Cases Of Child Physical Abuse Research Articles

Child physical abuse: changes over ten years in the perceptions of Finnish dental professionals.

This study aimed to assess perceptions and actions taken by Finnish dental professionals in suspected cases of child physical abuse (CPA) and to describe changes over 10 years. Data collected from two child abuse and neglect (CAN) surveys among Finnish dental professionals, working in public health care, covering suspicions of CPA and actions taken as well as training on CPA issues, were compared. The chi-squared (χ2) test was used to analyze associations. In total, 625 (2008) and 1,025 (2019) questionnaires were completed. Respondents reported that they suspected CPA more frequently in 2008 than in 2019 (21.0% vs. 8.7%, p<0.001). Out of all respondents, 1.1% had reported their concern to the police in 2019. Worries about the report's negative consequences to the child at home (44.5% vs. 56.4%, p<0.001) and to the informer (30.2% vs. 36.3%, p=0.016) increased between the surveys. The proportion of respondents with previous training on CPA issues increased between the surveys (5.9% vs. 36.4%, p<0.001). Recognition of CPA was low and decreased over the years. Furthermore, mandatory reporting to the police was low. Additional education on issues related to CPA is needed.

Association between missed appointments and hospitalization for child physical abuse

Missed cases of child physical abuse (CPA) persist despite known risk factors. Prior studies have not evaluated missed medical appointments as a risk factor for CPA. The objective of this study was to determine if an association exists between missed appointments and hospitalization for CPA.We conducted a 20-year, single health system, retrospective chart review of hospitalized patients ≤36 months of age meeting International Classification of Diseases (ICD) 9/10 criteria for CPA with ≥1 scheduled appointment in our system prior to their admission. Cases were categorized as definite CPA, high likelihood, or no concern for CPA/unable to be determined. Cases identified as definite or high likelihood of CPA were matched (5:1) with controls based on age, distance to primary care provider's (PCP's) office, sex, prior hospitalization, and race. Missed appointments were compared between cases (n = 146) and controls (n = 730).A significant difference was identified between cases and controls (26 % vs 9 %, p < 0.001) for the median proportion of missed appointments. After adjusting for matched and significant covariates, there was a 3 % increase in a patient's odds of admission for CPA for every 1 % increase in missed appointments.We found an association between missed appointments and future admission for CPA. This finding has potential to assist clinicians with CPA risk stratification and future child abuse research. Limitations include single healthcare system, ICD criteria determined by research team, and narrow definition of definite CPA.

Child traumatic physical abuse rates and comparisons during the COVID-19 pandemic: Retrospective paediatric single institution review in Texas.

The COVID-19 pandemic drastically altered human behaviour and socialisation and may have created an environment that could lead to increased incidence of domestic abuse and non-accidental trauma, or child physical abuse (CPA). Initial reports about the effect of the COVID-19 pandemic on the rates of CPA have been mixed. The purpose of this study is to describe the effects of COVID-19 on rates of CPA in a large metropolitan paediatric hospital and level I paediatric trauma centre. We identified and compared all CPA admissions under 18 years from May 2019 to February 2020 and considered that to be the pre-COVID time frame. The ensuing 12-month period of March 2020 to February 2021 was considered to be the intra-COVID time frame. There were 49 (0.32%) unique CPA patients pre-COVID and 83 (0.85%) unique CPA patients intra-COVID (P < 0.001) with lower total admissions for any reason during the intra-COVID time frame. Monthly CPA cases were increased (P < 0.03) during the intra-COVID time period (mean 6.9, 95% confidence interval: 5.8-12.7) compared to the pre-COVID time period (mean 4.9, 95% confidence interval: 3.3-8.2). During the COVID-19 pandemic, there were decreased overall hospital admissions in the period of mandated shutdowns and isolation. However, we saw an increased rate of CPA admissions compared to the time period prior to the pandemic. Knowledge of such data, trends and circumstances will help keep health-care providers alert and vigilant in identifying children at risk for maltreatment, and may impact child abuse protocols and guidelines.

Suboptimal care was frequent in severe child physical abuse cases and was mainly related to delayed diagnoses and ineffective secondary prevention.

Our aim was to assess suboptimal care before a diagnosis of severe child physical abuse in western France. A confidential inquiry was carried out, based on children under 6 years of age who were hospitalised in the Nantes regional university hospital from 2016 to 2018.Tworesearchers retrospectively reviewed the medical records of all the children who were reported to the authorities for suspected severe child physical abuse. Twoexperts determined the optimality of care and identified the main categories of suboptimal care. The median age of the 94 children included in the study was 8 months. A fifth of them had intra-cranial injuries and a quarter had fractures. One child died and a third had severe sequelae at hospital discharge. Included children frequently (37%)received suboptimal care before the diagnosis of severe CPA and this fell into two categories: delayed diagnosis was experienced by 17% and ineffective secondary prevention by 22%. Suboptimal care for severe child physical abuse was frequent and fell into two categories: delayed diagnosis and ineffective secondary prevention. These results can help us to design corrective actions.

Ghanaian radiographers experience and commitment to the mandatory reporting law regarding suspected child physical abuse

IntroductionThe best interests of the child shall be paramount in any matter concerning a child and it should be the primary consideration by any court, person, institution, or other body in any matter concerned with a child. This study sought to explore the influence of legislation on and professional commitment of radiographers towards suspected child physical abuse. MethodA semi-structured interview was conducted with 20 radiographers selected across all the regions in Ghana. The interviews were conducted exclusively by the first author with radiographers who reporting having experience of handling suspected child physical abuse cases. There were 14 male respondents with an age range of 30–54 years and six females aged from 25 to 57 years. Upon attaining data saturation, the thematically analysed data was managed using NVivo10 software. ResultsFindings from the study showed that the legal framework for mandatory reporting of suspected child physical abuse was not known by radiographers. A lack of professional commitment to report cases of suspected child physical abuse was also identified. Themes that emerged from the study formed the basis of the discussion. ConclusionThis study revealed that radiographers interviewed were not well acquainted with national legislation requiring mandatory reporting. There is the urgent need to train radiographers on the laws protecting children to enhance their commitment to the reporting of suspected child physical abuse. Implication for practiceThe understanding of the legal framework under which radiographers operate is imperative when considering obligations to report suspicious injuries among children.

Child physical abuse and COVID-19: Trends from nine pediatric trauma centers

BackgroundEconomic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with “shelter-in-place orders”, may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period. MethodsWe conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data. ResultsThere were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality. ConclusionsApparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.

Prevalence of recognition and reporting of child physical abuse by dental surgeons and associated factors.

Studies evaluating the factors associated with under reporting and with the recognition and reporting of child physical abuse are scarce and highly necessary. This study aimed to assess the prevalence of recognition and reporting of child physical abuse (CPA) by Brazilian dentistsin primary care and associated factors. A cross-sectional study was carried out with a representative sample of dentistsfrom the Family Health Strategy in Belo Horizonte. A self-administered questionnaire validated to Brazilian Portuguesewas used for data collection. Statistical analysis included univariate and multiple analyses through Poisson regression. A total of 181dentists participated in the study. Among them, 73 (40.3%) had already recognized some cases of CPA, but only 11 (6.1%) ended up reporting. Dentists with six to 19 years of experience as a municipal worker presented 2.38 times [PR = 2.38 (95%CI: 1.29-4.41)] more probability to recognize cases of CPA than the ones with less than six years. Having a graduate degree with a major in childcare [PR = 4.50 (95%CI: 1.08-18.68)] was associated with a larger number of reports. The employment duration as municipal worker was positively associated with the recognition of CPA cases and the prevalence of reporting was low.

Child physical abuse: awareness and practices of medical and dental doctors in Pakistan.

To determine the awareness and practices of doctors and dentists in detecting and reporting suspected cases of child physical abuse. The cross-sectional study was conducted from November 2017 to June 2018 at the Hamdard College of Medicine and Dentistry, Karachi, and comprised doctors and dentists practising in public and private hospitals across Pakistan. Data was collected using a predesigned questionnaire to assess knowledge of the social indicators of child physical abuse, response to child physical abuse, and actions taken by the professionals when they believed a child abuse case had been detected. Data was analysed using SPSS 22. Of the 575 healthcare professionals, 371(64.5%) were doctors and 204(35.5%) were dentists; 347(60.3%) were males; 446(77.6%) were working in private hospitals; 384(66.8%) had <10 years of experience; and 99(17.2%) had received formal training of child abuse. While 450(78.3%) subjects strongly agreed on the value of identifying and documenting child physical abuse, 336(58%) did not take any action in suspected cases. Although doctors and dentists had a positive attitude regarding child physical abuse, the majority preferred to remain silent in suspected cases.

Reporting of child physical abuse by a group of Brazilian primary care health professionals and associated factors

BackgroundEvidences points to the importance of health professionals to recognize child abuse, but also to a high frequency of underreporting, even in countries where reporting is mandatory, like Brazil. ObjectiveTo evaluate the frequency of non-reporting behavior of child physical abuse (CPA) among Brazilian primary care health professionals who recognized some cases in their careers and associated factors with reporting. MethodsCross-sectional study conducted with a representative sample of dentists, nurses, family physicians, and pediatricians from the Family Health Strategy network in the city of Belo Horizonte, Brazil. A validated self-administered questionnaire for use in Brazil was applied in-person to professionals in 2014 and 2015. Pearson’s chi-squared test (p < 0.05) and a binary logistic regression model was used. ResultsA total of 715 professionals participated (response rate: 98.89%), 414 (57.3%) recognized cases, of which 171 (41.3%) reported. Reporting was associated with the type of profession, as pediatricians reported cases more than dentists [OR = 6.05 (95% CI: 1.24-29.50)], with the willingness to become involved [OR = 2.01 (95% CI: 1.02-3.97)] and knowledge regarding where to report cases [OR = 2.68 (95% CI: 1.25-5.74)]. Confidentiality was the barrier associated with a lower probability of reporting CPA cases [OR = 0.22 (95% CI: 0.08-0.66)]. ConclusionsThere is a high frequency of non-reporting behavior. Pediatricians reported more CPA cases, followed by family doctors and nurses. Dentists were those who reported fewer cases. Reporting was also associated with a willingness to be involved in detecting/reporting abuse and knowing where to report CPA.

Turkish paediatric dentists’ knowledge, experiences and attitudes regarding child physical abuse

Numerous studies have shown that the education of health professionals is essential to effectively respond to child abuse. The present study aimed to evaluate Turkish paediatric dentists' knowledge, experiences and attitudes regarding child physical abuse. An electronic questionnaire was e-mailed to 518 paediatric dentists. Participants' knowledge of diagnostic indicators of child physical abuse, and their past experiences, attitudes and self-assessment of educational needs were evaluated. The response rate was 40.9% (n=212). Participants who completed their undergraduate education before 1997 received significantly less education on child physical abuse than participants who completed their education more recently (P<0.001). Although statistically insignificant, participants who completed their doctorate/specialty training after 2012 received increased education on child physical abuse (P=0.06). Of the participants, 43.9% suspected physical abuse; however, only 12.7% reported it. 'I did not know where and how to report' was the most common reason for not reporting physical abuse. The rate of suspicion was higher among dentists from state hospitals or oral health centres (P<0.05). Of the participants, 70.3% did not know about the legal sanctions for delay in or not reporting suspected cases. Only 15.6% assessed themselves as competent to diagnose and report physical abuse. Almost all of them acknowledged their need for more education on this topic. Turkish paediatric dentists' educational needs for diagnosing and reporting of child physical abuse cases should be met.

A retrospective approach to examining child abuse disclosure

BackgroundOften times, a child’s disclosure is the only forensic evidence available in child abuse cases. Therefore, understanding disclosure patterns of suspected child abuse victims plays a critical role in the forensic investigations of both child physical abuse (CPA) and child sexual abuse (CSA) cases. ObjectiveTo explore adults’ retrospective reports about childhood disclosure of CPA and CSA. Participants and settingCollege students (N = 907) were screened for reported histories of CSA (n = 94) or CPA (n = 109). MethodsThrough an online survey, participants provided anonymous information regarding CSA and CPA experiences along with information about any disclosure events or opportunities that they have encountered since the abuse. ResultsAmong the adults reporting CSA histories, 50 % indicated disclosing the abuse during childhood; 80 % indicated any lifetime disclosure. Among the adults indicating CPA histories, 32 % reportedly disclosed the abuse to someone during childhood with 52 % reporting any lifetime disclosure. For both groups, length of delay until disclosure was bimodal with many individuals reporting immediately and many waiting considerable time. Among adults reporting CSA, a minority (16 %) indicated the abuse came to the attention of authorities, with even fewer CPA cases (8%) reporting authorities were aware of their abuse. Denial and recantation in a formal setting was infrequent regardless of abuse type reported. ConclusionsGiven that participants experiencing CSA and CPA both reported low levels of denial and recantation, forensic investigators and practitioners may benefit from considering consistent interviewing approaches and protocols, regardless of the type of abuse suspected.

Recognition of child physical abuse by a group of Brazilian primary care health professionals.

Child maltreatment is a complex social and public health problem. To evaluate the frequency of the recognition by Brazilian health professionals in primary care of child physical abuse (CPA) and associated factors. A representative cross-sectional study was conducted with dentists, nurses, family physicians, and pediatricians who participated in the network of the Family Health Strategy in the city of Belo Horizonte, Brazil. Data collection involved in the administration of a questionnaire validated for use in Brazil. Data were collected from 181 dentists, 235 nurses, 203 family physicians, and 96 pediatricians. Among the 715 health professionals, 499 (69.8%) had some type of postgraduate degree and 414 (57.9%) recognized suspected or proved cases of CPA. The recognition was associated with occupation, as pediatricians recognized 14.11-fold [OR=14.11 (95% CI: 3.73 to 53.43)] more cases of CPA compared with dentists. The recognition was also associated with a longer period of time working in the city [OR=2.79 (95% CI: 1.24 to 6.29)]. The recognition of cases was positively associated with the longer working time in the municipal network and with pediatricians. The dentist was the category that was least associated with the recognition of CPA.

The Knowledge Level and Opinions of Physicians about the Medical and Legal Procedures Related to Physical Child Abuse.

Background:In order to diagnose child abuse, physicians need to consider the possibility of abuse in every child they encounter, have sufficient information about the topic and manage the cases according to current law.Aims:To determine the knowledge level of physicians on child abuse and to learn their opinions about the procedures when they suspect child abuse.Study Design:A questionnaire (cross-sectional) study.Methods:A detailed questionnaire was applied to 390 physicians of whom 233 were general practitioners. The first part of the questionnaire included demographic variables (age, gender, occupational experience) and the frequency of child physical abuse cases encountered, since that is the most easily diagnosed and proven form of abuse. The second part consisted of 32 questions about diagnosis of physical child abuse and procedures during the follow-up of the cases. Statistical analyses were performed using SPSS version 18.0.Results:Of the participating physicians, 47.4% (n=185) were female and only 13.1% of the physicians had some kind of postgraduate training on child abuse. The correct response rate of specialists compared to general practitioners was significantly higher. A total of 263 (72.3%) physicians thought that there was a specific law on physical child abuse in the Turkish Republic. More than two-thirds of physicians thought that reporting should only be addressed to Social Services and physicians should not be obliged to report to law enforcement.Conclusion:The results of the present study adds to the already known necessity for better training of physicians about physical child abuse and the need to refresh their knowledge through postgraduate courses. According to current regulations, it is obligatory to report abuse cases to the public prosecutor and/or police, therefore physicians also need training in respect of the legal status and medico-legal approach to these cases.

Knowledge, attitudes, and professional responsibilities among southern indian dental residents regarding child abuse: A cross-sectional survey

Aim: This study aims to assess the knowledge and attitudes about indicators, legal issues, professional responsibilities, and reporting mechanisms toward child abuse among South Indian dental residents. Methods: A self-administered structured questionnaire comprising of 15 questions, was distributed to 170 dental residents belonging to three private dental teaching institutions in South India. The data collected was descriptively analyzed using Pearson Chi-square test. Results: A total of 158 dental residents responded to the distributed questionnaires, with a response rate of 93%. Among them, 55% were females (n = 87) and the males were 45% (n = 71), with majority of the participants (n = 82) above 23 years of age (52%). Greater part of respondents (95%) in this study has the knowledge about the indicators of child abuse; 13% suspected a case of child abuse although only 62% of them had reported the incident. Most of the dental residents (85%) knew about legal issues and professional responsibilities but knowledge related to the reporting mechanisms was lacking. Almost 85% desired further training on the identification and reporting mechanisms for suspicious cases of child physical abuse. Conclusion: Knowledge on the indicators of child abuse is inadequate among the dental residents, and most of them did not recognize or report a case. The reasons might be due to limitations in lecture-based learning which was not practiced in clinical settings. Therefore, more comprehensive education on the topic of child abuse including recognizing and reporting procedures should be reinforced in clinical settings.

Child Abuse and Neglect: Do We know enough? A Cross-sectional Study of Knowledge, Attitude, and Behavior of Dentists regarding Child Abuse and Neglect in Pune, India.

Child abuse and neglect (CAN) is a significant global problem with a serious impact on the victims throughout their lives. Dentists have the unique opportunity to address this problem. However, reporting such cases has become a sensitive issue due to the uncertainty of the diagnosis. The authors are testing the knowledge of the dentists toward CAN and also trying to question the efforts of the educational institutions to improve this knowledge for the better future of the younger generation. Questionnaire data were distributed to 1,106 members regarding their knowledge, professional responsibilities, and behavior concerning child abuse. There were 762 responses to the questionnaire, yielding a response rate of 68.9%. Although dentists consider themselves able to identify suspicious cases, only a small percentage of the participants correctly identified all signs of abuse and 76.8% knew the indicators of child abuse. Most of them were willing to get involved in detecting a case and about 90% believed that it is their ethical duty to report child abuse. Only 7.2% suspected an abuse case in the past. The numbers indicate a lack of awareness about CAN in these participants. No differences were observed between sexes, year of graduation, types of license, frequency at which children were treated, and formal training already received. A large proportion of child physical abuse cases go undocumented and unreported. The data showed that not all dental care providers and students were prepared to fulfill their legal and professional responsibilities in these situations. There should be modifications in the dental school curriculum focusing on educational experiences regarding child abuse to strengthen their capability to care and protect children.

Primed neutrophil infiltrations into multiple organs in child physical abuse cases: A preliminary study

Physical abuse of the elderly induces a massive primed neutrophil infiltration into the lung and liver through chemotaxis by interleukin (IL)-8, similar to cases of traumatic or hemorrhagic shock. Here, we used immunohistochemical analyses to investigate this infiltration in cases of physically abused children. In addition, we examined the expression of neutrophil elastase (NE) as the inflammatory mediator and α1-antitrypsin (AAT) as the elastase inhibitor. The number of neutrophils in the abuse cases was increased significantly in the heart, lung, liver, and kidney, compared with that of control cases. IL-8-positive cells and NE-positive cells in all organs of abuse cases were significantly greater than those in control cases. Large quantities of oxidized AAT, which fails to inactivate NE and results in tissue damage, was detected in the liver of abuse cases. Neutrophil infiltration showed positive correlation with the degree of systemic accumulation of non-fatal injuries caused by repetitive abusive behavior. Although further investigation using more autopsy samples is necessary, results of our preliminary study indicate that massive neutrophil infiltration induced by IL-8 in multiple organs is a new complementary diagnostic indicator of physical abuse in children. Moreover, the demonstration of NE-positive cells and oxidized AAT provides firm evidence of tissue damage.

Knowledge, attitudes, and behaviors of dentists regarding child physical abuse in Jeddah, Saudi Arabia

A large proportion of child physical abuse cases go undocumented and unreported. Dentists can play an important role in identifying and reporting these cases, but little has been reported about this issue in Saudi Arabia. The aims of the study were to (1) assess dentists’ knowledge of child physical abuse, (2) assess dentists’ attitudes towards child physical abuse, and (3) assess the behaviors of dentists in identifying and reporting child physical abuse. A cross-sectional survey of pediatric dentists, pediatric dentistry residents, and dental interns practicing at all of the dental schools in Jeddah, Saudi Arabia was conducted using an anonymous, self-administered questionnaire. The participants in current study demonstrated insufficient knowledge of the signs and symptoms of child physical abuse, actions that should be taken in suspected cases, circumstances in which to report such cases, and the legal authorities to which they should be reported. The attitudes of participants towards detecting and reporting cases were generally positive. Only 11% of the participants had suspected a case of child abuse, and only 3% of them reported it. Lack of knowledge about referral procedures and fear of anger from family members were the main causes of underreporting. In conclusion, this study showed that dentists have insufficient knowledge about child physical abuse but positive attitudes towards their role in detecting and reporting it. This topic should be covered and emphasized in dental schools’ curricula, and healthcare and academic institutes must have a clear protocol to be followed if a case of abuse is suspected.

The Accuracy of ICD Codes: Identifying Physical Abuse in 4 Children's Hospitals

ObjectiveTo assess the accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), codes in identifying cases of child physical abuse in 4 children's hospitals. MethodsWe included all children evaluated by a child abuse pediatrician (CAP) for suspicion of abuse at 4 children's hospitals from January 1, 2007, to December 31, 2010. Subjects included both patients judged to have injuries from abuse and those judged to have injuries from accidents or to have medical problems. The ICD-9-CM codes entered in the hospital discharge database for each child were compared to the decisions made by the CAPs on the likelihood of abuse. Sensitivity and specificity were calculated. Medical records for discordant cases were abstracted and reviewed to assess factors contributing to coding discrepancies. ResultsOf 936 cases of suspected physical abuse, 65.8% occurred in children <1 year of age. CAPs rated 32.7% as abuse, 18.2% as unknown cause, and 49.1% as accident/medical cause. Sensitivity and specificity of ICD-9-CM codes for abuse were 73.5% (95% confidence interval 68.2, 78.4), and 92.4% (95% confidence interval 90.0, 94.0), respectively. Among hospitals, sensitivity ranged from 53.8% to 83.8% and specificity from 85.4% to 100%. Analysis of discordant cases revealed variations in coding practices and physicians' notations among hospitals that contributed to differences in sensitivity and specificity of ICD-9-CM codes in child physical abuse. ConclusionsOverall, the sensitivity and specificity of ICD-9-CM codes in identifying cases of child physical abuse were relatively low, suggesting both an under- and overcounting of abuse cases.

Public perceptions of child physical abuse in Beijing

AbstractThe present study focuses on public perceptions of parental child beating and child physical abuse (CPA) in mainland China. In‐depth interviews were conducted with 20 parents and a quantitative survey was administered to a sample of 1033 adults in urban districts of Beijing. The quantitative and qualitative results are consistent: both parents and the general public were hesitant to consider the beating of one's own child (by biological parents) as a case of CPA. Respondents indicated that only when parents beat their children malevolently and frequently, so as to cause serious physical injuries, could it be considered CPA. The majority of respondents supported governmental interventions in severe cases of CPA. However, respondents' perceptions of CPA in mainland China are different from those that are prevalent in the West. Therefore, it is essential to develop programmes that educate the public in order to improve their awareness and knowledge of CPA in mainland China.

Adaptação transcultural e reprodutibilidade de questionário para avaliação de conhecimento e atitude de profissionais de saúde frente a casos de abuso físico infantil

The scope of this study was to conduct cross-cultural adaptation and evaluate the reproducibility of a questionnaire designed by a team from the University of London to assess knowledge and attitudes of health professionals during primary care when faced with cases of child physical abuse. The translation rigorously followed the criteria described by Herdman (1998), to maintain maximum functional equivalence. The adapted questionnaire was tested on 107 health care professionals from Belo Horizonte. Standard and Weighted Kappa tests were used to evaluate the reproducibility of the instrument. Most of the questions achieved Kappa test values above 80% (excellent). The Brazilian version of the questionnaire was, therefore, adapted and had proven reproducibility.