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Contents lists available at ScienceDirect
Child Abuse & Neglect
Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors Elina A. Stefanovics a,c,∗ , Mauro V.M. Filho b , Robert A. Rosenheck a,c , Sandra Scivoletto b a
Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA The Equilibrim Program (TEP), Department and Institute of Psychiatry, Medicine School, University of São Paulo (USP), R.Ovidio Campos Pieres Campos, 785, São Paulo, Brazil c VA New England Mental Illness Research, Education and Clinical Center, Connecticut Healthcare System, West Haven, CT, USA b
a r t i c l e
i n f o
Article history: Received 9 July 2013 Received in revised form 24 October 2013 Accepted 30 October 2013 Available online xxx
Keywords: Maltreated children Mental health Program evaluation system care
a b s t r a c t This study sought to implement outcomes monitoring and to review outcome data from a community-based rehabilitation program for maltreated children and adolescents in São Paulo, Brazil. Maltreated children and adolescents (N = 452) were enrolled in The Equilibrium Program (TEP), a multidisciplinary community-based rehabilitation program. About half (n = 230) of the participants were successfully evaluated using the Children’s Global Assessment Scale (C-GAS) at entry, 3, and/or 6 months later. Analysis of outcomes used hierarchical linear modeling of functional change from baseline. With a baseline C-GAS score of 51.7 (SD = 14.22), average improvement was 2.8 and 5.5 points at 3 and 6 months, respectively (reflecting small to moderate effect sizes = 0.20 and 0.39). Improvement was associated with Problems related to upbringing (p < .02) at entry and absence of Physical abuse (p < .05) and Negative life events in childhood (p < .05) but was not associated with sociodemographics or any specific psychiatric diagnosis. This study showed that outcomes monitoring is feasible in a community-based program in a developing country. Although there was no untreated control group for comparison and specific evidence-based treatments were not used, it is notable that significant improvement, with small to moderate effect size, was observed. Published by Elsevier Ltd.
Introduction ˜ Child maltreatment is a global public health and social problem (Sadowski, Hunter, Bangdiwala, & Munoz, 2004) affecting both high and low/middle income countries (LMICs; Runyan et al., 2010). It is a general term used to describe all non-mutually exclusive forms of child abuse and neglect, including physical abuse, sexual abuse, emotional/psychological abuse, neglect, and other acts of commission or omission by a parent or other caregiver that result in harm, potential for harm, or threat of harm to a child (Leeb, Paulozzi, Melanson, Simon, & Arias, 2008). Maltreated children may experience a variety of behavioral problems, including anxiety disorders, post-traumatic stress disorder (PTSD; Gilbert et al., 2009), depression (Maciel et al., 2013), substance abuse (de Carvalho et al., 2006; Forster, Tannhauser, & Barros, 1996), risk for HIV infection (Inciardi & Surratt, 1998), low self-esteem, poor social skills and
∗ Corresponding author address: VA New England Mental Illness, Research, Education and Clinical Center, VA Connecticut Healthcare System (116A-4), 950 Campbell Avenue, Building 36, West Haven, CT 06516, USA. 0145-2134/$ – see front matter. Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.chiabu.2013.10.025
Please cite this article in press as: Stefanovics, E. A., et al. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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psychological functioning (Kaplow & Widom, 2007), and antisocial behavior. If not recognized and treated, these problems may worsen through adolescence and pose long-term adverse effects on the capacity to form adult relationships, vocational performance, and subjective well being. It may also inflict problems for society, resulting in crime, poverty, drug abuse, and increased health care costs. Studies have specifically demonstrated a high prevalence of child maltreatment in Brazil (Scivoletto, Silva, & Rosenheck, 2011; Tucci, Kerr-Corrêa, & Souza-Formigoni, 2010). There has been considerable interest in both identifying maltreated children, especially those who live, work, or spend most of their time on the street (Hutz & Koller, 1999; Martins, 1996; Neiva-Silva & Koller, 2002) and treating them with evidence based practices (Chaffin & Friedrich, 2004; Cohen & Mannarino, 1998; Cohen & Mannarino, 2000; Shipman & Taussig, 2009). Although most street children (68%) spend a majority of their time in the street, many of them maintain contact with their families (Forster et al., 1996; Raffaelli et al., 1993). In spite of the fact that many children in Brazil and elsewhere are victims of multiple forms of maltreatment (Edwards, Holden, Felitti, & Anda, 2003; Nguyen, Dunne, & Le, 2010), most studies of evidence based practices have examined trauma focused cognitive behavioral psychotherapies for one or another type of abuse but not for multiply maltreated youth. Interventions have also been developed to prevent abuse and neglect, to help abusive parents curtail their abusive behavior, and to serve children in foster care (Chaffin & Friedrich, 2004). Also, the healing role of supportive social environments has been highlighted but research has focused on single types of maltreatment (Ungar, 2013). In LMICs, as far as we know, there have been no outcome studies from real-world community-based programs working with children who suffered from multiple forms of maltreatment, most likely because of limited technical and analytic expertise in program evaluation and because of limited personnel to collect data. Published outcome studies have focused their attention on the analysis of certain singular traumata, such as exposure to sexual abuse (Cohen & Mannarino, 1998; Cohen & Mannarino, 2000), sexually transmitted infections and HIV (Aral & Ward, 2005; Avila et al., 1996; de Carvalho et al., 2006; Fallah, Azimi, & Taherkhani, 2007; Kissin et al., 2007), substance use (de Carvalho et al., 2006; Elkoussi & Bakheet, 2011; Huang, Barreda, Mendoza, Guzman, & Gilbert, 2004; Nada & Suliman el, 2010; Njord, Merrill, Njord, Lindsay, & Pachano, 2010; Obando, Kliewer, Murrelle, & Svikis, 2004; Olgar et al., 2008; Owoaje & Uchendu, 2009), violence (Agnihotri, 2001; Nada & Suliman el, 2010; Sherman, Plitt, ul Hassan, Cheng, & Zafar, 2005), or nutritional deprivation and poor growth status (D’Abreu, Mullis, & Cook, 1999; Greksa, Rie, Islam, Maki, & Omori, 2007; Worthman & Panter-Brick, 2008). No study, to our knowledge, has focused on children and youth exposed to multiple forms of maltreatment or has investigated functional outcomes, their predictors, and the effectiveness of a bundled psychosocial intervention in real-world clinical settings in LMICs. This study sought to demonstrate the feasibility of monitoring functional outcomes in a in a multidisciplinary, communitybased program for multiply maltreated children through the use of a simple but widely used functional outcome measure supported through an academic-community partnership implemented in São Paulo, Brazil. It also attempted to assess the magnitude of improvement 3 and 6 months after program entry; to identify baseline predictors of improvement in outcomes to support further development of effective treatment interventions; and to provide empirical data to policymakers, program implementers, and potential funders.
Method Program description The Equilibrium Program (TEP; Scivoletto et al., 2011) was developed and implemented through a partnership between academic psychiatrists from the University of São Paulo; the São Paulo city government; and children and adolescents living on the streets of the city, in group shelters, or who were referred from child protective services serving the largest city in Brazil. TEP seeks to integrate diverse professional services in an accessible community setting (e.g., a community athletic club) to meet the multiple needs of this marginalized population. Program development was guided by principals recently articulated by Ungar (2013) as emphasizing acceptability to consumers, flexibility in addressing diverse client needs, and placing a focus on high-risk subpopulations within a supportive environment. During a four-week diagnostic phase, assessments include general clinical evaluation to identify psychiatric, medical, or nutritional problems and specialized evaluations performed by neuropsychologists, occupational therapists, art therapists, social workers, educational therapists, and speech therapists to address unique problems and potential strengths of each participant. Psychiatric diagnoses are made through clinical interviews conducted by certified child and adolescent psychiatrists and later discussed with the psychiatrist coordinator of the program (Scivoletto et al., 2011). After these initial assessments, an individualized intervention plan, designed to address the specific needs of each child in each specialty area, was developed. These plans typically include psychiatric treatment, individual and group psychotherapy, art and speech therapy, school support, and recreational activity (e.g., theater, music, or athletic activities), all of which are integrated within the community center to create a flexible and accepting social environment (Ungar, 2013). A primary case manager was also assigned to foster coordination and continuity of care among these diverse providers from the time of the initial contact in group shelters to the point of full family reintegration or placement outside the family. Frequent treatment team meetings allow changes in treatment emphases to meet the evolving needs of each participant. Please cite this article in press as: Stefanovics, E. A., et al. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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Study subjects. All children who were admitted had judged to have been abused or neglected either by evaluating admission professionals or by the child protective services. They were recruited from September 2007 to August 2012. Criteria for admission were: (a) living in a socially vulnerable, high-risk situation, as determined either clinically or by the child protective services; and (b) no longer living in the streets (i.e., living in a group shelter, with their original family, or with a foster family). Exclusion criteria included: (a) children or adolescents from locations other than São Paulo and (b) age greater than 19 years at first assessment; and (c) refusal of all healthcare assessments or services. The lifetime prevalence of psychiatric disorder among the children and adolescents evaluated in TEP was approximately 86% (Silva, Cunha, & Scivoletto, 2010). Those children who were not diagnosed with a mental disorder in their initial assessment were also offered psychosocial interventions because most had a history of serious maltreatment of multiple types, and many had to be separated from their parents by child protective services. A total of 452 patients were admitted and evaluated at entry during the study period. Of these patients, 230 were successfully followed-up and assessed 3 and/or 6 months after admission. The remaining 222 subjects either stopped attending the program or declined to participate in follow-up assessments. All participants and their legal guardians provided written informed consent. For children living in group shelters, the shelter coordinator had legal responsibility and provided consent. The IRB of the Hospital das Clinicas in São Paulo approved the study as did the research ethics committee, of the Medicine School, University of São Paulo. Measures The variables used for analysis included age, gender, psychiatric diagnosis, residence at the time of treatment referral (i.e., living with family or in a group shelters), and documented social stressors. Social stressor data were collected at the first assessment and classified according to the parameters listed in the Z code of the 10th International Classification of Diseases (ICD-10, Second Edition, WHO, 2004). Social stressors were grouped in eight dichotomous categories: Physical abuse (z61.6)—any child injured by an adult in the household to a medically significant extent, or other form of violence; Sexual abuse (z61.4 and z61.5)—any exposure between an adult and the child that has led to sexual arousal, independent of the willingness of the child; Negative life events in childhood (z61.0, z61.1, z61.2, z61.3, z61.7 z61.8, z61.9)—events such as loss of a love relationship, removal from the home, having an altered pattern of family relationships in childhood; or events that resulted in loss of self-esteem or that were very frightening; Problems related to upbringing (z62)—physical and emotional neglect with inadequate parental supervision or requiring institutional upbringing; Problems related to the child’s primary support group (z63)—discord between partners resulting in severe interpersonal violence, problems in relationships with parents, or disruptions of family life; Psychosocial problems (z64)—unwanted pregnancy, seeking and accepting interventions known to be hazardous and harmful; Criminal involvement (z65)—criminal proceedings w/or without imprisonment or other legal problems and including being the victim of crime, terrorism or war; and Family history of mental and behavioral disorders (z81)—family history of psychiatric conditions. Baseline psychiatric diagnoses were assessed with Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-PL), a semi-structured diagnostic interview (Kaufman et al., 1997) to assess current and past episodes of psychopathology in children and adolescents based on DSM-IV criteria. The Brazilian version of the K-SADS-PL (in Portuguese) was developed by Brasil and Bordin from the original English version. Its development included translation, back-translation, cultural adaptation, and a study of psychometric properties (Brasil, 2003). Diagnoses were clustered in 13 categories based on the International Code System (ICD 10) which included: substance use (F10–F19); schizophrenia and schizoaffective disorder (F20, F25); other psychotic disorder (F21–F24 and F26–F29); bipolar disorder (F30, F31); depressive disorders (F32–39); anxiety disorders (F40–F48); eating disorders (F50); habit and impulse disorders (F63); mental retardation (F70–F79); disorders of psychological development (F80–F89); ADHD disorder (F90); conduct disorder (F91); and a category reflecting other disorders of early childhood (F92–F99). The functional outcome measure was the Children’s Global Assessment Scale (C-GAS; Shaffer et al., 1983). This tool is commonly used by mental health clinicians to rate the general functioning of children under the age of 18. The scale ranges from 1 (needs constant supervision) to 100 (superior functioning). Scores above 70 are considering as near normal functioning. Statistical analysis First, the frequency and percentages were calculated for all categorical variables (i.e., demographics, social and psychiatric diagnoses) and were used to compare those who completed followed up at either 3 or 6 months to those for whom no Please cite this article in press as: Stefanovics, E. A., et al. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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follow up occurred. Bivariate chi-square tests and then logistic regression were used to identify characteristics that were independently different between these groups. Next, the CGAS ratings were used as the dependant variable in a hierarchical linear model (Bryk & Raudenbush, 1992) that was used to identify the change in CGAS from baseline to 3 and 6 months, using all available data in a single analysis. Each participant could have an observation for baseline, and for 3 and or 6 months, representing their functional status at that assessment. A random effect was included in a mixed linear model to adjust for the correlatedness between observations from the same child at different times. Baseline values of the dependent variable (the C-GAS) were included to account for regression to the mean (i.e., the likelihood that lower functioning subjects would show the most improvement). Dichotomous independent variables represented 3- and 6-month outcome observations (with the baseline observation as the reference condition) were included in the model along with measures of sociodemographic characteristics, clinical diagnoses, and social stress indicators. Thus, the analysis included in all 599 observations the 230 subjects for whom data were available at baseline and one or both follow-up assessments. A stepwise procedure was used to identify independent predictors of change in functional status. Data for the present study were de-identified for analysis. Data management and statistical analysis were performed using SAS 9.1 statistical software (SAS institute, Cary, NC). PROC MIXED was used for the mixed linear model regression analysis (Bryk & Raudenbush, 1992). Statistical significance was evaluated at the .05 level. Results The total sample includes 452 children/adolescents. The majority of the sample were bosy (n = 295; 65.3%) were boys. The mean age of participants was 12 years (SD = 3.45). The most common psychiatric diagnoses were major depression (33.8%), substance abuse (31.9%), ADHD (20.8%), conduct disorder (15.9%), anxiety disorder (11.9%), Mental retardation (Intellectual disability; 11.7%), and developmental disorder (5.7%). The most common social problems were negative life events (i.e., loss of a love relationship, removal from the home, having an altered pattern of family relationships in childhood; 95.3%);problems related to upbringing (84.1%), a family history of mental illness (57.5%), physical abuse (32.5%), sexual abuse (15.7%), and criminal involvement (11.5%). Of the analytic sample, 230 (51.1%) received follow-up evaluations, (199 at 3 months and 170 at 6 months). Bivariate comparisons revealed few significant differences between the groups (Table 1) although the group that was successfully followed-up was slightly younger (11.5 vs. 12.3 years, p = .01); had higher C-GAS baseline score (51.7 vs. 47.6, p = .0002); had higher prevalence of developmental disorder (19 (8.3%) vs. 7 (3.1%), p = .02) and a lower prevalence of substance abuse disorder (59 (25.6%) vs. 77 (34.7%), p = .04). They also had higher prevalence of physical abuse (87(37.8%) vs. 60 (27.03%), p = .01) and were more likely to have a family history of mental illness (149 (64.8%) vs. 112 (50.4%), p = .002). Other measures did not show any significant differences between two groups. Logistic regression showed those successfully followed up had slightly higher functioning (C-GAS score B = .02, p < .01), and were less likely to have a history of physical abuse (B = 46, p < .03). With a baseline C-GAS score of 51.7 (SD = 14.22), hierarchical linear modeling showed average improvement of 2.8 at 3 months and 5.5 at 6 months, which reflects small to moderate effect sizes of .20 and .39, respectively. Improvement was positively associated with problems related to upbringing (p < .02) and negatively with physical abuse (p < .05) and negative life events in childhood (p < .05), but improved functioning was not associated with any socio-demographic characteristic or psychiatric diagnosis. Discussion This study is the first, to our knowledge, to demonstrate the feasibility of implementing outcomes monitoring with limited resources in a community-based program for multiply-maltreated youth in a multidisciplinary program operating in a large city in a LMIC. The choice of a simple but widely used outcome measure supported by an academic-community partnership was crucial to this demonstration effort. Small to moderate improvements in functioning were observed at both 3 and 6 months. Although there was no untreated control group in this study and specific evidence-based treatments were not used, it is notable and encouraging that making services available from a multidisciplinary team in a safe supportive environment was associated with significant improvement, albeit with small to moderate effect size. The observational nature of the data and the absence of a comparison group precluded causal conclusions of program effectiveness. Only half of the subjects had successful outcome assessment, which likely reflects the stigma the participants experienced in thinking of themselves as patients or as people in need of help. The major impetus for their help-seeking often came from their families, shelter staff, or from the court services. Although no psychiatric diagnoses were associated with improvement in functioning, three social diagnoses were significantly associated with outcome, a finding also reported by studies conducted in the developed world (Shipman & Taussig, 2009). The indicator of baseline Problems related to upbringing was a positive predictor of functional improvement, perhaps because these problems are related to active neglect, which may be especially responsive to changes in the supportive Please cite this article in press as: Stefanovics, E. A., et al. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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Table 1 Comparison between groups with follow-up and no follow-up in TEP. Variables
x2 /F
P
3.24
0.07
6.66 9.46
0.01 0.002
6 (2.6 41 (17.8) 56 (24.3) 35 (15.2) 59 (25.6) 76 (33.04) 33 (14.3) 19 (8.3) 21 (9.13) 13 (5.6) 1 (0.4) 1 (0.4) 1 (0.4) 179 (77.8)
2.31 0.61 3.58 0.18 4.38 0.13 2.57 5.44 3.05 3.41 0.97 0.0006 0.37 0.96
0.13 0.43 0.06 0.67 0.04 0.71 0.11 0.02 0.08 0.06 0.32 0.98 0.54 0.33
38 (16.5) 87 (37.8) 221 (96.1) 196 (85.2) 9 (3.9) 25 (10.9) 149 (64.8) 60 (26.1) 230 (100)
0.23 6 0.57 0.45 0.92 0.18 9.5 1.51 2.08
0.62 0.01 0.45 0.5 0.34 0.67 0.002 0.22 0.15
Patients who has no follow-up n = 222 (49.1%) N(mean)/%(STD)
Patients who has follow-up n = 230 (50.9%) N(mean)/%(STD)
Demographics Male Female Age (years) GAS baseline
154 (69.4) 68 (30.6) 12.3 (3.54) 47.6 (13.79)
141 (61.3) 89 (38.7) 11.47 (3.28) 51.7 (14.22)
Psychiatric diagnoses Bipolar Specific disorder of early childhood ADHD Conduct disorder Substance abuse Depressive disorder Anxiety disorder Developmental disorder Intellectual disability Impulse control disorder Eating disorder Schizophrenia Other psychotic diagnoses Any psychiatric diagnoses
12 (5.4) 46 (20.7) 38 (17.1) 37 (16.7) 77 (34.7) 77 (34.7) 21 (9.5) 7 (3.1) 32 (14.4) 5 (2.2) 0 (0) 1 (0.45) 2 (0.9) 181 (81.5)
Social diagnoses Sexual abuse Physical abuse Negative events Problems related to upbringing Psychosocial problems (including pregnancy) Criminal involvement Family history of mental illness Other social problems Any social problems
33 (14.9) 60 (27.03) 210 (94.6) 184 (82.9) 13 (5.9) 27 (12.2) 112 (50.4) 47 (21.2) 220 (99.1)
psychosocial environment offered by the program. On the other hand, physical abuse and negative life events in childhood were predictors of negative outcomes, suggesting that these specific social diagnoses are less amenable to environmental intervention. Several evidence-based interventions have been identified for physical abuse or traumas among children and youth (Kolko & Swenson, 2002; Runyon, Deblinger, Ryan, & Thakkar-Kolar, 2004; Shipman & Taussig, 2009). Abuse-focused cognitive behavioral therapy (AF-CBT; Kolko & Swenson, 2002), for example, is a short-term intervention that has been shown to reduce child-to-caregiver violence. Additionally, a program of psychoeducation and family cognitive behavioral training has been shown to improve family functioning—both in U.S. contexts (Kolko, 1996). Although manual guided therapies were not offered at TEP, the accessibility of a coordinated multidisciplinary team operating in a safe and supportive environment is most consistent with the principals embodied in the literature on assisting maltreated children and adolescents in resilienceenhancing social environments (Ungar, 2013).
Limitations The primary limitation of this study is a lack of an equivalent comparison group which received no services or a different array of services. Such a comparison group would be needed to conclude that the observed improvements were attributable to TEP, but it would not have been ethical to deny treatment to any participants. It is possible, if not likely, that other non-TEP related factors, such as regression to the mean, contributed to the observed improvements. In addition, detailed information on the specific multidisciplinary services delivered to each participant is not available. Such data might allow us to identify specific treatment elements associated with functional improvement. In addition, a substantial number of participants lacked follow-up data, limiting generalizability. However, baseline comparisons showed few differences between participants with and without follow-up data. The fact the outcome ratings were made by professionals who work at TEP and are involved with the delivery of services may also bias the C-GAS assessments in a positive direction, although they were unaware of the baseline ratings at the time of follow-up assessment. Future studies are needed to confirm and expand on these findings and to further demonstrate the feasibility and practical value of this approach. Please cite this article in press as: Stefanovics, E. A., et al. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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Conclusion In spite of these limitations, this study demonstrates the feasibility of real-world outcome evaluation in community based program for maltreated children and adolescents in Brazil, and revealed modest improvements in functional outcome scores for these maltreated children and adolescents after 3–6 months of program participation. Additional research and empirical evidence of the effectiveness of specific interventions are needed to improve services for maltreated children in LMICs. Given the importance of environmental and social context for child health and social development, there is also a need for basic studies that will assess the effectiveness of intervention programs over longer periods of time and in the present of informative comparison groups. Conflict of interest The authors report no financial interests or potential conflict of interest. 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Contents lists available at ScienceDirect
Child Abuse & Neglect
Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors Elina A. Stefanovics a,c,∗ , Mauro V.M. Filho b , Robert A. Rosenheck a,c , Sandra Scivoletto b a
Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA The Equilibrim Program (TEP), Department and Institute of Psychiatry, Medicine School, University of São Paulo (USP), R.Ovidio Campos Pieres Campos, 785, São Paulo, Brazil c VA New England Mental Illness Research, Education and Clinical Center, Connecticut Healthcare System, West Haven, CT, USA b
a r t i c l e
i n f o
Article history: Received 9 July 2013 Received in revised form 24 October 2013 Accepted 30 October 2013 Available online xxx
Keywords: Maltreated children Mental health Program evaluation system care
a b s t r a c t This study sought to implement outcomes monitoring and to review outcome data from a community-based rehabilitation program for maltreated children and adolescents in São Paulo, Brazil. Maltreated children and adolescents (N = 452) were enrolled in The Equilibrium Program (TEP), a multidisciplinary community-based rehabilitation program. About half (n = 230) of the participants were successfully evaluated using the Children’s Global Assessment Scale (C-GAS) at entry, 3, and/or 6 months later. Analysis of outcomes used hierarchical linear modeling of functional change from baseline. With a baseline C-GAS score of 51.7 (SD = 14.22), average improvement was 2.8 and 5.5 points at 3 and 6 months, respectively (reflecting small to moderate effect sizes = 0.20 and 0.39). Improvement was associated with Problems related to upbringing (p < .02) at entry and absence of Physical abuse (p < .05) and Negative life events in childhood (p < .05) but was not associated with sociodemographics or any specific psychiatric diagnosis. This study showed that outcomes monitoring is feasible in a community-based program in a developing country. Although there was no untreated control group for comparison and specific evidence-based treatments were not used, it is notable that significant improvement, with small to moderate effect size, was observed. Published by Elsevier Ltd.
Introduction ˜ Child maltreatment is a global public health and social problem (Sadowski, Hunter, Bangdiwala, & Munoz, 2004) affecting both high and low/middle income countries (LMICs; Runyan et al., 2010). It is a general term used to describe all non-mutually exclusive forms of child abuse and neglect, including physical abuse, sexual abuse, emotional/psychological abuse, neglect, and other acts of commission or omission by a parent or other caregiver that result in harm, potential for harm, or threat of harm to a child (Leeb, Paulozzi, Melanson, Simon, & Arias, 2008). Maltreated children may experience a variety of behavioral problems, including anxiety disorders, post-traumatic stress disorder (PTSD; Gilbert et al., 2009), depression (Maciel et al., 2013), substance abuse (de Carvalho et al., 2006; Forster, Tannhauser, & Barros, 1996), risk for HIV infection (Inciardi & Surratt, 1998), low self-esteem, poor social skills and
∗ Corresponding author address: VA New England Mental Illness, Research, Education and Clinical Center, VA Connecticut Healthcare System (116A-4), 950 Campbell Avenue, Building 36, West Haven, CT 06516, USA. 0145-2134/$ – see front matter. Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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psychological functioning (Kaplow & Widom, 2007), and antisocial behavior. If not recognized and treated, these problems may worsen through adolescence and pose long-term adverse effects on the capacity to form adult relationships, vocational performance, and subjective well being. It may also inflict problems for society, resulting in crime, poverty, drug abuse, and increased health care costs. Studies have specifically demonstrated a high prevalence of child maltreatment in Brazil (Scivoletto, Silva, & Rosenheck, 2011; Tucci, Kerr-Corrêa, & Souza-Formigoni, 2010). There has been considerable interest in both identifying maltreated children, especially those who live, work, or spend most of their time on the street (Hutz & Koller, 1999; Martins, 1996; Neiva-Silva & Koller, 2002) and treating them with evidence based practices (Chaffin & Friedrich, 2004; Cohen & Mannarino, 1998; Cohen & Mannarino, 2000; Shipman & Taussig, 2009). Although most street children (68%) spend a majority of their time in the street, many of them maintain contact with their families (Forster et al., 1996; Raffaelli et al., 1993). In spite of the fact that many children in Brazil and elsewhere are victims of multiple forms of maltreatment (Edwards, Holden, Felitti, & Anda, 2003; Nguyen, Dunne, & Le, 2010), most studies of evidence based practices have examined trauma focused cognitive behavioral psychotherapies for one or another type of abuse but not for multiply maltreated youth. Interventions have also been developed to prevent abuse and neglect, to help abusive parents curtail their abusive behavior, and to serve children in foster care (Chaffin & Friedrich, 2004). Also, the healing role of supportive social environments has been highlighted but research has focused on single types of maltreatment (Ungar, 2013). In LMICs, as far as we know, there have been no outcome studies from real-world community-based programs working with children who suffered from multiple forms of maltreatment, most likely because of limited technical and analytic expertise in program evaluation and because of limited personnel to collect data. Published outcome studies have focused their attention on the analysis of certain singular traumata, such as exposure to sexual abuse (Cohen & Mannarino, 1998; Cohen & Mannarino, 2000), sexually transmitted infections and HIV (Aral & Ward, 2005; Avila et al., 1996; de Carvalho et al., 2006; Fallah, Azimi, & Taherkhani, 2007; Kissin et al., 2007), substance use (de Carvalho et al., 2006; Elkoussi & Bakheet, 2011; Huang, Barreda, Mendoza, Guzman, & Gilbert, 2004; Nada & Suliman el, 2010; Njord, Merrill, Njord, Lindsay, & Pachano, 2010; Obando, Kliewer, Murrelle, & Svikis, 2004; Olgar et al., 2008; Owoaje & Uchendu, 2009), violence (Agnihotri, 2001; Nada & Suliman el, 2010; Sherman, Plitt, ul Hassan, Cheng, & Zafar, 2005), or nutritional deprivation and poor growth status (D’Abreu, Mullis, & Cook, 1999; Greksa, Rie, Islam, Maki, & Omori, 2007; Worthman & Panter-Brick, 2008). No study, to our knowledge, has focused on children and youth exposed to multiple forms of maltreatment or has investigated functional outcomes, their predictors, and the effectiveness of a bundled psychosocial intervention in real-world clinical settings in LMICs. This study sought to demonstrate the feasibility of monitoring functional outcomes in a in a multidisciplinary, communitybased program for multiply maltreated children through the use of a simple but widely used functional outcome measure supported through an academic-community partnership implemented in São Paulo, Brazil. It also attempted to assess the magnitude of improvement 3 and 6 months after program entry; to identify baseline predictors of improvement in outcomes to support further development of effective treatment interventions; and to provide empirical data to policymakers, program implementers, and potential funders.
Method Program description The Equilibrium Program (TEP; Scivoletto et al., 2011) was developed and implemented through a partnership between academic psychiatrists from the University of São Paulo; the São Paulo city government; and children and adolescents living on the streets of the city, in group shelters, or who were referred from child protective services serving the largest city in Brazil. TEP seeks to integrate diverse professional services in an accessible community setting (e.g., a community athletic club) to meet the multiple needs of this marginalized population. Program development was guided by principals recently articulated by Ungar (2013) as emphasizing acceptability to consumers, flexibility in addressing diverse client needs, and placing a focus on high-risk subpopulations within a supportive environment. During a four-week diagnostic phase, assessments include general clinical evaluation to identify psychiatric, medical, or nutritional problems and specialized evaluations performed by neuropsychologists, occupational therapists, art therapists, social workers, educational therapists, and speech therapists to address unique problems and potential strengths of each participant. Psychiatric diagnoses are made through clinical interviews conducted by certified child and adolescent psychiatrists and later discussed with the psychiatrist coordinator of the program (Scivoletto et al., 2011). After these initial assessments, an individualized intervention plan, designed to address the specific needs of each child in each specialty area, was developed. These plans typically include psychiatric treatment, individual and group psychotherapy, art and speech therapy, school support, and recreational activity (e.g., theater, music, or athletic activities), all of which are integrated within the community center to create a flexible and accepting social environment (Ungar, 2013). A primary case manager was also assigned to foster coordination and continuity of care among these diverse providers from the time of the initial contact in group shelters to the point of full family reintegration or placement outside the family. Frequent treatment team meetings allow changes in treatment emphases to meet the evolving needs of each participant. Please cite this article in press as: Stefanovics, E. A., et al. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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Study subjects. All children who were admitted had judged to have been abused or neglected either by evaluating admission professionals or by the child protective services. They were recruited from September 2007 to August 2012. Criteria for admission were: (a) living in a socially vulnerable, high-risk situation, as determined either clinically or by the child protective services; and (b) no longer living in the streets (i.e., living in a group shelter, with their original family, or with a foster family). Exclusion criteria included: (a) children or adolescents from locations other than São Paulo and (b) age greater than 19 years at first assessment; and (c) refusal of all healthcare assessments or services. The lifetime prevalence of psychiatric disorder among the children and adolescents evaluated in TEP was approximately 86% (Silva, Cunha, & Scivoletto, 2010). Those children who were not diagnosed with a mental disorder in their initial assessment were also offered psychosocial interventions because most had a history of serious maltreatment of multiple types, and many had to be separated from their parents by child protective services. A total of 452 patients were admitted and evaluated at entry during the study period. Of these patients, 230 were successfully followed-up and assessed 3 and/or 6 months after admission. The remaining 222 subjects either stopped attending the program or declined to participate in follow-up assessments. All participants and their legal guardians provided written informed consent. For children living in group shelters, the shelter coordinator had legal responsibility and provided consent. The IRB of the Hospital das Clinicas in São Paulo approved the study as did the research ethics committee, of the Medicine School, University of São Paulo. Measures The variables used for analysis included age, gender, psychiatric diagnosis, residence at the time of treatment referral (i.e., living with family or in a group shelters), and documented social stressors. Social stressor data were collected at the first assessment and classified according to the parameters listed in the Z code of the 10th International Classification of Diseases (ICD-10, Second Edition, WHO, 2004). Social stressors were grouped in eight dichotomous categories: Physical abuse (z61.6)—any child injured by an adult in the household to a medically significant extent, or other form of violence; Sexual abuse (z61.4 and z61.5)—any exposure between an adult and the child that has led to sexual arousal, independent of the willingness of the child; Negative life events in childhood (z61.0, z61.1, z61.2, z61.3, z61.7 z61.8, z61.9)—events such as loss of a love relationship, removal from the home, having an altered pattern of family relationships in childhood; or events that resulted in loss of self-esteem or that were very frightening; Problems related to upbringing (z62)—physical and emotional neglect with inadequate parental supervision or requiring institutional upbringing; Problems related to the child’s primary support group (z63)—discord between partners resulting in severe interpersonal violence, problems in relationships with parents, or disruptions of family life; Psychosocial problems (z64)—unwanted pregnancy, seeking and accepting interventions known to be hazardous and harmful; Criminal involvement (z65)—criminal proceedings w/or without imprisonment or other legal problems and including being the victim of crime, terrorism or war; and Family history of mental and behavioral disorders (z81)—family history of psychiatric conditions. Baseline psychiatric diagnoses were assessed with Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-PL), a semi-structured diagnostic interview (Kaufman et al., 1997) to assess current and past episodes of psychopathology in children and adolescents based on DSM-IV criteria. The Brazilian version of the K-SADS-PL (in Portuguese) was developed by Brasil and Bordin from the original English version. Its development included translation, back-translation, cultural adaptation, and a study of psychometric properties (Brasil, 2003). Diagnoses were clustered in 13 categories based on the International Code System (ICD 10) which included: substance use (F10–F19); schizophrenia and schizoaffective disorder (F20, F25); other psychotic disorder (F21–F24 and F26–F29); bipolar disorder (F30, F31); depressive disorders (F32–39); anxiety disorders (F40–F48); eating disorders (F50); habit and impulse disorders (F63); mental retardation (F70–F79); disorders of psychological development (F80–F89); ADHD disorder (F90); conduct disorder (F91); and a category reflecting other disorders of early childhood (F92–F99). The functional outcome measure was the Children’s Global Assessment Scale (C-GAS; Shaffer et al., 1983). This tool is commonly used by mental health clinicians to rate the general functioning of children under the age of 18. The scale ranges from 1 (needs constant supervision) to 100 (superior functioning). Scores above 70 are considering as near normal functioning. Statistical analysis First, the frequency and percentages were calculated for all categorical variables (i.e., demographics, social and psychiatric diagnoses) and were used to compare those who completed followed up at either 3 or 6 months to those for whom no Please cite this article in press as: Stefanovics, E. A., et al. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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follow up occurred. Bivariate chi-square tests and then logistic regression were used to identify characteristics that were independently different between these groups. Next, the CGAS ratings were used as the dependant variable in a hierarchical linear model (Bryk & Raudenbush, 1992) that was used to identify the change in CGAS from baseline to 3 and 6 months, using all available data in a single analysis. Each participant could have an observation for baseline, and for 3 and or 6 months, representing their functional status at that assessment. A random effect was included in a mixed linear model to adjust for the correlatedness between observations from the same child at different times. Baseline values of the dependent variable (the C-GAS) were included to account for regression to the mean (i.e., the likelihood that lower functioning subjects would show the most improvement). Dichotomous independent variables represented 3- and 6-month outcome observations (with the baseline observation as the reference condition) were included in the model along with measures of sociodemographic characteristics, clinical diagnoses, and social stress indicators. Thus, the analysis included in all 599 observations the 230 subjects for whom data were available at baseline and one or both follow-up assessments. A stepwise procedure was used to identify independent predictors of change in functional status. Data for the present study were de-identified for analysis. Data management and statistical analysis were performed using SAS 9.1 statistical software (SAS institute, Cary, NC). PROC MIXED was used for the mixed linear model regression analysis (Bryk & Raudenbush, 1992). Statistical significance was evaluated at the .05 level. Results The total sample includes 452 children/adolescents. The majority of the sample were bosy (n = 295; 65.3%) were boys. The mean age of participants was 12 years (SD = 3.45). The most common psychiatric diagnoses were major depression (33.8%), substance abuse (31.9%), ADHD (20.8%), conduct disorder (15.9%), anxiety disorder (11.9%), Mental retardation (Intellectual disability; 11.7%), and developmental disorder (5.7%). The most common social problems were negative life events (i.e., loss of a love relationship, removal from the home, having an altered pattern of family relationships in childhood; 95.3%);problems related to upbringing (84.1%), a family history of mental illness (57.5%), physical abuse (32.5%), sexual abuse (15.7%), and criminal involvement (11.5%). Of the analytic sample, 230 (51.1%) received follow-up evaluations, (199 at 3 months and 170 at 6 months). Bivariate comparisons revealed few significant differences between the groups (Table 1) although the group that was successfully followed-up was slightly younger (11.5 vs. 12.3 years, p = .01); had higher C-GAS baseline score (51.7 vs. 47.6, p = .0002); had higher prevalence of developmental disorder (19 (8.3%) vs. 7 (3.1%), p = .02) and a lower prevalence of substance abuse disorder (59 (25.6%) vs. 77 (34.7%), p = .04). They also had higher prevalence of physical abuse (87(37.8%) vs. 60 (27.03%), p = .01) and were more likely to have a family history of mental illness (149 (64.8%) vs. 112 (50.4%), p = .002). Other measures did not show any significant differences between two groups. Logistic regression showed those successfully followed up had slightly higher functioning (C-GAS score B = .02, p < .01), and were less likely to have a history of physical abuse (B = 46, p < .03). With a baseline C-GAS score of 51.7 (SD = 14.22), hierarchical linear modeling showed average improvement of 2.8 at 3 months and 5.5 at 6 months, which reflects small to moderate effect sizes of .20 and .39, respectively. Improvement was positively associated with problems related to upbringing (p < .02) and negatively with physical abuse (p < .05) and negative life events in childhood (p < .05), but improved functioning was not associated with any socio-demographic characteristic or psychiatric diagnosis. Discussion This study is the first, to our knowledge, to demonstrate the feasibility of implementing outcomes monitoring with limited resources in a community-based program for multiply-maltreated youth in a multidisciplinary program operating in a large city in a LMIC. The choice of a simple but widely used outcome measure supported by an academic-community partnership was crucial to this demonstration effort. Small to moderate improvements in functioning were observed at both 3 and 6 months. Although there was no untreated control group in this study and specific evidence-based treatments were not used, it is notable and encouraging that making services available from a multidisciplinary team in a safe supportive environment was associated with significant improvement, albeit with small to moderate effect size. The observational nature of the data and the absence of a comparison group precluded causal conclusions of program effectiveness. Only half of the subjects had successful outcome assessment, which likely reflects the stigma the participants experienced in thinking of themselves as patients or as people in need of help. The major impetus for their help-seeking often came from their families, shelter staff, or from the court services. Although no psychiatric diagnoses were associated with improvement in functioning, three social diagnoses were significantly associated with outcome, a finding also reported by studies conducted in the developed world (Shipman & Taussig, 2009). The indicator of baseline Problems related to upbringing was a positive predictor of functional improvement, perhaps because these problems are related to active neglect, which may be especially responsive to changes in the supportive Please cite this article in press as: Stefanovics, E. A., et al. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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Table 1 Comparison between groups with follow-up and no follow-up in TEP. Variables
x2 /F
P
3.24
0.07
6.66 9.46
0.01 0.002
6 (2.6 41 (17.8) 56 (24.3) 35 (15.2) 59 (25.6) 76 (33.04) 33 (14.3) 19 (8.3) 21 (9.13) 13 (5.6) 1 (0.4) 1 (0.4) 1 (0.4) 179 (77.8)
2.31 0.61 3.58 0.18 4.38 0.13 2.57 5.44 3.05 3.41 0.97 0.0006 0.37 0.96
0.13 0.43 0.06 0.67 0.04 0.71 0.11 0.02 0.08 0.06 0.32 0.98 0.54 0.33
38 (16.5) 87 (37.8) 221 (96.1) 196 (85.2) 9 (3.9) 25 (10.9) 149 (64.8) 60 (26.1) 230 (100)
0.23 6 0.57 0.45 0.92 0.18 9.5 1.51 2.08
0.62 0.01 0.45 0.5 0.34 0.67 0.002 0.22 0.15
Patients who has no follow-up n = 222 (49.1%) N(mean)/%(STD)
Patients who has follow-up n = 230 (50.9%) N(mean)/%(STD)
Demographics Male Female Age (years) GAS baseline
154 (69.4) 68 (30.6) 12.3 (3.54) 47.6 (13.79)
141 (61.3) 89 (38.7) 11.47 (3.28) 51.7 (14.22)
Psychiatric diagnoses Bipolar Specific disorder of early childhood ADHD Conduct disorder Substance abuse Depressive disorder Anxiety disorder Developmental disorder Intellectual disability Impulse control disorder Eating disorder Schizophrenia Other psychotic diagnoses Any psychiatric diagnoses
12 (5.4) 46 (20.7) 38 (17.1) 37 (16.7) 77 (34.7) 77 (34.7) 21 (9.5) 7 (3.1) 32 (14.4) 5 (2.2) 0 (0) 1 (0.45) 2 (0.9) 181 (81.5)
Social diagnoses Sexual abuse Physical abuse Negative events Problems related to upbringing Psychosocial problems (including pregnancy) Criminal involvement Family history of mental illness Other social problems Any social problems
33 (14.9) 60 (27.03) 210 (94.6) 184 (82.9) 13 (5.9) 27 (12.2) 112 (50.4) 47 (21.2) 220 (99.1)
psychosocial environment offered by the program. On the other hand, physical abuse and negative life events in childhood were predictors of negative outcomes, suggesting that these specific social diagnoses are less amenable to environmental intervention. Several evidence-based interventions have been identified for physical abuse or traumas among children and youth (Kolko & Swenson, 2002; Runyon, Deblinger, Ryan, & Thakkar-Kolar, 2004; Shipman & Taussig, 2009). Abuse-focused cognitive behavioral therapy (AF-CBT; Kolko & Swenson, 2002), for example, is a short-term intervention that has been shown to reduce child-to-caregiver violence. Additionally, a program of psychoeducation and family cognitive behavioral training has been shown to improve family functioning—both in U.S. contexts (Kolko, 1996). Although manual guided therapies were not offered at TEP, the accessibility of a coordinated multidisciplinary team operating in a safe and supportive environment is most consistent with the principals embodied in the literature on assisting maltreated children and adolescents in resilienceenhancing social environments (Ungar, 2013).
Limitations The primary limitation of this study is a lack of an equivalent comparison group which received no services or a different array of services. Such a comparison group would be needed to conclude that the observed improvements were attributable to TEP, but it would not have been ethical to deny treatment to any participants. It is possible, if not likely, that other non-TEP related factors, such as regression to the mean, contributed to the observed improvements. In addition, detailed information on the specific multidisciplinary services delivered to each participant is not available. Such data might allow us to identify specific treatment elements associated with functional improvement. In addition, a substantial number of participants lacked follow-up data, limiting generalizability. However, baseline comparisons showed few differences between participants with and without follow-up data. The fact the outcome ratings were made by professionals who work at TEP and are involved with the delivery of services may also bias the C-GAS assessments in a positive direction, although they were unaware of the baseline ratings at the time of follow-up assessment. Future studies are needed to confirm and expand on these findings and to further demonstrate the feasibility and practical value of this approach. Please cite this article in press as: Stefanovics, E. A., et al. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: Six-month improvement and baseline predictors. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.025
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Conclusion In spite of these limitations, this study demonstrates the feasibility of real-world outcome evaluation in community based program for maltreated children and adolescents in Brazil, and revealed modest improvements in functional outcome scores for these maltreated children and adolescents after 3–6 months of program participation. Additional research and empirical evidence of the effectiveness of specific interventions are needed to improve services for maltreated children in LMICs. Given the importance of environmental and social context for child health and social development, there is also a need for basic studies that will assess the effectiveness of intervention programs over longer periods of time and in the present of informative comparison groups. Conflict of interest The authors report no financial interests or potential conflict of interest. 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