Rozprawy doktorskie na temat „Children and Adolescents”

One area of history that historians have ignored is that of children and their relationship to witchcraft and the witch trials. This thesis begins with a survey of historical done on the general theme of childhood, and moves on to review secondary literature about children and the continental witch trials. The thesis also reviews demonological theory relating to children and the roles children played in the minds of continental and English demonologists. Children played various roles: murder victims, victims of dedication to Satan, child-witches, witnesses for the prosecution, victims of bewitchment or possession, and victims of seduction into witchcraft. The final section of the thesis deals with children and English witchcraft. In England children tended to play the same roles as described by the demonologists.

Aim: This thesis aims to describe perceived overall well-being, coping strategies, experiences of intimacy and sexuality, and global and dimension-specific self-esteem among children and adolescents with mobility impairment. Methods: The study included 141 children and adolescents aged 7–18 years with mobility impairment. Data was gathered by comprehensive semi-structured interviews and the self-report inventories “Children’s Coping Strategies Checklist” (CCSC) and “I Think I am”. Perceived overall well-being was measured by the nine-grade visual “Snoopy scale”. Motor function and pain were measured by the BL motor assessment, and independence or dependence by Katz Index of Independence in Activities of Daily Living. Results: The majority reported a favourable level of perceived overall well-being and positive global and dimension-specific self-esteem. Lower global self-esteem was significantly related to: greater age, being a first-generation immigrant, having an acquired disease or injury and experience of pain, while lower level of perceived overall well-being was significantly related to all of these in addition to not living with both parents. Generally, children and adolescents identified themselves as sexual beings and most expressed future aspirations as living together with partner having children. However, many had limited or no experience of partner-related intimacy and sexual activities, and socio-demographic and disability characteristics had a marginal influence. A history of sexual abuse was reported by 7% in the age cohort 13–18 years. A four-dimensional model of coping strategies including “active coping”, “distraction”, “avoidance” and “support seeking” strategies provided an adequate fit to the CCSC data. Three of the four strategies, all except “avoidance”, were significantly related to several demographic and disability features. Well-being was not significantly related to coping strategies, although the higher the trust in the strategies, the higher the estimation of well-being. Conclusion: The understanding of vulnerability factors as well as identification of coping strategies among children and adolescents with mobility impairment is essential for providing proper care, treatment and support during childhood and adolescence.

The 1980s mark the beginning of systematic research and theoretical advances in the field of psychic trauma in children. Posttraumatic stress disorder (PTSD) was a diagnosis for adults in the Diagnostic and Statistical Manual of Mental Disorders, DSM-III (American Psychiatric Association, 1980). In a later version, children and adolescents were partially included (American Psychiatric Association, 1987). Since 1980, a range of traumatic events have been identified as having the required stressor characteristics for posttraumatic stress reactions to manifest in children and adolescents.

In this study, the role of the stressor and peritraumatic reactions in PTSD of children and adolescents was studied. In addition, co-existing factors were assessed and related to the development and maintenance of PTSD reactions. A cascade of distressing events described the stressor in children who reported sexual abuse in daycare (paper I), and single-incident events were studied in adolescents (paper III). Subjective reactions during or immediately after the traumatic event, such as intense emotions, physiological arousal, dissociation and having thoughts of intervening, were strongly associated to the subsequent development of PTSD reactions in adolescents. The findings indicate that subjective responses to traumatic events play an important role in PTSD etiology. Objective features of the stressor, such as death or physical injury did not relate significantly to the levels of posttraumatic stress reactions. Half the children exposed to the cascade stressor in the case of alleged child sexual abuse, showed significant levels of PTSD reactions four years later. The objective features of the cascade stressor depended on the reported severity of child sexual abuse as well as media exposure, medical examinations, forensic interviews and the court trial. Children with high levels of PTSD reactions reported more severe CSA and were also more exposed to the media and the court trial, but the tendency was not significant.

Moreover, co-existing factors not related to the traumatic event may play important roles in the development and maintenance of PTSD reactions. After alleged sexual abuse and subsequent distressing events, older children displayed more PTSD reactions than younger children, which may indicate that younger children were more protected from developing distress in this situation. On the other hand, five weeks after a tram car accident, age was negatively associated with the levels of PTSD reactions in a group of children (paper IV). The findings may be due to the diverse nature of the stressors and methodological issues.

Other co-existing factors to PTSD, such as behavior problems in children and adolescents, may represent considerable difficulties in a young person’s life. In the current study, children displayed significant levels of behavioral problems four years after alleged sexual abuse.

The impact on parents and the rest of the child’s family cannot be ignored in the assessment of posttraumatic stress reactions of children and adolescents. In this study, comprehensive assessments were made of the parents’ experiences and levels of distress after alleged sexual abuse of their children. The parents were exposed to a cascade of events, including hearing about the sexual abuse, being involved in the police investigation and the court trial and being exposed in media reports. Four years after the events, elements of the stressor were significantly associated to the level of posttraumatic stress reactions. The findings illustrate how child sexual abuse reports may involve the children’s parents and expose them to high levels of distress over a long period of time.

In addition, interactions in the family may contribute in the development and maintenance of posttraumatic stress reactions in children and adolescents, and impede the healing processes.

After traumatic events in childhood, researchers tend to prefer parental reports of the children’s reactions to spare the children. In this study, children reported significantly higher levels of distress than observed by their parents after a tram car accident (paper IV). These findings indicate that parents unintentionally may bring in a response bias in their reports, which future research and clinical practice should take into account.

The study illustrates that traumatic events are complex experiences involving cognitive and emotional reactions, physiological arousal and dissociation, and that these reactions may induce posttraumatic stress reactions in children and adolescents. The cascade stressor subsequent to alleged sexual abuse of children showed how different elements of the stressor may lead to distress over a long period of time. The distress involved both children and parents in this study.

Paper II reprinted with kind permission of Elsevier, www.sciencedirect.com

The primary purpose of this study was to identify resiliency factors evident in parentally bereaved children and adolescents identified as "holis-tically well." The population for this study consisted of 7 parentally bereaved children and adolescents between the ages of 5 and 18 who were referred by the Children to Children support program for grieving youth. The instruments used in this study were specifically developed to assess holistic wellness and evidence of resiliency factors. The most prevalent resiliency factors evident in parentally bereaved children and adolescents identified as holistically well were: Constitutional Resiliency Factors of: social competence, positive personality characteristics, sense of purpose and hope, problem-solving skills, and autonomy. Resiliency Factors within the Home Environment of: caring and support, high parental expectations, and encouragement of participation in family. Resiliency Factors within the School Environment of: high academic expectations and caring and support.

The role of guilt within the context of interpersonal relationships, the definitions of guilt, the origins of guilt, and whether or not outcomes associated with guilt tend to be negative or positive are the focus of this research paper. Four hundred and seventy-two (472) articles, covering a period of thirty-three years (33), were tabulated as to their perspective concerning the phenomenon of guilt. A determination was made as to whether each article leaned toward presenting guilt as a negative or positive influence pertaining to human behavior and/or interaction. It is hypothesized that the literature reflects significantly more negative outcomes associated with guilt than it does positive outcomes; that, overall, guilt can be said to have but little constructive use in human behavior and/or interaction. The findings of this study support the hypothesis.

Background: Studies in adults have shown physiological protection of a 'set-point' for weight, explaining why obese adults who diet eventually regain weight. Objective: We hypothesised that set-points for weight, and their physiological defence, are flexible in childhood but become fixed around puberty. We aimed to show that obese children who lost weight had less 'reflex' changes in satiety hormone profiles (that would drive weight regain), compared with adolescents who had experienced a similar degree of weight change. Method: Prospective cohort study. 41 subjects; 21 obese pre-pubertal children (age 3-7 years; 11 male) and 20 obese adolescents (age 14-18 years; 10 male). Obesity defined as BMI > 2.4 SDS. Subjects recruited as either 'reducers' (relative/absolute weight loss of ≥ 10% in the preceding 9-15 months) or 'maintainers' (controls). Measures: Resting Energy Expenditure (REE), bioelectrical impedance, and fasting and post-prandial (every 30 minutes for 3 hours) satiety hormone profiles. Results: Post-pubertal adolescents had 31% lower Ghrelin concentrations (4%-51%, p=0.03) and 50% higher Amylin concentrations than pre-pubertal children (18%-91%, p=0.001). The association between Ghrelin, Amylin and GIP concentration and weight change was similar for both pre and post-pubertal children (p=0.79, p=0.39, p=0.79 respectively). No associations were found for Peptide YY, Pancreatic Polypeptide, or active GLP-1. Regarding satiety, post-pubertal reducers reported less hunger and higher satiety than pre-pubertal children (p < 0.05). REE in pre-pubertal weight reducers and maintainers were similar (50kcal lower, -143 to 242, p=0.6) but post-pubertal reducers had 250kcal lower REE compared to post-pubertal maintainers (-68 to 572, p=0.1). Conclusion: Satiety hormone profiles were similar between pre and post-pubertal subjects, and contrast with adult data where weight reduction leads to sustained increases in Ghrelin and reductions in the other hormones. These findings indicate that the physiological mechanisms which act to protect against weight change in adults develop later than in the adolescent years.

Childhood aggression affects a significant number of children and represents the majority of referrals to child clinical services (Ford, Hamilton, Meltzer, & Goodman, 2007). There are substantial costs for the child, their family and society more generally if aggressive behaviour remains untreated (Shivram et al., 2009). Social-cognitive models of aggression have provided the theoretical framework for much of the research into childhood aggression over the past twenty years and formed the focus of clinical interventions (Crick & Dodge, 1994). A key finding from this research is that aggressive children have a tendency to attribute hostility to the intentions of others in ambiguous situations (Orobio de Castro, Veerman, Koops, Bosch and Monshouwer, 2002). The aim of literature review is to explore the factors that lead to the development of this bias. Limitations to extant literature and suggestions for future research are discussed. Although evidence from a number of studies demonstrates the effects of socialisation or peer contagion on children’s aggressive and anti-social behaviour (Prinstein & Dodge, 2008; Thornberry & Krohn, 1997), currently no studies have examined peer contagion effects on hostile attribution bias. The empirical paper describes a study investigating whether hostile attribution biases are contagious amongst adolescents in a community sample of boys and girls. Using a computerised ‘Chat-room’ experimental paradigm, contagion effects were demonstrated across two conditions (hostile and benign) with those exposed to hostile group norms showing greater contagion effects. Four possible moderators on the effects of peer contagion were explored; gender, dispositional levels of aggression, social anxiety and friendship style. The role of peers in the socialisation of hostile intent attribution styles and implications for preventative interventions are discussed.

Social skills training is a need among autistic adolescents. This investigation examined a social skills training program involving several teaching strategies. Specific social skills were targeted for improvement. Attempts to decrease negative social behaviors were made. Five autistic adolescents participated in the program and five were selected for the no-treatment group. Two measures were used. A survey addressing the skills targeted in the program was completed by parents and teachers before and after the program. A test conversation with a stranger and a peer was conducted with each subject before and after the program. Anecdotal information was obtained from therapists, teachers, and parents. Results provided information on the effectiveness of this social skills program. The benefits and limitations of the program were discussed.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior
The presence of alterations of blood pression in children and adolescents has shown that arterial hypertension may have its initial history in this life stage. It is believed that the harmful effects of hypertension, when they exist, could be minimized if their presence was detected precociously, if the evaluation of blood pressure was done periodically and if it were a mandatory part of the consultations to children and adolescents. Epidemiologic studies about blood pressure in childhood also reveal that the persistence of high values in this stage of life reinforces the idea that hypertension in adulthood is a direct result of hypertension in childhood. One aimed to follow children and adolescents with family history of arterial hypertension for a long time, analyzing the evolution of percentage/classification of blood pressure in children and adolescents. The longitudinal/prospective study was developed in a poor community of Fortaleza-CearÃ. The blood pressure was evaluated in five meetings: first semester of 2004; first semester of 2005; second semester of 2005; first semester of 2006 and second semester of 2006. The data collection was conducted at home in pre-determined periods. By the data obtained, it was possible to confirm that children and adolescents can have high blood pressure, even without an specific cause and no sinthomatology. The group presented was composed by 141 participants, in the majority females (71). The ages varied from 6 to 21 years old in the period of accompaniment. The highest values of blood pressure were found in the male patients. A bigger percentage of the children and adolescents were relatives of second degree of arterial hypertension bearers (48.9%), and these showed the biggest average values of SBP and DBP. Out of 92 children, 30 remained with no alterations of the percentages of blood pressure in all evaluations; 42 presented alterations starting from the 3rd evaluation; eight showed alterations of the percentage only on the last evaluation conducted; 11 showed alterations of the percentages of blood pressure in all the evaluations and 20 presented alterations of the percentages in some evaluation, but in the last one showed normal percentage of blood pressure. Out of 49 adolescents, 32 remained with no alterations of the percentages of blood pressure in all evaluations; eight presented alterations starting from the 3rd evaluation; two individuals showed alterations of the percentages only on the last evaluation; six presented alterations of the percentages of blood pressure in all the evaluations and three presented alterations of percentages in some evaluation, but in the last one presented normal blood pressure percentage. It was not possible to identify statistic significance concerning the risk factors presented during the accompaniment, apparently being the family factor the biggest contribution to the high values of blood pressure. It is confirmed the necessity of a regular monitoring of children and adolescentsâ blood pressure and, even without significant statistic correlation, the precocious identification of risk factors such as overweight, obesity, sedentarism, positive history to hypertension, smoking and drinking in the prevention of future cardiovascular events.
A presenÃa das alteraÃÃes da pressÃo arterial em crianÃas e adolescentes tem evidenciado que a hipertensÃo arterial pode ter sua histÃria inicial nesta etapa de vida. Acredita-se que os efeitos deletÃrios da hipertensÃo, no caso de sua existÃncia, poderiam ser minimizados se a sua presenÃa fosse detectada precocemente, bastando para isso que a avaliaÃÃo da pressÃo arterial fosse feita periodicamente e constasse como parte obrigatÃria das consultas a crianÃas e adolescentes. Estudos epidemiolÃgicos sobre pressÃo arterial na infÃncia tambÃm revelam que a persistÃncia de valores elevados nesta fase da vida reforÃa a hipÃtese de que a hipertensÃo em adultos à resultado direto de hipertensÃo na infÃncia. Teve-se como propÃsito acompanhar por tempo prolongado crianÃas e adolescentes com histÃria familiar de hipertensÃo arterial, Analisando a evoluÃÃo dos percentis/classificaÃÃo de pressÃo arterial de crianÃas e adolescentes. O estudo longitudinal/prospectivo foi desenvolvido em uma comunidade da periferia de Fortaleza- CearÃ. A pressÃo arterial foi avaliada em cinco encontros: primeiro semestre de 2004; primeiro semestre de 2005; segundo semestre de 2005; primeiro semestre de 2006 e no segundo semestre de 2006. A coleta de dados foi realizada no domicÃlio em perÃodos prÃ-determinados. Pelos dados obtidos, foi possÃvel confirmar que crianÃas e adolescentes podem ter pressÃes arteriais elevadas, mesmo sem uma aparente causa especÃfica e sem sintomatologia. O grupo apresentado foi composto por 141 participantes, na sua maior parte do sexo feminino (71). As idades variaram de 6 a 21 anos no decorrer do perÃodo de acompanhamento. Os valores mais elevados de pressÃo arterial mostraram-se naqueles do sexo masculino. Um percentual maior das crianÃas e adolescentes tinha parentesco de 2 grau com o portador de hipertensÃo arterial (48,9%), sendo estes os que mostraram maiores valores mÃdios de PAS e de PAD. Das 92 crianÃas, 30 crianÃas permaneceram sem alteraÃÃes dos percentis de pressÃo arterial em todas as avaliaÃÃes; 42 apresentaram alteraÃÃes a partir da 3 avaliaÃÃo; oito mostraram alteraÃÃo dos percentis somente na Ãltima avaliaÃÃo realizada; 11 apresentaram alteraÃÃes dos percentis de pressÃo arterial em todas as avaliaÃÃes e 20 apresentaram alteraÃÃo dos percentis em alguma avaliaÃÃo, mas na Ãltima mostraram percentis normais de pressÃo arterial. Dos 49 adolescentes, 32 permaneceram sem alteraÃÃes dos percentis de pressÃo arterial em todas as avaliaÃÃes; oito apresentaram alteraÃÃes a partir da 3 avaliaÃÃo; dois indivÃduos mostraram alteraÃÃo dos percentis somente na Ãltima avaliaÃÃo; seis apresentaram alteraÃÃes dos percentis de pressÃo arterial em todas as avaliaÃÃes e trÃs apresentaram alteraÃÃo dos percentis em alguma avaliaÃÃo, mas na Ãltima mostraram percentis normais de pressÃo arterial. NÃo foi possÃvel identificar significÃncia estatÃstica em relaÃÃo aos fatores de risco apresentados ao longo do acompanhamento, parecendo ser o fator familiar o maior contribuinte para os valores elevados das pressÃes arteriais. Confirma-se a necessidade de monitoraÃÃo da pressÃo arterial rotineira de crianÃas e adolescentes e, mesmo sem correlaÃÃo estatÃstica significativa, a identificaÃÃo precoce de indicadores de risco como sobrepeso, obesidade, sedentarismo, histÃria positiva para hipertensÃo, uso de fumo e bebida alcoÃlica na prevenÃÃo de eventos cardiovasculares futuros.

Thesis (Ph. D.)--Ohio State University, 2004.
Title from first page of PDF file. Document formatted into pages; contains x, 115 p.; also includes graphics Includes bibliographical references (p. 105-115). Available online via OhioLINK's ETD Center

The main research question for this paper was; does adolescent exercise predict happiness and positive moods in adult life? Data was collected through an online questionnaire (N = 438). The questionnaire included a measure of happiness (The Subjective Happiness Scale), moods (The Profile of Mood States) and questions on current and adolescent exercise. Adolescent exercise was a significant predictor for positive moods, even when controlling for current exercise. This is as far as we know the first study to find this connection. There is also a connection between adolescent exercise and happiness, although it appears to be that adolescent exercise predicts exercise in adult life, which in turn has a connection to happiness. Exercise was not a significant predictor of negative moods in adulthood.
This review examines the psychological benefits exercise lead to in healthy children and adolescents. Studies on the effect of exercise on cognition, self-esteem, emotions and mood, and academic performance were examined. Exercise seems to have a positive effect on several aspects of cognition and self-esteem in healthy children and adolescents. There is not sufficient evidence to conclude that there are benefits from exercise in emotions, mood and academic performance.

Dissertation (Ph.D.) -- The Institute for Clinical Social Work, 1990.
A dissertation submitted to the faculty of the Institute of Clinical Social Work in partial fulfillment for the degree of Doctor of Philosophy.

Thesis (M.S.)--University of North Carolina at Chapel Hill, 2007.
Title from electronic title page (viewed Mar. 26, 2008). "... in partial fulfillment of the requirements for the degree of Masters of Science in the School of Dentistry (Pediatrics)." Discipline: Pediatric Dentistry; Department/School: Dentistry.

The objectives of The Identification and Prevention of Dietary and Lifestyle Induced Health Effects in Children and Infants study (child sample) and the Kenya Adolescent Physical Activity study (adolescent sample) conducted in this thesis was firstly, to assess the impact of methodological and practical decisions such as the appropriate epoch length and cutpoints to use in accelerometry studies involving children and adolescents across the physical activity continuum and the reliability of these accelerometer outcomes in predicting habitual physical activity. Secondly, the performance of uniaxial ActiTrainer accelerometry with heart rate (HR) monitoring was compared to triaxial GT3X accelerometry against indirect calorimetry during structured activities in the predominantly active Kenyan adolescent cohort. Similarly, the performance of uniaxial ActiTrainer accelerometry with HR monitoring vs. triaxial 3DNX accelerometry was compared against DLW under free living conditions in both children and adolescent cohorts. Finally, the validated uniaxial ActiTrainer was used to assess the impact of physical activity and the environment on energy expenditure and indices of adiposity in the two cohorts. The main findings of the thesis were: (a) that 15 s epoch reports significantly higher engagement in physical activity compared to a 60 s epoch in both the children and adolescents cohorts (b) choice of cutpoints significantly affected classification of physical activity and sedentary behaviour in both cohorts (c) a minimum of 6 h for 7 - 9 days in the cohort involving children and a minimum of 6 h for 4 - 5 days in the adolescents were required to reliably measure physical activity (d) triaxial accelerometry reported better predictive validity compared to uniaxial accelerometry during structured activities. In addition, HR monitoring did not improve the predictive validity of either accelerometer during structured activities (e) during free living activities, however, uniaxial and triaxial accelerometry reported comparable predictive validity. The addition of HR monitoring improved the predictive validity of uniaxial accelerometry by approximately 4% in both cohorts (f) in both cohorts, total volume of physical activity and patterns (time engaged in light and moderate to vigorous physical activity) were significantly associated with energy expenditure (g) physical activity and sedentary behaviour were significantly related to indices of adiposity in both cohorts (h) the environment was a significant predictor of physical activity and indices of adiposity in the adolescents but not children. The findings of this thesis have important implications on strategies to standardise accelerometry field protocols and future studies on the validation of accelerometers and the association between physical activity, the environment and health.

This thesis examines and describes children's and adolescent's responses to burn injuries, with a specific focus on traumatic responses. Fifty five children, adolescents and their parents took part in this longitudinal study, a recruitment rate of 35% of the total population. All of the children had sustained accidental burn injuries of varying severity at least one month before their first assessment. Children were aged between three and eighteen years, and the mean age was seven years. Children under 6 years were not personally assessed. Parents reported on these children using the Child Behaviour Checklist (CBCL), and the Posttraumatic Stress Reaction Index- parent version (PTS-RI). Children over six years took part in the Diagnostic Interview for Children and Adolescents (DICA), and completed the Impact of Events Scale (IES), the Children's Posttraumatic Stress Reaction Index (C-PTS-RI), the Fear Survey Schedule (FSS) and the Depression Self-Rating Scale (DSRS). Parents of these children also completed DICA, the PTS-RI and the CBCL. At six months, all procedures were repeated. Generally, children and adolescents adjusted well following their burn injuries. Traumatic symptoms had been experienced by over half the children, with intrusive symptoms most common. 14% had a PTSD diagnosis at some time since their burn injury. A quarter of the children were reported to have general borderline or clinical behavioural problems using the CBCL. Over half the children reported symptoms of depression. The results are described with reference to the existing literature on children's traumatic responses and children's responses to burn injuries. It is suggested that there may be a "normal" acute trauma response following burn injury. Theory surrounding children's response to burn injury is examined and directions for a new theory encompassing trauma and injury in the context of development are proposed. The methodological limitations to the study are discussed and recommendations are made.

Mestrado em Análises Clínicas
MSc in Clinical Analysis
PORTUGUÊS: A prevalência da obesidade está crescendo em todo o mundo, sendo este aumento particularmente notório na infância e adolescência. Os alimentos ricos em calorias e o estilo de vida sedentário são duas das características do estilo de vida moderno, que pode estar por de trás desta pandemia. A obesidade pediátrica é particularmente importante em nosso país: uma alta prevalência de sobrepeso / obesidade (30%) tem sido descrita em crianças e adolescentes portugueses, em comparação com seus pares de outros países europeus. A obesidade tem sido associada a várias outras doenças, como hipertensão, diabetes mellitus tipo 2, síndrome metabólica e doenças cardiovasculares. Além disso, a inflamação é conhecida por desempenhar um papel vital nessas doenças, ou seja, na iniciação e progressão da doença arteriosclerótica vascular, na resistência à insulina, e dislipidemia. Mais recentemente, a obesidade tem sido proposta como um estado de baixo grau inflamatório crónico. De fato, O tecido adiposo é uma importante fonte de várias substâncias que estão ligadas à resposta inflamatória e à imunidade - as adipoquinas. As dietas de indivíduos obesos são, geralmente, ricos em gorduras saturadas e ácidos gordos (AG) trans, e pobres em AG polinsaturados (AGPI), especialmente, em AGPI do tipo ω 3. Este tipo de hábitos alimentares causa alterações endógenas no metabolismo lipídico, e pode levar a mudanças na constituição em AG em diferentes tecidos do corpo. A composição lipídica das membranas celulares é importante para as propriedades reológicas e físico-químicas das células, influenciando a actividade dos canais protéicos e das bombas da membrana, assim como de transportadores e receptores membranares. Deste modo, o perfil lipídico da membrana é importante na modulação da sinalização celular e de várias funções biológicas da célula. Os lípidos da membrana dos glóbulos vermelhos estão em equilíbrio constante com lípidos e lipoproteínas plasmáticos. Apesar dos níveis dos lípidos plasmáticos serem altamente influenciados pelo estado de jejum, os níveis e tipo de lípidos da membrana eritrocitária reflectem o equilíbrio lipídico por períodos mais longos. Os glóbulos vermelhos (GV), por tratarem-se de células não-nucleadas, apresentam uma capacidade de biossíntese e mecanismos de defesa muito limitados. Portanto, quando expostos a stress físico e / ou químico, o eritrócito sofre e acumula o dano imposta por aquelas fontes durante sua vida em circulação. Em condições de stress oxidativo a membrana do eritrócito, pode sofrer danos em seus lípidos e proteínas. Deste modo, o eritrócito é um bom modelo para estudar os danos oxidativos dos lípidos e proteínas que ocorrem em estados pró-inflamatórios e oxidativas, e também pode fornecer um importante modelo para estudar o impacto dos hábitos alimentares na composição dos lípidos e proteínas das membranas celulares. O objectivo deste estudo foi analisar o impacto da obesidade no perfil lipídico, no metabolismo da glicose e na inflamação, bem como o impacto da obesidade, e das alterações a ela associadas, na composição da membrana do GV. Foram estudadas 34 crianças e adolescentes obesos [15 (44,1%), com idade média de 14,1 anos (8-17)] do Hospital S. João e do Hospital Infantil Maria Pia. O grupo total foi dividido de acordo com o percentil do índice de massa corporal (IMC) em 17 obesos, 8 sobre-pesos e 9 controles. Obesidade foi definida como um IMC superior ao percentil 95, ajustados para idade e sexo, segundo " gráficos de crescimento do Centro de Controle de Doenças de 2000". Sobrepeso foi considerado para os percentis de IMC igual ou superior a 85 e inferior a 95; e controles quando o IMC era inferior ao percentil 85, ajustado para sexo e idade. Os três grupos estavam equilibrados para a idade, sexo e estágio de maturação sexual de Tanner. Foram determinados os níveis circulantes de triglicerídeos, colesterol, colesterol de lipoproteína de alta densidade, colesterol de lipoproteína de baixa densidade, lipoproteína (a), apolipoproteína A, apolipoproteína B, proteína C-reativa, glicose e insulina. Um estudo hematológico básico foi realizado. A membrana eritrocitária foi estudada com a determinação de marcadores de lesão eritrocitária: hemoglobina ligada a membrana, carbonilação proteica, peroxidação lipídica e perfil de banda 3 – agregados de alto peso molecular, monómeros e fragmentos proteolíticos. O perfil de ácidos gordos da membrana foi também determinado. Os indivíduos obesos apresentaram, quando comparados com os controlos, alterações para um perfil lipídico mais aterogénico, um aumento da resistência à insulina e da inflamação. Assim, houve um aumento geral dos marcadores de risco de doença cardiovascular (DCV). Nenhuma diferença significativa foi encontrada no eritrograma ou nos marcadores de lesão eritrocitária. Quanto ao perfil de AG da membrana eritrocitária, os AG insaturados apresentaram uma tendência para o aumento, enquanto os AG saturados mostraram uma tendência para diminuir com a obesidade. Apesar disso, o AG beénico ácido (22:0) apresentou um aumento significativo nos obesos, em comparação com os controles. Uma proporção crescente de 20:0, 18:3n3, 20:3n6e 22:4n6 foram encontrados para indivíduos com sobrepeso e obesos, em relação aos controlos. Estes AG, que aumentaram com a obesidade, apresentaram as associações mais significativas com os marcadores de DVC estudados e que estão alterados com a obesidade na nossa população. Mais estudos são necessários para esclarecer as associações entre as alterações do perfil de AG da membrana eritrocitária e os marcadores de risco de DCV. Um estudo envolvendo mais participantes poderia ajudar a esclarecer algumas tendências observadas. Quanto à análise da membrana lipídica, algumas abordagens interessantes poderiam ser feitas, como analisar separadamente os AG ligados a fosfolípidos e ésteres de colesterol, ou analisar individualmente cada folheto da membrana plasmática (interno e externo). Além disso, a optimização da técnica de separação e identificação dos AG seria fundamental, pois no presente estudo não pudemos avaliar AG importante, como por exemplo o EPA (ácido eicosapentaenoico - 20:5n3) e GLA (ácido gama linolénico - 18:3 n6), devido a limitações técnicas.
ENGLISH: The prevalence of obesity is growing worldwide and in childhood the increase is particularly striking. The caloric rich foods and the reduced physical exercise practice are two of characteristics of the modern lifestyle that may underlie this pandemia. Childhood obesity is particularly important in our country, as a high prevalence of overweight/obesity (over 30%) has been reported for Portuguese children, as compared to other European countries. Obesity has been associated with several other diseases, such as hypertension, type 2 diabetes mellitus, metabolic syndrome and cardiovascular diseases. Moreover, inflammation is known to play a vital role in those diseases, namely, in the initiation and progression of the atherosclerotic vascular disease, in insulin resistance, and in dyslipidemia. More recently, obesity has been proposed as a chronic low grade inflammatory condition. The white adipose tissue is an important source of several substances that are linked to inflammatory response and to immunity - the adipokines. The diets of obese individuals are, usually, rich in saturated and trans fatty acids (FA), and poor in polyunsaturated FA (PUFA), especially, in ω 3 PUFA. These type of dietary habits, by leading to endogenous changes in FA and in lipid metabolism, may, ultimately, lead to changes in the proportions of the different FA in body tissues. The lipid composition of the cell membranes are important determinants in the rheological and physico-chemical properties of the cells, influencing the activity of membrane channels, pumps, transporters and receptors. Thus, it is important in the modulation of cell signalling and in several biological functions. The lipids of the red blood cell membrane are in constant equilibrium with plasmatic lipids and lipoproteins. While the levels of lipids in plasma are highly influenced by the fasting status, the levels and type of lipids of the erythrocyte membrane reflect the lipid balance of longer periods. The red blood cell (RBC), as a non-nucleated cell, exhibits a very limited biosynthesis capacity and poor repair mechanisms. Therefore, when exposed to physical and/or chemical stress, during their lifespan, the erythrocyte suffers and accumulates the damage imposed by such stress. In oxidative stress conditions the erythrocyte membrane, may suffer oxidative damage in membrane lipids and proteins. Thus, the erythrocyte is a good model to study the oxidative damage of lipids and proteins occurring in pro-inflammatory and oxidative conditions and may also provide an important model to study the impact of dietary habits in the lipid and protein composition of the cell membranes. The objective of this study was to analyse the impact of obesity in the lipid profile, glucose homeostasis and inflammation, as well as the impact of obesity and the associated changes in the RBC membrane composition. We studied 34 obese children and adolescents [15 (44.1%); mean age of 14.1 years (8-17)] from Hospital S. João and the Children’s Hospital Maria Pia. The total group was divided according to the body mass index (BMI) percentile in 17 obese, 8 overweight and 9 controls. Obesity was defined as a BMI higher than the 95th percentile, for age and gender, according to the “2000 Centre for Disease Control and Prevention (CDC) growth charts”. Overweight was considered for BMI percentiles equal or higher than 85 and lower than 95; and control subjects BMI were lower than the 85th percentile, adjusted for gender and age. The three groups were matched for age, gender and tanner stage. It were determined the circulating levels of triglycerides, cholesterol, high density lipoprotein cholesterol, Low density lipoprotein cholesterol, lipoprotein (a), apolipoprotein A, apolipoprotein B, C-reactive protein, glucose, and insulin. A basic hematologic study was also performed. The erythrocyte membrane was studied with the determination of erythrocyte damage markers: membrane bound haemoglobin, proteic carbonylation, lipid peroxidation and band 3 profile - high molecular weight aggregates, monomers and proteolytic fragments. The membrane fatty acid profile was determined. We found that the obese individuals, presented risk changes in the lipid profile, increased insulin resistance and inflammation, when compared to their lean counterparts. Thus, several changes in cardiovascular disease (CVD) risk markers were observed. No significant changes were found in the erythrogram and in the erythrocyte damage markers. Concerning the FA membrane profile, the unsaturated FA showed a trend to increase, while saturated FA showed a trend to decrease, with obesity. Despite that, behenic acid (22:0) presented a significantly increase in obese, in comparison with controls. An increasing proportion of 20:0, 18:3n3, 20:3n6 and 22:4n6 were found for overweight and obese individuals, as compared to control. These FA increased with growing obesity, and presented the most significant associations with the studied CVD markers associated with obesity. Further studies are needed to clarify the associations between membrane FA changes, and CVD risk markers. A larger study, with a higher number of individuals could also clarify some observed trends. Regarding the lipid membrane analysis, some interesting approaches could be made, such as to separate and analyze the different phospholipids and cholesterol ester and their associated FA, and to perform a separate study of inner and outer membrane sheets. Furthermore, optimization of the separation technique and consequent identification of FA would be crucial, as in this study we could not evaluate important FA, e.g. EPA (20:5n3) and GLA (18:3n6), due to technical limitations.

Rising prevalence of child and adolescent obesity worldwide poses a threat to the future health and wellbeing of individuals. A better understanding of the mechanisms involved in the regulation of energy balance and therefore energy intake should help devise dietary strategies conducive to the maintenance of a healthy bodyweight during growth. Indeed, eating habits established during childhood are powerful determinants of future food preferences and choices in adulthood. Appetite for food and calorie-containing drinks is an important driver of energy intake and is modulated by a variety of environmental, psychological and metabolic factors. For instance, macronutrient manipulation and particularly increasing the protein content of meals at the expense of carbohydrates has been previously shown to reduce appetite in adults. Less research has been carried out in children due to methodological limitations. The first study described in this thesis sought to establish whether salivary sampling could be a non-invasive alternative to intra-venous blood sampling for the quantification of an appetite inducing peptide called ghrelin. Chapter 4 describes the dietary habits of a cohort of children (8-10 years old) and adolescents (13-17 years old) with a specific focus on sugar consumption and a comparison of key dietary characteristics with the Scottish Dietary Goals and with data from national dietary surveillance programmes. Subsequently, chapter 5 assesses the effect of protein content and portion size of dairy breakfast drinks in children and adolescents on appetite and caloric intake at an ad libitum snack buffet in a randomised crossover design study. Differences between age groups, nutritional status and genders were examined. Chapter 6 examines the correlations between performance at cognitive tests of executive function and ad libitum snack intake and chapter 7 presents new avenues of research into appetite in children and adolescents.

This study attempts to quantify the dissociative experiences reported by children and adolescents, and to determine whether the variance in degree of dissociation in children has useful diagnostic and treatment implications.

Hodgkin lymphoma (HL) is a heterogeneous condition varying from engaging one single lymph node site to a widespread condition. The prognosis with contemporary treatment is excellent for the vast majority. However, the treatment might cause severe late adverse effects in a proportion of the affected individuals. We evaluated all children and adolescents diagnosed in Sweden and registered in the Swedish Childhood Cancer Register over a period of 25 years. The incidence has been stable and the overall survival (OS) is very good, comparable to the best results in the world. Approximately ten percent encountered a relapse, but even after relapse the chances of survival were good. During the study period there were no detectable changes in survival estimates. The use of radiotherapy has decreased. Epstein Barr virus (EBV) and numbers of eosinophils, mast cells and macrophages in the tumors were investigated in 98 cases. Young children were more likely to express EBV. In patients with advanced disease the mast cell and macrophage counts were higher and they also had more affected laboratory parameters. Patients with Nodular Lymphocyte Predominant Hodgkin Lymphoma did not express EBV in the tumor, had significantly lower numbers of eosinophils, mast cells and macrophages and less affected laboratory parameters compared to classical HL. Outcome and clinical presentation were investigated in a cohort of children, adolescents and young adults in Sweden and Denmark and treatment in pediatric and adult departments was compared. OS and event-free survival (EFS) did not differ between the three age groups nor between pediatric and adult treatment. However, the Danish pediatric patients had lower EFS, which corresponded to less use of radiotherapy. Adolescents and young adults shared similar characteristics, while children presented differently with less advanced disease and male preponderance. Hospitalization rates and outpatient visits after end of treatment were evaluated to see whether the excess need of resources described in the literature is evenly distributed among the survivors or whether it is limited to a smaller group. Most of the patients had a low burden of health care use and the relapsing patients were the main drivers of the excess need.

The present study examined psychological factors associated with individual variation in children's adjustment following minor surgery, and focused specifically on the process of coping with postoperative pain. Sixty children and adolescents (7 to 16 yrs) were interviewed on the day following surgery. They provided ratings and descriptions of their postoperative pain experience, perceived capacity for pain control, spontaneous coping strategies, and emotional distress. Parents also provided information about their efforts (both historical and present) to facilitate their child's coping, their own emotional distress, and perceptions of their child's distress following surgery. Thirdly, nurses rated children's pain behaviours displayed on the ward. Finally, information about analgesic medications and physical complications following surgery was recorded from children's medical charts. Qualitative data concerning the process of coping with postoperative pain and specific parental influences on children's coping were presented within a conceptual model adapted from the adult stress and coping literature. The data were also analyzed for age/developmental differences between older children (10 to 16 yrs) and younger children (7 to 9 yrs). Finally the predictive role of demographic, child coping process, and parental influence variables, in accounting for variations in child coping outcome, was analyzed. Results indicated that children and adolescents experienced moderate to severe pain following minor surgery. They reportedly tried a number of different cognitive and behavioural methods to deal with postoperative pain. Also, parents took an active role in facilitating children's coping. Age group differences were revealed in children's descriptions of postoperative pain, their reported ways of coping with pain, and their perceptions of control over pain and recovery. Age effects were interpreted with caution, however, since age and sex were confounded in this sample. Children who reported the most pain and emotional distress following surgery also reported more catastrophizing cognitions, felt less in control of their recovery, and reported having tried a greater number of behavioral coping strategies to manage pain. These results emphasize the role of children's appraisal processes in predicting coping effectiveness, and demonstrate that more coping does not imply better outcome. Future research directions and potential clinical appplications that follow from these findings were discussed.
Arts, Faculty of
Psychology, Department of
Graduate

Research suggests that optimising affect during exercise may be key to exercise adherence (Van Landuyt, Ekkekakis, Hall & Petruzzello, 2000; Williams et al. 2008; 2012). Recent advances in this area have explored factors that contribute to affective responses in adult populations (Ekkekakis, 2003), but whilst it has been hypothesised that these factors are the same for children and adolescents they have not been explored systematically in the same way. As such, one aim of this thesis was to investigate the relationships between affect and physical activity in child and adolescent populations. Following on from this, a further aim was to explore the factors that contribute to affective responses. Given the research that suggests positive affect experienced during exercise may result in enhanced adherence to physical activity (Williams et al. 2012), the final aim of this study was to determine how to elicit the most positive affective responses during an acute exercise session. This thesis comprises a review of relevant literature, and six study chapters which were the result of three empirical studies; two acute exercise studies and one questionnaire based study. The findings of Study 1 demonstrated that, as with adults, affective responses declined after the onset of ventilatory threshold in both children and adolescents, indicating that to achieve optimum affective responses, particularly with younger children, exercise needs to be prescribed at an intensity below the ventilatory threshold. The findings from studies 2 - 4 highlighted specific factors that contribute to affective responses, reporting that preference for, and tolerance of, different exercise intensities may be an important factor to consider when prescribing exercise (studies 2 & 4). Results also showed that affective associations with physical activity played a significant role in determining overall physical activity behaviour (study 3). The findings from studies 4 and 5a and b revealed that encouraging adolescents to self-select their own exercise intensity may elicit a more positive affective response during the exercise session compared to the affective responses elicited during a prescribed exercise session. This thesis provides substantial evidence to support the link between affect and physical activity in children and adolescents. More specifically, it highlights several important factors that should be considered when attempting to enhance affective responses during an acute exercise session.

Mestrado em Análises Clínicas
MSc in Clinical Analysis
PORTUGUÊS: A prevalência da obesidade está crescendo em todo o mundo, sendo este aumento particularmente notório na infância e adolescência. Os alimentos ricos em calorias e o estilo de vida sedentário são duas das características do estilo de vida moderno, que pode estar por de trás desta pandemia. A obesidade pediátrica é particularmente importante em nosso país: uma alta prevalência de sobrepeso / obesidade (30%) tem sido descrita em crianças e adolescentes portugueses, em comparação com seus pares de outros países europeus. A obesidade tem sido associada a várias outras doenças, como hipertensão, diabetes mellitus tipo 2, síndrome metabólica e doenças cardiovasculares. Além disso, a inflamação é conhecida por desempenhar um papel vital nessas doenças, ou seja, na iniciação e progressão da doença arteriosclerótica vascular, na resistência à insulina, e dislipidemia. Mais recentemente, a obesidade tem sido proposta como um estado de baixo grau inflamatório crónico. De fato, O tecido adiposo é uma importante fonte de várias substâncias que estão ligadas à resposta inflamatória e à imunidade - as adipoquinas. As dietas de indivíduos obesos são, geralmente, ricos em gorduras saturadas e ácidos gordos (AG) trans, e pobres em AG polinsaturados (AGPI), especialmente, em AGPI do tipo ω 3. Este tipo de hábitos alimentares causa alterações endógenas no metabolismo lipídico, e pode levar a mudanças na constituição em AG em diferentes tecidos do corpo. A composição lipídica das membranas celulares é importante para as propriedades reológicas e físico-químicas das células, influenciando a actividade dos canais protéicos e das bombas da membrana, assim como de transportadores e receptores membranares. Deste modo, o perfil lipídico da membrana é importante na modulação da sinalização celular e de várias funções biológicas da célula. Os lípidos da membrana dos glóbulos vermelhos estão em equilíbrio constante com lípidos e lipoproteínas plasmáticos. Apesar dos níveis dos lípidos plasmáticos serem altamente influenciados pelo estado de jejum, os níveis e tipo de lípidos da membrana eritrocitária reflectem o equilíbrio lipídico por períodos mais longos. Os glóbulos vermelhos (GV), por tratarem-se de células não-nucleadas, apresentam uma capacidade de biossíntese e mecanismos de defesa muito limitados. Portanto, quando expostos a stress físico e / ou químico, o eritrócito sofre e acumula o dano imposta por aquelas fontes durante sua vida em circulação. Em condições de stress oxidativo a membrana do eritrócito, pode sofrer danos em seus lípidos e proteínas. Deste modo, o eritrócito é um bom modelo para estudar os danos oxidativos dos lípidos e proteínas que ocorrem em estados pró-inflamatórios e oxidativas, e também pode fornecer um importante modelo para estudar o impacto dos hábitos alimentares na composição dos lípidos e proteínas das membranas celulares. O objectivo deste estudo foi analisar o impacto da obesidade no perfil lipídico, no metabolismo da glicose e na inflamação, bem como o impacto da obesidade, e das alterações a ela associadas, na composição da membrana do GV. Foram estudadas 34 crianças e adolescentes obesos [15 (44,1%), com idade média de 14,1 anos (8-17)] do Hospital S. João e do Hospital Infantil Maria Pia. O grupo total foi dividido de acordo com o percentil do índice de massa corporal (IMC) em 17 obesos, 8 sobre-pesos e 9 controles. Obesidade foi definida como um IMC superior ao percentil 95, ajustados para idade e sexo, segundo " gráficos de crescimento do Centro de Controle de Doenças de 2000". Sobrepeso foi considerado para os percentis de IMC igual ou superior a 85 e inferior a 95; e controles quando o IMC era inferior ao percentil 85, ajustado para sexo e idade. Os três grupos estavam equilibrados para a idade, sexo e estágio de maturação sexual de Tanner. Foram determinados os níveis circulantes de triglicerídeos, colesterol, colesterol de lipoproteína de alta densidade, colesterol de lipoproteína de baixa densidade, lipoproteína (a), apolipoproteína A, apolipoproteína B, proteína C-reativa, glicose e insulina. Um estudo hematológico básico foi realizado. A membrana eritrocitária foi estudada com a determinação de marcadores de lesão eritrocitária: hemoglobina ligada a membrana, carbonilação proteica, peroxidação lipídica e perfil de banda 3 – agregados de alto peso molecular, monómeros e fragmentos proteolíticos. O perfil de ácidos gordos da membrana foi também determinado. Os indivíduos obesos apresentaram, quando comparados com os controlos, alterações para um perfil lipídico mais aterogénico, um aumento da resistência à insulina e da inflamação. Assim, houve um aumento geral dos marcadores de risco de doença cardiovascular (DCV). Nenhuma diferença significativa foi encontrada no eritrograma ou nos marcadores de lesão eritrocitária. Quanto ao perfil de AG da membrana eritrocitária, os AG insaturados apresentaram uma tendência para o aumento, enquanto os AG saturados mostraram uma tendência para diminuir com a obesidade. Apesar disso, o AG beénico ácido (22:0) apresentou um aumento significativo nos obesos, em comparação com os controles. Uma proporção crescente de 20:0, 18:3n3, 20:3n6e 22:4n6 foram encontrados para indivíduos com sobrepeso e obesos, em relação aos controlos. Estes AG, que aumentaram com a obesidade, apresentaram as associações mais significativas com os marcadores de DVC estudados e que estão alterados com a obesidade na nossa população. Mais estudos são necessários para esclarecer as associações entre as alterações do perfil de AG da membrana eritrocitária e os marcadores de risco de DCV. Um estudo envolvendo mais participantes poderia ajudar a esclarecer algumas tendências observadas. Quanto à análise da membrana lipídica, algumas abordagens interessantes poderiam ser feitas, como analisar separadamente os AG ligados a fosfolípidos e ésteres de colesterol, ou analisar individualmente cada folheto da membrana plasmática (interno e externo). Além disso, a optimização da técnica de separação e identificação dos AG seria fundamental, pois no presente estudo não pudemos avaliar AG importante, como por exemplo o EPA (ácido eicosapentaenoico - 20:5n3) e GLA (ácido gama linolénico - 18:3 n6), devido a limitações técnicas.
ENGLISH: The prevalence of obesity is growing worldwide and in childhood the increase is particularly striking. The caloric rich foods and the reduced physical exercise practice are two of characteristics of the modern lifestyle that may underlie this pandemia. Childhood obesity is particularly important in our country, as a high prevalence of overweight/obesity (over 30%) has been reported for Portuguese children, as compared to other European countries. Obesity has been associated with several other diseases, such as hypertension, type 2 diabetes mellitus, metabolic syndrome and cardiovascular diseases. Moreover, inflammation is known to play a vital role in those diseases, namely, in the initiation and progression of the atherosclerotic vascular disease, in insulin resistance, and in dyslipidemia. More recently, obesity has been proposed as a chronic low grade inflammatory condition. The white adipose tissue is an important source of several substances that are linked to inflammatory response and to immunity - the adipokines. The diets of obese individuals are, usually, rich in saturated and trans fatty acids (FA), and poor in polyunsaturated FA (PUFA), especially, in ω 3 PUFA. These type of dietary habits, by leading to endogenous changes in FA and in lipid metabolism, may, ultimately, lead to changes in the proportions of the different FA in body tissues. The lipid composition of the cell membranes are important determinants in the rheological and physico-chemical properties of the cells, influencing the activity of membrane channels, pumps, transporters and receptors. Thus, it is important in the modulation of cell signalling and in several biological functions. The lipids of the red blood cell membrane are in constant equilibrium with plasmatic lipids and lipoproteins. While the levels of lipids in plasma are highly influenced by the fasting status, the levels and type of lipids of the erythrocyte membrane reflect the lipid balance of longer periods. The red blood cell (RBC), as a non-nucleated cell, exhibits a very limited biosynthesis capacity and poor repair mechanisms. Therefore, when exposed to physical and/or chemical stress, during their lifespan, the erythrocyte suffers and accumulates the damage imposed by such stress. In oxidative stress conditions the erythrocyte membrane, may suffer oxidative damage in membrane lipids and proteins. Thus, the erythrocyte is a good model to study the oxidative damage of lipids and proteins occurring in pro-inflammatory and oxidative conditions and may also provide an important model to study the impact of dietary habits in the lipid and protein composition of the cell membranes. The objective of this study was to analyse the impact of obesity in the lipid profile, glucose homeostasis and inflammation, as well as the impact of obesity and the associated changes in the RBC membrane composition. We studied 34 obese children and adolescents [15 (44.1%); mean age of 14.1 years (8-17)] from Hospital S. João and the Children’s Hospital Maria Pia. The total group was divided according to the body mass index (BMI) percentile in 17 obese, 8 overweight and 9 controls. Obesity was defined as a BMI higher than the 95th percentile, for age and gender, according to the “2000 Centre for Disease Control and Prevention (CDC) growth charts”. Overweight was considered for BMI percentiles equal or higher than 85 and lower than 95; and control subjects BMI were lower than the 85th percentile, adjusted for gender and age. The three groups were matched for age, gender and tanner stage. It were determined the circulating levels of triglycerides, cholesterol, high density lipoprotein cholesterol, Low density lipoprotein cholesterol, lipoprotein (a), apolipoprotein A, apolipoprotein B, C-reactive protein, glucose, and insulin. A basic hematologic study was also performed. The erythrocyte membrane was studied with the determination of erythrocyte damage markers: membrane bound haemoglobin, proteic carbonylation, lipid peroxidation and band 3 profile - high molecular weight aggregates, monomers and proteolytic fragments. The membrane fatty acid profile was determined. We found that the obese individuals, presented risk changes in the lipid profile, increased insulin resistance and inflammation, when compared to their lean counterparts. Thus, several changes in cardiovascular disease (CVD) risk markers were observed. No significant changes were found in the erythrogram and in the erythrocyte damage markers. Concerning the FA membrane profile, the unsaturated FA showed a trend to increase, while saturated FA showed a trend to decrease, with obesity. Despite that, behenic acid (22:0) presented a significantly increase in obese, in comparison with controls. An increasing proportion of 20:0, 18:3n3, 20:3n6 and 22:4n6 were found for overweight and obese individuals, as compared to control. These FA increased with growing obesity, and presented the most significant associations with the studied CVD markers associated with obesity. Further studies are needed to clarify the associations between membrane FA changes, and CVD risk markers. A larger study, with a higher number of individuals could also clarify some observed trends. Regarding the lipid membrane analysis, some interesting approaches could be made, such as to separate and analyze the different phospholipids and cholesterol ester and their associated FA, and to perform a separate study of inner and outer membrane sheets. Furthermore, optimization of the separation technique and consequent identification of FA would be crucial, as in this study we could not evaluate important FA, e.g. EPA (20:5n3) and GLA (18:3n6), due to technical limitations.

The concept of alexithymia refers to impairments in the ability to identify and communicate feelings. Alexithymia has repeatedly been linked to attachment impairments and different types of symptomatology, in particular, depression and somatic complaints. Very few studies have focused on children or adolescents when addressing this construct. Additionally, to date, there is no self-report questionnaire of alexithymia for such groups in the Spanish language. The main objectives of this study were therefore, (a) to translate and adapt the Alexithymia Questionnaire for Children to Spanish; (b) to assess the factor structure of the adapted questionnaire; and (c) to describe its reliability and validity, in a sample of N = 265 Peruvian adolescents aged 11-18 years. Internal consistency was acceptable for the DIF subscale ( α = .74), and low for the DDF and EOT subscales ( α = .55, and α = .47 respectively). A composite scale based on previous studies that merges DIF and DDF into one scale had an α = .75. Regarding the factor structure, a two–factor solution showed to have the best fit with the data (RMSEA = .05, SMRM = .04, CFI = .94). Convergent validity analyses indicated significant associations between alexithymia and attachment measurements (that ranged from r = - .15, p < .05, to r = .31, p < .05), somatic complaints (r = .38, p < .05, to r = .41, p < .05), and both internalizing and externalizing symptoms (r = .37, p < .05, to r = .46, p < .05). Future assessment and modifications are recommended for the EOT scale.
El concepto de alexitimia se refiere a las deficiencias en la capacidad de identificar y comu­ nicar sentimientos. Este constructo ha sido relacionado con deficiencias en apego y con dife­ rentes tipos de sintomatología, en particular, con depresión y quejas somáticas. Muy pocos estudios sobre alexitimia se han enfocado en niños o adolescentes. Además, hasta la fecha, no existe ningún cuestionario de auto-reporte de alexitimia para tales grupos en español. Por lo tanto, los principales objetivos de este estudio fueron, (a) traducir y adaptar el Cuestio­ nario de Alexitimia para Niños al español; (b) evaluar la estructura factorial del cuestionario adaptado; y (c) describir su confiabilidad y validez, en una muestra de n = 265 adolescentes peruanos de 11-18 años de edad. La consistencia interna fue aceptable para la subescala DIF ( α = .74), y baja para las subescalas DDF y EOT ( α = .55 y α = .47, respectivamente). Una escala compuesta basada en estudios previos que fusiona las subescalas DIF y DDF en una sola escala tuvo un α = .75. En cuanto a la estructura factorial, una solución de dos factores demostró tener el mejor ajuste con la data (RMSEA = .05, SMRM = .04, CFI = .94). Los análisis de validez convergente indicaron asociaciones significativas entre alexitimia y apego (con coeficientes desde r = -.15, p <.05, hasta r = .31, p <.05), quejas somáticas (r = .38, p <.05, hasta r = .41, p <.05), y síntomas internalizantes y externalizantes (r = .37, p <.05, hasta r =. 46, p <.05). Se recomienda la evaluación y/o modificación de la escala EOT.
O conceito de alexitimia se refere às deficiências na habilidade de identificar e comunicar sentimentos. A alexitimia tem sido frequentemente associada à deficiências de apego e dife­ rentes tipos de sintomatologia, em particular à depressão e queixas somáticas. Pouquíssimos estudos dão enfoque à crianças ou adolescentes ao tratar desse conceito. Além disso, até o momento não há questionários de autorrelato em espanhol sobre alexitimia para tais grupos. O objetivo principal deste estudo foi, portanto, (a) traduzir e adaptar o “Alexythymia Ques­ tionnaire for Children” para o espanhol; (b) avaliar a estrutura de fatores do questionário adaptado; e (c) descrever sua confiabilidade e validade numa amostra de N=265 adolescentes peruanos de 11 a 18 anos de idade. A consistência interna mostrou-se aceitável para a subscala DIF ( α = .74), e baixa nas subscalas DDF e EOT ( α = .55, e α = .47 respectivamente). Uma­ escala composta, baseada em estudos anteriores, combina DIF e DDF numa única escala e apresentou α = .75. Em termos da estrutura de fatores, uma solução de dois fatores foi a que            melhor se ajustou aos dados (RMSEA ==.05, SMRM = .04, CFI = .94). Análises de validade convergentes indicaram associações significantes entre alexitimia e medidas de apego (as quais variaram de r = -.15, p < .05, a r = .31, p < .05), queixas somáticas (r = .38, p < .05, a r = . 41, p < .05), e sintomas internalizantes e externalizantes (r = .37, p < .05, to r = . 46, p < .05). Avaliações futuras e modificações são recomendadas para a escala EOT.

PONTIFÍCIA UNIVERSIDADE CATÓLICA DO RIO DE JANEIRO
A presente pesquisa tem como objetivo discutir repercussões da violência conjugal como violência psicológica contra crianças e adolescentes, considerando a exposição da prole em espaços de convivência familiar onde a dinâmica de violência entre o (ex) casal parental é presente e frequente. Para tanto, foi realizada uma pesquisa qualitativa, através da análise de quatro casos atendidos em uma unidade de referência da rede de proteção a mulheres vítimas de violência doméstica no município do Rio de Janeiro. Os resultados demonstram a persistência de segmentação da rede de atendimento, desfavorecendo a abordagem da família em sua complexidade e dificultando a garantia, concomitante e integrada, dos direitos humanos de mulheres vítimas de violência conjugal e de seus filhos quanto às repercussões destes conflitos como expressão possível de violência psicológica.
The following research aims to discuss repercussions of domestic violence as well as psychological violence against children and adolescents, considering offspring exposure to family dynamics of frequent violence between parents. To do this, a qualitative study was conducted by analyzing four cases in a women s domestic violence treatment unit in Rio de Janeiro. The results demonstrate the continued segmentation of the service network, compromising the complexity of a family approach and making it difficult to guarantee the concurrent and integrated human rights of women domestic violence victims and their children on the impact of these conflicts as possible expressions of psychological violence.

O olhar para uma população específica, crianças/adolescentes, em uso/abuso de álcool e outras substâncias psicoativas foi o enredo desse trabalho. Partiu-se a priori da investigação de 38 casos de adolescentes que deram entrada no Pronto Atendimento Municipal (PAM) e foi-se construindo o caminho percorrido pela amostra dentro das possibilidades de atendimento em Taquaritinga-SP, este município do interior paulista pertencente à regional de Araraquara que tem como estrutura uma rede de serviços de saúde mental especializados: um ambulatório infantil (ASMi) e um centro de atenção psicossocial infantil (CAPSi). Identificou-se que não se tratava de uma questão simples, mas complexa com muitas facetas, vindo em direção às perspectivas de Morin que confrontam teorias e idéias sem preconceitos. Esse trabalho usa o estudo exploratório descritivo de abordagem quantitativa e qualitativa e teve por objetivo identificar o percurso de crianças/adolescentes usuários de álcool e outras substâncias psicoativas, além de verificar se o Centro de Atenção Psicossocial infantil (CAPSi) do município se faria presente como estratégia de tratamento prevista no Plano Emergencial de Ampliação do Acesso ao Tratamento e Prevenção de Álcool e outras Drogas (PEAD 2009-2011). A análise resultante desse estudo revelou que os serviços prestam acolhimento a população adscrita por várias portas de entrada, mesmo não tendo um programa para tratamento. Mostra também que o trabalho tem a necessidade de ser realizado em conjunto, ser articulado em rede e que sua concretização é um desafio. Com a inexistência de respostas prontas, alerta-se para a necessidade da busca de novas reflexões e construções a respeito do tratamento de crianças/adolescentes usuários de substâncias psicoativas.
The look for a specific population, children/adolescents, in the use/abuse of alcohol and other psychoactive substances was the scenario of this work. The starting point was the investigation of 38 cases of adolescents who were admitted to the Municipal Emergency Care (PAM) and has been built the road traveled by the sample within the possibilities of service in Taquaritinga-SP, this city in the interior belonging to regional Araraquara which has as structure network of specialist mental health services: a childhood ambulatory (ASMi) and a psychosocial care center for children (CAPSi). It was found that this was not a simple matter, but with many complex facets, coming towards the Morin´s prospects which confront theories and ideas without prejudice. This work uses the descriptive exploratory study of quantitative and qualitative approach and aimed to identify the route of children/adolescents who use alcohol and other psychoactive substances, besides to checking if the Psychosocial Care Center child (CAPSi) of the city would be present as treatment strategy referred on the Emergency Plan for Expansion of Access to Treatment and Prevention of Alcohol and other Drugs (PEAD 2009-2011). The resulting analysis of this study revealed that the hosting services are provided to enrolled population by various ports of entry, while not having a program for treatment. It also shows that the work has needed to be done together, to be articulated in the network and that its implementation is a challenge. With the lack of ready answers, it is cautioned to the need to search for new ideas and constructions concerning the treatment of children/ adolescents users of psychoactive substances.

Este estudo transversal investigou os tipos de gratidão expressos por crianças e adolescentes de Porto Alegre, para verificar se diferentes formas de expressar a gratidão aparecem ao longo do desenvolvimento humano. 430 escolares de 7 a 14 anos, de ambos os sexos, escolhidos por conveniência em 2 escolas públicas e 2 escolas particulares responderam às perguntas de Baumgarten-Tramer: "O que tu mais queres?" e "O que tu farias para a pessoa que te desse o que tu mais queres?". Uma análise de conteúdo das respostas à segunda pergunta indicou que a expressão do sentimento de gratidão varia de acordo com a idade, não sendo encontrada diferença significativa na forma como meninos e meninas expressaram a gratidão. Embora tenha sido fortalecida a hipótese de que a gratidão se desenvolve ao longo da infância, muitos estudos restam ser feitos ainda sobre o assunto.
This cross-sectional study investigated the types of gratitude expressed by school children and adolescents of Porto Alegre, aiming to verify whether different forms of expressing gratitude appear during human development. 430 students aged 7-14, of both sexes, chosen by convenience from 2 public schools and 2 private schools responded to Baumgarten-Tramer's questions: "What is your greatest wish?" and "What would you do for the person who granted you this wish?" A content analysis on the answers to the second question suggested that the expression of the feeling of gratitude varies by age. No significant difference was found in the way boys and girls expressed their gratitude. Although the hypothesis that gratitude develops throughout childhood has been supported, more studies should be conducted on this important topic.

The majority of UK children and adolescents are not meeting physical activity (PA) recommendations, despite the benefits for physical and psychological health (PH). Natural environments facilitate PA and in adults performing PA whilst exposed to nature ('green exercise') results in additional benefits for PH. However, the effects of exercise environment have not been extensively studied in children and adolescents. The primary aim of this study was to examine the effect of exercise environment on the time spent in moderate to vigorous PA (MVPA) in children and adolescents. The secondary aim was to determine whether green exercise provides additional benefits for PH. Due to variation in PA patterns and opportunities for contact with nature, children and adolescents were examined separately. For children, accelerometers (ACCs) determined whether school playtime (SP) on the field and participation in nature- based interventions lead to greater MVP A than play on the playground and participation in playground-based interventions. A child version of Rosenberg's Self- esteem Scale (RSES), developed and reported in this thesis, examined the effect of the environmental conditions on self-esteem (SE). In adolescents, heart rate (HR) examined and compared the effect of indoor and outdoor environments on MVP A, whilst ACCs assessed the influence of acute exposure to urban and rural environments on P A. RSES and the adolescent profile of mood states (POMS-A) questionnaire compared the effect of the environments on SE and mood. In both children and adolescents, results indicated that natural environments led to higher levels of MVP A. No additional benefits for PH were provided by performing PA in natural environments. Unlike in adults, the current generation of youth do not seem to be connected to nature in a way that allows it to influence their PH. Nature can be used to promote PA in children and adolescents and should thus be incorporated into everyday routines.

The principle aim of this work was to provide an insight into the prevalence of the metabolic syndrome (MetS) in children and adolescents and to examine the associations of body composition measures, cardiorespiratory fitness (CRF), and physical activity with cardiometabolic risk. The combined association of adiposity and CRF on cardiometabolic risk in youths is also explored, as is the association of CRF with potentially modifiable variables, such as physical activity. This work has shown that, dependent on the definition employed, MetS may be present in 2.3% to 9.8% of children and adolescents in Bedfordshire, UK. When applying modified Adult Treatment Panel III definitions (Cook et al. 2003; de Ferranti et al. 2004), the condition was significantly more prevalent in overweight compared to non-overweight youths. Backward regression analyses identified that only body mass index (BMI) explained significant amounts of variance in clustered cardiometabolic risk, although being overweight according to internationally proposed cut points for BMI, waist circumference (WC), and waist-to-height ratio conferred participants to increased risk compared to their non-overweight counterparts. Clustered risk was also elevated in children and adolescents with low levels of CRF compared to those with high levels, whereas time spent in moderate-to-vigorous physical activity and vigorous physical activity (VPA) held no association. When stratified into groups according to level of fatness (BMI z-score) and CRF, those with high fatness/low CRF generally exhibited the most unfavourable cardiometabolic risk profiles. Cardiometabolic risk was higher in the high fatness/low CRF group compared to those with low fatness/low CRF and low fatness/high CRF when excluding WC from the score, and those with low fatness/low CRF when including WC in the score. Multiple regression and ANCOVA revealed that increased visceral fatness (indirectly measured using WC) was associated with reduced CRF, while increased time spent in VPA was associated with elevated CRF. These data suggest that BMI may be the best simple measure of obesity to employ when exploring adiposity-related cardiometabolic in children and adolescents. In addition, results from this iv investigation indicate that low CRF and overweight/obesity may have deleterious effects on the cardiometabolic health of children and adolescents and that interventions to reduce risk may target decreases in fatness and improvements in CRF and VPA as standard.

This thesis starts with a quantitative investigation into the effectiveness of Cognitive Behaviour Therapy (CBT) school-based interventions on children and adolescents’ levels of social anxiety. The findings of this systematic review of the literature indicated that CBT interventions might effect a positive reduction in adolescents’ social anxiety on an immediate, post-test intervention basis. However, not enough evidence currently exists to suggest that CBT is effective on a longer-term basis due to studies’ lack of follow-up data and low/medium methodological quality (based on studies’ Weight of Evidence judgments). This thesis includes a bridging document. This document makes a link between the systematic review of the literature and the empirical research study. The bridging document aims to make explicit how I came to shift my research focus from a quantitative systematic review of the literature on CBT towards a small-scale, qualitative exploration into the perceptions of three parents. Parents were invited to reflect upon anxious adolescents’ transitions from compulsory school education into the adult world. The empirical research study details the rationale, design and findings from a small scale study which involved interviewing parents. The interviews were analysed using Interpretative Phenomenological Analysis (IPA). Three superordinate themes emerged which focussed on: parents’ perceptions of service delivery for anxious adolescents, anxious adolescents’ ability to cope in social situations, and the potential for anxious adolescents to make a fresh start as they transition into adulthood. This empirical work contributes to research into parental perceptions and social anxiety, and the practical implications for Educational Psychology practice are also considered.

Background and objective: Childhood obesity is a serious global health problem and it is associated with insulin resistance and significantly increased risk for development of type 2 diabetes and cardiovascular disease. Metformin reduces the risk of developing T2D in adult patients with obesity and insulin resistance. However there is limited and inconclusive data in obese non diabetic children and adolescents. The objective of the Metformin in Obese Children and Adolescents (MOCA trial) was to assess the effect of metformin on body composition, metabolic risk factors and adipokines. Design and methods: The MOCA trial was a six month multi-centre randomized, double-blind placebo-controlled trial of metformin (1.5g daily) in children and adolescents (8-18 years) with insulin resistance and/or impaired glucose tolerance. Auxology, blood pressure measurement and fasting blood tests (insulin, glucose, fasting lipids, ALT, bilirubin, CRP, lactate, resistin, adiponectin, leptin) were performed at baseline, three and six months. A prolonged oral glucose tolerance test was performed at baseline and after six months. Measures of insulin resistance/sensitivity were calculated including HOMA-IR and the adiponectin: leptin (A/L) ratio. Results: 151 obese children participated in the trial (metformin:77, placebo:78). 102 (67.5%) female, 99 (65.6%) post-pubertal, 115 (76.2%) White British and 36 (23.8%) British Asian or Afro-Caribbean. Mean age of participants was 13.7 ±2.3 year and mean BMI-SDS 3.4 (0.5). In regression analysis, controlling for baseline values, sex, ethnicity and pubertal status, metformin had a greater treatment effect over placebo for BMI at three months, that was sustained at six months (-0.25 kg/m2, p=0.01, 95% CI 0.29 to 1.86) and BMI-SDS (-0.1, p=0.01, 95% CI 0.02 to 0.19). Fasting glucose reduced (-0.03 mmol/l, p=0.03) and A/L ratio increased at three months (+0.04, p=0.03), but the improvements were lost at six months. The other measures of insulin sensitivity, metabolic risk factors and concentrations of adipokines did not change with metformin treatment. Conclusions: Metformin therapy for obese children with abnormal insulin glucose status is safe, well tolerated and has a small beneficial treatment effect over placebo for BMI, BMI-SDS, fasting glucose and A/L ratio at three months, with the changes in body composition sustained at six months. A three month course of metformin should be considered by Paediatricians to halt the inexorable rise in BMI-SDS in these children, improve insulin glucose status and act as catalyst and support for more radical change in lifestyle in the individual. Trial register number: ISRCTN 19517475.