Non-suicidal self-injury among adolescents: meanings for education and Primary Health Care professionals

ABSTRACT

Objective

to understand the perceptions of the health and education professionals about non-suicidal self-injury among adolescents.

Method

qualitative research, with Symbolic Interactionism as its theoretical framework. Data collection carried out with 20 professionals from a school and a Family Health Unit in São Carlos-SP, through focus groups and field diaries. Data analysis was carried out using the inductive thematic modality.

Results

It was revealed that adolescence is still seen as a period of transition, and self-injury emerges as transitioning and as the search for attention. Trivialization is reinforced, mainly due to the belief of the contagion effect, in which adolescents reproduce the act performed by peers. Family and Internet relations are signaled as propagators of the phenomenon. In view of these meanings, care is fragile, being based on specific actions.

Conclusion and implications for the practice

professionals act against self-injury in adolescence according to the meanings that are constructed by them. There is an urgent need for continuing education on such issues, the design of actions promoting mental health in the school context and the construction of protocols for intersectoral care.

Keywords:
Adolescent; Self-Injurious Behavior; Primary Health Care; School Health Services; Nursing

RESUMO

Objetivo

conhecer as percepções dos profissionais da educação e da saúde acerca da autolesão não suicida em adolescentes.

Método

pesquisa qualitativa, tendo como referencial teórico o Interacionismo Simbólico. Coleta de dados realizada junto a 20 profissionais de uma escola e de uma Unidade de Saúde da Família de São Carlos-SP, por meio de grupos focais e diário de campo. A análise de dados se deu pela modalidade temática indutiva.

Resultados

revelou-se que a adolescência ainda é vista como período de transição, e a autolesão emerge como passageira e pela busca por atenção. Reforça-se a banalização, principalmente, pela crença do efeito contágio, em que os adolescentes reproduzem o ato realizado por pares. As relações familiares e com a Internet são sinalizadas como propagadoras do fenômeno. Frente a esses significados, o cuidado é fragilizado, baseado em ações pontuais.

Conclusão e implicações para a prática

os profissionais agem frente à autolesão na adolescência de acordo com os significados que são construídos por eles. É urgente a necessidade de educação permanente sobre tais questões, o delineamento de ações promotoras de saúde mental no contexto escolar e construção de protocolos para cuidado intersetorial.

Palavras-chave:
Adolescente; Comportamento Autodestrutivo; Atenção Básica à Saúde; Serviços de Saúde Escolar; Enfermagem

RESUMEN

Objetivo

conocer las percepciones de los profesionales de educación y salud sobre la autolesión no suicida en adolescentes.

Método

investigación cualitativa, con el interaccionismo simbólico como marco teórico. Recolección de datos realizada con 20 profesionales de una escuela y una Unidad de Salud Familiar en São Carlos-SP, por medio de grupos focales y diarios de campo. El análisis de los datos se realizó utilizando la modalidad temática inductiva.

Resultados

La adolescencia todavía se ve como una fase, y la autolesión surge como pasajera y la búsqueda de atención, reforzada por la trivialización y el efecto de contagio. Las relaciones familiares y de Internet se señalan como propagadores del fenómeno. En vista de estos significados, la atención es frágil, ya que se basa en acciones específicas.

Conclusión e implicaciones para la práctica

los profesionales actúan contra la autolesión en la adolescencia de acuerdo con los significados que estos construyen. Existe una necesidad urgente de educación continua sobre estos temas, el diseño de acciones que promuevan la salud mental en el contexto escolar y la construcción de protocolos para la atención intersectorial.

Palabras clave:
Adolescente; Conducta Autodestructiva; Atención Primaria de Salud; Servicios de Salud Escolar; Enfermería

INTRODUCTION

According to the World Health Organization (WHO), adolescence comprises the period from 10 to 19 years old, with the initial period between 10 and 14 years old, and the end between 15 and 19 years old.¹ Adolescents have a significant representation in the Brazilian population despite the important demographic changes, mainly related to the decrease in infant mortality and fertility, and the increase in life expectancy.¹ In 2016, the population aged 10 to 24 years constituted a total of 51,402,821 people, about 36.89% of the Brazilian population.¹ On the world stage, this population totals 1.8 billion people, corresponding to 24% of the global population.²

In view of the different socio-cultural contexts, adolescence must be understood as a socially and culturally constructed category, thus defining singular forms about the being an adolescent.¹ As with any phase of human development, adolescence is also a singular, particular and contextual moment,³ therefore, it requires that the care for these subjects takes into account individualities and comprehensiveness.¹

In general, adolescence does not have high rates of illness or mortality when compared to other stages of human life. Even so, there are individuals who, when undergoing the process of change in an intense way and in the face of the need for new adaptations, may present some level of emotional suffering,^1-3 which may affect the development in different areas, such as school, family and/or affective. These factors can thus make them more vulnerable to behaviors that intentionally cause harm to their health, such as self-destructive behaviors,³ which have been responsible for most of the care provided to children and adolescents in emergency services.⁴

Non-suicidal self-injury (NSSI) is an action with no conscious intention of suicide, but which can generate serious injuries. This behavior is related to mechanisms of coping with emotions, it is often used to decrease tension or relieve suffering and, generally, it is related to negative interpersonal relationships.⁵

In addition to the impact on the health and development of individuals, NSSI is considered a public health problem, as it directly affects the relationships of the individual and the people in their social network, especially their family. It also impacts services that face a lack of resources to deal with the problem and the overload.³

Epidemiological data on NSSI are imprecise. As we can see, in Brazil, considering adolescence, 30,075 cases were registered among girls and 11,789 cases among boys, between 2011 and 2016.⁶ Worldwide, the literature review showed that the rates are between 17 to 60% of adolescents.⁷ In this sense, in 2016, WHO released a manual on practices to establish and maintain surveillance systems for suicide and self-injury attempts, which reinforces the need for understanding, developing care strategies in different areas of health care, in order to face this problem.⁸

The international literature presents aspects related to the care for these diseases. It is verified the need to break barriers in meeting these demands, especially in existing emergency services due to difficulties in handling adolescent needs and stressful situations.⁴

Studies reinforce the professionals’ lack of technical knowledge about the management of NSSI, especially because it overcomes the physical bias and brings the need to look at subjective aspects of care.^9,10

In this sense, care would be in the perspective of understanding the other, from a singular encounter. Care is established in the action, attitude and daily movement of teams and services when considering the presence of the other in the assistance space, in the optimization and diversification of the forms and quality of the “I-other” interaction and in the “enrichment of horizons of knowledge and actions” in health, in an interdisciplinary and intersectoral perspective.¹¹

Given the relevance of NSSI in adolescence expressed in professional practice and scientific literature, the object of this study was constituted by the perception of education and health professionals regarding this phenomenon. It is necessary that professionals are prepared for the identification, risk assessment and promotion of integrated actions between school, family and health.¹²

It is assumed that the look and care for NSSI in adolescents by health and education professionals are related to the meaning attributed to this phenomenon, as well as adolescence, by these professionals. Thus, the theoretical framework of this study was Symbolic Interactionism, which considers the analysis of human behavior based on the social act, composed of two dimensions – the “manifest” activity, conceived by external and observed behavior; and the “covert” activity, related to the individual’s internal experience.¹³

Assuming that people act based on the meaning that things have for them, we can verify that the meaning of these things emerges from social interaction, and the meanings are given through an interpretive process of the individual.¹³

In Brazil, studies have addressed NSSI through interactions on social networks,¹⁴ literature reviews⁵ and quantitative aspects of behavior.¹⁵ Considering the gaps in the Brazilian literature, the objective of this study was to understand the perceptions of education and health professionals (PHC) about NSSI in adolescents.

METHOD

Qualitative approach research.¹⁶ The study was carried out in a Family Health Unit (FHU) and a state elementary and high school in a district in the municipality of São Carlos, São Paulo. The choice for this field occurred because of the existence of a university extension project in that location, also due to the growing number of NSSI situations by adolescents reported to the municipality’s health services and because of the lack of interventions in this field because it is peripheral.

The study municipality has a population of approximately 3,000 inhabitants. The adolescent population is 385, being about 47% male and 53% female, and 13% of the total population.¹⁷

The study participants were health and education professionals, respecting the following inclusion criteria: having direct contact, whether in the past or present, with adolescents who self-injured; have been working in the services for at least six months. This last criterion was considered to enable greater contact and familiarization with the service. Professionals who were not active in the services during the data collection period were excluded.

The focus group and the field diary were used for data collection. Initially, the professionals answered a questionnaire for sociodemographic characterization and professional experience. The focus group is an important strategy for research that seeks to understand group experiences and transform reality, thus allowing the emergence of points of view and meanings that would be difficult to access through individual techniques.¹⁸

Thus, in this study, the focus group was chosen in order to favor group interaction, thinking and communication, through a participatory and critical approach, therefore, the participants were able to express their perception about the object of study. They were driven by the following questions: What do you understand about self-injury? How to take care of self-injury in adolescence? What can be done in addition to the actions already taken?

The period of data collection was between August and September 2019. A focus group was held at the school, of 1 hour and 49 minutes with 15 professionals and two focus groups at the FHU of 2 hours with five professionals. The groups were moderated and observed by the last and first author of this study, respectively.

Participants were previously invited during a health team meeting, and at school through a pedagogical planning meeting. All health professionals agreed to participate. In education, three professionals refused to participate because they revealed they had no interest in discussing the object. The speeches were recorded on a cell phone, with its own voice recording application. Then they were transcribed in full. In order to guarantee the anonymity of the participants, the statements were identified as EP for education professionals and HP for health professionals. They were listed in the sequence in which they appeared in the groups.

The field diary constituted itself as a relevant instrument for data analysis, in particular, anchored by the Symbolic Interactionism.¹³ In it, the investigative experience was described; the methodological process, in particular, of data collection; theoretical reflections based on empirical findings. To end the data collection, saturation of meaning was used, which corresponds to a deeper discussion, rich in details and complex with the data to ensure the understanding of a phenomenon of interest.¹⁹ The elements that allowed the occurrence of saturation were the dense answers to the study questions, and apprehension of meanings of NSSI and adolescence for professionals.

Qualitative data were analyzed using the technique of inductive thematic analysis,²⁰ through the following steps: familiarization with the data; coding; search for themes; review of topics; and definition and naming of themes. At the end, the data were linked to theoretical concepts and contextualized to the relevant literature in the area. The record in the field diary was essential for the construction of the process of coding, searching and reviewing themes, summarized in Box 1.

Box 1
Codification and definition of themes. Prepared by the authors. São Carlos, 2019.

Initial codes	Intermediate codes	Final themes
Transient phase		“This moment of adolescence”
Externalization of suffering
Trivialization	Adolescence as a phase
She wasn’t there for that	Contagion
Contagion	Trivialization
Teen Fashion	Risks
Seriousness of cases
Genre
Accelerated thinking syndrome		“Changes in the last 20 years”
Frustration resistance
Draw attention	Changes in family dynamics
Unstable family environment	No dialogue
Recent topic	Technology
Technological world
Interdisciplinarity		“Within our governance”
Governability	Referrals
School support
Interventions carried out	Possibilities – listening / professional commitment
Health-school relationship

The study followed the recommendations of Resolutions 466/2012 and 510/2016 on research involving human beings. It was initially approved by the municipal and local managers of the services, being approved by the Ethics Committee in Research with Human Beings of the Universidade Federal de São Carlos on 08/22/2019, under CAAE: 17176219.6.0000.5504. The participants agreed to participate in the research, by signing the Informed Consent Form.

RESULTS

The participants were 15 elementary and high school teachers at the school mentioned and five health professionals. Among the education professionals, two were men and the others, women. Two professionals were between 21 and 30 years old, five between 31 and 40 years old, four between 41 and 50 years old and four between 51 and 60 years old. The professional training comprised Geography, History, Arts, Pedagogy, Portuguese, Mathematics, Physical Education and Chemistry. A professional had the theme of NSSI in their training, and none of the teachers participated in updating on the theme during their professional activities.

Education professionals showed discomfort in the discussion of the topic, represented by verbal expressions of non-legitimacy of behavior and parallel conversations.

In health, all participants were women, being a doctor, a nursing technician, a nurse, a community health worker and a dentist. Three professionals were between 31 and 40 years old, one between 41 and 50 years old, and one between 61 and 70 years old. None of the professionals had the NSSI theme addressed in their training or participated in an update on the theme. Health professionals were participative, in particular, due to the growing demand for NSSI reported verbally by the service.

Next, the final themes will be presented.

Theme 1 – “This moment of adolescence” – meanings attributed to adolescence and NSSI

When asked about the phenomenon of NSSI, health and education professionals related to elements present in adolescence. This aspect was emphasized as a period of transition, changes and discoveries, in which people are lost and prone to these behaviors; the meaning attributed to NSSI was also placed in that area:

This moment of adolescence, because I associate this with a specific age group, I think that all these issues of transformation, of not having found themselves yet. (HP3)

What often happens is the dealing with differences during adolescence, a matter of 12, 13 years old, where people are discovering what they want, what they are, they are in conflict with themselves. (EP6)

Another issue raised was the characterization of adolescence pejoratively. The explanation of the lesions is related to hormones, in a way reduced to the biological aspect. In this sense, the professionals associated it as a “transient phase”:

Adolescent hormones are strong, so we know that, so we know that the cuts are transient. (EP2)

A trivialization of NSSI was present in the speeches of the professionals, very articulated to their understanding of adolescence. It was associated with the fact of “drawing attention” or fussiness, being considered a non-relevant topic in health:

I agree, I think it’s just a way to draw attention to some deviation that there was in the middle between being a child and being a teenager and when you are a teenager you need attention and from all sides, and if you are missing you will find a way of drawing, it can be through the cutting. (EP2)

The contagion effect was also a cited element, related to the issue of affecting mainly this population. This aspect was also presented in a trivialized way:

And then I started to realize that several people in the same age group appeared with those injuries and were people who, like that, seemed to know each other... then I saw that there was a singer, I don’t know if it’s Selena Gomes... Demi Lovato, that it had something to do with her, with this injury. (HP3)

They follow imitation a lot, “she drew the attention of the entire school, of her colleagues, of the management mutilating herself, so I will also mutilate myself”, and she becomes a fad because it is a fever. (EP3)

Some professionals brought different notes to these issues, signaling the need for a different look and free of preconceptions:

First thing, I think we should stop thinking that this is not relevant, that it is not important and that it is silliness... I think that if you are doing this the problem is more complex, so you have to stop analyzing it superficially like that, first thing. (EP4)

If it were a teenager’s trend, it would have passed, but it seems to be staying, right, so I don’t know if it also remains a psychic thing that the person comes and says that he/she did, so it might be a good idea for me to do it too, because if it relieves him/her it can relieve me too. (HP3)

The professionals also signaled possible risks of these behaviors, such as suicide, and the lack of understanding as a health problem:

This issue is very neglected, he/she thinks he/she wants attention, you hear it a lot, just when the person really tries to kill him/herself in a way, even taking medicine, many times in the Hospital Emergency I heard “he/she did this because he/she wants to get someone’s attention”. (HP3)

...so, many times, children that for example do not know what will happen, so they think that in their minds it is often a fun, often, to be part of a group, but this is actually a serious case, that they think is not going to lead anywhere. (HP2)

Theme 2 – “Changes in the last 20 years”: changes in relationships and the NSSI

This category referred to the understanding of NSSI as a product of the transformations that occurred mainly in family relationships that, consequently, influenced social relationships, and in the use of the Internet as a propagator of this phenomenon.

The professionals cited a compromised family dynamic, with not very stable nor affective relationships, unrelated to specific family arrangements:

The mother said that since the daughter was 5 years old, she has been home alone, because the mother needs to work and that the mother saw, found some letters from the girl, you know, and the girl saying “what did she exist for?” (HP1)

I think it’s not the quantity, it’s the quality of the relationship. (EP7)

So, you have to have that little dad, mom, man and woman role model, all so cute to work properly? No, there has to be a family structure which has dialogue, that has people who listen to this child, this teenager, where he/she can find support to put his/her anxieties, to talk, to put out what they are feeling. (EP4)

Technology was another element that education professionals reinforce as being of relevant importance for the practice of NSSI, signaling that many adolescents live in function of the virtual world:

I think it has always existed, only nowadays with the coming of the internet, there is a way that these guys are organizing themselves so that such behavior can be shown in a soap opera, because it has already been internalized in society, so for example, if you catch a group of them closed, there is only barbarity... You have to fight where they develop, which is the internet. And it is contagious. (EP10)

Right in my head, I think this virtual world hindered me, it helped a lot to increase this, I think people end up being very alone, there is no more talking, no being together. (EP4)

Another issue raised was the no dialogue between the adolescents, pointing to the possibility of the relationship with the overflow of emotions, which can result in performing NSSI:

Nobody talks about the weaknesses, everyone wants to be perfect, I will talk about what I have of quality, what’s going on with me... this is making people unbalanced because thoughts come. (HP5)

I think that much of the fault is not theirs, they did not have a dialogue about it at home, they have no one to talk to. (EP7)

Theme 3 – “Within our governance”: resources for the management of NSSI

Education and health professionals report that they would like to be able to help in other ways, but it is not within “governance”, reiterating the need for specific preparation or training to accommodate these situations:

We must do what is within our governance, the parents must be advised and the child must be referred, because I do not have the authority to talk to a child about this subject, I have not studied this. (EP13)

I don’t feel at all structured, trained to medicate a child or anyone, I’m not a health professional, I can’t because I don’t have this knowledge, now I can indicate that she go there at the FHU and talk to a suitable professional, we disregard these small actions. (HP3)

The professionals indicated that the interventions already carried out were notification of cases and the referral to a Health Unit, seeking assistance from a mental health professional:

They were referred to a mental health professional and continued to follow up here and in the other specialized service, they always ask you to come back to be followed up and there was improvement, there actually was improvement. (HP4)

Throughout the data collection, professionals used personal experiences, often with their own children, to talk about ways to manage NSSI among adolescents, at no time did they refer to scientific support materials.

Despite the absence of formal resources to deal with the phenomenon, such as training on the theme emerging from the speeches and the lack of improvement in school health services, professionals brought possibilities of listening and welcoming permeated by the bond they can build with adolescents:

But sometimes, just listening, them letting it out and you listening to it, you don’t even need to talk, let them be heard, it helps a lot. (EP4)

Furthermore, they brought the need and desire for permanent education with the theme:

We should be trying to do an active search or in some way do or prepare a workshop, even for us to first know how to approach this topic with the teenager, because I didn’t know how to ask, how it would be in a non-invasive way. (HP5)

Look, it is a subject that must be looked at many things, many, many... a look not at the act but at the risk factors, at the suffering, see that there is a person who is suffering, I will say “look don't cut yourself”, no, it’s not like that, it is about seeing the greater picture, it is the integral, it is the biopsychosocial. (HP5)

I think it really is an issue that has to be taken to an interdisciplinary and multidisciplinary circle and see which is the way. (HP3)

DISCUSSION

Meanings attributed to NSSI among adolescents by health and education professionals were unveiled. Some manifest activities were presented by the professionals – the look and care for this phenomenon is a challenge for the professionals, the adolescent public is presented as difficult to manage, who are not prepared to deal with frustrations and resort to self-injurious behaviors. The meanings attributed to NSSI and adolescence are transient and difficult, therefore, these phenomena are trivialized and their causes are directed to the technologies and families of these adolescents.

NSSI is related to a universal concept of adolescence – as a phase, lack of limits, disregard for rules and hormones. Consequently, care is outlined based on referral, merely bureaucratic notification and not taking place in the health field.

Some activities seen as deviant have difficulty finding a place, such as the possibility of a more singular look at the experiences and an active listening, free of judgments.²¹ The approach to the adolescent’s health and their demands are often invisible, due to the assumption supported by insufficient data, that adolescents are healthy. However, currently, there has been an increase in visibility in global health initiatives for adolescent health.²¹

Furthermore, a constructivist view of adolescence has emerged, perceived not as a phase or a passage, but as a social construction of a singular existence and acting in the world.¹ Such understanding has been reinforced in the main worldwide²¹ and national^l1 documents of care for this population. These understandings have not yet materialized in practice, as noted in this study.

Such data corroborate research that apprehended the conceptions about adolescence carried out with professionals from a Centro de Atenção Psicossocial Infantojuvenil – CAPSi (Child and Adolescent Psychosocial Care Center in free translation) in Santa Catarina.²² These professionals demonstrated difficulty in breaking a naturalized view of the adolescent, understood as a phase of conflicts, without locating it as a development process and signified by the society in which it is built.²²

Adolescence is a phase with greater intrapersonal and social vulnerability, so individuals have exercised self-injury to relieve negative feelings.¹² In a cross-sectional research that identified motivations for self-injury among 856 adolescents,⁹ it was found that 103 reported episodes of NSSI, and the most reported reason is to get relief from a bad feeling.

In the present study, it was noticed that the meaning attributed to NSSI was related to the search for attention in the adolescent phase. The literature points out that such a statement can be misinterpreted, relating to the model of interpersonal influence of NSSI in which behavior is used as a way to influence other people.⁹ Study found that few adolescents reported NSSI with this motivation, that many adolescents hide their cuts and scars, do not tell other people and do not report to health professionals.⁹

A study that analyzed the topics related to NSSI in blog posts, found that pro-suicidal behavior was presented as the only way to end suffering, in these terms, helplessness and continuous suffering were the main topics addressed.²³ Prevention and support themes occurred in a few posts, often with criticism and depreciation.²³

Social contagion, mentioned and trivialized by the professionals in our study, especially in education, is considered a trigger for the behavior of NSSI. This can happen offline or online and influenced by peers or idols.¹⁴ In adolescence, this aspect acquires relevance given the peculiar development process based on identification with peers, and should not be disregarded as suffering.¹⁴

The problem of the trivialization of NSSI and judgment of the “genuineness” or not of the behavior by the professionals is highlighted, as well as the tone of care for this phenomenon to be based on this impression. Adolescents and young people who seek health services to report NSSI have experienced stigmatizing attitudes such as labeling and minimizing suffering. These negative interactions can trigger the least intention to seek help.¹⁰ These results demonstrate that health professionals, especially nurses, due to the privileged place and protagonism in the teams, need to be aware that NSSI emerges as a significant response to real distress, reinforcing the need for permanent education of professionals to address this phenomenon.⁹

Another action punctuated by the professionals in this study and corroborated by the literature is the escalation of NSSI to suicide, because after such behavior, if there are no interventions, adolescents are at risk of repeating the act and/or suicide.²⁴ A Swedish study followed 8,387 patients who underwent NSSI and 0.16% (n=13) died of suicide in the first year.²⁵ Other studies indicate that one in three young people who committed suicide underwent NSSI in the last three months of life. This fact warns of early interventions to identify these behaviors, which can save lives.²⁴

The professionals brought the compromise of family relationships as one of the aspects related to NSSI in adolescence. Effectively, the family is the first protective factor for adolescents. When it is omitted, the possibility of this actor feeling isolated or lonely is great.²⁶ In a quantitative and qualitative study that sought to identify the factors that are associated with NSSI, adolescents reported that the reason for performing the act is the family problem, emerging categories such as “discussions”, “divorce”, “mourning”, that is, factors that may imply dysfunctional family dynamics.²⁷

Another study investigated the association between the level of perceived parental support during childhood and adolescence and the suicidal ideation in a sample of 10,015 French students.²⁵ It was found that low levels of perceived parental support lead to a high risk of suicidal ideation.²⁵ An American study evaluated the association of family factors with suicide and NSSI among 11,814 children between 9 and 10 years old. It was found that family conflicts and low parental monitoring are related to suicidal behaviors.²⁸

Still in this context, a study analyzed the contributions of social support from parents, close friends and school to suicidal ideation and attempt in 143 adolescents in the Central Atlantic area of the United States.²⁹ The results indicated that the perceptions of parental and school support are relatively more important than the support of friends. Perceptions of low parental support are associated with the history of attempted suicide.²⁹ Thus, family involvement in the care and possible strategies to prevent and cope with NSSI and suicidal behaviors are essential.²⁹ It is emphasized that the family should be seen as a partner and not punished or solely held liable for the children’s actions. It is reinforced that this family may also need care.

A research conducted in Madrid, Spain, showed that there is a significant correlation between cases of depression and anxiety and the level of satisfaction between family relationships, that is, the lowest levels of anxiety and depression were found among adolescents living in a family more affective.³⁰ A study that documented the current diversity and complexity of families of adolescents to rethink future parenting theories and studies, recommends the use of maps of the support network with adolescents.³¹ These maps, having the adolescent as the center of the network, allow a view of the key dimensions of family structures and processes.³¹

Professionals have repeatedly brought the impact of the advent of the Internet on relationships between adolescents and the world. Such relationships presented in a negative way and as a source of dissemination of NSSI. Literature review that sought evidence about the potential influence of the internet on suicidal or self-injurious behavior in young people, brought harm and benefits from this influence.³²

There is a risk of normalization, competition and contagion of the phenomenon through the dissemination of methods and images that encourage the act. On the other hand, the Internet can be used to perform interventions and treatments online, to reduce the feeling of loneliness and isolation, for crisis support. Addiction and high levels of internet use were particularly associated with suicidal behavior.

The study found that teenagers and young people use social networks to communicate distress, especially with peers. In this sense, the focus should be on the therapeutic use of these media, as well as problematizing the importance of bringing the use of the Internet as a standard in assessing the mental health of this population.³² It is recommended that the promotion of safe use of the Internet be part of intersectoral actions in schools, as well as being part of the nursing and health care aimed at adolescents, their families and communities.³³

Finally, the professionals brought that care for adolescents who practice NSSI is beyond their means. Through the data presented here, it is clear that this speech refers to the meaning that these professionals give to adolescence and the phenomenon of NSSI. Non-sensitization and little knowledge have also been reported in other studies.^9,10

Training and deepening in the theme are essential for the development of strategies and use of care practices for this population. The notification of cases, as advocated by the recent Política Nacional de Prevenção da Automutilação e do Suicídio – Law 13819, of April 26, 2019 (National Policy for the Prevention of Self-Mutilation and Suicide, in free translation), is necessary to guide public actions and policies, but must be integrated with interventions to promote mental health, prevention, and coping with suicidal behaviors. Referral to specific services and professionals is necessary in some situations, however non-pathological responses to NSSI are necessary. The phenomenon needs to be understood as a significant behavior to the adolescent, rather than a symptom of a disease.⁹

Actions identified by some professionals in this study, such as welcoming and listening to adolescents, are reinforced by the literature as good practices in the care of NSSI. Non-judgment, active listening and the person’s involvement in care decisions contribute to the satisfaction of adolescents and young people.^9,10 PHC and education professionals, being closer to the adolescents, have greater possibilities to access the role and understand the personal motivation and meaning of NSSI. Such an approach is essential for an appropriate, sensitive and individualized care plan for adolescents.⁹

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The results of this study reinforced the initial assumption: the actions taken or not by health and education professionals facing NSSI in adolescence are anchored in the meanings that these phenomena have for them. Adolescence is still seen as a complex and difficult to manage phase, and NSSI emerges in this context as transitory and search for attention, reinforced by trivialization and the contagion effect. Family and internet relations are signaled as propagators of the phenomenon. In view of these meanings, care is weakened. Some possibilities of welcoming and affective listening are presented.

The limitations of this study were related to data collection and analysis. In the first, by the use of a group technique, which could be complemented and bring new elements through the use of individual interviews. The analysis did not thoroughly investigate the differences between the sectors of health and education, which could be better discussed.

The study has important implications for the practice in Nursing and health, such as the views on a contemporary phenomenon by professionals directly involved in their care. Permanent education on adolescence and its development process, raising awareness and building strategies for welcoming adolescent suffering, which are sometimes expressed by NSSI, are urgent. This process can be favored by the construction of protocols and flows of intersectoral assistance to NSSI and suicidal behaviors.

In the school area, actions that promote mental health and the safe use of the internet are relevant, as well as support for families to become factors that protect adolescents and partners of their care.

Further studies exploring the perceptions of adolescents, families, and other health services and other sectors of child and adolescent protection are needed.

• FINANCIAL SUPPORT Fundação de Amparo à Pesquisa do Estado de São Paulo, São Paulo-SP, Brazil, Process No 2018/22949-6, Scientific Initiation scholarship to Isabela Martins Gabriel.

REFERÊNCIAS

• ¹
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Edited by

ASSOCIATE EDITOR Eliane Tatsch Neves

Publication Dates

• Publication in this collection
  13 July 2020
• Date of issue
  2020

History

• Received
  04 Mar 2020
• Accepted
  08 May 2020