Specificities of care to the adolescent crack user assisted in the psychosocial care network

ABSTRACT Objective: to analyze the specificities of care to the adolescent crack user assisted in the Network of Psychosocial Attention. Method: exploratory and descriptive study with qualitative approach. The participants were 20 professionals from the Center for Psychosocial Alcohol and Drug Attention and 10 professionals from the Center for Psychosocial Child and Adolescent Care. Data collection took place through semi-structured interviews and the data were processed by Nvivo 11 software and submitted to thematic analysis. Results: the care to the adolescent crack user assisted in the network involves care specificities in three scopes: adolescence as the life cycle stage, social aspects that involve the adolescent in the use situation, and differentiated care strategies to the adolescent using crack. Conclusion: the network services accessed by the adolescent crack user should be prepared to welcome him in their specificities, assessing the needs of care and promoting therapeutic workshops geared to the needs of this public in the specialized service. Implications for practice: the study may re-signify the care practices focused on the adolescent's needs. In addition, it is necessary to promote the strengthening of these services in the network with a view to subsidizing comprehensive and resolutive care.


INTRODUCTION
In Brazil, the use of crack in the adolescence gained visibility from the year 2000, before the scene presented at the media and the society about the use of crack, considered an urgent problem for the field of the health public policies. In the current scenario, researchers emphasize that the use of drugs among adolescents presents a strong relationship with grievances, which may compromise the life and the health in advance, such as psychotic symptoms, exposure to violence and criminality situations, and among these repercussions, are the early deaths. [1][2][3][4] In this sense, more specific services and actions to this public began to be developed, based on the Child and Adolescent Statute (ECA), in the strategies for dealing with Crack and in the Policy of the Ministry of Health for the Integral Attention to Users of alcohol and other drugs. In the scope of the Single Health System (SUS), in 2011, the work on Psychosocial Care Network (RAPS), which aimed to create, extend and articulation of the attention points to health of people with mental disorders and with needs resulting from the use of psychoactive substances was instituted. The services that compose the RAPS must offer a quality treatment, whose objective is the prevention, harm reduction, social reintegration and mechanisms for permanent training to the health professionals. 5 The RAPS implementation was an advancement in the attention in mental health, since it included the users of crack, alcohol and other drugs as target public of the actions and proposed institutionally the networking. However, the adherence to treatments for dependency of psychoactive substances remains a challenge, mainly among the adolescents. 6,7 Researches carried out in the RAPS point out that among the main weaknesses in the attendance of the adolescent user of crack, in the specialized devices of the network is the little attractive environment of the services and the lack of preparation of professionals for the care for this public. This way, the adolescents are not understood from the subjectivity, in the specific aspects of the phase in which they are. Such aspects reflect in the adherence to treatment and strengthen the maintenance of practices that put the adolescent's rights at risk. 8,9 According to studies, there is a greater effectiveness in the treatment and a stronger link with the service when therapeutic workshops are made available to the adolescent in their age category, targeting an integral approach, without focusing on the substance use, but considering the different problems and dimensions of the adolescent's life. These workshops should be developed in a playful, expressive and dynamic way. It also highlights strategies that consider the adolescent's cultural and socio-economic context. [9][10][11] For this reason, understand the specificities of the adolescent crack user attended in the services that compose the RAPS may bring contributions to re-signify the care practices addressed to the needs of this public. Moreover, promote the strengthening of these service in the network with a view to subsidize an integral and decisive in accordance with the approved in legislation and public policies for the adolescent. In this sense, this research aims to analyze the specificities of care to the adolescent crack user attended in the RAPS.

METHOD
It is an exploratory and descriptive study with qualitative approach of data linked to a wide research project, entitled "(Wrong) ways traversed by the adolescent crack user in the psychosocial care network: contribution for the Nursing". The study was carried out in the Psychosocial Care Center Alcohol and Drugs (CAPS AD) and in the Psychosocial Care Center for Children and Adolescent (CAPSi) in a medium-sized municipality in the interior of Rio Grande do Sul that integrates the Program "Crack, it is possible to overcome".
Twenty professionals active in the CAPS AD and ten professionals active in the CAPSi participated in the research. The selection of the participants was intentional and was in accordance with the inclusion criteria and objectives of research. The inclusion criteria were: be medium-sized or higher worker of the multi-professional team from the CAPS AD or from CAPSi; have at least six months of actions in the service. Professionals who were on holiday or health leave during the period of the data collection were excluded.
The number of participants was defined by the data saturation defined when, in the researcher's assessment, a certain redundancy or repetition occurs, not being considered relevant to persist in the data collection. 12 The data collection occurred in the first semester of 2017, through semi-structured interviews carried out by a single interviewer. 12 The semi-structured interviews involved issues regarding the professionals' perception about the discussion on the crack use among adolescents in the municipality, as well as the insertion of the referred service in the RAPS, the forms of access, the attendance and management of treatment of the adolescents crack users.
With a view on the participants' privacy, the interviews were carried out in available rooms in services, respecting the functioning of the CAPS AD and CAPSi. In order to preserve the original content and increase the accuracy of data obtained, the interviews were captured by an audio recorder, and subsequently, transcribed in full.
For the organization and treatment of the data, we used the Nvivo 11 software, program that helps in the analysis of qualitative material with coding tools and text storage. 13 Later, data were analyzed and categorized as Thematic Analysis. 14 The following thematic emerged from the analysis of the data, about the specificities of care to the adolescent crack user assisted by the RAPS: specificities of care adolescence as stages of the life cycle; social specificities that involve the adolescent in situation of the use; differentiated care strategies towards the adolescent.
The participants were included in the study, only, after manifesting their agreement to participate by signing the Informed Consent Form (TCLE), in order to ensure the ethical principles related to researches involving human beings. Furthermore, the anonymity of the participants was preserved by means of the

Specificities of care to the adolescence as phase of the vital cycle
The participants reveal that the care to adolescents crack users in the context of the RAPS demands specificities related to the own phase of the adolescence that are differentiated from the care to children and adults.
In this sense, it is necessary to use an adequate language with the adolescent and take into account his way of being and of relating to the world and the health service. The formation of groups within the service, ambivalence in the treatment, humor instability, identity formation, are some specificities highlighted by the participants: There is much a difference, by all characteristics of the own adolescence, then, they are much more questioners, they are more critical, they are much more courageous, They still bring moments of this ambivalence of wanting or not wanting be there. Many times, with the identity crisis, which is the stage that they are living. [...] there are all the crises of the adolescent, his forms that question of the group, and soon they form mini groups within the group and then, already complicate (P18 CAPS AD).
"You need to have a good management, since they are very instable of humor, at a moment they wish too much something and after they do not wish more (P7 CAPS AD).

Social specificities that involve the adolescent in the situation of crack use
With regard to the social specificities of adolescents crack user, the lack of the family infrastructure characterized by the paternal and/or maternal absence, use of drugs in the family and cases of abandonment by the parents.
So, to know the family situation can direct the professionals to better understand the issues that involve the abusive crack use by the adolescent, as well as to act, considering the weaknesses in this scope: It is not a coincidence that the adolescent uses. When you contact the family you see that there is a complete family destructuration (P15 CAPS AD).
I think that the conduct shall be different [...] from the own family weakness that in most cases is involved [...], many times, the majority of these cases that we have in our unity there is no father and mother. There is a strong relation in this, of the lack of family structure with the use of drugs, then, I think that the team's conduct shall be differentiated (P16 CAPS AD).
I already comes from a family not well structured. We see the most, not all of them, but a large part of them, the mother who has a son of every father, leave, abandon, and or they got tired and they do not want more (P19 CAPS AD).
One also evidences social weaknesses related to the engagement with crimes, violence, school leaving, trafficking in drugs and internment. In addition, it is considered that the adolescent has little access to resources of the education, health, social assistance and leisure. Therefore, it is a demand that requires articulation with other sectors, aiming at the social reinsertion: If you'll think in a general way, in the general scope of the Many adolescents who come here and can not even write their own name, because he has already abandoned the school. He no longer know who is the president, he does not know who is the prefect, he lost its identity, together with its identity he lost information he stopped, stationed (P17 CAPS AD).

Differentiated care strategies towards the adolescent
With regard to care strategies, the participants emphasized the need for therapeutic workshops directed towards the adolescent public independent of specialized service for which is being attended, either in the CAPSAD or in the CAPSi.
In accordance with the professionals of the CAPSi the adolescents crack users present less focus on the activities proposed by the service, due to a greater agitation, impulse, symptons of abstinence and low tolerance compared to children under psychic suffering: The attendance together with these two publics in the same service is seen with concern by the professionals, since due to the experience with the use of drugs the adolescents can influence in a negative way the therapy of the other children and adolescents under psychic suffering. In view of that, varied and differentiated therapeutic workshops should be offered in the Capsi, considering the behavior dynamics of the adolescent crack user. In CAPSAD it is also identified the need of care strategies to the adolescent crack user differentiated from those offerted to the adult drug user. The adolescent crack user has more difficult identifying the drugs abusive use as a problem, since it does not have a history of material, family and social losses yet, compared with the adult drug user.
[ [...] The adolescente, he is very agitated, he has more energy. There's no way to put an adolescent here together with persons who are more older, they're already slower that is, then, they do not accept some attitudes of the adolescents and then it gives confusion (P20 CAPS AD).

DISCUSSION
The understanding of the social and historical conception of the adolescence and the singular ways of living of the adolescent promotes the construction of more effective interventions that Care to the adolescent crack user Ribeiro JP, Gomes GC, Santos EO, Pinho LB have contributed to thinking about the interfaces in the face of the phenomenon of the drugs use. 3 In this sense, it is relevant to know the different specialities of care to the adolescent crack user attended in the RAPS.
In the present study, it is verified that the care adolescent crack user should be differentiated from the adult and the child due to the own characteristics of the adolescence as phase of the vital cycle, as the experience of the identity construction process, acquisition of a group identity, ambivalence in the treatment. These aspects report the need for organization of the services for the attendance of this public, facilitating access and adherence to treatment.
Researches point out that currently the mental health professionals present difficulties on understanding the adolescence phase and organizing the service for this public. The adolescents hardly seek some type of treatment for drug addiction and, when he does it, present low adherence to the service due to the precariousness of therapeutic strategies offered. 15,16 One of the aspects related to this difficulty is the view on the adolescence still charged of stereotypes, many times, focusing on the view of adolescent "problem", as a person in transition, valuing little the singular moment of this phase. The adolescence should be understood as a dynamic process and a moment in that the ways of life and expression are constantly changing. In addition, it is necessary to analyze the historical and social contexto, the territory in of life, the sociocultural and economic clippings, and the implications of being adolescent in a contemporary society. 3,17 In this sense, it is important that the professional understand the own aspects of the phase in that the adolescents have been reached, stripped of judgements and stereotypes, but caming closer to the adolescent and his family and, together, trace a therapeutic proposal in that the adolescent can feel as protagonist and coresponible for the treatment.
Regarding the social aspects, the fragile family structure in which the adolescents crack user are included, with family abandonment histories, absence of the maternal/paternal figure and use of drugs in the family.
Other studies carried out with adolescents drug user, also, evidence the historical precedence of the drug presence that permeate the family relationships since the childhood, considering a risk factor for the experimentation and continuity of the drug use in the adult life. Researches identify the severity of the situations experienced by the adolescent due to the drug use in the family, with an intergenerational transmission of behavior model and the access facilitated to drug in the own family environment. 18,19 During a research about the adolescents'social vulnerability under treatment in the CAPS AD, is shown that, besides the drug use in the family environment, the non-coexistence or lack of dialog with parents or responsible constitutes a social vulnerability to the drug use. 3 In this sense, it becomes essential the awareness on negative consequences of the consumption in the family environment, aiming at reducing the vulnerabilities that can motivate the drug use, and promote a more protected and healthy environment for the adolescent's development.
The importance of family being close, of getting involved in the care to adolescents is highlighted in a study, since it is a period of many transformations in all aspects of these subjects'life, from biological to social. The affective link among the members is considered one of the strategies to prevent the problem and aid in the treatment. 20 Besides the family fragility, it is also identified that the adolescent crack use is vulnerable from a social standpoint due to being frequently involved in crime, violence, trafficking, and abandonment of school and hospitalization situations.
In a study with adolescents under treatment in specialized service is shown violence and criminality situations in which the adolescent drug users are included. The involvement of the adolescent with ilicit activities was identified, many of them with history of conflict with law and involvement in trafficking, emphasizing the activity as an opportunity for acquisition of material goods that, till then, were unable to access, others still opted for the ilicit activity as a possibility of recognition on the territory where they live. 3 There is also difficulty to understand that there is difficulty to understand that the adolescent drug user involved with crime requires a treatment that is indeed socioeducative and comprehensive for all their demands, which requires mainly a change of vision about the adolescent that is behind the use of drugs and of the infrational act. Stop seeing such adolescent as a threat to order, and understand him as, and understanding him as subject of rights is the main challenge for the advancement of interventions. 21 Also with respect to the social vulnerability, it is verified in the present study the situation of abandonment of school that is associated with the use of drugs by the adolescents. It is not possible to say whether the drug use is cause or consequence of the abandonment of school and/or the difficulties experienced in this means. However, correlation with the drug use by adolescents to considerable school losses, associated with repetences, lack of concentration, low grades, desire to abandon the school, feelings of tedium in the school environment, do not make school tasks, to miss/arrive late and academic damages were pointed out by researches. 22 Such results serve as a wake-up call to health and education professionals, aiming at integrating preventive actions in the school against drugs, of earlier identification of problems that interfere in the learning and in the relationship of the adolescent with the school environment, aiming in that way, promoting a better learning environment, preventing the drug use and the school abandonment.
In that way, the social vulnerability to which the users are included, as the fragile family structure, the involvement with infractional acts, the violence, the drug trafficking, the school abandonment highlights the need to articulate different sectors of the society among them, the health, the school, and the judiciary sector in order to handle the complexity of the demands that involve the adolescent crack user. The permanent construction of Care to the adolescent crack user Ribeiro JP, Gomes GC, Santos EO, Pinho LB the network and intersectoriality with partnerships supported in the territory are increasingly urgents in the field of the psychosocial attention of children and adolescents, introducing a greater potential of resolutivity of the needs. 16 In relation to the care strategies differentiated to adolescents, it is considered that there are specificities compared to children in psychic suffering attended in the CAPSi and drug users attended in the AD CAPS.
The adolescent crack user have low tolerance and less focus in the activities proposed by the service compared to children in psychic suffering attended in the CAPSi. These behavior can be attributed to the own phase of the adolescence, or even to the abstinence symptoms. Faced with this specificity, it is suggested dynamic therapeutic workshops in the service and in the spaces of the community, involving music, sport, use of new technologies, that is, activities considered attractive to this public.
The increase in the number of adolescents with problems related to drug use that need of the CAPSi intervention, has been changing the demand of attendance of these services. This scenario brought to the professionals new challenges, among them the need for greater understanding about issues that envolve the drug use in the childhood and adolescence and the construction of interventions that would make it possible the care integration to different publics in this service. 16 A research carried out with adolescents crack users pointed out that the CAPSi has difficulties to deal with this demand, and the responsibility for this public, many times is delegated to only one professional specific of the service. It is denotated that there is a lack of human and material resources, reproducing, frequently, the hospitalocentric model of attention. 9 This way of working weakens the therapeutic proposal of the service in the providing integral care.
Researches emphasize that interventions differentiated to the adolescent public in the specialized service configured as effective, assisting the young people to work better with their own experiences and problems, being also clear about the relation of pleasure and suffering related to the drug use in the adolescence. 23 Thus, by means of qualification of human and material resources it is possible to enable in the CAPSi more atractive and specific activities to this public, seeking to motivate the adolescent in the adherence to the treatment and to achieve the results proposed by the therapeutic.
With regard to specificities compared with the adult drug user, it can be identified that the adolescent does not have material, family and social losses compared with the adult drug user, thus, he has greater difficulty in identifying himself with a problem related to the use of the substance and, consequently, to understand that he needs support.
The adherence to treatment of the adolescent crack use is complex, since for adolescents the use of drugs has different meanings. The studies have shown that in the adolescence, the use of drugs gains space as a source of pleasure, new sensations, escape from realities and impasses in the transfor-mations characteristics of this phase, as well as, a socialization and acquisition strategy of a group identity. 24 In this sense, the abusive use of drugs, many times, may not be concerned with physical and social losses by the adolescent.
In view of that, the adherence to the treatment and attitudes of changing in the life style becomes a challenge, considering that one of the factors that facilitate the treatment is the awareness of problems related to the abusive use of drugs and the need for professional support. The user who, many times, is forwarded to the treatment in relation to the external influences such as family pressure and or judicial orders has difficulty to adhere to the therapeutic programs. 25 In this sense, it becomes esssential rethinking the ways of approaches of the adolescent in relation to the theme about the drug use and, especially, to ensure that the adolescent can obtain a space of speaking and listening both in the school and in the family, by receiving clarification, sharing experiences, doubts, desires and distress with regard to this theme. In the specialized services, the therapeutic activities should encourage the reflection about the drug use, the physical and social losses and, moreover, the stimulation to the development of health behaviors by means of the art, education, culture and sport.
The AD CAPS AD is one of the devices of the RAPS for adolescent drug users and, in the context of this study, this service attends adolescent drug users older than 12 years. Before this age group, the treatment in the CAPSi is done together with the AD CAPS. Therefore, the AD CAPS is shown as an important device of the RAPS to attend these adolescents. Althoug the treatment jointly with the adults is not beeing treated as positive in the view of some professionals of this study.
Currently, the AD CAPS is the service of the RAPS that present a greater records of attendance to the adolescents with disturb related to the use of psychoactive substances. 16 However, is showed in the research that when the adolescent is attended in the AD CAPS, together with adultos, it is noted an attempt by the professionals to treat him as the adults. In this way, possibly, there are losses for the adolescent, who present physical, social and psychological characteristics still in development. This fact may be associated with the low adherence of the adolescents to the service and precarization of therapeutic strategies developed in the services, with regard to the juvenile attendance. 15 In this aspect, both the CAPSi and the AD CAPS, that attend this group need to be instrumentalized for the juvenile attendance and, furthermore, to strengthen the definition of their roles in the adolescent drug user care network, avoiding the fragmentation and lack of accountability for the care.
In the composition of the network, the specialized services addressed, in this study, are part of the continued care, with greater potential of resolution if integrated to other services of the RAPS and of the intersectorial network, aiming integrety of the care. The specialized services when acting in a single way are not aware of the social and health needs that involve the adolescent drug user. In this sense, it is essential the teamwork alongside the basic attention, schools and the networks in which Care to the adolescent crack user Ribeiro JP, Gomes GC, Santos EO, Pinho LB the adolescent is included.
The basic attention is one of them, important, coupled with the care for the adolescent drug user, since is included in the territory and know the families and their needs. Thus, the strenghtening of these teams in the network could prevent the use of drugs in the adolescence, improve the acess to the network in cases that a specialized treatment is indicated and give support in the follow-up in the territory of the adolescent drug users under treatment. [26][27] In this perspective, the articulation between the specialized service and the basic attention strengthens the health sector and may constitute as a basis for support for the development of articulations with other sectors, allowing the instauration of increased networks and the collaborative construction of the intersectorial care in the assistance for children and adolescents. 28 In order to integrate the different demands in the RAPS services, it is emphasized the need to rethink the organization of the services, as well as, to qualify professionals to ensure quality service to the adolescent in abusive use of drugs in all points of the RAPS, by identifying the needs and the more appropriate service for the monitoring of the case.
It is understood that the adolescent need to be included in different spaces, by sharing experiences with different persons, as well as is his dynamics of life out of the specialized service. That way, it becomes essential that the family, the school, the services and the public policies can provide subsidies to enable the adolescent to live together in the different spaces and can choose to adopt more health life styles.

CONCLUSION
In this study, it was verified that the care to the adolescent crack user, attended in the RAPS, envolve specialties related to the own phase of the adolescence, the social questions that envolve the adolescent in the situation of crack use, and the care strategies differentiated from the children in psychic suffering.
The care to the adolescent implies understanding his differentiated way of relating with the world and with the health service. The formation of groups within the service, ambivalence in the treatment, humor instability, identity formation, are aspects that in their specificities need to be considered in the approach and in the organization of the therapeutic workshops in the specialized services.
Moreover, the adolescent crack user presents itself weakened from the social point of view, due to the conflicts under the family, school, and judiciary environment. In this sense, it requires an intersectorial work that acts both in the prevention and the social reinsertion of the adolescent in the family and society.
With regard to the care specificities of the adolescent crack user regarding children in psychic suffering, it is identified the need for offering differentiated actions in the Infantile CAPS, aiming to adequate the activities to the adolescent 's demands which, many times, may present abstinence crises, less focus and tolerance to activities carried out within the service. In this sense, it is suggested workshops that includes the art, the expression, the music, the sport and use of new technologies, making the activities more attractive to this juvenile people.
In the same way, the attendance to the adolescent crack user in the AD CAPS requuires specificities of care. Different from the adult, the adolescent, many times, does not recognize himself with problems related to the crack use for not presenting significant affective and financial losses, that will be demanding from the team strategies of motivation to the treatment anda id for reflection about the situation-problem, integrating different publics and the different perceptions about the use of drugs.
In light of the above, it must be understood that the care flows established for the attendance of the adolescent in the local network are essential, however, the AD CAPS and CAPSi, which are the points accessed by the adolescent crack user in the RAPS, must be prepared to welcome him in his specificities, evaluating the needs for care and promoting therapeutic workshops aimed at the specialized needs of this public. In this way, it is also necessary to rediscuss with other services of the network situations and specific cases that require support and organization of new flows, depending on the particularities of the cases attended.
In this sense, the look on the care in network, as proposed in this study, can still strenghten other points of the RAPS and its articulations, in meeting the attributes of the APS, as ordinator of the network and of the integrality of the care.
The current study has as limitation the fact of these data present only the perspective of professionals in specialized services of the RAPS. Therefore, it suggests other researches about the perception of users, families and professionals included in other services as the Transitional host unit and specialized nurseries of general hospitals and of the basic attention. The perception of different actors and professionals broadens the understanding of the theme and could contribute to qualifying the knowledge and practices directed toward the care to adolescents.

FINANCIAL SUPPORT
Support from the CAPES through scholarship of the National Post-Doctoral Program (PNPD 01/2016), awarded to Juliane Portella Ribeiro.