common for individuals to go to the process that requires an extensive set of skills and doctor complaining of cognitive impairment (eg, a methodical effort. Firstly it is necessary to memory complaints), which is supported by those demonstrate

cognitive

and

functional who accompany him, it is even possible to

deterioration that may fall in the designation of objectify and characterize deficits through dementia, ie, it is necessary to prove a decline in cognitive cognitive

screening

extensive

function that originated evident neuropsychological assessment. However, these

damage in daily life activities of the individual, patients remain unaffected or minimally affected causing personnel functioning, family and social in their activities of daily living, it is therefore not changes (Massano, 2009, cit. in Sá, 2009; possible to establish the diagnosis of dementia. Whalley, 2002).

This has acquired several more or less equivalent

Secondly, the diagnosis of dementia involves alteration of more than one cognitive function (eg, memory, language, attention). Thirdly, the

designations in practical terms, the most used nowadays

Mild

Cognitive

Impairment

(Massano, 2009; cit. in Sá, 2009).

diagnosis of dementia can only be done in the absence of an acute confusional state (delirium). DEMENTIA STATES It is also necessary to make a differential Aging population is a global phenomenon that diagnosis with particular emphasis on depression, has direct consequences on the public health because depressed patients may experience system. One of the main consequences of this cognitive difficulties, sometimes months in population growth is the increased prevalence of duration, which appear to be similar to a dementia, especially Alzheimer's disease (AD) dementia, called "pseudo dementia". There are (Prince, Acosta, Chin, Scazufca, & Varghese, 2003; frequent complaints of changes of "memory" Herrera et al., 2002). (with

difficulties

remembering

events, Thus, identification of individuals at potential risk

appointments or names of people), decreased of

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developing

dementia

becomes

critical.

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Although still generate controversy, the early subcortical dementias we can include dementia diagnosis

dementia

allows

therapeutic associated

with

Parkinson's

disease

and

intervention, decrease levels of family stress, progressive supranuclear palsy; deficits typically reduces

the

risk of accidents,

extending include psychomotor slowing processing and

autonomy and perhaps, in some cases, avoid or changes in executive functions. Situations such as delay the onset of dementia process (Petersen et corticobasal degeneration and dementia with al., 2001a).

Lewy bodies can encompass us mixed frames,

As stated by Pontes (2007) the dementia have an where there are features of both previous groups important impact on economic, social and family (Massano, 2009; cit. in Sá, 2009). aspects of the patient. As symptoms advance, In all dementia cases there are also changes in the also increases the dependence of the patient and behavioral type (also called neuropsychiatric, the family burden, both emotional and financial. psychological or psychopathological). Many of The loss of neurons and the consequent these changes may be common to several deficiency in communication between them dementia, but are relatively other characteristics occur in all types of dementia, although the of either dementia in particular. Changes in specific causes of dementia are still largely a behavior are often those most concerned with mystery, it is known that they result in various and upset families and their caregivers, and can physical weaknesses, as well as, as to its cause include

apathy,

depression,

hallucinations,

i.e., differ depending on the age (Galton, 1999; delusions, aggression, abnormal sleep-wake cit. in Ballone & Moura, 2008).

cycles, among other (Massano, 2009; cit. in Sá,

Dementia can, in a practical way, be divided into 2009). cortical, subcortical, and mixed, according to Characterization and recognition of various whether a typical clinical alteration of cortical dementia types are not mere nosological lesions, subcortical or both. In the group of typical classification exercises; they have an essential cortical dementias is the existence of deficits in role in clinical management, prescribing and memory

(amnesia),

language

(aphasia), treatment success, and even the prognosis of

perceptive recognition (agnosia), calculation short and medium term. In the large group of (acalculia) or ability to perform motor tasks dementias, there are some likely to be improved (apraxia) - The Five A's. Examples of cortical when well-timed identified and corrected the dementias are Alzheimer's disease and front causes that triggered them. Others could be temporal lobar degeneration. In the group of prevented or affected by any prophylactic,

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precipitating or aggravating factors (Pontes, This new scientific discipline aims to analyze the 2007). Another

changes and higher cortical processes or psychic classification

was

proposed

for activity of a person, resulting from brain damage,

Dementia (Nitrini & Carameli, 2003; cit. in considering the relational aspects between the Nordon, 2009) that divide cognitive disorders in structure and function with the development and two groups: dementia resulting from impairment monitoring of individual (Sousa, 2009; cit. in Sá, of the central nervous system (CNS) and not due 2009). to CNS involvement (such as those caused by toxic-metabolic changes). The first group can be divided into primary and secondary dementias. Primary dementias are divided into two groups, one group that dementia is the main clinical manifestation

(Alzheimer's

Disease,

Front

Gazzaniga, Ivry and Mangun (1998; cit. in Maia, Correia, & Leite, 2009) held that the assessment of cognitive function had a large supply of neurologic disorders, ie, neuropsychology plays a major role in the understanding of brain function and their respective changes.

temporal Dementia [DFT], Dementia with Lewy bodies) and the other group that dementia may be the clinical manifestation of a secondary one (Parkinson's

disease,

Huntington's

disease,

progressive supranuclear palsy). The secondary are caused by changes in the CNS, such as cerebrovascular disease, tumors, infections and

Neuropsychological assessment is a procedure for investigating relationships between brain and behavior, especially of cognitive dysfunction associated with disorders of the Central Nervous System (Spreen & Strauss, 1998; cit. in Hamdan, 2008). Neuropsychological and cognitive assessments

hydrocephalus.

represent the most effective methods of NEUROPSYCHOLOGICAL

ASSESSMENT

OF differential diagnosis in the discrimination

COGNITIVE COMPLAINTS IN DEMENTIA CASES The term Neuropsychology was first used by Osler in 1913 when he tried to relate the behavior of human beings with intellectual processes, representing a new approach to the study of the brain (Sousa, 2009; cit. in Sá, 2009).

between normal and pathological, and between cognitive difficulties related to depression and other disorders and conditions of pernicious cognitive decline (Bertelli et al., 2007; cit. by Bertelli, Bianchi, & Cruz., 2009; Morris, Warsley, & Matthews, 2000). Among the causes cognitive decline are Alzheimer's disease and dementia with Lewy bodies.

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The profile of neuropsychological impairment in refinement of instruments and standardized tests AD and DCLewy reflects a poor performance in to obtain quantitative measures of cognitive visuospatial tasks and tests of attention (Sauer, variables, emotional and behavioral factors Ballard, Brown, & Howard, 2006).

(Cashman & Scherer, 1995; Goldstein, 1987;

The vast majority of tests used in clinical

Russel, 1986; cit. in Maia, 2006).

neuropsychology were specifically designed to Franzem (1989; cit. in Maia, 2006) states that measure

particular

function,

and

are clinical neuropsychologists point with pride the

standardized. Before starting the evaluation, fact that conduct objective evaluations through neuropsychologist should know the context of testing and instruments that constitute the this assessment, that is, knowing who sends the clinical repertoire. More than that, authors as patient and why. Then the clinical assesses the Lomg and Kibby (1995; cit. in Maia, 2006) and patient, whereupon the interview with the Chaytor and Schmitter-Edgecombe (2003; cit. in patient and, as a next step, in some cases, family Maia, 2006) underscore the relevance of / caregiver should be consulted. At the end, the neuropsychological tests in their ability to clinical general

neuropsychological

assessment

is diagnosis of neurological and neuropsychological

initiated (Manning, 2005). Any

neuropsychological

disturbances, so that the ecological validity of the assessment

should

test used is ensured.

provide a relatively general framework through In addition to the extensive research that tests measuring cognitive functions: reasoning concerns the evaluation of particular aspects in ability, memory, language, calculation, visual the field of neuropsychological phenomenology capabilities and spatial perception, praxis and (memory, attention, concentration, language, executive functions. To evaluate each of these executive functions, etc., Benton, 1994; cit. in functions neuropsychologist selects the type of Maia, 2006), many studies have systematically tests adapted to the patient, knowing that there seek to proceed neuropsychological assessment is a variety of tasks to different levels of in the evaluation of several diseases, such as examination of intended function (Manning, dementia (Butter & Dellis, 1995; cit. in Maia, 2005).

2006).

According to several authors, the main feature of the

strengthening

neuropsychological

assessment in the evaluation of dementia was the

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RESEARCH METHODOLOGY

- Structure of orientation issues were made to verify the self-psychological, temporal, and

PURPOSE AND OBJECTIVES OF RESEARCH

spatial orientation. The relationships between the variables that were

considered

and

constituents

Neuropsychological Screening Exploration (NSE) will be described in term of socio demographic characteristics and a posteriori will be settled the choices of structures and variables respective to NSE, took into account the learning drawn from national

and

international

literature

- Structure of the D2 attention test to assess selective attention and ability to concentrate were used. As was also used repetition of digits in reverse order and direct order, and finally, 20 sentences taken from the Token Test. - Structure of Memory exercises recalling

and words with interference, a visual test and an

summarized in the theoretical framework of this exercise of word pairs were applied. pilot study.

- In the framework of the Praxis is intended to

The 12 structures listed in the NSE are: Language, verify

the

execution

movements

and

Orientation, Attention, Memory, Praxis, Gnosis, perceptive activities through verbal commands Abstraction and Logical Reasoning, Mental and such as: "Pretend that you have to grab a cup and Written Capabilities,

Calculation Pre

Frontal

Visuoconstructive drink some water." Type

Activities,

Hemineglect and Disorders of the Self.

- On the structure of gnosis exercises were applied to assess the presence of visual gnosis for

The exercises used in these structures take into colors, digit gnosis, etc. account national and international references, and will be explained briefly:

- In the framework of Abstraction and Logical Reasoning used the Ab Raven Progressive

- Structure of Language evaluated the Matrices form. assessment of speech by Fluency, Articulation, Content, Structure and Prosody; exercises naming and verbal fluency; fulfillment of orders;

- In the Structure of Mental and Written Calculation some simple arithmetic operations were implemented.

repetition of words and phrases, reading and writing.

- In structure Visuoconstructive Capabilities has been used the Clock test in the form Copy, Memory, and a copy of a drawing of a simple house.

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- In the framework of the activities of GENERAL OBJECTIVES "prefrontal" type we sought to assess the executive functions of the subjects through the Luria Series, ability to criticize absurd situations and have verbal initiative, for example, when asked about what exists in a supermarket.

Construction

and

development

Neuropsychological Screening Exploration, and its

manual

review

the

Complaints

Frameworks dementia, emphasizing the 12 structures inserted in Screening.

- On the structure of Screening hemi negligence we try to assess the existence of sensory or spatial hemi neglect to the left or right,

SPECIFIC OBJECTIVES

depending on whether the lesion or dysfunction Check if the twelve structures and respective are located. This examination was accomplished assessment exercises inserted into each structure through

exercises

Cancellation

Line, assesses what you want to be evaluated.

Description of room on the left, right and center and simultaneous bilateral stimulation. - In structure of Self disorders, the assessment was checked throughout the session, i.e., check whether

the

subject

has

Understanding if the variables used in the twelve structures are a contribution to the review of complaints / Frameworks dementia.

anosodiaphoria,

anosognosia, parting its cooperation and how Examining was her mood.

the

impact

NSE

has

neuropsychological functioning, particularly in language, orientation, attention, memory, praxis, gnosis, abstraction and Logical reasoning, mental

INFERENTIAL OBJECTIVE STUDY / NEUROPSYCHOLOGICAL SCREENING EXPLORATION CONSTRUCTION

and written calculation, visuo constructive capabilities, "prefrontal" activities type for hemi negligence screening and disorders of the Self,

In line with the object of study, we present the

based on the characterization of the performance

following objectives:

of a sample of adults.

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STUDY HYPOTHESIS

SAMPLE AND PARTICIPANTS

Considering the literature review conducted, and To obtain the data we used a convenience based on the comparison between the group of sampling process. The sample consisted of 66 adults with diagnosis (ICD-10) and the group Portuguese, 54.5% were male and 45.5% were without

diagnosis

(presenting

cognitive female, with a mean age of 64.8 (SD = 1,553) from

complaints), was outlined the following general the Memory Clinic at the Department of hypothesis:

Psychiatry and Mental Health Hospital Center of

The group with no diagnosis has superior (no deficit)

results

the

variables

Alto Ave - Guimarães.

neuropsychological assessment at the expense of

CONCLUSION AND FINAL THOUGHTS

the group diagnosed. This research aimed to build and develop a Neuropsychological Screening Exploration (NSE), DATA STATISTICAL TREATMENT After

the

description

the

as well as its manual to review the Complaints assessment

instrument and structures and their respective exercises and to ascertain the validity of the assumption made in earlier times, proceed to the descriptive statistics to characterize the sample and then the statistical comparison between groups using Chi-square. Descriptive statistics is a procedure photographing the group studied, a

and Cognitive Frames of dementia, emphasizing the 12 structures inserted in the NSE, as follows: Language,

Orientation, Attention,

Memory,

Praxis, Gnosis, Abstraction and Logical Reasoning, Mental

and

Written

Calculation,

Visuoconstructive Capabilities, "prefrontal" type Activities of executive functions, Screening of hemi neglect and Disorders of the Self

basic procedure normally included in all We would like to emphasize that in this study investigations and in particular presented as were mean, median and fashions (Ribeiro, 1999). For performing all statistical procedures version 17 of the SPSS was used (Statistical Package for the Social Sciences).

included

adults

diagnosed

with

neuropsychophatologic state (performed by psychiatrist and neurologist) and adults without a diagnosis (presenting cognitive complaints) from Department of Psychiatry and Mental Health Hospital Center of Alto Ave - Guimarães, so the

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collection

this

sample

gives

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

more as NSE are complementary tests with a wide

homogeneity. The

range of tests and exercises, as well as rigorously

Neuropsychological Assessment

essential step in the diagnosis of various cognitive disorders, either in the elderly, adults and children, to determine whether the development

standardized techniques and are particularly useful in cases of suspected brain dysfunction affecting cognitive function, behavior, mood or personality.

of the individual is compared to normal values for In short, the Neuropsychological Assessment and age and education. By neuropsychological NSE are particularly important in diagnosing a assessment and clinical practice passes the use of neurodegenerative process still in its infancy, tests / batteries for the functional assessment of enabling healthcare professionals to outline a the brain. Brain function assessed with these more effective treatment plan to slow or stall the tests are, among others, attention, memory, progress of the dementia process, giving the language and executive functions. Apart from patient more autonomy and better quality of life assessment through these tests are also collected for longer. It is also a useful complementary test at social, behavioral and emotional level in the differential diagnosis between diseases information, together with the results of the tests that contribute to the explanation of clinical cases allowed fulfill several goals it proposes a of increasing complexity, thus contributing to a neuropsychological evaluation.

correct implementation of drug therapy and

The NSE and Neuropsychological Assessment, are

cognitive rehabilitation.

especially designed for people who show In objective

associated

subjective with

cognitive

neurological

the

neuropsychological

domain,

which

deficits constitutes the core of this pilot study - the diseases construction of NES and its manual - it was found

(Alzheimer's disease, stroke, Parkinson's Disease, that although 12 structures were evaluated into Epilepsy, Multiple Sclerosis, Traumatic Brain brain areas, it has been only obtained significant Injury), a psychiatric illness (schizophrenia, results in 4 structures (and their variables Depression, Bipolar Disorder, Anxiety Disorders, inserted) - results in the performance of Obsessive Compulsive Disorder, Post-Traumatic neuropsychological tasks of language, attention, Stress) syndrome, or other conditions that gnosis and mental and written calculation - these require

their

technical

and

professional structures were indicative of that in the first

assistance. Both neuropsychological assessment instance (object and purposes of the study) was

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intended to verify, i.e. if the 12 structures and However, this study has some limitations. The respective exercises inserted into each structure sample size (n = 66) calls for cautious evaluated were evaluated, as well as being a interpretation of the results presented here, it contribution to the assessment of cognitive, would therefore be desirable to reevaluate these neurodegenerative

and

dementia

frames findings in a larger sample and perhaps

complaints.

considering the inclusion of "purely" healthy

This profile of neuropsychological performance of

participants.

the participants in the implementation of the NSE, characterized by the results obtained in the

AKNOWLEDGEMENTS CHAA

various neurocognitive functions, is similar to that found in research and summarized national and international studies at the theoretical framework of this study (cf., Mendonça, 2005; Baron, 2004; Holland & Larimore, 2001), and although not all the tasks involving expressive language have significantly differentiated adults with

diagnosis

undiagnosed

adults,

significantly lower performance were observed in the control group, ie the group of adults without a

diagnosis,

which

confirms

the

general

This study would not be possible without the permission of the Alto Ave Hospital Center Guimarães for the collection of this sample in this study, as well as the contribution, logistics and support from the Department of Psychiatry and Mental Health, more specifically, and a special thanks to Professor Carlos Augusto de Mendonça Lima (Psiquiatra) and Dr. Emanuela Sofia Teixeira Lopes

(Psychologist

and

Coordinator

Psychology, Department of Psychiatry and Mental Health).

hypothesis formulated.

mentais

References

–

texto

revisto

(DSM-IV)

(4ª.

Ed.).Lisboa: Climepsi Editores. Alzheimer’s Disease International (2010). World Wide

Web.

Retrived

from

http://www.alz.co.uk/

Ballone, G. J., & Moura, E. C. (2008). Demências. World

Wide

Web.

Retrieved

from

www.psiqweb.med.br American Psychiatric Association (2002). Manual de diagnóstico e estatística das perturbações

Baron, I. (2004). Neuropsychological evaluation of the child. New York: Oxford University Press.

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Original Article Motivation for practice and not in school sports in youth of 2nd and 3rd cycle of basic education Júlio Martins (1,2), Samuel Honório (3), João Cardoso (1), Luís Duarte (1), Marco Batista (3) & João Brito (4). (1) University of Beira Interior – Covilhã, Portugal (2) (CIDESD) - Research Centre for Sport, Health and Human Development (3) Higher School of Education of Torres Novas – (CIFOC, Investigation Centre of Continuous Training), Portugal (4) Sport Sciences School of Rio Maior-Polytechnic Institut of Santarém; CIDESD

Abstract Purpose: The present study aims to investigate the motivations that lead young people to the practise, and non-practise, of School Sports. Methodology: The sample consists of 496 students of both genders, of which 171 students practise School Sports and 325 don’t participate in School Sports. As instrument it was applied the Motivation Questionnaire to Sport Activities – MQSA adapted and shortened version (Frias & Serpa, 1991) of the original Participation Motivation Questioner – PMQ (Gill, Gross, & Huddleston, 1983); and the Motivation Inquiry to the lack of Sport Activity – IMAAD, developed by Pereira and Vasconcelos-Raposo (1997) validated by Fernandes (2005) Results: From the factual analysis to the sports practise in School Sports we can infer that there are significant statistic differences in the independent variables: gender in the factor “Physical Fitness” (P=0,026); in the place of residence, “Status” (P=0,016); in the level of formation “Status” (P=0,000), “Emotions” (P=0,012), “Pleasure” (P=0,000), “Physical Fitness”, (P=0,000), “Technical Development” (P=0,000), “General Membership” (P=0,000) and “Specific Membership” (P=0,000); teaching cycle “Status” (P=0,000), “Emotions” (P=0,026), “Pleasure” (P=0,006), “Physical Fitness”, (P=0,000), “Technical Development” (P=0,003), “General Membership” (P=0,001) and “Specific Membership” (P=0,000). In what concerns factual analysis to the non-practise of School Sports one can state that there are significant statistic differences in the independent variables: gender in the factors “Sports’ Aversion/ Dissatisfaction” (P=0,000), “Aesthetics/Incompetence” (P=0,000), “Lack of Support/Conditions” (P=0,004) and “Lack of Interest in physical effort” (P=0,000); in terms of level of teaching “Lack of Interest in physical effort” (P=0,022) and “Lack of time” (P=0,000). Conclusions: The comparative analysis show that the independent variables contribute both positively and negatively to young people’s practice and non-practice of School Sports. Keywords: Motivation; School Sports; Practice and Non-Practice of Sports.

Resumo O presente estudo tem como objetivo investigar as motivações que levam os jovens à prática, e não- prática, de Desporto Escolar. Metodologia: A amostra é constituída por 496 estudantes de ambos os sexos, dos quais 171 estudantes praticam desportes escolares e 325 não participam de Desporto Escolar. Como instrumento foi aplicado o Questionário de Motivação para as atividades esportivas – MQSA, versão adaptada e encurtada (Frias & Serpa, 1991) do teste original - PMQ (Gill, Gross & Huddleston, 1983), e do Inquérito para a falta de Motivação da Atividade Esportiva - Imaad, desenvolvido por Pereira e Vasconcelos - Raposo (1997) e validado por Fernandes (2005).

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Resultados: A partir da análise factual para a prática de desportes em Desporto Escolar, podemos inferir que há diferenças estatisticamente significativas nas variáveis independentes: gênero no fator " Aptidão Física " (P = 0,026), no local de residência, "Status" (P = 0,016), no nível de formação "Status" (P = 0,000), " Emoções " (P = 0,012), "prazer" (P = 0,000), " aptidão Física " , (P = 0,000) , " desenvolvimento técnico " (P = 0,000) , " General Membership " (P = 0,000 ) e" sociedade específica " (P = 0,000 ); ciclo de ensino " Status " (P = 0,000), " Emoções " (P = 0,026), " prazer " (P = 0,006), " aptidão Física ", (P = 0,000)," Desenvolvimento Técnico " (P = 0,003), " Composição Geral " (P = 0,001) e " Composição específica " (P = 0,000). No que diz respeito a análise factual à não prática de Desporto Escolar é possível afirmar que existem diferenças estatisticamente significativas nas variáveis independentes: gênero nos fatores "' Sports - Aversão / Insatisfação " (P = 0,000), " Estética / Incompetência " (P = 0,000), " Falta de Suporte / Condições " (P = 0,004) e " falta de interesse em esforço físico " (P = 0,000), em termos de nível de ensino " falta de interesse em esforço físico " (P = 0,022) e " Falta de tempo " (P = 0,000). Conclusões: A análise comparativa mostra que as variáveis independentes contribuem positivamente e negativamente com a prática e não- prática dos jovens de Desporto Escolar. Palavras-chave: Motivação; Desporto Escolar; Prática e não- prática de Desportos.

Resumen El presente estudio tiene como objetivo investigar las motivaciones que llevan a los jóvenes a la práctica, y no la práctica, de los Deportes en la Escuela. Metodología: La muestra está compuesta por 496 estudiantes de ambos sexos, de los cuales 171 alumnos practican deportes escolares y 325 no participan en Deportes en la Escuela. Como instrumento se aplicó el Cuestionario de Motivación para Actividades Deportivas - MQSA versión adaptada (Frías y Serpa, 1991) del original Motivación Participación Interlocutor - PMQ (Gill, Gross y Huddleston, 1983), y el teste de falta de motivación para Actividad Deportiva - Imaad, desarrollado por Pereira y Vasconcelos -

421

Raposo (1997) validado por Fernandes (2005) Resultados : En el análisis de los hechos a la práctica deportiva en la escuela de deportes se puede inferir que existen diferencias estadísticamente significativas en las variables independientes: sexo en el factor " Físico " (P = 0,026 ), en el lugar de residencia, "Estado" (P = 0,016 ), en el nivel de formación ( P = 0,000 ), " Emociones" ( P = 0,012 ) , " voluntad" ( P = 0,000 ) "Estado" , " aptitud física " , (P = 0,000 ) , " Desarrollo Técnico " (P = 0,000 ) , " Membresía general "( P = 0,000 ) y " Membresía específico " ( p = 0,000 ); ciclo de enseñanza " Status " (P = 0,000 ) , " Emociones "( P = 0,026 )," Placer " (P = 0,006 ) , " aptitud física " , (P = 0,000 ) , " Desarrollo Técnico " (P = 0,003 ) , " Membresía general "( P = 0,001 ) y la " Membresía específico " ( p = 0,000 ) . En lo que se refiere al análisis de los hechos la no práctica del deporte escolar se puede afirmar que existen diferencias estadísticamente significativas en las variables independientes: el género en los factores de "Deportes " Aversión / Insatisfacción " (P = 0,000 ) , " Estética / incompetencia " ( P = 0,000 ) , " Falta de apoyo / Condiciones" (P = 0,004 ) y la " falta de interés en el esfuerzo físico " (P = 0,000 ), en términos de nivel de enseñanza "La falta de interés por el esfuerzo físico " (P = 0,022 ) y " Falta de tiempo " (P = 0,000 ) . Conclusiones: El análisis comparativo muestra que las variables independientes contribuyen tanto positiva como negativamente a la práctica de los jóvenes del Deporte Escolar. Palabras clave: Motivación; Deporte Escolar; Práctica y no Práctica de Deportes.

Our intention with this study is to obtain information about the motives that lead students to the practical and impractical of

School Sports, by gender, cycle of education, place of residence and level of education. To intervene with this population is important to know some aspects of his psychological

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profile, as the will and their motivation. These

a function of a number of factors (individual,

are some components in the area of

social , environmental and cultural ) .

psychology determinant for the practitioner can truly express their capacities in sport. This is no use if the motor capacities and psychic

METHODS

abilities do not lead to the activation of

Our sample consists in students from the 2nd

practitioner’s process. Therefore, you must

and 3rd cycle of basic education was carried

act according to the needs of this population,

out in ten classes of 2nd cycle ( 225 students )

becoming more attractive practice on school

and twelve 3rd cycle ( 271 students ) in a total

sports, granting him his justification as an

of 496 respondents , with 171 athletes and

essential instrument for the promotion of

325 non- practicing school sports.

health, social inclusion and integration in

This study involved 75 sports for male

promoting sport and combating school failure

students (43.9 %) and 96 females (56.1 %),

and dropout (SS program, 2009-2013).

aged 9 to 14 years (mean 11.53). With regard

From the standpoint of a more operational

to place of residence, 19 students (11.1 %) are

and integrative model, Dosil (2008) defines

rural and 152 medium (88.9 %) of the urban

motivation as a psychological variable that

environment. For the years of schooling, 54

moves the individual to the realization,

students (31.6 %) attending the 5th year, 43

guidance, maintenance and / or abandon of

(25.1 %) for the 6th grade, 27 (15.8%) of the

physical and sporting activities, and is usually

7th year, 26 (15.2 %) the 8th year and 21

determined by cognitive association that is the

(12.3%) year 9. Regarding the cycle of

subject of different situations (if it is positive,

education, 97 students (56.7 %) attending the

greater motivation, whether it is negative,

2nd cycle and 74 (43.3 %) third. Regarding the

lower motivation if it is neutral, will depend on

sports echelon, 118 (69 %) are infants and 53

the cognitive structure that performs the

(31 %) are initiating.

influence of environment and convictions) as

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INDEPENDENT VARIABLES

Gender

Masculine

43,9

Feminine

56,1

Rural

11,1

Urban

152

88,9

Academic school year 5 grade

31,6

6 grade

25,1

7 grade

15,8

8 grade

15,2

9 grade

12,3

2º Cycle

56,7

3º Cycle

43,3

Infant

118

Initiating

Residence place

Level of education Sport echelon

Table 1. Characterization of the sample of practitioner’s students in Sports School.

Regarding supply of school in the school sports club that consists in: Two groups of female basketball team in the ranking of infants and initiating a total of 40 (23.4%) enrolled students, two groups mixed team badminton (both gender) at the infants and initiating a total of 46 (26.9%) students enrolled, three groups of mixed gender in gymnastics team sports and all ages in a total of 36 (21.1%) students enrolled, a team group mixed gender and swimming all ages with 32 (18.7%) students enrolled and one team group expressive rhythmic activities with 17 (9.9%) students enrolled. Modality type in School Sports

Basketball

23,4

Badminton

26,9

Gymnastics

21,1

Swimming

18,7

Expressive rhythmic activities

9,9

Table 2: Characterization of sports modalities of practicing students of School Sports

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Regarding non-practicing students in school sports, this study had the participation of 325 students, with 180 (55.4%) were male and 145 (44.6%) females, aged 9 to 17 years (mean 12.25). Regarding the place of residence 43 (13.2%) students are from rural and 282 medium (86.8%) of the urban environment. As the school year it appears that 55 students (16.9%) attending the 5th year, 73 (22.5%) for the 6th grade, 72 (22.2%) the 7th grade, 59 (18.2%) 8th year and 66 (20.3%) year 9. Regarding the teaching cycle, 128 students (39.4%) attending the 2nd cycle and 197 (60.6%) in the third. With regard to sporting activities previously performed, 128 (39.4%) students have practiced sports school and 197 (60.6%) never practiced school sports. INDEPENDENT VARIABLES Gender Residence place Academic School year

Level of education

Masculine 180

55,4

Feminine

145

44,6

Rural

13,2

Urban

282

86,8

5 grade

16,9

6 grade

22,5

7 grade

22,2

8 grade

18,2

9 grade

20,3

2º Cycle

128

39,4

3º Cycle

197

60.6

128

39,4

197

60,6

Have practiced School Sports Yes No

Table 3. Characterization of the sample of students with no practitioners Sports School (n = 325)

INSTRUMENTS The instruments used in our study, were the

collection of biographical data, data on the

application of two questionnaires, consisting in

level of training, years of schooling and data

several parts: introductory section for the

relating to sport athlete.

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One of the questionnaires was used Motivation

sports activities in school sports because ... " .

Questionnaire for Sports Activities - MQSA , in

The response scale is the Likert 5 points, where

the case of a translated and adapted by Serpa

1 corresponds to fully disagree, 2 disagree, 3

and Frias (1991) based on instrument version

neither agree nor disagree, 4 agree and 5

originally developed by Gill et al. (1983), called

strongly agree. These 39 items are grouped

“Participation

into

Motivation

Questionnaire

“(PMQ).

five

factors:

Sporty

Aversion

dissatisfaction - items 7, 8, 10, 13, 18, 19, 20,

The MQSA consists of 30 items , which can lead young people to participate in sport, and the importance given by respondents in Liker (five)

21, 22, 23, and 24; Aesthetics / incompetence 27 , 28 , 29 , 32 , 34 , 35 , 37 and 38 ; Lack of support / conditions - 2 , 4 , 5 , 9 , 15 , 17 , 33 and 39 ; disinterest by physical exertion - 1 , 12

5 point scale, where 1 corresponds to anything important,

somewhat

important,

, 25 , 26 and 36 and lack of time - 3, 6 and 11.

important, 4 and 5 totally important very important. These 30 items are grouped into eight factors: Statute - items, 5, 14, 19, 21, 25 and 28; Emotions - 4, 7 and 13, Pleasure - items 16, 29 and 30; Competition - 3, 12, 20 and 26; Physical Form - items 6, 15, 17 and 24, Competency Development - items 1, 10 and 23;

After applied the assessment of internal consistency, Cronbach's alpha, factors in each of the two instruments showed reasonable internal

consistency,

ranging

MQSA

between ( 0.55 and 0.85) and in the Imaad between ( 0.63 and 0 8), as can be seen in Tables 4 and 5.

Affiliation General - items 2, 11 and 22 and

By performing the descriptive analysis of this

Affiliation Specific - items 8, 9, 18 and 27.

sample related to MQSA - Table 4 it can be seen

The other questionnaire was the survey Motivations for Absence of Sport Activity Imaad developed by Pereira and Vasconcelos Raposo (1997), consists of 39 items , preceded by the following statement " I do not practice

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that this is a normal distribution , since the values of Skewness (asymmetry ) and Kurtosis (flattening) are within the range ] -1 1 [, except for one factor (technical Development) which is slightly above this range .

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Mean

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Standard

Skewness

Kurtosis

deviation Status

2,87

1,05

0,197

-0,774

0,848

Emotions

3,41

1,01

-0,346

-0,310

0,772

Pleasure

3,90

0,88

-0,667

0,004

0,549

Competition

3,87

0,74

-0,332

-0,627

0,603

Physical Fitness

4,33

0,63

-0,997

0,256

0,657

Technical Development

4,45

0,58

-1,041

0,718

0,637

General affiliation

3,75

0,87

-0,531

-0,030

0,630

Specific affiliation

3,63

0,81

-0,140

-0,605

0,661

Table 4. Descriptive analysis of the dependent variables MQSA

For the descriptive analysis of Imaad - Table 5, it appears that are equally under a normal distribution, since the value of Skewness (asymmetry) and Kurtosis (flattening) are within the range] -1 1 [, except for one factor (Aesthetics / incompetence) which is slightly above this range. 426 Mean

Standard

Skewness

Kurtosis

0,60

0,882

0,361

0,815

1,65

0,66

1,043

0,653

0,823

or 1,68

0,51

0,621

-0,004

0,630

Disinterest for sports

1,80

0,71

0,695

-0,025

0,693

Lack of time

2,93

1,12

0,021

-0,775

0,657

deviation Sports

aversion

/ 1,71

dissatisfaction Aesthetics/incompetence Lack

support

conditions

Table 5: Descriptive analysis of the dependent variables Imaad

APPLICATION QUESTIONNAIRE Data collection was carried out personally by

having been completed by each student after a

the application of the above questionnaire,

brief explanation of the study objectives,

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providing

information

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necessary

for

the

Presentation of Results

fulfilment of those instruments, and clarifies

At this point we divide the presentation of the

any kind of doubts. Students were informed

results in two parts : first part : Study 1 – MQSA

about

and second part : Study 2 - Imaad .

the

confidentiality

information

gathered. These data were collected at the

1 - Study 1 - MQSA

beginning of the physical education classes,

According to Serpa (1992), the reasons

after consent from the school and the teachers

considered most important are those that have

who teach this course.

the highest average (≥ 4), which corresponds to the grounds Very and Totally Important on the

STATISTICAL ANALYSIS

scale of MQSA. For the less important, are

After fulfilling of the questionnaires by the

considered those with the lowest average (≤ 2),

students we have forward to the statistical

which correspond, on the scale of MQSA, to

treatment using SPSS v.17 program where, after

Little or Nothing important reasons.

created the database were performed using

Looking at Table 6 , we note that respondents

descriptive statistics (frequencies, mean and

cited as the main reasons for sporting,

standard deviation, Skewness and flatness) and

"Exercising", "Being in good physical condition",

internal consistency of the scales, to determine

"Learning new techniques", "Achieving a higher

the importance of the reasons for practicing

level sports", "Improving technical capabilities

sport and not, in school sports.

", "Keep fit", "team Spirit" Overcoming

In these tests of difference for comparative

challenges", "Fun" and "Doing something that is

analysis of the independent variables under

good."

study between factors was applied to the t test

(comparing the means test).

indicated, "Influence of family or close friends,"

less

important

reasons

respondents

"Having a sense of being important," "Being known" and "Excuse” to leave the house."

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Mean

Standard Deviation

1. improve technical capacities

171

4,37

,789

2. being with friends

171

3,58

1,137

3. win

171

3,23

1,312

4. discharge energies

171

3,40

1,254

5. travel

171

3,02

1,420

6. keep fitness levels

171

4,31

,941

7. have strong emotions

171

3,20

1,241

8. Team work

171

4,43

,796

9. influence of friends or family

171

2,74

1,357

10. learning new techniques

171

4,50

,739

11. make new friends

171

3,98

1,098

12. make something that i know i’m good at

171

4,20

,924

13. free the tension

171

3,61

1,149

14. Receive awards

171

3,47

1,325

15. make exercise

171

4,60

,699

16. have something to do

171

3,60

1,272

17. be active

171

3,87

1,111

18. team spirit

171

4,26

,911

19. reasons to go outside home

171

2,37

1,471

20. be in competitions

171

3,80

1,198

21. have the feeling of being important

171

2,71

1,327

22. belong to a group

171

3,70

1,223

23. reach a higher sport level

171

4,48

,762

24. be in a excellent physical condition

171

4,53

,762

25. be known by others

171

2,72

1,411

26. overcome challenges

171

4,24

,878

27. influence of coaches/trainers

171

3,11

1,410

28. being recognised or having prestige

171

2,94

1,394

29. fun

171

4,20

1,106

30. Pleasure in using sport facilities and sportive

171

3,88

1,269

materials. Table 6. Descriptive analysis due to the items of the MQSA

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Factor analysis of the reasons students to practice Sports School, emphasize the great importance attached to the "Technical Development", the "Physical Form" at the "Pleasure" and "Competition". With minor emphasizes the "Statute". (See table 7).

Mean

Standard deviation

Status

2,87

1,05

Emotions

3,41

1,01

Pleasure

3,90

0,88

Competition

3,87

0,74

Physical Fitness

4,33

0,63

Technical Development

4,45

0,58

General affiliation

3,75

0,87

Specific affiliation

3,63

0,81

Table 7. Factorial analysis of the presented reasons from students that practice Sports School.

Comparing the reasons given for the practice as determinants of Sports School, by respondents of both gender, we conclude that boys attributed greater importance than girls to "Status", "Emotions", "Competition", "Physical Form", "Development technical "and" specific Affiliation ". Moreover, it appears that girls attributed greater importance than boys to "Emotions," Pleasure "and" General Membership ". There are statistically significant differences in factor "Physical Form", with boys more importance to this factor (Table 8).

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Boys

Girls

(n=75)

(n=96)

M+DP

Status

2,97 + 1,22

Emotions

2,79 + 0,90

1,104

0,272

3,44 + 1,12

3,39 + 0,91

0,314

0,754

Pleasure

3,88 + 0,94

3,91 + 0,84

-0,276

0,783

Competition

3,90 + 0,82

3,84 + 0,67

0,503

0,616

Physical Fitness

4,50 + 0,55

4,23 + 0,67

2,252

0,026*

Technical

4,54 + 0,57

4,38 + 0,58

1,790

0,075

General affiliation

3,74 + 0,94

3,76 + 0,83

-0,135

0,893

Specific affiliation

3,72 + 0,91

3,57 + 0,72

1,208

0,229

Development

*p<0,05, **p<0,01, ***p<0,001 Table 8. Comparative analysis of the dependent variable (MQSA) regarding gender.

From the analysis in Table 9, it appears that the comparison of factors depending on the place of residence, respondents from rural attributed greater importance to all factors in the practice of School Sports. However, there are statistically significant differences in status factor, confirming our Hypothesis 1. By this, we verify that respondents residing in rural areas give more 430

importance to the residents of the urban environment, the factor "Status". Rural

Urban

(n=19)

(n=152)

M+DP

Status

3,41 + 1,20

Emotions

2,80 + 1,01

2,425

0,016*

3,49 + 1,22

3,40 + 0,98

0,384

0,702

Pleasure

4,12 + 0,95

3,87 + 0, 87

1,186

0,237

Competition

4,05 + 0,84

3,84 + 0,72

1,163

0,246

Physical Fitness

4,34 + 0,85

4,32 + 0,60

0,090

0,929

Technical Development

4,49 + 0,57

4,44 + 0,58

0,340

0,734

General affiliation

4,12 + 0,76

3,70 + 0,88

1,974

0,050

Specific affiliation

3,90 + 0,75

3,60 + 0,81

1,499

0,136

*p<0,05, **p<0,01, ***p<0,001 Table 9. Comparative analysis of the dependent variable (MQSA) regarding residence place.

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Regarding Table 10, it appears that there are statistically significant differences in terms of levels of training in all factors, confirming our Hypothesis 1 except for the factor "Competition". By this, it appears that students in the infant’s echelon give more importance comparing to the initiating echelon regarding "Bylaws", "emotions", "enjoyment", "Physical Form", "Technical Development", "General Membership" and "Specifies Affiliation”

Infant’s

Initiating

(n=118)

(n=53)

M+DP

Status

3,08 + 1,09

Emotions

2,40 + 0,77

4,667

0,000***

3,54 + 0,99

3,12 + 0,99

2,546

0,012*

Pleasure

4,08 + 0,83

3,48 + 0,85

4,299

0,000***

Competition

3,93 + 0,74

3,73 + 0,73

1,619

0,107

Physical Fitness

4,44 + 0,58

4,08 + 0,66

3,627

0,000***

Technical

4,57 + 0,53

4,18 + 0,61

4,203

0,000***

Development

431

General affiliation

3,93 + 0,87

3,36 + 0,77

4,246

0,000***

Specific affiliation

3,82 + 0,78

3,22 + 0,73

4,721

0,000***

*p<0,05, **p<0,01, ***p<0,001 Table 10. Comparative analysis of the dependent variable (MQSA) regarding their echelons.

As for table 11, it appears that there are significant differences depending on the cycle of education in all factors, confirming our Hypothesis 1, except for the factor "Competition". It appears that the students of 2nd cycle give greater importance than the level of insiders to the "Bylaws", "emotions", "enjoyment", "Physical Form", "Technical Development", "General Membership" and "Affiliation specify ". The results are similar to those in Table 10, as they differ only in the sample students of Year 7 (27 students)

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2 cycle

3 cycle

(n=97)

(n=74)

M+DP

Status

3,18 + 1,05

Emotions

2,46 + 0,91

4,674

0,000***

3,56 + 0,98

3,21 + 1,01

2,246

0,026*

Pleasure

4,06 + 0,85

3,68 + 0,88

2,797

0,006**

Competition

3,93 + 0,74

3,79 + 0,74

1,183

0,236

Physical Fitness

4,47 + 0,58

4,14 + 0,63

3,599

0,000***

Technical

4,56 + 0,55

4,30 + 0,60

3,040

0,003**

General affiliation

3,95 + 0,85

3,50 + 0,84

3,462

0,001**

Specific affiliation

3,86 + 0,79

3,34 + 0,75

4,380

0,000***

Development

*p<0,05, **p<0,01, ***p<0,001 Table 11. Comparative analysis of the dependent variable (MQSA) regarding their education level.

- Study 2 - Imaad Similar to what happened in practitioners Sports School students, we will use the same 432

procedures for non-practicing students. To select the most important reasons why students do not engage in school sports, and according to Pereira and Raposo (2008 ) we selected those with a higher average above value 3 . Soon the reasons that contribute most to the respondents do not engage in school sports were “Lack of time”, and “Have other things to do." For the less important reasons why students do not engage School Sports, we selected those with a lower average value 2. According to this, we have list the reasons that contribute least to the respondents do not engage in school sports , were "Lack of trainers / teachers ", "do not like sports", "Sport is boring / dull / boring", " I do not like coaches / teachers", "because of the age" and "because I do not like being in a group".

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Mean

Standard deviation

1. lack of interest or will

325

1,94

1,162

2. lack of sport facilities

325

1,55

,886

3. lack of time

325

3,25

1,461

4. lack of coaches or trainers

325

1,44

,797

5. lack of personal equipment

325

1,61

,942

6. work schedule is not compatible

325

2,51

1,422

7. health issues

325

1,50

,942

8. doesn’t like sports activities

325

1,49

,873

9. there aren’t practice possibilities

325

1,84

1,017

10. parents won’t let or support sport activities

325

1,66

1,041

11. others thing to do

325

3,03

1,499

12. lack of sport habits

325

1,92

1,138

13. sports are boring

325

1,46

,844

14. economic reasons (lack of money)

325

1,57

,933

15. sport facilities are far away from home

325

1,71

1,073

16. there aren’t interested people

325

1,84

1,045

17. schedules in sports facilities aren’t compatible

325

2,36

1,261

18. because shame of others

325

1,52

,931

19. difficult in operating tasks

325

1,99

1,155

20. don’t like most activities presented

325

2,30

1,277

21. i’m not good at sports

325

2,07

1,206

22. don’t like coaches

325

1,46

,844

23. don’t know how to play

325

1,82

,982

24. don’t like to make an effort

325

1,57

,860

25. have a bad physical condition

325

1,81

1,048

26. my friends don’t practice as well

325

1,75

1,010

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27. I’m afraid of doing incorrectly

325

1,88

1,135

28. I’m afraid to get hurt

325

1,83

1,161

29. lack of information

325

1,62

,880

30. sports don’t bring any kind of benefits

325

1,37

,778

31. don’t want to change my look

325

1,52

,898

32. lack of funding support

325

1,55

,886

33. because the way I look

325

1,57

,929

34. because of my age

325

1,43

,820

35. because I’m lazy

325

1,66

1,109

36. because I feel rejected

325

1,58

,902

37. because I don’t like physical contact

325

1,65

,920

38. lack of exercise motivation by school

325

1,58

,935

39. because I don’t like being on a group

325

1,38

,762

Table 12. Descriptive analysis according to IMAAD items.

434

Analysis of the reasons students do not practice Sports School emphasize the importance attributed to lack of time. With minor stress Aesthetics / incompetence (see Table 13).

Mean

Standard deviation

Sports

aversion

/ 1,71

0,60

dissatisfaction Aesthetics/incompetence

1,65

0,66

or 1,68

0,51

Disinterest for sports

1,80

0,71

Lack of time

2,93

1,12

Lack

support

conditions

Table 13. Factorial analysis of the presented reasons from students that don’t practice Sports School.

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In Table 14, we compared the reasons invoked as determinants for not practicing school sports by gender; it appears that only the factor "Lack of time" does not show statistically significant results, confirming our Hypothesis 2. It also appears that girls factors present higher values in all variables.

Masculine

Feminine

(n=180)

(n=145)

M+DP

1,96 + 0,61

-7,058

0,000***

1,47 + 0,60

1,87 + 0,67

-5,619

0,000***

or 1,61 + 0,49

1,77 + 0,53

-2,893

0,004**

Disinterest for sports

1,60 + 0,65

2,05 + 0,70

-5,934

0,000***

Lack of time

2,89 + 1,99

2,98 + 1,03

-7,717

0,474

Sports

aversion

/ 1,51 + 0,53

dissatisfaction Aesthetics/incompetence Lack

support

conditions

*p<0,05, **p<0,01, ***p<0,001 Table 14. Comparative analysis of the dependent variable (IMAAD) regarding gender.

From the analysis in Table 15, it appears that the comparison of factors depending on the place of residence, respondents from urban areas gave more importance to the rural-non practicing school sports, in all factors except the factor "Lack of support / conditions", which was attributed to the rural areas. It also appears that there are no statistically significant differences in any of the factors.

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Rural

Urban

(n=43)

(n=282)

M+DP

1,73 + 0,59

-1,348

0,178

1,60 + 0,72

1,66 + 0,65

-0,563

0,574

or 1,69 + 0,60

1,68 + 0,50

0,119

0,906

Disinterest for sports

1,70 + 0,79

1,81 + 0,69

-0,960

0,338

Lack of time

2,66 + 1,30

2,97 + 1,09

-1,499

0,140

Sports

aversion

/ 1,59 + 0,60

dissatisfaction Aesthetics/incompetence Lack

support

conditions

*p<0,05, **p<0,01, ***p<0,001 Table 15. Comparative analysis of the dependent variable (IMAAD) regarding the residence place.

Regarding Table 16, it appears that the third cycle students attributed greater importance to the reasons for not practically School Sports in all factors, there statistically significant differences in the factors "Disinterest by physical exertion" and "Lack of time" are confirming our Hypothesis 2.

436 2 cycle

3 cycle

(n=128)

(n=197)

M+DP

1,64 + 0,60

1,76 + 0,59

-1,843

0,066

1,60 + 0,66

1,68 + 0,66

-0,997

0,320

1,61 + 0,53

1,73 + 0,50

-1,958

0,051

Disinterest for sports

1,69 + 0,64

1,87 + 0,74

-2,305

0,022*

Lack of time

2,46 + 1,10

3,24 + 1,03

-6,469

0,000***

Sports

aversion

dissatisfaction Aesthetics/incompetence Lack

support

conditions

*p<0,05, **p<0,01, ***p<0,001 Table 16. Comparative analysis of the dependent variable (IMAAD) regarding level of education.

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In the comparative analysis of the independent variable depending on the sport there is no statistically significant differences in any of the factors Imaad, although respondents who have never practiced School Sports give greater importance to factors "sports Aversion / dissatisfaction", "Aesthetics / incompetence "and" disinterest by physical effort. "Respondents who have already practiced give greater importance to the factor "Lack of support / conditions" and "Lack of time". (See table 17) Practice

Non-Practice

(n=128)

(n=197)

M+DP

1,70 + 0,58

Aesthetics/incompetence

1,72 + 0,61

-0,382

0,703

1,60 + 0,61

1,68 + 0,69

-1,018

0,309

Lack of support or conditions

1,70 + 0,47

1,67 + 0,54

0,657

0,512

Disinterest for sports

1,78 + 0,65

1,81 + 0,74

-2,295

0,768

Lack of time

3,04 + 1,15

2,86 + 1,10

1,442

0,150

Sports

aversion

dissatisfaction

437

*p<0,05, **p<0,01, ***p<0,001 Table 17. Comparative analysis of the independent variable (Imaad) regarding sports practice.

Conclusions The research conducted with students of the

Sports School and the school board to achieve

School EBI C / JI Cidade de Castelo Branco

more success for the practice of school sports.

aimed to investigate the motivations that lead young people to practice and do not practice Sports School, according to the independent variables of the study. This research gave us the opportunity to meet the motivational

Regarding the motivation for the practice of Sports School (study 1 - MQSA), the conclusions withdrawn were as follows:

aspects of students, which should be

Respondents

indicated

the

most

considered by teachers of Physical Education /

important reasons : " Exercising " , " Being in good physical condition " , " Learning new

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techniques " , " Achieving a higher level sports

Physical Form ", " Technical Development ", "

" , " Improving the technical capacity " , " Keep

General Membership " and " Affiliation

fit " " team spirit " Overcoming challenges " , "

Specifies ".

Fun " and " Doing something that is good. " - Less important reasons: "Influence of family or close friends”, "Having a sense of being important”, "Being known” and “excuse to

Regarding the motivation for not practically School Sports (study 2 - Imaad), the conclusions withdrawn were as follows:

leave the house”. - The factor analysis conducted reasons, we evidence the importance attributed to the

Respondents

indicated

the

most

important reasons: “Lack of time” and “Have other things to do."

“Technical Development ", the “Physical Form - Less important reasons: "Lack of trainers /

“at the “Pleasure” and “Competition"

teachers", “do not like sports", "Sport is boring - With minor stress the “Statute“.

/ dull / boring", "I do not like the coaches /

- The boys gave more importance to the

teachers", "Because of the age" and " Why I do

"Bylaws ", " Emotions ", " Competition ",

not like being in a group".

"Technical Development " and " specific Affiliation ", there statistically significant differences in factor " Physical Form”.

“Pleasure”

and

stress the importance attributed to “lack of time “.

- Girls attributed greater importance to” Emotions,

- The factor analysis conducted reasons, we

“General

- With minor stress the “Aesthetics / incompetence”.

Membership “. - Girls significant value "sports Aversion / - Respondents from rural attributed greater importance in all factors, and it was found statistically significant differences in the

dissatisfaction ", " Aesthetics / incompetence ",” Lack of support / conditions “and” disinterest by physical effort.”

“Statute “. - Respondents from urban areas attributed - Students echelon of infant’s and 2nd level education

significantly

attributed

importance than the level of insiders to the

greater importance than the rural areas in all factors except the factor “Lack of support / conditions " , which was attributed to the rural

"Bylaws ", " emotions ", " enjoyment ", "

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areas. It appears that the values were

interest among young people for sport. On the

generally higher in urban areas relative to the

other hand, we must consider whether we are

rural environment, which is due to the fact

not filling the agenda of our children with

that pupils living in rural areas are more prone

numerous extracurricular activities that leave

to outdoor activities in our opinion, due to the

them time for physical activity in school

conditions in the environment, such as

sports.

security and space. -

The

third

cycle

In summary, we believe that our job as students

attributed

educators consist in finding strategies to

significantly more importance to factors

prevent the practice levels lower age groups

“Disinterest by physical exertion “and "Lack of

are not lost over time.

time “. - In the comparative analysis on the basis of

Principal References

sport it appears that respondents who have never practiced School Sports give greater importance to factors “sports Aversion / dissatisfaction", Aesthetics / incompetence "and"

disinterest

physical

effort.

Respondents who have already practiced give greater importance to the factor “Lack of support / conditions “and "Lack of time “. The lack of time is cited as the main reason for non- sport, which leads us to reflect on the troubling lack of motivation of non-practicing

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Motivação

das

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Fernandes, H. M., Lázaro, J., & Vasconcelos-

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Raposo, J. (2005). Razões para a não prática

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desportiva em adultos. Estudo comparativo

of action to raise awareness and generate

entre

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realidade

rural

urbana.

Year 0, Vol. I, nº 3, 2013

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Editor: Éditos Prometaicos – Portugal

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Intervention group in individuals with cerebral palsy Nuno Cravo Barata1, 2, 3 (1 CIDES – Faculty of Medicine, University of Porto – nbarata@med.up.pt;

Piaget Institute of Viseu;

Portucalense

University)

Abstract The aim of this study is to assess the importance of the weekly meeting for the «Group of Children» who has cerebral palsy and the impact of this meeting in terms of depression. The aim of this meeting is to find out strategies of coping in order to promote the autonomy and the social integration. 24 children with this syndrome were studied and observed in two different periods – t1 and t2 - half of the participants were under a group treatment during 10 weekly sessions, lasting 1 hour and 30 minutes each (Trial Group – GE) and the other half of the participants were not under any treatment (Control Group – GC). After analysing the data, we could conclude that the GE (Trial group) who was under a specific treatment suffered less from a depressive syndrome. On the other hand, any change could be observed in the other group (GC). Key words: Group of Children; Cerebral Palsy; Group Treatment; Depression.

Resumo O presente estudo procura avaliar a importância da reunião semanal do «Grupo de Jovens» com Paralisia Cerebral - intervenção grupal - e o seu impacto em termos de depressão. A reunião semanal do «Grupo de Jovens» tem como finalidade fornecer estratégias de coping no sentido de promover a autonomia e a interação social. O estudo realizou-se com 24 participantes com Paralisia Cerebral, avaliados em dois momentos temporais distintos – t1 e t2 - espaçados por dois meses e meio quanto aos sintomas depressivos. Metade dos participantes foram submetidos a intervenção grupal durante 10 sessões semanais com a duração aproximada de 1 hora e 30 minutos (Grupo Experimental - GE) e a outra não foi submetida a qualquer intervenção (Grupo Controlo - GC). A análise dos dados permitiu verificar a existência de uma redução significativa dos sintomas depressivos apenas no grupo de participantes que foram alvo de intervenção grupal (GE). Ao invés, nos participantes que não foram sujeitos a intervenção grupal (GC) não houve qualquer modificação significativa dos sintomas depressivos. Palavras-chave: Grupo de Jovens; Paralisia Cerebral; Intervenção Grupal; Depressão.

Resumen Este estudio evalúa la importancia de la reunión semanal del un Grupo de Jóvenes con parálisis cerebral intervención grupal - y su impacto en la depresión. La reunión semanal del Grupo de Jóvenes tiene como objetivo proporcionar estrategias de afrontamiento para promover la autonomía y la interacción social. El estudio se realizó con 24 participantes con parálisis cerebral que fueron evaluados en dos momentos diferentes - t1 y t2 - separados por dos meses y medio, relativamente de forma específica a sus síntomas depresivos. La mitad de los participantes fueron sometidos a intervención grupal para 10 sesiones

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semanales de aproximadamente 1 hora y 30 minutos (grupo experimental - EG) y el otro no fue sometido a ninguna intervención (grupo de control - CG ) . El análisis de datos ha demostrado la existencia de una reducción significativa de síntomas depresión en el grupo de participantes que fueron foco de intervención grupal (GE). En cambio, los participantes que no fueron objeto de grupo de intervención (CG) no hubo ningún cambio significativo en los síntomas depresivos. Palabras clave: Grupo de Jóvenes, la parálisis cerebral, la intervención grupal; depresión.

The first description of Cerebral Palsy (CP)

Nevertheless, Gonçalves and Borges (1990)

comes in 1843, performed by the physician Dr.

reported that the prevalence of CP shows no

Little, considering today is not the term

signs of fall, with 1.9/1000 newborns in Ireland

'cerebral palsy' the most suitable as it seems

(Dowding & Berry, 1988), 2.7/1000 in Sweden

to reflect a total absence of motor and

(Hagberg, Hagberg, Olow & Wendt, 1989) and

psychological function which does not untrue,

1.5 – 2.5/1000 in the UK (Edmond, Golding &

besides being a term rejected by patients and

Peckmann, 1989). More recent data indicate

their own families (Ferreira, Ponte, &

that the prevalence in Sweden is of 2.36/1000

Azevedo, 2000).

indicating an interruption in continuous

It is a chronic disability that arose early, not

increase since 1970 (Hagberg, et al., 1996).

being the result of a recognized progressive

In Portugal, it is thought there are about

disease (Ellenberg & Nelson, 1981, cit in

100,000 cases of Cerebral Palsy cases (Borges,

Schleichkorn, 1983). The disfunction is static

Fineza, Gomes, Nazário & Sousa, 1987, cit in

and non-progressive. There is a well-defined

Gonçalves & Borges, 1990), but there is no

clinical entity, but it is also a syndrome with

exact knowledge of the number, because of

different clinical forms and in many cases,

ignorance of the existence of Specialized

multiple etiology. The CP can also be referred

Centers in some areas of the country, and the

as a developmental disorder, a neuromotor

difficulty in establishing an early diagnosis.

disorder or a developmental motor disorders.

Andrada (1995) refers to a current prevalence

Numerous authors claim a decrease in the

of cases of Cerebral Palsy 1.5-2.5/1000 born

prevalence of CP, especially in regards to

alive.

Developed Countries (Hagberg, Hagberg, Olow, & Wendt, 1996).

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The incidence of this disease appears to be slightly higher in males by a ratio of 1.4 boys

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to 1 girl (Gilrou & Meyer, 1979, cit in

Prevalence studies in different Western

Schleichkom, 1983).

countries show that depression is a common

According to Marques (1998, p. 38), 'The etiology of PC is multiple and can occur at different stages of development - prenatal, perinatal and postnatal'.

disorder. The annual prevalence in the general population varies between 3% and 11% (Fleck et al., 2003). To Schuyler and Katz (1973, cited by Beck,

Andrada (1986, cited by Monteiro, 2002) says that there are three most common nosological types: (A) spastic syndromes, which can be classified into three types: hemiplegia,

Rush, Shaw, & Emery, 1997), at least 12% of adults have had or will have an episode of depression of sufficient severity to warrant clinical treatment.

diplegia, quadriplegia and Monoplegya; (B)

According to Vallejo (2003) among general

Discinetic Syndromes; (C) ataxic syndromes.

patients, in the overall, prevalence of

According to Menolascino (1990) there is an

depression varies according to statistics,

increased

disabled

between 10 and 20%, and among psychic

population in relation to expression of severe

patients increases to almost 50%. Only 10% of

behavioral problems or psychopathology, as

these patients are referred for psychiatric

compared to "normal" population; a risk

specialist consultations, so the remaining 90%

approximately two times higher.

are treated by general practitioners or other

vulnerability

the

This risk appears to result in part from

specialists not psychiatrists or untreated.

difficulties in information processing and

In general, it has been assumed that people

behavioral problems and emotional self-

with neuromotor disabilities are twice as likely

regulation, combined with physical or sensory

to develop serious behavioral problems or

changes, organic problems, cultural factors

mental illness than people without any deficit

and family as well as the non-acceptance of

(Eaton & Menoslacino, 1982, cit in Alonso &

people with disabilities - many behaviora

Bermejo, 2001). This risk may be due to the

problems appear to be caused by how people

result of the difficulty of the person with

with disabilities feel (or not) integrated into

disability in processing information, the

society (Marinho, 2000).

difficulties associated with medical, physical or sensory aspects, the organic problems, cultural factors-family, and rejection by

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society and unjust prejudices against it. Other

We used, at the establishment of the group,

factors relate to the inability to communicate

the Social Skills Training, as an ice break

their feelings, even when they appear to have

between the group members. Were asked to

a proper language, they have great difficulty in

group members who joined in pairs, getting

processing abstract feelings and emotions.

about ten minutes to talk, in which each

Given the aspects above, was of high relevance to implement Group Therapy, where the objectives were to promote the mental health of its participants, because it

member of the duo spends five minutes talking with each other. Later, people turn to the group and each member makes a short summary of her companion.

will focus in a number of competing factors

Other techniques, such as were used: (1)

(Vallejo, 2003). Thus: (i) the group provides

Monitoring Activity, or asked the subjects to

tranquility and protection to its members, (ii)

make a record of activities, (2) Program

the Group may facilitate verbal expression, (iii)

Activity, where plan enjoyable and rewarding

the person is aware that you have an

activities throughout the day and (3) Daily

opportunity to relearn how to relate to others;

Record of Negative / Dysfunctional Thoughts.

(IV) give it up fast and complex phenomena of

Keep a daily log of the negative thoughts that

identification to facilitate understanding of

triggered the depressive mood and associated

others and of their own difficulties, (V) the

situations, (4) Breathwork Training. Faced

group enhances the most of all personal

with more stressful situations, are asked to

characteristics, both the most positive and the

group elements that begin to breathe

most negative ones.

abdominally.

In short, Caballo (2002) indicates that group

We appealed to the mirror psychodrama

therapy is an ideal place to learn to relate and

technique in which the protagonist leaves the

interact with people in different ways, once it

scene and the viewer becomes an auxiliary

is a safe context in which possible to practice

ego representation that makes its previous

new behaviors.

statement, so he can identify how specific

Because of depressive symptoms, we resorted to the use of cognitive-behavioral technicians. Cognitive Beck therapy for depression was

aspects or conduct that is not recognizing is affecting her (Osorio, 2000). Also, we used the techniques of reversal and soliloquy.

used in group work.

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That said, we will present some of the key

ideas that emerged from the sessions: (1) I do

determine whether this meeting will have

whatever it takes to come to the center, (2) To

direct implications in the reduction or absence

stay at home is wound which does not suit, (3)

of depressive symptoms. It was concentrated

Everyone has the right to life; (4) Finally, I

on a small sample of users of the Centre for

know we're not alone, (5) Glad you came to

Rehabilitation of Cerebral Palsy of Porto

this group, (6) We are a family.

(CRPCP) and, as such, should not be

Regarding the initiatives undertaken abroad and

with

foreign

countries,

stress-the

following: (1) Visit to the center stage of the Porto Football Club in Gaia, with receipt by

depressive

symptoms.

seeks

generalized to all individuals who suffer from this condition, because this sample is negligible from a population that tends to increase in our country.

keeper Victor Baia and watching a training session of the team, (2) Visit the Graphic

Method

449

Navprinter, greater North Country, with access to evidence of the largest national, daily, weekly and sports newspapers; (3) participation in a television program "Praça da Alegria", in Gaia studio with several interviews over the issue with Jorge Gabriel, BBC1; (4) Realization of collective Exhibition, with individual and group work, (5) Participation in

This work intends to evaluate the importance of group intervention in a group of young people with cerebral palsy in relation to their effects on depressive symptoms. It seeks to determine whether this meeting will have direct implications in the reduction or absence of depressive symptoms.

morning radio program Sanjoanense, S. João

Regarding scientific question, arises the

da Madeira, in studio interview, conducted by

following hypothesis: The group intervention

Antonio Santos, (6) visit the new Dragon

promotes

Stadium to watch a game (Porto Football

symptoms before a group of young people

Club), (7) Visit to Secondary School Teixeira

with cerebral palsy.

the

reduction

depressive

Lopes in Gaia. This study aims to assess the importance of

This is a study based on the experimental

group intervention in a group of young people

design because the researcher acts on the

with cerebral palsy in relation to their effects

independent variable (intervention group) to

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identify whether this intervention produces

It is noted from the outset that the sample is

changes

not probabilistic, and the type of rational

the

dependent

variable

(depression) (Shaughnessy & Zechmeister,

selection

1997; Ribeiro, 1999). We defined two groups

'convenience samples' (or 'incidental' or

(experimental - with group intervention - and

'voluntary') and poses a fundamental problem

control - without intervention group), in which

lies in the impossibility of estimating sampling

the

errors, so the inferences for the population

research

subjects

are

randomly

distributed for each group, speaking up about one (experimental group) and not on the other (control group) and then compares the changes that occurred after the intervention.

sampling,

since,

refers

are largely affected. Two distinct groups were created: - the group intervention consisting of 12 elements (8 male and 4 female) (1) experimental group (EG), (2) control group (CG) - was not subject to

Sample

intervention group - consisting of 12 elements (8 males and 4 females) . It consists of subjects

The sample consisted of 24 participants suffering from Cerebral Palsy (8 females - 33.4 % - and 16 males - 66.6 % - selected from a population of CRPCP). Analyzing the sub samples (Experimental Group; Group control), we find that both have equal distribution of participants according to sex (8 males and 4

of both sexes, and 8 females (33.4 %) and 16 males (66.6 %). Analyzing the sub - samples (Experimental Group; Control Group), we find that

both

have

equal

distribution

participants according to sex (8 males and 4 females), corresponding respectively to 33.3 % and 16.7 % of total sample (Table 1).

females), corresponding respectively to 33.3 % and 16.7 % of the total sample.

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Particip.

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Tot.

Freq.

Male

33,3

66,6

Female

16,7

33,4

Total

100

Gender

Part. = Participants; Freq. = Frequency; % = percentages; GE = Experimental Group, GC = Control Group; Tot. = Total

Table 1. Frequency Distribution of Participants as to the Variable Gender

Regarding the age variable, we found that most of our sample lies between [23-26] years (50%) with a mean age of 23.17 (SD = 3.17).

451

Comparing the sub-samples, we can observe that in the experimental group the majority of participants (50%) are between 19-22 years with a mean age of 22.92 (SD = 3.40). In relation to the control group, we found that the majority of participants (58.3%) are between 23-26 years with a mean age of 23.42 (SD = 2.97). In both groups, the minimum age is 19 years and the maximum age is 30 years (Tables 2 and 3).

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Particip.

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Tot.

Freq.

[19-22]

50,0

33,3

41,7

[23-26]

41,7

58,3

[27-30]

8,3

Total

100

Age

Part. = Participants; Freq. = Frequency; % = percentages; GE = Experimental Group, GC = Group Control

Table 2. Frequency Distribution of Participants as to the Variable Age

Participants

Mean

Standard Deviation

Minimum

Maximum

452 GE

22,92

3,40

23,42

2,97

Total

23,17

3,13

N = sample; GE = Experimental Group, GC = Control Group

Table 3. Mean and Standard Deviation of Age of Participants in the Two Groups Considered Material

each of the participants, the Beck Depression Inventory-II (Beck Depression Inventory - BDI-

To assess the presence of depressive

II) in order to evaluate the intensity of

symptoms and characteristics, was passed to

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depressive

symptoms

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(before

and interviews with subsequent analysis of the

intervention group) and t2 (after the

symptomatology

intervention group). The BDI-II is a self-report

consultations) and selected which presented

questionnaire

fewer

consisting

items

(through

communicational

individual

difficulties

and

(categories of symptoms and attitudes - both

without mental retardation or mild mental

physical and psychological) scored from 0

retardation.3.

(low) to 3 (high), whereas, the higher the total score obtained (0 = min, 63 = max) the higher the rate of depression (0-12 points No depression, depression Take 12-18 points, 1824 points Average depression; over 24 points Severe depression). The mode of response to

Prior to implementation of the instrument, was told the participants that all data collected would be confidential. Was given to know the purpose of the study and obtained written and informed consent of the participants.

each of the items is in the form of Guttman, or are presented «claims 4 or 6, each reflecting the increasing degree of depression severity" (Beck et al., 1961, cited by Cunha, 1993), and for each item the subject area should opt for a single statement, as this accurately describe

Thus, it was passed to each of the participants, the Beck Depression Inventory in order to evaluate the intensity of depressive symptoms at t1 (before the group intervention) and t2 453

(after the group intervention).

the feelings and concrete target subjected

The inventory was read by all subjects and was

during the last two weeks, including the day of

asked

completion of the inventory.

safeguarding thus a possible misinterpretation

interpret

each

statement

of the subjects. To be no differences in completion of the inventory, this was Procedure

completed by the investigator, once many of

The selection of participants (both the

the participants had difficulty with fine motor

subjects who joined the group as experimental

skills.

subjects who integrated the control group) was taken by proceeding first on observation 3

According to Marinho (2000), mild mental retardation is described as being a criterion of intellectual functioning significantly lower than the

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average, referring to a typical score of about 7075, which takes into consideration the standard error of five potential points above or below the IQ score.

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Results After

t2) and paired samples (GE t1 vs GE t2; GC t1 vs answering

the

Beck

GC t2).

Depression

Inventory, it was proceeded to the intra and inter-group analysis of the results obtained by

For the analysis of Table 4 and Figure 1 it is

participants. We used the Statistical Package

shown that the experimental group showed a

for Social Sciences (SPSS), version 14.0, to

mean value at t1 of BDI of 17 (SD = 6.09) -

make the statistical treatment of the data,

'Slight

using for this purpose: Descriptive analyzes

Depression',

whereas

the

participants in the control group, the BDI

(study of the means and standard deviations

mean was of 19:08 - 'Middle Depression' (SD =

in the two groups and two time points);

8.92).

Differential Analysis (Student t test for independent samples (GE vs GC em t1 and in

Depression Groups GE

M t1

DP t2

17.00 10.00

6.09

3.59

Gl t2

p t2

t2 454

. -.668 -3.506 GC

19.08 20.58

8.92

.511 .004**

9.82

*p ≤ .05; **p ≤ .01

Table 4. Comparative Analysis of Depressive Symptoms between the two groups (EG and CG) in Two Temporal Moments (t1 and t2)

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Figure 1. Index Depression in the Experimental Group (IPBDI1 - in t1; IPBDI2 - at t2) and Control Group (SIPBDI1 - in t1; SIPBDI2 - at t2). 40

40 30

10 10

0 5

0 N=

-10 12

IPBDI1

IPBDI2

After the intervention, in a second assessment (t2), we found that the participants who joined the target group of group intervention, showed a decrease in mean depression, with a value of 10 (SD = 3:59), which equals to “no Depression”. Participants who were not subjected to any kind of intervention, did not

SIPBDI1

SIPBDI2

after implementing the intervention. Indeed, we found that participants who were the target group intervention (GE) present in t2, presents

mean

values

depression

significantly lower than those submitted by participants

who

did

not

receive

the

intervention (GC) [t (23) = -3506; p = .004].

show a significant change in the average

When we performed a comparative analysis of

values of the BDI in both time points,

what is happening in each group (EG and CG)

registering at t2 an average of 20:58 (SD =

over time (t1 to t2) (Table 5), we observe that

9.82),

there is a significant reduction in depressive

which

corresponds

'Middle

Depression'. We note also that the participants of both groupes (GE e GC) indistinguishable from the outset (t1) and to depressive symptoms [t (23) = - .668, p = .511]. The same does not pass

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symptoms among those who underwent intervention group [t (22) = 5.40, p = .000], which does not occur to such an extent or in the same sense among participants who were not targeted by the intervention (t (22) = -1.26,

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p =. 234]. indeed, we are witnessing on a GC, but not significant increase of depressive symptoms. Depression Mom. Aval.

M GE

DP GC

17.00 19.08

6.09

8.92

10.00 20.58

3.59

-1.26

. 5.40

.000** .234

9.82

*p ≤ .05; **p ≤ .01

Table 5. Comparative Analysis of Depressive Symptoms among Two Temporal Moments (t1 and t2) in both groups (EG and CG) Discussion

group and the control group, respectively, with a statistically significant difference.

We found that before the start of therapy group participants in both groups showed depressed levels, while the experimental group (with psychological intervention) has an average value of the depression index of 17, while the control group (no psychological intervention) has an average ratio of 19:08 without, however, be distinguished from each other. After the intervention group, we found that the sample means of the values obtained on the BDI in both groups differ markedly, with values of 10 and 20:58 for the experimental

Given these results, and based on the specific objectives proposed in this empirical study, it is confirmed that there are significant differences among subjects participating group therapy participants and not subject to this type of therapy, which is in line with other studies (Shipley & Fazio, 1973; Shaw, 1977; Dobson, 1989). In intra-group review it appears that the target group of the intervention group (EG) there are significant differences between time points (t1 and t2), attending to a significant reduction of depressive symptoms reported by participants (17 and 10 respectively). These results are in

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accordance with a study by Rush and Watkins

It can be stated that no improvement of

(1978, cited by Beck, Rush, Shaw, & Emery,

depressive symptoms in GC is due to the

1997), which also found that significantly

absence of any intervention, be it individual or

lower post-treatment values in the depressive

group

syndrome measurements compared with that

improvement of depressive symptoms in GE

had been shown in the pre-treatment.

due to the identification and subsequent

In the control group (CG) and in an intra-group perspective, it appears that there are no statistically significant differences in the two evaluation times (t1 and t2), which verifies a not

significant

increase

depressive

symptoms reported by participants (19:08 and 20:58, respectively).

intervention.

Therefore,

the

modification of processes and dysfunctional cognitive patterns. This type of therapy has allowed not only focus on cognitive aspects, but also in the mutual relations between affect, behavior and cognition, producing a change in these three areas. In the early stages of depression treatment,

Given these values, it can be shown that cognitive-behavioral therapy, experimental group that was targeted treatment, provides more satisfactory results (decrease) in relation to depressive symptoms, which corroborates studies by Shipley and Fazio (1973) and

we tried to use some techniques that focus largely on behavioral change and emphasize less cognitive change. The schedule of activities that provide satisfaction to the patient allowed participants to become more active and more involved in its environment. At the same time, it should be noted that

Dobson (1989).

behavioral changes do not get alone. Including According to the results mentioned above, this study confirms the relevance of a group intervention for individuals with disabilities, and in this study, there was an improvement in

depressive

symptoms,

which

comes

the schedule of events, the therapist knows the attitudes that the individual holds, so that he can choose activities that unite these attitudes

order

create

greater

antidepressant effect.

towards the findings of Gallimore and Zetlin (1980) and Goldstein (1972, cited by Marinho, 2000).

The daily record of dysfunctional thoughts, enabling participants to gain insight on the 'stream of thought' and the parade of images that influence its feelings and its behaviors.

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This technique allowed the identification of

the dramatic scene, so the use of mirror

situations that trigger negative automatic

technique allowed participants to identify

thoughts and discover the links between

certain attitudes and behaviors as their but

cognition and emotion. Allowed also to

represented by another person.

identify certain times of day that are particularly problematic.

We think that cognitive restructuring helped participants to identify their own negative

The introduction of psychodrama element in

automatic

the group proved to be extremely valuable, as

restructuring could be that participants

it allowed to work in situations where verbal

identify and would alter these thoughts

communication became difficult or in the

leading to subsequent changes in their mood,

presence of 'dead ends' in the evolution of the

in their physiology and behavior, which goes

group.

against the studies of Beck and Emery (1985).

The use of psychodrama techniques in group

It appears that cerebral palsy requires a high

allowed participants a better understanding of

degree of serenity and realism in their

cognitive distortions and incomprehensible

approach, but also optimism, without which

actions of participants in various situations

we would fall into nefarious nihilism that

experienced by them.

prevent us from helping patients to overcome

We found that it was very important to the participants to put themselves in another's place (role reversal), providing a habit or break the stereotypical view of the conflict always the same point of view. The verbalizing feelings and thoughts evoked during the

thoughts.

With

cognitive

their problems. We always remember a phrase from Gonzalez (1977), that was our motto for action «In the treatment of cerebral palsy must always remain at an intermediate point between euthanasia and utopia»4 (p. 22).

dramatic scene (soliloquy), proved crucial to

The experiments conducted with a group with

the participants because it provided a better

some motor and cognitive deficits showed

understanding of the situations depicted. In

that providing the necessary conditions, these

some situations the participants did not

subjects are capable of learning and engage in

recognize their behavior while representing

fields of interest exceeding expectations.

on an intermediate point between euthanasia and utopia '.

Translated into Portuguese would be "In the treatment of cerebral palsy have to always keep

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It appears that training the patients in these

this population, but 'normalize' the widely

cognitive abilities helped to sustain the

reported sense of value.

improvement

previously

concentration

problems

seemed

produce

acquired.

The

here-and-now

marked

relief

depressive symptoms.

We should conceptualize the person with cerebral palsy as a dynamic organism, experimenting, manipulating, and actively participating in their environment, trying to

All this allows us to infer that the technique of

put into perspective with an innovative way of

cognitive restructuring is effective even in

thinking

interventions carried out in small groups (12

interventions with this population.

participants), a suitable technique at present to intervene in subjects diagnosed with depression, which goes against a study by Ruiz (2003, cited by Rodríguez et al, 2003) which concluded that a group of more than 9 participants achieve better results than

and

conduct

psychological

In future research it is important, after assessment by BDI-II, the use of a structured clinical interview for DSM-IV (1996), such as Spitzer (SCID; First, Spitzer, Gibbon, & Williams, 1995), for better control of minimization or exaggeration of results.

groups 3-4 and 6-7 participants. According to Groth-Marnat (1990), results That said, it appears that group therapy may indeed be important for the treatment of depression. In this type of therapy the problems may be discussed collectively, helping to combat social isolation, reinforce

below 4 may indicate a possible denial of depressive symptoms and results over 40 may indicate a possible exaggeration of depressive symptoms, even in subjects with severe depression.

people with depression that they are not the only ones to have symptoms that afflict and provide

opportunity

for

mutual

encouragement and discussion of ways to overcome depression.

This study has the limitation of not being easy to find studies, which had participants as subjects with cerebral palsy and whose object of analysis was the group intervention. Disability is an area little explored, particularly

Therefore, we should invest highest in youth and adults with disabilities and society should

cerebral palsy, which complicates even further the perception of the skills of these subjects!

not infantilizing speech when interacting with

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References

Ferreira, M., Ponte, M., & Azevedo, L. (2000).

Alonso, M., & Bermejo, B. (2001). Atraso

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mental. Lisboa: McGraw-Hill.

crianças com deficiência neuromotora grave Andrada, M. G. C. (1986). Cerebral palsy: Issues in incidence, early detection and habilitation

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depression

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Williams, J. B. W. (1995). Structured clinical interview for DSM-IV: Axis I disorders. New York: Biometrics Research Unit, New York Psychiatric Institute.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1997). Terapia cognitiva da depressão. Porto Alegre: Artes Médicas. Caballo, V. E. (2002). Manual de técnicas de

de Almeida Fleck, M. P., Lafer, B., Sougey, E. B., Del Porto, J. A., Brasil, M. A., & Juruena, M. F. (2003). Diretrizes da Associação Médica Brasileira para o tratamento da

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Cunha, J. A. (1993). Psicodiagnóstico – R. Porto

Dobson, K. S. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of consulting and clinical psychology, 414-419.

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Dowding, V. M., & Barry, C. (1988). Cerebral

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cerebral: Que etiologia? Saúde Infantil,

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Groth-Marnat, G. (1990). The handbook of psychological assessment (2nd ed.). New York: John Willey & Sons. Hagberg, B., Hagberg, G., Olow, I., & Wendt, L. V. (1989). The changing panorama of cerebral palsy in Sweden. Acta Paediatrica, 78(2),

cerebral: Aspectos da deficiência,

283-290.

doi:10.1111/j.1651-

2227.1989.tb11071.x Hagberg, B., Hagberg, G., Olow, I., & Wendt, L. (1996). The changing panorama of cerebral palsy in Sweden. VII. Prevalence and origin in the birth year period 1987-1990. Acta Pediátrica, 85, 954-960. Marinho, S. M. (2000). Psicopatologia e Deficiência Mental – Fragmentos no cristal. Braga: Edições APPACDM. Marques, R. (1998). Comunicação e linguagem na interacção entre mãe e crianças com paralisia cerebral aos dois anos de idade – Estudo Exploratório. Porto: F.P.C.E.U.P. Menolascino, F. J., & Egger, M. L. (1978). Medical Dimensions of Mental Retardation. Lincoln: University of Nebraska Press. Monteiro, M. (2002). Adaptação psicológica

Osório, L. C. (2000). Grupos: teorias e práticas. Porto Alegre: Artmed. Ribeiro, J. (1999). Investigação e avaliação em psicologia e saúde. Lisboa: Climepsi Editores. Olivares Rodríguez, J., Rosa Alcázar, A. I., Caballo, V. E., García-López, L. J., Orgilés Amorós, M., & López-Gollonet, C. (2003). El tratamiento de la fobia social en niños y adolescentes: una revisión meta-analítica. Psicología Conductual, 11(3), 599-622. Shaughnessy, J., & Zechmeister, E. (1997). Research methods in psychology. New York: McGraw-Hill.

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Shaw, B. F. (1977). Comparison of cognitive therapy and behavior therapy in the treatment

depression.

Journal

Consulting and Clinical Psychology, 45(4), 543-551. Shipley, C. R., & Fazio, A. F. (1973). Pilot study of a treatment for psychological depression. Journal of Abnormal Psychology, 82(2), 372376. Schleichkorn, J. (1993). Coping with cerebral palsy. Texas: Pro-ed.

de mães cujos filhos apresentam paralisia

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Vallejo,

(2003).

Introducción

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psicopatología y la psiquiatría. (5ª ed.). Barcelona: Masson.

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Clinical Case A hazard life after a massive Stroke – Angels and Demons of recovering Luis Maia (1, 2) (1) Auxiliar Professor - Beira Interior University; Clinical Neuropsychologist, PhD (USAL - Spain); Neuroscientist, MsC (Medicine School of Lisbon - Portugal); Medico Legal Perit (Medicine Institute Abel Salazar - Oporto, Portugal); Graduation in Clinical Neuropsychology (USAL - Spain); Graduation in Investigative Proficiency on Psychobiology (USAL - Spain); Clinical Psychologist (Minho University - Portugal); Professional Card from Psychologist Portuguese norm, number 102. All correspondence about this article should be sent to luismaia.gabinete@gmail.com or lmaia@ubi.pt. (2) Integrated Researcher in CIDESD - Center for Investigation in Sports, Education and Health - UBI _ Portugal

__________________________________________________________________________ Abstract We present a Neuro Clinical Case with the following characteristics: Gender, Male; Current Age (at the moment of Stroke: 67 years); Occupation: Merchant (retired); Marital Status: Married; Children: no; Resident: Municipality of Covilhã – Portugal. In 1991 the patient suffered a massive hemorrhagic stroke in the left anterior fronto-parietal cortex and ventricular enlargement. The major semiology frame was: loss of consciousness; amnesia to all occurrences immediately before the stroke; right hemiplegia; difficulties in the articulation of language; paresthesia in the right morphological hemispace and generalized neuropsychological deficits (attention, memory, concentration, etc...). All the process of Neuropsychological Assessment as well as Neuropsychological Rehabilitation and Psychotherapy are presented and discussed. Key words: Neuropsychology; Neuroimaging; Cerebrovascular Disorder.

Resumo Apresentamos um caso Neuro clínico com as seguintes características: sexo, masculino; idade atual (no momento do surto: 67 anos); Profissão: Comerciante (aposentado); Estado civil: Casado, Filhos: não; Residente: Município da Covilhã - Portugal. Em 1991, o paciente sofreu um enorme acidente vascular cerebral hemorrágico no córtex anterior fronto-parietal esquerda e alargamento ventricular. A principal estrutura semiológica foi: perda de consciência; amnésia para todas as ocorrências imediatamente antes do acidente vascular cerebral; hemiplegia direita; dificuldades na articulação da linguagem; parestesia no hemi-espaço morfológico direito e déficits neuropsicológicos generalizados (atenção, memória, concentração, etc...). Todo o processo de Avaliação Neuropsicológica, bem como de Reabilitação Neuropsicológica e Psicoterapia são apresentados e discutidos. Palavras-chave: Neuropsicologia; Neuroimagem; Transtorno vascular cerebral.

Resumen Se presenta un caso Neuroclínico con las siguientes características: género, masculino, con una edad actual (en el momento de lo ocurrido: 67 años), Ocupación: Comerciante (retirado); Estado civil: Casado, Niños: no; Residente: Ayuntamiento de Covilhã - Portugal. En 1991, el paciente sufrió un accidente cerebrovascular hemorrágico masivo en la parte anterior de la corteza frontoparietal izquierda y dilatación ventricular. El marco principal en la semiología fue: pérdida de la conciencia; amnesia a todas las ocurrencias de inmediato antes del ocurrido; hemiplejía derecha; dificultades en la articulación del lenguaje;

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parestesia en el hemi-espacio morfológico derecho y déficits neuropsicológicos generalizados (atención, memoria, concentración, etc...). Todo el proceso de la Evaluación Neuropsicológica y Rehabilitación Neuropsicológica y Psicoterapia se presentan y discuten. Palabras clave: Neuropsicología; Neuroimagen; Trastorno cerebrovascular.

___________________________________________________________________________

Due to the great progress in terms of quality of

A Cerebrovascular accident (ACV) is any

life shown in the XX Century, particularly in the

cerebral dysfunction product of a pathological

health care field, the expectancy of life clearly

process involving the blood vessels (Brust,

increased. This increase in longevity was

2000; Victor, Ropper, & Adams, 2000).

accompanied by a set of standard conditions more likely to occur with aging – Stroke (Cerebrovascular accident - ACV) was definitely one of the most prevalent (Maia et al., 3003). In

terms

cases,

current

clinical

neuropsychology is involved in a large number of diagnosing and treating disorders in different contexts: profession, hospitals, clinics and colleges. Putnam

and

This kind of pathology causes more death and disability than any other disease (except heart disease and cancer cases in mixed analysis) (Lezak, 1995). In terms of semiological aspects, the most common neuropsychological and neuromotor deficits in ACV, according to several authors are (Tranel, 1993; Pliskin & Sworowski, 2003; Kauhanen, 1999; Wade, 2003; Lezak, 1995):

Luca

(1990),

through

memory;

language;

executive

functions;

interviews to neuropsychologists working in

emotional and affective disorders; attention

these contexts found the following sample:

and concentration; information processing;

traumatic brain injury, 22%; learning problems,

sensory - motor deficits and hemiplegia.

11.5%; dementia, 9%; Forensic Issues, 8%; cerebrovascular

accidents,

7%;

geriatric

problems including Parkinson's disease, 5%;

Clinical Case

epilepsy, 4%; substance Abuse, 4%; brain

Gender: Male; Current Age (at the moment of

tumors, 3%; pain syndromes, 2%; toxic

Stroke: 67 years); Occupation: Merchant

encephalopathy 2%; demyelinating disease as

(retired); Marital Status: Married; Children: no;

Multiple Sclerosis, 1% and AIDS, 1%.

Resident of: Municipality of Covilhã – Portugal.

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In 1991 the patient suffered a massive

the stroke; right hemiplegia; difficulties in the

hemorrhagic stroke in the left anterior fronto-

articulation of language; paresthesia in the

parietal cortex (see Figure 1) and ventricular

right

enlargement (see Figure 2. The major

generalized

semiology frame was: loss of consciousness;

(attention, memory, concentration, etc...).

morphological

hemi-space

neuropsychological

and deficits

amnesia to all occurrences immediately before

Figure 1. Magnetic Resonance at the moment of day 1

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Figure 2. Magnetic Resonance at the moment of day 1

Although the severity of the case, the patient was institutionalized for a period of 2 months in

idea of the so called natural recovering of the ischemic penumbra (McLeod et al., 2013).

an induced state of coma. After his release, three months after the massive stroke, the patient and his family looked for our help in our private clinic to deal with the major disabilities that remained as results of the wellknown sequels of ACV.

467

Three months later On figure 3 we can see that the most affected areas were those related with language (in fact, patients speech were characterized as a moderate expressive aphasia) and the, in figure

Our first preoccupation was to repeat the

4, locomotor and somato sensorial left regions

Magnetic Resonance Scan, in order to have an

(sustaining marked right sensory – motor deficits and hemiplegia on right limbs).

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Figure 3. Neighboring areas of expressive language

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Figure 4. Ventricular enlargement showing a strong dysfunction in left, locomotor and somatosensory regions

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In figure 5 we can see in detail the strong lesions on speech a somatosensory left areas

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We also asked to his neurologist to prescribe an ultrasonography study. By the analysis of the sequence of images we can see that the Stroke was essentially caused by partial occlusion of Right Carotid Siphon and almost total occlusion of Right Carotid Siphon (In figure 6).

Figure 6. Sequence of images showing ultrasonography study. Major causes of stroke: partial occlusion of Right Carotid Siphon and almost total occlusion of Left Carotid Siphon 471 1

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Figure 7. Doppler ultrasound

NEUROPSYCHOLOGICAL ASSESSMENT

After the neuropsychological assessment (three months

We used the Luria models assessment, particularly the Luria Nebraska Neuropsychological Battery (Golden, Hammeke, & Purisch, 1978). This battery was developed to access the neuropsychological functioning of brain affected subjects Hebben and Milberg (2002), Groth-

after the Stroke) we classified the results as representing Good to Moderate Functioning and 473

Bad Functioning: Good to Moderate Functioning: Immediate Memory (immediate recall)

Marnat (2000) and Goldstein and Incagnolli (1997). According to Golden, Freshwater and Vayalakkara

Associative Memory

(2000) this battery allows an integration of the

Intellectuals Process (solving problems)

phenomenological

Arithmetic calculation

model

Luria

with

the

psychometric test model. Also, according to Maia et al. (2003) it allows a hybrid approach that considers the

Visuospatial orientation

relevant issues of the these traditions: clinical versus

Positive Attitude towards the disease and

psychometric.

the future

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Bad Functioning:

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When we transform the results in a pattern that could

Memory with interference

be represented in a graph, we found the following distribution (Figure 7).

Expressive language Locomotion (paraesthesia, mild hemiplegia), etc.

Figure 7. Luria Nebraska Neuropsychological Battery – Clinical Scales

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In order to the reader could have a better interpretation of the figure 7 we ask you to pay attention that every scale (every red mark, not the line) correspond to a given scale. The first 11 scale are denominated Clinical Scales and the last 5 scales

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about dysfunction on right hemispheric functions. Summary Scale S4 (Profile Elevation) and Summary Scale S5 (Impairment) give us information about the stage or course of neuropsychological functions: stable, improving and worsening.

are denominated Summary Scales. So Regarding to C1 Motor Clinical Scale, give us information about locomotor ability; C2 Rhythm Clinical, give us

In face of these results we promoted a Therapeutic plan divided in three Major Areas

information about the behavioral prosody; C3 Tactile Clinical Scale, give us information about tactile functions; C4 Visual Clinical Scale, give us information about accuracy and effectiveness of visual functions; C5 Receptive Speech Clinical Scale give us information about understanding language in a receptive way; C6 Expressive Speech Clinical Scale give us information about expressing language; C7 Writing Clinical give us information about writing

a) Computerized Neuropsychological Rehabilitation (Rehacom Program – 3 sessions per week – 45 minutes per session). b) Family Psychoeducation specific for Cerebrovascular Patients (1 session, every 15 days – 1 hour per session). c) Individual Psychotherapy (1 session, every 15 days – 1 hour per session). 475

skills; C8 Reading Clinical give us information about ability to read; C9 Arithmetic Clinical Scale give us

Although the entire process have taken almost

information about calculation skills; C10 Memory

one entire year, we present here the results of the

Clinical Scale give us information about various types

pretest and posttest regard to the first three months

of memory and C11 Intellectual Clinical Scale give us

of intervention.

information about solving intellectual problems. Summary Scale S1 (Pathognomonic) give us

First of it, we will summarily describe the processes of intervention.

information about the level of global dysfunction measured by the entire battery; Summary Scale S2 (Left Hemisphere) give us information about

a) Computerized Neuropsychological Rehabilitation

dysfunction on left hemispheric functions; Summary

(Rehacom Program – 3 sessions per week – 45

Scale S3 (Right Hemisphere) give us information

minutes per session – figure 8).

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Figure 8. Rehacom

(*)

476 Next, we will describe the characteristics of this type

RehaCom is not only a product but an overall

of therapy, transcribing, with authorization, directly

concept based on 5 principles: modular structure of the

from the author and enterprise: “System RehaCom is

modules from training basic functions up to complex

a computer-assisted therapy system for cognitive

demands, optimal interaction therapist- client-

functions whose efficiency is proven in evaluating

computer as fundamental element.

studies. The system consists of a basic program and a

Modular structure

number of training procedures. RehaCom has a modular structure. At the moment RehaCom is a system by the therapist for the therapist.

procedures are available to train the following

With the training procedures of the system RehaCom

cognitive

an improvement of psychological capacities in people

Vigilance, Memory and learning ability, Visuo- motor

with impaired cognitive performances is achieved.

co-ordination, Reaction time and precision, Visuo-

These impairments might be caused by different

construktive ability, Solving problems and developing

athiopathogenesis.

strategies.

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skills:

Attention,

Concentration

and

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Furthermore there are modules for Sakkade and visual field training for clients e.g. with hemianopsie and

Major points worked:

neglect. Additionally there are training units serving the compensations of deficits and the imparting of abilities and skills even more complex. An important meta- aim is the integration of processing information of different sensoric modalities via stimulating several channels. RehaCom is in a process of constant development in which established procedures are mirrored in the experiences of the clinical routine, and new procedures

Management themes in primary family sessions. The influence of brain damage on different family memberships. Family treatment during active rehabilitation. End-of-life and existential reflections and positive aspects of caregiving. Rehabilitation therapy for long-term necessities.

are created.” (Rehacom, Hasomed - Cognitive therapy and brain training, 2010).

c) Individual Psychotherapy (1 session, every 15 days – 1 hour per session).

Family

Psychoeducation

specific

for

Traditional Psychotherapy sessions, introducing the

Cerebrovascular Patients (1 session, every 15 days – 1

precautions of Lincoln and Flannaghan to Stroke &

hour per session). [Based Han & Haley (1999). Family

Family

caregiving for patients with stroke. Review and

Psychotherapy for Depression Following Stroke: A

analysis]

Randomized Controlled Trial.

Patients

(2002).

Cognitive

Behavioral

FINAL RESULTS AND CONSIDERATIONS After three months of intervention we have to stress some outcomes surrounding two major areas.

First we have to consider that an interdisciplinary intervention is all that a Stroke patient needs in order to achieve new objectives to his life. As we saw in this case, we paid attention to several needs of the patient and respective family. With all the intervention provided, in only three months we eyewitnesses a great improvement in global neuropsychological functioning. In figure 9 we can see that not only the majority of clinical and summary scales presented a considerable reduction in terms of semiology manifestation, as none of the scales present, at that moment, clinical significance (note that all results are way below the clinical mark – black line, designated Critical Level = 60).

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477

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Figure 9 – Pre Intervention and Post intervention comparison

478

The second aspect that we would like to stress is that, as sustained by the first neuropsychologists, in a

worldwide

level,

neuroscience

since

diagnosis

intervention

(Bogousslavsky & Hommel, 1993; Kase, 1993).

the

A neuroscientist should have a vast knowledge about

integration of knowledge about several clinical and

cerebral anatomy, functional relationship between

other diverse technology applied to neuroscientific

the so called body – mind relationship in order to

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needs

application,

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

promote the best diagnostic devices as the best

quality of life of patients and their families after the

interventions, bringing to life, again, the work of,

occurrence of a stroke, then all work together on this

probably,

and many other patients will always continue to be

the

greatest

pioneer

human

neuropsychology (Luria, 1973a; b; 1980; 1995, 2003). With this article we managed to draw your attention

worthwhile

(Carod

Artal,

1999;

Williams,

Weingerger, Harris & Biller, 1999; Visser et al., 1995).

to the need to all work together to improve the

Groth-Manart

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