Revista Adolescência e Saúde

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

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 1 - Jan/Mar - 2018

Original Article Imprimir 

Páginas 66 a 72


Innovative Solutions for the Promotion of Adolescent Mental Health in Primary Care

Soluciones Innovadoras para la Promoción de Salud Mental de Adolescentes en la Atención Primaria

Soluções Inovadoras para a Promoção de Saúde Mental de Adolescentes na Atenção Primária

Autores: Marcelo Augusto do Amaral1; Edenir Aparecida Resende Andrade2; Goreti Maria Angnes3; Edna Rodrigues Sardeiro4; Lívia Batista Silva Carvalho5; Verônica Maria Abiorana Campos Fonseca6; Adair de Areda Vasconcelos7

1. Pediatrician. Specialist in Adolescent Health. Coordinator of the Comprehensive Health Care Program for Adolescents in Brazlândia - DF. Doctor of the Department of Health of the Federal District. Health Center 02 of Brazlândia. Brasília, DF, Brazil
2. Pediatrician. Specialist in Adolescent Health. Doctor of the Secretary of State of Health of the Federal District. Health Center 01 of Brazlândia. Brasília, DF, Brasil
3. Nursing Assistant of the Secretary of State of Health of the Federal District. Health Center 01 of Brazlândia. Brasília, DF, Brasil
4. Master in Music from the Federal University of Goiás (UFG). Goiânia, GO, Brazil. Postgraduate in Music Therapy from the Superior School of Health Sciences (ESCS). Technique in Health of the Secretary of State of Health of the Federal District. Health Center 01 of Brazlândia. Brasília, DF, Brasil
5. Specialist in Neurofunctional Physiotherapy. Physiotherapist of the Secretary of State for Health of the Federal District - Health Center 02 of Brazlândia. Brasília, DF, Brasil
6. Specialist in Adolescent Health. Social Assistant of the Secretary of State for Health of the Federal District - Health Center 02 de Brazlândia. Brasília, DF, Brasil
7. Public Health Agent - served in the Secretary of State for Health of the Federal District - Health Center 01 of Brazlândia. Brasília, DF, Brasil

Correspondência:
Marcelo Augusto do Amaral
Centro de Saúde 02 de Brazlândia
Quadra 45 Área Especial 1, Vila São José
Brazlândia, DF, Brasil. CEP: 72745-000
(marceloxamaral@gmail.com)

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Keywords: Adolescent, primary health care, mental health, health promotion, disease prevention.
Palabra Clave: Adolescente, atención primaria a la salud, salud mental, promoción de salud, prevención de enfermedades.
Descritores: Adolescente, atenção primária à saúde, saúde mental, promoção da saúde, prevenção de doenças.

Abstract:
OBJECTIVE: The goal of this study was to develop effective alternatives for the promotion of mental health and the prevention of psychosocial disorders in adolescents and their family members.
METHODS: Two modalities of support groups were developed in a Public Health Unit of Brazlândia, Distrito Federal. The first group was focused on parents and caregivers aiming to help them with the education of their children and give them support to deal with the specific challenges of adolescence. The other group, focused on youngsters as well as caregivers, consisted in the practice of an innovative body-based technique called T.R.E. (Tension and Trauma Releasing Exercises) that is very effective in reducing stress and relieving many symptoms of emotional and behavioral problems.
RESULTS: These new activities helped to improve family relationships, reduce conflicts and domestic violence and relieve many psychosocial symptoms observed in the teenagers as well as in their caregivers. This allowed improving the families´ quality of life, preventing mental disorders and reducing teenager's exposure to risk situations. Furthermore, these groups brought a better problem-solving capacity to the psychosocial demands in a primary care level, avoiding many referrals to specialized services.
CONCLUSION: It is possible to develop effective and low cost alternatives to promote adolescent mental health in a primary care setting. Such measures are very important in order to deal with the main psychosocial demands of adolescence and to prevent the major risk situations observed in this critical period of development.

Resumen:
OBJETIVO: El objetivo del presente estudio fue construir alternativas efectivas en la promoción de salud mental y en la prevención de trastornos psicosociales para adolescentes y sus familiares.
MÉTODOS: Fueron desarrolladas dos modalidades de servicio en grupo en una Unidad Básica de Salud de Brazlândia, en Distrito Federal. La primera fue dirigida a los padres y cuidadores con el objetivo de darles orientaciones con relación a la educación de los jóvenes y apoyo para manejar los desafíos propios de la adolescencia. La otra modalidad, dirigida tanto a jóvenes y cuidadores, consistió en la práctica de una técnica corporal innovadora llamada T.R.E. (Tension and Trauma Releasing Exercises) que se muestra muy efectiva para reducir el estrés y aliviar diversos síntomas de cuadros emocionales y comportamentales.
RESULTADOS: Estas nuevas actividades ayudaron a mejorar las relaciones entre padres e hijos, disminuir los conflictos familiares y la violencia doméstica y reducir muchos síntomas psicosociales evidenciados en los jóvenes y en sus cuidadores. Esto permitió mejorar la calidad de vida de las familias, prever trastornos mentales y disminuir la exposición de los jóvenes a situaciones de riesgo. Además de eso, esos grupos dieron mayor resolución a las demandas psicosociales a nivel de atención primaria, evitando muchos envíos a servicios especializados.
CONCLUSIÓN: Es posible desarrollar alternativas efectivas y de bajo costo para promover la salud mental de adolescentes en el ámbito de la atención primaria. Tales medidas son fundamentales para manejar las demandas psicosociales de esta franja etaria y prever las principales situaciones de riesgo observadas en esta fase crítica del desarrollo.

Resumo:
OBJETIVO: O objetivo do presente estudo foi construir alternativas efetivas na promoção de saúde mental e na prevenção de transtornos psicossociais para adolescentes e seus familiares.
MÉTODOS: Foram desenvolvidas duas modalidades de atendimento em grupo numa Unidade Básica de Saúde de Brazlândia, no Distrito Federal. A primeira foi voltada para os pais e cuidadores, com o objetivo de dar a eles orientações em relação à educação dos jovens e apoio para lidar com os desafios próprios da adolescência. A outra modalidade, voltada tanto para jovens e cuidadores, consistiu na prática de uma técnica corporal inovadora chamada T.R.E. (Tension and Trauma Releasing Exercises) que se mostra muito efetiva em reduzir o estresse e aliviar diversos sintomas de quadros emocionais e comportamentais.
RESULTADOS: Estas novas atividades ajudaram a melhorar os relacionamentos entre pais e filhos, diminuir os conflitos familiares e a violência doméstica e reduzir muitos sintomas psicossociais evidenciados nos jovens e em seus cuidadores. Isto permitiu melhorar a qualidade de vida das famílias, prevenir transtornos mentais e diminuir a exposição dos jovens a situações de risco. Além disto, esses grupos deram maior resolutividade para as demandas psicossociais no nível da atenção primária, evitando muitos encaminhamentos a serviços especializados.
CONCLUSÃO: É possível desenvolver alternativas efetivas e de baixo custo para promover a saúde mental de adolescentes no âmbito da atenção primária. Tais medidas são fundamentais para lidar com as demandas psicossociais desta faixa etária e prevenir as principais situações de risco observadas nesta fase crítica do desenvolvimento.

INTRODUCTION

Adolescent health care represents a challenge in many aspects. On one hand, adolescence is a challenge in itself. The teenager has the task to leave behind his childhood and grow into an adult world. These physical, emotional and social changes challenge not only the adolescent, but also the whole environment he lives in, including his family, teachers, health professionals and the society as a whole1. On the other hand, despite the extreme importance of this stage of development, there are in general few sensitive and trained professionals to deal with adolescence. Many health professionals, lacking knowledge, having cultural preconceptions or having had troubles as teenagers or as teenagers´ parents, are afraid of this phase and avoid working with this age range. One of the consequences is that there is a sad gap in adolescent health care.

With the intention of filling this gap, in 2004, a Public Health Unit of Brazlândia in Distrito Federal, Brazil, developed a specific program for adolescent health care. Initially, it offered only individual consultations for patients between 10 and 19 years old. As the program grew and statistical data became available, it was possible to observe that most of the demands coming from the teenagers and their families involved psychosocial issues2. Many of them were related to the adolescent's and his family´s difficult process of adjustment to the quick changes that occur in this phase, especially regarding the dynamics of family relationships. The complaints dealt with in the consultations involved topics like the lack of parental authority, family conflicts, violence, parental overprotection, neglect and difficulties the parents had to deal with the main issues related to adolescence (sexuality, autonomy, responsibility and independence). In non-rare occasions, the patients and their relatives had more severe behavioral problems, either because of the difficulty in adjusting to this phase of development, or because of the presence of factors like stress, violence and trauma in the family. Many youngsters and family members presented with issues related to stress, depression, anxiety crisis, aggressiveness, antisocial behaviors, cutting, suicidal attempts, eating disorders, abusive use of alcohol and other drugs, among others. These psychosocial problems and their consequences, when not addressed, represented serious troubles and risks in the life of the adolescents.

From these observations, it became evident that in order to offer an adequate health program for adolescents it would be necessary to address their mental health needs and to include their parents and caregivers in the treatment program. However, the availability of public psychological and psychiatric services in Brazlândia and in Distrito Federal in general is scarce. Moreover, when one is able to schedule an appointment of this kind, it is usually in the center of Brasilia, 35 miles away. Frequently the local population doesn´t show up for the appointment or doesn´t follow up with the treatment because of the distance and the cost of transportation.


OBJECTIVE

The goal of the program developed in Brazlândia was to find alternatives for mental health promotion and for the prevention of mental disorders that could be effective and accessible for the local population. The solution could not depend on specialized consultations in psychology and psychiatry, should be applicable in large scale in order to address the great existing demand and should be offered by primary care professionals.

Moreover, the adopted model would need to address two important issues: include the parents and caregivers in the program and offer an effective methodology to relieve the impact of psychosocial problems like stress, anxiety, depression, violence and trauma, so common among this population.


METHOD

In 2005, a parents support group was implemented in the adolescent health care program. It was held weekly and each meeting lasted two and a half hours (Figure 1). The methodology used for the parents support group was developed by Ana Carolina Bessa Linhares and Valdi Craveiros Bezerra at Adolescentro, a referral unit for adolescent health in Distrito Federal3. The focus of this group was to help parents and caregivers to exercise a healthy authority, learn new ways to deal with their children, promote dialog, be more present in the teenagers' lives and strengthen the affective bonds4,5,6.


Figure 1. Meeting of Parent Group held in the present study.



Besides the parents support group, it was necessary, also, to offer more objective help for teenagers and caregivers who had specific psychosocial problems (e.g. anxiety, depression, stress, sleep disorders, panic disorder and phobias, among others). For this purpose, T.R.E. (Tension and Trauma Releasing Exercises) was used. This innovative methodology consists of a simple technique of body-based exercises that helps to lower the level of arousal of the autonomic nervous system (Figure 2). T.R.E. was developed by David Berceli, PhD, social assistant and international expert in conflict resolution, with the purpose of assisting victims of extreme situations such as wars and natural disasters. In these contexts psychological and social assistance are rarely available7,8. The T.R.E. exercises induce spontaneous tremors in some muscular groups allowing a neuro-muscular discharge and consequently the release of bodily tensions as well as a deep physical and mental relaxation. When practiced regularly these exercises allow a progressive reduction in levels of hyper excitability of the autonomic nervous system, relieving many emotional and behavioral symptoms, especially in situations related to stress and physical and psychological violence9,10,11,12.


Figure 2. Practice in group of TRE (Tension and Trauma Releasing Exercises) in the present study.



In 2012, a training for T.R.E. providers took place in Brazlândia. Six new providers (community health agents, physiotherapist and social assistant) were able to keep weekly T.R.E. groups in the city, helping not only the adolescents and their caregivers but also the local community.


RESULTS

The parents support group became a complementary activity to the biopsychosocial consultations of adolescents without which it would be very difficult to deal with most of the complaints presented by the teenagers and their families. In 2016, 47 parents support groups were offered, with the participation of 888 parents and caregivers. The parents' attendance to the groups was essential for the success of the program. The group offers help, emotional support and counseling for caregivers, allowing them to establish rules and boundaries, to exercise parental authority without violence, to strengthen affective bonds with the teenagers and to promote dialog in the relationships. The parents redeem their capacity to solve the problems they face and learn new ways to deal with the adolescents so that they, parents, become active agents in the construction of healthier bonds and in the transformation process. The main results observed during the 11-year period of this group activity were the improvement of family relationships, the reduction and prevention of domestic violence, the prevention of teenager involvement in risk situations and an improvement in quality of life as a whole.

Below are some testimonials of parents and caretakers who attended the parents support group:


"As I started to attend the parents support group, I began to treat more peacefully my relationship with my family. I am having more dialog, I am trying to understand better my son´s situation and the phase he is going through. I am having more courage to get closer to him, to hug, to talk, to praise him, to tell the feelings I have for him and also what I expect from him, for his life, so that he gets better. I have improved a lot in this relationship." (Father of an adolescent).

"I am a stepmother. In the beginning, it was very difficult. As we started to attend the program, I saw a big change in my stepson. He couldn´t sleep alone, now he can. He couldn´t sleep with the lights off, now he can. He treats me with more kindness. He doesn´t reject me anymore. He now accepts my authority. He helps me more at home, because he didn´t help at all. He only messed things up. Now he messes things up and helps me to clean up." (Stepmother of an adolescent).


Although the parents support group is extremely important and gives excellent results in improving family relationships, the group was not able to solve completely, and it was not its goal, many of the psychosocial problems observed among teenagers and caregivers. Many of these emotional and behavioral problems needed to be addressed more directly in order to have better results and in order to offer a more effective assistance to these families. This was the purpose of the T.R.E. groups. They became also a parallel activity to the adolescent biopsychosocial consultations, filling a gap in mental health care. The main psychosocial demands began to be addressed without restrictions, lines, waiting list or cost for the population13. Only the more severe cases needed psychiatric or psychological treatment.

In 2016, 121 regular T.R.E. group meetings were offered in Brazlândia, with the participation of 1263 people, including youngsters and adults. With the regular practice of the exercises, participants reported improvements in conditions such as insomnia, muscular pains, anxiety, stress, fibromyalgia, depression, panic syndrome and Post Traumatic Stress Disorder, resulting in a better quality of life for the adolescents, their families and the community.

Case report of a mother who attended the T.R.E. group:


The mother of a teenager was 42 years old in 2012 when she brought her son to our service. At that time, this mother was having symptoms of depression and fibromyalgia for 6 years. She was feeling anguish, sadness, tightness in her chest, felt like crying all the time and had always the sensation that some kind of tragedy was about to happen. She didn´t feel like going out or seeing anyone. She felt pain in her body, especially in her legs. She had chronic headaches and a tiredness that did not improve even with sleep. It seemed for her as she didn´t sleep. In addition, she had a terrible insomnia. As she went to bed, she rolled back and forth without being able to sleep.

This mother had a difficult life history. Her first husband died right after the birth of her first daughter, more than 20 years ago. It was a trauma; she became depressed, had no job, and had to take care also of her deceased husband´s children. On certain occasions they didn´t even have what to eat. Even getting remarried a couple of years later and putting her life back together, she never improved completely. She used medication for depression, but the condition always returned.

She was referred to the T.R.E. group that she attended regularly for the following six months. Slowly, she significantly improved her symptoms. She was already using muscle relaxant and antidepressant regularly but felt only mild benefits. With regular T.R.E. practice, the change was remarkable: she started to sleep better, was less tense, the fears, the aches and the tiredness improved, she was able to control her nervousness and improve the depressive symptoms as well as her family relationships.

With this favorable evolution, she was able to withdraw the medications and continued to practice T.R.E. The improvement in her quality of life was significant as well as her family´s.



CONCLUSION

According to the World Health Organization (WHO)14,15,16, despite the potential to treat mental disorders, only a minority of people receive even the most basic mental health treatment. This reveals the need to integrate mental health services into primary care, especially in dealing with child and adolescent mental health.

Because of the specific characteristics of childhood and adolescence, it is difficult to imagine a child or an adolescent without the family context in which they live. Many of the teenagers´ demands are related to problems in family relationships and many of the behavioral problems they present, that disturb so much the parents, are usually directly or indirectly related to the dynamics of family relationships17. This becomes clear when we observe the difficulty parents have to deal with issues such as authority, affective bond, expression of affect, communication and support for the adolescent to overcome his developmental challenges. The innovative aspect of the parents support group is to offer a systemic approach, include the parents and caregivers in the treatment process and help them to have an active role in creating a better relationship with their children and a better family environment.

The T.R.E. groups were able to fill a gap in mental health care. The innovative aspect of this technique is the application of an easy to execute and low cost methodology to deal with psychosocial issues and to solve a chronic problem in mental health care, which is the difficult access of the population to the mental health services and the lack of preventive policies. T.R.E. is also innovative in the sense that it helps not only the adolescents, but also their caregivers who many times present psychosocial problems that interfere directly with the mental health and the quality of life of teenagers.

Because both these activities can be well implemented in groups and can be applied by non-specialists, they have a great potential for use in primary health care, especially in contexts where the access to specialized mental health treatment is difficult. Both can be successfully used as health promotion activities as well as in mental health prevention programs directed to populations at risk, helping to prevent and relieve many emotional and behavioral problems among adolescents, their families and the community as a whole.


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