Attention Changes and Victimization in a Sample of Adolescents Victims of Domestic Violence

Objective: To report attention changes in a sample of adolescents victims of domestic violence and discuss how this change may be related to an addictive and complex cycle of victimization and abuse. Methods: 78 adolescents went through psychiatric and neuropsychological evaluation. The Kiddie-Sads-Present and Lifetime Version and the Brazilian version of the Childhood Trauma Questionaire (CTQ) were applied. The neuropsychological assessment was conducted by trained professionals using the Wechsler Children’s Global Assessment Scale, 3rd edition-WlSC III. The sample was divided into 3 groups according to the intensity of the reported maltreatment-obtained by the CTQ score (comparison group, moderate degree of abuse and severe maltreatment). Results: The group that showed moderate maltreatment showed better performance in an attention task compared to the comparison group. At the severe maltreatment group, this difference was not observed. Conclusions: Children and adolescents who are victims of maltreatment are more alert to environmental details that surround them as a form of adaptation to defend themselves against potential threats. However, they could react precipitously with inappropriate behavior in some contexts. This can lead to a favorable environment for new and repeated situations of violence, abuse and a perpetuation of this victimization.


Introduction
The deleterious consequences of domestic violence in children and adolescents have been studied with great in-terest in the recent years [1] [2].It is known that individuals exposed to adverse situations in early ages are at high risk of developing various physical and psychological disorders [3] [4].Despite the magnitude of the problem, few studies about neuropsychological functioning of these individuals have been carried out in Brazil, impairing our understanding of this phenomenon and preventing that targeted and effective interventions are carried out.It is essential that studies are carried out in different locations, since the cultural aspects are fundamental in neuropsychological development of these individuals and their presentations of psychological distress [5].The purpose of this brief communication is to report how maltreatment related to domestic violence impacts attention levels in a group of socially vulnerable adolescents and to discuss how this change may be related to an addictive and complex cycle of victimization and abuse.

Methods
A psychiatric and neuropsychological evaluation was conducted in 78 adolescents (range of age: 12 to 16 years) at Programa Equilíbrio (Department and Institute of Psychiatry-University of Sao Paulo, in partnership with the Sao Paulo city hall), which serves children and adolescents who were victims of domestic violence that are currently living in shelters or with their families.A psychiatric evaluation was performed through semi-structured interview (Kiddie-Sads-Present and Lifetime Version-K-SADS-PL) [6].The Brazilian version of the Childhood Trauma Questionaire [7] was applied and individuals underwent neuropsychological by trained professionals.For this evaluation the Wechsler Children's global assessment scale, 3rd.edition (WlSC III) was used [8].The C-GAS instrument (Children's global assessment scale) [9] was used to quantify the overall level of functioning at the time of evaluation.
The sample was divided into 3 groups according to the intensity of the reported maltreatment-obtained by the CTQ score 1) CG (comparison group)-no mistreatment or light mistreatment group (total score <36); 2) GMT1-moderate degree of abuse (total score between 37 -51); 3) GMT2-severe maltreatment (total score >52).Although the frequency of mental retardation is high in children victims of abuse it was decided, in this study, to exclude individuals with an IQ below or equal to 70 due to the difficulty in neuropsychological assessment.The research project was approved by the ethics committee from the University of Sao Paulo School of Medicine.All subjects and their legal guardians signed a consent form.
The Anderson-Darling test was performed on all continuous variables.Comparisons between groups in terms of socio-demographic variables and Childhood Trauma Questionnaire scores were evaluated by the Student's t-test or chi-square test, according to variable normality.Categorical data were compared using Fisher's exact test.All analyses were performed with the he Statistical Package for the Social Sciences, version 14.0.

Results
Regarding the socio-demographic profile of the groups, there were no significant differences in age, education, gender and laterality (Table 1).
Regarding the overall functioning of the participants, the group of severe maltreatment individuals presented lower overall functioning, according to the C-GAS assessment and lower measures of estimated intellectual functioning (Table 2).The rate of psychiatric disorders on the sample was: 34.7% of internalizing disorders and 22.7% of externalizing disorders-at this current episode.The frequency of current externalizing disorders was higher in the severe maltreatment group.Regarding the neuropsychological assessment, the subtest "Complete the figures" by WISC-III was applied.It consists of a task in which the individual must identify and isolate the essential features of non-essential ones in familiar objects.This subtest is used to assess attention because it evaluates the perceived ability of part-whole relationships.The group that showed moderate maltreatment showed better performance compared to the control group and at the severe maltreatment group this difference was not observed.These results point to the impact of hypervigilance performance in this test.

Discussion
In a preliminary study with 14 children performed by Frankel and collaborators [10], it was found that preschool children who have suffered abuse performed better on the "Complete the figures" subtest than those who did not suffer maltreatment and 30% still showed better results than the average population.It is postulated that children who were victims of abuse are more alert to environmental details that surround them as a form of adaptation to defend themselves against potential threats.Ogata and colleagues [11] found similar results in a study that evaluated adolescent victims of maltreatment and a control group.They found better results in the group with a history of sexual abuse in the "Complete the figures" subtest.
A previous study conducted at Programa Equilíbrio also found that children who were victims of abuse have greater difficulty in inhibitory control and thus greater symptoms of impulsivity (unpublished data. in preparation).
Thus these individuals would have a greater tendency to identify signals of possible threat to the environment and could react precipitously with inappropriate behavior in some contexts.It would be like a hypersensitivity to threats suggestions.Similarly to the picture observed in subjects with posttraumatic stress disorder [10].It is vital that mental health professionals take this factor into consideration in the treatment.Since these and other changes that may be observed in these individuals can substantially impair the ability of reflection, learning, academic performance and other important activities in their daily lives.In many cases, even the caregivers of these children are also victims of abuse and may show these changes [12]- [14].This can lead to a favorable environment for new and repeated situations of violence, abuse and a perpetuation of this victimization.Thus it is the duty of the professionals who serve this population to make rational use of this information and break this addictive circle.However, there are some limitations to consider at this study, such as the small sample size and absence of other quantitative measures of hyper vigilance.

Conclusion
In summary, data indicate the presence of significant attention changes in adolescents who are victims of abuse and offer a vision of how these changes may be related to a perpetuation of victimization in these individuals.

Table 2 .
Summary of neuropsychological and Children's global assessment scale (GCAS) measures.