The accomplishments of occupational therapy in the field of child and adolescent mental health

Abstract

Introduction

Although, throughout history, Occupational Therapy has actively followed the development of the field of child and adolescent mental health, there is low production on the elements that characterize the core of the profession in this field, highlighting the importance of research that advances in this direction.

Objectives

To identify the perspective of occupational therapists involved in the psychosocial care of children and adolescents on the professional core of Occupational Therapy in the field of child and adolescent mental health and analyze how non-occupational therapists involved in the psychosocial care of children and adolescents describe the practice of occupational therapists in this field.

Method

Study with a qualitative and quantitative approach, developed in two phases. The first phase had the participation of 107 professionals working in the field of mental health of children and adolescents, who answered an online questionnaire. In the second phase, 32 professionals participated, who composed four virtual focus groups. The Iramuteq® software was used to analyze the data from both phases.

Results

The following were identified as characteristic occupations of Occupational Therapy in the field of mental health for children and adolescents: the focus on occupations, daily life activities, routines and daily life of individuals; the integral perspective on the subjects, the weave of networks and the promotion of intersectionality; the acting in situations of intense psychic suffering and handling crisis situations; the acting in the most serious and complex cases.

Conclusion

The study demonstrates the characteristics Occupational Therapy’s work in the field of mental health for children and adolescents, highlighting the importance of this professional core for the collective construction of care in this field.

Keywords:
Occupational Therapy; Mental Health; Child; Adolescent; Professional Competence

Resumo

Introdução

Embora, ao longo da história, a terapia ocupacional acompanhe ativamente o desenvolvimento do campo da saúde mental infantojuvenil, há pouca produção sobre os elementos que caracterizam o núcleo da profissão neste campo, destacando-se a importância de pesquisas que avancem nesta direção.

Objetivos

Identificar a perspectiva de terapeutas ocupacionais envolvidos na atenção psicossocial de crianças e adolescentes sobre o núcleo profissional da terapia ocupacional no campo da saúde mental infantojuvenil, além de analisar como os demais profissionais envolvidos na atenção psicossocial de crianças e adolescentes descrevem a prática de terapeutas ocupacionais neste campo.

Método

Estudo com abordagem qualiquantitativa, desenvolvido em duas fases. A primeira contou com a participação de 107 profissionais atuantes no campo da saúde mental de crianças e adolescentes, que responderam um questionário online. Na segunda fase, participaram 32 profissionais, que compuseram quatro grupos focais virtuais. Para análise dos dados de ambas as fases, foi utilizado o software Iramuteq®.

Resultados

Foram identificados como fazeres característicos da terapia ocupacional no campo da saúde mental infantojuvenil: o enfoque nas ocupações, atividades de vida diária, rotinas e cotidiano dos indivíduos; a perspectiva integral sobre os sujeitos, a tessitura de redes e o fomento à intersetorialidade; a atuação frente ao sofrimento psíquico intenso e o manejo das situações de crise; e a atuação nos casos mais graves e complexos.

Conclusão

O estudo demonstra as características dos fazeres da terapia ocupacional no campo da saúde mental infantojuvenil, destacando a importância deste núcleo profissional para a construção coletiva do cuidado no referido campo.

Palavras-chave:
Terapia Ocupacional; Saúde Mental; Criança; Adolescente; Competência Profissional

Introduction

Some studies indicate that children, as they are not considered in their specificities, but as miniatures of adults, have historically been neglected from all types of care, and it was only with the advent of the fields of pediatrics, pedagogy and child psychology that more attention was dedicated to child development and protection and assistance measures for this population. In this sense, occupational therapy has contributed to work aimed at children and adolescents, encouraging their development, autonomy, and social participation (Gomes & Oliver, 2010).

In Brazil, this work was driven by the increase in public policies aimed at this population, among which it is worth highlighting the Statute of Children and Adolescents – ECA (Brasil, 1990). ECA inaugurated a new way of looking at and understanding issues related to childhood and adolescence, based, among other aspects, on the regulation of socio-educational and protection measures for this population (Galheigo, 2003).

In the field of mental health, the history of little dedication to the specificities of the child and youth population was no different. A review of the issue of mental health in children and adolescents indicates that, until the 20th century, no diagnostic criteria were found for children who presented problems related to mental health, and they were treated just like “schizophrenic adults” or those with mental disabilities (Brunello, 2007). From 1980 onwards, the acronym GDD was adopted to name, respectively, Global Developmental Disorders. This would include children with “[…] developmental impairment in multiple vital areas, such as social interaction and communication disabilities and the presence of stereotypical behaviors, interests and activities” (Brunello, 2007, p. 309).

With this diagnostic framework and everything it can unintentionally entail, in terms of disinvestment in the face of determinism, it became important and necessary, for occupational therapy, to understand the way in which children who experienced such conditions placed themselves in the world, the suffering they presented, which prevented them from satisfying their needs and carrying out daily activities typical of childhood, so that this information could guide professional practices (Brunello, 2007).

Faced with this scenario, it is worth “[…] considering that the intervention of occupational therapy with children who present problems related to mental health followed along with the development of child psychiatry” (Matsukura, 1997, p. 29).

Internationally, before the 1990s, some studies already indicated that occupational therapists were being increasingly requested to work with children said to have mental disorders (Copley et al., 1987) and that, therefore, it became important to invest in research that could focus on and systematize the contributions of occupational therapy in this field and the possible theoretical references adopted (Sholle-Martin & Alessi, 1990).

Based on these and other international studies, Matsukura published, in 1997, an article considered a precursor to occupational therapy in the field of Brazilian child and adolescent mental health. In this manuscript, the author used a case study to raise the debate about the possible contributions of occupational therapy in the treatment of autism. Based on the psychodynamic approach, the author drew attention, especially, to the importance of using activity, inherent to occupational therapy processes, and the quality of the therapeutic relationship as potential strategies in the area in providing care to this public. According to the author, activities are instruments that allow both access to individuals' internal reality and their contact with the external reality that surrounds them (Matsukura, 1997).

In this sense, Matsukura (1997) highlighted, based on the results of the study in question, that carrying out activities during the implemented therapeutic process expanded the possibilities of experimentation, development, and interaction of the child, as well as the triadic relationship between therapist, patient and activity, characteristic of psychodynamic occupational therapy processes, which supported the development of a solid and powerful contact with the child.

A decade later, considering the field of mental health of children and adolescents, in a more general and broad way, Matsukura (2007) made points in relation to what the literature at the time already indicated as paths for said action. According to the author, the occupational therapist is the professional who intervenes directly with the child and who also reaches their different contexts and their network, implementing and developing, in the specific daily life of each individual, strategies and resources that promote organization in the face of conflicting situations. The role of occupational therapy in reducing risk factors and increasing protective factors, both emotional, social, and environmental, is also highlighted, with a view to promoting the healthy development of children and adolescents (Matsukura, 2007).

For Brunello (2007), the work of occupational therapy with this population “[…] must necessarily go through two aspects: offering resources so that life gains meaning and assisting in the search for actions that make these people’s lives more worth living” (Brunello, 2007, p. 311). The author also reinforces the role of the occupational therapist in the entire institutionalizing process, in favor of effective social inclusion, autonomy and freedom of different forms of existence.

It is worth highlighting here that in the Brazilian context, unlike other countries around the world, occupational therapy in public health sought to follow advances in local mental health policies for children and adolescents, with Psychosocial Care as its line of support. In this sense, it is noted that the field of mental health care for children and adolescents in Brazil is based on the Psychosocial Care Network (RAPS), established in 2011 for the entire population in psychological distress and with demands related to alcohol use. and other drugs, including the population of children and adolescents (Brasil, 2011).

According to the document “Psychosocial Care for Children and Adolescents in the Unified Health System – Weaving Networks to Guarantee Rights” (Brasil, 2014), care strategies for this population, specifically, must follow the following guidelines: the consideration that children and adolescents are subjects of rights (including the right to present their own demands in the care process); universal reception; the implicated and co-responsible referral; the permanent construction of the network and intersectorality; work in the territory; the continuous assessment of demands and the shared construction of mental health needs. It is also observed that RAPS is made up of different points of care, including: Basic Health Care, Strategic Psychosocial Care (CAPSij), Urgent and Emergency Care services; Residential Care of a transitional nature; Hospital Care (Brasil, 2014).

In this context, some national studies have highlighted the role of occupational therapy in the field of mental health for children and adolescents. Research carried out by Tszesnioski et al. (2015) highlights the importance of the occupational therapist's work, not only with individuals, but also with the child and youth mental health network. This study aimed to describe the care network for children in psychological distress and develop interventions in the territory, pointing out changes that occurred as a result of these actions. The research included the participation of children with a history of psychological distress and their respective families, registered at a Family Health Unit in the city of Recife (PE). The authors highlighted the importance of the presence of the professional occupational therapist in the composition of the team, especially in facilitating the relationship between the child and the support devices. Interventions aimed at strengthening bonds with family members and articulation with health and education services were highlighted, as well as the impact of these interventions on the social inclusion of the children in the study.

Bueno et al. (2021) carried out research that aimed to characterize the practices of occupational therapists in the child and youth mental health care network in Belo Horizonte (MG), identifying actions and approaches. 18 occupational therapists working in the network participated. As a result, they identified that occupational therapists were present in three child and adolescent mental health assistance devices in the municipality, namely: 1) Complementary ABS mental health teams; 2) CAPS for children and adolescents; and 3) Art of Health Program.

The results from the professionals of the Complementary Teams indicated the presence of three guiding perspectives for their practices: a) the developmental/enabling one, focusing on the acquisition and development of skills and the losses caused by illness; b) the principles of psychosocial rehabilitation, focusing on social insertion, role playing and citizenship; and c) the psychotherapeutic approach, focusing on expression, analysis of internal content expressed through activities and elaboration of this content (Bueno et al., 2021).

In the children's CAPS, the occupational therapists participating in the research showed tensions related to the loss of professional framework, since it is a collective model of assistance, with sharing of functions not differentiated by professional specialties. In the Art of Health Program, which aims to offer spaces for socialization and coexistence, through artistic and cultural workshops, the work of occupational therapists was characterized by management work, highlighting the proximity between the program proposal and training professional in occupational therapy (Bueno et al., 2021).

Research carried out by Bueno (2013) had the general objective of characterizing the insertion of occupational therapists in children's CAPS and identifying the actions developed by these professionals with the clientele served. A descriptive study was carried out with 24 occupational therapists from 18 CAPSij in the State of São Paulo, with data collection carried out through questionnaires. As a result, the author identified that the actions that characterize the specificity of occupational therapy are related to activity analysis, social insertion, and everyday activities, focusing on activities of daily living. The author also identified, together with the participants, gaps in their theoretical and practical training process regarding the role of occupational therapy in the field of child and adolescent mental health. Based on the results obtained, it highlights the importance of expanding and deepening the production of knowledge about the training and practices of occupational therapists in the field of child and adolescent mental health (Bueno, 2013).

Richter (2019) aimed to understand the process of discharging children and adolescents from Child and Youth Psychosocial Care Centers (CAPSij) from the perspective of occupational therapists. The author carried out a descriptive and exploratory study, in which 15 occupational therapists working in CAPSij in the city of São Paulo participated. It was identified that the contribution of occupational therapy in the discharge process was related to the expanded and contextualized assessment of children and adolescents with the interdisciplinary team, the strengthening of their families and the empowerment of subjects to appropriate social spaces external to CAPSij. The author points to the importance of more studies that focus on the contribution of occupational therapy in this context, as well as expanding the vision of the different actors involved, in addition to the occupational therapists themselves, and in the different Brazilian regional realities.

In view of the above, it is considered that the studies presented here identified, in their results, aspects about the core of occupational therapy in the field of child and youth mental health, highlighting, however, the need and importance of deepening the discussion about its location, characterization and demarcation of its elements, as a way of improving training in occupational therapy, as well as practical and technical performance in that field (Bueno, 2013; Bueno et al., 2021; Richter, 2019).

In this way, the present research converges with the intention of deepening the study and discussion regarding the professional core of occupational therapy in the field of Brazilian child and adolescent mental health, placing it as a focus. The field of child and adolescent mental health is understood as a multifaceted and multidisciplinary field. Based on Campos' (2000) field and core framework, the field of mental health can be understood as a space where each discipline and profession interact with each other to support each other in fulfilling the theoretical and practical activities of this field. Flexibly associated with this dynamic of the field are the nuclei, understood as a concentration of knowledge and practices, the agglutination of knowledge, the identity of an area of knowledge and professional practice (Campos, 2000).

Based on this reference and considering the engagement of occupational therapists in reformist movements and in the defense of minority populations, including people in psychological distress and children and young people, it is possible to identify occupational therapy as one of the nuclei that make up the field of child and adolescent mental health. In this sense, some studies in the area identify aspects and elements about the activities of this nucleus in this field, highlighting, however, the need for and importance of deepening this discussion, as a way of improving training in occupational therapy and practical and technical performance in that field. (Bueno, 2013; Pereira et al., 2014a; Santarosa, 2016; Richter, 2019).

In view of the above, the present study had the general objective of identifying the perspective of occupational therapists involved in the psychosocial care of children and adolescents on the professional core of occupational therapy in the field of child and adolescent mental health. And, as a specific objective, it intended to analyze how non-occupational therapist professionals involved in the psychosocial care of children and adolescents describe the practice of occupational therapists in the field of child and adolescent mental health.

Method

This is a descriptive-exploratory study, with a qualitative-quantitative approach, developed in two phases, which will be described below:

In Phase 1, 107 professionals participated, in which 59 were occupational therapists and 48 non-occupational therapists. Of these, the majority were cisgender women (92%), aged between 26 and 30 years old (26%) and resident in the State of São Paulo (61%). Among non-occupational therapists, the majority were psychologists, social workers, and nurses. The professionals mostly had between one and three years of experience at RAPSij (28%), worked, at the time of participating in the research, at CAPSij (30.4%) and had previous professional experience at CAPSij (21%).

As criteria for inclusion of these professionals in the research, the following were adopted: occupational therapists who worked or had worked for at least six months in psychosocial care for children and adolescents, in the national territory; and non-occupational therapist professionals, with higher or secondary education, who worked or had worked for at least six months in psychosocial care for children and adolescents, in whose teams there was at least one occupational therapist, in the national territory. All participants were located and accessed virtually, using the “snowball” method (Vinuto, 2014) as a means of dissemination, in addition to social networks, messaging applications and dissemination by the Regional Councils of Physiotherapy and Occupational Therapy – CREFITOs – from different Brazilian regions.

In Phase 1 data collection, a questionnaire was administered via the Google Forms tool – Form. The questionnaire, prepared by the researchers and validated by expert judges, began with multiple choice questions related to the sociodemographic characterization of the participants and, subsequently, presented open questions about aspects and elements perceived regarding the role of occupational therapy in the child and adolescent mental health field. At the end of the questionnaire, the participant could signal their interest in participating in Phase 2 of the study. The questionnaire was shared and was available for completion for around 40 days, between the months of February and March 2021.

To analyze the data collected in Phase 1, Microsoft Office Excel® spreadsheets were used to systematize and organize the data. The initial and objective questions of the questionnaire were analyzed using descriptive statistics. To analyze the open questions, the software Iramuteq® (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) was used, which consists of an open and free program, with a complete dictionary in the Portuguese language, which allows statistical analyzes of a certain textual material.

In Phase 2 of this study, 32 professionals participated, of which were 20 occupational therapists and 12 non-occupational therapists. Among occupational therapists, the majority lived in the State of São Paulo (40%), followed by Minas Gerais (15%), Mato Grosso (10%) and Ceará (10%). There was also a minority participation of occupational therapists from the states of the Federal District, Goiás, Rio Grande do Sul, Rio de Janeiro and Pará (each with 5%). Among non-occupational therapists, the majority were psychologists (41.8%), followed by speech therapists (16.7%). There was also the participation of nurses, social workers, psychiatrists, workshop workers and nursing assistants/technicians (each with 8.3%). Among these non-occupational therapist professionals, the absolute majority lived in the State of São Paulo (91.7%), with the other 8.3% being participants from the State of Minas Gerais.

All professionals participating in Phase 2 had signaled, in Phase 1, their interest in participating in the continuation of the research and were again accessed virtually. To collect data in this phase of the study, the Focus Group technique was adopted. Based on the themes identified in the analysis of the Phase 1 questionnaires, scripts were developed for conducting the focus groups, one for the focus groups with occupational therapists and the other for the focus groups with non-occupational therapist professionals. Both scripts included an initial moment of personal and combined presentations, a second moment of presentation of the themes identified after analysis of the questionnaires, which would trigger the discussion, and a third moment of closure. There were four focus groups, two with occupational therapists, held in May 2021, and two with non-occupational therapist professionals, held in June 2021.

The four focus groups were carried out using the Google Meet platform, recorded, and transcribed in full, with the exception, in this transcription, of the researcher's speeches. For data analysis, the Iramuteq® software was also used, analyzing separately the textual material obtained from OTs and non-OT professionals.

The research was developed entirely online, using a Free and Informed Consent Registry to allow participants to voluntarily participate in both phases, guaranteeing their anonymity. The study was submitted for evaluation by the Human Research Ethics Committee (CEP) of the Federal University of São Carlos (UFSCar), following the guidelines and regulatory standards of Resolution No. 510, of April 7, 2016, of the National Council of Health, obtaining a favorable opinion, whose number is 4,537,878.

Results and Discussion

The analysis of the results obtained in both phases of this study, both with occupational therapists and non-OT professionals, allowed us to identify common characteristics in occupational therapy practices in the field of child and adolescent mental health. They are: 1) the focus on occupations and activities of daily living, acting with routines and based on the daily lives of individuals; 2) the integral perspective on the subjects, the fabric of networks, intersectorality and action in interface with the field of Education; 3) action in the face of intense psychological suffering, management in crisis situations and action in situations of vulnerability and violence; and 4) action in the most serious and complex cases, including cases of Autism Spectrum Disorder (ASD).

The focus on occupations and activities of daily living, acting with routines and from the daily lives of individuals.

The focus on occupations and activities of daily living was brought up by both OT and non-OT participants, as an important aspect of occupational therapy in the field of child and adolescent mental health. Despite not being included in the theoretical framework of psychosocial care, which supports the practices of this field, they are considered to be founding constructs of occupational therapy and widely adopted and studied in different fields, in Brazil and around the world. The role of occupational therapy with and from the routine and daily lives of individuals was also significantly mentioned.

Assessment, adaptation and structuring of routine and ADLs. In occupations and activities that are at loss, assessment of occupational performance and guidance and support for families [text segment – Ots corpus – Phase 1].

But I try to look a lot at the occupations, the routine, how this suffering has impacted daily life, to think about where I can actually help as an OT [text segment – OTs corpus – Phase 2].

But my goal is always to try to look at occupations, how this psychological suffering impacts the occupations of children, adolescents, and their families too. That’s what I try to work on [text segment – OTs corpus – Phase 2].

I understand my role in the team when the demand is related to daily life, the team asks me a lot in this sense, they are having difficulty, from organizing the routine, to these other things that change daily life, sadness, insecurity, disability [text segment – OTs corpus – Phase 2].

Looking at all the users served, understanding ADLs and aiming for care based on their occupations, building care strategies together with users based on everyday life [text segment – NON-OTs – Phase 1].

Development of occupational and cognitive activities, in everyday life, always involves the role of an occupational therapy professional. Users rely in occupational therapy to develop daily activities for those who have difficulties with tasks [text segment – NON-OTs corpus – Phase 1].

Historically, the term “occupation” was used as a synonym for a meaningless activity for people in psychological distress confined in asylum institutions. This action aimed to organize the behavior of these people and maintain institutional discipline. Individuals were also encouraged to maintain a routine of daily living activities, equally seen as a possibility of behavioral adaptation, suppression of symptoms and control over their bodies (Carlo & Bartalotti, 2001), which had an important influence on the institutionalization of occupational therapy as profession.

In Anglophone literature, the term “occupation” was given a new meaning from the 1980s onwards, starting to refer to basic human needs, guarantee of survival, health, and well-being, and is therefore preferred over other terms that were previously interchangeable, as “activity”. In Brazil, the movement was opposite. With the advancement of Brazilian occupational therapists' criticism of the local socio-political context, there was a clear distancing from the influences of Anglophone literature and the concept of activity began to gain strength, as a way of breaking with moral treatment and biomedical and positivist practices. As for the term “occupation”, it remained associated with doing for the sake of doing and the alienation of asylum institutions. The concept of activity, therefore, became stronger in Brazil as a theoretical-practical guiding axis of occupational therapy. Thus, while, in English literature, there was an advance in studies on occupational science, in Brazil, the discussion on the concept of everyday life was deepening (Salles & Matsukura, 2020).

Therefore, “occupation”, in the terms presented by Salles & Matsukura (2020), does not dialogue with the psychosocial care framework, as it carries with it the historical association with the asylum model. However, it is known that in the field of occupational therapy there are other aspects that explore this term, both from a conceptual point of view and its application (Magalhães, 2013; Cruz, 2020). In this sense, it is important here to highlight the need for studies that are available to carry out a more in-depth analysis of the understanding of these terms (occupation and activity) and the implication of this understanding in the professional practice of occupational therapists in the field of mental health of children and teenagers. It is hypothesized that the terms are often used in an analogous way, without a theoretical foundation and/or a critical analysis of their implications. In any case, what is evident for occupational therapy, in the context of psychosocial care, is that participation in necessary and significant activities is something central to human life and that psychological suffering is directly interrelated with the performance of such activities. activities, highlighting the importance of everyday life and territory being taken as the main settings for care practices (Hirdes, 2001; Yasui, 2016).

Fernandes & Matsukura (2020) highlight the importance of directing the focus to activities and daily life, based on the inclusion of the occupational therapist in child and youth mental health devices, arguing that this is an important step towards overcoming exclusionary and alienating practices, and for the implementation of psychosocial logic. An association is assumed here between the concept of everyday life and that of psychosocial rehabilitation. It is assumed that the subject in psychological distress is capable of building a life in society – this being the commitment of the intervention – and that, for this, the focus needs to be on their day-to-day life and their everyday relationships – the background for guiding occupational therapeutic practices (Salles & Barros, 2006; Constantinidis & Cunha, 2020; Fernandes & Matsukura, 2020). This alignment between the know-how of occupational therapy and the premises of psychosocial care signals that “[…] occupational therapy fulfills a strategic role, as it enables individuals to focus on their interventions, organize and re-signify everyday life, which also responds to the premises of psychosocial rehabilitation” (Fernandes & Matsukura, 2020, p. 102).

The integral perspective on the subjects, the fabric of networks, intersectorality and action in interface with the field of Education

The results of this research showed that the occupational therapist is seen (both by OT and non-OT participants) as a professional who takes into account and acts on and from the individual as a whole, considering their physical-biological, emotional, social, family and the entire support and service network.

In my experience, the OT participated in the reception as the main professional, as they had a comprehensive view of the individual, and always remained a technical reference, especially in cases with serious problems in occupational performance [text segment – ​​OTs corpus – Phase 1].

The OT has a complete view of the context and, in my opinion, is the only professional qualified to intervene in all aspects of child and adolescent development, addressing both psychosocial issues and functionality and development [text segment – OTs corpus – Phase 1].

But I think we will collaborate within this team to bring this broader view, think about the context, move away from the checklist of symptoms and bring more discussion to what the context of this family is like [text segment – OTs corpus – Phase 2].

Whether in ADLs or cognitive and functional development, OT is capable of bringing a broader and more contextualized view of each individual's reality when proposing such interventions [text segment – ​​NON-OTs corpus – Phase 1].

Expanded and comprehensive view of the health of children, adolescents, and their families, looking at routine and daily activities, autonomy, belonging. Share and discuss cases and services in an interdisciplinary team [text segment – NON-OTs corpus – Phase 1].

Occupational therapy is a profession that has an interdisciplinary basis (Lima, 1997; Minatel et al., 2022), that is, the occupational therapist, during their training process, accesses and acquires knowledge from different fields and related areas. With this, it is possible to infer that this professional develops an ability to articulate this knowledge in a particular and complex way of perceiving the individual, a perception that is attentive to the entirety of life in question and everything that crosses it, at the same time in which is sensitive to its singularities.

In the field of child and adolescent mental health, comprehensive action with children and adolescents in psychological distress consists of an ethical commitment to occupational therapy, which aligns with the principle of integrality of the Unified Health System – SUS (Brasil, 2020), so that all aspects intrinsic to neuropsychomotor development, as well as the social and family context, are taken into account, in addition to the demands related to psychological suffering itself. Likewise, action takes place on the fronts of health prevention, promotion, and treatment, in direct and dynamic articulation with the entire network of supports and services available to this population. This justifies the understanding of the occupational therapist as a professional who promotes networking.

I realize that we always go further, expanding to everyday life and occupations, family relationships, territory, the support network [text segment – OTs corpus – Phase 1].

I believe that any case that arrives with a demand for child and adolescent mental health care will benefit from the care of an OT. Network articulation actions are well done by OTs because we have training in different areas and, therefore, have a lot of knowledge about network services [text segment – OTs corpus – Phase 1].

But I see myself making a lot of contact with other services, mediating many things, providing support for other services to carry out certain actions [text segment – TOs corpus – Phase 2].

Understanding the treatment, the bond that also expands with the family, the importance of occupational therapy also in contact with other networks that are part of our service as a whole [text segment – NON-OTs corpus – Phase 2].

That they [the OTs] have this capacity and this is put into practice, to increase this range and the bond within the service, family, user and other networks [text segment – NON-OTs corpus – Phase 2].

I see the power of occupational therapy in interdisciplinarity, in the multidisciplinary team, working in a network, a power that is very essential for my way of working, for my listening as a psychologist [text segment – ​​NON-OTs corpus – Phase 2].

Weaving networks and practicing intersectorality are not new technologies for occupational therapy (Avelar & Malfitano, 2022). Minatel et al. (2022) even highlight situations in which intersectoral work is built from occupational therapy, being justified by the interdisciplinary basis of the professional core, by its anchoring in public policies, by the approach to the territory and everyday life and by interventions in situations of vulnerabilities – aspects that require coordination between different sectors.

When dealing with children and adolescents, the creation of networks necessarily passes through the Education sector. According to studies in the area, schools and primary care are the devices that children and young people are closest to, and these should be the triggers for the construction of intra and intersectoral networking (Couto et al., 2008; Taño & Matsukura, 2019; 2020). In the results of the present study, the interface of the occupational therapist's work in the field of child and adolescent mental health with schools was cited, which is recognized as a characteristic and a strength of this professional's work in the field.

Help the school to think about inclusion strategies, accompany the user in some equipment in the territory, such as course registration, preparing documents, registering for a job vacancy [text segment – ​​OTs corpus – Phase 1].

Group with teenagers using SPA and involved in drug trafficking being monitored at CAPSij, in which the OT worked with return to school, helped those with learning difficulties and facilitated dialogue with the school [text segment – ​​OTs corpus – Phase 1].

I followed the demand of an adolescent who suffered disorders related to self-mutilation, the OT monitored the issue of school, communication with the network, meetings with family members and services, and enhanced the adolescent's self-care with themselves, strengthening the necessary care for their routine and ADLs [text segment – ​​NON TOs corpus – Phase 1].

Recent reports by Fernandes et al. (2019) and Souza et al. (2022) highlight the power of occupational therapy in developing actions to prevent and promote the mental health of children and adolescents in the school context, as well as the importance of occupational therapy in managing issues related to psychological distress within schools, supporting in psychosocial care and intersectorality.

In view of the above, it is possible to observe that considering children and adolescents as integral and complex beings, weaving networks, promoting intersectorality and working within the school context essentially consist of elements that make up the guidelines for psychosocial care for children and adolescents, which support the field of child and adolescent mental health. Despite this, these were aspects highlighted by the participants in the present study (OTs and non-TOs) as actions that characterize the core of the professional occupational therapist, which was corroborated by the studies and reports found in the literature studied. Therefore, these consist of prerogatives for all professionals working in this field.

It is hypothesized, therefore, that the professional occupational therapist seems to be able, in his practice, to consider such aspects in a more natural and pragmatic way, placing their body in concrete action, making themselves available to be and build new ideas and possibilities together with users and collectives, of activities and relationships in the contexts in which these people circulate, for example, at school. And, by doing it together, you can identify and activate new potential partners (such as family members, teachers, managers, technicians) and with them continue to sew possibilities, in a continuous process of affectations and constructions.

Action in the face of intense psychological suffering, management in crisis situations and action in situations of vulnerability and violence

Based on the results of the study, it was possible to find an emphasis on the work of occupational therapists with children and adolescents in intense psychological distress and crisis, as well as in situations of vulnerability and violence.

Look at the individual and their culture, valuing skills beyond the disease. Transmit to the team the sensitivity of what was assessed subjectively. Specific qualitative assessments of occupational therapy. Ambience in crisis situations. The management and reception of the OT are second to none [text segment – ​OTs corpus – Phase 1].

Situations of social and emotional vulnerability because in these, the OT can help with everyday life resources, offering activities that help regulate the suffering arising from these situations [text segment – ​​OTs corpus – Phase 1].

Mainly for behavioral and socialization issues. Children and young people who have difficulty modulating their emotions and who have problems performing their social roles as well. In addition to situations of vulnerability and conflicting emotional and family bonds that ended up culminating in anxious or depressive crises with self-mutilation [text segment – ​​OTs corpus – Phase 1].

The work of occupational therapy is of great importance. The mental health of children and adolescents is very fragile, especially in [institutional] foster care situations and the professional does relevant work in this sense, ensuring acceptance, listening, partnership, motivation, and care [text segment – ​​NON-OTs corpus – Phase 1].

I accompanied teenagers, for example, juvenile offenders for a certain period of time at CREAS and I really missed having an OT within social assistance policies [text segment – ​​NON TOs corpus – Phase 2].

Some previous studies have already recognized the importance and power of occupational therapy in crisis situations, in order to manage the intensification of psychological suffering, through action as a catalyst for care processes and the reinvention of individuals' daily lives, helping the team interdisciplinary team to treat the situation in an individualized way, articulated with the reality of the subject's life and encouraging the exercise of their autonomy, favoring adherence to the proposed treatments and the maintenance of the therapeutic process (Benetton, 1995; Kawashima, 2013; Rossi & Cid, 2019).

In the context of child and adolescent mental health, Moura et al. (2022) carried out a study in which they sought to identify the notions of crisis present in the speeches of CAPSij workers and managers, in light of the paradigms in force in the field, indicating possible impasses and advances in psychosocial care for children and adolescents. As a result, two categories were identified that express the identified notions of crisis. They are: the psychiatric crisis, understood as the expression and worsening of psychiatric symptoms, and the psychosocial crisis, understood as a singular experience, but also social, relational and cultural. The authors reflected on how much the dissent in this conceptualization and understanding reflects the process of paradigmatic transition in which the devices of the child and youth psychosocial care network are found, and highlighted that the understanding of the crisis from a complex and multifaceted perspective, whose responses must also be complex and reaching multiple actors is a current challenge.

Considering the results of this research, the occupational therapist can be seen as a professional who strives to align his intervention with the assumptions of the field. And this does not seem to happen just because it is a guideline for the work carried out, but, above all, because it is a convergent ethical and political commitment between the core of occupational therapy and the field of child and adolescent mental health. In the context of crisis care, this seems to translate into an occupational therapeutic practice that does not individualize its actions only towards the subject in crisis, but extends them to the family and the network of services and support, managing to deal with the unprecedented nature of the situation, being sensitive to its specificities, but, especially, betting on contractuality, being articulatory and active in the production of meanings, in designing paths and in inventing possibilities to be chosen with autonomy by the subject experiencing the crisis, in partnership with your family and your network.

Recognizing situations of violence and social vulnerability as potentially related to problems in the mental health of children and adolescents (Brasil, 2010a, 2010b), from a psychosocial crisis perspective, the literature accessed addresses the possibilities of occupational therapy in this context. Research carried out by Côrtes et al. (2011) aimed to describe and analyze occupational therapeutic intervention in preventing violence against adolescents, as well as verifying the potential of resources in promoting strategies to combat the phenomenon. As results, the authors highlighted the potential of the activities carried out in expressing the phenomenon and dynamics of violence in different adolescent contexts (home, school, community), as well as in developing strategies to combat violence in these different scenarios. They also highlighted that the horizontal way in which the OTs related to the adolescents made them feel valued for the knowledge they had and comfortable in expressing their ideas, without repression or judgment, and that the occupational therapeutic intervention mode, through doing and of action, it operated as a more fluid communication channel with the youth universe.

An experience report carried out by Pereira et al. (2014b) aimed to describe the performance of occupational therapy towards adolescents in vulnerable situations, using the cooking workshop as an intervention strategy. The authors observed that the workshop promoted positive emotional attitudes among adolescents, such as affection, affection, understanding, empathy, encouragement, and mutual support. They also observed that the meetings promoted an increase in group cooperation, the autonomy and independence of adolescents, in addition to the discovery of individual potential and skills and the glimpse of life projects, thus highlighting the power of occupational therapy in this context.

Based on the results of the present study, in dialogue with the aforementioned authors, it is possible to indicate that the core of occupational therapy in the field of mental health for children and adolescents is made up of elements that allow the professional, when faced with situations of violence and in contexts of intense social vulnerability, be able to approach horizontally the actors involved in the situation (children, adolescents, families, professionals and devices) and, with them, based on their contexts, values ​​and culture, produce shared actions that are translate into ways of dealing, whether at an individual, collective or political-territorial level, considering, especially, the search for access to the rights of children and adolescents.

Acting in the most serious and complex cases, including cases of Autism Spectrum Disorder (ASD)

The results of the present study also drew attention to the role of occupational therapy in cases considered more serious and complex in the context of child and adolescent mental health, in which several therapeutic actions have already been carried out by other professionals, without success. Among these cases, the work of the occupational therapist with individuals with Autism Spectrum Disorder (ASD) was highlighted.

And sometimes I also have the feeling that when they've tried everything, they call the OT, as if we had a magic wand to deal with impossible cases, with the team's impotence in some situation [text segment – ​​OTs corpus – Phase 1].

In my experience, I observed that very serious cases, it was usually the OTs who agreed to assist, I believe because of their ability to look at the potency and not the lack and because of their diversity and creativity in therapeutic actions [text segment – ​​OTs corpus – Phase 1].

For the most serious cases, non-verbal patients, patients with severe symptoms and internal and external disorganization. In serious cases and without response to treatment by other professionals from another area [text segment – ​​OTs corpus – Phase 1].

Work with children and critically ill patients, with psychosis, ASD, when there is difficulty in thinking about more concrete and sensorial activities for individuals [text segment – ​​NON-OTs corpus – Phase 1].

In severe cases of users with ASD and when there is serious harm in carrying out ADLs, there is little or no autonomy for the user [text segment – ​​NON-OTs corpus – Phase 1].

The OT pays attention to body movements, speech, word articulation, and development phases. Seeks numerous strategies to assist the patient in development. Serious cases in which therapeutic attempts were made without significant success in workshops, social gatherings and others [text segment – ​​NON-OTs corpus – Phase 1].

I think that the OT is a great professional in evaluating and proposing different activities for users with ASD, always valuing the uniqueness of the case and encouraging the user's autonomy [text segment – ​​NON-OTs corpus – Phase 1].

The production of knowledge in this field is still fragile with regard to the association between occupational therapy and the care of more serious and complex cases in the field of child and adolescent mental health, but it is possible to raise some hypotheses. With regard to cases considered more complex from a psychiatric point of view (ASD, for example), or serious and complex situations of psychological suffering, with exacerbation of symptoms, such as suicide attempts or psychotic crises among children and adolescents, the professional Occupational therapist seems to be more driven by the ability to evaluate the situation in a more practical and concrete way, seeking to understand the demands and, based on accepting the situation with the user and family, identify, also with them, possible ways to deal with it, such as: establishment of contracts based on the interests, needs and concrete elements of the subjects' reality, identification of people and services that can act as support, organization of routines and tasks necessary to face the situation, monitoring of users and family members in different contexts, among others.

Furthermore, when it comes to working directly with children and adolescents, the occupational therapist seems to be a professional capable of focusing on what is powerful in the situation, however critical and complex it may be. According to Marcolino (2009), occupational therapists sustain their practice based on valuing the subject and their potential. The author states that, through elaborate conditional clinical reasoning, the professional recognizes the factors that facilitate participation and then outlines future possibilities. With the results presented here, it is possible to infer that the occupational therapist, by focusing on contractuality and autonomy and directing their actions towards the specific situation, the activities, the routines, the people, the services involved, appears to foster in individuals the ability to create paths, repertoires and strategies, consequently, producing life.

With regard specifically to occupational therapy intervention in cases of ASD, the literature is broader. On the international scene, manuscripts are mostly dedicated to specific techniques from occupational therapy and other professions in interventions aimed at people with ASD (Matsukura & Soragni, 2013; Mire et al., 2015). On the national scene, the effort has been to demonstrate how such approaches can be complementary to other interventions, such as those carried out in the psychosocial care network devices, based on the individual needs of each subject, and not by their diagnosis.

Considering the results initially presented, which indicated the occupational therapist as a professional who considers and intervenes directly in the routines and activities that make up the subjects' daily lives, it is highlighted that they have a complete and integral perspective on individuals. Specifically, in the case of children and adolescents, they are subjects who are in the midst of their development phase, with the OT being an articulator and promoter of networking. Thus, considering Autism Spectrum Disorder as a condition that implies a particular way of existence and functioning, the occupational therapist appears to be a professional who has unique skills in intervening with this population.

Children and adolescents, throughout their development, are constantly learning, experimenting and creating repertoires. Biologically and socially, it is expected that, at each stage, they acquire independence and autonomy in their daily lives and in relationships, and the occupational therapist is a qualified professional to understand the importance and complexity of this process. While a delay in development is identified or, in this specific case, ASD is diagnosed, in addition to thinking about the importance of stimulation and gaining skills – which cannot be confused with the objective of standardization –, for attention child and youth psychosocial, it is important to think globally about the subject's mode of existence. The way you play, communicate, interact, spend your days; if he is treated as a child or teenager, and if they have the opportunity to be so, or if they are only seen as autistic; how much is considered a subject of rights and desires; the way in which participation in different spaces is encouraged; how much is valued in its capabilities and is invested in its power.

The occupational therapist seems to be able to understand the neurobiological organism and the intrinsic aspects of its neuropsychomotor development, but, more than that, they seem to understand the individual, their way of life and daily life, and what is possible to be constructed collectively, with the subject, the family and the network, that makes sense to them and meets the subjective’s needs and desires. They also seem to be the professional who, in moments of crisis and intensification of suffering, is able to welcome and act in a concrete way in response to needs, using strategies that involve listening, approaching and touching, or distancing and guaranteeing of space, doing, organizing the scenario and routine, activating people, establishing contracts, and other possible solutions to that unprecedented and exclusive situation.

Final Considerations

The present study had the general objective of identifying the perspective of occupational therapists involved in the psychosocial care of children and adolescents on the professional core of occupational therapy in the field of child and adolescent mental health. As a specific objective, it aimed to analyze how non-occupational therapist professionals involved in the psychosocial care of children and adolescents describe the practice of occupational therapists in the field of child and adolescent mental health.

The analysis of the results allowed us to identify the characteristic actions of occupational therapy in the field of child and adolescent mental health: the focus on occupations and activities of daily living, acting with routines and based on the daily lives of individuals; the integral perspective on the subjects, the fabric of networks, intersectorality and action in interface with the field of Education; action in the face of intense psychological suffering, management in crisis situations and action in situations of vulnerability and violence; and action in the most serious and complex cases, including cases of Autism Spectrum Disorder (ASD). Therefore, it is understood that the study achieved the proposed objective.

It is important to highlight that the aim here was not to identify “specificities” of occupational therapy in the field of child and adolescent mental health, in order to create a delimitation or professional framework in the field – which refers to “paranoid isolation”, called by Campos (2000, p. 220). Within contexts and devices that operate in a transdisciplinary logic, such as psychosocial care and CAPS, it is important to reflect on the place of professional specificities and the way in which each nucleus contributes to field work. In this sense, Constantinidis & Cunha (2020) argue that the delimitation of identities and professional territories, based on specialisms, does not contribute to overcoming the asylum model and the collective production of knowledge and meanings. On the contrary, such crystallization becomes an obstacle to the implementation of horizontality and the democratization of relationships and work and care processes. Thus, “[…] the formulation of the identity of the occupational therapist in mental health is 'semi-necessary'” (Constantinidis & Cunha, 2020, p. 54) and “[…] the fact that the lack of borders that demarcate our territory of action in mental health is a constituent of our identity means that we are open to the immanence of this field and we can collaborate so that collective production gains power” (Constantinidis & Cunha, 2020, p. 55).

In this sense, the results obtained with this research demarcate and highlight the importance of the core of occupational therapy in the field of child and adolescent mental health. The study is relevant for consolidating the place and role of this professional nucleus along with the other areas of knowledge that make up the aforementioned field, taking the collective construction of care not only as a modality of work, but, especially, as a guideline ethical-political for the qualification and complexity of care in the field of mental health. The study is also relevant with regard to the training of future occupational therapists and the updating of professionals who already work in the field of child and adolescent mental health, since the particularities of this field require specific and continued training. The research is still powerful to support the greater hiring of occupational therapists for health, education, social assistance and other sectors that make up the child and youth psychosocial care network.

Furthermore, it is worth noting that the study presented some limitations regarding its scope, both considering the small number of OT and non-OT participants, in proportion to the number of professionals working in the field of child and adolescent mental health in Brazil, and in its scope for other regions besides the Southeast.

Thus, the importance of more studies that can continue and deepen the practice of occupational therapy in the field of child and youth mental health stands out, considering different actors, regions, approaches and methodologies, providing opportunities for children, adolescents and young people, their families and professionals directly responsible for care are at the center of the research process, and scrutinizing the “know-how” of this profession which, according to this study and the literature in the area, has been presented as fundamental for strengthening psychosocial care for children and adolescents in Brazil.

• How to cite: Táparo, F. A., Constantinidis, T. C., & Cid, M. F. B. (2024). (2024). The accomplishments of occupational therapy in the field of child and adolescent mental health. Cadernos Brasileiros de Terapia Ocupacional, 32, e3568. https://doi.org/10.1590/2526-8910.ctoAO273935682

• Funding Source

  Coordination for the Improvement of Higher Education Personnel – CAPES – Code 001.

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Edited by

Section editor

Profa. Dra. Marta Carvalho de Almeida

Publication Dates

• Publication in this collection
  16 Aug 2024
• Date of issue
  2024

History

• Received
  03 May 2023
• Reviewed
  10 May 2023
• Reviewed
  16 Feb 2024
• Accepted
  10 Mar 2024