Socio demographic characterization of users of Child and Adolescent Psychosocial Care Centers in the state of São Paulo

The “Centros de Atenção Psicossocial Infanto-Juvenil” are dispositives of treatment for children and adolescents suffering from severe mental disorders. This article describes sociodemografic characteristics of users of those centers between September 2008 and February 2009 in the state of São Paulo, Brazil. Data from active files randomly selected was collected in 19 Centers in the state of São Paulo. The characteristics analyzed were divided in four groups of variables: identity; living conditions; family structure; schooling and occupation. The results indicated a higher concentration of users between 10 to 14 years-old; prevalence of males; tendency to nuclear and reduced family arrangements (45%); care primarily given by the mother (57%) and high frequency of users attending the regular school (86%). It was possible to identify a well-defined socio demographic profile of users, with differences regarding gender, attending the regular school and/or other institutions, as well as sharing a nuclear family arrangement. Uniterms: Adolescent; Children; Juvenile; Mental hearth services; Sociodemographic profile.

Various studies indicate a high prevalence rates of mental disorders in the child and adolescent population (from 15.8% to 50%), similar to those seen in the adult population (Almeida Filho, 1982;Laurindsen & Tanaka, 2005).The wide variation in results is due mainly to the large methodological heterogeneity found in the different studies (Brasil, 2004;2008).According to the World Health Organization (Organização Mundial da Saúde, 2002), the prevalence of mental disorders in childhood and youth is between 10% and 20% and the most common are the behavioral, attention, emotional and hyperactivity disorders.Relatively recently, in parallel to investigations on the prevalence of disorders, there has been the implementation of a new policy in mental health that includes child and adolescent health in its public and collective dimensions.The Centros de Atenção Psicossocial Infanto-Juvenil (CAPSi, Child and Adolescent Psychosocial Care Centers), created in 2002 and fundamental for the ongoing psychiatric reform in Brazil, are geared to meet the specific needs of children and adolescents when they have severe and/or persistent psychological distress (Hoffman, Santos & Mota, 2008;Lancetti & Amarante, 2008).In 2008 the state of São Paulo had 22 CAPSi.
The Centros de Atenção Psicossocial Infanto--juvenil are social facilities belonging to a field in which the paradigm implies constant readjustments and the creative search for solutions.Despite the official regulations, passed almost one decade after their creation, the CAPSi have possibly acquired particular and diverse features.Understanding the characteristics of the population attended by the CAPSi, beyond the epidemiologic interest (Pinto & Vansan, 1994), becomes a way of comprehending their public identity.Public policies, planning, review of intervention strategies, organization of services, and allocation of resources, among other things, rely on knowledge of the characteristics of the users.However, there are very few studies that describe the general sociodemographic characteristics of this population.With the exception of the study by Hoffmann et al. (2008), other investigations that attempt to describe the characteristics of the users of CAPSi have either been restricted to one or a few care units, or the populations of specific municipalities or schools (Assis, Avanci & Oliveira, 2009;Delfini, Dombi-Barbosa, Fonseca, Tavares & Reis 2009;Ferrioli, Marturano & Puntel, 2007).Couto, Duarte and Delgado (2008) analyzed publications and official data from the Brazilian government in 2000 regarding national public services related to children and adolescents.Crivelatti, Durman and Hofstatter (2006) carried out a qualitative study with six adolescents attending a CAPSi, investigating their feelings about depression and the knowledge they possessed about the disease, including sociodemographic data, such as gender, age, race, education, family income, time and type of treatment performed in the CAPSi.Delfini et al. (2009).correlated some sociodemographic data (gender, age group) with diagnoses of mental disorders in a CAPSi unit.
From a similar perspective to the work of Delfini et al. (2009) andHoffmann et al. (2008), the present article reports the results of a study that aimed to present the general characteristics of the CAPSi users in a geopolitical and demographic region that concentrates one third of the social facilities focused on mental health care, the state of São Paulo.It is comprehended that this problem becomes even more crucial when considering that the care directed toward the child and adolescent population has always been left in a marginal position in relation to the adult problem.The present study not only fills this gap but also provides the descriptive basis from which the public policy makers, the CAPSi team and the managers can reference in order to strengthen and implement actions aimed at this population.It was therefore decided to focus this report on the sociodemographic characteristics of the CAPSi of the state of São Paulo, analyzed from the active patient records from September 2008 to February 2009.

Method Participants
The representative sample for this descriptive study was composed of 921 patient records of children and adolescents, taking into account an expected 30% loss.The sample size calculation was based on the prevalence of twenty-one mental health problems of children and adolescents in Brazil and was proportional to the total number of active patient records in the units studied (2,216) with a significance level of 95% and an acceptable error of 3%.The inclusion criteria for the study were: the active patient records of users enrolled in nineteen units CAPSi in the state of São Paulo registered in the Ministry of Health for at least three months prior to the date of collection.

Instruments and Procedures
The data were extracted from the sample of patient records from all the units in the state of São Paulo at the time of the study.Once the unit and number of patient records to be consulted had been identified, a standardized research protocol, previously formulated for the collection, was used.Some of the categories of this protocol were based on a set of variables inferred from models of public network patient records, particularly used in the CAPSi.The data were recorded in the study protocols by trained researchers and, after the collection, were coded and entered into the Epi Info 3 v5.1 Database Program.The statistical software Stata 10.1 was used for the statistical analysis.The data, organized and arranged in tables, were then subjected to simple descriptive statistical analysis.
Patient records are a rich and convenient source of information for obtaining data regarding the health situation and characteristics of the population.Despite the known gaps in their completion, patient records are a valuable work instrument for any healthcare professional and have strong implications in the management of the services.Several studies have used them as a source of research data (Pereira et al., 2008;Prado & Fujimori, 2006;Reis et al., 2009).Conversely, as emphasized by Romero and Cunha (2006), the studies that use patient record data, such as this one, encounter a lack of data or gaps in the completion of the information as common obstacles.Thus, the limits of this study refer to the use of a particular and restricted source of information about the users, as it is not possible to define how much the written data correlate with the experience reported by the users and their caregivers.Furthermore, the patient records used as a data source for the study showed considerable differences in regularity and/or quality in the completion of the data in the different units.In the present study, when the proportion of missing data for a particular variable became significant, or omissions were above 50%, the data were used only as an indicative element.This was the case for the categories "skin color", "housing situation", "responsible for the income" and "performing an occupational activity".
For the socio-demographic analysis of the reference population four groups of variables were retained that comprise the following categories: 1) Identification: age group, gender, skin color.
3) Family structure: family composition (the relatedness between the inhabitants of the home of the user), who is responsible for the care of the user, who is responsible for the family income.4) Education and occupation: institutions attended by the user, type of institution and type of management of the institution (public or private), calculation of school adequacy (age relative to school grade), performance of occupational activities, performance of paid occupational activities, government benefits received by the family.

Identification
The age variable was divided into five age groups: from zero to 4 years; 5 to 9 years; 10 to 14 years; 15 to 19 years; and over 20 years of age.According to the sample data, the majority of the users were concentrated in the 10 to 14 years age group (40.2%), followed by the 5 to 9 years (26.3%) and the 15 to 19 years (24,3%) age groups.This variable, when considered together with the variable "gender" of the users, reveals significant data for the analysis of the CAPSi user population.These state facilities had 69.8% of boys and 30.2% of girls in attendance.The distribution of the users corroborated previous studies by presenting the prevalence of the 10 to 14 years age group and boys receiving healthcare (Delfini et al., 2009, Golfeto & Ribeiro, 1984;Hoffman et al., 2008;Ronchi & Avellar, 2010;Santos, 2006;Sposito & Savoia, 2006).Figure 1 presents the comparison between the total values of the age group and gender of the CAPSi users of the state of São Paulo studied.It is possible to note that up to the 10 to 14 years age group, the prevalence of boys who sought CAPSi was maintained, however, from the 15 to 19 years age group care for the female population prevailed.
As explained above, the percentage of missing data in the patient records regarding "skin color" prevented the analysis of this variable in this study.

Housing
In relation to the housing data, the volume of absence of notes in the patient records was 47.7% of the sample for "type of residence" and 67.3% for "housing situation".The findings are detailed in Table 1, taking into consideration that the "housing situation" data are purely indicative.It is worth noting that the majority of the patient records indicated that users inhabited houses or apartments and/or their own properties, which could indicate a relatively stable condition of life.This category also analyzed the situations in shelters, finding that 32 users, 3.5% of the sample, lived in shelters.The data collected from the patient records also showed that this small group was concentrated in the 10 to 14 years age group, in which a large part of the population was concentrated.

Family Structure
The patient records indicated that the CAPSi users in the state had a tendency to form nuclear families, constituted by the couple and their children, as 45.0% of the notes indicated that the users lived with both parents.A household with only one of the parents, the father or mother, was reported by 28.7% of the users according to the patient records.Other studies with CAPSi users from 0 to 14 years of age also highlighted the tendency for families formed by the couple and their children (Golfeto & Ribeiro, 1984;Pereira et al., 2008).Households with the mother, with or without other family members, composed 73.6% of the total.In the distribution analysis by age groups, 93.0% of the people aged 20 and over lived with their mother, with this value being 70.1% for the people in the 15 to 19 years age group.More detailed results regarding the family structure of users were found than those analyzed by Vasconcellos, Gribel and Moraes (2008), who said they was very little data related to the family situation in the patient records.In the present study, although it was not possible to specify characteristics such as age, education and occupation of the members of the users' family, data on co-habitation, as well as on the regulation and maintenance of the family living arrangements, revealed information about the context in which they were included.
Regarding the number of co-inhabitants, the majority lived with 4 people in the household (21.5%), followed by 5 (15.6%) and 3 people (14.2%), according to the user.There were very few who lived with more than seven people in the house, not even corresponding to 7.0% of the total.Considering that the information regarding those responsible for the income are only indicative, due to having 58.3% of the data missing, it can be observed, from the data, that in 20.4%   of the cases the father was responsible, in 9.0% the mother and in 3.4% both the father and mother.
Considering those responsible for the care, the mother appeared as the primary caregiver in 57.0% of cases, the grandparents in 7.8%, and the father in 2.5%, followed by care in shelters in 2.1% of cases.Thus, the intersection between the data on those responsible for the income, even if only indicative, and those responsible for the care of the child, revealed that in 82.7% of the cases where the mother was responsible for the income, she was also responsible for the care of the child.It was the same situation the grandmother, as in 84.2% of cases in which she was responsible for the household income she was also responsible for the care of the user.However, the father, when responsible for the income, was not responsible for the care in 93.5% of the families of the service, delegating this responsibility to the mother in 82.2% of cases.The considerable presence of the mother in the quotidian of the CAPSi users surveyed was therefore observed, regarding both the family living arrangements, as well as the function of care.

Education and occupation
Data on occupation of the CAPSi users of the State, collected through the patient records, revealed that 80.0% attended an institution in addition to CAPSi, as shown in Table 2. Of these, 89.0% attended a regular school and 6.3% attended a special school.The regular public school (state or municipal) was attended by the majority of the users entered in the school system and among those who attended a special school, the majority were in the public school network.
It was possible to infer information from the patient records regarding the school adequacy of the children and adolescents attending the CAPSi of the state.It was necessary to make a correction of the information regarding "age" in the patient records as it was only recorded when the patient record was created.The data used were the year of birth of the user, according to the information in the patient record, the grade in which they were in the school and the year of the information regarding the grade.However, once again, when performing the calculation between the year of birth of the child, the grade in which they were studying that year and the year in which this data was provided, in 45.0% of the cases there was at least one piece of information missing, making it impossible to make more precise statements about the school adequacy.From the data found, it was observed that the greater dispersion between the grades was at 12 years of age, in which there were children in the first grade through to the eighth grade of elementary education -equivalent to 8 years of dispersion considering the system of 8 years of study.At the ages 11 years, 13 years, 14 years and 16 years seven different school years were found for each age, configuring them as the ages with the second largest dispersion among the grades.
It is important to remember that the state of São Paulo had, at the time of the study, the continued progression system (São Paulo, 1997) that promotes the advance in the school grades focusing on the completion of the elementary education years by 14 or 15 years of age.By using this approach for the data of this study, it was observed that 67.7% of the young people aged 15 years were attending the 8 th grade of elementary education or the 1 st year of high school education.However, there was a wide dispersion in relation to the school years for the various ages and data was found regarding very advanced users in relation to their age.In the study by Ronchi and Avellar (2010), it was possible to identify that eighty percent of the CAPSi child and adolescent patients studied were mostly distributed in the initial stages of elementary education.These figures approach those found by Santos (2006), however, differ from the profile of users investigated in this study.
Finally, the information regarding the "occupational activities" performed by the users also did not appear in most of the patient records.From the indicative data existing in these documents, 12.0% of the CAPSi users of the state performed some type of occupational activity, and of these, 15.6% received payment for what they did, covering the age groups between 10 and 20 years, as shown in Table 3.It was not possible to define the type of work performed from the patient records.In addition to this information, it was observed that 22.7% received some benefits from the government, however, these varied widely, from free transportation, family support and school support to exemption from payment of electricity.

Discussion
Studies that investigate the scenario of child and adolescent mental health care provide subsidies for the implementation of practices and decisions with respect to specific care for this population.Few studies were found in Brazil that present the sociodemographic data of the users of child and adolescent mental health of the public network (Hoffman et al., 2008), as studies and services in the mental health public network are mostly aimed at the adult population.
The present study included sociodemographic data that allow the delineation of the child and adolescent population and their family contexts, inserted in the psychosocial care services.A higher frequency of users in the 10 to 14 years age group was obtained, a range in which it is possible to note the passage from the prevalence of male users to the prevalence of female users, due to the termination in the use of the service by the male population.
Given the above, it is worth questioning whether the prevalence of mental disorders according to gender is responsible for the unequal sexual composition of the CAPSi users, or whether there are other reasons for this.It should be noted that characteristics of the psychosocial development of the male and female children and adolescents, taking into consideration their different stages, contribute to or influence the unequal manifestation of mental disorders according to gender and that there are social configurations that lead to boys being more often taken as having severe mental disorders.Conversely, the relative decrease in the adolescent male population in the composition of the CAPSi user population in the higher age groups is explained by the classic male abandonment of healthcare.Associated with the male representation of omnipotence, this behavior of abandonment of the services by men is present and fairly widespread in the concept that public primary healthcare services are intended almost exclusively for women, children and the elderly (Figueiredo, 2005).The withdrawal of a portion of the male adolescents from these places identified with the feminine and with childhood is understandable from the point of view of the attributes assigned to the gender.However, the imaginary effects that lead to the withdrawal from the CAPSi cannot always be attributed to the isolated figure of the adolescent.Eventually, the family, the social group and even the characteristics of the service network operate in order to push them away or to undermine their adherence to the service.
It is also worth considering efforts made by some studies to investigate possible indicators of developmental problems or mental health problems in children.Kupfer et al. (2010) sought to analyze the predictive value of an instrument created by them to measure risks throughout the development and psychic constitution of children, and Assis, Pires, Pesce, Avanci and Oliveira (2011) examined psychosocial risk factors related to socioeconomic development.Both studies did not focus their analysis on gender differences, however, highlighted several factors that may contribute or hinder the development of children and adolescents.
In the present study, the family composition was seen to be predominantly nuclear, consisting of the mother, father and children, in which the mother plays the role of caregiver and is the more constant presence within the families.It was also possible to observe that most users lived under conditions which can be described as stable and they co-habited with a small number of people.It is possible to question the way in which the family organization affects the mental health of children and adolescents, considering the quality of the bond of care and attention with the caregivers and the economic conditions of the family.Pires, Silva and Assis (2012) point out in their study that the existence of family dysfunction may be related to the prevalence of attention deficit disorder and hyperactivity.Considering the issue of education, the CAPSi users were mostly students of regular public schools, who did not perform occupational activities outside of the school.It may be questioned whether, in view of the CAPSi policy of promoting social inclusion and intersectionality, the school would be the main link to the healthcare service.The analysis of the demographic data showed that the school is indeed very present in the lives of users, according to the patient records, either as point of connection and work with the network or as a depository for their problems.
As human beings fall under the various cultural norms of society due to certain characteristic processes, it can be asked what symbolic conditions are needed for the process of socialization of the child whose primary locus is the school?It can also be asked whether the school can be associated with the higher sensitivity to mental disorders of the male child and adolescent population, considering that in the school there may be a greater perception of behavioral components, which are probably less tolerated, such as agitation, aggression, and poor school performance, habitually linked to the social representation that are made about the boy.For the female infant universe the suffering might be confused with cultural characteristics related to gender, such as passivity, docility and melancholy.Within this perspective the problems that affect the mental health of girls only acquire greater social visibility as they enter puberty, with a transformation of their social role from child to adolescent and their greater social inclusion.It is understood that studies such as this one assist in the comprehension of how child and adolescent mental health has been accepted in Brazil and that, complemented with epidemiological studies and studies of the evaluation of the operation of the services, they can provide a basis for the development of new care strategies.
The study was conducted according to the regulations governing research with humans contained in resolutions nº 196/96 and nº 251/97 of the National Council of the Health Ministry of Health of Brazil, and approved by the Research Ethics Committee of the Faculty of Public Health, Universidade de São Paulo, under the protocol nº 1616, on April 20, 2007.All those responsible for the CAPSi units from which the patient records data were collected signed the Terms of Approval for the study.

Table 1
Type of residence and housing situation of the CAPSi users of the stateof São Paulo, 2008/2009According to Pearson's Chi-square test or Fischer's when Pearson's was not appropriate; ** Data regarding the presence of the variable in relation to their respective totals (n).

Table 2
Other institutions frequented by the CAPSi users of the stateof São Paulo, 2008/2009According to Pearson's Chi-square test or Fischer's when Pearson's was not appropriate; ** Data regarding the presence of the variable in relation to their respective totals (n).

Table 3
Extra activities and receiving benefits for the CAPSi users of the state ofSão Paulo, 2008/2009 Note: * According to Pearson's Chi-square test or Fischer's when Pearson's was not appropriate; ** Data regarding the presence of the variable in relation to their respective totals (n).