ANUARIO DE PSICOLOGÍA CLÍNICA Y DE LA SALUD ANNUARY OF CLINICAL AND HEALTH PSYCHOLOGY

www.institucional.us.es/apcs 2007, VOLUME 3

Department of Personality, Assessment and Psychological Treatments University of Seville

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical and Health Psychology, 3 (2007)

Index Editorial: Current Trends in Disability: A Psychological Approach pp v-vi Invited Articles An up-to-date review of the situation of university students with disabilities. Alcedo Rodríguez, M.A., Aguado Díaz, A.L., Real Castelao, S., González González, M. y Rueda Ruiz, B. pp 7-17 Cognitive treatment for children with attention deficit hyperactivity disorder (ADHD). Review and new contributions. Orjales Villar, I. pp 19-30 Ten noteworthy references about: Current trends in disability: a psychological approach. Lanzarote Fernández, M.D., Padilla Muñoz, E., Rubio Zarzuela, E.

pp 31-39 Regular Articles Retrosprective and prospective study of premenstrual symptomatology in the general population. Gómez Márquez, C., García García, M., Benítez Hernández, M.M., Bernal Escobar, L., Rodríguez Testal, J.F. pp 41-62 What does a trauma hide? From all that is indescribable to the process of recovery. Balbuena Rivera, F. pp 63-67 Theoretical Articles Attention Deficit Hyperactivity Disorder (ADHD) as a risk factor for addictive behaviour in adulthood. Romo Jiménez, L. pp 69-71 Norms for the publication of papers in Anuario de Psicología Clínica y de la Salud / Annuary of Clinical and Health Psychology pp 73-76 www.institucional.us.es/apcs 2007, VOLUME 3 Departamento de Personalidad, Evaluación y Tratamiento Psicológicos

Universidad de Sevilla

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical and Health Psychology, 3 (2007) v-vi

Editorial Following the line established by the previous two volumes, we submit the third one, which deals with a

monographic topic. On this occasion, we have decided to focus on “Current Trends in Disability: A Psychological Approach”, considering that it is a very relevant issue, and that interest in its research, far from diminishing, is on the increase, and it can even be stated that it has reawakened in past years, both in our country (seen in the recent introduction of the Dependence Act, and in the publication of the Act on Equal Opportunities, Non-Discrimination and Accessibility for Disabled People) and abroad (seen in the publication of the International Classification of Functioning, Disability and Health, and in the year 2003 declared the “Year of disabled people in Europe”, etc.)

The journal, which is still sponsored by the Personality, Assessment and Psychological Treatment Department of

University of Seville, is currently managed by a new management team that hopes to equal, at least, the work developed by the previous one, and that must continue offering specialized information about different aspects related to Clinical and Health Psychology.

It is quite encouraging that, among the pieces of work included in such an incipient electronic, free-access

publication, we were able to rely on the contributions of specialists on disability as important as professors Antonio Aguado and his team, from Universidad de Oviedo, and Isabel Orjales, from Universidad Nacional de Educación a Distancia (National University of Distance Learning).

The research “Una revisión actualizada de la situación de los estudiantes con discapacidad en la universidad” (An

updated revision of the situation experienced by disabled students at university), led by Alcedo, with contributions by Aguado, Real, González y Rueda, places the reader within the reality people with disabilities (of different kinds) face when they enter a university context urged by the realization of their higher education. Following an outstanding theoretical contribution as well as of aspects in relation to the Spanish law on the subject, said research offers empirical data from different foreign campuses where disabled students take university courses. Likewise, the authors analyse the needs registered students from Universidad de Oviedo have, and they highlight the importance these institutions should give to accessibility, resource adjustment and technical assistance promotion. Although there is a major increase of devices and services developed for this kind of students, the authors emphasize that the independence allowed to universities, as well as the lack of legal materialization, make it difficult to comply with legal requirements. However, the research offers a series of guidelines aimed at mitigating discriminatory situations, and it is committed to a triple proposal to resolve issues related to structure (accessibility), statutes (legal measures), and relationships (integration).

The second piece of work mentioned is about “El tratamiento cognitivo en niños con trastorno por déficit de

atención con hiperactividad (TDAH): revisión y nuevas aportaciones” (Cognitive Treatment of Children with Attention Deficit Hyperactivity Disorder (ADHD): revision and new contributions), whose author has extensive experience in this children’s disorder. Based on the presentation of various therapeutic models, highlighting the strong and weak points in each of them, this research broadens the self-instruction plan taken from the Meichenbaum Self-instruction Training Program, and its use for training tasks. Professor Orjales highlights the effectiveness of this model, and its positive impact from the clinical point of view. Nevertheless, she has discovered some failures in this self-instruction program, and she has directed her efforts towards broadening its phases. In this piece of work, she contributes an excellent account that gives the reader a general outlook on all the benefits of each of its components. She has also proved –and she confirms it- that it can become a major resource to improve cognitive performance when applied on children from 6 to 12 years old, but she highlights the need to use multidimensional programs on children with ADHD.

The research carried out by Lanzarote, Padilla and Rubio is focused on the analysis of Ten Outstanding

References on the monographic topic. It centres on those pieces of work that –from a clinical and health perspective- deal with the current situation disabled people go through, taking into account the difference among countries; thus, it includes recent bibliography by Spanish as well as foreign authors. The authors try to cover methodology, evaluation and treatment aspects in relation to the filed in question, and they do so using articles focused on conceptual and research matters. We believe that this article offers quite an extensive outlook on disability on a descriptive level,

Editorial

from a critical and constructive point of view. In this respect, their proposals in relation to the need for a consolidated interdisciplinary approach, as well as for prevention in high-risk populations, more professional training, greater work on the adjustment of evaluation means, and the promotion of the family as a resource and support facilitator, are quite though-provoking.

We hope that –through the deliberate reading of this monograph- all the professionals working in this field can

continue providing more insight into an issue so relevant to society, and that we all move towards its development and progress.

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical and Health Psychology, 3 (2007) 7-17

An up-to-date review of the situation of university students with disabilities

Alcedo Rodríguez, M.A., Aguado Díaz, A.L., Real Castelao, S., González González, M. y Rueda Ruiz, B.1

School of Psychology University of Oviedo, (Spain)

ABSTRACT This study seeks to provide information about the situation and needs of university students with disabilities. In this regard, the paper gives information related to Spanish legislation about this group, describes the services, programmes and opportunities offered to these students, and reviews and describes the main field studies in the scientific literature which carry out research on the situation, the characteristics and other aspects related to university students with disabilities. Finally, as an illustrative example, it presents the data and conclusions from a study conducted by the University of Oviedo, dealing with their disabled students Key Words: University and disability, disability, disabled students, university students with disabilities, inclusion, integration, accessibility, architectural barriers, social barriers, attitudes, attitudes to disability, change of attitude, assessment, needs analysis, intervention. INTRODUCTION

Studies on university and disability are recent, few, and isolated. As a matter of fact, no research was ever published before 1996. In addition to the quantitative shortage, the scientific literature sets out qualitative problems as regards procedures and findings. These problems entail a lack of a general vision of the situation of university students with disabilities and prevent inter- or intra-institutional comparative studies from being carried out.

The first difficulty arises when establishing the

quantitative relevance of these students, since there is no census of disabled university students, but only estimations. Secondly, the majority of the studies published have an action framework confined to their own university, and are based on the enrolment information provided when the students communicate their situation of disability in order to apply for free registration. This source of information does not provide access to national statistics, as not all the universities observe the tax exemption established by the law. According to data from CERMI (the Spanish Committee of Representatives for the Disabled), the

universities from the Spanish autonomous communities of Galicia, Extremadura and La Rioja did not yet have such tax exemption in the academic year 2005-2006. One more fact is that not all the students who tick the disability box are really disabled, since they also tick it if one of their the academic year 2005-2006. One more fact is that not all the students who tick the disability box are really disabled, since they also tick it if one of their parents is disabled and they depend economically on them. Furthermore, there are disabled students who do not tick the disability box for lack of information or for fear of being discriminated against.

According to data from the INE (Spanish Institute of National Statistics), out of the 2,339,200 disabled people aged 16 to 64, almost 225,000 completed secondary education. As regards higher education graduates, the percentage of disabled people who graduated hardly goes beyond a third of non-disabled people; in fact, the figures are 8.7% versus 23.7%. If the second cycle of secondary education (grades 11 and 12) and higher education are considered, the percentage of graduates with disability is 19.1%, whereas the non-disabled graduate population amounts to 44.9%. Yet, in spite of this discouraging data, an important increase of disabled students who gain access to university education can be noticed (Calvo, 2006; De la Red, De la Puente, Gómez and Carro,

1 School of Psychology, University of Oviedo, Spain Plaza Feijoo, s/n - 33003 - Oviedo - Fax: 98-5104144 Tel. 98-5103284 - E-mail: aaguado@correo.uniovi.es

Alcedo Rodríguez, M.A. et al.: An up-to-date review of the situation of university students with disabilities

2002; Forteza and Ortego, 2003; Papadopoulos and Goudiras, 2005; Segura and Andreu, 1999). It is estimated that the number of Spanish university students with disabilities is higher than 7,000, although it is worth mentioning that around 35% of them, that is to say, about 2,450 students, take distance learning courses at the Spanish Open University UNED (Gonzñalez-Badía and Molina, 2006a). If we bear in mind that the number of students registered only in universities that require attendance, the figure was 1,120,831 in the academic year 2006-2006 (MEC, 2007), the estimated 4,550 students with disabilities in this type of Spanish university represent 0.40% of the total number of university students.

On the basis of this data, and without disregarding

possible mistakes, it can be stated that the university does not seem to be the priority choice in the education of people with disabilities, either because of determining personal factors, or because of the requirements imposed by the institution itself. There are a number of authors who incline for the second alternative, and so brand the university as being segregationist and exclusive, or, rather, in more positive terms, as lacking preparation or resources for integrating these students. (Bausela, 2002; Bilbao, 2003; Susinos and Rojas, 2004). In the same line of thought, and from different contexts, Wright (2006), Calvo (2006), and González-Badía and Molina (2006a) agree in pointing out and denouncing the lack of resources in the institution of the university, and assert that it is the students themselves who need to find the necessary resources in order to overcome difficulties and barriers. This theme is, therefore, an emergent social problem for which the university community should provide solutions.

The circumstances we have described justify the

need for complete information about the situation and needs of the university students with disabilities. This is a basic requirement in order to increase equality of opportunities of these students and to encourage their full social integration. For this reason we now go on to deal with the Spanish legislation related to university students with disabilities, to the services, programmes and further measures that are offered, and, finally, we examine and describe the main field studies in the scientific literature devoted to finding out the situation, characteristics and other aspects of university students with disabilities. 1. SPANISH LEGISLATION ON UNIVERSITY STUDENTS WITH DISABILITIES

The legislation that regulates the full integration of

people with disabilities into society is established in the Spanish Constitution in Title I, on fundamental rights and duties, Chapter III, article 49, on the principles governing social and economic policies. From a more specifically legislative point of view, The Constitutional Law 13/1982, of the seventh of April, on the social integration of people with disabilities, widely known as the LISMI (“Ley de Integración Social de los Minusválidos”), regulates the principles of normalisation and integration of people with disabilities in all the spheres of social life.

As for education, article 27/10 of the Spanish Constitution recognises the autonomy of universities in the terms established by the law. The Constitutional Law 6/2001 of the twenty-first of December, on universities, establishes various actions in the twenty-fourth additional regulation, on persons with disabilities, titled “De la integración de estudiantes con discapacidad en las Universidades” (On the integration of students with disabilities into university), and its article 46 regulates equality of opportunities and admits no discrimination, for personal, social or disability circumstances in the access to, admission into or continuance in university; and in the exercise of academic rights.

The university law presently in force is

Constitutional Law 4/2007, of the twelfth of April, on Universities, which substitutes the controversial LOU (Constitutional Law on Universities) passed in 2001. Throughout six articles, the new law addresses the university’s role in its assistance to people with disabilities. Thus, the first three articles make reference to equality of opportunities; stress the avoidance of discrimination and the establishment of measures that may guarantee this basic right. The fourth article is centred on accessibility to university buildings and rooms, including virtual spaces, and refers, for accessibility conditions, to the so-called LIONDAU, that is, Law 51/2003, of the second of December, on Equality of Opportunities, no Discrimination and Universal Accessibility for the Disabled. The fifth article proclaims that all the study plans proposed by the universities need to bear in mind that, in any professional activity, education and training need to be developed through respect and promotion of human rights, and through the principles of universal accessibility and design for all. This is a measure that stresses laws as the aforementioned LISMI or LIONDAU. However, due to lack of precision, it may still stay at the theoretical level, as has happened so far. The sixth article regulates total exemption of tax and expenses leading to obtaining a university degree. A practical reality of this new legislative precision has been the approval of tax exemption for the 2007-2008 academic year in the autonomous communities of Madrid and Galicia, so joining the almost total number of Spanish universities which keep to this measure.

Finally, the content of the fourth additional

regulation, on specific assistance programmes, formerly dealing with universities of the Catholic Church, now has specific programmes, personalised assistance and adaptations for the group of people with disabilities.

After having set out the present-day legal

framework of actions for people with disabilities within the university, we now move on to show the services, programmes and further measures offered to these students. 2. UNIVERSITY PROGRAMMES AND SERVICES

In order to find out about university programmes

and services, we have carried out a search on the

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Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 7-17

actions that are being taken in Spanish universities. The aim of this process was to obtain information about people with disabilities at university, the actions put into effect and their results.

Thus, on the one hand, university associations for

the disabled do not abound in Spain. We have located some twenty of them which originated and function within the university. Among the associations found, three types can be differentiated:

First, there are associations of general disability

which do not mention any specific disability type, such as the Asociación pro-disminuídos, from the Autonomous University of Barcelona, or the Asociación pro-discapacitados from the University of Alicante, who have very similar objectives, fundamentally centred on the guarantee of rights, university integration, promotion of work integration, accessibility, advice, information, and so on.

Second, there are university associations with

names not related to disabilities, whose actions include programmes for disabled people, or collaborate with associations of non-university people with disabilities. Among them, the Asociación Progresista de Jóvenes Renovadores, from the University of Salamanca, organises conferences on the integration of disabled people into university, and the association Solidarios para el Desarrollo, from Madrid’s Complutense University, which carries out support actions for disabled students, both in the academic sphere and in the area of accessibility and it has branches in other Spanish universities.

Third and finally, the least frequent type of

associations are those whose action framework is restricted to one disability, such as the Asociación Universitaria de Personas con Parálisis Cerebral, from Madrid’s Complutense University. These associations pursue objectives similar to those of the first type of associations described, although they restrict their action framework to the disabilities under their names.

On the other hand, as for university research

groups whose area of interest is centred on disability, three aspects can be distinguished on the basis of the themes researched and on the objectives to reach:

Firstly, there are groups who do research on new

technologies and who seek the construction or improvement of technological tools which may facilitate the use of computerised resources for people with reduced mobility and with software tools which may facilitate the use of computers. For example, the Grupo de Investigación GT-1, from the University of Alcalá de Henares, the Proyecto de Iriscom and the University of Navarra, who carry out research on advanced technology for tetraplegics, or the Grupo de investigación multidisciplinar de I+D Informática para discapacitados, from the University of Oviedo. Secondly, there are research groups of an educational nature who address themes such as educational approaches to disability, the educational levels of these people, teaching models, or curriculum adjustments, such as the Proyecto Roma from the University of Málaga, or Estudios sobre nivel

educativo y discapacidad, from the University of Deusto.

Third and finally, there are research groups of a

psychological and psycho-social nature, who centre their work on themes such as integration, well-being, accessibility, work situation, and so on. Examples are the Instituto Universitario de Integración en la Comunidad, INICO, from the University of Salamanca or the Unidad de Investigación Polibienestar, from the University of Valencia.

Table 1. University programmes and services for

students

If we now look at the programmes or attention services to people with disabilities offered by universities, heterogeneity and diversity are dominant again. A guide has recently been published, “Universidad y Discapacidad: Guía de Recursos” (González-Badía and Molina, 2006b), which exhaustively collects the variety of services offered in each Spanish university. Given the fact that enumerating each and all of the activities developed by the different programs would widely exceed the extension of this text, we have chosen to report on those which show a greater level of development. On the basis of such criterion, it is interesting to mention the measures offered by the University of Alicante, the Autonomous University of Madrid, Madrid’s Complutense University, the UNED, and the universities from Granada, Huelva, Salamanca, Valencia (General Studies, UVEG), and Oviedo (Table 1).

University Programmes and services

U. Alicante Student support programme (CAE); incorporation programme for university students with disabilities; promotion of voluntary service programme; accompaniment programme; opportunities, social and work integration programme.

Madrid’s Autonomous U.

Disability area of the Office of Solidarity and Cooperation; MHADIE European Project (Measuring Health and Disability in Europe).

Madrid’s Complutense U.

Group for developmental support: Aid programme for disabled students

U. Granada Programme for disabled university students.; Aid programme for disabled university students; Aid service for documentary support for disabled people.

U. Huelva Plan of comprehensive attention: the figure of the collaborating student

U. Salamanca

Unit of university students with disabilities; The Destroying Barriers Programme

UNED Handynet; Star U. Valencia (UVEG)

University consultancy for students with disabilities; Programme of voluntary service; Programme of adapted housing; Programme for barrier elimination; Programme of educational consultancy; Programme of education and awareness raising; Programme for equality of opportunities; Programme of personal support

U. Oviedo Committee for disability

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Alcedo Rodríguez, M.A. et al.: An up-to-date review of the situation of university students with disabilities

The goal of the services and programmes developed by these Spanish universites is integrating this group socially by facilitating both class attendance and the development of all the activities related to their student activities; that is, choosing and adapting furniture, providing technical aids, facilitating adapted transportation, looking for volunteers, adjusting curriculum programmes, and so on.

In short, this revision allows us to verify the

presence of numerous actions, educational courses, master programmes, suppression of architectural barriers, services, programmes, and various types of measures, in a more or less successful but always well-intentioned manner, from the most varied focuses and viewpoints of the polyedric spectrum of integration. Some universities are more involved than others, but all make explicit reference to the need to facilitate the integration and access to university of this group.

3. RESEARCH ON UNIVERSITY STUDENTS WITH DISABILITIES

In order to find out about the existing scientific

literature on university students with disabilities, our first step consisted in making a bibliographical search stored in the six leading databases concerning our theme of interest, Psycinfo, Psyclist, Medline, Eric, Psicodoc y Dialnet, by using the following headings: “university students and disability and integration”, “university students and disability and needs”, “disabled students and inclusion and university”, “disabled students and integration and college” and “ disabled students and mainstream university”. We also used the corresponding Spanish headings, “estudiantes universitarios y discapacidad e integración”, “estudiantes universitarios y discapacidad y necesidades”, “estudiantes con discapacidad e inclusión y universidad”, “estudiantes discapacitados e integración y universidad” and “estudiantes con discapacidad e integración en la universidad”

Due to the heterogeneity of the publications found,

as much for the methodology and the procedures used as for the object of study and the themes dealt with, the articles found have been divided into two sections. In the first group are those centred on awareness raising campaigns, conducted for the training of those professionals who will be part of the educational environment of the students with disabilities, that is, teachers and other university staff. The change of attitude programmes carried out in a university setting are also gathered together.

The second group of publications classifies the

studies on the assessment of the situation of students with disabilities, that is to say, on the needs that they perceive, or on those reported on by other members and professionals of the university community. 3.1. AWARENESS RAISING CAMPAIGNS AND CHANGE OF ATTITUDE PROGRAMMES

To begin with, the first studies on awareness

raising campaings to be remarked on are those by

Schlosser and Millar (1991) in Canada, by the University of Syracuse (1981) in the United States, and by O’Hanlon (2003) in the United Kingdom. The general objective of all of them is to train and to raise the awareness both of the university teaching staff and those students whose future professional responsibilities will bring them close to the disabled.

In a more detailed way is, on the one hand, the

situational report by Schlosser and Millar (1991), conducted with information from the teaching staff of the University of Alberta, Canada. This report initially assesses the attitudes to disability of the participant teachers and their perception of their own responsibility in the integration of disabled students within the whole group of students. Next, the programme includes the teaching of courses to foster integration, which are conducted by support associations and support groups. Once the programme had been developed and assessed, the conclusions establish that the training of the teaching staff should necessarily continue, and that, according to the teachers’ preference, an action protocol for students with special educational needs should exist.

On the other hand, after analysing the situation of

students with problems and learning difficulties in the state-run education centres of the United Kingdom, the study by O’Hanlon (2003) emphasizes the need to go deeper into integration and equality, by following the guidelines established in the Special Educational Needs and Disability Act (2001). Therefore, it was insisted that the institutions run by the state improve the treatment of and adapt their assistance to the special needs of students with disabilities. In addition to the above, O’Hanlon’s book includes comic strips which show the everyday life of people with disabilities with the aim of bringing teachers closer to the difficulties that groups of disabled people face in their everyday lives. In this way, in addition to supporting public awareness raising, this publication provides a basic tool for the teachers who have to deal with students showing some disability.

Secondly, as for publications making reference to

change of attitude programmes in university settings, we can cite, first, the studies by Houck (1992), Sim, Milner and Love (1998), and Gliner, Haber and Weise (1999), in which research on attitudes is a priority and a basic condition for improving the adaptation of all students with some type of disability. In the same line, authors such as Aune and Kroeger (1997), Duquette (2000), and McCarthy and Misquez (2003) also analyse the importance of attitudinal variables, and they study the influence of others, such as personal and socio-demographic factors in achieving academic success of disabled students. In addition to these works, studies conducted by Wurst and Wolford (1994) and Reber (1995) are added and described in detail.

The first of these specific programmes, by Wurst

and Wolford (1994), was conducted at the State University of New York. In the different phases of the programme, a total of 18 students pretended to have a visual or auditory disability while they were carrying out everyday activities. Another aspect of the

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programme consisted in organising groups to discuss disability topics with experts on the subject. When the programme ended, the participants stated that their empathy to students with disabilities had increased as well as feeling that their sensorial ability has also increased. At the same time, they could better understand the stigma associated with disability. In short, the results of the programme showed better attitudes to visual and auditory disabilities, and the need to conduct more programmes which might favour a change of attitude in this direction.

As for the second programme, Reber’s (1995)

research puts forward three specific objectives: First, to analyse university students’ attitudes towards the need to include students with disabilities; second, to observe whether such attitudes vary in relation to the type of disability and third, to check the effects on university students with no disabilities, of three educational programmes based on different experiences about the inclusion of students with disabilities. The participants of the study were divided into three groups. Thus, 23 of them participated in a practicum, another 59 attended a theoretical review course, and the remaining 100 were in a self-education programme. As for the first two objectives, the findings support the idea that the attitudes vary in relation to the type of disability shown, the most negative being against the most visually impressive disabled people, such as those suffering epileptic fits. Finally, in relation to the third objective, the findings indicate that those students who did know about the theoretical situation of the disabled and had taken the practicum showed more positive attitudes towards these groups than the other students who had just taken the theoretical programme, and those who had only followed the self-education course.

All in all, the awareness raising campaigns and the

change of attitude programmes implemented in university settings have proved useful in modifying the attitudes of students and university staff towards their disabled peers. Even though the attitudes towards this group may be positive, these activities improve positive attitudes and eliminate many prejudices and stereotypes, especially those activities centred on providing information about disabilities, and the other activities which favour contact and exchange. However, this practice is not common, and the change of attitude programmes reported on or published in the usual documentary sources are very few and far between. Very recently, the results of two Spanish studies centred on the assessment of the attitudes shown by students registered on courses related to the scope of disability have emphasized the importance of these programmes, since the findings have pointed out that having information about disabilities improves the attitudes to disabled peers (López and Polo, 2006a; Moreno, Rodríguez, Saldaña and Aguilera, 2006). 3.2. ASSESSMENT OF THE SITUATION OF STUDENTS WITH DISABILITIES

Una vez expuestas las actuaciones llevadas a cabo

dentro de la comunidad universitaria en temas de sensibilización y cambio de actitudes en alumnos y profesores universitarios, se presentan en este apartado

los estudios que abordan las percepciones y necesidades que los alumnos universitarios con discapacidad encuentran en sus centros de estudio.

After having explained the actions carried out

within the university community in relation to awareness raising and change of attitude of university teachers and students, this section presents the studies that deal with the perceptions and needs encountered by university students with disabilities in their centres of study.

More than a decade ago, the report presented by

the Florida State Postsecondary Education Planning Comissionn (1991) pointed out a series of general recommendations that affected areas such as the state coordination of attention services to those with disability, the improvement of institutional resources for these groups, the elimination of access barriers, and the improvement in work offers and advisory services.

A few years later, Misquez, McCarthy, Powell and

Chu (1997) described the situation of students with disabilities in different university campuses, proposed basic adaptations for greater integration of students, such as note takers, sign language interpreters, Braille printers, adapted software, housing, support services, adapted computers, and so on. In the same way, other authors, such as Fichten, Asunción, Barile, Judo, Alapin, et al. (1998), interested in knowing about the use of computers by students with disabilities in different university centres in Canada, find that the most frequent needs are the adjustments for students with visual or motor problems and for financial advice to obtain these adjustments.

The field of new technologies for the disabled has

been an object of study for a long time. First of all we will mention the research by Federici, Micangeli, Ruspantini, Borgianni, Corrali, Pasqualoto et al. (2003), at the University of Rome. This study specifically analyses the use and accessibility of aid and support services for students with disabilities by following two different approaches. In one of them, which is top-down, the researchers analyse the adjustment of the aid service to national standards and to international institutions. In the case of the other approach, which is bottom-up, the students fill out a questionnaire which verifies their opinion about accessibility to the web page. Secondly, Fichten, Asunción, Barile, Genereux, Fossey, Judo et al. (2001) assess the needs related to technological accessibility for a total of 725 university students aged 17-75 with some type of disability. The results show that the majority of these students use computers, that almost half of them have had their computers adapted and so use them in an efficient way. The universal design of this specific type of service is also pointed out as a need which is demanded both by teachers and students. More recently, Limonche (2006) presents the results of an analysis of accessibility to web pages of different Spanish universities, and points out that 45.8% of these information portals do not meet any of the accessibility requirements. The author proposes the need for universal design, and so coincides with the study by Fitchen et al. (2001).

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Alcedo Rodríguez, M.A. et al.: An up-to-date review of the situation of university students with disabilities

The needs, such as they are perceived by the

students with disabilities themselves and evaluated in relation to diverse contextual and personal aspects have also given rise to some research interest. If we first focus on the studies developed outside the Spanish setting, one of the pioneering works is the study by Bowen (1983), which examines the needs of the students from the University of Florida with motor, visual and auditory disabilities. Among the most demanded improvements made by these subjects it is worth mentioning accessibility to parking, suppression of architectural barriers for wheel chairs, improvement in visual signs, in computer equipment and materials and in the attitude of the library staff. The study by West (1993), which includes a sample of 761 students with disabilities who were interviewed to measure their satisfaction as regards accessibility, attention services and housing, shows general satisfaction towards the services provided. However, the majority of the participants find problems in attitudes, accessibility and resources, which significantly limit their education. Furthermore, the study by Hill (1996), which analyses the needs perceived and the demands claimed by 264 university students with disabilities, points out that a fourth of the participants find a lack of institutional support in spite of the fact that the majority find the services provided in various fields adequate. On the other hand, two thirds find the teaching staff very receptive to making teaching adjustments, although the remaining third complains about the lack of these adaptations, and considers it very negative in their process of adjustment to the centre. In this way, Hill concludes that it is necessary to enhance the work of state-run centres in order to avoid that disability keeps on being a cause for discrimination. Finally, Berry and Mellard (2002) develop their study in 15 university centres in three states, and sent questionnaires to students and teachers in order to analyse the satisfaction with the adaptation to services, housing and other university settings. The conclusions are quite positive. The students with disabilities state that they feel comfortable in their university setting and academically prepared to successfully complete that educational stage.

A series of publications analyse services or

infrastructures specific to the university setting. In this area, Lum (2007), denounces the lack of adapted sports facilities in American universities; he found only 11 institutions in the country offered this service. For their part, Campos, Verdugo and Sancho (2006) contrast the situation of American and Spanish attention services to these students and conclude that, given the contextual differences, comparison is impossible, although they take the experiences of the USA as a point of reference, given that they have a long history. As for the services centred on a given disability, Beaupré (1993) and Weiner and Weiner (1996) investigate the adjustment needs of youngsters with mental disorders. Lifchez (1987) in his turn assesses problems of accessibility to different centres for the physically impaired. Montero (2002) focuses the object of his study on people affected by the lack of attention syndrome due to hyperactivity. McGuire, Hall and Litt (1991), Suritsky (1992), Keim (1996) and Egan (2001) analyse the adjustment priorities of

students with learning problems in the university setting. Finally, two publications appear which address the situation of mental health; one of them in the American setting, Cook (2007), and the other one in the Spanish setting, Lodeiro, Teasley, Vitales and Muñoz (2006). The results of all these studies coincide when pointing out the increasing number of university students with this problem and the lack of resources which respond to their needs.

Finally, we have only found four studies relating

to the needs of university students with disabilities registered in Spanish universities, such as they are perceived and informed about by the students themselves.

The work by López, Felipe, Ruiz and Vicente

(2006), a pilot study assessing the needs pointed out by eight students with disabilities at the University of Extremadura, finds that the most important needs lie in the lack of information provided by the university to the student, and on the teachers’ lack of training on educational needs. For their part, López and Polo (2006b) assess the physical, socio-personal, and work barriers of 29 students with disabilities from the University of Granada, and find that the most remarked upon needs are related to physical disability, integration, and technical aids. Likewise, Rodríguez, Romero and Luque (2006) assess the needs for support in a large sample of 188 students with disabilities from the University of Malaga, and find that the support most in demand is financial, followed by technical aids.

Finally, within the same theme, we would like to

present the illustrative example of the study conducted by our research team, (Aguado, Alcedo, González, García, Cuervo, Real et al., 2005, 2006), which collects information provided by 108 students with disabilities registered at the University of Oviedo. 3.2.1. STUDENTS WITH DISABILITIES AT THE UNIVERSITY OF OVIEDO

This research was promoted by the Mesa de la

Discapacidad (Disability Committee) and sponsored by the Vicerrectorado de Estudiantes y Cooperación (Vicerectorship of Students and Cooperation) of the University of Oviedo, set up in January 2005. This project was one of its first endeavours. This committee put forward the need to find about the situation and needs of the group of students with disabilities registered at the university, in order to put into practice appropriate solutions. With this purpose, the research focused on three basic objectives, namely, finding out about the situation and demands of the group of disabled students at the University of Oviedo; making the university community, both the institution and all its members, aware of and sensitive to these problems, offering measures and alternative solutions to the problems shown by this group and an improvement in the existing conditions.

The instrument used for data collection is an ad-

hoc designed open interview, entitled Entrevisa a Estudiantes Universitarios con Discapacidad (Interview for university students with disabilities).

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The final version of the interview1 has the following components: personal data, data relative to disability, questions related to accessibility, to access to curriculum adaptation, to integration within the university community, and to technical aids. To give the interview 20 interviewers or field researchers were selected and submitted to a ten- hour long theoretical and practical training course.

Out of the 196 students with disabilities included

in a census, 87 of them did not carry out the interview for various reasons, ranging from the fact that 14 students were not disabled in spite of being included in the general list, to the fact that another 40 directly refused being interviewed for different reasons.

As for socio-demographic characteristics, the

sample is exactly halved on gender, with an average age of 27.11, resident mostly in urban areas, and taking courses in eight campuses of the Asturian university, whose School of Business and Administration holds the highest number of students with disabilities registered.

As shown in Table 2, the clinical variables, which

are types of disability, there are 120 disabilities in the 108 people interviewed. This number is explained by the multiple disability of nine of those interviewed. From this distribution there is a principle category, namely physical disability, which brings together 50% of the disabilities, followed by chronic diseases, which amounts to 25% of all the cases.

Type of disability Total %

Physical disabilities Visual disability

Auditory disability Chronic diseases Mental disorders

60 18 9

30 3

50,0 15,0 7,5

25,0 2,5

Total 120 100 Note: The 108 students with disabilities have a total of 120 disabilities, which is due to the fact that nine of them show multiple disabilities

Table 2. Distribution of the sample by type of

disability.

As for the variables making reference to the situation of university students, the information was organised into three sections, namely, accessibility, adjustments for access to the curriculum, and technical aids. Each student was asked in each section both about what they considered adequate, and about what they considered necessary.

In the first section, on accessibility (access to the

centre of studies, to the buildings or rooms, spaces, and common services) the resulting data show that the students as a whole think that there are more problems to be solved, more needs, than issues solved adequately. This demand is present in most of the types of disabilities represented in our sample, the groups of physical and visual disabilities being those who point out the greatest number of difficulties in

access to the centres, builidings, rooms and common services both in the centre in which they are registered, and at university.

As for the second section, on adjustments for

access to the curriculum (planning, teaching approaches and resources, and evaluation), the tendency of the previous section is repeated in the answers related to the whole, that is to say, the average of positive responses, adequate, is lower than the average of negative responses, needs. However, the analysis of responses in relation to the different types of disabilities shows that the students with physical disability are the ones who point out the lowest number of needs, that in this group the number of responses under the category adequate is slightly higher than that under the category of needs.

For the rest of the groups this relation is reversed.

The students with auditory disability and mental disorder are those who consider that there are more needs, or problems waiting for a solution, than problems solved as regards access to the curriculum. Two generalised and reiterated claims are made in relation to all the issues related to the curriculum, namely, materials and resources adjusted to the needs of the disabled, and more information to the university community about disability, possibilities, difficulties and needs.

In relation to the third aspect, technical aids

(technical necessities for the different types of disability: motor, auditory, multiple and chronic diseases, mental disorders or unclassified disabilities), the demands from the students are various, multiple and relative to the type of disability. In short, we can generalise by saying that the aids demanded are basically centred on measures for improvement in personal mobility and displacement, on technical aids centred on the computer, on aids for facilitating reading and writing, for sound audition and transmission, and for favouring dialogue and communication.

In brief and on the general basis of the results, two

important conclusions can be drawn: - The data show a high number of answers in the “adequate” box, which leads to the conclusion that many aspects are valued positively by the students with disabilities in the University of Oviedo. However, in almost all the questions posed, this adequacy is lower than the deficits put forward. - In tune with the former statements, in practically all the questions assessed, the number of answers about needs has been higher than the number of adequate answers. That is to say, the students think that the number of needs to be solved as regards accessibility, adjustments for access to the curriculum, and technical aids is higher than the number of adequately solved problems.

After having revised the legislative measures and

regulations related to the integration of university students with disabilities as well as the various publications focusing on the analysis of the situation, and on the characteristics and needs found and pointed out by the different bodies of the university

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Alcedo Rodríguez, M.A. et al.: An up-to-date review of the situation of university students with disabilities

community (mainly teaching staff and students with and without disabilities), this is the moment to proceed and come to conclusions and to make suggestions.

CONCLUSIONS AND SUGGESTIONS The revision of the integration and situation of

students with disabilities in the Spanish universities permits us to verify, firstly, that the novelties in the national legislative scene come hand in hand with the reform of the LOU (the Constitutional Law on Universities), which makes numerous references to the issue of disability. It expands and legislates on the rights of these students, thus partially reducing the autonomy given to the universities by the Constitution. The legislation on this issue marks the distance between the situation in reality and the situation which should be taking place by right. Knowledge of it by the university community and especially, by the students with disabilities, favours the possibilities of educational integration and inclusion. However, the lack of compliance with the law is frequent on many of these precepts.

The autonomy that the Constitution bestows upon

the universities, and the lack of legal precision on assumption of responsibilities are usually cited as sources of discriminating situations (Alcantud, 2004; Forteza and Ortego, 2003; Gago, Malasaña, and Moya, 2002; Rodríguez, Romero, and Luque, 2005). This takes place in spite of the increase of measures and services developed for these students by the university centres themselves. It is obvious that the coverage and quality of these services is not yet adequate and do not respond to the actual needs of the students with disabilities. Secondly, after having analysed the publications and main field studies on the situation, the characteristics and needs of these students, we can draw the following conclusions:

- The research on this theme shows great heterogeneity and responds to specific needs arising in given contexts. There is no stable research line shared by the authors on the subject.

- In tune with the former statements but from a more specific point of view, there are many studies which share objectives but show discrepancies in approach and procedures to such an extent, that they make it impossible to contrast results.

- There is a lack of follow-up studies that could evaluate the needs of these students, since all the publications show specific actions on the population with disabilities at concrete moments. This fact impedes knowledge about the development of the changes and of what type, in the situation of these students.

- Nevertheless, the results of the majority of the studies make reference to weaknesses and limitations in such basic needs as availability of adequate premises, instrumental measures, administrative services, libraries that allow for the normal development of studies and so on. These results also show the lack of compliance of fundamental rights such as not being discriminated

against on access to university for personal or social circumstances, including disability; admission to the centres; continuance in the university and exercise of academic rights.

In the light of these conclusions, a series of

proposals aiming at providing solutions for the weaknesses and problems detected can be made. In tune with what has been pointed out above about the students with disabilities from the University of Oviedo (Aguado et al., 2005), the solutions proposed are grouped around three themes: problems of a structural nature, including both elimination of barriers and promotion of accessibility; problems of a statutory nature, and finally, problems of a relational nature, whose objective is the integration of people with disabilities. In greater depth:

The first proposal responds to problems of

accessibility, problems of a structural nature. In the face of these problems, three areas of action are put forward, namely, elimination of specific obstacles, a general plan of updating and modernizing technical aids and a general plan of accessibility in all the buildings of the different university centres. These measures would make physical access possible and in the case of technical aids, would provide the students with the resources necessary to develop their everyday activities.

The second proposal, on problems of a statutory nature, expresses the need to create legal measures which could regulate the situation of these students, so that the resolution of these everyday problems could result in a norm and not in the specific good will of some people, teachers, vice rectors or students. For specific and isolated problems, the constitution of Disability Committees is proposed in every centre, which should enhance the university community’s awareness of this problem and facilitate the resolution of specific problems.

The last proposal seeks to respond to the problems of integration in university life, problems of a relational nature, which require programmes that could encourage the promotion of integration. These programs should be founded on a change of attitudes, on raising the awareness of the university community and on the training of interpersonal skills for both students with disabilities and their peers in order to increase their relational skills. These programmes have proved fully efficient at other educational levels (Aguado, Flórez and Alcedo, 2003, 2004). For specific integration problems, we propose the ad hoc establishment of programmes adapted to the student’s individual problems.

These guidelines or action proposals would mitigate situations that may be branded as discriminating and which data up to this moment show; equality of opportunities and consequently, the integration of the students in an educational institution which is presupposed to be universal, at least

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etymologically, that is to say, belonging to all and for all, are still not fulfilled.

Thus, as a general conclusion, we can state that

even though the process of integration or inclusion of students with disabilities has improved in university settings in general and in Spanish universities in particular, that is to say, many things are good, the fact is that a number of things can still be done, and many are well-worth doing. REFERENCES Aguado, A.L., Alcedo, M.A., González, M., García, L., Cuervo, J., Real, S. y Casares, M.J. (2005). La Universidad de Oviedo ante las personas con discapacidad: Informe: Entrevista a Estudiantes con discapacidad-2005. Informe de investigación (xerocopiado). Oviedo: Universidad de Oviedo. Vicerrectorado de Estudiantes y Cooperación. Aguado, A.L., Alcedo, M.A., González, M., García, L., Cuervo, J., Real, S. y Casares, M.J. (2006). La Universidad de Oviedo y las personas con discapacidad. Intervención Psicosocial, 15 (1), 49-63. Aguado, A.L., Flórez, M.A. y Alcedo, M.A. (2003). Un programa de cambio de actitudes hacia personas con discapacidad en entorno escolar. Análisis y Modificación de Conducta, 29 (127), 673-704. Aguado, A.L., Flórez, M.A. y Alcedo, M.A. (2004). Programas de cambio de actitudes ante la discapacidad. Psicothema, 16 (4), 667-673. Aune, B.P. y Kroeger, S.A. (1997). Career development of college students with disabilities: an interactional approach to defining the issues. Journal of College Student Development, 38 (4), 344-356. Beaupré, P. (1993). Le perfectionnent des maîtres de classe ordinaire en intégration scolaire: une condition essentielle. Revue Francophone de la Déficience Intellectuelle, 4 (2), 165-176. Berry, G. y Mellard, D. (2002). Current status on accommodating students with disabilities in selected community and technical colleges (Fall 1999-Spring 2001). University of Kansas Center for Research on Learning. Bilbao, M. C. (2003). Necesidad de investigación en la integración de estudiantes con discapacidad en la universidad. En Casado, R. y Cifuentes, A., (Coords.), El acceso al empleo y a la universidad de las personas con discapacidad: barreras y alternativas (pp. 171-191).Burgos: Servicio de Publicaciones, Universidad de Burgos. Bowen, D. (1983). Library needs and uses by disabled students at the Florida State University: a survey. Ponencia presentada en la Conferencia del Servicio de la Biblioteca Académica para Estudiantes con Discapacidad, Tallahassee, Florida, 6-7-V. Campo, M, Verdugo, M.A., Díaz, E. y Sancho, I. (2006). En M. Barañano (Ed.): Adaptar la Igualdad,

normalizar la diversidad. II Congreso Nacional sobre Universidad y Discapacidad. XI Reunión del Real Patronato sobre Discapacidad. (pp. 367-377). Madrid: Vicerrectorado de Estudiantes, Universidad Complutense de Madrid. Constitución Española de 1978. Cook, L.J. (2007). Striving to help college students with mental health issues. Journal Psychosoc Nursing Mental Health, 45 (4), 40-44. De la Red, N., de la Puente, R., Gómez, M. C. y Carro, L. (2002). El acceso a los estudios superiores de las personas con discapacidad física y sensorial. Valladolid: Secretariado de Publicaciones e Intercambio Editorial. Universidad de Valladolid. Duquette, C. (2000). Experiences at university: perceptions of students with disabilities. Canadian Journal of Higher Education, 30 (2), 123-141. Forteza, D. y Ortego, J.L. (2003). Universidad y discapacidad: estado de la cuestión y temas pendientes. Bordón: Revista de Orientación Pedagógica, 55(1), 103-114. Egan, M. D. (2001). Case studies of reading processes and strategies of compensated learning-disabled adult readers. Abstracts International Section A: Humanities and Social Sciences, 62 (2-A), 158. Federici, S., Micangeli, A., Ruspantini, I., Borgianni, S., Corradi, F., Pasqualotto, E. y Beladinelli, M.O. (2003). Accessibility and usability evaluation of the help desk web page for students with disability in the University of Rome “La Sapienza” web site. Cognitive Processing, 4 (suppl.), 31-32. Fichten, C.S., Asuncion, J.V., Barile, M., Genereux, C., Fossey, M., Judo, D., Robillard, C., De Simona, C. y Wells, D. (2001). Technology integration for students with disabilities: empirically based recommendations for faculty. Educational Research and Evaluation: An International Journal on Theory and Practice, 7 (2-3), 185-221. Fichten, C.S., Barile, M., Asuncion, J., Judo, D., Alapin, I., Reid, E., Lavers, J., Genereux, C., Guimont, J. y Schipper, F. (1998). A comparison of postsecondary students with disabilities and service providers: Views about computer and information technologies. Ponencia presentada en la Conferencia Anual del California State University-Northridge 14th, Los Ángeles, CA, 15-20-III. Florida State Postsecondary Education Planning Commission (1991). Disabled student access to postsecondary education: update. Tallahassee: Report and Recommendations. Gliner, J.A., Haber, E. y Weise, J. (1999). Use of controlled vignettes in evaluation: does type of response method make a difference? Evaluation and Program Planning, 22 (3), 313-322.

15

Alcedo Rodríguez, M.A. et al.: An up-to-date review of the situation of university students with disabilities

González-Badía, J. y Molina, C. (2006a). Situación de los estudiantes con discapacidad en las universidades españolas. Fiapas, 111, 30-33. González-Badía, J. y Molina, C. (2006b). Universidad y Discapacidad. Guía de Recursos. Colección Telefónica Accesible. Madrid: Cinca, SA. Hill, J.L. (1996). Speaking out: perceptions of students with disabilities regarding adequacy of services and willingness of faculty to make accommodations. Journal of Postsecondary Education and Disability, 12 (1), 22-43. Houck, C.K. (1992). Students with learning disabilities in the university environment: a study of faculty and students perceptions. Journal of Learning Disabilities, 25 (10), 678-684. Keim, J. (1996). Academic success and university accommodation for learning disabilities: is there a relationship? Journal of College Students Development, 37 (5), 502-509. Ley Orgánica 13/1982, de siete de abril, de Integración Social de los Minusválidos (BOE, 10-4-1982). Ley Orgánica 6/2001, de 21 de diciembre, de Universidades (BOE, 24-12-2001). Ley Orgánica 51/2003, de 2 de diciembre, de Igualdad de oportunidades, no discriminación y accesibilidad universal de las personas con discapacidad (BOE, 3-12-2003). Ley Orgánica 4/2007, de 12 de abril, por la que se modifica la Ley Orgánica 6/2001, de 21 de diciembre, de Universidades (BOE, 13-4-2007). Lifchez, R. (1987). Rethinking architecture: design students and physically disabled people. University of California Press, xix, 191. Limonche, F. (2006). Universidad, nuevas tecnologías y difusión de valores. En M. Barañano (Ed.): Adaptar la igualdad, normalizar la diversidad. II Congreso Nacional sobre Universidad y Discapacidad. XI Reunión del Real Patronato sobre Discapacidad. (pp. 84-87). Madrid: Vicerrectorado de Estudiantes, Universidad Complutense de Madrid. Lodeiro, I., Teasley, C., Vitales, A. y Muñoz, P. (2006).Colaborar para fomentar la integración de las personas con enfermedades psíquicas en los estudios superiores. En M. Barañano (Ed.): Adaptar la igualdad, normalizar la diversidad. II Congreso Nacional sobre Universidad y Discapacidad. XI Reunión del Real Patronato sobre Discapacidad. (pp. 546-558). Madrid: Vicerrectorado de Estudiantes, Universidad Complutense de Madrid. López, V., Felipe, E., Ruiz, I. y Vicente, F. (2006). Necesidades, apoyos y satisfacción de estudiantes universitarios con discapacidad: un estudio cualitativo. En M. Barañano (Ed.): Adaptar la igualdad, normalizar la diversidad. II Congreso Nacional sobre Universidad y Discapacidad. XI Reunión del Real

Patronato sobre Discapacidad. (pp. 274-283). Madrid: Vicerrectorado de Estudiantes, Universidad Complutense de Madrid. López, M.D. y Polo, M.T. (2006a.). Actitudes hacia las personas con discapacidad de estudiantes de la Universidad de Granada. Revista Española de Orientación y Psicopedagogía. 17 (2), 195-211. López, M.D. y Polo, M.T. (2006b). Análisis de las barreras físicas y sociopersonales/laborales de los estudiantes con discapacidad. En J.L. Benítez, J. De la Fuente, A.B. García y F. Justicia, F. (Coords.): La universidad ante el reto del espacio europeo de educación superior: investigaciones recientes (pp. 281-294). Madrid: Egos. Lum, L. (2007). Got Game. Diverse: Issues in Higher Education, 23 (25), 24-26 . McCarthy, W. C. y Misquez, J. E. (2003). Engineering insights: developing stem education for students with disabilities leads to k-16 partnerships. Proceedings Frontiers in Education Conference, 2. McGuire, J. M., Hall, D. y Litt, A. V. (1991). A field-based study of the direct service needs of college students with learning disabilities. Journal of College Student Development, 32 (2), 101-108. Misquez, E., McCarthy, B., Powell, B. y Chu, L. (1997). University students with disabilities are the chief on-campus accommodation ingredient. Ponencia presentada al Annual CSUN (California State University, Northridge) Conference. Montero, J. (2002). ADHD management program: a program design for ADHD college students. Dissertation Abstracts International: Section B: The Sciences and Engineering, 63 (6-B), 3017. O´Hanlon, C. (2003). Educational inclusion as action research: An interpretive discourse. Mc Graw-Hill Education. Open University Press: Berkshire. Papadopoulos, K.S. y Goudiras, D.B. (2005). Alumnos con discapacidad visual y exámenes en la universidad. Entre dos mundos: Revista de Traducción sobre Discapacidad Visual, 28, 5-13. Reber, C.K. (1995). Attitudes of preservice teachers toward students with disabilities: do practicum experiences make a difference? Ponencia presentada en el Annual Meeting of the American Educational Research Association. San Francisco, CA. Rodríguez, G., Romero, J. F. y Luque D. J. (2005). Accesibilidad y Universidad: un estudio descriptivo. Intervención Psicosocial: Revista sobre igualdad y calidad de vida, 14 (2), 209-222. Segura, C. y Andreu, I. (1999). Panorama actual de la población universitaria con discapacidad de la Universidad Politécnica de Valencia. Valencia: Servicio de Publicaciones Universidad Politécnica de Valencia.

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17

Schlosser, G. y Millar, G. (1991). Special education professional development and training in Alberta: a status report. Informe presentado por el Alberta Department of Education. Education Response Centre. Edmonton. Sim, A. J., Milner, J. y Love, J. (1998). Definitions of need: can disabled people and care professionals agree? Disability & Society, 13 (1), 53-74. Suritky, S.K. (1992). Notetaking difficulties and approaches reported by university students with learning disabilities. Journal of Postsecondary Education and Disability, 10 (1), 3-10. Susinos, T. y Rojas S. (2004). Notas para un debate sobre los servicios de apoyo en la Universidad Española. Revista de Educación, 334, 119-130. Syracuse University (1981). Making integration work. Human policy reports: an action series. New York: Special Education Resource Center. Weiner, E., Weiner, J., (1996). Concerns and needs of university students with psychiatric disabilities. Journal of Postsecondary Education and Disability, 12 (1), 2-9. West, M. (1993). Beyond section 504: Satisfaction and empowerment of students with disabilities in higher education. Exceptional children, 59 (5), 456-467. Wright, A. (2006). Provision for students with learning difficulties in general colleges of further education-have we been going round in circles?. British Journal of Special Education, 33 (1), 33-39. Wurst, S.A. y Wolford, K. (1994). Integrating disability awareness into psychology courses: applications in abnormal psychology and perception. Teaching of Psychology, 21 (4), 233-235. Webgrafía Bausela, E. (2002). Atención a la diversidad en la educación superior. Profesorado, revista de curriculum y formación del profesorado, 6(1-2).: http://www.ugr.es/~recfpro/rev61COL4.pdf. Calvo, M. J. (2006). Universidad y Discapacidad. Revista Electrónica Informática de Terapia Ocupacional (R.E.I.T.O.): http://www.cs.urjc.es/revistas/reito/J1702.pdf. INE (2003). Las personas con discapacidad y su relación con el empleo. Encuesta de Población Activa del segundo trimestre de 2002: http://iier.isciii.es/er/pdf/er_pdre.pdf. MEC(2007):http://wwwn.mec.es/educa/ccuniv/html/estadistica/curso2006-2007/mat1y2c_upub.pdf. Moreno, F.J., Rodríguez, I.R., Saldaña, D., Aguilera, A. (2006). Actitudes ante la discapacidad en el alumnado universitario matriculado en materias afines. Revista Iberoamericana de Educación, 40 (5): http://www.rieoei.org/investigacion/1491Moreno.pdf.

 

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Cognitive treatment for children with attention deficit hyperactivity disorder (ADHD). Review and new contributions

Orjales Villar, I.1

Department of Developmental Psychology and Education.. School of Psychology. UNED (Spanish University for Distance Learning)

ABSTRACT This study reviews cognitive programmes applied to children with attention deficit hyperactivity disorder (ADHD). It carries out an in-depth analysis of the programmes that include self-regulation training, their efficiency, the most suitable conditions for their application and the effect produced by their combination with other cognitive and behavioural techniques. Finally, this study explains the clinical results derived from the application of a self-regulation scheme adapted from Meichenbaum’s Self-Instructional Training Programme (Orjales, 1991), the application of this scheme with new self regulations, and the use of such scheme for the selection and sequencing of training tasks. Key words: Attention deficit, hyperactivity, self-regulation, cognitive treatment, verbal mediation INTRODUCTION

The so-called attention deficit hyperactivity

disorder (ADHD) has given rise to great controversy among clinicians coming from different theoretical approaches and an overwhelming interest in its research in the areas of psychology, medicine and education. Even though the generalised awareness of ADHD in Spain could be centred around the year 1995, the first descriptions of similar cases appear at the end of the nineteenth century and in spite of the fact that we are currently offered a reconceptualisation of ADHD as a disorder of executive control (Barkley, 1997), back in 1892 Tuke defined hyperactivity as a symptom of impulse disorders and Clouston discussed states of impaired inhibition associated with excessive activity. Ever since that time, various terms have been coined to describe this type of child (for an in-depth historical review see García-Villamisar and Polaino-Lorente, 1997, and Cabanyes and Polaino-Lorente, 1997), and the diagnostic criteria have gone through several modifications (see Moreno and Polaino-Lorente, 1997). Nowadays, the last review by DSM-IV (APA, 2000) includes ADHD within the section entitled “Attention Deficit and Disruptive Behaviour Disorders”, so sharing a typology with three more disorders, namely, Oppositional Defiant Disorder,

Disocial Disorder and Unspecified Disruptive Behaviour Disorder. Subjects with ADHD must meet at least six out of the nine symptoms of inattention (predominant inattentive subtype), six of the nine symptoms of hyperactivity or impulsivity (predominant hyperactive-impulsive subtype), or six of both groups of symptoms (combined subtype). Furthermore, the symptomatology needs to be observed in two or more environments; some symptoms need to have appeared or caused alterations before age 7; there must be clear evidence of clinical significant deterioration of social, academic or work activity and the symptoms can neither exclusively appear during the course of pervasive developmental disorder, schizophrenia, or any other psychotic disorder, nor be better explained by the existence of another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder) or a personality disorder. This is the framework in which we are moving today, although everything points to it not being long before the next edition of this manual appears and this will bring about significant changes. At this moment in time, however, there is some agreement among the majority of researchers about the undeniable biological origin of the disorder, associated to some disfunction related to the frontal lobe (Swanson et al, 1998; Leo and Cohen, 2003; Faraone and Biederman, 1998; Castellanos and Acosta, 2004; Etchepareborda and col., 2004; Narbona-García and Sánchez-

1 PhD in Educational Science. Reader at the Department of Developmental Psychology and Education. School of Psychology. UNED (Spanish University for Distance Learning) Adress: C/ Juan del Rosal, 10. 28040 Madrid iorjales@psi.uned.es

Orjales Villar, I.: Cognitive treatmenfor children with attention deficit hyperactivity disorder (ADHD). New contributions

Carpintero, 1999; Capdevila-Brophy and col., 2005). Some neuro-psychopathological studies (Barkley, 1977) seem to suggest malfunction of the prefontral cortex, which intervenes in the individual’s activation of behaviour, in resistance to distraction, and in the development of time awareness; malfunction of the caudate nucleus and of the globus pallidus, which favours the inhibition of automatic responses and facilitates reflexion; and malfunction of the cerebellar vermis, probably associated to the regulation of motivation. As regards the hypotheses about the origin of this disorder, genetic hypotheses have taken on special strength since the late nineties. The interest in finding a genetic marker for ADHD has brought about a powerful trend in research (Goodman and Estevenson, 1989; Guillis et al., 1992; Barkley, 1990; Cook, 1995; Swanson and col., 1998) which occasionally seems to forget or ignore the real importance of educational and environmental factors in the modulation of the symptomatological expression of the disorder. In the last few years, research is being carried out on the greater frequency of a variant of the DRD4 gene (Lahoste, Brook and Marshall, 2000) and of the DRD5 gene (Kustanovich, 2004). The studies point to the existence of some defective genes which might be in charge of dictating to the brain on how to use the f dopamine, a brain transmitter which inhibits or modulates neurone activity, specifically the activity of those neurones which take a part in the control of emotions and movement. However, in spite of the effort made by clinicians and researchers, the fact is that the diagnosis of ADHD is currently limited to the clinicians’ ability to analyse the behaviour and the medical histories of the subjects, since there are not any biological markers available which speed up and optimise a good differential diagnosis and shed more light on the existence of different subtypes and high comorbility with other disorders. The diagnosis of ADHD thus requires, a multidisciplinar approach, a very deep knowledge about the patients, about the evolution of the symptoms throughout their lives, about their family antecedents, about their specific situation and about the level of misadaptation shown, always assessed on the basis of the environmental requirements and the supports available at each moment of their lives. At the end of the nineteen eighties, Dr. Barkey, director of the Psychology Ward in the Clinical Hospital of the University of Massachussets, proposed an explanatory approach that accounts for ADHD and entails the reconceptualisation of the traditional symptoms of inattention and impulsiveness and proposes that the behaviour of children with ADHD show two types of deficits. One of them is the inability to generate behaviour governed by rules (rule governed behaviour), when the objectives and consequences of behaviour depend on verbal stimuli and are not present in the environment. The other type of deficit is the abnormal response to the consequences of the environment, that is to say, lesser reaction to reinforcing stimuli, unusually rapid effect of feeling fulfilled by or getting used to some stimuli,

and a deficit in the response to reinforcement programmes (Servera-Barceló, 2005). With the passage of time and on the basis of previous approaches, Barkley shapes a comprehensive approach called Hybrid Model of Executive Function (Barkley, 1997). Even though such a model does not reflect in itself the importance of the environment as a modulator in the symptomatological expression of the disorder and focuses only on trying to account for the neurological and psycho-pathological factors that may be taking place in the environment, it provides valuable information for a better understanding of ADHD (Orjales, 2000a and 2000b). In his book ADHD and The Nature of Self-control, Barkley regards ADHD as a disorder in the development of behavioural inhibition, and understands self-control or self-regulation as the individual’s ability to stop the first response which was initiated after the appearance of a given stimulus, and as a way to protect his thinking from external or internal distraction and to elaborate a new and more suitable response which could substitute the first response (Barkley, 1997). During these moments when the response gets delayed, the executive functions are put into action. They are defined by this author as all those self-addressed mental activities which help the individual to withstand the distraction, to set up new more suitable aims than the initial inhibited response and to follow the steps necessary to meet such aims. Subjects with ADHD would have difficulty in carrying out the following processes: (1) inhibiting immediate responses to a given stimulus or event, (2) interrupting the response activated after a command or after feedback for their mistakes (error awareness) and (3) protecting such latent time and the self-regulation time period (executive control) from sources of interference (interference control or resistance to distraction). For this author there are four executive functions with a neuro-physiological correlation which are altered in children with ADHD. (1) The action of memory of work (or memory of non-verbal work), which makes it possible to retain information in order to use it when the stimulus that originated it disappears. This fact would affect the retrospective perception of subjects with ADHD, their awareness and control of time, and their ability to imitate a new and complex behaviour after observing other people. (2) The self-addressed or covert speech (or memory of verbal work), which permits in an autonomous way, the regulation of behaviour, to follow rules and directions, to wonder about how to solve a problem and to build up ‘meta-rules’. This would bring the subject with ADHD greater difficulty in regulating their own behaviour and making them responsible for their limited self-control and self-questioning. (3) The control of motivation, emotions, and states of alertness, which, according to this author, would account for the tendency of subjects with ADHD to show all their emotions, their inability to censure them with the maturity expected in people of the same age and their difficulty to self-regulate impulses, motivation and emotions. (4) The reconstitution process, which, for its part, consists of two sub-processes, namely, the fragmentation of the

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behaviours observed and the recombination of their parts in order to design new actions. The subjects with ADHD would lack the cognitive flexibility necessary to analyse learned behaviour and to use it in order to synthesise other behaviour, so their problem solving ability is limited. In this framework, the executive functions represent therefore, the internalisation of behaviour as a way of anticipating a change in the environment, which supposes the internalisation of time awareness as regards the ability to anticipate sequences of change in the environment (Barkley, 1997). INTERNALISED SPEECH

Internalised behaviour, which depends on internalised speech, is widely studied in developmental psychology (Díaz and Berk, 1992). In this sense, Laura E. Berk proved that internalised self-talk, which usually takes place gradually and is completed by age 10, gets delayed in children with ADHD (Berk, 1992). One decade earlier, Copelan had used a unidirectional mirror to observe that hyperactive children spoke more loudly when they were playing by themselves, expressed more immature self-talk and showed worse planning abilities when facing a hard problem-solving task, during which they uttered a greater number of exclamations and descriptions about themselves than about the strategies to use (Copeland, 1979). The literature seems to regard this fact as a reflection of the lack of maturity associated with ADHD and, in spite that I share this argument firmly, I also believe in the need to point out that externalised speech in subjects with ADHD may constitute a necessary adaptation measure, just as Barkley understands that executive functions working as self-addressed functions do not need to be concealed in order to be considered functions of an executive nature or an example of self-regulation. For this reason, as regards both evaluation and design of intervention programmes, we should bear in mind not only the child’s age and the existence of open or externalised verbalisations, but the actual types of verbalisations and especially, whether or not, they meet an executive function. Clinicians frequently observe that children with ADHD verbalise the emotions aroused by the task to carry out, to a greater extent, than they verbalise the strategies addressed to the successful fulfilment of the task, such as verbalisations to reorient their attention and keep centred on the objective, to plan their actions, to select relevant information, to keep the information in their work memory, or to evaluate their process or their results. However, we also observe externalised adaptive speech of high executive standard in older children or in cognitively trained children, which is, firstly, a product of need and secondly, the result of the need and the conscious awareness of its usefulness as a regulation measure. In the light of the above remarks, it seems logical to think that achieving private or covert talk in children with ADHD should be a secondary objective in intervention programmes, the first objective being to organise overt talk for the sake of greater operating

capacity. The therapist will be able to take advantage of the natural tendency of hyperactive children to externalise emotions and thoughts in order to analyse their executive operation and, more importantly, in order to restructure their behaviour. In this sense, we analyse the evolution of the intervention programmes which have aimed, first, at reducing impulsive behaviour and, second, at modifying impulsive information processing. EVOLUTION OF COGNITIVE PROGRAMMES FOR ADHD

From the perspective of Barkley’s model (1997) we now recover the intervention programmes derived from the peak of 1985-1995 studies on impulsiveness, which sought in the first instance the external control of behaviour and progressively moved on to the development of self-control strategies. Among the first attempts are programmes based on (Orjales and Polaino-Lorente,1997): (1) Imposed delay, which consisted basically in making the child delay his response a few minutes before allowing him to respond, and which managed to reduce the latency of the children’s response without a real improvement in performance. (2) The modelling of reflective behaviour strategies, whose success depended on the use of live or video-recorded adult or child models. The best results were achieved when peers were used, which in addition to reflexive methods, reflected exploration strategies. (3) Training based on providing the child with feedback from their errors, which was useful in showing that impulsive children did not modify their latency on the basis of their error feed-back. (4) Training in exploration and registration techniques, which manage to reduce errors even in the absence of latency reduction. Within this framework and with the aim of increasing performance and supporting self-control, Palkes et al. were the first to use self-addressed verbal commands in children with ADHD (Palkes, Stewart and Khana, 1968; Palkes, Stewert and Freedman, 1972). They wrote the verbal instructions, “Stop, look, listen and think” on posters for a two-session training programme in which such instructions were a support in carrying out motor-perceptive and visual discrimination tasks. The results revealed increase of latency but no significant improvement in the performance of a Porteus Labyrinth task. These results, which were similar to the results of imposed delay tasks, were found logical given the fact that these instructions were but a self-imposed delay type. These techniques were ineffective on their own, because children with ADHD do not manifest only a problem with inhibition of immediate responses to a stimulus or task and scarce resistance to distraction, but also alteration in the processes of perception and analysis of information, together with difficulty when elaborating and organising the response (Orjales, 1991). MEICHENBAUM’S COGNITIVE SELF-INSTRUCTIONAL MEDIATION PRO-GRAMME In the year 1971, on the basis of Jensen’s (1966) definition of verbal mediation, Meichenbaum

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Orjales Villar, I.: Cognitive treatmenfor children with attention deficit hyperactivity disorder (ADHD). New contributions

formulated the hypothesis that, due to their impulsiveness, hyperactive children do not analyse experience in terms of cognitive mediation or internalise rules that may work as guidelines for new learning situations. Given the theory of social learning and the Soviet developmental theories, and as a continuation of the work by Palkes and her team, Meichenbaum and Goodman (1971) developed the cognitive self-instructional mediational training. This training programme consisted of the combination of two types of modelling, namely overt and covert, and incorporated some modifications to former treatments: it first included the use of self-instructions which intended to interrupt the string of inadequate thoughts that the impulsive child elaborated some moments before solving a problem (prepotent responses) in order to apply their learning of these self-instructions and substitute them for a sequence of thoughts useful for solving problems. Meichenbaum (1974) even describes these self-instructions as a type of cognitive prosthesis which can be used to facilitate behaviour modification. Self-instructional training was designed to be carried out in five phases which show the attempt to move from measures of external control of behaviour to measures of internal control, or self-control measures: (1) Cognitive modelling: the therapist models the instructions aloud; the child listens and looks. (2) External guide: the child carries out the same task by following the therapist’s directions, by verbalising the self-instructions. (3) Manifest self-guide: the child carries out the task verbalising aloud and to himself the self-instructions. (4) Manifest attenuated self-guide: the child works by whispering the self-instructions to himself. (5) Covert self-instructions: the child uses his internal language to guide his performance in silence. As for the type of tasks used for self-instructional training, the tests ranged from simple sensory-motor abilities to abilities to solve more complex problems. Copying and reproducing design tasks; following sequences of instructions, taken from the Stanford-Bidet intelligence test; tasks such as completing a series of drawings, e.g. The Primary Mental Abilities Test and tests such as Raven’s matrices, were used. In each case the therapist modelled the most adequate self-instructions for each type of task (Meichenbaum, 1971). Around the same time other studies started to apply self-instructional training programmes which included the modelling of various strategies. For example, Douglas, Parry, Marton and Garson (1976) trained children to use the following verbalisations: (1) I need to stop and think before starting out. (2) Which plans (strategies) can I try? (3) How should I work if I do it this way? (4) What shall I try next time? (5) Have I done well so far? (6) Look, I made a mistake here; I have just corrected it. (7) Now let’s see, have I tried all I could have? And (8) I’ve done a good job. Meichenbaum found a common factor in the studies which included training in verbalising aloud. All of them focus their objective on teaching a series of abilities for a more efficient performance, and include (Meichenbaum y Asarnow, 1979, Meichenbaum, 1985): (a) identification and definition

of the problem and self-questioning (for example, “what do I need to do now?”); (b) an attempt to focus attention on the problem; (c) specific strategies to carry out the test and guide to the answer, (for example, “now I will stop and carefully repeat the instructions.”); (d) self-reinforcement for having tried, including evaluation and self-evaluation, (“well, I’m doing fine.”), and (e) coping abilities and proposal for error correction. “This is OK. Even if I make a mistake, I can always go more slowly.” Such cognitive training should be given, furthermore, by means of a wide range of tests, tasks, and people (trainers, teachers and parents) in order to make sure that the child does not develop a response to a specific task, but a generalised strategy (Meichenbaum and Asarnow, 1979). Another type of interesting verbalisations were the ones used by Brown, Wynne and Medenis (1985) in their cognitive behavioural therapy training scheme for children aged 6-11. By following Meichenbaum and Goodman’s (1971) self-instructional training scheme, they used what they called Super Hero Thinking Cards, which visually modelled the strategies to teach. (1) What is my problem, and what do I have to do? (2) How can I do it? (3) Am I thinking and using my plan? (4) If I make a mistake, I can go back and... correct it. (5) How did I do it?, and (6) You can do that too. You only need to learn my Super Thinking Tricks. COGNITIVE-BEHAVIOURAL TREATMENT PROGRAMMES For some years, self-instructional treatment was seen as a panacea at the head of the behavioural intervention programmes predominant at the time. Self-instructional treatment proved effective in reducing impulsiveness (Weithorn and Kagen, 1979; Brown, 1980), in increasing planning, concentration and reasoning capacities (Meichenbaum, 1976), in improving social skills (Shure, 1981) and in increasing academic performance (Cameron and Robinson, 1980; Abikoff and Gittleman, 1983). However, although numerous studies confirmed their efficiency (Hinshaw, Henker and Whalen, 1984; and Konstantareas and Hermatidis, 1983, among others), some other studies could not corroborate such positive results (Abikoff and Gittelman, 1985, among others). Meichenbaum (1977, 1992) makes some clinical suggestions to implement these programmes successfully: (1) use the child’s play environment to initiate and model self-talk; (2) use useful tests to train sequential cognitive strategies; (3) use peer teaching to obtain children’s cognitive patterns; (4) apply the programmes to the child’s rhythm and build up a self-statement pack; (5) keep the child from using self-statements in a mechanical way; (6) include a therapist who encourages the child to respond; (7) learn and use self-instructional training with low-intensity responses; (8) complement the training by using images such as the turtle technique (Scheider and Robin, 1976); (9) complete self-instructional training with correspondence training (Roger, Warren and Baer, 1976) and (10) complete self-instructional training with operative procedures such as response cost.

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During the following years there was an attempt to overcome the limitations of mediational cognitive therapy by the combination of other elements, both cognitive and behavioural, which included self-evaluation, self-register, training in exploration strategy and solution of cognitive, social and academic problems, such as role-playing, self-reinforcement, self-punishment, response cost or time-out (Barkley, Copeland and Sivage, 1980). In 1985 Meichenbaum defined a series of characteristics common to all these cognitive behavioural training therapies, either when applied to impulsive children or to children with social or academic disabilities. Such characteristics are still in use in the currently applied cognitive behavioural therapies. These programmes: (1) involve students as active participants or collaborators in their own learning process; (2) use open or external verbalisations as a starting point in the use of covert or internalised verbalisations and more specific verbalisations are used as a step for further more generalised verbalisations; (3) require careful analysis of the task and identification of the desired response across the development of a series of phases, (4) make use of modelling and repetition of task specific strategies elaborated out of children’s previous knowledge and abilities; (5) highlight the teaching of executive or metacognitive general strategies and (6) include prevention of relapses (in the sense of early reactions to failure and setbacks) and programmed generalisation. The effectiveness of cognitive behavioural treatment packs ranged from positive results (Kendall and Urbai, 1981; Moore and Cole, 1978, among others) as regards difficulty of generalised school performance (Douglas & col., 1976) to lack of significant findings. (For a more exhaustive review, see Meichenbaum, 1992, and Orjales and Polaino Lorente, 1988). The apparent ineffectiveness of many of these studies could be due to the small size of the samples, to the diversity and magnitude of the treatments used, the inflexibility of the packs, which were used irrespective of the characteristics and history of each subject, to the variable severity of the syndrome, the ages when used, the inclusion or not of pharmacological treatment or the existence of generalisation programmes which can transmit the knowledge learnt to the school setting (Orjales, 1977). During the last few years, as well, to the modification of diagnostic criteria; this has brought about the inclusion in our samples of subjects with only symptoms of lack of attention. A determining factor, though, is the brevity of the interventions that are carried out in these studies (in the best of cases, 30 sessions in a three or four month period), which allow for the corroboration of improvement in other areas, but which prove insufficient in order to assess the effectiveness of a cognitive treatment that aims at the development of a child’s reflective thought, which is so little in tune with their impulsive nature. In spite of the fact that programmes of cognitive behavioural training are still been used in the

treatment of children with ADHD over the last few years (Orjales 1991; Tomás, Jarque, Gómez and Miranda, 1998; Calderón, 2003; Miranda, Soriano, Presentación and Gargallo, 2000; Miranda, García and Presentación, 2002; Miranda et al., 1999; Arco, Fernández Martín and Hinojo, 2004; Miranda, Jarque and Rosel, 2006 ), more studies are necessary, not only those which focus on establishing the specific weight of the techniques used but most importantly, on elaborating cognitive behavioural profiles which, together with age and the degree of deterioration, allow for the establishment and selection of the most adequate corresponding techniques. On the basis of the above, and if we consider that the hyperactive child’s problem lies in lack of self-control and inhibition, failure to guide his conduct with internal instructions and inability to rectify inappropriate behaviour (Barkley, 1998), the treatment will need to aim at developing measures to inhibit activated responses (reduce cognitive and behavioural impulsiveness), to cope with distraction and to optimise executive performance. It seems indisputable, therefore, that within a basic intervention programme addressed to an ADHD patient (apart from the relevant and no less important educational and training programmes for parents and teachers) the following aspects need to be taken into consideration: pharmacological treatment (with detailed study of the need for its application, the time, dose and type of medicine to be used) and the application of behavioural, emotional and cognitive techniques; within the latter and with special weight, self-instructional training, among others. NEW CONTRIBUTIONS TO SELF-INSTRUCTIONAL TRAINING For over fifteen years I have included self-instructional training within cognitive behavioural programmes that I have designed and applied to specific cognitive, emotional, social, behavioural and academic profiles of children with ADHD. In the year 1991 I developed a cognitive behavioural programme for the treatment of children with this disorder to be applied in the school setting over thirty sessions. The programme included the application of techniques such as (Orjales, 1991): training the child with ADHD to evaluate their own participation in the programme and each one of the sessions modelling, training to identify feelings; to solve cognitive, academic and social problems; social reinforcement; positive individual and group self-reinforcement; the turtle technique; the protagonist of the week; the use of co-therapists; training in relaxation techniques; self-instructional training following Meichenbaum’s (1971) phases, and a specific programme of self-instructions to be generally applied in the classroom. (For a detailed review of the sessions and materials used, see Orjales and Polaino-Lorente, 2001). For the design of the self-instructional training programme, I made a first adaptation, basing my work on Meichenbaum’s writings and I incorporated support pictures. In this first adaptation, following the phases of mediational cognitive training by

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Orjales Villar, I.: Cognitive treatmenfor children with attention deficit hyperactivity disorder (ADHD). New contributions

Meichenbaum, the children had to repeat the following instructions until they were internalised, and they also had to apply them to different types of tasks: (1) Definition of the problem: “What do I have to do?” (2) Approximation to and setting out of general action strategy: “Now I know what I have to do. How am I going to do it?” (3) Attention focus on execution guidelines: “I need to be attentive and look at all the possible answers.” (4) Choice of answer and self-evaluation: “I think this is the right answer. Have I done well?” (5) Self-reinforcement and assessment of possible alternatives for correcting the mistakes made. If right: “Great! I’ve done well!” If wrong: “Why have I failed? (I go over each step). Next time I’ll try to go more slowly and won’t make that mistake. I’m sure I’ll do it better!” For this first adaptation I designed support pictures as appear in picture 1, steps 2-6 (later on I included step 1, which will be explained further on). For over ten years I have used this self-instruction as a part of the cognitive behavioural training programmes that I have carried out with children with ADHD and contrary to what some authors think, I can state that from a clinical point of view, this type of intervention has proved effective in subjects becoming aware of the thinking processes implied in problem solving, in reducing the impulsive reactions immediate to the presentation of a task, in achieving more reflective and systematic information processing and in heñping the development of problem solving strategies. The self-instructions, especially the last one (step 6) have proved especially useful for training in self-evaluation and for attributional training, they have reduced the perception of school failure by helping the children to become aware of and to define their errors (for example, “I failed the exam because I failed three problems as I forgot about carrying over”) and by avoiding wrong, internalised and negative attributions (“I failed the exam because I’m hopeless at maths.”) EXTENSION OF THE SELF-INSTRUCTION MODEL After the first few years when this first adaptation of Meichenbaum’s self instruction model was applied (chart 1, steps 2-6), I came across some difficulties which led me to the conclusion that an addition was necessary which included one more self-instruction, prior to the former ones (Orjales, 1999). Meichenbaum’s instructions start with a first instruction attempting to make the child become aware of what the problem is (identification and definition of the problem), which in our model was materialised as the verbalisation of the self-instruction: “I must be sure that I know what I have to do.” The big part of academic and re-education tasks is based on tasks which require the reading comprehension of a short statement. During the first few years of training with my first adaptation of the self-instruction model, I noticed that, as the children were being trained, they said this first step to themselves and memorised it and addressed their sights straight towards the reading of the written statement, so ignoring other contextual information

relevant for the comprehension of the instructions. I noticed that, previous to the reading of the statement and differently from reflective children, children with ADHD seldom carried out a general visual search which allowed them to position themselves in the task, for example, by looking at the number of exercises to be done, by previously matching the reading with the correct statement corresponding to each exercise, by spending a few seconds to look at the pictures and the possible number of choices or, most importantly, by noticing the inclusion of an example which illustrates how the task must be carried out. I noticed that this lack of previous analysis of context was evident, it greatly reduced the comprehension of the written instructions after a first reading of the statement and it was associated, in the child with ADHD, to one of the following reactions: (1) lack of motivation and decrease in the distraction threshold (which in cases of low tolerance to frustration might lead even to withdrawal from the task); (2) increasing complementary demands for help from the adult (so reinforcing these children’s natural tendency to emotional dependence) or (3) spending extra time on re-reading the statement, in most cases, without searching for additional information. This last more reflective attitude is uncommon in children with ADHD, although it is more likely in the least affected children, those who have not yet developed the two most frequent secondary emotional symptoms of this disorder (low tolerance to frustration and low tolerance to effort), or in those children who have support medication and so cope with fatigue better. In any case, it seemed necessary for them to comprehend written instructions as far as possible, in order to avoid unnecessary re-readings by children who get more tired with tasks that require continuous attention, due to the characteristics of their disorder. In the year 1999, in an attempt to make up for these difficulties (Orjales, 1999), I incorporated into our clinical actions one more step which would be previous to the model of self instructions that I had been using with my team throughout all these years. Inspired by one of the instruments in the Instrumental Enrichment Programme by Feuerstein and Hoffman (1994), this new self instruction was finally established as:”First I look and say all that I see,” and this would become the first instruction that the child applied within the extended self-instruction model. By utilising the same type of model with non covert verbal self-instructions that is used with the rest of the self-instructions, it is expected that the children will first apply and make automatic, then make a self-instruction that favours a previous contextual analysis that may come in useful as an introduction to the task. The inclusion of this new self-instruction, ”First I look and say all that I see,” has shown the following advantages in clinical practice: (1) It favours the inhibition of immediate emotional responses to a first reading of the statement without having analysed the context; both the positive responses, “It’s so easy. Now I know what I have to do,” and the negative responses, “This is very difficult. I’m never going to understand it,” or “This card is wrong.” (2) It assures a more comprehensive perception of the contextual

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25

information which is relevant to the task, which favours the comprehension of the instructions from the first very reading, so avoiding re-readings that might make the child tired and it also favours facilitating the retention of information in the work memory. (3) On the basis of such contextual information, it increases the probability that the child may generate hypotheses about the content of the statement and the objective of the task (precautions capacity), which the child will confirm or reject after applying the following self-instruction, which was the first instruction in the former model, “I must be sure that I do know what I have to do.”

PROCEDURE FOR APPLYING THE EXTENSION OF THE SELF-INSTRUCTION MODEL Although the extension of this self-instruction model (Orjales, 1999) follows the same phases described by Meichenbaum and Goodman (1971), it puts special emphasis on the initial model phase. We know that the hyperactive child tends to process information superficially by means of a more acoustic than semantic procedure (Polaino-Lorente, 1984) that he does not establish relationships or categories between the elements perceived. For this reason, during the training in self-instructions with the new model, the therapist needs to put special emphasis on

the modelling phase of the first self-instruction (First, I look and say all that I see.) Otherwise, the child will proceed with a superficial, unstructured and more visual than semantic analysis. For example, in front of an attention type-card in which the child needs to look for figures identical to the figure pointed out as a model, he will first verbalise ”First, I look and say all that I see” and then rush into a superficial analysis of the content of the cards, for example, “I can see elephants, bears and, I don’t know what this is, one of those things for making coffee,” instead of carrying out a better organised and more consistent analysis in their work memory, as following the case would be, “I can see a rectangular card; it is not a square because its four sides are not the same. There is a picture of a pencil drawing at the top of it. There are sentences inside that say what I have to do in this card. Below,

on the right hand side, it says 35, the number of the page,. An orange line comes out of the pencil tip and surrounds the whole card. There are four rows of pictures within this rectangle; the first row is elephants; all of them alike because they are not the same. Then there is one more row with bears, a third row with watering cans and the last row is, what? Oh, yes; they look like tea pots. The first picture of each row is within a square. Why? I guess, it must be the picture that is working as a model”. THE SELF-INSTRUCTION MODEL AS A GUIDELINE ON THE CHOICE AND SEQUENCING OF THE TASKS USED IN COGNITIVE TRAINING The researchers into mediational cognitive training have thought about the application of the general self-

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Chart 1: Meichenbaum’s (1971) Self-Instruction Model adapted by Orjales (1991) (Steps 2 to 6) and Extended Self-Instruction Model by Orjales (1999), (Steps 1 to 6).

Orjales Villar, I.: Cognitive treatmenfor children with attention deficit hyperactivity disorder (ADHD). New contributions

instruction model to various cognitive, academic and other types of tasks. Over the last ten years I have used an adapted self-instruction model (1991) and the extended self-instruction model (1999) in order to organise, as well, the sequencing of cognitive training tasks. In this way, self-instructions are not only applied to each specific task, but are also used as a guideline on the choice and sequencing of the tasks to do. Thus, to begin with, the therapist chooses the tasks that reinforce the first self-instruction; then, those that reinforce the second one, and so on. In this way, the therapist organizes the training as follows: 1) As a reinforcement for the first self-instruction (“First I look and say all that I see,”) the therapist chooses, firstly, those tasks that can reinforce visual search strategies and observation strategies: searching for differences between the two pictures, choosing the picture that is just the same as the picture used as a model, looking for what is missing in a picture, and so on. 2) As a reinforcement for the second self-instruction (“First I need to be sure that I do know what I have to do,”) the therapist chooses tasks that can reinforce the comprehension of complex written statements. In order to reinforce this step I developed a training programme for decoding written instructions (Orjales, 2000c, and Orjales, in press). 3) As a reinforcement for the third self-instruction (“How am I going to do it?”) the therapist chooses tasks that can reinforce cognitive flexibility and training in problem solving strategies for each type of task. Here the therapist chooses activities that allow the child to understand that there are different ways to carry out the same activity, by choosing mathematics problems, copying dot figures, labyrinths, puzzles, or games such as tangram, among others. This sequence allows training in self-instructions and specific strategies for each type of task. 4) As regards the fourth self-instruction (“I need to be very attentive and look at all the possible answers,” the therapist chooses tasks that allow the child to verify the usefulness of analysing the different possible answers before making a decision, for example, by training the child in the analysis of possible movements in games such as checkers or noughts and crosses. In this way, the self-instructions are, by themselves, a comprehensive thinking scheme for cognitive training and also a guide for the choice and sequencing of the material used in the training. 5) As regards the fifth self-instruction, the therapist chooses tasks that can be evaluated on the basis of various criteria that allow the child to contrast their self-evaluation with the evaluation carried out by the therapist and facilitate attributional training.

The effectiveness of self-instructional training requires learning about the cognitive, behavioural, emotional and social profiles of the child; carefully choosing from the self-instruction model and using it at the right moment of the treatment; choosing and sequencing the tasks to carry out, all of that within a

training programme with four levels which need to bear in mind the metacognitive development of the child. Level 1 refers to the child’s training to become aware of the existence of thinking processes and problem solving strategies. Before starting to explain the self-instruction model to the child, it is recommended to ask him to carry out a given task aloud while the therapist discretely takes notes of the sequences of his actions (decisions made, strategies used, mistakes or rectifications made, and so on). Once the child has completed the task, he will be asked to make up a list with the steps he would give a partner the same age who would like to complete this task without making the same mistakes. Comparing the child’s list with the therapist’s list will give the child a clear image that he has made decisions and applied many strategies without having been aware of them. Meichenbaum (1976) suggested that the child should be told about the existence of an internal dialogue, about the great variety of factors that influence the way the internal dialogue is uttered (objectives, attributions, expectations, and so on), and furthermore, about the way that internal dialogue influences decision making and the choice of various strategies (the set of thoughts and images that each person generates) in order to later set out how it is reflected on behaviour and on the tendency to make certain mistakes. All of this is useful to make the child understand that he can modify his behaviour if he modifies his internal dialogue and make it more efficient. These ambitious objectives depend on the child’s age and will be achieved across the following training levels. In level 2 lies the repeated application of self-instructions to all types of tasks, which influence twice as much those tasks in which the child manifests some specific difficulty, so making it possible for the child to perceive improvement of their performance when they carry out the tasks in a reflective manner. Level 3 would consist of training to extend the application of self-instructions onto other contexts of the child’s life without the explicit inducement of an adult and level 4, the most specifically cognitive training, organized in such a manner for the child with ADHD to get to know about their weaknesses and also recognise the situations and the types of tasks in which they need to restrain their impulsiveness and bring to light all the repertoire of known strategies, including the possibility of using open or externalised verbalisations. We still need scientific evidence that proves that children with ADHD may develop a really reflective thought processing style with time. In my clinical experience I have seen how children who have been trained for two years keep to a more reflective attitude and apply strategies learnt in those two or three years after having been discharged from the programme, even when they have not received any specific treatment whatsoever during that period.

26

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 19-30

Nevertheless, everything impresses those children who apply those strategies only or, especially, when the situation gives the task to do a special importance (an exam, follow-up exploration, and so on) or when they identify the task as complex and/or perceive some risk of failure (whenever they feel that failure is under their control). If the task is not perceived as difficult, which happens, for example, when they first carry out an apparently simple task such as the Test of Continuous Performance by Conners, they show their naturally impulsive thought processing style. I join those who support the hypothesis that this type of intervention programme for six- to twelve-year-old children with ADHD may provide an important resource to improve their cognitive performance, but cannot by itself completely modify their impulsive nature. Self-instructional training is a useful technique, but only a small part of the multidimensional programme that is required for the treatment of children with ADHD. Such training needs to lie in a family action plan, a school intervention programme and a specific treatment for the person affected by ADHD, which needs to include the assessment of a possible pharmacological treatment and an intervention programme which is not only cognitive/metacognitive and behavioural, but also emotional. The specific weight that each of these programmes may have in the treatment of subjects with ADHD will depend on age, personal, family and social characteristics and especially, on the current or potential level of maladjustment occurring in an immediate future. The use of a self-instructional training programme seems to be especially suitable for the cognitive programme of impulsive children between six and twelve years of age. Earlier studies confirmed greater effectiveness of general self-instruction in children aged 8-12 (Kendall and Wilcox, 1980) and of specific self-instructions for children of six or seven years of age (Denney, 1980). In children older than twelve the usefulness of this type of treatment needs to be weighed up. The older the children are, the greater the degree of automatism of their thinking patterns, and the more difficult the modifications in this sense is. Furthermore, the intervention with the majority of preadolescents acquires other priorities which are put before an attempt of cognitive change. More simple adaptations of specific self-instructions can be carried out successfully with pre-school children (Bornstein and Quevinllon, 1976; Tomás, Jarque, Gómez and Miranda, 1998, among others), but rather than with the objective of achieving autonomous and immediate management of the instructions, with the no less important objective of immersing the children in their use in order to educate them. REFERENCES Abikoff, H. y Gittelman, R. (1983) Academic cognitive training and stimulants in hyperactivity:a pilot study, Paper presented at the annual meeting of

The American Psychological Association, Abaheim, C.A. Abikoff, H. y Gittelman, R. (1985) Hyperactive children treated with stimulants: Is cognitive training a useful adjunct,Archives General Psychiatry, 11, 953-961 American Psychiatric Association (2002), Manual de diagnóstico estadístico de los trastornos mentales (DSM-IVTR . Barcelona: Masson.. Arco, J.L., Fernández Martín, F y Hinojo, F.J. (2004) Trastorno por déficit de atención con hiperactividad: intervención psicopedagógica, Psicothema, 16 (3), 408-414. Barkley, R.A. (1990)- Attention deficit Hyperactivity Disorder: a handbook for diagnosis and Treatment. New York: Guildford Press. Barkley, R.A (1997) ADHD and The Nature of Self-Control. New York: Guildford Press. Barkley, R.A. (1998). El desorden de hiperactividad y déficit de atención. Investigación y Ciencia, Noviembre, 48-53. Barkley, R.A., Copeland, Y Sivage (1980), A self-control classroom for hyperactive children, Journal of Autism and Developmental Disorders, 1 , 75-89. Berk, L.E. (1992). Children´s private speech: An overview of theory and the status of research. In R.M. Diaz y L.E.. Berk (Eds.), Private Speech: From social interaction to self-regulation (pp. 17-54). Mahwah, NJ: Erlbaum. Bornstein, P.H. y Quevillon, R.P. (1976), The effects of a self-instructional package on overactive preschool boys. Journal of Applied Behavior Analysis, 9, 179-188. Brown, R.T. (1980) Impulsivity and psychoeducational intervention in hyperactive children. Journal of Learning Disabilities, 13 (5), 249-253. Brown, R., Wynne, M. y Medenis, R. (1985), Methylpehnidate and cognitive therapy: A comparison of treatment approaches with hyperactive boys. Journal of Abnormal Child Psychology, 13, 69-88. Cabanyes, J. y Polaino-Lorente, A. (1997) Trastornos de la atención e hiperactividad infantil: planteamiento actual de un viejo problema, en Polaino-Lorente, A., Avila de Encío, C., Cabanyes y Truffino, J., Orjales, I. y Moreno, C., Manual de Hiperactividad infantil. Madrid: Unión Editorial. Calderón, C. (2003), Trastorno por Déficit de Atención con Hiperactividad. Evaluación y tratamiento psicológico. Tesis Doctoral presentada en el Departament Personalitat, Avaluació i Tractament Psicològic. Universidad de Barcelona. Cameron, M.I. y Robinson, V. M. (1980), Effects of cognitive training of academic and on-task behavior of

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hyperactive children, Journal of Abnormal Child Psychology, 8, 405-420. Capdevila-Brophy, C., Artigas-Pallarés, J., Ramírez-Mallafré, A., López. Rosendo, M., Real, J., Obiols-Llandrich, J.E. (2005), Fenotipo neuropsicológico del trastorno por déficit atencional/ hiperactividad: ¿existen diferencias entre los subtipos?, Revista de Neurología, 40 (supl1),17-23. Castellanos, F.X. y Acosta, M.T. (2004), Neuroanatomía del trastorno por déficit de atención con hiperactividad, Revista de Neurología, 38 (supl 1), s131-s136. Clouston, T.S. (1892), Mental Diseases, en Clinical Lectures on Mental Disease (3ª ed.). London: Churchill. Cook, E.H. (1995) Association of attention deficit disorder and the dopamine transporter gene, American Journal of Human Genetics, 56 Copeland, A.P. (1979). Types of private speech produced by hyperactive and nonhyperactive boys. Journal of Abnormal Child Psychology, 7, 169-177. Denney, D.R. (1975) The effects of exemplar and cognitive models and self-rehearsal on children´s interrogative strategies, Journal of Experimental Child Psychopatology, 19, 476-488. Diaz, R.M., Y Berk, L.E. (1992). A Vygotskian critique of self-instructional training. Development and Psychopathology, 7, 369-392. Douglas, V.I. Parry, P. Marton, P. y Garson, C. (1976), Assessment of a cognitive training program for hyperactive children, Journal of Abnormal Child Psychology, 4, 389-410.

Etchepareborda, M.C., Mulas, F., Capilla-Gonzalez, A., Fernandez-Gonzalez, S, Campo, P., Maestú, F., Fernández-Lucas, A., Ortiz, T. (2004), Sustrato neurofuncional de la rigidez cognitiva en el trastorno por déficit de atención con hiperactividad: resultados preliminares. Revista de Neurología, 38 (supl1), 145-148 Faraone, S.V., Biederman,J. (1998) Neurobiology of attention-deficit hyperactivity disorder. Biological Psychiatry, 44, 951-8. Feuerstein, R. y Hoffman, M. (1994) Programa de enriquecimiento instrumental. Madrid: Bruño. García Villamisar, D. y Polaino-Lorente, A. (1997) Breve aproximación histórica al concepto de hiperactividad infantil, en Polaino-Lorente, A., Avila de Encío, C., Cabanyes y Truffino, J., Orjales, I. y Moreno, C., Manual de Hiperactividad infantil. Madrid: Unión Editorial. Goodman, R. y Stevenson, J. (1989) A twin study of hyperactivity:II. The aetiological role of genes, family relationships and perinatal adversity, Journal of Child Psychology and Psychiatry, 30 (5), 691-709.

Guillis, J.J., Gilger, J.W., Pennigton, B.F. y DeFries, J.C. (1992). Attention deficit disorder in reading-disabled twins: Evidence for a genetic etiology.Journal of Abnormal Child Psychology, 20, 303-315. Hinshaw, S. P., Henker, B. y Whalen, C.K. (1984), Self-control in hyperactive boys in anger-inducing situations: Effects of cognitive-behavioral training and methylphenidate, Journal of Abnormal Child Psychology, (12): 55. Jensen, A. (1966) Verbal Mediation and educational potencial, Pyshology in the Schools, 3, 99-109. Kendall, P.C. y Urbain, E.S. (1981), Cognitive-behavioral self control therapy for children: A components analysis, Journal of cosulting and Clinical Psychology, 19, 672-689. Kendall,P.C. y Willcox, L.E. (1980), Cognitive Behavioral Treatment for impulsivity: concrete versus conceptual training in non-self-controlled problem children,Journal of consulting and Clinical Psychology, 48 (1), 80-91. Kirby, E.A. y Horn, A.M. (1982), Cognitive-behavioral modification with hyperactive attention deficit disorder children,, Whasington, D.C., presentado en el encuentro anual dela American Psychological Association. Konstantareas, M.M. y Hermatidis, S. (1983) , Effectiveness of cognitive mediation and behavior modifcation with hospitalizad hyperactives, Cannadian Journal of Psychiatry, 28, 462-470. Kustanovich, V, Ishi, J., Crawford, L., Yang, M., McCough, J.J., McCracken, J.T. et. al. (2004) Transmission disequilibrium testing of dopamine-related candidate gene polymorphisms in ADHD: confirmation of association of ADHD with DRD4 and DRD5. Molecular Psychiatry, 9, 711-717. LaHoste, G.J., Brook, H.L.. y Marshall, J.F. (2000) Dopamine b-sub1 receptors synergize with d-sub-2, but not d-sub-3 or d-sub 4, receptors in the striatum without the involvement of action potentials. Journal of Neurocience, 20, (17), 6666-6671. Leo, J., Cohen, D. (2003), Broken brains or flawed studies? A critical review of ADHD neuroimagen research. Journal of Mind and Behavior, 24,29-56. Meichenbaum, D. (1974), Self-instructional training: A cognitive prosthesis for the aged, Human Development, 17, 273-280 Meichenbaum, D. (1976), Cognitive-behavior modification, In J. Spence, R.C., Carson y J.W. Thibaut (Eds.), Behavior approaches to therapy, Morristown, NJ: General Learning Press. Meichenbaum, D. (1977), Cognitive- behavior modification: An integrative approach. New York: Plenum Press.

28

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 19-30

Meichenbaum, D. (1981), Una perspective cognitivo-comportamental del proceso de socialización, Analisis y Modificación de Conducta, 7 (14-15),85-111. Meichenbaum, D. (1985), Cognitive behavioral modification with hyperactive children. Paper presented at The International Conference on Hyperactivity as a Scientific Challenge. Groningen, The Netherlands. Meichenbaum, D. (1992) Teaching children self-control, en I. B. Lahey y A. Kazdin (Eds), Advances in child clinical psychology, 2. New York: Plenum. Meichenbaum, D. y Asarnow, J. (1979) Cognitive-behavioral modifcation and metacognitive development: implications for the classroom. En P.C. Kendall y S.D. Hollon (Eds.), Cognitive Behavioral Interventions: theory, research and procedures,. New York: Academic Press, 11-35 Meichenbaum, D.H. y Goodman, J. (1971), Training impulsive children to talk to themselves. A means of Developing Self-control, Journal of Abnormal Psychology, 77 (2), 115-126. Miranda, A., García, R. y Presentación, M.J. (2002) factores moduladores de la eficacia de una intervención psicosocial en niños con trastorno por déficit de atención con hiperactividad. Revista de Neuropsicología, 34 (1), 91-97. Miranda, A., Jarque, S. y Rosel, J. (2006) Treatment of children with ADHD: Psychopedagogical programa at school versus psychoestimulant medication, Psychothema, 18 (3), 335-341. Miranda, A. Presentación, M.J., Gargallo, B., Soriano, M., Gil., M.D. y Jarve, S. (1999) El niño hiperactivo: intervención en el aula: un programa de formación para profesores. Castellón: Universidad Jaime I. Miranda, A., Soriano, M., Presentación, M.J. y Gargallo, B. (2000), Intervención psicoeducativa en estudiantes con Trastorno por Déficit de Atención con Hiperactividad. Revista de Neurología Clínica, 1, 203-216. Moreno, C. y Polaino-Lorente, A. (1997), Una revisión crítica de la evolución de los criterios diagnósticos: del DSM-II al DSM-IV, en Polaino-Lorente, A., Avila de Encío, C., Cabanyes y Truffino, J., Orjales, I. y Moreno, C., Manual de Hiperactividad infantil. Madrid: Unión Editorial. Moore, S.F. y Cole, S.O. (1978) Cognitive self-mediation training with hyperkinetic children, Bulletin f Psychonomia Society, 12 (1) , 18-20. Narbona-García, J. Y Sánchez-Carpintero, R. (1999), Neurobiología del trastorno de la atención e hiperquinesia en el niño. Revista de Neurología, 28 (supl2), 160-164.

Orjales, I. (1991). Eficacia diferencial en técnicas de intervención en el síndrome hipercinético, Tesis Doctoral, Universidad Complutense de Madrid.

Orjales, I (1999).- Las autoinstrucciones de Meichenbaum: una modificación para el tratamiento de niños con Déficit de atención con hiperactividad. Comunicación presentada en el III Congreso Internacional de Psicología y Educación. Santiago de Compostela, Septiembre. Orjales, I. (2000a), Déficit de atención con hiperactividad: el Modelo Híbrido de las Funciones Ejecutivas de Barkley, Revista Complutense de Educación, 11 (1), 71-84. Orjales, I. (2000b). El tratamiento cognitivo de los niños con ADHD: actualización del programa de entrenamiento autoinstruccional en el marco del modelo de Barkley. Conferencia central en el VII Congreso Internacional de Psiquiatría. Buenos Aires: Argentina. Orjales, I. (2000c). Programa de entrenamiento para descifrar Instrucciones escritas. Madrid: CEPE Orjales, I. (2007) Déficit de atención con hiperactividad: manual para padres y educadores, 12ª ed. Madrid: CEPE Orjales, I. (en prensa), Programa de entrenamiento para descifrar instrucciones escritas con contenido matemático 1. Madrid: CEPE Orjales, I. Y Polaino-Lorente, A. (1988). Evaluación pediátrica de la eficacia terapéutica diferencial en el tratamiento de la hiperactividad infantil. Acta Pediátrica Española, 46 (1), 39-54.

Orjales, I. y Polaino-Lorente, A. (1997), Terapia cognitiva, trastorno de atención e hiperactividad infantil, en Polaino-Lorente, y col., Manual de hiperactividad infantil, Madrid: Unión Editorial. Orjales, I y Polaino- Lorente, A. (2007) Programas de intervención cognitivo conductual para niños con TDAH, 7ª ed. Madrid: CEPE Palkes, H. Stewart, W y Freedman, j. (1972) Improvement in maze performance of hyperactive boys as a function of verbal-training procedures, Journal of Special Education, 5, 337-342. Palkes, H., Stewart, W. y Kahana, B. (1968), Proteus maze performance of hyperactive boys after y training in self direction verbal comments, Child Development, 8, 817-826. Polaino-Lorente, A. (1984), Modificación de conducta en hiperactividad infantil, Revista Española de Pedagogía, 164-165, 233-255

Rogers-Warren, a., Warren, S. y Baer, D. (1977) A component analysis: modelling, self-reporting, and reinforcement of self-reporting in the development of sharing, Behavior Modification, 3, 307-322. Schneider, M. y Robin, A. (1976), The turtle technique: A method for the self-control of impulsive behavior. In J. Krumboltz Y C. Thoresen (Eds.) Couseling Methods. New Yorlk: Holt, Rinehart and Winston.

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30

Servera-Barceló, M. (2005) Modelo de autorregulación de Barkley aplicado al trastorno por déficit de atención con hiperactividad: una revisión. Revista de Neurología, 40 (6), 358-368. Shure, M.B. (1981) Social competente as a problem-solving skill, en J.D. Wine y M.D. Smye (Eds.), Social competence. New York: Guilford Press. Swanson, J.M., Sergeant, J.A., Taylor, E., Sonuga-Barke, E.J.S., Jensen, P.S., Cantwell, D.P. (1998) Seminar: attention-deficit hyperactivity disorder and hyperkinetic disorder. Lancet, 351,429-433. Taylor, E.A. (1991),El niño hiperactivo,Barcelona: Martínez Roca. Tomás, M.A., Jarque, S., Gómez, E. y Miranda, A. (1998), Análisis de la efectividad del programa “Piensa en Voz Alta” en el desarrollo de la competencia social de niños en la etapa de Educación Infantil, Revista de Psicología de la Educación, 24, 5-24 Tuke, D.H. (1892). A Dictionary of Psychological Medicine, 1. London: Churchill. Weithorn , C.J.y Kagen, E. (1979) Training first graders of high-activity level toimporve performance through verbal self-direction. Journal of Learning Desabilities, 12, 82-88.

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical and Health Psychology, 3 (2007) 31-39

TEN NOTEWORTHY REFERENCES ABOUT:

Current trends in disability: a psychological approach

Lanzarote Fernández, M.D.1, Padilla Muñoz, E.M. y Rubio Zarzuela, E. Department of Personality and Psychological Assessment and Treatment.

University of Seville. Spain

INTRODUCTION

From prehistoric times, we have been witness to both favourable and unfavourable happenings that have decisively marked our understanding of intellectual and other disabilities. However, the first studies differenciating deficiency and madness appear in Spain only at the beginning of the twentieth century. (Fierro, 1984; Ingalls, 1982; Muntaner, 1995).

The advances in the field of disability have been innumerable in the course of the twentieth century, but we needed to wait till its last years to detect an attempt to overcome failures in the guidelines followed with people with disability, in contrast to what could be observed in our neighbouring countries. We are referring to the delay in incorporating the terminology proposed by the WHO, the translation mistakes of some texts from the United Nations, the misuse of some terms, and the slow development of the 1982 Ley de Integración Social de los Minusválidos (LISMI)—Act for the Social Integration of People with Disabilities, to give some examples. At an international level, the transition to the twenty-first century, called the century of diversity, is associated with a new approach to the field of disability which addresses three key objectives, namely enhancement of independent functioning of handicapped people, the demand for efficient services and for improvement in long-term or indefinite treatments. This entails support, ___________________________ 1 Correspondence Dra Mª Dolores Lanzarote. Dpto of Personality and Psychological Assessment and Treatment. University of Seville. c/ Camilo José Cela s/n 41018 Sevilla (España). E-mail: lanzarote@us.es self-determination and quality of life, concepts which were the themes of the IV Jornadas Científicas de Investigación sobre Personas con Discapacidad (IV Congress of Scientific Research on Handicapped

People), held in Salamanca, Spain, in March 2001 (Verdugo and Jordán de Urríes, 2001). This change does not derive only from the scientific development of medicine, psychology, or education. It alludes instead to a change in the way of thinking about the people who suffer from some disability, and it also extends to the service and support provided (Schalock, 2001). In addition to the above we need to point out that the change of century and millenium unifies criteria for the new terminology on disability, which culminates in the publication of the International Classification of Functioning, Disability and Health. In this new project, the WHO abandones the former focus on consequences of the illness in order to direct attention to health and health-related states from a clearly bio-psycho-social perspective. Other iniciatives, such as proclaiming the year 2003, the European Year of People with Disabilities, are directed at shaping this new perspective on the approach to disability. In order to end this brief look at the latest international achievements, we can’t overlook the important support gained by the UN during the Convention on the Rights of People with Disabilities, held at the UN headquarters in New York on March 30, 2007. The Convention was the the first human rights treaty agreed upon in the twenty-first century and according to the High Commissioner for Human Rights, Ms. Louise Arbour, the support received by eighty countries constitutes an unprecedented backing in the history of the UN and its defence of human rights (EFE, 2007a). According to the UN expert on disability issues, Mr. Thomas Schimdlmayr, there are an estimated 650 million people with disabilities in the world, which represents the biggest minority there is, that is, ten percent of the world population (EFE, 2007b).

Lanzarote Fernández, M. D., Padilla Muñoz, E. M .y Rubio Zarzuela. Ten noteworthy references about: current trends in disability. A psychological approach

Our country, Spain, has also been willing to participate in this new general approach to disability; first, with the promulgation of Ley 51/2003, de 2 de diciembre, de Igualdad de oportunidades, No discriminación y Accesibilidad universal de las personas con discapacidad (Act 51/2003 of December 3, on Equality of opportunities, no discrimination, and universal accessibility for people with disabilities), and, more recently, with Ley 39/2006 de Promoción de la Autonomía Personal y Atención a las personas en situación de dependencia”, (Act 39/2006 on promotion of personal autonomy and attention for dependent people), which came into effect on January 1, 2007. The debate on the elaboration and passing of the Dependency Act has been followed by the Consejo General de Colegios Oficiales de Psicólogos (General Council of the Official College of Psychologists) with enormous attention, both because of the general interest that it has created in the society, and because of its specific importance for our profession. In this sense, one of the biggest concerns of the Council has been the limited presence of psychological aspects in the aforementioned law. Without any doubt, the new theoretical approaches and the latest social and political events are increasingly distant from the paternalist view about the disabled person, which used to advocate the traditional model based on the deficiency. Taking this fact as a starting point, we should ask ourselves about the main contributions that can be expected from psychology and, in particular, clinical psychology, in the field of disability. In this sense, we agree with Professor Aguado (2006) in that the emphasis should be placed on intervention processes, more specifically, on evaluation, treatment planning and programme appraisal. The selection of studies made for this analysis tries to reflect some of the main contributions to the field of disability made by clinical psychology and health psychology. To do that, studies of locally and internationally prestigious professionals published over the last five years are taken as points of reference. Nevertheless, in spite of relying on four works by foreign authors, contributions made by Spanish authors predominate, since, as Verdugo (2006) shows, politics, research, and services function differently in each country. Hence we turn to our nearest context, with the aim of understanding the current state of affairs on the work that is being done in relation with disabled people. The path taken uses as a reference, Professor Verdugo’s work published in 2003, in an attempt to cover conceptual, methodological, evaluation, and planning aspects of intervention in the field of disabled people. In this study he critically analyses the latest definition of intellectual disability put forward by the prestigious American Association on Mental Retardation, at the beginning of this decade and by outlining support models, he links up with the study published in the same year by Thompson and collaborators, who make use of a systematic approach to set out the best way to attend to the support needs of people with mental retardation and with associated developmental disabilities. This first block of works, centred on conceptual issues, finishes with a

representative selection from a recent paper by Schalock about quality of life, which is always a highly topical subject in clinical psychology. On this occasion it is not set out so much as a desire but rather as a challenge for the disabled, due to their personal limitations and to the social and cultural attitudes in relation to their worth as people. The second block of commented-on reports, also made up of three works, is a commitment on the part of psychological research to attend to an important demand for knowledge about the new needs of this population. The increase of life expectancy of disabled persons compels us to carry out follow-up studies, such as the one by Keogh, Bernheimer and Guthrie (2004); that patterns to facilitate young disabled peoples’ transition to adult life are established (Martínez Rueda, 2002) and to start attending to the ageing process of this group (Aguado and Alcedo, 2004). From our point of view, Bermejo’s work (2006) is a clear example of how it is possible to carry out empirical research with real methodological rigour, using groups of psychically disabled people as subjects of a study. This selection finishes with a set of works that try to show a wider vision of disability, which reveal the strengths and weaknesses of the attention given to disabled people. In the first case, we are referring to the role played by the families and the society in the integration of persons with disabilities. As regards the weak points in this area, we are not forgetting some of the deficiencies still to be found, such as the insufficient development of research regarding disabilities in Spain, and the limited specialised education or training still received by professionals of psychology in disabilities. Verdugo, MA (2003). Análisis de la definición de discapacidad intelectual de la AAMR de 2002. Siglo Cero. Revista Española sobre Discapacidad Intelectual, 205, 5-19. The work by Miguel Ángel Verdugo can be regarded as a critical analysis of the latest definition of mental retardation, which the prestigious American Association on Mental Retardation (AAMR) has given in their tenth edition. Ever since its foundation in 1876, it has oriented itself, like no other organisation or association, to the understanding, definition and classification of this phenomenon. As regards the terminology, the article by Miguel Ángel Verdugo disagrees on maintaining the use of the expression mental retardation instead of the increasingly accepted and widespread intellectual disability. As García, Cobacho, Berruezo, and Gosálbez (2002) defended, Verdugo argues that the main reason for proposing a change in the terminology derives from the “pejorative character of the meaning of ‘mental retardation’, which, in addition, reduces the understanding of people with intellectual limitations to a diagnostic category born from psychopathological perspectives.” (p. 6) In the same way, the study highlights the large number of European countries and institutions which have used the term ‘intellectual disability’ for some years now. Such is the case of the

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International Association for the Scientific Study of Intellectual Disabilities itself, which includes it in its name. In Spain, at an organisational level, this change is endorsed by FEAPS (Spanish Federation of Associations of Psychotherapists), whose name changes into Confederación Española de Organizaciones a favor de Personas con Discapacidad Intelectual (Spanish Confederation of Organisations in favour of people with intellectual disability). The development of the tenth edition devised by the Committee on Terminology and Classification of the AAMR (Luckasson et al., 2002) cannot be understood without the proposal made by this organisation itself in the former edition (Luckasson et al., 1992), which, as Verdugo points out, brought about a radical change in the traditional paradigm, by moving away from the conception of mental retardation as a feature into a conception based on the interaction of the person and the context (Verdugo, 1994). It was, without any doubt, the first multidimensional approach towards intellectual disability addressed to eliminating the reductionism of the exclusive use of tests for the diagnosis of IC. Furthermore, the evaluation process developed greatly, by proposing the search for information about individual needs in different dimensions which had to relate to further suitable support levels. In this sense, in the author’s opinion, the tenth edition might be regarded as a revision and improvement of the approach included in the ninth edition. So, as Verdugo states, once the change of paradigm had been accepted, the current version is commited (you bet on the geeges) to two objectives, namely, to operationalise the multidimensional nature of mental retardation with more clarity, and to provide guidelines of good practice to diagnose, classify and plan support. The new edition maintains the three criteria proposed in the 1983 and 1992 definitions; namely, significant limitations in intellectual functioning, limitations of adaptive behaviour, and these limitations are manifest in the developmental period. The specific terms that the definition finally sets out are the following: Mental retardation is a disability characterised by significant limitation of intellectual functioning and adaptive behaviour, as manifested in practical, social and conceptual abilities. This disability starts before eighteen years of age (Luckasson et al., 2002, p. 8). As for the diagnosis, classification and planning issues of intervention, the current system includes a fourth dimension, the so-called participation, interaction and social roles. This system develops planning of support, it demands greater precision in measuring intelligence (especially, in adaptive behaviour) and finally, it makes an effort to relate the proposed system to other systems of classification, such as the International Classification of Functioning, Disability and Health. Hence, Verdugo goes through the five dimensions proposed by the new system, namely, intellectual abilities; conceptual, social and practical adaptive behaviour; participation, interaction, and social roles; and health and context. In each dimension, the new

features and the differences in relation to the former editions stand out. As for the first dimension, that of intellectual abilities, the author argues that, in spite of the constraints, the current system keeps regarding the IC as the best representation of the intellectual functioning of a person. Although, it is essential that the IC is obtained from adequate evaluation tools, which need to be standardised in the general population. Apart from that, the criterion to establish the diagnosis of mental retardation is still that of “two typical deviations below the average.” This criterion is also extrapolated and so the restrictions on the evaluation of adaptive behaviour are also considered significant, which entails the further use of standardised measures in adaptive behaviour, applied to the general population. Without any doubt, this is one of the attempts to specify the evaluation of adaptive behaviour, which was a rather neglected issue in the former versions. In this sense, the AAMR proposes a series of tools with appropriate psychometric properties to evaluate this dimension. (You left this out) However, Verdugo admits that there are not any suitable adaptations of these instruments in the Spanish language, in spite of the increasing number of publications pointing in this direction (Gilman et al., 2002; Morreau, Bruininks y Montero, 2002; Verdugo, 1989/1997, 1996, 2000). As already stressed, the dimension of participation, interaction and social roles is one of the most important novelties of this new classification system. Furthermore, it is a clear commitment to getting closer to the WHO proposal in the International Classification of Functioning, Disability and Health (WHO, 2001). In this way, both systems highlight the role of analysing and bearing in mind the opportunties and restrictions of the individual to participate in the community. This is the dimension most concerned with interactional aspects, differently from the rest, which independently focus on personal or environmental aspects. It also supposes an important advance in the multidimensional conception of this model, as well as an approximation towards other classification systems, the definitive commitment to the assumption of the concept of health proposed by the WHO in 1980, where health is understood as being a state of physical, mental and social well-being. As Verdugo states, the AAMR had so far been criticised for excessively psychopathologising their conception of health, proposing in this new version that this dimension “should widen their approach and include non pathological aspects of emotional well-being. (Verdugo, 1999, pp.29-30). According to this author, it has been wise to place psychological and emotional aspects in this dimension. However, he thinks that the AAMR’s proposal “is limited in its development, on simply concentrating in placing the problems of mental health in this dimension and formulating a general proposal of the concept of health of the WHO” (p. 12). The fifth and last dimension, context, includes the new idea that not only should we attend to the environment in which the person performs, but also the culture, as many values and assumptions about

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Lanzarote Fernández, M. D., Padilla Muñoz, E. M .y Rubio Zarzuela. Ten noteworthy references about: current trends in disability. A psychological approach

behaviour are affected by it. As argued in earlier versions, the evaluation of context is not carried out with standardised measures, but is a component which should be included in the so-called clinical judgement. The last section focuses on the analysis of the three functions of the evaluation process, namely, diagnosis, classification, and support systems. First of all, it states that this version is much more explicit than earlier ones when relating the diagnostic process to the planning of support, that is, to intervention proper in the field of intellectual disability. In short, what the AAMR explicitely proposes is that the evaluation process should focus not only on the limitations of the individual but also on their abilities, the essential thing being obtaining data which allow for a suitable profile of support which may improve a person’s individual functioning. In this sense, Verdugo points out that the instruments used should be able to help to establish diagnosis criteria previously pointed out, and, most importantly, these instruments should be useful in showing which abilities a person may need to develop. From his point of view, the tools which might meet this requirement are the Curriculum for Adaptive Skills (CALS) (Gilman et al. 2002); the Inventario para la Planificación de Servicios y la Programación Individual (Inventory for the Planning of Service and Individual Planning) (ICAP) (Montero, 1993), and the Programas Conductuales Alternativos (PCA) (Alternative Behaviour Programs) (Verdugo 1996, 1989/1997, 2000). As for the third function of the evaluation processes, the support systems, the AAMR states that “Supports are resources and strategies that attempt to enhance the develoment, education, interests, and well-being of a person, and that improve individual functioning.” (Luckasson et al., 2002, p. 145). According to this approach, the ultimate objective of evaluation should be to establish a support needs profile for each person with intellectual disability. In this sense, nine areas of support are established, namely, human development, teaching and education, life at home, life in the community, employment, health and safety, behaviour, social, protection and defence. For each area it would necessary to identify the type of support necessary, the degree of support, and the person responsible for providing the support. In conclusion, the author considers that “the support model is a key aspect in the present-day conception of intellectual disability, and its funtioning depends to a great extent on the existence or not of real changes in the system of attention to the population with intellectual limitations. The current approach to support is directly related to the incorporation of planning focused on the individual.” (p. 17) Thompson, J.R., Hughes, C., Schalock, R.I., Silverman, W., Tassé, M.C., Bryant, B., Craig, E.M. y Campbell, E.M. (2003). Integrando los apoyos en la evaluación y la planificación. (Integrating supports into Assessment and Planning.) Siglo Cero. Revista Española sobre Discapacidad Intelectual, 34 (2), 36-55.

The study carried out by these authors presents, from a systematic focus, a proposal to attend to the support needs of people with mental retardation and associated developmental disabilities. They propose the definition of ‘support’ as being resources and strategies which enhance the interests and well-being of individuals, which improve personal and productive independence, and which increase participation in an interdependent society, in community integration and/or in the quality of life. Among the challenges they put forward are that the objectives should start from the needs and aspirations of the people directly concerned; to include improvement in personal development, empowerment, inclusion, and valued social roles; an evaluation of a wide range of individual support needs that are centred on the people should be flexible and adaptable, and to evaluate the changes in state and needs. The authors start from a focus of four components in order to be able to establish the support needs, and to develop plans which attend to those needs (identifying vital experiences and achievements desired by the person, establishing the degree of individual support in a wide range of environments and activities, developing an individual plan for support, monitoring the results and evaluating the effectiveness of the plan). These four components are developed within five suppositions on the nature of the support needs of people with mental retardation and associated developmental disabilities. The first supposition considers that the types of support should depend on the needs and preferences of the individual. The second one states that provision of support should be flexible, responding to the needs of people, who change in function of the circumstances, and they need periodic revisions. The third supposition suggests that some supports are more important to some people than to others; that is to say, we should allow for the prioritizing of some support needs. The fourth one states that systematic evaluation of support needs should guide the development and revision of individual support plans (ISP). Finally, the fifth supposition focuses on the multiple factors necessary for the evaluation of support needs. All four components focus on the identification of vital experiences and achievements desired by the person, and on the appraisal of the degree of support necessary in various environments and activities. In order to determine this support, the authors propose a scale created by themselves, the “Escala de Necesidades de Apoyo” (Support Intensity Scale (SIS), Thompson et al., 2002). The authors consider that the SIS is suitable to use at any moment when the support needs of an adult person have to be assessed. For this reason, it can be used independently of the focus of the four components in order to attend to the support needs described in the article. Following, they reflect on putting this type of intervention into practice. Thus, they consider that the ISP shoud bear in mind all the sources of support

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available for the individual, and the contexts in which they will be given. In this sense, cooperation and communication between the support providers and the planning team is crucial to assure that all support will be provided at the highest possible degree, and without any duplicity or interruption. Likewise, the individual’s satisfaction at the support received, and the areas of support which require modification or accomodation are believed to be necessary. As for identification of the degree of support necessary for each individual, they consider that the evaluation of young children with mental retardation should be focused on the identification of the types and the intensity of support needed by the children’s families, who are especially relevant and useful in this age group (Luckasson, Schalock, Snell y Spitalnik, 1996). They state that if people are identified according to the level of support they need or according to their level of personal competence, this should neither hide the need to assess both areas, nor distract attention from the importance of developing reliable and valid evaluation tools to measure both areas. They argue that the SIS seems to have the potential to identify both a person’s support needs in specific areas, as well as a global score. There is also some reflection on the financing of support. In this sense, they think that the disabled person, their family, and other members of the support team should be prepared to make choices about support priorities, since resources are limited. Finally, they raise a series of themes and challenges associated to the assessment and the planning of support needs. First of all, there is the need for greater acceptance of this work proposal and/or the lack of a clearly defined procedure for measuring support needs. (Polloway, Chamberlain, Denning, Smith y Smith, 1999). The assessment process needs to provide the structure and sufficient uniformity to allow for objective, unbiased, dynamic and realistic development of the ISP. The work finishes with the authors’ statement that their ultimate aim is to provide support with the greatest positive impact on the quality of life of every individual and they believe that the approach described in their article will bring about a significant step in that direction. Schalock, R.L. (2006). La calidad de vida como agente de cambio: oportunidades y retos. (Quality of life as an agent of social change. Opportunities and Challenges. In M.A. Verdugo Alonso y F.B. Jordán de Urríes Vega (Coord.). Rompiendo inercias. Claves para avanzar (Breaking routine habits. Keys for advance) (pp. 15-39). Salamanca: AMARÚ Ediciones. The selection of this paper, presented at the “VI Jornadas Científicas de Investigación sobre Personas con Discapacidad” (VI Scientific Conference on Disabled People), held in Spain in 2006, responds to two specific criteria, namely, the analysis of the current situation of the phenomenon carried out by a well-known researcher on disabled people in Spain, and the analysis of a work proposal on the issue. The author

states that, for every one of us, achieving a good quality of life is both a wish and a challenge, but for disabled people this challenge is even greater because of their personal limitations, because of the social and cultural attitudes in relation to their worth as people, and because of their social consideration within their communities. Even though an attitudinal change is taking place, ‘quality challenges’ still exist, especially as regards their social inclusion, personal development, self-determination and rights. The author reflects on the opportunities and challenges encountered by the disabled to achieve quality of life, and on how these challenges can be overcome by completely implementing the concept of quality of life in the individual, organisational, and systemic levels. First of all, the author focuses on the history of the concept of quality of life, and why our field adopted it in the 1980s. The four reasons he points out make reference to the following: the fact that the concept reflected a constant on-going change about people with disability; the fact that it provided a common language which described the programmes’ objectives of normalisation, disinstitutionalisation, integration, and responsibility; the fact that it was coherent with the quality revolution, which gave priority to quality results and quality products and finally, the fact that the expectations of the recipients of the service and the support provided had a significant and positive impact on their personal well-being. Secondly, he discusses the four conceptual and methodological advances that took place in the 1990s, which provided a clear notion of the concept of life, and a firm philosophical and empirical foundation for our present-day measures and for our efforts in applying them. These advances are: operational principles, basic dimensions of the quality of life, approaches for research and measurement, and a systemic perspective. An internacional group of researchers on the quality of life have validated a total of twelve operacional principles related to conceptualisation, measurement, and application of quality of life. These principles allow for the operational definition of the concept of quality of life as a relevant multidimensional concept. The basic dimensions of quality of life can be individual centred or family centred. Schalock defines them as: “the set of factors that shape personal well-being, encompass the concept of quality of life, and thus, define quality of life” (p. 18). The importance of identifying these basic dimensions lies in the fact that they allow our field to move on from a general concept of quality of life to a specific and multidimensional notion, with measurable properties and attributes. Within the approaches of researchers and of measurement, the basic indicators of quality of life are defined as: “the specific conditions, behaviour or perceptions of a dimension of quality of life which give an indication of a person’s well-being” (p. 19), a specific and multidimensional notion with measurable properties. According to the author, the methodological approach is characterised by having different

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Lanzarote Fernández, M. D., Padilla Muñoz, E. M .y Rubio Zarzuela. Ten noteworthy references about: current trends in disability. A psychological approach

assessment approaches, multi-variable research designs, and evaluation based on results. As regards the systemic perspective, it starts from the premise that people live in different ‘systems’ which influence the development of their values, beliefs, behaviour and attitudes, which to a large degree establish the quality of life that they experience (microsystem, mesosystem, and macrosystem). Finally, the author puts forward the notion that quality of life may act as an agent of social change for people with disability, but in this process we will need to adopt seven opportunities and challenges. Three of them are related to research, namely, confirming the structure of the factors in quality of life, measuring the personal results, and establishing the significant predictors of quality results. Four of the challenges and opportunities are related to organisations and systems in order to emphasise a quality-of-life programme, to put the most suitable methodologies into practice, to get involved in the continuous improvement of the programmes, and to exploit the mechanisms of social change. He considers that the first of these challenges is materialised in the increase in the studies on quality of life through statistical methods which confirm the stability of factors in the basic dimensions of quality of life in more countries and cultural groups. As regards the measurement of personal results, he considers that they contribute to personal well-being from the individual and family points of view. He states that the four essential aspects of the results are that they can be assessed by means of subjective measures, that they are influenced by variables of the process, that these variables are not the same as the social indicators, and that they can be used for various aims, including individual assessment. According to the author, establishing the significant predictors of the personal results would allow for the creation an acceptable model as to how a programme should function, the analysis of the scope and impact of external influences on the programme, the differentiation between the product of the programme and the short-term and long-term personal results, the development of a framework to analyse alternative strategies to achieve the desired personal results, the better understanding of the functioning of the agency by identifying a sequence of events and greater communication, and the analysis of the logic of human service programmes and public policies. As for the challenge of the transition to emphasis on quality of life within the programmes, the organisations should obtain results valued by the individual and oriented to quality of life, and make the concept of quality of life their main objective. Within the implementation of the most adequate methodologies, he thinks that the two most recommended practices are: the one referring to the recommended programme practice (which entails planning centred on the person/family), the strategies for improvement of quality, individualised support and

assistance technologies. The second practice is related to ethics in assessment. Involvement in the continuous improvement of the programmes has the aim of satisfying clients, improving services and support and increasing organisational effectiveness. Lastly, exploiting mechanisms of social change suggests five possible strategies, namely, ethical community (by interrelating human and community development, and by directing intervention activities to the improvement of support resources); social resources (changes in the relationship among people); education and professional training; solid defence (social change starts with the person); and the alignment of research, policies and practice. Finally, Schalock concludes that the most important issue about the concept of quality of life is that it makes us think differently about ourselves, about marginalised people, and about the means to actually achieve personal, organisational, systemic, community, and social change in order to improve people’s well-being. Even though the three last decades have witnessed great development, new methods and standards are necessary to plan, provide, manage, and assess both quality of service and personal quality results for the disabled. As this author thinks, if the concept of quality of life is to be a real agent of social change, the real agents of the change should be the disabled people themselves, our main challenge is to align research efforts, skills and educational programmes and public policies which may facilitate the change. To do that, he proposes three dimensions, centred on research, practice, and politics.

REFERENCES

Adelman, H.S., Taylor, L. y Nelson, P. (1989). Minors´dissatisfaction with their life circumstances. Child Psychiatry and Human Development, 20, 135-147. Aguado, A.L. (1995). Historia de las deficiencias. Madrid: Escuela Libre Editorial. Aguado, A.L. (2006). El cambio de actitudes sobre discapacidad es posible pero ha de ser programado. Entrevista concedida a Infocop Online con motivo del Día Mundial de la Discapacidad (2/12/2005). Aguado, A.L. y Alcedo, M. A. (2004). Necesidades percibidas en el proceso de envejecimiento de las personas con discapacidad. Psicothema, 16 (2), 261-269. Allison, K.W, Echemedia, R.J., Crawford, I. y Robinson, W.L. (1996). Predicting cultural competence: Implications for practice and training. Professional Psychology Research and Practice, 27, 386-393. ANFAS (2000). Las personas con discapacidad psíquica y sus familias en la Europa del futuro. Resumen de ponencias presentadas al Encuentro franco-español. Pamplona, 10-11-IX.

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Azúa, P. (2006). Datos y reflexiones sobre las asociaciones de síndromes específicos en personas con discapacidad intelectual. En VV.AA. Síndromes y Apoyos: una visión desde la ciencia y desde las asociaciones (pp. 397-406). Madrid: FEAPS. Barón, R.M. (1980). Contrasting approaches to social knowing: An ecological perspectiva. Personality and Social Psychology Bulletin, 6, 591-600. Bermejo, B. (2006). El mundo emocional de las personas con retraso mental: un estudio empírico sobre su capacidad para reconocer y experimentar emociones. [En prensa]. Blackorby, J. y Wagner, M. (1996). Longitudinal post school outcomes of youth with disabilities: Findings from the National Longitudinal Transition Study. Exceptional Children, 62, 399-413. Carney, J. y Cobia, D.C. (1994). Relationship of characteristics of counsellor-in-training to their attitudes toward persons with disabilities. Rehabilitation Counseling Bulletin, 38, 72-26. EFE (2007a). La ONU logra un respaldo masivo a la Convención de Derechos de las Personas Discapacitadas. EFE (30/03/2007). EFE (2007b). Casi 50 países firman Convención ONU sobre Derechos Personas con Discapacidad. EFE (29/03/2007). Epstein, M. H. y Sharma, J. (1997). Behavioral and emotional rating scale: A strength-based approach to assessment. Austin, TX.: Pro-Ed. Fantova, F. (2000). Trabajando con las familias de las personas con discapacidad. Siglo Cero. Revista Española sobre Discapacidad Intelectual, 31, 6, 33-49. Fierro, A. (1984). España: Historia reciente. En R.C. Scheerenberger, Historia del retraso mental (pp. 401-431). San Sebastián: Servicio Internacional de Información sobre Subnormales. García, J.M., Cobacho, J.P., Berruezo, P.P. y Gosálbez, C.G. (2002). Definiciones, modelos explicativos y comorbilidad. En J.M. García Fernández, J.P. Cobacho y P.P. Berruezo (Coords.), Discapacidad intelectual, desarrollo, comunicación e intervención (pp. 15-49). Madrid: CEPE. Gilman, C.J., Morreu, L.E., Bruininks, R.H., Anderson, J.L., Montero, D. y Unamunzaga, E. (2002). Currículum de destrezas adaptativas (ALSC). Bilbao: Ediciones Mensajero. HEART (1995). Coherencia entre los sectores industriales en tecnología de la rehabilitación. Comisión Europea (Versión española de CEAPAT, IMSERSO y M.T. y A.S., Madrid). Huitt, K., y Elston, R.R. (1991). Attitudes toward persons with disabilities expressed by professional counsellors. Journal of Applied Rehabilitation Counseling, 22, 42-43.

INE (2000). Encuesta sobre Discapacidades, Deficiencias y Estado de Salud, 1999:Avance de resultados. Datos básicos. Madrid: INE. Ingalls, R.P. (1982). Retraso mental: la nueva perspectiva. México: El Manual Moderno. Johnson, D.R, McGrew, K.S., Bloomberg, L., Bruininks, R. y Lin, H. (1997). Results of a national follow-up study of young adults with severe disabilities. Vocational Rehabilitation, 8, 119-133 Keogh, B.K., Bernheimer, L.P y Guthrie, D. (2004). Children with developmental delays twenty years later: where are they? How are they?. American Journal of Mental Retardation, 109 (3), 219-230. Keogh, B.K., Bernheimer, L.P., Gallimore, R. y Weisner, T. S. (1998). Child and family outcomes over time: A longitudinal perspective on developmental delays. In M. Lewis y C. Feiring (Eds.), Families, risk, and competence of parents (pp. 269-287). Mahwah, NJ: Erlbaum. Lang, P. (1980). El Maniquí de Autoevaluación SAM (Self-Assessment Manikin, SAM).Florida: NIHM Center for the study of Emotion and Attention. University of Florida. Lazarus, R.S. (1982). Thoughts on the relation between emotion and cognition. American Psychologist, 37, 1019-1024. Lazarus, R.S. (1984). On the primacy of cognition. American Psychologist, 39, 124-129. Luckasson, R., Borthwick-Duffy, S., Buntix, W.H.E., Coulter, D.L., Craig, E.M., Reeve, A., y cols. (2002). Mental Retardation. Definition, classification and systems of supports (9th ed.). Washington, DC: American Association on Mental Retardation. (Traducido a: Retraso Mental: Definición, clasificación y sistemas de apoyo. Madrid: Alianza, 1997). Luckasson, R., Coulter, D.L., Polloway, E.A., Reiss, S., Schalock, R.L., Snell, M.E., Spitalnik, D.M. y Stark, J.A. (1992). Mental Retardation. Definition classification and systems of supports (10th ed.). Washington, DC: American Association on Mental Retardation. Luckasson, R., Schalock, R.L., Snell, M.E., y Spitalnik, D.M. (1996). The 1992 AAMR definition and preschool children: Response from Committee on Terminology and Classification. Mental Retardation, 34, 247-253. Martínez Rueda, N. (2002). Juventud y discapacidad. Programas y herramientas para facilitar la transición a la vida adulta. Bilbao: Ed. Mensajero. Montero, D. (1993). Evaluación de la conducta adaptativa en personas con discapacidades.Adaptación y validación del ICAP. Bilbao: Instituto de Ciencias de laEducación, Universidad de Deusto.

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Moore, D.G. (1994). The nature of person perception: Experimental investigations with mentally retarded and non-retarded children. Unpublished doctoral dissertation. University College, London. Moore, D.G. (2001). Reassing emotion recognition performance in people with mental retardation: A review. American Journal on Mental Retardation, 106, 481-502. Moore, D.G., Hobson, R.P. y Lee, A. (1997). Components of person-perception: an investigation with autistic, nonautistic retarded and typically developing children and adolescents. British Journal of Developmental Psychology, 15, 401-423. Morreau, L.E., Bruininks y Montero, D. (2002). Inventario de destrezas adaptativas (CALS). Bilbao: Ediciones Mensajero. Muntaner, J.J. (1995). La sociedad ante el deficiente mental: normalización, integración educativa e inserción social y laboral. Madrid: Nancea. Organización Mundial de la Salud (2001). Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud. CIF. Madrid: Ministerio de Trabajo y suntos Sociales, Instituto de Migraciones y Servicios Sociales. Paulhus, D.L. (1999). Paulhus Deception Scales (PDS): Balanced Inventory of Desirable Responding (BIDR; Version 7). North Tonawanda, NY: Multi-Health Systems, Inc. Pérez Gil, R. (2000). La capacidad de decisión en las personas con retraso mental: una cuestión personal y social. Ponencia. Encuentro Franco-Español: Las personas con discapacidad psíquica y sus familias en la Europa del futuro. Resumen de ponencias presentadas al encuentro (pp. 145). Pamplona, 10-11-IX. Phillips, M.J. (1985). “Try harder”: The experience of disability and the dilemma of normalization. Social Science Journal, 22, 45-47. Phillips, M.J. (1990). Damage goods: Oral narrative of the experience of disability in American culture. Social Science Journal, 30, 849-855. Polloway, E.A., Chamberlain, J., Denning, C., Smith, J.D., y Smith, T.E.C. (1999). Levels of deficits or supports in the classification of mental retardation: Implementation practices. Education and Training in Mental Retardation and Developmental Disabilities, 34, 200-206. Rodríguez-Porrero, C. (1999). Nuevas tecnologías. Ayudas técnicas en rehabilitación. En A. Ruano, J.M. Muñoz Céspedes y C. Cid. (Coords.), Psicología de la rehabilitación (pp. 465-497).Madrid:Fundación MAPFRE de Medicina. Schalock, R.L. (1996). Quality of Life. Vol. I: Its Conceptualization, Measurement and Use. Washington, D.C.: American Association on Mental Retardation.

Schalock, L. (Ed.) (1997). Quality of life. Volumen II: Application to persons with disabilities. Washington, D.C.: American Association on Mental Retardation. Schalock, R.L. (1999). Hacia una nueva concepción de la discapacidad. En M.A. Verdugo y F. de Borja (Coords.), Hacia una nueva concepción de la discapacidad: Actas de las III Jornadas Científicas de Investigación sobre Personas con Discapacidad (pp. 79-109), Salamanca: Amarú. Schalock, R.L. (2001). Conducta adaptativa, competencia personal y calidad de vida. En M.A. Verdugo y F.B. Jordán (Coords.), Apoyos, autodeterminación y calidad de vida. Salamanca (pp. 83-104). Salamanca: Amarú. Schalock, R.L. (2006). La calidad de vida como agente de cambio: oportunidades y retos. En M.A. Verdugo Alonso y F.B. Jordán de Urríes Vega (Coord.). Rompiendoinercias. Claves para avanzar (pp. 15-39). Salamanca: AMARÚ Ediciones. Strike, D.L. (2001). Counseling Clients With Disabilities Survey. Unpublished manuscript. Strike, D.L., Skorholt, T.M. y Hummel, T.J. (2004). Mental health professionals’ disability competence: measuring self-awareness, perceived knowledge, and perceived skills. Rehabilitation Psychology, 49 (4), 321-327. Suttie,J., Ashman, A.F. y Bramley, J. (1993). Problems Undertaking Sur veys of Older People with a Disability in Australia. Irish Journal of Psychology, 14,1, 5-24. Thompson, J.R., Bryant, B., Campbell, E.M., Craig, E.M., Hughes, C., Rotholz, D.A., Schalock, R.I., Silverman, W., y Tassé, M.C. (2002). Supports Intensity Scala. Escala de evaluación no publicada, Washington, DC: American Association on Mental Retardation. Thompson, J.R., Hughes, C., Schalock, R.I., Silverman, W., Tassé, M.C., Bryant, B., Craig, E.M. y Campbell, E.M. (2003). Integrando los apoyos en la evaluación y la planificación. Siglo Cero. Revista Española sobre Discapacidad Intelectual,34 (2), 206, 36-55. Verdugo, M.A. (1989/ 1997). Programa de Habilidades Sociales (PHS). Programas Conductuales Alternativos. Salamanca: Amarú. Verdugo, M.A. (1994). El cambio de paradigma en la concepción del retraso mental: la nueva definición de la AAMR. Siglo Cero. Revista Española sobre Discapacidad Intelectual, 25 (5), 5-24. Verdugo, M.A. (1996). Programa de Habilidades de Orientación al Trabajo (POT). Programas Conductuales Alternativos. Salamanca: Amarú. Verdugo, M.A. (1999). Avances conceptuales y del futuro inmediato: Revisión de la definición de 1992 de

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la AAMR. Siglo Cero. Revista Española sobre Discapacidad Intelectual, 30 (5), 27-32. Verdugo, M.A. (2000). Programa de Habilidades de la Vida Diaria (PVD). Programas Conductuales Alternativos. Salamanca: Amarú. Verdugo, M.A. y Jordán de Urríes, F.B. (2001). Apoyos, autodeterminación y calidad de vida. Actas de las IV Jornadas Científicas de Investigación sobre Personas con Discapacidad. Salamanca: Amarú Ediciones. Verdugo, MA (2003). Análisis de la definición de discapacidad intelectual de la AAMR de 2002. Siglo Cero. Revista Española sobre Discapacidad Intelectual, 34(1), 205, 5-19. Verdugo, M.A. (2006). ¡Qué investiguen ellos! Ideas y propuestas para mejorar la investigación sobre discapacidad en España. En M.A. Verdugo Alonso y F.B. Jordán de Urríes Vega (Coord.). Rompiendo inercias. Claves para avanzar (pp. 41-54). Salamanca: AMARÚ Ediciones. Verdugo, M.A. y Sabeh, E.N. (2002). Evaluación de la percepción de la calidad de vida en la infancia. Psicothema, 14,1, 86-9 1. VV.AA. (2006). Síndromes y Apoyos: una visión desde la ciencia y desde las asociaciones. Madrid: FEAPS. Zetlin, A.G. y Turner, J.L. (1985). Transition from adolescence to adulthood: Perspectives of mentally retarded individuals and their families. American Journal of Mental Deficiency, 89, 570-579.

 

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Retrosprective and prospective study of premenstrual symptomatology in the general population1

Gómez Márquez, C. 2, García García, M. 3, Benítez Hernández, M.M. 3, Bernal

Escobar, L. 4 y Rodríguez Testal, J.F. 3

Dpto. de Personalidad, Evaluación y Tratamientos Psicológicos. Facultad de Psicología. Universidad de Sevilla (España)

ABSTRACT This study consisted of three phases in which a cross method and a prospective one were combined in order to observe three consecutive menstrual cycles. The procedure of statistic analysis (C by Young) was not merely a comparison of scores. It also analysed the trend changes in the observations and their attributions to the premenstrual phase or the follicular phase. If attention is paid exclusively to the prospective analysis of the subsyndromic incidence figure, the general population data is 7%. The women in the retrospective premenstrual group stood out because of a greater number of symptoms, their seriousness and the degree of inference in their jobs and relationships with others, and because they even tended to avoid social situations. Cognitive vulnerability common to depressive disorders can’t have been verified. The prospective analysis verified that there was no adequate equivalence between retrospective and prospective information, that remarkable symptom variations are evident within different cycles in the same woman (consecutive or alternate), and the expected pattern of premenstrual symptomatic increase and follicular decrease, although there was a distribution of follicular increase. Dysphoric symptoms stood out more than those characterised by a depressive state of mind. Key words: premenstrual dysphoric syndrome, symptomatology, prosprective, retrospective. INTRODUCTION

The End-of-Luteinic-Phase Dysphoric Disorder

(late luteinic phase), which was proposed as a diagnostic entity for research in Appendix A of DSM-III-R (APA, 1988), was later renamed as Premenstrual Dysphoric Syndrome in DSM-IV (APA, 1995). This change of label seemed to predict the difficulties and inconsistencies contained in its study results, and, definitively, by its scientific consideration as a second-degree mood change—which necessarily affects the attention paid to the health of those who suffer from it.

From a psychopathological point of view it should first be borne in mind that the field of analysis about premenstrual changes has been limited to Premenstrual Dysphoric Syndrome— in general terms, the classical _______________________ 1This study was possible thanks to the Ayuda de Investigación (Research Funding) within the Plan Nacional de Investigación Científica, Desarrollo e Innovación Tecnológica (I+D+I) del Ministerio de Trabajo y Asuntos Sociales. (Nacional Plan of Scientific Research, Development, and Technological Innovation of the Ministry of Labour and Social Matters. Spain.) 2Investigación y Terapia Cognitiva (INTECO). Av. Cardenal Bueno Monreal, 6, 1º B, 41013 Sevilla, Spain. 3Dpto Personalidad, Evaluación y Tratamiento Psicológicos. Universidad de Sevilla.(Department of Personality, and Psychological Evaluation and Treatment. University of Seville. C/ Camilo José Cela s/n 41018 Sevilla. Spain. testal@us.es 4Equipo Salud Mental de Distrito Huelva. Área Hospitalaria Juan Ramón Jiménez (Mental Health Team of the Huelva District. Hospital Area Juan Ramón Jiménez ) Huelva, Spain.

term of Premenstrual Disorder is being alluded here. This is an important fact, since different types and

degrees of disturbance affect many women, we could even say most of them, although the functional interference or upset may be limited. Most of the indicators of these premenstrual changes are physical (e.g. breast sensitivity), and the general affective manifestations are minor. Only in the most severe cases of Premenstrual Disorder would there be coincidende with Premenstrual Dsyphoric Syndrome (Freeman, Derubets and Rickels, 1996).

In consequence, Premenstrual Dysphoric Syndrome represents a subgroup of Premenstrual Disorders (Frackiewicz and Shiovitz, 2001; Freeman, 2003; Stearns, 2001) in which affective symptoms necessarily dominate both frequency and intensity (e.g. depressive mood, anxiety, emotional lability, irritability, and so on). The consequences on a woman’s degree of functioning are remarkable. interfering in social, work or (or studies), family or interpersonal life. Premenstrual dysphoric syndrome is far from having the status of a disorder—within mood disorders—given the difficulties in establishing a stable presentational pattern. Premenstrual dysphoric syndrome is also far from having a common aetiological model, since diagnosis requires prospective observation and, also in part, because the suffering woman’s subjective value is prominent.

It is commonly accepted that Premenstrual Dysphoric Syndrome has an incidence rate of 3-9%; in

Gómez Márquez, C., García García, M., Benítez Hernández, M.M2, Bernal Escobar, L y Rodríguez Testal, J.F. Retrosprective and prospective study of premenstrual symptomatology in the general population

the DSM-IV-TR (APA, 2000) 3-5 % is pointed out without midification in relation to what was stated by the DSM-IV years ago (APA, 1995). Halbreich, Borenstein, Pearlstein and Kahn (2003) argue that these figures may not respond to what was found in studies that focussed on more serious forms, and establish reference figures of between 13 and 19%. According to these authors what is really noteworthy, irrespective of percentage disagreement, is that the WHO study about the overburdening that several physical and mental diseases provoke, Premenstrual Dysphoric Syndrome is not mentioned. It is worth remarking on this omission by the WHO, as its international classification (CIE-10) requires the need of fewer diagnostic indicators (of Premenstrual Pressure Disorder) than the demanding APA classification. In other words, with less restrictive criteria in the case of CIE-10 (since the DSM have risen from 10 in the third revised edition to 11 in the fourth), the aforementioned study of disease overburden provides no information about the repercussions on the woman’s social-and-labour or, no doubt, on the social-and-family functioning, although criteria of both classification systems point out the interference with some area of functioning of the woman.

Out of the sphere of international classification, it is common to conceive Dysphoric Premenstrual Syndrome as the expression of a physical and emotional symptomatic pattern of perimenstrual interference. Thirty to ninety percent of women point out physical and emotional disturbance during that period, which may become really disrupting in 2-15% of all women (Marván & Cortés-Iniestra, 2001) as depression (Halbreich, 2003; Yonkers, Halbreich, Freeman, Brown et al., 1997) with acute postmenstrual disappearance (Kahn & Halbreich, 2003), and with no different manifestations in relation to a comparison group during the follicular phase (Trunnell, Turner & Keye, 1988).

This syndrome shows an additional effect with other comorbid conditions and, even though severity seems to increase with age, the pattern decreases as the woman’s reproductive phase comes to an end (Sternfeld, Swindle, Chawla, Long et al., 2002).

The problems with the study of this syndrome start out of specification of other non-merely symptomatic aspects. As it is argued by Kuan, Carter y Ott (2004) in a letter to the editor of a journal, some of the inconsistencies of the results may be due to the changes in the menstrual cycles which women go through during the reproductive years. One more origin of iconsistency may be due to cultural influence: Women tend to manifest more symptoms in some cultures than in others; more physical than emotional symptom variations have been shown, even when using self-registers (McFarland, Ross & DeCourville, 1989); and reverse symptom severity, consequently dependent on the state of health (Sternfeld et al., 2002).

As it has been argued above, the diversity of contributions made in the last few years conflicts with aspects which make the definition and follow up slippery, since prospective corroboration is necessary. This brings about designs with small samples in order to manage the extraordinary amount of data produced, which limits adequate generalization in spite of the improvement on the internal consistency of the results. Furthermore, there is no hormonal lab test so far which confirms or indicates the presence and gravity of the syndrome (Freeman, 2003), in spite of the evident

presence of neurohormonal change. In short, this conjunction of factors makes it difficult to reliably aprehend the components integrating a recognisable mosaic.In consequence, the interpretations made by Rivera-Tovar and Frank more than fifteen years ago (1990) seem up to date, in the sense that there is not a definitive agreement on the parts of the features componing this syndrome, and because of the serious inconvenient of relying on retrospective diagnoses, which affects a good part of the research carried out.

From an etiological point of view, the majority of the research carried out show that gonadal hormones can’t be held responsible for the whole burden that this syndrome covers, as it is successfully stood out by Uriel Halbreich (2003). Alterations in neurotransmission have been described, such as low levels of beta-endorfins, which bring about symptoms of anxiety and agitation similar to those coming from opiate abstinence syndrome; influence of serotonin levels, judging by the effectiveness of the ISRS; circadian modifications and disbalance of metabolites such as sodium and potassium (Halbreich & Endicott, 1985; Parry, 1994; Rivera-Tovar, Rhodes, Pearlstein & Frank, 1994). But this atomization of alteration indicates the existence of remarkable individual differences covering the operativeness of several systems, which is translated into neurohormonal modifications. In this way, the changes in the strogens take part all in the implied regulation of neurotransmission, in mood control, and in behavioural and cognitive functions (serotonin, noradrenaline, GABA, dopamine and acetylcholine). In general terms, greater neuronal excitability results from this disbalance.

In consequence, we should notice genetic predisposition or vulnerability, and make reference to biological variables (gonadal hormones and neurotransmission) in interaction with environmental precipitants (Khan & Halbreich, 2003), plus the personal coping resources facing stressful situations in progress.

Attempts have been made to establish the vulnerability factors participating in this syndrome, above all, due to their proximity to Depressive Disorders. For example, there seems to be a strong association between the symptoms of a previous disorder with the premenstrual symptoms (the so-called premenstrual exacerbation). For this reason, the case of premenstrual worsening due exclusively to previous medical or psychopathological condition is excluded for the diagnosis of this syndrome. The findings of the research do not suggest a connection with concrete diagnostic entities. However, the connection seems to be more outstanding among those who show anxious-depressive symptomatology (Hsiao, Hsiao & Liu, 2004) and, maybe, some sensitivity to alcohol (abuse) in the luteinic phase (Nyberg, Wahlström, Bäckström & Poromaa, 2004).

These results are not surprising. In fact, the symptoms that best characterise this syndrome are depression, irritability, fatigue, or emotional lability (Mortola, 1992), for example. Even though the Major Depressive Disorder has a different clinical and biological profile, the well-know fact is still intriguing that the younger the age of menarchy, the higher the probabilities that the disorder may develop (Kutcher, Kusumakar, LeBlanc, Santor et al., 2004). Therefore, the coincidence with other disorders, especially with the

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affective-type ones, is common (Bancroft, Rennie y Warner, 1994; DeJong, Rubinow, Roy-Byrne, Hoban et al., 1985; Endicott, Halbreich, Schacht y Nee, 1981), and the possibility exists that they, first, may share etiopathogenia, and, also, that a previous Premenstrual Disforic Syndrome gives way to a depressive disorder (DeJong et al., 1985).

Regarding cognitive vulnerability, some findings suggest that attributional and coping styles play a role in symptomatic expression and in syndrome severity (Sigmon, Whitcomb-Smith, Rohan y Kendrew, 2004). Halbreich (2003) proposes a model which integrates genetic, neurotransmitting, environmental and upbringing factors, up to the most immediate factors in time referring to perception and coping mechanisms. In the same sense, Bancroft et al. (1994) established a three-factor model for the syndrome under study, in which they stood out a vulnerability component, namely neuroticism, in its role as a predisposer to depression. Its importance lies in the way how the woman reacts in front of some changes (and instabilities) of menstruation. However, some studies have failed in their hope to show the role played by this type of variables in relation to the Premenstrual Disforic Syndrome (Trunnell et al., 1988).

This study is proposed on the basis on the following reasons: Because of fluctuations in the presence and type of symptoms during the cycle, which represent a precise portrait of what takes place in this pathology (Mortola, 1992); because divergences in manifestation intensity are observed, at a great extent due to methodological reasons (Steiner, 1992); because assessment of women’s repercussions of this manifestation from a socio-economic point of view has been avoided; and because, as a matter of fact, little is known about the role played by cognitive vulnerability in its development and maintenance.

Therefore, we set the following objectives: establishing the presence of Premenstrual Disforic Syndrome; characterising Premenstrual Disforic Syndrome from a clinical point of view, both retrospectively and prospectively; establishing the social, labour, and relatioship repercussions of Premenstrual Disforic Syndrome; testing the relation between Premenstrual Disforic Syndrome and cognitive vulnerability to depression, and differenciating Premenstrual Disforic Syndrome from Depressive Disorders.

The hypotheses of work were the following: verification of continuity in the clinical characteristics of the syndromic and subsyndromic groups, except when meeting the diagnostic criteria (A and/or B); the verification of significant social, economic, labour, and relational repercussions on women with Premenstrual Disforic Syndrome; the verification of cognitive vulnerability to depression with a different profile in each alteration; a central pattern that characterizes the syndrome: increase of premenstrual symptomatic intensity, follicular decrease, and dominance of indicators of the anxious-depressive spectrum; and, finally, lack of equivalence between retrospective and prospective assessment of symptom type and intensity of Premenstrual Disforic Syndrome.

METHODS Participants

In this research, which took place between December 2001 and December 2004, a total of 95 women participated initially. Their age was 23,60 years in average (t.d. of 3.05); most of them were single (98%) and middle-class (average Index of Social Class of 36.38; t.d. of 22.86). Twenty-three point two percent were university graduates; 58.9% had done some university course, and 17.9% had finished Compulsory Secondary Education, Post-Obligatory Secondary Education, or the first stage of Vocational Studies. Fourteen point seven percent developed a freelance professional activity or owned small companies, 1.1% as saleswomen, and 1.1% as non-qualified workers; the remaining 76.8% were students.

The evaluation of menstruation had a first phase during which self-applied initial interview (SAII) was applied to 85 women. This was the first step for retrospective analysis of Premenstrual Disforic Syndrome. Forty-four possible premenstrual cases were so established, 28 of them subsyndromic. Thirteen were control cases. After the first phase, 28 women who did not meet the proposed requirements were rulled out. In the second phase, in which all the tests and diagnostic criteria were applied by means of structured interviews of Axis I of the DSM-IV (SCID-I) (APA, 1999) and Axis II of clinical assessment plus the MCMI-II (Millon, 1999), a total of 29 women were rulled out and, finally, 16 more dropped out at the moment of carrying out daily self-registers for three consecutive months. This depuration of the sample brought about the remain of 12 cases for prospective study. The comparative analysis between the women object of study and those who were rulled out did not offer significant statistic differences for age (t= 0.775; p= 0,450); social class (t = 0,397; p = 0,697); educational level (X2 = 1,334; p = 0,513); profession (X2 = 1,957; p = 0,581), or current occupation (X2 = 2,378; p = 0,304).

Apart from this, according to age interval and marital status characteristics, women were chosen who met the current diagnostic requirements for Mood Disorder, Depressive Disorders to be precise (criteria DSM-IV; APA, 1995). In total there were 10 women who did not differ from the remaining 85 in average age (F = 2,457; p = 0,068); social class (F = 0,469; p = 0,705); educational level (X2 = 6,611; p = 0,358); or current occupation (X2 = 5,764; p = 0,450), but they did in regards profession (X2 = 29,286; p = 0,004). Design, variables and control conditions Design

A mixed design was carried out, in which a cross section for retrospective exploration was combined (by means of SAII, the presential interview for diverse diagnostic instruments and criteria) plus the comparison with the group of women with depressive disorders, and a prospective longitudinal section, given a selected group with the 85 initial participants (design of interrupted time series). For the cross moment, a correlation method for comparison of groups was used in one rate, and repeated rate group comparison for one of the objectives of study relative to mood criteria.

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Gómez Márquez, C., García García, M., Benítez Hernández, M.M2, Bernal Escobar, L y Rodríguez Testal, J.F. Retrosprective and prospective study of premenstrual symptomatology in the general population

Predictive Variables Socio-demoChartic Variables: Age (continuous quantitative variable); occupation (qualitative with five levels: student, unemployed, technical professional, administration personnel, non-qualified worker); educational level (qualitative with three levels: primary education/compulsary secondary education, post-obligatory education/first stage of vocational studies, and college/university graduate; marital status (single and married), and social class (SCI) based on Hollingshead (1975). If student, profession and educational level of the subjects or their parents are categorised: it adds the products of the professional value by seven, and those of educational level by four (Social Class Index). Data of interest regarding menstrual cycle: prescription of preconceptives; volume of menstrual bleeding; presence of pain; use of medicines; use of drugs, including alcohol; past and current physical and mental health. All these assigned variables were conceived as dicotomic qualitative variables in relation to presence/lack. Diagnostic criteria for Disorders of Axes I and II of the DSM-IV (APA, 1995): qualitative variables with presence/lack levels for each established diagnostic entity. Groups: Qualitative variable of four categories relative to retrospective diagnosis, namely premenstrual [1] (meeting at least five symptoms of Criterion A for diagnosis of Premenstrual Disforic Disease and meeting Criterion B, following the DSM-IV classification); subsindromic [2] (three to four symptoms of at least moderate intensity and/or interference with function); control [3] (no previous condition met), and depressive [4] (comparison group with depressive disorder diagnosis attended in private office).

Criterion Variables Cognitive vulnerability to depresión: Quantitative variable from the DAS scale of disfunctional attitudes and its three variables. Depressive symptomatology: Quantitative variable from the global score of the BDI depression inventory. Physiologic and cognitive anxious symptomatology: Quantitative variable from global rates of BAI and PSWQ inventories, respectively. Symptomatology of somatization: Quantitative variable from the global score of the SAS (somato-sensory amplification) scale. Indicators of Criterion A for diagnosis of Premenstrual Disforic Syndrome: Each one of the 11 symptoms indicated in Appendix B of the DSM-IV (APA, 1995) as members of Criterion A. Each symptom is taken as a discreet quantitative variable attending to intensity, provided the existence of the symptom (0-10 points). The qualitative version of this variable is also under consideration, by distributing the intensity in the following categories: laking [0]; slight [1-3]; moderate [4-7], and severe [8-10]. This Criterion was collected both in a self-informed retrospective way and prospectively. The indicators are: Anxiety, Mood, Lability, Irritability, Interest, Concentration, Energy, Apetite (including a separate form for food whims -frequency-), Sleep (including a separate form for night wakes up –frequency-), Excitability, and Physical Symptoms (including nine different ways for types of physical symptom: sensitive breasts, breast size

increase, body swelling, weight increase, headaches, in joint and muscle disturbance or pain, digestive problems, less urination, and skin changes). Indicators of Criterion B for diagnosis of Premenstrual Disforic Syndrome: In addition to the indicator pointed out in Appendix B of the DSM-IV (APA, 1995), different modalities are developed which indicate Degree of affectation or perturbation. They are taken as discreet quantitative variables attending to intensity, provided that the indicator does show (0-10 marks) (in some cases, given the variable nature, frequency is attended to). The qualitative version of each of these variables is also under consideration, by distributing the intensity in the following categories: laking [0]; slight [1-3]; moderate [4-7], and severe [8-10]. These criteria were collected both in a self-informed retrospective way and prospectively. The indicators are: Degree of interference with daily life; Degree of interference with occupation; Number of days during which occupation is not developed due to premestrual symptoms (frequency); Number of days during which occupation is not developed due to mestrual symptoms (frequency); Number of days on sick leave for premenstrual symptoms (frequency); Number of days on sick leave for menstrual symptoms (frequency); Degree of performance decrease for premenstrual symptoms; Degree of performance decrease for menstrual symptoms; Degree of overeffort to carry out such tasks; Degree of interference in the relationships with others; Degree of avoidance of social situations; Degree of challenge. Socio-sanitary cost related variables. Continuous quantitative variables related to medicine yearly costs coping with menstruation-related symptoms, and yearly costs of medical attention. Discreet quantitative variables related to the number of visits to state-ruled and private medical attention. Variables relativas al coste socio-sanitario. Variables cuantitativas continuas en cuanto al coste anual en fármacos para tratar los síntomas relacionados con la menstruación y el coste anual de la atención médica. Variables cuantitativas discretas en cuanto al número de visitas a los médicos de atención pública y de asistencia privada. Control conditions Inclusion criteria. For some menstruation-related groups:regular periods, lack of ingestion of oral contraceptives, lack of use of alcohol or other drugs, between 18 and 35 years of age, no current suffering from mental or personality disorders, no suffering from female genitalurinary-related physical disease or from a chronic disease which could modify menstruation, and reach more than six marks in the EPI Sincerity scale. In the second phase of the work, standard or expected answers to any control indicators of the MCMI-II were regarded inclusion criteria (validity, sincerity, social desirability, and alteration).

In the depressive-disorder group the participants included were 18- to 35-year-old women who searched for psychological attention in a private treatment center of Seville city from December 2002 to December 2004 (INTECO: address of the first author). The condition for participation was that these women should not have started the intervention why they were asking for aid, should not show relevant physical suffering, should lack well-known menstruation-related pathologies,

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should not have abused alcohol or drugs (other than psychomedicines), and should have scored 6 or more marks in the EPI sincerity scale. It was accepted that some cases might have a different diagnosis belonging to Axis II, either as a disorder, or as a depressive-disorder related marked style.

Instruments Self-Applied Initial Interview (SAII) (Rodríguez Testal and Gómez Márquez, 2001): This interview includes 16 items referring to socio-demoChartic data (age, marital status, socio-educational level, occupation), menstruation characteristics (regular, irregular, painful, abundantly bleeding, prolongued), use of oral contraceptives, current or past presence of physical or psychological disorders, pharmacologigal treatment for any disease and for menstruation, type and frequency of drugs used, including alcohol, and twelve questions referring to criteria A and B (interference in daily and social activities) of the DSM-IV (APA, 1995) for the SDP, whose answer pattern is Yes/No, followed by observation gaps.

Sincerity of the EPI. Obtained from the Eysenck Personality Inventory (Eysenck, H.J. y Eysenck, S.B.G., 1990), it consists of nine questions about situations and reactions that anybody may go through, to which the answers are Yes/No. The people scoring below 6 marks are excluded, as it is thought that they are trying to disguise some expectable aspects of general population.

Beck’s Anxiety Inventory (BAI, Beck, Epstein, Brown y Steer, 1988). It consists of 21 items describing diverse ansiety symptoms (most of them physiological) which take place in the seven days previous to the battery application, this inventory has a 0-3 intensity Likert response format, and a score margin of 0-63 marks. The cut point is established in 25.76 marks, which is the average considered for persons with significant anxiety indicators. Sanz and Navarro (2003) showed psychometric properties adecuate to this instrument in the Spanish population.

Beck’s Depression Inventory (BDI, 1978, Beck, Rush, Shaw and Emery, 1979; version by Vázquez and Sanz, 1997; 1999). It consists of 21 groups with four statements each, the subject points out the most adjusted one to how they were feeling over the last week. Each section scores 0-3 in depressive intensity, with a result range of 0-63 points. A 0-9 result implies lack of depression, and 10 onwards its presence. The cut point for university students is 11.

Dysfunctional Attitude Scale (DAS by Weissman and Beck, 1978. Version by Sanz and Vázquez, 1993; 1994). This scale contains 40 statements referred to frequent attitudes or beliefs to which a given degree or agreement has to be indicated according to seven response choices, from ‘total disagreement’ up to ‘total agreement’. As a result, a total score is obtained (DAS-T), with a cut point of 143.8 for depression-diagnosed subjects, as well as three factors identified as Dysfunctional Attitudes of Achievement (score significant for depressive subjects in 34 points), Dysfunctional Attitudes of Dependency (cut point in 32

points), and Dysfunctional Attitudes of Autonomy (cut point in 29.7 points). This scale is a procedural rate regarded as indicator of cognitive vulnerability to depression.

Somatosensory Amplification Scale (SAS, by Barsky, Wyshak and Klerman, 1990. Version by Belloch, Ayllón, Martínez, Castañeiras et al., 1999). This scale allows to evaluate people’s sensitivity to body changes and signals (not to the symptoms of a disease). It consists of 10 items in a five-point Likert-type gradation. The score ranges between 10 and 55 points. A score above 21 is considered to indicate psychopathological tendency to amplifying sensations.

Worry or cognitive anxiety questionnaire (PSWQ by Meyer, Miller, Metzger and Borkovec, 1990). This questionnaire holds the tendency to generalised, uncontrollable, pathological worry (Fresco, Heimberg, Mennim and Turk, 2002; Stanley, Novy, Bourland, Beck et al., 2001), which allows to differentiate between persons with Generalised Anxiety Disorder and persons with other anxiety disorders (Brown, Anthony y Barlow, 1992). There are 16 statements about anxious worries which have to be responded from 1 to 5 according to the statement’s degree of adjustment to the person evaluated; the margin of scores is 0-80 points. The average for subjects with significant levels of anxiety is 68.11, which is the limit borne in mind to regard a score as significant.

Structured clinical interview for disorders of Axis I of the DSM-IV, SCID-I, clinical version (APA, 1999). This interview consists of 26 general questions about demographic data, academic history, occupational history, current state of treatment, main reason for consultation and description of the problem, beginning of the disease or current exacerbation, new symptoms and recurrence, environmental context and possible precipitants, course of the disease or current exacerbation, history of previous treatments, other current problems, current social functioning, general vision of diagnoses, and six item modules for diagnosis: Module A: 69 items for affective episodes; Module B: 15 items for psychotic and associated symptoms; Module C: 39 items for the differential diagnosis of psychotic disorders; Module D: 19 items for the diagnosis of mood disorders; Module E: 32 items for the diagnosis of disorders derived from the use of alcohol and other substances; Module F: 91 items for the diagnosis of anxiety and other disorders. The responses in modules A, B, E, and F are coded as + (threshold or true, - (subthreshold or false), or ? (insufficient information to code the answer as – or +). In the cases of modules C and D, a decision-tree format is used, in which each diagnosis Criterion is placed in a box with two exit choices, and each Criterion is scored as true or false according to the responses to modules A and B. In this study questions from only modules A, B, E, and F were included, since modules C and D were evaluated later, according to the audio register of responses given to the questions asked in this interview.

Millon’s Clinical Multiaxial Interview (MCMI-II, de Millon, 1997) in the TEA Spanish version (1999). This questionnaire consists of 175 items with a true/false response format. It is made up of ten personality basic

45

Gómez Márquez, C., García García, M., Benítez Hernández, M.M2, Bernal Escobar, L y Rodríguez Testal, J.F. Retrosprective and prospective study of premenstrual symptomatology in the general population

scales (schizoid, phobic, dependent, histrionic, narcisist, antisocial, aggressive-sadist, compulsive, passive-aggressive, and selfdestructive-masochist) and three pathological personality scales (schizotypical, borderline, and paranoid). It includes elements from Axis 1 (six clinical syndromes of moderate seriousness and three severe ones) as well as control scales (validity, sincerity, social desirability, and change). The two personality scale groups were borne in mind for this study, and, especially, control scales plus clinical observation, in order to detect a possible change in this area. The cut-off point of the base measure greater than 75 was used to consider the possible existence of personality alteration.

Daily Register for Premenstrual Dysphoric Syndrome (RSDP-III, from the former version by Gómez Márquez and Rodríguez Testal, 2001). Based on each of the symptoms described in the diagnostic Criterion A for the SDP of the DSM-IV-TR (APA, 2000) and in the Brief Psychiatric Rating Scale (BPRS: Lukoff, Nuechterlein and Ventura, 1986), it, measures the intensity or degree to which a series of physical, psychological or behavioural phenomena are produced during the menstrual cycle. It consists of identification data, instructions, example of elaboration, presence/absence of menstruation, and 33 items referring to anxiety/tension/oppression (items 1-3), out of control/impulsiveness (item 4), decrease in energy and thus fatigue (items 5 and 7), decrease in concentration (item 6), depressive mood (items 8-13), lability and sensitivity (item 12), interest (item 13), excitability (item 14, not considered in the DSM-IV), expansiveness (item 15, not considered in the DSM-IV), irritability (item 16), anger or bad mood (item 17), sleep alterations (items 18-20), dissociative symptoms (items 21-24, not considered in the DSM-IV), psychotic

* p < .05 ** p < .01 *** p < .001

Note: Bold characters show the typical or most important DSM indicators. Chart 1. Equivalence between symptom items of the RSDP and Criterion A of the DSM-IV (appendix B) (APA, 1995). symptoms (items 25-28, based on the BPRS scale), appetite changes (items 29-32), and physical symptoms

(from 33.1 to 33.9). The responses are given in Likert-type format with 0-10 intensity.

Since the structure of this register does not closely follow the DSM-IV (APA, 1995) pattern, Chart 1 proposes equivalence between the RSDP-III and the criteria identification in the way they are shown in Appendix B of the former. Procedure Sampling and recruiting. The sampling was of a non-probabilistic type (incidental), based on those women who responded to an announcement about menstruation which was distributed in different centres in the city of Seville. A total of 70 posters were placed in different schools in the University of Seville (University College of Teacher Training, and Schools of Psychology, Pedagogy, Philosophy, History, History of Art, Geography, Law, Economics, Business Administration, Pharmacy, Mathematics, and Computer Science), as well as in Civic Centres of the Townhall of Seville, INEM employment centers (National Institute for Employment), and women’s associations. The participants were contacted by the phone calls made by the researchers, who briefly presented the study as their personal data were being collected (name, surnames, telephone number, age, oral contraceptives, cycle length, time availability). In this way, there was an initial contact with a total of 110 women.

A group of women with depressive disorders was also selected. They had to meet the general characteristics of the three menstruation-centred groups: age margin, single, mainly students. Cases with depressive diagnoses were also recruited (major depressive disorder, distymia, and unspecified depressive disorders), without previous psychological treatment which might interfere in the results of the tests administered. The women were evaluated by the main researcher of this study. In this case, the selection of the participants was ad hoc, according to the characteristics of the other groups. Conditions for participation. All the participants were asked for their verbal consent to use their data in the research. It was made clear that their names would be substituted by initials plus a number assigned by participation order. Evaluation systematization. An order of test administration was followed with all the participants in the first interview or first phase (retrospective): The Self-Administered Initial Interview (SAII), Scale S of the EPI, Beck’s Anxiety Inventory, the Worry Questionnaire, the Somatosensory Amplification Scale, and the Disfunctional Attitude Scale. All the tests were conducted in a self-informed format. The researchers took part only to resolve any doubts or questions during the evaluation process. In such cases the information was given neutrally, without any orientation or giving any lead that might bias the answers. In the second phase (diagnosis) (for those women in the menstruation-related groups), interviews were recorded and there was a check to see that the diagnosis criteria for disorders of Axis I or II were fulfilled, with structured interviews and the MCMI-II questionnaire. In the third phase (prospective), the participants were told to complete the self-reports before going to bed at

ÁREA

RSDP-III Ítem

Criteria A (DSM-IV)

Anxiety 1-3 (2) Out of

control/impulsiveness 4

(10)

Anergy (and fatigue)

5 y 7

(7)

Concentration 6 (6) Depressive 8-13 (1) Depressive

(lability/sensitivity) 12

(3)

Depressive (interest)

13

(5)

Excitability 14-17 Excitability

(irritable) 16

(4)

Sleep 18-20 (9) Dissociative 21-24

Psychotic 25-28 Appetite 29-32 (8) Physical 33.1-33.9 (11)

46

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 41-62

night, so that they all did it at the same time, that this reminded them to carry out the task, that it allowed for an evaluation of all that had taken place after a whole day, and that they should not make any changes through the day on account of the circumstances experienced. Phase 1 (retrospective): Administration of the Self-Administered Initial Interview. Even though initially there were 110 sure contacts relative to the study, 85 women came to the first interview (of the three menstruation-related groups). Before the evaluation process started, each participant was informed of what was going to be done and what their participation consisted of. The appraisal of the initial interview data permitted the establishment of three retrospective groups: 44 in the case of premenstrual women or with potential Premenstrual Dysphoric Syndrome; 28 in the case of women considered subsyndromic, that is to say, when rigorous diagnostic conditions are not met but others are shown, and 13 are considered witness or control subjects, or without a menstruation-related clinical symptomatology. In this phase the participation of 28 women was ruled out, because they met several exclusion criteria: use of oral contraceptives, current mental disorder, menstrual irregularity, current pregnancy, direct drop out of the interview phase, genitalurinary disease, or any other disease which could, potentially, alter menstruation. Phase 2 (of current diagnosis): Application of the SCID I, the MSMI-II of personality and clinical assessment. At this stage nine cases were detected with current mental disorder (mood alteration, four in total), and closely-related manifestations which might suggest a personality disorder or, at least, the possibility that functioning (personality style) might represent distortion or bias for the completion of the tests (a total of five cases). The reason for excluding women from the study, in whom a mood disorder had been detected, instead of including them in the depressive group, is so that a possible cross condition between mental disorder and menstrual alteration was avoided. Twenty more women have to be added to this total when in some of the control scales of the MCMI-II (validity, sincerity, desirability and/or alteration) scores were found to be insufficient for access to totally reliable information when the daily self-reports were done (this was especially important in case of the alteration scale or when the women tended to show themselves in a situation worse than their actual one).

The group of depressive women fulfilled a wide detailed protocol that coincides with the chosen criteria variables. Moreover, in a specific way, the protocol was made up of other disorder-related instruments, psychiatric treatments and variables of social and family functioning. The protocol also included personality tests administered to the three other groups of women mentioned. In spite of some differences with the structure of the protocol, the order of administration of the common tests was the same. Before the evaluation process, the patients gave their consent to use the information with research aims. Phase 3 (prospective): Day self-reports. The moment when the self-registers were submitted was especially important, since, as it was pointed out in the introduction to the study, it was necessary to count on

information of at least two consecutive cycles. Managing to have three was advantageous. In this way it was possible to reliably analyse consecutive and alternating cycles, to keep the information of at least two consecutive cycles (fundamental, according to the DSM criteria), and to repeat measures of depression criteria (BDI) and vulnerability (DAS). At this time, as shown in Chart 2, a total of 16 women dropped out. The rest of the participants were given a set of tests (in total 90 self-reports for each one). In order to avoid mistakes in this procedure, they were not told which given registers were going to be analysed, since, as a matter of fact, the information about the first three days after menstruation was discarded, the eight days corresponding to the follicular phase were taken versus eight days of the premenstrual phase, and the rest was eliminated. They were given the pattern that three days after the beginning of menstruation, for ten days and, approximately, ten days before the date estimated for the next menstruation, they had to start adding to the reports the BDI and DAS tests (for the cross calculation of repeated measures) which were also provided.

Groups Rreasons for

elimination Cases

excluded Premenstrua

l Direct exclusion criteria

16

Axis I 2 Axis II 2 MCMI-II control scales

9

On submitting reports

10

Subsindrómico

Direct exclusion criteria

8

Axis I 2 Axis II 2 MCMI-II control scales

7

On submitting reports

5

Control Direct exclusion criteria

4

Axis I 1 MCMI-II control scales

4

On submitting reports

1

Chart 2. Exclusion before the carrying out the prospective study. Summary of groups, reasons and number of cases. Establishment of the phases. From a physiological point of view, the cycle starts on the first day of menstruation, and with it the follicular phase. However, from a behavioural viewpoint, the premenstrual symptomatological remission takes place from the second day of menstruation. In contrast, it is established that, in case of an SDP (Mortola, 1992), the least amount of symptomatology appears after the first four days. For this reason, the three first days of the cycle are eliminated in order to avoid interference between the data of the current follicular cycle and the premenstrual symptomatology of the former cycle.

According to the literature consulted, six to seven data per phase are valid to detect the possible variability of the sample, and overlapping is avoided between the premenstrual and postmenstrual phases, in case of short cycles. Nevertheless, the length of phases has been

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Gómez Márquez, C., García García, M., Benítez Hernández, M.M2, Bernal Escobar, L y Rodríguez Testal, J.F. Retrosprective and prospective study of premenstrual symptomatology in the general population

48

established at eight days each, with a total of 16 data items, since, in spite of there being short cycles, the probability of overlapping is minimum, and we respect Young’s supposition C, with a minimum of eight data per period. It has been proved in trials that power is lost with fewer data, and the results are unreliable.

In this way, phase A or the base line matches the eight days of the follicular phase, and phase B or the contrast, fits the premenstrual phase of the same cycle, as follows:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

folicular phase (A) premenstrual phase (B)

Establishment of SDP cases in the prospective analysis. The criteria to establish when it was considered that an item met the pattern of increase in the premenstrual phase, and to establish the fulfilment of the SDP in relation to the number of symptoms, following Criteria A of the DSM-IV-TR (APA, 2000) are the following: Significant item: The change in the tendency of one phase to another in the global Zo of Young’s C. The Zo of the base line keeps steady. Visual analysis and the tendency of the straight line prove that there is an increase in the intensity of the premenstrual phase in relation to the follicular phase. Premenstrual Dysphoric Syndrome: At least five symptoms in two consecutive cycles, and influence in some functioning aspect (Criterion B). Subsyndromic: between three or four medium-intensity symptoms and/or some degree of interference in functioning. Absence of Premenstrual Dysphoric Syndrom: Less than three symptoms in each cycle. Statistical procedure Chi-squared nominal variable frequency analyses, percentages and contrasts have been used in the descriptive part of the study.

The assumptions for parametric tests were verified with the Kolmogorov-Smirnov test. The homogeneity of the variance was tested with Levene’s F.

Snedecor’s F was used for the inferencial statistics with normality and equality of variance; otherwise, Kruskal-Wallis’s H was applied for group comparison. Student’s t test was used as a post hoc test in relation to the presence or not of equal variances. Given the size of the sample, Friedman’s contrast test was used for the cross analysis of repeated measures.

All the analyses were established with a reliability level of 95% and probability was always below 0.05. The SPSSwin 11.5 statistical package was used.

Young’s C statistic was chosen for daily self-report statistical analysis given its following advantages: It operates with few successive data items (at least eight observations), it is easy to calculate, and it allows for a self-correlation estimation, as it is especially designed for contrast between the base line and the treatment (DeCarlo and Tryon, 1993; Tryon, 1982).

Since this was not a case of the application of a treatment, the statistical procedure consisted in dividing the total of the series into two equal parts (A, follicular or base line, and B, premenstrual or

contrast). It is expected that the application of C statistic will not have any effect on either of its parts separately (A or B), which would indicate stability in each series separately (observed Z < theoretical Z). Finally statistic C was applied to the whole series (A + B) as follows: if statistic C were non significant again, it would suggest that there was no change or trend in the symptomatology from one phase to another. On the other hand, should statistic C give a significant result (Zo > Zt), that would indicate a change in the tendency. In this case, visual observation and/or another statistical procedure (eg. the minimum square procedure) may indicate the score-derived straight line and so estimate if there is an increase or decrease along the series of points.

The interrupted time-series were analysed with a reliability level of 95% and with a probability of always below 0.05. A program for this specific purpose, designed by Dr. Vicente Manzano, Professor of Statistics of the University of Seville. We would like to here acknowledge its quick effectiveness in the data processing.

FINDINGS Descriptive Statistics. Degree of comparison of the samples The three groups of menstruation-related participating women (premenstrual, subsyndromic and control, with 44, 28, and 13 participants, respectively) were comparable in relation to socio-demographic variables in spite of the size differences). No age differences were found among the three groups (F= 1.396; Levene’s F = 0.038) or in social class (F = 0,635; Levene’s F = 0,411). Neither were there statistically significant differences in education (X2 = 4,940; p > 0,05), profession (X2 = 11,004; p > 0,05) or current occupation (X2 = 3,260; p > 0,05). The fourth group, selected post hoc in function of the three former ones (ten women with depressive disorders), did not show that its socio-demographic characteristics were different, except for the variable profession (p< 0.05), for which reason it was considered comparable to the three former ones. Moreover, the three menstruation-related groups did not differ in previous medical diseases (X2 = 5,045; p > 0,05); past mental disorders (X2 = 3,482; p > 0,05); drug use (in general) (X2 = 0,768; p > 0,05); smoking (X2 = 5,279; p > 0,05); alcohol use (X2 = 3,622; p > 0,05); cannabis (X2 = 1,875; p > 0,05) or cocaine (X2 = 2,060; p > 0,05); ‘party pills’ (acid, ecstasy or other amphetamines, and so on) were not used by any of the three groups. As to variables centred on the characteristics of menstruation, these three groups were comparable in relation to the degree of menstruation regularity (X2 = 0,144; p > 0,05); presence of painful menstruation

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 41-62

(X2 = 5,784; p = 0,055) (in this case, to the limit of significance); prolonged menstruation (X2 = 0,194; p > 0,05) and abundant bleeding (X2 = 1,016; p > 0,05). As for interference and disturbance in functioning, the premenstrual group shows that a good number of its members is affected, at least on average (72.7%); this is valid especially for general discomfort in any area of functioning (Criterion B such as it appears in the DMS), as well as at work (59.1%), performance (52.3%), extra effort to recover (70.5%), interference with other people (59.1%), tendency to avoid or escape other people (45.5%), and conflicts or disputes arising from these changes (54.5%). From a descriptive point of view, the work repercussion in this group is marked in eight women (18.2%) by premenstrual symptoms and brings about them not going to work for a minimum of one day and a maximum of two and a half days. Two point three percent of the cases are even on sick leave. When menstrual symptoms are taken into consideration, 23 women (52.3%) do not go to work for a minimum of half a day and a maximum of two days. Two point three percent of the total are on sick leave. This could be considered an objective or direct repercussion, but, in addition, the women in this group estimate that they need almost five days (average of 4.93 days; t.d. 14.62) to recover their capacity to work or perform fully. This data is linked to the extra effort that needs to be given to the job or occupation, as pointed out above. Thirty one point eight percent women in this group take medicines for the premenstrual phase (typically analgesics), 88.63% take them during their menstruation and spend an average of 14.34 euros per year. Eleven point four percent go to a public health doctor (another 4.5% even twice for this reason), and 15.9% go to a private doctor (2.3% go twice) with an average yearly cost of 33 euros. After phase 2 (of current diagnosis) 16 women were removed from this group (six for menstrual irregularity or for use of contraceptives, and ten for dropping out. See Chart 2). Two cases when some disorder of Axis I was detected; another two cases, for a likely misfunction of Axis II; nine for scores which suggest lack of validity or reliability, for tendency to show alteration or social desirability during the test administration (from the MCMI-II), and ten drop outs before the report daily follow-up phase (phase 3 or prospective); therefore, five remaining subjects were retrospectively identified or confirmed as being “pure” premenstrual cases. It is striking that the level of medium or moderate intensy is marked in the subsyndromic group, as well as in the symptomatic contents (Criterion A) referring to anxiety (67.9%), mood (60.7%), lability (50%), and irritability (60.7%). While the premenstrual group shares all the Criterion A indicators among the moderate and serious levels, the subsyndromic group seems to concentrate all four indicators mentioned in the medium or moderate level. In this subsyndromic group the repercussion of premenstrual symptoms (Criterion B) lies mainly at the low level (75%). Another particularity of this Criterion is that absenteeism is lower. Cases for menstrual, not premenstrual symptoms stand out (14.3%). There are no sick leaves for premenstrual symptoms, but there is a one-day-off case for menstrual symptoms. All of

this means an average of almost five days (average 4.67 and t.d. 18.51) to completely recover performance capacity, and shows women’s extra effort at work or in carrying out their occupation. In this group, 21.4% takes medicines in the premenstrual period; 85.71% do so during menstruation, which implies a yearly cost of 13.61 euros for this type of treatment. Three point six percent go to a public health doctor; another 3.6 go up to four times, and 10.7% go to a private doctor for this reason, which represents a yearly cost of 30 euros per person.

From this group eight subjects were eliminated in phase 2 (diagnostic), three of them for menstrual irregularity or for use of contraceptives, and five more for dropping out; also, seven for lack of sincerity, validity, tendency to show alteration or social desirability in the test administration (from MCMI-II); two more when an Axis I disorder was identified, and two for a possible Axis II disorder. Finally, five subject dropped out just when they were giving in the daily self-reports (phase 3 or prospective); eventually, four sub-threshold cases remained who showed occasional symptomatology which was not so marked as in the first group, and, mainly, because of absence of clear interference with the level of functioning.

Most of the symptoms were slightly absent or at a low level in the control group. Although the sample was small, there was a clear inversion of the indicators in this group in relation to the two other groups. In any case, physical symptoms abound and in the categories of greater severity (38.46%, gather all the physical disturbances in the moderate and serious categories). It is observed that the case of Criterion B is similar to the one of Criterion A, that is to say, the degree of incidence is nill or low(46.2% in both levels, and for the global interference value). This is corroborated by the fact that no woman stops attending to her normal tasks for this reason, only one woman does not carry out her job for menstrual symptoms, and there are no cases of sick leave at any moment of the cycle. Moreover, as regards the time necessary to recover normal performance, the average does not reach even half a day (average 0.30 days; t.d. 0.63). Fifteen point four percent of the women in this group take medicines (analgesics) for the premenstrual period; 46.2% do so during menstruation, with an average cost of ten euros for this type of treatment among those who use it. Seven point seven percent goes to a Social Security doctor, and none go to a private doctor for this reason. Finally, four women were removed from this group in phase 2 (diagnostic): one for menstrual irregularity or for contraceptive use, and three for dropping out; one case was rejected because an Axis II disorder was detected, four, because of non expected scores in the control scales of the MCMI-II, and one more case for dropping out just when the daily self-reports were handed in (phase 3 or prospective). Three cases of this group remained. Inferencial Statistics. A contrast of cross measures If we attend to the whole sampling (all four groups; N = 95), a normal distribution is observed in phase 1 (retrospective) (Kolmogorov-Smirnov, Z with p > 0,05) in the scores of the different tests.

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Gómez Márquez, C., García García, M., Benítez Hernández, M.M2, Bernal Escobar, L y Rodríguez Testal, J.F. Retrosprective and prospective study of premenstrual symptomatology in the general population

50

However, the menstruation related criteria have not been distributed in a normal way, for which reason non parametric tests were used for the comparison among groups. The contrasts among groups about the psycopathological criteria used show statistically significant differences in cases of physical anxiety (BAI), depression (BDI), cognitive anxiety (PSWQ), vulnerability in the global scores (DAS-T), achievement (DAS-L) and autonomy (DAS-A)

(Tables 1 and 2). These differences are due to the depressive group, who had higher scores in these criteria. There are not any differences between the two main groups in the study as regards BAI (t = -1,29; p > 0,05); BDI (t = -1,91; p > 0,05), PSWQ (t = -0,553; p > 0,05) or for the total of the DAS scale (t = -0,620; p > 0,05) and its dependency factors (t = -0,303; p > 0,05),achievement (t = -1,105; p > 0,05) or autonomy (t = 0,969; p > 0,05).

BAI Average Typ.Desv. F BDI Average Typ.Desv. F Premenstrual 12,45 7,632 13,776** Premenstrual 8,86 5,576 35,008** Subsyndromic 10,25 6,665 Subsyndromic 6,43 5,088 Control 4,23 4,764 Levene´s F Control 2,54 1,127 Levene´s F Depressive 23,10 8,595 2,425 Depressive 23,00 5,518 3,677**

SAS Average Typ.Desv. F PSWQ Average Typ.Desv. F Premenstrual 24,14 5,991 1,882 Premenstrual 54,52 11,601 6,344** Subsyndromic 23,18 4,707 Subsyndromic 53,07 9,560 Control 20,85 4,488 Levene´s F Control 50,77 11,483 Levene´s F Total 23,32 5,447 2,078 Depressive 68,20 4,104 2,285

(N = 95) SIGNIFICANCE * p < 0,05; ** p < 0,01 Nota: Information of the SAS measure was not available for the depressive group

Table 1. Unidirectional analysis of GROUPS’ variance in PHYSICAL ANXIETY (BAI) and DEPRESSION (BDI),

SOMATIZATION (SAS), AND COGNITIVE ANXIETY (PSWQ) rates.

DAS-T Average Typ.Desv. F DAS-D Average Typ.Desv. F Premenstrual 113,52 21,716 6,688** Premenstrual 31,07 7,654 2,486 Subsyndromic 110,04 25,560 Subsyndromic 30,50 8,012 Control 94,08 17,452 Levene´s F Control 25,46 5,517 Levene´s F Depressive 138,90 35,003 2,098 Depressive 34,20 11,793 2,271

DAS-L Average Typ.Desv.. F DAS-A Average Typ.Desv. F Premenstrual 31,64 9,504 23,283** Premenstrual 17,27 4,353 2,927* Subsyndromic 29,14 9,058 Subsyndromico 18,32 4,667 Control 24,85 6,631 Levene´s F Control 14,77 4,381 Levene´s F Depressive 54,60 11,452 1,555 Depressive 20,30 6,667 1,922

(N = 95) SIGNIFICANCE* p < 0,05; ** p < 0,01 Table 2. Unidirectional analysis of GROUPS’ variance in COGNITIVE VULNERABILITY (DAS-A) and other factors (dependence, achievement and autonomy) measures.

The BAI, BDI, PSWQ, DAS-T and DAS-L (t test; p < 0.05) measures of the depressive women group obtain significantly higher scores than the three other groups. However, it is interesting to note that there are not any statistically significant differences in the vulnerability for the emotional dependency measure of the depressive women’s group versus the three other groups (p > 0.05). The contrast of the depressive women’s group versus the three other groups is even more important in the autonomy measure: while the depressive women significantly show more dysfunctional attitudes in this sense than the women in the control group (t = -2.40; p < 0.05), they are not shown to be any different from the premenstrual (t = -1,37; p > 0,05) or the subsyndromic women (t = -1,02; p > 0,05). This result gets complemented by indicating that, in this measure, there are not any differences between the subsyndromic women and the control group (t = -1,81; p > 0,05), but there are between the subsyndromic and the premenstrual women (t = -2,31; p < 0,05).

As for the different areas related to premenstrual symptomatology (retrospective), non-parametric contrasts were followed (Kruskal-Wallis’s H). In the case of Criterion A (Table 3), statistically significant differences were found in most of the areas,

fundamentally due to the control group. Curiously enough, the components without any differences among the three groups are no be found in the physical symptoms area: five of the nine indicators. This suggests, as predicted, that physical or body changes and disturbances are not so specific. In consequence, this is not the most suitable area for differenciating women affected by this syndrome from those who are not. All in all, two of these nine indicators showed significant differences between the premenstrual and the subsyndromic groups; namely, increase of breast size (t = -3,25; p = 0,002) and discomfort or pain in muscles and joints (t = -2,30; p = 0,024). In this way, in these two indicators the group that diverges in scores is the one described as premenstrual, and the values of the two other groups are not statistically different.

The other areas with statistically significant differences were: loss of interest, (t = -3.59; p = 0.001); (loss of or difficulty in concentration) (t = -3.93; p = 0.0001); sleep alterations (t = -2.27; p = 0.026) and lack of control (t = -2.58; p = 0.013). These results are interesting because both the prospectively premenstrual group and the group which met these conditions incompletely or without sufficient degree of interference (Criterion B) show that, more importantly than purely dysphoric

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 41-62

symptoms, cognitive indicators outstand, such as loss of interest and concentration.

Total Average (t. d.)

K-W’s H Premenstrual Average (t.d.)

Subsyndromic Average (t. d.)

Control Average(t.d.)

Anxiety 5,16(2,94) 26,149** 6,27(2,39) 5,30(2,60) 1,08(1,49) Mood 5,46(2,94) 28,125** 6,66(2,10) 5,64(2,55) 1,00(1,78) Lability 6,51(2,93) 30,618** 7,66(1,85) 7,04(2,28) 1,46(1,71) Irritability 6,56(10,58) 18,811** 6,55(2,52) 8,79(17,87) 1,85(2,47) Interest 2,69(2,97) 22,712** 4,07(2,92) 1,71(2,56) 0,15(0,55) Concentration 2,44(3,13) 17,956** 3,84(3,31) 1,18(2,42) 0,38(0,87) Energy 4,41(3,33) 13,809** 5,43(3,03) 4,29(3,20) 1,23(2,61) Appetite 3,87(3,23) 9,170* 4,45(3,19) 4,11(3,31) 1,38(1,93) Whims (frequency) 5,38(20,98) 3,763 5,22(20,76) 8,00(25,75) 0,27(0,52) Sleep 1,85(3,13) 8,477* 2,80(3,58) 1,14(2,57) 0,15(0,55) Waking up (frequency) 1,40(10,73) 4,255 2,62(14,89) 0,053(0,28) 0,19(0,48) Lack of control 5,24(2,92) 19,667** 6,48(1,97) 4,71(3,24) 2,15(2,37) Very sensitive breasts 6,13(3,08) 3,478 6,73(2,87) 5,39(3,40) 5,69(2,84) Breast size increase 5,68(3,20) 11,236** 6,82(2,73) 4,25(3,56) 4,92(2,46) Body Swelling 4,78(3,20) 5,264 5,36(3,15) 4,68(2,89) 3,00(3,53) Weight increase 4,00(3,24) 3,909 4,18(3,37) 4,50(3,03) 2,31(2,86) Headaches 2,78(3,18) 7,738* 3,57(3,17) 2,39(3,34) 0,92(1,84) Discomfort or pain (joints, muscles))

3,20(3,67) 6,695* 4,16(3,79) 2,21(3,28) 2,08(3,40)

Digestive Problems (diarrhoea or constipation

4,09(3,51) 6,454* 4,80(3,65) 3,96(3,19) 2,00(2,97)

Less frequent or less amount of urination

0,92(1,81) 3,086 1,05(1,90) 1,07(1,99) 0,15(0,55)

Changes in the skin (spots, feeling dirty, oily, strong perspiration)

5,45(2,88) 4,852 5,98(3,01) 5,14(2,53) 4,31(2,95)

(N = 85) SIGNIFICACIÓN. * p < 0,05; ** p < 0,01 Note: Significant scores obtained with post-hoc analyses (t test) are highlighted in bold

Table 3. Kruskal-Wallis’s GROUP analysis (one-way ANOVA) of the intensity of the Criterion A indicators for the diagnosis of the Premenstrual Dysphoric Syndrome (retrospective)

Total Average

(t.d.)

K-W’s H Premenstrual Average (t.d.)

Subsyndromic Average (t.d.)

Control Average

(t.d.) Degree of interference with daily-life

5,34(10,63) 52,829** 6,09(14,04) 2,11(1,72) 0,62(1,79)

Degree of interference with job 3,94(2,94) 49,384** 8,44(1,98) 2,32(2,00) 1,31(0,96) Number of days when job is not carried out due to premenstrual symptoms

0,13(0,42) 5,700 0,23(0,55) 0,035(0,18) 0,00(0,00)

Number of days when job is notcarried out due to menstrual symptoms

0,37(0,56) 15,824** 0,60(0,64) 0,14(0,35) 0,07(0,27)

Number of days on sick leave for premenstrual symptoms

0,011(0,10) 0,931 0,02(0,15) 0,00(0,00) 0,00(0,00)

Number of days on sick leave for menstrual symptoms

0,023(0,15) 0,489 0,022(0,15) 0,035(0,18) 0,00(0,00)

Degree of performance reduction of premenstrual symptoms

3,06(2,88) 31,745** 4,70(2,76) 1,64(1,87) 0,54(1,19)

Degree of performance reduction of menstrual symptoms

4,38(3,15) 34,582** 2,93(2,19) 6,27(2,95) 1,08(1,65)

Number of days to recover acceptable performance

4,14(14,91) 30,340** 4,93(14,62) 4,67(18,51) 0,30(0,63)

Degree of extra effort to carry out tasks

4,46(2,88) 33,809** 6,11(1,90) 3,46(2,74) 1,00(1,68)

Degree of interference with relationships with people

4,87(2,88) 39,562** 6,59(1,78) 4,07(2,59) 0,77(1,09)

Degree of avoidance of social situations

2,87(2,94) 28,217** 4,41(2,93) 1,68(2,09) 0,23(0,59)

Degree of confrontation with others 3,69(2,76) 26,162** 4,70(2,46) 3,64(2,55) 0,38(1,12) (N = 85) SIGNIFICANCE. * p < 0,05; ** p < 0,01

Note: Significant scores obtained with post-hoc analyses (t test) are highlighted in bold Table 4. Kruskal-Wallis’s GROUP analysis (one-way ANOVA) of the intensity of the Criterion B’s indicators for the

diagnosis of Premenstrual Dysphoric Syndrome (retrospective)

As for Criterion B (Chart 4), differences were found among the three groups in the majority of the aspects considered. The ad hoc test showed

statistically significant differences, and with higher values in the case of the premenstrual group as far as interference with daily life is concerned (t = -2.85; p =

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Gómez Márquez, C., García García, M., Benítez Hernández, M.M2, Bernal Escobar, L y Rodríguez Testal, J.F. Retrosprective and prospective study of premenstrual symptomatology in the general population

0.006); in the specific case of change in carrying out their job (t = -8.24; p = 0.0001) and as regards to the number of days when they did not carry out their job due to premenstrual symptoms (t = -3.89; p = 0.001). Once again it can be noticed that the premenstrual group reaches higher levels in these criteria, in this case, in interference with carrying job activities in general. However, it is surprising that the main disturbance takes place during menstrual, and not during premenstrual days

When the degree of reduction in performance that each participant estimates is analysed, the premenstrual group is significant in the homonymous period (t = -5.60; p = 0.0001) and, at the premenstrual

time, the subsyndromic group (t = -5.15; p = 0.0001). Complementarily, the premenstrual group stands out in the degree of extra effort required to carry out tasks (t = -4.47; p = 0.001), in the degree of interference with relationships with people (t = -4.50; p = 0.001) and in the tendency to avoid social situations (t = 4.60; p = 0.001).

Finally, from an economic point of view, the principal piece of information about the analyses centres on the pharmaceutical expenses (analgesics) that these women need to cover. This result does not point out differences between the two groups in the study, but it does in relation to the comparison group (Table 5).

Total Average (t.d.)

K-W’s H Premenstrual Average (t.d.)

Subsyndromic Average (t.d.)

control Media (t.d.)

Yearly cost of medicines 11,65(19,06) 6,952* 14,34(22,71) 10,69(15,89) 4,61(6,63) Number of visits to a public health doctor

0,18(0,58) 1,429 0,20(0,50) 0,18(0,77) 0,08(0,27)

Number of visits to a private doctor

0,13(0,37) 2,493 0,18(0,44) 0,11(0,31) 0,00(0,00)

Yearly cost of medical visits 8,00(22,13) 3,206 12,05(27,32) 5,36(16,43) 0,00(0,00) (N = 85) SIGNIFICANCE* p < 0,05; ** p < 0,01

Table 5. Kruskal-Wallis’s GROUP analysis (one-way ANOVA) of the variables related to the socio-sanitary cost of Premenstrual Dysphoric Syndrome

A later statistical transformation done with the data of the study consisted in revising the specific number of Criterion A’s indicators of the DSM-IV with an intensity equal or higher than five (moderate-intensity category). In other words, the interest was not in the type, presence or lack of symptoms, but in which of them had sufficient intensity to be regarded as relevant. The somatic indicators were transformed into one indicator (by applying the average of theirmeasure). As expected when the variable was made discreet, Kolmogorov-Smirnov’s test proves that data distribution does not follow normal distribution (p< 0.05). Kruskal-Wallis’s test suggests statistically significant differences among the groups (Chi = 39.009; p < 0.05). It points out that the premenstrual group shows a minimum of up to seven moderate-intensity indicators or symptoms (average 7.22; t.d. 2.30) versus the subsyndromic group (average 5.42; t.d. 1.85) and the comparison group (average 0.61; t.d. 1.12). Nevertheless, no statistically significant differences were found between the two groups studied (Chi = 12.249; p > 0.05), probably because the degree of rate variation in the premenstrual group is rather heterogeneous. One can observe, in any case, that at least as a group-scale symptom average, both groups studied meet the DSM’s minimum requirements to make reference to the presence of the syndrome (Criterion A). When only the average intensity of all of Criterion A’s indicators are analysed, instead of the average number of symptoms, as has been said before, does the distribution prove to be normal. The variance analysis suggests statistically significant differences (F = 37.285; p = 0.0001). The premenstrual group stands out (average 5.35; t.d.1.22) over the subsyndromic (average 4.33; t.d. 2.05) or the comparison (average 1.24; t.d. de 0.84) groups. It is worth highlighting that intragroup differences seem to be greater than

intergroup differences, which makes reference to an important variability in each group in these aspects. The importance of this result lies in the justification of the little repercussion in the person’s functioning; in other words, the symptom array is great, but the average intensity is not, and, consequently, Criterion B will be affected only partially. The ad hoc analysis suggests that the differences keep being statistically valid in favour of the premenstrual group (t = -2.66; d.f. 70; p = 0.010). The same procedure was applied to the different ways in which Criterion B is detailed. One has to remember that the DSM only discusses in general terms the discomfort or the interference that the symptoms may bring about. However, the analyses were carried out by averaging the different ways in which the degree of influence or interference may take place. When the number of indicators with intensity equal to or higher than five is counted (K-S suggested lack of normality, p < 0.05), differences are observed among groups (K-W Chi = 51.86; p < 0.05) which remain between the two study groups (K-W Chi = 34.77; p < 0.05). This result suggests that the women in the premenstrual group had an average frequency of almost six influence or interference indicators with at least minimum intensity (average 5.86; t.d. 1.85), versus the subsyndromic group (average 2.03; t.d. 2.02) and the comparison group (average 0.23; t.d. 0.59). When global intensity is exclusively analysed, once again the premenstrual group turns out to be statistically significant against the other groups (F = 54.456; p = 0.0001); in this case, the intergroup differences are higher than the intragroup differences, and the post hoc differences between the two groups studied favour the premenstrual group (t = -7.000; d.f. 70; p = 0.0001). The average intensity in relation to interference is almost six points in the premenstrual group (average 5.91; t.d. 2.08) against the almost three

52

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 41-62

points of the subsyndromic group (average 2.73; t.d. 1.51) and the control group (average 0.74; t.d. 0.97). As argued above, one of the keys of the results reached from this analysis, in which the degree of interference or general influence has to be considered to be modest even for the main group of the study. Repeated measures Although belonging to the prospective register (Phase 3) of those participants who stayed in the study, the test rates of mood and vulnerability have

been shown in order to prove whether or not they underwent changes (taken as repeated measures), and in relation to their placement in the follicular or premenstrual phase. Since the size of the sample was very small (12 subjects), non-parametric contrasts were applied (Friedman’s chi-square). The results obtained can be seen in Table 6. It is worth mentioning that, in relation to the BDI depression measure, there are not any statistically significant differences between the follicular and premenstrual measures in any of the three consecutive cycles registered.

BDI Follicular Phase Average (t.d.)

Premenstrual Phase Average (t.d.)

X2

Ciclo 1 2,90 (3,41) 2,90 (1,82) 0,667 Ciclo 2 2,60 (3,80) 2,60 (4,83) 0,333 Ciclo 3 4,57 (5,88) 3,29 (2,49) 0,200

DAS-Total Follicular Phase Average

(t.d.) Premenstrual Phase

Average (t.d.) X2

Ciclo 1 111,70 (28,63) 114,70 (26,25) 0,400 Ciclo 2 110,88 (28,66) 115,77 (29,55) 0,111 Ciclo 3 122,14 (27,41) 118,42 (25,40) 0,000

DAS-Dependency Ciclo 1 29,70 (9,78) 32,00 (9,22) 4,50* Ciclo 2 29,80 (7,88) 29,70 (7,40) 0,143 Ciclo 3 31,12 (6,70) 30,87 (6,28) 0,000

DAS-Achievement Ciclo 1 28,70 (13,70) 30,30 (9,09) 0,111 Ciclo 2 28,10 (11,27) 30,40 (9,96) 0,500 Ciclo 3 30,50 (8,33) 31,00 (7,23) 0,000

DAS-Autonomy Ciclo 1 15,30 (4,90) 17,50 (4,11) 4,50* Ciclo 2 17,80 (5,75) 18,00 (4,69) 0,111 Ciclo 3 16,75 (4,94) 17,12 (4,99) 0,333

(N = 12) SIGNIFICANCE. * p < 0,05; ** p < 0,01 Table 6. Friedman’s contrast for the follicular and premenstrual phases of three consecutive cycles in relation to the

measurement of depression (BDI), cognitive vulnerability (DAS-A) and other factors

In relation to the DAS rate, in general terms, the results do not endorse the thesis that cognitive vulnerability to depression may change (in the expected sense that they may increase) in a statistically significant way during the premenstrual period. Nevertheless, practically all the averages are more marked in the premenstrual phase. The dependency factor (in only one cycle) and the autonomy factor (in the same cycle) prove to be significant. In consequence, this does not seem sufficient to support the idea that women may be more vulnerable to depression as a consequence of the changes that take place towards the end of the cycle. Prospective Analyses Following are the phase 3 or prospective findings about the daily self-report follow-up of the 12 participants who stayed until the end of the study (and who from now onwards appear with the number assigned to them in the study). This means the establishment of three time series per participant which cover a total of 90 days (three menstrual cycles) for each symptom. The findings are summarized in Table 7. Those symptoms in which a premenstrual pattern is evident have been considered, and, as the table shows, in no case has it been confirmed that at least five symptoms plus Criterion B appear in at least two consecutive cycles. The DSM-IV requires, moreover, some specificity for at least one symptom

of depression, anxiety, emotional lability, or irritability (disphoria) or anger. As can be seen, out of the five women who were retrospectively qualified as premenstrual (or SDP is present), the subsyndromic condition was established in four women (one of cases was doubtful), and the possibility of having the syndrome was ruled out in one woman. Out of the four cases initially catalogued as subsyndromic, three kept such condition (one of them doubtful), and the fourth case was ruled out. Two out of the three women considered witnesses were confirmed as truly negative, and one case was switched to the subsyndromic condition. A third cycle has been considered to observe the maintenance of the indicators between cycles. This information shows important variability between consecutive and alternate cycles. As can be seen in Table 7, physical symptoms, dysphoria-related symptoms (irritability, being at the limit, emotional lability, being out of control), depressive symptoms (hopelessness, dissatisfaction or self-disdain), anergy, and appetite changes (mainly whims and hunger fluctuation), in this order, stood out. However, others also stood out which do not appear in the DSM diagnosed criteria, such as tendency to hyperactivity or expansiveness, dissociative symptoms, euphoria and reference ideas. Finally, the fulfilment of the DSM criteria has been included in Table 7, but for the follicular phase

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Gómez Márquez, C., García García, M., Benítez Hernández, M.M2, Bernal Escobar, L y Rodríguez Testal, J.F. Retrosprective and prospective study of premenstrual symptomatology in the general population

of the three cycles. This data is relevant because it shows a good presence of symptoms before the premenstrual cycle, and because it includes significant

discomfort in many cases, and a source of variation which affects women in any of the groups, both prospective and retrospective.

Case consecutive

cycles DSM criteria

alternate cycles DSM Criteria

follicular phase DSM Criteria

Significant premenstrual symptoms (consecutive and alternate)

Initial and FinalCategory

1 A1 = 3 A2 = 5

A3 = 2 y B A1 = 3 y B A3 = 1

Anergy, “at the limit”, appetite, dysphoria, hypersomnia, physical

Premenstrual Subsyndromic

11 A1 = 1 A2 = 1

A3 = 4 A1 = 5 y B A2 = 1 A3 = 1

“At the limit”, hopelessness, physical Control Absent

17 A1 = 2 A2 = 1

A3 = 3 A1 = 4 A2 = 4 y B A3 = 1 y B

“At the limit”, impulsiveness, lack of interest, physical

Subsyndromic ¿Subsyndromic?

19 A1 = 2 A2 = 1

A3 = 3 y B A1 = 1 A2 = 2 A3 = 1

Lability, anergy, dissatisfaction, physical

Premenstrual Subsyndromic

30 A1 = 5 A2 = 5

A3 = 5 A1 = 4 y B A2 = 2 A3 = 1

Tension, anergy, sadness, dissatisfaction, lability, lack of

control, insomnia, appetite, physical

Premenstrual Subsyndromic

42 A1 = 3 A2 = 3 y B

A1 = 3 A2 = 1

Anergy, physical, sleepiness Subsyndromic

49 A1 = 3 y B A2 = 5 y B

A3 = 1 A3 = 1 Lability, disphoria, tension, sadness, lack of interest, physical

Control Subsyndromic

55 A1 = 2 A1 = 1 “At the limit”, physical Subsyndromic Absent

63 A1 = 4 y B A2 = 2

A3 = 1 A2 = 3 y B A3 = 2

“At the limit”, appetite, impulsiveness, physical

Subsyndromic Subsyndromic

65 Control Absent

74 A1 = 2 A1 = 3 y B Appetite, physical Premenstrual Absent

78 A1 = 7 Tension, dissatisfaction, lability, lack of interest, disphoria, impulsiveness,

physical

Premenstrual ¿Subsyndromic?

Table 7. Summary of the retrospective and prospective diagnoses in relation to consecutive and alternate cycles. Statistical verification of premenstrual Criterion A and B is indicated. (Young’s C < 0.05)

In order to illustrate the prospective findings

summarized in Table 7, and given the huge amount of resulting information, some charts have been selected which show score distribution.

Sujeto 1 ítem 7 "Anergia"

Ciclos 1 y 2 Sig 0,05

02468

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Fase Folicular Fase Premenstrual

Ciclo 1Ciclo 2

Chart 1: Case 1, ítem 7: anergy.

In the case of chart 1(case 1), focused on anergy, it is interesting to notice that there is no lack of manifestations in the follicular phase; however, the clearest and most statistically significant tendency is to be found in the premenstrual period in the form of symptomatology increase relative to lack or loss of energy or vitality in two consecutive cycles. (global C = 1.82 and 2.15, respectively, attributable to

premenstrual changes; p < 0.05). In contrast, in chart 2, in which depressive type symptoms are addressed, changes in trends are not to be found in a statistically significant way (the indicators appear in only one cycle). Visual analysis suggests the expected increase in symptom pattern on the arrival of the premenstrual phase. However, Young’s C analysis does not indicate any change in trends attributable to increase in the

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Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 41-62

premenstrual phase (or at least not exclusively): sadness, hopelessness, lability, and lack of interest (global C = 0.217; 0.108; 0.43 and 1.55, respectively; p > 0.05). In chart 3, correspondent to case 1, mentioned above, dysphoric-type mood alterations with variations (annoyance, bad mood) can be seen during two consecutive cycles. The time-series analysis supports the premenstrual pattern attributed to the change of trend in both cycles (C = 1.31 and 1.74, respectively, p < 0.05). In spite of the pattern observed in some of the symptoms of this participant, the

minimum of five clinical indicators (Criterion A) and disturbance in the functioning of some areas (Criterion B) is not obtained in two consecutive cycles in order to confirm syndrome presence from the diagnostic focus of the DSM. Besides, it is worth highlighting that, while the pattern seemed to manifest itself, to a great extent, during the two first consecutive cycles, in the third cycle a smaller number of symptomatic indicators were evident, but accompanied by significant disturbance (Criterion B).

Sujeto 1 Síntomas Depresivos (ítem 8, 9, 12 y 13)

Ciclo 1 No significativos

02468

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17Fase Folicular Fase Premenstrual

TristezaDesesperanzaLabilidadDesinterés

Chart 2: Case 1, items of depressive symptoms: sadness, hopelessness, lability and lack of interest.

Sujeto 1

ítem 17 "enfado-mal humor" Ciclo 1 (sig 0,05) Ciclo 2 (sig 0,05)

0

2

4

6

8

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17Fase Folicular Fase Premenstrual

Enfado Ciclo 1

Enfado Ciclo 2

Chart 3: Case 1, mood symptoms: annoyance or bad mood

In case 19 a relatively limited presence of symptoms can be seen meeting premenstrual dominance. However, some clearly premenstrual symptoms take place in the third cycle (Criterion A, anergy: 2.59; dissatisfaction: 2.85, and physical symptoms: 3.46; p < 0.05), together with Criterion B

general disturbance (2.65; p < 0.01) and some other indicators of Criterion B (extra effort: 2.65; avoidance: 2.45, and confrontation with other people: 2.45; p < 0.01) (chart 4).

Sujeto 19

ítem 34, 35 37 y 38 "Criterio B" Ciclo 3 Sig 0,01

0

2

4

6

8

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Fase Folicular Fase Premenstrual

Criterio BCriterio B SobreesfuerzoCriterio B Evitación de Situaciones SocialesCriterio B Enfrentamiento con otros

Chart 4: Case 19. Criterion B indicators

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Gómez Márquez, C., García García, M., Benítez Hernández, M.M2, Bernal Escobar, L y Rodríguez Testal, J.F. Retrosprective and prospective study of premenstrual symptomatology in the general population

Sujeto 30 ítem 33.1 "Aumento de la Sensibilidad Mamaria"

Ciclos 1, 2 y 3 Sig 0,01

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17Fase Folicular Fase Premenstrual

Ciclo 1Ciclo 2Ciclo 3

Chart 5: Case 30, physical symptoms. Increase of breast sensitivity .

One more example of premenstrual distribution can be illustrated in Chart 5, for participant 30; in this case, concerning physical symptoms such as increase of breast sensitivity in the three consecutive cycles (C = 3.87; 3.84 and 2.94; p < 0.01). This woman showed

the minimum amount of global premenstrual symptoms in the three consecutive cycles, but Criterion B did not prove significant for the diagnosis of the syndrome, (but which did prove significant in the follicular phase).

Sujeto 63 Síntomas Depresivos

ítem 8, 9, 10, 11 y 13 Ciclo 2 Sig 0,05

02468

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17Fase Folicular Fase Premenstrual

TristezaDesesperanzaAutoinsatisfacciónIdeas de MuerteFalta de Interés

Chart 6: Case 63. Depressive symptoms and follicular pattern

In the case of participant 63, a diversity of premenstrual symptomatic indicators are observed in the first cycle (being surpassed, to be at the limit: C = 2.04; impulsiveness: C = 2.07; appetite: C = 2.56, and physical symptoms: C = 4.08; p < 0.05) plus fulfilment of Criterion B; however, graph 6 illustrates fulfilment

of the follicular pattern for the second cycle (sadness, hopelessness, dissatisfaction, ideas of death, and lack of interest; C = 2.54; -0.46; 3.09; 2.80, and 1.97, respectively; p < 0.05).

Sujeto 63 Síntomas Psicóticos

ítem 25 y 26 Ciclo 2 Sig 0,01

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17Fase Folicular Fase Premenstrual

Ideas dereferenciaSuspicacia

Chart 7: Case 63, psychotic symptoms and follicular pattern.

Graph 7 sets out psychotic symptoms present in

case 63, but with low clinical relevance (reference ideas and mistrust). These are symptoms which do not appear in the DSM-diagnosed criteria, but which can be found in some participants. In this case they are also used to illustrate the follicular, not premenstrual pattern (C = 3.29 and 2.64; p < 0.01), although this patient also showed significant mistrust in the premenstrual period in cycle 1 (C = 1.82; p < 0.05).

Finally, because there were not any women with prospectively confirmed Premenstrual Dysphoric Syndrome, and if only undoubtable subsyndromic cases by means of this procedure are to be considered, one can refer to an incidence of seven percent of cases with premenstrual symptomatology needs to be pointed out (six cases out of 85, the doubtful ones being excluded). This suggests quite a small incidence of really premenstrual dysphoric cases such as specified by the DSM-IV.

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DISCUSSION This research study consisted of three phases in

which a cross method was complemented by a prospective method. This procedure entailed an important loss of cases due to the rigour used to select the population sample, who, in the last step, were subject to a prospective follow-up study. In this way there was up consecutive information available for up to three months; consecutive and alternate cycles could be reliably analysed; and in the case of the loss of the last cycle for any circumstance, it was possible to maintain the scores of at least two consecutive cycles (which was fundamental in following DSM criteria) and to carry out repeated rates for the psychopathological criteria. In order to apply this procedure, it was necessary to count on really motivated participants prepared to continue with such a long process, and although to carry it out was not exactly complicated, it did require great perseverance.

A good amount of the work dealing with this topic highlights the loss of cases that take place when the premenstrual symptomatology analysis is addressed from a prospective methodology and requires the use of self-reports (Marván and Cortés-Iniestra, 2001; Schnurr, 1989). Furthermore, a number of cases were ruled out in this research in order to avoid, on one hand, the scores of people with some mood(!!!) alteration, which might confuse the results (as happened in the study by Chawla et al., 2002), and on the other, that the scores might suggest loss of rigour, or for a tendency to exaggerate the manifestations during some part of the menstrual cycle (Alteration Scale of the MCMI-II). We think that this entailed the absolute elimination of false positives, which was important to us precisely because one of the main limitations of the studies on this pathology is bias in the real indication of symptoms and their gravity in face of what is expected. (Marván and Escobedo, 1999).

Moreover, this study provides a procedure of exhaustive statistical analysis which does not just come down to comparing scores, but analyses the changes in trends in the observations and whether or not it can be attributed to the premenstrual phase or to the follicular phase. Schnurr (1989) did not observe any differences among three statistical analysis procedures with diverse advantages for clinical and research application (percentage of change, size of effect, and analysis of trends). However, we believe that interrupted time series analysis adds greater accuracy than those estimations exclusively based on percentages, averages, or variances, given the fact that it makes it possible to work with a small amount of data per series, and makes the analysis feasible by means of the stability and instability of each phase (even though sharp changes in the values may take place).

As for the presence of Premenstrual Dysphoric Syndrome in this work, those cases detected retrospectively represent practically 52% of the total number of participants. This figure is much higher than expected (APA, 2000; Halbreich, 2003; Halbreich, Borenstein, Pearlstein and Kahn, 2003; Kahn and Halbreich, 2003; Rivera-Tovar and Frank, 1990), and it has to be realistically classified as women with significant complaints and discomfort

(Marván and Cortés-Iniestra, 2001). On the other hand, if only prospectively analysed cases are considered, even though they are catalogued as subsyndromic, the incidence rate to bear in mind is 7%. We have to keep in mind that these are subsyndromic cases, therefore the real incidence can be very small, considering that they deal with the general population and pure cases, that is, without any other associated psychopathology. At the same time, the findings have been based on the perseverance of the intensity of the indicators, and on the type of indicators and cycles, both consecutive and alternate, so that, necessarily, they have not been overestimated. Because syndromic cases were not found, it can be asserted that, besides eliminating false positives, this procedure has established an lower limit for the general population, which guarantees the control of a good deal of the distortions in the answers in this type of studies. From a descriptive (retrospective) point of view, as regards the delimitation of the analysed symptomatology, it is worth highlighting that the group which was retrospectively characterised as premenstrual stands out for the intensity in the symptoms of anxiety, impulsiveness, mood, irritability and appetite change. This aspect coincides totally with what was expected. The intensity of the symptomatology seemed to follow a continuous line across the groups, the premenstrual group having a greater range and intensity of symptoms, which has a logical repercussion on criterion B. In consequence, the comparison group showed fewer indicators and with less seriousness, except for the physical symptoms. As expected, the physical symptoms do not seem to be those which best separate the three groups, that is to say, they are the most common ones in general terms. In spite of the fact that the physical symptoms were unspecific, some of these upsets contributed to differentiate the two main groups in the study: increase in breast size and discomfort or pain in muscles and joints. The contrasts between the scores reached in the premenstrual and subsyndromic groups gave rise to few differences, both as regards psychopathological measures and with menstruation related retrospective variables. The premenstrual group was different to the subsyndromic group in cognitive and motivational indicators (loss of interest and concentration). Therefore, the four main symptoms in DSM (mood, anxiety, lability, and irritability) did not permit the separation of the borderline cases of the most clearly premenstrual cases, but they did of the control cases. This fact lends support to hypothesis 1 of continuity among the clinical characteristics of both groups, with influence in more diverse areas for the premenstrual group (evidence of greater influence). In this sense, not only mood symptoms, but also those influencing cognitive motivational symptoms represent a difficulty for the realisation of highly qualified professional work and intellectual activity (there was a large number of university women in the sample). It is interesting to note that, according to some studies, this alteration of cognitive manifestations is subjective, since the analysis of these psychological functions have not verified that performance ability is lost in learning, memory, or attention; a slight psychomotor

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decrease is always pointed out (Resnick, Perry, Parry, Mostofi et al., 1998). As set out in hypothesis 1, the differences between the two study groups would be based on the fulfilment of criteria A and B. This can be observed mainly in the criterion B contrasts, which implies for the premenstrual group, greater influence or disturbance in the functioning of these women, who are, evidently, different from those of the comparison group. Likewise, the global intensity of all the symptoms differentiated the two groups in the study, but it did not in relation to the number of criteria with minimum intensity. Therefore, there is a continuity between the premenstrual and the subsyndromic groups, which needs to be resolved by the presence of some indicators of a serious nature plus criterion B. This is probably more important than the mere counting of symptoms. This aspect can be used to go into another objective, namely the repercussions of these manifestations on the women who have them. The women of the premenstrual group stood out significantly for a greater degree of interference in general, in their jobs, in their relationships with others, and even with the tendency to avoid social situations. Some repercussions are objective (though retrospective), such as absenteeism that reaches a maximum of up to two and a half days in this group; other repercussions are subjective, such as their estimation of performance and the extra effort they make to compensate for their difficulties. These variables that suppose an appraisal do not lack importance. For example, in the specific case of depression, Stewart, Ricci, Chee, Hahn et al. (2003) observed that the reduction in execution or performance at work explained the variance of up to 85%, although the objective of this study was to establish the loss of productive time (5.6 hours per week, versus 1.5 hours in the comparison group). There is a result which requires further analysis as it is the greater menstrual than premenstrual degree of repercussion on some aspects evaluated, such as performance, absenteeism, or days off work (although only performance significantly differentiates the groups). This result, apparently opposite to what was expected, can be due to a usual division of the periods to observe, which is too strict, namely the appearance of the first bleeding, which completes the premenstrual observation. In this sense, the DSM-IV-TR (APA, 2000) regards as a basic symptomatic pattern its appearance in the week before menstruation and its full remission on the second day of its commencement. In his analysis of different classical studies, Palmero (1987) points out that the indicators must be absent four days at the most after the beginning of the menstrual flow. Halbreich (2003) merely states that the premenstrual symptoms should not appear in the middle of the follicular phase. In consequence, he may be rather strict especially concerning objective variables, such as days off or absenteeism, to the limit of the first day of menstruation. The data collected may indicate that some manifestations do not stop immediately but progressively, even though they do so rapidly. It might be advisable to establish the length of the premenstrual phase, whether it is variable between cycles, and whether it is different in each woman: some profiles

clearly suggest a sharp decrease in symptomatology decrease, and some others less than sharp. Some of the differences found among investigations may lie in this aspect. Generally speaking, if days on sick leave, pharmaceutical cost, and visits to the doctor are specifically considered, the manifestations of these repercussions on these women do not seem to be important in group terms. terms. As Halbreich et al. (2003) point out; it is a common statement that the greatest influence lies in the family circle. However, these authors also emphasize that many of the calculations may be undervalued, since borderline or subsyndromic cases should be borne in mind, too. As a matter of fact, the pharmaceutical cost (analgesics) does not differentiate the two groups in the study, but it does with regards to the comparison group. The work by Chawla et al. (2002), who detected 4.7% of cases that met the diagnostic criteria (plus three other groups with smaller symptomatic levels), coincides with the findings of this study in relation to the decrease in productivity at work, more than as far as direct costs are concerned. Only the severe cases estimated that activity had been limited for one day. The authors point out that economic repercussions and working rigidity may have been responsible for these figures. In this sense, it needs to be kept in mind that the sample make-up of this study had a large representation of students and freelance professionals. As a consequence, the numbers on sick leave and absent from work found in this study may be more realistic, since they show these people’s real needs, without work or economic pressures. Possibly, as Chawla et al. (2002) argue, with samples of women working freelance or with less labour flexibility, more modest findings may be obtained than the ones found in their study. These authors also coincide in the idea that productivity might be affected around menstruation and at the beginning of the follicular phase. In short, hypothesis 2 is partially fulfilled because the women in the subsyndromic group also show social, work, economic, and relational repercussions (although at a lower degree than the premenstrual group). Extrapolation with population data needs to be carried out in order to observe the importance and implication of the aspects analysed, as much in the economic cost (medicines, private medical attention) as in the labour cost (absenteeism, days on sick leave). However, other subjective variables are important for their repercussion on relationships with other people, performance, and job satisfaction: the degree of extra effort necessary to compensate for the symptoms (which differentiated the groups of the study), the days necessary to recover normal functioning (marked but without differences in the two groups of the study) and the degree of confrontation with others. As for the objective of verifying the role of cognitive vulnerability with the prediction that it would coincide with Depressive Disorders, the hypothesis cannot be initially accepted. On the one hand, it is the depressive group that clearly has the highest scores in these measures. The analysis of its factors indicates that it is the achievement component that clearly differentiates the depressive group from the three other groups, coinciding with another study and different sample from this one (Catalán,

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Rodríguez-Testal, León, Benítez et al., 1999). But the most interesting and important finding comes from the comparison in relation to the DAS autonomy factor, since no differences were found between the two menstruation related groups of women versus the group of women with depressive disorders. The post hoc test brought the premenstrual group closer to the group of depressive women. In consequence, this retrospectively formed group does provide a characteristic of a tendency or vulnerability to depression. Because some subjects suffering from present disorders were eliminated in phase II before initiating the prospective phase, the source of confusion might lie there. In any case, as Kirkby (1994) argues, thought distortions do not cause the syndrome. It is rather a result of the disturbance caused by premenstrual tension, that is to say, a mood dependent product. Nevertheless, as Teasdale (1996; Teasdale, Segal and Williams, 1995) pointed out, the cognitive components should be better considered as processes that give continuous feedback to depressive patterns and as contributors to the perpetuation of depression, rather than attributing to them a strictly causal sense. On the other hand, the analyses of repeated measurements did not reveal any data of interest about these criteria. At this point only the women submitted to the prospective study remained. We think that this line of thought should continue being investigated more deeply for two reasons. Firstly, because even though the findings are not significant, there are premenstrual score changes (two specific results appeared, but they were considered insufficient). However, the sample with which we have been able to work is small, so a greater representation may definitely clarify this proposal. Secondly, there aren’t any definitely premenstrual cases (prospectively defined), which means that the cognitive vulnerability component may play its role in the sense expected, is not definitely excluded. The groups of the study were clearly separated from the criteria of the groups of women diagnosed with depressive disorders in the measures of physical and cognitive anxiety, and mood, so that including the vulnerability test (total and the achievement factor, which, as stated above, best characterises depressive people), the profile came to be clearly differentiated. The prospective analysis stressed different aspects. In general terms, the expected pattern of premenstrual symptom increase and follicular decrease could be verified, even if in the definitive and refined sample, there were distributions in which follicular increase systematically stood out. As a consequence, diagnostic criteria DSM-IV-TR (APA, 2000) valid as for the number of symptoms (criterion A plus symptomatic specificity) and significant discomfort (criterion B) prospectively verified in at least two consecutive cycles, turns out to be very exacting. The differences between the initial premenstrual and subsyndromic groups should not restrict themselves to the retrospective indicators such as loss of interest or concentration, sleep alterations, lack of control, and physical indicators, as stated at the beginning in relation to the cross study. Prospectively, the dysphoric symptoms (irritability, bad mood, being out of control, being at the limit, emotional lability) stand out more than those characterised by depressive,

hopeless, or self depreciation moods (which put them among the most important symptoms for diagnosis, according to the DSM criteria). In any case, in general, these symptoms can generically be classified as disphoria, which is the precise term for the syndrome. For this reason, it makes sense that these are the most pronounced indicators, instead of the classical depressed mood. For all these reasons, hypothesis 4 is, partially, confirmed. Symptoms such as anergy and appetite alterations (mainly whims and hunger oscillations) stand out, as well as other indicators which are not considered diagnostic criteria. Among them, we can highlight the tendency to hyperactivity or expansiveness, dissociative symptoms, euphoria, and reference ideas. Another of the results obtained indicates that there are noticeable symptomatic inter-cycle variations in the same woman (consecutive or alternate) even when the set of resulting indicators may actually coincide (criterion A). This fact confirms hypothesis 5 and is in agreement with the idea that inter-cycle agreement is commonly low, above all in relation to symptom severity and, particularly, in symptoms of an emotional nature (Schnurr, 1989; Sternfeld et al., 2002). As it is widely known from the literature and, in consequence, was expected (hypothesis 6), there is no relevant equivalence between retrospective and prospective information (except for the physical symptoms). This is evident not only from the lack of an evident case of Premenstrual Dysphoric Syndrome, but also in the overvaluation of the retrospective information (DeJong et al., 1985). Some authors have clearly shown this phenomenon. McFarland et al., (1989), for example, pointed out that women fundamentally remember the negativity of the symptoms and the ideas consistent with the discomfort brought about by menstruation. It has been considered that menstruation stereotypes and expectations play a large role, by amplifying premenstrual changes. This finding is valid both for women (Marván and Cortés-Iniestra, 2001; Marván and Escobedo, 1999; Van Tilburg, Becht, Vingerhoets, 2003) and for the professionals who, in their daily life, do not carry out prospective evaluation, they limit medical exploration to physical symptoms, and overvalue socio-cultural indicators in the diagnosis (Gottheil, Steinberg, Granger, 1999). In an explanatory sense, Marván and Cortés-Iniestra (2001) emphasise the importance of the socialisation process for the negative expectations related to menstruation. This gives rise to a negative focus of attention on menstruation which interferes with and alters the experiences of the menstrual cycle. Complementarily, as McGuire and Troisi (1998) state, the woman with this type of manifestation uses the social atmosphere as a way that contributes to regulate them physiologically. This study has a number of limitations that have to be borne in mind. First of all, the size of the sample. A greater number of participants, both in the retrospective and in the prospective phases would have clarified many aspects. However, such an exhaustive follow-up requires especially motivated people and, as has been stated above, these participants were not patients looking for some type of treatment, but women from the general population. Secondly, for the calculation of variables on social, job and health

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repercussions, a wide sample that reduces type-II error against the wide variance that is typically found in this type of information, would have been required. On the other hand, the level of commitment needed to stay in the study was high, which provides great reliability to the findings. One more limitation is derived from the former, namely, it would have been useful to count on a broader group of Mood-Disorder patients in order to endorse the findings and to itemize the role played by cognitive vulnerability to depression. To finish, we have observed some issues which we consider of interest for future studies. First of all and coinciding with the opinion of several authors, limiting the study or the interventions to women with confirmed Premenstrual Dysphoric Syndrome obviates all and any kind of consequence really suffered by women considered as being subsyndromic. Secondly, we recommend that a prospective study of this alteration should take into account consecutive and alternate cycles, which would amplify the observation period to at least three cycles. Thirdly, the symptomatology in the follicular phase should be more deeply analysed in order to discern its relevance, since repercussions on functioning can be seen. Fourthly, the premenstrual phase should be analysed, and the limit in days from the moment menstruation starts should be verified, instead of making categorical divisions at the observation stage. Fifthly and finally, on the basis of the data obtained, we find it very important to delimit criterion B into several independent and hierarchal facets. This is due to the fact that many women complain about the interference that the symptomatology brings them. However, as even capacities at work, in dealing with the family and other occupations or interests are affected, women may choose to put a limit themselves, on their activities. When they reduce their capacity for action instead of asking for help, there is an apparently smaller repercussion on their health. REFERENCES American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. DSM-IV-TR. Washington, DC: APA. Asociación Americana de Psiquiatría (APA) (1988). Manual Diagnóstico y Estadístico de los Trastornos Mentales. DSM-III-R. Barcelona: Masson. (Publicación original en inglés: 1987). Asociación Americana de Psiquiatría (1995). DSM IV. Manual Diagnóstico y Estadístico de los Trastornos Mentales. Barcelona: Masson. (Publicación original en inglés, 1994). Asociación Americana de Psiquiatría (APA) (1999). SCID-I. Entrevista Clínica Estructurada para los Trastornos del Eje I del DSM-IV. Barcelona: Masson. Bancroft, J., Rennie, D. y Warner, P. (1994).Vulnerability to Perimenstrual Mood Change: The Relevance of Past History of Depression Disorder. Psychosomatic Medicine, 56, 225-231. Barsky, A., Wyshak, G. y Klerman, G.L. (1990). The Somatosensory Amplification Scale and Its

Relationship to Hypocondriasis. Journal of Psychiatric Research, 24, 323-334. Beck, A.T., Epstein, N., Brown, G. y Steer, R.A. (1988). An Inventory for Measuring Clinical Anxiety: Psychometric Properties. Journal of Consulting and Clinical Psychology, 56, 893-897. Beck, A.T., Rush, A.J., Shaw, B.F. y Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press. Belloch, A., Ayllón, E., Martínez, M.P., Castañeiras, C. y Jiménez, M.A. (1999). Sensibilidad a las Sensaciones Corporales e Hipocondría. Revista de Psicopatología y Psicología Clínica, 4, 1-14. Brown, T. A., Antony, M. M. y Barlow, D. H. (1992). Psychometric Properties of the Penn State Worry Questionnaire in Clinical Anxiety Disorders Sample. Behaviour Research and Therapy, 30, 33-77. Catalán Mahindo, M.C., Rodríguez Testal, J.F., León Fuentes, J.L., Benítez Hernández, M.M. y Carrasco Ortiz, M.A. (1999, Noviembre). Vulnerabilidad Cognitiva en la Depresión: La Utilidad de la DAS para su Valoración. Presentado en las XII Jornadas Internacionales sobre Psicología Clínica y Salud: La Clínica de las Depresiones. Murcia. Chawla, A., Swindle, R., Long, S., Kennedy, S. y Sternfeld, B. (2002). Premenstrual Dysphoric Disorder: Is There an Economic Burden of Illness? Medical Care, 40, 1101-1112. DeCarlo, L.T. y Tryon, W.W. (1993). Estimating and Testing Autocorrelation with Small Samples: A Comparison of the C-Statistic to a Modified Estimator. Behavior Research and Therapy, 31, 781-788. DeJong, R., Rubinow, D.R., Roy-Byrne, P., Hoban, M.C., Groven, G.N. y Post, R.M. (1985). Premenstrual Mood Disorder and Psychiatric Illness. American Journal of Psychiatry, 142, 1359-1351. Endicott, J., Halbreich, U., Schacht, S. y Nee, J. (1981). Premenstrual Changes and Affective Disorders. Psychosomatic Medicine, 43, 519-529. Eysenck, H.J. y Eysenck, S.B.G. (1990). Cuestionario de Personalidad E.P.I. Madrid: TEA (6ª Ed). Frackiewicz, E.J. y Shiovitz, T.M. (2001). Evaluation and Management of Premenstrual Dysphoric Disorder. Journal of American Pharmacology Association, 41, 437-447. Freeman, E.W. (2003). Premenstrual Syndrome and Premenstrual Dysphoric Disorder: Definitions and Diagnosis. Psychoneuroendocrinology, 28 (Supp3), 25-37. Freeman, E.W., Derubets, R.J. y Rickels, K. (1996). Reliability and Validity of Daily Diary for Premenstrual Syndrome. Psychiatry Research, 65, 97-106.

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Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 41-62

Fresco, D. M., Heimberg, R. G., Mennim, D. S. y Turk, C. L. (2002). Confirmatory factor analysis of the Penn State Worry Questionnaire. Behaviour Research an Therapy, 40, 313-323. Gómez Márquez, C. y Rodríguez-Testal, J.F. (2001). Registro del Síndrome Disfórico Premenstrual II – R.S.D.P. II. Manuscrito Inédito. Gottheil, M., Steinberg, R. y Granger, L. (1999). An Exploration of Clinicians’ Diagnostic Approaches to Premenstrual Symptomatology. Canadian Journal of Behavioural Science, 31, 254-262. Halbreich, U. (2003). The Etiology, Biology, and Evolving Pathology of Premenstrual Syndromes. Psychoneuroendocrinology, 28 (Supp3), 55-99. Halbreich, U., Borenstein, J., Pearlstein, T. y Kahn, L.S. (2003). The Prevalence, Impairment, Impact, and Burden of Premenstrual Dysphoric Disorder (PMS/PMDD). Psychoneuroendocrinology, 28 (Supp3), 1-23. Halbreich, U. y Endicott, J. (1985) Relationship of Dysphoric Premenstrual Changes to Depressive Disorders. Acta Psychiatrica Scandinavica, 71, 331-338. Hollingshead, A.A. (1975). Five Factor Index of Social Position. Unpublished manuscript. Yale University. New Haven.C.T. Hsiao, M.C., Hsiao, C.C. y Liu, C.Y. (2004). Premenstrual Symptoms and Premenstrual Exacerbation in Patients with Psychiatric Disorders. Psychiatry & Clinical Neurosciences, 58, 186-190. Kahn, L.S. y Halbreich, U. (2003). Understanding Premenstrual Syndromes. Primary Psychiatry, 10, 41-45. Kirkby, R.J. (1994). Changes in Premenstrual Symptoms and Irrational Thinking Following Cognitive-Behavioral Coping Skills Training. Journal of Consulting and Clinical Psychology, 62, 1026-1032. Kuan, A.J., Carter, D.M.G. y Ott, F.J. (2004). Premenstrual Complaints Before and After 40 Years of Age. Canadian Journal of Psychiatry, 49, 215 Kutcher, S., Kusumakar, V., LeBlanc, J., Santor, D., Lagace, D. y Morehouse, R. (2004). The Characteristics of Asymptomatic Female Adolescents at High Risk for Depression: The Baseline Assessment from a Prospective 8-Year Study. Journal of Affective Disorders, 79, 177-185. Lukoff, D. Nuechterlein, K.H. y Ventura, J. (1986). Manual para la Escala de Apreciación Psiquátrica Breve Ampliada (BPRS). En R.P. Liberman y K.H. Nuechterlein (1996). Symptom Monitoring in the Rehabilitation of Schizophrenic Patients. Schizophrenia Bull, 12; 578-603.

Marván, M.L. y Cortés-Iniestra, S. (2001). Women’s Beliefs About the Prevalence of Premenstrual Syndrome and Biases in Recall of Premenstrual Changes. Health Psychology, 20, 276-280. Marván, M.L. y Escobedo, C. (1999). Premenstrual Symptomatology: Role of Prior Knowledge About Premenstrual Syndrome. Psychosomatic Medicine, 61, 163-167. McFarland, C., Ross, M. y DeCourville, N. (1989). Women’s Theories of Menstruation and Biases in Recall of Menstrual Symptoms. Journal of Personality and Social Psychology, 57, 522-531. McGuire, M. y Troisi, A. (1998). Darwinian Psychiatry. New York: Oxford. Meyer, T.J., Miller, M.L., Metger, R.L. y Borkovec, T.D. (1990). Development and Validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487-495. Millon, T. (1999). Inventario Clínico Multiaxial de Millon-II. MCMI-II Manual. Madrid: TEA Publicaciones de Psicología Aplicada. (original: Millon Clinical Multiaxial Inventory-II (MCMI-II). 1997. Inc. Minneapolis: National Computer System). Mortola, J.F. (1992) Issues in the Diagnosis and Research of PMS. Clinical Obsetrics and Gynecology, 35, 587-598. Nyberg, S., Wahlström, G., Bäckström, T. y Poromaa, I.S. (2004). Altered sensitivity to alcohol in the late luteal phase among patients with premenstrual dysphoric disorder. Psychoneuroendocrinology, 29, 767-777. Palmero, F. (1987). El Síndrome Premenstrual: Enfoque Psicofisiológico. Valencia: Promolibro Parry, B.L. (1994). Biological Correlates of Premenstrual Complaints. En J.H. Gold y S.K. Severino (Eds.), Premenstrual Dysphorias. Myths and Realities (pp 47-66). Washington DC: American Psychiatric Press, Inc. Resnick, A., Perry, W., Parry, B., Mostofi, N. y Udell, C. (1998). Neuropsychological Performance Across the Menstrual Cycle in Women with and Without Premenstrual Dysphoric Disorder. Psychiatry Research, 77, 147-158. Rivera-Tovar, A.D. y Frank, E. (1990). Late Luteal Phase Dysphoric Disorder in Young Women. American Journal of Psychiatry, 147, 1634-1636. Rivera-Tovar, A., Rhodes, R., Pearlstein, T.B. y Frank, E. (1994). Treatment Efficacy. En J.H. Gold y S.K. Severino (Eds.), Premenstrual Dysphorias. Myths and Realities (pp 99-148). Washington DC: American Psychiatric Press, Inc. Rodríguez-Testal, J.F. y Gómez Márquez, C. (2001). Entrevista Inicial Autoaplicada – E.I.A. Documento

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Gómez Márquez, C., García García, M., Benítez Hernández, M.M2, Bernal Escobar, L y Rodríguez Testal, J.F. Retrosprective and prospective study of premenstrual symptomatology in the general population

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interno del Departamento de Personalidad, Evaluación y Tratamiento Psicológicos. Manuscrito Inédito. Sanz Fernández, J. y Navarro, M. E. (2003). Propiedades psicométricas de una versión española del Inventario de Ansiedad de Beck (BAI) en estudiantes universitarios. Ansiedad y Estrés, 9, 59-84. Sanz Fernández, J. y Vázquez Valverde, C. (1993). Adaptación Española de la Escala de Actitudes Disfuncionales (DAS) de Beck: Propiedades Psicométricas y Clínicas. Análisis y Modificación de Conducta, 19, 707-750. Sanz Fernández, J. y Vázquez Valverde, C. (1994). Algunas Consideraciones Adicionales sobre la Versión Española de la Escala de Actitudes Disfuncionales (DAS) de Weissman Beck. Análisis y Modificación de Conducta, 20, 669-673. Schnurr, P.P. (1989). Measuring Amount of Symptom Change in the Diagnosis of Premenstrual Syndrome. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 277-283. Sigmon, S.T., Whitcomb-Smith, S.R., Rohan, K.J. y Kendrew, J.J. (2004). The Role of Anxiety Level, Coping Styles, and Cycle Phase in menstrual Distress. Journal of Anxiety Disorders, 18, 177-191. Stanley, M. A., Novy, D. M., Bourland, S. L., Beck, J. G. y Averill, P. M. (2001). Assessing older adults with generalized anxiety: a replication and extension. Behaviour Research and Therapy, 39, 221-235. Stearns, S. (2001). PMS, PMDD, in the Domain of Mental Health Nursing. Journal of Psychosocial Nursing, 39, 16-27. Steiner, M. (1992). Female Specific Mood Disorders. Clinical Obsetrics and Gynecology, 35, 599-611. Sternfeld, B., Swindle, R., Chawla, A., Long, S. y Kennedy, S. (2002). Severity of Premenstrual Symptoms in a Health Maintenance Organization Population. Obstetrics & Gynecology, 99, 1014-1024. Stewart, W.F., Ricci, J.A., Chee, E., Hahn, S.R. y Morganstein, D. (2003). Cost of Lost Productive Work Time among US Workers with Depression. Journal of the American Medical Association, 289, 3135-3144. Teasdale, J.D. (1996). Clinically Relevant Theory: Integrating Clinical Insight with Cognitive Science, En P.M. Salkovskis (1996) (Ed.), Frontiers of Cognitive Therapy (pp 26-47). New York: Guilford Press. Teasdale, J.D., Segal, Z. y Williams, J.M.G. (1995). How Does Cognitive Therapy Prevent Depressive Relapse and Why Should Attentional Control (Mindfulness) Training Help? Behaviour Research and Therapy, 33, 25-39. Trunnell, E.P., Turner, C.W. y Keye, W.R. (1988). A Comparison of the Psychological and Hormonal Factors in Women with and Without Premenstrual

Syndrome. Journal of Abnormal Psychology, 97, 429-436. Tryon, W.W. (1982). A Simplified Time – Series Analysis for Evaluating Treatment Interventions. Journal of Applied Behavior Analysis, 15, 423-429. Van Tilburg, M.A.L., Becht, M.C. y Vingerhoets, A.J.J.M. (2003). Self-Reported Crying During the Menstrual Cycle: Sign of Discomfort and Emotional Turmoil or Erroneous Beliefs? Journal of Psychosomatic Obstetrics and Ginecology, 24, 247-255. Vázquez, C. y Sanz, J. (1997). Fiabilidad y Valores Normativos de la Versión Española del Inventario para la Depresión de Beck de 1978. Clínica y Salud, 8, 403-422. Vázquez, C. y Sanz, J. (1999). Fiabilidad y Validez de la Versión Española del Inventario para la Depresión de Beck de 1978 en Pacientes con Trastornos Psicológicos. Clínica y Salud, 8, 403-422. Weissman, A. y Beck, A.T. (1978). Development and Validation of the Dysfunctional Attitudes Scale. Paper presented at the meeting of the association for the Advacement of Behavior Therapy, Chicago,IL. Yonkers, K.A., Halbreich, U., Freeman, E., Brown, C., Endicott, J., Frank, E., Parry, B., Pearlstein, T., Severino, S., Stout, A., Stone, A. y Harrison, W. (1997). Symptomatic Improvement of Premenstrual Dysphoric Disorder with Sertraline Treatment. A Randomized Controlled Trial. Sertraline Premenstrual Dysphoric Collaborative Study Group. JAMA, 278, 983-988.

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What does a trauma hide? From all that is indescribable to the process of recovery

Francisco Balbuena Rivera1

Departamento de Psicología Universidad de Huelva (España)

ABSTRACT: Going through a trauma, in any of its forms (child abuse, domestic violence, etc.), is a devastating experience for the victim, whose life is stigmatized forever. The process of recovery depends on the victim’s own cognitive, emotional, motivational and behavioural resources, as well as on the degree, scope and depth of the physical, sexual and psychological sequelae caused by the trauma, all of which will be dealt with herein. Key words: trauma, recovery process, victim, perpetrator, violence.

INTRODUCTION

Throughout this research, in addition to carrying out an analysis of trauma, we attempt to prove some of the problems that emerged during the research of this disorder given the inextricable link existing between violence and victimization in this condition. It is worth mentioning the clash dividing those who put a premium on scientific objectivity and those who put individual/social acknowledgement before the rights of those affected.

On a different level, the difference between the

DSM-III-TR (APA, 1987) and its last edition, the DSM-IV-TR (APA, 2000), does not clarify what the term direct exposure means either, and reopens the debate it dealt with, according to which since the DSM-IV (APA, 1994) was published, the emphasis had to be placed on the individual’s reaction, and not on the kind of traumatic event, when it comes to approaching/treating this disorder, whether as a victim or as a witness. Likewise, the normal course or natural record of human reactions to stress is still unknown, so many of the psychological reactions considered symptoms, according to lists of diagnostic classifications, are actually recovery and adaptation responses whose vital meaning and temporary course still need to be better specified (Vazquez, 2005).

Disregarding these issues, it is worth mentioning

that the central dialectics underlying every trauma results from the internal conflict the victim has to face,

which involves denying such horrible events and their willingness to reveal them, so that if the first option prevails, silence will be accompanied by the psychic damage and emotional sequelae the victim suffers, and if the second one wins through, the victim will be able to begin the painful path towards the cure.

In any case, whichever the choice is, this will inevitably imply a high cost for the victims, whose credibility will be questioned, which will in turn encourage their stigmatization, given the strong alternative ingredient involved in researching the trauma, both in the individual and social sphere, of which denial, depression and dissociation are faithful images in reacting to such atrocities (Herman, 1997).

In addition, we should mention the complete lack

of conceptual distinction found on the current diagnostic systems among the traumas caused by humans (e.g. theft, rape, etc.) and the rest of traumas (e.g. natural disasters) (Vazquez, 2005), which in spite of having a vast and rich scientific tradition, would make it possible that trauma research could be compared to the clinical manifestations of an episodic amnesia, given the alternation periods of intense research with others of blatant oblivion. Backing these arguments there is the nature itself of its purpose of research, which results in the difficult situation in which researchers find themselves since they must face human vulnerability, on the one hand, and the ability to do evil, on the other. In turn, researchers’ work could also be marred by accusations that cast doubt on their supposed impartiality and objectivity, when their research is considered biased and influenced by the terrible events described by the victims, which sometimes lead them to isolate professionally from their colleagues (Baranowsky,

1 Francisco Balbuena Rivera. Temporary lecturer. Department of Psychology Universidad de Huelva (Spain). Home address: Avenida Luis Montoto, 130 A 1-1;41005 Sevilla. E-mail: balbuena@uhu.es

Balbuena Rivera, F.: What does a trauma hide? From all that is indescribable to the process of recovery

Gentry and Schultz, 2005). In the same way, although situated somewhere

else, is the witness (neighbours, relatives, etc.) who will have to face the dilemma of remaining deaf, blind and dumb as regards what happened, or telling what happened, thus standing next to the victim, and not the perpetrator (Alberdi, 2005), whose main purpose is to silence the victims or undermine their credibility using arguments of all kinds, so the greater his/her radius of influence, the firmer his/her belief, according to which he/she can name and define reality his/her own way.

FROM WHAT IS UNUSUAL TO WHAT HAPPENS EVERYDAY: THE CLINICAL FEATURES OF TRAUMA

Among the critical factors that had an influence on the research of trauma are the two World Wars that ravaged humanity in the 20th century, as well as other military conflicts such as the Vietnam War, through which trauma became known as a lasting and inevitable legacy for their survivors, even though it was not formally acknowledged until 1980, when for the first time the diagnostic category called Posttraumatic Stress Disorder (PTSD) was included in the DSM-III. The fact is that just after the date mentioned, due to the initiatives implemented by war veterans, the PTSD was legitimized, which helped corroborate that the psychological syndrome the victims of rape, domestic violence and incest were showing was inherently similar to what war survivors were going through (Herman, 1997).

That is how it came as obvious that such atrocities

are part of everyday life, and not of the extraordinary and unusual, as some lay people and experts believed, so the various symptoms of PTSD could be divided into three main categories: hyperactivation or constant on guard state, intrusion or indelible impression left by the traumatic experience, and finally, constriction, through which the emotional dullness and failure attitude the victim suffers due to the trauma experience are objectified.

And the truth is that bringing back a traumatic

experience, whether through the irruption of intrusive memories or dreams and other behaviour, always carries the emotional intensity of the original situation, which survivors have to face, because, if they choose to avoid it, they will aggravate the posttraumatic syndrome. Likewise, although such intrusive memories, like flashbacks, a dissociative paradigm for some authors and a simple memory component for others (Perez Sales, 2006), can be part of the trauma, both are made of different ingredients, since whereas the first ones constitute recurring memories of what happened before and during the traumatic event, the second ones push the individual to relive the traumatic experience as it were happening right now (Echeburúa, 2004). We should also take into account that, if flashbacks are the main symptom, the therapist’s task will involve training the patient in the set of suitable cognitive and behavioural techniques to reduce their frequency and duration.

In any case, both responses, intrusion and

symptom avoidance, will take turns, as the individual aims at finding a nonexistent balance, emphasizing at first the intrusive reliving of the traumatic event, which will plunge the victim into a state of restlessness and alertness when faced with new threats. The intrusive symptoms will reach their climax during the first days or weeks following the event, and they will be reduced to a certain extent between the following 3 to 6 months, tempering slowly as time goes by. However, the specific symptoms linked to the trauma could even be reproduced after many years, stimulated by different circumstances, such as the date when the tragic event took place.

At any rate, once the intrusive symptoms are

reduced, the avoidance symptoms increase, and victims pretend not to feel afraid, which would place them, at least ideally, in a suitable position to resume their life, watching everyday events from outside, with a huge affective distance, and a dullness and gulf feeling, which will help avoid experiencing the horror moment again only temporarily. And even if such affective dullness disappears, and victims are aware of the suitable way to express their emotions, this could negatively affect their perception of themselves and of their confrontation strategies since it makes them feel more vulnerable to traumatic memories (Echeburúa, 2004). Another task trauma survivors will have to undertake is the reliving of all their inner struggles to achieve autonomy, initiative, competence, identity and intimacy. Still, social support, whether through the family, through friends or through social/institutional networks, is necessary, since it exudes the victim’s primitive emotional bonds, as the community’s initiatives aimed at healing the deep wounds the traumatic experience inflicted on the victim, who longs to recover the trust on others and to know they are not alone on the difficult return to everyday life (Duque, Mallo and Álvarez, 2007). However, serious research endorse that those related to the victim must be flexible and tolerant, given the changing need they have as regards closeness and distance, as well as regards recovering their autonomy and self control. On the other hand, the victim’s uncontrolled aggressive episodes should not be tolerated, as these increase their guilt and shame load, as well as their social isolation; thus, together with high doses of patience, tenderness and understanding when treating the victim, those interested in them will be able to show some firmness.

TOWARDS THE “CURE”: PHASES IN THE PROCESS OF RECOVERY

It seems obvious to think that if the abuse

situations took place in certain family and social contexts, the victim’s recovery could happen in different contexts. What they long for, above all, is the feeling of power and autonomy they had before the trauma, the first one being the convergence of mutual support and individual autonomy, and the second one, the individual’s feeling of being able to stay alone and take important decisions on their own.

Having said this, so that the patient’s recovery

process can be considered successful, it would be

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necessary that a gradual change took place, from an unpredictable feeling of danger to one of reliable safety, as well as a transition from dissociated trauma to recognized memories, and from the stigmatized isolation to the restoration of social contact. Of these phases, the first one, restoring safety, is a top priority. Its length can go from days to weeks in traumatized people, and from months to years in survivors of chronic abuse, depending on the severity, duration and early start of the abuse.

In any case, restoring lost safety begins with

treating body control, and gradually starts going outwards, to treat context control. Thus, in order to reduce the victim’s reactivity and hyperactivation, medication could be applied, and relaxation and hard physical work out are useful to manage stress. Mental dullness can be treated keeping journals to record symptoms and adaptation responses, as well as to set tasks and develop specific safety plans. In turn, therapy can help increase the genuine trust on others, while social alienation can be confronted through natural support systems (family, partner, friends, etc.), self-help organizations or mental health, social well-being and justice institutions.

Once the body has been controlled, the victim’s

security within the context should be increased. The danger or safety potential must be carefully examined, since if a family member happens to be producing the trauma, the most suitable urgent measure could be staying temporarily in a shelter. While victims recover that feeling of being safe, some surround themselves with other people all the time, whereas others choose to isolate themselves. And since it is possible for them to choose people that instead of helping them recover, get in the way of recovery, the patient's initial evaluation must include a review of their most significant social relationships, because although some can be their source of protection, emotional support and practical help, others can be a source of potential danger.

Even so, relatives or close friends protecting the

victim must accept that, during a while, their lives will be altered more drastically when the victim demands almost constant support and care, and must also consider implementing a protection plan for the future.

The next phase, of remembering and mourning,

happens gradually, and a valid indicator of belonging to it is the victim's perception that they are no longer vulnerable or isolated. Then, this is the time when they have to fit into the traumatic experience, which some victims try to avoid, claiming that they are now able to protect themselves, control their most disturbing symptoms and know who to turn to for support.

However, one has to be cautious when

reconstructing traumatic memories, since if the individual faces them too suddenly, they will relive them unsuccessfully. Thus, therapist and patient must pay careful attention and agree widely. Monitoring intrusive symptoms will also be very useful, since it will unblock traumatic memories within bearable boundaries. In the event that symptoms dramatically worsen, therapy must be slowed down and redirected.

Reconstructing the trauma, in any case, demands reviewing the patient’s life before the event, as well as the circumstances preceding it, all of which provides context where to start to grasp the special meaning of the trauma, so that if an unsuitable psychological performance prior to the traumatic experience is detected, one should analyze what aspects of the current problem can be attributed to situations that took place before the trauma, such as which victimization profiles have been fostered due to the occurrence of these events before the traumatic experience, or if they are associated to personality traits the victim already had (Anglin, 1998). At any rate, and as the patient’s traumatic story comes closer to the most unbearable moments, they can spontaneously turn to other non-verbal communication methods (e.g. drawings), which can be the closest approach to these indelible memories. But for this to be really effective, it is also necessary that the victim physically expresses and feels all the emotions associated with such a fact, since memory without emotion hardly ever produces results (Duque, Mallo y Álvarez, 2007). In such a task, fantasies of revenge, as well as of compensation and forgiveness, burst in, with more or less affective intensity in the individual’s conscience, which once they achieved certain safety in the context can turn their vulnerable rage into justified indignation; thus, regaining control of their own life. But if they chose to forgive the aggressor or compensation, whether expected from a particular person or from society, the feeling of controlling their own life would depend on others’ actions, and the path towards recovery would be interrupted.

Likewise, the social and relational dimensions of

the traumatic experience must be included, because although direct exposure techniques, such as flooding, seem to improve intrusion and hyperactivation symptoms, the constrictive symptoms of mental dullness and social seclusion do not necessarily improve, as it happens with marital, social and work problems. Similarly efficient has been flooding when used to alleviate the intense reactions to the memories of only one traumatic event, but its therapeutic efficiency diminishes when used to treat prolonged and repeated traumatic experiences (Herman, 1997).

Despite what has been said, the trauma

reconstruction process will never be completed altogether because there will be new conflicts and challenges that will reawaken the trauma, disclosing other aspects of this terrible experience. But if the patient is able to come to terms with their own story and feel hopeful, they will be able to look backwards from a different perspective, working in the present to gradually start consolidating the future. Then, traumatized people will have entered the third phase, the one about the restitution of their own power and social reconnection, through which they will already feel ready to incorporate into their life the hard lessons derived from the traumatic experience, recognizing themselves as victims, and grasping the terrible impacts produced by their victimization.

As a result, victims will start learning to live with

fear, and even to use it as a source of impetus or energy, turning the anticipatory physical danger or

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Balbuena Rivera, F.: What does a trauma hide? From all that is indescribable to the process of recovery

mental distress in potentially dangerous situations into something regular in their lives. Now, their task will consist of becoming who they want to be, turning to the most outstanding personality traits they had before the traumatic experience, such as the ones built up during the experience and incorporated in the recovery process, whose integration will result in a new self, both at an ideal and at a real level.

From such identity signs, the most prominent ones

are those built up in the traumatic context, since only the victims recognize them and are able to give them up, when they show more willingness to forgive themselves realizing that the terrible damage inflicted on them is not permanent. Thus stimulated, some victims embark on social actions, whose main aim is to help others that, like them, have gone through traumatic experiences. Their private life and different social networks are also affected when they resume their old love relationship or start a new one, like it happens if they decide to have children, as all of them are concentrated on establishing a relational dynamics different from the previously existing one.

Rounding off, despite the time gone by from their

original formulation, we find it useful to make reference to the seven criteria pointed by Harvey (1990) to evaluate the degree of resolution of a trauma: First, PTSD symptoms must be within manageable boundaries. Then, the individual must be able to endure feelings associated with traumatic memories; third, the individual must have authority over such memories, so that they are able to choose between remembering the trauma or leaving it behind. Next, the traumatic event must be told as a coherent description associated with the feeling; fifth, the individual must have recovered their self-esteem. Last, the sixth criterion makes reference to the necessary restoration of the person’s most significant affective and social relationships, and the seventh criterion, to the person’s reconstruction of a coherent meaning and value system that embraces the trauma story.

The achievement of such criteria can be made

through individual or group therapy. The second therapeutic method is recommended once between six months and one year has gone by after the traumatic experience. And if, as we have mentioned, the first phase of the recovery process pursues the search for security, group work in the last phase should be highly cognitive and educational, and it should never deal with a deep exploration of the trauma, because if we did not try provide strategies for the individual’s own care and protection, we would increase group members' distress. Therefore, the group structure is centred on symptom relief, problem resolution, and basic care daily tasks.

On the other hand, exploring the trauma is

appropriate in the second phase, of remembering and mourning, since it is through group action that the trauma grows, releasing the victim from the isolation they have been subjected to. Sharing the story of the trauma in a group means not only relief or catharsis, but it is also the step prior to the active control of the trauma. And since initially there is no group member more trained than others to take on the group’s

leadership, we generally recommend a shared leadership, based on cooperation among equals, in order to avoid reproducing a dominance and subordination dynamics. In this way, the emotional weakness is distributed among several leaders, who are witnesses of the group members’ stories, and it is not taken on by just one of them (Anglin, 1998). Although we often see how the anxiety symptoms worsen at the beginning, group members have a feeling of euphoria for having met others, and for the first time, they feel they are recognized and understood.

Given the limited duration of group therapy, a

great deal of the integration work must be carried out towards the end, taking into account that it is a complement of the intensive, individual exploration of the trauma, and that, under no circumstances, does it replace individual therapy.

CONCLUSION

In tune with previous research that has already been published (Rodriguez Vega, Fernandez Liria and Bayón Perez, 2005), we believe that every effective and efficient intervention model when coming to grips with and treating PTSD must include the self psycho-physical experience –in relation to, and not exclusively the physical experience- in order to integrate the cognitive experience into the somatosensory emotional experience. Likewise, it is necessary to increase the number of studies that stress people’s psycho-social performance, which is a key criterion to determine whether a disorder affects individuals’ everyday life, to what extent, how, etc., something rarely dealt with in current epidemiologic research. In addition, we must examine measure methods used (clinic interviews, standardized tools, self-evaluations) into greater detail, since serious studies endorse that the kind and extent of reactions depends on such methods, as well as on the more or less strict criteria employed. The most predominant studies are those based on a dimensional approach that includes symptom scales that reflect different reaction degrees, but there others that have been centred on some of the most extreme responses, such as the development of a complete posttraumatic stress disorder (Vazquez, 2005). REFERENCES Alberdi I. (2005). Cómo reconocer y cómo erradicar la violencia contra las mujeres. En Violencia: Tolerancia Cero. Barcelona: Fundación “La Caixa”, 2005, 9-87. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., Text revised). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.,). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text revised,). Washington, DC: Author.

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Anglin, J. (coord) (1998). Trauma Recovery and empowerment. A Clinician’s guide for working with women in groups. New York: The Free Press.

Baranowsky, A. B., Gentry, J. E., & Schultz, D. F. (2005). Trauma Practice. Tools for Stabilization and Recovery. Cambridge, MA: Hogrefe & Huber Publishers.

Duque, F., Mallo, M., y Álvarez, M. (2007). Superando el trauma. La vida tras el 11-M. Barcelona: La Liebre de Marzo, S. L.

Echeburúa, E. (2004). Superar un trauma. El tratamiento de las víctimas de sucesos violentos. Madrid: Ediciones Pirámide.

Harvey, M. R. (1990). An Ecological View of Psychological Trauma [ms. no publicado, Cambridge Hospital, Cambridge (Massachusetts).

Herman, J. L. (1997). Trauma and Recovery. The aftermath of Violence from Domestic Abuse to Political Terror. New York: Basic Books (Trad cast.: Trauma y recuperación. Cómo superar las consecuencias de la violencia. Pozuelo de Alarcón (Madrid): Espasa-Calpe, 2004.

Pérez Sales, P. (Ed.) (2006). Trauma, culpa y duelo. Hacia una psicoterapia integradora. Bilbao: Desclée de Brouwer.

Rodríguez Vega, B., Fernández Liria, A., y Bayón Pérez, C. (2005). Trauma, disociación y somatización. Anuario de Psicología Clínica y de la Salud 1, 27-38.

Vázquez, C. (2005). Reacciones de estrés en la población general tras los ataques terroristas del 11S, 2001 (EE.UU.) y del 11M, 2004 (Madrid, España): Mitos y realidades. Anuario de Psicología Clínica y de la Salud, 1, 9-25.

 

Anuario de Psicología Clínica y de la Salud / Annuary of Clinical and Health Psychology, 3 (2007) 69-71

Attention Deficit Hyperactivity Disorder (ADHD) as a risk factor for

addictive behaviour in adulthood

Romo Jiménez, L.1

Lecturer, Research Director

Université Paris X-Nanterre (France)

ABSRACT This study points out the importance of diagnosing Attention Deficit Hyperactivity Disorder (ADHD) in adult patients and, for that purpose, the necessity to diagnose the disorder during childhood. The frequency of this disorder among adults is 4% of the population, with a similar proportion between men and women, whereas the disorder is more often male-related during childhood. Impulsiveness is less important during adulthood, but difficulties of attention and organization are more frequent. There is a wide range of literature about the possible relationship between ADHD and addiction problems or depressive disorders. This article analyses the most relevant works published in this field over the last few years, and insists on the need to improve evaluation tools to assess and to harmonise diagnosis criteria in order to keep developing the understanding of this disorder. Key words: Hyperactivity, attention deficit disorder, addiction, adults. INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder clearly identified during childhood. However, there is great controversy about it during adulthood. ADHD in adulthood occurs in 4% of the general population. This problem affects adult men almost the same as adult women, and appears above all as an attention disorder or as a mixed disorder.

The diagnosis of Attention Deficit Hyperactivity

Disorder creates a certain amount of controversy (Barkley, Fischer y Smalish, 2004). The problem is that the diagnosis criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) are not suitable for its diagnosis during adulthood. This is a disorder that evolves with age, but it has to be present during childhood to be regarded as ADHD. Assessment problems on the frequency of the disorder and on its comorbidity According to Wender (1995), in addition to attention deficit disorder or hyperactivity during childhood, in adulthood, emotional lability, a high _____________________ Maître de Conférences HDR, Université Paris X-Nanterre (France). Clinic Psychologist. CHU Louis Mourier. Service de Psychiatrie. 178, rue des Renouillers. 92701 Colombes Cedex France. E-mail: lucia.romo@wanadoo.fr

degree of impulsiveness, organisation difficulties and intolerance of stress are also present. An essential aspect to be considered is that adults do not consult their doctors about this problem because they regard it as forming part of their personalities and, as a consequence, they believe that a change will not be possible. All of this in spite of possible serious repercussions such as problems in keeping a job, frequent changes of partner and frequent traffic accidents (Hallowell and Ratey, 1994). According to Mannuzza and Klein (2002) the risk of an estimation lower than that diagnosed, is on the basis of three studies, between 20 and 40%. In short, the diagnostic criteria of ADHD provide grounds for disagreement among professionals as much as about the actual existence of the disorder in adults, especially in countries such as France, which traditionally are positioned far from the cognitive- behavioural model, and where this disorder continues being regarded as exclusively “psychological” or one with an origin based only in family relationships. Another complication arises from the fact that the diagnosis appears in almost 75% of cases with associated comorbidity, such as sleep disorders (Lecendreux, 2003). According to Goossennen, Vandegling, Carpentier et al. (2006) the most important comorbidities are anxiety disorders (20 to

Lucía Romo Jiménez: Attention Deficit Hyperactivity Disorder (ADHD) as a risk factor for addictive behaviour in adulthood

30%), mood disorders (25%) and drug abuse (15 to 45%). In a group of teenagers suffering from drug abuse or dependence, between 30 and 50% show the associated ADHD criteria, according to Wilson and Levin (2005). Differential diagnosis is difficult, above all in relation to tymic (I can’t find this word anywhere) disorders. According to some authors, these two disorders may be incompatible, whereas for others, the disorders would not be exclusive. (Adler, 2004) As regards personality disorders, the borderline personality type is a reason for the exclusion of ADHD. On the other hand, the antisocial personality is associated with higher alcohol consumption in patients with ADHD (Molina, Pelham, Gnagy, Thompson and Marshal, 2007). Objetive:

The objective of this study is to analyse the

presence of attention deficit hyperactivity disorder in people with an addiction disorder, generally addiction to alcohol. METHODS The bibliographic search was carried out in two databases, Medline and PsycInfo. We were interested in the most relevant aspects in the relationship between ADHD and addictive disorder in adulthood. The number of works indexed in Medline with the key words ‘ADHD’ and ‘alcohol’ was 301 in total, half of them over the last four years. The interest in ADHD by crossing the key words ‘addiction’ and ‘ADHD’ has increased dramatically. The number of studies increased from only one in 1981, 1987 and 1989, to two or three per year between 1989 and 1993. It is from 1997 onwards that the number of works published amount to almost one a month per year and in the year 2000 they were multiplied by two (20 articles) and, in 2006 and 2007, the number increases to over 40 per year. In our study we have been interested in disorders linked to drug abuse or dependence, but it should be borne in mind that some symptoms such as impulsiveness or alcohol related attention problems are similar to ADHD symptoms. As Brown (2003) argues, ADHD is a risk factor for developing addictive behaviour. King, Lacono and McGue (2004) found a very high proportion of hyperactivity and attention deficit disorders in drug addict and in alcoholic patients and they evoke the hypothesis of self medication, above all to struggle against attention problems. Using different tools such as Wender’s and Conner’s scales, Ohlheimer, Peters, Gordon et al (2007) state that the most important cigarette or alcohol consumption provides self-medication, especially for ADHD symptoms.

In a recent study by Romo, Dupont-Houdeyer, Aubry et al (2005) with a population sample of 117 patients with addictions such as to alcohol, pathologic games, compulsive shopping, and so on, 35% of these patients showed hyperactivity criteria according to three ADHD measures; one during childhood, which is Wender’s criteria (1995), and two adult-age assessments through Brown’s criteria and scale (1996). The patients with comorbid ADHD showed more anxiety and depression, but without significant differences. Nevertheless, the starting age for addictive behaviour was significantly earlier in the ADHD group. Furthermore, the consumption of cannabis was more important and self esteem was lower in this same group. It is very important to assess the teenagers diagnosed with ADHD and to follow them up over the long term. Biederman, Manuteaux, Mick et al (2006) state that young people with ADHD show more psychopathic problems, addictive disorders and anxiety and depressive disorders when they become adults. According to a meta-analysis by Flory and Lynan (2003), there is a high correlation between the presence of ADHD and abuse of drugs, above all tobacco. The behavioural disorder is regarded as a mediating variable related to the dependence on alcohol or other substances. However, Szobot, Rohde, Bukstein et al (2007) recently found a relationship between ADHD and drug use, independent from the behaviour disorder variable. In a study carried out by us (Romo et al., 2005), we stated that the patients with addictions and ADHD go to the doctor’s surgery less regularly. Furthermore, as they are more impulsive, the follow-up is more problematic and a very important point about these patients is that they attempt to commit suicide more frequently, as has been pointed out in another study by James, Lai and Dahl (2004). On the other hand, Kessler and others (2006) point out that only 10% of adults with ADHD receive clinical treatment, which is greatly inferior to the rates in relation to other psychiatric or psychological disorders. If we bear all of the above in mind, the treatment programmes should be multi-modal. Goossensen et al (2006) insist on the use of self-assessment, psycho-education, pharmacotherapy, coaching and team work with these patients. They also insist that pharmacological treatment does not increase the risk of a relapse. CONCLUSION The presence of attention deficit hyperactivity disorder may increase the risk of manifesting abuse or dependence on substances such as alcohol or tobacco, among others. It is necessary to develop longitudinal studies on children and teenagers diagnosed during their childhood in order to understand the mechanisms underlying this disorder and its relationship with addictive pathology. The limits of our research, such as considering the differential diagnosis of ADHD, are difficult in some cases, such as when dealing with bipolar disorders. On

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Anuario de Psicología Clínica y de la Salud / Annuary of Clinical And Health Psychology, 3 (2007) 69-71

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the other hand, the databases checked are not exhaustive and the number of articles published each year has increased greatly. We do not regard this study as a complete revision of the literature, but as a document that insists on one important aspect, namely, studying populations with addictive disorders in order to adapt treatment techniques, which should consider both of the disorders. It is necessary to assess patients with ADHD. This requires going deeper into the aspects linked to assessment tools and to the diagnostic criteria for adults, and furthermore, on accepting the continuity of this disorder during adulthood, and thus, on reducing the resistance of some professionals to accept the continuity of this disorder. REFERENCES Adler, L.A. (2004). Clinical presentation of adults patients with ADHD. Journal of Clinical Psychiatry, 65: (suppl. 3), 8-11. Barkley, R.A., Fischer, M., Smalish, M. (2002). The persistence of attention-deficit/hyperactivity disorders into young adulthood as a function of reporting source and definition of disorder. Journal of Abnormal Psychology, 111, 279-289 Biederman, J., Monuteaux, M.C., Mick, E., Spencer, T., Wilens, T.E., Silva, J.M. (2006). Young adult outcome of attention deficit hyperactivity disorder : a controlled 10-year follow-up study, Psychological Medicine, 36 (2), 167-179. Brown, TE. (2003). Trastornos por déficit de atención y comortibilidades en niños adolecentes y adultos. Barcelona. Masson. Flory, K.et Lynam, DR. (2003) The relation beween Attention Deficit Hyperactivity Disorder and Substance Abuse : What role does conduct disorder play. Clinical Child and Family Psychology Review, 6 (1), 1-16. Goossensen, MA., Vandegling,G., Carpentier, P.J., Wijsen, R.M., VanDuin, D., Kooij, J.J. (2006). An intervention program for ADHD in patients with substance use disorders. Preliminary results of a field trial. Journal of Substance Abuse Treatment, 30 (3), 253-259. Hallowell, E-M. y Ratey, JJ. (1994). TDA : Controlando la hiperactividad. Cómo superar el déficit de atención con hiperactividad (ADHD) desde la infancia hasta la edad adulta. Barcelona : Paidos. James, A., Lai, F.H., Dahl, C. (2004) Attention deficit hyperactivity disorder and suicide : a review of possible associations. Acta Psychiatrica Scandinavica, 110 , 408-415. Kessler, R.C., Adler, L., Barkley,R. et al. (2006). The prevalence and correlates of adult ADHD in the United States : Results from the National Comorbidity Survey Replication. American Journal of Psychiatry, 163 (4), 716-723.

King, S-M., Lacono, W.G., McGue, M.(2004). Childhood externalizing and internalizing psychopathology in the predictor of early substance use. Addiction, 99 (4) 1548-1559. Lecendreux, M. (2003). L’hyperactivité. Paris : Solar. Molina, B.S., Pelham, W.E., Gnagy, E.M., Thompson, A.L., Marshal, M.P. (2007). Alcohol Clinical and Experimental Research, 31 (4), 643-654. Mannuzza, S. y Klein, R.G. (2002) Accuracy of adult recall of childhood attention deficit hyperactivity disorders. American Journal of Psychiatry, 159, 1882-1888. Ohlmeier, M.D., Peters, K., Kordon, A., Seifert, J., Wildt, B. T., Wiese, B..et al. (2007). Nicotine and alcohol dependence in patients with comormid attention-deficit/hyperactivity disorder (ADHD). Alcohol and Alcoholism, 42 (6), 539-543. Romo Jiménez, L., Dupont-Houdeyer, K., Aubry, C., Deblock, D., Gérard, C., Petot, D., Adès, J (2005, diciembre) Evolution d’un TDAH chez des patients présentant des addictions. Communicación oral. XXVII Congrès de l’Association Française de Thérapie Cognitivo-Comportementale. Paris : Francia. Szobot, CM., Rohde, L.A., Bukstein, O., Molina, B.S., Martins, C., Ruaro, P. et al. (2007). Is attention-deficit/hyperactivity disorder associated with illicit susbtance use disorders in male adolecetes? A community-based case-control study. Addiction, 102 (7), 1122-1130. Wender,P.H. (1995). Attention –Deficit Hyperactivity Disorder in Adults. NewYork : Oxford University Press. Wilson, J.J.y Levin, F.R. (2005). Attention-deficit/hyperactivity disorder and early-onset substance use disorders. Journal of Children and Adolescents Psychopharmacology, 15 (5) 751-763.

 

Norms of publication

Norms for the publication of papers in Annuary of Clinical and Health Psychology

General:

The Annuary of Clinical and Health Psychology is a journal published by the Department of Personality

and Psychological Assessment and Treatment of the University of Seville (Spain), that tries to compile all those scientific contributions of the area of Clinical and Health Psychology that may be of interest for professionals and scientists dedicated to the study of human behaviour. Therefore, the journal would like to accept and publish empirical papers on any relevant aspect related to the field of Personality and Psychological Assessment and Treatment, as well as theoretical contributions, clinical cases, comments on researches, books’ reviews or any other type of work that may be relevant and / or of great contribution and impact for our scientific field. Papers sent to the journal are to be original and unpublished. Therefore, all papers already published or submitted at the same time to another journal will not be admitted. Once papers are accepted, authors will transfer copyright to the Department of Personality and Psychological Assessment and Treatment of the University of Seville (Spain) which is the publisher and may print and reproduce in any manner and by any means all papers submitted and accepted.

Opinions and information contained in papers are exclusive responsibility of the authors. Likewise, all persons subscribing a paper are understood to have given their agreement for the evaluation and spreading of the same. All published papers will follow the accepted guidelines of ethics and professional deontology.

General Norms for submission, structure and presentation:

Original papers are to be sent to the Annuary of Clinical and Health Psychology per common post

(annexing original and three copies) as well as per email (including all the related files in a compatible word processor and specifying the title of the attached file(s) as well as the name of the word processor in the email). This last means is to be used with the purpose of shortening the procedure for publication in case the paper is finally admitted.

Papers are to be sent to the following address: Departamento de Personalidad, Evaluación y Tratamiento Psicológicos Facultad de Psicología de la Universidad de Sevilla C/ Camilo José Cela s/n 41018 – SEVILLA (SPAIN)

The journal’s email is :anuarioclin@us.es Once the original paper is received, a confirmation will be sent as soon as possible to the main author of such paper.

Papers shall have a maximum length of 25 – 35 pages (see exceptions in paragraphs corresponding to specific norms for theoretical papers and clinical cases) written in double space (size DIN A-4), without indentations or page breaks, pages printed only one face and consecutively numbered. Articles are to be written in English or Spanish. Spanish versions will be traduced into English if accepted for publication.

The first page of every submitted article is to contain the following: Title of the paper in English and Spanish. Name and Surname of authors and degree or professional or academic qualification. Full address, including phone and email, of the author with whom the journal is to be in contact.

The second page is to contain the abstract of the paper in English, which will have a maximum length of 175 words (each section – objectives, methods, results, etc. – is to be mentioned), together with the key words (maximum 5). The third page is to include a Spanish abstract and the corresponding key words.

The fourth page is to again contain the title of the article, without the names of the authors, and the text is to be developed. The structure or sections to be included in the papers are specified in the specific norms for each type of publication: empirical (see paragraph 14), theoretical (see paragraphs 15 to 17) or clinical cases (see paragraphs 18 to 21).

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Tables and illustrations (graphics, figures, etc.) contained in papers are to be submitted separately, each one in a different page, correlatively numbered and together with a header containing the number and title of the same allowing the clear identification of its content. The desired and approximate place for tables and / or illustrations is to be indicated in the text. Tables are to be simple and in accordance with the norms and styles of APA and are not to include vertical lines.

All quotations appearing in the paper are to be present in the list of references and all references are to be quoted in the text. Quotations are to be inserted in the text (never as footnote). Authors’ surnames are to be written in lower-case with the exception of the first letter. Initials of names are not to be specified unless necessary in order to distinguish two authors with the same surname (Example: J.M. Zarit y Zarit, 1982).

If the author’s surname is part of the narration, only the year of publication of the article is to be included between brackets (example: According to Olesen (1991) three different types of sensory afferents in migraines can be distinguished…). If the surname and publication date are not part of the narrative, both elements are to be included between brackets, separated by a comma. (Example: Three different sensory afferents in migraines can be distinguished (Olesen, 1991)…)

If a paper has two authors, both surnames are to be quoted every time the reference appears in the text (ex: Folkman and Moskowitz (2004) reviewed the situation of the investigation of the confrontation strategies…). If a paper has three, four or five authors, all of them are to be quoted the first time the reference appears in the text, and, in the following quotations of the same paper, only the surname of the first author followed by the phrase “et all” and the year of publication are to be written (for ex: Rodríguez, Terol, López and Pastor (1992) adapted the questionnaire…As mentioned before, Rodríguez et al. (1992) adapted the questionnaire…). If a paper has six or more authors, then only the surname of the first author is to be mentioned followed by the phrase “et all” together with the date of publication, as from the first quotation in the text.

If two or more works by different authors are quoted in a same reference, they will be written alphabetically, surnames and respective publication dates separated by a semicolon within the same brackets (for example:…it is absurd to dissociate the confronting strategies from the personality of the person using them ((Bouchard, 2003; Bouchard, Guillemette and Landry-Léger, 2004; David and Suls, 1999; Ferguson, 2001; Vollrath and Torgersen, 2000)…). If there are several quotations of the same author, the surname and publication dates of the different works are to be written separated by commas and followed by a letter if being from the same year (for example:…as stated by McAdams (1995, 1997a, 1997b, 1997c)…)

The list of bibliographic references is to appear in a new page, at the end of the paper, in alphabetical order by the authors’ surnames and initials. The second line of each entry of the list is to be indented in five spaces (one indentation). The titles of books or journals are to be written in italics and, in the case of journals, the italics are to cover not only the title but up to the number of the issue (including the commas before and after the issue number). Only one space is to be left after every punctuation mark. For example: Aspinwall, L. G., and Taylor, S. E. (1997). A stitch in time: self-regulation and proactive coping. Psychological

Bulletin, 121, 417-436. Lazarus, R. S. (2000). Estrés y emoción. Manejo e implicaciones en nuestra salud. Bilbao: Descleé de Brower.

(Orig., 1996).

The format of periodic publications is to be the following: Author, Y. Y. (year). Title of Article. Title of journal, issue, number, pages. For example: Amirkhan, J. H. (1990). A factor analytically derived measure of coping: the Coping Strategy Indicator. Journal of

Personality and Social Psychology, 59 (5), 1066-1074.

The format of non-periodical publications is to be: Author, Y. Y. (year). Title of the work. Place of Publication: Publisher. For example: Miró, J. (2003). Dolor crónico. Procedimientos de evaluación e intervención psicológica. Bilbao: Desclée de

Brouwer.

In the case of chapters of books, the format is to be: Author, Y. Y. (year). Title of the quoted work. Directors, Publishers, Compilers or Coordinators (Dir., Pub., Comp. or Coord.), Title of the Book (pages). Place of Publication: Publisher. Sánchez-Cánovas, J. (1991). Evaluación de las estrategias de afrontamiento. En G. Buela-Casal y V. E. Caballo

(Eds.), Manual de Psicología Clínica Aplicada (pp 247-270). Madrid: Siglo XXI.

References to lectures are to have the following format: Author(s) followed by the year and month between brackets, the title of the lecture in italics, name of the conference and city where celebrated. For example:

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Norms of publication

Beixo, A. (2003, mayo). Personalidad y afrontamiento de enfermedades crónicas. Comunicación presentada en el III Congreso Internacional de Psicología de la Salud, Sevilla, España.

References to electronic resources have to provide, at least, the title of the resource, date of publication or

date of access and the address (URL) of the Web resource. If possible, the author of the resource is to appear as well. The basic format is to be: Author of the webpage. (Publication date or date of review of the page, if available). Title of the webpage or place. Recovered on(Date of Access), from (URL-address). For example: Sanzol. J. (2001). Soledad en el anciano. Recovered on May 12 of 2004, from http://www.personal.uv.es/sanzol.

In case of doubt on any other rule for publication not contemplated above, the guidelines established in the fifth edition of the Publication Manual of the American Psychological Association (2001) are to be followed.

Specific Norms for empirical works:

Articles of this section are to be relevant contributions in the field of Clinical and Health Psychology. They

will follow the logical order and a clear and structured presentation according to the following order: Introduction and Justification of the work. Objectives and hypothesis Method: participants; design, variables and control conditions; materials and / or instruments and procedure. Results Discussion Conclusions References

Specific Norms for theoretical works:

The Annuary of Clinical and Health Psychology gathers theoretical articles from different points of view

(cognitive, dynamic, behavioural, systemic, etc.) that represent important contributions on the different contemplated contents.

Articles in this section are to contain, as well as the others, a logical order and a clear and structured presentation. They are to express a justification for the relevance of the subject dealt with (in the introduction) and an express practical contribution so that the professional may obtain a reference of the application nature (independently from the theoretical line) of the subject to be treated (in the discussion of the same).

The maximum length of the entire work is to be of 10 pages and the structure is to be the following: Introduction and thesis (aspect to be expound or defended) Discussion Conclusions (short and clearly delimited). References (maximum 20).

Specific norms for the exposition of clinical cases:

In this section, the description of one or more clinical cases is to be collected, which presume a contribution

and / or important repercussion to the knowledge of the analyzed process, due to their peculiarities.

Articles in this section, besides following a logical order and clear presentation, may follow these structures: Theoretical Background Or: a) Introduction Participants b) Description of the clinical case(s) Processes for Assessment c) Discussion Treatment d) References Results References

Maximum length of the work is to be 5–20 pages and bibliographic references are not to exceed 20.

In the description of cases, no real name or initials of the patients with whom the research for publication has been performed are to be mentioned.

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Review and Publication of Works:

Works meeting the requirements mentioned above will be anonymously reviewed by experts on the subject,

who will inform the direction of the journal of the valuation and possible modifications to be made to the same. Such valuation will be sent by the direction to the author within a maximum period of three months.

Once the article has been valuated, modified (if applicable), reviewed and definitely accepted, the publication of the article is to be determined by the direction and the main author is to be informed of the date and issue where the article is to be published. In any case, the final decision for publication of an article is responsibility of the direction of the journal.

Accepted articles not appearing in the last issue of the journal, are to be published in the next editions, and, in the meantime, they will be kept in the list of accepted articles pending publication.

Articles not meeting the established norms or not accepted for publication will neither be submitted to review nor given back to the authors, although the reasons for their exclusions are to be notified. In any case, the journal reserves the right to introduce modifications appropriate for the fulfilment of the established norms.

The delivery of an article to the Annuary of Clinical and Health Psychology assumes the acceptance of all the above mentioned norms by the authors of the submitted original work.