Multidisciplinary health care in cases of childhood suicidal ideation: operational and organizational limits

Objective : to know the health care process performed by the multidisciplinary team in cases of suicidal ideation for children and adolescents in Primary and Secondary Care. Methods : a descriptive study with a qualitative approach carried out with 12 professionals from ESFs, EACS and CAPS II in the city of Santarém. The software IRAMUTEQ 0.7 alpha 2 was used to build the similarity tree and analyze speech content. Results: the word “no” is present prominently in the interviewees’ speeches about experiences and strategies for coping with suicide, revealing an absence of individual preparation and structure in the segments of SUS Primary and Secondary Care. Final considerations: health team assistance finds operational and organizational limits during the implantation of intervention strategies and coping with the factors that trigger child and youth suicide. It is important to make specific resources feasible, to organize reference protocols and support programs for patients and families. Descriptors: Suicidal ideation; Child; Adolescent; Patient Care Team; Delivery of Health Care.


INTRODUCTION
Currently, there is a growing concern with the topic related to suicide, justified by the increase in the number of cases worldwide. According to the World Health Organization (WHO), this figure is alarming, reaching more than 800 thousand per year, and is expected to increase to 1.6 million in 2020. However, these data may be underestimated and much larger than imagined , as many cases of suicide are underreported or unreported, especially in countries in Africa and the Middle East. The world rate, according to a 2014 report, is 11.4 deaths per 100 thousand inhabitants (1) .
In Brazil, suicidal ideation has been gaining prominence in the child and youth population. From 2000 to 2008, 43 cases of suicide were registered in children under 10 years old and about 6 thousand adolescents aged 10 to 19 years old (2) . According to the 2014 Violence Map, the number of suicides in the young population (between 15 and 29 years old) increased by 8.9 between the years 2002 and 2012 (3) .
According to the WHO report (4) , in 2012, the suicide rate in Brazil in the age group of 5 to 14 years was 0.40 for every 100 thousand inhabitants, and in the range of 15 to 29 years was 6.70. In the same year, the Mortality Information System (SIM -Sistema de Informação sobre Mortalidade) registered 3 cases of suicide in children between 5 and 9 years old, and 117 cases in the 10 to 14 age group. This raises many discussions among experts, since there is no consensus on the degree of awareness of the irreversibility of death in suicidal children under 12 years old (1) .
Suicidal behavior is a complex phenomenon, especially in children and adolescents. Its manifestation involves negative social, family and economic repercussions. Nowadays, it is considered a serious public health problem and a challenge for professionals working in the area; therefore, it is necessary to think about preventive, informative and enlightening strategies in an attempt to minimize the occurrence of this condition (5)(6) .
First of all, it is necessary that the health professional has an "open mind" and sensitivity to suicide outside the social standards and taboos established by society. The multidisciplinary team must be prepared to understand all the aspects that the attempt and the consummated suicide of children and adolescents can cause in the family and society (7) . Furthermore, health professionals play a key role in the early detection of risk factors for suicide, preventing self-destructive behavior during care. It is worth noting that this assistance should not be limited to Primary Care units, the hospital environment, the Psychosocial Care Center (CAPS -Centro de Atenção Psicossocial) or the health departments. If the professional is able to identify risk factors for children and adolescents that make them potentially suicidal, it is necessary to intervene with the community in which they are inserted (8) .
Suicide prevention planning must cover 4 primary components: health promotion, prevention/education, intervention and post-intervention, carried out by health professionals that aim to outline care measures and involve patients, families and the community in the process therapeutic (9) .
The preventive measures that can be used are: the implantation of social programs, prevention of ill-treatment, prevention strategies based on history, suicidal screening in schools and reduced access to lethal means (10) . Stressful situations, especially those related to the family and school, should be mitigated with strategies to reduce risk factors and increase protective factors (11) .

OBJECTIVE
To know how health care is developed, by the multidisciplinary team, in cases of suicidal ideation among children and adolescents in Primary and Secondary Health Care in the municipality of Santarém, PA.

Ethical aspects
The study was developed in accordance with the disciplinary guidelines of the  (12) . All participants had prior knowledge about the research objectives and, after all clarifications, signed the Informed Consent Form (ICF).

Type of study
To answer the proposed objective, a qualitative and descriptive research was carried out, since it was intended to dive into the lived universe of the characters with the intention of describing these experiences, analyzing difficulties, perspectives and health care provided by the multidisciplinary team. Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (13) , Equator tool, were used to guide the methodology used in this article.

Study setting
The study setting was the Psychosocial Care Center II (CAPS II) and the Family Health Strategies (FHS) in the neighborhoods of Fátima and Santo André and the Community Health Agents Strategy (CHAS) of Laguinho, located in the city of Santarém, Pará, Brazil. These places develop daily activities and care directed to adult patients, youth and children assisted by mental health services.

Data source
The theoretical sample of the research was composed by 12 health professionals, among them, 08 nurses, 02 doctors, 01 psychologist and 01 social worker, distributed among the teams of Primary Health Care and Specialized Care of CAPS II. The number of participants was defined based on the criterion of theoretical data saturation, that is, by the evidence of the repetition of information brought by the interviewees about the studied phenomenon and the absence of new relevant elements for data analysis. The inclusion criteria were adopted: to develop their professional activities in the health service for at least 01 year and to have experience in caring for children and adolescents.

Data collection and organization
Data collection was carried out from December 2017 to February 2018. The tool that guided the data collection was a semi-structured interview script, with open questions to facilitate freedom of expression and the exposure of the participants' points of view. In general, the questions focused on the experiences of each person in relation to the suicidal ideation of children and adolescents, in the organization of the service to face this problem, in the main predictive signs and the strategies for preventing suicide that they used in their daily work. The interviews were conducted in the workplace of the respective interviewees, each in a private environment, according to availability and by scheduling a time. A cell phone device was used to record audio of the interviews, which lasted an average of 30 minutes. After listening and literally transcribing the words, the textual corpus was prepared for the data treatment procedure and subsequent analysis.

Data analysis
The interview data after its transcription was coded and constituted the corpus of analysis. For the process of organizing and categorizing data, support was sought in the software Interface for the Multidimensional Analyzes of Textes and Questionnaires (IRAMUTEQ) version 0.7 alpha 2 -a free and open source software that performs analyzes lexical textual data (14) . This type of analysis proposes the use of statistical methods to the texts obtained from the speeches of the participants. Unlike content analysis, it revolutionizes the form of text analysis by providing systematization based on the identification, organization and quantification of the obtained textual data. In this way it is possible to make the interpretation of the text viable for the researcher and has the advantage of reducing subjectivism and arbitrariness when coding the texts.
In this research, Similitude Analysis was chosen, which is based on graph theory. This makes it possible to identify co-occurrences and connect the words of the textual corpus (15) . The methodological orientation used to support the study was content analysis (16)(17) . Field notes were made after the interviews to assist in the construction of the analysis and not to interrupt the flow of data during the conversation between researcher-participant. The speeches of the participants were identified with the initial "Nur" for Nurse, "Doc" for Doctor, "Psy" for Psychologist and "Sow" for Social Worker, followed by the number corresponding to the respective interview.

RESULTS
The texts of the participants' responses were divided into two parts, taking into account the similarities between their contents in order to facilitate the analysis process carried out by IRAMUTEQ. The first corpus consists of 2 Initial Context Units (ICU), divided into 79 segments; and the second is composed of by 3 UCIs and 206 segments. The first corpus covers the experiences that the participants have in relation to the suicidal ideation of children and adolescents and some situations experienced in their professional practice that enabled the identification of the main predictive signs and their performance in relation to them. The second corpus comprises the intervention and prevention strategies used in daily work and how the service provided to these children and adolescents is organized.
After the creation of corpora, the Similitude Analysis tree (or similarities) was built in the IRAMUTEQ software, which allowed to identify the relationship and connectivity between the most used words by the research participants. From these two corpora analyzed by the software, the need to divide the content into three main themes emerged during the construction process of the study, specified below:

THEME 1: The experience and the professional challenge in the face of the suicidal ideation of children and adolescents
The similarity dendogram produced from the first corpus ( Figure  1) refers to the experiences that professionals have in relation to the theme of suicide in children and adolescents.
It can be seen that in the center the word "no" stands out, making a strong connection with the word "adolescent", associated with "idea", "suicide" and "history". The peripheral zone "mother" is related to the words "start" and "perceive". And "child" is related to "seeing" and "history". Other more peripheral words are associated with the stories that the professionals told about their experience of suicidal ideation for children and adolescents. Regarding the experience of the study participants, some have already had contact with the suicidal ideation of children and adolescents, receiving patients who demonstrated depression and self-destructive behavioral crises, mainly on the part of adolescents. Much of this experience was acquired in daily work, consultations and contact with the community. However, most health professionals have never witnessed a suicidal situation, but they know this situation through patient histories, reports told by third parties, media or experience through courses conducted on their own initiative, among others. It is observed through the interviewees' speeches that the reference to suicide is more linked to young people/adolescents. In children, suicide is rarer or more difficult to be detected, taking into account the lack of experience of these professionals with this audience.

THEME 2: Predictive signs of suicidal ideation and professional performance in front of them
This second theme is still related to the first textual corpus, where the similarity tree is represented by Figure 1. The participants made some observations during the interview regarding what the young people reported during the consultations, the reasons why they wanted to take their own life and the main factors that triggered this feeling. [ She came home saying "look, mom, the girl, the neighbor took medicine", "but why?", "Oh, because she got a low grade and her mother was going to beat her". (Nur_08) There was that story of the blue whale, right, or else, because she is watching the video which is cool and then she will want to do it ... now the fashion, I don't know if you've seen it, it's that thing of doing everything the youtuber is doing it, the person recording the video. "Ah, let's try this", then, like "let's put a rope, look how you do it, like this", giving the teen an idea to commit, but in reality the teen from here thinks it's a cool thing, a joke, but on the other side there is another idea, which is the idea of suicide. (Nur_08) We can observe that the word "no" appears several times in the texts, but this time as an adverb of denial related to the stories told by the participants in their experiences with children/adolescents who presented suicidal ideation. The word "mother" also appears in this part of the reports more often than in other subjects.
According to the report of the health team professionals, the main performance during the care involves collecting the history, referring the child/adolescent to the psychologist according to need and multidisciplinary care following the Ministry of Health protocols. Another measure reported by them is the realization of dialogue with the patient and family guidance regarding the pathology, care, surveillance and safety with this patient and the risks that permeate him to carry out the suicidal act, as well as the way to avoid them.
There is the Ministry of Health's Suicide Manual, which recommends some risks for suicide, and within these risks, introducing protocols that must be followed. So CAPS II, according to one of the interviewees, has support groups formed by patients and their families, developed by nurses and psychologists who work at this Center. And it helps a lot who wants to share their story or seek help to overcome their problems.
of Multidisciplinary health care in cases of childhood suicidal ideation: operational and organizational limits Sousa KA, Ferreira MGS, Galvão EFC.

THEME 3: Organization of the Primary and Secondary Care Service and strategies for coping and preventing child and youth suicide
The second corpus (Figure 2) constitutes the professionals' speeches about strategies used in their daily work to face the problem, for prevention and actions that could be used to reduce the number of deaths by suicide in Brazil.
The results revealed the central word "no", establishing a strong relationship with the word "because", which connects to a network of words such as "strategy", "approach", "problem", "support". The other arm of similarity establishes the relationship with the word "child", which relates to the words "adolescent", "family member", "suicide", "suffering", "committing", "urgent", "avoiding". Another important part of the graphic is also highlighted by the word "patient", which is closely associated with the word "family", which follows "nucleus", "responsible", "guiding", "addressing, " preventing ". The word "patient" is also associated with "crisis", "reception" and "monitoring". In the periphery, the word "school" can be perceived, which follows "education", "health", "bond".
As a suicide prevention measure, the professionals judged the family as an important ally that, added to health education in schools, units or even in the community, constitute an important tool in the prevention of suicide in Brazil.
When we talk about children like that, we talk about education, identity, and especially the family context, which is the first nucleus. The interviewees also point to the need to create and execute viable and feasible public policies that improve access and user care in the Brazilian Unified Health System (SUS -Sistema Único de Saúde), especially those who urgently need it, such as the patient in crisis. In addition, another strategy cited is breaking the established social taboo that can be done by creating discussions about suicide, both in children and adolescents, as well as in adults.
Still related to the reports of this second corpus, one can notice many problems regarding the organization of Psychosocial Care Network (RAPS -Rede de Atenção Psicossocial) aimed at coping and preventing suicidal ideation. For instance, the lack of qualified professionals, the lack of communication between the levels of health care, the lack of physical structure and institutional support that cause a discontinuity in the patient care process.   In the speeches, the word "no" is closely associated with the lack of organization and structure of the service to welcome patients who need resolutive and quality care; and the word "patient" used here refers to a general public, including children and adolescents.
The lack of support to care for patients in crisis creates great difficulties for professionals who try to provide quality care. Getting the patient out of that state and making the appropriate treatment, both with regard to Primary and Secondary Care, is a major challenge for these professionals. [ There was a disparity in the care of suicidal patients in Primary Care in relation to Secondary Care. In the first, the patient does not continue to participate in the attendance at the Health Unit because there is no structure, medication to take out of the crisis or support to serve him right there. Factors that may lead the adolescent or child to suicide are rarely identified, mainly due to lack of knowledge and experience. In Secondary Care, the patient has already been referred from a health unit or goes to the Institution on demand, already with symptoms or with existing suicide attempts. However, there is also a lack of resources to care for patients in crisis. In this case, they are sent directly to the Municipal Hospital.
We need urgently in Santarém to have a CAPSi, which we don't have. I know there are projects that have already been done and everything, but we don't have them. [...] we care for children, we don't send anyone back, but we often refer them to CRAS to give this support, we call this patient's school, often the teacher comes here with us to ask for help, and then we are working that way, but we will not have an expected result. (Nur_05) As noted in this speech, the lack of the Child Psychosocial Care Center (CAPSi -Centro de Atenção Psicossocial Infantil) is also an evident problem. As there is no structure for the care of children and adolescents, they are served in the same place as adults or are referred to the Social Assistance Reference Center (CRAS -Centro de Referência de Assistência Social), which, according to reports, is made up of professionals who are closer to the community. and can make the necessary interferences. These professionals deal with problems related to the lack of structure in the Health Network on a daily basis, however, they try to solve it in different ways by partnering with other professionals.

DISCUSSION
RAPS is organized in several points, from Primary Care in health units, Strategic Psychosocial Care in CAPS, Urgent and Emergency Care and Hospital care with mental health beds. These access points to mental health must be organized, interconnected and communicating. In addition to providing care, these services must also identify the vulnerabilities and specificities of patients, as is the case with suicidal ideation for children and adolescents. Within the mental health policies, the professional cannot work today only in the treatment of the pathology, but rather do the welcoming, listening, counseling, care; and enable access to quality of life, taking into account each individual and their case (18) .
According to Ordinance 336, of February 19, 2002, CAPSi must be instituted for such demand in cities with more than 200 thousand inhabitants, with the aim of welcoming and providing assistance to children and adolescents who are psychically compromised, having physical structure, adequate human resources and articulation between the sectors of the network to guarantee comprehensive care (19) . As noted in this study, in practice this service is absent, despite the population of Santarém/PA being equivalent to 294,580 people, according to the 2010 census, and estimated at 302,667 inhabitants in 2018 (20) .
As the main conducts of professionals working in Primary Health Care, referrals to CAPS and medicalization are the most important (21) , in addition to health education and establishing a close relationship with the patient and family for health actions. health promotion (18) . However, it is possible to observe that both in Primary and Secondary Care, medication for patients in crisis is not always available, and it is necessary to refer them to a hospital. The intervention, which could be immediate, ends up becoming remote when there is difficulty in calling SAMU 192 (SAMU performs the urgency and emergency care, through ambulances, anywhere: homes, workplaces and public roads) or when there are no specific beds for mental health patients in the hospital. There is often no communication between health care levels and the patient ends up not receiving adequate assistance.
As observed in the speeches of the participants in this study, suicide in children and adolescents is becoming more and more increasing and the media ends up collaborating in a certain way for this. In a research that corroborates this aspect, the behavior of the so-called Werther Effect or suicide by contagion is discussed, in which a suicidal act becomes a trigger for others and ends up with mass deaths. With the eminence of the Blue Whale game, there was great repercussion of this subject in the media. In this, the participants are involved in high-risk and self-mutilation challenges, and always end with suicide as the final step. It was found, then, that the internet and the media are major influencers of childhood suicide, however, there is also the other side of the story, in which they can be used as means of prevention and help (22)(23) .
As a protective factor, the family ends up becoming the first instance to be taken into account by professionals. Since it is the main support center for coping with the suicidal ideation of of Multidisciplinary health care in cases of childhood suicidal ideation: operational and organizational limits Sousa KA, Ferreira MGS, Galvão EFC.
children and adolescents, health professionals invest in the care and education of the family together with the patient, in helping with family crises and in reducing risk factors. In this context, it is possible to observe the importance of the social worker, who forms a closer link to the family (24)(25) . In this study, however, all professionals end up getting involved in a certain way with the patient and family, especially the nurse. Information about suicidal behavior, signs and risk factors can help the population to identify, help and educate children and adolescents who have ideation, as observed in this study and others (26) . Thus, health professionals should invest in health education aimed at this audience and families, in addition to subsidizing access to mental health care, recommended by SUS (18) .
It is also important to discuss the relevance of the school to act in the promotion of protective factors for suicidal ideation and also in the detection of risk factors for mental illness on the part of children and young people, since it is a place where they are most concentrated. According to the Ministry of Health, it is not for the educational institution to identify and diagnose pathologies, but it is its duty to build a favorable environment for health promotion (18) .
The mental health policy, although very strict in its laws, decrees and ordinances, still has gaps and many restrictions with regard to the practice of professionals. There is no implantation of the guidelines established by the policy. However, it was observed that children and adolescents are being increasingly included in mental health care, with increased access to services previously available only to adults. Even though there are no specific care services for this age group, the policy provides that they should be attended to in services for adults, which opens up other questions about the lack of training of professionals and the lack of an adequate structure to receive this clientele (27) .

Study limitations
This study has a deep theoretical basis, but there are few studies developed on this theme, which makes it difficult to search for articles to discuss the topic. In addition, there is a difficulty in approaching the target audience for the interview, since it is a subject surrounded by many stigmas and taboos, especially when it relates to children and adolescents. The applied methodology, however, yielded great results and favored the construction of this study without the limitations making it difficult.

Contributions to the area of nursing, health and public policies
The information collected in this study is relevant and aims at the improvement of health professionals in the identification of potentially suicidal children and adolescents through knowledge about the subject in question, in addition to the effective collaboration for the training of students who may come across his academic and professional life with child and youth suicide.
The collection of information about the knowledge of health professionals through this problem allows a clear view of whether they are prepared to identify and provide the necessary care to these potentially suicidal children and young people and contribute to the detection, prevention and fight against this disease that affects many families and Brazilian companies.

FINAL CONSIDERATIONS
The survey results reveal operational and organizational limits. Health professionals still do not feel able to provide quality care to children and adolescents who have suicidal ideation. The similarity dendrogram constructed from his speeches about the experiences and strategies for coping and preventing suicide, reveals that the word "no" is present more prominently in the discourse tree, which refers to an absence of Public Health System preparation and structure. In addition, the great professional challenge that the health team faces on a day-to-day basis to provide quality care can be observed in the speeches during content analysis.
RAPS still has gaps that need to be overcome. Professionals feel the need to make resources available for the proper development of the service by the Government; to organize support programs for patients and families using mental health, with an emphasis on intersectoral communication between Primary Health Care and Specialized Care (CAPS); and to include referral and counterreferral protocols and itineraries for identifying, welcoming and referring patients with suicidal risk.
Even if there is no CAPSi for children and adolescents, professionals who serve adults know that they must be prepared to receive this clientele, since they cannot be returned to their homes without the necessary care and intervention. Therefore, it is important to expand the means of qualification provided by the service, to strengthen Primary Care in conjunction with specialized care, to structure the Mental Health Network and public health policies.
Family, schools, community must be informed about the risks, oriented about what to do when there are children and adolescents with suicidal ideation and how to intervene with health professionals so that there is a decrease in the number of deaths from this cause in Brazil.
Lately, the theme of suicide has been approached more constantly in the media, in research and reports from global and federal institutions that aim to reveal suicide and its attempt as a serious public health problem. In this sense, the great social, economic, family and individual impact that self-destructive behavior causes, raises the need to conduct more research that addresses suicide from other perspectives, involving other social actors, including children, adolescents and family, also evaluating the factors that lead to suicidal behavior and child and adolescent self-harm.