Psychiatry Research ()

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Factors related to the cortisol awakening response of children working

on the streets and siblings, before and after 2 years of a
psychosocial intervention
Andrea Feijo Mello a,n, Mario Francisco Juruena b,d, Mariana Rangel Maciel a,
Luciana Porto Cavalcante-Nobrega a, Giuliana Claudia Cividanes a, Victor Fossaluza c,
Vinicius Calsavara c, Marcelo Feijo Mello a, Anthony James Cleare d, Jair de Jesus Mari a
a

Department of Psychiatry, Paulista Medical School, Federal University of Sao Paulo, Sao Paulo, Brazil
Department of Neurosciences and Behaviour, Faculty of Medicine Ribeirao Preto, University of Sao Paulo, Sao Paulo, Brazil
Mathematics and Statistics Institute, University of Sao Paulo, Sao Paulo, Brazil
d
King's College London, Institute of Psychiatry, Department of Psychological Medicine, London, UK
b
c

art ic l e i nf o

a b s t r a c t

Article history:
Received 23 February 2014
Received in revised form
27 October 2014
Accepted 8 November 2014

The study objective was to observe the cortisol awakening response (CAR) pattern before and after a
psychosocial intervention with children from dysfunctional families who had at least one child working
on the streets, and to verify factors related to it. Two hundred and eleven children between 7 and 14
years old were selected and 191 were included, 178 were re-evaluated 2 years after, of whom 113 had
cortisol measures completed. Besides cortisol, they were evaluated at baseline and at end point
regarding: abuse/neglect, mental health symptoms, exposure to urban violence and family environment.
There was no signicant difference between the CAR area under the curve (AUC) before and after the
intervention. Two regression analysis models were built to evaluate factors related to the CAR before and
after intervention. Before the intervention, working on the streets (vs. not) was related to a greater
cortisol increase after awakening, at follow-up, having suffered physical punishment (vs. not) was
related to a attened cortisol response. The intervention was not associated with changes in the
magnitude of the CAR AUC, though the CAR was associated with psychosocial stressors pre- and postintervention. Effective interventions for children at risk that might shape a physiological cortisol
response are still needed.
& 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Hypothalamicpituitaryadrenal axis
Child work
Child maltreatment
Street children

1. Introduction
Numerous studies have linked stressful experiences during childhood to increased risk of mental disorders in adults. Situations such as
extreme poverty, family disruption, abuse and neglect, parental loss
and parental violence are all related to an increased risk of alcohol and
drug abuse, anxiety, depression and post-traumatic stress disorder
across the lifespan (Evans and Charney, 2003; Juster et al., 2010;
Dozier et al., 2012; Lokhmatkina et al., 2013).
According to Lupien and Schramek (2006) living with these types
of situations during development will shape a child's ability to
discriminate between threatening and non-threatening situations
and enhance sensitivity to stressors. Thus, exposure to childhood

Corresponding author. Tel.: 55 11 995971566; fax: 55 11 55764991  1064.

E-mail address: amfeijo@uol.com.br (A.F. Mello).

stress has health consequences and makes adolescents and young

adults view the world as more threatening and challenging (McEwen,
2003).
The physiological response of an organism to a threatening situation is mainly mediated by the locus coeruleus-norepinephrine
(LC-NE) system in conjunction with the hypothalamicpituitaryadrenal (HPA) axis. Cortisol is the nal product of the HPA axis and it is
responsible for a large variety of basic vegetative functions and behavioral, cognitive and emotional reactions. The response to threat can
be either ght or ight, and it is mediated by norepinephrine and
cortisol. This stress response system has a homeostatic balance and
regulates itself (Mello et al., 2003; Juruena et al., 2004).
However when the threat persists or, when it is too intense, the
system can fail to self-regulate and cortisol persists at elevated levels,
potentially causing damage within the system as well as in many
organs related to it. The system can therefore become permanently
hyper- or hyporesponsive to stimuli (Juruena and Cleare, 2007).

http://dx.doi.org/10.1016/j.psychres.2014.11.034
0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Mello, A.F., et al., Factors related to the cortisol awakening response of children working on the streets and
siblings, before and after 2 years of a psychosocial.... Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.11.034i

A.F. Mello et al. / Psychiatry Research ()

The relationship between cortisol response and early life stress is

complex: cerebrospinal uid corticotropin-releasing hormone (CSF
CRH) concentrations were negatively correlated (i.e., lower) with
adversity in the perinatal and pre-teen years (ages 613 years), but
positively correlated (i.e., higher) with stress in the pre-school years
(ages 05 years). These ndings were interpreted in light of considerable preclinical research in laboratory animals, demonstrating that
timing of exposure to stressors in early life is critically important in
determining their long-term effects on neurobiology and behavior
(Carpenter et al., 2004).
Studies in both animals and humans suggest that stress in the
early stages of development can induce persistent changes in the
response of the HPA axis to stress in adulthood (Shea et al., 2005;
Mello et al., 2007b). However, there remains controversy about
whether early life stress leads to hyper- or hypoactivity of the HPA
axis, or both. Although study results are not conclusive, there
seems to be a consensus that early life stress is associated with
modication of the HPA axis in the early stages of life, which leads
to a biological vulnerability to psychopathology (Newport et al.,
2004; Heim et al., 2008; Tyrka et al., 2008).
Post-traumatic stress disorder and melancholic depression are
frequently associated with history of maltreatment during childhood, while adults reporting childhood abuse/neglect have a
worse prognosis and usually need psychotherapy in addition to
medication to achieve better treatment results (Heim et al., 2008).
Unfortunately, the majority of studies are in adults who already
have psychiatric disorders, which makes it difcult to conclude if
alterations in the HPA axis response are cause or effect of the
illnesses. Cortisol is already high at awakening time and the
response to the challenges of the upcoming day produce a sharp
increase in cortisol production about 30 min post-awakening
called the cortisol awakening response (CAR) (Chida and Steptoe,
2009), which is a positive response to environmental stimulus. The
CAR is a reliable measure of the functioning of the HPA axis
(Pruessner et al., 1997).
Signicant differences in the cortisol awakening response
(CAR) can be seen in some psychiatric disorders or stressful
conditions, e.g. atypically large CARs were associated with high
current anticipatory stress, while atypically low CARs were seen in
chronic stress, post-traumatic stress disorder, burnout, fatigue and
childhood trauma (Quevedo et al., 2012).
Hypocortisolism has been found in samples of high-risk children and is believed to be a product of down-regulation of the HPA
axis following chronic elevations (Heim et al., 2000), Fernald et al.
reported hypocortisolism in children whose mothers were
severely depressed in communities in extreme poverty in Mexico
(Fernald et al., 2008). Bevans et al. (2008) also reported hypocortisolism in children who had experienced repeated and recent
traumatic events (Cutuli et al., 2010).
With regard specically to homelessness, one study of children
living in shelters published in the USA examined cortisol function
among early school-aged children, levels of socioeconomic resourcerelated risk and negative lifetime events related to morning cortisol
levels. The results showed that family level negative lifetime events
predicted higher morning cortisol levels, although a socioeconomic
cumulative risk was not associated with morning cortisol levels
(Cutuli et al., 2010); the authors concluded that family environment
is an important factor which needs to be better considered when
evaluating HPA axis functioning.
Regarding studies that have investigated the effects of therapeutic interventions, Fisher et al. (2007) tested the plasticity of
the HPA axis in response to a supportive caregiving environment
in foster care children. They observed blunted cortisol responses in
foster children before the intervention compared to community
children. The group that then received the family intervention had
cortisol levels comparable with children from the community at

end point, while children that received regular foster care maintained a blunted cortisol response. The conclusion was that early
intervention in caregiving could reverse HPA axis deregulation.
Graham et al. (2012) compared three groups of children and
their diurnal cortisol slope measured across the school day. The
rst group of children was from regular foster care, the second
from foster care combined with a multidimensional treatment
program for preschoolers and the third group from the community
with the same socioeconomic conditions. They found that the
foster children group with no intervention had higher cortisol
response to expected stress events compared to both other groups.
The researchers concluded that the multidimensional treatment
that supports foster parents in reinforcing positive attitudes of
preschoolers leads to changes in diurnal cortisol rhythm, normalizing the response of the children that received the treatment.
Cicchetti et al. (2011) showed that it is possible to decrease the
stress response of subjects who suffer from abuse/neglect by
improving their environment with protective measures. They
studied cortisol levels of 91 infants aged 13 years from maltreating families divided into three different intervention groups:
childparent psychotherapy, psychoeducational parenting intervention and a control group involving standard community
services, and compared them to a group of 52 infants from nonmaltreating families. Saliva was collected at 10:00 a.m. at 13, 19, 26
and 36 months after intervention. They found that the group that
received only the standard community intervention developed a
blunted cortisol response compared to the other groups after 19
months of intervention. The two maltreated groups that received
either psychotherapy or psychoeducation developed a cortisol
response comparable to the non-maltreated children. The authors
concluded that early interventions could normalize the cortisol
response in at risk infants.
There are a considerable number of studies available in the
literature about the consequences of maltreatment during childhood and their relationship to HPA axis deregulation, mainly in
adults; but there are few data regarding the effects of early
interventions during childhood with at risk groups and the stress
system response to those interventions. Furthermore, it is still not
clear if it is possible to change some response patterns by acting in
a preventive way.
Bearing this in mind, the present study was designed to
examine if factors previously reported in the literature to be
related to stress response alterations such as maltreatment, the
presence of mental symptoms, family functioning and exposure to
violent events could be related to the CAR in these groups of
children at risk, and if there was an impact of a 2-year intervention
program on their cortisol awakening response.
As the literature is inconclusive about hyper or hypocortisolism
as a response to environmental stressors during development, the
study design aimed to compare the same group before and after an
intervention of environmental enrichment, without any assumption for the type of cortisol response at the beginning of the study.
The intervention was expected to have an impact on decreasing
maltreatment, improving mental health of the children, reducing
domestic violence, and improving family functioning. It was
hypothesized that a more benecial environment might also have
an impact on the pattern of cortisol response.

2. Methods
The psychosocial intervention was developed and executed by the NGO with no
interference or participation of the University researchers.
The non-governmental organization (NGO)-RUKHA developed an intervention
to take children out of street work with a family focused intervention that included
8 steps:

Please cite this article as: Mello, A.F., et al., Factors related to the cortisol awakening response of children working on the streets and
siblings, before and after 2 years of a psychosocial.... Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.11.034i

A.F. Mello et al. / Psychiatry Research ()

A. Contact children working on the streets.
B. Contact the children's caregiver and other family members.
C. Recognize the neighborhood where the children live and nd resources in the
community.
D. Invite the whole family (parents and all children, including those who were
found working on the streets and their siblings who were either working or not
working on the streets) to participate in the project; receiving a monthly
amount of money to make sure that the family is not dependent on the
children's earnings.
E. Make sure that the children go to school regularly and also that they participate
in another educational activity provided by other NGOs in the neighborhood to
prevent them having free time to work on the streets.
F. Make sure that parents participate in educational activities to develop skills for
them to be included in the labor market.
G. Develop the family individual life projects for every member.
H. Visit the families on a weekly basis to ensure that they are kept within the
project.

2.1. Subjects
Educators identied children working on the streets of the city. These children
were found working in one of the wealthier neighborhoods of Sao Paulo. Their
caregivers were then found and invited to participate in a program to eliminate
child labor. The caregiver responsible for the children signed the informed consent
form to participate in the study. Children who were working on the streets before
the intervention, as well as their siblings who were not working on the streets, but
were living in the same home environment were included. Families with children
who were unwilling to participate were not included.
The inclusion criteria were: children between 7 and 14 years old whose parents
agreed to participate in the research protocol.
Exclusion criteria: mental retardation; neurological disorders not under treatment and diseases that could alter the HPA axis (e.g. Cushing's Syndrome or asthma
with present use of corticosteroids).
In the rst phase, data were collected between October 2008 and March 2009.
All the assessments were repeated 24 months after the beginning of the intervention. Two hundred and eleven children between 7 and 14 years old were selected
and 191 (126 children working on the streets and 65 siblings) were included; 178
were re-evaluated at 2 years, of whom 113 had cortisol measures completed for
both phases.
2.2. Ethics statement
Families were included in the study after the primary caregiver signed an
informed consent form approved by the institutional ethical committee of the
Federal University of So Paulo (IRB number: CEP 0550/08).

abuse (cut-off: 5); emotional neglect (cut-off: 9) and physical neglect (cut-off: 7).
The Urban Violence Questionnaire is an instrument with questions about viewing
or being a victim of violent events that happen in the streets of inner city regions,
such as seeing gun shots, viewing dead bodies and being beaten by gangs or others,
with yes or no answers. For more detailed descriptions of the instruments see
previously published data at Maciel et al. (2013) and Mello et al. (2014).

2.4. Cortisol measures

The caregivers were taught how to collect saliva during a meeting with the
NGO. The saliva was collected at their homes and refrigerated for one night in a
home refrigerator before being refrigerated at  20 1C until the analysis. Salivary
cortisol was collected with plain Salivettes (Sarsted) at awakening and 30 min
afterwards (cortisol awakening response: CAR) as was explained during the
training procedure at the NGO. The subjects marked the tubes with the collection
date and time. One sample of saliva was collected for each time of the day
described above before and after the intervention period.
Cortisol was analyzed using a DSL-10-671000 ACTIVE (EIA) kit. The kit has a
sensitivity of 0.011 g/dL. Intra-assay precision was calculated using the means of
12 replications of the analyzed samples. The variation coefcient for the total
sample was 0.1750.35 to 1.352.6 g/dL.
2.5. Analysis
Sociodemographical data were analyzed using percentages, mean and standard
deviation. Next, to verify differences between the nal sample and the dropouts,
chi-square tests were used for categorical variables and t tests for continuous
variables. To verify differences among maltreatment (CTQ and WorldSAFE scores;
categorical variables), urban violence (continuous variable), family functioning
(GARF scores; continuous variable) and children mental health (SDQ; categorical
variable) pre- and post-intervention Wilcoxon and McNemar tests were used.
Then the cortisol measures were log transformed to allow comparisons of
means and area under the curve (AUC) with parametric tests before and after the
intervention.
Two mixed regression analysis models were developed to understand CAR
patterns and factors related to the CAR including a family effect because some
children were from the same families. The stepwise selection model was used to
exclude variables that were not signicant (Neter et al., 1996). The models analyzed
factors related to the CAR including: abuse/neglect (CTQ), family functioning
(GARF), the presence of mental health symptoms (SDQ), urban violence and street
work, controlling for gender, age, skin color, years of schooling and time of cortisol
collection. Because these factors have been described in previous studies as related
to cortisol response patterns they were also analyzed by pre- and post-intervention
and described in Section 3.
The regression models also allow understanding the cortisol response patterns
difference between pre- and post-intervention periods, besides the AUC
comparisons.

2.3. Assessments
The primary caregivers answered a socio demographic questionnaire regarding
the age, gender, level of education, skin color, and religion of the children and their
parents. The sample was divided into three groups by participant skin colorwhite,
brown (parda) and blackusing the system of the Brazilian Institute of Geographic
and Statistics (IBGE), which uses skin color to analyze sociodemographic data from
the Brazilian population due to the number of mixed ethnicities (IBGE, 2009).
Instruments to collect data about violence exposure and maltreatment were
applied, and also a screening assessment for mental health problems as follows:
the caregivers answered the World Studies of Abuse in the Family Environment
(WorldSAFE) Core Questionnaire (Sadowski et al., 2004), and the Strengths and
Difculties Questionnaire (SDQ) (Woerner et al., 2004). Trained psychologists
applied the Global Assessment of Relational Functioning Scale (GARF) (Mello
et al., 2007a). Children completed the Childhood Trauma Questionnaire (CTQ)
(Bernstein et al., 1994) and the Urban Violence Questionnaire. The chosen assessment instruments had been previously used and validated in other studies with
Brazilian samples, except the Urban Violence Questionnaire.
The WorldSAFE results allowed the sample to be split between those having
suffered severe physical punishment and those not; the instrument categorizes as
cases those who have experienced an event such as being kicked, choked,
smothered, burned, beaten repeatedly or hit with an object on the buttocks or
other parts of the body. The SDQ is a screening instrument used to evaluate
behavioral problems in children. It has 25 questions and ve domains: hyperactivity/inattention; conduct problems; emotional problems; peer relationship
problems and pro-social behaviors. A cut off point of 14 was used to identify
children with mental health symptoms. The GARF measures the family functioning
and the scores are from 1 to 100 in a continuum ranging from the most
dysfunctional (disrupted) family relations (1) to an optimal family functioning
(100). The CTQ is a 28-item scale with ve subscales, each being scored from 5 to
25, which measure emotional abuse (cut-off: 8); physical abuse (cut-off: 7); sexual

3. Results
Two hundred and eleven (211) children between 7 and 14 years
old were included in the NGO project in 2008; one hundred and
ninety one (191) children were selected for the present research.
One hundred and seventy eight (178) children stayed in the
project for the full 2 years of intervention. One hundred and
thirteen (113) children had cortisol measures completed both
before and after intervention.
Table 1 shows demographic characteristics of the sample
before the intervention. There were no signicant differences
between the children that stayed in the project and the dropouts
regarding sociodemographic characteristics or maltreatment
measures.
Regarding cortisol measures, more black children (2 9.560,
d.f. 2, p-Value 0.008) and more children with fewer years of
study (t 1.961, p-Value 0.052, S.D. 0.318, 95%CI  1.250
0.004) collected cortisol in both phases.
Regarding the primary caregivers and their sociodemographic
characteristics, 92.8% were mothers, 2.4% were fathers, 3.6% were
grandmothers and 2.2% were aunts. Therefore, 97.6% were women
and were mostly single (69.9%). Their mean age was 36 years old,
and their mean level of education was 5.7 years. Twenty were
white (25%), 34 were brown (42.5%), and 26 were black (32.5%).

Please cite this article as: Mello, A.F., et al., Factors related to the cortisol awakening response of children working on the streets and
siblings, before and after 2 years of a psychosocial.... Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.11.034i

A.F. Mello et al. / Psychiatry Research ()

The mean family income was approximately US $2400/year, which

is below the minimum wage in Brazil (US $3600/year).

p-Value 0.015). A detailed description of mental health from this

sample can be found in Maciel et al. (2013).
3.3. Cortisol measures (Fig. 1)

3.1. Maltreatment, urban violence and family functioning

According to their caregivers' responses to the WorldSAFE Core
Questionnaire, 112 out of 180 children (62.2%) suffered from severe
physical punishment at home. After the intervention there was no
signicant decrease in the levels of physical punishment reported
by the caregivers.
The CTQ showed high levels of self-reported abuse and neglect in
the family environment for all the children evaluated before the
intervention. After the intervention there was a signicant decrease in
the amount of physical abuse, reported by the children, from 33.7% to
22% (z 4.357, p-Valueo0.001), sexual abuse from 18% to 13.6%
(z  3.359, p-Valueo0.001) and physical neglect from 52.2% to
42.4% (z  3.598, p-Valueo0.001).
Regarding exposure to urban violence, the children were all
exposed to a high degree of violent events on the streets. There
was no signicant difference between the amounts of exposure to
urban violent events after intervention.
The mean GARF score for the families was 49.7 (S.D.21.1).
All three aspects of family functioning including organization
(mean 50.9, S.D.20.3), problem solving (mean 49.6, S.D. 20.5)
and emotional climate (mean 49.6, S.D. 22.5) were equally dysfunctional. After the intervention, levels of family functioning were
signicantly better (z  3.456, p-Valueo0.001). The GARF total score
changed to 64.2 (S.D. 20.8).

3.2. Mental health

One hundred and thirteen children completed cortisol measures before and after the 2 years of intervention, comprising 78
who were initially working on the streets and 41 who were not
working on the streets. After the intervention no children were
working on the streets.
There was no signicant difference between the CAR area under
the curve (AUC) before and after the intervention (t0.573, pValue0.568, 95%CI  0.177, 0.212).
Two mixed regression analysis models as described in methods
were developed to evaluate factors related to the CAR before and
after intervention. The rst model showed that before the intervention working on the streets was related to a positive cortisol
response (estimate value of the variable working on the streets:
positive), while the tendency of response for the group as a whole
was to have cortisol decrease (estimate value of the intercept:
negative). The variable age was kept in the model although it did
not reach signicance because in a previous study published by
the same research group age was related to street work for this
group of children at risk (Table 2).
The second model showed that at end point suffering severe physical abuse was related to a negative cortisol response
(estimate of the variable physical abuse: negative) while the
tendency of response for the group was to have cortisol increase
(estimate value of the intercept: positive) (Table 3).

4. Discussion

The SDQ results showed that 62% of the children had an

abnormal score on the test completed by the primary caregiver.
After the 2-year intervention signicantly fewer children scored as
abnormal in the SDQ, 50.6% (McNemar Test: 2 5.93, d.f. 4,
Table 1
The sociodemographic characteristics of the children.
n

Gender
Male
Female

106
85

55.5
44.5

Skin color
White
Brown (Parda)
Black

39
106
40

21.1
57.3
21.6

Religion
Catholic
Protestant
Atheist
Others

99
58
3
21

54.7
32.0
1.7
11.6

Age
Years of study

Mean
10.5
4.0

S.D.
2.122
1.932

The family focused social intervention was able to take children off
the streets, reduce childhood abuse and neglect reported by the
children, decrease the frequency of abnormal psychological and
behavioral problems and improve family functioning. However, severe
physical punishment reported by the caregivers was not reduced and
the cortisol awakening response did not show a signicant difference
in its pattern, based on simple AUC comparisons.
However, the conclusion based on the regression analysis
values was that working on the streets was related to cortisol
increase seen before the intervention and it is probably an
important stressor for children at risk. After the intervention, no
more children were working on the streets, and physical punishment was related to a attened cortisol response, a nding that
has been reported before by other researchers in the eld
(Carpenter et al., 2011).
Some studies in the literature have reported reductions in AUC
cortisol levels after environmental interventions; this was not the
case in the present study. One important limitation that might
explain this result is that, because there is no control group, the
statistical analyses were limited to mean comparisons for the
same group. Another limitation is that the area under the curve is
a method that cannot consider differences in the patterns of
responses, such as sharper of more blunted curves, or initial

Table 2
Mixed regression analysis model before the intervention.
Parameter

Intercept
Working on the streets
Years of schooling

Estimate

 0.714
0.452
0.080

Std. error

0.206
0.184
0.044

d.f.

152.334
117.924
153.661

 3.466
2.450
1.816

p-Value

0.001
0.016
0.071

95% Condence interval

Lower bound

Upper bound

 1.122
0.086
 0.007

 0.307
0.818
0.168

Please cite this article as: Mello, A.F., et al., Factors related to the cortisol awakening response of children working on the streets and
siblings, before and after 2 years of a psychosocial.... Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.11.034i

A.F. Mello et al. / Psychiatry Research ()

Table 3
Mixed regression analysis model after the intervention.
Parameter

Intercept
Physical punishment

Estimate

0.253
 0.517

Std. error

0.147
0.200

d.f.

68.995
95.713

Fig. 1. Cortisol awakening response before and after intervention.

increases vs. decreases in the response pattern, if the areas under

them are the same.
Before the intervention the cortisol level after wake time
showed a small decrease (Fig. 1) and after the intervention a small
increase. Although this difference was not signicant in mean
differences in AUC cortisol levels, the regression analysis models
can explain more about the cortisol pattern responses.
The rst regression analysis model showed that before the
intervention working on the streets was related to a positive
cortisol response, while the tendency of response for the group
was to have a cortisol decrease. It is difcult to explain why this
group of children has a tendency for decreasing cortisol levels
after awakening before the intervention. This is not the normal
expected response for a regular pattern of cortisol for this age
group (Pruessner et al., 1997).
A possible explanation for this nding is that these children
were already affected by the number of stressful experiences that
they were suffering, and the response for the group was blunted,
while working on the streets was a stimulus still intense enough to
increase the cortisol level in some individuals. Thus the decreasing
cortisol levels after wake time found in the present study before
the intervention could be related to the amount of abuse and
maltreatment to which this group had been exposed during their
early childhood development, as reported previously by other
researchers in the eld.
A study by Gunnar et al. (2001) found a correlation between
blunted CARs and early higher physical and social neglect in postinstitutionalized youths. Cicchetti et al. (2010) also found that early
physical abuse and sexual abuse in school-aged children were
correlated with attenuated cortisol levels if they had depressive or
internalizing symptoms.
After the intervention, children were no longer working on the
streets and again, although the mean differences in AUC cortisol levels
were not signicant, the second regression analysis model showed
that at end point suffering severe physical abuse was related to a
negative cortisol response while the tendency of response for the
group was to have cortisol increase.
The tendency for children suffering physical punishment to
have decreasing levels after awakening is also supported by the

1.726
 2.583

p-Value

0.089
0.011

95% Condence interval

Lower bound

Upper bound

 0.039
 0.915

0.547
 0.119

literature described above. The tendency for an increasing

response after the intervention might be related to the intervention effect such that the children reached a cortisol response
pattern that is expected for healthy subjects, but unfortunately the
present study is inconclusive at this point because it has important
limitations.
First because of the difculties in accessing this population it
was not possible to have a control group with children from the
same neighborhood and this is the main limitation of the present
study; without a response pattern for children without maltreatment the conclusiveness of the results is jeopardized. There are
also limitations related to the cortisol collections, since not all
subjects followed the protocols adequately because of difculties
in understanding the procedures, even after training and explanations. Only 1 day of saliva collection was possible and only 113
subjects had cortisol measures for both phases. The use of a
convenience sample only allowed evaluating a proportion of
families living in an area of favelas (slums), since some areas
were difcult to access due to being controlled by drug dealers and
the families that did not adhere to the intervention could not be
reevaluated.
Several studies have concluded that early life stress may lead to
disruptions in HPA axis functioning, and that factors such as age,
parental responsiveness, subsequent exposure to stressors, type of
maltreatment and type of psychopathology or behavioral disturbance displayed may inuence the degree and pattern of HPA
deregulation (Bernstein et al., 1994; Lyons et al., 1999, 2000;
Dettling et al., 2002; Shea et al., 2005; Mello et al., 2007b). Thus,
there has been a consensus that early life stress is associated with
modication of the HPA axis in the early stages of life, which leads
to a biological vulnerability to psychopathology (Newport et al.,
2004; Heim et al., 2008; Tyrka et al., 2008). There is, therefore, a
great need for preventive interventions for at risk subjects in order
to avoid mental illness and its burden.
Our ndings seem to corroborate the evidence that a social
intervention can be correlated to underlying biological mechanisms,
as a dysfunctional HPA axis is a strong predictor and also a consequence of some psychiatric disorders. The results, although inconclusive, suggest that family focused interventions can be effective in
reducing stress levels for children at risk in a preventive way, although
changing patterns of biological responses may need interventions to
be implemented very early in child development.
It is encouraging to nd that this psychosocial intervention to
withdraw children from the streets had a positive impact on the social
functioning of these children and their families, an extremely at risk
group for mental health disorders. More studies testing replicable
interventions for children at risk are necessary with larger samples
and community control groups to provide a potential route to develop
more widespread preventive programs for vulnerable at risk children
and adolescents.

Funding
JJM is an I-A Researcher from the Brazilian Research Council
(CNPq).

Please cite this article as: Mello, A.F., et al., Factors related to the cortisol awakening response of children working on the streets and
siblings, before and after 2 years of a psychosocial.... Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.11.034i

A.F. Mello et al. / Psychiatry Research ()

AFM received a scholarship from CAPES PNPD 02772/09-4, and

a grant from CNPq 575114/2008-8. MFJ and MFM are researchers
from CNPq. MFJ received grants related from CNPq, CAPES, FAPESP,
FAEPA and from King's College London.

Acknowledgments
The authors wish to thank Dr. Yusaku Soussumi, who was
responsible for the partnership between the NGO-RUKHA and the
Federal University of Sao Paulo. The authors are grateful to the
comments raised by the anonymous referees who contributed a
great deal to improve the quality of the paper.
References
Bernstein, D.P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., et al., 1994.
Initial reliability and validity of a new retrospective measure of child abuse and
neglect. American Journal of Psychiatry 151, 11321136.
Bevans, K., Cerbone, A., Overstreet, S., 2008. Relations between recurrent trauma
exposure and recent life stress and salivary cortisol among children. Development and Psychopatholy 20, 257272.
Carpenter, L.L., Shattuck, T.T., Tyrka, A.R., Geracioti, T.D., Price, L.H., 2011. Effect of
childhood physical abuse on cortisol stress response. Psychopharmacology 214,
367375.
Carpenter, L.L., Tyrka, A.R., McDougle, C.J., Malison, R.T., Owens, M.J., Nemeroff, C.B.,
et al., 2004. Cerebrospinal uid corticotropin-releasing factor and perceived
early-life stress in depressed patients and healthy control subjects. Neuropsychopharmacology 29, 777784.
Chida, Y., Steptoe, A., 2009. Cortisol awakening response and psychosocial factors: a
systematic review and meta-analysis. Biological Psychology 80, 265278.
Cicchetti, D., Rogosch, F.A., Gunnar, M.R., Toth, S.L., 2010. The differential impacts of
early physical and sexual abuse and internalizing problems on daytime cortisol
rhythm in school-aged children. Child Development 81, 252269.
Cicchetti, D., Rogosch, F.A., Toth, S.L., Sturge-Apple, M.L., 2011. Normalizing the
development of cortisol regulation in maltreated infants through preventive
interventions. Development and Psychopathology 23, 789800.
Cutuli, J.J., Wiik, K.L., Herbers, J.E., Gunnar, M.R., Masten, A.S., 2010. Cortisol function
among early school-aged homeless children. Psychoneuroendocrinology 35,
833845.
Dettling, A.C., Feldon, J., Pryce, C.R., 2002. Repeated parental deprivation in the
infant common marmoset (callithrix jacchus, primates) and analysis of its
effects on early development. Biological Psychiatry 52, 10371046.
Dozier, M., Zeanah, C.H., Wallin, A.R., Shauffer, C., 2012. Institutional care for young
children: review of literature and policy implications. Social Issues Policy
Review 6, 125.
Evans, D.L., Charney, D.S., 2003. Mood disorders and medical illness: a major public
health problem. Biological Psychiatry 54, 177180.
Fernald, L.C., Burke, H.M., Gunnar, M.R., 2008. Salivary cortisol levels in children of
low-income women with high depressive symptomatology. Development and
Psychopathology 20, 423436.
Fisher, P.A., Stoolmiller, M., Gunnar, M.R., Burraston, B.O., 2007. Effects of a
therapeutic intervention for foster preschoolers on diurnal cortisol activity.
Psychoneuroendocrinology 32, 892905.
Graham, A.M., Yockelson, M., Kim, H.K., Bruce, J., Pears, K.C., Fisher, P.A., 2012.
Effects of maltreatment and early intervention on diurnal cortisol slope across
the start of school: a pilot study. Child Abuse and Neglect 36, 666670.
Gunnar, M.R., Morison, S.J., Chisholm, K., Schuder, M., 2001. Salivary cortisol levels
in children adopted from romanian orphanages. Development and Psychopathology 13, 611628.
Heim, C., Newport, D.J., Heit, S., Graham, Y.P., Wilcox, M., Bonsall, R., et al., 2000.
Pituitary-adrenal and autonomic responses to stress in women after sexual and
physical abuse in childhood. The Journal of the American Medical Association
284, 592597.
Heim, C., Newport, D.J., Mletzko, T., Miller, A.H., Nemeroff, C.B., 2008. The link
between childhood trauma and depression: insights from HPA axis studies in
humans. Psychoneuroendocrinology 33, 693710.

IBGE, 2009. Sntese de indicadores sociais. Uma anlise das condies de vida da
populao brasileira, Censo Demogrco Brasileiro. From: http://www.ibge.
gov.br/home/estatistica/populacao/condicaodevida/indicadoresminimos/sinte
seindicsociais2008/indic_sociais2008.pdf.
Juruena, M.F., Cleare, A.J., 2007. Overlap between atypical depression, seasonal
affective disorder and chronic fatigue syndrome. Revista Brasileira de Psiquiatria 29 (Suppl. 1), S19S26.
Juruena, M.F., Cleare, A.J., Pariante, C.M., 2004. The hypothalamic pituitary adrenal
axis, glucocorticoid receptor function and relevance to depression. Revista
Brasileira de Psiquiatria 26, 189201.
Juster, R.P., McEwen, B.S., Lupien, S.J., 2010. Allostatic load biomarkers of chronic
stress and impact on health and cognition. Neuroscience & Biobehavioral
Review 35, 216.
Lokhmatkina, N.V., Feder, G., Blake, S., Morris, R., Powers, V., Lightman, S., 2013.
Longitudinal measurement of cortisol in association with mental health and
experience of domestic violence and abuse: study protocol. BMC Psychiatry 13,
188.
Lupien, S.J., Schramek, T.E., 2006. The differential effects of stress on memory
consolidation and retrieval: a potential involvement of reconsolidation? Theoretical comment on Beckner et al. (2006). Behavioral Neuroscience 120,
735738.
Lyons, D.M., Lopez, J.M., Yang, C., Schatzberg, A.F., 2000. Stress-level cortisol
treatment impairs inhibitory control of behavior in monkeys. Journal of
Neuroscience 20, 78167821.
Lyons, D.M., Wang, O.J., Lindley, S.E., Levine, S., Kalin, N.H., Schatzberg, A.F., 1999.
Separation induced changes in squirrel monkey hypothalamicpituitaryadrenal physiology resemble aspects of hypercortisolism in humans. Psychoneuroendocrinology 24, 131142.
Maciel, M.R., Mello, A.F., Fossaluza, V., Nobrega, L.P., Cividanes, G.C., Mari, J.J., et al.,
2013. Children working on the streets in Brazil: predictors of mental health
problems. European Child & Adolescent Psychiatry 22, 165175.
McEwen, B.S., 2003. Mood disorders and allostatic load. Biological Psychiatry 54,
200207.
Mello, A.F., Blay, S.L., Kohn, R., 2007a. Global assessment of relational functioning
scale (GARF): a validity study in patients with recurrent major depression in
Brazil. Transcultural Psychiatry 44, 5564.
Mello, A.F., Juruena, M.F., Pariante, C.M., Tyrka, A.R., Price, L.H., Carpenter, L.L., et al.,
2007b. Depression and stress: is there an endophenotype? Revista Brasileira de
Psiquiatria 29 (Suppl. 1), S13S18.
Mello, A.F., Maciel, M.R., Fossaluza, V., de Paula, C.S., Grassi-Oliveira, R., CavalcanteNobrega, L.P., et al., 2014. Exposure to maltreatment and urban violence in
children working on the streets in Sao Paulo, Brazil: factors associated with
street work. Revista Brasileira de Psiquiatria 36, 191198.
Mello, A.F., Mello, M.F., Carpenter, L.L., Price, L.H., 2003. Update on stress and
depression: the role of the hypothalamicpituitaryadrenal (HPA) axis. Revista
Brasileira de Psiquiatria 25, 231238.
Neter, J., Kutner, M.H., Nachtsheim, C.J., Wasserman, W., 1996. Applied Linear
Regression Models, 3rd ed. Irwin.
Newport, D.J., Heim, C., Bonsall, R., Miller, A.H., Nemeroff, C.B., 2004. Pituitary
adrenal responses to standard and low-dose dexamethasone suppression tests
in adult survivors of child abuse. Biological Psychiatry 55, 1020.
Pruessner, J.C., Wolf, O.T., Hellhammer, D.H., Buske-Kirschbaum, A., von Auer, K.,
Jobst, S., et al., 1997. Free cortisol levels after awakening: a reliable biological
marker for the assessment of adrenocortical activity. Life Sciences 61,
25392549.
Quevedo, K., Johnson, A., Loman, M., Lafavor, T., Gunnar, M., 2012. The conuence of
adverse early experience and puberty on the cortisol awakening response.
International Journal of Behavioral Development 36, 1928.
Sadowski, L.S., Hunter, W.M., Bangdiwala, S.I., Munoz, S.R., 2004. The world studies
of abuse in the family environment (WorldSAFE): a model of a multi-national
study of family violence. International Journal of Injury Control and Safety
Promotion 11, 8190.
Shea, A., Walsh, C., Macmillan, H., Steiner, M., 2005. Child maltreatment and HPA
axis dysregulation: relationship to major depressive disorder and post traumatic stress disorder in females. Psychoneuroendocrinology 30, 162178.
Tyrka, A.R., Wier, L., Price, L.H., Ross, N., Anderson, G.M., Wilkinson, C.W., et al.,
2008. Childhood parental loss and adult hypothalamicpituitaryadrenal
function. Biological Psychiatry 63, 11471154.
Woerner, W., Fleitlich-Bilyk, B., Martinussen, R., Fletcher, J., Cucchiaro, G., Dalgalarrondo, P., et al., 2004. The strengths and difculties questionnaire overseas:
evaluations and applications of the SDQ beyond Europe. European Child
Adolescent Psychiatry 13 (Suppl. 2), SII47SII54.

Please cite this article as: Mello, A.F., et al., Factors related to the cortisol awakening response of children working on the streets and
siblings, before and after 2 years of a psychosocial.... Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.11.034i