Adolescents in psychological distress and mental health policy for children and youth

REVIEW ARTICLE

Adolescents in psychological distress and mental health policy for children and youth

Adolescentes em sofrimento psíquico e a política de saúde mental infanto-juvenil

Adolescentes en sufrimiento psíquico y la política de salud mental infanto-juvenil

Danielle Christine Moura dos Santos^I; Maria Salete Bessa Jorge^II; Consuelo Helena Aires de Freitas^III; Maria Veraci Oliveira Queiroz^III

^IGraduate Student (Master's), Academic Master's Program in Clinical Care in Health and Nursing, Universidade Estadual do Ceará - UECE – Fortaleza (CE), Brazil

^IIPh.D. in Nursing. Full Professor, Universidade Estadual do Ceará - UECE – Fortaleza (CE), Brazil

^IIIPh.D. in Nursing. Adjunct Professor, Universidade Estadual do Ceará - UECE – Fortaleza (CE), Brazil

Corresponding Author

ABSTRACT

This study is a literature review of published articles about the mental health of adolescents in Brazil, between January 2005 and April 2010. The keywords used in LILACS and SciELO databases were: mental health, adolescents, care, and outcomes of care. Thirty-five articles were analyzed, using the technique of content analysis. Studies show it is essential to recognize that the adolescent suffering psychologically is a subject and that he lives in a subjective context. In this way, the proposals of transformation will not have the necessary reach to the needs and demands of those individuals without an effective articulation between the diverse sectors, health care workers, patients and family. In this debate, there are few publications that discuss the new experiences, the dimension of the clinical act, expanded clinics or the output of the care in the attention to the mental health of these subjects.

Descriptors: Adolescent; Mental health; Health policy

RESUMO

O presente estudo é uma revisão de literatura dos artigos publicados a respeito da saúde mental de adolescentes no Brasil, entre janeiro de 2005 e abril de 2010. Os unitermos utilizados nos sites LILACS e SciELO foram: saúde mental, adolescentes, cuidado e produção do cuidado. Foram analisados 35 artigos, empregando-se a técnica de análise do conteúdo. Os estudos mostrarem ser indispensável reconhecer que o adolescente em sofrimento psíquico é um sujeito e que vive em um contexto subjetivo. Desta forma, as propostas de transformação não terão o alcance necessário às necessidades e demandas desses indivíduos sem uma articulação efetiva entre os diversos setores, trabalhadores de saúde, usuários e família. Neste debate, ainda são poucas as publicações que abordam as novas experiências, o redimensionamento do ato clínico, a clínica ampliada ou a produção do cuidado na atenção à saúde mental destes sujeitos.

Descritores: Adolescente; Saúde mental; Política de Saúde

RESUMEN

El presente estudio es una revisión de la literatura de los artículos publicados respecto a la salud mental de adolescentes en Brasil, entre enero del 2005 y abril del 2010. Las palabras clave utilizadas en los sites LILACS y SciELO fueron: salud mental, adolescentes, cuidado y producción del cuidado. Fueron analizados 35 artículos, empleándose la técnica de análisis de contenido. Los estudios mostraron que es indispensable reconocer que el adolescente en sufrimiento psíquico es un sujeto y que vive en un contexto subjetivo. De esta forma, las propuestas de transformación no tendrán el alcance necesario a las necesidades y demandas de estos individuos sin una articulación efectiva entre los diversos sectores, trabajadores de salud, usuarios y familia. En este debate, aun son pocas las publicaciones que abordan las nuevas experiencias, el redimensionamiento del acto clínico, la clínica ampliada o la producción del cuidado en la atención a la salud mental de estos sujetos.

Descriptores: Adolescente; Salud mental; Política de salud

INTRODUCTION

Various definitions of adolescence exist, deriving from different ways of analyzing this phase of life. According to Sociology, adolescence depends on man's insertion in each culture, thus varying according to the culture. Anthropology sees it as a transition phase between childhood and adult age, involving rites of passage and initiation, present in different cultures. Law defines this phase based on majority and minority issues, which vary according to the legislation in force. Medicine, then, sees adolescence as the period when the bodily growth and development process occurs, characterizes by great biopsychosocial transformations, which start in puberty and finish at the end of the second decade of life⁽¹⁾.

Despite the slowdown in the young population's growth rhythm, today, the generation of adolescents and young people between 10 and 24 years of age is the most numerous across Brazilian history, representing 51,429,397 people – 30.3% of the population – in the 2002 Population Census, with 35,287,882 adolescents between 10 and 19 years and 16,141,515 young people between 15 and 24 years⁽²⁾.

To define adolescence, the Ministry of Health follows the World Health Organization convention that delimits the period between 10 and 19 years, 11 months and 29 days of age, while the period between 15 and 24 years is called youth. Brazilian law, then, considers adolescence as the age range between 12 and 18 years. This reveals a difference between the age set in the Child and Adolescent Statute (CAS) and that of the World Health Organization⁽³⁾. Thus, these age limits represent a useful abstract framework to outline policies and strategies but, in people's concrete life and individual experience, the borders of adolescence are neither homogeneous nor fixed⁽²⁾.

In this context, the Brazilian adolescent mental health policy is highlighted, which groups them with the children in the same service, without any objective limit or chronological criterion for these age ranges. This can hamper child-juvenile mental health action planning and studies in these different human development phases⁽⁴⁾.

Some studies discuss that, in different countries' conjuncture, a clear lag is evident between the need for mental healthcare delivery to children and adolescents and the offering of a service network capable of taking charge of this care. Studies about the prevalence of mental disorders in this population present estimates of up to 20% in Brazil, dimensioning the magnitude and importance of the need for mental healthcare^(5-7).

Historically, the void in public attention to these patients in mental suffering and the lack of a political guideline to establish care in this area were completed by institutions, mostly private and/or philanthropic, which for many years were the only options for monitoring, orientation and/or care aimed at the subjects and their family members⁽⁴⁾.

To promote healthy development for citizens in these phases of life and achieve the complete development of their potentials, society, through the State, needs to guarantee mechanisms of education, social protection, inclusion, child, adolescent and family rights promotion and guarantee^(2,4).

Today, actions are taken to implant a specific mental health policy, integrated into the Unified Health System's (SUS) general mental health policy. The main goal of this policy is the construction of a care network that is capable of effectively responding to these users' needs. Two main actions are ongoing in recent years: the SUS' implantation of child-juvenile mental health services; and the construction of strategies for intersectoral articulation between mental health and sectors historically involved in care delivery to this population: general health, education, social services, justice and rights, with a view to comprehensive care⁽⁸⁾.

In this perspective, this study aims to analyze the knowledge produced in health databases about adolescent mental health in Brazil and care perspectives. The interest in analyzing this production emerges in the context of the acknowledged gravity of the psychic suffering's repercussions on adolescents and their conceptions as subjects, capable of talking about themselves and their pain. In line with the mental health policy, we consider it is relevant to get to know studies produced about attention and care delivery to adolescents in this area, which will permit further knowledge that facilitates professional activities and drives other studies capable of articulating care practices for these subjects with rights, experiencing psychic suffering.

METHODOLOGICAL TRAJECTORY

This study presents a literature review. Reviews are a form of research that uses bibliographic or electronic sources to obtain research results from other authors, with a view to theoretically supporting a given objective⁽⁹⁾.

It was elaborated based on Pimentel's methodological trajectory, who describes the instruments and means for content analysis, ranging from the organization and classification of material to the elaboration of analysis categories⁽¹⁰⁾.

A survey was developed in LILACS and SciELO. The uniterms were used individually and crossed: mental health, adolescents, care and care production.

The following inclusion criteria were established for the material selection phase: publication in journal, full text available online and in Portuguese, between January 2005 and April 2010. Thus, 140 article abstracts were surveyed which, after reading and initial analysis, resulted in 35 publications directly related with the proposed study goal.

The information was arranged in a table, summarizing the products based on the objects, methods and discussions proposed in the publications.

To analyze the 35 papers, common content analysis techniques were used to decipher, in each text, the emerging core that attended to the research goal. This phase comprised a process of coding, interpretation and inferences about the information contained in the publications, unveiling their manifest and latent contents⁽¹⁰⁾.

RESULTS

The aspects addressed in the studies range from the mental health services' care profile, child and adolescent violence situations, use of psychoactive substances, treatments used and the historical recovery of the mental healthcare policy.

Although some papers about mental health describe adolescence as a development process with different peculiarities, they do not detach it from childhood. In Brazil, the child-juvenile mental health policy exists and texts or documents published on this policy⁽⁴⁾ neither dissociate these phases nor present or discuss the particularities of each. This was also reflected in this study's difficulty to identify publications that only involved adolescents or, in some cases, the age ranges did not correspond to those established by the Ministry of Health, nor to the CAS. Thus, the elaborated categories corresponded not only to adolescence, but to child and adolescent mental health.

Studies on psychic suffering in this social group and the structuring of mental health services are relatively recent in Brazil. The production of papers has grown at a constant pace in the last five years, indicating the interest in scientific development on mental healthcare issues in this phase of life.

In view of the organization and analysis of the findings, publications were categorized in two thematic units: The child-juvenile psychosocial care policy and practices, care and activities in psychosocial care: the signs and meaning of psychic suffering in adolescents. In methodological terms, most publications were descriptive and quantitative original articles and/or bibliographic reviews, which were aimed at informing on or characterizing the vulnerable group or clinical conditions, in line with one of the studies⁽⁶⁾ analyzed, according to data in Table 1 below.

The limited frequency or absence of studies on care production, subjectivity aspects and care from the perspective of the expanded clinic was observed, as well as about service assessment. These are considered pertinent themes for mental healthcare, as the elaboration of the care network should be based on clinical practice, developed by health teams, and the formulation of effective public policies that include the singularities of these practices' live context⁽¹¹⁾.

In this context of the care network, the child-juvenile Psychosocial Care Centers - CAPSi emerged as the main Brazilian action to respond to the need to enhance access for these subjects. As from 2002, the CAPSi were proposed under the same principles ruling other types of CAPS in the country. These public territorial services are fully funded through SUS resources and their function is to deliver mental healthcare based on care comprehensiveness^(12-13).

The available indicators suggest that the expansion of the CAPSi network does not attend to the needs, and this represents an important challenge to be faced. Today, 128 CAPSi are functioning. The population parameter established in the Ministry of Health's normative guideline (200,000 inhabitants or more) directly affects 130 Brazilian cities, 14 or more have more than one million inhabitants. These are not the only cities where there should be more than one CAPSi, but that is not the really met^(8,14).

The first epidemiological information on child and adolescent mental health in Brazil dates back to 1982, indicating a prevalence level of 23.5% for some type of disorder in children between 5 and 14 years living in Salvador, Bahia. A second population-based study involving school-age children between 7 and 14 years found a prevalence rate of 12.7% of mental disorders in Taubaté, São Paulo. The prevalence rate for one or more psychiatric disorders in this same age range varied between 7% and 12.7%, according to a study on Ilha de Maré, Bahia⁽¹⁵⁾.

According to studies developed in the last five years, subjects and family members attending child-juvenile mental health services are mostly male and between 6 and 11 years of age. Regarding the reason for the consultation⁽²¹⁾, the families' main complaints are learning difficulties and aggressiveness. These data are in accordance with different literature sources, which actually indicate that prevalence rates of one or more psychiatric disorders in this age range are higher among boys than girls^(15-16).

As for studies that mention situations of suffering identified in the users' files as the research sources, the group of behavioral and emotional disorders stands out^(15,17). Among the male subjects, the most frequent diagnoses were schizophrenia, behavioral syndromes, psychological development disorders and behavioral disorders. In the female group, mood and neurotic disorders were more frequently diagnosed^(17-20).

Another aspect observed was the importance of the approach proposed to the families: one of the studies appointed⁽²¹⁾ that, in 52.5% of the files analyzed, no mention of therapeutic conduct is made to include parents or other family members in the therapeutic projects of children or adolescents attended at the research units. In the files where reference is made to some care modes for the parents, it is evidenced that the main therapeutic conduct indicated for the parents or other relatives is care through group activities.

DISCUSSION

Until the 1990's, and in some cases even today, the so-called "shelters for the disabled" were responsible for child and adolescent mental healthcare, which were at the margin of the formal mental health system and constituted asylums without treatment directives, which submitted these children and adolescents to the trivialization of their human condition. When reaching majority, many of them entered the psychiatric hospital network. A study in Rio de Janeiro at the start of 2000 indicated that approximately 70% used the philanthropic network devices as the main resource in care delivery to children and adolescents in Brazil. In only 20% of Brazilian cities did mental health program attend to diagnosed cases of autism and psychosis, most of which used the traditional outpatient model^(17,22-23).

There is no other way of envisaging health care for these subjects than interdisciplinary and intersectoral care.

Absolute priorities in the Federal Constitution, children and adolescents gain a singular position in the field of rights: the right to health and to personal and social development, as there is no way to make them grow and develop without the necessary social protection network. Comprehensiveness should be considered not only in terms of health, but also as comprehensive protection, in line with the Child and Adolescent Statute⁽¹²⁾.

This information entails reflections about the changes occurred in Brazilian health policies, and specifically in child and adolescent mental health. The landmark in this context is the Psychiatric Reform, which in this population is reinforced after the 1988 Brazilian Constitution and the confirmation of children and adolescents' rights in the CAS. The Ministry of Health and many official entities manifest themselves in favor of the implantation of these laws.

In this context, research about adolescence has gained increasing depth, mainly in health and education. It is during this phase that individuals develop physical and emotionally and adopt behaviors influenced by the socio-environmental midst. This means that this period of life starts in puberty, and ends when the young people enter what is culturally considered as adult age, going through intense transformations^(8,24).

It should be highlighted that adolescence has also been a preferential target of a pathologization effect (pedagogization, psychologization, psychiatrization) in which, in most cases, what emerges from the adolescent world echoes in the adult world as impertinence, apathy, disease and delinquency. Addressing youth from a "social problem" perspective, as an object of failure, dysfunction or anomie in the social integration process and as a risk theme for social continuity itself is historical and persistent⁽¹⁹⁾.

Because adolescents are at these crossroads between excess demands on the side of the adult world and countless institutional crossings, their conflicts and suffering inundate the entire social field, questioning adult ideals and implying adults. That is, because they cause crises in families and institutions, and mental disorders are able to challenge the adult world to permanently analyze its (conscious and unconscious) position in the world⁽²⁵⁾.

Mental health problems during adolescence are knowingly associated with public health problems and can be divided into four main groups: emotional, behavioral, concentration and drugs-related. Less frequent but potentially more severe are psychoses and food problems. Developmental alterations like autism are also less frequent and start during childhood, enduring into adult age^(1,8,18).

Themes related to depression, drugs, violence and family predominate, which emphasize the different factors that make adolescents vulnerable: individual (gender; age; psychological characteristics like self-esteem, self-confidence and determination). Family factors (history of mental health problems, especially on the maternal side; alcohol/drugs problems; physical, psychological and sexual violence; violence between parents; losses due to death; parental separation). Sociocultural (poverty, violence in the social context, social support) and biological. It is also highlighted that the main challenge is to understand how these factors articulate mutually and originate in human behavior and health^{(6,8,18-19,26-27)}.

These characteristics point towards the need to invest in the education of professionals who will act on the complexity of these subjects' demands, in view of the concrete components, knowledge and strengths of a care network that is still under construction. It is important to construct the clinical, therapeutic and social tools together with them, so that they present themselves to the world, even if they are radically different from ideal adolescents, going beyond the borders of exclusion^(12,21).

In this sense, it is highlighted that, through the CAPSi, families' integration in care strategies gains a new dimension, in which they celebrate the existing relation between the statute of subject with rights the CAS grants to adolescents and children and these subjects' dependence on the family group. There seems to exist a much broader dimension in family members' integration into care strategies than the mere facilitation of an adult's contact with the child/adolescent, which could be considered in view of this population's great dependence^(21-22).

They need to be surrounded with guaranteed social bonds, like a network with the right texture to welcome them, with a view to facing the hard task of growing and belonging to the world. These protective bonds should reconstitute the social, so as to establish social currents that do not break in their weakest links; a reconstruction that reverts the sedative, immobilizing and stiffening effect violence, misery and exclusion exert on us. In other words, the vulnerability and social risk that cross the bodies and lives of children and adolescents decrease as collective commitments are broadened⁽¹²⁾.

Child and adolescent mental health is constructed based on values, ideologies and, mainly, care practices that are shared with different professionals and institutions, including the family. Understanding this complex know-how, permeated with signs and meanings, expands nursing's look, making it easier to overcome a Cartesian view and stimulating the construction of spaces that enhance the constitution of children and adolescents entitled to healthy growth and development in all spheres of care for this population.

CONCLUSIONS

In this study, most of the papers analyzed discuss the care profile in child-juvenile mental health. It is fundamental to acknowledge, however, that adolescents going through psychic suffering are subjects living in a subjective context and, thus, the proposed transformations will not reach these individuals' needs and demands as necessary without effective articulation among different sectors, health workers, users and family. Hence, much remains to be done towards a new care mode.

In this debate, there are as of yet few publications on new experiences, redimensioning of the clinical act, the expanded clinic or care production in mental healthcare for these subjects. This hampers reflections and public health action planning in this field of practices, needs and demands of users, family and workers.

REFERENCES

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Publication Dates

• Publication in this collection
  03 July 2012
• Date of issue
  2011

History

• Received
  14 July 2010
• Accepted
  03 June 2011