Print version ISSN 0101-8108
Rev. psiquiatr. Rio Gd. Sul vol.29 no.3 Porto Alegre Sept./Dec. 2007
Josiane Lieberknecht WathierI; Débora Dalbosco Dell'AglioII
IMsc. student, Graduate Program in
Psychology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre,
IIPhD in Developmental Psychology, UFRGS. Professor, Graduate Program in Psychology, Instituto de Psicologia, UFRGS, Porto Alegre, Brazil
INTRODUCTION: The present study examined
the manifestation of depressive symptoms, as well as frequency and impact of
stressful events in institutionalized and non-institutionalized children and
METHOD: A total of 257 youths, of both genders, aged 7-16 years were included in this study. Of these, 130 lived in protection youth shelters and 127 lived with their families in the metropolitan area of Porto Alegre. All participants were attending 1st to 8th grades of public elementary schools located in low-income neighborhoods. Children's Depression Inventory and Stressful Events in Childhood and Adolescence Inventory were used.
RESULTS: Data pointed out a significant difference, with higher means in the Children's Depression Inventory and Stressful Events in Childhood and Adolescence Inventory for the institutionalized group. The most frequent events for the family group was "to have to obey your parent's rules," and "to be taken to a protection shelter" was most frequent for the other group. The events of greater impact were "death of one parent," "to be raped," "to be rejected by members of the family," and "to be sexually touched against one's will". Considering the participant's gender and context, differences were found in attributed impact. Adolescents, regardless of context, had a higher frequency of significant events than children, which did not occur concerning impact.
CONCLUSION: Results indicated that institutionalized youths were more exposed to potential risk situations, which could be related to the manifestation of more depressive symptoms. However, assessment of the impact of a stressful event was not correlated with the Children's Depression Inventory in any context.
Keywords: Children, adolescents, depressive symptoms, stressful events.
Depression in children and adolescents has been well investigated, since it affects many areas in the life of youths, causing significant psychosocial damages.1,2 Researches investigating depression in youths who experienced stressful events, such as violence, abandonment and losses, stand out.3-7 However, there are few specific studies including the population of children and adolescents living in protection shelters in Brazil, when compared to youths in the hospital or school setting, for example.
The term depression has been used in a variety of meanings, ranging from a normal affective status, presentation of symptoms, until characterization of a syndrome and specific disease.8 In clinical approach to depression, studies have demonstrated particularities of depressive symptoms in children and adolescents.2,9,10 Depression in childhood and adolescence can start with loss of interest in activities that would normally be attractive, being manifested as a type of constant bad mood in relation to games and sports.
As to investigation of depression, many methods have been used, with different diagnostic criteria, instruments and type of score. Although not aimed at diagnosis, depression scales, such as Beck Depression Inventory (Cunha11) and Children's Depression Inventory (CDI) (Kovacs12) proved to be able to discriminate groups previously diagnosed with major depressive disorder, dysthymia and depressive disorder with adjustment disorder, among others. The criteria used for these studies were those of the Diagnostic and Statistical Manual of Mental Disorders, DSM-III13 and DSM-IV14 (American Psychiatric Association). However, it is possible to extend these findings to DSM-IV-TR15 criteria, since there were no significant changes about construct or criteria of symptom assessment.
Prevalence of depression diagnosis varies according to sample and study characteristics, but there is a consensus among researchers as to multiplicity of social, psychological and biological factors involving occurrence of depression as a syndrome or disorder.9,16-19 Among these factors, involved in the study of depression, it is important to consider the different developmental settings for the youths and experienced stressful events. Developmental settings of children and adolescents, whether in their families or in shelter institutions, are characterized by presence of risk and protection factors, and may represent unfavorable environments or foster development. Some families may experience negative events as a threat and not be able to establish a healthy environment of interactions in the support network, resulting in a failure in their role20,21 concerning the emotional development of their members.22,23
Stressful events, such as separation of parents, large family, history of criminality by one of the parents, parents' mental disease and low income, are cited as risk factors for depression.24-26 In a longitudinal study, Sternberg et al.7 confirmed that children who suffered any type of intrafamily violence had more behavioral problems or depressive symptoms in adolescence than those who were not victims. Also, Feijó et al.5 reported that chronic events or daily microevents can be more disturbing for mental health than acute stressful events. Thus, situations involving violence, abandonment, lack of social support, break of bonds, among others, could be potentially associated with depression, as claimed by Dell'Aglio et al.4 Other authors also report that many psychopathological symptoms could be present secondary to exposure to violent and aggressive homes.17,27,28 When families cannot play their protective role, protection measures can be used, such as sheltering, predicted by the Child and Adolescent Statute (ECA).29,30
In a Tolfree study, cited by Pinheiro,29 it was estimated that around 8 million children worldwide were living in protection shelters, and most of them were sheltered due to family violence and disintegration, as well as to adverse socioeconomic conditions. In Brazil, Silva31 stressed that, in 2003, there were 20,000 children and adolescents living in 589 shelters receiving funds from the Federal Government, and more than half of youths included in the investigation were institutionalized due to poverty. Among the institutions included in the survey, 68.3% were non-governmental. Based on these studies, it is possible to identify that chronic or acute adversities, as well the setting in which children live and their individual characteristics are some of the variables that may interfere with their development. This study aimed at identifying presence of depressive symptoms and stressful events in children and adolescents living in protection shelters, compared with those who were living with their families.
A total of 257 youths aged between 7-16 years (mean - M = 11.30; standard deviation - SD = 2.10), of both genders participated in the study. Of these, 130 lived in seven governmental and two non-governmental protection institutions, 127 lived with their families in the metropolitan area of Porto Alegre, and they were all attending elementary public schools.
Based on lists of shelters provided by the Foundation of Special Protection of Rio Grande do Sul and by the Foundation of Social Care and Citizenship (state and municipal agencies, respectively), youths belonging to the age group mentioned above and who did not have difficulties that could prevent them from understanding content of instruments were included. Such shelters are inserted in the community, in which these children and adolescents use school resources, leisure centers, squares and municipal health network. For the sample of participants living with their families (control group), two public schools were selected by convenience. They are located in districts with rate of social vulnerability lower than 0.65; the closer to zero, the more socially vulnerable the district is.32
Two standardized instruments were used, as specified below.
Children's Depression Inventory
This instrument was developed by Kovacs12 and adapted from Beck Depression Inventory for adults. The objective of CDI is to detect presence and severity of depressive disorder, identifying affective changes in children and adolescents. It is composed of 27 items, with three-option answers, of which the participant has to choose the answer that best describes his status in the current period. CDI has been adapted to be used in Brazil, in João Pessoa, by Gouveia et al.,33 and has been showing adequate psychometric characteristics. Studies in Brazilian samples had internal consistency ranging between 0.79-0.92.4,19,34 Kovacs12 recommends that the cut-off point to indicate likely psychopathology should be above 1.5 standard deviation above mean sample score.
Stressful Events in Childhood and Adolescence Inventory (IEEIA)
Adapted from the Stressful Events in Adolescence Inventory (IEEA) (Kristensen et al.35), this inventory had 60 items that identify which negative events have already occurred with the participant and what his perception as to impact of each event is. For each item, the participant has to indicate whether the event occurred (yes or no) and, based on that, score in a five-point Likert scale the impact attributed to each event of experienced fact. The instrument showed, in its original instrument, a high internal consistency (Cronbach's alpha = 0.92), but it does not have normalization studies.
Procedures and ethical considerations
This study had minimal risk to participants and was approved by the Ethics Committee of UFRGS, following the ethical principles guiding human being research (Department of Health,36 Brazilian Council of Psychology37). The parents or caretakers of children living with their families signed a consent term, and the directors of shelters that have the formal custody of youths signed the Institution Agreement Term. In addition, adolescents older than 12 years, in both settings, also signed a consent term. For those younger than 12 years, in both settings, voluntariness of participation was granted and verbal consent was obtained. The instruments were applied in schools and shelters, in previously arranged schedules, by a research team composed of psychologists and psychology students who were given previous training. In situations in which the collection team observed participants with emotional discomfort, cases were discussed with institution psychologists for proper referrals.
Data from the instruments were typed in a table of the software SPSS, version 14.0, which was used to perform descriptive and inferential analyses. Internal consistency (Cronbach's alpha) of the instruments was verified. Student's t test, chi-square and Pearson's correlation test were also performed to find differences and associations between analyzed variables.
Sociodemographic data of the sample
Of an initial sample of 297 youths that participated in the present study, those who did not answer integrally to all items, both in IEEIA and in CDI, were excluded. After that adjustment in the database, all 257 youths who had answered both instruments completely were included in the analysis.
There were 66 institutionalized girls (50.8%) and 64 institutionalized boys (49.2%) (M = 11.29 years; SD = 2.04) and 58 girls (45.7%) and 69 boys (54.3%) living with their families (M = 11.30 years; SD = 2.17). Participants belonging to protection shelters (n = 130) had institutionalization time ranging between 1-150 months (M = 33.49 months; SD = 33.38).
CDI had high internal consistency in this study (Cronbach's alpha = 0.86). General mean of the sample (n = 257) in CDI score was 11.41 (SD = 8.02). Analyses were performed considering variables group, gender and age group (children aged 7-11 years and adolescents aged 12-16 years). There were significant differences as to gender only when separated by group; institutionalized girls had higher scores than those living with their families. Similarly, data indicated a significant difference as to depression score between both groups according to age group, mean of institutionalized children and adolescents being higher than that of the other group. However, there was no significant difference between CDI means according to gender, neither according to age group in each setting. Table 1 shows means, standard deviations and Student's t test values for the CDI according to group, gender and age group.
Kovacs12 suggests that 1.5 standard deviation should be used to obtain a cut-off point using CDI and considered a cut-off point of 19 points appropriate for the CDI (27 items) applied in his sample, as well as Bahls.38 In the present study, considering 1.5 standard deviation above average (24 points) as cut-off point, 25 cases of the total sample (9.72%) could have a likely diagnosis of depression. Considering each context, six participants were observed in the family group having score ≥ 24 points (4.72%) and 19 in the institution group (14.61%). A chi-square test (χ2 = 6.07; gl = 1; p = 0.014) showed significant association between likely diagnosis of depression and the institution group. Using the cut-off point of 19 points set by Kovacs12 and Bahls,38 we found 44 cases (17.1%) in the total sample, 15 (11.8%) in the family group and 29 (22.3%) in the institution group; there was also significant association (χ2 = 4.27; gl = 1; p = 0.039) between likely diagnosis of depression in CDI and the context.
To describe IEEIA data, analyses of total scores of sample frequency and impact were performed, as well as of differences according to group, gender and age group. Internal consistency (Cronbach's alpha) of the scale in relation to frequency of events was 0.88, and 0.92 in relation to impact.
As to frequency of events, there was significant difference between group means; institutionalized youths had a higher number of events than those living with their families. As to age group, institutionalized children and adolescents had higher number of events than those in families. There was difference between genders as to number of events experienced only within respective groups, i.e., institution girls had more events than family girls. This also occurred with the boys, as can be seen in Table 2.
Comparing children and adolescents in the institution context, there was also significant difference (t = -2.21; gl = 114.97; p < 0.03), and mean of youths older than 12 years was higher than that of children in this context. A similar result occurred among participants of the family context (t = -2.95; gl = 114.97; p < 0.05), and adolescents living with their families had significantly higher mean than children in this context.
The five events with higher frequency among institutionalized youths in relation to the other group were "to be taken to a shelter" (100%), "to have to live in a shelter" (98%), "to have to obey parents' rules" (89.4%) "to change school" (81.8%) and "to argue with friends" (83.3%). In the group of participants living with their families, the most frequent events were "to have to obey parents' rules" (89.7%), "death of family members" (84.5%), "to argue with friends" (72.4%), "to have low grades at school" (67.2%) and "to have fights with siblings" (70.7%).
As to events that had higher impact, considering Likert scale between 1 (not stressful) and 5 (very stressful), there was significant difference in impact attributed to some specific events for each group, and in most of these events the highest mean was found in the family group, as can be seen in Table 3. The most significantly stressful events for the female and male gender, according to context, are specified in Table 4.
As to difference according to age group in impact, there was significantly higher mean among institutionalized adolescents in relation to the other group only in the event "one of the parents having children with other partners" (t = 2.70; gl = 16.93; p < 0.01); mean of institutionalized youths (M = 2.83; SD = 1.65) was higher than among those living with their families (M = 1.60; SD = 1.07). That same event had significantly higher mean (t = -2.23; gl = 70; p < 0.03) in sheltered children (M = 2.30; SD = 1.61), in comparison to non-sheltered (M = 2.30; SD = 1.32).
There was significant correlation (r = 0.37; p < 0.01) between CDI results and number of stressful events, showing that the higher the number of stressful events, the higher the number of depressive symptoms. There was also significant correlation between age and number of events (r = 0.27; p < 0.01). There was no significant correlation between impact of events and CDI according to context.
This study allowed us to verify depressive symptoms and number of stressful events and their impact on children and adolescents in two different development contexts. However, it should be stressed that presence of depressive symptoms was evaluated, but not in the sense of nosological diagnosis. Presence of depressive symptoms, in a level above sample mean, may suggest a possible depressive syndrome or other nosological categories that share similar characteristics and symptoms. In this case, it is advisable to have a more detailed clinical investigation to provide diagnosis and treatment.11
As to cut-off points used to identify youths with depressive symptoms in each group, it is important to stress that, considering a 1.5 standard deviation above the mean (24 points or more), the percentage found for the sample of institutionalized youths was 14.71%, and 22.3% considering a cut-off point of 19. Dell'Aglio et al.3 used 29 as cut-off point (criteria of 2 standard deviations above the mean) and indicated a percentage of 6% in their sample with likely diagnosis of depression. In turn, Reppold39 used the limit value of 28 points, considering 2 standard deviations above the mean in a sample of non-clinical adolescents, and found prevalence of depressive mood in 5.8% of participants. It is worth stressing that the lack of a consolidated Brazilian norm and application in different samples make differences in scores relative and start being hard to compare. Anyhow, percentages of likely depression found in the sample of institutionalized participants are high, although clinical assessment is still essential to diagnose depression as disorder.
As to gender, this study did not show significant difference between boys and girls as to depressive symptoms in each context. In children, such difference has not been found, as shown in studies by Kovacs,40 Kim et al. 6 and Gouveia et al., 33 as well as in Barbosa et al. 41,42 On the other hand, Dell'Aglio et al., 3 Cole et al.,43 and Reppold39 claimed having found significant difference between genders using the CDI. Some authors stressed that, in samples of youths in early adolescence, such difference as to gender is more evident (Batista et al.,16 Reppold39), indicating higher scores among girls. After 14 years old, women have a two to three times higher risk of developing an affective change than men (Reppold39). The fact of not having difference between genders in the present study allows us to infer that this instrument can measure depressive symptoms regardless of gender, which demonstrates one of its aspects of having high sensitivity to detect potentially depressive youths, as concluded by Barbosa et al.41
With regard to development context of the participants, there were higher CDI scores in youths living in protection shelters. In their study using CDI, Dell'Aglio et al.4 also found higher scores among institutionalized girls in Southern Brazil than in girls living with their families. They argued that the family that can play a more protective role helps mediate the impact of stressful events in the life of adolescents. In addition, the result found can be linked to break of family bonds and further lack of family support to mediate the impact of stressful events in the life of institutionalized adolescents. Another study that investigated manifestation of depressive symptoms using CDI in rural and urban contexts did not find significant difference between these places of residence.41
Some authors demonstrated that children and adolescents living in institutions have more chances of manifesting psychiatric disorders than those living with their families.44,45 Abreu's44 argument is that the lives of sheltered children and adolescents were marked by many adverse events, which could explain the association between institutionalization and psychiatric disorders. Institutionalization, in that researcher's study, was associated with psychiatric disorders, regardless of presence of other risk factors. According to the author, the first best associative model for psychiatric disorders included living in institution, having disappeared or deceased mother, having poor school performance and being in poor hygiene conditions. Also, Pinheiro29 and Carvalho46 claimed that aspects such as employee turnover and lack of planned activities and affective support, for example, can bring impairments to youths living in institutions.
On the other hand, significant changes in environment and service quality in institutions start being perceived, according to Siqueira et al., 47 and shelters have proved to be more adequate in service and protection of children and adolescents, according to ECA specifications.30 Thus, the form how the institution is organized to fulfill recommendations of that Statute can be a risk or protection factor to the development of such youths.
Dell'Aglio34 investigated events in the life of institutionalized and non-institutionalized children and adolescents using paired samples, also in Southern Brazil. Quantitative analysis of positive and negative life events did not show significant difference as to mean number of events reported by both groups. However, there was a higher number of negative events than positive events, indicating low quality of life in both groups. Among negative life events, the most frequent were those concerning arguments with peers, diseases and violence.
In the present study, the most frequent events in both contexts, such as "to have to obey your parent's rules," "to argue with friends," "death of family members" and "failing at school," are similar to those found by Kristensen et al. 35 These findings are similar to those found by Dell'Aglio,34 considering the importance of peer relationship and difficulties experienced in school. However, the most frequent events were not those of higher impact. Event of higher impact, regardless of context ("death of one parent," "to be raped," "to be rejected by family members" and "to be sexually abused against your will"), were directly or indirectly related to the family, showing its importance.
However, experiencing a stressful situation can or not be called a risk situation. Rutter48 stresses that risk mechanisms should be analyzed as processes, not being an independent variable. Children and adolescents living with their families and that participated in this study also admitted having suffered many types of violence, although at a lower number, and we can conclude that they are also exposed to situations of social and personal vulnerability. On the other hand, there was a higher number of stressful events in the institutionalized group, although the higher impact of events was in the family group, which demonstrates the subjective character of what is considered risk. Thus, for participants in the family group, events are more stressful than for the institutionalized group. This may suggest that experimenting a higher number of events makes sheltered youths perceive some of them as less impacting than those living with their families. Unfortunately, IEEIA does not allow such inference, since it does not consider aspects of coping strategies used on the event, for instance. It is another issue to be further investigated, to differentiate adaptive cases from occurrences of hopelessness and stagnation toward adversity.
As to impact of events, the difference between boys and girls again occurred as the socially reinforced stereotype (Steinberg9) and according to Kristensen et al. 35 Sheltered girls had higher impact means in six out of eight events, with significant difference in relation to the group of girls living with their families.
Regarding frequency of events according to age group, our results corroborate previous researches indicating a higher number of negative events among adolescents than in children in both contexts.9,35 This result can be due to accumulation of events throughout the years or to increased internal and external demand during adolescence, as a result of development itself.9 It is also important to stress that the impact attributed to events was significantly higher in adolescents only in two out of 60 items ("not receive care and attention by parents" and "to have adjustment difficulties at school"). Thus, as stated by Kristensen et al.,35 "if the analysis is limited to frequency of events, it may induce to the interpretation that stress levels increase during adolescence: this does not seem to be the case" (p. 50). Therefore, although number of events is increased, there is no increased perception of stress level (impact) as to events experienced for these youths.
The study of manifestation of depressive symptoms in children and adolescents can be an important tool to improve quality of life of Brazilian children. It is a public health issue, since such symptoms are associated with many mental health problems. This study demonstrated the association between occurrence of stressful events and manifestation of depressive symptoms among children and adolescents. In addition, it quantitatively showed that children who are away from their biological families, due to protection measures, had higher scores of depressive symptoms. A more detailed and longitudinal evaluation of cases that had scores higher than the cut-off point (24 points) could help develop an explanatory model of factors influencing this situation.
The most frequent events in our sample refer to daily microevents as sources of stress, which are often chronic. In general, events such as arguing with friends and obeying parent's rules are among the results previously obtained in other studies.5,34,35,49 Similarly, events perceived as most impacting were acute and unexpected events, which can also be found in the literature.5,9,34,35,49 Institutionalized youths had higher number of stressful events, since they had generally suffered some type of negligence or violence, going through Protective Council, Youth and Juvenile Court, besides multiple professional evaluations. Such course probably contributed to attributions of lower impact to stressful events than youths living with their families.
Among the limitations of this study, it is important to perform a clinical investigation, which allows a more consistent evaluation of manifestation of depressive symptoms in the participants, since the CDI does not allow obtaining diagnostic hypotheses. Furthermore, it would be important to evaluate coping strategies used in each group, especially in those who had low CDI mean and high number of events, to allow programs of psychosocial intervention, for example. Another limitation is the cross-sectional nature of this study, since the evaluation was performed in only one moment, which could reflect an influence of unfavorable current circumstances. Thus, longitudinal studies should be performed, considering frequency and perception of event impact by children or adolescents and manifestation of depressive symptoms throughout time.
In summary, this study contributed to stress the need of providing care to institutionalized youths, considering high percentages in occurrence of stressful events and depressive symptoms. Furthermore, care policies for this population should be discussed, aiming at psychological well being of children and adolescents in protection measures.
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Josiane L. Wathier
Instituto de Psicologia, Rua Ramiro Barcelos, 2600/115, Bairro Santa Cecília
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Received June 3, 2007.
Accepted October 15, 2007.
This article is part of the master's thesis by the first author, entitled "Adverse experiences and depression: a study on institutionalized children and adolescents" (ongoing), developed at the Graduate Program in Developmental Psychology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. The research was developed as part of a larger project funded by Edital Pronex of the National Counsel of Technological and Scientific Development (CNPq) and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS), entitled "Institution, school and street as ecological contexts to promote resilience in youngsters at risk situation."