Family perception of the symptoms of Obsessive-Compulsive Disorder patient and the family accommodation

Abstract

Background:

Family members tend to modify their routine by assisting or participating in the patient’s rituals. These behaviors have been identified as family accommodation (FA).

Aims:

The aim of this study was to describe the relationship between family accommodation of relatives of Obsessive-Compulsive Disorder (OCD) patients and their perceptions about the obsessions and compulsions of the patient.

Method:

This was a cross-sectional study with family members of Obsessive-Compulsive Disorder in a Southern Brazilian city. The family perception of the OCD symptoms and their accommodation were assessed through the Family Accommodation Scale for Obsessive-Compulsive Disorder – Interviewer-Rated (FAS-IR).

Results:

The level of family accommodation was higher in those family members who lived with the patient when compared to those who did not live with them (p = .011). The obsessions associated with higher levels of family accommodation were: contamination (p < .001), hoarding/saving (p = .001), symmetry/exactness (p = .001), religious (p = .019), and diverse (p = .003). Regarding compulsions, the perception of all symptoms was associated with higher levels of family accommodation (p < .05).

Conclusion:

The family accommodation is present in family members of Obsessive-Compulsive Disorder patients, regardless of the type of obsessive/compulsive symptom perceived.

Keywords

Obsessive-Compulsive Disorder patients family relatives accommodation

Introduction

Obsessive-Compulsive Disorder (OCD) is defined as a clinically heterogeneous condition characterized by uncontrollable, intrusive, and repetitive thoughts and ritualized behaviors (American Psychiatric Association, 2014). A dimensional approach proposes that obsessive-compulsive symptoms tend to cluster in dimensions. Several authors have already proven that OCD is a multidimensional disorder and they identified types of symptoms that tend to cluster together (Bloch et al., 2008; Cullen et al., 2007; Mataix-Cols et al., 2005; Pinto et al., 2008; Rosario-Campos et al., 2006). However, the literature shows that there are disagreements about the definition of the clustering of OCD symptoms. Some authors state that symptoms are divided into four dimensions (Bloch et al., 2008; Cullen et al., 2007; Schulze et al., 2018), while others report five to six dimensions (Pinto et al., 2008; Rosario-Campos et al., 2006).

OCD symptoms cause a significant impact in family dynamics. The family members tend to modify their routine by assisting or participating in the patient’s rituals. These behaviors have been identified as family accommodation (FA) (Albert et al., 2017; Calvocoressi et al., 1995). In each family group, there may be different patterns of behavior regarding the family reactions to the patient symptoms. It is possible to observe that there are three types of family responses to OCD symptoms: families that support the rituals and directly participate and/or assist in the rituals, families that completely oppose OCD behaviors, and families with a divided position of two or more family members that give opposite responses (Maina et al., 2006). The family involvement may contribute to maintain or to ease the OCD symptoms (Gomes et al., 2014).

The behaviors of FA may be present in spouses, parents, friends, neighbors or relatives of OCD patients, being more frequent in spouses and/or partners (Gomes et al., 2014). FA may also be related to the severity of the patients OCD symptoms (Strauss et al., 2015; Wu, McGuire, Martino, et al., 2016), higher functional impairment and family dysfunction (Albert et al., 2010; Cherian et al., 2014; Lee et al., 2015; Ramos-Cerqueira et al., 2008; Torres et al., 2012; Vikas et al., 2011).

A study reported that over 95.0% of the relatives reported FA, while 59.1% had daily accommodating behaviors (S. Evelyn Stewart et al., 2008). The literature showed that 7.0% to 47.5% of the family members reassured the patients symptoms every day, 2.4% to 35.5% participate in the patient compulsive behavior, and 7.3% to 42.6% assisted the patient in avoidance (Albert et al., 2010; Gomes et al., 2014; Pinto et al., 2013; S. Evelyn Stewart et al., 2008; Wu, McGuire, & Storch, 2016). Furthermore, studies have shown that relatives of OCD patients reduce their social activities to dedicate more time to the patient care, and consequently, present higher levels of stress (Albert et al., 2010; Vorstenbosch et al., 2015). Up to 20.0% of them modify their personal routine (S. Evelyn Stewart et al., 2008), and up to 34.1% modify their family routine for the patient symptoms (Pinto et al., 2013).

Few authors state that even refusal to participate or involve in obsessive and compulsive behaviors of the patient leads to stress (Albert et al., 2017; Cherian et al., 2014; Guedes, 2001; Renshaw et al., 2005). The opposition to the OCD behaviors by the family member and their refusal to participate in rituals contribute to the development of conflict and tension. Thus, it is noticeable the negative effect that the symptoms of OCD patients have on the environment and the people they live with. According to some studies that often investigate relatives of OCD patients, these family members play an important role in improving or worsening the patient condition (Albert et al., 2010; Calvocoressi et al., 1999; Gomes et al., 2014; Vorstenbosch et al., 2015).

The relationship between FA and the severity of obsessive-compulsive symptoms has been extensively studied, but its relationship with symptom dimensions is still poorly understood. Few studies investigating the relationship between FA and symptom dimensions showed that family members present higher FA scores on cleaning/contamination symptoms (Albert et al., 2010; S. Evelyn Stewart et al., 2008; Verma et al., 2019). One study found no association between FA and OCD symptom dimensions (Gomes et al., 2014). Another study also did not find significant differences of FA between the symptom dimensions; however, there was a statistical tendency for patients with the cleaning/contamination dimension to have higher FA when compared to those who did not score for that dimension (Ferrão & Florão, 2010).

We should note that these studies mentioned above assessed symptom dimension by the clinician, showing a gap in knowledge about the family perception of the patient obsessive-compulsive symptoms and the way they settle. Thus, the main objective of this study was to evaluate the relationship between FA and the different patient obsessions, compulsions and other problems related to OCD observed by the family member.

Methods

Design

This is a cross-sectional study part of an intervention study that evaluated the dimensions of the Obsessive-Compulsive Disorder symptoms and the results obtained in an individual cognitive-behavioral therapy by patients between the ages of 18 and 60 years.

Participants

The study participants were 138 family members of 84 patients with OCD who attended to our research outpatient clinic for OCD treatment in Pelotas, a Southern Brazilian city. All patients were asked to indicate at least two family members to participate in the study. We considered family members those who spent more time with the patient (partner, parents, friends, neighbors or close relatives) and had to be at least 18 years old. Those who were unable to respond and/or understand the research instruments were excluded.

Data collection

Data collection was performed as follows: the patients were interviewed at the Research and Extension Outpatient Clinic of the Catholic University of Pelotas. After evaluation, they indicated at least two relatives with whom they spent more time. Subsequently, a contact with the family was made to schedule an interview at their residence.

Variables

Socio-demographic variables included age, marital status, people living with the patient, and socio-economic status using the classification proposed by the Associação Brasileira de Empresas de Pesquisa (2012). This classification is based on the accumulation of material goods and the educational level of the household head. It divides classes into five levels (A, B, C, D, or E), which “A” refers to the highest level and “E” to the lowest. For analysis, the levels were grouped into A + B, C, and D + E. A history of psychological or psychiatric treatment was investigated by asking the following questions: “Have you ever undergone any psychological or psychiatric treatment?” and “Have you ever been hospitalized because of psychological or psychiatric problems?”.

To confirm the patients’ OCD diagnosis we used the Mini International Neuropsychiatric Interview (MINI PLUS). This is a diagnostic interview (consisting of independent diagnostic modules) based on DSM-IV and ICD-10 criteria (Sheehan et al., 1998). The Brazilian version of MINI PLUS was developed to evaluate psychiatric disorders in primary care and in clinical trials. We also used MINI PLUS to investigate the current psychiatric disorders in family members: Major Depressive Episode, Suicide Risk, Panic Disorder, Social Phobia, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder and OCD (yes/no). In this study, this instrument was applied to patients by psychologists and to their relatives by trained Psychology students (Amorim, 2000).

The Family Accommodation Scale for Obsessive-Compulsive Disorder – Interviewer-Rated (FAS-IR) was developed by Calvocoressi et al. (1995) and translated and adapted to Brazilian Portuguese by Gomes et al. (2010). This is a semi-structured interview that can be answered by spouses, parents, siblings, and others. It has good reliability (Gomes et al., 2015) and is divided into two parts: an assessment of the interviewee’s (in this case, the family member) perception of the types of symptoms that the patient has and the level of FA. In the first part, the family members answered if the patient presented any OCD symptoms in the last week from a list. This list divides OCD symptoms into obsessions (harming, sexual, contamination, hoarding/saving, religious, symmetry/exactness, somatic, and diverse), compulsions (cleaning/washing, checking, repeating rituals, counting, ordering/arranging, hoarding/saving/collecting, and diverse), and other problems related to OCD (avoidance, indecision, overvalued sense of responsibility, slowness/inertia, and pathologic doubt). The variable concerning obsessions of sexual content was not included in the analysis because it was not perceived by any family member. The second part is evaluated through 12 questions with categorical responses. Among them are the reassurance provided by the relatives, the patient participation in rituals, and the changes in the family members daily routine. Items are anchored with respect to either frequency or magnitude utilizing a 5-point Likert scale ranging from 0 (Never) to 4 (Daily). The final score range from 0 to 48, with higher scores indicating greater parental accommodation (Calvocoressi et al., 1995; Gomes et al., 2010). A score of 1 point is already considered FA (Gomes et al., 2014), but this cut-off point was not used in this study, and we used the final variable as continuous. The logarithm of the FA variable was calculated as it did not show normal distribution.

In order to verify if the number of perceived symptoms influences the level of FA, we constructed three other variables: “number of obsessions,” “number of compulsions,” and “number of other problems related to OCD,” by adding up the symptoms presented in each one of these factors. These variables range from 0 to 4 or more symptoms.

Ethical aspects

This project was approved by the Ethics Committee of the University, protocol number 249.564. All participants signed an informed consent. Individuals with any indication of psychological or psychiatric disorder were referred to a psychological/psychiatric health care unit.

Statistical analysis

The data were entered directly into EpiInfo 6.0 program and they were later converted to the Statistical Package for the Social Sciences (SPSS). We tested the distribution of the sample and found that it did not show normality, so we choose to log the FA means and use parametric tests.

For the bivariate analysis, the Student’s t-test and ANOVA were used to compare the means of each group. The Bonferroni test for equal variances assumed (post-hoc) was used to determine the significant differences between categories of the number of symptoms associated with FA. We considered as a significance level a p-value ⩽ .05.

Results

Of 84 patients, 54 indicated two family members, and 30 indicated one, totaling 138 family members. Among the 13 refusals, six were related to the patient indication and seven were refusals of family members.

Table 1 shows the prevalence of sociodemographic and mental health characteristics and their association with the degree of accommodation of relatives of OCD patients. According to the sociodemographic characteristics, 35.0% (N = 48) aged between 18 to 31 years, 47.8% (N = 66) were middle socioeconomic status, 48.6% were married or lived with a partner (N = 67), 58.8% (N = 80) were working and 50.0% (N = 69) were living with the patient at the time of the interview. Regarding psychological or psychiatric treatment, 10.1% (N = 14) were undergoing some treatment and 2.9% (N = 04) were already hospitalized due to psychological or psychiatric problems. For mental disorders, the prevalence rates were as follows: 29.9% for major depressive episode (N = 41); 7.3% for suicide risk (N = 10); 4.4% for panic disorder (N = 06); 7.3% for social phobia (N = 10); 7.3% for OCD (N = 10); 4.4% for PTSD (N = 06); and 10.2% for GAD (N = 14). FA was associated with only those who lived with the patient (p = .011).

Table 1.

Mental health and sociodemographic characteristics of OCD patients’ family relatives and their association with family accommodation.

Variables	N (%)	Family accommodation (FAS-IR)	p-value
Variables	N (%)	Log mean (SD)	p-value
Age (N = 137)*			.104
18–31	48 (35.0)	0.74 (0.57)
32–52	45 (32.8)	0.54 (0.55)
53–80	44 (31.9)	0.54 (0.58)
Socioeconomic status			.243
A + B	64 (46.4)	0.62 (0.59)
C	66 (47.8)	0.64 (0.55)
D+E	08 (5.8)	0.28 (0.53)
Marital status			.346
Single	40 (29.0)	0.60 (0.56)
Married/living with partner	67 (48.6)	0.67 (0.59)
Separated or divorced	18 (13.0)	0.57 (0.57)
Widowed	13 (9.4)	0.36 (0.46)
Works (N = 136)*			.956
No	56 (41.2)	0.60 (0.56)
Yes	80 (58.8)	0.60 (0.58)
Lives with the patient			.011
No	69 (50.0)	0.49 (0.50)
Yes	69 (50.0)	0.73 (0.61)
Psychological or psychiatric treatment			.285
Never did	90 (65.2)	0.66 (0.60)
Already did, but not currently	34 (24.6)	0.51 (0.55)
Does currently	14 (10.1)	0.48 (0.60)
Hospitalized because of psychological orpsychiatric problems (N = 137)*			.436
No	133 (97.1)	0.62 (0.57)
Yes	04 (2.9)	0.39 (0.60)
Major Depressive Episode (N = 137)*			.447
No	96 (70.1)	0.58 (0.57)
Yes	41 (29.9)	0.66 (0.56)
Suicide Risk (N = 137)*			.204
No	127 (92.7)	0.59 (0.56)
Yes	10 (7.3)	0.82 (0.61)
Panic Disorder (N = 137)*			.996
No	131 (95.6)	0.60 (0.56)
Yes	06 (4.4)	0.60 (0.72)
Social Phobia (N = 137)*			.865
No	127 (92.7)	0.60 (0.56)
Yes	10 (7.3)	0.63 (0.67)
OCD (N = 137)*			.976
No	127 (92.7)	0.60 (0.56)
Yes	10 (7.3)	0.61 (0.66)
PTSD (N = 137)*			.107
No	131 (95.6)	0.59 (0.57)
Yes	06 (4.4)	0.99 (0.50)
GAD (N = 137)*			.217
No	123 (89.8)	0.58 (0.56)
Yes	14 (10.2)	0.78 (0.61)
Total	138 (100)	0.62 (0.57)	–

Variable with missing data. FAS-IR = Family Accommodation Scale for Obsessive-Compulsive Disorder – Interviewer-Rated; OCD = Obsessive compulsive disorder; PTSD = Post-Traumatic Stress Disorder; GAD = Generalized Anxiety Disorder.

Table 2 shows that higher levels of FA were observed with the presence of the following perceived obsessions: contamination (p < .001), hoarding/saving (p = .001), symmetry/exactness (p = .001), religious (p = .019), and diverse (p = .003). The presence of the following perceived obsessions was not associated with FA: harming (p = .123) and somatic content (p = .211). Concerning compulsions, the perception of all symptoms was associated with higher levels of FA: cleaning/washing, checking, repeating rituals, counting, ordering/arranging, diverse (p < .001), and hoarding/saving/collecting (p = .017). Also, the perception of other problems related to OCD was associated with higher levels of FA: avoidance, indecision, overvalued sense of responsibility, slowness/inertia, and pathologic doubt (p ⩽ .001).

Table 2.

Association between obsessions, compulsions and other problems perceived by the family and the level of family accommodation.

Variables	N (%)	Family accommodation (FAS-IR)	p-value	Effect Size Cohen’s d
Variables	N (%)	Log mean (SD)	p-value	Effect Size Cohen’s d
Perceived obsessions
Harming			.123	0.48
No	125 (90.6)	0.58 (0.57)
Yes	13 (9.4)	0.84 (0.52)
Contamination (N = 135)*			<.001	0.92
No	98 (72.6)	0.48 (0.54)
Yes	37 (27.4)	0.96 (0.50)
Hoarding/saving			.001	0.75
No	111 (80.4)	0.53 (0.56)
Yes	27 (19.6)	0.93 (0.51)
Religious (N = 137)*			.019	1.00
No	130 (94.4)	0.58 (0.56)
Yes	07 (5.1)	1.09 (0.45)
Symmetry/exactness (N = 137)*			<.001	1.08
No	86 (62.8)	0.41 (0.52)
Yes	51 (37.2)	0.95 (0.48)
Somatic			.211	0.29
No	115 (83.3)	0.58 (0.57)
Yes	23 (16.7)	0.74 (0.54)
Miscellaneous			.003	0.55
No	108 (78.3)	0.54 (0.70)
Yes	30 (21.7)	0.87 (0.49)
Perceived compulsions
Cleaning/washing			<.001	0.97
No	81 (58.7)	0.40 (0.50)
Yes	57 (41.3)	0.90 (0.53)
Checking (N = 137)*			<.001	0.72
No	87 (63.5)	0.46 (0.55)
Yes	50 (36.5)	0.85 (0.53)
Repeating rituals (N = 136)*			<.001	1.23
No	114 (83.8)	0.51 (0.54)
Yes	22 (16.2)	1.11 (0.43)
Counting			<.001	1.23
No	127 (92.0)	0.56 (0.56)
Yes	11 (8.0)	1.15 (0.38)
Ordering/arranging			<.001	1.19
No	99 (71.7)	0.44 (0.52)
Yes	39 (28.3)	1.03 (0.47)
Hoarding/saving/collecting			.017	0.55
No	115 (83.3)	0.56 (0.55)
Yes	23 (16.7)	0.87 (0.58)
Miscellaneous (N = 135)*			<.001	1.02
No	120 (88.9)	0.56 (0.57)
Yes	15 (11.1)	1.06 (0.40)
Perceived other problems related to OCD
Avoidance			<.001	1.24
No	117 (84.8)	0.52 (0.56)
Yes	21 (15.2)	1.10 (0.35)
Indecision (N = 137)*			<.001	1.14
No	97 (70.8)	0.44 (0.53)
Yes	40 (29.2)	1.00 (0.45)
Overvalued sense of responsibility			.001	0.73
No	114 (82.6)	0.54 (0.57)
Yes	24 (17.4)	0.92 (0.46)
Slowness/inertia			<.001	1.22
No	92 (66.7)	0.41 (0.51)
Yes	46 (33.3)	1.01 (0.47)
Pathologic doubt (N = 137)*			<.001	1.22
No	108 (78.8)	0.49 (0.55)
Yes	29 (21.2)	1.07 (0.39)

Variable with missing data. FAS-IR = Family Accommodation Scale for Obsessive-Compulsive Disorder - Interviewer-Rated; OCD = Obsessive compulsive disorder.

Table 3 shows significant differences between the levels of FA for all obsessions, compulsions and other problems related to OCD (p < .001). According to the Bonferroni test for obsessions, there were significant differences between categories 0 and 1 perceived obsession (p = .001). Similarly, significant differences were observed between 0 and 1 perceived other problems related to OCD (p < .001). About compulsions, we observed significant differences between 0 and 1 compulsion (p = .001), and between 3 and 4 or more compulsions (p = .011).

Table 3.

Differences between the means of family accommodation in relation of number of perceived obsessions, compulsions and other problems related to OCD.

Variables	N (%)	Family accommodation (FAS-IR)	p-value
Variables	N (%)	Log mean (SD)	p-value
Perceived obsessions
Obsessions*			<.001
0	47 (35.1)	0.18 (0.40)
1	36 (26.9)	0.72 (0.50)
2	19 (14.2)	0.87 (0.50)
3	18 (13.4)	1.06 (0.43)
4 or more	14 (10.4)	0.87 (0.54)
Compulsions*			<.001
0	40 (30.1)	0.14 (0.31)
1	36 (27.1)	0.57 (0.49)
2	22 (16.5)	0.95 (0.52)
3	19 (14.3)	0.80 (0.49)
4 or more	16 (12.0)	1.31 (0.20)
Other problems*			<.001
0	58 (42.6)	0.17 (0.37)
1	32 (23.5)	0.76 (0.51)
2	24 (17.6)	0.89 (0.48)
3	13 (9.6)	1.14 (0.30)
4 or more	09 (6.6)	1.26 (0.21)

Bonferroni test.

Discussion

This study aimed to investigate the levels of FA and obsessions and compulsions observed by the relative itself. Perceived obsessions such as contamination, hoarding/saving, religious, symmetry/exactness, and diverse were associated with higher levels of FA. We observed no association between harming and somatic obsessions and FA. Cordioli (2008) states that in most cases, the aggressive content of obsessions is not reproduced as behaviors because they are considered improper, and therefore their perception are less frequent in the family core. The disturbing thoughts make the family member notice the presence of an obsession, but if a behavior is absent it does not allow him/her to accommodate in some way. However, it is possible that the family members might feel ashamed of their accommodation behaviors on the patient’s unacceptable intrusive thoughts and they hid it from our interviewers. Offering reassurance, facilitating avoidance, and taking over responsibilities from the patient are examples of accommodating behaviors. Somatic obsessions (unrealistic worries about catching a particular illness), in most cases, can be identified by relatives as a clinical symptom of another disease, and not related to OCD, making it difficult to assess FA.

Our findings also showed that all perceived compulsions and other OCD related problems were associated with higher FA. Compulsions can be considered as stereotyped and repetitive due to their effectiveness in providing relief to the obsessions (Cordioli, 2008), thus becoming more apparent in everyday life and more susceptible to FA as a method of the patient’s support.

No studies were found on the use of the FA scale referring to the family’s perception of the patient’s symptoms. The existing studies on FA and OCD symptoms only assess symptoms by the clinician, not considering whether these symptoms are perceptible for the family member. Therefore, this is the first study that considers the importance of enhancing the perception of the family member which is more directly and frequently affected by OCD symptoms.

Regarding the characteristics of the family, a higher level of FA was only associated with those family members who lived with the patient when compared to those who did not. This association is in accordance with the literature and with OCD characteristics (Black et al., 1998; Calvocoressi et al., 1995, 1999; Gomes et al., 2014). This suggests that living with the patient provides a more regular contact with the OCD symptoms, which are more noticeable in the familiar environment.

Calvocoressi et al. (1995) conducted a study with relatives of OCD patients and found that 40% of them have changed their routine – especially the wives. According to Black et al. (1998) and Calvocoressi et al. (1999) over 80% of the spouses participated and/or assisted in the rituals. Gomes et al. (2014) also found higher rates of FA in spouses compared to other family members. Other two studies have showed a decrease in leisure activities, feelings of frustration, anger and guilt as characteristics of the relatives of OCD patients (Cooper, 1993, 1996).

Regarding the number of obsessions, compulsions and other perceived problems, we observed a higher FA in relatives who perceived one obsession when compared to those who did not perceived any obsessions. The same was true for other aspects related to OCD and compulsions. Besides, for compulsions, there were also significant differences of FA between perceiving three and four or more compulsions, showing that the more compulsions the greater the FA. It is known that the level of FA is related to the severity of the symptoms and certain symptoms, in particular, deeply interfering with the functioning of the family (Gomes et al., 2014; Steketee & Van Noppen, 2003; S. E. Stewart et al., 2008). However, it is possible that this relationship is bidirectional – family members who engage in more accommodating behaviors may be in a position to notice more compulsions.

Some limitations in this study should be considered. We should emphasize that the aspects related to the scale referred only to the previous week, which indicates that if the relative has not been in touch with the patient in the last 7 days it was considered “no” to accommodation issues. Also, since the inclusion criteria was the patient reporting that he had direct contact with the family member, not having information about the exact amount of time/hours the family member spent with the patient is a limitation. Another point to be considered is the lack of perception regarding sexual obsessions, as patients may have difficulty expressing thoughts considered inappropriate. Similarly, the lack of association between FA and somatic obsessions may result from the difficulty of the relative in understanding these obsessions as a symptom linked to OCD.

Finally, we can observe that the accommodation is common when relatives perceive the OCD symptoms in patients. Having in mind that the interference of the family member acts like a reinforcement for the obsessive-compulsive symptoms – helping the patient to avoid exposure to the feared stimuli and perform rituals to neutralize obsessions – it seems that the family is confirming that these behaviors are really necessary.

We can conclude that the FA is present in relatives of OCD patients, regardless of the type of the obsessive/compulsive symptom perceived. Further investigations are necessary to help both patients suffering from this disorder and the family members cohabiting with them.

Footnotes

Acknowledgements

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Authors contributions

Mariana Bonati de Matos: Conceptualization, Methodology, Formal analysis, Investigation, Data Curation, Writing – Original Draft; Andressa Jacondino Pires: Conceptualization, Methodology, Investigation, Writing – Review & Editing; Jéssica Puchalski Trettim: Investigation, Data Curation, Writing – Review & Editing; Carolina Coelho Scholl: Formal analysis, Investigation, Data Curation, Writing – Review & Editing; Viviane Porto Tabeleão: Investigation, Writing – Review & Editing; Rafaelle Stark Stigger: Investigation, Writing – Review & Editing; Bárbara Borges Rubin: Investigation, Writing – Review & Editing; Mariane Lopez Molina: Conceptualization, Methodology; Ricardo Tavares Pinheiro: Conceptualization, Methodology; Luciana de Avila Quevedo: Conceptualization, Methodology, Formal analysis, Writing – Original Draft, Project administration.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Carolina Coelho Scholl

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