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Cadernos Brasileiros de Terapia Ocupacional

On-line version ISSN 2526-8910

Cad. Bras. Ter. Ocup. vol.27 no.2 São Carlos Apr./June 2019  Epub May 06, 2019

http://dx.doi.org/10.4322/2526-8910.ctore1660 

Experience Report

Intersectoriality in the field of child and adolescent mental health: proposal of occupational therapy in the school context

Amanda Dourado Souza Akahosi Fernandesa 
http://orcid.org/0000-0001-8006-8117

Maria Fernanda Barboza Cida 
http://orcid.org/0000-0002-0199-0670

Marina Speranzab 
http://orcid.org/0000-0003-1186-1386

Cleonice Guerrero Copib 
http://orcid.org/0000-0002-9092-1588

aDepartamento de Terapia Ocupacional, Universidade Federal de São Carlos – UFSCar, São Carlos, SP, Brasil.

bUniversidade Federal de São Carlos – UFSCar, São Carlos, SP, Brasil.

Abstract

Introduction

Child and adolescent mental health care is based on some care guidelines, including the permanent construction of the network and intersectoriality. It is pointed out that intersectoral actions between the fields of education and health are extremely important so that childcare and adolescents to occur in a meaningful and integral way.

Objective

Identify the main demands regarding child development and mental health in the school context and to describe the possibilities of occupational therapy interventions in intersectoral practices in mental health with a focus on promotion and prevention.

Method

This is an experience report related to a university extension project developed in a Child Education Unit. The activities developed in the project involved different actions, These are presented in two stages - the first one focused on the identification and mapping of difficulties and demands in the field of child development and mental health, and the second step refers to the actions carried out in this context, such as the insertion in classrooms and follow-up of the activities developed, the orientation and instrumentalization of teachers after insertion, and the reflection group for school staff and family members.

Results

The interventions performed as positive were evaluated in order to contribute to the potentiation of the different contexts, being considered an important action of prevention and promotion of the development and the mental health of the children.

Conclusion

Actions of this nature contribute to the development of children and adolescents, as they are fundamental in guaranteeing comprehensive and effective care.

Keywords:  Growth and Development; Occupational Therapy; Mental Health; Intersectoral Collaboration

1 Introduction

Child and adolescent mental health care should be guided by some care guidelines, such as universal acceptance, co-responsibility and involvement, and the permanent construction of the network and intersectoriality. It is also imperative to convene intersectoral actors that without them, a powerful response to mental health issues will not be possible (BRASIL, 2014).

Among the guidelines, intersectoriality in the care process can be characterized in the health context as the relation of one or several sectors and their parts, aiming to achieve effective results, which would not be achieved only by the work of a single service, guiding the practices of networking. In this way, micro and macro intersectoral strategies, which are built in articulation through the State and society, bring significant contributions to health actions. Also, these articulations and arrangements can take place through the construction of partnerships between different sectors and social segments, such as health, culture, education, sports, leisure, community organizations, foundations, religious entities, among others (SILVA; RODRIGUES, 2010).

In the mental health area, intersectoriality has changed the user's conception, placing him not as a patient, but as an individual who needs a humanized intervention recognized by society. However, this was only possible with the strengthening of networks and the creation of social policies, aiming at the integrality of the individual (SCHEFFER; SILVA, 2014).

Therefore, with the support of child mental health care guidelines and its historical track record, occupational therapy is proposed as a profession that has been active in this area, comprising both the health sector and the teams of the Child and Adolescent Psychosocial Care Centers, in the basic health care services (Family Health Unit, Basic Health Unit, Street Office), hospital care and other points of attention of the current Brazilian mental health policy, as well as the education and social assistance sectors. Occupational therapy has a field of theoretical and practical knowledge essentially committed to the processes of social inclusion (CARDOSO; MATSUKURA, 2012; CID; GASPARINI, 2016; FERNANDES; MATSUKURA; LOURENÇO, 2018).

Thus, according to the national curricular guidelines that deal with the training of the professional occupational therapist, it must (BRASIL, 2002, p. 2):

[…] understand health-society relationships as well as social exclusion-inclusion relationships, and the participation in the formulation and implementation of social policies, both sectoral (health, childhood and adolescence, education, work, social promotion, etc.) or intersectoral policies.

From this perspective, the professional in the mental health area can act in different contexts of insertion of the child and the adolescent, enabling more effective and integral care. The school context, for example, is one of the possibilities for intervention, so the professional acts as a facilitator in the development of actions to prevent and promote mental health, and specialized care interventions, mediating the interaction of child who experiences psychic suffering with peers, educators, and family members. This intervention favors emotional well-being and assists in adapting to the environment in its institutional, social, emotional, physical and cultural aspects (OLIVEIRA; CASTANHARO, 2008; CID; GASPARINI, 2016).

Thus, the practice of the occupational therapist in the school is not clinical, but an intersectoral practice of promotion to mental health, from the collaborative construction of care. It is a work developed with educators, family members, and the community, aiming at guaranteeing access and inclusion to the school (ROCHA, 2007; CID; GASPARINI, 2016).

Based on the national and international literature, Cid and Gasparini (2016) reflect on actions of promotion and prevention in mental health carried out in the school environment. The authors argue that this type of interventions have positive effects and may also involve ongoing education processes with school professionals about the issue of child and adolescent mental health, the construction of more effective strategies for school inclusion through environmental modifications in the classroom and managing relationship, conduct, and content, and performing social skills training.

Intersectoral actions between the fields of education and health are extremely important for assistance to children and adolescents occurs in a meaningful and integral way, as paying attention to the individual within their own social context (ROCHA, 2007; OLIVEIRA; CASTANHARO, 2008; CARDOSO; MATSUKURA, 2012; CID; GASPARINI, 2016).

Thus, this paper reports an experience proposed to explore the possibilities of occupational therapy in intersectoral practices in mental health in the school context with a focus on its promotion and prevention.

The experience described here is a cut of the extension activity entitled “The intersectoriality in the mental health area in children and adolescents: training of teachers and actions of promotion and prevention of mental health in the school context”, offered during 2016, linked to the Mental Health Research Laboratory of the Occupational Therapy Department of the Federal University of São Carlos.

2 Method

This is an experience report related to a university extension action. The approach is based on the systematization of the notes of the field diaries of the authors, which contained records of observations and reflections of every process developed in a Child Education Unit of a city in the interior of the State of São Paulo from May to November 2016.

The Unit for Early Childhood Education as the focus of this action was inaugurated in 1992, and it is intended for the education of children from 0 to 5 years and 11 months old, constituting the first stage of basic education.

The contact between the team of the extension project and the direction of the Unit occurred through intersectoral actions carried out from the follow-up of children/students with psychic suffering, assisted by the occupational therapy in the context of the university school service. Such an approach favored the opening of a communication channel between the extension project team and the Child Education Unit so the direction presented to the project coordinator a demand for support to deal with some everyday situations related to mental health development.

Therefore, the project began to be developed, based on a process that involved two stages:

  • Stage 1: It aimed to identify and map the difficulties and demands related to children's mental health together with school professionals. For this, the project team met with the school team in three moments previously combined, with the pedagogical coordinator, the director, and three teachers. From a collaborative process, the main demands and difficulties were traced, as well as discussed the possible interventions to be carried out by the project;

  • Stage 2: It refers to the actions performed/implemented since Stage 1, involving some interventions developed by the extension project team: a) insertion in three classrooms and follow-up of the activities proposed by the teachers; b) meeting with the teachers, aiming at the orientation regarding the difficulties experienced in the classroom and instrumentalization of them regarding the strategies that could be adopted to face the difficulties and demands identified; c) group with relatives, aiming to address different demands related to the development and mental health of children. This group was composed of school staff members and family members.

3 Results

The results of the intervention process in occupational therapy conducted at the Infant Education Unit will be presented below. The results for Stage 1 and later Stage 2 will be presented first.

3.1 Stage 1: identifying school team needs

The demands identified in the development of Stage 1 regarding the experience reported here consisted of difficulties presented by three teachers in handling some behaviors presented by children in daily life, such as:

  • The little involvement of the children in the activities offered by the teachers;

  • Distraction behaviors during the activities;

  • Agitation and manifestations of aggression, which compromised teacher planning and interaction among children.

Faced with these demands, planning of actions to promote children's mental health in the context of the school was collectively built (among extension team and school staff).

The first planned action, still in line with Stage 1, was the observation by the project team of the three classes that were assisted by the three teachers who presented the demands, understanding and experiencing the difficulties presented and complementing the process of identifying needs for further planning of the most propositive actions.

In this way, the three classrooms (children from four to five years old) were observed by the project team. From this action, it was possible to map and identify different aspects: planning and development of the activities proposed by the teachers; identification of children, their difficulties, behaviors and development; differences and potentialities and established routine.

After this mapping and discussion with the extension project team, some meetings were held with the three teachers to reflect on this first insertion and to think collectively about strategies, tools, and possibilities that could favor everyday life. As an example, it was identified that children lost focus and were distracted in the environment by the provision of materials and furniture. Based on this identification, this aspect was pointed out at the meeting, so the teachers were able to dialogue with the project team about strategies and alternatives to this problem.

In this way, after completing Stage 1, it was possible to identify the following demands: orientation and reflection with the school staff on aspects of development, mental health and classroom management about the activities developed; reflection group with family and school staff.

3.2 Stage 2: action strategies

Based on the results from Stage 1, two action strategies were planned and implemented, as described as follows:

    a. Meetings with school staff to reflect on child development, child mental health, and classroom strategies

Four meetings with the school team were planned and developed with the objective of approaching and reflecting from theoretical assumptions such as the Bioecological Theory of Human Development and risk and protection factors, child development themes, development contexts (especially the family and school) and its influence to the process of growth, with the examples of the situations experienced in the classroom and reported by the teachers.

Child mental health was also approached to allow school professionals to reflect on the behavioral and emotional difficulties presented by some children as a form of communication of subjectivity, singularity, and expression. The intention at this time was to reflect on the importance of not pathologizing childhood and, consequently, to instrumentalize the school professionals in the management of daily difficulties, avoiding medical referrals and medicalization of natural situations, including those related to the development phase.

Also, in these meetings, the strategies and resources that the teachers were using in the classroom and the difficulties found by them, as well as possibilities of support were set out. This recognition and reflection enabled the identification of some contextual factors that seemed to impair the engagement of children in the proposed activities, such as:

  • Planning of the routine of the day determined by the teachers;

  • Choice of activities performed in the classroom;

  • Structure and arrangement of materials and resources in the classroom;

  • The lack of an immediate conflict management strategy among children.

Thus, together with teachers, a process was developed to create strategies to deal with such demands. The importance of a routine and the clear rules related to the environment and the relationship with the peers, as well as the disposition of the environment and the choice and preparation of the activities were discussed from dialogued reflections. Also, regarding children's behavior, the management of conflict situations and activities that would facilitate their interaction, cooperation and socialization were discussed.

In this process, the following strategies were implemented by teachers for two weeks:

  • Reorganization of the environment - change in the disposition of materials and furniture and delimitation of the spaces of the classroom;

  • Redefinition of time and duration for each activity stipulated from the children's age group;

  • Use of visual and concrete resources that draw the attention of children, favoring concentration, attention, and engagement in the most directed activities;

  • Establishment of rules and limits in the classroom to be worked daily with the children, for example, the moments of using the toy boxes, leaving the classroom and remaining in activity;

  • Management, based on dialogue and mediation, in situations involving agitation and aggressive behavior, aiming at children's perception of these behaviors and, consequently, creating coping strategies to face everyday situations.

After two weeks, the project team met with the school staff to assess the teachers' perceptions of the strategies implemented. The teachers evaluated the actions positively, since there were changes and differences in the behavior of the children and posture of the teachers, favoring the accomplishment of the proposed activities and consequently promoting the development.

    b. Sharing the knowledge: a group with parents and school staff

With the development of the first actions, many parents were informed about the completion of the extension project. They began to ask the school staff for moments when they could also share the difficulties they experienced in caring for their children.

Thus, the school team presented this demand to the coordinator of the extension project, considering that these moments could potentialize the work in the school context and favor the development of the children since different actors would be involved.

A proposal was then made to create a group where parents and school staff could meet with the project coordinator. The proposal was that these collective meetings could be exchanges, moments of sharing difficulties, powers and collective strategies that could be created to face the difficulties, with the coordinator of the project being only a mediator.

The entire school community was invited to participate in the group, and the families (parents and mothers) of children linked to the unit from different classrooms who expressed interest were present at the meetings.

Three meetings were held for two hours each, held at the School Unit.

In the first meeting, the proposal was presented to the participants, explaining the purpose of the group, and a discussion on child development was introduced in different aspects, addressing the power of childhood and the role of the contexts that are inserted. Thus, the concepts of risk factors and protection for development and their influence on the promotion of mental health and prevention of psychic suffering were addressed. It was a time of change, where parents and teachers could approach, share and talk about children and how they have developed in the family and school context. This first meeting strengthened the link between these two contexts and the actors involved to understand the need for family-school partnership and to support children's development.

In this meeting, it was agreed that in the next meeting would bring something difficulty or of potentiality that could share about the day to day with their children.

Thus, in the next two meetings, a lot was shared and the exchange of experiences was potent. For example, a parent brought the difficulty in presenting the limits to the daughter and how much this has negatively interfered in the family dynamics and routine. Another brought on the constant tantrum behavior and the difficulties of acting at that moment. In these discussions, the family and teachers identified with the situations and also brought their personal experiences.

As situations were exposed, the coordinator (researcher) led for the group reflect on strategies or share similar situations. Thus, the coordinator only mediated the speeches and clarified some points, so everyone could participate and share. In this process, the main themes that emerged were: difficulty in feeding children; difficulties in the routine establishment; the stimulation of out-of-school development; and the parent organization to share time with the children to play, to do the lesson and to have leisure activities.

This process was evaluated during the meetings, in which the participants said about the importance of times like these, since many of them felt impotent and solitary for the care of the child and, often, unprepared for to deal with the demands of development, generating situations of doubts, uncertainties, and insecurity. Also, both the school staff and parents saw this moment as a fundamental partnership to foster dialogue and exchanges, enabling more effective strategies to deal with the difficulties experienced.

4 Discussion

Studies have pointed out the importance of collaborative interventions, developed from horizontal relationships in care processes, as observed in the study by Cid and Gasparini (2016). When reflecting on the results of a systematic review of the literature on child mental health interventions in the school context, they indicate that the actions presented in the studies are predetermined by those who coordinate it, regardless of the needs and potentialities of the population and target contexts, as well as the policy of assistance offered by other child labor sectors. In this context, the authors advocate the implementation of practices and studies that consider the real demands of the context to become more meaningful and to promote the active participation of the actors involved (CID; GASPARINI, 2016).

Also, considering occupational therapy in the mental health area, actions are circumscribed in the context of a new paradigm, which considers that the individual/group and their fragilities and potentialities must have active participation in the intervention process, in the sense of producing autonomy and social participation. This practice was identified in the actions carried out in this project, since they involved horizontally the different intersectoral actors, such as family members, professionals in the field of education and the health project team (COSTA; ALMEIDA; ASSIS, 2015).

The action of occupational therapy in the context of prevention and promotion of children's mental health considers the attendance policies and the rights of children and adolescents, as the primordial right to education, as suggested by Couto and Delgado (2016). That is, in the mental health care of children, actions must be configured in a social dynamic that supports the different forms of existence of children and adolescents, being individuals of rights.

Vicentin (2006), arguing that actions of attention to children and adolescents should be fundamentally expanded, emphasizes that children and adolescents with their conflicts and suffering affect the whole social field, presenting challenges and questions to the ideal adults, involving them. In this way, their conflicts spread to families, schools and other institutions, calling the adult world to analyze and evaluate their positioning permanently.

Thus, agreeing that the care process in this field must be done in an intersectoral way, aiming at guaranteeing and enforcing the rights of this population, education becomes one of the fields of intervention of occupational therapy, which is based on interdisciplinarity. Its object is the collective individual, that is, the educators, the children, the school equipment, the relatives and the community (ROCHA, 2007). In this way, the professional's role is to support these actors, as they know about aspects of human development and mental health and development activities that facilitate the collective processes of changes in contexts (OLIVEIRA; CASTANHARO, 2008; CID; GASPARINI, 2016).

The actions carried out showed that the parents of the children and the school staff presented difficulties in understanding the child development issues. These actors demonstrated the need for clarification on this process, considering only the expected aspects of development according to the age group of the children. In this sense, Souza (2010) points out that it is a challenge for the school to resist the normalization of life, considering that educational processes enable to deal with the diversity of knowledge, behavior and life histories of people and communities to overcome the individualistic logic of the society of capital that suppresses differences, transforming into an illness what does not correspond to hegemonic normality.

According to the author, hegemonic knowledge is based on the concept of health as an absence of disease, which produces logic of care through rapid solutions, often translated into the use of medicines and the dissemination of diagnoses, which can function as a lens that highlights difficulties and suppresses potentialities (SOUZA, 2010). Nevertheless, the actions carried out within the scope of the project were based on the strengthening of the potential of children, families, and school in the process of promotion and prevention of mental health beyond the valuation of psychiatric diagnoses.

The implementation of the extension project favored the approach between the school and the families, sharing experiences and difficulties present in the school context. They were related to difficulties in understanding aspects of child development, and to the more subjective order of each agent involved in the life context of each child. The dialogue between the school and family members was not always possible and, after the intervention of the project, a communication channel was opened and established. In this way, the school and the families could leave the role of blaming the other for the difficulty, through the joint creation of coping strategies.

5 Conclusion

This experience report aimed to explore the potential of occupational therapy in the actions of prevention and promotion of children's mental health in the educational context, based on an intersectoral proposal built in partnership with the school staff. The demand was presented by the team, being a planned and implemented action based on the needs and the context of action, as well as the participation of the actors involved.

The relevance of performing intersectoral actions in the field of mental health of children and adolescents as proposed by the guidelines of care for this population in the scope of public policies is highlighted. Actions of this nature favor the development of children and youth, as they are fundamental in guaranteeing comprehensive and effective care, making responsible and empowering different actors involved in this care process.

Occupational therapy is a profession that presents the objective of participating in the formulation and implementation of sectoral and intersectoral policies and actions among its norms, and it can act in different contexts of insertion of the child and the adolescent. The professional works beyond the clinic, but mainly through an intersectoral practice of building shared care, developing a joint work with educators, family members, and children, seeking to guarantee the access to better conditions of development, mental health and life.

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Received: February 22, 2018; Revised: April 10, 2018; Accepted: June 01, 2018

Corresponding author: Amanda Dourado Souza Akahosi Fernandes, Departamento de Terapia Ocupacional, Universidade Federal de São Carlos, Rod. Washington Luís, Km 235, SP-310, CEP 13565-905, São Carlos, SP, Brasil, e-mail: amanda.d.fernandes@hotmail.com

Author’s Contributions Amanda Dourado Souza Akahosi Fernandes and Marina Speranza contributed throughout the development of the work, from field intervention to text design, writing, and review. Cleonice Copi contributed to data collection, text design and review. Maria Fernanda Barboza Cid contributed to the design of the text, writing, and revision. All authors approved the final version of the text.

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