CHILD AND ADOLESCENT MENTAL HEALTH IN SCHOOLS: NURSES’ PERCEPTION

ABSTRACT

Objective:

To understand the perception of nurses who work in the School Health Program about mental health in children and adolescents.

Method:

This was a qualitative, exploratory, and descriptive study carried out between December 2022 and February 2023, with nurses working in Family Health Strategies in a municipality on the western border of Rio Grande do Sul - Brazil. Data collection with semi-structured interviews and Minayo’s Thematic Analysis.

Results:

The concept of mental health was linked to both the traditional concept and the expanded clinic. The risk factors for the mental health of children and adolescents highlighted were family conflicts, prejudice, exposure to violence, digital influence, the use of psychoactive substances, and crime.

Conclusion:

There is a need to promote care strategies, especially for nurses, enabling them to take a more critical look at risk factors and mental health demands based on the specific characteristics of children and adolescents.

KEYWORDS:
Mental Health; Primary Health Care; Nursing; Child; Adolescent

RESUMO

Objetivo:

Conhecer a percepção de enfermeiros que atuam no Programa Saúde na Escola acerca da saúde mental infantojuvenil.

Método:

Pesquisa qualitativa, exploratória e descritiva realizada entre dezembro de 2022 a fevereiro de 2023, com enfermeiros atuantes em Estratégias Saúde da Família no município da Fronteira Oeste do Rio Grande do Sul - Brasil. Coleta dos dados com entrevistas semiestruturadas e Análise Temática de Minayo.

Resultados:

A concepção de saúde mental esteve atrelada tanto ao conceito tradicional quanto à clínica ampliada. Os fatores de risco à saúde mental das crianças e adolescentes destacados foram conflitos familiares, preconceito, exposição a violências, influência digital, uso de substâncias psicoativas e criminalidade.

Conclusão:

Destaca-se a necessidade de fomento às estratégias de cuidado, especialmente por parte dos enfermeiros, capacitando-os para realizarem um olhar mais crítico e centrado nos fatores de risco e nas demandas em saúde mental, de acordo com as especificidades do público infantojuvenil.

DESCRITORES:
Saúde Mental; Atenção Primária à Saúde; Enfermagem; Criança; Adolescente

RESUMEN

Objetivo:

Conocer la percepción de enfermeros que trabajan en el Programa de Salud Escolar sobre la salud mental en niños y jóvenes.

Método:

Estudio cualitativo, exploratorio y descriptivo realizado entre diciembre de 2022 y febrero de 2023, con enfermeros que trabajan en Estrategias de Salud de la Familia en el municipio de Fronteira Oeste do Rio Grande do Sul - Brasil. Recogida de datos con entrevistas semiestructuradas y Análisis Temático de Minayo.

Resultados:

TEl concepto de salud mental estaba vinculado tanto al concepto tradicional como a la clínica ampliada. Los factores de riesgo para la salud mental de los niños y adolescentes destacados fueron los conflictos familiares, los prejuicios, la exposición a la violencia, la influencia digital, el consumo de sustancias psicoactivas y la delincuencia.

Conclusión:

Es necesario promover estrategias de atención, especialmente por parte de los enfermeros, que les permitan tener una visión más crítica de los factores de riesgo y de las demandas de salud mental, de acuerdo con las características específicas de los niños y los jóvenes.

DESCRIPTORES:
Salud mental; Atención primaria de salud; Enfermería; Niño; Adolescente

HIGHLIGHTS

The concept of mental health is linked to two paradigms.

Family conflicts, violence, and digital influence as risk factors.

Taboos and prejudices make it difficult to approach the subject of mental health.

The need to promote care strategies for children and young people.

INTRODUÇÃO

Child and adolescent mental health (MH) has gained visibility in recent years and can be considered a relatively recent concern in Brazil. It is characterized as a political and ethical public health challenge that demands special attention in our country¹.

As a result, mental health issues related to the educational environment often transcend the school’s capacity to resolve them, requiring intersectionality, i.e., the articulation of governmental and non-governmental sectors for implementation². In addition, some studies point to a significant increase in demand before and after the COVID-19 pandemic, highlighting the weaknesses surrounding mental health approaches and interventions in primary health care and schools^3-4.

In this context, Primary Health Care (PHC) is the level of care considered to be the gateway, and its principle is to enable people’s first access to the health system, including those with mental health-related demands⁵. In addition, according to the National Primary Care Policy (NPCP), one of the duties of the Family Health Strategy (FHS) teams is to provide health care to registered individuals and families and, when indicated or necessary, at home and/or in other community spaces, including schools⁶.

To broaden the scope of PHC actions, the School Health Program (SHP) was created. This program seeks to contribute to the comprehensive education of students through health promotion and disease prevention actions and tackle the vulnerabilities that compromise the full development of children and young people in the public school system⁷.

Within this context, nurses mediate between health environments and the social context, identifying and welcoming patients, contributing to the collective construction of knowledge about health disease processes, and having a direct and positive impact. They also carry out prevention and health promotion activities in schools on a wide range of topics, one of which is mental health, encompassing bullying, family problems, and substance use, among others⁸.

Despite the importance of the FHS in providing comprehensive health care to individuals, there are difficulties involving the main elements of comprehensive care in the SUS: health promotion, protection, and recovery. Among the weaknesses, we can highlight problems related to the lack of theoretical knowledge about mental health to provide care for mental disorders; interferences in the transversality of care and referrals to specialized services; a lack of activities aimed at continuing education, training and specialization in mental health, which are the main obstacles highlighted and which generate incompatibility in resolving demands⁹.

In short, due to the growing demand for child and adolescent mental health, professionals need to understand and act on the social determinants and risk factors for the development of mental disorders in children and adolescents¹⁰. Obtaining this information will be linked to the aspects that can develop into a future disorder in this public, as well as intervening quickly and formulating specific actions for the promotion and prevention of MH¹¹.

Given the above, this study aims to investigate this demand, which is very present and recurrent in the current context but has been explored little in the Brazilian context and in the region where the study was carried out. Furthermore, studies are scarce in the area of child and adolescent mental health, which makes it difficult to develop effective public policies to mitigate these problems¹².

In addition, it is known that barriers exist related to the identification, promotion, and care of mental health demands in the school context. Given this scenario, this study aimed to understand the perceptions of nurses who work in the School Health Program about children and adolescents’ mental health.

METHOD

This qualitative exploratory and descriptive study¹³ was conducted in a municipality west of Rio Grande do Sul - Brazil, on the border with Argentina and Uruguay. This municipality has 18 FHSs, 17 in the urban area and one in the interior/rural area. Some of these units have a double team, totaling 24 family health teams, 23 in the urban perimeter and one in the rural area. There are also 47 primary and 17 secondary schools, with 15,383 children and adolescents enrolled in the initial years and 4,642 in the final years.

The participants were nurses working in ten Family Health Strategies (FHS). Nurses who had worked in Primary Health Care for at least two years and carried out activities in the School Health Program were included. Nurses who worked in FHSs in rural areas were excluded due to the difficulty of access and the smaller number of schools in the area.

Data collection took place between December 2022 and February 2023 through semi-structured interviews, with an instrument designed by the researchers themselves, carried out by the main researcher and guided by a script consisting of 16 questions, with closed questions aimed at characterizing the study participants (age, gender, length of training, specialization, post-graduation, doctorate), (age, gender, length of training, specialization, post-graduation, master’s or doctorate), and open questions about the activities carried out in the SHP and demands related to children and adolescents (What factors do you consider important for preventing psychological distress and promoting the mental health of children and adolescents?). Data collection ended after data saturation.

The interviews took place at each participant’s place of work after prior contact and/or by going there to formally invite them to participate in the research. All the interviews were carried out by the nursing student after training in the data collection technique with the main researcher, as this was part of the course completion work, and the main researcher has expertise in mental health. The interviewees received the researcher well in their units, where all the participants agreed to participate in the study during data collection, and there were no withdrawals or refusals. There were also no repetitions or changes to the instrument’s script during this period. A private room was used, and the interviews lasted approximately 20 minutes and were audio-recorded for later transcription and archiving on a data storage platform (Google Drive).

The transcription and coding of the data were carried out manually by the main researcher and were not shared with the participants. Coding into categories was done inductively based on the questions in the instrument. The data obtained was analyzed using the thematic content analysis method according to Minayo, which consisted of the following phases: pre-analysis, exploration of the material, and treatment of the results¹⁴. In addition, this information was related to the relevant theoretical materials, carrying out a reflective and critical analysis to answer the research question and fit into the main theme of this study.

The study was approved by the Research Ethics Committee (REC) of the Universidade Federal do Pampa under number 5.766.512. All the participants signed an informed consent form and, to guarantee their anonymity, they were identified by the code name “ENF” followed by a numeral in the sequence of the interviews.

RESULTS

Fourteen nurses working in FHSs in the chosen municipality took part in this study, one male and 13 female. Ages ranged from 29 to 50, with an average of 38. The training ranged from six to 21 years, with 13 nurses having been trained for more than seven years. All the nurses had one or more postgraduate degrees, including two with master’s degrees and one with a doctorate. As for the length of time they had been working in Primary Health Care, eight (57.14%) nurses had been working for less than five years, four (28.57%) had been working for between six and ten years, and two (14.29%) had been working at this level of care for more than 11 years.

To achieve the objectives set out in this study, two categories were constructed from the data analysis: concepts and risk factors for children’s mental health and facilities and challenges for approaching the subject of mental health at school.

Conceptions and risk factors for children’s mental health

When asked about their conception of mental health, it can be seen that some nurses related the concept of mental health strictly to diagnoses of mental disorders or the existence of signs and symptoms, as can be seen in the two statements below:

[...] it’s the child getting sick, right, it’s that child who feels sad, more depressed [...] And then we need to see if it’s not a symptom of depression, a symptom of anxiety, right, basically that. (NUR 1)

[...] I think that mental health does exist, we have a very high rate in adolescents, right, and then we see anxieties [...] a child with anxiety, a child signaling, not only depression, but a restlessness, right, that perhaps has been signaling things since childhood. (NUR 14)

From other statements, it was possible to identify a broader perception of mental health in children and adolescents, relating it to various factors such as the well-being of children and adolescents in terms of physical, emotional, environmental, social and family issues. Quality of life and sleep were also reported by the professionals, as can be seen in the statements below:

[...] it’s that physical, mental and social well-being, as the article says, not merely the absence of illness or the presence of illness, but that well-being, that child who has a good relationship with their father, with their mother, who lives in a family that is either structured or unstructured, right? (NUR 9)

For me, mental health starts from when they leave home, until they arrive at school, with their daily interaction, in every environment. (NUR 3)

Mental health, for children and adolescents, I think it’s more about having a good quality of life, sleep, being able to do activities, having a good relationship with friends, family and school [...] (NUR 4)

The participants also mentioned some risk factors and points that they consider harmful to mental health in childhood and adolescence, such as the lack of family structure and conflicts, prejudice and exposure to violence, digital influence, the use of psychoactive substances and crime, as can be seen in the following statements:

[...] they stayed at home with their families for a while, some things intensified as a result, family conflicts, and a lot of things came to light that weren’t so obvious before. (NUR 13)

[...] the role of abuse, right, abuse is closely related to the role of children and adolescents and unfortunately, it’s recurrent. Who ends up suffering. (NUR 3)

[...] as our neighborhood is, it has a lot of trafficking, prostitution, drug addiction, I think that these children sometimes get involved, because of the influence of other people [...] in this environment, so I think that the children, their protective factor is this family that they have, right. Also, the health network, the municipality [...] Because of online games they play, that’s what they refer to the most. (NUR 6)

It was depression, it was often self-mutilation, usually because of gender issues [...] what happens, the family doesn’t accept that you’re different, you have attitudes that society doesn’t think are normal, so parents don’t know how to understand this in adolescence. (NUR 13)

[...] of just being on the cell phone, just playing games, few friendships, I think (there is) a lack of guidance, both for family members, teachers, and students, because sometimes he (child/adolescent) thinks it’s normal for him, but it’s not... (NUR 8)

Facilities and challenges for addressing mental health at school

About the facilities found, most of the nurses pointed out issues such as good adherence and participation in the themes proposed within the SHP by children and young people, and teachers, as well as feedback from students during the themes, as can be seen in the following comments:

As far as mental health is concerned, I haven’t seen any difficulties at school, either in terms of, for example, teachers, principals, we don’t have this approach [...] at least in the schools I’ve been to, we haven’t had any difficulties, in terms of access, freedom to talk to children or adolescents. (NUR 1)

The facilities are their feedback and their participation, and we also have the facility of being right next door, so it’s much better for us [...] Access is much better. (NUR 4)

[...] as incredible as it may seem, they’re very interested in certain issues, and they take advantage of that opportunity that you’ve already mentioned, that you’ve already said, they’re more willing to talk and know that someone is willing to listen, who’s taking it seriously, right? (NUR 13)

On the other hand, about the challenges, some nurses mentioned the presence of prejudice and taboos from families about the various topics covered and the failure of children and young people to join in during specific activities. In addition, interferences were also reported, such as the organization of both the FHS team and the school, health professionals not feeling able or refusing to take part in activities on the subject, as was observed in the professionals’ responses:

The difficulties we’ve encountered, in some ways, are more a question of prejudice, you know: Oh, you can’t talk to children about that, the issue of sexual violence itself, how are you going to approach it and the teachers already think it’s bad, there’s always a parent who complains [...] (NUR 4)

There’s still a lot of prejudice, right, so as I told you, the approach, the language needs to be well thought out, it needs to be well planned, there’s still prejudice, a lack of maturity for them to understand what’s happening to them or why everything is happening, right, because it’s really difficult to understand a lot of things when you’re in psychological distress, right? (NUR 7)

What we do find difficult is that sometimes, when you put together your calendar for the year, you’ll find a professional who doesn’t like talking about mental health or who doesn’t feel up to it [...] sometimes you’ll find a technician like that, a nursing technician who doesn’t like it, it’s not her area, right? (NUR 11)

And there is a lot of difficulty, including acceptance from the father and the grandparents. That this person, this child, needs psychological assessment and help. Yes, there is resistance, often from the family. (NUR 14)

DISCUSSION

The professionals who participated in this study highlighted significant experiences related to the demands of children’s and young people’s mental health in the school context, which provide important information to be discussed in contemporary times.

According to the results observed in this study, the concept of mental health was linked to both the traditional clinical concept and the psychosocial perspective. From a biomedical perspective, it can be seen that some participants relate the concept of mental health strictly to diagnoses of mental disorders or the existence of signs and symptoms¹⁵. In this sense, some authors problematize that there is still a misunderstanding of the concept of mental health by professionals, which derives from a restricted concept of health where the parameter used is the absence of diseases, that is, a biologist concept, which does not take into account the subjective issues and the social dimension of the subjects¹⁶.

In contrast to the biomedical logic, the Expanded Clinic proposes revisiting the division of care by professional specialty, expanding the work of different health professionals with a view to integrated, person-centered care¹⁵. Furthermore, it is understood that children and adolescents’ mental health is dynamic and the result of a complex relationship between personal resources and abilities, contextual factors and social determinants, which in the everyday dimension are directly involved in recognizing and facing challenges and maintaining their mental health¹⁷.

Within this scope, the Expanded Clinic’s main premise is the division of care by professional specialty, expanding the work of the different health professional areas with a view to integrated, person-centered care¹⁸. This highlights the need to promote practices based on the expanded clinic within PHC to produce health comprehensively and articulated.

We need to make progress in reflecting on these dissonances between the biomedical and psychosocial paradigms so that we can look at the social production of health for individuals. While the former focuses exclusively on the disease and its manifestations, health is more complex and includes social, economic, cultural and environmental aspects. In this paradigm, mental illness is much more than a psychiatric diagnosis, where patients with a psychiatric disorder can have quality of life, participate in the community, work and develop their potential¹⁹.

In this context, we should reflect that mental health is complex and historically influenced by socio-political contexts and the evolution of health practices, so it is not considered a unified construct in current literature¹⁹. However, the World Health Organization (WHO) states that mental health is a state of well-being in which the individual can use their abilities, recover from routine stress, be productive and contribute to their community²⁰.

It must be remembered that, despite the lack of consensus in the literature on the concept of mental health, practices in this field must be aligned with the perspective of singularized care that considers the concrete implications of psychological suffering in people’s daily lives, making it necessary to develop preventive and health promotion actions that meet the subjectivities of individuals and meet their real needs²¹.

Lack of structure and family conflicts were pointed out as risk factors by the nurses interviewed, aspects also evidenced by another current study which highlights that conflicting or troubled interpersonal relationships with teachers, classmates and family are negatively linked to the emergence of depressive symptoms in young people, as well as problems with well-being and reduced socio-emotional skills²².

Regarding the consumption of alcohol, tobacco, and other substances among adolescents, even though it is one of the risk factors pointed out by the interviewees and is one of the themes addressed in the SHP, contemporary studies report that there was a reduction in drug use during the period of social isolation caused by the pandemic²³. A contemporary study correlating substance use with the development of substance use disorder in adolescents admitted to a hospital showed the marked presence of symptoms such as depressed mood and depressive thoughts among adolescents, highlighting the need for actions to promote and protect this public from the use of these substances²⁴.

Some nurses also mentioned the excessive use of screens and digital influence as factors that contribute negatively to children’s mental health. A current national study shows the relationship between the emergence of psychological and behavioral disorders and the use of multi-screens and the media among this audience. He points out that excessive exposure to these technologies can cause socio-emotional symptoms such as depression, anxiety, emotional imbalance, and difficulties in interpersonal relationships. It also aggravates symptoms of Attention Deficit Hyperactivity Disorder (ADHD) and is directly related to delays in neurocognitive development and in building interpersonal relationships among children and adolescents²⁵.

In line with the other results, some of the participants’ speeches mentioned issues related to prejudice, bullying, and family violence. Children and adolescents are the most affected by this type of psychological or physical violence, and it is one of the risk factors for mental and developmental disorders²⁶. Bullying is associated with the school context, given the relationship that can involve both the individual characteristics of young people and the contingencies of the school environment and the values of the community that permeate it²⁶. However, according to a study published nationwide, children and adolescents with family adversities, such as inter-parental or parental violence, tend to be the target of this form of disturbance in the extra-familial context, which is one of the causes of the development of psychosocial problems in this part of the population²⁶.

Barriers such as taboos and prejudices surrounding the themes proposed by nurses in the SHP were also highlighted in our study. This issue is corroborated in another study, which showed the presence of stereotypes related to a considerable degree of misinformation about self-care and preventive attitudes. He found these were linked to old beliefs, concepts, ideas, prejudices, stereotypes, and taboos from the family and society²⁷. Furthermore, the issues surrounding children’s and adolescents’ mental health are interlinked with the individual and collective socio-economic characteristics that permeate the family environment of these children and adolescents, which ends up making the practice of care difficult for professionals to carry out¹⁶.

In line with this, there are difficulties relating to this age group, mainly evidenced by the side conversations during the lectures, the shyness in dealing with a “taboo” subject, and the presence of jokes and pranks from some colleagues to others during the explanation. This behavior can be justified by the rush and a certain anxiety when approaching a topic of great interest and, simultaneously, very neglected and repressed²⁸.

Other negative points contribute to low adherence to the themes proposed within the school, one of them being issues related to socio-economic and cultural factors, such as low family income, which correlates with low schooling and difficulties in understanding on the part of those responsible for the students. These difficulties impact the students’ learning, as was evidenced by the interviewees²⁹.

Among the limitations identified in this research, the scope of the data is particularly noteworthy, as it is restricted to the municipal level and therefore portrays the reality experienced in the municipality investigated, making it difficult to generalize the results at a national level, since other problems may have arisen in other regions. Furthermore, there is a need for further studies to identify the impacts on the school, family, and social contexts of children and young people in greater depth.

FINAL CONSIDERATIONS

This study provided an insight into the perception of nurses who work in the School Health Program about children and adolescent’s mental health, prompting reflections and debates about a topic that is of fundamental relevance in contemporary times but which is still permeated by many challenges in the theoretical and practical fields.

The results of this study point to a fluctuation between two main paradigms that guide the discussion of the concept of mental health: the biomedical paradigm and the social production of health. They also discussed the difficulties involved in tackling the subject of mental health at school, such as prejudice and the taboo on issues related to it.

Given the reality investigated, there is a need to promote care strategies, especially on the part of nurses, by the specific characteristics of children and adolescents, to invest in actions to promote health and prevent mental health problems in children and adolescents within Primary Health Care services, as well as in schools.

This study has helped to identify the weaknesses of nurses in the area of mental health in children and young people, making it possible to articulate new methods and approaches involving psychosocial issues in primary care. Based on the results, there is a need to formulate continuing education activities for health professionals, enabling them to take a more critical look, focusing on risk factors and mental health demands, consequently reflecting a better reception for these young people and greater case resolution.

With this in mind, it is essential to develop future studies that contribute to a better understanding of this reality, broadening the knowledge and scope of the subject explored in this research.

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Edited by

Associate editor:

Dra. Tatiane Trigueiro

Publication Dates

• Publication in this collection
  22 July 2024
• Date of issue
  2024

History

• Received
  26 Oct 2023
• Accepted
  04 Mar 2024