L’intervention psychosociale auprès des jeunes vivant en Centre jeunesse est régie par la Loi sur la protection de la jeunesse (LPJ). La posture professionnelle des intervenants s’inscrit à la fois dans une relation d’autorité, renforcée par le cadre institutionnel et les obligations légales, et dans une relation d’aide. Ce mémoire s’est attardé à ce double mandat (réadaptation sociale et relation d'aide) et à son impact sur le lien jeune-éducateur. Le terrain de cette recherche s’est déroulé pendant trois mois dans une unité de réadaptation de Montréal (CJM-IU). L’analyse s’est faite à partir de la rencontre des corpus de données; les récits des jeunes et des éducateurs (entretiens semi-directifs) et l'observation de ce milieu de vie. L’approche utilisée, puisant à la fois dans la tradition ethnographique et dans la phénoménologie, nous a permis de faire émerger l’interprétation et les perceptions qu’ont les jeunes et leurs intervenants sur la question de la relation d’aide et de la relation d’autorité. Les résultats de recherche portent sur les conditions qui favorisent la conciliation ou la polarisation de ces mandats qui peuvent parfois sembler antagonistes. Il a ainsi été possible d’identifier les éléments qui fragilisent l’établissement de liens significatifs et de confiance entre les jeunes et leurs éducateurs ou au contraire les éléments qui les renforcent. Ultimement, les résultats ont permis d’illustrer les embûches à la création d’une alliance thérapeutique en centre de réadaptation pour mineurs et l’impossibilité de sa réalisation dans le contexte actuel. / Psychosocial intervention with children living in Youth Centers is legislated by the Youth Protection Act (YPA). The professional position of the youth workers is characterised by a relationship of authority, reinforced by an institutional framework and numerous legal obligations, and a counselling relationship. This research paper focuses on this double mandate and its impacts on building a connection between the children and their youth workers. The research’s fieldwork took place in a unit of a Youth Center of Montreal (YCM). The analysis is mostly based on a corpus of data, from living environment observations to the protagonist’s very own narratives throughout semi-directive interviews. The present approach combines the ethnographic and phenomenological traditions, enabling the interpretation of the children and youth workers’ perceptions on the questions of the relationships of authority and counselling. The research results pertain to the conditions supporting the conciliation and polarisation of these sometimes antagonistic mandates. Elements weakening the construction of meaningful bonds between the parties, or, to the opposite reinforcing them, were highlighted. Conclusively, this research illustrates the obstacles in creating a therapeutic alliance and its impossible concrete fulfilment within the context of Youth Centers.

L’intervention psychosociale auprès des jeunes vivant en Centre jeunesse est régie par la Loi sur la protection de la jeunesse (LPJ). La posture professionnelle des intervenants s’inscrit à la fois dans une relation d’autorité, renforcée par le cadre institutionnel et les obligations légales, et dans une relation d’aide. Ce mémoire s’est attardé à ce double mandat (réadaptation sociale et relation d'aide) et à son impact sur le lien jeune-éducateur. Le terrain de cette recherche s’est déroulé pendant trois mois dans une unité de réadaptation de Montréal (CJM-IU). L’analyse s’est faite à partir de la rencontre des corpus de données; les récits des jeunes et des éducateurs (entretiens semi-directifs) et l'observation de ce milieu de vie. L’approche utilisée, puisant à la fois dans la tradition ethnographique et dans la phénoménologie, nous a permis de faire émerger l’interprétation et les perceptions qu’ont les jeunes et leurs intervenants sur la question de la relation d’aide et de la relation d’autorité. Les résultats de recherche portent sur les conditions qui favorisent la conciliation ou la polarisation de ces mandats qui peuvent parfois sembler antagonistes. Il a ainsi été possible d’identifier les éléments qui fragilisent l’établissement de liens significatifs et de confiance entre les jeunes et leurs éducateurs ou au contraire les éléments qui les renforcent. Ultimement, les résultats ont permis d’illustrer les embûches à la création d’une alliance thérapeutique en centre de réadaptation pour mineurs et l’impossibilité de sa réalisation dans le contexte actuel. / Psychosocial intervention with children living in Youth Centers is legislated by the Youth Protection Act (YPA). The professional position of the youth workers is characterised by a relationship of authority, reinforced by an institutional framework and numerous legal obligations, and a counselling relationship. This research paper focuses on this double mandate and its impacts on building a connection between the children and their youth workers. The research’s fieldwork took place in a unit of a Youth Center of Montreal (YCM). The analysis is mostly based on a corpus of data, from living environment observations to the protagonist’s very own narratives throughout semi-directive interviews. The present approach combines the ethnographic and phenomenological traditions, enabling the interpretation of the children and youth workers’ perceptions on the questions of the relationships of authority and counselling. The research results pertain to the conditions supporting the conciliation and polarisation of these sometimes antagonistic mandates. Elements weakening the construction of meaningful bonds between the parties, or, to the opposite reinforcing them, were highlighted. Conclusively, this research illustrates the obstacles in creating a therapeutic alliance and its impossible concrete fulfilment within the context of Youth Centers.

Alors que le traitement standard du cancer du rectum (traitement néoadjuvant avec chirurgie d’exérèse et stomie temporaire) n’épargne ni la psyché ni le corps, peu d’études se sont intéressées à l’ajustement psycho-social des patients qui y sont confrontés. Le corps est bien souvent perçu, à la suite des traitements, comme dérivant de la norme et générant un sentiment de honte. Ainsi le premier travail de cette thèse a été de valider un outil, en population française, permettant de mesurer la honte liée à l’image du corps. Dans un deuxième travail, nous avons pu comparer la honte liée à l’image du corps ainsi que la qualité de vie, l’image du corps, et la détresse psychologique des patients ayant reçu un traitement standard à ceux traités par excision locale (nouvelle approche proposée aux patients présentant une bonne réponse clinique aux traitements néoadjuvants). Le traitement standard entraînant des difficultés psycho-sociales plus marquées, nous avons évalué plus spécifiquement ses conséquences sur la détresse psychologique et l’image du corps dans un troisième travail. La période avec la stomie temporaire représente un temps spécifique durant lequel les patients semblent mettre leur vie entre parenthèses. Ainsi, dans un quatrième travail, nous avons investigué le rôle du temps comme un déterminant possible de la qualité de vie de ces sujets. Nos résultats ont montré qu’il conviendrait de considérer, dans le parcours de soin du patient, la façon dont celui-ci perçoit le temps, en vue de prévenir une altération de sa qualité de vie. Cette altération persiste plusieurs mois après la fin des traitements mais peu d’études s’y sont, à ce jour, intéressées. Ainsi, dans un cinquième travail, nous avons exploré la qualité de vie, deux ans après le diagnostic de cancer, chez des survivants du cancer du côlon-rectum traités par chirurgie avec ou sans stomie temporaire. Nous avons alors constaté que la qualité de vie physique était significativement plus altérée chez les patients qui ont eu une stomie. Face à ces difficultés, il convenait de proposer une intervention psycho-sociale répondant aux besoins émotionnels de ces patients. Peu d’interventions ont été développées en ce sens. Dans un sixième travail, nous avons développé et mis à l’épreuve une intervention psycho-sociale qui semble s’inscrire davantage dans une approche préventive. L’ensemble de ces travaux pourrait contribuer à améliorer l’accompagnement proposé à ces patients, même s’il est nécessaire de souligner l’importance de promouvoir la recherche dans ce domaine pour mieux comprendre encore les enjeux psycho-sociaux de ce traitement. / While the standard treatment for rectal cancer (neoadjuvant treatment with rectal excision) has spared neither the psyche nor the body, few studies have focused on psychosocial adjustment of patients who have received this treatment. Following treatment, the body is often perceived as deviating from the norm, generating feelings of shame. The first objective of this thesis was to adapt, and validate, for the French population, a body image shame scale. The second step consisted in comparing body image shame, quality of life, body image, and psychological distress between rectal cancer patients treated by surgery with temporary stoma or local excision (a new treatment approach proposed for patients with rectal cancer after a good clinical response to neoadjuvant therapy). Since standard treatment leads to more psychosocial problems, in a third study, we examined the effects of standard treatment on psychological distress and body image. The temporary stoma period represents a specific time during which patients seem to temporarily suspend their lives. Thus, the fourth study of this thesis investigated how the role of time perspective might act as a determinant of quality of life for rectal cancer patients. The time perspective construct provides keys in order to improve quality of life of rectal cancer patients. Quality of life alterations persist several months after the end of treatments but, to date, few studies have focused on this topic. The fifth goal was to assess colorectal cancer survivors’ quality of life two years after diagnosis of colorectal cancer according to their stoma status (reversed or never formed). Participants with a reversed stoma score lower on the physical quality of life scale than participants without stoma. Patients with rectal cancer experience psychosocial challenges. To deal with these challenges, psychosocial interventions focused on emotional needs of rectal cancer patients treated by standard treatment should be proposed. There is a lack of this type of intervention for this population. The sixth purpose was to develop and test a psychosocial intervention which seems to be more in line with a preventive approach. Taken together, these works may contribute to improve the support offered to these patients, even though the importance of promoting research to deal with the psychosocial challenges of this treatment must be underlined.

Made available in DSpace on 2016-04-04T18:28:07Z (GMT). No. of bitstreams: 1 Etienne Janiake.pdf: 893829 bytes, checksum: adf272b07e40efe76554b6960534c855 (MD5) Previous issue date: 2012-12-11 / This paper reflects on the introduction of Psychology in the services and programs of the National Social Assistance, conducted by non-governmental entities socioassistenciais the "third sector". The specific objectives of the study are: to expose a critical overview of the development of the National Social Assistance; explain the reasons for the policy, opposing the guidelines expressed in legal frameworks, with observed reality programs and services operating in the country; reflecting on the role historically played by psychology in relation to the social question; introduce Critical Psychology as a perspective that points crucial to professional action on this policy. Based on the methodology Historical Materialist Dialectics, this theoretical work includes the following methodological steps: review of the legal framework underlying the policy of social assistance and predict the performance of psychologists in this policy; literature review of published scientific papers related to the introduction of Psychology in System Unified Social Assistance; reflection and professional practice performed on non-governmental organization. It is observed as a result, the impact of increasing privatization process this policy failures in process support, training, monitoring and control of services provided by the "third sector", by the government. Furthermore, we identified the lack of a theoretical and practical psychologists for this insertion, the result of the fragility own science and profession of psychology, that by placing the individual as the object of study and performance focus, historically brought few contributions understanding the dynamics of social exclusion. We conclude by pointing to the need for strengthening of a new ethical-political project for Psychology, that starting from a critical perspective, and constant liaison with existing public policies, encompassing understanding of the contradictions existing in society and the profession itself, resulting in a practice effectively committed to the transformation of social reality. / O trabalho reflete sobre a inser??o da Psicologia nos servi?os e programas da Pol?tica Nacional de Assist?ncia Social, realizados por entidades socioassistenciais n?o governamentais do terceiro setor . Apresenta como objetivos espec?ficos: expor um panorama cr?tico do desenvolvimento da Pol?tica Nacional de Assist?ncia Social; explicitar os fundamentos dessa pol?tica, contrapondo as diretrizes expressas nos marcos legais, com a realidade observada nos programas e servi?os em funcionamento no pa?s; refletir sobre o papel desempenhado historicamente pela Psicologia na rela??o com a quest?o social; introduzir a Psicologia Cr?tica, como uma perspectiva que aponta elementos fundamentais para a atua??o profissional nessa pol?tica. Baseado na metodologia Materialista Hist?rica Dial?tica, esse trabalho te?rico contempla as seguintes etapas metodol?gicas: revis?o dos marcos legais que fundamentam a pol?tica de assit?ncia social e prev?em a atua??o dos psic?logos nessa pol?tica; revis?o bibliogr?fica de trabalhos cient?ficos publicados, relacionados ? inser??o da Psicologia no Sistema ?nico de Assist?ncia Social; e reflex?o de pr?tica profissional executada em organiza??o n?o governamental. Observa-se, como resultado, o impacto do crescente processo de privatiza??o dessa pol?tica, com falhas no processo de suporte, capacita??o, acompanhamento e controle dos servi?os prestados pelo terceiro setor , por parte do poder p?blico. Al?m disso, identificou-se a car?ncia de um embasamento te?rico e pr?tico dos psic?logos para essa inser??o, fruto da fragilidade pr?pria da ci?ncia e profiss?o da Psicologia, que ao colocar o indiv?duo como seu objeto de estudo e foco de atua??o, historicamente trouxe poucas contribui??es ? compreens?o da din?mica social da exclus?o. Conclui-se, apontando para a necessidade de fortalecimento de um novo projeto ?tico-pol?tico para a Psicologia, que partindo de uma perspectiva cr?tica, e constante articula??o com as pol?ticas p?blicas vigentes, abarque a compreens?o das contradi??es existentes na sociedade e na pr?pria profiss?o, resultando em uma pr?tica efetivamente comprometida com a transforma??o da realidade social.

Made available in DSpace on 2016-04-04T18:29:38Z (GMT). No. of bitstreams: 1 Izabella M SantAna-1.pdf: 615209 bytes, checksum: 05d121a196fca4481286d6594d4487aa (MD5) Previous issue date: 2008-02-13 / The aim of this study is to verify: 1) how the teachers from an Elementary Public School perceived their practice during the development of a political pedagogical project based on an emancipatory conception of Education and during the implementation of two educational policies (Nine-year Elementary School and enlargement of the school schedule); 2) to know the teachers opinions about the policy mentioned; 3) to identify psychosocial processes as alienation and fatalism; and 4) to analyze the psychologist s practice in this context from the School Psychology and Community Social Psychology references. The study was carried out on a group of ten teachers. These teachers were surveyed by the researcher in their meetings for four semesters. The investigation procedures were: individual interviews, analysis of documents, and field notes from a research diary. The results indicated the importance of the educators participation in the discussions about the implementation of an educational policy and the preparation of the school for the proposed changes, the existence of contradictions between the adopted theory and practice carried out in school, the presence of different ways of alienation in the teachers work and ways of the teachers participation (immobilization, critical opinions and actions) concerning the problems, besides the existence of opposite opinions between the psychologists and the teachers about the intervention for students. Though the psychologist s practice was to strengthen the teachers and to develop their awareness about the oppressive conditions that they were submitted to, the group did not advance toward the adoption of emancipatory perspective in teachers professional action and did not recognize their political potential to change the reality. / Este estudo visou conhecer como professores de uma escola p?blica de Ensino Fundamental percebiam sua atua??o durante a efetiva??o de um projeto pol?tico-pedag?gico pautado em uma perspectiva emancipadora de Educa??o e no processo de implementa??o de duas pol?ticas educacionais (Escola de Nove Anos e Amplia??o do hor?rio escolar); conhecer a vis?o dos professores sobre as referidas pol?ticas educacionais, identificar processos psicossociais, como aliena??o e fatalismo, e analisar a a??o do psic?logo nesse contexto, a partir da ado??o de referenciais da Psicologia Escolar e da Psicologia Social Comunit?ria. Foi realizada uma pesquisa participante, na qual um grupo de 10 professoras foi acompanhado em suas reuni?es de trabalho docente ao longo de quatro semestres. Os procedimentos usados envolveram entrevistas individuais, consulta documental e registros em di?rios de campo. As informa??es obtidas indicaram a import?ncia da participa??o dos educadores nas discuss?es sobre a implanta??o dessas pol?ticas e de prepara??o pr?via da escola diante das mudan?as propostas; a exist?ncia de contradi??es entre a concep??o de educa??o adotada e a pr?tica realizada na escola; a presen?a de diferentes formas de aliena??o no trabalho docente e de participa??o das professoras (imobilismo, cr?tica e a??o) frente aos problemas encontrados, al?m da exist?ncia de concep??es divergentes de psic?logos e professores quanto ? interven??o junto aos educandos. Embora a atua??o do psic?logo estivesse voltada ao fortalecimento e ao desenvolvimento da conscientiza??o dos educadores sobre as condi??es de opress?o a que estavam submetidos, o grupo n?o avan?ou em dire??o ? ado??o da perspectiva emancipadora na pr?tica docente e n?o reconheceu a sua for?a pol?tica como instrumento de mudan?a da realidade.

Background: In young people with a first episode of psychosis (FEP), cannabis use is widespread and associated with a significantly worsened prognosis. Few cannabis-specific interventions for this population have been evaluated; most have focused on ceasing or reducing cannabis use, and none are considered highly effective in addressing cannabis use. For many young people with FEP who use cannabis, abstinence-focused approaches may be unappealing or unrealistic options potentially impacting intervention engagement or outcomes. Harm reduction interventions, which seek to reduce cannabis use-related harms rather than requiring abstinence, may present an appealing alternative to young people with FEP who continue using cannabis; few interventions have implemented this approach. Further, there is a scarcity of studies documenting preferences of young people with FEP for cannabis harm reduction interventions or evaluating cannabis harm reduction interventions in this population. Aims: This thesis aims to (a) synthesize the evidence on efficacy of preventive interventions focusing on cannabis use for people with psychosis (review); (b) determine the preferences of young people with FEP using cannabis in relation to key characteristics of cannabis harm reduction interventions (survey); and (c) describe the development of a technology-based harm reduction intervention for young people with FEP who use cannabis, and its associated pilot trial (protocol). Methods: Three studies were conducted. Review: Six databases were searched for randomized controlled trials (RCTs) of interventions aiming to reduce cannabis use-related harms or prevent cannabis use disorder in people with psychosis. Two independent reviewers assessed eligible studies for effectiveness and reporting quality. Intervention effectiveness was described by assessing cannabis-related harms and use outcomes. Survey: A survey, combining two discrete choice experiments (DCE) and conventional survey methodology, was developed to document preferences for cannabis harm reduction interventions. This survey was administered to 89 youth in Canada having FEP and using cannabis. One DCE focused on core attributes of harm reduction interventions (DCE 1) and the second on attributes of boosters (DCE 2). We analyzed these using mixed ranked-ordered logistic regression models. Conventional survey questions on preferences were analyzed using summary statistics. Protocol: A brief, technology-based cannabis harm reduction intervention for young people with FEP using cannabis, called the Cannabis Harm- reducing App to Manage Practices Safely (CHAMPS), was developed to complement FEP standard care. A pilot RCT aiming to recruit 100 young people with FEP and using cannabis was designed to assess the intervention acceptability and the feasibility of conducting a full-scale trial in this population and with this intervention. Results: Review: Five studies were assessed, none of which measured cannabis use-related harms or demonstrated clear efficacy in reducing cannabis use in young people with psychosis. All studies had high risk of bias. Survey: Preferred characteristics for cannabis-focused harm reduction interventions (DCE 1) were: shorter sessions; less frequent sessions; shorter interventions; and technology-based interventions. Preferences for post-intervention boosters (DCE 2) included opting into boosters and having shorter boosters. Protocol: The protocol describing the development of CHAMPS and its pilot RCT was published; the pilot RCT is currently underway. Significance: Few cannabis-specific interventions for young people with FEP have been conducted, none demonstrating clear efficacy or focusing on harm reduction outcomes. Survey findings suggest an interest in cannabis harm reduction interventions and highlight preferred characteristics of young people with FEP for cannabis harm reduction interventions. These findings can guide the design of cannabis harm reductions interventions, as with CHAMPS. CHAMPS represents a novel cannabis harm reduction intervention for young people with FEP who use cannabis, and its associated pilot RCT has the potential to advance knowledge for scientists regarding acceptability and feasibility of implementing cannabis harm reduction interventions in the cannabis and early psychosis fields. / Contexte: Chez les jeunes ayant un premier épisode de psychose (PEP), la consommation de cannabis est très répandue et associée à une détérioration significative du diagnostic. Peu d'interventions spécifiques au cannabis pour cette population ont été évaluées; la plupart se sont concentrées sur l'arrêt ou la réduction de la consommation de cannabis, et aucune n'est considérée comme très efficace pour traiter la consommation de cannabis. Pour de nombreux jeunes ayant un PEP et consommant du cannabis, les approches axées sur l'abstinence peuvent être peu attrayant ou irréaliste, ce qui peut avoir un impact sur l'engagement ou les résultats de l'intervention. Les interventions de réduction des méfaits, qui cherchent à réduire les méfaits liés à la consommation de cannabis plutôt que d'exiger l'abstinence, peuvent constituer une alternative attrayante pour les jeunes ayant un PEP qui continuent à consommer du cannabis; peu d'interventions ont mis en œuvre cette approche. En outre, il existe peu d'études documentant les préférences des jeunes ayant un PEP pour les interventions de réduction des méfaits du cannabis ou évaluant les interventions de réduction des méfaits du cannabis dans cette population. Objectifs : Cette thèse vise à (a) synthétiser les preuves de l'efficacité des interventions préventives axées sur la consommation de cannabis pour les personnes ayant un PEP (revue); (b) déterminer les préférences des jeunes ayant un PEP qui consomment du cannabis par rapport aux caractéristiques clés des interventions de réduction des méfaits du cannabis (sondage); et (c) décrire le développement d'une intervention de réduction des méfaits basée sur la technologie pour les jeunes ayant un PEP qui consomment du cannabis, ainsi que l'essai pilote associé (protocole). Méthodes: Trois études ont été réalisées. Revue: Six bases de données ont été consultées à la recherche d'essais contrôlés randomisés (ECR) portant sur des interventions visant à réduire les méfaits liés à la consommation de cannabis ou à prévenir les troubles liés à la consommation de cannabis chez les personnes ayant un PEP. Deux chercheurs indépendants ont évalué les études éligibles en termes d'efficacité et de qualité des résultats. L'efficacité des interventions a été décrite en évaluant les effets sur les méfaits liés au cannabis et les résultats de la consommation. Sondage: Un sondage, combinant deux expériences de choix discret (ECD) et une méthodologie d'enquête conventionnelle, a été élaboré pour documenter les préférences en matière d'interventions de réduction des méfaits du cannabis. Cette enquête a été menée auprès de 89 jeunes Canadiens ayant un PEP et consommant du cannabis. Une ECD mettait l’accent sur les caractéristiques principales des interventions de réduction des méfaits (ECD 1) et l'autre sur les caractéristiques des sessions de rappel (ECD 2). Nous les avons analysés à l'aide de modèles de régression logistique mixtes et ordonnés. Les questions conventionnelles de sondage sur les préférences ont été analysées à l'aide de statistiques sommaires. Protocole: Une brève intervention de réduction des méfaits du cannabis basée sur la technologie et destinée aux jeunes ayant un PEP et consommant du cannabis, appelée Cannabis Harm-reducing App to Manage Practices Safely (CHAMPS), a été développée pour accompagner les soins standards du PEP. Un ECR pilote visant à recruter 100 jeunes ayant un PEP et consommant du cannabis a été conçu pour évaluer l'acceptabilité de l'intervention et la faisabilité d'un essai à grande échelle au sein de cette population et avec cette intervention. Résultats: Revue: Cinq études ont été évaluées, dont aucune n'a mesuré les méfaits liés à la consommation de cannabis ou n'a démontré une efficacité claire dans la réduction de la consommation de cannabis chez les jeunes ayant un PEP. Toutes les études présentaient un risque élevé de biais. Sondage: Les caractéristiques préférées pour les interventions de réduction des méfaits du cannabis (ECD 1) étaient: des sessions plus courtes, des sessions moins fréquentes, des interventions plus courtes et des interventions basées sur la technologie. Les préférences pour les séances de rappel après l'intervention (ECD 2) comprenaient le choix de participer à des séances de rappel et des séances de rappel plus courtes. Protocole: Le protocole décrivant le développement de CHAMPS et son essai pilote a été publié; l'essai pilote est actuellement en cours. Impact: Peu d'interventions spécifiques au cannabis ont été menées auprès des jeunes ayant un PEP, aucune n'ayant démontré une efficacité évidente ou n'ayant mis l'accent sur la réduction des méfaits. Les résultats de l'enquête suggèrent un intérêt pour les interventions de réduction des risques liés au cannabis et mettent en évidence les caractéristiques préférées des jeunes ayant un PEP pour les interventions de réduction des risques liés au cannabis. Ces résultats peuvent guider la conception d'interventions de réduction des méfaits du cannabis, comme c'est le cas avec CHAMPS. CHAMPS représente une nouvelle intervention de réduction des méfaits du cannabis pour les jeunes ayant un PEP qui consomment du cannabis, et l'ECR pilote qui lui est associé a le potentiel de faire progresser les connaissances des scientifiques concernant l'acceptabilité et la faisabilité de la mise en œuvre d'interventions de réduction des méfaits du cannabis dans les domaines du cannabis et des psychoses précoces.

El TDAH és un trastorn neuroevolutiu de l’atenció i la impulsivitat de naturalesa crònica que afecta un 4% de la població i que freqüentment s’associa amb altres trastorns, com els problemes de conducta i les dificultats en l’aprenentatge. Actualment hi ha base empírica sobre el seu origen genètic i biològic, encara que el seu curs evolutiu i el seu pronòstic estan molt influenciats per factors ambientals. És per això que un abordatge adequat del procés d’avaluació i d’intervenció d’aquest trastorn ha de contemplar de forma primerenca els contextos en què el nen es desenvolupa (escola, família i comunitat) i ha de comptar amb un equip multidisciplinari. En aquesta línia, las modalitats d’intervenció que han evidenciat ser més efectives són les medicacions psicoestimulants, les intervencions psicosocials i els tractaments que combinen ambdues modalitats terapèutiques. L’estimulant més utilitzat per al TDAH, el metilfenidat, és el fàrmac més prescrit en psiquiatria infantil i s’ha constatat la seva efectivitat de forma reiterada. No obstant això, s’ha d’administrar amb cautela perquè presenta limitacions que a vegades no en compensen l’administració, com el efectes no desitjats, el desconeixement sobre els efectes a llarg termini o els escassos estudis sobre eficàcia i seguretat en nens preescolars. Aquests troballes ens fan considerar les intervencions psicosocials, que també són una bona opció terapèutica. Les intervencions psicosocials validades empíricament serveixen d’entrenament a pares i mestres per manejar el trastorn, com també al mateix nen, tot i que en menor mesura, per exercitar les seves habilitats socioemocionals. La finalitat d’aquestes teràpies és que paral•lelament o tres la formació, s’implementen intervencions conductuals, cognitiu-conductuals, escolars i sòcio-emocionals en els contexts naturals del nen. Encara que està provada la eficàcia d’aquestes modalitat d’intervenció de forma aïllada, s’han trobat millores superiors amb els tractaments combinats o multimodals, que cobren un ampli ventall de dificultats i plànols de funcionament, permetent en ocasions reduir la dosi de medicació amb un manteniment dels efectes positius. Però, malauradament, encara s’observa una relativa carència d’estudis que incloguin tractaments combinats per al TDAH infantil, si més no a España. En el millor del casos, les intervencions han estat breus i intensives. Tanmateix, no s’han publicat estudis sobre l’eficàcia d’aquestes intervencions per millorar variables com el clima escolar i familiar d’aquests nens. L’objectiu, doncs, d’aquest projecte és analitzar l’eficàcia relativa i diferencial d’un tractament combinat (medicació estimulant + entrenament a pares i mestres) versus un de farmacològic, durant un curs escolar, per millorar diverses variables relacionades amb el nen hiperactiu, com també amb els seus mestres i pares (símptomes, rendiment acadèmic, clima escolar i familiar, autoeficàcia percebuda i coneixements sobre TDAH). / El TDAH es un trastorno neuro-evolutivo de la atención, la actividad y la impulsividad de naturaleza crónica, que afecta a un 4% de la población, asociándose frecuentemente con otros trastornos, como los problemas de conducta y las dificultades de aprendizaje. En la actualidad, hay evidencia empírica sobre su origen genético y biológico, aunque su curso evolutivo y pronóstico están enormemente influidos por factores ambientales. De ahí que un adecuado abordaje del proceso de evaluación e intervención de este trastorno deba contemplar de forma temprana los contextos donde el niño se desenvuelve (escuela, familia y comunidad), contando con un equipo multidisciplinar. En esta línea, las modalidades de intervención que han mostrado ser más efectivas son las medicaciones estimulantes, las intervenciones psicosociales y los tratamientos que combinan ambas opciones terapéuticas. El estimulante más utilizado para el TDAH, el metilfenidato, es el fármaco más prescrito en psiquiatría infantil y se ha constatado reiteradamente su efectividad. Pero se debe administrar con cautela porque presenta limitaciones que en ocasiones no compensan su administración, como sus efectos indeseados; el desconocimiento sobre sus efectos a largo plazo; y los escasos estudios sobre su eficacia y seguridad en niños preescolares. Estos hallazgos nos instan a considerar las intervenciones psicosociales, que son también una buena opción terapéutica. Las intervenciones psicosociales validadas empíricamente son el entrenamiento a padres y a maestros en el manejo del trastorno, y en menor medida el entrenamiento en habilidades socio-emocionales al propio niño. La finalidad de estas terapias es que paralelamente o tras la formación, se implementen intervenciones conductuales, cognitivo-conductuales, escolares y socio-emocionales en los contextos naturales del niño. Sin embargo, a pesar de la eficacia de estas modalidades de intervención de forma aislada, se han mostrado mejoras superiores con los tratamientos combinados o multimodales, que cubren un amplio abanico de dificultades y planos de funcionamiento, permitiendo en ocasiones reducir la dosis de medicación con un mantenimiento de los efectos positivos. Pero desafortunadamente, aún se observa una relativa carencia de estudios que incluyan tratamientos combinados para el TDAH infantil, al menos en España. Y en el mejor de los casos, las intervenciones han sido muy breves e intensivas. Asimismo, no se han publicado estudios sobre la eficacia de estas intervenciones para mejorar variables como el clima escolar y familiar de estos niños. Precisamente, el objetivo de este proyecto es analizar la eficacia relativa y diferencial de un tratamiento combinado (medicación estimulante+entrenamiento a padres y maestros) versus farmacológico, durante un curso escolar, para mejorar diversas variables relacionadas con el niño hiperactivo, sus maestros y sus padres (síntomas, rendimiento académico, clima escolar y familiar, autoeficacia percibida y conocimientos sobre TDAH). / ADHD is a neuro-developmental disorder of attention, impulsivity and activity of a chronic nature, affecting 4% of the population, frequently associated with other disorders such as behavioral problems and learning disabilities. Today, there is empirical evidence on genetic and biological origin, although its clinical course and prognosis are greatly influenced by environmental factors. Hence, an adequate management of the process of assessment and intervention for this disorder should contemplate early contexts where the child develops (school, family and community), with a multidisciplinary team. In this stratum, the interventions that have proven most effective are stimulant medications, psychosocial interventions and treatments that combine both options. The stimulant used for ADHD, methylphenidate, is the most prescribed drug in child psychiatry and has been found repeatedly to be effective. But it should be administered with caution, because it has limitations, like its side effects, the lack of long-term effects, and the few studies on efficacy and safety in preschool children. These findings urge us to consider psychosocial interventions, which are also a good option. Empirically valid psychosocial interventions are parent training and teachers in the management of the disorder, and less training in socio-emotional skills the child itself. The purpose of these therapies is that, - parallel or after the training -, behavioral, cognitive-behavioral, and socio-emotional interventions would be implemented in the child's natural settings. However, despite the effectiveness of these modalities of intervention in isolation, greater improvement has been shown with combined or multimodal treatments covering a wide range of problems, allowing sometimes to reduce the dose of medication, with a maintenance of positive effects. But unfortunately there is still a relative lack of studies involving combined treatments for childhood ADHD, at least in Spain. And in most cases, interventions have been very brief and intensive. Also, there are no published studies on the effectiveness of these interventions to improve variables such as school and family environment of these children. The precise purpose of this project is to analyze the relative and differential efficacy of combined treatment (stimulant medication + training for parents and teachers) versus drug, during a school year, in order to improve various variables related to the hyperactive child, their teachers and their parents (symptoms, academic performance, school and family evironment, self-efficacy and knowledge about ADHD).

Made available in DSpace on 2016-12-23T14:38:06Z (GMT). No. of bitstreams: 1 Luiz Gustavo Silva Souza Parte 1.pdf: 1900726 bytes, checksum: b8adc8781ae13aedfc75f94a35c9e4bb (MD5) Previous issue date: 2012-05-28 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Alcohol misuse is frequent worldwide. Primary Health Care (PHC) has an important role in approaching alcohol problems and alcoholism in specific. In Brazil, the Family Health Strategy presents the possibility of enhancing care to these problems and to mental health conditions in general. It is relevant to analyze how PHC professionals construct knowledge about (and actions towards) alcoholism, alcoholic patients and associated objects. The research reported here aimed at investigating and analyzing social representations and social practices constructed by Family Health professionals working in a Brazilian Southeast municipality about alcoholism and alcoholic patients. Three studies were conducted: a participant observation carried out in one Family Health Center (FHC) for approximately eight months (84 participants); the administration of semistructured interviews (40 participants from 11 FHC) and of questionnaires with case vignettes (120 participants from 16 FHC). Content analysis was used to treat the data gathered with the observation and with the interviews. Answers of the interviewed professionals were also submitted to ALCESTE software. Data from the questionnaires were treated with analyses of variance (MANOVA, ANOVA) using SPSS. With the participant observation, it was possible to verify the contextual construction (through processes of objectification and anchoring) of five Images of alcoholic patients: the absent alcoholic ; the alcoholic as a difficult case ; the alcoholic present although absent ; the comic drunk and the problem drunk . Practices focused on the traditional cure-centered paradigm were observed as well as practices leading to physical and symbolical exclusion of the alcoholic. It was verified the emphasis on the attribution of otherness (alterity) to patients in general, alcoholics and non-alcoholics. The interviews suggested the presence of ambiguity in the perception of alcoholism, simultaneously represented as multifactorial disease demanding comprehensive care and social problem related to the poverty of the slums . In the process of attributing causes to alcoholism, it was possible to notice the coexistence of the scientific rationality and some beliefs related to the different culture of the poor neighborhoods and of their multi-problem families . Family Health Centers were represented simultaneously as important and as impotent to provide treatment to alcoholism. Data from the questionnaires indicated that the alcoholic was objectified as atypical and difficult patient, towards whom professionals held negative attitudes and socio-cognitive elements related to stigmatization. Mainly social and psychological factors were perceived as causes of alcoholism, in contrast to the lesser importance attributed to genetic (biological) factors. Female alcoholism was possibly perceived as more difficult to explain but not necessarily as more difficult to approach. Results from the three studies are integrated in analytical level, leading to a comprehension of the representational system that oriented the social practices (which were also ambiguous). The construction of the investigated social representations is analyzed from a historical perspective. The tradition of coercion and its association to historical hygienism in professionalpatient interactions are highlighted. The psychosocial determinants of difficulties faced to approach alcoholism are discussed as well as some suggestions to overcome these obstacles. The analyses lead to theoretical and methodological contributions regarding social practices and psychosocial interventions. / O uso problemático de álcool é frequente em todo o mundo. A Atenção Primária à Saúde (APS) tem importante papel na abordagem dos problemas com o álcool e do alcoolismo em específico. No Brasil, a Estratégia Saúde da Família apresenta potencial para melhorar a assistência a esses problemas e ao conjunto de questões de Saúde Mental. Torna-se relevante analisar como profissionais de APS constroem conhecimentos e condutas sobre o alcoolismo, sobre os usuários alcoolistas e sobre os objetos associados. A pesquisa relatada nesta tese teve o objetivo de investigar e analisar representações sociais e práticas sociais construídas por profissionais de Saúde da Família em um município do sudeste brasileiro sobre alcoolismo e usuários alcoolistas. Três estudos foram conduzidos: observação participante realizada em uma Unidade de Saúde da Família (USF) durante cerca de oito meses (84 participantes); entrevistas semiestruturadas (40 participantes de 11 USF); questionários com vinhetas (120 participantes de 16 USF). Dados da observação e das entrevistas foram tratados com análise de conteúdo temática. Falas dos entrevistados foram também submetidas ao programa ALCESTE. Dados dos questionários foram tratados com análises de variância (MANOVA, ANOVA) com auxílio do programa SPSS. A observação participante verificou a construção contextual de cinco Figuras do usuário alcoolista, por meio de processos de objetivação e ancoragem: alcoolista ausente; alcoolista como caso difícil; alcoolista presente e, no entanto, ausente; bêbadocômico e bêbado-problema. Foram observadas práticas centradas no paradigma biomédico tradicional e práticas com sentido geral de exclusão física e simbólica do alcoolista. Verificou-se ênfase na atribuição de alteridade aos usuários em geral, alcoolistas e não-alcoolistas. As falas em entrevistas indicaram ambiguidade da apreensão do alcoolismo, simultaneamente representado como doença multifatorial a ser tratada de forma integral e problema social, relacionado à pobreza das comunidades . Para a atribuição de causas ao alcoolismo, notou-se a coexistência da racionalidade científica e de crenças sobre a cultura diferente das comunidades pobres e sobre suas famílias desestruturadas . As Unidades de Saúde da Família foram representadas simultaneamente como importantes e como impotentes para o tratamento do alcoolismo. Resultados dos questionários indicaram que o alcoolista era objetivado como usuário atípico e difícil , ao qual se dirigiam atitudes negativas e elementos sócio-cognitivos de estigmatização. As causas do alcoolismo foram identificadas nos âmbitos psicológico e social, em contraste com menor ênfase na determinação genética (biológica). O alcoolismo feminino foi possivelmente percebido como mais difícil de explicar, mas não necessariamente como mais difícil de tratar. Os resultados dos três estudos são integrados em plano analítico, gerando compreensão sobre o sistema representacional que orientava as práticas (também ambíguas). A construção das representações é analisada sob ponto de vista histórico. Ressalta-se a tradição higienista-coercitiva na relação entre profissionais de saúde e classes populares. Reflexões são feitas sobre determinantes psicossociais dos obstáculos para tratar o alcoolismo e sobre formas de superar esses obstáculos. A partir das análises, são sugeridas contribuições teóricas e metodológicas sobre práticas sociais e intervenção psicossocia

Ce mémoire porte sur les effets de la participation à un programme d’intervention psychosociale par le sport chez des jeunes à risque d’exclusion, de délinquance et d’abandon scolaire. Plusieurs embûches peuvent compliquer leurs parcours et limiter leurs champs de possibilités: leurs conditions d’existence, certains environnements sociaux, des dynamiques d’exclusion et de ségrégation scolaire. Ils se retrouvent alors dans des établissements scolaires offrant peu de services adaptés et de possibilités de participer à des activités pouvant avoir un impact positif quant à leur réussite et leur bien-être. Pour modérer ces inégalités, la proposition de démocratiser les programmes particuliers en milieu scolaire est sur la table. À partir des discours d'anciens participants à un programme d’une école secondaire, nous avons reconstitué leurs parcours et dégagé des effets de leur expérience. Une approche globale (McAll, Fournier, & Godrie, 2014), l’idée que les personnes puissent tendre vers « une vie qui fait sens » (Sen A. , 2000), un principe de parité de participation (Fraser, 2004) qui vise à atténuer certaines barrières matérielles et sociales et une conception de l’école comme vecteur d’émancipation et de transformation sociale (Freire, 1974; hooks, 1989) ont guidé cette recherche. Les résultats suggèrent que ce programme a offert une échappatoire de vie, un accompagnement scolaire adapté et des opportunités considérables au sein d’un espace inclusif. Un terreau fertile était en place pour le développement d’apprentissages, ainsi que de valeurs qui ont pu être réappropriées, apportant certains effets sur les parcours de vie, tout en contribuant au bien-être des participants / This dissertation examines the effects of participation in a psychosocial intervention program through sport on young people at risk of exclusion, delinquency and school dropout. Several obstacles can complicate their lives and limit their possibilities: their living conditions, certain social environments, and the dynamics of exclusion and school segregation. They then find themselves in schools that offer limited adapted services and opportunities to participate in activities that could have a positive impact on their success and well-being. To moderate these inequalities, the proposal to democratize special programs in schools is on the table. Based on the discourse of former participants in a high school program, we reconstructed their backgrounds and identified effects of their experience. A holistic approach (McAll, Fournier, & Godrie, 2014), the idea that individuals can strive for "a meaningful life" (Sen A. , 2000), a principle of parity of participation (Fraser, 2004) that aims to alleviate certain material and social barriers, and a conception of school as a vehicle for emancipation and social transformation (Freire, 1974; hooks, 1989) guided this research. Findings suggest that this program offered a life escape, appropriate academic support, and considerable opportunities within an inclusive space. A fertile ground was in place for the development of learning and values that could be reappropriated, bringing some effects on life courses, while contributing to the well-being of participants.