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1.
2.
J Neurol Neurosurg Psychiatry ; 91(6): 638-649, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32111637

RESUMO

OBJECTIVES: We aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes. METHODS: A systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previous treatment studies. Searches of Embase, MEDLINE and PsycINFO were conducted between January 1965 and June 2019. The findings were discussed during two international meetings of the FND-Core Outcome Measures group. RESULTS: Five FND-specific measures were identified-three clinician-rated and two patient-rated-but their measurement properties have not been rigorously evaluated. No single measure was identified for use across the range of FND symptoms in adults. Across randomised controlled trials (k=40) and observational treatment studies (k=40), outcome measures most often assessed core FND symptom change. Other domains measured commonly were additional physical and psychological symptoms, life impact (ie, quality of life, disability and general functioning) and health economics/cost-utility (eg, healthcare resource use and quality-adjusted life years). CONCLUSIONS: There are few well-validated FND-specific outcome measures. Thus, at present, we recommend that existing outcome measures, known to be reliable, valid and responsive in FND or closely related populations, are used to capture key outcome domains. Increased consistency in outcome measurement will facilitate comparison of treatment effects across FND symptom types and treatment modalities. Future work needs to more rigorously validate outcome measures used in this population.

4.
Clin Child Psychol Psychiatry ; 25(1): 78-97, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31364391

RESUMO

Accumulating evidence indicates that psychological and neurophysiological processes interconnect and interact to activate the body's stress system and to trigger and maintain functional somatic symptoms. This study used the Early Life Stress Questionnaire, Depression Anxiety Stress Scales and biological markers (heart rate, heart rate variability, skin conductance, C-reactive protein (CRP) titre, respiratory rate, and accuracy and reaction time in an emotion-face identification task), to examine childhood adversity, psychological distress and stress-system activation in 35 children and adolescents (23 girls and 12 boys, 9-17 years old) disabled by chronic pain (vs two groups of age- and sex-matched healthy controls). Patients reported more early-life stress (U = 798.5, p = .026) and more psychological distress (U = 978, p < .001). They showed activation of the autonomic system: elevated heart rate (U = 862.5, p = .003), elevated electrodermal activity (U = 804.5, p = .024) and lower heart rate variability in the time domain (U = 380.5, p = .007) and frequency domain (U = 409.5, p = .017). The group showed an upward shift of CRP titres (with 75th and 90th CRP percentiles of 4.5 and 10.5 mg/L, respectively), suggesting the activation of the immune-inflammatory system. Elevated CRP titres were associated with elevated heart rate (p = .028). There were no differences in respiratory rate or in accuracy and reaction time in the emotion-face identification task. The results indicate that interventions for children and adolescents with chronic pain need a multidisciplinary mind-body approach that concurrently addresses psychological distress, physical impairment and stress-system dysregulation.


Assuntos
Dor Crônica/fisiopatologia , Resposta Galvânica da Pele/fisiologia , Frequência Cardíaca/fisiologia , Taxa Respiratória/fisiologia , Adolescente , Ansiedade/fisiopatologia , Sistema Nervoso Autônomo/fisiopatologia , Criança , Feminino , Humanos , Masculino , Testes Neuropsicológicos , Tempo de Reação/fisiologia
6.
Neurosci Biobehav Rev ; 103: 267-304, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31125635

RESUMO

The role of peripheral physiology in the experience of emotion has been debated since the 19th century following the seminal proposal by William James that somatic responses to stimuli determine subjective emotion. Subsequent views have integrated the forebrain's ability to initiate, represent and simulate such physiological events. Modern affective neuroscience envisions an interacting network of "bottom-up" and "top-down" signaling in which the peripheral (PNS) and central nervous systems both receive and generate the experience of emotion. "Feelings" serves as a term for the perception of these physical changes whether emanating from actual somatic events or from the brain's representation of such. "Interoception" has come to represent the brain's receipt and representation of these actual and "virtual" somatic changes that may or may not enter conscious awareness but, nonetheless, influence feelings. Such information can originate from diverse sources including endocrine, immune and gastrointestinal systems as well as the PNS. We here examine physiological feelings from diverse perspectives including current and historical theories, evolution, neuroanatomy and physiology, development, regulatory processes, pathology and linguistics.

7.
Arch Dis Child ; 104(8): 733-738, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30798255

RESUMO

OBJECTIVE: To estimate the paediatrician-diagnosed incidence of chronic fatigue syndrome (CFS) in Australia, and describe demographic and clinical features, as well as approaches to diagnosis and management. METHODS: The Australian Paediatric Surveillance Unit facilitates monthly national surveillance of uncommon conditions seen by paediatricians. Data from young people aged <18 years diagnosed with CFS were collected. Incidence was estimated based on new cases reported from April 2015 to April 2016. RESULTS: A total of 164 cases of newly diagnosed CFS in young people aged 4-17 years were identified for inclusion. The estimated national incidence for children aged 4-9 years was 0.25 per 100 000 per annum. In children aged 10-17 years, the estimated incidence of paediatrician-diagnosed cases for Victoria (17.48 per 100 000) was substantially greater than other Australian states (range 1.31-5.51 per 100 000). Most cases were female and Caucasian, most commonly presenting after an infectious illness with symptoms gradual in onset. The majority were diagnosed at least 13 months after symptom onset. Symptoms, associations, investigations and management strategies were highly variable. CONCLUSIONS: Current findings suggest that, consistent with other countries, the Australian incidence of CFS in children aged <10 years is very low. In contrast, the national incidence of CFS in older children and adolescents (aged 10-17 years) is more unclear, with marked variability between geographical regions apparent. This may be due to variation in service accessibility and clinician understanding of CFS. Accordingly, national initiatives to improve equity of care for children with CFS may be required.


Assuntos
Serviços de Saúde da Criança , Síndrome de Fadiga Crônica/epidemiologia , Adolescente , Austrália/epidemiologia , Criança , Pré-Escolar , Demografia , Síndrome de Fadiga Crônica/etiologia , Síndrome de Fadiga Crônica/prevenção & controle , Feminino , Humanos , Incidência , Masculino , Pediatras , Padrões de Prática Médica , Fatores de Risco
8.
Clin Child Psychol Psychiatry ; 24(1): 29-39, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30354283

RESUMO

Functional somatic symptoms (FSS) emerge when the stress system is activated in response to physical or emotional stress that is either chronic or especially intense. In such cases, the heightened state of physiological arousal and motor activation can be measured through biological markers. Our team have integrated the use of biological markers of body state - respiratory rate, heart rate (HR) and heart rate variability (HRV) measurements - as a way of helping families to understand how physical symptoms can signal activation of the body's stress systems. This study measured respiratory rates, HR and HRV in children and adolescents with FSS (and healthy controls) during baseline assessment to determine whether these biological markers were effective at differentiating patients with FSS. The study also implemented a biofeedback intervention during the assessment to determine whether patients with FSS were able to slow their respiratory rates and increase HRV. Patients with FSS had faster respiratory rates, faster HR, and lower HRV, suggesting activation of the autonomic nervous system coupled with activation of the respiratory motor system. Like controls, patients were able to slow their respiratory rates, but in contrast to controls, they were unable to increase their HRV. Our findings suggest that patients with FSS present in a state of physiological activation and struggle to regulate their body state. Patients with FSS are likely to need ongoing training and practice to regulate body state coupled with interventions that target regulatory capacity across multiple systems.


Assuntos
Frequência Cardíaca/fisiologia , Sintomas Inexplicáveis , Taxa Respiratória/fisiologia , Transtornos Somatoformes/diagnóstico , Adolescente , Criança , Feminino , Humanos , Masculino , Transtornos Somatoformes/terapia
9.
Eur Child Adolesc Psychiatry ; 28(4): 491-504, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30143887

RESUMO

There is accumulating evidence that patients with functional neurological symptom disorder (FND) show activation of multiple components of the stress system-the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and brain regions involved in arousal- and emotion-processing. This study aims to examine whether the immune-inflammatory component of the stress system is also activated. C-reactive protein (CRP) blood titre levels were measured in 79 children and adolescents with FND. CRP values ≥ 2 mg/L suggest low-grade inflammation. CRP values > 10 mg/L suggest a disease process. Sixty-six percent of subjects (n = 52) had CRP titres ≥ 2 mg/L. The upward shift in the distribution of CRP levels suggested low-grade inflammation (median CRP concentration was 4.60 mg/L, with 75th and 90th percentiles of 6.1 and 10.3 mg/L, respectively). Elevated CRP titres were not explained by sex, pubertal status, BMI, or medical factors. Confounder analyses suggested that history of maltreatment (χ2 = 2.802, df = 1, p = 0.094, φ = 0.190; ß = 2.823, p = 0.04) and a diagnosis of anxiety (χ2 = 2.731, df = 1, p = 0.098, φ = 0.187; ß = 4.520, p = 0.061) contributed to elevated CRP levels. Future research will need to identify the origins and locations of immune cell activation and the pathways and systems contributing to their activation and modulation. Because functional activity in neurons and glial cells-the brain's innate effector immune cells-is tightly coupled, our finding of elevated CRP titres suggests activation of the immune-inflammatory component of the brain's stress system. A more direct examination of inflammation-related molecules in the brain will help clarify the role of immune-inflammatory processes in FND.


Assuntos
Proteína C-Reativa/metabolismo , Doenças do Sistema Nervoso/sangue , Doenças do Sistema Nervoso/diagnóstico , Transtornos do Neurodesenvolvimento/sangue , Transtornos do Neurodesenvolvimento/diagnóstico , Adolescente , Ansiedade/sangue , Ansiedade/diagnóstico , Ansiedade/psicologia , Biomarcadores/sangue , Encéfalo/metabolismo , Criança , Feminino , Humanos , Sistema Hipotálamo-Hipofisário/metabolismo , Masculino , Doenças do Sistema Nervoso/psicologia , Transtornos do Neurodesenvolvimento/psicologia , Sistema Hipófise-Suprarrenal/metabolismo , Autorrelato/normas
11.
Neuroimage Clin ; 18: 730-743, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29876262

RESUMO

Objective: Children and adolescents with functional neurological symptom disorder (FND) present with diverse neurological symptoms not explained by a disease process. Functional neurological symptoms have been conceptualized as somatoform dissociation, a disruption of the brain's intrinsic organization and reversion to a more primitive level of function. We used EEG to investigate neural function and functional brain organization in children/adolescents with FND. Method: EEG was recorded in the resting eyes-open condition in 57 patients (aged 8.5-18 years) and 57 age- and sex-matched healthy controls. Using a topographical map, EEG power data were quantified for regions of interest that define the default mode network (DMN), salience network, and somatomotor network. Source localization was examined using low-resolution brain electromagnetic tomography (LORETA). The contributions of chronic pain and arousal as moderators of differences in EEG power were also examined. Results: Children/adolescents with FND had excessive theta and delta power in electrode clusters corresponding to the DMN-both anteriorly (dorsomedial prefrontal cortex [dmFPC]) and posteriorly (posterior cingulate cortex [PCC], precuneus, and lateral parietal cortex)-and in the premotor/supplementary motor area (SMA) region. There was a trend toward increased theta and delta power in the salience network. LORETA showed activation across all three networks in all power bands and localized neural sources to the dorsal anterior cingulate cortex/dmPFC, mid cingulate cortex, PCC/precuneus, and SMA. Pain and arousal contributed to slow wave power increases in all three networks. Conclusions: These findings suggest that children and adolescents with FND are characterized by overactivation of intrinsic resting brain networks involved in threat detection, energy regulation, and preparation for action.


Assuntos
Encéfalo/fisiopatologia , Rede Nervosa/fisiopatologia , Transtornos Somatoformes/fisiopatologia , Adolescente , Mapeamento Encefálico , Criança , Eletroencefalografia , Feminino , Humanos , Masculino , Vias Neurais/fisiopatologia
12.
J Pain ; 19(10): 1091-1101, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29733993

RESUMO

This review investigated whether youth exhibit attention or interpretation biases toward pain-related information and whether such biases are more pronounced in youth with chronic pain. Three databases were searched to identify studies that assessed attention or interpretation biases using an accepted experimental paradigm. Ten studies were identified, 8 examining attentional biases and 2 examining interpretation biases. As in the adult literature, there was no evidence of attentional biases toward pain in youth without chronic pain. Three studies investigating youth without chronic pain found evidence for relationships between catastrophizing or anxiety and indicators of vigilance or avoidance (in 2 cases, for youth with low self-reported attentional control). For attentional biases, 5 studies compared youth with and without chronic pain. Two of these studies measured cortical correlates and found evidence of neurologic activity indicating a bias in orienting to pain-related stimuli. Three studies examined biases toward pain-related words or pictures. Of those, 2 found evidence of biases at subliminal presentation times, indicating vigilance (although 1 only after a stressful task). For supraliminal presentations, 1 study found evidence of avoidance, one of difficulty disengaging, and one of general slowing of responses. Only 1 study compared youth with and without pain for interpretation bias in adolescents, and interpretation biases were greater for youth with chronic pain. As with attention, no evidence for interpretation biases were found in youth without chronic pain. Overall, there is weak evidence to support vigilance in youth with chronic pain compared with those without. However, whether pain affects the subsequent deployment of attention is unclear. There is no evidence for biases toward pain in youth without chronic pain, but evidence suggests that anxiety or catastrophizing and attentional control may moderate pain-related attentional biases. There is also weak evidence of interpretation bias in youth with chronic pain compared with those without. PERSPECTIVE: Children without chronic pain do not show interpretation or attention biases toward pain-related stimuli. However, there is weak evidence for the presence of attention biases, characterized by vigilance toward pain-related stimuli and pain-related interpretation bias in children with chronic pain compared with those without.

13.
Clin Child Psychol Psychiatry ; 23(1): 140-159, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28956448

RESUMO

Psychogenic non-epileptic seizures (PNES) are a nonspecific, umbrella category that is used to collect together a range of atypical neurophysiological responses to emotional distress, physiological stressors and danger. Because PNES mimic epileptic seizures, children and adolescents with PNES usually present to neurologists or to epilepsy monitoring units. After a comprehensive neurological evaluation and a diagnosis of PNES, the patient is referred to mental health services for treatment. This study documents the diagnostic formulations - the clinical formulations about the probable neurophysiological mechanisms - that were constructed for 60 consecutive children and adolescents with PNES who were referred to our Mind-Body Rehabilitation Programme for treatment. As a heuristic framework, we used a contemporary reworking of Janet's dissociation model: PNES occur in the context of a destabilized neural system and reflect a release of prewired motor programmes following a functional failure in cognitive-emotional executive control circuitry. Using this framework, we clustered the 60 patients into six different subgroups: (1) dissociative PNES (23/60; 38%), (2) dissociative PNES triggered by hyperventilation (32/60; 53%), (3) innate defence responses presenting as PNES (6/60; 10%), (4) PNES triggered by vocal cord adduction (1/60; 2%), (5) PNES triggered by activation of the valsalva manoeuvre (1/60; 1.5%) and (6) PNES triggered by reflex activation of the vagus (2/60; 3%). As described in the companion article, these diagnostic formulations were used, in turn, both to inform the explanations of PNES that we gave to families and to design clinical interventions for helping the children and adolescents gain control of their PNES.


Assuntos
Transtornos Psicofisiológicos/diagnóstico , Convulsões/diagnóstico , Adolescente , Criança , Emoções , Feminino , Humanos , Masculino , Transtornos Psicofisiológicos/psicologia , Convulsões/psicologia
14.
Clin Child Psychol Psychiatry ; 23(1): 160-176, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28956479

RESUMO

Psychogenic non-epileptic seizures (PNES) - time-limited disturbances of consciousness and motor-sensory control, not accompanied by ictal activity on electroencephalogram (EEG) - are best conceptualized as atypical neurophysiological responses to emotional distress, physiological stressors and danger. Patients and families find the diagnosis of PNES difficult to understand; the transition from neurology (where the diagnosis is made) to mental health services (to which patients are referred for treatment) can be a bumpy one. This study reports how diagnostic formulations constructed for 60 consecutive children and adolescents with PNES were used to inform both the explanations about PNES that were given to them and their families and the clinical interventions that were used to help patients gain control over PNES. Families were able to accept the diagnosis of PNES and engage in treatment when it was explained how emotional distress, illness and states of high arousal could activate atypical defence responses in the body and brain - with PNES being an unwanted by-product of this process. Patients and their families made good use of therapeutic interventions. A total of 75% of children/adolescents (45/60) regained normal function and attained full-time return to school. Global Assessment of Functioning scores increased from 41 to 67 ( t(54) = 10.09; p < .001). Outcomes were less favourable in children/adolescents who presented with chronic PNES and in those with a chronic, comorbid mental health disorder that failed to resolve with treatment. The study highlights that prompt diagnosis, followed by prompt multidisciplinary assessment, engagement, and treatment, achieves improved outcomes in children/adolescents with PNES.


Assuntos
Transtornos Psicofisiológicos/psicologia , Transtornos Psicofisiológicos/terapia , Convulsões/psicologia , Convulsões/terapia , Adolescente , Criança , Eletroencefalografia , Feminino , Humanos , Masculino , Transtornos Psicofisiológicos/diagnóstico , Convulsões/diagnóstico
16.
Clin Child Psychol Psychiatry ; 22(4): 588-602, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28994326

RESUMO

Pain is a signal of danger, and danger activates the attachment system. When a parent responds to a child's pain with appropriate protection and comfort, more often than not, the pain resolves. But what happens in families when a child's pain becomes chronic and continues to signal a danger that has long passed? This study explored patterns of attachment in 48 children and adolescents with chronic functional pain and 48 healthy controls using structured attachment interviews. Patterns of attachment were identified using the Dynamic Maturational Model of Attachment. Compared to controls, children and adolescents with chronic functional pain were classified into at-risk patterns of attachment (χ2 = 76.4, df = 2, p < .001) and had higher rates of unresolved loss and trauma (χ2 = 10.8, df = 1, p = .001), suggesting a long-standing history of relational stress and the disruption of nurturing relationships. The findings suggest that the quality of attachment relationships contribute to the development and maintenance of chronic functional pain. Ongoing anxiety within the attachment relationship, combined with unresolved loss and trauma, may function much like catastrophising, contributing to chronic functional pain by activating the body's arousal systems. The assessment process for chronic functional pain should include a family assessment to identify ruptures in attachment relationships, as well as unresolved loss and trauma events that need to be addressed through family interventions or individual therapy.


Assuntos
Catastrofização/fisiopatologia , Dor Crônica/fisiopatologia , Relações Familiares/psicologia , Apego ao Objeto , Trauma Psicológico/fisiopatologia , Transtornos Somatoformes/fisiopatologia , Adolescente , Catastrofização/psicologia , Criança , Dor Crônica/psicologia , Feminino , Humanos , Masculino , Trauma Psicológico/psicologia , Risco , Transtornos Somatoformes/psicologia
17.
Neuroimage Clin ; 15: 306-314, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28560155

RESUMO

OBJECTIVE: Functional neurological symptom disorder refers to the presence of neurological symptoms not explained by neurological disease. Although this disorder is presumed to reflect abnormal function of the brain, recent studies in adults show neuroanatomical abnormalities in brain structure. These structural brain abnormalities have been presumed to reflect long-term adaptations to the disorder, and it is unknown whether child and adolescent patients, with illness that is typically of shorter duration, show similar deficits or have normal brain structure. METHOD: High-resolution, three-dimensional T1-weighted magnetic resonance images (MRIs) were acquired in 25 patients (aged 10-18 years) and 24 healthy controls. Structure was quantified in terms of grey matter volume using voxel-based morphometry. Post hoc, we examined whether regions of structural difference related to a measure of motor readiness to emotional signals and to clinical measures of illness duration, illness severity, and anxiety/depression. RESULTS: Patients showed greater volumes in the left supplementary motor area (SMA) and right superior temporal gyrus (STG) and dorsomedial prefrontal cortex (DMPFC) (corrected p < 0.05). Previous studies of adult patients have also reported alterations of the SMA. Greater SMA volumes correlated with faster reaction times in identifying emotions but not with clinical measures. CONCLUSIONS: The SMA, STG, and DMPFC are known to be involved in the perception of emotion and the modulation of motor responses. These larger volumes may reflect the early expression of an experience-dependent plasticity process associated with increased vigilance to others' emotional states and enhanced motor readiness to organize self-protectively in the context of the long-standing relational stress that is characteristic of this disorder.


Assuntos
Substância Cinzenta/patologia , Doenças do Sistema Nervoso/patologia , Transtornos Somatoformes/patologia , Adolescente , Criança , Feminino , Substância Cinzenta/diagnóstico por imagem , Humanos , Imagem por Ressonância Magnética , Masculino , Doenças do Sistema Nervoso/diagnóstico por imagem , Doenças do Sistema Nervoso/fisiopatologia , Transtornos Somatoformes/diagnóstico por imagem , Transtornos Somatoformes/fisiopatologia
19.
Eur Child Adolesc Psychiatry ; 26(10): 1207-1217, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28341888

RESUMO

Psychogenic non-epileptic seizures (PNES) are a common problem in paediatric neurology and psychiatry that can best be understood as atypical responses to threat. Threats activate the body for action by mediating increases in arousal, respiration, and motor readiness. In previous studies, a range of cardiac, endocrine, brain-based, attention-bias, and behavioral measures have been used to demonstrate increases in arousal, vigilance, and motor readiness in patients with PNES. The current study uses respiratory measures to assess both the motor readiness of the respiratory system and the respiratory regulation of CO2. Baseline respiratory rates during clinical assessment and arterial CO2 levels during the hyperventilation component of routine video electroencephalogram were documented in 60 children and adolescents referred for treatment of PNES and in 50 controls. Patients showed elevated baseline respiratory rates [t(78) = 3.34, p = .001], with 36/52 (69%) of patients [vs. 11/28 (39%) controls] falling above the 75th percentile (χ 2 = 6.7343; df = 1; p = .009). Twenty-eight (47%) of patients [vs. 4/50 (8%) controls] showed a skewed hyperventilation-challenge profile-baseline PCO2 <36 mmHg, a trough PCO2 ≤ 20 mmHg, or a final PCO2 <36 mmHg after 15 min of recovery-signaling difficulties with CO2 regulation (χ 2 = 19.77; df = 1; p < .001). Children and adolescents with PNES present in a state of readiness-for-action characterized by high arousal coupled with activation of the respiratory motor system, increases in ventilation, and a hyperventilation-challenge profile shifted downward from homeostatic range. Breathing interventions that target arousal, decrease respiratory rate, and normalize ventilation and arterial CO2 may help patients shift brain-body state and avert PNES episodes.


Assuntos
Encéfalo/patologia , Dióxido de Carbono/uso terapêutico , Eletroencefalografia/métodos , Convulsões/tratamento farmacológico , Convulsões/psicologia , Adolescente , Dióxido de Carbono/farmacologia , Criança , Feminino , Humanos , Masculino , Convulsões/patologia
20.
Clin Child Psychol Psychiatry ; 22(2): 245-259, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27324573

RESUMO

Family therapists understand that children presenting for treatment are often bearers of symptoms signalling relational problems within the family system. Rather than addressing the children's symptoms in isolation, family therapists typically take those relational problems as their starting point in therapy. This study used the School-aged Assessment of Attachment (SAA) to assess the self-protective (attachment) strategies of the siblings of children presenting for psychiatric evaluation and also of the siblings of control children drawn from the normative population. Siblings of children in the clinical group were much more likely than siblings of control children to use at-risk self-protective strategies and to have markers suggestive of unresolved loss or trauma. School-aged siblings were found to use a broad range of strategies, and the pattern of change from first born to later born involved either a reversal of strategy or a shift to a more complex strategy. The study highlights that siblings of children presenting to mental health services are significantly affected by family relational stress. A family systems approach to assessment, one that enquires about the wellbeing of all family members, will ensure that the emotional needs of siblings are also addressed during the therapy process.


Assuntos
Mecanismos de Defesa , Relações Familiares/psicologia , Transtornos Mentais/diagnóstico , Apego ao Objeto , Trauma Psicológico/psicologia , Irmãos/psicologia , Adolescente , Criança , Feminino , Humanos , Masculino , Serviços de Saúde Mental
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