“LEARNING DIFFICULTIES” OR NOT LEARNING AT SCHOOL? REFERRALS IN THE SCHOOL-UBS RELATION”ABSTRACT
This article aims to present the perception of Health and Education professionals about learning difficulties and the school-UBS relation when these difficulties generate referrals. The researched educational institution is a municipal Elementary School and its reference UBS in the territory. This research was methodologically based on Action-Participation Research and González-Rey’s Qualitative Epistemology. Six semi-structured interviews were carried out with professionals, which were transcribed and analyzed using constructive-interpretive analysis. Learning difficulties are defined based on the expectations of the educational system and can generate referrals when the school suspects a disorder or disability, using generic markers about child development. There is a lack of feedback from the UBS to the educational institution. The relation between school-UBS depends on the family and education professionals, compromising the monitoring of children’s development.
Key-Words:
school psychology; learning difficulties; developmental psychology; public health; public education
RESUMO
Este artigo tem como objetivo apresentar a percepção de profissionais da Saúde e da Educação sobre as dificuldades de aprendizagem e a relação escola-UBS quando essas dificuldades geram encaminhamentos. A instituição de ensino participante é uma escola municipal de Ensino Fundamental e a sua UBS de referência no território. Esta pesquisa teve como fundamento metodológico a Pesquisa Ação-Participação e a Epistemologia Qualitativa de González-Rey. Foram realizadas seis entrevistas semiestruturadas com profissionais, as quais foram transcritas e analisadas a partir da análise construtivo-interpretativa. As dificuldades de aprendizagem são definidas a partir de expectativas do sistema educacional e podem gerar encaminhamentos quando a escola suspeita de algum distúrbio ou deficiência, utilizando marcadores genéricos sobre o desenvolvimento infantil. Observa-se a falta de devolutiva da UBS para a instituição escolar. A relação entre os serviços depende da família e dos profissionais da Educação, comprometendo o acompanhamento do desenvolvimento das crianças.
Palavras-chave:
psicologia escolar; dificuldades escolares; psicologia do desenvolvimento; sistema único de saúde; ensino público
RESUMEN
En este artículo se tiene como objetivo presentar la percepción de profesionales de la salud y de la educación sobre las dificultades de aprendizaje y la relación escuela-UBS cuando esas dificultades generan encaminamientos. La institución de enseñanza participante es una escuela municipal de enseñanza primaria y su UBS de referencia en el territorio. Esta investigación tuvo como fundamento metodológico la Investigación Acción-Participación y la Epistemología Cualitativa de González-Rey. Se realizaron 6 entrevistas semiestructuradas con profesionales, las cuales se transcribieron y analizadas a partir del análisis constructivo-interpretativa. Las dificultades de aprendizaje son definidas a partir de expectativas del sistema educacional y pueden generar encaminamientos cuando la escuela sospecha de alguna anormalidad o deficiencia, utilizando marcadores genéricos sobre el desarrollo infantil. Se observa la falta de devolutiva de la UBS para la institución escolar. La relación entre los servicios depende de la familia y de los profesionales de la educación, comprometiendo el acompañamiento del desarrollo de los niños.
Palabras clave:
psicología escolar; dificultades escolares; psicología del desarrollo; sistema único de salud; enseñanza pública
INTRODUCTION
This article presents part of a master’s dissertation research (Martins, 2022), developed in the context of the ECOAR Project (Space of Coexistence Action and Reflection). Thus, it is important to note that the research was conducted between 2020 and 2021, a period abruptly marked by the COVID-19 pandemic and the need to discontinue classroom classes due to protective measures against virus contamination.
Started in 2014 in the municipal network of a city in the interior of the state of São Paulo, the ECOAR Project works for the insertion of Psychology as part of the technical schools team, to monitor students development and build preventive actions against violence in conjunction with the school community (Guzzo, Ribeiro, Meireles, Feldmann, Silva, Santos, & Dias, 2019; Guzzo, Silva, Martins, Castro, & Lorenzetti, 2021).
The project is based on the understanding of the school as part of the Network for the Protection of Children and Adolescents (Dias & Guzzo, 2018; Gonçalves & Guará, 2010) and defends this space as a privileged institution to accompany the development of children and adolescents, since it is the only public policy of access and attendance mandatory from 4 to 17 years old in our country (Emenda Constitucional n. 59, 2009).
In view of these aspects and the context of the ECOAR Project, it is considered relevant to highlight the following tasks of Psychology in school, arising from the regulation of Law 13.935/19 (2019):
Propose intersectoral articulation in the territory, aiming at the integrality of care to the municipality, support to Educational Units and strengthening the Social Protection Network (...). Encourage the recognition of the territory in the articulation process of the educational establishment and other public, private institutions, local community organizations and social movements (CFP & CFESS, 2021, pp. 36-43).
One of the topics widely investigated in the School Psychology literature is the referral of children and adolescents to health institutions with issues related to learning difficulties (Gomes & Pedrero, 2015). However, there is a prevalence of studies with a focus on one of the spaces only, whether health or education. In this research we propose to investigate institutions that are in the same territory, that is, public policies that serve the same community and the same children. Thus, the objective was to investigate the relationship between a Municipal School of Elementary Education (EMEF) and its Basic Health Unit (UBS) of reference, focusing on the demands of learning difficulty.
In this way, the research proposal is aligned with the objectives recommended by the advice system and is put forward as the first step towards the consolidation of a network activity with the said services, starting from the ECOAR Project.
“LEARNING DIFFICULTIES” AND THE REFERRAL LOGIC
The discussion about “learning difficulties” of students in Basic Education is a recurrent theme since the beginning of School Psychology in Brazil. The origin of this specialty in Psychology was marked by an essentially pathologizing and individualizing action of the so-called “school complaints”, in which the diagnoses reinforced the blame of children and adolescents for the difficulties in their own schooling process. It was from the 1980s onwards that the movements within School Psychology began to question the way Psychology professionals had been acting and what its purposes were within this context (Almeida & Guzzo, 1992; CFP, 2019; Marinho-Araújo, 2010; Patto, 1999).
From then on, the area has progressed consistently over the last decades, mainly after the creation of the School Psychology Working Group of the National Association for Research and Postgraduate Studies in Psychology (ANPEPP), the foundation of the Brazilian Association of School and Educational Psychology (ABRAPEE) and the effort of the Psychology Advisory System (CFP and CRPs) for the elaboration of technical references. These initiatives sought to accompany the development of the area and brought new proposals for action of Psychology in schools for prevention and promotion of development with ways to contribute to the students schooling process and the school (Guzzo, Mezzalira, Moreira, Tizzei, & Silva Neto, 2010). It is noted that, to move away from the individualizing discourse that characterized School Psychology at its beginning, there was a distancing of the area in relation to learning issues (Correia, 2021). Therefore, it is understandable that it is necessary to resume this problem addressed to Psychology, with new theoretical benchmarks and ethical-political commitment.
However, it is observed that despite being a widely researched theme, there is no consensus among researchers about what would in fact define a learning difficulty, characterizing itself as a generic term indicating not learning in school (Gimenez, 2005).
Even without a clear definition, the so-called “learning difficulties” constitute one of the main causes of the school’s referral to health services, especially to UBS. It is estimated that about 70% of the demands that reach primary care, as far as children and adolescents are concerned, come from the school context (Gomes & Pedrero, 2015). These demands, materialized by referrals, usually occur when the school understands that it has already done what is possible, sees no further possibilities for action and expects from the health system a response to the difficulty faced in the school institution (Dias, 2017).
THE RIGHT TO EDUCATION AND DEVELOPMENTAL PSYCHOLOGY
After centuries of access to education concentrated under the control of few people, we are currently living at a time when most of the Brazilian population has access to Basic Education (IBGE, 2020; INEP, 2020). According to Santos (2019), the main milestone for this change was the 1988 Constitution, in which education came to be understood as a social right. According to the author, in this context, several documents were drawn up, such as the ECA (Statute of the Child and Adolescent), and the Law of Guidelines and Bases (LDB), which constituted the paradigm of the school as a protective space of rights.
According to the LDB, Primary Education aims to:
Art. 32.
I - the development of the ability to learn, having as basic means the full domain of reading, writing and calculation.
II - an understanding of the natural and social environment, the political system, technology, the arts and values on which society is founded.
III - the development of learning capacity, with a view to acquiring knowledge and skills and the formation of attitudes and values.
IV - the strengthening of family bonds, the bonds of human solidarity and mutual tolerance on which social life is based (Law 9.394, 1996).
Despite the advances mentioned, the high levels of abandonment and evasion indicate that the access expansion did not necessarily imply the universalization of teaching and the permanence in school. In addition, even when the permanence occurs, there are many students who finish elementary school without fulfilling some of their main objectives, such as literacy, being moved to the schools of Youth and Adult Education (EJA) ever earlier. According to data from the last School Census (INEP, 2020), most students in the EJA are under 20 years old.
In the historical-cultural approach, Vygotsky (2007/1935) points out that learning is a process that starts before the child enters school, but it is in the school institution that it acquires characteristics that are intrinsically related to psychic development. According to the author, the development of the higher forms of thought occurs from culture appropriation, which is constituted by signs and then, as the signs are internalized, psychic “tools” develop, such as language. From this perspective, the appropriation of signs is fundamental for development, and schools are a privileged space for this process to occur. For the author, learning is not the same thing as psychic development, but states that learning is a condition for it.
Martins and Rabanati (2011), based on Vygotsky’s studies, state that it is through school education that children develop reading and writing skills, which structure the bases for the higher development of other psychological functions, such as thinking. In this sense, it is in school that it is possible to have contact with the scientific knowledge accumulated by humanity in a systematized manner, that is, it is a space for culture socializing. Thus, Vygotsky sees in the culture appropriation the possibility of a process of humanization, which when it is not possible becomes an “obstacle to intentionally transformative action” (p. 356).
In view of the theoretical basis in Vygotsky (2007/1936, 2018/1934), we understand that the way education is structured today in the country, prevents the effective appropriation of culture by the subjects and limits their possibilities for action in the world. Thus, it is relevant to investigate the phenomenon of learning difficulties in the context of the school-UBS relationship, since referral to the health system brings us an indication of a limitation that the school has to promote learning within the school institution.
METHOD
Methodological Foundations
The present research was developed from the foundations of Action-Participation Research (PAP) and Qualitative Epistemology. PAP guides the ontological sense of scientific research, which aims for effective social transformation, the researcher is actively involved, and knowledge is produced collectively and collectivized with the social actors (Guzzo, 2020). Qualitative Epistemology presents a research committed to a new way of doing science, based on the following general attributes: the constructive-interpretative character of knowledge, the legitimation of the singular as an instance of production of scientific knowledge and research as a process of communication (González-Rey, 2017).
Context and scenario
The investigation took place in the backdrop of the global Coronavirus pandemic, which led to the suspension of in-person classes from all schools in the country and a change in the workforce dynamics of many workers. The scenario of this investigation was an EMEF and its reference UBS, in a peripheral region of a large city of the state of São Paulo. The school in question has been relying on the ECOAR project since 2014 and the professional researcher has been acting as a psychologist on the project since 2020.
Participants
The participants were six professionals, three from Education (three teachers) and three from Health (one nurse and two pediatricians). The participation criteria for the Education professionals were: to work in Primary Education in the school in question, to accept the invitation made by the researcher and to fill in the Informed Consent Form (TCLE). For the health professionals, the criteria were: to work at the school’s reference basic healthcare unit, to accept the invitation sent by the researcher and the institution’s coordinator, to have contact with school demands and to complete the TCLE.
Procedures
The search for information was divided into 4 moments: (a) the presentation of the research proposal, (b) the invitation to participate, (c) the conduct of the interviews and (d) the transcription of the interviews.
At school, (a) we present the research in a virtual meeting with the presence of the school management team. At the UBS, (a) the professionals were invited at a face-to-face meeting held between the school and UBS that had as its objective the presentation of the ECOAR Project and the UBS coordinator indicated the professionals with greater contact with school demands.
After approval in the Research Ethics Committee (Statement No. 4.809.906/2020), (b) we contacted the professionals through messaging application, considering the context of pandemic, and the six remote interviews were scheduled according to the availability of participants.
(c) At the time of the interview, the voluntary nature of participation and the signing of the TCLE was explained in a virtual manner. He was then asked about the consent to the audio recording of the interview. After the statement we started the recording and dialog of the meeting, which lasted an average of one hour. The researcher used a semi-structured script for each group of professionals, from which she sought to develop a dialog with the participants in an active way, that is, without limiting herself only to recording information, but to question and deepen the dialog (González-Rey, 2017).
(d) After completing all individual interviews, they have been transcribed and the audio files deleted.
Analysis Procedure
The analysis of the information obtained was done based on the constructive-interpretative model of Gonzalez-Rey (2017), in which the analysis is understood as a complex and dynamic process that develops throughout the research. The transcript files were read in full extend to search for meaning indicators in each group of interviews, looking for elements of contradictions and similarities in the participants’ dialog. After the identification of meaning indicators, syntheses were organized capable of translating specific dimensions related to the research objectives.
RESULTS ANALYSIS
The analysis was structured in three dimensions for each group of professionals: (a) Identification, (b) Decision and (c) Relationship. Therefore, the units of sense are presented from each dimension, in each group of professionals.
In this article, interviews with participants are indicated as follows: P1, P2 and P3 refer to Education professionals; and P4, P5 and P6 refer to the excerpts from interviews with Health professionals.
Education Professionals Perspective
In dimension (a) Identification, we discuss what each professional identifies as a learning disability in a student. The issues most cited by the participants of Education are the learning difficulties concerning the process of literacy and the follow-up of classes:
“He can neither read nor write anything” (P2)
And she said, “He’s going to be your student, because he needs help, he can’t read” (P2)
The biggest difficulties, is... I realize that it has to do with the acquisition of writing itself, of literacy. (P3)
This information brings us a very great concern, since literacy is a fundamental process for the school career, as well as for the process of development of the Higher Psychological Functions (FPS) of these students (Vygotsky, 2018/1934). It is noted that difficulties are centered on the student: “He doesn’t know”, “He can’t do it”, “He can’t cope” are common phrases. We wonder how this way of understanding can bring about a blame of the student for his own failure (Patto, 1999).
In the course of the interviews, we noticed that the learning difficulty is closely linked to what the school, teacher and/or educational parameters expect that student will be able to accomplish for the school year in which he is inserted, as well as the comparison of him with the class:
I understand difficulties as something that is too dissimilar from the average, so it requires a closer look. (P3).
He will often succeed, but he is much more gradual, much more punctual many times, and then the family begins to get anxious because he cannot cope with that school year. (P1)
So, at the end of the first grade, let’s assume, the kid has to learn the number sequence up to 100. It’s expected to be at least syllabic, so it’s a parameter that we have. (P3)
Behind this model of work one can suggest a conception of linear development and divided into stages, contrary to what is advocated by Vygotsky (2018/1934), of a development as a dialectical and non-linear process. In addition, they indicate universal expectations about the learning process.
The teachers’ reflections indicate that, although the difficulty is focused on the figure of the child, there is a broader understanding that it does not originate only in the subject but is constituted in the relationships that he establishes daily, and give prominence in the family dynamics. Furthermore, we realized that the participants emphasize the importance of not drawing hasty conclusions about the student, but investigating in depth different dimensions of his life, such as family and school career, since the difficulties would be multifactorial.
According to the participating teachers, the school carries out some actions to investigate the difficulty. The Special Education (EE) teacher seeks information about school history, family dynamics and whether the student attended any health or social care service. Parallel to this process of investigation, the school also offers activities in the counterculture as a form of reinforcement.
In dimension (b) Decision, we seek to understand the criteria for a child to be referred to professionals outside school. Three situations were scored: (1) the failure to advance learning despite school actions; (2) children who do not present a “good development” or “are immature” for their age; and (3) difficulties involving psychological or emotional issues, often being cited as “low self-esteem” or “lack of autonomy”.
In relation to (1) non-advancement of learning, there is an expectation that the external service will confirm or discard a diagnostic hypothesis of the school about the child. The second point (2) reinforces a vision of development, in which there is the comparison of the child with a supposed “ideal development”, from generic and universal markers on child development. In the third point (3) we realized the view that it would not be possible to work on emotional issues in the school itself, denoting a separation between the emotional and the cognitive.
Thus, it has been observed that the decision for referral is not based on specific criteria but depends on the evaluation and assumptions of the school team - focused on the perspective of EE - according to generic and universal markers on the development of children, often occurring disagreements between the teachers involved about who should or not be referred.
After the decision for referral to the health unit, a report on the child is drawn up. Although any teacher is free to refer their students to outside services, most feel more comfortable doing so with the support of the Special Education teacher.
To understand the relational dynamics between the services - dimension (c) Relationship - we observe that the report is delivered to the child’s family and this family is responsible for taking the document to the health service, that is, there is no direct institutional communication system between the two equipment. In addition, we note that in this report there is an expectation that the UBS will follow the steps suggested by the school, since they are brought even the specific professionals that the school wants the child to be attended. It should be noted that the EE teacher has an in-depth knowledge about the network, understanding what are the paths needed to arrive at a given service.
With this in mind, we observed that the EE teacher is a protagonist in the articulation between the spaces, moving to the services, asking and accompanying the students who are going to be referred or those who have already gone. These actions are usually accompanied by an intention for the child to be attended to by some institution, and at UBS this possibility is verified.
This movement is consistent with the National Special Education Policy, in which it is stated that one of the tasks of EE teachers is to act in partnership and articulation with multiprofessional and interdisciplinary teams (Ministry of Education, 2020). By understanding the dynamics of the network, the teacher establishes a bureaucratic relationship with the UBS, that is to say, she is aware that, for a child to be attended by a given service, one must pass through the UBS, however, it is not a space for dialog, but a passage to these services.
Health Professionals Perspective
In dimension (a) Identification, we observe the same movement of not being defined what is “learning difficulty” and present examples, and the process of literacy is also the most frequently cited:
She was ashamed already, because she was the biggest in the class, she was reclassified in the class with a lot of learning difficulties, of not knowing how to read, not knowing how to write, practically not even her first name. (P4)
You see kids in high school who were practically illiterate yet. (P5)
And he’s 15 years old and he can’t write his own name, you understand? (P5)
In these lines we can perceive the difficulty as synonymous with gap, that is, when one has the comparison between what the child manages to accomplish and what is expected of it in that school year. This way of observing the phenomenon of difficulty once again puts the child as responsible for non-learning. The logic is “you haven’t learned it so far, there must be something wrong with you”. This movement is explicit in the following excerpts: “The learning part was delayed (...) (P4); It has not yet reached what was expected for that series (P5)”.
In dimension (b) Decision, we seek to understand what are the actions developed by the UBS, when they receive the school referrals related to learning difficulties. As the teachers have said, the school referrals to confirm or discard a hypothesis: “Yes, normally the school sends to ward off some neurological disease” (E6). Thus, the UBS’s team of professionals carries out an evaluation on the child’s development, which may include home visits, family and child appointments.
Thus, it is investigated whether there is something organic that is interfering with school learning. According to the professionals, most of the children referred do not have biological or organic demands, but “learning”. Therefore, we ask the professionals how this differentiation is made:
What we’re most concerned about is usually that child who has the school issue, but then there’s another issue of social interaction. That child who sometimes doesn’t even play with the other children, even with family members. Or there’s some aggressiveness, there’s other things from the child’s other life contexts. (P5)
These cases are usually children whom we are investigating on the autism spectrum, and we know that they are referring to APAE, which we refer to Sabiá1, because they come with various other demands. But there are children and adolescents that we begin to perceive this difficulty from childhood. (P5)
The differentiation occurs by investigating the other contexts in which the child is inserted and by comparing how he or she behaves in these different spaces. If the difficulty is restricted to the school space, but it develops “well” at home and there is no suspicion of some organic condition, it is understood that it is a question of “learning” not being necessary to investigate other possibilities, which indicates a movement even tautological in the search for understanding the difficulty. However, the criteria for assessing what is a ‘normal development’ or ‘expected’ are not clear.
Once this differentiation has been made, the service can follow two lines of action: (1) to provide care for the child in the health unit or (2) to referral to specialized services. In the first case - which is more frequent according to the professionals - the team calls the family for provide guidance on the routine care and questions about development in general, such as feeding and ways of stimulating learning, and the child can participate in a reading and writing group carried out by the UBS resident team, coordinated mainly by professionals of Speech Therapy and Psychology. The group aims to train skills that are expected from the school.
In the second line of action, we have cases where there is a need to verify the development of vision, hearing and/or the investigation of suspected disabilities, disorders, or impairments. We observed some medical specialties, in addition to the UBS team, that are required for assessments such as psychiatry, neurology, ophthalmology or private associations that establish partnership with UBS, with a very great difficulty to get the scheduling of these appointments. One of the points that calls our attention is that, in some cases in which the referral is carried out, the child is attended and the service receives a response from the evaluation carried out by the specialties, which rule out a diagnostic hypothesis. The UBS team, in this case, may not agree with this assessment and try again the referral until the service confirms the hypothesis of the health unit, which characterizes a pressure for the diagnosis of disorders or deficiencies. While this disagreement occurs among professionals about what the child has or does not have, one remains with the same problems at school, without a proposal for effective action. This process can take up to 5 years, which is an enormous period of one school career, marked by day-to-day failure at school.
The pressure for diagnosis is explained by the need for a document that allows the child access to more educational resources, related to the EE Policy:
We try to make a referral to the resource room. ... And the child needs to have a medical report, with a CID. They ask for a diagnosis of a deficit to be able to access it. (P4)
We then seek to understand how the communication - dimension (c) Relationship - with the school is established after UBS visits. We ask the professionals about whether, and how, the feedback is made for the educational institution. According to the information brought by them, except when the school has a diagnostic suspicion, the feedback is done exclusively for the family, making impracticable all the possibility of integration between the public policies that serve the child.
FINAL CONSIDERATIONS
In summary, we have that the term “learning difficulties” is often used by Education and Health professionals to designate the gap between what is expected of the school and the way the student is developing. We observed that, despite professionals understanding not learning in school as something multifactorial, when referrals are carried out, they use generic markers about the development of children to substantiate the request for assessment.
We understand that developmental psychology, as a science committed to concrete reality, must be able to provide input to support markers of children’s development, to avoid common sense judgments and bring contributions to monitoring children throughout their school career beyond the cognitive/intellectual dimension.
It would also be important to characterize the referrals in order to systematize the criteria and foundation of the issues about learning difficulties.
The relationship established between the services is bureaucratic, and the one who suffers the consequences is the child and his family who circulate between the services. There is no integrated training to monitor these issues and this situation characterizes the main challenges in monitoring the development of children and adolescents.
The communication obstruction between the two services reveals the expectation that the school has that the health service can elucidate how to work with children who have difficulties. However, we understand that the school must be able to promote learning for all students, not just for “idealized students”. Furthermore, it is noted that both services are on the way to answer the question: “what does this child have?”, when we argue that the question to be asked should be: “what does this child need to advance in its development?”.
We agree with Correia (2021) when she states that the search for one or more culprits for the difficulty that is manifested by the student does not bring contributions to overcome its difficulty. We argue that the school should be the reference institution for the child in the protection network (Dias & Guzzo, 2018) and, for this, should be able to monitor the development of its students. We understand that the implementation of Law 13.935/2019 (2019), which provides for the insertion of professionals of Psychology and Social Service in Basic Education, is a necessary step for this monitoring to become possible, guaranteeing a multiprofessional technical team within schools.
Thus, like all the professionals participating in this research, we agree that it is necessary to narrow the wire of the school-UBS network. To do this, it is important to build real planning on how to act when accompanying students with learning difficulties.
The pandemic, added to the political conditions of education in our country, will have impacts on the learning and development of children and adolescents who were physically away from schools that have not yet been investigated. According to a report prepared by UNICEF (2021), during the first year of the pandemic, more than 5 million Brazilian students between 6 and 17 years of age did not have their access guaranteed to education, and more than 40% of these were children between 6 and 10 years of age, a period characterized by the process of literacy that is fundamental for school education.
With this in mind, it is understood that we run the risk of increasing the pathologization and medicalization of many learning processes in the coming years if we continue to categorize our students as those “learning” and those “with difficulties”. Thus, it is necessary that Psychology provides the construction of subsidies to, together with the school team, be able to monitor the development of children taking the commitment from their assignments, in facing this problem.
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