Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 14 nº 4 - Oct/Dec - 2017

Original Article Imprimir 

Páginas 41 a 47


Social vulnerability of adolescents who remained on treatment in CAPS-AD

Vulnerabilidad social de adolescentes que permanecieron en tratamiento en CAPS-AD

Vulnerabilidade social de adolescentes que permaneceram em tratamento em CAPS-AD

Autores: Grasiella Bueno Mancilha1; Luciana de Almeida Colvero2

1. Psychiatric nurse and specialist in chemical dependency. Master's Degree in Health Sciences from the School of Nursing of the University of São Paulo (USP). São Paulo, SP, Brazil. Lecturer at Faculdade Santa Marcelina (FASM). São Paulo, SP, Brazil
2. Doutora in Nursing, School of Nursing, University of São Paulo (EEUSP). Professor of the Department of Maternal and Child Nursing and Psychiatry at the University of São Paulo School of Nursing (USP). São Paulo, SP, Brazil

Correspondência:
Grasiella Bueno Mancilha
Av. Dr. Enéas de Carvalho Aguiar, 419
São Paulo, SP, Brasil. CEP: 05403-000
grasiella.mancilha@gmail.com

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Keywords: Adolescent, substance-related disorders, health services, health vulnerability.
Palabra Clave: Adolescente, trastornos relacionados al uso de sustancias, servicios de salud, vulnerabilidad en salud.
Descritores: Adolescente, transtornos relacionados ao uso de substâncias, serviços de saúde, vulnerabilidade em saúde.

Abstract:
OBJECTIVE: Describe and analyze the main social vulnerabilities of adolescents who remained in Centros de Atenção Psicossocial (CAPS-AD).
METHODS: A descriptive exploratory study where the analysis was performed through dialogue of the empirical data based on theoretical health vulnerability, the principles of harm reduction using the analysis technique of thematic content.
RESULTS:The teenagers, mostly male, aged 14-19 years, had incomplete primary education,single parents of female sex, felt idle and dissatisfied with their routine. They are are multiple drug users and made their first use, on average at 12 years, especially in clubs and in the street in the company of friends, where marijuana is the preferred substance. The current use pattern was smaller than in other times of life, and involvement with traffic was the main reason for historic conflict with the law.
DISCUSSION AND FINAL CONSIDERATIONS: It is important to know the profile of adolescents in order to develop more suitable strategies to their individual and collective singularities. Knowing the values and role models for adolescents has a fundamental importance for elaborations of more consistent and effective care strategies for this population.

Resumen:
OBJETIVO: Describir y analizar las principales vulnerabilidades sociales de los adolescentes que permanecieron en Centros de Atención Psicosocial (CAPS-AD).
MÉTODOS: Estudio descriptivo exploratorio donde el análisis fue realizado por medio de diálogo de los datos empíricos con el referencial teórico de la vulnerabilidad en salud, los principios de la reducción de daños utilizando la técnica de análisis de contenido temático.
RESULTADOS: Los adolescentes, en su mayoría del sexo masculino, con edad entre 14 a 19 años, poseían enseñanza fundamental incompleta, familias monoparentales del sexo femenino; se sentían ociosos e insatisfechos con su rutina. Estos son usuarios múltiples de drogas e hicieron el primer uso, en promedio, a los 12 años, principalmente en fiestas y en la calle en compañía de amigos, donde la marihuana es la sustancia preferida. El estándar de uso actual es menor que en otros momentos de la vida de los adolescentes analizados, y el envolvimiento con el tráfico fue el principal motivo de histórico de conflicto con la ley.
DISCUSIÓN Y CONSIDERACIONES FINALES: Es importante conocer el perfil de los adolescentes para que se desarrollen estrategias más conducentes con sus singularidades individuales y colectivas. Conocer los valores y modelos de referencia para el adolescente y joven es de fundamental importancia para elaboración de estrategias de cuidado más próximas y efectivas para esa población.

Resumo:
OBJETIVO: Descrever e analisar as principais vulnerabilidades sociais dos adolescentes que permaneceram em Centros de Atenção Psicossocial (CAPS-AD).
MÉTODOS: Estudo descritivo exploratório onde a análise foi realizada mediante o diálogo dos dados empíricos com o referencial teórico da vulnerabilidade em saúde, os princípios da redução de danos utilizando a técnica de análise de conteúdo temática.
RESULTADOS: Os adolescentes, em sua maioria do sexo masculino, com idade entre 14 a 19 anos, possuíam ensino fundamental incompleto, famílias monoparentais do sexo feminino; se sentiam ociosos e insatisfeitos com sua rotina. Estes são usuários múltiplas drogas e fizeram o primeiro uso, em média, aos 12 anos, principalmente em baladas e na rua em companhia de amigos, onde a maconha é a substância preferida. O padrão de uso atual é menor que em outros momentos da vida dos adolescentes analisados, e o envolvimento com o tráfico foi o principal motivo de histórico de conflito com lei.
DISCUSSÃO E CONSIDERAÇÕES FINAIS: É importante conhecer o perfil dos adolescentes para que se desenvolvam estratégias mais condizentes com suas singularidades individuais e coletivas. Conhecer os valores e modelos de referência para o adolescente e jovem é de fundamental importância para elaborações de estratégias de cuidado mais condizentes e efetivas a essa população.

INTRODUCTION

The historical-social conception of adolescence and the unique ways of being and living of the adolescent make possible different views before the adolescence and singular interpretations that allow more effective interventions before the phenomenon of the use of drugs1-4.

However, there are predominant views that bring the conceptions about adolescence as a period of emotional instability, a phase marked by physical, psychological and social transformations permeated by family conflicts, aggression and transgression. These characteristics are brought mainly by the biomedical field supported by signs and symptoms of puberty, such as hormonal changes, maturation of secondary sexual characteristics and psychosocial development, marked by crises and conflicts with parents, called by many stages of "abhorrence"5 -8.

By exploring these characteristics a little more, studies also emphasize the presence of impulsive behaviors, search for immediate pleasure and intense experiences that may incite adolescents to feel dissatisfied and discontented with the body, as well as being more prone to experimentation, searching through feelings of freedom, identifications before their social space and with their peer groups6,8.

The superficial analysis of what is diffused by the biomedical conception, even if it considers several dimensions of adolescence, also brings a vision rooted in stereotypes that tend to understand the adolescent or adolescence in a homogenizing way, often dwelling on the adolescent "problem" , as a subject in transition, valuing little the present moment and always considering it "a becoming" 1 . The conception of adolescence as a social historical construction advances in the sense of understanding adolescents and adolescents as a dynamic process, in which their ways of life and expression are constantly moving, and we need to analyze the historical-social context and the contours of being adolescent and young in a contemporary society1-4,9-13.

These discussions about the expansion of the conception of adolescence are brought mainly by descriptive studies in the clinical, anthropological and community areas of sociology and social psychology, demonstrating that age cuts are not enough if we consider the complexity that involves the biological and psychosocial parameters characteristic of adolescence1-4.

For the historical-social conception of adolescence, the various changes take place in an interconnected and interdependent way, which confers on adolescent singular experiences, quite distinct from homogenizing and universal attempts of this moment of life12,13. This historical-social conception of adolescence makes it possible to look at different adolescents, which has helped us to think about their interfaces in face of the phenomenon of drug use.

The permanence of the adolescent who makes problematic use of drugs in the treatment is a challenge pointed out by specialists in practical assistance as in the literature. The adolescent permanence in this study opposes the usual idea of the patient of health services, passive, submissive and obedient to the orientation of the professional and as the one most responsible for their adherence to the treatment. Thus, the concept of permanence will be understood as the presence of the adolescent in the health service as an autonomous user in a relationship of co-responsibility with health professionals for their therapeutic process and for the continuity of treatment8,14.

The construction of a unique therapeutic plan shared between the services of the psychosocial care network (RAPS) are described in Administrative Rule No. 3,088 of 2011 15 . The RAPS components are: the Basic Health Units (UBS); the Psychosocial Care Centers (CAPS); the Emergency and Emergency Attention Service (SAMU); Transient Residential Care; the Hospital Attention; the Deinstitutionalization and Psychosocial Rehabilitation Strategies Among the components of the RAPS we highlight the role of the CAPS, a secondary health service, which should function according to the territorial logic and make up one of the entry points in the Unified Health System - SUS. The CAPS is intended for the monitoring of people with moderate to severe mental disorders; have a role of articulator of the psychosocial care network, offering daily care to the users, care for the relatives or caregivers who are involved in the care and close coexistence of these, detoxification, therapeutic actions with a community focus aiming at social reintegration, among others.

The efforts for advancement in this area have privileged the speech of the adolescent himself, understanding him as the protagonist of his life, as well as to investigate and know better the territory in which he lives and its socio-cultural and economic cuts, the potentialities and obstacles of accessing information and articulate them and then transform them into protective actions. Thus, the theoretical framework of vulnerability in health allows a comprehensive analysis of adolescents in the face of problematic drug use, considering historical, social, economic and cultural aspects in which this use occurs. Vulnerability is composed of three components - individual, social and programmatic - that should be understood as interconnected and interdependent, but in this summary we present some aspects of the social component16,17.


OBJECTIVE

Describe and analyze the main social vulnerabilities of adolescents who remained in CAPS-AD.


METHOD

A descriptive exploratory study was conducted in which individual interviews were conducted with 12 adolescents who attended a group of adolescents from a CAPS-AD during the period of data collection. The analysis was carried out through the dialogue with empirical data, with the theoretical reference of the vulnerability in health16, more specifically to the social component and to the harm reduction principles using the Bardin content analysis technique18.

The social component of vulnerability points to the process of illness as a social process. The quality of information and the ability to critically analyze it and transform it into protective behaviors does not only depend on the individual and is correlated with the social aspect. That is, it will depend on the subject's access to the media, schooling, availability of material resources, the possibility of facing cultural barriers without being violated and with the possibility of protection. The aspects evaluated by this component are related to economic conditions, gender and racial relations, schooling, access to material resources, participation in political decisions and cultural aspects16.


RESULTS AND DISCUSSION

The data analyzed revealed that the 12 adolescents of the CAPS, mostly, are male, aged 14 to 19 years, 75% declared themselves black, have incomplete elementary school and school dropout.

All teens reported using various types of drugs and made their first use at age 12. The adolescent who experienced it most early did so at age seven, and what he did later with 16 years old. The most commonly used drug on the first occasion was weed, followed by scent lance, cocaine, tobacco, and alcohol. In relation to the place and with whom they were in the first use situation, four were in ballads or parties, four others were in the street with friends or even alone, two were in the house or in the house of friends and only one of them was in the school. We emphasize that nine of these adolescents report that they were with friends, corresponding to 75% of the situations of the first use. The substance of most adolescents is weed, and it is also the most used substance for the first time and they report having greater difficulty to be consumed.

Ricardo: At least cocaine and the perfume lance, right?! What's hard is weed. That's the way it is, the cocaine I already discarded, the perfume spearer as well. Only the hardest is weed.

Most of the adolescents (67%) live with their families, 50% of them are from the single parent family and 33% are institutionally welcomed. The frailties of family relationships constitute an important social vulnerability to drug use19. Households headed by women are considered more vulnerable20,21, being more susceptible to these adolescents. Only two of the teenagers live together in the same house with their father and mother. A teenager reports that he spends a few days with his family and others at his rented house with his girlfriend. Four of them are hosted institutionally and away from family life.

The severity of the situations experienced by these adolescents in the family dimension is evidenced by the historical precedence of the presence of the drug that permeates the family relationships from childhood. The declared family income was 1-4 minimum wages and the average number of people in the family per household is four people.

Still on family relationships, adolescents bring the perception that family conflict, non-cohabitation with family members, and the fact that they have close family members who also made or used drugs interfered with and interfered negatively in their use of drugs. Each twelve adolescents, seven reported having close relatives who did or used drugs, including mother, father, siblings and uncles.

Vagner: My father, my uncle, my cousin, my brother. Almost the whole family, except women. In my father's world everyone drinks. My father is already deceased, but he drank and smoked weed. My father just did not smell.

The lack of coexistence and the lack of dialogue with parents and guardians are significant in the adolescents' reports, once again showing the fragilities of parental relationships14,19,22. The absence of parental monitoring for these adolescents becomes clear when describing their family dynamics. Some parenting practices related to monitoring include monitoring the activities of their children, know what they are doing in their spare time, with what they are spending money and who their friends19. Inability to control children, lack of support, drug use by parents, and permissive attitudes towards drug use are important parental behaviors predisposing to adolescent experimentation and continuity of drug use19,22. Anotherpotentiating factor of social vulnerability was evidenced when most adolescents reported feeling idle, denouncing dissatisfaction by saying that they spend most of their time watching television.

Roberto: Oh, I wake up, I eat breakfast, then I'm going to watch television. After lunch, I go down to my grandfather's bar, stay for a while, then go upstairs and watch TV. This is how I spend my day.

According to the literature, the routine of a teenager is often organized through his attendance at school and complementary activities such as sports activities, language courses, among others. These activities organize and limit the schedules of the adolescent's agenda, which should have a time to wake up, to sleep, to do school duties, etc. However, when there is no such programmed activities, we perceive an emptying of meanings attributed to their other activities and their consequent disorganization23.

Teenagers who report having a lot of free time, who have many friends who use drugs, and who frequent parties are those who use the most drug (heaviest use pattern) and those who least stay in treatment. Many moments of amusement cited by teenagers coincide with times of drug use. These situations contribute to the increase of their social vulnerability8,14.

José: (...) how am I going to tell you, we are humble, we did not have a suitable place for us to have fun. It was more funk dance, so funk dance if you find this, damn it. That was our fun. It was the only fun we knew. Understood? It was what we knew, what we saw and what we liked. It was the influence we had (...).

The adolescents point out that what is most disturbing in the continuity of their treatment is the negative influence of their group of peers, which is composed of other adolescents and adolescents who are considered as reference and who, for the most part, also use drugs14,22.

Michel: What's happend? Weak mind. (...) Why does he have a weak mind? Because it goes with the head of the others

In addition to the question of whether or not they are abstinent, many adolescents report that the current pattern of use (on the day of the interview) was done in smaller amounts than they did at other times in life, alerting us that it is possible to work with strategies with adolescents who remain in CAPS-AD. Strategies that can take advantage of the presence of the adolescent in the service, seeking to foster with him moments of reflection on their use and non-use of drugs, thinking and building together (professional-adolescent) practical and realistic ways about the relationship with the drug consumed.

Michel: There're not the same thing, which has even stopped baforar.

[when speaking if you want to stop or continue use]
No, a little bit of it every now and then.        

On the other hand, the involvement of a friend in the treatment favors the continuity of the treatment by the adolescent. Reinforcing their importance in the life of the adolescent22. Recent integrative review data have identified that the strengthened family relationship may minimize the influence of the group of friends of the users and adds that family relationships may be more determinant in drug abuse than peers 19 . Thus, as the family relationships of the adolescents participating in the research are mostly weakened and present some predisposing factors to drug abuse, the peer group assumes a greater importance for them. These friends are models and references with which the teenager feels himself to belong.The absence of the family member who accompanies the treatment is a factor of negative influence on the adolescent's stay in the health service8,14,22.

Most of the adolescents in this research stated their involvement in drug trafficking, highlighting the activity as an opportunity to acquire material goods that until then could not have access. Many of them mentioned that they "opted" for illicit activity as a possibility of recognition that guaranteed them a status of power in the territory in which they live24-26. This data was also pointed out in other studies involving adolescents who use drugs in conflict with the law27. Of the male adolescents, five of them have a history of conflict with the law, a fact that contributes to the situation of social marginalization of these adolescents. Of the three female adolescents, two of them report involvement with the trafficking, but none of them had been apprehended until the moment of the research.

The traffic leaves no doubt as to the strong attraction it exerts on a part of the youth of the periphery. Interviews with young offenders in different neighborhoods of São Paulo indicate that this "fascination" for delinquency is expressed in the desire to dominate, impose their will on the other, and is seen by all other members as an attitude of great relevance24.

As a consequence of the growing involvement of adolescents and young people in illicit activities, especially in drug trafficking, there is a growing increase in violence. The involvement of adolescents in illicit activities is presented as one of the easiest ways to have the financial means to obtain the drug or even as an opportunity to acquire material goods such as hats, sneakers and clothes from famous brands. We show that these adolescents are exposed to many situations of violence and crime, and thus some of the consequences of involvement in these situations are early deaths.

Thus, this involvement in illicit activities, especially in drug trafficking, is the way in which the adolescent who makes harmful use obtains the drug and does not owe it to the traffickers, or even when the adolescent does not use drugs increases the ease of access and availability of the substance. Such factors are important predispositions for him to initiate drug use25,26,28.


FINAL CONSIDERATIONS

The social component of vulnerability involves important difficulties reported by adolescents. Knowing the profile of adolescents is necessary to develop strategies that are more in line with their needs. Knowing the values and models of reference for adolescents and young people is of fundamental importance to guide the discussions and elaboration of care strategies for this population. Factors such as frailty of family ties, availability of drugs in the street, culture of the investigated group, their values and references, and other psychosocial factors are found in this research as important elements that favor the use (and continuity) of drugs for these adolescents.


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