Objetivos. Esta tese vai ao encontro da proposta da psiquiatria do desenvolvimento, investigando sintomas clínicos, fatores de risco e potenciais endofenótipos que possam colaborar com diagnósticos precoces e o desenvolvimento de estratégias de prevenção. Métodos. O primeiro estudo relata a investigação e caracterização de uma amostra de crianças e adolescentes em risco para o desenvolvimento do transtorno obsessivocompulsivo (TOC). Para este propósito, 66 crianças e adolescentes com um familiar de primeiro grau com diagnóstico de TOC tiveram seus dados analisados de acordo com a presença ou ausência de sintomas obsessivocompulsivos. O segundo estudo consistiu no desenvolvimento e testagem de um paradigma dot probe de viés atencional relacionado a sintomas do TOC e na sua investigação enquanto possível endofenótipo do transtorno. Para tanto, três grupos de crianças foram selecionados: crianças com diagnóstico de TOC, em alto risco para o desenvolvimento de TOC (com presença de sintomas obsessivo-compulsivos e história familiar de primeiro grau de TOC) e crianças controle. O paradigma incluiu pares de estímulos aversivos (ativos) e neutros das dimensões de sintomas de contaminação/limpeza e simetria apresentados em 500 ms e 1250 ms. Resultados. O primeiro estudo obteve três resultados importantes. Primeiro, a amostra de crianças com familiar de primeiro grau com TOC apresentou elevada prevalência de sintomas obsessivo-compulsivos, confirmando a familiadade do transtorno. Segundo, crianças com e sem sintomas obsessivo-compulsivos apresentam prevalências diferentes de comportamento coercivo relacionados ou não aos sintomas obsessivo-compulsivos. Terceiro, familiares de crianças com sintomas obsessivo-compulsivos apresentaram mais frequentemente a dimensão de sintomas de contaminação/limpeza do que familiares de primeiro grau de crianças sem sintomas obsessivo-compulsivo. O segundo estudo teve como principais resultados: 1) crianças com TOC apresentam índices mais altos de desconforto pelos estímulos ativos comparados aos dos outros dois grupos de crianças, indicando que o paradigma é eficiente na sua avaliação; 2) a avaliação dos estímulos ativos da dimensão de contaminação/limpeza está associada à presença de seus respectivos sintomas no sujeito; 3) o grupo de crianças com TOC apresentou viés atencional na direção do estímulo aversivo em todas as quatro condições do paradigma (contaminação/limpeza e simetria com 500ms e 1250ms); 4) crianças com TOC apresentaram viés atencional maior do que crianças em risco para o desenvolvimento de TOC e controles sucessivamente, sempre na direção do estímulo aversivo exceto, no paradigma de simetria de 500ms; 5) O viés atencional na direção do estímulo ativo de contaminação no paradigma de 1250ms está associado à presença da dimensão de sintomas de contaminação. Conclusões. Os achados aqui descritos reforçam a familialidade do TOC, contribuem com achados de características associadas ao transtorno na infância e adolescência, reforçam a presença de um marcador de risco importante para o desenvolvimento de estratégias de detecção e prevenção precoces. Os resultados encontrados têm importantes implicações para a melhora do conhecimento de fatores de risco para o desenvolvimento do TOC e características associadas, que devem ser considerados em contextos clínicos e de pesquisa / Objective. This thesis goes in line with the concept of developmental psychiatry investigating clinical symptoms and risk factors that can further provide earlier diagnoses and preventive interventions. Methods. The first study reports the investigation and characterization of a sample of children and adolescents at risk for the development of obsessive compulsive disorder (OCD). For this purpose, 66 children and siblings with a first degree relative diagnosed with OCD had their clinical data analyzed according to the presence of obsessive compulsive symptoms. The second study consisted on the development and testing of an attentional bias dot probe paradigm with OCD relevant content to evaluate pediatric patients with OCD and further investigate it as a possible phenotype of OCD. For this purpose three groups of children were selected: 1) children with OCD; 2) children at risk for OCD (presenting obsessive compulsive symptoms and with a first degree relative diagnosed with OCD); 3) control group (children with none of the Axis I Psychiatric diagnoses). The paradigm included pairs of aversive (active) and neutral stimulus of contamination/cleaning and symmetry symptom dimensions and had two different time presentations of the stimulus, 500 and 1250 milliseconds. Results. The first study had with tree main findings. First, our sample of children with a first degree affected with OCD had a very high prevalence of obsessive-compulsive symptoms, confirming the familiality of the disorder. Second, children with and without obsessive-compulsive symptoms presented different rates of coercive behaviours, that can be related or not to obsessive-compulsive symptoms. Third, first degree relatives of children who had obsessive compulsive symptoms had significantly more contamination/cleaning dimension of obsessive compulsive symptoms than relatives of children without obsessive compulsive symptoms. The second study had the following main findings: 1) children with OCD had higher rates of discomfort caused by active stimulus than the other two groups of children, indicating that the paradigm is efficient for its purpose; 2) the evaluation of active stimulus of the contamination/cleaning dimension is associated to the presence of its respective symptoms; 3) the group of children with OCD had attentional bias towards the active stimulus in all four conditions of the paradigm (cleaning/contamination and symmetry in 500ms and 1250ms); 4) children with OCD had higher attention bias than children at risk and controls always towards the active stimulus with the exception of the 500 ms symmetry paradigm; 5) the attentional bias towards the active stimulus in the 1250 ms contamination paradigm is associated to the presence of symptoms of the contaminations dimension. Conclusions. The results reinforce the familiality of OCD, contributing with findings of associated characteristics to the disorder in childhood and adolescence and reinforcing the presence of an important risk marker for the development of strategies of early detection and prevention. The results have important implications to the improvement of the knowledge of OCD and associated characteristics, which should be considered in clinical and research contexts

O objetivo central desta tese de doutorado foi investigar as características clínicas de sintomas obsessivo-compulsivos (SOC), como fenômeno intermediário entre o desenvolvimento normal e o transtorno obsessivo-compulsivo (TOC), em uma ampla amostra comunitária (não-clínica) composta por crianças em idade escolar (6 a 12 anos) e seus familiares biológicos. Para tal, determinou-se a prevalência e a distribuição sociodemográfica dos SOC descrevendo sua fenomenologia caracterizada a partir de dimensões de SOC, agregação familiar, associação com outras comorbidades psiquiátricas e outras variáveis de comprometimento clínico (ex: fatores de risco, problemas sociais, escolares e de comportamento). Dividimos o presente estudo em duas etapas. Na Etapa I, o objeto de estudo foram 9.937 crianças de 6 a 12 anos regularmente matriculadas em escolas públicas (crianças-index) e seus familiares biológicos (n total=29.459). Nesta etapa utilizou-se a Family History Screening (FHS), escala de rastreamento para sintomas psiquiátricos internacionalmente validada, e um módulo adicional com sete itens para identificar quatro dimensões de SOC (\"Agressão/ sexual/ religiosa\"; \"arranjo/ simetria\"; \"contaminação/ lavagem\" e colecionismo\"). Nessa primeira etapa obtivemos dados sobre 9.937 crianças-index (podendo ser irmãos entre si), 3.305 irmãos biológicos (13 a 18 anos) e 16.218 pais. As mães biológicas foram informantes em 88% das entrevistas. Os SOC estiveram presentes em 19.4% da amostra total, sendo 14,7% das crianças-index; 15,6% dos irmãos; 34,6% das mães e 12,1% dos pais. A presença dos SOC foi associada ao sexo masculino e aumento da idade em crianças e adolescentes. Houve agregação familiar das dimensões de SOC nas famílias, sendo que a dimensão de \"contaminação/ lavagem\" foi a mais familiar (OR: 1,44; IC 95% 1,23-1,67; p < 0,001). Crianças-index com SOC apresentaram maior frequência de outros sintomas psiquiátricos, bem como maior comprometimento escolar, social e busca por tratamentos prévios. As principais limitações desta etapa incluem entrevista indireta (by proxy) e utilização de um instrumento ainda não validado para triagem de dimensões de SOC. Na Etapa II, o objeto de estudo foi uma sub-amostra da Etapa I e foram coletados dados de 2.512 crianças-index [média de idade: 8,86 anos (DP: 1,84); 44,59% sexo feminino], com um rigoroso e abrangente protocolo de avaliação clínica, incluindo diagnósticos de transtornos mentais pela DSM-IV/ DAWBA (Development and Well-Being Assessment), padrões específicos de comportamento pelo CBCL (Child Behavior Checklist), fatores de risco, comprometimento escolar, social e tratamentos prévios. A amostra foi dividida em grupos TOC (n=77; 3,07%), SOC (n=488; 19,43%) e controles (n=1.947; 77,5%), que foram comparados em relação às suas características fenotípicas. Não houve diferenças significativas de sexo, idade e classificação socioeconômica entre os três grupos estudados. O grupo TOC apresentou, mais frequentemente, obsessões ou compulsões em geral, obsessões de contaminação, compulsões de lavagem, repetição e colecionismo. Os grupos TOC e SOC foram semelhantes em relação às frequências de obsessões de agressão e compulsões de simetria, verificação e contagem. Em relação às comorbidades pelo DAWBA, o grupo TOC apresentou mais frequentemente transtornos de humor (agrupados), transtorno de ansiedade de separação, transtorno de ansiedade generalizada, transtorno de déficit de atenção e hiperatividade, e transtornos disruptivos (agrupados), quando comparado aos grupos SOC e controles. Os grupos TOC e SOC apresentaram prevalências semelhantes de fobia social, transtornos ansiosos (agrupados), transtorno de oposição e desafio, transtorno de tiques e transtornos alimentares, com prevalência superior àquela encontrada entre controles. Fatores de risco perinatais e abuso físico ou sexual foram significativamente mais frequentes no grupo TOC, em relação a SOC e controles. O grupo SOC exibiu padrão intermediário entre TOC (maior pontuação) e controles (menor pontuação) em relação aos escores totais e às dimensões de problemas de comportamento \"internalizantes\", \"externalizantes\" e sociais da CBCL. O grupo SOC revelou o mesmo padrão encontrado no grupo TOC acerca de vulnerabilidade social, problemas escolares (repetência, expulsão ou abandono), comprometimento funcional, comportamento delinquente e busca por tratamentos prévios. A principal limitação dessa etapa foi a adaptação dos critérios do DAWBA para a DSM-IV, para se estabelecer o diagnóstico de TOC na infância e adolescência. Portanto, este estudo transversal sugere que os SOC são um fenômeno relativamente frequente (aproximadamente 15 a 20%) em escolares de 6 a 12 anos e, sua prevalência se assemelha àquela descrita em adolescentes e adultos. Os dados desta tese fornecem evidências adicionais de que há um contínuo psicopatológico e de impacto clínico entre SOC e TOC o que é importante, não apenas para aprimorar a compreensão da natureza do TOC, mas para estabelecer estratégias de tratamento e prevenção / The present thesis investigated the clinical characteristics of obsessive-compulsive symptoms (OCS), as an intermediate phenomenon between normal development and obsessive-compulsive disorder (OCD) by assessing an extensive community (non- clinical) sample of schoolchildren (6-12 years) and their biological relatives. We determined the prevalence and sociodemographic status of OCS, describing its phenomenology characterized from OCS dimensions, familial aggregation, association with other psychiatric comorbidities, and other variables of clinical impairment (e.g.: risk factors , social, school and behavior problems). The study was divided in two phases. In phase I, 9,937 children (aged 6 to 12 years) enrolled in regular public schools (index-children) and their biological relatives (overall n = 29,459) were assessed. In this phase, we used the Family History Screening (FHS), an internationally validated instrument developed for psychiatric symptoms assessment. An additional seven-item module to identify four OCS dimensions (\"aggressive/ sexual/ religious\"; \"symmetry/ arranging\", \"contamination/ cleaning\" and \"hoarding \") was also used. In the first phase data on 9,937 index-children (may be siblings to each other), 3,305 biological siblings (13-18 years) and 16,218 parents were obtained. The biological mothers were informants in 88 % of the interviews. OCS were present in 19.4 % of the total sample, 14.7 % of index-children, 15.6 % of siblings, 34.6 % of mothers and 12.1 % of parents. The presence of OCS was associated with male gender and increasing age in children and adolescents. Familial aggregation of OCS dimensions was found; the \"contamination/ cleaning\" was the most familial dimension (OR: 1.44; 95% IC 1.23 to 1.67; p < 0.001). OCS were associated with higher frequency of other psychiatric symptoms as well as greater rates of social/ school problems and searching for previous treatments. The main limitations of this phase include by proxy interviews and use of an instrument for assessing OCS dimensions not yet validated. In phase II, a sub-sample (n=2,512) of phase I index-children [mean age: 8.86 (PD: 1.84); 44.59% female] was submitted to a rigorous and comprehensive clinical evaluation protocol, including structural diagnoses of mental disorders DSM-IV/ DAWBA (Development and Well-Being Assessment), specific behavioral patterns from CBCL (Child Behavior Checklist), risk factors, school/ social problems and searching for previous treatments. The sample was divided in three groups: OCD (n = 77; 3.07 %), OCS (N=488; 19.43 %) and controls (n=1,947; 77.5 %), compared according to their clinical features. There were no significant age/ gender and socio-economic status differences between groups. OCD group presented higher rates of overall obsessions and compulsions, contamination obsessions, cleaning and repetition compulsions and \"hoarding\". OCD and OCS groups showed similar prevalence rates of aggressive, symmetry, checking and counting symptoms. Regarding DAWBA comorbidities, OCD group showed increased prevalence of mood disorders (as a group), separation anxiety disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, and disruptive disorders (as a group) compared to OCS and control groups. OCD and OCS groups showed similar prevalences of social phobia, anxiety disorders (as a group), oppositional defiant disorder, tic disorders and eating disorders, showing higher prevalence than controls. Perinatal risk factors and physical or sexual abuse were significantly more frequent in the OCD group in comparison to OCS and control groups. The OCS group exhibited intermediate pattern between OCD (higher scores) and controls (lower scores) concerning total and \"internalizing\", \"externalizing\" and social dimensions scores of the CBCL. The OCS group showed the same pattern found in the OCD group concerning social vulnerability, school problems (failure, expulsion or dropout), functional impairment, delinquent behavior, and searching for previous treatments. The main limitation of this phase was the adaptation of the DAWBA criteria for DSM -IV diagnosis for pediatric OCD. Therefore, this cross-sectional study suggests that OCS is fairly frequent in schoolchildren 6-12 years (about 15 to 20%) and its prevalence is similar to that described in adolescents and adults. Data from this thesis provide further evidence that there is a psychopathological and clinical impact continuum between OCS and OCD, which is important not only to enhance the understanding of the nature of OCD but to develop treatment and prevention strategies

Tangible User Interfaces (TUIs) offer the potential for new modes of social interaction for children with Autism Spectrum Conditions (ASC). Familiar objects that are embedded with digital technology may help children with autism understand the actions of others by providing feedback that is logical and predictable. Objects that move, playback sound or create sound – thus repeating programmed effects – offer an exciting way for children to investigate objects and their effects. This thesis presents three studies of children with autism interacting with objects augmented with digital technology. Study one looked at Topobo, a construction toy augmented with kinetic memory. Children played with Topobo in groups of three of either Typically Developing (TD) or ASC children. The children were given a construction task, and were also allowed to play with the construction sets with no task. Topobo in the task condition showed an overall significant effect for more onlooker, cooperative, parallel, and less solitary behaviour. For ASC children significantly less solitary and more parallel behaviour was recorded than other play states. In study two, an Augmented Knights Castle (AKC) playset was presented to children with ASC. The task condition was extended to allow children to configure the playset with sound. A significant effect in a small sample was found for configuration of the AKC, leading to less solitary behaviour, and more cooperative behaviour. Compared to non-digital play, the AKC showed reduction of solitary behaviour because of augmentation. Qualitative analysis showed further differences in learning phase, user content, behaviour oriented to other children, and system responsiveness. Tangible musical blocks (‘d-touch') in study three focused on the task. TD and ASC children were presented with a guided/non-guided task in pairs, to isolate effects of augmentation. Significant effects were found for an increase in cooperative symbolic play in the guided condition, and more solitary functional play was found in the unguided condition. Qualitative analysis highlighted differences in understanding blocks and block representation, exploratory and expressive play, understanding of shared space and understanding of the system. These studies suggest that the structure of the task conducted with TUIs may be an important factor for children's use. When the task is undefined, play tends to lose structure and the benefits of TUIs decline. Tangible technology needs to be used in an appropriately structured manner with close coupling (the distance between digital housing and digital effect), and works best when objects are presented in familiar form.

<p>Individuals afflicted with childhood and adolescent mental disorders have an increased risk for poor outcome in adulthood. The progression of psychopathology from childhood to adult life may be influenced by a multitude of interacting variables, both biological and psychosocial. There is limited information on the relationships between child psychopathology and adult personality and personality disorders. The main aim of this thesis was therefore to gain better knowledge concerning adult personality outcome in patients with early onset of mental disorders. </p><p>Former child psychiatric patients as compared to controls had a significantly higher prevalence of all DSM-IV personality disorders (38.0 vs. 10.9 percent, p<0.001) and also a considerably higher personality disorder co-morbidity. They also had more psychosocial and environmental problems. This was exaggerated in those diagnosed with a personality disorder. Major depression, disruptive disorders and substance use disorders at a young age were strong predictors for adult personality disorder.</p><p>Patients with an early onset major depression had more personality disorders and more deviant personality traits than those with a late onset. </p><p>Forensic psychiatric male patients diagnosed with a previous conduct disorder as compared to those without had more cluster B personality disorders, and more repeated violent criminality and mixed abuse. They also exhibited more deviant personality traits and higher psychopathy scores.</p><p>The instrument "Child and Adolescent Psychiatric Screening Inventory-Retrospect" had acceptable sensitivity and specificity for assessment of child psychiatric disorders. Subscales demonstrated good internal reliability (Crohnbach´s alpha = 0.76-0.93).</p><p>The results suggest that adult personality disturbances are prevalent in individuals affected with mental problems at young ages. A better understanding of the transition of psychopathology from childhood to adulthood and a better identification of those at risk will be of help in attempts to prevent permanent impact on the adult personality.</p>

Individuals afflicted with childhood and adolescent mental disorders have an increased risk for poor outcome in adulthood. The progression of psychopathology from childhood to adult life may be influenced by a multitude of interacting variables, both biological and psychosocial. There is limited information on the relationships between child psychopathology and adult personality and personality disorders. The main aim of this thesis was therefore to gain better knowledge concerning adult personality outcome in patients with early onset of mental disorders. Former child psychiatric patients as compared to controls had a significantly higher prevalence of all DSM-IV personality disorders (38.0 vs. 10.9 percent, p&lt;0.001) and also a considerably higher personality disorder co-morbidity. They also had more psychosocial and environmental problems. This was exaggerated in those diagnosed with a personality disorder. Major depression, disruptive disorders and substance use disorders at a young age were strong predictors for adult personality disorder. Patients with an early onset major depression had more personality disorders and more deviant personality traits than those with a late onset. Forensic psychiatric male patients diagnosed with a previous conduct disorder as compared to those without had more cluster B personality disorders, and more repeated violent criminality and mixed abuse. They also exhibited more deviant personality traits and higher psychopathy scores. The instrument "Child and Adolescent Psychiatric Screening Inventory-Retrospect" had acceptable sensitivity and specificity for assessment of child psychiatric disorders. Subscales demonstrated good internal reliability (Crohnbach´s alpha = 0.76-0.93). The results suggest that adult personality disturbances are prevalent in individuals affected with mental problems at young ages. A better understanding of the transition of psychopathology from childhood to adulthood and a better identification of those at risk will be of help in attempts to prevent permanent impact on the adult personality.

Diss. (sammanfattning) Linköping : Linköpings universitet, 2005. / Härtill 5 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2005. / Härtill 4 uppsatser.

O objetivo central desta tese de doutorado foi investigar as características clínicas de sintomas obsessivo-compulsivos (SOC), como fenômeno intermediário entre o desenvolvimento normal e o transtorno obsessivo-compulsivo (TOC), em uma ampla amostra comunitária (não-clínica) composta por crianças em idade escolar (6 a 12 anos) e seus familiares biológicos. Para tal, determinou-se a prevalência e a distribuição sociodemográfica dos SOC descrevendo sua fenomenologia caracterizada a partir de dimensões de SOC, agregação familiar, associação com outras comorbidades psiquiátricas e outras variáveis de comprometimento clínico (ex: fatores de risco, problemas sociais, escolares e de comportamento). Dividimos o presente estudo em duas etapas. Na Etapa I, o objeto de estudo foram 9.937 crianças de 6 a 12 anos regularmente matriculadas em escolas públicas (crianças-index) e seus familiares biológicos (n total=29.459). Nesta etapa utilizou-se a Family History Screening (FHS), escala de rastreamento para sintomas psiquiátricos internacionalmente validada, e um módulo adicional com sete itens para identificar quatro dimensões de SOC (\"Agressão/ sexual/ religiosa\"; \"arranjo/ simetria\"; \"contaminação/ lavagem\" e colecionismo\"). Nessa primeira etapa obtivemos dados sobre 9.937 crianças-index (podendo ser irmãos entre si), 3.305 irmãos biológicos (13 a 18 anos) e 16.218 pais. As mães biológicas foram informantes em 88% das entrevistas. Os SOC estiveram presentes em 19.4% da amostra total, sendo 14,7% das crianças-index; 15,6% dos irmãos; 34,6% das mães e 12,1% dos pais. A presença dos SOC foi associada ao sexo masculino e aumento da idade em crianças e adolescentes. Houve agregação familiar das dimensões de SOC nas famílias, sendo que a dimensão de \"contaminação/ lavagem\" foi a mais familiar (OR: 1,44; IC 95% 1,23-1,67; p < 0,001). Crianças-index com SOC apresentaram maior frequência de outros sintomas psiquiátricos, bem como maior comprometimento escolar, social e busca por tratamentos prévios. As principais limitações desta etapa incluem entrevista indireta (by proxy) e utilização de um instrumento ainda não validado para triagem de dimensões de SOC. Na Etapa II, o objeto de estudo foi uma sub-amostra da Etapa I e foram coletados dados de 2.512 crianças-index [média de idade: 8,86 anos (DP: 1,84); 44,59% sexo feminino], com um rigoroso e abrangente protocolo de avaliação clínica, incluindo diagnósticos de transtornos mentais pela DSM-IV/ DAWBA (Development and Well-Being Assessment), padrões específicos de comportamento pelo CBCL (Child Behavior Checklist), fatores de risco, comprometimento escolar, social e tratamentos prévios. A amostra foi dividida em grupos TOC (n=77; 3,07%), SOC (n=488; 19,43%) e controles (n=1.947; 77,5%), que foram comparados em relação às suas características fenotípicas. Não houve diferenças significativas de sexo, idade e classificação socioeconômica entre os três grupos estudados. O grupo TOC apresentou, mais frequentemente, obsessões ou compulsões em geral, obsessões de contaminação, compulsões de lavagem, repetição e colecionismo. Os grupos TOC e SOC foram semelhantes em relação às frequências de obsessões de agressão e compulsões de simetria, verificação e contagem. Em relação às comorbidades pelo DAWBA, o grupo TOC apresentou mais frequentemente transtornos de humor (agrupados), transtorno de ansiedade de separação, transtorno de ansiedade generalizada, transtorno de déficit de atenção e hiperatividade, e transtornos disruptivos (agrupados), quando comparado aos grupos SOC e controles. Os grupos TOC e SOC apresentaram prevalências semelhantes de fobia social, transtornos ansiosos (agrupados), transtorno de oposição e desafio, transtorno de tiques e transtornos alimentares, com prevalência superior àquela encontrada entre controles. Fatores de risco perinatais e abuso físico ou sexual foram significativamente mais frequentes no grupo TOC, em relação a SOC e controles. O grupo SOC exibiu padrão intermediário entre TOC (maior pontuação) e controles (menor pontuação) em relação aos escores totais e às dimensões de problemas de comportamento \"internalizantes\", \"externalizantes\" e sociais da CBCL. O grupo SOC revelou o mesmo padrão encontrado no grupo TOC acerca de vulnerabilidade social, problemas escolares (repetência, expulsão ou abandono), comprometimento funcional, comportamento delinquente e busca por tratamentos prévios. A principal limitação dessa etapa foi a adaptação dos critérios do DAWBA para a DSM-IV, para se estabelecer o diagnóstico de TOC na infância e adolescência. Portanto, este estudo transversal sugere que os SOC são um fenômeno relativamente frequente (aproximadamente 15 a 20%) em escolares de 6 a 12 anos e, sua prevalência se assemelha àquela descrita em adolescentes e adultos. Os dados desta tese fornecem evidências adicionais de que há um contínuo psicopatológico e de impacto clínico entre SOC e TOC o que é importante, não apenas para aprimorar a compreensão da natureza do TOC, mas para estabelecer estratégias de tratamento e prevenção / The present thesis investigated the clinical characteristics of obsessive-compulsive symptoms (OCS), as an intermediate phenomenon between normal development and obsessive-compulsive disorder (OCD) by assessing an extensive community (non- clinical) sample of schoolchildren (6-12 years) and their biological relatives. We determined the prevalence and sociodemographic status of OCS, describing its phenomenology characterized from OCS dimensions, familial aggregation, association with other psychiatric comorbidities, and other variables of clinical impairment (e.g.: risk factors , social, school and behavior problems). The study was divided in two phases. In phase I, 9,937 children (aged 6 to 12 years) enrolled in regular public schools (index-children) and their biological relatives (overall n = 29,459) were assessed. In this phase, we used the Family History Screening (FHS), an internationally validated instrument developed for psychiatric symptoms assessment. An additional seven-item module to identify four OCS dimensions (\"aggressive/ sexual/ religious\"; \"symmetry/ arranging\", \"contamination/ cleaning\" and \"hoarding \") was also used. In the first phase data on 9,937 index-children (may be siblings to each other), 3,305 biological siblings (13-18 years) and 16,218 parents were obtained. The biological mothers were informants in 88 % of the interviews. OCS were present in 19.4 % of the total sample, 14.7 % of index-children, 15.6 % of siblings, 34.6 % of mothers and 12.1 % of parents. The presence of OCS was associated with male gender and increasing age in children and adolescents. Familial aggregation of OCS dimensions was found; the \"contamination/ cleaning\" was the most familial dimension (OR: 1.44; 95% IC 1.23 to 1.67; p < 0.001). OCS were associated with higher frequency of other psychiatric symptoms as well as greater rates of social/ school problems and searching for previous treatments. The main limitations of this phase include by proxy interviews and use of an instrument for assessing OCS dimensions not yet validated. In phase II, a sub-sample (n=2,512) of phase I index-children [mean age: 8.86 (PD: 1.84); 44.59% female] was submitted to a rigorous and comprehensive clinical evaluation protocol, including structural diagnoses of mental disorders DSM-IV/ DAWBA (Development and Well-Being Assessment), specific behavioral patterns from CBCL (Child Behavior Checklist), risk factors, school/ social problems and searching for previous treatments. The sample was divided in three groups: OCD (n = 77; 3.07 %), OCS (N=488; 19.43 %) and controls (n=1,947; 77.5 %), compared according to their clinical features. There were no significant age/ gender and socio-economic status differences between groups. OCD group presented higher rates of overall obsessions and compulsions, contamination obsessions, cleaning and repetition compulsions and \"hoarding\". OCD and OCS groups showed similar prevalence rates of aggressive, symmetry, checking and counting symptoms. Regarding DAWBA comorbidities, OCD group showed increased prevalence of mood disorders (as a group), separation anxiety disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, and disruptive disorders (as a group) compared to OCS and control groups. OCD and OCS groups showed similar prevalences of social phobia, anxiety disorders (as a group), oppositional defiant disorder, tic disorders and eating disorders, showing higher prevalence than controls. Perinatal risk factors and physical or sexual abuse were significantly more frequent in the OCD group in comparison to OCS and control groups. The OCS group exhibited intermediate pattern between OCD (higher scores) and controls (lower scores) concerning total and \"internalizing\", \"externalizing\" and social dimensions scores of the CBCL. The OCS group showed the same pattern found in the OCD group concerning social vulnerability, school problems (failure, expulsion or dropout), functional impairment, delinquent behavior, and searching for previous treatments. The main limitation of this phase was the adaptation of the DAWBA criteria for DSM -IV diagnosis for pediatric OCD. Therefore, this cross-sectional study suggests that OCS is fairly frequent in schoolchildren 6-12 years (about 15 to 20%) and its prevalence is similar to that described in adolescents and adults. Data from this thesis provide further evidence that there is a psychopathological and clinical impact continuum between OCS and OCD, which is important not only to enhance the understanding of the nature of OCD but to develop treatment and prevention strategies

Objetivos. Esta tese vai ao encontro da proposta da psiquiatria do desenvolvimento, investigando sintomas clínicos, fatores de risco e potenciais endofenótipos que possam colaborar com diagnósticos precoces e o desenvolvimento de estratégias de prevenção. Métodos. O primeiro estudo relata a investigação e caracterização de uma amostra de crianças e adolescentes em risco para o desenvolvimento do transtorno obsessivocompulsivo (TOC). Para este propósito, 66 crianças e adolescentes com um familiar de primeiro grau com diagnóstico de TOC tiveram seus dados analisados de acordo com a presença ou ausência de sintomas obsessivocompulsivos. O segundo estudo consistiu no desenvolvimento e testagem de um paradigma dot probe de viés atencional relacionado a sintomas do TOC e na sua investigação enquanto possível endofenótipo do transtorno. Para tanto, três grupos de crianças foram selecionados: crianças com diagnóstico de TOC, em alto risco para o desenvolvimento de TOC (com presença de sintomas obsessivo-compulsivos e história familiar de primeiro grau de TOC) e crianças controle. O paradigma incluiu pares de estímulos aversivos (ativos) e neutros das dimensões de sintomas de contaminação/limpeza e simetria apresentados em 500 ms e 1250 ms. Resultados. O primeiro estudo obteve três resultados importantes. Primeiro, a amostra de crianças com familiar de primeiro grau com TOC apresentou elevada prevalência de sintomas obsessivo-compulsivos, confirmando a familiadade do transtorno. Segundo, crianças com e sem sintomas obsessivo-compulsivos apresentam prevalências diferentes de comportamento coercivo relacionados ou não aos sintomas obsessivo-compulsivos. Terceiro, familiares de crianças com sintomas obsessivo-compulsivos apresentaram mais frequentemente a dimensão de sintomas de contaminação/limpeza do que familiares de primeiro grau de crianças sem sintomas obsessivo-compulsivo. O segundo estudo teve como principais resultados: 1) crianças com TOC apresentam índices mais altos de desconforto pelos estímulos ativos comparados aos dos outros dois grupos de crianças, indicando que o paradigma é eficiente na sua avaliação; 2) a avaliação dos estímulos ativos da dimensão de contaminação/limpeza está associada à presença de seus respectivos sintomas no sujeito; 3) o grupo de crianças com TOC apresentou viés atencional na direção do estímulo aversivo em todas as quatro condições do paradigma (contaminação/limpeza e simetria com 500ms e 1250ms); 4) crianças com TOC apresentaram viés atencional maior do que crianças em risco para o desenvolvimento de TOC e controles sucessivamente, sempre na direção do estímulo aversivo exceto, no paradigma de simetria de 500ms; 5) O viés atencional na direção do estímulo ativo de contaminação no paradigma de 1250ms está associado à presença da dimensão de sintomas de contaminação. Conclusões. Os achados aqui descritos reforçam a familialidade do TOC, contribuem com achados de características associadas ao transtorno na infância e adolescência, reforçam a presença de um marcador de risco importante para o desenvolvimento de estratégias de detecção e prevenção precoces. Os resultados encontrados têm importantes implicações para a melhora do conhecimento de fatores de risco para o desenvolvimento do TOC e características associadas, que devem ser considerados em contextos clínicos e de pesquisa / Objective. This thesis goes in line with the concept of developmental psychiatry investigating clinical symptoms and risk factors that can further provide earlier diagnoses and preventive interventions. Methods. The first study reports the investigation and characterization of a sample of children and adolescents at risk for the development of obsessive compulsive disorder (OCD). For this purpose, 66 children and siblings with a first degree relative diagnosed with OCD had their clinical data analyzed according to the presence of obsessive compulsive symptoms. The second study consisted on the development and testing of an attentional bias dot probe paradigm with OCD relevant content to evaluate pediatric patients with OCD and further investigate it as a possible phenotype of OCD. For this purpose three groups of children were selected: 1) children with OCD; 2) children at risk for OCD (presenting obsessive compulsive symptoms and with a first degree relative diagnosed with OCD); 3) control group (children with none of the Axis I Psychiatric diagnoses). The paradigm included pairs of aversive (active) and neutral stimulus of contamination/cleaning and symmetry symptom dimensions and had two different time presentations of the stimulus, 500 and 1250 milliseconds. Results. The first study had with tree main findings. First, our sample of children with a first degree affected with OCD had a very high prevalence of obsessive-compulsive symptoms, confirming the familiality of the disorder. Second, children with and without obsessive-compulsive symptoms presented different rates of coercive behaviours, that can be related or not to obsessive-compulsive symptoms. Third, first degree relatives of children who had obsessive compulsive symptoms had significantly more contamination/cleaning dimension of obsessive compulsive symptoms than relatives of children without obsessive compulsive symptoms. The second study had the following main findings: 1) children with OCD had higher rates of discomfort caused by active stimulus than the other two groups of children, indicating that the paradigm is efficient for its purpose; 2) the evaluation of active stimulus of the contamination/cleaning dimension is associated to the presence of its respective symptoms; 3) the group of children with OCD had attentional bias towards the active stimulus in all four conditions of the paradigm (cleaning/contamination and symmetry in 500ms and 1250ms); 4) children with OCD had higher attention bias than children at risk and controls always towards the active stimulus with the exception of the 500 ms symmetry paradigm; 5) the attentional bias towards the active stimulus in the 1250 ms contamination paradigm is associated to the presence of symptoms of the contaminations dimension. Conclusions. The results reinforce the familiality of OCD, contributing with findings of associated characteristics to the disorder in childhood and adolescence and reinforcing the presence of an important risk marker for the development of strategies of early detection and prevention. The results have important implications to the improvement of the knowledge of OCD and associated characteristics, which should be considered in clinical and research contexts

Research shows that the integration of physical and mental healthcare in paediatric settings is beneficial in terms of clinical and cost effectiveness (Kahana, Drotar, & Frazier, 2008; Douglas & Benson 2008, Griffin & Christie, 2008). Due to the high rates of mental health problems within this population, several studies have shown that referral to paediatric psychology should be increased (e.g. Wagner & Smith, 2007). However, there are few studies investigating factors influencing healthcare professionals’ referral behaviour. The current study used theory of planned behaviour (Ajzen, 1988; 1991) to develop a questionnaire which explores factors influencing the referral of children and families to paediatric psychology. Psychometric properties of the questionnaire were examined. Findings indicate that the questionnaire holds good reliability and validity and that the main constructs of theory of planned behaviour are useful in predicting intention to refer to paediatric psychology. Specific beliefs about referral were also shown to influence intention to refer. Findings that individual referrer factors such as attitudes and beliefs can impact healthcare professionals’ referral behaviour indicates that multidisciplinary interventions and inter-professional education relating to the psychological aspects of illness are required. Recommendations for future research are discussed.