Autism: Late Discovery, Importance of Cognitive-Behavioral Therapy in Psychotherapeutic Intervention

REVIEW ARTICLE

LOBATO, Makatiney de Farias ^[1], MARTINS, Maria das Graças Teles ^[2]

LOBATO, Makatiney de Farias. MARTINS, Maria das Graças Teles. Autism: Late Discovery, Importance of Cognitive-Behavioral Therapy in Psychotherapeutic Intervention. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 05, Ed. 12, Vol. 02, pp. 88-105. December de 2020. ISSN: 2448-0959, Acess link: https://www.nucleodoconhecimento.com.br/psychology/late-discovery

ABSTRACT

Introduction: Autism Spectrum Disorder (ASD) has an early onset and a chronic course with a set of socialization disorders. It manifests before the age of three and is characterized by anomalies affecting the spheres of social interaction, communication, and restricted and repetitive behavior. Various sources emphasize that early diagnosis and the application of therapeutic interventions are essential for the overall rehabilitation and promotion of the quality of life of individuals with autism. Objective: To understand Autism Spectrum Disorder (ASD), its history, characteristics, impairments, late diagnosis, and to present the interventional contributions of Cognitive-Behavioral Therapy in psychotherapeutic treatment. Issue: How does Cognitive-Behavioral Therapy contribute to the psychotherapeutic intervention in the treatment of autistic patients with a late diagnosis? Methodology: The research is exploratory and bibliographic, based on literature reviews from websites and books addressing this topic. Results: Cognitive-Behavioral Therapy is one of the most well-developed, reliable, and effective therapies for individuals with autism. This is because it has a flexible approach adaptable to developmental changes, promoting a specific model of therapeutic treatment that includes acquisition, fluency, maintenance, generalization, and adaptation. Each aspect can be tailored to meet the learning needs of individuals with autism. It is noteworthy that this approach, when implemented responsibly and targeted, can bring about even minimal changes in the behavior of individuals diagnosed late with autism, representing a significant step toward improving their quality of life. This approach facilitates better adaptation to society and stimulates communication development, aiming for autonomy and independence in these individuals.

Keywords: Autism Spectrum Disorder, Cognitive-Behavioral Therapy, Late diagnosis.

1. INTRODUCTION

The objective of the present study is to understand Autism Spectrum Disorder (ASD), its history, characteristics, impairments, and late diagnosis in adults, and to present the interventional contributions of Cognitive-Behavioral Therapy in psychotherapeutic treatment.

Autism Spectrum Disorder (ASD) has an early onset and a chronic course with a set of socialization disorders. It manifests before the age of three and is characterized by anomalies affecting the spheres of social interaction, communication, and restricted and repetitive behavior. Various sources emphasize that early diagnosis and the application of therapeutic interventions are essential for the overall rehabilitation and promotion of the quality of life of individuals with autism.

The motivations that led to this topic originated from the principle of understanding how autism has affected the lives of adults who were not diagnosed early and how psychology has worked with these individuals to alleviate the impact on the main areas of human development.

This study is justified because it is a topic with relatively few productions, as a significant portion of the literature focuses on autism in childhood. Late-diagnosed autism has not been widely discussed, despite causing more pronounced impairment in the lives of individuals in adulthood. In this context, Cognitive-Behavioral Therapy is believed to bring benefits to the treatment of these individuals, as it is flexible and can be used for various treatments, including late-diagnosed autism.

In light of the above, the hypothesis was established that individuals with a late diagnosis would have more significant impairments, given that brain development mechanisms are already formed. Thus, it was assumed that long-term outcomes could be more complex. It was estimated that with the intervention of Cognitive Behavioral Therapy (CBT), significant results could be achieved through stimulation using techniques, aiming to enhance the development of socialization and communication skills, reducing symptoms, and mitigating the developmental impairments caused by the disorder. Additionally, the study aimed to present the historical context of autism, its concept and characteristics, identify the impairments caused by the late diagnosis of Autism Spectrum Disorder (ASD) in adults, and describe the interventional contributions of cognitive-behavioral therapy to the complex scenario of autism in adults. In the classification of mental and behavioral disorders proposed by the International Classification of Diseases – ICD-10, autism is categorized under pervasive developmental disorders (OMS, 1996).

In accordance with this institution, Autism Spectrum Disorder is characterized by qualitative abnormalities in three important areas: social interaction, communication, and restricted and repetitive behavior. Another important factor to note is that the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders – DSM-5 (APA, 2013) clarifies that the diagnosis of ASD should be based on the following criteria: a) persistent deficit in communication and interaction in various contexts, unrelated to developmental delay; b) absence or difficulty in emotional and social reciprocity; c) abnormal social approach, failure in conversation, and reduced sharing of interests; d) reproduction of failure to demonstrate emotions and affection; and e) difficulty initiating social interaction.

Thus, this study sought to answer the following research question: How does Cognitive-Behavioral Therapy contribute to the psychotherapeutic intervention in the treatment of autistic patients with a late diagnosis?

It is worth noting that Cognitive-Behavioral Therapy presents cognitive and behavioral interventional strategies and techniques that can be applied to individuals with autism. These include intensive intervention, where routine home activities such as bathing or eating can be included, as well as addressing complex behaviors such as the acquisition of communication and social interaction. It also involves self-monitoring, where individuals learn to define their own feelings and thoughts and communicate them to others. This approach can reduce frustration, anxiety, and aggression.

The hope with this study is to highlight knowledge about autism and its implications in cases diagnosed late, not only in the field of psychology but also as relevant to society in general, and especially for autistic adults who, for some reason, could not be diagnosed in childhood.

2. METHODOLOGY

This study was supported by the methodological approach of literature review with the bibliographic and exploratory research method. Gil (2017) demonstrates that bibliographic research is understood as the reading and comprehension of already published works to explain or seek answers to a problem or hypothesis. The materials used included books and scientific articles available on the platforms of the Scientific Electronic Library Online (Scielo), Biblioteca virtual em saúde (BV-Saúde), and Periódicos eletrônicos em Psicologia (Pepsic), published in the period from 2010 to 2019.

Cervo and Bervian (2013) state that exploratory research defines objectives and seeks more information on the studied subject, providing precise descriptions of the situation to discover the relationships between its component elements. The inclusion and exclusion criteria relate to content relevant to the proposed theme and containing the keywords: Autism Spectrum Disorder, Cognitive-Behavioral Therapy, Late Diagnosis. Materials that did not fit the theme were excluded. Regarding the critical analysis of risks and benefits, due to this work being bibliographic in nature, the Informed Consent Form (TCLE) was not used.

3. HISTORICAL CONTEXT OF AUTISM, CONCEPT, AND CHARACTERISTICS

The first diagnoses of autism were made over half a century ago, and even today, in 2020, it remains an enigma for professionals seeking answers and treatments for this disorder. The term “autism” was first used by the Austrian psychiatrist Eugen Bleuler in 1911 to refer to one of the criteria adopted at that time for diagnosing schizophrenia. Thus, it is evident that before studies on autism, individuals with this disorder were considered schizophrenic (LINHARES, 2012).

Despite the use of the term “autistic” by Eugen Bleuler, as explained in the above paragraphs, the diagnosis of a person considered autistic occurred for the first time in 1943, under the care of the physician Leo Kanner. On that occasion, he observed and evaluated 11 children (KANNER, 1966, p. 720, apud ANDRADE, 2018, p. 17).

In this context, Kanner found that autistic children exhibited characteristics outside the norms considered normal, as they lacked behavioral skills related to social relationships. Additionally, they demonstrated difficulties in communication and imagination, characteristics that were later used as the “triad” for autism diagnosis.

Another name that would gain great prominence decades later in studies with autistic children was Hans Asperger in 1944 when he presented cases similar to autism, cases that exhibited affective disturbances (GUPTA et al., 2006). Only in the 1980s was Asperger’s work translated into English, leading to new discoveries about the disorder. However, in Asperger’s studies, the children he examined did not present echolalia as a linguistic problem but preferred isolation to interaction (BAPTISTA and BOSA, 2002).

According to Baptista and Bosa (2002), it is evident that for a long time, autism was considered a psychosis, but this understanding changed as studies evolved, as can be observed:

As primeiras edições do CID não fazem qualquer menção ao autismo. A oitava edição o traz como uma forma de esquizofrenia, e a norma agrupa-o como psicose infantil. A partir da década de 80, assiste-se a uma verdadeira revolução paradigmática no conceito, sendo o autismo retirado da categoria de psicose no DSM-III e no DSM-III-R, bem como na CID-10, passando a fazer partes dos transtornos globais do desenvolvimento (BAPTISTA e BOSA, 2002, p. 28).

Based on the perception of the aforementioned authors, it is evident how complex the understanding of autism was so that individuals with this disorder could be fully assisted. The absence of more in-depth studies on autism for many years allowed autistic individuals to be considered schizophrenic, mentally ill, among other attributions and nomenclatures.

Autism was included in 1968 in the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) under the category of childhood-onset schizophrenia. However, starting in the 1980s, it was removed from the classification of psychoses and included in DSM-III as pervasive developmental disorder (DIAS, 2015). However, it was only in DSM-IV, in 1994, that autism became part of pervasive developmental disorders, alongside others such as Asperger’s Syndrome and Rett Syndrome (AMERICAN PSYCHIATRIC ASSOCIATION, 2013).

According to DSM-V (2014), autism is now classified as Autism Spectrum Disorder due to the immense variety of characteristics that individuals with autism present, being different from one another. As a general rule, it is understood that each person with autism is unique; therefore, it should not be said that a person with autism does this or that, in this or that way. Some people with autism do not speak, while others do not stop talking (LOVAAS, 2010). According to this researcher, some individuals may self-harm or harm others, while others do not harm anyone. Similarly, many individuals with autism are extremely attached to rigid routines, while others do not care about them.

In the ICD-10, autism is classified under Pervasive Developmental Disorders, while in ICD-11, which is not yet in force but has already been released for institutions to become familiar with, autism is classified as “Neurodevelopmental Disorder” according to the Pan American Health Organization’s website (ORGANIZAÇÃO PAN-AMERICANA DA SAÚDE, 2018).

6A02.0 – Autism Spectrum Disorder without Intellectual Disability (ID) and with mild or absent functional language impairment;

6A02.1 – Transtorno do Espectro do Autismo com Deficiência Intelectual (DI) e com comprometimento leve ou ausente da linguagem funcional;

6A02.2 – Autism Spectrum Disorder without Intellectual Disability (ID) and with impaired functional language;

6A02.3 – Autism Spectrum Disorder with Intellectual Disability (ID) and impaired functional language;

6A02.4 – Autism Spectrum Disorder without Intellectual Disability (ID) and with absence of functional language;

6A02.5 – Autism Spectrum Disorder with Intellectual Disability (ID) and with absence of functional language;

6A02.Y – Other Specified Autism Spectrum Disorder;

6A02.Z – Autism Spectrum Disorder, unspecified. (ICD-10, p. 246).

Therefore, the new ICD-11 unified all diagnoses of Autism Spectrum Disorders, classifying the different forms that autism presents in individuals but considering intellectual disability and functional language. The document was based on the change made in 2013 in the new version of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, which merged all disorders within the autism spectrum into one diagnosis: ASD.

Autism is characterized by slow or altered development in which individuals with this disorder exhibit behavioral disturbances of affective, emotional, and cognitive nature, with impairments in social interactions, communication, and repetitive focused behavior (BARON COHEN; LAI, 2015). Autism Spectrum Disorder (ASD), commonly known as autism, is characterized by a clinical picture; there are no specific tests such as blood tests, brain mapping, or MRI scans that will diagnose an individual with this type of disorder (BARON COHEN and LAI, 2015).

It should be noted that individuals with ASD can show differences among themselves. Autism is a very common disorder when considering the latest statistics from the CDC (Centers for Disease Control and Prevention of the U.S. government, 2014), which indicate a significant number of autism diagnoses today; according to this agency, for every 59 people, one is diagnosed with autism. According to Beck et al., (2014), for an individual to be considered autistic, they must show impairments in three essential areas of human development: communication, behavior, and social interaction.

From Fonseca’s perspective (2009), autistic individuals may exhibit echolalia, i.e., the repetition of something someone has just said, including words, expressions, or dialogues. According to the reviewed literature, despite consensus among experts regarding possible alterations in the central nervous system leading to a disorder in the developmental pattern of autistic individuals, as asserted by Mello (2007), it is not possible to determine any biological and/or environmental aspect that decisively contributes to the manifestations of this disorder.

Thus, it is emphasized that the specific and definitive causes capable of explaining autism have not yet been identified. Studies indicate that the disorder predominantly affects males, estimating about three to four boys affected for every girl. However, girls tend to be more severely affected when affected (SILVA; MULICK, 2009).

Literature also found some studies conducted by Baio et al., (2014) and Christensen, Baio, Braun, (2016) in which, through investigations, they estimated a drastic increase in cases, reaching an average of 40 to 60 cases per 10,000 births. Previous studies, conducted in 2012 with 8-year-old children in the United States, indicated a global prevalence of 14.6 per 1,000 or 1 in 68 children (BAIO et al., 2013).

As can be seen, studies with children prevail in the literature; however, in autistic individuals who could not be diagnosed in childhood and became young adults, adults in whom their families could not know the cause for isolation, lack of communication, and social interaction, the impairment of interactions tends to be greater.

3.1 THE IMPAIRMENTS REGARDING LATE-DIAGNOSED AUTISM

It is understood that autism is a disorder that has generated many speculations about the impairment and implications in the daily lives of individuals with Autism Spectrum Disorder (ASD). Thus, recommendations from specialists and professionals in the field about the importance of early diagnosis have become common so that treatment and interventions can have positive effects on the lives of autistic individuals.

However, considering that this is a relatively new disorder in which existing research tends to focus on childhood, little is known about the lives of young or adult individuals with a late diagnosis. “In adults, unlike what has been happening in the child population, they have not been extensively studied, which is reflected in difficulties in diagnosis and treatment in this age group” (RAMOS et al., 2014, p. 36).

In the understanding of this author, over the years, autistic individuals may show some progress in social interaction and communication if stimulated in childhood. Fecteau (2017) argues that most adults with ASD live a completely dependent life without any autonomy.

According to the studies conducted by the aforementioned researchers, less than a third have regular employment; most live with their parents or with support; and those who are employed usually have jobs that pay below a decent wage. In the same line of research, Seltzer (2017) draws attention to the fact that due to these high levels of dependence, most individuals with ASD will need some form of support or intervention, often at intense levels, during adolescence and adulthood.

The author Gádia (2014) clarifies that language deficits are common in adults, among which a significant number of autistics remain non-verbal. Thus, in terms of those who acquire verbal skills, they may consistently demonstrate deficits in conversation, such as a lack of reciprocity, difficulties in understanding language subtleties, jokes or sarcasm, as well as problems in interpreting body language and facial expressions.

Often in childhood, autism goes unnoticed, becoming more evident in late childhood. In adolescence and adulthood, peculiarities tend to have fluctuations, with a lack of empathy in relationships, an inability to grasp the emotions of their respective partners, causing discomfort in the environments they are part of, being considered antisocial, isolated in their “own world” (BRITES, 2019).

On the other hand, in autistic adults, there is an improvement in adaptation to changes, but “restricted interests persist, and those with adequate cognitive abilities tend to focus their interests on limited topics, such as train/plane schedules, maps, or historical facts, etc., which dominate their lives” (ROBERTSON, 2015, p.23).

In adults, one of the impairments that can be identified is antisocial behavior, difficulties in understanding speeches, and providing feedback in non-verbal languages. Adults with autism rarely hide what they think, have direct language, and do not worry about affecting someone with their words (GÁDIA, 2014).

4. RESULTS AND DISCUSSION

4.1 INTERVENTIONAL CONTRIBUTIONS OF COGNITIVE BEHAVIORAL THERAPY IN INDIVIDUALS WITH LATE DIAGNOSIS OF ASD

Considering all the specific needs of autism, psychology has presented various ways that can contribute to better performance in individuals with ASD even in adulthood. In this context, there is Cognitive Behavioral Therapy, developed by Aaron Beck in the early 1960s, a scientifically tested form of psychotherapy considered effective in over 300 clinical research studies for various types of disorders. ‘It is a therapy focused on solving the patient’s problems, usually brief, and has scientific and experimental efficacy’ (SANTOS, 2017, p. 30).

Moniz (2010) asserts that the major precursors of clinical and educational behavioral practice were Wolpe (1952), Eysenck (1959, 1960), and Skinner (1938). However, it is to Skinner and his disciples Lindsley, and Salamon (1953) that the term behavior modification is owed. White et al., (2013) investigated the effect of CBT on social skills in adults with ASD, and the results indicated success in improved communication performance.

Similarly, the study conducted by Hesselmark et al., (2013) pointed out that Cognitive Behavioral Therapy provides an important structure and predictability for people with ASD. Goal-setting techniques, homework assignments, and the practice of social skills, as well as other conventional CBT techniques, are considered appropriate for assisting in the treatment of these individuals. Lima and Dilascio (2016) explain how CBT provides adults with ASD with improvement in social awareness, social strategies, quality of life, and the reduction of psychiatric symptoms.

It is noteworthy that Cognitive Behavioral Therapy focuses on manipulating behaviors and variables in individuals, believing that all behaviors, both appropriate and inappropriate, are learned. The same author mentioned above states that behavioral therapy understands that the patient is unique, and their problems are the product of a particular history. ‘This humanizes the therapy process, as it seeks to understand each patient and each story before proposing any intervention’ (SILVEIRA, 2015, p. 19).

According to Bahls and Navolar (2010), the techniques and conceptual purposes of Cognitive Behavioral Therapy (CBT) come from two main approaches: cognitive and behavioral, which are analyzed in the context of the integrative movement in psychology that culminated in what is currently called cognitive-behavioral therapies. Behavioral Therapy is based on behaviorism and is effective in reducing symptoms and recurrence rates, with or without medication, in a wide range of psychiatric disorders (KNAPP; BECK, 2011).

In Borges’ understanding (2013), the most common techniques for intervention include:

• Psychoeducation provides a way to assist in the treatment of mental illnesses through behavioral, social, and emotional changes, thus enabling health prevention. In this way, psychotherapy involves an educational process applied to both patients and their respective caregivers, aiming to teach them about their psychotherapeutic treatment, raising awareness, and preparing them to deal with changes through coping strategies, communication strengthening, and adaptation (BHATTACHARJEE et al., 2016).
• Psychoeducation is one of the most relevant techniques used in cognitive-behavioral therapy, as its effectiveness can be enhanced. Through this intervention, the patient can be equipped in their process of change. In this regard, when this technique is employed, the chances for the patient to acquire autonomy are significant, given the therapeutic process that enables the patient to feel capable of identifying and changing thoughts, managing emotions, and breaking patterns of behavior that do not help (AGUIAR, 2018).
• ABA (Applied Behavior Analysis) is a therapy that focuses on improving specific behaviors, such as social skills, communication, reading, and academic skills, as well as adaptive learning skills, such as fine motor skills, hygiene, household chores, punctuality, and professional competence (REICHOW, 2012). One of the methods of ABA is the so-called ‘Discrete Trial Training,’ in which learning occurs in divisions, taught step by step, one at a time during a series of trials. ‘This procedure is repeated several times until the behavior is acquired and emitted independently of physical assistance’ (BORBA and BARROS 2018, p.13).
• PECS (Picture Exchange Communication System) is a communication system often used in individuals with autism and/or limited functional speech (MIZAEL, 2013);
• TEACCH (Treatment and Education of Autistic and Related) – is a program that involves both educational and clinical spheres, employing a psychoeducational approach in practice (KWEE, 2018);
• Miller Method – this method aims to develop functional behavior through playful systems while stimulating oral language accompanied by sign language (SERRA, 2014);
• Virtual Reality and Cognitive Stimulation – it is the interface between the user and computerized simulation in a specific environment, providing interactions through multiple sensory channels found in video games and computers in general, offering the individual the possibility to experience various emotions (CAIANA, 2016);

Due to the various techniques used by CBT for the better development of autistic adults, it is evident that this therapy is considered by many researchers as the most well-developed, reliable, and effective approach in treating individuals with autism, as it is a flexible approach that can adapt to changes that occur at the developmental level (GAUDERER, 2010).

Soares (2012) states that the applicability of CBT in patients with ASD promotes a specific model of therapeutic treatment that focuses on acquisition, fluency, maintenance, generalization, and adaptation, with each item being tailored to meet the learning needs of the autistic individual.

In addition to these techniques, Cognitive-Behavioral Therapy presents other strategies that can be applied to individuals with autism, among which stand out:

• Intensive intervention, where routine home activities such as bathing or eating and complex behaviors such as acquiring communication and social interaction skills can be included, has been gaining attention for its demonstrated effectiveness in promoting social engagement in individuals with severe communication impairments (ZEEDYK et al., 2010).
• Self-monitoring, in which the person learns to define their own feelings and thoughts and communicate them to others, enables a reduction in frustration, anxiety, and aggression behaviors. The self-instruction technique is employed so that the person can guide their own behavior. Sampaio (2005, p. 2) states, ‘The technique consists of teaching the child how to guide their own behavior, with the therapist serving as the model for the child to follow in their learning.’

In this model, the therapist performs a relatively simple activity, verbally guiding aloud every step of their action. Subsequently, the person is encouraged to perform the same activity guided by the therapist’s speech. Then, the autistic individual takes responsibility for directing their activity, verbally stating the steps they should follow (self-instruction). In this perspective, it is understood that when the approach is done responsibly and directed, it is possible for the behavior of individuals diagnosed late with autism to undergo even minimal changes, which constitute a significant step towards improving the quality of life for people with ASD, providing better adaptation to society and promoting communication development, aiming for autonomy and independence for these individuals.

It is worth noting that CBT works in the context of autism by addressing specific symptoms, such as anxiety, through gradual exposure to aversive stimuli, where patients are prevented from using tactics to reduce anxiety until it naturally decreases (UNG et al., 2015).

5. CONCLUSION

In this study, we sought to understand Autism Spectrum Disorder (ASD), its history, characteristics, impairments, and late diagnosis in adults, and to present the intervention contributions of Cognitive Behavioral Therapy in psychotherapeutic treatment.

It was observed that autism is a disorder that affects the main areas of human development. It was considered relevant to understand the main characteristics of this syndrome and how individuals with a late diagnosis could be affected, and how Cognitive Behavioral Therapy could assist them in this context.

Taking into account the analyses of the literature used in this work, it was found that the research question was answered. It was verified that Cognitive Behavioral Therapy can assist individuals with a late diagnosis in directing them towards self-care, providing social functionality, preparing individuals with autism for autonomy, and thus reducing their difficulties, aiming to reduce anxiety and dependence on family and caregivers. The set objectives were achieved through literature reviews, understanding what autism is, the implications in the lives of individuals with a late diagnosis, and the possibilities of intervention through Cognitive Behavioral Therapy.

In this perspective, the hypotheses were confirmed since Cognitive Behavioral Therapy can help these individuals to have more autonomy, control their anxieties, and live better in the society in which they are inserted. Throughout this study, it was observed that the characteristics of autistic individuals are often confused with other disorders, leading to delays in diagnosis. Therefore, it is important to have keen observations, considering that individuals with autism are born with this disorder and do not acquire it later in life. The characteristics are present from childhood and persist throughout life, with patterns that may change depending on social and behavioral stimuli received.

It is concluded that there is a wide variability of autism symptoms, and each individual with autism presents different behaviors depending on the stimuli they have received. An autistic individual who has been monitored by doctors and a multidisciplinary team from childhood, receiving all the stimuli, reaches adolescence and adulthood without significant impairment in social, communication, and cognitive aspects. Given the above, it is considered that when the diagnosis is made at the most appropriate time, the results of interventions tend to be more promising overall.

It is worth noting that the literature addressing the importance of CBT for assisting autistic patients with late diagnosis is still scarce. It is necessary for more studies to articulate the significance of CBT in this context. Thus, it is proposed that further research be conducted in this area, aiming for improved development across all aspects for individuals with late-diagnosed autism.

In conclusion, it is hoped that this study contributes to healthcare, education, and social professionals. When dealing with individuals with ASD, a multidisciplinary dialogue among all involved in the care of those with this disorder is considered important to provide a more positive adaptation process in society. It is important to emphasize that the relationship of professionals with the family is fundamental in the process of care, monitoring, and development of autistic individuals, as it can bring advances in the social, educational, and inclusive fields.

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^[1] Bachelor’s degree in Psychology.

^[2] Advisor. Bachelor’s degree in Psychology – Centro Universitário de João Pessoa UNIPÊ (2000), Specialization in Health Psychology Development and Hospitalization (UFRN-2003/2004), specialization in human sexuality (UFPB-2001/2002). Master’s degree in Education Sciences – Universidade Lusófona de Humanidades e Tecnologias – ULHT- Portugal (2005), recognized by UFBA (28.10.2009). Master’s degree in Collective Health – UNIFESP (2010).

Submitted: October 2020.

Approved: December 2020.