Guidelines for child health : language development on focus

Language disorders impact on child overall development. Policy directives for the child guide on ways to follow up child development for greater efficiency and effectiveness. The aim of this paper was to identify the policies positions of the proposals on the attention to language problems in the child health field. From a documental research, national and international guidelines were reviewed in order to identify actors, objectives, contexts, motivations, arguments, justifications and proposals regarding the follow of child development and child language. We performed a critical analysis in order to explain these positions and place on discussion the arguments that support them. The results point out to consensual aspects that place the problems of child development as vulnerabilities producers. Language problems cross the boundaries of political, scientific and social matters. These issues are challenges to interdisciplinary and intersectoral work and guide the need to promote the most effective responses of public policy for people requiring language support. The link of this discussion with the concepts of life cycle and human development for achieving full citizenship requires further deepening.


Introduction
Children with developmental problems are considered to be more vulnerable and require specific support, such as legislation and policies that are adequate to meet their needs and guarantee their rights 1 .
In the Americas, there is no statistical data showing the true prevalence of developmental problems in children, given the complexity of their definition and the different theoretical perspectives on normal development 2 .
As an important aspect of child development, language and communication are beginning to take on new relevance in today's societies, given their centrality to socialization and learning.In addition, new values and demands of the globalized world are pointed out as factors that lead to changes in employability standards, making the ability to communicate be effectively seen as a requirement for better opportunities in the productive world.Thus, "communication diseases" are beginning to be identified as "a new public health problem" [3][4][5] .
In the course of child development, some language disorders may be considered primary, involving a broad description of abilities, which develop differently in comparison to the development considered typical 6 .They encompass Specific language impairment (SLI), with prevalence of 7% in preschool children 7 and reading/ writing ones, the estimated rate of which is 5 to 10% in the general population 8 .These conditions are diagnosed by exclusion criteria, that is, in the absence of a pathology justifying them 9 .In Brazil, there are no nationwide data on the specific problems of language development, but a local scope study indicates rates of 7% and 7.5% at the ages of 4 and 5 years 10 .
The relationship of interdependence between oral and written language and its repercussions on schooling is widely reported in the literature and it is considered that severe weaknesses or changes in language and communication skills in the preschool stage increase the risk of school failure, low self-esteem, psychosocial problems and poor social skills [11][12][13][14] .
Thus, concerns for children's healthy growth and development lead to the adoption of different strategies for this follow-up, such as screening, evaluation, monitoring and surveillance of development 15 .Questions related to language needs have been discussed and prioritized based on arguments that include effects on children's social and emotional development, literacy and literacy processes, vulnerabilities and risk of social exclusion [16][17] .
Thus, in a conjuncture of recent approval of the Brazilian government National Policy of Integral Attention to Children's Health (PNAISC, in the Portuguese abbreviation) 18 , it is worth reflecting on language problems, asking about ways in which these are incorporated in national guidelines for children's health care and on the pertinence of this topic in the agenda on children's health policies in Brazil.
For the purpose of this article, the aim has been to identify how children's health proposals are placed on attention to language problems.

Methodology
A documentary review 19,20 was conducted to analyze the ways in which language-related issues are incorporated into documents aimed at children's health.Two national and two international documents were included (Chart 1).The national ones were the Manual for Child Development Monitoring in the context of Brazilian government Integrated Attention to Diseases Prevalent in Childhood (AIDPI, in the Portuguese abbreviation) 15 ; the Brazilian government Basic Care Brochure (CAB, in the Portuguese abbreviation): Growth and Development 21 .The international ones were the Bercow Report 22 , from the United Kingdom and the Action Plan for Children Suffering from Language-Specific Disorders (Plan d'action pour les enfants atteints d'un trouble spécifique du langage) 23 , from France.
Criteria for selecting these documents were: (1) having been published by official government bodies of the respective countries; (2) in the case of national documents, due to incorporating commitment to Brazilian children's integral health care, including the aspect of healthy growth and development in early childhood, and to presenting general guidelines for the accomplishment of such monitoring; (3) For the international documents, due to representing, within the framework of years 2000 of the 21 st century, the efforts of two countries to face children's language and communication problems as major issues, with governmental actions at a national level and raising them to the status of a "public health problem".
The French document was made available by the Reference Center for Assessment of Language Disorders and Learning Difficulties in Children (University Hospital Center -CHU, [in the French abbreviation], in the city of Toulouse, France) through an interinstitutional agreement between that institution and Brazilian institutions Instituto Fernandes Figueira/Fundação Oswaldo Cruz (Fiocruz; Oswaldo Cruz Foundation).The British report has resulted from a bibliographic search and has been selected due to synthesizing results from a research on evidence related to the topic and public consultation in order to provide information on arrangements for the organization of service care systems for children and young people with language and communication needs.
Systematization of the analysis material was carried out from three blocks of questions presented in the documents: a) who the actors were A critical analysis was performed in order to explain the positions adopted by the countries and to discuss the arguments supporting them, generating reflections on the ways of approaching the problems related to children's language development.

Results and Discussion
Production of political documents results from mobilization processes that reflect certain sociohistorical contexts.Thus, actions at central levels in the three countries are identified to respond to demands from children's health care and devel-opment but with specificities about what constitutes priority and ways of doing so.
In the Brazilian case, contextual references of the first decade of the 2000s refer to a scenario of a developing country with great socioeconomic inequalities and deterioration and demographic and epidemiological changes that present new challenges to the government.Since the 1988 Brazilian Federal Constitution 24 , many changes have been observed in the health care sector in Brazil, with paradigm and structural changes that have marked the establishment of new regulatory frameworks for health care 25 that started to value actions of promotion and protection, prevention of diseases and an integral attention to people, taking as its principles the integrality, interdisciplinarity and intersectorality of care.
With positive results from the Integrated Attention to Diseases Prevalent in Childhood (AIDPI, in the Portuguese abbreviation) 26 15 acknowledges then the need to extend care to Brazilian children in order to guarantee them an integral right to health care 27 .
In its text, it incorporates different theories and scientific evidences about child development, understanding it as a vital process resulting from the interaction of growth, maturation and learning phenomena influenced by environmental conditions.It constructs arguments that point to children's greater vulnerability to health problems in this phase of life but with better responses to stimuli due to greater brain plasticity.Thus, it highlights the importance of development monitoring in the first two years of life by primary care professionals as an essential action to promote children's maximum potential and to expand their possibilities of social insertion.It further justifies that this strategy may be central to reducing social inequities and to the development of human and social capital 15 .
Language development is encompassed by the inclusion of milestones in the development of this skill in the proposed guidelines and by warning that language and learning problems are more difficult to perceive and may lead to delayed diagnosis and referral for treatment, representing greater impact on quality of life.
Also in the Brazilian context, the Brazilian government Basic Care Brochure (CAB, in the Portuguese abbreviation): Growth and Development 21 is updated and resumes the valuation of childcare in attention to children's health, mainly due to the increase in the prevalence of chronic noncommunicable diseases (NCDs).With the objective of supporting and guiding primary care teams, qualify care and development in the system, CAB-33 broadens references for monitoring development until the age of ten and includes new topics such as healthy eating, accident prevention, social care and protection systems, the importance of playing in child development 21 .
As an important milestone directly related to prevention of language problems, this document refers to hearing evaluation through neonatal hearing screening (TAN, in the Portuguese abbreviation), which has been mandatory in Brazil since Federal Law n o .12,303/2010 28 .Regarding an adequate management of problems identified, including those of language, the guidelines remain in the field of health promotion and prevention, with emphasis on an interdisciplinary and intersectoral approach 21 .
From this perspective, it is possible to consider that providing health care professionals with better information and conditions to recognize children's overall development and health needs enhances the capacity to intervene more consistently on the health-disease process and transforms care practices in health towards some more integral attention 29 .
Another point to consider is in theoretical references and scientific evidences supporting Brazilian documents, which include very broad and integrative approaches to understanding the normal course and developmental deviations, with marked presence in the field of developmental psychology, but also with references from biomedical, social and educational fields 15,21 .In both national documents, the concern with children and childhood is highlighted, from a per- spective of integral health, seeking to situate this period as being of greater risk and vulnerability, understood as the chance or opportunity to suffer losses or delays in their development due to the influence of individual, social and programmatic factors, which constitute adverse situations 29 .Theoretical foundations present in the political documents provide evidence of how children are situated in relation to the place and role that they occupy in society.Aspects of development and its changes, including language, are placed as value, with potential to influence the individuals' potentialities and their future status, which may favor or reduce full exercise of citizenship and the economic and social capital of a nation 5 .
In this sense, looking at children and childhood at different historical moments helps us to understand the ways in which the policies and strategies of action directed to them are conformed 30 .The cultural context, understood as a structured and consistent symbolic system, allows the formation and recognition of new meanings and significance, and the social context, as a producer of interactions and relationships, gives society the characteristic of being constantly produced by the agency of its social actors.From this perspective, children leave the condition of being incomplete and passive in the process of acquisition of competences and personality formation and gains some new protagonism and legitimacy, starting to play an active role in the definition of their own condition.The social construction of childhood and its recognition as a particular period of life legitimize children as social actors and establish them in the field of rights.The concepts of risk and vulnerability come to occupy a central place and establish, in the political field, the need to extend care.
Therefore, it is possible to situate these documents as important milestones of the Brazilian political position in relation to children's health.By introducing the development monitoring strategy, they not only broaden the focus on children and their health needs but also situate them in relation to future social and productive opportunities, strengthening the integrated vision of children's health, contributing to guarantee basic rights to protection, health, education and culture (ECA, 1990) 31 and enhancing medium-and long-term changes in the country's scenario of social inequalities.
The UK document -Bercow Report 22 -is the result of an extensive research commissioned by a parliamentarian who mobilizes militants from the field of speech, language and communication needs to explore aspects related to efficiency and effectiveness of provision of care for children and young people with difficulties in these domains.In a context where support and access to speech and language therapies are assessed as unsatisfactory by the population and marked by inequities, and faced with a prevalence of specific language alterations of around 7% at the time of access to primary school in this country, different sectors of society have been heard in order to increase national visibility for speech, language and communication needs and to propose recommendations for reforms to the system of attention and care for children and young people with such needs.
As main arguments, there is a consensus about the centrality of language and communication as essential life skills, which support the social, emotional and educational development of children and young people.In addition, the document states that policymakers, managers, professionals, service providers and families lack sufficient understanding on these issues and priority is low.Aspects of early identification and intervention, as well as risks underlying language and communication problems are reinforced, with emphasis on those related to school learning, mental health effects, social and professional integration, with repercussions on social and economic spheres 22 .
Identifying the need for a more efficient child and family support system, the document presents 40 recommendations to central political instances, focusing five axes: centrality of speech, language and communication in a person's life; early identification and intervention and development of health and education systems; provision of resources for continuity of services; joint work; equation of the problem of lack of equity in access to services 22 .
In spite of the emphasis given to the greatest impacts of language and communication problems from the beginning of the formal learning cycle and in the future life of individuals, action proposals are located, as in the Brazilian case, in the initial years of life, privileging measures of early identification by monitoring development in primary care, valuing the transition ages.In addition to an integrated multiprofessional work, the document highlights the need for training the workforce to address language development problems, as well as the need for greater strategizing with the education sector, focusing on inclusive approaches to special education 22 .
The French Action Plan 23 is part of a scenario of the country's backwardness compared to other developed countries with regard to strategies for addressing oral and written language acquisition problems, and is the result of a joint interministerial effort with participation and representation from various sectors of society to produce responses to a preliminary situation diagnosis report 32 .Based on the analysis of consensus and dissent and seeking to protect competencies and democratically validate proposals, this document emphasizes that the pressures exerted by interest groups need to be considered and answered to with state action, turning the field of oral and written language development disorders into an element of national policy and priority in public health.Such an attempt requires some governmental positioning of ministerial integration with an incorporation of common and objective strategies that promote coordination among the areas of health, education and research 23 .
Arguments revolve around the centrality of the domain of language for school success, social integration and professional insertion, and adds particular emphasis to the aspect of the suffering generated by the cumulative effects of language development disorders throughout the life of children and families.Considering the need for greater support for the 4 to 5% of children affected in this country, 1% being of severe cases, it is recommended that, around 3 years and 6 months to 4 years, in the area of childcare, all serious disturbances in oral language acquisition should be considered of concern and require identification and screening.Also, at the time of literacy this guidance should be performed by schools' physicians regarding severe disorders in acquisition of written language 23 .
Other measures are proposed in this document, including the identification of warning signs from preschools, multiprofessional diagnosis in university referral hospital centers, as well as the development and use of collective schooling strategies for children with moderate and severe difficulties and the development of personalized academic aid programs, involving participation by students, families, teachers and health teams.Awareness and training for health and education professionals, organization of the health care system to respond more effectively to demands as well as the dissemination of information to society about such problems are also among the main strategies 23 .
In analyzing the international documents, it is noticed that among the elements placed in value some are consensual among the three countries but also raise other important problematizations.The consensual aspects are mainly related to the acknowledgment of children's life initial years as essential to the development of their maximum potential.Therefore, there must be public policies to protect biological and environmental risks that represent vulnerabilities to the expression of child development.In this regard, developmental monitoring in primary health care has been presented as a potent strategy for early identification of developmental problems.
The international documents go further in this approach proposal and specifically highlight the needs of speech, language and communication in the United Kingdom and disorders of development of oral and written language in France, identifying language and communication as central aspects for human and social development.Therefore, they advocate improving registration of language development at key ages and screening in the most severe cases, in addition to identifying early warning signs in preschools.
Regarding the need for better organization and development of services and training of health professionals in basic care, the English document problematizes the need for a review of the modalities of attention to speech, language and communication problems as well as regularization of the provision of services and the integration of care systems.It values that the set of needs of people with these difficulties be known in greater depth as a requirement to produce modifications in political scenarios directed to these problems.They include in this discussion not only the challenge of statistical measures due to insufficient epidemiological data to improve the quality of information on these needs but also knowledge about environmental and individual risk factors, social determinants of health and supply, demand and conditions of the services available to stakeholders 4,[33][34] .
Then one can discuss the need to move a model focused on individual therapeutic care, which is no longer sufficient to meet the demands, to another one, the focus of which is on activities directed to the community by means of programs of health promotion and prevention 4,35 .This approach is referred to a more "modern" perspective of public health, which tends to focus on the impact of preventable or avoidable factors, such as those arising from the level of socioeconomic well-being, lifestyle, environmental exposure, geographic location, ethnicity, among others, on the definition of health needs and the population's access to different services 4 .
These considerations lead to reflections on Brazilian programs that, based on the political redefinition of the health care model, adopt broader conceptions of public health, with care designs based on individual and collective actions, but which impact people's health situation and autonomy and also the determinants and health determinants of collectivities, taking into account aspects such as management, participation and social responsibilities, and definition of territories and their needs 25 .
The documents also present a consensus in placing children in the perspective of the future by evoking the initial stages of development as critical and sensitive periods of greater vulnerability, therefore requiring policies to protect, promote, prevent, increase and reevaluate care at the risk of even greater impacts from social and economic points of view 15,[21][22][23] .
It is also highlighted in the international documents that language development problems are long-term phenomena that affect the persons throughout their life cycle, with impacts on social inclusion, literacy and employability and access to the market so that people with these types of difficulties are considered even more vulnerable than those with other types of disability 4,[22][23] .At this point, reflection by Sen 35 is valuable, which considers that different types and degrees of deprivation affect development possibilities, reduce the freedom to make choices and equal opportunities and directly affect the individuals' ability to act, participate and decide in the social and economic world.
In a more critical perspective of deconstruction of arguments that are dominant in sociohistorical contexts, some considerations can be presented about the notion of risk 36 , whether it is understood as a health hazard as a consequence of lifestyles or as something posed by social disadvantages.Thus, as a result of a social construct that has gained great value in Western societies, the notion of risk related to language needs and difficulties is evidenced in various ways, either by the risk of not being competent enough to communicate and to learn, or of being excluded, not being able to find a job or being competitive, among others, which limits chances and opportunities.From this perspective, new scientific evidence is produced, from which the logics of care centered on diagnostic tests, early diagnostic and therapeutic intervention and prevention find their foundations to justify public health programs aimed at the contingency of "new health problems." Finally, still highlighting the French document 23 towards the problematization and deconstruction of arguments constructed from partic-ular sociohistorical contexts, the dimension of suffering for individuals and families and societal plans generated by language difficulties deserve attention.Both the French action plan and the English report argue that these are considered public health problems and that early intervention measures are taken at national level and in an articulated way, with a view to minimizing their effects 22,23 .
Some aspects of this debate highlight the phenomenon of "medicalization" 37 , in that they place language problems as a "deviant behavior," different from the norm, defining them as disorders; they require investments in research in order to better understand, define and classify such disorders and establish criteria for diagnosis, prognosis and modes of intervention; they strengthen the perspective of early monitoring and intervention as the main way of coping with the problem.They also promote the mobilization of stakeholders (parents, teachers) and other actors (health professionals, scientists) in the search for solutions that carry the perspective of law, and school and social inclusion.
These elements combine several factors that are discussed by Conrad 37 , which circumscribe the phenomenon of life medicalization and the mechanisms of authority delimitation and medical jurisdiction and they can be located to define, classify and treat problems, an authority that is demarcated by scientific research that propose explicative and deterministic models of language alterations and measurement of deviation in relation to norms and standards established from quantitative criteria, as in the case of the use of screening tools and diagnostic tests of language.
The participation of associations of parents of children with language and communication difficulties is also very expressive, demanding not only greater possibilities to understand and deal with their children's problems, but also the right of access to services and treatment and, above all, the guarantee of rights to insertion, inclusion and educational support.Thus they highlight what Conrad 37 interprets as a movement of society itself, which, organized through social movements or stakeholders, produces medicalization, consolidating it from the claim of access to treatment, greater equity and guarantee of civil rights.
Thus, it is important to note the French plan of action 23 when it stresses that the impacts that language disorders present for people's life cycles should be acknowledged but attention must be paid to risks of hypermedicalization of responses.That is, it is necessary to consider how the medicalization of this phenomenon, which includes early screening, diagnosis, prognosis, therapy, (social and school) inclusion/exclusion, is useful for children affected, as it is also a labeling process, and that it interferes with the degree of accountability of various actors, such as teachers, health professionals and families.
Analysis of this material has made it possible to identify a differentiated line of political positioning construction for each of the countries mentioned regarding actions on inclusion of language problems in an agenda for children's health.
In the Brazilian scenario, the political effort to broaden attention and care for children and infants is evident, considering the complexity and interrelationship of other social markers and public management which impact children's health conditions, translated into still high rates of infant morbidity and mortality by diseases prevalent in our reality 38 .
Regarding child development, opting for the strategy of developmental monitoring at the level of primary health care better qualifies the Brazilian commitment agenda for child care.However, issues related to children's language are treated in a generic or specific ways, as in the case of the law that requires the performance of neonatal hearing screening.
It would be possible to locate the UK document 22 in an intermediate position by conducting a living and comprehensive situation diagnosis whose main challenge was to problematize and shed light, with policymakers and decision makers, on how central language and communication problems are, their impact on individual and social levels and the necessary interfaces to the fields of action called for to dialogue politically and pragmatically.
The French document 23 can be situated in another point of this line of political position, because, besides acknowledging the language centrality for individuals' life cycles and the need to look at it early and act on these problems, it highlights the specific and persistent oral and written language disorders.It emphasizes the degree of suffering generated for children and families with these difficulties and that there may be good responses when they are identified early and treated appropriately.It is important to emphasize the role of the State as the main actor in taking responsibility, with a view to structuring a support system for children and youth with such needs, through the establishment of specific mechanisms that seek greater integration of health and education systems.

Conclusions
In this article, it was sought to discuss contextual aspects, motivations, arguments, justifications and propositions that have guided different governmental positions on guidelines for monitoring child development and, in the context of three experiences portrayed, it was approached as the language, which in such a striking way inscribes children as subjects and social actors and has been approached in these political constructions.
The material analyzed focuses the first age groups of development and points out children's integral health and their full development as conditions for greater social equity.Language has been cited as a central value for this purpose in view of its transversality towards other stages of life, such as adolescence and adult life.Considering the different social contexts and realities, this aspect of child development has been incorporated in a differentiated way in the countries' political guidelines.
Thinking and proposing political strategies and actions for children brings these positions closer in several aspects, especially regarding the acknowledgment of the childhood period as of great vulnerability and priority.Children, understood from a perspective of the future, makes the discussion about the basic competence of language and the effects that the changes in this field can represent for individuals' lives at individual, social and economic levels emerge.Thus, articulating this discussion with ideals of democracy and concepts of life cycle and human development can also be fruitful in terms of mobilizing even more strongly the political agenda aimed at children and adolescents in their process of evolution and social insertion.Some aspects seem central to the development of new debates and deepening.Among them, it is possible to point out that the choice of children up to 10 years of age or even in previous lifetimes, for rehabilitation services, impound demands, compromise self-esteem and life processes and other spheres of attention to children and, in particular, the educational one.Language problems also cross boundaries of political, scientific and social fields and put into perspective the imperative of joint, interdisciplinary and intersectorial works.They also pose the challenge of fostering more effective responses in the field of public policies for people with such needs, which would increase the scope and universality of access to therapeutic and educational services, which are mechanisms for development of individual capacities and social inclusion.

Collaborations
DTC Lamego participated in the design and design, revision of the documents, preparation of the article and analysis and interpretation of the data.OM Bastos participated in the design and design and critical review of the article.MCN Moreira participated in the design and design, preparation and critical review of the article and approval of the final version of the text.

Chart 1 .
National and international political documents examined.

and Chart 2. Contextual and motivational aspects. Manual for Child Development Monitoring CAB 33 Bercow Report -UK Action Plan -France Context
of infant mortality due to acute health problems, other foci of political action have occurred in relation to children's health care in Brazil and the need to look at child development in the first two years of life became a government goal.The Manual for Child Development Monitoring in the context of Brazilian government Integrated Attention to Diseases Prevalent in Childhood (AIDPI, in the Portuguese abbreviation) reduction